Paediatrics 2 Flashcards
Name some specific types of epilepsy that can be diagnosed in a child:
Childhood onset Absent seizures
~ 6 years old
- Sodium Valproate
- Ethosuximide
Lennox- Gastuat syndrome
- multiple seizure types, usually atonic
- cognitive impairment
- Slow spike wave on EEG
Juvenile myoclonic epilepsy
- muscle twitches/ contractions/ jumps
West’s syndrome/ Infantile spasms:
~4-6 months
- Extension of trunk and extension of arms
- usually underlying neurological condition
- poor prognosis
- predinislone is 1st line
Dravet syndrome
- severe myoclonic epilepsy
- resistant to drugs
What are the different types of cerebral palsy seen?
Spastic hypertonia
- motor cortex
Dyskinetic (basal ganglia)
- Athenoid (hyper movement, grimace, drooling)
- Dystonic
Ataxic
- cerebellum
What are some gait changes seen with cerebral palsy?
Circumductive gait
- seen with spastic hemiplegia
Scissoring
- spastic diplegia
Ataxic gait
What are some causes of cerebral palsy?
Antenatal:
- Maternal infection (rubella, toxoplasmosis)
- intrauterine injury
- maternal disease (hypothyroidism)
Perinatal:
- birth asphyxia
- pre-term
Post-natal:
- meningitis
- severe neonatal jaundice
- heady injury
What prostaglandin drug can be given to maintain the ductus arterioles?
Alprostadil
How is vesicoureteral reflux diagnosed and how is scarring assessed?
Micturating Cystourethrogram
- diagnosis
DMSA Scan
- for evidence of scaring
If a neonate goes into cardio-respiratory arrest and on auscultation you can hear tingling in the chest, what is the most likely diagnosis?
Diaphragmatic hernia
- leading to bowel within the thoracic cavity which affects lung maturity
Intubation is needed as the baby can fail quickly after birth
Causes pulmonary aplasia
What is your emergency treatment of croup?
High flow oxygen
Nebulised adrenaline
IV dexamethasone
*used for severe croup
What are some features of cystic fibrosis in the new born and later life?
Meconium ileus
Recurrent chest infections
Malabsorption
Nasal polyps
Later life:
- short stature
- delayed puberty onset
- male infertility
What are some features in children with cystic fibrosis (usually in those who were missed at birth)
Short stature
Reduced growth (drop in centiles)
Diabetes
Nasal polyps
What are the serious complications of measles?
Acute otitis media
Pneumonia
Encephalitis
- Subacute sclerosing panencephalitis
- appears some 5-10 years after infection due to reactivation and inappropriate immune response
- behaviour changes / personality changes
- memory changes
- Seizures
What investigations would be warranted into suspected biliary atresia?
Bilirubin
- conjugated
- unconjugated
LFTs
Sweat tests (check for cystic fibrosis)
Alpha -1 antitrypsin
Biopsy**
Ultrasound**
HIDA scan**
What testing is done at birth to assess for hearing loss, and what is the follow on test if abnormal?
Otoacoustic emission test
- small click generated which then creates an echo if the cochlear is normal
Auditory brainstem response
- done next if Otoacoustic emission test is abnormal
What is the formula for blood resuscitation in paediatrics?
Change in Hb (g) x Weight (kg) x 4
How is pyloric stenosis diagnosed and what will be seen? and what is the mangement?
Diagnosed via ultrasound
- thickened pyloric muscle
Correct Electrolyte imbalance
NG tube
Ramstedt pyloromyotomy
List some causes of bilious vomiting in a child:
Intestinal atresia Necrotizing enterocolitis Hirschsprung disease Intussusception Malrotation volvulus Meconium plug
What are the signs and symptoms of NEC and how is it investigated and treated?
Stable preterm who goes off feeding Abdominal distention Bloody stools Bilious vomit/ aspirates Pyrexia Haemodynamically unstable
Investigations:
- FBC **platelets reflect severity
- Cultures
- CRP
- ABG
- Culture stool
- Abdominal x-ray
- left lateral decubitus
Management:
- Stop feeds and insert TPN
- IV fluids
- Antibiotics IV broad spectrum
- NG tube - for aspirates
Surgical:
needed for stage III onwards
- bowel resection
- stoma formation
How does malrotation of the gut present and what is the diagnostic procedure?
Due to failure of intestinal rotation typically affected the duodenal-jejunal flexure which comes to lie on the right instead of the left of the midline.
Presentation:
- Bilious vomiting
- abdominal distention
- blood per rectum (late sign due to gut ischemia)
- Metabolic acidosis
Diagnosed:
- G.I contrast study
Treatment:
- IV fluids
- NG drainage
- IV broad spectrum antibiotics
- Emergancy laparotomy *surgical Emergancy
- if necrotic gut it removed and stoma
- if entire midgut is affected palliative care
What condition is intestinal atresia highly associatted with and what sign is seen on x-ray?
Down’s syndrome
Double bubble
What condition is a meconium plug associated with and how is it diagnosed and treated?
Cystic fibrosis
- 5-10& will have CF
Features:
- obstruction
- bilious vomit
Diagnosed:
- Gastrografin
Treatment:
- Bowel rest
- IV fluids
- NG tube decompression
- Antibiotics
- Gastrografin - breaks up material
if medical failure then:
- lapartomy +/- ileostomy
When approaching a Surgical abdomen what investigations should be done in what order?
History Examination Urine Beta hCG Blood tests Repeat examination Ultrasound
In a female child patient presenting with abdominal pain what must one make sure to ask:
Have they started menarche
What are the signs and symptoms of intussusception:
*most common place is the ileocaecal valve, usually due to enlarged Peyer Patches following viral infection (in older children there tends to be a history of HSP or lymphoma)
Abdominal pain
Pale and unwell
Redcurrent jelly stools
Floppy and hemodynamically unstable
Classic triad is:
- abdominal pain
- Bilious vomit
- redcurrent jelly stools
What are the maximum hourly rates of fluids for children?
104ml/hr for males
83ml/hr for females
What calculation can be done if the weight of a child is not available to work out how much fluids should be given?
(Age (years) +4) x 2
What fluid should be used for resuscitation in paediatrics?
Normal saline 0.9%
- no additional electrolytes
If a girls of 50kg requires maintanance fluids what is amount that should be given?
this would equate to 90ml/hour which is above the max dose, therefore answer is:
- 83ml/hour
In a trauma patient how much fluid bolus should a child recieve?
10ml/kg
*10ml/kg for trauma.
if you do not have childs weight you need to age. then:
(Age +4) x 2
When should inguinal hernias be fixed in a neonate/ infant:
Neonate: before discharge
Infant: next available list
*if there is an emergency they should be seen as such i.e. incarceration
When is surgery indicated for a hydrocele.
If not closed by age 3
*90% close by 1 year old
Name some situations which may suggest non-accidental injury:
Discrepancy between the history and degree of injury
Prolonged time between injury and seeking care
Repeats of injury
Inconsistent history between caregivers
History of “doctor hospital shopping”
When parents do not comply with medical advice
Area of injuries:
- groin
- face
- metaphysis
- multiple bruises of varying age
- injury not consistent with age of child
What types of injuries are suggestive of NAIs?
Injuries to the genital/ perianal area
Fractures of long bones <3 years old
- especially humorous
Skull and rib fractures <24 month year old
Metaphysis fractures
Well demarcated burns
Subdural haemorrhages
Retinal haemorrhages
Bruises of different colours
- multiple at different healing states
Injuries not consistent with age of child
- child with shin bruises but doesn’t walk
What advice can be given out to help parents with a child after a concussion?
After concussion - Return to normality
- ACoRN
Which ribs in children are least likely to get fractured? and if they are what does this suggest?
1st ribs.
if these are fractured then it is very likely there are much more severe injuries present
If you suspect NAI in a child what is the most important action you should take?
Inform the most senior person on shift
Admit the child
Safe guard for other children
What is the most common benign cause of inspiratory stridor in an infant?
Laryngomalacia
- congenitally soft larynx which leads to partial collapse during inspiration
usually self resolves by age 2
How is whooping cough treated?
Macrolides (if within the 1st 21 days)
+
Notify public health
What is the history and investigations into whooping cough?
History:
- severe coughing that causes child to turn red in face and flail arms
- Inspiratory whoop
Diagnosis:
- FBC - lymphocytosis
- Peri-nasal swabs - diagnostic
- CXR - atelectasis
What are the first set of vaccines given and when?
2 months:
- DTaP
- IPV
- Hib
- HepB
- MenB
- PCV
- Rotavirus
When is the MMR vaccine given?
12 months
and
3 years 4 months
What type of test should be done of a LP sample for S.Pneumonia and Meningococcus?
PCR testing
When is chicken pox no longer contagious?
After all the lesions have crusted over - usually 5 days after rash starts
What is the schedule regime for immunisations for 12- 18 year olds:
DTaP
PCV
MMR
HPV
Men ACWY
What is the initial management of Hirschsprung disease before surgical input?
Bowel irragation
What is the management of a child with mild and severe croup?
Mild
- Dexamethasone - PO
- Supportive
Severe:
- Nebulised adrenaline
- Oxygen
- Dexamethasone - IV
At what age do you start steroids in suspected meningitis? and what antibiotics should be given?
> 3 months old
Antibiotics only:
- ceftriaxone
- amoxicillin
- for listeria cover as well
If a child is diagnosed with threadworms what is the medication that should be used and who should be treated?
Mebendazole
*the whole family needs to be treated
Lymphadenopathy is very common in children and usually benign, list the features which are suggestive of malignancy and list some differentials:
Features:
- Supraclavicular site
- Epitrochlear site
- Systemic symptoms
- Hepatosplenomegaly
- Signs of bone marrow failure
Differential malignancies:
- leukaemia (ALL)
- Lymphoma (Hodgkins, Burkits)
- Neuroblastoma
- Rhabdomyosarcoma
What are the fluid resuscitations volumes used in paediatrics:
20ml/kg
10ml//kg used when:
- haemorrhagic shock
- cardiogenic shock
- DKA
- Neonate
- Trauma
**if a child is requiring >2 boluses then ICU should be contacted.
What is the algorithm for paediatric life support? 1 - puberty:
Get help
Assess airway and open
Look, feel, listen
5 rescue breathes
Check for ciruclation
15:2 ratio compression
What diet advice would you give to CF?
High calorie + high fat + pancreatic supplements
What diagnostic tests should be done into kawasaki disease? and what is the management:
There is no definitive test:
Bloods:
- FBC - raised plts
- CRP - raised
- ESR - raised
- LFTs - raised ALT
ECG
- looking for conduction defects pericarditis signs
Echocardiogram
- coronary artery aneurysm
Management:
- IV immunoglobulin
- Aspirin
- Serial echocardiograms
Following a diagnosis of diabetes type I in a child, what is likely to occur regarding their insulin regimen in the first 3-6 weeks?
The regime is likely to be lower than usual because there is a honeymoon period.
Typically a child needs 1unit/kg/ day but in the first 3-6 weeks this can be as low as 0.5units/kg/day
What is the phenomenon called when children wake up with hyperglycaemia and why is this?
What is it called when they wake up with hypoglycaemia?
Dawn Phenomenon
- due to growth hormone and sex hormone released during growth
Somogyi phenomenon
- hypoglycaemia in the morning
What tests are important to conduct in a female who is primary ammenoreachic?
FSH, LH
TFTs
Karyotyping
- Turner’s syndrome
- Androgen insensitivity (XY chromosome) - but lack the androgen sensitivity
In a neonate with poor feeding, what are the main differentials to consider?
Infection
Sepsis
Congenital heart disease
Bronchiolitis
What would you expect to see on the biochemical results for congenital adrenal hyperplasia? and what test is conducted to establish the cause?
Hyponatremia
Hyperkalemia
Acidosis
*they will also be tachycardia and underfilled
Hyperpigmentation may also be seen, especially of testes due to excessive ACTH release
Test:
17 - hydroxyprogesterone
- precursor to 21-alpha hydroxylase which doesn’t come about
What is the assessment score used to assess croup?
Modified Westley Clinical Scoring System
- stridor
- intercostal recession
- Air entry
- Cyanosis
- Level of consciousness
Outline the differences between cephalohematoma and caput succedaneum:
Cephahaematoma forms later and is between the bone and periosteum and thus does not cross the periosteal/ suture lines.
caput succedaneum forms immediately after birth and is above the periosteum and this can cross the suture lines.
