Paediatrics Flashcards

Question

What is the treatment of Kawasaki disease

Answer 1

Intravenous immunoglobulin (2 g/kg over 10 hours; preferably within the first 10 days of the illness.)Aspirin 3 - 5 mg/kg once a day for at least 6 to 8 weeks

Answer 2

Follow-up echocardiogram in 6-8 weeks

Answer 3

Bedside testsECG - check for ischaemia / infarctionUrine dipstick - negativeLaboratory TestsFBE - neutrophilia, anaemia, thrombocytosisESR/CRP - markedly raisedLFTs - ALT raisedImagingEchocardiogram

Answer 4

Common- purpuric rash over legs and buttocks- migrating arthlagia and swelling- abdominal painLess common- HSP nephritis (HT, proteinuria, haematuria)- intussuception- malaena and haematemesis- scrotal swelling

Answer 5

Basics- analgaesia for joint pain (paracetamol not NSAIDs)- analgaesia for abdo pain (steroids have evidence)Place & Person- Referral to outpatient paeditrician for ongoing observationDefinitive management- Education & supportive carePrevention- continue to review for 6 months (including BP and urine dipstick)- steroids are NOT indicated for nephritis prophylaxis

Answer 6

'SHIELD'Sepsis (meningoccoal)HSP / HUS / HaemophiliaITPEvents (Trauma or non-accidental injury)LeukaemiaDIC (usually in the setting of severe illness)

Answer 7

An isolated thrombocytpoaenia (platelet count of

Answer 8

Basics- stop any active bleedingPlace and Person- refer to paediatric haematologyInvestigations and confirm diagnosis- FBE and blood film to confirm isolated thrombocytopaenia- BMAT if unsure / need to rule out leuakaemiaConservative Management- avoid contact sports / high-risk activities- monitor menstural bleeding if post-pubertal female- avoid NSAIDs and 5-ASA- ongoing follow up and FBEDefinitive Management'- steroids (low or high dose)- IVIg

Answer 9

Intra-cranial haemorrhageAlthough the risk if

Answer 10

GBS E. Coli Listeria Hep B HIV

Answer 11

**TORCHSHPV** Toxoplasmosis Other Rubella CMV HSV Syphillus (treponema pallidum) Hep B Parvovirus B19 Varicella zoster

Answer 12

Generally, the earlier in gestation the foetus congenitally acquires a TORCH infection, the higher the risk of severe congenital abnormalities and developmental delay. A conversation is therefore usually had with mothers (especially in the first trimester) about the option of termination. Some TORCH infections can be treated in the neonate, but for the majority of TORCH infections the treatment is supportive and includes only management of complications.

Answer 13

**All mums - *SARaH*** Syphillus (assays) Asymptomatic bacteruria (mid stream urine culture, treat empirially to avoid pyelonephritis) Rubella (anti-Rubella antibodies) HIV (Western blot and ELISA, give anti-retrovirals to mum, deliver by C-section) Hep B (HB-sAG, vaccinate and give IgG in delivery room) GBS (after 37 weeks) **High risk mums - *SARaH + 1G, 3T, 4C*** Gonorrheoa Trichomoniasis, Toxoplasmosis & Thyroid function Chlamydia, Hepatitis C, CMV and cervical abnormalities (pap smear)

Answer 14

If 1st trimester low risk of transmitting to foetus but high rate of severe complications If 3rd trimester high risk of transmitting the infection but low rate of severe complications **Diffiuse calcifications throughout the brain visible on USS** **Seizures** Plus the general effects of TORCHSHPV * Anaemia * Hepatosplenomegaly * Symmetrical IUGR (microcephaly) * Developmental delay * Sensorineural deafness * Visual problems

Answer 15

Outcome depends on gestation age at which it was transmitted. * congenital rubella syndrome (\>90%) * 12-18/40 --\> sensorineural deafness (20%) * \>18/40 --\> complications rare

Answer 16

**Periventricular calcifications** Symmetrical IUGR with microcephaly Developmental delay Hepatospleenomegaly Anemia Sensorineural hearing loss Visual problems

Answer 17

Rhinitis develops at 1 week and worsens. Initially clear then progressively purulent and blood stained. Neurosyphillis Bone problems Maculopapular rash

Answer 18

Severe anaemia --\> high output cardiac failure --\> hydrops foetalis

Answer 19

**EARLY Vertical transmission --\> GBS, E coli, Listeria Risk factors** * Maternal infection: UTI, GBS+ * Previous child with GBS sepsis * Prolonged rupture of membranes (\>18h) * Preterm labour **LATE \>5 days = ACQUIRED AFTER BIRTH** Staphylococcus, streptococcus (plus above pathogens) Risk factors * NICU stay (just like ICU stay causes infections) * Foreign bodies eg ETT, catheters * Malformations

Answer 20

**Every visit** * BP * Weight * Urine dipstick * Foetal auscultation (after 12weeks) * Foetal movements (after 18 weeks) * Fundal height measurement (after 20 weeks) **Because it's the first visit** * LNMP for dating (+ 1 year, - 3 months, + 7 days) * ABO, Rh, Rh antibody levels * FBE to screen for anaemia * EPNDS * Routine torch screening --\> SARaH * Syphilis * Asymptomatic bacteruria (MSU culture) * Rubella * HIV * Hep B * ****If high risk, additional TORCH screening --\> 1G, 3T, 4C * Gonorrheoa * Trichomoniasis, Toxoplasmosis & Thyroid function * Hep C, chlamydia, CMV, cervical abnormalities (pap smear)

Answer 21

* * at least 1 episode of faecal incontinence per week * history of retentive posturing * large and/or painful and/or hard bowel movements * large faecal mass in rectum

Answer 22

oesophagitis failure to thrive aspiration

Answer 23

Crying is normal physiological behaviour in young infants. At 6 - 8 weeks age, a baby cries on average 2 - 3 per 24 hours. Excessive crying is defined as crying \>3 hours/day for \>3 days/week. This is often referred to as "colic". However, many babies present with lesser amounts of crying, as the parents perceive it as excessive.

Answer 24

* Pronounced irritability with arching * Refusal to feed / failure to thrive * Feeding and behavioural problems * Weight loss or crossing percentiles * Haematemesis * Chronic cough/wheeze * apnoeas

Answer 25

**Non-invasive management** * Prone position after feeding (supervised) * Milk thickening agents (eg. rice cereal) reduce the number of episoes of vomiting but not the total time of oesophageal acidity * Don't encourage parents to change formulas * Never change a breastfed child to formula **Definitive management** PPIs relieve symptoms and assist mucosal healing Omeprazole Under 10kg: 5mg daily 10-20kg: 10mg daily Over 20kg: 20 mg daily **Surgical** Failure of medical therapy or recurrent respiratory symptoms (aspiration) may necessitate Nissen fundoplication:

Answer 26

**Most common - benign** 1. Tiredness 2. Hunger - this is more likely if a mother reports: 1. inadequate milk supply 2. poor weight gain 3. baby has frequent feeds (ie, **Also consider** 1. GORD 2. Cows milk intolerance 1. Check if vomiting, blood/mucus in diarrhoea, poor weight gain, family history in first degree relative, signs of atopy (eczema / wheezing), significant feeding problems 3. Lactose intolerance (rare) **If Acute onset consider:** * UTI * Otitis media * Raised intracranial pressure * Hair tourniquet of fingers / toes * Corneal foreign body / abrasion * Incarcerated inguinal hernia

Answer 27

colicky abdominal pain, currant jelly stool, palpable abdominal mass

Answer 28

Prematurity and low birth weight Feeding (especially enteral/cow’s milk/early formula) Infection/ sepsis Bowel ischemia Hypotension and congenital heart disease Hypoxia/respiratory distress/ birth asphyxia

Answer 29

The incidence of NEC is inversely proportional to birth weight. In general, the age of onset is inversely proportional to gestation; therefore smaller babies present later. 90% of babies with NEC are preterm.

Answer 30

**Basics** NBM (gut rest) NGT (drainage) Insert IV line for fluids and to take sample for FBE & blood cultures **Place and Person** Refer to paeds gastroenterology / surgery **Investigate and confirm diagnosis** AXR is gold standard Rationalise ABx once cultures back **Definitive management** Empirical antibiotic therapy: Metronidazole Ampicillin Gentamycin Only in stage 3B disease: Surgery to resect affected section with stoma diversion and abscess drainage if needed

Answer 31

Projectile, non-bilious vomiting First born, Caucasian male with a positive family history Hypochloraemic, hypokalaemic metabolic alkalosis (also get hyponatraemia too, but not included in the buzz word)

Answer 32

Usually between 2-6 weeks of life

Answer 33

A sudden onset of vomiting between 2 and 6 weeks of life. Before the onset of vomiting, these infants feed well and are thriving. The infant then loses weight (or inadequately gains weight) and becomes dehydrated Projectile, non bilious vomiting. May contain altered blood. "Hungry vomiters" – vomit immediately after feeding, and then are hungry again May be constipated (not absolute) **Examination** Palpable, mobile pyloric tumour in the midline of the epigastrium between the rectus abdominal muscles OR the right rectus and the liver edge ("olive")

Answer 34

Behaviour/demeanour HR/BP Cap refill (check centrally) Sinking of the anterior fontanelle and eyes Tear production/Urine output Skin turgour Mucus membranes Weight loss

Answer 35

**Usually a clinical diagnosis** ## Footnote **Bedside** ABG --\> hypochloremic, hyponatremic, hypokalaemic, metabolic alkalosis BGL **Bloods and urine** FBE UEC --\> hydration Coags **Imaging** Ultrasound If very unsure you can do a barium meal (not usually needed)

Answer 36

It is particularly important to fully correct serum bicarbonate before theatre because of the risk of hypoventilation/ apnoeas post-operatively in the setting of metabolic alkalosis.

Answer 37

**Medical (not surgical) emergency** ## Footnote **Basics** IV access and fluid resusc if required and as directed by UEC/ABG results NBM NG tube if continuing to vomit **Place and person** Paediatric gastroenterology, admit **Definitive** Pyloromyotomy (Ramstedt operation).

Answer 38

10-20ml/kg of normal (0.9%) saline, which may be repeated

Answer 39

Malrotation + volvulus until proven otherwise!

Answer 40

**History** Presents day 1-3 of life (60–80% of all cases of malrotation present in the first month of life, mostly in the first week.) Bilious vomiting (malrotation until proven otherwise!) No dirty nappies once there is volvulus Rectal bleeding (a late symptom/sign) Abdominal pain **Examination** Abdominal distension (late sign) Peritonism (late sign)

Answer 41

AXR - non-specific, gas in bowel, can get "double bubble sign" **Barium swallow - corkscrew sign** USS - whirlpool sign

Answer 42

**Basics** NBM NGT – check aspirates for bile Insert IV and commence fluids **Place and person** Admit and refer to paediatric surgeon **Ix** ABG Septic screen Blood group and hold **Definitive management** Urgent surgical correction with follow up Ladd procedure: untwist counter-clockwise, divide Ladd’s band, widen mesentery attachment, appendicectomy, and replace the bowel in the right location. Where there is necrotic bowel second laparotomy performed in 24-48hrs later to see if viable gut can be saved – resection

Answer 43

**Gastro** FAMINE HIP GAIT **Neurological** Increased ICP **Infectious** Gastroenteritis Meningitis Pertussis (post tussive cough) **Endocrinological** DKA Errors of Inborn Metabolism **Psychogenic / Behavioural** Overfeeding in infants Bulaemia in adolescents Pregnancy in adolescents

Answer 44

FAMINEHIPGAIT

Answer 45

Oxygen therapy if hypoxic Assisted ventilation if increased work of breathing NG feeding if poor feeding NG or IV fluids if dehydrated

Answer 46

**Basics** DRSABCD NBM **Place and person** Transport to surgical unit via NETS **Ix** ECG, ABG, BGL FBE, UEC, LFTs, LDH, Coags, Group and hold AXR, CT, USS **Definitive** * *Drip and suck-* * NBM and NG tube suction - relieves any respiratory distress from abdominal distension (may also be caused by vomit aspiration) * Rapid IVF resuscitation with boluses of 10mL/kg given at 15 minute intervals if shocked otherwise give maintenance and mL by mL match for NGT losses. * Glucose- monitor BSLs and glucose solution should be given with IVF (glucose stores low, no absorption --\> anaerobic metabolism) * Correct acidosis * correction of fluid loss, hypothermia and glucose will correct acidosis * Correct Hypothermia * monitor temperature and have overhead heater * Sepsis * if at risk administer IV Abx after cultures taken * Surgical correction if required- according to cause

Answer 47

* Prematurity issues * Asphyxia * Meconium aspiration syndrome * Hypoglycaemia, hypocalcaemia * Hypothermia * Polycythaemia * Impaired immune function * BM suppression * NEC * Mechanism = hypoxic gut as foetus shunts blood to brain * Neurodevelopmental * Cerebral palsy * Learning and behavioural issues * Foetal origins of adult dz * DM, HT, obesity, CAD, hypercholesterolaemia

Answer 48

Plus also ask about sleep

Answer 49

**SCOFF** Do you make yourself **Sick** because you feel uncomfortably full? Do you worry you have lost **Control** over how much you eat? Have you recently lost more than **One** stone (6.35kg) in a three month period? Do you believe yourself to be **Fat** when others say you are thin? Would you say **Food** dominates your life? **Plus to screen for bulimia nervosa:** Are you satisfied with your eating pattern? Do you ever eat in secret?

Answer 50

The 5 Hs 1. Height (growth retardation) 2. Heart (arrythmia, QT, bradycardia, hypotension) 3. Happy Bones (irreversible osteoporosis) 4. Hormones (osteporosis, hypothyroid, delayed puberty/amenorrheoa) 5. Heads (poor concentration, slowed mentation)

Answer 51

History provided not consistent with injury Delay in presentation Claims that injury caused by young sibling Denial that it is an injury Multiple injuries of different types and ages Injuries not consistent with developmental age Child brought in by person other than parent **Shaken baby syndrome --\> subdural haematoma + retinal haemorrhage**

Answer 52

Macrosomia \>4500g Low Birthweight (LBW) Very Low Birth Weight (VLBW) Extremely LBW (ELBW)

Answer 53

Infancy - 25cm/yr Childhood - 10cm/yr Puberty - 5cm/yr

Answer 54

Unless it is catastrophic epilepsy, early treatment does not change long term outcome Be hesitant to make a diagnosis because it will change a child's life forever Epilepsy will declare itself by progression or resolution.

Answer 55

**Time course** Red is raised ICP Green is migraine Blue is muscular **Severity** Best to ask what they did during the headache to determine severity (confined to dark room = severe)

Answer 56

**Relief by sleep** **Dizziness/pallor** Abdo pain Nausea and vomiting Prodrome Characteristic location of pain

Answer 57

**Rhinovirus** Adenovirus Influenza and parainfluenza RSV Enterovirus EBV Streptococci

Answer 58

* ear, nose, or throat infection * acute respiratory infection * gastroenteritis * urinary tract infection * meningitis * osteomyelitis / septic arthritis

Answer 59

Bacterial infection

Answer 60

Urine dipstick not useful in babies under 1 because they pee as soon as urine created which means not enough time for bacteria/WCC to accumulate Can cause false negative!

Answer 61

MR SARS EEK! * Measles * Rubella * Systemic JCA (Still’s disease) * Allergy * Roseola infantum (HHV6) * Scarlet fever * Erythema infectiosum (Parvovirus B19) * Erythema multiforme * Kawasaki disease

Answer 62

Mild, diffuse dilatation of coronary arteries usually begins on day 10 from fever onset. If left untreated, 25% of these patients progress to true aneurysms, with 1% becoming ‘giant aneurysms’ (\>8 mm internal diameter). These giant aneurysms have the worst prognosis, with risk of acute thrombosis and long-term risk of myocardial ischaemia

Answer 63

Rash from strep throat. Tx with phenoxymethylpenicillin (PO) or benzathine penicillin (IM) to prevent post strep GN or acute rheumatic fever

Answer 64

Hand, foot and mouth Chickenpox Herpes simplex (Remember: vesicular just means blistering)

Answer 65

Fever Stiff neck\*/Kernig's sign Bulging fontanelle Irritable Drowsiness Poor feeding/vomiting **Palpable non-blanching purpuric rash =\> meningococcal meningitis** Convulsions/coma/shock --\> consider meningitis **Stiff neck is not relevant in infants**

Answer 66

Transplacental transfer of IgG happens in the third trimester. Very premature babies can miss out on this process rendering them very vulnerable to infection NB: The process is actually active and means that the baby ends up with a higher concentration of IgG than their mum!

Answer 67

**\> 38.0 degrees** **INVESTIGATE IT!** FBE blood culture CRP Urine dipstick/Urine MCS CXR only if respiratory signs are present stool culture, if diarrhoea is present

Answer 68

Viral lower respiratory tract infection Up to 18 months

Answer 69

**_RSV_** Human metapneumovirus Adenovirus --\> bad because causes bronchiolitic obliterans! Parainfluenza Influenza

Answer 70

Exposure to cigarette smoke Maternal smoking during pregnancy Prematurity Chronic cardiorespiratory diseases (including congenital heart disease and cystic fibrosis) Immunodeficiency

Answer 71

None, clinical diagnosis However, nasopharyngeal aspirate is usually done because we like to know which viruses are doing the rounds in the community and to rule out pertussis (which is life threatening to infants)

Answer 72

**Basics** * Oxygen therapy if hypoxic * Assisted ventilation if increased work of breathing * NG feeding if poor feeding * NG or IV fluids if dehydrated **Person and Place** Admit to paeds ward if patient requires any of the above, or if concerned **Investigations and Diagnosis** Clinical diagnosis, NPA if required to isolate virus or exclude pertussis **Definitive Management** Supportive management only. Usually resolves within a week. **Long-Term Management** RSV is a highly infectious virus, ensure good hand hygiene to prevent spread. Ensure immunizations are up to date

Answer 73

Bronchiolitis Asthma Inhaled foreign body Pneumonia Pertussis Bronchiomalacia/tracheomalacia Cardiac failure CF or other suppurative lung dz Recurrent aspiration

Answer 74

6 months to 12 years of age, with a peak incidence at age 2

Answer 75

If you're thinking about hypoxia the croup is life threatening. Adequate SPO2 should not be reassuring – low oxygen saturations is a BAD sign.

Answer 76

Parainfluenza Influenza Adenovirus

Answer 77

* Begins with coryzal symptoms for 1-2 days * Fever is generally low grade (38-39) – no signs of toxicity * Barking cough – usually begins at night or early hours of morning. Peaks at day 2 and 3 of disease * It takes two or three days before the sub-glottic area narrows enough to cause the barking cough * It happens first at night, usually, because we have reduced upper airway tone when we sleep * Inspiratory stridor is heard as the disease progresses * The viral illness typically lasts 7-10 days, but the **typical croupy cough only lasts 2-3 nights** * May have associated widespread wheeze, increased work of breathing and hypoxia – child may become distressed and restless, cyanosis is a late and ominous sign * Recurrent spasmodic croup * ‘Upper airway hyperresponsiveness’ * No viral prodrome * Children are well when they go to bed, and wake up in the early hours of the morning with a barking cough and stridor * Fever is unusual in this form of croup * Children often have asthma or atopy, or a FHx of asthma and atopy

Answer 78

None, dont distress the kid!

Answer 79

**Basics** Minimal handling Oxygen is not usually required unless severe obstruction IV access should be deferred **Place and person** Grade 1 – manage at home Grade 2 – admit to hospital via ED Grade 3 – admit to ICU If having to administer oxygen, contact anesthetics! If having to administer a second dose of adrenaline, contact anaethetics! **Investigate and confirm diagnosis** Clinical diagnosis **Non-invasive management** Keep child relaxed **Definitive management** *Mild to moderate* Oral prednisolone 1mg/kg OR Oral dexamethasone 0.15mg/kg – 0.6mg/kg *Severe* * Oxygen * Nebulised adrenaline 1:1000 solution * Works by vasoconstriction * Beware of possible rebound effect after 2-3 hours – must observe * This is more symptomatic treatment to buy you time * Dexamethasone IV 0.2mg/kg * Follow with oral steroids * ETT if going into respiratory failure **Long term** Consider transfer when no improvement following nebulized adrenaline **Discharge requirements** Four hours post nebulized adrenaline Half hour post oral steroid Stridor free at rest **Recurrent-Spasmodic Croup** Usually don’t require treatment as attacks are very short-lasting. But can treat the same as acute viral croup. Some evidence to suggest that ICS may reduce frequency of attacks, but children will most likely grow out of this.

Answer 80

Most common age group in community is adolescents and young adults, but not dangerous for this group except for being vector Under 12 months deadly Under 6 months VERY deadly

Answer 81

Transmission: Direct contact with droplet discharges Highly contagious – spreads to 80-90% of susceptible individuals coming in contact with disease

Answer 82

**Catarrhal stage (7-14 days)** * Anorexia * Rhinnorrhoea * Conjunctivitis/lacrimation * Dry cough **Paroxysmal stage (about 4 weeks)** * Paroxysms of severe coughing with inspiratory ‘whoop’ * Vomiting (after coughing) * Coughing mainly at night * Lymphocytosis **Convalescent stage** * Chronic cough which may last for weeks

Answer 83

FBE --\> lymphocytosis CXR to exclude pneumonia Culture and/or PCR of nasopharygeal aspirate (within 1 week from onset of cough). Both of these tests have 70% sensitivity

Answer 84

**Basics** ABC **Place and person** If younger than 6 months – hospitalization School exclusion until at least 5 days of antibiotic use **Investigate and confirm diagnosis** Nasopharygeal aspirate FBE, IgA serology CXR – to exclude pneumonia **Non-invasive management** Good ventilation Avoid emotional excitement or distress Avoid overfeeding during paroxysmal stage **Definitive management** * Antibiotics minimize transmission but do not effect course of disease * Azithromycin 500 mg 5 days OR * Clarithromycin 7 days **Prophylaxis** Same treatment as above for household and other close contacts if commenced within 3 weeks of onset of cough in the patient **Prevention** * Acellular pertussis is part of the immunization schedule * Initial protection * 2, 4 and 6months * Booster (dTpa) * 4 years * 10-15 years * Parents or household contacts of newborns

Answer 85

Pneumonia Atelectasis Pneumothorax Seizure Asphyxia Apnoea/bradycardia Rib fracture Encephalopathy Otitis media

Answer 86

SABA PRN only, NO ROLE FOR PREVENTER IT IS NOT EFFICACIOUS

Answer 87

**Step 1: RELIEVER** SABA **Step 2: PREVENTOR** Low dose ICS (200 – 400mcg / day) OR LTRA OR inhaled cromone **Step 3: ADD OR INCREASE STEROID** Increase ICS (Double: 400 – 800mcg / day) LTRA / inhaled cromone + low dose ICS **Step 4: ALL PREVENTORS AND HIGHEST ICS DOSE** LTRA / cromone + ICS (800mcg) **Step 5: ADD SYMPTOM CONTROLLER / ORAL STEROIDS** LABA (not in children

Answer 88

Rrecurrent wheezing episodes which are responsive to salbutamol.

Answer 89

Boys generally have smaller airways than girls and tend to suffer more from asthma. However, after adolescence the prevalence is higher in females.

Answer 90

Very safe, almost not clinically significant long term side effects Hoarseness and pharyngeal candidiasis are not common particular dry-powder formulas with pH Treatment beginning before puberty is associated with a small (mean approximately 1 cm) reduction in adult height

Answer 91

autosomal recessive

Answer 92

**MR PANCREAS** ## Footnote M - Meconium ileus (at birth) and distal intestinal obstruction (children and adults) R - Recurrent infections P - Pancreatic failure (exocrine and endocrine) A - Allergic bronchopulmonary aspergillosis N - nasal polyps and recurrent sinusitis C - Cirrhosis of hepatobiliary system E - Emotions (teenagers often depressed) and electrolyte disturbances (low Na+) A - Airway leaks (pneumothorax) S - Sterility in males

Answer 93

**Basics** NA **Place and person** Referral to * Respiratory physician * Chest physiotherapy * Dietitian **Investigate and confirm diagnosis** Sweat test and genotyping **Non-invasive management** * Chest physiotherapy * Monitoring and optimizing nutrition * High intake of dietary fat * Pancreatic enzyme supplements * Fat soluble Vitamin supplements **Definitive management** * For respiratory infections * S. aureus infection * Di/flucloxacillin * S. aureus and Haemophilus influenzae infection * Augmentum or trimethoprim and sulfamethoxazole * Initial pseudomonal infection * Ciprofloxacin PLUS * Tobramycin by nebulizer OR * Colistimethate sodium by nebulizer * Chronic pseudomonal exacerbation * Ciprofloxacin PLUS * Tobramycin by nebulizer OR * Colistimethate sodium by nebulizer OR * Gentamicin by nebulizer **Long term** * Respiratory * Daily chest physiotherapy * Aerosolised mucolytics * Dornase alfa * Nebulised hypertonic saline * Inhaled bronchodilators * Inhaled corticosteroids **Chronic pseudomonal infection** Azithromycin orally 3 times weekly **GORD** PPI

Answer 94

Exomphalos is a type of abdominal wall defect. It occurs when a child’s abdomen does not develop fully while in the womb. Tx = surgical correction in first 2 days of life

Answer 95

Hydrocele. It will self resolve within a few weeks. But you must make sure to rule out testicular torsion.

Answer 96

Gastroschisis Urgent surgical repair

Answer 97

Phimosis (the foreskin cannot be fully retracted over the glans penis), normal up until puberty

Answer 98

Paraphimosis (the foreskin becomes trapped behind the glans penis, and cannot be reduced)

Answer 99

**1,2,3,4,5 T’s** 1 vessels (Truncus arteriosus) 2 vessels swap (Transposition of the Great Arteries) 3 = Tricuspid atresia 4 = Tetralogy of Fallot 5 words (Total Anomalous Pulmonary Venous Return)

Answer 100

Septal defects cause L --\> R shunts ACEi, diuretics to reduce preload and strain on right heart plus feeding to increase baby's weight ready for surgical correction

Answer 101

Identified if infant experiences heart failure, or later in life because doctor hears machinery murmur or notices wide pulse pressure (caused by the run-off of blood flow from the aorta to the pulmonary artery during diastole). **What is the problem?** Blood flows from the high pressure aorta into the low pressure pulmonary artery, overloading pulmonary circulation and causing pulmonary hypertension and heart failure (dyspeneoa, FTT, recurrent infections). If not picked up until adulthood pulmonary hypertension can be a significant issue. Children with a small PDA are often asymptomatic, but may develop Infective Endocarditis.

Answer 102

**Bedside tests** ECG – normal with small PDAs. Left ventricular hypertrophy with larger PDAs **Bloods and urine** Nil **Imaging** CXR – full pulmonary artery silhouette and increased pulmonary vascularity. Cardiomegaly may be present in a larger shunt. Echocardiography – visualise the PDA to confirm diagnosis **Special tests** Nil

Answer 103

**Premature infants** * IV indomethacin in patients with very low birth weight * IV indomethacin or ibuprofen of premature infants of larger weight * Treatment can be given before evidence of a PDA becomes evident * Prophylactic indomethacin might increase ductal closure and decrease the incidence of intraventicular haemorrhage **Term infants** * In asymptomatic or symptomatic patients, percutaneous catheter closure is the first-line treatment in order to treat heart failure and prevent elevated pulmonary pressures or endarteritis. * Infants who are symptomatic and too small to undergo percutaneous device closure need ACEi/diuretic treatment and feeding until they are large enough for surgical management

Answer 104

**When does it present?** If severe: acute circulatory collapse at 2 days of life after being previously well (duct closure). This is the usual scenario. If mild: Later in life, often discovered when pt is being investigated for refractory hypertension. The later the abnormality is discovered the harder the HTN is to treat. **How does it present?** Sick baby Hypertension Unequal BP between arms Absent femoral pulses Severe metabolic acidosis May have an ejection systolic murmur between the shoulder blades **MGMT?** ABC, prostaglandins, urgent surgery

Answer 105

The Norwood operation, which connects the aorta and the returning pulmonary veins to the R heart – a one chamber heart! Usually receives follow up operations at 3 months and 6 years

Answer 106

In the immediate newborn period blood flows through the 'Ductus' into the Descending Aorta and hence reaches the lower part of the circulation. Fortunately these babies usually have a VSD, meaning that the blood that flows through the pulmonary artery, though the ductus and into the descending aorta is at least partly oxygenated. As the ductus closes after birth blood pressure in the lower circulation becomes inadequate and severe symptoms develop. Most affected infants develop severe symptoms (difficulty breathing and impaired kidney function) in the first week of life and need urgent surgery **Mx = ABC, prostaglandins, surgery in days**

Answer 107

Presents early in life (usually D2 when duct closes) as the "shocked neonate" – dusky colour, weak or absent pulses, low BP, reduced UO, metabolic acidosis

Answer 108

duct dependent In the first week of life When the ductus closes

Answer 109

Small VSD – high pitched pan-systolic murmur, associated with a thrill Large VSD – Quiet pansystolic murmur, heave

Answer 110

VSD in both

Answer 111

Small --\> conservative management and monitoring Large --\> surgical repair

Answer 112

Secundem (most common) Primium (AVSD)

Answer 113

Most affected children are free of any major symptoms, but the risk of heart failure developing later in life makes closure desirable, unless the defect is very small. These defects may be repaired surgically or by using an expanding plug ("Device"), which can be inserted through a heart catheter without an operation (Device Closure)

Answer 114

OH CRAP THAT BABY IS BLUE! DONT SWEAR IN FRONT OF THE BABY! OH, I SAID, **CRIP** * *C**yanotic Heart Disease (1,2,3,4,5 Ts) * *R**espiratory disease (Meconium aspiration syndrome, pulmonary hypoplasia) * *I**nfection (GBS) * *P**ersistent pulmonary HTN of the newborn (PPHN)

Answer 115

Pulmonary stenosis Right ventricular hypertrophy Overriding aorta VSD Pentology --\> ASD

Answer 116

Murmur, cyanosis or congestive heart failure, typically develops over the first 6-12 weeks of life If mild disease not picked up until later childhood. Presentation at this stage is characterised by FFT, clubbing of the fingers, reduced exercise tolerance and ‘Tet spells’

Answer 117

Comfort the child Rest younger infants against the parents shoulders with knees tucked in Encourage older children to squat O2, IV fluids Beta-blockade and ICU support may be required IM morphine can reduce pain and venous return Phenylephrine is last line\* \*Used to increase systemic venous resistance by direct simulation of peripheral alpha-adrenergic receptors. The goal is to increase the systemic vascular resistance above the resistance of the pulmonary outflow tract so that blood in the right ventricle preferentially flows through the pulmonary circulation, rather than across the ventricular septal defect and into the systemic circulation.

Answer 118

Heart failure is rare. But cyanosis --\> polycythemia --\> thromboembolism can occur. Infective endocarditis and cerebral abscess too!

Answer 119

**CATCH** **22q11 (Di George Syndrome)** Tetralogy of Fallot is famously associated with the deletion of the long arm chromosome 22 Cardiac anomalies (tetra, transpos) Abnormal facies Thymic hypolasia (T cell deficiency) Cleft palate Hypocalcaemia/hypoparathyroidism

Answer 120

Prostaglandins Atrial baloon septostomy Arterial switch is definitive surgical correction at 6-9 months

Answer 121

Right ventricular hypertrophy Coarse ES murmur on ULSE

Answer 122

* This defect is a form of Tetralogy of Fallot * Blood cannot enter the pulmonary circulation via the pulmonary valve. * Blood entering the right ventricle moves into the left ventricle via an ASD/VSD or foramen ovale, is pumped via the left ventricle and then shunts back to the pulmonary circulation via the PDA. * Survival depends on the ductus remaining open in the early days of life * Cyanotic heart disease * Surgical correction with a shunt is required immediately, with complete repair performed after age 1.

Answer 123

A single ventricular outflow tract straddles a large VSD. It has an **abnormal** valve. Presents in newborn period with **mild** cyanosis and congestive heart failure. The abnormal valve is often stenosed (systolic murmur) and may be regurgitant (diastolic murmur). Urgent surgery

Answer 124

ASD If symptomatic or causing R ventricular dilation, catheter closure at 3-5 years Partial AVSD needs surgery at 3 years Complete AVSD: 3-5 months

Answer 125

Small VSD Usually no treatment required, spontaneous closure

Answer 126

**Large VSD** Diuretics, captopril Extra calories Surgery at 3-6 months

Answer 127

Contact senior help Arrange urgent echocardiography (and potentially an ECG and CXR in the meantime) Give O2 Use frusemide or spironolactone to relieve vascular congestion Use captopril to reduce after load High nutrient feeds may be required Consider inotropes for low-output failure **If neonate consider prostaglandins**

Answer 128

* Normally, the pulmonary valve closes a little after the aortic (A2, P2). * During inspiration, venous return in increased at the R ventricle takes a little longer to empty. * Blood pools in the lower pressures of the pulmonary circuit, reducing return to the left heart, which now finishes emptying a little sooner. * Therefore, the split normally widens on inspiration * During expiration, the right heart is given the chance to catch up a little and the split is narrowed

Answer 129

* Stabilise with diuretics, ACEIs and high caloric diet * Treat if: * Heart failure or failure to thrive on medical management * Pulmonary hypertension * Aortic valve prolapse * Infective endocarditis * Surgical and trans-catheter options exist

Answer 130

* Small VSD may have no abnormal findings * Larger VSDs may demonstrate cardiomegaly and pulmonary plethora of CXR * Biventricular hypertrophy can be shown on ECG * Diagnose with echo

Answer 131

High flow VSDs can suck in the nearby aortic leaflet by the Venturi effect and cause aortic regurgitation

Answer 132

Essentially all congenital heart abnormalities increase your risk, except for secundum ASDs

Answer 133

ALL until proven otherwise

Answer 134

Intracranial haemorrhage - 1% of ITP cases

Answer 135

* Pallor – conjunctival, palmar crease * Fatigue, listlessness * Poor growth * Flow murmur * Air hunger (severe) * Hypotension and cardiac failure (severe) * Iron deficiency can present with poor attention span, irritability and pica (eating dirt, clay, ice etc)

Answer 136

Malabsorption and occult blood loss (although rare) should be considered, but usually after failure of dietary measures. Polyps, haemangiomas, Meckel’s diverticula and hereditary telangectiasia are rare causes of GI blood loss.

Answer 137

One of the most common and serious complications of parvovirus B19 infection is transient aplastic crises in patients with chronic haemolytic anaemia such as sickle cell disease and hereditary spherocytosis. Pure red cell aplasia may also develop with a persistent infection of parvovirus B19 in immunocompromised individuals.

Answer 138

FBE Blood film Ferritin Reticulocyte count

Answer 139

A raised APTT in the absence of anticoagulant therapy suggests a deficiency in a factor or an inhibitor. An inhibitor is usually an antibody made against a factor, such as lupus anticoagulant or antibodies formed by haemophilia patients receiving recombinant factors

Answer 140

**Presentation** Clinical manifestations of platelet disorder develop **acutely** – mucosal and skin petechiae, epistaxis, rectal bleeding, haematuria, bleeding gums **Examination** Normal examination – no pallor, no lymphadenopathy or hepato-/spleno- megaly (exclude leukaemia) **Investigations** FBE --\> thrombocytopaenia, blood film shows isolated low platelets with no other findings A bone marrow aspirate is an invasive procedure with some morbidity in children who bruise easily, and is only necessary if the diagnosis is uncertain. It is rarely necessary in uncomplicated ITP. ***ITP is a diagnosis of exclusion, but an FBE and blood film may be sufficient for diagnosis if Hx and Ex consistent. It can be thought of as isolated thrombocytopenia with no other suggestive findings on Hx, Ex, FBE or blood film.***

Answer 141

Acute is ITP less than 12 months This is the common type of childhood (2-5 y/o) Chronic ITP lasts \>12 months Occurs in children \>7 y/o and adults Women affected more often Recurrent ITP exists but is rare.

Answer 142

Platelets consistently under 10

Answer 143

Untreated 75% in 6 weeks, 90% will resovle within 6 months With standard dose steroids 1 week With high dose steroids 2-4 days With IVIG 1-3 days

Answer 144

* **Safety precautions are key** * Allow for generous supervision, especially of young children * Avoid contact sports or any moderate-impact activity * Regular follow up * Parents must receive thorough education * Avoid NSAIDs and 5-ASA Splenectomy is a last line option. Often very effective but vaccinations and life-long antibiotic prophylaxis required.

Answer 145

**Neonates** * Often picked up on screening due to FMHx * Cord blood can be used for genetics and coagulation studies * Intracranial haemorrhage, severe birth bruising and excessive bleeding after circumcision can suggest the disese **Older children** * Haemarthroses tend to occur in walking children

Answer 146

* Mild-moderate haemophilia A can be treated with DDAVP after appropriate challenge test (\>5y/o) * Not adequate for major bleeding * Tranexamic acid can reduce mucosal bleeds and epistaxis * Severe disease can be treated with 25-40 units/kg of recombinant factor concentrates three times a week.

Answer 147

AML (less common than ALL)

Answer 148

* **CXR** is used to investigate the possibility of mediastinal masses (occurs in 50% of T-ALL). * **Lumbar punctures** are mandatory to detect occult CNS infiltration. They are often delayed until treatment has begun to reduce the risk of seeding into CNS. Also because often thrombocytopenic Many more tests are done. This is the realm of a paediatric oncologist. Tumour lysis bloods, liver and renal function, lactate dehydrogenase and coagulation studies all form part of the initial work-up at baseline.

Answer 149

It is commonly quoted that cure rates (in children) are 80%. The current rate is probably higher, especially in low risk disease. **Remission Induction** * Aims to eliminate 99% of the tumour cell population. This should achieve normal haematopoiesis and functional status. * Does the ‘heavy lifting’ --\> remaining treatment is about total eradication, relapse prevention and cure * High risk of tumour lysis in early chemo. * the breakdown products of dying cells causes hyperkalaemia, hyperphosphataemia (which causes hypocalcaemia), high blood uric acid and high urine uric acid and consequent acute uric acid nephropathy and acute kidney failure. * Tumour lysis prevention: * bicarb to alkylise urine and prevent uric acid crystal formation in kidney * allopurinol * fluid diuresis * monitor all electrolytes **CNS protection** * Most chemo penetrates the BBB poorly * Intrathecal and IV methotrexate can obviate the need for cranial irradiation (CI). CI is still used for overt CNS disease or high risk patients.

Answer 150

Strangulation/NAI Vomiting Coughing + other causes of petechiae (SHIELD)

Answer 151

Immature megakaryocytes in BM churning out platelets. The platelets are young/healthy/sticky. Vs kids with cancer with same low platelet count who will bleed because unhealthy platelets.

Answer 152

· **Oral** – paracetemol, ibuprofen, oxycodone · **Intranasal** – fentanyl (device that makes a mist out of it) · **IV** – morphine, ketamine · **IM** – (rare) ketamine, morphine · Local anaesthetic

Answer 153

* Wet nappies * Tears * Fontanelles * Skin turgor * Mucus membranes * Cap refill * HR/BP * Weight * Vomits/diarrheoa * Alertness

Answer 154

Tracheo-oesophageal fistula

Answer 155

pyloric stenosis (if age 2-7wks) duodenal atresia

Answer 156

A 'Slipped Upper Femoral Epiphysis' (also called a 'SUFE') is when the femoral epiphyseal plate is weak and the ball head of the femur slips downward and backward. The exact cause of this condition is not known. A 'SUFE' is not usually associated with an injury. The symptoms often develop slowly - over several months - and may seem like a pulled muscle in the hip, thigh or knee. It is important to get an early diagnosis and treatment before the slip gets worse and children may need to have the unaffected side treated as well to prevent future slipping. Clasically happens to obese teenage boys, can be bilateral True hip pathology causes GROIN pain! **Signs and symptoms** Groin, hip, thigh or knee pain. (Some people only have knee pain, even though the condition affects the hip) Limp Limited movement of the hip joint There may be slight shortening of the affected leg. **Diagnosis** Diagnosis is usually made by physical examination of hip movement and an x-ray. Attached X ray shows how in the abnormal side the line does not cut off the femoral head like it should **Management** Surgical correction with screw

Answer 157

Refusal to weight bear in a child is a red flag! Septic arthritis Osteomyelitis Malignancy

Answer 158

Refusal to weight bear Fever (\>38.5) Raised WBC ESR \>40 CRP \>20

Answer 159

6 weeks, it gets better after that

Answer 160

Bring them back if: 1. They become dehydrated (because of vomiting/diarrheoa) with poor oral intake and no wet nappies 2. Become drowsy or not responsive to interactions 3. Puffing very hard or finding it difficult to breathe 4. Uncontrollably irritable, not able to be soothed

Answer 161

Nothing, vomiting is not a localising sign in a kid. Could be anything from UTI to meningitis.

Answer 162

Meningitis Pneumonia UTI Sepsis

Answer 163

**Febrile convulsions / seizures are seizures in which** * Fever \>38 degrees * No evidence of CNS infection * No history of afebrile seizures * No history of neurological deficits or developmental delay **Simple febrile seizures are** * generalized tonic and/or clonic seizures * Short in duration * Do not recur within the same febrile illness **Complex febrile seizures are** * focal features at onset or during the seizure * duration of more than 15 minutes * Recurrence within the same febrile illness * Incomplete recovery within 1 hour.

Answer 164

6 months to 6 years

Answer 165

3 in 100 babies

Answer 166

* Signs and symptoms of infection (often URTI, otitis media or UTI). * Description of a generalized, tonic-clonic seizure (simple) or a focal seizure (complex). Normal neurological exam post-ictally. * \*NB if eyes deviate to one side this is a sign of a focal seizure

Answer 167

**Bedside tests** * BGL – this is the only investigation you should do if the child is \>6 months and the source of the fever can be identified * Urine dipstick and MC&S **Bloods and urine** * FBE * CRP * Blood culture * UEC / CMP * check for electrolyte derangement. * Feeding babies water bottles causes hyponatraemic seizures **Imaging** CXR if respiratory symptoms **Special tests** LP – low threshold if unknown source of fever. From RCH "consider LP if the child is less than 12 months and not up to date with immunisations, if they are clinically unwell, or if they are already on oral antibiotics that may mask meningitis."

Answer 168

* Recurrence rate depends on the age of the child; * the younger the child at the time of the initial convulsion, the greater the risk a further febrile convulsion * (1 year old 50%; 2 years old 30%). * Risk of future afebrile convulsions (epilepsy) is increased by: * family history of epilepsy, * any neurodevelopmental problem, * atypical febrile convulsions (prolonged or focal). * With none of these risk factors risk of recurrence is similar to the rest of the population (1%). With 1 risk factor, risk is 2%, with \>1 risk factor, 10%.

Answer 169

* Fever control: * minimal clothing, nappy alone or light outer layer depending on ambient temperature * Tepid sponging, baths and fans are ineffective at lowering core temperature and are NOT recommended * Paracetamol has not been shown to reduce the risk of further febrile convulsions. It may be used for pain/discomfort associated with febrile illnesses (e.g otitis media),it should not be solely used to control fever * If the seizure recurs, roll him onto his side and allow him to fit, Seizure should not last longer than 3-5 minutes. Any longer and an ambulance should be called. * If Henry was to have recurrent or prolonged febrile seizures, prophylactic oral diazepam or rectal diazepam (rescue therapy) may be prescribed

Answer 170

No, not at all

Answer 171

Teething will not cause fever \> 38.5oC

Answer 172

**History** * Headache (if child can talk) * Photophobia (if child can talk) * Cough * Coryza * Diarrheoa * Vomiting * Abdominal pain * Joint symptoms * Dysuria/foul smelling urine * Travel history * Sick contacts * Immunisations **Exam**: * Vitals, general appearance, conscious state * Neck stiffness * ENT examination * Work of breathing * Abdominal exam * Skin rash * Joint swelling

Answer 173

* Sick child with fever * Vomiting * Red-yellow bulging TM * Discharge * Loss of TM landmarks * Persistent fever and pain after 3 days of conservative approach * Bilateral AOM *

Answer 174

Birth incidence is about 1 in 1000 **live** births. Overall incidence rises after maternal age of 35 years.

Answer 175

50% have congenital heart defects particularly AVSD

Answer 176

**Medical** * Growth * Plot growth on Trisomy 21 specific growth charts * Prevent obesity * Cardiac * ECHO at birth * Annual follow up * GIT * Coeliac screening * Endocrine * Annual TSH (at increased risk of hypothyroidism) * Haeamtological * Annual FBE (at increased risk of polycythaemia) * Hearing * Hearing test as new born and at six months of age * Opthalmology * Eye examination every 3 years * MSK * Education RE: atlanto-axial instability, avoid trampoline and high risk activities, discuss positioning of the spine during anasthaesia/surgery * Low threshold for imaging. Routine spinal xray is not recommended. **Non-Medical** * ?Early intervention * ?Funding / Carer’s Pension * ?Educational and Vocational Training

Answer 177

CVS = 1% above the background risk Amniocentesis = 0.5%

Answer 178

**Diagnosis** = herpes simplex gingivostomatitis **Management** = Pain relief (codeine may be required as it is very sore). Antivirals inneffective **Prognosis** = Child may have a fever and become irritable, a day or two later ulcers develop on the lips and gums. These are painful and often lead to drooling and a refusal to eat or drink, dehydration can occur. The pain normally subsides after 3-4 days, the blisters usually take from 10 -14 days to go away. The blisters never leave scars.

Answer 179

Discuss with registrar/consultant Full sepsis work-up: FBE/film, blood culture, urine culture (SPA), LP ± CXR Admit for empirical antibiotics

Answer 180

* Discuss with registrar/consultant * Full sepsis workup: * FBE/film, blood culture, urine culture (SPA) ± CXR (only if respiratory symptoms or signs) ± LP * Discharge home with review within 12 hours if the child is: * Previously healthy * Looks well * WCC 5,000 - 15,000 * Urine microscopy clear * CXR (if taken) clear * CSF (if taken) negative * If the child is unwell or above criteria are not all satisfied, admit to hospital for observation +/- empiric i.v. antibiotics

Answer 181

**Idiopathic Nephrotic Syndrome (90% of presenting children)** * Minimal change disease * Focal segmental glomerulosclerosis * Also called steroid-sensitive nephrotic syndrome as 80+90% of cases will respond to initial steroid therapy ******Non-idiopathic Nephrotic Syndrome (rare)** * Secondary * SLE * Henoch Schonlein Purpura * Membranoproliferative GN * Membranous nephropathy * Congenital nephrotic syndrome

Answer 182

* 80% of children with Minimal change will relapse * Steroid-responsive patients have little risk of chronic renal failure * Patients with FSGS may initially respond to steroids but later develop resistance * Many children with FSGS progress to end-stage kidney failure * Recurrence of FSGS occurs in 30% of children who undergo renal transplantation

Answer 183

**Membranoproliferative glomerulonephritis** Characterised by hypocomplementemia (low C3 and C4) with signs of glomerular renal disease 5 to 15% of children with primary nephrotic syndrome Typically persistent Has a high likelihood of progression to renal failure over time **Membranous nephropathy** Less than 5% of children with primary NS Seen most commonly in adolescents and children with systemic infections Hep B, syphilis, malaria and toxoplasmosis Or on specific medications Gold, penicillamine

Answer 184

**Usually neonates or teenagers** Sudden onset testicular pain and swelling; occasionally nausea, vomiting. Note: pain may be in the iliac fossa, may be associated with sports activity Discolouration of scrotum; exquisitely tender and swollen testis, riding high. Cremasteric reflex is usually absent. **Management**: Early surgical consultation is vital, as delay in scrotal exploration and detorsion of a torted testis will result in testicular infarction within 8-12 hours. Keep the child fasted.

Answer 185

* Perform a reduction manoeuvre (see below) * expect distress and pain * a click may be felt over the radial head * review after ten minutes * if reduction fails, consult with senior medical staff https://youtu.be/-0ROu4hCXwQ

Answer 186

Intussusception

Answer 187

**Primary – ages 3 months – 2 year olds** *Ileocaecal location* Idiopathic **Secondary – ages 4 years – 12 year olds** *Ileoileul location* Mesenteric lymph nodes HSP --\> pathological lead point of submucosal haemorrhage Meckels diverticula Haemophilia --\> submucosal haemorrhage

Answer 188

1. Fluid resuscitation 2. Analgesia 3. Air enema 4. Definitive surgery if necessary

Answer 189

Like a sock folding in on itself

Answer 190

99% in first day Rest in second day If not passed on 3rd day it's a sign of abnormality

Answer 191

In hirschprungs on rectal exam there is explosive discharge of flatus and faeces

Answer 192

Suction rectal biopsy

Answer 193

1/25 1/2500

Answer 194

Cardiac defects Down syndrome

Answer 195

Ask if either parent had pyloric stenosis when they were born.

Answer 196

20% chance

Answer 197

The vomiting may continue for 3 - 5 days, that is normal.

Answer 198

Immediately after birth = duodenal atresia 3 days after birth = malrotation with volvulus First few days of life with failure to pass stools = MI or Hirschsprungs 3-4 weeks after birth = pyloric stenosis

Answer 199

Mild dehydration = No signs Moderate dehydration = 4-6% depleted - **Signs of dehydration** Severe dehydration is \>= 7% depleted - **Shock** *For the purposes of calculation of fluid requirements use:* Mild - 3% Moderate - 5% Severe - 10%

Answer 200

**First:** For shock give 10-20ml boluses of normal saline until signs of shock improve. **Second:** Replace deficit, so for a 6kg kid if they're moderately shocked that approx 5%, so their deficit is approx 300ml, give 300ml normal saline **Third**: Give maintenance fluids using normal saline + 5% glucose. Using the 4,2,1 rule for a 6 kg infant that is 24ml/hr of normal saline + 5% glucose. **Monitor electrolytes daily and consider adding 20mmol K**

Answer 201

In non-dehydrated children, consider using 2/3 maintenance doses in unwell children, especially those with pneumonia or meningitis.

Answer 202

Cryptosporidium Giardia Lamblia

Answer 203

dysentery w blood, pus, pain and tenemus

Answer 204

**Bedside** None **Bloods and urine** UECs and glucose a minimum if commencing any IV rehydration **Cultures** Faecal culture and MCS if significant abdominal pain, blood or mucus, or septic child Faecal ova, cysts and parasites – if considering parasitic causes C difficile toxin if recent use of antibiotics

Answer 205

Post-gastroenteritis lactase deficiency Mx - Lactose free diet for a few weeks

Answer 206

Coeliac disease!

Answer 207

**Bedside** NA **Bloods** * *(not anti TTG or IgA like normal as low sensitivity under 2 years)* * Anti Gliadin * HLA testing * Screen for T1DM and thyroid disease * FBE * May show microcytic or macrocytic anaemia from iron or folate deficiency * U&E * may reveal reduced concentrations of calcium, magnesium, total protein, albumin or vitamin D **Imaging** None **Special** Gastroscopy and small bowel biopsy

Answer 208

Exclusion of gluten (barley, rye, wheat, and oats) Dietary fortification – iron, folate, calcium and vitamin D

Answer 209

1/25 boys born

Answer 210

Parental anxiety

Answer 211

What worries you the most?

Answer 212

Subacute onset, prominent cough, +/- headache, +/- sore throat Roxithromycin PO for 10 days

Answer 213

The response of fever to paracetemol is not significant, and is not an indicate of illness severity. However, if the child was tachycardic and the paracetemol does not bring their HR down, you would consider myocarditis. If it was myocarditis admit them for monitoring and supportive care.

Answer 214

* malrotation and volvulus * duodenal atresia (if obstruction distal to Ampulla of Vater 80% of cases) * jejunoileal atresia * meconium ileus * necrotising enterocolitis

Answer 215

The first stool is passed within 24 hours of birth in 99 percent of healthy full-term infants and within 48 hours in all healthy full-term infants. Failure of a full-term newborn to pass meconium within the first 24 hours should raise a suspicion of intestinal obstruction.

Answer 216

Exophalos (omphalocoele) - large defect at the umbilicus with herniation of bowel and liver into a sac covered by fused amniotic membrane and peritoneum. **Associations** Prematurity/IUGR 30% will have CVS defects Also associated with trisomy 13 and 18, renal abnormalities and other syndromes. **Diagnosis** Usually diagnosed on the 12 and 20 week scans. Aim is to then monitor them and deliver them in a tertiary centre. **Management**: * Glad wrap * NG decompression * IV Ab and fluids * Catheter to monitor fluid output * Heater * BSL * Look for associated malformations * Delayed operation (as often unstable initially). * appendix is removed and the goal is to get it all inside the abdomen. This is not always possible and thus a 'silo reduction' may be used.

Answer 217

Gastroschisis - defect immediately to the right of the umbilicus through which bowel (and sometimes gonads) herniate. There is no covering sac and the eviscerated small and large bowel is thickened and densely matted with exudate as the result of amniotic peritonitis before birth. **Associations** Prematurity/IUGR Related to maternal drug use. **Diagnosis** Usually diagnosed on the 12 and 20 week scans. Aim is to then monitor them and deliver them in a tertiary centre. **Management:** * Glad wrap * NG decompression * IV Ab and fluids * Catheter to monitor fluid output * Heater * BSL * Look for associated malformations * Immediate operation * appendix is removed and the goal is to get it all inside the abdomen. This is not always possible and thus a 'silo reduction' may be used.

Answer 218

The 9 S's of development ## Footnote Neonate 6 weeks 3 months 6 months 9 months 12 months 18 months 3 years 5 years

Answer 219

SHIELD + vWD vWD less likely to be acute diagnosis. The story is "abnormally prolonged bleeding when prompted (like teeth brushing)" versus SHIELD which is acute onset petechiae

Answer 220

Because remember that desmopressin/DDAVP is just synthetic ADH. ADH causes aquaporins to be plugged in to the distal collecting tubule allowing for resorbtion of water which can cause dilutional hyponatremia. The challenge test it to make sure the kid doesn't get hyponatraemic.

Answer 221

**ABCDEFGHI** * A - Appendicitis * B – Balls (testicular torsion) * C – Chest infection * D – Diverticulum (Meckel’s) + DKA * E – E.Coli (UTI) * F – Faecal or urinary retention * G - Gastroenteritis * H – Hernias/HSP * I – Intussusception + intestinal malrotation

Answer 222

* Following infectious diarrhoea, infants may have temporary lactose intolerance. * This sequela of acute gastroenteritis used to be prominent in infants * This may be due in part to early oral feeding which aids mucosal recovery. * Clinical features of sugar intolerance include: * Persistently fluid stool * Excessive flatus * Excoriation of the buttocks * Typically, these infants appear well. Breast feeding should continue unless there are persistent symptoms with buttock excoriation and failure to gain adequate weight. Formula-fed infants should be placed on a lactose-free formula for 3–4 weeks.

Answer 223

A clinical syndrome characterised by chronic diarrhoea often with undigested food in the stools of a child who is otherwise well, gaining weight and growing satisfactorily. Stools may contain mucus and are passed 3–6 times a day; they are often looser towards the end of the day. Onset is usually between 8 and 20 months of age. **Management** Reassurance and explanation. No specific drug or dietary therapy has been shown to be of value in toddler diarrhoea.

Answer 224

* Headache/neck stiffness/photophobia/Rash * Cough, coryza, sore throat * Dysuria/frequency * Vomiting/diarrheoa/abdominal pain * Joint or elsewhere pain? * Contacts * Travel * Immunisations * Intake/vomiting/urine production

Answer 225

* **Tumour** * painless * **Henoch Schonlein purpura** * purpuric rash on testicle * **Varicocele** * bag of worms, left side, teenager * **Hydrocele** * transilluminates, soft, can feel testis * **Incarcerated inguinal hernia** * **Epididymoorchitis** * fever, nausea, vomiting, urinary symptoms * **Torsion of the appendix testis (hydatid of Morgagni)** * More gradual onset. Focal tenderness at upper pole of testis; "blue dot" sign - necrotic appendix seen through scrotal skin. * **Torsion** * Sudden onset testicular pain and swelling; occasionally nausea, vomiting. Discolouration of scrotum; exquisitely tender and swollen testis, riding high. Cremasteric reflex is usually absent. * **Idiopathic scrotal oedema** * It usually affects boys between 5-9 years of age. There is insidious onset of redness and swelling of perineum or inguinal region (groin), extending to scrotum. It may be itchy but is not often painful.

Answer 226

* observation of the patients gait and resting position * natural position of the testis in the scrotum while standing * presence or absence of cremasteric reflex (this is absent in torsion) * palpation of lower abdomen, inguinal canal and cord * palpation of scrotum and contents, compare with unaffected hemiscrotum * transillumination * Is the swelling reducible?

Answer 227

**Without failure to thrive** * Infectious * Bacterial - campylobacter, salmonella * Antibiotic induced - C difficile colitis * Parasitic - Giardia lamblia * Post-infectious - secondary lactase deficiency * Toddler's diarrhoea * Lactase deficiency (lactose intolerance) * Irritable bowel syndrome - a diagnosis of exclusion in an older child/adolescent **Chronic diarrhoea with failure to thrive** * GI causes * Coeliac disease * Milk protein allergy - cow's milk, soya protein, etc. * Inflammatory bowel disease * Pancreatic insufficiency --\> Cystic fibrosis * Others * Thyrotoxicosis * Food allergy

Answer 228

The classical presentation is of a profound malabsorptive syndrome at 6-24 months of age after the introduction of wheat-containing weaning foods (e.g. steatorrhoea, vomiting in some cases). * FTT with poor appetite * Steatorrhoea * Anorexia, nausea and vomiting, abdominal pain * Abdominal distention * Buttock wasting * General irritability, apathy and fatigue - consider Fe deficiency Presentation is highly variable, and may be less acute later in childhood.

Answer 229

Most commonly functional constipation (99%) - due to lack of fibre, poor fluid intake, behavioural things (especially around toilet training), and changes in diet (esp. when changing to cow's milk). **Management** Clean out + maintain with stool softeners and adequate fibre. Address any underlying problems. This may need to be done multiple times.

Answer 230

**Basics** * Keep breastfeeding * Regular small volume flood intake * Ondansetron **Place and person** Admit the following: * Infants with moderate-severe dehydration * Diagnosis in doubt * Those who are high risk of dehydration (keep in hospital for 4-6 hours): * Infants * Infants * High frequency diarrhoea (8 per 24 hours) * High frequency vomiting (\>4 per 24 hours) **Investigations** * Mostly not required. * UECs and glucose - if severe dehydration and needs resuscitation. * If there is significant abdominal pain, or blood or mucus in the stools, or if the child appears septic * Faecal culture * Faecal leukocytes or blood * Faecal ova, cysts and parasites - when considering parastic infections * C difficile toxin (faecal) - if recent use of antibiotics **Definitive** Oral, NG or IV rehydration There is no role for antibiotics in bacterial gastroenteritis. **Long term** Early feeding as soon as rehydrated reduces stool output and aids gut recovery. Anti-diarrhoeals and maxalon are not recommended.

Answer 231

The proportion of boys with retractile foreskins is: 40% at 1 year, 90% at 4 years and 99% at 15 years. **Management of true phimosis** * 0.05% betamethasone cream should be used twice daily for 2 to 4 weeks. * Gently retract foreskin without causing any discomfort and apply a thick layer of cream to the tightest part of the foreskin. * Circumcision (if significant phimosis and steroid creams fail)

Answer 232

Smegma = white/yellow lumps are called smegma and are made up of the cells that once attached the foreskin to the head of the penis. Smegma is normal and will eventually disappear. No treatment is needed. Balanitis: severe inflammation of the glans penis +/- foreskin is often due to infection and is usually termed balanitis. Tx is Soaking in a warm bath with the foreskin retracted plus topical steroid.

Answer 233

* Enterovirus * HSV * Other herpes viruses (EBV, CMV, HHV6, VZV) * Arboviruses. * Less commonly, encephalitis can be caused by bacteria, fungi or parasites.

Answer 234

**Below 2 months of age** * Group B streptococcus * E. coli and other Gram-negative organisms * Listeria monocytogenes * Plus the below.... *Use cefotaxime and ben pen* **Above 2 months of age** * Streptococcus pneumoniae * Neisseria meningitidis * Haemophilus influenzae type B (in unimmunised children) * As a result of immunisations Hib meningitis is now rare and there has been a reduction in the incidence of pneumococcal meningitis. *Use ceftriaxone and dexamethasone*

Answer 235

25% of people with autism will have normal/high IQ 75% will have some degree of intellectual disability The child's level of ability is often uneven, with areas of strength and weakness.

Answer 236

There are three problems: 1. Protrusion of the bowel through the processus vaginalis can obstruct it's blood supply causing necrosis/peritonitis/sepsis 2. Obstruction of the processus vaginalis can put pressure on and ultimately obstruct the blood supply to the testicles and the spermatic cord, resulting in death of the testis and/or reduced fertility 3. obviously there is the risk of bowel obstruction

Answer 237

Ballooning of the foreskin during urination due to physiological phimosis. In itself is not a concern, no need for management, will resolve as phimosis resolves.

Answer 238

4 years old, topical steroid.

Answer 239

* Hernia is reducable (unless strangulated, in which case it will be extremely painful) * Hydrocele is not reducable, it would take hours for you to squeeze the fluid back up the narrow patent processus vaginalisis * Hydrocele transilluminates, hernia does not * You can get above a hydrocele but not a hernia * Hydrocele doesn’t really ever have to be fixed, but you do for cosmesis after age 2.

Answer 240

* Pre-term baby, typically in the 2nd-3rd week of life * Infant stops tolerating feeds --\> vomiting (bilious sometimes) * Abdominal distention * Rapidly becomes shocked * Other features: * Bloody stools * Pneumatosis intestinalis - gas cysts in the bowel wall; diagnostic for NEC * Diminished bowel sounds * Signs of bowel perforation - sepsis, shock, peritonitis, DIC

Answer 241

Tracheo-oesophageal fistula in 85% of cases Diagnosis is confirmed by passing a large firm catheter through the mouth and finding that it cannot be passed more than about 10cm from the gums. A plain XRAY of the torso will show gas in the bowel (if there is distal TOF).

Answer 242

Slipped upper femoral epiphysis (SUFE) is the most common hip disorder in the adolescent age group. It occurs when weakness in the proximal femoral growth plate allows displacement of the capital femoral epiphysis. The metaphysis displaces anteriorly and superiorly, leading to the slipped state. There are a number of ways that SUFE can be classified **Stable vs unstable** The patient is able to weight bear on the affected leg (stable) versus unable to weight bear even with crutches (unstable). **Acute, chronic or acute on chronic** Acute = Sudden onset of severe symptoms and inability to weight bear Chronic = Gradual onset and progression of symptoms for more than 3 weeks, without sudden exacerbation. This is the most common presentation (85% of patients with SUFE) Acute on chronic = Sudden exacerbation of symptoms due to acute displacement of a chronically slipped epiphysis **Radiographical degree of displacement** ``` Type I (0 to 33% displacement) Type II (34 to 50% displacement) Type III (\>50% displacement) ``` The likelihood of complications increases with displacement

Answer 243

A very reliable sign of chronic SUFE is detection of obligatory external rotation during flexion of the hip. As the hip is flexed on the affected side, the thigh will automatically rotate and abduct

Answer 244

**Basics** Nil by mouth Depending on severity, pain management according to WHO pain management ladder. **Place and person** Urgent orthopaedic referral **Investigate and confirm diagnosis** AP and frog lateral pelvis x-rays of both hips **Non-invasive management** The patient needs to be kept non-weight bearing **Definitive management** Immediate surgical screw fixation across the physis (within 24 hours)

Answer 245

1. pulmonary stenosis 2. RVH 3. VSD 4. over-arching aorta (5. ASD)

Answer 246

When the child is \>3 months of age Presents as failure to thrive, reduced exercise tolerance, clubbing of fingers and tet spells. They are not cyanosed at birth - may be cyanosed after 6-12 weeks

Answer 247

The classic story is severe, painful cyanosis on exertion/stress (feeding or crying). Older children will classically squat in order to increase systemic resistance and reduce R--\>L shunting

Answer 248

**Basics** Comfort the child in a position with their hips and knees flexed to increase systemic resistance and thereby R--\>L shunt. Oxygen IV fluids B blockers IM morphine **Place and Person** Refer to paediatric cardiac surgery **Ix and confirm diagnosis** With echocardiogram **Definitive management** Surgical **Long Term** Ongoing paediatric review

Answer 249

Deletion of the long arm of choromosome 22 What else is related? Think **CATCH 22** Cardiac (TOD, TGA) Abnormal facies Thymic hypolasia (T cell deficiency) Cleft palate Hypocalcaemia/hypoparathyroidism

Answer 250

small VSD: loud pansystolic murmur large VSD: softer pansystolic murmur + loud P2 (due to pulmonary hypertension)

Answer 251

GBS E. Coli Listeria Hep B HIV

Answer 252

**TORCHSHPV** Toxoplasmosis Other Rubella CMV HSV Syphillus (treponema pallidum) Hep B Parvovirus B19 Varicella zoster

Answer 253

Generally, the earlier in gestation the foetus congenitally acquires a TORCH infection, the higher the risk of severe congenital abnormalities and developmental delay. A conversation is therefore usually had with mothers (especially in the first trimester) about the option of termination. Some TORCH infections can be treated in the neonate, but for the majority of TORCH infections the treatment is supportive and includes only management of complications.

Answer 254

**All mums - *SARaH*** Syphillus (assays) Asymptomatic bacteruria (mid stream urine culture, treat empirially to avoid pyelonephritis) Rubella (anti-Rubella antibodies) HIV (Western blot and ELISA, give anti-retrovirals to mum, deliver by C-section) Hep B (HB-sAG, vaccinate and give IgG in delivery room) GBS (after 37 weeks) **High risk mums - *SARaH + 1G, 3T, 4C*** Gonorrheoa Trichomoniasis, Toxoplasmosis & Thyroid function Chlamydia, Hepatitis C, CMV and cervical abnormalities (pap smear)

Answer 255

If 1st trimester low risk of transmitting to foetus but high rate of severe complications If 3rd trimester high risk of transmitting the infection but low rate of severe complications **Diffiuse calcifications throughout the brain visible on USS** **Seizures** Plus the general effects of TORCHSHPV * Anaemia * Hepatosplenomegaly * Symmetrical IUGR (microcephaly) * Developmental delay * Sensorineural deafness * Visual problems

Answer 256

Outcome depends on gestation age at which it was transmitted. * congenital rubella syndrome (\>90%) * 12-18/40 --\> sensorineural deafness (20%) * \>18/40 --\> complications rare

Answer 257

**Periventricular calcifications** Symmetrical IUGR with microcephaly Developmental delay Hepatospleenomegaly Anemia Sensorineural hearing loss Visual problems

Answer 258

Rhinitis develops at 1 week and worsens. Initially clear then progressively purulent and blood stained. Neurosyphillis Bone problems Maculopapular rash

Answer 259

Severe anaemia --\> high output cardiac failure --\> hydrops foetalis

Answer 260

**EARLY Vertical transmission --\> GBS, E coli, Listeria Risk factors** * Maternal infection: UTI, GBS+ * Previous child with GBS sepsis * Prolonged rupture of membranes (\>18h) * Preterm labour **LATE \>5 days = ACQUIRED AFTER BIRTH** Staphylococcus, streptococcus (plus above pathogens) Risk factors * NICU stay (just like ICU stay causes infections) * Foreign bodies eg ETT, catheters * Malformations

Answer 261

**Every visit** * BP * Weight * Urine dipstick * Foetal auscultation (after 12weeks) * Foetal movements (after 18 weeks) * Fundal height measurement (after 20 weeks) **Because it's the first visit** * LNMP for dating (+ 1 year, - 3 months, + 7 days) * ABO, Rh, Rh antibody levels * FBE to screen for anaemia * EPNDS * Routine torch screening --\> SARaH * Syphilis * Asymptomatic bacteruria (MSU culture) * Rubella * HIV * Hep B * ****If high risk, additional TORCH screening --\> 1G, 3T, 4C * Gonorrheoa * Trichomoniasis, Toxoplasmosis & Thyroid function * Hep C, chlamydia, CMV, cervical abnormalities (pap smear)

Answer 262

* * at least 1 episode of faecal incontinence per week * history of retentive posturing * large and/or painful and/or hard bowel movements * large faecal mass in rectum

Answer 263

oesophagitis failure to thrive aspiration

Answer 264

Crying is normal physiological behaviour in young infants. At 6 - 8 weeks age, a baby cries on average 2 - 3 per 24 hours. Excessive crying is defined as crying \>3 hours/day for \>3 days/week. This is often referred to as "colic". However, many babies present with lesser amounts of crying, as the parents perceive it as excessive.

Answer 265

* Pronounced irritability with arching * Refusal to feed / failure to thrive * Feeding and behavioural problems * Weight loss or crossing percentiles * Haematemesis * Chronic cough/wheeze * apnoeas

Answer 266

**Non-invasive management** * Prone position after feeding (supervised) * Milk thickening agents (eg. rice cereal) reduce the number of episoes of vomiting but not the total time of oesophageal acidity * Don't encourage parents to change formulas * Never change a breastfed child to formula **Definitive management** PPIs relieve symptoms and assist mucosal healing Omeprazole Under 10kg: 5mg daily 10-20kg: 10mg daily Over 20kg: 20 mg daily **Surgical** Failure of medical therapy or recurrent respiratory symptoms (aspiration) may necessitate Nissen fundoplication:

Answer 267

**Most common - benign** 1. Tiredness 2. Hunger - this is more likely if a mother reports: 1. inadequate milk supply 2. poor weight gain 3. baby has frequent feeds (ie, **Also consider** 1. GORD 2. Cows milk intolerance 1. Check if vomiting, blood/mucus in diarrhoea, poor weight gain, family history in first degree relative, signs of atopy (eczema / wheezing), significant feeding problems 3. Lactose intolerance (rare) **If Acute onset consider:** * UTI * Otitis media * Raised intracranial pressure * Hair tourniquet of fingers / toes * Corneal foreign body / abrasion * Incarcerated inguinal hernia

Answer 268

colicky abdominal pain, currant jelly stool, palpable abdominal mass

Answer 269

Prematurity and low birth weight Feeding (especially enteral/cow’s milk/early formula) Infection/ sepsis Bowel ischemia Hypotension and congenital heart disease Hypoxia/respiratory distress/ birth asphyxia

Answer 270

The incidence of NEC is inversely proportional to birth weight. In general, the age of onset is inversely proportional to gestation; therefore smaller babies present later. 90% of babies with NEC are preterm.

Answer 271

**Basics** NBM (gut rest) NGT (drainage) Insert IV line for fluids and to take sample for FBE & blood cultures **Place and Person** Refer to paeds gastroenterology / surgery **Investigate and confirm diagnosis** AXR is gold standard Rationalise ABx once cultures back **Definitive management** Empirical antibiotic therapy: Metronidazole Ampicillin Gentamycin Only in stage 3B disease: Surgery to resect affected section with stoma diversion and abscess drainage if needed

Answer 272

Projectile, non-bilious vomiting First born, Caucasian male with a positive family history Hypochloraemic, hypokalaemic metabolic alkalosis (also get hyponatraemia too, but not included in the buzz word)

Answer 273

Usually between 2-6 weeks of life

Answer 274

A sudden onset of vomiting between 2 and 6 weeks of life. Before the onset of vomiting, these infants feed well and are thriving. The infant then loses weight (or inadequately gains weight) and becomes dehydrated Projectile, non bilious vomiting. May contain altered blood. "Hungry vomiters" – vomit immediately after feeding, and then are hungry again May be constipated (not absolute) **Examination** Palpable, mobile pyloric tumour in the midline of the epigastrium between the rectus abdominal muscles OR the right rectus and the liver edge ("olive")

Answer 275

Behaviour/demeanour HR/BP Cap refill (check centrally) Sinking of the anterior fontanelle and eyes Tear production/Urine output Skin turgour Mucus membranes Weight loss

Answer 276

**Usually a clinical diagnosis** ## Footnote **Bedside** ABG --\> hypochloremic, hyponatremic, hypokalaemic, metabolic alkalosis BGL **Bloods and urine** FBE UEC --\> hydration Coags **Imaging** Ultrasound If very unsure you can do a barium meal (not usually needed)

Answer 277

It is particularly important to fully correct serum bicarbonate before theatre because of the risk of hypoventilation/ apnoeas post-operatively in the setting of metabolic alkalosis.

Answer 278

**Medical (not surgical) emergency** ## Footnote **Basics** IV access and fluid resusc if required and as directed by UEC/ABG results NBM NG tube if continuing to vomit **Place and person** Paediatric gastroenterology, admit **Definitive** Pyloromyotomy (Ramstedt operation).

Answer 279

10-20ml/kg of normal (0.9%) saline, which may be repeated

Answer 280

Malrotation + volvulus until proven otherwise!

Answer 281

**History** Presents day 1-3 of life (60–80% of all cases of malrotation present in the first month of life, mostly in the first week.) Bilious vomiting (malrotation until proven otherwise!) No dirty nappies once there is volvulus Rectal bleeding (a late symptom/sign) Abdominal pain **Examination** Abdominal distension (late sign) Peritonism (late sign)

Answer 282

AXR - non-specific, gas in bowel, can get "double bubble sign" **Barium swallow - corkscrew sign** USS - whirlpool sign

Answer 283

**Basics** NBM NGT – check aspirates for bile Insert IV and commence fluids **Place and person** Admit and refer to paediatric surgeon **Ix** ABG Septic screen Blood group and hold **Definitive management** Urgent surgical correction with follow up Ladd procedure: untwist counter-clockwise, divide Ladd’s band, widen mesentery attachment, appendicectomy, and replace the bowel in the right location. Where there is necrotic bowel second laparotomy performed in 24-48hrs later to see if viable gut can be saved – resection

Answer 284

**Gastro** FAMINE HIP GAIT **Neurological** Increased ICP **Infectious** Gastroenteritis Meningitis Pertussis (post tussive cough) **Endocrinological** DKA Errors of Inborn Metabolism **Psychogenic / Behavioural** Overfeeding in infants Bulaemia in adolescents Pregnancy in adolescents

Answer 285

FAMINEHIPGAIT

Answer 286

Oxygen therapy if hypoxic Assisted ventilation if increased work of breathing NG feeding if poor feeding NG or IV fluids if dehydrated

Answer 287

**Basics** DRSABCD NBM **Place and person** Transport to surgical unit via NETS **Ix** ECG, ABG, BGL FBE, UEC, LFTs, LDH, Coags, Group and hold AXR, CT, USS **Definitive** * *Drip and suck-* * NBM and NG tube suction - relieves any respiratory distress from abdominal distension (may also be caused by vomit aspiration) * Rapid IVF resuscitation with boluses of 10mL/kg given at 15 minute intervals if shocked otherwise give maintenance and mL by mL match for NGT losses. * Glucose- monitor BSLs and glucose solution should be given with IVF (glucose stores low, no absorption --\> anaerobic metabolism) * Correct Hypothermia * monitor temperature and have overhead heater * Correct acidosis correction of fluid loss, hypothermia and glucose will correct acidosis * Sepsis * if at risk administer IV Abx after cultures taken * Surgical correction if required- according to cause

Answer 288

* Prematurity issues * Asphyxia * Meconium aspiration syndrome * Hypoglycaemia, hypocalcaemia * Hypothermia * Polycythaemia * Impaired immune function * BM suppression * NEC * Mechanism = hypoxic gut as foetus shunts blood to brain * Neurodevelopmental * Cerebral palsy * Learning and behavioural issues * Foetal origins of adult dz * DM, HT, obesity, CAD, hypercholesterolaemia

Answer 289

Plus also ask about sleep

Answer 290

**SCOFF** Do you make yourself **Sick** because you feel uncomfortably full? Do you worry you have lost **Control** over how much you eat? Have you recently lost more than **One** stone (6.35kg) in a three month period? Do you believe yourself to be **Fat** when others say you are thin? Would you say **Food** dominates your life? **Plus to screen for bulimia nervosa:** Are you satisfied with your eating pattern? Do you ever eat in secret?

Answer 291

The 5 Hs 1. Height (growth retardation) 2. Heart (arrythmia, QT, bradycardia, hypotension) 3. Happy Bones (irreversible osteoporosis) 4. Hormones (osteporosis, hypothyroid, delayed puberty/amenorrheoa) 5. Heads (poor concentration, slowed mentation)

Answer 292

History provided not consistent with injury Delay in presentation Claims that injury caused by young sibling Denial that it is an injury Multiple injuries of different types and ages Injuries not consistent with developmental age Child brought in by person other than parent **Shaken baby syndrome --\> subdural haematoma + retinal haemorrhage**

Answer 293

Unless it is catastrophic epilepsy, early treatment does not change long term outcome Be hesitant to make a diagnosis because it will change a child's life forever Epilepsy will declare itself by progression or resolution.

Answer 294

**Time course** Red is raised ICP Green is migraine Blue is muscular **Severity** Best to ask what they did during the headache to determine severity (confined to dark room = severe)

Answer 295

**Relief by sleep** **Dizziness/pallor** Abdo pain Nausea and vomiting Prodrome Characteristic location of pain

Answer 296

**Rhinovirus** Adenovirus Influenza and parainfluenza RSV Enterovirus EBV Streptococci

Answer 297

* ear, nose, or throat infection * acute respiratory infection * gastroenteritis * urinary tract infection * meningitis * osteomyelitis / septic arthritis

Answer 298

Bacterial infection

Answer 299

Urine dipstick not useful in babies under 1 because they pee as soon as urine created which means not enough time for bacteria/WCC to accumulate Can cause false negative!

Answer 300

MR SARS EEK! * Measles * Rubella * Systemic JCA (Still’s disease) * Allergy * Roseola infantum (HHV6) * Scarlet fever * Erythema infectiosum (Parvovirus B19) * Erythema multiforme * Kawasaki disease

Answer 301

Mild, diffuse dilatation of coronary arteries usually begins on day 10 from fever onset. If left untreated, 25% of these patients progress to true aneurysms, with 1% becoming ‘giant aneurysms’ (\>8 mm internal diameter). These giant aneurysms have the worst prognosis, with risk of acute thrombosis and long-term risk of myocardial ischaemia * Carditis during the febrile phase * myocarditis with ST-T changes (25%) * pericardial effusions (20-40%) * valvular dysfunction (1-2%) * cardiac failure (~5%) * Coronary vessel abnormalities (occur in 20% of cases if untreated and * aneurysm formation * may lead to fatalities from * thrombosis, * rupture or * ischemia-related dysrhythmia

Answer 302

Rash from strep throat. Tx with phenoxymethylpenicillin (PO) or benzathine penicillin (IM) to prevent post strep GN or acute rheumatic fever

Answer 303

Hand, foot and mouth Chickenpox Herpes simplex (Remember: vesicular just means blistering)

Answer 304

Fever Stiff neck\*/Kernig's sign Bulging fontanelle Irritable Drowsiness Poor feeding/vomiting **Palpable non-blanching purpuric rash =\> meningococcal meningitis** Convulsions/coma/shock --\> consider meningitis **Stiff neck is not relevant in infants**

Answer 305

Transplacental transfer of IgG happens in the third trimester. Very premature babies can miss out on this process rendering them very vulnerable to infection NB: The process is actually active and means that the baby ends up with a higher concentration of IgG than their mum!

Answer 306

**\> 38.0 degrees** **INVESTIGATE IT!** FBE blood culture CRP Urine dipstick/Urine MCS CXR only if respiratory signs are present stool culture, if diarrhoea is present

Answer 307

Viral lower respiratory tract infection Up to 18 months

Answer 308

**_RSV_** Picornovirus Human metapneumovirus Adenovirus --\> bad because causes bronchiolitic obliterans! Parainfluenza Influenza

Answer 309

Exposure to cigarette smoke Maternal smoking during pregnancy Prematurity Chronic cardiorespiratory diseases (including congenital heart disease and cystic fibrosis) Immunodeficiency

Answer 310

None, clinical diagnosis However, nasopharyngeal aspirate is usually done because we like to know which viruses are doing the rounds in the community and to rule out pertussis (which is life threatening to infants)

Answer 311

**Basics** * Oxygen therapy if hypoxic * Assisted ventilation if increased work of breathing * NG feeding if poor feeding * NG or IV fluids if dehydrated **Person and Place** Admit to paeds ward if patient requires any of the above, or if concerned **Investigations and Diagnosis** Clinical diagnosis, NPA if required to isolate virus or exclude pertussis **Definitive Management** Supportive management only. Usually resolves within a week. **Long-Term Management** RSV is a highly infectious virus, ensure good hand hygiene to prevent spread. Ensure immunizations are up to date

Answer 312

Bronchiolitis / bronchitis Asthma / viral induced wheeze Viral pneumonitis Croup (can cause wheeze) Pneumonia Pertussis Bronchiomalacia/tracheomalacia Cardiac failure CF or other suppurative lung dz Recurrent aspiration Inhaled foreign body

Answer 313

6 months to 12 years of age, with a peak incidence at age 2

Answer 314

If you're thinking about hypoxia the croup is life threatening. Adequate SPO2 should not be reassuring – low oxygen saturations is a BAD sign.

Answer 315

Parainfluenza Influenza Adenovirus

Answer 316

* Begins with coryzal symptoms for 1-2 days * Fever is generally low grade (38-39) – no signs of toxicity * Barking cough – usually begins at night or early hours of morning. Peaks at day 2 and 3 of disease * It takes two or three days before the sub-glottic area narrows enough to cause the barking cough * It happens first at night, usually, because we have reduced upper airway tone when we sleep * Inspiratory stridor is heard as the disease progresses * The viral illness typically lasts 7-10 days, but the **typical croupy cough only lasts 2-3 nights** * May have associated widespread wheeze, increased work of breathing and hypoxia – child may become distressed and restless, cyanosis is a late and ominous sign * Recurrent spasmodic croup * ‘Upper airway hyperresponsiveness’ * No viral prodrome * Children are well when they go to bed, and wake up in the early hours of the morning with a barking cough and stridor * Fever is unusual in this form of croup * Children often have asthma or atopy, or a FHx of asthma and atopy

Answer 317

None, dont distress the kid!

Answer 318

**Basics** Minimal handling Oxygen is not usually required unless severe obstruction IV access should be deferred **Place and person** Grade 1 – manage at home Grade 2 – admit to hospital via ED Grade 3 – admit to ICU If having to administer oxygen, contact anesthetics! If having to administer a second dose of adrenaline, contact anaethetics! **Investigate and confirm diagnosis** Clinical diagnosis **Non-invasive management** Keep child relaxed **Definitive management** *Mild to moderate* Oral prednisolone 1mg/kg OR Oral dexamethasone 0.15mg/kg – 0.6mg/kg *Severe* * Oxygen * Nebulised adrenaline 1:1000 solution * Works by vasoconstriction * Beware of possible rebound effect after 2-3 hours – must observe * This is more symptomatic treatment to buy you time * Dexamethasone IV 0.2mg/kg * Follow with oral steroids * ETT if going into respiratory failure **Long term** Consider transfer when no improvement following nebulized adrenaline **Discharge requirements** Four hours post nebulized adrenaline Half hour post oral steroid Stridor free at rest **Recurrent-Spasmodic Croup** Usually don’t require treatment as attacks are very short-lasting. But can treat the same as acute viral croup. Some evidence to suggest that ICS may reduce frequency of attacks, but children will most likely grow out of this.

Answer 319

Most common age group in community is adolescents and young adults, but not dangerous for this group except for being vector Under 12 months deadly Under 6 months VERY deadly

Answer 320

Transmission: Direct contact with droplet discharges Highly contagious – spreads to 80-90% of susceptible individuals coming in contact with disease

Answer 321

**Catarrhal stage (7-14 days)** * Anorexia * Rhinnorrhoea * Conjunctivitis/lacrimation * Dry cough **Paroxysmal stage (about 4 weeks)** * Paroxysms of severe coughing with inspiratory ‘whoop’ * Vomiting (after coughing) * Coughing mainly at night * Lymphocytosis **Convalescent stage** * Chronic cough which may last for weeks

Answer 322

FBE --\> lymphocytosis CXR to exclude pneumonia Culture and/or PCR of nasopharygeal aspirate (within 1 week from onset of cough). Both of these tests have 70% sensitivity

Answer 323

**Basics** ABC **Place and person** If younger than 6 months – hospitalization School exclusion until at least 5 days of antibiotic use **Investigate and confirm diagnosis** Nasopharygeal aspirate FBE, IgA serology CXR – to exclude pneumonia **Non-invasive management** Good ventilation Avoid emotional excitement or distress Avoid overfeeding during paroxysmal stage **Definitive management** * Pertussis infection (Group B disease) requires written notification within five days of diagnosis. * Antibiotics minimize transmission but do not effect course of disease * Azithromycin 500 mg 5 days OR * Clarithromycin 7 days **Prophylaxis** Same treatment as above for household and other close contacts if commenced within 3 weeks of onset of cough in the patient **Prevention** * Acellular pertussis is part of the immunization schedule * Initial protection * 2, 4 and 6months * Booster (dTpa) * 4 years * 10-15 years * Parents or household contacts of newborns

Answer 324

Pneumonia Atelectasis Pneumothorax Seizure Asphyxia Apnoea/bradycardia Rib fracture Encephalopathy Otitis media

Answer 325

SABA PRN only, NO ROLE FOR PREVENTER IT IS NOT EFFICACIOUS

Answer 326

**Step 1: RELIEVER** SABA **Step 2: PREVENTOR** Low dose ICS (200 – 400mcg / day) OR LTRA OR inhaled cromone **Step 3: ADD OR INCREASE STEROID** Increase ICS (Double: 400 – 800mcg / day) LTRA / inhaled cromone + low dose ICS **Step 4: ALL PREVENTORS AND HIGHEST ICS DOSE** LTRA / cromone + ICS (800mcg) **Step 5: ADD SYMPTOM CONTROLLER / ORAL STEROIDS** LABA (not in children

Answer 327

Rrecurrent wheezing episodes which are responsive to salbutamol.

Answer 328

Boys generally have smaller airways than girls and tend to suffer more from asthma. However, after adolescence the prevalence is higher in females.

Answer 329

Very safe, almost not clinically significant long term side effects Hoarseness and pharyngeal candidiasis are not common Treatment beginning before puberty is associated with a small (mean approximately 1 cm) reduction in adult height

Answer 330

autosomal recessive

Answer 331

**MR PANCREAS** ## Footnote M - Meconium ileus (at birth) and distal intestinal obstruction (children and adults) R - Recurrent infections P - Pancreatic failure (exocrine and endocrine) A - Allergic bronchopulmonary aspergillosis N - nasal polyps and recurrent sinusitis C - Cirrhosis of hepatobiliary system E - Emotions (teenagers often depressed) and electrolyte disturbances (low Na+) A - Airway leaks (pneumothorax) S - Sterility in males

Answer 332

**Basics** NA **Place and person** Referral to * Respiratory physician * Chest physiotherapy * Dietitian **Investigate and confirm diagnosis** Sweat test and genotyping **Non-invasive management** * Chest physiotherapy * Monitoring and optimizing nutrition * High intake of dietary fat * Pancreatic enzyme supplements * Fat soluble Vitamin supplements **Definitive management** * For respiratory infections * S. aureus infection * Di/flucloxacillin * S. aureus and Haemophilus influenzae infection * Augmentum or trimethoprim and sulfamethoxazole * Initial pseudomonal infection * Ciprofloxacin PLUS * Tobramycin by nebulizer OR * Colistimethate sodium by nebulizer * Chronic pseudomonal exacerbation * Ciprofloxacin PLUS * Tobramycin by nebulizer OR * Colistimethate sodium by nebulizer OR * Gentamicin by nebulizer **Long term** * Respiratory * Daily chest physiotherapy * Aerosolised mucolytics * Dornase alfa * Nebulised hypertonic saline * Inhaled bronchodilators * Inhaled corticosteroids **Chronic pseudomonal infection** Azithromycin orally 3 times weekly **GORD** PPI

Answer 333

Exomphalos is a type of abdominal wall defect. It occurs when a child’s abdomen does not develop fully while in the womb. Tx = surgical correction in first 2 days of life

Answer 334

Hydrocele. It will self resolve. But you must make sure to rule out testicular torsion.

Answer 335

Gastroschisis Urgent surgical repair

Answer 336

Phimosis (the foreskin cannot be fully retracted over the glans penis). Most kids born with non-retractile foreskin. Normal up until puberty. If not loosening by age 4 prescribe steroid cream to promote loosening of the skin.

Answer 337

Paraphimosis (the foreskin becomes trapped behind the glans penis, and cannot be reduced). Management: Apply local or general anaesthetic, compress the oedema (may have to apply pressure for \>5 mins) to drain the fluid. If that fails contact paeds surg to puncture the skin with a needle and aspiration fluid. Then replace the foreskin.

Answer 338

**1,2,3,4,5 T’s** 1 vessels (Truncus arteriosus) 2 vessels swap (Transposition of the Great Arteries) 3 = Tricuspid atresia 4 = Tetralogy of Fallot 5 words (Total Anomalous Pulmonary Venous Return)

Answer 339

Septal defects cause L --\> R shunts ACEi, diuretics to reduce preload and strain on right heart plus feeding to increase baby's weight ready for surgical correction

Answer 340

Identified if infant experiences heart failure, or later in life because doctor hears machinery murmur or notices wide pulse pressure (caused by the run-off of blood flow from the aorta to the pulmonary artery during diastole). **What is the problem?** Blood flows from the high pressure aorta into the low pressure pulmonary artery, overloading pulmonary circulation and causing pulmonary hypertension and heart failure (dyspeneoa, FTT, recurrent infections). If not picked up until adulthood pulmonary hypertension can be a significant issue. Children with a small PDA are often asymptomatic, but may develop Infective Endocarditis.

Answer 341

**Bedside tests** ECG – normal with small PDAs. Left ventricular hypertrophy with larger PDAs **Bloods and urine** Nil **Imaging** CXR – full pulmonary artery silhouette and increased pulmonary vascularity. Cardiomegaly may be present in a larger shunt. Echocardiography – visualise the PDA to confirm diagnosis **Special tests** Nil

Answer 342

**Premature infants** * IV indomethacin in patients with very low birth weight * IV indomethacin or ibuprofen of premature infants of larger weight * Treatment can be given before evidence of a PDA becomes evident * Prophylactic indomethacin might increase ductal closure and decrease the incidence of intraventicular haemorrhage **Term infants** * In asymptomatic or symptomatic patients, percutaneous catheter closure is the first-line treatment in order to treat heart failure and prevent elevated pulmonary pressures or endarteritis. * Infants who are symptomatic and too small to undergo percutaneous device closure need ACEi/diuretic treatment and feeding until they are large enough for surgical management

Answer 343

**When does it present?** If severe: acute circulatory collapse at 2 days of life after being previously well (duct closure). This is the usual scenario. If mild: Later in life, often discovered when pt is being investigated for refractory hypertension. The later the abnormality is discovered the harder the HTN is to treat. **How does it present?** Sick baby Hypertension Unequal BP between arms Absent femoral pulses Severe metabolic acidosis May have an ejection systolic murmur between the shoulder blades **MGMT?** ABC, prostaglandins, urgent surgery

Answer 344

The Norwood operation, which connects the aorta and the returning pulmonary veins to the R heart – a one chamber heart! Usually receives follow up operations at 3 months and 6 years

Answer 345

In the immediate newborn period blood flows through the 'Ductus' into the Descending Aorta and hence reaches the lower part of the circulation. Fortunately these babies usually have a VSD, meaning that the blood that flows through the pulmonary artery, though the ductus and into the descending aorta is at least partly oxygenated. As the ductus closes after birth blood pressure in the lower circulation becomes inadequate and severe symptoms develop. Most affected infants develop severe symptoms (difficulty breathing and impaired kidney function) in the first week of life and need urgent surgery **Mx = ABC, prostaglandins, surgery in days**

Answer 346

Presents early in life (usually D2 when duct closes) as the "shocked neonate" – dusky colour, weak or absent pulses, low BP, reduced UO, metabolic acidosis

Answer 347

duct dependent In the first week of life When the ductus closes

Answer 348

Small VSD – high pitched pan-systolic murmur, associated with a thrill Large VSD – Quiet pansystolic murmur, heave

Answer 349

VSD in both

Answer 350

Small --\> conservative management and monitoring Large --\> surgical repair

Answer 351

Secundem (most common) Primium (AVSD)

Answer 352

Most affected children are free of any major symptoms, but the risk of heart failure developing later in life makes closure desirable, unless the defect is very small. These defects may be repaired surgically or by using an expanding plug ("Device"), which can be inserted through a heart catheter without an operation (Device Closure)

Answer 353

OH CRAP THAT BABY IS BLUE! DONT SWEAR IN FRONT OF THE BABY! OH, I SAID, **CRIP** * *C**yanotic Heart Disease (1,2,3,4,5 Ts) * *R**espiratory disease (Meconium aspiration syndrome, pulmonary hypoplasia) * *I**nfection (GBS) * *P**ersistent pulmonary HTN of the newborn (PPHN)

Answer 354

Pulmonary stenosis Right ventricular hypertrophy Overriding aorta VSD Pentology --\> ASD

Answer 355

Murmur, cyanosis or congestive heart failure, typically develops over the first 6-12 weeks of life If mild disease not picked up until later childhood. Presentation at this stage is characterised by FFT, clubbing of the fingers, reduced exercise tolerance and ‘Tet spells’

Answer 356

Comfort the child Rest younger infants against the parents shoulders with knees tucked in Encourage older children to squat O2, IV fluids Beta-blockade and ICU support may be required IM morphine can reduce pain and venous return Phenylephrine is last line\* \*Used to increase systemic venous resistance by direct simulation of peripheral alpha-adrenergic receptors. The goal is to increase the systemic vascular resistance above the resistance of the pulmonary outflow tract so that blood in the right ventricle preferentially flows through the pulmonary circulation, rather than across the ventricular septal defect and into the systemic circulation.

Answer 357

Heart failure is rare. But cyanosis --\> polycythemia --\> thromboembolism can occur. Infective endocarditis and cerebral abscess too!

Answer 358

**CATCH** **22q11 (Di George Syndrome)** Tetralogy of Fallot is famously associated with the deletion of the long arm chromosome 22 Cardiac anomalies (tetra, transpos) Abnormal facies Thymic hypolasia (T cell deficiency) Cleft palate Hypocalcaemia/hypoparathyroidism

Answer 359

Prostaglandins Atrial baloon septostomy Arterial switch is definitive surgical correction at 6-9 months

Answer 360

Right ventricular hypertrophy Coarse ES murmur on ULSE

Answer 361

* This defect is a form of Tetralogy of Fallot * Blood cannot enter the pulmonary circulation via the pulmonary valve. * Blood entering the right ventricle moves into the left ventricle via an ASD/VSD or foramen ovale, is pumped via the left ventricle and then shunts back to the pulmonary circulation via the PDA. * Survival depends on the ductus remaining open in the early days of life * Cyanotic heart disease * Surgical correction with a shunt is required immediately, with complete repair performed after age 1.

Answer 362

A single ventricular outflow tract straddles a large VSD. It has an **abnormal** valve. Presents in newborn period with **mild** cyanosis and congestive heart failure. The abnormal valve is often stenosed (systolic murmur) and may be regurgitant (diastolic murmur). Urgent surgery

Answer 363

ASD If symptomatic or causing R ventricular dilation, catheter closure at 3-5 years Partial AVSD needs surgery at 3 years Complete AVSD: 3-5 months

Answer 364

Small VSD Usually no treatment required, spontaneous closure

Answer 365

**Large VSD** Diuretics, captopril Extra calories Surgery at 3-6 months

Answer 366

* Normally, the pulmonary valve closes a little after the aortic (A2, P2). * During inspiration, venous return in increased at the R ventricle takes a little longer to empty. * Blood pools in the lower pressures of the pulmonary circuit, reducing return to the left heart, which now finishes emptying a little sooner. * Therefore, the split normally widens on inspiration * During expiration, the right heart is given the chance to catch up a little and the split is narrowed

Answer 367

* Stabilise with diuretics, ACEIs and high caloric diet * Treat if: * Heart failure or failure to thrive on medical management * Pulmonary hypertension * Aortic valve prolapse * Infective endocarditis * Surgical and trans-catheter options exist

Answer 368

* Small VSD may have no abnormal findings * Larger VSDs may demonstrate cardiomegaly and pulmonary plethora of CXR * Biventricular hypertrophy can be shown on ECG * Diagnose with echo

Answer 369

High flow VSDs can suck in the nearby aortic leaflet by the Venturi effect and cause aortic regurgitation

Answer 370

Essentially all congenital heart abnormalities increase your risk, except for secundum ASDs

Answer 371

ALL until proven otherwise

Answer 372

Intracranial haemorrhage - 1% of ITP cases

Answer 373

* Pallor – conjunctival, palmar crease * Fatigue, listlessness * Poor growth * Flow murmur * Air hunger (severe) * Hypotension and cardiac failure (severe) * Iron deficiency can present with poor attention span, irritability and pica (eating dirt, clay, ice etc)

Answer 374

Malabsorption and occult blood loss (although rare) should be considered, but usually after failure of dietary measures. Polyps, haemangiomas, Meckel’s diverticula and hereditary telangectiasia are rare causes of GI blood loss.

Answer 375

One of the most common and serious complications of parvovirus B19 infection is transient aplastic crises in patients with chronic haemolytic anaemia such as sickle cell disease and hereditary spherocytosis. Pure red cell aplasia may also develop with a persistent infection of parvovirus B19 in immunocompromised individuals.

Answer 376

FBE Blood film Ferritin Reticulocyte count

Answer 377

A raised APTT in the absence of anticoagulant therapy suggests a deficiency in a factor or an inhibitor. An inhibitor is usually an antibody made against a factor, such as lupus anticoagulant or antibodies formed by haemophilia patients receiving recombinant factors

Answer 378

**Presentation** Clinical manifestations of platelet disorder develop **acutely** – mucosal and skin petechiae, epistaxis, rectal bleeding, haematuria, bleeding gums **Examination** Normal examination – no pallor, no lymphadenopathy or hepato-/spleno- megaly (exclude leukaemia) **Investigations** FBE --\> thrombocytopaenia, blood film shows isolated low platelets with no other findings A bone marrow aspirate is an invasive procedure with some morbidity in children who bruise easily, and is only necessary if the diagnosis is uncertain. It is rarely necessary in uncomplicated ITP. ***ITP is a diagnosis of exclusion, but an FBE and blood film may be sufficient for diagnosis if Hx and Ex consistent. It can be thought of as isolated thrombocytopenia with no other suggestive findings on Hx, Ex, FBE or blood film.***

Answer 379

Platelets consistently under 10

Answer 380

Untreated 75% in 6 weeks, 90% will resovle within 6 months With standard dose steroids 1 week With high dose steroids 2-4 days With IVIG 1-3 days

Answer 381

* **Safety precautions are key** * Allow for generous supervision, especially of young children * Avoid contact sports or any moderate-impact activity * Regular follow up * Parents must receive thorough education * Avoid NSAIDs and 5-ASA Splenectomy is a last line option. Often very effective but vaccinations and life-long antibiotic prophylaxis required.

Answer 382

**Neonates** * Often picked up on screening due to FMHx * Cord blood can be used for genetics and coagulation studies * Intracranial haemorrhage, severe birth bruising and excessive bleeding after circumcision can suggest the disese **Older children** * Haemarthroses tend to occur in walking children

Answer 383

* Mild-moderate haemophilia A can be treated with DDAVP after appropriate challenge test (\>5y/o) * Not adequate for major bleeding * Tranexamic acid can reduce mucosal bleeds and epistaxis * Severe disease can be treated with 25-40 units/kg of recombinant factor concentrates three times a week.

Answer 384

AML (less common than ALL)

Answer 385

* **CXR** is used to investigate the possibility of mediastinal masses (occurs in 50% of T-ALL). * **Lumbar punctures** are mandatory to detect occult CNS infiltration. They are often delayed until treatment has begun to reduce the risk of seeding into CNS. Also because often thrombocytopenic Many more tests are done. This is the realm of a paediatric oncologist. Tumour lysis bloods, liver and renal function, lactate dehydrogenase and coagulation studies all form part of the initial work-up at baseline.

Answer 386

It is commonly quoted that cure rates (in children) are 80%. The current rate is probably higher, especially in low risk disease. **Remission Induction** * Aims to eliminate 99% of the tumour cell population. This should achieve normal haematopoiesis and functional status. * Does the ‘heavy lifting’ --\> remaining treatment is about total eradication, relapse prevention and cure * High risk of tumour lysis in early chemo. * the breakdown products of dying cells causes hyperkalaemia, hyperphosphataemia (which causes hypocalcaemia), high blood uric acid and high urine uric acid and consequent acute uric acid nephropathy and acute kidney failure. * Tumour lysis prevention: * bicarb to alkylise urine and prevent uric acid crystal formation in kidney * allopurinol * fluid diuresis * monitor all electrolytes **CNS protection** * Most chemo penetrates the BBB poorly * Intrathecal and IV methotrexate can obviate the need for cranial irradiation (CI). CI is still used for overt CNS disease or high risk patients.

Answer 387

Strangulation/NAI Vomiting Coughing + other causes of petechiae (SHIELD)

Answer 388

Immature megakaryocytes in BM churning out platelets. The platelets are young/healthy/sticky. Vs kids with cancer with same low platelet count who will bleed because unhealthy platelets.

Answer 389

· **Oral** – paracetemol, ibuprofen, oxycodone · **Intranasal** – fentanyl (device that makes a mist out of it) · **IV** – morphine, ketamine · **IM** – (rare) ketamine, morphine · Local anaesthetic

Answer 390

* Wet nappies * Tears * Fontanelles * Skin turgor * Mucus membranes * Cap refill * HR/BP * Weight * Vomits/diarrheoa * Alertness

Answer 391

Tracheo-oesophageal fistula

Answer 392

pyloric stenosis (if age 2-7wks) duodenal atresia

Answer 393

A 'Slipped Upper Femoral Epiphysis' (also called a 'SUFE') is when the femoral epiphyseal plate is weak and the ball head of the femur slips downward and backward. The exact cause of this condition is not known. A 'SUFE' is not usually associated with an injury. The symptoms often develop slowly - over several months - and may seem like a pulled muscle in the hip, thigh or knee. It is important to get an early diagnosis and treatment before the slip gets worse and children may need to have the unaffected side treated as well to prevent future slipping. Clasically happens to obese teenage boys, can be bilateral True hip pathology causes GROIN pain! **Signs and symptoms** Groin, hip, thigh or knee pain. (Some people only have knee pain, even though the condition affects the hip) Limp Limited movement of the hip joint There may be slight shortening of the affected leg. **Diagnosis** Diagnosis is usually made by physical examination of hip movement and an x-ray. Attached X ray shows how in the abnormal side the line does not cut off the femoral head like it should **Management** Surgical correction with screw

Answer 394

Refusal to weight bear Fever (\>38.5) Raised WBC ESR \>40 CRP \>20

Answer 395

6 weeks, it gets better after that

Answer 396

Bring them back if: 1. They become dehydrated (because of vomiting/diarrheoa) with poor oral intake and no wet nappies 2. Become drowsy or not responsive to interactions 3. Puffing very hard or finding it difficult to breathe 4. Uncontrollably irritable, not able to be soothed

Answer 397

Nothing, vomiting is not a localising sign in a kid. Could be anything from UTI to meningitis.

Answer 398

Meningitis Pneumonia UTI Sepsis

Answer 399

**Febrile convulsions / seizures are seizures in which** * Fever \>38 degrees * No evidence of CNS infection * No history of afebrile seizures * No history of neurological deficits or developmental delay **Simple febrile seizures are** * generalized tonic and/or clonic seizures * Short in duration * Do not recur within the same febrile illness **Complex febrile seizures are** * focal features at onset or during the seizure * duration of more than 15 minutes * Recurrence within the same febrile illness * Incomplete recovery within 1 hour.

Answer 400

6 months to 6 years

Answer 401

3 in 100 babies

Answer 402

* Signs and symptoms of infection (often URTI, otitis media or UTI). * Description of a generalized, tonic-clonic seizure (simple) or a focal seizure (complex). Normal neurological exam post-ictally. * \*NB if eyes deviate to one side this is a sign of a focal seizure

Answer 403

**Bedside tests** * BGL – this is the only investigation you should do if the child is \>6 months and the source of the fever can be identified * Urine dipstick and MC&S **Bloods and urine** * FBE * CRP * Blood culture * UEC / CMP * check for electrolyte derangement. * Feeding babies water bottles causes hyponatraemic seizures **Imaging** CXR if respiratory symptoms **Special tests** LP – low threshold if unknown source of fever. From RCH "consider LP if the child is less than 12 months and not up to date with immunisations, if they are clinically unwell, or if they are already on oral antibiotics that may mask meningitis."

Answer 404

* Recurrence rate depends on the age of the child; * the younger the child at the time of the initial convulsion, the greater the risk a further febrile convulsion * (1 year old 50%; 2 years old 30%). * Risk of future afebrile convulsions (epilepsy) is increased by: * family history of epilepsy, * any neurodevelopmental problem, * atypical febrile convulsions (prolonged or focal). * With none of these risk factors risk of recurrence is similar to the rest of the population (1%). With 1 risk factor, risk is 2%, with \>1 risk factor, 10%.

Answer 405

* Fever control: * minimal clothing, nappy alone or light outer layer depending on ambient temperature * Tepid sponging, baths and fans are ineffective at lowering core temperature and are NOT recommended * Paracetamol has not been shown to reduce the risk of further febrile convulsions. It may be used for pain/discomfort associated with febrile illnesses (e.g otitis media),it should not be solely used to control fever * If the seizure recurs, roll him onto his side and allow him to fit, Seizure should not last longer than 3-5 minutes. Any longer and an ambulance should be called. * If Henry was to have recurrent or prolonged febrile seizures, prophylactic oral diazepam or rectal diazepam (rescue therapy) may be prescribed

Answer 406

No, not at all

Answer 407

Teething will not cause fever \> 38.5oC

Answer 408

**History** * Headache (if child can talk) * Photophobia (if child can talk) * Cough * Coryza * Diarrheoa * Vomiting * Abdominal pain * Joint symptoms * Dysuria/foul smelling urine * Travel history * Sick contacts * Immunisations **Exam**: * Vitals, general appearance, conscious state * Neck stiffness * ENT examination * Work of breathing * Abdominal exam * Skin rash * Joint swelling

Answer 409

* Sick child with fever * Vomiting * Red-yellow bulging TM * Discharge * Loss of TM landmarks * Persistent fever and pain after 3 days of conservative approach * Bilateral AOM *

Answer 410

Birth incidence is about 1 in 1000 **live** births. Overall incidence rises after maternal age of 35 years.

Answer 411

50% have congenital heart defects particularly AVSD

Answer 412

**Medical** * Growth * Plot growth on Trisomy 21 specific growth charts * Prevent obesity * Cardiac * ECHO at birth * Annual follow up * GIT * Coeliac screening * Endocrine * Annual TSH (at increased risk of hypothyroidism) * Haeamtological * Annual FBE (at increased risk of polycythaemia) * Hearing * Hearing test as new born and at six months of age * Opthalmology * Eye examination every 3 years * MSK * Education RE: atlanto-axial instability, avoid trampoline and high risk activities, discuss positioning of the spine during anasthaesia/surgery * Low threshold for imaging. Routine spinal xray is not recommended. **Non-Medical** * ?Early intervention * ?Funding / Carer’s Pension * ?Educational and Vocational Training

Answer 413

CVS = 1% above the background risk Amniocentesis = 0.5%

Answer 414

**Diagnosis** = herpes simplex gingivostomatitis **Management** = Pain relief (codeine may be required as it is very sore). Antivirals inneffective **Prognosis** = Child may have a fever and become irritable, a day or two later ulcers develop on the lips and gums. These are painful and often lead to drooling and a refusal to eat or drink, dehydration can occur. The pain normally subsides after 3-4 days, the blisters usually take from 10 -14 days to go away. The blisters never leave scars.

Answer 415

Discuss with registrar/consultant Full sepsis work-up: FBE/film, blood culture, urine culture (SPA), LP ± CXR Admit for empirical antibiotics

Answer 416

* Discuss with registrar/consultant * Full sepsis workup: * FBE/film, blood culture, urine culture (SPA) ± CXR (only if respiratory symptoms or signs) ± LP * Discharge home with review within 12 hours if the child is: * Previously healthy * Looks well * WCC 5,000 - 15,000 * Urine microscopy clear * CXR (if taken) clear * CSF (if taken) negative * If the child is unwell or above criteria are not all satisfied, admit to hospital for observation +/- empiric i.v. antibiotics

Answer 417

**Idiopathic Nephrotic Syndrome (90% of presenting children)** * Minimal change disease * Focal segmental glomerulosclerosis * Also called steroid-sensitive nephrotic syndrome as 80+90% of cases will respond to initial steroid therapy ******Non-idiopathic Nephrotic Syndrome (rare)** * Secondary * SLE * Henoch Schonlein Purpura * Membranoproliferative GN * Membranous nephropathy * Congenital nephrotic syndrome

Answer 418

* 80% of children with Minimal change will relapse * Steroid-responsive patients have little risk of chronic renal failure * Patients with FSGS may initially respond to steroids but later develop resistance * Many children with FSGS progress to end-stage kidney failure * Recurrence of FSGS occurs in 30% of children who undergo renal transplantation

Answer 419

**Membranoproliferative glomerulonephritis** Characterised by hypocomplementemia (low C3 and C4) with signs of glomerular renal disease 5 to 15% of children with primary nephrotic syndrome Typically persistent Has a high likelihood of progression to renal failure over time **Membranous nephropathy** Less than 5% of children with primary NS Seen most commonly in adolescents and children with systemic infections Hep B, syphilis, malaria and toxoplasmosis Or on specific medications Gold, penicillamine

Answer 420

**Usually neonates or teenagers** Sudden onset testicular pain and swelling; occasionally nausea, vomiting. Note: pain may be in the iliac fossa, may be associated with sports activity Discolouration of scrotum; exquisitely tender and swollen testis, riding high. Cremasteric reflex is usually absent. **Management**: Early surgical consultation is vital, as delay in scrotal exploration and detorsion of a torted testis will result in testicular infarction within 8-12 hours. Keep the child fasted.

Answer 421

* Perform a reduction manoeuvre (see below) * expect distress and pain * a click may be felt over the radial head * review after ten minutes * if reduction fails, consult with senior medical staff https://youtu.be/-0ROu4hCXwQ

Answer 422

Intussusception

Answer 423

**Primary – ages 3 months – 2 year olds** *Ileocaecal location* Idiopathic **Secondary – ages 4 years – 12 year olds** *Ileoileul location* Mesenteric lymph nodes HSP --\> pathological lead point of submucosal haemorrhage Meckels diverticula Haemophilia --\> submucosal haemorrhage

Answer 424

1. Fluid resuscitation 2. Analgesia 3. Air enema 4. Definitive surgery if necessary

Answer 425

Like a sock folding in on itself

Answer 426

99% in first day Rest in second day If not passed on 3rd day it's a sign of abnormality

Answer 427

In hirschprungs on rectal exam there is explosive discharge of flatus and faeces

Answer 428

Suction rectal biopsy

Answer 429

1/25 1/2500

Answer 430

Cardiac defects Down syndrome

Answer 431

Ask if either parent had pyloric stenosis when they were born.

Answer 432

20% chance

Answer 433

The vomiting may continue for 3 - 5 days, that is normal.

Answer 434

Immediately after birth = duodenal atresia 3 days after birth = malrotation with volvulus First few days of life with failure to pass stools = MI or Hirschsprungs 3-4 weeks after birth = pyloric stenosis

Answer 435

Mild dehydration = No signs Moderate dehydration = 4-6% depleted - **Signs of dehydration** Severe dehydration is \>= 7% depleted - **Shock** *For the purposes of calculation of fluid requirements use:* Mild - 3% Moderate - 5% Severe - 10%

Answer 436

**First:** For shock give 10-20ml boluses of normal saline until signs of shock improve. **Second:** Replace deficit, so for a 6kg kid if they're moderately shocked that approx 5%, so their deficit is approx 300ml, give 300ml normal saline **Third**: Give maintenance fluids using normal saline + 5% glucose. Using the 4,2,1 rule for a 6 kg infant that is 24ml/hr of normal saline + 5% glucose. **Monitor electrolytes daily and consider adding 20mmol K**

Answer 437

In non-dehydrated children, consider using 2/3 maintenance doses in unwell children, especially those with pneumonia or meningitis.

Answer 438

Cryptosporidium Giardia Lamblia

Answer 439

dysentery w blood, pus, pain and tenemus

Answer 440

**Bedside** None **Bloods and urine** UECs and glucose a minimum if commencing any IV rehydration **Cultures** Faecal culture and MCS if significant abdominal pain, blood or mucus, or septic child Faecal ova, cysts and parasites – if considering parasitic causes C difficile toxin if recent use of antibiotics

Answer 441

Post-gastroenteritis lactase deficiency Mx - Lactose free diet for a few weeks

Answer 442

Coeliac disease!

Answer 443

**Bedside** NA **Bloods** * *(not anti TTG or IgA like normal as low sensitivity under 2 years)* * Anti Gliadin * HLA testing * Screen for T1DM and thyroid disease * FBE * May show microcytic or macrocytic anaemia from iron or folate deficiency * U&E * may reveal reduced concentrations of calcium, magnesium, total protein, albumin or vitamin D **Imaging** None **Special** Gastroscopy and small bowel biopsy

Answer 444

Exclusion of gluten (barley, rye, wheat, and oats) Dietary fortification – iron, folate, calcium and vitamin D

Answer 445

1/25 boys born

Answer 446

SpO2 Oral intake Parental anxiety

Answer 447

What worries you the most?

Answer 448

Subacute onset, prominent cough, +/- headache, +/- sore throat Roxithromycin PO for 10 days

Answer 449

The response of fever to paracetemol is not significant, and is not an indicate of illness severity. However, if the child was tachycardic and the paracetemol does not bring their HR down, you would consider myocarditis. If it was myocarditis admit them for monitoring and supportive care.

Answer 450

* malrotation and volvulus * duodenal atresia (if obstruction distal to Ampulla of Vater 80% of cases) * jejunoileal atresia * meconium ileus * necrotising enterocolitis

Answer 451

The first stool is passed within 24 hours of birth in 99 percent of healthy full-term infants and within 48 hours in all healthy full-term infants. Failure of a full-term newborn to pass meconium within the first 24 hours should raise a suspicion of intestinal obstruction.

Answer 452

Exophalos (omphalocoele) - large defect at the umbilicus with herniation of bowel and liver into a sac covered by fused amniotic membrane and peritoneum. **Associations** Prematurity/IUGR 30% will have CVS defects Also associated with trisomy 13 and 18, renal abnormalities and other syndromes. **Diagnosis** Usually diagnosed on the 12 and 20 week scans. Aim is to then monitor them and deliver them in a tertiary centre. **Management**: * Glad wrap * NG decompression * IV Ab and fluids * Catheter to monitor fluid output * Heater * BSL * Look for associated malformations * Delayed operation (as often unstable initially). * appendix is removed and the goal is to get it all inside the abdomen. This is not always possible and thus a 'silo reduction' may be used.

Answer 453

Gastroschisis - defect immediately to the right of the umbilicus through which bowel (and sometimes gonads) herniate. There is no covering sac and the eviscerated small and large bowel is thickened and densely matted with exudate as the result of amniotic peritonitis before birth. **Associations** Prematurity/IUGR Related to maternal drug use. **Diagnosis** Usually diagnosed on the 12 and 20 week scans. Aim is to then monitor them and deliver them in a tertiary centre. **Management:** * Glad wrap * NG decompression * IV Ab and fluids * Catheter to monitor fluid output * Heater * BSL * Look for associated malformations * Immediate operation * appendix is removed and the goal is to get it all inside the abdomen. This is not always possible and thus a 'silo reduction' may be used.

Answer 454

The 9 S's of development ## Footnote Neonate 6 weeks 3 months 6 months 9 months 12 months 18 months 3 years 5 years

Answer 455

SHIELD + vWD vWD less likely to be acute diagnosis. The story is "abnormally prolonged bleeding when prompted (like teeth brushing)" versus SHIELD which is acute onset petechiae

Answer 456

Because remember that desmopressin/DDAVP is just synthetic ADH. ADH causes aquaporins to be plugged in to the distal collecting tubule allowing for resorbtion of water which can cause dilutional hyponatremia. The challenge test it to make sure the kid doesn't get hyponatraemic.

Answer 457

**ABCDEFGHI** * A - Appendicitis * B – Balls (testicular torsion) * C – Chest infection * D – Diverticulum (Meckel’s) + DKA * E – E.Coli (UTI) * F – Faecal or urinary retention * G - Gastroenteritis * H – Hernias/HSP * I – Intussusception + intestinal malrotation

Answer 458

* Following infectious diarrhoea, infants may have temporary lactose intolerance. * This sequela of acute gastroenteritis used to be prominent in infants * This may be due in part to early oral feeding which aids mucosal recovery. * Clinical features of sugar intolerance include: * Persistently fluid stool * Excessive flatus * Excoriation of the buttocks * Typically, these infants appear well. Breast feeding should continue unless there are persistent symptoms with buttock excoriation and failure to gain adequate weight. Formula-fed infants should be placed on a lactose-free formula for 3–4 weeks.

Answer 459

A clinical syndrome characterised by chronic diarrhoea often with undigested food in the stools of a child who is otherwise well, gaining weight and growing satisfactorily. Stools may contain mucus and are passed 3–6 times a day; they are often looser towards the end of the day. Onset is usually between 8 and 20 months of age. **Management** Reassurance and explanation. No specific drug or dietary therapy has been shown to be of value in toddler diarrhoea.

Answer 460

* Headache/neck stiffness/photophobia/Rash * Cough, coryza, sore throat * Dysuria/frequency * Vomiting/diarrheoa/abdominal pain * Joint or elsewhere pain? * Contacts * Travel * Immunisations * Intake/vomiting/urine production

Answer 461

* **Tumour** * painless * **Henoch Schonlein purpura** * purpuric rash on testicle * **Varicocele** * bag of worms, left side, teenager * **Hydrocele** * transilluminates, soft, can feel testis * **Incarcerated inguinal hernia** * **Epididymoorchitis** * fever, nausea, vomiting, urinary symptoms * **Torsion of the appendix testis (hydatid of Morgagni)** * More gradual onset. Focal tenderness at upper pole of testis; "blue dot" sign - necrotic appendix seen through scrotal skin. * **Torsion** * Sudden onset testicular pain and swelling; occasionally nausea, vomiting. Discolouration of scrotum; exquisitely tender and swollen testis, riding high. Cremasteric reflex is usually absent. * **Idiopathic scrotal oedema** * It usually affects boys between 5-9 years of age. There is insidious onset of redness and swelling of perineum or inguinal region (groin), extending to scrotum. It may be itchy but is not often painful.

Answer 462

* observation of the patients gait and resting position * natural position of the testis in the scrotum while standing * presence or absence of cremasteric reflex (this is absent in torsion) * palpation of lower abdomen, inguinal canal and cord * palpation of scrotum and contents, compare with unaffected hemiscrotum * transillumination * Is the swelling reducible?

Answer 463

**Without failure to thrive** * Infectious * Bacterial - campylobacter, salmonella * Antibiotic induced - C difficile colitis * Parasitic - Giardia lamblia * Post-infectious - secondary lactase deficiency * Toddler's diarrhoea * Lactase deficiency (lactose intolerance) * Irritable bowel syndrome - a diagnosis of exclusion in an older child/adolescent **Chronic diarrhoea with failure to thrive** * GI causes * Coeliac disease * Milk protein allergy - cow's milk, soya protein, etc. * Inflammatory bowel disease * Pancreatic insufficiency --\> Cystic fibrosis * Others * Thyrotoxicosis * Food allergy

Answer 464

The classical presentation is of a profound malabsorptive syndrome at 6-24 months of age after the introduction of wheat-containing weaning foods (e.g. steatorrhoea, vomiting in some cases). * FTT with poor appetite * Steatorrhoea * Anorexia, nausea and vomiting, abdominal pain * Abdominal distention * Buttock wasting * General irritability, apathy and fatigue - consider Fe deficiency Presentation is highly variable, and may be less acute later in childhood.

Answer 465

Most commonly functional constipation (99%) - due to lack of fibre, poor fluid intake, behavioural things (especially around toilet training), and changes in diet (esp. when changing to cow's milk). **Management** Clean out + maintain with stool softeners and adequate fibre. Address any underlying problems. This may need to be done multiple times.

Answer 466

**Basics** * Keep breastfeeding * Regular small volume flood intake * Ondansetron **Place and person** Admit the following: * Infants with moderate-severe dehydration * Diagnosis in doubt * Those who are high risk of dehydration (keep in hospital for 4-6 hours): * Infants * Infants * High frequency diarrhoea (8 per 24 hours) * High frequency vomiting (\>4 per 24 hours) **Investigations** * Mostly not required. * UECs and glucose - if severe dehydration and needs resuscitation. * If there is significant abdominal pain, or blood or mucus in the stools, or if the child appears septic * Faecal culture * Faecal leukocytes or blood * Faecal ova, cysts and parasites - when considering parastic infections * C difficile toxin (faecal) - if recent use of antibiotics **Definitive** Oral, NG or IV rehydration There is no role for antibiotics in bacterial gastroenteritis. **Long term** Early feeding as soon as rehydrated reduces stool output and aids gut recovery. Anti-diarrhoeals and maxalon are not recommended.

Answer 467

The proportion of boys with retractile foreskins is: 40% at 1 year, 90% at 4 years and 99% at 15 years. **Management of true phimosis** * 0.05% betamethasone cream should be used twice daily for 2 to 4 weeks. * Gently retract foreskin without causing any discomfort and apply a thick layer of cream to the tightest part of the foreskin. * Circumcision (if significant phimosis and steroid creams fail)

Answer 468

Smegma = white/yellow lumps are called smegma and are made up of the cells that once attached the foreskin to the head of the penis. Smegma is normal and will eventually disappear. No treatment is needed. Balanitis: severe inflammation of the glans penis +/- foreskin is often due to infection and is usually termed balanitis. Tx is Soaking in a warm bath with the foreskin retracted plus topical steroid.

Answer 469

* Enterovirus * HSV * Other herpes viruses (EBV, CMV, HHV6, VZV) * Arboviruses. * Less commonly, encephalitis can be caused by bacteria, fungi or parasites.

Answer 470

**Below 2 months of age** * Group B streptococcus * E. coli and other Gram-negative organisms * Listeria monocytogenes * Plus the below.... *Use cefotaxime and ben pen* **Above 2 months of age** * Streptococcus pneumoniae * Neisseria meningitidis * Haemophilus influenzae type B (in unimmunised children) * As a result of immunisations Hib meningitis is now rare and there has been a reduction in the incidence of pneumococcal meningitis. *Use ceftriaxone and dexamethasone*

Answer 471

25% of people with autism will have normal/high IQ 75% will have some degree of intellectual disability The child's level of ability is often uneven, with areas of strength and weakness.

Answer 472

There are three problems: 1. Protrusion of the bowel through the processus vaginalis can obstruct it's blood supply causing necrosis/peritonitis/sepsis 2. Obstruction of the processus vaginalis can put pressure on and ultimately obstruct the blood supply to the testicles and the spermatic cord, resulting in death of the testis and/or reduced fertility 3. obviously there is the risk of bowel obstruction

Answer 473

Ballooning of the foreskin during urination due to physiological phimosis. In itself is not a concern, no need for management, will resolve as phimosis resolves.

Answer 474

4 years old, topical steroid.

Answer 475

* Hernia is reducable (unless strangulated, in which case it will be extremely painful) * Hydrocele is not reducable, it would take hours for you to squeeze the fluid back up the narrow patent processus vaginalisis * Hydrocele transilluminates, hernia does not * You can get above a hydrocele but not a hernia * Hydrocele doesn’t really ever have to be fixed, but you do for cosmesis after age 2.

Answer 476

* Pre-term baby, typically in the 2nd-3rd week of life * Infant stops tolerating feeds --\> vomiting (bilious sometimes) * Abdominal distention * Rapidly becomes shocked * Other features: * Bloody stools * Pneumatosis intestinalis - gas cysts in the bowel wall; diagnostic for NEC * Diminished bowel sounds * Signs of bowel perforation - sepsis, shock, peritonitis, DIC

Answer 477

Tracheo-oesophageal fistula in 85% of cases Diagnosis is confirmed by passing a large firm catheter through the mouth and finding that it cannot be passed more than about 10cm from the gums. A plain XRAY of the torso will show gas in the bowel (if there is distal TOF).

Answer 478

Slipped upper femoral epiphysis (SUFE) is the most common hip disorder in the adolescent age group. It occurs when weakness in the proximal femoral growth plate allows displacement of the capital femoral epiphysis. The metaphysis displaces anteriorly and superiorly, leading to the slipped state. There are a number of ways that SUFE can be classified **Stable vs unstable** The patient is able to weight bear on the affected leg (stable) versus unable to weight bear even with crutches (unstable). **Acute, chronic or acute on chronic** Acute = Sudden onset of severe symptoms and inability to weight bear Chronic = Gradual onset and progression of symptoms for more than 3 weeks, without sudden exacerbation. This is the most common presentation (85% of patients with SUFE) Acute on chronic = Sudden exacerbation of symptoms due to acute displacement of a chronically slipped epiphysis **Radiographical degree of displacement** ``` Type I (0 to 33% displacement) Type II (34 to 50% displacement) Type III (\>50% displacement) ``` The likelihood of complications increases with displacement

Answer 479

A very reliable sign of chronic SUFE is detection of obligatory external rotation during flexion of the hip. As the hip is flexed on the affected side, the thigh will automatically rotate and abduct

Answer 480

**Basics** Nil by mouth Depending on severity, pain management according to WHO pain management ladder. **Place and person** Urgent orthopaedic referral **Investigate and confirm diagnosis** AP and frog lateral pelvis x-rays of both hips **Non-invasive management** The patient needs to be kept non-weight bearing **Definitive management** Immediate surgical screw fixation across the physis (within 24 hours)

Answer 481

(1 - 50%) Oligoarticular JIA (peak age 2-3, rare after age 10, F\>M) (2 - 40%) Polyarticular JIA (dual peaks at 2-5 then 10-14 years, F\>M) (3 - 10%) Less common types like systemic JIA, psoriatic and enthesitis (HLAB27+) (anyone less than 17, M=F)

Answer 482

JIA diagnosed if age 6 weeks of symptoms **Systemic arthritis** * 1 or more joints * Preceded by at least 2 weeks of fever * Signs/symptoms include one or more of: * evanescent rash, * generalised lymphadenopathy, * hepato/splenomegaly, * serositis **Oligoarthritis** * Arthritis affecting 1-4 joints _during the first 6 months_ * Persistent oligoarthritis affects up to 4 joints throughout the course of the disease **Polyarthritis** * 5 or more joints during the first 6 months * RF+ disease is more aggressive than RF- **Psoriatic arthritis** * Diagnosed if there is arthritis and psoriasis, or * arthritis plus 2 or more of: * dactylitis, * nail pitting, * onycholysis, * fam hx of psoriasis **Enthesitis-related arthritis** * Diagnosed if there is arthritis and/or enthesitis with 2 or more of: * hx of sacroiliac joint tenderness * HLA B27 antigen, * onset of arthritis in a male over 6 years of age * acute anterior uveitis * Fhx of ankylosing spondylitis, enthesitis-related arthritis, sacroiliitis with inflammatory bowel disease, Reiter’s syndrome, or acute anterior uveitis in a first-degree relative

Answer 483

**Basics** Rule out septic arthritis **Place and person** Refer to specialist paediatric rheumatology multidisciplinary team **Ix and confirm diagnosis** * FBE (anaemia, thrombocytosis, WCC) * ESR/CRP * RhF, anti-CCP * ANA (for anterior uveitis risk) * HLA B27 genotyping if suspect enthesitis * Fe studies (reactive ferritin) * Xray **Non-invasive management** Physiotherapy and occupational therapy Swimming and cycling encouraged, weight-bearing activities for those at greater risk of low bone mineral density **Definitive management** Varies depending on type of JIA, sounds very specialized. * Pain relief with NSAIDs or corticosteroid injections * Methotrexate, sulfasalazine, steroids * Biologics (anti-TNFa) increasingly used

Answer 484

* 70% of patients will have minimal or no joint disease by age 15 * Oligoarticular disease has the best prognosis, with most patients achieving remission * RF+ve patients and those with systemic arthritis have a worse prognosis, with more continuing to have active disease after several years

Answer 485

**MAS – Macrophage activation syndrome** * Life-threatening emergency * Usually occurs early in the onset of systemic JIA * high fever, hepatosplenomegaly, lymphadenopathy, pancytopenia, liver dysfunction, disseminated intravascular coagulation, hypofibrinogenemia, hyperferritinemia, and hypertriglyceridemia * **Reduced ESR** * Tx with high dose steroids and cyclosporin

Answer 486

Now. You have 6 hours before bowel becomes ischaemic and patient dies

Answer 487

* Wide-calibre feeding tube is passed and checked by X-ray to see if it reaches the stomach * AXR shows gasless abdomen --\> absent gastric bubble * If not diagnosed at birth, presents clinically with: * Persistent salivation and drooling from the mouth after birth * Infant will cough and choke when fed, and have cyanotic episodes

Answer 488

Check for others, they tend to co-occur.... **VACTERL** V - Vertebral anomalies A - Anal atresia C - Cardiovascular anomalies T - Tracheoesophageal fistula E - Esophageal atresia R - Renal (Kidney) and/or radial anomalies L - Limb defects

Answer 489

Enterocolitis Decompression washout enemas, IV ABx and intensive care

Answer 490

* Surgery too hard in neonate, use colonic washout enemas until baby is 5-6kgs * Pull-through procedure * Involves resection of distal bowel to transition point (established via contrast enema X-ray), and mobilisation of proximal bowel to allow pull-through to anal anastomosis * Complications * Prone to dehydration as large bowel is responsible for absorption of sodium, potassium and fluid Increased frequency of bowel movements due to increased fluidity of stools * Often incontinent * Technically difficult procedure due to risk of damage to continence muscles, possibility of anastomotic breakdown, stricture * Prone to Hirschsprung’s Enterocolitis even years after corrective procedure * Requires IV antibiotics every time

Answer 491

**HAI! DONT TAP SAM** ## Footnote H - HSP A - Appendicitis I - Inguinoscrotal pathology/testicular torsion D- DDH (age 1-4) O- Osteomyelitis/septic arthritis N- NAI T- Toddler’s fracture (age 1-4) T- Transient synovitis A- Arthritis/JIA P- Perthes disease (age 4-10) S- SUFE (aged \>10) A- Articular or non-articular stress fracture M- Malignancy (ALL)

Answer 492

**Basics** Bed rest is important for children with transient synovitis. Analgesia; NSAID (eg ibuprofen) +/- paracetamol **Place and person** Review with local doctor within 3 days. **Ix** None **Definitive** Analgesia **Long term/follow up** Return to hospital if febrile, unwell or getting worse Patients with symptoms for greater than 4 weeks can be referred to rheumatology clinic.

Answer 493

* General appearance, temp * Gait - running may exaggerate a limp * Neurological examination - look for ataxia, weakness * Generalised lymphadenopathy (viral infection / haematological cause) * Excessive bruising or bruising in unusual places (NAI, haematological) * Abdomen, scrotum and inguinal area (masses) * Bony tenderness * All joints * knee pain can be referred from the hip, and thigh pain can be referred from the spine * Include sacro-iliac joints and spine in joint assessment - look for pain on flexion and/or midline tenderness which may be present in discitis * Exaggerated lordosis (discitis) * Hip abduction and internal rotation are often the most restricted movements in hip pathology

Answer 494

Staphylococcus aureus but can be caused by group A b-haemolytic streptococci and Haemophilus influenzae.

Answer 495

A self-limiting disease of the femoral head comprising of necrosis, collapse, repair, and re-modelling that presents in the first decade of life and is more commonly seen in boys. **Presentation** * An occasional limp in the early phase * Knee pain * Worsening pain and limping as the disease progresses * Pain in the knee, thigh or groin on movement or when putting weight through the leg * Decreased movement * Uneven leg length – the affected leg may become shorter **Investigation** - Xray +/- MRI **Management** If the hip joint is only mildly affected, no immediate treatment may be required. If there is pain or stiffness, they will need to rest to relieve the hip joint from weight-bearing movements (no high-impact activities, like jumping or running, until the joint has recovered.) Low impact activities like swimming and gentle cycling are recommended. Ortho referral for consideration of surgical repair

Answer 496

**Acute** Gastro **Chronic** Coeliac Lactose intolerence (temporary after gastro or permanent) Pancreatic insufficiency from CF

Answer 497

It's an umbilical hernia. Common condition and \> 95% will resolve spontaneously by 2-3 years. In infants, hernia may become large and increase in size in the first 6 months. No treatment needed Refer to the OPD of General Surgery if still present after 2 years or if there is parental anxiety due to large size in infancy

Answer 498

None. This is an indirect inguinoscrotal hernia protruding through a patent processus vaginalis. If the duct was smaller it would just cause a hydrocele. There are **no tests indicated.** Ultrasound can not see anything.

Answer 499

**History** * *Microcytic anaemia -- Iron deficiency* * Intake * diet, meat, chicken, veges * Absorbtion * Screen for malabsorbtion * diarheoa, steatorheoa, poor growth, abdo pain * Family history or coeliac * Loss * blood loss * *Microcytic anaemia -- thalassaemia* * family history of thalassaemia * *Normocytic anaemia -- aplastic anaemia* * Weight loss, night sweats, predisposition to infection, bruising/petechiae * Slapped cheek picture or rash (transient erythroblastopenia of Parvovirus) * *Macrocytic anaemia -- B12 and folate* * adequate intake of folate and B12? **Exam** * Vitals * Growth charts * Pallor palmar creases/conjunctiva * Jaundice * Flow murmur? * Hepatosplenomegaly * Lymphadenopathy **Investigations** * FBE * Blood flm * Reticulocyte count * Fe studies

Answer 500

80% of preterm infants 60% of term infants

Answer 501

If \>15% of total bilirubin is conjugated or absolute conjugated bili of 15umol, that’s when to consider a hepatic/post-hepatic causes

Answer 502

1. Too early ( 2. Too high (More than 320) 3. Rising too quickly (Increasing at a rate of greater than 85 micromol per day) 4. Too late (more than 2 weeks)

Answer 503

Slera = 50 Body = 100 (progresses cephalocaudally)

Answer 504

**Before 24 hours** * Haemolysis due to blood group incompatibility * Rhesus incompatibility * ABO incompatibility * Minor blood group incompatibility * Haemolysis due to congenital infection/sepsis * Haemolysis due to RBC abnormality * RBC enzyme deficiency --\> G6PD * RBC membrane defect --\> hereditory spherocytosis

Answer 505

* Premature infants * Low albumin * Sepsis (esp meningitis) * Unconjugated bilirubin \>350 micromol/L * Asphyxia, acidosis, hypoxia and hypothermia

Answer 506

**Introduction** **Explanation (before, during and after)** * Phototherapy transforms your baby’s bilirubin into a less harmful chemical * Your baby is placed in an incubator, they are undressed and wear eye protection * Because they can dehydrate, you will need to feed your baby every 3-4 hours * This therapy will normally last 1-2 days until the bilirubin levels are rechecked are low enough to be safe **Benefits** Safe way to reduce the level of bilriubin and protect the brain **Risks** Overheating, water loss, diarrhea, rash, (theoretical) retinal damage **Alternatives** A bili-blanket is a pad that applies light directly to the skin. Can allow your baby to stay in the cot

Answer 507

**Depends whether it is conjugated or not…** *_Unconjugated_* * G6PD * Hypothyroidism * Breast mild jaundice * Sepsis *_Conjugated_* * Hepatitis due to TORCH infections * Alpha1 antitrypisin * Cholestasis due to biliary atresia or choledocal cyst

Answer 508

**Acute signs** * Lethargy/drowsiness * Poor feeding * Irritability * Temperature instability * Arching of the head, neck and back (opisthotonos) * Seizures **Long term** * Death * Permanent brain damage including: * Athetoid cerebral palsy * Deafness * Mental retardation

Answer 509

* Inflammation * Crohn’s, ulcerative colitis * Infection * C diff, giardia, enamoeba, shigella, other causes of gastro * Meckel’s * Milk * Cow’s milk protein intolerance is a common cause of rectal bleeding * Trial a non-milk (and non-soy) diet * Often resolves with age

Answer 510

Breast milk is high calories of low volumes --\> more enterohepatic circulation Don’t stop breast feeding! In fact, important to keep feeding to rehydrate and to interrupt enterohepatic circulation / ‘get the gut moving’

Answer 511

1. Determine the time course of the jaundice 1. early, high, accelerating, late 2. Ask after the underlying cause 1. Blood groups/anti-D 2. PPROM/GBS/infections 3. Family history of blood disorders 4. Instrumental delivery/cephalhaematoma 5. Dirty nappes/bowel obstruction 3. Ask about symptoms of kernicterus 1. irritability 2. decreased appetite 3. seizures 4. drowsiness 5. arching back 4. Screen for kernicterus risk factors 1. prematurity 2. low albumin 3. Sepsis, particularly meningitis 4. Asphyxia, acidosis, hypoxia and hypothermia

Answer 512

an X-linked recessive genetic condition that predisposes to hemolysis and resultant jaundice in response to a number of triggers, such as certain foods, illness, or medication. There is no treatment.

Answer 513

Frickety Fuck Bloody Mum Seems To Give Crappy Antibodies - Liver Ultrasound ## Footnote FBE/Retics/film Fractionated SBR Bloood group and hold Mothers blood type Septic screen Thyroid function tests G6PD deficiency Coombs Direct antibody test (detects IgG attached to RBCs suggesting autoimmune haemolysis) Alpha1 anti-trypsin LFTs Ultrasound

Answer 514

**Basics** Ensure adequate caloric intake / glucose (breast, formula) Ensure kept at warm temperature (incubator) **Place and person** Contact Paeds Admit to SCN / NICU **Investigate and confirm the diagnosis** *Frickety Fuck Bloody Mum Seems To Give Crap Antibodies – Liver Ultrasound* * FBE/Retics/film * Fractionated SBR * Bloood group and hold * Mothers blood type * Septic screen * Thyroid function tests * G6PD deficiency * Coombs Direct antibody test (detects IgG attached to RBCs suggesting autoimmune haemolysis) * Alpha1 anti-trypsin * LFTs * Ultrasound **Definitive management** * Treat cause if possible * Phototherapy * IVIG if immune mediated haemolysis * Exchange transfusion if anaemic * Low threshold for empirical ABx

Answer 515

* All the causes of early jaundice * Cephalhaematoma * Polycythemia (were they IUGR?) * Poor feeding * Bowel obstruction causing increased enterohepatic circulation

Answer 516

* Pallor – conjunctival, palmar crease * Fatigue, listlessness * Poor growth * Flow murmur * Air hunger (severe) * Hypotension and cardiac failure (severe) * Iron deficiency can present with poor attention span, irritability and pica (eating dirt, clay, ice etc)

Answer 517

* FBE * Blood film (e.g. spherocytosis) * Bilirubin * Reticulocytes * Direct Coombs test * G6PD assay

Answer 518

G6PD deficiency Common in Chinese, Mediterranean and African people X-linked defect in the enzyme that protects cells from oxidative damage Triggered by infections, fava beans and drugs (sulfurs, antimalarials)

Answer 519

**Hereditary Spherocytosis** * Fairly common * Usually associated with neonatal jaundice. * These RBCs have a membrane defect, that causes their funny shape and predisposed them to destruction in periods of illness. May present with jaundice, anaemia and splenomegaly throughout life (even in adult life with recurrent cholelithiasis!)

Answer 520

**MIDGUT MISHAP** Migraines - abdominal Intussception DKA Gastroenteritis UTI Testiicular Torsion Malignancy (Wilm’s, Leukaemia, Neuroblastoma) Inguinal hernia - stranulated Stuck poo (constipation) HSP Appendix + mimickers (mesenteric adenopathy / Meckel’s diverticulum) Pregnancy / ectopics / gynae

Answer 521

It's the common cold of the hip It affects kids age 3-10 It should **improve** within 3 days It should be **resolved** within 2 weeks

Answer 522

* Home care should involve complete rest and pain relief * Time off school until better * Avoidance of sport and strenuous activity until completely better * **Paracetemol** * NSAIDs should be used with caution in asthmatics * Aspirin should be avoided in children * Importantly, tell them to come back if: * High fevers * Swelling * Redness * Severe or worsening pain * Pain that does not improve after 3 days or significantly resolve in a week. As a side note the concern with aspirin in kids under 16 is Reyes Syndrome. It is a very rare condition of acute deadly noninflammatory encephalopathy and fatty degenerative liver failure.

Answer 523

**Basics** Admit, ABC support and monitoring **Investigation** Blood – FBE, ESR, cultures Imaging – plain film Special – joint aspiration, bone scan (best test) **Definitive Management** Refer to orthopaedics Urgent aspiration +/- arthrotomy and washout Flucloxacillin IV **Follow up**

Answer 524

Breech presentation (10x) Female (4x) Oligiohydraminos (4x) Macrosomia (\>4kg) (2x) 1st born baby (2x) FMHx Essentially, anything that causes the foetus to be squished can cause hip development issues.

Answer 525

Infants with a suggestive clinical examination **OR** risk factors (breech birth, oligohydraminos, macrosomia and FMHx)

Answer 526

Before 4-6 weeks, the hip is largely cartilaginous --\> No test is useful **Formal investigation is often deferred until after 6 weeks** Before 4-6 months, ossification of the upper femur has not occurred --\> Ultrasonography is the best test. After 4-6 months, there is sufficient ossification to enable interpretable radiography --\> Plain film becomes the best test

Answer 527

**After 3 months, the Barlow and Ortolani tests are less useful** More meaningful signs include: * Asymmetrical hip abduction * Uneven leg length * Asymmetrical skin creases (weak sign) * High greater trochanter (dislocated) * Gait disturbance and chronic limp (older children)

Answer 528

**A radiologically subtle spiral fracture of the distal tibia that occurs in toddlers (9 months to 3 years). The periosteum remains intact and the bone is stable. These fractures occur as a result of a twisting injury.** Suspect when: * Unexpected pain or duration of limp after a relatively minor injury * Twisting one leg causes no pain, twisting the affected leg is very painful * Tender tibia on palpation **Management** * Above-knee plaster can give pain relief, but if the pain is minimal treat conservatively. * May continue to limp for 6 weeks.

Answer 529

Orthopaedics referral Normal recovery expected in 18-36 months Femoro-acetabular contact is key to normal growth Treatment depends on severity: Symptomatic --\> slings/braces --\> broomstick plaster --\> surgery

Answer 530

Notice that a line along the lateral edge of the femoral neck does not cross the epiphysis on the affected side.

Answer 531

This is a SUFE Order a plan x ray No weight bearing until definitive management Urgent orthopaedic review In situ pinning of the epiphysis to the femoral neck

Answer 532

* Pain * Warmth * Swelling * Erythema --\> usually suggests an infectious pathology! * Stiffness, worse in morning * Loss of function (reduced range of movement)

Answer 533

* Oligoarthritis * 4 or fewer joints affected _in the first 6 months of the disease_ * Broken down into normal and extended * Polyarthritis * 5 or more joints affected _in the first 6 months of the disease_ * RH - and RF + * RF + is basically just RA, bad prognosis * Systemic Arthritis * Formerly called ‘Still’s disease’ * Systemic symptoms like fever, rashes, lymphadenopathy and hepatosplenomegaly predominant the early illess * Beyond the joint * psoriatic * enthesitis (HLA B27+)

Answer 534

* **Osgood-Schlatter syndrome** is a painful knee condition that affects adolescents. * It often occurs during a growth spurt and is associated with physical activity. Symptoms include pain and local swelling in the front of one or both knees. * It is thought that the quadricepts tendon becomes tight and causes inflammation and micro-fractures in the tibial tuberosity. * Diagnosis * Clinical but get an Xray * Management * Physio referral for excercises * Rest * NSAID analgesia * Prognosis * The condition usually completely resolves within 12 months but the prominent tibial tuberosity will always be there.

Answer 535

Chronic inflammation can lead to hyperaemia of the affected joint and the local epiphysis. This can lead to abnormally increased growth and lengthening of the affected bone!

Answer 536

Oligo = no Poly = can be, particularly if RF+

Answer 537

* High spiking (\>39) fever, with resolution between spikes. May occur 1-2x daily. * 95% have a salmon pink rash on the limbs or trunk that forms during the fever spike. Rash may be urticarial. * The rash may be triggered by warm baths or skin irritation (Koebner phenomenon) * Lymphadenopathy, hepatosplenomegaly often occur * Pericarditis and pleuritis are common * There may be severe anaemia. * **Joint disease may manifest months to years after systemic presentation.**

Answer 538

\>6yo boys 10% progress to AnkSpond

Answer 539

Only a small proportion of polyarticular JIA. Associated with poor prognosis.

Answer 540

Increases risk of anterior uveitis Commonly positive in oligo and polyarticular JIA Anterior uveitis is often asymptomatic, opthal review 2-6 monthly is needed If untreated, can lead to cataract, adhesions in the anterior chamber and glaucoma. Treat with topical steroids, dilators (mydriatics) and maybe MTX

Answer 541

Jumping up and down leading to severe pain

Answer 542

Boot shaped heart Tetralogy of Fallot

Answer 543

Damage from intubation Presents with chronic fixed stridor Classically an ex-preterm infant who had long term ventilation May require endoscopic ablation to resolve

Answer 544

Palivizumab monoclonal antibody against RSV Super expensive, only for very high risk babies Give as monthly injections throughout RSV season

Answer 545

Around 9 months old - no pathological lead point - respond well to air enema Over 3 years - pathological lead point (Meckels, polyp, lymphoma, TB, HSP) - often require surgery

Answer 546

**Inheritance pattern =** autosomal recessive **Pathophysiology** = Enzyme defect leading to impaired production of glucocorticoids and mineralocorticoids by the adrenal glands. \>95% of cases are caused by a 21-hydroxylase deficiency. Reduced negative feedback to the hypothalamus and pituatary leads to increased ACTH secretion and adrenal stimulation. The adrenal gland can only respond with hyperplasia and increased sex steroid synthesis. **Forms =** simple virilising and salt-losing **Clinical presentation =** in females either form presents with ambiguous genitalia. If this is missed they may present with salt losing adrenal crisis in the following 1-2 weeks. Missing this can lead to death. In males the virilising form leads to signs of puberty as a toddler.

Answer 547

Long term mineralocorticoid and glucocorticoid replacement.

Answer 548

E. Coli. IV cephalosporin Why? In a child this young they cant present with dysuria so they present late when septic. In an older child trimethoprim would be fine?

Answer 549

If he's had one there's a 30-40% chance he'll have another one at some point. But they generally occur early in the course of a febrile illness. At day 3.5 it's less likely to occur now.

Answer 550

Good. Most grow out of it.

Answer 551

* Infantile spasms / West syndrome * catastrophic childhood epilepsy * Seizures start between 4 - 12 months * Urgent neuro referral * 1/20 mortality * Poor prognosis with developmental delay and long term serious epilepsy

Answer 552

**What is it?** Malabsorbtion due to severe disease or surgical removal of a significant proportion of the small intestine. **Causes** Although SBS may rarely be a congenital condition, most patients with SBS have undergone bowel resection for one of the following: * A congenital anomaly such as an omphalocele, gastroschisis, or intestinal atresia * Necrotizing enterocolitis associated with prematurity * Intestinal ischemia from malrotation and volvulus * Crohn disease (infrequent with current treatment) **Management** Usually dependent on TPN **Prognosis** Fairly catastrophic In newborn infants, the 4-year survival rate on parenteral nutrition is approximately 70%. In newborn infants with less than 10% of expected intestinal length, 5 year survival is approximately 20%

Answer 553

The inferior ureter can insert low down in the bladder leading to VU reflex and hydronephrosis

Answer 554

Tachycardia, Tachypnoea Metabolic acidosis. Lactate commonly high. Controversial: can cause VQ mismatch and **worsen** symptoms in very high doses

Answer 555

The lactate is high because of the large amounts of salbutamol the child would have received. The glucose is likely high because the kid has probably been given prednisolone. Metabolic acidosis and hypokalaemia are a sign of salbutamol toxicity. You would worry about this (stop salbutamol) but not so much the other stuff.

Answer 556

Henoch-Schonlein purpura (HSP) is the most common vasculitis of childhood and affects the small vessels. HSP is characterised by the classic tetrad of rash, abdominal pain, arthritis/arthralgia, and glomerulonephritis. **Age groups** Between the ages of 3 and 15 years. Males twice as commonly as females **Aetiology** The underlying cause of HSP remains unknown. It is an immune-mediated vasculitis, with a variety of infectious and chemical triggers having been proposed as a cause. Many cases of HSP occur after a URTI, especially streptococcal infections **Complications/other symptoms** * Nephritic syndrome and long term renal damage * Subcuteneous oedema * Intussusception * Pancreatitis * Sponteneous bowel perforation * bloody stools * Haematemesis * Painful scotal swelling

Answer 557

Uncomplicated abdominal pain often resolves spontaneously within 72 hours. However serious abdominal complications may occur including intussusception, bloody stools, haematemesis, spontaneous bowel perforation, and pancreatitis.

Answer 558

**Bedside** None **Bloods and urine** Urinalysis and urine microscopy (to quanitify haematuria) FBE UEC (elevated creatinine indicated renal Cx) Blood culture **Imaging** USS of scrotum of abdo if suspect intusscusception, testicular torsion or other **Special** Can biopsy lesions in legs if really need to

Answer 559

**Basics** Analgesia **Place and person** Any purpuric rash should be reviewed by at least a Reg Consider admission if renal complications, suspicion of abdominal complications or severe pain **Investigate and confirm diagnosis** Urinalysis and urine microscopy FBE/UEC Blood cultures **Definitive** * Document the child's blood pressure * Consider a surgical consult if abdominal features are prominent. Testicular torsion can be hard to differentiate from the pain of vasculitic testicular pain. * The use of prednisolone has *_not_* been shown to make clinically important improvements in the rate of long-term renal complications. It has been shown to reduce the duration of abdominal and joint pain and may reduce the risk of abdominal complications. It may be considered for use in patients with more than mild joint or abdominal pain. Consider prednisolone 1mg/kg while symptoms persist.

Answer 560

**Come back if...** if your child has increasing stomach pains or swelling, blood in the stools or urine, or if you are worried for any other reason. **What you need to do now....?** BP and urinalysis with GP monthly for 6 months to ensure that if a kidney problem does arise it is picked up early.

Answer 561

Foetal alcohol syndrome Most distintive features are thin upper lip and indistinct philtrum

Answer 562

**What is it?** Delayed relaxation of the pulmonary vascular bed at birth means that the baby maintains it's foetal circulation (right to left shunt across the ductus arteriosus and foramen ovale ). **What causes it?** PPHN is seen in association with many neonatal respiratory diseases including: * lung hypoplasia (eg diaphragmatic hernia) * meconium aspiration syndrome * pneumonia * surfactant deficiency _The syndrome may also be seen in the absence of triggering diseases._

Answer 563

Nitric oxide (NO)

Answer 564

No, meconium stained liquor suggests he could have mec in his oropharynx. Suction his oropharynx first before stimulating. Intubate immediately.

Answer 565

If they lose 10% or more of their birth weight you would worry.

Answer 566

15mg / kg So a 30kg 6 year old would get 450mg

Answer 567

**What is it?** An abnormal leaflet of tissue exists in the urethra, causing an obstruction to urine flow. It is a developmental anomaly, present before birth and only affects boys. **How common?** PUV is rare, occurring in 1 in 4000-6000 boys **Why is it a problem?** Urethral blockage near the bladder makes it hard for the bladder to expel urine, so the bladder has to push harder to try to empty. This increases pressure in the urinary tract. The pressure may push the urine back through the ureters to the kidney and cause the ureters, kidneys and bladder to dilate (expand).

Answer 568

**Investigations...** * UEC * Ultrasound * Micturating cystourethogram (MCU) * This is the definitive test for PUV. It is performed with a catheter placed through the urethra into the bladder. Contrast material is injected through the catheter to outline the bladder. An X-ray is taken which will show the shape of the bladder, whether there is any back flow up the ureters (reflux). Xrays are taken to identify the contrast outlining the urethra and any internal obstruction (valve). * Cystoscopy * This is both a confirmatory and therapeutic intervention. It is a surgical procedure, performed under anaesthesia. A small telescope is placed inside the urethra to identify the obstruction. Treatment of the valves can be performed at the same time. Other tests may be needed to check the function of the kidneys, the drainage, and to monitor treatment **Management** Catheter insertion then ablation via cystoscopy **Prognosis** About one third will develop kidney failure at some stage, requiring dialysis or renal transplant. About one third of patients will have a degree of renal impairment, managed with medication and diet. About one third of patients will have normal kidney function, but may have ongoing issues with urinary tract drainage, infection and bladder function.

Answer 569

An infant should gain 180g/week within the first three months of life

Answer 570

Think of: 1. Reduced calories in 2. Reduced absorption 3. Increased calories out 4. Increased caloric requirement 5. Inability to use calories * Reduced calories in * Recurrent vomiting / possets * Poor sucking reflex * Cleft palate * Underlying organic pathology --\> tiring at the breast * Reduced absorption * Coeliac disease * Milk protein allergy * Pancreatic insufficiency (eg. CF) * Increased calories out * Diarrhoea * Increased caloric requirement * Anything! * Congenital heart disease * Sepsis * Hyperthyroidism * Inability to use calories * Inborn errors of metabolism

Answer 571

An innocent murmur is a murmur arising from turbulent blood flow through a normal heart, for reasons which may be unclear. The 5 ‘S’s of an innocent murmur are: * innoSent * aSymptomatic * Soft * Systolic * left Sternal edge Innocent murmurs are very common and may be heard in around 50% of normal school aged children and approximately 80% of children in early infancy An important DDx from an innocent murmur is an atrial septal defect (ASD). Therefore must carefully listen for wide or fixed splitting of S2 before concluding that it is an innocent murmur. Innocent murmurs are made louder, and hence more easily detected, during an illness with a fever (as the heart works harder and this increases the turbulence in blood flow). If you hear the mumur during an illness wait until they've recovered then review it again.

Answer 572

**FRANGRANT PPP THHD** ## Footnote F - Feeding difficulty R - Respiratory distress syndrome (RDS) A - Anaemia G - GORD R - Retinopathy of prematurity A - Apneoa of prematurity N - NEC T - Transient tachypneoa of the newborn P - Patent PDA P - Physiological jaundice P - Periventricular leukomalacia T - Thermoregulation problems H - Hypoglycaemia H - Haemorrhage (intraventricular) D - Developmental problems (ID, cerebral palsy)

Answer 573

Immature capillary bed lining the ventricles / vascular fragility of the germinal matrix. Occurs within 48 hours of birth. **Clinical presentation** * Often asymptomatic * Tense fontanelles * Floppy / limp * Seizure activity * Decerebrate posture **How is it diagnosed?** U/S between 5 and 7 days of life. Repeat at 28 days of life **Grades** Grade I - bleeding occurs just in the germinal matrix Grade II - bleeding also occurs inside the ventricles, but they are not enlarged Grade III - ventricles are enlarged by the accumulated blood Grade IV - bleeding extends into the brain tissue around the ventricles Grades I and II are most common, and often there are no further complications. Grades III and IV are the most serious and may result in long-term brain injury to the infant. After a grade III or IV IVH, blood clots may form which can block the flow of cerebrospinal fluid, leading to hydrocephalus and then cerebral palsy, epilepsy, hearing/visual problems. **Management** Grade 1 and 2 have no treatment. Grade 3 and 4 --\> VP shunt + follow up to monitor development

Answer 574

**What is it?** * Also known as hyaline membrane disease or surfactant deficiency syndrome * Due to immaturity of the type 2 pneumocytes --\> surfactant deficiency --\> alveolar collapse --\> stiff lungs --\> increased WOB --\> decreased tidal volume --\> hypoxaemia --\> respiratory acidosis * Lung surfactant is only adequate by 30-32 weeks gestation * RDS affects 50% of neonates with GA * RDS affects almost 100% of those born * Causes: * Prematurity * Perinatal asphyxia (hypoxia inhibits surfactant production) * Maternal diabetes (delays surfactant synthesis) * RDS affects about 1% of newborn infants and, along with NEC, is the leading cause of death in preterm infants **Clinical picture:** Signs of increased WOB (increased RR, nasal flaring, use of accessory muscles, grunting) Hypoxaemia, cyanosis Whether treated or not, the clinical course for the acute disease lasts about 2 to 3 days. During the first day the patient worsens and requires more support. During the second day the baby may be remarkably stable on adequate support and resolution is noted during the third day, heralded by a prompt diuresis. **Prevention** Antenatal betamethasone is used in the prevention of RDS, given to a mother expecting a premature baby (up to 24 hours before birth, should be given two courses. Unlikely to give beneficial effect if given \>2 weeks prior to birth) **Mx** * Oxygen * Nasal CPAP * Surfactant administration (can be given down ETT!) * Mechanical ventilation (severe) * Non respiratory * Attention to thermoregulation can reduce the severity of the condition * Antibiotics commence penicillin and gentamicin therapy after initial investigations. * Minimal handling * No feeding until resolved

Answer 575

Defined no respiratory effort for greater than 20 seconds. No respiratory effort for shorter periods of time may also be classified as apnoea if accompanied by cyanosis or bradycardia **Why does it happen/what are the types?** * Central apnoea:* (40%) Caused by decreased central nervous system stimuli to respiratory muscles. Both the respiratory effort and airflow cease simultaneously. (Absence of chest wall movement and airflow). * Obstructive apnoea:* (10%) Caused by pharyngeal instability / collapse, neck flexion or nasal obstruction. Absence of airflow in presence of inspiratory efforts. (Presence of chest wall movement but no airflow). * Mixed apnoea*: (50%) Has a mixed aetiology. Central apnoea is either preceded (usually) or followed by obstructed respiratory effort NB: Short episodes of apnoea are usually central whereas prolonged ones are often mixed

Answer 576

**When does it happen?** Onset is from days 2-7 of life. Apnoea beginning immediately after birth suggests another cause. **Management** * Monitoring in SCN/NICU * Positioning: * Ensure the neonate's head and neck are positioned correctly (head and neck in neutral position) to maintain a patent airway. * Tactile stimulation: * Gentle rubbing of soles of feet or chest wall is usually all that is required for episodes that are mild and intermittent. * Clear airway: * Suction mouth and nostrils. * Methyxanthines * caffeine or theophyllline * Improve diaphragm contraction and stimulates the respiratory centres * Nasal CPAP (reducing obstruction; reducing work of breathing) * Mechanical ventilation (if severe) **Prognosis** Since AOP is fundamentally a problem of the immaturity of the physiological systems of the premature infant, it is a self-limited condition that will resolve when these systems mature. It is unusual for an infant to continue to have significant problems with AOP beyond 42 weeks post-conceptual age.

Answer 577

In the fetus, the ductus venosus shunts a portion of the left umbilical vein blood flow directly to the inferior vena cava. Thus, it allows oxygenated blood from the placenta to bypass the liver. Compared to the 50% shunting of umbilical blood through the ductus venosus found in animal experiments, the degree of shunting in the human fetus under physiological conditions is considerably less, 30% at 20 weeks, which decreases to 18% at 32 weeks, suggesting a higher priority of the fetal liver than previously realized. **Clinical significance** You use the ductus venosis for venous access in resusc of the neonate.

Answer 578

If less than 7 you score it every 5minute until it gets to 7

Answer 579

The risk is much greater in preterm babies, but if you pick a random kid with CP 60% of them will have been born at term

Answer 580

HIE is the most common identifiable risk factor, but it contributes to less than a quarter of cases

Answer 581

non-independent walking non-independent feeding epilepsy blindness hearing problems Later then have learning difficulties and behavioural problems

Answer 582

Varies from 60-95% depending on the skill of the clinician. Make sure where you send them have a Certificate of Obstetric and Gynaecological Ultrasound (COGU).

Answer 583

Viral illnesses which occur in winter cause swelling of Peyer's patches in the bowel which serve as pathological lead points for intussusception

Answer 584

XO females * short stature * infertility * congenital heart defects * spatial awareness issues – problems with tasks such as maths **but otherwise normal IQ** * Amenorrhoea * Hearing problems * no breays * extra skin (‘webbing’) on the neck * puffy hands and feet * low hairline.

Answer 585

**Turner's syndrome XO females** * short stature * infertility * congenital heart defects * spatial awareness issues – problems with tasks such as maths **but otherwise normal IQ** * Amenorrhoea * Hearing problems * no breays * extra skin (‘webbing’) on the neck * puffy hands and feet * low hairline.

Answer 586

Eisenmenger's syndrome is defined as the process in which a left to right shunt caused by a congenital heart defect in the fetal heart causes increased flow through the pulmonary vasculature, causing pulmonary hypertension, which in turn causes increased pressures in the right side of the heart and reversal of the shunt into a right-to-left shunt. Eisenmenger syndrome is a cyanotic heart defect characterized by a long-standing intracardiac shunt (caused by ventricular septal defect, atrial septal defect, or less commonly, patent ductus arteriosus) that eventually reverses to a right-to-left shunt. This syndrome is less frequent today because of medical screening withechocardiography early in life. Prognosis is poor if early intervention doesn't happen. After pulmonary hypertension has developed, a heart–lung transplant or a lung transplant with repair of the heart is a possible option.

Answer 587

The VACTERL association (also VATER association) refers to the non-random co-occurrence of birth defects Vertebral anomalies, Anal atresia Cardiac defects Tracheoesophageal fistula Esophageal atresia Renal & Radial anomalies Limb defects. The reason it is called an association, rather than a syndrome is that while the complications are not pathogenically related they tend to occur together more frequently than expected by chance. In general, the etiology of "associations" are not defined.

Answer 588

* It's very common * Very likely will self resolve * However, it will probably get bigger when the baby starts crawling as gravity takes it's course * If it hasn't resolved by age 2 get a surgical consult to consider repair * Tell parents warning signs * can't reduce * skin changes * pain (when able to talk) * constipation/vomiting late signs

Answer 589

For kids under 6 = 6 puffs For kids over 6 = 12 puffs Give every 20mins as required, then stretch. Can discharge when stretched to 3 hourly

Answer 590

* 10-20ml/kg boluses of normal saline until not shocked * Maintenance fluids of normal saline + 5% glucose according to 4,2,1 rule * Slowly correct deficit * ignore bolus fluid volumes given * If severe shock assume 10% dehydrated * Give 10% of bodyweight in fluids * Give first half of this over the first 6 hours * Give the second half of this over the second 18 hours * You can do this more slowly if needs be

Answer 591

**Presentation** Itching around the anus (pruritus ani). The itchiness tends to be worse at night and can cause trouble sleeping. The itching is caused by an inflammatory reaction to the adult worm and eggs on the skin. **Diagnosis** Sticky tape the kid's bum at night, examine the tape for worms/eggs. **How are they spread?** Through swallowing the eggs. When someone with pinworm scratches their anus, the eggs get lodged beneath their fingernails, and are then deposited on clothing and furniture. Uninfested individuals can come in contact with pinworm eggs and ingest them unknowingly. Infested individuals continue to ingest the eggs (auto-infection). Other family members are at particular risk of pinworm infestation. **Management** * Pyrantel (Combantrin) or mebendazole (Banworm). * Very safe medications * Treat the entire household * Shower the night before taking and the morning after. Wash all sheets in very hot water and vacuum the bedroom. * Have the child wash his/her hands with warm soapy water for at least 10 seconds after going to the toilet. **Prognosis** Reinfection is very common It's a mild disease though so doens't really matter

Answer 592

4 to 14. It’s also possible for older teens and adults to have absence seizures, but it’s less likely.

Answer 593

Ethosuximide is used commonly to treat absence seizures. Ethosuximide is ineffective in controlling tonic-clonic seizures, so is not used in children with juvenile absence epilepsy. Treatment is usually for 2 years only in typical childhood absence epilepsy, with an expectation of seizure remission, and through puberty in juvenile absence epilepsy, with later appearance of tonic-clonic seizures being a risk. Intellectual development isusually normal.

Answer 594

* Attacks usually commence in the first or second year of life. * Crucial to the diagnosis is recognition that attacks are precipitated by either physical trauma, such as a knock or a fall, or emotional trauma such as fright, anger or frustration, the precipitants not always being significant and noticed. * Attacks usually commence with crying, but this may be brief or absent. Apnoea then occurs with cyanosis or pallor, and may then either terminate without apparent loss of consciousness, or progress with the child becoming unconscious, limp and sometimes briefly stiffening or jerking in response to the cerebral hypoxia. Incontinence may occur with such convulsive features. * Recovery is usually rapid, although some children are drowsy and lethargic after an attack with convulsive features. Attacks usually cease by the third or fourth year of life. * They are not a cause of death, epilepsy, intellectual disability or cerebral damage in later life. * The pathophysiology of breath holding attacks is not well understood,

Answer 595

**Salmon patch** Also known as nevus simplex or "angel kisses", these are a common capillary malformations that are present at birth. Eyelid spots generally fade over several months. Lesions on the glabella may take several years to resolve, and occasionally the outlines can be seen into adulthood, especially when the face is flushed.

Answer 596

Milia are keratin filled epithethial cysts which occur in up to 40% of newborns. Spontaneous exfoliation and resolution is expected within a few weeks. Parents will occasionally mistake these lesion for neonatal acne, but milia are present at birth and have no inflammatory component.

Answer 597

**Craniosynostosis** ## Footnote One or more of the fibrous sutures in an infant skull prematurely fuses by turning into bone (ossification), thereby changing the growth pattern of the skull. Because the skull cannot expand perpendicular to the fused suture, it compensates by growing more in the direction parallel to the closed sutures. Sometimes the resulting growth pattern provides the necessary space for the growing brain, but results in an abnormal head shape and abnormal facial features. In cases in which the compensation does not effectively provide enough space for the growing brain, craniosynostosis results in increased intracranial pressure leading possibly to visual impairment, sleeping impairment, eating difficulties, or an impairment of mental development combined with a significant reduction in IQ.

Answer 598

Anterior fontanelle closes at 18-24 months Posterior fontanelle closes at 3 months

Answer 599

**Layers** Under periosteum of skull bone but superficial to skull **Where on the head** Usually parietal bones, because this is where forceps attach **What do they look/feel like?** Margins are firm w/ a soft fluctant centre. They do not cross suture lines (help in by periosteum). **What causes them?** The usual causes of a cephalohematoma are a prolonged second stage of labor or instrumental delivery, particularly ventouse. **Management** Phototherapy may be necessary if blood accumulation is significant leading to jaundice. Rarely anaemia can develop needing blood transfusion. Do not aspirate to remove accumulated blood because of the risk of infection and abscess formation. The presence of a bleeding disorder should be considered but is rare. Skull radiography or CT scanning is also used if concomitant depressed skull fracture is a possibility. It may take weeks and months to resolve and disappear completely.

Answer 600

Caput succedaneum is a neonatal condition involving a serosanguinous, subcutaneous, extraperiosteal fluid collection with poorly defined margins caused by the pressure of the presenting part of the scalp against the dilating cervix (tourniquet effect of the cervix) during delivery. It involves bleeding below the scalp and above the periosteum. **Features on examination** Caput succedaneum presents as a scalp swelling that extends across the midline and over suture lines and is associated with head molding. **Management** Caput succedaneum does not usually cause complications and usually resolves over the first few days.

Answer 601

**What is it?** Subgaleal hemorrhage or hematoma is bleeding in the potential space between the skull periosteum and the scalp galea aponeurosis. It presents as a fluctuant boggy mass developing over the scalp (especially over the occiput) with superficial skin bruising. The swelling develops gradually 12–72 hours after delivery, although it may be noted immediately after delivery in severe cases. The hematoma spreads across the whole calvaria as its growth is insidious and may not be recognized for hours. If enough blood accumulates a visible fluid wave may be seen. **Cause** The majority (90%) result from applying a vacuum to the head at delivery (Ventouse assisted delivery). **Management** Management consists of vigilant observation over days to detect progression. **Complications** The subgaleal space is capable of holding up to 50% of a newborn baby's blood and can therefore result in acute shock and death. Fluid bolus may be required if blood loss is significant and patient becomes tachycardic. Transfusion and phototherapy may be necessary. Investigation for coagulopathy may be indicated.

Answer 602

Ankyloglossia May require surgery if severe

Answer 603

Pierre Robin Sequence microganthia and cleft palate can cause severe respiratory problems

Answer 604

Around 18 months

Answer 605

* Can't hold their head up * Feels floppy when picked up * Unusual posturing * Stiff muscles * Delayed developmental milestones * rolling * sitting * standing * walking

Answer 606

Dystonia: characterized by involuntary, sustained contractions Chorea: rapid, involuntary, jerky and fragmented motions Athetosis: slower, constantly changing, writhing or contorting movements Ataxia: loss of muscular coordination with abnormal force and rhythm and impairment of accuracy

Answer 607

**Spastic cerebral palsy:** - most common type (86%) * stiffness or tightness of muscles on movement * Monoplegia – single limb involvement * Hemiplegia: involvement of an ipsilateral upper and lower extremity * Diplegia: predominant involvement of both lower extremities, greater than upper limbs * Quadriplegia: involvement of all limbs and trunk. **Dyskinetic** * involuntary, recurring and occasionally stereotyped movements with a varying muscle tone. * Dystonia: characterized by involuntary, sustained contractions * Chorea: rapid, involuntary, jerky and fragmented motions * Athetosis: slower, constantly changing, writhing or contorting movements **Ataxic** Loss of muscular coordination with abnormal force and rhythm and impairment of accuracy **Mixed**

Answer 608

1 in 500 Australian babies is diagnosed with cerebral palsy.

Answer 609

* Antenatal (70-80% of cases) * premature birth (less than 37 weeks) * low birth weight (small for gestational age) * maternal thrombophilia * placental abruption * TORCH infections * Perinatal * RH or A-B-O blood type incompatibility between mother and baby * Asphyxia during birth (contributes to less than 10% of cases) * Postnatal * hyperbilirubinaemia, * neonatal sepsis, * respiratory distress, * early-onset meningitis, * intraventricular haemorrhage, * head injuries prior to 3 years (including child abuse and shaken baby syndrome).

Answer 610

4 – 9 years Idiopathic but strong genetic component Absence seizures (can be up to 100s per day) It is rare for children to have other seizure types at first, but about 40% of children with childhood absence epilepsy develop tonic-clonic seizures as well. Ethosuximide and sodium valproate are equally effective, but ethosuximide is better tolerated. However, unlike sodium valproate, ethosuximide does not protect against associated generalised tonic-clonic seizures. Usually resolves two to five years after the seizures begin or when the child is a teenager

Answer 611

10 – 15 years Idiopathic but strong genetic component Absence seizures (less frequent that childhood absence epilepsy) 80% of children with juvenile absence epilepsy also have tonic-clonic seizures. These may begin later than the absence seizures. Some also have myoclonic seizures and absence status epilepticus. Ethosuximide and sodium valproate are equally effective, but ethosuximide is better tolerated. However, unlike sodium valproate, ethosuximide does not protect against associated generalised tonic-clonic seizures. We don’t have a lot of data. The seizures usually respond well to anti-epileptic drugs, but children with this syndrome may need to take medication to control seizures all their lives.

Answer 612

15-19 Myoclonic jerks that occur on awakening from sleep either in the morning or from a nap. They are typically described as shock-like, irregular and arrhythmic movements of both arms. Sometimes these movements are restricted only to the fingers making the patient or individual look clumsy or prone to dropping things. They ALL have tonic clonic seizures One third have absence seizures sodium valproate; however, avoidance of sleep deprivation and excessive alcohol may also be necessary to achieve complete freedom from seizures. Although full remission is unlikely and most patients require lifelong treatment, the prognosis for seizure control is very good. Most patients remain neurologically normal

Answer 613

2 - 13 Seizures usually occur during sleep and begin in the face or mouth, producing a typical glugging sound. Speech arrest is common. The partial (focal) seizure may become secondarily generalised. The EEG is typical and shows epileptiform discharges in the centrotemporal region. Carbamazepine, sodium valproate and sulthiame are the drugs of choice. Treatment is not always indicated. most children are seizure-free by early adolescence

Answer 614

* What were you doing at the time the headache first commenced? * What had you been doing beforehand? * What was the first thing you noticed and how long did it take from when you first noticed the symptom until it reached its maximum severity? * Headache Differentials QUESTION CLUSTERS * MIGRAINE * Did you see any funny smells, flashing lights, a funny sensations leading up to the headache, some people say it’s like an aura? * Did you vomit? * Does the light hurt your eyes? * CLUSTER HEADACHE * Did you get very bad pain in your eye? * Or have you had any tearing up in one eye? * Or was there watery discharge from your nose? * Do you have any sinus symptoms? * TENSION HEADACHE * Is it recurrent? How regularly do you get it? * Do they get worse over the day? * How are things going generally? Is work okay? Is any thing stressful going on in your life? * HAEMORHAGE (Sub-Arachnoid) * Have you had any trauma? * Did it feel like a thunderclap when it started? * Does your neck feel stiff? * Is it at the back of the head? * Have you noticed any weakness in your body? Numbness? Have you had any speech or vision changes? * STROKE * Have you felt any weakness anywhere in your arms leg or face? * Have you had any funny sensations anywhere in arms legs or face? * Has your vision been affected? * Has your speech become slurred? * Did you lose any control of your bladder? * MENINGITIS * Have you felt any neck stiffness? * Any fevers? Sweats? Shakes? * Are you sensitive to light? * TEMPORAL ARTERITIS * When you chew food does it hurt? * Have you lost vision in one eye? * Is your scalp tender, say when you comb your hair? * MALIGNANCY * Fever, sweats, shakes * Loss of weight, loss of appetite, fatigue, * Nausea & vomiting * Prominent headache behind your eye * Weakness * Better on leaning back, worse leaning forward * REBOUND HEADACHE * Are you taking any medication to manage the pain? * What kind and how much?

Answer 615

**Anatomy** Extradural space. Between the dura mater and the skull. (That is, both layers of dura are squashed against brain by pooling blood). Classically transection of the anterior division of the middle meningeal artery running behind the pterion. **Clinical vignette** Traumatic injury to side of head in kids or young adult. Fluctuating conscious state. Symptoms come on within hours of injury (arterial bleed --\> fast!) **Management** Surgical evacuation

Answer 616

**Anatomy** In the potential space between the dura and the subarachnoid. That is, both layers of dura are squashed against skull, the arachnoid is pushed against brain. Transection of the cerebral veins (as they enter the sinuses). **Presentation** Older people, usually after acceleration-deceleration injury (imagine the brain shakes around in the head) eg. after fall. This is because in the older population the brain shrinks, stretching the veins which bridge the subdural space. This occurs in alcoholics too for the same reasons. Symptoms come on more slowly, within weeks to months. Think of the little old lady who has a fall and presents with focal neurology 3 weeks later. **Management** Surgical evacuation

Answer 617

**Anatomy** Subarachnoid space. Between the arachnoid and pia mater, mixed in with the CSF. Classically an aneurysm of the Circle of Willis. **Presentation** * Often sponteneous. * 1-6% of genpop have a subdural aneurysm. 1% of aneurysms bleed. * Classically women under 60 with lots of vascular risk factors. * "Thunderclap headache" * The worst headache the patient has ever experienced. * The pt will be able to pinpoint the second the headache started à "I was reaching for the remote." * May also get signs of meningism, as the pia and arachnoid mater are irritated (positive Kernig’s and Brudzinski’s sign, nuchal rigidity and photophobia). * They also can get a ‘sympathetic surge’. **Management** Calcium channel blockers Surgery (coil/clip)

Answer 618

Has the child had an URTI or other illness recently -- is this mesenteric adenitis!?

Answer 619

**PATIOS** * Psychosocial * Absorption * CF * Coeliac * Milk allergy * Thyroid disease * Intake * Milk/formula supply * Sucking * GORD * Output --\> diarrheoa * Sick

Answer 620

Breastfeeding every 2 to 3 hours for 15mins per breast May be less on formula. Around 60ml per time but massive variation. Around 800ml per day Start to introduce solids at 6 months

Answer 621

* Antenatal * Normal scans? * Complications during pregnancy? High blood pressure or sugars? * Blood type and anti D * GBS status * Birth * Gestational age * NVB or LUSCS * Instrumental (forceps/vacuum( * PROM? * Did baby need resus? Prolonged hospital stay? * Heel prick test done? * Prolonged jaundice?

Answer 622

Cystic fibrosis transmembrane conductance regulator (CFTR) ΔF508 Chromosome 7

Answer 623

**_Measles_** **What are the symptoms?** * High fever * Irritability * Exudative conjunctivitis * Rhinorrhea * Otitis media * Exanthem = mobilloform, blotchy and raised * Enanthem = Koplik’s spots **Who gets it?** In developed countries --\> unimmunised In developing countries --\> Malnourished and Vit A deficient **Management** Report, isolate, supportive **Complications** Complications can include otitis media, pneumonia and encephalitis. Measels specific IgM or IgG

Answer 624

6 puffs every 20 minutes x 3 if 12 puffs every 20 minutes x 3 if \> 6 yo

Answer 625

**FIT CAMPSITES** ## Footnote F - Frequency and severity of attacks I - Interval symptoms? T - Technique using inhaler C - Compliance with preventer A - Atopy - personal or family history M - Medications, past and current P - Pets in the house S - School missed I - ICU or hospital admissions T - Triggers E - Exercise tolerance S - Smokers in the house

Answer 626

* Testicular torsion. * Inguinal hernias through the patent processus vaginalis * Lower fertility - the body temperature in the abdomen is higher than in the scrotum. This can affect sperm production in the testes. * Risk of testicular cancer. The risk is usually less than 1 in 100. * Poor self esteem.

Answer 627

**Cryptorchidism, pronounced kript-ork-id-iz-im** **Congenital** * In premature babies, the testes may not have dropped down yet (usually happens in the eight month of pregnancy). * Some hormone and genetic disorders can cause undescended testes * Usually idiopathic **Acquired - boys who develop undescended testes after birth.** * This can happen between 1-10 years of age. * The testes are in the scrotum at birth * As the boy grows the cord attached to the testes (spermatic cord), fails to grow at the same rate. It ends up too short and pulls the testes back up into the groin.

Answer 628

**Is he walking?** If no --\> How does it get around? If yes --\> does he walk steadily? Does he run? Does he jump? **Is he talking?** If no --\> does he babble? If yes --\> how many words? What does he say? **Does he point to things to show you?** If no --\> does he wave bye bye? **How does he hold small objects?** **Does he draw?**

Answer 629

**SHIRTFRONT LAD AJ** ## Footnote Sepsis Hypoglycaemia (Intraventricular haemorrhage Respiratory distress syndrome/Meconium ileus syndrome Transient tachypneoa of the newborn Feeding difficulties Retinopathy of prematurity Osteopaenia of prematurity NEC Temperature instability ``` Leukomalacia (periventricular) Anaemia / Fe deficiency Developmental problems (ID, cerebral palsy) ``` Apneoa of prematurity Jaundice

Answer 630

**Foetal** Chromosomal disorders Congenital anomalies Multiple gestation TORCH infection **Placental** Uteroplacental insufficiency Abnormal implantation Placental abruption **Maternal** Chronic illness Pre-eclampsia Early or advanced age Malnutrition Substance abuse (e.g. cigarettes, alcohol, narcotics, cocaine) Medications (e.g. warfarin, anticonvulsants)

Answer 631

MR PANCREAS Meconium Ileus / Distal Intestinal Obstruction Recurrent infections Pancreatic failure (exocrine and endocrine) Allergic Bronchopulmonary Aspergilliosis Nasal polyps and sinusutus Cirrhosis of the liver Restricted growth Emotions Airway leaks (males) Sterility in males

Answer 632

Levels of immunoreactive tripsin are tested for on the Gutherie Card (with the blood collected via heel prick test).

Answer 633

CFTR gene mutations screened for on Gutherie Card (most common is delta F507) +/- Sweat Test

Answer 634

1:2500 autosomal recessive Delta F507 (Long arm of Chromosome 7)

Answer 635

Congenital hypothyroidism CF Metabolic disorders eg. PKU

Answer 636

**Concerning Airway Wall** * Constrction* * Asthma * Compression* * Mediastinal mass * Congenial heart disease eg. causing L-R shunt and causing engorgment of the pulmonary vasculature *Structure* * Bronchomalacia * Tracheomalacia * Bronchopulmonary Dysplasia **Concerning Airway Lumen** *Pus / Infection* * Bronchiolitis * Viral Induced Wheeze / Asthma * Pneumonia * Petussis * Croup (even though an URTI) * Gunk* * CF * Other* * FB

Answer 637

**With Fever** * Abcess (peritonsillar - qunsiy, or retrophrayngeal) * Big tonsils / bacterial tonsillitis * Croup * Diptheria * Epiglottitis **Without Fever** * Floppy airways (tracheomalacia, laryngomalacia) * Gagging on a foreign body * Hypersensitivity / haemangioma

Answer 638

Infrequent Intermittent Frequent Intermittent Persistent * Mild * Moderate * Severe

Answer 639

Attacks are \>6 weeks apart No interval symptoms (morning cough / wheeze, night cough / wheeze, exercise tolerance, days at school missed)

Answer 640

Attacks are No interval symptoms (morning cough / wheeze, night cough / wheeze, exercise tolerance, number of days missed at school)

Answer 641

Attacks Mild = interval symptoms are less than 1 x per week Moderate = 1 x per week Severe = \>1 x per week

Answer 642

Morning cough / wheeze? Night cough / wheeze? Reduced exercise tolerance? (Able to keep up with kids in sport / at school) Missed days at school because of asthma?

Answer 643

Q - how often do you have attacks? Q - when you do have attacks, do you have to * miss school * go to ED * be admitted to the ward * be admitted to ICU * take prednisolone (how many times have you used prednisolone in the last 12 months) A - what triggers your asthma? A - which medications allieviate it? Have you had to take prednisolone in the last 12 months? How often do you have to use your reliever?

Answer 644

SABA prn +preventor (ICS or chromone or LTRA or combination)

Answer 645

SABA prn Symptoms controller: ICS + or minus LTRA / cromone LABA oral corticosteroid

Answer 646

**Primary Features** * WOB * Neurological Status **Secondary Features** * SPO2 * HR * Ability to talk

Answer 647

* Increased RR * Cyanosis * Grunting * Nasal flare * Intercostal / Subcostal recession * Head bobbing

Answer 648

OASIS ## Footnote Oxygen And (Amyophilline / MGSO4 if severe, in ICU) Salbutamol Ipatropium Bromide Steroids

Answer 649

**Basics** * make comfortable and reassure * paracetamol for comfort if febrile due to viral induced * assess hydration status: oral, NG or IV fluids if dehydrated (but avoid IV, procedure will make breathing more difficult) **Place and Person** * Contact Paeds resp team, likely to be monitored in ED **Ix and Confirm Diagnosis** * SpO2 **Definitive Management** O - no oxygen unless SpO2 is A Salbutamol - 6 puffs if 6 I Steroids - 1mg/kg of prednisolone for 3 days **Plan / Follow Up** Medication review Education RE asthma delivery devices

Answer 650

**Basics** * Make the child comfortable * Paracetamol for comfort if febrile (viral-induced exacerbation) * Assess hydration status - encourage oral fluids, consider NGT or IV fluids if necessary, but try to avoid procedures as this may further upset patient **Place and Person** * Contact paediatric team **Ix and confirm Dx** * SpO2 **Definitive Management** * Oxygen via NP * A * Salbutamol - burst therapy: * Six puffs every 20 minutes x 3 if * 12 puffs every 20 mins x 3 if \>6yo * Iprtropium bromide - not in moderate asthma in victoria * Steroids: 1mg/kg for 5 days **Follow Up** * Medication review * Ensure correct use of asthma delivery devices

Answer 651

6 puffs of salbutamol every 20 minutes x 3 if 12 puffs of salbutamol every 20 minutes x 3 if \>6yo In moderate or severe exacerbations of asthma

Answer 652

in severe exacerbations of asthma 4 puffs every 20 mins if 8 puffs every 20 minutes if \>6 years old (with salbutamol)

Answer 653

Basics * Comfort child (but the child is usually flat) * Paracetamol for comfort if febrile * Oral, NG or IV fluids if dehydrated Place and Person * Contact paeds resp / paeds ICU * Contact PIPER if rurally Investigate and confirm Dx * SpO2 * ABG (if doesn't further upset child) Definitive management: * Oxygen - via HFNP or CPAP or consider intubation * Salbtamol Burst therapy - MDI or nebulised * Ipretropium bromide * 4 puffs every 20 minutes if * 8 puffs every 20 minutes if \>6yo, x 3 * Steroids - IV methylprednisolone * MgSO4 or amiophilline in ICU Follow Up * Medication review * Ensure correct understanding and usage of asthma delivery devices