Paediatrics Flashcards
Jaundice differentials in a baby
Depends on timing
<2days => ABO incompatability or rhesus incompatability
Sepsis
2 days - 2 weeks G6PD Hereditary spherocytosis Sepsis Breast milk jaundice
> 2weeks
Biliary atresia
Causes of failure to thrive
Increased energy requirement => chronic issue =>CF, hyperthyroidism
Malabsorption = coeliac
Poor intake/neglect
(ask about school and mental health) or issue with feeding e.g. cleft palate
Features of failure to thrive
Crossing growth centiles
Child persistently in the bottom 5th percentile
Investigation and management of failure to thrive
Ensure adequate nutrition
Ensure social support and support at school as well as financial support
Ix for any potential Dx = sweat test, anti-TTg, FBC (anaemia), TFTs (hyperthyroidism)
Organic cause in <5%!
Dietician
Regular appointments to check progress
Factors that determine good growth in a child
Adequate intake Endocrine levels Co-morbidities Emotional health (supported child)
Until which age should you correct height/weight etc. for prematurity?
2 years old
Whats the cut off for concern for number of centiles crossed?
2
By what age should a baby have doubled their original weight?
Around 4 months
Average age of puberty in females
11
Order of puberty development in females
Breast budding
Pubic hair
Menarche
Cut offs for precocious puberty in males/females
<8 for females
<9 for males
Causes of precocious puberty
Central (most common), just normal puberty happening earlier
Peripheral = intracranial tumour, endocrine tumours e.g. McCune Albright syndrome
Congenital adrenal hyperplasia
Ix for precocious puberty
Brain MRI to rule out central tumour
USS of ovaries/testis to assess size + determine if gonadal tumour present
Endocrine levels
Mx of precocious puberty
Ix to rule out sinister causes
Give GnRH analogues to delay puberty and help with development and mental health
Causes of delayed puberty
Late bloomer (most common, check with hand bone xray)
High gonadotrophin secretion
Kallmans syndrome
Turner’s syndrome
Low gonadotrophin secretion
Pituitary tumour
Systemic issues such as CF or Crohn’s
Definition of delayed puberty in boys and girls
No pubertal development by the age of 14 in girls and 15 in boys
Most common cause of delayed puberty
Late bloomer
First line tests for delayed puberty
Hand xray for bone age
LH and FSH levels to rule out gonadotrophin issues
Symptoms of acute lymphoblastic leukamia (ALL)
Any children presenting in GP with bruising, enlarged lymph nodes and systemic illness should be referred for specialist assessment.
Lymphadenopathy is the most common sign in ALL.
Other symptoms which may be present include: hepatosplenomegaly, pallor or petechiae, fever, fatigue, dizziness, weakness, and epistaxis.
Congential disorder that increases the risk of ALL
Down’s syndrome
Diagnosis of ALL
Firstly do FBC and blood film
Bone marrow biopsy
Remember to screen for coagulopathy
Features of child with bone cancer
FLAWS Limp or bone painn Ask about pain at NIGHT Ask if any signs of trauma Rule out NAI
Causes of short stature
Familial Delayed puberty (this tends to catch up) Nutritional Chronic illness Genetic (Turner's and Down's) Thyroid issues GH deficiency Chronic steroid use (e.g. Crohn's or another chronic illness)
Ix for short stature
Growth charts (plot mid parental height)
Bloods for FBC, thyroid, CRP, U&E
Imaging of bones
Who should manage children with endocrine issues?
Paediatric endocrinologist
How do you calculate predicted height for a boy/girl
Mum + Dad + 13 all divided by 2 for a boy
- 13 for a girl
DDx or jaundice in a child
Pre-hepatic => haemolysis = G6PD, SCD, AIHA, HUS
Hepatic => Gilbert’s, hepatitis
Post-hepatic => Gallstones
Neurological symptoms of jaundice indicate…
Kernicterus
Management of jaundice in a newborn
Try to rule out sinister causes of jaundice
Plot on a bilirubin chart and use phototherapy or exchange transfusion if severe (very high levels)
Symptoms of croup
Viral URTI progressing to barking cough
Hoarse cry
Inspiratory stridor
Respiratory distress in severe cases
Symptoms get worse when the child is distressed
Fever
Most common cause of croup
Parainfluenza virus
Causes tissue swelling and oedema, limiting airflow and causing stridor
Signs of respiratory distress
Nasal flaring Pursed lips Head bobbing Tracheal tug Intercostal recessions Subcostal recessions Use of abdominal muscles (belly breathing) Frightened look Sweating due to increased work Grunting
DDx for croup
Croup
Bacterial tracheitis (similar but with purulent secretions)
Epiglottitis
Foreign body (for the stridor)
Mx of croup
Admit if <6mo or severe
Give wafted O2
Single dose of dexamethasone
Nebulised adrenaline
What is bronchiolitis?
LTRI infection of infants between 2-6 months old
What causes most cases of bronchiolitis?
RSV
RF for severe bronchiolitis
Prematurity
Chronic lung disease
Typical features of bronchiolitis
Coryzal symptoms (fever, snotty nose and cough)
Then get LRTI Sx like dry cough and WHEEZE
They go off their feeds
Ex shows fine inspiratory crackles, widespread wheeze
Fever
Dx of bronchiolitis
Nasopharyngeal aspirate for rapid RSV testing incase you want to isolate them
DDx for bronchiolitis
Viral wheeze
Asthma
Pneumonia
Mx of bronchiolitis
Usually self-limiting unless signs of severe disease = hydration, antipyrexial meds such as ibuprofen and paracetamol
Hospital admission if: Poor feeding (<50% normal), resp distress, low O2 sats, Hx of apnoea, resp rate >70
Mx in hospital = oxygen and NG feeding
Definition of pneuomia
LRTI with radiological changes (this is how you differentiate from croup and bronchiolitis)
Common causes of pneumonia
S. pneumoniae, H influenzae, S aureus
A typical = M pneumonia
Diagnoses to consider in an unwell, febrile child
Pneumonia
UTI
Meningitis
Features of pneumonia in infants
Cough Fever Preceded by URTI Sx Signs of respiratory distress SPUTUM
Mx of pneumonia in children
Antibiotics
Anti-pyrexials
Consider admission if signs of repsiratory distress or low O2 sats
Why dont we use aspirin in young children <16yo?
Reyes syndrome
Most common cause of epiglottitis
H influenzae
Symptoms of epiglottitis
Child stooped forward Drooling Dyspnoea Looks toxic High temperature
Mx of suspected epiglottis
Keep the child calm and give wafted O2 and nebulised adrenline
Get the crash trolley
Alert senior and anaesthetist as well as ENT
Intubate the patient
IV antibiotics
IV steroids and IV maintenance fluids
Features of a viral wheeze
SYMPTOM FREE BETWEEN BOUTS
Precipitated by viral infection e.g. coryzal
Unpredictable, non-sterotyped response
Features of asthma
Precipitated by triggers May be wheezy in the interim Responds to B agonist History of atopy Night time cough
Symptoms of pertussis infection
Dry hacking cough Continuous cough Petichae on face Child looks unwell Afebrile
Mx of pertussis infection
Supportive :(
Features of a life threatening asthma infection
Hypotension Silent chest Unable to talk Confusion Coma Exhaustion PEFR <33%
Mx of asthma (chronic)
SILLI
Mx of asthma (acute)
O2 NEBS IV hydrocortisone or oral pred IV salbutamol (ITU) IV aminophylline
What is HSP?
IgA mediated vasculitis
Often triggered by preceding strep nfection
Features of Henoch-Scholein purpura
Palpable purpuric rash
Arthralgia
Abdominal pain
Renal involvement (nephrotic syndrome)
Mx of HSP
Supportive and symptomatic treatemnt
= simple analgesia
Steroids for any renal involvement
Features of a Wilm’s tumour
Abdominal mass Loss of appetite Weight loss Fever Blood in urine
Ix for Wilms tumour
Abdominal USS
Urine dip
Abdominal CT
Mx of Wilm’s tumour
Surgery on kidneys (very sucessful)
Features of IgA nephropathy
Sore throat (centor => strep) Few days later -> blood in urine
Management of IgA nephropathy
ACEi
Supportive
Management of post-streptococcal glomerulonephritis
Treat the infection (Abx)
Otherwise supportive unless high BP in which case give ACEi
Additional questions to ask in paeds Hx
DFIBS Development Feeding Immunisations Birth School and social worker
Red flags of bedwetting
Headache
They were fine and now bad again
Bad causes of bed wetting
Abuse
SOL
UTI
Stepwise Mx of bedwetting
Ix Star chart Reduce caffeine and other drinks before bed Enuresis alarm Desmopressin
Features of SUFE
Limping child
Obese
Externally rotated leg
Frog’s leg xray shows disruption of Klein’s line
Management of SUFE
Bilateral screwing
Features of Perthes disease in children
Painful knee/hip
Limp
X-ray shows avascular necrosis
Management of Perthes
<6yo and/or <50% damage = conservative (analgesia and physiotherapy)
>6yo and/or >50% necrosis -> operative
Red flags of joint pain in children
Fever
Weight loss
Night pain!
Features of transient synovitis
Illness 4-6w ago (usually viral)
Now cant see, pee or climb a tree
Multiple joints painful
Management of transient synovitis
Supportive with analgesia
Features of measles infection
Rash that starts on the face and spreads to the rest of the body
Koplik spots
Features of Scarlet fever infection
S Scarlet fever Strep Sore throat Strawberry tongue
Features of rubella infection
Rubella = fruit juice
Pink rash on the back and torso
Features of parvovirus infection
Red cheeks thats warm to touch
Systemically unwell
Features of hand foot and mouth infection
Vesicles in mouth, on hands and sole of feet
Features of roseola infection
RoseOla
Fever then as it subsides a rash appears thats maculopapular
Features of Kawasaki’s disease
Strawberry tongue Refratory, >5day fever Peeling palms and soles Irritable child Lymphadenopathy Rash is never vesicular
Ix in Kawasakis disease
Bloods (infective picture)
ECG
Echocardiogram for coronary artery aneurysm
Mx of Kawasaki
High dose aspirin (watch out for Reyes)
IVIG
What is Reyes syndrome
Acute encephalopathy and fatty degeneration of the liver
Seen with aspirin Mx in children
Features of chickenpox
Caused by VZV
Viral prodrome (mild fever, headache, malaise)
Pruritic rash thats very itchy, they crust over
Features of meningitis
Headache Photophobia Neck stiffness Feel very unwell Non-blanching rash
Complications of chickenpox
Encephalitis
Meningitis
Bacterial infection e.g. impetigo
Risks of chickenpox
Pregnant women
Neonates
Immunocompromised
Ix and Mx for measles
Salivary swab is required to Dx
Mx = supportive
Complication of port wine stain on head
Sturge Weber syndrome
What is cerebral palsy?
Permanent issue with motor or positional function
Causes of cerebral palsy
Usually prenatal (ischaemic event) Shoulder dystocia or traumatic birth Seizures Kernicterus Meningitis/encephalitis
Symptoms of cerebral palsy depend on…
Where the lesion is
Cortex -> UMN
Lower than cerebellum -> LMN
Delayed development
Stiff muscles or floppy
Persistence of primitive reflexes
Types of cerebral palsy
Spastic (most common) damage in the brain leads to say a hemiplegia
Dyskinetic = issues with basal ganglia causing poor coordination, hypotonia etc
Managment of cerebral palsy
MDT Physio Pain management School support Nutrition Spasticity medication
Features of idiopathic thrombocytopaenic purpura
Viral illness followed by sudden onset of purpura and petichiae in a child
Epistaxis
Low platelet count
Diagnosis of exclusion
Must rule out HUS, TTP, DIC, NAI!
Mx of ITP
Usually supportive
Can use oral steroids or IVIG if severe bleeding
Features of pyloric stenosis
Projectile vomiting
Olive shaped mass
Still wanting to feed
Mx of pyloric stenosis
Dx = abdominal USS
ABG shows hypochloaraemic, hypokalaemic metabolic acidosis
Supportive until Ramstedt pyloromyotmy
Features of DKA
Abominal pain Vomiting Diabetes background or features (weight loss, increased urination) Hyperkalaemia Ketonuria High ketones in blood High glucose
Management of DKA
Fluids until systolic >90
1L over 1 hour
1U insulin / kg / hr
Once glucose <14, add dextrose
Monitor potassium and correct accordingly
Keep monitoring ECG for tented T waves or arrythmia
Look out for hypercoagubility
Features of T1DM
Excess urination Weight loss Dizzy spells Sweet breath Hx of atopy
Mx of T1DM
Insulin
Capillary glucose measurements
Regular monitoring and screening with opthal and urine creatinine
Features of coeliac disease
Weight loss Chronic diarrhoea Dermatitis herpetiformis Failure to thrive Abdominal pain Fatigue Buttocks wasting Angular stomatitis and ulcers (iron deficiency)
Coeliac disease biopsy features
Villous atrophy and crypt hyperplasia
Common anaemia alongside coeliac
Microcytic because of poor iron absorption
Auto-antibody in coeliac
Anti-TTG
Definitive diagnosis of coeliac disease
Jejunal biopsy
DDx for coeliac disease
IBS
IBD
Pancreatic issues (CF)
Lactose intolerance
Coeliac disease Mx
Gluten free diet
Screening for MALT
Iron supplements if needed
Dietician involvement
Features of neglect/abuse
Posterior rib fracture Spiral fractures Retinal haemorrhages Failure to thrive Wetting and soiling Self harm Dishevelled appearance Story not lining up
Who do you inform if any suspicion of neglect or abuse?
Senior immediately
Features of otitis media
Child tugging at ear
Fever
Distracted and not feeding well
Bulging tympanic membrane
When should you perform your ENT assessment?
At the end of the examination (can cause distress)
Managment of URTI (coryzal, bit of a cough and fever)
Steam inhalation
Calpol
Lemsip if older
Management of otitis media
Analgesia
Management of otitis media with effusion
Topical chlorphenamine and oral analgesia
Management of ear wax blocked ears
Olive oil drops
Features and diagnosis of Hirschsprungs
Delayed passage of meconium
Rectal biopsy shows decreased ganglion cells
Features of Down’s syndrome during birth and 1st few days
Hypotonia
Poor feeding
How can a diagnosis of Down’s syndrome be made?
Amniocentesis during pregnancy
Karyotype testing
Clinical features of Down’s syndrome
Flat nasal bridge
Single palmar crease
Sandal gap between toes
Learning difficulties
Conditions you are more likely to develop in Down’s syndrome
Leukaemia
Cardiac defects
Hypothyroidism
Alzheimers
Most common cardiac defect in Down’s
Atrioventricular septal defect
Core features of autism
Poor social skills Impaired language (e.g. speech delay) Repetitive behaviours (hand flapping, tip-toe gait)
Features of Asperger’s
Retain IQ and language levels
Ix for autism
HEARING ASSESSMENT
Heel prick looking for metabolic issues such as phenylketonuria
Remember that this could just be a normal child, wide variety of personalities
Management of autism
MDT
BIOPSYCHOSOCIAL
Educational support at school
SALT
Support groups
Behaviour analysis
Medical = anti-psychotics if the child has repetitive tendency to injury themselves
Associated issues with autism
Mood disorders Seizures Learning difficulties Anxiety OCD ADHD Hyperactivity Sleep deficits
Causes of PUO (fever >3w)
Infection (Kawasaki)
Malignancy (leukaemia)
Rheumatic disease (JIA)
Inflammatory (IBD)
Causes of neonatal sepsis
E.coli
Group B strep
Listeria
Features of intussception
Child crying and off food Bringing knees up to chest Red current jelly stool Colicky pain Vomiting (billous early) Sausage shaped mass in upper abdomen
Ix of intussception
Abdo USS shows target sign
Contrast enema = gold standard
Mx of intussception
NBM
IV fluid
Air sufflation
Analgesia
DDx rectal bleeding in child
Meckels IBD Cows milk protein intolerance (younger child) Abuse Coagulopathy Anal fissure
What is epilepsy?
The enduring predisposition for generating unprovoked seizures
Dx of epilepsy
> 2 unprovoked seizures
>24hr apart
What are infantile spasms
West syndrome
Poor prognosis, associated with tuberous sclerosis
Have Salaam attacks (can be mistaken for colic)
DDx for seizure in infants
Epilepsy Breath holding spell (injury/upset, hold breath, go blue, collapse, recover quickly) Vasovagal attack Febrile convulsion Encephalitis
