Paeds Flashcards
Intussusception
“Telescoping” of the bowel
- Reduction by rectal air insufflation (fluoroscopy guidance)
- 75% success rate - 25% need surgery
- Contraindication = Signs of peritonitis
- Contrast (Barium) enema reduction
- Contraindications =
- Peritonitis
- Perforation
- Hypovolaemic shock
- Contraindications =
- Supportive
- IV fluids + NG tube aspiration may be needed
- Broad-spectrum Abx
- Clindamycin + Gent OR
- Tazocin
Enuresis
Dry by day+night = 5yrs
Dry by day only = 4yrs
Primary bedwetting (no day Sx)
Children <5
- Reassure that its common in under 5s and should resolve without Tx
- Ensure easy access to toilet at night
- Encourage bladder emptying before bed
- Reward system (Star charts)
Children 5+
- If infrequent (<2 per wk) reassure + observe
- Reward system (Star charts)
- Dont punish or embarass child
Long term Tx
- 1st line = Alarm + Reward system
- 2nd line = Desmopressin
Short term (e.g. school trips) = Desmopressin
If recurrence = Restart previously successful Tx, offer combineddesmopressin + alarm Tx
If no response after 2 courses of Tx = REFERRAL to secondary care/enuresis clinic/community paediatrician
Primary Bedwetting (WITH day Sx) = REFERRAL
Secondary Bedwetting (previously dry at night for >6months) = Investigate underlying cause
- UTI + Constipation -> Primary care
Following need specialist referral:
- Diabetes
- Recurrent UTI
- Psychological problems
- Family problems
- Developmental, attention, learning difficulties
- Known/suspected physical/neuro problems
SUMMARY
- Look for underlying causes (UTI, diabetes, constipation)
- BED
- Behavioural - Reduce fluid intake before bed, diet + toilet behaviour, REWARD SYSTEM
- Enuresis alarm
- Desmopressin - 1st line if >7yrs or short-term Tx (trip/holiday)
Cystic Fibrosis
Autosomal recessive. Defect in CFTR gene (Cystic Fibrosis Transmembrane conductance Regulator)
80% of cases in UK -> Delta F508 mutation, chromosome 7
1 in 2500 births
Carrier rate = 1 in 25
Common organisms:
- Staph aurerus
- Pseudomonas aeruginosa
- Burkholderia cepacia
- Aspergillus
Inherited condition that causes sticky mucus build-up in lungs & digestive system. This causes lung infections + problems digesting food. Sx start in early childhood and varies from child to child. Condition gets slowly worse over time as lungs/digestive system gets more damaged. Tx are available to help reduce problems caused by CF and make it easier to live with, but sadly life expectancy is shorted to 50-55yrs.
- Pulmonary = Physio + Mucolytics
-
Physio - Airway clearance techniques
- Mucoactive agents
- 1st = rhDNase
- 2nd = Hypertonic NaCl ± rhDNase
- 3rd = Mannitol dry powder (inhaled)
- Mucoactive agents
-
Infection = Prophylactic Abx + Monitoring
- S. aureus pneumonia prophylaxis = Flucox (can be given up to 6yo)
-
Pseudomonas aeruginosa
- ACUTE = Oral/inhaled Abx (Follow local guidelines) - consider IV if unwell
- Chronic/persistent
- 1st = Nebulised/inhaled Colistimethate sodium + Abx (if unwell with pulmonary exacerbation)\
- 2nd = Tobramycin DPI(aminoglycoside)
- Deteriorating lung function = Azithromycin, Oral steroids
-
GI + Nutrition = Enzyme tablets + High-calorie diet + Monitor growth
- Pancreatic enzyme replacement - Creon
- H2 antagonist or PPI
Bacterial Meningitis
Causes <3m = GBS, Listeria monocytogenes, E. coli
Causes >3m = Neisseria meningitides + Strep pneumoniae
CSF:
- Cloudy/turbid
- HIGH protein
- HIGH polymorphs (WCC)
- LOW glucose
Mx:
- <3m = IV amoxicillin + cefotaxime
- >3m = IM BenPen + IV ceftriaxone
- Supportive therapy
- Analgesia + antipyretics
- O2 (Reservoir rebreathing mask)
- IV fluids 0.9% saline + 5% dextrose
- If presenting in GP
- Check for penicillin allergy
-
IM BenPen (if recent foreign travel add Vancomycin)
- If allergic Moxifloxacin + Vancomycin
-
Call 999 - Emergency transfer to hospital
*
Bronchiolitis
<1yo, peaks at 3-6m.
Causes: RSV (80%), parainfluenza, rhinovirus, influenza
RFs: Pre-term infants (BPD), Underlying lung disease (CF), congenital heart disease
Mx
- Self-resolving within 2wks
- Bring back in if resp. distress, apnoea
- Palivizumab (monoclonal Ab against RSV)
Admission criteria
- Apnoea, central cyanosis, grunting
- SpO2 <92%
- Poor fluid intake <50% in <24hrs
- RR >70
Hospital Mx: Nasal O2 + NG fluids/feeds
Asthma
<5m
- SABA
- SABA + 8wk trial ICS then stop
- Sx recur <4wks of stopping = Low-dose ICS
- Sx recur >4wks = REPEAT 8wk trial
- Sx not resolving = consider alternative diagnosis
>5m
- SABA
- SABA + ICS
- Add LTRA (montelukast)
- Replace LTRA with LABA
Other Mx
- Assess baseline asthma status
- Education + Personalised asthma action plan (from Asthma UK)
- Information - Asthma UK
- Identify/avoid triggers
- Explain Peak flow meter
- Explain inhaler technique
- Carry blue inhaler everywhere, use it when breathless
Constipation
Exclude Red flags
- Failure to pass meconium <24hrs
- Poor growth
- Gross abdo distension
- Abnormal lower limb neurology/deformity
- Spina bifida
- Abnormal anal anatomy
- Perianal bruising/fissures - Sexual abuse
- Perianal fistulae/abscesses/fissures
Mx
- Aim is to break the cycle of hard stool being difficult to pass
- Laxatives - will be taking for several months
- Faecal impaction = Disimpaction regimen
- Movicol (osmotic laxative) escalating dose over 2wks
- Diet + Lifestyle
- Add senna
- Maintenance laxative Tx
- Movicol (osmotic diuretic)
- Diet + Lifestyle
- Gradually reduce dose
- Lifestyle interventions
- Bowel habit diary
- Scheduled toileting (after meals, before bed)
- Reward system/Star chart for attempting poo
- Address any anxiety, make sure not to embarass
- Diet
- Fluids + Fibre (fruit + veg)
- More exercise
- Follow-up appointment
Osmotic - draws up water, softens poo - Movicol
Bulk-forming - Fybogel
Stimulant - Senna
Coeliac
Autoimmunity to GLIADIN
Common - 1 in 100 children
HLA-DQ2 association
- anti-tTG (tissue transglutaminase)
- anti-EMA (endomysial cell antibodies)
- FBC + Blood smear (micro/macrocytic anaemia)
- Vitamin D, B12, Folate, Calcium
Older children = OGD + Biopsy
Younger childnre = No histological confirmation needed
MDT
- Gluten-free diet for LIFE
- Dietician referral
- ANNUAL review 6-12m
- Check height, weight, BMI
*
- Check height, weight, BMI
Febrile convulsion
- 6m to 6yo
- Protect from injury (cushion), do not restrain
- <5 mins = Do nothing, UNLESS:
- 1st febrile convulsion
- Severe cause
- Breathing problems
- >5 mins, no drugs = CALL AMBULANCE
- >5 mins, drugs available
- Rectal diazepam or Buccal midazolam
- Can repeat after 10 mins if seizure not stopped
- If 10 mins after 1st dose seizure hasn’t stopped, CALL AMBULANCE
- Rectal diazepam or Buccal midazolam
Post-seizure
- Treat cause of fever
- Admit + Immediate paeds assessment IF:
- 1st febrile seizure
- COMPLEX febrile seizure (>15mins, focal seizure, recurring seizure within 24hrs/within same illness)
- <18m old
- Decreased consciousness prior to seizure
- Recent Abx (could mask CNS infection)
- Uncertain diagnosis of cause
Advice to parents
- NOT the same as epilepsy
- Simple seizure = no increased risk of epilepsy
- Complex seizure = slightly higher risk of epilepsy (4-12%)
- 1/3 will have another febrile convulsion
- Short seizures are NOT harmful to child
- Remember for future seizures: Protect from injury, Do not restrain, check airway/put them in recovery position when finished
- Reducing fever DOES NOT prevent future febrile convulsions.
- Use paracetamol/ibuprofen
- Adequate fluids
Epilepsy
- 1st seizure - Refer to 1st fit clinic
- Advice for parents
- How to recognised seizure
- Record future seizures using phone
- Avoid dangerous activities (swimming, bathing) until diagnosis confirmed
- Epilepsy specialist nurse - can give further advice
Specific Mx:
- Childhood Epilepsy w/ Centro-Temporal Spikes (Rolandic) = NO Tx needed, children will outgrow this by puberty
- Childhood Absence Epilepsy = maximise education potential + support social development
Anti-Epileptic Drug (AED) Therapy:
- Not all children need this
- Balance based on seizure/epilepsy type, social/educational consequences, SIDE EFFECTS
- MONOTHERAPY at MINIMUM dosage to reduced SE profile
AED Choices:
- Tonic-clonic = Sodium Valproate, lamotrigine (childbearing age)
- Absence = ethosuximide (girls childbearing age), Valproate
- Myoclonic = valproate
- FOCAL = Carbamazepine, lamotrigine (childbearing age)
Status Epilepticus
- 1 epileptic seizure lasting >5 minutes; OR
- ≥2 seizures within a 5-minute period without the person returning to normal between them; OR
- 1 febrile seizure lasting >30 minutes
Mx
- 0 min - Secure airway, ABC, high-flow O2, blood glucose
- 5 min - IV lorazepam OR Rectal diazepam/Buccal midazolam
- 15 min - 2nd dose of IV lorazepam, call for senior help
- 25 min - Call anaesthetist, inform ICU, phenytoin
West Syndrome (Infantile Spasms)
Prednisolone or Vigabatrin
POOR prognosis
ADHD
As child gets older, less hyperactivity and more inattention as the tasks they face become more complex.
Some may grow out of it!
- MDT approach - Paediatrician, psychiatrist, ADHD nurses, mental health + LD trusts, CAMHS, parents groups
- Diagnosis only made by specialist psychiatrist/paediatrician with expertise in ADHD
-
10 wk watch and wait period
- If they persist, referral to specialist (developmental paeds, CAMHS)
Specialist Mx
- <5 yo
-
ADHD-focused group parent-training programme
- Teaches various parenting techniques to deal with ADHD and meet other parents in similar situations
- If this fails, seek specialist ADHD service
-
ADHD-focused group parent-training programme
- >5 yo
- ADHD-focused group parent-training programme
- If this fails, pharmacotherapy
-
1st = Methylphenidate (6wk trial)
- SEs: Loss of appetite, mood change, palpitations, tics
- 2nd = lisdexamphetamine
-
1st = Methylphenidate (6wk trial)
- Drug monitoring
- BASELINE ECG as these are cardiotoxic
- Height (every 6m) + weight (every 3m)
- BP + HR
- Balanced diet + regular exercise important
- Food diary - explore foods that influence behaviour, ?dietician
- Consider CBT as well
Extradural haemorrhage
LUCID INTERVAL, contralateral limb paresis
Fluid resus - Correct hypovolaemia
- Urgent evacuation of haematoma
- Arrest bleeding
Migraine
Tension = Symmetrical, gradual onset, “tight band”
Migraine
- 90% WITHOUT aura: 1-72hrs, can be bilateral/unilateral, pulsatile temporal. GI symptoms. Worse with physical activity
- 10% WITH aura:
- Explore possible triggers
- Headache diary for minimum 8wks to identify triggers
- F/U in 1 month, return sooner if Sx get worse
Acute Mx (12-17yo)
- Paracetamol/ibuprofen
- NASAL sumatriptan
- Combination of both
Prophylaxis: Need specialist referral - Topiramate or propranolol
Cerebral Palsy
Cerebral palsy is the name for a group of lifelong conditions that affect movement and co-ordination. It’s caused by a problem with the brain that develops before, during or soon after birth.
Damage to the brain doesn’t get worse but the condition can put a lot of strain on the body and later on in life can cause problems like painful joints.
There is currently no cure, but lots of Tx available to ensure your child is as active and independent as possible. Team of professionals will work with you to come up with a plan.
- MDT main members
- Paediatrician, nurse
- Physio
- OT
- SALT
- Dietician
- Psychologist
-
Referral to Paediatrician specialising in developmental disorders
- Provide necessary medications
-
Physio
- Encourage movement, improve strength, stop muscles from losing range of motion
-
SALT
- Improve language and communication difficulties
- Assess eating/drinking/swallowing + create a plan
- 50% have communication difficulty
- 33% have speech & language difficulty
-
Occupational Therapy
- Identify problems that you or child has carrying out everyday tasks and suggests ways to make these easier
- Vision & Hearing assessment
-
Medications
- Stiffness - Baclofen, diazepam
- Sleeping - Sleep hygiene + trial of melatonin
- Constipation - Laxatives
- Epilepsy - Anticonvulsants
- Drooling/Muscle spasms/Tremors- Anticholinergics (glycopyrrolate)
Condition may affect your child’s activities and independence, but most children with CP go on to live full independent lives and live for many decades.
Many children go to mainstream schools, but some may need special educational needs and benefit from
Charity = SCOPE
Care team can also provide details of support groups in local area
Duchenne’s Muscular Distrophy
The muscular dystrophies (MD) are a group of inherited genetic conditions that gradually cause the muscles to weaken, leading to an increasing level of disability.
MD is a progressive condition, which means it gets worse over time. It often begins by affecting a particular group of muscles, before affecting the muscles more widely.
Some types of MD eventually affect the heart or the muscles used for breathing, at which point the condition becomes life-threatening.
There’s no cure for MD, but treatment can help to manage many of the symptoms.
X-linked recessive. Deletion of dystrophin gene. Symptoms by 5yo, Wheelchair by 12yo. Live to 20s or 30s. Calf pseudo-hypertrophy, Gower’s sign (using arms to stand up). Raised CK, definitive diagnosis = Genetic testing for mutation in dystrophin.
- Physio + exercise - help clear lungs and prevent contractures
- Dietician - Vitamin D + Calcium may be necessary to prevent bone fragility
- Medical
- Overnight CPAP - helps with daytime headache/irritability/loss of appetite caused by nocturnal hypoxia (weak breathing)
- Glucocorticoids (prednisolone) may help delay wheelchair dependence but balanced with SEs (weight gain)
- Carvedilol for cardioprotection
- Ataluren = drug that restores dystrophin synthesis, conditional licensing for >5yo
- Scoliosis surgery may be required
- Support for parents/child
- Local Support groups
- Charity = Muscular Dystrophy UK
Most common heart complication = Dilated cardiomyopathy
Becker Muscular Dystrophy
Similar to Duchenne but slower progression
Develops after 10yo.
Learn to walk later than usual, struggle with sports at school. Struggle to lift objects. Can walk up to their 40s or 50s then need wheelchair.
So management is same supportive
Myotonic Muscular Dystrophy
Autosomal Dominant. Tri-nucelotide repeat.
Most common ADULT onset MD. (20s-30s)
Genetic anticipation: Gets worse as gene is passed down generations
Varied life-expectancy - from death as neonate, to normal life expectancy
- Muscles unable to relax
- Progressive muscle loss + weakness
- SMALLER muscles > large muscles (opposite of Duchenne)
- Heart problems, cataracts, myotonia
Mx
- MDT approach
- Muscle involvement
- Physio
- Occupational therapy - utensils for hand weakness
- SALT - swallowing + dysarthria
- Analgesia for muscle pain - NSAIDs, gabapentin
- Myotonia - Mexiletine (w/ careful supervision)
- Heart problems - Refer to cardiology
- Resp. function + sleep - may need Non-invasive PAP ventilation
- Cataract -> SURGERY
- Support for parent + child
- Local Support groups
- Charity = Muscular Dystrophy UK
Malrotation/Volvulus
Early in pregnancy, the bowel is a long straight tube leading from the stomach to the rectum. The bowel then moves into the umbilical cord temporarily while it develops into the large and small bowel. Around the tenth week of pregnancy, the bowel moves back into the abdomen and coils up to fit into the limited space there. If the bowel does not coil up in the correct position, this is called malrotation.
GORD
- Due to immature gullet, leading to food coming back the wrong way
- Reassure it is very common - usually gets lets frequent
- Refer if haematemesis, melaena, dysphagia
Breastfed:
- Breastfeeding assessment
- Alginate trial 1-2wks
- PPI
- Refer to specialist
Formula fed:
- Review feeding history
- Smaller, more frequent feeds
- Thickened formula (or anti-regurg formula)
- Alginate trial 1-2wks
- PPI
- Refer to specialist
Safety net = Look out for blood or bile in vomit
Acne
Mild-moderate (Blackheads, whiteheads, papules, pustules)
- Topical retinoid (adapalene) + Benzoyl peroxide (BPO)
- Topical clindamycin 1% + BPO or Tretinoin
- Azelaic acid 20%
Moderate (papules, pustules) not responding to topicals
- Oral Doxy/Lymecycline + Topical BPO/adapalene
- COCP (alternative to Abx in girls)
Derm referal for SEVERE (*Nodulocystic, scarring or not responding to 2wks of Abx*):
- Oral isotretinoin (Roaccutane)
- High dose Abx >6m
- Systemic steroids
Follow-up every 8wks (Tx may take 8wks to work)
Maintenance = Topical retinoids or Azelaic acid 20%
Eczema
Infants = Face + trunk
Older child = extensors
Young adult = flexures
Skin prick (food allergy) + Patch testing (contact dermatitis)
Eczema characterised by dry, itchy skin. Very common, many children grow out of it.
If worried about steroid use: Its TOPICAL, not systemic. Also only short course required (1-2wks). Better get rid of it rather than let child suffer for months without steroids.
Frequent, liberal use of emollient. Associated with other atopic conditions
Avoid triggers (certain clothes, soaps, animals)
Avoid scratching
Safety net for signs of infection - Oozing, red, fever
Itchysneezywheezy.co.uk - Great website showing how to apply emollients
Mild = INFREQUENT itching
- Emollient + MILD topical steroid (Hydrocortisone)
Moderate = FREQUENT itching
-
Emollient + Betnovate 0.025% OR Eumovate 0.05%
- Consider 1-month trial antihistamine (cetirizine, loratidine) if severe itching or urticaria
- 2nd line = Calcineurin inhibitor (Tacrolimus)
Severe = INCESSANT (non-stop) itching
- Emollient + Betnovate 0.1%
- Maintenance topical steroids
- Consider 1-month trial antihistamine if severe itching
- If SEVERE extensive eczema causing psychological distress, consider ORAL steroids
- 2nd line = Calcineurin inhibitor (Tacrolimus)
- Last resort = Phototherapy
Henoch Schonlein Purpura
PPA: Purpura, Polyarthritis, Abdo pain
Can also get signs of nephritic syndrome (proteinuria, haematuria, HTN)
Management:
- Most cases self-resolving within 4wks
- Joint pain -> NSAIDs or paracetamol
- Severe abdo pain/scrotal involvement -> Oral prednisolone
- Renal involvement -> IV corticosteroids
Follow-up weekly for first month
Regular follow-ups for a year: Measure BP + Urine dipsticks (haematuria)
Scarlet Fever
Sore throat, fever, strawberry tongue
Fine punctate rash (pinpoint), appears on torso, spares palms/soles
a.k.a. Rough “sandpaper” rash
Cause = Group A Strep (Strep pyogenes)
Mx = Oral Pencillin V 5 days (Azithromycin if pen allergic)
Can return to school 24hrs after starting Abx
Otitis media = most common complication
Boy with delayed puberty, lack of smell. Normal/above avg height.
Low LH, low testosterone
Kallman’s
X-linked recessive
10yo boy lacks secondary sexual characteristics. Gynaecomastia. Small firm testes. Normal height.
High LH, low testosterone
Klinefelter’s 47XXY
Primary hypogonadism (testicles aren’t functioning)
Girl comes in with primary amennorrhoea. Bilateral groin swellings. Normal height.
High LH, normal/high testosterone.
Androgen Insensitivity Syndrome (46XY)
X-linked recessive
Actually a male child resistant to testosterone.
Congenital Adrenal Hyperplasia
Virilisation in girls (male pattern coarse body/facial hair, deepening of voice, enlarged clitoris)
Precocious puberty in males (<9yo)
90% = 21-hydroxylase deficiency
Causes of delayed puberty with short stature
- Turners
- Webbed neck, widely spaced nipples, short ring finger
- Horse-shoe kidney = most common renal abnormality
- Hypothyroidism very common
- Bicuspid aortic valve OR coarctation
- Prader-Willi
- Fat + Floppy, hungry all the time
- Noonan’s
- Webbed neck, pectus excavatum (chest looks sunken in)
