Paediatrics Flashcards

Question

Consent children

Answer 1

The General Medical Council have produced guidelines on obtaining consent in children: at 16 years or older a young person can be treated as an adult and can be presumed to have capacity to decide under the age of 16 years children may have capacity to decide, depending on their ability to understand what is involved where a competent child refuses treatment, a person with parental responsibility or the court may authorise investigation or treatment which is in the child's best interests\* With regards to the provision of contraceptives to patients under 16 years of age the Fraser Guidelines state that all the following requirements should be fulfilled: the young person understands the professional's advice the young person cannot be persuaded to inform their parents the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer the young person's best interests require them to receive contraceptive advice or treatment with or without parental consent Gillick or Fraser? Some doctors use the term Fraser competency when referring to contraception and Gillick competency when referring to general issues of consent in children. The (widespread) rumours that Victoria Gillick removed her permission to use her name or applied copyright have recently been debunked. More information can be found in the following article: Wheeler R. Gillick or Fraser? A plea for consistency over competence in children BMJ 2006;332:807 \*in Scotland those with parental responsibility cannot authorise procedures a competent child has refused

Answer 2

The frequency at which children open their bowels varies widely, but generally decreases with age from a mean of 3 times per day for infants under 6 months old to once a day after 3 years of age. NICE produced guidelines in 2010 on the diagnosis and management of constipation in children. A diagnosis of constipation is suggested by 2 or more of the following: Child \< 1 year Child \> 1 year Stool pattern Fewer than 3 complete stools per week (type 3 or 4 on Bristol Stool Form Scale) (this does not apply to exclusively breastfed babies after 6 weeks of age) Hard large stool 'Rabbit droppings' (type 1) ``` Fewer than 3 complete stools per week (type 3 or 4) Overflow soiling (commonly very loose, very smelly, stool passed without sensation) 'Rabbit droppings' (type 1) Large, infrequent stools that can block the toilet ``` Symptoms associated with defecation Distress on passing stool Bleeding associated with hard stool Straining Poor appetite that improves with passage of large stool Waxing and waning of abdominal pain with passage of stool Evidence of retentive posturing: typical straight legged, tiptoed, back arching posture Straining Anal pain History ``` Previous episode(s) of constipation Previous or current anal fissure ``` Previous episode(s) of constipation Previous or current anal fissure Painful bowel movements and bleeding associated with hard stools The vast majority of children have no identifiable cause - idiopathic constipation. Other causes of constipation in children include: dehydration low-fibre diet medications: e.g. Opiates anal fissure over-enthusiastic potty training hypothyroidism Hirschsprung's disease hypercalcaemia learning disabilities After making a diagnosis of constipation NICE then suggesting excluding secondary causes. If no red or amber flags are present then a diagnosis of idiopathic constipation can be made: Prior to starting treatment the child needs to be assessed for faecal impaction. Factors which suggest faecal impaction include: symptoms of severe constipation overflow soiling faecal mass palpable in abdomen (digital rectal examination should only be carried out by a specialist) NICE guidelines on management If faecal impaction is present polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen as the first-line treatment add a stimulant laxative if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if Movicol Paediatric Plain is not tolerated inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain Maintenance therapy very similar to the above regime, with obvious adjustments to the starting dose, i.e. first-line: Movicol Paediatric Plain add a stimulant laxative if no response substitute a stimulant laxative if Movicol Paediatric Plain is not tolerated. Add another laxative such as lactulose or docusate if stools are hard continue medication at maintenance dose for several weeks after regular bowel habit is established, then reduce dose gradually General points do not use dietary interventions alone as first-line treatment although ensure child is having adequate fluid and fibre intake consider regular toileting and non-punitive behavioural interventions for all children consider asking the Health Visitor or Paediatric Continence Advisor to help support the parents. The NICE guidelines do not specifically discuss the management of very young child. The following recommendations are largely based on the old Clinical Knowledge Summaries recommendations. Infants not yet weaned (usually \< 6 months) bottle-fed infants: give extra water in between feeds. Try gentle abdominal massage and bicycling the infant's legs breast-fed infants: constipation is unusual and organic causes should be considered Infants who have or are being weaned offer extra water, diluted fruit juice and fruits if not effective consider adding lactulose

Answer 3

Cow's milk protein intolerance/allergy (CMPI/CMPA) occurs in around 3-6% of all children and typically presents in the first 3 months of life in formula-fed infants, although rarely it is seen in exclusively breastfed infants. Both immediate (IgE mediated) and delayed (non-IgE mediated) reactions are seen. The term CMPA is usually used for immediate reactions and CMPI for mild-moderate delayed reactions. Features regurgitation and vomiting diarrhoea urticaria, atopic eczema 'colic' symptoms: irritability, crying wheeze, chronic cough rarely angioedema and anaphylaxis may occur Diagnosis is often clinical (e.g. improvement with cow's milk protein elimination). Investigations include: skin prick/patch testing total IgE and specific IgE (RAST) for cow's milk protein Management If the symptoms are severe (e.g. failure to thrive) refer to a paediatrician. Management if formula-fed extensive hydrolysed formula (eHF) milk is the first-line replacement formula for infants with mild-moderate symptoms amino acid-based formula (AAF) in infants with severe CMPA or if no response to eHF around 10% of infants are also intolerant to soya milk Management if breastfed continue breastfeeding eliminate cow's milk protein from maternal diet. Consider prescribing calcium supplements for breastfeeding mothers whose babies have, or are suspected to have, CMPI, to prevent deficiency whilst they exclude dairy from their diet use eHF milk when breastfeeding stops, until 12 months of age and at least for 6 months CMPI usually resolves in most children in children with IgE mediated intolerance around 55% will be milk tolerant by the age of 5 years in children with non-IgE mediated intolerance most children will be milk tolerant by the age of 3 years a challenge is often performed in the hospital setting as anaphylaxis can occur. The milk ladder can be used after 6 months of age to reintroduce milk protein in children with cows milk protein allergy.

Answer 4

Cystic fibrosis (CF) is an autosomal recessive disorder causing increased viscosity of secretions (e.g. lungs and pancreas). It is due to a defect in the cystic fibrosis transmembrane conductance regulator gene (CFTR), which codes a cAMP-regulated chloride channel In the UK 80% of CF cases are due to delta F508 on the long arm of chromosome 7. Cystic fibrosis affects 1 per 2500 births, and the carrier rate is c. 1 in 25 Organisms which may colonise CF patients Staphylococcus aureus Pseudomonas aeruginosa Burkholderia cepacia\* Aspergillus \*previously known as Pseudomonas cepacia CF is inherited in an autosomal recessive manner. The incidence of CF in the UK is approximately 1/2500, and the carrier rate is 1/25. As the condition is autosomal recessive, there is a 25% chance she will have a child who does not have CF and who is not a carrier, a 50% chance that she will have a child who does not have CF however is a carrier, and a 25% chance that she will have a child who has cystic fibrosis.

Answer 5

Developmental dysplasia of the hip (DDH) is gradually replacing the old term 'congenital dislocation of the hip' (CDH). It affects around 1-3% of newborns. Risk factors female sex: 6 times greater risk breech presentation positive family history firstborn children oligohydramnios birth weight \> 5 kg congenital calcaneovalgus foot deformity DDH is slightly more common in the left hip. Around 20% of cases are bilateral. Screening for DDH the following infants require a routine ultrasound examination first-degree family history of hip problems in early life breech presentation at or after 36 weeks gestation, irrespective of presentation at birth or mode of delivery multiple pregnancy all infants are screened at both the newborn check and also the six-week baby check using the Barlow and Ortolani tests Clinical examination Barlow test: attempts to dislocate an articulated femoral head Ortolani test: attempts to relocate a dislocated femoral head other important factors include: symmetry of leg length level of knees when hips and knees are bilaterally flexed restricted abduction of the hip in flexion Ultrasound is used to confirm the diagnosis if clinically suspected Management most unstable hips will spontaneously stabilise by 3-6 weeks of age Pavlik harness (dynamic flexion-abduction orthosis) in children younger than 4-5 months older children may require surgery Kallman's syndrome is a cause of delayed puberty secondary to hypogonadotrophic hypogonadism. It is not associated with snoring

Answer 6

Referral points doesn't smile at 10 weeks cannot sit unsupported at 12 months cannot walk at 18 months Fine motor skill problems hand preference before 12 months is abnormal and may indicate cerebral palsy Gross motor problems most common causes of problems: variant of normal, cerebral palsy and neuromuscular disorders (e.g. Duchenne muscular dystrophy) Speech and language problems always check hearing other causes include environmental deprivation and general development delay

Answer 7

Risk of Down's syndrome with increasing maternal age Age (years) Risk 20 - 1 in 1,500 30 - 1 in 800 35 - 1 in 270 40 - 1 in 100 45 - 1 in 50 or greater One way of remembering this is by starting at 1/1,000 at 30 years and then dividing the denominator by 3 (i.e. 3 times more common) for every extra 5 years of age Cytogenetics Mode % of cases Risk of recurrence Nondisjunction 94% 1 in 100 if under mother \< 35 years Robertsonian translocation (usually onto 14) 5% 10-15% if mother is translocation carrier 2.5% if father is translocation carrier Mosaicism\* 1% The chance of a further child with Down's syndrome is approximately 1 in 100 if the mother is less than 35 years old. If the trisomy 21 is a result of a translocation the risk is much higher \*Mosaicism is defined as the presence of two genetically different populations of cells in the body Down's syndrome: features Clinical features face: upslanting palpebral fissures, epicanthic folds, Brushfield spots in iris, protruding tongue, small low-set ears, round/flat face flat occiput single palmar crease, pronounced 'sandal gap' between big and first toe hypotonia congenital heart defects (40-50%, see below) duodenal atresia Hirschsprung's disease Cardiac complications multiple cardiac problems may be present endocardial cushion defect (most common, 40%, also known as atrioventricular septal canal defects) ventricular septal defect (c. 30%) secundum atrial septal defect (c. 10%) tetralogy of Fallot (c. 5%) isolated patent ductus arteriosus (c. 5%) Later complications subfertility: males are almost always infertile due to impaired spermatogenesis. Females are usually subfertile, and have an increased incidence of problems with pregnancy and labour learning difficulties short stature repeated respiratory infections (+hearing impairment from glue ear) acute lymphoblastic leukaemia hypothyroidism Alzheimer's disease atlantoaxial instability

Answer 8

Eczema occurs in around 15-20% of children and is becoming more common. It typically presents before 6 months but clears in around 50% of children by 5 years of age and in 75% of children by 10 years of age Features in infants the face and trunk are often affected in younger children eczema often occurs on the extensor surfaces in older children a more typical distribution is seen, with flexor surfaces affected and the creases of the face and neck Management avoid irritants simple emollients: large quantities should be prescribed (e.g. 250g / week), roughly in a ratio of with topical steroids of 10:1. If a topical steroid is also being used the emollient should be applied first followed by waiting at least 30 minutes before applying the topical steroid. Creams soak into the skin faster than ointments. Emollients can become contaminated with bacteria - fingers should not be inserted into pots (many brands have pump dispensers) topical steroids in severe cases wet wraps and oral ciclosporin may be used

Answer 9

Benign rolandic epilepsy is a form of childhood epilepsy which typically occurs between the age of 4 and 12 years. Features seizures characteristically occur at night seizures are typically partial (e.g. paraesthesia affecting face) but secondary generalisation may occur (i.e. parents may only report tonic-clonic movements) child is otherwise normal EEG characteristically shows centro-temporal spikes Prognosis is excellent, with seizures stopping by adolescence Rolandic seizures are a form of epilepsy that is often seen in children but will disappear as they reach adolescence. The seizures start around the central sulcus of the brain (located near the rolandic fissure) and usually present with facial symptoms such as hypersalivation, drooling, loss of speech, facial twitching and numbness of the face or tongue. The seizures can also spread to other parts of the brain and present with symptoms in other areas. Consciousness usually remains during the seizures but it is possible for the patient to not have any recollection in the post-ictal period.

Answer 10

The 2011 NICE guidelines differentiate between IgE mediated and non-IgE mediated allergies. It should be noted that the guidance does not govern food intolerance, which is not caused by immune system dysfunction. The first step is to identify possible food allergy and differentiate the possible causes: IgE-mediated Non-IgE-mediated Skin pruritus erythema urticaria angioedema Gastrointestinal system nausea colicky abdominal pain vomiting diarrhoea Respiratory system upper respiratory tract symptoms - nasal itching,sneezing, rhinorrhoea or congestion (with or without conjunctivitis) lower respiratory tract symptoms - cough, chest tightness, wheezing or shortness of breath Symptoms of anaphylaxis Skin pruritus erythema atopic eczema Gastrointestinal system gastro-oesophageal reflux disease loose or frequent stools blood and/or mucus in stools abdominal pain infantile colic food refusal or aversion constipation perianal redness pallor and tiredness faltering growth plus one or more gastrointestinal symptoms above (with or without significant atopic eczema) If the history is suggestive of an IgE-mediated allergy offer a skin prick test or blood tests for specific IgE antibodies to the suspected foods and likely co-allergens If the history is suggestive of an non-IgE-mediated allergy eliminate the suspected allergen for 2-6 weeks, then reintroduce. NICE advise to 'consult a dietitian with appropriate competencies about nutritional adequacies, timings and follow-up'

Answer 11

Gastro-oesophageal reflux is the commonest cause of vomiting in infancy. Around 40% of infants regurgitate their feeds to a certain extent so there is a degree of overlap with normal physiological processes. Risk factors preterm delivery neurological disorders Features typically develops before 8 weeks vomiting/regurgitation following feeds Diagnosis is usually made clinically Management (partly based on the 2015 NICE guidelines) advise regarding position during feeds - 30 degree head-up infants should sleep on their backs as per standard guidance to reduce the risk of cot death ensure infant is not being overfed (as per their weight) and consider a trial of smaller and more frequent feeds a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum) a trial of alginate therapy e.g. Gaviscon. Alginates should not be used at the same time as thickening agents NICE do not recommend a proton pump inhibitor (PPI) or H2 receptor antagonists (H2RA), to treat overt regurgitation in infants and children occurring as an isolated symptom. A trial of one of these agents should be considered if 1 or more of the following apply: unexplained feeding difficulties (for example, refusing feeds, gagging or choking) distressed behaviour faltering growth prokinetic agents e.g. metoclopramide should only be used with specialist advice Complications distress failure to thrive aspiration frequent otitis media in older children dental erosion may occur If there are severe complications (e.g. failure to thrive) and medical treatment is ineffective then fundoplication may be considered NICE advise that breastfed infants who have persisting symptoms of frequent regurgitation associated with marked distress should be given a 1-2 week trial of alginate therapy (eg. Gaviscon) following every feed. If symptoms persist following this then a 4-week trial of a proton pump inhibitor (such as oral omeprazole) or a histamine-2 receptor antagonist (such as oral ranitidine) should be given. If symptoms still persist despite this then a referral to paediatrics should be considered. Thickened feeds should be given to bottle-fed infants with reflux.

Answer 12

Hand, foot and mouth disease is a self-limiting condition affecting children. It is caused by the intestinal viruses of the Picornaviridae family (most commonly coxsackie A16 and enterovirus 71). It is very contagious and typically occurs in outbreaks at nursery Clinical features mild systemic upset: sore throat, fever oral ulcers followed later by vesicles on the palms and soles of the feet Management symptomatic treatment only: general advice about hydration and analgesia reassurance no link to disease in cattle children do not need to be excluded from school the HPA recommends that children who are unwell should be kept off school until they feel better they also advise that you contact them if you suspect that there may be a large outbreak.

Answer 13

Some of the following is based on an excellent review article on the Great Ormond Street Hospital website. Epidemiology up to 50 per cent of 7-year-olds and up to 80 per cent of 15-year-old have experienced at least one headache equally as common in boys/girls until puberty then strong (3:1) female preponderance Migraine Migraine without aura is the most common cause of primary headache in children. The International Headache Society (IHS) have produced criteria for paediatric migraine without aura: Acute management ibuprofen is thought to be more effective than paracetamol for paediatric migraine NICE CKS recommends that triptans may be used in children \>= 12 years but follow-up is required sumatriptan nasal spay (licensed) is the only triptan that has proven efficacy but it is poorly tolerated by young people who don't like the taste in the back of the throat it should be noted that oral triptans are not currently licensed in people \< 18 years side-effects of triptans include tingling, heat and heaviness/pressure sensations Prophylaxis the evidence base is limited and no clear consensus guidelines exist the GOSH website states: 'in practice, pizotifen and propranolol should be used as first line preventatives in children. Second line preventatives are valproate, topiramate and amitryptiline' Tension-type headache (TTH) Tension-type headache is the second most common cause of headache in children. The IHS diagnostic criteria for TTH in children is reproduced below: Ibuprofen is the first-line treatment for paediatric migraine Important for meLess important Ibuprofen is the first-line treatment for paediatric migraines. Sumatriptan nasal spray is only licensed in children \>12 years of age. Oral sumatriptan is not licensed in people \<18 years old. Neither codeine or oramorph is offered for paediatric migraine. Oral indomethacin is not used to treat paediatric migraines.

Answer 14

Hypospadias is a congenital abnormality of the penis which occurs in approximately 3/1,000 male infants Hypospadias is characterised by a ventral urethral meatus a hooded prepuce chordee (ventral curvature of the penis) in more severe forms the urethral meatus may open more proximally in the more severe variants. However, 75% of the openings are distally located. Hypospadias most commonly occurs as an isolated disorder. Associated urological abnormalities may be seen in up to 40% of infants, of these cryptorchidism is the most frequent (10%). Corrective surgery is performed before 2 years of age. It is essential that the child is not circumcised prior to the surgery as the foreskin may be used in the corrective procedure. In boys with very distal disease no treatment may be needed

Answer 15

The current UK immunisation schedule is as follows. Age Recommended immunisations At birth BCG if risk factors (see below) 2 months '6-1 vaccine' (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B) Oral rotavirus vaccine Men B 3 months\* '6-1 vaccine' (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B) Oral rotavirus vaccine PCV 4 months '6-1 vaccine' (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B) Men B 12-13 months Hib/Men C MMR PCV Men B 2-8 years Flu vaccine (annual) 3-4 years '4-in-1 pre-school booster' (diphtheria, tetanus, whooping cough and polio) MMR 12-13 years HPV vaccination 13-18 years '3-in-1 teenage booster' (tetanus, diphtheria and polio) Men ACWY At birth the BCG vaccine should be given if the baby is deemed at risk of tuberculosis (e.g. Tuberculosis in the family in the past 6 months). Meningitis ACWY vaccine Note that the meningitis ACWY vaccine has replaced meningitis C for 13-18 year-olds. This is due to an increased incidence of meningitis W disease in recent years. The ACWY vaccine will also be offered to new students (up to the age of 25 years) at university. With respect to getting the vaccine, the NHS give the following advice to patients: 'GP practices will automatically send letters inviting 17-and 18-year-olds in school year 13 to have the Men ACWY vaccine. Students going to university or college for the first time as freshers, including overseas and mature students up to the age of 25, should contact their GP to have the Men ACWY vaccine, ideally before the start of the academic year'

Answer 16

The Department of Health published guidance in 2006 on the safe administration of vaccines in its publication 'Immunisation against infectious disease' General contraindications to immunisation confirmed anaphylactic reaction to a previous dose of a vaccine containing the same antigens confirmed anaphylactic reaction to another component contained in the relevant vaccine (e.g. egg protein) Situations where vaccines should be delayed febrile illness/intercurrent infection Contraindications to live vaccines pregnancy immunosuppression Specific vaccines DTP: vaccination should be deferred in children with an evolving or unstable neurological condition Not contraindications to immunisation asthma or eczema history of seizures (if associated with fever then advice should be given regarding antipyretics) breastfed child previous history of natural pertussis, measles, mumps or rubella infection history of neonatal jaundice family history of autism neurological conditions such as Down's or cerebral palsy low birth weight or prematurity patients on replacement steroids e.g. (CAH)

Answer 17

Children in the UK have been routinely immunised against serotypes A & C of meningococcus for many years. As a result meningococcal B became the most common cause of bacterial meningitis in the UK. A vaccination against meningococcal B (Bexsero) has recently been developed and introduced to the UK market. The Joint Committee on Vaccination and Immunisation (JCVI) initially rejected the use of Bexsero after doing a cost-benefit analysis. This descision was eventually reversed and meningitis B has now been added to the routine NHS immunisation. Three doses are now given at: 2 months 4 months 12-13 months Bexsero will also be available on the NHS for patients at high risk of meningococcal disease, such as people with asplenia, splenic dysfunction or complement disorder.

Answer 18

Pathophysiology S .pneumoniae is the most likely causative agent of a bacterial pneumonia in children The British Thoracic Society published guidelines in 2011 on the management of community acquired pneumonia in childhood. Key points are summarised below: Treatment Amoxicillin is first-line for all children with pneumonia Macrolides may be added if there is no response to first line therapy Macrolides should be used if mycoplasma or chlamydia is suspected In pneumonia associated with influenza, co-amoxiclav is recommended

Answer 19

Jaundice in the first 24 hrs is always pathological Causes of jaundice in the first 24 hrs rhesus haemolytic disease ABO haemolytic disease hereditary spherocytosis glucose-6-phosphodehydrogenase Jaundice in the neonate from the c. 2-14 days is common (up to 40%) and usually physiological. It is more commonly seen in breast fed babies If there are still signs of jaundice after 14 days a prolonged jaundice screen is performed, including: conjugated and unconjugated bilirubin: the most important test as a raised conjugated bilirubin could indicate biliary atresia which requires urgent surgical intervention direct antiglobulin test (Coombs' test) TFTs FBC and blood film urine for MC&S and reducing sugars U&Es and LFTs Causes of prolonged jaundice biliary atresia hypothyroidism galactosaemia urinary tract infection breast milk jaundice congenital infections e.g. CMV, toxoplasmosis Most newborn girls have some mucoid white vaginal discharge which usually disappears by 3 months of age Important for meLess important Most newborn girls have some mucoid white vaginal discharge which usually disappears by 3 months of age. The most appropriate step is to reassure. There is no need to refer to paediatrics at this stage. There is no evidence for sexual abuse. It is inappropriate to arrange a transvaginal ultrasound for these symptoms. Haemorrhagic disease of the newborn Newborn babies are relatively deficient in vitamin K. This may result in impaired production of clotting factors which in turn can lead to haemorrhagic disease of the newborn (HDN). Bleeding may range from minor brushing to intracranial haemorrhages Breast-fed babies are particularly at risk as breast milk is a poor source of vitamin K. Maternal use of antiepileptics also increases the risk Because of this all newborns in the UK are offered vitamin K, either intramuscularly or orally

Answer 20

Kawasaki disease is a type of vasculitis which is predominately seen in children. Whilst Kawasaki disease is uncommon it is important to recognise as it may cause potentially serious complications, including coronary artery aneurysms. Features high-grade fever which lasts for \> 5 days. Fever is characteristically resistant to antipyretics conjunctival injection bright red, cracked lips strawberry tongue cervical lymphadenopathy red palms of the hands and the soles of the feet which later peel Kawasaki disease is a clinical diagnosis as there is no specific diagnostic test. Management high-dose aspirin Kawasaki disease is one of the few indications for the use of aspirin in children. Due to the risk of Reye's syndrome aspirin is normally contraindicated in children intravenous immunoglobulin echocardiogram (rather than angiography) is used as the initial screening test for coronary artery aneurysms Complications coronary artery aneurysm Coronary artery aneurysms are a complication of Kawasaki disease and this should be screened for with an echocardiogram

Answer 21

The table below summarises the key features of common knee problems: Condition Key features Chondromalacia patellae Softening of the cartilage of the patella Common in teenage girls Characteristically anterior knee pain on walking up and down stairs and rising from prolonged sitting Usually responds to physiotherapy Osgood-Schlatter disease (tibial apophysitis) Seen in sporty teenagers Pain, tenderness and swelling over the tibial tubercle Osteochondritis dissecans Pain after exercise Intermittent swelling and locking Patellar subluxation Medial knee pain due to lateral subluxation of the patella Knee may give way Patellar tendonitis More common in athletic teenage boys Chronic anterior knee pain that worsens after running Tender below the patella on examination

Answer 22

A common presentation in General Practice is a child complaining of pain in the legs with no obvious cause. Such presentations, in the absence of any worrying features, are often attributed to 'growing pains'. This is a misnomer as the pains are often not related to growth - the current term used in rheumatology is 'benign idiopathic nocturnal limb pains of childhood' Growing pains are equally common in boys and girls and occur in the age range of 3-12 years. Features of growing pains never present at the start of the day after the child has woken no limp no limitation of physical activity systemically well normal physical examination motor milestones normal symptoms are often intermittent and worse after a day of vigorous activity Growing pains are a common complaint in children aged 3-12 years. These usually present with children complaining of pains in their legs. When seeing children who are presenting with these symptoms it is important to check that there are no 'red flags' Osteosarcoma is rare, but it is an important diagnosis to rule out. Features of osteosarcoma include an unexplained lump, unexplained bone pain or unexplained swelling. Juvenile rheumatoid arthritis usually presents as fever, rash and symmetrical joint pain and swelling. Osteochondritis dissecans is a joint disorder in which cracks form in the articular cartilage and underlying subchondral bone. This results in joint pain, locking and swelling. Bipartite patella is a condition in which the kneecap is formed of 2 separate bones -it is usually asymptomatic.

Answer 23

Juvenile idiopathic arthritis (JIA), now preferred to the older term juvenile chronic arthritis, describes arthritis occurring in someone who is less than 16 years old that lasts for more than 6 weeks. Pauciarticular JIA refers to cases where 4 or less joints are affected. It accounts for around 60% of cases of JIA Features of pauciarticular JIA joint pain and swelling: usually medium sized joints e.g. knees, ankles, elbows limp ANA may be positive in JIA - associated with anterior uveitis

Answer 24

Labial adhesions Labial adhesions describe the fusion of the labia minora in the midline. It is usually seen in girls between the ages of 3 months and 3 years and can generally be treated conservatively. Spontaneous resolution tends to occur around puberty. It should be noted that the condition is different from an imperforate hymen. The majority of cases are symptomatic. Features may include: problems with micturition including pooling in the vagina on examination thin semitranslucent adhesions covering the vaginal opening between the labia minora are seen, which sometimes cover the vaginal opening completely Management conservative management is appropriate in the majority of cases if there are associated problems such as recurrent urinary tract infections oestrogen cream may be tried if this fails surgical intervention may be warranted

Answer 25

Measles is now rarely seen in the developed world following the adoption of immunisation programmes. Outbreaks are occasionally seen, particularly when vaccinations rates drop, for example after the MMR controversy of the early 2000s. Overview RNA paramyxovirus spread by droplets infective from prodrome until 4 days after rash starts incubation period = 10-14 days Features prodrome: irritable, conjunctivitis, fever Koplik spots (before rash): white spots ('grain of salt') on buccal mucosa rash: starts behind ears then to whole body, discrete maculopapular rash becoming blotchy & confluent Koplik spots Investigations IgM antibodies can be detected within a few days of rash onset Management mainly supportive admission may be considered in immunosuppressed or pregnant patients notifiable disease → inform public health Complications otitis media: the most common complication pneumonia: the most common cause of death encephalitis: typically occurs 1-2 weeks following the onset of the illness) subacute sclerosing panencephalitis: very rare, may present 5-10 years following the illness febrile convulsions keratoconjunctivitis, corneal ulceration diarrhoea increased incidence of appendicitis myocarditis The rash typically starts behind the ears and then spreads to the whole body Management of contacts if a child not immunized against measles comes into contact with measles then MMR should be offered (vaccine-induced measles antibody develops more rapidly than that following natural infection) this should be given within 72 hours

Answer 26

Investigations Contraindication to lumbar puncture (any signs of raised ICP) focal neurological signs papilloedema significant bulging of the fontanelle disseminated intravascular coagulation signs of cerebral herniation For patients with meningococcal septicaemia a lumbar puncture is contraindicated - blood cultures and PCR for meningococcus should be obtained. Management 1. Antibiotics \< 3 months: IV amoxicillin + IV cefotaxime \> 3 months: IV cefotaxime 2. Steroids NICE advise against giving corticosteroids in children younger than 3 months dexamethsone should be considered if the lumbar puncture reveals any of the following: frankly purulent CSF CSF white blood cell count greater than 1000/microlitre raised CSF white blood cell count with protein concentration greater than 1 g/litre bacteria on Gram stain 3. Fluids treat any shock, e.g. with colloid 4. Cerebral monitoring mechanical ventilation if respiratory impairment 5. Public health notification and antibiotic prophylaxis of contacts ciprofloxacin is now preferred over rifampicin Consider adding steroids in the management of children \> 3 months with meningitis Paediatric drug doses: emergency The current BNF should always be consulted prior to prescribing drugs you are unfamiliar with, the following is just a guide IM benzylpenicillin for suspected meningococcal septicaemia in the community Age Dose \< 1 year - 300 mg 1 - 10 years - 600 mg \> 10 years - 1200 mg Neonates are at a greater risk of meningitis, with greater risks associated with low birth weight, prematurity, traumatic delivery, fetal hypoxia and maternal peripartum infection. Initial presentation is usually nonspecific. Possible features include raised temperatures, respiratory distress, apnoea, bradycardia episodes, hypotension, feeding difficulty, irritability and reduced activity.

Answer 27

Roseola infantum (also known as exanthem subitum, occasionally sixth disease) is a common disease of infancy caused by the human herpes virus 6 (HHV6). It has an incubation period of 5-15 days and typically affects children aged 6 months to 2 years. Features high fever: lasting a few days, followed later by a maculopapular rash Nagayama spots: papular enanthem on the uvula and soft palate febrile convulsions occur in around 10-15% diarrhoea and cough are also commonly seen Other possible consequences of HHV6 infection aseptic meningitis hepatitis School exclusion is not needed.

Answer 28

Causes of a napkin ('nappy') rash include the following: Type Notes Irritant dermatitis The most common cause, due to irritant effect of urinary ammonia and faeces Creases are characteristically spared Candida dermatitis Typically an erythematous rash which involve the flexures and has characteristic satellite lesions Seborrhoeic dermatitis Erythematous rash with flakes. May be coexistent scalp rash Psoriasis A less common cause characterised by an erythematous scaly rash also present elsewhere on the skin Atopic eczema Other areas of the skin will also be affected General management points disposable nappies are preferable to towel nappies expose napkin area to air when possible apply barrier cream (e.g. Zinc and castor oil) mild steroid cream (e.g. 1% hydrocortisone) in severe cases management of suspected candidal nappy rash is with a topical imidazole. Cease the use of a barrier cream until the candida has settled Roseola infantum - fever followed later by rash

Answer 29

Necrotising enterocolitis is one of the leading causes of death among premature infants. Initial symptoms can include feeding intolerance, abdominal distension and bloody stools, which can quickly progress to abdominal discolouration, perforation and peritonitis. Abdominal x-rays are useful when diagnosing necrotising enterocolitis, as they can show: dilated bowel loops (often asymmetrical in distribution) bowel wall oedema pneumatosis intestinalis (intramural gas) portal venous gas pneumoperitoneum resulting from perforation air both inside and outside of the bowel wall (Rigler sign) air outlining the falciform ligament (football sign) Early signs of necrotising enterocolitis: feeding intolerance, abdominal distension and bloody stools Important for meLess important Early signs of necrotising enterocolitis include feeding intolerance, abdominal distension and bloody stools. Given that this baby is preterm, the risk of developing necrotising enterocolitis is high. GORD does not present with abdominal distension and bloody stools. Duodenal atresia usually present with bilious vomiting within the first day of life. It would not cause bloody stools. Given that this baby was recently discharged, hospital-acquired infection is a possibility. However, given the clinical picture and the preterm status, necrotising enterocolitis is more likely and in reality, needs to be ruled out first.

Answer 30

Neonatal blood spot screening (previously called the Guthrie test or 'heel-prick test') is performed at 5-9 days of life The following conditions are currently screened for: congenital hypothyroidism cystic fibrosis sickle cell disease phenylketonuria medium chain acyl-CoA dehydrogenase deficiency (MCADD) maple syrup urine disease (MSUD) isovaleric acidaemia (IVA) glutaric aciduria type 1 (GA1) homocystinuria (pyridoxine unresponsive) (HCU)

Answer 31

The majority of children achieve day and night time continence by 3 or 4 years of age. Enuresis may be defined as the 'involuntary discharge of urine by day or night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract' Nocturnal enuresis can be defined as either primary (the child has never achieved continence) or secondary (the child has been dry for at least 6 months before) NICE issued guidance in 2010. Management: look for possible underlying causes/triggers (e.g. Constipation, diabetes mellitus, UTI if recent onset) advise on fluid intake, diet and toileting behaviour reward systems (e.g. Star charts). NICE recommend these 'should be given for agreed behaviour rather than dry nights' e.g. Using the toilet to pass urine before sleep NICE advises: 'Consider whether an alarm or drug treatment is appropriate, depending on the age, maturity and abilities of the child or young person, the frequency of bedwetting and the motivation and needs of the family'. Generally: an enuresis alarm is first-line for children under the age of 7 years desmopressin may be used first-line for children over the age 7 years, particularly if short-term control is needed or an enuresis alarm has been ineffective/is not acceptable to the family please see the link for more details

Answer 32

Defining obesity is more difficult in children than adults as body mass index (BMI) varies with age. BMI percentile charts are therefore needed to make an accurate assessment. Recent NICE guidelines suggest to use 'UK 1990 BMI charts to give age- and gender-specific information' NICE recommend consider tailored clinical intervention if BMI at 91st centile or above. consider assessing for comorbidities if BMI at 98th centile or above By far the most common cause of obesity in childhood is lifestyle factors. Other associations of obesity in children include: Asian children: four times more likely to be obese than white children female children taller children: children with obesity are often above the 50th percentile in height Cause of obesity in children growth hormone deficiency hypothyroidism Down's syndrome Cushing's syndrome Prader-Willi syndrome Consequences of obesity in children orthopaedic problems: slipped upper femoral epiphyses, Blount's disease (a development abnormality of the tibia resulting in bowing of the legs), musculoskeletal pains psychological consequences: poor self-esteem, bullying sleep apnoea benign intracranial hypertension long-term consequences: increased incidence of type 2 diabetes mellitus, hypertension and ischaemic heart disease Obesity can cause snoring in children Snoring is the description of noisy breathing during sleep. The snoring sound can be generated in the nose, at the level of the soft palate and uvula, at the level of the pharyngeal wall and tonsils and/or at the base of the tongue. Some of the most common causes of snoring in children are; obesity nasal problems: polyps, deviated septum, hypertrophic nasal turbinates recurrent tonsillitis Down's syndrome hypothyroidism **Snoring in children** Causes obesity nasal problems: polyps, deviated septum, hypertrophic nasal turbinates recurrent tonsillitis Down's syndrome hypothyroidism

Answer 33

Ophthalmia neonatorum simply means infection of the newborn eye. Responsible organisms include Chlamydia trachomatis Neisseria gonorrhoeae Suspected ophthalmia neonatorum should be referred for same-day ophthalmology/paediatric assessment.

Answer 34

The 2015 Resuscitation Council guidelines made the following changes to paediatric basic life support compression:ventilation ratio: lay rescuers should use a ratio of 30:2. If there are two or more rescuers with a duty to respond then a ratio of 15:2 should be used age definitions: an infant is a child under 1 year, a child is between 1 year and puberty Key points of algorithm (please see link attached for more details) unresponsive? shout for help open airway look, listen, feel for breathing give 5 rescue breaths check for signs of circulation 15 chest compressions:2 rescue breaths (see above)

Answer 35

Embryology During development the umbilicus has two umbilical arteries and one umbilical vein. The arteries are continuous with the internal iliac arteries and the vein is continuous with the falciform ligament (ductus venosus). After birth, the cord dessicates and separates and the umbilical ring closes. Umbilical hernia Up to 20% of neonates may have an umbilical hernia, it is more common in premature infants. The majority of these hernias will close spontaneously (may take between 12 months and three years). Strangulation is rare. Paraumbilical hernia These are due to defects in the linea alba that are in close proximity to the umbilicus. The edges of a paraumbilical hernia are more clearly defined than those of an umbilical hernia. They are less likely to resolve spontaneously than an umbilical hernia. Omphalitis This condition consists of an infection of the umbilicus. Infection with Staphylococcus aureus is the commonest cause. The condition is potentially serious as infection may spread rapidly through the umbilical vessels in neonates with a risk of portal pyaemia, and portal vein thrombosis. Treatment is usually with a combination of topical and systemic antibiotics. Umbilical granuloma These consist of cherry red lesions surrounding the umbilicus, they may bleed on contact and be a site of seropurulent discharge. Infection is unusual and they will often respond favourably to chemical cautery with topically applied silver nitrate. Persistent urachus This is characterised by urinary discharge from the umbilicus. It is caused by persistence of the urachus which attaches to the bladder. They are associated with other urogenital abnormalities. Persistent vitello-intestinal duct This will typically present as an umbilical discharge that discharges small bowel content. Complete persistence of the duct is a rare condition. Much more common is the persistence of part of the duct (Meckel's diverticulum). Persistent vitello-intestinal ducts are best imaged using a contrast study to delineate the anatomy and are managed by laparotomy and surgical closure.

Answer 36

Perinatal mortality rate still births + neonatal deaths in 7 days per 1,000 births after 24 weeks gestation around 8 per 1,000 Maternal mortality rate = deaths in pregnancy, labour & 6 weeks afterwards / total maternities \* 1000 Stillbirth rate = babies born dead after 24 weeks / total births (live + stillborn) \* 1000 Neonatal death rate = babies dying between 1-28 days / total live births \* 1000 Meconium aspiration syndrome Meconium aspiration syndrome refers to respiratory distress in the newborn as a result of meconium in the trachea. It occurs in the immediate neonatal period. It is more common in post-term deliveries, with rates of up to 44% reported in babies born after 42 weeks. It causes respiratory distress, which can be severe. Higher rates occur where there is a history of maternal hypertension, pre-eclampsia, chorioamnionitis, smoking or substance abuse. Chest x-ray in transient tachypnoea of the newborn may show hyperinflation and fluid in the horizontal fissure Important for meLess important It is important to note that even if you suspect transient tachypnoea of the newborn the baby should be screened and treated for sepsis. Transient tachypnoea of the newborn is the commonest cause of respiratory distress in a neonate and will resolve in 24-48 hours. X-ray will show hyperinflation and fluid in the horizontal fissure. Ground glass appearance and low volume lungs are seen in respiratory distress syndrome. Asymmetric patchy opacities are seen in meconium aspiration syndrome. A pneumothorax is associated with mechanical ventilation but should be carefully looked for in all chest x-rays. Transient tachypnoea of the newborn Transient tachypnoea of the newborn (TTN) is the commonest cause of respiratory distress in the newborn period. It is caused by delayed resorption of fluid in the lungs It is more common following Caesarean sections, possibly due to the lung fluid not being 'squeezed out' during the passage through the birth canal Chest x-ray may show hyperinflation of the lungs and fluid in the horizontal fissure Supplementary oxygen may be required to maintain oxygen saturations. Transient tachypnoea of the newborn usually settles within 1-2 days s two trained members of staff are present the ratio of chest compressions to ventilations should be 15:2

Answer 37

Perthes' disease is a degenerative condition affecting the hip joints of children, typically between the ages of 4-8 years. It is due to avascular necrosis of the femoral head, specifically the femoral epiphysis. Impaired blood supply to the femoral head causes bone infarction. Perthes' disease is 5 times more common in boys. Around 10% of cases are bilateral Features hip pain: develops progressively over a few weeks limp stiffness and reduced range of hip movement x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening Diagnosis plain x-ray technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist Complications osteoarthritis premature fusion of the growth plates

Answer 38

Definition 'development of secondary sexual characteristics before 8 years in females and 9 years in males' more common in females Some other terms thelarche (the first stage of breast development) adrenarche (the first stage of pubic hair development) May be classified into: 1. Gonadotrophin dependent ('central', 'true') due to premature activation of the hypothalamic-pituitary-gonadal axis FSH & LH raised 2. Gonadotrophin independent ('pseudo', 'false') due to excess sex hormones FSH & LH low Males - uncommon and usually has an organic cause Testes bilateral enlargement = gonadotrophin release from intracranial lesion unilateral enlargement = gonadal tumour small testes = adrenal cause (tumour or adrenal hyperplasia) Females - usually idiopathic or familial and follows normal sequence of puberty Organic causes are rare, associated with rapid onset, neurological symptoms and signs and dissonance e.g. McCune Albright syndrome

Answer 39

Males first sign is testicular growth at around 12 years of age (range = 10-15 years) testicular volume \> 4 ml indicates onset of puberty maximum height spurt at 14 Females first sign is breast development at around 11.5 years of age (range = 9-13 years) height spurt reaches its maximum early in puberty (at 12) , before menarche menarche at 13 (11-15) there is an increase of only about 4% of height following menarche Normal changes in puberty gynaecomastia may develop in boys asymmetrical breast growth may occur in girls diffuse enlargement of the thyroid gland may be seen

Answer 40

Pyloric stenosis typically presents in the second to fourth weeks of life with vomiting, although rarely may present later at up to four months. It is caused by hypertrophy of the circular muscles of the pylorus. Epidemiology incidence of 4 per 1,000 live births 4 times more common in males 10-15% of infants have a positive family history first-borns are more commonly affected Features 'projectile' vomiting, typically 30 minutes after a feed constipation and dehydration may also be present a palpable mass may be present in the upper abdomen hypochloraemic, hypokalaemic alkalosis due to persistent vomiting Diagnosis is most commonly made by ultrasound. Management is with Ramstedt pyloromyotomy.

Answer 41

Retinoblastoma is the most common ocular malignancy found in children. The average age of diagnosis is 18 months. Pathophysiology autosomal dominant caused by a loss of function of the retinoblastoma tumour suppressor gene on chromosome 13 around 10% of cases are hereditary Possible features absence of red-reflex, replaced by a white pupil (leukocoria) - the most common presenting symptom strabismus visual problems Management enucleation is not the only option depending on how advanced the tumour is other options include external beam radiation therapy, chemotherapy and photocoagulation Prognosis excellent, with \> 90% surviving into adulthood

Answer 42

Scarlet fever is a reaction to erythrogenic toxins produced by Group A haemolytic streptococci (usually Streptococcus pyogenes). It is more common in children aged 2 - 6 years with the peak incidence being at 4 years. Scarlet fever is spread via the respiratory route by inhaling or ingesting respiratory droplets or by direct contact with nose and throat discharges, (especially during sneezing and coughing). Scarlet fever has an incubation period of 2-4 days and typically presents with: fever: typically lasts 24 to 48 hours malaise, headache, nausea/vomiting sore throat 'strawberry' tongue rash - fine punctate erythema ('pinhead') which generally appears first on the torso and spares the palms and soles. Children often have a flushed appearance with circumoral pallor. The rash is often more obvious in the flexures. It is often described as having a rough 'sandpaper' texture. Desquamination occurs later in the course of the illness, particularly around the fingers and toes Diagnosis a throat swab is normally taken but antibiotic treatment should be commenced immediately, rather than waiting for the results Management oral penicillin V for 10 days patients who have a penicillin allergy should be given azithromycin children can return to school 24 hours after commencing antibiotics scarlet fever is a notifiable disease Scarlet fever is usually a mild illness but may be complicated by: otitis media: the most common complication rheumatic fever: typically occurs 20 days after infection acute glomerulonephritis: typically occurs 10 days after infection invasive complications (e.g. bacteraemia, meningitis, necrotizing fasciitis) are rare but may present acutely with life-threatening illness

Answer 43

The table below summarises Health Protection Agency guidance on school exclusion Advice Condition(s) No exclusion Conjunctivitis Fifth disease (slapped cheek) Roseola Infectious mononucleosis Head lice Threadworms Hand, foot and mouth 24 hours after commencing antibiotics Scarlet fever 2 days after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics ) Whooping cough 4 days from onset of rash Measles Rubella All lesions crusted over Chickenpox\* 5 days from onset of swollen glands Mumps Until symptoms have settled for 48 hours Diarrhoea & vomiting Until lesions have crusted over Impetigo Until treated Scabies Until recovered Influenza \*the official advice regarding school exclusion for chickenpox has gone back and forth over recent years. In September 2017 Public Health England advocated the following: Cases of chickenpox are generally infectious from 2 days before the rash appears to 5 days after the onset of rash. Although the usual exclusion period is 5 days, all lesions should be crusted over before children return to nursery or school. However, Clinical Knowledge Summaries are a bit vaguer: Advise that the most infectious period is 1-2 days before the rash appears, but infectivity continues until all the lesions are dry and have crusted over (usually about 5 days after the onset of the rash)

Answer 44

Seborrhoeic dermatitis is a relatively common skin disorder seen in children. It typically affects the scalp ('Cradle cap'), nappy area, face and limb flexures. Cradle cap is an early sign which may develop in the first few weeks of life. It is characterised by an erythematous rash with coarse yellow scales. Management depends on severity mild-moderate: baby shampoo and baby oils severe: mild topical steroids e.g. 1% hydrocortisone

Answer 45

Sudden infant death syndrome is the commonest cause of death in the first year of life. It is most common at 3 months of age. Major risk factors putting the baby to sleep prone: the relative risk or odds ratio varies from 3.5 - 9.3. If not accustomed to prone sleeping (i.e. the baby usually sleeps on their back) the odds ratio increases to 8.7-45.4 parental smoking: studies suggest this increases the risk up to 5 fold prematurity: 4-fold increased risk bed sharing: odds ratio 5.1 hyperthermia (e.g. over-wrapping) or head covering (e.g. blanket accidentally moves) Other risk factors male sex multiple births social classes IV and V maternal drug use incidence increases in winter It is important to remember that these odds are additive. For example, if both parents smoke, the mother had consumed two units of alcohol and they then shared a bed with the infant the adjusted odds ratio was shown to be 89.7. Protective factors breastfeeding room sharing (but not bed sharing, which is a significant risk factor) the use of dummies (pacifiers) Following a cot death siblings should be screened for potential sepsis and inborn errors of metabolism.

Answer 46

Surfactant deficient lung disease (SDLD, also known as respiratory distress syndrome and previously as hyaline membrane disease) is a condition seen in premature infants. It is caused by insufficient surfactant production and structural immaturity of the lungs The risk of SDLD decreases with gestation 50% of infants born at 26-28 weeks 25% of infants born at 30-31 weeks Other risk factors for SDLD include male sex diabetic mothers Caesarean section second born of premature twins Clinical features are those common to respiratory distress in the newborn, i.e. tachypnoea, intercostal recession, expiratory grunting and cyanosis Chest x-ray characteristically shows 'ground-glass' appearance with an indistinct heart border Management prevention during pregnancy: maternal corticosteroids to induce fetal lung maturation oxygen assisted ventilation exogenous surfactant given via endotracheal tube Neonatal respiratory distress syndrome (NRDS) is primarily a disease of pre-term neonates due to surfactant deficiency. Deficiency of surfactant results in an increased alveolar surface tension, thereby resulting in decreased compliance and increased work of breathing. Natural maternal glucocorticosteroids are very important for surfactant production in the foetus, and therefore synthetic steroids are the first line agents for preventing NRDS in pregnancies at risk of pre-term birth. Tocolytics are agents that can be used to suppress pre-term labour, however they are not routinely used. Since administration of maternal steroids takes one to two days to increase surfactant levels, tocolytics can be considered in certain situations to buy time. Although curosurf, continuous positive airway pressure, and extracorporeal membrane oxygenation can be an effective form of treatment for NRDS they are not used prophylactically.

Answer 47

Infestation with threadworms (Enterobius vermicularis, sometimes called pinworms) is extremely common amongst children in the UK. Infestation occurs after swallowing eggs that are present in the environment. Threadworm infestation is asymptomatic in around 90% of cases, possible features include: perianal itching, particularly at night girls may have vulval symptoms Diagnosis may be made by the applying Sellotape to the perianal area and sending it to the laboratory for microscopy to see the eggs. However, most patients are treated empirically and this approach is supported in the CKS guidelines. Management CKS recommend a combination of anthelmintic with hygiene measures for all members of the household mebendazole is used first-line for children \> 6 months old. A single dose is given unless infestation persists

Answer 48

Transient synovitis is sometimes referred to as irritable hip. It generally presents as acute hip pain associated with a viral infection. The typical age group is 2-10 years. A low-grade fever is present in a minority of patients but high fever should raise the suspicion of other causes such as septic arthritis. It is the commonest cause of hip pain in children. Transient synovitis is self-limiting, requiring only rest and analgesia.

Answer 49

Undescended testis occurs in around 2-3% of term male infants, but is much more common if the baby is preterm. Around 25% of cases are bilateral. Complications of undescended testis infertility torsion testicular cancer psychological Management Unilateral undescended testis NICE CKS now recommend referral should be considered from around 3 months of age, with the baby ideally seeing a urological surgeon before 6 months of age Orchidopexy: Surgical practices vary although the majority of procedures are performed at around 1 year of age Bilateral undescended testes Should be reviewed by a senior paediatrician within 24hours as the child may need urgent endocrine or genetic investigation

Answer 50

In contrast to adults, the development of a urinary tract infection (UTI) in childhood should prompt consideration of a possible underlying causes and damage to the kidneys (renal scarring) NICE guidelines for imaging the urinary tract infants \< 6 months who present with a first UTI which responds to treatment should have an ultrasound within 6 weeks children \> 6 months who present with a first UTI which responds to treatment do not require imaging unless there are features suggestive of an atypical infection (see below) or recurrent infection Features of suggestive of an atypical infection seriously ill poor urine flow abdominal or bladder mass raised creatinine septicaemia failure to respond to treatment with suitable antibiotics within 48 hours infection with non-E. coli organisms Possible further investigations urine for microscopy and culture: urine should be sent for culture as only 50% of children with a UTI have pyuria. Microscopy or dipstick of the urine is therefore inadequate for diagnosis static radioisotope scan (e.g. DMSA): identifies renal scars. Should be done 4-6 months after initial infection micturating cystourethrography (MCUG): identifies vesicoureteric reflux. Only recommended for infants younger than 6 months who present with atypical or recurrent infections

Answer 51

Whooping cough (pertussis) is an infectious disease caused by the Gram-negative bacterium Bordetella pertussis. It typically presents in children. There are around 1,000 cases are reported each year in the UK. Immunisation infants are routinely immunised at 2, 3, 4 months and 3-5 years. Newborn infants are particularly vulnerable, which is why the vaccination campaign for pregnant women was introduced neither infection nor immunisation results in lifelong protection - hence adolescents and adults may develop whooping cough despite having had their routine immunisations Features, 2-3 days of coryza precede onset of: coughing bouts: usually worse at night and after feeding, may be ended by vomiting & associated central cyanosis inspiratory whoop: not always present (caused by forced inspiration against a closed glottis) infants may have spells of apnoea persistent coughing may cause subconjunctival haemorrhages or even anoxia leading to syncope & seizures symptoms may last 10-14 weeks\* and tend to be more severe in infants marked lymphocytosis Diagnostic criteria Whooping cough should be suspected if a person has an acute cough that has lasted for 14 days or more without another apparent cause, and has one or more of the following features: Paroxysmal cough. Inspiratory whoop. Post-tussive vomiting. Undiagnosed apnoeic attacks in young infants. Diagnosis per nasal swab culture for Bordetella pertussis - may take several days or weeks to come back PCR and serology are now increasingly used as their availability becomes more widespread Management infants under 6 months with suspect pertussis should be admitted in the UK pertussis is a notifiable disease an oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread household contacts should be offered antibiotic prophylaxis antibiotic therapy has not been shown to alter the course of the illness school exclusion: 48 hours after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics ) Complications subconjunctival haemorrhage pneumonia bronchiectasis seizures Vaccination of pregnant women In 2012 there was an outbreak of whooping cough (pertussis) which resulted in the death of 14 newborn children. As a temporary measure, a vaccination programme was introduced in 2012 for pregnant women. This has successfully reduced the number of cases of whooping cough (the vaccine is thought to be more than 90% effective in preventing newborns developing whooping cough). It was however decided in 2014 to extend the whooping cough vaccination programme for pregnant women. This decision was taken as there was a 'great deal of uncertainty' about the timing of future outbreaks. Women who are between 20-32 weeks pregnant will be offered the vaccine. \*weeks, not days

Answer 52

Wilms' nephroblastoma is one of the most common childhood malignancies. It typically presents in children under 5 years of age, with a median age of 3 years old. Associations Beckwith-Wiedemann syndrome as part of WAGR syndrome with Aniridia, Genitourinary malformations, mental Retardation hemihypertrophy around one-third of cases are associated with a loss-of-function mutation in the WT1 gene on chromosome 11 Features abdominal mass (most common presenting feature) painless haematuria flank pain other features: anorexia, fever unilateral in 95% of cases metastases are found in 20% of patients (most commonly lung) Referral children with an unexplained enlarged abdominal mass in children - possible Wilm's tumour - arrange paediatric review with 48 hours Management nephrectomy chemotherapy radiotherapy if advanced disease prognosis: good, 80% cure rate