Paediatrics (Quesmed) Flashcards
What is the APGAR score used to assess and what is it?
It assesses the state of a newborn baby at 1, 5 and 10 minutes
Appearance- (Colour of Child)
- 2- pink
- 1- blue peripherally and pink centrally
- 0- blue all over
Pulse
- 2>100bpm
- 1<100bpm
- 0- non detectable
Grimace- response to stimulation
- 2- crying on stimulation scores
- 1- grimace
- 0- no response
Activity
- 2 flexed limbs that resist extension
- 1 some flexion
- 0 floppy baby
Respiration
- 2 for strong cry
- 1 for weak cry
- 0 for respiratory effort
What should be done if the baby’s APGAR Score is 3 or low?
Resuscitation- 5 breaths via 250ml bag-valve mask
If there is visible meconium on inspection of the mouth, then Suction is not needed- otherwise SUCTION
Urgent Stimulation and Reassessment if APGAR 5
Which virus causes Acute Epiglottitis?
Haemophilus Influenzae B
What are the signs of Acute Epiglottitis? (7)
How does the child look like in general
What is a late stage sign?
1-6 year old children
(Fever, Painful throat for swallowing and breathing, muffled voice)
High fevers
Toxic looking child (Drooling, Struggling to Breath and sometimes even a barking cough that would make it seem like Croup but the toxic appearance makes Acute Epiglottitis more likely)
Painful sore throat that prevents child from speaking or swallowing
Cough is either MINIMAL or ABSENT- so only really sore throat- Usually NOT PRODUCTIVE even when it happens
Child sits immobile- upright with open mouth
Soft Inspiratory Stridor (late sign) and rapidly increasing respiratory difficulty over hours
How is Acute Epiglottitis managed?
Emergency
Senior ENT, Anaesthetic and Paediatric Support is needed asap
- Do NOT examine the child outside of senior support
- Securing the airway is FIRST LINE (Endotracheal Intubation may be necessary
- After the airway is secure, take Cultures and Examine the Throat
- Treat with IV Antibiotics (Cefuroxime)
What are the differences between Acute and Chronic Leukaemia?
Acute- due to impaired cell differentiation- leads to a large number of Malignant Precursor Cells in the bone marrow
Chronic- excessive proliferation of Mature Malignant Cells but cell differentiation itself is Unaffected
What is the difference between Myeloid and Lymphocytic Leukaemia?
Myeloid- Myeloid Precursor Cells- like Neutrophils
Lymphocytic- Lymphocytes like B Cells
What are the signs, diagnosis and management of Acute Myeloid Leukaemia?
Acute Myeloid- Marrow (Blood Stuff) and Infiltration (Big Stuff)
PLUS GUM
AML- AUER
Most common Acute Leukaemia in Adults
Associated with Myelodysplastic Syndromes
Signs
- Bone Marrow Failure (Anaemia, Bleeding, Bruising Infections)
- Infiltration (Hepatomegaly, Splenomegaly and Gum Hypertrophy)
Diagnosis-
- Leucocytosis usually (although can also be high or low), therefore diagnosis is better through Bone Marrow Biopsy
- AUER RODS on Biopsy
Management- Chemotherapy or Bone Marrow Transplants
Prognosis- Death occurs within 2 months without treatment, only 20% 3 year survival rate even with treatment
What are the signs, diagnosis and management of Acute Lymphocytic Leukaemia?
ALL has them ALL (i.e. Loads of Symptoms)
Acute Lymphocytic-
- Marrow (Blood Stuff)
- Infiltration (Big Stuff (minus Gum)- and NOW the BONES are hurting as well cos ALL is ALL out))
- A NERVOUS TESTICLE
- Painless LYMPHADENOPATHY
- PLUS Fever
ALL- BLAST
Most common cancer in Children- abnormal proliferation of Lymphoid Progenitor Cells
- Higher risk with Down Syndrome
Signs
- Marrow Failure (Anaemia- so Fatigue, Bleeding and Bruising because of Low Platelets, Infections due to Low WBC)
- Bone Pain (due to Organ Infiltration)
- Painless Lymphadenopathy
- Hepatosplenomegaly
- CNS Involvement (Cranial Nerve Palsies and Meningism)
- Testicular Infiltration (Painless Unilateral Testicular Enlargement)
- and FEVER
Diagnosis-
- Leucocytosis
- BLAST CELLS on Blood Film and Bone Marrow Analysis
Management-
- Chemotherapy Regimens
Prognosis- CURE RATE of 70-90% in Children
What are the signs, diagnosis and management of Chronic Myeloid Leukaemia?
Chronic Myeloid-
- Marrow (Blood Stuff)
- Infiltation (Big Stuff)
- plus B SYMPTOMS (Weight Loss, Fever, Night Sweats)
- Also GOUT (CML is HENRY VIII)
CML- -PHIL
Middle-Aged Patients
Involves the PHILADELPHIA CHROMOSOME
Signs-
- COMMON SIGNS- Massive Splenomegaly, Bleeding (due to Thrombocytopaenia) and GOUT
- WEIGHT LOSS
- Fatigue
- FEVER
- Sweating
- GOUT AS WELL
Diagnosis-
- Leucocytosis (raised myeloid cells- all the -phils and monocytes)
Management- Chemotherapy
Prognosis- Median Survival is 5-6 years
What are the signs, diagnosis and management of Chronic Lymphocytic Leukaemia?
- NOTHING
- Marrow (Blood Stuff) is rare
- Infiltration (Big Stuff)
- B Symptoms (seen in all Chronic Ones)
- Painless Lymphadenopathy- seen in Lymphocytic Leukaemias)
CLL- SMUDGE
Most Common in Male Patients over 60 years old- Proliferation of Functionally Incompetent Malignant B Cells
Signs-
- TYPICALLY ASYMPTOMATIC (unlike ALL)
- Painless Lymphadenopathy (seen in both Lymphocytic Leukaemias)
- HEPATOSPLENOMEGALY
- B Symptoms (Weight Loss, Night Sweats, Fevers)
- LESS COMMON- Marrow Failure (Anaemia, Bleeding/ Bruising, Infections)- assume Acute if these show up
Diagnosis-
- Lymphocytosis
- Blood test- SMUDGE CELLS- cells damaged as they lack Cytoskeletal Protein
Management- Chemotherapy
Prognosis- 1/3 of cases don’t progress, 1/3 progress slowly, 1/3 actively progress
What are the 3 signs of Severe Asthma Exacerbation and 7 signs of Life-threatening Asthma Exacerbation in children?
Resp, Heart, PEF
CHESS PW
Severe
- Respiratory Distress (use of Accessory Muscles, Breathlessness- so inability to complete sentences, Resp Rate>40/min (1-5yo)/ >30/min (>5yo)
- Heart Rate >140bpm (1-5 yo)/ >125bpm (>5yo)
- PEF that is 33-50% of predicted
Life-threatening
- Confusion
- Hypotension
- Exhaustion
- Silent Chest on Auscultation
- Saturations of O2<92%
- PEF<33% of Predicted
- Weak or No Respiratory Effort
What is the management of an Asthma Attack in Children?
What is needed to discharge?
When should they be admitted into hospital?
- Oxygen and Steroids (Oral Prednisolone daily for 5 days)
- !! Give NEBULISED SABA with O2 if there are life threatening features
///////// - Inhaled (if not life-threatening or worse) Salbutamol
- Nebulised (if Life-threatening) Salbutamol
- Add Nebulised Ipratropium Bromide (if Severe/ Life threatening)
//////// - If O2 saturations remain below 92%, then add Magnesium Sulphate
- If Severe or Life Threatening Asthma, add Aminophylline
Contact Senior if they are not responding to Salbutamol or Ipratropium
To DISCHARGE-
- Stable on their discharge medication for 24 hours
- Inhaler Technique is fine
- PEF>75%
Admit if-
- Life threatening Asthma Attack
- Severe Asthma Attack where they did not recover following initial treatment
- Pregnant/ Past History of Near-Fatal Asthma (ALWAYS Admit them despite whether they recover or not)
What are the signs of Otitis Media in general in Children?
What 2 things are seen in Otitis Media that is unusual?
what kind of disease does it usually follow?
Pain (Ear) and Discharge (NOT seen in OTITIS EXTERNA)
FEVER
Irritability
ANOREXIA AND VOMITING
(usually presents following a Viral Upper Resp Tract Infection)
What are the 4 types of Otitis Media and what are their signs?
Acute Otitis Media (Ear is like a Bag full of Infection)
- Deep seated pain
- HEARING LOSS
- Fever
- Rapid Onset with feeling of Aural Fullness followed by Discharge when the Tympanic Membrane Perforates with Relief of Pain
- Tympanic Membrane shows injection of Blood Vessels and then Diffuse Erythema
- In Children it is usually following a BACTERIAL INFECTION
Benign Chronic Otitis Media- (The Dry Hole)
-Dry Tympanic Membrane Perforation without signs of Chronic Infection
Chronic Secretory Otitis Media- (Glue Ear) (The ONLY one you need to call ENT Surgeons for if it is RECURRENT so that grommets can be inserted)
- Hearing loss MAINLY but also may be Persistent Pain- lasting a Couple Weeks
- Drum looks abnormal- REDUCED MOBILITY of the MEMBRANE (Retracted Tympanic Membrane)
Chronic Suppurative Otitis Media- (Pus-filled Hole)- Otorrhoea for > 6 weeks
- Persistent Purulent drainage through Perforated Tympanic Membrane
- History of Recurrent Ear Infections and Intermittent Ear Pain
- Antibiotics and Surgical Intervention to treat
What is the management of Otitis Media?
What 2 medications are given if antibiotics are not needed?
Tympanic Membrane Examination
If under 3 months- Admit them if temperature is 38C or more or if they have any Complications of Otisis Media and maybe if they are Systemically Unwell
Otherwise, treat their pain and fever with Paracetamol or Ibuprofen
Most children do NOT require Antibiotics- DELAYED Antibiotic strategy can work as well- ask them to take antibiotics if symptoms don’t go away after 4 DAYS
Give Antibiotics if:
- Systemically Unwell (but don’t need admission)
- At risk of Complications (immunocompromised)
- Perforated Tympanic Membrane
- Under 3 months old
- Under 2 years old with BILATERAL Infection
- Symptoms persist for 4 or more days
What are the 7 Complications of Otitis Media?
F(7)ML P(6)M BS
What is Petrositis lead to?
Facial Nerve Palsy- Nerve 7 LMN Disease- relieved y treatment of Otitis Media
Mastoiditis- Post Auricular Swelling- pushing Auricle Out and Forward
Labyrinthitis- Inflammation of Semicircular Canals- Vertigo, Imbalance and Nausea and Vomiting
Petrositis- Otorrhoea, Pain deep in Ear and Eye, Ipsilateral Nerve 6 Palsy- leads to GRADENIGO SYNDROME
Meningitis- Sepsis, Photophobia, Phonophobia, Headache, Vomiting
Brain Abscess- Sepsis and Cranial Nerve Signs
Sigmoid Sinus Thrombosis- Sepsis, Swinging Fever and Meningitis (so Meningitis with a Swinging Fever)
What is Acyanotic Heart Disease and what are the 3 types?
Congenital Heart Defects that do NOT cause Cyanosis- they can be caused by Foetal Alcohol Syndrome
- Ventricular Septal Defect
- Coarctation of Aorta
- Patent Ductus Arteriosus
What are the 3 ways Acyanotic Heart Disease is detected and what is the investigation to diagnose it?
- Antenatal Imaging
- Auscultation of Murmur
- Presenting in Heart Failure
Usually Diagnosed by
- Echocardiography
What is the management of Acyanotic Heart Disease?
What is the main condition that should be managed in Acyanotic Diseases?
Depends on the clinical status of the patient and the specific defect
General management-
- Managing Heart Failure if present
- Surveillance of Defect if the patient is well and not Decompensating
- Surgical Correction of the Defect is needed
Most small septal defects close spontaneously whereas the large ones require an intervention
- A Patent Ductus Arteriosus may respond to NSAID treatment, otherwise requires Surgical Intervention
- Coarctation of Aorta can be corrected with Angioplastic Interventions
What are the 6 causes of Anaemia due to Reduced RBC Production and 5 causes of Anaemia due to Increased Erythrocyte Destruction?
Reduced RBC Production
- Folic Acid Deficiency
- Iron Deficiency
- B12 Deficiency
- Red Cell Aplasia (Parvovirus B19 Infection)
- Chronic Renal Failure
- Chronic Inflammation
Increased Erythrocyte Destruction
- Sickle Cell Disease
- Thalassaemia
- Glucose 6 Phosphate Dehydrogenase Deficiency
- Hereditary Spherocytosis
- Haemolytic Disease of the Newborn
What are 4 facts about Iron Deficiency Anaemia in Babies?
It is a common cause of Anaemia in Infants and Children
Can be Caused by Reduced Iron Intake, Poor Iron Absorption and/or Chronic Blood Loss (Menstruation)
Excessive Ingestion of Cow’s Milk can cause Iron Deficiency in Infants as it is Low on Iron and it Reduces Iron Absorption
Children and Infants with Iron Deficiency may present with Pica (Urge to eat non-food things like Soil) to compensate for the missing mineral
What are the signs of Anaphylactic Shock?
ABCGS
Airway- swollen lips/ tongue, sneezing
Breathing- Wheezing, Shortness of Breath
Cardia- Tachycardia/ Hypotension/ Shock, Angioedema
Gastrointestinal- Abdominal Pain, Diarrhoea, Vomiting
Skin- Urticaria, Pruritus, Flushed Skin
How is Anaphylactic Shock managed?
Adrenaline
4
4
4
Adrenaline (1:1,000, IM)- 300mcg for 6-12 year olds
General Management (4)
- Remove Trigger
- Call for help early
- Lie patient down flat and raise their legs
- Administer Adrenaline
When Skills and Equipment are available (4)
- Manage Airways and Administer High-flow Oxygen
- IV Fluids if Shocked
- Administer Hydrocortisone (this is Not Urgent)
- Attach Patient to Monitoring
Patients should be monitored for 6-12 hours in case of a rebound episode
Newly Diagnosed patients and their carers should have the following before they are discharged (4):
- Counselling on Adrenaline Auto-Injectors
- Supply of 1 Auto-Injectors
- Written Advice
- Referral to Local Allergy Services for a Follow Up
What are the symptoms of Asthma in children?
Cough, Breathlessness, Wheeze and Chest Tightness
Widespread Wheeze heard on Auscultation of the Chest during an Acute Episode
4 Investigations
- Serial Peak Flow Readings when both symptomatic and asymptomatic- as airflow obstruction is reversible
- Those with high probability of Asthma can be started on SABA
- Spirometry should be performed where possible
- If Unclear, FeNO tests may be needed
What is the stepside management of Asthma in Children?
What should be offered to patients on ICS?
Spacer preferred in children
1) Inhaled SABA PRN and CONSIDER monitored Inhalation of Very Low to Low dosed Inhaled ICS
2) Add Very Low dosed ICS (or LTRA if <5 years old)
3) Very Low dose ICS AND (<5 years old= add LTRA, >5 years old= add LTRA or LABA) (so both this time)
—-Add-on therapies-
- No response to LABA- stop LABA and increase ICS to Low Dose
- If some benefit from LABA but not enough, increase ICS to Low Dose
- If benefit from LABA and Low Dose ICS but inadequate, Consider Trial of LTRA
High-dose Therapies-
- Increase ICS to Medium Dose
- Addition of Theophylline (or other 4th Drug)
- Refer to specialist care
If the above is still not enough, use Daily Steroid Tablet and maintain Medium-dose ICS. Consider Other treatments to minimise steroid use
OFFER INFLUENZA VACCINATION TO PATIENTS ON ICS as they are IMMUNOCOMPROMISED
What are the signs of Atrial-Septal Defect?
remember SSS
May be Asymptomatic
Ejection-Systolic Murmur on Auscultation and Fixed Split Second Heart Sound
Loudest on Left-Sternal Edge and is a Flow Murmur through the Pulmonary Valve
May present with Heart Failure
How is Atrial-Septal Defect Managed and Diagnosed?
What are its 2 complications?
Diagnosed via Echocardiogram
Management depends on the severity of the lesion. Most are managed Conservatively but some may require Surgery. they are kept under Surveillance through routine Echocardiograms
2 Complications-
- Heart Failure- Occurs in Patient’s 20s or 30s
- Paradoxical Embolism
How is ADHD managed in Children?
Conservative- Behavioural Techniques and Extra Support at School
Medical- Stimulant medication like Methylphenidate increases activity of Frontal Lobe. If Methylphenidate does not help, then switch to Atomexitine
MAIN SIDE EFFECT of Methylphenidate= Growth Suppression due to Appetite Suppression
How does Autism Spectrum Disorder present in children?
What 2 conditions are associated with ASD?
In its most severe form:
- Children with Autism are not able to understand that other people have thoughts and feelings and prefer to play alone and avoid eye contact
- Children with Autism have SPEECH AND LANGUAGE DELAY, Monotonous Tones of Voice with Limited Expression and problems using Pronouns. They also interpret speech literally and have problems with the use of Idioms
- In terms of behaviour, they have Narrow Interests, Ritualistic Behaviours that rely on heavy routine and Stereotyped Movements (Rocking, Flapping Hand Movements))
ASDs are associated with Learning Difficulties
!!! About 25% of children with ASD may also have Seizures
!!! Down Syndrome is commonly associated with ASD
What is the management of Autism Spectrum Disorders?
MDT management needed with extra support to the family
Applied Behavioural Analysis can help- encouraging positive behaviours and discouraging negative behaviours
<10% of children with ASD can live independently as adults
What is Bacterial Tracheitis and how is it managed?
What causes it?
It is a rare condition that presents similar to a VIRAL CROUP but the child would have a HIGH FEVER and RAPIDLY PROGRESSIVE AIRWAY OBSTRUCTION with COPIOUS THICK AIRWAY SECRETIONS
It is most commonly caused by Staphylococcus Aureus, typically following an Upper Respiratory Tract Infection
It is managed via IV Antibiotics in Severe Cases and May require Intubation
If Croup with Fever (>38.5C) and does not resolve following medication, THINK BACTERIAL TRACHEITIS
What is Biliary Atresia and how does it present and how is it diagnosed?
What type of Jaundice is present?
How big is the liver?
Also rule out ALPHA 1 AT DEFICIENCY
What is the main complication?
The bile ducts of an infant are fibrosed and destroyed which leads to hyperbilirubinaemia, liver failure with HEPATOMEGALY and death
It presents as prolonged obstructive conjugated jaundice (>14 days) and biliary obstruction- dark urine and white stool
Diagnosis-
- Raised CONJUGATED bilirubin and DERANGED LFTs
- Hepatic Scintigraphy highlights the liver but has poor excretion into the bowel as the bile ducts connecting the liver to the bowel have been destroyed
- Abdominal ultrasound reveals Echogenic Fibrosis
- Definitive diagnosis is confirmed with Cholangiography which fails to show normal architecture of the biliary tree
Complications
- Liver Disease and Hepatocellular Carcinoma
How is Biliary Atresia managed?
Surgery- Hepatoportoenterostomy (Kasai Procesure)
How do Brain Tumours present in children? (3)
Persistent headaches that are worse in the morning
Signs of raised ICP
Seizure in an older child with NO past history of seizure and NO fever
What are the 5 types of brain tumors in children?
Astrocytoma (most common)
- Pilocystic astrocytoma (doesnt cross midline)
- Glioblastoma multiforme (crosses midline- more aggressive)
Medullablastoma (second most common- highly aggressive)
Meningioma (tumours of arachnoid cells in meninges)
Craniopharyngioma (pituitary- can lead to homonymous hemianopia)
Ependymomas (tumours of the cells of the ventricular system- lateral etc.)
What is the diagnosis and management of Brain Tumors in Chidlren?
Diagnosis- MRI or CT
Management- Depends on tumor size and staging- Chemotherapy, Radiotherapy and Surgery
What is a Branchial Cyst and how is it managed?
Embryological remnant from development of branchial arches- painful cyst in front of sternocleidomastoid
(Posterior to sternocleidomastoid and hyperechoic= Lymphatic Malformation)
(Moves on swallowing= Thyroglossal Cyst)
Management- Conservatively or Surgery
What are the 3 advantages of breastfeeding for mothers and children?
Mothers-
- Reduction in risk of diabetes
- Reduction in risk of breast cancer
- Reduction in risk of ovarian cancer
Children-
- Protection against infection
- Protection against eczema
- Protection against Sudden Infant Death Syndrome
What is Breast Milk low in so supplementation is needed?
Vitamin D
Risk of Hepatitis B and HIV to be transferred to baby through breastfeeding?
HIV mothers should REFRAIN from breastfeeding
Hepatitis B mothers do not need to refrain, provided the child is immunised
What are the issues with breastfeeding?
Sore Nipples
Blocked Ducts
Mastitis/ Abscess- may need ORAL ANTIBIOTICS and DRAINAGE
Thrush and Breastfeeding/ DUCTAL CANDIDIASIS
Insufficient Milk
When is breastfeeding contraindicated??
3 infections
2 others
1 thing that is safe that you should remember is safe
Mother taking amiodarone
Neonatal Galactosaemia
Mother has HIV
Mother has active HSV
Mother has TB infection
(IBUPROFEN is SAFE)
What are Reflex Anoxic Seizures?
Benign causes of SEIZURES in children due to Temporary Lack of Blood Flow. This is because of the VAGUS NERVE BEING OVERACTIVE
Precipitant- sudden pain or vomiting
Child recovers quickly once oxygen is given so management is just REASSURANCE
What are Breath Holding Attacks?
Young children cry so much, they hold their breath and faint- may turn blue and jerk limbs
Management- Just reassurance, they’ll be fine
What is Bronchiolitis?
Chest infection- winter epidemic at 1-12 month olds
Caused by Respiratory Syncytial Virus
What are the signs of Bronchiolitis?
Is the cough productive?
What 2 red flags warrant O2 asap?
What are the crackles and breathing like?
1-12 month olds
Cough, Laboured Breathing, Wheeze, Tachypnoea, Nasal Flaring, FEVER (High-grade in Pneumonia)
(Breathing Hard and Fast- so hard you’re using Big Nostrils)
NASAL FLARING or RR>70 is a RED FLAG- may need O2
NON PRODUCTIVE COUGH (productive in Pneumonia)
May also be FINE CRACKLES (Focal in Pneumonia)
What is the management of Bronchiolitis?
What 2 things make patients at risk of Bronchiolitis?
ORaS
Pavilizumab Prophylaxis if at risk- CONGENITAL HEART DEFECTS/ CYSTIC FIBROSIS
Oxygen Therapy
RIBAVIRIN
Supportive Care
What metabolic condition is Bronchiolitis associated with?
Hyponatraemia
What is the rare complication of Bronchiolitis?
Which pathogen causes it?
- Bronchiolitis Obliterans
Narrowing of airways due to Chronic Inflammation which causes Scar Tissue
Caused by ADENOVIRUS, not RSV, OR transplants
How is Bronchiolitis Obliterans diagnosed and managed?
CXRs may often appear normal
so CT/ Lung Biopsy needed
- FEV1 is decreased (16-21%)
Management-
- No cure
- Immunosuppressants like Cyclosporin, Mycophenolate Mofetil, Tacrolimus and Prednisone can treat it POST-TRANSPLANT
What is Caput Succedaneum?
Cephalohaematoma is the main differential if it doe NOT cross the suture line
Pressure of top of Infant’s skull against the Dilating Cervix during Labour
Presents as Subcutaneous Serosanguineous Fluid Collection superficial to cranium but below the skin. It CROSSES SUTURE LINES (like a blister when your foot has been rubbing against the show lol)
Management- resolves on its own
Which antibiotics are not safe in Breastfeeding?
Ciprofloxacin (causes Joint Problems)
Nitrofurantoin (G6PD Deficiency)
Teicoplanin
Clindamycin (antibiotic associated colitis)
Co-trimoxazole
Most antibiotics cause loose motions in the baby or tummy aches- they don’t need treatment
What antibiotics are not safe in Pregnancy?
Ciprofloxacin (Joint Problems)
Nitrofurantoin (G6PD Deficiency)
Teicoplanin
Clindamycin (Antibiotic-associated Colitis)
Co-trimoxazole
Most antibiotics cause loose motion or tummy aches in the baby- they don’t need treatment for this
What analgesia are not safe in Pregnancy?
Aspirin (causes Reye’s Syndrome)
Codeine
Dihydrocodeine is the preferred Opiate Analgesic for stronger painkillers but observe baby for drowsiness
How long should breastfeeding be done for?
1st hour to 6 months of life- no other foods
What is Cerebral Palsy?
Permanent movement issues due to CNS damage
It does NOT get worse though (non-progressive)
What are the causes of Cerebral Palsy?
2,5
Before Birth-
- Hypoxic Ischaemic Encephalopathy (suspect if PROLONGED DELIVERY)
- Infection
After Birth-
- Meningitis
- Haemorrhage
- Trauma
- Medication Toxicity
- Kernicterus (high amount of bilirubin enters baby’s brain) (wouldn’t be due to breastmilk jaundice though)
Idiopathic
What are the classifications of Cerebral Palsy?
Spastic (90% of patients with CP have spastic features)-
- damage to PYRAMIDAL PATHWAYS
- Increased TONE and REFLEXES, Clasp Knife, Flexed hip and elbow
- may be MONOPLEGIC, DIPLEGIC, HEMIPLEGIC
- Scissor Walking- due to Periventricular Lesion
Dyskinetic/ Athetoid (this is usually due to KERNICTERUS)-
- Damage to Basal Ganglia
- Choreiform Movements (involuntary movements)
- Signs of Parkinsonism
Ataxic-
- Damage to CEREBELLAR PATHWAYS
- Uncoordinated movements (lack of balance and coordination)
- Signs of cerebellar lesions
What is the management of Cerebral Palsy?
Specialist and MDT input to deal with complications-
- Physiotherapy, Occupational therapy, Speech and Language therapy and Dietician input due to swallowing difficulties
Medical management-
- BACLOFEN for the spasms
- Botox Injections for Contractures
Surgical Management-
- Orthopaedic Surgery for MSK deformities
- General Surgery for PEG feeding tube
What is the presentation and management of Chickenpox?
What kind of spots are they? and where do they first appear and then spread to?
How do the spots transform?
due to HUMAN HERPES VIRUS 3 (Varicella)
Can take up to 3 weeks for symptoms to appear after exposure
(so remember the number THREE)
Raised, Red Itchy Spots on the face or chest that spread to the rest of the body
They then become small Fluid-filled Blisters that then Crust up
Conservative management as it is Self-Limiting
- Simple measures are to keep fingernails short and wear long clothing to avoid scratching
What are the Verbal Scores for the Children GCS?
(other sections are the same as normal, but M6 is Spontaneous Movement for under 5 year olds and Obeys Command for over 5 years old)
Over 5-
- V5= Orientated to Place or Person
- V4= Confused
- V3= Inappropriate Words
- V2= Incomprehensible Sounds
- V1= No Response
Under 5-
- V5= Alert, Babbles, Coos, or Sentences to Normal Abilities
- V4= Less than normal ability
- V3= Cries to Pain
- V2= Moans to Pain
- V1= No Response
What is Coarctation of the Aorta and How does it Present?
What condition is it associated with?
What 2 H’s are seen?
It is when the Aorta Narrows (usually location is just before DUCTUS ARTERIOSUS)
It is associated with TURNER’s Syndrome
May be asymptomatic OR
- Systolic Murmur- heard LOUDEST BETWEEN SHOULDER BLADES
- Radio-femoral and maybe Radio-radial Delay
- Hypertension
- Heart Failure
- If Coarctation is severe, the infant has Shock once the Ductus Arteriosus closes
What is the management of Coarctation of the Aorta?
- Monitored via Echocardiography and Antihypertensives to control the BP
- Angioplasty and Stent Insertion may be needed as Intervention
- If they have Shock, give them Prostaglandins to keep the Ductus Arteriosus open
What are the main complications of Coarctation of the Aorta and Atrial-Septal Defects?
Coarctation of Aorta= Cerebral Strokes due to Cerebral Aneurysms and Hypertension
Atrial-Septal Defects= Ischaemic Stroke (due to Paradoxical Embolism)
What is Coeliac Disease? (Paediatrics)
T-cell mediated autoimmune inflammation of the small bowel
The sensitivity to Prolamin results in VILLOUS ATROPHY and MALABSORPTION
What is Coeliac Disease associated with and when does it present?
And what are the possible differentials?
HLA-DQ2 gene and other autoimmune conditions T1DM
It presents at INFANCY and at 50-60 YEARS OLD
(Crohn’s presents at Adolescence)
(Cystic Fibrosis has high Trypsinogen, also look for Resp Infections and Meconium Ileus)
(Cow’s Milk Allergy= Rash over Face, Reflux, Colicky pain)
What are the symptoms of Coeliac Disease?
What is seen if it is severe?
(Spots, Bruises, Short, Butt)
Do NOT forget Anaemia and Steatorrhoea!!
Abdominal pain
Abdominal Distension
Nausea and Vomiting
Diarrhoea
Steatorrhoea (if severe)
(Imagine tummy is full on diarrhoea and vomiting and so full that its ballooning so distension)
Systemic Symptoms-
- Fatigue and Weight Loss (due to Low Absorption)
- Pallor (ANAEMIA)
- Short Stature and Wasted Buttocks (if severe) (MALNUTRITION)
- VITAMIN DEFICIENCY (like Bruising due to Vitamin K Deficiency)
Dermatological (if severe)= Dermatitis Herpetiformis (itchy lesions over bum and extensors (arms, legs, trunk))
What investigations should be ordered if Coeliac Disease is suspected?
Do the Antibodies before Biopsy
Then Bloods
A.B.B.
ANTIBIOTICS=
- Anti-TTG IgA is First Line (check their IgA level as well as they may be IgA Deficient- if so then measure Anti-TTG IgG instead)
- If this doesn’t work as well (Weakly Positive) then Anti-Endomyseal Antibody as well
NICE do not recommend HLA-DQ2 if non specialist or Anti-Gliadin
OTHER TESTS=
GOLD STANDARD- OGD and SMALL BOWEL BIOPSY= refer if Positive serological test or Negative with High Suspicion
Stool Culture- Exclude Infection
Histology shows= VILLOUS ATROPHY, CRYPT HYPERPLASIA and INTRAEPIPHELIAL LYMPHOCYTES (cos lymphocytes are breaking villi down and making the crypts bigger)
BLOODS=
= FBC- Microcytic Anaemia cos of Iron Deficiency, Normocytic Anaemia cos of Chronic Inflammation or Macrocytic Anaemia due to Folate Deficiency
= U&Es and Bone Profile (Vitamin D absorption may be affected)
= LFTs (Albumin may be low due to Malabsorption)
= Iron, B12, Folate (Anaemia stuff)
What is the management of Coeliac Disease?
Life-long Gluten Free Diet and monitor them to make sure they are following it
What are the complications of Coeliac Disease?
4
Anaemia (due to B12, Iron or Folate Deficiency)
Hyposplenism (and therefore susceptibility to organisms)- AUTOIMMUNE HYPOSPLENISM
OSTEOPOROSIS (so DEXA scan)
Enteropathy-associated T Cell Lymphoma (rare type of Non-Hodgkin’s)- because of the Intraepithelial T Lymphocytes
What is Conduct Disorder and what are the signs and management?
What is the main differential?
Physical aggression, Destructive Behaviour and Stealing in under 18’s
Prognosis is generally poor-
- 50%= Antisocial Personality Disorder
- 50%= Substance Misuse
- 40%= Become Young offenders
Oppositional Defiant Disorder= Anger and Temper, but no Aggression, No Destruction and No Stealing
What is Congenital Adrenal Hyperplasia and what are the signs?
1) Sexual Features
2) Loss of Fluid
Genetic Defect in one of the enzymes involved in the synthesis of hormones in the adrenal cortex
Signs
- Ambiguous Genitalia
- Virilisation (female has male features)
- HYPOTENSION due to DEHYDRATION and VOMITING
- Precocious (Early) Puberty (so these ambiguous changes are more evident)
What are the 2 types of Congenital Adrenal Hyperplasia?
What is lost more than it should be and what is gained more than it should be?
What is low in Salt Wasting but normal in Virilising?
What does the Hyperkalaemia lead to?
Salt Wasting CAH
- 21-hydroxylase deficiency
- Leads to Cortisol and Aldosterone deficiency
- This leads to High levels of ACTH Production- this leads to Adrenal Hyperplasia
- This leads to Androgen Steroids production- Testosterone and DHEA
- Low Aldosterone may not lead to symptoms at birth as baby has Mineralocortoid supply from placenta
- Few weeks after birth though- Large amounts of Sodium are lost and Potassium is retained. Leads to Blood Volume Loss and HYPOTENSION. the high amounts of Potassium leads to Metabolic Acidosis and Vomiting and therefore DEHYDRATION
Virilising CAH
- Residual 21-hydroxylase activity may be retained so Aldosterone levels are normal
- Exposure to high levels of Testosterone leads to female fetuses being VIRILISED- leading to Ambiguous Genitalia (same with BOTH TYPES of CAH btw)
- In males, no changes like this but can cause Early puberty
What is the management of Congenital Adrenal Hyperplasia?
Intravenous Saline (if Salt-Wasting) and give Hydrocortisone to replace low Glucocorticoids and Mineralocorticoids
Lifelong Treatment with deficient hormones (Glucocorticoids and Mineralocorticoids)
Virilised Females- need Surgery
What is Congenital Heart Block and what are the signs?
Which maternal condition is it associated with?
No coordination between Atria and Ventricles- so P waves are dissociated from QRS complexes
Causes- most commonly associated with maternal SYSTEMIC LUPUS ERYTHEMATOSUS. Linked to Maternal Anti-Ro and Anti-La antibodies
Presentation- May range from being Asymptomatic to Severe Heart Failure.
- Neonates may be Bradycardic or Circulatory Shock
MOST CHILDREN- no symptoms for first few years of life and then Syncope and Pre-Syncope
How is Congenital Heart Block managed?
Pacemaker if Symptomatic
How is Hypothyroidism managed in Paediatrics (same symptoms as adults)? And what are the TWO side effects of this? B,H,
What is the most common cause of HYPOTHYROIDISM?
LEVOTHYROXINE is FIRST LINE
Side effects- Osteoporosis and Cardiac Arrhythmias (Weak Bones and Buzzed Heart)
AUTOIMMUNE THYROIDITIS
What are the signs of Congenital Hypothyroidism?
Hypotonia (FLOPPY)
Macroglossia (Large Tongue)
UMBILICAL HERNIA
Reduced Feeding
Constipation
Remember Floppy and Umbilical Hernia
How is Constipation in children defined and what are the common causes?
Child defecates less than 3 times a week or has difficulty passing stool- may also be overflow diarrhoea
- Most common Cause is diet
- LOW FIBRE diet
- Dislike of using toilet
- Pain on passing stool
- not recognising sensation of needing to pass stool
How is Constipation in children defined and what are the causes?
Child defecates less than 3 times a week or has difficulty passing stool- may also be overflow diarrhoea
- Most common Cause is diet
- LOW FIBRE diet
- Dislike of using toilet
- Pain on passing stool
- Not recognising sensation of needing to pass stool
How is Constipation managed and diagnosed?
Diagnosis-
- History and palpation of hardened faeces on abdominal examination
Management-
- Movicol Disimpaction Regimen
- Then Maintenance Movicol, alongside a High Fibre Diet and advice about encouraging Good Toileting Habits
What is Hirchsprung’s Disease and what are the signs?
The distal colon of the baby is not innervated properly so the AGANGLIONIC colon is shrunken and not able to distend properly- this causes a back pressure of stool trapped in the proximal colon
AT BIRTH maybe–
- Delay in passing MECONIUM (>2 days and no first poop)
- Distended abdomen
- Forceful evacuation of meconium after Digital Rectal Examination
POOR RESPONSE to MOVICOL REGIMENS may occur and POOR WEIGHT GAIN
How is Hirchsprung’s diagnosed and managed?
Diagnosis- Rectal Suction Biopsy
Management- Removal of Aganglionic Colon and Healthy Bowel is pulled through
What is the difference in DRE for Constipation and Hirchsprungs?
Constipation- Hard stools
Hirchsprungs- Explosive release of liquid faecal matter
What is Croup and what are the causative organisms?
AKA Laryngotracheobronchitis
Caused by:
- Parainfluenza- MAIN cause
- ADENOVIRUS, INFLUENZA, RSV
Usually 6 months to 6 years
What are the signs and management of Croup?
What should be given if there is concerns about the airway?
What should be done if there is an audible stridor AT REST or if the child is UNDER 6 months?
Barking, seal cough (apparently leads to Productive)
Stridor (ADMIT IF THERE IS A STRIDOR AT REST !!!!!!!!!!!!!!!!!!!!)
FEVER
Coryza
Management
- MILD- Dexamethasone
- SEVERE- Oxygen and Nebulised Budesonide. (Supplemental Oxygen is MAINSTAY for Bronchiolitis)
If significant concerns about airway- Nebulised Adrenaline
Make sure they do NOT CRY as this can worsen the Croup
What is Cyanotic Heart Disease and what are 3 examples?
Congenital Heart Disease that results in a Right to Left Shunt
1) Transposition of the great arteries (Pulmonary Artery and Aorta have swapped their insertion)
2) Pulmonary and Tricuspid Atresia (so the right side of the heart is a Dead end)
3) Tetraology of Fallot (Pulmonary Stenosis and Large Ventricular Septal Defect shunting at the Ventricular Level)- also OVERRIDING AORTA and RIGHT VENTRICULAR HYPERTROPHY
How are Cyanotic Heart Diseases diagnosed and managed?
Usually antenatally during scans
- Presentation occurs within first few weeks of life with babies being VISIBLY CYANOTIC
- ECHOCARDIOGRAPHY can help characterise the anatomy and the heart function
Management-
- Surgical Correction or Heart transplant
- Prostaglandin E can be given to delay Ductus Arteriosus closing
- AVOID Ibuprofen as it causes the Ductus Arteriosus to close faster
What are saturations like for Transposition of the Great Arteries?
Babies can maintain Normal Saturations if Large VSD (so NO MURMUR) and Patent Ductus Arteriosus (whose murmurs are not heard until pressure builds up) to compensate the Transposition of the Great Arteries
So when the ductus does close, saturations can fall due to Right-to-Left Shunting. Giving Oxygen does not make a difference as Pulmonary Circulation is already saturated well
What is Cystic Fibrosis and what are the causes of Cystic Fibrosis?
Autosomal Recessive Disorder- causes LUNG INFECTIONS and LIMITS ability to breathe
Cause- Mutations affecting CFTR protein (most common one affects the DELTA Protein)
What is the pathophysiology of Cystic Fibrosis?
Respiratory System-
- Thick Mucus in lungs
- !!!!!!!!!!!!SINUSITIS and NASAL POLYPS is also very common. Patients usually have Pseudonomas colonisation by 20 years old
Digestive System-
- Reduced Pancreatic Enzyme Secretion inhibits the absorption of Fat which causes Steatorrhoea
- This leads to the deficiency of Fat-Soluble Enzymes (Vitamin ADEK)
- Poor Absorption of fat leads to Poor Weight Gain
- Damage to Pancreas puts patients at risk of Diabetes
Reproductive System-
- Seminiferous Tubes get blocked- most men with Cystic Fibrosis are unable to conceive naturally
- Fertility is also lower in women due to Thicker Cervical Membrane
How does Cystic Fibrosis present in Neonates, Infants, Toddlers and Older Children?
Remember DELAYED PUBERTY
Neonates-
- Meconium Ileus due to the Thick Mucus making the Meconium Thicker
- Treated with GASTROGRAFFIN ENEMA
Infants- (like NaCli with breathing issues)
- Salty Sweat
- Faltering Growth
- Recurrent Chest Infections
Toddlers- (NaCli with digestive issues)
- Faltering Growth
- Recurrent Chest Infections
- MALABSORPTION
Older Children-
- Faltering Growth
- Recurrent Chest Infections
- MALABSORPTION
- DELAYED onset Puberty
How is Cystic Fibrosis diagnosed and managed?
Diagnosis-
- Sweat Test (Definitive and better)- High Chloride
- Heel Prick Test- High Trypsinogen
Management- (Clear the Chest, give them ABD, support the Pancreas and VACCINATE)
- MDT management
- Chest Physiotherapy to clear Mucus and prevent Pneumonia
- Medical management- Antibiotics, Bronchodilators and Secretion-thinners (Dornase Alfa)
- Pancreatic Enzyme Replacement (CREON) and Vitamin supplementation (ADEK)
- INFLUENZA and PNEUMOCOCCAL Vaccinations
- LAST RESORT= Lung Transplant
What does Zinc Deficiency cause?
ACRODERMATITIS ENTEROPATHICA
- Rash
- Hairloss
- Diarrhoea
What does Vitamin B3 deficiency cause?
Pellagra (the 3 D’s)
- Dermatitis
- Diarrhoea
- Dementia
What is Delayed Puberty and what are the causes?
3 low
3 high
No puberty by 14 in boys and 13 in girls
Most common cause is Constitutional Delay (confirmed with WRIST XRAY- Epiphyseal Plates are late to fuse)
Rarer Causes
- Low gonadotrophin- Hypothyroidism, Systemic Disease (Cystic Fibrosis or Coeliac Disease), Pituitary Disorders
- High gonadotrophin- Chromosomal Disorders (Klinefelters and Turners), Congenital Adrenal Hyperplasia, Hypogonadism (like after Chemotherapy)
What are the 9 signs of Depression (5 needed for diagnosis (at least 2 weeks or longer))?
Sad most of the day
Change in sleep
Change in physical activity
Change in Weight and Appetite
Fatigue
Concentration affected
Anhedonia
Guilt/ Worthlessness
Suicidality
What are the 6 main differentials for Depression?
1) Neurological (Parkinson’s, Dementia, Multiple Sclerosis)
2) Endocrine Disorders (Thyroid/ Hypo or Hyperadrenalism)
3) Drugs (Steroids, Isoretinoin, Alcohol, Beta blockers, Benzodiazepines, Methyldopa)
4) Chronic Conditions (Diabetes, Obstructive Sleep Apnoea, Long-standing infections like Mononucleosis)
5) Neoplasms and Cancers
6) Other Psychiatric Conditions- Bipolar Disorder, Schizophrenia, Dementia, Seasonal Affective Disorder)
What is the management of Depression generally?
How long should antidepressants be carried on for?
1st Line- Group CBT/ Low Intensity Psychological Interventions
2nd Line- Pharmacological Therapy (SSRIs) / CBT
Antidepressants should be continued for at least 6 MONTHS after Remission, gradually reducing over a 4 WEEK PERIOD
IF Actively Suicidal= then URGENT REFERRAL, so SCREEN for this asap
If SEVERE= Start with Pharmacological and add on Psychological Therapy
- ECT for Life-threatening (but can cause memory loss and risk of damage to teeth as it is an Induced Seizure)
What is the management of Depression in Children?
Mild- watchful waiting and healthy habits
Moderate to severe- refer to CAMHS
- First Line- Psychological Therapy
- FLUOXETINE- first line in children
- Admission if risk of self harm and suicide
What is Developmental Dysplasia of the Hip? What are the risk factors?
Ball of the Femur and Acetabulum of the Pelvis do not articulate properly
5 Fs for Risk Factors
- Firstborn
- Female
- Fanny First (Breech Presentation)
- Fluid (Oligohydramnios)
- Family History
What is the screening, diagnosis and management of Developmental Dysplasia of the Hip?
Screening- 2 Manouevres
- Barlow (To find out if there is Posterior Dislocation)
- Ortalani (Relocation of the Dislocated hip on Abduction of Hip)
Diagnosis- Hip Ultrasound
Management-
- Mild= sorts itself out in first few months (if no noticeable symptoms)
- Severe= PAVLIK Harness or Surgery
GALLEAZI TEST= if there is shortening, this helps figure out if it is the Tibia or the Femur
What is the most common cause of Hip Pain in Children? and how is it treated?
Transient Synovitis
- Treated with NSAIDs and Bed Rest
What are the 9 differentials for VOMITING in CHILDREN?
When should Whooping Cough be suspected?
1= normal
4= tummy
4- not tummy
Posseting- Small amounts of white fluid is common after feeds in infants (this is normal)
Testicular Torsion- If testicular pain
Brain Tumour- If neurological signs
Infection- More FORCEFUL vomits may be signs of infection, so ENT EXAMINATION is recommended for all vomiting children
Whooping Cough- Vomiting after long periods of Coughing (especially if UNVACCINATED)- Bordetella Pertussis
GORD- Large volume regurgitation can be GORD- manage with Positioning and Burping advice
Pyloric Stenosis- PROJECTILE vomiting in Young Boys whilst Palpable OLIVE Mass is felt at 6-8 weeks, after feeding- Surgery needed
GI Obstruction- If BILIOUS vomiting- like Malrotation
Appendicitis- Vomiting with Appendicitis type pain
What are the causes of vomiting in Older Children?
If more acute- Diabetic Ketoacidosis
If more chronic- Migraine/ Chronic Vomiting
Early morning headaches- RAISED ICP
In teenagers- consider pregnancy (CHECK PREGNANCY FIRST) , drugs and alcohol
What kind of infection does Mesenteric Adenitis follow usually?
An Upper Respiratory Tract Infection
What is Duodenal Atresia and what 3 conditions are associated with it?
Duodenum has a blind end and is NOT patent as a result. So it obstructs the Duodenum
- Down’s Syndrome
- Other Intestinal Atresias
- VACTERL association (Vertebral defects, Anal atresias, Cardiac defects, Tracheooesophageal fistula, Renal anomalies and Limb abnormalities)
What are the 3 signs of Duodenal Atresia
What is it associated with?
Is the vomiting bilious?
May be associated with Polyhydramnios as the baby can not ingest amniotic fluid normally
Distended Abdomen
Vomiting may be Bilious or Non-bilious
How is Duodenal Atresia diagnosed and managed?
Abdominal X ray (Double Bubble)
- One gas bubble visible in the Stomach, and one in the proximal part of the Duodenum, proximal to the Atresia
- Due to air from the stomach being between the Pyloric sphincter and the blind end of the Duodenum
Management- Surgical Repair- Duodenoduodenostomy (reconnecting proximal and distal segments of duodenum)
What is Eisenmenger Syndrome?
The reversal of a left-to-right shunt to a right-to-left shunt
So it is only seen in patients with a shunt to begin with-, like AtrioSeptal Defect
So it is an Acquired Right-to-Left Shunt
This is due to Increased Pulmonary Pressures changing the Pulmonary Vasculature and leading to Pulmonary Hypertension
What are the signs and management of Eisenmenger Syndrome?
WHEN DOES IT PRESENT?
Occurs in LATE TEENS
Includes Cyanosis and Right Heart Failure
Management- Best treatment by prevention by promptly treating Left-to-Right Shunts
- Otherwise treat the Syndrome itself with Heart-Lung Transplant or Palliation
What kind of murmur is heard with Left-to-Right Shunts?
Holosystolic Murmur loudest at Left Sternal Edge
What are 4 common Enterovirus conditions?
Hand, Foot and Mouth Disease- Coxsackie A
Myocarditis- Coxsackie B
Poliomyelitis- Poliovirus
- Mostly Asymptomatic
- A quarter of children have Upper Respiratory Tract symptoms
- MAY be PARALYSIS if the CNS is affected
Meningitis- Echovirus can cause an Aspectic Meningitis
How do you determine the right dose for children?
WETFLAG mnemonic
Weight-
- 1-5 years old= (Agex2)+8
- 6-12 years old= (Agex3)+7
Energy- 4J/kg
Tube size- (Age/4) +4 (cm)
Fluids- 20ml/kg on normal Saline bolus (10ml/kg if Trauma or Heart Failure)
Lorazepam- 0.1mg/kg
Adrenaline- 10micrograms/kg
Glucose- 2ml/kg of 10% dextrose
What is Ewing’s Sarcoma? And what are its signs?
It is the second most common bone cancer in children
It starts with LOWER body bones-
- Bone pain at NIGHT
- Mass or swelling
- Restricted movement in a joint
How is Ewing’s Sarcoma diagnosed and managed?
Bone Biopsy is Definitive
- Histology will show small blue round cells with clear cytoplasms
Xray shows LAMELLATED PERIOSTEAL REACTION (onion skinning)
MRI shows a large mass with Necrosis
Management- Surgery, Radiotherapy and Chemotherapy
What are some causes of Hydrocephalus?
Meningitis
Traumatic Brain Injury
Haemorrhage
What are 3 examples of Innocent Murmurs in Children and what are the 6 S’s that summarise them?
Still’s Murmur
Venous Hum
Acute Infective Illness
The 6 S’s
- Soft
- Systolic (as ALL diastolic murmurs are pathological)
- Sensitive (changes with child’s position and respiration)
- Short (not holosystolic)
- Single (no additional sounds)
- Small (localised, non radiating)
What is the management of Innocent Murmurs in Children?
Often made prominent when the child has a Febrile Illness
Management- the best option is to review the child in a few weeks. If the murmur persists, then Echocardiogram.
How are Febrile Convulsions diagnosed and managed?
What type of seizure usually occurs? and How is this seizure managed?
6 MONTHS to 5 YEARS OLD
What are the chances of it recurring?
What condition most likely causes it?
Febrile seizures are seizures associated with fevers
They are usually SHORT and Tonic Clonic
Management-
- Manage seizure like all other seizures- Benzodiazepam
- Find the Source of the fever and treat that
- Parents should be advised on Anti-Pyretics and not to use them prophylactically
Prognosis- it does NOT increase the chances of Epilepsy if simple. Complex= lasts for a LONG time or happens MULTIPLE times with the same fever
30-40% recurrence chance
Caused by Roseola Infantum
What are the Maintenance (not Acute) Fluid and Electrolyte requirements in children?
What is the fluid bolus that should be given for Acute Fluid Resuscitation?
1st 10 kg of bodyweight- 100ml/kg/day
2nd 10kg of bodyweight- 50ml/kg/day
Remaining bodyweight- 20ml/kg/day
Sodium- 2-4mmol/kg/day
Potassium- 1-2mmol/kg/day
Acute Fluid Resuscitation- 10ml/kg (give 2 then call for help)
How much fluid should be given to treat Fluid Deficit in children?
Percentage dehydration- ((Normal Weight- Current Weight)/Normal Weight) multiplied by 100
Multiply % dehydration by their normal weight (just the number, don’t divide by 100) (fluid deficit) then multiply this by 10
(So basically Normal Weight-Current Weight x 1,000)
Give this fluid over 1-2 days with their normal fluids
What is Foetal Alcohol Syndrome?
It is a condition resulting from In-Utero Alcohol Exposure
Signs-
- Functional/ Structural Nervous System Abnormalities (decreased cranial size, structural brain abnormalities, problems with attention, cognition)
- Growth Impairments (low birth weight, decelerating birth weight over time)
- Specific facial abnormalities (short palpebral fissures, smooth philtrum and thin upper lip)
There is NO CURE- just to support throughout life
What are the signs of Fragile X Syndrome and what is the management?
What genetic abnormality causes it?
Caused by CGG repeat in the FMR1 gene on the X chromosome
Signs- (Socially Awkward Clicking Horse)
- Long face and Large protruding ears
- Intellectual impairment
- Macroorchidism (Large testes)
- Social Anxiety and Autism Spectrum
- MITRAL VALVE PROLAPSE
- Echolalia (Repeating what you say)
Management
- Support throughout life- MDT
What are the 5 points in the Fraser Guidelines (required to give advice to <16 year olds about sexual health without breaking confidentiality)?
1) They are mature and intelligent
2) They can not be persuaded to tell the parents or allow the doctor to tell them
3) They are likely to have sexual intercourse with or without contraception
4) Their mental health will suffer unless they receive advice
5) The advice or treatment is in their best interests
What are the signs and management of Gastrooesophageal Reflux in Children?
What type of motion is seen in GORD?
(VERY VERY COMMON IN INFANCY- common cause of vomiting)
(if NOT BILIOUS or STAINED and happens AFTER EATING)
Signs-
- Milky vomit after feeding
- Crying/ Irritability
- Arching of the back and Drawing up of the KNEES TO CHEST
(These movements may be mistaken for Seizures)
Management-
- Keep baby upright after feeding and keep cot on an incline
Medical- GAVISCON and OMEPRAZOLE (Quesmed also said Alginate)
Surgical- FUNDOPLICATION
What is Gastroenteritis and what are the main bacterial and viral causes?
Common Cause of DIARRHOEA and VOMITING after ingestion
Bacterial-
- Staphylococcus Aureus- cooked meats and creams
- Cereus- Reheated Rice
- Perfringens- Reheated or cooked meat
- E-coli - if recently TRAVELLED to ASIA/ AFRICA
Viral-
- Rotavirus (most common cause in infants)
- Norovirus (most common cause in all ages)
- Adenoviruses (resp infections as well)
How is Gastroenteritis managed?
Fluid Replacement (WATER) and antibiotics if severe
Antibiotics if:
- Systemically unwell
- Immunosuppressed
- Elderly
Specific antibiotics (Stay Clean, Cook Everything, Clean Thoroughly)
- Salmonella or Shigella- Ciprofloxacin
- Campylobacter- Erythromycin
- Cholera- Tetracycline
What is Henoch-Schonlein Purpura?
What are the signs and management?
RESP-> HSP -> RENAL
(PURPURA on EXTENSORS, ABDO PAIN, ARTHRITIS)
ACHY TUMMY, JOINTS, LOWER LIMBS and BUM
Small vessel vasculitis- in 3-5 year olds
Signs- PANAF
- Purpura or petechiae on Buttocks and Lower Limbs
- Abdominal Pain
- Arthralgia (Knee and Ankles usually)
- Nephritis (Haematuria and Proteinuria)
- Usually happens after an UPPER RESPIRATORY INFECTION
- May have fever
Diagnosis- Biopsy with immunofluorescence for C3 and IgA- but rarely don- Pick DIPSTICK over this for investigations
Management-
- NSAIDs for analgesia
- Antihypertensives for blood pressure
- Urine dipstick for a year to check for renal function
What are the signs, diagnosis and management of Hodgkin’s Lymphoma?
What are the 2 markers of poor prognosis?
Signs
- Alcohol-Induced PAIN in Lymph Nodes
- Cervical or Supraclavicular Non-tender Lymphadenopathy
- Symptoms caused by compression of surrounding structures- !!!!!!!SHORTNESS OF BREATH/ ABDOMINAL PAIN
- B symptoms (weight loss, night sweat, fatigue)- only seen in 30% of patients
- Hepatosplenomegaly
Diagnosis-
- Lymph Node Biopsy- REED STERNBERG CELLS
- !!!!!!!!!Low Hb (Anaemia) and Raised LDH is poor prognosis
Management- Chemotherapy
What are the causes and management of Hydrocele?
FLUCTUANT AND TRANSILLUMINATES (on Ultrasound)
Causes- Processus Vaginalis does not close (the path the testes take to descend)
Management- Most resolve within a year, so wait ONE YEAR, then surgical correction if still not resolved
Prognosis if untreated- Inguinal Hernia
What are the causes of a Communicating and Non-communicating Hydrocephalus?
Non-communicating- there is an OBSTRUCTION in the Ventricular system
- Congenital Malformation (AQUEDUCT STENOSIS or CHIARI MALFORMATION)
- Tumour or Vascular Malformation in the Posterior Fossa
- Intraventricular Haemorrhage (consider in PREMATURE infants)
Communicating- Failure to reabsorb CSF
- Meningitis
- Subarachnoid Haemorrhage
- Traumatic Brain Injury
What is the diagnosis and management of Hydrocephalus?
(From the ventricles to the peritoneum)
Diagnosis- Cranial Ultrasound or CT/MRI of the brain
Management- Ventriculoperitoneal Shunt to move CSF to the abdominal cavity (look out in case the shunt gets infected though)
What is the ICP in Hydrocephalus and what are the signs of this?
Remember Victor and VILS
RAISED ICP
Signs-
- Vomiting
- Irritability
- Lethargy
- Sunsetting of Eyes
Hydrocephalus- Tense Anterior Fontanelle, Distended Scalp Veins
What are the features of Hypotestosteronism?
(FAT, SLOW, SAD, not Sexual male)
What 2 conditions is this associated with- or it can lead to?
Weight Gain
Lethargy
Erectile Dysfunction and Loss of Libido
Depression
Gynaecomastia
- Associated with Infertility and OSTEOPOROSIS
How is Hypotestosteronism managed?
What 4 things do you monitor?
Low Testosterone= BONE, LIVER, BLOOD, Prostate
HRT (give them testosterone)
Monitor for-
- Polycythaemia (testosterone affects erythrocytosis)
- Bone mineral density (DEXA)
- Prostate status
- LFTs (hormones affect Liver Function)
What is Hypoxic Ischaemic Encephalopathy?
what is the Immediate and Delayed effects?
What are pre intra and post partum causes?- 1,2,1
It is Brain Damage resulting from antenatal or perinatal Hypoxia
Primary Neuronal Death (Immediate) and Secondary Reperfusion Injury (Delayed)
Caused by anything that causes HYPOXIA
- Pre-Partum (PLACENTAL ABRUPTION)
- During Delivery (Prolonged Delivery, Cord Compression)
- Post-Partum (Prolonged Respiratory Arrest)
What are the signs of Hypoxic Ischaemic Encephalopathy? How is it diagnosed and managed?
Annoyed or (Floppy and Seizures)
5 steps to treat:
remember the Oxygen, transport of oxygen and medium for transport
plus hypothermia and seiziures
Ranging from Mild (Irritability) to Severe (Hypotonia, Poor Responses, Prolonged Seizures)
Diagnosis- EEG monitoring and multiple MRI scans
Management-
- Respiratory Support
- Anticonvulsant Therapy
- Careful Fluid Balance and Electrolyte Monitoring
- The use of INOTROPES
- COOLING THE BABY TO INDUCE HYPOTHERMIA protects against Secondary Reperfusion Injury
What is Immune Thrombocytopaenic Purpura?
Autoimmune disease of an unknown cause where the Number of Platelets is reduced
In Children it is SELF LIMITING
Adults- CHRONIC RELAPSING
What are the symptoms and management of Immune Thrombocytopaenic Purpura?
Non-Blanching After Viral Infection
Excessive Bruising and Bleeding (NON-Blanching, PETECHIAL RASH)
Tiny Reddish-purple Dots
May develop this after a Viral Infection
Managed with- Platelet Transfusion avoid unless Life-threatening. Steroids are used if Persistent and Splenectomy if Refractory
What are the 3 core symptoms of ALL?
RECURRENT infections
Anaemia (Pallor and Fatigue)
Thrombocytopaenia (PURPURIC Rash)
What is Impetigo? What are the Signs and Management?
The Gold Crusts
FUS FLU
Skin Infection caused by Staph/ Strep
Signs-
- Pruritic Rashes with GOLD CRUSTING
- May also be fever
- In Children
Management-
- Fusidic Acid and Oral Flucoxacillin
- It is HIGHLY INFECTIOUS so isolate until 48 hours of antibiotic treatment
What is the management of an Ingested Foreign Body?
Investigations are UNNECESSARY if Asymptomatic Child with Low-Risk Ingestion
Otherwise- ENDOSCOPY or OPEN SURGERY
What are the symptoms that point to an Ingested Foreign Bosy?
Sudden Onset Shortness of Breath with a Focal Site of the Lungs
Especially MONOPHONIC WHEEZE in RIGHT LOWER LOBE
What is Intussusception and what are the signs?
Blood In Stool
Invagination of small intestine into large intestine
Signs-
- SUDDEN, SEVERE COLICKY pain and draws legs up
- Child recovers but becomes Lethargic
Other symptoms-
- May refuse feeds
- Abdominal Distension
- Sausage Shaped Mass in Abdomen
- REDCURRENT Jelly Stool
What are the investigations and management of Intussusception?
Abdominal Ultrasound- TARGET Sign (Concentric Echogenic and Hyperechogenic Bands)
Management-
- Rectal Air Insufflation (Air Enema) or Contrast Enema (only to be performed if the child is stable)
- Laparoscopic Correction if haemodynamic unstable, PERITONITIS and PERFORATION
What are the indications for CT HEAD?
Remember these 2 key ones- I know theres more in Emergency Med
Loss of Consciousness >5 minutes
Vomiting more than twice and Drowsiness- CT within 8 hours
What is Juvenile Dermatomyositis? What are the signs?
(RASH and WEAKNESS)
It is a disease which causes Muscle Weakness and Skin Rash (on areas exposed to sunlight- face, back, limbs)
Signs-
1) Fatigue
2) Joint Pain
3) Weakness of Proximal Muscles
4) Malar Rash
5) Heliotrope Rash over eyes (Purple Rash over Eyes)
What are the investigations and management of Juvenile Dermatomyositis?
4 investigations- 1- bloods (2) and 3 to confirm diagnosis (MMA)
SS for management
Investigations
- High ESR and Creatine Kinase
- POSITIVE ANAs
Diagnosis can be confirmed via
-MRI (Muscle Oedema)
-Muscle Biopsies
-Nailfold Capillaroscopy showing Microangiopathy
Management-
- Steroids for flares
- Steroid-sparing immunosuppression for maintenance (Methotrexates or Biologics)
What is Juvenile Idiopathic Arthritis? What are the Signs?- THREE FEATURES other than joint pain
It is a diagnosis of Exclusion (Make sure it is not Infection, Malignancy, Lupus)
It is the MOST COMMON CAUSE of CHRONIC JOINT PAIN in Children
Signs-
- Pain with (3) (Fevers, Malaise, Salmon pink Rash) and Joint Pain
What is the management and complications of Juvenile Idiopathic Arthritis?
FJAG
Management-
- MDT input needed
- Walking Aids needed, may need Psychological support to help with coping as well
- Medical management-
1) NSAIDs for Symptoms
2) Oral or IV Corticosteroids (Prednisolone) if Systemic Symptoms, if NO Systemic Symptoms (Intra-articular Methylprednisolone Injection)
3) Steroid-sparing agents (Methotrexate, Biologics)
Complications-
1) Flexion Contractures
2) Joint Destruction
3) Growth Failure (from the STEROIDS and CHRONIC DISEASE)
4) Anterior UVEITIS
What is Kawasaki Disease and what are the signs?
CRASH and BURN
It is an AUTOIMMUNE MEDIUM-VESSEL VASCULITIS
Seen in UNDER 5 YEAR OLDS USUALLY
Signs-
CRASH and Burn
- Conjunctivitis
- Rashes
- Adenopathy (Lymphadenopathy)
- Strawberry Tongue (and Cracked Lips)
- Hands and Feet Red, Swollen and Skin Peeling
and High Fever
Usually very unwell
What is the management of Kawasaki Disease?
What should be monitored for?
Intravenous Immunoglobulin and Aspirin (high dose)
Surveillance of Coronary Artery Aneurysm (ECHOCARDIOGRAM for THIS)
What is the management of Kawasaki Disease?
Intravenous Immunoglobulin and Aspirin (high dose)
Surveillance of Coronary Artery Aneurysm (ECHOCARDIOGRAM for THIS)
What Drugs can cause Long-QT Syndrome?
SAM TAM QQ
- Sotalol
- Antipsychotics
- Metoclopramide
- Tricyclics
- Amiodarone
- Macrolides (-Mycins)
- Quinolones (-Floxacins)
- Quinidine
How many squares should a normal QT Interval be and what is the management?
What is the main Complication? (Ventricular Fibrillation)
10 small squares
Cardiologist should supervise them to see whether they need an Implantable Defibrillator
BETA BLOCKERS may help
What is Malrotation? What are the Signs?
Seen from the FIRST DAY of LIFE
The Midgut rotates and fixes in an abnormal position- this makes it more likely for VOLVULUS to occur and the duodenum is likely to be compressed by LADD’s BANDS
SIGNS-
- Bilious Vomiting within the FIRST DAY of LIFE (as the gut is already developed like that from the start)
- Distension and Constipation
How is Malrotation diagnosed and managed?
Diagnosis- Upper GI Contrast Study shows Corkscrew in proximal bowel. Contrast can not pass beyond this area
Management- Urgent Surgery
What is Meckel’s Diverticulum?
It is the most common Congenital GI Abnormality- It is a remnant of the Vitello-Intestinal Duct of the Embryo (which should completely disappear at 6 weeks gestation)
It is a True Diverticulum (contains all 3 layers of the bowel wall)
It presents in INFANTS, not in NEONATES
What are the signs of Meckel’s Diverticulum? What are the 3 complications (POI)?
APPENDICITIS LIKE PAIN and RECTAL BLEEDING- so they USUALLY NEED TRANSFUSION!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Symptomless (found in operation)
May be BILIOUS (GREEN) Vomiting
If Patent Vitello-intestinal Duct- may be discharging intestinal content
PAINLESS Rectal Bleeding (most common cause in Children)- due to potential ectopic pancreatic tissue that may also form in there
RIF Abdominal Pain (due to diverticulum inflammation)
THREE COMPLICATIONS-
Intussusception (may act as the APEX for ILEOILEAL TYPE)
Obstruction- if it becomes trapped in a Hernia
Perforation by foreign body
What are the investigations and management of Meckel’s Diverticulum?
4 for Investigation
2 for Management- N, R.
99mm Technetium scan
CT scan
Small Bowel Enema
May show FLUID FILLED POUCH on ULTRASOUND
Management
- Treat Clinical Presentation (Obstruction with NG Tube)
- Resection of Diverticulum (Wedge Excision or Small Bowel Resection and Anastamosis)
What is the management of a choking child?
rule of 5s
Conscious and Coughing-
- Encourage them to cough
Conscious but can’t Cough-
- 5 back blows and 5 chest (infant), abdominal (child) thrusts
Unconscious-
- 5 rescue breaths and CPR
What are the 3 main causes of Acute Stridor?
Croup-
- Cough and Fever and inspiratory stridor in Moderate and Severe Cases
- Symptoms WORSEN at NIGHT, which is when patients typically present
Epiglottitis-
- Fever, inspiratory stridor and Drooling and Struggling to breath
- Normally VERY IRRITABLE- it is not advised to disturb these children as they will cry
Bacterial Tracheitis-
- Symptoms between Croup and Epiglottitis
- Difficulty Breathing and Fever
What increases the risk of Congenital Heart Disease?
Remember RITA Lived Through Acute Heartache
R.I.T.A.L.T
Maternal Rubella (and other infections)
Drugs (Thalidomide, Isotretinoin, Lithium) and Alcohol
Maternal Diabetes (poorly controlled Type 1 or Type 2 Diabetes- NOT cos of Gestational Diabetes)
What is Ebstein’s Anomaly?
A Large Right Atrium, a Small Right Ventricle due to Low Insertion of the Tricuspid Valve
What are the 4 signs of Transposition of the Great Arteries?
What is seen on chest xray?
TGA= RIGHT VENTRICULAR IMPULSE!!!!!!!!!!!!!!
Peripheral and Central Cyanosis
Respiratory Distress
!!!!!!!!!!!!!!!!!!A single loud S2 (+maybe patent ductus arteriosus murmur)
Chest X ray shows Egg-on-a-String appearance (“bulbous” upper portion that represents the enlarged pulmonary artery, and a “pinched” lower portion that represents the narrowed aorta. This appearance is caused by the anterior position of the pulmonary artery and posterior position of the aorta, and can be a helpful diagnostic clue for TGA.)
What are the symptoms of Measles?
1) Fever and Cold
2) Spots and Rash
2) Measles starts in the EYES
Fever> 40 degrees
Coryzal (cold-like symptoms)
Conjunctivitis then Maculopapular rash (Face and Trunk) 2-5 days after symptoms
KOPLIK SPOTS- small grey spots in mouth
What investigations should be ordered in Measles?
1) Measles specific IgM and IgG serology (ELISA) is most sensitive after 3 days
2) Measles RNA detection by PCR (best for 13 days after rash)
What is the management and complications of Measles?
Management-
- Antipyrexial medication
- Vitamin A (if under 2 years old)- think Vit A helps the eyes and Measles affects the eyes first (Conjunctivitis)
- Ribavarin (but not routinely used)
Complications- (Ear, Lung, Head)
- Acute Otitis Media
- Bronchospasms
- Encephalitis
What is Meconium Ileus and how is it managed?
What are the symptoms and what investigation is ordered to check for it and what is seen?
It is a condition where the first poop is so thick that it does not pass within the first 2 days
BILE-STAINED VOMIT and DISTENDED ABDOMEN
It is associated with Cystic Fibrosis
In Abdominal Xray- you will see a BUBBLY APPEARANCE of the INTESTINE with a lack of air-fluid levels
Management-
- Drip and Suck (IV Fluid and Stomach Drainage with Ryles Tube) with enemas to remove the Meconium
- Surgery needed in Severe Cases
What are the 4 bacterial causes of Meningitis?
Streptococcus pneumoniae (Positive)
Neisseria meningitidis (Negative)
Haemophilus influenzae
Listeria monocytogenes (extremities of age)
What are the 3 viral causes of Meningitis?
Echoviruses
Coxsackie A and B
Polio
What are the Fungal (2), Parasitic (2) and Non-infective (6) causes of Meningitis (My Chemical Drugs SeriouSly Behave)?
Fungal- Cryptococcus and Mycobacterial
Parasitic- Acanthamoeba (associated with Keratitis) and Toxoplasma
Non infective-
- Malignancy
- Chemical Meningitis
- Drugs (NSAIDs and Trimethoprim)
- Sarcoidosis
- Systemic Lupus Erythematosus
- Behcet’s Disease (inflammation of blood vessels- consists of ulcers, itchy eyes and acne)
What are the signs of Menignitis?
Headache
Fever
Neck Stiffness
Photophobia
Nausea and Vomiting
FOCAL NEUROLOGICAL SIGNS
SEIZURES
What 2 tests are done to test for Meningitis? And how sensitive are they?
Kernig’s and Brudzinski’s
These tests are not sensitive so sometimes patients may not have these signs and still have meningitis
What is the acute management of Meningitis?
Remember to Give IV DEXAMETHASONE for LONG TERM PROTECTION against neurological signs
Bacterial- 2g IV Ceftriaxone (twice daily), add IV Amoxicillin if very young or very old to cover Listeria. If <1 month, Cefotaxime can be used
Viral- IV Acyclovir
Fungal- Amphotericin, Flucytosine and Fluconazole
If community-based, IM/IV Benzylpenicillin may be used if there is a Non-blanching Rash while waiting for Hospital transfer. so give this FIRST in GP
If Penicillin-allergic, !!!!!!Chloramphenicol may be used
What investigations should be ordered if Meningitis is suspected?
Give Antibiotics First though
Blood cultures, gas and test
Arterial blood gas
CT HEAD and LUMBAR PUNCTURE
Blood tests
What are the Cerebrospinal Fluid features of Meningitis?
Bacterial
- Clear or Turbid
- HIGH OPENING PRESSURE
- usually Neutrophil Leukocytosis
- 100-200 PMN (Polymorphonuclear leukocyte)
- Positive culture results (may be negative)
- High Protein (due to bacterial contamination)
- Low Glucose (<0.4g/L) (bacteria use it as an energy source) (LESS THAN HALF of SERUM GLUCOSE)
Aseptic (Viral) Meningitis
- Clear or Slightly turbid with 15-100 Leukocytes
- usually Lymphocytic Leukocytosis
- Negative culture results (cos Aseptic)
- 0.5-1g/L (<100mg/L) of proteins with Normal Glucose (>0.4g/L) (as Viruses use cell machinery to replicate)
Tubercular Meningitis (history of recent foreign travel)
- Clear or Slightly Turbid
- Fibrin web may develop
- 30-500 lymphocytes plus PMNs (but apparently it is actually MONONUCLEATED), with NEGATIVE gram stain
- High Protein
- Low Glucose
Cryptococcal Meningitis
- HIGH OPENING PRESSURE
- May give any of the results above so always think of this as a possible differential if they have HIV or are immunocompromised
- Cryptococcal Antigen testing or India Ink Staining should be requested
What are the 6 complications of Meningitis?
SDSNS
Disseminated Intravascular Coagulation (look out for Conjunctival Haemorrhages)
Subdural Effusions
Syndrome of Inappropriate Antidiuretic Hormone Secretion
Seizures/ Coma
- Hydrocephalus, Hearing loss, Ataxia, Blindness, Cranial Nerve Dysfunction
Which form of Meningitis causes the least symptoms- Bacterial or VIral?
Viral causes less symptoms than Bacterial
What is the normal range of Protein, Glucose and Opening pressure in Lumbar Puncture?
Protein= Up to 1.5g/L
Glucose= 2.5-4.4 mmol/l
Opening pressure= (10-25 cmH2O)
WCC= 0-8
What bacteria causes Non-blanching rashes typically in Meningitis and which one causes Ear infections?
Neisseria- Non blanching rashes
Strep Pneumoniae- Ear Infections
What are the signs of Encephalitis?
(HSV1)
Altered Mental State (not seen in Meningitis)
Fever
Convulsions
FOCAL NEUROLOGICAL SIGNS
Headache with MENINGISMS
What investigations should be ordered in Encephalitis?
Same as Meningitis
Blood cultures
Arterial blood gas
CT HEAD and LUMBAR PUNCTURE
Blood tests
What is the management of Encephalitis?
Give both viral and bacterial stuff basially
2g IV Cefriaxone and 10mg/kg IV Acyclovir
What are the 6 side effects of Acyclovir? (tired, vomiting, scared of light and rash (a sick vampire))
turns you into sick cartoon dracula
and affects liver, kidney and blood
Generalised Fatigue/ Malaise (common)
GI Disturbances (common)
Photosensitivity (so can make this worse in Meningitis) and urticarial rash (common)
Renal Failure
Hepatitis
Haematological abnormalities
What is seen in CNS imaging in Viral Encephalitis?
MRI btw- CT head is usually normal for Encephalitis
Bilateral Multifocal Haemorrhages in the Temporal Lobes
What is the infection by Neisseria Meningitidis called?
Meningococcal Infection
What are the 5 ways Meningococcal Infection can presetn?
2 Mening-
2 Shocks
1 thats both Mening-
Meningococcaemia
Meningitis (lethargy, headache, fevers, vomiting)
Mixture of both- associated with a rapidly developing Purpuric Rash
Hypovolaemic Shock (cold peripheries, poor cap refill, tachycardia, low urine output)
WATERHOUSE-FRIDERICHSEN (adrenal haemorrhage and septic shock also happen)
What is the form of Meningicoccal Infection that presents with a Massive Adrenal Haemorrhage and Septic shock?
Waterhouse-Friderichsen Syndrome
What are the 2 approaches to diagnosing Meningococcal Infections?
Blood or CSF Cultures
PCR testing for Neisseria
What is the management of Meningococcal Infections?
What should be given to household contacts?
Broad Spectrum Antibiotics
PICU admission if Septicaemia
Ciprofloxacin or Rifampicin for household contacts
When are Lumbar Punctures contraindicated?
6 things
3 things kinda linked to neuro/infections
heart, lung, blood
Sepsis (tachycardia, hypotension, tachypnoea, petechial rash) (bear this one in mind)
Raised ICP (remember the Victor VILS story)
Focal Neurological Signs (bear this one in mind)
Coagulation Disorder
Cardiovascular Instability
Respiratory Failure
How does Neisseria Meningitidis cause the symptoms?
Intravascular Coagulation
What is Mesenteric Adenitis?
What are the main signs? What is the investigation and what condition should be ruled out?
What is the management?
The inflammation of Mesenteric Lymph Nodes
Signs-
- Diffuse Abdominal Pain following a previous Upper Respiratory Tract Infection (BUT may be RIF pain as well)
- Low Grade fever with general abdominal tenderness
- Also Diarrhoea, Vomiting, Fatigue and Loss of Appetite
- Pharyngitis in the mouth MAY be there
- US Abdomen shows ENLARGED MESENTERIC LYMPH NODES
- Rule out Appendicitis based on Clinical Presentation (MORE SEVERE and not after URTI)
Management-
- Monitor them overnight to look for worsening of their clinical status
- Mesenteric adenitis will also improve spontaneously, whereas appendicitis will not
What is Galactosaemia?
When does it present and what are the symptoms?
What happens if it is not managed properly?
It is the body being unable to properly metabolise Galactose, which leads to toxic levels that accumulate in the blood
It presents in the first 1-2 weeks of life (DIARRHOEA, VOMITING and LETHARGY)
Management-
- Remove Galactose and Lactose from their diet otherwise can lead to NEUROLOGICAL complications
This is screened for at the Newborn Blood Spot Test
What is Maple Syrup Disease?
It is an enzyme defect leading to the accumulation of BRANCHED AMINOACIDS
This leads to KETOACIDS in the bloodstream which accumulates in the urine giving a MAPLE SYRUP SMELL
Symptoms- LETHARGY, POOR FEEDING ABILITY and IRRITABILITY
Management-
- Tight Lifelong diet to prevent build up of branched aminoacids (valine, leucine and isoleucine) otherwise can lead to NEUROLOGICAL COMPLICATIONS
This is screened for at the Newborn Blood Spot Test
What is Medium chain acyl-coA dehydrogenase deficiency (MCADD)?
It is a disorder affecting Fatty Acid Oxidation where the body’s ability to convert Fatty Acids to Acetyl-Coenzyme is affected
This is AUTOSOMAL RECESSIVE
It presents as (LOW KETONES, LOW GLUCOSE and LETHARGY)
Management-
- Avoid FASTING and eat SIMPLE CARBS
This is screened for at the Newborn Blood Spot Test
What 6 conditions are newborns screened for with the Guthrie Heelprick (blood spot)?
Medium chain acyl-coA dehydrogenase deficiency
Galactosaemia
Maple Syrup Disease
Sickle Cell Disease
Congenital Hypothyroidism
Cystic Fibrosis
What is Minimal Change Disease?
What are the 4 signs, 2 symptoms and the investigation?
Protein loss from blood (although this is usually within the normal range) and goes into urine
4 steps to management
-steroids
-immunosuppression
-fluid
-albumin and furosemide
It is the MOST COMMON FORM of NEPHROTIC SYNDROME in children (Proteinuria, Oedema, Hypoalbuminaemia) Also Hyperlipidaemia
Signs-
- OEDEMA (facial swelling usually)
- Frothy Urine (cos of the proteinuria)
- If a child has nephrotic syndrome, assume it is Minimal Change Disease
Investigations- Urine Dipstick for Proteinuria/ Haematuria
Management-
- Corticosteroid (Prednisolone)
- then other immunosuppressive agents (Ciclosporin)
- FLUID RESTRICTION and reduced SALT INTAKE
- Human Albumin and Furosemide
What are the 4 complications of Minimal Change Disease?
Spontaneous Peritonitis
Thrombosis (high proteins)
Renal Damage (cos it is a kidney disease)
Increased Risk of Infections
What is seen in the Renal Biopsy of Minimal Change Disease?
Minimal or No changes to Histology on biopsy
What is Muscular Dystrophy? What causes them? And is their INHERITANCE (recessive, dominant etc)?
A range of conditions where the muscles break down and get weaker over time
The most common form of this is Duchenne’s Muscular Dystrophy
Causes-
- Mutations that reduce Dystrophin expression (protein involved with contraction)
- Duchenne’s- protein is NOT express, Becker’s- expressed at LOW LEVELS
They are X LINKED RECESSIVE
What is the presentation of Duchenne’s Muscular Dystrophy? and what about Becker’s Muscular Dystrophy?
Duchenne’s
- Muscle Wasting (and weakness) in early childhood, also the GAIT is OFF
- Usually wheelchair bound before puberty and they DIE from RESPIRATORY FAILURE by early 20s
- They may appear BULKY- as fat REPLACES muscle in these cases
- The child may SLIP THROUGH parents’ hands when they pick them up (due to loose shoulder muscles) and they WALK THEIR ARMS when getting up
Becker’s
- Muscle wasting and weakness presents in LATE childhood- they usually survive oto their 30s
What is the diagnosis and management of Muscular Dystrophies?
First Line- Creatine Kinase
Genetic Testing detects Duchenne’s and is the gold standard
Muscle biopsies are sometimes performed but Genetic testing is better
Management- just support and therapy
What is Necrotising Enterocolitis?
The bowels of premature infants becomes Ischaemic and Infected
What are the 4 risk factors for Necrotising Enterocolitis?
Prematurity and Low Birth Weight
Non-breast milk feeding
Sepsis
Hypoxia and Poor Intestinal Perfusion
What are the signs of Necrotising Enterocolitis (BBAAS) and how is it diagnosed and managed? How do you prevent this?
Presents in PREMATURE infants in the first 3 weeks of life
Bile-streaked vomiting and Bloody diarrhoea
Abdominal Distension with Absent bowel sounds (cos there is air)
Systemic Compromise (like ACIDOSIS)
Diagnosis-
- Abdominal Xray (Dilated bowel loops and Pneumatosis intestinalis (gas in intestine which dilates it), Portal Venous Gas and Pneumoperitoneum (so gas everywhere basically))
- Staged using Bell’s classification
Management- (Antibiotics and Airways, Control their feeding and arrange for surgery)
- Nil by mouth and give them a Nasogastric Tube
- Broad-spectrum antibiotics
- Give them Total Parenteral Nutrition to rest the bowel
- Supportive Treatment with IV Fluids and Ventilation is crucial
- Surgery to Resect Necrotic Sections of the bowel may be necessary- especially if there are PERFORATIONS. Contact the surgeons early
How to prevent this-
- BREASTFEED and DELAY UMBILICAL CORD CLAMPING
What are the causes of Neonatal Jaundice if 24 hours-14 days after birth?
And what are the causes after 14 days after birth?
If <24 hours, it is ALWAYS AN ISSUE and not physiological- think (3) HAEMOLYTIC DISEASES, SEPSIS and CONGENITAL INFECTIONS
3 for both before and after 14 days. plus DPC, HPN
24 hours- 14 days-
Physiological Jaundice (high UNCONJUGATED bilirubin)
Breast Milk Jaundice (no symptoms- just Jaundice)
Infection
Dehydration
Polycythaemia, Bruising or Haemolysis
Crigler-Najjar Syndrome (liver can’t break down bilirubin so it builds up)
> 14 days-
Physiological Jaundice
Breast Milk Jaundice (no symptoms- just Jaundice)
Infection
HYPOTHYROIDISM
Biliary Obstruction (Biliary Atresia)
Neonatal Hepatitis
What causes Physiological Neonatal Jaundice?
Elevated Bilirubin due to
- Babies may just be Polycythaemic at birth
- Red cell life span of newborns is shorter than adults
- Hepatic Bilirubin metabolism is less efficient for the first few days
What is the management of Neonatal Jaundice?
Measure their bilirubin levels
1) Depending on this- Phototherapy may be done (repeat bilirubin in 24 hours if this is the case).
After starting Phototherapy, monitor bilirubin levels regularly in 4-6 hours
- once they are >50 micromoles below the threshold, then stop phototherapy and check again- if it still below >50 micromoles below the threshold then no further action needed.
2) If significantly high, then Exchange Transfusion should be done
If not managed, it can lead to KERNICTERUS
What causes Acute Bilirubin Encephalopathy? (Hypotonia and Lethargy and Jaundice are the symptoms)
A Tired Yellow Flopper
A build up of Unconjugated Bilirubin
What should be done if Jaundice presents within 24 hours after birth?
Direct Coomb’s Test to look for Haemolytic Disease of the Newborn (Rhesus Negative and ABO Incompatibility)
What is a risk factor for Neonatal Jaundice?
Breastfeeding
What is Neonatal Respiratory Distress Syndrome?
How is it diagnosed and managed?
What should be given to the mother to prevent Neonatal Resp Distress?
It is caused by a lack of Alveolar Surfactant
This is produced from 26 weeks gestation so PREMATURE babies are at high risk of this
Diagnosis-
- Generally based on history- Neonatal Respiratory Distress Syndrome (Grunting, Flaring, Intercostal Recession)
- CXR- ground glass
Management-
- Intratracheal Instillation of ARTIFICIAL SURFACTANT
- Give the mother Glucocorticoids (Corticosteroids) if preterm delivery is suspected
What is Stillbirth, Neonatal Death and Perinatal Death?
Stillbirth- Death after 24 weeks of gestation- before or during birth
Neonatal Death- Death within first 28 days of life
Perinatal Death- Stillbirth plus Neonatal Death
What are the biggest risk factors for Stillbirth and Neonatal Death?
Stillbirth- Foetal Growth Restriction
Neonatal Death- Preterm Birth
What is the Neonatal Resuscitation Protocol?
1) Birth
2) Dry the baby and perform the Initial Check (tone, breathing, heart rate)
3) If not breathing, try PHYSICAL STIMULATION FIRST, then open airway and give 5 artificial inflation breaths and consider Oxygen (but generally avoided in newborns)
4) See if this helps
5) If chest is not moving, optimise the airway control by repeating INFLATION
< 60- Ventilate, Compression, IV drugs
6) When the chest is moving, ventilate for 30 seconds if HR<60
7) If HR is still< 60 start chest compressions (3:1 rate)
8) If HR still<60 start IV drugs
What is the aetiology of Early Onset (<72 hours) and Late Onset (>72 hours) Neonatal Sepsis?
Early Onset-
- Group B Strep if Ascending microorganisms from Cervix
- Colonises Urinary Tract
- Can cause Asymptomatic Bacteriuria or UTI in the mother
- Treat with IV BENZYLPENICILLIN Intrapartum if
1) Previous baby had GBS, Maternal Fever, Positive swab in pregnancy
Transplacental- CMV, Rubella, Listeria, Toxoplasma
Late onset-
- Staph Aureus commonly
What are the risk factors for Early Onset Neonatal Sepsis?
Prematurity
Rupture of membranes> 18 hours for pre-term babies
Rupture of membranes> 24 hours for term babies
Maternal Intrapartum Fever
Chorioamnionitis
What is the management of Neonatal Sepsis?
Suspect if Grunting (Resp Distress)
usually due to GBS and E. Coli
BLOOD CULTURE before antibiotics- also FBC and CRP
- BENZYLPENICILLIN and GENTAMYCIN
Strongly consider LUMBAR PUNCTURE
- Chest Xrays only if there is strong suspicion of a Resp source
- URINE CULTURE if late onset (>72 hours)
Repeat CRP 18-24 hours hours after initial Antibiotics
What are the causes of Nocturnal Enuresis (bedwetting)?
Diabetes Mellitus
Urinary Tract Infection
Constipation (due to compression of the bladder)
What are the investigations and management of Nocturnal Enuresis?
History, Examination and Urinary Dip should always be performed
If secondary- Urine dip, Urine Osmolarity and Renal Ultrasound
Management
- Reassure that this is normal
- Nocturesis Alarm
- If over 7 and alarm doesn’t work, a drug called Desmopressin- DDAVP (a type of synthetic ADH) can be given
What is Non-Accidental Injury?
It is any bodily injury in a child that had been deliberately afflicted on them or any injury where the caregiver has failed to prevent such an injury
Investigations- Radiology and Bloods (exclude organic causes such as clotting disorders or haematological malignancy)
Management- Inform a senior and admit the child for safeguarding
What is Oesophageal Atresia and what is a Tracheo-oesophageal Fistulae?
Oesophageal Atresia- blind-ended oesophagus
Trachek-oesophageal Fistula- there is communication between the oesophagus and the trachea
Most patients that present with them have both
What are the signs of Oesophageal Atresia and Tracheo-Oesophageal Fistula?
1 Antenatal and 4 Postnatal
Antenatal- POLYHYDRAMNIOS as fluid cannot pass to the baby to be absorbed
Postnatal-
- Respiratory Distress
- Distended Abdomen
- Choking/ Problems with swallowing
- Difficulty with passing NG tube down
Check with NG Tube and Chest Xray
Management- Surgery
What is Oppositional Defiant Disorder?
Child shows persistent defiant and hostile behaviour towards FIGURES of AUTHORITY like a parent or teacher
Managed with Therapy
What is Osteosarcoma and how does it present and how is it diagnosed?
What does the Xray Show?
It is the most common bone cancer in children
Presentation-
- Pain and Swelling with Prolonged Onset that occurs in the Metaphyses of Long Bones (The ends of Long Bones). Pain is worse at morning and night
Diagnosis-
- First- Urgent Xray shows new bony growth and periosteal reaction which causes a Sunburnt Appearance
- Definitive diagnosis- Bone Biopsy
Management- surgery, radiotherapy and chemotherapy
What is the ABCDE approach in Paediatrics?
Call for help
Open airways
If breathing but not normal- 5 rescue breaths
If no signs of life- 15 chest compressions and 2 rescue breaths
Repeat 15:2
What are the 3 airway positions and 2 differences in breathing aspects in Paediatrics?
Airway Positions-
- Infants- Neutral position
- Young children- “sniffing the morning air”
- Older children- Head tilt chin lift and Jaw thrust
Differences-
- Paediatrics first intervention is 5 rescue breaths
- Children are more likely to suffer from RESPIRATORY ARRESTS rather than CARDIAC ARRESTS
How do you measure pulses and how do you perform chest compressions in Paediatrics?
Pulses-
- Carotid Pulses in >1 year olds
- Brachial or Femoral pulses in Infants
How to perform Chest Compressions-
- 100-120 compressions per minute
- Make sure there is full recoil of the chest
- Infants- 2 fingers from one hand or both thumbs
- Small children- One handed compressions with the Heel of your hand
- Larger children- Two handed compressions with Interlocking hands- like an Adult
Compression depth-
- Babies and young children- 1/3 of chest depth
- Adult children- 5cm
What is the most common rhythm found in collapsed children?
Asystole
What are the signs of Heart Failure in Infants and Children?
Suspect if FALTERING GROWTH and Hepatomegaly in infants
Infants-
- Difficulty feeding and Faltering Growth
- Poor Appetite
- Abdominal Pain and Vomiting
- Fatigue
- Hepatomegaly (more evident than oedemas and cyanosis)
Children-
- Exercise Intolerance
- Fatigue
- Hepatomegaly
What are the investigations and management of Paediatric Heart Failure?
Investigations-
- Bloods (BNP, Magnesium, Bone Profile, TFTs, CRPs, LFTs, FBC, U&Es)
- Imaging- Chest Xray and Echocardiogram
- ECG
Management- (reduce fluid in, increase fluid out AND surgical)
- Fluid Restriction and Feeding Plan from Dietician
- Diuretics with Inotropic Support if Needed
- Surgical- Correction of Defect and Heart Transplant in End-stage cases
What 7 Paediatric Syndromes have Cardiac Involvement? And their most common defect(s)?
PATEND G
(Patent G)
Trisomy 21- SEPTAL DEFECTSs- mainly ATRIOVENTRICULAR SEPTAL DEFECTS
Foetal Alcohol Syndrome- Ventricular Septal Defects
Edward’s Syndrome (Trisomy 18) - (Ventriculo) Septal Defects
DiGeorge Syndrome (22 q Deletion)- Aortic Arch Defects
Turner Syndrome (45XO)- Bicuspid Aortic Valves and Coarctation of the Aorta
Noonan Syndrome- Pulmonary Stenosis
Patau Syndrome- Dextrocardia (heart is on the right instead of the left) (also PDA, VSD, ASD etc)
Who has Parental Responsibility of the child usually?
What 3 things make the father have parental rights?
What about for same sex couples or couples who adopt?
Biological mother usually
If someone does not have Parenteral Right, you either start a new agreement or speak to someone who used to have Parental Right
Father has Parental Rights if (3)
- Married to the child’s mother at the time of birth
- Listed on the birth Certificate
- Is in a Parental Responsibility agreement
Adoption- both parents have PR if they have both jointly adopted
Same-sex partners-
- If civil partners at time of fertility treatment- both have PR
- If not civil partners, the second parent can obtain PR by
1) applying for Parental Responsibility
2) becoming Civil Partners and jointly registering the birth
3) becoming Civil Partners and forming a Parental Responsibility
Married Step parents or Registered Civil Partners-
- Can obtain PR via Parental Agreement or spplying through courts
How can someone lose Parental Responsibility?
If awarded by courts, only the courts can remove them
Parental Responsibility is NOT LOST through divorce, loss of contact with the child or lack of financial contribution
What are the 3 other names for Parvovirus B19 and how does it present? How is it managed?
What 3 things are seen in the Prodrome?- DFC- Dallas Fried Chicken Slaps
What are the 2 other symptoms?- one of which is the only one seen in adults
And what are the 3 complications?
Fifth Disease
Slapped Cheek Syndrome
Erythema Infectiosum
Signs-
- Prodrome of FEVER, CORYZA and DIARRHOEA
- Arthralgia
- a LACE-LIKE RASH develops across the body with RED RASH on CHEEKS (may not be present in adults and would only present with Arthralgia)
Management is Supportive
Complications
1) Red cell aplasia (they didnt develop properly)
- Parvovirus infection reduced Erythropoeisis and is NOT significant for most patients, however in VULNERABLE groups that rely on Erythropoeisis (like Sickle Cell Anaemia and Hereditary Spherocytosis) it can cause SEVERE ANAEMIA which can cause an APLASTIC CRISIS
2) Infection in first half of pregnancy can cause Severe Foetal Anaemia which precipitates Hydrops Foetalis and Miscarriage
3) Cardiomyopathy
What is Patent Ductus Arteriosus and how is it managed?
The ductus arteriosus is open, even after 4 weeks of life
- May be asymptomatic or present with signs of HEART FAILURE
- Breathing issues and bradycardia is COMMON
- NO CYANOSIS- remember it is one of the Acyanotic Conditions
- Collapsing Pulse
- Unlikley to have Radio-femoral delay or Clubbing
- A MURMUR is heard- continuous MACHINE WHIRRING MURMUR throughout the cardiac cycle
Management-
- Only needed if the baby is Symptomatic
- 1/3 of patients need an NSAID- Paracetamol may be used instead as well
- Medical Closure is more successful in Premature babies
- 8% will need Surgical Ligation
What is Perthe’s Disease and how does it present?
It is the AVASCULAR NECROSIS of the femoral head occurring in children aged 4-8 years old
It presents with GRADUAL ONSET LIMP and HIP PAIN. The pain can also be referred to the knee. Transient Synovitis pain would be similar but would only last up to 2 WEEKS. If >4 WEEKS, suspect PERTHE’s
Worsening Hip pain with no other symptoms- pain hurts on passive movement
What is the diagnosis and management of Perthe’s Disease?
Diagnosis- Frog Leap Hip Xray shows INCREASED DENSITY of the FEMORAL HEAD, SCLEROSIS and FRAGMENTATION of the EPIPHYSIS. An Xray may be normal however
Management- If <50% of the femoral head is involved- Bed Rest and Traction. >50% of the femur head is involved, PLASTER CAST to keep the hip abducted or OSTEOTOMY
What is Pertussis (Whooping Cough) and how does it present?
It is a severe URTI characterised by bouts of SPASMODIC COUGHING which can lead to apnoea in infants, followed by gasping for breath
Caused by Bordetella Pertussis
It presents as a cough- where there is a PROLONGED PERIOD OF COUGHING PER EPISODE
There will also be
- Inspiratory Whooping (coughing for ages, followed by massive gasp)
- Rhinorrhoea
- Post-tussive Vomiting (Coughing after vomiting)
- Apnoea
Also High RR and Fever as expected
How is Pertussis (Whooping Cough) prevented and managed?
How is it diagnosed?
Prevented by the Pertussis Vaccination- although there may be breakthrough cases despite vaccination
Diagnosed via PCR
Management-
- First line= Macrolides, unless >21 days then Paracetamol
- If antibiotics are started late, they may not alter the course of illness but may minimise transmission to other patients
What is Phenylketonuria? How does it present?
PHenyl SMell
What are the 3 complications?
It is an AUTOSOMAL RECESSIVE MUTATION in the Phenylalanine Hydroxylase enzyme. This causes a high amount of Phenylalanine to build up to toxic levels in the blood which DAMAGES the NERVOUS SYSTEM
Signs-
- Seizures
- Poor Growth
- Hypopigmentation- leading to Fair Skin and Hair
- Musty Body Odour
Long term complications-
- Intellectual impairment
- Hyperactivity
- High risk of Eczema
How is Phenylketonuria diagnosed and managed?
It is screened for on the Blood Spot Test within the first week of life
Management-
- Lifelong Low Protein Diet and Supplemental amino acids to avoid Phenylalanine
- They must also avoid the artificial sweetener Aspartame as this becomes converted to Phenylalanine (this is found in diet fizzy drinks, sugar-free squash drinks and chewing gums)
What is Pierre Robin Sequence (or Syndrome) and how is it managed?
It is a condition where the infant is born with Micrognathia (small jaw), Glossoptysis (Posterior Tongue) and a Cleft Palate. Therefore, the infants may have breathing or feeding difficulties after birth
Management-
- Airway or feeding support. Physiological effects usually resolve within 3-6 months but surgical repair may be needed- specifically for the cleft palate. Most babies will go on to lead a normal life
What are the signs of Polycystic Kidney Disease?
4 renal (2 are linked to 2 things that happen to the cysts) and 4 extra renal (2 are linked to tube-structures)
Renal-
- Flank pain and Haematuria= Cyst Rupture
- Flank pain, Fever and Urinary Symptoms= Cyst Infection
- Hypertension
- Renal Failure (Slowly progresses to CKD)
Extra-renal-
- Extrarenal cysts- Liver, Pancreas, Spleen
- Intracranial Berry Aneurysms- commonly at the junction of the Anterior Communicating Artery and Anterior Cerebral Artery
- Mitral Valve Prolapse, Aortic Regurgitation
- Diverticular Disease
What are the 5 complications of Polycystic Kidney Disease?
4 from the renal symptoms in the other flashcard
1 from berry aneurysms
Cyst Rupture
Cyst Infection
CKD
Subarachnoid Haemorrhage (due to aneurysm)
Intracerebral Haemorrhage (due to hypertension)
What are the Investigations and Management of Polycystic Kidney Disease?
Investigations-
- Ultrasound (40, 60, 60+)- 324
1) 15-39 years old> 3 cysts
2) 40-59 years old >2 cysts bilaterally
3) >60 years old> 4 cysts bilaterally
- CT/MRI can determine the extent of the disease
Management-
- Supportive management of CKD
- Treat the hypertension
- Tolvaptan slows the Formation of Cysts
What is Potter’s Sequence?
What causes it and what are the symptoms?
Issue with Kidneys and Lungs
Also Parrot/ Chin
Caused by Pressure in utero due to Oligohydramnios
When Oligohydramnios occurs due to Bilateral Renal Agenesis, it is called Potter’s Syndrome
(SQUASHED FACE because of low amniotic fluid)
Flattened “parrot-beaked” nose
Recessed chin
Downward Epicanthal Folds
Low-set, Cartilage deficient ears
Pulmonary Hypoplasia
What is Prader Willi Syndrome?
It is a condition caused by Genetic Imprinting (meaning genes from a specific parent are interpreted differently)
A gene on Chromosome 15 is imprinted in a way that the child only expresses the maternal gene (Either deletion of the paternal copy or Disomy of the maternal copy) (“Prada has no Father”)
If the same thing happens with the maternal copy then it is called Angelman
What are the signs and management (2) of Prader Willi Syndrome?
HUSL H
How is it diagnosed?
H - Hypotonia
U - Undescended Testicles and Hypogonadism
S - Short Stature and Poor growth/ feeding initially
L - Learning Disability
H - Hyperphagia and Obesity in older child
Diagnosis- genetic testing
Management- MDT approach (locking up fridges and giving Growth Hormone for Short stature)
What is Precocious Puberty and what are the possible causes?
3 Gonadotropin Dependent
3 Gonadotropin Independent
It is when puberty occurs before 8 years in girls and 9 years on boys
Gonadotropin-Dependent Precocious Puberty (GDPP)-
- Idiopatic (90% of cases)
- Brain Tumours and Cranial Radiotherapy
- Any form of Structural Damage- Hydrocephalus, Post Infection (Meningitis), Traumatic Head Injury
Gonadotropin-Independent Precocious Puberty (GIPP)-
- Gonadal Tumours
- Adrenal or Liver Tumours
- Congenital Adrenal Hyperplasia
What investigations should be ordered in Precocious Puberty and what is the management of Precocious Puberty?
Investigations- (done by specialist)
- Testosterone
- Adrenal Androgens
- Brain MRI
- Pelvic Ultrasound
- Intra-abdominal imaging if Adrenal or Hepatic tumour is suspected
- Bone Age
Management-
- GnRH analogues (-relin)
If left untreated- Reduced Final Height and Psychology of child is also affected
What are the first signs of puberty in boys and girls?
Boys- Enlargement of Testes >4ml
Girls- Breast development
What is Preseptal and Orbital Cellulitis? What are the 2 main risk factors?
Being Immunocompromised (Diabetes) and Having other Skin Conditions
It is a Bacterial infection of the Dermis and Subcutaneous Tissue of the EYE AREA caused by Strep or Staph
What are the signs of Preseptal and Orbital Cellulitis?
What additional symptoms are seen in Orbital Cellulitis?
Remember to look out for BACTERIAL SINUSITIS as this causes Orbital Cellulitis
- Erythema, OEDEMA, Calor, Pain over the EYES
- Poorly Demarcated Margin
- Systemic Upset (Fever, Malaise)
- Lymphadenopathy
- some kind of Skin Breach (Ulcer, Wound)
Orbital Cellulitis- Visual Symptoms and Eye Movements are limited and there is ALSO a HEADACHE - there will also be Erythema and Oedema. If No Visual Symptoms= Preseptal
What is the management of Preseptal and Orbital Cellulitis?
CT SCAN to check the depth of the infection and whether the CNS is affected- then IV Co-amoxiclav
Blood Tests and Cultures (NOT CSF)
Skin Swab for Culture
Oral or IV Co-Amoxiclav (Do these asap)
Mark the area of Erythema to aid in the detection of rapidly developing cellulitis
Elevate if possible
Wound Debridement may be needed
What is a common trigger of Orbital Cellulitis?
Bacterial Sinusitis (Frontal Headache- worse when bending over, Fever, Excessive Mucous)
What are the 4 causes of Proteinuria in Children?
Orthostatic Proteinuria (most common cause)
- generally benign and requires no intervention, presents in adolescence
- repeat dipstick again in 6 hours if TRACE of protein, OR protein:creatinine ratio if POSITIVE to confirm this
Transient Proteinuria
- Children are found to have it incidentally
- commonest cause are recurrent infections and seizures (so think this BEFORE Minimal Change Disease)
- usually Benign and Self-Limiting as long as the Precipitant is treated
Nephrotic Syndrome-
- If 3+ Proteinuria in Dipstick
- Usually due to Minimal Change Disease (look for Hypertension and Puffy Eyes (or other peripheral oedema)
Type 1 Diabetes Mellitus-
- If poorly controlled diabetes- leads to Diabetic Glomerulopathy
- Good control of diabetes can limit this
How should Proteinuria in Children be managed?
2 separate urine samples should be sent for Protein:Creatinine Ratios
If it is only a trace, then repeat a DIPSTICK in 6 hours
They should also have Blood Pressure measured
What is Pyloric Stenosis?
What is seen on examination?
What metabolic readings are seen in Pyloric Stenosis?
What investigation is used to image this?
It is a condition caused by Hypertrophy of the Pyloric Sphincter
It leads to VOMITING after feeding, such as PROJECTILE VOMITING
It may increase with Intensity as the obstruction becomes more severe
There will be a SMOOTH PALPABLE OLIVE SIZED MASS especially during feeding
It is diagnosed through ABDOMINAL ULTRASOUND
They will have Hypokalaemic, Hypocholoraemic Metabolic Alkalosis
How is Pyloric Stenosis managed?
Surgical- Laparoscopic Pylorotomy
Until then they should be Nil-by-mouth and kept on IV Fluids
They may need resuscitation if Severe Dehydration
What are the 9 common causes of Rashes in Children?
Sarah’s skin had several maladies, usually concerning rash and redness
Septicaemia (or other causes of a Purpuric Rash)
Slapped Cheek Syndrome
Hand, Foot and Mouth Disease
Scarlet Fever
Measles
Urticaria (Hives)
Chickenpox
Roseola
Rubella
What are the signs and management of Septicaemia in Children?
What other disease should you watch out for if they present with Septicaemia? and what should be given if it is suspected?
(Patient is rapidly deteriorating after a recent surgery/ infection with multiple signs below)
Suspect if there is a RAPIDLY-DEVELOPING, NON-BLANCHING PURPURIC RASH which occurs AFTER any of the following:
- Lethargy
- Headache
- Fever
- Rigors
- Vomiting
Management-
- Cultures and IV Antibiotics ASAP (Septicaemia therefore CULTURE and Abx ASAP)
- Inform Senior Paediatrician
- IM Benzylpenicillin if Meningitis is suspected
Apart from Septicaemia, what are the other 8 differential diagnoses of a Purpuric Rash in Paediatrics?
4 related to coagulation
+ VMTL
Trauma
Liver Disease
Drugs (Anticoagulants)
Coagulopathy
Thrombocytopaenia
Disseminated Intravascular Coagulation
Vasculitis
Malignancy
What is Hand, Foot and Mouth Disease? What causes it and what is the management?
Blisters in the hands and feet and Grey Ulcerations in the mouth
It is preceded by 1 day of Fever and Lethargy
It is caused by Coxsackie Virus A16
It resolves within 1 week and children do not need to be isolated
What is Scarlet Fever? What causes it and what is the management?
A Sandpaper Coarse Red Rash on the Cheeks with a Bright Red Tongue
Other signs- (Scarlet H. Fever)- In addition to the TONGUE and the RASH
- Sore Throat
- Headache
- Fever (<5 days- otherwise consider kawasaki)
It is caused by Streptococcus
It is managed with 10 days of Phenoxymethylpenicillin
Children remain infectious until 1 day after first Antibiotics dose
What is Urticaria (Hives) and how is it managed?
Raised, Itchy Red Rashes that are NOT accompanied by a Fever. Can present as part of an Anaphylaxis reaction
Antihistamines and Maybe Steroids can be given but it is usually self limiting
What are the 6 red flags to look out for in Vomiting in Children?
- Signs of Dehydration (Sunken Eyes, Drowsy, Floppy, Dry Mucous Membranes)
- Projectile Vomiting- Pyloric Stenosis
- Bile-stained (green) and Abdominal Distension- Intestinal Obstruction
- Bloody Stool with Vomiting- Dysentery, Intussusception
- Paroxysmal Coughing up to the point of vomiting- Whooping cough
- Seizures/ Bulging Anterior Fontanelle- Raised Intracranial Pressure
What is Reye’s Syndrome?
Brain Liver Vomit
It is a Neurological Condition associated with Aspirin Use while the Child has a Viral Infection
So Aspirin is Contraindicated in Children
It is confirmed by Liver Biopsy (Steatosis)
It presents as Abnormal LFTs, Vomiting and Encephalopathy (Slurred Speech, Coma, Lethargy, Death)
BTW- management is just supportive- Fluids and Electrolytes
What is Rickets and how does it present?
What is the additional sign that Rickets causes that is not to do with bones? (3 signs + 1 extra)
It is Vitamin D Deficiency in Children (Osteomalacia in Adults)
(Especially seen in children with high skin pigmentation living in low sunlight areas)
Signs
- Aching bones and joints
- Poor growth and development
- Delayed Dentition (No teeth have come through by 18 months)
- Weakness and Constipation (as calcium is needed by muscles in gut and limbs)
How is Rickets Diagnosed and Managed?
What are the 3 radiological evidence that should be looked out for in rickets?
BOW WOW HARRIS
Diagnosis- Low level of Blood Vitamin D and additional Radiological evidence such as Bowed Femurs and Widened Epiphyseal Plates, also Harrison’s Sulci
Managed- Oral Vitamin D supplements
What are the Differentials for Right Iliac Fossa pain in Children?
5 GI-
The 2 M’s and 3 others
4 Gynae
2 Urological
GI Causes-
- Acute Appendicitis
- Mesenteric Adenitis
- Inflamed Meckel’s Diverticulum
- Diverticulitis (although this is more common on the left)
- Inflammatory Bowel Disease (Crohn’s)
Gynaecology Causes-
- Ectopic Pregnancy
- Ovarian Torsion
- Ovarian Cyst Rupture
- Pelvic Inflammatory Disease
Urological Causes-
- Pyelonephritis
- Ureteric Colic
What is Roseola Infantum and how does it present? How is it managed?
What virus causes it?
What other disease has the same initial symptoms, and what is the difference between these initial symptoms between these two diseases?
Is the rash Blanching or Not?
It is caused by Human Herpes Virus 6
Presentation-
- Children are initially Febrile and Lethargic like HFM Disease for up to 5 days. Fevers can be as high as 40 degrees C
- There is also a BLANCHING, ROSE-PINK MACULAR RASH which typically covers the trunk. This can also spread to the face and limbs. TRUNK FIRST
Management is supportive
How does Rubella present and what is it?
How is it diagnosed?
It is caused by a virus transmitted by Aerosols
It presents as non-specific signs such as Fever, Coryza, Arthralgia and a Rash (F.A.C (E=Ear lymph nodes))- which starts on the FACE and then moves to the TRUNK (usually sparing the limbs). There is also Post-Auricular Lymphadenopathy. Measles involves the limbs
MACULOPAPULAR RASH STARTING AT THE FACE
Diagnosis is Serological Testing and Management is Supportive
What is Salmonella Typhii (Typhoid) Infection and how does it present?
CHARADO (CHARD)
It occurs in developing countries usually due to contaminated waters
It presents as a Long Febrile Condition in a patient who has returned from a developing country (usually the Indian Subcontinent)
Symptoms-
C - Constipation then Diarrhoea
H - Hepatosplenomegaly and Abdominal Pain
A - Anorexia and Lethargy
R - Rose Spot Rash
A - Associated with Salmonella Typhi
D - Dull frontal headache
O - Other systemic symptoms
How is Salmonella Typhii (Typhoid) diagnosed (2) and managed?
CIPCEPH
WCC is normal or Low
Blood and Stool Cultures are NEEDED to confirm diagnosis
Management- Ciprofloxacin or Cephalosporin is usually first line
What are the complications of Typhoid?
Sepsis
Intestinal Perforation and Haemorrhage (Typhoid damages intestines)
Focal Infections in Other Sites (Osteomyelitis)
How does Epilepsy present and how is it diagnosed and managed?
Focal Seizures- Visual Phenomena (Occipital Lobe Focal Seizure), Strange Smells (Temporal Lobe Focal Seizures)
Generalised Seizures- Tonic (muscles stiffening), Tonic-Clonic (muscles stiffen then jerk), Myoclonic (brief jerking movements), Atonic (children fall to the floor) or Absence (unresponsive episodes where the child appears to be Daydreaming)
Diagnosed with EEG. CT and MRI should be used only to find structural abnormalities.
Management-
- MDT input for Antiepileptics and Emergency Seizure management plans
What are Febrile Convulsions and how do they present?
They happen in 6 month to 6 year olds
They are diagnosed from history alone
They are managed with antiepileptics and the source of the infection is also managed
What is West Syndrome/ Infantile Spasms and how is it diagnosed?
Seizures consisting of Myoclonic (Jack Knife Jerking) that occurs in clusters
They are diagnosed with history and EEG findings of HYPSARRHYTHMIA
It is associated with Developmental Regression
What are Benign Rolandic Seizures and how are they diagnosed?
When do they occur?
What is seen on EEG?
They affect children between 3-10 years old and almost always occur when they are sleeping
Tonic Seizure overnight- parents sometimes find the child has fallen out of bed in the morning with messy sheets
Diagnosis-
History and EEG findings of CENTRO-TEMPORAL SPIKES during sleep
Most children outgrow the condition during puberty
Jerking can also occur in Vasovagal Syncope
Remember that!
What are the potential signs of Sepsis?
Lethargy and Poor Social Interaction
Generally feeling unwell
Altered Consciousness
Continuous Crying
Pale or Mottled Skin
Poor Feeding and Decreased Urine Output
Cool Peripheries
Increased Respiratory Rate and Effort
Bradycardia or Tachycardia
Dehydration
Fever (may not always be there)
What are the 6 CONCERNING SIGNS of Sepsis in Children?
2 Heart, 2 Skin, 2 Breathing
Cyanosis
Bradycardia or Tachycardia
Mottled Skin
A Non-Blanching Rash
Bradypnoea or Tachypnoea
Child does not Stay awake
What are some tests that should be ordered in Sepsis?
Do the simplest ones first that allow you to find the source of the infeciton
FBC
CRP
U&Es
Blood Cultures and Cultures of other tissues where necessary
Creatinine
Clotting Screen
Lactate
Blood Gas
To find the source of infection-
- Urinalysis
- Chest Xray
- Abdomen and Pelvic Xray
- Lumbar Puncture if there are no contraindications (Raised ICP, Focal Neurological Signs or Fluctuating Consciousness)
- Swabs
What is the management of Sepsis in Children?
Broad Spectrum Antibiotics (TAZOCIN) ASAP
Oxygen and Fluids if Necessary
Escalate to a Senior Paediatrician within 1 hour for Review
Close Monitoring
They may need to Move to HDU/ PICU and may need INOTROPIC SUPPORT
Which Test Result is Specific for Bacterial Sepsis?
Procalcitonin
What is Osteomyelitis and what usually causes it?
Which 2 pathogens?
What are the main risk factors?
What should you look out for in patients that would increase the risk of this diagnosis?
It is a Bacterial or Fungal Infection of the bone which can be Acute or Chronic
The most common underlying pathogens are Staph Aureus and Coagulase Negative Staphs
Usually occurs due to risk factors such as Diabetes and Peripheral Vascular Diseases (also Malnutrition, Malignancy and Immunosuppression)
It can occur if an infection is inoculated into the bone due to a Wound Contamination during a Surgery or Trauma
What are the signs of Acute and Chronic Osteomyelitis?
Acute- (signs of inflammation and a fever)
- Fever
- Pain
- Swelling
- Erythema
Chronic-
- Long History of Pain
- A Wound or Sinus Tract that is Persistently Draining and Soft Tissue Damage
- Risk Factors such as Diabetes and Peripheral Vascular Disease increase the likelihood of these occurring
What investigations should be ordered if Osteomyelitis is suspected?
What is needed for definitive diagnosis?
What is the imaging modality of choice and what are the 2 other imaging options?
How long does it take the Xray to be positive?
For Definitive Diagnosis- Bone Biopsy needed for Pathology and culture
Other tests to aid diagnosis-
- Blood Inflammatory Markers
- Imaging-
1) MRI- This is the imaging Modality of Choice
2) X ray (may be negative early on as it takes 7 days for the Periosteal Reaction to be seen, and bone necrosis is see after 10 days).
3) CT- Helps identify Necrotic Tissue and good for guiding the biopsy
Other tests= Blood Cultures and Culture any Expressed Pus (Aside from the ones from Sinus Tracts)
What is the management of Osteomyelitis?
FUSFLU or RIFLU and Vancomycin if MRSA is suspected
IV first
What should be done if it is Chronic (2)
Antibiotics for 4-6 weeks
- Flucoxacillin plus Fusidic Acid/ Rifampicin, or Vancomycin if MRSA is suspected
- If they are Penicillin-allergic then give them Clindamycin
- Start with IV Antibiotics and THEN Switch to Oral Antibiotics when they are stable or 2 weeks post surgery
- If it is Chronic Osteomyelitis- then delay treatment until Cultures have been taken
Surgical Debridement-
- This is the definitive treatment if Chronic
- If Acute, Extensive Surgical Cleaning can be given early on with the Antibiotics
What is Short Stature defines as and what are the main Primary Causes?
A height that is <2.5th Percentile or >2 standard deviations below their mid-parental height
- Familial Causes
- Constitutional Delay in Growth and Puberty
- Syndromes (Down’s and Turner Syndrome)
- Skeletal Dysplasia (Achondroplasia (Dwarfism) and Hypochondroplasia)
What are the Secondary Causes of a Short Stature?
- Malnutrition
- Neglect
- Chronic Conditions (Heart Failure, Coeliac Disease, Sickle Cell, Cystic Fibrosis, IBD, Renal Failure, Inflammatory Conditions)
- Endocrine (Hypothyroidism, Cushing’s, Growth Hormone Deficiency)
What are the signs of Turner’s Syndrome?
It only occurs in women
Shield-Shaped Chest
Low Posterior Hairline
Amenorrhoea
Webbed Neck
Short Stature
How does Sickle Cell Disease cause Hyposplenism (means low Spleen function NOT Small Spleen)?
Sickle Cells sequester (hide away) in the Spleen and undergo Phagocytosis which leads to Extravascular Haemolysis. This leads to Spleen Congestion and Splenomegaly.
The spleen is needed for Phagocytosis and this becomes compromised so the patient is at risk of infections
How does Sickle Cell Disease Present?
Progressive Anaemia post-natally as Foetal Hb levels fall
Vaso-Occlusive Crises (pain in bones, joints and abdomen)-
- Microvascular Obstruction due to the Sickle Cells- could be triggered by Local Hypoxia (Like Cold Weather)
- Pain and ischaemia of downstream tissues
Acute Chest Crises-
- The most dangerous presentations
- Tachypnoea
- Wheeze
- Cough
- Hypoxia
- Pulmonary Infiltrates
How is Sickle Cell Disease managed?
What is given for crisis (3) and added if Acute CHEST Syndrome is suspected?
What is given for the management of Chronic Sickle Cell Disease? (4+Immune)
In Crisis-
- Oxygen, Fluids and Analgesia (IV Opiates)
- Treat any suspected infections
- Spirometry and Physiotherapy if Acute Chest Syndrome- to prevent Atelectasis (Collapse or incomplete inflation of Lung)
Chronic Sickle Cell Disease-
- Hydroxycarbamide if frequent crises- which Increases Fetal Haemoglobin Concentration
- Top-up Transfusions, Folic Acid and Iron Chelations
- Regular Exchange transfusions may be needed if Severe Anaemia
- If Splenic Infarction and Immunocompromise as a result- Vaccinations (Influenza and Pneumococcal) and Antibiotics (Penicillin)
What would investigations show for Sickle Cell Disease?
M - Microcytic anemia with haemolysis (reticulocytosis and unconjugated hyperbilirubinaemia)
B3 - Blood film: sickle cells, target cells, reticulocytosis with polychromasia
H2 - Hyposplenism signs: Howell-Jolly bodies and nucleated red blood cells
D - Definitive diagnosis: haemoglobin electrophoresis and genetic testing
What are the complications of Sickle Cell Disease?
S.O.S.
P.A.G.I.C.
Sequestration Crisis (Splenomegaly, Pale Skin, Headache, Fatigue)- as oxygen flow is low to organs and splenomegaly compresses LUQ which can lead to a headache
Osteomyelitis
Stroke
Pulmonary Fibrosis and Pulmonary Hypertension
Aplastic Crisis (Red Cell Aplasia) (Low red cells which leads to anaemia)- If tachycardia and tachypnoea and no jaundice
Gallstones
Iron Overload
Chronic Kidney Disease
What is Slipped Upper Femoral Epiphysis? What are the 3 categories of risk factors and signs?
It is the most common hip disorder in adolescents (10-16 year olds). It occurs when weakness in the proximal femoral growth plate allows Displacement of the Capital Femoral Epiphysis
- Obese, Adolescent Males
- Endocrine Disorders (Hypothyrodism and Hypogonadism)
- Afro-Caribbean or Hispanic Ethnicity
Signs-
- Hip pain and a limp (It can be acute or chronic)
- Pain may be referred to the KNEE
- Reduced range of movement of Hip Flexion- and AFFECTED LEG may appear shorter
- Positive Trendelenburg Sign (Pelvis opposite affected leg drops when the unaffected leg is lifted)
What is the diagnosis (2 things seen on Xray) and management of Slipped Upper Femoral Epiphysis?
Diagnosed- Anterolateral and Frog-Leg Xrays which may show Short-Displaced Epiphysis and Widened Growth Plate (Ice cream falling off cone)
Management- Surgical management- Fixation with a Screw. Prompt treatment is needed to avoid Blood Flow being Disrupted and reduce the risk of Avascular Necrosis of the Femoral Head
What is the management of Status Epilepticus in Paediatrics?
- Roll on side (if safe to do so) and give OXYGEN and GLUCOSE
- First line Treatment if seizure has not resolved within 5 minutes= IV Lorazepam or Buccal Midazolam or Rectal Diazepam
- If Seizures continue after 10 minutes- IV Lorazepam
- If they continue for another 10 minutes- IV Lorazepam (consider anaesthesia and call for senior support)
- IV Phenytoin (IV Phenobarbitane if they Normally take Phenytoin)
- Rapid Sequence Induction with Sodium Thiopentane
What are the Complications of Status Epilepticus?
Focal Neurological Deficit
Memory Loss
Behavioural Problems
Hypoxic Brain Injury
How does a Strangulated Hernia present and how is it managed?
It is a hernia that cuts off the blood supply to the intestines and tissue in the abdomen
- Abdominal pain and vomiting
- They can have an intermittent history of pain. The bowel that forms the hernia can become ischaemic and necrotic which leads to Sepsis or Perforations
Management-
- Surgery and follow up with a Mesh to strengthen the site
What are the 3 causes of Stridor in Paediatrics?
Croup (temperature usually not seen)
- Cough and Coryzal symptoms
- Symptoms are worse at Night
Epiglottitis
- High Temperature, Struggling to Breathe and Drooling
- Very irritable
Bacterial Tracheitis
- Intermediary symptoms between Croup and Epiglottitis
- Shortness of Breath and Temperature
What are the signs of Testicular Torsion? How is it managed?
A sudden-onset severe pain in one testicle- often following a minor trauma
It will be high-riding in the scrotum
Unilateral loss of Cremasteric Reflex
Negative Prehn’s Sign (No relief on lifting the testicle)
Management- Orchidopexy. BOTH testicles should be fixed to prevent the other one undergoing torsion as well
How is Torsion of the Epididymal Appendage (Hydatid of Morgagni) different from Testicular Torsion?
It is a remnant of the Mullerian Duct
It causes less pain than Torsion and here may be a tiny blue dot visible
What is Tetralogy of Fallot?
It is a Cyanotic Heart Disease consisting of 4 parts and 1 extra part
- Ventricular Septal Defect
- Overriding Aorta (An Aorta that overrides the right and the left ventricle as a result of the Ventral Septal Defect)
- Right Ventricular Hypertrophy
- Right Ventricular Outflow Tract Obstruction due to Pulmonary Stenosis= the main cause of the Cyanosis
How does Tetralogy of Fallot present and how is it managed?
It is diagnosed Antenatally (Boot Shaped Heart on ECHO) or on the detection of a Murmur within the first few months of life
- Murmur
- Cyanosis
- Weakness or Fatigue during feeding or physical activity
- Tet Spells= Acute Episodes of Cyanosis (there is Reversal of the shunt across the VSD leading to a Right-to-Left Shunt and Worsening Cyanosis)
Management-
- Tet Spell=
1) Emergency- Lie the Baby on their back and bend their knees
2) Give them Oxygen as well
3) A Vasoconstrictive Agent (Phenylephrine) is reserved for Severe Episodes
3) Prophylaxis- Propanolol
- General Tetralogy of Fallot=
1) Surgery- Fixing the Ventricular Septal Defect and Right Ventricular Outflow Tract Obstruction is Definitive
What pathogen causes Tonsilitis? How doe you differentiate between Bacterial and Viral?
Strep Pneumoniae for Bacterial and EBV for Viral
Bacterial- Cervical Lymphadenopathy
Viral- Headache, Apathy, Abdominal Pain
Also the CENTOR Criteria gives the likelihood of the infection being bacterial
What is the CENTOR Criteria for Bacterial Tonsilitis? (More of these signs= more likely it is bacterial and not viral)
4 criteria= TTFA
1) Tonsilar Exudate
2) Tender Anterior Cervical Lymphadenopathy
3) Fever over 38
4) Absence of Cough
What is the management of Bacterial Tonsilitis?
If CENTOR = 3 or 4 or if they are Immunosuppressed or Systemically Upset
1) Penicillin V 500mg PO QDS for 5-10 days
2) Otherwise Clarithromycin/ Erythromycin 250-500mg PO BD for 5 days
Tonsilectomy IF-
- Sore Throats are due to Tonsilitis
- Person has at least 5 episodes per year
- Symptoms have been occurring for at least a year
- The episodes prevent normal functioning
What is Transient Synovitis and what causes it? What are the signs of Transient Synovitis?
What is usually seen before it?
3-10 year olds
It is a benign cause of LIMPING due to inflammation of the Synovial Lining
It is caused by a Viral Infection (usually an Upper Respiratory Tract Infection) that happens before the limp
Signs-
- Pain in Hip and Knee (referred from hip)
- Low Grade Fever
- Similar to Septic Arthritis but Transient Synovitis is more MILD (Milder pain and Milder pain)
How is Transient Synovitis diagnosed and managed?
3 Investigations- What conditions should be ruled out with these investigations?
Blood tests- High WCC and Inflammatory markers point to Septic Arthritis but may be Normal or Raised inboth conditions
Ultrasound may show Joint Effusion but may be normal
If unsure whether it is Septic Arthritis or Transient Synovitis- do Joint Aspiration (with Ultrasound Guidance and Cultures)
Culture- If Septic Arthritis= Aspiration shows Bacteria within the joint space
MANAGEMENT-
- Supportive treatment as it resolves in 7 days
What are Kocher’s Criteria (factors that make Septic Arthritis more likely)?
4 things- 3 things are about inflammation ond 2 of these are about the blood
Fever> 38C
Refusal to weight bear on affected side (so the pain is SUPER BAD)
Raised Inflammatory Markers (ESR and CRP)
Raised WCC
What is Transient Tachypnoea of the Newborn?
It is a PULMONARY OEDEMA that occurs due to the delayed clearance of Foetal Alveolar Fluid. It is the MOST COMMON cause of respiratory distress in newborns
It usually occurs after C Section as passage through the birth canal usually puts pressure on the baby thorax to help them expel the fluid
Signs-
- Respiratory Distress= Tachypnoea, Laboured breathing and Cyanosis/ Pale
How is Transient Tachypnoea of the Newborn diagnosed and managed?
Diagnosis- Clinical Diagnosis and Chest X ray shows HYPERINFLATED LUNGS and FLUID LEVEL
Management- Oxygen Support and TTN should resolve on its own on the first 3 days of life
What is Transposition of the Great Arteries? How is it diagnosed and managed?
What maternal condition increases the risk of TGA occurring?
When does the cyanosis occur and what type of murmur is heard?
It is a Cyanotic Heart Condition where the origins of the Aorta and the Pulmonary Artery are swapped
Usually in the babies of Diabetic Mother
Diagnosis- Most are made Antenatally, Some may be diagnosed Postnatally with Cyanosis in the first 24 hours of life and a LOUD S2
Management- Surgery is needed ASAP. Give them PROSTAGLANDIN E (Alprostadil) to keep the Ductus Arteriosus open until they get the surgery
What are the 3 major Trisomy Disorders?
Patau, Edward and Down Syndrome
Remember Patau= Puberty (13). Edward= Education (18), Down= Degree (21)
What are the signs of Patau and Edwards Syndrome?
Patau- They rarely survive more than a few weeks
- Holoprosencephaly (failure of the 2 cerebral hemispheres to divide so may only have ONE EYE and ONE NOSTRIL)
- Cleft lip and palate
- Microcephaly
- Polydactyl
- Congenital Heart Disease
- Rocked Bottomed feet (Clubbed Feet) (seen in Edward Syndrome as well)
- Outer fingers overlap the inner fingers
Edward- they rarely survive more than a few months
- Low set ears
- Micrognathia
- Microcephaly
- Overlapping 4th and 5th fingers
- Congenital Heart Disease
What is Tuberous Sclerosis? What are the signs and how is it managed (4)?
Some Angels Sing Radiating Charisma
(SASRC)
It is an Autosomal Dominant, Neurocutaneous Syndrome consisting of Cellular Hyperplasia, Tissue Dysplasia and Hamartomas involving multiple organs
Signs-
- Spasms (repetitive behaviours) with Hypsarrhythmias seen on EEG
- Ash-leaf Macules (Hypopigmentation), Shagreen Patches (leathery patches) , Facial Angiofibromas, Subungal Fibromas (Skin)
- Subependymal nodes, Seizures and Learning Disability (Neurological/ Cognitive)
- Renal- Angiomyolipomas
- Cardiac- Cardiac Rhabdomyomas
Management-
- Angiofibromas<2mm= LASER
- Angiofibromas>2mm= Dermabrasion or Surgical Resection
- If Renal disease, they may require Antihypertensive therapy
- Tubers should be regularly imaged and may require RESECTION
What is Turner’s Syndrome and how does it present? How is it managed?
It is caused by an XO Karyotype and it affects ONLY FEMALES as a result of this
Signs-
- Delayed Puberty and Short Stature
- Lymphoedema of hands and feet in neonate
- Spoon-shaped nails
- Webbed neck
- Wide spaced Nipples (Shield Shaped Chest)
- Hypothyroidism
- Recurrent Otitis Media
- Congenital Heart Defect (Bicuspid Aortic Valve Usually so Aortic Stenosis, but can also be Coarctation)
Managed with Growth Hormone therapy and Oestrogen Replacement to allow the Secondary Sexual Characteristics to develop
How does Type 1 Diabetes Mellitus present? How is it diagnosed and managed?
Polyuria
Polydipsia
Weight Loss
Can lead to DKA so may present with this
Diagnosis-
- Raised Blood Glucose (>11), High HbA1c, Ketones and Fasting Glucose (>7)
Management-
- Insulin Replacement (short acting- after meals and long acting-at night)
What is the Honeymoon Period of Type 1 Diabetes Mellitus?
Insulin requirements may be low if the pancreas is still able to produce a significant amount of insulin. This is the Honeymoon period until all the beta cells are destroyed
What are the complications of T1DM?
Delayed Puberty and Obesity
Hypertension
Renal Disease
Retinopathy
Associated with Thyroid Disease (most associated with this) and Coeliac Disease
What are the signs of a UTI? How is it Diagnosed
Signs (REMEMBER THE FIRST 4)
- Fever
- Vomiting
- Poor Feeding
- Lethargy
- Irritability
- Failure to Thrive
- Offensive Urine
- Abdominal Pain
- Dysuria
Diagnosis- Positive Leucocytes and Nitrites and Positive Urine Cultures
What is the management of a UTI?
Oral Antibiotics (Lower UTI= Nitrofurantoin and Upper UTI= Cephalosporin)
Conduct pregnancy test if necessary
What are the 6 signs of an Atypical UTI?
Perform an ULTRASOUND if these are present
Poor Urine Flow
Abdominal or Bladder mass
Raised Creatinine
Infection with non-E.Coli organisms
Septicaemia
Failure to respond to treatment within 2 days
What are the 3 follow up imaging choices for a UTI?
Ultrasound- for structural abnormalities, only needed if Atypical UTI
DMSA (Scintigraphy)- for Scarring- don’t do until 4 months after UTI
MCUG- check for abnormal bladder function
How should urine be collected in babies who can’t voluntarily urinate or arent potty trained?
Urine Collection Pad
What are the common and rare side effects of Vaccinations?
Common-
- Tenderness and aches around site of injection
- Fever and unwell for few hours
- Fever is common with Meningococcal vaccination so should give them Prophylactic Paracetamol and parents should be warned
Rare-
- Anaphylaxis
- Rotavirus vaccination can cause Intusussception
- MMR can cause Seizures and Idiopathic Thrombocytopaenia Purpura
What are the 4 contraindications to vaccinations?
2 obvious ones and 2 specific ones dependent on 2 diseases
Egg Allergy
- Avoid Yellow Fever vaccination
- Avoid Influenza if they have been admitted to PICU because of their egg allergy
Previous anaphylaxis to vaccine components
Immunosuppression- should not have live attenuated vaccinations
Intussusception- should not have Rotaviruses
What is the presentation and diagnosis of Ventral Septal Defects? How are they managed?
What type of murmur do they have?
What 3 investigations can be conducted and what is seen on the CXR and ECG?
They are the MOST COMMON CONGENITAL CARDIAC ABNORMALITY
Signs- (Effort when breathing and murmur)
- Asymptomatic if small
- Pan-Systolic Murmur
- If Large, Shortness of Breath on exertion (such as when breastfeeding)
- As breathing is more effort, they GROW LESS
- Heart Failure
Diagnosis-
- ECHOCARDIOGRAM
- CXR and ECG show Enlarged Left Ventricle
Management-
- Majority of them self-resolve so just observe calorie intake and follow up
- If they don’t resolve, close them via catheter intervention
What is the Vesicouretic Reflex and how is it diagnosed? What are the 2 main risk factors?
It is the abnormal flow of Urine from the Bladder into the Upper Urinary Tract due to either a Short or Absent Valve. Backflow of urine basically
It is diagnosed through MCUG
2 main risk factors-
- Neurogenic Bladder
- Posterior Urethral Valves (only occurs in males)
It presents as:
- RECURRENT UTIS (if this happens in general, FIND OUT WHY via US/ if<6 months MCUG)
- Incomplete Voiding
What are the 5 Grades and management of Vesicoureteric Reflex?
Grade 1- into Ureters only
Grade 2- into Pelvis causing no dilatation of Ureters
Grade 3- into Pelvis causing Mild Dilatation
Grade 4- into pelvis causing Moderate Dilatation
Grade 5- through to Calyces
Management-
- Grades 1-3 resolve on their own
- Surgery may be needed if Grade 4 or 5 or if Scarring, Sepsis, CKD, Reflux Nephropathy
What are the 5 causes and other causes of Visual Impairment in Children?
Oculocutaneous Albinism
Retinoblastoma
Retinopathy of Prematurity
Cataracts
Juvenile Idiopathic Arthritis
What is Oculocutaneous Albinism?
What is the Genetic Inheritance?
Autosomal Recessive
Poor Development in the Fovea of an Albino patient
Care should be taken to avoid further damage
What is a Retinoblastoma?
What makes this likely?
What gene causes this?
It is a tumour of the retina that occurs in Infancy or Childhood
Children present with White Eye Reflex (basically no Red Eye Reflex)
It occurs due to a Double Hit of the Rb Suppressor Gene
What is Retinopathy of Prematurity?
What causes it?
What warrants screening?
What is the treatment
It is a visual impairment in Premature Babies
It is thought to be due to Free Radicals released by the Supplemental Oxygen Therapy which leads to Retinal Fibrosis, Retinal Detachment and then Blindness
Babies born <32 weeks gestation or <1.5kg should be screened for Retinopathy of Prematurity via Fundoscopy
Treatment- Laser Therapy
What are Cataracts?
They are a cause of Absent Red Reflex, typically caused by Infections or Metabolic Defects
How can Juvenile Idiopathic Arthritis cause Visual Loss?
Through Chronic Anterior Uveitis- so Screen for this in Juvenile Idiopathic Arthritis
What is Vitamin K Deficiency and how is it managed?
It occurs especially if the babies are exclusively Breastfed
Babies BRUISE more easily and there may be INTERNAL BLEEDING which can lead to Jaundice
Management-
- Subcutaneous Vitamin K injections to prevent Haemorrhagic Disease of the Newborn
- Can also be Oral
If Unmanaged it can lead to Haemorrhagic Shock
What is Wilm’s Tumour (Nephroblastoma)? What are the signs?
It is the Most Common Abdominal Tumour in Children occurring in 2-5 year olds
It presents as:
- An Abdominal mass that does NOT cross the midline
- Abdominal Distension
- Haematuria
- Hypertension
- Although it is usually Asymptomatic
How is Wilm’s tumour diagnosed (2- one for definitive diagnosis and one for identifying spread) and managed?
Diagnosis-
- CTAP identifies extent and spread of disease
- DEFINITIVE DIAGNOSIS- Renal Biopsy which shows Small Round Blue Cells
Management-
- Nephrectomy, Chemotherapy, Radiotherapy
Explain the Suitability of the Progesterone Only Pill
It can be used by women who can not use Oestrogen
Women who have contraindications such as >15 cigarettes, >35 years old and migraine
It can also be used by Breastfeeding Women
What are the different patterns of Inheritablity of Down Syndrome?
Meiotic Dysjunction (94% of cases)
- Error during meiosis
Robertsonian Translocation (5% of cases)
- A piece of chromosome 21 or a complete copy of it are attached to another chromosome (usually 14)
Mosaicism (rare)
- some cells have trisomy 21 while others do not
What is seen in Xray for Croup and Acute Epiglottitis?
Croup= STEEPLE ANGLE (subglottic narrowing)
Acute Epiglottitis= THUMB SIGN
