paediatrics Flashcards
A 3-year-old boy presents to the GP with nightly coughing bouts for the last 2 weeks. He has noisy breathing with an inspiratory whoop but no cyanosis or other signs on clinical examination. The GP diagnosis the patient with a whooping cough.
Which of the following would be the best first-line treatment for this patient?
NICE guidelines suggest that if admission is not needed, you should prescribe an antibiotic if the onset of the cough is within the last 21 days. In children over 1-month-old, the first line antibiotics are macrolides (specifically azithromycin or clarithromycin for children aged 1 month or older, and non-pregnant adults).
When do you usually immunize people from whooping cough?
infants are routinely immunised at 2, 3, 4 months and 3-5 years. Newborn infants are particularly vulnerable, which is why the vaccination campaign for pregnant women was introduced
neither infection nor immunisation results in lifelong protection - hence adolescents and adults may develop whooping cough despite having had their routine immunisations
Is subconjunctival haemorrhage dangerous in whooping cough?
No- persistent coughing may cause subconjunctival haemorrhages or even anoxia (body/brain completely loses oxygen) leading to syncope & seizures
What are the complications of bronchiectasis?
Subconjunctival haemorrhage
Seizures
Pneumonia
Bronchiectasis
How do you treat bordatella pertussis?
infants under 6 months with suspect pertussis should be admitted
in the UK pertussis is a notifiable disease
an oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread
household contacts should be offered antibiotic prophylaxis
antibiotic therapy has not been shown to alter the course of the illness
school exclusion: 48 hours after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )
A 32-year-old woman gives birth to a baby boy at 39 weeks gestation in a ventouse (vacuum-assisted) delivery. Shortly after, she asks one of the doctors to review her baby, concerned about a swelling on his forehead.
On examination, the neonate has a soft, puffy swelling overlying the vertex. It appears to cross suture lines.
Given the most likely diagnosis, which of the following is the best advice to give to the mother?
Reassure and advise the parent that this should go down within a few days
This is capput succedeneum
Caput succedaneum is a puffy swelling that usually occurs over the presenting part and crosses suture lines
Occurs shortly after childbirth
Caput succedaneum describes oedema of the scalp at the presenting part of the head, typically the vertex. This may be due to mechanical trauma of the initial portion of the scalp pushing through the cervix in a prolonged delivery or secondary to the use of ventouse (vacuum) delivery.
How can you tell the difference between caput succedaneum and cephalohaematoma?
Caput succedaneum is present at childbirth
Resolves within days
Typically forms over vertex and crosses suture lines
Cephalohematoma doesn’t cross suture lines, typically develops several hours after childbirth and takes months to resolve
Most common in parietal region
Both have conservative management
A 8-year-old boy presents to the GP as his mother is worried about a fever that is not settling with regular paracetamol and ibuprofen. He has had the fever for 7 days now.
On examination, he has a widespread erythematous rash on his torso and arms. In particular, his palms and soles of his feet are very red. There is conjunctival injection with no discharge. Tender cervical lymphadenopathy is palpated. You measure his temperature at 38ºC.
Following resolution of this condition, which of the following investigations should be used to screen for potential complications
This question describes a patient with Kawasaki disease. This should always be suspected if a child has a fever lasting longer than 5 days and resistant to anti-pyretics. In the later stages, the fever may subside, but further symptoms can develop, such as palms and sole desquamation, abdominal pain, vomiting, diarrhoea, headache and joint pain. A serious complication that needs to be screened for is coronary artery aneurysms, and this can be diagnosed using echocardiography. Angiography could be used to diagnose aneurysms but echocardiography is preferred. The other investigations would not be used for screening for coronary artery aneurysms.
How do you manage kawasaki disease?
high-dose aspirin
Kawasaki disease is one of the few indications for the use of aspirin in children. Due to the risk of Reye’s syndrome aspirin is normally contraindicated in children
intravenous immunoglobulin
echocardiogram (rather than angiography) is used as the initial screening test for coronary artery aneurysms
What is kawasakis?
Kawasaki disease is a type of vasculitis which is predominately seen in children. Whilst Kawasaki disease is uncommon it is important to recognise as it may cause potentially serious complications, including coronary artery aneurysms.
How does kawasakis present?
high-grade fever which lasts for > 5 days. Fever is characteristically resistant to antipyretics
conjunctival injection
bright red, cracked lips
strawberry tongue
cervical lymphadenopathy
red palms of the hands and the soles of the feet which later peel
What is the diagnostic criteria for kawasakis?
Whooping cough should be suspected if a person has an acute cough that has lasted for 14 days or more without another apparent cause, and has one or more of the following features:
Paroxysmal cough.
Inspiratory whoop.
Post-tussive vomiting.
Undiagnosed apnoeic attacks in young infants.
How do patients with biliary atresia present?
Patients typically present in the first few weeks of life with:
Jaundice extending beyond the physiological two weeks
Dark urine and pale stools
Appetite and growth disturbance, however, may be normal in some cases
How do you manage biliary atresia?
Kasai procedure
This works by cutting out part of the liver and the bile duct and then attaching the small intestine to the liver
This is effective but infants still often need a transplant by 2 years
How do you investigate biliary atresia?
Serum bilirubin including differentiation into conjugated and total bilirubin: Total bilirubin may be normal, whereas conjugated bilirubin is abnormally high
Liver function tests (LFTs) including serum bile acids and aminotransferases are usually raised but cannot differentiate between biliary atresia and other causes of neonatal cholestasis
Serum alpha 1-antitrypsin: Deficiency may be a cause of neonatal cholestasis
Sweat chloride test: Cystic fibrosis often involves the biliary tract
Ultrasound of the biliary tree and liver: May show distension and tract abnormalities
Percutaneous liver biopsy with intraoperative cholangioscopy
What are the complications of biliary atresia?
Unsuccessful anastomosis formation
Progressive liver disease
Cirrhosis with eventual hepatocellular carcinoma
A mother brings her 5-week-old newborn baby to see you. She reports that she has noticed that his belly button is always wet and leaks out yellow fluid. On examination, you note a small, red growth of tissue in the centre of the umbilicus, covered with clear mucus. The child is otherwise well, apyrexial and developing normally.
Which one of the following is the most likely diagnosis?
An umbilical granuloma is an overgrowth of tissue which occurs during the healing process of the umbilicus. It is most common in the first few weeks of life. On examination, a small, red growth of tissue is seen in the centre of the umbilicus. It is usually wet and leaks small amounts of clear or yellow fluid. It is treated by regular application of salt to the wound, if this does not help then the granuloma can be cauterised with silver nitrate.
What is the difference between umbilical and periumbilical hernia?
Umbilical hernia
Up to 20% of neonates may have an umbilical hernia, it is more common in premature infants. The majority of these hernias will close spontaneously (may take between 12 months and three years). Strangulation is rare.
Paraumbilical hernia
These are due to defects in the linea alba that are in close proximity to the umbilicus. The edges of a paraumbilical hernia are more clearly defined than those of an umbilical hernia. They are less likely to resolve spontaneously than an umbilical hernia.
What is omphalitis?
This condition consists of an infection of the umbilicus. Infection with Staphylococcus aureus is the commonest cause. The condition is potentially serious as infection may spread rapidly through the umbilical vessels in neonates with a risk of portal pyaemia, and portal vein thrombosis. Treatment is usually with a combination of topical and systemic antibiotics.
What is a persistent urachus?
This is characterised by urinary discharge from the umbilicus. It is caused by persistence of the urachus which attaches to the bladder. They are associated with other urogenital abnormalities.
What is persistent vitello intestinal duct?
This will typically present as an umbilical discharge that discharges small bowel content. Complete persistence of the duct is a rare condition. Much more common is the persistence of part of the duct (Meckel’s diverticulum). Persistent vitello-intestinal ducts are best imaged using a contrast study to delineate the anatomy and are managed by laparotomy and surgical closure.
When do children start smiling?
6 weeks (Refer at ten weeks)
At what ages do children play?
Plays 'peek-a-boo' 9 months Waves 'bye-bye' Plays 'pat-a-cake' 12 months Plays contentedly alone 18 months Plays near others, not with them 2 years Plays with other children 4 years
A 28-year-old lady is on the post-natal having delivered her first baby at 38 weeks gestation. She had an elective lower segment caesarian section as her baby was in breech position with a failed external cephalic version attempt at 37 weeks. Both mother and baby appear to be happy and healthy and there is no family history of any medical conditions. The baby’s newborn examination was unremarkable. The mother mentions that one of the leaflets given to her during her antenatal appointments discussed screening for developmental dysplasia of the hip (DDH) and asks you whether her baby will need further tests.
If a baby is born >36 weeks gestation with breech presentation, then s/he requires a bilateral hip USS at 6 weeks regardless of method of delivery.
What features will patients with DDH present with later in life?
Waddling gait
Lumbar lordosis
Pain in lower back
What signs will be on the baby with DDH?
extra folds of skin on thigh
restricted abduction
Leg length discrepancy
How is DDH treated?
Pavlik harness
Holds the hips in a way that they can develop normally
If diagnosis is made after 1 year then open reduction is needed
In older children surgery and pelvic/femoral osteotomies
Most hips will spontaneously resolve at about 3-6 weeks
What are the risk factors for DDH?
female sex: 6 times greater risk breech presentation positive family history firstborn children oligohydramnios birth weight > 5 kg congenital calcaneovalgus foot deformity
