Paediatrics - Management Flashcards
Neonatal Jaundice - Examinations
Press skin to blanch
Yellowing of sclera
Yellowing of skin (cranio-caudal)
Neonatal Jaundice - Investigations
Split bilirubin (conjugated vs unconjugated) Plot on chart Direct Coombes test (agglutination of RBC)
Neonatal Jaundice - Treatment
Plot bilirubin chart on graph
- Phototherapy
- Exchange transfusion
Neonatal Jaundice - Complications
Kernicticus
- Unconjugated bilirubin crosses blood brain barrier
- Causes sensorineural deafness, seizures, coma, opisthotonus (arched back), poor feeding.
Immunisations - At Birth
- BCG for TB if high risk population (live)
- Hep B if mother is +ve
Immunisations - 2 months
- Rotavirus
- PCV
- Men B
- 5 in 1 (diptheria, tetanus, pertussis, polio, HIb)
Immunisations - 3 months
- Rotavirus
- 5 in 1
Immunisations - 4 months
- Men B
- PCV
- 5 in 1
Immunisations - 12 months
- Hib
- Men C
- Men B
- PCV
- MMR
Immunisations - 3y 4m
- DTaP/IPV (4 in 1)
- MMR
Immunisations - 2-7 years
- Influenza
Immunisations - 12 years (girls)
- HPV
Immunisations - 12-17 years
- Td (Diptheria and tetanus)
- IPV
Meningitis - Signs
- Brudinski’s sign - flexion of neck laid down causes flexion of hips
- Kernig’s sign - back pain on extension of the knee
Meningitis - Bloods
- FBC (high WCC)
- CRP
- U&Es
- Glucose
- Clotting
- Blood cultures
Meningitis - LP results
Bacterial (BNBN) - high neutrophils, low glucose, turbid Viral - high lymphoctes, clear, normal protein TB - lymphocytes, very high protein, low glucose
Meningitis - Causes
Neonate
- Group B Strep,
- listeria monocytogenes
- E coli
1 month - 6 years
- Nesseria meningitidis
- Strep pneumoniae
- H. influenza
> 4 years
- Nessieria meningitidis
- Strep Pnuemoniae
Meningitis - Antibiotics (for bacterial)
Prophylaxis for household contacts
ABCDE Approach
<3 months
- Cefotaxime + amoxicillin
> 3 months
- Ceftriaxone
- Rifampicin for household contacts
Meningitis - Complications
- Hearing loss
- Local vasculitis
- Local infarction -> seizures -> epilepsy
- Hydrocephalus
- Cerebral abscess
- Subdural effusion
Purpura - Description
Purple discolouration of the skin <1cm
Indicative of vasculitis and bleeding under the skin
Purpura - Causes and Presentation
Meningococcal septicaemia
- Systemically unwell child
Henoch-Schonlein Purpura
- Abdo pain, swelling in legs and ankles
- Well child
- Haematuria: do a urine dip
Immune thrombocytopenia (ITP)
- 1-3 weeks post viral infection, self resolving
- FBC - platelets <20 is concerning
Septicaemia - Examination
- High Temp
- High RR, High HR
- Low BP, late sign
- Purpuric Rash
- Evidence of end organ damage
Septicaemia - Management
ABCDE Approach
- Stabilise and transfer to PICU
Iron Deficiency Anaemia - Hb
- Neonate <14
- 1-12 months <10
- 1-13 years <11
May only be symptomatic at 6-7
Iron Deficiency Anaemia - Investigations
- FBC (low Hb, low MCV)
- Blood film (microcytic, hypochromic)
- Low ferritin (poor iron stores)
Iron Deficiency Anaemia - Management
- Dietary advice (red meat, leafy green vegetables)
- Syntron supplementation until Hb is normal, then for another 3 months to replenish stores
- Failure to respond - consider non dietary cause
Blood transfusions not necessary for diet related
Innocent Murmur - Characteristics (7 s’)
- Systolic
- Soft (<3)
- Sounds normal (HS 1+2)
- Symptom-less
- Special tests normal
- Standing/sitting
- Still (does not radiate)
Asthma - Examination
- May be NAD
- Harrison sulci (depression at diaphragm)
- Hyperinflated, barrel chest
- Wheeze/prolonged expiration
Asthma - Investigations
PEFR diary
Most likely diagnosis
- Begin treatment and monitor response
Intermediate likelihood
- Spirometry to assess for obstructive pattern
Asthma - Management
Step 1
- SABA
Step 2
- SABA and ICS (100-200mg bd)
Step 3
- Add LABA (salmetarol)
- If no effect, stop LABA, try LTRA, increase ICS to 400mg
Step 4
- ICS to 800mg
Step 5
- Oral steroid (Prednisolone)
Asthma - Review
- Inhaler technique
- Symptom control
- School attendance
- Mood
- Triggers (smoking, pets, cold, exercise)
- Growth
Bronchiolitis - Examination
- Bilateral wheeze
- Fine crackles
- Over expansion of chest
Bronchiolitis - Imaging
CXR
- Hyperinflation
- Patch collapse/consolidation
Bronchiolitis - Mild disease
- No resp distress
- Feeding >50%
- No risk factors
Send home WITH SAFETY NETTING
Bronchiolitis - Management
Admit if feeding <50%
Supportive therapy
- O2 to aim for sats >92%
- IV Fluids
- NGT feeding if required
- Assisted ventilation
May be discharged when successful trial without O2 for 12 hours
Mild Croup - Symptoms
- Occasional cough
- No resp distress
- Sats >94%
Mild Croup - Management
Reassure parents
Discharge with safety netting (stridor)
Moderate Croup - Symptoms
- Barking cough
- Intermittent stridor
- Mild resp distress
Moderate Croup - Management
Oral steroids
- Dexamethasone/prednisolone
Nebulised steroids
- Budesonide
Low threshold for admitting <12 months due to risk or airway narrowing
Severe Croup - Symptoms
- Severe resp. distress
- Fatigue
- Altered mental state
- Cyanosis
- Sats <92%
Severe Croup - Management
ABCDE Approach
- O2 therapy
- Oral steroids
- Nebulised adrenaline
- CALL ANAESTHETIST
Epiglottitis - Examination
DO NOT EXAMINE THROAT
- Drooling, excessive saliva
- high RR, HR,
Epiglottitis - Management
CONTACT ANAESTHETIST
- Intubation
- Steroids
Epiglottits - Antibiotics + Prophylaxis
Ceftrioxone for 7 days
Rifampicin for household contacts
Pneumonia - Causes
Newborn - Group B strep Infants - RSV, strep pneumoniae School age - Strep pneumoniae, mycoplasma, chlamydia
CONSIDER TB
Pneumonia - Severe, needs admitting (IV abx)
- Resp distress : increased RR, grunting, nasal flaring, accessory muscle use - O2 sats <93% - Cyanosis around mouth - Reduced oral intake
Pneumonia - Mild, treat at home (oral abx)
- No resp distress
- 02 Sats >93%
- PU and taking fluids
- Unilateral local chest signs
Pneumonia - Antibiotics
<5 years
- Amoxicillin for strep pneumoniae
> 5 years
- Erythromycin for mycoplasma
If severe/staph aureus
- Co-amoxiclav
- Cefotaxime
- Ceftriaxone
Tonsillitis - Criteria
Centor criteria (likelihood of strep A infection)
- Absence of cough
- history of fever
- White exudate
- Cervical lymphadenopathy
- Under 15 years
Tonsillitis - Management
0-1 = no abx 2-3 = throat swab then abx 4-5 = abx and rapid swab
Give penecillin/erythromycin for 10 days
NO AMOXICILLIN
Tonsillitis - Tonsillectomy indications
- Recurrent
- Quinsy (peri-tonsillar abcess)
- Obstructive sleep apnoea
Acute Otitis Media - Management
Most resolve spontaneously
- Co-amoxiclav/Amox if systemically unwell
Glue Ear - Management
- Self resolving
- Grommets if conductive hearing loss
Wheeze - Viral induced (+RF)
- <5 years
- Episodic
- Absence of atopy
RF - prematurity and maternal smoking
Wheeze - Recurrent
- > 5 years
- IgE: dust, pollens, pets
Cystic Fibrosis - Examination
- Hyperinflation of chest
- Crepitations
- Expiratory wheeze
- Clubbing
- Low growth and weight
Cystic Fibrosis - Investigations
- Guthrie test (Day 5-8)
- Sweat test (diagnostic) - Cl >60
- Genetic CFTR mutation
- CXR: hyperinflation, bronchiectasis
- Spirometry = obstructive
Cystic Fibrosis - Respiratory Management
- Physiotherapy BD to clear secretions
- Abx prophylaxis with penicillin
- Anti puedemonas nebulisers
- Bronchodilators
- Mucolytics (saline neb)
Cystic Fibrosis - Nutritional Management
- Creon to replace pancreatic enzymes
- kCal 150% intake
- ADEK vitamin supplements
Constipation - Red Flags
No meconium in first 48 hours, increased abdo distention - Hirschprung’s
Reduced growth - hypothyroid, coeliac disease
Sacral dimple - Spina biffida
Bruising - sexual abuse
Fissures - Chron’s
Constipation - Behavioral Management
- Increase oral intake (10 cups of water a day)
- Increase fibre in diet (fresh fruit and veg)
- Regular toilet time after meals
- Reassure parents
Constipation - Medication
Disimpaction - Movicol up to 4 sachets daily for 2 weeks If not working - Senna Then consider - Enema or manual evacuation (referral)
Maintenance 3 months (Movicol OD)
Gastroenteritis - Causes
Viral - faeco-oral
- Rotavirus (winter)
- Adenovirus, norovirus)
Bacterial - blood in stools
- Campylobactor
- Shigella, salmonella, e-coli
Gastroenteritis - Investigations
- Weight (to record level of dehydration)
- Fluid status (urine output, BP, HR)
If severe:
- U&Es
- Capillary blood gas (Metabolic acidosis - H+ loss from vomiting, bicarb loss from diarrhoea)
Gastroenteritis - Management
0-5% dehydration - Encourage oral fluids
5-10% - ORS, 50ml/kg over 4 hours
10% - shock
Calculate fluid deficit
dehydration (%) x weight x 10
- Give in addition to maintainance fluids
Management of shock
- 20ml/kg fluid bolus (0.9% saline)
- 10ml/kg in DKA/trauma
- Replace deficit + give maintenance
Maintenance fluids
0.45 % saline and 5% dextrose
100ml for first 10kg
50ml for 2nd 10 kg
20 for subsequent kg
Clinical Shock
- High HR, Low BP,
- Sunken eyes
- Dry mucous membranes
GORD - Feeding Management
Bottle feeding
- Do not overfeed ( <200ml/kg/day
- Nurse at 30 degrees
General
- Do not lie on back straight away (1 hour)
GORD - Medication
- Thickening feeds (bottle or paste for breast)
- Gaviscon
- PPI/domperidone (rare)
Vomiting - Classification
Non-forceful
- Possetting, small amounts with air
- Regurgitation, larger more frequent losses
Forceful
- Vomiting, ejection of contents
Vomiting - Red Flags
Bilious - obstruction
Projectile, first weeks of life - pyloric stenosis
Blood in stool - intususseption
Bulging fontanelle/seizures - raised ICP
Vomiting - Management
Oral/IV Fluids
- Capillary blood gas to assess if metabolic acidosis
- Electrolyte replacement
Medications
- Anti-emetic e.g. cyclazine
- 5HT3 antagonists - ondansetron
Diabetes - Investigations
Diagnostic
- BM >11
- Fasting BM >7.0
Urine
- Glucose +++
- Ketones +++
Diabetes - Hypo
- Sugary drink then complex carb, recheck BM in 15 mins
- IM Glucagon 0.5-1mg or 5mg/kg glucose IV
Diabetes - DKA
ABCDE approach
- Fluid resus (10ml/kg)
- Fixed rate insulin (continue long acting)
Diabetes - Education
- Insulin management
- Benefits of good control
- Support with school
- Hypo/hyper management
- Sick day rules
Diabetes - Insulin regimes
Twice daily
- Long acting and short acting mix
- Before breakfast and dinner
Basal bolus (most physiological)
- Long acting at night
- Short acting before each meal (carb counting)
Infusion Pump
- Continuous basal rate with bolus dosing
- Based on continuous BM monitoring
Failure to Thrive - Classification
- Fall of more than 2 centiles in weight
- On or below second centile
FtT - Cause
G - Genetically determined (metabolic)
I - Inadequate intake ( unskilled feeding, too little breastmilk)
V - Vomiting - GORD
F - Failure to utilise: infection, hypothyroid, Heartfailure, renal failure
E - Emotional deprivation - neglect, domestic violence
D - Digestion problems - coeliac, cystic fibrosis
FtT - Investigations
- Accurate growth measurements
- Check breastfeeding technique
- Sweat test, stool test, urine dip
- FBC, U&Es, glucose, LFTs,
FtT - Management
Treat underlying pathology
Increase feeds if due to poor intake
Involve dietician
Febrile fits - Simple
- 6 months to 6 years
- Single seizure
- <15 minutes
- No neuro defecit before or after
- Fever not due to CNS infection
Febrile Fits - Complex
- > 15 minutes duration
- focal seizure
- Multiple seizures in same fever
- status epilepticus
Febrile Fits - Advice to parents
- 1/3 risk of recurrence
- Manage fever, increase oral intake
- No increased risk of epilepsy with one convulsion
Management of fitting child
- Keep safe (not fall off, not near sharps, nothing in mouth) - Time fit - Recovery position - >5 minutes call ambulance
Status Epilepticus - Management
ABCDE
- Buccal lorazepam/rectal diazepam
- IV lorazapam/diazepam
- IV phenytoin
- Call anaesthetist
Eneuresis - Classification
Primary
- Dry periods (if any) less than 6 months
Secondary
- Wetting after period of dryness >6 months
- Pathological cause
Eneuresis - Investigations
Urine dip
- DM: Glucose
- UTI - nitrites
Psychological screening
Eneuresis - Initial Management
Behavioural
- Increase fluid intake in the day to increase bladder capacity
- Voiding before bed
- No fizzy drinks
- Reassurance re condition (very common)
Eneuresis - Further Management
- Star chat
- Behaviours such as voiding before bed - Eneuresis alarm
- Over 7 years - Desmopressin
- Reduce urine production, for special occasions e.g. holiday, sleepovers
UTI - Investigations
Urine dip
- Nitrites/WCCs
Eczema - Examination
Infants
- Behind ears, scalp and cheeks
Children
- Skin Flexures
Eczema - Management
Emollients
- Use as much as possible
- Consistent application
Sterioids
- Hydrocortisone
- sparing use: 1 fingertip to 1 palm size
Prevent scratching
- antihistamines
- mittens at night
Septic A - Examinations
- Hot and swollen joint
- fever and systemic illness
- Pain on active and passive movement
Septic A - Investigations
Bloods
- FBC
- CRP
- Culture if systemically unwell
Joint X-ray
- widening of joint space
Joint aspiration
- Purulent fluid
- Infection confirmed
Septic A - Management
- Contact orthopaedics
- Surgical joint wash our
- High dose IV flucoxacillin
Septic A - Follow Up
- 3 weeks oral Abx
- 2 year follow up with orthopaedics
- risk of cartilage and growth plate damage
Cerebral Palsy - Infantile Presentation
- Poor sucking
- Hypotonia
- Persistent Primitive reflexes
- Delayed development
Cerebral Palsy - Child Presentation
- Spasticity (contracted muscles)
- Ataxia (reduced co-ordination)
- Dyskinesia (involuntary movements)
Cerebral Palsy - Investigations
Rule out related conditions
- Epilepsy
- Learning Disability
- Vision/hearing defects
Cerebral Palsy - Management
- Physio and Speech Therapy
- Botox injections
- Adductor release surgery
- OT: wheelchairs, walking aids
Down’s Syndrome - Features
- Brachycephaly (flat occiput)
- Epicanthal folds
- Almond shaped eyes
- Tongue Protrusion
- Short Fingers
- Single palmar crease
- Sandal gap
Down’s Syndrome - Medical Problems
Spectrum!
- Learning difficulty
- AVSD heart defect
- Duodenal atresia
- Early alzheimer’s
Down’s Syndrome - Investigations
- Developmental assessment (only social normal)
- ECHO
- Hearing test
- TFTs (hypothyroid)
Down’s Syndrome - Management
- Special education assessment
- Genetic counselling and support
Monitoring
- risk of otitis media
- hypothyroid
- leukaemia
- respiratory infections
Squint - Classification
Paralytic
- Squint varies with direction of eyes
Non-paralytic
- squint constant
- may be manifest (always), or latent (when tired)
Squint - Examination
Corneal Reflection
- Shine light in eyes, ask for straight gaze
- Symmetrical reflection if no squint
Cover Test
- Cover good eye
- Watch which way squint flicks when covered
Squint - Types of non-paralytic
Convergent
- To midline
Divergent
- Outwards
- Pathological
Squint - Management (3 O’s)
Refer to ophthalmology
Optical
- refractive error corrections with glasses
Orthoptic
- patching of good eye to increase use of squint eye
Operation
- rectus muscle realignment
Squint - Complications
Untreated
- suppressed vision in affected eye to prevent diplopia
- cortical blindness
Behaviour - ABC
A - What happened before/trigger
B - What is the behaviour?
C - Consequences of behaviour?
Colic - Advice
- Feeding position
- Winding
- Carry rather than lay down flat
- Keep breast feeding
- Limit mum’s cows milk consumption
- Resolves by 3 months
Sleeping - Advice
- Clear bed time routine
Controlled crying
- Leave for 5 minutes, then 10 etc
- Firm and consistent approach
Tantrums - Advice
- Avoid situation (not overtired/ hungry)
- Ignore
- Firm and consistent approach
- Time out (1 min/year of age)
Aggressive Behaviour - Advice
- Reassure is common
- Time outs
- Star charts for good behaviour
- If persistent, refer
Star Charts
- Must concern behaviour that can be controlled
- Won for good behaviour
- Give straight away
- Cannot be lost for bad behaviour
- Decide value of stars beforehand
- Child can decorate chart
UTI - Urine Dip Results
Leukocytes +ve, Nitrites +ve = UTI
Leukocytes -ve, Nitrites +ve = Abx, urine culture
Leukocytes +ve, Nitrites -ve =Abx if clinical UTI
Leukocytes -ve, Nitrites -ve = Unlikely
UTI - < 6M, typical
Renal USS 6 weeks after
UTI - Abx
ORAL - trimethoprim, co-amoxiclav
IV - Cefuroxime, gentamicin
<3 months
- Admit
- IV abx (local guidelines)
> 3 months (upper)
- Oral abx 7-10 days
- IV abx 2-4 days
> 3 months (lower)
- Oral abx 3 days
Septic Screen
LP
Blood cultures
Urine dip/culture
CXR only if resp symptoms
UTI <6 M, atypical or recurrent
USS KUB 6 weeks after
DMSA/MCUG
UTI 6M-3Y Typical
No imaging
UTI - 6M-3Y atypical/recurrent
USs KUB
DMSA
