Paeds Flashcards
Risk factors for DDH (developmental dysplasia hip)
Breech presentation in 3rd trimester
FHx DDH (parent or sibling)
Oligohydramnios
Twins
Congenital or position talipes
Congenital knee dislocation
Plagiocephaly or torticollis
Neuromuscular or syndromic condition
Birth weight>4.5 kg
Examination features DDH
Age<3m, barlow and ortolani’s causing hip clunk when relaxed
Age>3m asymmetrical limited abduction, leg length discrepancy, asymmetrical hip skin creases
Limp/toe walking due to shorter leg
USS via hip screening or in 2ndary care
If older, urgent T+O appt
What features show flat foot as being flexible?
Arch reconstitutes when on tiptoes
Arch reconstitutes when not weight-bearing
Heel swings into varus
Obs meaning a child should be admitted
Sats<92%
Fever:
Age<3 months >=38°C
Aged 3 -6 months>=39°C
RR:
Aged 0- 5 months>60
Aged 6-12 months >50
Age>12 months>40
HR:
<1 year>160
Age 1-2 years >150
Age 3-4 years>140
CRT> 2 seconds
Examination findings meaning a child should be admitted
Appears seriously unwell, does not wake or doesn’t stay awake
Nasal flaring, Tracheal tug
Cyanosis, Apnoea
Grunting
Intercostal/subcostal recessions
Marked abdominal breathing
Auscultation suggesting effusion, abscess, or empyema
Poor feeding < half of normal
Dehydration (no wet nappy 12 hrs)
Management acute severe wheeze in children
Salbutamol neb:
Age<5 years – 2.5 mg
Age>5 years – 5 mg
Ipratropium neb – 250 micrograms
repeat every 20 minutes for the first hour.
Or salbutamol MDI 10 puffs via spacer, 5 tidal breaths each puff. Can be repeated every 10 to 20 minutes if needed. + ipratropium MDI via spacer 2 puffs every 20 minutes for 1 hour
PO prednisolone:
Age< 5 years – 20 mg
Age> 5 – 40 mg
What age do you start giving pred for wheeze?
Don’t give under age 2
Do not routinely given under age 4 unless known asthma
Features septic arthritis/osteomyelitis
a limp.
single, painful, or swollen limb.
refusal to weight-bear
unable to move a limb normally (in infants who are not yet mobile).
unwell with a fever, but no obvious cause.
skin infection that is slow to resolve especially if over a joint.
Features bronchiolitis
Coryzal, then persistent cough, increased work of breathing, widespread wheeze or crackles, and a fever of less than 39°C
usually peaks day 3- 5 and resolves within 3 weeks.
Features diabetes
Thirst (polydipsia)
Thinner (weight loss)
Toilet – passing urine frequently (polyuria)
Tired
Enuresis or nocturia in a previously toilet trained child
Recurrent thrush esp if prepubertal
Recurrent UTI
When should you consider IBD in abdo pain in children?
perioral and/or perianal symptoms
blood in stool
poor growth
FHx
raised platelets + CRP
When should you consider coeliac disease in abdo pain in children?
non-specific GI symptoms
lethargy
poor growth
refractory iron deficiency
FHx
Delayed puberty, short stature
Features functional abdo pain
Recurrent central abdominal pain (context of anxiety)
Recurrent of nausea and upper GI pain (before school)
Strong colic reflex (cramps before soft bowel motions, usually soon after meals)
Abdominal migraines (periodicity of attacks, associated nausea +/- vomiting, FHx migraines)
Ix for abdo pain in children
Diarrhoea – molecular enterics
upper GI – H. Pylori faecal antigen
sus IBD – faecal calprotectin if teen
Consider urinalysis.
FBC, ferritin, CRP, U+E, bone, LFT.
Coeliac screen (need 6 weeks of normal gluten intake) and total IgA.
Finger prick glucose if ?diabetes
Where is gluten found?
Wheat, rye, and barley.
Oats are generally tolerated but normal oats can be heavily contaminated with wheat. 5% of coeliac patients will be intolerant to oats.
Untreated coeliac disease risks
anaemia
nutritional deficiencies
osteopenia or osteoporosis
malignancy, particularly small bowel carcinoma or lymphoma
If low total IgA, symptoms suggestive coeliac disease and negative IgA TTG, what is the next step?
IgG TTG
as could be false negative
Red flags for constipation in children
Meconium passage>48 hours after birth
Symptoms within 1st week of life
Faecal incontinence or soiling in a school-aged child without known constipation
Ribbon stools from birth
Leg weakness
Unintentional weight loss
-> same day paeds
Contributory factors for constipation in children
Medications or supplements (eg thickener)
Excessive cow’s milk intake
When solids are introduced, during toilet training, or when starting school.
Features of faecal impaction
Failing to pass a stool for several days, followed by a large, often painful or distressing, bowel motion.
Soiling of underclothes between bowel motions
Vomiting.
Severe abdominal pain.
Palpable mass.
Loss of awareness.
Urinary retention or wetting.
Management constipation
Adequate fluid (eg adding water inbetween feeds if bottle fed)
Regular toileting (5 mins BD after meals)
Fibre (6 fruit/veg daily with peel)
Cycling legs, massage
When to do cxr in children with cough
Cough> 8 weeks.
features suggesting a chronic respiratory condition, e.g. poor growth, chest deformity, finger clubbing.
Features IgE mediated cows mild protein allergy
Reactions <2 hours after ingestion, usually within 20mins
Urticaria, angio-oedema, itching, cough, hoarseness, wheeze, or breathlessness
Vomiting, diarrhoea, oral itching
Unlikely if no eczema
Featured non IgE mediated CMPA
Delayed until 2-72hrs after ingestion.
GORD, abdominal discomfort, constipation, diarrhoea, or atopic eczema, particularly if symptoms are severe or resistant to treatment.
Unlikely if no eczema
Blood/mucus stool, perianal redness
Management CMPA
trial elimination of all cows’ milk.
If non‑IgE‑mediated symptoms, planned early reintroduction of cows’ milk after 4 weeks
Prescribe an appropriate hydrolysed formula (nutramigen or aptamil pepti)
If severe symptoms/no reponse to hydrolysed, trial amino acid based (alfamino/neocate)
If symptoms resolve, and return on reintroduction- urgent dietician
cows’ milk-free diet until 9 -12 months old, for a duration of at least 6 months.
Referral criteria CMPA
Admit if unwell +:
rectal bleeding ?proctocolitis.
profuse vomiting and/or diarrhoea 2 -4 hours after food (?enterocolitis)
Routine paeds if CMPA suspected +:
faltering growth, or
significant IgE‑mediated CMPA symptoms or severe non‑IgE mediated symptoms.
Features croup
Sudden‑onset, seal‑like barking cough, often accompanied by stridor, hoarseness, and increased work of breathing.
Symptoms are typically worse at night and increase with agitation.
Management croup
Reduce anxiety
O2 non rebreathe 15 L
Nebulised adrenaline (5 mL 1:1000)
Dexamethasone 0.15 mg/kg as 2 mg/5 mL oral solution
or prednisolone 1-2 mg/kg
When to admit ?diabetes
Blood glucose >7 (>11 ?DKA)
Features DKA (vomiting, abdo pain, ketotic breath, lethargy)
What is a simple febrile seizure?
Generalised seizures lasting <5 mins, not occurring > once per febrile illness.
No hx of afebrile seizures, neurological abnormality or evidence of CNS infection.
Recurrence rate of febrile seizures is around 30%, with 10% of children having more than 3 febrile seizures.
Define complex febrile seizure
Focal or prolonged>15 minutes, or recurring within a 24‑hour period.
Increased risk of afebrile seizures.
Lifetime risk of developing epilepsy increases from 1.5% to 4%.
Risk factors for febrile seizure
T> 39°C
Aged 6 months-5yrs
Viral infection- HHV‑6, influenza, adenovirus
Recent vaccination – DTP, MMR
Acute seizure management
Recovery position.
Ensure adequate airway and ventilation.
Administer oxygen by mask.
Check finger‑prick glucose level.
If blood sugar<3 mmol/L, treat hypoglycaemia with Glucogel
If>5 mins 999 and buccal midazolam
Younger than 1 year – 2.5 mg
Aged 1 to 4 years – 5 mg
Aged 5 to 9 years – 7.5 mg
Referral criteria febrile seizure
Admit if:
Hypoglycaemia after treatment.
Persisting postictal paresis or other neurological abnormality.
1st presentation of febrile seizure
If occurs after the 2nd day of febrile illness.
Symptoms or signs of meningism.
Prolonged seizure or postictal period.
Recurrent complex febrile seizure.
Focal neurological deficit.
Decreased level of consciousness before the seizure.
Recently antibiotics (may mask signs of CNS infection).
Parent or carer anxiety and/or difficulty coping.
Age< 1 year.
Diagnostic uncertainty
>1 seizure per febrile illness.
Features kawasaki
High fever>5 days
Widespread macular rash
Swelling or peeling of hands and feet
Conjunctival redness or injection
Red, dry, or cracked lips
Lymphadenopathy
Concerning features for admission in D+V
Temperature more than:
38°C <3 months
39°C > 3-6 months
Neck stiffness
Bulging fontanelle
Non-blanching rash
Blood and/or mucous in stool
Bilious vomit
Severe or localised abdominal pain
Abdominal distension or rebound tenderness
When to do stool culture in D+V in children
blood/mucus in stool.
immunocompromised
recently been abroad.
diarrhoea that has not settled by day 7.
multiple attendances.
an uncertain diagnosis.
Symptoms of underlying cardiac abnormality in school age children
Reduced exercise tolerance
Dyspnoea or cough on exertion – may be misdiagnosed as exercise‑induced asthma
Angina
Palpitations
Syncope with exertion
Symptoms of underlying cardiac abnormality in infants
Poor feeding
Rapid breathing
Failure to thrive
Profuse sweating (when feeding)
Cyanosis or dusky spells
Frequent or recurrent respiratory infections
Risk factors for congenital heart disease
Maternal diabetes, antenatal infection, maternal medications, alcohol in pregnancy
FHx CHD, SIDS, sudden cardiac death, HOCM
Trisomy 21, and 22q deletions
Syndromic or dysmorphic features
Marfan syndrome
Features of innocent murmur
Systolic, Short
Musical, high‑pitched, whistling
Soft
Left sternal edge
Non‑radiating, no associated thrill, clicks, or extra heart sounds
Varying with body position and breathing
Intermittent with high heart rate
Normal femoral pulses
No syndromic features
Thriving
Sats> 95%
Pathological murmur features
Pansystolic, diastolic, or continuous
High‑grade, harsh sounding, loud
Widespread or radiating
Abnormal pulses (bounding or absent femorals)
Associated click, abnormal S2, added heart sound, thrill
Tachypnoea
Poor perfusion, mottling, CRT>2
Central cyanosis – blue tongue, not just perioral duskiness
Sats<95%
Hepatomegaly
Clubbing (rare, late sign)
In a child with a head injury, when should you be concerned about NAI
injury details are absent, vague, or change over time or between caregivers.
injury is inconsistent with the developmental stage of the child.
unexplained delay in seeking help.
history or findings of repeated injuries.
unexplained loss of consciousness, persistent vomiting, or oro-nasal bleeding in a young infant
Definition of prolonged jaundice
> 14 days if term (37+/40)
21 days if preterm
Meanings of split bilirubin results
Unconjugated hyperbilirubinaemia:
Can be physiological
Commonly breast milk jaundice
can also be caused by UTI, sepsis, hypothyroidism, and liver disease.
Conjugated hyperbilirubinaemia:
when conjugated fraction>20 or >20% of the total serum bilirubin
Congenital biliary atresia
Always needs Ix
Risk factors neonatal jaundice
Birth trauma (bruising), prematurity, maternal diabetes
ABO and Rh incompatibility
Sepsis or congenital infection
FHx neonatal jaundice
G6PD deficiency (African, Middle Eastern, Mediterranean ethnicity)
Neonatal hypothyroidism
Referral criteria neonatal jaundice
Admit it:
jaundice within 24 hours of birth.
unwell with jaundice.
jaundice and pale stools.
bilirubin level is above treatment line.
conjugated hyperbilirubinaemia.
weight gain or feeding is unsatisfactory.
Phases of measles
Incubation period – 10 days
Prodromal period – 2- 4 days with malaise, fever, cough, conjunctivitis, then the rash develops, behind ears then spreads.
Infectious period – from the day symptoms first appear (about 4 days before the rash) to 4 days after the onset of rash.
Features measles
Prodrome lasting 2 to 4 days with:
Fever, typically over 39°C, persists until the eruption of the rash and spikes when the rash erupts
Cough
Coryza
Conjunctivitis
Malaise
Koplik spots- blue-white spots on the inside of the mouth opposite the molars, occur 24–48 hours before the rash
Rash- flat, red macules non-itchy rash begins on the face and behind the ears. Within 24–36 hours it spreads over the entire trunk and extremities (palms and soles rarely involved), becomes confluent
Name 6 complications of measles
Pneumonitis
Otitis media
Diarrhoea, stomatitis, dehydration
Encephalitis
Keratoconjunctivitis
Myocarditis
Features rubella
typically mild illness, rash not confluent. If fever is present, it rarely starts on the day of the rash. Post-auricular or suboccipital lymphadenopathy may occur. Koplik spots absent.
Features HSV6
Roseola infantum
mild illness, may be asymptomatic. Typically fever for 3 to 5 days followed by maculopapular rash as clinical improvement occurs
Features parvovirus B19
Slapped cheek disease
bright red rash on cheeks, lacy rash on trunk, Koplik spots absent. Arthralgia or arthritis may occur in adults.
Management measles
Admit if complications or very unwell Public Health
Paeds advice if age<2 or immunocompromised
Pt will be sent 2 swabs in post
Self isolate min 4 days after the onset of rash, ideally until they are fully recovered
Avoid contact with susceptible individuals – those not immunised or partially immunised, pregnant, or immunocompromised.
Features + risk factors for craniosyntosis
Palpable raised sutures
Slowing of head growth
Syndromic appearance
Family history
Maternal sodium valproate use in pregnancy
Features + risk factors for hydrocephalus
Excessive head growth
Tense bulging fontanelle
Sunsetting eyes
Features raised ICP
Unwell, vomiting, often irritable with altered or fluctuating consciousness level
Abnormal posturing
Abnormal pupils(sunset eyes)
Classic triad of low heart rate, high blood pressure, and abnormal breathing (late sign)
Features congenital torticollis
Breech position or difficult delivery.
Few weeks -few months after birth.
Resting position of head is rotated to opposite side and tilted to same side as the tight muscle.
Tight and a painless swelling
Plagiocephaly
Referral criteria for plagiocephaly
Urgent paeds:
?hydrocephalus or craniosynostosis
Community paeds:
Plagiocephaly with dysmorphic features
Paediatric physiotherapy if:
neck movements are restricted and suspected congenital muscular torticollis
plagiocephaly with developmental delay.
Features pyloric stenosis
Progressive thickening of the circular muscle of the pylorus. This leads to gastric outlet narrowing.
Age 2- 6 weeks.
Vomiting is:
Progressively more forceful and may be projectile
Non-bilious
Blood-stained in up to 10% of cases.
Predominantly in male patients
The infant is often hungry after vomiting.
There may be weight loss or inadequate weight gain.
Risk factors for GORD in children
patients with neurological impairment, e.g. cerebral palsy.
premature infants.
cystic fibrosis.
oesophageal abnormalities.
Management GORD if formula fed
Each 1-2 weeks
1) Reduce volume of feeds if >150 mL/kg.
2) smaller, more frequent feeds
3) Thickener Carobel, SMA Staydown (if doesn’t work, stop)
4) Alginates: gaviscon infant
5) PPI: 4‑week trial lansoprazole
Management GORD if breastfed
1) Gaviscon infant, review at 2 weeks and stop if no improvement.
2) 4‑week trial of PPI lansoprazole
Referral criteria GORD
Admit if:
?pyloric stenosis.
bile-stained vomiting.
poor weight gain.
haematemesis.
altered responsiveness.
aspiration.
malaena.
dysphagia.
Routine paeds if:
symptoms do not resolve or recur after treatment.
possetting ongoing aged 18 months.
Features of childhood OSA
habitual noisy breathing or snoring >3 nights a week without URTI
parent observes snorting, gasping, coughing, choking during sleep
witnessed apnoea events
nasal obstruction and daytime mouth breathing.
a parent reports being afraid for their child’s health because of breathing difficulties at night.
the child needs to be woken in the morning.
daytime hyperactivity or sleepiness.
What would you examine in bedwetting/incontinence?
Abdomen – look for distension, feel for faecal loading, masses
Spina bifida.
Lower limb power, tone, reflexes, sensation.
Perineum and genitalia – assess morphology and perineal sensation, look for inflammation.
BP
Urine dip
Blood glucose
Management night time wetting
Drinking earlier in the day.
Bedtime routine
Child has their own bed and access to a toilet
Avoid lifting or waking the child
If using continence products, the child should have time off pull‑up nappies, but try pants or underwear under the pull‑ups
Makw the bed in layers so top layers can be taken off in the night.
Consider mattress protectors, duvet protectors, pillow protectors, and waterproof sleeping bag liners for sleep‑overs and camping trips.
Refer continence service re enuresis alarm and desmopressin
Can consider short term desmopressin for school trip via GP
Referral criteria urinary incontinence in children
Routine paeds:
Recurrent UTIs
always wet during the day (constant dribble).
straining to void or weak stream.
Paediatric continence:
Support for child age>5years
No improvement in daytime wetting after treatment.
for alarm programmes or desmopressin.
Features UTI in children
Unexplained fever, lethargy, irritability
Poor feeding, vomiting
Dysuria, frequency, urgency, poor flow, or new incontinence
Abdominal, suprapubic, or loin pain
Haematuria or offensive urine
Unexplained poor growth
High BP
Indications for USS KUB in children with UTI
Infection with non-E coli organisms
Seriously ill
Poor urine flow
Abdominal or bladder mass
Raised creatinine
Septicaemia
Failure to respond to treatment within 48hrs
OR recurrent UTI:
2+ upper UTI
1+ upper UTI and 1+ lower UTI
3+ lower UTI
Or age<6 months – USS within 6 weeks of infection if responds well to abx treatment within 48hrs and not atypical or recurrent infection.
Referral criteria UTI
Admit:
Age<3 months
Acutely unwell/suspected sepsis
Poor urinary flow
Enlarged bladder or any other abdominal mass
Unable to tolerate oral medications.
Fever>39 age 3-6 months
No improvement 24-48hrs
Recurrent UTI age<6 months.
Routine if recovered from UTI and:
age<6 months.
atypical UTI or recurrent UTI.
When to Ix childhood obesity
If >98th centile:
Fasting glucose and HbA1c (if CBG normal)
Fasting lipid profile if age>10
LFT
Full blood count and ferritin
Vitamin D levels and bone profile
TFTs
If short stature or high blood pressure, arrange 24‑hour urinary cortisol.
When to suspect 2ndary causes obesity
Pregnancy – exclude in sexually active young people.
Endocrine causes- hypothyroidism, Cushing’s syndrome, growth hormone deficiency – usually also cause short stature.
Single gene mutations – suspect if severe, early onset obesity in patients younger than 5 years.
Genetic disorders- Prader‑Willi, Down, Turner, Noonan – suspect if dysmorphism or intellectual impairment.
Red flag in ingestion of objects
Disc battery ingestion- hearing aid or camera
Objects > 5 cm long, sharp objects
Multiple magnets
