Paediatrics Flashcards
Describe the components of a paediatric clinical history
Name
Age
PC
HPC - origin, duration, progress
Birth hx - full term, normal delivery, weight, SCBU
Feeding hx - breast/bottle, weaned, weight gain
Immunisation hx - up to date
Developmental hx - milestones, concerns, school performance
SH - nursery/school, home environment, travel
FH - conditions, genogram, consanguinity
Describe relevant questions in a systems review
Cardioresp - tachypnoea, grunting, wheeze, cyanosis, smokers in family, cough (barking/whooping)
GI - appetite, vomiting, feeding, jaundice, bleeding, weight, passed meconium
Genitourinary - wet nappies, smell, haematuria
ENT - noisy breathing, ear infections, hearing
Skin - rash, birthmarks
Describe the components of a paediatric examination
Vital signs - temp. O2 sats, HR, RR, cap. refill,
Plot and interpret growth chart
Describe the components of a paediatric respiratory examination
Observation - respiratory distress (nasal flaring, recession, accessory muscle use, wheeze, stridor, grunting), restless, drowsy, cyanosis, finger clubbing
Palpation - expansion, trachea (central), apex beat, chest deformity, percussion
Auscultation - air entry, breath sounds, expiratory wheeze, transmission of upper airway sounds
Describe the components of a paediatric ENT examination
Ear - grey, shiny/red, bulging/dull, retracted
Nose - inflammation, obstruction, polyps
Throat - enlarged, red tonsils
Describe the components of a paediatric cardiology examination
Observation - central cyanosis, breathless/pale/sweaty, finger clubbing, failure to thrive
Palpation - apex beat, RVH, thrills, hepatomegaly, pulse (radial/femoral)
Auscultation - murmurs (diastolic = pathological), BP, CRT
Describe the components of a paediatric abdominal examination
Observation - nutritional status (BMI, upper arm circumference), jaundice, pallor, abdominal distension, wasting of buttocks (coeliac), genitalia (hypospadias, undescended testes, hydrocele, hernia)
Palpation - tenderness, organomegaly (spleen, kidneys), masses
Auscultation - bowel sounds
Describe the components of a paediatric neurological examination
Observation - conscious level, posture, movement, gait, limb deformity, contractures, growth, head circumference, shoes (unequal wear)
Tone - hypotonia, spasticity (toe walking)
Power
Sensation
Reflexes - *plantar reflex is up until ~8mo
Coordination
Developmental exam
Describe the NICE guidelines on fever in children
Green = normal colour, responds normally to social cues, smiles, stays awake, not crying/strong cry. normal skin and eyes, moist mucous membranes
Amber = pale, not responding normally to social cues, no smile, wakes only with prolonged stimulation, decreased activity, nasal flaring, tachypnoea, tachycardia, CRT >3s, dry mucous membranes, poor feeding, low urine output, temp. >38, rigors, fever >5 days, non weight bearing limb
Red = pale/mottled/ashen/blue, no response to social cues, appears ill to HCP, does not wake, weak high pitched continuous cry, grunting, reduced skin turgor, age <3mo with temp. >38, non blanching rash, bulging fontanelle, neck stiffness, focal neurology
Define the terms prematurity, extremely premature, low birth weight, very low birth weight, extremely low birth weight and small for gestational age
Prematurity = <37 weeks Extremely premature = <28 weeks Low birth weight = <2.5kg Very low birth weight = <1.5kg Extremely low birth weight <1kg SGA = <10th centile
List risk factors for prematurity
Maternal - smoking, alcohol, pre-eclampsia, young age
Uterine - structural abnormality, cervical incompetence
Fetal - multiple, distress, infection, chromosomal abnormality
Placental - praevia, abruption, insufficiency
Describe the APGAR score
Appearance - pink/blue/white (2/1/0)
Pulse - >100/<100/absent
Grimace (reflex to suction) - cough or sneeze/grimace/none
Activity (floppy) - good flexion/some flexion/limp
Respiration - strong cry/irregular/absent
*normal score at 1 min = 7/10
List and describe the management of some common newborn respiratory problems
TTN - often in C-section baby –> dry and give oxygen
RDS - surfactant deficiency, ground glass appearance on CXR –> dexamethasone, surfactant
Apnoea - not breathing for >20s –> caffeine
Bronchopulmonary dysplasia - chronic oxygen requirement for >28 days or 36 weeks corrected
Meconium aspiration syndrome - seen on Xray –> suction
List and describe the management of some common newborn cardiac problems
PDA –> NSAIDs (indomethacin), ligation
Hypotension –> ITU
List and describe the management of some common newborn haematology problems
Anaemia - iatrogenic (multiple blood tests), underdeveloped kidneys producing low EPO –> iron tablets, transfusions
List and describe the management of some common newborn gastrointestinal problems
NEC - breast milk is protective, abdominal distension, bloody stools –> ABx, NBM, surgery if perforated
Inguinal hernia –> surgery due to strangulation risk
Describe causes and management of neonatal jaundice
<24h - Rh/ABO incompatibility, G6PD, spherocytosis, sepsis
24h-2 weeks - breastfeeding, physiological, dehydration
>2 weeks - biliary atresia, hypothyroidism, pyloric stenosis
Mx = watch and wait/phototherapy/exchange transfusion (*risk of kernicterus)
What precautions must be taken when a neonate undergoes phototherapy
Cover eyes
Ensure adequate fluids (IV)
Describe the clinical presentation and management of biliary atresia
CFs - jaundice, yellow urine, chalky, white stool, splenomegaly
Ix - HIDA scan
Mx - surgery (Kasai procedure), liver transplantation
List different causative agents for neonatal infection
Early onset (<48h) - GBS, listeria (maternal infection/PROM) Late onset (>48h) - staph aureus, E. coli (central line, catheter infection)
List and describe the management of some common newborn endocrine/metabolic problems
Jaundice
Hypoglycaemia (BM <2.6) –> IV 2mls/kg of 10% dextrose
Thermoregulation –> incubator box
Osteopenia
List and describe the management of some common newborn neurological problems
Intraventricular haemorrhage (IVH) - cranial USS, increased cerebral palsy risk Hypoxic ischaemic encephalopathy - cord blood pH <7.0 --> therapeutic hypothermia (cooling to 33.5 for 72h)
Describe causes and management of retinopathy of the newborn
Screen neonates <1.5kg or born <32 weeks
Caused by high oxygen - keep neonate at <92% sats
Mx = laser ablation
List benefits of breastfeeding
Maternal - bonding, lower risk of PPH (oxytocin release), lowers risk of breast/ovarian cancer, contraceptive effect, low cost
Fetal - receive maternal IgG, lowers risk of NEC, long term health benefits
List some negatives of breastfeeding
Cracked nipples
Increased sodium loss –> dehydration
Higher costs (formula)
List contraindications of breastfeeding
HIV +ve mother
Active TB (+ treatment)
Illicit drug use
List medications that are contraindicated in breastfeeding
Amiodarone Antineoplastic (e.g. methotrexate) Chloramphenicol Lithium Tetracyclines
List signs of a healthy breastfed baby
Wet nappies
Pooing regularly
Gaining weight (30-40g/day)
What is the NIPE?
Newborn and Infant physical examination - performed within 72h of delivery
General - weight, length, head circumference, tone, reflexes
Skin - jaundice, pallor, cyanosis, erythema toxicum rash, birthmarks
Head - anterior fontanelle, chignon
Eyes - red reflex, jaundice, coloboma
Mouth - cleft lip/palate, tongue tie
Chest - heart murmur, respiratory distress
Abdomen - distention, defects, organomegaly
Hips/limbs - pulses, barlow & ortolani, clubfoot
Genitalia/anus - ambiguity, undescended testes
Spine - spina bifida
Describe clinical presentation, investigations and management of bronchiolitis
<1 year, viral (RSV, parainfluenza, rhinovirus), lasts 7-10 days
CFs - wheeze, crackles, fever, poor feeding, <92% sats
Ix - CXR (hyperinflation, collapse/consolidation)
Mx - supportive (oxygen, feeding)
List the admission criteria for bronchiolitis
Apnoea
<92% sats
RR >70
Decreased oral intake
Describe the clinical presentation, management and long term advice given in cystic fibrosis
Cystic fibrosis = genetic disorder causing defect in CFTR chloride channel –> thick mucus
CFs - Guthrie heel prick (screening), sweat test (>60mmol/L Cl-), meconium ileus, failure to thrive, (recurrent chest) infections
Ix - CXR (overinflation, hilar enlargement, ring shadows)
Mx - ABx, steroid therapy, nebulised DNAse, regular bronchodilators, chest physiotherapy
Long term advice - prophylactic ABx, immunisations (pneumococcal, influenza)
List common organs affected in cystic fibrosis
Lungs - recurrent infections
Pancreas - malabsorption, pancreatic failure (requires vitamins ADEK, pancreatic enzymes), diabetes
Liver - cirrhosis
Gallbladder - biliary disease
Reproductive - sub fertility (absence of vas deferens in men)
Describe clinical presentation, investigations and management of croup
Croup = swelling of trachea
6mo-6 years, viral (RSV, parainfluenza)
CFs - seal like barking cough, stridor, sternal recession, agitation, lethargy, coryza illness, usually self limiting
Mx = dexamethasone oral/IV
Describe clinical presentation, investigations and management of epiglottitis
Epiglottitis = inflammation of epiglottis
1-6 years, haemophilus influenza B bacteria (*immunisation history)
CFs - 4Ds (drooling, dysphonia, dyspnoea, distress)
Ix - DO NOT EXAMINE
Mx - intubate, IV ABx, steroids
Describe clinical presentation, investigations and management of tonsilitis
Tonsilitis = inflammation of tonsils
Often viral (adenovirus, rhinovirus), bacterial (group A b-haemolytic streptococcus)
CFs - sore throat, red swollen tonsils, odynophagia, fever, malaise, lymphadenopathy
Mx - supportive (paracetamol, ibuprofen) or ABx (penicillin V), tonsillectomy
Describe the Fever PAIN score
Predicts likelihood of strep. throat: Fever in past 24h Purulent tonsils (exudate) Attend rapidly (symptoms <3 days) Inflamed tonsils No cough
0-1 = no ABx 2-3 = delayed ABx\ >4 = ABx
Describe the NICE guidelines regarding tonsillectomy
Sore throat is due to acute tonsillitis
The episodes of sore throat are disabling and prevent normal functioning
>7 in one year OR 5 in two years OR 3 in three years
Describe clinical presentation, investigations and management of whooping cough
Whooping cough = highly infectious bacterial (bordella pertussis) infection *infants not fully vaccinated
CFs - paradoxical coughing spasms during expiration followed by a sharp intake of breath, apnoea
Ix - mostly clinical, lymphocytosis, nasal swab culture
Mx - supportive, ABx (erythromycin)
*advise cough may continue for months
List cyanotic heart defects
Transposition of the Great Arteries (TGA)
Tetralogy of Fallot (ToF)
List acyanotic heart defects
VSD
PDA
Coarctation of the aorta (CoA)
Describe clinical presentation, investigations and management of Transposition of the Great Arteries
TGA = two parallel unconnected circulations (*only viable if ASD/PDA/VSD = bidirectional shunting)
CFs - cyanosis in 24h, tachypnoea, tachycardia, failure to thrive (3-6 weeks), prominent right ventricular heave, systolic murmur (if VSD), no respiratory distress
Ix - blood gas (metabolic acidosis, lactate), ECHO, CXR (egg on a string = narrowed mediastinum, cardiomegaly)
Mx - PG infusion (keeps duct patent), correct metabolic acidosis, surgery (<4 weeks)
List some maternal risk factors for fetal TGA
Age >40 Diabetes mellitus Rubella infection Poor nutrition Alcohol
Describe clinical presentation, investigations and management of Tetralogy of Fallot
ToF = VSD + pulmonary stenosis + RVH + overriding aorta
CFs - asymptomatic until age 1-3 (mild), cyanosis, respiratory distress recurrent chest infections, failure to thrive (moderate - severe), marked respiratory distress, cyanosis (extreme), central cyanosis, clubbing, thrill/heave, murmur, hepatosplenomegaly
Ix - ECG (RAD, RVH), CXR (boot shaped heart), ECHO
Mx - squatting, PG infusion, definitive surgery (3mo-4years)
Describe clinical presentation, investigations and management of VSD
VSD = hole in the septum separating left and right ventricles
CFs - exercise intolerance, dizziness, chest pain, blue-ish complexion, clubbing, undernourished, sweaty, tachypnoea, blowing pan systolic murmur
Ix - ECG, bloods, CXR, ECHO
Mx - diuretics, ACEi, surgical repair
What is Eisenmenger’s syndrome?
Pressure in RV > LV –> shunt reversal –> cyanotic patient
List some maternal risk factors of fetal VSD
Maternal diabetes Rubella Alcohol FH (Fetal Down's syndrome/trisomy 18)
Describe clinical presentation, investigations and management of PDA
PDA = ductus arteriosus fails to close after birth (common in preterm babies - prevent with indomethacin, *associated with IVH, NEC)
CFs - systolic/continuous machinery like murmur, full bounding pulses
Ix - ECHO, CXR (cardiomegaly)
Mx - ibuprofen, surgical closure
Describe clinical presentation, investigations and management of Coarctation of the Aorta
CoA = narrowing of descending aorta
CFs - shock (if closure of PDA), weak/absent femoral pulses, BP in arms > legs
Mx - PGs (keep duct open), surgical repair
Describe clinical presentation, investigations and management of gastro-oesophageal reflux disease
GORD = passage of gastric contents into the oesophagus causing symptoms or complications
CFs - distressed behaviour, feeding difficulties, chronic cough, pneumonia, faltering growth, alleviated when held upright
Mx - reassurance (*usually resolves by 1 year of age), alginate (Gaviscon) + water, lower feed volume and higher frequency, feed thickener/alginate added to formula, PPI (omeprazole), H3 antagonist (ranitidine), domperidone, fundoplication
List reasons neonates are more likely to experience GORD
Lower tone of lower oesophagus
Short narrow oesophagus
Delayed gastric emptying
High ratio of gastric volume:oesophageal volume
List some risk factors of GORD
Prematurity Obesity Hx of congenital diaphragmatic hernia Hx of oesophageal atresia Neurodisability
Describe clinical presentation, investigations and management of cow’s milk protein intolerance/allergy
IgE (acute, rapid onset, skin signs, angioedema) vs non IgE (non acute, delated onset, faltering growth) mediated allergy
Ix - clinical, IgE blood test (RAST)
Mx - cow’s milk avoidance (baby + mother) for >6mo, nutritional counselling, growth monitoring, extensively hydrolysed formula/amino acid formula
*NOT soya based formula due to oestrogenic effects
List some risk factors for CMPI
Atopy (asthma, eczema, allergic rhinitis, other food allergies)
FH of atopy
Describe clinical presentation, investigations and management of Coeliac Disease
CD = lifelong gluten (wheat, barley, rye) sensitive autoimmune disease
CFs - failure to thrive, abdominal distension, buttock wasting, diarrhoea, anaemia, osteoporosis, dermatitis herpetiformis
Ix (if on gluten diet) - serology testing, duodenal biopsy
Mx - gluten free diet, iron supplementation
What is the diagnostic criteria of Coeliac Disease?
Positive serology - IgA for anti-endomyseal, anti TTG
On biopsy - increased intraepithelial lymphocytes, villous atrophy, crypt hypertrophy
Resolution of symptoms on gluten free diet and catch up growth
List some risk factors for Coeliac Disease
Autoimmune conditions (T1DM, thyroid, RA), Down’s syndrome, Turner’s syndrome
Describe clinical presentation, investigations and management of gastroenteritis
Viral (rotavirus, norovirus, adenovirus) or bacterial (campylobacter, E.coli)
CFs - sudden onset diarrhoea +/- vomiting, abode pain, mild fever, dehydration
Ix - stool sample, bloods (Na+/K+, urea, creatinine, glucose)
Mx - continue feeds, encourage fluid intake, offer rehydration solution (if dehydrated), oral therapy or NG tube
*IV therapy if shock/red flags/lots of vomit
List some complications of gastroenteritis
Haemolytic uraemic syndrome
Toxic megacolon
Acquired lactose intolerance
State the paediatric maintenance fluid calculation formula
1st 10kg - 100ml/kg/day
2nd 10kg - +50ml/kg/day
>20kg - +20ml/kg/day
Calculate the maintenance fluids of a 35kg child
1800ml/day
State how to correct for dehydration in children
%dehydration x 10 x weight
Describe clinical presentation, investigations and management of Hirshsprung’s Disease
HD = absence of ganglionic cells from plexuses in large bowel, association with trisomy 21
CFs - no meconium >48h, obstruction, abdominal distension, bilious vomit, chronic constipation, faltering growth
Ix - full thickness rectal biopsy, barium enema
Mx - rectal washout, anorectal pullthrough
Describe clinical presentation, investigations and management of intussusception
= telescoping of one part of bowel into another, 3mo-2 years, commonly ileum –> caecum, caused by enlarged lymphatics (post viral, polyp, lymphoma)
CFs - episodic abdo pain, screaming, drawing up legs, pallor, passage of blood/mucus (red current jelly stool), palpable sausage mass
Ix - AXR (rounded edge of intussusception against gas filled lumen, proximal bowel obstruction), abdominal USS (target/doughnut sign)
Mx - fluid, IV ABx, reduction enema, laparotomy
Describe clinical presentation, investigations and management of mesenteric adenitis
= inflammation of intraabdominal lymph nodes following URTI/gastroenteritis
CFs - abdo (RIF) pain, no peritonism/guarding, evidence of infection
Mx - analgesia (normally self limiting), otherwise appendicectomy
Describe clinical presentation, investigations and management of Meckel’s diverticulum
= congenital out-pouching leftover from umbilical cord releases acid, rule of twos (2% population, 2% symptomatic, 2 inches, 2 feet from ileocaecal valve) *intussusception risk, appendicitis risk, volvulus risk
Ix - AXR, USS, faecal sample, Meckel’s scan, laparoscopy
Describe clinical presentation, investigations and management of malrotation
= failure of duodenojejunal flexure to rotate around superior mesenteric vessels –> mesentery is not fixed, presents in first few days of life
CFs - obstruction +/- ischaemic bowel, blood stained bilious vomit
Ix - upper GI contrast study (corkscrew sign)
Mx - surgical correction
Describe clinical presentation, investigations and management of pyloric stenosis
= hypertrophy of pylorus muscle, 2-8 weeks, first born male
CFs - non bilious projectile vomiting (immediately after feed), constipation, hungry baby, failure to thrive, prominent peristaltic wave, palpable epigastric mobile mass
Ix - USS (thickened, elongated pyloric muscle), bloods (hypochloraemic hypokalaemia metabolic acidosis)
Mx - rehydration + correction of electrolytes/acidosis), Ramstedt’s pyloromyotomy
Describe clinical presentation, investigations and management of congenital diaphragmatic hernia
CFs - respiratory distress in neonate, not responsive to resuscitation, displaced apex beat, poor air entry to left lung
Ix - X-ray (bowel loops in chest)
Mx - NG with suction (to decompress bowel), intubation, surgical repair
Describe clinical presentation, investigations and management of tracheoesophageal fistula/oesophageal atresia
CFs - polyhydramnios, not feeding, cyanosis on feeding
Ix - CXR (air in stomach)
Mx - NG with suction, surgical repair
List some causes of nephritic syndrome
= inflammation –> haematuria
Post streptococcal glomerulonephritis - red cells, casts, HTN, group A strep, 1-2 weeks post throat/2-6 weeks post skin, penicillin 10 day course
Vasculitis - SLE, Wegener’s granulomatosis, HSP
IgA nephropathy (Berger’s disease)
Goodpasture’s syndrome (anti GBM)
Alport’s syndrome (X-linked recessive, sensorineural deafness + ESRD)
Sickle cell disease
PCKD (recessive –> infancy, dominant –> adolescence)
List some causes and complications of nephrotic syndrome
= inflammation –> proteinuria, oedema, hypoalbuminaemia, hyperlipidaemia
Minimal change glomerulonephritis - oedema, URTI hx, fluid restriction, low salt diet, steroids (renal biopsy +/- cyclophosphamide if steroid resistant), penicillin (pneumococcal peritonitis risk)
Focal segmental glomerulosclerosis - rule of 1/3 (resolve/infrequent relapse/frequent relapse)
Complications - hypovolamia, thrombotic disease, hypercholesterolaemia
List different causes of UTI in a child
Pelviureteric obstruction - due to abnormal tissue/external compression at point of renal pelvis joining ureter Vesicoureteric reflux (VUR) - retrograde flow of urine from bladder into ureters due to abnormally short and straight insertion of ureters into bladder, Mx - monitor, ABx prophylaxis
List some causes of anaemia in a child
Impaired RBC production:
- Red cell aplasia - parvovirus B19, leukaemia, aplastic anaemia
- Ineffective erythropoiesis - chronic renal failure, folic acid deficiency
- Iron deficiency anaemia - blood cells, malabsorption, low intake
Increased RBC destruction:
- Haemolytic anaemia (hereditary sperocytosis, G6PD, sickle cells)
Blood loss:
- ITP - post viral infection, mucocutaneous bleed, Mx = steroid)
- Haemophilia A - joint bleeds, F8 deficiency, raised APTT
- DIC - raised D dimer, PT/APTT, trauma, metastatic cancer, sepsis
- von Willebrand’s - raised APTT, mucosal bleeding, Mx = desmopressin
Describe the features of Kawasaki Disease
Conjunctivitis Rash Adenopathy (cervical) Strawberry tongue Hand/feet reddening Fever for >5 days *risk of coronary artery aneurysms
Describe the features of Henloch Shonlich Purpura (HSP)
Rash on buttocks, extensor surfaces
Arthralgia
Abdo pain
Nephritis (haematuria/proteinuria)
Describe risk factors, investigations and management of Developmental Dysplasia of the Hip (DDH)
= abnormal relationship of femoral head to acetabulum
RFs - female, FHx, breech, oligohydramnios, positive screening (Barlow&Ortolani)
CFs - painless limp
Ix - USS if <6mo/XR hip if >6mo
Mx - pavlik harness if <6mo, closed reduction if >6mo, ORIF if unsuccessful
Describe clinical presentation, investigations and management of septic arthritis
CFs - hot, swollen, painful joint +/- erythema, severely reduced ROM, non weight bearing
Ix - USS joint (effusion) *never aspirate
Mx - urgent IV ABx, surgical washout
Define Kocher’s criteria
Likelihood of septic arthritis WBC >12 ESR >40 Temp >38.3 Non weight bearing
Describe clinical presentation, investigations and management of transient synovitis
Similar to septic arthritis but inflammatory markers normal, hx of viral illness
Self limiting
*if >18mo = septic arthritis
Describe clinical presentation, investigations and management of Perthes’ disease
= idiopathic osteonecrosis of femoral head, peak 4-7 years
CFs - painless limp *rule out sickle cell
Ix - radiography/MRI
Mx - symptom control, surgery –> THR in adult life
Describe clinical presentation, investigations and management of SUFE
= salter halter 1 fracture, adolescents, overweight/obese
CFs - gradual onset groin/knee pain
Ix - X-ray hip + frog leg lateral
Mx - surgical (prophylaxis vs. damage control)
List red flags for a limping child
Child <3y Unable to weight bear Fever Systemic illness >9y with a hip problem
List red flags for development
Regression Plateau Hyper/hypotonia Not holding an object by 5mo Can't sit unsupported by 10mo No speech by 18mo Not pointing by 2y
List red flags of gross motor development
Primitive reflexes >6mo
Unable to sit unsupported >10-12mo
Can’t walk >18mo
List red flags for fine motor development
Hand preference <6mo
List red flags for speech and language development
No sounds >10mo
<6 words at 18mo
Not responding to commands >2y
List red flags for social development
Not smiling responsively >10weeks
Little interest in others >6mo
List important development milestones
4-6 weeks - fixes to face, smiles responsively
6-7 months - sits unsupported
9 months - gets to sitting position
10 months - pincer grasp, waves bye bye
12 months - walks unsupported, 2-3 words
18 months - feeds self with spoon, throws a ball
2y - 2-3 word sentences, runs, kicks a ball
