paeds

Question 1

management for acute otitis media ? q

Answer 1

no abx, will resolve on its own. give ibruprof/paracet

if sx worsen/ do not improve after 3 days - amoxicciliin i first line

Question 2

what is perthes and what age group and how present ?

Answer 2

avascarlar necrosis of femoral head

4-8 y/o

reduced ROM / pain over a couple of weeks

Question 3

osteomyeltiis most commonly cause by what organism ?

Answer 3

staph aureus

Question 4

what is ewings sarcoma ?

Answer 4

Ewing
sarcoma is a malignant bone tumour that most commonly affects long bones.

Presenting features depend on the size and location of the tumour, but bone pain is classically worst at night. There may be swelling or tenderness over the site
and tumours may be incidentally discovered following a pathological fracture

Question 5

manage a severe/lifethreatening asthma attack steps

Answer 5

ADMIT TO HOSPITAL

1. oxygen
2. nebulised salbutomol
3. nebulised ibratropium bromide
4. nebulised mag sulphate
5. prednisolone (can be IM if oral not poss)

• 2nd line treatments (if above fails): IV salbutamol/ IV aminophylline/ IV magnesium sulphate
• Discuss with senior clinician, PICU or paediatrician

Question 6

manage a moderate asthma attack

Answer 6

ADMIT TO HOSPITAL

1. oxygen
2. salbutamol (metered dose inhaler + spacer)
3. ipratropium bromide oral (given if poor response to above)
4. prednisolone (oral)

Question 7

features of life threatening asthma attack

Answer 7

peak expiratory flow rate (PEFR) less than 33% of expected,

oxygen saturation
less than 92%,

altered consciousness,

exhaustion,

cyanosis

silent chest

Question 8

what happens after kid has had meningitis and its been treated ?

Answer 8

Patients should be reviewed by a
paediatrician 4–6 weeks after discharge and a formal audiological assessment
should be offered.

Question 9

3 nephritic and 3 nephrotic

Answer 9

nephrotic

1. minimal change disease
2. focal segmental glomerulosclerosis
3. membraneous glomerulonephritis

nephritic
1. post strep glomerulonephritis
2. IgA glomerulonephritis
3. rapidly progressing glomerulonephritis

Question 10

how to manage paeds dka ?

Answer 10

1. Initial fluid bolus at 10ml/kg of 0.9% NaCl over 30 minutes
2. give 0.9% saline with 40 mmol/L potassium chloride
3. once plasma glucose is < 14 mmol/L Change to 0.9% saline + 5% glucose
4. Start IV insulin infusion 1-2 hours after beginning IV fluid therapy in children with DKA

*remeber continuous ecg to check for hypokalaemia

Question 11

crohns vs UC

presentation

Answer 11

UC =
Diffuse abdominal
pain, rectal
bleeding, and
mucus

crohns=c
Right iliac fossa pain,
failure to thrive between
attacks, loose stools, and
rectal bleeding

Question 12

crohns vs uc

exam findings

Answer 12

both =
Clubbing, anterior uveitis, erythema nodosum,
pyoderma gangrenosum, and signs of anaemia

just crohns=
Aphthous ulcers, fissures,
and fistulae

Question 13

crohns vs uc

commonly affected areas and distribution and pattern

Answer 13

uc =
rectum, rectum and colon, continuous lesions

crohns=
terminal ileum, anywhere from mouth to anus, skip (disconinuous) lesions

Question 14

crohns vs uc

depth of inflamm

Answer 14

uc =
submucosa and mucosa only

crohns =
transmural

Question 16

crohns vs uc complications

Answer 16

uc =
Colonic
adenocarcinoma
and toxic
megacolon

crohns=
Abscesses, fistulae,
adhesions, strictures,
fissures, obstruction and
perforation

Question 17

different child hearing tests and when theyre carried out

Answer 17

The newborn hearing test is carried out in the first 4–5 weeks of life using the
automated otoacoustic emission test. If this suggests a hearing problem, the newborn is offered an
automated auditory brainstem response test.

Visual reinforcement audiometry is
used in children aged 6 months to 2.5 years,

pure tone audiometry is used to screen a child’s hearing before starting school at 4–5 years of age

tympanometry is used to assess for otitis media with effusion (glue ear).

Question 18

what heart stuff is turners associated with?

Answer 18

bicuspid aortic valve, aortic
stenosis, and coarctation of the aorta

Question 19

how is acne managed

Answer 19

1. benzoyl peroxidase, adapalene, azaleic acid
2. oral abx for 3 month (doxycycline)
3. alt abx
4. isotretinoin (accutane)

Question 20

what is the word when you get too much billirubin as a neonate and it messes up the brain ?

Answer 20

kernicterus

Question 21

how is pulse scored on apgar

Answer 21

2 >100
1 < 100
0 nil

Question 22

how is resp scored on apgar

Answer 22

2 = strong / crying
1 = weak, irregular
0 = nil

Question 23

how is colour scored on apgar

Answer 23

2 = pink
1 = pink body / blue extremtieis
0 = blue all over

Question 24

how is muscle tone scored on apgat

Answer 24

2 = active movement
1 = linmb flexion
0 = flaccid

Question 25

hw is reflex scored on apgar

Answer 25

2 = cries on stimaulation / coughs / sneezes
1 = grimace
0 = nil

Question 25

what is a normal apgar score ?

Answer 25

7 or above

Question 26

is it bad to have blue extremities when you’re born ?

Answer 26

Apgar score is therefore 9. This is likely to be describing a
case of acrocyanosis — a benign condition that causes peripheral cyanosis
immediately after birth in healthy infants and resolves within 48 hours

Question 27

threadworm caused by ?

Answer 27

Enterobius vermicularis

Question 28

Children aged 3 months or
older with acute pyelonephritis/upper UTI - how managed ?

Answer 28

7–10 day course of
either oral cephalexin or oral co-amoxiclav.

Question 29

Children aged 3 months or older
with cystitis/lower UTI management ?

Answer 29

should be given a 3-day course of oral trimethoprim or
oral nitrofurantoin

Question 30

failure to pass
meconium within 48 hours, bilious vomiting, and abdominal distention - diagnosis

Answer 30

Hirschsprung disease

Question 31

difference between lukaemia and lymphoma

Answer 31

leukaemia = abnormal cells accumulate in blood or bone marrow

lymphoma = form solid tumours in lypmh nodes, thmus, spleen

Question 32

how to differentiate AML vs ALL in clincial presentation

Answer 32

ALL =
children more likely &
Lymphadenopathy +++
CNS involvement +++
Testicular enlargement
Thymic enlargement (mediastinum)

AML =
Lymphadenopathy less common

Quick subtype facts:
M3: Acute promyelocytic leukaemia 15;17– prone to DIC & bleeding
M4+5: Monoblasts/monocytes - Skin / gum infiltration + hypokalaemia

Question 33

staging for hodgkins lymphoma

Answer 33

ann-arbor staging

Staging (Ann-Arbor)
Stage 1 – one LN region (LN region can include spleen)
Stage 2 – two or more LN regions on the same side of the diaphragm
Stage 3 – two or more LN regions on opposite sides of the diaphragm
Stage 4 – extra nodal sites (liver, BM)

A: No constitutional symptoms B: Constitutional symptoms

E.g. Stage 2a – patient with involvement in 3 LN regions above the diaphragm, pain after alcohol and SVC syndrome but no weight loss, night sweats etc.

Question 34

management for viral induced wheeze

Answer 34

salbutomol - burst therapy

Question 35

how to manage bronchiolitis ?

Answer 35

mainly supportive

humidifed oxygen

Question 36

rsv stands for ?

Answer 36

respiratory syncytial virus (RSV)

Question 37

neonate has conjuctivitis what are implications ?

Answer 37

Ophthalmia neonatorum simply means infection of the newborn eye.

Responsible organisms include
Chlamydia trachomatis
Neisseria gonorrhoeae

Suspected ophthalmia neonatorum should be referred for same-day ophthalmology/paediatric assessment.

Question 38

how to manage whooping cough ?

Answer 38

Pharmacological Treatment - if admission is not needed, prescribe an antibiotic if the onset of the cough is within 21 days.

o < 1 month old = clarithromycin
o >1 months old and not pregnant = azithromycin
o If macrolides contraindicated, give co-trimoxazole

Question 39

neonate is irritability and jitteriness, drowsiness and poor feeding

Answer 39

neonatal hypoglycaemia

Question 40

how long for delivery for cat 1 and cat 2 c section?

Answer 40

cat 1 = 30 mins

cat 2 = 75 mins

Question 41

perthes painful or painless limp ?

Answer 41

can be either

Question 43

purpuric rash, athralgia, recent viral illness, proteinuria

Answer 43

IgA vascultitis (henoch-schonlein purpura)

Question 44

surgery for biliary atresia ?

Answer 44

• Kasai hepatoportoenterostomy

ideally within first 60 days of life

Question 46

what is Klinefelter’s syndrome

give features

Answer 46

is associated with karyotype 47, XXY.

Features
often taller than average
lack of secondary sexual characteristics
small, firm testes
infertile
gynaecomastia - increased incidence of breast cancer
elevated gonadotrophin levels but low testosterone

Question 47

for cyanotic congenital heart defect what do you need to give baby

Answer 47

Prostaglandin E1 infusion (alprostadil)

this keeps ductus arteriosis open

Question 48

baby stools contain undigested food ?

Answer 48

toddler’s diarrheoa

Question 49

surgery for pyloric stenosis

Answer 49

Management is with Ramstedt pyloromyotomy

Question 50

which heart abnormaility associated with downs syundrome ?

Answer 50

AVSD

Question 51

name of criteria for septic arthiritis

Answer 51

The Kocher criteria for the diagnosis of septic arthritis:

fever >38.5 degrees C
non-weight bearing
raised ESR
raised WCC

Question 52

which abx for septic arthiritis ?

Answer 52

• Prolonged course of antibiotics (initially IV for 2 weeks, followed by 4 weeks of oral antibiotics)

o Neonate to <3 months:
 IV cefotaxime

o 3 months to </=5 years:
 IV ceftriaxone
 If penicillin allergic, give clindamycin

o >/=6 years
 IV flucloxacillin
 If penicillin allergic, give clindamycin

Question 53

if suspected testicular torsion how do you manage ?

Answer 53

o IV fluids, NBM, antiemetics, analgesia

straight to surgery

Question 54

difference between kawasaki and scarlet fever + management

Answer 54

kawasaki:
- high-grade fever which lasts for > 5 days. Fever is characteristically resistant to antipyretics
- conjunctival injection
- bright red, cracked lips
- strawberry tongue
- cervical lymphadenopathy
- red palms of the hands and the soles of the feet which later peel

mx = aspirin

scarlet fever:
- Scarlet fever has an incubation period of 2-4 days and typically presents with:
- fever: typically lasts 24 to 48 hours
- malaise, headache,
- nausea/vomiting
- sore throat
- ‘strawberry’ tongue
- rash (sandpaper rash)/fine punctate erythema

mx= oral penicillin V for 10 days (also called phenoxymethylpenicillin)

Question 55

difference between kawasaki rash onset and scarlet fever rash onset …

Answer 55

kawasaki = 5-14 days after fever

scarlet fever = 12-48 hours after fever

Question 56

for severe / life threatening asthma when do you give salbutomal and when do you give ipratropium??

Answer 56

you give them together

Question 58

eye infection in neonate discuss ??

Answer 58

Ophthalmia neonatorum (conjunctivitis in the neonate)

Responsible organisms include
* Chlamydia trachomatis
* Neisseria gonorrhoeae

Management
* Mild bacterial conjunctivitis:
o Chloramphenicol eye drops
* Moderate-severe bacterial conjunctivitis:
o Chlamydial (most common):
 Oral erythromycin
o Gonococcal:
 Single dose of parenteral (IV or IM) cefotaxime/ ceftriaxone
o Pseudomonal:
 Gentamicin eye drops plus systemic antibiotics
* Viral: no specific antiviral, may use topical antihistamine and artificial tears to relieve itching
* For chlamydia or gonococcal infections, the mother and her sexual partner also require treatment

Question 59

neonatal group b strep infection how to prevent / manage?

Answer 59

Prevention
* Offer intrapartum benzylpenicillin (or vancomycin if allergic to penicillin) to pregnant women who have had:
o a previous baby with an invasive group B streptococcal infection
o group B streptococcal colonisation, bacteriuria, or infection in the current pregnancy
o are in pre-term labour

Neonatal infection management
* Penicillin (IV Benzylpenicillin) and gentamicin
* First-line antibiotics recommended in NICE NG195 guidelines, but local antibiotic policies may vary

Question 60

how to manage haemolytic disease of the newborn

Answer 60

o Resuscitation
 A to E approach particularly if preterm, anaemic or hydropic(swelling/taking up fluid)
o Phototherapy
 if significant jaundice (test with transcutaneous bilirubin)
o Exchange transfusion if:
 Bilirubin rapidly rising (>8-10 μmol/l/hr) despite adequate phototherapy
 Severe hyperbilirubinaemia insufficiently responsive to phototherapy and supportive care
 Significant anaemia (Hb <100 g/l)
o IVIG
 Only for immune haemolysis; if bilirubin continues to rise by > 8.5mmol/L/hour

Question 61

how to manage neonate hep B virus ?

Answer 61

• Infants of mothers who are HBsAg positive should receive exposure immunization schedule:
  o Monovalent Hepatitis B vaccine within 24 hours of birth (also at 4 weeks and 1 year of age)
  o 6-in-1 vaccine (DT/aP/IPV/Hib/HepB) at usual times (8, 12 and 16 weeks)
• HBIG should be given to the neonate if:
  o Mother is HBsAg positive (even if she is HBeAg negative)
  o Mother had acute hepatitis B during pregnancy
  o Mother had an HBV DNA level equal or above 1x10^6IUs/ml in any antenatal sample during the current pregnancy
• HBIG should be ideally given simultaneously as initial Hep B vaccine, but at a different site
• Acute Hep B infection: supportive care

Question 62

neonate at risk of hypoxic brain injury what can you do ?

Answer 62

hypoxic ischaemic encephalopathy:

Babies born near or at term with HIE can benefit from therapeutic hypothermia

Question 63

how to manage listeria neonatal infection?

Answer 63

Management
* Amoxicillin and gentamicin
o If blood cultures or CSF comes back as positive for Listeria

Question 64

asymmetrical patchy opacities on chest x-ray in neonate + how would you manavge ?

Answer 64

meconium aspiration syndrome

more common in post term delivery / also could have meconium stained amniotic fluid

• If normal term infant with meconium-stained amniotic fluid but no history of GBS, observation is recommended
• If there are risk factors or laboratory findings that are suggestive of infection, consider antibiotics
  o IV ampicillin AND gentamicin

Question 65

premature neonate developing feeding intolerance, vomiting, lethargy and abdominal distension which progresses into bloody stools at around 9 days of age + how to manage ?

Answer 65

Necrotising Enterocolitis

Management
* Stop enteral feeding and medications
o TPN may be required if feeds stopped >24 hours
o For confirmed NEC cases feeds stopped for 7 days
* NG tube
o Used to drain fluid and gas from the gut
o Monitor hourly gastric aspirates
* Broad-spectrum IV antibiotics
o Must cover both aerobic and anaerobic organisms
o For example: cefotaxime and vancomycin
* IV Fluids
o For cardiovascular support, may require addition of inotropes
* Surgery
o Indicated if:
 Perforation
 Failure to respond to medical treatment
o Laparotomy with resection of necrosed bowel with either a primary anastomosis or a defunctioning stoma

Question 66

Pneumatosis intestinalis. Seen as gas in the bowel wall on x-ray

Answer 66

necrotising enterocolititis

Question 67

threshold for managing neonatal hypoglycaemia and what to do ?

Answer 67

If pre-feed glucose <2mmol/L or symptomatic (BNFC)
o Immediate glucose IV infusion

if above this, just encourage feeding.

Question 68

how to manage increased unconjugated biliirubin - jaundice in neonate ?

Answer 68

serum bilirubin threshold graph

1. subthreshold no treatment
2. in between the 2 lines on graph - phototherapy
3. above top line –> exchange transfusion

Question 69

ground-glass shadowing and
air bronchograms.

Answer 69

Respiratory distress syndrome

Question 70

how to manage RDS ?

Answer 70

Management
* ABC resuscitation
o Review history and examine baby to identify cause of respiratory distress
* Respiratory support
o Intubation and ventilation
 Used when severe RDS
o Endotracheal surfactant
o Continuous positive airway pressure (CPAP)
 Helps keep the lungs inflated
o Supplementary oxygen
 Aim between 91-95% for preterm neonates

• Fluids
• IV antibiotics
  o Broad spectrum combination
   Such as benzylpenicillin and gentamicin (unless listeria in which case start amoxicillin and gentamicin)
• CXR
  o Do ASAP unless mild respiratory distress where this can be delayed

Question 71

managment of toxoplasmosis in newborn

Answer 71

Management of symptomatic babies
* Refer to paediatric infectious diseases
* Pyrimethamine + Sulfadiazine + Folinic acid
o Continue all 3 for 1 year
* Monitor LFTs and FBCs every 4-6 weeks
* + Glucocorticoids (prednisolone)
o If CSF protein >1g or active chorioretinitis threatens vision

Question 72

Transient tachypnoea of the newborn - what is it

Answer 72

Transient tachypnoea of the newborn (TTN) is the commonest cause of respiratory distress in the newborn period. It is caused by delayed resorption of fluid in the lungs

It is more common following caesarean sections, possibly due to the lung fluid not being ‘squeezed out’ during the passage through the birth canal

Chest x-ray may show hyperinflation of the lungs and fluid in the horizontal fissure.

mx –> largely observational

Question 73

common organisms for neonatal sepsis ? + how to manage ?

Answer 73

are Group B Streptococcus, Escherichia coli, and Listeria monocytogenes.

The antibiotics used to treat early-onset sepsis may vary depending on the trust, but they typically include a penicillin (e.g. benzylpenicillin) and an aminoglycoside (e.g. gentamicin) to cover Gramnegatives

Question 74

murmur for ASD

Answer 74

Classically causes a mid-systolic, crescendo-decrescendo murmur loudest at the upper left sternal border with fixed splitting of the second heart sound

Question 75

how is coartation of aorta managed ?

Answer 75

• 98% occur distal to the left subclavian artery, usually at the origin of the ductus arteriosus
• Most common presentation is at 48 hours old when the ductus arteriosus closes
  Management
• Prostaglandin E1 infusion
  o To maintain duct patency
• Surgical repair
  o End-to-end anastomosis or arch reconstruction with patch placement or bypass graft
  o Older patients may require stent insertion or surgical resection

Question 76

which pharmocological agent do you need to give in cyanotic heart disease ??

Answer 76

Maintain duct patency: key to early survival

o Start prostaglandin E1 infusion

Question 77

how to manage PDA

Answer 77

if cyanotic disease you need to keep it open so give prostaglandin E1

if not then close it up… give them:

o IV Indomethacin – 1st line treatment
o Prostacyclin synthetase inhibitor
o Ibuprofen
 Usually done in premature/VLBW infants
* If pharmacological methods are unsuccessful, surgical ligation or percutaneous catheter device closure may be used

Question 78

what is rheumatic fever ?

Answer 78

Rheumatic fever develops following an immunological reaction to a recent (2-4 weeks ago) Streptococcus pyogenes infection.

Type 2 hypersensitivity reaction….

Question 79

diagnosis for rheumatic fever

Answer 79

Diagnosis is based on evidence of recent streptococcal infection accompanied by:
2 major criteria
1 major with 2 minor criteria

Evidence of recent streptococcal infection
raised or rising streptococci antibodies,
positive throat swab
positive rapid group A streptococcal antigen test

Major criteria
erythema marginatum
Sydenham’s chorea: this is often a late feature
polyarthritis
carditis and valvulitis (eg, pancarditis)
The latest iteration of the Jones criteria (published in 2015) state that rheumatic carditis cannot be based on pericarditis or myocarditis alone and that there must be evidence of endocarditis (the clinical correlate of which is valvulitis which manifests as a regurgitant murmur)
subcutaneous nodules

Minor criteria
raised ESR or CRP
pyrexia
arthralgia (not if arthritis a major criteria)
prolonged PR interval

Question 80

how to manage rheumatic fever?

Answer 80

Prophylaxis
* Benzathine penicillin every 3-4 weeks

Management
1. Naproxen

2. Anti-streptococcal antibiotics if persistent infection = e.g. penicillin V, benzathine benzylpenicillin, amoxicillin)
3. Symptomatic heart failure
   o Treated with diuretics and ACE inhibitors
   o Prednisolone may be required

Question 81

how to manage supraventricular tachycardia ?

Answer 81

1. vagal manouveres
2. adenosine
3. DC cardiovert / amiodarone

if haemo unstable –> DC cardiovert

Question 82

how to manage TofF TET spell/ hypercyanotic spell

Answer 82

o Place the patient in the knee-to-chest position
o Supplementary oxygen
o IV fluids
o Beta blockers (relax the right ventricle and improve flow to the pulmonary vessels)
o Morphine (decrease the respiratory drive)
o Sodium bicarbonate (counteracts any metabolic acidosis)
o Phenylephrine infusion (increase systemic vascular resistance)

Question 83

how to manage TofF?

Answer 83

• If severe with worsening cyanosis:
  o Prostaglandin E1 infusion
  o Blalock-Taussig shunt

surgery performed from 4 months of age onwards

Question 84

give an example of prostaglandin E1?

Answer 84

Prostaglandin E1 infusion (alprostadil)

Question 85

surgery for tricupsuid atresia >

Answer 85

• Blalock-Taussig shunt insertion

Question 86

murmur with VSD?

Answer 86

loud pansystolic murmur heard best at the lower left sternal edge in the third and fourth intercostal spaces; quiet pulmonary second heart sound

Question 87

what murmur with TofF?

Answer 87

ejection systolic murmur due to pulmonary stenosis (the VSD doesn’t usually cause a murmur)

Question 88

what do patients with a VSD need to be careful with ??

Answer 88

Whilst the VSD is present, bacterial endocarditis should be prevented by maintaining good dental hygiene

o Prophylactic amoxicillin to patients at high risk of developing endocarditis e.g. during surgical procedures

Question 89

path of acute otitis media

Answer 89

whilst viral upper respiratory tract infections (URTIs) typically precede otitis media, most infections are secondary to bacteria, particularly Streptococcus pneumonaie, Haemophilus influenzae and Moraxella catarrhalis
viral URTIs are thought to disturb the normal nasopharyngeal microbiome, allowing bacteria to infect the middle ear via the Eustachian tube

Question 90

how to manage acute otitis media ?

Answer 90

don’t really need abx - normally resolves in 3 days

if it doesnt the you can give abx

 Amoxicillin - 5-7 days is first-line
 Penicillin allergy: clarithromycin, erythromycin

Question 91

what procedure for acute otitis media with effusion ?

Answer 91

Myringotomy is the most common surgical option for OME. It involves making
an incision in the tympanic membrane to drain the fluid, followed by insertion of
grommets which stay in place for 6–12 moths to prevent recurrence

Question 92

what organism causes acute epiglottisis?

Answer 92

haemophilus influenza type B

Question 93

rapid onset
high temperature, generally unwell
stridor
drooling of saliva
‘tripod’ position: the patient finds it easier to breathe if they are leaning forward and extending their neck in a seated position

Answer 93

acute epiglottitis

Question 94

how to manage acute epiglottitis ?

Answer 94

• Secure airway, do NOT examine the throat
  o Direct rigid laryngoscopy and intubation is the most common approach
• Take a blood culture

abx = ceftriaxone

Question 95

managment for angioedema ?

Answer 95

• Patients with rapidly developing angio-oedema without anaphylaxis:
  o Chlorphenamine and hydrocortisone
• Patients with symptoms requiring treatment:
  o Cetirizine (or other non-sedating antihistamine such as fexofenadine, or loratadine)
  o Oral corticosteroid (for example prednisolone 40 mg daily for up to 7 days)

Question 96

manage asthma in kids both age groups

Answer 96

< 5 y/o
1. SABA
2. paed mod dose ICS
3. LTRA (montelukast)
4. stop LTRA –> refer to paeds

5-16 y/o
1. SABA
2. paed low does ICS
3. montelukast
4. stop montelukast, start LABA
5. stop ICS , stop LABA. start MART with paed low dose ICS
6. Increase ICS to moderate dose
7. refer to paeds

Question 97

gold standard for diagnosing bronchiectasis

Answer 97

High resolution CT is the gold standard investigation to diagnose bronchiectasis

o Radiological features indicative of bronchiectasis include:
o Bronchial wall thickening
o Diameter of bronchus larger than that of the bronchial artery (‘signet ring’ sign)
o Visible peripheral bronchi

Question 98

CF bronchiectasis common organism is ?

Answer 98

o Pseudomonas spp. Is characteristic of CF bronchiectasis

Question 99

features of RSV bronchiolotiis

Answer 99

• coryzal symptoms (including mild fever) precede:
• dry cough
• increasing breathlessness
• wheezing, fine inspiratory crackles (not always present)
• feeding difficulties associated with increasing dyspnoea are often the reason for hospital admission

Question 100

managemnt of bronchiolitis

Answer 100

1. humidified o2
2. CPAP
3. upper airway suciton
   4.fluids

Question 101

features of cow milk protein allergy

Answer 101

regurgitation and vomiting
diarrhoea
urticaria, atopic eczema
‘colic’ symptoms: irritability, crying
wheeze, chronic cough
rarely angioedema and anaphylaxis may occur

Question 102

how to manage cows milk protein allergy

Answer 102

breastfeeding mum:
exclude cow’s milk from her diet

bottlefed:
* Trial of extensively hydrolysed formula

Question 103

epideiomology of croup

Answer 103

• peak incidence at 6 months - 3 years
• more common in autumn

Question 104

features of croup

Answer 104

• cough
• barking, seal-like
• worse at night
• stridor
• remember, the throat should be not examined due to the risk of precipitating airway obstruction
• fever
• coryzal symptoms
• increased work of breathing e.g. retraction

Question 105

how to manage croup ?

Answer 105

every gets oral dexamethasone

moderate croup can give oxyen

severe croup can also give nebulsied adrenaline (1 in 1000)

Question 106

Cystic firbosis diagnosis ?

Answer 106

Sweat test
patient’s with CF have abnormally high sweat chloride

normal value < 40 mEq/l, CF indicated by > 60 mEq/l

Question 107

common mutation in CF

Answer 107

 F508 delta

Question 108

how do you holistically manage a CF patient ?

Answer 108

o Pulmonary – physiotherapy, mucolytics
o Infection – prophylactic antibiotics, monitoring
o Nutrition – enzyme tablets, high-calorie diet, monitor growth
o Psychosocial – provide support for child and carers

Question 109

gold standard for diagnosis of food allergy ?

Answer 109

Food challenge
o After 6-12 months of being symptoms-free consider a food challenge

 This involves administration of increasing quantities of the food allergen under medical supervision, starting with direct mucosal exposure (allergen contact with the lips), and then titrated oral ingestion as tolerated. If no symptoms are provoked, the test is negative and clinical allergy can be excluded

Question 110

foreign body inhalation pathway ?

Answer 110

1. ecnourage cooughing
2. back blows
3. abdo thrusts

in hosputal
1. flexi bronchoscopy / or rigid bronchoscopy
2. surgery / trachotomy

Question 111

what is laryngomalacia and what are features

Answer 111

Laryngomalacia is the most common congenital laryngeal abnormality characterised by flaccidity of the supraglottic structures. The larynx is soft and floppy as a result and collapses during breathing.

Features
Inspiratory stridor: high-pitched and crowing. This is usually intermittent, occurring in the supine position e.g. when the child lies on its back, when feeding or when agitated
Symptoms increase in severity during the first 8 months but tend to resolve by 18-24 months
Respiratory distress, failure to thrive and cyanosis are rare

Question 112

which pathogen causes scarlet fever and how do you manage it ?

Answer 112

Group A haemolytic streptococci (usually Streptococcus pyogenes

Pencillin V (phenoxymethylpenicllin)

Question 113

how does scarlet fever present ?

Answer 113

• fever: typically lasts 24 to 48 hours
• malaise, headache, nausea/vomiting
• sore throat
• ‘strawberry’ tongue
• rash
  fine punctate erythema (‘pinhead’) which generally appears first on the torso and spares the palms and soles
  children often have a flushed appearance with circumoral pallor. The rash is often more obvious in the flexures
  it is often described as having a rough ‘sandpaper’ texture
  desquamination occurs later in the course of the illness, particularly around the fingers and toes

Question 114

sore throat scoring system in paeds sore throat

Answer 114

FeverPAIN score (4 or 5) or Centor score (3 or 4)

Question 115

management for sore throat (tonsilitis / parhyngitis )

Answer 115

sore throat is tonsilittis / pharingitis

normally from GAS inection

therefore treat with Penicilin V

Question 116

score used to assess severity of urticaria ? hwo do you manage it

Answer 116

• Urticaria Activity Score (UAS7)

cetirizine (anti histamine)

Question 117

how does viral induced wheeze present + how to manage ?

Answer 117

wheeze

salbutamol
 Burst Therapy is often used for viral-induced wheeze

Question 118

features of whooping cough

Answer 118

catarrhal phase
* symptoms are similar to a viral upper respiratory tract infection
* lasts around 1-2 weeks
paroxysmal phase
* the cough increases in severity
* coughing bouts are usually worse at night and after feeding, may be ended by vomiting & associated central cyanosis
* inspiratory whoop: not always present (caused by forced inspiration against a closed glottis)
* infants may have spells of apnoea
* persistent coughing may cause subconjunctival haemorrhages or even anoxia leading to syncope & seizures
* lasts between 2-8 weeks
* convalescent phase
* the cough subsides over weeks to months

Question 119

how to manage whooping cough ? which pathogen + give type ?

Answer 119

bordetella pertussis (gram neg coccobacillli)

• Pharmacological Treatment - if admission is not needed, prescribe an antibiotic if the onset of the cough is within 21 days.
  o < 1 month old = clarithromycin
  o >1 months old and not pregnant = azithromycin
  o If macrolides contraindicated, give co-trimoxazole
   Do not use in infants <6 weeks of age

Question 120

appendicitis in kids - things to think about

Answer 120

Appendicitis is one of the most common acute surgical problems facing children. Diagnosis is often made difficult by a presentation which is far from the classically history of:
central abdominal pain which later radiates to the right iliac fossa
low-grade pyrexia
minimal vomiting

Children who are younger or have a retrocaecal/pelvic appendix are more likely to present in an atypical way

Appendicitis is uncommon in children under 4 years old but in this group often presents with perforation

Question 121

how does coeliac present in kids ?

Answer 121

Features may coincide with the introduction of cereals (i.e. gluten)
failure to thrive
diarrhoea
abdominal distension
older children may present with anaemia
many cases are not diagnosed to adulthood

Question 122

what are the differrent types of laxatives ?

Answer 122

o Bulk-forming: fybogel, methylcellulose
o Osmotic: lactulose, Movicol
o Stimulant: Bisacodyl, senna, sodium picosulphate
o Stool-softener: arachis oil, docusate sodium

Question 123

important questions to ask in constipation hx to rule out sinister cause…

Answer 123

Red Flag for Constipation
- Ribbon stool
- >24 hrs meconium at birth
- Distension
- any blood

Amber Flag for Constipation
- Faltering growth

Ribbon stool pattern — may indicate anal stenosis (more likely to present in a child younger than 1 year of age)

Question 124

when shoudl neonates pass meconium

Answer 124

Meconium should be passed ideally within the first 24 hours and less frequently within the first 48 hours

Question 125

how to manage simple constipation in kids

Answer 125

if impaction:
1. movicol (osmotic lax), can increase dose over 2 weeks, also diet advice. (movicol are satchet packets)
2. if unresponsive can give senna (stimulative laxative)
3. if stools are hard can also use lactulose/docusate

if no impaction:
1. movicol
2. if movicol not tolerated can give senna (stimulative laxative)
3. if stools are hard can also use lactulose/docusate

Question 126

crohns in kids management

Answer 126

The shift in guidance to start anti-TNF agents such as infliximab as a first-line treatment (‘top-down therapy’) as opposed to the previous ‘step-up’ model was informed by studies such as the TISKIDS and REACH trials where this approach was associated with much better outcomes for children

Question 127

failure to thrive differentials

Answer 127

1. Inadequate nutritional intake. e,g, neglect, poverty, iron def anaemia, maternal malnurtiion if breastfeeding
2. Difficulty feeding - poor breastfeeding/suck, cleft lip, cleft palate, pyloric stenosis,
3. Malabsorption - crohns, coeliac, CF, perniciois anaemia
4. Increased energy requirements - CF, hyperthyroid, malignancy. HIV
5. Inability to process nutrition - type 1 diabetes, inborn errors of metabolism

Question 128

how to manage GORD ?

Answer 128

• Breastfeeding: offer assessment → alginate therapy
• Formula: review feeding history → smaller, more frequent feeds → thickeners → alginate therapy

Question 129

what is hirschprung disease ?

Answer 129

Hirschsprung’s disease is caused by an aganglionic segment of bowel due to a developmental failure of the parasympathetic Auerbach and Meissner plexuses.

parasympathetic neuroblasts fail to migrate from the neural crest to the distal colon → developmental failure of the parasympathetic Auerbach and Meissner plexuses → uncoordinated peristalsis → functional obstruction

Question 130

how does hirschprung’s disease present ?

Answer 130

Possible presentations
neonatal period e.g. failure or delay to pass meconium
older children: constipation, abdominal distensionh

Question 131

gold standard diagnosis for hirschsprungs disease ?

Answer 131

rectal biopsy

Question 132

how to manage hirschsprungs disease ?

Answer 132

bowel irrigation

surgery = anorectal pull through

Question 133

how does intussuseption present ?

Answer 133

• intermittent, severe, crampy, progressive abdominal pain
• inconsolable crying
• during paroxysm the infant will characteristically draw their knees up and turn pale
• vomiting
• bloodstained stool - ‘red-currant jelly’ - is a late sign
• sausage-shaped mass in the right upper quadrant

Question 134

Ix for intussuseptin and give findings

Answer 134

abdo ultrasound

target like mass

Question 135

how to manage intussuseption

Answer 135

1. A-E
2. NG aspitation
3. IV fluids
4.  Clindamycin + gentamicin
5. rectal air insufflation

surgery = if peritonitis / big problem

Question 136

anatomy reason for intussuseption??

Answer 136

• If recurrent intussusception - consider investigating for a pathological lead point (e.g. Meckel’s diverticulum)

Question 137

most common cause of painless massive GI bleeding in kids age 1-2?

Answer 137

meckel’s diverticulum

Presentation (usually asymptomatic)
* abdominal pain mimicking appendicitis
* rectal bleeding
* Meckel’s diverticulum is the most common cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years
* intestinal obstruction
* secondary to an omphalomesenteric band (most commonly), volvulus and intussusception

Question 138

ix for meckels diverticulum ?

Answer 138

Investigation
* if the child is haemodynamically stable with less severe or intermittent bleeding then a ‘Meckel’s scan’ should be considered
* uses 99m technetium pertechnetate, which has an affinity for gastric mucosa
* mesenteric arteriography may also be used in more severe cases e.g. transfusion is required

Question 139

surgery for intestinal malrotation / volvulus

Answer 139

Ladd procedure - detorting the bowel and surgically dividing the Ladd bands

Question 140

how does volvulus / malrotation present ?

Answer 140

constipation
abdominal bloating
abdominal pain
nausea/vomiting

Question 141

what is mesenteric adenitis and how is it managed ?

Answer 141

Mesenteric adenitis is inflamed lymph nodes within the mesentery. It can cause similar symptoms to appendicitis and can be difficult to distinguish between the two.

It often follows a recent viral infection and needs no treatment

pain can take 2-4 weeks to resolve

Question 142

how does peptic ulcer present ?

Answer 142

epigastric pain
nausea

duodenal ulcers
more common than gastric ulcers
epigastric pain when hungry, relieved by eating

gastric ulcers
epigastric pain worsened by eating

Question 143

how does pyloric stenosis present ?

Answer 143

Pyloric stenosis typically presents in the second to fourth weeks of life with vomiting, although rarely may present later at up to four months. It is caused by hypertrophy of the circular muscles of the pylorus.

NON BILOUS VOMITING

• ‘projectile’ vomiting, typically 30 minutes after a feed
• constipation and dehydration may also be present
• a palpable mass may be present in the upper abdomen
• hypochloraemic, hypokalaemic alkalosis due to persistent vomiting

Question 144

target sign on ultrasound ?

Answer 144

pyloric stenosis or intussusecption

Question 145

definitive management of pyloric stenosis ?

Answer 145

• Definitive treatment is by performing a Ramstedt pyloromyotomy

Question 146

how to manage paeds UC?

Answer 146

• Proctitis
  o 1st line - Topical aminosalicylate for 4 weeks,
• Mild UC:
  o 5-ASA
• Moderate UC:
  o Oral prednisolone for 2-4wks and taper
• Severe UC:
  o Medical emergency
  o High dose IV Methylprednisolone

o Surgical Treatment

Question 147

how to manage primary sclerosing cholangitis

Answer 147

ursodeoxycholic acid

Question 148

how does biliary atresia present ?

Answer 148

Patients typically present in the first few weeks of life with:
- Jaundice extending beyond the physiological two weeks
- Dark urine and pale stools
- Appetite and growth disturbance, however, may be normal in some cases

Signs:
Jaundice
Hepatomegaly with splenomegaly
Abnormal growth
Cardiac murmurs if associated cardiac abnormalities present

The perinatal form presents in the first two weeks of life, and the postnatal form presents within the first 2-8 weeks of life
Biliary atresia occurs in 1 in every 10,000-15,000 live births

Question 149

ix for biliary atresia

Answer 149

Ultrasound of the biliary tree and liver: May show distension and tract abnormalities

Percutaneous liver biopsy with intraoperative cholangioscopy

Question 150

important to avoid which painkiller in hep A

Answer 150

paracetamol

Question 151

scoring system for wilson’s disease severityu

Answer 151

• Nazar score or Kings Wilson score used to assess severity

Question 152

how does wilson’s present ? + outline it + ix + manage

Answer 152

Wilson’s disease is an autosomal recessive disorder characterised by excessive copper deposition in the tissues. Metabolic abnormalities include increased copper absorption from the small intestine and decreased hepatic copper excretion. Wilson’s disease is caused by a defect in the ATP7B gene located on chromosome 13.

The onset of symptoms is usually between 10 - 25 years. Children usually present with liver disease whereas the first sign of disease in young adults is often neurological disease

Features result from excessive copper deposition in the tissues, especially the brain, liver and cornea:
- liver: hepatitis, cirrhosis
neurological:
- basal ganglia degeneration: in the brain, most copper is deposited in the basal ganglia, particularly in the putamen and globus pallidus
speech, behavioural and psychiatric problems are often the first manifestations
- also: asterixis, chorea, dementia, parkinsonism
- Kayser-Fleischer rings
green-brown rings in the periphery of the iris due to copper accumulation in
Descemet membrane present in around 50% of patients with isolated hepatic Wilson’s disease and 90% who have neurological involvement
renal tubular acidosis (esp. Fanconi syndrome)
haemolysis
blue nails

Investigations
slit lamp examination for Kayser-Fleischer rings
reduced serum caeruloplasmin
reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin)
free (non-ceruloplasmin-bound) serum copper is increased
increased 24hr urinary copper excretion
the diagnosis is confirmed by genetic analysis of the ATP7B gene

mx = penicillamine (chelates copper) has been the traditional first-line treatment

Question 152

contraindications to lumbar puncture in meningitis

Answer 152

Contraindication to lumbar puncture (any signs of raised ICP)

focal neurological signs
papilloedema
significant bulging of the fontanelle
disseminated intravascular coagulation
signs of cerebral herniation

Question 153

how to manage bacterial meningitis in kids ?

Answer 153

< 3 months = amoxicillin/ampicillin + cefotaxime

> 3 months = ceftriaxone

dexamethsone (don’t give if < 3months)

• Presenting in primary care: single dose of IM/IV benzylpenicillin

all children should be followed up 4/6 weeks for hearing assessment

Question 153

meningitis presentation in babies and toddlers

Answer 153

1. fever
2. drowsy, floppy, unresponsive
3. refusing food
4. vomiting
5. tense bulging fontanelle
6. unusual cry
7. rapid breathing
8. seizures

Question 154

how does chicken pox present ?

Answer 154

1. fever initially
2. itchy, rash starting on head/trunk before spreading.
3. Initially macular then papular then vesicular
   systemic upset is usually mild

Question 155

counsel for chicken pox

Answer 155

mainly supportive treatment
- fluids, smooth cotton frabirc, nails short
- paracetamol, topical calamine lotion for itch
- infective until lesions have crusted over so until this point no school, no pregnant ladies, no immunocompromised
- admit to hospital if serious complications

Question 156

how does dengue present ?

Answer 156

Dengue fever
fever
headache (often retro-orbital)
myalgia, bone pain and arthralgia (‘break-bone fever’)
pleuritic pain
facial flushing (dengue)
maculopapular rash
haemorrhagic manifestations e.g. positive tourniquet test, petechiae, purpura/ecchymosis, epistaxis
‘warning signs’ include:
abdominal pain
hepatomegaly
persistent vomiting
clinical fluid accumulation (ascites, pleural effusion)

Severe dengue (dengue haemorrhagic fever)
this is a form of disseminated intravascular coagulation (DIC) resulting in:
thrombocytopenia
spontaneous bleeding
around 20-30% of these patients go on to develop dengue shock syndrome (DSS)

Question 157

how does EBV/ infective mononucleosis present ?

Answer 157

The classic triad of sore throat, pyrexia and lymphadenopathy

Question 158

management and counsel for EBV / infective mononucleosis

Answer 158

• Explain the expected course of the illness
  o Symptoms usually last for 2–4 weeks.
  o Tiredness is common
  o Exclusion from work or school is not necessary but tailor activities to what they find comfortable
  o Limit spread by avoiding kissing and sharing of eating utensils
  o Avoid heavy lifting and contact or collision sports for the first month of the illness - due to risk of splenic rupture

supportive management (rest, paracemolm . iburpofen)

Question 159

features and management of roseola infantum

Answer 159

Features
* high fever: lasting a few days, followed later by a
* maculopapular rash
* Nagayama spots: papular enanthem on the uvula and soft palate
* febrile convulsions occur in around 10-15%
* diarrhoea and cough are also commonly seen

supportive mx (paraceotmol & ibrufpofen)
risk of febrile seizures

Question 160

how does erythema infectiosum present ?

Answer 160

The illness may consist of a mild feverish illness which is hardly noticeable.
- noticeable rash which appears after a few days.
- The rose-red rash makes the cheeks appear bright red, hence the name ‘slapped cheek syndrome’.
- The rash may spread to the rest of the body but unlike many other rashes, it only rarely involves the palms and soles.

The child begins to feel better as the rash appears and the rash usually peaks after a week and then fades.

Most children recover and need no specific treatment. School exclusion is unnecessary as the child is not infectious once the rash emerges. In adults, the virus may cause acute arthritis.

Question 161

outline impetigo - features and what its caused by ? + give mx

Answer 161

caused by either Staphylcoccus aureus or Streptococcus pyogenes.

It can be a primary infection or a complication of an existing skin condition such as eczema (in this case), scabies or insect bites.

Features
‘golden’, crusted skin lesions typically found around the mouth
very contagious

tx = topical fusidic acid

Question 162

slapped cheek caused by which pathogen ?

Answer 162

human parvovirus b19

Question 163

features of kawasaki disease and mx

Answer 163

Features
* high-grade fever which lasts for > 5 days. Fever is characteristically resistant to antipyretics
* conjunctival injection
* bright red, cracked lips
* strawberry tongue
* cervical lymphadenopathy
* red palms of the hands and the soles of the feet which later peel

mx = high dose aspirin / IVIG

Question 164

school exclusion for measles ?

Answer 164

• Stay away from school for at least 4 days after the development of the rash

Question 165

features of measles and how it presents + mx

Answer 165

prodromal phase
irritable
conjunctivitis
fever

Koplik spots
typically develop before the rash
white spots (‘grain of salt’) on the buccal mucosa

rash
starts behind ears then to the whole body
discrete maculopapular rash becoming blotchy & confluent
desquamation that typically spares the palms and soles may occur after a week

diarrhoea occurs in around 10% of patients

mx = supportive , stay away from sschool at least 4 days after developement of rash

Question 166

school exclusion with mumps

Answer 166

• Stay away from school for 5 days after the development of parotitis

Question 167

how does mumps present ?

Answer 167

Clinical features
fever
malaise, muscular pain
parotitis (‘earache’, ‘pain on eating’): unilateral initially then becomes bilateral in 70%

Question 168

how does rubella present ?

Answer 168

Features
prodrome, e.g. low-grade fever
rash: maculopapular, initially on the face before spreading to the whole body, usually fades by the 3-5 day
lymphadenopathy: suboccipital and postauricular

Question 169

mx for tyhphoid

Answer 169

• Supportive care: IV fluids and antipyretics
• Suspected: Ceftriaxone and azithromycin
• Known:
  o Ciprofloxacin 7d treatment
  o If no response after 4/5d of treatment add azithromycin
  o If encephalopathic, add high-dose dexamethasone

Question 170

rubella school exclusion

Answer 170

• Stay away from school for at least 5 days after initial development of rash

Question 171

what is eczema herpaticum ?

Answer 171

Eczema herpeticum describes a severe primary infection of the skin by herpes simplex virus 1 or 2.

It is more commonly seen in children with atopic eczema and often presents as a rapidly progressing painful rash.

admit and tx = acyclovir

Question 172

general overview of eczema management

Answer 172

1. emolient
2. topical corticosteroids - hydrocortisone
3. Topical Calcineurin Inhibitors

wet wraps / bandages
non-sedating anti-histamine (cetirizine)
tacrolimus

infected eczema = flucoxacillin

Question 172

what is guttate psoriasis

Answer 172

Guttate psoriasis is more common in children and adolescents. It may be precipitated by a streptococcal infection 2-4 weeks prior to the lesions appearing.

Features
tear drop papules on the trunk and limbs
gutta is Latin for drop
pink, scaly patches or plques of psoriasis
tends to be acute onset over days

mx = phototherapy

Question 173

collection of small blood vessels forming a lump under the skin / strawberry mark

what is it ? and how do you treat

Answer 173

Haemangioma

Most haemangiomas will have disappeared completely by the age of five to seven years.

• If there is functional impairment (near eyes, nose, mouth) or cosmetic disfigurement:
  o Beta-blocker: PO (propranolol) or topical (timolol)
  o Corticosteroid: PO or topical
  o Until theoretical involution or 12m
  o If cosmetically-sensitive or high-risk/ulceration, can additionally consider:
   Pulsed laser dye
   Surgical excision

Question 173

how does hand foot and mouth disease present ? and mx

Answer 173

Clinical features
* mild systemic upset: sore throat, fever
* oral ulcers
* followed later by vesicles on the palms and soles of the feet

Hand, foot and mouth disease is a self-limiting condition affecting children. It is caused by the intestinal viruses of the Picornaviridae family (most commonly coxsackie A16 and enterovirus 71). It is very contagious and typically occurs in outbreaks at nursery

self limiting / symptomatic tx

Question 174

features of infantile seborrhoeic dermatitis

Answer 174

• ‘Cradle-cap’
• Erythematous scaly eruption in first 2 months of life
• Progresses to thick yellow adherent layer
• Starts on scalp, spreads to the face, flexures and napkin area
• Not itchy
• Management –
  o Infants: baby shampoo/oil, barrier emollients, topical antifungal creams (clotrimazole, miconazole)
  o Children/adolescents: ketoconazole shampoo/creams, selenium sulphide shampoo, coal tar, salicylic acid ointment

Question 175

features of atopic eczema

Answer 175

• Itchy rash typically in face, trunk and flexor surfaces (age-dependent)
• Common in first year of life
• Associated with asthma and hay fever
• Scratching causes excoriation, crusting, infection and eventually lichenification
• Management – avoid precipitants, emollients, topical corticosteroids, occlusive bandages, antihistamine, antibiotics, immunomodulators

Question 175

how to manage nappy rash

Answer 175

o Disposable nappies are better than towel nappies
o Expose nappy area to air where possible
o Apply barrier cream (e.g. Sudocrem)
o Mild steroid cream (e.g. 1% hydrocortisone) in severe cases
o Manage suspected candida nappy rash with topical imidazole (cease the use of barrier cream until candida has settled)

Question 176

features of candida infection paeds

Answer 176

• Both causes and complicates napkin rashes
• Spares flexures
• Satellite pustules
• Management – ensure good hygiene, topical antifungals

Question 177

features of molluscum contagiosum

Answer 177

• Caused by a poxvirus
• Pearly papules with central umbilication through which the infectious central core is shed
• Usually disappear spontaneously
• Management (if needed) – cryotherapy, topical antibacterials to prevent/treat secondary bacterial infection

Question 178

features of scabies

Answer 178

• Caused by Sarcoptes scabiei
• Severe itching worse at night and in warmth
• Ask about family’s living situation
• Between fingers and toes, axillae, palms, soles and trunk in younger children
  Treatment – treat child and whole family, 5% permethrin cream or 0.5% malathion lotion to whole body below neck, washed off after 12 hours

Question 178

features of ring worm

Answer 178

• Annular lesions with a crusted edge caused by dermatophyte fungi
• Kerion – severe inflammatory pustular ringworm
• Treatment – topical antifungals, systemic antifungal for severe infection, treat source (often animals)

Question 179

features of erythema multiforme

Answer 179

• Target lesions, can also be vesicular or bullous
• Caused by herpes simplex, Mycoplasma pneumonia and other infections and drugs
• Usually resolves spontaneously within a few weeks

Question 179

features of psoriasis

Answer 179

• Most commonly guttate psoriasis following strep/viral URTI
• Small erythematous patches with silvery scale on trunk and upper limbs
• Rare before 2 years, rarely chronic
• Management – emollients, coal tar, dithranol (for resistant cases), calcipotriol (over 6 years of age)
• Can be associated with arthritis

Question 180

features of acne vulgaris

Answer 180

• Can occur 1 – 2 years before onset of puberty
• Due to obstruction of sebum flow in sebaceous follicle
• Open/closed comedones, papules, pustules, nodules, cysts on face, neck, back, shoulders
• Can produce scarring
• Treatment – topical – benzoyl peroxide, antibiotics, retinoids. Systemic – oral antibiotics (tetracyclines only licensed if over 12 years old), isotretinoin

Question 181

features of erythema nodosum

Answer 181

• Tender discrete red nodules on the shins
• Caused by Strep, primary TB, IBD, drugs
• Treatment – treat underlying cause, compression, anti-inflammatories

Question 182

features of meningococcal septicaemia rash

Answer 182

• Caused by Neisseria meningitides septicaemia
• Characteristic non-blanching purpuric lesions irregular in size and outline with a necrotic centre
• Called ‘purpura fulminans’ if widespread
• Often non-specific initial presentation – fever, vomiting, poor feeding, irritability, lethargy, seizures, reduced consciousness, shock; later bulging fontanelle, neck stiffness and opisthotonus
• Typically headache, neck stiffness and photophobia
• Diagnosis – LP (turbid fluid, polmorphs, high protein, low glucose)
• Management – rapid initiation of antibiotics – 3rd generation cephalosporin e.g. ceftriaxone)

Question 182

features of Erythema infectiosum / fifth disease / slapped cheek syndrome

Answer 182

• Common infection caused by parvovirus B19
• Often asymptomatic
• Rash – initially ‘slapped cheek’, progresses to maculopapular lace-like rash on trunk and limbs
• Rash associated with fever, malaise, headache and myalgia
• Infects erythroblastoid red cell precursors in BM, so causes aplastic crisis in sickle cell (↑ RBC turnover), also in immunocompromised
• Maternal transmission can cause hydrops and foetal death due to severe anaemia
• Paracetamol or ibuprofen and encourage adequate fluid intake
• Secondary arthritis may be treated with ibuprofen

Question 183

head lice mx

Answer 183

1. wet combing
2. dimeticone lotion (insecticide)
   3.

Question 184

tx periorbital cellultiis

Answer 184

cefotaxime or clindamycin)

Question 185

ringworm mx

Answer 185

Tinea Corporis (body), Tinea Cruris (jock)

o Mild infections - terbinafine cream, clotrimazole
o If marked inflammation- hydrocortisone 1% cream
o severe infections:
 1st line: oral terbinafine
 2nd line: oral itraconazole
o Topical aluminium acetate (in some)

• Tinea Capitis (head)
  o Systemic antifungal therapy (e.g. griseofulvin or terbinafine)
  o 2nd line: itraconazole or fluconazole
  o Adding topical antifungal shampoo is recommended in some patients (e.g. selenium sulfide or ketoconazole topical)
• NOTE: any animal source of the infection will also need treatment
• Advice
  o Wear loose-fitting cotton clothing
  o Wash affected areas of skin daily
  o Dry thoroughly after washing
  o Avoid scratching
  o Do not share towels
  o Wash clothes and bed linen frequently
  o No need for school exclusion

Question 186

scabies mx

Answer 186

permethrin 5% cream

apply to whole body

Question 187

normal age for children being dry ?

Answer 187

• Most children are dry by day and night by the age of 5 years
  o Children are dry by day only by the age of 4 years

Question 188

mx for enuresis

Answer 188

o BED
 Behavioral - Advise onreduced fluid intake before bed, diet and toileting behaviour & Reward systems (e.g. star charts)
 Enuresis alarm
 Desmopressin: may be used 1st line if > 7 years or if short-term control is needed (e.g. holiday)

Question 189

outline henoch schonlein purpura

Answer 189

IgA vascultitis

HSP is an immune-mediated small vessel vasculitis. IgA and complement components (C3) are deposited in vessel walls leading to inflammation.

The mechanism underlying this is not entirely clear, but HSP can follow an upper respiratory tract infection, so it is thought to be triggered by an abnormal immune system response.

Features
palpable purpuric rash (with localized oedema) over buttocks and extensor surfaces of arms and legs
abdominal pain
polyarthritis
features of IgA nephropathy may occur e.g. haematuria, renal failure

Question 190

how does UTI present in children ?

Answer 190

Presentation in childhood depends on age:
* infants: poor feeding, vomiting, irritability
* younger children: abdominal pain, fever, dysuria
* older children: dysuria, frequency, haematuria
* features which may suggest an upper UTI include: temperature > 38ºC, loin pain/tenderness

Question 191

how to collect urine in child ?

Answer 191

Urine collection method

clean catch is preferable
if not possible then urine collection pads should be used
cotton wool balls, gauze and sanitary towels are not suitable
invasive methods such as suprapubic aspiration should only be used if non-invasive methods are not possible

Question 192

causes of epididimoorchitis

Answer 192

o Sexually transmitted infection
* Age <35 yrs
* 1+ sexual partner in last 12 months
* Urethral discharge

o Gonorrhoeal
* Previous gonorrhoeal infection
* Purulent urethral discharge
* Men who have sex with men
* Black ethnicity

o Enteric organisms associated with UTIs
* Age >35 yrs
* Low risk sexual history
* History of penetrative anal sex
* Recent catheterisation
o Consider testing for HIV, hepatitis, syphilis, trichomoniasis and mumps

Question 193

how to manage a hydrocele ?

Answer 193

• < 2 years (congenital hydrocoele) = most resolve spontaneously before the age of 2 so observation is appropriate unless there is bowel palpable in the groin and provided there is no evidence of underlying pathology
• 2-11 years - hydrocele persists beyond 2 years
  o Open repair
  o Laparoscopic exploration
  o Bilateral repair
  o Abdominoscrotal hydrocoeles - require surgery through an abdominal incision
• 11-18 years - commonly non-communicating hydrocoele
  o Idiopathic hydrocoele - observation is appropriate, however, surgery may be considered if it is large or uncomfortable
  o Hydrocoele after varicocelectomy - conservative management is the initial approach, surgery is considered in cases that do not resolve
  o Filarial-related hydrocoele (parasitic infection) - complete excision of the tunica vaginalis

Question 194

young boy with ball pain - what should you think about … outline the features + how to manage

Answer 194

pain is usually severe and of sudden onset
the pain may be referred to the lower abdomen
nausea and vomiting may be present
on examination, there is usually a swollen, tender testis retracted upwards. The skin may be reddened
cremasteric reflex is lost
elevation of the testis does not ease the pain (Prehn’s sign)

management:

• Presenting within 4-6 hours of symptom-onset has a greater likelihood of testicular viability

Management
* If suspected admit immediately to urology or paediatric surgery
o IV fluids, NBM, antiemetics, analgesia

Question 195

mx Wilm’s Tumour (Nephroblastoma)
*

Answer 195

Surgery (nephrectomy) and chemotherapy (may be post-operative or pre-operative)

Question 196

mx beta thalassaemia major

Answer 196

regular blood transfusions

Question 197

non-accidental injury – red flags:

Answer 197

o Bruises are on a child who is not yet independently mobile (crawling, cruising, or walking).

o Bruises have indicative features - unusually large, multiple sites or in clusters, similar shape and size, patterned in the shape of a hand print, ligature, stick, tooth, grip, or implement (such as a belt).

o Bruises are found in indicative places - any non-bony part of the body or face (including the eyes, ears, cheeks, back, abdomen, buttocks, arms, and genitalia).

o Explanation for the bruising is implausible, inadequate, or inconsistent

o Delay in presentation.

o If suspicions of NAI, screen for other injuries and perform skeletal survey to investigate. Inform safeguarding team.

Question 198

prophylaxis in sickle cell for kids

Answer 198

• Immunisation against encapsulated organisms (e.g. S. pneumoniae and H. influenzae type B)
• Daily oral penicillin
• Daily oral folic acid
• Vaso-occlusive crises should be minimised by avoiding exposure to cold, dehydration, excessive exercise, undue stress or hypoxia

Question 198

different type of bleeding for platelet disrder vs coagulation disorder

Answer 198

platelet=
Site Skin, mucus membranes (epistaxis, gum, vaginal, GI)

coagulation =
Soft tissues, joints, muscles

Question 199

Role of von Willebrand factor and therefore consequences of VWD

Answer 199

1. large glycoprotein which forms massive multimers up to 1,000,000 Da in size
2. promotes platelet adhesion to damaged endothelium
3. carrier molecule for factor VIII

Types
type 1: partial reduction in vWF (80% of patients)
type 2*: abnormal form of vWF
type 3**: total lack of vWF (autosomal recessive)

Investigation
prolonged bleeding time
APTT may be prolonged (it stablises factor 8)
factor VIII levels may be moderately reduced
defective platelet aggregation with ristocetin

Question 200

acute and chronic management of acute sickle cell crisis

Answer 200

Management of Acute Crises
* Oral and IV analgesia (avoid morphine < 12 years)
* Good hydration (oral or IV)
* Infection should be treated with antibiotics
* Oxygen (if reduced saturation)
* Exchange transfusion is indicated for acute chest syndrome, priapism and stroke

Management of Chronic Problems
* Children who have recurrent hospital admission (>3 in 12 months) for acute chest syndrome or vaso-occlusive crises could benefit from hydroxycarbamide (stimulated HbF production)
o Monitor for white blood cell suppression (side-effect of hydroxycarbamide)
* Splenectomy with immunisation against encapsulated organisms
* Bone marrow transplant may be considered in severe cases

Question 200

types of von willebrand disease

Answer 200

Types
type 1: partial reduction in vWF (80% of patients)
type 2*: abnormal form of vWF
type 3**: total lack of vWF (autosomal recessive)

Question 201

ballooning under the foreskin during urination

Answer 201

paraphimosis

Question 202

mx for retinoblastoma

Answer 202

• Average age of diagnosis: 18 months
• In propriety, goals of treatment: Save life, save eye, save vision
• Frequent eye examinations under anaesthesia to assess the response to treatment

Management
* Gross vitreous seeding present (tumor cells floating within the vitreous cavity)
o 1st LINE: Enucleation (surgical removal of the eye without resection of the lids or extraocular muscles
o Infiltration of the iris, ciliary body or sclera: Adjuvant chemotherapy: carboplatin, etoposide, and vincristine
* Minimal or no vitreous seeding present
o 1st LINE: systemic chemotherapy (carboplatin, vincristine, etoposide)
o PLUS: focal therapy (cryotherapy or laser therapy)
* Family history of retinoblastoma/detected at birth
o Usually treated by laser alone
o Followed up with an examination under anaesthesia every month for at least 1 year
* Vitreous seeding after chemotherapy and/or focal therapy
o 1st LINE: external beam radiotherapy

• Most patients are cured (90%)
• However, many will be visually impaired
• Significant risk of second malignancy (especially sarcoma) among survivors of hereditary retinoblastoma

Question 203

bruising in kids what should you think striaght away ?

Answer 203

NAI

Question 204

blood results in DIC

Answer 204

• ↓ platelets, ↓ fibrinogen, ↑ PT & APTT, ↑ fibrinogen degradation products

Question 205

signs of acute haemolysis in g6pd

Answer 205

• Parents should be advised on the signs of acute haemolysis (jaundice, pallor, dark urine)

Question 205

ITP Mx

Answer 205

• In 80% of children, the disease is acute, benign and self-limiting
• It will resolve spontaneously within 6-8 weeks
• Most children can be managed at home
• Treatment is indicated if there is evidence of major bleeding (e.g. intracranial or gastrointestinal) or persistent minor bleeding that affects daily life (e.g. excessive epistaxis)
  Management
• Life- or Organ-threatening bleeding
  o IVIG + corticosteroid + platelet transfusion
  o Antifibrinolytics (Aminocaproic and tranexamic acid) may be used
• Newly Diagnosed Child
  o Asymptomatic or Minor Bleeding
   Observation (most will achieve a normal platelet count eventually)
   Most manifestations are limited to the skin
  o Major Bleeding
   Corticosteroids
   IVIG OR anti-D immunoglobulin
• Child with Chronic Disease
  o Mycophenolate mofetil
  o Rituximab
  o Eltrombopag (thrombopoietin receptor agonist)
  o 2nd line: splenectomy (if persistent)

Question 206

mx for haemophilia A and B

Answer 206

• Recombinant factor VIII concentrate for haemophilia A
  o 10-15% of patients will develop antibodies to factor VIII treatment
• Recombinant factor IX concentrate for haemophilia B

Management
* Acute bleeds are treated with factor concentrates and anti-fibrinolytics (e.g. aminocaproic acid, tranexamic acid)
* NOTE: these should be given by prompt IV infusion whenever there is any bleeding
* Analgesia and physiotherapy may be required for deep bleeds into muscles and joints
* Orthopaedic and pain team review may also be necessary
* In patients with haemophilia, the following should be AVOIDED:
o IM injections
o Aspirin
o NSAIDs

Question 207

outline sickle cell management acute and chronic

Answer 207

Prophylaxis
* Immunisation against encapsulated organisms (e.g. S. pneumoniae and H. influenzae type B)
* Daily oral penicillin
* Daily oral folic acid
* Vaso-occlusive crises should be minimised by avoiding exposure to cold, dehydration, excessive exercise, undue stress or hypoxia

Management of Acute Crises
* Oral and IV analgesia (avoid morphine < 12 years)
* Good hydration (oral or IV)
* Infection should be treated with antibiotics
* Oxygen (if reduced saturation)
* Exchange transfusion is indicated for acute chest syndrome, priapism and stroke

Management of Chronic Problems
* Children who have recurrent hospital admission (>3 in 12 months) for acute chest syndrome or vaso-occlusive crises could benefit from hydroxycarbamide (stimulated HbF production)
o Monitor for white blood cell suppression (side-effect of hydroxycarbamide)
* Splenectomy with immunisation against encapsulated organisms
* Bone marrow transplant may be considered in severe cases

Prognosis
* Can cause premature death due to complications
* 50% of patients with the most severe form of sickle cell disease will die < 40 years

Question 207

DDH risk factors

Answer 207

Risk factors
* female sex: 6 times greater risk
* breech presentation
* positive family history
* firstborn children
* oligohydramnios
* birth weight > 5 kg
* congenital calcaneovalgus foot deformity

Question 208

clinical exam findings in DDH + ix

Answer 208

Clinical examination
* Barlow test: attempts to dislocate an articulated femoral head
* Ortolani test: attempts to relocate a dislocated femoral head
* other important factors include:
* symmetry of leg length
* level of knees when hips and knees are bilaterally flexed
* restricted abduction of the hip in flexion

Imaging
ultrasound is generally used to confirm the diagnosis if clinically suspected
however, if the infant is > 4.5 months then x-ray is the first line investigation

Question 209

how is DDH screened ?

Answer 209

Screening for DDH
the following infants require a routine ultrasound examination
* first-degree family history of hip problems in early life
* breech presentation at or after 36 weeks gestation, irrespective of presentation at birth or mode of delivery (they need an ultrasound of the pelvis at 6 weeks)
* multiple pregnancy
* all infants are screened at both the newborn check and also the six-week baby check using the Barlow and Ortolani tests

Question 210

mx for DDH

Answer 210

• Summary
  o Most unstable hips will resolve spontaneously by 3-6 weeks
  o Pavlik harness in children younger than 4-5 months
  o Older children may require surgery
  o Female sex at greater risk

Question 211

how does juvenile idiopathic arthritis present ?

Answer 211

Features of systemic onset JIA include
* pyrexia
* salmon-pink rash
* lymphadenopathy
* arthritis
* uveitis
* anorexia and weight loss

REMEMBER YOU CAN GET A FEVER!!

Investigations
ANA may be positive, especially in oligoarticular JIA
rheumatoid factor is usually negative

Juvenile idiopathic arthritis (JIA) refers to persistent joint swelling lasting longer
than 6 weeks in patients under the age of 16 years.

Question 212

mx forf juvenile idiopathic arthritis ?

Answer 212

Management
* Pharmacological management:
o Simple analgesia e.g. Paracetamol
o NSAIDs are useful for controlling pain and stiffness
o Consider weak opioids e.g. codeine
* Intra-articular, oral or IV corticosteroids are useful adjunctive agents (whilst waiting for second-line agents to have an effect) – avoided if possible due to risk of growth suppression and osteoporosis
* DMARDs - used when the disease fails to respond to conventional treatments
o 1st line: oral or SC methotrexate
o 2nd line: sulfasalazine
* Other treatments: Inflammatory cytokine blockade e.g. TNF-alpha inhibitors, interleukin receptor antagonists, anti-emetics

Question 213

outline osgood schlatter disease

Answer 213

Osgood-Schlatter disease (tibial apophysitis) is a type of osteochondrosis characterised by inflammation at the tibial tuberosity. It is a traction apophysitis thought to be caused by repeated avulsion of the apophysis into which the patellar tendon is inserted

Management is supportive

• Seen in sporty teenagers (‘osGOOD at sports)
  Management
• Advise about pain relief
  o Analgesia - paracetamol or NSAIDs
  o Intermittent application of ice packs over the tibial tuberosity (10-15 mins up to 3 times per day, including after exercise)
  o Protective knee pads (may relieve pain when kneeling)
• Reassure the patient and parents that this will resolve over time but may persist until the end of a growth spurt
• Reassure that usually stopping all sporting activity is not necessary
  o Reduce sporting activity (intensity, frequency or duration)
  o Change the type of exercise to limit the amount of running and jumping requiring powerful quadriceps contraction if they cannot tolerate normal activity
  o As symptoms decrease, they can gradually increase their exercise levels
  o Introduce low-impact quadriceps exercises (e.g. isometric quadriceps contractions, straight leg raises, cycling or swimming)
• Reassure that usually stopping all sporting activity is not necessary
• If symptoms do not improve or worsen OR symptoms persist into adulthood despite the above management, refer for specialist assessment by orthopaedic surgeon.
  o ADVICE
   Victorian Paediatric Orthopaedic Network fact sheet on Osgood-Schlatter disease has an explanation of the condition as well as instruction on some useful stretches
   Proper stretching before and after exercise may reduce symptoms

Question 214

what is this ?

Knee pain and swelling, typically after exercise
Knee catching, locking and/or giving way
Feeling a painful ‘clunk’ when flexing or extending the knee

Answer 214

Osteochondritis Dissecans

Osteochondritis dissecans (OCD) is a pathological process affecting the subchondral bone (most often in the knee joint) with secondary effects on the joint cartilage, including pain, oedema, free bodies and mechanical dysfunctions. It generally affects children and young adults. OCD may progress to degenerative changes if untreated.

Patients typically present with a subacute onset of:
Knee pain and swelling, typically after exercise
Knee catching, locking and/or giving way: more constant and severe symptoms are associated with the presence of loose bodies
Feeling a painful ‘clunk’ when flexing or extending the knee - indicating the involvement of the lateral femoral condyle

Signs:
Joint effusion
Tenderness on palpation of the articular cartilage of the medial femoral condyle, when the knee is flexed
Wilson’s sign for detecting medial condyle lesion - with the knee at 90° flexion and tibia internally rotated, the gradual extension of the joint leads to pain at about 30°, external rotation of the tibia at this point relieves the pain

Investigations:
X-ray (anteroposterior, lateral and tunnel views) - may show the subchondral crescent sign or loose bodies
MRI - used to evaluate cartilage, visualise loose bodies, stage and assess the stability of the lesion

Management
Early diagnosis is important
Clinical signs may be subtle in the early stages hence there should be a low threshold for imaging and/or orthopaedic opinion.

• Pain relief (paracetamol or ibuprofen)
• Rest and quadriceps exercises
• Sometimes surgical intervention is needed (to remove intra-articular loose bodies)

Question 215

anterior knee pain exacerbated by running, climbing stairs, and getting up from a chair.

Passive movements are usually painless, but repeated extension may produce
pain and a grating feeling, and crepitus or a small effusion may be palpable.

what is it ?

Answer 215

Chondromalacia patellae

Chondromalacia patellae is defined as anterior knee pain caused by degeneration
of the articular cartilage on the posterior surface of the patella. It is particularly
common in young adults as a result of overuse in physical activities. The pain
may be exacerbated by running, climbing stairs, and getting up from a chair.
Passive movements are usually painless, but repeated extension may produce
pain and a grating feeling, and crepitus or a small effusion may be palpable.
Patients should receive physiotherapy to strengthen the quadriceps.

Question 216

• hip pain: develops progressively over a few weeks
• limp
• stiffness and reduced range of hip movement

Answer 216

perthes

Question 217

what age group for perthes ?

Answer 217

4-8 y/o

Question 218

arthritis, uveitis, and urethritis

Answer 218

Reactive Arthritis

can’t see, can’t pee, can’t climb a tree

Question 219

how does septic arthritis present , give ix + mx

Answer 219

Symptoms
joint pain
limp
fever
systemically unwell: lethargy

Signs
swollen, red joint
typically, only minimal movement of the affected joint is possible

Investigations
joint aspiration: for culture. Will show a raised WBC
raised inflammatory markers
blood cultures

The Kocher criteria for the diagnosis of septic arthritis:
fever >38.5 degrees C
non-weight bearing
raised ESR
raised WCC

• Prolonged course of antibiotics (initially IV for 2 weeks, followed by 4 weeks of oral antibiotics)
  o Neonate to <3 months:
   IV cefotaxime
  o 3 months to </=5 years:
   IV ceftriaxone
   If penicillin allergic, give clindamycin
  o >/=6 years
   IV flucloxacillin
   If penicillin allergic, give clindamycin
  o Oral stepdown:
   Co-amoxiclav
   Flucloxacillin
• Joint aspiration - affected joints should be aspirated to dryness as often as required (through closed needle aspiration or arthroscopically)
• Washing out of the joint or surgical drainage may be required

Question 220

Slipped Capital Femoral Epiphysis (SUFE)

Answer 220

Slipped upper femoral epiphysis

Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%.

X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severity

• Ensure patient remains non-weight-bearing, analgesia, immediate orthopaedic referral
• Surgical repair
• In situ screw fixation across the growth plate
  Viva Tips
   What are the X-ray findings?
  o Trethowan’s sign: line of Klein does not intersect superior femoral epiphyses/asymmetry between line of Klein’s on either side

Question 220

features of rickets and mx

Answer 220

Rickets is a term that describes inadequately mineralised bone in developing and growing bones. This results in soft and easily deformed bones. It is usually due to vitamin D deficiency. In adults, the equivalent condition is termed osteomalacia

Predisposing factors
dietary deficiency of calcium, for example in developing countries
prolonged breastfeeding
unsupplemented cow’s milk formula
lack of sunlight

Features
aching bones and joints
lower limb abnormalities:
in toddlers genu varum (bow legs)
in older children - genu valgum (knock knees)
‘rickety rosary’ - swelling at the costochondral junction
kyphoscoliosis
craniotabes - soft skull bones in early life
Harrison’s sulcus

Investigations
low vitamin D levels
reduced serum calcium - symptoms may results from hypocalcaemia
raised alkaline phosphatase

mx=
* If calcium deficient rickets with vitamin D deficiency
o Daily calcium AND
o Ergocalciferol (vit D2) / colecalciferol (vit D3)
* If pseudo-vitamin D deficiency (defect in 1-alpha hydroxylase)
o Calcitriol / alfacalcidol
* Phosphate salts are used in hypophosphataemic rickets
* Dietary: oily fish, egg yolk

Question 221

how does transient synovitis present ?

Answer 221

Transient synovitis is sometimes referred to as irritable hip. It generally presents as acute hip pain following a recent viral infection. It is the commonest cause of hip pain in children. The typical age group is 3-8 years.

Features
* limp/refusal to weight bear
* groin or hip pain
* a low-grade fever is present in a minority of patients
* high fever should raise the suspicion of other causes such as septic arthritis

Question 222

diagnosis of ADHD ?

Answer 222

diagnosis of attention deficit hyperactivity disorder (ADHD) which requires the presence of symptoms for at least 6 months in at least two different environments. If not hitting criteria then watchful waiting is important

Question 223

classification of cerebral palsy

Answer 223

Classification

spastic (70%)
subtypes include hemiplegia, diplegia or quadriplegia
increased tone resulting from damage to upper motor neurons
dyskinetic
caused by damage to the basal ganglia and the substantia nigra
athetoid movements and oro-motor problems
ataxic
caused by damage to the cerebellum with typical cerebellar signs
mixed

Question 224

risk factors for cerebral palsy

Answer 224

• Risk Factors
  o Antenatal: Chorioamnionitis, maternal respiratory or GU infection
  o Perinatal: Preterm birth, LBW, neonatal encephalopathy, neonatal sepsis, maternal infection (e.g. respiratory or genito-urinary)
  o Postnatal: Meningitis, head trauma prior to 3 years

Question 225

o Delayed motor milestones for cerebral palsy

Answer 225

(correct for gestational age)
 Not sitting by 8 months
 Not walking by 18 months
 Hand preference before 1 year

o Refer all children with persistent toe walking

Question 226

mx for cerebral palsy

Answer 226

• Summary
  o Physiotherapy – encourage movement, improve strength and stop muscles from losing range of motion
  o Speech therapy – improve language abilities
  o Occupation therapy – identify everyday tasks that may be difficult and help make these tasks more accessible
  o Medication
   Stiffness – baclofen, diazepam
   Sleeping – melatonin
   Constipation – laxatives
   Drooling – anticholinergic

Question 227

gross motor development milestones

Answer 227

3 months Little or no head lag on being pulled to sit
Lying on abdomen, good head control
Held sitting, lumbar curve

6 months Lying on abdomen, arms extended
Lying on back, lifts and grasps feet
Pulls self to sitting
Held sitting, back straight
Rolls front to back

7-8 months Sits without support (Refer at 12 months)

9 months Pulls to standing
Crawls

12 months Cruises
Walks with one hand held

13-15 months Walks unsupported (Refer at 18 months)

18 months Squats to pick up a toy

2 years Runs
Walks upstairs and downstairs holding on to rail

3 years Rides a tricycle using pedals
Walks up stairs without holding on to rail

4 years Hops on one leg

Question 228

speech and hearing development milestones

Answer 228

Age Milestone
3 months Quietens to parents voice
Turns towards sound
Squeals

6 months Double syllables ‘adah’, ‘erleh’

9 months Says ‘mama’ and ‘dada’
Understands ‘no’

12 months Knows and responds to own name

12-15 months Knows about 2-6 words (Refer at 18 months)
Understands simple commands - ‘give it to mummy’

2 years Combine two words
Points to parts of the body

2½ years Vocabulary of 200 words

3 years Talks in short sentences (e.g. 3-5 words)
Asks ‘what’ and ‘who’ questions
Identifies colours
Counts to 10 (little appreciation of numbers though)

4 years Asks ‘why’, ‘when’ and ‘how’ questions

Question 229

fine motor development milestones

Answer 229

The tables below summarises the major fine motor and vision developmental milestones

Age Milestone
3 months Reaches for object
Holds rattle briefly if given to hand
Visually alert, particularly human faces
Fixes and follows to 180 degrees
6 months Holds in palmar grasp
Pass objects from one hand to another
Visually insatiable, looking around in every direction
9 months Points with finger
Early pincer
12 months Good pincer grip
Bangs toys together

Bricks

Age Milestone
15 months Tower of 2
18 months Tower of 3
2 years Tower of 6
3 years Tower of 9

Drawing

Age Milestone
18 months Circular scribble
2 years Copies vertical line
3 years Copies circle
4 years Copies cross
5 years Copies square and triangle

Book

Age Milestone
15 months Looks at book, pats page
18 months Turns pages, several at time
2 years Turns pages, one at time

Question 230

social and play development mielstones

Answer 230

Developmental milestones: social behaviour and play
The table below summarises the major social behaviour and play milestones

Age Milestone
6 weeks Smiles (Refer at 10 weeks)
3 months Laughs
Enjoys friendly handling
6 months Not shy
9 months Shy
Takes everything to mouth

Feeding

Milestone Age
May put hand on bottle when being fed 6 months
Drinks from cup + uses spoon, develops over 3 month period 12 -15 months
Competent with spoon, doesn’t spill with cup 2 years
Uses spoon and fork 3 years
Uses knife and fork 5 years

Dressing

Milestone Age
Helps getting dressed/undressed 12-15 months
Takes off shoes, hat but unable to replace 18 months
Puts on hat and shoes 2 years
Can dress and undress independently except for laces and buttons 4 years

Play

Milestone Age
Plays ‘peek-a-boo’ 9 months
Waves ‘bye-bye’
Plays ‘pat-a-cake’ 12 months
Plays contentedly alone 18 months
Plays near others, not with them 2 years
Plays with other children 4 years

Question 231

rescue therapy for seizure lasting longer than 5 mins ?

Answer 231

buccal midazolam

Question 232

drug for tonic clonic seizures

Answer 232

sodium valproate

Question 233

drug for absense seizures

Answer 233

ethosuximide

Question 234

drug for focal seizures

Answer 234

levetiracetam, lamotrigine

Question 235

age for febrile convulsions

Answer 235

6 months - 5 years old

Question 236

causes of febrile seizure

Answer 236

Any febrile illness can cause febrile seizures, but around 80% are viral. Common causes include:
* Respiratory tract infections
* Otitis media (this will be the kid who is touching his ear a lot – could ask about this in Hx)
* Urinary tract infections
* Influenza.

Question 237

what is recovery like after febrile convulsion?

Answer 237

The majority of children (75%) present with a simple febrile convulsion. This is typically a generalised tonic-clonic seizure, presenting with muscle stiffness and jerking or shaking of the limbs, without focal features. Additional features may include:
* Breathing difficulties
* Pallor
* Cyanosis
* Loss of consciousness

This is often followed by post-ictal drowsiness and confusion, which may last anywhere from several minutes to hours. Seizures rarely last longer than 10 minutes, occur once within 24 hours or within the same febrile illness, and resolve spontaneously, the vast majority with full recovery within 1 hour

Question 238

febrile status epilepticus ?

Answer 238

febrile seizure lasting longer than 30 misn

Question 238

red flag sx of headahce in kids

Answer 238

red flag symptoms:
o Waking at night or present on waking in the morning
o Features of meningism
o Vomiting or ataxia
o Aggravated by coughing, sneezing, or bending down
o Progressively worsens
o Change in conscious level or pervasive lethargy
o Within 5 days of head injury
o Squint or failure of upward gaze
o New onset cognitive dysfunction

Question 239

important to ask about specificvs of teh seiure ?

Answer 239

An eyewitness history is key to establish the duration and nature of the seizure. Important features to ask about:
Presence of fever
* Onset
* Peak temperature
* Duration
Details of seizure
* Characteristics
* Duration

It is also important to clarify whether this is the first presentation of a seizure.

Additional factors to note include developmental history and immunisation history, including any recent immunisations.

Question 240

mx for hydrocephalus

Answer 240

ventriculoperitoneal shunt

Question 241

mx migraine

Answer 241

1. paracetoml / ibruprofen
2. nasal sumatriptan
3. combination of above ^

Question 242

portwine
stain in the distribution of the ophthalmic division of the trigeminal nerve with
associated intracranial lesions.

Answer 242

Sturge–Weber syndrome

Question 243

café au lait spots, neurofibromas, optic gliomas, Lisch nodules, and sphenoid dysplasia.

Answer 243

neurofibromatosis type 1

Question 244

schwannomas of the vestibulocochlear nerve (causing hearing loss), meningiomas, and spinal cord ependymomas.

Answer 244

neurofibromatosis type 2

Question 245

mx for status epilepticus

Answer 245

• Step 1: (0 min)
  o Secure airway
  o Check ABC, high flow Oxygen2 if available
  o Check blood glucose
  o Confirm clinically that it is an epileptic seizure
• Step 2: (5 min)
  o If IV access, IV lorazepam
  o If NO immediate IV access:
   Buccal midazolam
   Rectal diazepam
• Step 3: (15 min)
  o if no response, give a second dose of IV lorazepam
  o Call for senior help
  o Start to prepare phenytoin for step 4
  o Re-confirm it is an epileptic seizure
• Step 4: (25 min)
  o Seek senior anaesthetist / inform ICU
  o Phenytoin 20 mg/kg by intravenous infusion over 20 mins
   or (if on regular phenytoin): Phenobarbital 20 mg/kg intravenously over 5 mins
  o Consider rectal paraldehyde 0.8 ml/kg
• Step 4: (45 min)
  o Rapid sequence induction of anaesthesia using thiopental sodium
• Consider dexamethasone if vasculitis/cerebral oedema is possible
• NOTE: treat reversible causes if identified (e.g. thiamine if malnourished or glucose if hypoglycaemic)

Question 246

mx for CAH

Answer 246

• Affected females sometimes need corrective surgery for external genitalia (they have a uterus and ovaries so they are reared as girls)
• Definitive surgical correction is usually delayed until puberty
• Acute (salt losing crisis)
  o IV saline (0.9% sodium chloride), IV hydrocortisone 200mg, IV dextrose
• Long Term
  o Life-long glucocorticoids (hydrocortisone) to suppress ACTH levels (and hence testosterone)
  o Mineralocorticoids (fludrocortisone) if there is salt loss
  o Monitoring growth, skeletal maturity, plasma androgens and 17α-hydroxyprogesterone levels
  o Additional hormone replacement at times of illness or surgery

Question 246

names of teh specific enzymes in CAH ?

Answer 246

21-hydroxylase deficiency (90%)
impairs the conversion of 17-hydroxyprogesterone to 11-deoxycortisol, leading to cortisol deficiency and excess androgen production
11-beta hydroxylase deficiency (5%)
results in hypertension due to excess deoxycorticosterone
17-hydroxylase deficiency (very rare)
leads to mineralocorticoid excess with low androgen and estrogen levels

Question 247

short repeated spasms in kids

Answer 247

Infantile spasms
Infantile spasms, or West syndrome, is a type of childhood epilepsy which typically presents in the first 4 to 8 months of life and is more common in male infants. They are often associated with a serious underlying condition and carry a poor prognosis

Features
characteristic ‘salaam’ attacks: flexion of the head, trunk and arms followed by extension of the arms
this lasts only 1-2 seconds but may be repeated up to 50 times
progressive mental handicap

Investigation
the EEG shows hypsarrhythmia in two-thirds of infants
CT demonstrates diffuse or localised brain disease in 70% (e.g. tuberous sclerosis)

Management
poor prognosis
vigabatrin is now considered first-line therapy / high dose pregnisolone
ACTH is also used

Question 248

how to manage cerebral oedema as a consequence of DKA ?

Answer 248

The osmotic pressure range between intravascular and brain cells during DKA treatment has also been proposed as a cause of cerebral edema. Diabetic ketoacidosis causes an increase in plasma osmolality, whereas osmolytes accumulate in brain cells, resulting in no osmotic pressure gap

mannitol or hypertonic sodium chloride

Question 249

what can cause a first epsiode of DKA in t1dm kido?

Answer 249

• Discuss factors that led to this episode
• Advice on how to manage intercurrent illness (e.g. viral infections leading to increased insulin demand)

Question 250

what are the different types of insulin therpay for t1dm in kids ?

Answer 250

o Three Types of Insulin Therapy
 Multiple Daily Injection Basal-Bolus: injections of short-acting insulin or rapid-acting insulin analogue before meals, with 1 or more separate daily injections of intermediate acting insulin or long-acting insulin analogue
 Continuous Subcutaneous Insulin Infusion (insulin pump therapy): programmable pump and insulin storage device that gives regular or continuous amounts of insulin (usually rapid-acting insulin or short-acting insulin) by a subcutaneous cannula
 One, Two or Three Insulin Injections Per Day: injections of short-acting insulin or rapid-acting insulin analogue mixed with intermediate-acting insulin
o Offer multiple daily injection basal-bolus insulin regimens from diagnosis
o If this is inappropriate, consider continuous subcutaneous insulin infusion (CSII or pump therapy)

Question 251

mx for hyperthyroidism

Answer 251

• 1st line: Medical - Carbimazole or propylthiouracil
• 2nd line: Radioiodine treatment, Surgery (partial thyroidectomy)

Question 252

side effects of hyperthroid medication ?

Answer 252

• 1st line: Medical - Carbimazole or propylthiouracil
• Important: both thionamides are associated with a risk of neutropaenia
  o Families should be safe-netted about seeking urgent medical attention and a blood count if a sore throat or fever occur whilst on treatment

Question 253

hypocalcaemia mx

Answer 253

• Management of Acute Symptomatic Hypocalcaemia
  o IV calcium gluconate
• Management of Chronic Hypocalcaemia
  o Oral calcium
  o High dose vitamin D analogues
  o Important: avoid hypercalciuria because it can lead to nephrocalcinosis so urinary excretion should be monitored

Question 254

features of hypocalcaemia ?

Answer 254

CATS go numb

Convulsions
arrythmias
tetany
spasms and stridor

numb = parathesia

Question 255

precocious puberty
cafe-au-lait spots
polyostotic fibrous dysplasia
short stature

Answer 255

McCune-Albright syndrome

Question 255

define precocious puberty and what are the causes ?

Answer 255

Precocious puberty
Definition
‘development of secondary sexual characteristics before 8 years in females and 9 years in males’
more common in females

Some other terms
thelarche (the first stage of breast development)
adrenarche (the first stage of pubic hair development)

May be classified into:

1. Gonadotrophin dependent (‘central’, ‘true’)
   due to premature activation of the hypothalamic-pituitary-gonadal axis
   FSH & LH raised
2. Gonadotrophin independent (‘pseudo’, ‘false’)
   due to excess sex hormones
   FSH & LH low

Males - uncommon and usually has an organic cause

Testes
bilateral enlargement = gonadotrophin release from intracranial lesion
unilateral enlargement = gonadal tumour
small testes = adrenal cause (tumour or adrenal hyperplasia)

Females - usually idiopathic or familial and follows normal sequence of puberty

Organic causes
are rare, associated with rapid onset, neurological symptoms and signs and dissonance
e.g. McCune Albright syndrome

Question 256

mx hypoglycaemia

Answer 256

• Mild-to-Moderate Hypoglycaemia
  o Give fast-acting glucose by mouth (usually liquid carbohydrate (e.g. Lucozade))
  o May need to be given in small amounts if vomiting
  o Recheck blood glucose within 15 mins and repeat fast-acting glucose if hypoglycaemia persists
  o As symptoms improve, give oral complex long-acting carbohydrate to maintain blood glucose levels
• SEVERE Hypoglycaemia
  o Treat in hospital
   Give IV 10% glucose (maximum dose of 500 mg/kg of bodyweight (5 ml/kg))

o If NOT in hospital: unresponsive or PO route cannot be used
 IM glucagon or concentrated oral glucose solution (e.g. glucogel)
* IM glucagon: 500 µg for < 8 years; 1 mg for > 8 years
 Seek medical help if blood glucose remains low after 10 mins
 Once symptoms improve, give oral complex long-acting carbohydrate
* NOTE: alcohol is a risk factor for hypoglycaemia (they should eat carbohydrates before and after drinking)

Question 257

in A-E outline A

Answer 257

Secretions, foreign body
Stridor
See-sawing

Open airway – jaw thrust and position:
* Infant – neutral position
* Children – ‘sniffing’ position
* NB. C-spine control
Remove obstruction if safe

Question 257

in A-E outline B

Answer 257

Respiratory rate
Symmetry
Wheeze
Work of breathing

Auscultate and monitor
Oxygen
Support breathing

Question 258

in A to E outline C

Answer 258

Pulse rate and volume
Blood pressure
Capillary refill time

Fluid/blood
Chest compressions
Defibrillation
Look at the colour and temperature of peripheries
Measure capillary refill time
Auscultate the heart
Insert 1 or 2 large bore cannulas
Reassess every 5 mins
Consider fluid bolus if hypotensive

Question 259

in A to E outline D

Answer 259

Disability

Consciousness
Pupils
Posture

AVPU/GCS
Collateral history re. seizures, trauma, poison, sepsis, diabetes

Question 260

what to give in anaphylaxis

Answer 260

• Give IM adrenaline 1: 1000 (as per age-related guidelines)
• Give high flow oxygen
• Give IV fluids
• Give IV chlorphenamine 10 mg + IV hydrocortisone 200 mg

Question 261

neonatal resuss

Answer 261

• At birth, delayed cord clamping if possible
• Dry the baby, remove any wet towels and covers and start the clock or note the time
• Within 30 seconds: assess tone, breathing and heart rate
• Within 60 seconds: if gasping or not breathing – open the airway and give 5 inflation breaths
  o Consider SpO2 and ECG monitoring
• Re-assess: if no increase in heart rate, look for chest movement
• If chest NOT moving:
  o Check mask, head and jaw position
  o Consider 2-person airway control
  o Consider suction, laryngeal mask/tracheal tube
  o Repeat inflation breaths and look for a response
  o Consider increasing inflation pressure
• If NO increase in heart rate: look for chest movement
• When chest is moving: if heart rate is not detectable or slow (< 60/min) ventilate for 30 seconds
• Reassess heart rate: if still < 60 bpm
  o Start chest compressions with ventilation breaths (3:1)
  o Increase oxygen to 100%
  o Consider intubation if not already done or laryngeal mask if not possible
• Reassess heart rate every 30 seconds: if heart rate is not detectable or slow (< 60/min):
  o Vascular access and drugs (e.g. atropine)
  o Consider other factors, e.g. pneumothorax, hypovolaemia, congenital abnormality

Question 261

in paeds life support if no signs of life / not breathing normally ?

Answer 261

5 rescue breaths

Question 262

outline gillick competence

Answer 262

Gillick Competence
* At 16 years or older, a young person can be treated as an adult and be presumed to have capacity to decide
* Under the age of 16 years, children may have capacity to decide, depending on their ability to understand what is involved
* Where a competent child refuses treatment, a person with parental responsibility or the court may authorise investigation or treatment which is in the child’s best interests
* Family Law Reform Act (1969)
o Those over 16 can consent to treatment but CANNOT REFUSE TREATMENT under 18 years old, unless there is one consenting parent, even if the other disagrees

Question 263

non accidental injury who to involve and what to do ?

Answer 263

• Variety of Presentations
  o Bruising
  o Broken bones
  o Drowsiness (subdural haematoma)
  o Neglect (e.g. unkempt)
  o Failure to thrive
• Is the child in DANGER?
  o Could the siblings or parents be in danger?
  o MAKE SURE THE CHILD IS IN A SAFE PLACE
• Who to get involved?
  o Senior colleagues
  o Named doctor for child protection
  o Contact social services and make a formal referral
  o Consider contacting the police (Child Abuse Investigation Team (CAIT))
  o Consider contacting Multi-Agency Safeguarding Hub (MASH)
   This includes a variety of people that help manage different aspects of a child’s life
• Investigations
  o Skeletal survey
  o CT +/- MRI head scan
  o Bloods and bone profile
   Rule out leukaemia, ITP etc.
  o Ophthalmology referral (fundoscopy for retinal haemorrhages)
• GENERAL RULE: if you are suspecting NAI, it is always safe to admit the child

Question 264

school exclusion for scarlet fever ?

Answer 264

24 hours after abx

Question 265

whooping cough school eclusion ?

Answer 265

48 hours after abx

Question 266

measles school exclusion

Answer 266

4 days from onset of rash

Question 267

rubella school exclusion

Answer 267

5 days from onset of rash

Question 268

chickenpox school exlcusion

Answer 268

once all lesions crusted over

Question 269

impetigo school exclusion

Answer 269

once all lesions have crusted over

Question 269

mumps school exclsuion

Answer 269

5 days from onset of swollen glands

Question 270

normal vitals for < 1

Answer 270

30 – 40 110 – 160 70 – 90

Question 271

diarhoea and vomiting school exclusion

Answer 271

until sx settled for 48 hours

Question 272

normal vitals 2 -5

Answer 272

20 – 30 95 – 140 80 – 100

Question 273

noraml vitals 5-12

Answer 273

15 – 20 80 – 120 90 – 110

Question 274

normal vitals > 12

Answer 274

12 – 16 60 - 100 100 - 120