Paediatrics Flashcards
How would you measure temperature in a child <4 weeks?
Electronic thermometer in the axilla
How would you measure temperature in a child aged 4weeks to 5 years
- Electronic thermometer in axilla
- Infrared tympanic thermometer
- Chemical dot thermometer in axilla
How would you manage a child with a fever?
ABCDE
Traffic light asseessment measuring:
Temperature, oxygen saturations, resp rate, heart rate, capillary refill time
If under 6 months, temperature alone may signify high or intermediate risk. If over 6 months, look at other factors as well
Look for site of infection
Check for rash, behaviour, feeding, contacts, duration
What temperatures are high or intermediate risk in children under 6 months?
3-6 months = 39 or more
Under 3 months = 38 or more (RED)
How might you assess dehydration in a child?
Urine output, feeding and fluid intake Prolonged capillary refill time Abnormal skin turgor Abnormal respiratory pattern Weak pulse Cool extremities
When would you consider meningococcal disease?
Fever and non-blanching rash Purpura >2mm in size Cap refill >3s Neck stiffness Ill-looking child
When would you consider meningitis?
Fever Neck stiffness Bulging fontanelle Decreased level of consciousness Convulsive status epilepticus
When would you suspect Herpes Simplex Virus Encephalitis?
Fever
Focal seizures or neurological signs
Decreased level of consciousness
When would you consider pneumonia in a child?
Fever Tachycardia (>60 under 6 months, >50 6-12 months, >40 over 12 months) Crackles Respiratory recession/indrawing Nasal flaring Cyanosis Oxygen sats 95% or less
When would you consider a UTI in a child?
Always suspect a UTI, especially in child under 3 months with fever Over 3 months - fever with Vomiting/poor feeding Lethargy Irritability Abdominal pain/tenderness Frequency or dysuria
When would you consider septic arthritis in a child with a fever?
Swelling of limb or joint
Non-weight bearing on one limb
Not using extremities
What are some features suggesting Kawasaki disease in a child with a fever?
PROLONGED fever >5 days Conjunctivitis Rash (polymorphous) Oedema (palms or soles) Adenopathy - cervical, often unilateral M - mucosal involvement e.g. (cracked lips, strawberry tongue, peeling of fingers and toes)
What are the risks with children under 1 and Kawasaki disease?
May present with fewer clinical features other than fever
AND may be at increased risk of coronary artery abnormalities
How would you manage a fever in a child UNDER 3 MONTHS?
Observe and vital signs - temp, HR, RR
Ix: FBC, blood culture, CRP, urine testing
(CXR if resp signs, stool culture if diarrhoea)
LP first, then IV Abx - if under 1 month or appears unwell or WBC<5 or >15
IV Abx: Ceftriaxone or Cefataxime + Amoxicillin (listeria)
How would you manage a child over 3 months with a fever that has no apparent source?
Observe, vital signs, traffic light assessment
If one or more red symptoms - FBC, CRP, blood culture, urine testing
Consider: LP, CXR, serum electrolytes + blood gas (depending on clinical)
If amber symptoms - same as above except LP only in children under 1 year (unless indicated clinically), CXR only if >39C and WBC>20
How would you manage a febrile child with a viral co-infection of RSV or influenza?
Assess for serious illness
Urine testing
How might a child over 3 months be managed in hospital with a fever without apparent source?
Period of observation with anti-pyretics
If red or amber symptoms - reassessed every 1-2 hrs
What children presenting to ED would get immediate fluid bolus and parenteral antibiotics?
Any age if fever and shock
also unrousable, signs of meningococcal disesase
What fluid bolus would be given in ED for child with fever and shock?
IV 20ml/kg 0.9% saline, then actively monitored and given further fluids as necessary
What parenteral antibiotics would be given if child presents to ED with fever, shock or decreased level of consciousness?
Third generation cephalosporin - Cefotaxime, Ceftriaxone
If under 3 months - add in ampicillin/amoxicillin to cover listeria
What other medication may be given IV in child with fever and decreased level of consciousness, aside from antibiotics and fluids?
If signs of HSV encephalitis - IV aciclovir
Oxygen if in shock or sats <92% or <95% if clinically indicated
How should anti-pyretics in children be used?
Not to relieve febrile convulsions or body temp - more for distressed child
- continue until child less distressed, discontinue once distress stops
- do not use simultaneously (paracetamol+ibuprofen)
- consider changing to other agent if distress not relieved
- only alternate if not reducing distress or acting long enough between doses
What signs might you tell parents to look out for when managing a child at home with fever?
Signs of dehydration: sunken eyes, sunken fontanelle, dry mouth, absence of tears, poor overall appearance
Non-blanching rash
Check on child at night
What advice would you give to parents managing a child at home with a fever?
Encourage fluid intake (e.g. breastfeeding), watch for signs of dehydration, non-blanching rash, check on child at night, keep away from school/nursery until fever subsides
When should parents managing a child with a fever at home seek further help?
Behaviour change/appears unwell Signs of dehydration Non-blanching rash Fever last>5 days Has seizure Parent distressed/unable to manage/more concerned
What is the commonest cause of hospital admission for children?
Infection
What is the commonest site of infection for children?
Respiratory tract
Give some links between viral and bacterial illnesses
Mild viral illnesses can appear similarly to very severe bacterial infection
Viral infections can predispose to secondary bacterial infections, or can make bacterial infections worse
How is chickenpox related to bacterial infections?
Varicella Zoster Virus infection can increase risk of secondary bacterial infection for a few weeks after infection
Vesicular rash may become infected - necrotic skin lesions (Group A strep/s. pyogenes, staph)
Why might children with cold sores need admission to hospital?
HSV infection may lead to difficulty swallowing
What is the difference to the purpura in HSP vs meningococcal septicaemia?
HSP - purpura are PALPABLE
What cardiac health risks are associated with Kawasaki disease? How is this prevented?
Coronary artery inflammation or aneurysms
Prevented by treating Kawasaki disease with HIGH DOSE Ig and ASPIRIN
How are children presenting with COVID-19?
3-4 wks post-infection with inflammation in lungs, sepsis-like response
Most are not ill during RTI
What investigations are part of the septic screen?
FBC, CRP, blood culture, urine sample
Consider: CXR, LP, rapid antigen screen on blood/CSF/urine, meningococcal and pneumococcal PCR on blood/CSF, PCR for viruses in CSF (especially HSV and enterovirus)
What organisms cause bacterial meningitis in children under 3 months?
Group B strep
E.coli and other coliforms
Listeria monocytogenes
What organisms cause bacterial meningitis in children 1 months-6 yrs?
Neisseria meningitidis
Streptococcus pneumoniae
Haemophilus influenzae
What organisms cause bacterial meningitis in children over 6 yrs old?
Neisseria meningitidis
Streptococcus pneumoniae
How would you treat bacterial meningitis?
Third-generation cephalosporin - Cefotaxime, ceftriaxone
(+ Amoxicillin/Ampicillin if under 3 months)
(+ dexamethasone if over 3 months)
What are some cerebral complications of bacterial meningitis?
Hearing loss Local vasculitis - cranial nerve palsies, focal deficit Local cerebral infarction Subdural effusion Hib or pneumococcal meningitis Hydrocephalus Cerebral abscess
What prophylactic treatment is given to all household contacts of children with bacterial meningitis?
Rifampicin to all household contacts - eradicate nasopharyngeal carriage of meningococcal or Hib meningitis
If MenC - give household contacts MenC vaccine
What might the LP show on a child with bacterial meningitis that has already been given antibiotics prior to LP?
CSF - raised white cells
No organism on culture
Do rapid antigen screen and PCR to help if not clinically sure
What are the viral causes of meningitis?
Enterovirus
Epstein-Barr virus
Adenovirus
Mumps
What investigations can be done in a child to identify meningitis if lumbar puncture contraindicated?
Blood cultures
PCR, rapid antigen screens on blood and urine
Throat swabs for culture
Serological diagnosis 4-6wks after presenting illness
How can viral meningitis be diagnosed?
LP - culture or PCR of CSF stool culture urine culture nasopharyngeal aspirate throat swabs serology
If meningitis is atypical or not responding to usual antibiotics and supportive therapy, what should be considered?
Uncommon pathogens e.g. Mycoplasma, or Borrelia burgodorferi, fungal infections
- likely in children who are immunodeficient
Or aseptic meningitis - malignancy, autoimmune
What should be given to any child with fever and purpuric rash?
IM benzylpenicillin
What are the different aetiologies of encephalitis/encephalopathy?
Direct invasion cerebrum by neurotoxic virus (HSV)
Delayed swelling due to immune response (post-infectious encephalopathy e.g. VZV)
Slow virus infection (HIV, subacute sclerosing panencephalitis following measles)
Metabolic causes
What are the common features in children presenting with encephalitis?
Fever
Altered consciousness
Seizures
How should you manage a child with encephalitis?
Treat for both meningitis and encephalitis if unsure
Encephalitis = high dose IV aciclovir 3wks
Do LP for CSF PCR, CT/MRI, EEG (may be normal and need to be repeated if child not improving)
What is toxic shock syndrome?
Caused by toxins produced by S.aureus or Group A streptococci
Fever>39
Hypotension
Diffuse erythematous, macular rash
Toxins can be from infection at any site, may look minor e.g. small skin abrasions, burns. Superantigens causing immune response
What other features of organ dysfunction may occur in toxic shock syndrome?
Mucositis - conjunctivae, oral mucosa, genital mucosa
GI - vomiting, diarrhoea
Renal impairment
Liver impairment
Clotting abnormalities and thrombocytopenia
Central nervous system - altered consciousness
Desquamation of palms, soles, fingers, toes 1-2wks later
How is toxic shock syndrome managed?
Intensive care support
Infection areas debrided surgically
Ceftriaxone with Clindamycin
Iv Ig
What are the characteristics of a meningococcal rash?
Non-blanching on palpation
Irregular in size + outline
Necrotic centre
Where are pneumoccal infections carried and what can they cause?
Commonly carried in nasopharynx of asymptomatic, healthy children, but spread by respiratory droplets
Can cause: pharyngitis, otitis media, conjunctivitis, sinusitis, pneumonia, bacterial sepsis, meningitis
What diseases may be caused by Haemophilus influenzae B?
Otitis media, pneumonia, epiglottitis, cellulitis, osteomyelitis, septic arthiritis, meningitis.
Systemic diseases rare now due to vaccinations
What organisms commonly cause impetigo?
Staphylococcus
Group A streptococcus
What are the common features of impetigo?
Commoner in children with pre-existing skin disease
Lesions usually on face, neck and hands
Erythematous macules - vesicular/pustular/bullous over time
Vesicule rupture - exudate - honey-coloured crusted lesions
Infective exudate infects adjacent areas
How can impetigo be treated?
Topical antibiotics (fusidic acid/mupirocin) if mild, not widespread
Widespread - topical fusidic acid OR flucloxacillin 5 days
Unwell, bullous - Flucloxacillin 5 days
If poor adherence - co-amoxiclav, cefaclor
Other than treating the infection, how else might you manage impetigo?
Advise not to go to school/nursery until lesions are dry
Eradicate nasal carriage with nasal cream mupirocin, chlorhexidine, neomycin
What occurs with periorbital cellulitis? What causes it?
Fever, erythema, tenderness and oedema of eyelid, usually unilateral
Cause - staph, group A strep, (Hib not imm)
Can follow local trauma to skin
Older children - may spread from nasal sinus infection or dental abscess
Why should periorbital cellulitis be treated with IV antibiotics promptly (Clindamycin or Amoxicillin)?
To prevent orbital cellulitis - proptosis, painful, limited ocular movements, reduced visual acuity
Do CT to check spread infection
LP may be needed to exclude meningitis
What is scalded skin syndrome?
Staphylococcal toxin causes separation of epidermal skin. Affects young children and infants
Features: fever, malaise, purulent crusting localised infection around eyes, nose, mouth with subsequent erythema and tenderness of skin
Epidermis separates on gentle pressure (Nikolsky sign)
Denuded areas of skin dry and heal without scarring
How would you manage scalded skin syndrome?
IV anti-staphylococcal antibiotic (e.g. flucloxacillin)
Analgesia
Monitor fluid balance
Give some examples of herpesviruses. What is their common feature?
HSV1 and HSV2
VZV
EBV
Human herpes virus 6-8 (HHV8 associated Kaposi sarcoma in HIV positive)
After primary infection, latency period where dormant within host, stimuli may reactivate infection
How HSV transmitted? What are its typical features?
Mucous membranes or skin contact
Asymptomatic
Gingivostomatitis - (vesicles lips, gums, tongue, hard palate - painful ulceration and bleeding), fever, miserable, dehydration
Skin manifestations - cold sores (HSV1), Eczema herpeticum (vesicles on eczema, secondary bacterial infection), Herpetic whitlows (white pustules on broken skin of fingers)
Eye disease - blepharitis, conjunctivitis, corneal scarring, vision loss
CNS - encephalitis, disseminated infections and pneumonia in immunocompromised
How is chickenpox transmitted?
Respiratory droplets, contact with blisters
What are the stages of the chickenpox rash?
Rash comes in crops over 3-5 days (if more than 10 days, may be immunocomprised) - head, trunk then spreads to peripiheries
Papules, VESICLES, pustules, crusts
Scratching may cause permanent scar or secondary infection
What are some complications of chickenpox?
Bacterial superinfection - staph, strep - toxic shock, necrotising fasciitis
Central nervous system - cerebellitis, encephalitis
Immunocompromised - haemorrhagic lesions, pneumonitis, disseminated infection, DIC
How would you treat chickenpox?
Symptomatic
Immunocompromised/severe - IV aciclovir or oral valaciclovir, if contact - VZV Ig
Adolescents or adults - Valaciclovir
What is shingles?
Reactivation of VZV in dermatomal distribution
Rare in children and often no neuralgic pain, more common in those who had VZV in 1st yr of life
Recurrent shingles may mean immunocompromised
What are the features of Infectious mononucleosis?
Fever, malaise Tonsillopharyngitis Lymphadenopathy - prominent cervical and often diffuse adenopathy Petechiae on soft palate Spleno or hepatomegaly Maculopapular rash Jaundice
How is infectious mononucleosis diagnosed?
Blood film - atypical lymphocytes
Positive Monospot test
Seroconversion - production IgM and IgG to EBV
How is infectious mononucleosis treated?
Symptomatic treatment - symptoms usually resolve in 1-3 months
Corticosteroids if airway compromised
If group A strep on tonsils - penicillin (not amoxicillin/ampicillin as may cause maculopapular rash in children with EBV)
How is CMV transmitted?
Breast milk or genital secretions
Rare: blood products, organ transplatns, transplacentally
What are the features of CMV infection?
Infectious mononucleosis syndrome but not as bad as EBV
Congenital infection from maternal CMV may present at birth
Immunocompromised - retinitis, pneumonitis, bone marrow failure, encephalitis, hepatitis, colitis, oesophagitis. Very important pathogen post-organ transplant - close monitored by PCR blood tests for CMV
How might CMV be treated?
Disease - ganciclovir or foscarnet (SEs)
Reduce risk of transmission - CMV negative blood transfusions or antiCMV drug prophylaxis
What are the features of HHV6 and HHV7?
Most children infected by age 2 through oral secretions
Exanthem subitum - high fever and malaise lasting few days, macular rash as fever wanes
Frequently misdiagnosed as measles/rubella, allergic antibiotic reaction
Common cause of febrile convulsions
Rare - aseptic meningitis, encephaltiis, hepatitis, glandular fever
What is slapped cheek syndrome?
Parvovirus B19 infection causing erythema infectiosum
Spring is commonest time for infection
Transmission - respiratory secretions, vertical transmission, contaminated blood products
Infects erythroblastoid red cell precursors
What symptoms might you get with slapped cheek syndrome?
Asymptomatic
Erythema Infectiosum - fever, malaise, headache, myalfia followed by slapped cheek rash on face
Aplastic crisis - in children with chronic haemolytic anaemia or immunodeficient
Foetal disease - maternal parvovirus can cause foetal hydrops and death
Give some examples of common enteroviruses
Coxsackie
Echovirus
Poliovirus
What is the primary transmission of enteroviruses?
Faecal-oral route
What is the course of enterovirus infection?
Replicates pharynx and gut, spreads to infect other organs (common in summer and autumn)
Often asymptomatic, some non-specific febrile illness, sometimes blanching rash over trunk
Loose stools or vomiting, contacts
How would you manage a child with non-blanching rash, fever but not systemically unwell with suspected enterovirus?
Admit for observation
48hr parenteral antibiotics (ceftriaxone)
What are the clinical syndromes for enteroviruses?
Hand, foot and mouth disease Herpangina Meningitis/encephalitis Pleurodynia (Bornholm disease) Myocarditis, pericarditis
How should measles be diagnosed for epidemiological purposes?
Serology of blood or saliva
What are the clinical features of measles?
Fever
Cough, coryza
Conjunctivitis
Malaise
Koplik spots (white spots on buccal mucosa)
Maculopapular rash (spreads from behind ears to whole of body)
What are some serious complications of measles?
Encephalitis 8 days after onset
Subacute sclerosing panencephalitis (SSPE) - loss in neurological function, dementia and death
What is the treatment for measles?
Symptomatic
Isolated from other children
If immunocompromised - Ribavirin, vitamin A
How are measles and mumps transmitted?
Respiratory droplets
When does mumps usually occur? What is its course?
Winter and spring
Virus replicates within epithelial cells - gains access to parotid glands first
Incubation period 15-24 days, infectivity for up to 7 days after onset of parotid swelling
What are the clinical features of mumps?
Fever, malaise, parotitis, sometimes subclinical
Starts unilateral swelling, then bilateral over few days
Ear ache, pain on eating, drinking
Abdominal pain if pancreatic involvement
What are the complications of mumps?
Pancreatic involvement - raised plasma amylase
Hearing loss - usually transient and unilateral
Viral meningitis/encephalitis
Orchitis - infertility unusual
What are the clinical features of rubella?
Dangerous if in foetus - congenital
Low-grade fever or none
Maculopapular rash starting on face then to body
Lymphadenopathy - suboccipital, postauricular
What are some possible complications
of mumps?
Arthritis
Encephalitis
Thrombocytopenia
Myocarditis
What age group is most commonly affected by Kawasaki disease?
6 months to 4 years
How would you diagnose Kawasaki disease?
No diagnosis - based on clinical findings (characteristic features, high fever, inflammation of BCG vaccination)
Might do echo at 6 wks to rule out coronary aneurysms
How do you treat Kawasaki disease?
High dose aspirin
IV Ig in first 10 days
If coronary aneurysm - long-term warfarin and follow up
Persistent inflammation - infliximab, steroids or ciclosporin
Describe the course of TB
Respiratory droplet spread, close proximity
TB infection (latent TB) more likely to progress to active TB in children
Children usually acquire from an infected adult in their household
Give some features of TB
non-specific, prolonged fever, malaise, anorexia, weight loss, focal signs of infection
How would you diagnose TB in a child
Mantoux - (false positive with vaccination and false
positive if HIV)
Interferon gamma release assays- not affected by vaccine, but negative in HIV
Can’t do sputum samples under 8yrs- Gastric washings on 3 consecutive mornings before food (NG tube, rinse out with saline)
Urine
Lymph node excision
CSF
CXR
How do you treat active TB in children?
Initial: rifampicin, isoniazid, pyrazinamide, ethambutol for 2 months
Then 4 months: rifampicin and isoniazid
After puberty give pyroxidine with isoniazid to prevent peripheral neuropathy
How would a person with latent TB be detected and how would you treat them?
Positive mantoux test but no symptoms
Rifampicin and isoniazid for 3 months
Which groups are recommended for BCG vaccination at birth?
Asian, African origin
TB family member in last 5 years
Local area high prevalence rate
- do not give to immunocompromised children
How would you treat a child who is a contact of someone that has TB?
Do Mantoux test
If positive - treat for latent TB
If negative - BCG if over 5 yrs old, if under 5, isoniazid and rifampicin for 3 months
How is HIV diagnosed in children?
Before 18 months - IgG HIV from mother is sign of exposure, HIV DNA PCR diagnostic
Over 18 months - HIV antibodies
What is the course of HIV for most children?
Most remain asymptomatic for months or years
Some only identified in adolescence at routine screening
Lymphadenopathy, parotitis, recurrent bacterial infections, candidiasis, chronic diarrhoea, lymphocytic interstitial pneumonitis
Severe - opportunistic infections, failure to thrive, encephalopathy, malignancy
What is the treatment for HIV?
Based upon viral load, CD4 count, clinical status - may start ART
May get co-trimoxazole as prophylaxis for pneumonia
Vaccines - routine except BCG, give influenza, hep A+B, VZV
MDT management
Follow up - monitor neurological signs
How can vertical transmission of HIV be reduced?
Use maternal ART drugs
Avoid breastfeeding
Active management labour and delivery (avoid PROM, unnecessary instruments)
Pre-labour CS if viral load detectable close to time of delivery
What organism causes Lyme disease?
spirochaete Borrelia burgdorferi, transmitted by the hard tick
When is Lyme disease most common?
Summer months in rural settings
What are the typical features of Lyme disease?
After 4-20d, erythematous macule at site of tick bite enlarges (erythema migrans), red outer spreading edge
Fever, headache, malaise, myalgia, arthralgia, lymphadenopathy
Symptoms fluctuate over several weeks, then resolve
Late stage - cranial and peripheral neuropathies, meningoencephalitis, myocarditis, heart block, migratory arthralgia, chronic erosive joint disease mnths-yrs after infection
How is Lyme disease diagnosed?
Clinical features, serology - may be negative early so repeat 2-4 weeks
How is Lyme disease treated?
If over 12 - doxycycline
Under 12 - amoxicillin
If carditis or neuro - IV ceftriaxone
What are the 2 types of immune deficiency in children?
Primary- often X-linked or recessive
Secondary - caused by another disease/treatment e.g. HIV, intercurrent infection, immunosuppressants, splenectomy, nephrotic syndrome
Give the acronym for how to recognise immune deficiency in children
SPUR Severe Prolonged Unusual Recurrent infections (also failure to thrive, lymphadenopathy, splenomegaly)
What are some forms of management for children with immune deficiencies?
Antimicrobial prophylaxis, antibiotic treatment (prompt, appropriate choice, longer courses, lower threshold for IV) Screening for end-organ disease Immunoglobulin replacement Bone marrow transplant Gene therapy
Describe features of congenital rubella
Passed from mother to baby during pregnancy in blood Heart problems Intellectual disability, developmental delay, growth retardation Deafness, eye problems Diabetes Hepato or splenomegaly Skin lesions Bleeding
What is the more common type of meningococcus in the UK?
Men B
What other organisms may cause non-blanching purpuric rash?
Group A strep
Pneumoccocus
Why are childrne more vulnerable to infections at 6 months of age?
Babies can’t make IgM and IgA
Mothers actively transport IgG across placenta in pregnancy
At 6 months, maternal IgG stores in foetus diminish, but not making enough own IgG
How might you test for immune deficiencies?
FBC (WCC, neutrophils, lymphocytes)
IgG, A, M, E
Response to routine imms
Lymphocytes - T, B cells, function
What are the live vaccines that should not be given to immunocompromised children?
BCG
MMR, rotavirus, VZV
What extra vaccinations may be given to special or immunocompromised groups?
VZV
Pneumovax
TB
Influenza
What are the clinical features of whooping cough?
Long inspiratory effort with high pitched “whoop” after cough
Numerous rapid coughs as difficult to expel mucus - thick mucus production
Cyanosis
Vomiting or exhaustion
What are the clinical features of diphtheria?
Thick grey-white coating at back of throat Fever Sore throat Headache Swollen glands Dyspnoea and dysphagia (often travel history)
What treatment would you give for diphtheria?
Penicillin or erythromycin
How is whooping cough treated?
Antibiotics
If under 6 months admit to hospital
What should you always exclude in a child with a fever and travel history?
MALARIA!
If diarrhoea, vomiting and fever - Typhoid
What 3 diseases are all pregnant mothers screened for?
HIV, HepB, Syphilis
If HIV detected early, foetus may not be affected
Transmission HIV is 25% if untreated
What are the common clinical features of scarlet fever?
Fever, sore throat, headache, N+V
Cervical lymphadenopathy
Sandpaper rash on trunk
White coating on tongue, which peels to show strawberry tongue
Flushed cheeks
Small petechiae on hard+soft palate (Forchheimer spots)
Lasts about a week
How is scarlet fever diagnosed?
Clinical findings
Throat swabs - Group A strep
Measure anti-streptolysin antibodies for post-infection complications (acute rheumatic fever, glomerulonephritis)
What is the treatment for scarlet fever?
Amoxicillin 10 days
What is a hypersensitivity?
Objectively reproducible symptoms or signs following exposure to a defined stimulus at a dose which is tolerated by normal people
What is allergy?
Hypersensitivity reaction initiated by specific immunological mechanisms
What is atopy?
Personal and or familial tendency to produce IgE antibodies in response to ordinary exposures (usually proteins). Associated with asthma, allergic rhinitis, conjunctivitiys, eczema and food allergy
What is anaphylaxis?
Serious allergic reaction that is rapid in onset and may cause death
How might allergies be classified?
IgE-mediated
Non-IgE-mediated
What is the course of IgE mediated allergic reactions?
Early phase (within mins) - histamine + mediator release from mast cells - urticaria, angioedema, sneezing, bronchospasm Late phase - 4-6hrs, nasal congestion, cough, bronchospasm
How do non IgE mediated allergic reactions compare to IgE mediated allergic reactions?
Non-IgE-mediated have delayed onset of symptoms and more varied clinical course
What is the allergic march?
Progression of allergies
Infancy - eczema, food allergy
Primary school - allergic rhinitis, conjunctivitis, asthma
Often precedes asthma
What features may suggest a child has an allergy apart from allergic reaction?
Mouth breathing, allergic salute, pale and swollen inferior nasal turbinates
Hyperinflated chest (chronic asthma)
Atopic eczema in limb flexures
Allergic conjunctivitis (Dennie-Morgan folds), blue-grey discoloration below lower eyelids
Faltering growth
What are the most common food allergies in infancy?
Milk, egg, peanuts
What are the most common food allergies in older children?
Peanut
Tree nut
Fish
Shellfish
What is oral allergy syndrome?
Where child develops secondary allergy from allergy to a pollen/protein with a similar shape e.g. birch tree pollen allergy may lead to apple allergy
What are the typical features of non-IgE-mediated food allergy?
Diarrhoea Vomiting Abdo pain, colic Failure to thrive, eczema Proctitis in first few weeks of life may lead to blood in stools
What are the screening tests for IgE-mediated food allergies?
Skin prick tests
RAST test - measures specific IgE antibodies in blood
What are diagnostic tests for non-IgE-mediated food allergies?
Mostly based on clinical picture
If indicated - endoscopic and intestinal biopsies - eosinophillic infiltrates
What are the features of allergic rhinitis?
Conjunctivitis and coryza (rhinoconjunctivitis)
Cough-variant rhinitis - if post-nasal drip
How would you treat allergic rhinitis?
non-sedating antihistamines (topical or systemic)
Topical corticosteroid nasal or eye
Cromoglycate eye drops
Montelukast
Nasal decongestants (no more than 7-10d)
Allergen immunotherapy(sublingual, subcutaneous)
What is angioedema?
Swelling of lower level of skin - lips, eyes, tongue, larynx
What are the features of urticaria?
Urticarial rash upper layers
Possible angioedema if lower layers also swell
What are the features of acute urticaria?
Resolves within 6wks
Triggered by allergies or infection
What are the features of chronic idiopathic urticaria?
Intermittent for at least 6 weeks
Non-allergic in origin usually
Treat 2nd generation non-sedating antihistamines
What causes physical urticaria??
Cold Delayed pressure Heat contact Solar Vibratory urticaria
What are other causes of urticaria?
Water, sweating, exercise-induced
Aspirin and NSAIDs
C1-esterase inhibitor deficiency (angioedema only)
How would you manage anaphylaxis?
ABCDE
IM Adrenaline (every 5 mins until recover)
Oxygen and IV fluids
supportive - SABA, antihistamines, vasopressors, corticosteroids
How would you manage atopic eczema in children under 12?
Mild - emollient, topical corticosteroids
Moderate - same as above + topical calcineurin inhibitors (tacrolimus), bandages and dressings
Severe - same as above + phototherapy, systemic therapy
DO NOT use topical corticosteroids on face and neck
When to the majority of severe mental illnesses start?
Adolescence
Is ASD an environmental disorder?
No, it is a developmental disorder
Give some similarities and differences between AMH and CAMHS
Similarities: both deal with severe mental illness and developmental disorders
Differences: CAMHS much more development and system framework focused, AMH more focussed on medication
What is the triad of symptoms in ASD?
Rituals - routines
Unusual/delayed language - odd/stilted, SLT
Social difficulty - can’t read others emotions, social cues
Why might someone with ASD only be diagnosed when older child or adult?
Developmental disorder always been there but may have been adapted for in previous settings. ASD behaviour may not be that different from young child behaviour, but differences are seen at school etc.W
What is the triad of symptoms for PTSD?
Intrusive sensations/memories/flashbacks
Avoidance
Anxiety
(caused by life-threatening or event threatening integrity of self)
Give the features of ADHD
Affects males more than females
Cannot sustain attention, excessively active, socially disinhibited, easily distracted and impulsive, may be poor at relationships, prone to temper tantrums, poor school performance
How is ADHD managed?
Educational psychologist assessment
Behavioural programmes at school
Parenting intervention
Diet? - reduce caffeine intake, careful with sugar
Medication if necessary - reduce motor activity and improve concentration
(methylphenidate/dexamphetamine - stimulants) or non-stimulants - atomoxetine
What might signify conduct disorder?
Antisocial behaviour that infringes upon rights of others and is so severe that handicaps general functioning - chronically angry, lack of social skills/negotiation
Screen for ADHD and depression
How might you manage conduct disorder?
Parenting groups
Child group-based problem-solving, anger management
Give features of bulimia nervosa
Self-induced vomiting after repeated binges, possible diuretic or laxative use
Can lead to hypokalaemia and alkalosis
Can occur at normal body weight or in association with anorexia
More common than anorexia, and more in older girls
How is bulimia nervosa managed?
At normal body weight - regular diet, monitor with diary, individual or group CBT
How is anorexia nervosa managed?
Refeeding
Family therapy!!
Individual psychological therapy
Give some features of chronic fatigue syndrome
Combination physical and psychological
Myalgic encehalomyelitis (ME) and post-viral fatigue syndrome (Coxsackie B, EBV, hepatitis virus)
Exhaustion on minimal exertion, aching, stomach pain, eye pain, scalp tenderness, tender lymphadenopathy
How is chronic fatigue syndrome managed?
Graded exercise
CBT
Recovery can take months or yrs
How is depression managed in children?
Watchful waiting up to 4 weeks if mild Then supportive or guided self-help Moderate-severe - CAMHS CBT, family therapy, interpersonal therapy If insufficient, try SSRI - fluoxetine Admit to psychiatric unit if suicidal
Give the features of Asperger’s syndrome and what it now falls under in diagnosis?
Asperger syndrome is child with social impairments of ASD but at the milder end, with near-normal speech and development.
Diagnosis no longer separate and under broad ASD diagnosis
How is ASD managed?
Applied Behaviour Analysis (25-30hr individual therapy a week)
Appropriate educational placement
What is development coordination disorder/dyspraxia?
Problems of motor planning and/or execution with no findings on neurological examination
HIgher cortical processing problem - interpretation of seeing and hearing, use of language
common presentations - messy handwriting, difficulty doing up buttons, messy eating
How is dyspraxia managed?
Assessment and advice from OT
SLT if necessary
Visual assessment if helpful
What is dyslexia?
Disorder of reading skills disproportionate to child’s IQ - more than 2 years behind reading age of other children
Assessment - vision, hearing, educational psychologist
What are the names for disorders of calculation or writing skills?
Dyscalculia - calculation
Dysgraphia - writing
Where are lesions for sensorineural and conductive hearing loss?
Sensorineural - cochlea or auditory nerve, usually present at birth
Conductive - ear canal, middle ear, often otitis media or effusion
What is the prevalence of sensorineural hearing loss and how is it managed?
1 in 1000 live births
Irreversible, Management - hearing aids or cochlear implants if hearing aid insufficient
SLT if speech delay, school informed, Makaton signing
Usually mainstream school, but may need to go to deaf school
Which children are more prone to conductive hearing loss?
Chronic otitis media
Down syndrome
Cleft palate
Atopy
How might conductive hearing loss be managed if not transient?
Insertion of grommets (tympanostomy tubes)
Adenoid removal
What are the signs of otitis media?
Ear pain (especially on lying down) Tugging or pulling at ear Difficulty sleeping, crying, tired, miserable Fever Loss of balance Fluid discharge Headache Often after or with a viral URTI
What causes otitis media?
Viral or bacterial infection
Swollen eustachian tubes in children more prone to blockage, keeping fluid in middle ear which can become infected
Swelling of adenoids may also block the eustachian tubes
What is otitis media with effusion?
Fluid build up persisting in middle ear without infection.
Chronic is when fluid build up returns without infection - susceptible to new infections and hearing loss
What is chronic suppurative otitis media?
Ear infection that does not go away with normal treatment. May lead to perforation of eardrum and pus draining from ear
How would you manage otitis media?
Give advice and analgesia to manage fever, wait and see for 3 days
If perforated eardrum +discharge or bilateral under 2yrs - antibiotic straight away
If not resolved after 3 days, give antibiotics
= amoxicillin 7d or clarithromycin 7d
What are the features of otitis externa?
Pain and swelling in ear canal (swimmer’s ear)
Red ear canal
Discharge of liquid or pus from ear
Temporary hearing loss
How would you manage otitis externa?
Cleansing - usually resolves
Corticosteroid ear drops or aluminium acetate solution
Chloramphenicol ear drops
Oral antibiotics if spreading cellulitic infection/unwell
What is mastoiditis?
Serious bacterial infection of bony process behind ear
Presents with - pain, redness, swelling behind ear, discharge from ear, fever, miserable, tired, headache, hearing loss in affected ear
How is mastoiditis managed?
Refer to ENT specialist
Antibiotic treatment - possibly IV
Bloods and ear culture
Surgery - myringotomy (drain middle ear) or remove part of mastoid bone (mastoidectomy)
What are the potential complications of mastoiditis?
Hearing loss
Meningitis
Blood clot
Brain abscess
Give some epidemilogical features of self-harm in children
10% will self-harm
Female to male ratio 4:1
Highest in levels of poverty
3rd most common cause of death in adolescents worldwide
What treatments might you offer for children that are self-harming?
Find cause and act on it e.g. bullying, depression
Coping/distraction strategies
Tell parents and help them to develop a plan
If severe - inpatient admission
If parents unable to work to protect child - social care
Give the features of Cavernous haemangioma and its alternative name
Strawberry mark
Not present at birth but develops a few days later, very common, not to worry!
Collection of dilated blood vessels - benign vascular tumour
Usually disappear by 18 months
If get enormous, can lead to DIC
How would you treat haemangiomas if they are in an awkward place or keep growing?
Beta blockers
What are some side effects of long-term beta blocker use for children?
hypoglycaemia
bradycardia
Reduced vascular development of brain so longer
What is another name for a port wine stain birthmark? What are its features?
Capillary haemangioma
Present at birth, doesn’t go away
Dark red, purple discolouration irregular outline on face
What is another name for a mole? What are its features?
Also called naevus
Dark spot. Turners syndrome have lots of them but normal too.
Only harmful if sun damage and become cancerous
What are mongolian blue spots?
Bruise-like spots, common in children with darker skin
Remains throughout life and normal
What is a cafe au lait spot?
coffee-coloured patches
Normal if small size and small amounts
If more than 5 over 5mm in children or over 15mm in adolescents - could be neurofibromatosis
What are yellowish spots on the nose of a baby that’s just been born?
Milia (milk spots)
Normal and disappear after a few weeks
What are the features of erythema toxicum neonatorum?
Spots surrounded by red area on newborn - normal and common in neonates
check child is well - otherwise could be a staph infection
What does CCCK stand for in measles? What are typical features of rash?
Cough, Coryza, Conjunctivitis, Koplik spots
Angry rash, often includes mouth and eyes
Maculopapular rash, then becomes blotchy and confluent. Desquamates in 2nd week
Describe the rash in rubella
Starts on face and spreads
Vague, lacy, ill-defined, not itchy
What virus causes hand, foot and mouth disease? What are the features of this disease?
Coxsackie virus
Sore throat, then mouth ulcers, tender red lumps on hand and feet which can blister
Clears in 7-10 days
What is another name for exanthem subitem? What virus causes it? What are the rash features?
Roseola infantum
HHV6
Non-specific rash which usually appears as child gets better from fever, headache, miserable, possible convulsions
What causes eczema herpeticum? What are the problems with this and how should it be treated?
HSV
Can be disfiguring, and dangerous especially if in eyes
Acyclovir or prophylactic acyclovir if immunocompromised
Give the features of molluscum contagiosum
Small raised papules on skin with small dimple in the middle
Spreads across body, often armpit, knee, groin
Resolves up to 2 years time on own
Virus = mollucscum contagiosum virus (MCV)
How might warts be treated? What is the causative organism
Topical podophyllum or cryotherapy
HPV
What investigations might you do if there is a large red swelling on a child’s neck? How would you treat?
Bloods USS - to find infection centre If abscess - drain Cellulitis - antibiotics Lymphadenitis - find cause
How might you treat scalded skin syndrome?
Blood MC+S
Differentiate between staph and strep or treat both of these
Flucloxacillin, cephalosporin or Clindamycin may be used
Give the features of the rash in HSP
Similar to meningococcal septicaemia in appearance
Non-blanching purple rash
Over buttocks and lower limbs (extensor surface)
May be associated with joint and abdominal pain
What investigations might you do in a child presenting with HSP?
Check blood pressure
Urinalysis
To check kidney disease (haematuria or proteinuria)
What is the main causative organism of erysipelas?
Group a beta haemolytic strep (S.pyogenes)
Can also get staph
How does erysipelas vary from cellulitis (which is mostly staph)
Erysipelas is infection of upper dermis layer, whereas cellulitis is infection of lower layers
Erysipelas (aka St Anthony’s fire) - intense rash, raised edge, bright edge, swollen, can blister
What are the main childhood infections predominantly caused by Group A strep?
Tonsilitis - can lead to glomerulonephritis
Scalded skin syndrome
Erysipelas
Scarlet fever
What is acanthosis nigrans?
Darkening rash common in axilla or back of neck
Found in minority ethnicities and in diabetes
What is the name for a fungating mass on a child’s head that weeps and has surrounding hair loss?
What is causative agent?
Tinea capitis
If in other areas would be called tinea…then body part
Caused by RINGWORM
How would you treat tinea capitis, or other ringwom infections?
Oral anti-fungal (Griseofulvin 6-8wks)
What are the typical features of nappy rash?
Irritant dermatitis/ammoniacal nappy rash
Red Rash - CREASES SPARED
Affects convex surface of buttocks, perineum, lower abdomen and top of thighs
How would you treat nappy rash?
Mild - emollient
Severe - mild topical corticosteroid
If candida complication - topical antifungal agent e.g. clotrimazole
How might you spot candida infection in nappy rash?
Erythematous rash which INCLUDES skin flexures
Satellite lesions
Where else might babies commonly get candida? How would you treat?
Mouth and mother’s nipples - oral thrush
Miconazole gel
What are the symptoms of congenital toxoplasmosis?
Microcephaly
Low birthweight
Retinal lesions
Seizures
How might you reduce nits and lice in children’s hair?
Hair conditioner - leave it on, repeat every few days for a few weeks
What are the features of Scabies infection?
Tiny mites burrow into skin
Silver lines from fingers where entered body
ITCHING
Extensive red rash with tiny spots - apart from head
Often a sign of poor hygiene, possible neglect!
How do you treat scabies?
Permethrin cream or malathion lotion over whole body
Repeat treatment after 1 week
Treat whole family/household twice too
What is a torn frenulum a typical sign of?
Force-feeding with spoon/bottle
What is Frey’s syndrome?
Redness over side of face during breast-feeding in forceps delivered babies
Type of urticaria
What distribution of rashes should be suspicious of abuse?
Symmetrical, linear
Unusual presentation, unexplained
Look for bruising, petechiae to understand mechanism of injury
When should you suspect NAI?
Injury in a child that is non-mobile
Bruising on soft tissues, bum, head and neck, backs of legs and back
Recurrent fractures
Inconsistent history
What are the different type of disorders under paediatric haematology?
Anaemia - iron deficiency, haemolytic
Bone marrow failure
Bleeding disorders
Thrombosis in children
When is the trough of Hb in babies? Why?
around 8 weeks - foetal Hb has fallen, takes a while for adult Hb production to compensate
What are is mean cell volume like after birth?
High after birth, then falls over time
How does the proportion of white cells vary between babies, toddlers and adults?
Babies - HIGH WCC, neutrophils>lymphocytes
Toddlers - lymphocytes>neutrophils
Adults - neutrophils>lymphocytes
What are the branches of leukocytes?
Agranulocytes - lymphocytes, monocytes
Granulocytes - neutrophils, basophils, eosinophils
