Paediatrics Flashcards
Pathophysiology of bronchiolitis.
Increased mucus in bronchioles (already very narrow in children.)
Causes wheeze/crackles and >resp effort.
List O2 sats for admission for bronchiolitis
- < 90% if > 6 weeks
- < 92% if < 6 weeks or having underlying condition e.g. congenital heart defects.
For discharge: they must maintain sats above aforementioned values for at least 4 hours and have good oral fluid intake.
Others:
- feeding < 50%
- Persistent respiratory distress e.g. recessions, grunting
- Apnoea
Main management option for bronchiolitis in hospital.
Supportive management: e.g.
- O2 supplementation
- Fluids (PO ideally). NG feeding if needed.
- Apnoea/secretions require suction, otherwise not needed.
- CPAP if impending respiratory failure. (+CBG)
Community Mx: supportive.
Whooping cough treatment.
Macrolides i.e. clarithromycin or azithromycin.
If <1 mo: clarithryomycin
If pregnant: erithromycin
If unsuitable: co-trimoxazole (but CI in pregnancy and <6 weeks)
Describe how a rash starts for:
- Measles
- Rubella
- Chickenpox
- Scarlet fever
- Roseola infantum (HHV-6)
- Slapped cheek disease
Measles: post-auricularly, spreads to trunk
Roseola infantum: pink, lacy rash starting from trunk, spreads to face.
Describe the measles morbillivirus. (Class and genetics)
A Paramyxovirus, a single-stranded RNA virus.
Presentation of measles
Skin and others.
- 3Cs: cough, coryza, conjunctivitis (prodrome)
- Koplik spots preceding rash (prodrome)
- Rash starting post-auricularly, spreading to trunk
Spread through droplets. (Hence CCC) Disseminates systemically, where rash is due to auto-immune destruction of endothelial cells of small blood vessel.s
A 21-year-old male presents with altered behavior, irritability, and cognitive decline over six months. (rapid onset).
He had measles as a child.
What is a diagnosis specific to his case to consider?
Subacute sclerosing panencephalitis. (SSPE)
Best prevented with measles vaccine to avoid measles infection.
Rare and devastating neurological disorder caused by a persistent infection with the measles virus.
Notifiable childhood infectious diseases
- MMR
- Pertussis
Whooping cough vaccination regime for babies?
3 doses
8 weeks, (+4) 12 weeks, (+4), 16 weeks
When is the first MMR vaccine given?
12 months
Kawasaki is a widespread vasculitis of ____________ - sized arteries, such as _____________ arteries.
Medium-sized arteries, such as coronary arteries
Leads to aneurysms –> thrombus and MI/death
Caused by immune activation: Initial triggering event (e.g., infection) → activation of innate and adaptive immunity.
Two main treatment options for Kawasaki disease.
- IVIG
- Aspirin (high dose, then low dose)
A 4 year-old patient presents with 7 days of persistent fever, often accompanied by bilateral red eyes without discharge, cracked red lips, and a ras over the trunk. They may also exhibit swollen, red hands and feet with peeling skin and unilateral neck swelling. The child appears irritable and unwell, and parents may report recent viral illness symptoms.
What’s the likely diagnosis?
Kawasaki disease.
Diagnosis with these symptoms i.e. 5 days of high fever with 4 other symptoms.
Supported by blood tests - inflammation.
When does the rash for roseola infantum start?
Starts abruptly after fever cessation (high-grade 3-5 days)
Pink, starts from trunk, non-pruritic. ‘Nagayama’ spots in mouth.
Clinical diagnosis
Organism of slapped cheek disease.
Parvovirus B19
Parvo = small. One of the smallest DNA virus discovered.
Self-limiting.
What is the appearance of the rash in slapped-cheek disease?
Lacy, reticular. On the cheeks.
Unlike Scarlet fever — no strawberry tongue.
Is parvovirus B19 harmful in pregnancy?
Yes.
It is a transplacental virus.
Which groups of people do toxoplasmosis affect?
Lifelong infection and usually just causes self-limiting lymphadenopathy
- Pregnant women (due to immune system changes) —can cause encephalitis.
- Immunocompromised people e.g. HIV
Vector of toxoplasmosis gondii.
Protozoa.
Recall treatment >
Cat.
Excreted through cat poop.
Diagnose using IgM serology.
Treat with pyrimethamine (dihydrofolate reductase inhibitor) + folinic acid
What is the most serious outcome towards a foetus with TORCH infections?
E.g. toxoplasmosis, CMV
Miscarriage.
CMV presentation in CMV-infected infants.
- Rash (resembles small, blue or purple spots, similar to the appearance of blueberry muffins),
- Jaundice, microcephaly (small head), low birth weight
Treatment of CMV infection. e.g. for congenital CMV infection.
Ganciclovir and valganciclovir.
CMV presentation in babies who have undiagnosed/untreated congenital CMV infection.
List all 4
- CMV retinitis
- Sensorineural hearing loss
- Learning disability
- Seizures
- Coordination issues.
All sensory and brain deficits (eyes, ears, brain)
Most common congenital infection.
CMV
Often worst when contracted during pregnancy.
What is croup and what are its common causes?
Croup is a respiratory condition characterised by a barking cough, stridor, and hoarseness. It is commonly caused by viral infections, particularly the parainfluenza virus.
Pathophysiology: inflammation and oedema of the subglottic region and subsequent narrowing of the upper airway, including vocal cords - stridor, cough, hoarseness
Describe the typical age group affected by croup.
Croup typically affects children between 6 months and 3 years of age.
What are the hallmark symptoms of croup?
The hallmark symptoms of croup include a barking cough, stridor (a high-pitched breathing sound), hoarseness, and respiratory distress.
Stridor indicates upper airway obstruction and is a key sign of croup severity. It is caused by inflammation and narrowing of the larynx and trachea.
What are the signs of severe croup that require immediate medical attention?
Signs of severe croup include persistent stridor at rest, severe respiratory distress, cyanosis, lethargy, and decreased responsiveness.
How is croup typically diagnosed in a clinical setting?
Clinical presentation, including the characteristic barking cough, stridor, and hoarseness.
What role does a neck X-ray play in diagnosing croup?
A neck X-ray is not routinely required but can be used to rule out other conditions. It may show the “steeple sign,” which indicates subglottic narrowing.
1st-line medication for treatment of croup.
Dexamethasone (single dose)
to reduce airway inflammation
mild croup: include supportive care, such as keeping the child calm, providing humidified air, and ensuring adequate hydration.
When are nebulised adrenaline treatments indicated for croup?
Nebulised adrenaline is indicated for moderate to severe croup with significant stridor and respiratory distress. It provides rapid relief by reducing airway swelling.
Most common causative organism of croup.
Parainfluenza. (common URTI)
Others include:
RSV
Adenovirus
Influenza virus
Rhinovirus
Croup differentials.
> Epiglottitis. Absence of barking cough. Unlike in croup, the patient often sits upright and leans forward to breather (‘tripod position’).
> Bacterial tracheitis: severe toxic appearance with high fever and purulent secretions. The child appears more unwell compared to typical viral croup and may have rapidly progressing respiratory distress.
> Foreign body aspiration: sudden onset of stridor and respiratory distress, often in a previously well child, with a history of choking. There is typically no preceding viral illness.
> Allergic reaction (e.g., angioedema): can cause upper airway obstruction, but typically associated with history of allergen exposure, and swelling is often present in other areas (e.g., lips and face).
> Pertussis: prolonged coughing episodes followed by an inspiratory ‘whoop’. Symptoms tend to last longer and are not associated with the barking cough or stridor seen in croup.
What is a febrile seizure?
Describe type, duration, and recovery time.
A seizure associated with a fever (≥38°C, or any temperature) in a child aged 6 months to 6 years.
It is typically generalized, lasts less than 5 minutes, and the child recovers fully within an hour.
Common triggers include viral infections (e.g., upper respiratory tract infections, gastroenteritis) and bacterial infections (e.g., otitis media, urinary tract infections). Risk factors include family history of febrile seizures, recent vaccinations (e.g., MMR, DTaP), and age 6 months to 5 years.
What are the 2 types of febrile seizures?
- Simple : Generalized tonic-clonic seizure, lasts <15 minutes (typically <5 minutes), no recurrence within 24 hours, no focal features or post-ictal neurological deficits.
- Complex : Focal features, prolonged duration (>15 minutes), or recurrence within 24 hours, may have post-ictal neurological deficits.
A seizure is complex if…?
- Focal features
- Prolonged: > 5/15 minutes
- Recurrence in 24 hours
- Post-ictal state more than 1 hour. Features of child being systemically unwell.
How do you differentiate febrile seizures from meningitis?
Febrile seizure: Child is well before and after the seizure, no signs of meningeal irritation, no non-blanching rash.
Meningitis: Child appears unwell, drowsy, or irritable, signs of meningeal irritation, non-blanching rash, prolonged or focal seizures.
What investigations are needed for a simple febrile seizure? You have no concerns for the child.
None routinely if the seizure is simple and the child is well.
Some tests to consider for a child with febrile seizures.
E.g. unknown source of infection, clinically unwell.
- Urine dipstick in children <2 years,
- Blood tests (glucose, UnE, CRP) if dehydration or atypical features,
- lumbar puncture if meningitis is suspected, neuroimaging only if focal neurological signs or concern for structural abnormalities.
List 3 most important principles of managing a febrile seizure in hospital?
- Recovery position
- If the seizure lasts >5 minutes, treat as status epilepticus: administer buccal midazolam or rectal diazepam, call for emergency help.
- Fever management: Use paracetamol or ibuprofen for fever and discomfort
What is the prognosis of febrile seizures?
Excellent: Most children outgrow febrile seizures by age 5-6 years, no long-term neurological damage.
Recurrence risk: 1 in 3 children may have further febrile convulsions in the future
Epilepsy risk: Slightly increased (2-5%) compared to the general population (1%), higher if the child has complex febrile seizures, developmental delay, or a family history of epilepsy.
What is the differential diagnosis for febrile seizures?
Infections: Meningitis, encephalitis, sepsis.
Metabolic causes: Hypoglycemia, electrolyte imbalances.
Neurological causes: Epilepsy, intracranial hemorrhage, brain tumor. Other: Breath-holding spells, syncope.
What is the role of antiepileptic drugs in febrile seizures?
Not routinely used: Risks of side effects outweigh the benefits. Febrile seizures are generally benign and self-limiting.
What is the most important thing to tell parents about febrile seizures?
Reassure them that febrile seizures are common and usually harmless.
Educate them on recognizing and managing future seizures, and when to seek urgent medical help (e.g., prolonged seizures, recurrent seizures, or signs of serious illness).
Mechanisms of injury in child abuse and some corresponding signs.
- Shaking – neurological impact - behavioural changes, feeding/sleeping difficulties.
- Direct trauma: hitting, belting
- Burns
Impact on child: emotionally withdrawn, lethargic, visible bruises (clustering e.g. fingerprints, symmetrical, unlikely locations. different stages of healing), fractures, swelling,
Physical, emotional, sexual, and neglect.
Immediate actions upon suspecting child abuse/Non-accidental injury.
- Clear documentation of everything (seen, heard, did) for potential legal action
- Escalating to senior (safeguarding lead or consultant)
- Alert social services
- Admission - for investigations, e.g. X-ray, blood tests
Which parental/social factors increase risk of child abuse that you should enquire?
List 4
- Younger parents, single parent
- Parental stress/ mental health issues
- Parental drug use
- Domestic violence, forensic history
- Lower socio-economic group (increase above risks and education)
Describe injuries that may not be developmentally appropriate.
- Infants
- Crawling toddlers
- Children (walking/running)
- Infants: Head trauma, bruises or falls (neglect?)
- Crawling toddlers - head trauma, bruises in unlikely locations (beyond knees/shins etc.)
- Children - unlikely bruises (head trauma can happen)
Standard investigations for non-accidental injury in a child. (after admission)
- X-ray: skeletal survey
- If head injury: CT/MRI head, fundoscopy to look for retinal haemorrhage
- Bloods: Bleeding disorder, toxicology screen
Why is it important to educate parents on managing a crying baby?
- Can be stressful/draining for parents
- Risk of being shaken > shaken baby syndrome (permanent neurological damage)
Diffuse axonal injury, O2 deprivation, haematoma, retinal haemorrhage
Complications include seizures, visual impairment, hearing loss, epilepsy, cerebral palsy, cognitive impairment, cardiac arrest, coma, and death.
Emily, a 3-year-old girl, is brought to the pediatric clinic by her parents. They are concerned because Emily has had multiple fractures over the past year, often from minor falls or even seemingly without any significant trauma. Her parents also mention that Emily has blue sclerae (a bluish tint to the whites of her eyes) and seems to be shorter than other children her age.
What is the likely diagnosis and tests?
Osteogenesis Imperfecta Type I, (the mildest and most common form of the disease; affects type 1 collagen.)
Tests: X-ray for fractures, and genetic testing
mx:
* Orthopedic Care
* Physical Therapy: To improve muscle strength and mobility
* Bisphosphonate Therapy: To increase bone density and reduce fracture risk
* Genetic Counseling: For the family to understand the condition and its implications for future pregnancies
