PAEDS 1: Respiratory and Childhood Infections Flashcards
What are causes of neonatal tachypnoea?
- transient tachypnoea of the new-born
- respiratory distress syndrome
- sepsis
What are key features of transient tachypnoea of the new-born?
- within 4-6 hours of delivery
- C-section, fast delivery
- no O2 requirement
What are key features of respiratory distress syndrome?
- prematurity
- O2 requirement
- persistent
What are key features of sepsis?
- RF: maternal temp, PROM, GBS
- other abnormal observations
- persists > 4 hrs
What are risk factors for transient tachypnoea of the newborn?
- <39 weeks (prematurity)
- gestational diabetes
- maternal asthma
- male
- SGA, or LGA
- c-section
Sx of transient tachypnoea of the newborn?
tachypnoea (RR > 60), grunting, nasal flaring recessions, respiratory deterioration
Rx of transient tachypnoea of the newborn?
- Saturations - pre and post ductal
- examination +/- blood gas
- initial obs and monitoring if TTN seems likely
- persistent - septic screen, CXR
- O2 requirement - NICU admission
- consider - congenital anomalies, cardiac causes, inborn errors
What is the aetiology of respiratory distress syndrome?
Surfactant production starts at ~20 weeks - sufficient levels reached by 35-36wks.
Surfactant deficiency leads to increased surface tension of small alveoli - atelectasis - collapse
RFs of respiratory distress syndrome?
Prematurity, GDM, multiple gestation, birth asphyxia
Signs and Sx of Respiratory Distress Syndrome?
tachypnoea (RR > 60), cyanosis, within mins of delivery
uniformly decreased air entry, poor peripheral perfusion, work of breathing: grunting, recessions, accessory muscles
Rx of Respiratory Distress Syndrome?
Antenatally - steroids
Neonate - apply PEEP w/mask +/- O2, whilst monitoring sats
Examine HS, lung fields, assess prematurity if unknown gestation
Give surfactant via LISA or endotracheal tube
CXR + blood gas
Septic screen
Assess level of resp support required - high flow/CPAP/invasive ventilation
Consider: pneumothoraces, response to O2 therapy
What is a classical CXR finding of Respiratory Distress Syndrome?
“diffuse ground glass appearance”
What is bronchopulmonary dysplasia?
supplemental oxygen or respiratory support required >36 weeks corrected gestation
RFs for bronchopulmonary dysplasia?
Lower gestational age, lower birthweight, SGA, invasive ventilation <24hrs, clinical sepsis, CPR required
What are complications of bronchopulmonary dysplasia?
systemic HTN, pulmonary HTN, poor neurodevelopmental outcome, left ventricular hypertrophy
What is early intervention for bronchopulmonary dysplasia?
supplemental O2 (target sats >90% after first 10mins of life), NIV where able e.g. CPAP, early surfactant use, early caffeine initiation (<3 days), volume targeted ventilation, low dose dexamethasone
What is established management for bronchopulmonary dysplasia?
diuretic therapy, tracheostomy consideration, home oxygen support, RSV immunisation
What is the prognosis of bronchopulmonary dysplasia?
high rates of readmission in 1st year
reactive airway disease e.g. bronchiolitis, wheeze, asthma
may need home O2 for a period
impact on development and growth
What are some imaging changes you might see for bronchopulmonary dysplasia?
CXR - reticular markings
CT - bronchial wall thickening
What are some causes of tachypnoea/cough in a child?
- Pneumonia
- CF
- TB
What are key features of pneumonia in a child?
Acute cough, fever >39C, cyanosis, raised RR, increased WOB, focal crackles, sats <95%, absent breath sounds
What is the diagnostic criteria of bacterial pneumonia?
consider where: persistent fever >38.5 with chest recessions and raised RR
What are complications of pneumonia?
empyema, lung abscess, atypical pathogen
What pathogens cause pneumonia in neonates?
GBS, Klebsiella, E. Coli, Listeria
What pathogens cause pneumonia in children <2yrs?
Viruses - RSV, influenza
What pathogens cause pneumonia in children 2-5yrs?
S. pneumoniae, H. influenzae
What pathogens cause pneumonia in children >5yrs?
Mycoplasma pneumoniae, S. pneumoniae
Rx of pneumonia in children?
- Assess severity to decide if admission needed. Red flags = sats <92, not responding to Abx, absent breath sounds, increasing WOB
- community management = anti-pyretics, fluids, identifying deterioration
- hospital management = O2 to maintain sats >92%, IVF as required (monitor U&Es)
- Follow up radiography - only in those w/round pneumonia, complications or persistent sx
When are antibiotics not used in pneumonia?
if <2 years w/mild sx (but review if persistent)
When are antibiotics indicated?
Oral if tolerated, IV if unable to tolerate/absorb, septicaemia, complicated pneumonia, Abx given if clear clinical diagnosis of pneumonia
What is the 1st line antibiotic for childhood pneumonia if non-severe sx?
amoxicillin (clarithromycin if pen allergic)
What is the 1st line antibiotic for childhood pneumonia if severe sx?
co-amoxiclav + clarithromycin
What is Cystic Fibrosis?
an inherited disease caused by mutations in a gene called the cystic fibrosis transmembrane conductance regulator (CFTR)
How is CF diagnosed?
Infant screening - immunoreactive trypsin test
Sweat test
Genetic testing (AR)
How does CF present?
Meconium ileus, faltering growth, recurrent/chronic resp disease, chronic sinus disease, acute/chronic pancreatitis
What are complications of CF?
malnutrition (fat soluble vitamin deficiences - ADEK), infertility, CF-related diabetes, reduced bone density
Rx of CF?
Support and education
MDT - specialist nurse, physio, dietitian, pharmacists, psychologist
Antibiotics - long term, IV courses, nebs, prophylaxis vs treatment
Physio - twice daily, extensive, airway clearance
Mucoreactive agents - DNAase, hypertonic saline
Monitor colonisation - eradication where needed
Enzyme supplements
Gene therapy e.g. Kaftrio (F508del mutation)
What is TB?
Infection caused by mycobacterium tuberculosis
What are RFs for TB?
born outside UK, high prevalence areas, <5yo, close contacts w/active TB, co-morbidities, e.g. HIV, DM, ESRF, underserved groups
Sx of TB?
cough, fever, night sweats, malaise
lymphadenopathy
faltering growth, fatigue, persistent fever
meningitis
children typically present w/non-specific signs and usually can’t expectorate <5yrs
Ix for TB?
CXR, deep cough sputum, gastric washings, induced sputum, rapid testing (NAAT), additional scans/tests if extra-pulmonary sx
Exposure testing:
- Mantoux test (tuberculin skin test)
- IGRA (blood test detecting response of WBC to TB antigens)
How is TB managed in children?
Active TB should be managed by a TB specialist
Active w/o CNS involvement = RIFE (+pyridoxine) 2/12, then just RI for 4/12
Active w/CNS = RIFE (+pyridoxine) 2/12, then just RI for 10/12
Consider drug susceptibility testing, fixed dose combo, daily directly observed therapy for MDR-TB
Summarise rhinitis/common cold?
Causes = viral (rhinoviruses, RSV, coronaviruses, parainfluenzae, influenza, human meta-pneumovirus)
Complications = predisposes to bacterial sinus and ear infections
Mx = supportive care, reassurance, education, safety netting
Summarise key features of tonsilitis?
Definition = palatine tonsil inflammation (tonsil grading system 0-IV)
Cause = adenovirus, EBV, group A strep
Sx = 5-7 days painful swallowing, fever, snoring, halitosis
Signs = red inflamed tonsils, white exudate spots, cervical lymphadenopathy
Mx = antibiotics if likely bacterial (Centor 3+)
What is the Centor criteria for tonsilitis?
- Tonsillar exudate
- Tender cervical LNs
- Fever
- Absence of cough
Summarise otitis media?
Sx = pain, malaise, fever, coryza, peak age 6-15 months, seasonal
Signs = erythematous tympanic membrane, can be a tear, purulent discharge
Mx = analgesia (most resolve in 3 days), send swab of discharge, consider abx in some
What are indications for Abx in otitis media?
systemically unwell, known RFs, unwell >4 days, bilateral in <2 years, persistent illness
What are complications of otitis media?
mastoiditis, meningitis, facial nerve paresis, chronic otitis media, hearing loss
Summarise epiglottitis?
AIRWAY EMERGENCY
Cause = HiB
Sx = sudden fever, sore throat, drooling, tripod positioning, toxic appearance
Mx = minimise stimulation, secure airway, antibiotics
RFs = lack of HiB vaccination
What are the phases of Whooping cough (Bordatella Pertussis)?
Catarrhal Phase - 7-10 days, coryzal, mild cough, low grade fever, infectious
Paroxysmal phase - rapid violent coughing fits, thick mucus in bronchi, more common at night, fever absent
Convalescent phase - 2-3 weeks, gradual improvement, subsequent resp infections may cause recurrent paroxysms
Who is at highest risk if they have whooping cough?
children <6 months old (low threshold for hospital admission)
How might whooping cough present in a child <3 months old?
only apnoea
How is whooping cough diagnosed?
NP aspirate or swab/pernasal swab (cough < 21 days)
PCR if cough < 21 days (more sensitive)
Serology in >16yo
Oral fluid testing if <16yrs, >2/52 cough - test for anti-pertussis toxin IgG
How is whooping cough treated?
Admission for breathing difficulties or complications
Appropriate isolation - school exclusion 21 days from onset of untreated OR 48hrs if appropriate abx rx
1st line = macrolide if cough < 21 days
Supportive care
Manage close contacts - prophylaxis for priority groups (unimmunised infants, HCWs etc.)
Ensure up-to-date immunisations
How does laryngomalacia present and how is it investigated and treated?
Sx = first weeks of life, resolves by 2 years usually, high pitched inspiratory stridor w/normal cry
Ix = flexible endoscopy
Rx = mild - no treatment; severe - elective surgery; life-threatening - adrenaline nebs, dex, vent support
What is laryngomalacia?
Congenital airway disorder (immature laryngeal cartilage, omega shaped epiglottis)
Most common cause of neonatal stridor, usually self-limiting, can be life-threatening
What are some differentials to consider if a child presents with a rash?
Chicken pox
Hand, foot and mouth disease
Measles
Scarlet fever
Erythema infectiosum
Rubella
Roseola infantum
Kawasaki disease
What is chicken pox and how does it present and spread ?
crops of small papules - vesicles on erythematous base, crust over (stop being infectious), rash mixed of above stages over scalp, face, trunk centred
spreads via airborne respiratory droplets, contact w/vesicular fluid
What groups are particularly at risk of chicken pox?
pregnancy, neonates, immunocompromised children
What are complications of chickenpox?
bacterial superinfection (GAS)
encephalitis/cerebellitis
necrotising fasciitis
stroke
How is chickenpox managed?
Supportive - antihistamines, moisturisers
Aciclovir in at risk populations
Vaccination!
Outline the symptoms, spread and treatment of hand, foot and mouth disease?
Cause = coxsackie virus
small macular lesions become small vesicles (1w) then resolve w/o scars
small vesicles and ulcers around mouth, lips, palate, dorsal and palmar surfaces of hands and feet
spread via respiratory droplets and fluid from blisters, stool
Mx = analgesia - anaesthetic throat spray to aid oral intake, no exclusion from school or nursery
What is erythema infectiosum?
Parvovirus B19 - firm red cheeks, feel hot (2-4 days), pink rash on limbs/trunk - lace like pattern, can persist for 6 weeks
Rash presents 2-3 days AFTER initial illness (mild fever, headache)
How is erythema infectiosum diagnosed?
clinical - slapped cheek/lacy rash
serology - IgG, IgM
PCR
How is erythema infectiosum managed?
analgesia, cold cloths for cheeks
supportive unless complications
no exclusion - infective prior to rash
What are some complications of erythema infectiosum?
aplastic crisis in those w/blood disorders (e.g. sickle cell)
chronic infection in immunodeficient patients
Describe symptoms of measles and it’s cause?
Cause = paramyxovirus
Sx = maculopapular rash + acute resp infection, spread from ears to head to trunk to extremities, Koplik spots (white spots on buccal mucosa), rash lasts 7d
Describe the incubation, spread and prodrome of measles?
Incubation = 14 days
Spread = droplets
Prodrome = cough, coryza, conjunctivitis (3 C’s)
How is measles treated?
Notify health protection team
High risk = <1 year, pregnant, immunocompromised
Usually self-limiting (1 week), supportive care
Exclusion - 4 days after development of rash, avoid contact
Safety netting - SOB, uncontrolled fever, convulsions
What are some complications of measles?
otitis media
bronchopneumonia
subacute sclerosing
panencephalitis (fatal degenerative disease of CNS 7-10 yrs post infection)
Describe the cause and symptoms of rubella?
small pink spots spreading to neck, trunk and extremities
can be itchy, skin may flake off as resolves
less widespread than typical measles
URTI sx may occur before rash
retroauricular lymphadenopathy common
mucosal involvement e.g. petechiae on soft palate and uvula
How is rubella managed?
supportive (rest, fluids, analgesia)
What are complications of rubella?
arthralgia/arthritis
thrombocytopenic purpura
otitis media
encephalitis
What is the incubation, spread and symptoms of scarlet fever?
incubation = 2-5 days
spread = saliva, mucous
sx = illness 24-28h before rash, resolves in 1 week
rash = sandpaper like, worse in skin folds, starts on abdomen, strawberry tongue, peri-oral pallor, cervical LNs, illness inc. fever, sore throat, fatigue, headache
How is scarlet fever diagnosed?
clinical
throat swab
looking for group A strep
How is scarlet fever managed?
self-resolving
abx to prevent complications and transmission
exclusion = for 2 weeks if untreated OR 24h post antibiotics
Abx = 10d phenoxymethylpenicillin (Penicillin V)
NOTE: Second-line options for people with penicillin allergy are:
Birth to 6 months — clarithromycin for 10 days.
Non-pregnant adults and children aged 6 months to 17 years — azithromycin for 5 days, or clarithromycin for 10 days.
Pregnant or postpartum (within 28 days of childbirth) — erythromycin for 10 days.
Outline the spread, cause, sx and mx of roseola infantum?
Cause = HHV6B/7
spread = droplet
infectious = first few days, peak 6m - 3yo
sx = 3-5 days illness, coryza, high fever, fatigue, as sx resolve get rash which lasts 2 days
rash = fine macular red/pink rash over trunk, can have soft palate and uvula lesions, painless, non-itchy, no blisters
Mx = none required, complications rare but may inc. febrile convulsions
What is Kawasaki disease?
acute febrile illness - inflammation of small and medium sized blood vessels (esp. coronary arteries)
What are the 5 cardinal signs of Kawasaki disease?
RASH - morbilliform, maculopapular, erythematous, persistent, skin peeling
ORAL SIGNS - red mouth/pharynx, strawberry tongue, red/cracked lips
EYE SIGNS - non exudative conjunctivitis
LIMB SIGNS - redness of plasma and soles +/- swelling, desquamation
LYMPHADENOPATHY - typically unilateral neck, at least one > 1.5cm
What is the diagnostic criteria for Kawasaki disease?
Fever > 5 days
4/5 cardinal signs
absence of alternative illness
How is Kawasaki disease managed?
analgesics/anti-pyretics
IVIG (5th - 10th day)
Low dose aspirin
What are the phases of acute viral hepatitis?
Prodromal phase (3-10d) = flu sx, gastro sx, low grade fever
Icteric phase (1-3w) = jaundice, pruritus, fatigue, anorexia/nausea, hepatosplenomegaly, LNs
Convalescent phase (up to 6mths) = malaise, anorexia, weakness, hepatic tenderness
Outline hepatitis A in children?
most children asx
RFs = travel, clotting factor disorders, IVDU, occupational risk
transmission = faecal-oral, contaminated water
Ix = HAV-IgM and IgG
Rx = supportive, HPT notification, treat nausea and itch, education, follow up w/repeat LFTs 1-2 weekly
Prognosis - majority fully recover in 6mths
Complications - 15% relapsing course, <1% liver failure
Outline hepatitis B in children?
RFs = exposure, needlesticks, HIV +ve
Often no signs if chronic infection
Transmission = BBV
Ix = HBsAg (infectious), HBeAg (high replication), IgM (recent), HBV DNA (viral load)
Mx = supportive for acute, specialist referral for anti-viral consideration, HPT notification, baseline Ix
Infants = HBV screening for those born to +ve mothers, vaccination programme (+ HBIG)
Outline hepatitis C in children?
RFs = high prevalence countries, IVDU, close contacts
Transmision - BBV
Ix = antibody and HCV RNA test
Mx = specialist referral (antiviral consideration), HPT notification, STI screening, baseline liver ix (NOTE: NO VACCINE)
Outline hepatitis D symptoms and spread?
contact w/infected blood
prevent w/hep B vaccine, avoiding sharing needles, toothbrushes, razors or nail scissors
Sx = fever, fatigue, loss of appetite, N&V, abdominal pain, dark urine, pale stool/clay-coloured
Outline hepatitis E symptoms and spread?
eating contaminated food or drinking contaminated water, prevent w/practicing good hygiene, avoid drinking water that has come from a potentially unsafe source
sx = nausea, fatigue, jaundice
Outline Sx, spread, Ix and Mx of EBV?
Sx = fever, cervical lymphadenopathy, sore throat, non-specific rash/prodromal sx, hepatosplenomegaly
Spread = contact w/saliva, usually asx in children <3yrs
Ix = FBC, LFTs, EBV serology (IgG, IgM), monospot - heterophile antibodies
Mx = supportive care, sx last 2-4 wks, avoid contact sports for 1 month, avoid penicillins (rash)
Outline symptoms and treatment of mumps?
painful swelling of parotid glands, fever, joint pain, headaches
spread via saliva droplets
lasts 1-2 weeks
supportive care
What are complications of mumps?
- viral meningitis
- testicular swelling
Outline the Sx, Ix, spread and Mx of headlice (pediculosis capitus)?
Sx = itchy scalp, brown eggs and white shells in hair, feeling of movement in hair
Spread = hair to hair contact, common
Ix = combing hair
Mx = wet combing, comb out eggs and shells after washing and conditioning hair, medicated lotions and sprays
Outline the symptoms and management of rheumatic fever?
Complication of Group A strep infection
Sx of GAS = fever, pharyngitis, headaches
Sx of acute rheumatic fever = can be asx until cardiac presentation, consitutional sx may include arthralgia
- carditis (tachycarida, new murmur)
- derm (SC nodules, erythema marginatum)
- neuro (Syndenham’s chorea)
Mx = GAS eradication, symptomatic therapy (analgesia for arthritis), derm and neuro sx usually self-limiting, carditis can lead to HF and require valve replacement
What is the diagnostic criteria for rheumatic fever?
Duckett-Jones diagnostic criteria (MAJOR and MINOR criteria)
MAJOR = CASES
C - carditis
A - arthritis
S - SC nodules
E - erythema marginatum
S - sydenhams chorea
MINOR = FRAPP
F - fever
R - raised ESR/CRP
A - arthralgia
P - prolonged PR interval
P - prev. RF
must be evidence of streptococcal infection + 2 major or 1 major + 2 minor
What are the SCORTCH neonatal infections?
S = syphilis
C = CMV
O = other (parvovirus B19, enterovirus, Zika virus, chagas, malaria)
R = rubella
T = toxoplasmosis
C = chickenpox
H = HSV, HIV, HBV, HCV, HTLV-1
What is important in a maternal history when suspecting a SCORTCH infection?
untreated or treated, lesions, exposure and risks, scans and serology, placental specimens
What is important in examination when suspecting a SCORTCH infection?
HC and weight - plot, fully body exposure, hearing screen, ophthalmology, symmetry
What are red flags for SCORTCH infection?
Symmetrical IUGR
Hx of miscarriage
Outline the RFs, Sx, Ix and Mx of cellulitis?
Definition = deep bacterial infection of the skin
RFs = trauma, bites, burns, comorbidities e.g. DM, pathogen exposure
Sx = red, hot, tender, swollen, rapid spread, systemic sx, look for entry point
Ix (if required) = skin swab, inflammatory markers, cultures, US, skin biopsy
Mx = assess if admission required - systemic illness, oral or IV abx, mark area to monitor spread, monitor response to abx
Outline the definition, Sx, Ix and Mx of dermatitis?
Definition = itchy inflammatory condition w/epidermal changes, classified by cause, location or clinical appearance
Acute Sx = redness, swelling, vesicles, blisters
Chronic Sx = skin thickening, hyperkeratosis, scaling, excoriation
Ix = skin scrapings, skin swab, patch testing, biopsy, bloods e.g. IgG, TFTs
Mx = allergen/irritant identification and avoidance, skin protection, topical therapies e.g. emollients, soaks, paste bandages, steroids, anti-inflammatories, UVB light therapy + systemic treatments if needed
What is eczema and how does it usually present?
Chronic inflammatory skin condition causing dry, pruritic skin, episodic disease with flares and remission, typically atopic (assoc. w/eczema, asthma, hayfever)
Hx: onset - typically infancy, pattern - episode, trigger factors, itching - almost always present, atopic history (family Hx)
Describe the difference between the acute and chronic manifestations of eczema and between children and infants
Acute = poorly demarcated erythema, vesicles, scaling, crusting
Chronic = thickened skin, hyperkeratosis
Children = often localised to flexures
Infant = face, scalp, extensor surfaces
Generally signs of excoriation
Outline the management for eczema
Education on use of creams is crucial!
MILD = generous emollients, 1% hydrocortisone
MODERATE = increase steroid potency, consider dressings, continue to assess for infection, if frequent flares consider maintenance therapy
SEVERE = increase steroids, derm referral
What is eczema herpeticum?
Medical emergency in <2 year olds
HSV infection - grouped vesicles and punched out lesions coalesce into widespread bleeding areas across body
Sx = fever, malaise, lymphadenopathy
Mx = admit + IV acyclovir
What is a dermoid cyst and symptoms, investigations and management?
Definition = benign tumour, germ cell layers foreign to that body site
On skin - appear in early childhood (before 5yrs)
Other areas - can appear any time in life, mostly on face, can be associated to pit or sinus tract
Dx = clinical appearance, typical pathology on biopsy
Rx = surgical excision
What is a key difference between orbital and peri-orbital cellulitis?
Orbital involves the eye
In peri-orbital the eye is unaffected
What pathogens commonly cause orbital and periorbital cellulitis?
S. aureus
S. pneumoniae
H. influenzae
What are the Sx, Ix and Mx of periorbital cellulitis?
Sx = gradual onset eyelid swelling, can extend to cheek and face, low grade fever, often spread from entry point e.g. scratch, bite, eczema
Ix = routine bloods, cultures, CT/MRI orbits and sinuses
Mx = IV antibiotics, monitor carefully
What are the Sx, Ix and Mx of orbital cellulitis?
Sx = pt usually has more toxic appearance, high grade fever, proptosed eye & pain on eye movements, sight-threatening
Ix = routine bloods, cultures, CT/MRI orbits and sinuses
Mx = incision and drainage, high dose IV abx
What is amblyopia and how is it managed?
AKA lazy eye
One eye cannot focus as clearly as the other leading to decreased vision
Common in <5yrs
Mx = glasses, eye patch or eye drops (blur vision in stronger eye), rx should start before 7 years of age
What is Strabismus?
Definition = misalignment of the visual axis (eyes not aligned)
May be found on routine eye checks: birth, 8 weeks, school entry
‘Turning eye’ - taken seriously even if intermittent
How do you examine squint?
General inspection - asymmetry, eye movements, nystagmus
Corneal light reflex - fixate on light and notice any asymmetry in reflection
Cover test - cover each eye in turn as focusing on object, manifest squint
Cover/uncover test - to look for latent squint
