Paediatrics Flashcards
What are the three broad causes of delayed puberty?
Constitutional delay
Hypogonadotrophic hypogonadism
Hypergonadogrophic hypogonadism
Give some examples of causes of hypogonadotrphic hypogonadism.
Hypothalamo-pituitary disorders - panhypopituitarism, intracranial tumours, kallman syndrome.
Systemic disease - anorexia nervosa, crohn’s disease, cystic fibrosis
Give some examples of hypergonadotrophic hypogonadism.
Chromosomal abnormalities - klinefelter syndrome (XXY), turner syndrome (X0)
Steroid hormone enzyme deficiencies
Gonadal trauma - direct trauma, post surgery, post chemotherapy, torted testicle.
What are the top 5 areas of concern in sexual health?
Age <13 years old Power imbalance in relationship Evidence of coercion Substance misuse Whether the behaviour places them at risk
What are the top 4 risk factors for STIs?
Avoidance of barrier contraception
Multiple partners
Mental illness
Substance misuse
What are the top 5 risk factors for substance misuse?
Conduct disorder Poor parenting Early experience of substance abuse Peer group pressure Poor social environment
What are the top 5 negative effects of chronic illness?
Constitutional delay in growth and puberty Negative self-image Low mood Poor school attainment Poor peer development
What are the top 5 factor to optimise transition to adult services for a teenager?
Inform the adolescent and parents early
Run specific teenage clinics
Involve the GP - continuity throughout process
Encourage the young person to take control of their health - making appointments, ordering medication, administering medication
Support and educate parents who will often struggle to let their child with a chronic medical condition to take on these adult roles.
What are the prenatal causes of developmental impairment?
Genetic syndromes (Down syndrome, fragile X, Williams, Angelmanns, Rett syndrome)
Metabolic e.g. PKU
Structural e.g. tuberous sclerosis
Acquired e.g. foetal alcohol syndrome, drug exposure, rubella, infarct.
Unknown e.g. dysmorphic/brain malformation e,g. microcephaly, agenesis
What are the perinatal causes of developmental delay?
Intra-ventricular haemorrhage, hypoxic ischaemic encephalopthy
What are the post natal causes of developmental delay?
Post cranial radiotherapy, acquired brain injury
What is meant by global developmental delay?
Affecting 2 or more areas
When should a child be referred due to gross motor delay?
Failure to walk by 18 months
What are the possible causes of gross motor delay?
Cerebral palsy Duchenne muscular dystrophy Antenatal insult Part of developmental impairment (Bottom shufflers - normal variant)
What is the management of a child with speech delay?
Speech and language therapy referral and hearing test.
What are the causes of speech delay?
Familial Hearing impairment Poor social interaction/deprivation Autistic spectrum disorder Duchenne muscular dystrophy Part of developmental impairment e.g. Down syndrome
Which three domains do children with autism have impairments in?
Social interaction
Social communication
Repetitive/ritualised behaviour
Give examples of specific issues babies with Down’s syndrome face.
Feeding difficulties
Congenital heart disease
Duodenal atresia
What is the management of children with cerebral palsy?
Speech and language therapy.
If problems with feeding - referral to a dietician, considered for gastrostomy.
Spacticity and dyskinesia require joint medical and physio management. Consider botulinum toxin injections for local spacticity.
What are the causes of primary bed wetting, without daytime symptoms?
Lack of sleep arousal
Polyuria
Bladder - small capacity/overactive
What are the causes of primary bed wetting with day time symptoms?
Overactive bladder Structural abnormalities Neurological disorders Chronic constipation Urinary tract infection
What is meant by secondary bedwetting?
Previously dry at night for more than 6 months.
What are the causes of secondary bed wetting?
Diabetes UTI Constipation Inadequate fluid intake Psychological problems Family problems
What are possible reasons for delay in passing meconium?
Cystic fibrosis
Hirschprung’s
What is tested for in the Guthrie test?
Medium-chain acyl-coenzyme A dehydrogenase deficiency (MCAD) Sickle cell disease Phenylketonuria (PKU) Congenital hypothyroidism Cystic fibrosis Maple syrup urine disease Isovoleic acidaemia Homocystinuria Glutaic aciduria type 1
Which immunisations do babies get at 8 weeks old?
Diptheria Tetanus Pertussis Polio Haemophilus influenza type B Pneumococcal conjugate Rotavirus
Which immunisations do babies get at 3 months old?
Meningococcus C
Which immunisations do babies get at 13 months old?
MMR
Which immunisations do babies get at 2 years old?
Influenza (then annually)
Which immunisation do children get between 12 and 14 years old?
HPV
What is meant by neglect?
Persistent failure to meet child’s basic physical or psychological needs resulting in serious impairment of health or development.
What are the psychological consequences of emotional abuse?
Low self esteem
Difficulties in relationships
Difficulties in giving and accepting affection
Often impulsive and aggressive
Can be frustrated, anxious and non-compliant
What is the most important cause of conjugated hyperbilirubinaemia in the neonate?
Biliary atresia
What are the causes of unconjugated hyperbilirubinaemia in the neonate?
Physiological Breast milk jaundice Haemolytic disease (rhesus, ABO or other antibodies) Infection (UTI, sepsis) Congenital hypothyroidism
How is prolonged jaundice defined?
Visible jaundice lasting more than 14 days in a term infant or 21 days in a preterm infant.
What is the most common cause of prolonged jaundice?
Breast feeding
What are the top 5 reasons for respiratory distress in a newborn?
Transient tachypnoea of the newborn (first 8 hours)
Respiratory distress syndrome (surfactant deficiency)
Meconium aspiration
Pneumothorax
Respiratory infection
What are the top 5 causes for cyanosis in a newborn?
Any cause of respiratory distress can cause cyanosis.
Persistent pulmonary hypertension of the newborn.
Congenital cyanotic heart disease.
Tracheo-oesophageal fistula
Diaphragmatic hernia.
What are the risk factors for neonatal sepsis?
Prolonged rupture of membranes. Premature rupture of membranes. Maternal infection (esp. group B strep)
How will gastrointestinal disorders present in the newborn?
Poor feeding
Vomiting
Delay in passage of meconium
Abdominal distension
What is the differential for bile stained vomit in a newborn?
Intestinal obstruction until proven otherwise.
What are the main causes for gastrointestinal disorders in a newborn?
Meconium plug/ileus Duodenal atresia, or other small bowel atresia Oesophageal atresia Malrotation with volvulus Hirschsprung disease
What causes neural tube defects?
Maternal folic acid deficiency, especially at 3 weeks post conception.
What is meant by anencephaly?
Large portion of scalp, skull and cerebral hemispheres do not develop. Usually detected antenatally, always fatal. Caused by defect in closure of neural tube.
What is meant by encephalocele?
Neural tube defect. Protrusion of brain and meninges through midline defect in skull. Usually associated with craniofacial abnormalities and/or other cerebral abnormalities.
What is meant by microcephaly?
Small head due to incomplete brain development or arrest of brain growth.
What are the causes of microcephaly?
Usually genetic aetiology.
TORCH infections.
Maternal substance abuse.
Perinatal hypoxia.
What are the symptoms of microcephaly?
Occipito-frontal circumference crossing centiles Shallow sloping forehead Developmental delay Seizures Short stature
How frequently does a cleft lip or palate occur?
1 in 1000 live births
What causes a cleft lip or palate?
Failure of fusion of maxillary processes
At what age is a cleft lip repaired?
3 months
At what age is a cleft palate repaired?
6-12 months
What are the complications of a cleft lip or palate?
Can interfere with feeding and lead to speech problems, psychological issues and aspiration pneumonia.
How does a tracheo-oesophageal fistula present?
Coughing or choking during feeding, abdominal distension or recurrent chest infections.
How is a tracheo-oesophageal fistula diagnosed?
Bronchoscopy
Contrast studies of the oesophagus
Which syndrome is dueodenal atresia often associated with?
Downs syndrome
What is the presentation of duodenal atresia?
Bilious vomiting shortly after birth
How is duodenal atresia diagnosed?
Double-bubble sign on abdominal x-ray
What is exomphalos/omphalococele?
Hernia into base of umbilical cord, covered by a sac
Which syndromes and medical conditions is exomphalos/omphalocoele often associated with?
Edward’s syndrome
Patau’s syndrome
Cardiac defects
How is gastroschisis detected?
Antenatal ultrasound
What is gastroschisis?
Defect in abdomen to the right of the umbilicus with protrusion of abdominal contents not covered by a sac.
The bowel is often in poor condition and may need to be resected as part of the surgical repair.
What is hypospadias?
Uretrhal opening on underside of penis.
When is surgical repair for hypospadias done?
12-18 months
What should parents be advised about in hypospadias?
Don’t have son circumcised as foreskin is often used in repair.
How does an imperforate anus present?
Presents shortly after birth with failure to pass meconium, bilious vomiting and abdominal distension.
How are diaphragmatic hernias diagnosed?
May be detected on antenatal ultrasound.
Present with scaphoid abdomen, apparent dextrocardia and respiratory distress at birth.
Which side do most diaphragmatic hernias occur on?
Left side
What is a common problem after surgical repair of diaphragmatic hernias?
Pulmonary hypoplasia
What is the presentation of achondroplasia at birth?
Short limbs Large head Flat midface Frontal bossing Lumbar lordosis Trident hand
What is the incidence of Downs syndrome?
About 1 per 1000 births
How is Down syndrome screened for?
1st trimester blood tests beta-hCG, PAPP-A.
Age combined with above calculate risk.
Raised foetal nuchal translucency scan at first trimester also adds to risk.
Screen positive mothers offered chorionic villus sampling or amniocentesis.
Both CVS and amniocentesis carry a risk of miscarriage (1.5% and 1%).
What is the facial appearance of a baby with Down’s syndrome?
Prominent epicancthic folds. Upward slanting palpebral fissures. Brushfield spots on iris (white spots) Protruding tongue, with small mouth. Small chin, flat nose, round face and small low set ears.
What is the relation between heart disease and Down’s syndrome?
Up to 50% of children with Down’s syndrome have congenital heart disease.
All infants with Down syndrome will have a screening echocardiogram soon after birth.
Atrioventricular septal defect is the most common congenital heart defect.
Ventricular septal defect is next most common.
Tetralogy of fallot is relatively common in Downs syndrome.
Which gastrointestinal defects are associated with Down’s syndrome?
Increased risk of Hirschprung’s disease.
Increased risk of duodenal atresia and imperforate anus.
High incidence of umbilical hernia.
High incidence of gastro oesophageal reflux.
Coeliac disease common.
List 5 characteristics of Down’s syndrome on physical examination.
Generalised hypotonia. Short neck with excess skin at nape. Brachycephaly Single palmar crease, short hands and fingers and a sandal toe gap in feet. Poor growth and short stature.
List 5 neurological complications of Down’s syndrome.
Learning difficulties
Hearing impairment (recurrent otitis media)
Strabismus, cataract (require regular vision and hearing checks)
Increased incidence of epilepsy
Atlanto-axial instability - affects 10-20%, may cause spinal cord compression.
List 5 miscellaneous potential complications in Down’s syndrome.
Significantly raised incidence of haematological malignancy, e.g. ALL, AML. Hypothyroidism - annual TFTs. Recurrent respiratory infection Obstructive sleep apnoea. Alzheimer's disease.
Give 5 features of Edward’s syndrome.
Microcephaly, small chin. Low set ears. Overlapping fingers (thumb across palm, index over middle, little over ring) Rocker bottom feet. Cardiac: VSD, ASD, PDA.
Give 5 features of Patau’s syndrome.
Holoprosencephaly Structural eye defects Polydactyly Cutis aplasia (skin defects) Cardiac and renal defects.
Give 5 features of Turner’s syndrome.
Downward-turned mouth, downward slanting palpebral fissures.
Webbed neck, wide spaced nipples, lymphoedema.
Coarctation of aorta.
Streak gonads, lack of secondary sexual development.
Short stature.
Give 5 features of Klinefelter’s syndrome.
Infertility Hypogonadism, microorchidism. Gynaecomastia Tall stature Intelligence from normal to moderate learning difficulties.
Give 5 features of fragile X syndrome.
Long face, prominent ears, large chin.
Learning difficulty.
Macroorchidism.
Connective tissue problems such as flat feet, hyperflexible joints.
Behavioural characteristics, autistic behaviours, hand flapping, ADD
What are the more common intrauterine infections?
Toxoplasmosis
Rubella
Cytomegalovirus
Herpes simplex
What is the presentation of congenital cytomegalovirus?
Low birth weight Microcephaly Cerebral calcification. Hepatosplenomegaly with jaundice Petechiae
What is the treatment for congenital cytomegalovirus?
Gancyclovir
What are the possible complications of congenital cyclomegalovirus?
Hearing loss Mental retardation Psychomotor delay Cerebral palsy Impaired vision
What is the presentation of congenital rubella syndrome?
Cataracts
Microphthalmos
Sensorineural hearing loss
Thrombocytopenic purpura (blueberry muffin rash)
Cardiac: pulmonary artery stenosis or patent ductus arteriosus
Hepatomegaly
What are the presentations/complications of congenital toxoplasmosis?
Hydrocephalus or microcephaly Chorioretinits Cerebral calcification Cerebral palsy Epilepsy
List 5 features of foetal alcohol syndrome.
Microcephaly
Facial features (epicanthic folds, low nasal bridge, absent philtrum, thin upper lip, small chin)
Cardiac defects: VSD, ASD
Growth retardation, limb abnormalities
Learning difficulties and behavioural problems
List 5 teratogenic drugs in pregnancy.
Phenytoin Sodium valproate Lithium Warfarin Tetracycline
What are the potential effects of taking phenytoin in pregnancy?
Cleft lip/palate
Cardiac defects
Hypoplastic nails
Craniofacial abnormalities
What are the potential effects of taking sodium valproate or carbamazepine in pregnancy?
Neural tube defects
What are the potential effects of taking lithium in pregnancy?
Ebstein’s anomaly - congenital heart defect in which the septal and posterior leaflets of the tricuspid valve are displaced towards the apex of the right ventricle of the heart.
What are the potential effects of taking warfarin in pregnancy?
Frontal bossing Cardiac defects Microcephaly Nasal hypoplasia Epiphyseal stippling
What are the potential effects of taking tetracycline in pregnancy?
Discolouration of teeth.
What is the presentation of Prader Willi syndrome?
At birth - hypotonia, feeding problems, hypogonadism.
Later - failure to thrive, scoliosis.
Hyperphagia and obesity.
Developmental delay and learning difficulties.
Physical appearance: almond shaped eyes, pale skin and light hair, small hands and feet with hypogonadism.
Which problems are associated with prematurity?
Temperature control Fluid balance, feeds and nutrition. Lung disease Infection Brain haemorrhage and cysts Retinopathy of prematurity Hearing impairment Developmental delay
Which problems can cause failure of respiratory adaptation (mixing of blood in heart)?
Transient tachypnoea Respiratory distress syndrome Meconium aspiration syndrome Sepsis Pneumothorax
What is the management of babies with hypoxic ischaemic encephalopathy?
Therapeutic cooling (33.5 degrees). This significantly decreases death and disability.
What is Erb’s palsy?
A brachial plexus injury
What is caput succedaneum?
Swelling of an infant’s scalp
How high does bilirubin have to be for neonatal jaundice?
> 85
What is the problem with excessively high bilirubin (>400)?
May cause kernicterus
How can neonatal jaundice be treated?
Phototherapy
What is prescribed to pregnant women for hypertension?
Labetalol
What conditions are implemented for resuscitation of the preterm infant?
Room temp >25 Plastic bags Neopuff CPAP Delayed cord clamping Intubation and surfactant
What causes respiratory distress syndrome?
Surfactant deficiency
Which infections are most common in preterm babies?
Group B strep
E coli
Coagulase-negative streptococcus
Why are preterm babies at higher risk of infection?
Poor immune function
High numbers of peripheral lines, central lines, chest drains and ET tubes.
High antibiotic usage in NICUs - can breed resistance
What are the risk factors for necrotising entercolitis?
Low birth weight
Prematurity
Feeding - enteral feeds. Breast milk reduces risk.
What is the management for necrotising entercolitis?
Nil by mouth
Total parenteral nutrition
Antibiotics
Some babies require:
Intubation and ventilation
Inotropic support
Laparotomy
What are the indications for therapeutic cooling in neonates?
Low apgars at 5 minutes
Metabolic acidosis
Clinical encephalopathy
Abnormal CFAM
What can an absent red reflex in an infant be a sign of?
Cataract
Retinoblastoma
When is a heel-prick test done?
When the baby is 5 days old.
What are the risk factors for neonatal jaundice?
Family history Breastfeeding Infection Antibody derived: - rhesus disease - ABO incompatibility Glucose-6-phosphatase deficiency
Which hormone governs breast milk production?
Prolactin
What are the benefits of breastfeeding for the baby?
Reduced gut infection Reduced respiratory infection Reduced ear infection Reduced cardiovascular disease Reduced autoimmune conditions Reduced sudden infant death syndrome Improved cognitive ability
What are the benefits of breast feeding for the mother?
Reduced breast cancer
Reduced ovarian cancer
Reduced diabetes
Possibly reduced postnatal depression
What is the average birth weight?
3.3-3.5kg
Babies drop weight straight after birth, by what age should they have regained their birth weight?
By day 10-14
Which investigations should be carried out in cases of early puberty?
Imaging of hypothalamus with MRI in both sexes. It is usually normal in girls.
In a girl what age is considered precocious puberty?
<8 years
In a girl what age is considered early puberty?
8-10 years
In a girl what age is considered delayed puberty?
> 13 years
In a boy what age is considered precocious puberty?
<9 years
In a boy what age is considered early puberty?
9-11 years
In a boy what age is considered delayed puberty?
> 14 years
What is the function of growth hormone?
Proliferation of resting zone chondrocytes. Stimulates local IGF-1 expression.
What is the function of IGF-1?
Increases proliferation of resting and proliferative chondrocytes. Increases hypertrophic cell size.
What can cause malnutrition to result in abnormal growth?
Malabsorption e.g. coeliac disease Inflammatory bowel disease Connective tissue disease Renal disease Cystic fibrosis Anorexia nervosa Chronic infections
Which endocrine disorders can cause abnormal growth?
GH/IGF-1 axis defects, GH deficiency
Hypothyroidism
Cushing syndrome (glucocorticoid excess)
Disorders of puberty - hypogonadism, precocious puberty
How can chronic disease affect growth?
Negative energy balance - increased requirements and decreased intake. The disease itself/chronic inflammation Stress Treatment: steroids, cytotoxic drugs - suppression of hormone release - resistance in hormone action - pubertal delay
What are the ways in which weight can be assessed?
Centiles: height, weight Height velocity Target height Pubertal stage Skeletal proportion Dysmorphic features
When should a child’s short stature be investigated?
Height <3rd centile.
Height velocity low for age (and Tanner stage)
Outwith the mid-parental height range
What are the baseline investigations for a child who is not growing properly?
FBC ESR U&E LFT, proteins, albumin Bone profile IGF-1 TSH, fT4 Coeliac abs Bone age Karyotype (girls, when suspicion for Turners)
Which virus is responsible for epiglottitis?
H. influenzae b
What the symptoms of epiglottitis?
Stridor
Drooling
What are the differentials for epiglottitis?
Foreign body
Croup
Retropharyngeal abscess
Diphtheria
What is the age range in which children develop croup?
6 months to 3 years
What are the symptoms of croup?
Inspiratory stridor
Mild fever
Constitutional upset
What is the management for croup?
Don’t distress child
Oxygen
Steroids - dexamethasone
Nebulised adrenaline 1:1000
What are the clinical signs of acute respiratory failure?
Restless
Agitated from hypoxia
Cyanosis
Silent chest
What is the presentation of acute bronchiolitis?
Cold is followed 3-5 days later by progressive cough, wheeze, difficulty in feeding.
Signs similar to asthma.
Fine inspiratory crepitations.
What is the typical age range for bronchiolitis?
6 weeks to 6 months old
Which virus is typically responsible for bronchiolitis?
Respiratory syncitial virus (RSV)
What are the signs of acute asthma?
Expiratory wheeze Difficulty in speaking Head extended Nostrile flared Chest incresaed anteroposterior diameter Accessory muscles owrking Rapid pulse May have pulsus paradoxus (pulse weaker on inspiration) Cyanosis on air
What is the management for acute asthma?
Nebulised salbutamol Oxygen Combi nebs: salbutamol/atrovent (ipratroprium bromide) (+MgSO4) Steroids Magnesium sulphate IV Aminophylline IV Salbutamol IV
Which type of pneumonia is more common in the preschool child?
Bronchopneumonia more common than lobar pneumonia.
What are the investigations of suspected pneumonia?
Chest x-ray Hb WBC Throat swab Blood culture Mantoux
What is the management of pneumonia in young children?
Suck out secretions from airway
Give physiotherapy
Give oxygen
Nasogastric or IV feeds according to need.
Antibiotics e.g. ampicillin or gentamicin or penicillin.
Add flucloxacillin if staphylococcal pneumonia is suspected.
What are the symptoms of cardiac failure in infants?
Lethargy Feeding problems Breathless on feeding Sweating Failure to thrive Recent excessive weight gain or oedema Blue attacks.
What are the signs of cardiac failure in infants?
Rapid pulse and respiration
Hepatomegaly
What are the investigations of cardiac failure in infants?
Chest x-ray ECG Hb WBC Bacteriology U&Es
What is the management of cardiac failure in infants?
Diuretic e.g. furosemide
Digoxin
Oxygen
Morphine for agitation
Position: sitting or on an incline, head up
Treat precipitating event, i.e. anaemia or infection
Monitor weight, pulse, respirations, liver size
What is the initial management of cardiorespiratory arrest of a child or infant?
Airway - clear muck iwth swab round finger/suction. Meconium in newborns should be aspirated as head is delivered.
Breath - baby’s nose and mouth should be covered in mouth to mouth, older children mouth only. Bag and mask.
Cardiac output - neonate, use 2 fingers on mid sternum. <1 year old, circle chest with hands, thumbs pressing down on mid sternum. >1 year old, use heel of hand on mid to lower sternum.
Rate: 1 breadth to 5 compressions at 80-100 compressions per minute.
What is the medical management of cardiorespiratory arrest in children?
Adrenaline/atropine/antidote
Bicarbonate
Calcium salts
Dextrose
What is the immediate action in the home for burns and scalds?
Scald: strip off affected clothing as it retains the hot liquid.
Scald/burn: if small immerse in cold running water, or add ice to a basin of water, until cool. Cover area in a clean dry sheet, towel or dressing.
What is the management of burns or scalds in the hospital?
Airway
IV access
Appropriate analgesia e.g. morphine IV
Plasma expanders (fluid) if >10% of surface affected, to prevent shock, renal failure
Weight
Hb check for early haemoconcentration and subsequent anaemia in full thickness burn
Monitor urine output, blood and urine biochemistry, beware of renal failure.
Consider NAI - history very important.
What are the investigations for moderate to severe cases of diarrhoea?
Hb
WBC
U&Es
Bacteriology of stool (x3), throat, urine and blood
What is the management for acute diarrhoea?
Oral or nasogastric feeds. In shock give plasma or 0.9% saline IV 20ml/kg over 20 minutes. If IV fluids are needed give 4% dextrose/0.18% saline for 24 hours.
Oral rehydration solution little and often.
Reintroduce diluted whole/powdered cow/s milk over 1-3 days, starches in 1-2 days.
What are the investigations for suspected bacterial meningitis?
CSF cells - gram stain and glucose, bacteriology, Hb, WBC, U&Es
Blood glucose
Chest x-ray
How is bacterial meningitis diagnosed on lumbar puncture?
CSF cloudy
Polymorphs >20/mm3
Protein/0.45.gl
Glucose <2/3
What is the treatment for bacterial meningitis?
Until culture and sensitivities are known:
Neonate: e.coli and group B strep likely, therefore newer cephalosporin or chloramphenicol is given with benzyl penicillin. Treat for 3 weeks.
After 3 months old: H. influenzae, meningococcus and pneumococcus likely, therefore ampicillin in high dose often with chloramphenicol in case H. influenzae is resistant. Treat for 10 days.
What are the complications of bacterial meningitis?
Convulsions
Cerebral oedema, subdural effusion, hydrocephalus.
Hyponatraemia from inappropriate antidiuretic hormone release.
Deafness: always screen hearing immediately on recovery.
Drug fever: rise of fever after initial fall.
Long term: mental handicap, cerebral palsy, epilepsy, deaf.
Which joint is often involved in osteomyelitis?
Hip
What are the investigations of osteomyelitis or septic arthritis?
Urgent aspiration with immediate microscopy and gram stain, culture and sensitivity. Blood culture Hb WBC X-rays
What is the treatment of osteomyelitis/septic arthritis?
IV antibiotics e.g. flucloxacillin plus ampicillin
Immobilise the limb
Watch.
Surgery indicated immediately in septic hip in infants and in indicated in older children if poor response to treatment after 24 hours.
What are the symptoms of UTI?
Dysuria, frequency, haematuria, smelly urine. Bed wetting Abdominal pain Pyrexia General malaise/not feeding
What are the investigations of suspected UTI?
Blood pressure Hb WBC U&Es Serum cretainine Urine culture Blood culture Ultrasound
What is the purpose of an ultrasound in UTI?
To look for calyceal radio isotope studies for scarring, pelvic-ureteric obstruction and ureteral reflux, duplex collecting systems, bladder diverticuli/obstruction
What is the most commonly found organism in UTI?
E.coli
What are in the investigations for suspected DKA?
Blood glucose Blood gas U&E Hb WBC Bacteriology
What is the management for severe ketoacidosis?
Rehydrate using 0.9% saline.
Insulin
What is the management for poisoning in the home?
Induce vomiting with fingers, not salt water etc.
What is the management in the hospital setting for poisoning?
Establish poison, name, amount, when, how.
Check with national poisons information services centre.
Induce vomiting with ipeacac 15ml +glass fo water within 6 hours of ingestion, up to 24 hours fo salicylates. Repeat after 20 minutes if no result. Gastric lavage for the unconscious with protected airway.
Specific antidotes.
When is inducing vomiting contraindicated for poisoning?
Caustic
Petrol
White spirit ingestion.
Which investigations should be done after a first seizure?
Blood glucose
Lumbar puncture
What blood glucose is considered hypoglycaemia in a child?
<2.6
What are the investigations for suspected volvulus?
Abdo x-ray
Upper GI contrast
What is the management for volvulus?
Drip and suck IV access NG tube IV fluids Urgent surgical opinion Definitive treatment is Ladd procedure.
What is intussusception often preceded by?
URTI
What is a complication of developmental dysplasia of the hip?
Premature hip arthritis
What are the risk factors for developmental dysplasia of the hip?
Breech after 35 weeks Oligohydramnios Female gender First born Positive family history Torticollis Lower limb deformity e.g. clubfoot, metatarsus adductus, congenital vertical talus
What how DDH diagnosed clinically?
Asymmetric buttock and groin creases.
Asymmetric leg length.
Range of abduction.
Barlow/Ortolani tests
What are the investigations for DDH?
Ultrasound
Radiograph
What are the three different categories of joints?
Fibrous (sutures of the skull)
Cartilaginous (symphisis pubis)
Synovial (most skeletal joints)
Describe the synovial joint.
Covered by hyaline cartilage.
Joint space enclosed by synovium.
Produces synovial fluid in small amounts to lubricate the joint.
What happens when there is inflammation of the synovium?
Excessive synovial fluid produced, increased cellularity and altered cytokines. This environment is destructive of first hyaline cartilage and then underlying bone.
What are the clinical features of dermatomyositis?
Painful, proximal weakness
What are the clinical features of viral myositis?
Local area of painful muscles.
What are red flags of MSK pain?
Unable to sleep, unremitting pain.
Deep boring pain, unresponsive to simple analgesia.
Loss of function.
Unilateral.
Change in posture
Examination findings, e.g. tenderness/mass
What are the top 3 organisms responsible for septic arthritis?
Staphyloccocus aureus
Streptococcus pneumoniae
Haemophilus influenza
What is the most important indication of septic arthritis in a neonate?
Pseudoparalysis
Which factors differentiate septic arthritis from transient synovitis?
Pyrexia >38.5 within the last week.
Inability to weight bear through that limb.
A raised ESR >40mm/h
WBC > 12
What is the classic presentation of osteomyelitis?
Acutely unwell child
Pyrexia
Local erythema and tenderness
What has commonly preceded osteomyelitis?
Recent varicella zoster infection.
What is the management of osteomyelitis?
Blood cultures
Bone aspiration if an abscess is present.
High dose IV antibiotics
Splintage of the limb
What is the most common cause of joint swelling in children?
Reactive arthritis
What are the differential diagnoses of reactive arthritis?
Rheumatic fever
Reiter’s syndrome
Transient synovitis of the hip
Discitis
What is rheumatic fever caused by?
Streptococcal infection
What are the features of rheumatic fever?
Carditis
Arthritis
Neurological features
Rash
What are the findings on investigation of rheumatic fever?
Raised ESR
ASO titre
Dnase B
What is the treatment of rheumatic fever?
Penicillin
Including lifelong penicillin prophylaxis
What are the features of Reiter’s syndrome?
Urethritis, arthritis, conjunctivitis
+/- plantar fasciitis after gram negative infection or sexually transmitted infection
Give some examples of gram negative infections.
Yersinia
Shigella
Salmonella
E coli
What are the risk factors for Reiter’s syndrome?
Boys
HLA B27 positive
What is transient synovitis of the hip?
Idiopathic disorder in children, often preceded by infection. Effusion of hip. Give child analgesia and allow to rest until happy to weight bear. Should resolve within a week.
What are the investigations of transient synovitis of the hip?
ESR and WCC are normal or mildly raised.
Ultrasound confirms effusion.
What are the clinical features of disciits?
Child (often aged 1-3 years) refusing to walk with low grade fever
What is found on examination in disciitis?
Examination of spine reveals well localised tenderness, usually in lumbar spine.
What are the clinical features of juvenile idiopathic arthritis?
Persistent joint swelling in one or more joints
Early morning stiffness
Warmth
Which other conditions are associated with juvenile idiopathic arthritis?
Chronic anterior uveitis SLE Dermatomyositis Scleroderma Vasculitis
Which two vasculitis conditions are more common in children than adults?
Henoch Schonlein Purpura
Kawasaki disease
Which malignancies can have an MSK presentation?
ALL
AML
Neuroblastoma
Primary bone tumours e.g. Ewing’s sarcoma and osteosarcoma
What is the name of the classification of growth plate injuries?
Salter-Harris Classification
How long do femoral fractures take to heal in chlidren?
“age in years + 1” weeks
What is Legg-Calve-Perthes (more commonly Perthes) disease?
Necrosis of part of the femoral capital epiphysis. A growth disturbance in the physeal and articular cartilage which can lead to deformity of the femoral head and degenerative joint disease.
How does Perthes disease present?
Groin pain Knee pain Limp Reduction in hip abduction Reduction in internal rotation.
Who is most commonly affected by perthes disease?
Boys aged 4-8 years
What do radiographs show in Perthes disease?
Asymmetry of the femoral capital ossific nucleus, white affected side smaller, or in more severe cases, fragmented.
What is the treatment for perthes disease?
Rest
Possibly casts
Possibly surgery
What are the risk factors for slipped upper femoral epiphysis (SUFE)?
Early adolescence (due to period of rapid growth)
Obesity
Hypothyroidism
Chronic renal failure
How does slipped upper femoral epiphysis present?
Insidious onset of hip pain (often referred to knee) and limp.
Affected limb is often externally rotated.
Affected limb often shortened.
How is diagnosis of SUFE made?
Plain raidographs, including a frog leg projection.
What is the treatment of SUFE?
In-situ pinning
Which diagnoses does DDH include?
Neonatal hip instability
Acetabular dysplasia
Frank dislocation of hip joint
What is the more common name for talipes equinovarus?
Club foot
Describe the deformity in club foot?
Heel points down and in
Sole points medially
How can positional talipes be managed?
Stretching by the parents
How are most cases of club foot treated?
Ponseti technique:
Initially plaster casts changed weekly, most require cutting of the achilles tendon, abduction foot orthosis initially used full time and then part time until age 4.
Minority need surgery.
What is scoliosis?
Lateral curvature of the spine.
What are red flags of back pain in children?
Under 4 years old Night pain Functional disability Postural shift Lasting more than 4 weeks Limitation of movement due to pain Neurological signs
What is Osgood Schlater’s syndrome?
Common overuse syndrome. Typically occurs in boys aged 11-12 who are physically active.
Pain is felt over tibial tuberosity at insertion of patellar ligament. May be accompanied by swelling and local tenderness.
What happens in a pulled elbow?
Radial head partially slips from the enfolding annular ligament.
What are the causes of rickets?
Vitamin D deficiency Caclium deficiency Hypophosphataemic Vitamin D dependent rickets Hypophosphatasia
Name 5 acyanotic congenital heart lesions.
Ventircular septal defect Pulmonary stenosis Atrial septal defect Coarctation of the aorta Patent ductus arteriosus
Name 4 cyanotic congenital heart lesions.
Tetralogy of Fallot
Transposition of the great arteries
Tricuspid atresia
Pulmonary atresia
What are the main effects form a large ventricular septal defect?
Left ventricular overload
Increased pulmonary blood flow leading to cardiac failure
If VSD has led to heart failure what is the medical management?
Diuretics ACE inhibitors Maximise nutrition NG feeds Earlier surgery indicated if infant continues to fail to thrive.
What is patent ductus arteriosus associated with?
Prematurity
Maternal rubella
What can be picked up clinically in a baby with patent ductus arteriosus?
Bounding femoral pulses
Continuous murmur under left clavicle
What are the complications of patent ductus arteriosus?
Heart failure
Failure to thrive
What is the treatment for patent ductus arteriosus?
NSAIDs
Surgical ligation
In older children device occlusion by cardiac catheterisation
How does coarctation of the aorta present in neonates?
As collapse, cardiac failure or weak/absent femoral pulses.
Older children - raised blood pressure/absent femoral pulses or radio-femoral delay
What does chest x-ray show in coarctation of the aortra?
Cardiomegaly
Rib notching
What is the treatment of coarctation of the aorta?
Surgery.
Balloon dilatation/stenting
What is the commonest neonatal cyanotic condition?
Transposition of the great arteries
What does chest x-ray show in transposition of the great arteries?
Egg on side
What is the medical management of transposition of the great arteries?
Prostaglandin
What is the surgical management of transposition of the great arteries?
May need urgent balloon atrial septostomy to increase mixing at atrial level.
Definitive surgery - arterial switch, with good long term outcome.
Which 4 conditions does tetralogy of fallot encompass?
Ventricular septal defect
Right ventricular outflow tract obstruction
Aortic override of VSD
Right ventricular hypertrophy
What could be found on blood test that is characteristic of tetralogy of fallot?
Polycythaemia
What does chest x-ray show in tetralogy of fallot?
Boot shaped heart with an upturned apex
Which syndrome is tetralogy of fallot associated with?
Di George syndrome
What is the most common infective agent in endocarditis?
Strep viridans
How might endocarditis present?
Fever Malaise Weight loss Arthralgia Haematuria Splenomegaly Splinter haemorrhages
How is infective endocarditis diagnosed?
Blood cultures
Echo (vegetations)
How is endocarditis treated?
IV antibiotics, 6 weeks.
What are the causes of cerebral palsy?
Antenatal - toxins, teratogens, inutero infection
Perinatal - hypoxic insult, sepsis
Postnatal - meningitis, trauma
What are the classifications of cerebral palsy?
Spastic Dystonic Choreoathetoid/dyskinetic Ataxic Mixed
What are common comorbidities in cerebral palsy?
Epilepsy Learning disability Behaviour problems Feeding problems/reflux Osteoporosis
How can neural tube defects be prevented?
Maternal folic acid supplementation from 1 month prior to conception
What will be found on examination in a child with spina bifida?
Flaccid weakness of lower limbs
Absent reflexes
Lack of sensation
What is myelomeningocele?
Outpouching of spinal cord and its coverings through a defect in posterior elements of vertebral arches
Which problems are associated with meningocele?
Mobility Sensation Bowel and bladder function Hydrocephalus Learning problems
Which sign is classically seen on examination of a child with muscular dystrophy?
Gowers sign
What is the definition of an epileptic seizure?
An epileptic seizure is a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain.
How is epilepsy defined?
- At least two unprovoked seizures occurring more than 24 hours apart.
- One unprovoked seizure and a probability of further seizures similar to the
general recurrence risk after two unprovoked seizures (approximately 75% or
more). - At least two seizures in a setting of reflex epilepsy.
What is a focal epileptic seizure?
A seizure originating within networks limited to one heimsphere.
In what percentage of children will a febrile convulsion recur?
30%
What are the differential diagnosis of acute cough?
Upper respiratory tract infection Croup Bronchiolitis Pneumonia Acute exacerbation of asthma/viral induced wheeze Pertussis Inhaled foreign body
What are the differential diagnosis of a chronic cough?
Asthma
Infection (TB, recurrent aspiration)
Gastro-oesophageal reflux
Chronic illness - cystic fibrosis, kartagener syndrome (primary ciliary dyskinesia)
Rare - extrinsic compression of trachea/bronchus by enlarged heart, glands or tumour
What is the differential diagnosis of acute stridor?
Croup
Acute epiglottitis/bacterial tracheitis
Inhaled foreign body
Rare retropharangeal abscess
What is croup usually caused by?
Parainfluenza
What are the symptoms of croup?
Hoarse voice
Barking cough
Stridor
How is croup treated?
Do not upset child.
Treat with oral dexamethasone and give nebulised adrenaline in severe cases.
On which days of illness is bronchiolitis worse?
Days 3-5 (but symptoms last 7-21 days)
What is the management of bronchiolitis?
Supportive
O2 if hypoxic
NG feeds or IV fluids if poor feeding
What is the pathophysiology of asthma?
Bronchial hyper-responsiveness
Smooth muscle contraction prevents normal expiration
Thickening and oedema of bronchial wall by cellular infiltration and inflammation
Mucus hypersecretion
In which gene is the mutation found in cystic fibrosis?
CFTR gene, chromosome 7.
Most common mutation is delta F508.
What is the pathophysiology of cystic fibrosis?
When CFTR acts normally it allows chloride ions out of a mucosal cell into the lumen. If defective this results in thickened secretions which can’t be cleared from the chest and infection and airway obstruction occurs.
If CF is suspected in somebody that didn’t have it picked up on newborn screening how should it be investigated?
Sweat test (excess chloride in sweat) Genetic testing
What is the management of cystic fibrosis?
Daily physiotherapy
Daily antibiotics (usually flucloxacillin prophylaxis)
Exacerbations: Double dose of prophylactic antibiotic, give planned 2nd line antibiotic, may require admission for IV antibiotic.
Portacath implantation may be required for repeated courses of IV antibiotics.
Creon
Fat soluble vitamin supplements
High calorie diet.
What are the acquired causes of deafness?
Prenatal - toxoplasma, rubella, CMV
Perinatal - hypoxia, jaundice (kernicterus)
Postnatal - Meningitis, head injury, ototoxic drugs (e.g. cisplatin)
Which gene is most commonly associated with congenital deafness?
Connexin 26 gap junction protein
At what age do the adenoids shrink?
After 6 years
What is the most common cause for sleep apnoea in children?
Physiological hypertrophy of the tonsils and adenoids.
In which ages is sleep apnoea most commonly a problem?
2-7 year olds
How is sleep apnoea diagnosed?
Sleep studies:
Overnight pulse oximetry
Full 12-channel polysomnography
What are the causes of amblyopia?
Reduced view through eye, ptosis or cataract. Unequal focus (one eye is long or short sighted) Misalignment of eyes (e.g. squint)
How is amblyopia treated?
Eye patch
Atropine eye drops
What is the most common reason for absent red reflex?
Cataract
What are the top 5 causes of hepatomegaly?
Infection Congestive cardiac failure Infiltration (tumours) Storage (fat - cystic fibrosis, glycogen storage diseases) Idiopathic
What are the top 5 causes of splenomegaly?
Infection: malaria
Haematological: hereditary spherocytosis, sickle cells
Extramedullary haemopoesis: thallassasemia
Portal hypertension
Neoplastic
What are the top 5 causes of hepatosplenomegaly?
Infection: EBV, CMV Portal hypertension Infiltration: leukaemia, lymphoma Haematological: e.g. thalassaemia Idiopathic
What are the top 6 causes of rectal bleeding?
Anal fissure Swallowed blood from epistaxis Gastroenteritis Acid ulceration Intussusception Inflammatory bowel disease
What are the risk factors for inflammatory bowel disease?
Family history of inflammatory bowel disease Family history of autoimmune conditions Parental smoking Bottle feeding Peri anal signs
What are the top 5 causes of haematemesis?
Swallowed blood Repeated vomiting, acute gastritis Ulceration: hiatus hernia, drugs, peptic ulcer Bleeding disorders Very rarely oesophageal varices
At what age does coeliac disease commonly present?
6-9 months
What are the clinical features of coeliac disease in an infant?
Pale, bulky stools
Distended abdomen
Buttocks wasted
What is the test for coeliac disease?
Tissue transglutaminase (TTG-IgA) Duoedenal mucpsal biopsy is necessary in patients with moderately elevated TTG.
What would a mucosal biopsy show in coeliac disease?
Villous atrophy
Crypt hyperplasia
Increased intraepithelial lymphocytosis
What are the top 5 causes of acute diarrhoea?
Infection (rota and enterovirus, e. coli, salmonella, campylobacter)
Staphylococcal toxin
Response to infection e.g. pneumonia
Starvation stools (watery, green mucous)
Surgical: intussusception, pelvic appendicits, Hirschprung’s
What are the main causes of chronic diarrhoea?
Toddler's diarrhoea Constipation with overflow Post infectious food intolerance Inflammatory bowel disease Malabsorption e.g. CF, coeliac
How would you investigate chronic diarrhoea?
Stool culture and sensitivity Bloods - FBC, CRP, LFTs, ESR Serum TTG Faecal calprotectin Peri anal insepection
What are the medical cause of acute abdominal pain?
Infection (e.g. gastroenteritis, mesenteric adenitis) Constipation Henoch-Schonlein purpura Acute nephritis DKA Sickle cell crisis
What are the top 5 surgical causes of acute abdominal pain?
Acute appendicits Intussusception Volvulus Strangulated inguinal hernia Torsion of testis/ovary
Which virus is reponsible for most cases of gastroenteritis?
Rotavirus
How does renal disease commonly present?
Flank mass Haematuria Proteinuria with/without oedema Polyuria/oliguria Hypertension
What are the most common anomalies of the urinary tract?
Absent kidney
Multicystic dysplastic kidney (irregular cysts with no normal renal tissue)
Duplex (upper pole ureter tends to obstruct, lower pole ureter tends to reflux)
Horseshoe
Obstruction
What are the top 5 causes of oedema in children?
Heart failure
Nephrotic syndrome
Liver failure
Malnutrition
What are the pathological causes of proteinuria?
Gomerular disease (e.g. glomerulosclerosis, glomerulonephritis)
Tubular
Physiological stress e.g. exercise/cold
How is nephrotic syndrome defined?
Proteinuria (>1g/m2/day), Hypoalbuminaemia (<25 g/l) and oedema
What are the most common reasons for nephrotic syndrome?
Minimal change disease (90%)
Focal segmental glomerulosclerosis
Which investigations would you carry out in a child with nephrotic syndrome?
FBC U&Es LFTs C3/C4 Varicella status Urine: protein creatinine ratio, culture BP
What are the complications of nephrotic syndrome?
Hypovolaemia
Thrombosis
Infection (loss of immunoglobulin in the urine)
Hypertension
How is nephrotic disease treated?
Prednisolone: initially high dose with reducing course
20% Albumin + Furosemide for hypovolaemia or symptomatic
oedema
Pneumococcal Vaccination
Penicillin prophylaxis for risk of encapsulated organism
infection
Salt/fluid restriction
What are the non-glomerular causes of haematuria?
Infection (commonest) Trauma Stones Sickle Cell Coagulopathy/Bleeding disorder Renal Vein Thrombosis Tumour Structural abnormality (PUJ obstruction) Munchausen by proxy
What are the glomerular causes of haematuria?
Acute or chronic glomerulonephritis
IgA nephropathy
Familial nephritis
What are the investigations of haematuria?
Blood: FBC, Coag, U+E’s, ASOT, ANF, Complement
Urine: MC&S, oxalate, calcium, phosphate and urate levels, calcium
creatine ratio
AXR, Renal USS, +/- Renal biopsy
What are the causes of hypertension in children?
Renin-dependent Coarctation of the aorta Catecholamine excess Endocrine Essential hypertension Obesity Pharmacological (e.g. steroids)
What are the investigations for hypertension?
• FBC, U&E, creatinine, albumin, bicarbonate, Ca,PO4,LFTs
• Plasma renin activity,aldosterone, plasma catecholamines
• Urinalysis, urine microscopy and culture, urinary protein to creatinine ratio,
urinary catecholamines
• Renal ultrasound with Doppler flow of the renal vessels, Echocardiography,
ECG, Chest X-ray, DMSA ( Di Mercapto Succinic Acid)
What are the methods of collecting urine for urinalysis?
Mid stream specimen urine
Catheter specimen urine
Suprapubic aspiration
Urine bags
What are the causes for acute renal failure?
Pre-renal ▪ Commonest ▪ Hypovolaemia ▪ Cardiac Failure o Renal ▪ Vascular e.g. Haemolytic uraemic syndrome ▪ Tubular e.g. ATN ▪ Glomerular e.g. Glomerulonephritis ▪ Interstitial e.g. Drugs (NSAIDS) o Post – renal – urinary obstruction
What are the indications for dialysis?
Severe volume overload
Severe hyperkalaemia Symptomatic Uraemia
Severe metabolic acidosis
Removal of toxins
Give modalities for renal imaging.
Ultrasound
DMSA (delineates divided function of kidneys. Identifies scars, needs to be done at least 3 months after UTI)
DTPA (dynamic scan allows assessment of drainage and obstruction)
MCUG (looks for vesicoureteric reflux, bladder outlines)
AXR - to look for stones
What are the top five causes for a vomiting baby?
Overfeeding Possetting Gastro-oesophageal reflux Pyloric stenosis Obstruction
What is the normal age of onset of pyloric stenosis?
2-6 weeks
What is the clinical presentation of pyloric stenosis?
Rapidly progressive projectile vomiting, without bile, soon after feeds.
What will be the metabolic derangements in a baby with pyloric stenosis?
Hypochloraemic, hypokalaemic metabolic acidosis
How is pyloric stenosis diagnosed?
Test feed (visible peristalsis and palpable pyloris - olive shaped mass in RUQ) Ultrasound
What is the management of pyloric stenosis?
Correct electrolyte imabalance with IV fluids.
Pyloromyotomy
What are the top 5 causes of bilious vomiting in a baby?
Malrotation +/- volvulus until proven otherwise Necrotising enterocolitis Atresia Hirschprungs disease Meconium ileus/plug
In normal embryological development when should rotation and fixation of the gut occur?
Between 4 and 12 weeks gestation
Where do parts of the gut lie after normal rotation?
DJ flexure lies to the left of the midline.
Caecum lies in right iliac fossa
Transverse colon lies anterior to the small bowel
mesentery
What is the commonest problem with malrotation?
Caecum lies close to the duodenojejunal flexure, resulting in abnormally narrow midgut mesentery which is liable to twist.
How might malrotation present?
Collapse and acidosis early due to intestinal infarction, or late with bile stained vomiting and distension.
How is malrotation diagnosed?
Barium contrast studies
How is malrotation treated?
Resuscitation
Early laparotomy
What is necrotising enterocolitis?
An acute inflammatory disease occuring in the intestines of premature infants, can lead to necrosis of the bowel.
What are the clinical features of necrotising enterocolitis?
Abdominal distension Blood in the stool Feeding intolerance Vomiting (often bilious) Pyrexia
How is necrotising enterocolitis managed?
Stop feeds
IV fluids
IV antibiotics
If severe may need surgical intervention such as bowel resection and stoma formation
What is the most common site of atresia of the intestine?
Jejunum and ileum.
What percentage of infants with duodenal atresia have Down syndrome?
30%
What is Hirschsprungs disease?
Aganglionic section of bowel.
Which part of the bowel is affected by Hirschprung’s disease?
Starts at the anus and progresses upwards.
How do most cases of Hirschprung’s present?
Delayed passage of meconium
How does Hirschprung’s present if it is a later presentation?
Abdominal distension
Constipation
Failure to thrive
Features of obstruction
What are the x-ray appearances of acute appendicitis?
Scoliosis due to pain
Faecolith
Absent right psoas shadow
Intraperitoneal gas indicating perforation
Abnormal caecal gas or small bowel dilatation
What is intussussception?
Full thickness invagination of the proximal bowel to distal intestine.
What is the most common site of intussusception?
Ileo-colic junction
What is the common cause of intussusception?
Enlarged peyer’s patches secondary to preceding viral illness.
Which disease can predispose to intussusception?
Henoch-Schonlein purpura
Cystic fibrosis
Lymphoma
What is the classic triad of symptoms in intussusception?
Intermittent abdominal pain
Redcurrant jelly stools
Vomiting
What might be seen on abdominal x-ray in intussusception?
Absence of air in ascending colon.
Soft tissue density in ascending colon.
How is intussusception diagnosed?
Ultrasound - target lesion, doughnut sign.
Contrast enema
How is intussusception managed?
Air enema
If unsuccessful operative intervention may be indicated
What is the commonest surgical condition in children?
Inguinal hernia
What are the risk factors for inguinal hernia?
Premature
Low birth weight
What are the major complications of inguinal hernias?
Incarceration
Strangulation
Are inguinal hernias more likely to be direct or indirect?
99% are indirect hernias
What is the management of umbilical hernias?
Watch and wait until 5 years of age - may then be surgically repaired if still clinically present
What causes a hydrocoele?
Patent processus vaginalis
What can make a hydrocele more noticeable?
Systemic illness
What is found on examination of a hydrocoele?
Swelling
Blue hue
Can get above it on examination
Transilluminates
What is the management of hydrocoele?
90% resolve spontaneously in first 3 years.
If not resolved by 3 years surgery required.
When should undescended testis be operated on?
By 1st birthday
What are the differential diagnoses of testicular pain?
Testicular torsion
Torsion of the appendage (hydatid of morgagni)
Epididymo-orchitis
Hydrocoele (rarely painful)
Idiopathic scrotal oedema (rarely painful, usually bilateral)
What are the clinical features of epididymo-orchitis?
Swelling
Erythema
Oedema
Gradual onset
What is an associated symptom with epididymo-orhcitis?
Dysuria
What are the indications for CT scan for head injury in children?
Witnessed loss of consciousness >5 minutes
Amnesia (antegrade or retrograde) >5 minutes
Abnormal drowsiness
≥3 Discrete episodes of vomiting
Clinical suspicion of non-accidental injury
Post-traumatic seizure (no PMH of epilepsy)
GCS <14 in emergency room
(Paediatric GCS <15 if aged <1)
Suspected open or depressed skull fracture or tense fontanelle 11
Signs of base of skull fracture*
Focal neurological deficit
Aged <1 - bruise, swelling or laceration on head >5 cm
Dangerous mechanism of injury (high-speed RTA, fall from >3 m, high-speed
projectile)
What can cause thrombocytopaenia?
Malignancy Bone marrow failure Inherited platelet conditions Microangiopathic haemolytic anaemia Idiopathic thrombocytopaenia
What can cause bone marrow failure?
Aplastic anaemia
Fanconi’s anaemia
Neolastic infiltration by neuroblastoma/lymphoma/Ewing’s sarcoma
What is the presentation of idiopathic thrombocytopaenia?
Acute onset bruising, petechiae, epistaxis following a recent viral illness in a previously well child.
What is the typical age of onset of idiopathic thrombocytopaenia?
1-5 years
What will blood tests show in idiopathic thrombocytopaenia?
Platelets <20
What are the complications of idiopathic thrombocytopaenia?
Intracranial haemorrhage (rare) Failure to resolve - becomes chronic ITP
How long does it usually take for ITP to resolve?
A few month, most have resolved by 6 months
What is the management of ITP?
Careful observation Limit high impact activities Platelet transfusion if bleeding (but destroyed rapidly) IV Ig Consider steroids Consider splenectomy
What is Henoch Schonlein Purpura?
Vasculitis - due to deposition of IgA containing immune complexes in capillaries, arterioles and venules.
What is the clinical presentation of HSP?
Purpura over extensors aspects of lower limbs and buttocks.
Arthritis
Colicky abdo pain, blood and mucus on PR exam
Haematuria, proteinuria, hypertension
How is HSP diagnosed?
Clinically: Tests to rule out other things e.g: FBC (platelets may be raised) CRP ESR Urinalysis BP Abdo USS
What is the prognosis of HSP?
Usually resolves spontaneously
What is tHE management of HSP?
Supportive. Analgesia Monitor renal function Urinalysis BP Monitor for intussusception
Which vitamin can increase iron absorption?
Vitamin C
How long should iron supplementation be continued after Hb normalises?
3 months
What is the presentation of leukaemia?
Bone marrow failure (anaemia, pallor, dyspnoea, low WCC, increased infections, low platelets, bruising, petechiae, epistaxis) Bone pain/limp Lymphadenopathy Hepatosplenomegaly Testicular enlargement Cranial nerve palsies, meningism
Which investigations should be done in suspected leukaemia?
FBC Blood film Bone marrow aspirate Lumbar puncture Coag screen U&Es LDH CXR
What is the management of leukaemia?
Multi drug chemotherapy
+/- radiotherapy
+/- bone marrow transplant
What is deficient in haemophilia A?
Factor VIII
What is deficient in haemophilia B?
Factor IX
What is the presentation of haemophilia?
Spontaneous join/muscle bleed or due to minor trauma
Raised lumpy bruises
How is haemophilia diagnosed?
Isolated prolonged APTT
Specific factor deficiency
How is haemophilia treated?
Recombinant factor administration IV
What are the complications of haemophilia?
Progressive arthropathy
Transmission of blood borne infections
Allergic reactions
Factor antibody production
Which clotting factor is affected in Von Willebrand disease?
Factor VIII
How is Von Willebrand disease diagnosed?
Prolonged APTT
Reduced factor VIII:VWF levels
No platelet aggregation on Ristocetin co-factor assay
What is the presentation of von Willebrand disease?
Mucosal bleeding from GI, gums, epistaxis, menorrhagia, prolonged bleeding post trauma/surgery
What is the management of von Willebrand disease?
DDAVP prophylaxis
Recombinant FVIII for bleeding episodes
What are the features suggestive of malignancy in children?
Supraclavicular, epitrochlear nodes. Associated systemic symptoms. Hepatosplenomegaly Other palpable masses Signs of bone marrow infilgration ie anaemia/bruising/petechiae
Name 5 malignant causes of lymphadenopathy?
Acute leukaemia Lymphoma Hodgkin's disease Neuroblastoma Rhabdomyosarcoma
What are the common infectious causes of lymphadenopathy?
Bacterial lymphadenitis Viral infection Cat scratch disease TB Atypical mycobacterium
Name 5 autoimmune causes of lymphadenopathy?
Kawasaki's disease JIA SLE Sarcoidosis Drug reactions
What are the signs of a brain tumour?
Raised ICP - early morning headaches, vomiting, papilloedema Focal seizures Neurological signs Endocrine disturbance Raised occipitofrontal circumference Developmental delay/regression
What are the investigations of a suspected brain tumour?
Brain/spinal MRI Tumour biopsy Consider tumour markers Endocrine screen - craniopharyngioma CSF - cytology and tumour markers
What is the management of a brain tumour?
Neurosurgical referral.
Consider dexamethasone to reduce peritumour oedema
Consider chemotherapy
Consider radiotherapy
What are the most common paediatric malignant tumours?
Osteosarcoma
Ewing’s sarcoma
What is the presentation of malignant bone tumours?
Persistent pain Swelling Deformity Pathological fractures Systemic symptoms e.g. including fever, anorexia, weight loss
How do you diagnose a bone tumour?
Imaging of lump and distant sites
Biopsy
What is the management of osteosarcoma?
Chemotherapy
Surgery
What is the management of Ewing’s sarcoma?
Chemotherapy
Surgery
Autologous stem cell transplant
Radiotherapy
What are the effects of chemotherapy?
Marrow suppression Temporary hair loss Nausea and vomiting Hearing loss Renal impairment
What are the late effects of chemotherapy?
Cardiac toxicity
Infertility
Risk of secondary malignancies
Give 7 examples of live attenuated vaccines.
BCG Measles Mumps Rubella Rotavirus Influenza Oral polio
Give 6 examples of inactivated vaccines.
Inactivated polio Trivalent influenza Diptheria & tetanus Pertussis HPV MenB
What are the contraindications to vaccination?
Anaphylactic reaction to a previous dose of a vaccine containing the same antigens.
Anaphylactic reaction to another component contained in the relevant vaccine.
What is the incubation period for measles?
7-14 days
What is the infectivity period for measles?
1-2 days before symptoms to 4 days after appearance of rash.
What are the clinical features of measles?
Prodrome )3-5 days) of fever, coryza, cough, conjunctivitis and Koplik’s spots.
Maculopapular rash starts behind ears, migrates to face and trunk and then to limbs.
Cervical lymphadeopathy
High fever.
What are the complications of measles?
Otitis media Lymphadenitis Interstitial pneumonitis Secondary bacterial bronchopneumonia Myocarditis Post infectious demyelinating encephalomyelitis Sub acute sclerosing panencephalitis
What is the treatment for measles?
Supportive
What is the incubation period for chicken pox?
14-21 days.
What is the infectivity period for chicken pox?
2 days before until 5 days post rash
What are the clinical features of chicken pox?
Fever Malaise Headache Abdominal pain for 48 hours Itchy crops of erythematous macules that evolve into papules then vesicles containing serous fluid. Usually start on trunk then spread to limbs.
What are the complications of chicken pox?
Secondary bacterial infection. Pneumonia Encephalitis Progressive disseminated varicella Cerebellar ataxia Thrombocytopenia Purpura fulminanas Post-infectious encephalitis
What is the treatment for chicken pox?
Supportive
Aciclovir in high risk patients
What is the post exposure prophylaxis for chicken pox in those with high risk of severe disease?
IV Ig
What is the incubation period for mumps?
14-21 days
What is the infectivity period for mumps?
1-2 days prior to parotid swelling, 9 days after.
What are the clinical features of mumps?
Prodrome of fever, anorexia, headache
Painful uni/bilateral salivary +/- submandibular gland swelling
What are the complications of mumps?
Menngoencephalitis Deafness Orchitis Epididymitis Pancreatitis Nephritis Myocarditis Arthritis Thyroiditis
What is the treatment for mumps?
Supportive
What is the incubation period for erythema infectiosum?
4-14 days
What is the infectivity period for erythema infectiosum?
Not infective once rash apperas
What are the clinical features of erythema infectiosum?
Prodrome of low grade fever, general malaise, followed after a few days by maculopapular psots on cheeks, which coalesce to give ‘slapped cheek’ appearance. Fine rash extends to trunk and limbs.
What are the complications of erythema infectiosum?
Aplastic crisis in chronic haemolytic disease.
What is the incubation period for rubella?
14-21 days
What is the infectivity period for rubella?
1-2 days before, to 7 days after the rash appears.
What are the clinical features of rubella?
Prodrome of coryza, tender cervical lymphadenopathy followed by development of a fine maculopapular rash.
Starts on face from where it fades and spreads down the trunk.
arthralgia
Palatal petechiae
What are the complications of rubella?
Encephalitis
Thrombocytopenia
Congenital rubella syndrome if diagnosed in 1st 10 weeks of pregnancy
What is the incubation period of roseola infantum?
7-14 days
What is the infectivity period for roseola infantum?
Until fever subsides
What are the clinical features of roseola infantum?
Sudden onset high fever with only mild coryza.
On day 3-4 fever resolves and a maculopapular rash appears on trunk and limbs
Lasts for 1-2 days.
What are the complications of roseola infantum?
One of the commonest causes of febrile convulsions in 6-18 month old age group, usually happen on first day of illness.
What is the incubation period for petussis?
7-14 days
What are the clinical features of pertussis?
Catarrhal phase: Low grade fever, coryza, conjunctivits for 1-2 weeks followed by paroxysmal phase:
paroxysms of severe cough with or without whoop, vomiting. May develop cyanosis and apnoea. Paroxysmal phase lasts 2-8 weeks.
Convalescent stage: cough subsides over weeks to months.
What are the complications of pertussis?
Apnoea
Secondary bacterial pneumonia
Weight loss secondary to feeding difficulties
Subsequent bronchiectasis,
otitis media, seizures, encephalopathy, subconjunctival, subarachnoid or intra-ventricular
haemorrhage, umbilical and inguinal hernia, rupture of diaphragm
How is pertussis diagnosed?
Perinasal swab for PCR testing, culture.
Associated lymphocytosis
What is the treatment for pertussis.
Supportive, low threshold for admission in neonates.
Macrolides e.g. azithromycin may reduce complications
What are the most common organisms found in bacterial meningitis?
Neisseria meningitidis
Streptococcus pneumonia
Which virus is commonly responsible for viral meningitis?
Enterovirus
In neonates what is meningitis usually caused by?
Group B strep
What is the clinical presentation of bacterial meningitis?
Fever Headache Nausea Vomiting Neck stiffness Photophobia Lethargy Decreased conscious level
How is meningitis diagnosed?
Lumbar puncture
What will CSF analysis of lumbar puncture find in bacterial meningitis?
WCC>5 cells/mcl (>20 cells/mcl in neonates),
o Polymorphs if bacterial, after 24hrs lymphocytes if viral
• Elevated protein (>0.4g/L) & decreased glucose (<0.6 CSF:blood ratio)
o Bacterial& TB
• Organisms seen on gram staining (though negative 60% bacterial
meningitis) & cultured if bacterial, ZN/auramine stain & mycobacterial
culture if TB
• Perform PCR testing for pneumococcus/meningococcus/Hib& HSV/VZV/enterovirus
What is the empirical treatment for suspected bacterial meningitis?
IV cefotaxime,
add amoxicillin & gentamicin if under 6 weeks.
Over 3 months if no petechiae/purpuric lesions add dexamethasone and
continue for 2 days; reduces the risk of deafness from Hib meningitis.
What is the treatment for meningitis caused by N. meningitidis?
7 days IV cefotaxime/ceftriaxone
What is the treatment for meningitis caused by s. pneumoniae?
14 days IV cefotaxime/ceftriaxone
What are the public health measures around meningitis?
Refer to public health for contact tracing and chemoprophylaxis.
What are the possible sequlae of meningitis?
Hydrocephalus Deafness Neuromotor disorders Seizures Visual disorders Speech and language disorders Learning difficulties Behavioural problems
What is sepsis?
A systemic inflammatory response to infection.
What happens in meningococcal sepsis?
Capillary leak, coagulopathy, myocardial depression, metabolic derangement.
Which gene do about half of severe cases of eczema have a mutation in?
Filaggrin gene
What is impetigo caused by?
Staph aureus
What are the characteristic features of impetigo?
Annular erythematous lesions with honey coloured crust and may become bullous as a result of cleaving of the peidermis by exfoliative staph.
What is molluscum contagiosum caused by?
DNA Pox virus
