Paediatrics - RF, pathology and symptoms

Question 1

Febrile convulsions

RF
Pathology
Symptoms

Answer 1

Seizures provoked by fever in otherwise normal children (6 months - 5 years)

RF - Young, male, fever, family history, viral or bacterial infection

Sx
- May occur early in a viral infection causing high temperatures (>38)
- Seizures (status epilepticus = >30mins) - usually <5-15 mins.

Question 2

What kind of diet would be good for children with epilepsy?

Answer 2

Ketogenic diet (high fat, low carbs, controlled protein)

Question 3

Pneumonia in children

RF
Pathology
Symptoms

Answer 3

RF - Children <2 years (<5 years risk of severe CAP), males, prematurity, overcrowded house, parental smoking

Pathology
Viral cause is more common.
Bacterial cause - S.pneumoniae is most common
others - Haemophilus.influenzae

(Neonates - Group B streptococci)

Sx
- Fever
- Tachypnoea, dyspnoea
- Cyanosis
- Cough
(Wheeze alongside these Sx)
(O/E chest crackles, SATS <95%)
(Possible chest pain in bacterial pleural inflammation)

Question 4

Croup (laryngotracheobronchitis)

RF
Pathology
Sx

Answer 4

URTI characterised by sudden onset seal-like barky cough, accompanied by stridor, voice hoarseness and respiratory distress

RF - 6 months - 3 years, males, prior intubation (more common in late autumn/winter?)

Pathology
- Parainfluenza virus most common cause

• Symptoms occur due to inflammation of the airways (and laryngeal oedema/secretions)

Sx
- Seal-like barky cough that is worse at night
- Stridor
- Fever
- Coryzal sx (runny nose, sore throat)
(increased work of breathing)

Question 5

Asthma in children

RF
Pathology
Symptoms

Answer 5

RF - Atopic disease, respiratory tract infections in early life, family history, maternal smoking in pregnancy, male

Pathology
- Hyper responsiveness to inhaled stimuli –> Airway OBSTRUCTION due to bronchospasm, inflammatory changes and mucus hypersecretion.

Sx (>3 years usually)
- Dry night time cough
- Wheeze
- Dyspnoea on exertion

Question 6

Viral induced wheeze

RF
Pathology
Symptoms
Treatment

Answer 6

RF- Premature baby, bronchiolitis in infancy, exposed to cigarette smoke

Pathology
(usually seen <5 years old)
Airway becomes irritated and inflamed by a cold virus.

Sx
- Starts with a cough and cold
- Wheeze develops after and can last for 2-4 days
- Fever

(May go on to develop asthma)

Tx
- Salbutamol with a spacer

(Severe - 3 days oral prednisolone)

Question 7

Bronchiolitis

RF
Pathology
Symptoms

Answer 7

RF - <3 years, prematurity, passive tobacco smoke exposure, air pollution, winter months

Pathology
Leading cause of hospital admissions in infants <1 year
- Acute viral LRTI - Respiratory syncytial virus is the most common cause
- Epithelial destruction, cellular oedema and airway obstruction by inflammatory debris and mucus.
(Maternal IgG provides protection against RSV)

Sx
(Can be more severe with congenital heart disease)
- Coryzal sx (running nose, sore throat, mild fever) FIRST
- THEN dry cough, increasing dyspnoea, wheezing
(Poor feeding)

Red flags –> Immediate referral to hospital
- Grunting - severe respiratory distress
- Apnoea
- Central cyanosis

Question 8

Cystic fibrosis

RF
Pathology
Syptoms

Answer 8

RF - Family history, white ethnicity

Pathology
Autosomal recessive disorder - defect of CFTR gene on chromosome 7- Delta F508

Results in disorder of chloride channels found in cells lining the lungs, pancreatic ducts, intestines

Key consequences
1) Thick pancreatic and biliary secretions causing blockage of ducts –> results in lack of digestive enzymes e.g. pancreatic lipase in the digestive tract –> calorie malabsorption
2) Thick airway secretions that reduce airway clearance, resulting in bacterial colonisation and susceptibility to airway infections

Sx
1) Neonates –> MECONIUM ILEUS (not passing stool in the first 24 hours of being born, possible vomiting) - due to meconium being thick and sticky thus getting stuck and obstructing the bowel
2) Respiratory –> Recurrent chest infections (mentioned above)
3) GI –> Steatorrhoea (lack of lipase enzyme), bowel obstruction, malnutrition, failure to thrive
Others: Atrophy of vas deferens, salty sweat, short stature, finger clubbing

Question 9

Potential organisms which may colonise cystic fibrosis patients

Answer 9

S.aureus
P.aeruginosa
Aspergillus

Question 10

Acute epiglottis

RF
Pathology
Symptoms

Answer 10

RF - Not vaccinated against haemophilus influenzae type B, immunocompromised, middle aged

Pathology
An infection of the supraglottis with the potential to compromise the airway due to inflammation and swelling.

Sx
- Rapid onset sore throat (over a few hours)
- Dysphagia
- Drooling
- Fever
- Tripod position –> Easier to breathe leaning forward

Question 11

Otitis Externa

RF
Pathology
Symptoms

Answer 11

RF - External auditory canal obstruction, humid and warm environment, swimming, children/young adults

Pathology
Diffuse inflammation of the external ear canal most commonly caused by
- P.aeruginosa
- S.Aureus
(Other causes: swimming, contact dermatitis)

Sx
- Tenderness over the tragus and pinna (acute ear pain)
- Ear itching and discharge
- Ear canal swelling and erythema (skin redness)
(pain intensified with jaw motion)

Question 12

Complication of otitis externa

Answer 12

Malignant otitis externa – where there is an extension of the infection into the bony ear canal –> IV antibiotics may be required

More common in elderly diabetics

Question 13

Acute otitis media

RF
Pathology
Symptoms

Answer 13

RF - Day care attendance, older siblings (increased risk of exposure to respiratory virus?), young age, family history

Pathology
- A complication of viral respiratory illnesses involving infection of the middle ear space. (via the eustachian tube)
(E.g. S.pneumoniae, Haemophilus.influenzae)

Sx
- otalgia (ear pain)
- Recent URTI symptoms
- Ear discharge
- Hearing loss
(Fever)

(Complication of mastoiditis)

Question 14

Otitis media with effusion (glue ear)

RF
Pathology
Sx
Tx

Answer 14

The presence of fluid in the middle ear WITHOUT associated signs of ear infection.

RF - Males, siblings with glue ear, day care attendance, peaks at 2 years of age

Typical following episodes of acute otitis media once the acute inflammation resolves. (commonest cause of conductive hearing loss in childhood)

Sx
- Hearing loss (conductive)
- Aural fullness
- Speech and language delay

Tx
- Active observation for 3 months

(If likely to persist more than 3 months –> tympanostomy tube/grommet placement) - can drain fluid from the ear and allows air to pass through into the middle ear.

Question 15

Orbital and Peri-orbital cellulitis

RF
Pathology
Symptoms

Answer 15

Orbital cellulitis - an infection affecting the fat and muscles posterior to the orbital septum –> usually caused by a spreading URTI from the sinuses (high mortality rate)

Periorbital cellulitis - Less serious Inflammation and infection of the superficial eyelid (anterior to the orbital septum) –> Usually a result of superficial tissue injury - insect bite/eyelid infection (can progress to orbital cellulitis)

RF - Sinusitis, male children aged 7-12, lack of haemophilus influenzae type b vaccination

Pathology
- Most common bacterial causes - Steptococcus, S.aureus, Haemophilus influenzae B

Sx
Both
- Redness and swelling around the eye
- Severe ocular pain

Mainly orbital cellulitis
- Visual disturbance
- Proptosis (bulging eyes)
- Ophthalmoplegia/painful eye movements

Question 16

What can a lack of haemophilus influenzae type B vaccine put you at risk of?

Answer 16

Pneumonia, Acute epiglottitis, orbital/peri-orbital cellulitis, Acute otitis media

Question 17

Squint/Strabismus

RF
Pathology
Symptoms
Main complication if untreated?

Answer 17

RF - Family history, prematurity, low birth weight, maternal smoking during pregnancy

Pathology

There is misalignment of the visual axes of the eyes.

Two types
1) Concomitant (more common)
- Due to imbalance in extraocular muscles
- CONVERGENT is more common than divergent

2) Paralytic (rare)
- Due to paralysis of extraocular muscles

Sx
- Diplopia (only present when both eyes are open)
(horizontal diplopia = eso/exotropia)
(vertical diplopia = hyper/hypotropia)
- Eye misalignment
- Amblyopia

Main complication if untreated: Amblyopia - decreased vision in an anatomically normal eye (due to the brain favouring the normal eye after a period of time.

Question 18

Atrial septal defects

RF
Pathology
Symptoms/characteristics
What 2 complications can it lead to?

Answer 18

RF - Females, consumption of alcohol during pregnancy

Pathology - Acyanotic congenital heart defect
- Ostium secundum (center of atrial septum) is more common than ostium primum (lower portion of atrial septum)

Sx
- Ejection systolic murmur
- Fixed splitting of the second heart sound (Pulmonary valve delayed)

Complications
1) Embolism from venous system may pass to the left side of the heart causing a stroke

2) Eisenmenger’s syndrome - Clubbing, cyanosis

Question 19

Briefly what is eisenmenger syndrome?

Answer 19

The development of pulmonary hypertension due to an untreated congenital heart defect. (Reversal of a left to right shunt)

A left to right shunt in a congenital heart defect –> increased pulmonary pressure due to increased blood flow on the right side to the lungs –> leads to increased pressure in the right ventricle –> which becomes higher than the left side of the heart, shunting blood from the right to left(Eisenmenger’s syndrome)

Deoxygenated blood bypasses the lungs and gets into the left sided circulation to the rest of the body –> Cyanosis –> Leads to polycythaemia (as body produces more RBC to meet oxygen demand)

Clubbing
Cyanosis

Heart-lung transplantation required.

Question 20

Ventricular septal defects

RF
Pathology
Symptoms

Complications

Answer 20

RF - Chromosomal disorders (Down’s, Edward’s, Patau), family history, (maternal consumption of alcohol/smoking in pregnancy),

Can be acquired post MI (2-5 days after)

Pathology - Acyanotic congenital heart defect
- Most common cause of congenital heart disease (close spontaneously 50% of the time)
(Membranous region)

Sx
- Failure to thrive
- Pansystolic murmur - lower left sternal border
- Right side Heart failure symptoms - Dyspnoea, pallor, hepatomegaly

Complications
- Aortic regurgitation
- Infective endocarditis
- Eisenmenger syndrome
- Right sided heart failure
- Pulmonary hypertension

Question 21

What are the 5 circulatory changes that occur when a baby takes its first breath?

Answer 21

1) Closure of foramen ovale - opening between right and left atrium to allow oxygenated blood from the placenta to bypass the lungs –> Fossa ovalis

2) Closure of ductus arteriosus - connects the pulmonary artery to the aorta to allow blood to bypass the lungs –> Ligamentum arteriosum

3) Closure of ductus venosus - connects the umbilical vein to the IVC, thus allowing blood to bypass the liver to reach the heart –> Ligamentum venosum

4) Closure of umbilical arteries - which carry deoxygenated blood from the fetus to the placenta –> Medial umbilical ligament

5) Closure of umbilical vein - which carries oxygenated blood from the placenta to the fetus –> Ligamentum teres (the round ligament of the liver)

Question 22

Tetralogy of fallot

RF
Pathology - 4 characteristics
Symptoms

Answer 22

RF - Down’s syndrome (21), Edwards syndrome (18), Patau’s syndrome (13), family history, Di George syndrome

Pathology
- The most common cause of cyanotic congenital heart disease
- presents at 1-2 months.

4 characteristics:
- Ventricular septal defect
- Right ventricular hypertrophy
- Right ventricular outflow tract obstruction - determines degree of cyanosis
- Overriding aorta

Sx
- Cyanosis - (Tet spells - hypercyanotic episodes when babies cry, eat –> due to sudden drop in oxygen). Tet spells can result in LOSS OF CONSCIOUSNESS when infant is upset, in pain or has a fever
- Right to left shunt (ventricular septal defect)
- Ejection systolic murmur due to pulmonary stenosis

Question 23

Transposition of the great arteries

RF
Pathology
Sx

Answer 23

RF - Diabetic mothers, males

Pathology
(Failure of aorticopulmonary septum to spiral during septation)
Switching of the pulmonary artery and aorta. 2 separate systems now
(Left ventricle pumps blood to lungs through pulmonary artery which comes back to left ventricle) - never gets deoxygenated
(Right ventricle pumps blood to body through aorta which comes back to right ventricle) - never gets oxygenated

Sx
- Cyanosis
- Loud S2
- Prominent right ventricular impulse on palpation

Question 24

Patent ductus arteriosus

RF
Pathology
Sx

Answer 24

RF - Prematurity, females, maternal rubella in first trimester, born in high altitudes

Pathology - acyanotic
Ductus arteriosus connects the pulmonary artery to the aorta - bypasses the lungs in the fetus.

Oxygenated blood in the aorta can move through the ductus arteriosus to go back to the lungs rather than going to the body

Sx
- Pansystolic machine like murmur
- Left subclavicular thrill
- Bounding pulse - wide pulse pressure
- Failure to thrive
- SOB

Question 25

Coarctation of the aorta

RF
Pathology
Sx
Investigations
Treatment

Answer 25

RF- Males, turner’s syndrome, family history

Pathology
Narrowing in the aorta (most commonly at the site of the insertion of the ductus arteriosus)

High pressure before the narrowing and low pressure after the narrowing (where the body is) - results in RAAS and thus even more increased BP

Sx
- Hypertension (longstanding and difficult to treat)
- Diminished lower extremity pulses
- Radio-femoral delay

Investigation
- TOE
- CXR
- ECG

Tx
- Balloon dilation
- Surgical removal of the coarcted segment

(Prostaglandin E1 to maintain patency of ductus ateriosus (in neonates))