Paediatrics Flashcards
- Sickle cell disease (SCD)
- Cystic fibrosis (CF)
- Congenital hypothyroidism (CHT)
- Inherited metabolic diseases (IMDs). These are genetic diseases that affect the metabolism and include:
- phenylketonuria (PKU)
- medium-chain acyl-CoA dehydrogenase deficiency (MCADD)
- maple syrup urine disease (MSUD)
- isovaleric acidaemia (IVA)
- glutaric aciduria type 1 (GA1)
- homocystinuria (HCU)
When should a patient with bronchiolitis be referred into hospital as an emergency?
- apnoea (observed or reported)
- child looks seriously unwell to a healthcare professional
- severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute
- central cyanosis
- persistent oxygen saturation of less than 92% when breathing air.
When should a child with bronchiolitis be considered for hospital referral (discuss with consultant)?
- a respiratory rate of over 60 breaths/minute
- difficulty with breastfeeding or inadequate oral fluid intake
- clinical dehydration.
What are the red flag symptoms to inform parents about when their child has bronchiolitis?
- worsening work of breathing (for example grunting, nasal flaring, marked chest recession)
- fluid intake is 50–75% of normal or no wet nappy for 12 hours
- apnoea or cyanosis
- exhaustion (for example, not responding normally to social cues, wakes only with prolonged stimulation).
What are the guidelines for different types of milk children should drink ?
- breast milk best for babies (especially first 6 months)
- Infant formula only suitable alternative to breast milk in first 12 months
- full fat cows milk can be given from age 1
- Soya, almond, oat milk can be used from age 1
- semi-skimmed cows milk can be introduced from age 2
- skimmed milk is not recommended until over age 5 (lack of calories)
What are the risk factors for DDH?
- female (80%) cases
- genetic - FHx
- Internal - shallow acetabulum, connective tissue laxity, decreased hip resistance
- External - breech position, large for gestational age, oligohydramnios, multiple pregnancy
In the NICE traffic light system, what are the red ‘high risk’ features of serious illness in under 5s?
- pale/mottled/ashen/blue
- no response to social cues
- appears ill to HCP
- Does not wake/stay awake
- weak high-pitched or continuous cry
- grunting
- tachypnoea RR >60
- moderate-severe chest indrawing
- reduced skin turgor
- Age <3months with temp >=38
- non blanching rash
- bulging fontanelle
- neck stiffness
- focal neuro signs/focal seizures
- status epilepticus
How should headlice solution be used?
- apply the lotion to dry hair and scalp, allow to dry naturally, remove by washing after eight hours.
- The application can then be repeated in seven days.
What is the definition of constipation?
Passing less than 3 complete stools per week
When is constipation classed as chronic?
When it has lasted longer than 8 weeks
What are the common symptoms of constipation in children?
- reduced appetite
- abdo discomfort relieved by opening bowels
- straining
- anal pain
- overflow soiling
- rabbit droppings or large hard stool
- may lead to urinary infections
- may lead to nocturnal enuresis
what can cause constipation in children?
- weaning
- changing from breast to bottle feed
- change in diet
- Inadequate food/fluid intake
- low fibre diet
- social stressors/changes
- if breastfed - mothers diet
- changes in medication - alginates in GORD, antihistamines
- family history
- physically inactive/neurodevelopmental disorder
How should a child with constipation be examined?
- abdo exam
- growth and development
- neurological assessment
- check spine, buttocks, anus, legs for abnormalities
What are the red flags for constipation?
- delayed meconium >48hrs - CF or Hirschprung’s disease
- within 2 weeks of life - inadequate feeding/intake
- abdo pain, distension and vomiting - surgical cause
- faltering growth
- persistent blood in stool
- thin stringy stools/abnormal appearance of anus - anal stenosis
- weakness in legs/unexplained motor signs
- motor delay
- FHx Hirschprung’s disease
- abnormal spine, lumbosacral region or gluteal muscles.
- child maltreatment
If there are concerns re growth, or inadequate response to treatment in a child with constipation, what should be done?
- test: coeliacs, hypothyroidism
- refer secondary care
- Idiopathic constipation in a child <1 year - if not responding within 4 weeks of treatment - should be referred to secondary care.
- Children >1year who have been terated for 12 weeks without success - refer secondary care
- Children who have been unable to wean off laxatives after 12 months of treatment - should also be referred.
Which toileting behaviours can help with childhood constipation?
- simple reward systems (star charts)
- Sitting exercises - sit and push for several minutes (30 mins after each meal), can sit with toys/bok, blowing bubbles on toielt can loosen muscles.
What is the first line laxative in children with idiopathic constipation?
- macrogol
- laxxative can be mixed with other food/drink to aid compliance.
When should a disimpaction laxative regime be considered in children with idiopathic constipation? What should parents be advised? When should they be reviewed?
- not opened bowels effectively for >7days
- advise: may cause increase in soiling, distension, abdo pain - but this is transient. Consider timing with school holiday, abscence needed.
- review after 1 week.
What advice should parents be given about maintenance laxatives?
- once disimpaction successful (type 7 stool)- switch to maintenance dose
- do not abruptly stop laxatives
- should continue for several weeks after regular bowel movements achieved.
- dose should then be gradually reduced over months in response to stool frequency & consistency - this allows the bowels to recover.
- stopping it too early can cause recurrence.
- review progress after 6 weeks
What diet (food and fluid) advice should be given to parents about constipation?
- from 7-12 monhts - babies need 600ml water/day in drinks
- from age 4-8 years old need 1200ml/day
- varies depending on how active the child is, weight, climate
- exclusively breastfed babies do not need additional water - it displaces nutritional value from breastmilk
- fruits with sorbitol - pear, prune, apple - act as natural laxatives
- High fibre foods - fruits, vegs, baked beans, wholegrain cereals, dried fruits.
Which topical anaesthetics can be used in children prior to blood taking?
- EMLA (lidocaine with prilocaine)
- Ametop (tetracaine)
Purulent unilateral nasal discharge in a young child is most likely due to…
foreign body
What does the image show? It has been present since birth
A salmon patch
* a common capillary vascular malformation which occurs in approximately 40% of all newborns.
* present at birth and commonly found at the nape of the neck (stork bite), glabella (angel’s kiss) and eyelids.
* Lesions on the face often resolve spontaneously within the first year of life, but 50% of stork bites persist into adulthood. No treatment is needed.
How should suspected IgE- mediated CMPA be managed?
- If breastfeeding: mother should have cow’s milk free diet, continue breastfeeding (daily maternal ca/vitD supplement)
- If formula fed or ‘mixed-feeding’ - actively support continued breastfeeding. If unable to convert to fully breastfeeding - trial Extensively Hydrolysed Formula (eHF)
* refer dietician - organise allergy testing to confirm diagnosis - if confirmed then follow up arranged by clinic (to test for acquired tolerance)
- give allergy action plan
- ensure oral antihistamines available at home.
How should patients with severe non-IgE mediated CMA be managed?
- if mother breastfeeding - exclude all CMP from her diet, continue breastfeeding. Ca/Vit D supplement
- If formula fed or ‘mixed feeding’ - revert to fully breastfeeding. If cannot revert - try Amino Acid Formula (AAF).
*** urgent referral to local paeds allergy service - urgent dietician referral.**
How should mild-moderate non-IgE mediated CMA be managed?
- usually present at onset of formula feeding.
- several mild symptoms often present: ‘colic’, ‘reflux’, food refusal, flatus, stools changes, blood/mucus in other wise well infant, persistent atopic dermatitis. If first line treatments e.g for GORD/eczema fail - more likely to be allergy related.
- If breastfed - cows milk free diet in mother and ca/vit D supplement. Refer dietician.
- If formula fed or mixed feeding - revert back to breastfeeding. if cannot revert - trial EHF.
- Trial the elimination for 2-4 weeks.
- If there is a clear improvement in symptoms - home reintroduction of cows milk to confirm diagnosis of Non-IgE mediated CMA (IMAP home reintroduction protocol available for parents)
- If there is NO return of symptoms - CMA NOT confirmed so resume normal feeding.
- If there is RETURN of symptoms - non-IgE CMA confirmed. Continue to exclude cows milk until 12 months old. Refer paeds dietician for ongoing support.
Management of mild to moderate non-IgE CMA flowchart
