Paediatrics Flashcards
What is Autism Spectrum Disorder and when does it present?
- Behaviour beyond cultural norms
- Affects communication, social relatedness, movement, and interpersonal relations.
- Presents 2-4y
Diagnosis of Autism Spectrum Disorder
At least 6 of:
- Failure to use eye contact, facial expression and body language
- Lack of socio-emotional repicoty
- Language delay
- Lack of spontaneously seeking to share enjoyment
- Failure to initiate and sustain conversation
- Stereotyped repetitive words
- No make believe play
- Regimented routines
- Failure to develop peer relationships
Complications/ co-morbidities of autism
- Mental retardation
- Language delay
- ADHD
- Epilepsy (1/4)
- Learning and attention difficulties
Investigations and managment of autism spectrum disorder
- Ix: Educational psychologist, information from school, SALT assessment
- Tx: Psychoeducation. MDT- paeds, school, SALT, OT. ?Respiridone ?melatonin to improve sleep
What are the features of ADHD?
- = Neurodevelopmental disorder with Sx <7y in 2 different environments (home and school)
- Inattention - poor attention to detail, fails to engage with tasks, poor organisation, loses things, distracted, forgetful
- Impulsivity - Blurts out answers, fails to wait in line
- Hyperactivity - Fidgets, leaves seat when expected to sit, runs inappropriately, noisy, persistent pattern excessive motor activity
ADHD Ix and Tx
- Ix: Conner’s questionairre, home/ school assessment
- Tx:
- Conservative: psychoeducation, involvement of parents, routine
- Medical: Psychostimulatns (eg methylfenidate) to improve concentration, non-stimulants (eg atomoxetine)
What are the 2 patterns of attachment disorder and their features?
- Disinhibited- Result of institutional care and no main care giver. ++ friendly with strangers, overreactive
- Reactive- Result of abuse/neglect. Fearfullness and hypervigilance
What is attachment disorder?
Abnormal social functioning that is aparent during 1st 5y of life, causing significant emotional disturbance. Persists into later childhood.
Treatment of attachment disorder
- Support care givers
- Nurturing care setting
- Family therapy, play therapy
- High risk of other mental health conditions –> screen
What are the main pathogens of pneumonia in different age groups of children?
- Newborn- Bacteria from genital tract eg Group B Strep
- Infants- RSV, Strep. pneumoniae, HiB
- >5y- S. pneumoniae, chlamydia pneumoniae
- Newborn= broad spectrum IV ABx
- Older infants- ?PO ABx
What might you suspect in a child diagnosed with pneumonia with persistent fever despite 48h ABx?
?Parapneumonic effusion –> drainage w/ USS
Indications for admission of a child with pneumonia
- Sats <93%
- Tachypnoea
- Respiratory distress
- Poor feeding
- <6 months
- Apnoeas
How might a child with croup present?
- 6m-6y
- Often in Autumn
- Stridor
- Barking cough
- Temp >38.5
- Hoarse voice
- Often preceded by fever and coryza
- Respiratory distress and cyanosis
- DON’T EXAMINE THROAT- ?epiglottitis
Croup- investigations and management
- Ix: O2 sats, NPA (parainfluenza)
- Tx: Usually home.
- Humidified air
- Dexametasone/pred PO
- NEB budesonide
- Adrenaline + o2 in severe
How might a child with Bronchiolits present? + RF + organisms
- <2y
- RF: Prematurity, CF, congenital heart disease
- Organisms: RSV, S. pneumoniae, H. Influenzae
- Sx:
- Coryza –> dry cough –> SOB
- Poor feeding
- Apnoeas
- Crackles
- Hyperinflation
- Tachypnoea/Tachycardia
- Signs of resp distress
Investigations and management of bronchiolitis
- Ix: Obs, NPA, CXR, ?ABG
- Tx:
- Conservative- Humidifies o2, NG
- Medical- IVT, ?trial bronchodilator
- NIV in severe
What are the key features of Epiglottitis?
- ++ Unwell. DO NOT EXAMINE THROAT
- Rapid onset, no prodrome
- No cough
- Unable to drink, drooling, mouth open
- Temp >38.5C
- Stridor (soft)
- Unable to speak/cry
- –> Intubation and IV ABx eg cefuroxime
Signs of respiratory distress in a child
- Tachypnoea
- Tachycardia
- Low GCS
- Nose flaring
- Recessions
- Sweating
- Stridor
- Wheezing
- Accessory muscles
- Grunting
- Cyanosis
Presentation of inhaled foreign body
- Hoarse
- Cough
- Dysphonia
- Haemoptysis
- Stridor
- Wheeze
- SOB
- Cyanosis
- Apnoea (complete obstruction)
Congenital heart disease: Types of non-cyanotic (L –> R shunt)
- Atrial septal defect
- Ventricular septal defect
- Persistent ductus arteriosus
- Coarction of aorta
- Aortic stenosis
Atrial septal defect: Presentation, Ix, Tx
- Murmur- Ejection systolic, ULSE
- Sx- ASx, recurrent chest inf
- Ix: ECG (RAD), CXR (cardiomegaly), ECHO
- Tx: Surgery 3-5y with occlusion device
Ventricular septal defect: Presentation, Ix, Tx
- Small <3mm: ASx, loud pansystolic murmur LLSE
- Large >3mm: quieter murmur. Sx- HF + SOB, FTT, recurrent chest inf, raised RR/HR
- Ix: ECG, CXR, ECHO. Cardiomegaly
- Tx: Small= none. HF= diuretics, ++ calories. Surgery 3-6m.
Persistent Ductus Arteriosis (>1m): Presentation, Ix, Tx
- Presentation: Continual machinery murmur under L clavicle. Collapsing pulse. Usually ASx.
- Ix: CXR + ECG normal, seen on ECHO
Coarction of the Aorta: Presentation, Ix, Tx
- Presentation: Systolic murmur. Day 1 normal. Day 2 neonatal circulatory failure. No femoral pulses
- Ix: Severe metabolic acidosis, CXR (cardiomegaly)
- Tx: Surgery/ stent. Prostaglandins
Aortic Stenosis in children: Presentation, Ix, Tx
- Presentation: Ejection systolic murmur in RSE –> carotids. Most ASx. Exercise intolerance, chest pain, syncope.
- Ix: ECG (LV hypertrophy), CXR (cardiomegaly)
- Tx: Balloon valvotomy/ replacement valve
Congenital Heart Disease: Types of cyanotic (R –> L shunt)
- Transposition of the great arteries
- Tetralogy of Fallot
- Hypoplastic L Heart syndrome
- Eisenmenger Syndrome
- Tricuspid atresia
Transposition of the Great Arteries: Presentation, Ix and Tx
- Cyanosis (++ Day 2) as DA closes
- Ix: ECG, CXR (narrow upper mediastinum), ECHO
- Tx: Prostaglandins, balloon septostomy
Tetralogy of Fallot: Presentation, Ix and Tx
- = Large VSD, overriding aorta, subpulmonary stenosis, RV hypertrophy
- Presentation: Harsh ejection systolic murmur LSE. Sx- cyanosis, irritable, SOB, pallor, cyanotic spells.
- Ix: CXR- boot shaped heart, ECG- RV hypertrophy, ECHO, catheterisation
- Tx: Surgery at 6m to close VSD and relieve RV obstruction.
Hypoplastic L heart syndrome: Presentation, Ix and Tx
- = Underdevelopment of L side –> no flow through L side –> no o2 to body. Rely on ductal circulation.
- Presentation: Profounf acidosis, rapid CVS collapse, weak/ absent peripheral pulses
- Tx- Surgery, prostaglandins
What is Eisenmenger Syndrome?
Large L-R shunt not treated early –> pulmonary arteries thick and resistant. 10-15y shunt reverses –> RHF, cyanosis
Causes of Heart failure in children
- Neonates- Obstructed systemic circulation, hypoplastic L heart syndrome, critical aorta stenosis, interruption of aortic arch
- Infants- Pulmonary hypertension, VSD, ASD, PDA
- Older children- R/L HF, Eisenmenger’s, rheumatic heart disease, cardiomyopathy
Presentation of heart failure in children
- SOB - exertion/ feeding
- FTT
- Cyanosis
- Tachycardia/tachypnoea
- Murmur
- Enlarged heart
- Hepatomegaly
- Recurrent chest infections
- Poor feeding
- Sweating
BTS stepwise management for asthma in kids
- ALL THROUGH SPACER
- INH salbutamol PRN
- V. low ICS or montelukast in <5y
- V. low ICS + LABA or montelukast <5y
- Response to LABA - cont/stop/increase ICS. ?+montelukast
- Med dose ICS trial. Addition of theophylline. Refer.
- PO steroid, cont. med dose ICS. Refer.
- ** personalised asthma action plan **
HR and RR parameters in severe asthma attack in kids
- RR:
- 2-5y: >40
- 5-12y: >30
- 12-18y: >25
- HR:
- 2-5y: >140
- 5-12y: >125
- 12-18y: >110
Key features of coeliac in children
- RF: T1DM, AI, Down’s
- Presentation:
- 8-24m when weaning
- FTT
- Abnomal disstention
- Irritability
- Muscle wasting
- Abnormal stools
- Anaemia
- Ix: Anti-transglutaminase, biopsy
- Tx: GF diet. No wheat, barley or rye
What is CF and how does it present?
- = Autosomal recessive disease from Ch 7. Defective CFTR. Mutation= deltaF508
- Affects exocrine glands - resp tract, pancreas (lipase, amylase, protease), sweat glands.
- Presentation:
- Newborn - Dx on screening, meconium uleues
- Infant - prlonged neonatal jaundice, FTT, recurrent chest infections w/ HiB/Staph A (hyperinfaltion, creps, wheeze), malabsorption –> steatorrhoea. Salty sweat –> dehydration
- Young child - bronchiectasis, nasal polyps, sinusitis
- Adolescent - DM, cirrhosis, intestinal obstruction, finger clubbing, sterility in males
Ix and Tx of CF
- Ix:
- Bedside:
- Heelprick (high immunoreactive trypsinogen)
- Sputum sample
- Sweat test= Dx. ++Chloride
- Faecal elastase
- Bloods - LFTs
- Imaging - CXR
- Special - genetic testing, spirometry
- Bedside:
- Tx: MDT!!!
- Cons- chest physio, psych, school support, exercise, vaccinations, high calorie diet, avoid other CF Pt
- Med- ABx, ?prophylactic ABx eg anti-pseudomonal INH, NEB hypertonic saline, creon, ursodeoxycholic acid, laxatives
- Surg- lung/ liver transplant
Childhood obesitity - definition, complications, Tx
- Overweight = BMI >91st centile, obese = BMI >98th centile
- Complications:
- SUFE
- Hypoventilation
- NAFLD
- PCOS
- T2DM
- HTN
- Higher risk obesity as adults
- Tx:
- Cons - healthy eating, physical activity, less TV etc
- Med/surg- ?orlistat in children >12y with BMI> 40 or >35 w/ complications
Key features of allergic rhinitis in children
- Presentation:
- Seasonal
- Conjunctivitis
- Coryza/ discharge
- Cough/ sneezing
- Poor sleep and concentration
- Ix: IgE, skin testing
- Tx: Avoid allergens, antihistamines, topical steroids, immunotherapy, decongestants –> montelukast?
Key features of mesenteric adenitis
- = Inflammation and swelling of LNs in abdo.Mimics acute appendicitis
- Presentation:
- Usually + viral infection
- Fever
- Malaise
- Central abdo pain
- N+V
- Diarrhoea
- Ix: Period of observation - will stay same/ get better
- Tx: Conservative - HWB, para, IVT
Paeds Development milestones
- Birth - 8w: Primitive reflexes, pull to sit, fix + follow, startles to noise, social smile
- 6m: sit without support, roll, palmar grasp, transfer hand-hand, babbles
- 9m: cruising, pincer grip, responds to name, stranger fear
- 12m: walks unaided, bricks x2, 3 words, waves “bye bye”
- 18m: runs + jumps, drawing, bricks x4, 1-6 words
- 2y: Throws ball, stairs 2 feet, bricks x8, 2 words together, eats with spoon
- 2.5y: kicks ball, draws horizontal line
- 3y: stairs 1 foot, draw circle, fork and spoon, shares toys
- 4y: draws shapes, complex instructions, bladder contol, dressing, eats skillfully
Paeds development limit ages
- Motor
- Head control- 4m
- Walking - 18m
- Fine motor + vision:
- Fix + follow- 3m
- Transfers- 9m
- Pincer grip - 12m
- Speech and language:
- Babble - 7m
- 6 words + meaning - 2y
- Social and emotional:
- Smile- 8w
- Feeds self - 18m
- Symbolic play- 2-2.5y
What is cerebral palsy and what causes it?
- = Chronic disorder of movement and/ or posture
- Cause= static injury of developing brain
- 80% antenatal. Vascular occlusion, cortical migration, structural maldevelopment
- Genetic
- Congenital infection
- 10% hypoxic ischaemic injury
- Post-natal - meningitis, encephalitis, head trauma
Presentation of cerebral palsy
- Presentation:
- ?Hx prematurity/ hypoxic-ischeamic injury
- Presentation <2y –> persists
- Delayed milestones
- Abnormal limb/ trunk posture
- Feeding difficulties - incoordination, gagging, vomiting
- Asymmetrical hand function <12m
- Primitive reflexes persist
- Abnormal gait
Clinical forms of cerebral palsy
- Spastic (90%): UMN. Increased tone + brisk reflexes. Spasticity. Paralysis. Dysphagia/ dribbling. Tip toe walking
- Choreoathetosis/ dyskinetic- invol, uncontrolled, stereotyped movements. Chorea (sudden)/ dystonia (twisting)/ athetosis (writhing). ++ tone awake, not asleep.
- Ataxic: Genetic. Reduced tone, poor balance. Dealyed motor development.
Ix and Tx of cerebral palsy
- Ix: MRI scan - pyramidal tracks
- Tx: MDT. Cons- physio. Movement and posture exercises, wheelchair, OT + aids, education
What is Down’s syndrome and how does it present?
- Trisomy 21
- RF: FHx, maternal age
- Presentation:
- Facial appearance - round face, flat nasal bridge, epicanthic folds, brushfield spots on iris, small mouth, protruding tongue, small ears + low folded, flat occiput
- Small stature, short neck
- Single palmar crease
- Delayed motor milestones
- Learning difficulties
- Hearing impairment
- Visual impairment - cataract, swuint, myopia
- Reduced tone
- Hyperflexibility
- At higher risk of: leukaemia, solid tumour, hypothyroid, coeliac, congenital heart defects (40%), epilepsy, dementia, duodenal atresia/hirschprung’s,
Ix and Tx of Down’s
- Ix:
- Antenatal - beta-hCG, PAPA + nuchal translucency –> amniocentesis >15w
- Suspect at birth - bloods + FISH
- Newborn screening in Down’s - cardiac, feeding, vision, hearing, thyroid, haematological abnormalities
- Tx: MDT. Aim to reduce complications
- Cons- parental support
- Annual r/v - feeding, bowel, bladder, behavioural disturbance, vision, hearing, resp, cardio
Presentation of adenoidal enlargement in kids
- Adenoids enlarge until 8y. Airway narrowing 2-8y
- Presentation:
- Difficulty breathing/ noisy
- Nasal voice
- Snoring
- Apnoeas
- Inc. otitis media
Intestinal obstruction in kids - presentation, causes, Ix and Tx
- Causes:
- Small bowel - duodenal atresia/ stenosis, volvulus, meconium plug, Meckel’s diverticulum
- Large bowel - ileal atresia, intussesception, Hirschsprung’s, meconium ileus, rectal atresia
- Presentation:
- Colicky abdo pain
- Bilious vomit
- Abdominal distention
- Absence of meconium
- Resonant bowel sounds
- Ix: USS, AXR
- Tx:
- Cons - NG tube, IVT , air enema
- Med - analgesia
- Surg
- Complications - dehydration, perforation, peritonitis
Constipation in children - causes, presentation, Ix and Tx
- Normal fequency:
- 1st week: 4/d
- 1st year: 2/d
- >4y = Normal
- Causes:
- Babies - Hirschprung’s, anorectal deformity, hypothyroid, hypercalcaemia
- Dehydration
- Immobility
- Toilet training/ stress
- Sx- abdo pain, infants sit in way to hold poo
- Ix- detailed dietary Hx, bloods
- Tx:
- Diet - increased fluid + fibre
- Behaviour training
- Warm water/ vaseline
- Abdo massage
- Med - laxatives
Key features of non-organic abdo pain in children
- Chemicals from brain/ gut –> hypersensitivity
- Presentation:
- Older children
- Umbilical pain
- Acute/ insidious, constant/ fluctuating
- +/- dyspepsia, N+V, early satiety
- Psychogenic Sx es anxiety + depression
- Dx of exclusion
- Tx: reassurance, lifestyle, antispasmodics, TCAs
Common organisms of gastroenteritis in children
- Rotavirus - most common. Immunization.
- Bacterial more common <2y. Include: Salmonella, campylobacter, shigella, E. coli, C. diff, cholera
- Transmission: faecal-oral. Water, meat, eggs, prev. cooked rice etc.
- Bacterial - ++ unwell, blood,
- Ix- stool sample, bloods, culture
- Tx- Usually supportive- IVT. ABx if ?sepsis
How does IBD present in children?
- As per adults. 1/4 present children/ adolescents.
- Faltering growth, pubertal delay
- UC- 90% pancolitis in children
- Systemic features - eyes, skin, arthritis, weight loss
GORD in children - presentation, Ix, Tx
- Common in infancy. Usually resolves by 12m.
- Cause- inappropriate relaxation of LOS as a result of functional immaturity.
- Contributing factors - overfeeding, mainly fluid diet, horizontal posture
- Presentation:
- Frequent, non-forceful regurg of milk/ gastric contents
- Put on weight. Otherwise well.
- Ix:
- Usually clinical
- 24h oesophageal pH monitoring
- Endoscopy + oesophageal biopsy
- Tx:
- Parental reassurance. Feed at 30 degrees
- ?Thickening agents
- Serious –> ranitadine (surg)
Pyloric stenosis - presentation, Ix, Tx
- = Hypertrophy of pyloric muscle –> gastric outlet obstruction. M:F 4:1
- Presentation:
- Projective vomiting
- Visible peristalsis
- Olive shaped mass RUQ
- Hunger after feeding
- Weight loss
- Dehydration
- Hypokalaemia, hyponatraemia, alkalosis, low chloride
- Ix: Test feed +/- USS
- Tx:
- IVT - fluid + electrolyte correction
- Surg - pyelomyotomy. Post-op feed 6h –> discharge 2h later.
Key features of overfeeding in infants
- Reccommended feding vol = 150mL/kg/24h
- Presentation:
- Weight gain
- >8 heavily wet nappies/ d
- Frequent sloppy, foul smelling bowel motions
- Extreme flatulance and belching
- Milk regurg
- Irritability + sleep disturbance
- Tx: education
Key features of food intolerance/ allergy in children
- Intolerance= hypersensitivity, allergy= IgE mediated
- Infants - milk/ egg (often resolve by 2y), peanut
- Children- peanut, tree nut, fish, shellfish. Persist.
- Presentation:
- IgE mediated- FTT, urticaria, swelling, anaphylaxis
- Non-IgE mediated - few hours later. D+V, FTT, abdo pain, eczema, colic
- Ix:
- Skin prick test - RAST for IgE
- 6-12m Sx free –> controlled food challenge
- Tx:
- Cons- avoid food, educate on acute Tx
- Med- antihistamines, anaphylaxis Tx
Key features of lactose intolerance
- Commonly post-viral gastroenteritis eg rotavirus
- Rarely primary congenital lactase deficiency. Severe.
- Usually transient - 4-6w
- Older children - lactase levels decline –> intolerance of varying severity
- Presentation:
- Diarrhoea
- Flatus
- Colic
- Peri-anal excoriation
- Stool pH <5
- Tx: lactose-free formula milk. X soya milk <6m
Key features of abdominal migraine
- Presentation: 4% paeds migraines!
- Nausea +/- vomiting
- Abdo pain
- Pallor
- Headaches
- Anorexia
- Strong FHx of migraines
- Tx:
- Dietary - avoid citrus, choco, caffeine, solid cheese
- Drugs - pizotifen, sumitriptan, gabapentin, amitriptylline
Key features of cow’s milk protein allergy
- = commonest allergy in infancy. Usually present 3m
- Presentation: (depends where inflamm)
- Upper GI - Vomiting, feeding aversion, pain, regurg
- Small intestine - Diarrhoea, abdo pain, FTT
- Large intestine- acute colitis w/ blood + mucus
- Other - wheeze, chronic cough, urticaria, atopic eczema
- May occur in breast-fed infant when mum drinking milk
- Ix: Skin prick, IgE
- Tx:
- Limit cow’s milk (+goats, soy) intake. Mum- no cow’s milk
- ?Elemental formula
- After weaning, intro cow’s milk protein free diet. ?Challenge after 6-12m
- Majority resolve by 5y.
Intussusception- definition, presentation
- = Telescoping of proximal bowel into distal segment. Esp ileocaecal valve.
- Presentation:
- <2y. Peak 6-18m
- Pallor
- Draw knees up
- Palpable sausage shaped mass
- Red current jelly stools
- Vomit
- Intermittent colicky pain- 2-3mins –> pale and floppy between.
Ix and Tx of intussusception + complications
- Ix: USS - target sign
- Tx:
- ABCDE + Resus - IVT
- Cons - NG, air enema
- Med - ABx, analgesia
- Surg - reduction
- Complications:
- Dehydration
- Venous obstruction
- Small bowel obstrution –> perforation
- Peritonitis + gut perforation
- Shock
Hepatitis in children - causes, presentation, Ix, Tx
- Presentation:
- N+V
- Jaundice
- Malaise, anorexia
- RUQ pain
- Ascites
- Varices
- Hepatosplenomegaly
- Fulminant - Jaundice,
- Causes:
- Viral - hep A/B/C/D/E, EBV, HIV, CMV
- Poisons - paracetamol
- Wilson’s
- AI hepatitis
- Reye’s syndrome - aspirin
- Neonatal liver disease
- CF
- Ix: LFTs, glucose, viral serolosy, paracetmol level, Ix for AI/ hereditary liver disease
- Tx: supportive, IVT, manage sugar, haemorrhage, cerebral oedema
Febrile convulsions - Presentation, Ix, Tx
- Presentation:
- 6m-6y, ?FHx
- Temp >39 eg viral illness
- Generalised tonic-clonic seizures
- No focal signs
- Brief <15m. Quick recovery - should no longer be drowsy by 1h.
- Complex - Focal, >15mins, >1 ep in a day
- Ix: Infection screen - cultures, urine dip, LP. EXCLUDE MENINGITIS
- Tx: Self limiting
- Cons - educate: strip off, safe area
- Med- antipyretics
- >5 mins –> 999
- >10mins= status epilepticus
- Risk of recurrence= 1/3. 2% –> epilepsy
Presentation of brain tumours in children
- Headache - worse lying down/ in morning
- Confusion
- Morning N+V
- Fits/ seizures
- Recent change in personality/behaviour/ performance
- Weight loss/ FTT
- CN abnormality
- Torticolis
- Incoordination, loss of balance
- Gait change
- Eye changes
- Back pain
Ix and Tx of brain tumours in children
- Ix:
- Bedside - Obs, fundoscopy (?papilloedema), BMI, full neuro exam, head circumference, pubertal status
- Bloods - ?infection
- Imaging - MRI
- Special - LP, biopsy
- Tx: Refer! Same day if high risk
- Support of carers + of education
- Palliation
- Chemo/ radio/ surgery
Key features of neonatal epilepsy
- Presentation - lip smacking may be sign of seizure
- Ix-
- Bloods - FBC, CRP, glucose, electrolytes
- LP
- Tx:
- Phenobarbital
- Pyridoaxal phosphate
- Clonazepam
Key features of West Syndrome
- Triad of:
- Infantile spasms - short tonic contractions of trunk with upward elevation of arms
- Developmental delay/ regression
- EEG - hypsarrhythmia
Head injury in children - presentation, causes, Tx
- Haemorrhage in kids:
- Epidural - direct trauma
- Subdural - direct trauma/ shaking
- Presentation:
- ++ Vomiting
- ++ Crying
- ++ Headache
- Bulging fontanalles
- Seizures
- Reduced GCS
- ?Basal skull #
- Neck stiffness
- Neuro eg gait change
- Red flags for NAI: <1y, skull haemorrhage, injury around eye
Ix and Tx of head injury in children
- Ix- bloods, CT head
- Tx:
- ABCDE
- Mild - home, written advice
- Severe - Resus, CT scan, neuro referral
- Med- analgesia, steroids, diuretics, anticonvulsants
- ?Surg
Treatment of migraines in children
- Dx after at least 5 attacks lasting 1-48h
- Features:
- Unilat or bilat in children, pulsatile, mod-severe, aggravated by routine activity.
- During attack - N+V, photo/phonophobia
- Cons - avoid triggers, hydration, reg meals/sleep
- 1st line - Paracetamol, domperidone (tx headache and nausea)
- Prophylaxis - if frequent enough to affect school. 1st line = pizotofen –> propranalol –> amitryptilline. Sumatriptan if >12y
Meningitis organisms in children
- Organisms:
- Neonates - GBS, E. Coli, listeria monocytogenes
- Infants - Hib
- Older children - N. Meningitidis, S. Pneumoniae, Hib
- Ix- CT head, LP
- Tx- IM dexamethasone –> IV cefotaxime + Ben Pen
Idiopathic Thrombocytopoenia- what is it? Presentation, Ix, Tx
- ITP = AI - type 2 hypersensitivity. Ab to surface platelet antigens secondary to viral infection –> ++ bleeding
- Presentation:
- Petechiae/purpura
- Bruising
- Non-blanching rash
- Bleeding - nose, gums, haematuria, rectum
- Rare - intracranial bleed
- Ix:
- FBC (isolated thrombocytopoenia - platelets <150)
- Blood film to exclude DDx
- DDx- leukaemia, sepsis, haemophila, NAI, aplastic anaemia
- Tx: Based on Sx
- No bleeding - supportive. Education on red flags
- Mild bleeding - tranexamic acid
- Specialist - steroids, IV immunoglobulins, splenectomy last resort
Henoch Schonlein Purpura - what is it? presentation, Ix, Tx
- = Vasculitis. IgA deposited in BVs. Triggers- URTI (90%)
- Classically in pre-pubertal boys
- Presentation: (Triad= Arthralgia, palpable purpura, abdo pain)
- Abdo pain - diffuse, colicky
- Joint pain/ swelling - esp lower limbs
- Palpable painless purpura on buttocks/ backs of legs. Gravity driven.
- Bloody diarrhoea
- Renal - microscopic haematuria +/- proteinuria
- Ix:
- Bedside- urine dip
- Bloods- FBC, U+Es
- Biopsy - crescentic IgA GN
- Tx:
- Cons- supportive, self-resolving
- Med- NSAIDs for joint pain
- Monitor protein + BP
NAI red flags
- Trigger usually inconsolable crying baby :(
- Bruising - immobile babies, buttocks, cheeks, upper arms, ears, abdo, feet, hands, neck, forearm
- Scalding/ burns - Post. location, well demarcated lines, sparing of creases, absence of splash marks, glove and stocking appearance
- Bites
- Fractures - metaphyseal fracture, rib, femoral
- Shaken baby - apnoea, retinal haemorrhage, seizure, irritability, lethargy, poor feeding, vomiting, subdural haematoma
- Oral injuries
- DON’T ALLOW TO GO HOME
Key features of measles
- = RNA Paramyxovirus
- Presentation:
- Rash- macularpapular, palmar sparing. Starts behind ears –> spreads
- Prodrome- 4-5d cold like Sx, cough, fever, conjunctivitis
- Koplik spots
- Ix: IgM, IgG
- Tx:
- Notifiable disease
- Supportive, isolation, prevent secondary infection
- Prevention - MMR
- Complications - otitis media, deafness, pneumonia, encephalitis
Key features of mumps
- = Paramyxovirus. Infective 7d before and 9d after parotid swelling
- Presentation:
- Parotid swelling
- Fever, headache, malaise, myalgia, anorexia
- +/- Erythematous rash on extensor surfaces
- Tx: Supportive. MMR vaccine = prevention
- Complications - liver involvement, encephalopathy, infertility
Key features of Rubella (German Measles)
= German measles. Incubation 2-3w
- Presentation:
- Arthralgia
- Maculopapular rash - pink macules
- Swollen tender LNs
- Fever
- Tx: Supportive. Prevention with MMR. Notifiable.
- Complications- artheritis, in utero malformations
Key features of Erythema Infectiosum (Fifth Disease)
- = Parvovirus B19
- Presentation:
- Usually quite well
- Slapped cheeks - firm, red, hot
- Lace pattern rash on limbs + trunk
- Slight fever
- Ix- IgM +ve
- Tx- supportive
- Complications with pregnant contacts - hydrops foetalis, death
Key features of chicken pox
- = VZV. Highly contagious between school children. Spreads through air/ skin.
- Presentation:
- Vesicular rash. Chest –> spreads
- Fever
- Malaise
- Headache
- Tx: Usually supportive. Aciclovir in severe. Prevention= vaccine.
- Shingles = reactivation of VZV –> dermatomal distribution.
Key features of Roseola
- = HHV-6/7
- Presentation:
- High fevers
- Coryza
- Irritability
- Rash - appears as recovery. Papular, red/pink, blanching. Starts trunk. Surrounding halo.
- Tx- supportive
- Complications - liver, encephalopathy
Key features of scarlet fever
- = Strep pyogenes. 2-4d incubation
- Presentation:
- Fever
- Rash - Perioral sparing. Palpable (sandpaper) on trunk and limbs
- Sore throat, irritability
- Strawberry tongue
- Tx: 10d penicillin V PO (alt azithromycin)
Key features of hand, foot and mouth disease
= Viral - coxsackie, enterovirus 71
- Presentation:
- Ulcers - mouth and tongue
- Sore throat
- Anorexia
- Temp >38
- Red spots - blisters on hands and feet. Vesicular rash
- Tx: self resolving - 7-10d. Fluids, paracetamol.
Key features of transient synovitis
- ‘Irritable hip’
- 2-12y. Offen + viral infection
- Presentation:
- Sudden onset pain in hip w/ limp. Non-weight bearing.
- No rest pain
- Reduced ROM
- Pain may be referred to knee
- Afebrile, doesn’t appear ill
- Ix: NEWS, bloods, joint aspiration if ?septic arthritis. Normal WCC, ESR, X-ray. USS - ?fluid in joint
- Tx: bed rest - improves in a few days
Key features of Perthes Disease
- ‘Painless limp’
- = Transient avascular necrosis of femoral head due to interruption of blood supply –> revascularisation + reosification over 18-36m.
- Male > Female. 5-10y.
- Presentation:
- Insidious
- Limp
- Hip/ knee pain
- Bilateral 10-20%
- Antalgic gait
- Proximal thigh atropy
- Effusion
- Groing/ thigh tenderness
- Reduced ROM
- Trendelenburg
- Ix:
- X-ray both hips + frog views. Increased density in femoral head, fragmented and irregular
- Bone scan
- MRI
- Tx:
- NSAIDs, walking aids, physio
- Early + <1/2 femoral head affected - bed rest and traction
- Late/ severe - maintain in abduction with cast - acetabulum acts as mould for re-ossification
- Higher risk of arthritis later in life.
Key features of SUFE
- = Slipped upper femoral epiphysis. Displacement of epiphysis of femoral head postero-inferiorly.
- 10-15y. Esp obese adolescent boys. Associated with hypothyroidism/ hypogonadism.
- Presentation:
- Limp
- Hip/ knee pain
- Acute or insidious
- O/E reduction in adduction + internal rotation.
- Ix: X-ray inc frog and lat views
- Tx: ASAP to prevent avascular necrosis. Surgical fixation.
What is Juvenile Idiopathic Arthritis? + Types and presenatation
- = Persistent joint swelling >6w presenting <16y in absence of infection or other cause.
- Types:
- Polyarthritis - >4 joints
- Oligoarthritis - upto 4 joints
- Systemic - + fever/ rash
- Presentation:
- Gelling - stiffness after long periods of rest
- Morning stiffness and pain
- Joint swelling
- Inflammation
- Long erm –> bone expansion and valgus deformity
Management and complications of JIA
- Management: Specialist paeds rheum team
- Cons - continue sport at school unless flare
- Med -
- NSAIDs
- Joint injections
- Methotrexate - minimise joint damage. Weekly dose.
- Avoid systemic corticosteroids
- Biologics and immunotherapies
- 1/3 ongoing active disease into adult years.
Key features of UTI in children
- Presentation <3m:
- Fever
- Vomiting
- Lethargy, irritable
- Poor feeding, FTT
- Abdo pain
- Offensive urine/ haematuria
- >3m:
- Fever
- Frequency, dysuria, incontinence
- Abdo pain, loin tenderness
- Vomiting, diarrhoea
- Poor feeding, lethargy, irritable
- Recurrent –> underlying cause eg VUR?
- Ix:
- Bedside- urine dip + culture
- Imaging
- Abdo USS if <6m or atypical UTI
- DMSA isotope scan - renal morphology, structure and function. ?scarring
- MCUG - ?reflux
- USS and DMSA on any child with proven UTI <8y!!!
- Tx: (NB to avoid long term damage).
- Mild - nitrofuranroin
- Severe - IV cefuroxime/ gentamicin
- VUR - prophylactic ABx
Key features of daytime enuresis in kids
- Lack of bladder control >3y. Should be dry by day at 2y.
- Causes: neuropathic bladder, detrusor muscle instability, bladder neck weakness, UTI, constipation, ectopic ureter
- Ix:
- Bedside - Urine dip + culture
- Imaging - USS - incomplete emptying, X-ray spine, ?MRI
- Special - ?urodynamics
- Tx:
- Cons - star charts, bladder training, pelvic floor exercises, portable alarm activated by urine
- Med- oxybutinin
Key features of nocturnal enuresis
- Should be dry by night at 3y
- M:F 2:1
- Cause= genetically determined delay in sphincter competence. Most pyschologically and physiologically normal.
- Organic causes: UTI, constipation, DM
- Ix: Urine sample
- Management:
- Cons - explanation, star chart, supportive parents, no punishment
- –> enuresis alarm
- Med - desmopressin
Key features of HUS
- = Haemolytic Uraemic Syndrome. 2 Types:
- Atypical - no diarrhoea
- Epidemic - E. coli 0157 –> toxins cause gastroenteritis and bloody diarrhoea
- Presentation:
- Prodrome - gastroenteritis w/ bloody diarrhoea
- Triad:
- Thrombocytopoenia
- Microangiopathic haemolytic anaemia
- Acute renal failure
- Pancreas - glucose intolerance, pancreatitis, jaundice
- Ix:
- Bedside - stool + urine C+S
- Bloods - culture, FBC, film, U+Es, LFTs, E. Coli PCR
- Tx: Early liason with paeds renal team
- Mainly supportive. Monitor and Tx electrolytes, fluid balance, nutrition, HTN
- No ABx
- ?Transfusion ?dialysis
Key features of neonatal ‘small for dates’ + risk after birth
- = Birthweight <10th centile for gestational age. Usually small but normal. +/- Preterm +/- IUGR
- Low birthweight = <2.5kg
- At birth liable to:
- Hypothermia
- Hypoglycaemia - poor fat/ glycogen stores
- Hypocalcaemia
- Polycythaemia
Neonatal intestinal obstruction - main causes
- Proximal - duodenal atresia, duodenal web, annular pancreas
- Distal - Ileal atresia, intussusception, Hirschsprung’s, meonium ileus (CF), meconium plug syndrome, anorectal malformation
- Both - volvulus, pseudoobstruction, SOL (hernia, cyst, tumours)
Neonatal intestinal obstruction- presentation, Ix, Tx, complications
- Presentation:
- Vomiting - green
- Constipation
- Abdo pain/ tenderness
- Reduced appetite
- No wind/ stool
- Lethargy
- Distention
- Jaundice
- Dehydration/ sunken fontanalles
- Ix:
- NEWS
- Bloods
- USS, AXR/ CT
- Tx:
- Cons - NG tube, air enema
- Med - Analgesia
- Surg
- Complications:
- Dehydration and electrolyte imbalance
- Infection/ peritonitis –> necrotising enterocolitis
Key features of Hirschsprung’s Disease
- = Failure of ganglion cells to migrate to hindgut –> lack of peristalsis. Congenital.
- Sx- no meconium passage, resistant constipation, green bile vomit/ obstruction
- Ix- AXR, rectal biopsy (no ganglion cells)
- Tx- Bowel washout, pull through operation.
Key features of Meckel’s diverticulum
- = Persistence of embyronic vitelline duct –> GI bleeding, obstruction, imflammation, umbilical discharge
- Tx: laparotomy, resection
Key features of intestinal atresia
- = Complete blockage of bowel. Rare in colon.
- Presentation:
- Well at birth
- –> no passage of meconium
- –> Intestinal obstruction
- Ix:
- Antenatal USS
- AXR
- Laparoscopy
- Tx:
- NG tube
- Surgical
Key features of neonatal hypoglycaemia
- Esp in 1st hour of life!
- RF: IUGR/ macrosomia, DM in mum, hypothermia, polycythaemia, ill
- Presentation:
- Jittery/ irritable
- Apnoea
- Lethargy/ drowsy
- Seizures
- Neonates tolerate well - utilise lactate and ketones
- Tx:
- Reg BMs
- IV dextrose
- Prevention= early feed.
Neonatal respiratory distress syndrome - RF, presentation, DDx
- Affects 1/2 babies 28-32w
- Pneumocytes usually produce surfactant form 30w –> more compliancy and don’t collapse. Premature babies have insufficient surfactant.
- RF:
- Premature
- DM in mum
- C-section
- FHx
- Lack of antenatal steroids
- Peri-partum hypoxia
- Presentation: 4-6h
- Apnoeas + hypoxia
- Fatigue
- Signs of respiratory distress
- DDx: Transient tachypnoea of newborn (c-section, usually term), infection, MAS, pneumothorax, congenital heart disease.
Ix and Tx + prevention of neonatal respiratory distress syndrome
- Ix:
- Bedside - O2 + obs
- Bloods - ABG, U+Es, glucose, LFTs, culture
- Imaging - CXR= ground glass appearance, bell shaped thorax, reduced lung vol, air bronchograms. RDS ruled out if normal CXR at 6 hours
- ECHO if ?heart disease
- Tx:
- Resus and stabilise + o2 (91-95%)
- Surfactant replacement
- Supportive - monitor bloods, obs, min handling, temps regulation, NG feed
- NIV
- Prevention - Mums given steroids if delivering <34w gestation. ABx if PPROM or GBS
Complications of neonatal respiratory distress syndrome
- Acute:
- Alveolar rupture
- Pulm haemorrhage
- Procedure associated
- Patent ductus arteriosis
- Persistent pulm. HTN
- Chronic:
- Bronchopulmonary dysplasia = chronic lung disease. >28d.
- Retinopathy of prematurity (sats too high)
- Neurological sequelae
- Developmental delay
- More prone to bronchiolitis
Key features of transient tachypnoea of the newborn
- = Lung fluid fails to resorb.
- Term babies, esp after c-section
- Presentation:
- Tachypnoea
- Recessions
- Nasal flaring
- Grunting
- +/- cyanosis
- Ix:
- CXR - fluid on horizontal fissure
- Tx: Supportive. Resolves 24h.
Key features of meconium aspiration syndrome
- 5% term babies with meconium stained liquor –> MAS
- Hypoxia –> peristalsis –> reflex gasping –> meconium aspiration –> inhibits surfactant + pneumonitis
- RF: Foetal distress, post-term, maternal drug abuse
- Presentation:
- Meconium stained liquor
- Low Apgar score
- Resp distress- tachypnoea, cyanosis
- Ix:
- ECG - ?pulm hypertension
- Bloods - ABG (resp acidosis), U+Es, FBC, CRP, culture
- Imaging - CXR (patchy infiltrate, hyperinflation), lung USS
- Tx:
- Supportive - o2, airway suction, ventillatory support
- Med- surfactant replacement, broad spec ABx, +/- steroids and antisurfactants
- Usually subsides 2-4d. Increased risk of asthma.
Key features of hypoxic ischeamic encephalopathy
- = Brain injury due to perinatal asphyxia
- Causes:
- Maternal HTN
- Foetal compromise - IUGR, anaemia
- Placental failure - abruption
- Umbilical failure - cord prolapse, cord compression
- Failure to breath at birth
- Presentation:
- Mild - irritability, hypoventilation, hypertonia, poor feeding
- Mod - abnormal movement, hypotonia, seizures
- Severe - no spontaneous movements/ pain response, fluctuating tone, prolonged seizures, multiorgan failure
- Tx:
- Resus + stabilise
- Mild hypothermia - cooling therapy to reverse hypoxia
- Prog - mild recover completely, mod recovery by 2w or long term issues, severe- mortality 30-40%, 80% neurodevelopmental disability
Key features of neonatal sepsis
Early onset infection (<48h)
- Bacteria from birth canal - GBS, listeria monocytogenes
- RF: PPROM, chorioamnionitis
- Presentation- resp distress, apnoea, temp instability
- Ix - CXR, septic screen
- Tx- IV ABx: BenPen, amox + gent. At least 48h.
Late Onset (>48h)
- Esp in NICU - catheters, tracheal tube, invasive procedures. Most common organism = staphylococcus epidermidies
- Presentation- Fever, resp distress, jaundice, seizures, neutropoenia, irritability, high or low glucose, shock, abdo distention, temp instability, vomiting, bulging fonanalles
- Tx: Fluclox + gent –> vancomycin?
Newborn jaundice - why and what causes it?
- Haemolysis of FBC in first few days of life + hepatic bilirubin metabolism less efficient
- <24h causes:
- Haemolysis= unconjugated
- Rh/ ABO incompatibility –> haemolytic disease of the newborn
- G6PD deficiency - Esp Mediterranean, Middle East, Far East, S American
- Congenital infection
- 24h-2w causes:
- Physiological
- Breast-milk jaundice - more prolonged. Enterohepatic bilirubin
- Infection - less fluids, haemolysis
- Dehydration
- Haemolysis
- Bruising eg ventouse
- Polycythaemia - more RBCs being broken down
- Crigler-Najjar syndrome - inborn error of metabolism
- >2 weeks causes (prolonged):
- Physiological/ breast milk
- Infection
- Hypothryoid - heel prick test
- Haemolytic anaemia
- High GI obstruction
- Bile duct obstruction
- Neonatal hepatitis
Causes of congenital infection = TORCH
- Toxoplasmosis
- Other - HIV, syphilis, measles
- Rubella
- CMV
- HSV
Ix and Tx of neonatal jaundice
- Ix:
- Bilirubin - heel prick
- Bilirubinometer - check severity
- Coomb’s test - RBC clump?
- TORCH screening
- FBC - infection, RBCs
- Tx:
- Hydration
- 1st line - phototherapy. Break down bili.
- Exchange transfusion
- Tx underlying cause
What is Kernicterus?
- = Complication of neonatal jaundice. Bilirubin neuro toxicity. Unconjugated bilirubin > albumin binding capacity –> crosses BBB
- Presentation:
- Early - Lethargy, poor feeding
- Late - Irritability, increased muscle tone
Key features of haemorrhagic disease of the newborn
- AKA Vit K deficient bleeding. Vit K doesn’t pass freely from Mum to baby and less Vit K in mum’s milk after colostrum.
- Babies at risk: <37w, forceps/ventouse/c-section, hypoxia at birth, maternal co-morbidity + meds in pregnancy (lower Vit K)
- Presentation:
- Bleeding eg heel prick test, umbilical cord
- Bruising
- Haematuria
- Bleeding after procedures
- Ix: Exam, obs, coags, clotting factors, PIVKA (non-carboxylated clotting factors)
- Tx:
- IVT
- Vit K 1-2mg parenteral
- FFP (10-20ml/kg) in life threatening
- Bloods transfusion - ifi shock
- Prevention - single dose IM vit K at birth (1mg IV Vit K for those at risk). PO version - birth, 2, 4 weeks.
What’s involved in Heel Prick / Blood Spot test at 5d?
- Sickle Cell
- CF
- Congenital hypothyroidism
- Inherited metabolic diseases:
- Phenyketonuria
- Maple syrup urine disease
- Isovaleric acidaemia
- Gluteric aciduria type 1
- MCADD
- HCU
Key features of developmental dysplasia of hip
- ‘Clicky hip’ on newborn exam
- RF: F>M, breech, FHx, 1st child, oligohydramnios, birth weight >5kg
- O/E - Barlow and ortaloni test
- Ix- USS
- Tx- Most spont 3-6w, harness, surgery
Key features of laryngomalacia
- = Floppy epiglottis
- Noisy breathing –> worse on eating. Stridor
- Tx- usually self limiting. Surgery if signs of resp distress/ FTT