Paediatrics Flashcards
Mnemonic for gluten foods?
BROWS: barley rye oats wheat and spelt (type of wheat).
HEADSS mnemonic
Home and environment Education and employment Activities Drugs Sexuality Suicide/ depression
Podophyllotoxin
Podophyllotoxin, also known as podofilox, is a medical cream that is used to treat genital warts and molluscum contagiosum. It is not recommended in HPV infections without external warts. It can be applied either by a healthcare provider or the person themselves.
aflatoxin
Bladder cancer
New differentials for paeds headache
Stress
Eye Strain
Dental Carries
Tumours: Medulloblastoma and infratentorial medulloblastomas.
How do paeds headaches present?
Irritability and changes in feeding, toileting/ nappies, behaviour, etc.
Paracetamol dosing in children? What is it in adults?
15mg/kg 4 hourly with a maximum of 100mg/kg/day OR 1g in a day according to Jess.
1g 4-6 hourly is max normal dose paracetamol for adults
How do we manage a simple headache in kids? What about migraine? What about meningitis if it’s under 2 months of age.
If it’s simple, give them paracetamol dude.
If they are a kid under 12, give them ibuprofen. If they are a kid over twelve, aspirin and sumitriptan can be added (INTRANASAL)
Cefotaxime and benzylpenicilin.
Questions to ask on a puberty history?
Age at takeoff (i.e. onset of growth acceleration)
- Age at peak height velocity + peak height velocity
- Duration of puberty
- Contribution of the pubertal growth spurt to final adult
height
HISTORY:
- Presence of absence of acne, body odour, oiliness of skin,
erections and nocturnal emissions in boys, PV discharge or
bleeding in girls
- Increase or decrease in growth rate
- Family history unexplained early death in male sibling (may
suggest CAH), PP in male relatives (suggests familial limited PP)
- Family history of pubertal onset
- Activities (e.g. ballet dancers and gymnasts tend to have delayed
puberty)
- Diet
Investigations for a precocious puberty?
Investigations: - Bloods: o FSH, LH, testosterone, estrogen o GnRH stimulation test o DHEA, DHEAS, hCG o TFTs o Tumour markes (alpha-fetoprotein, Bhcg)
- Imaging: o XR wrist + hand (bone age) o USS abdo (if adrenal tumour suspected + in girls) o Testicular USS o CT head o MRI brain + pituitary
What is Ramsay hunt?
Post herpes zoster infection, we get a facial nerve palsy and hearing loss in that ear.
DDX for precocious puberty?
It’s iether GnRH dpeendent or independent, and we test this by looking at the LH and FSH which will be elevated.
Idiopathic, hypothal hamartoma (also look for seizures, adipsia, diabetes inspidius, obesity or cachexia) and literally ANY intracranial pathology. Prolonged hypothyroid is also in this category.
Peirpheral (GnRH independent) includes CAH, Adrenal/ testicular neoplasm, exposure to exogenous testosterone.
Investigations for a delayed puberty?
Investigations: - FSH, LH, testosterone, oestrogen, serum prolactin, other pituitary hormones - FBC, ESR - Urea, creatinine, serum proteins - TFTs - Karyotype - Bone age - ?urine MCS (metabolic abnormalities assoc w/ assoc conditions) - ?MRI
DDX for dleayed puberty?
If there are normal or low serum gonadotrophins, the problem is central:
Constitutional delay. Usually familial.
Chronic illness/ poor nutrition.
Kallman’s/ hyperprolactin.
Elevated serum gonadotrophins:
- Primary gonadal failure (tunrner’s klinefelter’s Noonan’s)
ANorchia
Gonadal destruction secondary to trauma etc.
Child has a learning disability: how do you work this up?
History:
- Standard history and physical exam – include history from
parents/ caregivers regarding onset and source of symptoms and
family history of similar patterns
o Demographic data
o Birth, developmental and medical history
o Family and social history
- Hearing and vision assessment
- School history
- Consider contributing causes, e.g. anxiety, family dysfunction,
auditory processing problems
- Consider co-morbidities, e.g. ADHD, other behavioural disorders,
language disorders, developmental disorders, intellectual
disability
- Copies of any previous assessments (mental health, language,
cognitive, audiology)
DDX for a learning disability? Thus, ask around this.
Causes for learning difficulties: - Genetic syndromes: o Sotos o Tuberous sclerosis o Neurofibromatosis - Metabolic conditions: o Hypothyroidism o Diabetes - Common: o Dyslexia o ADHD o Down’s syndrome o Fragile X syndrome o qTuberous sclerosis o ASD o FAS o Absence epilepsy
Hx and exmaination for behavioural problesm?
History:
- full paediatric history
- ABC:
o Antecedent = what were the events preceding the
behavior?
o Behaviour = what is the behavior exactly?
o Consequence = what did the parents do to resolve the
situation?
- Clarify where the behaviours occurs behavior occurring acorss
two or more settings (home, educational and/or social setting)
are more likely to be indicative of an underlying mental health
problem
o Behavior occurring in one setting only may reflect an
issue specific to that setting
- Nutrition
- Sleep patterns
- Family functioning
- Ask about parent mental health, parenting practices
- Family risk factors – unemployment, drug and alcohol misuse,
financial stress
- Social support
- Family history of developmental/behavioural problems
Examination:
- Observe the child’s behavior
o But be aware that some kids behave well when they
know they are being observed
o Also observe parent-child interaction
- Dysmorphic features
- Full physical examination
- Consider brief developmental assessment
General management of behavioural problems?
- Establish clear goals: what do they want to improve? What is your capacity to do this?
- Set a positive example, and incentivise the kid with some rewards
- Set up consistency, between parents, at school and at other houses
- Set clear boundaries and expectations.
What are the specific behavioural problems for kids throughout different age groups and how are they managed?
Specific behavioural problems:
TANTRUMS + OPPOSITIONAL BEHAVIOUR IN TODDLER (1-3 yo):
- Can occur at any time, but commonly during meals and sleep time
- Management of tantrums:
o Stay calm, walk away and ignore behavior until
tantrum stops
o Praise child when appropriate behavior begins again
o Behavior will initially escalate, but quickly decline
- Management of aggressive behavior:
o Remain calm and don’t raise voice, ask child to stop and
redirect them to another activity
o If they do stop, praise them
o If they don’t stop ‘quiet time’ in same room
o If still don’t stop or leave quiet time go to time out in
another room
ANGER AND AGGRESSION IN PRESCHOOLERS (3-5yo):
Low priority behavior (e.g. whinging) can be dealt with by:
- ignoring the behavior
- distracting the child
- logical consequences for the child’s action, e.g. if draw on wall
with pen, take pen away from them for a few minutes but make
sure to give pen back so child can practice using it properly on
paper
High priority behaviour, such as behavior with associated safety
concerns (e.g. kicking, punching, absconding):
- time out
HYPERACTIVITIY OR INATTENTION IN SCHOOL AGED CHILDREN (5-
11yo):
Management needs to be implemented both at home and school.
School:
- In school, first priority is to exclude co-morbid learning
difficulties
o Test hearing + vision
o If required, special education and cognitive assessment
can be organized through school
- Classroom strategies:
o Sitting the child up front, next to quiet student
o Having frequent breaks
o Rewarding for staying on tasks
- Parents should liase with teacher for a management plan
- Fidget toys
Home:
- Withdrawal of privileges (e.g. no TV for 1 hour)
Social Hx for a fever? Remember I’m just going to write a huge list of differentials from the systems i covered last year and go through a review. Just remember otitis media, HIV, UTI and neoplasma, also osteomyelitis.
Travel history and sick contacts
Causes of chronic fever in kids?
Occult abscess Atypical pneumonia Hepatitis UTI Osteomyelitis HIV Infectious mononucleosis Tuberculosis Infective endocarditis Collagen vascular disease Neoplastic disease Factitious fever
What is the traffic light screening system for fever?
Looks at the risk of the deterioration by doing a full systems review etc. Looks at colour, activity, respiratory, hydration, and other.
How do we manage septic shock in a bebe?
Fluclox and gent if normal csf
If unknown csf do fluclox and cefotaxime
change once sensitivites come back. If culture negative treat for 48 hours or stop if clinically improving
UTI antibiotic in a kid?
Trimethoprim and not sulfa
Tonsilitis management?
Pencillin V if risk factors for ARF, but consider no antibiotics
Cellulitis management?
Cephalexin, and fluclox if severe
Discharge requirements for fever management?
Discharge requirements:
o Infants less than 1 month of age with fever should be admitted.
o Infants 1 to 3 months of age:
The child is well
All investigations are normal
The child has been reviewed by a senior registrar/consultant
Follow up in 12 hours has been arranged
o Children older than 3 months:
The child is well
Follow up has been arranged
Go back over fever investigations and management in notes. Not sure how to tackle this. Maybe just know the severe criteria.
KK
Go over the 6 week check notes from Shamwow
kk
When do we not use charcoal?
If they have swallowing difficulties, ALOC, or if they have ingested a drug that typically develops ALOC.
What are some ways we can decontaminate?
We can do activated charcoal, we can do gastric lavage, whole bowel irrigation. These are done with specialist consultations.
List some high risk paediatric ingestions in low doses? If you don’t know them before, what are some features?
Amphetamines, Calcium channel blockers, chloroquine, opioids, propranolol, sulfonylureas, theophylline, TCA’s, paraquat?
Calcium channel blockers: bradycardia, hypotension, refractory shock, delayed toxicity is possible due to the slow release formulations of nifedipine etc. that are possible.
Beta blcokers: hypoglycaemia, ventricular dysrhythmias, coma, seizures
theophylline: SVT and seizures
TCA’s: ventricular tachy, hypotension, seizures, coma
Paraquat: oropharyngeal burns, multi organ failure, pulmonary fibrosis.
Need to admit if they’ve ingested any of these substances.
Any child that has come in with a potential overdose how do we investigate and manage?
ECG and paracetamol levels in ALL cases
Monitor blood gases, anion gap and osmolality.
Consider doing specific drug levels and get specialist help with these:
Ethanol
Phenobarbitone, carbimazepine, valproic acid, salicylates if they have an unexplained metabolic acidosis
Urine drug screen can be used but shouldn’t change management.
Most are managed with supportive care.
Airway protection? Do we need to hyperventilate them?
Specific management points of delerium in kids?
Management
Follow general management principles as they apply to ABC stabilisation, blood glucose,
electrolytes, infection, trauma
Hyperpyrexia is a high risk situation and urgent advice should be sought
Specific management guidelines are:
o Calm environment with frequent reassurance, explanation and orientation.
o Physical restraint until pharmacological sedation can be achieved to ensure
safety for patient and staff if required
o IV diazepam titrated to effect is first line agent for sedation. An oral dose can be
tried in mild cases.
o Antipsychotic agents are effective second line agents to calm patients resistant to
control with diazepam alone.
o Haloperidol should be used with caution in cases of poisoning with agents
having anticholinergic effects.
o Olanzapine has a better side effect profile and can frequently be given orally to
augment diazepam in calming an agitated patient.
How do we manage drug induced seizures?
Usually we temrinate with some IV benzodiazepines as per local protocol. Probably use midazolam. Phenobarb is second line. I think for a drug induced seizure, you wouldn’t wait for that five minute mark before intervening because they are unlikely to stop.
Digoxin and calcium channel blockers can often cause arrhtyhmias in kids. How do we treat both?
Digibind (fab) and calcium lol.
Classic findings in an aspirin poisoning? WHat investigatiosn?
Met acid, resp alk, tinnitus, vomiting, hyperventilation, seizures.
Blood gas UEC ECG (hyperkal) BSL Salicylate concetation (remember they can be enteric, so you often have to repeat these levels).
Who gets treatment in an aspirin poisoning? How?
If they have more than 150mg/kg, if they have unknown amounts or if they are symptomatic.
Fluid resus, particularly correcting the hyperkalaemia (calcium gluconoate?)
May need intubation (note that you may need to load them with bicarb as they can worsen the acidosis). Maintaining an alkalosis can also prevent it from going into the CNS.
Activated charcoal can often be indicated because they have an enteric coating on the tablets.
Enhancing elimination is done by:
- COrrecting the acidosis (remember this limits the uptake to the CNS)
Alkalinse the urine with bicarb infusions and using a catheter to monitor (only done if we have high or normal K+)
Consider for haemodialysis if refractory or severe or can’t overload with fluid.
If asymptomatic after 6 hours, can go home.
Who needs paracetamol management? How?
What happens in allergies?
If they are having an acute ingestion of 200mg (aspirin was more than 150) or more, if unknown substance, or chronic ingestion of subtherapeutic amount (can get a chronic failure).
1) Paracetamol levels 4 hrs post and chart on nomogram
2) This data needs to be available within 8 hours
3) If they present beyond this or have symptoms like vomiting, tenderness etc. then put them on NAC.
4) Give them NAC based on the specialist advice.
Anaphylactoid reactions to NAC may occur (wheeze, rash). In these cases, cease the
infusion for 30 minutes, give promethazine then recommence the infusion at half the
previous rate. Slowly increase the rate until the desired rate is again reached.
Worrying foreign bodies?
Multiple magnets and button batteries. Will need to do endoscopic removal if they are in the stomach (do an x-ray) but if they are beyond this then if they need close follow up and may need surgical intervention if it causes an obstruction.
Management protocol for a foreign body ingestion? I
If radio-opaque, do an x-ray. If it’s seen in stomach or beyond, observe at home. Watch for abdo pain, persistent vominting, haematemis, melena, fever. If in oesophagus, consult surgeons.
If radiolucent, watch for symptoms of drooling, chest pain, can’t tolerate diet. If so, call surgeons as in oesophagus. If not, observe at home.
IF IT IS A BUTTON BATTERY, OGD.
Management - Oesophageal Foreign Bodies
Button batteries lodged in the oesophagus need urgent removal.
http://www.poison.org/battery/guideline
An object causing total oesophageal obstruction requires removal under anaesthesia.
An object causing partial obstruction where the child is able to swallow saliva
successfully and the object has a good chance of passing, may be observed for a few
hours if it does not pass it will need to be removed.
Once the object is in the stomach it will almost certainly pass spontaneously.
If food is thought to have impacted in the lower oesophagus, small amounts of fizzy
cola drink may help move it.
Inform parents to return immediately if there is abdominal pain, vomiting,
haematemesis or melaena.
There is no place for arranging follow-up visits, repeat X-rays or parental faecal examination.
This does not apply to the ingestion of lead foreign bodies which can cause systemic lead
absorption if they are retained for more than a few days.
What are some symptoms aside from cardiac and respiratory symptoms in congenital heart defects? Note remember that they can get a cardiac wheeze
Failure to thrive Poor feeding Developmental delay Diaphoresis Easily fatigued Poor exercise tolerance
What are some substances associated with heart defects in utero?
FASD (ASD, VSD, ToF)
SSRI’s (mild VSD and bicuspid aortic valve)
Valproate coarctation and hypoplastic left heart
Maternal diabetes: hypertrophic cardiomyopathy, ToF.
Marfan’s, Turner’s and Down’s are associated with which cardiac defects?
Marfan’s: aortic regurg, aortic root dilatation and mitral valve prolapse
Turner syndrome: coarctation of the aorta, LVH
DOwn’s: ASD, VSD, tet of fallot. Also PDA.
Red flags of mumurs?
Multiple Pansystolic or diastolic Grade 3 or higher Harsh quality Abnormal S2 Heard loudest at the left sternal edge Systolic click Increased intensity on standing
List some examples of innocent murmurs? What are the 7 S’s?
Aortic systolic, peripheral pulmonary stenosis, pulmonary flow murmur, venous hum
Sensitive (changes with respiration or posture), short, single (no others or it’s got added sounds), small, soft, sweet, systolic
Come back to murmurs
kk
What examinatin features are important in scabies?
Need to look for superinfection and also BP and vitals because of PSGN
ddx for the Kawasaki?
Measles, EBV and amoxicillin, lepto, arbovirus, Steven’s Johnson, Scarlet fever, parvovirus, Still’s disease
Warm cream is the diagnosis of kawasaki (note that the rash is POLYMORPHOUS). What are some other features?
Cough and coryza Vomiting and diarrhoea Uveitis Gallbladder hydrops Arthritis Myocarditis Nappy rash
Helpful investigations despite it being a clinical diagnosis?
Rule out differentials basically. ASOT and Anti DNAse B
FBC (neutrophilia and can have an anaemia)
CRP ESR
UEC
LFT (low albumin)
Blood cultures
ECHO needs to be done both on the day of presentation and at 6 weeks.
You know the management of Kawasaki. Why do we delay the MMR vaccine by 3-6 months?
2% rate of recurrence is something I also need to remember.
We delay it because the immunoglobulins can reduce the effectiveness of the MMR vaccine.
What is Nokolsky sign? What other features are typical of SSSS
How do differentiate from TENS?
When you rub the skin it disintegrates.
They will be in a lot of pain, and they won’t like being in contact with Mum.
It starts as exudation and crusting, which progresses to wrinkling, bullae formation and the exfoliation.
TENS will have mucosal involvement (they have eye involvement). Also note SSSS does not scar because it’s only the epidermis.
Clinical features of varicella? What are some complications?
They get a viral prodrome of fever, lethargy and anorexia, before progressing to a rash over 3-5 days which is vesicular, extremely itching, and they crust over. Crusted by 10 days.
Complications are Reye’s (happens when given a virus in a period of being systemically unwell), pneumonias, shingles, encephalitis/ cerebellitis, hepatitis, arthritis, bacterial superinfection.
Manage varicella infection?
Vaccines…
Symptomatic treatment (calamine lotion, cool compresses, antihistamines can be used to improve the patients sleep), keep skin cool to reduce number of lesions
Avoid scratching - trim the nails
Aciclovir if they are immunocompromised and avoid aspirin at all costs
They are infectious even before the onset of the rash, and should be excluded from school until they have all crusted over. Also you need to avoid the hospital because of the rate of transmission.
Investigate and manage impetigo?
Investigations:
- Swab for Gram stain + MCS is discharge present
- FBC + BC if systemic symptoms present – low yield
- ESR, XR +/- bone scan if osteomyelitis suspected
- USS if fluctuance present
Management:
- Wash crusts off – topical mupirocin 2% ointment 8 hourly
- If extensive / multiple lesions / not responding to topical
treatment treat as for cellulitis
o Flucloxacillin 25mg/kg (max 500mg) PO Q6H for
7 days
- Highly contagious
o Exclude from school until treatment has started
and sores need to be completely covered with watertight dressing (school sores).
If get time go over bruising, but mostly just think about the NAI case on the OSCE.
k
Is there a way to diagnose meningococcal on blood cultures after antibiotics were started?
Yeah do a PCR.
Why do you have to be careful of giving too much fluid in meningitis?
How do you isolate the cases?
Chemoprophylaxis?
SIADH and overload (worsen the oedema).
Isolate on the ward until 12 hours of IV antibiotics.
Chemoprophylaxis is rifampicin to close contacts and should be given within 24 hours. Give them ceftriaxone.
COmmonest vasculitides in children?
HSP and Kawasaki. Kawasaki under 2 and HSP above 2 - 8.
Discuss the clinical features of HSP
Palpable purpura with arthritis, arthralgia, abdo pain and / or renal involvement (haematuria, proteinuria, HTN)
Pulmonary + neuro involvement are both rare but may be life threatening if present.
PAAR
Remember the abdo pain is in intussuseption.
Investigations for HSP?
Urinalysis
Only need to do further investigations if there is severe abdo symptoms, or significant renal impairment (BP, gross haematuria).
FBE, UEC, LFT (albumin)
BC + Urine MCS
Abdominal imaging
ANA, ANCA, C3/C4 (this will tell if there is any unclear dx features).
USS for intususception if severe pain.
How would you manage the
Depends if there is mild or moderate/ severe pain.
Mild: subcut oedema managed by bed rest + elevation of the affected area. Paracetamol and NSAID’s.
Mod/ severe: glucocorticoids reduce the duration of joint pain and abdo pain. No impact on long term kidneys.
If there is significant renal, pulmonary, neurological or abdo comp, refer to paeds and consider admission.
Follow up is referral to the GP or paediatrician to identify subsequent renal involvement, monitoring for HTN, proteinuria or macroscopic haematuria.
What is global developmental delay?
MOre than two domains of development impaired. Cognitive is included in this.
Developmental history?
Start from before birth:
- Drugs? Infections? Alcohol or smoking? Any problems with the pregnancy? Folate supplements?
Birth: Method? Trauma? Complications?
Post-partum? APGAR, NICU, ventilation?
Full developmental history: ask how they started doing the different milestones. DID THEY REGRESS?
Vision or hearing concerns?
Behaviour? Sleep? Toileting? Growth? Diet?
Also do a full history.
Examination is vitals, anthropometry, and a general exam looking for dysmorphic features and neurocutaneous markers like NF1, 2 and Sturge Weber port wine spots.
Investigations for a developmental delay?
Screen using a developmental screening tool (we use Denver II) and work up based on hx.
Hearing and vision should be assessed in most patients. Consider that they might be having NDIS funding available.
DDX for infant or child with an abnormal gait or sore joints?
Toddler 1-4 DDH Toddlers fracture Transient synovitis of the hip Talipes equinovarus, talipes calcaneovalgus,
Child 4-10 Transient synotivitis of the hip DMD Perthes Growing pain
10 to ado SUFE Overuse syndromes (Osgood)
Also note that we can get at any age: infectious (osteomyelitis, septic arthritis), HSP, ARF, JIA, Trauma, Malignancy (bone tumours, ALL), NAI, APpendicitis/ IBD), Testicular torsion, functional limp, cerebral palsy, neural tube defects
How do we follow up our HSP patients?
Review urinalysis and check BP at these intervals – weekly for 1 month,
fortnightly from weeks 5-12, single reviews at 6 and 12 months
Rf’s for DDH and how do we diagnose and manage?
Risks include a family history, being a breech, being a first born, and being a twin.
Before 6 months do an ultrasound, after 6 months do an x-ray.
Management by either using a Pavlik Harness for several months or by doing an open or closed reduction.
What is a toddler’s fracture?
Spiral or oblique undisplaced fracture to the distal shaft of the tibia with intact periosteum and no fibula involvement. Usually occurs in a twisting injury. THey will not be weight bearing.
We manage with supportive care and a backslab! Most heal without complications in 8-12 weeks.
MOst common cause of limp in childre?
How do we manage it?
Transient synovitis of the hip joint. Often follows falls and viruses. Usually unilateral. Diagnosis of exclusion. Can get pain all along the leg, and they find it difficult to move. If severe limitation, suspect a septic arthritis.
Paracetamol and rest. Resolves around 2 weeks and gets better at 3 days.
Bishop score mnemonic?
C the PEDS!
Consistency position effacement dilation station
