Paediatrics

Question 1

describe the traffic light system for assessment of a child with fever

Answer 1

green
- colour: normal
- activity: content, smiling, normal cry
- breathing: normal resp exam
- hydration: normal skin and eyes
- other: no amber or red features

amber
- colour: pallor
- activity: decreased activity, not responsive
- breathing: increased resp rate, crackles in chest, nasal flaring
- hydration: dry mucous membranes, reduced urine output, dry nappies, poor feeding
- other: fever >5 days, not weight bearing

red
- colour: pale, mottled
- activity: high pitched cry, unarousable
- breathing: grunting, severe intercostal and subcostal recession, tracheal tugging, head bobbing
- hydration: reduced skin turgor
- other: non-blanching rash, bulging fontanelle, focal neurological deficit

green: discharge with fever leaflet and worsening advice
amber: intervene then reassess
> if improves and all green, discharge
> if remains amber, admit for observation
red: proactive intervention and admit; assess for safety and suitability for transfer

Question 2

state the paediatric dose of paracetamol and ibuprofen

Answer 2

paracetamol - 15mg/kg
ibuprofen - 7.5mg/kg (half of paracetamol)

Question 3

describe bronchiolitis

Answer 3

commonly caused by respiratory syncytial virus (RSV)

most commonly affects under 2s

clinical features
- dyspnoea, tachypnnoea
- poor feeding
- apnoeas
- fever
- coryzal symptoms: runny nose, sneezing, watery eyes
- harsh breath sounds
- wheeze, widespread crackles on auscultation

management: supportive
- ensuring adequate intake
- saline nasal drops and nasal suctioning
- oxygen
- ventilatory support

prophylaxis: palivizumab if premature or congenital heart disease

Question 4

describe the categorisation of acute wheeze in children

Answer 4

mild:
- >92% O2
- Normal PEFR
- normal mental state
- able to talk normally
- subtle or no increased WOB
- normal HR and RR

moderate
- >92% O2
- PEFR >50% of best
- normal mental state
- dyspnoea resulting in limitation of full sentences
- moderate increase in WOB (accessory muscle use and chest wall recession)
- HR PEWS <2 RR PEWS <2

severe
- <92% O2
- PEFR 33-50% of best
- agitated/distressed
- marked dyspnoea resulting in <3 word sentences
- severe increased WOB
- HR PEWS <=2 RR PEWS >=2

life-threatening
- <92% O2
- PEFR <33% of best
- confused / drowsy
- unable to talk due to dyspnoea
- cyanosed
- maximal WOB
- exhaustion may lead to poor respiratory effort
- silent chest

Question 5

describe the clinical features of croup

Answer 5

aka laryngotracheobronchitis

causes: parainfluenza virus, RSV
> more common in autumn months

viral upper respiratory tract infection leading to subglottic narrowing secondary to inflammation

features
- night cough
- barking or seal-like cough
- biphasic harsh stridor
- hoarseness
- respiratory distress

CXR: steeple sign
> posterior-anterior view shows subglottic narrowing
> if epiglottitis, lateral view shows thumb sign (swelling of epiglottis)

never perform throat examination due to risk of airway obstruction

Question 6

describe the categorisation of severity of croup and its management

Answer 6

mild:
- no signs of severe croup, no symptoms at rest
- give oral dexamethasone 0.15mg/kg
- home with croup discharge leaflet

moderate:
- no signs of severe croup
- symptomatic at rest
- worsened by exertion
- give oral dexamethasone 0.15mg/kg, observe for 2-3 hours
- if changes to mild croup discharge
- if remains moderate give nebulised adrenaline (5ml 1:1000) and admit

severe:
- respiratory distress
- cyanosis
- exhaustion
- quiet chest and lack of respiratory effort are pre-terminal signs
- management: nebulised adrenaline, oral/IV dexamethasone 0.15mg/kg, oxygen, admit and consider ICU r/v

give prednisolone if dexamethasone not available

Question 7

describe the clinical features of UTI in children

Answer 7

lower UTI
- frequency
- bed wetting
- vomiting
- loin pain
- frank haematuria

upper UTI
- fever
- abdominal pain
- lethargy and malaise
- urgency

atypical UTI
- seriously ill child
- poor urine flow
- septicaemia
- failure to respond to antibiotics after 48h

first-line antibiotic: trimethoprim 4mg/kg

Question 8

describe pulled elbow

Answer 8

occurs when a child’s arm is suddenly pulled resulting in subluxation of proximal radioulnar joint

exam
- no specific findings
- child refuses to use arm

reduction
- move hand into pronation
- gently flex elbow

Question 9

describe buckle fracture

Answer 9

common paediatric fracture to distal radius

injury to cancellous bone without actual break in cortex

manage symptomatically unless rotational deformity (requires manipulation)

Question 10

describe toddler’s fracture

Answer 10

torus or twisting injury resulting in spiral fracture of distal tibia

examination
- mild disseminated tenderness over anterior tibia
- localised erythema or warmth
- non-weight bearing child

management
- analgesia
- below-knee back-slab

Question 11

describe a hair tourniquet

Answer 11

clinical features
- inconsolable child
- unilaterally isolated swollen digit

remove with scalpel

Question 12

describe transient synovitis

Answer 12

aka irritable hip

usually affects hip and preceded by viral illness

clinical features
- mild/moderate hip pain (referred thigh/knee pain)
- acute onset <1 week
- no/mild restriction of hip movements (especially abduction and internal rotation)
- positive log roll test
- able to weight bear with limp
- otherwise well and afebrile

self-resolves within1-2 weeks

management
> advise regular analgesia and rest
> ask to return if no improvement in 3 days

Question 13

describe Perthes disease

Answer 13

avascular necrosis of capital femoral epiphysis, can be bilateral

onset over weeks between ages 3-9

clinical features
- mild hip/groin pain
- referred pain to knee/thigh
- limp
- limitation of hip rotation
- associated with hyperactivity and short stature

AP pelvis X-ray: flattening of femoral head with joint space widening
> may be absent in early disease

child is systematically well with no other joint involvement and no evidence of joint inflammation

management
- <6y: serial X-rays, observation, analgesia, physiotherapy
- surgical containment - guided by arthrogram, osteotomy

Question 14

describe slipped upper femoral epiphysis (SUFE)

Answer 14

SUFE occurs in late childhood/adolescence

onset: acute or subacute, bilateral in 20% of cases

common in overweight children

examination
- antalgic gait, out-toeing
- external rotation and shortening of affected limb
- hip, groin, medial thigh or knee pain
- loss of internal rotation of leg in flexion
- afebrile
- systemically well
- no other joint involvement

diagnosis: AP pelvis X-ray + frog leg view

management: internal fixation

complications: OA, avascular necrosis of the femoral head, leg length discrepancy

Question 15

describe the presentation of malignancy/leukaemia in children

Answer 15

• malaise
• anorexia
• weight loss
• bone pain
• nocturnal pain
• neurological symptoms: paralysis / paraesthesia
• new incontinence/retention/constipation
• fever
• pallor/jaundice
• lymphadenopathy
• organomegaly
• mass/swelling in bones
• erythema / inflammation at tumour site

Question 16

describe juvenile idiopathic arthritis (JIA)

Answer 16

diagnosis of exclusion

clinical features
- joint swelling affecting more than one joint
- symptoms (pain/stiffness) worse in the morning
- relevant family history
- symptoms persistent >6 weeks

most common type is oligoarticular ( or pauciarticular) JIA
> systemic onset diagnosis requires fevers

Question 17

what are key points to ask about in an airway history?

Answer 17

• ex-prematurity/neonatal intubation
• noisy breathing
• voice/cry
• cough/cyanotic spells
• recurrent croup or LRTIs
• feeding difficulties
• failure to thrive
• exercise tolerance

Question 18

list areas to examine to determine a child’s airway patency

Answer 18

• voice / cry / cough
• RR, HR
• nasal flaring, grunting, head bobbing
• tracheal tug, recession - sternal, intercostal
• stridor / stertor

ENT examination
- fibreoptic nasendoscopy
- microlaryngobronchoscopy (MLB)

Question 19

describe choanal atresia

Answer 19

babies are obligate nasal breathers

in choanal atresia, cyanotic episodes during feeding but pink while crying (due to mouth breathing)

• investigations: CT scan
• management:
  > feeding tube temporarily
  > oropharyngeal airway
  > definitive - surgical intervention

Question 20

describe obstructive sleep apnoea (OSA) in children

Answer 20

often due to adenotonsillar hypertrophy

features
- heavy snoring
- snort arousals
- apnoeic episodes
- disturbed sleep
- enuresis
- night terrors

effects
- poor concentration
- cognitive impairment
- fatigue
- hyperactivity
- hypertension
- cor pulmonale

investigations: sleep studies
> polysomnogram
> sleep study test

management: tonsil/adenoidectomy

Question 21

list causes of stridor in children

Answer 21

• laryngomalacia (commonest cause)
• webs
• cysts
• clefts
• vocal cord paralysis
  > bilateral can be due to Arnold-Chiari malformation
• papillomatosis
• subglottic stenosis (neonatal history of intubation)
• haemangioma
• tracheobronchomalacia
• tracheal stenosis
• foreign bodies
• vascular compression (abnormal aortic arch)

Cotton-Myer grading system can be used to categorise airway stenosis

Question 22

describe a thyroglossal duct cyst

Answer 22

thyroglossal duct cyst
> commonest midline neck swelling

> congenital, embryology: foramen caecum - neck

> moves with tongue protrusion and on swallowing

> investigations: ultrasound

> management - surgical removal

Question 23

describe epistaxis management in children

Answer 23

causes:
> commonly idiopathic
> juvenile nasal angiofibroma: teenage males with recurrent epistaxis
> coagulopathies

basic first aid:
- head forward, pinch cartilaginous part of nose, spit blood out

• naseptin cream (AVOID in peanut or soy allergy)
• nasal cautery (Little’s area)
  > spray anaesthetic
  > silver nitrate cautery

Question 24

list neck lumps that can be found laterally

Answer 24

• lymph nodes

> benign: small, mobile, multiple, often after URTI

> malignant (lymphoma): >2,5-3cm, firm, non-mobile, may be tethered, type B symptoms, assess lymphadenopathy elsewhere

most common nodes in children are reactive nodes, if in neck
> sore throats, ear infections, URTIs, skin and scalp conditions e.g. eczema, dental problems

• cysts
• congenital malformations

Question 25

describe foreign bodies (aural, nasal, airway, oesophageal)

Answer 25

- aural foreign body > live foreign body: flush with saline or olive oil > inorganic: not an emergency > organic: remove sooner > deep foreign body: theatre > management: remove with wax hook, crocodile forceps, Jobson's horne - nasal foreign body > features: persistent unilateral nasal discharge, foul smell > potential risk of aspiration > management: Mother's kiss first-line, grasping crocodile forceps extraction, suction - airway foreign bodies > features: stridor, airway distress, cyanosis, previous choking episodes > if complete occlusion or glottic FB: emergency scope or emergency tracheostomy > most commonly in right mainstem bronchus > lung hyperinflation if bronchial occlusion > can lead to chronic lung infections - oesophageal foreign bodies > commonly lodged at upper oesophageal sphincter (cricopharyngeus) > features: drooling, unable to swallow saliva/liquids > can cause upper airway obstruction > removal under GA with oesophagoscopy Button batteries need to be removed immediately (surgical emergency) - double ring sign on CXR

Question 26

describe post-tonsillectomy haemorrhage and its management

Answer 26

causes: infection, coughing, vasospasm can be fatal management - early contact with ENT/anaesthetics for definitive surgical management

Question 27

describe epiglottitis

Answer 27

very rare but critical airway features - stertor/stridor - dysphagia - drooling - muffled voice - relatively normal respiratory rate - pyrexial, tachycardic, tachypnoeic (septic) - tripod position: sat forward with a hand on each knee most common cause is Haemophilus influenza type B but children are usually vaccinated > other causes: S. pneumoniae, S. pyogenes, candida in immunocompromised investigations - clinical diagnosis - CXR: thumb sign of epiglottis - avoid examination to avoid worsening respiratory distress management - secure airway with intubation - antibiotics + fluids + steroids > abx: cephalosporin > contacts and index case: rifampicin - theatre if abscess

Question 28

describe infections in lymph nodes

Answer 28

abscess > after URTI > lymphadenopathy > systemically unwell, pyrexial > large fluctuant swelling, erythematous > management: incision and drainage, washout, antibiotics Atypical mycobacterium - cold node > not infectious, not TB, do not incise > well, not distressed, apyrexial, no rising blood count > chronic but eventually self-resolviing

Question 29

describe tonsillitis

Answer 29

examination: exudative erythematous enlarged tonsils exclude peritonsillar abscess (quinsy) > uvular deviation > trismus or unilateral tonsillitis management - penicillin V oral unless difficulty swallowing complications: deep neck space infections > quinsy > retropharyngeal/parapharyngeal abscess >> restricted mouth opening (trismus) , restricted neck movement, torticollis, drooling, inability to swallow, pyrexial, tachycardic, requires drainage

Question 30

describe tongue tie (ankyloglossia)

Answer 30

baby born with short and tight lingual frenulum prevents proper extension of tongue, makes it difficult to latch onto breast presentation: poor feeding, noticed during newborn check management - mild: monitor - affects feeding: frenotomy

Question 31

describe acute otitis media

Answer 31

very common 12 months-4 years risk factors - daycare, nursery - parental smoking - non-breastfed - ASD/learning difficulties features - otalgia / pulling ear - disconsolate child - reduced hearing - fever - +/- discharge if TM perforation commonly viral but can be S. pneumoniae, H. influenzae, S. pyogenes Management - paracetamol and ibuprofen first 48-72h, usually self-limiting - antibiotic treatment if failed watch & wait OR less than 2 years old - 5 day course of amoxicillin/co-amoxiclav 2nd line) > erythromycin if penicillin allergic - consider topical antibiotics (ciprofloxacin) if prolonged otorrhoea

Question 32

list complications of AOM

Answer 32

- intracranial abscess - facial nerve palsy - mastoiditis - meningitis

Question 33

describe mastoiditis

Answer 33

recent episode of AOM + 2 of following - proptosed auricle - post-auricular swelling - post-auricular erythema - post-auricular tenderness investigations - largely clinical diagnosis - CT mastoids management - surgical intervention > grommet insertion > cortical mastoidectomy

Question 34

list complications of mastoiditis

Answer 34

- subperiosteal abscess - facial nerve palsy - Gradenigo syndrome (OM, trigeminal distribution pain, 6th nerve palsy) - venous sinus thrombosis - otogenic meningitis / temporal lobe abscess - Bezold (deep to SCM), Citelli (digastric), Luc (meatal) abscesses

Question 35

describe cervical lymphadenitis

Answer 35

neck lump following recent URTI/tonsillitis/ear infection/superficial skin trauma e.g. cat scratch commonly affects children 1-4 years features - large, firm, tender lymph nodes - commonly post-auricular - swinging pyrexia - torticollis - paediatric systemic upset: poor oral intake, reduced urine output, miserable and unsettled complications - lymph node abscess (suppurative cervical lymphadenitis) requiring IV co-amoxiclav - I+D for abscess

Question 36

list different types of deep neck space infections (DNSI)

Answer 36

types - parapharyngeal abscess - retropharyngeal abscess - submandibular space abscess (Ludwig's angina)

Question 37

describe laryngomalacia

Answer 37

congenital abnormality of laryngeal cartilage causes dynamic airway collapse during inspiratory phase usually affects 6 months-24 months features - inspiratory stridor - cyanotic episodes - failure to thrive - worse when feeding or lying on back - associated with reflux investigations - dynamic assessment on flexible laryngoscopy > classically omega-shaped epiglottis > short aryepiglottic folds > arytenoids prolapse into glottis during inspiration mangement - mild: observe, tend to outgrow by 24 months - moderate: anti-reflux medications - severe: surgery

Question 38

describe retropharyngeal abscess

Answer 38

potential life-threatening ENT emergency infection spreading to potential space anterior to pre-vertebral fascia, can be due to necrotising lymph nodes in children features - odynophagia - dysphagia - difficulty breathing - voice changes (hoarseness, loss of voice) - drooling - neck stiffness management - broad spectrum IV antibiotics and IV fluids - IV dexamethasone - oxygen and nebulised adrenaline - drainage and washout in theatre

Question 39

describe vesicoureteric reflux

Answer 39

abnormal backflow of urine from the bladder into the ureter and kidney predisposes to UTI Clinical features - antenatal period: hydronephrosis on ultrasound - recurrent childhood UTIs - reflux nephropathy (chronic pyelonephritis secondary to VUR) - hypertension Investigation - micturating cystourethrogram - DMSA scan: renal scarring

Question 40

describe paediatric basic life support

Answer 40

unresponsive? - shout for help - open airway, look, listen, feel for breathing - give 5 rescue breaths - check for signs of circulation > infants: use brachial or femoral pulse, children use femoral pulse - 15 chest compressions:2 rescue breaths > rate 100-120/min for both infants and children

Question 41

list risks of prematurity

Answer 41

- respiratory distress syndrome - intraventricular haemorrhage - necrotizing enterocolitis - chronic lung disease - hypothermia - feeding problems - infection - jaundice - retinopathy of prematurity (<32 weeks) - hearing problems

Question 42

describe the management of hernias in children

Answer 42

umbilical hernias - spontaneously resolve by 3 years old > if large/symptomatic: elective repair at 2-3 years > small/asymptomatic: elective repair at 4-5 years inguinal hernias: high risk of incarceration > clinical features: bulge inferior and lateral to pubic tubercle on crying - < 6 weeks old: correct within 2 days - <6 months old: correct within 2 weeks - <6 years old: correct within 2 months

Question 43

describe neonatal hypoglycaemia

Answer 43

blood glucose <2.6 mmol/L in neonates risk factors: prematurity, maternal diabetes, IUGR, macrosomic babies, mothers taking beta blockers, hypothermia, neonatal sepsis features - asymptomatic - autonomic: jitteriness, irritable, tachypnoea, pallor - neuroglycopaenic: poor feeding, weak cry, drowsy, hypotonia, seizures - other features: apnoea, hypothermia management - asymptomatic: encourage normal feeding and monitor BMs - symptomatic/very low blood glucose (<1mmol/L): admit to neonatal unit and give IV 10% dextrose

Question 44

list red flag features in croup and indications for admission

Answer 44

red flags: - audible stridor at rest - suprasternal and sternal wall retraction at rest - distress/agitation/restlessness/lethargy - tachycardia - hypoxaemia indications for admission - moderate/severe croup - <3 months of age - known upper airway abnormalities e.g. Down's, laryngomalacia - uncertainty about diagnosis (?DNSI, epiglottitis...)

Question 45

describe developmental dysplasia of the hip

Answer 45

risk factors: female sex, first born children, oligohydramnios, birth weight >5kg, congenital calcaenovalgus foot deformity more common in left hip, can be bilateral screening: ultrasound 6 weeks after birth > first-degree family history of hip problems early in life > breech presentation at or after 36 weeks gestation > multiple pregnancy > X-ray if infant >4.5 months clinical examination - Barlow test: attempt to dislocate an articulated femoral head - Ortolani test: attempt to relocate an dislocated femoral head - examine: > symmetry of skin creases > symmetry of leg length > level of knees when hips/knees bilaterally flexed - asymmetry is Galeazzi sign > restricted abduction of hip in flexion management - most stabilise by 3-6 weeks of age - pavlik harness ( dynamic flexion-abduction orthosis) if under 4-5 months - older children may require surgery

Question 46

describe the developmental milestones for a child of 6 weeks

Answer 46

- gross motor > good head control: raises head to 45 degrees when on tummy > stabilises head when raised to sitting position - fine motor/vision > tracks object/face - speech/language > stills, startles at loud noise - social > social smile (visual problem if not)

Question 47

describe the developmental milestones for a child of 6 months

Answer 47

- gross motor > sit without support, rounded back > rolls tummy (prone) to back (supine) > cruises - fine motor/vision > palmar grasp (5m) > transfer hand to hand > forgets fallen objects - speech/language > turns head to loud sounds > understands "bye bye" / "no" (7m) > babbles (monosyllabic) - says ma, da > 9 months: polysyllables dada, mum-mum - social > puts objects to mouth (stops at 1yr) > shakes rattle > reaches for bottle/breast > stranger aware

Question 48

describe the developmental milestones for a child of 9 months

Answer 48

- gross motor > pulls self from sitting to standing > straight back sitting (7 1/2m) > crawls (some children bottom-shuffle) - fine motor/vision > inferior pincer grip > points with finger > object permanence - looks for fallen objects - speech/language > responds to own name > imitates adult sounds - social > stranger fear (6-9mths-2 years) > holds and bites food

Question 49

describe the developmental milestones for a child of 12 months

Answer 49

- gross motor > walks alone (9-18m) > 18m is threshold for worry (Duchenne's, hip problems, cerebral palsy) > can rise to sitting position from lying down - fine motor/vision > builds 2 brick tower > bangs blocks together > neat pincer grip (10m) > casting bricks (should disappear by 18m) - speech/language > shows understanding of nouns (where's mummy?) > responds to own name > 1-3 words with meaning > points to own body parts (15m), doll (18m) - social > waves "bye bye" > hand clapping > plays alone if familiar person nearby > drinks from beaker with lid > comes when called > cooperates with dressing

Question 50

list indications for head CT in children with a head injury

Answer 50

CT head within 1h - 3 or more episodes of vomiting - LOC >5 mins - amnesia >5mins - abnormal drowsiness - suspicion of non-accidental injury - post-traumatic seizure if non-epileptic child - GCS <14 or <15 if baby under 1 - suspicion of skull fracture or tense fontanelle - focal neurological deficit - if under 1 year, presence of bruise more than 5cm on head - dangerous mechanism of injury

Question 51

describe the management and complications of undescended testes

Answer 51

unilateral undescended testis - review at 3 months - if persistent refer for orchidopexy bilateral undescended testes - review by senior paediatrician within 24h complications - infertility - torsion - testicular cancer - psychological

Question 52

describe Edward's syndrome

Answer 52

trisomy 18: edward rock n roll (can go clubbing at 18) features - micrognathia - low-set ears - rocker bottom feet (rock musician) - overlapping of fingers (edward scissorhands) - clenched fist (around microphone) - short sternum - congenital heart disease

Question 53

describe Patau syndrome

Answer 53

trisomy 13 features - cleft lip / palate - polydactyly - microphthalmia, microcephaly - scalp defects - congenital heart disease

Question 54

describe fragile X syndrome

Answer 54

X-linked dominant trinucleotide repeat disorder features - intellectual disability - macrocephaly - macro-orchidism - characteristic long face, large ears, hyperextensible joints - behavioural problems: ADHD, ASD

Question 55

describe William's syndrome

Answer 55

features - elfin facies: wide mouth, small nose, full lips - cardiovascular disease: supravalvular aortic stenosis - hypercalcaemia - intellectual disability - outgoing personality

Question 56

describe Noonan syndrome

Answer 56

features - webbed neck - pectus excavatum - short stature - pulmonary stenosis

Question 57

describe Pierre-Robin syndrome

Answer 57

features - micrognathia - posterior displacement of tongue (may result in upper airway obstruction) - cleft palate

Question 58

describe Prader-Willi syndrome

Answer 58

genetic imprinting: phenotype depends on whether the deletion occurs on a gene inherited from mother or father features - neonatal hypotonia - learning difficulties - hypogonadism, infertility - obesity - short stature

Question 59

describe cri du chat syndrome

Answer 59

chromosome 5p deletion syndrome features - characteristic cry due to larynx and neurological problems - feeding difficulties and poor weight gain - learning difficulties - microcephaly and micrognathism - hypertelorism

Question 60

describe the management of a child with a palpable abdominal mass

Answer 60

- urgent referral to on-call paediatric registrar for assessment of neuroblastoma or Wilms tumour

Question 61

describe a neuroblastoma

Answer 61

tumour arising from neural crest cells in adrenal medulla and sympathetic nervous system features - palpable abdominal mass - pallor, weight loss - bone pain, limp - hepatomegaly - paraplegia - proptosis investigations - raised urinary vanillylmandelic acid (VMA) and homovanillic acid (HVA) - calficiation may be seen on abdo X-ray - biopsy

Question 62

describe viral-induced wheeze

Answer 62

causes: RSV, rhinovirus, coronaviruses, parainfluenza features - children >2y - shortness of breath - signs of respiratory distress - expiratory wheeze throughout chest - no atopic history - only occurs during viral infections, as opposed to asthma management - same as acute asthma: > inhalers/nebulisers > oral prednisolone

Question 63

list signs of respiratory distress in children

Answer 63

- nasal flaring - grunting - stridor - wheeze - head bobbing - tracheal tugging - subcostal and intercostal recessions - increased respiratory rate - use of accessory muscles - cyanosis

Question 64

describe the management of acute asthma

Answer 64

management - supplementary oxygen - bronchodilators - salbutamol, ipratropium bromide - steroids - antibiotics if infection suspected severe: magnesium sulphate, aminophylline

Question 65

describe chronic asthma and its treatment

Answer 65

features - diurnal variability - dry cough with wheeze and shortness of breath - history of atopy: eczema, hay fever, food allergies - bilateral widespread polyphonic wheeze diagnosis in children: 1. fraction eNO (>=35 ppb) 2. bronchodilator reversibility with spirometry 3. peak expiratory flow variability 4. skin prick test to house dust mite OR total IgE and blood eosinophils Management - child <5y: 8-12 week trial of twice daily paediatric low-dose ICS + SABA prn - child >5y: > twice daily paediatric low-dose ICS + SABA prn > if uncontrolled consider paediatric low-dose MART > if uncontrolled consider increase to paediatric moderate-dose MART

Question 66

describe whooping cough

Answer 66

URTI caused by Bordatella pertussis features - coryzal symptoms - fever - paroxysmal cough - inspiratory whoop when coughing ends - intensity of cough may precipitate faint, vomit or pneumothorax - apnoeas diagnosis - nasopharyngeal / per nasal swab: PCR testing / bacterial culture - lymphocytosis - cough present >2 weeks: anti-pertussis toxin immunoglobulin G management - notifiable disease - supportive care - macrolide antibiotics e.g. azithromycin in first 21 days - close contacts: prophylactic antibiotics - symptoms typically resolve within 8 weeks complication - bronchiectasis school exclusion: 2 days after commencing antibiotics or 21 days from onset of symptoms if no antibiotics

Question 67

describe chronic lung disease of prematurity

Answer 67

aka bronchopulmonary dysplasia occurs in premature babies (<28 weeks) after the infant requires oxygen therapy after 36 weeks gestational age features - low oxygen saturations - increased WOB - poor feeding and weight gain - crackles and wheezes on chest auscultation - increased susceptibility to infection prevention - giving steroids to mothers in premature labour - once the neonate is born > avoid intubation/ventilation, use CPAP if possible > caffeine to stimulate respiratory effort > avoid over-oxygenation with supplementary oxygen diagnosis - CXR changes, sleep study management - low dose oxygen at home to be weaned over first year of life - monthly injections of palivizumab to protect against RSV

Question 68

describe the clinical features of cystic fibrosis

Answer 68

AR condition affecting chloride channels in mucus glands most common mutation is delta-F508 features - chronic cough and thick sputum production - recurring airway infections - pancreatic insufficiency (steatorrhoea), pancreatitis - failure to thrive - abdominal pain and bloating - salty sweat - congenital bilateral absence of vas deferens in males - meconium ileus - finger clubbing - nasal polyps - crackles and wheezes on auscultation

Question 69

describe the diagnosis of cystic fibrosis

Answer 69

diagnosis - screening at birth with newborn bloodspot test: raised immunoreactive trypsinogen (IRT) - sweat test: gold standard - genetic testing: CFTR gene during pregnancy by amniocentesis or chorionic villous sampling, or blood test after birth common colonisers: staph aureus, haemophilus influenza, klebsiella pneumoniae

Question 70

describe testing for parvovirus B19 in pregnant women with infected contacts

Answer 70

parvovirus B19 causes erythema infectiosum aka slapped cheek infectious from up to 3 weeks before rash develops > no longer infectious once rash appears infection in pregnancy mostly causes no issues but complications can include hydrops fetalis and fetal death > pregnant women with infected contacts require immediate serological testing Serological testing > IgM positive and IgG negative: recent infection, refer to fetal medicine > IgG positive and IgM negative: immunity to parvovirus > IgG negative and IgM negative: repeat test in 4 weeks

Question 71

describe the clinical features of erythema infectiosum aka slapped cheek

Answer 71

aka fifth disease, caused by parvovirus B19 features - asymptomatic - mild fever - noticeable rose-red rash in cheeks - rash may spread to rest of body - child feels better as rash appears and this peaks after a week and then fades - heat can sometimes make rash reappear for several months after aplastic anaemia can be precipitated in > sickle cell disease, thalassaemia, hereditary spherocytosis, haemolytic anaemia > presents with low Hb and low reticulocyte count

Question 72

describe fluid prescription in children

Answer 72

child's circulating blood volume = 75-80mls/kg fluid resuscitation: > fluid bolus: 10 mls/kg > children with severe DKA: 10mls/kg of 0.9% NaCl (risk of cerebral oedema) maintenance fluids: > 100ml/24h for every kg between 0-10kg (or 4ml/kg/hr) > 50ml/24h for every kilo from 11-20kg (or 2ml/kg/hr) > 20ml per kilo thereafter (or 1ml/kg/hr) e.g. child weighing 13.5kg = 100 + 3.5*50 = 1175ml/24h potassium: 1-2mmol/kg/24h

Question 73

describe the developmental milestones expected of a child of 18 months of age

Answer 73

- gross motor > climbs stairs holding rail / two feet a step > squats to pick up toy > runs unsteadily (16m) > jumps (18m) - fine motor/vision > fisted grasp of pencil: to and fro scribbles (15m) > builds 4 block tower > turns pages of book several at a time - speech/language > shows understanding of nouns ("show me the xxxx") > 1 to 6 different words > obeys simple instructions > 10 words - social > imitates every day activities > spoon feeds self, lifts and drinks from cup > takes off shoes, socks, hat

Question 74

describe the developmental milestones expected of a 2- 2 1/2 year old child

Answer 74

- gross motor > runs > walks upstairs, both feet/each step > throws ball at shoulder level > kicks ball - fine motor/vision > draws a vertical line or horizontal line > build 8 block tower > puzzles: shape matching is >2 year skill, random effort is <2 year > turns pages of book one at a time - speech/language > shows understanding of verbs ("what do you draw with, what do you eat with?") > 2-4 words joined together (50+ words) > shows understanding of prepositions in/on "put the cat on the bowl" social > eats skilfully with a spoon > dry by day > no sharing > simple imaginative play

Question 75

describe the developmental milestones expected of a 3- 3/12 year old child

Answer 75

- gross motor > walks upstairs, one foot per step; downstairs two feet per step > rides a tricycle - fine motor/vision > draws a circle > builds a tower of 9-10 bricks > builds a bridge or train > puzzles: shape matching is > single cuts or cuts pieces > Griffiths beads - speech/language > gives full name and sex > counts by rote up to ten or more > comprehends meaning of under, over, in > understands negatives "which of these is NOT an animal" > understands adjectives "which one is red?" - social > begins to share toys with friends > plays alone without parents > eats with fork and spoon > understands comparatives "which boy is bigger than this one" while pointing to middle-sized boy > bowel control

Question 76

describe the developmental milestones expected of a 4-5 year old child

Answer 76

gross motor - walks upstairs / downstairs in adult manner - hops - single leg stand, runs on tiptoe fine motor/vision - 4 years: draws a cross and square - 5 years: draws a triangle/person - build a tower of 10 or more blocks - can imitate a bridge with three blocks - cuts paper in half - small beads - matches and names 4 colours language/speech - understands complex instructions "before you put x in y, give z to mummy" - uses complex narrative / sequences to describe events - counts by rote to 20 or more social - concern/sympathy for others if hurt - has best friend - bladder control (4 1/2 years) - engages in imaginative play, observing rules (4 1/2 to 5 years old) - understands taking turns and sharing - eats skilfully with little help - dressing and undressing - handles knife (at 5 years) - brushes teeth

Question 77

list routine screening opportunities for children

Answer 77

- Neonatal hearing screening (newborn babies) - Newborn Infant Physical examination (baby check) - Health visitor first visit (around 10 days of age) - 6 to 8-week review (second baby check) - 13 to 15-month review - 27 to 30-month review - 4 to 5-year review - Preschool Orthoptist Vision Screen - Primary School height and weight and health check (school nurses)

Question 78

describe the neonatal blood spot test

Answer 78

between days 5-9 of newborn’s life: heel prick test screens for 9 inherited conditions: - Sickle cell disease - Cystic fibrosis (CF) - Congenital hypothyroidism (CHT) - Phenylketonuria (PKU) - Medium-chain acyl-CoA dehydrogenase deficiency (MCADD) - Maple syrup urine disease - Isovaleric acidaemia (IVA) - Glutaric aciduria type 1 (GA1 ) - Homocystinuria (HCU) Infant must have been on milk feeds for at least 48 hours and not had a blood transfusion within last 72 hours for tests to be accurate

Question 79

describe UK's routine immunisation schedule

Answer 79

at birth: BCG (if risk factors) - TB in family in past 6 months 8 weeks - diphtheria, tetanus, pertussis, polio, haemophilus influenzae B, hepatitis B "6-in-1 vaccine" - meningococcal group B "men B" - oral rotavirus vaccine 12 weeks - diphtheria, tetanus, pertussis, polio, Hib, hepatitis B "6-in-1 vaccine" - pneumococcal (PCV) - oral rotavirus vaccine 16 weeks - diphtheria, tetanus, pertussis, polio, Hib, hepatitis B "6-in-1 vaccine" - Meningococcal group B "Men B" 1 year - Hib and MenC - pneumococcal (PCV) - Measles, mumps and rubella (MMR) - MenB 2-8 years: annual flu vaccine 3 years 4 months - diphtheria, tetanus, pertussis and polio "4-in-1 pre-school booster" - MMR 12-13 years - HPV vaccine 14 years - tetanus, diphtheria and polio "3-in-1 teenage booster" - menACWY 65 years - pneumococcal - influenza - shingles

Question 80

describe a formula used to estimate weight in a child

Answer 80

Weight (kg) = (age + 4) x 2 (use if aged >12 months)

Question 81

describe feeding in babies

Answer 81

volumes gradually increase in the first week of life as tolerated > 60mls/kg/day on day 1 > 90mls/kg/day on day 2 > 120mls/kg/day on day 3 > 150mls/kg/day on day 4 and onwards breast fed babies can lose 10% of birth weight and formula fed babies can lose 5% of their body weight by day 5 of life > must be back at birth weight by day 10 weaning around 6 months of age

Question 82

describe normal puberty

Answer 82

girls: 8-14 years - development of breast buds (first sign) - pubic hair - menstrual period boys: 9-15 years - testicular growth (first sign >4ml volume) - penile enlargement - darkening of scrotum - development of pubic hair - deepening of voice Tanner staging - examination findings of sex characteristics delayed puberty is due to hypogonadism

Question 83

describe hypogonadotrophic hypogonadism

Answer 83

- LH and FSH deficiency causes - iatrogenic damage to hypothalamus/pituitary - growth hormone deficiency - hypothyroidism - hyperprolactinaemia - serious chronic conditions e.g. cystic fibrosis, IBD - excessive exercise/dieting - constitutional delay in growth and development - Kallman syndrome (associated with anosmia)

Question 84

describe hypergonadotrophic hypogonadism

Answer 84

- high FSH and LH, failure of gonads to respond to stimulation causes - previous damage to gonads e.g. testicular torsion, cancer or infections e.g. mumps - congenital absence of testes/ovaries - Klinefelter's syndrome (XXY) - Turner's syndrome (XO)

Question 85

list different types of learning disability

Answer 85

- dyslexia - dysgraphia - dyspraxia aka developmental coordination disorder - auditory processing disorder - non-verbal learning disability - profound and multiple learning disability

Question 86

describe a cephalohaematoma

Answer 86

bleeding between periosteum and skull clinical features - swelling on newborn head - does not cross suture lines - presents several hours after birth - associated with instrumental extraction - most commonly parietal region - may take up to 3 months to resolve complication: jaundice

Question 86

describe Down's syndrome

Answer 86

trisomy 21 dysmorphic features - upslanting palpebral fissures - prominent epicanthic folds - Brushfield spots in iris - protruding tongue - small low-set ears - round/flat face clinical features - flat occiput - single palmar crease - pronounced "sandal gap" between big and first toe - hypotonia - congenital heart defects: atrioventricular septal defect most common, VSD, Tetralogy of Fallot - GI: duodenal atresia, Hirschprung's disease, imperforate anus later complications - hypothyroidism - acute lymphoblastic leukaemia - subfertility - learning difficulties - conductive hearing loss due to recurrent otitis media - short stature - repeated respiratory infections - early onset Alzheimer's disease - atlantoaxial instability - increased risk of neck dislocation

Question 87

describe a caput succedaneum

Answer 87

clinical features - diffuse subcutaneous fluid collection (oedema) - poorly defined margins: crosses suture lines - caused by pressure on presenting part of head during delivery - resolves over days

Question 88

describe a subgaleal haemorrhage

Answer 88

clinical features - bleeding between aponeurosis of scalp and periosteum - large, fluctuant collection crossing a suture lines - rare but may cause life-threatening blood loss

Question 89

describe a craniosynostosis

Answer 89

- one or more fibrous sutures in infant skull prematurely fuses - changes growth pattern of skull - results in raised ICP and damage to intracranial structures management: surgery - excision of prematurely fused suture - correction of associated skull deformities

Question 90

describe measles

Answer 90

measles: RNA paramyxovirus, spread via droplets clinical features - prodromal phase: irritable, fever - cough - coryzal symptoms - purulent conjunctivitis - fever - Koplik spots: white spots on buccal mucosa, pathognomic - diarrhoea - discrete maculopapular rash "lace-like": > starts behind the ears > spreads down the body between days 3 and 5 > becomes blotchy and confluent > desquamation sparing the palms and soles may occur after a week investigations: IgM antibodies management: supportive > admission if immunosuppressed / pregnant > notifiable disease > child contacts who are not immunised: MMR within 72h > can return to school 4 days from onset of rash

Question 91

list complications of measles

Answer 91

complications - acute otitis media: most common - pneumonia: most common cause of death - encephalitis: after 1-2 weeks - febrile convulsions - keratoconjunctivitis, corneal ulceration - increased incidence of appendicitis - myocarditis - subacute sclerosing panencephalitis: very rare, 5-10 years following illness

Question 92

describe threadworm infestation

Answer 92

Enterobius vermicularis or pinworms causes: swallowing eggs in environment clinical features - asymptomatic - perianal itching, especially at night - girls: vulval symptoms diagnosis > apply sellotape to perianal area and send for microscopy to see eggs > or treat empirically management - anthelmintic + hygiene measures for ALL members of the household - mebendazole first-line for children >6 months old > single dose given unless infestation persists

Question 93

why are the following avoided in children - aspirin - codeine - tramadol

Answer 93

aspirin: risk of Reye syndrome (except Kawasaki disease) Reye syndrome: rapidly worsening brain disease features - confusion - vomiting - personality changes - seizure - loss of consciousness - hepatotoxicity codeine and tramadol have unpredictable metabolism so are avoided

Question 94

describe a Meckel's diverticulum

Answer 94

congenital disorder causing malformation in the small intestine - outpouching remnant of omphalomesenteric duct rule of 2s - occurs in 2% of population, 2 feet from ileocaecal valve, 2 inches long features - asymptomatic - painless massive rectal bleeding - nausea and vomiting - constipation - abdominal pain mimicking appendicitis - intestinal obstruction investigations - haemodynamically stable: Meckel's scan (99m technetium pertechnetate) - mesenteric arteriography in more severe cases e.g. transfusion required management - removal if narrow neck or symptomatic > wedge excision or formal small bowel resection and anastomosis

Question 95

describe chickenpox

Answer 95

primary infection with varicella zoster virus (shingles is a reaction of dormant virus in dorsal root ganglion) - spread via respiratory route (highly contagious) - infectivity: 4 days before rash until lesions dry and crusted over (usually 5 days after rash first appeared) features - fever - itchy rash starting on head/trunk before spreading - initially macular then papular then vesicular > spots > blisters > scabs - mild systemic upset management - keep cool, trim nails - calamine lotion - ibuprofen is contraindicated due to nec fasc risk - school exclusion - immunocompromised and newborns with peripartum exposure: varicella zoster immunoglobulin > if chickenpox develops consider IV aciclovir

Question 96

list developmental red flags in children

Answer 96

red flags: - absence of social smile by 6 weeks - no sitting by 8 months - hand preference before 12 months > could be an indicator of cerebral palsy > risk factors: low birth weight - not walking by 18 months - persistent toe walking management: - refer urgently to child development service for multidisciplinary assessment - check hearing, vision - exclude environmental deprivation and general developmental delay

Question 97

describe intussusception

Answer 97

invagination of one portion of small bowel into lumen of adjacent bowel, most commonly ileocaecal region usually affects infants 6-18 months old features - intermittent, severe, crampy, progressive abdominal pain - inconsolable crying - vomiting - bloodstained stool - "red currant jelly" - late sign - during paroxysm infant will draw legs up towards chest and turn pale - sausage-shaped mass RUQ investigations - AXR: rule out obstruction - US: target sign management - first-line: reduction by air insufflation under radiological control - if this fails or signs of peritonitis: surgery

Question 98

describe pyloric stenosis

Answer 98

usually 2-4 week of life, but may present up to 4 months caused by hypertrophy of circular muscles of pylorus features - projectile vomiting, usually 30 mins after feed (non-bilious) - constipation and dehydration - palpable mass in upper abdomen - visible peristalsis as stomach tries to push past obstruction bloods: hypochloraemic, hypokalaemic alkalosis due to persistent vomiting diagnosis - ultrasound management: Ramstedt pyloromyotomy

Question 99

describe rickets

Answer 99

inadequately mineralised bone resulting in soft/easily deformed bones usually due to vitamin D deficiency features - aching bones and joints - lower limb abnormalities > toddlers: genu varum (bow legs) > older children: genu valgum (knock knees) - rickety rosary: swelling at costochondral junction - kyphoscoliosis - craniotabes: soft skull bones in early life - Harrison's sulcus investigations - low vitamin D levels - low serum calcium - raised ALP management: oral vitamin D

Question 100

describe normal lower limb variants in children

Answer 100

features - flat feet (pes planus) > all ages > absent medial arch on standing > usually resolves between ages 4-8 years > orthotics not recommended, reassurance - in-toeing > 1st year > resolves in majority - out-toeing > all ages > usually resolves by age 2 years - bow legs (genu varum) > 1st-2nd years > usually resolves by age 4-5 - knock knees (genu valgum) > 3rd-4th year > usually resolves spontaneously

Question 101

describe febrile convulsions

Answer 101

seizures provoked by fever in otherwise normal children > occur in 3% of children between 6 months and 5 years > 10% risk of febrile convulsion if history in a 1st degree relative features - seizures usually brief <5 mins - appear hot and flushed before losing consciousness - tonic-clonic seizure-like episodes - post-ictal period types of febrile convulsions - simple: > <15 mins > generalised seizure > typically no recurrence within 24h > complete recovery within 1h - complex > 15-30 mins > focal seizure > repeat seizures within 24h - febrile status epilepticus: >30 mins management - first seizure OR features of complex seizure: admit to paeds - ongoing > parents should call ambulance if seizure >5mins > recurrent febrile convulsions: benzodiazepines e.g. rectal diazepam / buccal midazolam - may be linked to epilepsy if: family history, complex febrile seizures, neurodevelopmental disorder

Question 102

describe a Wilms' tumour

Answer 102

Wilms' nephroblastoma - one of most common childhood malignancies usually children <5 years associations: Beckwith-Wiedemann syndrome, WAGR syndrome, hemihypertrophy features - abdominal mass - painless haematuria - flank pain - other: anorexia, fever - unilateral in most cases - metastasises most commonly to lung management - unexplained abdo mass: paeds review within 48h - nephrectomy - chemotherapy, radiotherapy in advanced disease

Question 103

describe Turner's syndrome

Answer 103

chromosomal disorder caused by only one sex chromosome (45,X) features - short stature - shield chest, widely spaced nipples - webbed neck - bicuspid aortic valve (ejection systolic murmur), coarctation of aorta - primary amenorrhoea - cystic hygroma - high-arched palate - short fourth metacarpal - multiple pigmented naevi - lymphoedema in neonates - elevated gonadotrophin levels - hypothyroidism - horseshoe kidney complications: autoimmune disease, aortic dissection management: growth hormone

Question 104

list signs of childhood sexual abuse

Answer 104

- pregnancy - STIs - recurrent UTIs - sexually precocious behaviour - anal fissure, bruising - reflex anal dilatation - perianal warts - enuresis and encopresis - behavioural problems, self-harm - recurrent symptoms e.g. headaches, abdominal pain

Question 105

describe scarlet fever

Answer 105

reaction to erythrogenic toxins produced by Group A haemolytic streptococci e.g. Streptococcus pyogenes more common in children aged 2-6 years, spread via respiratory route features - fever - malaise - headache - nausea and vomiting - sore throat / tonsillitis - bright red tongue "strawberry tongue" - rash > fine punctate erythema "pinhead" which appears first on torso and spares palms and soles > rough sandpaper texture > later in illness, desquamation occurs diagnosis: throat swab (commence antibiotics before results) management - oral penicillin V for 10 days (azithromycin if penicillin allergic) - can return to school 24h after commencing antibiotics - notifiable disease complications - otitis media: most common - rheumatic fever - acute glomerulonephritis - invasive complications: bacteraemia, meningitis, necrotising fasciitis

Question 106

describe nocturnal enuresis

Answer 106

involuntary discharge of urine at night in a child aged 5 years or older in the absence of defects in nervous system or urinary tract > if under 5 years, reassure parents management - exclude underlying causes: constipation, diabetes, UTI - general advice > reduce fluid intake before bed > encourage regular bladder emptying during day and before sleep > lifting and waking - reward systems e.g. Star chartd - enuresis alarm: first-line for children - desmopressin > if short-term control is needed or enuresis alarm is ineffective / not acceptable to family

Question 107

describe the Kocher's criteria for septic arthritis

Answer 107

assesses probability of septic arthritis in children features - non-weight-bearing: 1 point - fever >38.5 degrees: 1 point - WCC >12: 1 point - ESR>40mm/hr

Question 108

describe features of early and late shock in children

Answer 108

blood pressure - early: normal - late: hypotension heart rate - early: tachycardia - late: bradycardia respiration - early: tachypnoea - late: acidotic (Kussmaul) extremities - early: pale or mottled - late: blue urine output - early: reduced - late: absent

Question 109

describe gastroenteritis

Answer 109

most common cause in UK is rotavirus features - diarrhoea lasting 5-7 days and stops within 2 weeks - vomiting lasting 1-2 days and stopping within 3 days - dehydration > decreased consciousness > cold extremities > pale/mottled skin > tachycardia > tachypnoea > weak peripheral pulses > prolonged CRT > hypotension investigations - assess hydration status - stool culture if: suspected septicaemia, blood or mucus in stool, immunocompromised child management - clinical shock: IV rehydration - no evidence of dehydration > continue breastfeeding and other milk feeds > encourage fluid intake > discourage fruit juices and carbonated drinks - dehydration suspected > give 50mls/kg low osmolarity oral rehydration solution over 4h + ORS for maintenance > continue breastfeeding + supplementing with usual fluids

Question 110

describe plagiocephaly

Answer 110

skull deformity producing unilateral occipital flattening, which pushes ipsilateral forehead ear forwards producing parallelogram appearance most improve by age 3-5 due to adoption of more upright posture management - reassurance - conservative > turn cot around > tummy time > supervised supported sitting differentiate between craniosynostosis as ear moved with skull in plagiocephaly v fixed in craniosynostosis

Question 111

describe the Apgar score

Answer 111

assesses health of newborn baby > assess at 1 and 5 minutes of age > if low score repeat again at 10 mins A - appearance - pink all over: 2 points - body pink, extremities blue: 1 point - blue all over: 0 points P - pulse - >100 bpm: 2 points - <100: 1 point - absent: 0 points G - grimace (reflex irritability) - cries on stimulation/sneezes, coughs: 2 points - grimace: 1 point - nil: 0 points A - activity (muscle tone) - active movement: 2 points - limb flexion: 1 point - flaccid: 0 points R - respiratory effort - strong, crying: 2 points - weak, irregular: 1 point - nil: 0 points scores - 0-3: very low - 4-6: moderate low - 7-10: good state

Question 112

describe acute lymphoblastic leukaemia (ALL)

Answer 112

peak incidence 2-5 years of age clinical features - lethargy and pallor - frequent or severe infections - easy bruising, petechiae - epistaxis - bone pain, limp - splenomegaly, hepatomegaly - fever - testicular swelling investigations - bloods: anaemia, neutropaenia, thrombocytopaenia - lumbar puncture - bone marrow aspirate worse prognostic factors: male, WCC>20 at presentation, <2 or >10 years, having B or T cell surface markers, non-Caucasian ethnicity

Question 113

describe precocious puberty

Answer 113

<8 years in females and <9 years in males > thelarche: first stage of breast development > adrenarche: first stage of pubic hair development classification - gonadotrophin-dependent: > premature activation of hypothalamic-pituitary-gonadal axis > FSH and LH raised - gonadotrophin-independent; > excess sex hormones > FSH & LH low causes - females: usually idiopathic/familial. Organic cause is rare but happens rapidly e.g. McCune Albright syndrome - males: uncommon, usually organic cause > bilateral testicular enlargement: gonadotrophin release from intracranial lesion > unilateral testicular enlargement: gonadal tumour > small testes: adrenal tumour / hyperplasia

Question 114

describe investigations and management of meningitis in children

Answer 114

indications for LP > all children <1 month presenting with fever > 1-3 months: fever and unwell > under 1 year with unexplained fever and unwell management: notifiable disease - antibiotics > primary care: stat IV/IM benzylpenicillin > <3 months: IV amoxicillin (cover Listeria) + IV cefotaxime > >3 months: IV cefotaxime (or ceftriaxone) - steroids > avoid in children under 3 months > consider dexamethasone if LP reveals: frankly purulent CSF, CSF WCC >1000, bacteria on gram stain - fluids - cerebral monitoring - prophylaxis for contacts: ciprofloxacin

Question 115

describe head lice aka pediculosis capitis

Answer 115

aka nits caused by parasitic insect Pediculus capitis diagnosis: fine toothed combing of wet or dry hair management - only treat if living lice are found - choice of treatments: > malathion > wet combing > dimeticone > isopropyl myristate > cyclomethicone school exclusion is not advised

Question 116

describe haemolytic uraemic syndrome

Answer 116

Caused by E. coli O157 (STEC) which produces Shiga-like toxin (verotoxin), usually in children > associated with exposure to farm animals > can also be D -ve, caused by pneumococcal infection, HIV, SLE, drugs, cancer Classic triad - Microangiopathic haemolytic anaemia - AKI / uraemia - Thrombocytopaenia clinical features - bloody diarrhoea - abdominal pain - fever - vomiting - haematuria, oliguria - hypertension - bruising, pallor, lethargy - jaundice - confusion investigations: blood film, stool culture Management - supportive treatment only: IV fluids, transfusions and dialysis if needed - no role for antibiotics - plasma exchange or eculizumab if severe

Question 117

describe immune thrombocytopaenic purpura (ITP)

Answer 117

type II hypersensitivity reaction - antibodies against glycoprotein IIb/IIIa features - bruising - petechial or purpuric rash - bleeding is less common but may present as epistaxis or gingival bleeding - no fever - preceded by viral illness/vaccination labs: - FBC: isolated thrombocytopaenia - blood film - bone marrow examination if atypical features management - resolves in most children within 6 months - advice to avoid activities that may result in trauma e.g. team sports - if platelet count <10 or significant bleeding: steroids, immunoglobulins, platelet transfusions in emergency

Question 118

describe rubella

Answer 118

caused by rubella virus > highly contagious, respiratory spread features - mild erythematous macular rash > starts on face and spreads to rest of the body > classically lasts 3 days - mild fever - joint pain - sore throat - post-auricular and suboccipital lymphadenopathy Management - supportive - notifiable disease - avoid pregnant women due to risk of congenital rubella syndrome > triad of deafness, blindness and congenital heart disease Complications: thrombocytopenia, encephalitis school exclusion: 5 days from onset of rash

Question 119

describe mumps

Answer 119

clinical features - fever - malaise - muscular pain - parotitis: ear ache, pain on eating, facial swelling complications: - abdominal pain (pancreatitis) - testicular pain (orchitis) - confusion, neck stiffness and headache (meningitis/encephalitis) management: supportive; notifiable disease school exclusion: 5 days from onset of swollen glands

Question 120

describe impetigo

Answer 120

- acute superficial bacterial infection - very contagious features - honey coloured or golden crusting around mouth/nose - annular erythematous lesions - bullous impetigo causes blisters and erosions caused mostly by staph aureus management > localised non-bullous impetigo, systemically well: hydrogen peroxide 1% cream > widespread non-bullous impetigo, systemically well: topical fusidic acid 2% OR oral antibiotic > systemically unwell: - oral antibiotic: flucloxacillin (or erythromycin) school exclusion: until lesions are crusted and healed, or 48h after commencing antibiotic treatment

Question 121

describe the presentation and causes of meningitis in neonates and children

Answer 121

causes - neonates: group B strep, Listeria monocytogenes, E.coli - children: Neisseria meningitidis (gram negative diplococci) and Streptococcus pneumoniae presentation > neonates - lethargy, irritability - hypotonia - poor feeding - hypothermia - bulging fontanelle > children - fever - neck stiffness - photophobia - vomiting - non-blanching rash - altered consciousness - seizures complications: skin necrosis, abscesses / subdural empyema

Question 122

list contraindications to LP

Answer 122

contraindication to LP (any signs of raised ICP) - focal neurological signs - papilloedema - significant bulging of fontanelle - DIC - signs of cerebral herniation - meningococcal septicaemia > obtain blood cultures and PCR for meningococcus

Question 123

describe Kernig's and Brudzinski's test

Answer 123

Kernig’s test: creates a slight stretch in the meninges - lying the patient on their back, flexing one hip and knee to 90 degrees - then slowly straightening the knee whilst keeping the hip flexed at 90 degrees - positive Kernig's: spinal pain or resistance to movement Brudzinski’s test - lying patient flat on their back - use hands to lift head and neck off the bed and flex their chin to their chest - positive Brudzinski's: involuntary flexion of hips and knees

Question 124

list long-term complications of meningitis

Answer 124

- sensorineural hearing loss (most common) - seizures and epilepsy - memory loss - cognitive impairment and learning disability - cerebral palsy with focal neurological deficits e.g. limb weakness or spasticity

Question 125

describe roseola infantum

Answer 125

aka sixth disease > caused by human herpesvirus 6 (HHV-6) and less frequently HHV-7 features - high fever (up to 40ºC) that comes on suddenly - fever lasts for 3 – 5 days and then disappears suddenly - coryzal symptoms: sore throat, swollen lymph nodes - mild erythematous macular rash across the arms, legs, trunk and face > not itchy > appears for 1 – 2 days AFTER fever settles complication: febrile convulsions does not require exclusion from school Immunocompromised patients: complications e.g. myocarditis, thrombocytopenia and Guillain-Barre syndrome

Question 126

describe hand, foot and mouth disease

Answer 126

caused by coxsackie A16 virus features - fatigue - sore throat - dry cough - low-grade fever - small painful mouth ulcers - blistering red spots across body (mostly on hands, feet and mouth) > rash may be itchy - onychomadesis (nails split and peel 2-6 weeks later) management - supportive: adequate fluid intake, analgesia > resolve after 7-10 days does not require exclusion from school but highly contagious complications: dehydration, bacterial superinfection, encephalitis

Question 127

describe primary ciliary dyskinesia

Answer 127

aka Kartagener's syndrome AR condition causing dysfunction of motile cilia Kartagener's triad - paranasal sinusitis - bronchiectasis - situs inversus also male infertility investigations - biopsy of ciliated epithelium via nasal brushing or bronchoscopy - semen analysis for infertility management - daily physio - high calore diet - antibiotics

Question 128

describe an abdominal migraine

Answer 128

features - episodes of central abdominal pain lasting more than 1h - nausea and vomiting - anorexia - pallor - headache - photophobia - aura - normal examination management - acute attack: paracetamol / ibuprofen / sumatriptan, low stimulus environment - prevention: pizotifen, propranolol

Question 129

describe gastro-oesophageal reflux

Answer 129

in infants <8 weeks due to immature lower oesophageal sphincter, most improve by one year presentation - milky vomits after feeds - distress, crying, unsettled after feeding - reluctance to feed - chronic cough - hoarse cry - pneumonia - poor weight gain - children >1 year experience similar symptoms to adults management - advice: small frequent meals, burping regularly, keeping baby upright after feeding - breastfed baby: gaviscon first-line - bottle fed baby: feed thickeners - PPIs (omeprazole)

Question 130

describe biliary atresia

Answer 130

congenital condition where a section of the bile duct is narrowed or absent resulting in cholestasis clinical features - persistent jaundice > >14 days in term babies, >21 days in premature babies - high proportion of conjugated bilirubin - hepatomegaly with splenomegaly - dark urine and pale stools - abnormal growth management: surgery > Kasai portoenterostomy: prolongs survival but often full liver transplant is required > ursodeoxycholic acid as an adjuvant following surgery

Question 131

list causes of jaundice in neonates

Answer 131

unconjugated hyperbilirubinaemia - physiological jaundice - breast milk jaundice (commonest cause of prolonged jaundice) - haemolytic disease of the newborn - infection (UTI, sepsis) - congenital hypothyroidism - cephalohaematoma / bruising - hereditary spherocytosis - G6PD deficiency conjugated hyperbilirubinaemia - biliary atresia - idiopathic neonatal hepatitis - Alagille syndrome

Question 132

list causes of intestinal obstruction in neonates and children

Answer 132

- meconium ileus: soap bubble appearance on AXR - Hirschprung's disease - oesophageal atresia - duodenal atresia: double bubble sign on AXR - intussusception - imperforate anus - malrotation of intestines with a volvulus - strangulated hernia

Question 133

describe Hirschprung's disease

Answer 133

congenital condition where parasympathetic ganglion cells are absent from myenteric (Auerbach's) plexus in distal bowel and rectum features - delay in passing meconium (>24h) - chronic constipation since birth - abdominal pain and distension - vomiting - poor weight gain and failure to thrive - aganglionic megacolon - may be improvement after PR exam investigations: > AXR: dilated loops of bowel with fluid levels > barium enema: cone with dilated ganglionic proximal colon and distal aganglionic bowel failing to distend > rectal biopsy management - initial: NG tube decompression, rectal washouts / bowel irrigation - surgical removal of aganglionic section of bowel: abdominoperineal pull-through with diverting colostomy

Question 134

describe Hirschprung-associated enterocolitis

Answer 134

aka HAEC inflammation and obstruction of intestine occurring in 20% of neonates with Hirschprung's features - fever - abdominal distension - bloody diarrhoea - sepsis investigations: AXR complications: toxic megacolon, perforation management - antibiotics - fluid resuscitation - decompression of obstructed bowel

Question 135

describe congenital adrenal hyperplasia

Answer 135

defect in 21-hydroxylase enzyme which converts progesterone into aldosterone and cortisol > excess progesterone is converted into testosterone lab features: low aldosterone, low cortisol, high testosterone features - skin hyperpigmentation - mild CAH: presents during childhood/puberty > tall for age > early puberty > deep voice > females: facial hair, absent periods, ambiguous or virilised genitalia, enlarged clitoris > males: large penis, small testicles - severe CAH: presents shortly after birth > hyponatraemia, hyperkalaemia, hypoglycaemia > poor feeding > vomiting > dehydration > arrhythmias management: cortisol and aldosterone replacement with hydrocortisone and fludrocortisone

Question 136

describe growth hormone deficiency

Answer 136

congenital or acquired features - neonates > micropenis (males) > hypoglycaemia > severe jaundice - older infants/children > poor growth > short stature > slow development of movement/strength > delayed puberty investigations - growth hormone stimulation tests with glucagon, insulin, arginine and clonidine - test for pituitary abnormalities and genetic testing treatment - daily SC injection of growth hormone (somatropin) - treatment of associated hormone deficiencies

Question 137

describe congenital hypothyroidism

Answer 137

features - prolonged neonatal jaundice - poor feeding - constipation - increased sleeping - reduced activity - slow growth and development investigations: TFTs, thyroid US, thyroid antibodies management: levothyroxine

Question 138

describe vulvovaginitis

Answer 138

inflammation and irritation of vulva and vagina - common condition affecting girls between ages of 3 and 10 risk factors: wet nappies, chemicals/soaps to clean the area, tight clothing, poor toilet hygiene features - soreness - itching - erythema around labia - vaginal discharge - dysuria - constipation management - lifestyle: good toilet hygiene, avoiding chemicals/soaps, emollients, loose cotton clothing - severe: oestrogen cream

Question 139

describe nephrotic syndrome

Answer 139

features - frothy urine - generalised oedema - pallor classic labs - low serum albumin - high urine protein content - oedema - deranged lipids: high cholesterol, triglycerides - high BP - hypercoagulability: increased risk of VTE causes > minimal change disease: most common in children > others: glomerulonephritis, secondary to HSP, diabetes...

Question 140

describe a posterior urethral valve

Answer 140

tissue at the proximal end of the urethra causing obstruction of urine output leading to hydronephrosis > occurs in newborn boys features - difficulty urinating - weak urinary stream - chronic urinary retention - palpable bladder - recurrent UTIs - impaired kidney function - severe cases are identified antenatally due to oligohydramnios and hydronephrosis investigations: abdominal US, micturating cystourethrogram (MCUG), cystoscopy management - catheter (temporary) - definitive: ablation or removal of extra urethral tissue during cystoscopy

Question 141

describe hypospadias

Answer 141

congenital condition where urethral meatus is abnormally placed on underside (ventral side) of penis towards scrotum > epispadias when meatus is on top side of penis associated condition: chordee (head of penis bends downwards) management - surgery at around 12 months to correct position of meatus and straighten penis - do not circumcise infant

Question 142

describe erythema toxicum neonatorum

Answer 142

normal rash in newborns features > erythematous macules, papules, and pustules Lesions usually appear from 48 hours of age and resolve spontaneously

Question 143

describe congenital dermal melanocytosis

Answer 143

aka slate grey naevi or Mongolian blue spots - often resolves/fades by age 4-5 more common in african & asian babies - Benign, flat, congenital birthmark - Wavy borders and irregular shape - Usually located over sacrum - Commonly blue in colour can be mistaken for bruise - Disappear within 3-5 years after birth

Question 144

describe eczema

Answer 144

aka atopic dermatitis, onset usually <2yrs Chronic inflammatory skin condition associated with atopy > associated with filaggrin (FLG) mutation (dry skin, hyperlinear palms, keratosis pilaris) clinical features - itchy flexural rash > cheeks, forehead and outer limbs in <4y - excoriation marks - general dry skin - history of asthma, allergic rhinitis, food allergy (or atopy in 1st degree relative in <4y) - dark skin: > dry skin > can have reverse pattern (outer elbow/front of knees) > follicular pattern esp. trunk > discoic eczema: well-demarcated plaques > lichenoid "thickened" areas > looks purple or "darker" when inflamed > leaves hypopigmentation as it resolves management - emollients - topical steroids (consider wet wrapping) - calcineurin inhibitor (Tacrolimus) - UVB phototherapy - immunosuppression: methotrexate, ciclosporin - biologics & JAK inhibitors - treat superadded infection > bacterial (usually staph aureus): golden crust, systemically unwell > viral e.g. eczema herpeticum

Question 145

describe a port wine stain

Answer 145

Aka naevus flammeus Red/purple marks on face and neck due to capillary malformation Typically present from birth (bright red) and do not regress but become violaceous with time Can be associated with Sturge-Weber syndrome and Klippel-Trenaunay syndrome

Question 146

describe infantile colic

Answer 146

occurs in infants <3 months old and resolves by 6 months features - bouts of excessive crying - pulling up of legs - worse in evening unknown cause

Question 147

describe toddler's diarrhoea

Answer 147

benign condition due to fast transit through their digestive system features - stools vary in consistency - contains undigested food no treatment required

Question 148

describe Kawasaki disease

Answer 148

clinical features - fever >5 days - maculopapular rash on trunk - lymphadenopathy - perioral changes: cracked lips, strawberry tongue - desquamation of palms and soles - bilateral non-purulent conjunctivitis clinical diagnosis, inflammatory changes on bloods complications: coronary artery aneurysms > screen with echocardiogram management - high dose aspirin, then low-dose on d/c - single dose of intravenous immunoglobulin - steroids - cardiology follow-up

Question 149

explain delayed umbilical cord clamping

Answer 149

Delayed clamping of the umbilical cord provides time for placental blood to enter the circulation of the baby - placental transfusion leads to - improved haemoglobin, iron stores and blood pressure - reduction in intraventricular haemorrhage and necrotising enterocolitis - negative effect: an increase in neonatal jaundice, potentially requiring more phototherapy Current guidelines - uncompromised neonates: delay at least one minute in the clamping of the umbilical cord - neonates requiring resuscitation: clamp sooner to prevent delays in resuscitation

Question 150

describe Erb's palsy

Answer 150

injury to C5/C6 nerves in the brachial plexus during birth > associated with shoulder dystocia, traumatic or instrumental delivery and large birth weight clinical features - weakness of shoulder abduction and external rotation, arm flexion and finger extension - affected arm has a “waiters tip” appearance > internally rotated shoulder, extended elbow, flexed wrist facing backwards (pronated) > lack of movement in the affected arm management - function normally returns spontaneously within a few months - if function does not return: neurosurgical input

Question 151

describe neonatal sepsis

Answer 151

Common Organisms - Group B streptococcus (GBS): Streptococcus agalactiae - Escherichia coli (e. coli) - Listeria - Staphylococcus aureus Risk Factors: vaginal GBS colonisation, GBS sepsis in a previous baby, Maternal sepsis, chorioamnionitis or fever > 38ºC, prematurity, PROM Clinical Features - fever - reduced tone and activity - poor feeding - respiratory distress or apnoea, hypoxia - vomiting - tachycardia or bradycardia - seizures - hypoglycaemia - jaundice within 24h management - benzylpenicillin + gentamicin first line

Question 152

describe hypoxic ischaemic encephalopathy (HIE)

Answer 152

complications: cerebral palsy, death causes - maternal shock - intrapartum haemorrhage - prolapsed cord - nuchal cord HIE grading - Sarnat Staging - mild: > poor feeding, general irritability, hyper-alert > resolves within 24h > normal prognosis - moderate > poor feeding, lethargic, hypotonic, seizures > weeks to resolve > 40% develop cerebral palsy - severe > reduced consciousness, apnoeas, flaccid/absent reflexes > 50% mortality, 90% develop cerebral palsy management - supportive care - therapeutic hypothermia

Question 153

list causes of jaundice in a neonate

Answer 153

increased production of bilirubin - haemolytic disease of the newborn - ABO incompatibility - haemorrhage - intraventricular haemorrhage - cephalohaematoma - polycythaemia - sepsis and DIC - G6PD deficiency decreased clearance of bilirubin - prematurity - breast milk jaundice - neonatal cholestasis - extrahepatic biliary atresia - endocrine disorders (hypothyroid and hypopituitary) - Gilbert syndrome

Question 154

describe haemolytic disease of the newborn

Answer 154

caused by incompatibility between the rhesus antigens on the surface of the RBCs of the mother and fetus Usually due to mothers being sensitisation in a previous pregnancy and forming antibodies which then cross placenta features - haemolysis - anaemia - high bilirubin complications: kernicterus (high bilirubin causing brain damage) > deafness, learning disability, cerebral palsy

Question 155

describe physiological jaundice

Answer 155

high concentration of red blood cells in the fetus and neonate > more fragile than normal red blood cells > less developed liver function Fetal RBC break down releases lots of bilirubin > causes mild yellowing of skin and sclera from 2 – 7 days of age > usually resolves by 10 days management - monitor according to bilirubin level on treatment threshold chart > phototherapy > exchange transfusion if severe

Question 156

describe apnoea of prematurity

Answer 156

when breathing stops spontaneously for >20 seconds, or shorter periods with oxygen desaturation/bradycardia occurs in almost all babies <28 weeks due to immaturity of the autonomic nervous system that controls respiration and heart rate can be a sign of developing illness e.g. infection, anaemia, airway obstruction, GORD, neonatal abstinence syndrome, CNS pathology Management - apnoea monitors > use tactile stimulation to prompt baby to restart breathing - IV caffeine to prevent apnoea and bradycardia if recurrent episodes - self-resolves

Question 157

describe retinopathy of prematurity

Answer 157

screening for ROP - babies born <32 weeks or <1.5kg should be screened for ROP Treatment - transpupillary laser photocoagulation first line > halt and reverse neovascularisation - cryotherapy - injections of intravitreal VEGF inhibitors - surgery if retinal detachment occurs

Question 158

describe respiratory distress syndrome

Answer 158

affects premature neonates due to lack of surfactant, aka surfactant deficient lung disease (SDLD) Chest xray: “ground-glass” appearance features - atelectasis (lung collapse) - hypoxia, cyanosis - hypercapnia - respiratory distress: tachypnoea, intercostal recession, expiratory grunting Management - antenatal steroids (i.e. dexamethasone) for mothers in preterm labour - CPAP via nasal mask - supplementary oxygen - severe: intubation, ventilation - endotracheal surfactant complications: > short-term: pneumothorax, infection, apnoea, pulmonary haemorrhage > long-term: chronic lung disease of prematurity, ROP, neurological impairment

Question 159

describe necrotising enterocolitis (NEC)

Answer 159

disorder affecting premature neonates where part of the bowel becomes necrotic > life threatening emergency: death of bowel can lead to perforation risk factors: prematurity, formula feeding, respiratory distress, sepsis, congenital heart disease clinical features - intolerance to feeds - bilious vomiting - distended, tender abdomen - absent bowel sounds - blood in stools - if perforation: peritonitis, shock Investigations - supine abdominal xray > dilated loops of bowel > bowel wall oedema > pneumatosis intestinalis: gas in the bowel wall > pneumoperitoneum if perforation Management - Nil by mouth with IV fluids, total parenteral nutrition (TPN) and antibiotics - NG tube insertion to decompress stomach - immediate referral to neonatal surgical team Complications: perforation, sepsis, death, strictures, abscess formation, long-term stoma

Question 160

describe neonatal abstinence syndrome

Answer 160

Withdrawal from - opiates, diazepam, SSRIs and alcohol: 3 – 72h after birth. - methadone / other benzodiazepines: 24h - 21 days clinical features - Irritability - Increased tone - High pitched cry - Tremors - Seizures - Yawning - Sweating - Unstable temperature / pyrexia - Tachypnoea - Poor feeding - Regurgitation / vomiting - Hypoglycaemia - Loose stools with a sore nappy area Management - monitoring with NAS chart for at least 3 days - urine sample to test for substances - quiet, dim environment with gentle handling / comforting - pharmacological (moderate to severe) - Oral morphine sulphate (opiate withdrawal) - Oral phenobarbitone (non-opiate withdrawal)

Question 160

describe minimal change disease

Answer 160

most common cause of nephrotic syndrome in children most cases are idiopathic but can be associated with - drugs: NSAIDs, rifampicin - Hodgkin's lymphoma, thymoma - Infectious mononucleosis Features - nephrotic syndrome - normotension - highly selective proteinuria - renal biopsy > light microscopy - normal > EM: fusion of podocytes and effacement of foot processes Management - oral steroids e.g. prednisolone - diuretics for oedema - cyclophosphamide if steroid-resistant prognosis is good but relapse is common

Question 161

describe post-streptococcal glomerulonephritis and its management

Answer 161

Occurs 7-14 days after group A beta-haemolytic streptococcus infection (usually Streptococcus pyogenes) > 1-3 weeks following URTI > 3-6 weeks following skin infection e.g. impetigo Caused by immune complex deposition (IgG, IgM and C3) in the glomeruli most common cause of nephritic disease in children features > malaise, headache > visible haematuria, proteinuria > hypertension > oliguria bloods: raised anti-streptolysin O titre (confirms recent strep infection), low C3 management - supportive: fluid balance, penicillin, anti-hypertensives, diuretics if oedema Renal biopsy - acute diffuse proliferative glomerulonephritis - endothelial proliferation with neutrophils - EM: subepithelial humps caused by immune complex deposits - immunofluorescence: granular or starry sky appearance

Question 162

describe mesenteric adenitis

Answer 162

inflammation of abdominal lymph nodes secondary to viral infection common cause of abdominal pain in children under 16

Question 163

describe testicular torsion

Answer 163

features - severe sudden onset testicular pain - no relief of pain on elevation (negative prehn's sign) - absent cremasteric reflex in torsion of spermatic cord - more common in young men (<18) - risk factors: Bell-clapper deformity (transverse lie on examination), physical activity, trauma - uss: whirlpool sign - spiral appearance to the spermatic cord and blood vessels - management: - <6h: scrotal exploration, urgent surgical reduction with fixation of both testes (bilateral orchidopexy) - >6h: urgent orchidectomy and contralateral orchidopexy

Question 164

describe phimosis

Answer 164

non-retractile foreskin physiological in children aged 2-4 > avoid forcible retraction management - personal hygiene - if >2y and UTIs/recurrent balanoposthitis, then treatment

Question 165

describe paraphimosis

Answer 165

rectracted foreskin which cannot be pulled forward leads to progressive pain and swelling in glans, can lead to necrosis if untreated management - reduce ASAP with analgesia: lubricant and manual pressure

Question 166

describe balanitis

Answer 166

inflammation of the glans penis (posthitis is inflammation of the foreskin) clinical features - erythema - penile pain - itch - bleeding - urethral discharge management > hygiene advice > bacterial infection: topical antibiotics > fungal infection: topical antifungal > hydrocortisone cream if dermatitis

Question 167

describe torsion of the testicular appendage (hydatid)

Answer 167

torted hydatid of Morgagni > most common cause of testicular pain/swelling in children clinical features > cremasteric reflex is preserved > gradual onset (2-3 days) > blue spot under skin > reactive hydrocoele > localised to upper scrotum management - discharge home with analgesia

Question 168

describe a congenital diaphragmatic hernia

Answer 168

condition resulting from a developmental defect in the diaphragm leading to protrusion of abdominal contents into the thoracic cavity clinical features - feeding problems - respiratory distress - displaced heart sounds - bowel sounds in respiratory exam - scaphoid abdomen presence of liver in thoracic cavity is a poor prognostic factor management: surgical repair > complications: pulmonary hypoplasia and hypertension

Question 169

describe irritant contact napkin dermatitis

Answer 169

seen with cloth nappies (uncommon with disposable nappies), chronic diarrhoea, neglect moisture & friction disrupt skin barrier - penetration of irritants from urine & faeces > erythema spares skin folds > candida overgrowth common (satellite papules & pustules) management - frequent nappy changes - avoid soap/wipes - emollient to repair skin barrier - thick barrier preparation (Zinc) every change - topical steroid/antifungal if very inflamed

Question 170

describe staphylococcal scalded skin syndrome

Answer 170

due to release of exotoxins produced by a staphylococcal strain features - malaise - fever - erythroderma - flaccid bullae peri-orificially and in flexures - spreads in sheets - dehydration due to fluid loss management - IV penicillin and flucloxacillin - IV fluids

Question 171

describe herpes simplex (HSV)

Answer 171

reactivation at site of primary infection management - aciclovir (prophylaxis if recurrent) - caution if periorbital involvement - if eczema may spread rapidly > acute deterioration > pain > monomorphic punched out lesions

Question 172

describe viral warts

Answer 172

caused by HPV - can be found on hands - may auto-inocculate or may be through vertical transmission (caution for CSA) management - salicylic acid with duct tape occlusion - cryotherapy - cantharadin - curettage - bleomycin, 5-FU, PDL and CO2 laser

Question 173

describe acute urticaria

Answer 173

features - itchy papules (hives) and plaques - wheal and flare - last up to 6-8 weeks triggers - infection: bacterial, viral (lasts weeks) - ingestion: drugs, foods (lasts hours) - injection: drugs, immunisation, blood products - aero: pollen, moulds

Question 174

describe infantile haemangioma

Answer 174

benign tumour of blood vessels > form raised red lump on skin which appears soon after birth Aka strawberry marks Get bigger over 6-12 months then shrink and disappear by age 7 > may have a precursor at birth: bruise, flat pink area, white area more common in premature infants and girls management - Require treatment if affecting vision, breathing or feeding - beta-blockers: propranolol - laser therapy if not involuting for cosmetic purposes > concern about segmental HOI (large, occur as plaque, associated with underlying abnormalities) complications: ulceration, infection, bleeding

Question 175

describe a salmon patch

Answer 175

Aka stork mark or nevus simplex Red or pink patches often on eyelids, head or neck Caused by congenital capillary malformation Very common Usually fade by age two

Question 176

describe transient tachypnoea of the newborn

Answer 176

most common cause of respiratory distress in the newborn period caused by delayed reabsorption of fluid from the lungs more common following C-sections

Question 177

what conditions might the absence of a fundal reflex indicate?

Answer 177

- retinoblastoma (RB1 tumour suppressor gene mutation) - congenital cataracts

Question 178

describe talipes equinovarus

Answer 178

aka clubfoot - deformity of ankle & foot causing plantarflexion and inversion management - ponseti technique: serial plaster casting, cutting of achilles and foot orthosis positional talipes can be corrected: physio

Question 179

describe sticky eye

Answer 179

usually due to blocked lacrimal duct > conservative: massage lacrimal duct

Question 180

describe Epstein's pearls, Bohn nodules and neonatal teeth

Answer 180

Epstein's pearls - white calcific nodule on palate > resolve by around 3 months Bohn nodules - found on inner labial aspect of maxillary alveolar ridges (gum) Neonatal teeth - very rare, present at site of incisors

Question 181

describe spina bifida

Answer 181

neural tube defect associated with folate deficiency in pregnancy types: spina bifida occulta, spina bifida cystica signs - lower back pain - dysesthesia below lesion - hip dysplasia - leg weakness - nystagmus - clubfoot - scoliosis complications: meningitis, neurogenic bladder/bowel, seizures, hydrocephalus, nerve damage paralysis

Question 182

describe diastasis recti

Answer 182

weakness of fascia between rectus abdominis muscles not a hernia spontaneously resolves

Question 183

describe ophthalmia neonatorum

Answer 183

conjunctivitis in first 28 days of life exclude Neisseria gonorrhoea (first few days) and Chlamydia trachomatis (5-14 days) > urgent swab and treatment with IV antibiotics >> IV cefotaxime - gonorrhoea >> oral erythromycin - chlamydia >> saline eye washouts >> urgent ophthalmology review

Question 184

list complications of chickenpox

Answer 184

- secondary bacterial infection of lesions > chicken pox is a risk factor for invasive group A streptococcal soft tissue infections >> necrotising fasciitis >> toxic shock syndrome - rare: pneumonia, meningoencephalitis, cerebellitis (ataxia), disseminated haemorrhagic chickenpox, arthritis, nephritis, pancreatitis

Question 185

describe androgen insensitivity syndrome

Answer 185

X-linked recessive disorder: phenotypically female genitalia in a genetic male features - breast bud development, sparse pubic hair - primary amenorrhea due to inherent absence of ovaries/uterus - inguinal hernia (immature testes) diagnosis - high LH - normal/high testosterone - buccal smear/chromosomal analysis: 46XY genotype management - counselling - bilateral orchidectomy due to testicular cancer risk - oestrogen therapy

Question 186

describe neonatal resuscitation guidelines

Answer 186

- birth: dry baby, remove wet towels, cover and start clock - within 30s: assess tone, breathing and heart rate - within 60s: gasping/not breathing then open airway and give 5 inflation breaths - re-assess: if no increase in heart rate look for chest wall movement - if chest not moving: airway manoeuvres, repeat inflation breaths - if chest is moving and heart rate not detectable/slow: chest compressions at rate of 3:1

Question 187

describe idiopathic thrombocytopaenic purpura

Answer 187

immune-mediated reduction in the platelet count: antibodies against the glycoprotein IIb-IIIa or Ib complex, usually children <10y features - recent viral illness - bleeding: gums, epistaxis, menorrhagia - bruising - petechial/purpuric rash (non-blanching) investigations - isolated thrombocytopaenia - antiplatelet autoantibodies (IgG) - bone marrow aspiration if atypical features (lymph node enlargement / splenomegaly): megakaryocytes in marrow management - usually no treatment required and self-resolves within 6m - avoid contact sports - if platelets <10 > oral/IV steroids > IV immunoglobulins > platelet transfusion if bleeding

Question 188

describe exomphalos

Answer 188

aka omphalocoele abdominal contents protrude through the anterior abdominal wall, defect in UMBILICUS abdominal contents are covered in amniotic sac formed by amniotic membrane and peritoneum associations: Beckwith-Wiedemann syndrome, Down's syndrome, cardiac/kidney malformations management - C-section to reduce risk of sac rupture - staged repair as primary closure may be difficult due to lack of space / high intra-abdominal pressure

Question 189

describe gastroschisis

Answer 189

congenital defect in anterior abdominal wall, LATERAL to umbilicus abdominal contents NOT covered in peritoneum associated with socioeconomic deprivation (maternal age <20, alcohol/tobacco use) management - attempt vaginal delivery - newborns should go to theatre asap after delivery (within 4h)

Question 190

describe the classical triad of shaken baby syndrome

Answer 190

features - retinal haemorrhages > other features may include subconjunctival haemorrhage, signs of increased ICP - subdural haematomas - encephalopathy

Question 191

describe cow's milk protein intolerance/allergy

Answer 191

present in first 3 months of life in formula-fed infants, rarely breastfed babies features - regurgitation/vomiting - diarrhoea, blood in stool - urticaria, atopic eczema - "colic" symptoms: irritability, crying - wheeze, chronic cough - rarely angioedema/anaphylaxis diagnosis > clinical: improvement with cow's milk protein elimination > skin prick/patch testing > total IgE and specific IgE for cow's milk protein management > formula fed - trial of extensively hydrolysed formula (eHF) if mild-moderate - amino acid-based formula (AAF) in infants with severe CMPA / no response to eHF > breastfed - continue breastfeeding - eliminate cow's milk protein from maternal diet, use eHF when breastfeeding stops - maternal calcium supplements

Question 192

describe fetal alcohol syndrome

Answer 192

features - microcephaly - thin upper lip - smooth flat philtrum - short palpebral fissure - learning disability - behavioural difficulties - hearing/vision problems - cerebral palsy

Question 193

describe the following congenital varicella syndrome

Answer 193

congenital varicella syndrome - mother: varicella pneumonitis, hepatitis or encephalitis - fetal varicella syndrome: fetal growth restriction, microcephaly, hydrocephalus, learning disability, scars, limb hypoplasia, cataracts and chorioretinitis - severe neonatal varicella infection if mum is infected around delivery

Question 194

describe features for the following congenital syndromes - congenital cytomegalovirus - congenital toxoplasmosis - congenital zika syndrome

Answer 194

congenital cytomegalovirus - fetal growth restriction - microcephaly - hearing loss, vision loss - learning disability, seizures congenital toxoplasmosis - intracranial calcification, hydrocephalus, chorioretinitis congenital zika syndrome (spread by Aedes mosquito) - microcephaly, fetal growth restriction, intracranial abnormalities

Question 195

describe sudden infant death syndrome (SIDS)

Answer 195

aka cot death, usually in first 6 months of life risk factors: prematurity, low birth weight, smoking during pregnancy, male baby minimising risk - put baby on back, keep head uncovered - avoid co-sleeping, maintain comfortable room temp - avoid smoking support: lullaby trust

Question 196

describe Angelman syndrome

Answer 196

features - fascination with water - happy demeanour - widely spaced teeth - inappropriate laughter - delayed development/learning disability

Question 197

describe cerebral palsy

Answer 197

causes: maternal infections, birth asphyxia, meningitis features - abnormal tone early infancy - delayed milestones - abnormal gait - feeding difficulties types: - spastic > hemiplegia, diplegia or quadriplegia > increased tone from UMN damage - dyskinetic: damage to basal ganglia/substantia nigra > abnormal, involuntary movements > dystonia: twisting movements > athetosis: slow, writhing movements - ataxic: damage to cerebellum - mixed neurological examination - hemiplegic/diplegic gait - broad based gait/ataxic gait - high stepping gait - waddling gait - antalgic gait management: MDT > spasticity: diazepam, baclofen, botulinum toxin, surgery > anticonvulsants, analgesia

Question 198

describe Duchenne's muscular dystrophy (DMD)

Answer 198

X-linked recessive condition, defective dystrophin gene boys present around 3-5 years, life expectancy of 25-35 years features - progressive proximal muscle weakness from 5 years - calf pseudohypertrophy - Gower's sign: hands on legs to help them stand up - intellectual impairment diagnosis - raised creatinine kinase (CK) - genetic testing: confirm diagnosis management - supportive

Question 199

describe severe combined immunodeficiency

Answer 199

aka SCID - due to absent/dysfunctioning T and B cells presentation within first few months of life - persistent severe diarrhoea - failure to thrive - opportunistic infections - unwell after live vaccinations - Omenn syndrome management - immunoglobulin therapy - sterile environment - haematopoietic stem cell transplantation

Question 200

describe reflex anoxic seizures

Answer 200

common non-epileptic paroxysmal event in infants/children due to vagal-induced brief cardiac asystole provoked by sudden distressing stimulus which causes LOC > followed by stiffening and brief clonic movements affecting some or all limbs management: exclude cardiac arrhythmia, reassure

Question 201

describe growing pains

Answer 201

common cause of MSK pain in children features - intermittent symptoms usually worse after vigorous activity - typically affect legs - occur at night, never present at the start of day - usually bilateral and self-limiting - no other associated symptoms/signs: no limp, no limitation of physical activity unremarkable clinical examination, motor milestones normal

Question 202

describe the management of cystic fibrosis

Answer 202

- lumacaftor/ivacaftor: homozygous delta F508 mutation - chest physio and postural drainage: twice daily - high calorie and high fat diet + CREON - prophylactic flucloxacillin - bronchodilators e.g. salbutamol - nebulised DNAase (dornase alfa): clear secretions - nebulised hypertonic saline - vaccinations: pneumococcal, influenza, varicella - pseudomonas colonisation: nebulised antibiotics e.g. tobramycin, or oral ciprofloxacin OTHER - lung transplantation in end-stage respiratory failure > Burkholderia cepacia colonisation is a contraindication - liver transplant in liver failure - fertility treatment + genetic counselling monitoring: diabetes, osteoporosis, vitamin D deficiency, liver failure

Question 203

describe infantile spasms

Answer 203

aka West syndrome, type of childhood epilepsy features - characteristic "salaam" attacks: flexion of the head, trunk and arms followed by extension of arms - lasts 1-2 seconds but may be repeated up to 50 times - progressive mental handicap child is distressed between spasms investigations: - EEG: hypsarrhythmia - MRI head: abnormal management (poor prognosis) - vigabatrin first-line - ACTH

Question 204

list the top 5 causes of respiratory distress and cyanosis in the newborn

Answer 204

respiratory distress - transient tachypnoea of the newborn - respiratory distress syndrome (surfactant deficiency) - meconium aspiration syndrome (association with post-term delivery) - pneumothorax - infection cyanosis - any cause of respiratory distress - persistent pulmonary hypertension of the newborn - congenital cyanotic heart disease - tracheo-oesophageal fistula - congenital diaphragmatic hernia

Question 205

list causes of bilious vomiting in neonates

Answer 205

- meconium plug / ileus - duodenal atresia > management: duodenoduodenostomy - oesophageal atresia - Hirschprung's disease - malrotation with volvulus

Question 206

describe tracheo-oesophageal fistula

Answer 206

features - coughing/choking during feeds - inability to pass NG tube / coiling of NG on CXR - recurrent chest infections - abdominal distension diagnosis: bronchoscopy, contrast studies of oesophagus management: surgical correction

Question 207

describe diGeorge syndrome

Answer 207

CATCH-22 - congenital heart disease: tetralogy of fallot - abnormal facies - thymus gland not developed - cleft palate - hypoparathyroidism / hypocalcaemia 22q11 deletion syndrome

Question 208

describe malrotation with volvulus

Answer 208

features - bilious vomiting - abdominal pain and cramping - lethargy - poor appetite - infrequent bowel movements - swollen, firm abdomen associated with exomphalos and diaphragmatic hernia diagnosis: upper GI contrast showing corkscrew / whirlpool appearance management: Ladd's procedure

Question 209

describe benign rolandic epilepsy

Answer 209

childhood epilepsy occurring between 4-12 years features - nighttime seizures - partial seizures with potential for secondary generalisation - child is otherwise normal EEG: centrotemporal spikes excellent prognosis, seizures stop by adolescence

Question 210

describe the clinical features and management of meconium ileus

Answer 210

abnormal bulky and viscid meconium, usually due to CF clinical features - gross abdominal distension - bilious vomiting - failure to pass meconium in first days of life diagnosis: - AXR: distended loops of bowel, mottled ground glass appearance > fluid levels are scarce as meconium is viscid management: - NG decompression - IVF - antibiotics > daily washouts > surgical management in some cases (temporary stoma)

Question 211

describe UTI management of children

Answer 211

infant <3 months: immediate referral to paediatrician children >3 months with - upper UTI: consider hospital admission - lower UTI: oral antibiotics for 3 days e.g. trimethoprim consider antibiotic prophylaxis in recurrent UTIs

Question 212

describe a retinoblastoma

Answer 212

AD condition caused by loss of function of retinoblastoma tumour suppressor gene features - absence of red reflex, replaced by a white pupil (leukocoria) - strabismus - visual problems management - external beam radiation therapy, chemotherapy, photocoagulation - enucleation if salvage not possible excellent prognosis

Question 213

describe constipation and its management in children

Answer 213

features - <3 complete stools per week - hard large stool "rabbit droppings / pellets" - distress on passing stool / straining - bleeding / anal fissure - abdominal pain - faecal impaction > overflow soiling > faecal mass palpable in the abdomen management - first-line: advice on diet/ fluid intake + macrogols (e.g. Movicol) > stimulant + osmotic laxative if not tolerated

Question 214

describe the management of choking in infants / children

Answer 214

if cough effective, encourage coughing if not - unconscious: initiate basic life support - conscious: > infant: alternate between 5 back blows and 5 chest thrusts > child: alternate between 5 back blows and 5 abdominal thrusts once obstruction is relieved, urgent medical follow-up

Question 215

list complications found in babies of diabetic mothers

Answer 215

- macrosomia > shoulder dystocia > Erb's palsy: waiter's tip >> brachial trunks C5-C6 >> arm hanging loose at side, pronated and medially rotated > Klumpke palsy >> brachial trunks C8-T1 >> weakness of hand intrinsic muscle, may have Horner's syndrome - jaundice - polycythaemia - hypoglycaemia - TTN

Question 216

describe fluid prescription for maintenance fluids correcting for dehydration

Answer 216

% dehydration x 10 x weight (kg) / 2 > split over 48h, divide by 2 for daily requirement e.g. 10kg child, 5% dehydration maintenance fluids: 10 x 100 = 1000mL/24h 5 x 10 x 10 = 500/2 = 250mL total = 1250mL/24 = 52ml/h

Question 217

describe juvenile polyps

Answer 217

usually hamartomas may occur as part of the familial polyposis coli syndromes clinical features - rectal bleeding - cherry red lesion at anal verge

Question 218

describe breastfeeding problems - nipple pain - blocked duct - nipple candidiasis

Answer 218

minor - nipple pain: may be caused by poor latch - blocked duct or "milk bleb": nipple pain when breastfeeding > breastfeeding should continue > seek advice regarding positioning of baby, try massage - nipple candidiasis > miconazole cream for mother and nystatin suspension for baby mastitis engorgement - usually first few days after infant is born - pain usually worse before a feed - milk does not flow well, fever may be present and breast may appear red - complications: blocked milk ducts, mastitis and difficulties with breastfeeding raynaud's disease of the nipple - intermittent pain present during and immediately after feeding - blanching of nipple may be followed by cyanosis and erythema - management: minimise exposure to cold, use heatpacks following breastfeed, avoid caffeine and stop smoking > trial of nifedipine

Question 219

describe concerns about poor infant weight gain in breastfed babies

Answer 219

losing >10% threshold in the first week of life investigations: exclude common breastfeeding problems management: midwife-led breastfeeding clinics, monitor weight

Question 220

list questions to asks adolescents (HEADDDSSSS)

Answer 220

Home - relationships, social support Education - exams, higher education Activities - hobbies, interests Drugs - which ones, how often Driving - desire to drive Drinking - how much, concerning practices Suicidal intent - self-harm, thoughts of suicide Sex - risky behaviour, contraception Sleep Smoking - how much, how often, vaping

Question 221

what is the most common site for osteomyelitis in children

Answer 221

metaphysis