Paediatrics Flashcards
Epiglottitis
Medical emergency
Rapidly progressive infection that leads to inflammation of the epiglottis and adjacent tissues and can rapidly block upper airway - risk of death
Causative organism (most common):
- Haemiphilus influenza B (HiB) - but take cultures
Differentiating signs/symptoms:
- Drooling (cant swallow)
- Soft inspiratory stridor
- Sat Upright, open mouth
- Usually absent cough
Management:
- Endotracheal intubation
- IV certuroxime (antibiotic: cephalosporin)
Bacterial tracheitis
Medical emergency
Characterized by a high fever and rapidly progressive airway obstruction due to accumulation of copious, thick airway secretions. It may present similarly to viral croup but tends to be more severe and rapidly progressive.
Most causative organism: Staph aureus, usually following a URTI (virus predisposing the trachea to bacterial colonisation)
Differentiating signs/symptoms:
- High fever
- Stridor
- Barking cough
- Rapid & difficulty breathing
- Cyanosis
Management:
- Broad spec IV antibiotics (until causative organism identified)
- In severe cases: intubation
- Airway humidification and chest physiotherapy may assist in the clearance of secretions
Bronchiolitis
- A widespread chest infection, predominantly affecting infants aged 1-12 months. This lower respiratory tract disease targets the bronchioles, causing inflammation and congestion.
- 90% are 1-9months, peak incidence 3-6months (very common during winters)
Typical causative organism:
- Respiratory Syncytial Virus (RSV) around 80% of cases
Typical symptoms:
- Dry Cough
- Laboured breathing/breahtlessness
- Wheezing
- Tachypnoea
- **Intercostal recession
- Grunting
- Nasal flaring
SIGN guidelines: make a diagnosis of acute bronchiolitis in an infant with: nasal discharge with wheezy cough, in the presence of fine inspiratory crackles and/or high pitched expiratory wheeze
NOTE: feeding difficulties associated with. W increased dyspnoea is often main reason for hospital admission
Complications:
- Bronchiolitis obliterans (popcorn lung) - rare chronic complication
Bronchiolitis obliterans (constrictive bronchiolitis/popcorn lung)
A pathological condition characterized by permanent obstruction of the bronchioles, the smallest airways in the lung.
Caused from: chronic inflammation that leads to the formation of scar tissue within the bronchioles (also a rare complication of Bronchiolitis)
- Viral infections (Adenovirus most frequent)
- Complication of bone marrow or lung transplants
Signs/Symptoms:
- Dry cough
- Shortness of breath
- Hypoxia
- Wheezing
- Lethargy
Management (supportive no cure):
- Immunosuppresive agents: Tacrolimus, cyclosporin, mycophenolate mofetil, and prednisone have been used to treat bronchiolitis obliterans after transplant.
Common presentations to the GP during the neonatal period (up to 4 weeks)
- Jaundice - Breast milk jaundice, more serious: biliary atresia, infection - UTI, toxoplasmosis, CMV, VZV, HIV, Hep B galactosaemia, hypothyroidism, sepsis, haemolysis (ABO comparability/rhesus disease) = refer to paed unit
- Vomiting - infantile reflux, CMP (cows milk protein). intolerance, more serious: pyloric stenosis, sepsis, duodenal atresia (congenital absence of part of the duodenum)
- Failure to thrive - feeding problems
- infection/sepsis
- “Trivia”
Any child <3months of age w a temp >38 degrees = RED FLAG - refer to paed unit for full sepsis screen
Common paediatric respiratory problems
- RSV Bronchiolitis
- Virul URTIs e.g. rhinovirus, adenovirus, influenza
- Croup - parainfluenza (barking cough)
- Asthma (new or exacerbated, particularly nocturnal cough)
- Acute tonsillitis
Rare respiratory paediatric problems
- Cystic Fibrosis
- Acute epiglottitis
- Foreign body
- Pneumonia
- Cardiac causes
- Malignancy
What is nasal flaring & intercostal recession a sign of?
Respiratory distress
What are you going to do/look for when assessing the respiratory system in neonates/children?
- Cyanosis
- Tachypnoeic (RR)
- Nasal flaring/intercostal recession
- Wheeze/stridor/cough
- Pulse oximetry
- Percussion
- Auscultation
- ENT Examination
What are the normal resp rates in children?
<1 = 30-40 BPM
1-2 = 25-35 BPM
2-5 = 25-30 BPM
5-12 = 20-25 BPM
>12 = 15-20 BPM
GI problems - Presentations in children
- abdominal pain
- vomiting
- diarrhoea
- nausea
- constipation
MSK problems - Presentations in children
- Painful joint(s)
- Limbs - DDH (developmental dysplasia of the hip - should be picked up in neonatal screening but not all are)/Perthes
- Trauma - sprain/fracture/NAI
Joint pain differentials in children
- Transisent synovitis - child maybe has a concurrent viral infection and they get some joint inflammation with it like their hips and knees
- More rarely: inflammatory arthritis (RA), Perthes disease (vascular necrosis of the hip joint), slipped femoral epiphyses, Osgood schlatters (normally in sporty adolescence - overuse injury and needs rest), growing pains
- Even more rarely: bone tumours, infective causes (septic arthritis)
Impetigo treatment
- Topical fuscidic acid (rarely oral flucloxacillin)
- Make sure towels etc aren’t shared
Slapped cheek syndrome
Caused by Parvovirus B19
Self limiting - reassurance and explanation
Molluscum spots
Reassurance - may have for 2 years but do go eventually
Scarlet fever
- Group A streptococcus
- Sand paper rash
- Strawberry tongue - Film over tongue then peels off to reveal a really red tongue
Hand foot and mouth disease
- Cosxsakie or enterovirus
- Self-limiting but very unpleasant, children got extremely Sore mouth
- Papules on hand, feet mouth and sometimes on the buttocks
What is screened for at the GP during the childhood development screening at 6-8 weeks
- Heart sounds
- Red light reflex e.g. for a congenital retinoblastoma
- Hips (barlows/ortalanis = no CDH or DDH)
- Genitalia (e.g. making sure testes have both descended)
- Femoral pulses (??coarctation if any femoral pulse missing)
- Disease notification e.g. Measles to inform public health (Group A strep in England but not in Scotland)
When do children get immunised against MMR?
Just after 1 year for first one then second one = pre-school (3-4)
Cerebral palsy
An outcome to an insult to the developing brain - mostly in neonatal period but maybe later as an infant => a group of disorders of development of movement and posture aka a motor issue, often accompanied with disturbances of sensation, cognition, communication, behaviour and seizures
Basically: at some point there’s been some damage to the brain => No oxygen to brain => softness and lack of white matter => motor damage to the brain
Not a single thing causes it:
- Increases risk: prematurity, small, twins
- Before birth: periventricular leukomalacia, injury to the womb, congenital infection
- During/after birth: Meningitis, head injury, HIE (Hypoxic ischaemic encephalopothy - lack of O2 at come point during delivery)
What is Makaton?
A simplified form of British sign language (BSL) - good for individuals with cerebral palsy
Measles
Highly contagious
- Caused by: measles morbillivirus - a single stranded enveloped RNA virus
- Transmission: droplets from the nose, mouth or throat of infected persons
- Most common in unvaccinated children
Signs/symptoms: develop 10-14 days post-exposure, last 7-10 days
- fever >40
- Corzyal symptoms
- Conjunctivitis
- Maculopapular Rash 2-5 days after onset of symptoms
- Koplik spots: grey discolorations of the mucosal membranes in the mouth
Investigations for suspected measles include:
- 1st: Measles-specific IgM and IgG serology (ELISA), most sensitive 3-14 days after onset of the rash.
- 2nd: Measles RNA detection by PCR, best for swabs taken 1-3 days after rash onset.
Croup (Laryngotracheitis)
A common childhood viral URTI which causes nasopharyngeal inflammation
Spreads from the larynx to the trachea
Generally self-limiting
Occurs mainly in the spring and autumn
Most common viral causative agent: Parainfluenza virus
Affects: 6 months -3 years
Presentation:
- Barking cough
- Stridor
- Non-specific URTI symptoms: fever (<38.5), runny nose, sore throat, cough
- Respiratory distress
NOTE:
- If you suspect croup do NOT examine the back of the throat - patients airway already narrowed and if you check their throat, they become more anxious -> may further reduce the patency of the airway
- Try give O2 mask if hypoxic, but avoid if anxious
- reassure child and parent - children mimic parents so if parent becomes anxious so too will the child and will worsen the already compromised airway
How to classify the severity of Croup?
Severe croup:
- Cyanosis
- Severe resp distress
- Exhaustion
- Be aware: Paradoxial decrease in stridor and respiratory distress as the child becomes fatigues
Moderate croup:
- NO signs of severe croup
- Clinical signs PRESENT at REST, but worsen when aggravated
Mild croup:
- NO signs of severe croup
- Clinical signs NOT present at REST, only when aggravated
Management of coup (depending on the severity)
Severe:
-
NEB Adrenaline
-Oral/IV dexamethasone - O2
- Senior help + URGENT PICU review
Moderate:
- Oral dexamethasone
- Observe (2-3 hours) -> no symptoms (rest)
- Stable -> home
- Unstable -> NEB Adrenaline
Mild:
- Oral dexamethasone
- rest at home
Management of Bronchiolitis
Supportive management - in the hospital. All bellow including: hydration, nutrition and fever, management
AIRWAYS:
- Nasal suction to clear secretions
BREATHING:
- Monitor SPO2 using pulse oximetry
- Supplemental O2 via nasal cannulae in infants O2 stats <92% or severe resp distress or cyanosis
- Assisted ventilation in the room of nasal or facemask CPAP or full ventilation (only required in some infants admitted)
CIRCULATION:
- Fluids may be given by nasogastric tube or intravenously for those who can not maintain oral intake or hydration
SIGN guideline: most infants with acute bronchitis will have mild disease and can be managed at home with primary care support - partner/carer given information in case of deterioration
- Prophylaxis in high-risk patients - Palivizumab (this info from quesmed)
Investigations for Bronchiolitis
- PCR analysis of nasopharyngeal secretions (to identify respiratory virus)
- Pulse oximetry - measure and monitor arterial O2 saturation continuously
Infants with an O2 sat <92% = inpatient care
Infants with an O2 >94% in room air may be considered for discharge
In between 92-94% = clinical assessment for decision
What indicates an infants prompt referral to the hospital with acute bronchitis?
- Poor feeding (<50% of usual fluid intake preceding 24hrs)
- Resp rate >70
- Lethargy or history of apnoea
- Presence of nasal flaring and/or grunting
- Severe chest wall recession
- Cyanosis
- O2 saturation <94%
- Uncertainty over diagnosis
SIGN guidelines: Hospitilisation threshold lowered for those with co-morbidities, <3 months old, infants born <35 weeks gestation
Urinary tract infection
Up to 3% of girls and 1% of boys get a UTI during childhood
Cause: bowel flora entering the urinary tract via the urethra (except in newborns where its more likely to be haematogenous)
Most commonest organism in children: E.coli (Klebsiella, Proteus, Pseudomonas and Strep. Faecalis follow)
A UTI in childhood because:
1. Up to half of patients have a structural abnormality of their urinary tract
2. Pyelonephritis may damage growing kidneys by forming scars, predisposing to hypertension and to chronic renal failure if the scarring is bilateral
Presentation: varies with age
1. Infants <3 months (preverbal): non-specific
- Fever
- Vomiting/diarrhoea
- Poor feeding/failure to thrive
- Prolonged neonatal jaundice
- Classical UTI symptoms become more common in increasing age (verbal infants and children >3 months):
- Frequency
- Dysuria (pain when urinating)
- Loin pain
FEATURES OF AN UPPER UTI
1. Temperature >38
2. Loin pain and tenderness
How to diagnose a UTI
A urine sample
Key points:
- samples should be microscopes and cultured straight away
What investigations would you carry out for a child with an atypical or recurrent UTI
- Ultrasound of kidneys and urinary tract
- Dimercaptosuccinic acid (DMSA) scan to check for renal scars 3 months post UTI
- Micturating cystourethrogram (MCUG) to detect obstruction and vesicoureteric reflux
Management of a UTI in all infants <3 months old with suspicion or seriously unwell
- REFER IMMEDIATELY to paediatric specialist in hospital
- IV antibiotic therapy (e.g. cefotaxime) until temperature has settles
Management of a UTI in infants >3 months old and children with acute Pyelonephritis/upper UTI
Oral antibiotics with low resistance patterns e.g. co-amoxiclav for 7-10 days
OR
IV antibiotics (cefotaxime) for 2-4 days followed by oral antibiotics for 7-10 days
Management of a UTI in infants >3 months and children with cystitis/lower UTI
Oral antibiotics for 3 days
Choice depends on local guidance but examples include: trimethoprim, nitrofurantoin, cephalosporin or amoxicillin
Vesicoureteric Reflux (VUR) - pathophysiology, investigations and grading
Abnormal back flow of urine from bladder into the ureter and kidney
- relatively common abnormality and predisposes children to a UTI - investigate for VUR in children following a UTI
Pathophsyiology: ureters displaced laterally, entering bladder in a more perpendicular fashion rather than at an angle => shortened intramural course of ureter, Vesicoureteric junction cannot function adequately
Investigations:
1. Micturating cystourethrogram (MCUG) to detect obstruction and vesicoureteric reflux
2. Dimercaptosuccinic acid (DMSA) scan (look for renal scarring)
Grading:
I - Reflux into ureter only, no dilation
II - Reflux into the renal pelvis, no dilation
III - Mild.moderate dilation of ureter, renal pelvis and calyces
IV - Dilation of renal pelvis and calyces with urethral tortuosity
V - Gross dilation or ureter, pelvis and calyces with urethral tortousity
Turbeculosis investigations in a low income country
- Acid fast bacilli (low yield in children)
- Interferon-gamma release assays
- Chest x-ray
- Mantoux (skin prick test - be careful of a false positive)
Turbeculosis treatment in a low income country
Two months of: Isoniazid, Rifampicin, Pyrazinamide +/- Ethambutol (use in an area with high resistance against isoniazid or the child is HIV positive)
The Four months of: Isoniazid and Rifampicin
Acronym: RIPE
- longer if TB meningitis, spinal or Osteo-articular disease
