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Y5 PACES Management > Paeds > Flashcards

Paeds Flashcards

1
Q

Intussusception

A

“Telescoping” of the bowel

  1. Reduction by rectal air insufflation (fluoroscopy guidance)
    • 75% success rate - 25% need surgery
    • Contraindication = Signs of peritonitis
  2. Contrast (Barium) enema reduction
    • Contraindications =
      • Peritonitis
      • Perforation
      • Hypovolaemic shock
  3. Supportive
    • ​​IV fluids + NG tube aspiration may be needed
    • Broad-spectrum Abx
      • Clindamycin + Gent OR
      • Tazocin
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2
Q

Enuresis

A

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)
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3
Q

Cystic Fibrosis

A

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.

  1. Pulmonary = Physio + Mucolytics
  2. Physio - Airway clearance techniques
    • Mucoactive agents
      • 1st = rhDNase
      • 2nd = Hypertonic NaCl ± rhDNase
      • 3rd = Mannitol dry powder (inhaled)
  3. 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
  4. GI + Nutrition = Enzyme tablets + High-calorie diet + Monitor growth
    • Pancreatic enzyme replacement - Creon
    • H2 antagonist or PPI
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4
Q

Bacterial Meningitis

A

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
      *
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5
Q

Bronchiolitis

A

<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

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6
Q

Asthma

A

<5m

  1. SABA
  2. 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

  1. SABA
  2. SABA + ICS
  3. Add LTRA (montelukast)
  4. 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
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7
Q

Constipation

A

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

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8
Q

Coeliac

A

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
      *
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9
Q

Febrile convulsion

A
  • 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

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
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10
Q

Epilepsy

A
  • 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)
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11
Q

Status Epilepticus

A
  • 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
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12
Q

West Syndrome (Infantile Spasms)

A

Prednisolone or Vigabatrin

POOR prognosis

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13
Q

ADHD

A

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
  • >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
    • ​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
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14
Q

Extradural haemorrhage

A

LUCID INTERVAL, contralateral limb paresis

Fluid resus - Correct hypovolaemia

  • Urgent evacuation of haematoma
  • Arrest bleeding
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15
Q

Migraine

A

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)

  1. Paracetamol/ibuprofen
  2. NASAL sumatriptan
  3. Combination of both

Prophylaxis: Need specialist referral - Topiramate or propranolol

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16
Q

Cerebral Palsy

A

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

17
Q

Duchenne’s Muscular Distrophy

A

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

18
Q

Becker Muscular Dystrophy

A

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

19
Q

Myotonic Muscular Dystrophy

A

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
20
Q

Malrotation/Volvulus

A

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.

21
Q

GORD

A
  • 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:

  1. Breastfeeding assessment
  2. Alginate trial 1-2wks
  3. PPI
  4. Refer to specialist

Formula fed:

  1. Review feeding history
  2. Smaller, more frequent feeds
  3. Thickened formula (or anti-regurg formula)
  4. Alginate trial 1-2wks
  5. PPI
  6. Refer to specialist

Safety net = Look out for blood or bile in vomit

22
Q

Acne

A

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%

23
Q

Eczema

A

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
24
Q

Henoch Schonlein Purpura

A

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)

25
Q

Scarlet Fever

A

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

26
Q

Boy with delayed puberty, lack of smell. Normal/above avg height.

Low LH, low testosterone

A

Kallman’s

X-linked recessive

27
Q

10yo boy lacks secondary sexual characteristics. Gynaecomastia. Small firm testes. Normal height.

High LH, low testosterone

A

Klinefelter’s 47XXY

Primary hypogonadism (testicles aren’t functioning)

28
Q

Girl comes in with primary amennorrhoea. Bilateral groin swellings. Normal height.

High LH, normal/high testosterone.

A

Androgen Insensitivity Syndrome (46XY)

X-linked recessive

Actually a male child resistant to testosterone.

29
Q

Congenital Adrenal Hyperplasia

A

Virilisation in girls (male pattern coarse body/facial hair, deepening of voice, enlarged clitoris)

Precocious puberty in males (<9yo)

90% = 21-hydroxylase deficiency

30
Q

Causes of delayed puberty with short stature

A
  • 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)

Y5 PACES Management (4 decks)

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