Paeds Flashcards
Sore throat - management and Ix in aboriginal peoples
Testing for GAS is recommended in children with pharyngitis who do not have symptoms of viral illness.
Initial evaluation is typically with rapid antigen detection testing (RADT), which is quick and highly specific but has limited sensitivity.
Because the risk of acute rheumatic fever is much higher in high risk group such as Aboriginal and Torres Strait Islander people, a negative RADT in a child should be confirmed with a throat culture, which has greater sensitivity.
Start antibiotics if GAS suspected in high risk groups. Stop if culture is negative.
Phenoxymethylpenicillin Oral
15 mg/kg (max 500 mg) two times daily for
10 days
Amoxicillin Oral 50 mg/kg (max 1 g) once daily for 10 days
Antistreptolysin O antibodies peak approximately a month after streptococcal infection and are not helpful in diagnosing acute pharyngitis.
Main cause of bacterial meningitis in the neonate? Dx?
After first 7 days, is most commonly caused by in developed countries.
Group B Streptococcus (GBS), Escherichia coli, and other gram-negative bacilli are most common <7 days.
In the neonate, a cerebrospinal fluid white cell count of more than 20 to 30 cells/microL is consistent with meningeal inflammation, and bacterial meningitis should be a consideration.
A cerebrospinal fluid glucose concentration (less than 1.7 mmol/L) in a term infant is consistent with bacterial meningitis in the neonate.
Gram stain may be negative in up to 60% of cases of bacterial meningitis even without prior antibiotics. Neither a normal gram stain nor a lymphocytosis excludes bacterial meningitis
Baby gags, gasps, turn blue and stops breathing for few seconds. There is no vomiting after these episodes. He is up to date on his vaccines. What’s the most likely diagnosis? How to find out?
Whooping cough - Nasopharyngeal swab PCR
Don’t dismiss the Dx because coughing paroxysms, post-tussive whoop or post-tussive vomiting are often absent.
Nephrotic syndrome in children - overview, most common cause, main cause of death
Classically characterised by four clinical features, but the first 2 are used diagnostically because the last 2 may not be seen in all patients:
1-Nephrotic range proteinuria-urinary protein excretion greater than 50 mg/kg per day.
2-Hypoalbuminemia-serum albumin concentration less than 30 g/L.
3-Edema
4-Hyperlipidemia.
Most common cause: minimal change disease
It has generally good prognosis and the majority of children with the idiopathic nephrotic syndrome are steroid-responsive.
Children with the idiopathic nephrotic syndrome are at increased risk of developing a serious bacterial infection, especially with encapsulated bacteria.
Sepsis remains one of the main causes of death in children with NS.
Streptococcus pneumoniae is known to be the most important organism in primary peritonitis. However, other organisms such as β-hemolytic streptococci, Haemophilus and Gram-negative bacteria are also frequently found.
Autism - indacated pharmacoterapy and clinical features in adolescence
Aggression and irritability can be a feature of autism, especially during adolescence.
Atypical antipsychotics have been seen to improve behavioural symptoms such as repetitive behaviour, hyperactivity, irritability and aggression.
Risperidone, an atypical antipsychotic is the drug of choice for management of anger outbursts in children with autism in Australia and is (PBS)
Bronchodilators are effective in any age in Asthma?
Bronchodilators inhaled or oral; both are ineffective under 12 months.
Use a spacer with a face mask in children age between 1-2 years for adequate delivery of medication.
Isolated thrombocytopenia in an otherwise healthy child following an URTI is highly suggestive of?
Immune (idiopathic) thrombocytopenic purpura (ITP).
Immune (idiopathic) thrombocytopenic purpura (ITP) - Overview
TP in children is a benign disease of unknown aetiology.
ITP is an autoimmune bleeding disorder characterised by all three of:
- Isolated thrombocytopenia (platelet count of <100 x109/L, often <20 x109/L)
- Well child with no concerning features on clinical history or examination
- Otherwise normal FBE and film
ITP is the most common cause of symptomatic thrombocytopenia in children.
It is a diagnosis of exclusion as there is no specific laboratory test to confirm the diagnosis.
Newly diagnosed ITP is within 3 months of diagnosis. ITP often resolves within 3 months, and resolves in 75% of children by 6 months. Chronic ITP is longer than 12 months.
The decision to treat a child should be based on the clinical symptoms and not the platelet count. Treatment decisions also need to take into consideration the presence of active bleeding, the risk of future bleeding (eg impending surgery) and psychosocial factors.
Intravenous immunoglobulin (IVIG) is not routinely used and is reserved for patients with severe, life threatening hemorrhage
Immune thrombocytopenic purpura (ITP) - Risk classification and management
Low Risk of bleeding:
Many petechiae or large bruises
Painless oral/palatal petechiae or purpura
Blood crusting in nares
Treatment:
Outpatient without medical treatment (unless significant psychosocial or safety concerns)
Repeat FBE and review in 1 week
Moderate: Often require hospital admission
Epistaxis >5 mins
Haematuria
Haematochezia
Painful oral purpura
Significant menorrhagia
Treatment: Film must be reviewed by a haematologist prior to starting treatment
Increase platelet count to stop bleeding (not to normal level)
First line: oral prednisolone 2 mg/kg (max 60 mg) for 4–7 days
Second line if poor response or rapid platelet rise is required (eg prior to surgery): IVIG 0.8–1 g/kg (discuss with haematology team)
Additional treatments:
epistaxis: oral tranexamic acid 25 mg/kg (max 1.5 g), may need ENT intervention
heavy menstrual bleeding
!!!!!tranexamic acid must not be used if haematuria present
> Severe
Suspected internal haemorrhage (brain, lung, muscle, joint, etc) OR mucosal bleeding that requires immediate intervention
Urgent consultation with haematology team
Ttx: Combination IVIG 0.8–1 g/kg and pulse IV methylprednisolone 15–30 mg/kg (max 1 g) daily for 3 days
Platelet transfusion 20 mL/kg, continuous if required
IV tranexamic acid 15 mg/kg
Urgent surgical intervention or referral depending on site of bleeding
Life-threatening: Documented intracranial haemorrhage or life-threatening bleeding at any site
Ttx:
Urgent surgical intervention or referral depending on site of bleeding
Hives/Generalized urticaria - overview and management
If isolated, without other symptoms envolvement:
Oral antihistamines (e.g. promethazine) are mainstay of therapy in most cases.
EV route is used when the urticaria is severe or eyelids are involved.
If there is no response to antihistamines,oral corticosteroids are considered.
Croup (laryngotracheobronchitis) - overview (cause, epidemiology, symptoms)
The croup is a viral illness and is caused by
Parainfluenza viruses are the most common cause of croup
Occurs generally between the ages of 6 months and 6 years
Symptoms:
– Barking cough
– Inspiratory stridor
– Widespread wheeze
– Work of breathing is increased
– Fever with no signs of toxicity
- Often worse at night
Epidemiology:
It is most common in 1 to 3-year-old children and has the duration of 2 to 5 days
Croup (laryngotracheobronchitis) - severity classification and management
The severity of croup is assessed by key features:
1-Mild airway obstruction: mild chest wall retractions and tachycardia, but no stridor at rest.
2-Moderate airway obstruction: stridor at rest, chest wall retractions, use of accessory respiratory muscles (TWO MUSCLES) and tachycardia.
3-Severe airway obstruction: persistent stridor at rest, irritable or drowzy, increasing fatigue, markedly decreased air entry, marked tachycardia, USE OF THREE ACESSORY MUSCLES
Mild and Moderate = steroids alone
- Dexamethasone 0.15mg/kg orally OR
- Prednisolone 1mg/kg orally with repeated dose the next evening.
- Budesonide 2mg by nebulizer if oral route not tolerated
! Discarge if stridor free at rest!!! - Severe:
Nebulised adrenaline 5ml of undilluted 1:1000 OR 0,5ml of 1% respirator solution (10mg/ml) dilluted to 4ml AND Dexamethasone 0,6mg/kg (IV, IM, PO)
!! Discharge after 4h if no stridor at rest or repeat dose if deterioration
Supplemental oxygen is not often required, except in children with severely obstructed airway. Even so, nebulized adrenaline takes precedence to provide a patent airway for oxygen supplementation.
7yo with fever, ataxia, weakness, headache, and emesis and tonic-clonic seizures - what dx to think?
Acute disseminated encephalomyelitis
Acute disseminated encephalomyelitis - overview, cause, dx, symytoms, ttx
It is an autoimmune-demyelinating disease seen in children less than 10 years of age.
Presents with fever, ataxia, weakness, headache, and emesis and tonic-clonic seizures
It may follow many different types of infections, including upper respiratory tract infections, varicella, mycoplasma, herpes simplex virus, rubella, rubeola, and mumps; it may also follow immunizations.
The history and physical examination is similar to multiple sclerosis; differences include age of onset (ADEM is usually seen in < 10-year olds), the presence of systemic findings like fever and emesis, and the lack of progression in the lesions once identified.
MRI of the brain shows disseminated multifocal white matter lesions that enhance with contrast
Mortality is high, with 10% to 30% of affected patients dying.
Treatment is high-dose corticosteroids.
Coin sitting sagittal or sideways - aspiration or ingestion?
Aspiration is likely
When it is localized in the trachea it is seen in the sagittal plane because the cartilaginous tracheal rings in children are incomplete and remain open posteriorly, causing the coin to sit sagittal or sideways.
Undescendent testes - overview, normal range
Testes which are undescended at birth may well descend into the scrotum during the first TWO WEEKS of life;
> The descent is UNLIKELY AFTER 1 YEAR
A testis which was palpable in the scrotum in infancy may ascend and become impalpable due to the failure of the spermatic cord to elongate at the same rate as body growth.
Orchidopexy is best performed by 12-18 months of age as spermatogenesis in the undescended testis is impaired if surgery is done after the age of two years.
The undescended testis is at 5-10 times greater risk of developing a malignancy.
Postpartum clavicular fractures - manegement
Conservador - reassurance and guidance
Birth weight >4 kg, shoulder dystocia, and vacuum delivery are risk factors
Infantile hemangiomas - overview
Most common benign vascular tumour of childhood, and they affect up to 10% of infants.
Arise in the first few weeks-to-months of life
Risk factors include female sex, breech delivery, amniocentesis, Caucasian ethnicity, premature birth, low birthweight and advanced maternal age.
Differentials for IHs include congenital haemangiomas, which are present at birth; pyogenic granulomas; tufted angiomas; and vascular malformations that do not show any signs of regression and grow in proportion with the child.
Most IHs are usually small superficial lesions that spontaneously resolve and parents require only reassurance and education.
Some of these lesions are high risk, and up to 10% can cause complications including ulceration, airway obstruction, functional impairment or disfigurement.
In this situation, treatment is initiated with oral or topical β-blockers, most commonly oral propranolol, and monitored closely.
Primary survey of a sick child - PALS ASSESSMENT
Airway
Breathing
Circulation
Disability (neurological assessment)
Exposure
Fluids: in and out
Glucose
How to check neurological response in children?
A is Alert, or
V responds to Voice, or
P responds to Pain by localizing appropriately, flexing limbs or extending limbs to pain, or
U is Unresponsive.
Acute management of anaphylaxis
Oxygen 6-8 L by mask
Adrenaline IM (.01ml/kg 1:1000 dilution)
Nebulised salbutamol
IV crystalloid or colloid
> > Intubate, admit, OBSERVE FOR AT LEAST
12 HOURS
Long Term management of anaphylaxis
Anaphylaxis action plan
Prescribe Epipen
Medicalert bracelet
Referral to paediatric allergy specialist
Treatment of acute Urticaria (< 6 weeks):
Remove identifiable cause if any
If symptomatic:
Cool Compresses
Avoid aggravating factors such as excessive heat or spicy foods
Aspirin and other NSAIDs should also be avoided as they often make symptoms worse
Anti-histamines to alleviate itching. A non-sedating antihistamine is preferred
> > Cetirizine (Zyrtec) 0.25mg/kg/dose 12-24H oral. Can give up to 4 times the recommended dose to a maximum total daily dose of 40mg. Can be used in children from 6 months of age
Steroid creams do not work.
> > For severe cases, not responding to increased doses of non-sedating antihistamines, a single dose of oral prednisolone may be considered
Croup - other name and causative organism
Laryngotracheobronchitis
Parainfluenza virus
How to differ Croup from Epiglotitis?
Croup has URI signs preceding the acute laryngeal obstruction.
- harsh, barking cough in a febrile, miserable, but otherwise well child
Epiglotitis presents WITHOUT COUGH and with low pitched expiratory stridor and drooling
Assessment of severity of croup and management
MILD - barking cough + stridor only when active or upset
> Symptomatic management at home
+
Prednisolone if stridor present
MODERATE - Some irritability + stridor at rest (during activity) + Increased Resp rate, Tracheal Tug, Nasal Flaring + none or minimal accessory muscle use
> Prednisolone 1mg/kg AND prescribe second dose for the next evening.
Observe 30 minutes post steroid administration.
Discharge once stridor-free at rest.
SEVERE - Increasing irritability and/or lethargy + Stridor present at rest + high RR, use of accs. mm, hypoxemia
> Nebulised adrenaline, IM/IV dexamethasone, Observe for 4 hours post adrenaline, Consider discharge once stridor free at rest.
Epiglottitis - overview
HiB is the usual causative organism
Life threatening emergency, toxic febrile illness
Signs: fever, soft voice, soft stridor, sitting quietly (child sits with limited head movements to protect compromised airway), toxic look (lethargic, pale, drooling)
DO NOT EXAMINE THE THROAT. Initial diagnosis made on history and appearance.
Management: keep child calm, transport to hospital via ambulance, give oxygen, may need emergency cricothyroidotomy, intubation in hospital & IV antibiotics
> > cefotaxime 50 mg/kg up to 1 g IV 8 hourly for 5 days or ceftriaxone 50 mg/kg to max 1 g/day IV daily for 5 days)
When X-rays are recommended under suspicion of nasal foreign body?
When there is possibility of button battery or paired magnets which cannot be directly visualised.
When to give ipratropium during asthma crisis?
Severe and Critical presentations
Severe:
1 dose - 3 times in 1st hr only (20 minutely)
(250microgram)
Critical:
Nebulised 3 times in 1hr
www.rch.org.au/clinicalguide/guideline_index/Asthma_acute/
Indication of corticosteroid in Asthma
From moderate-on presentations
(limited ability to talk, work of breathing slightly increased)
Moderate-severe
Oral prednisolone 1mg/kg/dose OD for up to 3 days
Critical
IV Methylprednisolone on day 1 only
Asthma classification per symptoms and treatment
Infrequent episodic => SABA
Duration between attacks = 6-8w;
mild symptomatic and WITHOUT interval symptoms
Frequent episodic => SABA + ICS (or Montelukast for 4-6w - if no symptom improvemente -> ICS)
DBA < 6 w
Moderate symptomatic and WITH interval symptoms
Persistent => SABA + ICS + LABA
DBA < 6 w
Severe
Severe pneumonia in children - Treatment
Ceftriaxone 50mg/kg (max 1g) IV dailly
PLUS
Flucloxacilin 50mg/kg (max 2g) IV 6-hourly
Consider addition:
- Vancomycin IF MRSA SEPSIS SUSPECTED
- Azithromycin 10mg/kg (max 500mg) IV Daily IF PNEUMONIA PROGRESSING DESPITE ANTIMICROBIAL THERAPY
- Oseltamivir for Influenza
Pneumonia in children - Treatment
Amoxicillin 30mg/kg (max 1G) orally TDS for 3-5 Days
If admitted and unable to tolerate oral intake or vomiting:
- Consider benzylpenicilin 60mg/kg (max 1.2g) IV 6-hourly
Bronchiolitis - overview
Commonest acute LRTI in infants - caused by SRV
2 weeks to 12 months (after 1 year, consider overlap with asthma)
Prodromal symptoms for 48 hrs, 3-5 days of severe symptoms
Wheezy breathing, often distressed, nasal flaring, tachypnoea, hyperinflated chest, bilateral crepitations
Severe bronchiolitis is associated with respiratory failure
Infants < 6weeks are at risk of apnoea
Self limiting disease in 7 to 10 days
CXR findings in bronchiolitis
Chest Xray not routinely recommended but when performed show hyperinflated lungs and perihilar or bronchial markings.
Bronchiolitis classification, management and treatment
(see table)
MILD
O2 sat > 93%
> Improve fluid intake at home
Red flags
MODERATE
Tachypnea; Tracheal tug/nasal flaring
Sat 90-93%
> O2 for 1-2 hrs NG or I/V fluids 2/3rd maintenance
SEVERE
Lack of apetite, fatigues, hypoactive,
SO2 < 90%
> O2, IVF, CPAP, ICU
Meningococcemia - overview and management
Rapid onset of symptoms, may appear shocked, petechial rash on limbs & trunk, may deteriorate rapidly
Investigations: LP (in stable child), CT scan, Blood culture & CSF MCS/ PCR
Acute Management:
Antibiotics IV ceftriaxone/cefotaxime (50mg/kg) or benzylpenicillin for 7 days
Fluids if shocked give 20ml/kg Normal saline
Steroids IV dexamethasone (0.15mg/kg IV)(for >2mo)
Isolate till >12 hr of antibiotics
Notify DHS
Meningococcemia - chemoprophylaxis (general and pregnancy)
Chemoprophylaxis with Rifampicin FOR TWO DAYS for all household, day care or intimate contacts within 7 days of onset.
If pregnant or BF women are contacts then ceftriaxone IM as single dose
Assessment of degree of dehydration
Bare child weight estimation & comparison with premorbid weight is more accurate
Assessing with clinical signs (sunken eyes, lethargy, dry mucous membranes) is less reliable
Mild Dehydration <4% body weight loss
may have increased thirst, no clinical signs, manage with Oral Resuscitation
Moderate Dehydration 4-6% body weight loss
- Delayed CRT > 2 secs, high respiratory rate, mildly decreased tissue turgor, manage with NG resuscitation
Severe Dehydration >/=7% body weight loss
- Very delayed CRT > 3 secs, mottled skin, other signs of shock (tachycardia, irritable or reduced consciousness, hypotension), deep, acidotic breathing, decreased tissue turgor, manage with IV resuscitation
Dehydration - management
Urgent component: Boluses of 10-20ml/kg of normal (0.9%) saline, which may be repeated.
Do not include this fluid volume in any subsequent calculations of hydration
Slow Component: Maintenance Fluid
- For child’s 1st 10 kg -> 100ml/kg/24hrs
- 2nd 10 kg -> 50ml/kg/24hrs
- Remaining kgs -> 25ml/kg/24hrs
(max is 2400ml in 24 hrs or 100mls/hr)
Deficit = (weight x body weight loss x 10 )
Assessment and management of head injury
Minor:
No LOC, Stable, alert conscious state, may have scalp bruising or laceration, normal examination otherwise
Discharge home with analgesia and warn of red flags
Moderate:
Brief LOC at time of injury, may be drowsy, two or more episodes of vomiting, persistent headache
May have a large scalp bruise, haematoma or laceration, normal examination otherwise
Observe in ED for 4 hours, anti-emetics, analgesia, discuss with senior, discharge if improving
Severe:
Decreased conscious state – responsive to pain only or unresponsive
Localising neurological signs (unequal pupils, lateralising motor weakness)
Signs of raised ICP, penetrating head injury, CSF leak from nose or ears
Maintain oxygenation, ventilation and circulation, avoid rises in ICP.
Urgent CT of head and c-spine. Ensure early neurosurgical and ICU intervention.
Hypoglicaemia in children - definition and management
Hypoglycaemia is defined as a blood glucose level of <2.6 mmol/L.
The most appropriate treatment of severe hypoglycemia when the patient is unconscious and unable to take oral glucose is with a bolus of intravenous dextrose 10%, 2.5 to 5 ml/Kg followed by 0.03 to 0.05 ml/Kg/minute until the patient is stable.
In adults with hypoglycemia, 50% glucose solution is used for treatment of severe hypoglycemia. This solution is not recommended for children because it can result in serum hyperosmolarity and death.
In a conscious and cooperative child, oral route is preferred.
What’s the most common prenatal viral infection
CMV
The most common cause of noisy breathing in infancy.
Laryngomalacia
Laryngomalacia - overview
Laryngomalacia is congenital softening of the tissues of the larynx above the vocal cords. This is the most common cause of noisy breathing in infancy. The laryngeal structure is malformed and floppy, causing the tissues to fall over the airway opening and partially block it.
Laryngomalacia symptoms are usually present at birth, and can become more obvious within the first few weeks of life.
Most children outgrow laryngomalacia by 18 to 20 months of age.
Symptoms of laryngomalacia include:
Noisy breathing – an audible wheeze when a baby inhale. It is of ten worse when the baby is agitated, feeding, crying or sleeping on his back
High pitched sound
Difficulty feeding (in severe cases)
Poor weight gain (in severe cases)
Choking while feeding (in severe cases)
Measles - transmission
Patients with established measles should be excluded until 4 days after the onset of rash.
Guillain-Barre syndrome - Presentation
The initial diagnosis of GBS is based on the clinical presentation.
The cardinal clinical features of GBS are progressive, mostly symmetric muscle weakness and absent or depressed deep tendon reflexes.
The weakness can vary from mild difficulty walking to nearly complete paralysis of all extremities, facial, respiratory, and bulbar muscles
Guillain-Barre syndrome - Diagnostic tests
The diagnosis of Guillain-Barre syndrome (GBS) is confirmed if cerebrospinal fluid (CSF) and clinical neurophysiology studies show the typical abnormalities.
Therefore, lumbar puncture and clinical neurophysiology studies are performed in all patients with suspected GBS.
Of these two however, nerve conduction studies (NC) and needle electromyography (EMG) are more accurate.
They are used not only for confirmation of diagnosis. but also for providing information regarding prognosis.
Performance of a detailed neurophysiologic study enables diagnosis of pediatric GBS in as many as 90 percent of cases during the first week of symptoms
The typical CSF finding, known as albuminocytologic dissociation, starts approximately 48 hours after symptoms onset and is present in 50-66% o f the patients in the first week and over 75% in the third week.
Nerve conduction studies show a typical demyelinating pattern . NCV changes often slower than those of CSF.
Guillain-Barre syndrome - How to monitor?
Patients with GBS should always be managed in an inpatient setting.
Vital capacity should be monitored 4- hourly, using forced vital capacity (FVC), and if it falls to less than 20ml/kg or is declining rapidly, the patient should be transferred to an intensive care unit.
FVC monitoring is not diagnostic though.
Cardiac monitoring is also recommended for such patients due to significant risk of cardiac arrhythmia.
What’s the most common congenital cardiovascular diseases?
The congenital heart disease is very common, and it is reported to affect 1 in 100 Australian infants
1 - Ventricular septal defects.
2- atrial septal defects
3 - patent ductus arteriosus
4- pulmonary stenosis.
Febrile convulsions - presentation and types
Simple febrile convulsions are generalized, have duration of less than 15 minutes and do not occur more than once in 24 hours.
Complex seizures are focal in onset, may last for longer than 15 minutes and recur in the course of 24 hours.
Terminal haematuria in early adolescents without other findings
benign condition associated with hormonal changes leading to engorged vessels
Ventricular septal defect - overview (presentation, dx, ttx)
Ventricular septal defect is the most common congenital heart lesion.
The defect connects the two ventricles with the left to right shunt. The child may present with following clinical features:
-The breathlessness of crying and feeding.
-Recurrent chest infections.
-Failure to thrive.
-Congested heart failure.
The cardiac examination is remarkable with a palpable thrill at the left sternal edge and a pansystolic murmur at the right sternal edge.
If a child with a ventricular septal defect, develop heart failure symptoms, consider surgical closure by six months of age or at any age when the child is diagnosed with the condition.
Risk Factors for Cerebral Herniation in Patients Undergoing Lumbar Puncture
Altered mental status
Focal neurologic deficit
History of central nervous system disease
Hypertension with bradycardia
Immunosuppression
Papilledema
Respiratory abnormalities
Seizure (in the previous 30 minutes to one week)
thyroglossalduct cyst - REVIEW
TDCis the most common type of developmental cyst encountered in the neck region, and is a condition that results from the failure of obliteration of the thyroglossal duct that results in the formation of a bridge between the base of the tongueand the thyroid gland.
A TDC usually presents with a palpable asymptomatic midline neck mass usually at or below the level of the hyold bone, above the thyroid cartilage. The mass is most often in the midline, although it can present slightly off the midline to one side or the other. A TDC may present in childhood (less than 50%) or later in life, usually as a young adult below the age of 20 years.
Characteristically on examination, a TDC moves up when the tongue is protruded, and moves up and down upon swallowing reflecting the attachment of these cysts to the base of the tongue by the thyroglossal tract. Some patients have neck or throat pain, or dysphagia, but usually most patients are just concerned by the lump itself.
A TDC may become complicated. Complications of TDCs include:
Infection.
Malignancy
Overgrowth and pressure of the underlying structures.
Rupture and fistula formation.
Of these, Infection Is the most common complication. An Infected TDC usually presents with redness and swelling.
Malignancy is the second most common complication of TDCs. It can complicate the cyst in approximately 1% of patients. Papillary carcinoma is the most common malignancy arising from a TDC. Follicular, papillary and Squamous cell carcinoma follow in order of commonality.
Cyst enlargement and compression or the underlying structures is another complication of TDCs. Obsrtuction of the airway is of significance importance. However, compared to infection and malignancy, this complication is less common.
Categories and Risk factors for neonatal sepsis
Neonatal sepsis is categorized as either early onset defined as up to 48 hours after birth and late onset sepsis if it happens after 48 hours of birth.
Risk factors for early onset sepsis include:
– Maternal group B streptococcus colonization in current pregnancy.
– A previous baby with GBS infection.
Risk factors for late-onset sepsis:
– Artificial ventilation with an endotracheal tube.
– Extreme prematurity.
– Total parenteral nutrition.
jaundiced within 24 hrs after delivery - Diganosis? Investigations?
Haemolysis **
Neonatal Hepatitis (rare and due to high conjugated bilirubin)
Sepsis
Investigations:
SBR (split unconj&conj)
Maternal & neonatal blood group
**Direct Coomb’s Test (Antibodies on baby’s cells)
FBE/film/reticulocyte, CRP,
Blood cultures ( septic screen if required)
Causes of severe haemolysis
ABO incompatibility
Rh iso-immunisation
Sepsis
Other rare causes:
red cell enzyme defects such as G6PD deficiency (x-linked)
red cell membrane defects, for example, hereditary spherocytosis( AD)-abnormal shapes in blood film (spherocytes-can also be seen in ABO incomp.)
Prolonged Jaundice
(Jaundice persisting > 2 weeks in term baby, > 3 weeks in preterm).
Can be unconjugated:
breast milk jaundice, hypothyroidism etc.
OR
conjugated:
Galactosemia etc.
Exclude important causes but breast milk jaundice is very common.
Always investigate!
Rarely requires treatment.
Breast milk jaundice:
Cause is not known but unsaturated fatty acids or a lipase, which inhibits glucuronyl transferase have been suspected.
Common, Jaundice may continue for many weeks
Cessation of breast feeding is NOT indicated
Transient tachypnea of the newborn - overview (risk factors, clinical features, cause)
TTN
Term or late preterm (≥34 weeks-36 GA).
C/S delivery, maternal diabetes and asthma.
Inadequate clearance of fetal lung fluid at birth.
Signs of increased work of breathing:
Tachypnoea: RR>60/min, intercostal, subcostal recessions, nasal flaring, cyanosis, expiratory grunting.
Mostly starts at 2 hours after birth and resolves at 24 hours. If persists exclude Pneumonia and other DDX.
Supportive Mx: Fluid restriction, nutrition support, oxygen supply
Start AB if tachypnoea persists beyond 6 hours or there is other risk factors.
Physiological VS Pathological neonatal jaundice - aspects
Physiological
Day 2-14
Mild jaundice
Common & harmless
Dx of exclusion
Self resolves in 2 weeks in term infants (in 3 weeks for preterm)
Unconjugated hyperbilirubinemia
Pathological
> > > > Too early (< 24 hours of age)
> > > > Too high ( SBR >200-250 umol/L, 24 hours -10 days of age)
> > > Too Long (> 10 days of age, especially > 2 weeks)
> > > Conjugated hyperbilirubinemia
Congenital Diaphragmatic Hernia - overview (clinical features, cause, dx)
Failure of fusion of the components of the diaphragm (posterolateral).
Some abdominal contents (bowel, liver, spleen and stomach) herniate into the thoracic cavity through a congenital defect.
Causes pulmonary hypoplasia and severe respiratory distress at birth.
Mostly left-sided (so called Bochdalek- type hernia).
- Signs and Symptoms:
»» Triad of respiratory distress, scaphoid abdomen and barrel chest.
Respiratory distress SOON AFTER BIRTH and CYANOSIS occurs.
Decreased air entry on the left side.
Displaced heart sounds to the right.
Diagnosis:
Chest X-ray: loops of bowel within the thoracic cavity
Barium studies, routine blood tests.
