Paediatrics Flashcards
1
Q
Neonatal Cardiovascular Physiology
Changes in fetal circulation before delivery (6)
A
Umbilical vein: transports blood from placenta to fetus
Ductus venosus: connects umbilical vein to IVC
Foramen ovale: blood flows through from right atrium to left atrium
Ductus arteriosus: a smaller volume of blood goes from right atrium to right ventricle and into the pulmonary artery, the ductus arteriosus is a channel between pulmonary artery and aortic arch to allow blood to bypass lungs
Lungs: no respiratory function; filled with amniotic fluid, alveoli are small, arterioles + venules are contracted
Umbilical arteries (2): come off left and right iliac arteries and take blood back to placenta
2
Q
Neonatal Cardiovascular Physiology
Changes in fetal circulation after delivery (4)
A
Lungs: as body passes through birth canal, amniotic fluid is squeezed out of lungs, alveoli become larger, vessels relax and vascular pressure stops to allow more blood to lungs
Ductus venosus: fibroses to become hepatic ligamentum teres
Foramen ovale: closes (if stays open, oxygenated blood flows from left -> right atrium)
Ductus arteriosus: functional closure at days 2-3 and anatomical closure by fibrosis at days 10-14 (if stayed open, blood would flow from aorta to pulmonary artery)
3
Q
Innocent Murmurs
Proportion of murmurs (1)
A
70-80%
4
Q
Innocent Murmurs
Types (4)
A
Still’s murmur
Pulmonary outflow murmur
Carotid/brachiocephalic arterial bruits
Venous hum
5
Q
Innocent Murmurs Common features (5)
A
Sysotlic murmur (except venous hum which is continuous)
No other signs of cardiac disease
Soft murmurs, grade 1/6 or 2/6
Vibratory, musical
Varies with position, respiration, exercise
6
Q
Innocent Murmurs
Still’s Murmur (4)
A
Most common
LV outflow murmur
Soft systolic murmur
Heard at apex- left sternal border
7
Q
Innocent Murmurs
Chromosomal causes of congenital heart disease (4)
A
Trisomy 18 (Edwards syndrome)- VSD + ASD
Trisomy 21 (Downs syndrome)- AVSD
Turner syndrome- coarctation of aorta
Noonan syndrome- pulmonary stenosis
8
Q
Coarctation of the Aorta
Aetiology (2)
A
Narrowing of aortic wall, usually at start of aorta
Turner’s syndrome
9
Q
Coarctation of the Aorta
Signs + symptoms (8)
A
Poor feeding Lethargy Tachypnoea Radial-radial or radial-femoral delay Cold lower limbs Crescendo-decrescendo systolic or continuous murmur in left infraclavicular area or under left scapula Severe cardiovascular collapse after ductus arteriosus closure Acyanotic
10
Q
Coarctation of the Aorta
Investigations (4)
A
ECG (RVH in neonates, LVH in adults)
CXR (congestive cardiac failure, indentation of aortic shadow)
Echocardiography
Cardiac MRI
11
Q
Coarctation of the Aorta
Treatment (3)
A
Need to keep ductus arteriosus open: prostaglandin E1 infusion reopens it to allow some blood to flow from pulmonary artery to aorta and to systemic circulation
Congestive cardiac failure: inotropes and diuretics
Balloon angioplasty +/- stenting followed by resection with end to end anastomosis
12
Q
Coarctation of the Aorta
Complications (3)
A
Hypertension
Re-coarctation
Aortic dissection
13
Q
Paediatric Pulmonary Stenosis
Aetiology (1)
A
Noonan syndrome
14
Q
Paediatric Pulmonary Stenosis
Signs + symptoms (3)
A
Ejection systolic murmur at right upper sternal edge with radiation to back, pulmonary ejection click, delayed S2 (if severe), parasternal thrill and heave
Reduced exercise tolerance
Exertional chest pain and syncope if severe
15
Q
Paediatric Pulmonary Stenosis
Investigations (3)
A
ECG (RVH, RAH, RAD)
Echo (measure flow across valve)
CXR
16
Q
Paediatric Pulmonary Stenosis
Treatment (2)
A
Balloon valvuloplasty to increase blood supply before puberty (causes pulmonary regurgitation but usually well tolerated)
Valve replacement surgery
17
Q
Paediatric Aortic Stenosis
Aetiology (2)
A
William’s syndrome
Bicuspid valve
18
Q
Paediatric Aortic Stenosis
Signs + symptoms (6)
A
Ejection systolic murmur at the right upper sternal edge with radiation to the carotids Heave Angina Syncope Dyspnoea Fatigue
19
Q
Paediatric Aortic Stenosis
Investigations (2)
A
ECG (LAD, LVH)
Doppler echo
20
Q
Paediatric Aortic Stenosis
Treatment (2)
A
Balloon valvuloplasty to increase blood supply before puberty (causes aortic regurgitation but less well tolerated than pulmonary) Valve replacement (earlier than in pulmonary)
21
Q
Ventricular Septal Defect
Classification (2)
A
Muscular: lower and smaller
Pemimembranous: higher and larger
22
Q
Ventricular Septal Defect
Associations (4)
A
Maternal TORCH infection
Drugs: phenytoin, lithium, alcohol, cocaine
Maternal diabetes
Down’s syndrome
23
Q
Ventricular Septal Defect
Signs + symptoms (3)
A
Pansystolic murmur at lower left sternal edge
Signs of heart failure (tachycardia, tachypnoea)
Failure to thrive
24
Q
Ventricular Septal Defect
Treatment (2)
A
Small and asymptomatic defects: monitoring, 50% resolve spontaneously
Surgery if large
25
Ventricular Septal Defect
| Complications (3)
Eisenmenger's complex
Right heart failure
Right ventricular hypertrophy
26
Ventricular Septal Defect
| Eisenmenger's complex (3)
RVH leads to pressure in the right ventricle exceeding pressure in the left ventricle during systole
Causing a reversal of the shunt to become R-->L
So the defect becomes cyanotic (if this happens it needs a heart-lung transplant)
27
Atrial Septal Defect
| Associations (1)
Down's syndrome
28
Atrial Septal Defect
| Pathology (2)
Failure of ostium secundum to close
| Fewer presenting features in childhood as atria have much lower pressure and pressure is similar between the two
29
Atrial Septal Defect
| Signs + symptoms (2)
Ejection systolic murmur at pulmonary area
| Usually asymptomatic in childhood and can present in adulthood with AF, heart failure or pulmonary hypertension
30
Patent Ductus Arteriosus
| Anatomy (3)
In fetal circulation it allows a connection between the pulmonary trunk and aorta
Helps oxygenated blood from the right heart bypass the lungs and go straight to the body
When the fetal lungs open and the placenta is no longer the source of oxygenation, this shunt should close to allow blood to get to the lungs
31
Patent Ductus Arteriosus
| Pathology (2)
Pressure in aorta is greater than in the duct causing L-->R shunts
Causes additional blood in the pulmonary circulation leading to lung hyperperfusion and steal from systemic circulation causing systemic ischaemia
32
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Patent Ductus Arteriosus
Risk factors (2)
```
Prematurity
| Down syndrome
33
Patent Ductus Arteriosus
| Signs + symptoms (4)
Infra-clavicular continuous murmur
Thrill
Pulse may be bounding and collapsing
If large, may show symptoms of circulatory overload: shortness of breath, feeding difficulties and poor weight gain
34
Patent Ductus Arteriosus
| Treatment (2)
Form term babies there is good chance of spontaneous closure within the first year, so monitor with echos and prostaglandin inhibitors (eg. indomethacin) may help to promote closure
For preterm babies give prostaglandin inhibitors and surgical closure
35
Transposition of the Great Vessels
| Pathology (4)
Failure of spiralling of the aorticopulmonary septum in development
Aorta comes from right ventricle
Pulmonary artery comes from the left ventricle
Leads to 2 separate right heart and left heart systems, so the oxygenated and deoxygenated blood exist in 2 separate circuits- incompatible with life unless a fetal shunt is maintained in the neonate (patent foramen ovale, PDA, VSD)
36
Transposition of the Great Vessels
| Signs + symptoms (3)
Cyanosis
Tachypnoea
No murmur
37
Transposition of the Great Vessels
| Treatment (2)
Buy time: prostaglandin E1 to maintain patency of ductus arteriosus, Rashkind's procedure (catheter used to poke a hole through atrial septum to re-open foramen ovale)
Transfer to specialist unit for surgical 'switch' procedure
38
Tetralogy of Fallot
| Pathology (4)
Right ventricular outflow tract obstruction (pulmonary stenosis)
Right ventricular hypertrophy
Ventricular septal defect
Overriding aorta
39
Tetralogy of Fallot
| Associations (2)
22q11 deletion syndrome (DiGeorge)
| Down's
40
Tetralogy of Fallot
| Signs + symptoms (3)
Cyanosis (because even though the heart pumps more blood it is at least partly deoxygenated)
Ejection systolic murmur (pulmonary stenosis)
Tet spells: develop blue skin/lips after crying/feeding due to rapid drop in O2 in blood, toddlers or older children might instinctively squat when they're short of breath to increase blood flow to the lungs by kinking the femoral arteries to create a temporary LV outflow tract obstruction
41
Paediatric Heart Failure
| Aetiology (6)
```
Left to right shunt (volume overload): VSD, PDA
Valvular regurgitation (volume overload)
Outflow tract obstruction (pressure overload): stenosis of valves
Coronary insufficiency (low O2 supply): coronary artery anomalies
Cardiomyopathies: systolic dysfunction (low cardiac output), diastolic dysfunction (elevated pulmonary capillary pressure)
Arrhythmias: systolic dysfunction (low cardiac output)
```
42
Paediatric Heart Failure
| Presentation in infants (4)
Difficulty in feeding
Cyanosis
Tachypnoea
Sinus tachycardia
43
Paediatric Heart Failure
| Presentation in children (5)
```
Fatigue
SOB
Tachypnoea
Exercise intolerance
Abdominal pain
```
44
Normal Development
| Weight (2)
```
Initial weight loss: acceptable for breast fed babies to lose up to 10% and formula fed to lose up to 5% by day 5, should be back at birth weight by day 10
Average weekly weight gain:
- 0-3 months 200g
- 3-6 months 150g
- 6-9 months 100g
- 9-12 months 75-50g
```
45
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Normal Development
6 weeks (1)
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Smiling (social)
46
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Normal Development
8 weeks (2)
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Fix eyes on object and attempt to follow, prefer face to object (fine motor)
RED FLAG- no social smile
47
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Normal Development
3 months (2)
```
Cooing noise, comfort from parents (language)
| Takes things to mouth (social)
48
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Normal Development
4 months (1)
```
Supports head up, rolls from belly to back (gross motor)
49
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Normal Development
5 months (1)
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RED FLAG- can't hold an object
50
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Normal Development
6 months (4)
```
Can hold body up but not have balance to sit unsupported, rolls back to belly (gross motor)
Palmar grip (fine motor)
Noise with consonants, responds to tone of voice (language)
Recognises several people (social)
51
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Normal Development
9 months (4)
```
```
Sits unsupported, crawling (bottom shuffling is a normal variant), pulls to standing (gross motor)
Scissor grip (fine motor)
Babbles with certain sounds for different things, may respond no, looks for toys that fall out of sight (language)
Apprehensive of strangers (social)
```
52
```
Normal Development
12 months (5)
```
RED FLAG- cannot sit unsupported
Walks whilst holding onto furniture (gross motor)
Pincer grip, scribbles (fine motor)
Single words, follows simple instruction (language)
Points, waves, claps, copies actions (social)
53
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Normal Development
15 months (1)
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Walking (gross motor)
54
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Normal Development
18 months (3)
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RED FLAG- can't stand independently
RED FLAG- no words
RED FLAG- no interest in others
55
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Normal Development
2 years (4)
```
RED FLAG- can't walk themselves
Run and kick a ball (gross motor)
Pencil grip (fine motor) but v basic
Dry by day
56
Normal Development
| 2.5 years (1)
RED FLAG- not running
57
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Normal Development
3 years (2)
```
Climb stairs 1 foot at a time
| Bowel control
58
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Normal Development
4 years (2)
```
Walks up stairs normally
| Dry by night, dresses self
59
```
Normal Development
RED FLAGS (9)
```
```
Loss of milestones
No social smile by 8 weeks
Can't hold object by 5 months
Can't sit unsupported by 12 months
Can't stand independently by 18 months
No words by 18 months
No interest in others by 18 months
Can't walk by 2 years
Can't run by 2.5 years
```
60
Newborn Examination (3)
HBV immunisation if mother HBV +ve
Bloodspot: CF, congenital hypothyroidism, sickle cell disease
Clinical examination
61
Newborn Hearing Screening (2)
Otoacoustic emission test by 28 days
| Auditory brainstem response test if abnormal
62
Health Visitor Input (4)
1st visit: feeding, maternal mental health, jaundice
Health visitor + GP review at 6-8 weeks
27-30 month review of development and physical measurements
Last visit age 5
63
Immunisation
| 5 in 1 (3)
Don't tell Peter's Parents, Bro
Diphtheria, tetanus, pertussis, polio, H.influenzae B
2 months, 3 months, 4 months
64
Immunisation
| Pneumococcal Conjugate Vaccine (PCV) (1)
2 months, 4 months, 1 year
65
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Immunisation
Rotavirus vaccine (1)
```
2 months, 3 months
66
Immunisation
| Meningococcal B vaccine (1)
2 months, 4 months, 1 year
67
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Immunisation
MMR vaccine (2)
```
1 year
| 3 years 4 months
68
Immunisation
| 4 in 1 (2)
Don't tell Peter's Parents
| Diphtheria, tetanus, pertussis, polio
69
Immunisation
| 3 in 1 (3)
Don't tell Peter
Diphtheria, tetanus, polio
14 years
70
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Immunisation
2 months (4)
```
5 in 1
PCV
Rotavirus
Men B
71
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Immunisation
3 months (2)
```
5 in 1
| Rotavirus
72
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Immunisation
4 months (3)
```
5 in 1
PCV
Men B
73
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Immunisation
1 year (3)
```
PCV
Men B
MMR
74
Immunisation
| 3 years 4 months (2)
MMR
| 4 in 1
75
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Immunisation
14 years (1)
```
3 in 1
76
Developmental Delay
| Definition (2)
Performance 2 standard deviations below the mean of age-appropriate norm
Correct for prematurity until 2 y/o
77
Developmental Delay
| Differentials (5)
Global developmental delay (performance 2SD below expected in 2+ domains)
Motor impairment: delayed maturation, cerebral palsy, muscular dystrophy
Sensory impairment: deafness, visual impairment
Speech and language impairment: specific language impairment, deaf, lack of stimulus, learning difficulty, bilingual
Social impairment: autism, elective mutism, learning disability, attachment issues, neglect
78
Global Developmental Delay
| Aetiology (4)
Prematurity
Genetic disorder
Neglect
Congenital infection
79
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Cerebral Palsy (Motor Delay)
Definition (1)
```
Permanent non-progressive (lesion is static, however clinical picture isn't) motor disorder due to brain damage before birth
80
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Cerebral Palsy (Motor Delay)
Aetiology (3)
```
Prenatal: placental insufficiency, smoking, alcohol, drugs, ToRCH infection
Perinatal: prematurity, anoxia
Postnatal: CMV, rubella, head trauma
81
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Cerebral Palsy (Motor Delay)
Classification (4)
```
Spastic: increased tone and reduced function- damage to UMNs
Dyskinetic: problems controlling muscle tone with hypertonia and hypotonia- damage to basal ganglia
Ataxic: problems with coordinated movement- damage to cerebellum
Mixed
82
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Cerebral Palsy (Motor Delay)
Patterns (4)
```
Monoplegia (one limb)
Hemiplegia (one side of body)
Diplegia (four limbs affected but mostly the legs)
Quadriplegia
83
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Cerebral Palsy (Motor Delay)
Signs + symptoms (7)
```
```
Spasticity
Weakness/paralysis
Poor coordination
Delayed walking
Sensory impairment
Contractures
Primitive reflexes (persistence of 2+ suggests child will be non-ambulatory): moro startle reflex, parachute reflex, tonic neck reflex, neck righting reflex, extensor thrust
```
84
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Muscular Dystrophy (Motor Delay)
Aetiology (3)
```
Duchenne's muscular dystrophy (X-linked recessive- Xp21)
Becker's muscular dystrophy
Myotonic dystrophy
85
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Muscular Dystrophy (Motor Delay)
Signs + symptoms (8)
```
```
Delayed gross motor skills
Progressive muscle weakness
Shoulders and arms held back when walking
Protruding abdomen
Poor balance
Toe walking
Foot drop
Symmetrical proximal weakness: waddling gait, calf hypertrophy, +ve Gower's sign (uses hands to push up onto legs)
```
86
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Muscular Dystrophy (Motor Delay)
Investigations (4)
```
Creatinine kinase (>1000)
Muscle biopsy
DNA serology
EMG
87
Autism Spectrum Disorder (Social Delay)
| Epidemiology (2)
1:100
| M>F 4:1
88
Autism Spectrum Disorder (Social Delay)
| Signs + symptoms (4)
Reciprocal social interaction difficulties: lack of socio-emotional cue recognition, difficulty modifying behaviour in social situation
Communication difficulties: poor use of language, inflexible language use (stereotypies and persistent echolalia- repeating what you say)
Restricted, repetitive and stereotyped patterns of behaviour, interests and activities: rituals, routines, resistance to change
Infants tend to hit early milestones but may lose some around 2y/o
89
Clef Lip and Palate
| Epidemiology (2)
70% of cleft lip cases have cleft palate too
| Associated with T13, T18 and 22q11 deletion syndrome
90
Clef Lip and Palate
| Pathology (2)
```
Cleft lip: maxillary and fronto-nasal facial processes fail to merge at around 5 weeks gestation (complete if continues to nose)
Cleft palate: 2 skull plates forming
Hard palate (palatine process and nasal septum) fail to merge at around 9 weeks
```
91
Clef Lip and Palate
| Treatment (2)
Special bottles and teats for feeding
| Surgical repair at 6-12 months
92
Short Stature
| Definition (1)
Height 2+ SDs below the mean for children of that sex and age
93
Short Stature
| Physiological (3)
Familial: grow at normal rate and end up as predicted
Constitutional delay: normal growth but timing of puberty delayed, appear to fall off centiles until reach puberty and become a normal height
Small for gestational age
94
Short Stature
| Pathological (8)
```
Iatrogenic (steroids)
Under-nutrition
Psychosocial
Chronic disease (IBD, JIA, coeliac)
Hypothyroidism
Growth hormone deficiency
Turner's syndrome
Noonan's syndrome
```
95
Toddler's Diarrhoea
| Pathology (1)
Motility disturbance
96
Toddler's Diarrhoea
| Signs + symptoms (1)
Quickly after eating food and still has obvious food particles in it
97
Toddler's Diarrhoea
| Treatment (1)
Self-limiting (most common cause of diarrhoea in children), although it is viral (rotavirus gastroenteritis)
98
Newborn Examination
| Head (8)
Circumference (50th centile = 35cm)
Shape (odd shapes from difficult labour soon resolve)
Fontanelles (tense if crying or intracranial pressure increases, sunken if dehydrated)
Red reflex (absent in cataract and retinoblastoma)
Breathing out the nose whilst closing mouth tests for choanal atresia
Otoacoustic screening
Complexion (cyanosed, pale, jaundiced)
Check mouth for cleft palate
99
Newborn Examination
| Arms and hands (3)
Single palmar creases (normal or trisomy 21)
Waiter's tip sign of Erb's palsy
Clinodactyly (5th finger is curved towards the ring finger- normal or trisomy 21)
100
Newborn Examination
| Thorax (3)
Watch respirations
Check grunting and intercostal recession
Listen to heart and lungs
101
Newborn Examination
| Abdomen (3)
Expect to feel liver
Assess skin turgor
In first 24h ensure baby passes urine (consider posterior urethral valves in boys if not) and stool (consider Hirschprung's, CF, hypothyroidism if not)
102
Newborn Examination
| Legs (2)
```
DDH
Femoral pulses (exclude coarctation)
```
103
Newborn Examination
| Back (1)
Tufts of hair +/- dimples suggests spina bifida occulta
104
Newborn Examination
| Dysmorphism (7)
Down's (T21): excess nuchal folds, single palmar crease, sandal gap, hypotonia, oval face, small smooth + protruding tongue, small + low set ears, small nose with flat + low bridge
Patau's (T13): microcephaly, cleft lip + palate, hypotonia, FTT
Edward's (T18): low set ears, rockerbottom feet, overlapping fingers, IUGR, low birth weight
22Q11: cleft palate, hooded eyes, tubular nose and broad nose tip
William's: sunken nasal bridge, puffy eyes, blue eye with Starburst pattern, long philtrum, small chin
Noonan's: neck webbing, pectus evatum, deep philtrum, arched palate
Fragile X: enlarge testicles, facial symmetry, macrocephaly, long ears
105
Neonatology
| Definitions (2)
Preterm <37wks, extremely preterm <28wks
| Low birth weight <2.5kg, v low birth weight <1.5kg, extremely low <1kg
106
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Neonatology
APGAR Score (7)
```
Respiratory effort: strong, crying (2), weak, irregular (1), nil (0)
Colour: pink (2), blue extremities (1), blue all over (0)
Muscle tone: active movement (2), limb flexion (1), flaccid (0)
Reflex irritability: cries on stimulation (2), grimace (1), nil (0)
0-3= v low
4-6= low to moderate
7-10= good condition
107
Respiratory Distress Syndrome
| Aetiology (1)
No surfactant before 34 weeks
108
Respiratory Distress Syndrome
| Pathology (2)
Increased work of breathing as lungs collapse after end of each breath
No functional residual capacity
109
Respiratory Distress Syndrome
| Signs + symptoms (6)
```
Tachypnoea
Expiratory grunting
Subcostal and intercostal recession
Cyanosis
Nasal flaring
Fatigue
```
110
Respiratory Distress Syndrome
| Treatment (2)
Surfactant
| CPAP
111
Respiratory Distress Syndrome
| Complications (2)
```
Pneumothorax
Bronchopulmonary dysplasia (inflammation and scarring of lungs)
```
112
Respiratory Distress Syndrome
| Prevention (1)
Antenatal steroids
113
Intraventricular Haemorrhage
| Aetiology (1)
Rupture of germinal matrix blood vessels
114
Intraventricular Haemorrhage
| Pathology (1)
Blood vessels in germinal matrix (lateral to ventricles) lack structural support and rupture
115
Intraventricular Haemorrhage
| Signs + symptoms (7)
```
Diminished/absent reflex
Poor muscle tone
Drowsiness
Tense/bulging fontanelle
Cyanosis
Failure to suck
Twitching/convulsions
```
116
Intraventricular Haemorrhage
| Investigations (1)
Cranial USS
117
Intraventricular Haemorrhage
| Treatment (3)
Fluid replacement
Anticonvulsants
Acetazolamide (prevents post-haemorrhagic hydrocephalus)
118
Neonatal Jaundice
| Physiological jaundice causes (4)
Increased bilirubin production in neonates due to shorter RBC lifespan
Decreased bilirubin conjugation due to hepatic immaturity
Absence of gut flora impedes elimination of bile pigment
Exclusive breast feeding
119
Neonatal Jaundice
| Physiological jaundice classification (3)
After 24h
Unconjugated (yellow skin, normal urine and stools)- pre-hepatic
Total serum bilirubin <15mg/dL and daily risk <5mg/dL
120
Neonatal Jaundice
| Early jaundice causes (5)
Sepsis: abnormal conjugation
Slow gut motility: hypothyroidism, CF, Hirschprung's disease
HAEMOLYSIS:
- Rhesus haemolytic disease: 2nd Rh+ve pregnancy after Rh-ve mum delivers Rh+ve baby in 1st pregnancy
- ABO incompatibility: haemolysis from maternal antibodies, eg. A/B babies born to O mothers
Red cell anomalies: hereditary spherocytosis, G6PD
121
Neonatal Jaundice
| Early jaundice classification (6)
Jaundice within 24h of birth is always abnormal
Peak total serum bilirubin >15mg/dL and daily rise >5mg/dL
Sepsis screen: urine and blood cultures
Haemolysis: ABO and rhesus typing, direct and indirect Coomb's test, G6PD assay
Coomb's test: rhesus, haemolytic disease- +ve direct, ABO incompatibility- +ve indirect
Unconjugated (yellow skin, normal urine and stools)
122
Neonatal Jaundice
| Prolonged jaundice causes (5)
```
Breastfeeding
Sepsis
Hypothyroidism
Cystic fibrosis
Biliary atresia
```
123
Neonatal Jaundice
| Prolonged jaundice classification (2)
```
Split bilirubin (conjugated = biliary atresia, yellow skin, dark urine + pale stools)
USS biliary tree if conjugated
```
124
Neonatal Jaundice
| Treatment (2)
Phototherapy: converts bilirubin to soluble products that can be excreted without conjugation
Exchange transfusion: blood warmed to 37 degrees, aim is to remove bilirubin in those with severe or rapidly rising hyperbilirubinaemia
125
Neonatal Jaundice
| Complications (1)
Kernicterus: more likely if bilirubin >360mmol/l, yellow staining of brain, lethargy, poor feeding, hypertonicity, shrill cry
126
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Neonatal Jaundice
Breastfeeding jaundice (3)
```
Pathology: increased beta-glucuronidase in breast milk leads to increased deconjugation and reabsorption of bilirubin and the persistence of physiological jaundice
Unconjugated jaundice within 2 weeks of brith
Treat by continuing breastfeeding with formula, supplementation, phototherapy if required
127
Neonatal Sepsis
| Aetiology (2)
Early onset: transplacental or ascending infection by GBS, E.coli, listeria
Late onset: environmental infection by coagulase negative staphylococci, Staph aureus, GBS, candida
128
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Neonatal Jaundice
Risk factors (2)
```
Early onset: prolonged rupture of membranes, maternal infection (chorioamnionitis, UTI, pyrexia), preterm labour, fetal distress
Late onset: central lines and catheters, congenital malformations
129
Neonatal Jaundice
| Pathology (1)
More at risk if <28wks as maternal IgG not passed on until 3rd trimester
130
Neonatal Jaundice
| Signs + symptoms (7)
```
Non-specific
Temp may be high or low
Lethargy
Poor feeding
Early jaundice
Cyanosis
Hypo/hyperglycaemia
```
131
Neonatal Jaundice
| Investigations (3)
FBC, CRP, blood cultures, glucose
VBG
CXR
132
Neonatal Jaundice
| Treatment (2)
Early onset: IV penicillin + gentamicin until cultures
| Late onset: IV flucloxacillin + gentamicin until cultures
133
Neonatal Jaundice
| Complications (4)
Meningitis
DIC
Pneumonia + respiratory failure
Hypotension and shock
134
Hypoxic Ischaemic Encephalopathy
| Pathology (1)
Brain injury secondary to hypoxia during birth
135
Hypoxic Ischaemic Encephalopathy
| Aetiology (5)
```
Maternal hypoxia
Intrapartum haemorrhage (placental abruption)
Cord prolapse
Nuchal cord (wrapped around neck)
Inadequate neonatal resuscitation
```
136
Hypoxic Ischaemic Encephalopathy
| Signs + symptoms (3)
If mild presents with poor feeding, irritability, hyper-alert (usually resolves within 24h)
If moderate presents with poor feeding, lethargy, hypotonic seizures, takes weeks to resolve and up to 40% develop cerebral palsy
If severe presents with reduced consciousness, apnoeas, flaccid and reduced (absent reflexes, up to 50% mortality and up to 90% develop cerebral palsy)
137
Hypoxic Ischaemic Encephalopathy
| Investigations (2)
Umbilical artery blood gas- acidosis
| Poor Apgar scores
138
Hypoxic Ischaemic Encephalopathy
| Treatment (2)
Resuscitation and ventilation
| Therapeutic hypothermia to reduce inflammation and neurone loss after the acute hypoxic injury
139
Biliary Atresia
| Pathology (2)
Occlusion of biliary tree
| Bile outflow obstruction
140
Biliary Atresia
| Signs + symptoms (2)
```
Conjugated jaundice (dark urine and pale stool) around week 3 of life
Hepatosplenomegaly
```
141
Biliary Atresia
| Investigations (4)
Total serum bilirubin
Split bilirubin (conjugated)
Abdominal USS
Liver biopsy
142
Biliary Atresia
| Treatment (2)
```
Kasai procedure (hepatoportoenterostomy): intestinal limb (Roux-en-Y) attached to bile duct to drain bile from porta hepatis
Liver transplant
```
143
Rhesus Haemolytic Disease
| Aetiology (1)
2nd Rh+ve pregnancy after Rh-ve mother delivers Rh+ve baby in 1st pregnancy (1st Rh+ve pregnancies can be affected by threatened miscarriage, APH)
144
Rhesus Haemolytic Disease
| Pathology (2)
During 1st pregnancy fetal RBCs leak into the Rh-ve mother's circulation stimulating isomerisation (production of anti-D IgG)
In subsequent Rh+ve pregnancies, these antibodies cross the placenta causing haemolytic anaemia
145
Rhesus Haemolytic Disease
| Signs + symptoms (6)
```
Early unconjugated jaundice
CCF
Hepatosplenomegaly
Progressive anaemia
Bleeding
Kernicterus
```
146
Rhesus Haemolytic Disease
| Investigations (2)
+ve direct Coomb's test
| Total serum bilirubin
147
Rhesus Haemolytic Disease
| Treatment (3)
Exchange transfusion
Phototherapy
IV immunoglobulin
148
Rhesus Haemolytic Disease
| Prevention (1)
Anti-D immunoglobulin for Rh-ve mothers
149
Necrotising Enterocolitis
| Pathology (1)
Inflammatory and ischaemic bowel necrosis
150
Necrotising Enterocolitis
| Signs + symptoms (8)
```
Abdominal distension with increasing gastric aspirates
Visible bowel loops
Altered bowel movements and mucoid bloody stool
Palpable bowel mass
Tenderness
Bilious vomit
Loss of bowel sounds
Erythematous abdomen
```
151
Necrotising Enterocolitis
| Investigations (3)
AXR (pneumatosis intestinalis- visible air in gut wall)
Stool cultures
Platelets- marker of disease severity, lower = severe
152
Necrotising Enterocolitis
| Treatment (3)
TPN
IV antibiotics
Laparotomy if progressive
Distension/perforation
153
```
Meconium Aspiration Syndrome
Risk factors (3)
```
Post dates
Maternal DM/HTN
Difficult labour (fetal distress)
154
Meconium Aspiration Syndrome
| Signs + symptoms (1)
Respiratory distress
155
Meconium Aspiration Syndrome
| Investigations (3)
Sepsis screen
Capillary gas
CXR
156
Meconium Aspiration Syndrome
| Treatment (4)
Suction below vocal cords
Intubation and ventilation
IV fluids and antibiotics
Surfactant
157
Meconium Aspiration Syndrome
| Complications (1)
Persistent pulmonary hypertension of the newborn
158
Vitamin K Deficiency Bleeding
| Aetiology (1)
No enteric bacteria to vit K
159
Vitamin K Deficiency Bleeding
| Signs + symptoms (2)
2-7 days post partum
| Baby is usually well, apart from bruising/bleeding
160
Vitamin K Deficiency Bleeding
| Investigations (2)
Prothrombin time increased
| Platelets normal
161
Disseminated Intravascular Coagulation
| Signs + symptoms (4)
Septic signs
Petechiae
Venepuncture oozings
GI bleeding
162
Disseminated Intravascular Coagulation
| Investigations (4)
Platelets low
INR high
Fibrinogen low
D-dimer high
163
```
Autoimmune Thrombocytopenia (ITP)
Pathology (3)
```
Develops in utero
Fetomaternal incompatibility of platelet antigens
Most are first born, 80% recurrence in later pregnancies
164
```
Autoimmune Thrombocytopenia (ITP)
Treatment (1)
```
Platelet transfusion
165
```
Capillary Hemangioma (Strawberry Naevus)
Risk factors (4)
```
Female
Premature
White
Mother underwent chorionic villus sampling
166
```
Capillary Hemangioma (Strawberry Naevus)
Signs + symptoms (2)
```
Erythematous, raised, multi-lobed lesion that can appear on any site in the body (usually face, scalp or back) in 1st month of life (usually not at birth)
Increase in size until 6-9 months before regressing over next few years
167
```
Capillary Hemangioma (Strawberry Naevus)
Treatment (1)
```
Usually none unless visual field obstruction where can use propranolol
168
Stork Mark
| Pathology (1)
Areas of capillary dilatation on the eyelids, central forehead and back of the neck (where stork holds baby), they blanch on pressure and fade with time
169
Oesophageal Atresia
| Pathology (2)
```
Oesophageal atresia and tracheo-oesophageal fistula are a spectrum of abnormalities
Isolated OA (7%) and TOF (4%) can occur but are rare
```
170
```
Oesophageal Atresia
Prenatal signs (2)
```
Polyhydramnios
| Small stomach
171
```
Oesophageal Atresia
Postnatal signs (7)
```
```
Cough
Airway obstruction
Increased secretions
Blowing bubbles
Distended abdomen
Cyanosis
Aspiration
```
172
Oesophageal Atresia
| Treatment (3)
Stop feeding
Suck out oesophageal pouch
Surgical repair
173
Congenital Diaphragmatic Hernia
| Pathology (2)
A developmental defect in the diaphragm allowing herniation of abdominal contents into the chest
Leads to impaired lung development
174
Congenital Diaphragmatic Hernia
| Signs + symptoms (3)
Difficulty resuscitating at birth
Respiratory distress
Bowel sounds in one hemithorax
175
Congenital Diaphragmatic Hernia
| Investigations (2)
Prenatal: US
Postnatal: CXR
176
Congenital Diaphragmatic Hernia
| Treatment (2)
Prenatal: fetal surgery
Postnatal: NG tube, surgery
177
Febrile Fit
| Definition (1)
A simple febrile convulsion is a single tonic-clonic symmetrical generalised seizure lasting <15 min, occurring as temp rises rapidly in a febrile illness (typically in a normally developing child 6m-6y, occurring in 3% of kids)
178
Febrile Fit
| Investigations (6)
```
Need to rule out more serious causes
FBC, U&E, Ca, glucose
Glucose
MSU
CXR
Temp
```
179
Febrile Fit
| Treatment (4)
Recovery position
If fit >5 mins: IV lorazepam, buccal midazolam or PR diazepam
If fit >10 mins: treat as status epilepticus
1/3 have recurrences
180
Hydrocephalus
| Pathology (2)
CSF building up abnormally within the brain and spinal cord
| Due to either over-production or a problem with draining/absorbing
181
Hydrocephalus
| Aetiology (4)
Most commonly, aqueductal stenosis (congenitally stenosed aqueduct between 3rd and 4th ventricle) leading to insufficient drainage of CSF and build up in the lateral and third ventricles
Chiari malformation
Haemorrhage
Infection
182
Hydrocephalus
| Presentation in babies/children (6)
```
Enlarged and rapidly increasing head circumference since cranial bones don't fuse until 2 years
Bulging fontanelles
Poor feeding
Vomiting
Poor tone and head control
Irritability
```
183
Hydrocephalus
| Presentation in adults (6)
```
Headache
Lethargy
Gait abnormality
Memory/concentration decline
Visual changes
Vomiting
```
184
Hydrocephalus
| Treatment (1)
VP (ventriculoperitoneal) shunt which drains the CSF from the ventricles- needs replaced every 2 years
185
Failure to Thrive
| Definition (1)
Significantly low rate of weight gain- crossing centiles
186
Failure to Thrive
| Non-organic causes (7)
```
Poverty
Maternal depression
Maternal drug use
Difficult parent-child interactions
Child neglect
Poor feeding skills
Eating disorders
```
187
```
Failure to Thrive
Organic causes (6)
```
Poor lactation or incorrectly prepared feeds
Prematurity
Oro-palatal anomaly
Neuromuscular disease
Congenital: CF, inborn errors of metabolism, cardiac disease
Nutrient loss: pyloric stenosis, malabsorption, diarrhoea, coeliac, pancreatic insufficiency
188
Failure to Thrive
| Investigations (2)
Check feeding techniques
| Trial of feeding in hospital, if weight gain = non-organic
189
Attention Deficit Hyperactivity Disorder
| Signs + symptoms (3)
Inattention: can't listen to detail, sustain attention in activities follow instructions, finish homework, loses/forgets things
Hyperactivity: squirming/fidgeting, talks incessantly, restless, always on the go
Impulsivity: blurts out answers, interrupts, intrudes on others
190
```
Attention Deficit Hyperactivity Disorder
Differential diagnoses (4)
```
Age-appropriate behaviour
Low (or high) IQ
Hearing impairment
Behavioural disorders
191
Attention Deficit Hyperactivity Disorder
| Treatment (4)
Parent training/education
CBT
1st line methylphenilate (Ritalin)
Atomoxetine for more long term option
192
Oppositional Defiant Disorder
| Signs + symptoms (3)
Negative, hostile and defiant behaviour without serious violation of societal norms or rights of others
May only be present in one environment
More evident in interactions with familiar adults/peers
193
Oppositional Defiant Disorder
| Treatment (3)
Parent training programme
Cognitive therapy
Multisystem therapy (eg. with young person, family, school)
194
Paediatric Asthma
| Treatment (6)
```
1: as required SABA
Proceed if needed >3x per week or if many exacerbations or if wakes from sleep >1x per week
2: low dose ICS
3: LABA if >5, LTRA if <5
4: increase ICS +/- theophylline
5: prednisolone
```
195
Paediatric Asthma
| Treating an attack (7)
1: high flow 100% O2
2: salbutamol nebuliser with ipratropium bromide
3: hydrocortisone
4: one dose IV magnesium sulfate
5: aminophylline
6: nebulisers continuously until improving
7: CPAP, ITU
196
Croup
| Epidemiology (2)
6m-3y
| Parainfluenza type 1
197
Croup
| Signs + symptoms (4)
2 day duration, well child, stridor, hoarse voice, barking cough, worse at night
Mild: occasional barking cough, no stridor at res, no/mild recessions, child looks well
Moderate: frequent barking cough and stridor at rest, recessions at rest, no distress
Severe: prominent inspiratory stridor at rest, marked recessions, distress, agitation, lethargy
198
Croup
| Treatment (3)
Single dose oral dexamethasone
Nebulised adrenaline if distressed
Inhaled ICS if severe
199
Testicular Torsion
| Epidemiology (2)
Neonates
| 13-16y/o
200
Testicular Torsion
| Signs + symptoms in neonates (2)
Painless
| Smooth testicular enlargement with a dark colour that doesn't transilluminate
201
Testicular Torsion
| Signs + symptoms in adolescents (8)
```
Sudden onset
Constant unilateral testicular pain and swelling (may follow minor trauma or sport)
Associated nausea and vomiting
Hemi-scrotum discolouration and tenderness
High riding and horizontal testis
Absent cremasteric reflex
Reactive hydrocele
Impaired gait
```
202
Testicular Torsion
Investigations (2)
Treatment (1)
```
Investigations:
- urinalysis and MC&S
- USS if doubt
Treatment:
- urgent de-torsion (delay will result in testicular infarction)
```
203
Hydrocele
| Epidemiology (1)
Neonates
204
Hydrocele
| Aetiology (1)
Collection of fluid in scrotum due to patent processus vaginalis
205
Hydrocele
| Signs + symptoms (5)
Scrotal swelling that increases with crying and straining
Bluish in colour
Transilluminates
Soft and non-tender
May occur in torsion, trauma, epididymitis or on its own
206
Hydrocele
| Investigations (1)
USS if doubt
207
Hydrocele
| Treatment (2)
Not required, 90% resorb and tunica vaginalis closes by 2 y/o
Consider surgical repair if still present after 2 y/o
208
Intussusception
| Epidemiology (2)
Most common cause of intestinal obstruction in children
| Typically 6-12 months, more common in boys
209
Intussusception
| Aetiology (1)
Telescoping of one intestinal segment into another causing obstruction
210
Intussusception
| Signs + symptoms (5)
```
Bilious vomiting
Episodic intermittent inconsolable crying, with drawing the legs up (colic)
PR blood (like redcurrant jelly)
Sausage shaped mass in RUQ
In between pains there may be no signs
```
211
Intussusception
| Investigations (1)
US abdo shows target sign
212
Intussusception
| Treatment (2)
Enema reduction
| Laparotomy if fails or signs of peritonitis
213
Pyloric Stenosis
| Epidemiology (2)
More common in boys
| 3-8 weeks
214
Pyloric Stenosis
| Signs + symptoms (6)
Non-bilious projectile vomiting after feeds
Constipation
Alert, anxious and always hungry
Palpable left --> right LUQ peristalsis during a feed
Olive-sized pyloric mass
Dehydration
215
Pyloric Stenosis
| Investigations (2)
U&E: metabolic alkalosis with hypokalaemia and hypochloraemia
US if unsure
216
Pyloric Stenosis
| Treatment (2)
Fluid resuscitation bolus of 09% saline then replacement at 1.5x maintenance rate with 5% dextrose + 0.45% saline
Surgery
217
Non-Accidental Injury
| Definitions (3)
Child abuse: deliberate infliction of harm to a child or failure to prevent harm
Neglect: persistent failure to meet a child's basic physical or psychological needs that is likely to result in serious impairment of the child's health and development
Munchausen's by proxy: parent fabricates symptoms in child to gain attention via unnecessary interventions
218
Paediatric UTI
| Signs + symptoms (3)
Neonatal: fever, vomiting, lethargy, irritability, failure to thrive
Pre-verbal: fever, abdo/loin pain, vomiting
Verbal: frequency, dysuria, changes in continence
219
Paediatric UTI
| Investigations (2)
Clean catch samples- urinalysis, microscopy and culture
| US
220
Paediatric UTI
| Treatment (3)
<3m: IV amoxicillin + gentamicin
>3m: trimethoprim, nitrofurantoin
Pyelonephritis: gentamicin, cefotaxime/co-amoxiclav
221
Fetal Alcohol Syndrome
| Signs + symptoms (3)
Failure of growth: reduced eight, length and head circumference
Craniofacial abnormalities: microcephaly, flat philtrum, thin upper lip
Neurodevelopment: learning difficulty, hyperactivity, attention deficit
