Paediatrics: NOTES Flashcards
What is the most common cause of bacterial pneumonia in children?
S.pneumonia
What bacteria causes atypical chest x-ray findings in paediatric pneumonia?
S.aureus
What is the definition of pneumonia?
An infection of the lower respiratory tract and lung parenchyma that leads to consolidation
What is the most common causative pathogen of pneumonia in newborns?
Group B Streptococcus (organisms from the mother’s genital tract).
Others: E.coli, Klebsiella, S.aureus
What is the difference in most common cause of pneumonia in young children vs older children?
Young Children: viruses
Older children: bacteria
What is the most common viral cause of pneumonia?
RSV
What is the typical clinical features of a child with pneumonia?
Fever, cough (typically wet and productive), rapid breathing. Also; lethargy, poor feeding
What are the characteristic chest signs of pneumonia on examination?
Bronchial breath sounds, focal coarse crackles, dullness to percussion (due to consolidation), tactile vocal fremitus
What resp rate indicates severe illness in children+infants? (different for each)
Infants: >70/min
Children: >50/min
What are bronchial breath sounds?
Harsh breath sounds that are equally loud on inspiration and expiration
What are the signs of respiratory distress?
Tachypnoea, grunting, intercostal recession, use of accessory muscles for breathing
What are the indications for a child being sent to hospital for pneumonia?
Oxygen less than 92%, recurrent apnoea, grunting, inability to maintain adequate feed/fluid
What investigations should be done for pneumonia?
Sputum sample, CXR (confirm dx but can’t differentiate between viral and bacteria), nasopharyngeal aspirate (identify viral in infants), blood culture, pleural fluid (if significant pleural effusion, sample should be taken when drained)
What is the antibiotic therapy for children under 5 with bacterial pneumonia?
Amoxicillin (S.pneumoniae; most common cause)
What is the antibiotic therapy for children over 5 with bacterial pneumonia?
Amoxicillin (mycoplasma.pneumoniae is most common in this age group)
What antibiotic course should be used in severe pneumonia?
Co-amoxiclav, cefotaxime, or IV cefurozime
What % saturation indicates need for oxygen use?
92%
What are the indications for requiring aspiration of a effusion (as a complication of pneumonia)
Large effusion, no clear underlying diagnosis, respiratory distress, persistent fever despite abx, history longer than 14 days
What is an empyema
A collection of pus in a cavity in the body, especially pleural
What is croup?
Viral laryngotracheobronchitis. It is mucosal inflammation affecting anywhere from the nose to the lower airway
What is the most common cause of croup? What are other possible causes?
Parainfluenza virsues. Other causes can be rhinovirus, RSV, influenca
What age group does croup affect?
6 months to 6 years, with peak incidence in the 2nd year of life in autumn
What was a previous common cause of croup (we now vaccinate against this)
Diptheria, which led to epiglottitis
What is the class presentation of croup?
coryza and low grade fever, followed by hoarseness (inflammation of the vocal chords), barking cough attacks (due to tracheal oedema and collapse), harsh stridor, difficulty breathing, worse at night
What is stridor?
Noisy breathing that occurs due to obstructed air flow through a narrowed airway
What should + not be examined in croup?
Do not examine the throat (due to risk of closure). Assess degree of stridor and subcostal recession, RR, HR, LOC, pulse oximetry
What is the 1st line treatment for croup?
Oral dexamethasone (0.15mg/kg). Croup responds well to steroids (can also use oral prednisolone or nebulized steroids)
what should be the management for severe upper airways obstruction?
Nebulised adrenaline with oxygen by facemask
What is the typical aetiology of epiglottitis?
Haemophilus influenza type B
What is the pathophysiology of croup?
URTI causing oedema in the larynx
What is the typical presentation of epiglottitis?
unvaccinated child presenting with a fever, sore throat, difficulty swallowing, sitting forward (tripod position) and drooling. Scared and unwell. Muffled voice (can be called hot potato voice). Minimal cough
What is a major differential dx for croup?
Epiglottitis
What is epiglottitis?
Intense swelling of the epiglottitis and surrounding tissues, associated with septicaemia. High risk of obstruction
How is Epiglottitis Diagnosed?
Direct visualisation by airway trained staff, or xray. DO NOT EXAMINE THROAT DUE TO OBSTRUCTION RISK, DO NOT DISTRESS PATIENT
What is the xray sign of epiglottitis?
Lateral: thumb sign (swelling of the epiglottis)
Anterior-posterior: steeple sign (subglottic narrowing)
What is the management of epiglottitis?
Urgent airway management (intubation/tracheostomy). Blood culture. ABx
What is the first line abx tx for epiglottitis?
IV 2nd/3rd generation cephalosporin (cefuroxime, ceftriaxone, cefotaxime)
What prophylactic abx is offered to household contacts in epiglottitis?
Rifampicin
What is a potentially life threatning complication of epiglottitis?
Epiglottic abscess
What is asthma
Chronic inflammatory airway disease leading to variable airway obstruction
What are common triggers for asthma
FHx, dust, animals, cold air, exercise, smoke, food allergens
What other conditions may someone with asthma have?
atopy; eczema, hayfever, food allergies
What is the typical presentation of asthma?
Diurnal variability, dry cough, progressively worsening SOB, signs of respiratory distress, tachypnoea, expiratory wheeze, improvements of symptoms with bronchodilators
What wheezing is heard on ausculation of a child’s chest with asthma?
Bilateral widespread polyphonic wheeze (believed to represent many airways of different sizes vibrating from abnormal narrowing)
What is a ominous sign of asthma on auscultation?
Silent chest; the airways are so tight it isn’t possible for a child to move air through the airways to create a wheeze
What is a unilateral wheeze suggestive of?
Focal lesion, inhaled foreign body, infection
What peak flow percentages are seen for moderate, severe, and life threatening asthma?
Moderate: >50%
Severe: <50%
Life-threatening: <33%
What are the signs of severe asthma?
<50% peak flow, <92% oxygen saturations, unable to complete sentences in one breath, signs of respiratory distress, tachypnoea, tachycardia
What are the signs of life threatening asthma?
<33% peak flow, <92% O2 sats, exhaustion and poor respiratory effort, hypotension, silent chest, cyanosis, altered consciousness/confusion
At what age is spirometry with reversibility testing generally done?
Over 5 years (requires a degree of cooperation from the child)
What might a CXR show for asthma?
Hyperinflation, flattened hemi-diaphragms, peribronchial cuffing, atelectasis (partial or incomplete inflation of lung)
What s/e can salbutamol cause, and how should this be managed?
Hypokalaemia; manage serum K+. Can cause tachycardia and a tremor
What are the 3 patterns of wheezing for children?
Vial episodic wheezing (only in response to viral infections), multiple trigger wheeze (in response to multiple triggers, can develop into asthma over time), asthma
What is a viral episodic wheeze?
Thought to result from small airways being more likely to narrow and obstruct due to inflammation and immune responses to viral infection. Episodic, as often triggered by common cold viruses
What is the pathophysiology of asthma?
Bronchial inflammation (oedema, execessive mucus production, infiltration with cells), bronchial hyperresponsiveness (exaggerated twitchiness to inhaled stimuli), airway narrowing (reversible airflow obstruction)
What is an example of a long acting beta2-agonist?
Salmeterol, formoterol
What should LABAs not be used without and why?
Inhaled corticosteroid (preventers; decrease airway inflammation, result in decreased symptoms)
What are examples of inhaled corticosteroids
Budesonide, beclametasone, fluticasone
What systemic side effects may be seen from use of high dose steroids in asthma?
Imapired growth, adrenal suppression, altered bone metabolism. Ensure to always monitor the child’s growth
What is ipratropium bromide, and when might it be used in the tx of asthma?
An anticholinergic dilator. Can be given to young infants when other bronchodilators ineffective, or for the tx of severe acute asthma
What is an example of a leukotriene receptor antagonist (LTRA)?
Montelukast
What is the pathway for treating an ACUTE flare up of asthma?
- Salbutamol inhalers via spacer device
- Nebulisers with salbutamol/ipratroium bromide
- Oral prednisolone
- IV hydrocortisone
- IV magnesium sulfate
- IV salbutamol
- IV aminophylline
What is the first treatment for mild intermittent asthma?
SABA: salbutamol
What is the third step of treatment of mild intermittent asthma (after SABA and ICS)
- less than 5 years: add LTRA (montelukast)
- if more than 5 years, add a LABA. If poor response, can either increase ICS. If very poor response, stop LABA, add LTRA
What is the next step of medication of asthma after addition of LTRA and increased dose of ICS?
Theophylline
When should oral steroids be given for asthma?
After all other avenues explored, such as high dose inhaled corticosteroids, LTRA, theophylline
What is the criteria for the admission of a child to hospital for asthm?
if after high dose inhaled bronchodilator therapy;
- havent response: eg, still breathless or have tachypnoea
- exhausted
- still reducing peak flow
- <92% O2 sat
What is the difference in chest recession in moderate, severe and life threatening asthma?
Moderate: some intercostal recession
Severe: accessory neck muscles
Life threatening: poor respiratory effor
What are the common causes of viral induced wheeze?
RSV or rhinovirus
What physic’s law explains why viral induced wheeze has more of an impact on young children?
Poiseuille’s law; small diameter of the airwar, proportionally larger restriction in airflow
How can you differentiate between viral induced wheeze and asthma?
- asthma is a clinical diagnosis, and rarely made before the age of 5. Viral induced wheeze is a symptom rather than a diagnosis
- VIW is preceded by a coryzal illness, and has no atopic history
What is the difference in the pathophysiology of bronchiolitis and viral induced wheeze?
The symptoms of viral induzed wheeze are due to bronchospasm, whereas in bronchiolitis there is diameter narrowing but also secretions (leading to wet lungs)
What is the main cause of bronchiolitis?
RSV
What is the pathophysiology of bronchiolitis?
Long and short: inflammation and infection in the bronchioles.
RSV invades the nasopharyngeal epithelium and spreads to the lower airways where it causes increased mucous production, desquamation, and then bronchiolar obstruction. The net effect is pulmonary hyperinflation and atelectasis
Why does bronchiolitis affects children and not adults?
In adults, when there is swelling and mucus in the airways, there is little affect on breathing due to size of the lumens. In infants, airways are small, so there is reduced air movement to and from the alveoli; airflow obstruction
what are the RF for a child developing bronchiolitis?
Prematurity, congenital heart disease, immunodeficiency, other chronic lung conditions (eg, CF)
What is the typical presentation of bronchiolitis?
Coryzal symptoms, dry wheezy cough, increasing breathlessness, fever
What is heard on auscultation of a baby with bronchiolitis?
Fine end-respiratory crackles, high pitched wheeze
What population is affected by bronchiolitis
Children under 2, generally under 1. In the winter/spring
What preventative measures can be given to preemies at risk of bronchiolitis
Monthly IM injection of palivizumab (monoclonal antibody antibody). This reduces risk of hospitalisation and need for mechanical ventilation
What investigations should be taken for bronchiolitis?
- nasopharyngeal swab: immunoflourescent antibody testing for RSV binding
- pulse oximetry
- CXR and blood gases if respiratory failure is suspected
When is hospital admission indicated for bronchiolitis?
- Sleep apnoea
- persistent oxygen sats <90%
- inadequate oral fluid intake (below 50% of normal)
- severe respiratory distress: grunting, marked chest recession, RR >70/min
What is the management of bronchiolitis: what is and isnt indicted?
- supportive management with O2 (via nasal cannula)
- nasal suction
- fluids by NG tube or IV
- no evidence for use of nebulised bronchodilators, abx, or steroids
- may need ventilation if distress: CPAP to maintain airways, and intubation and ventilation via endotracheal tube if indicated
What is type 2 respiratory failure?
Increase in CO2 and decrease in O2
What is bronchiolitis obliterans
Constrictive bronchiolitis; rare condition associated with permanent obstruction of the bronchioles due to chronic inflammation, leads to scar tissue formation
What is the common cause of bronchiolitis obliterans?
Adenovirus
What is the inheritance of cystic fibrosis?
autosomal recessive
What mutation occurs in cystic fibrosis, and on what chromosome?
Chromosome 7, mutation to CFTR gene (CF transmembrane conductance regulator). Leads to defective ion transport in exocrine glands.
What is the carrier rate of cystic fibrosis?
1 in 25
How is cystic fibrosis diagnosed in newborns?
Bloodspot screening (Guthrie card). Measures immunoreactive trypsinogen.
What causative organism causes chronic infections in children with CF?
pseudomonas aeruginosa
What are the multisystem impact of cystic fibrosis?
- Airways: reduction in airway surface liquid, impaired ciliary function, retention of mucopurulent secretions
- dysregulation of inflammation and defence against infection
- pancreatic duct: blocked by thick secretions, leads to pancreatic enzyme deficieny and malabsorption
- infertility
What is a common first sign of CF in newborn babies?
Meconium ileus (the meconium is thick and sticky, therefore gets stuck and obstructs the bowel). Presents as not passing meconium within 24 hours, abdominal distension and vomitingW
What are later symptoms of cystic fibrosis?
- chronic cough
- thick sputum production
- recurrent respiratory tract infections (pneumonia, bronchiectasis)
- steatorrhoea (due to lack of fat digesting lipase enzymes)
- abdominal pain and bloating
- failure to thrive
- older children: diabetes, delayed onset puberty
What are possible signs of cystic fibrosis on examination?
- nasal polyps
- finger clubbing due to chronic hypoxia
- crackles and wheezes on auscultation
- hyperinflation of the chest
What conditions can cause finger clubbing?
cyanotic heart disease, infective endocarditis, TB, IBD, liver cirrhosis, CF (conditions that cause chronic hypoxia, or have malabsorption)
What can the impacts of cystic fibrosis be on the pancreas?
Thick pancreatic and biliary secretions block the ducts. Leads to pancreatic exocrine insufficiency (lipase, amylase, protease). Results in maldigestion and malabsorption
What is the gold standard dx for CF?
Sweat test
What is the diagnostic concentration of chloride ions for the sweat test for CF?
60 mmol/L
Why is pseudomonas aeruginosa risky for children with CF?
Very hard to treat and worsens prognosis. Can be passed between CF patients
What is the treatment for pseudomonas aeruginosa
Tobramycin
What is a very common coloniser of the lungs in CF patients? and tx?
S.aureus. Treatment is continuous prophylactic oral abx (fluclox)
What is seen on a CXR for children with CF?
hyperinflation, increased antero-posterior diameter, bronchial dilation, cysts, linear shadows, infiltrates
What is the only therapeutic option for end stage CF lung disease?
Bilateral sequential lung transplantation
What investigations should be done in a CF exacerbation?
Pulmonary function test (10-15% decrease), sputum cultures, CXR
What treatment can help digestion in patients with CF?
CREON tablets to help digest fats in patients with pancreatic insufficiency (replaces lipase enzymes)
What treatment is given to CF patients to help make secretions easier to clear?
Nebulised DNase. This is an enzyme that can break down the DNA material in respiratory secretions, making them less viscous and easier to clear
What is whooping cause caused by?
Bordetella pertussis (gram negative bacteria)
What is the disease progression of whooping cough?
- Mild coryzal symptoms, fever, cough (1 week)
- Severe paroxysmal cough, followed by inspiratory whoop and vomiting
What causes the characteristic cough in whooping cough?
Coughing fits so severe that the child is unable to take in any air between coughs and subsequently makes a loud whooping sounds as they forcefully suck in air after the coughing finishes (paroxysmal cough). Can cough so hard, followed by fainting, vomiting, nosebleed, or even developing a pneumothorax. During coughing, mucus normally flows from nose and mouth.
Known as 100 day cough, as can persistent for a long time!
When is vaccination of whooping cough done?
- offered to pregnant women
- children; 2, 3, and 4 months. Then booster ~3 years
What is the dx of whooping cough?
nasopharyngeal nasal swab for culturing organism
What prophylactic treatment is given to close contact for whooping cough?
Macrolide prophylaxis
What is the 1st line treatment for chidlren with whooping cough?
Azithromycin. This will reduce contagiousness (infectivity period), but doesn’t alter clinical course.
Other than this, supportive management
How long should children with whooping cough avoid school?
Until cough for 21 days, or antibiotics for 5 days. Not contagious after this
What is transient tachypnoea of the newborn?
Parenchymal lung disorder characterised by pulmonary oedema resulting from delayed resorption and clearance of foetal alveolar fluid
What is the commonest risk factor for transient tachypnoea of the newborn?
C-section
What are common differentials for acute SOB in neonates?
TTN, respiratory distress syndrome, meconium aspiration, pneumothorax
What causes respiratory distress syndrome?
Lack of surfactant
What age group does respiratory distress syndrome affect?
Premature, <32 weeks
What is the commonest cause of respiratory distress in newborns?
TTN
What is the management and course of TTN?
Treatment is O2. It should resolve in a few days with resorption of lung fluid
What are signs of moderate respiratory distress?
Tachypnoea
Tachycardia
Nasal Flaring
Use of accessory respiratory muscles
Intercostal and subcostal recession
Head retraction
Inability to feed
What are the signs of severe respiratory distress
Cyanosis
Tiring because of increased work of breathing
Reduced consciousness level
Oxygen saturation <92% despite O2
What are risk factors for respiratory distress
- E-preemies with bronchopulmonary dysplasia
- Haemo-dynamically significant congenital heart disease
- disorders causing muscle weakness
- CF
- immuno deficiency
What is stridor?
Predominantly inspiratory. From extra thoracic airway obstruction in the trachea and larynx
What is wheeze?
Predominantly expiratory from intrathoracic airway narrowing
What are the symptoms of foreign body aspiration?
- sudden onset dyspnoea
- decreased breath sounds
- inspiratory stridor
- expiratory wheezing (focal)
What is the most common cause of stridor?
Laryngeal and tracheal infection, eg, croup
What is laryngomalacia?
Immature cartilage of the upper larynx collapses during inhalation
How does laryngomalacia present?
stridor; noisy breathing in an otherwise well child
How can the severity of obstruction be assessed?
Degree of stridor and chest retraction
What symptoms suggest complete obstruction of the upper airway?
Central cyanosis, drooling or reduced level of consciousness
What weeks is surfactant produced, and what cells produce it?
From 24-28 weeks. Type II pneumocytes
How does Respiratory Distress Syndrome appear on CXR?
Diffuse granular/’ground glass appearance’
How can respiratory distress syndrome be prevented?
Dexamethasone given to mothers at risk of premature delivery
What are the differences of consolidation on CXR for viral vs bacterial pneumonia?
- viral: bilateral consolidation
- bacterial: lobar consolidation
What % improvement is required following spirometry reversibility texting for a asthma diagnosis?
10% improvement
Why is magnesium sometimes used in asthma treatment??
Causes smooth muscle relaxation
What is the most common cause of bacterial tonsilitis?
Group A strep
What is the commonest cause of viral tonsilitis?
Rhinovirus, Corona Virus, Parainfluenza
What is the Centor criteria for tonsilitis?
Determines probability of bacterial infection, and will benefit from ABx
What is the fever pain score?
Calculates the likelihood of strep throat and the need for antibiotic prescription
Why does lack of surfactant production lead to RDS?
surfactant decreases the surface tension on the small airways and alveoli, which prevents the collapse of alveoli. Leads to increased surface tension, so increased pressure is required to maintain the alveolar shape. Atelectasis occurs throughout the lung, which reduces gas exchange. Repeated atelectasis results in an inflammatory response as the respiratory epithelium is damaged. Pulmonary oedema can develop.
What is the tx for laryngomalacia?
Usually resolves over time as the larynx matures and grows and is able to support itself
What anatomical changes lead to laryngomalacia?
the aryepiglottic folds are shortened, which pulls on the epiglottis and changes it shape to a characteristic “omega” shape. During inspiration, the soft tissue of the supraglottic larynx is soft and pulls across the airway and partially obscures it.
Embryologically, what do the head and neck structures develop from?
Pharyngeal (branchial) arches, pouches, and clefts
What makes up the external ear?
The auricle/pinna, and external acoustic meatus (ear canal)
What makes up the middle ear?
Tympanic cavity (air filled section in the temporal bone), lined with a mucous membrane. Auditory ossicles + eustachian tube
What makes up the inner ear?
Formed of the bony and membranous
labryinth, Vestibulocochlear organs: bony labryinth, membranous labryinth, utricle and saccule, semicircular ducts, cochlear duct
What is otitis media?
Infection of the middle ear
What is the common bacterial entry method of otitis media?
Bacteria enters from the back of the throat via the eustachian tube
What are the common causative organism of otitis media?
Viruses, streptococcus pneumoniae, h. influenzae, s.aureus
What are risk factors for otitis media?
Younger age, male sex, smoking in the household, formula feeding, craniofacial abnormalities (downs, cleft palate)
Why is otitis media less common in older children?
As children grow bigger, the angle between the Eustachian tube and the wall of the pharynx becomes more acute, so that coughing or sneezing tends to push it shut. In small children, the less acute angle facilitates infected material being transmitted through the tube to the middle ear
What is the presentation of otitis media, and what typically precedes it?
Typically preceded by a viral upper respiratory tract infection. Ear pain (otalgia) , reduced hearing the in the affected ear, fever, irritability, coryzal symptoms. If vestibular system affected; balance + vertigo
If there is discharge with suspected otitis media, what has caused this?
Rupture of the tympanic membrane
What are risk factors for Otitis media?
Younger age, male sex, smoking in the household, formula feeding, craniofacial abnormalities (downs, cleft palate)
What is seen when investigating otitis media with a otoscope?
Red and bulging tympanic membrane with the loss of a normal light reflex. May see acute perforation
What is a possible complication of recurrent otitis media?
Glue ear
What is secretory otitis media?
Middle ear effusion without the symptoms and signs of acute otitis media. Duration is often months, and there may be effusions
What are rare but serious complications of otitis media?
Mastoiditis, meningitis, brain abscess, facial nerve paralysis
What is the most common age for otitis media to occur?
6-12 months
What is the most common cause of conductive hearing loss in children?
Otitis media
How do viruses cause otitis media?
Viral URTIs are thought to disturb the normal nasopharyngeal microbiome, allowing bacteria to infect the middle ear via the Eustachian tube
What symptoms suggest a middle ear effusion?
Bulging of the tympanic membrane, otorrhoea (discharge from the ear), decreased mobility on pneumatic otoscopy
What is the general treatment of acute otitis media?
It is generally a self-limiting condition that does not require an abx prescription. Analgesia can be given to relieve otalgia. Parents advised to seek further help if symptoms worsen/dont improve after 3 days
What are the indications for abx in the treatment of otitis media in children?
<2 years old and bilateral, present for more than 4 days, immunocompromised or at high risk of complications, otitis media with perforation/discharge in the canal
What are gromments, and why would they be indicated?
Tympanostomy ventilation tubes. They are treatment for recurrent secretory otitis media
How do Grommets work?
Allow fluid from the middle ear to drain through the tympanic membrane to the ear canal
What is the first line abx treatment for otitis media?
5-7 days of amoxicillin
What is the common sequelae of otitis media?
Perforation of the tympanic membrane leads to chronic supprative otitis media. This is defined as perforation of the tympanic membrane with otorrhoea for >6 weeks. Leads to hearing loss.
How does glue ear appear on otoscopy?
Eardrum is seen as dull and retracted, often with visible fluid level
What is the potential complication of glue ear?
Usually resolves spontaneously but may cause conductive hearing loss as shown on pure tone audiometry (if >4 years) or a flat trace on tympanometry hearing testing in younger children
What is the main presentation of glue ear?
Hearing loss (can be asymptomatic other than this)
If Grommets have to be replaced twice and still no improvement, what surgery can be considered?
Tonsillo-adenelectomy
What is the pathophysiology of glue ear?
Effusion in the middle ear without an infection, that can occur after slowly resolving/recurrent acute otitis media. The fluid has a deadening effect on the vibrations of the eardrum and ossicles
How can issues with hearing present in paediatric populations?
Mishearing, difficulty communicating in a group, listening to the TV at high volumes. Lack of concentration, withdrawal. Impaired speech and language development, impaired school progress. Balance problems
What is otitis externa?
Inflammation of the external ear canal (also known as Swimmer’s ear)
What is the common presentation of otitis externa?
It commonly presents with minimal discharge, itch and pain due to acute inflammation of the skin of the external auditory meatus.
What are the most common organisms of otitis externa?
Pseudomonas spp., and s. aureus
What is the most common trigger for otitis externa?
Swimming
What are the causes of otitis externa?
Infection (bacterial or fungal), seborrhoeic dermatitis, contact dermatitis
What is the first line treatment for otitis externa?
Topical antibiotic
What are the two categories of hearing loss?
Sensorineural and conductive
What is the most common cause of sensorineural hearing loss?
Genetics
What are the antenatal and perinatal causes of sensorineural hearing loss?
Congenital infection (such as rubella), preterm, hyperbilirubinaemia
What are the postnatal causes of sensorineural hearing loss?
Meningitis/encephalitis, head injury, drugs (such as aminoglycosides, furosemide), neurodegenerative disorders
What extent of hearing loss is seen with sensorineural loss?
May be profound (>95-dB hearing loss)
What is the management of sensorineural hearing loss?
Amplification or cochlear implant if necessary
What is the causes of conductive hearing loss?
Otitis media with effusion (glue ear), Eustachian tube dysfunction, Wax (rarely)
What are possible causes of Eustachian tube dysfunction?
Down Syndrome, Cleft palate, Pierre Robin Sequence, midfacial hypoplasia
What is the extent of hearing loss with conductive loss?
Maximum of 60-dB hearing loss. This is often intermittent and resolves
What is sensorineural hearing loss?
Caused by a lesion in the cochlea or auditory nerve and is usually present at birth. It is irreversible, and can be of any severity
Abnormalities in what part of the ear can cause conductive hearing loss?
Middle ear
How is Conductive hearing loss diagnosed?
Impedance auditory tests, which measure the air pressure within the middle ear and the compliance of the tympanic membrane, determine if the middle ear is functioning normally.
What is the most common cause of bacterial tonsillitis, and what is the treatment?
Group A streptococcus (Streptococcus pyogenes). This can be effectively treated with penicillin V (phenoxymethylpenicillin).
Is tonsillitis more commonly viral or bacterial?
Viral
What is the anatomy of the tonsils, and which are is affected in tonsilitis?
In the pharynx, at the back of the throat, there is a ring of lymphoid tissue. There are six areas of lymphoid tissues, making up the adenoid, tubal tonsils, palatine tonsils and the lingual tonsil. The palatine tonsils are the ones typically infected and enlarged in tonsillitis. These are the tonsils at either side at the back of the throat.
What is the typical presentation of tonsillitis?
A typical presentation is a child with a fever, sore throat and painful swallowing. It can also present with non-specific symptoms, particularly in younger children (fever, poor oral intake, headache, vomiting)
What score of the centor criteria indicates a probability of bacterial tonsillitis?
A score of 3 or more gives a 40 – 60 % probability of bacterial tonsillitis, and it is appropriate to offer antibiotics
What is a possible serious complication of tonsillitis?
Peritonsillar abscess (quinsy)
What is the presentation of quinsy?
Sore throat, painful swallowing, fever, neck pain, referred ear pain, lymphadenopathy, trismus (unable to open mouth), hot potato voice (due to pharyngeal swelling)
How can visual impairment present in a infant or young child?
Obvious ocular malformations, not smiling responsively by 6 weeks post-term, concerns about poor visual response (including eye contact), nystagmus, squint
What can be the causes of an absent red reflex or white reflex?
Opacification of introcular structures, corneal abnormalities, or intraocular tumour (retinoblastoma)
What is nystagmus?
Repetitive, involuntary, rhythmical eye movement
What is peri-orbital cellulitis?
Infection of the peri-orbital skin
What are the most common causative organisms of periorbital cellulitis?
S.aureus or H.influenzae type B
What is the typical course of infection for peri-orbital cellulitis?
URTI followed by a painful swollen eye
What should be the response to suspected periorbital cellulitis?
Medical emergency – requires prompt treatment with a 5-7 day course of IV antibiotics
What is the presentation of peri-orbital cellulitis?
- Systemically unwell with fever, erythema, tenderness over affected area
- pain and swelling over the region
What can happen if periorbital cellulitis is left untreated?
May develop into orbital cellulitis with evolving ocular proptosis, limited ocular movement, and decreased visual acuity. Orbital cellulitis can be life and sign threatening
What investigation can differentiate periorbital cellulitis and orbital cellulitis?
CT scan
What is the difference in the pathology of peri- and orbital cellulitis?
Periorbital cellulitis: eyelid and skin infection infront of the orbital septum
Orbital cellulitis: infection around the eyeball that involves tissues behind the orbital septum (anterior boundary of the orbit)
What are the potential complications of orbital cellulitis?
Surgical emergency with major complications including loss of vision, abscess formation, venous sinus thrombosis and extension to intracranial infection with subdural empyema, and meningitis
What unusual causative organisms should be considered for neonatal presentation of periorbital/orbital cellulitis?
Gonorrhoea and Chlamydia
What are red flag symptoms regarding orbital cellulitis?
Painful or restricted eye movements, Visual impairment: reduced acuity or relative afferent pupil defect or diplopia, Proptosis, Severe headache or other features of intracranial involvement
What is strabismus?
A squint. This is a misalignment of the visual axes
What is manifest strabismus?
Misalignment of the eyes. May only happen intermittently or when tired
What is esotropia?
Squint, eyes inwards
What is exotropia?
Squint, eyes deviated outwards
What is hypertropia?
Squint, eyes drift or look upwards
What is hypotropia?
Squint, eyes drifts or looks downwards
What is latent strabismus?
The eyes are straight when both eyes are open but a deviation of the visual axis can be elicited when each eye is covered. The affected eye will move when covered; eyes stopped from working together. This can develop to manifest strabismus
What is pseudostrabismus?
Looks like there is a squint, but there is not. This may be due to facial appearance (hooded eyes, unilateral ptosis, deepset eyes, facial asymmetry)
What are the possible aetiology of strabismus?
Hereditary, refractive error (eg, hypermetropia, anisometropia) unknown cause (common), secondary to loss of vision, anatomical/mechanical effects, neurological (rare), paralysis of muscles
What is hypermetropia?
Long-sightedness
What is anisometropia?
Condition of asymmetric refraction between the two eyes (eg, different glasses prescription between eyes).
What are the common causes of anisometropia?
This is often due to one eye having a slightly different shape or size from the other causing unequal curving (astigmatism), unequal far-sightedness (hyperopia), or unequal near-sightedness (myopia)
What is Hirschberg’s test? What does it test for?
Strabismus. Shine a pen-torch at the patient from 1 meter away. When they look at it, observe the reflection of the light source on their cornea. The reflection should be central and symmetrical. Deviation from the centre will indicate a squint. Make a note of the affected eye and the direction the eye deviates
What is the cover test?
Test for strabismus. Cover one eye and ask the patient to focus on an object in from of them. Move the cover across to the opposite eye, and watch the movement of the previously covered eye. If this moves inwards, means it had drifted outwards before when covered.
What is paralytic strabismus?
the inability of the ocular muscles to move the eye because of muscular paralysis. Can be sinister due to possibility of underlying space-occupying lesion
What investigations should be done for strabismus?
General inspection, Eye movements, fundoscopy (rule out retinoblastoma, cataracts), visual acuity, Hirschberg’s test, cover test, ocular movements
What is concomitant strabismus?
The deviation of the eyes remains constant with changes in angle of gaze. Usually due to refractive error in both eyes. Glasses often corrects the squint
What is the definition of ambylopia?
Defective visual acuity which persists after correction of the refractive error and removal of any pathology
What is the pathophysiology of strabismus?
When a squint occurs in childhood, before the eyes have fully established their connections with the brain, the brain copes with this misalignment by reducing the signal from the less dominant eye. This results in one eye that is used to see (dominant eye) and one eye they ignore (lazy eye). If this is not treated, the lazy eye gets and more disconnected from the brain (amblyopia)
What is the management for strabismus?
- conservative: glasses, orthoptic exercises
- surgery: muscle resection
- botulinum toxin (inject muscle. Can also be an excellent diagnostic tool pre-operatively)
What muscle should be injected with botox in esotropia?
Medial rectus
What muscle should be injected with botox in exotropia?
Lateral rectus
What lenses are used to correct hypermetropia?
Convex lenses
Where is the image focused in hypermetropia and myopia?
- hypermetropia (long sight): image is focused behind the retina
- myopia (short sight): image focused in front of the retina
What lenses are used to correct myopia?
Concave
What are the most common causes of amblyopia?
Squint, refractive errors, and obstruction to the visual pathway (eg, cataract)
Why does strabismus cause amblyopia?
Amblyopia may occur in squint when the brain is unable to combine the markedly differing images from each eye – the vision from the squinting eye is “switched off” to avoid double vision
What is the treatment for amblyopia?
- treat the underlying condition
- early tx essential: after 7 years old, improvement is unlikely
- patching the good eye for periods in the day to force the ‘lazy’ eye to work
- wear appropriate glasses
- atropine drops in the better eye to dilate the pupil and paralyse accomodation. Makes the other eye work.
What is comitant vs incomitant strabismus?
Comitant: angle of deviation is the same in all positions of gaze, and extraocular movements are full
Incomitant: angle of deivation is different in different positions of gaze. Extraocular movements are not full (worse)
Why is incomitant strabismus a worrying sign?
May be due to restriction or paralysis of extraocular muscles.
How does palsy of the 3rd cranial nerve present
- down and out
- upper eyelid ptosis
- inability to adduct, infraduct, or supraduct
- dilated pupil with sluggish reaction
How does 6th nerve palsy present
inturned eye (esotropia)
What serious conditions can strabismus/amyblyopia suggest in a child?
Retinoblastoma, congenital cataract
What is trisomy 21?
Down’s Syndrome
What is seen in Tetraology of Fallot?
Pulmonary stenosis, Right ventricular hypertrophy, Overriding aorta, Ventricular septal defect (babies with TOF need to PROVe themselves)
What is the first line management of acute status epilepticus?
Benzodiazepine
What is the most common cause of haematemesis in children?
EPHVO (extrahepatic portal vein obstruction)
What is the typical presentation of EHPVO in children?
Child is typically well and the presenting symptom is vomiting out blood. Blood tests are often normal, and the liver is only involved in very advanced cases.
What is leukocoria?
Absent red eye reflex
What childhood infection is associated with Koplik spots?
Measles
How should a bronchodilator best be delievered to a child under 5?
Metered dose inhaler with large-volume spacer
Why are nebulisers less safe than other inhaler options?
They produce more hypoxia than bronchodilators with metered dose inhaler with spacer. They are also more expensive!
Why might genetic screening for cystic fibrosis miss some cases?
Large variety of mutated genes
What investigation can confirm pancreatic insufficiency in children with cystic fibrosis?
Decreased faecal elastase
What is the definition of diarrhoea?
change in consistency and frequency of stools with enough loss of fluid and electrolytes to cause illness
What is the most common cause of diarrhoea? What may it present with?
Infective gastroenteritis. Usually presents with fever and vomiting
What are the causes of diarrhoea (x9)
Infective gastroenteritis, non-enteric infections, food hypersensitivity reactions, NEC, drugs (eg, antibiotics), henoch-schonlein purpura, intussusception, haemolytic-uremic syndrome, pseudomembranous enterocolitis
What is the definition of chronic diarrhoea?
Diarrhoea persisting for >14 days
What initial observational assessments should be made for a child presenting with diarrhoea?
Hydration and vital signs, pallor, abdominal tenderness, signs of associated illness
What treatment is necessary for mild/moderate dehyration?
No tests necessary. Replace fluid and electrolyte losses with oral glucose-electrolyte based rehydration fluid
What investigations + treatment is recommended in severe/shock dehydration?
U&E, creatinine, FBC, blood gas, stool M,C&S/virology, tests for specific disease. Then IV fluid and electrolyte replacement.
What are the possible causes of chronic diarrhoea for children aged 0-24 months?
Malabsorption, food hypersensitivity, chronic non-specific diarrhoea (toddler diarrhoea), excessive fluid intake, protracted infectious gastroenteritis, immuno-deficiencies, hirschsprung’s disease, tumours, fabricated induced illness
What are the possible causes of chronic diarrhoea in older children?
IBD, constipation (impaction), malabsorption, IBS, chronic infections, laxative abuse, excessive fluid intake, fabricated induced illnesses
What can be the aetiology of malabsorption in chronic diarrhoea?
Post-infective gastroenteritis syndrome, lactose intolerance, cystic fibrosis, coeliac disease
What investigations should/could be done for chronic diarrhoea?
Stool sample (microscopy for bacteria or parasites, leucocytes, fat globules, fatty acid crystals, faecal occult blood), blood (U+Es, FBC, increased CRP/ESR), radiology, breath hydrogen test, GI endoscopy, sweat/genetic testing, rectal biopsy
Why is hydrogen breath test done?
Lactose malabsorption or bacterial overgrowth
What is Toddler’s diarrhoea?
Chronic non-specific diarrhoea occurring from 6 months to 5 years
What are the possible pathophysiology for chronic diarrhoea?
Reduced GI absorptive capacity (eg, coeliac disease), osmotic diarrhoea (lactase deficiency), inflammatory (eg, ulcerative colitis), secretory
How does Toddler’s diarrhoea usually present?
With colicky intestinal pain, increased flatus, abdominal distension, loose stools with undigested food (‘peas and carrots’ stools). Child is otherwise well and thriving
What are usually the results of investigations in Toddler’s diarrhoea?
Examination and investigations are normal
What is the treatment for Toddler’s diarrhoea?
Reassurance: dietary (increased fat intake, normalise fibre intake, less milk, fruit juice and sugary drink intake. Loperamide occasionally may be necessary.
What is encopresis?
Voluntary defaecation in unacceptable places, including the child’s pants in older children. No organic abnormality is present – it is a symptom of an emotional disorder
What is the investigations for encopresis?
Once organic disease or spurious diarrhoea secondary to constipation with loading are excluded, consider behavioural problems and referral to a child and adolescent psychiatrist
What are the three types of vomiting?
Acute, chronic, cyclic
What is the definition of acute vomiting vs chronic?
Acute: discrete episode of moderate to high intensity. Most common and usually associated with an acute illness.
Chronic: low-grade daily pattern, frequently with mild illness
What is the definition of cyclic vomiting?
severe, discrete episodes associated with pallor, lethargy +/- abdominal pain. The child is well in between episodes
What are the signs of pathologic vomiting in infants?
Increased volumes, projectile, green/yellow, signs of illness
What are the differentials for bilious vomiting in infants?
Intestinal malrotation with volvulus, atresia/stenosis of the duodenum, Hirschprung’s
What are the differentials for infants with non-bilious vomiting?
Hypertrophic pyloric stenosis, annular pancreas
What are the key differentials for infants >3 months and children of vomiting?
Gastroenteritis, intussusception, gastroparesis, cyclic vomiting syndrome
What are the differentials for adolescents with vomiting?
appendicitis, functional dyspepsia, pregnancy, eating disorders
What are the differentials for cyclic vomiting?
idiopathic, CNS disease, abdominal migraine, endocrine, metabolic, intermittent GI obstruction, fabricated illness
What investigations (if any) should be done for acute vomiting?
FBC, U&E, Creatinine, Stool for culture and virology, AXR, Surgical opinion if obstruction or acute abdomen possible, Exclude systemic disease
What investigations should be done for chronic vomiting?
FBC, ESR/CRP, U&Es,LFTs, Helicobacter pylori serology, urinalysis, abdominal US, small bowel enema, sinus X-rays, test feed or abdominal US for pyloric stenosis, brain imaging (CNS tumour), consider urine pregnancy testing, upper GI endoscopy
What investigations should be done for cyclic vomiting?
Serum amylase, serum lipase, blood glucose, serum ammonia
What are possible complications of vomiting?
- metabolic (potassium deficiency, alkalosis, sodium depletion) - nutritional - mechanical injuries to oesophagus and stomach (Mallory-Weiss, Boerhaave’s syndrome, tears of the short gastric arteries resulting in shock) - dental (erosions and cavities) - oesophageal stricture - anaemia
What is the definition of constipation?
Infrequent passage of stool associated with pain and difficulty or delay in defecation
What is idiopathic constipation?
If it cannot be explained by any anatomical or physiological abnormality
What is possible aetiology of idiopathic constipation?
Low fibre diet, lack of mobility and exercise, poor colonic motility
What is the possible GI related aetiology of constipation?
Hirschsprung’s disease, anal disease (infection, stenosis, ectopic, fissure, hypertonic sphincter), partial intestinal obstruction, food hypersensitivity, coeliac disease
What are the possible non-GI causes of constipation?
Hypothyroidism, hypercalcaemia, neurological disease (eg, spinal disease), chronic dehydration (eg, diabetes insipidus), drugs (eg, opiates and anticholingergics), sexual abuse
What is desensitisation of the rectum?
Patients can develop a habit of not opening their bowels when they need to and ignoring the sensation of a full rectum. Over time they loose the sensation of needing to open their bowels, and they open their bowels even less frequently. They start to retain faeces in their rectum
At what time point does constipation become chronic?
8 weeks
What is the presentation of constipation?
Straining/infrequent stools, anal pain on defecation, fresh rectal bleeding (anal fissure), abdominal pain, anorexia, involuntary soiling (impaction), flatulence, decreased growth, abdominal distension, palpable abdominal masses, anal fissure, abnormal anal tone
What symptoms can be associated with constipation in infants less than 1 year?
Poor appetite that improves with the passage of large stool, waxing and waning of abdominal pain with passage of stool, anal pain
What is Hirschsprung’s disease?
Congenital aganglionic megacolon
What can ribbon stool pattern indicate?
Anal stenosis
What can constipation along with leg weakness or motor delay indicate?
neurological or spinal cord abnormality
What are possible complications of constipation?
Anal fissure (Cycle of pain can then lead to chronic issues), haemorrhoids, rectal prolapse, megarectum, faecal impaction and soiling, volvulus, distress for child and family
What lifestyle management is required for chronic constipation?
Treat underlying cause, dietary improvements (high fibre), behavioural measurements (toilet training measures, such as 5 minute toilet time after meals)
What medical management can be taken for children with chronic constipation where lifestyle factors haven’t made improvements?
Faecal softeners (movicol/lactulose), oral stimulant laxatives (senna, sodium picosulphate)
How can faecal impaction be treated?
High dosage laxatives, such as movical
How can anal fissures be treated?
GTN cream, 2% lidocaine ointment.
What treatments can be given for bowel clean out?
Oral magnesium citrate or magnesium phosphate
What are common organic causes of acute abdominal pain in children?
GORD, peptic ulcer disease, H pylori infection, food intolerance, coeliac disease, IBD, constipation, UTI, dysmenorrhoea, pancreatitis, hepato-biliary disease
What are alarm symptoms of abdominal pain in children?
Involuntary weight loss, deceleration of linear growth, GI blood loss, significant vomiting, chronic severe diarrhoea, persistent right upper or lower quadrant pain, unexplained fever, family hx of IBD, abnormal or unexplained physical findings
What is GORD?
GORD occurs when there is an inappropriate effortless passage of gastric contents into the oesophagus. GORD exists where reflux is repeated and severe enough to cause harm.
What are vomiting red flag symptoms?
Not keeping any food down, projectile or forceful vomiting, bile stained vomit, haematemesis or melaena, abdominal distension, reduced consciousness/bulging fontanelle (meningitis/raised ICP), blood in stools, signs of infection, rash, apnoeas
What causative (non-pathological) factors is GORD associated with?
Slow gastric emptying, liquid diet, horizontal posture, low resting lower oesophageal sphincter
Why is GORD so common in babies??
In babies there is immaturity of the lower oesophageal sphincter, allowing stomach contents to easily reflux into the oesophagus. Most infants stop having reflux by 1 year old.
To what degree is GORD common/unproblematic, and when does it become cause for investigations?
It is normal for a baby to reflux, especially after large feeds. However, signs of being problematic is when it is causing distress, chronic cough, hoarse cry, reluctance to feed, pneumonia, and poor weight gain
What are some possible pathological causes of GORD?
lower oesophageal sphincter dysfunction (eg, hiatus hernia), increased gastric pressure, external gastric pressure, gastric hypersecretion, food allergy, CNS disorder (such as cerebral palsy)
What respiratory symptoms can GORD cause?
Apnoea, hoarseness, cough, stridor, lower respiratory disease (aspiration, pneumonia)
What are the key signs of GORD in a history?
Effortless regurgitation in relationship to feeds
What are the possible complications of problematic GORD?
Oesphageal stricture, Barrett’s oesophagus (premalignant intestinal metaplasia), faltering growth, anaemia, lower respiratory disease, Sandifer’s syndrome
What is Sandifer syndrome?
Rare condition causing brief episodes of abnormal movements associated with GORD in infants. Causes paroxysmal spasms of the head, neck, and back arching, but spares the limbs
What are the key features of Sandifer’s syndrome?
Torticollis (forceful contraction of the neck muscles causing twisting of the neck), dystonia (abnormal muscle contractions causing twisting movements, arching of the back or unusual positions)
What is the stepwise treatment of GORD
- Positioning: nurse infants on head-up slope of 30 degrees. Burp regularly to help milk settle
- Dietary: thickened milk feeds (infants), small frequent meals, avoid food before sleep + fatty foods
- Drugs: gastric acid reducing drugs e.g. H2 receptor antagonists (ranitidine) or omeprazole (if oesophagitis) or Gaviscon
- Surgery; if all else fails
What drugs can reduce gastric acid?
H2 receptor antagonists (ranitidine), PPIs (eg, omeprazole)
What are the contraindications for antidiarrhoeal medications in paediatrics (and why)?
Being under 5 and having D+V caused by gastroenteritis. They have a lack of benefit and cause side effects
What is the common transmission rate for viral gastroenteritis?
Faecal-oral route, often contaminated water
What is the most common cause of viral gastroenteritis in children? What are the other possible causes?
Rota Virus or norovirus (most common). Also enteric adenovirus, astrovirus, CMV in immunocopromised
What is the paediatric presentation of gastroenteritis?
Watery diarrhoea (rarely bloody), vomiting, cramping abdominal pain, fever, dehydration, electrolyte disturbance, upper respiratory tract signs common with rotavirus
What is the treatment for viral gastroenteritis?
Give supportive rehydration orally or with a nasogastric tube, or IV glucose and electrolyte solution
When should hospitalisation be considered with viral gastroenteritis?
> 10% dehydration, unable to tolerate oral fluids
What viral gastroenteritis may cause long term symptoms?
Enteric adenovirus; diarrhoea frequently goes beyond 10 days
What are the common causes of paediatric bacterial gastroenteritis?
Salmonella, Campylobacter jejuni, Shigella, Yersinia enterocolitica, E.coli, C.diff,, vibrio cholerae
What is the presentation of bacterial gastroenteritis?
Same as viral, plus malaise, dysentery (bloody and mucous diarrhoea), abdominal pain (can mimic appendicitis or IBD), tenesmus
(VIRAL SIGNS: Watery diarrhoea (rarely bloody), vomiting, cramping abdominal pain, fever, dehydration, electrolyte disturbance, upper respiratory tract signs common with rotavirus)
What are the possible complications of bacterial gastroenteritis?
Bacteraemia, secondary infections (particularly salmonella, campylobacter), Reiter’s syndrome (Shigella, campylobacter), Guillian-Barre syndrome
What is Reiter’s syndrome?
Can’t see, can’t pee, can’t climb a tree (reactive arthritis after an infection)
What investigations need to be done in bacterial gastroenteritis?
Stool +/- blood culture, stool C.diff toxin, sigmoidoscopy if IBD or colitis
Are antibiotics used in the treatment of gastroenteritis? If yes, when
Antibiotics are not indicated, as the duration of symptoms is not altered and may increase chronic carrier status, unless there is high risk of disseminated disease, presence of artificial implants, severe colitis, severe systemic illness, age <6mths, enteric fever, cholera or E.coli 0157
What is the treatment for campylobacter?
Erythromycin
What is the tx for C.Diff?
Oral vancomycin or metranidazole
What is a possible side effect of C.diff?
Pseudomembranous colitis
What is a possible side effect of E.coli? Why? What treatment should be avoided?
Haemolytic uraemic syndrome due to blood cells being destroyed. The use of antibiotics increases the risk of haemolytic uraemic syndrome, therefore antibiotics should be avoided if E. coli gastroenteritis is considered
What causes bacillus cereus infection?
Spread through inadequately cooked food. It grows well on food not immediately refrigerated after cooking. The typical food is fried rice left out at room temperature.
What is the disease course of gastroenteritis caused by bacillus cereus?
Whilst growing on food it produces a toxin called cereulide. This toxin causes abdominal cramping and vomiting within 5 hours of ingestion. When it arrives in the intestines it produces different toxins that cause a watery diarrhoea. This occurs more than 8 hours after ingestion. All of the symptoms usually resolves within 24 hours.
SHORT COURSE
What bacterial cause of gastroenteritis can particularly cause lymphadenopathy?
Yersinia enterocolitica
What specific presentation can Yersinia Enterocolitica cause? What is the key differentiation
Older children or adults can present with right sided abdominal pain due mesenteric lymphadenitis (inflammation in the intestinal lymph nodes) and fever. This can give the impression of appendicitis.
How long do children need to be isolated from school after gastroenteritis?
48 hours
What electrolyte differences will be seen in secretory diarrhoea?
Increased sodium and potassium. Commonly due to salmonella and e.coli
What are the classifications of dehydration in children?
Mild (<5%), Moderate (5-10%), Severe (10%)
What is the presentation of children with moderate dehydration?
Reduced urine output and dry mucous membranes
What are the red flag features of dehydration?
Pale mottled appearance, cool extremities, tachycardia, tachypnoea, hypotension, delayed capillary refill, change in consciousness
How is moderate dehydration managed?
Oral rehydration fluids (eg, diorlyte)
How is severe dehydration managed?
IV fluids
What is the routine fluid type used in rehydration in children?
0.9% NaCl + 5% dextrose with 10mmol KCl
What are the total daily fluid requirements in children?
1st 10kg of bodyweight at 100ml/kg/day
2nd 10kg of bodyweight at 50ml/kg/day
Remaining bodyweight at 20ml/kg/day
What are the paediatric electrolyte requirements for sodium and potassium?
Sodium: 2-4 mmol/kg/day
Potassium: 1-2 mmol/kg/day
How do you calculate percentage dehydration by weight?
Percentage dehydration = ([well weight(kg)-current weight (kg)]/well weight(kg)) x 100
How do you calculate percentage dehydration by clinical assessment?
Detectable clinical dehydration, but no red flag symptoms: 5%
Red flag symptoms: 10%
When should a fluid bolus be used before replacement fluids in dehydration?
When the child is in signs of shock
How do you calculate fluid deficit?
Fluid deficit (mL)= % dehydration x weight (kg) x 10
What is the difference in where crohn’s disease vs ulcerative colitis affects?
Crohn’s disease favours the ileum, but can occur anywhere along the intestinal tract. Ulcerative colitis affects the colon only
What are pathological changes to the bowel in Crohn’s?
Normal goblet cells, preserved glandular architecture, variable lymphocyte infiltration, granulomas present, transmural granulomatous inflammation. Skip lesions.
What are the pathological changes to the bowel in ulcerative colitis?
Depleted goblet cells, crypt abscesses, atrophic glandular architecture, heavy lymphocytic infiltrate, thickened muscularis mucosa
What is the crows NESTS nmemonic in Crohns?
N: No blood or mucus
E: Entire GI tract
S: Skip lesions on endoscopy
T: terminal ileum most affected and transmural inflammation
S: Smoking is a risk factor
Where is most affected in Crohn’s?
terminal ileum
What is the CLOSE-UP nmeumonic in Ulcerative Colitis?
C: continuous inflammation
L: limited to colon and rectum
O: only superficial mucosa affected
S: smoking is protective
E: excrete blood and mucous
U: use aminosaliclyates
P: primary sclerosing cholangitis
What are the general symptoms of Crohn’s disease?
Diarrhoea, abdominal pain, weight loss/failure to thrive, systemic symptoms (fatigue, fever, malaise, anorexia)
What are the GI signs of Crohn’s disease?
Aphthous ulcers, abdominal tenderness, perianal abscess/fistula/skin tags, anal strictures, abdominal distension, RIF mass
What are the non-GI signs of IBD?
finger clubbing, anaemia, erythema nodosum, pyoderma gangrenosum, arthritis, ankylosing spondylitis, eye issues (iritis, conjunctivitis, episcleritis), poor growth, delayed puberty, renal stones
What investigations should be done for Crohn’s?
Blood: FBC, ESR, CRP, U+E, LFT, ferritin, B12, folate. Serum serological markers (ASCA)
Stool: faecal calprotectin
Colonoscopy and biopsy (gold standard)
Radiology
What are the possible radiological presentation of Crohn’s disease?
Mucosal cobblestone appearance, ulceration, dilatation, narrowed segments, fistula, skip lesions
When are ASCA antibodies present?
Crohn’s disease
What is the treatment for Crohn’s disease?
Inducing remission: steroids (oral prednisolone or IV hydrocortisone). If insufficient, add immunosuppressant medication (azathioprine, methotrexate, infliximab).
Maintaining remission: first line; azathioprine
Surgery can treat strictures and fistulas.
What is the presentation of ulcerative colitis?
Episodic/chronic diarrhoea, crampy abdominal discomfort, bowel frequency dependent on severity, urgency/tenesmus, systemic features. Blood and mucus in excretions
What GI condition is co-morbid with primary sclerosing cholangitis?
Ulcerative colitis
What is seen on histology for UC?
crypt abscesses, mucosal inflammation only, goblet cell depletion
What bacteria should be excluded via a stool sample in IBD?
Campylobacter, C.diff
What is seen on radiology in U.C?
Mucosal ulceration, haustration loss, colonic narrowing +/- shortening
What is the treatment for U.C?
Mild/moderate: 5-ASA (mesalazine) is 1st line. Can be used to maintain remission
Severe: Prednisolone to induce remission
Maintaining remission: mesalazine, azathioprine. Infliximab in severe cases
Surgery
What is erythema nodosum?
tender, red nodules on the shins caused by inflammation of the subcutaneous fat
