Paediatrics Flashcards
describe the traffic light system for assessment of a child with fever
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
state the paediatric dose of paracetamol and ibuprofen
paracetamol - 15mg/kg
ibuprofen - 7.5mg/kg (half of paracetamol)
describe bronchiolitis
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
describe the categorisation of acute wheeze in children
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
describe the clinical features of croup
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
describe the categorisation of severity of croup and its management
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
describe the clinical features of UTI in children
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
describe pulled elbow
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
describe buckle fracture
common paediatric fracture to distal radius
injury to cancellous bone without actual break in cortex
manage symptomatically unless rotational deformity (requires manipulation)
describe toddler’s fracture
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
describe a hair tourniquet
clinical features
- inconsolable child
- unilaterally isolated swollen digit
remove with scalpel
describe transient synovitis
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
describe Perthes disease
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
describe slipped upper femoral epiphysis (SUFE)
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
describe the presentation of malignancy/leukaemia in children
- 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
describe juvenile idiopathic arthritis (JIA)
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
what are key points to ask about in an airway history?
- ex-prematurity/neonatal intubation
- noisy breathing
- voice/cry
- cough/cyanotic spells
- recurrent croup or LRTIs
- feeding difficulties
- failure to thrive
- exercise tolerance
list areas to examine to determine a child’s airway patency
- voice / cry / cough
- RR, HR
- nasal flaring, grunting, head bobbing
- tracheal tug, recession - sternal, intercostal
- stridor / stertor
ENT examination
- fibreoptic nasendoscopy
- microlaryngobronchoscopy (MLB)
describe choanal atresia
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
describe obstructive sleep apnoea (OSA) in children
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
list causes of stridor in children
- 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
describe a thyroglossal duct cyst
thyroglossal duct cyst
> commonest midline neck swelling
> congenital, embryology: foramen caecum - neck
> moves with tongue protrusion and on swallowing
> investigations: ultrasound
> management - surgical removal
describe epistaxis management in children
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
list neck lumps that can be found laterally
- 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
describe foreign bodies (aural, nasal, airway, oesophageal)
- 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
describe post-tonsillectomy haemorrhage and its management
causes: infection, coughing, vasospasm
can be fatal
management
- early contact with ENT/anaesthetics for definitive surgical management
describe epiglottitis
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
describe infections in lymph nodes
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
describe tonsillitis
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
describe tongue tie (ankyloglossia)
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
describe acute otitis media
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)
- consider topical antibiotics (ciprofloxacin) if prolonged otorrhoea
list complications of AOM
- intracranial abscess
- facial nerve palsy
- mastoiditis
- meningitis
describe mastoiditis
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
list complications of mastoiditis
- 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
describe cervical lymphadenitis
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
list different types of deep neck space infections
(DNSI)
types
- parapharyngeal abscess
- retropharyngeal abscess
- submandibular space abscess (Ludwig’s angina)
describe laryngomalacia
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
describe retropharyngeal abscess
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
describe vesicoureteric reflux
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
describe paediatric basic life support
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
list risks of prematurity
- respiratory distress syndrome
- intraventricular haemorrhage
- necrotizing enterocolitis
- chronic lung disease
- hypothermia
- feeding problems
- infection
- jaundice
- retinopathy of prematurity (<32 weeks)
- hearing problems
describe the management of hernias in children
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
describe neonatal hypoglycaemia
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
list red flag features in croup and indications for admission
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…)
describe developmental dysplasia of the hip
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
describe the developmental milestones for a child of 6 weeks
- 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)
describe the developmental milestones for a child of 6 months
- 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
describe the developmental milestones for a child of 9 months
- 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
describe the developmental milestones for a child of 12 months
- 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
list indications for head CT in children with a head injury
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
describe the management and complications of undescended testes
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
describe Edward’s syndrome
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
describe Patau syndrome
trisomy 13
features
- cleft lip / palate
- polydactyly
- microphthalmia, microcephaly
- scalp defects
- congenital heart disease
describe fragile X syndrome
features
- intellectual disability
- macrocephaly
- macro-orchidism
- characteristic long face, large ears, hyperextensible joints
- behavioural problems: ADHD, ASD
describe William’s syndrome
features
- elfin facies: wide mouth, small nose, full lips
- cardiovascular disease: supravalvular aortic stenosis
- hypercalcaemia
- intellectual disability
- outgoing personality
describe Noonan syndrome
features
- webbed neck
- pectus excavatum
- short stature
- pulmonary stenosis
describe Pierre-Robin syndrome
features
- micrognathia
- posterior displacement of tongue (may result in upper airway obstruction)
- cleft palate
describe Prader-Willi syndrome
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
describe cri du chat syndrome
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
describe the management of a child with a palpable abdominal mass
- urgent referral to on-call paediatric registrar for assessment of neuroblastoma or Wilms tumour
describe a neuroblastoma
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
describe viral-induced wheeze
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
list signs of respiratory distress in children
- nasal flaring
- grunting
- stridor
- wheeze
- head bobbing
- tracheal tugging
- subcostal and intercostal recessions
- increased respiratory rate
- use of accessory muscles
- cyanosis
describe the management of acute asthma
management
- supplementary oxygen
- bronchodilators - salbutamol, ipratropium bromide
- steroids
- antibiotics if infection suspected
severe: magnesium sulphate, aminophylline
describe chronic asthma and its treatment
features
- diurnal variability
- dry cough with wheeze and shortness of breath
- history of atopy: eczema, hay fever, food allergies
- bilateral widespread polyphonic wheeze
Management
- child <5y: moderate-dose ICS 8 week trial
- child >5y: asthma management if uncontrolled by SABA
describe whooping cough
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
describe chronic lung disease of prematurity
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
describe the clinical features of cystic fibrosis
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
describe the diagnosis of cystic fibrosis
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
describe testing for parvovirus B19 in pregnant women with infected contacts
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
describe the clinical features of erythema infectiosum aka slapped cheek
aka fifth disease
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
describe fluid prescription in children
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
describe the developmental milestones expected of a child of 18 months of age
- 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
describe the developmental milestones expected of a 2- 2 1/2 year old child
- 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
describe the developmental milestones expected of a 3- 3/12 year old child
- 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
describe the developmental milestones expected of a 4-5 year old child
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
list routine screening opportunities for children
- 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)
describe the neonatal blood spot test
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
describe UK’s routine immunisation schedule
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
describe a formula used to estimate weight in a child
Weight (kg) = (age + 4) x 2 (use if aged >12 months)
describe feeding in babies
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
describe normal puberty
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
describe hypogonadotrophic hypogonadism
- 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)
describe hypergonadotrophic hypogonadism
- 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
- Kleinfelter’s syndrome (XXY)
- Turner’s syndrome (XO)
list different types of learning disability
- dyslexia
- dysgraphia
- dyspraxia aka developmental coordination disorder
- auditory processing disorder
- non-verbal learning disability
- profound and multiple learning disability
describe a cephalohaematoma
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
describe Down’s syndrome
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
describe a caput succedaneum
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
