Paediatrics Flashcards
What if you need to attend to the child urgently during the history?
At this stage I would like to assess the patient or check whether there is medical support with the child at the moment.
“I’m sorry to stop you but I’m going to look after your child now and I will come back as soon as I can to talk further”
I will call for help and manage the patient with a systematic A to E approach according to hospital protocol.
What is your structure for paeds Hx?
PC, HPC \+ systems review - behaviour - neuro: seizures/fits, headache - cough, sore throat, noisy breathing - GI vom, pain, diarrhoea/constipation - GU wetting nappies, stinging, going more or less often
BFG Birth Feeding Growth + development - red book
PMHx
Drug Hx
- immunisation
- allergies
How would you manage this child with DKA?
A to E assessment of the child and take a stepwise approach using the trust protocol for DKA management and ask for senior support.
This would include a full set of observations
HR, RR, temp, O2 sats
Urine dip, Capillary BG, Capillary ketones,
ECG
Baseline bloods
RESUS shocked - 20ml/kg, otherwise 10ml/kg/60 mins -
CALC MAINTENANCE - weigh the child and use the severity of DKA to determine deficit(-10ml/kg)/48 + maintenance
IV FIXED-RATE INSULIN
MONITOR V CLOSELY
Complications: hypokalaemia, cerebral oedema
If the patient was not responding to this management or there was any sign of developing cerebral oedema (headache, confusion > dec conscious, abnormal breathing, eye palsies/pupils) I would escalate to my senior, with consideration of IV hypertonic saline or mannitol and transfer to PICU.
How would you manage this child with an acute asthma exacerbation?
Alongside my A to E management I would take a stepwise approach and follow the trust protocol for acute asthma and ask for senior support. This would include assessing the severity of the attack and a CBG would be useful to look at O2 and CO2.
IF MODERATE
Salbutamol via pressurised metered dose inhaler + spacer, up to 10 puffs every 30 secs with 5 deep breaths.
(Children less than three years of age are likely to require a face mask connected to the mouthpiece)
IF SEVERE/LIFE-THREATENING
I will give the patient salbutamol via an air or O2-driven nebuliser, adding ipratropium bromide if there is a poor response.
I would also prescribe oral prednisolone.
I would reassess the patient and repeat salb every 15 minutes if needed.
If the patient was not responding to this management I would escalate to my senior for consideration of Mg sulphate. If the patient was deteriorating or their CO2 rising I would seek immediate help from an anaesthetist/PICU.
Discharge when child is reliably spacing 4 hours between inhalers, with a asthma action plan and review with the GP within 2 days.
What’s the long term management of a child with asthma?
General
- assess Sx, PEFR diary, check inhaler technique, trigger avoidance, update self-management plan, Asthma UK website, tell school
- SABA PRN
+/- very low ICS
*move up if 3 or more doses a week - SABA PRN
+ very low ICS
OR LTRA <5yrs - SABA + vl ICS
>5yrs + LABA or LTRA
<5yrs + LTRA - inc ICS to low
OR >5yrs + LABA or LTRA - Specialist care
What’s the long term management of a child with diabetes?
This patient will be managed by an specialist paediatric diabetes MDT including a consultant, specialist nurse, dietician and psychologist support.
In hospital - the team will visit you to support and train in insulin injecting (basal/bolus) + BG monitoring + CHO counting + ?pump therapy if hypoglycemic unawareness
On discharge - appt in clinic in 1 week, OOH telephone line, regular F/U monitoring for control and complications
How would you investigate and manage this child with constipation?
Look out for red flags in the Hx - from birth, delayed mec (Hirschsprung’s), leg weakness, abdo distention + vomit (obstruction)
Relative - ftt (?hypothyroid)
Ix: full examination, growth chart, may test for coeliac disease (Fe, B12, folate) and hypothyroidism if ongoing
Conservative - inc fluids, inc fibre, staying active, regular toileting w/star chart, any need psychological or dietician input, inform school nurse
Medical
*Faecal impaction - overflow diarrhoea
movicol escalating disimpaction regimen for 2 weeks
*Maintenance 2 sachets/day
*Anal fissure - simple analgesia, refer to specialist
How would you investigate and manage this child with fever?
NICE traffic lights
Red flags - COLOUR (pale/mottled/ashen/blue), ACTIVITY (unresponsive, weak/HP cry), RESP (grunting + indrawing), HYDRATION (dec skin turgor), <3M >38
*non-blanching rash, bulging fontanelle, neck stiff, neuro
Ask about ICE!!!
Top to toe - further tests to seek out causes • FBC, U&Es, CRP • Cultures (urine, blood, +/-CSF) • CXR • VBG/CBG LP if under 1/meningitis suspected
Head - meningitis, otitis media
ENT/resp - tonsillitis, croup, pneumonia
Abdo - acute abdomen, UTI
Bones/joint - septic arthritis, osteomyelitis
> 5 days fever ?UTI, Kawasaki, pneumonia, leukaemia
Kawasaki disease Particularly <2 • Conjunctivitis • Rash – mac pap • Adenopathy - cervical • Strawberry tongue/red lips • Hands – palmar erythema and peeling skin • BURN - 5-7 days fever
Rx: IVIG + high dose aspirin
Complications - HEART DISEASE
• Myocarditis, pericarditis responds to IVIG
• CAA – dilation, aneurysms
Sudden death, long term IHD disease
Meningitis - GET SENIOR SUPPORT! RX ACCORDING TO HOSPITAL GUIDELINES GP - IM benzylpen A to E, give O2, IV access <3M - IV cef + IV amox >3M - IV cef + dex if not shocked
?LP
CIs - raised ICP, shock, local infection, coagulopathy
?bolus if shocked, transfer to PICU
Ongoing Rx - +/- NGT, catheter, CXR 2 hrly U&Es/gas + BM Fluid balance - contact infection control - Abx prophylaxis for household - leaflets
F/U - hearing test, OPD appt, vaccines
What would you offer a child with high BMI?
MANAGEMENT OPTIONS (building in patient concerns)
Cutting down on snacks and sugary food, decreased portions, eating together
Increasing exercise - fun activities, family participation (limiting screen time)
MDT management School nurse Dietician input - Starting a food diary - Weight management program - Support group (for mum and child)
What’s your approach to differentiating causes of abdo pain?
Abdo Hx
• Acute or chronic?
- Acute = UTI, DKA, surgical (appendix, intussusception, torsion)
- Chronic = constipation, IBD, coeliac, malignancy, abdominal migraine, psychological
• Serious cause?
Eating and drinking
• Passing urine
• Opening bowels
DDx not to miss
- UTI/pyelonephritis
- Bowel obstruction
- Appendicitis
- IBD
Rare but serious
- Wilm’s tumour
- Neuroblastoma
What’s your approach to suspected NAI?
Suspected if:
- unexplained injuries
- subdural haematoma
- neglect
- failure to thrive
1st step
- make sure child and siblings are in a safe place i.e. ADMIT the child
- discuss with senior and named safeguarding lead
- > referral to social services
Ix:
- bloods - bone profile
- skeletal survey
- CT head
“Whenever we have a case where we don’t know why an injury has occurred, we have to
involve some other people. This includes social services and the child safeguarding team (and maybe the police). This is a routine requirement for all children in these situations, and our aim is to keep your child safe. Sometimes when children have similar injuries, they do not happen by accident and they are caused by someone else.”
What is your differential for limp/joint problems in a child?
Differentials • Developmental dysplasia of the hip • Perthes • Slipped Upper Femoral Epiphysis = posterior migration of the epiphysis (obesity >10y/o M>F decreased abd & int rot, Ix with frog leg lateral X-ray - Rx = int pinning&fixation) • Irritable hip
General
• Trauma (eg toddler’s fracture)
• Infection (septic arthritis, osteomyelitis)
• Inflammation (Juvenile idiopathic arthritis, Osgood-Schlatter)
• Malignancy (leukaemia, ewing’s, osteosarcoma)
What is your approach to neonatal jaundice?
HPC: exact day of jaundice, symptoms (lethargy, poor feeding, drowsy, stupor, hypotonia, fever, high-pitched cry, seizures)
Antenatal Hx: anything picked up on blood tests or scans?
infections, blood group incompatibilities, anti-D
Birth Hx: weeks, delivery, weight, how long was the stay, meconium, vit K, heel prick
Neonatal period: breastfeeding? how often, wet/dirty nappies (colour of stool), sleeping
other - drowsy, floppy, fever, vomiting, rash, weight now % change (RED BOOK)
*any other concerns from health visitor?
FHx: inherited blood diseases in family
SHx: who’s at home, smokers, social worker
Ix: DISCUSS WITH SENIOR
full neonatal exam, obs plotted on PEWS, weight plotted in red book, urine dip
*transcut bilirubinometer
serum bili - plot on nomogram
If ?pathological
?haemolysis - FBC, blood film, enzymes, blood group, coomb’s test
?sepsis - SEPSIS 6 = cultures i.e. blood, urine, LP, CXR
?liver - LFTs, HIDA scan
Jaundice differentials
<24hrs = pathological
- haemolysis (HDON)
- infection (antenatal, sepsis)
24hrs - 2wks = physiological - p. jaundice - breast feeding - breast milk OR pathological - haemolysis, sepsis, hypothyroidism, metabolic
>2wks = prolonged - biliary atresia - choledochal cyst /prolonged breast milk /hypothyroidism /infection
Explain diagnosis of physiological jaundice
Explain diagnosis = physiological jaundice
What is it? New babies process their red blood cells quickly to produce bilirubin and their livers are not quite mature enough to remove all the bilirubin from the blood just yet. It’s a normal process and we’ve found no evidence of infection or any other causes so nothing to worry about.
Why did this happen? This could also be because she appears dehydrated at the moment, which worsens jaundice. We often find that it is more common in babies who needed help from the ventouse during delivery and babies who are breastfed. It is likely to be a combination of normal jaundice, ventouse, dehydration and the breastfeeding.
Epidemiology? This is very common. Up to 60% neonates.
Risks? There is a risk that the bilirubin can enter the brain and cause long term problems but at the moment Satia’s levels aren’t high enough for that.
Prognosis? Baby’s liver will soon mature and the jaundice will begin to disappear over the next 2 weeks.
Rx of jaundice
Baby unwell - A TO E
Treating high serum bilirubin
Phototherapy - special blue light that shines on the skin and changes the bilirubin into a product that baby will be able to break down easily.
Exchange transfusion - type of blood transfusion where a small amount of baby’s blood would be replaced from a matching donor through a thin plastic tube.
May need IV fluids and antibiotics
Health visitor follow up + review of breastfeeding
- regular feeding every 3 hours + may need topping up with formula
- leaflet and breastfeeding support groups
What’s your approach to GI bleed?
Black, tarry (melaena) = upper GI Fresh red blood = lower GI HPC: acute/chronic, stool (colour, amount, timing), assoc w/foods Diarrhoea/constipation, vomiting, pain Fever, rash, behaviour Recent illness, travel BFG + behaviour DHx: NSAIDs/steroids, ALLERGIES FHx: IBD, anyone else been ill? SHx: who's at home? any smokers? any social worker? ICE!!!!!!!
What are your differentials for GI bleed?
Neonate
Well - CMPA, anal fissure, swallowed maternal blood
Unwell - necrotizing enterocolitis, malrotation with volvulus
Small child
Well - Infectious
Unwell - intussusception, Meckel’s diverticulum, (HSP)
Older child
Well - gastritis, Mallory Weiss
Unwell - IBD
What’s your approach to vomiting in a baby?
DDx:
GORD, overfeeding, pyloric stenosis, hiatus hernia, gastroenteritis/UTI, malrotation/volvulus, CMPA
Regurgitation of a small quantity of milk after a feed, without any other symptoms = possetting - normal!
GORD = recurrent non forceful regurg or vomit in babies due to incompetence of GOJ sphincter. 8wks - 1 yr. May present with BRUE/respiratory problems, FtT.
*RFs - prem, FHx, diaphragmatic hernia, neurodisability
Red flags
- forceful/bile stained/haematemesis
- late onset i.e. >6 mnth
- unwell ?infection ?meningitis
- chronic diarrhoea
Pyloric stenosis = muscle near the stomach leading to the small bowel becomes thicker, causing an obstruction, leading to milk being unable to pass through. Instead the child vomits the milk back up
Treat with IV fluids, electrolyte replacement, followed by pyloromyotomy (can be open or laparoscopic) May need NG tube *RFs • Prematurity • First born male infant • Family history of pyloric stenosis
Blood gas - hypochloremic, hypokalemic metabolic alkalosis
What is your DDx and red flags for a headache in children?
DDx- common= tension, migraine, eyesight, post ictal headache
less common but serious- sinuisits, meningitis, encephalitis, raised ICP
Hx Red flags- meningism (stiff neck, photophobia), worse on coughing or straining, on waking up or lying down, confusion, N+V, change in personality or behaviour, visual field defect, other signs of raised ICP, focal neurology/seizure
What is your management of migraines in children?
Preceded by ? in childhood
Can be preceded by- Cyclical vomiting, abdominal migraines and BPPV in childhood
C- Keep a diary to identify triggers. Avoid precipitants (cheese, chocolate, caffeine, alcohol, exercise/travel). Lie down in dark, quiet space when having one. Inform the school.
M- NSAIDS and if necessary refer to a neurologist for nasal triptans e.g. sumitriptan to treat. Prophylactic beta blockers e.g. propanolol/topiramate (If >2/ month/ significanty affects school or social life or dont respond to treatment). Anti-emetic e.g. prochlorperazine may be needed.
How would you manage GORD in an infant?
Reassure parents that its common. Normally self resolves without treatment or investigations
1st line- Feeding advice
- Advise upright positioning post feeds and avoid overfeeding
- If breastfeeding, carry out breastfeeding assessment. If issue persists, try a 1-2 week trial of alginate therapy
If bottle fed, reduce feed volumes (smaller more frequent?), offer thickened formula, offer alginate therapy.
Consider PPI trial if child v distressed or has faltering growth. Surgical = nissen fundoplication
Safety net to come back if no improvement, blood stained or green vomitus, worried about growth.
Approach to baby with cows-milk protein allergy
Differentiate from simple GORD coz baby may have lip swelling, rash, abdo pain and diarrhoea etc.
If breast fed, eliminate cows milk from mums diet (takes 2-3 weeks to be eliminated fully from breast milk). Consider supplementing calcium and vit D.
If formula fed, switch to hypoallergenic formula.
Offer help from a paediatric dietician. Monitor growth.
Reassure mum that many kids grow out of it and we will re-evaluate the child to assess tolerance every 6-12months by slowly reintroducing cows milk using cows milk protein ladder (available from allergy UK)
Approach to seizure?
Hx: get before, during and after
any medications given
recent illness
signs of meningitis - rash, fever, N&V, photophobia, neck stiffness
prev head injury
DURING - awareness, limbs moving (describe progression), eyes, colour, floppy or stiff, loss of bowel or bladder control, tongue biting
AFTER - how did they seem? headache?
Differentials
- Seizure
- febrile convulsion
- epilepsy
- reflex anoxic
- breath holding attacks
- drug withdrawal
- head injury
- infection esp meningitis
- metabolic esp hypoglycaemia
- Non-seizure
- faint
- arrhythmia
Investigating and managing seizures
A to E approach • Note time. • Call for help. • Check glucose. • Establish IV access. • Monitor obs signs, especially SpO2. • Give 100% O2 via mask.
5min: IV lorazepam (100mcg/kg, up to 4mg), OR
• If no IV/IO access: rectal diazepam (0.5mg/kg) or buccal midazolam (0.5mg/kg).
15min: If there is no response, repeat the dose of lorazepam IV
Ix: full obs, top to toe exam looking for infective focus, neuro exam fluid status, urine dip/MSU, BM Bloods - FBC, U&E, Ca/Mg, glucose ?CBG ?LP
Likely febrile seizure - harmless seizure sometimes occurring during illness from ages 6mo- 6 years.
1st ep - Observation for 2 hrs & consult with senior
Safety netting- give calpol to keep child comfortable, although will not reduce likelihood of further seizures. If further seizure, monitor seizure length, protect child from injury, do not restrain or put anything in mouth, place child in recovery position once seizure has stopped. Bring child in if recurring within 24 hrs or the same illness. In future - if tonic clonic seizure lasting > 5 min = CALL AMBULANCE
Approach to a small baby with DIB
Newborn
- TTP due to delay in lung fluid resorbtion (c section?)
- Surfactant deficient lung disease (?prem)- tachypnoea, grunting, o2, ground glass on Mx=exongenous surfactant, cpap
- PPH due to pulm vasc resistance being high
3-6 months
1. Bronchiolitis (RSV) most likely
Increased risk- Chronic resp conditions, cardiac problems, premature, CF
Signs- coryzal sx, wheeze, cough, fine insp crackles, all signs of resp distress (admit), feeding problems, dehydration
NPA to Ix?
Mx
Supportive (neb saline, humidified O2, ?NG, fluids if dehydrated)
6m-3years
Croup (Parainfluenza) most likely
Signs- Stridor, fever, coryza, barking cough
Mx
Dex, humidified O2, neb adrenaline
Ddx- Laryngomalacia (but well child), Acute epiglottitis/Bacterial tracheitis/Retropharangeal abscess (but no cough normally)
Common causes of rashes
- Eczema- ask about atopy Hx,
- Psoriasis- ?guttate in response to strep throat
- Kawasaki disease- CRASH and burn
- Viral exanthum- any concurrent infectious signs
- Contact dermatitis
- Scabies- ?itchy
- Ringorm
How would you mange this child with eczema?
If suspect eczema, check for family Hx or personal Hx of atopy. Use POEM (patient orientated eczema measure) to assess severity Assess impact on everyday activities, psychosocial functioning, wellbeing, sleep to categorise into mild, mod or severe.
Mx
C- Refer to paediatric dermatologist if moderate-severe eczema
Use unperfumed emollients for washing, moisturising, bathing.
Trigger avoidance (?soap, detergent, contact allergens, food allergens, inhalent allergens)
BAD website for more info.
M-
Mild- Emollients+ mild top steroid cream
Mod- Change to mod steroids, topical calcineurin inhib (tacrolimus cream), wet bandages +/- antihistamines if itchy or sleep disturbance
Severe- Change to potent steroid, phototherapy, systemic therapy
Advise parents to emollient very frequently and all over body. But steroids only on eczema areas (v thinly, fingertip units). Recognise signs of eczema herpeticum or staph infection. Refer to specialist if not responding to simple treatment, recurrent infections or if big impact on wellbeing.
Steroid ladder Hydrocortisone Eumovate- clobetasone Betnovate- betamethaosne Dermovate- clobetasol
