Paediatrics Flashcards
Maternal antibodies are present until what age?
Approx 6-9 months
Differentiate between neonate, infant and child
According to WHO: Neonate = from birth til 1 month Infant = 1 month til 2 years Young child = 2-6 years Child = 6-12 years Adolescent = 12-18 years
http://archives.who.int/eml/expcom/children/Items/PositionPaperAgeGroups.pdf
Stridor on exertion, high-normal RR and some intercostal recessions would be an example of (mild/ mod/ severe) respiratory distress?
Mild resp distress
What are the indications for performing neuro obs on a child?
Raised ICP Neurosurgical procedure Encephalopathy (metabolic, hepatic) Endocrine disorder (DKA, DI) Seizures Demyelinating neuro disorder (e.g. GBS) Electrolyte disturbance Increased risk of stroke e.g. VAD, abnorm INR
What ages are the FLACC, Faces and Numerical pain scales used for assessing pain score in children?
FLACC: 2mths - 8yo (or cognitive impairment/ disabled)
Faces scale: >3yo
Numerical scale: >8yo
What is the normal reference range for HR and RR for a 6 month-2 year old? A 5-8 year old?
6mth-2yo: HR 100-160, RR 25-40
5-8yo: HR 80-130, RR 20-30
What does HEADS stand for in assessment of an adolescent (clue: HE2ADS3)
Home Education/ employment Activities Drugs/ alcohol Sex/ safety/ suicide
At what age do you switch from measuring the child’s length to height?
2 years old
What does SAVE-A-CHILD stand for plus examples?
Skin (colour, mottled, petechiae) Activity level Ventilation (signs of resp distress) Eye contact Abuse (any suspicion) Cry (consolability) Heat (or cold) Immune (underlying immunocompromise) Level of consciousness Dehydration (e.g. skin turgor, mucous membranes, cap refill)
Children have [smaller/ larger] diameter airways compared to adults?
Smaller diameter -> means even minor injury/ swelling can compromise ventilation
What does APGAR stand for, when is it performed and what are normal values?
A = Appearance (skin colour)
P = Pulse rate
G = Grimace (reflex irritability)
A = Activity (muscle tone)
R = Respiration
Performed @ 1 & 5mins (±10mins) after birth
Score
≥7 = normal
4-6 = low –> requires medical attention (do a cord gas if ≤5 @ 5mins)
≤3 = critically low –> immediate resuscitation
Name 5 of the 9 genetic conditions that are being tested for in a neonatal heel-prick test?
1 - Cystic fibrosis 2 - Congenital hypoTH 3 - PKU (phenylketonuria) 4 - Homocystinuria (HCU) 5 - Sickle cell disorders 6 - Maple syrup urine disease (MSUD) 7 - Isovaleric acidaemia (IVA) 8 - Glutaric aciduria 1 (GA1) 9 - Medium-chain acyl-CoA dehydrogenase deficiency (MCADD)
What are the 4 domains of childhood development?
1 - Motor (gross & fine)
2 - Language (speech & written)
3 - Social/ emotional
4 - Cognitive
List 4 ‘general’ red flags for childhood development
Any of: Strong parental concern Regression in 1+ developmental domain Non-responsive to visual/ verbal stimuli Significant hypo/ hypertonia Lack of eye contact Poor interaction with adults or other children Asymmetry of movement/ strength/ tone bw L & R sides
At what ages are most children a) starting to stand with support, b) walking, c) running and d) talking full sentences?
a) 5-9months
b) 12 months
c) 18 months
d) 3 years
It is a red flag if a child is not smiling by 6 months or cannot walk independently by 2 years or run & jump by 3 years
6 months
2 years
3 years
What is the difference between global and specific developmental delay?
Global is where delay occurs in 2+ developmental domains; specific is only a delay in 1 domain
List 4 DDx for respiratory distress in a neonate
Any 4 of:
- Sepsis (resp distress in newborn is sepsis til proven otherwise)
- Transient tachypnoea of newborn
- Respiratory distress syndrome aka hyaline membrane disease
- Meconium aspiration syndrome
- Pneumothorax
- Persistent pHTN
- Pneumonia
- Congenital cardiac malformation
- Congenital lung malformation
What are the risk factors for transient tachypnoea of the newborn?
Pre-term delivery (esp 34-37wks); rapid labour or C/S without labour; maternal asthma or diabetes; SGA or LGA
Connect the following causes of neonatal resp distress & underlying pathology/ 'classic' feature: A - Transient tachypnoea of newborn B - Resp distress syndrome C - Persistent pHTN D - Sepsis E - Pneumothorax
1 - increased pulm vasc resistance causing R->L shunt & hypoxia; assoc with congenital diaphragmatic hernia and meconium aspiration; systolic murmur
2 - surfactant deficiency; resp distress appears later & progressively worsens
3 - maternal fever, GBS+, baby has non-specific signs (poor tone, malodour, apnoea, poor feeding, nausea, poor perfusion)
4 - baby required resuscitation and has unequal air entry; higher risk of pulm hypoplasia, pneumonia and meconium aspiration
5 - pulm oedema; onset usually within 2hrs of birth and resolves spontaneously after 12-24hrs
A = 5 B = 2 C = 1 D = 3 E = 4
List signs of respiratory distress in a neonate/ infant
Poor respiratory effort: tachypnoea, grunting, nasal flaring, head bobbing, recessions (intercostal, subcostal, substernal)
Poor respiratory efficacy: reduced chest expansion, added breath sounds, low SpO2
Poor respiratory effect: cyanosis (poor perfusion), tachycardia, impaired mental state
What antibiotics are used as empirical therapy for neonatal sepsis?
*Bonus points for doses
Penicillin or ampicillin plus gentamicin
Doses:
Penicillin: 60mg/kg BD
Ampicillin: 50mg/kg BD
Gentamicin: 2.5mg/kg OD
List 4 aims of the well baby discharge check
Any 4 of:
- Identify for congenital abnormalities
- Educate parents & address concerns (e.g. feeding, sleeping, bathing)
- Assess for jaundice
- Assess establishment of feeding, elimination
- Record & assess growth parameters
- Complete infant personal health record
- Arrange appropriate monitoring & follow-up
What are the common & not-to-miss DDx for jaundice in a 48hour old baby?
Common:
Physiological jaundice
Breastfeeding jaundice (infreq, limited intake -> reabsorption of bilirubin from bowel)
Breakdown of extravasated blood (e.g. cephalohaematoma)
Not-to-miss:
Haemolysis: Rh disease, ABO/ blood group incompatibility
RBC enzyme (G6PD deficiency) or membrane (spherocytosis) defect
Sepsis
Polycythaemia
True or false: Jaundice that occurs in the first 24hours of life is not overly concerning
FALSE - never ignore jaundice (of any severity) that presents <24hours –> most likely pathological (haemolysis, rbc enzyme or membrane defect)
Which of the following is NOT a cause of conjugated hyperbilirubinaemia (e.g. in a 10d old baby with jaundice)? A - Bile duct stenosis B - Hyperthyroidism C - Galactosaemia D - Alpha-1 antitrypsin deficiency E - Hepatitis B infection
B - hyperthyroidism
HyPOthyroidism can cause conjugated hyperbilirubinaemia
How frequent should breastfeeding be in a neonate with jaundice?
Feeding frequency should be increased to 8-12 feeds per 24hrs (i.e. 2-3 hourly, max 3hrs between feeds)
How often should serum bilirubin levels be checked for babies receiving phototherapy? Once phototherapy is ceased?
Every 4-6 hours until rise of bilirubin is controlled, and then 12-24 hourly
Re-check levels 12-24hrs after stopping phototherapy
Vit K deficient bleeding in a neonate typically presents with bleeding at which sites? There is a higher risk of occurrence with (breast/ formula) feeding.
GI bleeding; mucosal membranes; umbilicus; circumcision wounds
(intracranial bleeding is rarer, but accounts for ~50% of late presentations and has a mortality rate of 20-50%)
Higher risk with breast feeding (low levels of vit K compared to formula)
What is the underlying pathogenesis of hypoglycaemia in a preterm neonate?
Provide 3 other risk factors for hypoglycaemia in a neonate (regardless of gestation)
Preterm hypoglycaemia d/t a) limited glycogen & fat stores; b) impaired gluconeogenesis; c) increased glucose utilization for relatively larger brain size; d) unable to mount counter-regulatory response
Other causes of neonatal hypoglycaemia:
Maternal: diabetes, intrapartum glucose, meds (oral hypoglycaemics, citalopram, ß-blockers, valproate)
Neonatal: IUGR/SGA or macrosomia, resp distress, sepsis, congen cardiac defect, metabolic disorder, hyperinsulinism, hypopituitarism, hypoxic insult, hypothermia, inadequate feeding, Rh haemolytic disease
Which of the following is NOT a clinical sign of neonatal hypoglycaemia? A - jitteriness B - sweating C - poor feeding D - bradycardia E - pallor
D - bradycardia
Neonates with hypoglycaemia more likely present with TACHYCARDIA
True or false: the risk of a serious bacterial infection is greatest in the neonatal period?
Why/ why not?
True
Young infants
- Are more likely to present with non-specific signs & can’t localise infection due to immature hypothalamic and immune systems
- Are too young to have received vaccines for potential pathogens
- Have declining levels of maternal antibodies & are only beginning to produce their own
- Can deteriorate rapidly
Classify each of the following clinical signs into the appropriate 'colour' (green, amber or red) of the traffic light system as per the NICE guidelines for assessing an unwell child: Ashen or mottled colour; Wakes only with prolonged stimulation; Grunting; RR 55; Moist mucous membranes; CRT >3 seconds; Fever <3months old; Fever for >5 days
Green: moist mucous membranes
Amber: wakes only with prolonged stimulation; RR 55, CRT >3 seconds, fever for >5 days
Red: Ashen or mottled colour; grunting; Fever <3months old
What are the 4 features of Tetralogy of Fallot?
- Overriding aorta
- Membranous VSD
- Pulm stenosis causing RV outflow obstruction
- RVH
What are the suppurative and non-suppurative complications of group A strep pharyngitis?
Suppurative: peritonsillar or retropharyngeal abscess
Non-suppurative: acute RF, post-strep GN
What are the 3 key supportive treatments for a sore throat?
- Simple analgesia
- Maintain hydration
- Corticosteroids if severe pain despite analgesia: dexamethasone or prednisolone
Where antibiotics are indicated in GAS pharyngitis, they are given to prevent [suppurative/ non-suppurative] complications?
Non-suppurative: rheumatic fever/ heart disease, post-strep GN
GAS pharyngitis is more likely to affect (<4yo/ >4yo)?
> 4yo
It is uncommon in children <4yo
What are the CENTOR criteria for assessing likelihood of strep throat to guide subsequent management?
C = Cough ABSENT E = Exudate present N = Nodes enlarged (ant cervical LNs) T = temp >38 OR = young OR old -> 1 point if 3-14yo
Compare Perthes disease and SUFE (slipped upper femoral epiphysis) in terms of 1) age group affected, 2) pathophysiology, 3) risk factors and 4) treatment
1) Age group
Perthes ~4-8yo
SUFE ~10-15yo
2) Pathophysiology
Perthes: avascular osteonecrosis –> flattened femoral head
SUFE: separation of prox femoral shaft & epiphysis
3) Risk factors
Both: male
Perthes: Caucasian, short stature/ growth delay, FHx (10%)
SUFE: overweight, African-American/ Pacific Islander, renal osteodystrophy, hypoTH or hypopituitarism, gonadal conditions
4) Treatment
Perthes: conservative (rest, avoid weight bearing), bracing/ petrie casting or surgical (‘shelf procedure’, hip replacement)
SUFE: surgical reduction & internal fixation
What are the risk factors for DDH?
'BOFFF': Breech presentation Oligohydramnios Female FHx First born
What is the peak age for 1) pyloric stenosis, 2) intussusception and 3) malrotation with volvulus
1) 6-8 weeks
2) 6-12 months
3) 1/3rd present <1mth, 75% <5yo
Fluid prescribing in paediatrics: what are the formulas for 1) resuscitation, 2) deficit and 3) maintenance
1) Resuscitation: 20mL/kg bolus
2) Deficit (total): body weight (kg) x % deficit x 10mL
- > usually replace over 4 hours
3) Maintenance: 4mL/kg/hr for first 10kg, 2mL/kg/hr for next 10kg, 1mL/kg/hr thereafter
Pyloric stenosis is more common in (males/ females)
Males
True or false: rapid IV rehydration should be given to a 8-week old with moderate dehydration?
FALSE
Rapid IV rehydration should only be given to children >6months
Younger children cannot tolerate rapid fluid shifts
Which of the following is NOT an indication for delivering a fluid bolus in a child?
A) Signs of circulatory shock (e.g. tachycardia & hypotension)
B) Estimated deficit 7-8%
C) Severe dehydration
D) Significant sodium derangement (hypo or hyper)
B) Estimated deficit 7-8% is moderate dehydration, and is not an indication for a fluid bolus/ resuscitation
Which of the following is NOT a requirement for discharging a child with gastroenteritis?
A) Tolerating oral intake
B) Able to be looked after at home
C) No further episodes of vomiting/ diarrhoea
D) Absence of cyanotic heart disease
E) No clinical signs of dehydration
C
There should be infrequent episodes of vomiting/ diarrhoea, however it needn’t be zero
(Viral/ bacterial) infections account for 70% of acute gastroenteritis. The most common pathogens are rotavirus & norovirus
Viral infections are most common, with rotavirus & norovirus being the leading causes.
(Bacterial infections account for 15% of cases, most commonly Salmonella or Campylobacter species)
What does FLACC stand for in paediatric pain assessment?
Faces Legs Activity Cry Consolability
What type of pathology does tenderness suggest and what examination technique is used to best elicit it?
Indicates a degree of peritonism
Best elicited through percussion
What are the most common positions (2) of the appendix?
1) Retrocaecal
2) Para-caecal
What is the classic triad for intussusception?
Abdominal pain + palpable ‘sausage-like’ mass on R-side of abdomen + red currant jelly stool
True or false: you should examine the groin/ scrotum in all children who present with abdominal pain
True
Need to check for hernias, testicular torsion
But once performed on initial assessment, if low index of suspicion then don’t need to repeat
Which of the following findings is most useful in favouring appendicitis over other causes of abdominal pain in children? A) Elevated WCC B) Elevated CRP C) Pain migrating to RLQ D) Fever E) Vomiting
D) Fever
Intussusception is the telescoping, or invagination, of the (proximal/ distal) loop of bowel into the (proximal/ distal) loop of bowel.
This more often occurs at the ileo-caecal valve
Proximal into the distal
The Ileo-caecal valve is the most common site for intussusception
Match the following conditions to the commonly affected age group
A: Sigmoid volvulus
B: Caecal volvulus
C: Intussusception
1: 2mths-2yo
2: Child/ young adult
3: >60yo
A - 3
B - 2
C - 1
At what age does infantile colic peak?
4-6 weeks
Contrast the major sites of haematopoiesis in an infant vs adolescent/ adult
Throughout skeleton as a infant (including long bones e.g. tibia/ femur) but then mostly axial skeleton (vertebrae, pelvis) at an older age
Bleeding due to platelet deficiency usually occurs in
A) Skin and mucosa
B) Deep tissues
C) Joints
A) Skin & Mucosa
Bleeding in deep tissues or joints suggests coagulation factor deficiency
What ion is particularly important for the coagulation cascade to occur?
Calcium
Link the Haemophilia subtypes with their deficient factor & genetic inheritance
Haemophilia A = factor VIII deficiency, X-linked recessive
Haemophilia B = factor IX deficiency, X-linked recessive
Haemophilia C = factor XI deficiency, auto recessive
List 4 possible causes of anaemia secondary to blood loss in a neonate
1) Severe fetal-materal haemorrhage e.g. twin-to-twin transfusion syndrome
2) Cephalohaematoma
3) Subgaleal bleed
4) Occult organ trauma
What are the recommended volumes for formula/ breast feeding in an infant <3months and 3-6 months?
<3 months: 150mL/kg/d
3-6 months: 120mL/kg/d
After 4 weeks, how frequently should babies be feeding and how long should this take?
Approx 7-9 times per day (every ~3 hours) for 8-10mins
List 4 risk factors for iron deficiency anaemia in children
Any 4 of:
- Prematurity
- Low birth weight
- Cow’s milk <6months
- Cow’s milk protein allergy
- Exclusive breastfeeding >6mths
- Low iron intake
- Excessive cow’s milk intake (>600mL/d): incl bottle > cup feeding in >2yo
- Giardia
- Coeliac
Which of the following is NOT a likely clinical manifestation of IDA in a child?
A) Pallor and lethargy
B) Developmental delay
C) Cravings for eating ice
D) Breath-holding spells
E) None of the above (i.e. they are all possible manifestations)
E
All are possible manifestations of iron deficiency, although many children are asymptomatic. Cravings for eating ice refers to pica
What are normal amounts of sleep for children 0-2 months, 2-12 months and 12 months to 3 years old?
0-2mths: 16-20 hours per day/night
2-12mths: total 11-16hrs (9-12hrs overnight + 2-4hrs daytime naps)
12mths-3yo: 12-13hrs with 1 daytime nap
List 4 physical causes of sleep difficulties in children
Any 4 of:
- GORD
- Hunger
- Cow’s milk protein allergy
- Seizures
- OSA
- Cardiac failure, arrhythmia
- Hypoglycaemia
- Eczema, asthma, allergic rhinitis
- Arthritis
- ADHD on stimulants
At what age can honey be given to infants/ children and what risk dose it pose before this?
> 12mths
Infant botulinism
Select each of the features most consistent with atopic dermatitis (eczema)
Dry vs wet
Pale vs red
Itchy vs painless
Dry, red, itchy
What are the five ‘principles’ for treating eczema?
1) Avoid triggers & irritants: cooler baths, soap-free washes, thin cotton clothing, avoid allergens ± foods if intolerant
2) Regular emollients
3) Topical steroids (cortisone) for flares
4) Control itch: cool towels/ dressings, moisturiser
5) Promptly diagnose & treat super-infection