Paediatrics Block

Question 1

What is the most common cause of raised urea?

Answer 1

Dehydration

Question 2

What is featoris oris?

Answer 2

The belief that your breath smells bad when it doesn’t. This is seen in appendicitis.

Question 3

What is Murphy’s triad?

Answer 3

This is a triad of symptoms associated with acute appendicitis.

Lower right abdominal pain, vomiting and fever

Question 4

What is the first line investigation for appendicitis?

Answer 4

Ultrasound and then CT.

Bloods are FBC, LFTS, CRP and potentially blood cultures

Question 5

What should be provided to the patient as soon as a diagnosis of appendicitis is made?

Answer 5

IV antibiotics and IV fluids

Question 6

What is the pathophysiology of appendicitis?

Answer 6

The infection causes a build up of mucus which causes luminal obstruction. The mucus provides nutritional support for the bacteria and hence bacterial overgrowth.

Question 7

What investigations should be done for a child with constipation?

Answer 7

Blood tests of TFTs, coeliac screen and Hirschsprung’s disease should be considered if the neonate hasn’t passed meconium in the first two days. This requires a biopsy to confirm.

Question 8

What is the treatment for neonatal faecal impaction?

Answer 8

Macrogol 3350 (laxido)

Dietary advice, hydration, and exercise are important. Toilet training and an awards system may be helpful as constipation has a psychological element to it.

Question 9

What are the red flags for children with constipation?

Answer 9

Meconium has not been passed in 46 hours, weakness of the less or locomotor delay and abnormal spine.

Always assess family history of Hirschsprung’s disease.

Question 10

What are the amber flags for children with constipation?

Answer 10

Concern of maltreatment, constipation triggered by cows milk and any evidence of faltering growth.

Question 11

What is mesenteric adenitis?

Answer 11

Mesenteric lymphadenitis, also known as mesenteric adenitis, is an inflammation of the lymph nodes in the mesentery. The mesentery attaches the intestine to the abdominal wall and holds it in place. Typically, mesenteric lymphadenitis results from an intestinal infection.

Mesenteric adenitis has a history of preceding URTI, palpable lymph nodes, mimics appendicitis, high temperature and shifting dullness.

Question 12

What are the signs of breathlessness in a child?

Answer 12

Observe appearance and behaviour including alertness and cyanosis. Indrawing is more common in children as is use of accessory muscles and head bobbing as there is less power to sustain heavy breathing. Respiratory rate over 60 is red traffic light. 02 SATs should always be assessed. Grunting is where a baby is attempting to create their own CPAP. Wheeze is seen in VIW, allergies and anaphylaxis and bronchiolitis.

Question 13

Why do children and adults respond differently to respiratory infections?

Answer 13

Differences in immune competency and build-up of immunity over time. Paediatric lungs are smaller, less ridged and more prone to obstruction. Children have a higher natural respiratory rate as well. Young children have a relatively larger tongue in the oropharynx which can increase the risk of blockage. RSV is a common cause of bronchiolitis but in adults it only causes mild disease, this is because RSV is a disease of small airways which are more vital in children.

Question 14

What is normal feeding for a neonate?

Answer 14

Children at three months of age should be having 8-10 feeds a day at around 90-120 mills each. 50% would be acceptable. 150ml/kg/day is the general rule.

Question 15

What factors are important when deciding whether or not to admit a child with breathlessness?

Answer 15

When assessing a child in a secondary care setting, admit them to hospital if they have any of the following: apnoea (observed or reported), persistent oxygen saturation of less than 92% when breathing air, inadequate oral fluid intake (50–75% of usual volume, taking account of risk factors, persisting severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute.
When deciding whether to admit a child with bronchiolitis, take account of any known risk factors for more severe bronchiolitis such as: chronic lung disease (including bronchopulmonary dysplasia), haemodynamically significant congenital heart disease, age in young infants (under 3 months), premature birth, particularly under 32 weeks, neuromuscular disorders, and immunodeficiency. Pavilizumab is a monoclonal antibody can be given as an injection to prevent high-risk RSV illness.

When deciding whether to admit a child, take into account factors that might affect a carer’s ability to look after a child with bronchiolitis, for example: social circumstances, the skill and confidence of the carer in looking after a child with bronchiolitis at home, confidence in being able to spot red flag symptoms and
distance to healthcare in case of deterioration.

Question 16

What is the difference between viral induced wheeze and asthma?

Answer 16

The difference between asthma and viral-induced wheeze is that children with asthma will wheeze at times other than when they have a cold – often with exercise or when they are exposed to particular ‘triggers’ like house dust mites or pets.

Question 17

How should severe viral induced wheeze be treated?

Answer 17

Corticosteroids, ipratropium bromide and finally IV magnesium sulphate Aminophylline may consider in life threatening cases.

O - oxygen

S – Salbutamol
H – Hydrocortisone
I – Ipratropium Bromide
T – Theophylline

M – Magnesium
E – Escalate

Children under 11-12 months have no SABA receptors and so salbutamol will have no effect.

Question 18

Describe some of the key attributes of RSV bronchiolitis?

Answer 18

Bronchiolitis is mainly caused by RSV, but other viruses are possibilities. This causes respiratory distress, wheezing, difficulty feeding and periods of apnoea. Treatment is supportive with aim of oxygen over 92% even when they are asleep. This is usually worst on day 3-5 and then gets better.

Question 19

Why are asthma symptoms worse at night?

Answer 19

Asthma symptoms are worse at night because there is a lower cortisol level at night.

Question 20

What is glue ear?

Answer 20

Glue ear is the most common cause of acquired deafness and it is caused by acute otitis media with effusion.

Question 21

What are the elements of the TORCH screen?

Answer 21

TORCH screen stands for Toxoplasmosis, Rubella, CMV and herpes/HIV

Question 22

When is a red flag for not walking?

Answer 22

18 months

Question 23

What is Gower’s sign?

Answer 23

Climbing up the body to get upright. This is seen in muscular dystrophies. There will be an elevated creatine kinase due to the breakdown of muscle.

Question 24

How does earache present in small children?

Answer 24

Hands on their ears, tugging their ears and external erythema or discharge.

Always inquire about nose and throat symptoms.

Question 25

What are the bacterial and viral causes of acute otitis media?

Answer 25

Streptococcus pneumonia, haemophilus influenza and Moraxella catarrhalis

Most respiratory viruses can cause otitis media.

Question 26

How should acute otitis media be treated?

Answer 26

Treatment of AOM is analgesia alone for first 48 hours and then antibiotics if symptoms persist or are severe. Oral amoxicillin, cefaclor or azithromycin are current local policy guidelines or topical drops of ciprofloxacin if there ear drum has perforated and there is persistent discharge.

Question 27

What is Glue ear and what are the complications?

Answer 27

Glue ear is when there is persistent fluid after the infection which is properly known as Otitis Media with Effusion. Recurrent Acute Otitis Media (ROAM), persistent perforation or chronic otitis media and acute mastoiditis (can lead to meningitis) are potential complications.

Question 28

Describe the natural history of bronchiolitis

Answer 28

RSV accounts for 80% of cases but other causes include adenovirus, parainfluenza and rhinovirus. It starts as a URTI which moves onto smaller airways or bronchioles causing further inflammation. It is the leading cause of hospitalisation in children under one. It almost always affects children under the age of 2 and occurs in the winter months.
Vulnerable infants include preterm, chronic lung disease, cardiac disorders, early age of onset and tobacco exposure. They usually catch it from siblings or parents.

The acute inflammation caused by a viral infection of the lower respiratory tract is characterised by epithelial cell destruction, cellular oedema, and airway obstruction due to inflammatory debris and mucus.

Question 29

How does bronchiolitis present?

Answer 29

Signs and symptoms include coryzal symptoms, cough, fever (low grade), tachypnoea, subcostal recession, tracheal tug, nasal flaring, abdominal breathing, use of accessory muscles, grunting and head bobbing.

The end of the bed examination in paediatrics in the most important indicator of health on examination. On examination look for increased work of breathing, crackles or wheeze, struggling to head, nasal flaring, snotty, any rashes, capillary refill, hydration status and behaviour.

Question 30

How should bronchiolitis be treated?

Answer 30

Treatment is mainly conservative with supplementary O2, NG tube or IV feeds, saline nebuliser or other nasal decongestant and in severe cases CPAP may be required. Generally, bronchiolitis resolves itself within 10-14 days and tends to be worst on days 3-5. Antibiotic and salbutamol nebulisers will have no effect.

Question 31

Describe the natural history of febrile convulsions

Answer 31

These are convulsions (involuntary contraction of muscles/seizure) in the presence of a high-grade fever. There is no CNS infection associated with the convulsions and they are usually secondary to viral infection. These typically occur in children aged between 6 months – 5 years of age.

In the differentials it is important that a convulsion secondary to an organic brain pathology is ruled out.

The pathophysiology of convulsions is that multiple excitatory neurone release glutamate (excitatory neurotransmitter) which causes and influx of sodium and calcium into the cells, triggering an action potential. Febrile convulsions are defined as simple or complex. Simple convulsions are generalised with all limbs involved, less than fifteen minutes in duration, occurs once in 24 hours and have a normal neurological examination and no history of febrile convulsions.

Complex convulsions are partial or focal, last for longer than fifteen minutes, have a compromised neurological state and have a history of febrile convulsions

Question 32

How should febrile convulsions be treated?

Answer 32

For simple seizures no treatment is required as it is usually self resolving. These children can be confidently discharged on the same day if the source of the fever is found. If the child has had a complex seizure then bloods, lumbar puncture, EEG and neurological imaging may be necessary to rule out another cause. Antipyretics and benzodiazepines if the seizure was prolonged.

Use of anti-epileptics going forward is not advised but there is a very small increased risk of epilepsy but no harm to cognition or other neurological function. Providing antipyretics has no evidence of reducing fever frequency.

Question 33

How does croup present?

Answer 33

Croup is usually caused the virus parainfluenza and results in upper airway obstruction leading to stridor and respiratory distress. It usually affects children between 6 months and 3 years old and cases peak in winter.

There will be a 1–2-day history of coryzal symptoms and on say three a barking cough develops. Stridor occurs with a hoarse voice. There may be signs of respiratory distress such as intercostal recession, they may be lethargic with a mild to moderate fever. And the symptoms are worse at night. The chest sounds are often normal unless associated with a secondary LRTI bacterial infection.

Question 34

How is croup categorised?

Answer 34

Recognising the severity of croup and can be assessed with the Westly clinical score:

1. Mild: Barking cough but no stridor or signs of respiratory distress
2. Moderate: Barking cough with stridor and signs of respiratory distress but no agitation or lethargy
3. Severe: Barking cough with stridor and signs of respiratory distress which is associated with agitation and lethargy
4. Impending Respiratory Failure: Signs of respiratory distress including a respiratory rate greater than 70, asynchronous chest wall and abdominal movement, pallor/cyanosis and decreased level of consciousness

Question 35

How is croup treated?

Answer 35

In primary care, children with mild croup are treated with a single oral dose of dexamethasone (0.15mg/kg). Encourage the use of paracetamol and ibuprofen, encourage oral fluid intake, advise parents check on their child through the night and symptoms should resolve within 48 hours, if not they should call for the safety net advice.

Moderate croup is treated with oral dexamethasone which can be given again in 12 hours. The child should be observed for 2-3 hours once asymptomatic and then sent home with safety net advice.

Severe croup should be treated with oral/IV dexamethasone which can be repeated after 12 hours. They should have O2 via a facemask, nebulised adrenaline and senior review with PICU input.

Question 36

What are the signs of UTI in children?

Answer 36

Signs and symptoms of a UTI in children include frequency, pain and incontinence and abdominal pain in older children. In younger, non-verbal children look for symptoms of fever, abdominal pain on palpation, vomiting and poor feeding. Irritability, haematuria, offensive urine and lethargy are also signs to watch out for.

Children under three months of age are at risk of sepsis and CNS infection and so fever, vomiting, lethargy, irritability, poor feeding, failure to thrive, abdominal pain, jaundice, haematuria and offensive urine are indicative of a UTI.

Question 37

What does it mean if Leukocytes + and nitrates + in a paediatric urine dipstick?

Answer 37

The child should be regarded as having a UTI and antibiotic treatment started.

Question 38

What does it mean is leukocytes are negative and nitrates are positive in a paediatric urine dipstick?

Answer 38

Antibiotic treatment should be started and a urine sample sent for culture.

Question 39

What does it mean is leukocytes are positive and nitrates are negative in a paediatric urine dipstick?

Answer 39

A urine sample should be sent for microscopy and culture.

Antibiotic treatment should NOT be started.

Question 40

What does it mean if both leukocytes and nitrates are negative?

Answer 40

The child should be regarded as not having a UTI.

Question 41

What are the indications for a paediatric urine sample to be sent for microscopy?

Answer 41

1. Infants and children who are suspected to have acute pyelonephritis/upper UTI
2. In infants and children with a high to mediate risk of serious illness
3. Infants under three months of age
4. Infants and children with a positive result for leukocyte esterase or nitrite
5. Infants and children with recurrent UTI
6. Infants and children with an infection that does not respond to treatment within 24-48 hours
7. When clinical symptoms and dipstick test do not correlate

Question 42

What is important to rule out in a paediatric recurrent or atypical UTI case?

Answer 42

Vesicoureteric reflex.

This should be investigated with a micturating cystogram or a DMSA.

Question 43

How is recurrent UTI defined?

Answer 43

Recurrent is two or more episodes of a UTI with acute pyelonephritis/UUTI infection or 1 episode of UTI with acute pyelonephritis plus one or more UTI or three or more episodes of UTI.

Question 44

What are the risk factors for newborn sepsis?

Answer 44

Risk factors for sepsis in a newborn baby include GBS in previous or current pregnancy, prelabour rupture of membranes, preterm birth following spontaneous labour (before 37 weeks), suspected or confirmed rupture of membranes more than 18 hours in a preterm birth, intrapartum fever over 38 or suspected or confirmed infection in the other baby if multiple pregnancy.

A septic screen for a baby is performed if they have the clinical signs of altered behaviour or responsiveness, altered muscle tone, feeding difficulties, feed intolerance, abnormal heart rate, signs of respiratory distress, hypoxia, jaundice within 24 hours of birth, apnoea, neonatal encephalopathy, seizures, temperature abnormality, signs of shock, unexplained excessive bleeding, thrombocytopenia or abnormal coagulation, oliguria persisting for longer than 24 hours, altered glucose homeostasis, metabolic acidosis and local signs of infection on the skin.