Paediatrics COPY Flashcards
1
A
- Sickle cell disease (SCD)
- Cystic fibrosis (CF)
- Congenital hypothyroidism (CHT)
- Inherited metabolic diseases (IMDs). These are genetic diseases that affect the metabolism and include:
- phenylketonuria (PKU)
- medium-chain acyl-CoA dehydrogenase deficiency (MCADD)
- maple syrup urine disease (MSUD)
- isovaleric acidaemia (IVA)
- glutaric aciduria type 1 (GA1)
- homocystinuria (HCU)
2
Q
When should a patient with bronchiolitis be referred into hospital as an emergency?
A
- apnoea (observed or reported)
- child looks seriously unwell to a healthcare professional
- severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute
- central cyanosis
- persistent oxygen saturation of less than 92% when breathing air.
3
Q
When should a child with bronchiolitis be considered for hospital referral (discuss with consultant)?
A
- a respiratory rate of over 60 breaths/minute
- difficulty with breastfeeding or inadequate oral fluid intake
- clinical dehydration.
4
Q
What are the red flag symptoms to inform parents about when their child has bronchiolitis?
A
- worsening work of breathing (for example grunting, nasal flaring, marked chest recession)
- fluid intake is 50–75% of normal or no wet nappy for 12 hours
- apnoea or cyanosis
- exhaustion (for example, not responding normally to social cues, wakes only with prolonged stimulation).
5
Q
What are the guidelines for different types of milk children should drink ?
A
- breast milk best for babies (especially first 6 months)
- Infant formula only suitable alternative to breast milk in first 12 months
- full fat cows milk can be given from age 1
- Soya, almond, oat milk can be used from age 1
- semi-skimmed cows milk can be introduced from age 2
- skimmed milk is not recommended until over age 5 (lack of calories)
6
Q
What are the risk factors for DDH?
A
- female (80%) cases
- genetic - FHx
- Internal - shallow acetabulum, connective tissue laxity, decreased hip resistance
- External - breech position, large for gestational age, oligohydramnios, multiple pregnancy
7
Q
In the NICE traffic light system, what are the red ‘high risk’ features of serious illness in under 5s?
A
- pale/mottled/ashen/blue
- no response to social cues
- appears ill to HCP
- Does not wake/stay awake
- weak high-pitched or continuous cry
- grunting
- tachypnoea RR >60
- moderate-severe chest indrawing
- reduced skin turgor
- Age <3months with temp >=38
- non blanching rash
- bulging fontanelle
- neck stiffness
- focal neuro signs/focal seizures
- status epilepticus
8
Q
How should headlice solution be used?
A
- apply the lotion to dry hair and scalp, allow to dry naturally, remove by washing after eight hours.
- The application can then be repeated in seven days.
9
Q
What is the definition of constipation?
A
Passing less than 3 complete stools per week
10
Q
When is constipation classed as chronic?
A
When it has lasted longer than 8 weeks
11
Q
What are the common symptoms of constipation in children?
A
- reduced appetite
- abdo discomfort relieved by opening bowels
- straining
- anal pain
- overflow soiling
- rabbit droppings or large hard stool
- may lead to urinary infections
- may lead to nocturnal enuresis
12
Q
what can cause constipation in children?
A
- weaning
- changing from breast to bottle feed
- change in diet
- Inadequate food/fluid intake
- low fibre diet
- social stressors/changes
- if breastfed - mothers diet
- changes in medication - alginates in GORD, antihistamines
- family history
- physically inactive/neurodevelopmental disorder
13
Q
How should a child with constipation be examined?
A
- abdo exam
- growth and development
- neurological assessment
- check spine, buttocks, anus, legs for abnormalities
14
Q
What are the red flags for constipation?
A
- delayed meconium >48hrs - CF or Hirschprung’s disease
- within 2 weeks of life - inadequate feeding/intake
- abdo pain, distension and vomiting - surgical cause
- faltering growth
- persistent blood in stool
- thin stringy stools/abnormal appearance of anus - anal stenosis
- weakness in legs/unexplained motor signs
- motor delay
- FHx Hirschprung’s disease
- abnormal spine, lumbosacral region or gluteal muscles.
- child maltreatment
15
Q
If there are concerns re growth, or inadequate response to treatment in a child with constipation, what should be done?
A
- test: coeliacs, hypothyroidism
- refer secondary care
- Idiopathic constipation in a child <1 year - if not responding within 4 weeks of treatment - should be referred to secondary care.
- Children >1year who have been terated for 12 weeks without success - refer secondary care
- Children who have been unable to wean off laxatives after 12 months of treatment - should also be referred.
16
Q
Which toileting behaviours can help with childhood constipation?
A
- simple reward systems (star charts)
- Sitting exercises - sit and push for several minutes (30 mins after each meal), can sit with toys/bok, blowing bubbles on toielt can loosen muscles.
17
Q
What is the first line laxative in children with idiopathic constipation?
A
- macrogol
- laxxative can be mixed with other food/drink to aid compliance.
18
Q
When should a disimpaction laxative regime be considered in children with idiopathic constipation? What should parents be advised? When should they be reviewed?
A
- not opened bowels effectively for >7days
- advise: may cause increase in soiling, distension, abdo pain - but this is transient. Consider timing with school holiday, abscence needed.
- review after 1 week.
19
Q
What advice should parents be given about maintenance laxatives?
A
- once disimpaction successful (type 7 stool)- switch to maintenance dose
- do not abruptly stop laxatives
- should continue for several weeks after regular bowel movements achieved.
- dose should then be gradually reduced over months in response to stool frequency & consistency - this allows the bowels to recover.
- stopping it too early can cause recurrence.
- review progress after 6 weeks
20
Q
What diet (food and fluid) advice should be given to parents about constipation?
A
- from 7-12 monhts - babies need 600ml water/day in drinks
- from age 4-8 years old need 1200ml/day
- varies depending on how active the child is, weight, climate
- exclusively breastfed babies do not need additional water - it displaces nutritional value from breastmilk
- fruits with sorbitol - pear, prune, apple - act as natural laxatives
- High fibre foods - fruits, vegs, baked beans, wholegrain cereals, dried fruits.
21
Q
Which topical anaesthetics can be used in children prior to blood taking?
A
- EMLA (lidocaine with prilocaine)
- Ametop (tetracaine)
22
Q
Purulent unilateral nasal discharge in a young child is most likely due to…
A
foreign body
23
Q
What does the image show? It has been present since birth
A
A salmon patch
* a common capillary vascular malformation which occurs in approximately 40% of all newborns.
* present at birth and commonly found at the nape of the neck (stork bite), glabella (angel’s kiss) and eyelids.
* Lesions on the face often resolve spontaneously within the first year of life, but 50% of stork bites persist into adulthood. No treatment is needed.
24
Q
What is primary nocturnal enuresis (bedwetting)?
A
has never achieved continence at night
PLUS or MINUS daytime symptoms (wetting, frequency, urgency)
25
What is secondary nocturnal enuresis?
bedwetting occurs after the child has previously been dry at night for >6 months
26
What are possible underlying causes of secondary enuresis?
* child maltreatment
* constipation
* diabetes
* UTI
* Emotional/stress
27
What general advice should be given for nocturnal enuresis?
* not child's fault - explain volume of urine produced at night exceeds the bladder capacity. The sensation of full bladder is not waking the child.
* if age <5 - usually resolves without treatment - develop increased capacity, produce less urine at night, learn to wake up to the sensation.
* diet and fluid: adequate daily fluid intake, avoid caffeine drinks
* toilet patterns: empty bladder regularly in day and before sleep (4-7 times/day)
* easy access to toilet/potty at night
* waterproof mattress
* lifting and waking does not promote long term dryness. If they wake - take them to toilet.
* reward systems - for dry nights, also for going to toilet before bed, drinking right amounts
* ERIC support
28
What is the first line treatment for nocturnal enuresis whose bedwetting has not responded to advice on fluids, toileting or reward system?
* enuresis alarm (sensor pads, wakes child if becomes wet). Borrow from local advisor or bought from ERIC
* if age <7 - depends on maturity
* use reward system in combination
* assess response after 4/52 - if no response - stop. If signs of response - continue until 2/52 dry nights achieved
29
What is second line treatment for nocturnal enuresis if not responded to alarm treatment?
* combination of alarm and desmopressin
* desmopressin alone if don't want the alarm
* desmopressin can also be used if rapid short term improvement needed e.g. sleepovers, school trips.
* it may be needed first line in children 5-7 years who are not mature enough for an alarm.
30
When should desmopressin treatment be reviewed and stopped for nocturnal enuresis?
* assess after 4 weeks
* if signs of response - continue for 3 months
* stop after 3 months for 1 week to check if dryness has been achieved. Repeated courses can be used.
* if partial response - can increase dose, advise to take 1-2 hrs before bedtime. Continue for 6 months
* if no response - stop
31
What advice should parents be given about desmopressin?
* take at bedtime
* mimics ADH - reduces amount of urine produced at night
* in most children, ADH increases overnight to reduce urine output
* if relapses when treatment withdrawn - can repeat course - 3 month courses. Can gradually withdraw it over 8 weeks. Can try alarm instead if wish.
* restrict fluid intake to sips only 1 hour before taking desmopressin until 8 hours after (to avoid fluid voerload/hypnatraemia)
* Avoid NSAIDS - can cause water retention and hyponatraemia.
* STOP if have diarrhoea and vomiting, until back to normal.
32
What is the most common cause of vomiting in infancy?
GORD
posseting (regurgitation) is common >40% infants - does not require further Ix or treatment.
33
When does GORD develop in children? When does it resolve?
usually before 8 weeks
90% resolve by age 1.
34
When should GORD be suspected?
* distressed behaviour - excessive crying when feeding, unusual neck postures
* hoarseness/ chronic cough
* single episode of pneumonia
* feeding difficulties - refusing, gagging, choking
* vomiting/regurgitation - milky after feeds or after lying flat
* faltering growth
In children >1 year - may get heartburn, retrosternal pain, epigastric pain
Clinical diagnosis
35
What are the red flags in inflants &children who present with regurgitation and vomiting? These red flags suggest a condition other than GORD:
* frequent forceful projectile vomiting = hypertrophic pyloric stenosis (up to 2 months old)
* bile-stained (green or yellow-green) vomit = intestinal obstruction
* abdo distension, tenderness, palpable mass = intestinal obstruction / surgical emergency
* Blood in vomit (not due to cracked maternal nipple or nosebleed swallowed blood) = bleed from oesophagus/stomach/upper gut
* bulging fontanelle, altered responsiveness - lethargy/irritability = raised ICP e.g. meningitis
* rapidly increasing head circumference (more than 1cm each week), persistent morning headache, vomiting worse in the morning = raised ICP e.g hydrocephalus/brian tumour
* chronic diarhhoea = CMPA
* with atopy/high risk of atopy = CMPA
* Dysuria = UTI. Esp if fever, irritability, jaundice, haematuria, offensive urine.
* unwell and fever = infection
* onset after 6 months of age/persisting after 1 year - suggests other cause e.g. UTI
36
What are the risk factors for GORD?
* premature
* parental Hx GORD
* Obesity
* hiatus hernia
* congenital diaphragmatic hernia (repaired)
* congenital oesophageal atresia (repaired)
* neurodisability e.g. cerebral palsy
37
How is a child with GORD assessed?
* feeding history
* examine - chest, abdo, temp, head circumference.
* Weight, growth charts - look for flatering growth
38
When should possible GORD be referred to paeds?
* uncertain Dx, any red flag features
* faltering growth
* unexplained distress in children with communication difficulties
* GORD not responding to medical Rx
* unexplained IDA
* no improvement after 1 year of age
* suspected sandifer's syndrome: episodic torticollis, neck extension and rotation, back arching)
* recurrent aspiration pnuemonia
* unexplained apnoeas
* seizure-like events
* recurrent acute AOM (3 episodes in 6 months)
* dental erosion
39
what simple advice should be given for GORD?
* advise on position during feeds - 30 degrees head up
* ensure not overfed for weight - trial smaller more frequent feeds
40
What interventional managements are there for GORD?
* trial thickened formula if feeds already small and frequent (e.g. pre thickened formula Enfamil AR, or a thickener can be added to the usual formula e.g Carobel) These can be used for 6 months.
* If thickened feed not successful, STOP and trial alginate therapy e.g gaviscon. This is first line if breastfed. If symptoms improve- try stopping it every 2 weeks to see if improved and can be stopped completely.
* If alginate therapy unsuccessful after 1-2 weeks: try 4 week trial of PPI e.g omeprazole.
* if no response, or symptoms return after stopping - refer paeds/paeds gastro.
If child aged 1-2 with persistent heart burn/epigastric pain - try 4/52 PPI. If not resolved or return after stopping - refer paeds/paeds gastro.
41
What volume of feed is recommended for formula fed babies, in a 24 hour period?
a total feed volume of 150 mL/kg body weight over 24 hours [6–8 times a day] is usually recommended.
42
When does CMPA typically present?
In first 3 months of life in formula-fed infants
Rarely seen in exclusively breastfed babies (co
Affects 3% of all children
43
What is cows milk protein allergy?
* a reproducible immune-mediated allergic response to one or more proteins in cow's milk
* Milk contains casein and whey fractions made up of about 20 potentially sensitizing proteins, which a person can react to.
44
How can cow's milk allergy be classified?
According to the underlying immune mechanism and timing of symptoms.
* IgE- mediated food allergy: immediate and consistently reproducible symptoms (up to 2 hours after ingestion - usually within 20-30mins)
* Non-IgE-mediated food allergy - cell mediated mechanism - delayed reactions 2-72 hours after ingestion (the most common CMPA)
* mixed IgE and on-IgE (typically delayed)
45
What are food intolerances?
non-immune adverse reactions to foods/additives.
- non specific GI symptoms, headache, fatigue
- exact cause unknown
46
What are the symptoms and signs of CMPA?
* skin: pruritis, erythema, urticaria, atopic eczema, acute angio-oedema (lips, face,eyes, lips, tongue)
* GI: oral prutitis, nausea, vomiting, diarrhoea, colicky abdo pain, blood or mucus in stools, food refusal/aversion, constipation, perianal redness, pallor, tiredness. Faltering growth with Gi symptoms.
* Resp: LRTI: cough, wheeze, SOB. Upper: nasal itching, sneezing, rhinorrhoea, congestion, conjunctivitis.
Symptoms usually develop within a week of cows milk introduction.
Onset rare after 12 months.
47
When should a patient with suspected IgE mediated CMPA be referred to A&E?
* systemic symptoms
* suspected anaphylaxis - with or without angioedema
48
When should a patient with suspected IgE mediated CMPA be referred to specialist allergy clinic? For allergy testing (skin prick/patch, total IgE and specific IgE for CMP - RAST) to confirm diagnosis and guide management
* Allergy testing to confirm diagnosis not available in primary care
* one or more severe systemic reactions
* concurrent asthma / severe reaction to trace of another food allergen
* significant atopic eczema
* uncertain diagnosis
* failure to thrive
* multiple suspected food allergies
* persisting parental concern
* to assess if tolerance has developed in person with confirmed allergy
Whilst a/w assessment, refer to paeds dietician
49
How should suspected IgE- mediated CMPA be managed?
* If breastfeeding: mother should have cow's milk free diet, continue breastfeeding (daily maternal ca/vitD supplement)
* If formula fed or 'mixed-feeding' - actively support continued breastfeeding. If unable to convert to fully breastfeeding - trial Extensively Hydrolysed Formula (eHF)
*** refer dietician**
* **organise allergy testing to confirm diagnosis -** if confirmed then follow up arranged by clinic (to test for acquired tolerance)
* give allergy action plan
* ensure oral antihistamines available at home.
50
When should a patient with suspected non-IgE mediated CMPA be referred to allergy clinic?
* suspected severe non-IgE mediated CMA - severe delayed reaction: D&V, abdo pain, food refusal, blood/mucus in stool
* faltering growth
* severe atopic dermatitis
* concurrent asthma / severe reaction to trace of another food allergen
* uncertain diagnosis
* multiple suspected food allergies
* persisting parental concern
* to assess if tolerance has developed
Urgent referral to paeds dietician if severe non-IgE mediated CMA
51
How should patients with **severe** non-IgE mediated CMA be managed?
* if mother breastfeeding - exclude all CMP from her diet, continue breastfeeding. Ca/Vit D supplement
* If formula fed or 'mixed feeding' - revert to fully breastfeeding. If cannot revert - try Amino Acid Formula (AAF).
*** urgent referral to local paeds allergy service
* urgent dietician referral.**
52
How should severe IgE CMA be managed?
* emergency A&E admission
* then treat as per severe non-IgE mediated allergy:
* if mother breastfeeding - exclude all CMP from her diet, continue breastfeeding. Ca/Vit D supplement
* If formula fed or 'mixed feeding' - revert to fully breastfeeding. If cannot revert - try Amino Acid Formula (AAF).
* **urgent referral to local paeds allergy service
* urgent dietician referral.**
53
How should mild-moderate non-IgE mediated CMA be managed?
* usually present at onset of formula feeding.
* several mild symptoms often present: 'colic', 'reflux', food refusal, flatus, stools changes, blood/mucus in other wise well infant, persistent atopic dermatitis. If first line treatments e.g for GORD/eczema fail - more likely to be allergy related.
* If breastfed - cows milk free diet in mother and ca/vit D supplement. Refer dietician.
* If formula fed or mixed feeding - revert back to breastfeeding. if cannot revert - trial EHF.
* **Trial the elimination for 2-4 weeks.**
* If there is a clear improvement in symptoms - **home reintroduction of cows milk to confirm diagnosis of Non-IgE mediated CMA** (IMAP home reintroduction protocol available for parents)
* If there is NO return of symptoms - CMA NOT confirmed so resume normal feeding.
* If there is RETURN of symptoms - non-IgE CMA confirmed. Continue to exclude cows milk until 12 months old. **Refer paeds dietician for ongoing support.**
54
Management of mild to moderate non-IgE CMA flowchart
55
Which children should amino acid formulas be reserved for? (AAFs)
* With severe symptoms of IgE- or non-IgE-mediated allergy or a history of anaphylaxis.
* Who cannot tolerate or have ongoing symptoms with eHFs.
* Whose symptoms do not respond to maternal avoidance of cow's milk when excluively breastfeeding.
EHFs are first line otherwise.
