Paediatrics Flashcards
1
Q
Grading the severity of croup
A
2
Q
When should you consider admission for a child with croup?
A
- < 6 months of age
- known upper airway abnormalities (e.g. Laryngomalacia, Down’s syndrome)
- uncertainty about the diagnosis (important differentials include acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation)
3
Q
Investigations for Croup
A
- Clinical Diagnosis
- CXR:
- PA view shows subglottic narrowing (steeple sign)
- Lateral view shows swelling of the epiglottis - the ‘thumb sign’
4
Q
Management of Croup
A
- Single dose of oral dexamethasone (0.15mg/kg) to all children regardless of severity
- prednisolone is an alternative
- Emergency treatment
- high-flow oxygen
- nebulised adrenaline
5
Q
Medical asthma management (5-16)
A
- Short-acting beta agonist (SABA)
- SABA + paediatric low-dose inhaled corticosteroid (ICS)
- SABA + paediatric low-dose ICS + leukotriene receptor antagonist (LTRA)
- SABA + paediatric low-dose ICS + long-acting beta-agonist (LABA)
- SABA + switch ICS/LABA for a maintenance and reliever therapy (MART), that includes a paediatric low-dose ICS
- SABA + paediatric moderate-dose ICS MART
- SABA + one of the following options:
increase ICS to paediatric high-dose, either as part of a fixed-dose regime or as a MART
- Consider trial of theophylline
- Seek advice
6
Q
How do you diagnose asthma?
A
FeNO
- in adults level of >= 40 parts per billion (ppb) is considered positive
- in children a level of >= 35 parts per billion (ppb) is considered positive
Spirometry
- FEV1/FVC ratio less than 70% (or below the lower limit of normal if this value is available) is considered obstructive
Reversibility testing
- in adults, a positive test is indicated by an improvement in FEV1 of 12% or more and increase in volume of 200 ml or more
- in children, a positive test is indicated by an improvement in FEV1 of 12% or more
7
Q
Definition of asthma
A
Episodic, reversible airway obstruction due to bronchial hyper-reactivity to a variety of stimuli.
8
Q
Conservative management of asthma
A
M TAME
General
- MDT: GP, specialist nurses, respiratory physician
- Technique for inhaler use
- Avoidance: allergens, smoke (ing), dust
- Monitor: Peak flow diary (2-4x/d)
-
Educate
- Liaise with a specialist nurse
- Need for Rx compliance
- Emergency action plan
9
Q
Features of acute asthma exacerbations
A
Anormal pCO2 in an acute asthma attack indicates exhaustion and should, therefore, be classified as life-threatening.
10
Q
Features of bronchiolitis
A
- coryzal symptoms (including mild fever) precede:
- dry cough
- increasing breathlessness
- wheezing, fine inspiratory crackles (not always present)
- feeding difficulties associated with increasing dyspnoea are often the reason for hospital admission
11
Q
When should you definitely admit a child with bronchiolitis?
A
- Apnoea (observed or reported)
- Child looks unwell
- Severe respiratory distress
- grunting
- marked chest recession,
- RR > 60 breaths/minute
- Central cyanosis
- Oxygen saturation
12
Q
When should you consider admission to a hospital for a child with bronchiolitis?
A
- RR > 60
- Difficulty with breastfeeding/ oral intake (50-75%)
- Clinical dehydration
13
Q
Management of bronchiolitis
A
- Humidified oxygen via a head box (for persistently < 92%)
- NG if refusing feeds
- Suction for excess secretions
- Consider palivizumab
14
Q
How do you manage respiratory disease caused by CF?
A
1st Line: Physio to mobilise secretions. VEST therapy (a vest which vibrates at high frequencies)
- Plus: Inhaled bronchodilator
- Plus: Inhaled mucolytic (hypertonic saline)
- Adj: Inhaled tobramycin for chronic Pseudomonas
- Adj: Inhaled corticosteroid
- Adj: Ivaftor- CFTR potentiator (increases the number proteins carried to the cell surface
2nd Line: Lung transplant
15
Q
General management for CF patients
A
- high calorie diet, including high fat intake*
- patients with CF should try to minimise contact with each other to prevent cross infection with Burkholderia cepacia complex and Pseudomonas aeruginosa
- vitamin supplementation
- pancreatic enzyme supplements taken with meals
16
Q
How do you diagnose CF?
A
Sweat test
- Normal value < 40 mEq/l
- CF indicated by > 60 mEq/l
Causes of a false-positive sweat test
- malnutrition
- adrenal insufficiency
- glycogen storage diseases
17
Q
Features of intussuception
A
- Paroxysmal abdominal colic pain
- During paroxysm, the infant will characteristically draw their knees up and turn pale
- Vomiting
- Bloodstained stool - ‘red-currant jelly’ - is a late sign
- Sausage-shaped mass in the right upper quadrant
18
Q
Management of intussuception
A
- Reduction by air insufflation under radiological control, which is now widely used first-line compared to the traditional barium enema
- Signs of peritonitis, surgery is performed
19
Q
Management of Coeliac disease
A
- Avoid gluten
- Dietician
- wheat: bread, pasta, pastry
- barley: beer
- Rye and oat
- Vitamin supplementation
- Pneumococcal vaccines due to functional hyposplenism
Annual monitoring
20
Q
Biopsy of a patient with coeliac
A
- Crypt hyperplasia
- Villous atrophy
- Infiltrative lymphocytes
21
Q
Investigations and management of pyloric stenosis
A
- Ix: US, test feed
- Correction of hypochloraemic, hypokalaemic alkalosis
- Ramstedt pyloromyotomy
22
Q
Counselling for febrile seizure
A
- Occur between the ages of 6 months and 5 years
- Seen in 3% of children
- Usually occur early in a viral infection as the temperature rises rapidly
- Lasting less than 5 minutes
- If recurrences, try teaching parents how to use rectal diazepam or buccal midazolam.
- Parents should be advised to phone for an ambulance if the seizure lasts > 5 minutes
- Regular antipyretics have not been shown to reduce the chance of a febrile seizure occurring
23
Q
Management of UTI
A
- <3 months old should be referred immediately
- >3 months old with an upper UTI should be considered for admission to hospital.
- If not admitted oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days
- > 3 months old with a lower UTI should be treated with oral antibiotics for 3 days according to local guidelines, usually trimethoprim, nitrofurantoin, cephalosporin or amoxicillin.
- Parents should be asked to bring the children back if they remain unwell after 24-48 hours
- Antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs
24
Q
Vaccination counselling
A
- vaccination programme is very safe (almost all children have it)
- Protects child and other children
- stops spread
- stops short and long term consequences
*
25
Q
Management of Migraine
A
- ibuprofen
- NICE CKS recommends that triptans may be used in children >= 12 years but follow-up is required
- Sumatriptan nasal spay (licensed) is the only triptan that has proven efficacy but it is poorly tolerated by young people who don’t like the taste in the back of the throat
- it should be noted that oral triptans are not currently licensed in people < 18 years
- the GOSH: pizotifen and propranolol
26
Q
Causes of constipation
A
- dehydration
- low-fibre diet
- medications: e.g. Opiates
- anal fissure
- over-enthusiastic potty training
- hypothyroidism
- Hirschsprung’s disease
- hypercalcaemia
- learning disabilities
27
Q
Management of constipation
A
- polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen as the first-line treatment
- add a stimulant laxative if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks
- substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if Movicol Paediatric Plain is not tolerated
- inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain
28
Q
Management of CMPA
A
- Continue breastfeeding
- Eliminate cow’s milk protein from maternal diet.
- Consider prescribing calcium supplements for breastfeeding mothers whose babies have, or are suspected to have, CMPI, to prevent deficiency whilst they exclude dairy from their diet
- Use eHF milk when breastfeeding stops, until 12 months of age and at least for 6 months
