Paediatrics Flashcards
What is the other name for croup
acute laryngotracheobronchitis
Who is most commonly affected by croup
ages 6 months to 3 years
more common in boys
When is croup most common?
autumn/early winter
What pathogens can cause croup?
parainfluenza type 1 (most common) and type 2
adenovirus
influenza a and b
RSV
Describe the pathophysiology of croup
- virus initially infects the nasopharyngeal mucosa
- It spreads to the larynx and subglottic airways
- Inflammation of the larynx and subglottic airways leads to swelling and obsrtuction
Symptoms of croup
seal like barking cough
hoarse voice
fever
nasal congestion
stridor
Mild croup symptoms
-occasional barking cough
-no audible stridor
- no recession
-child can eat and drink normally
moderate croup symptoms
-frequent barking cough
- audible stridor at rest
- suprasternal recession
- no agitation
severe croup symptoms
-frequent barking cough
- prominent stridor
- marked sternal recession
- child agitated and distressed
- tachycardia
red flags of resp failure in croup
-drowsiness
-cyanosis
-laboured breathing
- lethargy
-tachycardia
Diagnosis of croup
usually clinical diagnosis
May x-ray to exclude foreign body
What X ray sign may be seen in croup
steeple sign (subglottic narrowing)
How is croup treated
- single dose oral dexamethasone (0.15 mg/kg) and antipyretics
- if no improvement= nebulised adrenaline
Can give O2 if required
What are 2 potential complications of croup
otitis media and superinfection leading to pneumonia
What is bronchiolitis
Viral infection of the bronchioles
Who is affected by bronchiolitis?
- under 2’s
When is bronchiolitis most common?
winter and spring
Risk factors for bronchiolitis
-prematurity
-congenital heart disease
- chronic lung disease
- tobacco exposure
- pollutants
-older siblings in nursery/school
What is the most common cause of bronchiolitis?
RSV
What type of inflammation is predominate in bronchiolitis?
neutrophilic inflammation
Symptoms of bronchiolitis
Corzyal prodrome lasting 1-3 days then development of a persistent cough plus either:
- tachypnoea or chest recession (or both)
- wheeze or crackles (or both)
May also have:
- low grade fever
- poor feeding
- apnoea
Signs of respiratory distress in bronchiolitis
- nasal flaring
- tracheal tug
- head bobbing
- grunting
- sub/intercostal recession
Bronchiolitis on examination
- dry wheezy cough
- cyanosis or pallor
- hyperinflation of the chest
- subcostal or intercostal recession
- fine end inspiratory crackles and high-pitched wheezes.
Investigations for bronchiolitis
- pulse oximetry
- nasopharyngeal aspirate for RSV culture
When is hospital admission suggested in bronchiolitis
-apnoea
-persistent O2 <90
- inadequate fluid intake
-severe resp distress
Treatment of bronchiolitis
supportive management at home
Palvizumab vaccine for prophylaxis if suggested
hospital admission if severe (O2, fluids, CPAP)
When should Palvizumab be given for bronchiolitis
- under 9 months if chronic lung disease of prematurity
- under 2 years if severe immunodeficiency
given once monthly
Who is most commonly affected by acute epiglottitis?
children aged 1-6
What is the most common cause of acute epiglottitis?
human influenzae virus type b (Hib)
Describe the pathophysiology of acute epiglottitis
Inflammation leading to oedema of the airways, increasing airway resistance and narrowing of the supraglottic aperture
How does acute epiglottitis present
-very acute onset
- very ill, toxic looking child
- high fever
- drooling saliva
- can’t speak or swallow
- soft whispering stridor
- tripoding position (upright with open mouth)
What should you not do to a child with suspected acute epiglottitis
EXAMINE
What sign would be seen on an x ray of acute epiglottitis
Thumb sign and epiglottic swelling
How is acute epiglottitis treated?
Secure airway- direct rigid laryngoscopy and intubation in theatre
IV antibiotics (cefotaxime, ceftriaxone)
Corticosteroids
adrenaline nebuliser
What is the most common cause of pneumonia in young infants?
Viruses
Causes of pneumonia in neonates
organisms from the mother’s genital tract
E.coli
Klebsiella
staph aureus
group b strep
causes of pneumonia in infants
respiratory viruses (mainly RSV)
bacteria (strep pneumoniae, chlamydia tracheomatis)
Causes of pneumonia in school age children
staph aureus
group a strep
mycoplasma bacteria
strep pneumonia
4 ways in which bacteria can spread to the lungs to cause pneumonia
- inhalation
- aspiration of oropharyngeal secretions in the trachea
- haematogenous spread from localised infections
- direct extension from adjacent foci
How does pneumonia present?
-preceding upper respiratory tract infection
- fever
- shortness of breath
- lethargy
- poor feeding
- signs of respiratory distress
- cyanosis
- wheeze and hyperinflation
How would pneumonia present of examination
-tachypnoea
-nasal flaring
-chest indrawing
-end-inspiratory crackles
how is pneumonia diagnosed?
-mainly clinical diagnosis
-X ray not routinely used but may be done if hypoxic, in significant respiratory distress or if considering pleural effusion
-bloods
-microbiology
How is pneumonia treated?
oral antibiotics (amoxicillin/ co-amoxiclav)
O2
IV fluids
What signs indicate that pneumonia should be treated in the hospital?
-hypoxaemia (<92)
-severe resp distress
-dehydration
-toxic appearance
-underlying condition
-indication of complications
What two types of virally induced wheeze are there?
-episodic viral wheeze
- multi-trigger viral wheeze
Explain what episodic viral wheeze is
wheezing that occurs at distinct periods associated with upper respiratory tract infections.
Asymptomatic between periods
Explain multi-trigger wheeze
Same distinct exacerbations as episodic plus symptoms inbetween periods (potentially in response to allergens, emotions, activity etc)
What is used to the predict whether virally induced wheeze will develop into asthma
the asthma predictive index (API)
Explain how the asthma predictive index works
For children under the age of 3 who have had 4 or more episodes of wheeze in the past year.
Determines likelihood of developing asthma based on fulfilling one major or two minor criteria
major criteria for the API
parent with asthma
diagnosis of eczema
sensitivities to air allergens (RAST or skin prick test)
minor criteria of API
- food allergens
- more than 4% blood eosinophils
- wheezing apart from colds
What is a wheeze
A high pitched musical sounds on expiration
Differentials for virally induced wheeze
Asthma, bronchiolitis, inhaled foreign body, CF, GORD
Long term management of viral induced wheeze
Give salbutamol during exacerbations and if multi-trigger then consider inhaled corticosteroid
acute management of viral induced wheeze
O2
salbutamol
consider inhaled ipatropium bromide if severe
consider oral steroids if no improvement after 8-12 hours
RF for asthma
genetic predisposition, atopy, environmental triggers (URTI, smoking, pollutants, cold air, exercise)
Symptoms of asthma
wheeze
dry cough
breathlessness
chest tightness
What 3 physical sign may be present in long term asthma
hyperinflation of the chest
generalised polyphonic expiratory wheeze
Harrison’s sulci - depression at base of thorax associated with the muscular insetions of the diaphragm
How is asthma diagnosed
spirometry showing obstructive pattern (bronchodilator reversible)
Peak expiratory flow rate
Results of spirometry in asthma
FEV1 reduced
FVC normal
FEV1/FVC <70%
what can long term steroid use in asthma lead to
adrenal suppression
Explain the 6 steps of asthma management
- SABA (salbutamol)
- add ICS (beclomethasone)
- add LTRA (montelukast)
- swap LTRA to LABA (salmeterol)
- Stop LABA and use ICS + mart regimine
- LABA+ ICS + MART
Explain the emergency management of an asthma attack
- O2- high flow, non-rebreathing mask
- nebulised salbutamol
- nebulised ipatropium bromide
-oral prednisolone - IV magnesium sulphate, IV salbutamol, IV aminophylline
Indications asthma is life threatening
- SpO2 <92%
- PEF <33%
- silent chest
- poor resp effort
-cyanosis - exhaustion
- hypotension
- confusion
Indications asthma is acute and severe
SpO2 <92
PEF 33-50%
can’t speak in complete sentences
RR >40 (age 2-5) or >30 (>5)
HR >140 (2-5) or >125 (>5)
Definitive test for biliary atresia
Cholangiography
What is the definitive diagnosis of hirschsprung disease
Rectal suction biopsy
What are the Fraser guidelines?
A set of guidelines that can be applied when giving advice about contraception and sexual health in under 16s
Rash associated with juvenile idiopathic arthritis
Salmon pink rash
What medication is given to prevent ductus arteriosus from closing in transposition of the great arteries
Alprostadil
Presentation of rickets
Bow legs, Harrison sulci and constipation
Management of a small ventricular septal defect
Monitor and reassure
Common x ray findings in rickets
Bowed femur and widened epiphyseal plates
Presentation of Kawasaki disease
Fever for more than 5 days
Conjunctivitis
Erythema
Edema of hands and feet
Peeling
Cervical lymphadenopathy
What antibiotic should be avoided in long qt syndrome
Macrolides such as clarithromycin
Common cause of resp tract infections in cystic fibrosis
Pseudomonas aeruginosa
What are brushfield spots a symptom of?
Trisomy 21
What is congenital adrenal hyperplasia a deficiency of?
21- hydroxylase
What is another trinucleotide repeat disorder other than huntingtions?
myotonic dystrophy
First step of paediatric life support if no sign of breathing
5 rescue breaths (before checking pulses)
How does congenital CMV present
microcephaly, petechial rash, seizures, low birth weight and hearing loss
Is Perthes disease more common in men or women?
5 times more common in men
What is Perthes sidease
idiopathic avascular necrosis of the femoral head in children
How does Perthes disease typically present
irritable hip, limp and reduced range of motion despite no trauma or systemic symptoms
Difference in presentation between transient synovitis and Perthes disease
transient synovitis typically has proceeding infection and self-resolved within 7-10 days.
Perthes disease is much longer (2-3 years)
What respiratory rate is a red flag at any age according to NICE traffic lights
> 60
side effect of methyphenidate
stunted growth
What drugs might be used in the long term treatment of MS to prevent relapses
biologics:
- natalizumab
- ocrelizumab
- fingolimod
- beta interferon
what is
