Paediatrics Flashcards
Question to ask in Cerebral Palsy?
- How old was he when he was able to hold his head up? (3 months)
- How old was he when he sat up?
- Does he have a hand preference?
- Tip-toe gait?
- Do any of his/her limbs stay in the same position? (flexed)
- Assess the rest of the developmental domains
Questions for Dyskinetic Cerebral Palsy?
- Chorea → irregular and sudden non-repetitive movements (brief)?
- Athetosis → fanning of fingers?
- Dystonia → twisting of repetitive movements?
Ataxic Cerebral Palsy
- Not symmetrical
- Not hypotonia
- No intention tremor
- Unsteady, shaky movements or tremor
- Difficulties maintaining balance
What are the risk factors for Cerebral Palsy?
- Pre-term - can cause damage via periventricular leukomalacia secondary to ischaemia and or severe intraventricular haemorrhage and venous infarction
- Post-natal - Meningitis, encephalopathy/phalitis, head trauma (accidental/non-accidental), hypoglycaemia, hydrocephalus, hyperbilirubinaemia
How do you treat Cerebral Palsy?
- To treat hypertonia - botulinum toxin injections in to muscles
- Selective dorsal rhizotomy (portion of the nerve roots in the spinal cord are selectively cut to reduce spasticity)
- Intrathecal Baclofen (skeletal muscle relaxant)
- Deep brain stimulation of the basal ganglia
Emollient Ladder
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Anaphylaxis
- ABCDE approach
- Call for help - lay them flat and raise their legs
(Repeat adrenaline every 5 minutes if they’re unwell)
- 0.15 ml (1:1000) - < 6 years
- 0.3 ml (1:1000) - 6-12 years
- 0.5 ml (1:1000) - > 12 years
When Equipment is Available
- Establish airway
- High flow oxygen Monitor
- IV fluid challenge - 20ml/kg
- Chlorphenamine
Monitor
- ECG
- Hydrocortisone
- Blood pressure
- Pulse oximetry
What are the life-threatening features of anaphylaxis?
Airway
- swelling
- hoarseness
- stridor
Breathing
- rapid breathing
- wheeze
- fatigue
- cyanosis
- SpO2 < 92%
- confusion
Circulation
- pale
- clammy
- low blood pressure
- faintness
- drowsy/coma
What is the definition of asthma?
Asthma is a chronic lung condition in which there is chronic inflammation of the airways, and hypersensitivity of the airways.
Symptoms include wheeze, cough, chest tightness and SOB (dyspnoea). It is often worse at night.
What are the symptoms in Otitis Media (w effusion)?
Otitis Media
- not seeming themselves
- less responsive
- shouting
- volume turned up when watching TV
- ear is red and painful
- recent ear infections?
- fever/feeding difficulties/general sepsis/unwell symptoms
Otitis Medai w Effusion
- hearing loss is a more predominant
N.B.
- acute otitis media occurs more rapidly with signs and symptoms of inflammation
- otitis media with effusion has no signs or symptoms of acute inflammation, generally asymptomatic
How is asthma assessed?
> 5 years old
- objective tests such as FeNO - fractional exhaled nitric oxide (of 35 ppb - parts per billion)
- spirometry (< 70% = positive for asthma)
- usually followed by bronchodilator reversibility test if > 12% increase = asthma)
- peak flow variability
< 5 years old
- treat based on observation and clinical judgement as they cannot do test
- review every 6 months
Examination of Otitis Media?
- bulging or fullness of the tympanic membrane (TM)
- erythema of the TM
- possible perforation with otorrhea
- possibe absence of light reflex
What are the risk factors for Otitis Media?
- trisomy 21 (Down’s Syndrome)
- cleft palate
- cystic fibrosis
What is the management of Otitis Media?
Investigation
- Otoscopy – ear drum may appear normal. usually no signs of discharge or inflammation O/E
- Exclude foreign body, wax, perforated eardrum
- Audiometry/Tympanometry - otitis media w effusion diagnosis
Management
- active observation over 6–12 weeks is appropriate for most children, as spontaneous resolution is common
- possible referral to ENT (down’s, signficiant impairment)
- amoxicillin
- recurrent otitis media = polymixin ear drops
- effusion = grommets (ventilation tubes)
What are the symptoms of rickets?
- Progressive bowing of legs (be aware that bowing of legs can be a normal finding in toddlers).
- Progressive knock knees.
- Painful wrist swelling.
- Rachitic rosary (swelling of the costochondral junctions).
- Craniotabes (skull softening with frontal bossing and delayed fontanelle closure).
- Delayed tooth eruption and enamel hypoplasia
Chronic Symptoms
- Long-standing (3 months or longer), unexplained bone pain
- Muscular weakness (for example difficulty climbing stairs, waddling gait, difficulty rising from a chair, or delayed walking)
- Features of hypocalcaemia (tetany or seizures)
- Cardiomyopathy (in infants)
How would you investigate rickets?
- A radiological assessment, if rickets is suspected.
- A definitive diagnosis of rickets requires radiological assessment of a long bone, which may show cupping, splaying, and fraying of the metaphysis (the so-called champagne glass wrist appearance on X-ray)
- Check vitamin D levels, by measuring serum 25-hydroxyvitamin D (25[OH)D) levels, if radiograph shows signs of osteopenia or rickets
-
Bone profile (calcium, phosphate, and alkaline phosphatase [ALP]), to assess for hypocalcaemia and markers of bone disease
- check vitamin D levels if there is low serum calcium or phosphate, and/or high ALP (greater than the local age-appropriate reference range)
Spiral Fracture
How is rickets managed?
Conservative
- Poor diet – cow’s milk contains little iron and he is not getting enough vitamin D
- Structured mealtimes, be patient with introducing foods
Medical
- 3-month course of oral vitamin D3 (cholecalciferol) followed by lower maintenance dose
- REVIEW again to measure bone chemistry and see how patient is developing – check for hypercalcaemia
- 3-month course of oral IRON
- Possible dietician input
Patient Question - How long will it take? How will I know he’s better?
- healing occurs in 2–4 weeks
- can be monitored from the lowering of ALP, increasing vitamin D levels and healing on x-rays
- complete reversal of bony deformities may take years
What are the symptoms of an Incarcerated Hernia?
- Hasn’t been producing wet nappies since yesterday
- Hasn’t opened bowels since yesterday
- Vomiting
- Greatly reduced feeding
- Very upset and irritable and seems to be in a lot of pain (very worried)
- Persistant bulge which is now tender (screamed when I opened the nappy)
- visible upon straining or crying
- Abdominal distention
Complications
- Pain
- Intestinal Obstruction
- Damage to the Testis (strangulation)
- strangulation – i.e. so tightly constricted that the contents become ischaemic or gangrenous ⟶ w consequent testicular atrophy
What are the risk factors for an incarcerated hernia?
- Male (6:1)
- Premature
As explained by the embryology, a hernia is usually caused by a persistently patent processes vaginalis (normally obliterates after birth) and emerges from the deep inguinal ring through the inguinal canal
⟶ it is through this that the bowel herniates
It is therefore usually indirect
How would you manage an inguinal hernia?
Most hernias can be successfully reduced by ‘taxis’ ⟶ gentle compression in the line of the inguinal canal (with good analgesia).
Surgery can then be planned for a suitable time when any oedema has settled and the child is well.
- ligation and division of the processus vaginalis, which has become the hernial sac
- herniotomy – removal of the hernia sac (as opposed to herniorrhaphy in adults, when the inguinal abdominal wall is also reinforced, usually with a mesh)
- > 3 months of age = can be safely performed as a day case
⟶ If reduction is impossible, emergency surgery is required because of the risk of compromise of the bowel or testis
Examination of an inguinal hernia?
- irreducible lump (particularly visible upon straining or crying – increased abdominal pressure)
- There is a 5-20% chance of developing a contralateral hernia in paediatric patients, so examine both sides.
- parents should be made aware that following repair on one side, development of a hernia on the contralateral side can occur.
Explain plagiocephaly to a patient?
Plagiocephaly is a disorder that affects the skull, making the back or side of a baby’s head appear flattened.
Positional plagiocephaly is produced by pressure from the outside on part of the skull. It can occur while the baby is still developing in the womb but in recent years, flattening occurring after the baby is born has become much more frequent.
The skull is made up of several ‘plates’ of bone which, when we are born, are not tightly joined together. As we grow older, they gradually fuse – or stick – together. When we are young, they are soft enough to be moulded, and this means their shape can be altered by pressure on it to give part – usually the back – of a baby’s head a flattened look.
What is a differential diagnosis for plagiocephaly?
Craniosynostosis
- skull plates fuse early
- a condition in which one or more of the fibrous sutures in an infant (very young) skull prematurely fuses by turning into bone (ossification), thereby changing the growth pattern of the skull
- craniosynostosis doesn’t always need to be treated. your child may just have regular check-ups to monitor it –> SURGERY
- no long-term impact but may have scar
What are the symptoms of mumps?
- Discomfort in the salivary glands (in the front of the neck) or the parotid glands (immediately in front of the ears)
- Difficulty chewing
- Pain and tenderness of the testicles
- Fever
- Headache
- Muscle aches
- Tiredness
What is the treatment of Malaria?
- NICE guidelines say to arrange immediate admission for specialist assessment and treatment if you suspect malaria in a child.
- REMEMBER, children under 12 can’t be given NOT doxycycline so don’t mention this (is sometimes given in combo with quinine for treatment).
- They can be given quinine or mefloquine. BUT this all depends on which strain of plasmodium they are infected with = counsel parents accordingly.
- Riamet (see pathology!) is safe to be given in children with uncomplicated malaria.
- Recent data supports the use of IV artesunate for the treatment of severe malaria in children.
What is the rating scale for Croup?
Westley Croup Score
mild –> moderate –> severe
6 months - 3 years
Moderate
- 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
Severe
- 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
How is croup managed?
- consider admitting if moderate-severe
- < 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)
Obesity in Children
A child above the 91st centile is overweight and above the 98th centile is obese (do NOT use BMI)
- Complete history
- Collateral history from Mother
- Full physical examination
- Simple obesity
- Pink stretch marks
- Insulin resistance signs
- Thickening and darkening of skin in axilla, neck and groin= acanthosis nigricans
- Cushing
- Purple striae
- Simple obesity
DRUG TREATMENT –> Orlistat >12 yrs old, Metformin
- TFTs/LFTs/glucose/lipids
Delayed Speech
- Environmental Deprivation and General Developmental Delay and Hearing
- Speech Discrimination Tests can be performed after 2.5 years to assess children’s ability to discern different spoken words
-
Milestones
- 3 months = turns towards sound
- 6 months = ‘adeh’ ‘erleh’
- 12 months = responds to name
- 12-15 months = 2-6 words (refer at 18 months)
- 2 years = combines 2 words
- 2.5 years = 200 words
- 3 years = short sentences
- 4 years = why, when, how questions
- languages @ home/school
- exposure to other languages
- TV
- desire vs ability to speak (autism)
- other forms of communication
- speech impairment (stutter)
- any other aspects of social communication
Management
- read aloud to child to increase exposure to new words
- encourage child to comment on pictures/on the story to promote conversation
- narrate daily activities
- listen and respond to their conversational output even if limited
- reduce exposure to electronic toys
- ask questions and have the child voice respond
Risk Factors for Epilepsy after Febrile Convulsions?
- family history of epilepsy
- having complex febrile seizures
- background of neurodevelopmental disorder
Causes of Epilepsy?
- NO cause in 50%
- Cerebral Malformations
- Genetics –> Down’s syndrome; Fragile X Syndrome; Neurodegenerative disorders; Inborn Errors of Metabolism
- Tumours
- Damage due to Hypoxia/Asphyxia
Foetal Varicella Syndrome?
Foreign Body Inhalation?
- Encourage coughing
- Bronchoscopy to remove the object
Symptoms of Inhaled Foreign Body?
- stridor
- coughing
- choking
- vomiting
- stridor
Inhaled Foreign Body Management?
- Encourage Cough
- External Manoeuvres (back blows, chest thrusts, abdominal thrusts)
- Fexible bronchoscopy
- Rigid bronchoscopy
- Surgery
- Thoracotomy
