Paediatrics

Question 1

Kawasaki Disease

Answer 1

Diagnostic Criteria: Fever >5 days Unilateral cervical lymphadenitis, node > 1.5cm Bilateral conjunctivitis without discharge Strawberry tongue/lips Maculopapular rash without vesicles Extremities – painful oedema hands and feet -> desquamation Treatment IVIg 2g/kg Prednisolone 2mg/kg max 60mg Aspirin 3-5mg/kg daily

Question 2

Severe Asthma

Answer 2

Salbutamol > 6 years: 6 puffs / 12puffs, NEB continuous 2 x 5mg Ipratropium > 6 years: 4 puffs / 8puffs, NEB 250microg q20mins x3 only Prednisolone 2mg/kg PO OR Methylprednisolone: 1 mg/kg (max 60mg) IV q6hr Aminophylline: LOADING DOSE: 10 mg/kg IV over 60mins then infusion Magnesium Sulfate 50% (500mg/ml = 2mmol/ml): *** each 5ml ampule contains 10mmol MgSO4 or 2.5g MgSO4 *** LOADING DOSE: 0.2 mmol/kg (max 8mmol) over 20 mins INFUSION: 0.12 mmol/kg/hr, aim to keep serum magnesium between 1.5 – 2.5mmol/L Consider Adrenaline (if not improving): 10 microg/kg IM, can repeat after 5 mins if no improvement Consider Salbutamol IV (limited evidence): LOADING DOSE: 5 microg/kg/min for one hour INFUSION: 1-2 microg/kg/min ongoing **Beware salbutamol toxicity: tachycardia, tachypnoea, metabolic acidosis/lactate, hypokalaemia RCH Guidelines

Question 3

Paeds Intubation - laryngoscope size

Answer 3

Premature infant 0 Miller Infant 1 Miller 2 - 6 yr 2 Miller 5 - 12 yr 2 Macintosh >12 yr 3 Macintosh Dunn

Question 4

Paeds ET Tube size

Answer 4

Term neonate 3.5 < 1 year old 3.5 - 4.0 > 1 year (Age/4) + 4 (uncuffed) (Age/4) + 3 (cuffed) Dunn

Question 5

Paeds ET Tube distance from teeth to carina

Answer 5

•teeth to carina length -2 x internal diameter of ETT + 5 Dunn

Question 6

Neonatal Jaundice - hx and exam

Answer 6

Background

Jaundice (or hyperbilirubinaemia) occurs in approximately 60% of full term babies (80% of pre-term babies) within the first week of life

Visual assessment of bilirubin level is unreliable

Kernicterus is a rare complication of unconjugated hyperbilirubinaemia that can lead to major long-term neurological sequelae

History & Examination- features particularly relevent to jaundice:

Is the infant unwell? (sepsis & GIT obstruction can cause jaundice)

Is there dehydration or poor wt-gain? (both exacerbate jaundice)

Jaundice before 48 hrs of age (suggests haemolysis)

Onset of jaundice after 3 days of age (more likely to be pathological)F

Birth trauma such as cephalhaematoma, significant bruising (breakdown of heme)

Maternal history (blood group, viral serology)

Family history of haemolytic disease (ABO/G6PD, spherocytosis)

Dark urine or pale stools (suggest biliary obstruction)

Level of icterus in terms of cephalocaudal progression (but often unreliable)

Plethora (may suggest polycythaemia)

Hepatosplenomegaly (viral hepatitis, metabolic problems)

RCH

Question 7

Jaundice Flow Chart RCH

Answer 7

Question 8

Unconjugated Hyperbilirubinaemia

Answer 8

Unconjugated Hyperbilirubinaemia

Causes:

Physiological Jaundice

• Is an exaggerated physiological response
• Should resolve within 2 weeks in a term baby (3 weeks in a pre-term baby).

Breast Milk Jaundice

• Common
• jaundice may continue for many weeks
• Cessation of breast feeding is NOT indicated

Other Causes

• Sepsis- rarely presents with jaundice alone (occasional for UTI); usually unwell
• Haemolysis from Bl grp incompatibility and red cell defects - early onset for ABO, Rhesus
• Excessive, non-haemolytic red cell destruction (such as polycythaemia, bruising or cephalhaematoma)
• GIT obstruction or ileus (eg. pyloric stenosis)
• Prematurity
• Hypothyroidism (TSH included in newborn screening tests, results available by ph: 8341 6272)

Management of unconjugated hyperbilirubinaemia:

Treat underlying sepsis

Prolonged jaundice (>2wks term, > 3 wks pre-term) rarely requires treatment

Jaundiced neonates requiring admission to RCH should be discussed with NNU fellow/ consultant

Suspected haemolysis should be discussed with haematologist on call.

See NETS handbooktables for treatment ranges

a. Discharge instructions

• Sunlight exposure is not recommended as a treatment for jaundice
• Arrange early follow-up with MCHN and/or GP to ensure adequate oral intake, especially if:
• < 3 days old
• Exclusively breastfeeding or still establishing adequate oral feeds
• bilirubin level is borderline for requiring treatment
• Recheck bilirubin in 24-48 hours if borderline level or still rising
• Parents should be advised to represent if:
• Stools become pale or urine becomes dark
• Baby unwell or feeding poorly
• Jaundice prolonged beyond 2 wks, for term, or 3 wks, for preterm babies

b. Phototherapy

• Particular attention should be paid to fluid intake and hydration status, with monitoring of weights and electrolytes at least daily.
• Correct dehydration over at least 24 hours
• Bilirubin should be rechecked 6 hours after initial test
• NB. If rate of rise of bilirubin is >10 micromol/L/hour - Contact NNU fellow/ NETS for further advice

c. Exchange Transfusion

• This should only be carried out in a Tertiary Neonatal Intensive Care Unit
• Obtain advice from NNU fellow or NETS

Question 9

Conjugated Hyperbilirubinaemia

Answer 9

Conjugated Hyperbilirubinaemia

Pale stools/ dark urine, raised conjugated bilirubin (>15% total or >15umol/l)

The causes of conjugated hyperbilirubinaemia are potentially serious

All cases warrant further investigation and discussion with Paediatric Gastroenterology

Causes:

Biliary atresia:

Needs to be detected early to improve chances of success of surgical repair (Kasai)

Kasai best operated on before 45-60 days of life.

Other causes:

Choledochal cyst

Neonatal hepatitis (congenital infection, alpha-1 antitrypsin deficiency; often idiopathic)

Metabolic (galactosaemia, fructose intolerance - ask about sucrose/fructose in food/medication)

Complication of TPN

RCH