paediatrics tutorials

Question 1

A child with a fever but no focus and is under 2 months- what is the septic screen?

Answer 1

FBE, CRP, CSF, SPA/clean catch urine, blood cultures +/- CXR

Question 2

what fluid and how much do we use for a fluid bolus in kids with moderate dehydration?

Answer 2

normal saline 0.9%

general bolus 10-20mls/kg

Question 3

what are some normal maintenance IV fluids that we use for kids?

Answer 3

hartmann’s
plasma-lyte
normal saline 0.9% + 5% dextrose
half normal saline 0.45% + 5% dextrose

Question 4

what is the 4, 2, 1 rule for calculating IV/NG fluid requirements in a child?

Answer 4

4mls/kg for the 1st 10kg
2mls/kg for the 2nd lot of 10kg (e.g. 10-20kg)
1mls/kg for >20kg

Question 5

what is the fluid maintenance requirements for a 16kg child

Answer 5

4 x 10= 40
6 x 2 = 12

40+12= 52mls/hour

Question 6

what is the fluid maintenance requirements for a 25kg child?

Answer 6

4 x 10= 40
2 x 10= 20
1 x 5= 5

65mls/hour

Question 7

what is the best way to rehydrate a child?

Answer 7

oral or nasogastric

Question 8

what are the paracetamol requirements for a child

Answer 8

15mg/kg every 6 hours

Question 9

what are the nurofen requirements for a child

Answer 9

10mg/kg every 8 hours

Question 10

What antibiotics do we use for a child with UTI

Answer 10

bactrim for about 1 week

Question 11

a patient under 6 months with confirmed UTI needs what consideration?

Answer 11

need to order renal tract ultrasound

Question 12

a 11kg child has vomiting and diarrhoea (gastro + moderate dehydration) how do you resuscitate them? ***

Answer 12

NGT resuscitation:
-replace the 5% deficit FIRST over the first 6 hours using gastrolyte
+
-total daily maintenance weight over 24hrs (so 42mls/L x 24), given in the next 18 hours

Question 13

how do we calculate the fluid deficit in a child with moderate dehydration?

Answer 13

5% x kg

or 5 x kg of child x 10

they equal the same thing

–> note that 5% is an estimate. in severe dehydration, the deficit can be up to 10% or more.

Question 14

what do we need to monitor in a patient who is undergoing fluid resuscitation and maintenance?

Answer 14

Output/losses
Fluid Intake
Body weight!!
Vitals

Question 15

an unwell child is admitted to hospital. the child is NOT dehydrated. what are their fluid maintenance requirements and why?

Answer 15

2/3 of their normal maintenance requirements as they may be secreting ADH at higher levels as they are unwell

Question 16

what are the signs of severe dehydration in a child?

Answer 16

floppy child
sunken fontanelles/eyes
reduced conscious state
deep acidotic breathing
dry mucous membranes
slow cap refill
cool peripheries
signs of shock
muscle weakness

Question 17

what is the risk of NGT?

Answer 17

pulmonary aspiration

Question 18

why are hypotonic solutions like 0.18% saline or 4% dextrose NOT used in fluid resus?

Answer 18

can cause cerebral oedema and hyponatremia

Question 19

how might we manage reflux in a baby?

Answer 19

you can try thickening the breast milk or formula with thickeners

or you can try esomeprazole (but no good evidence for this)

Question 20

What is the most common presentation of a child with anaemia?

Answer 20

Child with pallor or child with reduced exercise tolerance , child with poor concentration and lethargy

Question 21

Megaloblastic anaemias in children are caused by —- and —-need to be treated (fill in gaps). Why?

Answer 21

Megaloblastic anaemias in children are caused by B12 or folate deficiency and DO need to be treated.

Need to correct because can cause neurological defects

Question 22

Which children are at risk of B12 deficiency?

Answer 22

Those born from maternal b12 deficient mothers, those with pernicious anaemias, those raised on vegan diets and those who do not have ileum where b12 is absorbed

Question 23

How might a child become iron deficient?

Answer 23

Poor diet, cows milk excess and intolerance, menorrhagia, pr bleeding, occult blood in faeces due to bowel disorders

Question 24

what are the key features of HUS on investigation results?

Answer 24

Anaemia
Thombocytopenia
DCT -ve (not immune mediated)
Raised fibrinogen
AKI

Fragments of RBC in the blood film

Question 25

what are some ways we can manage pain in an infant?

Answer 25

Consider sucrose
Breast feeding
Swaddling

Question 26

what is the volume limit of cows milk we can give to a > than 2 yr old?

Answer 26

500mls

Question 27

outline your management of a crying infant with colic?

Answer 27

Exclude medical cause
Explanation and reassurance.

A) Engage in a partnership with the parents

B) Explain normal crying and sleep patterns

Use a sleep / cry diary to explain the infant’s cry / sleep / feeding patterns
Work out the amount of sleep over a 24 hour period using the Sleep / Crying Diary
Encourage parents to recognize signs of tiredness (frowning, clenched hands, jerking arms or legs, crying, grizzling)

C) Assist parents to help their baby deal with discomfort and distress

Establish pattern to feeding / settling / sleep
Aim to settle the baby for daytime naps and night-time sleep in a predictable way (eg, quiet play, move to the bedroom, wrap the baby, give the baby a brief cuddle, then settle in the cot while still awake)
Avoid excessive stimulation - noise, light, handling. Excessive quiet should also be avoided. Most babies find a low level of background noise soothing
Darken the bedroom for daytime sleeps
Carry baby in a papoose in front of the chest
Baby massage / rocking / patting
Gentle music
Respond before baby is too worked up
Give the mother permission to rest once a day without the need to carry out household chores. Have somebody else care for the baby for brief periods to give the parents a break.

D) Assess maternal and emotional state and mother-baby relationship. Invite the mother to talk about how stressful it is to care for a baby who cries persistently.
Ascertain whether the mother is worried that she is depressed. Consider screening for postnatal depression using the Edinburgh Postnatal Depression Scale.

E) Provide printed information as parents are unlikely to remember much given their state of mind at the time.

Question 28

what is your management of an infant with suspected lactose intolerance?

Answer 28

if baby formula-fed, consider change to lactose-free or extensively hydrolysed formula

if baby breastfed, advise to space feeds to 3 hourly or longer, empty breasts at each feed, and alternate sides for feeding.

Consider referral to lactation consultant for feeding advice / trial of lactase-treated breast milk if no improvement.

Question 29

when might we suspect cow’s milk allergy as a cause of an infant who is unconsolably crying? how might we diagnose this

Answer 29

suspect if there is vomiting, blood or mucus in diarrhoea, poor weight gain, family history in first degree relative or signs of atopy (eczema / wheezing), significant feeding problems (especially worsening with time)

diagnosis is made clinically by a trial of eliminating cow milk by modifying the mother’s diet or changing to an extensively hydrolysed formula for a period of 2 weeks

Question 30

what are some non-pathological causes of crying in an infant?

Answer 30

excessive tiredness

hunger

Question 31

what are some management options for mild gastroenteritis that you can advise a parent to perform at home for their child?

Answer 31

1. fluids fluids fluids. Don’t worry about food, they will eat when hungry. Try to give ORS or clear fluids after every vomit.
2. do not use medications to stop vomiting/diarrhoea as they are often unhelpful.
3. keep children away from school until diarrhoea has cleared up because they are infectious.
4. practice good hand hygiene to prevent further spread of the gastro to other family members.
5. if the gastro continues for longer than expected, child refuses oral fluids or has not eaten for > 24 hours, child significantly dehydrated or unwell, other infective symptoms, seek medical attention