Paediatrics Flashcards
Gross Motor Milestones
3 Months - head control 6 Months - rolls front to back, back straight when held sitting 7-8 Months - sits without support 9 Months - pulls to standing, crawls 12 Months - cruises, walks with one hand held 12-15 Months - walks unaided 18 Months - squats to pick things up 2 years - runs 3 years - rides a tricycle 4 years - hops on one leg
Gross motor milestones - when to be concerned (2 things)
Not sitting without support by 12 months
Not walking without support by 18 months.
Age at which continence usually achieved
3 to 4 years
Management of Nocturnal Eneuresis (4 things)
1) rule out other causes e.g. constipation, diabetes, UTI
2) advise on fluid intake, diet, toileting behaviour
3) give rewards for agreed behaviour i.e. toileting before bed
4) failing these measures, generally enuresis alarm for children under 7 or desmopressin for children over 7 years. (depending on family needs and preferences.)
Causes of Microcephaly
Normal Varient Familial Congenital Infection Perinatal brain injury FAS syndromes e.g. Patau craniocyntosis
Presentation of Heart failure in Infants (4)
Breathlessness worse on exertion e.g. feeding
sweating
poor feeding
recurrent chest infections
Causes of Heart Failure in Infants
< 2 weeks - duct dependant systemic circulations e.g. coarctation of the aorta
> 2 weeks - VSD as the pulmonary vasculature resistance falls
Risk assessment in febrile children -colour
Green - normal
Amber - pallor reported by care giver
Red - pale or mottled
Risk assessment in febrile children - Activity
Green - responds normally, content, easily rousable or awake, not crying or strong cry
Amber - not responding normally to social cues, no smile, takes time to wake, decreased activity
red - no response to social cues, appears ill, does not wake or does not stay awake when roused, weak, high pitched or continuous cry.
Risk assessment in febrile children - Respiratory
Amber - nasal flaring, tachyponea (>50b/m in 6-12 months or >40b/p in ae >12 months), 02 sats = 95% in air, Crackles in the chest.
red - grunting, tachyponea >60 bpm, moderate or severe chest indrawing
Risk assessment in febrile children - circulation and hydration
green - normal skin and eyes, moist mucous membranes
amber - tachycardia >160 b/m in <12 mnths, >150 b/m in 12-24 mnths, >140 b/m in 2-5yrs, cap refil >/= 3 secondsm dry mucous membranes, poor feeding, reduced urine output
red - reduced skin turgor
Risk assessment in febrile children - other
green - no amber or red signs
amber - age 3-6 mnths temp >39 degrees, fever for 5 days or more, rigors, swelling of a joint or limb, non-weight bearing or not using an extremety.
red - age <3 months temp >38, non blanching rash, bulging fontanelle, neck stiffness, status epilepticus, focal neurology, focal seizures.
management of febrile illness in infants
GREEN - supportive care at home, advice when to seek help
AMBER - safety net or paeds specialist review
RED - urgent referal to paeds specialist
What would these parameters be in early (compensated) shock in a child? BP, HR, Resp rate, appearance, urine output
BP - Normal HR - tachy RR - tachy appearance - pale or mottled UP - reduced
What would these parameters be in late (decompensated) shock in a child? BP, HR, Resp appearance, urine output
BP - hypo HR - Brady Resp - acidotic appearance - blue UO - absent
Fluid Bolus in children
20ml/kg (15ml/kg in neonates) in 10 mins of saline
initial management of duct dependent congenital heart disease
prostaglandins e.g. alprostadil as they maintain patency of the ductus arteriosus
Red flags for constipation (5) (and two amber)
reported from first few weeks of life
Meconium passed later than 48 hrs post birth
‘ribbon’ stools
previously undiagnosed leg weakness or locomotor delay
abdominal distension
Amber - safeguarding concern, faltering growth
Causes of Constipation in Children
Majority are Idiopathic dehydration low-fibre diet opiate medication anal fissure over enthusiastic potty training hypothyroidism hirschsprung's disease hypercalcaemia learning disability
what is Hirschsprung’s Disease?
the absence of ganglions in a segment of the bowel causing loss of peristalsis and ability to move stool through the intestine
What is perthes’ disease and who gets it?
degenerative condition of the hips, typically affecting boys (5:1) aged 4 - 8 years. It is due to AVN of the femoral epiphysis.
presentation of Perthes’
Hip pain, progressive over weeks
limp
stiffness and reduced ROM
radiographical changes in perthes’
widening of joint space, decreased femoral head size, femoral head flattening
management of perthes’
Cast and braces to keep femoral head in acetabulum
if older than 6 consider surgical management
What is Juvenile idiopathic arthritis
arthritis occurring in someone less than 16 years old lasting more than 6 weeks.
Types of JIA and their features (5)
Pauciarticular - most common, 4 or less joints effected, medium sized joints e.g. knees, shoulders elbows
Systemic-onset JIA -anaemia, thrombocytosis, lecucytosis and rasied ESR present
RF positive JIA - RF is positive, nodules on extensor surface of tendons
Polyarticular JIA - 4 or more joints effected
Ethesitis related JIA - inflammationof the entheses present (site of tendon and ligament insertion into bone.)
What is plagiocephaly?
parallelogram shaped head - normal in infants due to sleeping on back. usually resolves between 3-5 years. Reassure and recommend moving cot/ focus of attention, encouraging supervised supported sitting out during the day and supervised tummy time.
What is biliary atresia and when does it occur?
oliteration or discontinuity of the extrahepatic biliary system, resulting in obstructive jaundice. Usually presents in first few weeks of life.
Fine motor developmental milestones - general
3 months - reaches for objects, holds rattle briefly
6 months - holds in palmar grasp, passess objects from one hand to the other
9 months - points with finger, early pincer
12 months - good pincer, bangs toys together
visual developmental milestiones
3 months - fixes and follows to 180 degrees
6 months - visually insatiable - looking around in every direction
Towers of Bricks milestones
15 months - tower of 2
18 months - tower of 3
2 years - tower of 6
3 years - tower of 9
drawing milestones
18 months - circular scribble 2 years - copies vertical line 3 years - copies circle 4 years - copies cross 5 years - copies square and triangle
book milestones
15 months - looks at pages and pats pages
18 months - turns several pages at a time
2 years - turns pages one at a time
What is Croup
URTI most common in 6mnths to 3 yrs causing laryngeal oedema and secretions caused by parainfluenza viruses.
features of croup
stridor
barking cough
fever
coryzal symptoms
severity of croup
mild - occasional barking cough, no stridor, no recessions, well child
moderate - frequent barking cough, audible stridor at rest, some suprasternal and sternal wall retraction at rest. No or little distress, child can be placated and is interested in surroundings
severe - frequent barking cough, prominent stridor, marked sternal retractions, significant distress, lethargy or restlessness, tachycardia, hypoxia
management of Croup
oral dexamethasone 0.15mg/kg
admit if moderate or severe, child under 6mnths old, known upper airway abnormalities, uncertain diagnosis. In emergencies give high flow oxygen and nebulised adrenaline.
What are infantile spasms?
type of childhood epilepsy which typically first present in 4-8mnths. they carry a poor prognosis.
Presentation of infantile spasms
‘salaam’ attacks - flexion of head, trunk and arms, followed by extension of the arms, lasting a few seconds but may be repeated many times.
progressive learning disability.
investigation of infantile spasms
CT - brain disease in 70%
EEG - hypsarrhythmmia in 66%
management of infantile spasms
vigabatrin first line (prevents breakdown of GABA)
ACTH
complications of respiratory distress syndrome at birth
renal failure and retinopathy of prematurity
What is transient synovitis and how should it be managed.
Acute hip pain following a viral infection in 2 to 10 years. There may be a low grade fever. Rest and analgesia.
What is Ebstein’s anomaly?
CHD where the tricuspid valve is positioned low, in the right ventricle resulting in a large atrium and small ventricle. It is associated with tricuspid regurg and Wolff-Parkinson White and may be caused by intrauterine lithium exposure.
Features of Turner’s Syndrome (12)
short stature shield chest widely spaced nipples webbed neck bicuspid aortic valve (15%), coarctation of the aorta (5-10%) primary amenorrhoea cystic hygroma (often diagnosed prenatally) high-arched palate short fourth metacarpal multiple pigmented naevi lymphoedema in neonates (especially feet) gonadotrophin levels will be elevated
5 Red flags and 2 amber flags for constipation in children
Present since the first few weeks of life
>48hrs to meconium passage
‘ribbon’ stools
new leg weakness or locomotor delay
Abdominal distention
Amber: Faltering growth and safeguarding concerns
Epiglottitis causative organism
Haemophilus infleunzae type B
Pyloric stenosis Who gets it? Features Diagnosis Treatment
M>F, 4-6 weeks old
Projectile non bile stained vomiting
Diagnosis is made by test feed or USS
Treatment: Ramstedt pyloromyotomy (open or laparoscopic)
Acute appendicitis
Who gets it?
Presentation
Uncommon under 3 years
When occurs may present atypically
Intussusception What is it? Where does it usually occur? Age? Presentation? Management?
Telescoping bowel
Proximal to or at the level of, ileocaecal valve
6-9 months of age
Colicky pain, diarrhoea and vomiting, sausage-shaped mass, red jelly stool.
Treatment: reduction with air insufflation
Malrotation What is it? Associated conditions? Complications? Diagnosis? Management?
High caecum at the midline
Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia
May be complicated by the development of volvulus, an infant with volvulus may have bile stained vomiting
Diagnosis is made by upper GI contrast study and USS
Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a Ladd’s procedure is performed
Hirschsprung's disease What is it? Presentation Diagnosis Management
Absence of ganglion cells from myenteric and submucosal plexuses
Delayed passage of meconium and abdominal distension
Full-thickness rectal biopsy for diagnosis
Treatment is with rectal washouts initially, after that an anorectal pull through procedure
Oesophageal atresia
Associations
Presentation
Associated with tracheo-oesophageal fistula and polyhydramnios
May present with choking and cyanotic spells following aspiration
Meconium ileus
Presentation
associated diagnosis
Management
Usually delayed passage of meconium and abdominal distension
The majority have cystic fibrosis
PR contrast studies may dislodge meconium plugs and be therapeutic, NG N-acetyl cysteine useful,
Infants who do not respond will require surgery to remove the plugs
Biliary atresia
Presentation
Investigation finding
Management
Jaundice > 14 days
Increased conjugated bilirubin
Urgent Kasai procedure
Necrotising enterocolitis Who gets it? Features X-ray findings Risk factor Management
Premature babies
Early features include abdominal distension and passage of bloody stools
X-Rays may show pneumatosis intestinalis and evidence of free air
Increased risk when empirical antibiotics are given to infants beyond 5 days
Treatment is with total gut rest and TPN, babies with perforations will require laparotomy
Mesenteric adenitis
Presentation and management
Central abdominal pain and URTI
Conservative management
VACTERL conditions
Vertebral defects Anal atresia Cardiac defects Tracheo-esophageal fistula Renal anomalies Limb abnormalities
Management of UTI
Under 3 months - refer same day to paeds
Over 3 months - upper UTI - refer to hospital
- lower UTI - 3 days Abx and safety netting
when to admit a child with bronchiolitis
RR over 60 breaths/minute
difficulty with breastfeeding or inadequate oral fluid intake (50–75% of usual volume
clinical dehydration
Patau syndrome (trisomy 13) 4x features
Microcephalic, small eyes
Cleft lip/palate
Polydactyly
Scalp lesions
Edward’s syndrome (trisomy 18)
4x feautres
Micrognathia
Low-set ears
Rocker bottom feet
Overlapping of fingers
Fragile X
5x features
Learning difficulties Macrocephaly Long face Large ears Macro-orchidism
Noonan syndrome
4x features
Webbed neck
Pectus excavatum
Short stature
Pulmonary stenosis
Pierre-Robin syndrome*
3x features
Micrognathia
Posterior displacement of the tongue (may result in upper airway obstruction)
Cleft palate
Prader-Willi syndrome
3x features
Hypotonia
Hypogonadism
Obesity
William’s syndrome
5x features
Short stature Learning difficulties Friendly, extrovert personality Transient neonatal hypercalcaemia Supravalvular aortic stenosis elfin facies
Cri du chat syndrome (chromosome 5p deletion syndrome)
5x features
Characteristic cry (hence the name) due to larynx and neurological problems
Feeding difficulties and poor weight gain
Learning difficulties
Microcephaly and micrognathism
Hyperteloris
Causes of Hypertension in children (6)
Renal parenchymal disease renal vascular disease coarctation of the aorta phaeochromocytoma congenital adrenal hyperplasia essential or primary hypertension
Imaging developmental dysplasia of the hip
newborn - ultrasound
>4.5 months - X-ray
