Paediatrics Flashcards
What is Kernig’s Sign?
Pain on leg straightening
What is Brudzinski’s sign?
Supine neck flexion resulting in Knee/hip flexion
What are the clinical manifestations of meningitis?
Bulging fontanelle, hyperextension of the neck and back (opisthotonos)
-Headache, photophobia, neck stiffness, fever
What is Cushing’s Triad?
- High Blood Pressure
- Low heart rate
- Irregular Respiratory Rate
What is the routine first-line diagnostic investigation for meningitis if there are no signs of raised ICP?
Lumbar puncture
What ABx is prescribed to children <3 months with meningitis?
IV Cefotaxime
IV Amoxicillin/ampicillin
Which type of abnormal cell is characteristic of Hodgkin’s lymphoma?
Reed-Sternberg Cells
What B symptoms are associated with Hodgkin’s lymphoma?
-Fever (Pel-Ebstein) for 3 consecutive days
-Weight Loss
-Pruritus
-Night sweats
What is the clinical presentation of Hodgkin’s lymphoma?
- B symptoms
- Lymphadenopathy - painless non-tender cervical/supraclavicular, asymmetric
-Alcohol-induced - Medistinal mass
What is the diagnostic investigation for Hodgkin’s lymphoma?
Excisional lymph node biopsy
What does a CXR reveal in Hodgkin’s lymphoma?
Mediastinal disease burden + hilar lymphadenopathy
What does FBC with differential show in Hodgkin’s lymphoma?
- Low Hb and platelets
- Eosinophilia
- Raised LDH
What are Reed-Sternberg cells?
Multinucleated cells (with bilobed nucleus and prominent eosinophilic inclusion-like nucleoli)
What investigation is used to stage Hodgkin’s lymphoma?
PET-CT scan to assess progression and staging
What chemotherapy regimen is initiated for Hodgkin’s lymphoma?
Doxorubicin, bleomycin, vinblastine and dacarbazine (administered intravenously).
What is bronchiectasis?
Abnormal bronchial dilatation secondary to recurrent infections
What is the leading cause of bronchiectasis?
Cystic fibrosis
What is the leading cause of bronchiectasis?
Cystic fibrosis
What is the clinical manifestation of bronchiectasis?
-Chronic wet/productive cough
-Recurrent infections - >3 episodes of protracted bacterial bronchitis
-Haemoptysis
-Dyspnoea
What is the clinical manifestation of bronchiectasis?
-Chronic wet/productive cough
-Recurrent infections - >3 episodes of protracted bacterial bronchitis
-Haemoptysis
-Dyspnoea
What are the physical findings associated with bronchiectasis?
- Crackles
-Digital clubbing
-Chest rhonchi and wheeze
-Hyperinflation, Harrison sulci, pectus carinatum
What feature is observed on chest radiograph in a paediatric patient with bronchiectasis?
Tram track appearance
What is the gold standard diagnostic investigation for paediatric bronchiectasis?
HRCT + Multidetector CT
What is the gold standard diagnostic investigation for paediatric bronchiectasis?
HRCT + Multidetector CT
What is observed on HRCT in bronchiectasis?
- Increased bronchoarterial ratio
- Signet ring sign
- Bronchial wall thickening
What type of pattern is observed in spirometry in a patient with bronchiectasis?
Obstructive pattern (Reduced FEV1, normal FVC)
What type of pattern is observed in spirometry in a patient with bronchiectasis?
Obstructive pattern (Reduced FEV1, normal FVC)
What investigations should be performed in a paediatric patient with bronchiectasis?
HRCT + Multidetector CT
Spirometry
Sweat chloride testing
Screeing for antibody deficieincy
What 2 screening investigations should be performed in a patient with bronchiectasis?
Sweat chloride testing - CF
Antibody deficiency - IgG, IgM, IgA
What is the first-line ABx therapy for bronchiectasis (aged 1 month - 11 years)?
Amoxicillin or Clarithromycin
For patients aged 12-17 years, what Oral ABx should be prescribed in bronchiectasis?
Doxycycline
What IV ABx is administered for severely unwell patients with bronchiectasis?
Co-amoxiclav
Pipieracillin and tazobactam
What is the management strategy for paediatric bronchiectasis?
Chest physiotherapy
Antibiotic therapy
Inhaled hypertonic saline for high sputum load
What vaccinations should be offered in bronchiectasis?
Streptococcus pneumonia
Seasonal influenza
What is Epiglotitits?
Inflammation of the epiglottis and adjacent supraglottic structures
It is a life-threatening obstruction
What is the most common causative pathogen for Epiglottitis?
Haemophilusinfluenzae type B
What is the characteristic voice associated with Epiglottitis?
Hot potato voice - muffled
A tripod position with drooling and a muffled voice is associated with what diagnosis?
Epiglottitis
What is the clinical presentation of Epiglottitis?
Irritability, fever, dysphonia (‘hot potato voice’), and dysphagia
Respiratory distress with tripoding (child sitting up, leaning forward, neck hyperextended and bracing upper body)
Drooling/increased oral secretions
Tachycardia and tachypnoea
Oedematous and cherry-red epiglottis
Absence of cough
Anxiety
Fever > 38.8-40.0°C
Stridor
Due to airway obstruction
What is the first-line management for Epiglottitis?
Endotracheal intubation
Immediate ENT and anaesthetics referral + 100% inspired oxygen
What radiological sign is observed in Epiglottitis?
Thumb sign
What ABx is administered in Epiglottitis?
3rd generation cephalosporins - ceftriaxone for 7-10 days.
What prophylaxis should be offered to close contacts in Epiglottitis?
Rifmapicin
What is the most common causative organism in bronchiolitis?
RSV
What is the clinical presentation of bronchiolitis?
Fever - <38.3°C
Cough
Respiratory distress
Increased RR, retractions, wheezing, crackles
Preceded by 1-3 day Hx of symptoms of URTI (Nasal congestion, rhinorrhoea)
Rapid onset of wheezing
Irritability, malaise, and poor feeding
TYPICALLY RESOLVES within 2 WEEKS.
When is an urgent referral indicated in bronchiolitis?
Apnoea
The child looks seriously unwell
Severe respiratory distress
Grunting, marked chest recession or a RR > 70 breaths/minute
What is the diagnostic investigation for bronchiolitis?
Immunofluorescence of nasopharyngeal secretions –> RSV
What is the management for non-severe bronchiolitis?
Oxygenation and hydration
Humidified oxygen via a headbox if Spo2 <92%
Nasogastric feeding if cannot tolerate feed by mouth
Paracetamol > 3 years
What is the management for severe bronchiolitis?
Trial of inhaled bronchodilator
Nebulised hypertonic saline
CPAP for impending respiratory failure
Intravenous fluids
What RSV prophylaxis should be administered in high-risk preterm infants?
palivizumab
Projectile non-bilious vomiting occurring 30 minutes post-feed is associated with what diagnosis?
Pyloric stenosis
What type of alkalosis is associated with pyloric stenosis?
Hypercholraemic alkalosis - due to a loss of gastric acid
What palpable mass is observed in pyloric stenosis?
Olive-like mass
What is the diagnostic investigation indicated in pyloric stenosis?
Ultrasound - direct visualisation of pyloric muscle
- >3mm
>15 mm length
What is the definitive management of pyloric stenosis?
Surgical pyloromyotomy (Ramstedt)
- Can be open or laparoscopic
What pre-operative management is indicated for pyloric stenosis?
- Pre-operative fluid and electrolyte therapy to correct electrolyte disturbance.
- 0.45% Saline + 1.5x Maintenance rate with 5% dextrose
What is included in the 6 in 1 vaccine?
Polio, whooping cough, Haemophilus influenzae type B, diphtheria, tetanus and hepatitis B
What vaccines are administered at 2 months?
6 in 1 Vaccine
Oral rotavirus vaccine
Men B
What vaccines are administered at 3 months?
6 in 1 Vaccine
PCV - Pneumococcal (13 serotypes)
Rotavirus
How many serotypes are included in the PCV vaccine?
13
When is the PCV vaccine administered in infants?
12 weeks
What vaccines are administered at 4 months (16 weeks)?
6 in 1
Men B
What vaccines are administered at 12-13 months?
Hib/Men C
MMR
PCV
Men B
When is the MMR vaccine is administered?
1 year
When is the HPV (Gardasil) vaccine administered?
12-13 years - 2 doses 6-24 months apart.
What are the contraindications to vaccination?
- Acute febrile illness
- Egg allergy - Influenza, yellow fever, and tick born encephalitis
- Previous anaphylaxis to vaccine containing ro constituent antigens/components
- Immunocompromised
What is the definitive management of biliary atresia?
Kasai hepatoportoenterostomy
- with ABx cover for the first year of life.
What is administered for biliary atresia post-Kasai HPE?
Choleretics - Ursodeoxycholic acid - to promote bile flow.
Nutritional supplementation - medium chain triglyceride formula
Fat-soluble vitamin
Which ABx is prescribed in a patient with bacterial meningitis < 3 months?
IV amoxicillin + cefotaxime
Management of bacterial meningitis >3 months?
IV Ceftriaxone
Management of bacterial meningitis in primary care?
IM Benzylpenicillin + arrange emergency transfer to secondary care centre.
What follow-up is required post-meningitis?
Auditory assessment within 4 weeks after discharge
What prophylactic ABx should be prescribed to close meningitis contacts?
Ciprofloxacin
What is the causative organism of pertussis?
Bordetella pertussis (Gram-negative)
When is the pertussis immunisation?
2,3,4 months (as part of the 6 in 1 vaccination schedule) + 3-5 years.
- Paroxysms of coughing
- Inspiratory whoop
- Post-tussive vomiting.
- Apnoea, with or without cyanosis.
What is the most likely diagnosis?
Pertussis
What is the first stage of pertussis?
Catarrhal stage
-Viral upper respiratory tract infection symptoms:
-Low-grade fever, cough gradually increases, coryza
-Most. infectious stage
What is the paroxysmal stage of pertussis?
Coughing spells increase in severity
Gagging, breathlessness
Sweating episodes between paroxysms
Bothersome at night
What is the first-line investigation for pertussis?
Nasal swab culture for Bordetella pertussis - nasopharyngeal aspirate or swab
(Suitable for all age groups <21 days of cough duration)
What is the gold-standard investigation for pertussis?
PCR and serological testing
What are the admission criteria for pertussis?
Admit:
1. Significant breathing difficulties – apnoea episodes, severe paroxysm, or cyanosis.
2. Low threshold for children <6 months
3. Significant complications – pneumonia or seizures.
What is the age threshold for admission in a paediatric patient presenting with whooping cough?
< 6 months
What class of ABx is prescribed in pertussis?
Macrolide (cough within 21 day duration).
Which macrolide is prescribed for pertussis?
Clarithromycin for infants <1 month of azithromycin aged >1 year
What is the school exclusion protocol for pertussis?
Children are to return to school having completed 48 hours of Abx management.
What are the three major risk factors for bronchopulmonary disorder?
- Less than 28 weeks’ gestation
- IUGR infants
- Chorioamnionitis – Increases risk of developing a systemic inflammatory response.
What is the presentation of bronchopulmonary disorder?
- Breathing difficulties and is oxygen-dependent.
- Poor growth
- Feeding problems
What CXR changes are present in bronchopulmonary dysplasia?
Hyperinflation, cystic changes and streaky infiltrates
What prophylactic measure is necessitated for BPD?
Corticosteroids for suspected/established preterm labour (<34 weeks).
What respiratory support is indicated in BPD?
High flow oxygen via a nasal cannula or if >2L/min - humidified oxygen
CPAP
Invasive ventilation + prescribe surfactant
What medications are prescribed in BPD?
- Dexamethasone – If > 8 days and on ventilator
- Caffeine criteria – If <30 weeks corrected gestational age
- Consider if preterm and apnoeic
- Nitric oxide
- Only if pulmonary hypoplasia or pulmonary hypertension
When is dexamethasone prescribed in BPD?
If >8 days and on ventilator
When is caffeine prescribed in BPD?
In preterm and apnoeic patients
OR
<30 weeks corrected gestational age
What is PPHN?
Persistent Pulmonary Hypertension of the Newborn
PPHN occurs when pulmonary vascular resistance remains abnormally elevated after birth.
* Resulting in right-to-left shunting of blood through foetal circulatory pathways.
- Associated with hypoxic-ischaemic encephalopathy, meconium aspiration and RDS.
What are the risk factors for PPHN?
- Maternal diabetes
- Maternal obesity
- Advanced maternal age
- In utero exposure of SSRIs
- Meconium-stained amniotic fluid
- Prolonged premature rupture of membranes
Which vessel does blood bypass pulmonary circulation in PPHN?
Ductus arteriosus (resulting in a right-to-left shunt)
What is the clinical presentation of PPHN?
Presentation within the first 24 hours of life with signs of respiratory distress:
* Tachypnoea
* Retractions
* Grunting
* Cyanosis
* Meconium staining of skin and nails.
- Indicative of intrauterine stress.
Cardiovascular examination
* Prominent precordial impulse
* Narrowly split and accentuated S2
What monitoring investigation is indicated in PPHN?
Pre- and post-ductal oxygen saturation
- A difference >10% indicates PDA right-to-left shunting.
What is the diagnostic investigation to confirm PPHN?
Echocardiography
What is the management support for PPHN?
- Oxygen
- Maintain high PO2 (10-13 kPa in infants born >34 weeks’ gestation).
- Ventilation
- Intubate
- High-frequency oscillatory ventilation
- Minimise handling
- Surfactant – To optimise lung function
- Suction of secretions from ETT
- Fluids and inotropes – to optimise cardiac output
- Inhaled nitric oxide.
What is the most common cause of respiratory distress in newborns?
TTN
What are the 3 major risk factors for TTN?
- Caesarean section
- Maternal diabetes
- Maternal asthma
What is the pathophysiology of TTN?
Characterised by pulmonary oedema resulting from delayed resorption and clearance of foetal alveolar fluid.
* Reduced pulmonary compliance –> Compensatory tachypnoea.
* Fluid accumulation in the peribronchiolar lymphatics and interstitium –> Partial collapse of the bronchioles.
What is the time of onset for TTN?
Between time of birth and two hours post-delivery
What are the features of respiratory distress?
- Nasal flaring
- Expiratory grunting
- Cyanosis
- Subcostal and intercostal retractions
- Tracheal tug
- Increased anterior-posterior diameter of the chest.
What features are revealed on CXR in TTN?
Fluid in horizontal fissure + hyperinflation
When does TTN resolve?
12-24 hours
What are the target O2 sats in TTN?
> 94%
What are the indications for nutritional support in TTN?
RR is 60-80 breaths per minute
What are the indications for prescribing Ampicillin + gentamicin in TTN?
If tachypnoea persists >4-6 hours
What ABx are prescribed if TTN lasts >4-6 hours?
Ampicillin + gentamicin
What radiographic sign is observed in a lateral neck radiograph in epiglottitis?
Thumb sign
What is the most common causative organism for bronchiolitis?
RSV
What criterions are associated for admitting a patients with bronchiolitis?
- Apnoea – Observed or reported
- Persistent SpO2 <92% in RA
- Inadequate fluid intake (50-70% normal)
- Features of severe respiratory distress
- RR >70 breaths per minute
-Cyanosis
What is the diagnostic investigations for RSV?
Immunofluorescence of nasopharyngeal secretions RSV
- + Rapid antigen testing
Which type of infection is associated with Hodgkin’s lymphoma?
Epstein-Barr virus
Which type of cell is associated with Hodgkin’s lymphoma?
Reed-Sternberg Cells
What is the most common type of Hodgkin’s lymphoma?
Nodular Sclerosis
What is the peak incidence of ALL?
2-5 years of age
What WBC is a poor prognostic factor for ALL?
> 2 X 109/L at diagnosis
What are the poor prognostic factors for ALL?
- Age <2 years or >10 years
- WBC > 2 x109/L at diagnosis
- T or B cell surface markers
- Non-Caucasian
- Male sex
What type of cell is associated with ALL?
Lymphoid progenitor cells
What are the clinical features associated with ALL?
Bone Marrow Failure
1. Thrombocytopenia
- Bruising and petechiae
2. Anaemia
- Pallor, fatigue
3. Neutropenia
- Fever, and frequent infections
Lymphadenopathy
Hepatosplenomegaly
* Anorexia, weight loss, abdominal distension, and abdominal pain
Musculoskeletal pain – Limp or refusal to bear weight.
Testicular swelling – A persistent, painless, solid testicular mass
What is the first-line investigation for ALL?
FBC with differential
Peripheral blood smear
What is the gold-standard diagnostic investigation for ALL?
Bone marrow aspiration and trephine biopsy
What is the diagnostic result on bone marrow aspiration in ALL?
> 20% lymphoblasts
Which gene is associated with Burkitt lymphoma?
MYC gene on chromosome 8
What is endemic Burkitt lymphoma associated with?
Equatorial Africa and New Guinea - with jaw or facial bone tumours
What are the two types of Burkitt lymphoma?
- Endemic
- Sporadic
Clinical presentation of endemic Burkitt lymphoma?
- Jaw or facial bone tumour
- Involves the mandible or maxilla
- Extranodal sites: Mesentery, ovary, testis, kidney, breast and meninges.
Clinical presentation of sporadic Burkitt lymphoma?
Sporadic
Abdominal presentation
* Ascites
* Ileo-caecal tumours
* Mimic acute appendicitis
* ~25% involve jaw or facial bones
* Localised lymphadenopathy
What syndrome is associated with Burkitt Lymphoma?
Spontaneous tumour lysis syndrome
-Raised serum lactate dehydrogenase and uric acid
What is revealed on histological examination of Burkitt lymphoma?
Starry Sky Appearance
Medium-sized cells with basophilic cytoplasm and a high Ki67 fraction
What is the induction regimen for ALL?
- Prednisolone or Dexamethasone
- Cyclophosphamide
- Vincristine
- Doxorubicin
- L-asparaginase
What drug is prescribed to prevent cardiotoxicity from doxorubicin?
Dexrazone
What tyrosine kinase inhibitor is indicated in ALL, Philadelphia chromosome-positive patient?
Imatinib
What prophylactic is prescribed to ALL patients at risk of febrile neutropenia?
CSF - Filgrastim
How should anaemia be treated in ALL prior to management?
Blood transfusions
What prophylaxis should be prescribed to prevent tumour lysis syndrome in ALL?
Allopurinol
Rasburicase
What is the CNS prophylaxis in ALL?
Intrathecal methotrexate
What is the management of TLS in Burkitt’s?
Management of tumour lysis syndrome
* Rasburicase – Recombinant version of urate oxidase.
What is the management of Burkitt’s lymphoma?
Chemotherapy
CODOX-M with IVAC
* Cyclophosphamide
* Vincristine
* Doxorubicin
* High-dose methotrexate
* Ifosfamide, cytarabine, etoposide and intrathecal methotrexate.
What type of hypersensitivity is associated with immune thrombocytopenia?
Type 2 hypersensitivity
What is the common presentation of Meckel diverticulum?
- Symptomatic
- Intermittent painless lower GI bleeding Excision of the diverticulum with blood transfusion
- Obstruction Excision of diverticulum and lysis of adhesions
- Perforation/peritonitis Laparoscopic excision of the diverticulum or small bowel segmental resection with perioperative antibiotics.
o Cefotaxime, clindamycin/metronidazole
What is the diagnostic investigation for Meckel Diverticulum?
Meckel’s scan (Technetium-99m Scan).
- Reveals ectopic focus or hot spot
What is the most common symptomatic presentation of Meckel Diverticulum?
Intermittent painless lower GI bleeding
What is the pathogenesis of Intestinal malrotation?
Fibrous bands called ‘Ladd bands’ tether the caecum to the RUQ, and these cause intestinal obstruction by compression of the duodenum.
What is the most common complication with intestinal malrotation?
Volvulus
What is the characteristic presentation of intestinal malrotation?
Presents in the first few days of life.
* Bilious vomiting – dark green vomiting Urgent gastrointestinal contrast study to assess intestinal rotation.
* Abdominal pain
* Signs of vascular compromise
* Scaphoid abdomen (concave)
What type of vomiting is associated with intestinal malrotation?
Bilious vomiting - dark green.
What is the most urgent investigation performed for intestinal malrotation?
Upper GI contrast study
What findings are revealed in an upper GI contrast study?
Right-sided duodenum
Bird-beak cut-off
Corkscrew
What does a plain abdominal X-ray reveal in intestinal malrotation?
Distended stomach and proximal duodenum with a paucity of bowel gas seen distally.
What surgical procedure is corrective for intestinal malrotation?
Ladd’s procedure
Where is the maximal tenderness point in Appendicits?
McBurney’s point
What does an FBC reveal in appendicitis?
Leuckocytosis
What clinical scoring system is used to assess paediatric appendicitis?
PAS > 7 or 8 - high risk - surgical consultation
What investigation is performed in children with an atypical presentation of appendicits?
Abdominal ultrasound
What are the risk factors for perforation in appendicits?
- Abdominal pain >48 hours
- WBC >18 micro/mol
- Raised CRP
- Appendicolith present on imaging
- Appendix diameter >1.1 cm on imaging
What is the pre-operative management for appendicitis?
– Nil-by-mouth from the time of diagnosis
* Intravenous hydration + analgesia
* Consider prophylactic IV ABx (cefoxitin, ampicillin, piperacillin/tazobactam)
What is the definitive management for appendicitis?
Perform appendectomy without delay – open/laparoscopic.
* With peritoneal lavage, if perforation
* In complicated appendicitis e.g., with perforation, abscess, appendix mass present:
- If there is generalised guarding consistent with perforation IV fluids, and Abx prior to laparotomy.
What is the presentation of biliary atresia?
Infants are born full term, have a normal birth weight and initially thrive.
* Jaundice (Birth-8 weeks).
- Scleral icterus
- Jaundice extends beyond the physiological two weeks
* Alcoholic stool
- Range in colour from white to tan or light yellow
* Dark urine
- Bilirubin excretion into the urine
* Bruising
- Secondary to Vitamin K deficiency related to chronic cholestasis.
What is the gold-standard investigation for biliary atresia?
Abdominal ultrasound
What does an abdominal ultrasound reveal in biliary atresia?
- Absence of gallbladder, irregular morphology, polysplenia
- Triangular cord sign
What is the definitive management for biliary atresia?
A Kasai Hepatoportoenterostomy (HPE) to restore bile flow from the liver to the proximal small bowel.
- 2nd line: Liver transplantation following unsuccessful HPE or at presentation infants have end-stage liver disease.
What is the most common site of Intussusception?
Ileocolic Intussusception
What is the presentation of Intussusception?
Sudden onset of intermittent, severe, crampy, progressive abdominal pain.
- Associated with inconsolable crying + pallor.
- Drawing up of the legs toward the abdomen, often pallor.
- Episodes last ~ 15–20-minute intervals
- Inter-episode free pain.
- Vomiting – Bilious emesis as intestinal obstruction progresses.
- Sausage-shaped abdominal mass
- Palpated in the RUQ
- Redcurrant jelly stools/blood per rectum
What is a late sign of Intussusception?
Redcurrant jelly stools
What type of mass is palpated in Intussusception?
Sausage-shaped abdominal mass
What age group is commonly affected by Intussusception?
3-12 months
What is the diagnostic investigation for Intussusception?
Ultrasound
What ultrasound sign is observed in Intussusception?
Target sign
What is the definitive first line management for Intussusception?
Pneumatic pressure or saline/contrast enema under fluoroscopic/US guidance respectively
What is the second line management for Intussusception?
Surgical reduction using immediate laparotomy with broad-spectrum antibiotics (clindamycin + gentamicin).
Which age group is predominantly affected by bilious vomiting?
3-6 week old infants
MALES 5:1
What is the characteristic presentation of pyloric stenosis?
- Projectile non-bilious vomiting
- Progressively more forceful over time
- Typically occurs ~30 minutes post-feeding
- Difficulty feeding
o Multiple formula changes - Constipation and dehydration
- Dry mucous membranes
- Decreased wet nappies
- Tachycardia
- Hypochloraemic alkalosis– Due to loss of gastric acid
- Palpable olive-like mass
- Strong appetite
What type of alkalosis is observed in pyloric stenosis?
- Hypochloraemic alkalosis
What type of mass is palpable in pyloric stenosis?
Olive-like mass
What is the definitive management for pyloric stenosis?
Surgical pyloromyotomy (Ramstedt)
- Can be open or laparoscopic
What is the diagnostic investigation for pyloric stenosis?
Ultrasound – Direct visualisation of pyloric muscle and canal.
- Diagnosis is based on the thickness (>3 mm) of the muscle measured on a transverse view and pyloric canal length >15mm.
What is the pre-operative management for pyloric stenosis?
- Pre-operative fluid and electrolyte therapy to correct electrolyte disturbance.
- 0.45% Saline + 1.5x Maintenance rate with 5% dextrose
What is the most common malignancy in children under aged 5?
Nephroblastoma (Wilm’s tumour)
What syndrome is associated with Wilm’s tumour?
Beckwith-Wiedemann Syndrome
What is the clinical presentation for Wilms tumour?
- Abdominal mass (Most common presenting feature)
- Unilateral
- Painless haematuria
- Flank pain
- Anorexia, fever
- Metastases in ~20% of patients (predominantly within the lung).
What is the management for an unexplained abdominal mass in children?
Arrange a paediatric review within 48 hours
What is the diagnostic investigation for Wilm’s tumour?
Surgical excision or biopsy - histological confirmation
What is the initial investigation for a Wilm’s tumour?
Abdominal ultrasound
What is the definitive management for Wilms tumour?
Nephrectomy
What is the leading cause of mortality among preterm infants?
Necrotising enterocolitis
What is the main risk factor for NEC?
IUGR
What is the presentation for NEC?
- Feeding intolerance AND vomiting
- Bile-stained
- Abdominal distension
- Can cause shock Require mechanical ventilation.
- Rectal bleeding
Non-specific systemic findings: Apnoea, respiratory failure, lethargy, or temperature instability.
What characteristic sign is observed in NEC?
Intramural gas - pneumatosis intestinalis
What findings are observed in NEC (XR)?
- Asymmetrical dilated bowel loops
- Bowel wall oedema
- Pneumatosis intestinalis (intramural gas)
- Portal venous gas
- Rigler sign – Air both inside and outside the bowel wall
What is the management for NEC?
Store oral feeding and prescribe broad-spectrum antibiotics. Stop Feed for 7 days in confirmed NEC.
Start parenteral nutrition
What ABx is indicated NEC?
- Ampicillin + Gentamicin + metronidazole.
When does reflux in an infant typically resolve by?
Resolves by 2 years
What is the most common cause of vomiting in infants?
GORD
What are the risk factors for GORD in infants?
Risk factors
* Premature birth
* Parental history of heartburn or acid regurgitation
* Obesity
* Hiatus hernia
* History of congenital diaphragmatic hernia, oesophageal atresia and neurodisability.
What is the presentation of GORD?
- Distressed behaviour shown:
- Excessive crying, crying while feeding, and adopting unusual neck postures (Sandifer syndrome)
- Hoarseness and/or chronic cough
- Single episode of pneumonia
- Pulmonary aspiration
- Unexplained feeding difficulties – refusing to feed, gagging, or choking.
- Faltering growth.
- Oesophagitis Haematemesis, discomfort on feeding or heartburn.
- Vomiting/Regurgitation
- Milky vomits after feeds
- May occur after being laid flat.
What is the first-line therapy for patients with GORD and are breastfed?
1–2-week trial of alginate therapy (Gaviscon).
What is the first line of management for formula-fed infants with GORD?
Review feeding history (reduce the volume of the feeds if excessive for the child’s weight): Total feed = 150 mL/kg body weight over 24 hours. 1–2-week trial of smaller, more frequent feeds
What is the second line for fomulra-fed infants with GORD?
Feed thickeners
What is the third line therapy for GORD in infants?
Consider 1–2-week trial of alginate therapy.
If 1-2 week trial of alginate therapy does not work in GORD, what is indicated next?
4 weeks of PPI – Omeprazole suspension
What is the clinical presentation of ITP?
cutaneous bleeding - petechiae, purpura, and ecchymoses.
Mucosal bleeding - nasal passages, buccal and gingival surfaces.
Bruising
Preceding illness
N.B: There is an absence of systemic symptoms
What investigation findings are consistent with a diagnosis of ITP?
Isolated thrombocytopenia (<100 x 10^9/L)
WCC is normal
What is the first-line management for a patient with ITP?
Self-limiting in 80% children, resolves within 6-8 weeks.
What is the management for severe life-threatening ITP (e.g., intracranial bleeding)?
Intravenous immunoglobulin + platelet transfusion
Antifibrinolytics
Define disseminated intravascular coagulation:
An ACQUIRED syndrome characterised by systemic activation of coagulation
- Haemorrhage and thrombosis.
What is the main cause of DIC in children?
Sepsis - in meninigoccocaemia
Neontal viral infections - Rubella, Herpes, CMV and enterovirus + TORCH infections.
What are the clinical manifestations associated with DIC?
Bleeding (Bleeding from at least three unrelated sites).
* Venepuncture sites and gastrointestinal tract
* Fever and confusion
* Thrombosis – widespread ischaemia or infarction leading to renal failure, liver failure and CNS involvement.
* Purpura fulminans
* Gangrene
* Petechiae, ecchymosis or haematuria
* Circulatory collapse
- Oliguria, hypotension, or tachycardia
What investigations are consistent with the diagnosis of DIC?
Platelet count (<100,000/microL)
Prolonged PT and aPTT
Decreased Factor V and VIII levels
Fibrin formation
* Decreased fibrinogen - low
* D-dimer/fibrin-degradation products.
- Elevated
What is the fibrinogen level in a patient presenting with DIC?
Low
What replacement therapy is indicated in DIC?
Platelet transfusion, FFP an cryoprecipitate transfusions.
What is prescribed in a patient with purpura fulminans due to meningococcal septicaemia?
Protein C concentrates
How many settings must ADHD symptoms of impulsivity and inattention need to occur in for diagnosis?
Two or more settings - including social, familial or educational.
What is the indication of a watchful waiting period in ADHD?
Children with behaviour/inattention problems adversely affecting their life in one setting.
How long is the watchful waiting period in a patient with suspected ADHD?
10 weeks
What is the first-line management for a pre-school aged child (4-6 years) with ADHD?
Parent training in behaviour management
What is the first-line management for a school-aged child (Aged 6-18 years) with ADHD?
methylphenidate or amphetamine + psychoeducation
What is the side effect profile of methylphenidate?
Abdominal pain, nausea, and dyspepsia.
Weight and height - stunted growth
What should be monitored every 6 months in a patient with ADHD managed by methylphenidate?
Height and Weight
What investigation should be performed before initiating methylphenidate?
ECG
What medication should be prescribed in a patient with known tic disorder or stimulant induced tics with ADHD?
Guanfacine or clonidine.
What is the second-line therapy if methylphenidate is unsuccessful in ADHD?
lisdexamfetamine
What is a febrile seizure?
A seizure occurs in a febrile child (>38.0°C) between the ages of 6mo-6 years.
Which age category is most commonly affected by febrile seizures?
6 months to 6 years
How long do febrile seizures typically last?
Approximately 2-3 minutes (<5 minutes)
Which type of seizure is associated with febrile seizures?
Generalised tonic-clonic
- Stiffening followed by rhythmical jerking
-Post-ictal period - drowsiness, irritability or confusion with complete recovery in 1 hour.
What risk factors are associated with febrile seizures?
High fever
Viral infection
Recent immunisation
Family history
Which is the most common causative virus for febrile seizures?
Human herpes simplex virus 6 (HH6) in Roseola.
Management for febrile seizure >5 minutes
Ambulance - call
Seizure lasts >5minutes
(drugs available)→administer one of the below:
* PR diazepam (repeated once after 5 minutes if the seizure hasn’t stopped); OR
* Buccal midazolam
▪ 10 minutes after first dose ongoing seizure,twitching, or another seizure
What is the rescue for febrile convulsions?
Buccal midazolam
Advice during febrile convulsion
Monitor the duration of the seizure; cushion their head and remove harmful objects.
* Do not restrain and check the airway.
There is a 2-6% increased risk of epilepsy,
Management of fever in febrile convulsions
Do not try and cool the child
Regular paracetamol and ibuprofen
Adequate fluid intake
Seek advice if prolonged fever
Definition of a complex seizure
- 15-30 minutes
- Focal seizure
- Repeat seizures within 24 hours
What chromosomal aberration is characterised by Down’s syndrome?
Trisomy 21 - meiotic nondisjunction
What craniofacial appearances are associated with Down’s syndrome?
Microcephaly
Flattened occiput
Flat facial profile
Midface hypoplasia
Upward slanting eyes with epicanthal folds
Brush field spots on the iris
Flat nasal bridge
Small dysplastic ears
Third fontanelle
With ocular abnormalities is associated with Down’s syndrome?
Brush field spots on the iris
What is the presentation of Down’s syndrome?
- Craniofacial appearance:
- Microcephaly, flattened occiput, flat facial profile, midface hypoplasia, upward slanting eyes with epicanthal folds, brush field spots on the iris, flat nasal bridge, small dysplastic ears, third fontanelle.
- Hypotonia (Improves with age)
- Poor Moro reflex
- Short stature
- Small feet, hands, digits
- Wide gap between first and second toes (sandal gap)
- Single palmar crease.
What cardiac abnormalities is associated with Down’s syndrome?
AV Canal defect
VSD
ASD
TOF
PDA
Pulmonary HTN
What gastrointestinal abnormalities is associated with Down’s syndrome?
Duodenal atresia
Hirshprung’s disease
Omphalocele
What joint laxity is associated with Down’s syndrome?
Atlantoaxial instability
What advanced medical co-morbidities is associated with Down’s syndrome?
- Delayed motor milestones
- Learning difficulty
- Short stature
- OSA (50-75%)
- Visual impairment
- Secretory otitis media (75%).
What type of Leukaemia is associated with Down’s syndrome?
ALL
What antenatal testing is performed at 11-13 weeks to detect Down’s syndrome?
Nuchal translucency measurement
- Serum B-HCG - raised
-Pregnancy-associated plasma protein (PAAP-A reduced).
Which antenatal biomarker is reduced in Down’s syndrome?
Pregnancy-associated plasma protein
What is the quadruple diagnostic antenatal test for Down’s syndrome?
AFP, Unconjugated oestriol, HCG, and inhibin A
What is the immediate management plan for Down’s syndrome?
Echocardiogram -ASVD
Genetic counselling
Early intervention programme
- Physiotherapy
-OT
-SALT
Definition of autism
A neurodevelopmental disorder characterised by qualitative impairment in social interaction, and communication.
* Repetitive stereotyped behaviour, interests, and activity.
What are the core symptoms of autism (2)?
CORE SYMPTOM 1: Impaired social communication and interaction
CORE SYMPTOM 2: Restricted and repetitive behaviour, interests, and activities
Stereotyped behaviours
What screening and diagnostic questionnaires are performed for the diagnosis of Autism Spectrum disorder?
Autism diagnostic observational schedule
DISCO
SCQ, CAST, CARS, SRS, ASQ
Define Breath Holding Attacks:
These typically occur in toddlers.
* Provoked by temper, frustration, or strong emotion.
- Cries rigorously for <15 seconds silent
* The screaming toddler holds his or her breath Cyanosis and loss of consciousness.
* Rapid recovery
Which vitamin is deficient in haemorrahgic disease of the newborn?
Vitamin K
Which type of babies are at an increased risk of haemorrhagic disease of the newborn?
Breast-fed babies - poor source of vitamin K
+ Maternal use of anti-epileptic drugs
What is the management for haemorrhagic disease of the newborn?
Once-off Intramuscular injection of vitamin K
What murmur is associated with the following description:
A continuous blowing noise heard below both clavicles
A venous hum
What causes a venous hum?
Turbulent blood flow in the great veins and returns to the heart - a continuous bilateral blowing noise inferior to the clavicles
Where is a venous hum predominantly heard?
Inferior to both clavicles
What is a Still’s murmur?
Low-pitched sound heard at the lower left sternal edge
Where is a Still’s murmur heard?
At the lower left sternal edge
What antibiotic management is prescribed in Scarlet Fever?
10-day cause of an oral penicillin (benzylpenicillin or azithromycin is penicillin allergic).
What is the first line management for Kawasaki disease?
High-dose aspirin and intravenous immunoglobulin
What investigations are necessitated in a patient with Kawasaki disease?
Echocardiogram to detect coronary artery aneurysm
A slapped cheek appearance is associated with what viral exanthem?
Fifth disease - Parvovirus B19 infection - Erythema infectiosum
Define West’s Syndrome:
Infantile spasms - characterised by hypsarrythmia on an EEG
What EEG pattern is observed in infantile spasms?
Hypsarrhythmia
What is the first-line management for infantile spasms?
vigabatrin
What characteristic feature is associated with infantile spasms?
‘salaam’ attacks
What is the first line management for transposition of the great arteries?
Prostaglandin E1 - to maintain the PDA until surgical correction is performed
Name 3 causes of cyanotic congenital heart disease
Tetralogy of Fallot
Transposition of great arteries (TGA
Tricuspid atresia
What is the causative organism for acute epiglotitis?
Haemophilus influenzae type B
What is the management for asymptomatic neonatal hypoglycaemia?
Encourage normal feeding and monitor glucose
What is the threshold for neonatal hypoglycaemia?
<2.6 mmol/L
What are the symptomatic features associated with neonatal hypoglycaemia?
Jitteriness
Irritabile
Tachypnoea
Pallor
+ neuroglycopenic symptoms - poor feeding, weak cry, drowsy, hypotonia, seizures
What is the most common causative organism for early-onset neonatal sepsis?
GBS and Escherichia coli, L. monocytogenes
What is the management for symptomatic hypoglycaemia?
Intravenous infusion of 10% dextrose
What is the inheritance pattern for Tay-Sachs disease?
Autosomal recessive
What are the four features of tetralogy of fallot?
ventricular septal defect (VSD)
right ventricular hypertrophy
right ventricular outflow tract obstruction, pulmonary stenosis
overriding aorta
What are the CXR features in ToF?
Boot shaped heart
What ECG findings are associated with ToF?
Right ventricular hypertrophy
What is the 1st line management for Scarlet fever?
Oral Penicillin V for 10 days
What school exclusion advice is recommended for Scarlet fever?
Return to school 24 hours after commencing ABx
Is a notifiable disease
What is the causative organism for Scarlet Fever?
Streptococcus pyogenes (group A)
What is the most common complication associated with Scarlet Fever?
Otitis media
target sign on ultrasound is consistent with what diagnosis?
Intussusception
What is the diagnostic investigation for Intussusception?
Abdominal ultrasound revealing target sign
What is the definitive management for Intussusception?
Air insufflation under radiographic guidance or barium enema
What investigation is performed as part of the newborn hearing screening programme?
Otoacoustic emissions
What investigation follows an abnormal hearing test at birth?
Auditory brainstem response test
What prophylaxis is prescribed in immunocompromised patients exposed to varicella zoster?
Varicella zoster immunoglobulin
What is the first line management for nocturnal enuresis?
Enuresis alarm and reward systems - star charts (given for agreed behaviour not dry nights)
What is the second line management for nocturnal enuresis if an enuresis alarm is ineffective?
Desmopressin
What is the first step for newborn resucitation?
Dry the baby followed by 5 inflation breaths
Name the childhood syndrome characterised by a small chin, posterior displacement of the tongue and cleft palate.
Pierre-Robin Syndrome
Supravalvular aortic stenosis , short stature, learning difficulties and an extrovert personality is associated with what childhood syndrome
William’s Syndrome
Rocker bottom feet, small chin, overlapping of fingers is associated with what childhood syndrome?
Edward’s syndrome
Which condition is associated with hypospadias?
Cryptorchidism
What is the causative organism for croup?
Parainfluenza virus
What is the management for a patient with Perthes disease <6 years?
Observation
What is the definitive management for SUFE?
In situ screw fixation
What condition is associated with precipitating meconium ileus?
Cystic fibrosis
What is a poor prognostic factor for congenital diaphragmatic hernia?
The presence of the liver in the thoracic cavity
Respiratory rate admission criteria in neonate?
> 60 breaths per minute
What is the first line of management for Hirschprung’s disease?
Rectal washout/bowel irrigation
What is the gold-standard investigation for Hirschprung’s disease?
Rectal biopsy
Which age group is most affected by SUFE?
10-15 years
Which demographic of patients is most affected by SUFE?
10-15 Year olds
Boys
Obese
What is the presentation of SUFE?
Common: Altered gait, and pain.
* Nonradiating, dull, aching pain in the hip, groin, thigh, or knee.
* Loss of internal rotation of the leg in flexion.
Gait
* Trendelenburg’s gait
* Affected leg externally rotated.
- Unable to bear weight on the affected leg.
Define SUFE:
Displacement of the femoral head epiphysis postero-inferiorly
What radiological investigations are performed in SUFE?
Bilateral AP X-rays
Lateral (frog-leg X-rays)
What specific radiological sign is consistent with SUFE?
Klein’s lines do not intersect the femoral head
- Trethowan’s sign
What is the first line management for SUFE?
Immediate (urgent) orthopaedic referral for in situ screw fixation across the growth plate
Define Perthe’s disease:
LCP is an idiopathic osteonecrosis of the hip.
* Avascular necrosis of the femoral head.
What is the peak age incidence of Perthes diseae?
5-8 years
Which sex is most affected by Perthes disease?
5x boys
Presentation of Perthes disease
nsidious onset of hip pain
* Activity-related
* Progressive over weeks
* Pain referred down the anterior hip and medial thigh.
Limp
* Short stature
* Muscle wasting
- Gluteal muscles and quadriceps
Positive roll test
Supine position: Roll the affected extremity into internal and external rotation Guarding.
Stiffness and reduced range of hip movement
* Limited abduction and internal rotation.
N.B: No history of trauma
Bilateral in 10-20%
What is the first line Ix for suspected Perthes disease (+ findings)?
Bilateral AP X-rays: - reveals femoral head collapse and fragmentation
What is the confirmatory diagnostic Ix for Perthe’s disease?
Technetium bone scan
What is the acute management for Perthe’s disease?
Analgesia + supportive (protective pad over tibial tubercule)
What is the definitive management for a patient with Perthe’s disease <5 years of age?
Mobilisation and monitoring
What is the definitive management for Perthe’s disease in patients aged 7-12 years?
Surgical containment - keep femoral head within the acetabulum.
Presentation of transient synovitis
Limited movement
* Limited arch of motion – apparent in abduction and internal rotation.
* Pain on passive movement
* Tenderness on palpation of the hip or groin.
Limp
* Refusal to weight bear
Positive log roll
Most SENSITIVE test for transient synovitis.
* Supine: Involuntary muscle guarding in affected limb.
N.B: Fever is a red flag – consider septic arthritis.
* Urgent specialist assessment in fever.
What is transient synovitis?
Predominantly affects children between 2-12 years with a recent URTI
* Self-limiting inflammatory disorder of the hip; more common in boys.
Management of limp + fever?
Red flag for septic arthritis - urgent specialist assessment using kocher criteria
What are the first line investigations for transient synovitis?
FBC - WCC within normal range (Raised = septic arthritis).
X-ray - Exclude Perthe’s disease (normal in TS)
What is the management for transient synovitis?
Symptomatic relief – ibuprofen, naproxen or paracetamol.
A painful swelling of the growing tibial tuberosity in adolescents is diagnostic of what disease?
Osgood-Schlatter Disease
What is the aetiology of Osgood-Schlatter disease?
Osteochondrosis secondary to repeated avulsion and microtrauma of the apophysis into the patellar tendon insertion.
What is the presentation of Osgood-Schlatter Diseae?
- Gradual onset of pain and swelling of the tibial tubercle.
- Worsening of pain with athletic activity
- Dull ache exacerbated by jumping or climbing stairs.
- Tenderness to touch over tibial tubercle, particularly with restricted knee extension.
What are the radiological findings on lateral x-ray for OSD?
Separation and fragmentation of the upper tibial epiphysis
What is the acute management approach for OSD?
- ICE after exercise (over the tibial tuberosity, 10-15 minutes up to 3 times per day).
- Pain relief: NSAIDs/Paracetamol
- Quadriceps stretching exercises and cross-training with low-impact sports
- Protective knee pads (relieve pain when walking)
- Injections of local anaesthetic mixed with dextrose
How long should ice after exercise be applied over the tibial tuberosity for in OSD?
10 to 15 minutes up to 3 times per day
What specific guided advice referral should be given to patients with OSD?
Victorian Paediatric Orthopaedic Network – Fact sheet + instructions on stretches.
what is the most common causative organism of septic arthritis in children?
Staphylococcus aureus
Causative organism of septic arthritis in SCD patients?
Salmonella
Risk factors for septic arthritis
RhA, osteoarthritis, joint prosthesis, crystal arthritis, chronic disease, immunosuppression.
Presentation of septic arthritis:
- Single joint – Knee, hip, and ankle (~80%).
- Limited range of motion
- Infants will hold their limbs still (pseudoparalysis)/cry
- Erythematous, warm and tender joint
What is the common causative organism of septic arthritis in neonates?
GBS, N. gonorrhoea and gram-negative enteric bacilli.
What are the first line investigations in a patient presenting with a hot, tender, erythematous joint?
Septic screen, - raised crp, esr
FBC - Raised WCC
What is the gold standard investigation and management for septic arthritis?
Joint aspiration of synovial fluid - to identify causative organism for MCS
Radiographic findings for septic arthritis (x4)?
- Capsular swelling, soft tissue swelling
- Widening of the joint space
- Increased opacity within the joint
- Distension of the joint capsule
What criteria is used to screen for septic arthritis in a child?
Kocher criteria
What are the 4 parameters of Kocher’s criteria?
- Fever >38.5
- Non-weight bearing
- Raised ESR
- Raised WCC
What ABx is prescribed in a neonate <3 months with septic arthritis?
IV cefotaxime + amoxicillin
What ABx is prescribed in a child 3 months to <5 years with septic arhritis?
- IV ceftriaxone
- Penicillin allergic – Clindamycin
What ABx is prescribed to patients with septic arthritis (Aged >6 years)?
- IV flucloxacillin
o Allergic - Clindamycin
o MRSA - Vancomycin
o Gram-negative - Cefotaxime
What is the peak incidence age of osteosarcoma?
13-16 years of age - coincides with adolescent growth spurt
- occurs at an earlier age in children - more frequently in black children
What are the risk factors of osteosarcoma?
Risk factors: Radiation therapy, chemotherapy (alkylating agents).
o Syndromes: Gardner Syndrome, Li-Fraumeni, NFT1, Retinoblastoma
Which syndromes are associated with osteosarcoma?
Gardner Syndrome, Li-Fraumeni, NFT1, Retinoblastoma
What are the common sites of osteosarcoma?
Metaphysis of long bones:
1. Distal femur
2. Proximal tibia
3. Proximal humerus
4. Middle and proximal femur
Presentation of osteosarcoma?
- Worsening pain over weeks to months
- More severe at rest and at night.
- Dull, deep, boring, and relentless
- Mass/swelling – Firm, tender and warm to the touch.
- Decreased range of motion of the affected limb
- Rapid metastases to the lungs.
What is the first line investigation in patients with suspected osteosarcoma?
Plain conventional radiograph
Unexplained bone swelling in children and young people (NICE Ix recommendation)?
Urgent direct access X-ray within 48 hours
What are the radiological findings associated with osteosarcoma?
Codman’s triangle - Elevated periosteum
Sunburst appearance - soft tissue calcification
What is Codman’s triangle in osteosarcoma?
Elevated periosteum
What is the confirmatory diagnostic Ix in osteosarcoma?
Bone biopsy - highly pleomorphic spindle cell neoplasm with lace-like appearance
What is the management for low-grade disease at presentation?
Resection and reconstruction
What is the management approach for high-grade non-metastatic disease?
Complete surgical resection of the primary tumour
What is the prognosis of osteosarcoma?
POOR
60% - 5 year survival rate
Definition of Ewing Sarcoma:
A malignant tumour of the bone or soft tissue is characterised by the presence of small, round, blue cells of immunohistochemical evaluation.
- Primitive neuroendocrine tumour (PNET)
- Associated t (11:22) (EWSR1/FLI1) (q24; q12)
Presentation of Ewing Sarcoma:
- Painful soft tissue mass is often present.
- The midshaft of a long bone is usually affected.
- Long bone of arms, legs, chest, skull and trunk.
- Weight loss, fever, and lethargy
- Localised pain or swelling of a few weeks or months’ duration.
What is the radiological finding associated with Ewing Sarcoma?
(Bone destructions with overlying onion-skin layers of periosteal bone formation).
What is the histological appearance of Ewing Sarcoma?
Small round blue cells
What is the definition of DDH?
DDH refers to the abnormal development of the acetabulum and proximal femur and mechanical instability of the hip joint.
- Aetiology: Ligamentous laxity Spontaneous dislocation and reduction of the femoral head.
- Results in: Flattening of the acetabulum, muscle contractures that limit motion and joint capsule tightening.
o Left hip – Affected 3x than the right hip.
Which sex is most affected by DDH?
Female infants are at a higher risk 9:1 ratio
What are the main risk factors for DDH?
Breech presentation (>34 weeks)
Firstborn child
Oligohydramnios
Positive family history
Macrosomia (birth weight >5kg)
Congenital calcaneovulagus foot deformity
What is the Barlow test?
- Attempts to dislocate an articulated femoral head.
What is the Ortolani test for DDH?
- Evaluates the stability of the hips.
o Attempts to relocate a dislocated femoral head.
o Used in infants 3-6 months of age.
o Palpable clunk
What is the Galeazzi sign for DDH?
- Limb-length discrepancy (Galeazzi sign – baby on back, legs together and knees flexed)
what is the diagnostic investigation for DDH?
- Ultrasonography:
- Diagnostic investigation for assessing morphology and stability of the infant’s hip.
- > 4.5 months then X-ray.
What are the indications for a 6 week ultrasound scan to check for DDH?
- Breech presentation at 36/40 weeks (regardless of presentation at delivery)
- Breech delivery (including <36/40)
- Family history of DDH
note: from >6 months = hip x-ray
What are the complications of DDH?
Avascular necrosis
Temporary femoral nerve palsy
What is the first line of management for osteomyelitis?
High dose IV empirical antibiotics - - Flucloxacillin
What is the most common site for osteomyelitis?
Distal femur and proximal tibia.
What disease staging classification is used for osteomyelitis?
Cienry-Mader classification
What are the indicators for NAI?
- Delay in seeking medical help.
- Mechanism inconsistent with injury or developmental stage of child
- Signs of neglect
o Failure to meet basic physical or psychological needs (food, shelter, medical care, and supervision). - Unusual behaviour of child (e.g., withdrawn, overly affectionate with strangers, distress/recurrent nightmares.
- Multiple injurie
- Injuries suggestive of an implement
o Rib fractures
o Fractures in a nonambalant child
o Multiple bruisers in unusual locations
o Shaken baby syndrome.
Irritability
Retinal haemorrhages
Sign of raised intracranial pressure.
What are the three features associated with shaken baby syndrome?
o Shaken baby syndrome.
Irritability
Retinal haemorrhages
Sign of raised intracranial pressure.
What types of bruising should be recognised in suspected NAI?
In shape of a hand, ligature, stick, teeth mark, grip or implement.
What types of fractures are concern for NAI?
Rib or long bone fractures
What physical features should be recognised for NAI?
- Bruising – in shape of a hand, ligature, stick, teeth mark, grip or implement.
o Petechiae (unexplained) – in clusters, similar shape/size, non-bony part (e.g. face, eyes, ears and buttocks); ankles and neck (attempted strangulation). - Bites
- Lacerations, abrasions, or scars
- Burns or scald injuries – glove and stocking.
- Fractures – X-ray of occult fractures.
- Torn frenulum labii superioris.
o Rib fractures. - Intracranial injury
o Under <3 years
o Retinal haemorrhages
o Rib or long bone fractures
o Subdural haemorrhages.
Anogenital warts under what age should warrant further escalation?
Under the age of 13 - suspected sexual abuse
What is a feature of sexual abuse in children?
anogenital warts
What is the first line management for a patient with suspected NAI?
- Admit the child to a place of safety,
- Contact child abuse investigation team (CAIT)
- Contact Social services
Which factor is deficient in Haemophilia A?
Factor VIII
What is the most common causative organism for late-onset neonatal sepsis?
Coagulase-negative Staphylococcus (CoNS)
▪ I.E.Staphylococcusepidermidis
What are the red flag signs for high-risk sepsis in paedaiaitric patients?
Hypotension
Prolonged capillary refill time >5s
Oxygen saturation <92% (requiring oxygen saturation)
Pale/mottled skin or non-blanching purpuric rash
RR>60 breaths per minute
Grunting
AVPU - V, P or U
What is the initial fluid resuscitation infusion rate for paediatric sepsis?
20 mL/kg 0.9% NaCl bolus over 5-10 minutes
What is the preferred ABx of choice for meningococcal sepsis? (Community versus hospital)
Community - IM benzylpenicillin
Hospital - IV cefotaxime
What is the time frame for early onset sepsis?
<72 hours
What is the ABx option for late-onset sepsis (>72 hours) for Coagulase negative staphylococcus aureus?
IV meropenem + amikacin + ampicillin
What are the risk factors for neonatal sepsis?
PROM/PPROM, chorioamnionitis (i.e. fever during labour)
What is the first step for neonatal Resuscitation?
Dry the baby (note the time) and within 30s, assess tone, RR, and HR
Where is HR palpated in neonates?
Femoral , brachial
How many inflation breaths are administered within 60s of neonatal resuscitation?
5 (1:2:3, 2:2:3, 3:2:3, 4:2:3, 5:2:3)
How many 5 inflation breaths should be administered prior to ventilation?
3
What is the ventilation rate in neonates?
15 over 30s
What is the compression to breath ratio in neonates?
3:1
When is the Apgar score assessed?
First minute and 5 minutes post-delivery
What are the parameters of the APGAR score?
Appearance
Pulse
Grimace
Activity Respiration
What is the chromosomal abnormality associated with Patau Syndrome?
Trisomy 13
What are the features associaaited with Patau syndrome?
Microcephaly (and brain defects)
* Microphthalmia (small eyes)
* Other eye defects
* Cleft lip/palate
* Polydactyl
* Omphalocele / Gastroschisis
Trisomy 18 is defined as what chromosomal syndrome?
Edward’s syndrome
What are the clinical features associated with trisomy 18?
LBW
* Small mouth/chin
* Low-set ears
* ‘Rocker-bottom’ feet
* Overlapping fingers
* Intellectual disability
* Cardiac, renal and GI abnormalities
* Omphalocele / Gastroschisis
What are the characteristic features associated with Trisomy 21?
Characteristic facies
* Hypotonia and short neck
* Single palmar crease
* ‘Sandal gap’ on feet
* Short stature
* Upslanting palpebral fissures
* Flat occiput
* Congenital heart defects in 40%
* Omphalocele / Gastroschisis
- Webbed neck
- Trident hairline
- Pectus excavatum
- Short stature
- Pulmonary stenosis
Diagnosis?
Noonan Syndrome
Pulmonary stenosis is associated with what chromosomal syndrome?
Noonan syndrome
What are the clinical features associated with Prader-willi?
Prader-Willi Syndrome
* Hypotonia
* Hyperphagia
* Almond-shaped eyes
* Hypogonadism
* Obesity (in later childhood)
* Epicanthal folds
* Flat nasal bridge + upturned nose
* Learning disability
What are the characteristic features associated with Turner’s syndrome?
Lymphoedema of hands/feet in neonate
* Short stature, spoon-shaped nails
* Wide carrying angle
* Thick or webbed neck
* Infertility
* Bicuspid aortic valve > Aortic coarctation
o ESM over aortic valve
* Delayed puberty
* Hypothyroidism
* Omphalocele / Gastroschisis
What genetic mechanism is assocaited with Prader-Willi Syndrome?
Genetic imprinting - Expression of gene is influenced by the sex of the parent who has transmitted it.
What paternal PWS chromosome is affected in PWS?
chromosome 15
Which type of mutation is associate with Fragile X syndrome?
CGG trinucleotide repeat expansion of the FMR1 gene.
What are the characteristic clinical features associated with Fragile X?
IQ 20-80 (mean 50) – 2nd most common cause of low IQ after Down’s Syndrome
* Macrocephaly, macroorchidism
* Characteristic facies:
o Large, low-set ears
o Long, thin face
* Other – autism, joint laxity, scoliosis
* Complication: Mitral valve prolapse
Which cardiac complication is associated with Fragile X?
Mitral Valve prolapse
Microcephaly, absent philtrum, reduced IQ, and IUGR are associated with what congenital aberration?
Foetal alcohol syndrome
When is Patau and Edward Syndrome diagnosed?
USS analysis during the 2nd trimester - chromosomal analysis from amniocentesis and cffDNA (NIPT)
What is the inheritance pattern assocaited with Noonan’s syndrome?
Autosomal dominant
What are the neonatal complications associated with Turner’s syndrome?
Pyloric stenosis
Coarctation of the aorta
Biscuspid aortic valve - aortic stenosis -ESM murmur
What murmur is associated with Turner’s syndrome?
Ejection systolic murmur secondary to biscspid aortic valve
What is the term used to describe the skin on the back of the neck in Turner’s syndrome?
Cystic hygroma
What is the management of Turner’s syndrome?
Growth hormone replacement therapy - plot growth and height charts
Oestrogen replacement at the time of puberty for the development of secondary sexual characteristics
What is the most common genetic chromsomal pathogenesis for trisomy 21?
Meiotic non-disjunction
What neonatal complications are associated with trisomy 21?
Congenital heart defects - AVSD
Duodenal atresia
Hirschprung’s disease
Omphalocele
What childhood complications are associated with trisomy 21?
Secretory otitis media
Learning difficulty
Short stature
Delayed developmental milestones
OSA
ALL
What are the late-stage complications associated with trisomy 21?
ALL
Hypothyroidism and Coeliac’s disease
Epilepsy
Early-onset Alzheimer’s disease
Joint laxity - screen for atlantoaxial instability
Which congenital heart defect is most commonly associated with Trisomy 21?
ASVD
What defines as a low birth weight baby?
<2.5 kg
Very low birthweight baby?
<1.5kg
Extremely low birthweight baby?
<1 lg
What is the first newborn auditory investigation in neonates?
Evoke otoacoustic emission testing
What is the second line investigation post-failed EOAE?
Automated auditory brainstem repsonse audiometry
What is the preferred hearing modality in >4 year olds?
Pure tone audiometry
Define positional talipes?
Feet remain in the in-utero position due to intrauterine compression
What is the management of talipes equinovarus?
Ponsetti method - plaster casting and bracing
What trisomy is associated with Patau syndrome?
Trisomy 13
Trisomy 18 describes which syndrome?
Edward’s syndrome
What is the prophylaxis for bronchopulmonary dysplasia?
Maternal corticosteroids <34 weeks (consider 34-36 weeks)
What is the first line respiratory support for BPD?
High flow oxygen followed by CPAP
What effect does caffeine citrate have in the management of BPD?
Stimulates respiratory effort
What prophylactic drug for bronchiolitis is prescribed infants with bronchopulmonary dysplasia?
Paliviziumb
What is the first line management for cleft palate?
Refer to the cleft lip and palate MDT team - EARLY REFERRAL
Speech and language therapy input for long-term
Definitive surgical closure
When is the primary closure of the cleft lip done?
3 months
When is the primary closure of the cleft palate occur?
6-12 months
Feeding support for infants with cleft lip and palate?
Dental plates, specially shaped bottles, teats
How is CMV diagnosis made in a newborn?
Urine or saliva PCR testing within the first 2 weeks.
What is the first line drug to management CMV in the newborn?
Oral valgancilovir or IV ganciclovir (if oral not tolerated)
+ Barrier nursing (CMV is shed in the urine and body secretions).
Mode of delivery for CDH?
Elective c-section
Neonatal management of congenital diaphragmatic hernia?
Intubation and ventilation
ECMO - used if pulmonary hypertension is not improving
Wide-bore NG tube - decompress the stomach to prevent vomiting and swelling
Neonatal ICU
When should surgical repair of CDH be performed?
Within 48 to 72 hours
Management of opthalamia neonatorum?
Same-day referral to ophthalmologist.
Topical chloramphenicol eye drops for mild to moderate
Most common cause of opthalamia neonatorum?
Chlamydia
ABx of choice for chlamydia induced opthalamia neonatorum?
Oral erythromycin
Treat partner and mother
Abx choice for gonococcal induced opthalamia neonatorum?
Single dose of parenteral (IV or IM) cefotaxime/ceftriaxone
Treat partner and mother
Complications of Down Syndrome?
Hypothyroidism
Duodenal atresia
Hirschprung’s disease
Coeliac disease
Epilepsy
Atlantoaxial instability
Frequency of TFT investigations for hypothyroidism in Down syndrome?
At birth, 6 months, 1 year and annual surveillance
Which malignant blood disorder is associated with Down syndrome?
ALL
Which charity is used for Down’s syndrome?
Down’s syndrome association
Prophylaxis for Group B streptococcal infection (obstetrics)?
Intrapartum benzylpenicillin (or vancomyin if allergic)
Indications for Group B prophylaxis in mothers?
Previous baby born with invasive group B streptococcal infection
Group B colonisation, bacteriuria, or infection
Are in pre-term labour
Neonatal infection management for Group B streptoccous?
Penicillin (IV benzylpenicillin) and gentamicin
What is the prophylaxis prescribed for haemolytic disease of the newborn to mothers?
Anti-D immunoglobulin to RhD negative non-sensitised mothers at 28 weeks (single dose of 1500 IU)
or two doses of 500 IU at 28 and 34 weeks and delivery
Neonatal management for haemolytic disease of the newborn?
Resus protocol
Initiate phototherapy
Exchange transfusion (if Bilirubin is rising rapidly 8-10 umol/L/hr despite adequate phototherapy; significant anaemia <100 g/L or severe hyperbilirubinaemia)
IVIG for immune haemolysis
HepB virus for HBsAG positive mothers?
Monovalent Hepatitis B vaccine within 24 hours of birth (and at 4 weeks + 1 year)
6 in 1 vaccine at 8,12,16 weeks
Indications for HBIG in neonates?
Maternal HBeAg positive
Maternal anti-Be negative
Maternal HBV DNA ≥1x106 IU/ml
Acute maternal HBV infection during pregnancy
Birthweight <1.5 kg.
Prophylaxis in primary genital herpes mothers (<28 weeks)?
Prophylactic regular aciclovir is given from 36 weeks onwards
Vaginal delivery if asymptomatic and >6 weeks after initial infection
What is the indication for C-section in HSV positive mothers?
Symptomatic presentation
Management for primary genital herpes after 28 weeks gestation?
C-section + acyclovir
What clinical grading is used for HIE?
Sarnat grading - classifies into 3 stages
First line management for HIE?
A-E resuscitation
-Therapeutic hypothermia within neonatal ICU
How does therapeutic hypothermia work?
Active cooling the core temperature of the baby to between 33 and 34 degrees - reduces inflammation and neurone loss following an acute hypoxic injury
Over 72 hours.
Management of listeria monocytogenes infection?
Amoxicillin and gentamicin
Asymmetrical patchy opacities on chest X-ray post-term delivery are associated with what diagnosis in the neonate?
Meconium aspiration
Management of meconium aspiration in normal term infant without history of GBS?
Observation
Management of high-risk meconiun aspiration neonate?
IV ampicilllin and gentamicin
Oxygen and non-invasive ventilation
What is the first line approach for NEC?
Stop feeding and begin TPN for 7 days.
NG tube - used to drain fluid and gas from the gut; monitor hourly aspirates
Broad-spectrum IV antibiotics - cefotaxime and vancomyin
What is the surgical approach for necrotising eneterocolitis?
Laparotomy with resection of the necrosed bowel with either a primary anastomosis or a defunctioning stoma
How is neonatal hypoglycaemia prevented?
Feed baby within 30 minutes; subsequent feeding 2-3 hours.
Management of asymptomatic neonatal hypoglycaemia?
Confirm hypoglycaemia via blood glucose assay.
- Support breastfeeding technique; consider supplement breast milk substitute or IV glucose
Remeasure glucose every 1 hour
Indications for IV glucose infusion in neonatal hypoglycaemia?
Symptomatic
OR
Pre-feed glucose <2 mmol/L
What initial bolus of glucose should be administered for neonatal hypoglycaemia?
2 ml/Kg of 10% glucose infusion
Management for neonatal hypoglycaemia if <1mmol/L
1st line - buccal glucose gel
arrange IV glucose infusion (2 ml/Kg 10% glucose bolus)
Which non-invasive screening test is performed for low-risk neonates of jaundice?
Transcutaneous bilirubin
First line investigation for pathological jaundice?
Serum bilirubin (<24 hours of age onset or born <35 weeks)
Management of physiological jaundice?
Reassurance
Management of unconjugated pathological jaundice (1st line)
Phototherapy
What investigation determines the indication for phototherapy in pathological jaundice?
Serum bilirubin threshold (between lower blue and upper red line)
Second line management for pathological jaundice following phototherapy?
Intensified phototherapy and adjuncts (IVIG)
First line management for severe (above upper red line) pathological neonatal jaundice?
Exchange transfusion
Common cause of pathological CONJUGATED jaundice?
Biliary atresia
Protective precautions for phototherapy?
Eye protection
What resources are available for neonatal jaundice?
NHS choices neonatal jaundice factsheet
The breastfeeding network
Bliss (for premature and sick babies)
Management for persistent pulomnary hypertension of the newborn?
Oxygen
Ventilation
Surfactant
Suction of secretions from ETT
Inhaled nitric oxide
Management for small pneumothorax in neonate?
Close observation and 100% oxygen for 1-2 hours to wash out nitrogen
Consider needle decompression
Management for tension pneumothorax?
Chest drain insertion
What prophylaxis is prescribed to mitigate the risk of respiratory distress syndrome in neonates?
Antenatal corticosteroids - increases foetal lung maturation
Management of toxoplasmosis in the newborn?
Refer to paediatric infectious diseases
-Pyrimethamine + Sulfadiazine + Folinic acid
Continue all 3 for 1 year
Management for active chorioretinitis in toxoplasmosis?
Prednisolone
Follow-up investigations for asymptomatic toxoplasmosis newborns with positive serology?
Ophthalmology and audiology assessment
Management for Type A Transoesophageal fistula?
Stabilisation and gastrostomy + replacement
Management for type B/D Transoesophageal fistula?
Suction catheter and surgical correction
Management for type E Transoesophageal fistula?
NBM and surgical division of the fistula
Management for transient tachypnoea of the newborn if the respiratory rate is 60-80 breaths/minute?
Nutritional support - NGT or TPN
Indication for TPN/NGT in transient tachypnoea of the newborn?
Respiratory rate 60-80 breaths/minute
What is the gold-standard investigation for aortic stenosis?
Echocardiogram
What is the definitive management for aortic stenosis?
Percutaneous balloon aortic valvuloplasty
OR
Transcatheter aortic valve replacement (TAVR) or surgical valvotomy
What are the three main types of atrial septal defect?
- Ostium secondum - septum secondum fails to completely close
- Patent foramen ovale
- Ostium primum
Which is the commonest ASD observed?
Ostium secondum
Which murmur is auscultated in ASD?
Mid-systolic, crescendo-descrescendo murmur loudest at the upper left sternal border with fixed splitting of the second heart sound.
Management for ASD (ostium secondum)?
Transcatheter closure after 2 years. of age in asymptomatic patients
Definitive management for ostium primum ASD?
Open heart surgery
Indications for surgical closure in ASD?
Right heart enlargement
Symptomatic pulmonary over circulation
Evidence of substantial left-to-right shunting (ratio of pulmonary to systematic blood flow >1.5)
Commonest site of coarctation of the aorta?
Distal to the left subclavian artery - at the origin of the ductus arteriosus
What is the first line management for coarctation of the aorta?
Prostaglandin E1 infusion - to maintain duct patency
What is the definitive surgical repair coarctation of the aorta?
End-to-end anastomosis or arch reconstruction or bypass graft
What are the three main causes of congenital cyanotic heart disease?
- Tetralogy of Fallot
- Transposition of the great arteries
- Tricuspid atresia
Drug to maintain duct patency?
Prostaglandin E1 infusion
Drugs to reduce preload in heart failure?
Diuretics Furosemide
Venous dilators - Nitroglycerin
Drugs to enhance cardiac contractility in heart failure?
Using IV agents (e.g., dopamine)
Other options - dobutamine, digoxin, adrenaline
Drugs to reduce afterload in heart failure?
Oral ACE inhibitors
IV agents (e.g., hydralazine, nitroprusside, alprostadil)
Drugs to improve oxygen delivery
Beta-blockers (e.g., carvedilol)
Initial empirical therapy for infective endocarditis in native valves?
Beta-lactams +/- low-dose gentamicin
low-dose gentamicin + vancomycin
Complications of PDA?
Bacterial endocarditis
Pulmonary vascular disease
Management of PDA
IV indomethacin - 1st line
What class of drug is indomethacin
Prostacyclin synthetase inhibitor
Surgical options for PDA
Surgical ligation or percutaneous catheter device closure
Management for moderate to severe pulmonary stenosis
Transcatheter balloon dilatation
Surgical valvuloplasty (2nd line)
Rheumatic fever prophylaxis?
Benzathine penicillin every 3-4 weeks
Which type of antibiotics indicated for rheumatic fever?
Anti-streptococcal antibiotics - benzathine penicillin, benzylpenicillin, amoxicillin, penicillin V
Drug management for Rheumatic fever?
NSAIDs (naproxen/ibuprofen)
Anti-streptococcal antibiotics
Criteria for diagnosis of Rheumatic fever?
Jones criteria
Management of symptomatic heart failure in rheumatic fever?
ACE inhibitors and diuretics
1st line management for SVT?
Vagal manoeuvres
2nd line for SVT?
Adenosine
3rd line for SVT?
DC cardioversion, amiodarone, procainamide, flecainide
ToF management shunting device?
Blalock-Taussig Shunt - artificial tube between subclavian artery and pulmonary artery
1st line management for worsening/severe ToF?
Prostaglandin E1 infusion
Blalock-Taussing Shunt
Definitive surgical management for ToF?
Total surgical repair by open heart surgery - performed from 4 months of age onwards
What determines the severity of ToF?
Right ventricular outflow tract obstruction
What are the complications associated with ToF?
Hypercyanotic ‘Tet’ spells - intermittent symptomatic periods when the right-to-left shunt worsens due to increased pulmonary vascualr resistance.
Management of Tet spells?
Place the patient in the knee-to-chest position
Supplementary oxygen
IV fluids
Beta-blockers
Morphine
Sodium bicarbonate
Phenylphrine infusion
Admission criteria for acute otitis media?
Severe systemic infection
Complications e.g. meningitis, mastoiditis, facial nerve palsy
Children <3 months with a temperature >38 degrees
Common bacterial cause of otitis media (3)?
Haemophilus influenzae
Streptoccous pneumoniae
Moraxella catarrhalis
Risk factors for acute otitis media?
Daycare attendance, limited or no breastfeeding, tobacco smoke exposure, pacifier use.
Which clinical feature is the best predictor for acute otitis media?
- Ear pain (otalgia) – rapid-onset
What are the complications associated with acute otitis media?
- Perforation with ottohorea
- Acute mastoiditis – Postauricular swelling and protrusion of the auricle.
- Facial nerve palsy
- Vestibular symptoms
- Dizziness, vertigo, balance, and motor problems.
First line investigation for suspected acute otitis media?
Otoscopic examination
Otoscopic findings observed in acute otitis media?
- Moderate to severe bulging of the tympanic membrane, with loss or normal landmarks.
- Obscures the malleus.
- Loss of normal light reflex.
- Perforation of the tympanic membrane
- Purulent discharge
How long does acute otitis media typically last?
3 days to one week - offer symptomatic relief - ibuprofen for pain (oral or rectal) or paracetamol
What is the mainstay management for acute otitis media?
AOM spontaneously resolves within 3 days; provide symptom relief with analgesia
Provide back-up antibiotic prescription
What are the criteria for antibiotic prescription in acute otitis media?
- Otorrhoea, and aged <2 years with bilateral infection.
- Back-up antibiotic prescription – if symptoms do not improve within 3 days or significantly worsen.
- 5–7-day course of amoxicillin (or clarithromycin).
Which antibiotics are prescribed for acute otitis media?
Amoxicillin or clarithryomycmocyin for 5-7 days.
What are the risk factors for glue ear?
Risk factors:
* Palate abnormalities
* Decreased muscle tone.
* Cleft palate – Impaired function of the eustachian tube
* Primary ciliary dyskinesia
* Allergic rhinitis
* Down Syndrome – Mucociliary function impairment.
Acquired: Smoking, exposure to other children, low socioeconomic group, frequent URTIs, bottle feeding.
What is the diagnosis of the following clinical features:
Absent infective signs – the predominant symptom – hearing loss (speech and language delays).
* Mild intermittent ear pain with aural fullness or ‘popping’.
* Aural discharge – foul-smelling (persistent = urgent referral).
* Recurrent acute otitis media infections, URTIs, and rhinorrhoea.
* Paroxysmal sneezing or nasal itching.
* Snoring
Acute otitis media with effusion - Glue ear
What is the characteristic developmental feature assocaiaited with glue ear?
Hearing loss – Failed newborn hearing screen (Auditory brainstem response).
* Conductive hearing loss – mild-to-moderate and fluctuating Communication difficulties, withdrawal and inattention.
What type of hearing loss is observed in glue ear?
Conductive hearing loss
What is the first line investigation for glue ear?
Pneumatic otoscopy
What are the findings for glue ear revealed by pneuamamtic otoscopy?
- An effusion can be serous, mucoid, or purulent:
- Loss of light reflex
- Abnormal colour of the drum
- Opacification of the drum
- Air bubbles
- Retracted, concave or indrawn drum.
- No signs of inflammation or discharge.
What are the NICE recommended formal hearing assessment tools for glue ear (2)?
- Auditory brainstem response
- Tympanometry
Monitoring period for glue ear?
3 month period - audiology + speech and language assessment
What is the management for persistent bilateral glue ear and hearing loss?
Hearing aids
What is the surgical management for glue ear?
Myringotomy and insertion of grommets
What are the complications associated with grommets?
Complications associated with Grommets:
* Otorrhoea (Consider ciprofloxacin for 5-7 days).
* Tympanosclerosis
* Perforation
* Fibrosis
* Cholesteatoma
* Bleeding
What high-risk groups are predisposed to severe malaria infection?
Young children (6 to 59 months)
Low birth weight newborns
What is the incubation period for malaria?
12 to 35 days
What are the clinical features of malaria (paediatric)?
- Fever - >39°C, sweats and/or chills – the absence of fever should not remove the suspicion of malaria.
- Headache
- General malaise, lethargy, and fatigue – Somnolence in children
- Anorexia
- Poor feeding
- Sore throat, cough, lower respiratory tract symptoms and respiratory distress
- Confusion
- Hepatomegaly, splenomegaly, and somnolence on examination.
What are the features of complicated malaria in children (6 features)?
- Cerebral malaria – impaired conscious level – GCS <11
- Severe anaemia
- Respiratory distress or acidosis
- Hypoglycaemia (<2.2 mmol/L)
- Prostration (inability to stand or sit)
- Parasitaemia >2% red blood cells parasitised.
What are the prophylactic measures for malaria?
- Malaria chemoprophylaxis
- Precautions against biting insects
- Travel immunisations.
What is the gold-standard investigation for malaria?
Microscopy of thick and thin films with Giemsa staining
What is the management of uncomplicated malaria?
- Artemisinin combination therapy (artemether with lumefantrine or artenimol with piperaquine phosphate).
What is the management of severe malaria?
- Parenteral artesunate then after at least 24 hours of treatment, switch to oral artemisinin combination therapy.
- Supportive care +/i intensive care.
What are the non-falciparum strains of malaria?
Plasmodium vivax and less commonly P. ovale, P. malariae, and P. Knowlesi
What are the main complications associated with malaria?
- AKI – Renal tubular necrosis
- Cerebral malaria – due to severe P. falciparum infection with coma, or coma >30 minutes post-seizure.
- ARDS
- Spontaneous bleeding and coagulopathy
- Severe anaemia – direct red cell lysis
- Sepsis
- Hypoglycaemia
- Metabolic acidosis
- Nephrotic syndrome
- Splenic rupture - seen in P. vivax infection.
What is cerebral malaria defined as?
due to severe P. falciparum infection with coma, or coma >30 minutes post-seizure.
Which malaria strain is associated with splenic rupture?
P. vivax
Which coma scale is used to assess GCS in children too young to talk?
Blantyre Coma scale
2 or less - coma
What are the 7 red-flag features for paediatric sepsis?
- Hypotension
- Prolonged capillary refill time > 5 seconds
- Oxygen needed to maintain saturation >92%
- AVPU = V, P or U
- Pale/mottled or non-blanching (purpuric) rash
- RR >60 min-1 or >5 below normal or grunting.
- Abnormal behaviour*
What RR is a red flag feature?
> 60 breaths per minute
What are the common causative organisms associated with sepsis?
Group B Streptococcus
Listeria monocytogenes
E coli
What are the common causative organism for late ons-et neonatal sepsis?
Coagulase-negative staphylococcus (CoNS)
What are the risk factors associated with neonatal sepsis?
- Premature (<37 weeks) - Approximately 85% of neonatal sepsis.
- Low birth weight (<2.5 kg) – Approximately 80% are low birthweight.
- Evidence of maternal chorioamnionitis
What time period defines early-onset sepsis?
Within 72 hours of birth
What is a significant risk factor for early onset sepsis?
PROM
What is an independent risk factor for neonatal sepsis?
Black ethnicity
What is the presentation for neonatal sepsis?
- Respiratory distress (85%)
- Grunting
- Nasal flaring
- Use of accessory respiratory muscles
- Tachypnoea
- Tachycardia: common but non-specific
- Apnoea (40%)
- Apparent change in mental status/lethargy
- Jaundice
- Seizures
- Poor/reduced feeding
- Abdominal distension
- Vomiting
What is the ABx of choice for GBS infection (neonatal sepsis <72 hours)
IV cefotaxime + amikacin + ampicillin.
What is the antibiotic of choice for late-onset sepsis (>72 hours)?
IV meropenem + amikacin + ampicillin
Which ABx are indicated for meningococcal sepsis?
- IM benzylpenicillin (in the community)
- IV cefotaxime (in hospital)
- Age up to 17 years old
- IV ceftriaxone 80 mg/kg OD (max 4g)
What is the sepsis 6 protocol for neonatal sepsis?
- Give high-flow oxygen
- Obtain IV/IO access and take bloods.
- Blood gas and lactate (FBC, U&E, CRP)
- Blood glucose (treat hypoglycaemia)
- Blood cultures
- Give IV/IO antibiotics.
- Blood cultures
Which virus causes mumps?
paramyxovirus
How is mumps transmitted?
Respiratory droplets, fomites, or saliva.
Incubation period for mumps?
16-18 days
When is the most infectious period for mumps?
1-2 days before onset of symptoms
What is the clinical presentation of mumps?
- Fever
- Headache
- Myalgia
- Fatigue
- Anorexia
- Salivary gland swelling within 48 hours of symptom onset
- Parotitis occurs among children 2-9 years of age.
- Tenderness associated with earache precedes parotid swelling
o Parotid swelling persists for ~10 days. - Epidiymo-orchitis – Affects up to 38% of infected men.
- Dimmish sperm count, mobility, and morphology transiently
- In bilateral orchitis 30-87% risk of infertility.
What is the characteristic clinical feature associated with mumps?
Bilateral parotid swelling
How long does parotid swelling approximately persist for in mumps?
~10 days
What long-term reproductive complication is associated with mumps?
Epidiymo-orchitis - diminished sperm count and infertility
What are the complications associated with mumps?
- Meningitis
- Encephalitis
- Orchitis
- Deafness – Sensorineural hearing loss.
Is mumps a notifiable disease?
Yes - notify HPU
What is the diagnostic investigation to confirm the diagnosis of mumps?
Saliva sample to detect IgM mumps antibody
Which enzyme is raised in parotitis in mumps?
Serum amylase
What is the school exclusion time for mumps?
5 days after the development of parotitis
What is the first line drug therapy for head lice?
Malathion
In preterm infants <32 weeks, what retinal complication is commonly observed?
Retinopathy of prematurity
Which mass is Located in the anterior triangle, usually in the midline and below the hyoid (65% cases) and moves on tongue protrusion?
Thyroglossal cyst
For recurrent vaginal candidiasis, which investigation should be performed to assess for underlying cause?
HbA1C
What investigation is performed for jaundice >24 hours and <2 weeks?
Transcutaneous bilirubin
What investigation is performed for jaundice <24 hours?
Serum bilirubin
Which investigation is performed for jaundice >2 weeks?
Split bilirubin, TFTs and LFTs
What is the major complication of unmanaged pathological jaundice?
Kernicterus
Kernicterus can develop into which type of cerebral palsy?
dyskinetic cerebral palsy
What is the management of pathological jaundice?
Phototherapy + IVIG or exchange transfusion.
Phototherapy works on which type of bilirubin?
Unconjugated bilirubin
When should phototherapy be stopped in the management of jaundice?
Once BR >50 umol/L
What is the threshold for exchange transfusion in term infants?
> 450 total serum bilirubin
What is the threshold for phototherapy in term infants?
350-450 total serum BR
What is the first line immediate management for a patient with Congenital diaphragmatic hernia?
Immedaite ventilation and intubation
When are most CGH detected?
Routine antenatal scans
Once a CDH is detected through antenatal screening what is the next line of management?
Transferred to the specialist neonatal surgical unit – a planned delivery (induction of labour or caesarean section)
What is the definitive management for Congenital Diaphragmatic Hernia?
Delayed surgical repair within 48-72 hours, once the patient is stabilised.
What is type A oesophageal atresia?
- Type A: OA without TOF (6%)
What is type B TOF?
- Type B: OA with a TOF to the proximal oesophageal segment (5%)
What is type C TOF?
- Type C: OA with a TOF to the distal oesophageal segment (84%)
- Mx: Stabilisation and surgical correction.
What is type E TOF?
- Type D: OA with a TOF to the proximal and distal oesophageal segments (~1%).
What is type E TOF?
- Type E: A TOF without OA (H-type fistula) – 4%.
- NBM and surgical division of fistula.
What is the characteristic finding for a patient with TOF?
Respiratory distress with cyanotic episodes + inability to pass a nasogastric tube
What is the first line investigation for TOF?
Chest X-ray
What is the main cause of neonatal respiratory distress syndrome?
Surfactant deficiency
When do type 2 pneumocytes begin secrete surfactant? to
At 20 weeks’ gestation
What is the peak incidence for NRDS?
24-34 weeks’
Which type of pneumocytes secrete surfactant?
Type 2
What is the characteristic radiograph appearance seen in a patient with NRDS?
Ground-glass reticulo-grannular appearance
What is the first line management for NRDS?
A-E - immediate respiratory support with CPAP and high flow oxygen (91-95%)
and exogenous surfactant therapy
Which ABx are used for the management of NRDS?
Benzylpenicillin and gentamicin
Which criteria is used to diagnose ARDS?
Berlin criteria
Which gene is implicated in cystic fibrosis?
Delta f508
What is the inheritance pattern for cystic fibrosis?
Autosomal recessive
What is the neonatal presentation for cystic fibrosis?
Meconium ileus
What is the most common cause of bronchiectasis in a child?
Cystic fibrosis, followed by primary ciliary dyskinesia
What test is performed to diagnose CF at 5 days?
Immunoreactive trypsinogen
What test is used to help diagnose cystic fibrosis?
Sweat chloride test >60 mmol/L
Which drug (not licensed in the UK) is effective in mediating respiratory symptoms in patients >2 years with CF?
Kaftrio
What is the first line management (NICE) for patients with respiratory symptoms associated with cystic fibrosis?
rhDNase (dornase alfa)
Which prophylactic antibiotic is prescribed to CF patients against staph aureus pneumonia?
- Flucloxacillin
What is the common causative pathogen of bronchiectasis in cystic fibrosis patients?
Pseudomonas aeuroginosa
What antibiotics are prescribed to patients with Pseudomonas aeruginosa respiratory tract infections in cystic fibrosis?
ceftrizaide, ciprofloxacin followed by chronic azithromycin therapy
What dietary advice is recommended for patients with cystic fibrosis?
- High-calorie diet
What is the first step for anaphylaxis management?
Call for Help, remove trigger and lie the patient flat
Where should IM adrenaline be prescribed for anaphylaxis?
Anterolateral aspect - middle third of the thigh
What is the first drug prescribed for anaphylaxis management?
IM adrenaline
What dose of adrenaline is given to patients under the age of 6 years to 6 months?
150 micrograms
Adrenaline dose for anaphylaxis in 6-12 years?
300 micrograms
No response to adrenaline after 5 minutes in anaphylaxis, management?
Repeat dose of adrenaline and administer a fluid bolus
Which enzyme is deficient in a patient with hereditary angiodema?
C1 esterase deficiency
What are the three anatomical location affected by hereditary angioedema?
- Cutaneous attacks
- Gastrointestinal attacks
- Upper airway attacks
Episodic wheeze in under 5 years old, diagnosis?
Viral induced wheeze
What term describes a depression at the base of the thorax in asthmatics?
- Harrison’s sulci
What is the diagnostic test for confirming asthma >5 years?
Spirometry testing + bronchodilator reversibility and PEFR variability
Waht pattern is seen on spirometry in a patient with asthma?
Restrictive pattern FEV1/FVC <70%
What pre-post difference value is associated with bronchodilator reversibility in asthma?
12%
What test should be performed if there is diagnostic uncertainty regarding asthma?
Fractional exhaled nitric oxide (>35 ppb = positive test)
What PEFR value - life-threatening asthma?
<33%
PEFR value for severe asthma?
33-50%
What SPO2 value = life-threatening asthma?
<92%
What are the indicators for life-threatening asthma?
Altered consciousness
PEFR <33%
SPO2 <92%
Normal/elevated PaCO2
Exhaustion
hypotesion
Cyanosis
Silent chest
signs of respiratory distress
What is the first-line management for mild-moderate asthma attack?
1 puff every 30-60s, maximum of 10 puffs
Other than salbutamol, what drug should be co-prescribed to patients with acute exacerbation on asthma, following discharge?
Short-course of oral prednisolone for 3-5 days
What should a follow-up be conducted following an acute exacerbation of asthma?
48 hours
What is the first line management for an acute exacerbation of asthma?
Supplemenary oxygen using a venturi face mask or nasal cannula (6 L/minute)
What is the salbutamol dose for acute exacerbation of asthma in <5 years?
5 mg
What is the salbutamol dose for acute exacerbation of asthma in 2-5 years old?
2.5 mg
What is the oxygen flow rate for an acute exacerbation of asthma?
6L/min
What is the maximum number of salbutamol doses for acute exacerbation of asthma?
3 every 20 minutes
What drug is co-prescribed to patients with acute exacerbation of asthma with salbutamol?
- Nebulised ipratropium bromide (250 micrograms) is considered in life-threatening asthma or unresponsive to nebulised salbutamol x2.
What drug is prescribed with ipratropium bromide and salbutamol?
Prednisolone and IV hydrocortisone
If burst therapy fails to work, what is the next line of management?
- IV bolus step – Magnesium sulphate
- IV bolus salbutamol – Monitor ECG
- IV bolus aminophylline – Monitor ECG, infuse slow (arrhythmia).
What is the first line of management for chronic asthma?
SABA PRN
When should asthma management be stepped up from step 1?
More than 3 exacerbations a week
What is step 2 of asthma management?
low-dose inhaled corticosteroid
What is step 3 of asthma management?
Leukotriene receptor antagonist
What is step 4 of asthma management following montelukast?
- Stop LTRA and add a LABA
What is step 5 of asthma management?
- Switch ICS and LABA to a MART regimen with a paediatric low-dose ICS.
What is the diagnostic investigation for laryngomalacia?
- Flexible fibreoptic laryngoscopy
What is the management for mild laryngomalacia?
Observation and reassure; consider GORD therapy
What is the most common cause of bacterial pneumonia in children?
Streptococcus pneumonia
What is the most common cause of bacterial pneumonia in a neonate?
Group B streptococcus
What is the commonest cause of pneumonia in children <2 years?
RSV (influenza).
When is oxygen therapy indicated for a child with pneumonia?
<92% saturations
Define walking pnuemonia
Respiratory symptoms do not interfere with normal activity.
What is the first-line drug for moderate pneumonia in a child?
Amoxicillin (or clarithromycin)
What is the commonest cause of tonisllitis?
Group A streptococcus
What is the CENTOR criteria?
- Tonsillar exudate or swelling
- Age (3-14 yo)
- Tender/swollen anterior lymphadenopathy.
- Absence of cough
- Fever >38C
A score of 2-3 on CENTOR criteria warrants what maangement?
Optional rapid strep testing and/or culture
What is the CENTOR criteria threshold for prescribing antibiotics?
4-5
What is the 1st line investigation for tonsillitis?
Throat culture or a rapid streptococcal antigen test
What drug and course is recommended for tonsilitis?
Phenoxymethylpenicillincilin, 10 days, QDS
Why should amoxicillin be avoided for sore throat?
Can cause widespread maculopapular rash if due to infectious mononucleosis
What indicates are severe recurrent tonsilitis?
Severe recurrent tonsillitis (a frequency of more than 7 episodes/year).
* OR 5 per year for 2 years
* OR 3 per year for 3 years
What is the most common cause of OSA in a child?
- Adenotonsillar hypertrophy , obesity
Which first line investigation scales can be performed to screen OSA?
STOP-bang questionnaire or Epworth Sleepiness Scale.
What is the diagnostic investigation for OSA?
Polysomnography (PSG-overnight) AND/OR referral to a sleep specialist.
What is the first line management fro OSA?
Adenotonsillectomy – to correct the anatomic obstruction causing symptoms – curative approach.
What is the first line management for pneumothorax?
Immediate needle decompression
What is the management for a tension pneumothorax?
Chest drain
Radiograph findings for meconium aspiration syndrome?
patches of collapse and consolidation.
What is the commonest cause of sinusitis in a child?
Viral upper respiratory tract infection – rhinovirus, RSV, parainfluenza, influenza –
What investigation is indicated for sinusitis?
- Anterior rhinoscopy
What is the management for acute sinusitis <10 days?
Self-management - paracetamol OR ibuprofen, nasal saline etc.,
When should you consider high dose nasal corticosteroids for 14 days for children >12 years, for sinusitis?
If symptoms >10 days
When do you consider a back-up prescription of phenoxymethylpenicillin for sinusitis?
If symptoms do not improve within 7 days or rapidly worsen
Most common cause of perennial sinusitis?
House dust mites
Most common cause of seasonal sinusitis?
Pollen
What is the first line test for diagnosing allergic rhinitis?
Skin-prick testing or measuring serum IgE
What is the first line of management for mild allergic rhinitis?
Oral non-sedating antihistamines or intranasal (have a faster onset)
What is the management for moderate to severe allergic rhinitis?
Intranasal corticosteroids and oral antihistamines
When are patients reviewed following treatment for allergic rhinitis?
2-4 weeks
How is oropharyngeal candidiasis diagnosed?
Clinical diagnosis
What is the first line drug for candidiasis in a child (oral)?
Oral miconazole, consider nystatin suspension in a child
What is the common cause of candida diaper dermatitis?
Candida albicans
What is the commonest cause of diaper dermatitis?
Irritant contant dermatitis
Does non-candida diaper dermatitis affect the skin folds?
No (skin-fold sparing)
What is the appearance of candidal diaper dermatitis?
Beefy red papules, satellite papules and superficial pustules – does not spare skin folds.
When should you consider candida in terms of >days?
> 3 days
What is the first line management for non-candida diaper dermatitis?
- Topical barrier and good nappy practice
- Frequent nappy changes: Changed every 2 hours and cleansed the nappy area with warm water, using alcohol-free and fragrance-free wipes.
- Zinc oxide barrier cream
- Nappy free time is advised.
What is the second line management for diaper dermatitis?
Consider nystatin topical or miconazole or low potency corticosteroids for non candida
What is the characteristic presentation of bacterial conjunctivitis?
Purulent discharge
What is the cause of hyperacute bacterial conjunctivitis?
Neisseria
What is the first step in management for suspected Neisseria cojunctivitis?
- Requires immediate ophthalmologic referral.
What is the presentation for hyperacute bacterial conjuntcivitis?
- Characterised by profuse purulent discharge within 12 hours – copious.
- Tenderness to palpation
- Irritation, marked chemosis, lid swelling and tender preauricular adenopathy.
What is the characteristic presentation for viral cojunctivitis?
- Watery conjunctival injection (mucoid discharge)
- Profuse tearing
- Gritty sensation
- Tender pre-auricular lymphadenopathy
- Conjunctival follicles – follicular appearance on the tarsal follicles.
- Bilateral presentation within 24-48 hours
- Petechial subconjunctival haemorrhages
Conjunctival follicles are associated with what type of conjunctivitis?
Viral
What is Hutchinson’s sign in terms of viral herpes?
lesions present at the tip of the nose.
What is the most common bacterial organism in conjunctivitis?
Haemophilus Influenza
Streptococcus pneumoniae
Moraella cararrhalis
What is the most common viral aetiology for viral conjunctivitis?
Adenovirus, enterovirus
What is the first line management for viral conjunctivitis?
Viral conjunctivitis (Resolves within 1-2 weeks)
* Clean with saline/boiled and cooled water
* Cool compresses around the eye area
* Artificial tears or lubricating drops
* Topical antihistamines
- Epinastine ophthalmic (>2 years), azelastine (>3 years), naphazoline (>6).
- First-line adenoviral
First line management for bacterial conjunctivitis?
Self-limiting and resolves within 5-7 days without treatment
By how many days should you wait before prescribing antibiotics in bacterial conjunctivits?
than 3 - four
Which antibiotic is recommended for staph/strep conjunctivitis?
- Chloramphenicol or neomycin
What is the management step for Ophthalmia Neonatorum ?
Immediate same-day referral to an ophthalmologist; chloramphenicol eye drops.
What is the most common cause of opthahlmia neonatorum?
- Chlamydia
What two medications are prescribed for moderate disease allergic conjunctiitis?
Anti-histamines and a mast cell stabiliser e.g. sodium cromoglicate
What is the most common cause for cellulitis?
Streptococcus pyogenes (Group A beta-haemolytic streptococci)
Which classification is used to assess for cellulitis?
ERON classification
What i the first line drug for ERON-I cellulitis?
Oral flucloxacillin
What is the admission management for ERONIII-IV cellulitis?
- Admit + Oral/IV Co-amoxiclav, clindamycin, cefuroxime, or ceftriaxone
What are the common organisms implicated in peri-orbital cellulitis?
Staphylococcus aureus, streptococcus pneumoniae, haemophilus influenzae.
How does orbital cellulitis present?
Proptosis, painful or limited ocular movement with or without reduced visual acuit
What is the next step for suspected orbital cellulitis?
CT or MRTI scan of the orbits and refer
Which antibiotics are prescribed for orbital cellulitis?
High dose ceftriaxone
What is the mot common complication of scarlet fever?
Otitis media
When can a child return to school with Scarlet fever?
24 hours after commencing antibiotics and notify HPU
Which ABx and duration is prescribed for scarlet fever?
Penicillin V for 10 days
Which spots are seen in measels?
Koplik spots
Where does the rash begin for measles?
Rash – cephalocaudal progression (behind the ears, head, neck)
School exclusion for measles duration?
5 days
What are the complications are associated with measles
Otitis Media – Common
Pneumonia – Common cause of mortality
Encephalitis - 1-2 weeks post-onset
Subacute sclerosing panencephalitis - Rare
What spots are seen on the soft palate in rubella?
Forchheimer spots
Rubella duration of exclusion?
5 days
What virus is the cause of Roseola infantum?
Human herpesvirus 6
Which spots are seen in roseola infantum?
- Nagayama spots – papular enanthem on the uvula and soft palate.
What is the common complication for roseola infantum?
Febrile convulsions
What is the characteristic rash seen in erythema infectiosum?
Slapped-cheek
What is the cause of Erythema infectiosum?
Parvovirus b19
Which HPV strains cause anogenital warts?
6 and 11
What is suspected in a child with anogenital warts <13 years?
Sexual abuse - begin safeguarding protocol
What is the first line drug for anorectal genital warts?
Imiquimod (5% cream) and podophyllotoxin (Anti-mitotic agent)
What is the common cause of acute otitis media?
- Haemophilus influenzae
- S pneumoniae
- Moraxella catarrhalis
What clinical sign is the best predictor for acute otitis media?
Ear pain - rapid onset
What are the complications for acute otitis media?
Complications
1. Perforation with ottohorea
2. Acute mastoiditis – Postauricular swelling and protrusion of the auricle.
3. Facial nerve palsy
4. Vestibular symptoms
- Dizziness, vertigo, balance, and motor problems.
What is is seen on examination in acute otitis media?
Investigations
Otoscopic examination: Distinctly red, yellow, or cloudy tympanic membrane.
* Moderate to severe bulging of the tympanic membrane, with loss or normal landmarks.
- Obscures the malleus.
- Loss of normal light reflex.
- Perforation of the tympanic membrane
- Purulent discharge
What is the first line management fora acute otitis media?
- Regular doses of paracetamol or ibuprofen for pain (oral or rectal).
What are the indications for antibiotics for acute otitis media?
- Otorrhoea, and aged <2 years with bilateral infection.
- Back-up antibiotic prescription – if symptoms do not improve within 3 days or significantly worsen.
- 5–7-day course of amoxicillin (or clarithromycin).
What is the pathogenesis of Acute Otitis Media with Effusion (Glue ear)?
Pathogenesis: Persistence of otitis media with effusion (OME) – impaired eustachian tube causing poor aeration of the middle ear.
* Low-grade viral or bacterial infection.
* Adenoidal infection or hypertrophy
* Persistent local inflammatory reaction.
Which syndrome is associated with glue ear?
Down syndrome
What are common acquired factors for Acute Otitis Media with Effusion (Glue ear)?
Smoking
What is the common presentation of Acute Otitis Media with Effusion (Glue ear)?
Hearing loss, mild ear pain, aural discharge, recurrent ear infections, snoring
What type of hearing loss is associated with Acute Otitis Media with Effusion (Glue ear)?
Conductive hearing loss
What is the first line investigation for Acute Otitis Media with Effusion (Glue ear)?
Pneumatic otoscopy
What is the formal assessment for glue ear?
Hearing loss - Auditory brainstem response and tympanometry
What is the monitoring period for glue ear?
Monitor for 3 months with regular follow-up + speech and audiology support
Management for glue ear without hearing loss?
Reassurance and monitor
When are hearing aids recommended for patients with glue ear?
Patients with hearing loss and persistent bilateral OME
What is the surgical management for glue ear?
- Myringotomy and insertion of grommets (ventilation tubes to equalise air pressure – immediate improvement of hearing).
- Advice: Avoid swimming and take care when bathing or washing hair – 2 weeks post-grommet care.
- Grommet will fall out (weeks to months) – eardrum healing.
What is the management for uncomplicated malaria?
- Artemisinin combination therapy
Which type of malaria is associated with splenic rupture?
Vivax
What are the common causes of early onset neonatal sepsis?
- GBS and E. coli, listeria monocytogenes
What are the common causes for late onset neonatal sepsis?
- Coagulase-negative staphylococcus (CoNS) – Late-onset neonatal sepsis
- Staphylococcus epidermis
When is early onset sepsis (duration)?
Within 72 hours of birth
Drug regimen for early onset sepsis?
IV cefotaxime + amikacin + ampicillin.
Drug regimen for late onset sepsis?
IV meropenem + amikacin + ampicillin
What are the indications for intrapartum benzylpenicillin during pregnancy?
- A previous baby with an invasive group B streptococcal infection
- Group B streptococcal colonisation, bacteriuria, or infection in the current pregnancy
- Are in pre-term labour
What is the main cause of toxic shock syndrome?
Methiccillin-suspectible S. aureus
Which toxin is produced by staph aureus in toxic shock syndrome?
TSST-1 exotoxin.
Risk factor for toxic shock syndrome?
Recent tampon use, recent surgery, recent soft tissue/skin infection.
What is a severe subcutaneous infection of chickenpox?
Necrotising fasciitis
Which organism causes necrotising fasciitis?
Group A streptococcus or S. aureus.
What is the management for necrotising fasciitis?
Surgical debridement of necrotic tissue
What is the diagnostic investigation for TB?
Acid-fast bacilli microscopy smear from sputum sample/sputum culture
What screening investigation for latent TB >2 years if recommended?
- Interferon-gamma release assays
Which screening investigation is recommended for latent TB in children <2 years?
- Tuberculin skin test (Mantoux test)
Which screening test for TB is susceptible to prior BCG vaccination?
Mantoux test
What is the drug regimen for tuberculosis?
Rifampicin, isoniazid (for 6 months), pyrazinamide, ethambutol (for first 2 months)
Which TB drug is associated with orange secretions?
- Rifampicin
Which TB drug is administered and causes peripheral neuropathy?
- Isoniazid
Which is co-prescribed with Isoniazid ?
pyridoxine) – Vitamin B6
Which TB drug is associated with gastro-intestinal symptoms, gout and hepatitis?
- Pyrazinamide
What is the complication of ethambutol?
- Optic neuritis.
What are the indications to perform an ultrasound during an acute urinary tract infection in a child?
<6 months (recurrent or atypical)
What are the indications to perform an ultrasound scan within 6 weeks of a UTI in a child?
> 6 months and recurrent
<6 month and typical
Which scan assesses for bladder scarring following a UTI?
DMSA
When is a DMSA scan performed?
4-6 months following an atypical or recurrent UTI in a child <6 months?
Which scan is performed to assess for vesicoureteric reflux?
Micturating urethrogram
What urine dipstick test confirms a UTI?
Positive leucocyte esterase and nitrite
Which is the specific urine dipstick marker for a UTI?
Nitrite
What is the management for a <3 month child with a UTI?
<3 months Admit to Hospital, IV co-amoxiclav, 5-7 days Switch to oral prophylaxis Refer to paediatrician.
What is the management for a child with a UTI >3 months (Upper)?
Consider hospital admission and IV ABx; OR oral ABx – 7-10 days.
What is the management for a >3 month with lower uTI?
Oral ABx (trimethoprim, nitrofurantoin), 3 days.
What are the features for an atypical UTI?
Poor urine flow, abdominal or bladder mass, raised creatinine, septicaemia, failure to respond to treatment within 48 hours, infection with non-E-coli organisms.
What is a sign of upper UTI?
Loin pain and tenderness
Lower UTI is also known as?
Cystitis
CREAM mnemonic for Kawasaki disease criteria?
WARM = Fever for >5 days
* C – Conjunctivitis without exudate
* R – Rash
* E – Edema or erythema of hands or feet followed by desquamation and nail changes (Beau’s lines)
* A – Adenopathy, unilateral, cervical node >1.5 cm
* M – Mucosal erythema, fissures, or crushing of lips or Strawberry tongue
What is the route of transmission for hepatitis A?
Faecal-oral route
What is the route of transmission for hepatitis B?
IV drug user - blood products and vertical transmission
What anti-viral is prsecribed to patients with a recent infection of hepatitis C?
Peiginterferon alpha 2b
What are the chronic antiviral treatment modalities for hepatitis C?
- Glecaprevir/Pibrentasvir
- Sofosbuvir/velpatasvir.
What is the immediate management for a newborn born to a hepatitis S Ag positive mother?
immediate monovalent hepatis B vaccine within 24 hours at birth
When should HBig be considered to the neonate when born to a hepb positive mother?
- Maternal HBeAg positive
- Maternal anti-Be negative
- Maternal HBV DNA ≥1x106 IU/ml
- Acute maternal HBV infection during pregnancy
- Birthweight <1.5 kg.
What is the most common cause of meningitis in a neonate?
Streptococcus agalactiae (GBS), Escherichia coli, S. pnuemoniae and listeria monocytogenes.
What is the most common cause of meningitis in a child >3 months <3 years?
Streptococcus pneumoniae
What is the most common cause of meningitis from >3 years to 10 years?
N. meningitides
Define Kernig sign?
Supine position with the hip and knee flexed at 90 degrees – cannot extend the knee more than 135 degrees.
Which sign is demonstrated by this?
‘Supine position, flexes the lower extremities during attempted passive flexion of the neck’
- Brudzinski sign
What is Cushing’s triad?
High blood pressure
Low heart rate
Irregular respiratory rate
What is the first line drug for suspected meningitis in the community?
IM benzylpenicillin
What is the antibiotic treatment for a child <3 months with meningitis?
o IV cefotaxime AND IV amoxicillin/ampicillin.
What is the antibiotic treatment for a child >3 months with meningitis?
o IV Ceftriaxone
When should you prescribe steroids in meningitis?
Steroids (dexamethasone) if CSF shows:
* Purulent CSF, WBC >1,000 U/L, Raised CSF WCC + protein >1g/L, bacteria gram stain, >1m old & HiB.
* NON-MENINGOCOCCAL.
* Do not prescribe dexamethasone if <3 months.
What drug is prescribed as prophylaxis to manage patients with meningitis?
ciprofloxacin
What are the most common causes for viral meningitis?
- Coxsackie Group B, Echovirus
What antigen is used by influenza to enter into a host cell?
Haemagglutinin
Which surface antigen for influenza is used to leave a host cell?
neuraminidase
When should an anti-viral be prescribed in a child with influenza?
Within 48 hours of onset and offered to reduce the duration of symptoms to high risk patients
Which is a common neuraminidase inhibitor?
oseltamivir
How long should a child be excluded from school for with influenza?
1 week
What are at risks for influenza?
- Children <6 months
- Asthma, cystic fibrosis
- Previous admission for lower respiratory tract disease
What respiratory complication is associated with infleunza?
Secondary pneumonia by staph aureus
What virus is the most common cause of encephalitis?
HSV type 1
What is the gold standard investigation for confirming encephalitis?
Lumbar puncture
What is seen on lumbar puncture in a encephalitis?
- CSF pleocytosis (present in 60-80%): Lymphocytic predominance.
- Absent red blood cells
- Protein-CSF protein normal or moderately elevated
- Glucose normal
What is the first line management for a child with encephalitis?
All suspected cases of encephalitis Admitted and treated as an emergency (A-E approach).
1st line: Empirical IV acyclovir (age-dependent dose).
- Consider empirical antibiotics (vancomycin, cefotaxime) for suspected bacterial origin.
NOTE: For HSV-1/2 – High dose acyclovir for 2-3 weeks, as relapses may occur.
* Varicella zoster – Acyclovir or ganciclovir.
* CMV – Ganciclovir + foscarnet – 2-3 weeks.
When is chickenpox most infectious?
From 24 hours before the rash appears until the vesicles are dry or have crusted over ~5 days
What are the complications associated with varicella zoster infection following NSAID use?
- Secondary infections – bacterial pneumonia (superinfection) – if using NSAIDs (increased risk of necrotising fascititis).
Where does the varicella zoster virus persist?
Sensory nerve root ganglia - reactivtion - shingles
What is the first line symptomatic management for a patient with chickenpox?
- Topical calamine lotion to alleviate itch.
- Chlorphenamine for treating itching - >1 years.
What is the management for severe chickenpox?
Oral acyclovir 700 mg 5 times a day for 7 days
Which parasite causes scabies?
Sarcoptes scabiei
How is scabies transmitted?
Skin to skin contact
what are the risk factors for crusted scabies?
Crusted scabies (due to attenuated immune response):
* People with HIV, lymphoma, or long-term corticosteroid treatment.
* Reduced ability to scratch.
* Learning difficulties e.g., Down’s syndrome, dementia.
What are the common sites that are affected in patients with scabies?
Webs of the fingers, wrists, axillae, areolae, and genitalia.
What is the presentation for classical scabies?
severe and worse at night (delayed-type IV hypersensitivity reaction to the mite, mite faeces and mite eggs) – begin 3-6 weeks after primary infestation.
What type of hypersensitivity reaction is associated with scabies?
Type IV hypersensitivity
What are the examination findings associated with scabies?
serpiginous lines
What is the pathognomonic sign for scabies?
burrows
What is the definitive diagnosis for scabies?
Confirmed through the detection of scabies mite, eggs, or faecal pellets (scybala) + Dermoscopy.
OR ink burrow test
What is the first line drug for the management of scabies?
5% permethrin cream
What is the management used to treat post-scabietic itch?
Crotamiton 10% cream
What are the complications associated with scabie?
- Secondary staphylococcal or streptococcal infections – impetigo, ecthyma, paronychia and furunculosis.
- Secondary eczematisation due to scratching.
- Nodular scabies – Pruritic nodules of the axillae, groin and male genitalia can persist for weeks or months following treatment due to a prolonged immune response to mite antigens.
What is the cause for infectious mononucleosis?
Epstein–Barr virus (HHV-4)
How is glandular fever transmitted?
Contact with saliva
What is the peak incidence for glandular fever?
15 and 24 years
What is the triad of infectious mononucleosis?
Fever
Tonsillar pharyngitis
Severe sore throat characterised by whitewash tonsillar exudate
Lymphadenopathy
What organomegaly is a major concern associated with infectious mononucleosis?
Splenomegaly - risk of splenic rupture
What is the diagnostic test for a patient with IM <12 years?
EBV serology
What is the diagnostic test for glandular fever in children >12 years?
- FBC with differential white cell count AND monospot test (heterophile antibodies) in the second week of illness.
What is the management for glandular fever?
Analgesia (e.g., ibuprofen/paracetamol) – symptoms last ~2-4 weeks.
When is a monospot test performed in glandular fever?
Within the second week of illness
What is the definition for vesicourethral reflux?
VUR – Abnormal retrograde flow of urine from the bladder into the ureter and kidney into the upper urinary tract.
When should a patient with bilateral undescended testes be EXAMINED for?
Reviewed within 24 hours - indicates Klinefelters or genetic cause
What is the cause of hand foot and mouth disease?
Coxsackie A16 virus.
School exclusion protocol for hand foot and mouth disease?
Not required
What are the clinical presentations of Hand foot and mouth disease?
Mild systemic upset: Sore throat, fever
* Mouth or throat pain (dysphagia)
* Oral ulcers
* Followed later by vesicles on the palms and soles of the feet.
Examination findings:
* Oral exanthem – oral lesions are anterior to the faucial pillars – tongue and the buccal mucosa.
- Begins as: Erythematous macules – and progresses as vesicles surrounded by a thin halo of erythema.
What is the first hearing assessment test as part of the newborn hearing screening programme?
Otoacoustic emission test
If the otoacoustic test is abnormal, what is the next investigation?
Auditory brainstem response test
What assessment is performed for a child at 6-9 months regarding hearing?
Distraction test (Requires 2 trained staff).
Which auditory investigation is performed at school entry for children >3 years?
Pure Tone Audiometry
What lateral radiograph sign is seen in croup?
Steeple sign
What is the glucose threshold for neonatal hypoglycaemia?
<2.6 mmol/L
What are the risk factors associated with neonatal hypoglycaemia?
- Preterm birth (< 37 weeks)
- Maternal diabetes mellitus
- Intrauterine growth retardation
- Hypothermia, neonatal sepsis, inborn errors of metabolism, nesidioblastosis, Beckwith-Wiedemann syndrome.
What are the autonomic symptoms associated with neonatal hypoglycaemia?
- Jitteriness
- Irritable
- Tachypnoea
- Pallor
What are neuroglycopenic symptoms associated with neonatal hypoglycaemia?
- Poor feeding/sucking
- Weak cry
- Drowsy
- Hypotonia
- Seizures
What is the prevention for neonatal hypoglycaemia?
Feed baby within 30 minutes of birth
What is the glucose threshold of beginning IV 10% glucose?
<1.5 mmol/L or if there are symptoms
What is the management for a neonate with hypoglycaemia without symptoms?
support breast-feeding technique; offer additional feed if willing and increase the frequency thereafter.
What is the most common type of atrial septal defect?
Secondum ASD (70%)
What is the most second common type of atrial septal defect?
Primum ASD
What are the two main risk factors for ASD?
- Female sex
- Maternal alcohol consumption
Where and which murmur is seen in ASD?
Ejection systolic murmur at the left upper sternal border radiating to the back
What is immediate management for ASD once detected?
Referred to paediatric cardiology for management.
What is the investigation of choice for a patient with ASD?
Echocardiography demonstrating left to right shunting
When is ASD surgical correction usually deferred until?
2 years of age
What are the indications for surgical treatment for a patient with ASD?
Indications for treatment:
Measurement ratio of pulmonary to systemic blood flow (Qp:Qs).
* >1.5
* ASD is large enough to cause right ventricular dilatation.
* Symptomatic: Fatigue, exertional dyspnoea, palpitations, and syncope.
What Qp:Qs ratio indicates management for ASD?
> 1.5
What is the surgical approach for the management of secondum ASD?
Transcatheter approach
What is the surgical approach for primum ASD?
Open heart surgery - direct repair
Which syndrome associated with abnormalities of the hand is associated with ASD?
- Holt-Oram Syndrome
What is the most common type of septal defect?
Ventricular septal defect
Which septal defect is associated with tetralogy of fallot?
VSD
Which chromosomal disorder (4) are associated with VSD?
- Down’s syndrome
- Edward’s syndrome
- Patau syndrome
- Cri-du-chat syndrome
Which murmur and where is associated with VSD?
Loud pan systolic murmur at the lower eft sternal edge
Where does the aorta rise from in TGA?
Aorta arises anteriorly from the right ventricle - hence deoxygenated blood enters into systemic circulation
What radiographic appearance is associated with transposition of the great arteries?
Egg on string’ appearance.
What is the diagnostic investigation that is performed for transposition of the great arteries?
Echocardiography
What drug is the first line management for transposition of the great arteries?
Prostaglandin (Alprostadil, PGE1) infusion (IV 0.05 mcg/kg/minute) to maintain patency of ductus arteriosus
What is the first surgical stage for management of TGA?
- Blalock–Taussig shunt insertion
When is an arterial SWITCH procedure performed in TGA?
Within 2 weeks of life
What is the definitive management for TGA?
Balloon atrial septostomy
What are the four major features of ToF?
- Right ventricular outflow tract obstruction
- Malalignment ventricular septal defect
- Overriding aorta
- Blood flows from both ventricles, entering the aorta. - Concentric RV hypertrophy
The severity of ToF is dictated by what?
right ventricular outflow tract obstruction
What is the main symptomatic complication in infants with ToF?
Tet spells
Which murmur is associated with ToF?
Ejection systolic murmur
What type of shunting is associated with ToF?
Right to left shunting (due to right ventricular outflow tract obstruction)
What is the radiological appearance seen on CXR seen in ToF?
Boot-shaped heart
What is seen on ECG for ToF?
Right ventricular hypertrophy
What is the first line medical therapy for ToF?
- Prostaglandin E1 infusion
Which test is used to diagnose cyanotic heart disease?
hyperoxia test: start 10 minutes 100% oxygen; if SpO2 persistently low = congenital cyanosis heart disease.
What is the DEFINITIVE management for TOF?
Definitive surgery to repair underlying heart defect from 4 months of age onwards.
Coarctation of the aorta is distal to which artery?
left subclavian artery
CoA occurs at the origin of what?
ductus arteriosus
CoA is associated with what (4)?
o Turner’s syndrome
o Bicuspid aortic valve
o Berry aneurysms
o Neurofibromatosis
What systolic feature is observed in coarctation of the aorta?
- Systolic apical click
In infants what is seen with coarctation of the aorta?
- Blood pressure – Lower systolic blood pressure in the lower extremities < Upper extremities.
- Upper extremity hypertension.
- Radio-femoral delay.
and rib notching
What is the diagnostic test for coarctation fo the aorta?
Two-dimensional and Doppler transthoracic echocardiography – Discrete narrowing in the thoracic aorta – pressure gradient across.
Posterior rib notching is seen in which congenital heart disease?
Coarctation of the aorta
What is the definitive surgical management for coarctation of the aorta?
Percutaneous balloon angioplasty with or without stenting or surgical repair (arch reconstruction, end-to-end anastomosis).
Diastolic component with innocent murmur, true or false?
- NO diastolic component
Which type of murmur varies with posture?
Innocent murmurs
A venous humis heard where?
Heard as a continuous blowing noise heard infraclavicular.
What innocent murmur has this description?
Low-pitched sound heard at the lower left sternal edge.
What syndrome is characterised by a switch to right to left shunting?
Eisenmenger Syndrome
Which congenital infection is associated with patent ductus arteriosus?
Rubella infection
PDA is associated with a life-long risk of what?
Bacterial endocarditis
Which type of murmur is associated with patent ductus arteriosus?
Continuous ‘machine-like’ murmur
What is the first-line drug prescribed to neonates with PDA?
indomethacin to neonate.
What class of drug is indomethacin ?
- Prostacyclin synthetase inhibitor
What is the surgical management for PDA?
percutaneous catheter device closure.
What is the first step for neonatal resus?
- Dry/warm/stimulate the baby – Note time/start clock.
Within 60 seconds after drying the babies and assessing colour, tone HR, what should be done for neonetal resus?
5 inflation breaths
Where is HR assessed for a neonate?
Femoral and brachial
Following 5 inflation breaths - what is the next step for neonatal resus?
Ventilate for 30s 15 over 30s
What i the chest compression and ventilation rate for a neonate?
3:1
What is a normal Apgar scale?
> 7
What are the five categories for APGAR?
Appearance, Pulse, Grimace, Activity, Respiration.
When is the APGAR scoring system used?
Used at 1 minute and 5 minutes after delivery and every 5 minutes if remains poor
What is the compression rescue breath rate for a paediatric infant?
15:2
What is the neonatal compression technique?
two thumb or two fingers
What is the commonest cause of rheumatic fever?
Group A streptococcus (GAS) Lancefield group
What are the major manifestations for rheumatic fever?
- Arthritis – Migratory polyarthritis
- Presents within 21 days.
- Carditis and valvulitis
- Mitral regurgitation – pansystolic murmur (Carey–Coombs murmur)
- Sydenham chorea
- Non-rhythmic, involuntary and abrupt movements – present within 1-8 months.
- Subcutaneous nodules
- Painless lesions
- Erythema marginatum
What are the minor manifestations for acute rheumatic fever?
Fever, arthralgia, elevated ESR/CRP and prolonged PR interval (>200 ms) on ECG.
What criteria is used for rheumatic fever?
Jones criteria
What is the medication for acute rheuammatic fevever?
Pen V, or amoxicillin or benzylpenicillin
What is the monthly prophylaxis antibiotic for rheumatic fever?
Monthly injections of benzathine penicillin.
* Until 10 years after the last episode OR until the age of 21 years (OR lifelong if severe valve disease)
What are the prenatal causes of cerebral palsy?
- Prenatal – 80%
- Cortical migration disorders or structural maldevelopment during gestation
- Cerebrovascular haemorrhage or ischaemia
- Rubella, CMV or toxoplasmosis
What are the perinatal causes of cerebral palsy?
- Hypoxic-ischaemic injury before or during delivery
- Neonatal sepsis
- Periventricular leukomalacia
- Birth asphyxia/trauma
What are the postnatal causes for cerebral palsy?
- Meningitis/encephalitis/encephalopathy
- Head trauma from NAI
What is the limit age for walking unsupported?
18 months
What is the most common type of cerebral palsy?
Spastic cerebral palsy
What is the site of injury for spastic cerebral palsy?
Pyramidal or corticospinal tract
For diplegic cerebral palsy what body part is affected the most?
Legs
Dyskinetic cerebral palsy affects which structure of the brain?
Basal ganglia and the substantia nigra
What are the common causes of dyskinetic cerebral palsy?
HIE or kernicterus
What type of cerebral palsy is associated with chorea?
Dyskinetic cerebral palsy
What is the characteristic features of dyskinetic cerebral palsy>
- Athetoid movements and oro-motor problems.
o Causes: HIE or kernicterus.
o Variable muscle tone predominated by primitive motor reflexes.
o Chorea – Irregular, sudden, brief non-repetitive movements.
o Athetosis Slow, writhing movements distally Fanning fingers
o Dystonia
Which drug is prescribed to manage stiffness in a patient with CP?
Diazepam, baclofen
What disability charity is used for CP?
SCOPE disability charity
what staging is used to stage HIE?
Sarant staging
What is is grade 1 HIE?
- Grade 1 (mild): Irritability, responds excessively to stimulation – staring of the eyes, and hyperventilation.
- Complete recovery can be expected.
What is grade 2 HIE?
- Grade 2 (Moderate): Marked abnormalities of movement, hypotonia, cannot feed as cannot suck, brief apnoea’s, seizures.
- Good prognostic indicator: Complete recovery by 2 weeks of age.
what is grade 3 HIE?
- Grade 3 (Severe): No normal spontaneous movements or response to pain, hypotonic, prolonged, and refractory seizures + multi-organ failure.
What intervention can be done to reduce the progression of HIE to cerebral palsy?
Therapeutic hypothermia
Which is the most common type of paediatric brain tumour?
Pilocytic astrocytoma
Pilocytic astrocytoma on histology shows what type of fibres?
Rosenthal fibres
What is the second most common brain tumour type?
Medulloblastoma
What risk factors are there for brain tumours?
- Personal or family history of a brain tumour, leukaemia, sarcoma
- Prior therapeutic CNS irradiation
- Neurofibromatosis 1 and 2
- Tuberous sclerosis 1 and 2
- Von Hippel-Lindau syndrome
Which type of cell is associated with pilocytic astrocytoma?
Piloid hairy cell
Which mutation is commonly implicated in pilocytic astrocytoma?
BRAF mutation
What focal signs are associated with supratentorial brain tumours?
Focal neurological deficits, seizures, personality change.
What focal signs are associated with subtentorial brain tumours?
Cerebellar ataxia, long tract signs, cranial nerve palsies
What is the investigation of choice for brain tumours?
Brain MRI
What is the definitive management for brain tumours?
Maximal safe resection
What the most common intra-ocular malignancy?
Retinoblastoma
What is the average age of diagnosis for Retinoblastoma ?
18 months
Which gene is implicated for Retinoblastoma ?
RB1 on chromosome 13
What is the inheritance pattern for Retinoblastoma ?
Autosomal dominant
What ocular sign is seen in retinoblatoma?
- Leukocoria (<3 years)
- White reflex or white pupil
What is the diagnostic investigation for retinoblastoma?
Fundoscopy and examination under anaesthesia
Dilated fundus examination with 360-degree scleral depression to identify peripheral tumours.
* White-grey retinal mass
* Retinal detachment with retinal vessels behind the lens
What is the first step of management for a patient with suspected retinoblastoma?
Consider an urgent referral within 2 weeks for assessment
What is the first line management for retinoblastoma with gross vitreous seeding?
Enucleation
What is the management for retinoblasatoma in a child without vitreous seeding?
Systemic chemotherapy
What EEG pattern is characteristic for West syndrome?
Hypsarrhythmia
What is the age of onset for infantile spasms?
- Age of onset – 3 and 12 months.
What are the risk factors for infantile spasms?
Tuberous sclerosis (ash-leaf macules), brain malformation, intraventricular haemorrhage, intrauterine infection.
What is the characteristic feature of infantile spasms?
o ‘Salaam attacks’
When do infantile spams occur the most?
With waking or before sleeping
Which drug is used to manage West Syndrome?
- Vigabatrin
What is seen on EEG for benign rolandic seizures?
centrotemporal spikes
Benign rolandic seizures affect which cortex?
perisylvian sensorimotor cortex
Which seizure is associated with sleep, hypersalivation and drooling?
Benign Rolandic Seizures
What is required for a diagnosis of epilepsy?
- At least two unprovoked seizures occurring more than 24 hours apart.
What type of seizure is associated with a Jacksonian march?
Focal motor seizures
Which type of seizure is associated with a sudden profound impairment of consciousness for ~5-10 s?
Absence
Which seizure is this * Patients fall unconscious.
* Violent muscle contractions and shaking
* Eye may roll back, tongue biting, incontinence.
Tonic-clonic
Which type of seizure occurs after waking up and is associated after puberty?
Juvenile myoclonic epilepsy
Following a seizure, what is the next step?
Referral to a neurologist if 1st (First fit clinic) within 2 weeks. Whilst waiting referral, advice:
* How to recognise a seizure, video record future seizures.
* Avoid dangerous activities.
ECG – Identify cardiac-related conditions.
What is the diagnostic test for epilepsy?
Routine EEG
What is the management for generalised tonic clonic seizures for boys?
Sodium valproate
What is the alternative to sodium valproate for the management of tonic clonic seizures?
Lamotrigine
What is the first line drug for focal seizures?
Lamotrigine or levetiracetam as first line.
What is the first line drug for absence seizures?
Ethosuximide
Which drug should be avoided for absence seizures?
(AVOID carbamazepine).
Which drug exacerbates myoclonic seizures?
Lamotrigine
What is the rescue therapy for a prolonged seizure?
Buccal midazolam
What is status epilepticus?
1 Epileptic seizure lasting >5 minutes OR >2 within a 5-minute period without the person returning to normal between them; Or 1 febrile seizure lasting >30 minutes?
What is the first line agent for status epilepticus?
Midazolam buccal or IV lorazepam
Afer 5-10 minutes which drug is given to resolve a Status Epilepticus, despite initial loading dose of benzodiazepine?
IV lorazepam
What is the dose of lorazepam given for Status Epilepticus?
0.1 mg/kg IV infusion
What is the next intervention to terminate Status Epilepticus despite 2 doses of lorazepam?
Levitracetam, phenytoin or phenobarbital
What is the main difference in terms of headache character between tension and migraine?
Non-throbbing headache in TTH
What is the most frequent type of primary headache in a child?
Tension headache
What is the ICD-3 criteria for diagnosing a tension type headache?
At least 10 episodes of headache lasting for 30 minutes to seven days
What is the management for tension type headaches?
simple analgesia
Which type of haemorrhage is associated with non-accidental injury?
Subdural Haemorrhage
On brain imaging, what is seen for a subdural haemorrhage?
Concave
What is the surgical management for a subdural haemorrhage?
- Craniotomy/craniectomy in acute.
- Burr-hole
What is the neurosurgical management for a subarachnoid haemorrhage?
Endovascular clipping and coil embolisation
What predisposes patients to a subarachnoid haemorrhage?
Ruptured saccular aneurysm.
* Arteriovenous malformations/fistulae
What is the inheritance pattern for DMD?
X-linked recessive
Which gene is implicated in DMD?
Dystrophin gene
The deletion of the dystrophin gene in DMD results in the influx of whcih ion within cells?
Calcium influx results in calmodulin breakdown - free radical release - myofibre necrosis
Pseudohypertrophy of the calves = what?
DMD
What is Gower’s sign?
Hand support to push themselves to an upright position.
What serum investigation is raised in duchenne dystrophy?
Serum creatine kinase (CK) level
What is the diagnostic test for DMD?
Genetic analysis: The DMD gene is identified
Which drug forms part of the management of DMD?
Glucocorticoids (prednisolone):
* Improve motor function and pulmonary function.
- Reduce the risk of scoliosis.
Communicating hydrocephalus occurs because of what?
impaired reabsorption of CSF in the subarachnoid space - due to inflammation of the subarachnoid villi
What is the main cause of communicating hydrocephalus?
Meningitis
What is the main cause of non-communicating hydrocephalus?
Obstructive e.g., Aqueduct stenosis, Dandy-walker formation and chiari formation
What is the most common cause of hydrocephalus in a child?
Obstructive - aqueduct stenosis between the 3rd and fourth ventricle
What characteristic sign is seen in hydrocephalus?
Sunset sign - the appearance of the sclera above the iris
What is the definitive management for hydrocephalus?
Ventriculoperitoneal shunt
What investigation is performed to visualise ventriculomegaly in hydrocepahlus?
Cranial Ultrasonography
A throbbing primary headache with a bilateral presentation is associated with what?
Migraine
What is the first line symptomatic management for migraines?
Simple analgesia
What is the second line migraines management for migraines?
Nasal triptans
What is the prophylaxis drug for migraines?
- Propranolol OR topiramate
How long should a headache diary be performed for, for migraines?
Minimum of 8 weeks
Which chromosomal syndrome is associated with cleft palate, polydactyly and scalp lesions?
Trisomy 13
Which chromosomal syndrome is associated with low-set ears, micrognathia, rocker bottom feet and overlapping of fingers?
Trisomy 18
Which genetic syndrome is associated with a CGG trinucleotide repeat?
Fragile X
Macrocephaly and macro-orchidism is associated with which genetic disorder?
Fragile x
Pulmonary stenosis, webbed neck and pectus excavatum is associated with what?
Noonan syndrome
What is the inheritance pattern for Noonan syndrome?
Autosomal dominant
Which genetic disorder is associated with micrognathia and glossoptosis and cleft palate?
Pierre–Robin Syndrome
What is the genetic mechanism for Prader Willi syndrome?
Genetic imprinting
Which genetic disorder is associated with epicanthal folders, almond shaped eyes, obesity and learning disablity>
Prader Willi Syndrome
Which syndrome is associated with supravalvular aortic stenosis?
William’s syndrome
Which chromosomal disorder is associated with hypertelorism, feeding difficulties and poor weight gain?
Cri du Chat Syndrome
Which drug can cause a cleft lip/palate?
Folate antagonists e.g., phenytoin, sodium valproate, carbmazepine,
What maternal environmental factor can result in cleft lip/palate?
- Foetal alcohol syndrome
- Cigarette smoking
When is the primary closure of the cleft lip peformed?
3 months
When is the primary closure of cleft palate?
6-12 months
Which neurological disorder is associated with ‘Waiter’s tip sign’?
Erbs’s palsy
Erb’s palsy involves which cervical spinal nerves?
C5 -C6
What is the most common cause associated with ERB’s palsy?
Shoulder dystocia and macrosomia
What is the characteristic sign seen in Erb’s palsy?
Waiter’s tip sign
What is the medical management for treating contractures in Erb’s palsy?
Botulinum toxin
What are the indications for an immediate CT head in a child within 1 hour of a risk factor?
NAI
post-traumatic seizure
GCS <14
Open or depressed skull injury or tense fontanelle
Sign of basal skull fracture e..g, panda eyes, csf leakage, or battle sign
For children <1 with a bruise or laceration >5 cm
Focal neurological deficit
Which factors indicate a need for a minimum of 4 hour observation following head injury?
Witnessed loss of consciousness >5 minutes
Abnormal drowsiness
Dangerous mechanism of injury, fall of >3 m
Amnesia
3 or more episodes of vomiting
What is the histology of neuroblastoma?
Small round pale blue cells - Homer-wright Pseudorosettes
What is the characteristic sympathetic nervous system sign of neuroblastoma?
- Horner syndrome (triad of ptosis, miosis, and anhidrosis) – involvement of superior cervical ganglia.
- Spinal cord compression
- Paraplegia
What is the investigation for suspected neuroblastoma?
- HVA and VMA
What is the inheritance pattern for tuberous sclerosis?
Autosomal dominant
Which gene is implicated in tuberous sclerosis?
TSC1 or TSC2, encodes for hamartin and tuberin
What is the characteristic features of tuberous sclerosis in infancy?
eizures, hypomelanotic macules, and cardiac rhabdomyoma.
What is Shagreen patch associated with?
Tuberous sclerosis
What are Ash-leaf shaped macules and angiofibromas associated with?
Tuberous sclerosis
What are the major diagnostic for tuberous sclerosis?
- Angiofibromas (≥3) or fibrous cephalic plaque
- Hypomelanotic macules (≥3 lesions, each ≥5 mm in diameter); Ash leaf-shaped white macules.
- Shagreen patch.
- Subependymal nodules
- Subependymal giant cell tumour
- Retinal nodular hamartomas
- Cardiac rhabdomyoma
- Lymphangiomyomatosis
- Renal angiomyolipomas (≥2)
- Nontraumatic ungual or periungal fibroma
- Cortical dysplasias
What is the Vogt diagnostic triad for tuberous sclerosis?
Seizures
Intellectual disability
Facial angiofibromas
Which autosomal disorder is characterised by cafe au lait spots?
Neurofibromatosis Type 1
Which optic manifestations are associated with Neurofibromatosis Type 1?
Lisch nodules
Optic pathway glioma
Which disorder is associated with peripheral precocious puberty?
McCune–Albright syndrome
What is the triad of McCune–Albright syndrome?
Polyosotic fibrous dysplasia
Cafe aut lait macules
Endocrine hyperactivity
What is the management of McCune–Albright syndrome?
Aromatase inhibitors e.g., letrozole to reduce heightened oestrogen exposure
When is nocturnal enuresis not considered normal?
Over the age of 5 years old
What are the risk factors associated with nocturnal enuresis?
Positive family history, male gender (2:1 ratio), developmental delay, constipation, faecal incontinence, day-time urinary incontinence, and behavioural disorder e.g., ADHD, ASD, anxiety, and conduct disorders
What is the first line investigation for a patient presenting with nocturnal enuresis?
Urine dipstick
What is the first line management for nocturnal enuresis?
Dietary and lifestyle advice with positive reward systems + enuresis alarm
How does an enuresis alarm work?
A sensor is typically inserted in the child’s underwear, whereby an alarm is triggered upon exposure to fluid – as such waking the child and prompting them to pass urine in the toilet
Minimum duration for enuresis alarm until desmopressin?
3 months (if complete dryness has not been achieved)
What is the second-line intervention for a patient with nocturnal enuresis?
Low dose of oral desmopressin
What is the management indicated for the short-term resolution of nocturnal enuresis in a child?
Desmopressin
What class of drug is desmopressin?
8-arginine vasopressin
How long should desmopressin be continued for?
3 months followed by a 1-week cessation period to assess for complete dryness
When is desmopressin administered before bedtime?
60 minutes before bed-time
What are the referral criteria for nocturnal enuresis?
Referral to a paediatric urologist or an enuresis-specialist (e.g., developmental-behavioural paediatrician, child psychologist) is indicated in the following circumstances for further evaluation and assessment for underlying causes:
* Daytime incontinence, urgency, holding measures, increased ((≥8 times/day), or decreased (≤3 times/day) voiding frequency.
* Weak stream, use of abdominal pressure, continuous incontinence, micturition in more than one phase.
* Proteinuria, nausea, weight loss, or fatigue
* Behavioural or emotional problems
* Developmental, attentional or learning difficulties
* Excessive thirst, nocturnal polydipsia.
* Refractory enuresis (despite two courses of treatment)
What is the biggest risk factor for sudden infant death syndrome?
Bed-sharing
Name 3 protective factors of sudden infant death syndrome:
- Breastfeeding
- Room sharing (not bed sharing)
- Use of dummies (pacifiers)
What is the characteristic presentation of Rett synrome?
Developmental regression and stereotypic hand movements e.g., wringing, clapping and twisting
What squint term describes eyes turning in?
Esotropia
What is exotropia?
Eyes turning out
Which type of strabismus is most common?
Convergent (esotropia)
What are the two tests to assess for squint?
Hirschberg Test – Corneal Light Reflex Test
Cover Test
What are the major complications associated with strabismus?
Ambylopia
Which benign oedema of the scalp crosses suture lines?
Caput Succedaneum
Which is the commonest risk factor for Caput Succedaneum?
Vacuum-assisted delivery
Caput Succedaneum is an accumulation of fluid above which layer?
Superior to the periosteum
What is the management for Caput Succedaneum?
Observational - self-resolve within 48 hours
Cephalohaematoma occurs when?
Delayed within 1-3 days of birth
Cephalohaematoma occurs between which two layers?
inferior to the periosteum and above the bone
What are the risk factors for Cephalohaematoma?
- A prolonged second stage of labour
- Macrosomia
- Weak or ineffective. Uterine contractions
- Abnormal fetal presentation
- Instrument-assisted deliver
What is the characteristic presentation of Cephalohaematoma?
Does not cross suture lines
What is the management for a subagaleal haemorrhage?
Fresh-frozen plasma to correct hypovolaemia
What is the investigation for an intraventricular haemorrhage?
Transcranial US Doppler Screening
Another term for HSP?
IgA Vasculitis
what is the tetrad of symptoms associated with HSP?
- Palpable purpura
- GI symptoms (colicky abdominal pain, GI bleed)
- Renal disease
- Arthritis/Arthralgia
What is the major triggers for HSP?
URTI
Where is the characteristic appearance of HSP rash (site and location)?
- Palpable purpura
- Lower extremities (palms and soles) and areas subjected to pressure – buttocks.
- Extensor surface
- Urticarial Maculopapular, spares trunk
What are the investigations of choice associated with HSP?
- Urinalysis
What is the management for HSP (normal GFR)?
Oral corticosteroid
* Prednisolone
o IV corticosteroids are recommended in patients with nephrotic-range proteinuria and those with declining renal function.
what is the management for rapidly progressive nephritis?
IV corticosteroids + oral prednisolone + cylcophosphamide
what is the triad of symptoms associated with. haemolytic uraemic syndrome?
Microangiopathic haemolytic anaemia
AKI
Thrombocytopenia
What is the most common causative pathogen implicated in HUS?
Shiga toxin-producing Escherichia coli (STEC) 0157:H7
What is the pro-drome phase associated with HUS?
Precedes the development of HUS by 5 to 10 days.
* Abdominal pain
* Vomiting
* Diarrhoea
- Bloody – E. coli.
What is the peripheral blood smear results associated with HUS?
- Schistocytes and helmet cells
What is the management for atypical HUS?
Eculizumab (A C5 inhibitor monoclonal antibody) – plasma exchange in atypical HUS.
What is the most common cause of nephrotic syndrome in children?
Minimal change disease
What are the three major factors for nephrotic syndrome?
- Nephrotic range proteinuria 40 mg/hr/m2 in a 24-hour urine collection.
- Hypoalbuminaemia
- Oedema
What are the clinical manifestations of minimal change diseae?
- Facial or generalised oedema
- Periorbital – misdiagnosed as asn allergy.
- Age >1 year <8 years.
- Normal BP
- Absence of haematuria
What is the first line investigation for minimal change disease?
Urinalysis with microscopy
- Protein: 3+ to 4+; no significant haematuria
What is seen on renal electron microscopy for minimal change disease?
Podocyte effacement
What is the first line management implicated in nephrotic syndrome?
Prednisolone
Why is there a hypercoagulable state in nephrotic syndrome (what is lost in the urine)?
Anti-thrombin 3
What is the most common cause of nephritic syndrome in a child?
Post-streptococcal glomerulonephritis
Which bacteria is associated with nephritic syndrome?
Group A beta-haemolytic streptococcus.
When does PSGN arise following GAS pharyngitis?
1-3 weeks
What is the characteristic colour of urine for PSGN?
Red cola-coloured
Which antibiotic is prescribed for PSGN?
Phenoxymethylpenicillin
What is the most common causative organism of epidimytis and orchitis?
Neisseria gonorrhoea and chlamydia trachomatis
Which deformity predisposes children to testicular torsion?
Bell-clapper deformity
Which reflex is absent in testicular torsion?
Cremasteric reflex
What is Prehn’s sign in testicular torsion?
Elevation of the testis does not ease the pain.
What is the first line investigation for testicular torsion?
Power/colour Doppler Ultrasound
And immediate scrotal exploration
Which ABx is prescribed in patients with epdidymiytis?
- Ceftriaxone 1g IM single dose PLUS
- Doxycycline
Hypospadias affects what part of the penis?
Abnormal ventral placement of the urethral opening
What is a risk factor associated with hypospadias?
Cryptorchidism
Which type of hypospadias is associated with a more severe presentation?
Penoscrotal
When is surgical correction performed for hypospadias?
3 months
What term describes this:
‘A testis that is not within the scrotum and does not descend spontaneously by four months of age’.
Cryptorchidism
What term describes the following:
Normally descended testes that can be pulled into a suprascrotal position by the cremasteric reflex.
- Retractile testes
Name three main risk factors for cryptorchidism?
- Prematurity = ~30% of premature male infants are born with an undescended testis – the majority (~70%) resolve spontaneously by one year.
- Small gestational weight
- Low birth weight <2.5 kg
Which side is mainly affected by cryptorchidism?
Left side- unilateral presentation
cryptorchidism is associated with which main complication?
Increased risk of testicular cancer
What are the associated conditions associated with cryptorchidism?
Abdominal wall defects (Eagle-Barret syndrome), neural tube defects, cerebral palsy, mixed gonadal dysgenesis, Kallmann syndrome, Klinefelter syndrome, Prader-Willi Syndrome or androgen insensitivity.
What is the management for retractile testicles?
Annual follow-up examination
What is the management for bilateral Cryptorchidism at birth?
24-hour hour referral (ensure child is seen by 6 months)
What is the management for bilateral Cryptorchidism presenting at 6-8 weeks?
2-week referral
When should unilateral Cryptorchidism be re-examined?
Re-examine at 6-8 weeks and 4-5 months - refer to paediatric surgery
Which gender is most affected by indirect inguinal hernias?
boys 3-4 x
Which conditions are associated with indirect inguinal hernias?
Abdominal wall defects (E.g., Eagle-Barret syndrome) and connective tissue defects (e.g., Ehlers-Danlos syndrome).
Highest incidence of indirect inguinal hernia at what age?
1 year
What is the management for inguinal hernias?
Urgent surgical correction (within 2 days if <6 weeks, 2 weeks for under 6 months, and 2 months for under 6 years
Which defect is associated with a full thickness abdominal wall defect with evisceration of the bowel?
Gastroschisis
What is the management for Gastroschisis?
1st line: Cover with transparency occlusive wrap (Delivery = vaginal).
Definitive = Surgical primary closure (within four hours)
Omphalocele is covered by three layers of what?
amnion, Wharton’s jelly and peritoneum
Which midline abdominal wall defect is associated with a three-layer covered?
Omphalocele
What is the first line management for Omphalocele?
Placement of nasogastric tube, IV Abx, and covering the sac with a damp gauze before wrapping the abdomen in clingfilm.
What is the definitive management for omphalocele?
- Definitive = Surgical closure (staged repair over 12 months) – allows the sac to granulate over months.
Mode of delivery for detected omphalocele?
Caesarean section to reduce the risk of sac rupture.
What are the genetic associations with omphalocele?
Trisomy 13 (Patau’s), 18 (Edward’s), 21 (Down’s); Turner’s.
When is congenital hypothyroidism assessed?
newborn Guthrie test at 5 days
What is the most common cause of congenital hypothyroidism?
- Thyroid dysgenesis
What is a cause of transient hypothyroidism?
Transient hypothyroidism – Resolves during the first few months or years of life – due to iodine deficiency.
* Maternal antithyroid drugs (carbimazole) during pregnancy
* Maternal antibiotics (Hashimoto’s)
* Iodine exposure during gestation
* ‘Gland in situ’
What is the management of congenital hypothyroidism?
Oral levothyroxine
What is the complication associated with untreated congenital hypothyriodism?
Short stature (cretinism) and intellectual disability
What is the most common acquired cause of hypothyroidism?
Hashimoto’s autoimmune thyroiditis.
What is the blood glucose threshold for a diagnosis of DKA?
> 11 mmol/L
What is the venous pH threshold for DKA?
<7.3 or bicarbonate <15 mmol/L
What is the level of ketones in the blood for DKA?
> 3 mmol/L
What is Kussmaul respiration?
Deep hyperventilation
- Respiratory compensation for metabolic acidosis
What is the first line management for DKA?
Emergency fluid resuscitation.
What fluid bolus is given for DKA?
- 10 mL/kg of 0.9% NaCl over 60 minutes if NO shock.
What is the fluid deficit calculation for DKA?
[Body weight (kg) x % dehydration x 10] – [Initial bolus if NOT SHOCKED] - Replace over 48 hours.
What is mild dehydration in terms of venous pH and bicarbonate?
<7.2 - 7.29 HCO3 <15
5% dehydration
What is moderate dehydration in terms of venous pH and bicarbonate?
7% dehydration – Venous pH 7.1 – 7.19 or bicarbonate <10 mmol/L
What is severe dehydration in terms of venous pH and bicarbonate?
10% dehydration – Venous pH <7.1 or bicarbonate <5 mmol/L
What is the maintenance requirement in terms of the first 10kg?
100 mL/kg/24 hours
What is the maintenance requirement in terms of the next 10kg?
+ 50 mL/kg/24 hours
What is the maintenance requirement in terms of the >20kg?
+ 20 mL/kg/24 hours
Once plasma glucose drops below 14 mmol/L what type of fluid should be given?
- Change to 0.9% saline + 5% glucose
What is co-administered if potassium is <5.5 in DKA?
40 mmol/L potassium chloride
After fluid therapy is initiated in DKA, what dose of insulin is given?
- 0.05-0.1 units/kg/hour – Soluble insulin infusion
What is the most common cause of delayed puberty in boys?
Constitutional delay
When should you make a faltering growth referral in a child >75th centile?
if it falls by more than 3 centiles
When should you make a faltering growth referral in a child 25-75th centile?
If it falls by more than 2 centiles
When should you make a faltering growth referral in a child <25th centile?
If it falls by more than 1 centile
What is the threshold in terms of age for delayed puberty in boys?
No testicular development (volume <4 mL) by age 14 years.
What is the threshold in terms of age for delayed puberty in girls?
No breast development by age 13 years OR no periods by age 15 years.
What are the features of constitutional delay of growth and puberty?
Low bone age, no puberty signs, no organic causes.
What are the common hypogonadotrophic causes of hypogonadism?
- Hypothalamic-pituitary disorders – panhypopituitarism, intracranial tumours
- Kalman’s syndrome: LHRH deficiency and ANOSMIA)
- Prader–Willi Syndrome.
What are the common hypergonadotrophic causes of hypogonadism?
- Congenital: Cryptorchidism, Klinefelter’s syndrome (47 XXY), Turner’s syndrome (45 XO)
- Acquired – Testicular torsion, chemotherapy, infection (mumps), trauma, autoimmune.
What tool is used to assess testicular volume for boys?
- Prader’s orchidometer
What imaging modality is used to assess bone age?
Wrist X-ray
What is the diagnosis for a ‘girl’ with delayed puberty with bilateral groin swellings?
Androgen insensitivity syndrome
What is the management for constitutional delay of growth and puberty?
Reassurance and offer observation
consider short course sex hormone therapy as second line
What is the course of testosterone that is prescribed for delayed puberty in boys?
Short course IM testosterone or oxandrolone
What is the course of oestrogen that is prescribed for delayed puberty in girls?
- Girls Transdermal oestrogen (6 months) Cyclical progesterone once established.
What is the early puberty range for girls?
- Girls = 8 < age <10
What is the early puberty range for boys?
- Boys = 9 < age <12
What is the threshold age for precocious puberty for girls?
8 years old
What is the threshold age for precocious puberty in boys?
9 years old
What is puberty determined by in girls?
Tanner Breast Development Stages
What is the threshold for testicular volume in boys with precocious puberty?
> 4 mL
What type of precocious puberty is associated with bilateral testicular enlargement?
Gonadotrophin-dependent (intracranial lesion)
What type of precocious puberty is associated with unilateral testicular enlargement?
Gonadal tumour
Which cell in boys produced testosterone?
Leydig cell tumour
What happens to testes size in adrenal related causes of precocious puberty?
Small testes
What is the gold-standard investigation for confirming precocious puberty?
GnRH stimulation test – Suppressed LH/FSH if G-independent.
* FSH, LH low = GIPP
* FSH, LH high = GDPP
What is the management for Gonadotrophin-dependent precocious puberty?
- GnRH agonist (e.g., leuprolide) + GH therapy.
Agonists overstimulate pituitary and arrest GnRH release.
What class of drug is cyproterone?
Anti-androgen
What is the management for McCune Albright syndrome?
1st: Ketoconazole, or cyproterone, 2nd: Aromatase inhibitors.
Name three ACTH-dependent causes of Cushing’s syndrome?
- Cushing disease (pituitary hypersecretion of ACTH) – pituitary adenoma.
- Solitary neoplasm
- Ectopic ACTH (SCLC)
What are the ACTH-independent causes?
- Exogenous administration of glucocorticoids (adrenal glands are atrophic).
- Adrenal hyperplasia/tumours – Common in children.
What is the confirmatory investigation for Cushing’s?
Inferior Petrosal Sinus Sampling
What is the first line management for an adrenal causing Cushing’s?
Adrenal Mass - Adrenalectomy
What syndrome occurs following a bilateral Adrenalectomy ?
Nelson’s Syndrome
Management for ectopic Cushing’s? (drug)
Ketoconazole, metyrapone
Fasting blood glucose threshold for diagnosis of DM?
o Fasting plasma glucose >7.0 mmol/L
What is the threshold for diagnosis of diabetes mellitus on a 2-hour plasma glucose test?
> 11.1 mmol/L
What is the first line management for type 1 diabetes mellitus?
Basal-bolus insulin regimen
What is the first-line drug for T2DM?
Metformin
What class of drug is acarbose?
A-glucosidase inhibitor
What is the threshold for obesity regarding BMI?
> 30
What is the management for infantile Haemangioma?
Medical photography + review in 3 months
What is the management for infantile Haemangioma (near the eyes, nappy area, lips and nasal tip)?
Topical timolol
Which scoring criteria is used for urticaria?
Urticaria Activity Score (USA7)
What is the first line management for urticaria?
Second-generation, non-sedating antihistamines (Cetirizine, fexofenadine) for up to 6 weeks.
What is the main cause of impetigo?
Staphylococcus aureus
Bullous impetigo is caused by which toxins?
exfoliative toxins (A and B)
Which type of impetigo is associated with a characteristic golden crust?
Non-bullous impetigo
Which type of impetigo is associated with large flaccid bullae which rupture?
Bullous impetigo
What is the first line drug for non-bullous impetigo?
o Hydrogen peroxide 1% cream consider topical fusidic acid
What is the second line management for non-bullous impetigo?
offer 5 days of topical fusidic acid 2% or mupirocin 2%
What is the management for bullous impetigo?
o Oral flucloxacillin (or clarithromycin if penicillin allergic)
Which gene is involved with the pathogenesis of atopic dermatitis?
- Filaggrin gene
What is the common affected site for atopic dermatitis?
Face and trunk.
What is the management for eczema herpeticum?
IV acyclovir and immediate referral
Which virus is the commonest cause of eczema herpticum?
HSV-1
What is the characteristic appearance of eczema herpeticum?
punched-out erosions
What is the first line corticosteroid choice for mild eczema?
Topical 1% hydrocortisone
What is the first line corticosteroid choice for moderate eczema?
- 0.025% betamethasone valerate or 0.05% clobetasone butyrate)
What is the management for severe eczema (widespread)?
Occlusive dressings of dry bandages are used in acutely flared or lichenified skin.
What is the second line drug for eczema despite steroid use?
Topical calcineurin inhibitors (tacrolimus).
What 12-week course is indicated for the management of mild to moderate acne?
- Fixed combination of topical adapalene + topical benzoyl peroxide.
OR - Fixed combination of topical tretinoin + topical clindamycin.
- Fixed combination of topical benzoyl peroxide + topical clindamycin.
Management for moderate to severe acne?
- A fixed combination of topical adapalene + topical benzoyl peroxide OD in the evening (together with either oral lymecycline 408 mg or oral doxycycline 100 mg).
- Topical azelaic acid (15% or 20%) for a maximum of 3 months– TDS + oral lymecycline or doxycycline.
Which antibiotic is used to manage moderate to severe eczema?
oral lymecycline 408 mg or oral doxycycline 100 mg
What drug is the management for severe acne?
isotretinoin
When is the first review for acne?
12 weeks
What neonatal birth mark is associated with grey-blue discolouration?
Mongolian spot
What is the management for Mongolion spot?
Commonly fades within 1 year. Lesions on the buttocks typically resolve by 5 years.
What capillary malformation is associated with unilateral pink or red discolouration of the skin?
Port wine stain
Which mutation is associated with port wine stains?
GNAQ mutation
Which syndrome is associated with port wine stain distributed along the trigeminal nerve?
Sturge–Weber Syndrome
What congenital rash is associated with a self-limiting evanescent eruption?
Erythema toxicum
Which neonatal rash is associated with supepidermal keratin cysts?
Milia
What is the cause of molluscum contagiosum?
DNA poxvirus
What is the pathogen implicated for guttate psoriasis?
streptococcus pyogenes
What is the first line management for guttate psoriasis?
Phototherapy
What is the management for congenital melanocytic naevi?
prompt referral to the paediatric dermatologist and plastic surgeon (consideration of excision).
First line management for cradle cap?
Topical emollient
What investigation is used to diagnose ringworm?
Woods light
microscopic examination of the skin scrapings
What is the diagnostic criteria to confirm head lice?
Detection combing: Confirmed by visualisation of live lice on wet or dry hair. - a live louse must be found
What is the first line management for head lice?
Wet combing - four sessions spaced over 2 weeks
When is the 5th detection session for head lice?
day 17
Which lotion is indicated in the management for head lice?
- Dimeticone 4% lotion
When should a child be expected to stand unsupported?
12 months
How many blocks can be stacked by 18 months?
3
What is the moro reflex?
Sudden head drop - Arms outstretched
Average age of onset for palmar grasp?
6 months
Average age of onset for pincer?
10 months
What is the average of onset for head control?
1 month
What is the average age of onset for sitting unsupported?
6-8 months
Age of drawing vertical straight line?
2 years
Age of onset for circle?
3 years
Age of onset for square?
4 years
Age of onset for cross?
3.5 years
Age of onset for crawling?
8-9 months
Age of onset for waling steadily?
12-15 months
Age of onset for transferring toys from one hand to another?
7 months
Age of onset to make a bridge?
3 years
Age of onset for 6 block tower?
2 years
Age of onset to saying dad mama?
9 months
age of onset to saying 2-3 words?
12 months
Age of onset to saying 6-10 words?
18 months
age of onset to responding to name
12 months
Age of onset for 2-word sentences?
2 years
What is the limit age for saying 6 words with meaning?
18 months
Age of onset for smiling?
6 weeks
Age of onset for interactive play?
2.5 to 3 years
What is the threshold for concern for children not being able to walk?
18 months
When can a child kick a ball?
2.5 years
Which 3 vaccines are administered at 2 months?
6 in 1 vaccine
Men B
Rotavirus
Which 3 vaccines are administered at 3 months?
6 in 1 vaccine
Rotavirus
PCV
Which 2 vaccine are administered at 4 months?
6 in 1
Men B
Which 4 vaccines are given at one year?
MMR
Men B booster
PCV
Hib/MenC
When is the HPV vaccine given?
at 12-13 years
When is the Men ACWY given?
14 years
What % of weight loss is normal?
10% of birth weight - restored by 3 weeks of age
