Paediatrics 3A Flashcards
Signs of respiratory distress in children?
- Raised respiratory rate
- Use ofaccessory musclesof breathing, such as thesternocleidomastoid,abdominal andintercostalmuscles
- Intercostalandsubcostal recessions
- Nasal flaring
- Head bobbing
- Tracheal tugging
- Cyanosis(due to low oxygen saturation)
- Abnormal airway noises
- Wheeze - whistling sound caused by narrowed airways, typically heard during expiration
- Grunting - caused by exhaling with the glottis partially closed to increase positive end-expiratory pressure
- Stridor - high pitched inspiratory noise caused by obstruction of the upper airway, for example incroup
Stridor vs wheeze?
Stridor - on inspiration (croup + acute epiglottitis)
Wheeze - on expiration
Vaccine given to babies with chronic lung disease of prematurity?
Palivizumab - to prevent RSV causing bronchiolitis
This involvesmonthly injectionsof amonoclonal antibody against the virus calledpalivizumab.
Coryzal symptoms?
Runny nose
Sneezing
Mucus in throat
Watery eyes
(signs of viral URTI)
Features making viral induced wheeze more likely than ASTHMA?
- Presenting before 3 years of age
- No atopic history
- Only occurs during viral infections
- Not triggered by asthma triggers like cold, exercise, strong emotions, dust
Presentation of viral induced wheeze?
Evidence of a viral illness for 1-2 days (fever, cough and coryzal symptoms) preceding the onset of:
- Shortness of breath
- Signs of respiratory distress
- Expiratorywheezethroughout the chest
Complications of mumps?
- Pancreatitis (abdo pain)
- Orchitis (testicular painand swelling)
- Meningitis (confusion, neck stiffness, headache)
- Sensorineural hearing loss
Presentation of measles?
- Incubation periodof10 days
- Prodromal period (flu-like illness with conjunctivitis) with fever OVER 39
- Koplik’s spots (RED in mouth; 1-2 days before rash)
- RASH (spreads down from face)
erythematous, macular rash with flat lesions.
Complications of measles?
Pneumonia
Diarrhoea
Dehydration
Encephalitis
Meningitis
Hearing loss
Vision loss
Death
Differential diagnoses for measles?
All of them have NO Koplik’s spots
- Rubella
- Parvovirus B19
- HSV6 (roseala infantum)
- Scarlet fever (strep)
- May be early meningococcal disease (it later becomes purpuric
- Kawasaki disease
- EBV - infectious mononucleosis
When is the MMR given?
- 1 year
- 3 years + 4 months
What vaccines are given at 8 weeks (2 months)?
- 6 in 1 (Hib, Hep B, diphtheria, tetanus, polio, pertussis)
- Meningococcal B
- Rotavirus (oral gel)
When is the 6-in-1 vaccine given?
- 8 weeks (2 months)
- 12 weeks (3 months)
- 16 weeks (4 months)
What vaccines are given at 12 weeks (3 months)?
- 6 in 1 (Hib, Hep B, diphtheria, tetanus, polio, pertussis)
- Pneumococcal
- Rotavirus (oral gel)
What vaccines are given at 16 weeks (4 months)?
- 6 in 1 (Hib, Hep B, diphtheria, tetanus, polio, pertussis)
- Meningococcal B
What vaccines are given at 1 year?
- 2-in-1 (haemophilus influenza type B and meningococcal type C)
- Pneumococcal
- MMR(measles, mumps and rubella)
- Meningococcal type B
When is the pneumococcal vaccine given?
12 weeks + 12 months
What vaccines are given at 3 years + 4 months?
- 4 in 1(diphtheria, tetanus, pertussis and polio)
- MMR vaccine(second dose)
When is the flu vaccine given to children?
Annually from age 2 – 8
When is the HPV vaccine given?
12-13 years
2 doses given 6-24 months apart
What vaccines are given at 14 years?
- 3 in 1(diphtheria, tetanus, polio)
- Meningococcal ACWY
Newborn blood spot screening test
Taken on day 5 (day 8 at the latest) after consent from the parent.
Heel prick - 4 drops onto screening card.
Sickle cell disease
Cystic fibrosis
Congenital hypothyroidism
Phenylketonuria
Medium-chain acyl-CoA dehydrogenase deficiency (MCADD)
Maple syrup urine disease (MSUD)
Isovaleric acidaemia (IVA)
Glutaric aciduria type 1 (GA1)
Homocystin
Presentation of slapped cheek syndrome / parvovirus B19?
Associated with arthritis
- Starts with mild fever, coryza and non-specific viral symptoms such as muscle aches and lethargy.
- After 2 - 5 days the rash appears quite rapidly as a diffuse bright red rash on both cheeks, as though they have “slapped cheeks”.
- A few days later areticularmildly erythematous rash affecting the trunk and limbs appears that can be raised and itchy. Reticular means net-like.
Most dangerous complication of slapped cheek syndrome?
Aplastic anaemia
(parvovirus B19 reduces erythropoiesis)
When is the newborn examination?
Performed within the first 72 hours after birth. Repeated at 6 – 8 weeks by their GP.
Features of FASD?
- Microcephaly(small head)
- Thin upper lip
- Smooth flat philtrum(the groove between the nose and upper lip)
- Short palpebral fissure(short horizontal distance from one side of the eye and the other)
- Learning disability
- Behavioural difficulties
- Hearing and vision problems
- Cerebral palsy
What is the diagnosis?
6mnth old weaning child with recent viral URTI preceding current features of intestinal obstruction (vomiting, absolute constipation and abdominal distention + RUQ pain)
Intusseption.
Weaning = bacteria in food = bowel telescopes in on itself = bowel ischaemia
(confirm with ultrasound)
Investigation & management for intusseption?
- Abdominal ultrasound TO CONFIRM
- Catheter via anus: AIR ENEMA - insert air ⇒ pressure forces the bowel to un-telescope
SURGERY - if unsuccessful (10% cases)
Differential diagnoses:
VOMITING - 6 months old
- Intusseption (milky then green vomit)
- Gastroenteritis
=> caused by weaning
Differential diagnoses:
VOMITING - 6 hours old
- GORD (reflux)
- Overfeeding (>150ml/kg/day)
- Duodenal atresia/stenosis
- Sepsis
- Malrotation - causes green/biliary vomiting
Differential diagnoses:
VOMITING - 6 weeks old
- Pyloric stenosis - milky, projectile vomiting
- Overfeeding
- GORD
- Sepsis
Differential diagnoses:
baby with blood in stools
- gastroenteritis
- cows milk protein allergy
Causes of paediatric intestinal obstruction?
- Malrotation of the intestines with avolvulus
- Intussusception
- Meconium ileus
- Hirschsprung’s disease
- Oesophageal atresia
- Duodenal atresia (or colonic atresia)
- Imperforate anus
- Strangulated hernia
Differential diagnosis for baby with persistent jaundice?
> 14 days in term babies
21 days in premature babies
Suspect biliary atresia in babies with apersistent jaundice, lasting more than 14 days in term babies and 21 days in premature babies.
Investigation for suspected biliary atresia?
Conjugatedandunconjugated bilirubin.
- Ahigh levelofconjugated bilirubinsuggests the liver is processing the bilirubin for excretion (by conjugating it), but it is not able to excrete the conjugated bilirubin because it cannot flow through the biliary duct into the bowel.
Surgery for biliary atresia?
The “Kasai portoenterostomy” involves attaching a section of the small intestine to the opening of the liver, where the bile duct normally attaches. This is somewhat successful and can clear the jaundice and prolong survival.
Often patients require a full liver transplant to resolve the condition.
Jaundice within 24hrs of birth?
TOM TIP: Jaundice in the first 24 hours of life is pathological. This needs urgent investigations and management. Neonatal sepsis is a common cause.
Babies with jaundice within 24 hours of birth need treatment for sepsis if they have any other clinical features or risk factors.
When does physiological jaundice present in a newborn?
Normal rise in bilirubin shortly after birth, causing a mild yellowing of skin and sclera from 2 – 7 days of age.
This usually resolves completely by 10 days.
There is a high concentration of red blood cells in thefetusandneonate. These RBCs are more fragile than normal RBCs. The fetus and neonate also haveless developed liver function.
Fetal RBCs break down more rapidly than normal red blood cells, releasing lots of bilirubin.
Normally this bilirubin is excreted via theplacenta, however at birth the foetus no longer has access to a placenta to excrete bilirubin.
Most babies remain otherwise healthy and well.
What is breast milk jaundice?
Babies that are breastfed are more likely to have neonatal jaundice.
- Components of breast milk inhibit the ability of the liver to process the bilirubin.
Breastfed babies = more likely to become dehydrated => slow passage of stools => increasing absorption of bilirubin in the intestines.
What is kernicterus?
High levels of unconjugated bilirubin can cause kernicterus
(yellow basal ganglia)
Kernicterus is brain damage due to high bilirubin levels. Bilirubin levels need to be carefully monitored in premature babies, as they may require treatment.
Bilirubin can cross theblood-brain barrier. Excessive bilirubin causes direct damage to theCNS.
- Less responsive, floppy, drowsy baby with poor feeding.
The damage to the nervous system is permeant, causingcerebral palsy,learning disabilityanddeafness.
Blood gas finding in pyloric stenosis?
‘HYPOCHLORIC METABOLIC ALKALOSIS’
- Cl- low (due to vomiting HCl)
- High pH (alkalosis)Hypernatraemia due to dehydration from vomiting = more conc Na+
Management of pyloric stenosis?
Laparoscopic pyloromyotomy(Ramstedt’s operation)
An incision is made in the smooth muscle of the pylorus to widen the canal allowing that food to pass from the stomach to the duodenum as normal.
Investigation to diagnose pyloric stenosis?
Abdominal ultrasound
=> shows thickened pyloric sphincter
What is Hirschsprungs disease?
Congenital - absence of nerve cells in colon (in the myenteric plexus)
=> reduced bowel peristalsis
=> constricted area of bowel
Presentation of Hirschsprungs disease?
- Failure to pass meconium when born (>24 hours)
- Chronic constipation since birth
- Vomiting
- Poor weight gain & failure to thrive
- Progressive abdominal distension
Key complication of Hirschsprungs disease?
Hirschsprung-associated enterocolitis (HAEC)
=> inflammation and obstruction of the intestine occurring in around 20% of neonates with Hirschsprung’s disease.
Presents within 2-4 weeks of birth
Fever, abdominal distention, diarrhoea (often with blood) and features of SEPSIS
It is life threatening and can lead totoxic megacolonandperforationof the bowel.
It requires urgentantibiotics,fluid resuscitationanddecompressionof the obstructed bowel.
Management of Hirschsprung’s disease?
- Abdominal X-ray: to diagnose intestinal obstruction & any demonstrated features of HAEC
- Rectal biopsy (to confirm diagnosis - absence of ganglionic cells)
- Definitive management ⇒ surgical removal of the aganglionic section of bowel
Complications of Meckel’s diverticulum?
- usually asymptomatic
- it may produce acid => bleed, become inflamed, rupture (peritonitis)
- cause avolvulusorintussusception
Differential diagnoses for diarrhoea in children?
- Infection (gastroenteritis)
- Inflammatory bowel disease
- Lactose intolerance
- Coeliac disease
- Cystic fibrosis (steatorrhoea)
- Toddler’s diarrhoea
- Irritable bowel syndrome
- Medications (e.g. antibiotics)
Causes of finger clubbing in children?
Hereditary clubbing
Cyanotic heart disease
Infective endocarditis
Cystic fibrosis
Tuberculosis
Inflammatory bowel disease
Liver cirrhosis
Cause of meconium ileus?
When meconium is not passed within 24 hours, this is usually the first sign of cystic fibrosis.
with:
- Distended abdomen
- Green vomiting
Treatments for abdominal migraine in children?
ACUTE:
- ibuprofen/paracetamol
- dark quiet room
- sumatriptan
PREVENTATIVE:
- pizotifen (serotonin antagonist)
- Propranolol
- Cyproheptadine (antihistamine)
- Flunarazine (CCB)
Painless rectal bleeding in young child?
Key investigation?
?Meckels diverticulum
(ectopic gastric mucosa produces acid = ulcers that bleed)
Technetium-99 scan (Meckel’s scan) is the investigation of choice for detecting ectopic gastric mucosa in suspected Meckel’s diverticulum
Signs and symptoms of paediatric brain tumours?
- Persistent headaches that are worse in the morning
- Signs of raised ICP; such as nausea, vomiting, and altered consciousness
- Vision changes (blurring or double vision)
- Seizure in an older child with no fever and no previous history of seizures
- Depending on the location of the tumour, patients may present with focal neurological deficits
- If the child is young, they may have macrocephaly and hydrocephalus
What are focal neurological deficits?
- Movement changes => paralysis, weakness , loss of muscle control, increased/decreased muscle tone, or movements a person cannot control (involuntary movements, such as tremor)
- Sensation changes => paresthesia (abnormal sensations), numbness, or decreases in sensation
- Ataxia
- Horner syndrome
- Neglect to surroundings (inattention)
- Speech issues
- Visual changes (reduced fields, diplopia, vision loss)
A boy is born at term requiring ventilatory support shortly after delivery. He has low set ears, downward slanting eyes and noticeably appears to have a ‘twisted’ posture and extremities. An ultrasound reveals multicystic, dysplatic kidneys.
What is this condition + what is it caused by during pregnancy?
Potter syndrome
Caused by oligohydramnios
=> oligohydramnios (lack of amniotic fluid) means there is a lack of ‘cushioning’ of the foetus, resulting in it getting squashed by the surrounding maternal organs - resulting in their characteristic appearance
11 month old boy. Increasingly lethargic over the past 3 days. Kicking his legs in the air. Vomited 3 times yesterday.
Blood in his nappy this morning which she reports looking like ‘jelly.’ There is no evidence of peritonitis.
He is afebrile.
US abdomen reveals concentric echogenic and hypoechogenic bands.
What is the best intervention?
Intusseption -> air enema
(red currant stool, vomiting, pulling knees up due to crampy pain, palpable RUQ mass)
Child coughing at home, dad worried she swallowed something.
Child is fine by the time they got to A&E.
Xray shows halo sign.
What should you do?
Urgent endoscopy
The x-ray findings (halo sign) suggest that this child has swallowed a button battery. Ingestion of button batteries is extremely dangerous as the battery can react with bodily fluids such as saliva, which allows the battery to leak a strong alkaline fluid which can burn through the tissue.
The next best management step is to perform an urgent endoscopy under general anaesthetic to remove the battery and decide if further treatment is needed, for example, if the battery has caused a tracheo-oesophageal fistula.
if you visualise them, they have two “levels” or layers - a smaller circle sits on top of the large circle - this is what creates the “halo” on imaging
Diagnosis?
5yo boy
2 days lethargy, headache, sore throat, runny nose + FEVER
Erythematous rash on torso and both cheeks which blanches under pressure
Tongue and buccal mucosa appear normal
Slapped cheek
Parvovirus B19
Diagnosis?
6yo boy
Over the past 48 hrs he has developed sore throat, headache and fever.
In the past 24 hrs he has developed a coarse, erythematous rash on his face and torso.
Bright red tongue
Scarlet fever
3x S’s of scarlet fever:
- Strep pyogenes
- Strawberry tongue
- Sandpaper rash (‘coarse’
Cause of rheumatic fever?
5-15 yo
Autoimmune conditiontriggered bystreptococcus bacteria (untreated strep throat or scarlet fever)
Occurs 2–6 weeks following infection with group A streptococcus (GAS), such as Streptococcus pyogenes.
Presentation of rheumatic fever?
Jones criteria: (J<3NES for both minor and major)
[<3 means heart]
Major criteria (J<3NES)
- Joint pain (typically a migratory polyarthritis affecting one joint then others in quick succession; most commonly affected joints are the knees, ankles, elbows and wrists)
- Pancarditis (<3)/myocarditis/endocarditis/pericarditis (this may manifest as tachycardia or new murmur)
- Nodules (subcutaneous nodules on tendons/joints)
- Erythema marginatum (pink rings)
- Sydenham’s chorea (late sign)
Minor criteria (J<3NES)
- Joint pain - arthralgia not meeting major criteria
<3: prolonged PR interval
- Nothing
- E: ESR/CRP are raised
- S: ‘shivering’ (fever)
Presentation of Henoch-Schonlein Purpura (HSP)
IgA vasculitis (IgA deposits in blood vessels)
Can be triggered by upper airway infection (i.e. tonsilitis) or gastroenteritis
Most common under 10 years old
- Non-blanching purpuric rash - start on legs and spreads up
- Joint pain
- Abdo pain
- Kidney impairment (haematuria+proteinuria)
