Paeds Flashcards
Abdominal wall defects
Omphacoele- sealed in a sac
Gastrochisis- no peritoneal sac, lots of fluid loss
What is the diagnosis of a preterm 2 week old which is crying, abdo distension, bloody stool?
Necrotising enterocolitis
What Ix do you do for NEC?
Cultures, FBC, blood gas
CRP
Diagnosis is made by AXR
What is the management of NEC
Frrd
Causes of LBO in a newborn?
Rectal atresia
Hirschsprungs
What is hirschsprungs disease?
How do you diagnose?
How do you treat?
Absence of ganglion cells from the myenteric and submucosal plexuses
Occurs in 1/5000 births
Full thickness rectal biopsy for diagnosos
Delayed passage of meconium and abdo distension
Treatment is with rectal washouts followed by anorectal pull through procedure
How would you manage suspected haematological malignancy?
Any of the following features in a person aged 0-24 years should prompt a very urgent full blood count (within 48 hours) to investigate for leukaemia: Pallor Persistent fatigue Unexplained fever Unexplained persistent infections Generalised lymphadenopathy Persistent or unexplained bone pain Unexplained bruising Unexplained bleeding
What is a cephalohaematoma?
Swelling due to birth
doesnt cross suture lines
what is caput succedaum?
swelling, crosses suture lines
What is turners associated with?
Bicuspid aortic valve causing aortic stenosis and ejection systolic murmur
What does croup present with?
Stridor
Barking cough
Mild pyrexia
Coryzal sx
What is the cause of croup?
URTI caused by parainfluenza virus
Peak incidence 6 months- 3 years
When should a child be admitted with croup?
<6months of age
Known upper airway abnormalities- laryngomalacia, downs
uncertainty about diagnosis
Moderate or severe croup
How do you treat croup?
CKS recommend giving a single dose of oral dexamethasone (0.15mg/kg) to all children regardless of severity
Prednisolone is an alternative if dex is not available
Emergency treatment; high flow oxygen, nebulised adrenaline
When should you never examine a childs throat?
In croup!
What should you do if a baby is jaundice in the first 24 hours of life?
You have to urgently measure and record the serum bilirubin level urgently (within 2 hours) in all babies with suspected or obvious jaundice as this is likely to be pathological rather than physiological jaundice
What are the causes of jaundice in the first 24 hours of life?
Rhesus haemolytic disease
ABO haemolytic disease
Glucose 6 phosphodehydrogenase
hereditary spherocytosis
What are the causes of jaundice from 2-14 days?
usually physiological
less developed liver, more RBC, fragile RBC
more common in breastfed babies
What Ix to do in prolonged jaundice (>14 days?)
14 days or 21 days premature, a perolonged jaundice screen is performed
Conjugated and unconjugated bilirubin (very improtant as raised conjugated bilirubin could indicate biliary atresia which requires urgent surgical intervention)
Coombs test (Direct antithyroglobulin test)
FBC
TFTS
Urine for MC+s and reducing sugars
UES
LFTS
What are the causes of prolonged jaundice?
Biliary atresia Hypothyroidism Galactosaemia UTI breast milk jaundice Prematurity CMV/Toxoplasmosis
What is scarlet fever?
A reaction to erythrogenic toxins produced by group A haemolytic streptococci (Staph pyogenes)
Spread via. the resp route by inhaling/ingesting resp droplets
Fever, malaise, headache, nausea, vomiting, sore throat, strawberry tongue, sandpaper rach
How do you manage scarlet fever?
Oral pen V for ten days
Azithromycin for pen allergy
Children can return to school 24 hours after commencing abx
Scarlet fever is a notifiable disease
What is the no.1 cause of painless massive GI bleeding requiring a transfusion in children aged 1-2?
Meckles diverticulum
What is VUR diagnosed by?
MCUG
What should be given to women who test positive for GBS on vaginal swabs or urine dip?
IV benzylpenicillin in labour
How does the Centor criteria work?
Used for tonsillitis to estimate whether it is bacterial or viral and whether antibiotics will work CAFE C= absence of cough A= Anterior cervical lymphadenopathy F= Fever (present) E= Exudate
If 3/4 are present then there is 40-60% chance the kid has Group B strep and needs antibiotics
How do you treat Group B strep tonsilitis?
Penicillin V for 5-10 days
How do you treat UTIs in kids?
If they are 3months- 12 years then cefalexin
If they are 12-17 years then nitrofurantoin
3 days!
What are the indications for ultrasound in urinary tract infections?
If they are younger than 6 months then they should all have one in 6 weeks
If they have atypical UTIs; seriously ill, poor urine flow, abdo or bladder mass, raised serum creatinine, failure to respond to suitable abx within 48 hours, infection with non E coli organisms
Recurrent UTI; > or equal to upper UTIS/ pyelonephritis, 1 upper UTI + > or equal to 1 lower UTI, > or equal to 3 UTIs/cusyotos
How can you prevent a kid from getting a UTI?
Stay hydrated use the potty more often time the kids potty times empty bladder completely proper wiping (front to back) avoid constipation clothing choices- cotton underwear, avoid nylon, synthetic and tight fitting underwear
Whats the difference between simple and complex seizures in kids?
simple= <15 mins
Generalized seizure
No recurrence within 24 hrs
Complex=
>15 mins
focal
may have repeat in 24 hrs
What causes bile stained vomit and distended abdomen in a child?
Intestinal malrotation
What would the diagnosis be if a 4-6 week old has projectile non bilious vomiting and weight loss alongside a palpable mass?
hypertrophy of the pyloric stenosis
What does hypochloraemic metabolic alkalosis suggest?
Hypertrophy of the pyloric sphincter
How do you diagnose pyloric stenosis?
USS
How do you treat pyloric stenosis?
Ramstedt pyloromyotomy
What is intussusception and how does it present?
telescoping of the bowel proximal to the ileocaecal valve presents at 6-9 months sausage shaped mass colicky pain, diarrhoea, vomiting redcurrant jelly stool
How do you treat intussuseption?
Reduction w/ air insufflation
What does congenital rubella present with?
sensironeural deafness and congenital cataracts
What is croup?
What is it caused by?
URTI with laryngeal oedema and secretions which cause a stridor
Parainfluenza virus
What are the features of croup and how do you treat it?
Stridor, barking cough worse at night, fever, coryzal sx
Single dose of dex- 0.15mg/kg (pred if not)
emergency treatment is O2 and neb adrenaline
What are the causes of stridor in children?
Croup
Acute epiglottitis (caused by haemophilus influenzae type B)
Inhaled FB
Laryngomalacia (present at 4 weeks)
What are the features of PDA and how do you treat?
Left subclavicular thrill continous machinery murmur large volume, bounding, collapsing pulse wide pulse pressure heaving apex beat
Indomethacin (Inhibits prostaglandin synthesis)
What murmur would you hear with Teratology of fallor?
ejection systolic
What causes meningitis in children?
Neonatal to 3 months=
Group B streptococcus
1 month to 6 years=
Neisseria meningitidis
> 6 years=
Neisseria meningitides
Strep pneumonia
Whats the difference between gastrochisis and exopthalmos?
exopthalmos covered by amniotic sac
Whats the difference between gastrochisis and exopthalmos?
exopthalmos covered by amniotic sac
What is kawasaki and what causes it?
What are the features?
Its a type of vasculitis
High grade fever which lasts for >5days, CHARACTERICALLY RESISTANT TO ANTIPYREXIALS
conjunctival injection
bright red, cracked lips
Strawberry tongue
Cervical lymphadenopathy
red palms on hands and sole of feet which later peel
What is the management of kawasaki?
High dose aspirin
IV immunoglobulin
Echocardiogram to look for coronary artery aneursyms
What is used to assess the probability of septic arthritis in children?
Kochers
What does kochers criteria involve?
High WCC
High ESR
High fever
Non weight bearing
What are the signs and symptoms of septic arthritis?
Symptoms= joint pain, limp, fever, lethargy Signs= Swollen red joint with limited movement
Do joint aspiration for culture (will show raised WCC)
Blood cultures
What are the signs and symptoms of septic arthritis?
Symptoms= joint pain, limp, fever, lethargy Signs= Swollen red joint with limited movement
Do joint aspiration for culture (will show raised WCC)
Blood cultures
What is perthes disease?
What is the classical presentation?
What are the complications?
Management?
idiopathic avascular necrosis of the femoral head
Limp in a 4-8 year old boy with an irritable hip, limp and reduced range of movement despite no hx of trauma or systemic symptoms (5x more common in boys)
OA, premature fusion of growth plate
Under 6- observe, if older then surgery, cast/braces
What are the two types of enuresis?
Primary- the child never achieved continence
Secondary- the child has achieved continence and been dry for 6 months before
What are the management options for enuresis?
Reward systems
Enuresis alarm
Desmopressin
What are the features of respiratory distress?
Intercostal and subcostal recession
Tracheal tug
Nasal flaring
Accessory muscles
What are the risk factors for developmental dysplasia of the hip?
Female
Breech
FHX
Oligohydramnios
What are the tests for developmental dysplasia of the hip?
Barlow and ortolani
US if these are positive
What is the management of DDH?
Normally they spontaneously stabilise by age 3-6 weeks
Hips that remain unstable at 6 weeks require some treatment…
<4.5 months=long term splinting (Pavlik Harness)
6-8 months= closed reduction
> 18 months= open reductiom
What is the most common cause of hip pain in children aged 4-10?
Transient synovitis
What are the features of transient synovitis?
Acute onset hip (and/or knee’ pain and limp, usually comfortable at rest)
Fever in a minority of pts
Following a recent viral infection or autoimmune disease
What is the management of transient synovitis?
All investigations will be normal
It is self limiting after a few weeks, treat with rest and simple analgesia
What are the risk factors for septic arthritis?
Pre existing joint disease DM Immunosuppression CKD Joint prosthesis IVDU
What are the causes of septic arthritis?
Staph aureus= most common
Neisseria gonorrhoea (sexually active patients)
Salmonella= sickle cell
What are the clinical features of septic arthritis?
Hot swollen joint Reduced ROM Erythema Fever Rigid joint and pt wont tolerate passive movement
What is the criteria used for septic arhritis?
Kocher criteria
Fever >38.5
Non weight bearing
Raised ESR
Raised WCC
What are the investigations done for septic arthritis?
Joint aspiration for MC and S Bloods- raised WCC, ESR, CRP Blood culture X-ray (widening joint space) US will demonstrate fluid
What is the management of Septic arhritis?
What are the complications?
Antibiotics; 6 week course of flucloxacillim
Osteoarthritis and osteomyelitis are the complications
What is osteomyelitis and what are the risk factors?
Infection of the bone
In children it affects the metaphyses of long bones due to high vascular supply
In adults it affects the vertebra and feet (diabetics)
Risk factors= DM, sickle cell, IVDU, immunosuppression, alcohol
What are the causes of osteomyelitis?
Staph aureus (most common) Salmonella (sickle cell)
Ahat is the pathophysiology of osteomyelitis?
Haematogenous spread
Direct inoculation from trauma or surgery
Contigous spread from nearby infection
What investigations are done for osteomyelitis?
Bloods- raised ESR, CRP, WCC
Blood culture
MRI= imaging of choice (x ray changes arent apparent for 10-14 days)
Bone biopsy and culture are gold standard
What is the management of osteomyelitis?
Antibiotics- 6 week course of flucloxacillin
Start IV and swap to PO once temperature and inflammatory markers settle (after 4 weeks)
Surgical drainage may be required
What is perthes disease?
Normally affects boys aged 4-8 years
It is avascular necrosis of the femoral head
What are the clinical features of perthes disease?
Hip pain that develips progressively over a few weeks, limp, stiffness and reduced ROM.
What investigations are done for perthes disease?
X- ray
Technetium bibe scan or MRI if x-ray is normal and symptoms persist
What is used to stage perthes disease?
Catterall
What is the management of perthes disease?
Conservative management with rest, analgesia, PT
Keep the femoral head within the acetabulum using a cast or braces
Surgery may be required for older children
Most cases resolve with conservative management
What is juvenile idiopathic arthritis?
An autoimmune inflammation in the joints lasting >6weeks in children <16
What rashis associated sigh JIA?
Salmon pink rash
What is the management of JIA?
PT/OF and regular exercise
NSAIDS (ibuprofen and naproxen)
Corticosteroids
- intra articular injections are often used
DMARDS used if corticosteroids dont work
Biologics are highly effective
What is SUFE?
How do you diagnose?
How do you manage?
Displacement of the femoral head epiphysis postero inferiorly
Diagnosis is confirmed by AP and frog leg lageral
Management is internal fixation with a single cannulaged screw
What is Immune thrombocytopenia?
Immune mediated reduction leading to thrombocytopenia
What are the clinical features of ITP?
Acute
- more common in children
- petechiae, purpura, superficial bruising and mucosal bleeding (gums and nose)
- presents 1-2 weeks following a viral infection (or vaccination)
What is chronic ITP?
More common in women
Runs a relapsing- remitting course
What will the investigations results of immune thrombocytopenic purpura be?
How do you treat it?
Isolated thrombocytopenia
Mild symptoms do not raire treatment
Persistent minor or major bleeding may require treatment with oral prednisolone, IV anti D and IVimmunoglobulins
Life threatening haemorrhage can be treated with platelet transfusions
What are the clinical features of appendicitis?
Abdo pain Nausea Vomiting Anorexia Low grade fever Ovsings Pain is dull and poorly localised initially before localising to the right iliac fossa
It is aggregated by coughing, jumping, walking
What are the IX for appendicitis?
FBC- raised WCC, ESR, CRP
Urinalysis yo exclude pregnancy/UTI
What is pyloric stenosis?
What are the risk factors?
Hypertrohy of the pyloric muscle leading to gastric outlet obstruction
FHx, male, first born
Clinical features Projectile vomiting (non bilious) around 30 mins afer feeding
Babies are still hungry and continue to feed until they become dehydrated and lose interest
What investigations are done for pyloric stenosis?
Test feed- may be able to see visible peristalsis and olive sized palpable mass in RUQ
Stomach aspiration via. NG tube may be required to allow palpation
US abdomen
Hypochloraemic metabolic alkolisis with hypokalaemia and hyponatraemia on ABG
Management of pyloric stenosis?
Stop oral feeding, pass NG tube and aspirate every 4 hours
IV fluids
Blood gases and U+Es
Surgical management- Ramstedts pyloromyotomy
What are the clinical features of cows milk allergy?
Presents in first 3 months of life in formula fed infants
It is either IgE mediated or non IgE mediated
Pruritus Erythemia Urticaria Angio oedema Diarrhoea Vomiting Colicky pain
What are the investigations done for cowsmilk allergy?
IgE mediated- blood test for total IgE and specific IgE for cows milk protein (RAST test)
Skin prick/ patch testing
Non IgE= clinical diagnosis
What is the management of cows mik protein allergy?
Avoid cows mik
Growth monitoring
Hypoallergenic formula - extensively hydrolysed formula
Nutritional counselling
Do not recommend soya base formulas!
What is the aetiology of constipation?
Mostly idiopathic Dehydration Low fibre Drugs- opioids, antihistamines Hypothyroidism Hirschsprungs disease Hypercalcaemia
What are the red flag symptoms with constipation?
Symptoms from birth or first few weeks of life
Meconium passed after 48 hours- hirschsprungs
Ribbon stools- anal stenosis
Abdo distension w/ vomiting
FHx of hirschsprungs
Leg weakness or motor delay
Abnormal appearance of anus (position, patency, bruising, fissures)
Abnormal appearance of gluteal/ sacral region (spina bifida ovculta)
Prior to treatment of constipation, children need to be assessed for faecal impaction, what would suggest faecal impaction?
Symptoms of severe constipation
Overflow soiling
Faecal mass palpable in the abdomen (DRE should only be carried out by a specialist)
How is faecal impaction managed?
Movicol paediatric plain
Add a stimulating laxaruve if no disimpaction after 2 weeks
What general measures can you suggest for constipation?
Adequate fluid and fibre intake
Adequate physicak activity
Behavioural interventions- bowek habit diary, scheduled toileting, reward system
Seek help from health visitor
How should you manage constipation in infants?
Not yet weaned;
Breast fed- constipation is unusual and should be investigated
Bottle fed- extra water between feedsm gentle abdo massage, bicycle infants legs
Being weaned/ weaned…
Extra warwr, diluted frit juice and fruit
Consider adding lactulose
What are the risk factors for gord?
Prematurity
Cerebral palsy
Hiatus hernia
Congenital diaphragmatic hernia
What are the management options for gord?
General measures- 30 degrees head tilt when feeding
Dont overfeed, give small frequent feeds
Specific measures…
. Breast fed: mix an alginate (gavisvon) with water and use immediately after feeds
Formula fed- add thickener or alginate to formula
. Omeprazole or ranitidine If alginate unsucessful
. Surgery (nissen fundoplication) may be required
What are the signs and symptoms of clinical dehydration in children?
Symptoms
Appears unwell
Altered responsiveness (irritable or lethargic)
Decreased urine output
Signs Sunken fontanelles Sunken eyes Dry mucous membranes Reduced skin turfor Tachycardia Tachypnoea
What are the symptoms and signs of shock?
Symptoms
Decreased levek of consciousness
Pale/mottled skin
Cold extremities
Signs Tachycardia Tachypnoda Weak peripheral pulses Prolonged CRT Hypotension
What is the pathophysiology of hirschsprungs disease and what is the median age?
Hischsprungs disease is where there is absence of gabglionic cells of the myenteric (auerbachs) and submucosal (meissners) plexuses
The median age is 2 days
What are the risk factors for hisrchsprungs disease?
Male
Down syndrome
FHx
What are the clinical features of Hirschsprungs disease?
Failure to pass meconium within the first 48 hours of birth, abdo distension, bilious vomiting
What are the differentials for failure to pass meconium?
Hirschsprungs Meconium ileus Intestinal atresia Midgut malrotation Imperforate anus Anal stenosis Constipation
What investigations are done for hirschsprungs?
Plain abdominal xray Contrast enema (enemas should not be used if there is a perforation)
Rectal biopsy (GOLD standard)
What is the management of hirschsprungs disease?
IV abx
NG tube
Bowel decompression
Surgical resection of the aganglioni bowel
What is the most common cause of intestinal obstruction in children?
Intususseption
When does intususseption occur?
3-12 months
What are the clinical features of intususseption?
Paroxysmal abdo pain;
Infant will cry, draw their knees up, turn lale, vomit
Blood stained stool- redcurrant jelly
Sausage shaped mass- RUQ
What are the Ix and management of intususseption?
USS will show target like mass/ donut sign
Also want to do abdo xray (obstruction)
Management is reduction by air insufflation/enema
What is mesenteric adenitis?
Acute enlargement of the lymoh nodes within the mesentery
If often follows a recent viral infection
Child will get acute abdo pain, often vonfused with acute appendicitis
It is diagnosis of exclusion
In what time frame should you operate when the child has an inguinal hernia?
Baby <6weeks, operate in 2 days
Baby <6 months, operate in 2 weeks
Baby <6 years, operate in 2 months
What are the DDx for small bowel obstruction in children?
What about large bowel?
Duodenal atrsia Jejunal/ileal atresia Meconium ileus Meconium plug syndrome Intussusception
Large bowel- hirschsprungs
Rectal atresia
What are the investigatons and management of midgut malrotation?
Ix;
- AXR (double bubble sign)
- upper GI contrast series (corkscrew sign)
Non sufgical management- asymptomatic pts can be managed with observation and GI decompression
Surgically with a Ladds procedure
What are the causes of UTI (organisms)?
Staph aureus Escerichia coli Klebsiella Proteus (boys) Pseudomonas Strep faecalis
What are the risk factors for UTI?
<1 years old Female Poor hygiene Previous UTI Incomplete bladder emptying VUR Sexual abuse
What are the clinical features of UTI?
Infants- poor feeding, vomiting, irritability, lethargy, fever, offensive urine, jaundice
Children- dysuria, frequency, urgency, fever, abdo pain, loin tenderness, lethargy, anorexia, haematuria
When do you suspect acute pyelonephritis?
Temperate >38 and bacteriuria
Or temperature <38 with bacteriuria and loin tenderness
