Paediatrics - Cardio, resp and gastro Flashcards
1
Q
what are the three fetal shunts
A
ductus venosus
foramen ovale
ductus arteriosus
2
Q
what is the ductus venosus
A
it is a shunt that connects the umbilical vein to the inferior vena cava and allows blood to bypass the liver
3
Q
what is the foramen ovale
A
it is a shunt that connects the right atrium with the left atrium and allows blood to bypass the right ventricle and pulmonary circulation
4
Q
what is the ductus arteriosus
A
it is a shunt that connects the pulmonary artery with the aorta and allows the blood to bypass the pulmonary circulation
5
Q
what in the body helps to maintain the ductus arteriosus
A
prostaglandins
6
Q
what are the three causes of pan-systolic murmur
A
mitral regurgitation
tricuspid regurgitation
ventricular septal defect
7
Q
what are the three causes of an ejection systolic murmur
A
aortic stenosis
pulmonary stenosis
hypertrophic obstructive cardiomyopathy
8
Q
what causes splitting of the second heart sound
A
during inspiration there is a negative intra-thoracic pressure. This causes the right side of the heart to fill faster. the increased volume in the right ventricle causes it to take longer for the right ventricle to empty during systole causing a delay in the pulmonary valve closing. As it closes slightly later than the aortic valve it causes the second heart sound to be split
9
Q
what murmur does an atrial septal defect cause
A
a mid systolic crescendo decrescendo murmur
- loudest at the upper left sternal boarder
- with a fixed split second heart sound
10
Q
what murmur is heart with a patent ductus arteriosus (normally severe one)
A
continuous crescendo -decrescendo machinery murmur which may continue into the second heart sound
11
Q
what murmur is heart with a tetralogy of fallot
A
an ejection systolic murmur due to the pulmonary stenosis
12
Q
what conditions can/do cause cyanotic heart disease
A
- ventricular septal defect
- atrial septal defect
- patent ductus arteriosus
- transposition of the great arteries
13
Q
how does a patient ductus arteriosus usually present
A
shortness of breath
difficulty feeding
poor weight gain
lower respiratory tract infections
14
Q
how is patient ductus arteriosus diagnosed
A
echocardiogram
- use of doppler flow studies
15
Q
how is a patient ductus arteriosus managed
A
monitored up until 1 year of age using echo
then after 1 its highly unlikely for the PDA to spontaneously close and trans-catheter or surgical closure will be performed
16
Q
what are the different types of atrial septal defect
A
- ostium secundum, where the septum secundum fails to fully close leaving a hole
- patient foramen ovale
- ostium primum, where the septum primum fails to fully close leaving a hole
17
Q
what are complications of atrial septal defect
A
stroke (VTE)
atrial fibrillation or atrial flutter
pulmonary hypertension and right sided heart failure
eisenmenger syndrome
18
Q
how does atrial septal defect present
A
mid systolic crescendo decrescendo murmur
fixed splitting of the second heart sound
shortness of breath
difficulty feeding
poor weight gain
lower respiratory tract infections
19
Q
how does atrial septal defect present in adults
A
dyspnoea
heart failure
stroke
20
Q
how is atrial septal defect managed
A
small and asymptomatic - watch and wait
large/symptomatic - transvenous catheter closure and anticoagulants
21
Q
what conditions is ventricular septal defect often associated with
A
downs syndrome
turners syndrome
22
Q
how does ventricular septal defect present
A
poor feeding
dyspnoea
tachpnoea
failure to thrive
23
Q
how is a ventricular septal defect treated
A
small/asymptomatic - watch and wait
larger/symptomatic - transvenous catheter closure, open heart surgery and antibiotic prophylaxis due to increased IE risk
24
Q
what is Eisenmenger syndrome
A
it occurs when blood flows from the right side of the heart to the left across a structural lesion bypassing the lungs
25
what three underlying lesions can lead to Eisenmenger syndrome
atrial septal defect
ventricular septal defect
patient foramen ovale
26
what is the pathophysiology of Eisenmongers syndrome
ASD or VSD allows a left to right shunt causing pulmonary hypertension. When pulmonary pressure becomes greater than systemic pressure then the shunt reverses and becomes right to left. This means that blood bypasses the lungs and causes cyanosis
27
what types of examination finding would you have in Eisenmengers syndrome
ones relating to the pulmonary hypertension
- right ventricular heave, loud P2, raised JVP, peripheral oedema
ones relating to the underlying septal defect
ones relating to the right to left shunt and chronic hypoxia
- cyanosis, clubbing, dyspnoea, plethoric complexion
28
what is the prognosis for someone with Eisenmenger syndrome
reduced life expectancy by around 20 years
- main causes of death are heart failure, thromboembolism, infection and haemorrhage
29
what is the management for Eisenmenger syndrome
once pulmonary pressure is high enough to cause the syndrome it is irreversible so you have to control the symptoms
- oxygen
- treatment of pulmonary htn with sildenafil
- treat arrhythmias
- treat poylcythaemia with venesection
- prevent and treat thrombosis with anticoags
- prevent IE with prophylactic abx
only definitive treatment is a heart -lung transplant
30
what is coarctation of the aorta
when there is a narrowing of the aortic arch, usually around the ductus arteriosus
31
what genetic condition is coarctation of the aorta associated with
Turners syndrome
32
how does coarctation of the aorta present
- week femoral pulses
- tachypnoea
- poor feeding
- grey floppy baby
- left ventricular heave
- underdeveloped left arm
- underdeveloped legs
33
how is coarctation of the aorta managed
in severe cases babies will require input very soon after birth
- prostaglandin E is given to keep the ductus arteriosus open while awaiting surgery
- surgery will be performed to correct the coarctation and ligate the ductus arteriosus
34
how does aortic stenosis present
fatigue
shortness of breath
dizziness
fainting
symptoms are typically worse on exertion
35
what are signs of aortic valve stenosis
ejection systolic murmur - crescendo decrescendo and radiates to carotids
- ejection click
- palpable thrill
- slow rising pulse and narrow pulse pressure
36
how is aortic valve stenosis managed
regular echo, ECG and exercise testing to monitor the progression of the disease
- percutaneous balloon aortic valvoplasty
- surgical aortic valvotomy
- valve replacement
37
what are complications of aortic valve stenosis
left ventricular outflow tract obstruction
heart failure
ventricular arrhythmias
bacterial endocarditis
sudden death, often on exertion
38
what other conditions is pulmonary valve stenosis associated with
tetralogy of fallot
william syndrome
noonan syndrome
congenital rubella syndrome
39
how does pulmonary valve stenosis present
normally discovered during routine baby checks
fatigue on exertion
shortness of breath
dizziness
fainting
40
what are the signs associated with pulmonary valve stenosis
ejection systolic murmur
palpable thrill
right ventricular heave
raised JVP - giant A waves
41
how is pulmonary valve stenosis managed
mild - follow up with watch and waiting
severe - balloon valvuloplasty via venous catheter or open heart surgery
42
what is tetralogy of fallot
a condition where there are four coexisting pathologies
1. ventricular septal defect
2. overriding aorta
3. pulmonary valve stenosis
4. right ventricular hypertrophy
43
what are risk factors for tetralogy of fallot
rubella infection
increased age of the mother (over 40)
alcohol consumption in pregnancy
diabetic mother
44
what investigations are done with tetralogy of fallot
Echo and doppler flow studies
- boot shaped heart due to right ventricular thickening
45
how does tetralogy of fallot present
mostly picked up on antenatal scans before the child is born
- cyanosis
- clubbing
- poor feeding
- poor weight gain
- ejection systolic murmur
- tet spells
46
what is a tet spell
this is intermittent symptomatic periods where the right to left shunt becomes temporarily worsened - if a child is walking, physically exerting themselves or crying.
the child will become irritable, cyanotic and short of breath
47
how do you treat a tet spell
older children - squat
younger children - pull their knees to their chest
- supplementary oxygen
- beta blockers to relax the ventricle
- IV fluids to increase pre load
- morphine
- sodium bicarb to buffer metabolic acidosis
- phenylephrine infusion to increase SVR
48
how is tetralogy of fallot managed
in neonates prostaglandin infusion is given to maintain the ductus arteriosus
total surgical repair by open heart surgery is the definitive treatment
49
what is Ebsteins anomaly
it is a congenital heart condition where the tricuspid valve is set lower in the right side of the heart than normal causing a bigger right atrium and a smaller right ventricle
50
what other heart conditions is Ebsteins abnormality associated with
atrial septal defect
Wolff-parkinson-white syndrome
51
how does Ebsteins anomaly present
evidence of heart failure
gallop rhythm heard on auscultation
addition of a third and fourth heart sound
cyanosis
shortness of breath
tachypnoea
poor feeding
collapse
cardiac arrest
52
how is Ebsteins abnormality treated
- treating the arrhythmias and heart failure
- prophylactic antibiotics
- surgical correction
53
what is transposition of the great arteries
this is where the right ventricle pumps blood into the aorta and the left ventricle pumps blood into the pulmonary circulation creating two separate circulations that dont mix
54
what other heart conditions is transposition of the great arteries associated with
ventricular septal defect
coarctation of the aorta
pulmonary stenosis
55
what does immediate survival of a baby with transposition of the great arteries depend on
depends on having a shunt
- patient ductus arteriosus
- atrial septal defect
- ventricular septal defect
56
how does transposition of the great arteries present
often diagnosed during antenatal screening
presents with cyanosis at/within a few days of birth
respiratory distress
tachycardia
poor feeding
poor weight gain
sweating
57
how is transposition of great arteries managed
prostaglandin infusion to maintain ductus arteriosus
balloon septostomy to create a large atrial septal defect to allow blood to flow to the lungs
open heart surgery is the definitive management - arterial switch procedure
58
what is bronchiolitis
it is when there is inflammation and infection in the bronchioles. it is normally caused by a virus
59
what is the most common cause of bronchiolitis
respiratory syncytial virus (RSV)
60
how does bronchiolitis present in children
coryzal symptoms - runny nose, sneezing, mucus in throat and watery eyes
signs of respiratory distress
dyspnoea
tachypnoea
poor feeding
mild fever (under 39)
apnoeas (episode where child stops breathing)
wheeze and crackles on auscultation
61
what are signs of respiratory distress
raised resp rate
use of accessory muscles
intercostal and subcostal recessions
nasal flaring
head bobbing
tracheal tugging
cyanosis
abnormal airway sounds
62
what are abnormal airway sounds
wheezing - whistling heard on expiration
grunting
stridor - high pitched inspiratory noise caused by obstruction of upper airway
63
what is the typical course of an RSV infection
- usually starts as an upper resp tract infection with coryzal symptoms
- from this point half get better spontaneously
- the other half will develop chest symptoms over the first 1-2 days following onset of coryzal sx
- symptoms generally are worse on day 3-4
- symptoms will usually last 7-10 days total
64
when might a child need admission for bronchiolitis
aged under 3 months
pre existing conditions - prematurity, downs syndrome, cystic fibrosis
50-75% or less of their normal milk intake
clinical dehydration
resp rate over 70
oxygen sats under 92
moderate to severe resp distress
apnoeas
parents not confident in ability to manage at home
65
how is bronchiolitis managed
supportive management
- ensuring adequate intake: orally, NG or IV
- saline nasal drops and nasal suctioning
- supplementary oxygen
- ventilator support if needed
66
what ventilator support may be required in children with bronchiolitis
1. high flow humidified oxygen via tight nasal cannula (has positive end expiratory pressure)
2. continuous positive airway pressure, using a sealed nasal cannula
3. intubation and ventilation
67
what signs indicate a poor ventilation
rising pCO2
falling pH
68
what is Palivizumab
it is a monoclonal antibody that targets RSV
- monthly injection is given as a prevention against bronchiolitis
- given to high risk babies
- not a true vaccine, only provides passive protection
69
what is viral induced wheeze
describes an acute wheezy illness caused by a viral infection
70
how to tell if its viral induced wheeze or asthma
typically viral induced wheeze
- presents before 3
- no atopic history
- only occurs during viral infections
where as asthma can be triggered by many things, has many signs and symptoms associated with it and shows variable and reversible airflow obstruction
71
how does viral induced wheeze present itself
evidence of a viral illness for 1-2 weeks preceding the onset of:
- shortness of breath
- signs of respiratory distress
- expiratory wheeze throughout the chest
72
How is viral induced wheeze managed in children
it is managed the same way as acute asthma in children
73
what is acute asthma
it is an acute exacerbation of asthma characterised by rapid deterioration in the symptoms of asthma
74
how does acute asthma present
progressively worsening shortness of breath
signs of respiratory distress
fast respiratory rate (tachypnoea)
expiratory wheeze
chest can sound tight on auscultation
75
what is the criteria for a moderate acute asthma attack
peak flow > 50% predicted
normal speech
saturations normal
76
what is the criteria for a severe asthma attack
peak flow <50 % predicted
saturations <92%
unable to complete sentences in one breath
signs of respiratory distress
resp rate >40 in 1-5yrs and >30 in over 5yrs
heart rate >140 in 1-5 yrs and >125 in over 5yrs
77
what is the criteria for life threatening asthma attack
peak flow <33% predicted
saturations <92%
exhaustion and poor resp effort
hypotension
silent chest
cyanosis
altered consciousness/confusion
78
how is acute asthma managed
1. supplementary oxygen
2. bronchodilators (salbutamol, ipratropium, magnesium sulphate)
3. steroids to reduce airway inflammation
4. antibiotics
79
how are bronchodilators stepped up in acute asthma attack
1. inhaled or nebulised salbutamol
2. inhaled or nebulised ipratropium bromide
3. IV magnesium sulphate
4. IV aminophylline
80
in moderate to severe acute asthma what is the stepwise approach taken to control the attack
1. salbutamol inhalers via a spacer (10 puffs every 2 hours)
2. nebulisers with salbutamol/ipratropium bromide
3. oral prednisolone
4. IV hydrocortisone
5. IV magnesium sulphate
6. IV salbutamol
7. IV aminophylline
81
what ion should be monitored when on high doses of salbutamol
potassium - can cause a hypokalaemia
82
when a child is leaving hospital after acute asthma attack what should they be discharged home with
can be discharged when the child is well on 6 puffs 4 hourly of salbutamol
- prescribed a reducing regime of salbutamol to continue at home
- finish steroids if those were started
- provide safety net information
- provide individualized asthma action plan
83
what are the atopic conditions
asthma
eczema
hay fever
food allergies
84
what presentation might suggest a diagnosis of asthma
episodic symptoms with intermittent exacerbations
diurnal variability, typically worse at night and early mornings
dry cough with wheeze
shortness of breath
typical triggers
history of other atopic conditions such as eczema/hay fever
family history
bilateral widespread polyphonic wheeze
symptoms improve with bronchodilators
85
what are typical triggers for asthma
dust
animals
cold air
exercise
smoke
food allergies
86
how is asthma diagnosed
history and examination
- spirometry with reversibility testing
- direct bronchial challenge test with histamine or methacholine
- fractional exhaled nitric oxide
- peak flow variability
87
how do you treat asthma in children under the age of 5
1. start with a short acting beta 2 agonist inhaler (salbutamol)
2. add low dose corticosteroid inhaler or leukotriene antagonist
3. add the other option from step 2
4. refer to specialist
88
how do you treat asthma in children aged 5-12
1. salbutamol
2. add a regular low dose corticosteroid
3. add salmeterol (LABA)
4. titrate up the corticosteroid
5. consider adding oral leukotriene receptor antagonist or oral theophylline
6. increase the dose of corticosteroid
7. refer to specialist
89
how do you treat asthma in children over the age of 12
the same as in adults
1. salbutamol
2. low dose corticosteroid inhaler
3. LABA i.e salmeterol
4. titrate up the corticosteroid to medium dose
5. consider oral leukotriene receptor antagonist or oral theophylline or LAMA
6. titrate up the corticosteroid to high dose
combine additional treatments from step 5
7. add oral steroids and refer to specialist
90
how does pneumonia present
cough - wet, productive
high fever - >38.5
tachypnoea
tachycardia
increased work of breathing
lethargy
delirium
91
what are signs that indicate pneumonia
tachypnoea
tachycardia
hypoxia
hypotension
fever
confusion
92
what are the characteristic chest signs of pneumonia
bronchial breath sounds - harsh, loud on inspiration and expiration
focal coarse crackles - air passing through sputum
dullness to percussion - lung tissue collapse/consolidation
93
what are causes of pneumonia
strep. pneuminia
group A strep
group B strep
staph aureus
haem. influenzae
mycoplasma pneumonia
respiratory syncytial virus
parainfluenza virus
influenza virus
94
how is pneumonia investigated
chest X ray
sputum cultures/throat swabs
viral PCR
blood cultures
capillary blood gas
blood lactate
95
how is pneumonia managed
amoxicillin (plus adding a macrolide such as clarithromycin/azithromycin will cover atypical)
- macrolides used as monotherapy in patients with penicillin allergy
96
what is croup
croup is an acute infective respiratory disease affecting children 6 months to 2 years (normally)
it affects the upper respiratory tract
97
what are causes of croup
parainfluenza
influenza
adenovirus
RSV
diphtheria (rare)
98
how does croup present
increased work of breathing
barking cough (clusters)
hoarse voice
stridor
low grade fever
99
how is croup managed
can be managed at home with supportive treatment
during an attack sit the child up to help them breath
oral dexamethasone is very effective (150mcg/kg)
100
what stepwise options are there is severe croup to get control of symptoms
oral dexamethasone
oxygen
nebulised budesonide
nebulised adrenalin
intubation and ventilation
101
what is epiglottitis
inflammation and swelling of the epiglottis caused by infection
102
what is the typical cause of epiglottitis
haem. influenza type B
103
what are presentations that suggest a possible epiglottitis
sore throat and stridor
drooling
tripod position
high fever
difficulty or painful swallowing
muffled voice
scared and quiet child
septic and unwell appearance
104
what investigations are done for suspected epiglottitis
if the patient is acutely unwell and epiglottitis is suspected then investigations should not be performed
- can do lateral x ray of the neck (thumb sign)
105
how is epiglottitis managed
Emergency !
key think is to not distress the child as it can make the airway close
alert senior paediatrician and anaesthetits
- secure the airway via intubation
- potentially do a tracheostomy
- once the airway is secure give IV antibiotics (ceftriaxone) and steroids (dexamethasone)
106
what is a common complication of epiglottitis
epiglottic abscess - collection of pus around the epiglottis
107
what is laryngomalacia
it is a condition affecting infants where the part of the larynx above the vocal cords is structured in a way that allows it to cause partial airway obstruction
108
what are the structural changes in laryngomalacia
the aryepiglottic folds are shortened which pulls on the epiglottis and changes its shape to a characteristic omega shape
the tissue surrounding the supraglottic larynx is softer and has less tone than normal, meaning it can flow across the airway, which happens particularly in inspiration
109
how does laryngomalacia present
inspiratory stridor - becomes more prominent when feeding, upset, lying on their back, in upper respiratory tract infections
110
what is the management of laryngomalacia
the problem resolves as the larynx matures and grows, usually no interventions are required
- rarely a tracheostomy is necessary
- surgery can improve symptoms
111
what is whooping cough
it is an upper respiratory tract infection caused by bordetella pertussis
112
how does whooping cough present
starts with mild coryzal symptoms
low grade fever
more severe cough after about a week - paroxysmal cough
113
how is whooping cough diagnosed
nasopharyngeal or nasal swab with PCR testing or bacterial culture
where the cough has been present for more than 2 weeks patients can be tested for the anti-pertussis toxin immunoglobulin G
114
how is whooping cough managed
1. its a notifiable disease - tell public health
2. supportive care
3. macrolide antibiotics: azithromycin, erythromycin, clarithromycin (co-trimoxazole as alternative)
4. close contacts given prophylactic antibiotics
115
what is a key complication of whooping cough
bronchiectasis
116
what is chronic lung disease of prematurity
typically occurs in babies under 28 weeks. They suffer respiratory distress syndrome, due to their lungs not being mature
117
what are features of chronic lung disease of prematurity
low oxygen saturations
increased work of breathing
poor feeding and weight gain
crackles and wheezes on chest auscultation
increased susceptibility to infection
118
how can you prevent chronic lung disease of prematurity
pre birth
- giving corticosteroids to mothers that show premature signs of labor (less than 36 weeks)
once the neonate is born
- use CPAP rather than intubation and ventilation where possible
- using caffeine to stimulate resp effort
- not over oxygenating with supplementary oxygen
119
how is chronic lung disease of prematurity managed longer term
sleep study to assess oxygen saturations during sleep
babies may be discharged from the neonatal unit with low dose oxygen to use at home
monthly injections of palivizumab to protect them against RSC and reduce the risk of bronchiolitis
120
what genetic mutation causes cystic fibrosis
mutation of the cystic fibrosis transmembrane conductance regulatory gene (CFTR) on chromosome 7
- most common is the delta - F508
121
what channels are affected in cystic fibrosis
chloride channels
122
what are the key consequences of the cystic fibrosis mutation
1. thick pancreatic and biliary secretions causing blocked ducts and lack of digestive enzymes
2. Low volume thick airway secretions
3. congenital bilateral absence of the vas deferens
123
how does cystic fibrosis present
meconium ileus is often the first sign
recurrent lower respiratory tract infections
failure to thrive
pancreatitis
124
how is cystic fibrosis screened for
it is screened for at birth with the newborn bloodspot test
125
what is primary ciliary dyskinesia
it is an autosomal recessive condition which affects the cilia of various cells in the body
126
what does primary ciliary dyskinesia cause dysfunction in
in motile cilia around the body, most notably in the respiratory tract leading to a build up of mucus in the lungs
also affects cilia in fallopian tubes in women
127
what is the Kartagner's triad
it describes the three key features of primary cilia dyskinesia
- paranasal sinusitis
-bronchiectasis
-sinus inversus
128
what is sinus inversus
it is a condition where all the internal organs are mirrored in the body
- 25% of patients with sinus inversus have primary ciliary dyskinesia
- 50% of patients with primary ciliary dyskinesia have sinus inversus
129
how is primary ciliary dyskinesia diagnosed
- patients typically present with recurrent respiratory tract infections
- examination
- chest x ray
- semen analysis can diagnose male infertility
Sample of ciliated epithelium = gives diagnosis
130
how can a sample of ciliated epithelium be obtained
nasal brushing or bronchoscopy
131
how is primary ciliary dyskinesia managed
daily physiotherapy
high calorie diet
antibiotics - prophylaxis
132
what are medical causes of abdominal pain
constipation
urinary tract infection
coeliac disease
IBD
IBS
mesenteric adenitis
abdominal migraine
pyelonephritis
henloch-schnlein purpura
tonsilitis
diabetic ketoacidosis
infantile colic
dysmenorrhoea
Mittelschmerz
ectopic pregnancy
PID
ovarian torsion
pregnancy
133
what are surgical causes of abdominal pain
appendicitis
intussusception
bowel obstruction
testicular torsion
134
what are red flags for serious abdominal pain
persistent or bilious vomiting
severe chronic diarrhoea
fever
rectal bleeding
weight loss or faltering growth
dysphagia
nighttime pain
abdominal tenderness
135
what investigations can be done which may indicate the abdominal pathology
- anaemia can indicate IBD/coeliac
- raised inflammatory markers can indicate IBD
- raised anti-TTG/EMA indicated coeliac
- raised faecal calprotectin indicated IBD
- positive urine dipstick indicated UTI
136
what is recurrent abdominal pain
a diagnosis of recurrent abdominal pain is made when a child presents with repeated episodes of abdominal pain without an identifiable underlying cause
137
what other diagnosis does recurrent abdominal pain overlap with
abdominal migraine
irritable bowel syndrome
functional abdominal pain
138
what does recurrent abdominal pain often correspond with
stressful life events
- increased sensitivity and inappropriate pain signals from visceral nerves in the gut
139
what is the management for recurrent abdominal pain
distracting the child from the pain
encourage parents to not ask about the pain
advice about sleep, eating, diet, exercise, stress
probiotic supplements
avoid NSIADS
address psychological trigger and exacerbating factors
support from school
140
what is abdominal migraine
it is episodes of central abdominal pain which lasts more than 1 hour which may be associated with
- nausea and vomiting
- anorexia
- pallor
- headache
- photophobia
- aura
141
how are acute attacks of abdominal migraine managed
low stimulus environment
paracetamol
ibuprofen
sumatriptan
142
what are prevention medications used for abdominal migraine
pizotifen - serotonin agonist
propranolol
cyproheptadine - antihistamine
flunarazine
143
what are causes of constipation in children
idiopathic
functional constipation
Hirschsprungs
cystic fibrosis
hypothyroidism
spinal cord lesions
sexual abuse
intestinal obstruction
anal stenosis
cows milk intolerance
144
how does constipation present in children
less than 3 stools a week
hard stools that are difficult to pass
rabbit dropping stool
straining and painful passages of stool
abdominal pain
holding abnormal postures
rectal bleeding
faecal impaction causing overflow diarrhoea
hard stool may be palpable
loss of sensation of need to open bowels
145
what is encopresis
it is the term for faecal incontinence and is usually a sign of chronic constipation where the rectum becomes stretched and looses sensation
146
at what age is encopresis considered pathological
4 and above
147
what are other causes of encopresis other than chronic constipation
spinal bifida
Hirschprungs disease
cerebral palsy
learning disability
psychological stress
abuse
148
what lifestyle factors can contribute to the development of constipation
habitually not opening the bowels
low fibre diet
poor fluid intake and dehydration
sedentary lifestyle
psychological issues
149
what is desensitisation of the rectum
this is when patients keep ignoring the sensation of a full rectum and not opening their bowels, leading to a loss of that sensation and they start to retain faeces. This leads to faecal impaction which further exacerbates the problem
150
what are red flags in regard to constipation
not passing meconium within 48hrs of birth
neurological signs or symptoms
vomiting
ribbon stool - anal stenosis
abnormal anus
abnormal lower back or buttocks
failure to thrive
acute severe abdominal pain and bloating
151
what are complications of constipation
pain
reduced sensation
anal fissures
haemorrhoids
overflow and soiling
psychosocial morbidity
152
how is constipation managed
correct any reversible contributing factors - high fibre diet and good hydration
start laxatives - movicol
faecal impaction may require a disimpaction regimen with a high dose of laxatives at first
encourage and praise visiting the toilet
153
what causes in GORD in infants
in babies there is immaturity of the lower oesophageal sphincter which allows reflux easily
154
how does GORD in children present
signs of problematic reflux includes
0 chronic cough
- hoarse cry
- distress, crying or unsettled after feeding
- reluctance to feed
- pneumonia
- poor weight gain
children over 1 year - heartburn, acid regurgitation, retrosternal or epigastric pain, bloating and nocturnal cough
155
what are possible causes of vomiting in children
overfeeding
GORD
pyloric stenosis - projectile vomiting
gastritis or gastroenteritis
appendicitis
infections such as UTI, tonsillitis or meningitis
intestinal obstruction
bulimia
156
what are red flags of vomiting in children
not keeping any feed down
projectile or forceful vomiting
bile stained vomit
haematemesis or meleana
abdominal distension
reduced consciousness, bulging fontanelle or neurological signs
respiratory symptoms
blood in the stool
signs of infection
rash, angioedema and other signs of allergy
apnoea
157
how is GORD in children managed
conservative: small frequent meals, burping regularly, not over feeding, keep the baby upright after feeding
medical: Gaviscon mixed with food, thickened milk or formula, proton pump inhibitors
surgical: barium meal and endoscopy, surgical fundoplication
158
what is sandifers syndrome
it is a rare condition causing brief episodes of abnormal movements associated with gastroesophageal reflux in infants
159
what are the key features of sandifers syndrome in children
torticollis - forceful contraction of the neck muscles causing twisting of the neck
dystonia - abnormal muscle contractions causing twisting movements and arching of the back
160
what causes pyloric stenosis
hypertrophy and narrowing of the pylorus which prevents food traveling from the stomach into the duodenum
161
what age does pyloric stenosis present
the first few weeks of life
162
how does a child with pyloric stenosis typically present
thin
pale
failure to thrive
projectile vomiting
163
why do you get vomiting in pyloric stenosis
after feeding there is increasingly powerful peristalsis in the stomach as it tries to push food into the duodenum. This eventually becomes so powerful it ejects food into the oesophagus and out of the mouth
164
what might the stomach of a baby with pyloric stenosis feel like post feeding
firm round mass in the upper abdomen
165
what will a blood gas of a child with pyloric stenosis show
hypochloric (low chloride) metabolic alkalosis
- due to the vomiting of hydrochloric acid
166
how is pyloric stenosis diagnosed
abdominal ultrasound
167
how is pyloric stenosis treated
laparoscopic pyloromyotomy (Ramstedts operation)
- incision in the smooth muscle to widen it
168
what is acute gastritis
it is inflammation of the stomach
169
what is enteritis
it is inflammation of the intestines
170
what is gastroenteritis
it is inflammation all the way from the stomach to the intestines
171
how does gastroenteritis present
with nausea, vomiting and diarrhoea
172
what is the most common cause of gastroenteritis in children
viral - rotavirus, norovirus, (and adenovirus)
173
what is the main concern with gastroenteritis
dehydration
174
what is steatorrhoea
greasy stools with excessive fat content
175
what are differential diagnosis for the causes of diarrhoea
infection - gastroenteritis
inflammatory bowel disease
lactose intolerance
coeliac disease
cystic fibrosis
toddlers diarrhoea
IBS
medications - antibiotics
176
what type of e.coli produces the shiga toxin
e.coli 0157
177
how is E.coli gastroenteritis spread
contact with infected faeces, unwashed salads or contaminated water
178
what are symptoms of E.coli 0157
abdominal cramps
bloody diarrhoea
vomiting
179
what can Shiga toxin lead to
haemoytic uraemic syndrome
180
do you use antibiotics to treat E.coli
NO - antibiotics increase the risk of haemolytic uraemic syndrome so antibiotics should be avoided if gastroenteritis is considered
181
what is a common cause of travelers diarrhoea
campylobacter jejuni
182
what is the most common bacterial cause of gastroenteritis worldwide
campylobacter jejuni
183
what type of bacteria is campylobacter jejuni
it is a gram negative bacteria
it has a curved or spiral shape
184
how is campylobacter jejuni spread
raw or improperly cooked poultry
Untreated water
Unpasteurised milk
185
what are symptoms of campylobacter jejuni
abdominal cramps
diarrhoea - often with blood
vomiting
fever
186
what is the disease course with campylobacter jejuni
incubation in normally 2-5 days
symptoms resolve after 3-6 days
187
what are common treatments of campylobacter jejuni
azithromycin
ciprofloxacin
188
how is shigella spread
by contaminated water, swimming pools and food
189
what is the disease time course for shigella
incubation period is 1-2 days
symptoms resolve within 1 week without treatment
190
what are symptoms of shigella infection
bloody diarrhoea
abdominal cramps
fever
191
what toxin can shigella produce and what can it cause
shiga toxin which can cause haemolytic uraemic syndrome
192
how is severe cases of shigella treated
azithromycin
ciprofloxacin
193
how is salmonella spread
eating raw eggs or poultry
eating food contaminated with the infected faeces of small animals
194
what are symptoms of salmonella
watery diarrhoea - can have mucus or blood
abdominal pain
vomiting
195
what is the disease course of salmonella infection
incubation is 12 hours to 3 days
symptoms normally resolve within 1 week
196
what type of bacteria is bacillus cereus
it is a gram positive rod which is spread through inadequately cooked food
197
what food does bacillus cereus grow on
fried rice left out a room temperature
198
what toxin does bacillus cereus produce which causes symptoms
cereulide
199
what is the symptoms of bacillus cereus infection
abdominal cramping and cramping within 5 hours of ingestion
produce different toxins in intestines which causes watery diarrhoea
200
how quick do the symptoms of bacillus cereus resolve
within 24 hours
201
what is the typical course of bacillus cereus infection
vomiting within 5 hours
diarrhoea after 8 hours
resolution after 24 hours
202
How is Yersinia Enterocolitica spread
eating raw or undercooked pork
contamination with urine or faeces of other mammal such as rats/rabbits
203
who does Yersinia most frequently affect
children
204
what are symptoms of Yersinia
watery and bloody diarrhoea
abdominal pain
fever
lymphadenopathy
older children and adults present with abdominal pain due to mesenteric lymphadenitis
205
what is the infection course in Yesinia
incubation is 4-7 days
illness can last 3 weeks or more
206
how can staphylococcus aureus cause gastroenteritis
through production of toxin which cause intestinal inflammation
207
what are symptoms of Staphylococcus aureus toxin
diarrhoea
perfuse vomiting
abdominal cramps
fever
208
how does staphylococcus aureus toxin cause gastroenteritis
it grows on food such as eggs, dairy and meat and when they are ingested it causes intestinal inflammation
209
what is Giardia lamblia
it is parasite which lives in the intestines of mammals
210
how does giardia lamblia cause gastroenteritis
they release cysts in stools of infected mammals which contaminate food or water
- foecal oral transmission
211
how can Giardia lamblia present
chronic diarrhoea
212
how is Giardia lamblia diagnosed
stool microscopy
213
how is giardia lamblia treated
metronidazole
214
what are principles of gastroenteritis management
good hygiene
barrier nursing
patient isolation
maintaining patient hydration
microscopy, culture and sensitivities
215
what are post gastroenteritis complications
lactose intolerance
irritable bowel syndrome
reactive arthritis
guillian barre syndrome
216
what is coeliac disease
it is an autoimmune condition where exposure to gluten causes an immune reaction which created inflammation in the small intestine
217
what are the antibodies present in coeliac disease
anti tissue transglutaminase
anti endomysial
deaminated gliadin peptides antibodies
218
what area of the bowel is particularly affected by coeliac disease
jejunum
219
what is the effect coeliac disease has on the small intestine
causes atrophy of the intestinal villi as the antibodies target the epithelial cells of the intestine
220
how does coeliac disease present
can be asymptomatic
failure to thrive
diarrhoea
fatigue
weight loss
mouth ulcers
anaemia secondary to iron, B12 or folate deficiency
dermatitis herpetiformis - itchy blistering rash
neurological symptoms - peripheral neuropathy, cerebellar ataxia, epilepsy
221
what are the genetic associations with coeliac disease
HLA- DQ2 gene - 90%
HLA - DQ8
222
how is coeliac disease diagnosed
must be on gluten while being diagnosed
- total immunoglobulin A levels to exclude IgA deficiency
- check anti TTG and EMA
- endoscopy and biopsy of the jejunum
223
what will endoscopy and biopsy of the small intestine show in coeliac disease
crypt hypertrophy
villous atrophy
224
what are complications of untreated coeliac disease
vitamin deficiency
anaemia
osteoporosis
ulcerative colitis
enteropathy associated T cell lymphoma of the intestine
non Hodgkin lymphoma
small bowel adenocarcinoma
225
what is the treatment of coeliac disease
life long gluten free diet
226
what are features of Crohns disease
No blood or mucus in stool (less common)
Entire GI tract
Skip lesions on endoscopy
terminal ileum is most affected
transmural thickness
smoking is a risk factor
weight loss
strictures
fistulas
227
what are features of ulcerative colitis
continuous inflammation
limited to the colon and the rectum
only the superficial mucosa is affected
smoking is protective
excrete blood and mucus
associated with primary sclerosing cholangitis
228
how does IBD present in children
suspect IBD in children/teenagers with:
perfuse diarrhoea
abdominal pain
bleeding
weight loss
anaemia
systemically unwell during flairs with fevers, malaise and dehydration
229
what are the extra-intestinal manifestations of IBD
finger clubbing
erythema nodosum
pyoderma gangrenosum
episcleritis and iritis
inflammatory arthritis
primary sclerosing cholangitis - ulcerative colitis
230
how is IBD diagnosed
bloods - anaemia, infection, thyroid, kidney and liver function
Faecal calprotectin - 90% sensitive and specific
endoscopy - OGD and colonoscopy with biopsy
imaging - ultrasound, CT and MRI to identify any fistulas/abscesses/strictures
231
what things are important to monitor in children with IBD
growth and pubertal development
- particularly during exacerbations or being treated with steroids
232
how is remission induced in crohns
Steroids - oral prednisolone or IV hydrocortisone
if steroids dont work consider adding an immunosuppressant - azathioprine, mercaptopurine, methotrexate, infliximab, adalimumab
233
how is remission maintained in crohns
First line: Azathioprine or mercaptopurine
Alternatives: methotrexate, infliximab, adalimumab
234
when is crohns treated surgically
then the disease only affects the distal ileum it is possible to resect this area
can be used to treat strictures and fistulas
235
how is remission induced in ulcerative colitis
First line: aminosalicylate (mesalazine)
second line: corticosteroids
severe disease: first line IV corticosteroids and second line IV ciclosporin
236
how do you maintain remission in ulcerative colitis
aminosalicylate
azathioprine
mercaptopurine
237
how can ulcerative colitis be treated surgically
as it only affects the colon and rectum removal of both will remove the disease
- patient is left with a permanent ileostomy or an ileo-anal anastomosis (J pouch)
238
what is biliary atresia
it is a congenital condition where a section of the bile duct is either narrowed or absent resulting in cholestasis
239
how does biliary atresia present
presents shortly after birth with significant persistent jaundice
240
what causes jaundice in babies with biliary atresia
high levels of conjugated bilirubin
241
what are initial investigations done in babies with significant jaundice
conjugated and unconjugated bilirubin to determine where the cause of the jaundice is
242
what is the management of biliary atresia
surgery - kasai portoenterostomy
involves attaching a section of the small intestine to the opening of the liver
often patients require a full liver transplant to resolve the condition
243
what are causes of intestinal obstruction
meconium ileus
Hirschsprungs disease
oesophageal atresia
duodenal atresia
intussusception
imperforate anus
malrotation of the intestines with a volvulus
strangulated hernia
244
how does intestinal obstruction present
persistent vomiting - may be bilious
abdominal pain and distension
failure to pass stool or wind
abnormal bowel sounds - high pitched, tinkling, absent
245
how is intestinal obstruction diagnosed
abdominal X ray - loops of dilated bowel
absence of air in the rectum
246
how is intestinal obstruction managed
referral to the paediatric surgical unit
nil by mouth
nasogastric tube
IV fluids
treat underlying cause
247
what is Hirschsprungs disease
it is a congenital condition where nerve cells of the mesenteric plexus are absent in the distal bowel and rectum
248
what is the mesenteric plexus
it forms the enteric nervous system, which runs all the way along the bowel in the bowel wall. It is responsible for stimulating peristalsis of the large bowel
249
what is the key pathophysiology of Hirschsprungs disease
there is the absence of parasympathetic ganglion cells
- dont travel all the way down to the colon so section left without the cells
250
what is total colonic aganglionosis
this is when the entire colon is affected - no nerve innervation in the entire colon
251
in Hirschsprungs disease is the aganglionic bowel constricted or dilated
it is constricted as it cant relax leading to the loss of movement of faeces and subsequent obstruction
252
what other syndromes is Hirschsprungs disease associated with
Downs syndrome
neurofibromatosis
Waardenberg syndrome
multiple endocrine neoplasia type II
253
how does Hirschsprungs disease present
varies on the individual and the how much bowel is affected
- delay in passing meconium
- chronic constipation since birth
- abdominal pain and distension
- vomiting
- poor feeding and failure to thrive
254
what is Hirschsprung associated enterocolitis
it is inflammation and obstruction of the intestine occurring in about 20% of neonates with Hirschsprungs disease
255
how does Hirschsprung associated enterocolitis present
2-4 weeks after birth with fever, abdominal distension, diarrhoea (blood) and features of sepsis
- life threatening !!!!
256
what can Hirschsprung associated enterocolitis lead to
toxic megacolon and perforation of the bowel
257
how is Hirschsprung associated enterocolitis treated
antibiotics
fluid resuscitation
decompression of the obstructed bowel
258
how is Hirschsprungs disease managed
definitive management is surgical removal of the aganglionic section of the bowel
259
how is Hirschsprungs disease diagnosed
Abdominal ultrasound
rectal biopsy is used to confirm the diagnosis
260
what is intussusception
it is a condition where the bowel invaginates or telescopes into itself
261
what is intussusception associated with
concurrent viral illness
Henoch-schlonlein purpura
cystic fibrosis
intestinal polyps
Meckel diverticulum
262
what occurs during intussusception
the bowel folds inwards in itself when thickens the overall size of the bowel and narrows the lumen in the folded area leading to palpable mass in the abdomen and obstruction to the passage of faeces
263
who does intussusception typically occur in
infants 6 months to 2 years
more common in boys
264
how does intussusception present
severe colicky abdominal pain
pale, lethargic and unwell child
redcurrant jelly stool
upper right quadrant mass on palpation - sausage shaped
vomiting
intestinal obstruction
265
how is intussusception managed
therapeutic enemas
surgical reduction if enemas dont work
266
how is intussusception diagnosed
ultrasound scan or contrast enema
267
what are complications of enemas
obstruction
gangrenous bowel
perforation
death
268
what is appendicitis
it is inflammation of the appendix due to infection trapped within the appendix by an obstruction
269
what are signs of appendicitis
central abdominal pain which moves to the right iliac fossa over time and becomes localised there
loss of appetite
nausea and vomiting
Rosvings sign
guarding
rebound tenderness
percussion tenderness
270
how is appendicitis diagnosed
clinical presentation and raised inflammatory markers
CT scan
ultrasound scan in women to exclude ectopic pregnancy and ovarian torsion
271
what are differential diagnosis of appendicitis
ectopic pregnancy
ovarian cysts
Meckels diverticulum
mesenteric adenitis
appendix mass
272
what is the management of appendicitis
appendicectomy - definitive management
laparoscopic surgery
273
what are complications of an appendicectomy
bleeding
infection
pain
scars
damage to bladder, bowel and other organs
anaesthetic risks
removal of normal appendix
venous thromboembolism
274
what should be checked routinely though out childhood to ensure a child is growing normally
height
weight
275
when is the most rapid rate of growth in a childs life
in the first year of life
276
when is it acceptable for a child to loose weight
in the first few days of life when feeding is being established it is acceptable for a child to lose up to 10% of their birth weight
277
what are the thresholds of concern based on a childs growth chart
- a fall across one or more weight centile spaces if the birthweight was below 9th centile
- a fall across two or more centile spaces if if the birthweight was between 9-91st centile
- a fall across three or more centile spaces if birthweight was above the 91st centile
- when current weight is below the second centile for age, no matter the birthweight
278
what is the most common cause of faltering growth in children
inadequate dietary intake
279
which children may have their own/different growth charts to normal
those with certain genetic conditions
- downs syndrome
- achondroplasia
- DiGeorge syndrome
- turners syndrome
280
what are causes of inadequate nutritional intake in children
inadequate food provided - social
problems with eating - fussiness, mechanical issues
lifestyle - unbalanced diet
281
what are causes of inadequate nutrient absorption or increased losses in children
malabsorption - CF, crohns, coeliac
vomiting - GORD, pyloric stenosis
diarrhoea - chronic infection, ulcerative colitis
282
what are causes of increased nutritional requirements or ineffective utilisation in children
congenital heart disease
malignancy
metabolic syndromes - T1DM, hyperthyroidism
chronic inflammation or recurrent infections
chronic systemic disease
283
what are the three causes for faltering growth in children
inadequate nutrient intake
inadequate nutrient absorption or increased losses
increased nutrient requirements or ineffective utilisation
284
what is mid parental height
it gives an estimate of the childs predicted final height - genetic potential
285
how do you calculate mid parental height
Males: (mums height + dads height)/2 +7cm
Females: (mums height +dads height)/2 -7cm
286
when might mid parental height indicate an issue
if the childs current height centile is more than two centiles below the mid parental height centile
287
what investigations should be done when a child is exhibiting faltering growth
history and examination
FBC
blood film
iron studies
vitamin D levels
U+E
LFT
inflammatory markers
tTG
288
what is the management for a child with faltering growth
- dietary advice and advice about mealtimes and then plot again to reassess after time
- dietician referral
- investigate and treat any underlying cause
289
what advice should be given around mealtimes for children
Mealtimes should be relaxed and enjoyable
Balanced, nutritional meals should be offered
Ideally children should eat with the family- parents and/or other children
Young children should be encouraged to feed themselves, even if this is messy
Mealtimes should not be too brief or too long
Reasonable boundaries should be set for mealtime behaviour (while avoiding punitive approaches)
Coercive feeding should be avoided
There should be regular eating schedules (for example three meals and two snacks in a day)
290
what are complications of faltering growth
permanent short stature
immunodeficiency
damage to growing brain - behavioral issues, poorer developmental and cognitive outcomes
291
what are the three common stages constipation presents in childhood
weaning in infants
toilet training in toddlers
starting school
292
what is chronic constipation
when it has lasted more than 8 weeks
293
what are risk factors for paediatric constipation
diet low in fibre
low fluid intake
intercurrent illness
post operative bed rest or analgesia
psychological difficulty with toilet training
294
what is type 1 on the bristol stool chart
separate hard lumps, like nuts
hard to pass
295
what is type 2 on the bristol stool chart
sausage shaped but lumpy
296
what is type three on the bristol stool chart
like a sausage but with cracks on the surface
297
what is type 4 on the bristol stool chart
like a sausage/snake
smooth and soft
298
what is type 5 on the britol stool chart
soft blobs
clear cut edges
passed easily
299
what is type 6 on the bristol stool chart
fluffy pieces with ragged edges
mushy stool
300
what is type 7 on the bristol stool chart
watery
no solid pieces
entirely liquid
301
what is necrotising enterocolitis
it is the most common surgical emergency in neonates
- acute inflammatory disease predominantly affecting preterm infants
302
what causes necrotising enterocolitis
exact cause is unknown
damage to the intestinal mucosa can occur due to vascular insults, toxin exposure, infection and genetic factors
this damage allows pathogenic colonisation of normal commensal bacteria
303
what are risk factors to developing necrotising enterocolitis
85% of cases in premature babies or low birth weight
abnormal dopplers
antibiotic treatment lasting longer than 10 days or multiple courses
enteral feeding
cows milk formula
congenital heart disease
304
how does necrotising enterocolitis present
new feed intolerance
vomiting
increasing volume of NG aspirate
distended abdomen which is tender and tense
Haematochezia - fresh blood in the stool
305
what clinical findings may be present in a child with necrotising enterocolitis
abdominal distension, tender to palpation and can feel tense or wooden
reduced bowel sounds
palpable abdominal mass
visible intestinal loops
signs of sepsis
306
what are differential diagnosis to necrotising enterocolitis
sepsis
intussusception
volvulus
hirschsprungs disease
307
what investigations should be done for suspected necrotising enterocolitis
bloods - FBC, CRP
blood cultures
blood gas - raised lactate or acidosis
imaging - abdominal ultrasound 1st, X-ray
308
what is the management of necrotising enterocolitis
infant nil by mouth
NG tube
assess for sepsis
IV fluids
IV antibiotics
surgery - if there is evidence of perforation, laparotomy carried out to remove perforated and necrotic bowel
309
what are complications of necrotising enterocolitis
bowel perforation
DIC
sepsis
adverse neurodevelopmental outcomes
short bowel syndrome
formation of strictures
enterocolic fistulae
abscess formation
310
what is marasmus
it is severe undernutrition - a deficiency in all the macronutrients that the body required to function (carbohydrates, fats and protein)
311
what happens to the body in marasmus
the body will use its own storage of adipose tissue and then muscle for energy
it begins to shut down functions to conserve energy - cardiac activity slows, low blood pressure, low body temperature
immune system compromised
digestive system may begin to atrophy due to lack of food
312
what are causes of marasmus
poverty and food scarcity
wasting diseases such as AIDS
infections such as chronic diarrhoea
anorexia
inadequate breastfeeding or early weaning
child abuse or neglect
313
what are the external signs of marasmus
visible wasting of fat and muscle
prominent skeleton
head appears large for the body
face may appear old
loose dry skin
dry brittle hair or hair loss
sunken fontanelles in infants
lethargy, apathy, weakness
weight loss of more than 40%
BMI below 16
314
what other symptoms can marasmus cause
dehydration
electrolyte imbalance
low blood pressure
slow heart rate
low body temperature
gastrointestinal malabsorption
stunted growth
developmental delays
anaemia
osteomalacia or rickets
315
how is marasmus diagnosed
physical examination
plot on growth chart
measure upper arm circumference and height to weight ratios
bloods - FBC and look for deficiencies
316
how is marasmus treated
stage 1: rehydration and stabilisation (REhydration SOlution for MALnutrition- ReSoMal)
stage 2: nutritional rehabilitation - may last 2-6 weeks
stage 3: follow up and prevention
317
what is Kwashiorkor
it is a type of malnutrition characterised by severe protein deficiency causing fluid retention and a swollen distended abdomen
318
who does Kwashiorkor affect
found in developing countries with high rates of poverty and food scarcity
poor sanitary conditions and high prevalence of infectious diseases
most common in children (3-5)
319
what are the symptoms of Kwashiorkor
oedema
bloated stomach with ascites
dry brittle hair and hair loss
dermatitis - dry peeling skin, scaly patches
enlarged liver
depleted muscle mass but retained subcutaneous fat
dehydration
loss of appetite
irritability and fatigue
stunted growth in children
320
what other complications can Kwashiorkor cause
hypoglycaemia
hypothermia
hypovolaemia
electrolyte imbalances
immune system failure
cirrhosis of the liver and liver failure
atrophy of the pancreas
atrophy of the gastrointestinal mucosa
growth and developmental delays
starvation and death
321
what causes Kwashiorkor
diet of mostly carbohydrates
weaning with inadequate food replacement
lack of essential vitamins and minerals
lack of dietary antioxidants
parasites, and infectious diseases
significant life stress
322
how is Kwashiorkor diagnosed
physical examination
history
measure childs weight to height ratio
measure childs height to age ratio
323
how is Kwashiorkor treated
1. treat/prevent hypoglycaemia (can occur when calories are introduced)
2. treat/prevent hypothermia
3. treat/prevent dehydration - ReSoMal
4. correct electrolyte imbalances
5. treat/prevent infection - antibiotics
6. correct any micronutrient deficiencies
7. start cautious feeding
8. achieve catch up growth - once child is stabilised calories can be increased to 140%
9. provide sensory stimulation and emotional support
10. prepare for follow up after recovery
324
what can happen in Kwashiorkor and marasmus if feeding occurs to quickly
re-feeding syndrome
life threatening !!
325
what is meckels diverticulum
it is a congenital disorder where there is a small outpouching of the inner wall of the intestine
326
what are the rule of 2s of meckels diverticulum
Meckels diverticulum occurs in 2% of the population
only 2% of people with it develop complications or symptoms
symptoms usually appear in children under 2
symptoms occurs twice as often in those assigned male at birth
it is usually located about 2 feet from the lower end of the small intestine
it may have either two types of ectopic tissue in it - stomach or pancreatic
327
what are symptoms of meckels diverticulum
there wont be any unless there are complications
- blood in the stool
- anaemia symptoms
- abnormal abdominal swelling
- tenderness of stomach
- cramping
- nausea and vomiting
328
what complications may arise in meckels diverticulum
1. Gastrointestinal bleeding due to ectopic tissue secreting digestive juices leading to ulcers
2. diverticulitis due to bacterial infection
3. intestinal obstruction either due to extra tissue obstructing the bowel or intussusception
329
what causes Meckels diverticulum
it occurs early in fetal development when the yolk sac is replaced by the placenta
the duct which connected the yolk sac to the embryo (vitelline duct) detaches and the fetus absorbs it
sometimes it doesnt detach or resorb fully and a remnant is left which becomes meckels diverticulum
330
what are risk factors for Meckels diverticulum
may be more likely to have it if you have other congenital disorders such as oesophageal atresia or anorectal malformation
male sex
age under 50
331
how is Meckel's diverticulum diagnosed
accidental finding due to other condition
when symptoms present - history and exam
Meckels scan - imaging that can detect ectopic stomach tissue in diverticulum
Mesenteric arteriography (angiogram)
endoscopy
332
what is the treatment for Meckels diverticulum
if it causes complications the patient can have a small bowel resection, cutting out the small piece of bowel with the diverticulum in it
- laparoscopic
333
what is colic
when a baby cries nonstop for more than three hours a day at least three days a week
- inconsolable
334
when does colic start
colic typically starts within the first ew weeks after birth
it peaks between 4 and 6 weeks of age
it typically ends rather abruptly when the baby is 3-4 months
335
how common is colic
affects about 20% of babies
336
what are symptoms of colic
repeated periods of inconsolable crying - hours
clenches fists
legs curled up over their tummy
arched back
hard swollen abdomen
passing of gas
active grimacing or painful look on their face
face turning bright ref or deeper shade after long periods of crying
337
what causes colic in babies
abdominal pain or discomfort from gas
reflex
food allergies
milk protein intolerance
under or overfeeding
overstimulation
early form of migraine headache
emotional reaction to frustration, fear or excitement
underdeveloped digestive system
338
what are complications of colic
toll on parents - stress
postpartum depression
shaken baby syndrome
339
how is colic diagnosed
history and exam
- check for physical illness
340
how is colic treated
there is no cure
keep a record - breastfeeding
try different brands of formula
skin to skin contact
rocking
swaddling
singing/white noise
burping the baby
warm baths
341
what is cows milk allergy
unlike lactose intolerance CMA is an allergic reaction to proteins in the milk
342
what are the two types of cows milk allergy
IgE mediated food allergy - immediate
non IgE mediated food allergy - delayed
343
what are symptoms of cows milk allergy
often start in the early weeks and months of life
skin reactions - hives, eczema, redness, itching
GI issues - vomiting, diarrhoea, abdo pain, discomfort
resp symptoms - sneezing, runny nose, coughing, wheezing, SOB
general discomfort can display fussiness, irritability and refusal to feed
344
how is cows milk allergy diagnosed
history and exam
referral to childrens specialist allergy service
allergy focused history
trial elimination of all cows milk protein
345
what alternatives can be used for cows milk
breastfeeding - mother to not eat dairy products
hypoallergenic formula
amino acid formula
346
how is cows milk allergy managed
dietician referral
use hypoallergenic formula
avoid all cows milk
347
what is a choledochal cyst
they are congenital cystic dilations of the biliary tree
348
what are choledochal cysts associated with
biliary atresia
hepatic fibrosis
349
how does choledochal cysts present
typical triad:
abdominal pain
jaundice
abdominal mass
350
what are type 1 choledochal cysts
these are the most common
1a. dilation of extrahepatic bile duct (entire)
1b. dilation of extrahepatic bile duct (focal segment)
1c. dilation of the common bile duct portion of extrahepatic duct
351
what are type 2 choledochal cysts
true diverticulum from extrahepatic bile duct
352
what are type 3 choledochal cysts
dilation of extrahepatic bile duct within the duodenal wall
353
what are type 4 choledochal cysts
4a. cysts involving both intra and extrahepatic ducts
4b. multiple dilations/cysts of extrahepatic ducts only
354
what are type 5 choledochal cysts
multiple dilations or cysts of intrahepatic ducts only
355
what are type 6 choledochal cysts
dilation of cystic ducts
356
how are choledochal cysts diagnosed
imaging can be achieved with US, CT ERCP and PTC or MRI
history and examination
357
how are choledochal cysts treated
people with type 1, 2 and 4 usually undergo surgical resection of the cyst due to risk of malignancy
- hepaticojejunostomy
358
what are complications of choledochal cysts
stone formation
malignancy - cholangiocarcinoma
cyst may rupture leading to bile peritonitis
pancreatitis
359
what is poor feeding in infants
term used to describe an infant that has little interest in feeding, or not feeding enough to receive the necessary nutrition required for adequate growth
360
what are causes of poor feeding in infants
premature birth - havent developed sucking reflex
diarrhoea
ear infections
cough and colds
teething
congenital hypothyroidism
Downs syndrome
hypoplastic left heart/heart defects
moving to solid foods
361
what is neonatal hepatitis
it is inflammation of the liver in newborns typically between 1-2 months after birth
362
what viruses are known to cause neonatal hepatitis
rubella
CMV
Hepatitis A, B, C
363
what are causes of neonatal hepatitis
Viral
Genetic disorders - cholestasis, alpha 1 anti-trypsin deficiency, whilsons
idiopathic
364
what are symptoms of neonatal hepatitis
jaundice
dark urine
light stools
swelling of the abdomen
failure to grow and gain weight at expected rate
365
how is neonatal hepatitis diagnosed
history and exam
bloods - infection
liver biopsy - distinguish biliary atresia from neonatal hepatitis
366
how is neonatal hepatitis treated
no specific treatment - depends on underlying cause
vitamin supplements
phenobarbital - stimulates liver to secrete more bile
formular containing more easily digested fats are also given
367
how long does neonatal hepatitis caused by hep A take to clear up
within about six months
368
what is imperforate anus
it is a congenital anorectal malformation where a normal anal opening is absent at birth
369
what are symptoms of imperforate anus
failure to pass first meconium within 24 hours
meconium in the urine
girls may have fourchette fistula
boys may have posterior urethral fistula
370
how is imperforate anus treated
posterior sagittal anorectoplasty
371
what is gastroschisis
it is a paraumbilical defect with evisceration of the abdominal contents
372
what is omphalocele
it is a defect of the umbilical ring with herniation of the abdominal viscera. it is covered by the peritoneum and amniotic membrane
373
what are the two types of liver failure
acute liver failure (fulminant hepatic failure)
chronic liver failure
374
what are common causes of acute liver failure in children
toxin or virus exposure causing liver damage
- too much paracetamol
375
what are common causes of chronic liver failure
long term liver disease
- biliary atresia
- metabolic liver disease (Wilson)
- hepatitis
376
what are symptoms of liver failure
confusion and disorientation
pain or tenderness
weakness
fatigue
nausea
vomiting
dark urine
easy bleeding
itching
small, spider like vessels visible in the skin
chills
377
what are complications of liver failure
liver encephalopathy
jaundice
coagulopathy
portal hypertension
ascites
hepatomegaly
378
how is liver failure diagnosed
bloods - FBC, albumin, bilirubin, LFTs, PT
ultrasound
CT scan
379
how is liver failure treated
treatment depends on stage of liver failure, and the underlying cause
- may require liver transplant
380
at what age is toddlers diarrhoea most common
between the ages of 1-5
381
what are the symptoms of toddlers diarrhoea
chronic nonspecific diarrhoea
- three or more loose watery stools per day (can be more than 10 per day)
- can sometimes see undigested food in stool
- mild abdominal pain
- child will seem generally well in themselves
382
what causes toddlers diarrhoea
thought that the balance of fluid, fibre and undigested sugars/food in a childs large bowel prevents fluid being absorbed correctly leading to loose stools
- NOT due to malabsorption or food intolerance
383
how can toddlers diarrhoea be treated
the four Fs
Fat - want a higher fat diet in children
Fluid - 6-8 cups per day and reducing sugary drinks
fruit juice/fruit squash and fruit - high amounts can irritate the gut
fibre - too low or too high fibre diet can contribute to the diarrhoea
384
what are the commonest viruses/bacteria in small children
strep pneumonia
RSV
mycoplasma
Human metapneumovirus
pertussis
influenza/parainfluenza
385
what are the mot common reasons a child presents to the hospital with breathlessness
asthma
bronchiolitis
pneumonia
croup
386
what is Galactosemia
rare hereditary disorder of carbohydrate metabolism that affects the bodies ability to convert galactose to glucose
386
what causes galactosemia
deficiency in the GALT enzyme which is vital for conversion of galactose into glucose
387
what are symptoms of galactosemia
within a few days of birth baby loses appetite and will vomit excessively
jaundice
hepatomegaly
amino acids and protein in urine
growth failure
ascites
oedema
diarrhoea
irritability
lethargy
failure to thrive
388
what can galactosemia lead to
liver failure
kidney dysfunction
brain damage - arrested mental development
cataracts
ovarian impairement
389
what causes symptoms in galactosemia
due to loss of GALT enzyme there is an abnormal accumulation of galactose related chemicals in organs leading to SX
390
what is the inheritance pattern of galactosemia
autosomal recessive
391
how is galactosemia diagnosed
bloods - Galactose-1-phosphate elevated in RBC and GALT is reduced
genetic testing
newborn screening programs
392
what is the treatment for galactosemia
lactose restricted diet - do NOT do lactose tolerance test
speech therapy
individual education plans/learning help
hormone replacement therapy
antibiotics
genetic counselling
393
what is infective endocarditis
this is an infection of the endothelium (inner surface) of the heart, most commonly affecting the heart valves
394
what are risk factors for developing infective endocarditis
IV drug use
structural heart pathology
chronic kidney disease (particularly on dialysis)
immunocompromised
history of infective endocarditis
395
what structural abnormalities can increase the risk of endocarditis
Valvular heart disease
Congenital heart disease
Hypertrophic cardiomyopathy
Prosthetic heart valves
Implantable cardiac devices (e.g., pacemakers)
396
what are causes of infective endocarditis
The most common cause is Staphylococcus aureus.
Other causes include:
Streptococcus (notably the viridans group of streptococci)
Enterococcus (e.g., Enterococcus faecalis)
Rarer causes include Pseudomonas, HACEK organisms and fungi
397
what are presenting symptoms of infective endocarditis
Fever
Fatigue
Night sweats
Muscle aches
Anorexia (loss of appetite)
failure to thrive
398
what are key examination findings for infective endocarditis
New or “changing” heart murmur
Splinter haemorrhages (thin red-brown lines along the fingernails)
Petechiae (small non-blanching red/brown spots) on the trunk, limbs, oral mucosa or conjunctiva
Janeway lesions (painless red flat macules on the palms of the hands and soles of the feet)
Osler’s nodes (tender red/purple nodules on the pads of the fingers and toes)
Roth spots (haemorrhages on the retina seen during fundoscopy)
Splenomegaly (in longstanding disease)
Finger clubbing (in longstanding disease)
399
what investigations should be done for infective endocarditis
blood cultures BEFORE starting antibiotics
ECHO - transoesophageal echo is more sensitive and specific
400
what is the modified dukes criteria
it is a criteria that can be used to diagnose infective endocarditis and requires either:
one major plus three minor
five minor criteria
401
what are the major criteria in the modified dukes criteria
persistently positive blood cultures
specific imaging findings i.e vegetation seen
402
what are minor criteria in the modified dukes criteria
predisposition
fever above 38 degrees
vascular phenomena (splenic infarction, intracranial haemorrhage, janeway lesions)
immunological phenomena (osler nodes, roth spots and glomerulonephritis)
microbiological phenomena
403
how is infective endocarditis managed
IV broad spectrum antibiotics (amoxicillin and optional gentamicin) given for 4 weeks for patients with native heart valves and 6 weeks for those with prosthetic heart valves
surgery is required for heart failure relating to valve pathology, large vegetations or abscesses, infections not responding to antibiotics
404
what are the key complications for infective endocarditis
Heart valve damage, causing regurgitation
Heart failure
Infective and non-infective emboli (causing abscesses, strokes and splenic infarction)
Glomerulonephritis, causing renal impairment
405
what is an innocent murmur
it is a common murmur in children caused by fast blood flow through various areas of the heart during systole
406
what are the typical features of a innocent murmur
Soft
Short
Systolic
Symptomless
Situation dependent, particularly if the murmur gets quieter with standing or only appears when the child is unwell or feverish
407
what are the differential diagnosis for pan-systolic murmurs
Mitral regurgitation heard at the mitral area (fifth intercostal space, mid-clavicular line)
Tricuspid regurgitation heard at the tricuspid area (fifth intercostal space, left sternal border)
Ventricular septal defect heard at the left lower sternal border
408
what is cyanotic hear disease
this occurs when deoxygenated blood enters the systemic circulation
409
how does cyanotic heart disease occur
it occurs when blood is able to bypass the pulmonary circulation and the lungs. This occurs due to a right to left shunt
410
what causes heart failure in children
heart muscle disease or enlargement of the heart muscle (cardiomyopathy)
decrease in the blood supply to the heart (rare in children)
heart valve disease
cardiac arrhythmias
anaemia
infections
medicine side effects
411
what are the symptoms of heart failure in children
oedema of the feet, ankles, legs, stomach, liver and neck veins
respiratory distress, especially with activity
poor feeding and weight gain
fatigue
excessive sweating while feeding, playing or exercising
weight loss
syncope
chest pain
412
how do you diagnose heart failure in a child
Blood and urine tests.
Chest X-ray. The X-ray may show heart and lung changes.
Electrocardiography (ECG). .
Echocardiography (echo).
Cardiac catheterization. The doctor puts a small, flexible tube (catheter) into a blood vessel and moves it to the heart. This measures pressure and oxygen levels inside the heart.
413
what are the most common causes of heart failure in children
cardiomyopathies and congenital heart defects
414
how is heart failure treated in children
control of symptoms - nutritional support, oxygen support
diuretics - furosemide, spironolactone
ACE inhibitors
Beta blockers
inotropes - digoxin
dopamine and dobutamine to increase CO and decrease systemic and pulmonary vascular resistance
devise therapy; implantable cardioverted defibrillator and cardiac resynchronization therapy
heart transplant
415
what types of arrhythmias are there in infants and children
AV nodal reentrant tachycardia
atrial flutter
atrial fibrillation
premature atrial contractions
premature ventricular contractions
ventricular tachycardia
ventricular fibrillation
bradycardia
heart block
sick sinus syndrome
416
what is AV nodal reentrant tachycardia
this is causes sudden episodes of an abnormally fast heart rate starting in the atria. THis is the most common cause of super-ventricular tachycardia in children
417
what are symptoms of arrhythmia in children
chest pain
difficulty eating
dizziness, syncope
fatigue or weakness
heart palpitations
irritability
shortness of breath
418
what are causes of arrhythmia in children
most children have no underlying structural issues
- cardiomyopathy
- inherited conditions like long QT syndrome or catecholaminergic polymorphic ventricular tachycardia
- certain medications
- congenital heart disease
- electrolyte imbalance
- fever, dehydration, stress, inflammation
- infection
419
how is arrhythmia diagnosed in children
bloods
echo
ECG
holter monitor - measures electrical activity over 24 hours
420
how is arrhythmia treated in children
some done need treatment
antiarrhythmic medications: beta blockers or calcium channel blockers
ablation
cardioversion - traditional or chemical
implantable device
maze surgery - cuts/burns in heart tissue to stop faulty electrical signals
421
what is sick sinus syndrome
where the sinus node is affected/damaged meaning it is unable to generate normal heartbeats at a normal rate, which can result in heartbeats that are too slow or too fast
422
what are symptoms of sick sinus syndrome
Fainting.
Lightheadedness or dizziness.
Heart palpitations.
Exhaustion.
Shortness of breath.
While exercising: Feel tired, Have trouble breathing.
423
what causes sick sinus syndrome
injury or breakdown of current in heart or SA node directly
injury to SA node
medication
genetic causes
metabolic causes
424
what are risk factors for sick sinus syndrome
heart surgery
medications such as beta blockers or calcium channel blockers
metabolic issues such as high potassium or low calcium
diseases such as rheumatic fever, sarcoidosis or diphtheria
genetic mutations
425
how is sick sinus syndrome treated
permanent pacemaker
medication for a fast heart rate
catheter ablation
426
what might produce a false positive on the CF sweat test
malnutrition
G6PD
nephrogenic diabetes insipidus
adrenal insufficiency
427
what is a contraindication for lung transplant in cystic fibrosis
chronic infection with burkholderia cepacia
428
what medication can be given in CF which helps increase number of CFTR channels
Orkambi - works in those with delta F508 mutation
429
what errors with taking the test might give a false positive result on the chloride sweat test for cystic fibrosis
if the patient is oedematous
inadequate quantity of sweat was collected
methodologic and technical errors
430
what can be used to treat cystic fibrosis in patients who are homozygous for the delta F508 mutation
Lumacaftor and ivacaftor
- used together which helps to increase the amount of time the CFTR channel is open and help it form so it can move to the cell surface
