Paediatrics Flashcards
Vaccine adverse reactions
Local: induration, tenderness, redness, swelling
Systemic: fever rash, irritability
Allergic: urticaria, rhinitis, anaphylaxis
Growth parameters infants
Up to 10% weight loss in first week of life, should regain by second week.
2x birth wt by 4-5 months
3x birth wt by 1yr
4x birth wt 2yrs
Fine motor milestones
1m: hands fisted
2m: pulls clothes
4m: reaches for objects
6m: grasp, transfer*
9m: early pincer*
12m: neat pincer, throws ball
18m: tower of 3, scribbling
24m: tower of 6, line
3yrs: circle, turns individual pages
4yrs: cross, scissors
5yrs: shapes, prints name
Gross motor milestones
1m: turns head
2m: holds head up
4m: lifts head and chest while prone
6m: tripod sit
9m: sits without support, pulls to stand*
12m: stands without support, walks*
18m: runs
24m: 2 feet up stairs, kicks
3yrs: tricycle, 1 foot up stairs
4yrs: hops, 1 foot down stairs
5yrs: skips
Speech and language milestones
1m: cries
2m: coos
4m: turns head to sound*
6m: babbles*
9m: imitates words
12m: 1-2 words, points to wants
18m: 10 words, simple commands
24m: 2-3 word phrases, 2 step commands
3yrs: >3 words in sentence, colours, counts to 10
4yrs: speech intelligible
Social skills milestones
1m: calms when comforted
2m: smiles
4m: laughs, follows movement
6m: stranger anxiety, beginning of object permanence*
9m: plays games
12m: responds to name
18m: points to interest
24m: parallel play
3yrs: knows age, sex, make believe
4yrs: cooperative play, toilet trained by day
5yrs: Separates from caregiver easily
Pediatric development milestones 1-4yrs
1 yr: single word
2 yrs: 2 word sentences
3 yrs: 3 word combos, rides tricycle
4 yrs: counts 4 objects
Developmental red flags
Gross motor: 18m not walking
Fine motor: <10m handedness
Speech: 18m <3 words
Social: 3m not smiling, 15-18m not pointing
Nutrition requirement
1-10kg: 100 cal/kg/d
10-20kg: 50 cal/kg/d
>20kg: 20 cal/kg/day
Dietary recommendations
Supplementation: vit K, vit D, iron, fluoride may be required
Solid introduction: at 6 months, 2-3 new foods per weeks
Breast feeding
Advantages: easily digested, immunologic (IgA and immune cells), good gut bacteria, bonding, economical
Contraindicated: chemo/radiotherapy, HIV/AIDS, untreated TB, alcohol, fat soluble medications
Complications: breast feeding jaundice, inadequate intake
Signs of inadequate intake <6 wet nappies/d <7 feeds/d Weight loss >10% Lethargic, sleeping through the night
Breath holding spells
Starts in children 6m-4yrs. Child is usually provoked and holds breath, spontaneously resolves or loses consciousness.
Enuresis
Involuntary urinary incontinence by day/night in child >5yrs.
DDx
- UTI
- Neurologic pathology
Primary nocturnal enuresis: can be normal up to age of 7.
- Time and reassurance
- Behaviour modification: limit fluids before bed, voiding prior to sleep
- Conditioning: wet alarm
- Medications: desmopressin
Secondary enuresis: develops after a child has sustained bladder control for >6m.
- Stress, anxiety
- Secondary to organic cause: UTI, DM, DI, neurogenic bladder, CP, sickle cell disease
Diurnal enuresis: daytime wetting.
- Micturition deferral, psychologic stressors
- Structural anomalies: neurogenic bladder, ectopic ureteral site
- UTI
- Constipation
- CNS disorders
Encopresis
Fecal incontinence in a child >4yrs Causes: - Retentive encopresis (chronic constipation) - Hirschsprung disease - Hypothyroidism - Hypercalcemia - Spinal cord lesions - Anorectal malformations
Failure to thrive
Definition: <3rd percentile, falls across 2 major percentile curves.
Hx: dietary and feeding hx, bowel habits, family height, weight.
Ex: height, weight, head circumference, arm span, U/L segment ratio, dysmorphism
Investigations: FBC, blood film, U&E, TSH, urinalysis, bone age, karyotype
Organic FTT (10%)
- Insufficient feeding: insufficient breast milk production, vomiting, weak suckling, anorexia
- Inadequate absorption: malabsorption (celiac, CF, pancreatic insufficiency), loss from GI tracts (chronic diarrhea)
- Renal loss: inborn errors of metabolism, endocrine disorders
- Increased energy requirements: CF, cardiac disease, endocrine, malignancy, chronic infections
- Decreased growth potential: chromosomal abnormalities
Non-organic FTT:
- Malnutrition, inadequate nutrition, poor feeding technique
Infantile colic
Unexplained paroxysms of irritability and crying for >3h/d, >3d/wk for >3wks in an otherwise healthy baby. In under 3m.
SIDS
Prevention:
- Sleeping on back
- Supervised tummy play
- Avoid overheating
- Appropriate infant bedding
- No smoking
- Avoid bed sharing
Child abuse and neglect
Physical abuse
Sexual abuse
Neglect
Management:
- Clear documentation
- Report all suspicions to CYFs, request emergency visit if imminent risk to child.
- Hospitalize for treatment as indicated
Adolescent assessment
Home Education/Employment Eating Activities Drugs Sexuality Suicide and depression Safety/violence
Fetal circulation change at birth
First breath decreases pulmonary resistance, increases pulmonary flow and LA pressure -> foramen ovale closure
Separation of placenta -> ductus venosus closure
Increased oxygen concentration, decrease prostaglandins -> ductus arteriosus closure
Congenital heart disease
Acyanotic - blood passes through the lungs. L=>R shunt: - ASD - VSD - PDA - AVSD Obstructive: - Coarctation Aortic stenosis Pulmonic stenosis
Cyanotic - blood bypasses the lungs. R=>L shunt: - Teratology of Fallots - Ebstein's anomaly Other: - TGA - Total anomalous pulmonary venous drainage - Tricuspid atresia - Hypoplastic left heart syndrome
Atrial septal defect (ASD)
3 types:
- ostium primum
- ostium secundum (most common)
- sinus venosus
80-100% spontaneous closure rate if ASD <8mm. May lead to CHF and pulmonary HTN if remains patent.
Surgical treatment with catheter closure at 2-5yrs
Ventricular septal defects (VSD)
Most common congenital heart defect.
Small VSD (majority)
- Asymptomatic
- Systolic murmur at LLSB
- Spontaneous closure.
Moderate-large VSD
- CHF by 2m, late secondary pulmonary HTN if untreated
- Delayed growth and exercise tolerance, recurrent URTI
- Systolic murmur LLSB, mid-diastolic rumble at apex.
- Treatment of CHF and surgical closure by 1yr
Patent ductus arteriosus
Functionally closes in the first 15hs of life. Can be delayed in premature infants.
- Spontaneous closure in preterm, less common in term
- Asymptomatic or apneic/bradycardic spells, poor feeding.
- Tachycardia, continuous machinery murmur L infraclavicular.
- Indomethacin (PGE2 antagonist), surgical closure
Coarctation of the aorta
Commonly associated with bicuspid valve and Turner syndrome.
- Asymptomatic
- Radiofemoral delay
- May present with shock if severe and PD closes
- PGE2 until surgical corrective measures
Aortic stenosis
4 types:
- Valvular 75%
- Subvalvular 20%
- Supravalvular
- Idiopathic hypertrophic subarotic stenosis
- Asymptomatic but associated with CHF
- Systolic ejection murmur at RUSB with ejection click
- Balloon valvuloplasty
Pulmonary stenosis
Associated with Tetratology of Fallot, congenital rubella, Noonan syndrome.
- Asymptomatic to CHF
- systeolic ejection murmur at LUSB, pulmonary ejection click
- Surgical repair
Tetralogy of Fallots
Features:
- VSD
- RV outflow tract obstruction
- Over-riding aorta
- RV hypertrophy
Cyanosis during exertional states with rapid and deep breathing.
- Single loud S2, systolic ejection murmur LSB
- CXR: boot shaped heart with decreased pulmonary vasculature.
- O2, knee-chest position, fluid bolus, morphine/propanolol, surgical repair at 4-6m
Transposition of great arteries
Survival dependant on mixing through PDA/septal defects.
- Rapidly progressive severe hypoxemia, unresponsive to O2 therapy.
- Prostaglandin infusion, balloon atrial septostomy
Hypoplastic left heart syndrome
Most common cause of CHD in the first month of life. LV hypoplasia with systemic hypoperfusion, dependent on patent PDA. Closure of PDA results in circulatory shock and metabolic acidosis.
- Intubate
- IV PGE2
- Surgical palliation
Congestive heart failure
Infant: feeding difficulties, early fatigability, diaphoresis while sleeping, respiratory ditress lethargy, FTT
Child: decreased exercise tolerance, fatigue, decreased appetite, FTT, respiratory distress, frequent URTI
Findings:
Tachycardia, tachypnea, cardiomegaly, hepatomegaly.
FTT
Dysmorphic features
CXR: cardiomegaly, pulmonary venous congestion
Management:
General: sitting, O2, Na and water restriction, increased caloric intake
Pharmacologic: diuretics, ACEi
Curative: correction of underlying cause
Dysrhythmias
Sinus arrhythmia - variations with respiration
Premature atrial contractions - normal, electrolyte imbalance, hyperthyroidism, digitalis toxicity
Premature ventricular contractions - common in adolescents and benign if single.
Supraventricular tachycardia - most frequent and caused by re-entry via accessory connection. Vagal maneuvers, valsalva, adenosin, DC cardioversion.
Complete heart block - often diagnosed in utero, maternal SLE
Innocent murmurs
Asymptomatic
Systolic ejection murmur
Low grade <3/6
Murmur changes with position and respiration
Global developmental delay
Performance significantly below average in 2 or more areas of development.
Etiology
- CNS abnormalities (meningitis, brain malformation, trauma)
- Sensory deficits (hearing, vision)
- Environmental (psychosocial neglect, lead exposure, antenatal drug)
- Metabolic disorders (inborn errors of metabolism, hypothyroidism)
- Obstetrical (prematurity, hypoxic ischemic encephalopathy, TORCH infections)
Fetal alcohol syndrome
Growth: low birth weight, decelerating weight
Facial: short palpebral fissures, flattened philtrum, thin upper lip, flat midface
CNS: microcephaly, ADHD, learning disabilities
Intellectual disability
<18yrs with limitations in both intelligence and adaptive skills
Causes:
Prenatal - TORCH infections, fetal alcohol syndrome
Genetic - DS, Fragile X, PKU, congenital hypothyroidism, CNS abnormalities
Short stature
Height <3rd percentile
IUGR
- Chromosomal (Down’s Turner’s)
No IUGR
- Disproportionate
> skeletal dysplasia
- Proportionate
> Normal growth velocity: constitutional growth delay, familial
> Slow growth velocity: endocrine (GH deficiency, Hypothyroidism, hypercortisolism, hypopituitarism), chronic disease, psychosocial neglect
Congenital hyperthyroidism
Results from transplacental passage of maternal thyroid stimulating antibodies from mother with Grave’s.
Features: tachycardia, heart failure, goitre, irritability FTT
Tests: TSH, T4
Management: propylthiouracil, B-blockers
Congenital hypothyroidism
Causes: maternal antibody mediated, iodine deficiency, prenatal exposure to antithyroid drugs.
Features: prolonged jaundice, constipation, lethargy, poor feeding, macroglossia
Tests: TSH, T4
Management: thyroxine
Ambiguous genitalia
Disorders of Sex Differentiation
46XY DSD - inborn error of testosterone biosynthesis or Leydig cell hypoplasia, 5-a-reductase deficiency, androgen receptor deficiency or insensitivity.
46XX DSD - virilising congenital adrenal hyperplasia, maternal source of androgens.
Ovotesticular DSD - both ovarian follicles and seminiferous tubules in the same patient.
Investigations: karyotype and genetic workup, 17-OH-progesterone, androgens, FSH, LH, abdominal imaging
Normal puberty
Increase pulsatile release of GnRH.
Females 8-13yo - Thelarche - Pubarche - Growth spurt - Menarche 12.5yrs Early puberty common, late puberty rare
Males 9-14yo
- Testicular enlargement
- Penile enlargement
- Pubarche
- Growth spurt
Early puberty uncommon, late puberty common.
Gynecomastia is seen in 50% of male during puberty.
Tanner Breast staging
1) Nipple elevation
2) Breast and nipple elevated
3) Enlargement of breast and areolar
4) Areolar and nipple form secondary mound
5) Mature, nipple projects, no secondary mound
Tanner Female Genital staging
1) No hair, prepubertal
2) Small amount of hair along labia majora
3) Darker coarser hair sparsly over pubis
4) Adult type hair, no extension to medial thighs
5) Mature distribution with spread to medial thighs
Tanner Male Genitalia staging
1) No hair, prepubertal
2) Small amount of hair, enlargement of testes and scrotum, reddening of scrotal skin
3) Darker coarser hair sparsly over pubis, lengthening of penis, further scrotum enlargement.
4) Adult type hair, no extension to medial thighs, increase penile circumference, darkening of scrotal skin
5) Mature distribution with spread to medial thighs, adult size
Precocious puberty
<8yo for females and <9yo for males.
Females 90% idiopathic
Males 50% pathologic
Central GnRH dependent - hypergonadotropic hypergonadism, premature activation of HPG axis
Peripheral GnRH independant - hypogonadotropic hypergonadism - adrenal disorders, testicular/ovarian tumour
Tests: bone age, serum hormone levels, DHEA, 17-OH progesterone
Delayed puberty
Lack of testicular enlargement by 14yo for males and lack of breast development by 13yo for females OR absence of menarche by 16yo
Constitutional delay more common in males, more suggestive of pathology in females.
Causes:
Central causes - constitutional delay in activation of HPA axis, hypogonadotrophic hypogonadism
Peripheral causes - hypergonadotrophic hypogonadism
Tests: bone age, serum hormone levels, thyroid levels, LFTs,
Neonatal vomiting - non-bilious
Tracheoesophageal fistula
- vomiting soon after birth, respiratory distress, coughing, inability to feed
- inability to pass NG tube, CXR
- Rx: early surgical repair
Pyloric stenosis
- projectile vomiting after feeds, dehydrated, palpable mass, hungry
- US of pylorus
- Rx: correction of metabolic alkalosis, surgical pyloromyotomy
GERD
- fussiness after feeds, spilling, poor weight gain
- trial of acid suppression
- Rx: thickened and smaller feeds, ranitidine, omeprazole
Sepsis
- fever, lethargy, tachycardia, tachypnea, widening pulse pressure
- FBC, culture (blood, urine, CSF), CXR
Inborn error of metabolism
- poor feeding, FTT, jaundice, hepatosplenomegaly
- U&E, ABG, lactate
Neonatal vomiting - bilious
Duodenal atresia
- bilious vomiting, associated with Down syndrome, jaundice
- AXR
- Rx: decompression with NG tube, correct metabolic abnormalities, surgical correction
Malrotation with volvulus
- bilious emesis, abdominal distension, pain, bloddy stool
- AXR
- NG tube decompression and surgical correction
Hirshsprung disease
- bilious emesis, abdominal distension, pain, failure to pass stools
- AXR, rectal biopsy
Children and adolescence vomiting
Gastroenteritis
- diarrhea, fever, sick contact, recent travel
- FBC, stool culture
Appendicitis
- periumbilical discomfort that localises to RLQ, fever, anorexia
- abdominal US
Intussusception
- colicky progressive abdo pain, bloody stool
- abdominal US
Non-GI infection
- fever, other symptoms
Increased intracranial pressure
- nocturnal wakening, progressive recurrent headache worse with valsalva
- brain CT without contrast
Toxic ingestion
- varies by substance
Pregnancy
- amenorrhea, morning sickness, bloating, breast tenderness
- pregnancy test
Cyclic vomiting
- >3 self-limited episodes of vomiting with intervals between episodes
Diarrhea
Pathophysiology
- Osmotic: lactose intolerance
- Secretory: increased secretion of Cl and water
- Malabsorption: decreased GI surface area
Acute diarrhea
<2 weeks
Viral
- rotavirus
- enteric adenovirus
Bacterial
- salmonella
- campylobacter
- shigella
- E. coli
- yersinia
- C. difficile
Parasitic
- giardia
- entamoeba hisolytica
Non-infectious
- antibiotic induced
- Hirschsprung’s disease
- toxin ingestion
Chronic diarrhea with no FTT
GI infection
Toddler’s diarrhea - most common cause in infancy, onset 6-36m, ceases between 2-4yrs
Lactase deficiency - lactose intolerance, can be post viral/bacterial infection
IBS
Chronic constipation
Chronic diarrhea with FTT
Disaccharidase deficiency
Milk protein allergy - dairy intolerance, remove dairy from mother’s diet if breast feeding.
Cystic fibrosis
Celiac disease - usually 6-24 months with introduction of gluten into the diet.
IBD
Endocrine/neoplastic
Constipation
<3 stools/week
Functional constipation
- lack in fiber, poor fluid intake or behavioural
- management with laxsol for clean out and maintenance with dietary fibers or stool softeners
Hirschsprung’s disease
- failure or normal innervation of the distal colon by myenteric plexus, colon remains contracted
- suspicion if no meconium in first 24h, palpable stool but tight empty rectum, intermittent diarrhea
- AXR shows no air in rectum, rectal biopsy is definitive
- non-surgical (increase fiber and fluid), surgical re-anastomosis
Endocrine
- hypothyroidism
- DM
- hypercalcemia
Neurologic
- spina bifida
Anatomic
- bowel obstruction
- anus anomalies
Drugs:
- opioids
- lead
- chemotherapy
Acute abdominal pain - GI etiology
Gastroenteritis, malabsorption Incacerated hernia, intussusception Apendicitis, Meckel's diverticulitis Malrotation, volvulus IBS, mesenteric adenitis Cholecystitis, pancreatitis Somatization Constipation Ileus
Acute abdominal pain - non-GI etiology
UTI Henoch-Schonlein Purpura Sickle cell crisis Pneumonia DKA Nephrolithiasis Gynaecological (ectopic, PID, menstruation) Testicular/ovarian torsion
Chronic abdominal pain - red flags
- Age <5yrs
- Fever
- Localisez pain away from midline
- Anemia
- Rectal bleeding
- Rash
- Pain awakens child at night
- Travel history
- Prominent vomiting/diarrhea
- Weight loss/FTT
- Joint pain
Abdominal mass
Renal
- Benign: hydronephrosis, PCKD, hamartoma
- Malignant: nephroblastoma (Wilm’s), renal cell carcinoma
Adrenal
- Malignant: neuroblastoma
Ovarian
- Benign: cysts
- Malignant: tumours
Other
- Benign: splenomegaly, pyloric stenosis, abdominal hernia, teratoma, fecal impaction
- Malignant: lymphoma, rhabdomyosarcoma, retroperitoneal sarcoma.
Trisomy 21
Down syndrome
1:1500 in 20’s, 1:20 by 45.
Features:
- Head: 3rd fontanelle
- Face: upslanting eyes, refractive errors, low set ears, frequent AOM, small nose, flat nasal bridge
- Skeletal: short stature, joint hyperflexibility
- CNS: hypotonia, low IQ, early onset of Alzheimer’s
- Internal organs: Heart defects (AVSD), GI atresia, TE fistula, crytorchidism,
- Associations: leukaemia 1%, polycythemia, hypothyroidism, celiac’s
Investigations: Chromosomal analysis Echocardiogram Thyroid and celiac's screen Hearing and vision assessment
Trisomy 18
Edwards syndrome
Features:
- Head: microcephaly
- Face: microopthalmia, iris coloboma, low set ears, cleft lip/palate, small mouth
- Skeletal: short stature, polydactyl
- CNS: hypertonia, profound intellectual disability
- Internal organs: heart defect (VSD, PDA, ASD), hernia, PCKD, crytorchidism.
Prognosis: 44% die in first month, 10% survive past 1 yr
Trisomy 13
Patau syndrome
- Head: microcephaly
- Face: small eyes, low set ears, 60-80% cleft lip/palate.
- Skeletal: severe growth retardation, polydactyly
- CNS: seizures, deafness, severe developmental delay
- Internal organs: heart defect 80% (VSD, PDA, ASD), PCKD
Prognosis: 90% die by 1 yr from FTT
Fragile X syndrome
X-linked with genetic anticipation. Most common heritable cause of intellectual disability in boys
Features:
- Prominent jaw, forehead, nasal bridge, long face, protuberant ears, macroorchidism
- Mild to moderate intellectual disability
- Carrier females at risk of premature ovarian failure
- Complications: seizures, scoliosis, mitral valve prolapse
Klinefelter’s syndrome
47 XXY, 48 XXXY
Features:
- Tall slim, underweight
- Pubertal delay, gynaecomastia, lack of facial hair
- Mild intellectual disability
- Infertile and have increased risk of germ cell tumours and breast cancer
Turner syndrome
45 XO
Features:
- Short stature, webbed neck, broad chest, widely spaced nipples
- Lymphedema of hands and feet, cystic hygroma, lung hypoplasia in newborn
- Coarctation of aorta, bicuspid aortic valves, renal abnormalities and increased risk of HTN
- Mildly deficient to normal intelligence
- Infertile, primary amenorrhea, impaired development of secondary sexual characteristics
Noonan syndrome
46 XX or 46 XY AD with variable expression
Features:
- Short stature, webbed neck, triangular face, low set ears, pectus excavatum
- Right sided CHD, pulmonary stenosis
- Moderate intellectual disability in 25%
- Delayed puberty
DiGeorge Syndrome
Microdeletions of chromosome 22q1
"CATCH 22" Cyanotic CHD Anomalies: micrognathia, low set ears Thymic hypoplasia, recurrent infections Cognitive impairment Hypoparathyroidism, hypocalcemia 22q11 microdeletions
Prader-Willi syndrome
Lack of paternally imprinted genes on 15q11
"H3O" Hypotonia/weakness Hypogonadism Hyperphagia Obesity
CHARGE syndrome
Coloboma congenital Heart defects choanal Atresia mental Retardation GU anomalies Ear anomalies
VACTERL association
Vertebral dysgenesis Anal atresia Congenital heart defect Tracheo-esophageal fistula Renal anomalies Limb deformities
Duchenne muscular dystrophy
Progressive skeletal and cardiac muscle degeneration due to muscle fibre fragility. X-linked recessive
Features:
- Proximal muscle weakness by 3, Gower’s sign, waddling gait, toe walking
- Wasting of thighs and decreased reflexes
- Cardiomyopathy
Management:
- Supportive frames, prevent obesity.
- Surgery for scoliosis
- Steroids
- Wheelchair bound by age 12, flexion contractures, scoliosis, osteopenia of immobility, respiratory failure, CHF
Phenylketonuria
AR disease. Deficiency of phenylalanine hydroxylase, prevents conversion of phenylalanine to tyrosine.
Features:
- Baby norma lat birth, then develops musty odour, eczema, hypertonia, tremors and mental retardation
- Hypopigmantation
Management:
- dietary restriction of phenylalnine
Galactosemia
AR disease. Most commonly deficiency of galactose-1-phosphate uridyltransferase leading to inability to process lactose/galactose.
Features:
- Liver and renal failure, jaundice, FTT, cataracts
Management:
- elimenation of galactose from diet, soy-based diet
Anemia
Decreased reticulocytes (production problem)
- Microcytic: IDA, thalassemia, anemia of chronic disease, lead poisoning, sideroblastic anemia
- Normocytic: anemia of chronic disease, renal failure, marrow infiltration
- Macrocytic: megaloblastic, marrow failure
Increased reticulocytes (hemolysis) - Intrinsic to RBC \+ Hemoglobinopathies: sickle cell, thalassemia \+ Membrane problem: hereditary spherocytosis \+ Enzyme: G6PD deficiency - Extrinsic RBC \+ Immune hemolysis: ITP, AIHA \+ Non-immune hemolysis: TTP, HUS
Iron deficiency anemia
Most common cause of anemia in childhood, full term infants exhaust iron reserves by 6m. Also commonly diagnosed 11-17 years due to periods of rapid growth.
Features (severe):
- Behavioural and intellectual deficiencies
- Angular chelitis, glossitis, koilonychia
Prevention and management:
- Iron supplementation of breast milk at 4-6m
- Early introduction of red meat and iron-rich veggies
- Oral iron therapy for replacement
Sickle cell disease
Presentation:
- At 5-6months after fall in fetal Hb
- Anemia, fever, jaundice, splenomegaly, crisis
- Later develop functional asplenia by age 5 due to auto-infarction.
- Long term complications are growth delay, bony abnormalities, gallstones, retinopathy
Crises types:
- Vaso-occlusive crisis due to obstruction of blood vessels by sickled cells, presents as fever and pain in any organ (long bones, chest, abdomen, CNS, dactylitis, priapism)
- Aplastic crisis due to depression of erythopoiesis associated with parovirus B19
- Acute splenic sequestration due to sudden massive pooling of RBC’s in the spleen
Management:
- Acute crisis: supportive and symptomatic treatment (fluids, oxygen, analgesia, antibiotics), RBC exchange transfusion if persistent.
- Chronic: early aggressive treatment of infections, vaccination against encapsulated organisms (pneumococcal, meningococcal, H. influenza), prophylatic antibiotics
Immune thrombocytopenic purpura
Most common cause of thrombocytopenia in childhood. Caused by autoantibodies that bind to platelet membranes, destruction of platelets.
Features:
- 50% present 1-3wks after viral illness
- Sudden onset of petechiae, purpura, epistaxis in otherwise well child
Tests: thrombocytopenia, normal RBC, WBC.
Management:
- Observation
- Treatment with IVIG or prednisone if mucosal or internal bleeding.
Oncology
Newborns: Wilm’s tumour, retinoblastoma
Infancy and childhood: leukaemia, neuroblastoma, Wilm’s tumour, retinoblastoma
Adolescence: lymphoma, gonadal tumours, bone tumours
Leukemia
Mean age of diagnosis 2-5yrs: ALL 75%, AML 10%, CML 5%.
Features:
- Infiltration of leukemic cells into bone marrow results in bone pain, and bone marrow failure
- Infiltration into tissues: lymphadenopathy, hepatosplenomegaly, CNS manifestations
Prognosis:
- 80-90% 5yr event-free survival for ALL, 50% 5yr survival for AML
- risks stratified into standard risk and high risk based on WBC and age.
Lymphoma
Hodgkin’s lymphoma
- peak at age 15-34 and 50+
- most common presentation is persistent, painless, firm, cervical or supraclavicular lymphadenopathy
Non-Hodgkin’s lymphoma
- incidence peak 7-11 yrs
- catergorised: lymphoblastic, large cell, Burkitt’s.
Wilms’ tumour (nephroblastoma)
Usually diagnosed between 2-5yrs, most common primary renal neoplasm of childhood.
Features:
- 80% asymptomatic, unilateral abdominal mass
- hypertension, gross hematuria, abdominal pain vomiting
Associated congenital abnormalities:
- WAGR syndrome (Wilms, Aniridia, Genital anomalies, Retardardation)
- Beckwith-Wiedemann syndrome
- Denys-Drash syndrome
Management:
- staging + nephrectomy
- chemotherapy
- 90% long-term survival
Neuroblastoma
Most common cancer occurring in the first year of life. Arises from adrenal medulla, sympathetic chain.
Features:
- Location features: thoracic (dyspnea, Horner’s), abdomen (palpable mass), spinal cord compression
- Metastases are common at presentation
- Paraneoplastic: HTN, palpitations, sweating, diarrhea, FTT
Investigations:
- VMA, HVA levels
- CT or MRI for staging
Rhabdomyosarcoma
Third most common extracranial solid tumour of children.
Features:
- Firm painless mass
- Common sites of origin are structures of the head and neck, GU tract and extremities
- Metastases to lung, bone marrow and bone
Lymphadenopathy
Benign: fluctuance, warmth, tenderness
Malignant: firm, discrete, non-tender, enlarging, immobile + suspicious mass
DDx: - Infection: \+ Viral: URTI, EBV, CMV, adenovirus \+ Bacterial: S. aureus, GAS, anaerobes, TB, cat scratch \+fungal, protozoa, rickettsia - Autoimmune- RA, SLE - Malignancy
Acute otitis media
Middle ear effusion/inflammation. Peak incidence 6-15 months
Etiology
- Structure: Eustachian tube dysfunction
- Bacterial: S. pneumonia, H. influenza, M. catarrhalis, GAS, S aureus
- Viral: RSV, influenza, parainfluenza, adenovirus
Risk factors:
- Young age, family hx, prematurity, orofacial abnormalities, immunodeficiencies, Down Syndrome, race and ethnicity.
- Lack of breast feeding, day care attention, household crowing, second hand smoke, pacifier use
Management:
- Observe 48-72hrs without abx if >6m as most will self resolve
- Amoxicillin +/- clavulanate for 10d
- Symptomatic relief with paracetamol and NSAIDs
Complications:
- Extracranial: hearing loss, TM perforation, extension of infection, cholesteatoma, facial nerve palsy, vestibular dysfunction
- Intracranial: meningitis, epidural and brain abcess, subdural empyema, lateral and cavernous sinus thrombosis, carotid artery thrombosis
HIV infection
20-30% risk of vertical transmission in untreated HIV women, <1% with antiretroviral treatment.
Transmission: transplacental, maternal blood, rexposure to secretions during childbirth, breast milk.
Risks:
- Infection by candidiasis, chronic interstitial pneumonitis, Pneumocystis jiroveci
- Encephalopathy
- Hepatosplenomegaly
Management:
- HAART
- prompt treatment of infections, prophylactic treatment and immunizations
GAS infections and complications
Strept throat, AOM, sinusitis, cervical adenitis, mastoiditis, retropharyngeal/peritonsillar abcess, sepsis.
Labs: GAS throat culture, rapid Ag detection, anti-streptolysin O titres (ASOT)
Immune mediated complications
- Scarlet fever: delayed-type hypersensitivity reaction to pyrogenic exotoxin of GAS (fever, sore throat, strawberry tongue, sandpaper rash)
- Rheumatic fever: antibody cross-reactivity following GAS (myocarditis, conduction aberrations, valvulitis, pericarditis, valvular heart disease)
- Post-streptococcal glomerulonephritis: antigen-antibody mediated complement activation (micro/macroscopic hematuria)
- Reactive arthritis
