Paediatrics

Question 1

Discuss the clinical workup for a child that is ‘Failing to Thrive’ in terms of History?

Answer 1

Feeding History:
Infants
1) Breastfeeding (timing with presence of vomiting, settled?, mothers perception)
2) formula feeding (dilutions, vomiting, diarrhoea)
3) timing of introduction to solids. (force feeding? pleasant/unpleasant?)

Toddlers

• food refusal
• parental attitude towards food

Other Hx:

• antenatal complications
• vomiting/diarrhoea
• developmental delay?

Split up into Categories:

1) caloric intake
- restricted diet (vegan)
- inadequate nutrition
- vomiting
- early or delayed solids
2) psychosocial
- parental depression
- disability
- poverty
3) absorption
- CLD, coeliacs, chronic diarrhoea
4) excessive caloric utilisation
- CHF, resp disease, Hyperthyroidism, CG

Question 2

Discuss the clinical workup for a child that is ‘Failing to Thrive’ in terms of Examination?

Answer 2

Appearance

• look sick?
• loss of muscle bulk?

look for signs of child abuse and neglect

observe feeding in younger infants

Question 3

Discuss the clinical workup for a child that is ‘Failing to Thrive’ in terms of Investigations?

Answer 3

• FBE
• U&E/LFT
• iron studies
• TFT
• BSL
• coeliac screen
• stool microscopy
• urine microscopy

Question 4

Management for Failure to Thrive?

Answer 4

Admit if :

• ill or dehydrated
• signs of neglect discuss with senior doctor (child protection services)

infants less than 3 months require weekly weight monitoring
- avoid weighing too frequently.

0-3months 150-200g/week
3-6months 100-150g/weel
6 to 12 months 70-90g/week

Question 5

Constipation in a child Management?

Answer 5

Can be many causes:

• Functional (due to behaviour)
• <6 weeks more likely medical

Non-Pharm Management:

1) fluid and fibre
2) behavioural (positive encouragement)
3) toilet sits,
4) too much cows milk

Pharmacological:

1) stool softeners (parachoc - mix with desert, coloxyl drops - babies)
2) Osmotics (movicol, osmolax)
3) stimulants - senna (try to avoid)
4) rectal suppositories (best avoided)

stop when you have 1 soft stool everyday.

Question 6

What do you do for a child who has an impacted bowel?

Answer 6

RCH guidelines - movicol dis-impaction regime
- drinking increasing amounts until you get a large bowel action.

suppositories should be avoided unless very acute.

Question 7

John’s mother brings him in for 12 month immunisations, his 2 and 4 month ones were uneventful. At 6 months he developed high fever, erythematous swelling and was later taken to hospital with febrile convulsion. John has no allergies. The mother is concerned about allergic reaction and would prefer to avoid vaccines. What would you counsel?

a) refer to paediatrics so his next vaccine can be administered
b) advice given his allergic reaction its appropriate to abstain from future vaccinations
c) advise the mum that John had a reaction but its a side effect and he will be able to have others.
d) reassure that the vaccines are different at 12 months from 2,4 and 6 thus no need to avoid
e) refer to the paediatric team for further Ix

Answer 7

C - he can have other vaccines

Question 8

What extra immunizations could you give for a child in an Aboriginal community?

Answer 8

• BCG
• Hep A
• pneumococcal 13PCV

Question 9

What do you do if you’re worried a kid is having an anaphylactic reaction to vaccines in a GP clinic?

Answer 9

a) adrenaline
b) BP and O2
c) call ambulance (give a medical handover ISBAR) - details of vaccine and what was given
d) document everything in the medical record

other vaccinations should be fine but if you’re worried do immunisations clinic at the children’s

Question 10

A child presents with fever - what investigations would you perform?

Answer 10

• <1mo corrected age (or <3.5kg in older child) 
	• Full sepsis workup
		○ FBE 
		○ Blood film
		○ Blood culture 
		○ Urine culture (SPA) 
		○ LP
		○ ± CXR 
	• Admit for empirical ABX 
• 1-3mo corrected age 
	• Full sepsis workup
		○ ± CXR (only if resp. syx/signs) 
		○ ± LP
	• d/c home w. r/v in 12h if: 
		○ Previously healthy 
		○ Looks well
		○ WCC 5000-15000
		○ Urine microscopy clear 
		○ CXR + CSF clear (if taken) 

perform a lumbar puncture if:

• decreased conscious state
• focal neurology
• haemodynamically unstable

Question 11

Quickly run through the 6 week exam in infants, what are some key features to look for?

Answer 11

Head to toe examination

Observations

• syndrome
• well/unwell
• limb movements, eyes follow (nystagmus)

Growth

• head circumference
• length/weight
• plot velocities

CV

• heart murmurs
• femoral pulses
• normal liver edge (exclude CCF)

Abdomen
- exclude organomegaly (3-4 finger widths below right costal for liver)

Genitals

• descended testicles
• genital abnormalities

Hip
- developmental dysplasia (barlow test, Ortolani test, RF (female, FHx, breech, intrauterine problems)

Neurological

also address parents concerns and see how they are doing:

• exhaustion
• read baby cues
• substances/violence
• parental depression

Question 12

What medications can be used in children for constipation?

Answer 12

Oral laxitives:
Children - stool softener (parafin oil) or iso-osmotic laxative (movicol)
Infants (6-12months) - coloxyl drops or lactulose
< 6months coloxyl drops

Disimpaction:
- oral meds as outpatient - stop once rectal effluent is clear then give maintenance

Rectal meds:
only in acute severe cases due to pain/distress.
Sedation consider
sodium citrate enemas

Inpatient Mg
- macrogol solutions via NGT at a rate of 25ml/kg/hr

Question 13

Apply the traffic light system screening tool for young children presenting with acute febrile illness.

Answer 13

Go through categories: 
Colour: 
green - normal, 
yellow - pallor, 
red - pale/mottled 

Activity:
green - normal, content, awake,
yellow - responds abnormally to cues, wakes only to stimulation,
red - weak high pitched cry, no waking, appears ill

Respiration
green - normal
yellow - RR high (>50 6-12months, >40 >12months), SpO2 <95%, nasal flaring
red - grunting, RR>60, stridor, indrawing

Hydration
green - normal
yellow - dry, cap refill >3secs
red - skin turgor decreased, sunken eyes

Other
green - NA
yellow - swelling, new lump >2cm, fever >5days
red - high fever (>39 3-6months, >38 0-3months), bulging frontanelle, neck stiff, bile-stained vomit, neurological

Question 14

What is involved in a hip exam? What are you looking for?

Answer 14

Developmental dislocation of the hip

• firm surface
• observe with knees flexed and knees extended for symmetry

Barlow manoeuvre

• identifies instability (repeat several times on each side to ensure infant is relaxed)
• abduct the hip with posterior force

Ortolani manoeuvre
- reducibility of the dislocation

due to capsular laxity (acetabular dysplasia)

Question 15

What is the treatment for a child with eczema?

Answer 15

Face and nappy - hydrocortisone 1% (low potency less likely to have adverse reactions) - sigmacort.
Body - betamethasone 0.02% celestone or memenzone 0.1% (alocon) - moderate
Always ointments - emollient protective barrier (not cream).

Fear of steroids using them sparingly.

Avoid triggers - Dietary or other.
Antihistamines - less effective in eczema
Wet dressings for anti-itch, tar creams sometimes too.
Moisturising - 4-6x a day. (2x a day at least).
Bleech baths can help if severe (or infected)

Question 16

What is nappy rash? How would you treat it?

Answer 16

Contact dermatitis - which may produce ammonia when mixed with faeces and this can burn the skin

Infection with bacteria, candida yeasts, atopic dermatitis and psoriasis

Not an indicator of infantile eczema and is not more common in boys.

Tx - prevention (disposable absorbent nappy changing) and fluid feeding early in the day to lessen nighttime urination

Anti-fungal and lotrimin lotions if associated with candidal infection.