Paediatrics Flashcards
Describe the changes to fetal circulation that occur at birth
In utero blood bypasses lungs. Goes from RV to aorta via DA. Right sided pressure high because of blood from placenta. Left sided pressure lower because no blood coming from lungs. So R –> L via foramen ovale. At birth baby breathes, umbilical arteries constrict, pulmonary arteries dilate, DA closes.
Causes of congenital heart defects
Diabetes
Rubella
SLE
Lithium, anticonvulsants, fetal alcohol syndrome
Turners, Downs, Edwards, Pataus, DiGeorge, Marfarns
Which direction is the shunt in acyanotic congenital heart defects
Left to right
Which direction is the shunt in cyanotic congenital heart defects
Right to left
Are cyanotic or acyanotic congenital heart defects more common
Acyanotic
Causes of acyanotic congenital heart defects
Septal defects Patent ductus arteriosus Coarctation of the aorta Aortic stenosis Pulmonary stenosis
Causes of cyanotic congenital heart defects
Tetralogy of Fallot
Transposition of great arteries
Atresia
What is Eisenmenger reaction
When an acyanotic shunt (left to right) becomes a cyanotic shunt (right to left)
Ventricular septal defect murmur
Pansystolic at left lower sternal border
Atrial septal defect murmur
Mid-diastolic murmur at the left upper sternal border
Also get widely split S2
Murmur associated with patent ductus arteriosus
Continuous machine like murmur at the left upper sternal border
Findings associated with coarctation of the aorta
Upper limb hypertension
Weak/absent femoral pulses
Headache, chest pain, cold peripheries
Causes of paediatric heart failure
Anaemia Arrhythmia Myocarditis Cardiomyopathy Structural defects Hypertension Kawasaki disease
Signs of right sided cardiovascular congestion
Hepatomegaly Ascites Abdo pain Oedema JVP
Signs of left sided cardiovascular congestion
High resp rate
Respiratory distress
Pulmonary oedema
Features of decreased cardiac output in a child
Fatigue Pallor Sweating Cool extremities Nausea/vomiting Poor growth Dizziness Syncope
Features of heart failure in infants
High HR High RR Restless/irritable SOB Acidosis Sweating Trouble feeding
What is the hyperoxia test
Used to differentiate cause of cyanosis in infants
If cause is pulmonary then cyanosis resolves with 100% oxygen
If cause is cyanotic congenital heart defect then cyanosis will persist
Management of heart failure in children
If duct dependent give prostin and stop oxygen Diuretics ACE inhibitors High calorie diet Inotropes Surgery Drain pleural effusions
Duct dependent congenital heart disease
Hypoplastic left heart Coarctation of the aorta Severe aortic stenosis Pulmonary atresia Severe tetralogy of fallot
What are the 4 features of tetralogy of fallot
Ventricular septal defect
Over-riding aorta
Pulmonary stenosis
Right ventricular hypertrophy
Causes of myocarditis
Viral - coxsackie, parvovirus, mononucleosis
Bacterial - beta haemolytic strep A, diphtheria, TB
Fungal - candida, aspergillus
SLE
Kawasaki
Radiation/chemotherapy
Alcohol/cocaine
Clinical features of Kawasaki disease
Children <5 High fever Desquamative rash Conjunctivitis Mucositis - strawberry tongue Cervical lymphadenopathy Erythema and oedema of distal extremities !! coronary artery aneurysm
Treatment for Kawasaki disease
IV immunoglobulins
High dose Aspirin
Symptoms of acute rheumatic fever
JONES Joints Pancarditis Nodules Erythema marginatum Sydenham chorea
Causative organism of rheumatic fever
Group A beta-haemolytic streptococcus
Differential diagnosis of stridor
Croup Bacterial tracheitis Epiglottitis Laryngomalacia Inhaled foreign body Anaphylaxis
Causative organism of croup
Parainfluenza virus
Causative organism of whooping cough
Bordetella pertussis
Causative organism of bronchiolitis
Respiratory syncytial virus
3 key features of epiglottitis
Dysphagia
Drooling
Distress
Typical presentation of bacterial tracheitis
Rapid deterioration following a cold/croup
At roughly what age should laryngomalacia have resolved by
2 years
Management of chronic asthma in children
SABA Low dose ICS LABA/LTRA Increase ICS Refer
Management of acute asthma in children
Oxygen Salbutamol pMDI + spacer or Neb Steroids (continue for 3 days) Ipratropium bromide MgSO4 nebuliser IV salbutamol
Discharge criteria for children following an acute asthma episode
Stable on 3-4 hourly salbutamol
Sats >94%
PEFR >75%
Definition of anaphylaxis
Airway compromise and hypotension in the setting of an allergic reaction
Management of anaphylaxis
Oxygen Raise legs Adrenaline Antihistamines Steroids Fluids
What are the 4 different types of hypersensitivity reaction
Type 1 - immediate
Type 2 - cytotoxic (autoimmune)
Type 3 - immune complex (vaccinations and vasculitis)
Type 4 - delayed (SJS, transplant rejection)
Management of choking
Assess cough effectiveness - if effective encourage
If cough not effective then: 5 back blows followed by 5 abdo thrusts (chest if <1)
Inheritance pattern of cystic fibrosis
Autosomal recessive
Systems affected by cystic fibrosis
Respiratory Pancreas Liver Bile duct Bowel Fertility
Gold standard test for cystic fibrosis
Sweat test
Management of cystic fibrosis
Phsyio Dietary supplements Vitamins ADEK replacement Pancreatic enzyme replacement Hypertonic saline, mucolytics Bronchodilators Vaccinations
Intake requirements of a <1 month old and an >1 month old
<1 month: 150ml/kg/day
>1 month: 100ml/kg/day
At what age would you expect GORD to be getting better in infants
6-9 months
If a child has had gastroenteritis what should you advise them about going to school
Stay off school until 48hrs symptom free
Is fecal calprotectin raised or lowered in IBD
Raised
Causes of gastroenteritis
Viral - rotavirus
Bacterial - campylobacter, salmonella, e.coli
Parasites - giardia
Indications for stool microscopy
Recent travel No improvement in diarrhoea by day 7 Blood/mucus in stool Sepsis Immunocompromise
What % fluid loss counts as mild, moderate and severe dehydration
Mild 4%
Moderate 4-7%
Severe 7%
How much ORS should be given after each loose stool
5ml/kg
Fluid replacement for shock
20ml/kg 0.9% NaCl IV bolus by rapid infusion
Maintenance fluids
0.9% NaCl + 5% glucose with 10mmol KCl
100ml/kg for the first 10kg
50ml/kg for the next 10kg
20ml/kg for each kg after that
This gives total 24hrs so divide by 24 to get ml/hr rate
Calculation to work out % dehydration
(weight loss/original weight) X 100
Calculation to work out fluid deficit
(% dehydration X current weight) X 10
What is Kernigs sign
When hip is flexed can’t straighten leg
Sign of meningism
What is Brudzinski sign
Neck flexion causes hips/knees to flex too
Sign of meningism
When does the posterior fontanelle close
1-2 months old
When does the anterior fontanelle close
9-18 months old
Sepsis 6
Oxygen Antibiotics Fluids Blood cultures Lactate Urine output
Common causes of meningitis in children < 3 months old
Group B strep
E.coli
Listeria
Common causes of meningitis in children > 3 months old
Niesseria meningitides
Strep penumoniae
Viral causes of meningitis
Coxsackie Adenovirus Mumps Varicella zoster EBV
Antibiotics for bacterial meningitis/meningococcal treatment in < 3 month olds vs > 3 month olds
< 3 months: IV Cefotaxime + Amoxicillin
> 3 months: IV Ceftriaxone
Why do you give steroids within the first 12 hours of the first antibiotic dose
To reduce the chance of deafness
How does listeria look on microscopy
Gram positive rod
Differentials for seizure in children
Febrile convulsions Encephalitis/meningitis Sepsis/shock Epilepsy Metabolic disease Poisoning Trauma SOL Hydrocephalus
Definition/diagnostic criteria of epilepsy
2 unprovoked seizures >24hrs apart or dx of epilepsy syndrome or dx of high chance of recurrence
What is a reflex anoxic seizure
A seizure after insult e.g. knock on head
Features of non-epileptic attack disorder
Mainly trunk/proximal movements
Crying
Eyes shut
Age range for febrile convulsions
6 months - 5 years
Management of seizures in children
Buccal midazolam/rectal diazepam
IV Lorazepam dose 1
If not improved in 10 mins dose 2 of Lorazepam
IV Phenobarbitol/Phenytoin
If not stopped in 20 mins then IV Midazolam/Thiopental
Early hand dominance occurs before what age
12 months
Early hand dominance and persistent toe walking should make you think of which disease
Cerebral palsy
Features of autism spectrum disorder
Difficulty with communication and social interaction
Inflexible thinking
Repetitive/restricted/stereotyped behaviour
Motor stereotypies
Sensory interests
Often associated medical conditions - Down’s, epilepsy, ADHD, fragile X
Which medication is used to treat ADHD
Methylphenidate
What monitoring advice is required for Methylphenidate
BMI, HR, BP, ECG: frequency depends on if younger or older than 10
If weight loss concern then take after food, add snacks, high calorie foods, take planned break from treatment
Diagnostic criteria for ADHD
Must be present by age 12 and in two or more settings (e.g. home and school)
What are the 3 main types of cerebral palsy
Spastic
Ataxic
Dyskinetic
3 physical/developmental key features/red flags for cerebral palsy
Early hand dominance
Persistent toe walking
Outswinging of leg when running
What is the inheritance pattern of duchenne muscular dystrophy
X linked recessive
Chance of someone with DMD having an affected a) child b) son
1 in 4 chance of affected child
1 in 2 chance of affected son
Clinical features of duchenne muscular dystrophy
Calf hypertrophy with proximal muscle weakness
Gowers sign
Muscles gradually weaken over time
Why do you avoid 100% oxygen in premature babies
Risk of retinopathy of prematurity
Most common UTI pathogen in children
E.coli
What age group with suspected UTI warrants urgent admission
<3 months old
How long after discharging a child with UTI do you perform USS
Within 6 months
2 specialist urology investigations
DMSA - radionucleotide scan
MCUG - micturating cystourogram
How long after UTI do you wait before performing DMSA
4-6 months
How long after UTI do you wait before performing MCUG
A few weeks
Definition of secondary nocturnal enuresis
Nocturnal enuresis after a minimum of 6 months dry period
Developmental age needs to be > 5 years
At what age is encopresis considered a medical condition
Developmental age needs to be >4 years
What is the difference between renal hypoplasia, renal dysplasia and renal agenesis
Hypoplasia is less nephrons
Dysplasia is undifferentiated
Agenesis is absence
Features of colic
Cries >3 hours per day, 3 days a week, for at least 1 week Hard to soothe Clenched fists Goes red in the face Brings knees up and arches back Wind
When age does colic usually resolve by
6 months
General advice if baby has colic
Hold upright during feeds
Wind after feeds
Gentle rocking
Warm baths
Signs/symptoms of cows milk allergy
Typically develops when cows milk first introduced. Two main types; immediate CMA (sx within minutes), delayed CMA (sx hours or days after) Skin reactions - mouth, face, eyes Stomach ache Vomiting Colic Diarrhoea/constipation Coryzal symptoms Eczema
Management of cows milk allergy
Remove cows milk protein from mums diet if breastfeeding, or change formula if bottle fed (Aptamil Pepti, Nutramigen)
Review every 6-12 months and introduce small amount to see if they’ve developed a tolerance
Usually grow out of it by age 5
Is lactose intolerance an allergy?
No - it’s an inability to digest lactose
What food intolerance can develop after an infection (e.g. gastroenteritis)
Lactose intolerance
Features of reflux in infants
Vomits after feeds Hiccups/coughing when feeding Unsettles Crying Not gaining weight
Management options for reflux in children
Thickened formulas
PPI
Fundoplication
When does reflux usually start and get better by
Starts before 8 weeks old and usually better by 1 year
What is coeliac disease
An autoimmune reaction to gluten
What is gluten
A protein found in wheat, barley and rye
Features of coeliac disease
Diarrhoea Abdo pain Flatulance Indigestion Constipation Fatigue Malnutrition Weight loss Dermatitis herpetiformis IDA B12 anaemia Other autoimmune diseases - T1DM, thyroid
