Paediatrics Flashcards
causes of meningitis in children neonates to 3 months?
GBS
E. coli
listeria monocytogenes
causes of meningitis in children aged 1 month to 6 years?
Neisseria meningitis (meningococcus) strep pneumoniae (pneumococcus) H.influenzae
causes of meningitis in children aged >6 months?
neisseria meningitis
strep penumoniae
what is the sepsis 6 for children?
O2 IV access and bloods- lactate, CRP, BG, ABG IV or IO antibiotics fluid resuscitation get senior help inotropes e.g. DA
what is meningococcal septicaemia?
gram negative diplococci
abx for meningococcal septicaemia in child <3 months and child >3 months?
<3 months- cefotaxime and amoxicillin to cover for listeria
>3 months- cefotaxime
what also needs to be given if h. influenzae is the cause of meningococcal septicaemia?
dexamethasone
prophylaxis of meningitis?
PHE notification
ciprofloxacin
rifampicin
what does rifampicin contraindicate with?
jaundice, liver failure, abnormal LFTs, alcoholism, polyphyria, diabetes, interacts with COCP
what should be given in the community of any febrile child with a purpuric rash?
IM benzylpenicillin and taken to hospital
what is scarlet fever?
Group A haemolytic streptococci
children aged 2-6 years
spread via respiratory route
features of scarlet fever?
fever (24-48 hours) malaise, headache, N&V sore throat strawberry tongue rash- fine punctate erythema which generally appears on torso and spares the palms and soles spares around the mouth
diagnosis of scarlet fever?
throat swab
tx of scarlet fever?
start Abx before results- oral penicillin V for 10 days
children can return to school 24 hours after commencing Abx
NOTIFIABLE DISEASE
4 main differentials of an unwell neonate?
sepsis
congenital heart disease
NAI/ trauma
metabolic
what is impetigo?
localised highly contagious staph or strep skin infection
features of impetigo?
vesicular/pustular or bullous lesions on hands, face and neck
rupture causes fluid leak which causes honey-coloured crusted lesions
tx of impetigo?
mild- topical abx e.g. mupirocin
severe- flucloxacillin
childhood viral infections?
HSV chicken pox EBV Roseola Slapped cheek syndrome hand, foot and mouth disease Kawasaki MMR
severe symptoms of HSV?
eye disease (blepharitis or conjunctivitis) CNS infections (aseptic meningitis and encephalitis) gingivostomatitis
rash progression in chicken pox?
macular -> papules -> vesicles -> pustular -> crusts
complications of chicken pox?
- Secondary bacterial infection- group A strep-> can lead to toxic shock syndrome and necrotising fasciitits
- encephalitis- ataxia with cerebellar signs
- purpura fulminans
- pneumonia
- disseminated haemorrhagic chicken pox
how long is school exclusion in chicken pox?
until lesions are dry and have crusted over (normally 5 days after rash starts)
tx of chocken pos?
calamine lotion
oral acyclovir
VZIG if immunocompromised or newborn
what is roseola infection?
HHV 6 (6th disease)
high fever followed by maculopapular rash, diarrhoea, cough
febrile convulsions in 10-15%
what causes slapped cheek syndrome?
parvovirus B19 -> infects erythroblastoid red cell precursors in the bone marrow
transmitted via resp secretions, vertical transmission, blood products
features of slapped cheek syndrome?
asymptomatic
erythema infectiosum- fever, malaise, headache followed by a ‘slapped cheek’ characteristic rash
aplastic crisis
foetal hydrops and death if severe anaemia
cause and treatment of hand, foot and mouth disease?
coxsackie A16 virus
admit for observation and give 48 hours parental abx e.g. ceftriaxone
what is Kawasaki disease?
systemic vasculitis, uncommon
children aged 6 months- 4 years
features of Kawasaki disease?
fever >5 days AND 4/5 of:
- not-purulent conjunctivitis
- red mucous membranes
- cervical lymphadenopathy
- rash
- red and oedematous palms and soles or peeling of fingers and toes
complication of Kawasaki disease?
coronary aneurysms (look on ECHO)
tx of Kawasaki disease?
IVIG within 10 days to reduce risk of coronary artery aneurysms
aspirin- high dose to reduce thrombosis risk then low dose for anti-platelet
4 features of measles?
Cough
Coryza
Conjunctivitis
Kolip spots- white spots on buccal mucosa
rash starts behind ears then spreads to whole body
complications of measles?
encephalitis, febrile convulsions, subacute sclerosing panencephalitis, diarrhoea, keratoconjunctivitis
features of mumps?
fever, malaise, muscular pain
parotitis: unilateral then bilateral
complications of mumps?
viral meningitis and encephalitis, orchitis
what is rubella known as?
german measles
features of rubella?
pink maculopapular rash on the face before spreading to whole body
lymphadenopathy- sub-occipital and post-auricular
congenital infection
what is in the 6-in-1 vaccine and when is it?
diphtheria tetanus whooping cough polio Hib Hep B given at 2,3 and 4 months
differentials of a child with fever and bone pain?
arthritis
leukaemia
ewing’s sarcoma
neuroblastoma
features of neuroblastoma?
abdo mass, crosses the midline spinal cord compression weight loss and malaise pallor bruising bone pain
arises from neural crest tissue in the adrenal medulla and sympathetic nervous system
what is a wilm’s tumour?
nephroblastoma
originates from embryonal renal tissue
features of wilm’s tumour?
large abdo mass pain anorexia anaemia haematuria child can be well
what is a retinoblastoma?
malignant tumour of retinal cells
it commonly presents when a red pupillary reflex is replaces with a white one, or a squint
screening if positive FH
good prognosis
red flags for a painful limb in a child?
young age high fever night waking painful scoliosis focal neurological signs weight loss systemic malaise
kocher’s criteria for septic arthritis?
fever >38.5
cannot weight bear
ESR >40 in 1st hour
WCC >12
what is transient synovitis?
irritable hip
can be associated with viral illness
features of transient synovitis?
acute limp
child often looks well, WCC normal
comfortable at rest
mx= rest and analgesia
when is developmental dysplasia of the hip diagnosed?
usually diagnosed in infancy by screening tests
Ortolani- attempts to relocate a dislocated femoral head
Barlow- assess if the hip is dislocatable
signs= unequal leg length and asymmetrical skin creases in the thigh or buttock
RFs for DDH?
Extended breech babies prematurity twins first born child female oligohydramnios birth weight >5kg
what do breech babies require to look for DDH?
breech babies at or after 36 weeks require USS at 6 weeks regardless of mode of delivery
tx of DDH?
splits and harnesses or traction
hip realignment may be needed later in life
what is perthes disease?
Avascular necrosis of the capital femoral epiphysis of the femoral head due to interruption of the blood supply followed by revascularisation and reosification over 18-36 months
RFS for perthes disease?
low birth weight
short stature
low SE status
passive smoking
Ix of perthes disease?
flattened femoral head on XR
roll test- rolling of the hip of the affected extremity invokes guarding or spasm, esp with internal rotation
tx of perthes disease?
remove pressure from joint to allow normal development
PT
usually self-limiting
epidemiology and features of slipped upper femoral arthritis?
typically seen in obese adolescent males positive FH pain is often referred to the knee bilateral in 20% limitation to internal rotation is usually seen
XR of SUFE?
femoral head is displaced and falling infero-laterally (melting ice cream cone)
tx of SUFE?
best rest and non-weight bearing
percutaneous pinning of the hip may need pinning
what is JIA?
autoimmune disease that involves a single joint or ankle in children or adolescents
examination for JIA?
abdo
MSK
lymph nodes
rash exam
features of JIA
persistent joint swelling
high fever
salmon-coloured pink rash
eye inflammation
Ix of JIA?
bloods- FBC, U&E, LFT, albumin, ESR/CRP blood cultures USS/XR ECHO CT/MRI
mx of JIA?
NSAIDS (acute)
corticosteroids for symptomatic relief and systemic disease
analgesia
methotrexate- if multiple joint involvement
sulfasalazine and leflunomide
etanercept (TNF alpha inhibitor)
Tocilizumab
complications of JIA?
chronic anterior uveitis flexion contractures of the joints growth failure OP amyloidosis anaemia of chronic disase
mx of GORD in infants?
add thickening agents to feeds e.g. Nestargel
positioning of head after feeds
H2 receptor antagonists e.g. ranitidine
PPI e.g. omeprazole
surgery if complicated- Nissen fundoplication
what is pyloric stenosis?
hypertrophy of the pyloric muscle causing gastric outlet obstruction
more common in boys aged 2-7
features of pyloric stenosis?
projectile vomiting post feeds, not bile stained
hypochloraemic hyponatraemic metabolic alkalosis
diagnosis of pyloric stenosis?
gastric peristalsis may be seen as a wave after feed
pyloric mass felt in RUQ
USS- hypertrophy of pylorus muscle
mx of pyloric stenosis?
IV fluids
pyloromyometry- division of the hypertrophied muscle
what could a redcurrant jelly stool comprising blood-stained mucus and sausage shaped mass in RUQ infer?
intussusception
child may draw up legs and become pale during episodes with severe pain
Ix of intussusception?
XR- distended small bowel and absence of gas in distal colon and rectum
abdo USS- can show a target sign and response to treatment
mx of intussusception?
reduction by air insufflation under radiological control
surgery if failure of this or signs of peritonitis
what is the main cause of massive painless GI bleed in children aged 1-2 years?
Meckel diverticulum
this is a remnant of the vitello-intestinal duct which contains ectopic gastric mucosa or pancreatic tissue
features of Meckel diverticulum?
most are asymptomatic but they may present with severe rectal bleeding, which is classically neither bright red nor true melaena
can also mimic appendicitis
mx of Meckel diverticulum?
surgical resection
what is bile stained vomit in 1st week of life until proven otherwise?
malrotation- when the mesentery is fixed at the duodenal flexure or ileocaecal region
features of malrotation?
obstruction with bilious vomiting
vascular compromise
Ix of malrotation?
upper GI contrast study- diagnostic
USS abdo
tx of malrotation?
surgical correction (ladd’s procedure)- corrects volvulusc
clinical signs of dehydration?
appears unwell dry mucous membranes lethargic decreased urine output sunken eyes tachycardia tachypnoea sunken fontanelle reduced skin turgor
main causes of GE in children?
norovirus, rotavirus, adenovirus
campylobacter jejuni
what fluid is given in a fluid bolus for children?
0.9% saline -> fluid bolus. 20mls/kg normally except 10mls/kg in a diabetic or severe trauma (due to risk of cerebral oedema)
what maintenance fluid is given in children?
0.9% saline with 5% dextrose
OR 10% dextrose in a neonate (<48 hours old)
what blood products are given to a child in shock?
FFP (clotting factors) and cryo (concentrated factors and fibrinogen)
how to calculate fluid replacement in a child?
1) estimate weight= (age +4) x 2
if <1 year- (age (months) +9) / 2
2) calculate bolus e.g. 20mls/kg
3) calculate maintenance requirements for 24 hours
1st 10kg= 100mls/kg
2nd 10kg= 50mls/kg
subsequent kg= 20mls/kg
4)calculate deficit- if dehydrated
% dehydration x weight = deficit (need)
5) fluid need = maintenance + deficit - bolus = amount per day
what should be given if a child is hypoglycaemic?
10% dextrose 2mls/kg STAT
what are maintenance fluids for a neonate?
days term preterm (mls/kg) 1 60 80 2 80 100 3 100 120 4 120 140 5 150 150
how to replace electrolytes in a child?
Na K+ energy (mmol/kg/day)
1st 10kg 2-4 1.5-2.5 110
2nd 10kg 1-2 0.5-1.5 75
sub kg 0.5-1 0.2-0.7 30
how does cow’s milk protein intolerance present?
in first 3 months of life in formula fed infants regurgitation and vomiting diarrhlea urticaria, atopic eczema 'colic' symptoms- irritability, crying wheeze, chronic cough
diagnosis of CMPI?
skin prick/patch testing
can be IgE mediated (immediate) or non- IgE mediated (delayed)
test total IgE and specific IgE (RAST) for cow’s milk protein
mx of CMPI?
refer to a paediatrician if failing to thrive
if formula fed- extensive hydrolysed formula (eHF) 1st line, amino acid-based formula (AAF) in infants with severe CMPA if no response to eHF
if breast-fed- continue breastfeeding, eliminate cow’s milk protein from maternal diet. Use eHF milk when breast-feeding stops
usually resolves by 1-2 years
what is necrotising enterocolitis?
more common in premature babies fed with cow’s milk
part of the bowel becomes necrotic, cause is unknown
features of necrotising enterocolitis?
bilious vomiting feeding intolerance abdominal distension bloody stools can progress to abdo discoloration, perforation and peritonitis
ix of necrotising enterocolitis?
abdo XR- dilated bowel loops, bowel wall oedema, pnematosis intestinalis, portal venous gas, pneumoperitoneum, Rigler sign (air inside and outside the bowel wall), football sign (air outlining the faleiform ligament)
mx of necrotising enterocolitis?
ABCDE
stop oral feeds
broad spectrum antibiotics
laparotomy if bowel perforation
causes of diarrhoea in a child?
toddler's diarrhoea coeliac disease cow's milk protein intolerance gastroenteritis overflow from constipation lactose intolerance IBD following bowel resection -> malabsorption
mx of constipation in a child?
- macrogol laxative e.g. polyethylene glycol and electrolytes- Movicol paediatric plan-2 weeks
- osmotic laxative e.g. lactulose
- stimulant laxative e.g. senna or picosulphate
- consider enema or manual evacuation under GA
what does failure to pass meconium <24 hours after birth indicate?
hirschsprung’s disease
red flags for failure to thrive/growth failure in a child?
hypothyroidism
coeliac disease
what is hirschsprung’s disease?
large bowel obstruction
the absence of parasympathetic ganglion cells
associations with hirschsprung’s disease
male
down’s syndrome
features of hirschsprung’s disease
neonatal period- failure to pas meconium
older children- constipation, abdominal distension, bile-stained vomiting
diagnosis of hirschsprung’s disease
PR- can cause a release of flatus and faeces that can relieve symptoms and diagnose
Suction rectal biopsy- absence of ganglionic cells and Ach positive nerve trunks
mx of hirschsprung’s disease
whole bowel irrigation for symptomatic relief
enemas
surgical and usually involves an initial colostomy followed by anastomosing normally inverted bowel to the anus
name an anti thelemintic used for worms?
mebendazole
when to refer a child with bronchiolitis?
a respiratory rate of over 60 breaths/minute
difficulty with breastfeeding or inadequate oral fluid intake (50–75% of usual volume, taking account of risk factors and using clinical judgement)
clinical dehydration.
