Paediatrics- respiratory and ENT Flashcards
Mild croup
- Occasional barking cough
- No audible stridor at rest
*No or mild suprasternal and/or intercostal recession - The child is happy and is prepared to eat, drink, and play
Moderate croup
- Frequent barking cough
- Easily audible stridor at rest
- Suprasternal and sternal wall retraction at rest
- No or little distress or agitation
- The child can be placated and is interested in its surroundings
Severe croup
- Frequent barking cough
- Prominent inspiratory (and occasionally, expiratory) stridor at rest
- Marked sternal wall retractions
- Significant distress and agitation, or lethargy or restlessness (a sign of hypoxaemia)
- Tachycardia occurs with more severe obstructive symptoms and hypoxaemia
Croup- when to admit to hospital
- Moderate or severe croup
- <6 months of age
- Known upper airway abnormalities i.e. Laryngomalacia, Down’s syndrome
- Uncertainty about diagnosis
Croup- investigations
- the vast majority of children are diagnosed clinically
- however, if a chest x-ray is done: a posterior-anterior view will show subglottic narrowing, commonly called the ‘steeple sign’. In contrast, a lateral view in acute epiglottis will show swelling of the epiglottis - the ‘thumb sign’
Tonsilitis- causes and symptoms
Inflammation of palatine tonsils (often due to infection)
* Causes: Viruses (rhinovirus, coronavirus, RSV, EBV); bacteria (mainly group A beta-haemolytic streptococci = ‘strep throat’)
*Symptoms: Throat pain; odynophagia; referred ear pain; hoarse voice(esp. if associated laryngitis); headache; small children may have abdominal pain
* Signs: Red, swollen tonsils +/- exudate; fever; cervical lymphadenopathy
Tonsillitis- investigations and when to refer
- Investigations: Usually not needed; sepsis 6 if septic; consider throat swab (esp. for streptococci)
- Refer: Difficulty breathing; dehydration; systemic illness/possible sepsis; peritonsillar/retropharyngeal abscess
Tonsilitis- centor criteria
- Exudate on tonsils (1 point)
- Tender anterior cervical lymph nodes (1 point)
- Absence of cough (1 point)
- Fever >38 degrees (1 point)
Tonsilitis- management
- Conservative: Explanation and reassurance, ‘delayed prescription’
- Medical: Analgesia/antipyretics (paracetamol/ibuprofen); topical analgesia (benzydamine spray); consider antibiotics if Centor score >3 (10 days penicillin V/clarithromycin)
Interpreting centor score
- A score of 0, 1 or 2 is thought to be associated with a 3 to 17% likelihood of isolating streptococcus.
- A score of 3 or 4 is thought to be associated with a 32 to 56% likelihood of isolating streptococcus.
A Centor criteria score of 3/4 would warrant prescribing antibiotics or evidence of systemic upset/immunosuppression
Antibiotics prescribed in tonsilitis
- 1st line: Penicillin V 500mg PO QDS for 5-10 days
- Alternative in penicillin allergy: Clarithromycin/Erythromycin 250-500mg PO BD for 5 days
Surgical management of tonsillitis
- Tonsillectomy if recurrent episodes (3 yearly for 3 years; 5 for 2 years or 7 in 1 year)
- Also indicated for obstructive sleep apnoea from enlarged tonsils/adenoids
- Admit for drainage if peritonsillar abscess forms
Otitis media- symptoms
Bacteria transfer more easily in children from the nasopharynx due to a shallower Eustachian tube angle
Signs and symptoms
* Symptoms: ear pain (young children may pull at affected ear), fever, coryza, vomiting
* Signs: fever, red eardrum, if discharging (suppurative) suggests perforation, sometimes red pinna
Types of otitis media
- Benign chronic otitis media: dry tympanic membrane perforation without chronic infection
- Chronic secretory otitis media (glue ear): presents as persistent pain, lasting a couple of weeks after the initial episode. The drum looks abnormal and shows reduced mobility of the membrane
- Chronic Suppurative Otitis Media: diagnosed when there is persistent purulent drainage through the perforated tympanic membrane
Management of otitis media
- Investigations: usually none (swab if recurrent/grommets in situ)
- Conservative: reassurance, ‘delayed prescription’, safety net advice
- Medical: simple analgesia/antipyretics. 5 days amoxicillin/erythromycin IF systemically unwell/AOM for > 4 days/ comorbidities (e.g/ congenital heart disease/chronic lung disease/immunocompromise)
- Surgical: refer to ENT surgeon if recurrent episodes or complications
Otitis media- when to admit
- Admit any children under 3 months with a temperature of 38 or more, or children with suspected acute complications of otitis media such as meningitis, mastoiditis or facial nerve palsy.
- Consider admitting any children who are very systemically unwell.
- Otherwise, treat pain and fever with paracetamol or ibuprofen
Otitis media: complications
- Extra-cranial: Facial nerve palsy, Mastoiditis, Petrositis, Labrynthitis
- Intra-cranial: Meningitis, Sigmoid sinus thrombosis, Brain abscess
Glue ear
Build up of middle ear fluid causing hearing loss in affected ear (often self limiting). No acute inflammation, often follows AOM.
Glue ear- presentation
- Presentation: ear fullness/popping/pain; hearing loss (loud TV, poor communication, speech/language delay, difficulty at school)
- Signs: yellow, retracted tympanic membrane, fluid level/bubbles behind it, loss of light reflex
Glue ear- investigation
- Hearing test: audiometry/McCormick toy test if preschool repeat in 3 months
- McCormick toy test: the child is shown 7 pairs of toys whose names sound similar (e.g. tree and key, plane and plate) and asked at different volumes to indicate a particular toy
Glue ear- management
- Conservative: reassure parents that majority self-resolve, safety net, advice to speak loudly/clearly, face child, turn off competing sounds
- Medical: no evidence for antihistamines, decongestants or antibiotics
Glue ear: surgery
Children may benefit from grommet insertion if
* Bilateral OME for >3 months
* Hearing loss >25 dB in better ear
* Hearing loss and social/educational or developmental difficulties
Inhaled foregin body- management
- If presenting with choking symptoms assess level of obstruction: If ineffective cough, signs of choking, cyanosis, reduced consciousness then immediately begin choking algorithm
- If in respiratory distress then leave comfortable and contact ENT and anaesthetic teams
- If no respiratory distress then organise X Ray to find location of foreign body
- Ultimately, treatment is removal (in theatre, sometimes endoscopy/bronchoscopy)
- NB: button battery inhalation/ingestion is an emergency and MUST be removed within 6 hours due to risk of erosion
Identifying hearing loss in children
- Newborn screening: at birth if in hospital, can be done up to 3 months before
- Further hearing tests when starting school at around 4 or 5 years old
Conductive hearing loss
- Abnormality of external or middle ear
- E.g. otitis media with effusion or “glue ear” (OME)
- Important to pick up as early as possible in children as can affect language development
Sensorineural hearing loss
- Abnormality of inner ear or nerves carrying impulses to brain – (cochlear branch of vestibulocochlear nerve)
- E.g. Congenital (1 in 1000, can be genetic); infection during pregnancy (e.g. rubella, CMV); Meningitis
Hearing loss: audiogram
- Horizontal axis is frequency (pitch) in hertz (Hz) whilst the vertical axis is sound intensity (loudness) in decibels (dB)
- Quietest sounds are at the top
- Normal adult hearing is between 0 to 25dB across the frequency range, children’s are normal between 0 to 15 dB across the frequency range
- Bone conduction is normal in conductive hearing loss, reduced in sensorineural
Food allergy/tolerance: Investigations
- Offer skin prick test and blood tests for specific IgE antibodies in food
- Skin prick tests should only be done where there are facilities to deal with an anaphylactic reaction
- If non-IgE-mediated food allergy is suspected, trial elimination of the suspected allergen (normally for between 2–6 weeks) and reintroduce after the trial
Food allergy/tolerance: symptoms
- The skin: Pruritus, Erythema, Acute urticaria, acute angioedema
- The gastrointestinal system: Angioedema (lips, face and eyes), oral pruritis, nausea, colicky abdominal pain, vomiting, diarrhoea
- Respiratory: nasal itching, sneezing, rhinorrhoea or congestion, cough, chest tightness, wheezing, shortness of breath
Food allergy/tolerance: Management
- Avoidance – dietetic advice helpful. Can continue to have egg as baked ingredient as tolerated previously.
- Antihistamine to use in case of allergic reaction – chlorphenamine for children under 1 year of age, cetirizine in older children.
- Adrenaline pens- if history of anaphylaxis or asthma
Most children with milk and egg allergies outgrow it
Anaphylaxis: Management
- ABCDE, oxygen
- IM (intramuscular) adrenaline
- Can repeat IM adrenaline after 5 minutes if needed
- Consider IV fluid bolus
- Can give salbutamol nebuliser if wheezy, and consider oral prednisolone if has asthma exacerbation, but priority is adrenaline!
- Don’t give IV hydrocortisone and IV chlorphenamine acutely.
- Once anaphylaxis has resolved and stabilised, then can give oral cetirizine.
UTI: causative organisms and predisposing factors
Causative organisms: E.coli (80%), Proteus, Pseudomonas
Predisposing factors
* Incomplete bladder emptying: infrequent voiding, hurried micturition, obstruction by full rectum due to constipation, neuropathic bladder
* Vesicoureteric reflux: a development anomaly found in 35% of children with a UTI
* Poor hygiene
UTI- epidemiology
More common in boys until 3 months of age (due to more congenital abnormalities) after which the incidence is substantially higher in girls. At least 8% of girls and 2% of boys will have a UTI in childhood
UTI- presentation in childhood
Depends on age:
* infants: poor feeding, vomiting, irritability
* younger children: abdominal pain, fever, dysuria
* older children: dysuria, frequency, haematuria
* features which may suggest an upper UTI include: temperature > 38ºC, loin pain/tenderness
UTI: NICE guidelines for checking urine samples in a child
- if there are any symptoms or signs suggestive or a UTI
- with unexplained fever of 38°C or higher (test urine after 24 hours at the latest)
- with an alternative site of infection but who remain unwell (consider urine test after 24 hours at the latest)
Urine collection method
- clean catch is preferable
- if not possible then urine collection pads should be used
- cotton wool balls, gauze and sanitary towels are not suitable
- invasive methods such as suprapubic aspiration should only be used if non-invasive methods are not possible
Treatment for UTI- special cases
- infants less than 3 months old should be referred immediately to a paediatrician
- children aged more than 3 months old with an upper UTI should be considered for admission to hospital. If not admitted oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days
- children aged more than 3 months old with a lower UTI should be treated with oral antibiotics for 3 days, usually trimethoprim, nitrofurantoin, cephalosporin or amoxicillin. Parents should be asked to bring the children back if they remain unwell after 24-48 hours
UTI management
- antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs
- Lower UTI’s are usually treated with nitrofurantoin, upper UTI’s are usually treated with cephalosporin
Investigations following UTI
- Renal ultrasound- only if they have an atypical UTI
- Micturating cystourethragram- to assess for abnormal bladder function
- DMSA scan- 4 to 6 months after acute infection to detect renal parenchymal defects
Special tests for a UTI
What investigations are recommended for children under 6 months after a first atypical urine infection or recurrent UTI?- Renal ultrasound, DMSA and MCUG.
Gold standard for renal cortical scarring: DMSA
Atypical UTI
A UTI is classed as atypical if any of the following are present:
* Poor urine flow
* Abdominal or bladder mass
* Raised creatinine
* Septicaemia
* Failed to respond to treatment with suitable antibiotics within 48 hours
* Infection with non E.coli organisms
Clinical features of a UTI
- Under 3 months: fever, vomiting, lethargy, irritability, poor feeding, failure to thrive, offensive urine
- 3-12 months: fever, poor feeding, abdominal pain, vomiting
- Above 1 year: frequency, dysuria, abdominal pain
UTI: diagnosis
- Positive leukocytes and nitrites on urine dip
- Positive urine culture with appropriately collected urine (clean catch; non-contaminated collection pad/catheter sample/suprapubic aspirate)
Nephrotic syndrome
Defined as a tetrad of
* proteinuria (> 1 g/m^2 per 24 hours)
* hypoalbuminaemia (< 25 g/l)
* oedema
* Hyperlipidaemia (hypercholesteralaemia
Nephrotic syndrome: symptoms
- Most patients have periods of remission and relapses
- Swelling- around the eyes and lower legs
- Susceptibility to infections
- Frothy urine and reduced output
- Increased risk of blood clots
Nephrotic syndrome: causes and other features
Causes= glomerulosclerosis, glomerulonephritis, HIV/Hepatitis, lupus, diabetes, sickle cell anaemia, certain types of cancer i.e. leukaemia.
Other features include hyperlipidaemia, a hypercoagulable state (due to loss of antithrombin III) and a predisposition to infection (due to loss of immunoglobulins)
Nephrotic syndrome: main cause
- In children the peak incidence is between 2 and 5 years of age.
- Around 80% of cases in children are due to a condition called minimal change glomerulonephritis.
- Means the kidneys will look fine under a microscope.
- The condition generally carries a good prognosis with around 90% of cases responding to high-dose oral steroids.
Nephrotic syndrome: side effects of steroid treatment
- Short term: behaviour change (irritability, mood swings), increased appetite, gastric irritation
- Long term: changes to facial appearance, weight gain, hypertension, hyperglycaemia, osteopenia, immunosuppression
Nephrotic syndrome: Pathophysiology
- Podocytes are damaged within the glomerulus, this causes proteins to pass through into the nephrons tubule and joins the urine.
- Can also cause haematuria, antibodies can also be lost.
- The liver then detects the loss of proteins and causes more cholesterol and albumin production.
- There is also a reduction in plasma oncotic pressure causing oedema and decreased venous return.
- There is then decreased GFR and renin production
Nephrotic syndrome: signs and symptoms
- Xanthelasma: deposits of cholesterol around the eye
- Fatigue
- Leukonychia: changes to the nail bed
- Periorbital oedema, ascites, peripheral oedema
- Breathlessness: pulmonary oedema, pleural effusion
Nephrotic syndrome: Investigations
- Urine dipstick, MSU
- FBC, U&E, LFT, Ca+2, CRP, glucose
- Serum and urine immunoglobulins
- Autoimmune screen
- Hep B&C, HIV
- Chest x-ray: to show pleural effusion
- Ultrasound of the kidneys, renal biopsy
