Paediatrics 2 Flashcards
What are the 4 most common paediatric malignancies?
Leukaemia/lymphoma Brain tumours Neuroblastoma Wilm's tumour Bone tumours
What is a Wilm’s tumour?
A rare kidney cancer that primarily affects children
How do brain tumours present?
Raised ICP - early morning headache, vomiting, papilloedema Focal seizures Neurological signs Endocrine disturbance Raised OFC Developmental delay/regression
What investigations should be done if a brain tumour is suspected?
CT or MRI Tumour biopsy Tumour markers Endocrine screen CSF cytology and tumour markers
What are the most common malignant bone tumours in children?
Osteosarcoma
Ewing’s sarcoma
How do bone tumours present?
Often delayed Persistent nocturnal pain Swelling Deformity Pathological fractures Systemic symptoms - fever, weight loss
How is Ewing’s sarcoma treated?
Chemotherapy
Surgery
Autologous stem cell transplant
Radiotherapy
How is osteosarcoma treated?
Chemotherapy
Surgery
Why is long term follow up required for patients treated for bone tumours?
Significant toxicity associated with treatment
What are the common malignant causes of an abdominal mass?
Neuroblastoma Wilm's tumour Hepatoblastoma Lymphoma Germ cell tumour Soft tissue tumour
What are blueberry muffin skin nodules associated with?
Neuroblastoma
What investigation should be done if neuroblastoma is suspected?
Urinary catecholamines
What malignancy causes leucocoria?
Retinoblastoma
What malignancy causes a bitemporal hemianopia?
Craniopharyngioma
What are children receiving chemotherapy at increased risk of?
Neutropenic sepsis
What is tumour lysis syndrome?
Breakdown of malignant cells results in hyperuricaemia, hyperkalaemia, hypophosphataemia and hypocalcaemia, causing AKI, seizures, arrhythmia and death if left untreated
When is tumour lysis syndrome most likely to occur?
During induction chemotherapy
How is tumour lysis syndrome managed?
Regular observation and monitoring U&Es and bone profile IV fluids Xanthine oxidase inhibitor (allopurinol) Manage hyperkalaemia Renal dialysis
What are the early and late effects of chemotherapy?
Early - marrow suppression, temporary hair loss, nausea and vomiting, renal impairment
Late - cardiac toxicity, infertility, risk of secondary malignancy
Give an example of passive immunisation
Normal immunoglobulin (IV/subcutaneous) Specific antibodies (e.g. varicella zoster IgG)
Give an example of active immunisation
Foreign antigen stimulates a host immune response
Live attenuated vaccines
Inactivated vaccines
Give 2 examples of live attenuated vaccines
BCG MMR Rotavirus Influenza Oral polio
Give 2 examples of inactivated vaccines
Polio Trivalent influenza Diphtheria and tetanus Pertussis HPV MenB
What is the major difference in immune response between children and adults in regards to vaccination?
Polysaccharide antigens do not stimulate an effective and lasting immune response in children < 2
Polysaccharide blocks opsonisation, preventing phagocytosis and subsequent antigen presentation to T-cells in association with MCH by APCs. The immune response is therefore largely T-cell independent and relies on the formation of antibody by B-cells.
Infants have low numbers of/immature B cells, and without T-cell activation may produce only small numbers of short-lived antibodies.
To induce T-cell responses the polysaccharide antigen of pathogenic microbes can be linked to a carrier protein (e.g. tetanus or diphtheria toxoid), to which the child reacts.
Give 2 examples of conjugates vaccines
Hib
Group C meningococcus
Pneumococcal
Group ACWY meningococcal
What immune protection is offered by the placenta, covering babies up to 2 months?
IgG
Why are booster vaccinations needed?
Live vaccine produce long lasting immunity after 1 or 2 doses but inactivated vaccines need several doses
What is the main contraindication to vaccination?
Confirmed anaphylaxis to previous vaccine with same antigens or other vaccine components (e.g. neomycin/streptomycin)
In what population is the yellow fever vaccine contraindicated?
Those with a confirmed anaphylaxic reaction to egg
In whom are live vaccines contraindicated?
Immunosuppressed
Primary immunodeficiency, chemo/radio therapy in last 6 months, bone marrow transplant treatment in last 12 months, high dose steroids until 3 months without, immunosuppressant medication in last 6 months
HIV (no BCG but may have MMR)
How long should there be between live vaccine administration?
3 weeks
How long should vaccination be postponed for if a patient has received immunoglobulin?
3 months
What is subacute sclerosing panencephalitis?
Very rare, but fatal disease of the central nervous system that results from a measles virus infection acquired earlier in life
SSPE generally develops 7 to 10 years after a person has measles, even though the person seems to have fully recovered from the illness
What is the incubation and infectivity period for measles?
7-14 days
1-2 days before symptoms to 4 days after rash
What are the clinical features of measles?
3-5 days prodrome of fever, coryza, cough, conjunctivitis and Koplik’s spots
Maculopapular rash starts behind ears and migrates to face/trunk/limbs
Associated cervical lymphadenopathy and fever
What are the complications of measles?
Otitis media Lymphadenitis Interstitial pneumonitis Secondary bacterial bronchopneumonia Myocarditis Post-infectious demyelinating encephalomyelitis SSPE
What is the incubation and infectivity period for chicken pox?
14-21 days
2 days before and 5 days after rash
What are the clinical features of chicken pox?
48 hours of fever, malaise, headache and abdominal pain
Itchy crops of erythematous macules -> papules -> vesicles of serous fluid
What are the complications of chicken pox?
Secondary bacterial infection (Group A strep, S.aureus) Pneumonia Encephalitis Progressive disseminated varicella Cerebellar ataxia Thrombocytopenia Purpura fulminans Post-infectious encephalitis
How is zaricella zoster prevented?
Vaccination for high-risk patients
Post-exposure prophylaxis with varicella zoster immunoglobulin (IVIG) if immunocompromised
What is the incubation and infectivity period for mumps?
14-21 days
1-2 days prior to 9 days after parotid swelling
What are the clinical features of mumps?
Prodrome - fever, anorexia, headache
Painful uni/bilateral salivary +/- submandibular gland swelling
What are the complications of mumps?
Meningoencephalitis Deafness Orchitis Epididymitis Pancreatitis Nephritis Myocarditis Arthritis Thyroiditis
What is the incubation and infectivity period for parvovirus B19?
4-14 days
Not infectious once rash appears
What is parvovirus B19 also known as?
Erythema infectiosum
Slapped cheek
Fifth’s disease
What are the clinical features of parvovirus B19?
Prodrome - low grade fever, malaise
Maculopapular spots on cheeks which coalesce to give slapped cheek appearance
Fine lacy rash extends to trunk and limbs
Associated arthralgia and arthritis
Lasts 2-30 days
What are the complications of parvovirus B19?
Aplastic crisis in sickle cell/thalassaemia/immunocompromised
What is the incubation and infectivity period for rubella?
14-21 days
1-2 days before to 7 days after rash appears
What are the clinical features of rubella?
Prodrome - coryza, tender cervical lymphadenopathy
Fine maculopapular rash on face and spreads to trunk
Arthralgia and palatal petechiae
What are the complications of rubella?
Encephalitis
Thrombocytopaenia
Congenital rubella syndrome
What is the incubation and infectivity period for HHV6?
7-14 days
Until fever subsides
What is HHV6 also known as?
Human herpes virus 6
Roseola infantum
Sixth disease
What are the clinical features of HHV6?
Sudden onset high fever with mild coryza which resolves on day 3-4 and maculopapular rash appears on trunk and limbs for 1-2 days
What are the complications of HHV6?
Febrile convulsions in 6-18 month olds
Encephalitis
What is the incubation and infectivity period for pertussis?
7-14 days
Whilst coughing during catarrhal phase
What are the clinical features of pertussis?
Catarrhal phase - low grade fever, coryza, conjunctivitis for 1-2 weeks
Paroxysmal phase - severe cough +/- whoop, vomiting, cyanosis, apnoea for 2-8 weeks
Convalescent phase - cough subsides over weeks/months
What are the complications of pertussis?
Apnoea Secondary bacterial pneumonia Weight loss Bronchiectasis Otitis media Seizures Encephalopathy Subconjunctival/subarachnoid/intraventricular haemorrhage Umbilical/inguinal hernia Ruptured diaphragm
How is pertussis diagnosed?
Nasal swab for PCR testing and culture
Associated lymphocytosis
How is pertussis treated?
Supportive
Macrolides
Give 4 causes of meningitis
Bacterial Viral Fungal Parasitic Malignancy Immune-mediated Drugs
What are the 2 most common causative bacterial organisms in meningitis in children?
Neisseria meningitidis
Streptococcus pneumoniae
Haemophilus influenzae
TB
Group B strep
What is the most common cause of viral meningitis in children?
Enterovirus
What is the most common cause of bacterial meningitis in neonates?
Group B streptococcus
Listeria monocytogenes
E.coli
How does bacterial meningitis present?
Fever Headache Nausea and vomiting Neck stiffness Photophobia Lethargy Decreased level of consciousness Seizures Positive Kernig's sign and Brudzinski sign
What is Kernig’s sign?
Positive when flexing the thigh at the hip and knee to 90 degree angles, and subsequently extending the knee is painful (leading to resistance)
This may indicate subarachnoid haemorrhage or meningitis
What is Brudzinski’s sign?
Severe neck stiffness causes a patient’s hips and knees to flex when the neck is flexed
Give 4 ways in which an infant may present with bacterial meningitis
Unexplained fever Lethargy High pitched/irritable cry Cannot be soothed by parents Poor feeding Apnoeic/cyanotic attacks Posturing Seizures Bulging fontanelle
How is bacterial meningitis diagnosed?
LP
What are the contraindications to LP?
Cardiovascular compromise
Signs of increased ICP (herniation risk)
Abnormal clotting/low platelets (subdural/epidural haematoma)
Skin infection at site
Give 4 signs of increased ICP
GCS <9/drop of 3 or more Bradycardia and HTN Focal neurological signs Abnormal posturing Unequal/dilated/poorly responsive pupils Papilloedema Abnormal doll's eye movements
What will CSF analysis reveal in suspected meningitis?
WCC >5 (>20 neonates) - polymorphs = bacterial, lymphocytes = viral
Elevated protein and decreased glucose = bacterial or TB
Organisms may be seen on staining
PCR for pneumococcus/meningococcus/Hib/HSV/ZVZ/enterovirus
What is the empirical treatment for suspected bacterial meningitis?
IV cefotaxime
(+ amoxicillin and gentamicin if <6 weeks)
(+ dexamethasone if >3 months and no purpura)
What is the definitive treatment for Neisseria meningitidis meningitis?
7 days IV cefotaxime/ceftriaxone
What is the definitive treatment for Streptococcus pneumoniae meningitis?
14 days IV cefotaxime/ceftriaxone
What are the complications of meningitis?
Hydrocephalus Deafness (Hib) Neuromotor disorders Seizures Visual disorders Speech and language disorders Learning difficulties Behavioural problems
What is the difference between septicaemia and sepsis?
Septicaemia - infection of the blood stream
Sepis - systemic inflammatory response to infection
What is sepsis syndrome/severe sepsis?
When sepsis is associated with hypoperfusion resulting in organ dysfunction which can lead to septic shock and multiple organ failure
What is the pathophysiology of meningococcal sepsis?
Capillary leak
Coagulopathy
Myocardial depression
Metabolic derangement
How does meningococcal bacteraemia present?
Fever
Petechial/purpuric rash
Relatively well child who rapidly deteriorates
What are the features of septic shock?
Difficulty breathing Tachycardia Hypotension Cool extremities Leg pain CRT >2 secs Decreased conscious level Moribund
How is septic shock managed?
High flow oxygen 15L via facemask with reservoir bag
IV fluid bolus of 20ml/kg of 0.9% saline; repeat once if needed, then consult PICU
IV cefotaxime 50mg/kg
Correct any metabolic derangements and coagulopathy
What are the 5 F’s of abdominal distension?
Fat Fluid Faeces Flatus Foetus
Give 2 scars that might be present on abdominal examination of a nephrology patient
Nephrectomy - hockeystick at flank
Renal transplant - LIF
Give 3 renal causes of a unilateral mass on abdominal examination
Multicystic kidney Compensatory hypertrophy Obstructed hydronephrosis Wilms tumour Renal vein thrombosis Neuroblastoma
Give 3 renal causes of a bilateral mass on abdominal examination
AR/AD polycystic kidney disease
Tuberous sclerosis
Renal vein thrombosis
Give 3 urinary tract abnormalities
Absent kidney/s Multicystic dysplastic kidney Duplex Horseshoe/pelvic kidney Obstruction
What is Potter’s syndrome?
Describes the typical physical appearance caused by pressure in utero due to oligohydramnios, classically due to bilateral renal agenesis
What is a duplex kidney and what are its complications?
2 ureters
Upper - obstructs, associated with ureterocele
Lower - reflux (VUR)
Give 2 points of the urinary system which commonly obstruct
Posterior urethral valves - bladder hypertrophy, hydronephrosis, renal failure
VUJ
PUJ
Give 2 causes of oedema in children
HF
Nephrotic syndrome
Liver failure
Malnutrition
Give 3 pathological causes of proteinuria
Glomerular - sclerosis, nephritis, nephrotic syndrome, familial haematuria
Tubular
Physiological stress - exercise, cold, febrile, HF
Define nephrotic syndrome
Proteinuria (>1g/m2/day),
Hypoalbuminaemia (<25 g/l)
Oedema
What test can be used to diagnose nephrotic syndrome?
Protein to creatinine ratio from one early morning urine sample
Normal <20 mg/mmol
Nephrotic >150 mg/mmol
What type of patient is at higher risk of nephrotic syndrome?
Asian (x6) boys (2:1)
How is nephrotic syndrome classified?
Idiopathic - minimal change disease, focal segmental glomerulosclerosis
Secondary - HSP, SLE
Congenital
Give 3 investigations for nephrotic syndrome
Bloods - FBC, U&Es, LFT’s, C3/C4, Varicella status and ASOT
Urine - protein creatinine ratio, culture
BP
Give 2 complications of nephrotic syndrome
Hypovolaemia
Thrombosis
Infection
Hypertension
How is nephrotic syndrome treated?
Prednisolone - high dose and then reduce
20% albumin and furosemide - hypovolaemia/oedema
Pneumococcal vaccination
Penicillin prophylaxis
Salt/fluid restriction
What percentage of patients with nephrotic syndrome will have a relapse?
60-70%
Give 5 non-glomerular causes of haematuria
Infection Trauma Stones Sickle cell Coagulopathy/bleeding disorder Renal vein thrombosis Tumour Structural abnormality Munchausen by proxy
Give 2 glomerular causes of haematuria
Acute/chronic glomerulonephritis
IgA nephropathy
Familial nephritis
Give 3 things to find out about while taking a history for haematuria
Pain Timing Trauma Recent URTI Rash Medications FH renal disease or deafness
Give 4 investigations for haematuria
Bloods - FBC, coagulation, U&Es, ASOT, ANF, complement
Urine - MC&S, oxalate, calcium, phosphate and urate levels, calcium creatine ratio
AXR, renal USS, +/- renal biopsy
How is hypertension defined in children?
BP persistently >95th% for age and gender/height
Give 5 causes of hypertension
Renal parenchymal disease Renovascular Renal tumours Coarctation of the aorta Phaeochromocytoma Neuroblastoma Congenital adrenal hyperplasia Cushing's Hyperthyroidism Essential HTN Obesity Drugs - steroids, stimulants, recreational, liquorice
Give 5 first line investigations for hypertension
Bloods - FBC, U&Es, creatinine, albumin, bicarbonate, calcium, phosphate, LFTs, plasma renin activity, aldosterone, plasma catecholamines
Urine - urinalysis, urine microscopy and culture, urinary protein to creatinine ratio, urinary catecholamines
Imaging - renal USS with Doppler flow of the renal vessels, echo, ECG, CXR, DMSA
What is a DMSA scan?
Radionuclide scan that uses di mercapto succinic acid (DMSA) in assessing renal morphology, structure and function
How can end organ damage be assessed in hypertension?
Echo
Fundoscopy
Urinalysis for proteinuria
How is hypertensive crisis treated?
Labetalol/sodium nitroprusside infusion
What can be caused by UTI in presence of VUR?
Scarring of the kidneys
Give 3 causes of UTI
Infrequent voiding Vulvitis Hurried micturition Constipation VUR Neuropathic bladder
What is the most causative organism in UTI?
E.coli (85%)
Proteus (boys) Staphylococcus Klebsiella Enterococcus Pseudomonas (structural)
What are the symptoms of a UTI in an infant and older child?
Infant - fever, vomiting, lethargy, irritability, poor feeding, failure to thrive, sepsis, shock
Older - frequency, dysuria, changes in continence, abdominal pain, loin tenderness, fever, malaise, vomiting, haematuria
What investigations should be done in suspected UTI?
Urinalysis
Urgent urine culture and microscopy if <3 months
MSSU
Imaging
How does the imaging required for UTI differ depending on age?
<6 months - USS in 6 weeks (acute if recurrent/atypical); DMSA and MCUG 4-6 months after infection if recurrent/atypical
>6 months - atypical need acute USS and DMSA at 4-6m; recurrent need USS at 6w and DMSA at 4-6m
What are most UTIs resistant to?
Amoxicillin
How can recurrence of UTI be prevented?
Fluids
Prevention/treatment of constipation
Complete bladder emptying
Good perineal hygiene (girls)
Give 3 methods of urine collection in babies/children
Clean catch - unable to do MSSU (too young)
MSSU - mid-stream, gold standard
CSU - catheter
SPA - suprapubic aspiration
Urine bags - not sterile, can be used to measure volume
Define acute renal failure
Sudden reduction in renal function
Oliguria <0.5ml/kg/hr
Give a pre-renal, renal and post-renal cause of acute renal failure
Pre - hypovolaemia, HF
Renal - HUS, ATN, GN, NSAIDs
Post - urinary obstruction
What are the 5 indications for dialysis?
Severe volume overload Severe hyperkalaemia Symptomatic uraemia Severe metabolic acidosis Removal of toxins
AEIOU - acidosis, electrolyte imbalances, ingestion, overload (volume), and uraemia
What is a renal USS good for?
General idea of renal anatomy (size, shape, symmetry and position of kidneys and tracts)
Vascular perfusion by Doppler
Screening tool
What is a DMSA scan good for?
Static scan to delineate divided function of kidneys
Identifies scars
Needs to be done at least 3 months after UTI
What is a DTPA scan good for?
Dynamic scan allows assessment of drainage and obstruction Micturating cystourethrogram (MCUG) - looking for vesicoureteric reflux, bladder outline, and the presence of posterior urethral valves
What is an AXR good for (renal)?
Stones
Define diabetes mellitus
Metabolic disorder of multiple aetiology characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both.
What is the pathophysiology of type 1 diabetes?
Autoimmune beta cell destruction, leading to absolute insulin deficiency
What is the pathophysiology of type 2 diabetes?
Non-autoimmune, multifactorial condition with insulin resistance and/or relative deficiency
What does ‘walking wounded’ mean?
Presentation of 70% Glasgow paediatric new-diagnoses - patient walks into hospital with absent/minimal dehydration and acidosis
Give 5 signs/symptoms of diabetes
Thirst Weight loss Polydipsia Dehydration Polyuria Nocturia Nocturnal enuresis Lethargy Behavioural change Infection (balanitis, candidiasis)
Give 5 signs/symptoms of ketoacidosis
Ketotic breath Dehydration Laboured breathing - Kussmaul's Nausea/vomiting Abdominal pain Headache Irritability Confusion Unrousable Features of cerebral oedema - sunken eyes, reduced skin turgor, CRT >2 secs, cool peripheries, tachycardia, hypotension Raised ICP/altered consciousness
Name 4 types of diabetes
Type 1 Type 2 MODY Disease related - CF, haemochromatosis, acromegaly, Cushing's Steroid induced Syndromal - Trisomy 21, Prader-Willi
Name 2 types of insulin regimen
Twice daily - rarely used, inflexible, simple
Split evening - young children
Basal bolus - flexible, correction doses
What are correction and ketone doses?
Correction - rapid acting insulin to lower high BG if > 8mmol/l and ketosis minimal; dependent on blood glucose
Ketone - rapid acting insulin to clear moderate/large ketosis if BG > 14 mmol/l; independent of blood glucose
Give 3 methods of insulin administration
Subcutaneous fat injection (pen & needle device or (rarely) syringe)
Subcutaneous fat infusion (via “insulin pump”)
Intravenous infusion (ketoacidosis or while fasting (+ IV dextrose))
Other - islet cell transplant, implanted pump
Give 3 causes of ketosis/ketoacidosis
Lack of awareness Delay of diagnosis Infection Trauma Insulin pen/pump failure Insulin omission (accidental/deliberate)
How is ketoacidosis investigated?
Glucose, U&E, Blood Gas ([H+], [HCO3-], UA (ketosis)
Other - Osmolality; consider Septic screen (blood, urine, etc.)
How is ketoacidosis managed?
Managed in HDU/ITU A-E assessment IV fluids - rehydrate slowly IV insulin - syringe driver IV K+ - once shock is corrected Monitoring - BP, ECG, neuro
What are the complications of ketoacidosis?
Cerebral oedema
Arrhythmia
Renal failure
How is cerebral oedema secondary to ketoacidosis managed?
Exclude hypoglycaemia Restrict fluid Mannitol Ventilate CT
What are the signs/symptoms of hypoglycaemia?
Mild neuroglycopenia - feeling faint, hunger, headache, confusion
Autonomic symptoms - pallor, sweating, nausea, tachycardia
Severe neuroglycopenia - slurred speech, seizure, coma, death
How is hypoglycaemia treated in the outpatient setting?
Rapid-acting oral glucose, followed by slower-acting carbohydrate
“GlucaGel” oral glucose gel (if can tolerate oral intake)
IM Glucagon injection, anterior thigh (if unconscious, fitting)
How is hypoglycaemia treated in the inpatient setting?
Oral glucose if conscious and able to take orally
IV dextrose bolus +/- infusion (if unconscious, persistent low BG)
Why do diabetics need additional management when ill?
Immune response impaired in those with T1DM
Metabolic stress causes catabolism and hormone release
May cause relative insulin deficiency and increased insulin requirement
Causes hyperglycaemia with ketosis/ketoacidosis
How does acute epiglottitis present?
3-7 year old
Drooling and stridor
Toxic within a few hours
What should be avoided in a child presenting with epiglottitis and why?
Visualisation of epiglottis or distressing the child (e.g. cannulation)
May precipitate respiratory arrest
How should epiglottitis be managed?
ITU
Intubation
Humidified air/oxygen
IV chloramphenicol/ampicillin
What is the differential diagnosis for epiglottitis?
Foreign body
Retropharyngeal abscess
Diphtheria
Croup
How does croup present?
Age 6 months - 3 years May have preceding coryzal symptoms Inspiratory stridor Wheeze Mild fever and fatigue Barking cough
How is croup managed?
Humidified air/oxygen
No antibiotics
Give 5 causes of acute respiratory failure
Central - head injury, drugs, convulsion, infection
Airway - acute epiglottitis, foreign body
Parenchymal - pneumonia, bronchiolitis, asthma
Chest wall - polio, trauma
How does acute respiratory failure present?
Restless, agitated from hypoxia, cyanosis, silent chest not moving sufficient air
Blood gases - low PaO2 and/or rising CO2 on oxygen
How is acute respiratory failure managed?
Secure airway - bag valve mask, intubation, assisted ventilation
Deal with primary cause
How does acute bronchiolitis present?
6 weeks - 6 months old Preceding coryzal symptoms 3-5 days prior Progressive cough Wheeze Difficulty feeding Similar signs to asthma Fine inspiratory crepitations
What causes bronchiolitis?
Respiratory syncytial virus
How is bronchiolitis managed?
Oxygen
Suction of secretions
Tube feeding/IV fluids if unable to tolerate oral
Antibiotics if bacterial infection suspected
What is the prognosis of bronchiolitis?
May recur
Third develop asthma in later life
How does acute asthma present?
>1 year old Expiratory wheeze Difficulty speaking Extended head Flared nostrils Increased AP chest diameter Accessory muscle use Tachycardia Cyanosis
How is acute asthma managed?
Oxygen Nebulised salbutamol and ipratropium bromide Oral prednisolone IV theophylline Monitor
What type of pneumonia is more common in pre-school children?
Bronchopneumonia (as opposed to lobar pneumonia)
How does pneumonia present?
Babies - ill, grey, cyanosed, increased WOB and RR, febrile convulsion
Children - can mimic acute appendicitis, upper respiratory rattle
What investigations should be done for pneumonia?
CXR Bloods - Hb, FBC Throat swab Blood culture Mantoux (if severe) Sweat test (if recurrent or staph)
How is pneumonia managed?
Suction of secretions PT Oxygen NG/IV feeds Antibiotics - ampicillin/penicillin and gentamicin (sick) +/- flucloxacillin (staph)
Give 3 symptoms which may indicate cardiac failure
Lethargy Feeding problems/breathless on feeding Sweating Failure to thrive Recent excessive weight gain/oedema Blue attacks Precipitated or exacerbated by illness
Give 2 signs which may indicate cardiac failure
Tachycardia
Tachypnoea
Hepatomegaly
Femoral pulse changes
How is cardiac failure managed?
Position - sitting/incline, head up Diuretic (e.g. furosemide) Digoxin Oxygen Morphine Treat cause
In what condition is digoxin contraindicated?
Tetralogy of Fallot
How should burns and scalds be managed immediately at home?
Strip off soaked clothing
Immerse in cold running water
Cover area in clean dry sheet/towel/dressing
How should burns and scalds be managed in hospital?
Airway - soot in nostrils, wheeze IV access Analgesia - IV morphine Plasma expanders if >10% surface affected to prevent shock/renal failure Blood transfusion for full thickness Weight Check Hb for anaemia Monitor closely for renal failure
How is % burn calculated in children?
Head 18%, legs 13%, arms 8%, trunk 18%
Child’s palm = 1%
What is the difference between superficial and superficial dermal burns?
Superficial - sunburn, no blisters
Superficial dermal - good blood supply, blistered
How do deep dermal and full thickness burns differ?
Deep dermal - altered sensation but not painless, may have blisters, well demarcated, speckled appearance
Full thickness - painless, white/brown, dry
What % cut offs are important clinically in regards to burns?
> 3% need referral
Full thickness >1% need to be seen
10% needs IV fluids
30% needs ICU
How is isotonic dehydration quantified in children?
As percentage loss of body weight
5% = mild = 50ml/kg
10% = moderate = 100ml/kg
15% = severe = 150ml/kg
Give 2 symptoms/signs of mild dehydration
Lethargic
Loss of skin turgor
Dry mouth
Slack fontanelle
Give 2 symptoms/signs of moderate dehydration
Tachycardia Tachypnoea Sunken fontanelle Sunken eyes Mottled skin Oliguria
Give 2 symptoms/signs of severe hydration
Shock
Coma
Hypotension
How are fluid boluses calculated in children?
20ml/kg
How should oral rehydration solution be administered?
5-10ml every 1-5 minutes (to replace deficit in 6 hours)
How might meningitis present?
Gastroenteritis Irritable cry Coma Convulsion Apnoea Bulging fontanelle Head retraction and resistance to flexion Otitis media Purpura
What investigations should be done for meningitis?
LP for CSF cells, Gram stain and glucose
Bacteriology
Hb, WBC, U&Es, blood glucose
Chest x-ray
How is meningitis treated?
Neonate - probably e.coli/GBS = benzylpenicillin and chloramphenicol
>3 months - probably H.influenzae/meningococcus/pneumococcus = ampicillin and chloramphenicol
Give 4 important complications of meningitis
Convulsions Cerebral oedema Subdural effusion Hydrocephalus Hyponatraemia (inappropriate ADH) Deafness Fever (rises after initial fall) Mental handicap Cerebral palsy Epilepsy
What early symptoms may indicate osteomyelitis/septic arthritis?
Reluctance to use a limb
Local swelling
Local tenderness
How are osteomyelitis/septic arthritis treated?
IV antibiotics - flucloxacillin and ampicillin
Immobilise the limb
Monitor
When is surgery indicated for osteomyelitis/septic arthritis?
Infants - immediately for septic hip
Older children - poor response to treatment after 24 hours
Give 4 symptoms of UTI
Dysuria Frequency Haematuria Foul smelling urine Bedwetting Abdominal pain Pyrexia of unknown origin Malaise Not feeding
What investigations should be done for UTI?
BP
Hb, WBC, U&Es, serum creatinine, urine and blood culture
Ultrasound
Radio isotope studies for scarring, pelvi-ureteric obstruction and ureteral reflux, duplex collecting systems, bladder diverticuli/obstruction
What bacteria are most commonly implicated in UTI?
<1 year = E.coli
> 1 year = E.coli, proteus
Give 4 symptoms/signs of DKA
Polydipsia/polyuria for days or weeks Weight loss Dehydration Vomiting Abdominal pain, Infection associated Coma
How is severe DKA managed?
0.9% saline
K+ supplementation
Insulin bolus and then IV infusion until glucose falls to 15mmol/L
Then give dextrose instead of saline and insulin every 4-6 hours
How is poisoning managed immediately at home?
Induce vomiting with fingers (unless volatile hydrocarbons, caustics or the child is unconscious)
How is poisoning managed in hospital?
Establish what has been taken, in what volume, when and how
Induce vomiting with 15ml syrup of ipecac and water, repeat if no result after 20 mins/gastric lavage if unconscious
Give specific antidotes
What is the antidote for paracetamol poisoning?
Acetyl cysteine/methionine
What is the antidote for TCA or theophylline poisoning?
Activated charcoal
What is the antidote for opiate poisoning?
Naloxone
What is the antidote for alcohol poisoning?
Glucose (hypoglycaemia can be severe)
How should pyrexia be investigated?
Infection screen - blood culture, urine culture +/- lumbar puncture, Hb, WBC, ESR, chest x-ray
How are seizures managed?
Keep child safe
Give diazepam IV or rectal -> paraldehyde if no response after 10 minutes
How are infantile spasms treated?
ACTH/corticosteroids
Benzodiazepines
How is a petit mal seizure treated?
Ethosuximide
Sodium valproate
How is temporal lobe/focal epilepsy treated?
Carbamazepine
Phenytoin
What is sudden infant death syndrome?
Sudden and unexpected death of an apparently normal 1 month-1 year old after which a properly performed autopsy fails to reveal a major cause of death
What are the risk factors for SIDS?
Male
Low birth weight
Winter
Adverse social/domestic conditions
How should SIDS be managed?
Attempt resuscitation if appropriate
Inform parents cot death is likely
Offer holding the baby
Inform GP, health visitor and social services
Procurator Fiscal and police will investigate
Emphasise routine nature of inquiries and remove blame from parents/carers
Suppress lactation if breastfeeding
What is non-accidental injury?
Where abuse is inflicted or knowingly not prevented by person(s) caring for a child and signs are present of physical injury and/or neglect, drug administration, failure to thrive, emotional or sexual abuse
What factors may make you consider NAI?
Injuries inconsistent with explanation
Delay in seeking help
Medical advice sought for many minor injuries
Young, single parent
Known to social services
Handicapped child
Physical signs of neglect/abuse - bruising of different ages, black eyes, torn frenulum, retinal detachment/bleeds, genital bruising, withdrawn, drugged, burns/scalds, fractures
What gene mutation is associated with eczema?
Filaggrin
How can the skin barrier be improved in eczema?
Bathing without soap
Liberal and frequent emollients
What are the main areas of management for eczema?
Improve skin barrier
Avoid irritants
Reduce itching
Topical steroids
How can itching be improved in eczema?
Sedative anti-histamines
Cotton clothing
Scratch mitts
Keep nails short
What steroids regimen is suitable for eczema of the body?
Medium potency for 7 days for flares and 2-3 times weekly for chronic patches
Increase to potent steroid if suboptimal response
What steroids regimen is suitable for eczema of the face?
1% hydrocortisone safe for daily use (eyelids 3 times weekly only)
Short 3 day course of moderate steroids for flares
How does irritant contact napkin dermatitis occur?
Moisture and friction disrupt skin barrier and allow irritants from urine/faeces to penetrate
Give 3 features of irritant contact napkin dermatitis
Can be associated with candida and bacterial overgrowth
Glazed erythema
Sparing of skin folds
Can ulcerate if left untreated/diarrhoea occurs
Wrinkled scaly appearance during resolution
How is irritant contact napkin dermatitis treated?
Frequent nappy changes Avoid soap/wipes Greasy zinc-based emollient Topical steroid/antifungal cream if very inflamed Anti-yeast if candida infection
How does candida associated with irritant contact napkin dermatitis present?
Satellite papules and pustules which spread to flexures
Give 3 features of vulvitis
Pre-pubertal girls
Localised eczema
Atopic children
Itch, erythema, discharge, stinging passing urine
Why is candidiasis not a probable differential in young girls?
pH of vulval skin before puberty does not support candidal overgrowth
How is vulvitis managed?
Cotton underwear
Avoid tights and soap/wipes
Greasy zinc-based emollient
Topical steroid cream if very inflamed
How is lick lip dermatitis managed?
Greasy emollient
Topical steroid with anti-yeast when red
How does pityriasis alba present?
Hypopigmentation Dry rough skin on cheeks of atopic children 4-12 year olds Coloured skin Patchy and poorly demarcated
How is pityriasis alba managed?
Emollients
Sunscreen (prevent surrounding skin tanning which makes it more obvious)
Give 3 features of juvenile plantar dermatosis
Affects anterior plantar surface Predominantly boys Onset 4-7 years, resolves with puberty Main trigger is sweating Worse in winter Erythema, hyperkeratosis and fissuring
How is juvenile plantar dermatosis treated?
Avoid occlusive footwear/synthetic socks
Aluminium hydrochloride powder can reduce sweating
Emollients and topical steroids
What area should be carefully managed if affected by HSV skin infection and why?
Periorbital
Check eyes for corneal involvement as it can cause scarring
What organism commonly causes impetigo?
Staphylococcus aureus
How does impetigo present?
Annular erythematous lesions with honey coloured crust
May become bullous if epidermis is exfoliated by staph
How is impetigo managed?
Reduce spread
Topical antiseptic
Topical/oral antibiotics (flucloxacillin)
How does molluscum contagiosum present?
Small pearly umbilicated papules
What causes molluscum contagiosum?
DNA pox virus
How is molluscum contagiosum treated?
Usually resolve spontaneously
Topical antiseptics to avoid infection
Can be physically/chemically irritated to clear
How does scabies present in children?
Extremely itchy rash
Burrows may be seen on the soles of the feet
Nodules may be seen in warm/moist areas (e.g. axilla, groin)
What organisms cause tinea capitis?
Trichophyton tonsurans
Microsporum canis
How does tinea capitis present?
Diffuse scale/patchy alopecia with black dots (broken hairs) or widespread pustules with associated lymphadenopathy
How is tinea capitis managed?
Terbinafine (unlicensed)
Ketoconazole shampoo prevents spread to other children
Give 4 common dermatological conditions seen in newborns
Sebaceous hyperplasia Milia Miliaria Naevus flammeus Mongolion/blue spot Congenital melanocytic naevi Haemangiomas Capillary malformations/port wine stain Urticaria
What causes sebaceous hyperplasia, what does it look like and how is it managed?
Hypertrophy of sebaceous glands due to maternal androgens
Yellow/white pinpoint lesions clustered around the nose
Resolves spontaneously in 4-6 weeks
What is milia, what does it look like and how is it managed?
Epidermal inclusion cysts
Discrete white/yellow papules on chin/cheeks/forehead/mouth/genitalia
Spontaneously resolve in few weeks
What are the 2 types of miliaria, what do they look like and what is their cause?
Crystalina - clear vesicles which may wipe away; superficial duct obstruction and trapping of sweat
Rubra - erythematous papules/pustules over head/neck/trunk; deep obstruction of sweat ducts
What is a naevus flammeus and where does it most commonly occur?
Capillary vascular malformation
Nape of neck (persist)/face (fade)
What causes the blue colour of Mongolion spots and when do they resolve?
Deep dermal melanocytes
Resolve within 4 years
Give 3 features of congenital melanocytic naevi
Macular area of pigmentation
Colour varies from light brown to near black
Scalp lesions may disappear with time and overlying hair may be hyperpigemented/thicker
What are the complications of congenital melanocytic naevi?
Risk of melanoma in very large naevi >25cm is 5-14%
Naevi overlying spine or skull may be associated with neurological pathology
How are congenital melanocytic naevi managed?
Cover and sunscreen
Monitoring advice
Can excise if monitoring difficult or cosmetically visible
Why might dermabrasion/cutterage in first few weeks of life be counterintuitive?
Theoretically by reducing the melanocytic load it could reduce the risk of malignant transformation but by leaving only the deeper melanocytes it may mask the appearance of melanoma
Give 2 features of epidermal naevi
Linear plaques of warty pigmented skin along Blaschko’s lines
Become darker and more verrucous with age
May be uni/bilateral
What are Blaschko’s lines?
Lines of normal cell development in the skin
Give 3 features of sebaceous naevi
Predominantly on scalp and face
Usually flat and pale at birth with waxy smooth surface
Can darken and become verrucous over time, especially behind ears
May develop into secondary tumours after puberty
Most are benign
How are sebaceous naevi managed?
Excise for cosmesis
CO2 resurfacing laser and dermabrasion can be used to flatten but scarring and recurrence common
How are vascular anomalies classified?
Vasclar tumours - infantile haemangioma
Vascular malformation - fast flow, slow flow, combined
Name 2 infantile haemangiomas
Kaposiform haemangioendothelioma (HE)
Tufted angioma (TA)
Rapidly involuting congenital haemangioma (RICH )
Non-involuting congenital haemangioma (NICH)
Name a fast flow, slow flow and combined vascular malformation
Fast - arterial, arteriovenous fistula, arterial venous malformation
Slow - venous, lymphatic, capillary
Combined - CLM, CVM, CLVM, LVM, CAVM,
What are the risk factors for infantile haemangiomas?
Female
Preterm
Low birth weight
Twin pregnancies
How do infantile haemangiomas present?
Within first 6 weeks
Preceded by bruising/telangiectasia/pallor
Superficial, deep or mixed
Grow rapidly for 6 week to 6 months and then very slowly involute
How do infantile haemangiomas involute?
Darkening of superficial redness
Slow breaking up of colour starting from the centre
Softening and flattening of deep component
Deep component need fibrofatty tissue/lax skin surgically removed
Give 2 features of segmental haemangiomas
Large
Plaques
Associated with underlying visceral lesions/abnormalities related to their location
What are the complications of segmental haemangiomas and how are they treated?
Ulceration - beta-blocker (3 months)
Infection - antibiotics
Bleeding - pressure for 10-15 minutes
Obstruction of visual axis or airway - beta-blocker (12-18 months)
Give 2 features of capillary malformations/port wine stain
Present at birth
Size remains constant
Occur anywhere on the body
Bright red initially, violaceous with time
What should be considered if a port wine stain overlies the V1 distribution of the facial nerve?
Sturge Weber syndrome - neurological and ocular complications
What is Klippel-Trenaunay syndrome?
Capillary malformation associated with lymphatic and venous malformation
Limb overgrowth may occur
Give 4 triggers for urticaria
Infection Infestation - worms Injection - drugs, blood, vaccination Ingestion - drugs, food Inhalation - pollen, mould
Over what duration is urticaria classed as being acute?
<6-8 weeks
How is urticaria managed?
Chlorpheniramine (and antihistamine if >6 months)
How much fluid/milk do neonates need per day?
150 ml/kg/day
How are fluids prescribed in children?
421 rule
First 10kg = 4ml/kg/hr
Next 10kg = 2ml/kg/hr
Rest = 1ml/kg/hr
What are the daily requirements for Na, Cl and K?
Na 2-4 mmol/kg/day
Cl 2-4 mmol/kg/day
K 1-2 mmol/kg/day
Give 3 important features to ask about when a baby presents with vomiting
Bilious Projectile Feeding Weight gain Fever Rash
How do oz of milk equate with mls?
1 oz = 30mls
Give 4 causes of a vomiting baby
Overfeeding Posseting GORD Pyloric stenosis Obstruction
At what age does pyloric stenosis present and what factors make it more likely?
2-6 weeks
Male, FH
How does pyloric stenosis present?
Rapidly progressive projectile vomiting Soon after feeds No bile Hungry baby Acute weight loss Dehydration Hypochloraemic hypokalaemic metabolic alkalosis
How is pyloric stenosis diagnosed and managed?
Diagnosis - test feed (visible peristalsis and palpable olive in RUQ), USS
Management - correct electrolyte imbalance, pyloromyotomy
Give 3 causes of bilious vomiting in a baby
Malrotation +/- volvulus Necrotising enterocolitis Atresia Hirschsprungs Meconium ileus/plug
What causes malrotation?
Failure of intestinal rotation (270 degrees) and fixation which should occur at week 4-12 of gestation
What is the most common abnormality with malrotation?
Caecum lies close to DJ flexure resulting in abnormally narrow midgut mesentery which is liable to twist (volvulus)
How does malrotation present?
Early - collapse and acidosis due to intestinal infarction
Late - bile stained vomit and distension
How is malrotation diagnosed and managed?
Barium contrast studies
Resuscitation and laparotomy
What is necrotising enterocolitis?
Acute inflammatory disease occurring in the intestines of premature infants which can lead to necrosis of the bowel
How does necrotising enterocolitis present?
Abdominal distension Blood in stool Feeding intolerance Vomiting (bilious) Pyrexia
How is necrotising enterocolitis managed?
Conservative - stop feeds, give IV fluids and antibiotics
Needs surgery if severe - bowel resection and stoma formation
What is intestinal atresia?
Congenital malformation resulting in narrowing/absence of a segment of intestine
What is the most common site for intestinal atresia?
Ileum and jejunum
What condition is associated with duodenal atresia?
Down’s syndrome
Give 3 features of Hirschsprungs
Aganglionic section of bowel
Starts at anus and progresses upwards
Causes bowel obstruction
Often presents with delayed passage of meconium
Can present late with distension, constipation, failure to thrive and obstruction
Give 3 things to ask about in acute abdomen
SOCRATES pain Urinary/bowel symptoms LMP in girls Last meal DH and allergies
Give 3 differentials for acute abdomen in children
Acute appendicitis Mesenteric adenitis Constipation Gastroenteritis UTI
Give 3 features of acute appendicitis on abdominal x-ray
Scoliosis due to pain
Faecolith
Absent right psoas shadow
Intraperitoneal gas indicating perforation
Abnormal caecal gas or small bowel dilatation
What is intussusception?
Full thickness invagination of proximal into distal bowl
Telescoping
Where does intussusception most commonly occur and why?
Ileo-colic
Enlarged Peyer’s patches due to viral illness/Meckel’s diverticulum
Give 2 conditions associated with intussusception in older children
HSP
Lymphoma
CF
What is the classic triad of intussusception symptoms?
Severe intermittent abdominal pain
Redcurrant jelly stools
Vomiting
What imaging modalities are available for intussusception, what do they show and which is better?
Abdominal x-ray - absence of air and soft tissue density in ascending colon
Abdominal USS* - target lesion/doughnut sign
How is intussusception diagnosed and managed?
Contrast enema can do both
May need surgery
What is a hernia?
Protrusion of a viscus/part of a viscus into a cavity where it should not lie
How are incarcerated hernias managed?
Resuscitate
Reduce
Repair
What are the risk factors of hernias in neonates?
Male
Premature
LBW
What is a hydrocele?
Fluid in the scrotum due to a patent processus vaginalis
Give 2 features of a hydrocele
Noticed with systemic illness Can have a blue hue Can get above it on examination Transilluminates Most resolve spontaneously in first year of life
What is the management pathway for undescended testes?
Detected at baby check/8 week check –> referred as outpatient to surgeon –> surgical correction before first birthday
Give 3 causes of an acute scrotum
Testicular torsion
Torsion of the appendage (hydatid of Morgagni)
Epididymo-orchitis
Hydrocele (rarely painful)
Idopathic scrotal oedema (rarely painful)
What is the difference in pain of testicular torsion, appendage torsion and epididymo-orchitis?
TT - sudden, severe
AT - gradual over 2-3 days
EO - gradual, less severe
What is the difference in examination of testicular torsion, appendage torsion and epididymo-orchitis?
TT - high riding, swollen, hard, red, tender
AT - localised to upper scrotum, blue spot, hydrocele
EO - swelling, red, oedema
What are the 2 peaks of age for testicular torsion?
0-2 and 10-15 years
At what fluid resuscitation requirement following trauma should a surgeon be called?
> 40ml/kg
Give 3 anatomical features of children which need to be considered in trauma situations
Small body size Large surface area Relatively large head Compliant elastic skeleton Airway differences (small cavity, large tongue, short trachea, <6m are nose breathers)
What are the 5 principles of a primary survey?
Airway and C-spine
Breathing – look listen feel; administer O2
Circulation; HR BP CRT; IV access, bloods
Disability – GCS (modified) /AVPU
Exposure - remember hypothermia and glucose
How can a child’s weight be estimated for calculation of fluid/drug doses?
Weight = (age + 4) x 2
Weight at birth average 3.5kg, 6 months 7.5kg and 1 year 10kg, gain 2kg a year after that
Give 3 features to ask about when a child presents with head injury
Mechanism Vomiting LOC Amnesia Other injuries NAI
Give 3 things to check on examination when a child presents with head injury
GCS/AVPU HR and BP Head examination - boggy haematoma Signs of skull fracture Neurological examination
Give 6 indications for head CT on head injury in children
Witnessed loss of consciousness >5 minutes
Amnesia (antegrade or retrograde) >5 minutes
Abnormal drowsiness
≥3 Discrete episodes of vomiting
Clinical suspicion of non-accidental injury
Post-traumatic seizure (no PMH of epilepsy)
GCS <14 in emergency room (Paediatric GCS <15 if aged <1)
Suspected open or depressed skull fracture or tense fontanelle
Signs of base of skull fracture
Focal neurological deficit
Aged <1 - bruise, swelling or laceration on head >5 cm
Dangerous mechanism of injury (high-speed RTA, fall from >3 m, high-speed projectile)
Define amblyopia
Poor vision in a structurally normal eye
E.g. if image from one eye is clearer, the brain will switch off the other blurrier eye and cause visual loss
By what age is most visual development complete?
7 years
Give 2 causes of amblyopia
Reduced view through eye - ptosis, cataract
Unequal focus - one eye more long/short sighted (anisometropia)
Misalignment of eyes - squint
How is amblyopia treated?
Occluding patch over stronger eye
Atropine eye drops
What are the 2 types of squint?
Inwards/esotropia/convergent
Outwards/exotropia/divergent
What is an important differentials to consider for squint?
Eye movement syndromes
Cranial nerve palsies
How is a squint managed?
Glasses (correct long-sightedness)
How do you know if a squint is fully or partially accommodative?
Fully - will correct fully with glasses
Partially - only partially corrected with glasses
Give 2 causes of leukocoria
Cataract Retinoblastoma Retinal detachment Toxoplasmosis Uveitis
What may be seen on examination of the eye in NF1?
Lisch nodules
What may be seen on examination of the eye in albinism?
Iris transillumination
What may be seen on examination of the eye in Marfan’s syndrome?
Dislocated lens
What may be seen on examination of the eye in JIA?
Anterior uveitis
What is nasolacrimal duct obstruction?
Incomplete canalisation of the duct causing a sticky watery eye in the absence of conjunctivitis; resolves by 1 year
What is the most common type of permanent deafness?
Sensorineural
How are neonates screened for deafness?
Auditory brainstem response (ABR) screening
Give 3 acquired causes of deafness
Prenatal - toxoplasma, rubella, CMV
Perinatal - hypoxia, kernicterus, aminoglycoside antibiotics
Postnatal - meningitis, head injury, ototoxic drugs (e.g. cisplatin, antibiotics)
Give 2 congenital causes of deafness
Syndromic - Usher’s, Pendred’s, branchio-oto-renal, Jervell and Lange-Nielsen, Stickler’s
Non-syndromic - AR mutation in connexin 26 gap junction protein gene
How is deafness managed?
Cochlear implantation
What condition can cause a transient conductive deafness?
Otitis media with effusion (glue ear)
When is glue ear considered pathological?
Mucus fluid present for >3 months
How does the tympanic membrane look on examination in otitis media with effusion?
Dull
Retracted
Yellow/grey colour
How does conductive hearing impairment due to OME present?
Speech delay
How is hearing investigated in OME?
Audiometry - excludes sensorineural
Tympanometry - fluid pressure
How is OME managed?
Watch and wait
Grommet insertion
Removal of adenoids
What are the signs/symptoms of tonsillitis?
Prolonged sore throat Tonsillar exudate Fever Cervical lymphadenopathy Malaise
When is tonsillectomy advised for tonsillitis?
5 episodes per year over 2 years or 7 episodes in 1 year
What is the most common cause of nasal obstruction in pre-school children and what are its associations?
Physiological hypertrophy of adenoids
Snoring and green rhinorrhoea
When do adenoids spontaneously shrink?
6 years old
How is nasal obstruction due to adenoids managed?
Saline nasal douches
Adenoidectomy (severe)
What is the most common cause of nasal obstruction in school children and what are its associations?
Allergic rhinitis
Sneezing and clear rhinorrhoea
How is allergic rhinitis managed?
Topical nasal steroid spray
Oral non-sedating antihistamine
What is the most important thing to ask in the history of nasal obstruction?
Sleep quality
What can cause obstructive sleep apnoea in children aged 2-7?
Physiological hypertrophy of tonsils and adenoids
How can OSA be diagnosed?
Sleep studies - overnight pulse oximetry/12 channel polysomnography
Give 3 points to ask about in a sleep history when OSA is suspected
Sleep quality Snoring Breath holding during sleep Waking during the night Restless/sweaty at night
Give 3 causes of chronic stridor
Laryngomalacia (benign, self-limiting)
Subglottic stenosis
Airway haemangioma
Tracheal stenosis
How is the cause of chronic stridor established?
Airway endoscopy
Give 2 causes of lumps/bumps in the head and neck area
Branchial lesions
Thyroglossal cysts
Dermoids
What is the most common cause of cervical lymphadenopathy?
Reactive lymphoid hyperplasia (infection)
What 2 types of cancer are common in the head and neck of children?
Lymphoma
Rhabdomyosarcoma
From what sources can information be gathered when carrying out a psychiatric assessment?
Interview parents/carers FH, PMH, PH Interview and observe child Other assessments - community paediatrics, psychologist, SLT, OT Educational attainment
What contextual factors should be taken into account for psychiatric assessment?
Ability of parent to meet child's needs Parental mental health Child's relationships with other family members Child's home environment Major life events
What are the 2 main groups of mental disorder a child may present with? Give examples
Internalising/emotional behaviour disorder (e.g. phobias, OCD, depression, psychosomatic complaints)
Externalising/disruptive behaviour disorder (e.g. ADHD, conduct disorder, oppositional defiant disorder)
What are the biopsychosocial features of ADHD?
Restlessness, overactivity, inattentiveness, impulsivity
Poor self-esteem, low mood, learning difficulties
Poor peer and family relationships
How can ADHD be managed?
Stimulant (methylphenidate) or non-stimulant medication
Therapy - individual, family
Clubs/activities
How is ADHD diagnosed?
Careful evaluation of full history and observation
Features must occur in >1 setting
What is conduct disorder?
Group of behavioural problems where a child is aggressive (verbal or physical), antisocial and defiant to a much greater degree than expected for their age
What are the features of conduct disorder?
Violation of rights of others and social norms
Fighting and physical cruelty (people and animals)
Destructiveness (usually of property)
Lying and stealing
Violation of rules (e.g. truancy, running away from home)
What is the relevance of age in conduct disorder?
<10 years old = early onset conduct disorder
>10 years old = adolescent onset conduct disorder
What are the risk factors for conduct disorder?
Genetic - parent with antisocial personality disorder/who had CD
Individual - difficult temperament
Physical - problems processing social information/cues (e.g. disability, brain injury)
Environmental - family/parenting problems, deprived area
Emotional - depression, isolation
How are conduct disorders managed?
Group based parent training/education programmes
CBT
What is reactive attachment disorder (RAD)?
Hypersensitive to changes in their environmental circumstances due to their adverse early life experiences
What are the features of RAD?
Lack of emotional responsiveness
Fearfulness and hypervigilance
Aggressive or defiant behaviour
Inhibition or hesitancy in social interactions
Disinhibition or inappropriate familiarity or closeness with strangers
RAD may be accompanying disorder of a child who shows a failure to thrive
What is the most common type of mental health disorder in children?
Anxiety disorders
What is PANDAS?
Paediatric autoimmune neuropsychiatric disorders associated with strep (A infection) - can cause OCD which presents suddenly
Give 7 signs/symptoms of depression in children
Appearing unhappy much of the time
Outbursts of shouting, crying or unexplained irritability
Having poor self-esteem, guilt or recurrent feelings of worthlessness
Loss of interest/lack of pleasure in enjoyable activities
Suicidal thoughts
Spending a lot of time in bed but sleeping badly and experiencing early morning awakening
Major changes in weight and appetite
Headaches, stomach aches, tiredness and other vague physical complaints that appear to have no obvious cause.
When is medication used to treat depression in children?
Severe cases
Give 3 conditions associated with autism spectrum disorder
Depression Anxiety disorders (social, OCD) ADHD Learning disability Epilepsy GI (IBS) Tourette’s Genetic disorders
What is the ASD triad of impairment?
Social interaction
Social communication
Stereotyped behaviour/sensory sensitivites/restricted interests
What is the difference between autism and Asperger’s syndrome?
Asperger’s syndrome - IQ is at least average and there was no language delay in early childhood
Autism - IQ can be anywhere on the scale and there is a history of language delay
How is ASD managed?
Behavioural interventions SLT Appropriate schooling OT Medication for anxiety/aggression Education
What are tics?
Tics are sudden, involuntary, non-rhythmic motor movements or vocal productions which are purposeless, happen rapidly and are often repetitive in nature
What types of tics exist?
Simple motor - blinking, twitching
Complex motor - facial grimace and head twist
Simple vocal - grunt, cough
Complex vocal - full words/sentences
What is Tourette’s?
Combined vocal and motor tic disorder that can often persist into adult life
Give 2 behaviours occurring in anorexia nervosa
Intense fear of weight gain Obsession with eating Weighs self repeatedly State they are overweight and exercise excessively Counts or portions food carefully and may only eat certain foods Increased consumption of liquids Rigid meal or eating rituals May refuse to eat in front of others
What are the physical signs/symptoms of anorexia?
Weight loss
Cessation of growth/arrested pubertal development
Osteopenia
Lanugo body hair, brittle nails and hair, dry skin
Constipation/abdominal discomfort
What biopsychosocial developmental changes occur in early adolescence?
Bio - males (testicular enlargement), females (breast buds, pubic hair development)
Psych - concrete thinking, moral concepts, awareness of sexual identity
Soc - emotional separation from parents, peer identification, exploratory behaviours
What biopsychosocial developmental changes occur in mid adolescence?
Bio - males (sperm production, voice breaks, growth spurt), girls (menarche, change in body shape)
Psych - abstract thinking, believe they are immortal, increasing verbal dexterity, fervent ideology
Soc - continuing parental separation, heterosexual peer interest, early vocational plans
What biopsychosocial developmental changes occur in late adolescence?
Bio - males (continued growth in height)
Psych - complex abstract thinking, increased impulse control, development of personal identity
Soc - social autonomy, develop intimate relationships, develop financial independence
What tool should be used to take a history from an adolescent?
HEADS H - home life E - education A - activities D - drinking, driving, drugs S - sex, smoking, suicide
What is the sequence of puberty in females?
Breast development (8-12 years) -> pubic hair growth -> rapid growth spurt -> menarche (2.5 years after puberty starts)
What is the sequence of puberty in males?
Testicular enlargement -> pubic hair growth (10-14 years) -> height spurt (1.5 years after puberty starts)
Define delayed puberty
Absence of pubertal development by age 14 in girls and 15 in boys
More common and benign in boys
Give 2 causes of delayed puberty
Constitutional delay Hypogonadotrophic hypogonadism (Crohn's, CF, anorexia, intracranial tumour, panhypopituitarism) Hypergonadotrophic hypogonadism (Turner/Klinefelter syndrome, trauma, chemotherapy, torsion)
How is delayed puberty assessed?
Male - pubertal staging, growth parameters, exclude chronic systemic disease
Female - pubertal staging, growth parameters, karyotype, thyroid hormone, sex hormones
How is delayed puberty managed?
Reassurance
Male - oxandrolone/low dose testosterone
Female - oestradiol
Give 2 concerning features when considering sexual health of adolescents
Age <13 years Power imbalance Coercion Substance misuse Risk
Give 2 risk factors for STIs in adolescents
Avoidance of barrier contraception
Multiple partners
Mental illness
Substance misuse
Give 2 risk factors for substance misuse in adolescents
Conduct disorder Poor parenting Early experience of substance misuse Peer group pressure Poor social environment
Give 2 negative effects of chronic illness in adolescents
Constitutional delay in growth/puberty Negative self-image Low mood Poor school attainment Poor peer development
How can transition from paediatric to adolescent services be optimised?
Inform adolescent and parents early Run specific teenage clinic Involve GP to maintain continuity Encourage adolescent to take charge Support and educate parents to allow adolescent to take over
In what situation would it be necessary to administer a drug by IM injection (which is usually avoided where possible due to pain)?
Benzylpenicillin should be given IM by GP in suspected meningococcal sepsis
Other than according to age and weight, how else can medications doses be prescribed?
Body surface area (e.g. aciclovir) using Boyd equation (back of BNF)
How does drug absorption differ in babies?
Gastric and bile acid secretion and intestinal motility are reduced in babies which affects bioavailability especially of acidic drugs
How does drug distribution differ in young children?
Higher percentage body weight is water and there is reduced plasma protein binding due to low albumin so higher doses of water soluble drugs are needed
How does drug metabolism differ in babies?
Immature liver enzymes Conjugation reactions (e.g. oxidation) are not developed until 1 year (limits drugs which can be used before 1 year)
How does drug metabolism differ in children 1-12 years old?
Faster than adults until 2 years and then slowly declines
May need to increase dose or frequency for drugs which undergo hepatic metabolism
How does drug excretion differ in babies and children?
Increased half-lives of renally excreted drugs; renal function complete at 6-8 months
Under what circumstances does a man have parental rights?
If they are listed on the birth certificate
If they are married to the child’s mother
Who has parental rights in a same sex partnership?
Both if they were civil partners at time of conception
If not, they can apply for parental responsibility
At what age would a young person be considered unable to consent to sex and therefore it be considered statutory rape?
13 years of age
