Paediatrics Flashcards
When is jaundice in babies always pathological
In the first 24 hours
What are the causes of jaundice in the 24 hours?
- Rhesus haemolytic disease
- ABO haemolytic disease
- hereditary spherocytosis
- glucose-6-phosphodehydrogenase
What are the causes of jaundice in babies aged 2-14 days?
- usually physiological
- combination of factors including more red blood cells and more fragile red blood cells, and less developed liver function
- seen more commonly in breast fed babies
Screen for prolonged jaundice
- conjugated and unconjugated bilirubin
- direct antiglobulin test (coomb’s)
- TFTs
- FBC and blood film
- urine and MC&S and reducing sugars
- U+Es and LFTs
What are the causes of a prolonged jaundice (post 14 days)
- biliary atresia
- hypothyroidism
- galactosaemia
- urinary tract infection
- breast milk jaundice
- prematurity (due to immature liver function)
- congenital infections e.g. CMV, toxoplasmosis
What is biliary atresia?
Obliteration or discontinuation within the extrahepatic biliary system, resulting in the obstruction of bile flow
Type 1 biliary atresia
Proximal ducts are patent, common duct is obliterated
Type 2 biliary atresia
Atresia of the cystic duct and cystic structures are ofund in the porta hepatis
Type 3 biliary atresia
Atresia of the left and right ducts to the level of the porta hepatis
Signs of biliary atresia
- jaundice beyond 2 weeks
- hepatomegaly with splenomegaly
- abnormal growth
- cardiac murmurs
Presentation of biliary atresia
- jaundice
- appetite and growth disturbance
- dark urine and pale stools
Investigations for biliary atresia
- serum bilirubin: conjugated bilirubin abnormally high
- LFTs
- sweat chloride test to exclude CF as a cause
- ultrasound of the biliary tree and liver
- serum alpha 1 antitrypsin
- percutaneous liver biopsy with intraoperative cholangioscopy
What is the management of biliary atresia?
- surgical intervention
What are the complications of biliary atresia?
- unsuccessful anastamosis formation
- progressive liver disease
- cirrhosis with eventual hepatocellular carcinoma
What is neonatal sepsis?
- sepsis within the first 28 days
What are the most common causes of neonatal sepsis?
- group B streptococcus (main cause of early onset sepsis)
- escherichia coli
What are the risk factors of neonatal sepsis?
- mother who has had a baby with GBS infection, who has current GBS colonisation, current bacteruria, intrapartum tmep of ≥38, membrane rupture of ≥18 hours, or current infection throughout pregnancy
- prematurity
- low birth weight
- maternal chorioamnionitis
Presentation of neonatal sepsis
- respiratory distress (grunting, nasal flaring, use of accessory respiratory muscles, tachypnoea)
- tachycardia
- apnoea
- lethargy/change in mental state
- jaundice
- seizure
- poor/reduced feeding
- abdominal distension
- vomiting
- temperature
Investigations suspected neonatal sepsis
- blood culture
- FBC
- CRP
- blood gases (metabolic acidosis is particularly concerning)
- urine microscopy, culture and sensitivity
- lumbar puncture
What is the management of neonatal sepsis?
- IV benzypenicillin with gentamicin
- re-measure CRP after 18-24 hours after presentation if given antibiotics
Simple febrile convulsion
- <15 minutes
- generalised seizure
- typically no recurrence within 24 hours
- should be a complete recovery within an hour
Complex febrile seizure
- 15-30 minutes
- focal seizure
- may have repeat seizure within 24 hours
Febrile status epilepticus
> 30 minutes
Presentation of febrile convulsion
- usually occur early in viral infection as the temperature rises rapidly
- seizures are usually breig, last less than 5 minutes
- more commonly tonic clonic
What ages do febrile seizures typically occur?
Between the ages of 6 months and 5 years
What is the management of febrile seizure?
- first seizure or any complex seizure should be admitted
Ongoing management:
- phone ambulance if lasts >5 minutes
- if recurrent then benzodiazepine rescue medication may be considered
What are the risk factors for developing epilepsy from febrile convulsion?
- age of onset <18 months
- fever <39
- shorter duration of fever before the seizure
- family history of febrile convulsions
What is cystic fibrosis
- autosomal recessive disorder
- increased viscosity of secretions
- due to defect in CFTR
What causes a false positive sweat test
- malnutrition
- adrenal insufficiency
- glycogen storage disease
- nephrogenic diabetes insipidus
- hypothyroidism, hypoparathyroidism
- G6PD
- ectodermal dysplasia
What is the most common cause of a false positive sweat test
Skin oedema
Diagnosis of CF
- sweat test
- high sweat chloride
- normal is less than 40, CF indicated if >60
Neonatal presentation of CF
- meconium ileus
- prolonged jaundice
Presentation of CF in children
- recurrent chest infection
- malabsorption: steatorrhoea, failure to thrive
- liver disease
Short, diabetes, delayed puberty, rectal prolpase, nasal polyps, male infertility, female subfertility
Management of cystic fibrosis
- twice daily chest physio and postural drainage
- high calorie, high fat intake
- vitamin supplementation
- pancreatic enzyme replacement
- lung transplant
- lumacraftor/ivacaftor if homozygous for delta F508 mutation
What is a contra indication for a lung transplant in someone with CF?
Chronic infeciton with burkholderia cepacia
What is the main cause of croup
PArainfluenze viruses
What is the peak age incidence of croup
6 months to 3 years
Presentation of croup
- cough: seal bark, worse at night
- stridor
- fever
- coryzal symptoms
- increased work of breathing
When should you admit a child with croup
- moderate or severe croup
- <3 months
- uncertainty about diagnosis
Diagnosis of croup
- clinical diagnosis
- can consider a chest Xray: steeple sign and thumb sign
Management of croup
- single dose of dexamethasone
- emergency treatment: high flow oxygen, nebulised adrenaline
Severe croup
- frequent barking cough
- prominent inspiratory stridor at rest
- marked sternal wall retractions
- significant distress, agitation, lethargy or restlessness
- tachycardia
What is the cause of bronchiloitis?
Respiratory syncytial virus
What is the peak incidence age of bronchiolitis?
- 3-6 months
- 90% are 1-9 months
What are the features of bronchiolitis?
- coryzal symptoms
- dry cough
- increasing brethlessness
- wheeze, fine inspiratory crackles
- feeding difficulties associated with dyspnoea
When should you admit a child with bronchiolitis?
- resp rate of over 60
- difficulty breastfeeding or inadequate oral fluid intake (50-75% usual volume)
- clinical dehydration
What is the management of bronchiolitis?
- humidified oxygen
- nasogastric feeding may be needed if children cant take enough fluid/feed by mouth
- suction is sometimes used for excessive upper airway secretions
Severe asthma attack
- spo2 <92%
- PEF 33-50% best or predicted
- too breathless to talk or feed
- HR: >125 if over 5, >140 if 1-5
- RR: >30 if over 5, >40 if 1-5
- Use of accessory neck muscles
Life threatening
- sp02 <92%
- PEF <33% best or predicted
- silent chest
- poor respiratory effort
- agitation
- altered consciousness
- cyanosis
What is the management of moderate acute asthma in children?
- beta 2 agonist via a spacer
- give 1 puff every 30-60 seconds up to a maximum of 10 puffs
- if symptoms are not controlled then repeat beta 2 agonist and refer to hospital
- steroid for 3-5 days
stepwise approach for asthma in children
- SABA
- SABA + ICS
- SABA + ICS + LTRA
- SABA + ICS + LABA
- SABA + MART
In which cases should you start an ICS for asthma at presentation?
symptoms ≥3 times a week or night time waking
What are the most commonly affected joints in septic arthritis?
- hip
- knee
- ankle
What are the symptoms of septic arthritis?
- joint pain
- limp
- fever
- systemically unwell: lethargy
- swollen, red joint
Investigations for septic arthritis
- joint aspiration
- raised inflammatory markers
- blood cultures
Kocher criteria
septic arthritis:
- fever>38.5
- non weight bearing
- raised ESR
- raised WCC
What are the types of osteomyelitis?
- haematogenous osteomyelitis
- non-haematogenous
Which type of osteomyelitis is most common in children?
Haematogenous
What is the most common cause of osteomyelitis?
staph aureus
investigation osteomyelitis
MRI
management of osteomyelitis
flucloxacillin for 6 weeks, clindamycin if penicillin allergic
What is the management of viral wheeze?
Episodic:
- symptomatic treatment
- salbutamol via a spacer
multiple trigger wheeze:
- corticosteroid trial for 4-8 weeks
What is the most common cause of pneumonia in children?
s.pneumoniae
Treatment of pneumonia
- amoxicillin
- macrolides can be added if no response to first line, or if chlamydia or mycoplasma is suspected
- if influenza associated then co-amoxiclav
Risk factors for GORD in kids
- preterm
- neurological disorder
Features of GORD
- typically develops before 8 weeks
- vomiting/regurgitation
- excessive crying, especially whilst feeding
Management of GORD
- 30 degree head up position for feeds
- sleep on back
- ensure no overfeeding, can trial more frequent, smaller feeds
- can trial thickened formula
- trial alginate therapy e.g. Gaviscon
Diagnosis of constipation in children under 1
Fewer than 3 complete stools per week (type 3 or 4) , hard large stool, rabbit droppings (type 1)
Diagnosis of constipation in children over 1
fewer than 3 complete stools per week (type 3 or 4)
- overflow soiling
- rabbit droppings
- large, infrequent stools that can block the toilet
Causes of constipation in children
- idiopathic
- dehydration
- low fibre diet
- anal fissure
- hypothyroidism
- hirschprungs
- hypercalcaemia
- learning difficulties
Red flag symptoms in constipation
- symptoms from birth or first few weeks of life
- > 48 hours
- ribbon stools
- faltering growth = amber
- abdomen distension
- previously unknown or undiagnosed weakness in the legs or locomotor delay
Factors suggesting faecal impaction
- symptoms of severe constipation
- overflow soiling
- faecal mass palpable in the abdomen
Management of constipation if faecal impaction is present
- polyethylene glycol 3350 + electrolytes
- add stimulant laxatives if doesn’t lead to disimpaction after 2 weeks
Features of coeliac disease
- failure to thrive
- diarrhoea
- abdominal distension
- anaemia if older
Diagnosis of coeliac
- jejunal biopsy showing subtotal villous atrophy
Features of cows milk protein intolerance/allergy
- regurgitation/vomiting
- diarrhoea
- urticaria, atopic eczema
- colic symptoms: irritable, crying
- wheeze, chronic cough
Diagnosis of cows milk protein intolerance
- skin prick/patch test
- total IgE and specific IgE
Management of cows milk protein intolerance if breast fed
- continue breast feeding
- eliminate cows milk protein from maternal diet
Management of cows milk protein intolerance if formula fed
- extensive hydrolysed formula (eHF) if mild/moderate symptoms
- amino acid based formula if severe or if no response
Prognosis of cows milk protein intolerance
- IgE mediated, around 55% tolerant by age 5
- non- IgE mediated, most tolerant by age of 3
What is intussusception?
Invagination of one portion of the bowel into the lumen of the adjacent bowel, most commonly around the ileocaecal region
most common age intussusception
between 6 and 18 months
Features of intussusception
- intermittent, crampy, severe, progressive abdo pain
- inconsolable crying
- draw knees up to chest and turn pale
- vomiting
- bloodstained stool, red currant jelly as late sign
- sausage shaped mass in the right upper quadrant
Investigation intussusception
USS- target like mass
Management of intussusception
Reduction by air insufflation under radiological control
If this fails/peritonitis then surgery
Presentation of meckels diverticulum
- abdominal pain mimicking appendicitis
- rectal bleeding
- intestinal obstruction
What is meckels diverticulum?
- congenital diverticulum of the small intestine
- remnant of the omphalomesenteric duct
investigation meckels diverticulum
- meckels scan
- mesenteric ateriography in more severe cases
Management of meckels diverticulum
- removal if narrow neck or symptomatic: wedge excision or formal small bowel resection and anastomosis
Features of necrotising enterocolitis
- feeding intolerance
- abdominal distension
- bloody stools
- abdominal discolouration, perforation, peritonitis
Abdominal X ray necrotising enterocolitis
- dilated bowel loops
- bowel wall oedema
- pneumatosis intestinalis (intramural gas)
- portal venous gas
- pneumoperitoneum resulting from perforation
- air both inside and outside of the bowel wall (rigler sign)
- air outlining the falciform ligament (football sign)
Diagnosis of malrotation
upper GI contrast study and USS
Treatment of malrotation
- laparotomy
- Ladd’s procedure if volvulus is present or at high risk of recurrence
Meconium ileus on x ray
no fluid level
Management of necrotising enterocolitis
total gut rest and TPN, babies with perforation require laparotomy
What is hirschprungs?
aganglionic segment of bowel due to developmental failure of the parasympathetic auerbach and meissner plexuses leading to uncoordinated peristalsis
Associations of hirschprungs
down’s syndrome
Presentation of hirschprungs
- failure or delay to pass meconium
- in older children: constipation, abdominal distension
Investigation for hirschprungs
- abdominal X ray
- rectal biopsy: gold standard for diagnosis
Management of hirschprungs
- rectal washout/bowel irrigation
- definitive management to the affected segment of the colom
What are the complications of undescended testis?
- infertility
- torsion
- testicular cancer
- psychological impacts
Management of undescended testis
Unilateral:
- referral from 3 months of age, uroglogical surgeon before 6 months
- orchidoplexy at around 1 year
Bilateral
- reviewed by a senior paesiatrician within 24 hours as child may need ugent endocrine or genetic investigation
Features of testicular torsion
- pain is usually severe and sudden onset
- pain may be referred to the lower abdomen
- nausea and vomiting
- swollen, tender testis, retracted upwards
- loss of the cremasteric reflex
- elevation of the testis does not ease the pain (prehns sign)
Management of testicular torsion
Urgent surgical exploration, both testis should be fixed
cause of measles
RNA paramyxovirus, aerosol transmission
Features of measles
- prodrome: irritable, conjuncitvitis, fever
- koplik spots, typically develop before the rash, white spots on the buccal mucosa
- rash: starts behind the ears then whole body, maculopapular rash becoming blotchy
- diarrhoea in 10%
Investigation measles
IgM antibodies
Management measles
- supportive
- admission in immunosuppressed or pregnant
- inform public health
Complication of measles
- otitis media
- pneumonia
- encephalitis
- subacute sclerosing panencephalitis 5-10 years after
Managment of contacts: measles
- MMR vaccine within 72 hours if not immunized
Cause of chicken pox
Varicella zoster
Features of chicken pox
- fever initially
- itchy rash, starting on head/trunk before spreading
- initally macular then papular then vesicular rash
- systemic upset normally mild
Management of chicken pox
- keep cool, trim nails
- calamine lotion
- keep off school until all lesions are dry and crusted over (5 days after onset of rash)
- if immunosuppressed then varicella zoster immunoglobulin, if chicken pox develops then consider IV aciclovir
Complication of chicken pox
secondary bacterial infection of lesions
features of mumps
- fever
- malaise
- muscular pain
- parotitis (ear ache/pain on eating)
Management of mumps
- rest
- paracetamol for high fever/discomfort
- notifiable disease
Complications of mumps
- orchitis
- hearing loss
- meningoencephalitis
- pancreatitis
What causes slapped cheek?
Parvovirus B19
What causes rubella?
Togavirus
Features of rubella
- prodrome e.g. low grade fever
- rash: maculopapular, initially on the face before spreading to the whole body, usually fades by day 3-5
- lymphadenopathy: suboccipital and postauricular
Complications of rubella
- arthritis
- thrombocytopenia
- encephalitis
- myocarditis
What causes sixth disease?
Human herpes virus 6
Features of sixth disease
- high fever lasting a few days then maculopapular rash
- nagayama spots on the uvula and soft palate
- febrile convulsion
- diarrhoea and cough
What causes whooping cough?
Bordetella pertussis
Features of whooping cough
- catarrhal phase: similar to URTI
- paroxysmal phase: cough increases in severity, central cyanosis, post tussive vomiting, inspiratory whoops, may have spells of apnoea, lasts between 2-8 weeks
- convalescent phase: cough subsides over weeks to months
Investigation for whooping cough
- nasal swab for bordetella pertussis
Management of whooping cough
- if under 6 months then admit
- notifiable disease
- oral macrolide if onset of cough is within the last 21 days
- household contacts offered antibiotic prophylaxis
What are the complications of whooping cough?
- subconjunctival haemorrhage
- pneumonia
- bronchiectasis
- seizures
what are the contraindications to lumbar puncture?
- focal neurological signs
- papilloedema
- significant bulging of the fontanelle
- disseminated intravascular coagulation
- signs of cerebral herniation
What is the management of meningitis in under 3mnth old
- IV amoxicillin + IV cefotaxime
- fluids
- cerebral monitoring
- public health notification and antibiotic prophylaxis (ciprofloxacin)
What is the management of meningitis in over 3mnth olds
- IV cefotaxime or ceftriaxone
- fluids
- cerebral monitoring
- public health notification and antibiotic prophylaxis (ciprofloxacin)
- consider steroids
Meningitis neonatal causes
- Group B streptococcus
- E.coli
- lsiteria monocytogenes
Meningitis 1 month to 6 years causes
- neisseria meningitidis
- streptococcus pneumoniae
- haemophilus influenzae
Diagnosis of epiglottitis
- direct visualisation
Meningitis causes older than 6
- neisseria meningitidis
- streptococcus penumoniae
What causes acute epiglottitis?
Haemolphilus influenzae type B
Features of acute epiglottitis
- rapid onset
- high temperature
- generally unwell
- stridor
- drooling of saliva
- tripod position
X ray epiglottitis
- thumb sign: swelling of epiglottis
- steeple sign: subglottic narrowing
management of epiglottitis
- immediate senior involvement (endotracheal intubation may be needed to protect the airway )
- if suspected dont examine the throat
- oxygen
- IV antibiotics
Symptoms of uti in babies
- fever
- lethargy
-irritability - vomiting
- poor feeding
- urinary frequency
Symptoms of UTI in children
- fever
- abdominal pain
- vomiting
- dysuria
- urinary frequemcy
- incontinence
When is a diagnosis of acute pyelonephritis made?
- temperature over 38
- loin pain or tenderness
Who should get an ultrasound when presenting with a UTI
- all children under 6 months with their 1st UTI (scan within 6 weeks)
- children with recurrent UTIs
- Children with atypical UTI
When should DMSA scans be used?
- used 4-6 months after illness to assess for damage after reucrrent or atypical UTI
- if dye not taken up by part of the kidney suggests scarring
What is vesico-ureteric reflux?
- urine has a tendency to flow from the bladder back into the ureters
How do you diagnose vesico-ureteric reflux?
Micturating cystourethrogram
What is the management of vesico-ureteric reflux?
- avoid constipation
- avoid an excessively full bladder
- prophylactic antibiotics
- surgical input from paediatric urology
Triad of nephrotic syndrome
- low serum albumin
- high protein content
- oedema
Most common cause of nephrotic syndrome in kids
minimal change disease
Kidney disease causes of nephrotic syndrome
- focal segmental glomerulosclerosis
- membranoproliferative glomerulonephritis
What systemic illnesses can cause nephrotic syndrome?
- henoch schonlein
- diabetes
- infection: HIV hepatitis malaria
Management of minimal change disease
- corticosteroids
Urinalysis of minimal change
- small molecular weight proteins
- hyaline casts
Management of nephrotic syndrome
- high dose steroids for 4 weeks then wean for 8
- low salt diet
- diuretics for oedema
- albumin infusion
- antibiotic prophylaxis in severe cases
Complications of minimal change disease
- hypovolaemia
- thrombosis
- infection
- acute or chronic renal failure
- relapse
Nephritic syndrome
- haematuria
- protein uria
What are the most common causes of nephritic syndrome in children?
- post streptococcal
- IgA (bergers)
Presentation of post streptococcal glomerulonephritis
- 1-3 weeks after a beta haemolytic streptococcus e.g. tonsilitis
Management of post streptococcal glomerulonephritis
-supportive
- may need help managing if there is a worsening of renal function e.g. antihypertensive or diuretics
Biopsy of IgA nephropathy
- IgA deposits
- glomerular mesangial proliferation
Management of IgA nephropathy
- supportive treatment of renal failure
- immunosuppressant medications e.g. steroids, cyclophosphamide to slow the progression
What are the causes of UTI in children?
- e. coli
- proteus
- pseudomonas
What are the factors that predispose to UTI
- incomplete bladder emptying (infrequent voiding,
hurried micturition,
obstruction by full rectum due to constipation,
neuropathic bladder) - poor hygiene
- vesico-ureteric reflux
Other features of nephrotic syndrome
hyperlipidaemia, a hypercoagulable state (due to loss of antithrombin III) and a predisposition to infection (due to loss of immunoglobulins)
What is the most common cause of gastroenteritis in children?
Rotavirus
Signs of clinical dehydration in children
- Appears to be unwell or deteriorating
- Decreased urine output
- Altered responsiveness (for example, irritable, lethargic)
- Sunken eyes
- Dry mucous membranes
- Tachycardia
- Tachypnoea
- Reduced skin turgor
- Skin colour unchanged
- Warm extremities
- Normal peripheral pulses
- Normal capillary refill time
- Normal blood pressure
Signs of clinical shock in children (dehydration)
- Decreased level of consciousness
- Cold extremities
- Pale or mottled skin
- Tachycardia
- Tachypnoea
- Weak peripheral pulses
- Prolonged capillary refill time
- Hypotension
Features of hypernatraemic dehydration
- jittery movements
- increased muscle tone
- hyperreflexia
- convulsions
- drowsiness or coma
What is the most common age of SIDs?
3 months
What are the major risk factors of SIDs?
- putting the baby to sleep prone
- parental smoking
- prematurity
- bed sharing
- hyperthermia or head covering
What are the protective factors against SIDs
- breastfeeding
- room sharing (but not bed)
- use of dummies
What should happen following a cot death?
- siblings screened for potential sepsis and inborn errors of metabolism
Management of eczema
- avoid irritants
- emollients
- topical steroids
- wet wrappings
Management of eczema herpeticum
Aciclovir oral or IV if severe
Presentation of eczema herpeticum
- widespread painful vesicular rash
- systemic symptoms
- lymphadenopathy
Virus eczema herpeticum
Herpes simplex virus 1 or VZV
Management of urticaria
- fexofenadine
- oral steorids can be considered for a severe flare
Cause of impetigo
Stpahy aureus
non bullous vs bullous impetigo
non bullous: golden crust, no systemic symtpoms, bullous: fluid filled vesicles
Management of non bullous impetigo
- topical fusidic acid or hydrogen peroxide cream
- oral flucloxacillin if more wide spread
- need to be off school until all the lesions have healed over or they have been treated with antibiotics for at least 48 hours
Describe molluscum contagiosum
Small, flesh coloured papules that have a central dimple
Management of molluscum contagiosum
- heal by themselves
- avoid sharing towels, scratching
Presentation of scabies
- very itchy
- small red spots
- finger webs
Management of scabies
Permethrin cream left for 8-12 hours then washed off then repeated a week later
Oral ivermectin for difficult to treat or crusted scabies
Wash all clothes/bedsheet on a hot wash
What are the cyanotic heart diseases?
- Tetralogy of fallot
- transposition of the great arteries
tricuspid atresia
What are the acyanotic heart diseases?
- ASD
- VSD
- Coarctation of the aorta
- Patent ductus arteriosus
- Aortic valve stenosis
Auscultation of ASD
Fixed split second heart sound
Mid systolic, crescendo-decrescendo
Auscultation of VSD
Pan-systolic murmur best heard at L lower sternal edge
Auscultation of coarctation of the aorta
Systolic murmur
Auscultation of aortic valve stenosis
Ejection systolic, radiates to the carotids
Eisenmenger syndrome
Reversal of a L to R shunt as pulmonary pressure rises to a level above that of the systemic pressure. Resulting in cyanosis
When does the ductus arteriosus normally close?
2-3 weeks after birth
What keeps ductus arteriosus open?
Prostaglandins
Sign of coarctation of the aorta
Weak femoral pulses
Sign of aortic valve stenosis
Slow rising pulse and narrow pulse pressure
What are the risk factors of tetralogy of fallot?
- maternal diabetes
- alcohol consumption during pregnancy
- rubella
- maternal age over 40
What to give in tet spell
- oxygen
- beta blocker
- morphine
- sodium bicarbonate
- phenylephrine
- IV fluids
What are the features of tetralogy of fallot?
- over riding aorta
- right ventricular hypertrophy
- pulmonary valve stenosis
- ventricular septal defect
Management of transposition of the great arteries
- prostaglandins to keep ductus arteriosus open
- balloon septostomy into foramen ovale
- open heart surgery = definitive
Auscultation of tricuspid atresia
single s2 with pan-systolic murmur
association of coarctation of the aorta
turner’s
innocent murmurs
- soft
- short
- systolic
- symptomless
- situation dependent
Presentation of type 1 diabetes
- DKA
- triad of hyperglycaemia: polyuria, polydipsia, weight loss
What should you check if someone has just been diagnosed with type 1 diabetes?
- FBC
- glucose
- UEs
- HbA1c
- TFTs and TPO antibodies
- anti TTG
- Insulin antibodies, anti GAD, islet cell antibodies
Why should you cycle insulin injection sites?
Lipodystrophy
Symptoms of hypoglycaemia
- hunger
- tremor
- sweating
- irritability
- dizziness
- pallor
Long term complications of type 1 diabetes
- Macrovascular
- coronary artery disease
- peripheral ischaemia
- stroke
- hypertension - Microvascular
- peripheral neuropathy
- retinopathy
- kidney disease especially glomerulosclerosis - Infection related:
- UTI
- pneumonia
- skin/soft tissue
- fungal
What is haemolytic disease of the newborn
Destruction of fetal erythrocytes by maternal antibodies
What are the causes of haemolytic disease of the newborn
- ABO incompatibility: O mother with A/B antibodies, baby with group A or B blood group
- Rhesus incompatibility (Rh negative mother, Rh positive baby)
What are the sensitisation events?
- normal delivery
- abortion or stillbirth
- chorionic villus sampling
- amniocentesis
- antenatal haemorrhage
- maternal trauma
- idiopathic
What are the antenatal causes of cerebral palsy?
- maternal infection
- trauma during pregnancy
What are the perinatal causes of cerebral palsy?
- birth asphyxia
- pre term
What are the post natal causes of cerebral palsy?
- meningitis
- severe neonatal jaundice
- head injury
What are the types of cerebral palsy?
- spastic: UMN, increased tone
- Dyskinetic: basal ganglia, increased and reduced tone
- ataxic: cerebellum, unco-ordinated movement
- mixed
cerebral palsy one limb affected
monoplegia
cerebral palsy one side of body
hemiplegia
cerebral palsy, all 4 limbs but legs worse
diplegia
What are the signs/symptoms of cerebral palsy?
- failure to meet milestones
- hand preference before 18 months
- increased or reduced tone
- difficulty with co-ordination, speech, walking, swallowing
what can be used to help spasticity in cerebral palsy?
Baclofen (muscle relaxant)
What can be used to help with drooling in cerebral palsy?
glycopyrronium bromide
How can you grade fractures at the growth plate?
Salter harris
Salter harris grades
Type 1: Straight across
Type 2: Above
Type 3: beLow
Type 4: Through
Type 5: cRush
Greenstick fracture
One side of the bone breaks but other side stays intact
Presentation of transient synovitis
- limp
- refusal to weight bear
- mild fever
- groin or hip pain
What is Perthes disease?
Avascular necrosis of the femoral head
Presentation of Perthes disease
- limp
- pain in the hip or groin that may radiate to the knee
- restricted hip movement
- no history of trauma
What is the management of perthes disease?
- bed rest
- traction
- crutches
- analgesia
- physiotherapy
What is SUFE?
- slipped upper femoral epiphysis
- head of the femur is displaced along the growth plate
age SUFE
8-15
Presentation of SUFE
- hip, groin, thigh, or knee pain
- restricted internal rotation
- painful limp
- restricted hip movmement
Management of SUFE
Surgery
What are the risk factors for Developmental Dysplasia of the Hip?
- first degree family history
- breech
- multiple pregnancy
Tests to check for DDH
- ortolani: abduct hip and try to displace it anteriorly
- barlow test: hips abducted and flexed at 90 degrees, press down on the knee to try to displace the hip posteriorly
investigation for DDH
Ultrasound
Management of DDH
- palvik harness - removed after 6-8 weeks
- surgery if harness fails, or if diagnosed after 6 months
Treatment of vulvovaginitis
- Avoid washing with soap and chemicals
- Avoid perfumed or antiseptic products
- Good toilet hygiene, wipe from front to back
- Keeping the area dry
- Emollients
- Loose cotton clothing
- Treating constipation and worms where applicable
- Avoiding activities that exacerbate the problem
Symptoms of vulvovaginitis
- soreness
- itching
- erythema around the labia
- vaginal discharge
- dysuria
- constipation
What is otitis media?
Infection of the middle ear
How does otitis media occur in children?
Through infection via the eustachian tube - often preceded by a viral URTI
What is the most common bacterial cause of otitis media?
Streptococcus pneumoniae
Presentation of otitis media
- ear pain
- reduced hearing
- URTI symptoms
- if affecting the vestibular system then can cause balance issues
appearance of the tympanic membrane in otitis media
bulging red, inflamed looking membrane. May be a perforation
Management of otitis media
- if not very unwell then simple analgesia
- can consider delayed antibiotics to be picked up after 3 days if there has been no improvement
Antibiotic of choice for otitis media
amoxicillin
What are the complications of otitis media?
- otitis media with effusion
- hearing loss
- perforated ear drum
- recurrent infection
- mastoiditis
- abscess
What is the most common bacterial cause of tonsilitis?
Group A streptococcus
What criteria can you use when diagnosing tonislitis?
Centor or feverPAIN
Centor
Score of 3 or more: treat with antibiotics
- fever over 38
- exudate on tonsils
- absence of cough
- tender anterior cervical lymph nodes
antibiotics for tonsilitis
Penicillin V for 10 days
Complications of tonsillitis
- chronic tonsilitis
- peritonsillar abscess (quinsy)
- otitis media
- scarlet fever
- rheumatic fever
- post streptococcal glomerulonephritis or reactive arthritis
What is hypoxic ischaemic encephalopathy
Lack of oxygen during birth resulting in ischaemia to the brain
Causes of hypoxic ischaemic encephalopathy
- maternal shock
- intrapartum haemorrhage
- prolasped cord
- nuchal cord
Mild hypoxic ischaemic encephalopathy
- Poor feeding, generally irritability and hyper-alert
- Resolves within 24 hours
- Normal prognosis
Moderate hypoxic encephalopathy
- Poor feeding, lethargic, hypotonic and seizures
- Can take weeks to resolve
- Up to 40% develop cerebral palsy
Severe hypoxic encephalopathy
- Reduced consciousness, apnoeas, flaccid and reduced or absent reflexes
- Up to 50% mortality
- Up to 90% develop cerebral palsy
Caput Succedaneum
Oedema collects on the outside of the scalp outside the periosteum
Able to cross the suture lines
Cephalohaematoma
Blood between the skull and the periosteum
Below the periosteum so doesn’t cross the suture lines
Management of cepahlohaematoma
Should resolve by itself
Monitor for jaundice and anaemia
Nerves erbs palsy
C5/6
Erbs palsy
- weakness of shoulder abduction and external rotation, arm flexion and finger extension
- waiter’s tip
- internally rotated shoulder
- extended elbow
- flexed wrist facing back
- lack of movement in the affected arm
Signs of a fractured clavicle after birth
- lack of movement in affected arm or asymmetry of movement
- pain and distress on movement of the arm
What is the most common cause of respiratory distress in the newborn?
Transient tachypnoea of the newborn
TTP on x ray
- hyperinflation
- fluid in the horizontal fissure
Management of Transient Tachypnoea of the newborn
- observation
- supplementary oxygen
- normally settles in 1-2 days
What is respiratory distress syndrome?
- premature neonates (born before surfactant develops)
Apnoea in baby
20 seconds no breathing or shorter periods with desaturation or bradycardia
X ray of respiratory distress syndrome
Ground glass appearance
Retinopathy of prematurity
Abnormal development of blood vessels in the retina
Can lead to scarring, retinal detachment and blindness
Exomphalos
Abdominal wall defect - intestines outside of the body covered in amniotic sac (amniotic membrane and peritoneum)
Exomphalos management
- caesarean if picked up antenatally
- staged repair
Gastroschisis
Congenital defect in the anterior abdominal wall lateral to the umbilicus
Gastroschisis management
Newborns should go to theatre straight after delivery
Diaphragmatic hernia
Concave shape of the abdomen, intestines/abdominal contents in the chest
What is rickets
Defective bone mineralisation causing soft and deformed bones
What causes rikcets?
Deficiency in either vitamin D or calcium
Bone deformity in rickets
- bowing of the legs
- knock knees
- craniotabes (soft skull)
- ribs expand at the costochondral joints
Symptoms of retinoblastoma
- absence of red-reflex, replaced by a white pupil (leukocoria) - the most common presenting symptom
- strabismus
- visual problems
Prognosis of retinoblastoma
> 90% make it to adulthood
What is the most common malignancy affecting children?
Acute lymphoblastic leukaemia
Features of acute lymphoblastic leukaemia
- anaemia: lethargy pallor
- neutropenia: frequent or severe infections
- thrombocytopenia: easy bruising, petechiae
- bone pain
-splenomegaly and hepatomegaly - fever
- testicular swelling
Benign rolandic epilepsy
- between age 4 and 12
- seizures characteristically at night
- typically partial seizures
EEG benign rolandic epilepsy
Centrotemporal spikes
Hypogonadotrophic hypogonadism (Kallman’s syndrome) LH and testosterone
Low LH, low testosterone
Primary hypogonadism (Klinefelter’s syndrome) LH and testosterone
high LH, low testosterone
Androgen insensitivity syndrome LH and testosterone
High LH, normal/high testosterone
Klinefelters karyotype
47 XXY
What is duchenne muscular dystrophy?
X linked recessive disorder in dystrophin genes
Features of duchenne muscular dystophy
- progressive proximal muscle weakness from 5 years
- calf pseudo hypertrophy
- Gower’s sign: child uses arms to stand up from squatted position
- 30% have intellectual impairment
Gower’s sign
Child uses their arms to stand from squatted position
association duchenne muscular dystrophy
Dilated cardiomyopathy
prognosis duchenne muscular dystophy
Cannot walk by aged 12, typically survive to age 25-30
Features of growing pains
- never present at the start of the day
- no limp
- no limitation of physical activity
- systemically well
- normal physical development
- meeting all physical milestones on time
- symptoms intermittent and more common after vigorous activity
immunisation at birth
BCG if at risk
Immunisation at 2 months
6 in 1, oral rotavirus, MENb
What is included in the 6 in 1 vaccine?
- diptheria
- tetanus
- whooping cough
- polio
- Hib
- hep B
Immunisation at 3 months
- 6 in 1
- oral rotavirus
- PCV (pneumococcal)
Immunisation at 4 months
- 6 in 1
- men b
Immunisation at 12/13 months
- hib/men C
- MMR
- PCV
- Men B
Immunisation 3-4 years
- MMR
- 4 in 1 booster: diptheria, whooping cough, polio, tetanus
Features of kawasaki disease
- high grade fever lasting over 5 days, classically resistant to anti-pyretics
- conjunctival injection
- bright red, cracked lips
- strawberry tongue
- cervical lymphadenopathy
- red palms of the hands and soles of the feet
Management of kawasaki disease
- high dose aspirin
- intravenous immunoglobulin
Complication of kawasaki diseae
Coronary artery aneurysm
What are the causes of a nappy/napkin rash?
- irritant dermatitis |(most common due to urine+ faeces, creases spared)
- candida dermatitis (satellite lesions)
- seborrhoeic dermatitis
- psoriasis
- atopic eczema
Management of nappy rash
- disposable nappy
- expose napkin area to air when possible
- apply barrier cream
- mild steroid cream
- candida- topical imidazole cream
When does blood spot screening take place?
5-9 days
What does the neonatal blood spot test check for?
- congenital hypothyroidism
- cystic fibrosis
- sickle cell disease
- phenylketonuria
- medium chain acyl-CoA dehydrogenase deficiency (MCADD)
- maple syrup urine disease (MSUD)
- isovaleric acidaemia (IVA)
- glutaric aciduria type 1 (GA1)
- homocystinuria (pyridoxine unresponsive) (HCU)
Newborn resuscitation
- dry baby
- assess tone, resp rate and heart rate
- If gasping or not breathing give 5 rescue breaths
- reassess
- If heart rate not improving and less than 60 start compressions and ventilation breaths at a rate of 3:1
What are the causes of obesity in children?
- growth hormone deficiency
- hypothyroidism
- Down’s syndrome
- Cushing’s syndrome
- Prader-Willi syndrome
What are the consequences of childhood obesity?
- orthopaedic problems: slipped upper femoral epiphyses, Blount’s disease (a development abnormality of the tibia resulting in bowing of the legs), musculoskeletal pains
- psychological consequences: poor self-esteem, bullying
- sleep apnoea
- benign intracranial hypertension
- long-term consequences: increased incidence of type 2 diabetes mellitus, hypertension and ischaemic heart disease
Precocious puberty small testes
Adrenal cause
precocious puberty enlarged testicles
astrocytoma
sex cord-gonadal stromal tumour
unilateral enlargement of the testis
What makes up the agpar score?
- respiratory effort
- colour
- tone
- heart rate
- reflex irritability
When is the agpar score assessed?
- 1 minute
- 5 minutes
- 10 minutes if low
good score for Agpar
7-10
What is the compression ratio for a child?
15:2
Compression type in child
Lower half of the sternum
Compression type in infant
two thumb encircling technique
Age to smile
6 weeks, refer if no smile by 10 weeks
Age to laugh
3 months
What is the most common cause of stridor in a neonate
Laryngomalacia
What is a wilms tumour?
- nephroblastoma
- renal malignancy in children
Presentation of wilms tumour
- abdominal mass
- painless haematuria
- flank pain
Presentation of congenital cytomegalovirus
- hearing loss
- low birth weight
- petechial rash
- microcephaly
- fever
How should you check for complication of kawasaki disease?
Echocardiogram
What is the most common cause of billious vomiting on the first day?
Intestinal atresia
