Paediatrics Flashcards
Developmental milestones (There is a deck of 10 cards in paeds for it). Answer has the table. Take a look and move from 1-5.
When should solids be introduced into a baby’s diet?
6 months and never before 17 weeks
If started before, sterilise everything and no gluten, eggs, or fish. Pureed food or finger food with no added sugar or salt
Milk should be the primary source of food until?
Other than age, what would indicate that a baby is ready to be weaned?
1 year
Baby’s are ready to be weaned once:
1) They can sit up
2) They mouth objects
3) Can reach and grab properly
4) Interested in food and chewing
Changes to stool consistence is normal on weaning
What foods are should babies under 1 year of age not eat?
raw eggs or honey
Many parents worry about faltering growth due to feeding problems. It is actually common for food intake to vary day to day. Good tips include the following
1) Sit down for family meals and have conversations about other things
2) Restrict snacks and sugary drinks
3) Avoid using food as a reward
4) Show little emotion if the child rejects food
Based on the growth chart, what is the definition of Faltering Growth for children <2yo
After 2 years of age, the growth chart is not used. What is used instead to determine faltering growth? What are the parameters to investigate?
If BW <9th centile -> Fall by 1 centile
If BW is 9th to 91st centile -> Fall by 2+ centiles
If BW is >91st centile -> Fall by 3+ centiles
After 2yo -> BMI
<2nd centile -> May need to be assessed
<0.4th centile always needs investigations
What are the causes of faltering growth
Organic:
1) Congenital heart disease
2) CF, chronic lung disease
3) DM
4) Coeliac disease
5) Cleft palate
6) Pyloric stenosis
Non-organic (multifactorial)
Situation at home
Finances
Neglect
Pyloric stenosis occurs in the first 3-6 weeks of life. It is also a familial disease (especially in first male born lol).
What congenital conditions are associated with pyloric stenosis?
How does pyloric stenosis present? (including exam findings)
How is it managed?
Familial a/w Turner’s, oesophageal atresia, and PKU
Presents w/
Projectile vomiting (no bile)
Child hungry after vomiting
Faltering growth
Dehydration
Constipation (Rabbit pellet stool)
Exam:
Signs of Dehydration
Olive mass on palpation!!!
Visible peristalsis in epigastrium after test feed
Management: Refer to paediatric surgery for Ransted’s Pyloroplasty
How would you note dehydration on exam?
Reduced urine output
Dark yellow, strong odour urine
Dizziness/lightheadedness
Xerostomia
Reduced skin turgor (red flag)
Give 10 red flag symptoms in paediatrics
Systemically unwell
Pyrexia >38
Colour: Pale, mottled, ashen blue
RR>60
Sx of resp distress
Not feeding
Weak/ high pitched cry
Grunting
Blood in stool/urine
No response to social queues
Difficult to stay awake
Reduced skin turgor (dehydration)
Non-blanching rash, neck stiffness
Focal neurological signs/seizures
How do you test for neck stiffness on exam?
Cannot flex neck on exam
Temperature is measured via the axilla in paediatrics mostly. If >4weeks old, infrared ear thermometer also works. What are the causes of pyrexia in childhood?
Childhood infections
UTI
URTI/LRTI
TB, tropical disease
Endocarditis
Prolonged chronic fever:
Malignancy: Lymphoma, leukemia, RCC/hypernephroma
Immunological: Kawasaki (vasculitis), Still’s disease
Liver/renal, Autoimmune disorders (RA, SLE, polymyalgia rheumatica)
How long does a viral URTI typically last in a child?
7-10 days
A 6 year old patient presents to the clinic with pyrexia and no other sx. What investigation must you perform?
Check vitals and check urine dipstick to exclude UTI
A paediatric patient presents with suspected pneumonia. What findings on exam would support the diagnosis?
Temp >38.5
Tachypnoea
Sx of respiratory distress
Chest/abdominal pain
Chest auscultation with bronchial breathing, reduced breath sounds, and crepitations
A paediatric patient presents with penumonia. What is the management?
If child is well => No AB, give paracetamol and hydration
If unwell, give AB (Amoxicillin, azithromycin, co-amoxiclav)
If no response in 48 hours go to A&E
Advise to look out for red flag sx
What is the main prevention of pneumonia in children?
Pneumococcal vaccine given at 2,4, and 12 months
A paediatric patient comes with recurrent chest infections. What conditions would you investigate for to explain the cause? Give 5
1) Asthma
2) Reflux (aspiration)
3) Sickle cell disease/thalassemia
4) Post-infective bronchiectasis
5) Congenital heart/lung disease
6) Immune disorders (leukemia, HIV)
7) TB
What is the main culprit of bronchiolitis in paeds?
What age group is mostly affected?
What is given to prevent this? Who gets this prevention?
How is it given?
RSV mostly in those <1yo
Monthly IM Pavilizumab during fall to spring (given to premature babies, those <12 weeks old, and those with comorbidities (sickle cell, congenital heart/lung…)
Most patients with bronchiolitis recover in <14 days, 50% have wheeze and subsequent URTI. What are the sx of Bronchiolitis caused by RSV?
How would you manage?
Coryzal sx for 1-3 days followed by persistent cough, tachypnoea and feeding difficulties
If feeding well and mild recession, hydration and paracetamol, prevent exacerbation with smoking, dust etc..
If any red flag, admit
Till what age do GPs give childhood vaccinations
<5yo, after that they take it at school
What are the general contraindications to vaccine administration (not limited to paeds)?
If it were to be a live vaccine, what additional contraindications are present?
General:
1) Acute illness
2) Serve local or generalised reaction to last dose (swelling, redness, high fever (>39.5) etc… within 48 hours)
If live:
1) Pregnant
2) Immunocompromised
3) 3 weeks before or 3 months after immunoglobulin administration
An HIV patient who has normal CD4 count would like a vaccination. Is it contraindicated?
No, those with HIV who are not severely immunocompromised can have live vaccines
EXCEPT BCG and Yellow fever
Go over the vaccine schedule in ireland
Lymphadenopathy is the palpaple enlargement of LN. What are the causes of lymphadenopathy in paediatrics?
Benign
1) Infective: St. aureus, strep pyogenes, TB, brucella, vital (EBV, CMV), fungal
2) Non-infective: Sarcoid, CTD, Skin eczema, psoriasis
Malignant: Lymphoma, CLL, ALL, Metastasis to LN
How would you differentiate between benign and malignant lymphadenopathy?
How is each managed?
Benign: Soft, !tender, mobile, concurrent infection
Tx: Give 2 weeks to settle and then refer
Malignancy: Hard, Non-tender!, firm, night sweats, prolonged pyrexia, rash, rapidly growing
Tx: Immediate referral for assessment by specialist
What temperature is considered pyrexia?
37.5
What is the cause of rigors (chills)
Quick sike in temp
A patient (not necessarily paeds) presents with night sweats. Other than malignancies, what can cause this?
TB
Menopause
Drugs (opioids, SSRI)
Define neutropenic sepsis
What are the main causes?
Give 4 signs of neutropaenia
Fever >38 for 2+ hours when neutrophil count <1x10^9
caused by
1) Chemotherapy
2) Radiotherapy
3) Malignant infiltration of bone marrow
Signs:
Fatigue
Mouth ulcers
Recurrent infection
Infection by opportunistic organisms
Give 10 causes of immunosuppression
1) Extremes of ages
2) HIV
3) Burns
4) Neoplasm +/- bone marrow infiltration
5) Chemo/radiotherapy
6) Metabolic disorders (PKU)
7) Organ transplant (adjuvant immunosuppression e.g. azathiprine)
8) Steroids
9) iatrogenic (indwelling catheter)
10) Dialysis (Tenchkoff catheter, AV fistula)
11) Asplenic/sickle cell
12) Complement deficiency
What does functionally asplenic mean
Abnormal haemoglobin e.g. sickle cell or thalassemia
What is the general management of an asplenic or functionally asplenic patient
Give patients oral penicillin until 16yo or 2 yr post-splenectomy
+ stand-by amoxicillin if symptoms of infection begin
If a patient is receiving a splenectomy, they should make sure all vaccines are given. When should these vaccines be given?
2 weeks before splenectomy
Give 3 examples of scenarios where patients should receive prophylactic antibiotics
1) Recurrent UTIs (e.g. diabetic with recurrent UTIs from renal scarring)
2) TB and meningitis in exposed patients (houselhold)
3) Infection in asplenic/hyposplenic patients
4) Bacterial infections in granulocytopenic patients
5) Pneumocystitis in AIDS
A patient with unknown past history presents with a laceration. They do not know if they are immunised against tetanus. What should they recieve?
Tetanus immunoglobulins + 3 doses of tetanus vaccine
IVig should be given to prevent certain diseases in select immunocompromised patients. Give 3 examples
1) Herpes Zoster
2) Hep A&B
3) Measles
4) CMV
UTI is very common especially in the first year of life. What is the most common organism?
80% due to E.coli, just like in adults
Among neonates, boys are more often affected when compared to girls. What are risk factors for UTI in the paediatric population? (6)
1) Poor urine flow
2) Renal abnormality (epididymorchitis, Horseshoe kidney, double ureter, ectopic kidney)
3) Vesicoureteric reflux
4) Posterior urethral valves
5) Constipation
6) Enlarged bladder
7) Spinal lesion
8) Poor growth
9) Raised BP
10) Recurrent fever of unknown origin
You should suspect UTI in any child with fever and no obvious cause. How do infants and toddlers present with UTI?
Vomiting, irritability, fever, poor feeding, abdominal pain, failure to thrive, jaundice
Older kids present like adults + enuresis
What investigations would you perform if a 6 month old presents with pyrexia, abdominal pain, poor feeding, and vomiting.
This is very general but we suspect a UTI in any child presenting with unknown pyrexia. =>
1) Urine dipstick for leukocytes, blood and nitrates
2) Microscopy + C&S send to lab
How would you obtain a urine sample from an infant presenting with pyrexia?
Clean catch urine
What is the management of UTIs in Paeds
<3 months => Urgent referral to paediatrics for IV antibiotics (to prevent renal scarring)
> 3 months => Start antibiotics (after sending sample) via trimethoprim or Nitrofurantoin
A 2 year old patient presents with pyrexia. You conduct a urine dipstick test and results show
Negative leukocytes and nitrites
Negative leukocytes, positive Nitrates
Positive leukocytes, negative nitrates
Positive leukocytes, negative nitrates but child is age 3y
for each of the following state your next step
Both negative => Do not start antibiotics but send urine for M, C&S
Negative leukocytes, positive Nitrates => Send urine and start antibiotics
Positive leukocytes, negative nitrates => Send urine and start antibiotics (If patient <3yo, we give)
Positive leukocytes, negative nitrates but child is age 3y => Only send urine if patient unwell or hx of UTI
In summary, if positive nitrates always do both. If only positive leukocytes check age and if child is unwell
Give features indicative of asthma in children (hint, same as adults)
1) Recurrent episodic asthma symptoms (wheeze, SOB, chest tightness)
2) Exacerbated by exercise, pets, cold air, laughter
3) Diurnal variability
4) Expiratory wheeze on auscultation
5) Documental variable/reversible airflow obstruction (PEFR/spirometry)
6) Personal/family hx of atopy or aspirin sensitivity
Spirometry is only diagnostic when the child is symptomatic. It should still be performed to obtain a baseline. At what age can spirometry be performed?
Other than spirometry, give 3 other methods of diagnosing suspected asthma
5 yo
1) Spirometry
2) FeNO testing
3) Serial PEFR
4) Reversibility testing in response to bronchodilator or in response to 8-week trial of inhaled corticosteroids
If a patient is under 5yo, what is the only method of diagnosing asthma?
8-week trial of inhaled corticosteroids
Give 2 positive and 2 negative prognostic factors for asthma in children
Positive:
1) Early-onset wheeze (the earlier the onset the more likely they will grow out of it)
2) Male
Negative:
1) Co-existant/family hx of atopy
2) Severe/frequent exacerbations
Go through the escalations of asthma management in children
<5
5+
<5: After 8-week trial of inhaled steroids
0) SABA (for short-lived/infrequent wheeze)
1) Inhaled very low dose (paeds dose) steroid OR Leukotriene receptor antagonist (LTRA)
2) Inhaled very low dose (paeds dose) steroid AND Leukotriene receptor antagonist (LTRA)
3) Refer for specialist care AND increase steroid to low dose
5+:
0) SABA (for short-lived/infrequent wheeze)
1) Inhaled very low dose (paeds dose) steroid
2) Inhaled very low dose (paeds dose) steroid AND (LABA OR LTRA)
3) Inhaled LOW dose steroid OR add LABA/LTRA (based on choice before, if LABA didnt work then stop it)
4) Refer for specialist care AND continue steroid + LABA + LTRA while waiting
Budenoside is an example of a
Inhaled corticosteroid along with fluticazone and beclomethasone
Budenoside is in symbicort
Fluticazone is in seretide
It must be emphasised that the patient must slowly inhale when using a spacer and hold their breath for 10 seconds. Dry-powder inhalers and breath-activated inhalers are recommended fore older children. Spacers are most recommended for what age bracket?
<5 y
a 12 month old infant is brought into your clinic with episodes of LOC. The mother describes it as them getting upset and frustrated before stiffening up. What is the most likely diagnosis?
How would you explain what happened to the mother?
How will you manage?
Simple Blue breath-holding attacks or breath-holding spells
when child is upset they hold their breath until they turn blue (cyanosis) => +ve valsalva manouvre causing them to lose consciousness
Management: Non necessary, they typically grow out of it by 3y
A 1 year old child is brought into the clinic with episodes of LOC. The mother describes it occurring after minor anxiety when the child hit their hand on the wall. She describes the episode with the child turning pale, upward eye movement and stiffening. She also mentioned they sometimes pee themselves. What is the most likely diagnosis?
How is this managed?
White Reflex Asystolic (anoxic) attacks
No management, spontaneous recovery
What non-epileptic attack is characterised by vagal asystole?
White Reflex Asystolic (anoxic) attacks
What non-epileptic attack is chatacterised by valsalva manouvre
Simple Blue breath-holding attacks or breath-holding spells
What are febrile convulsions (include type of seizure)
Is it associated with a family hx
Brief <5 min generalised epileptic seizure provoked by fever in an otherwise normal child.
Yes there is often a family hx
Note: This is not the same as Dravet syndrome. Dravet occurs in those with mild fever. Here it needs to be a major fever (think meningitis, otitis media, tonsillitis etc…)
A mother comes and asks you if she can give paracetamol to prevent their son getting febrile seizures. What would you say
paracetamol does not prevent febrile seizures but does help with symptom control
A mother brings their child in after their child has suffered a seizure while suffering from a UTI. How would you know whether to send the patient to A&E?
1) First febrile seizure
2) Complex seizure (Focal -not generalised-, prolonged ->15min- post-ictal symptoms not resolved within 1 hour -e.g. drowsy or irritable.
3) Cause of fever requires admission it its own right
