PAEDIATRICS

Question 1

How to calculate bladder capacity in a child?

Answer 1

Bladder capacity increases until puberty.
Pre-pubescent child = (age+1) x 30 ml

Question 2

Definition of nocturnal enuresis / bedwetting?

Answer 2

Discrete episodes of bedwetting overnight in children OVER 5 YEARS OLD

Question 3

By what age group should children be dry in the day and night respectively?

Answer 3

Should be dry in the day by 3 years old and dry at night by 5 years old

Question 4

Children who were previously continent that develop new incontinence (regression) always need clinical assessment - true or false?

Answer 4

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

Question 5

What is the definition of secondary enuresis?

Answer 5

Development of bedwetting after > 6 months of continence

Question 6

What is the typical presentation of nocturnal polyuria in a child and what causes it?

Answer 6

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.

Question 7

What is the concept of urotherapy?

Answer 7

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)

Question 8

What are 1st line treatments for nightime bed wetting (can be started from age 5) that can be started in GP?

Answer 8

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

Question 9

Generally, in the absence of red flags, when should continence or constipation issues be referred to secondary care?

Answer 9

After 3 months of primary care management if nil improvement

Question 10

Summarise the faecal disimpaction regime?

Answer 10

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.

Question 11

What is the causative organism behind hand, foot and mouth and how does it normally present?

Answer 11

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

Question 12

What is the typical presentation of Noonan syndrome?

Answer 12

Autosomal dominant genetic condition

Presents from birth with:
-> Pectus excavatum
-> Pulmonary stenosis
-> Short stature
-> Webbed neck

Question 13

What is the national guidance on restriction from school for common childhood infections?

Answer 13

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

Question 14

What per centage of chidren with CMPA are also allergic to soya?

Answer 14

~ 10%

Question 15

What complication of measles is the most common cause of death from measles?

Answer 15

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

Question 16

What is the causative organism for measles?

Answer 16

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.

Question 17

How should you manage when a child not vaccinated against measles comes into contact with a positive measles case?

Answer 17

The unvaccinated child should be offered the MMR vaccine within 72 hours of contact

Question 18

What is the risk of Down’s Syndrome for future pregnancies if a woman has a child with Down’s?

Answer 18

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

Question 19

What is Barrter’s syndrome

Answer 19

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

Question 20

How should you manage mild labial adhesions in young infant girls?

Answer 20

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

Question 21

How should you approach consent for childhood vaccinations?

Answer 21

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.

Question 22

Is Scarlet fever a notifiable disease in england?

Answer 22

YES!! if clinically suspect, need to inform public health england

-> caused by Group A strep -> strep pyogenes

Question 23

When should antibiotics be given for pertussis / whooping cough?

Answer 23

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)

Question 24

What is the most common causative organism for croup?

Answer 24

Parainfluenzavirus causes most cases of croup

Question 25

What is the first line treatment for intussuception?

Answer 25

Rectal insufflation under radiological guidance
(If unwell child / suspicion of peritonitis then will have surgical correction)

Question 26

What is intussuception and how does it present?

Answer 26

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

Question 27

Prior to what age is hand preference considered abnormal, possibly suggesting cerebral palsy?

Answer 27

Hand preference before 12 months is abnormal and should be referred to paediatrician

Question 28

By what age should a child be able to respond to their own name?

Answer 28

By 12 months

Question 29

By what age should a child be able to say Mama and Dada?

Answer 29

9 months

Question 30

How should unilateral descended testes picked up at the 6 wk check be managed?

Answer 30

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

Question 31

What is Osgood-Schlatter disease and how does it present?

Answer 31

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

Question 32

How should ballooning of the foreskin / non-rectractible foreskin be managed, in a child under 2 and then in in children over 2.

Answer 32

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

Question 33

What is the typical presentation of threadworm / pinworm in children

Answer 33

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

Question 34

What is the most common form of primary headache in children?

Answer 34

Migraine without aura

Question 35

What are the International Headache Society diagnostic criteria for paediatric migraine without aura?

Answer 35

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

Question 36

What are the NICE recommended treatments for head lice and what advice should you give parents?

Answer 36

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

Question 37

What is the optimum management of paediatric migraine?

Answer 37

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

Question 38

When is the newborn heelprick / Guthrie test performed?

Answer 38

Day 5 - 9

Question 39

How do labial adhesions present and how should they be managed?

Answer 39

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

Question 40

What advice should you give the parents of children with suspected CMPA?

Answer 40

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.