PAEDIATRICS Flashcards
How to calculate bladder capacity in a child?
Bladder capacity increases until puberty.
Pre-pubescent child = (age+1) x 30 ml
Definition of nocturnal enuresis / bedwetting?
Discrete episodes of bedwetting overnight in children OVER 5 YEARS OLD
By what age group should children be dry in the day and night respectively?
Should be dry in the day by 3 years old and dry at night by 5 years old
Children who were previously continent that develop new incontinence (regression) always need clinical assessment - true or false?
TRUE
To exclude causes of regression such as UTI, constipation, vulvovaginitis, overactive bladder, threadworms or Type I diabetes
May simply be caused by emotional upset e.g moving house, birth of a sibling but need to exclude the above causes first
What is the definition of secondary enuresis?
Development of bedwetting after > 6 months of continence
What is the typical presentation of nocturnal polyuria in a child and what causes it?
Nocturnal polyuria is a caused by a lack of vasopressin release during the night. Vasopressin helps suppress night-time urination.
Typically presents with larger volume urination early on in the night and may have family Hx of bedwetting in parents/siblings.
What is the concept of urotherapy?
Ensuring the child is drinking adequate quantities of fluid spaced throughout the day and avoiding fluids in the last hour before bed. This helps prevent dehydrated urine in the bladder which causes irritable bladder, also helps improve bladder capacity.
Child 4 - 8 = 1,000 - 1,400 ml / day
Child 9-13: Females = 1,200 - 2,100 ml/day. Male = 1,400 - 2,300ml/day
Encourage footstool when on the toilet to help passage of stool and reduce vesico-vaginal reflux in girls (pooling of urine in the vaginal vestibule while slumped on the toilet which then leaks when stand up)
Encourage regular toilet attendance throughout the day (5-7 times)
What are 1st line treatments for nightime bed wetting (can be started from age 5) that can be started in GP?
Joint first line treatments are enuresis alarms and Desmopressin.
You can also try them both concurrently.
Enuresis alarms - have a sensor that go off as soon as child starts to wee, trains them to recognise when they have a full bladder. Effective if child and family motivated to use them.
Review their effectiveness at 4 WEEKS - if no improvement stop, if had 2x weeks of dryness then also don’t need to continue. If improving then can continue - about 75% will be dry by ~ 2-3 months.
Desmopressin
Given as a tablet or melt 1 hour before bed
Given for 3 months then 1-week medication free to review response
Renal function / monitoring bloods ARE NOT required during desmopressin use
NOT SUITABLE FOR DAYTIME WETTING
Generally, in the absence of red flags, when should continence or constipation issues be referred to secondary care?
After 3 months of primary care management if nil improvement
Summarise the faecal disimpaction regime?
Macrogol first line
Esclating doses of macrogol daily over 1-2 weeks until consistently passing brown water (type 7 with no formed stool). Start with 2 sachets daily in children 1-5 and 4 sachets daily in children 5-12 then increase by 2 sachets daily upto 8 per day in children 1-5 and 12 per day in children 5-12.
(Can consider senna, bisacodyl, picosulphate or docusate with added lactulose if not tolerating macrogol)
If not disimpacted after 2 wks of macrogol disimpaction then add in stimulant laxative.
Once disimpaction achieved, then reduce to half the disimpaction dose daily then cautiously reduce until soft type 4/5 stool consistently produced daily.
Warn parents that soiling is likely to get worse before it gets better
Continue maintenance laxatives for at least 3 months after normal stool habit achieved and for a 1 yr or more if soiling was present.
What is the causative organism behind hand, foot and mouth and how does it normally present?
Caused by viruses within the Picornoviridaem family.
Presents with initial mild systemic upset (fever, sore throat) followed by oral ulcers & ulcers on soles of hands & feet
Children DO NOT need to be kept away from school /isolate if they have H,F & M, only if they are too unwell to attend
What is the typical presentation of Noonan syndrome?
Autosomal dominant genetic condition
Presents from birth with:
-> Pectus excavatum
-> Pulmonary stenosis
-> Short stature
-> Webbed neck
What is the national guidance on restriction from school for common childhood infections?
No exclusion Conjunctivitis
Fifth disease (slapped cheek) / parvovirus B19
Roseola (caused by herpes virus - sudden onset high fever for a few days, then onset of reddish-pinkish flattened rash after the fever has settled
Infectious mononucleosis
Head lice
Threadworms
Hand, foot and mouth
24 hours after commencing antibiotics: Scarlet fever
2 days after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics : Whooping cough
4 days from onset of rash - Measles
5 days from onset of rash Rubella
All lesions crusted over - Chickenpox*
5 days from onset of swollen glands - Mumps
Until symptoms have settled for 48 hours - Diarrhoea & vomiting
Until lesions are crusted and healed, or 48 hours
after commencing antibiotic treatment - Impetigo
Until treated - Scabies
Until recovered- Influenza
What per centage of chidren with CMPA are also allergic to soya?
~ 10%
What complication of measles is the most common cause of death from measles?
Measles pneumonia!
This is the most common cause of death related to measles
Other
complications include
Otitis media - the most common complication from measles
Encephalitis, subacute sclerosing panencephalitis (presents with motor decline, myoclonus and mental deterioration 5-10 years after initial infection, due to reactivation of the measles virus or abnormal reaction to it, typically fatal after a few years, but very rare)
keratoconjunctivitis, corneal ulceration, diarrhoea, increased incidence of appendicitis, and myocarditis
What is the causative organism for measles?
RNA Paramyxovirus
Aerosol transmission
Infectious from onset of prodrome to 4-days post appearance of rash
Incubation period - 10-14 days
Fever + general viral prodrome then kopliks spots then Rash appears behind the ears then spreads to body.
How should you manage when a child not vaccinated against measles comes into contact with a positive measles case?
The unvaccinated child should be offered the MMR vaccine within 72 hours of contact
What is the risk of Down’s Syndrome for future pregnancies if a woman has a child with Down’s?
Risk in future pregnancies is 1/100 or 1%
Non-dysjunction trisomy 21 - due to a failure of the pair of chromosome 21 to split in the sperm or the egg.
Mosaic down’s syndrome - the 3x copies of chromosome 21 is only present in SOME not all cells in the body
What is Barrter’s syndrome
A congenital cause of hypothyroidism due to a defective potassium/sodium/chloride channel in the loop of henle that makes you lose potassium into your urine
Presents in childhood with
Low K+
NORMOtension
Weakness / failure to thrive
Polyuria / polydipsia
How should you manage mild labial adhesions in young infant girls?
This is caused by the hypo-oestrogenic state
It will resolve by itself as the girl gets older however if associated with discomfort or dysuria 1st line is trial of topical oestrogen cream
How should you approach consent for childhood vaccinations?
Written consent is not required
for children not competent to give or withhold consent a person with parental responsibility may give consent on their behalf
parental responsibility is defined by the Children Act 1989. Mothers automatically have parental responsibility. Fathers have responsibility if they are married to the mother when the child was born or subsequently marry her. Unmarried fathers may acquire parental responsibility by:
1. Parental Responsibility Order granted by the court
2. Residence Order granted by the court
3. Parental Responsibility Agreement
since 2003 unmarried fathers can acquire parental responsibility if they are named on the child’s birth certificate
a step parent can can acquire parental responsibility if they marry the mother and either get a Parental Responsibility Agreement or the court grants a Parental Responsibility Order
if parents disagree then immunisation cannot go ahead without specific court approval
a person with parental responsibility does not need to be present at the time of immunisation. A grandparent or childminder, for example, may bring the child provided that the healthcare provider is satisfied that the person with parental responsibility has consented in advance. Written confirmation is not required.
Is Scarlet fever a notifiable disease in england?
YES!! if clinically suspect, need to inform public health england
-> caused by Group A strep -> strep pyogenes
When should antibiotics be given for pertussis / whooping cough?
If presents within the initial 21 days / 3 wks of cough onset then a course of a macrolide (Azithromycin, Erythromycin or Clarithromycin) should be given
Should also offer household contacts abx
Need to stay away from school until 48 hrs post-starting abx OR >21 days since cough onset.
Pregnant women now offered whooping cougb booster between 16-32 wks to reduce rates of neonatal whooping cough
(Vaccination immunity wanes and doesn’t give 100% protection)
What is the most common causative organism for croup?
Parainfluenzavirus causes most cases of croup
What is the first line treatment for intussuception?
Rectal insufflation under radiological guidance
(If unwell child / suspicion of peritonitis then will have surgical correction)
What is intussuception and how does it present?
Typically presents ~ 6-18 months
Invagination of one part of the colon into the lumen of the adjacent bowel. Most commonly affects ileo-caecal region.
May presents with severe colicy pain, drawing knees up and going pale. May have RUQ mass/. Redcurrent / bloody stools are late sign
1st line Ix is USS abdomen
Prior to what age is hand preference considered abnormal, possibly suggesting cerebral palsy?
Hand preference before 12 months is abnormal and should be referred to paediatrician
By what age should a child be able to respond to their own name?
By 12 months
By what age should a child be able to say Mama and Dada?
9 months
How should unilateral descended testes picked up at the 6 wk check be managed?
If one testes is palpable at 6 wks, review again at 3 months. If still unilateral undescended testes then refer at 3 months.
Is definitely abnormal if undescended by 6 months. Should be seen by surgeons then who can plan orchidopexy for ~ 12 months
What is Osgood-Schlatter disease and how does it present?
Osgood-Schlatter is a common cause of knee pain in children 10-15 yrs ie early teens.
It is inflammation of the patellar tendon where it inserts onto the tibia
It presents with pain just below the kneecap, often exacerbated by exercise/sports
O/E see Pain, tenderness and swelling over the tibial tubercle
How should ballooning of the foreskin / non-rectractible foreskin be managed, in a child under 2 and then in in children over 2.
Ballooning of foreskin during micturition or not able to retract foreskin
If < 2 = physiological phimosis - Mx with an expectant approach, DO NOT advice forceful retraction as this can lead to scarring. Encourage hygiene of the area.
If > 2 and recurrent UTI or balanoposthitis then refer to paeds urology
What is the typical presentation of threadworm / pinworm in children
Very common in children
Presents with perinanal itching, especially at night. Girls may present with vulval itch.
Dx = normally clinical, but can apply sellotape to the perianal region and send to the lab to see if grows eggs. May see some small perinanal white flecks. Normally just treat on clinical suspicion
-> single dose Oral Mebendazole first line treatment and treat everyone else in the house. Recommend hygiene measures.
Can repeat the mebendazole after 2 wks if no improvement
What is the most common form of primary headache in children?
Migraine without aura
What are the International Headache Society diagnostic criteria for paediatric migraine without aura?
More than 5 attacks that meet the below criteria:
- Headache has at least 2 of the following qualities *Unilateral or bilateral fronto/temporal location *Pulsating nature * Moderate-severe intensity * worsened by physical activity
- Headaches lasts between 4- 72 hrs
- At least 1 associated features of nausea OR vomiting OR photophobia OR phonophobia
What are the NICE recommended treatments for head lice and what advice should you give parents?
Evidence based head lice treatments:
- Dimeticone - apply to the scalp once weekly for 2 wks and leave on at least 8 hours before washing hair. It blocks the water supply to the lice as a physical barrier.
- Isopropyl myristate and cyclomethicone - physical barrier to the lice similar to dimeticone but advantage of only needing to be on for 10 mins
- Malathion - an insecticide - apply once weekly for 2 weeks, wash off after 12 hours.
- Wet combing - fine nit comb through wet hair to physically remove the head lice.
Head lice only spread by physical contact - can’t jump or fly
No need to keep off school
No need to treat other family members unless symptomatic
What is the optimum management of paediatric migraine?
1st line ibuprofen / paracetamol (ibuprofen more effective for paediatric migraine)
2nd line reliever - nasal triptan licensed in > 12 - SEs include sensation of tingling & heat. Oral triptans not licensed until > 18
1st line preventers in children - Pizotifen or Propranolol
When is the newborn heelprick / Guthrie test performed?
Day 5 - 9
How do labial adhesions present and how should they be managed?
Labial adhesions typically present in young girls aged 3 mths - 3 years due to a lack of oestrogen
Unless causing problems with micturition / recurrent UTIs then reassure self-resolves by puberty and no action needed
If recurrent UTIs then consider topical oestrogen cream
What advice should you give the parents of children with suspected CMPA?
If formula-fed, would normally present within first 3 months of life. 1st line is switch to extensively hydrolysed formula and assess reponse after 2-4 wks. If nil improved, second line is amino acid formula.
If breast-feeding, mother should go dairy free for 2-4 wks trial. When she stops breast feeding should switch to extensively hydrolysed formula for at least 6 months or until 1 year of age.
If > 1 can consider milk ladder
Advised ~ 10% of CMPA are also allergic to soy
Advise most children with non-IgE mediated will grow out of it by aged 3. Around half of those with IgE mediated will grow out of it by aged 5.
What is the gold standard method of checking temperature in an infant < 4 weeks?
An electronic thermometer in the axilla
What is the most important F/U investigation to do after meningococcal meningitis in children AND adults?
Audiogram
Hearing loss is a common after-effect of meningococcal meningitis. Hearing should be tested within 4 weeks of diagnosis (once well enough) and ideally before leaving hospital
Upto what age is it normal for young boy’s to have a non-retractile foreskin (assuming asymptomatic and no ballooning)
Upto 10 years is normal
Can trial topical steroid if > 10 with non retractile foreskin or if younger and symptomatic
Which babies should be referred to the paediatric / nenonatal unit for assessment with neonatal jaundice?
If jaundice presents < 24 hrs of birth they need URGENT SERUM bilirubin levels checking within 2 hours with repeat levels until falling or under treatment threshold and a medical review within 24 hrs to exclude more serious causes of jaundice
After 24 hrs, need biluribin testing either with TCB or serum bilirubin if visibly jaundiced at any age.
Refer to neonatal unit if baby unwell, pale stools or dark urine, poor feeding or poor weight gain, gestation < 35 weeks, prolonged jaundice (> 21 days of jaundice if born < 37 weeks or > 14 days of jaundice if born > 37 weeks)
