Paeds Flashcards
What are red flags to be seen by neonatologist post birth in terms of vitals
CRT> 3 seconds
HR>160
HR< 100
RR> 60
Fever>38^C
Until when is bow legs normal
3-4 years
When refer bow legs to paediatric surgeons
Pain
Difficulty walking
Failure to thrive
Growth restriction
Intercondylar length over 6cm
What investigations are done for a child under 3 months presenting with fever
In all children
- FBC
- CRP
- Blood cultures
- urine dip
Stool sample if diarrhoea
CXR if chest signs
If under 1 months do LP
If 1-3 months then do LP
If under 3 months in A&E with fever who give parenteral antibiotics to
Under 1 month if fever
1-3 months if fever and unwell
Give ampicillin and cefotaxime
AXR of meconium ileus
No air fluid levels
Distended bowel
Bruises at different stages of healing
NAI
Cause of pediculosis
Pediculus capitis
Contraindications for steroids in meningitis
Under 3 months
Non-bacterial cause
WCC under 1000/mml3
Low protein
Why are steroids given in meningitis
To prevent hearing loss
What measure bilirubin in neonate with
If under 24 hours- serum level
Over 24 hours- transcutaenous
What cause of nec fasc does chickenpox predispose to
Group A strep
Immediate congenital diaphragmatic hernia management
Intubate and ventilate
NG tube
What is used to assess chance of having septic arthritis
Kocher criteria
- WCC over 12
- fever over 38.5
- ESR over 30
- unable to weight bear
White lump in babys mouth and otherwise asymptomatic
Epsteins pearl
What are benign murmurs
Venous hum- Heard as a continuous blowing noise heard just below the clavicles
Still’s murmur- Low-pitched sound heard at the lower left sternal edge
Differentiating branchial cyst and cystic hygroma
Branchial cyst- anterior triangle, anechoic on USS
Cystic hygroma- posterior triangle, transilluminates
Signs on examination of aortic stenosis and what is management
ESM radiating to neck
Slow rising pulse
Thrill
Managment is a balloon valvulotomy
Management of aortic coarctation
When PDA closes will get collapse so need to give prostaglandins
Balloon repair
Systolic murmur head loudest in the back and low leg BP
Aortic coarctation
Management of tet spells
A-E
Bring knees up
Propanolol, adrenaline, morphine and sodium bicarbonate
Management of ASD vs VSD
Only when severe symptoms in ASD
Seccundum- catheter
Primum- surgical
Small VSD (<3mm) can be monitored with echos
Large VSD (>3mm) catopril, furosemide and calories with NG tube if needs be
Murmurs in
- tricuspid atresia
- ASD
- TGA
- VSD
- aortic coarctation
Tricuspid atresia- ESM at LLSE
ASD- fixrd splitting of S2, can be ESM at ULSE
TGA- single loud S2 but can be no murmur
VSD- holosystolic murmur at LLSE which can radiate over praecordium
Aortic coarctation- systolic murmur loudest at the back
PDA features on examination
Wide pulse pressure
Collapsing pulse
Machine like continuous murmur
Management of rheumatic fever
High dose aspirin
Steroids and pain relief
First line and gold standard for intussuception
USS
Gold standard- contrast enema
Management of meconeum ileus
Gastrograffin enema
Surgery if unsuccessful
Antibiotics for NEC
Vancomycin and cefotaxime
First line and gold standard for oesophageal atresia
NG tube with CXR
Gold standard- gastrogaffin swallow
Imaging for malrotation
AXR with barium contrast
What are the types of TOF
A- failure of proximal and distal to connect
B- proximal oesophagus connects to trachea
C- distal oesophagus connects to trachea
D- both proximal and distal connect
E- oesophagus normal but is fistula halfway up
What will show whirlpool on abdo USS of infant
Malrotation
Management of hirschprungs
Bowel irrigation with barium enema
Ano-rectal pull through definitive
Management of pityriasis versicolor
Ketoconazole shampoo
Management of pityriasis rosea
None unless itching when use emollients
When is USS needed during the infection
Recurrent UTI under 6 mths
Atypical
- abdo mass
- poor urinary flow
- sepsis
- raised creatinine
- non-ecoli
- does not respond in 48 hours
When is USS done 6 weeks post infection
Recurrent UTI older than 6 months
First UTI under 6 months
When do DMSA and MCUG 6 months later
Under 3 with atypical or recurrent UTI
Older than 3 with recurrent UTI
How deal with leukocyte positive and nitrites negative on urine dip in kids
Older than 3 do not give abx but take culture
Younger than 3, give abx and treat
How manage undescended testicles
Unilateral
- Patient should be referred from around 3 months seeing a urological surgeon by 6 months of age
- if bilateral reveiwed within 24 hours as needs urgent genetic or endocrine investigation
Management of constipation in a child
If any red features do not treat and refer for urgent review
- Symptoms of constipation appearing from birth or during the first few weeks of life — may indicate Hirschsprung’s disease
- Delay in passing meconium for more than 48 hours after birth, in a full-term baby
- Abdominal distention with vomiting
- Family history of Hirschsprung’s disease
- Ribbon stool pattern
- Leg weakness or motor delay
- Examination may reveal unexplained lower limb deformity or abnormal neuromuscular signs, including abnormal reflexes.
- Abnormal appearance of the anus
- Abnormalities in the lumbosacral and gluteal regions
If amber features, refer in 2 weeks and do treat
- signs of poor care
- failure to thrive or signs of other cause like sx suggesting hypothyroidism
When refer for umbilical hernias
3 years
How manage faecal disimpaction
Macrogol and review after 1 week
If after 2 weeks does not work use stimulant laxative like Senna
If does not work refer to specialist
If not tolerant of macrogol use senna and if the stools are hard add lactulose or docusate
How manage constipation
Macrogol (drug depends on age) If over 12 Mavicol, if under mavicol paediatric
If not tolerated use senna and add lactulose if not tolerated
If does not improve use Senna however if get diarrhoea reduce dose
Difference between red and brown coloured urine
Red- lower tract bleed
Brown- glomerular pathology as broken down into casts
Management of active UC
Mild to moderate
- topical aminosalicylates for 4 weeks
- if dont work use oral
- can use steroids too if ineffective (topical or oral)
Moderate to severe
- infliximab, adalimumab
Management of active crohns
Oral steroids
How to induce remission in UC
Oral aminosalicylate
How to induce remission in crohns
Azathioprine
Management of lactose intolerance
Refer to dietician
Encourage vit d and calcium intake
Mass in groin area with severe vomiting and tense abdomen
Incarcerated hernia
When refer for hydrocele
3 years
How is mesenteric adenitis investigated
USS
What investigation should be done on any child presenting with swelling or pain in testicle
USS to loko for cancer
PA versus lateral CXR finding in croup
PA- shows subglottic narrowing (steeple sign)
Lateral- acute epiglottis (thumb sign)
What is given for epiglottitis
Dexamethasone and cephalosporin
Antibiotics in pertussis
Offer antiobiotic if cough has lasted less than 21 days
- clarithomycin if less than 1 month
- clarithomycin or azithromycin if over 1 month
If contraindicated use co-trimoxazole (not licensed if under 6 weeks)
Pneumothorax guidelines
Breathless or over 2 cm= needle aspiration -> if fails chest drain
Any intervention needs followup in 2 weeks in OPD
Under 2cm= discharge and see in OPD in 2 weeks
How does bacterial tracheitis present
Croup like
Very high fever
Copious airway secretions
Caused by stpahylococcus aureus
What is bronchiolitis obliterans and what causes it
Repair of lung tissues is in overdrive leading to scar tissue formation
Adenovirus
Guidelines for asthma if over 5
1st: SABA or start on low dose ICS if ave asthma symptoms three times a week or more or are woken at night by asthma symptoms once weekly
2nd: If not already on ICS start this
3rd: Add LTRA
4th: Swap LTRA for LABA
5th: Change LABA and ICS for MART
6th: Increase dose to medium dose ICS
7th: Refer to specialist
Guiedlines for asthma under 5
- SABA or go straight to ICS if symptoms over 3x a night
- Paediatric moderate dose ICS for 8 weeks and monitor
- if no resolvement consider different diagnosis
- sx reoccurred within 4 weeks of stopping ICS restart low dose ICS as maintenance
- sx reoccurred beyond 4 weeks restart moderate dose ICS - SABA, low dose ICS, LTRA
- Stop LTRA and refer to paediatric asthma specialist
How investigate asthma in all patients
Refer for spirometry
If unclear refer for FeNO
Management of acute asthma
Trial nebulised salbutamol
Ipatropium nebulised
If after 1 hour sats below 92 add mag sulph to nebuliser
Steroids- oral or IV depending on tolerance
Then if these unsuccessful consider
- IV salbutamol
- IV mag sulphate
- IV aminophylline
Doses of steroids in asthma attack
- oral
-IV
Under 2- 10mg
2-5- 20mg
Over 5- 30-40mg
IV= (4 mg/kg repeated four hourly
Management of WEST syndrome
Refer for tertiary centre assessment within 24 hours
Combination therapy with vigabatrin and prednisolone
Causes of each CP
Spastic
- hemiplegic= antenatal/genetic cause
- diplegic= PVL
- quadriplegic= HIE
Dyskinetic= HIE and kernicterus
Red flags for CP
Cant sit before 8mths
Cant walk before 18mths
Hand preferance before 1 year
Persistent toe walking
What happens in each of the focal seizures
Parietal- dyaesthesia
Frontal- motor symptoms unilaterally
Temporal- automatisms or strange smells
Occipital- positive or negative visual signs
EEG finding of absence seizures and lennox gastaut syndrome
Absence- Symmetrical 3hz wave and spike pattern
Lennox gastaut- slow spike
Management of plagiocephaly
Turn cot around
Supervised time in day on fornt
Management of benign intracranial hypertension
Repeated LPs
How do MS vs tuberous scleoris lesions appear
MS= demyelinating, hypointense, white matter lesions
Tuberous sclerosis= calcified, subependymal
Presentation of tuberous sclerosis
Ash leaf macules
Brain ependymomal
Lumps under nails
Management of juvenile myoclonic seizures
Sodium valproate
Lamotrigine second line
Investigating first time seizure
Bloods - metabolic causes
12 lead ECG
EEG within 72 hours
MRI if suspecct underlying structural cause
Refer to be seen in 2 weeks
Management of
- tonic clonic seizures
- focal seizures
- absence seizures
- myoclonic seizures
- atonic or tonic
Tonic clonic- Sodium valproate if male and girl under 10
Lamotrigine if over 10 and will have to be on long term therapy
Focal- Lamotrigine or levetiracetam
Absence- ethosuximide
Myoclonic- Sodium vaproate if male and girl under 10
Levetiracetam if girl over 10 who may need to continue long term
Atonic- Sodium vaproate if male and girl under 10
lamotrigine if girl over 10 who may need to continue long term
Status epilepticus
Over 5 minutes
Buccal midazolam, rectal diazepam or IV lorazepam
Wait 5 minutes
Give second dose of diazepam
If no response
- phenytoin
- levetiracetam
- sodium valproate
If no response try these again
If no response phenobarbital or general anaesthesia
What is scissor walking seen in
Diplegic CP
If febrile seizure repeats within 24 hours what type of febrile seizure is it
Complex
X-ray finding of perthes disease
Loss of joint space initially then loss of femoral head
Management of chondromalacia patellae
Physio
Difference in presentation of the spina bifidas
Occulta- can be incidental or through tethered chord syndrome
Meningocele- no abnormal neurology but sac can burst causing meningitis or hydrocepahlus
Myelomeningocele- severe abnormal neurology like bladder/bowel dysfunction, club foot or paresis
Up until when is pes planus normal and what is it
4-8
Flat feet
Pathophysiology and presentation of osteochondritis dissecans
Reduction in blood flow to patella which fragments off
Pain after exercise
Locking and catching of knee
Gives way easily
Management of osteomyelitis and septic arthritis abx wise
IV flucloxacillin (clindamycin if pen allergic)
Vancomycin if MRSA
Spinal muscle atrophy presentation
Difficulty to maintain head
Breathing difficulties
Weak cough and cry
Proximal muscle weakness
Hypotonia
Autosomal recesive
What is differnece between anencephaly and encephalocele
Anencephaly- failure of fusion of cranial neural tube which presents with with stillbirth
Enancephalocele- herniation of brain and meninges through midline skull defect
Difference in location and presentation of osteosarcoma vs ewings sarcoma
Ewings- feverish, middle of long bones
Osteosarcoma- Swelling around a joint, Painless most often, Reduced mobilityaround knee
Investigations for EBV
Over 12 in second week do blood film- see over 20% atypical (activated) lymphocytes
Under 12- if ill over a week do serology
Investigation for rubella
Oral fluid sample for NAAT
Management of mumps if very immunocompromised/HIV but no immunisation
MMR vaccine
When give aciclovir for varicella
Oral
- Under 1 month
- Over 14 if within 1 day of rash starting
IV
- immunocompromised
Teenager presents with cyanosis after being born abroad
Eisenmgenger
What can cause BCG scar to become inflammed
Kawasaki
What is used for sedation in children
Nitrous oxide or midazolam
When approaching an ill child what is initial approach
A-E
Initially either jaw thrust or head tilt and chin lift depending on if trauma
How can mesenteric adenitis present
Very unwell in a lot of pain
Diffuse lymph node enlargement
How long does WHO recommend breast feeding for
Up to and beyond 2 years
Management of tongue tie
1st line; refer for breastfeeding support
2nd line; if dropping weight centile then frenotomy
What does torn frenulum in mouth suggest
NAI from forced feeding
Dropping centiles with no evidence of systemic disease after age of 2
GH deficiency
How manage febrile convlusion if evidence of infection source like pneumonia
Want to admit and manage in hospital
Differentiating between osteomyelitis and septic arthritis on history
Osteomyelitis more insidious
What do if sexual abuse suspected
Refer to hospital for forensic examination
Indications for immediate head CT
- NAI suspected
- post traumatic seizure
- GCS less than 14 on assessment, GCS less than 15 in under 1 YO
- focal neurology
- 2 hours after injury GCS less than 15
- suspected skull fracture
- tense fontanelle
- for children under 1 a bruise or laceration over 5 cm
Indications for CT within 1 hour or observe
If one of following then observe for 1 hour, if MORE than 1 have to do in less than 1 hour
- LOC over 5 mins
- high velocity impact (RTA, over 3m fall)
- 3 or more vomiting episodes
- amnesia over 5 mins
- abnormal drowsiness
If develop either abnormal drowsiness, vomits again or abnormal drowsiness with 1 of above RFX then do CT in less than 1 hour
What is a a child protection plan
Put in place to protect children at high risk of harm
Management of Cows milk allergy
- Avoid trigger
- If formula fed use hypoallergenic formula
- If breast fed exclude from diet (takes2-3 weeks tho) and can give maternal calcium and vit D supplements - must regularly monitor growth
- Reintroduce in 6-12 months using Milk Ladder
What is bucket handle fracture and what seen in
Fracture of the metaphyseal corner in tibia
Seen in NAI
What is long term complication of measles
Subacute sclerosing panencephalitis
What vaccine is given at birth
BcG sometimes
- born in areas of uk where high rate (40 in 1000)
- parent or grandparent born in country where (40 in 1000)
- live with or close contact of someone with infectious TB
What is in the 6 in 1
Diphteria
HBV
Tetanus
Polio
Pertussis
HIB
How is flu vaccine administered in children
Intranasal
Vaccinations done at 2,3 and 4 months
2 months
- 6 in 1
- oral rotavirus
- Men B
3 months
- 6 in 1
- PCV (pneumococcal)
- oral rotavirus
4 months
- 6 in 1
- Men B
What vaccinations are done at 1 year
MMR
Men B
PCV
Men C/HIB
What vaccinations are done at 3 years and 4 months
MMR
4 in 1
What in the 4 in 1
Diphteria
Tetanus
Whooping cough
Polio
When is the flu vaccine given to children
Every year in september 2-10
When is HPV vaccine given
12-13 years
What given at 14 years
MEN ACWY
3 in 1
- tetanus
- dipheteria
- polio
What prophylactic antibiotic is given in SCD
Penicillin V
How is G6PD diagnosed
Enzyme assay 2-3 months after crisis
What appears with red, ragged fibres on muscle biopsy
Mitochondrial disorder
How do mitochondrial disorders present
Myopathy- muscle cramps and weakness
Presentation of folate deficiency
Anaemia
Glossitis- smooth beefy red tongue
Angular stomatitis
When is exchange transfusion indicated for SCD crisis
Priapism
Stroke
Acute chest syndrome
What is found on electrophoresis of sickle cell anaemia
HbS and HbF
Management of sickle cell crises
Fluids
Oxygen
Analgesia
What are the types of biliary atresia
T1- common bile duct
T2- cystic dict
T3- fulla tresia where over 90%
What causes a bleed in sclera of eye- newborn
Subconjunctival haemorrhage
CXR of RDS vs CLD
RDS- groundglass with air bronchogram
CLD- Widespread opacification
Can be atelectasis, multicystic appearance, emphysema or pulmonary scarring
Abx in RDS
Benzylpenicillin and gentamicin
Management of ROP
Treated for up to 2 years
MDT approach
Photocogulation
CLD treatment
Manage oxygen therapy- wean off if necessarty or give what necessary
Caffeine citrate
Nitric oxide if pulmonary hypoplasia or pulmonary HTN
Management of cleft lip and palate
MDT- surgeons, ENT, orthodontist, SALT, feeding team
Orthodontic devices may be needed if feeding difficult
Speech and language therapy
Cleft lip repaired in first 3 months of life
Cleft palate between 6-12 months of life
Causes of pulmonary hypoplasia
Congenital diaphragmatic hernia- most common
Oligohydramnios
Tetralogy of fallot
Osteogenesis imperfecta
Diaphram agenesis
Management of chlamydia vs gonrrhoea opthalmia neonatorum
Chlamydia- Oral erythomycin
Gonorrhoea- single dose cefotaxime
Neonatal hypoglycaemia management
Less than 1.5
- admit to neonatal unit
- confirm with lab blood glucose assay
- IV 10% glucose 2ml/kg bolus
- followed by infusion of 3.6ml/kg/hr
- monitor regularly
Between 1.5 and 2.5
- feed immediately
- recheck glucose after 30 mins and if still low consider admitting and starting IV glucose
Cyanosis after birth with absent heart murmurs and signs of HF
PPHN
Causes of persistent pulmonary hypertension of the newborn
Idiopathic
OR
Secondary to neonatal pulmonary conditions
- meconium aspiration
- ttn
- congenital diaphragmatic hernia
- RDS
SSRI or NSAIDS
Abx for meconeum aspiration
IV ampicillin and gentamicin
Neonatal resus
- Dry baby
- Assess tone, resp rate, HR
- If gasping or not breathing 5 INFLATION breaths
- Reassess
- If HR less than 60 bpm start chest compression and VENTILATION breaths at rate of 3:1
Management of choledochal cyst
Surgical excision with roux en y anastamosis to biliary duct
What is it when urine passes through the umbilicus
Urachus
Foetal alcohol syndrome
Learning difficulties
Microcephaly
Growth retardation
Cardiac malformations
Epicanthic folds
Sooth philtrum (area between nose and mouth)
Small palpebral fissue
What congenital infection will present with an asymptomatic mother
Toxoplasmosis
What is craniosyntiosis
When sutures of the brain fuse prematurely
What are the 2 types of craniosyntiosis
Sagittal (AP suture)- long flat head
Lamdoidal synostosis (posteriorly, goes laterally)- appears like plagiocephaly
What tends to cause sagittal craniosyntosis
Premature infants lying on their sides
What is difference between low and high anorectal anomalies
Low- at level of anus it has close in, may be a fistula to the surrounding skin
High- bowel has closed off higher up, associated with fistulas to bladder etc
Management of retractile testes
Reassurance and follow-up annually
Surgical management of undescended testes
If in inguinal canal- orchidopexy
If anywhere else- laparoscopy
Difference between early and late onset sepsis
Within 72 hours of birth is early
What determines what bilirubin measuring device used
Within 24 hours of life or born under 35 weeks- serum reading
After 24 hours- transcutaneous bilirubinometer
Potter sequence presentation
Pulmonary hypoplasia
Renal agenesis
Clubbed feet
Low set ears
Flattened nose
Downwards epicanthal folds
What is chorioretinitis
Posterior uveitis
Management of phototherapy in neonate
Aim for 50 under target
Once 50 micromoles below can stop then re measure in 12-18 hours
If this is 50 below then no further measurement required
If less than 50 below remeasure in 12 hours
How does mycoplasma pneumonia present
Insidious onset compared to normal pneumonia
Abx for AOM
1st line- amoxicillin
2nd line/penicillin intolerant- macrolide
If does not respond in 2-3 days use co-amox and in this scenario if penicillin allergic seek micro advice
What presents with choking on feeding, cyanosis on feeding and relieved by crying
Choanal atresia
What are the 2 types of squint and how manage
Concomitant- one eye diverges typically inwards
Paralytic- varies with gaze direction
Check red reflex
If over 3 months refer to opthalmologist
Management of otitis externa
If very mild- Hygiene measures
- avoid swimming for 10 days
- dont clean ears
If more severe
- topical neomycin or clotrimazole with or without topical corticosteroids
If immunocompromised or severe infection
- oral flucloxacillin
Investigation and management of cholesteatoma
Otoscopy then do diffusion weighted MRI
Mastoidectomy
Difference in when things need to be removed from ear
Within 6 hours
- glue
- battery
- corrosive
Same day
- insect
- food matter
Next available appointment
- cotton ear buds etc
How are things from ear removed
First try to remove self- is best chance
If not refer to ENT for removal with ENT microscope
If unsuccessful will need general anaesthetic as children can become very agitated
Management of sinusitis
Under 10 days just fluids etc
Over 10 days
If over 12 prescribe high dose nasal corticosteroids (mometasone)
Consider back up abx(pen V) to be used if symptoms do not improve within 10 days
If severe illness or comlpications prescribe oral coamoxiclav
Antibiotics for sinusitis
Phenoxymethicillin for 5 days
If allergic or intolerant clarithomycin but can use doxy if over 12
If no improvement use co-amoxiclav
Management of orbital cellulitis
Contrast CT scan of face
IV co-amoxiclav
When to treat tonsilitis/pharyngitis
Do fever pain or centor
If FPAIN over 4 or centor over 3
Consider antibiotics- phenoxymethicillin
Lower threshold if increased risk of rheumatic fever, immunosuppressed or compromised
What does fluctuant neck lump suggest
Abscess from lymphadenitis
Bacterial vs viral conjunctivitis management
Bacterial
- If severe chloramphenicol or fusidic acid drops
- If not that bad can give back-up
Viral
- Will resolve in 2 weeks
- Warm dress with saline for symptoms
- Send swabs if return to GP with symptoms
Viral conjunctivitis management
Will resolve in 2 weeks
Warm dress with saline for symptoms
Send swabs if return to GP with symptoms
When suspect herpetic conjunctivtis
It causes a blepharoconjunctivitis typically
Ulcers on periocular skin
Refer to opthal
What is in fever pain
F- fever in last 24 hours
A- absence of cough
P- prurulent discharge
S- symptoms over 3 days
S- severe inflammation
Management of different F-Pain scores
Under 2 do nothing
2-3- delayed antibiotics
4 or more- give abx
What used for seborrheic dermatitis in infant
For both scalp and nappy rash
- wash in emollient and then use clotrimazole if does not work
What is used if cellulitis around the eyes and nose
Co-amoxiclav
What used if cellulitis on top of chicken pox
Flucloxacillin and amoxicillin
Pen allergic- Ciprofloxacin and metronidazole/clarithomycin
Management of infantile haemangioma if cosmetic disfugurement or near to nose, eyes or mouth
If small then topical timolol
If large then oral propanolol
Treatment of irritant dermatitis nappy rash
If mild erythema +asymptomatic- OTC barrier protection
If inflamed and bothersome- 1% hydrocortisone and OTC barrier protection
Candida nappy rash tx
No barrier protection
Use imidazole cream
Organisms and tx for scabies, head lice and threadworms
Scabies
- sarcopetes scabiei
- permethrin
Head lice
- pediculus capitis
- dimeticone lotion
Threadworms
- enterobius vermicularis
- <6mths= hygiene measures, >6mths= membendazole
Tinea corporis and cruris tx
Mild- clotrimazole/terbinafine cream
Severe- oral terbinafine
How is HSP managed
NSAID or paracetamol and bed rest
Typically will resolve in a few weeks
Oral pred if GI bleeding, severe abdo pain or scrotal involvement
IV if nephrotic range proteinuria or declining renal function
How is HSP managed
NSAID or paracetamol and bed rest
Typically will resolve in a few weeks
Oral pred if GI bleeding, severe abdo pain or scrotal involvement
IV if nephrotic range proteinuria or declining renal function
How does each nappy rash appear and its features
Irritant dermatitis- creases spared
Candida- erythematous rash which i- nvolves the flexures and has satellite lesions
Seborrheic dermatitis- has flakes and concomitant scalp rash
Psoriasis- scaly erythematous rash
Complications of chicken pox
Immunosuppressed- leads to severe streptococcal and staphylococcal infection affecting the joints and bones
Glomerulonephritis
Myocarditis
Pneumonitis
Bacterial superinfection
Management of bacterial superinfection in chicken pox
Admit to hospital
IV flucloxacillin and aciclovir
Management if labial fusion
If no major symptoms can reassure and review
If significant symptoms topical oestrogen for 4-6 weeks
Surgical management if thick and severe or trapped urine causing terminal dribbling and vulval inflammation
Management of tinea captits in children
Exclude kerion
Take hair and scalp sample for culture
Commence oral terbinafine or griseofulvin
When culture comes back change antifungal accordingly
Management of branchial cyst
Antibiotics if infected
Surgical excision is needed
Impetigo management
Localised and not unwell
Hydrogen peroxide 1% cream
If unsuitable
- fusidic acid 2%
- mupirocin 2%
Widespread and not unwell
Offer oral or topical
Topical
1st fusidic acid 2%
2nd mupirocin 2%
Oral
Flucloxacillin
Clarithomycin if aged 1month-11 years erythomycin if 11-17
Bullous or unwell
1st fluclox
2nd Clarithomycin if aged 1month-11 years erythomycin if 11-17
First line for acne
Mild/moderate
Combination of topical adapalene and benzol peroxide
Combination of topical tretinoin and clindamycin
Benzoyl peroxide and clindamycin
Moderate/severe
Combination of topical adapalene and benzol peroxide
Combination of topical tretinoin and clindamycin
Benzoyl peroxide and clindamycin
ALSO
Topical azelaic acid and oral doxycycline and lymecycline
ALL GIVEN FOR 12 weeks
If have cellulitis on top of chicken pox- what is most likely cause
Strep pyogenes
Most common neck lump in kids
Lymphadenitis
What are congenital warts
It is possible to be born with congenital viral warts on the anus or genitals transmitted from the mother to baby during birth
Difference in presentation of scarlet fever vs guttate psoriasis
Scarlet fever- within 24 hours of sore throat
Guttate psoriasis- a few days later with scaly papules
Management of alopecia areata
If evidence of hair regrowing then can use watchful waiting
If no hair regrowth or severe distress then very potent corticosteroids- betamethasone valerate 0.1%
Boggy and pustular raised area where is hair loss
Kerion
Gold standard for CMPA
Double blind oral food challenge
Differentials for small circular rashes
Discoid eczema
Tinea- not very itchy and localised
Neonatal features of Downs
Upslanting palpebral features
Smal low set ears
Round flat face
Flat occiput
Hypotonia
Brushfield spots in iris
Single palmar crease
Duodenal atresia
Hirschprung disease
Complications of edwards
Gastro
- Omphalocele
- Eosophageal atresia
- Hepatoblastoma
Renal
- wilms tumour
- horseshoe
Cardiac
- septal
- PDA
Examination of edwards findings
Prominent occiput
Cleft lip and palate
Low set ears
Rockerbottom feet
Overlapping fingers
Microcephaly
Micrognathia (small jaw)
Whats in pierrer robin sequence
Micrognathia
Posterior displacement of tongue which can cause airway obstruction (glossoptosis)
Cleft palate
Fragile X presentation
Intellectual disability
Delayed speech
Delayed motor development
Autism
ADHD
Seizure disorders
Premature ovarian failure
Examination features of fragile X
Long narrow face
Prominent jaw
Large ears
Large testes post puberty
Macrocephaly
Examination of patau
Scalp lesions from failure of skin to develop
Micropthalmia
One eye in middle of face
No nose
Polydactyly
Rockerbottom feet
Problems of pataus
GI-omphaloce
Renal- PCKD
Cardio- VSD, PDA, dextrocardia
Neuro- myelingocele, developmental delay
Examination findings of noonans
Webbed neck
Trident hairline
Pectus excavatum
Short
Widespaced nipples
Defect in noonan syndrome
Autosomal dominant
Protein kinase mutation Chr 12
Complications of noonans
Pulmonary valve stenosis
Factor Xi deficiency
Ptosis
Presentation of prader-willi and angelmans
Hypotonia
Hyperphagia
Almond shaped eyes
Hypogonadism
Epicanthal folds
Flat nasal bridge and upturned nose
Learning disability
Difference between prader-willi and angelman syndrome
Both have deletion of 15q (long arm)
Paternal deletion= prader willi
Maternal deletion= angelman
Get myoclonic seizures in angelmans
Genetic inheritance of prader wili
Imprinting
Cardiac complication of fragile X
Mitral valve prolapse
Klinefelters features
Infertility
Hypogonadism
Gynaecomastia
Tall
47 XXY
Defining obesity in children
If under 12 use weight centiles
- overweight above 91st centile
- obese above 98th centile
- severe above 99.6 centile
If over 12 use BMI
- overweight above 25
- obese above 30
Inheritance of fragile X
X linked autosomal dominant
What are categories of DKA
Mild- pH 7.2-7.29
Moderate- pH 7.1-7.19 or bicarb less than 10
Severe- pH under 7.1 or bicarb less than 5
How to treat cerebral oedema from DKA
Mannitol
Gonadotrophin dependant causes of precocious puberty
Idiopathic/familial
CNS abnormalities
- hydrocephalus
- infection
- post irradiation
- surgery
- tumours
Hypothyroidism
Gonadotrophin independent causes of precocious puberty
Adrenal
- tumours
- congenital hyperplasia
McUne Albright Syndrome
Tumours producing sex hormones
Exogenous tumours
What would suggest tumour producing sex hormones as cause of precocious puberty
Virilisation
Lots of pubic hair in isolation
What is tumours cause precocious puberty in girls vs boys
Girls- granulosa
Boys- leydig
When should late puberty be investigated in a boy
Past 14- expect it 9-14
What can present with premature thelarche between 6- 24 months
Premature thelarche provided no accompaniement of growth spurt or pubic hair development
How is gonadotrophin dependant precocious puberty treated
Treat cause
Gonadotrophin agonists with GH as GNRH stunts bone growth
Causes of delayed puberty
Constitutional delay
Low gonadotrophin
- systemic disease/exercise/stress causing function hypogonadotrophins
- panhypoituitarism
- intracranial pathology
- hypothyroidism
- kallmann
High gonadotrophin
- klinefelters
- turner
- acquired gonadal failure
Management of congenital adrenal hyperplasia
IV hydrocortisone
IV dextrose
Investigating CAH in children
17 hydroxyprogesterone
In neonate have to do USS as 17 OHprogesterone confounded for by mother
Management of constitutional delay of puberty
1st line- reassure and observe
2nd- IM testosterone every 6 weeks for 6 months if male
transdermal oestrogen
Management of primary gonadal failure causing delayed puberty
Boys- testosterone injection
Girls- oestrogen replacement
How is gonadotrophin independant precocious puberty treated
Ketoconazole
How treat precocious puberty from CAH
Hydrocortisone
GNRH agonist
What is unilateral gynaecomastia in puberty
Normal part of process
Presentation of marfans
High arched palate
Chest wall deformity
Lens dislocation
Arm span > height
Joint hypermobility
Tall
Mitral valve prolapse
Aortic arch abnormalities
Myopia- short sighted
Recurrent AOM in a short female
Turners
What are spoon shaped nails seen in
Turners due to lymphoedema
Clinical features of GH deficiency
Normal growth until 6-12 months
Drastically reduced bone age
Associated with neonatal hypoglycaemia, doll like face( round face with short chin and nose) and jaundice
How should height centiles be assessed with regards to referrals
Under 2nd centile= seen by GP
Under 0.4th centile= seen by paediatrician in outpatient setting
When refer for sitting unsupported
12 mths
Gross motor milestones
6wks- control head
6 mths- sit unsupported
1 year- stand
15mths- walk
2 years- run
3- rides tricycle
4- hops on 1 leg
Fine motor skills milestones
6wks- follows object
6mths- palmar grasp and transfers between hand
12 months- pincer grip
Building bricks milestones
15 mths- 2 blocks
18 mths- 3 blocks
2 years- 6 blocks
3 years- 9 blocks
When can draw line, circle and triangle
2 years- line
3 years- circle
5 years- triangle
Speech and language milestones
6wks- stills or startles to noise
6 months- turns head to sounds, can babble
12 months- knows and responds to name
15 mths- 2-6 words
2 years- combine 2 words
3 years- sentences
when refer for not having 2-6 words
18 months
Social milestones
6 wks- smiles
6 mths- puts hand to bottle when feeding
12 mths- waves
18 mths- plays alone
2 years- can play near others and use spoon
3 years- uses spoon and fork
4 years- plays with others
In DKA what is first thing assess and what determines
If in shock?
Yes
- 100% oxygen
- 10ml/kg 0.9% fluid bolus
- repeat until circulation restored (if do 4x then consider ionotropes)
No
- 10ml/kg 0.9% fluid over 30 mins
Once patient has received bolus how manage DKA
Calculate fluid requirements with 40mmol/L potassium depending on K level
Start insulin 0.05-0.1 units/kg/hour 1-2 hours after bolus
Observe with hourly blood glucose and ketones
How manage cerebral oedema in DKA
20% mannitol or 2.7% NaCl
Fluid resuscitation for children
10ml/Kg over less than 10 minutes
Calculating fluid maintenance for children
First 10kg- 100ml/kg/day
Next 10kg- 50ml/kg/day
Any Kg over 20kg- 20ml/kg/day
Red flags for clinical dehydration
Alterred consciousness
- irritable
- lethargic
Sunken eyes
Tachycardia
Tachypnoea
Reduced skin turgor
Red falgs for shock
Weak peripheral pulses
Cold extremities
Prolonged CRT
Pale or mottled skin
Hypotension- sign of decompensated shock
Management of clinical dehydration
Use ORS 50ml/kg over 4 hours with maintenance fluids
If vomiting and cant keep down use NG tube
How to calculated % dehydration if no weights
Clincal dehydration- 5%
Shock- 10%
How to calculate fluid deficit
Fluid deficit (mL) = % dehydration x weight (kg) x 10
Anaphylaxis guidelines
Remove trigger
Lie flat
IM adrenaline
A-C
Repeat adrenaline if no response after 5 mins with IV bolus
Doses of adrenaline
> 12= 500mcg
6-12= 300mcg
6 months-5 =150 mcg
<6 months= 100-150mcg
Management of GORD in child breastfeeding
- Breastfeeding assessment and advice
- 1-2 week trial of alginate therapy- if symptoms improve after 2 weeks continue the therapy. Stop at regular intervals to see if symptoms have improved
If have not then medical treatment
Mangement of GORD in formula fed
- Reduce volume of milk if excessive (150ml a day per kg)
- Offer 1-2 weeks of smaller more frequent unless they already are small and frequent
- 1-2 weeks of feed thickeners
- Alginate therapy
- Medical management
Medical management of GORD
4 week suspension of omeprazole
If doesnt work refer for possible endoscopy and potential metoclopramide treatment
When should arrange a specialist assessment by paediatrician GORD
Uncertain diagnosis
Growth issues
Unexplained distress in those with communication difficulty
Not responding to treatment
Avoiding food
Unexplained IDA
No improvement in GORD after a year
Sandifers syndrome suspected
Recurrent aspiration pneumonia
Upper airway erosion
Dental erosion in child with neurodisability
Recurrent otitis media (more than 3 episodes in 6 months)
Who give abx in AOM
- ottorrhoea
- perforation
- under 1 month
- systemically unwell
- bilateral under 2
- lasts 4 days
