Paeds Flashcards
Whooping cough:
- immunisation?
- symptoms?
- bloods?
- complications?
- Ix?
- Rx?
2, 3, 4 months and 3-5 years
2-3 days coryza symptoms followed by:
- inspiratory whoop (forced inhalation against a closed glottis - not always present)
- infants may have spells of apnoea
- persistent coughing
marked lymphocytosis
Can last 10-14 weeks
Coughing can lead to subconjunctival haemorrhage
Nasal swab for culture
However, PCR and serology more available now
Clarithromycin/Azithromycin if present within 21 days of cough onset
4 day old premature baby not passed meconium with abdominal distension and bilious vomiting:
- What is it?
- Cause?
- More common in?
- Ix?
- Rx?
Hirshprung disease
Parasympathetic neuroblasts fail to migrate from neural crest to distal colon, uncoordinated peristalsis, functional obstruction
Classically PR exam leads to passing stool
Abdo XR can be done
Gold standard - rectal biopsy
Initially rectal washouts
Resection of affected bowel definitive
Kawasaki disease:
- symptoms?
- Ix?
- Rx?
- Complications?
- high grade fever for 5 days, resistant to anti-pyrexial
- conjunctival injection
- strawberry tongue
- cervical lymphadenopathy
- red palms and soles which later peel
No Ix, clinical
High dose aspirin
IVIG
Coronary artery aneurysm - all patients get echo to screen for this
4 year old kid with non-tender palpable mass in LLQ?
Refer urgently <48 hrs to paediatrics for assessment of neuroblastoma/nephroblastoma
This applies to any kid with palpable abdominal mass or unexplained organomegaly
Neuroblastoma:
- where do tumours arise?
- Ix?
Neural crest of adrenal medulla (most common) or sympathetic nerves
Ix:
- raised urinary VMA and HVA
- Calcification on XR (potentially)
- Biopsy
Who gets screened for DDH if no Ortolani/Barlow test?
USS at 6 weeks if breech >36 weeks, regardless of successful ECV
Definitive diagnosis of epiglottitis?
Management?
Direct visualisation by senior, airway trained staff (anaesthetics/ENT)
However, if there is concern e.g. of foreign body
- lateral view XR - thumb sign
(posterior view in croup will show subglottic narrowing - steeple sign)
Rx:
O2
Abx
Intubation may be necessary
Presentations of vesicoureteric reflux?
Ix?
- Antenatal: hydronephrosis on USS
- Recurrent childhood UTI
- Reflux nephropathy - chronic pyelonephritis, renal scarring may cause renin release and hypertension
Diagnosing VUR: micturating cystourethrogram
Renal scarring: DMSA
Achondroplasia inheritance?
AD but 70% cases sporadic
Mutation of fibroblast growth factor 3 causing abnormal cartilage
Most common malignancy in kids?
Presentation?
Ix?
Prognosis?
ALL
- Anaemia, neutropenia, thrombocytopaenia
(tiredness, pallor, infections, easy bruising, petechiae) - Bone pain
- Hepatosplenomegaly
- Fever
- Testicular swelling
Bloods - low everything
>20% blasts
Bone marrow >20% blasts
Most common type CD10
90% cure rate, chemo for 2-3 years
When is short child normal?
Familial - normal if within 2SD predicted
Slow growth during childhood without normal growth spurt, but after puberty will grow normally to reach normal adult height
Pathological:
- Neglect
- Endocrine: thyroid, GH
- Malabsorption: Crohn’s, lactose intolerance, CF
When is puberty precocious and delayed?
How is puberty defined in boys and girls?
Precocious:
- Girls <8
- Boys <9
Delayed:
- Girls >13
- Boys >14
Boys: growth of testes >4ml
Girls, 3 stages:
- thelarche - breast budding
- adrenarche - body hair and odour
- menarche - period
Usual cause of acute diarrhoea in children?
Causes of chronic?
Rotavirus - vomiting and fever for first 2 days as well
Rehydration
Chronic:
- Cow’s milk intolerance
- Toddler’s diarrhoea - vary in consistency, often contains undigested food
- Coeliac disease
- post-gastroenteritis lactose intolerance
Newborn is born be emergency C sec due to foetal distress, what are steps of neonatal resus?
- Dry baby
- Check HR, breath and tone
- If gasping/not breathing give 5 inflation breaths
- Reassess for increase in HR, if none then repeat
- If adequate inflations and HR still <60, start chest compressions
3: 1 compressions:inflations
Paediatric BLS?
Check for pulses and breaths - use femoral/brachial pulses if <1 y/o
Give 5 rescue breaths
If on your own give 30:2 compressions
If help give 15:2 compressions
Causes of constipation in kids?
Vast majority idiopathic
- dehydration
- low-fibre
- meds e.g. opiates
- anal fissure
- hypothyroidism
- Hirschprung disease
- hypercalcaemia
- learning disability
Management of constipation in kids?
Check for faecal impactation: severe constipation, overflow soiling (very loose or rabbit droppings, or very large stools that can block toilet), faecal mass palpable in abdo
If impaction present:
- polyethylene glycol + electrolytes (Movicol)
- add lactulose if no improvement in 2 weeks
Maintenance is same - Movicol 1st line, lactulose added if no response
Ensure dietary fibre and enough fluids but don’t use this as 1st line alone
Causes of jaundice <24 hours?
Prolonged?
Ix for prolonged?
Early: Rhesus disease ABO haemolytic disease Hereditary spherocytosis G6PD deficiency
Prolonged:
- biliary atresia
- hypothyroidism
- galactosaemia
- UTI
- breast milk jaundice (actually caused by suboptimal intake)
- infection (CMV, toxoplasma)
Ix:
- Split bili - most important
- direct coombs test
- TFT
- FBC and film
- urine MC&S and reducing sugars
- U&E and LFT
Management of Perthes?
Cast/braces may be used to keep femoral head in acetabulum
If <6y/o - observe, most resolve with time
> 6y/o - surgery
DDH management?
Most unstable hips will spontaneously stabilise by 3-6 weeks of age
Pavlik haress in kids <5 months and still unstable
If older - surgery
Kocher criteria for septic arthritis in kids?
Non-weight bearing
Fever >38.5
WCC >12
ESR >40
0 = pretty much 0 risk 1 = 3% chance 2 = 40% chance 3 = 93% chance 4 = 99% chance
Age and time of year for croup?
6 months-3 years
Autumn
Stridor
Barking cough worse at night
Fever, coryzal
Admit if:
- <6 months
- Co-existant airway e.g. laryngomalacia, Down’s Synd
- uncertainty about diagnosis
Ix:
- Usually clinical diagnosis
- CXR: PA subglottic narrowing (steeple sign)
Management:
Everyone - single dose oral dexamethasone
Chicken pox incubation and infectivity?
Presentation?
Management?
Complications?
Incubation 10-21 days
Infective 4 days before rash appears until rash completely crusts over (usually about 5 days)
Fever initially, then itchy rash starting on head/trunk then spreading.
Initially macular then papular then vesicular
- Calamine lotion
- School exclusion until rashes heal
- If immunocompromised/newborn then VZIG, aciclovir if it develops
- Secondary bacterial infection - can be a small area of cellulitis to group A strep necrotising fasciitis (needing morphine etc)
- pneumonia
- encephalitis
Cow's milk protein intolerance/allergy presentation? Investigation? Management if formula fed? Management if breast fed? Prognosis?
Appears around 3 months in formula fed infants (can be in breast-fed rarely if mum drinks milk)
- regurg and vomiting
- diarrhoea
- urticaria/atopic eczema
- ‘colic’ - irritability/crying
- wheeze/chronic cough
- rarely angioedema/anaphylaxis
Usually clinical, but if needed:
- ski prick/patch
- total IgE and specific IgE (RAST) for cow’s milk protein
- -> both type I/type IV can occur
Formula fed:
- Extensive hydrolysed formula if formula-fed
- amino acid-based formula if severe/still reacting to eHF
Breast fed:
- continue breastfeeding
- eliminated cow’s milk from maternal diet and consider calcium supplements
- eHF when stop breastfeeding until 12 months
Prognosis:
- IgE - 55% tolerant by 5y/o
- Type IV - almost all tolerant by 3y/o
Management of febrile convulsions?
Chance of epilepsy?
Any kid with first seizure admit to paeds
Risk of further = 1/3
If recurrences, teach parents to use rescue meds - buccal midazolam or rectal diazepam. Phone ambulance if >5 mins
Regular antipyretics = no benefit
2.5% chance of epilepsy in general public
Febrile convulsions alone raise this slightly
febrile convulsions + complex seizure + neurodevelopment disorder = 50% chance
Complex = 15-30 mins, focal, or repeat within 24 hours
2y/o, dropping centiles, nasal polyps?
Consider CF
Positive immunoreactive trypsinogen on heel prick test?
Next test?
Causes of false positive on this test?
CF
Sweat test showing raised Cl
False positive:
- malnutrition
- adrenal insufficiency
- glycogen storage disease
- nephrogenic diabetes insipidus
- G6PD deficiency
False neg:
- Skin oedema due to hypoalbuminaemia due to pancreatic exocrine insufficiency
Management of congenital umbilical hernia?
Usually self-resolve
Elective repair if 2-3 y/o if large or if symptomatic
If asymptomatic/small wait until 4-5 y/o to perform elective repair
Classification of types of precocious puberty?
Gonadotrophin dependent (true)
- premature activation of hypothalamic-pituitary-gonadal axis
- FSH and LH raised
Gonadotrophin independent (false)
- excess sex hormone
- FSH and LH low
Males:
- Rare, usually false
- bilateral testes enlargement = true
- unilateral testicle enlargement = tumour
- small testes (normal for age) = adrenal cause (BAH or tumour)
Female:
- usually idiopathic/familial, follows normal sequence
- If false, due to rare things like McCune Albright Syndrome
LH and Testosterone pattern in:
- Primary hypogonadism (Klinefelter’s)?
- Hypogonadotrophic hypogonadism (Kallman’s syndrome)
- Androgen insensitivity syndrome?
- Testosterone secreting tumour?
Primary hypogonadism (Klinefelter’s):
LH - high
Testosterone - low
Hypogonad Hypogonad (Kallman’s):
LH - low
Testosterone - low
Androgen insensitivity:
LH - high
Testosterone - normal/high
Testosterone secreting tumour:
LH - low
Testosterone - high
Klinefelter’s karyotype?
Features?
47 XXY
Primary hypogonadism
- tall
- lack of secondary sex characteristics
- small, firm testes
- infertile
- gynaecomastia (increased oestrogen:testosterone)
- elevated gonadotrophin levels
Kallman’s inheritance?
Features?
X-linked recessive
Delayed puberty
Hypogonadotrophic hypogonadism
Failure to GnRH neurones to migrate to hypothalamus
ANOSMIA and delayed puberty
- delayed puberty
- hypogonadism
- cryptorchidism
- anosmia
- sex hormones low, LH/FSH low
- tall
Also cleft lip/palate
Androgen insensitivity genetics?
Features?
Management?
X-linked recessive Male genome (46XY) with female phenotype
Primary amenorrhoea
undescended testes - groin swelling
breast development may occur due to testosterone being converted to estradiol
Ix: chromosomal analysis
Counselling - raise as female Bilateral orchidectomy (testicular cancer - seminoma?) Oestrogen therapy
Define primary amenorrhoea?
Causes of primary amenorrhoea?
No period by 15 y/o but with normal development of breasts and pubic hair
OR
No puberty at all by 13 (girls only obvz)
- Gonadal dysgenesis (e.g. - Turner’s Syndrome 45X) - most common
- Androgen insensitivity (testicular feminisation)
- Congenital malformations of genital tract
- Functional hypothalamic amenorrhoea (e.g. anorexia)
- Congenital adrenal hyperplasia
- Imperforate hymen
Initial Ix of primary amenorrhoea?
Management?
- bHCG
- FBC, U&E, coeliac, TFT
- Gonadotrophin
- -> low = hypothalamic cause
- -> raised = ovarian cause (e.g. Turner’s)
- PRL
- androgen levels
- oestradiol
- Treat underlying cause
- If Turner’s likely need HRT to prevent osteoporosis
Contraindications for breast feeding?
HIV Drugs: - lithium - amiodarone - chemo (plus methotrexate and leflunomide) - antidepressants (not SSRI)
Gross motor milestones:
6 weeks, 3 months, 6 months, 9 months, 12 months, 18 months, 2 years, 3 years, 4 years, 5 years?
6 weeks - head control
3 months - no head lag on pulling up to sit
6 months - pushes onto arms when lying on stomach
9 months - sits without support, pulls to stand, holds onto furniture, may crawl
1 year - cruises furniture, walks with one hand held
18 months - runs, squats to pick up ball
2 years - stairs with 2 feet
3 years - stairs with 1 foot
4 years - hops, tip toes
5 - bike
Fine motor milestones:
6 weeks, 3 months, 6 months, 9 months, 12 months, 18 months, 2 years, 3 years, 4 years, 5 years?
6 weeks - follows torch with eyes
3 months - hand regards - hands held in midline
6 months - palmar grasp
9 months - index finger to point
1 year - pincer grip
18 months - tower of 3 bricks
2 years - scribbles, tower of 6-7 bricks
3 years - draw circles, tower of 9
4 years - simple picture of man
5 - triangle
Language milestones:
6 weeks, 3 months, 6 months, 9 months, 12 months, 18 months, 2 years, 3 years, 4 years?
6 weeks - stills to voice
3 months - starting to vocalise
6 months - babbles, screams when annoyed, mama/dada
9 months - localises to sound, babbles for self-amusement
1 year - responds to name
18 months - knows 5-20 words
2 years - simple instructions, 50+ words, combine 2 words
3 years - knows own name, asks who/what questions
4 years - stories, count to 20, asks when/where/how questions
Social milestones:
6 weeks, 3 months, 6 months, 9 months, 12 months, 18 months, 2 years, 3 years, 4 years, 5 years?
6 weeks - social smile
3 months - reacts pleasurably to familiar sounds
6 months - friendly with strangers
9 months - distinguishes strangers, plays peek-a-boo
1 year - drinks from cup
18 months - feeds with spoon, mimics adults
2 years - puts on shoes, messy, symbolic play
3 years - vivid imagination, understands sharing
4 years - dresses & undresses
5 - ties shoe laces
What is specific and global delay?
Deviation?
Regression?
specific - delay on 1 of 4
global - significant delay in 2 or more of 4
deviation - not delay but not normal -> autism
regression - loss of previously attained skills -> rest syndrome, metabolic stuff
Red flags of development?
- asymmetrical movement
- not reaching for objects by 6 months
- unable to sit unsupported by 12 months
- unable to walk by 18 months
- no speech by 10 months
- loss of skills
- concern over vision and hearing
- showing signs of handedness before 12 months - possible cerebral palsy
Ddx of stridor in a kid?
- foreign body
- anaphylaxis
- croup
- epiglottitis
- laryngomalacia (soft, floppy trachea, worse on crying, lying, eating, resolves by around 2 y/o)
foreign body:
- if choking, back slaps/abdo thrusts
- if not, remove via bronchoscopy under GA
Indications for CT head in kids after injury?
- LOC >5 mins
- amnesia lasting >5 mins
- drowsy
- 3+ vomits
- suspicion of NAI
- seizure
- GCS <14
- bony depression/bulging fontanelle
- sign of skull # (haemotympanym, panda eyes, CSF in ear/nose, Battle sign)
- focal neurological deficit
- If <1, presence of bruise/swelling >5cm
- dangerous mechanism of injury
Initial fluid bolus in a dehydrated kid e.g. sepsis?
20ml/kg
When should you do a school culture for kids with D&V?
Management of kids with D&V if they are not dehydrated?
Culture if:
- septic
- blood/mucus in stool
- immunocompromised
Consider culture if:
- recently abroad
- not improved by 7 days
- uncertain about diagnosis
Management if NOT dehydrated:
- continue feeds
- encourage fluid intake
- discourage fruit juices/fizzy juice
If dehydration suspected:
- give 50ml/kg oral rehydration solution over 4 hours, plus ORS as maintenance as small amounts
- continue breastfeeding
Hypernatraemic dehydration?
- jittery
- increased muscle tone
- hyperreflexia
- convulsions
- drowsy/coma
Features of growing pains?
- usually at night after lots of exercise
- never present in morning
- no limp
- no limit on activity
- systemically well, normal milestones
Gastroschisis birth and management?
Exomphalos?
What is exomphalos assoc w?
Gastroschisis - defect in anterior abdo wall just next to cord
- vaginal delivery may be attempted
- theatre asap (<4 hours after birth)
Exomphalis - abdo contents protrude through wall but covered in amniotic sac formed by amniotic membrane and peritoneum
- C-section at 37 weeks
- staged repair
- if repair too difficult, leave sac to ‘granulate/epithelialise’ and repair when older
assoc w Down syndrome, cardiac and kidney malformations
Caput succedaneum?
Cephalhaematoma?
Neonatal intracranial haemorrhages?
Caput - pressure in scalp causing swelling/bruising, reduces over a few days
Cephal - SVD/ventouse/forceps - tense swelling limited to frontanelle - weeks-months
Intracranial - epidural never happens. Subdural may occur rarely with forceps. SAH more common than that and can cause irritability/convulsions in first 2 days. Intraventricular commonest and occur if premature, also cause irritability and convulsions and hypotonia. USS scan
Causes of hypertension in kids?
Renal parenchymal disease Renal vascular disease Coarctation of aorta Phaeochromocytom Congenital adrenal hyperplasia Essential/primary hypertension
Infantile spasms pattern of movement?
Flexion of head, trunk and arms followed by extension of arms - this lasts 1-2 seconds and they repeat it 50 times
West syndrome - EEG hypsarrhythmia, poor prognosis
Infantile colic:
- age?
- what does it look like?
<3 months
Bouts of excessive crying and pulling-up of legs, often worse at evenings
Happens to 20% infants, cause unknown
Dermoid cysts:
- common locations?
- defining features?
Desmoid cyst?
Locations:
- Midline neck
- external angle of eye
- posterior pinna of ear
Features: all 3 germ cell origins, include things like hair follicles etc. (aka teratomas)
Desmoid - large infiltrative masses usually around abdo, chest wall, back and thigh. Arise from the muscle. Most common in FAP.
Amber flags for feverish child?
What should you do?
Amber:
- Pallor seen by parent/carer but resolving/intermittent
- No smile, decreased activity, not responding to normal social cues
- Nasal flaring
- Resp rate 50 (6-12 months) or 40 (>12 months)
- sats <95%
- crackles
- Age 3-6 months and fever >39
- tachycardia >160 (<12 months), >150 (1-2 years), >140 (2-5 years)
- CRT 3secs
- dry mucous membranes
Send home with strict safety netting or refer to paeds specialist for further assessment
Red flags for feverish child?
What should you do?
- pale/mottled/blue skin
- No response to social cues, appears ill
- weak, high-pitched cry
- Grunting
- tachypnoea >60, chest indrawing
- reduced skin turgor
- Age <3 months and >38 degrees
- Neck stiffness, non blanching rash, bulging frontanelle, neck stiffness, seizure
Refer urgently up to paeds
Don’t prescribe abx unless apparent source
Features of had foot and mouth?
Cause?
Management?
School exclusion?
Fever, systemic upset
Oral ulcers
Followed by vesicles on foot/hand
Coxsackie A16 or enterovirus 71
Rx: analgesia and hydration
No link to cattle
Children do not need kept off school (obvz if they are too ill to go in then keep them off)
Head lice:
- spread?
- symptoms/incubation?
- Diagnosis?
- management?
- school exclusion?
Head to head contact - cannot jump/fly/swim
Itchy head when infected, remaining itchy for 7-10 days
Ix: wet fine tooth comb to expose roots - nits are the empty white shells
Rx; only if evidence of live lice. Malathion, dimeticone etc.
Household contacts do not need treatment
No need to exclude from school
Hearing tests in children?
Otoacoustic emission test - newborn
Auditory brainstem response testing - if otoacoustic abnormal - newborn
Distraction test - 6-9 months - performed by health visitor and requires 2 trained staff
1.5-2.5 years - recognition of familiar objects “what one’s a teddy bear?”
> 2.5-3 years - Speech discrimination test
Pure tone audiometry (done at school entry in most of UK)
Management of hypospadias?
Corrective surgery at 12 months
Essential they are not circumcised prior as the foreskin may be used in repair
Most common cause of hypothyroidism in kids?
Also autoimmune
Others include:
- Post total-body irradiation (e.g. for ALL)
- Iodine deficiency (in developing world)
Central causes of hypotonia at birth?
Other causes?
Down Syndrome
Prader-willi
Hypothyroidism
Cerebral palsy (hypotonia before hypertonia)
Others:
- infection
- hypoxia
- encephalopathy
- spina bifida, spinal muscular atrophy, GBS, MG, myotonic dystrophy
ITP in kids:
- antibodies against?
- features?
GP IIb/IIIa complex
More acute than in adults
Following infection or vaccination
usually self limiting over 1-2 weeks
Contraindication to vaccines?
When should it be delayed?
Live vaccines?
Specific for diphtheria/tetanus/polio vaccine?
- previous anaphylaxis to same vaccine or components (e.g. egg protein for yellow fever/flu)
Delayed:
- current febrile illness
CI live vaccine:
- pregnancy
- immunosuppression
DTP vaccine:
- defer in kids with evolving/unstable neurological condition
Vaccines given:
- at birth?
- 2 months?
- 3 months?
- 4 months?
- 12 months?
- 3-4 years?
- 12-13 years?
- 13-18 years?
- annually 2-8 years?
Birth: BCG if at risk
2 months: 6 in 1, oral rotavirus, MenB
3 months: 6 in 1, oral rotavirus, pneumococcal
4 months: 6 in 1, Men B
12 months: HiB/MenC, MMR, pneumococcal, MenB
3-4 years: 4 in 1 booster, MMR
12-13 years: HPV
13-18 years: 3 in 1 teenage booster, MenACWY
Annually 2-8 years: flu
What’s in the 6 in 1 vaccine?
What’s in the 4 in 1 pre-school booster?
tetanus, diphtheria, polio, whooping cough, HepB, H influenza B
(given at 2, 3, 4 months)
4 in 1: tetanus, diphtheria, polio, whooping cough
3 in 1 teenage: tetanus, diphtheria, polio
Type of fluid for maintenance in young people/kids?
0.9% saline (+ glucose if needed)
as opposed to more dilute for adults
T1DM risks what in foetus?
Spina bifida
Cardiac malformation
Do frequent doctors appts point towards child abuse?
Torn frenulum?
3 commonest fractures in NAI of kids of any age?
A&E yes, GP no
A&E suggests want to see different doc each time to avoid suspicion
Suggests forcing bottle in baby’s mouth
Fracs:
- humerus
- radius
- femur
5 significant RF for sudden infant death syndrome?
- sleeping prone
- sleeping in same bed as baby
- parental smoking
- room too hot or head covered
- prematurity
General management points of CF?
- Regular chest physio, at least twice daily
- high calorie, high fat diet with pancreatic enzyme supplements every meal
- Vitamin supplements
- Minimise contact with other CF patients to prevent Burkholderia/Pseudomonas infection
- Lung transplantation - contra-indicated in chronic Burkholderia infection
Premature babies vaccines and developmental milestones?
Normal chronological age, don’t delay
If parent brings in kid to have MMR vaccine a few years late?
What book has all the info about vaccines?
Give 2 doses 3 months apart
Green book
Reflex anoxic seizure?
Kids 6 months - 3 years old
In response to painful/emotional stimuli:
- goes pale
- falls to floor
- may start starts shaking (anoxic seizure)
- rapid recovery
Neurally mediated by vagus nerve
Mongolian blue spots? Milia? Stork mark/salmon patch? Port wine stain? Strawberry haemangioma? Spitz naevi?
Mong B: Slate grey congenital melanocytosis usually over buttocks/back, start regressing after 1y/o
Milia: Small, benign, keratin filled cysts on face, occur at any age but common in newborns
Stork/Salmon: blotchy pink vascular birthmarks found on forehead, eyelids or nape of neck, usually disappear over a couple of months but may persist. 50% prevalence in newborns
Port wine: deep red/purple, vascular birth marks that tend to be unilateral. Unlike others, they remain and tend to darken and raise over time. Rx cosmetic camouflage/laser therapy
Strawberry: erythematous, multilobed haemangioma that grows until 6-9 months then regresses, usually gone by 10y/o. Common on face, neck, scalp. If blocking visual field/bleeding then propranolol.
Spitz: pink/red naevus which grow rapidly to about 1cm in kids on face or legs, usually excised to be safe
Nappy rash?
Management?
Irritant contact dermatitis, spares skin folds
- Keep skin clean and dry - change nappies regularly
- Leave undressed if possible
- topical steroids if bad
- barrier creams with every nappy once healed (zinc/castor oil)
seborrhoeic dermatitis in newborns - how does it usually present?
in infants?
Management?
Cradle cap - itchy, yellow (maybe erythematous) scale on scalp
Infants - flexures - axillae, neck creases, groin with NO skin fold sparing
Rx: emollients +/- steroids
Roseola cause?
Presentation?
How to differentiate from Rubella?
HHV-6
High fever followed by discrete pink macular rash once fever subsides
High fever, lack of sub occipital lymph nodes
Parvovirus B19 presentation in a child?
if in pregnancy what to do?
Complications of it?
School exclusion?
- Mild feverish illness, may not even be noticeable
- slapped cheeks, followed by lacy maculopapular rash all over body
- Can get polyarthritis
If mother catches in pregnancy <20 weeks she’ll need to get IgM and IgG antibodies checked as can result in foetal death (polyarthritis and severe anaemia more common in adults)
Comps:
- pancytopenia if immunosuppressed
- aplastic crisis in sickle cell (suppresses erythropoiesis for 1 week so aplastic crisis if chronic haemolysis)
No need as child is no longer infectious once rash appears
What is erythema toxicum?
Harmless rash seen in babies aged 2-5 days old
Pustules with surrounding erythema, can become widespread and confluent
Self limiting, no Rx
Causes of meningitis <3 months?
3 months-6 years?
>6 years?
Listeria, GBS
Neisseria, Strep pneumo, HiB
Strep pneumo, neisseria
Initial management of meningitis?
Contacts?
IM BenPen if primary care
<3 months, >60 years or immunocompromised: amoxicillin + cefotaxime
Otherwise:
Dexamethasone + Cefotaxime
(hold dex if septic shock)
Single dose oral Cipro for close contacts in <7 days for meningococcal, plus booster vaccine once serotypes available (generally not needed for pneumococcal)
Definition of reduced consciousness in a kid?
When to intubate?
GCS 14 or less
P or U on AVPU
If GCS <9, unresponsive or signs of raised ICP
Fluid challenge if hypotensive in a kid?
20ml/kg fluid chalenge
10ml/kg isotonic saline if assoc with raised ICP
If BM<3 in kid?
2ml/kg 10% dextrose
Urgent CT in kid with reduced consciousness?
Signs of raised ICP?
GCS <8
Raised ICP
Focal neurology
ICP: bulging fontanelle, bradycardia (+/- hypertension), abnormal pupils, abnormal posturing, abnormal breathing pattern
When to do LP in kid with reduced consciousness?
CNS infection suspected or febrile illness of unknown origin
CI:
- Raised ICP
- GCS <8 or deteriorating
- Focal neurology
- Clinical evidence of circulatory/septic shock
-> only carry out if CT says it is safe to do so
Causes of raised ICP?
Management?
SOL, cerebral oedema, intracranial haemorrhage
Management:
- GCS <9
- tilt head to 20-30 deg
- fluid restriction +/- mannitol
- PICU
- urgent imaging
Differential of flaccid paralysis of a kid?
GBS
Acute spinal cord lesion: SOL, demyelination, transverse myelitis
How to measure temperature in a kid?
<4 weeks - electronic axillary thermometer
4 weeks - 5 years - electronic axillary or infrared in axilla
Onset ADHD?
Diagnosis?
Management?
Monitoring?
More common in boys aged 5-9, triad:
hyperactivity, impulsivity, inattention
Diagnosis:
- present for at least 6 months
- Observation at school and home using tools
Non-pharm management:
- parental training, social skills training
- sit at front of class
- melatonin for sleep cycle, diet change
Pharm (last line):
- methylphenidate - 6 week trial
- lisdexamfetamine if no response
Both need ECG monitoring
Methylphenidate needs height and weight monitoring, can stunt growth
Autism - apart from rigid thought, difficult relationship establishment, delay/poor communication (and odd speech) what else is there?
Diagnosis?
Management?
Sensory hypersentitivity, doesn’t like taste/texture of foods or objects on skin
Asperger’s - social abnormality but no cognition or language
Diagnosis:
- 6 months
- semi-structured interviews/assessments
Management:
- social skills training
- SALT
- school interventions
Presentation of McArdle’s disease?
Stiffness and myalgia during exercise then typical second wind
Myoglobinuria after exercise
What is term? Normal birth weight? Perinatal mortality? Neonatal mortality? Postnatal mortality? Infant mortality?
Term = 37 - 41+3
Weight = 2.5-4kg
Perinatal mortality = 24 weeks - 1 week post partum
Neonatal = <28 days
Postnatal = 28 days - 1 year
Infant = birth - 1 year
Normal values or HR, RR and systolic BP at:
- <1?
- 1-5?
- 5-12?
<1:
HR 110-160
RR 30-40
Sys BP 70-90
1-5:
HR 95-140
RR 25-30
Sys BP 80-100
5-12:
HR 80-120
RR 20-25
Sys BP 90-110
After same as adult
When is guthrie heel prick taken?
What does it test for?
5 days
CF
Sickle cell
Congenital hypothyroidism
5 inherited metabolic conditions including PKU, homocystinuria and maple syrup
Postnatal baby check?
What does it include?
Done by GP at 6-8 weeks
Preterms done at 6 weeks after expected delivery
Includes:
- red reflex and squint
- CVS, resp, abdo
- genitalia
- barlow and ortolani
- head control when sitting and social smile
What can hypothermia cause in newborn?
increased work of breathing, hypoxia, hypoglycaemia
When is surfactant produced? Presentation of ARDS? O2 and CXR? Management? Complications?
Production starts 24-28 weeks, usually enough to breathe normally by 34 weeks
Tachypnoea, grunting, nasal flaring, intercostal recession
Usually onset <4 hours after birth
Symptoms do not resolve in <24 hours unline TTN
O2 low
CXR ground glass
Surfactant and non-invasive/invasive ventilation
BPD: barotrauma and oxygen toxicity causing nectotising bronchitis and hyperinflation, difficulty weaning off ventilatory and long-term morbidity
Apnoea of prematurity?
Gaps of breathing >20 seconds as breathing centres in brain not fully developed
May require ventilation
Early onset and late onset sepsis and causes of each?
Risk factors?
EOS <72hrs - GBS (75%), E Coli
LOS 7-28 days - environmental - staph epi, listeria, klebsiella, pseudomonas
RF: mother with previous GBS infection or colonisation screened, PPROM, intraparum infection
Low birth weight, prematurity, maternal chorioamnionitis
Presentation of neonatal sepsis?
Subacute onset
Resp distress - grunting (85%), nasal flaring, accessories etc Tachycardia Apnoea (40%) Jaundice Seizures poor/reduced feeding Abdo distension Vomiting
Temp:
- term infants likely to be febrile
- pre-term likely to be cold
Ix for neonatal sepsis?
Empirical abx?
Blood culture (90% sensitive) FBC CRP Blood gases (met acid) Urine MC&S LP (usually part of any septic screen <28 days)
Benzylpenicillin + gentamicin
(fluid, electrolyte, temperature, oxygen, glucose and prevention/management of acidosis paramount)
TTN?
Failure to adequately clear fluid from lungs following delivery - common in Csec
RR >60
Otherwise completely well, no increased work of breathing
Monitor, should resolve in 24 hours
Meconium aspiration syndrome?
More common in post-terms
Meconium stained liquor
Foetal distress - hypoxia, increased work of breathing
Suction and supportive care
Causes of heart failure in newborn?
Infections: TORCH
Chromosomal abnormalities
Rhesus haemolytic disease
TORCH:
Toxoplasma, others, Rubella, CMV, HSV
Presentation of heart failure
Hypoxia, pul oed, sacral ankle and periorbital oedema, hepatosplenomegaly
Supportive care (prostaglandins if needed to keep PDA)
PPHN?
Features?
Management?
Failure to pulmonary pressure to drop, causing right to left shunt and hypoxia
Features:
- resp distress
- cyanosis
- loud S2
Supportive care and inotropes whilst baby adapts
Causes of neonatal seizures?
Infection Kernicterus Hypoglycaemia Hypocalcaemia Drug withdrawal Peri/intra-ventricular haemorrhage Hypoxic ischaemic encephalopathy - most common
Subtle:
Posturing, sucking, lip smacking, nystagmus
Phenobarbital
If prolonged jaundice, what should be screened for?
G6PD deficiency
Galactosaemia
Hypothyroidism
a1-antitrypsin deficiency
Presentation of kernicterus?
Management?
Long term sequelae?
Jaundice, poor feeding, shrill cry, hypertonicity
Exchange transfusion
Deafness, reduced IQ
Foetal circulation?
Umbilical arteries from internal iliac arteries to placenta
Umbilical vein enters at umbilicus and diverts to liver
Skips liver via ductus venosus
Foramen ovale - R to left shunt allowing oxygenated blood into L heart
Ductus arteriosus - from pulmonary trunk to descending aorta
Causes of microcephaly? (5)
- normal variation/familial
- foetal alcohol syndrome
- congenital infection
- perinatal brain injury (hypoxic ischaemic encephalopathy)
- Patau syndrome
What conditions are assoc w down syndrome? (8)
Hypothyridism ALL Alzheimer's AVSD Duodenal atresia Hirschprung's Atlantoaxial instability T1DM
Undescended testes in newborn incidence?
Management if unilateral and bilateral?
Complications?
Occurs in 2-3%, 25% bilateral
Unilateral:
Wait until 3 months of age, if not descended then refer. Ideally see urology surgeon before 6 months of age and orchidopexy before 1 year
Bilateral:
Urgent pads appt within 24 hours for endocrine and/or genetic Ix
Comps:
- testicular cancer
- torsion
- infertility
Inheritance of Huntington’s?
AD
Are VSD repaired?
What complications are they at risk of?
If large defect causing haemodynamic instability yes, otherwise no
Endocarditis
Pulmonary hypertension
Ventricular septum aneurysm
(endocarditis - turbulent blood flow across defect damages endothelium, exposing vWF, allowing platelets to stick and bacteria to adhere if any is present in blood at time transiently and asymptomatically)
How to tell if a child is in shock rather than just dehydrated?
How to tell if it is compensated (early) shock?
Decompensated (late) shock?
- cold peripheries
- CRT >2 secs
- lethargic/altered responsiveness
Normotension
Will be tachycardic, tachypnoeic, have reduced urine output, reduced skin turgor etc - hypotension is ominous and indicates decompensated shock, which is ominous
Late:
hypotension, bradycardia, Kussmaul (acidotic) breathing, blue extremities, absent urine output
Atrial septal defect:
- why systolic murmur and fixed splitting S2?
- Presentation?
Increased flow into RA and RV means increased flow than expected through pulmonary valve causing murmur and splitting of heart sounds
Usually asymptomatic
If severe, may have SOB, causing lethargy, poor appetite, poor growth and increased susceptibility to resp infections
ABG of pyloric stenosis?
ABG of diarrhoea?
hypokalaemic, hypochloraemic metabolic alkalosis
Metabolic acidosis
Cyanotic heart defects?
Transposition of great vessels - aorta arises from R ventricle, egg shaped cardiomegaly
TOF - overriding aorta, pulmonary stenosis, VSD, RVH
-> boot shaped cardiomegaly, ejection systolic murmur, tet spells
Tricuspid atresia
Pulmonary atresia
Severe ebstein’s anomaly
Acyanotic heart heart defects?
VSD - most common
ASD - systolic murmur, fixed splitting of S2
Aortic stenosis
Coarctation - Assoc w turner’s syndrome, diminished lower limb pulses, radio-femoral delay, CXR rib notching
PDA - continuous machine ike murmur
Indomethacin
VSD:
- assoc?
- post-natal presentations if not picked up in 20-week scan?
- Management?
- Complications?
the 3 trisomies, congenital infections - most common heart defect, 50% resolve naturally
Pres:
- failure to thrive
- HF - tachycardia, tachypnoea, hepatomegaly, pallor
- pan systolic murmur (louder in smaller defects)
Management:
- small usually close on own and asymptomatic
- mod-large usually result in signs of HF in first few months
- Nutritional support, symptomatic (diuretics etc), surgical closure
Comps:
- aortic regurg
- endocarditis
- pulmonary hypertension
- Right heart failure
- Eisenmenger: prolonged pul HTN, causing left to right shunt, therefore cyanosis and clubbing - indication for heart and lung transplant
Management of tet spells?
B blockers
Causes of pulmonary hypoplasia?
Oligohydramnios
Congenital diaphragmatic hernia
Congenital diaphragmatic hernia presentation?
Often picked up in antenatal scans
Resp distress soon after birth due to pulmonary hypertension and hypoplasia
Risk factors for cleft lip/palate?
Maternal anti epileptic use
Inheritance (polygenic)
glucose level for neonatal hypoglycaemia?
Management if asymptomatic?
If symptomatic?
<2.6
If asymptomatic - encourage breastfeeding and monitor regularly
If symptomatic (jittery, pale, tachypnoeic, irritable, weak cry, hypotonia) - admit to neonatal unit for 10% dextrose infusion
