Paediatrics 4 Flashcards
Outline the types of febrile convulsions, the management and prognosis:
6months - 5 years
*> 5 years warrants further investigation
Simple:
- 1 seizure for that febrile illness
- <15 mins
- no focal neurology
Complex:
- > 15 mins
- > 2 seizure for that illness
- focal neurology
Management:
Simple:
- anti-pyretics
> 5mins:
- Benzodiazepines
Education and advice. >5mins to call ambulance
Complex:
- admit to hospital
Also admit to hospital if:
- <18 months
Prognosis:
- 2% chance of developing epilepsy over 1% as normal
Discuss the management of a child with epiglottitis:
Immediately contact:
- ICU
- Anaesthetist
*do not annoy, examine or distress the child.
Definitive management:
- Intubation
- IV Ceftriaxone + Clindamycin
- Nebulized adrenaline
- High Flow oxygen
Describe the x-ray appearances of respiratory distress in the new born and transient tachypnoea of the new born:
Respiratory distress:
- ground glass appearance
Transient tachypnoea of newborns:
- Perihilar mass
- cardiomegaly
- horizontal fissure lines
- pleural effusion
*this is essentially fluid in the lungs like seen with congestive heart failure
What is the management of a neonate with respiratory distress syndrome and what neonates are at risk of it?
Artificial surfactant via endotracheal tube
Supportive care
+/-
Intubation
Risk:
- preterm
- those with diabetic mothers
What is the management of transient tachypnoea of the new born?
Supportive therapy
- usually resolves in the first hour
Outline what is meant by atypical and recurrent UTIs in children:
Atypical:
- seriousness illness
- sepsis
- non- respondent to antibiotics within 48 hours
- Abdo/ renal masses felt
- Infection of non-E. Coli
- Renal dysfunction
Recurrent:
- > 2 episodes of pyelonephritis
- > 1 episode cystitis + Pyelonephritis
- > 3 episodes of cystitis
What investigations should be implemented of a <6 month old who develops a UTI?
Typical UTI:
- Renal US: within 6 weeks
Atypical UTI:
- Immediate US
- DMSA
- MCUG
Recurrent:
- Immediate US
- DMSA
- MCUG
What investigations should be implemented of a >6 month old who develops a UTI?
Typical:
- no further investigations
Atypical:
- Immediate US
- DMSA
Recurrent:
- USS within 6 weeks
- DMSA
What is the treatment of a UTI in a < 3 month old baby?
Admit to hospital
- IV antibiotics
- Supportive therapy
*will require further investigations including renal USS, and if atypical a MCUG and DMSA to establish any damage and structural abnormalities
If a child is in shock - how much fluid are you going to give and what is your management if not working?
20ml/kg fluid bolus of:
- blood
or
- Hartmanns
*this can be done twice. after this ITU should be contacted as the child is either very ill or bleeding
What is the calculation for 24 hour fluid maintenance in a child and what fluids is used for maintenance and how does this differ to fluids used in shock?
Calculation for 24hour management:
- <10kg = 100ml/kg
- 10-20kg = 50ml/kg
- > 20kg = 20ml/kg
- 45% saline + 5% dextro for maintenance
* normal saline used for shock
In a feverish child who will always get a LP?
Feverish child < 3 months
How does a child with congenital heart disease present and what are the general investigations carried out into congenital heart disease?
Presentation:
- Cyanosis
- Shock
- Heart failure
Investigations:
- ECG
- CXR
- Echocardiogram
- Cardiac Catherization
- 4 limb BP
What is the immediate management of a child with cyanotic congenital heart disease?
Acutely:
- Infusion of prostaglandin - keeping the ductus arterioles opening allowing shunting from the aorta to pulmonary vessels
All children should be referred to a Tertiary Cardiology centre
- to await surgical input
Outline the differences between viral induced wheeze and asthma?
Wheeze
- more common in preschool age
- Symptoms only exacerbated by chest infection
- No nocturnal symptoms (unless active infection)
- Dilators only help during infective periods
- Steroids of no benefit
Asthma:
- affects all age groups
- symptoms exacerbated by multiple triggers
- nocturnal symptoms present
- dilators help even when stable
- steroids reduce severity and duration
At what are the stages for asthma management in children and what stage in the management should referral to paediatrician with special interest be made?
Step 1.
- SABA
Step 2.
- SABA + ICS
Step 3.
<5 years: Leukotriene antagonist (Montelukast)
>5 years: LABA (salmeterol)
Step 4.
<5 years: Increase ICS dose
>5 years: Leukotriene antagonist (Montelukast)
Step 5.
- Oral steroids
**step 3 is when referral should be made
When is there said to be complete control of asthma?
No daytime symptoms
No need for reliver meds unless exercising
No limitation on daily activity
Normal lung function
What are the symptoms of life threatening asthma?
33 92 CHEST
<33% PEF
<92% sats
Cyanosis Hypotension Exhaustion Silent chest Tachycardia
Outline the management of a mild asthma attack in children:
2-10 puffs of salbutamol
Stable in 4 hours?
Yes - discharge with reducing regime
No - Admit for increased frequency
Outline the management of a severe asthma attack in a child:
10 puffs of salbutamol \+ Steroids (prednisone or IV hydrocortisone) \+/- Oxygen
20mins reassess:
no improvement?
- Nebulised Ipratropium
3x back to back nebs
If no improvement of 3x back to back nebs then:
- IV salbutamol
- IV magnesium
- IV theophylline
What are the two most common causes of tachyarrhythmias in children and how do you differentiate SVT from normal sinus?
Most common:
- SVT
- VT
SVT is distinguished by: >180bpm (in children) >220bpm (in babies) - no P waves - Acute onset
How is SVT managed in children?
Vagal Manoeuvres :
- Ice in face of infant (trigger vagal reflex)
- children Valsalva manoeuvres (blow into empty 10ml syringe)
Unstable child:
- adenosine
- DC cardioversion
Outline some causes of bradycardia in children:
Benign
Vagal stimulation (suctioning)
Drugs (Clonidine)
Heart block:
- congenital
- Rheumatic fever
- Lyme disease
- Maternal SLE
*note that maternal SLE associated with Anti- Ro and Anti- La is associated with congenital heart block
If a child has a fainting episode or seizure what important investigations should be conducted and what is a common abnormality which may cause this?
ECG
Long QT syndrome
- usually there is a family history
What are the general causes of congenital heart disease?
Chromosomal defects
Intrauterine infection
- especially rubella
Maternal disease
- diabetes
- SLE - heart block
Drugs in pregnancy
- alcohol
- anti-convulsant
What treatment option should be avoided in tetrology of fallot and what murmur is typically heard?
Initially Oxygen therapy should be avoided as it can worsen symptoms
Ejection systolic murmur over the pulmonary valve
- the VSD is too large to really cause a murmur
How are mitochondrial diseases inherited?
maternal
- only DNA for mitochondria is passed through them
If a child is premature do you delay the vaccine schedule?
No - vaccination is carried on at normal rate
What is the time frame for neonatal sepsis?
Sepsis within the first 28 days of life
<48 hours being early onset and life from the mother (Group B, Benzylpenicillin + gent)
What is the management for meningitis in infants?
<3 months:
- Amoxicillin + Ceftriaxone (cover for listeria monocytogenes)
> 3 months
- Ceftriaxone + steroids
What kind of face is William’s syndrome patients said to have?
Elfin Faces
- looks like elfs
What is the signs of severe hypoxic ischemic encephalopathy and what is the management of a baby with HIE?
Severe:
- stupor
- coma
- hypotonia
- poor respiratory effort
- irregular heart rhythm
Management:
- Respiratory support
- Therapeutic cooling (full body or head cooling)
List some conditions seen in paediatrics which are AD and AR inheritance:
AD: Neurofibromatosis Tubal sclerosis Marfan's syndrome Achondroplasia
AR: Cystic fibrosis PKU Congenital adrenal hyperplasia Sickle cell disease
What ages are children with Henock scholien likely to be and what are the absolute investigations that must be done?
What are some of the important complications to be aware of?
Usually primary school age
Investigations that must be done:
- BP
- Urine analysis: PCR
Complications:
- nephritis
- intussupection
- orchitis
- severe arthritis
What is the key investigations and management of minimal change disease?
Bloods:
- FBC
- U&Es
- Bone profile
- Albumin levels
Orifices:
- PCR
Examination:
- BP
Management: 1st line: High dose Steroids - on a reducing regime Albumin infusions antibiotic prophylaxis pneumococcal vaccine
What are the complications of minimal change disease?
• Hypovolaemia
- They are actually depleted due to the fluid shifts that are occurring
• Bacterial infection - especially spontaneous bacterial peritonitis - This is especially true in those with ascites • Thrombosis - Loss of anti-thrombin III - Most common is cerebral venous sinus thrombosis - presents as a headache
Hypercholesteremia
When can you start antibiotics in children with suspected UTI?
As long as there is positive nitrites then ABx can be started.
if only leukocytes are present then hold off for cultures
How is antibiotics delivered in a < 3 month year old baby with a UTI?
IV for at least 48 hours
What is the most common type of anaemia in children?
Iron deficiency
- usually due to dietary insufficiency
- will tend to eat things like soil
**remember not to rule out other causes such as absorption defects.
treatment:
- dietary advice
- Iron supplementation
What are the definitions of faltering growth/ failure to thrive?
Inadequate weight gain in and infant or young child who:
- Drops >2 centiles of weight
or
- persistently below <5th centile
Specifics:
Fall of more than >1 centile if Birth weight was <9th centile
Fall of more than >2 centiles if Birth weight was between 9th - 91st centile
Fall of more than >3 centiles if Birth weight was >91st centile
Weight loss >10% in last 3-6 months
Is Hep C transmitted through breast milk?
No.
What are the causes of constipation in children:
Idiopathic:
- Lack of exercise
- Diet
Nerve pathology:
- Spinal cord injury
- spina bifida
- Hirschsprung
Blockages:
- Atresia
- Stenosis
- Meconium ileum
Psychological:
- stool holding
Medications:
Hormonal:
- Hypothyroidism
- Hyperparathyroidism
What are some red flags relating to constipation?
No passage of meconium in first 48 hours
Excessive thirst
Anal ulcers
Severe pain
Abdominal distension
What are some causes of speech delay in a child?
Hearing impairment
Learning difficulties
ASD
Cerebral palsy
Psychological deprivation
What are some non-pharmacological treatments for ADHD?
Tight boundaries
Single task instruction
*not “go get ready for school” but instead “brush your teeth” “get shoes on”
Physical activity
Sleep hygiene
What are some of the outcomes of adverse childhood experiences (ACEs)? What is the number of ACEs which increase the risk to these?
More likely to attempt suicide
More like to use drink and drugs
More like to engage in under-age sex
More likely to develop psychiatric illness (esp depression)
> 4 or more ACEs
What the differentials to epilepsy?
Vasovagal
Arrhythmia
Breath holding attacks
Reflex Anoxic Seizures
- massive vasovagal reflex in response to stress
Pseudoseizures
What is the vaccine given for epiglottis?
H. Influenzas Type B vaccine/
HiB vaccine
What are some red flags to a limping child?
Suspected NAI
> 2 weeks
Pallor/ petechia
Multiple joints
Hepatosplenomegaly
LLD
Abnormal neurology
Night sweats
What investigations are you going to do into a limping child?
Bloods:
- FBC
- CRP
- U&Es
- Blood cultures
X-ray:
- AP pelvis
- AP and frog leg (<8 years old)
Special tests:
- aspiration if needed *before antibiotics
- *aspiration is not done for septic arthritis
What is the criteria for septic arthritis in a child?
Kocher’s criteria:
- non- weight baring
- CRP >20/ ESR >40
- WCC >12
- Temperature >38.5
*tells you the likelihood of there being septic arthritis
What investigations do you want to do into Kawasaki disease and what is the management?
Blood:
- FBC
- CRP
- ESR
- Coagulation
Xrays:
- Echocardiogram *to check for coronary aneurysm
ECG
Diagnosis:
- Persistent fever + 4 of the features or fewer than 4 if aneurysms are present
Management:
- High dose aspirin
- IV immunoglobulins
- PPI
Discharge:
- low dose aspirin
Follow up:
- Echocardiogram (6-8 weeks later)
What is the management of Scarlet fever?
10 days of penicillin V
*it is also a notifiable disease
What is the diagnostic investigation and What is the general management for sickle cell disease?
Investigation:
- Hb Electrophoresis
Lifelong prophylactic Penicillin V
Vaccinations
Hydroxycarbamide
Blood transfusions
*in the young a haematopoietic stem cell transplant can be done.
What are the main differentials for ITP and what is the management?
Differentials:
- sepsis
- DIC
- HUS
- Leukaemia
Management:
- Intravenous immunoglobulins
- steroids
**note that unless severe bleeding a bone aspirate should be done prior to steroids as this can mask leukaemia
Severe cases:
- Platelet transfusion
- splenectomy
What are the main causes for iron deficiency in a child and what are some risk factors and what is the management?
Dietary intake
Malabsorption
Bleeding (Merkel’s diverticulum)
Risk factors:
- exclusively breast fed >6 months
- preterm
- low birth weight
Management:
- Dietary advice
- Iron supplements (needs 2-3 months prior to working)
What is the definition of global developmental delay and what are some routine tests which should be done into it? and what is the subsequent management?
Global development delay = >2 or more developmental delays in at least 2 domains
Routine investigations:
Bloods:
- FBC (anaemia)
- B12/ Folate
- U&Es (chronic kidney disease)
- LFTs (metabolic disease)
- Bone profile + vitamin D
- CK levels (Duchene)
- TFTs (hypothyroidism)
- hearing tests
special tests:
- karyotyping
- metabolic screen
- MRI of brain
- EEG
How should hypoglycaemia in a child be managed?
Oral route of dextrose tablets or fizzy drink if possible
Non-oral:
Neonate: 2.5ml/kg 10% dextrose
Child: 2ml/kg 10% dextrose
*both then placed on IV infusion of dextrose to prevent rebound hypoglycaemia
What are the numbers for hypoglycaemia in children and neonate and list some common risk factors:
neonate: <2.6mmol
Child: <3mmol
Diabetic child: <4mmol
Risk factors: Neonate: - preterm - low birth weight - hypothermia - sepsis - diabetic mothers - drug induced - labetalol
child:
- over use of insulin
- perfuse D&V
- Congenital adrenal hyperplasia
What are children with Henoch schonlein at risk of?
HTN
Intussusception
Nephritis
Orchitis
Severe joint pain
What skin finding may you see in congenital adrenal hyperplasia and what is the enzyme defect?
Pigmented skin
- due to the excessive ACTH release
21- hydroxylase
