Paediatrics Flashcards
Components of the Paediatric Examination (9)
1) General Observation
2) Initial measurements - height/weight/head circumference, vitals
3) Respiratory Exam
4) Cardiovascular exam
5) Abdominal Exam
6) Neurological Screen - general function
7) Skin Exam
8) Head and Neck - fontanelle closure, teeth, lymph nodes
9) ENT Screen - vision, hearing, throat
Paediatric Age Categories
Neonate = first 4 weeks of life Infant = up to first year of life Preschool Child = from 2-5 School Child = from 6-18 Teenager/Adolescent = 13-18
Normal Vitals - Neonate
RR - 30-60
HR - 100-160
Systolic - 50-85
Normal Vitals - Infant
RR - 20-40
HR - 90-140
Systolic - 60-100
Normal Vitals - Child
RR - 20-40
HR - 80-120
Systolic - 70-110
Normal Vitals - Adolescent
RR - 15-20
HR - 60-100
Systolic 80-120
4 Major domains of child development
> Gross motor
> Fine Motor/Vision
> Hearing/Language/Speech
> Social, emotional and behavioral
Developmental Correction
Correction needs to be made if the baby was born premature - should be staged from the expected date of birth. Correction no longer needed after 2 years of age.
The Primitive Reflexes (5)
Reflexes present in neonates, should disappear by 2-4 months of age.
> MORO - sudden head extension causes symmetrical arm extension then slow flexion
> GRASP - fingers grasp what is in palm
> ROOTING - head turns to stimulus when touched near mouth
> STEPPING RESPONSE - stepping movements when held vertically with feet touching floor
> ASYMMETRICAL TONIC NECK REFLEX - when lying down, limbs coordinate to head rotation
The Postural Reflexes (4)
Develop from the primitive reflexes, must be present for sitting and walking to occur
> LABRYNTHE RIGHTING - head moves in opposite direction of body tilting
> POSTURAL SUPPORT - when held upright, legs take weight and push up (bounce)
> LATERAL PROPPING - When sitting, arm extends to side when falling
> PARACHUTE - when face down, arms extend out
NEWBORN - development
- ## Head support when pulled up-Startled by noise
-
6-8 WEEKS - development
- Head elevated when lying on belly
- Follows objects with head
- Smiles responsively
6 MONTHS - development
- Sits without support
- Palmar grasp
- Vocalize
- Stranger Anxiety/Puts food in mouth
9 MONTHS - development
- Crawling
- Three finger grip
- “Mama”/”Dada”
- Waves bye/peek-a-boo
12 MONTHS - development
- Unsteady walking/with assistance
- 2 finger pincer grip
- 2-3 words apart from “Mama”/”Dada”
- Drinks from cup
18 MONTHS - development
- Walks well
- 3 block stack
- 6-10 words
- Eats w/spoon
2 YEARS - development
- 2 stairs
- 6 block stack/can draw line
- simple sentences
- Symbolic play
3 YEARS
- Tricycle
- Can draw circle
- 3-4 word speech
- Brush teeth
4 YEARS
- Hops
- Can draw square/triangle
- -
Vision - development
Babies born with immature fovea and unmyelinated optic nerve, so very poor vision. Reaches adult levels at around 3-4 years.
Causes of abnormal delay
> Genetic - e.g. down's, fragile X
> Teratogens
> TORCH infection
> Extreme prematurity
> Birth complications - asphyxia
> Trauma
> Infection
> UnknownCerebral Palsy - Definition and Causes
Defined as abnormal movement/posture, due to non-progressive disturbance of foetal brain - often with cognitive and communicative delay.
It is the most common cause of motor impairment in children, with 80% of cases caused by vascular occlusion, cortical migration disorders, or structural maldevelopment. 10% from postnatal causes.
Cerebral Palsy - Presentation and Subtypes (3)
Can present in the Neonatal period with abnormal posture, delayed motor milestones, feeding difficulty, and persistence of primordial reflexes.
There are 3 main clinical subtypes:
> SPASTIC CP - 90%. Damage to the pyramidal/corticospinal UMN tracts, with spasticity, brisk reflexes, and positive babinski. May be further divided into hemiplegic (one-sided, flexed and tiptoe walk), quadriplegic (severe) and diplegic (legs>arms)
> DYSKINETIC CP - 6%. Arises from damage to the basal ganglia/extrapyramidal systems, resulting in tremor, chorea and athetosis.
> ATAXIC CP - 4%. Arises from genetic abnormalities of cerebellum, results in hypotonia, poor balance, and uncoordinated movements.
Autism Spectrum Disorders - Presentation
Presents between 2-4 years of age, with the triad of:
> Impaired social interaction
> Speech/Language problems
> Imposition of routines with ritualistic behaviour
Other features include general learning/attention problems, seizures, and poverty of imagination.
Management involves support and applied behavioural analysis (ABA).
Hearing Impairment - Types (2), Causes and Management
Divided into 2 main causes
SENSORINEURAL - Uncommon
Present at birth, usually caused by:
> Genetic factors
> Congenital infection (e.g. rubella)
> Meningitis
> Head Trauma
Does not improve, requires hearing aids/cochlear
CONDUCTIVE HEARING LOSS
From middle ear disease caused by:
> Chronic otitis media/glue ear
> Eustachian tube dysfunction (e.g. down's, cleft palate)
Often mild and transient.
Neonatal Blood Gas Targets in Resuscitation
2 min - 65-70% 3 min - 70-75% 4 min - 75-80% 5 min - 80-85% 10 min - 85-95%
Neonatal Resuscitation - Adrenaline Dosing
Adrenaline given is 0.1mg/mL (catastrophic adrenaline)
Dosage is based on gestational age:
<26 = 0.1mL
27-34 = 0.25mL
>34 = 0.5mL
Can also be based on 10-30 micrograms/kg
Neonatal Resuscitation - Algorithm
Term Gestation? Breathing/Crying? Good tone?
NO
Warm baby, position and clear airway, and stimulate
If after a few seconds, still apnoea/gasping, or HR<100
START VENTILATION 30-60/min Pulse oximeter on right hand continue stimulating Continue for 60 seconds before re-assessing
Re-assess
Is HR<100?
Is airway blocked?
IF NO
Continue ventilating for another 60 seconds
IF YES - Start CPR (3:1) - Give 100% oxygen - Consider intubation Check HR and breathing every 30-60 seconds, give adrenaline every 3 minutes.
Complications of Suction in Neonates
- Vagal stimulation = bradycardia
- Laryngospasm
Paediatric Amiodarone Dosage
5mg/kg
Common Causes of Cardiac Arrest in Children (4H’s and 4T’s)
> Hypoxia
> Hyper/Hypokalaemia
> Hypovolaemia
> Hypothermia
> Tamponade
> Tension Pneumothorax
> Thromboembolism
> Toxins/PoisonsWETFLAG Mneumonic
WEIGHT ESTIMATION
1-12 months = (0.5age in months) +4
1-5 years = (2age in years) +8
6-12 years = (3*age in years) +7
ELECTRICITY DOSE (DEFIB) 4 J/kg biphasic
TUBE Internal diameter (age/4+4 = mm) and length (age/2+12=cm) estimation
FLUIDS
20mL/kg
LORAZEPAM DOSE
0.1mg/kg
ADRENALINE DOSE
0.1 mg/kg of 1:10000
GLUCOSE
2mL/kg of 10% dextrose
Fluid Calculation in Paediatrics - per hour and per 24 hours.
FOR HOURLY AMOUNT, 4:2:1 RULE
4mL/kg/hr ==> for first 10 kg
2mL/kg/hr ==> for next 10 kg
1mL/kg/hr ==> every kg over 20kg
FOR 24 HOUR AMOUNT, 100:50:20 RULE
100mL/kg ==> for first 10kg
50mL/kg ==> for next 10kg
20mL/kg==> for every kg over 20kg
Sepsis - Causes (4 pathogens) and Management Priorities (5)
Pathogenic causes include:
> Neisseria Meningococcus - MOST COMMON
> S. Pneumoniae
> Haemophilus Influenza B (Not in Norway)
> Group B Streptococcus (neonates)
Management priorities include:
> RESUSCITATION
> Antibiotics - depends on pathogen
> Fluids
> ICU admission if required
> Watch for pulmonary oedema and DIC
Important causes of Coma in children (5)
Disturbance of cerebral function/RAS, most important causes include:
> Hypoglycaemia/Diabetes
> Poisoning
> Sepsis/Meningitis
> HSV Encephalitis
> Raised ICPStatus Epilepticus - Definition and Management (with Dose)
Seizures lasting >30 minutes
Primary and Secondary Survey
CHECK BLOOD GLUCOSE
Administer Lorazopam (0.1mg/kg)(if IV access) or Diazepam (0.5mg/kg)
If no response, administer Lorazepam again, call seniors
Anaphylaxis Management (and Dose)
Adrenaline IM 1:1000 (Dose - <5 = 0.15mL, 5-12=0.3mL, >12 = 0.5mL)
Fluids
Chlorpheniramine
Hydrocortisone
SIDS - Definition and Risk Factors (6)
Defined as sudden death in infants >1 month, most common cause of death in infants from 1 month-1 year old, most common between 2-4 months old.
Risk factors include
> Low birthweight/Preterm
> Male
> Low socioeconomic family status
> Maternal age and parity
> Smoking
> Sleeping prone in high temperature
Down Syndrome - Pathophysiology
The extra chromosome on 21 may occur in 1 of 3 ways:
> MEIOTIC NON-DISJUNCTION (94%) - from failure of chromosomal split in Meiosis II, related to maternal age.
> TRANSLOCATION (5%) - from Robertsonian translocation, occurs when the extra 21 is attached to another chromosome (usually 14).
> MOSAICISM (1%) - from mitotic non-disjunction in fertilized embryo
Down Syndrome - Clinical Features (12, 9 on face) and Survival
> Round, flat face
> Third fontanelle
> Wide nasal bridge
> Epicanthal folds
> Almond-shaped, slanted eyes
> Brushfield Iris spots
> Short nose
> Low set years
> Protruding (hypotonic) tongue
> Single palmar crease > Neck folds > Intellectual disability
85% survive past 1 year (most die from AV canal defect in heart), 50% live past 50 years.
Down Syndrome - Clinical Diagnosis and Management
Usually screened for during pregnancy, using US and amniocentesis. FISH can be performed on blood sample once born to confirm diagnosis.
Once born, requires urgent physical examination, CXR, EKG and Echo (screen for cardiac defects)
Management involves multidisciplinary team for medical and developmental problems, parental support, and medical management of complications.
Down Syndrome - Complications
CONGENITAL HEART DISEASE
Seen in 40-50%, AV defects most common, however PDA, ASD and VSD common.
ORTHOPAEDIC PROBLEMS
Atlanto-axial instability is a worry, may lead to spinal cord injury later in life
AUTOIMMUNE DISEASE
Hypothyroidism, Diabetes type I and Coeliac disease
BOWEL PROBLEMS
Duodenal atresia
LEUKEMIA
LOW FERTILITY
PRESENILE DEMENTIA/ALZHEIMER’S
Other Trisomies
EDWARD’S SYNDROME (Tri-18)
Characterised by low birthweight, overlapping fingers, cardiac and renal malformation
PATAU SYNDROME (Tri-13) Structural brain defects, polydactyly, cardiac and renal malformation
Turner’s Syndrome (5 features)
Caused by missing sex chromosome - 45, XO, 95% of cases miscarry. US screen will show foetal oedema.
Characterised by:
> SHORT STATURE
> Neck webbing
> Delayed puberty and ovarian dysgenesis (infertility)
> Shield-shaped chest, wide spaced nipples
> Wide carrying angle
Managed with growth hormone therapy and ovarian replacement for puberty
Kleinfelter Syndrome (4 features)
Caused by extra sex chromosome - 47, XXY. Results in:
> Infertility
> Hypogonadism
> Gynaecomastia
> Tall statureDiGeorge Syndrome - Cause, Face (6), and Complications (6)
Relatively common deletion syndrome, from deletion of 22q11.2.
Present with:
> Long face
> Small Jaw
> Short philtrum/fish mouth
> High, broad nasal bridge
> Epicanthal fods
> Low-set, malformed ears
Complications:
> Cardiac Malformation (80%) - usually involves vessels
> Cleft Palate (70%)
> Hypocalcaemia (from hypoparathyroidism)
> Immune deficiency
> Developmental Delay/Learning difficulty
> Behavioural abnormality
Stillbirth - Definition
Foetus born at or before 24 weeks with no signs of life
Perinatal Mortality Rate
Stillbirths + Deaths in first week, given per 1000 stillbirths + live births
Neonatal Mortality Rate
Deaths of live neonates (within 28 days) per 1000 live births
Low Birthweight
Birthweight <2500g
Very Low Birthweight
Birthweight <1500g
Foetal Alcohol Syndrome - Diagnosis (3) and Associated conditions (3)
Diagnosed by 3 characteristic features:
> CHARACTERISTIC FACIAL ANOMALIES - small head, small eyes, small mouth, thin upper lip, indistinct philtrum, epicanthal folds
> GROWTH RETARDATION - IUGR, failure to catch up
> CNS INVOLVEMENT - Cognitive impairment and learning difficulties
Can be present with brain underdevelopment, VSD, bone and kidney problems.
Routine Newborn Examination (13)
> General observation - gross abnormalities?3)
> Head/chest circumference
> Weight
> Auscultation and Pulses - detect CHD
> Hip displasia check
> Check eyes and mouth
> Tone of baby, abnormal movements
> Fontanelle palpation
> Check for jaundice
> External genitalia and anus
> Abdominal palpation
> Back and spine palpation
> Reflexes - moro, gripRoutine Neonatal Biochemical Screening (4 diseases)
> Phenylketonuria
> Hb-opathy
> CF (via serum trypsin)
> MCAD)
Hypoxic Ischaemic Encephalopathy
From hypoxia and metabolic acidosis damage to the brain - presents up to 48h after birht, 3 grades:
> MILD - irritable infant, hyperventilation, poor feeding
> MODERATE - marked abnormality of tone and movement
> SEVERE - no normal spontaneous movement or responses, severe seizures
Management involves skilled respiratory support, EEG, anticonvulsants, and hypothermic treatment
Subgaleal Haemorrhage
Occurs between the periosteum and the galeal aponeurosis of the scalp, dangerous as can hide severe blood loss.
Prematurity Co-morbidities
> Respiratory Distress Syndrome (74%)
> Pneumothorax
> Apnoea Episodes
> Hypothermia
> PDA
> Infection risk
> Intraventricular Haemorrhage
> Paraventricular leukomalacia
> Necrotising Enterocolitis
> Retinopathy of prematurity
> Bronchopulmonary Dysplasia
> Issues following discharge - anaemia, poor growth, bronchiolitisRespiratory Distress Syndrome
Arises from lack of surfactant, leading to alveolar collapse and formation of hyaline membranes. Can be prevented with antenatal glucocorticoids.
Presents within 4 hours of birth with:
> Tachypnoea >60
> Laboured breathing with nasal flaring
> Cyanosis (if severe)
CXR will show diffuse granular “ground glass” appearance, management involves CPAP and surfactant therapy.
Paraventricular Leukomalacia
The most common ischaemic brain injury in premature infants - occurs in the white matter beside the lateral ventricles, leading to cyst formation. May lead to spastic CP, intelligence deficit, and visual disturbance.
Needs urgent cranial US and EEG, no management available.
Necrotising Enterocolitis
A serious illness affecting premature infants in the first few weeks of life - occurs as a result of bacterial invasion of ischaemic bowel. Most commonly seen in the terminal ileum.
Presents with pain, abdominal distension, and vomiting - can perforate, leading to pneumoperitoneum and shock.
Managed by stopping oral feeding and giving antibiotics (ampicillin+gentamicin+clindamycin) - may require surgical resection if perforate.
Retinopathy of prematurity
Affects developing blood vessels - proliferation may lead to retinal detachment, fibrosis and blindness. Increased risk from high concentration oxygen administration, needs weekly screen from ophthalmologist
Bronchopulmonary Dysplasia
Defined as infants requiring oxygen past 36 weeks - usually from barotrauma, infection, or oxygen toxicity. Requires slow weaning off CPAP
Kernicterus
Unconjugated bilirubin deposition in the basal ganglia and brainstem, leading to neurotoxicity and severe damage. Not correlated with specific bilirubin level.
Presents with lethargy, poor feeding. Increased muscle tone (opisthotonos = arched back lie), seizures and coma in severe cases.
Clinically apparent jaundice - bilirubin level
80 μmol/L
Jaundice <24 hours - Causes (5)
Usually from haemolytic disease, more concerning. Causes include:
> Rh Haemolytic Disease
> ABO Incompatibility (most common) - from transfer of IgG anti-A Ab’s from mother via milk to A-group baby. Usually very mild disease.
> G6PD Deficiency - screened for via Guthrie testing, avoid precipitating drugs
> Spherocytosis - rare
> Congenital infections - present with hepatosplenomegaly and skin changes
Jaundice from 2 days to 2 weeks - Causes (4)
Causes include:
> Physiological - normal transition (ddx of exclusion)
> Breast milk jaundice
> Dehydration
> Infection - jaundice from dehydration, reduced hepatic function. Common with UTI.
Investigation and Management (2) of Neonatal Jaundice
Investigation involves blood bilirubin testing, and/or transcutaneous bilirubin meter. Rate of rise needs to be plotted.
Management involves addressing the underlying issue, as well as:
> Phototherapy - 450nm wavelength light used to break down unconjugated bilirubin to pigment.
> Exchange transfusion - baby blood gradually replaced with donor blood.
Jaundice >2 weeks - Causes (4)
Called persistent neonatal jaundice. Causes include:
> BILIARY ATRESIA - important ddx, requires urgent attention
> Breast milk jaundice - most common, fades in 4-5 weeks
> Infection - UTI
> Congenital Hypothyroidism
Respiratory Disease in Infants - Causes (7)
> Transient Tachypnoea of Newborn (MOST COMMON) - diagnosis of exclusion, settles in a few days
> Meconium Aspiration - May be due to foetal stress or hypoxia, CXR shows lung collapse and consolidation. Requires mechanical ventilation
> Pneumonia
> Pneumothorax
> Milk aspiration
> Persistent pulmonary HTN of newborn - life threatening, associated with asphyxia, meconium aspiration, and RDS. Requires mechanical ventilation and NO.
> Diaphragm Hernia
Early-onset Infection - Causes & Management
Occurs within 48 hours of birth, usually either from infected amniotic fluid or maternal infection. May lead to neonatal meningitis, pneumonia, or sepsis.
Most common pathogens include GBS, listeria monocytogenes, and other gram positives/negatives. Requires amoxicillin+gentamycin
Late-onset Infection - Causes and Management
Occurs after 48 hours, from environmental/nosocomial causes.
Common pathogens include:
> Staphylococcus epidermidis
> Gram positives - s.aureus, e.faecalis
> Gram negatives - e.coli, pseudomonas, klebsiella
IV antibiotics - flucloxacillin + gentamycin
Neonatal meningitis - antibiotics (2)
Ampicillin + cefotaxime (CNS penetration)
Listeria
Listeria monocytogenes is uncommon but serious, arising from unpasteurised milk, soft cheeses, and uncooked poultry. Causes bacteraemia and foetal infection, leading to:
> Spontaneous abortion
> Neonatal sepsis
> Preterm delivery
> Meconium staining
30% foetal mortality.
Foetal HSV Infection
Uncommon, contracted from infected birth canal - 40% transmission rate, more common in preterm infants.
Presents with:
> Skin and eye herpetic lesions
> Encephalopathy
> Disseminated diseaseNeonatal Hypoglycaemia - definition and risk factors (4)
Defined as blood glucose <2.6mmol/L, particularly likely in first 24h with IUGR, diabetes, hypothermia or infection.
4 Phases of Normal Human Growth
FOETAL - fastest period of growth, determined by placental and maternal factors
INFANCY - depends on nutrition, good health
CHILDHOOD - slow but steady, hormonal and nutritional
PUBERTY - Sex hormones cause GH boost and growth spurt
Normal Female Puberty
Begins from 8.5-12.5 years old, goes through stages:
> Breast development (thelarche) - first sign, keeps going until 16
> Pubic Hair (pubarche) and growth spurt (just afterwards)
> Menarche - on average occurs 2.5 years after onset of puberty. Signals end of puberty, 5cm growth left
Normal Male Puberty
Begins usually around 8.5 - 12 years of age, stages are:
> Testicular Enlargement - growing over 4 mL, first sign of puberty, continues until 16
> Pubic hair development - usually from 10 years old, continues until 16
> Height Spurt - begin when testicles are at 12-15mL, lasts until 18 years old
Staging of Puberty
Tanner Staging used, involves three measures:
> BREAST DEVELOPMENT (BI-BV)
> PUBIC HAIR CHANGES (PHI-PHV)
> MALE GENITAL CHANGES (GI-GV)
Short Stature - Causes (5, 4 in 1)
> Normal Variant
> IUGR and Prematurity - never catch up
> Nutritional Deficiency
> Genetic disorder
> Endocrine - uncommon
- Hypothyroidism
- GH deficiency
- Cushing's syndrome
- Chronic illnessMicrocephaly and Macrocephaly - Causes (3 and 4)
MICROCEPHALY
> Familial - when present from birth
> Genetic - chromosomal abnormality
> Congenital infection
MACROCEPHALY
> Raised ICP - important to rule out
> Familial
> Tumor
> Hydrocephalus
Precocious Puberty - Definition, Causes, and Differentiating Causes Clinically
Defined as puberty occurring before 8 in females and 9 in males. Classified according to gonadotrophin involvement - premature activation of hypothalamus (gonadotrophin dependent) or from excess sex steroids (gonadotrophin independent)
DEPENDENT
> Familial
> Tumor
> Hydrocephalus
> Hypothyroidism
INDEPENDENT
> Exogenous Sex Steroids
> Adrenal Disorders
> Testicular/Ovarian Tumor
Size of gonads are usually helpful for diagnosis - BIG = dependent (stimulated by LH/FSH), SMALL = independent (lack of LH/FSH via negative feedback)
Delayed Puberty - Definition and Causes
Abscence of pubertal development after 14 in girls and 15 in boys - more common in males from normal familial variance. Can also be from chronic disease (e.g. asthma, CF), nutritional deficiency, excess physical activity, pituitary deficiency, or chromosomal abnormality.
Congenital Adrenal Hyperplasia
Autosomal recessive disorder, deficiency in enzyme producing cortisol and mineralocorticoids - buildup of androgens.
Presents in females with virilization and cliteromegaly/fusion of labia
Presents in males with precocious puberty, salt-losing adrenal crisis, and hypoglycaemia.
Requires corrective genital surgery (for females), as well as hydrocortisone and fludrocortisone replacement therapy.
Why are children vulnerable to poor nutrition? (3 reasons)
> Poor Reserve - low stores of fat and protein
> High Demand - energy and nutrients used for growing
> Rapid Neuronal Development - in first 2 years
Breast Feeding - Physiology
Suckling stimulates tactile receptors in breast, leads to hypothalamic release of oxytocin (“let down” reflex) and prolactin (production of milk)
Breast Milk - Advantages
> Reduced incidence of GI infection/NEC
> Cheap and convenient
> Furthering maternal relationship
> Reduce incidence of maternal breast cancer
> Reduce adult incidence of DM and obesity
Breast Milk recommendations
Continue until 12-18 months old, combine with solids from 6 months - ensure iron and vitamin rich.
Failure to Thrive - Definition and Causes (4 and 4)
Falling rate of growth past 2 centile lines.
Causes can be classified into two groups:
NON-ORGANIC (95%)
> Inadequate food - socioeconomic status, availability
> Problems feeding infant
> Psychosocial - maternal depression, poor education regarding feeding
> Neglect
ORGANIC (5%)
> Impaired suckling/swallowing
> Chronic disease
> Malabsorption
> Increased requirement
Measuring Malnutrition
Via anthropometry, expressed with:
> Weight vs height % - measure of wasting
> height vs age % - measure of stunting
> Mid upper arm circumference (MUAC) - severe if under 115mm
Marasmus
Severe wasting due to protein-energy deficiency. Defined as 70% weight:height (under 3 standard deviations)
Kwashiorkor Disease
Protein deficiency, with generalized oedema, distended abdomen, flaky skin, thin hair, and cardiovascular disturbance.
Rickets - Causes (5) and Presentation (5)
Caused by:
> Vitamin D/Calcium deficiency
> Intestinal malabsorption
> Liver disease
> Kidney Disease
> Genetic enzyme abnormality
Clinically presents with
> CRANIOTABES - soft skull bones
> Bowed legs
> Harrison's sulcus
> Delayed dentition
> Seizures (severe hypocalcaemia)
Vomiting - red flag symptoms (6)
> Bile-stained vomit - obstruction
> Haematemesis - oesophagitis, peptic ulcer
> Projectile vomiting - pyloric stenosis
> Coughing-fit induced - whooping cough
> Abdominal tenderness/distension
> Bulging fontanelle - Raised ICP
Gastro-oesophageal Reflux
Extremely common in infancy, due to relaxed lower sphincter. Should resolve by 12 months, managed with solids and upright position. Diagnosed clinically, may require 24h pH monitor.
Pyloric Stenosis
Hypertrophy of the pyloric muscle, causing obstruction. Presents in 2-7 weeks of age with:
> Vomiting (worse over time)
> Hunger after vomiting
> Weigh loss
> Gastric peristalsis
> Olive sign - Palpable in RUQ
Management involves fluids, electrolyte correction, and surgical management with pyloromyotomy.
Acute Abdominal Pain - Important differentials (5)
> Appendicitis
> DKA
> Testicular torsion
> Lower lobe pneumonia
> Mesenteric adenitisAcute Appendicitis
Uncommon <3, most common surgical reason for acute abdomen.
Perforation occurs rapidly in children, usually within 72 hours, requires constant monitoring and urgent surgical management with appendicectomy.
Antibiotics required if complications, may also be used in conservative management - ampicillin + metronidazole + gentamycin.
Intussuception
Describes invagination of proximal bowel into a distal segment - most commonly the ileum into the caecum. MOST COMMON CAUSE IN INFANTS. Thought to be from swollen peyer’s patches from infection.
Presents with colicky abdominal pain, vomiting, anorexia, palpable mass, REDCURRANT JELLY STOOL (bloody mucous), and distension. Can lead to infarction, perforation and necrosis.
Mx involves rectal air insufflation (75% successful), may require laparotomy
Meckel’s Diverticulum
Reminant of Vitelline duct, contains gastric or pancreatic tissue sometimes. Presents with rectal bleeding and abdominal pain. Complications include obstruction, bleeding, diverticulitis and perforation.
Rule of 2’s (5)
Refers to Meckel’s diverticulum:
> Found in 2% of the population
> Within 2 feet (~85cm) of the ileocaecal valve
> About 2 inches (~5cm) long
> 1/2 present in the first 2 years of life, only 4% ever become symptomatic
> 2x as common in males
Gastroenteritis
Causes include:
> Rotavirus - most common
> Norovirus
> Adenovirus
> Bacterial - campylobacter jejuni, salmonella, e.coli, shigella
Clinical assessment required for dehydration - check for weight loss. No other ix indicated.
Managed with fluid replacement and electrolyte balancing.
Managing Dehydration, and rehydration formula
Dehydration best managed by replacing 5% of dehydration on top of maintenance fluids - any more risks cerebral oedema.
Replacement amount calculated via:
Volume (mL) = weight (kg) * (% dehydration) * 10
Coeliac Disease
Enteropathy where portion of gluten results in T-cell mediated destruction of intestinal mucosa and villi.
Presents with:
> Failure to thrive
> Abdominal pain/distension
> Anaemia
Diagnosed with:
> Screening serology - IgA transglutaminase and endomysial antibodies
> Small bowel biopsy => to confirm
Management involves avoiding wheat, rye and barley
Causes of Malabsorption (6)
> Cholestatic liver disease
> Biliary atresia
> Cystic Fibrosis - pancreatic dysfunction
> Coeliac disease
> IBD
> Short Gut SyndromeCrohn’s Disease - Cause and Presentation
May affect any part of the GIT, most commonly the terminal ileum and the perianal region. Involves transmural inflammation and deep fissured ulcers = cobblestoning.
Presents with lethargy, weight loss, abdominal pain and diarrhoea, and failure to thrive. Systemic features include arthralgia, uveitis, oral lesions, and erythema nodosum
Crohn’s Disease - Management
Management involves:
> Anti-inflammatories - 5-ASA’s, Sulfasalazine, corticosteroids
> Immunomodulators - Azathioprine & Methotrexate
> Infliximab - MAB to TNF-alpha
Ulcerative Colitis - Cause and Presentation
Only affects the colon, has crypt abscesses and pseudopolyps. Presents wth rectal bleeding, diarrhoea, and pain, as well as anaemia, uveitis, dermatitis, and sclerosing cholangitis.
UC - Management
> Remission with 5-ASA
> Corticosteroids
> Immunosuppressants - Azathioprine = “steroid sparing”
AVOID NSAIDS
Hirschsprung Disease
Abscence of ganglion cells from myenteric and submucosal plexii in the large bowel, from the rectum proximally. 75% of cases only involve the rectosigmoid colon.
Usually presents in neonatal period with constipation, obstruction, and abdominal distension. May lead to hirschsprung enterocolitis with clostridium difficile
Diagnosis via rectal biopsy, management is surgical colostomy and resection.
Features of Premature Baby (5)
> Thin skin
> Soft pinna/no cartilage
> Smooth scrotum, no testes
> Poor eye movement
> Little subcutaneous fatSepsis in Children - Antibiotics
cefotaxime + ampicillin
Meningitis - Viral and Bacterial Causes
Viral responsible for 2/3 of cases, caused by:
> Enterococci - most common
> EBV
> Adenovirus
Bacterial meningitis - 5-10% mortality, organisms based on age:
> NEONATE
- GBS
- E.coli
- Listeria
> 1 month - 6 years
- S. pneumoniae (MOST COMMON)
- N. meningitidis
- h influenzae
> Over 6 years
- S. pneumoniae
- N. meningitidis
S. Pneumoniae - gram stain and appearence
Gram positive, diplococcus
N. Meningitidis - gram stain and appearence
Gram negative, diplococcus
H. Influenzae - gram stain and appearence
Gram negative rods
Bacterial Meningitis - signs
KERNIG SIGN - when hip flexed at 90 degrees, leg straightening is painful
BRUDZINSKI’S SIGN - head flexion causes hip and leg flexion.
Lumbar Puncture - Results (4 parameters)
NORMAL
> Clear appearence
> 0-5/mm3 WBC
> Under 0.4 g/L protein
> Glucose levels less than 50% of blood levels
BACTERIAL
> Turbid
> Polymorphic WBC
> High levels of protein
> Very low glucose levels
VIRAL
> Clear
> Lymphocytes
> Normal or slightly raised protein levels
> Normal or slightly reduced glucose levels.
Contraindications to LP (5)
> Raised ICP
> Infection over LP site
> Unstable patient
> Focal neurological signs
> CoagulopathyComplications of Bacterial Meningitis (4)
More common in s.pneumonia meningitis
> Hearing loss
> Local vasculitis
> Abscesses
> HydrocephalusManagement of Bacterial Meningitis
Ampicillin and cefotaxime. Consider dexamethasone to reduce complication risk.
Causes of Encephalitis, and prognosis
Inflammation of brain parenchyma, usually from viral cause:
> Enterovirus - most common
> Herpesviruses - HSV-2 common, BAD PROGNOSIS 70% mortality)
> Respiratory Viruses - EBV
Usually cannot be differentiated from meningitis
Toxic Shock Syndrome
Caused by toxins produced by s.aureus and GAS, characterised by
> Fever
> Hypotension
> Diffuse, macular rash
> Organ dysfunction
Needs ICU admission, antibiotics, and IV immunoglobulin.
Complications of Chickenpox (3)
> Secondary bacterial infection
> Encephalitis
> Disseminated disease (20% mortality)
Infectious Mononucleosis
Caused by EBV (most commonly), attacks pharynx epithelium and T-cells, presents with
> Fever
> Tonsillopharyngitis
> Lymphadenopathy
> Splenomegaly and petichiae
Self limiting within 1-3 months.The Numbered Diseases (6)
FIRST - Measles
SECOND - Scarlet Disease (s.pyogenes)
THIRD - Rubella
FOURTH - Staphylococcal Scalded Skin Syndrome
FIFTH - Parvovirus B19 (Erythema Infectiosum)
SIXTH - Roseola (HHV-6 and -7)
FIRST DISEASE
Measles, presents with:
> Fever
> Cough/Runny nose
> Rash - maculopapular, spreading down from ears
> Koplik spots - in buccal mucosa
Symptomatic management, complications include pneumonia, encephalitis, subacute sclerosing panencephalitis (SSPE) and febrile seizures.
SECOND DISEASE
Caused by s.pyogenes, presents with rough, papular rash and strawberry tongue. Can lead to rheumatic fever, and post-strep glomerulonephritis
THIRD DISEASE
Rubella, generally mild in childhood. Presents with rash and fever, danger is exposure during pregnancy.
FOURTH DISEASE
Staphylococcal Scalded Skin Syndrome - Caused by s.aureus, epidermal blistering and shedding, sparing mucous membranes
FIFTH DISEASE
Parvovirus B19, transmitted via respiratory secretions, infects erythroblasts in bone marrow. Can present in one of three ways:
> Erythema infectiosum - fever, headache, slapped cheek rash followed by maculopapular rash
> Asymptomatic
> Aplastic disease - most serious, more likely in immunodeficiency
SIXTH DISEASE
Roseola, caused by HHV-6 and -7, causes abruptly high fever, and macular rash spreading down from the neck. Can cause febrile convulsions.
Causes of Prolonged Fever (4 with 5 in 1)
> Bacterial Infection/Abscess
> Infective endocarditis
> TB
> Non-infective causes - SLE, Vasculitis, IBD, Malignancy, Drug fever
Kawasaki Disease - Cause and Diagnosis
Systemic vasculitis mainly affecting children under 4, more common in Japanese. Clinical diagnosis with WARM CREAM
WARM - fever of >5 days (required)
Plus 4 of 5 of:
> Conjunctivitis
> Rash - maculopapular, erythematous
> Erythema - palms and soles
> Adenopathy - cervical
> Mucous membranes - dry, red, strawberry tongue
Kawasaki Disease - Management and Complications
Requires immediate IVIG for 10 days, as well as aspirin for 6 weeks. Echo follow-up.
Complications include coronary and peripheral aneurysms, as well as MI and sudden death.
Respiratory Infection - Causes
VIRAL (80-90%)
> RSV - most common
> Rhinoviruses
> Parainfluenza/Influenza
> Adenovirus
BACTERIAL
> S.pneumoniae
> M. pneumoniae
> H. influenzae
Tonsillitis and Indications for Tonsillectomy
Caused by GAS and EBV causing pharyngitis and tonsil swelling.
Indications for tonsillectomy include:
> Recurrent, severe episodes
> Peritonsillar abscess
> OSACroup - “false” croup
Laryngotroncheobronchitis caused by parainfluenza (most commonly), influenza and RSV - common in second year of age.
Presents with
> Barking cough
> Stridor
> Dyspnoea
> Fever
Classically gets worse at night when lying down
Managed with oxygen and airway management, may require dexamethasone, adrenaline if severe.
Diptheria
True croup, caused by cornyebacterium diptheriae (gram + aerobe), adheres to mucosal epithelium and causes URTI with formation of pseudomembrane.
May cause myocarditis in 60%
Managed with supporting airway and erythromycin.
Epiglottitis
Caused by H.influenzae (can be non-infective), presents with triad of
> Distress
> Dysphagia
> Drooling
Managed with securing airway, radiographs and laryngoscopy may be indicated for diagnosis. Needs ceftriaxone and amoxicillin.
Whooping cough
Caused by Bordetella pertussus, characterised by fits of coughing with inspiratory whoop. Requires admission and isolation, managed with erythromycin.
Bronchiolitis
Most common serious RTI in young children, rare after 1y.o - 80% caused by RSV. Presents with dry cough, dyspnoea, and feeding difficulty. Children have hyperinflated chest and fine end-expiratory crackles with wheeze.
Requires urgent CXR (flat diaphragms, increased markings), supportive management
Pneumonia - Causes
NEONATAL - mostly bacterial
> GBS
> Enterococci
INFANT - Mostly viral
> RSV
> other resp viruses
CHILD over 6 - mostly bacterial
> s.pneumoniae (shows lobar consolidation on CXR)
> M. pneumoniae
> Chlamydia pneumoniaePneumonia - Indications for admission, and management
Indications for admission include:
> Low O2 saturation
> Severe tachypnoea/dyspnoea
> Not feeding
Managed with amoxicillin and clavulanate
Asthma - Diagnostic criteria
Requires several episodes, with:
> Episodic airway obstruction
> Reversible obstruction
> Alternate diagnoses excluded
Confirmed with spirometry where possible - FEV1 increase >12% from baseline after bronchodilator
Asthma - Attack Red Flags (6)
> Tachypnoea >30
> Tachycardia >120
> Accessory muscles used
> Wide pulsus paradoxus
> O2 Sats under 91%
> Wheezes disappear, or patient cannot talkAsthma Management (5)
STEP 1
- SABA as required
- Consider ipratropium in young kids
STEP 2
- SABA with regular preventer fluticasone
- If under 5, consider montelukast
STEP 3
- LABA with fluticasone
- Assess control with LABA
STEP 4
- Max out inhaled steroids
- Refer to respiratory paediatrician
STEP 5
- Oral steroids - prednisolone
Acute Asthma Attack - Admission criteria (4) and Management
Criteria are:
> No response to medical management
> Exhaustion
> Marked reduction in predicted peak flow rate
> Reduced SaO2
If mild attack, use SABA puffs - 4*4 puffs over 4 minutes, reassess within 1 hour
If severe - need SABA 10 puffs, oral prednisolone, with/without ipratopium bromide
Bronchiectasis - Causes (4)
Permanent bronchi dilation, may be from
> CF
> Primary ciliary dyskinesia - recurrent infection, 50% have dextrocardia/situs inversus.
> Immunodeficiency
> Chronic aspiration/pneumoniaCystic Fibrosis - Cause and Presentation
Caused by mutation in Cystic Fibrosis Transmembrane Conductance Regulator (CFTR), most commonly due to ΔF508 gene mutation. Leads to thick secretions.
Presents with recurrent infections, meiconium ileus, clubbing, and failure to thrive.
Cystic Fibrosis - Diagnosis and Management
Diagnosed with sweat test - raised Cl- ions. Confirmed with genetic testing.
Managed with MDT, aiming to slow progression and maximise health and development.
> Physiotherapy - percussion and drainage
> Prophylactic flucloxacillin (PREVENTS PSEUDOMONAS)
> Azithromycin - helps with immunomodulation
> Nutritional management
Cystic Fibrosis - Complications
> Diabetes
> Pancreatic insufficiency - failure to thrive
> GIT obstruction
> Recurrent resp infections
> Male sterility (absent vas deferens)
> Liver disease –> failure rare
