Paediatrics Flashcards
What are the 7 treatment steps for asthma for kids aged 5-16
Step Notes
1: Newly-diagnosed asthma Short-acting beta agonist (SABA)
2: (Not controlled on previous step
OR
Newly-diagnosed asthma with symptoms >= 3 / week or night-time waking)
SABA + paediatric low-dose inhaled corticosteroid (ICS)
3 SABA + paediatric low-dose ICS + leukotriene receptor antagonist (LTRA)
4 SABA + paediatric low-dose ICS + long-acting beta agonist (LABA)
In contrast to the adult guidance, NICE recommend stopping the LTRA at this point if it hasn’t helped
5 SABA + switch ICS/LABA for a maintenance and reliever therapy (MART), that includes a paediatric low-dose ICS
6 SABA + paediatric moderate-dose ICS MART
OR consider changing back to a fixed-dose of a moderate-dose ICS and a separate LABA
7 SABA + one of the following options:
-increase ICS to paediatric high-dose, either as part of a fixed-dose regime or as a MART
-a trial of an additional drug (for example theophylline)
-seeking advice from a healthcare professional with expertise in asthma
Describe the stepwise approach for asthma in children less than 5 years old
1
Newly-diagnosed asthma Short-acting beta agonist (SABA)
2
Not controlled on previous step
OR
Newly-diagnosed asthma with symptoms >= 3 / week or night-time waking SABA + an 8-week trial of paediatric MODERATE-dose inhaled corticosteroid (ICS)
After 8-weeks stop the ICS and monitor the child’s symptoms:
-if symptoms did not resolve during the trial period, review whether an alternative diagnosis is likely
-if symptoms resolved then reoccurred within 4 weeks of stopping ICS treatment, restart the ICS at a paediatric low dose as first-line maintenance therapy
-if symptoms resolved but reoccurred beyond 4 weeks after stopping ICS treatment, repeat the 8‑week trial of a paediatric moderate dose of ICS
3 SABA + paediatric low-dose ICS + leukotriene receptor antagonist (LTRA)
4 Stop the LTRA and refer to an paediatric asthma specialist
How much budesonide is in paediatric low / moderate / high dose ICS inhalers
<= 200 micrograms budesonide or equivalent = paediatric low dose
200 micrograms - 400 micrograms budesonide or equivalent = paediatric moderate dose
> 400 micrograms budesonide or equivalent= paediatric high dose.
Severe asthma attack
-Sp02
-PEF
-HR
-RR
-clinical feature
Severe attack
SpO2 < 92% (unlike in adults, SpO2 < 92% may be consistent with a ‘severe’ attack in children)
PEF 33-50% best or predicted
Too breathless to talk or feed
Heart rate
>125 (>5 years)
>140 (1-5 years)
Respiratory rate
>30 breaths/min (>5 years)
>40 (1-5 years)
Use of accessory neck muscles
What are the features of life-threatening asthma attack in children?
SpO2 <92%
PEF <33% best or predicted
Silent chest
Poor respiratory effort
Agitation
Altered consciousness
Cyanosis
What is the treatment for children with mild-moderate acute asthma exacerbation?
For children with mild to moderate acute asthma:
Bronchodilator therapy
give a beta-2 agonist via a spacer (for a child < 3 years use a close-fitting mask)
give 1 puff every 30-60 seconds up to a maximum of 10 puffs
if symptoms are not controlled repeat beta-2 agonist and refer to hospital
Steroid therapy
should be given to all children with an asthma exacerbation
treatment should be given for 3-5 days
Describe the usual prednisolone dose for children aged:
2-5yrs
>5yrs
Age Dose as per BTS Dose as per cBNF
2 - 5 years 20 mg od 1-2 mg/kg od (max 40mg)
> 5 years 30 - 40 mg od 1-2 mg/kg od (max 40mg)
what are the two different types of preschool wheeze?
Over recent years, led by the European Respiratory Society Task Force, the favoured classification for pre-school wheeze is to divide children into one of two groups;
-episodic viral wheeze: only wheezes when has a viral upper respiratory tract infection (URTI) and is symptom free inbetween episodes
-multiple trigger wheeze: as well as viral URTIs, other factors appear to trigger the wheeze such as exercise, allergens and cigarette smoke
Episodic viral wheeze is not associated with an increased risk of asthma in later life although a proportion of children with multiple trigger wheeze will develop asthma.
What is the management of episodic viral wheeze?
Episodic viral wheeze
-treatment is symptomatic only
-first-line is treatment with short acting beta 2 agonists (e.g. salbutamol) or anticholinergic via a spacer
-next step is intermittent leukotriene receptor antagonist (montelukast), intermittent inhaled corticosteroids, or both
-there is now thought to be little role for oral prednisolone in children who do not require hospital treatment
What is the management of multiple trigger wheeze?
Multiple trigger wheeze
trial of either inhaled corticosteroids or a leukotriene receptor antagonist (montelukast), typically for 4-8 weeks
What is acute epiglottitis in children caused by?
Haemophilus influenzae
Give 5 clinical features of acute epiglottitis in children?
Features
-rapid onset
-high temperature, generally unwell
-stridor
-drooling of saliva
-‘tripod’ position: the patient finds it easier to breathe if they are leaning forward and extending their neck in a seated position
What is the diagnosis of acute epiglottitis in children?
Diagnosis is made by direct visualisation (only by senior/airway trained staff, see below). However, x-rays may be done, particularly if there is concern about a foreign body:
a lateral view in acute epiglottis will show swelling of the epiglottis - the ‘thumb sign’
in contrast, a posterior-anterior view in croup will show subglottic narrowing, commonly called the ‘steeple sign’
What is the management of acute epiglottitis in children?
Management
immediate senior involvement, including those able to provide emergency airway support (e.g. anaesthetics, ENT)
endotracheal intubation may be necessary to protect the airway
if suspected do NOT examine the throat due to the risk of acute airway obstruction
the diagnosis is made by direct visualisation but this should only be done by senior staff who are able to intubate if necessary
oxygen
intravenous antibiotics
What is bronchiolitis?
-who is affected?
-Which maternal abs provide protection against this?
Bronchiolitis is a condition characterised by acute bronchiolar inflammation. Respiratory syncytial virus (RSV) is the pathogen in 75-80% of cases. NICE released guidelines on bronchiolitis in 2015. Please see the link for more details.
Epidemiology
most common cause of a serious lower respiratory tract infection in < 1yr olds (90% are 1-9 months, with a peak incidence of 3-6 months). Maternal IgG provides protection to newborns against RSV
higher incidence in winter
What is the most common cause of RSV?
Give 5 clinical features
Basics
respiratory syncytial virus (RSV) is the pathogen in 75-80% of cases
other causes: mycoplasma, adenoviruses
may be secondary bacterial infection
more serious if bronchopulmonary dysplasia (e.g. Premature), congenital heart disease or cystic fibrosis
Features
-coryzal symptoms (including mild fever) precede:
-dry cough
-increasing breathlessness
-wheezing, fine inspiratory crackles (not always present)
-feeding difficulties associated with increasing dyspnoea are often the reason for hospital admission
What 5 features would warrant 999 call for bronchiolitis?
NICE recommend immediate referral (usually by 999 ambulance) if they have any of the following:
-apnoea (observed or reported)
-child looks seriously unwell to a healthcare professional
-severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute
-central cyanosis
-persistent oxygen saturation of less than 92% when breathing air.
Which 3 features would warrant you to consider referral for bronchiolitis?
NICE recommend that clinicians ‘consider’ referring to hospital if any of the following apply:
-a respiratory rate of over 60 breaths/minute
-difficulty with breastfeeding or inadequate oral fluid intake (50-75% of usual volume ‘taking account of risk factors and using clinical judgement’)
-clinical dehydration
What is the investigation and management of bronchiolitis?
Investigation
immunofluorescence of nasopharyngeal secretions may show RSV
Management is largely supportive
humidified oxygen is given via a head box and is typically recommended if the oxygen saturations are persistently < 92%
nasogastric feeding may be needed if children cannot take enough fluid/feed by mouth
suction is sometimes used for excessive upper airway secretions
What is croup? What is the most common cause?
-Who gets croup?
-When is this most common?
Croup is a form of upper respiratory tract infection seen in infants and toddlers. It is characterised by stridor which is caused by a combination of laryngeal oedema and secretions. Parainfluenza viruses account for the majority of cases.
Epidemiology
peak incidence at 6 months - 3 years
more common in autumn
Give 4 clinical features of croup
Features
-stridor
-barking cough (worse at night)
-fever
-coryzal symptoms
Describe mild croup
-cough
-stridor
-chest wall recession
-Child behaviour
Occasional barking cough
No audible stridor at rest
No or mild suprasternal and/or intercostal recession
The child is happy and is prepared to eat, drink, and play
Describe moderate croup
-cough
-stridor
-chest wall recession
-Child behaviour
Frequent barking cough
Easily audible stridor at rest
Suprasternal and sternal wall retraction at rest
No or little distress or agitation
The child can be placated and is interested in its surroundings
Describe severe croup
-cough
-stridor
-chest wall recession
-Child behaviour
Frequent barking cough
Prominent inspiratory (and occasionally, expiratory) stridor at rest
Marked sternal wall retractions
Significant distress and agitation, or lethargy or restlessness (a sign of hypoxaemia)
Tachycardia occurs with more severe obstructive symptoms and hypoxaemia
Who should be admitted with croup?
CKS suggest admitting any child with moderate or severe croup. Other features which should prompt admission include:
< 6 months of age
known upper airway abnormalities (e.g. Laryngomalacia, Down’s syndrome)
uncertainty about diagnosis (important differentials include acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation)
What is the management/emergency management of croup?
Management
CKS recommend giving a single dose of oral dexamethasone (0.15mg/kg) to all children regardless of severity
prednisolone is an alternative if dexamethasone is not available
Emergency treatment
high-flow oxygen
nebulised adrenaline
Cystic fibrosis
-How is this inherited?
-What is the gene affected?
-How many births are affected and what is the carrier rate?
Cystic fibrosis (CF) is an autosomal recessive disorder causing increased viscosity of secretions (e.g. lungs and pancreas). It is due to a defect in the cystic fibrosis transmembrane conductance regulator gene (CFTR), which codes a cAMP-regulated chloride channel
In the UK 80% of CF cases are due to delta F508 on the long arm of chromosome 7. Cystic fibrosis affects 1 per 2500 births, and the carrier rate is c. 1 in 25
What 4 organisms colonise cystic fibrosis?
Organisms which may colonise CF patients
Staphylococcus aureus
Pseudomonas aeruginosa
Burkholderia cepacia*
Aspergillus
What are 7 presenting features of cystic fibrosis? what percentage of patients are diagnosed after 18 years of age? Give 6 other features?
Presenting features
neonatal period (around 20%): meconium ileus, less commonly prolonged jaundice
recurrent chest infections (40%)
malabsorption (30%): steatorrhoea, failure to thrive
other features (10%): liver disease
Whilst many patients are picked up during newborn screening programmes or early childhood, it is worth remembering that around 5% of patients are diagnosed after the age of 18 years.
Other features of cystic fibrosis
short stature
diabetes mellitus
delayed puberty
rectal prolapse (due to bulky stools)
nasal polyps
male infertility, female subfertility
Give 6 points of general management of cystic fibrosis?
Management of cystic fibrosis (CF) involves a multidisciplinary approach
Key points
-regular (at least twice daily) chest physiotherapy and postural drainage. Parents are usually taught to do this. Deep breathing exercises are also useful
-high calorie diet, including high fat intake*
-patients with CF should try to minimise contact with each other to prevent cross infection with Burkholderia cepacia complex and Pseudomonas aeruginosa
-vitamin supplementation
-pancreatic enzyme supplements taken with meals
-lung transplantion
(chronic infection with Burkholderia cepacia is an important CF-specific contraindication to lung transplantation)
what is the use of Lumacaftor/Ivacaftor in cystic fibrosis?
Lumacaftor/Ivacaftor (Orkambi)
-is used to treat cystic fibrosis patients who are homozygous for the delta F508 mutation
-lumacaftor increases the number of CFTR proteins that are transported to the cell surface
-ivacaftor is a potentiator of CFTR that is already at the cell surface, increasing the probability that the defective channel will be open and allow chloride ions to pass through the channel pore
What is whooping cough caused by?
Whooping cough (pertussis) is an infectious disease caused by the Gram-negative bacterium Bordetella pertussis. It typically presents in children. There are around 1,000 cases are reported each year in the UK. It is sometimes called the ‘cough of 100 days’.
Describe the immunisation of whooping cough? does this confer lifelong protection?
Immunisation
-infants are routinely immunised at 2, 3, 4 months and 3-5 years. Newborn infants are particularly vulnerable, which is why the vaccination campaign for pregnant women was introduced
-neither infection nor immunisation results in lifelong protection - hence adolescents and adults may develop whooping cough despite having had their routine immunisations
What are the three phases of whooping cough?
Features
catarrhal phase
-symptoms are similar to a viral upper respiratory tract infection
-lasts around 1-2 weeks
paroxysmal phase
-the cough increases in severity
coughing bouts are usually worse at night and after feeding, may be ended by vomiting & associated central cyanosis
-inspiratory whoop: not always present (caused by forced inspiration against a closed glottis)
infants may have spells of apnoea
-persistent coughing may cause subconjunctival haemorrhages or even anoxia leading to syncope & seizures
-lasts between 2-8 weeks
convalescent phase
the cough subsides over weeks to months
What is the diagnostic criteria for whooping cough?
Whooping cough should be suspected if a person has an acute cough that has lasted for 14 days or more without another apparent cause, and has one or more of the following features:
-Paroxysmal cough.
-Inspiratory whoop.
-Post-tussive vomiting.
-Undiagnosed apnoeic attacks in young infants.
What are 6 management points of whooping cough?
Diagnosis
-per nasal swab culture for Bordetella pertussis - may take several days or weeks to come back
-PCR and serology are now increasingly used as their availability becomes more widespread
Management
-infants under 6 months with suspect pertussis should be admitted
-in the UK pertussis is a notifiable disease
-an oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread
-household contacts should be offered antibiotic prophylaxis
-antibiotic therapy has not been shown to alter the course of the illness
-school exclusion: 48 hours after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )
Give 4 complication of whooping cough
Complications
-subconjunctival haemorrhage
-pneumonia
-bronchiectasis
-seizures
When are pregnant women offered whooping cough vaccine?
Vaccination of pregnant women
In 2012 there was an outbreak of whooping cough (pertussis) which resulted in the death of 14 newborn children. As a temporary measure, a vaccination programme was introduced in 2012 for pregnant women. This has successfully reduced the number of cases of whooping cough (the vaccine is thought to be more than 90% effective in preventing newborns developing whooping cough). It was however decided in 2014 to extend the whooping cough vaccination programme for pregnant women. This decision was taken as there was a ‘great deal of uncertainty’ about the timing of future outbreaks.
Women who are between 16-32 weeks pregnant will be offered the vaccine.
What is laryngomalacia? when does this present?
Laryngomalacia is the most common congenital laryngeal abnormality characterised by flaccidity of the supraglottic structures. The larynx is soft and floppy as a result and collapses during breathing.
Epidemiology
Affects both sexes equally
Accounts for 60-70% of cases of congenital stridor
Presents within the first few weeks of life (typically at 4-6 weeks) with noisy respiration and inspiratory stridor
What are the three types of laryngomalacia?
Types
Type 1: tightening of the aryepiglottic folds
Type 2: redundant tissue in the supraglottic region
Type 3: associated with other disorders such as neuromuscular weakness or gastro-oesophageal reflux disease
Give 3 features of laryngomalacia?
Features
-Inspiratory stridor : high-pitched and crowing. This is usually intermittent, occurring in the supine position e.g. when the child lies on its back, when feeding or when agitated
-Symptoms increase in severity during the first 8 months but tend to resolve by 18-24 months
-Respiratory distress, failure to thrive and cyanosis are rare
What investigations are required for laryngomalacia?
Investigations
Oxygen saturation should be monitored and blood gases taken if there is desaturation
Laryngoscopy and bronchoscopy are only indicated if there are severe features, or if there is diagnostic difficulty
What is the management of laryngomalacia?
Management
-99% of cases usually resolve spontaneously by 18-24 months
-Symptomatic relief may be provided by hyperextending the neck during episodes of stridor
-Surgical intervention is only required with severe respiratory distress e.g. tracheostomy, laryngoplasty, excision of redundant mucosa, laser epiglottopexy or laser division of the aryepiglottic folds
Give 4 features of chicken pox
Fever initially
Itchy, rash starting on head/trunk before spreading. Initially macular then papular then vesicular
Systemic upset is usually mild
Measles
-Give 3 clinical features
-Prodrome: irritable, conjunctivitis, fever
-Koplik spots: white spots (‘grain of salt’) on buccal mucosa
-Rash: starts behind ears then to whole body, discrete maculopapular rash becoming blotchy & confluent
What is measles caused by? how is this spread? what is the incubation and infectivity period?
Overview
RNA paramyxovirus
one of the most infectious known viruses
spread by aerosol transmission
infective from prodrome until 4 days after rash starts
incubation period = 10-14 days
What are the investigations and management of measles?
Investigations
IgM antibodies can be detected within a few days of rash onset
Management
mainly supportive
admission may be considered in immunosuppressed or pregnant patients
notifiable disease → inform public health
What are 9 complications of measles?
Complications
-otitis media: the most common complication
-pneumonia: the most common cause of death
-encephalitis: typically occurs 1-2 weeks following the onset of the illness)
-subacute sclerosing panencephalitis: very rare, may present 5-10 years following the illness
-febrile convulsions
-keratoconjunctivitis, corneal ulceration
-diarrhoea
-increased incidence of appendicitis
-myocarditis
Describe how contacts of measles are managed?
Management of contacts
if a child not immunized against measles comes into contact with measles then MMR should be offered (vaccine-induced measles antibody develops more rapidly than that following natural infection)
this should be given within 72 hours
Mumps
-Give 4 clinical features?
Fever, malaise, muscular pain
Parotitis (‘earache’, ‘pain on eating’): unilateral initially then becomes bilateral in 70%
Describe the rubella rash? where is lymphadenopathy found?
Rash: pink maculopapular, initially on face before spreading to whole body, usually fades by the 3-5 day
Lymphadenopathy: suboccipital and postauricular
Erythema infectiosum
-What is this AKA
-What is this caused by?
-give 4 clinical features
Also known as fifth disease or ‘slapped-cheek syndrome’
Caused by parvovirus B19
Lethargy, fever, headache
‘Slapped-cheek’ rash spreading to proximal arms and extensor surfaces
Scarlet fever
-What is this caused by?
-Give 5 clinical features?
Reaction to erythrogenic toxins produced by Group A haemolytic streptococci
Fever, malaise, tonsillitis
‘Strawberry’ tongue
Rash - fine punctate erythema sparing the area around the mouth (circumoral pallor)
When is scarlet fever most commonly found? how is this spread?
Scarlet fever is a reaction to erythrogenic toxins produced by Group A haemolytic streptococci (usually Streptococcus pyogenes). It is more common in children aged 2 - 6 years with the peak incidence being at 4 years.
Scarlet fever is spread via the respiratory route by inhaling or ingesting respiratory droplets or by direct contact with nose and throat discharges, (especially during sneezing and coughing).
Describe the rash seen in scarlet fever
rash
-fine punctate erythema (‘pinhead’) which generally appears first on the torso and spares the palms and soles
-children often have a flushed appearance with circumoral pallor. The rash is often more obvious in the flexures
-it is often described as having a rough ‘sandpaper’ texture
-desquamination occurs later in the course of the illness, particularly around the fingers and toes
Give 4 complications of scarlet fever
Scarlet fever is usually a mild illness but may be complicated by:
-otitis media: the most common complication
-rheumatic fever: typically occurs 20 days after infection
-acute glomerulonephritis: typically occurs 10 days after infection
-invasive complications (e.g. bacteraemia, meningitis, necrotizing fasciitis) are rare but may present acutely with life-threatening illness
What is roseola infantum? what is this caused by?
Roseola infantum (also known as exanthem subitum, occasionally sixth disease) is a common disease of infancy caused by the human herpes virus 6 (HHV6). It has an incubation period of 5-15 days and typically affects children aged 6 months to 2 years.
Give 5 clinical features of roseola infantum? what 2 other possible consequences can occur?
Features
-high fever: lasting a few days, followed later by a
maculopapular rash
-Nagayama spots: papular enanthem on the uvula and soft palate
-febrile convulsions occur in around 10-15%
-diarrhoea and cough are also commonly seen
Other possible consequences of HHV6 infection
aseptic meningitis
hepatitis
Hand, foot and mouth disease
-What is this caused by?
-Give 4 clinical features
Caused by the coxsackie A16 virus
Mild systemic upset: sore throat, fever
Vesicles in the mouth and on the palms and soles of the feet
What is the management of hand, foot and mouth disease? Do they need to be excluded from school?
Management
symptomatic treatment only: general advice about hydration and analgesia
reassurance no link to disease in cattle
children do not need to be excluded from school
the HPA recommends that children who are unwell should be kept off school until they feel better
they also advise that you contact them if you suspect that there may be a large outbreak.
How are thread worms diagnosed and what is the manageemnt
Diagnosis may be made by the applying Sellotape to the perianal area and sending it to the laboratory for microscopy to see the eggs. However, most patients are treated empirically and this approach is supported in the CKS guidelines.
Management
CKS recommend a combination of anthelmintic with hygiene measures for all members of the household
mebendazole is used first-line for children > 6 months old. A single dose is given unless infestation persists
What is the most common cause of D+V in children?
Diarrhoea and vomiting is very common in younger children. The most common cause of gastroenteritis in children in the UK is rotavirus. Much of the following is based around the 2009 NICE guidelines (please see the link for more details).
How long does diarrhoea and vomiting typically last for?
NICE suggest that typically:
diarrhoea usually lasts for 5-7 days and stops within 2 weeks
vomiting usually lasts for 1-2 days and stops within 3 days
what are 7 risk factors for dehydration during D+V in children?
The following children are at an increased risk of dehydration:
-children younger than 1 year, especially those younger than 6 months
-infants who were of low birth weight
-children who have passed six or more diarrhoeal stools in the past 24 hours
-children who have vomited three times or more in the past 24 hours
-children who have not been offered or have not been able to tolerate supplementary fluids before presentation
-infants who have stopped breastfeeding during the illness
-children with signs of malnutrition
Give 5 clinical features suggestive of hypernatraemic dehydration?
Features suggestive of hypernatraemic dehydration:
-jittery movements
-increased muscle tone
-hyperreflexia
-convulsions
-drowsiness or coma
In which 3 situations should you do a stool sample in D+V in children? In which 3 situations should you consider a stool sample?
NICE suggest doing a stool culture in the following situations:
-you suspect septicaemia or
-there is blood and/or mucus in the stool or
-the child is immunocompromised
You should consider doing a stool culture if:
-the child has recently been abroad or
-the diarrhoea has not improved by day 7 or
-you are uncertain about the diagnosis of gastroenteritis
what is the management of D+V in children
If clinical shock is suspected children should be admitted for intravenous rehydration.
For children with no evidence of dehydration
continue breastfeeding and other milk feeds
encourage fluid intake
discourage fruit juices and carbonated drinks
If dehydration is suspected:
give 50 ml/kg low osmolarity oral rehydration solution (ORS) solution over 4 hours, plus ORS solution for maintenance, often and in small amounts
continue breastfeeding
consider supplementing with usual fluids (including milk feeds or water, but not fruit juices or carbonated drinks)
What is classed at tachypnoea in 6-12 months, >12 months
Tachypnoea: respiratory rate
>50 breaths/minute, age 6-12 months;
>40 breaths/minute, age >12 months
What is classed as tachycardia at <12mths, 12-24mths, 2-5years
> 160 beats/minute, age <12 months
150 beats/minute, age 12-24 months
140 beats/minute, age 2-5 years
In a child less than 1 year old, when is a diagnosis of constipation given?
2 or more:
Stool pattern:
-Fewer than 3 complete stools per week (type 3 or 4 on Bristol Stool Form Scale) (this does not apply to exclusively breastfed babies after 6 weeks
of age)
-Hard large stool
-‘Rabbit droppings’ (type 1)
Symptoms assoc. with defeacation:
-Distress on passing stool
-Bleeding associated with hard stool
-Straining
History:
-Prev. episode constipation
-Prev. or current anal fissure
In a child older than 1 year, when is a diagnosis of constipation given?
Stool pattern:
-Fewer than 3 complete stools per week (type 3 or 4)
-Overflow soiling (commonly very loose, very smelly, stool passed without sensation)
-‘Rabbit droppings’ (type 1)
-Large, infrequent stools that can block the toilet
Symptoms assoc. with defeacation:
-Poor appetite that improves with passage of large stool
-Waxing and waning of abdominal pain with passage of stool
-Evidence of retentive posturing: typical straight-legged, tiptoed, back arching
posture
Straining
Anal pain
History:
-Prev. episode
-Prev.or current anal fissure
-Painful bowel movements and bleeding associated with hard stools
Give 7 red flags suggesting underlying disorder in constipation
-Reported from birth
->48hrs to pass meconium
-Ribbon stools
-Faltering growth
-Prev. unknown or undiagnosed leg weakness/locomotor delay
-Abdo distension
-Any signs that raises child protection concerns
What has a child got to be assessed for prior to starting treatment for constipation?
Prior to starting treatment, the child needs to be assessed for faecal impaction. Factors which suggest faecal impaction include:
-symptoms of severe constipation
-overflow soiling
-faecal mass palpable in the abdomen (digital rectal examination should only be carried out by a specialist)
How to treat childhood constipation if faecal impaction is present? What have families got to be informed about?
-If faecal impaction is present
polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen as the first-line treatment
-add a stimulant laxative if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks
-substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if Movicol Paediatric Plain is not tolerated
-inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain
Describe the maintenance regime for childhood constipations
Maintenance therapy
very similar to the above regime, with obvious adjustments to the starting dose, i.e.
-first-line: Movicol Paediatric Plain
add a stimulant laxative if no response
-substitute a stimulant laxative if Movicol Paediatric Plain is not tolerated. Add another laxative such as lactulose or docusate if stools are hard
-continue medication at maintenance dose for several weeks after regular bowel habit is established, then reduce the dose gradually
How is constipation managed in infants not yet weaned?
Infants not yet weaned (usually < 6 months)
bottle-fed infants: give extra water in between feeds. Try gentle abdominal massage and bicycling the infant’s legs
breast-fed infants: constipation is unusual and organic causes should be considered
How do you manage constipation in infants who have or are being weaned?
Infants who have or are being weaned
offer extra water, diluted fruit juice and fruits
if not effective consider adding lactulose
Infantile colic
-What is this?
-is there a recommended tx?
Infantile colic describes a relatively common and benign set of symptoms seen in young infants. It typically occurs in infants less than 3 months old and is characterised by bouts of excessive crying and pulling-up of the legs, often worse in the evening.
Infantile colic occurs in up to 20% of infants. The cause of infantile colic is unknown.
NICE Clinical Knowledge Summaries do not recommend the use of simeticone (such as Infacol®) or lactase (such as Colief®) drops.
CMPA/CMPI
-How common is this?
-What type of immune reaction is seen?
Cow’s milk protein intolerance/allergy (CMPI/CMPA) occurs in around 3-6% of all children and typically presents in the first 3 months of life in formula-fed infants, although rarely it is seen in exclusively breastfed infants.
Both immediate (IgE mediated) and delayed (non-IgE mediated) reactions are seen. The term CMPA is usually used for immediate reactions and CMPI for mild-moderate delayed reactions.
What are 6 features of CMPI/CMPA
Features
-regurgitation and vomiting
-diarrhoea
-urticaria, atopic eczema
-‘colic’ symptoms: irritability, crying
-wheeze, chronic cough
-rarely angioedema and -anaphylaxis may occur
What is the diagnosis of CMPI/CMPA?
Diagnosis is often clinical (e.g. improvement with cow’s milk protein elimination). Investigations include:
skin prick/patch testing
total IgE and specific IgE (RAST) for cow’s milk protein
What is the management of CMPA if formula-fed?
If the symptoms are severe (e.g. failure to thrive) refer to a paediatrician.
Management if formula-fed
extensive hydrolysed formula (eHF) milk is the first-line replacement formula for infants with mild-moderate symptoms
amino acid-based formula (AAF) in infants with severe CMPA or if no response to eHF
around 10% of infants are also intolerant to soya milk
What is the management of CMPI if breastfeeding?
Management if breastfed
continue breastfeeding
eliminate cow’s milk protein from maternal diet. Consider prescribing calcium supplements for breastfeeding mothers whose babies have, or are suspected to have, CMPI, to prevent deficiency whilst they exclude dairy from their diet
use eHF milk when breastfeeding stops, until 12 months of age and at least for 6 months
What is the prognosis of CMPI?
CMPI usually resolves in most children
-in children with IgE mediated intolerance around 55% will be milk tolerant by the age of 5 years
-in children with non-IgE mediated intolerance most children will be milk tolerant by the age of 3 years
-a challenge is often performed in the hospital setting as anaphylaxis can occur.
Food allergy in children, What is seen in:
Skin
GI system
Rep system
If this is IgE mediated?
Skin
-pruritus
-erythema
-urticaria
-angioedema
Gastrointestinal system
-nausea
-colicky abdominal pain
-vomiting
-diarrhoea
Respiratory system
-upper respiratory tract symptoms - nasal itching,sneezing, rhinorrhoea or congestion (with or without conjunctivitis)
-lower respiratory tract symptoms - cough, chest tightness, wheezing or shortness of breath
-Symptoms of anaphylaxis
Food allergy in children, what is seen in skin and GI system if not IgE mediated?
Skin
pruritus
erythema
atopic eczema
Gastrointestinal system
gastro-oesophageal reflux disease
loose or frequent stools
blood and/or mucus in stools
abdominal pain
infantile colic
food refusal or aversion
constipation
perianal redness
pallor and tiredness
faltering growth plus one or more gastrointestinal symptoms above (with or without significant atopic eczema)
what should be offered to children who’s history is suggestive of an IgE mediated allergy?
If the history is suggestive of an IgE-mediated allergy
offer a skin prick test or blood tests for specific IgE antibodies to the suspected foods and likely co-allergens
What should be done to manage a child with suspect non-IgE mediated food allergy?
If the history is suggestive of an non-IgE-mediated allergy
eliminate the suspected allergen for 2-6 weeks, then reintroduce. NICE advise to ‘consult a dietitian with appropriate competencies about nutritional adequacies, timings and follow-up’
GORD in infancy
-What are 2 risk factors?
Gastro-oesophageal reflux is the commonest cause of vomiting in infancy. Around 40% of infants regurgitate their feeds to a certain extent so there is a degree of overlap with normal physiological processes.
Risk factors
preterm delivery
neurological disorders
Give 5 clinical features of GORD in infancy? what is the diagnosis?
Features
-typically develops before 8 weeks
-vomiting/regurgitation
-milky vomits after feeds
-may occur after being laid flat
-excessive crying, especially while feeding
Diagnosis is usually made clinically
Describe the management of GORD in infancy
Management (partly based on the 2015 NICE guidelines)
-advise regarding position during feeds - 30 degree head-up
-infants should sleep on their backs as per standard guidance to reduce the risk of cot death
-ensure infant is not being overfed (as per their weight) and consider a trial of smaller and more frequent feeds
-a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum)
-a trial of alginate therapy e.g. Gaviscon. Alginates should not be used at the same time as thickening agents
NICE do not recommend a proton pump inhibitor (PPI) to treat overt regurgitation in infants and children occurring as an isolated symptom. A trial of one of these agents should be considered if 1 or more of the following apply:
-unexplained feeding difficulties (for example, refusing feeds, gagging or choking)
-distressed behaviour
-faltering growth
Give 5 complications of GORD in infancy?
Complications
distress
failure to thrive
aspiration
frequent otitis media
in older children dental erosion may occur
If there are severe complications (e.g. failure to thrive) and medical treatment is ineffective then fundoplication may be considered
Pyloric stenosis
-What is this?
-Who does this affect? 4
Pyloric stenosis typically presents in the second to fourth weeks of life with vomiting, although rarely may present later at up to four months. It is caused by hypertrophy of the circular muscles of the pylorus.
Epidemiology
-incidence of 4 per 1,000 live births
-4 times more common in males
10-15% of infants have a positive family history
-first-borns are more commonly affected
What are 4 clinical features of pyloric stenosis?
-How is the diagnosis made?
-What is the management?
Features
-‘projectile’ vomiting, typically 30 minutes after a feed
-constipation and dehydration may also be present
-a palpable mass may be present in the upper abdomen
-hypochloraemic, hypokalaemic alkalosis due to persistent vomiting
Diagnosis is most commonly made by ultrasound.
Management is with Ramstedt pyloromyotomy.
What is hirschsprungs disease? What is the pathophysiology?
Hirschsprung’s disease is caused by an aganglionic segment of bowel due to a developmental failure of the parasympathetic Auerbach and Meissner plexuses. Although rare (occurring in 1 in 5,000 births) it is an important differential diagnosis in childhood constipation.
Pathophysiology
parasympathetic neuroblasts fail to migrate from the neural crest to the distal colon → developmental failure of the parasympathetic Auerbach and Meissner plexuses → uncoordinated peristalsis → functional obstruction
What are 2 assoc. with hisrchsprungs disease? What are possible presentations in neonates vs in older children?
Associations
3 times more common in males
Down’s syndrome
Possible presentations
neonatal period e.g. failure or delay to pass meconium
older children: constipation, abdominal distension
What are the investigations and management of hirschsprungs disease?
Investigations
abdominal x-ray
rectal biopsy: gold standard for diagnosis
Management
initially: rectal washouts/bowel irrigation
definitive management: surgery to affected segment of the colon
What is intussusception? who does this usually affect?
Intussusception describes the invagination of one portion of the bowel into the lumen of the adjacent bowel, most commonly around the ileo-caecal region.
Intussusception usually affects infants between 6-18 months old. Boys are affected twice as often as girls
What are 6 features of intussusception?
Features
-intermittent, severe, crampy, progressive abdominal pain
-inconsolable crying
-during paroxysm the infant will characteristically draw their knees up and turn pale
-vomiting
-bloodstained stool - ‘red-currant jelly’ - is a late sign
-sausage-shaped mass in the right upper quadrant
What is the investigation and management of intussusception?
Investigation
ultrasound is now the investigation of choice and may show a target-like mass
Management
the majority of children can be treated with reduction by air insufflation under radiological control, which is now widely used first-line compared to the traditional barium enema
if this fails, or the child has signs of peritonitis, surgery is performed
What is meckels diverticulum? what is the rule of 2’s?
Meckel’s diverticulum is a congenital diverticulum of the small intestine. It is a remnant of the omphalomesenteric duct (also called the vitellointestinal duct) and contains ectopic ileal, gastric or pancreatic mucosa.
.
Rule of 2s
occurs in 2% of the population
is 2 feet from the ileocaecal valve
is 2 inches long
What is seen on presentation of meckels diverticulum? 3
Presentation (usually asymptomatic)
-abdominal pain mimicking appendicitis
-rectal bleeding
-Meckel’s diverticulum is the most common cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years
-intestinal obstruction
secondary to an omphalomesenteric band (most commonly), volvulus and intussusception
What is the investigation and management of meckels diverticulum?
nvestigation
if the child is haemodynamically stable with less severe or intermittent bleeding then a ‘Meckel’s scan’ should be considered
uses 99m technetium pertechnetate, which has an affinity for gastric mucosa
mesenteric arteriography may also be used in more severe cases e.g. transfusion is required
Management
removal if narrow neck or symptomatic
options are between wedge excision or formal small bowel resection and anastomosis
How should temperature be measured in children?
Measuring temperature should be done with an electronic thermometer in the axilla if the child is < 4 weeks or with an electronic/chemical dot thermometer in the axilla or an infra-red tympanic thermometer.
