Paediatrics Flashcards
What are the clinical abdominal signs of intussusception?
Abdominal distension, tenderness, sausage-shaped mass on palpation.
What investigations would you perform for ?intussusception and what would you be looking for?
Abdominal USS - may reveal the mass, ‘target’ appearance
AXR - small bowel obstruction (fluid levels, dilated loops of small bowel)
Air enema - may be therapeutic as well as diagnostic
How would you manage intussusception?
Inital fluid resus as needed - ‘drip and suck’ = NG tube and IV fluids
Air (or contrast) enema reduction
Surgical reduction +/- resection if enema contra-indicated
What are contra-indications to managing intussusception with an air enema?
Rectal bleeding
Peritonism (i.e. Guarding, Rebound tenderness, rigid abdomen)
What are common pathological causes of intussusception?
Meckel’s diverticulum (75%).
Polyps and Peutz-Jeghers syndrome (16%).
Henoch-Schönlein purpura (3%).
Lymphoma and other tumours (3%).
What organisms are common causes of intussusception?
Viral - Rotavirus, adenovirus, HHV-6
Amoebomata, shigella, yersinia.
What is Meckel’s Diverticulum?
A congenital bulge of the small intestine, usually ileal, which is a remnant of the yolk stalk.
How can Meckel’s Diverticulum present?
Asymptomatically
Painless rectal bleeding (melena)
Epigastric pain
Mimics appendicitis
What are patients with Meckel’s Diverticulum at risk of developing?
Intestinal obstruction
Volvulus
Intussusception
What diagnostic test would you like to perform to confirm your ?meckel’s diverticulum
A technetium scan - gastric mucosa of the diverticulum show increased uptake
How should you manage a Meckel’s Diverticulum?
Small bowel resection
What is the “rule of 2’s” for Meckel’s Diverticulum?
2% of population affected
2 inches long
2 feet proximal to ileocaecal valve
2 types of mucosa - gastric and pancreatic
2 years old is a common age of presentation
2:1 male:female
What investigations would you like to perform for ?pyloric stenosis
FBC, Glucose, Serum electrolytes (low Cl, low potassium)
LFTs if jaundiced
Blood gas - venous or capillary (alkalosis)
Test feed = infant feeds, palpate olive mass and observe for peristalsis moving from left to right.
or
Abdo USS = outline the ‘dough-nut’ ring of the hypertrophic stenosis.
can sometimes do x-rays with contrast agent.
How would you manage a child with pyloric stenosis?
NBM, NG tube with aspirations
Fluid monitoring and correct dehydration - something with KCl and dextrose in.
Regular BM and serum electrolyte/pH monitoring.
Once stable - discuss with surgeons for ?pyloromyotomy
What do you want to know in a status epilepticus history? (it’s a mnemonic!)
Duration of convulsions and any treatment given already?
also, "PEE FIT" Poisons ingested? Epilepsy history? Eaten recently? Febrile illness recently? Illnesses that are ongoing? Trauma recently?
What does AVPU stand for?
Alert
Voice responsive
Pain Responsive
Unresponsive
Easy Paediatrics book:
What’s the fluid requirement for children weighing 0-10kg?
100-120 mL/kg/24hr
Easy Paediatrics book:
What’s the fluid requirement for children weighing 10-20kg?
1000 + [50mL for each kg over 10] mL/kg/24hr
Easy Paediatrics book:
What’s the fluid requirement for children weighing >20kg?
1500 + [20mL for each kg over 20] mL/kg/24hr
What is the initial management of DKA?
ABCDE approach
If shocked, fluid bolus 10mL/kg 0.9% saline
BM, U+Es, blood gas (venous or capillary)
Maintain potassium levels by giving potassium in each IV bag
Insulin IV after beginning IV fluids
intraventricular haemorrhage is most commonly associated with the development of what type of cerebral palsy?
spastic diplegic cerebral palsy
because of the anatomical proximity to the corticospinal tracts.
What does seborrhoeic dermatitis present like?
erythematous rash with yellow flakes in first few weeks of life.
Affects the scalp, nappy area, face and limb flexures.
Causes of short stature (it’s a mnemonic!)
"ABCDEFG" Alone (neglect) Bone (rickets, achondrodysplasia, scoliosis) Chromosome (Down's, Turner's) Delayed Endocrine (low GH, Cushing's, hypothyroidism) Familial GI malabsorption (Crohn's, Coeliac)
What are the causes of true (gonadotrophin-dependent) precocious puberty (it’s a mnemonic!)
“FACT” (i.e. facts are true!)
Familial
Acquired (post-sepsis, surgery, radiotherapy)
Central (neurofibromatosis, hydrocephalus)
Tumours
What are the causes of false (gonadotrophin-independent) precocious puberty (it’s a mnemonic!)
“HE GAS” (i.e. he gasses a lot of hot air = false)
Hypothyroidism
Exogenous sex steroids
Gonadal (ovarian/testicular tumour)
Adrenal (CAH, tumour)
Syndrome - McCune-Albright
What are the triad of symptoms in McCune-Albright syndrome?
- Precocious puberty
- polyostotic fibrous dysplasia
- Cafe-au-lait spots that are large with irregular borders stopping at midline
Causes of delayed puberty?
Gonadotrophins are either low or high.
Low “CHEST”:
Congenital - familial or sporadic
Hypothyroidism
Hypothalamic-pituitary, e.g. panhypopituitarism or GnRH deficiency
Emotional, e.g. anorexia nervosa
Systemic Disease
Tumour (intracranial), e.g. prolactinoma.
High "Gonadotrophins Climb Stairs" Gonadal dysgenesis Gonadal disease Chromosomal - klinefelter Steroid hormone deficiencies
Neonate in first few days of life develops a diffuse macular rash with papules and pustules predominantly on the trunk. The infant is well and goes on to resolve within 2 days. This recurs over the next two weeks.
Erythema toxicum neonatorum
- occurs in first few days of life
- blotchy red papules +/- pustules
- anywhere on body (not palms/soles)
- infant WELL
- resolve in a few days but can recur over next couple of weeks
Neonate with pinpoint white papules over the nose and cheeks
Sebaceous gland hyperplasia
What are Epstein’s Peals?
milia in the mouth (white keratinous cysts) along the alveolar ridge and at the junction of the hard/soft palate
What is the other name for Mongolian blue spot?
Dermal melanocytosis?
What is the other name for Dermal melanocytosis?
Mongolian blue spot
What causes dermal melanocytosis?
melanocytes entrapped in the dermis
How long does it take for dermal melanocytosis to fade?
a few years
usually all gone by puberty
very rarely for life
Differentials for paediatrics constipation
Intake: Diet, dehydration, too much milk
Gut passageway: stricture, anal fissure, Hirschsprung’s disease
Metabolic: Hypothyroidism; cystic fibrosis; hypercalcaemia
Neuromuscular: cerebral palsy; spinal cord lesions
Drugs: narcotics, antidepressants
What is the first-line medical treatment for faecal impaction?
Macrogols (polyethylene glycol 3350) and electrolytes
What is first-line maintenance therapy in constipation?
Macrogols (polyethylene glycol 3350) and electrolytes
in conjunction with diet and lifestyle advice
How should the maintenance therapy in constipation be adjusted if the patient doesn’t respond to the first-line treatment?
First-line is polyethylene glycol 3350 + electrolytes.
If there is little responsethen add a stimulant laxative, e.g. senna, to the first-line.
How long should a child be on maintenance therapy for constipation?
Several weeks after the first normal bowel movement - don’t stop the medications abruptly
What diet + lifestyle advice would you offer to the parent of a child with constipation?
Lifestyle:
- scheduled toilet time
- Bowel diary
- Reward system
Intake:
- Encourage adequate fluid intake
- Encourage adequate fibre intake (fruit, vegetables)
How should you manage faecal impaction?
1st-line: macrogol (polyethylene glycol) and electrolytes
2nd-line: if no improvement after two weeks add a stimulant (e.g. senna) to the macrogol
Consider rectal medications if the above fails
Consider enema if the above fails
Consider manual evacuation under anaesthetic if the above fails
What are big red flags in a constipation history?
Constipation from birth or first few weeks of life
Failure to pass meconium in first 48 hours of life
Abdominal distension with vomiting
Weakness in legs or locomotor delay
What are red flags in an examination for constipation?
Abnormal appearance/position/patency of anus
Gross abdominal distension
Abnormal spine/gluteal region
Abnormal neurological reflexes
What are long term complications of constipation?
Faecal impaction –> overflow diarrhoea
Megacolon –> risk of ulcers and perforation
Anal fissures –> pain and chronic fissures
Psychological and behavioural effects
Basically: blockages, tears and psych
How would you manage an anal fissure?
Osmotic laxative and pain relief (e.g. paracetamol or ibuprofen)
How might a child with Hirschprung Disease present?
Failure to pass meconium in first 48 hours of life
Vomiting
Abdominal distension
Explosive bowel movements, particularly following examination
What genetic condition is associated with Hirschprung Disease?
Down syndrome
What specific investigations would you like to perform for Hirschprung Disease?
Consider Abdominal X-ray (megacolon) or contrast enema
Definitive: Rectal biopsy demonstrating absent ganglions (older children require anaesthetic)
What is the management for Hirschprung Disease?
Bowel irrigation (this is not an enema)
- involves small volume of liquid introduced into rectum
- repositioning a tube to evacuate gas and liquid from the rectum.
Definitive surgery:
- Removal of aganglionic section and pull-through of normal ganglionic section to rectum
- usually done by first few months of life
What are the differentials for reflux?
Possetting (physiological passive reflux)
Allergy (skin rash, vomiting, diarrhoea –> use special formula)
GORD ( weakness or inappropriate relaxation of oesophageal sphincter)
Oesophageal stricture
Pyloric Stenosis
What are common causes of pharyngitis?
Viral: Adenovirus or parainfluenza virus
Bacterial: Group A Streptococcus
What are the treatment options for pharyngitis?
Antipyretics and fluids
Antibiotics if ?bacterial
How would a child with laryngomalacia present?
Stridor (‘floppy’ airway that collapses on inspiration)
Develops early in life (like days)
What investigation might you perform to diagnose laryngomalacia?
Laryngoscopy
How would you manage a child with laryngomalacia?
Reassurance - most cases will resolve with time
Rule out GORD
If severe, consider surgical review for endoscopic supraglottoplasty
What is the treatment for moderate/severe croup?
Consider oxygen if below 92%
Oral dexamethasone (0.15mg/kg)
Paracetamol or ibuprofen for fever and pain relief
Consider neubulised adrenaline
Consider intubation and ventilation if not responding to treatment
What is the organism that causes whooping cough?
Bordetella Pertussis
Gram negative coccobacillus
What are the symptoms/stages of whooping cough?
Catarrhal stage:
- runny nose, conjunctivitis, wheeze
- lasts one to two weeks
Paroxysmal stage:
- Coughing with whoop and vomiting
- May have apnoeas following coughing spasms
- up to three months
Convalescence:
- Resolution of symptoms
- around two weeks
What is the management for whooping cough?
Admit if less than 6 months old or if severe breathing difficulties
Prescribe antibiotics to patient and close contacts:
- less than 1 month old = clarithromycin
- greater than 1 month old = clarithromycin or azithromycin
- pregnant = erythromycin
What should patients be advised regarding staying off school with whooping cough?
Stay off school for 5 days after starting antibiotics
OR
Three weeks after onset of cough
… whichever is sooner
How can the causes of ataxia be classified?
Acute or Chronic
Intermittent or Progressive
An enlarged 4th ventricle with cerebellar hypoplasia. The patient has an increased head circumference, ataxia and signs of raised ICP.
Dandy-Walker syndrome
characterised by the enlarged 4th ventricle and cerebellar hypoplasia
An autosomal recessive condition that leads to degeneration of cerebellar tracts and dorsal columns displaying progressive ataxia, lower limb weakness, loss of deep tendon reflexes and many more signs.
Friedrich ataxia
A non-progressive brain lesion within the developing brain that develops during the antenatal, neonatal or early postnatal period. Impacts upon cognition, sensory, motor, communication and psychological domains.
Cerebral Palsy
Categories and examples of cerebral palsy causes?
Antenatal = cerebral malformation/dysgenesis or congenital infection
Intrapartum = Hypoxic-ischaemic encephalopathy (birth asphyxia)
Post-natal = Intraventircular haemorrhage, head trauma, cerebral ischaemia
Types of cerebral palsy?
Spastic
Dyskinetic
Ataxic
A cerebral palsy demonstrating velocity-dependent increased tonic stretch reflexes with clonus. It can be classified as monoplegic, hemiplegic, diplegic or quadraplegic.
Spastic cerebral palsy
A cerebral palsy demonstrating involuntary, recurring, stereotyped movements with varying tone.
Dyskinetic cerebral palsy
A cerebral palsy demonstrating hypotonia, poor balance and coordination as well as a tremor.
Ataxic cerebral palsy
What investigations would you like to order for a patient demonstrating signs of cerebral palsy?
MRI brain
Congenital infection screen
Metabolic screen
Who from the MDT would you involve in the management of a patient with cerebral palsy?
Movements: OTs, PTs, SALT
Development: Social worker, teacher, developmental psychologists
Health: Paediatricians, orthopaedics, neurology, audiology, ophthalmology
What is the treatment for a breath holding spell?
Reassurance
Most kids grow out of them
An arthritic type picture affecting less than 4 joints?
oligoarthritis
An arthritic type picture affecting more than 5 joints?
polyarthritis
Treatment for JIA?
DMARDs = methotrexate/sulphasalazine
NSAIDs = ibuprofen
oral corticosteroids = prednisolone
Teenager with limited hip movement, external rotation but decreased internal rotation.
Antalgic gait, pain down to knee.
Slipped upper femoral epiphysis
Management of slipped upper femoral epiphysis?
Don’t walk
Pain killers
Ortho referral for surgical fixation with pin
Interruption of blood supply to femoral head leading to necrosis
Perthes disease
What are risk factors for developmental dysplasia of the hip?
Oligohydramnios Breech position Prematurity Great than 5kg birth weight Positive family history Spinal problems
What is the Barlow test?
flex and adduct baby legs and push posteriorly on knee
What is ortolani test?
flex, anterior pressure on thigh and abduct - should feel a clunk
When are a baby’s hips checked for hip dysplasia?
within 72 hours of birth
again at 6 week check
Management for a child less than 6 months old with developmental dysplasia of the hip?
Pavlik’s harness
Management for a child older than 6 months or if first-line management didn’t work?
Closed reduction (anaesthetic and cast with imaging) for 12 weeks
Management for a child in which 2nd-line treatment didn’t work?
open reduction
What’s the problem if developmental dysplasia of the hip is not treated?
Arthritis of the hip –> pain and movement issues later in life
Inflammation of the patellar tendon at the tibial tubercle with pain below the knee
Osgood-schlatter (apophysitis of the tibial tubercle)
What investigations for Duchenne Muscular Dystrophy?
Creatine Kinase (massively elevated)
Biopsy (lack of dystrophin)
EMG
Genetics (Xp21)
What signs of Duchenne Muscular Dystrophy?
Gower's sign - lying then rolling onto front and using knees to get back up Trendelenburg gait Calf pseudohypertrophy (fat/connective tissue replaces muscle)
What age does Duchenne Muscular dystrophy tend to present?
3 years old
Prognosis of Duchenne Muscular dystrophy?
life expectancy of 20s/30s
Common causes of neonatal conjunctivits?
Staph Aureus
Neisseria Gonorrhoea
Chlamydia Trachomatis
Chemical irritants
Common causes of infant/young child conjunctivitis?
Staph aureus
Streptococcus pneumoniae
Haemophilus influenza
Moxarella
Treatment of neonatal conjunctivitis?
Chloramphenical eyedrops
chlamydia = erythormycin and tetracycline
Gonococcus = penicillin eye irrigation
Treatment of infant/young child conjunctivitis?
Fusidic acid/chloramphenicol/neomycin
Signs/symptoms in periorbital vs orbital cellulitis?
periorbital = basically normal eye movements/reflexes/vision etc Orbital = inflamed conjunctiva/sclera, impaired reflexes/vision
Management of periorbital/orbital cellulitis?
peri=oral, orbital=broad spec IV
ENT team to r/o sinus involvement
ophthalmology input
Management of retinoblastoma?
Chemo/radiotherapy
If local involvement - enucleation (removal of eye!)
Management of congenital adrenal hyperplasia?
Hydrocortisone (lifelong) oral
If salt-wasting CAH –> fludrocortisone
Surgery for virilised genitalia
