Paeds Flashcards
Differentials for Stridor in kids <6months
- Laryngomalacia
- Laryngeal cyst, haemangioma or web
- Laryngeal stenosis
- Vocal cord paralysis
- Vascular ring
- Gastro-oesophageal reflux
- Hypocalcaemia (laryngeal tetany)
- Respiratory papillomatosis
- Subglottic stenosis
Croup and epiglottis less common in <6 months olds
Differential diagnosis of acute stridor in kids >6months to 5yrs
- Laryngotracheobronchitis
- Inhaled foreign body
- Anaphylaxis
- Epiglottitis
- Rare causes include:
– Bacterial tracheitis
– Severe tonsillitis with very large tonsils
– Inhalation of hot gases (e.g. house fire)
– Retropharyngeal abscess
Croup typically occurs in children aged 6 months to 5 years. It is characterized by an
upper respiratory tract infection that is followed by a barking-type cough, a hoarse
voice, stridor and a low-grade fever. Croup is most commonly caused by the parainfluenza virus.
The upper airway of a child with stridor should not be examined as this may
precipitate total obstruction.
Treatment for croup
Supportive care + PO dex/pred +/- nebulised adrenaline
If unsuccesful ventilation, intubation and ENT emergency tracheostomy
Indications for hospital referral
- Apnoeic episodes (commonest in babies 2 months and may be the presenting feature)
- Intake 50 per cent of normal in preceding 24 hours
- Cyanosis
- Severe respiratory distress – grunting, nasal flaring, severe recession, respiratory rate 70/min
- Congenital heart disease, pre-existing lung disease or immunodeficiency
- Significant hypotonia, e.g. trisomy 21 – less likely to cope with respiratory compromise
- Survivor of extreme prematurity
- Social factors
Key points about bronchiolitis
Bronchiolitis is a viral lower respiratory tract infection, generally affecting children under 12 months of age.
It is a clinical diagnosis, based on typical history and examination. No investigations are typically performed for management.
Peak severity is usually at around day two to three of the illness with resolution over 7–10 days.
Usually self-limiting, often requiring no treatment or interventions.
The cough may persist for weeks.
Differential diagnosis of a recurrent or persistent cough in childhood
- Recurrent viral URTIs – very common in all age groups but more so in infants
and toddlers - Asthma – unlikely without wheeze or dyspnoea
- Allergic rhinitis – often nocturnal due to ‘post-nasal drip’
- Chronic non-specific cough – probably post-viral with increased cough receptor
sensitivity - Post-infectious – a ‘pertussis (whooping cough)-like’ illness can continue for
months following pertussis, adenovirus, mycoplasma and chlamydia - Recurrent aspiration – gastro-oesophageal reflux
- Environmental – especially smoking, active or passive
- Suppurative lung disease – cystic fibrosis or primary ciliary dyskinesia
- Tuberculosis
- Habit
Presentations of cystic fibrosis
Neonatal
* Meconium ileus
* Intestinal atresia
* Hepatitis/prolonged jaundice
Infant
* Rectal prolapse (may be recurrent)
* Failure to thrive
* Malabsorption and vitamin deficiency (A, D, E, K)
Older children
* Recurrent chest infections
* ‘Difficult’ asthma
* Haemoptysis
* Nasal polyps
* Distal intestinal obstruction syndrome
* Liver disease
* Diabetes mellitus
Diagnosis and management of Cystic Fibrosis
Diagnosis can be made by the sweat test, which will demonstrate elevated sweat sodium and chloride concentrations, and by genetic testing.
National newborn screening using blood spots collected on day 5 of life are now tested for immunoreactive trypsinogen (at
the same time as testing for phenylketonuria, congenital hypothyroidism and sickle cell
disease). This is now leading to the identification of cases before the onset of clinical disease.
Once a child is diagnosed with CF, he or she will need multidisciplinary team management under the supervision of a paediatric respiratory consultant. Optimal care will aim
to maintain lung function by treating respiratory infections and removing mucus from the airways with physiotherapy, and to maintain adequate growth and nutrition with
pancreatic enzyme and nutritional supplements.
Signs of impending respiratory failure
- Exhaustion (this is a clinical impression)
- Unable to speak or complete sentences
- Colour – cyanosis +/- pallor
- Hypoxia despite high-flow humidified oxygen
- Restlessness and agitation are signs of hypoxia, especially in small children
- Silent chest – so little air entry that no wheeze is audible
- Tachycardia
- Drowsiness
- Peak expiratory flow rate (PEFR) persistently <30 per cent of predicted for height
(tables are available) or personal best. Children <7 years cannot perform PEFR
reliably and technique in sick children is often poor
Doses for acute asthma
Doses:
Salbutamol (100 mcg/puff) dose:
<6 years old: 6 puffs MDI
6 years or older: 12 puffs MDI
Ipratropium bromide (21 mcg/puff) dose:
<6 years old: 4 puffs MDI
6 years or older: 8 puffs MDI
Oral prednisolone
2 mg/kg (max 60 mg) initially, only continuing with 1 mg/kg daily for further 1-2 days if there is ongoing need for regular salbutamol
Management of pneumonia in a child
- Oxygen to maintain saturation at 92 per cent
- Adequate pain relief for pleuritic pain
- Intravenous antibiotics according to local guidelines, e.g. co-amoxiclav
- Initial fluid restriction to two-thirds maintenance to help correct the hyponatraemia.Fluid restrict even if no hyponatraemia, as SIADH may still develop
- Fluid balance, regular urea and electrolytes – adjust fluids accordingly. Weigh
twice daily - Physiotherapy, e.g. bubble blowing. Encourage mobility
- Monitor for development of a pleural effusion. If the chest X-ray is suspicious,
an ultrasound will be diagnostic. If present, a longer course of antibiotics is
recommended to prevent empyema (a purulent pleural effusion). A chest drain
may be necessary if there is worsening respiratory distress, mediastinal shift on
the chest X-ray, a large effusion or failure to respond to adequate antibiotics - Ensure adequate nutrition – children have often been anorectic for several days.
Low threshold for supplementary feeds probably via nasogastric tube - Organise immunization programme before discharge
- Arrange a follow-up chest X-ray in 6–8 weeks for those with lobar collapse and/
or an effusion. If still abnormal, consider an inhaled foreign body
Differential diagnosis of chest pain in children
- Trauma, e.g. fractured rib
- Exercise, e.g. overuse injury
- Idiopathic
- Psychological, e.g. anxiety
- Costochondritis
- Pneumonia with pleural involvement
- Asthma
- Severe cough
- Pneumothorax
- Reflux oesophagitis
- Sickle cell disease with chest crisis and/or pneumonia
- Rare: pericarditis, angina, e.g. from severe aortic stenosis, osteomyelitis, tumour
Congenital cardiac lesions presenting with neonatal collapse
- Severe aortic coarctation
- Aortic arch interruption
- Hypoplastic left heart syndrome
- Critical aortic stenosis
Differential diagnosis of a collapsed neonate
- Infection – e.g. group B Streptococcus, herpes simplex
- Cardiogenic – e.g. hypoplastic left heart syndrome, supraventricular tachycardia
- Hypovolaemic – e.g. dehydration, bleeding
- Neurogenic – e.g. meningitis, subdural haematoma (‘shaken baby’)
- Lung disorder – e.g. congenital diaphragmatic hernia (late presentation)
- Metabolic – e.g. propionic acidaemia, methylmalonic acidaemia
- Endocrine – e.g. panhypopituitarism
Features of heart failure in a baby
- Tachycardia
- Tachypnoea
- Hepatomegaly
- Poor feeding
- Sweating
- Excessive weight gain (acutely)
- Poor weight gain (chronically)
- Gallop rhythm
- Cyanosis
- Heart murmur
Clinical findings in innocent murmurs in children
- Asymptomatic
- No thrills or heaves
- Normal heart sounds, normally split with no added clicks
- Quiet and soft
- Systolic (isolated diastolic murmurs are never innocent)
- Short, ejection (pansystolic murmurs are pathological)
- Single site with no radiation to neck, lung fields or back
- Varies with posture (decreases or disappears when patient sits up, loudest when
they’re lying)
Causes of a funny turn
- Epileptic seizure: Aura, incontinence, tongue biting, family history
- Cardiac arrhythmia: Palpitations, sudden collapse, exercise-related
- Neurally mediated syncope: Preceding stimulus, dizziness, nausea
- Panic attack: Hyperventilation, paraesthesia, carpopedal spasm
- Breath-holding attack: Usually a toddler, upset/crying
- Reflex anoxic seizure: Usually infant/toddler, painful stimulus
- Pseudoseizures: Psychological problems
Other causes
- Hypoglycaemia
- Other metabolic derangements
- Drugs, alcohol
biochemical criteria for diagnosis of DKA
- Serum glucose >11 mmol/L
- Venous pH <7.3 or Bicarbonate <15 mmol/L
- Presence of ketonaemia/ketonuria
Differentials of familial tall stature
- Marfan
- Klinefelter (47, XXY) syndrome,
- Endocrine cause is e.g. sexual precocity, thyrotoxicosis or growth hormone excess
Clinical signs suggesting a pathological cause for short stature
- Extreme short stature – on or below 0.4th centile.
- Short for family size – outside target range for parents
- Short and relatively overweight – suggests an endocrinopathy
- Short and very underweight – suggests poor nutrition malabsorption
- Growth failure – crossing the centiles downwards
- Dysmorphic features
- Skeletal disproportion – charts available for ratio between sitting height
and leg length. Significant disproportion suggests a skeletal dysplasia, e.g.
achondroplasia - Signs of systemic disease, e.g. clubbing
Surgical operation for pyloric stenosis
Ramstedt’s pyloromyotomy.
Causes of rectal bleeding
- Gastroenteritis
- Anal fissure
- Intussusception
- Cow’s milk protein allergy
- Meckel’s diverticulum
- Inflammatory bowel disease
- Polyp
- Clotting abnormality
- Sexual abuse
Causes of chronic diarrhoea (14 days)
Infection
* Bacterial (Salmonella, Campylobacter)
* Protozoal (e.g. Giardia)
* Post-gastroenteritis diarrhoea
Malabsorption
* Lactose intolerance
* Cow’s milk protein intolerance
* Cystic fibrosis
* Coeliac disease
Gastrointestinal disorders
* Crohn’s disease
* Ulcerative colitis
Miscellaneous
* Toddler’s diarrhoea/irritable bowel syndrome
* Drugs (e.g. laxatives, antibiotics, chemotherapy)
* Immunodeficiency
Indications for surgery in Crohns Disease
Surgery is considered when medical therapy fails.
Indications include:
- intractabledisease with growth failure,
- obstruction (due to strictures or adhesions), abscess drainage,
- fistula,
- intractable haemorrhage and
- perforation.
Signs of dehydration in children
Fluid requirement in a child
Fluid requirement for 24 hours = maintenance x correction of deficit x replacement of ongoing losses
Maintenance fluid = 100 mL/kg for first 10 kg body weight, 50 mL/kg for next 10 kg, 20 mL/kg thereafter
Causes of right lower quadrant pain
- Appendicitis
- Mesenteric adenitis
- Urinary tract infection
- Gastroenteritis
- Crohn’s disease
- Ovulation pain: ‘mittelschmerz’
- Ovarian cyst/torsion
- Ectopic pregnancy
- Pelvic inflammatory disease
Clinical tests for appendicitis
McBurney’s sign involves tenderness with palpation of McBurney’s point, which is located at one-third of the distance from the anterior superior iliac spine to the umbilicus.
Rovsing’s sign is positive when palpation in the left lower quadrant (LLQ) causes referred pain in the RLQ
Differential diagnosis of chronic abdominal pain
- Psychosomatic
- Urinary tract infections
- Constipation
- Gastro-oesophageal reflux
- Coeliac disease
- Inflammatory bowel disease
- Cow’s milk intolerance
- Abnormal renal anatomy, e.g. pelviureteric junction obstruction
- Abdominal migraine
- Peptic ulcer
- Sexual or other abuse
Causes of constipation
- Dietary
- Dehydration
- Anal fissure/stenosis
- Hirschsprung’s disease
- Intestinal obstruction e.g. stricture post-necrotizing enterocolitis
- Spinal cord lesion
- Cystic fibrosis (meconium ileus equivalent)
- Cow’s milk intolerance
- Drugs, e.g. opiates, vincristine, lead poisoning
- Hypothyroidism
- Sexual abuse
Causes of failure to thrive
Inadequate intake of food
* Poor feeding
* Mechanical problem such as a cleft palate or bulbar palsy
Malabsorption
* Coeliac disease
* Cystic fibrosis
Excessive loss of nutrients
* Vomiting due to gastro-oesophageal reflux
* Protein-losing enteropathy, e.g. cow’s milk protein intolerance
Increased nutrient requirement
* Congestive cardiac failure
* Chronic infection, e.g. HIV
Miscellaneous causes
* Dysmorphic syndromes, e.g. Russell–Silver syndrome
* Inborn errors of metabolism
Psychosocial
* Child abuse and neglect
* Emotional and social deprivation
Causes of jaundice
Early onset (first 24 hours, haemolytic jaundice)
* Rhesus haemolytic disease
* ABO incompatibility
* G6PD deficiency (commonest in those of African, Asian, or Mediterranean
descent)
* Hereditary spherocytosis
Normal onset
* Physiological (all newborns get a degree of jaundice peaking at 4–5 days)
* Bruising
* Polycythaemia
* Causes of early jaundice
Late onset (14 days, prolonged jaundice)
* Persistence of a pathological earlier jaundice
* Breast milk jaundice
* Neonatal hepatitis
* Biliary atresia
* Hypothyroidism
* Galactosaemia
Differential diagnosis of measles
Examples of factors predisposing to recurrent infections
Causes of macrocephaly
Causes of developmental regression
Features of conductive and sensorineural hearing loss
Features of anorexia nervosa and bulimia nervosa
Causes of a floppy infant
Complications of birth asphyxia
