Paeds Flashcards
FLUIDS (in notebook); osteogenesis imperfecta; go to resp FC and update asthma new Mx; JIA?
NICE Immediate referral criteria?
- apnoea (observed or reported)
- child looks seriously unwell to a healthcare professional
- severe respiratory distress
- a respiratory rate of over 70 breaths/minute
- central cyanosis
- persistent oxygen saturation of less than 92% when breathing air.
NICE consider referral criteria
- a respiratory rate of over 60 breaths/minute
- difficulty with breastfeeding or inadequate oral fluid intake (50–75% of usual volume, taking account of risk factors
- clinical dehydration.
Management of Perthes disease in <6?
Observation
What is the management of umbilical hernias?
- Usually self-resolve
- If large/symptomatic, repair at 2-3 years
- If small and asymptomatic, repair at 4-5 years
What is the management of meningitis in children < 3 months?
IV Cefotaxine plus IV Amoxicillin
progressive hip pain, limp and stiffness
Perthes disease
Brushfield spots in the iris are suggestive of which genetic condition?
Downs
painless rectal bleeding with no other acute abdominal signs?
Think Meckels Diverticulum
What should not be given to children <3 months with bacterial meningitis?
Corticosteroids
What should you do if there are no signs of breathing on initial assessment of a child?
Give 5 rescue breaths
Blue sclera is associated with what?
Osteogenesis imperfecta
What should be given to all children who have an asthma attack?
Oral prednisolone for 5 days
What criteria is used to assess the likelihood of septic arthritis in children?
- Inability to weight bear
- Fever > 38.5
- WCC > 12
- ESR > 40
Management of bow legs
If <3 - normal variant and usually resolves by 4 years old
If >3 - refer to paediatrics
Management of Children presenting with glue ear with a background of Down’s syndrome or cleft palate
Refer to ENT
When should a child be reviewed by a senior endocrinologist?
If ketonaemia and acidosis have not resolved within 24 hours of DKA
A lesion where causes finger abduction weakness
T1
What are risk factors for SUFE?
- Obesity
- Male
- Local trauma
- Hormone deficiencies: thyroid, GH
- Chemo/Radio
What are examination findings for SUFE?
Limp on walking, external rotation of limb, hip motion is limited (flexion, abduction and medial rotation)
What are signs of decompensated congenital heart disease?
Poor feeding, dyspnoea, tachycardia, weak pulse, cold peripheries, hepatomegaly, engorged neck veins, gallop rhythm
What is Eisenmenger’s syndrome?
When a left-to -right shunt leads to pulmonary hypertension and shunt reversal, therefore turning an acyanotic heart defect into a cyanotic heart defect.
What are risk factors for respiratory distress syndrome?
Maternal diabetes, Caesarean sections, second twins, males, hypothermia, perinatal asphyxia, FH,prematurity
Which cells in the lung produce surfactant?
T2 Pnemocytes
What will be seen on CXR for RDS?
Ground glass appearance
Simple febrile convulsion vs complex
Complex - Focal, >15 minutes, Repeat seizure within 24 hours
What is cerebral palsy?
A chronic disorder of movement and posture due to non progressive brain abnormalities occurring before the brain is fully developed
What are non-motor signs of cerebral palsy?
Delayed milestones, failure to thrive, epilepsy, urinary
incontinence, constipation, drooling, sleep disturbance,
contractures
What are signs of intussception on abdo x ray?
Right lower quadrant opacity, dilated gas-filled proximal bowel with absence of gas distally, multiple fluid levels, perforation
What are indications for surgery with intussception?
- Peritonitis
- Failed enema
- Perforation
- Prolonged history
Murmur for ASD vs VSD
ASD - ejection systolic
VSD - pansystolic at left sternal border
What is Turners chromosomal abnormality?
XO karotype
What is the most common cardiac defect with Turners syndrome?
Bicuspid aortic valve
Slow movements of hand and feet with difficulty holding objects + drooling in a child?
Dyskinetic CP
Paeds BLS
- 5 rescue breaths
- 15:2 (3:1 for newborn) chest compressions on lower half of sternum with depth of 1/3 of chest
- Use 2 thumb encircling technique for chest compression for infants
Where is the damage in dyskinetic cerebral palsy?
Basal ganglia and substantia nigra
Craniopharyngioma vs pituitary adenoma?
PA - bitemporal superior quadrantinopia
CP - bitemporal inferior quadrantinopia
What age do febrile convulsions normally stop?
5 years
Aplastic crisis vs sequestration crisis?
Aplastic - reduced reticulocytes
Sequestration - increased reticulocytes
What should not be given to patients with suspected meningococcal sepsis?
Dexamethasone
ALL can present with haemorrhage or thrombotic complications due to what?
DIC
How does TTP present?
FAT RN
Fever
Anaemia
Thrombocytopenia
Renal dysfunction
Neuro abnormalities
Cystic fibrosis associations?
- Short stature
- DM
- Delayed puberty
- Nasal polyps
- Rectal prolapse
- Male infertility
Swollen and retracted testicle
Testicular torsion
What is the investigation for sickle cell anaemia?
Haemoglobin electrophoresis
Which seizures appear in the morning after waking?
Myoclonic -> treat with sodium valproate/leviteracetam
Infant <3 with suspected UTI?
Refer to Paeds
What should be measured in patients with active HSP?
- Blood pressure and urinalysis
What is used for the longer term management of sickle cell anaemia?
Hydroxyurea -> increases levels of HbF
Signs of tetralogy of fallot on examination?
- Loud systolic murmur in pulmnary area
- Ejection systolic murmur
Sign of TOF on ECG?
Right axis deviation
What conditions are screened for in NIPE?
- Congenital cataracts
- Congenital HD
- Undescended testes
- DHH
- Newborn hearing
What are signs of DDH on X-ray?
Reduced alpha and beta angles
Reduced bony coverage of femoral epiphysis
What are complications of DDH?
- Premature joint degeneration
- Arthritis
- Chronic lower back pain
- Delay in walking
- Avascular necrosis
Treatment for muscle spams in CP?
- Diazepam
- Baclofen
- Botox
Vomiting vs Reflux
Vomiting - forceful and active, Reflux - sphincter incompetence
Which organism causes hand, foot mouth/slapped cheek/roseola?
Coxsackie - HFM
Slapped Cheek - Parvovirus
Roseola - HH6
steeple sign
Croup
What is Eisenmenger’s syndrome?
Reversal of left-right shunt to a right-left shunt due to pulmonary HTN
ADHD has reduced function of where?
Frontal lobe
What is the most common small vessel vasculitis in children?
Henoch-Schonlein Purpura
Meningitis + septic shock + massive adrenal haemorrhage?
Waterhouse-Friderichsen syndrome
Rash organisms
Roseola - HH6
Slapped Cheek - Parvovirus
Hand, foot mouth - Coxsackie virus
Chickenpox - Varicella
small round blue cells on histology
Think Wilms tumour
What are the S of innocent murmurs?
- Soft
- Systolic
- Sensitive
- Short
- Symptomless
What is the treatment for epiglottitis?
- Intubation
- IV Cefuroxime
What can be given to promote closure of the duct and what to keep the duct open?
Keep open - Prostaglandins
Promote closure - Ibuprofen/Indomethacin
How long should patients be kept in for observation after anaphylactic reaction?
6 hours
Components of Fraser guidelines
the patient cannot be persuaded to inform their parents or carers
the patient understands the advice or treatment
the patient’s physical and/or mental health will suffer if they do not receive the treatment/advice
the treatment/advice is in the patient’s best interest
the patient is likely to continue having sex with or without treatment
Whooping cough is a risk factor for?
Bronchiectasis
Which chromosome is Downs, Edwards, Patau?
Patau - 13
Edward - 18
Down - 21
sensorineural deafness and a desquamating rash in a neonate?
Think congenital syphilis
Rickets can present as what?
Widening of the joints
Hearing tests in children
Newborn - otoacoustic emission test
If abnormal - auditory brainstem response test
3 years - Pure tone audiometry
What is not a red flag referral criteria?
Nasal flaring
grey spots on his buccal mucosa
Koplik spots -> measles
Signs of Turners?
- Short stature
- Lymphoedema
- Spoon shaped nails
- Webbed neck
- CHD
- Delayed puberty
- Wide spaced nipples
What is intusseception?
Telescoping of a segment of proximal bowel into a distal one
What is the management of intussusception?
- Rectal air insufflation/air enema if stable
- If unstable: laparoscopic reduction
What is DDH?
Where the femoral head and acetabulum do not articulate correctly
What are Barlow and Ortolani tests?
Barlow - attempt to dislocate the femoral head
Ortolani - attempt to relocate the dislocated femoral head
Investigations for DDH?
If <4.5 months: US
If >4.5 months: X-ray
When would you use correction for gestational age when assessing for milestones?
Until 2 years
Features of Patau?
- Microcephaly
- Clef lip and palate
- Polydactyly
Features of Edwards?
- Micrognathia
- Low set ears
- Rocker-bottom feet
- Overlapping fingers
What is the management of minimal change disease?
- Prednisolone
- Immunosuppressives such as ciclosporin
- Fluid restrict and low salt
Diffuse ‘lace-like’ rash develops across the body
Slapped cheek syndrome
What is a big maternal risk factor for transposition of the great arteries?
Diabetes
Triad of ADHD
- Impulsivity
- Inattention
- Hyperactivity
What must be performed before starting someone on methylphenidate?
ECG -> can be cardiotoxic
What are signs of foetal alcohol syndrome?
- Microcephaly
- Short palpebral fissures
- Absent philtrum
- Reduced IQ
- Cardiac abnormalities
What causes a tet spell?
Reversal of the shunt across the VSD leading to a right to left shunt and exacerbated cyanosis
Indications for tonsillectomy
seven or more episodes in a single year, five or more episodes/year in two years, or three or more episodes/year in three years
Crampy abdo pain with sore throat and some lymphadenopathy?
Think mesenteric adenitis
First line therapy for anorexia in kids?
Family therapy
How long can maternal antibodies protect foetus?
Upto 6 months
Dehydration, vomiting, hyponatraemia and hyperkalaemia shortly after birth?
Think Congenital adrenal hyperplasia
Grunting, cyanosis with barrel chest and scaphoid abdomen?
Think congenital diaphragmatic hernia -> tinkling bowels sounds
Yawning in a newborn baby that was previously well is a sign of what?
Opioid withdrawal
sunburst appearance on x ray?
Osteosarcoma
Gram negative coccobacillus?
Bordetella pertussis -> whooping cough
Inheritance of DMD?
X-linked recessive
recurrent otitis media in a girl?
Think Turners
Cataracts, deafness, hepatosplenomegaly, heart mumur + rash?
Think congenital rubella
Murmurs
ASD - Ejection systolic
VSD - pan systolic at lower left sternal edge
Pulmonary stenosis - Ejection systolic
Tricuspid regurg - pan systolic at lower left sternal edge
Management of hydrocephalus?
VP shunt insertion
What causes Kernicterus?
Toxic build up of unconjugated bilirubin
What are the live vaccines?
MMR
Influenza
BCG
Oral polio
Oral rota
Typhoid
Yellow fever
Acute epiglottitis is caused by what?
Haemophilus influenzae type B
Why is prompt recognition and Tx essential in acute epiglottitis?
airway obstruction may develop
What age group is acute epiglottitis most common in?
previously children but now more common in adults due to immunisation programme (Hib vaccine)
Features of acute epiglottitis?
- tripod position= easier to breathe leaning forward and extending neck in seated position
- drooling
- rapid onset
- high temp but generally well
- stridor
Diagnosis of acute epiglottitis?
direct visualisation ONLY by senior/airway trained staff
may do x-ray if concern about foreign body
X-ray findings in acute epiglottitis if done (eg. if concern about foreign body)?
lateral view= thumb sign (swelling of epiglottis)
X-ray= posterior-anterior view showing subglottic narrowing, commonly called the ‘steeple sign’
croup
X-ray= lateral view will show swelling of the epiglottis - the ‘thumb sign’
acute epiglottitis
Mx of acute epiglottitis?
DO NOT EXAMINE THE THROAT due to risk of acute airway obstruction
immediate senior invl eg. anaesthetics or ENT= direct visualisation & endotracheal intubation may be needed
- O2 and IV Abx
fever, rash, arthralgia
eosinophilia
mild renal impairment
hypertension
Ix= white cell casts and sterile pyuria
? acute interstitial nephritis= drug induced AKI eg. penicillin, NSAIDs, rifampicin; SLE; infection
marked interstitial oedema and interstitial infiltrate in the connective tissue between renal tubules
Tubulointerstitial nephritis with uveitis (TINU)
young females.
Symptoms include fever, weight loss and painful, red eyes.
Urinalysis is positive for leukocytes and protein.
What may be a Cx of bacterial tonsillitis?
peritonsillar abscess (quinsy)
otitis media
rare= RF, glomerulonephritis
Features of peritonsillar abscess (quinsy)?
deviation of uvula to unaffected side, trismus (difficulty open mouth); severe throat pain (lateralises to one side); reduced neck mobility
Mx for peritonsillar abscess (quinsy)?
urgent ENT review
needle aspiration or incision & drainage + IV Abx
consider tonsillectomy to prevent recurrence
Anaphylaxis= adrenaline dose for baby <6m?
100 - 150 micrograms (0.1 - 0.15 ml 1 in 1,000)
Anaphylaxis= adrenaline dose for child 6m-6yrs?
150 micrograms (0.15 ml 1 in 1,000)
Anaphylaxis= adrenaline dose for child 6-12yrs?
300 micrograms (0.3ml 1 in 1,000)
Anaphylaxis= adrenaline dose for child/adult >12yrs?
500 micrograms (0.5ml 1 in 1,000)
What features suggest a severe asthma attack in children? (6)
SpO2 < 92% (unlike in adults)
PEF 33-50% best or predicted
Too breathless to talk or feed
Heart rate
>125 (>5 years)
>140 (1-5 years)
Respiratory rate
>30 breaths/min (>5 years)
>40 (1-5 years)
Use of accessory neck muscles
What features suggest a life-threatening asthma attack in children? (7)
SpO2 <92%
PEF <33% best or predicted
Silent chest
Poor respiratory effort
Agitation
Altered consciousness
Cyanosis
What features suggest a moderate attack asthma attack in children? (3)
SpO2 > 92%
PEF > 50% best or predicted
No clinical features of
severe asthma
Mx for mild to moderate acute asthma in children?
give a beta-2 agonist via a spacer (for a child < 3 years use a close-fitting mask)
give 1 puff every 30-60 seconds up to a maximum of 10 puffs
if symptoms are not controlled repeat beta-2 agonist and refer to hospital
steroid therapy for all children for 3-5d
Dose of prednisolone for children following acute asthma exacerbation?
2 - 5 years= 20 mg od OR 1-2 mg/kg od (max 40mg)
> 5 years= 30 - 40 mg od OR 1-2 mg/kg od (max 40mg)
Ix for suspected asthma in children aged 5-16yrs?
1st line= FeNO, diagnosis if ≥ 35 ppb
- if normal or not available= BDR with spirometry: diagnose if FEV1 increase ≥ 12% or ≥ 10% of predicted normal
- if not available= PEF bd for 2w: diagnose if PEF variability ≥ 20%
- if still not confirmed= skin prick to house dust mite OR total IgE level and blood eosinophil count: diagnose if sensitisation or raised total IgE level and the eosinophil count is > 0.5 x 109/L
- still doubt then refer to paeds and ?bronchial challenge test
Ix for suspected asthma in children aged <5yrs?
difficulty performing tests so:
- treat with ICS
- if still symptoms at age 5 then attempt Ix
- refer to specialist resp paeds any child with admission to hospital or 2+ admissions to A&E with wheeze in 12m period
Mx of asthma in children aged 5-11yrs?
1) SABS + low dose ICS bd
then consider MART pathway (new) or conventional pathway
2) SABA + low dose MART
3) SABA + moderate MART
or
2) SABA + low dose ICS + LTRA (trial 8-12w, stop if ineffective)
3) SABA + low dose ICS + LABA (with or without LTRA depending on trial)
4) SABA + moderate dose ICS + LABA (+/- LTRA)
4/5) specialist referral
Mx of asthma in children <5yrs?
1) 8 to 12 week trial of twice-daily paediatric low-dose ICS as maintenance therapy + SABA as required
consider stopping ICS and SABA treatment after 8 to 12 weeks if symptoms are resolved. Review the symptoms after a further 3 months
2) if symptoms restart then SABA + low dose ICS
3) SABA + moderate dose ICS
4) SABA + moderate dose ICS + LTRA trial
5) refer
In asthma, when should we consider stepping down Tx?
every 3m
When reducing dose of ICS in asthma Mx, how much should you reduce it by?
25-50%
(only the ICS nothing else)
Biliary atresia?
involves either obliteration or discontinuity with the extrahepatic biliary system resulting in an obstruction
Neonatal presentation of cholestasis in the first few weeks of life?
biliary atresia
How does biliary atresia present?
cholestasis in the 1st few weeks of life= jaundice beyond physiological 2w; dark urine and pale stools; appetite and growth disturbances (may be normal)
Pathogenesis of biliary atresia?
unclear but infectious agents, congenital malformations and retained toxins within bile all contribute
Extrahepatic biliary atresia more common in who?
females
What age does biliary atresia present?
unique to neonatal children:
- perinatal form= within 1st 2w of life
- postnatal form= within 2-8w of life
How many types of biliary atresia?
3
Type 1 biliary atresia?
proximal ducts are patent however the common duct is obliterated
Type 2 biliary atresia?
atresia of the cystic duct and cystic structures are found in the porta hepatisw
Type 3 biliary atresia?
atresia of the left and right ducts to the level of the porta hepatis, this occurs in >90% of cases of biliary atresia
Signs of biliary atresia?
- jaundice
- hepatomegaly with splenomegaly
- abnormal growth
- cardiac murmurs if associated with cardiac abnormalities
Ix for biliary atresia?
- Serum bilirubin= total bilirubin may be normal but conjugated bilirubin high
- LFTs= serum bile acids and aminotransferases raised (but can’t differentiate between other causes of neonatal cholestasis)
- USS of biliary tree and liver= may be distension and tract abnormalities
- Percutaneous liver biopsy and intraoperative cholangioscopy
- Rule out= serum alpha 1-antitripsin def and sweat chloride test (CF invl biliary tract and a 1-a def may be a cause of neonatal cholestasis
Mx of biliary atresia?
Surgery is definitive= dissection of abnormalities into distinct ducts and anastomosis creation
- then after surgery= Abx and bile acid enhancers
Cx of biliary atresia?
- Unsuccessful anastomosis formation
- Progressive liver disease
- Cirrhosis with eventual hepatocellular carcinoma
Prognosis of biliary atresia?
- good if surgery successful
- surgery fails= liver transplant in 1st 2yrs of life
Bronchoectasis?
permanent dilation of airways (bronchi) secondary to chronic infection or inflam causing irreversible damage to elastic and muscular components of bronchial wall
List causes of bronchiectasis?
- post infective= TB, measles, pertussis, pneumonia
- CF
- bronchial obstruction= lung ca, foreign body
- immune def= selective IgA, hypogammaglobulinaemia
- ABPA
- ciliary dyskinetic syndrome= Kartagener’s syndrome, Young’s syndrome
- yellow nail syndrome
Features of bronchiectasis?
- persistent cough with large volumes of sputum
- dyspnoea
- haemoptysis
Signs of bronchiectasis?
- coarse crackles and wheeze
- clubbing
What may be seen on CXR and CT in brochioectasis?
CXR= tramlines
CT= widespread tram-track and signet ring signs
Mx for bronchiectasis (after assessing treatable causes eg. immune deficiency)?
- physical training eg. inspiratory muscle training good for non-CF
- postural drainage
- Abx for exacerbations + long term rotating Abx in severe
- bronchodilators in severe
- immunisations
- surgery in selected (eg. localised disease)
Most common organisms isolated from pts with bronchiectasis?
- H.influenzae (most common)
- Pseudomonas aeruginosa
- Klebsiella spp.
- Strep pneumoniae
What Abx can be used in acute exacerbation for bronchiectasis?
use previous microbio cultures if available, if not then:
- local guidelines or amox 500mg 3xd 7-14d ( if 1-4yrs then 250mg, 1-11m then 125mg)
or clarithromycin 250- 500mg bd 7-14d (if 1m-11yrs= if 30-40kg then 250mg; 20-29kg 187.5mg; 12-19kg 125mg; 8-11kg 62.5mg; <8kg then 7.5mg/kg)
When to consider URTI in child?
cough, symptoms & signs of infection and clear chest on exam
Causes of cough in children?
pneumonia, COVID, viral-induced wheeze, or an infective exacerbation of asthma
When does viral induced wheeze occur?
children 6m-5yrs who present with wheeze with resp tract infection
What age is predominantly affected by bronchiolitis?
<12m
How may a child present with bronchiolitis?
typically <12m
high RR, wheeze may be present, hyperinflation, fine crackles throughout lung fields
Most common cause of bronchiolitis?
respiratory syncytial virus (RSV)
When to consider CAP in a child?
feverish child, RR 60+, signs of increased work of breathing and/or crackles in chest and/or cyanosis
Assessment of child with resp symptoms?
- ?agitation and consciousness= agitation and behavioural change may be sign of hypoxia
- signs of exhaustion, cyanosis, invl of accessory muscles at rest
- examine chest, RR, pulse and BP
- O2 sats on air
- peak flow if possible in viral-induced wheeze or infective asthma exacerbation
- assess hydration status
What indicates urgent hospital admission in a child with resp symptoms?
- RR 60-70+
- apnoea, grunting, moderate or severe chest indrawing
- cyanosis
- no response to social cues, unable to be roused or cannot stay awake
- look ill
- clinical dehydration
- <3m + temp at least 38°C
- > 3m with temp >39°C
- PEF rate <50% best or predicted
- O2 sats 90% on air or less; or 92% or less in <6w old or underlying health issue
When to consider hospital admission in child with resp symptoms?
- 6-12m + RR 50-60 or >12m with RR 40-60, nasal flaring, crackles
- O2 sats 92% or less on air
- pallor reported by parent/carer
- no response to normal social cues, awakes only with prolonged stimulation, decreased activity
- Poor feeding in infants (less than 50% of normal fluid intake in preceding 24 hours), dry mucous membranes, reduced urine output.
- CRT equal to or greater than 3 seconds.
Child with resp symptoms who are assessed at being low risk?
may be Tx at home but how to seek advice if any deterioration
infants who have experienced a coryzal prodrome lasting 1–3 days, followed by persistent cough and:
Either tachypnoea or chest recession (or both) and
Either wheeze or crackles on chest auscultation (or both)
bronchiolitis
What age is affected by bronchiolitis?
<2yrs, peak incidence 3-6m
Features of bronchiolitis?
- coryzal prodome 1-3d followed by persistent cough
- tachypnoea, chest recessions
- wheeze/crackles
- fever, usually less than 39
- poor feeding (typically after 3-5d of illness)
- apnoea without other clinical signs in young infants eg. <6w
apnoea without other clinical signs in young infants eg. <6w
think bronchiolitis
What may be a sign of hypoxia in children?
agitation and behavioural changes
Prognosis of bronchiolitis?
usually self-limiting, symptoms tend to peak between 3-5d of onset
Mx of bronchiolitis?
- immediate admission if indicated
- If O2 sats <92% give supp O2 whilst awaiting hospital admission
- usually self-limiting= paracetamol if child is distressed; regular fluids; don’t try to reduce fever by undressing
- check on child through night
When to immediately refer child to hospital with bronchiolitis (999)?
- apnoea
- looks very unwell
- severe resp distress= grunting, marked chest recession, RR >70
- central cyanosis
What may impending resp failure in a child be indicated by?
listlessness or decreased respiratory effort, recurrent apnoea, and/or failure to maintain adequate oxygen saturation despite oxygen supplementation.
When to consider admission to hospital in a child with bronchiolitis?
- RR >60
- difficulty breastfeeding/ oral intake 50-75% of usual
- clinical dehydration
- <92% sats on air
What factors in children lower the threshold for hospital admission in bronchiolitis?
Chronic lung disease (including bronchopulmonary dysplasia).
Haemodynamically significant congenital heart disease.
Neuromuscular disorders.
Immunodeficiency.
Age under three months.
The infant having been born prematurely, particularly before 32 gestational weeks.
Factors that might affect a carer’s ability to look after a child
Longer distance to healthcare in case of deterioration.
Signs of clinical dehydration?
educed skin turgor and/or a capillary refill time of more than three seconds, and/or dry mucous membranes, and/or reduced urine output
Viral induced wheeze summary?
typically…
- <5yrs
- RR normal or increased
- hyperinflation may be present
- wheeze
- not usually any crackles present
Admission to hospital in child with viral induced wheeze/exacerbation of asthma?
life-threatening features.
severe attack persisting after initial bronchodilator treatment.
moderate attack with worsening symptoms despite initial bronchodilator treatment and/or who have had a previous near-fatal asthma attack.
infant/child having been born prematurely, any significant medical history, such as congenital heart disease, chronic lung disease of prematurity, cystic fibrosis, bronchiectasis, and immune deficiency, and the ability of the child’s carers to cope with the ill child (in particular, assess the carer’s experience, their level of anxiety, and the time they have available to care for the child).
Mx of viral induced wheeze/exacerbation of asthma?
- supp O2 if life-threatening or sats <94%
- SABA= nebulised salbutamol (5 mg >5 yrs, and 2.5 mg to children 2–5 yrs). Should be O2 driven (flow rate 6L/min)
- if mild/moderate= pressurised metered dose inhaler with large volume spacer; one puff with 5 tidal breaths every 30-60secs up to 10 puffs; can repeat every 10-20mins if responsive, if not successful- nebuliser + admission
- monitor peak flow for response to Tx
- prednisolone if diagnosed with asthma
- Abx if bacterial infection= amoxicillin or doxy (if >12yrs)
Follow up for child following viral induced wheeze/exacerbation of asthma?
48hrs later= peak flow, may need maintenance Tx if mild intermittent wheeze and other resp symptoms only with viral URTI
Bronchiolitis?
acute bronchiolar inflam
What provides protection to newborns against RSV (and so incidence of bronchiolitis most common in 3-6m)?
maternal IgG
Causes of bronchiolitis?
- RSV (most common)
- adenovirus
- mycoplasma
- may be secondary bacterial infection
- more serious if bronchopulmonary dysplasia (eg. premature); congenital heart disease or CF
CP of bronchiolitis?
- 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
Ix for bronchiolitis?
nasal swab= immunofluorescence of nasopharyngeal secretions may show RSV
Summarise Mx of bronchiolitis?
humidified oxygen is given via a head box and is typically recommended if the oxygen saturations are persistently < 92%
NG feeding may be needed if children cannot take enough fluid/feed by mouth
suction is sometimes used for excessive upper airway secretions
Infant definition in paediatric basic life support?
child <1yr
Child definition in paediatric basic life support?
1yr-puberty
Paediatric basic life support?
- look, feel, listen for breathing
- 5 rescue breaths
- circulation= brachial or femoral pulse in infants, children use femoral
- chest compressions 15:2
(100-120/min) for both infants & children
Chest compressions in paediatric life support?
15:2
100-120/min
depth: depress the lower half of the sternum by at least one-third of the anterior-posterior dimension of the chest (which is approximately 4 cm for an infant and 5 cm for a child)
in children: compress the lower half of the sternum
in infants: use a two-thumb encircling technique for chest compression
Most common cause of nephrotic syndrome in children?
minimal change disease (75%)
Causes of minimal change disease (causes nephrotic syndrome)?
most idiopathic
- drugs= NSAIDs, rifampicin
- Hodgkin’s lymphoma, thymoma
- infectious mononucleosis
Pathophysiology of minimal change disease (cause of nephrotic syndrome?
T-cell and cytokine-mediated damage to the glomerular basement membrane → polyanion loss
the resultant reduction of electrostatic charge → increased glomerular permeability to serum albumin
Features of minimal change disease?
nephrotic syndrome
normotension - hypertension is rare
highly selective proteinuria
only intermediate-sized proteins such as albumin and transferrin leak through the glomerulus
signs on renal biopsy
Signs on renal biopsy in minimal change disease?
normal glomeruli on light microscopy
electron microscopy shows fusion of podocytes and effacement of foot processes
Mx of minimal change disease (cause of nephrotic syndrome)?
oral corticosteroids (80% steroid responsive)
if resistant= cyclophosphamide
Prognosis of minimal change disease (causing nephrotic syndrome)?
1/3 have just one episode
1/3 have infrequent relapses
1/3 have frequent relapses which stop before adulthood
normotension - hypertension is rare
highly selective proteinuria
(only intermediate-sized proteins such as albumin and transferrin leak through the glomerulus)
renal biopsy= electron microscopy shows fusion of podocytes and effacement of foot processes
Minimal change disease causing nephrotic syndrome
Measles?
Measles is a highly contagious, airborne infection caused by a morbillivirus of the paramyxovirus family.
Infects via the resp tract.
Once infected with measles, the pt develops…
lifelong immunity
Cx of measles?
- otitis media (most common)
- pneumonia (most common cause of death)
- encephalitis= 1-2w following onset of illness
- subacute sclerosing panencephalitis= very rare, 5-10yrs following illness
- febrile convulsions
- keratoconjunctivitis, corneal ulceration
- diarrhoea
- increased incidence appendicitis
- myocarditis
Measles tends to be more severe in who?
adults, infants, immunocompromised people, during pregnancy
Prognosis of mealses?
usually self-limiting, symptoms resolve over about a week
What symptoms are highly suggestive of measles?
- prodromal symptoms= fever (39C+), cough, coryza, conjunctivitis
- maculopapular rash (with or without Koplik’s spots)
Measles differential diagnosis?
Parvovirus B19, or fifth disease (also known as slapped cheek syndrome).
Streptococcal infection (for example, scarlet fever).
Herpes virus type 6 (roseola infantum).
Rubella.
Kawasaki disease.
Early meningococcal disease.
Mx once measles is suspected?
- notify local Health Protection Team (HPT) to confirm clinical diagnosis
- Rest, drink fluids, paracetamol/ibuprofen
- susceptible pt who are unwell= specialist advcie or admission
- advice from HPT for Mx if immuocomp, pregnant or infants who have been in contact with measles
School/work exclusion advice for measles?
exclusion for 4d after initial development of rash and avoid susceptible people
When may admission be necessary for measles?
serious Cx eg. pneumonia, neuro problems (febrile convulsions, encephalitis)
Prodromal phase in measles?
occurs 10–12 days after contracting the infection and lasts for 2–4 days before the rash becomes apparent.
increasing fever (typically 39C without antipyretics), malaise, cough, rhinorrhoea, and conjunctivitis.
This latter symptom may help differentiate measles from other flu-like illnesses.
Fever in measles?
increases during the prodromal phase to around 39ºC at about the time the rash appears, and then gradually decreases
Koplik’s spots in measles?
may appear on the buccal mucosa at the end of the prodromal phase, a day or so before, or around the same time as the rash, and disappear over the next 2-3 days.
2–3 mm red spots with white or blue-white centres.
These are pathognomonic for measles but can easily be confused with other mouth lesions.
Rash in measles?
erythematous and maculopapular and may become confluent as it progresses.
It appears on the face and behind the ears first (when other symptoms tend to be at their most severe), before descending down the body to the trunk and limbs, and forming on the hands and feet last, over the course of about 3–4 days.
The rash fades after it has been present on an area for about 5 days, with the total duration of rash being up to 1 week, after which time the person should feel better.
What pts with measles may not have a rash?
immunocompromised
In cases of measles in those who have been vaccinated or previously been infected (breakthrough or modified measles), sypmtoms may be
mild and have a shorter duration, and there may not be the typical rash.
rare
Ix for measles?
- notify public health if suspect clinically
- they will send pt oral fluid testing kit for IgM/IgG and/or viral RNA testing to confirm diagnosis
How to manage possible contacts of measles?
contact public health if= immunocomp, <1yr, preg, MMR vaccine contraindicated:
- immunoglobin in infants <6m within 72hrs; MMR in others within 3d (repeat after at least 1m; if <15m when had 2 doses then give 3rd dose at 18m; if <12m with 2 doses give a further 2 doses
Measles caused by what virus?
RNA paramyxovirus
one of most infectious viruses
How is measles spread?
aerosol transmission
When is pt with measles infective?
from prodrome until 4d after rash starts
Measles incubation period?
10-14d
Summarise features of measles?
- prodrome= fever, irritable, conjunctivitis
- Koplik spots before the rash= white spots on buccal mucosa
- rash= behind ears then to whole body; discrete maculopapular becoming blotchy and confluent; desquamation typically spares the palms and soles may occur after a week
- diarrhoea in 10%
What may occur in pt with measles after a w?
desquamation that typically spares the palms and soles may occur
Where does measles rash start and what does it look like?
starts behind ears then to the whole body
discrete maculopapular rash becoming blotchy & confluent
Ix to diagnose measles?
IgM antibodies can be detected within a few days of rash onset
Summarise Mx of measles?
mainly supportive
admission may be considered in immunosuppressed or pregnant patients
notifiable disease → inform public health
Most common Cx of measles?
otitis media
Most common cause of death in measles?
pneumonia
What is a very rare Cx of measles that presents 5-10yrs following illness?
subacute sclerosing panencephalitis
Summarise Mx of contacts in measles?
if a child not immunized against measles comes into contact with measles then MMR should be offered (vaccine-induced measles antibody develops more rapidly than that following natural infection)
this should be given within 72 hours
Constipation?
decrease in the frequency of bowel movements, characterized by the passing of hardened stools that may be large and associated with straining and pain.
Normal stool frequency in children?
4 per day in 1st week of life to 2 per day at 1yrs
Between 3 per day and 3 per week is usual by 4yrs
Functional (idiopathic) constipation?
constipation that cannot be explained by any anatomical or physiological abnormality
Contributing factors for constipation?
pain, fever, inadequate fluid intake, reduced fibre intake, toilet training issues, effects of drugs, psychosocial issues, FHx
What clinical features indicate a child has constipation?
2 or more of:
- <3 complete stools per week (unless exclusively breastfed-stools may be infrequent)
- hard large stool
- rabbit droppings stool
- overflow soiling in children >1yrs (loose, smelly, passed without sensation/awareness)
When to suspect faecal impaction in a child?
- Hx of severe constipation
- overflow soiling
- faecal mass palpable on abdo exam
Ix for constipation?
- no Ix for idiopathic/functional
- if diagnosed then exclude underlying cause:
if red flags= urgent referral without Tx in primary care; amber flags= referral and Tx in primary care
Mx of functional (idiopathic) constipation?
- maintenance laxtative Tx
- impaction= disimpaction regimen
- Behavioural interventions= scheduled toileting, bowel habit diary, rewards system
- fluid and fibre intake
Dietary advice for child with constipation?
high fibre= fruit, veg, high fibre bread, baked beans, wholegrain cereals
Approximately three-quarters of the daily fluid requirement in children is obtained from
water in drinks
Higher intakes of total water will be required for children who are
physically active, exposed to hot environments, or obese.
Recommended fluid intake per day (including water in food) roughly= infant 0-6m?
700mL (from milk)
Recommended fluid intake per day (including water in food) roughly= babies 7-12m?
800 mL from milk and complementary foods and beverages, of which 600 mL is assumed to be water from drinks.
Recommended fluid intake per day (including water in food) roughly= child 1-3yrs?
1300mL (900mL from drinks)
Recommended fluid intake per day (including water in food) roughly= child 4-8yrs?
1700mL (1200mL from drinks)
Recommended fluid intake per day (including water in food) roughly= 9-13yrs?
boys= 2400mL (1800mL from drinks)
girls= 2100mL (1600mL from drinks)
Recommended fluid intake per day (including water in food) roughly= 14-18yrs?
boys= 3300mL (2600mL from drinks)
girls= 2300mL (1800mL from drinks)
Laxative regimen for child with constipation?
- Movicol Paediatric Plain/Movicol
- If fails after 2w then + a stimulant (if stool hard add lactulose/docusate)
Treat faecal impaction in children?
may initially increase symptoms of soiling and abdo pain
1) oral laxative regimen then review within 1w= Movicol Paediatric Plan
2) Once disimpacted start maintenance laxative Tx (half of the disimpaction dose)
Mx of constipation in children (functional)?
Maintenance Tx (even if only constipated for few days) aim for regular soft stools
1) Movicol Paediatric Plain
2) Persists then add stimulant; if hard consider + lactulose
3) Continue dose for several weeks after regular bowel movements established
4) Specialist advice if fails after 3m if >1yr or 4w if <1yr
5) follow up
Secondary care Mx of functional constipation in children if primary care Tx fails?
- manual evacuation of bowel under anaesthesia (oral and rectal meds failed)
- Psychological/behavioural interventions eg. toilet training
- polyethylene glycol solutions for whole-gut lavage (often via nasogastric tube).
- antegrade colonic enema (a surgical procedure).
What features suggest idiopathic constipation in children?
- meconium passed within 48hrs of birth (full-term baby)
- constipation after a few weeks after birth at least
- precipitating factors= poor diet/fluids; anal fissure; infection; opitates/sedating antihistimines; timing of toilet training; psychosocial factors
Physical exam in child with idiopathic constipation?
There is normal appearance of the anus and surrounding area. Digital rectal examination is not routinely required to make the diagnosis.
The abdomen is soft and flat, or distended only to a degree consistent with age or excess weight.
They are generally well with normal development, and height and weight are within normal limits.
Motor and neurodevelopment are within normal limits (including normal gait, tone, and power in lower limbs).
How to know if constipation in child is associated with perianal strep infection?
bright red erythema and local oedema
Red flags in constipation in children (suggest serious underlying cause)?
- present from birth or 1st few weeks of like ?Hirschsprungs
- > 48hrs to pass meconium ?Hirschspungs or CF
- abdo distension with vomiting ?H
- FHx H
- Ribbon stool pattern <1yr ?anal stenosis
- leg weakness or motor delay
- fistuale, fissure, bruising, tight anus
- lumbosacral or gluteal abnormalities: asymmetry ect
Amber flags in constipation in children (specialist referral but can be Tx in primary care until assessment)?
- faltering growth, developmental delay, systemic features
- started on intro of cows milk
- possible maltreatment
Movicol Paediatric Plain (macrogol) for constipation in children?
Polyethylene glycol 3350 plus electrolytes (macrogol)= can add fruit squash: 1 sachet in 62.5mL water
Movicol if 12yrs+
Movicol Paediatric Plain (macrogol) for constipation in children doses?
polyethylene 3350 plus electrolytes (MPP):
1-11m= half sachet daily
1-6yrs= 1 sachet daily
7-11yrs= 2 sachets daily
Movicol:
12-18hrs= 1 sachet daily
adjust to produce regular soft stools eg. 1 sachet every 2-3d
Movicol Paediatric Plain (macrogol) for constipation with impaction in children doses?
Disimpaction MPP:
1-11m= half sachet daily
1-5yrs= 2 sachets day 1, then 4 for 2d, then 6 for 2 days then 8 daily until resolves
5-12yrs= 4 sachets day 1, then increase by steps of 2 daily to max of 12 daily until impaction resolves
Movicol:
12-18yrs= 4 on day 1, then increase by steps of 2 until max 12 daily until resolves
then for maintenance use half the disimpaction dose
Constipation definition in child <1yr?
2+ of:
stool pattern= Fewer than 3 complete stools per week (type 3 or 4 on Bristol Stool Form Scale) (this does not apply to exclusively breastfed babies after 6 weeks of age); Hard large stool ‘Rabbit droppings’ (type 1)
Symptoms associated with defecation= Distress on passing stool; Bleeding associated with hard stool; Straining
History= Previous episode(s) of constipation; Previous or current anal fissure
Constipation definition in child >1yr?
2+ of:
stool pattern= Fewer than 3 complete stools per week (type 3 or 4); Overflow soiling (commonly very loose, very smelly, stool passed without sensation); ‘Rabbit droppings’ (type 1); Large, infrequent stools that can block the toilet
Symptoms associated with defecation= Poor appetite that improves with passage of large stool; Waxing and waning of abdominal pain with passage of stool; Evidence of retentive posturing: typical straight-legged, tiptoed, back arching
posture; straining; anal pain
History= Previous episode(s) of constipation; Previous or current anal fissure; Painful bowel movements and bleeding associated with hard stools
Causes of constipation in children?
idiopathic
dehydration
low-fibre diet
medications: e.g. Opiates
anal fissure
over-enthusiastic potty training
hypothyroidism
Hirschsprung’s disease
hypercalcaemia
learning disabilities
> 48hrs to pass meconium
? Hirschsprungs disease or CF
Ribbon stools
red flag in child constipation
Normal time to pass meconium?
<48hrs
Should you do a digital rectal exam on a child if you suspect impactation?
only by specialist
Summarise Mx of faecal impaction in child?
polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen as the first-line treatment
+ a stimulant laxative if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks
substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if Movicol Paediatric Plain is not tolerated
inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain
Summary of Mx of constipation in children?
first-line: Movicol Paediatric Plain
add a stimulant laxative if no response
substitute a stimulant laxative if Movicol Paediatric Plain is not tolerated. Add another laxative such as lactulose or docusate if stools are hard
continue medication at maintenance dose for several weeks after regular bowel habit is established, then reduce the dose gradually
General points for constipation in children?
do not use dietary interventions alone as first-line treatment although ensure the child is having adequate fluid and fibre intake
consider regular toileting and non-punitive behavioural interventions
for all children consider asking the Health Visitor or Paediatric Continence Advisor to help support the parents.
Mx of constipation in infants not yet weaned (<6m)?
bottle-fed infants: give extra water in between feeds. Try gentle abdominal massage and bicycling the infant’s legs
breast-fed infants: constipation is unusual and organic causes should be considered
Mx of constipation in infants who have been or being weaned?
offer extra water, diluted fruit juice and fruits
if not effective consider adding lactulose
What type of infection is croup?
URTI
Stridor caused by combination of laryngeal oedema and secretions
croup
Peak incidence of croup?
6m-3yrs
What time of year is croup most common?
autumn
Features of croup?
- cough= barking seal-like, worse at night
- stridor= DO NOT examine throat
- fever
- coryzal symptoms
- increased work of breathing eg. retraction
Mild croup?
-Occasional barking cough
- No audible stridor at rest
- No or mild suprasternal and/or intercostal recession
- The child is happy and is prepared to eat, drink, and play
Moderate croup?
- Frequent barking cough
- Easily audible stridor at rest
- Suprasternal and sternal wall retraction at rest
- No or little distress or agitation
- The child can be placated and is interested in its surroundings
Severe croup?
- Frequent barking cough
- Prominent inspiratory (and occasionally, expiratory) stridor at rest
- Marked sternal wall retractions
- Significant distress and agitation, or lethargy or restlessness (a sign of hypoxaemia)
- Tachycardia occurs with more severe obstructive symptoms and hypoxaemia
Why to not examine throat in croup?
risk of precipitating airway obstruction
When to admit a child with croup?
- moderate or severe croup
- <3m
- known upper airway abnormality eg. laryngomalacia, Down’s
- uncertain about diagnosis
Croup differentials?
acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation
Ix for croup?
- most clinically
- CXR= steeple sign (PA view shows subglottic narrowing)
Mx for croup?
single dose oral dexamethasone (0.15mg/kg) regardless of severity (alternative is pred)
Emergency Tx= nebulised adrenaline and high flow O2
Another name for croup?
laryngotracheobronchitis
Most common cause of croup?
parainfluenza virus type 1 or 3
Symptoms in croup?
Symptoms are typically worse at night and increase with agitation.
Prodromal, non-specific upper respiratory tract symptoms (cough, rhinorrhoea, coryza, and fever) may have been present for between 12 and 72 hours.
The clinical features of croup result from inflammation, swelling of upper airway structures (larynx, vocal cords and trachea), and oedema, leading to narrowing of the subglottic region.
Impending respiratory failure in croup?
increasing upper airway obstruction, sternal/intercostal recession, asynchronous chest wall and abdominal movement, fatigue, pallor or cyanosis, decreased level of consciousness or tachycardia. The degree of chest wall recession may diminish with the onset of respiratory failure as the child tires.
How long for symptoms of croup to resolve?
48hrs but can be up to 1w
What if child with croup is too unwell to take oral dexamethasone single dose?
inhaled budesonide (2 mg nebulised as a single dose) or intramuscular dexamethasone (0.6 mg/kg as a single dose) are possible alternatives.
When is IV fluid generally required?
if child is >10% dehydrated or 5-10% and oral/enteral rehydration not tolerated/possible
Child less than 10% dehydrated?
oral rehydration adequate
24hr fluid requirement in child <10kg?
100 mL/kg
24hr fluid requirement in child 10-20kg?
100 mL/kg for the first 10 kg
50 mL/kg for each 1 kg body weight over 10 kg
24hr fluid requirement in child >20kg?
100 mL/kg for the first 10 kg
50 mL/kg for each 1 kg body weight between 10-20 kg
20 mL/kg for each 1 kg body weight over 20 kg
(max. 2 litres in females, 2.5 litres in males)
Fluid used in fluid therapy for children?
0.9% sodium chloride + 5% dextrose
potassium is added as required
Abnormal development/developmental delay?
significant lag in a child’s physical, cognitive, behavioural, emotional, or social development, relative to established growth milestones.
It is crucial for clinicians to identify and address these delays promptly to improve long-term outcomes.
Main areas in childhood development?
Gross motor
Fine motor and Vision
Hearing, speech and language
Social, emotional and behavioural
What may cause abnormal child development?
genetic disorders; prenatal exposure to toxins/drugs/alcohol; premature; nutritional deficiencies; environmental factors
Examples of developmental delay?
doesn’t smile at 10w
can’t sit unsupported at 12m
can’t walk at 18m
What is fine motor skill in children is abnormal?
hand preference before 12m is abnormal and may indicate cerebral palsy
Most common causes of gross motor problems in development?
variant of normal, cerebral palsy and neuromuscular disorders eg. Duchenne muscular dystrophy
Causes of speech and language delay in development?
always check hearing
environmental deprivation and general developmental delay
Differential diagnosis for developmental delay?
1) ASD
2) Cerebral palsy
3) Fragile X syndrome
4) Down syndrome
5) Fetal Alcohol Spectrum Disorders (FASDs)
Fetal Alcohol Spectrum Disorders (FASDs)
A range of effects that can occur in an individual exposed to alcohol before birth.
Autism Spectrum Disorder (ASD)
Characterised by impairments in social interaction and communication alongside restricted interests and repetitive behaviours.
What does the initial Mx of a child with suspected developmental delay involve?
1) examination= physical and neuro for developmental milestones
2) Ix= genetic testing, metabolic screening, neuroimaging (MRI/CT), hearing/vision assessment
3) Refer for specialist assessment
4) Early intervention Services= regardless of cause; eg. occupational therapy, SALT, physio and educational support
Vision and fine motor development= 3m?
Reaches for object
Holds rattle briefly if given to hand
Visually alert, particularly human faces
Fixes and follows to 180 degrees
Vision and fine motor development= 6m?
Holds in palmar grasp
Pass objects from one hand to another
Visually insatiable, looking around in every direction
Vision and fine motor development= 9m?
Points with finger
Early pincer
Vision and fine motor development= 12m?
Good pincer grip
Bangs toys together
Vision and fine motor development= tower of 2 bricks
15m
Vision and fine motor development= tower of 3 bricks?
18m
Vision and fine motor development= tower of 6 bricks?
2yrs
Vision and fine motor development= tower of 9 bricks?
3yrs
Vision and fine motor development= draws a circular scribble?
18m
Vision and fine motor development= copies vertical line?
2yrs
Vision and fine motor development= copies a circle?
3yrs
Vision and fine motor development= copies a cross?
4yrs
Vision and fine motor development= copies a square and triangle?
5yrs
Vision and fine motor development= looks at a book, pats page?
15m
Vision and fine motor development= turns pages of a book several at a time?
18m
Vision and fine motor development= turns pages of a book one at a time?
2yrs
Hand preference before what age is abnormal and what may it indicate?
12m
cerebral palsy
Vision and fine motor development= reaches for objects, holds rattle briefly if given to hand, visually alert; fixes and follows to 180 degrees?
3m
Vision and fine motor development= palmar grasp; pass objects from one hand to another; looks around in every direction?
6m
Vision and fine motor development= points with finger and early pincer?
9m
Vision and fine motor development= good pincer grip and bangs toys together?
12m
Gross motor milestones= 3m?
Little or no head lag on being pulled to sit
Lying on abdomen, good head control
Held sitting, lumbar curve
Gross motor milestones= 6m?
Lying on abdomen, arms extended
Lying on back, lifts and grasps feet
Pulls self to sitting
Held sitting, back straight
Rolls front to back
Gross motor milestones= 7-8m?
Sits without support (Refer at 12 months)
Gross motor milestones= 9m?
Pulls to standins
Crawls
Gross motor milestones= 12m?
Cruises
Walks with one hand held
Gross motor milestones= 13-15m?
Walks unsupported (Refer at 18 months)
Gross motor milestones= 18m?
squats to pick up a toy
Gross motor milestones= 2yrs?
Runs
Walks upstairs and downstairs holding on to rail
Gross motor milestones= 3yrs?
Rides a tricycle using pedals
Walks up stairs without holding on to rail
Gross motor milestones= 4yrs?
Hops on one leg
Most children crawl on all fours before walking but what if child ‘bottom-shuffles’?
normal variant and runs in families
Gross motor milestones= little or no head lag on being pulled to sit; Lying on abdomen, good head control; Held sitting, lumbar curve?
3m
Gross motor milestones= pulls self to sitting; rolls front to back; held sitting with back straight; lying on abdo arms extended; lying on back lifts and grasps feet?
6m
Gross motor milestones= sits without support?
7-8m (refer at 12m)
Gross motor milestones= crawls and pulls to standing?
9m
Gross motor milestones= cruises and walks with one hand held?
12m
Gross motor milestones= walks unsupported?
13-15m (refer at 18m)
Gross motor milestones= squats to pick up a toy?
18m
Gross motor milestones= runs; walks up and down stairs holding onto rail?
2yrs
Gross motor milestones= tricycle using pedals; walks up stairs without rail?
3yrs
Gross motor milestones= hops on one leg?
4yrs
Social, emotional and behavioural milestones= 6w?
smiles (refer at 10w)
Social, emotional and behavioural= 3m?
laughs, enjoys friendly handling
Social, emotional and behavioural= 6m?
not shy
may put hand on bottle when being fed
Social, emotional and behavioural= 9m?
shy; takes everything to mouth
plays peek-a-boo
Social, emotional and behavioural= 12m?
waves bye-bye
plays pat-a-cake
Social, emotional and behavioural= 12-15m?
drinks from cup + uses spoon, develops over 3m period
helps getting dressed/undressed
Social, emotional and behavioural= 18m?
takes off shoes, hat but unable to replace
plays contentedly alone
Social, emotional and behavioural= 2yrs?
competent with spoon, doesn’t spill with cup
puts hat and shoes on
plays near others but not with them (parallel play)
Social, emotional and behavioural= 3yrs?
uses spoon and fork
Social, emotional and behavioural= 4yrs?
can dress and undress independently except for laces and buttons
plays with other children
Social, emotional and behavioural= 5yrs?
uses knife a fork
Social, emotional and behavioural= smiles?
6w (refer at 10w)
Social, emotional and behavioural= laughs and enjoys friendly handling?
3m
Social, emotional and behavioural= not shy; may put hand on bottle when being fed?
6m
Social, emotional and behavioural= shy, takes everything to mouth; plays peek-a-boo?
9m
Social, emotional and behavioural= waves bye-bye and plays pat-a-cake?
12m
Social, emotional and behavioural= drinks from cup + uses spoon (develops over 3m period); helps getting dressed/undressed?
12-15m
Social, emotional and behavioural= takes off shoes and hat but unable to replace; plays contentedly alone?
18m
Social, emotional and behavioural= competent with spoon and doesn’t spill with cup; puts on hat and shoes; plays near others but not with them (parallel play)?
2yrs
Social, emotional and behavioural= can dress and undress independently except for laces and buttons; plays with other children?
4yrs
Social, emotional and behavioural= uses knife and fork?
5yrs
Speech, language and hearing milestones= 3m?
Quietens to parents voice
Turns towards sound
Squeals
Speech, language and hearing milestones= 6m?
Double syllables ‘adah’, ‘erleh’
Speech, language and hearing milestones= 9m?
says mama and dada
understands no
Speech, language and hearing milestones= 12m?
knows and responds to own name
Speech, language and hearing milestones= 12-15m?
knows about 2-6 words (refer at 18m)
understands simple commands- ‘give it to mummy’
Speech, language and hearing milestones= 2yrs?
combines 2 words
points to parts of the body
Speech, language and hearing milestones= 2 1/2 yrs?
vocab of 200 words
Speech, language and hearing milestones= 3yrs?
Talks in short sentences (e.g. 3-5 words)
Asks ‘what’ and ‘who’ questions
Identifies colours
Counts to 10 (little appreciation of numbers though)
Speech, language and hearing milestones= 4yrs?
Asks ‘why’, ‘when’ and ‘how’ questions
Speech, language and hearing milestones= Quietens to parents voice; Turns towards sound; Squeals?
3m
Speech, language and hearing milestones= Double syllables ‘adah’, ‘erleh’?
6m
Speech, language and hearing milestones= Says ‘mama’ and ‘dada’;
Understands ‘no’?
9m
Speech, language and hearing milestones= knows and responds to own name?
12m
Speech, language and hearing milestones=
Speech, language and hearing milestones=Knows about 2-6 words; Understands simple commands - ‘give it to mummy’?
12-15m (refer at 18m if doesn’t know 2-6 words)
Speech, language and hearing milestones= combines 2 words and can point to parts of the body?
2yrs
Speech, language and hearing milestones= vocabulary of 200 words?
2 1/2 yrs
Speech, language and hearing milestones= Talks in short sentences (e.g. 3-5 words); Asks ‘what’ and ‘who’ questions; Identifies colours; Counts to 10 (little appreciation of numbers though)?
3yrs
Speech, language and hearing milestones= Asks ‘why’, ‘when’ and ‘how’ questions?
4yrs
Gross motor milestones= Raises head to 45 degrees in prone (tummy-time)?
6-8w
Vision and fine motor milestones= Transfers toys from one hand to another?
7m (refer at 9m)
Hearing, speech and language development= startles to loud noise?
newborn
Hearing, speech and language development= Vocalises alone or when spoken to, coos and laughs “aa, aa”?
3-4m
Social, emotional and behavioural= Symbolic play (uses objects to represent other objects)?
18-24w (refer 2-2.5yrs)
Social, emotional and behavioural= Toilet training dry by day?
2yrs
Test to screen for Down’s syndrome?
combined test
When should the combined test be done to screen for Down’s syndrome?
between 11-13+6 weeks
What does the combined test to screen for Down’s include? (3)
nuchal translucency measurement + serum B-HCG + pregnancy-associated plasma protein A (PAPP-A)
What results from the combined test suggest Down’s syndrome?
↑ HCG, ↓ PAPP-A, thickened nuchal translucency
Results that suggest trisomy 18 (Edward syndrome) and 13 (Patau) in screening?
combined test= similar to Downs but hCG LOWER
so lower HCG, ↓ PAPP-A, thickened nuchal translucency
What if women books later in pregnancy and so she misses the combined test to screen for Down’s which should be done at 11-13+6w?
Quadruple test
offered if women book later in pregnancy, offered betweeen 15-20w
When is the quadruple test to screen for Down’s offered if the women misses the combined test (eg. booked in later than 13+6w)?
between 15-20w
Antenatal testing: what is included in the quadruple test? (4)
alpha-fetoprotein,
unconjugated oestriol, human chorionic gonadotrophin and inhibin A
Quadruple test results that suggest Down’s syndrome?
alpha-fetoprotein= ↓
unconjugated oestriol= ↓
human chorionic gonadotrophin= ↑
Quadruple test results that suggest Edward’s syndrome?
alpha-fetoprotein= ↓
unconjugated oestriol= ↓
human chorionic gonadotrophin= ↓
Quadruple test results that suggest neural tube defects?
alpha-fetoprotein= ↑
unconjugated oestriol= ↔
human chorionic gonadotrophin= ↔
What type of result do the combined and quadruple tests in antenatal screening return?
either a ‘lower chance’ or ‘higher chance’ result
lower chance= 1 in 150 chance or more eg. 1 in 300
higher= 1 in 150 chance or less eg. 1 in 100
Antenatal screening: what if women has a ‘higher chance’ result on combined or quadruple test?
offered a second screening test (NIPT) or a diagnostic test (e.g. amniocentesis or chorionic villus sampling (CVS)
NIPT preferred as non-invasive and very high sensitivity and specificity
How does the NIPT test work?
analyses small DNA fragments that circulate in the blood of a pregnant woman (cell free fetal DNA, cffDNA)
cffDNA derives from placental cells and is usually identical to fetal DNA
analysis of cffDNA allows for the early detection of certain chromosomal abnormalities
What does the NIPT test stand for?
Non-invasive prenatal screening test
Is the NIPT test good?
sensitivity and specificity are very high for trisomy 21 (>99%) and similarly high for other chromosomal abnormalities
private companies (e.g. Harmony) offer NIPT screening from
10w gestation
Antenatal screening eg. for Down’s syndrome- how is it done (steps)?
1) Combined test= 11-13+6w
or quadruple test 15-20w (only if miss the combined)
2) If result comes back as ‘higher chance’, women is offered NIPT (preferred) or diagnostic test (eg. amniocentesis or chorionic villus sampling)
Risk of Down’s depending on maternal age?
increased in age…
20yrs 1 in 1,500
30 1 in 800
35 1 in 270
40 1 in 100
45 1 in 50 or greater
remember this is by starting at 1/1,000 at 30 years and then dividing the denominator by 3 (i.e. 3 times more common) for every extra 5 years of age
Down’s syndrome genetics?
mode:
- nondisjunction (94% of cases)= risk of recurrence is 1 in 100 if mother <35yrs
- Robertsonian translocation
(usually onto 14) (5%)= risk of recurrence is 10-15% if mother is translocation carrier or 2.5% if father is translocation carrier - Mosaicism (1%)
Mosaicism?
the presence of two genetically different populations of cells in the body
Mosaicism in Down’s?
caused by a random event shortly after the egg and sperm join together. When cells are dividing, some cells receive an extra copy of chromosome 21. Others do not. People with mosaic Down syndrome have some cells with two and some cells with three copies of chromosome 21
diagnosed when there is a mixture of two types of cells. Some have the usual 46 chromosomes, and some have 47. Those cells with 47 chromosomes have an extra chromosome 21
Chance of a further child with Down’s syndrome?
approx 1 in 100 if the mother is less than 35 years old. If the trisomy 21 is a result of a translocation the risk is much higher
Clinical features of Down’s syndrome?
face= upslanting palpebral fissures, epicanthic folds, Brushfield spots in iris, protruding tongue, small low-set ears, round/flat face
flat occiput
single palmar crease, pronounced ‘sandal gap’ between big and first toe
hypotonia
congenital heart defects (40-50%)
duodenal atresia
Hirschsprung’s disease
Name 3 clinical features associated with Down’s syndrome (not appearance)?
congenital heart defects (40-50%)
duodenal atresia
Hirschsprung’s disease
Name some facial features in Down’s syndrome? (6)
upslanting palpebral fissures
epicanthic folds
Brushfield spots in iris
protruding tongue
small low-set ears
round/flat face
Name 3 features that affect appearance in down’s syndrome other than facial features?
flat occiput
single palmar crease,
hypotonia
Cardiac Cx associated with Down’s syndrome? (5)
multiple may be present
endocardial cushion defect (most common, 40%, also known as atrioventricular septal canal defects)
ventricular septal defect (c. 30%)
secundum atrial septal defect (c. 10%)
tetralogy of Fallot (c. 5%)
isolated patent ductus arteriosus (c. 5%)
Name some later Cx in Down’s syndrome? (8)
- sub fertility
- learning difficulties
- short stature
- repeated resp infections (+hearing impairment from glue ear)
- ALL
- hypothyroidism
- Alzheimer’s disease
- atlantoaxial instability
How is fertility affected in Down’s?
Males are almost always infertile due to impaired spermatogenesis.
Females are usually subfertile, and have an increased incidence of problems with pregnancy and labour.
Name some conditions associated with down’s syndrome?
Features= duodenal atresia, Hirschsprungs and congenital heart defects
Later Cx= ALL, alzheimer’s, hypothyroidism, atlantoaxial instability
upslanting palpebral fissures, epicanthic folds, Brushfield spots in iris, protruding tongue, small low-set ears, round/flat face
flat occiput
single palmar crease
hypotonia
Down’s syndrome
Vision problems in Down’s syndrome?
refractive errors are more common
strabismus: seen in around 20-40%
cataracts: congenital and acquired are both more common
recurrent blepharitis
glaucoma
Hearing problems in Down’s syndrome?
otitis media and glue ear very common= hearing problems
Gastro-oesophageal reflux (GOR)?
describes the passage of gastric contents into the oesophagus with or without regurgitation and/or vomiting.
It is considered a normal physiological process after feeds and meals in healthy infants, and it is often asymptomatic.
Gastro-oesophageal reflux disease (GORD)?
GOR that causes troublesome symptoms or complications that may need treatment.
It can be clinically difficult to differentiate between GOR and GORD.
Why does GOR occur in healthy infants?
result of transient lower oesophageal sphincter relaxation and other anatomical and physiological features
normal process after feeds in infants
RFs for GOR?
preterm birth, parental history, obesity, hiatus hernia, neurodevelopmental disorders or genetic conditions, asthma, and cystic fibrosis.
Cx of GOR?
most don’t get any Cx
reflux oesophagitis, oesophageal stricture, faltering growth, aspiration pneumonia, and dental erosion.
Prognosis of GOR?
generally self-limiting, and symptoms usually begin before the age of 8 weeks and resolve before one year of age in 90% of infants.
When should GORD (not GOR) be suspected in infants/children?
visible regurgitation and one or more of the following:
- Distressed behaviour such as excessive crying, crying when feeding, back arching.
- Hoarseness and/or chronic cough.
- A single episode of pneumonia.
- Unexplained feeding difficulties such as refusing to feed, gagging, choking.
- Faltering growth.
- Heartburn, retrosternal pain, or epigastric pain (in children over one year of age).
Assessment of a child with suspected GORD?
- red flags
- RFs and previous Tx
- abdo exam
- developmental history
- weight and growth
- feeding assessment eg. by health visitor
When to refer to paeds if a child has suspected GORD?
uncertainty; faltering growth; unexplained distress; GORD not responding to or needing ongoing treatment(s); feeding aversion; unexplained iron deficiency anaemia; onset after six months of age or persisting after one year of age.
Mx of GORD in children?
- advise about breastfeeding technique, positioning and attachment
- 1-2w trial of reducing feed volumes if formula fed
- 1-2w trial of thicken formula if formula fed
- 1-2w trial alginate theraoy
- consider trial of Mx for possible cow’s milk allergy if appropriate
- consider 4w trial of omeprazole suspension if appropriate
- consider referral if don’t resolve or reoccur
When do symptoms of regurg and GORD usually begin if they get it?
before 8w and 90% resolve before 1yr
if regurg +/or vomiting after 6m of age or >1yrs then ?different diagnosis
Pattern and estimated volume of regurgitation or vomiting in GORD in children?
nocturnal, immediately post-prandial, long after meals, digested or undigested).
Regurgitation may be frequent, with 5% of affected infants having six or more episodes each day.
Is there a diagnostic test to determine if the condition is GOR or GORD?
no
What to ask in feeding history in child with suspected GORD?
breast-, formula-, or mixed feeding, and any feeding problems, including resistance or refusal to feed or dietary restrictions.
If bottle-fed, ask about the type of formula used; how it is prepared; the size, timing, frequency, and duration of feeds; and the volume consumed over 24 hours.
If breastfed, ask about the timing, frequency, and duration of feeds; quality of milk supply; and any feeding problems.
Wet and dirty nappy frequency and any change.
Frequent, forceful (projectile) vomiting in infants up to 2m?
?hypertrophic pyloric stenosis
Bile-stained (green or yellow-green) vomit in infant?
? intestinal obstruction, for example, due to Hirschsprung disease, intestinal atresia, mid-gut volvulus, or intussusception.
Abdominal distension, tenderness, or palpable mass in infant + regurg/vomiting?
? intestinal obstruction or another acute surgical condition such as strangulated hernia or anatomic abnormality.
Bulging fontanelle or altered responsiveness (lethargy or irritability); rapidly increasing head circumference (more than 1 cm each week); vomiting worse in the morning or at night; persistent morning headache
? raised intracranial pressure (for example, caused by meningitis, hydrocephalus, or brain tumour)
Blood in the stool
? cow’s milk allergy, gastroenteritis, inflammatory bowel disease, or an acute surgical condition such as intussusception or mid-gut volvulus.
Chronic diarrhoea, may be associated with atopy
? cow’s milk allergy or food allergy
Onset of regurgitation and/or vomiting after 6 months of age or persisting after one year of age?
? suggests another cause for symptoms (not GORD/GOR), such as UTI.
When to arrange same day hospital admission in suspected GORD?
Blood-stained vomit (haematemesis) not caused by blood ingested from a nosebleed or cracked maternal nipple and/or melaena — suggesting an upper gastrointestinal bleed.
Bile-stained (green or yellow-green) vomiting, abdominal tenderness, mass, and/or distension — suggesting intestinal obstruction or another acute surgical condition needing paediatric surgery assessment.
Frequent, forceful (projectile) vomiting in infants up to two months of age — suggesting hypertrophic pyloric stenosis needing paediatric surgery assessment.
Fever and systemically unwell or dehydrated.
Dysphagia — for example, due to an oesophageal motility disorder or other obstruction.
How to reassure parent about their child with suspected GOR?
If an infant is well, thriving, and presents with effortless regurgitation of feeds and suspected gastro-oesophageal reflux (GOR)= It is normal and usually becomes less frequent with time and resolves in 90% of affected infants before one year of age.
It does not usually need further investigation or treatment.
Mx of suspected GORD in breastfed infant?
- breastfeeding technique
- if persists= 1-2w trial alginate therapy (Gaviscon infant)
- If improves= continue and stop Tx at regular intervals eg. every 2w to see if symptoms are improving and ?stop Tx
- No improvement= 4w trial omeprazole suspension
- Still no improvement= refer
What should you not recommend to Tx symptoms of GORD in sleeping infants?
Do NOT recommend the use of positional management (head elevation or left lateral positioning)
Mx of GORD in formula fed infant?
- reduce volume of feeds if XS for child’s weight
1) 1-2w trial smaller more frequent feeds
2) 1-2w trial thickened formula
3) unsuccessful= stop thickened formula and 1-2w trial Gaviscon infant (alginate therapy) added to infant formula
4) If works then continue and stop Tx at regular intervals eg. every 2w to see if symptoms are improving and ?stop Tx
Commonest cause of vomiting in infancy?
GOR (40% of infants regurg their feeds to certain extent so degree or normal physiology)
Features of GOR in children?
typically develops before 8 weeks
vomiting/regurgitation= milky vomits after feeds, may occur after being laid flat
excessive crying, especially while feeding
Diagnosis of GOR?
clinical
GOR vs GORD?
GOR=
A normal physiological process where stomach contents occasionally flow back into the oesophagus; Typically occurs after meals and resolves without intervention, especially in infants and young children.
Does not cause significant symptoms or complications in most cases
GORD= pathological condition where reflux causes troublesome symptoms or complications (e.g., oesophagitis, stricture, or Barrett’s oesophagus).; Symptoms include heartburn, regurgitation, chest pain, or difficulty swallowing, often requiring treatment.; Distinguished from GOR by frequency, severity, and impact on quality of life.
GOR is benign and transient, while GORD is a chronic condition requiring medical attention due to associated symptoms and risks.
How is GORD distinguished from GOR?
GORD distinguished from GOR by frequency, severity, and impact on quality of life.
GOR= no signif symptoms or Cx, resolves without intervention and normal
GORD= troublesome symptoms eg. pain, regurg; Cx eg. failure to thrive; impact on QOL, frequent and severe
Cx of GORD?
distress
failure to thrive
aspiration
frequent otitis media
in older children dental erosion may occur
What may be considered in child with GORD if there are severe Cx eg. failure to thrive?
if medical treatment is ineffective then fundoplication may be considered
IgA mediated small vessel vasculitis, usually seen in children following an infection? (degree of overlap with IgA nephropathy-Berger’s disease)
Henoch-Schonlein purpura
Features of Henoch-Schonlein purpura?
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
palpable purpuric rash (with localized oedema) over buttocks and extensor
surfaces of arms and legs, abdo pain, polyarthritis, haematuria?
Henoch-Schonlein purpura
Tx for Henoch-Schonlein purpura?
analgesia for arthralgia
Tx of nephropathy supportive
Prognosis of Henoch-Schonlein purpura (HSP)?
usually excellent, HSP is a self-limiting condition, especially in children without renal involvement
BP and urinanalysis should be monitored to detect progressive renal involvement
around 1/3rd of patients have a relapse
What should be monitored in child with Henoch-Schonlein purpura (HSP) to detect progressive renal involvement?
BP and urinalysis
2 types of abdo wall hernias in children?
Congenital inguinal hernia and Infantile umbilical hernia
Congenital inguinal hernia (abdo wall hernia)?
Indirect hernias resulting from a patent processus vaginalis
Occur in around 1% of term babies. More common in premature babies and boys
60% are right sided, 10% are bilaterally
Should be surgically repaired soon after diagnosis as at risk of incarceration
Congenital inguinal hernia (abdo wall hernia) Mx?
Should be surgically repaired soon after diagnosis as at risk of incarceration
Infantile umbilical hernia (abdo wall hernia)?
Symmetrical bulge under the umbilicus
More common in premature and Afro-Caribbean babies
The vast majority resolve without intervention before the age of 4-5 years
Complications are rare
Mx of Infantile umbilical hernia (abdo wall hernia)?
The vast majority resolve without intervention before the age of 4-5 years
primary attack of herpes occurs during pregnancy at greater than 28 weeks gestation
elective caesarean section at term is advised
women with recurrent herpes who are pregnant should be treated with
suppressive therapy and be advised that the risk of transmission to their baby is low
Causes of hypoglycaemia?
- insulinoma
- self-administration of insulin/sulphonylureas
- liver failure
- Addison’s
- alcohol
- nesidoblastosis
What is nesidoblastosis that causes hypoglycaemia?
beta cell hyperplasia
Why does insulinoma cause hypoglycaemia?
increased ratio of proinsulin to insulin
it is a tumour in your pancreas (makes extra insulin)
Why can alcohol cause hypoglycaemia?
causes exaggerated insulin secretion
mechanism is thought to be due to the effect of alcohol on the pancreatic microcirculation → redistribution of pancreatic blood flow from the exocrine into the endocrine parts → increased insulin secretion
2 physiological responses to hypoglycaemia?
hormonal response and sympathoadrenal response
Hormonal response (physiological) to hypoglycaemia?
the first response of the body is decreased insulin secretion. This is followed by increased glucagon secretion. Growth hormone and cortisol are also released but later
Sympathoadrenal response (physiological) to hypoglycaemia?
increased catecholamine-mediated (adrenergic) and acetylcholine-mediated (cholinergic) neurotransmission in the peripheral autonomic nervous system and in the central nervous system
Features of hypoglycaemia- what determines severity of symptoms?
Blood glucose levels and severity of symptoms are not always correlated, esp in pts with diabetes
Hypoglycaemia: blood glucose concentrations <3.3 mmol/L features?
cause autonomic symptoms due to the release of glucagon and adrenaline:
- Sweating
- Shaking
- Hunger
- Anxiety
- Nausea
Hypoglycaemia: blood glucose concentrations <2.8 mmol/L features?
cause neuroglycopenic symptoms due to inadequate glucose supply to the brain:
- Weakness
- Vision changes
- Confusion
- Dizziness
Severe and uncommon features of hypoglycaemia?
convulsion and coma
Symptoms of hypoglycaemia?
BM <3.3:
- sweating, shaking, hunger, anxiety, nausea
BM <2.8:
- weakness, vision changes, confusion, dizziness
Severe and rare:
- coma and convulsion
Ix for hypoglycaemia?
is cause is not clear then= serum insulin and c-peptide levels
Why do you measure serum insulin and c-peptide levels to Ix cause of hypoglycaemia?
insulin and C-peptide are released in equimolar amounts from the pancreas, making C-peptide a marker of endogenous insulin production.
Hypoglycaemia:
- High insulin level
- High c-peptide level
Interpretation and potential causes?
Interpretation= endogenous insulin production
Causes= Insulinoma, Sulfonylurea use/abuse
Hypoglycaemia:
- High insulin level
- Low c-peptide level
Interpretation and potential causes?
Interpretation= Exogenous insulin administration
Causes= Exogenous insulin overdose, Factitious disorder
Hypoglycaemia:
- Low insulin level
- Low c-peptide level
Interpretation and potential causes?
Interpretation= Non-insulin-related cause
Causes= Alcohol-induced hypoglycaemia, Critical illness (e.g., sepsis), Adrenal insufficiency, Growth hormone deficiency, Fasting/starvation
Mx of hypoglycaemia in the community (eg. DM pts who inject insulin)?
Initially, oral glucose 10-20g should be given in liquid, gel or tablet form
Alternatively, a propriety quick-acting carbohydrate may be given: GlucoGel or Dextrogel.
A ‘HypoKit’ may be prescribed which contains a syringe and vial of glucagon for IM or SC injection at home
Mx of hypoglycaemia in hospital setting?
If the patient is alert, a quick-acting carbohydrate may be given (like in the community)
If the patient is unconscious or unable to swallow, subcutaneous or intramuscular injection glucagon may be given.
Alternatively, intravenous 20% glucose solution may be given through a large vein
When was the 2009 H1N1 influenza (swine flue) outbreak first observed?
in Mexico in early 2009. In June 2009, the WHO declared the outbreak to be a pandemic.
pandemic caused by new strain of H1N1 virus
H1N1 virus?
subtype of influenzae A virus and most common cause of flu in humans
What groups are particularly at risk of H1N1 influenza?
patients with chronic illnesses and those on immunosuppressants
pregnant women
young children under 5 years old
Features of H1N1 influenza?
fever greater than 38ºC
myalgia
lethargy
headache
rhinitis
sore throat
cough
diarrhoea and vomiting
A minority of patients may go on to develop an acute respiratory distress syndrome which may require ventilatory support.
Tx of H1N1 influenza?
2 main Tx available:
1) Oseltamivir (Tamiflu)= oral
2) Zanamivir (Relenza)= inhaled (or IV if acutely unwell)
MOA and s/e of Oseltamivir (Tamiflu) for H1N1 influenzae?
a neuraminidase inhibitor which prevents new viral particles from being released by infected cells
nausea, vomiting, diarrhoea and headaches
MOA and s/e of Zanamivir (Relenza) for H1N1 influenzae?
a neuraminidase inhibitor
may induce bronchospasm in asthmatics
CT showing distension of small bowel loops proximally (duodenum and jejunum) with abrupt transition to intestinal segment of normal caliber. Presence of small amount of free fluid intracavity?
Small bowel obstruction secondary to adhesions
Abdominal film (x-ray) findings in small bowel obstruction?
Maximum normal diameter = 35 mm
Valvulae conniventes extend all the way across
Abdominal film (x-ray) findings in large bowel obstruction?
Maximum normal diameter = 55 mm
Haustra extend about a third of the way across
Intussusception?
Invagination of one portion of the bowel into the lumen of the adjacent bowel, most commonly around the ileo-caecal region
What age does intussusception usually affect?
6-18m old
boys>girls
Features of intussusception?
- intermittent, severe, crampy, progressive abdo pain
- inconsolable crying
- during paroxysm (attack) infant will draw knees up and turn pale
- vomiting
- bloodstained stool= ‘red-current jelly’ late sign
- sausage-shaped mass in RUQ
Sausage shaped mass in RUQ?
intussusception
What is a late sign of intussusception?
red-current jelly like stool (bloodstained)
Infant aged 6-18m draws knees up and turns pale during paroxysm (sudden attacks), inconsolable crying?
intussusception
Ix for intussusception?
USS= target like mass
Mx for intussusception?
1) reduction by air insufflation under radiological control
2) fails or signs of peritonitis= surgery
Kawasaki disease?
type of vasculitis predominately seen in children
rare but important to diagnose as serious Cx
Serious Cx of Kawasaki disease?
coronary artery aneurysm
Features of kawasaki? (6)
- high grade fever >5d resistant to antipyretics
- conjunctival injection
- bright red, cracked lips
- strawberry tongue
- cervical lymphadenopathy
- red palms of hands and soles of feet which later peel
Diagnosis of kawasaki?
clinical- no specific diagnostic test
Mx of kawasaki?
high-dose aspirin + IV Ig and ECHO to screen for coronary artery aneurysm
One of the only indications for aspirin use in children (due to the risk of Reye’s syndrome it is normally contraindicated in children)?
kawasaki
Type of fever in kawasaki?
high-grade, lasts for >5d and resistant to antipyretics
Acute bronchitis vs pneumonia?
History= Sputum, wheeze, breathlessness may be absent in acute bronchitis whereas at least one tends to be present in pneumonia.
Examination= No other focal chest signs (dullness to percussion, crepitations, bronchial breathing) in acute bronchitis other than wheeze. Moreover, systemic features (malaise, myalgia, and fever) may be absent in acute bronchitis, whereas they tend to be present in pneumonia.
Malnutrition definition?
BMI of less than 18.5; or
unintentional weight loss greater than 10% within the last 3-6 months; or
a BMI of less than 20 and unintentional weight loss greater than 5% within the last 3-6 months
Screening tool for malnutrition?
MUST (Malnutrition Universal Screen Tool).
Mx of malnutrition?
dietician support if the patient is at high-risk
a ‘food-first’ approach with clear instructions (e.g. ‘add full-fat cream to mashed potato’), rather than just prescribing oral nutritional supplements (ONS) such as Ensure
if ONS are used they should be taken between meals, rather than instead of meals
What causes mumps?
RNA paramyxovirus
When does mumps tend to occur?
in winter and spring
How is mumps spread?
by droplets
respiratory tract epithelial cells → parotid glands → other tissues
When is pt with mumps infective?
infective 7 days before and 9 days after parotid swelling starts
Incubation period for mumps?
14-21d
Clinical features of mumps?
- fever
- malaise, muscular pain
- parotitis (‘earache’, ‘pain on eating’)= unilaterally 1st then becomes bilateral in 70%
Prevention for mumps?
MMR vaccine= 80% efficacy
Mx for mumps?
- rest
- paracetamol for high fever/discomfort
- notifiable disease
Cx of mumps?
- orchitis
- hearing loss= unilateral and transient
- meningoencephalitis
- pancreatitis
Cx of mumps: orchitis?
uncommon in pre-pubertal males but occurs in around 25-35% of post-pubertal males. Typically occurs four or five days after the start of parotitis.
Unilateral= only transiently, diminish sperm count, mobility, and morphology.
Bilateral= 15-30% men; causes infertility in 30-87% of them.
Mumps?
acute infectious disease caused by a paramyxovirus, characterised by bilateral parotid swelling. It is spread by respiratory droplets, fomites or saliva.
When is mumps most infectious?
from around 1–2 days before onset of symptoms to about 9 days afterwards, although it may be asymptomatic in 15–20% of people.
Asymptomatic mumps infection is common in who?
children
Immunity to mumps after infection?
most have life-long immunity after 1 episode of infection
What may occur in mumps n 5% of post-pubertal women?
oophoritis but rarely causes infertility or premature menopause
Rare Cx of mumps?
cerebellar ataxia, facial palsy, transverse myelitis, and Guillain–Barre syndrome, thyroiditis, mastitis, prostatitis, hepatitis, and thrombocytopenia.
Any suspicion of mumps infection, what should you do?
inform local Health Protection Team
Mumps prognosis?
usually self resolves ever 1-2w with no long term Cx
School exclusion rules for mumps?
stay off for 5d after the initial development of parotitis
When to admit pt with mums to hospital?
There are signs of mumps encephalitis (for example, an altered level or loss of consciousness, focal neurological signs, or seizures).
The person develops mumps meningitis (characterized by severe headache, neck ache, high fever, lethargy, and vomiting).
Following epididymo-orchitis (particularly if it was bilateral), a man has an abnormal semen analysis or is experiencing infertility.
How to manage people who have been in contact with possible mumps?
offered immunization with the combined measles, mumps, and rubella vaccine if they are not already fully immunized, unless they are pregnant or severely immunocompromised.
Can MMR vaccine be given in pregnancy?
no as it is a live vaccine
How to manage pregnant women with suspected mumps/mumps exposure?
same way as otherwise healthy people but can’t give vaccine if a contact so if they develop symptoms seek medical advice
How to manage suspected mumps epididymo-orchitis?
Bed rest.
Scrotal support.
Application of warm or cold packs.
Paracetamol or ibuprofen.
Inform the man that, in most cases, the symptoms will completely resolve within 2 weeks, and there are unlikely to be long-term problems with fertility.
If the man is concerned about fertility, offer semen analysis at least 3 months after the mumps has resolved
Child abuse includes what?
physical, emotional, sexual abuse, neglect, fabricated or induced illness
Neglect= features where you should consider abuse?
Severe and persistent infestations (e.g. Scabies or head lice)
Parents who do not administer essential prescribed treatment
Parents who persistently fail to obtain treatment for tooth decay
Parents who repeatedly fail to attend essential follow-up appointments
Parents who persistently fail to engage with child health promotion
Failure to dress the child in suitable clothing
Animal bite on an inadequately supervised child
Neglect= features where you should suspect abuse?
Failure to seek medical advice which compromises the child’s health
Child who is persistently smelly and dirty
Repeat observations that:
- poor standards of hygiene that affects the child’s health
- inadequate provision of food
- living environment that is unsafe for the child’s development stage
Sexual abuse= features where you should consider abuse?
Persistent dysuria or anogenital discomfort without a medical explanation
Gaping anus in a child during examination without a medical explanation
Pregnancy in a young women aged 13-15 years
Hepatitis B or anogenital warts in a child 13-15 years
Sexual abuse= features where you should suspect abuse?
Persistent or recurrent genital or anal symptoms associated with a behavioural or emotional change
Anal fissure when constipation and Crohn’s disease have been excluded as the cause
STI in a child younger than 12 years (where there is no evidence of vertical or blood transmission)
Sexualised behaviour in a prepubertal child
Physical abuse= features where you should consider abuse?
Any serious or unusual injury with an absent or unsuitable explanation
Cold injuries in a child with no medical explanation
Hypothermia in a child without a suitable explanation
Oral injury in a child with an absent or suitable explanation
Physical abuse= features where you should suspect abuse?
Bruising, lacerations or burns in a child who is not independently mobile or where there is an absent or unsuitable explanation
Human bite mark not by a young child
One or more fractures if there is an unsuitable explanation, including:
- fractures of different ages
- X-ray evidence of occult fractures
Retinal haemorrhages with no adequate explanation
What factors point towards child abuse?
- story inconsistent with injuries
- repeated attendances at A&E (see different doctors)
- delayed presentation
- usual changes in behaviour/emotion/developmental stage not explained by anything else
- child with a frightened, withdrawn appearance = ‘frozen watchfulness’
- child discloses abuse themselves
- refusing to let child to speak to healthcare professional on their own
- poor school attendance
- failure to attend appointments
Possible physical presentations of child abuse include?
bruising
fractures: particularly metaphyseal, posterior rib fractures or multiple fractures at different stages of healing
torn frenulum: e.g. from forcing a bottle into a child’s mouth
burns or scalds
failure to thrive
STIs e.g. Chlamydia, Gonorrhoea, Trichomonas
What fractures in particular may indicate child abuse?
metaphyseal, posterior rib fractures or multiple fractures at different stages of healing
What does physical abuse involve?
causing physical harm to a child such as shaking, hitting, throwing, burning, or suffocating.
What does sexual abuse involve?
forcing or tempting a child to take part in sexual activities.
What does emotional abuse involve?
conveying to children/young people that they are worthless, unloved, or a burden.
What does neglect involve?
persistent failure to meet the child’s basic physical and/or psychological needs.
Child abuse- what does fabricated or induced illness involve?
misrepresentation of the child as ill by the caregiver by fabricating or inducing symptoms.
If there is any uncertainty about when to consider or suspect maltreatment, or about the immediate risk of harm to the child, what should you do?
advice should be sought from a named professional for child safeguarding or a senior colleague.
Consent should be obtained before sharing confidential information unless this will increase the risk of harm to the child or young person.
What to do if child maltreatment is suspected?
Children’s social care should be contacted to discuss the need for a referral.
If the child or young person is thought to be in immediate danger, they should be referred immediately to children’s social care and/or the police.
If hospital admission is needed, the admitting paediatrician should be made aware of any safeguarding concerns.
What to do if child maltreatment is considered?
Other alerting features should be sought, then:
Information should be obtained from other agencies and colleagues.
If these investigations lead to a suspicion of maltreatment, children’s social care should be contacted to discuss the need for a referral.
If it is thought that referral is not justified, the child should be reviewed regularly.
A written record needs to be made of the outcome in cases where maltreatment has been considered.
2 examples of brachial plexus injuries?
Erb-Ducenne paralysis and Klumpke’s paralysis
Brachial plexus injuries= Erb-Duchenne paralysis?
damage to C5,6 roots
winged scapula
may be caused by a breech presentation
Brachial plexus injuries= Klumpke’s paralysis?
damage to T1
loss of intrinsic hand muscles
due to traction
Suspected sexual abuse= examination?
Do not perform an intimate examination unless there is an urgent health need to do so.
A forensic intimate examination should only be undertaken by professionals specifically trained in forensic aspects of sexual assaults (such as the police if the person wishes to report the assault, or to a Sexual Assault Referral Centre (SARC) if locally available).
DNA can be gathered for up to 7 days after vaginal penetration, up to 2 days in oral penetration and for up to 3 days in anal/penile penetration irrespective of washing or bathing.
Assess the need for emergency contraception (EC)
Assess the need for prophylaxis against sexually transmitted infection (STI
After a referral, children’s social care should decide within what time frame of receipt of a child protection referral, and should provide feedback on the decisions taken both to the family and to the referrer.
1 working day
A child/young person who has the capacity to understand or make their own decisions may give (or refuse) consent to share information. What age can they consent?
child over the age of 12 years has sufficient understanding, and it is presumed by law that a young person aged 16 and older has the capacity to consent to medical treatment.
Suspected child maltreatment, what to document?
Document all actions in the child or young person’s clinical record, including:
- What was observed and/or heard, from whom, and when.
- Any concerns, including those considered minor.
- Decisions or actions relating to those concerns.
- Any outcomes.
Injuries or features that led you to suspect child maltreatment, what should you do?
Arrange hospital admission where required. Ensure that the receiving paediatrician is aware of your concerns.
If the child or young person is thought to be in immediate danger, refer immediately to children’s social care and/or the police. Consider the safety of other children living with or in contact with the suspected perpetrator.
If the child or young person is not thought to be in immediate danger, contact children’s social care to discuss the need for a referral to them, using local multi-agency safeguarding procedures.
A referral may trigger a child protection investigation, a family assessment to determine whether supportive services need to be offered, or alternative explanations may be identified.
Pyloric stenosis?
caused by hypertrophy of the circular muscles of the pylorus
When does pyloric stenosis typically present?
2-4w of life with vomiting, although rarely may present later at up to 4m
Epidemiology of pyloric stenosis?
boys 4x > girls
first borns most commonly affected
10-15% +ve FHx
Features of pyloric stenosis?
‘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
Electrolyte abnormality in pyloric stenosis due to persistent vomiting?
hypochloraemic, hypokalaemic alkalosis
Where may you feel a palpable mass in pyloric stenosis?
upper abdo
Type of vomiting in pyloric stenosis?
‘projectile’ vomiting, typically 30 minutes after a feed
Diagnosis of pyloric stenosis?
USS
Mx of pyloric stenosis?
Ramstedt pyloromyotomy.
Projectile vomiting 30mins after feed?
pyloric stenosis
Why is septic arthritis important to recognise?
prompt Tx can reduce risk of permanent damage to joint and systemic infection
Gender is septic arthritis more common in?
boys
Most commonly affected joints in septic arthritis?
hip, knee and ankle
Symptoms of septic arthritis?
joint pain
limp
fever
systemically unwell: lethargy
Signs of septic arthritis?
swollen, red joint
typically, only minimal movement of the affected joint is possible
Ix for septic arthritis?
joint aspiration: for culture. Will show a raised WBC
raised inflammatory markers
blood cultures
Diagnosis of septic arthritis?
Kocher criteria:
- fever >38.5 degrees C
- non-weight bearing
- raised ESR
- raised WCC
Staphylococcal toxic shock syndrome?
severe systemic reaction to staphylococcal exotoxins, the TSST-1 superantigen toxin.
Commonly known be related to infected tampons.
Staphylococcal toxic shock syndrome= Centers for Disease Control and Prevention diagnostic criteria?
1) fever: temperature > 38.9ºC
2) hypotension:SBP < 90
3) diffuse erythematous rash
4) desquamation of rash, especially of the palms and soles
5) involvement of three or more organ systems: e.g. gastrointestinal (diarrhoea and vomiting), mucous membrane erythema, renal failure, hepatitis, thrombocytopenia, CNS involvement (e.g. confusion)
Mx of staphlococcal toxic shock syndrome?
removal of infection focus (e.g. retained tampon)
IV fluids
IV antibiotics
UTI in children prompts what?
Ix for possible underlying cause and damage to kidneys (unlike in adults)
Causative organisms of UTI in children?
E. coli (responsible for around 80% of cases)
Proteus
Pseudomonas
Predisposing factors of UTI in children?
- incomplete bladder emptying= infrequent voiding, hurried micturition, obstruction by full rectum due to constipation, neuropathic bladder
- Vesicoureteric reflux= developmental anomaly found in 35% children with UTI
- Poor hygiene eg. not wiping front to back in girls
UTI in children are more common in who?
boys until 3m (due to more congenital abnormalities) then it is a lot higher in girls
What % of girls and boys will get UTI in childhood?
8% girls and 2% boys
Presentation of UTI in children depends on what?
age
features of UTI in infants?
poor feeding, vomiting, irritability
features of UTI in younger children?
abdo pain, fever, dysuria
features of UTI in older children?
dysuria, frequency, haematuria
Features that may suggest an upper UTI in children include what?
T >38C, loin pain/tenderness
When to get a urine sample in child with suspected UTI?
- any signs or symptoms
- unexplained fever 38C or higher (test urine after 24hrs at latest)
- have an alternative site of infection but who remain unwell (consider urine test after 24hrs at latest)
Urine collection method for suspected UTI in children?
clean catch
if not possible= urine collection pads
(cotton wool balls, gauze & sanitary towels NOT suitable)
if non-invasive methods not possible= invasive methods eg. suprapubic aspiration
Mx of UTI in children?
<3m= immediate referral to paeds
> 3m with upper UTI= admit to hospital or oral Abx cephalosporin or co-amox 7-10d
> 3m with lower UTI= oral Abx 3d depending on local guidelines eg. trimeth, nitro, cephalo or amox; bring back if unwell still after 24-48hrs
Recurrent UTI= Abx prophylaxis
Ix for UTI in children?
urine collection for microscopy and culture (not just microscopy or dip- inadequate for diagnosis)
may need imaging of urinary tract:
- static radioisotope scan eg. DMSA= 4-6m after initial infection if recurrent UTI
- MCUG= only if <6m and present with atypical or recurrent infections
What children with UTI may need imaging of urinary tract?
- <6m with 1st UTI which responds to Tx should have USS within 6w
- > 6m with 1st UTI which responds to Tx don’t need imaging unless recurrent or atypical infection
Why may children with UTI need imaging of the urinary tract but adults normally don’t?
need prompt consideration of possible underlying causes and damage to kidneys (renal scarring)
Features suggestive of an atypical infection in child with UTI?
seriously ill
poor urine flow
abdominal or bladder mass
raised creatinine
septicaemia
failure to respond to treatment with suitable antibiotics within 48 hours
infection with non-E. coli organisms
What should be done 4-6m after initial infection with UTI in child?
static radioisotope scan (e.g. DMSA): identifies renal scars.
When should micturating cystourethrography (MCUG) be done in children with UTI?
if <6m and present with atypical or recurrent infections
identifies vesicoureteric reflux
How is recurrent UTI defined?
2+ episodes of UTI with acute pyelonephritis/upper urinary tract infection
or
1 episode of UTI with acute pyelonephritis/upper urinary tract infection plus one or more episode of UTI with cystitis/lower urinary tract infection
or
3+ episodes of UTI with cystitis/lower urinary tract infection.
All children with recurrent UTI should be…
referred to paeds specialist for assessment and Ix
child >3m with recurrent UTI?
Tx, specialist advice and consider Abx prophylaxis if behavioural and hygiene measures not effective
If Abx prophy review within 6m
When to USS of urinary tract in child with UTI?
During the acute infection for children aged under 6 months with recurrent UTI.
Within 6 weeks for children aged 6 months and over with recurrent UTI.
Cause of chickenpox?
primary infection with varicella zoster virus
Shingles?
reactivation of dormant varicella zoster virus in dorsal root ganglion
How is chickenpox spread?
very infectious
spread via resp route
can be caught by someone with shingles
When is chickenpox infectious?
4d before rash until 5d after rash first appeared
Chickenpox incubation perioid?
10-21d
Clinical features of chickenpox tend to be more severe in who?
older children/adults
Clinical features of chickenpox?
- fever initially
- itchy rash starting on head/trunk before spreading
- rash initially macular then papular then vesicular
- systemic upset mild
Mx of chickenpox?
supportive= trim nails, keep cool, calamine lotion
School exclusion for chickenpox?
most infectious period is 1-2 days before the rash appears, but infectivity continues until all the lesions are dry and have crusted over (usually about 5 days after the onset of the rash).
Mx of immunocompromised pts and newborns with peripartum exposure to chicken pox?
varicella zoster immunoglobulin (VZIG)
if chickenpox develops consider IV aciclovir
Common Cx of chickenpox?
secondary bacterial infection of the lesions= usually single infected lesion/small area of cellulitis
but in small no can cause= invasive group A strep soft tissue infections resulting in necrotising fasciitis
Cx to be aware of in chicken pox?
secondary bacterial infection of the lesions causing invasive group A strep soft tissue infections resulting in necrotising fasciitis
What may increase the risk of secondary bacterial infection of chickenpox lesions?
NSAIDs
Rare Cx of chickenpox?
- pneumonia
- encephalitis (cerebellar invl may be seen)
- disseminated haemorrhagic chickenpox
- arthritis, nephritis, pancreatitis v rare
Characteristic appearances for healed varicella pneumonia on CXR?
miliary opacities secondary to healed varicella pneumonia. Multiple tiny calcific miliary opacities noted throughout both lungs. These are of uniform size and dense suggesting calcification. There is no focal lung parenchymal mass or cavitating lesion seen.
Fever initially then vesicular rash and malaise
chickenpox
What % of susceptible close contacts of chickenpox develop the disease?
90%
Varicella zoster virus causes chickenpox then what?
virus persists in sensory nerve ganglia of dorsal root, yrs later it can reactivate causing herpes zoster (shingles)
Cx of chickenpox more common in who?
young children= bacterial skin infection
adults= lung invl
pregnancy= severe materal chickenpox and fetal varicella syndrome; later preg, varicella can cause neonatal chickenpox
immunocompromised= evere disseminated chickenpox with varicella pneumonia, encephalitis, hepatitis, and haemorrhagic complications.
Type of rash in chickenpox?
Small, erythematous macules which appear on the scalp, face, trunk, and proximal limbs, and progress over 12–14 hours to papules, clear vesicles (which are intensely itchy), and pustules.
Vesicles can also occur on the palms and soles, and mucous membranes, with painful and shallow oral or genital ulcers.
Vesicles appear in crops. Crusting occurs usually within 5 days, and crusts fall off after 1–2 weeks.
Breastfeeding women gets chickenpox?
urgent specialist advice on whether to continue to breastfeed & whether baby needs Tx to minimise risk of Cx
When to consider antiviral Tx for chickenpox?
immunocompetent adult or adolescent 14yrs+ who presents within 24hrs of rash, esp if severe or at risk of Cx
What can be considered to treat the itch associated with chickenpox?
chlorphenamine (avoid in preg, breastfeeding and <1yrs)
Pregnant women with chickenpox?
immediate specialist advice from obs:
- may advise antivirals
- close monitoring daily and low threshold for admission (or if can’t monitor admit)
- deteriorat= admission
admit if= resp or neuro symptoms, haemorrhagic rash, bleeding, severe disease, immunosuppression eg. recent use of systemic corticosteorids
Mx of chickenpox in immunocompromised?
admit if suspect serious Cx
specialist advice ?admission for IV aciclovir
When is exposure significant in chickenpox?
- contact in same room 15mins+
- face-to-face (conversation)
- chickenpox contact from 24hrs before onset of rash to crusting of lesions
- disseminated zoster contact from 48hrs before rash onset to crusting of lesions
- localised zoster contact eg. opthalmic from day of rash onset until crusting of lesions
When can immunity be assumed for chickenpox?
definitie history of chickenpox or shingles or 2 doses of varicella containing vaccine and not immunocompromised
Pregnant women comes in contact with chicken pox and has no history/uncertain?
urgent specialist advice
- varicella zoster IgG within 24-48hrs of exposure= if shows V-Z IgG then evidence of immunity so can just reassure; if negative then prophylaxis needed (antivirals or VZ immunoglobulin)
Summarise chickenpox features?
Fever initially
Itchy, rash starting on head/trunk before spreading. Initially macular then papular then vesicular
Systemic upset is usually mild
Summarise features of measles?
Prodrome: irritable, conjunctivitis, fever
Koplik spots: white spots (‘grain of salt’) on buccal mucosa
Rash: starts behind ears then to whole body, discrete maculopapular rash becoming blotchy & confluent
Summarise features of mumps?
Fever, malaise, muscular pain
Parotitis (‘earache’, ‘pain on eating’): unilateral initially then becomes bilateral in 70%
Summarise features of rubella?
Rash: pink maculopapular, initially on face before spreading to whole body, usually fades by the 3-5 day
Lymphadenopathy: suboccipital and postauricular
Summarise features of erythema infectiosum?
Also known as fifth disease or ‘slapped-cheek syndrome’
Caused by parvovirus B19
Lethargy, fever, headache
‘Slapped-cheek’ rash spreading to proximal arms and extensor surfaces
Summarise features of scarlet fever?
Reaction to erythrogenic toxins produced by Group A haemolytic streptococci
Fever, malaise, tonsillitis
‘Strawberry’ tongue
Rash - fine punctate erythema sparing the area around the mouth (circumoral pallor), ‘sand paper like’
Summarise features of hand, foot and mouth disease?
Caused by the coxsackie A16 virus
Mild systemic upset: sore throat, fever
Vesicles in the mouth and on the palms and soles of the feet
Different names for slapped-cheek syndrome?
Erythema infectiosum or fifth disease
Erythema infectiosum?
slapped cheek
What causes slapped cheek syndrome?
parovirus B19
Features of slapped cheek syndrome?
- mild feverish illness hardly noticeable
- rash appears after a few days= rose-red rash on cheeks, may spread to rest of body but rarely involves palms and soles
- child starts to feel better when rash appears
- rash peaks after a week
- for months after warm bath, sunlight, heat or fever will trigger bright red cheeks and the rash again
Sunlight, warm bath, heat, fever causes bright red cheeks and rash
recurrence of slapped cheeked for months after initial illness
Mild feverish illness then after a few days bright red cheeks and rash for around 1w, then will be retriggered over the next few months by eg. sunlight, heat or fever?
slapped cheek
Tx for slapped cheek?
no Tx needed
adults= virus may cause acute arthritis
Pregnant women exposed to slapped cheek?
if exposed before 20w then prompt advice as can affect unborn baby in 1st 20w of preg
How is slapped cheek spread?
resp route
How long is pt with slapped cheek infectious?
3-5d before the appearance of the rash, no longer infectious once rash appears
School exclusion for slapped cheek?
no school exclusion as no longer infectious by time rash occurs
Hand, foot and mouth disease?
self-limiting condition affecting children
What causes hand, foot and mouth disease?
Coxsackie A16 (most common)
Enterovirus 71 (more serious)
(intestinal viruses of the Picornaviridae family)
Is hand, foot and mouth disease infectious?
very contagious and typically occurs in outbreaks at nursery
Clinical features of hand, foot and mouth disease?
- mild systemic upset= sore throat, fever
- oral ulcers
- followed later by vesicles on palms and soles of the feet
- mild systemic upset= sore throat, fever
- oral ulcers
- followed later by vesicles on palms and soles of the feet
Hand, foot and mouth disease
Mx of hand, foot and mouth disease?
symptomatic= hydration and analgesia, soft diet, measures to reduce risk of transmission
reassurance no link to disease in cattle
School exclusion for hand, foot and mouth disease?
do not need school exclusion
keep child off if they are unwell until feel better; contact school if you suspect may be large outbreak
What does hand, foot and mouth disease cause?
vesicular eruptions in the mouth and papulovesicular lesions of the distal limbs
mild and self-limiting
Most common cause of hand, foot and mouth?
Coxsackie A16 virus
Atypical HFMD (hand foot and mouth)?
caused by the Coxsackie virus A6 and presents with a more widespread and extensive skin disease, nail shedding, and a higher risk for adult infection.
Can adults be affected by hand, foot and mouth disease?
normally immune following previous exposure but adult cases can occur
Cx of hand, foot and mouth?
rare
dehydration most common due to oral pain
secondary bacterial infection of lesions
rare= encephalitis, aseptic meningitis, acute flaccid paralysis
Diagnosis of hand, foot and mouth?
clinical= fever (38-39), malaise, loss of apeitie, cough, abdo pain, sore mouth; scattered ulcerative lesions of oral cavity within 1-2d; macules and papules of hands and feet after oral lesions; sides of fingers, dorsum of hands and margins of heels most common
Pregnant women comes in contact with hand, foot and mouth disease?
avoid close contact, esp around time of delivery
if contact within 3w of delivery then seek specialist advice
Signs of dehydration in child?
educed urine output, lethargy, cold peripheries, and reduced skin turgor
Prodromal period in hand, foot and mouth?
may last 12–36 hours.
Early symptoms are fever (typically 38–39°C), malaise, loss of appetite, cough, abdominal pain, and sore mouth. Rarely, vomiting occurs if HFMD is caused by enterovirus 71.
Course of illness in hand, foot and mouth?
mild illness= sore mouth/throat, low grade fever (38C typically), abdo pain, cough
within 1-2 days get scattered ulcerative lesions of oral cavity
then soon after get macules and papules of the hands and feet
Oral lesions in hand, foot and mouth?
Scattered ulcerative lesions of the oral cavity occur within 1–2 days.
Typically, they begin as 2–8 mm erythematous macules and papules, and appear most commonly on the hard palate, tongue, and buccal mucosa, but also on the lips and pharynx.
Lesions progress rapidly to vesicles, which readily erode leaving shallow yellow-grey ulcers surrounded by an erythematous halo.
In severe cases, the lesions may coalesce leaving the tongue red and oedematous.
Rash in hand, foot and mouth?
Macules and papules of the hands and feet usually soon follow the oral lesions.
Typically, they are 2–5 mm sparse erythematous macules and papules, often with a central greyish vesicle.
The sides of the fingers, dorsum of the hands, and margins of the heels are more frequently affected than the palms or the soles.
Lesions are frequently elliptical with the long axis running parallel to the skin lines.
The buttocks and groin area may also be affected.
Lesions may be asymptomatic or painful.
HFMD caused by Coxsackie virus A6 may present with…
more widespread rash that extends beyond the palms and soles and may preferentially occur in areas prone to atopic dermatitis (the antecubital and popliteal fossae). Petechiae and severe blistering may be observed. There may be subsequent skin peeling and/or nail shedding.
Another name for roseola infantum?
exanthem subitum or sixth disease
Exanthem subitum
roseola infantum
Sixth disease
Roseola infantum
What causes roseola infantum?
human herpes virus 6 (HHV6)
Incubation period of roseola infantum?
5-15d
Roseola infantum typically affects who?
children 6m-2yrs
Features of roseola infantum?
- high fever lasting a few days
- followed by maculopapular rash
- Nagayama spots
- febrile convulsions in 10-15%
- diarrhoea and cough
Nagayama spots in roseola infantum?
papular enanthem on the uvula and soft palate
Other possible consequences of HHV6 infection (as well as roseola infantum)?
aseptic meningitis
hepatitis
School exclusion for roseola infantum?
not needed
Mx of roseola infantum?
supportive
maintain fluids
Rubella also known as what?
German measles
Rubella caused by?
viral infection caused by togavirus
What if rubella is contracted in pregnancy?
risk of congenital rubella syndrome
- if 20w gestation or less need to refer urgently to obs and arrange serology testing and contact HPT
Why is rubella very rare (<5 cases in UK per yr)?
MMR vaccine
When in the year is rubella more common?
winter and spring
Rubella incubation period?
14-21d
How long are pts with rubella infectious?
from 7d before symptoms appear to 4d after the onset of the rash
Features of rubella?
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
Rash in rubella?
maculopapular, initially on the face before spreading to the whole body, usually fades by the 3-5 day
Cx of rubella?
arthritis
thrombocytopaenia
encephalitis
myocarditis
What Cx can occur if pregnant women gets rubella and is not immune (eg. by MMR)?
miscarriage, stillbirth, congenital rubella syndrome (CRS)
Severity and type of congenital defects in congenital rubella syndrome depends on?
ary according to the stage of pregnancy when infection occurs — before 8–10 weeks gestation there is a high likelihood of multiple defects.
Diagnosis of rubella?
not specific to clinical features, needs to be confirmed with lab Ix
1) notify HPT
2) pregnant= serology testing
3) others= HPT will provide advice on testing eg. may request an oral fluid sample
Rash that typically starts on the face and neck before spreading down the body and becoming generalized — the rash is pink or light red, maculopapular, and usually present for 3–4 days.
rubella
Lymphadenopathy in rubella?
suboccipital, postauricular, and cervical) — may precede rash and last for 2 weeks after the rash resolves.
Rubella must be excluded in what population with a rubella-like rash regardless of previous immunisation history?
pregnant women
Mx of rubella?
- notify local Health Protection Team immediately if suspect
- drinks fluids, rest, paracetamol/ibuprofen
- school exclusion for 5d after rash starts
School exclusion in rubella?
at least 5d after the rash starts and avoid contact with pregnant women
Pregnant women >20w gestation comes in contact with rubella/
no documented risk of congenital rubella syndrome
Prevent congenital rubella syndrome?
no Tx to prevent
Do not give MMR in preg if haven’t already have it, wait till after delivery
Serology testing in pregnant women who has been in contact with rubella (>20w gestation)?
rubella IgM not detected and IgG detected= likely rubella infection is remote and advise to return if rash develops
IgM and IgG not detected= susceptible to rubella, retest after 4w
IgM detected (regardless of IgG)= second confirmatory test
What is scarlet fever?
Reaction to erythrogenic toxins produced by Group A haemolytic strep (usually strep pyogenes)
Who is scarlet fever more common in?
2-8yrs, peak at 4yrs
Cause of scarlet fever?
Group A haemolytic strep (usually strep pyogenes)
How is scarlet fever spread?
via the respiratory route by inhaling or ingesting respiratory droplets or by direct contact with nose and throat discharges, (especially during sneezing and coughing)
Incubation period of scarlet fever?
2-4d
How does scarlet fever present?
- fever 24-48hrs
- malaise, headache, N/V
- sore throat
- strawberry tongue
- rash= fine punctate erythema 1st on torso and spares palms and soles; more obvious in flexures; rough sandpaper texture; flushed appearance with cicumoral pallor
- desquamination later around fingers and toes
Rash in scarlet fever?
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
fever 24-48hrs
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
scarlet fever
Diagnosis of scarlet fever?
throat swab (not routinely indicated) but start Abx immediately don’t wait for results
Mx for scarlet fever?
- notifiable disease
- phenoxymethylpenicillin (penicillin V) 10 days
- azithromycin if allergy
Is scarlet fever a notifiable disease?
yes
School exclusion with scarlet fever?
can return to school 24hrs after starting Abx
Scarlet fever is usually a mild illness, but may have some Cx….
- otitis media (most common)
- rheumatic fever= 20d after infection
- acute glomerulonephritis= 10d after infection
- invasive Cx= bacteraemia, meningitis, necrotizing fasciitis; rare but may present acutely with life-threatening illness
Most common Cx of scarlet fever?
otitis media
How long are pts with scarlet fever infectious?
incubation period is usually 2–3 days. People can be infectious for 2–3 weeks after the onset of symptoms, unless they are treated.
How is a scarlet fever outbreak defined?
‘a credible report of two or more probable or confirmed scarlet fever cases attending the same school or nursery or other childcare setting, notified within 10 days of each other (two maximum incubation periods), with an epidemiological link between cases, for example they are in the same class or year group’.
Scarlet fever: what people are at risk of invasive Group A streptococcal infection (iGAS) and Cx?
- pregnant
- postpartym (within 28d giving birth)
- neonates (up to 28d)
- 75yrs+
-immunocompromised/suppressed - DM
- CVD
- malignancy
- chickenpox with active lesions within 7d before iGAS infection
- within 48hrs starting Abx if exposure ongoing
- IVDU
- alcohol dependent
- cormorbidities eg. skin breakdown
Rare Cx of scarlet fever?
Invasive GAS infection, such as pneumonia, meningitis, streptococcal toxic shock syndrome, or necrotizing fasciitis.
Normally how long until scarlet fever resolves?
1w
When to suspect scarlet fever?
Initial sore throat, fever, headache, fatigue, nausea, and vomiting.
A pinpoint, sandpaper-like blanching rash that develops on the trunk within 48 hours after initial symptoms, before spreading to the rest of the body and flexures.
Possible strawberry tongue, cervical lymphadenopathy, circumoral pallor.
Useful criteria for assessment of viral URTI?
children <5yrs= NICE fever traffic light system
FeverPAIN score= assess likelihood of Strep infection in adult with sore throat and guide decision making re antibiotic usage
Cx of viral URTI in children?
otitis media
Viral wheeze, bronchiolitis and croup in infants and young children
sinusitis
Volvulus?
torsion of colon around its mesenteric axis resulting in compromised blood flow and closed loop obstruction
Types of volvulus?
Sigmoid volvulus (80%)= large bowel obstruction caused by the sigmoid colon twisting on the sigmoid mesocolon.
A similar problem may also occur at the caecum (20% of cases).
Why is caecum volvulus more rare than a sigmoid volvulus?
In most people (around 80%) the caecum is a retroperitoneal structure so not at risk of twisting.
In the remaining minority there is however developmental failure of peritoneal fixation of the proximal bowel putting these patients at risk of caecal volvulus.
Name 2 types of volvulus?
Sigmoid and caecal
Sigmoid volvulus associations?
older patients
chronic constipation
Chagas disease
neurological conditions e.g. Parkinson’s disease, Duchenne muscular dystrophy
psychiatric conditions e.g. schizophrenia
Caecal volvulus assocations?
all ages
adhesions
pregnancy
Features of volvulus?
constipation
abdominal bloating
abdominal pain
nausea/vomiting
Ix for volvulus?
Abdo xray
Abdo xray findings in sigmoid volvulus?
large bowel obstruction (large, dilated loop of colon, often with air-fluid levels) + coffee bean sign
Abdo xray findings in caecal volvulus?
small bowel obstruction may be seen
Mx of volvulus?
sigmoid volvulus: rigid sigmoidoscopy with rectal tube insertion
caecal volvulus: management is usually operative. Right hemicolectomy is often needed
Meckel’s diverticulum?
congenital diverticulum of the small intestine.
It is a remnant of the omphalomesenteric duct (also called the vitellointestinal duct) and contains ectopic ileal, gastric or pancreatic mucosa.
Diverticulum?
irregular, bulging pouch in the colon wall
Meckel’s diverticulum rule of 2’s?
occurs in 2% of the population
is 2 feet from the ileocaecal valve
is 2 inches long
Most common cause of painless massive GI bleeding requiring a transfusion in children aged 1-2yrs?
Meckel’s diverticulum
Presentation of Meckel’s diverticulum?
- usually asymptomatic
- abdo pain mimicking appendicitis
- rectal bleeding= painless massive GI bleeding
- intestinal obstruction= secondary to omphalomesenteric band (most common), volvulus and intussusception
Abdo pain mimicking appendicitis and rectal bleeding
Meckel’s diverticulum
Painless massive rectal bleeding
Meckel’s diverticulum
Meckel’s diverticulum most common in what age group?
1-2yrs
Ix for Meckel’s diverticulum?
- haemodynamically stable with less severe or intermittent bleeding= Meckel’s scan
- more severe eg. transfusion required= mesenteric arteriography
Meckel’s scan?
uses 99m technetium pertechnetate, which has an affinity for gastric mucosa
haemodynamically stable with less severe or intermittent bleeding in Meckel’s diverticulum
Mx for Meckel’s diverticulum?
removal if narrow neck or symptomatic
options are between wedge excision or formal small bowel resection and anastomosis
Pathophysiology of Meckel’s diverticulum?
normally, in the foetus, there is an attachment between the vitellointestinal duct and the yolk sac. This disappears at 6 weeks gestation
the tip is free in the majority of cases
associated with enterocystomas, umbilical sinuses, and omphaloileal fistulas.
arterial supply: omphalomesenteric artery.
typically lined by ileal mucosa but ectopic gastric mucosa can occur, with the risk of peptic ulceration. Pancreatic and jejunal mucosa can also occur.
Deliberate self-harm (DSH) in children and adolescents most often takes the form of either:
overdoses (e.g. paracetamol)
self-mutilation (e.g. cutting, burning)
Deliberate self-harm (DSH) in children most common in who?
girls
Deliberate self-harm (DSH) in children RFs?
mental health or behavioural problems, e.g. depression, severe anxiety and impulsivity
a history of self-harm
living in care or a secure institution
abusive home life
poor communication with parents
Deliberate self-harm (DSH) in children- reasons they may do it?
some feel that has positive purpose= way to relieve unbearable pressure or pain
some view it as suicide prevention strategy, means of protecting themselves
coping strategy over which they have control
may be means of communicating pain and distress to others
Head banging?
normal behaviour for a 2-year-old. However, if this behaviour persists beyond 3 years it could be a sign of autism.
Head banging is normal for a 2yr old but what if it persists beyond 3yrs?
could be sign of autism
When may bruising be more worrying in chldren?
if excessive or usual patterns
What is important not to miss in a child with bruising?
haematological cause or non-accidental injury
Possible causes of bleeding in neonates?
Coagulation disorders=
- haemorrhagic disease of the newborn
- haemophilia
Thrombocytopaenia=
maternal alloimmune thrombocytopaenia
birth trauma: cephalohaematoma
congenital infections e.g. rubella
Possible causes of bleeding in infants?
Accidental injury
Non-accidental injury
Coagulation disorders=
haemophilia
Thrombocytopaenia=
- ITP
- Thrombocytopaenia with Absent Radius (TAR)
- congenital infection
Possible causes of bruising in older children?
Accidental injury
Non-accidental injury
Coagulation disorders=
- haemophilia
- von Willebrand’s disease
- liver disease
Thrombocytopaenia=
- ITP
- ALL
- meningococcal septicaemia
- Thrombocytopaenia with Absent Radius (TAR)
- congenital infection
Common sites of bruising due to normal play?
bony prominences
- shins
- elbows
- forehead
Bruises which may cause concern?
excessive multiple bruises of different ages
bruise patterns which may indicate slapping, being gripped tightly (fingertip marks) or the use of inflicting instruments (e.g. belt)
Sites of bruising that may raise concern?
sites which may raise concern include the face, ears, neck, buttocks, trunk or proximal parts of limbs
Colour changes in bruises?
initially red
then changes to purple, blue or black (over 1-3 days)
later fades to yellow or green
light bruises typically fade within 2 weeks, more severe bruising may take longer
Immune (or idiopathic) thrombocytopenic purpura (ITP)?
immune-mediated reduced in platelet count
What happens in Immune (or idiopathic) thrombocytopenic purpura (ITP)?
antibodies are directed against the glycoprotein IIb/IIa or Ib-V-IX complex
example of type II hypersensitivity reaction
ITP in children vs adults?
more acute in children and may follow an infection or vaccination
Features of ITP?
bruising
petechial or purpuric rash
bleeding is less common and typically presents as epistaxis or gingival bleeding
What does ITP stand for?
Immune (or idiopathic) thrombocytopenic purpura (ITP)
Ix for ITP?
- FBC= isolated thrombocytopenia
- blood film
- if atypical features= bone marrow examination
Isolated thrombocytopenia on FBC?
ITP
What does FBC show in ITP?
isolated thrombocytopenia
When do you only take a bone marrow exam in suspected ITP?
only if atypical features eg:
- lymph node enlargement/splenomegaly, high/low white cells
- failure to resolve/respond to Tx
Suspected FBC but FBC shows thrombocytopenia and high/low WBC (normally just isolated thrombocytopenia)?
atypical so do bone marrow exam
Child has had recent infection (or vaccination), now presents with brusising, petechial/purpuric rash and epistaxis?
ITP
Mx of ITP?
- usually no Tx needed
- avoid activities that may result in trauma eg. team sports
- other options if platelet count very low (<10 *10^9) or significant bleeding
Why is there usually no Tx needed in ITP?
it resolves in around 80% of children within 6m with or without Tx
When would Tx be indicated in ITP?
if the platelet count is very low (e.g. < 10 * 109/L) or there is significant bleeding.
Mx of ITP if= if the platelet count is very low (e.g. < 10 * 109/L) or there is significant bleeding?
oral/IV corticosteroid
IV immunoglobulins
platelet transfusions can be used in an emergency (e.g. active bleeding) but are only a temporary measure as they are soon destroyed by the circulating antibodies
Why in ITP is the use of platelet transfusions in an emergency only a temporary measure?
they are soon destroyed by the circulating antibodies
Legal framework which governs child protection?
Children’s Act of 1989 and 2004
RFs for child abuse- child factors?
prematurity
low birth weight
disability
chronic illness
RFs for child abuse- parental factors?
personal history of child abuse
teenage parents
single parent
substance abuse
psychiatric disorder
isolation
large family size
Another name for seborrhoeic dermatitis?
cradle cap
Seborrhoeic dermatitis?
quite common skin disorder seen in children
typically affects the scalp (cradle cap), nappy area, face and limb flexures
Early sign of seborrhoeic dermatitis?
cradle cap
Features of sebirrhoeic dermatitis?
cradle cap in 1st few weeks of life- early sign
erythematous rash with coarse yellow scales
Mx of seborrhoeic dermatitis?
reassure it doesn’t affect the baby and resolves within few weeks
massage topical emollient onto scalp to loosen scales, brush gently with soft brush and wash off with shampoo
if severe/persistent= topical imidazole cream
Prognosis of seborrhoeic dermatitis?
tends to resolve spontaneously by around 8 months of age.
How common is cleft lip and palate?
1 in every 1000 babies
Most common congenital deformity affecting orofacial structures?
cleft lip and palate
Cleft lip and palate may be an isolated developmental malformation or they may also be…
a component of more than 200 birth defects
Commonest variants of cleft lip and palate?
isolated cleft lip (15%)
isolated cleft palate (40%)
combined cleft lip and palate (45%)
What increases risk of cleft lip and palate?
maternal antiepileptic use
Cleft lip and palate inheritance?
polygenic inheritance
Cleft lip and palate pathophysiology?
cleft lip results from failure of the fronto-nasal and maxillary processes to fuse
cleft palate results from failure of the palatine processes and the nasal septum to fuse
Problems associated with cleft lip and palate?
feeding: orthodontic devices may be helpful
speech: with speech therapy 75% of children develop normal speech
increased risk of otitis media for cleft palate babies
Mx of cleft lip and palate?
cleft lip is repaired earlier than cleft palate, with practices varying from repair in the first week of life to three months
cleft palates are typically repaired between 6-12 months of age
Developmental dysplasia of the hip (DDH)?
typically affects 1-3% newborns
the socket of the hip is too shallow and the femoral head is not held tightly in place, so the hip joint is loose. In severe cases, the femur can come out of the socket (dislocate).
RFs for developmental dysplasia of the hip (DDH)?
- female (6x > boys)
- breech presentation
- FHx
- 1st born
- oligohydramnios
- birth weight >5kg
- congenital calcaneovalgus foot deformity
What hip is developmental dysplasia of the hip (DDH) more common in?
left
20% bilateral
What imaging to screen for developmental dysplasia of the hip (DDH)?
USS
What babies need USS screening for developmental dysplasia of the hip (DDH)?
- 1st degree FHx of hip problems in early life
- breech at or after 36w no matter the presentation at birth or mode of devlivery
- multiple pregnancy
Screening for developmental dysplasia of the hip (DDH)?
all infants at newborn and 6w baby check using Barlow and Ortolani test
certain babies need USS too
Physical exam to screen for developmental dysplasia of the hip (DDH)?
Barlow and Ortolani test at newborn and 6w check
Barlow test?
attempts to dislocate an articulated femoral head
screens for developmental dysplasia of the hip
Ortolani test?
attempts to relocate a dislocated femoral head
screens for developmental dysplasia of the hip
Clinical exam to screen for developmental dysplasia of the hip (DDH)?
- Barlow and Ortolani test
- symmetry of leg length
- level of knees when hips and knees are bilaterally flexed
- restricted abduction of hip flexion
Imaging to scren for developmental dysplasia of the hip (DDH) if clinically suspected? What if infant is >4.5m?
USS
> 4.5m= x-ray first line
Mx for developmental dysplasia of the hip (DDH)?
- most unstable hips will spontaneously stabilise by 3-6w
- Pavlik harness (dynamic flexion-abduction orthosis) in children <4-5m
- older children may need surgery
What results in a neural tube defect?
failure of the neural plate to fuse normally during early development of the fetus
Name 4 types of neural tube defects?
- spina bifida occulta
- meningocele
- myelomeningocele
- anencephaly
Neural tube defects= spina bifida occulta?
Often an incidental finding
May be overlying skin lesion such as tuft of hair, birth mark or sinus
Involvement of the spinal cord may result in neurological defects
Often an incidental finding
May be overlying skin lesion such as tuft of hair, birth mark or sinus
Involvement of the spinal cord may result in neurological defects
Spina bifida occulta (neural tube defect)
Neural tube defects= meningocele?
Cyst of meninges and cerebrospinal fluid
No neurological involvement
Good prognosis following surgical correction
Cyst of meninges and cerebrospinal fluid
No neurological involvement
Good prognosis following surgical correction
Meningocele (neural tube defect)
Neural tube defect= myelomeningocele?
Cyst of meninges and cerebrospinal fluid but also involving the spinal cord nerves
Often results in bladder and bowel incontinence,
paraparesis of the legs and hydrocephalus (associated Arnold-Chiari malformation)
Cyst of meninges and cerebrospinal fluid but also involving the spinal cord nerves
Often results in bladder and bowel incontinence,
paraparesis of the legs and hydrocephalus (associated Arnold-Chiari malformation)
Myelomeningocele (neural tube defect)
Neural tube defect= anencephaly?
Absence of cranium and brain.
Affected babies are stillborn.
Absence of cranium and brain.
Affected babies are stillborn.
Anencephaly (neural tube defect)
Diagnosis for neural tube defects?
Intrauterine diagnosis= serum alpha-feto protein (AFP) at 15-17w
may also be detected by routine USS at 18-20w
Prevention of neural tube defects?
folic acid 0.4 mg per day from before conception and until the end of the first trimester
if either partner has a neural tube defect, or if they have had a previous pregnancy with a neural tube defect then folic acid 5 mg per day should be used. The risk of recurrence in future pregnancies is around 1 in 50.
When should the mother take 5mg folic acid per day before conception and until end of 1st trimester?
- either parent has neural tube defect
- previous preg with neural tube defect
- FHx neural tube defects
- pts taking anti-epileptics
- DM
- coeliac disease (or other malabsorption states)
- sickle cell anaemia
Whooping cough?
infectious disease typically presents in children
‘cough of 100 days’
What causes whooping cough?
Gram-negative bacterium Bordetella pertussis
When is whooping cough vaccine?
2, 3, 4 m and 3-5yrs
pregnant women as newborns vulnerable
Whooping cough vaccine?
infection or immunisation does not result in lifelong protection so adolescents and adults may develop whooping cough even if they had routine vaccines
3 phases of whooping cough?
1) catarrrhal phase
2) paroxysmal phase
3) convalescent phase
pertussis
whooping cough
Whooping cough= catarrhal phase?
symptoms similar to viral URTI, lasts around 1-2w
Whooping cough= paroxysmal phase?
- cough increases in severity
- coughing bouts worse at night and after feeding
- cough may be ended by vomiting and central cyanosis
- inspiratory whoop (not always present; caused by forced inspiration against closed glottis)
- infants= may have spells of apnoea
- persistent coughing -> subconjunctival haemorrhages or anoxia leading to syncope and
seizures - lasts 2-8w
Whooping cough= convalescent phase?
cough subsides over weeks to months
Whooping cough diagnostic criteria?
pt has acute cough 14d or more without another apparent cause, and one or more of the following features:
- Paroxysmal cough.
- Inspiratory whoop.
- Post-tussive vomiting.
- Undiagnosed apnoeic attacks in young infants.
Diagnosis for whooping cough?
- nasal swab for Bordetella pertussis= may take days-weeks to come back
- PCR
- serology= can be used if cough 21d+ but the others need to be within 21d
Mx of whooping cough?
<6m= admit
Notifiable disease
- Oral macrolide eg. calrithromycin, azithro or erythro= if onset of cough within 21d (erraditate and reduce spread)
- household contacts= Abx prophy
- Abx does not seem to alter course of the illness
School exclusion for whooping cough?
until 48hrs after starting Abx or 21d from onset of symptoms if no Abx
Cx of whooping cough?
subconjunctival haemorrhage
pneumonia
bronchiectasis
seizures
When will pregnant women be offered whooping cough vaccine?
16-32w pregnant
How is whooping cough spread?
resp secretions
Whooping cough incubation period?
7-10d
How long is pt with whooping cough infectious?
if untreated then infectious 21d from onset of coughing
Do pts with whooping cough get a fever?
uncommon and low grade
1–2 weeks and presents similarly to common upper respiratory tract infection
then 1 week bouts of paroxysmal (rapid, violent, and uncontrolled) coughing followed by the characteristic ‘whoop’ (caused by sharp inhalation of breath) and/or post-tussive vomiting
2-3w cough slightly improves; paroxysms can recur with subsequent respiratory infections.
whooping cough
The whoop in whooping cough is less common in who?
adults and young infants (who may present with apnoea)
Whooping cough in infants <6m?
may be atypical, and is associated with high rates of hospitalization, severe illness, and death.
Notify who if suspect whooping cough?
local Public Health England centre within 3 days
When to give Abx in whooping cough?
if the onset of the cough is within the previous 14 days or 21 days in the case of close contact of a group1 priority individual.
Infantile colic?
quite common and benign set of symptoms seen in young infants
Infantile colic typically occurs at what age?
<3m
Infantile colic features?
bouts of XS crying and pulling-up of the legs, often worse in the evening
How common is infantile colic?
20% infants
cause unknown
Clinical diagnostic criteria for infantile colic?
1) <5m when symptoms start and stop
2) recurrent & prolonged crying, fusing or irritability without obvious cause that can’t be prevented or resolved
3) no evidence of faltering growth, fever or illness
- most common in late afternoon/evening
- drawing up knees to abdo or arching back when crying
- clenching of fists
bouts of XS crying and pulling-up of the legs to abdo/arching back, often worse in the evening; symptoms started and stopped <5m of age
infantile colic
Cause of infantile colic?
unknown
may be due to a neurodevelopmental stage causing an exacerbation of normal infant crying due to abnormal gastrointestinal motility and gas production; reduced gut microbiome diversity; central nervous system deregulation; and psychosocial factors.
What age is infantile colic most common in?
1st 6w of life
equally in breastfed and bottle fed infants
Cx of infantile colic?
parent or carer stress and sleep deprivation, fatigue, loss of confidence in parenting skills, anxiety or depression, premature cessation of breastfeeding, and increased risk of child maltreatment.
Red flags in infantile colic?
serial weight measurements; orofacial conditions that may affect feeding; muscle tone and neurological signs suggesting an underlying cause; and parent/carer interaction with the infant.
Mx for infantile colic?
- advice about info and support
- reassure- holding baby, gentle motion, white noise, winding techniques
- encourage parent/carer to look after own wellbeing by resting when able, taking ‘time out’ if needed
- continue breastfeeding where possible
- use of simeticone or lactase drops NOT RECOMMENDED
When to refer to specialist/advice for infantile colic?
Parents/carers feel unable to cope despite reassurance and advice in primary care.
There is suspected faltering growth, or symptoms are severe, worsening, or persist beyond 5 months of age.
There is a suspected underlying cause for symptoms which cannot be managed in primary care.
When is infantile colic unusual?
> 5m
Types of acyanotic congential heart disease? (5)
- ventricular septal defect (VSD)= most common, 30%
- atrial septal defect (ASD)
- patent ductus arteriosus (PDA)
- coarctation of the aorta
- aortic valve stenosis
Most common cause of acyanotic congential heart disease?
VSD
What is more common, VSD or ASD?
VSD more common
but in adults ASD more common new diagnosis as generally present later
What presents later- ASD or VSD?
ASD
Causes of cyanotic congenital heart disease? (3)
- tetralogy of Fallot
- transposition of the great arteries (TGA)
- tricuspid atresia
What is common common- TGA or tetralogy of Fallot?
Fallot more common
Most common cause of cyanotic congenital heart disease?
tetralogy of Fallot (presents 1-2m)
but TGA most common lesion at birth
What presents later- tetralogy of Fallot or TGA?
Fallot presents at 1-2m old
TGA presents at birth
What determines the presence of cyanosis in pulmonary valve stenosis?
depends very much on the severity and any other coexistent defects.
Peripheral cyanosis in newborn?
common in hands and feet in 1st 24hrs of life, may occur when baby is crying or unwell from any cause
Central cyanosis?
can be recognised clinically when the concentration of reduced haemoglobin in the blood exceeds 5g/dl
What can be used to differentiate cardiac from non-cardiac causes of cyanosis in the neonatal period?
Nitrogen washout test (also known as the hyperoxia test)
The infant is given 100% oxygen for ten minutes after which arterial blood gases are taken. A pO2 of less than 15 kPa indicates cyanotic congenital heart disease
Initial Mx of suspected cyanotic congenital heart disease?
supportive care
prostaglandin E1 e.g. alprostadil
Why is prostaglandin E1 eg. alprostadil used in the initial Mx of suspected cyanotic congenital heart disease?
used to maintain a patent ductus arteriosus in ductal-dependent congenital heart defect
this can act as a holding measure until a definite diagnosis is made and surgical correction performed
Acrocyanosis?
often seen in healthy newborns and refers to cyanosis around the mouth and the extremities such as the hands and feet.
It is differentiated from other causes of peripheral cyanosis with significant pathology as it occurs immediately after birth in healthy infants.
It is a common finding and may persist for 24 to 48 hours.
Cyanotic congenital heart disease at birth?
TGA
Cyanotic congenital heart disease presenting at 1-2m (may not be picked up until 6m)?
TOF
When does tetralogy of Fallot (TOF) usually present?
around 1-2m but may not be picked up until 6m
Most common cause of cyanotic congenital heart disease?
TOF
What is the cause of TOF?
TOF is the result of anterior malalignment of the aorticopulmonary septum
4 Characteristic features of TOF?
- VSD
- RV hypertrophy
- RV outflow tract obstruction, pulmonary stenosis
- overriding aorta
What determines the degree of cyanosis and clinical severity of TOF?
the severity of right ventricular outflow tract obstruction (pulmonary stenosis)
Features of TOF?
- the 4 characteristics
- cyanosis= episodic hypercyanotic tet spells when infant upset, in pain or has fever
- causes right-to-left shunt
- ejection systolic murmur due to pulmonary stenosis (VSD doesn’t usually casue a murmur)
- right-sided arotic arch in 25%
CXR and ECG findings in TOF?
CXR= ‘boot-shaped’ heart
ECG= right ventricular hypertrophy
Boot shaped heart on CXR?
TOF
Episodic hypercyanotic ‘tet’ spells in TOF?
in unrepaired TOF
due to near occlusion of the RV outflow tract (pulmonary stenosis)
features= tachypnoea, severe cyanosis that may result in loss of consciousness
typically when infant is upset, in pain or has a fever
Infants crying and then has temp loss of consciousness?
?TOF tet spells
Type of murmur in TOF?
ejection systolic murmur
due to pulmonary stenosis (the VSD doesn’t usually cause a murmur)
Mx of tetralogy of Fallot?
surgical repair is often undertaken in two parts
cyanotic episodes may be helped by beta-blockers to reduce infundibular spasm
Transposition of the great arteries (TGA)?
form of cyanotic congenital heart disease
What causes TGA?
failure of the aorticopulmonary septum to spiral during septation
Anatomical changes in TGA? (2)
1) aorta leaves the right ventricle
2) pulmonary trunk leaves the left ventricle
Clinical features of TGA?
- cyanosis
- tachypnoea
- loud single S2
- prominent right ventricular impulse
Auscultation in TGA?
loud single S2
prominent right ventricular impulse
CXR findings in TGA?
‘egg-on-side’ appearance
Mx for TGA?
maintenance of the ductus arteriosus with prostaglandins
surgical correction is the definite treatment.
Congenital heart defect= loud single S2 and
prominent right ventricular impulse?
TGA
Congenital heart defect= ejection systolic murmur?
TOF
Example of how GCS is generally written?
‘GCS = 13, M5 V4 E4 at 21:30’.
How many points for M, V and E in GCS?
M6 V5 E4 (for both adults and children)
GCS in children= motor response options?
- Infant moves spontaneously or purposefully
- Infant withdraws from touch
- Infant withdraws from pain
- Abnormal flexion to pain for an infant (decorticate response)
- Extension to pain (decerebrate response)
- No motor response
GCS in children= verbal response options?
- Smiles, oriented to sounds, follows objects, interacts.
- Cries but consolable, inappropriate interactions.
- Inconsistently inconsolable, moaning.
- Inconsolable, agitated.
- No verbal response.
GCS in children= eye opening options?
- Eyes opening spontaneously
- Eye opening to speech
- Eye opening to pain
- No eye opening or response
Name 9 childhood syndromes?
Patau (trisomy 13)
Edward’s (trisomy 18)
Fragile X
Noonan
Pierre-Robin
Prader-Willi
William’s
Cri du chat (chromosome 5p deletion syndrome)
Down’s (trisomy 21)
Trisomy 13
Patau syndrome
Trisomy 18
Edward’s
Trisomy 21
Down’s
Chromosome 5p deletion syndrome
Cri du chat syndrome
Patau syndrome= trisomy?
13
Edward’s syndrome= trisomy?
18
Down’s= trisomy?
21
Cri du chat syndrome= genetics?
chromosome 5p deletion syndrome
Key features of Patau syndrome (trisomy 13)?
Microcephalic, small eyes
Cleft lip/palate
Polydactyly
Scalp lesions
Key features of Edward’s syndrome (trisomy 18)?
Micrognathia
Low-set ears
Rocker bottom feet
Overlapping of fingers
Key features of fragile X?
Learning difficulties
Macrocephaly
Long face
Large ears
Macro-orchidism
Key features of Noonan syndrome?
Webbed neck
Pectus excavatum
Short stature
Pulmonary stenosis
Key features of Pierre-Robin syndrome?
Micrognathia
Posterior displacement of the tongue (may result in upper airway obstruction)
Cleft palate
Key features of Prader-Willi syndrome?
Hypotonia
Hypogonadism
Obesity
Key features of William’s syndrome?
Short stature
Learning difficulties
Friendly, extrovert personality
Transient neonatal hypercalcaemia
Supravalvular aortic stenosis
Key features of Cri du chat syndrome (chromosome 5p deletion syndrome)?
Characteristic cry (hence the name) due to larynx and neurological problems
Feeding difficulties and poor weight gain
Learning difficulties
Microcephaly and micrognathism
Hypertelorism
Childhood syndromes=
Microcephalic, small eyes
Cleft lip/palate
Polydactyly
Scalp lesions
Patau syndrome (trisomy 13)
Childhood syndromes=
Micrognathia
Low-set ears
Rocker bottom feet
Overlapping of fingers
Edward’s (trisomy 18)
Childhood syndromes=
Learning difficulties
Macrocephaly
Long face
Large ears
Macro-orchidism
Fragile X
Childhood syndromes= Webbed neck
Pectus excavatum
Short stature
Pulmonary stenosis
Noonan syndrome
Childhood syndromes=
Micrognathia
Posterior displacement of the tongue (may result in upper airway obstruction)
Cleft palate
Pierre-Robin syndrome
Childhood syndromes= Hypotonia
Hypogonadism
Obesity
Prader-Willi syndrome
Childhood syndromes= Short stature
Learning difficulties
Friendly, extrovert personality
Transient neonatal hypercalcaemia
Supravalvular aortic stenosis
William’s syndrome
Childhood syndromes= Characteristic cry due to larynx and neurological problems
Feeding difficulties and poor weight gain
Learning difficulties
Microcephaly and micrognathism
Hypertelorism
Cri du chat syndrome (chromosome 5p deletion syndrome)
Characteristic cry in cri du chat syndrome?
high pitch cry that sounds like a cat
What condition is very similar to Pierre-Robin syndrome?
Treacher-Collins syndrome.
One of the key differences is that Treacher-Collins syndrome is autosomal dominant so there is usually a family history of similar problems
Cause of Turner’s syndrome?
presence of only 1 sex chromosome (X) or deletion of the short arm of one of the X chromosomes
45,XO or 45,X
Turner’s
Features of Turner’s syndrome?
- short stature
- shield chest, widely spaced nipples
- webbed neck
- primary amenorrhoea
- bicuspid aortic valve (15%), coarctation of aorta (5-10%)
- cystic hygroma (diagnosed prenatally)
- high-arched palate
- short fourth metacarpal
- multiple pigmented naevi
- lymphoedema in neonates (especially feet)
- gonadotrophin levels will be elevated
- hypothyroidism
horseshoe kidney
Increased incidence of what in Turner’s?
autoimmune disease (esp autoimmune thyroiditis) and Crohns
Cardiac features in Turner’s?
bicuspid aortic valve (15%), coarctation of the aorta (5-10%)
an increased risk of aortic dilatation and dissection are the most serious long-term health problems for women with Turner’s syndrome
regular monitoring in adult life for these complications is an important component of care
most serious long-term health problems for women with Turner’s syndrome
increased risk of aortic dilatation and dissection
What is often diagnosed prenatally in pt with Turner’s?
cystic hygroma
Turner’s in neonates?
lymphoedema in neonates (especially feet)
Bloods in Turner’s syndrome?
gonadotrophin levels will be elevated
Immediate emergency hospital admission in child with suspected pneumonia?
Persistent oxygen saturation of less than 92% when breathing air.
Grunting, marked chest recession, or a RR >60
Cyanosis (indicated by pale/mottled/ashen/blue skin, lips or tongue).
Note: auscultation revealing absent breath sounds with a dull percussion note should raise the possibility of a pneumonia complicated by effusion and should trigger a referral to hospital.
Child looks seriously unwell, does not wake, or if roused does not stay awake, or does not respond to normal social cues.
A temperature of 38°C or higher in a child aged three months or less.
Children aged less than two years presenting with mild symptoms of lower respiratory tract infection
do not usually have pneumonia, and need not be treated with antibiotics, but should be reviewed if symptoms persist. A history of conjugate pneumococcal vaccination gives greater confidence to this decision.
Mx of pneumonia in child who does not need hospital admission?
amoxicillin 1st line 5 days
or clarithromycin
co-amox if penumonia associated with influenzae
Cow’s milk protein intolerance/allergy (CMPI/CMPA) occurs in who?
3-6% all children
usually in 1st 3m of life in formula fed infants and rarely seen in breastfed
Type of reaction in cow’s milk protein intolerance/allergy?
both immediate (IgE mediated) and delayed (non-IgE mediated) seen
CMP allergy= immediate reactions
CMP intolerance= mild-moderate delayed reactions
Features of cow’s milk protein intolerance/allergy?
- regurg and vomiting
- diarrhoea
- urticaria, atopic eczema
- colic symptoms= irritability, crying
- wheeze, chronic cough
- rare= angioedema and anaphylaxis
Diagnosis of cow’s milk protein intolerance/allergy?
often clinical= improvement with cow’s milk protein elimination
Ix= consider refer to specialist allergy clinic for skin prick/patch testing; total IgE and specific IgE (RAST) for cow’s milk protein (if suspect IgE mediated allergy or faltering growth or significant atopic eczema with multiple or cross-reactive food allergies)
Mx of cow’s milk protein intolerance/allergy?
severe (failure to thrive)= refer to paeds
Formula fed= extensive hydrolysed formula (eHF) milk 1st line; if severe then use amino acid-based formula (AAF)
Breastfed= continue breastfeeding; eliminate cow’s milk protein from maternal diet; consider Ca supplements to prevent deficiency; when breastfeeding stops use eHF until 12m and at least for 6m
around 10% of infants with cow’s milk protein intolerance/allergy who are formula fed also are intolerant to what?
soya milk
Prognosis of cow’s milk protein intolerance/allergy?
CMPI usually resolves in most children
in children with IgE mediated intolerance around 55% will be milk tolerant by the age of 5 years
in children with non-IgE mediated intolerance most children will be milk tolerant by the age of 3 years
a challenge is often performed in the hospital setting as anaphylaxis can occur.
Lactose Intolerance vs. Cow’s Milk Protein Intolerance/Allergy?
L= inability to digest lactose (sugar in milk) due to low/absent lactase enzyme; non-immune mediated (enzyme def); bloating, diarrhoea, abdo pain; older children/adults; lifelong; Dx= lactose hydrogen breath test/lactose elimination; Mx= lactose free products
CMPI/A= immune reaction to proteins in cows milk eg. whey, casein; immune mediated (IgE or non-IgE); vomiting, diarrhoea, skin rash, wheeze or anaphlyaxis; infants; Mx= specialised hypoallergenic formulas and avoid all cows milk & dairy; often resolves by early childhood
What type of cows milk protein intolerance/allergy resolves faster?
non-IgE mediated= by 3yrs
IgE mediated= usually by 5yrs
What is cows milk allergy?
reproducible immune-mediated allergic response to one or more proteins in cow’s milk.
Types of cows milk allergy?
IgE-mediated food allergy produces immediate symptoms, which may affect multiple organ systems, typically up to 2 hours after cow’s milk ingestion.
Non-IgE-mediated food allergy reactions usually manifest between 2 and 72 hours after cow’s milk ingestion.
Mixed IgE and non-IgE allergic reactions involve both IgE and non-IgE mediated responses.
Cx of cows milk allergy?
Parental/carer stress and reduced quality of life.
Restricted diet and malnutrition.
Development of atopic comorbidities.
Severe and life-threatening reactions.
When to suspect IgE mediated cows milk protein allergy?
urticaria, angio-oedema, itch, cough, hoarseness, wheeze, or breathlessness after cow’s milk ingestion.
When to suspect non-IgE-mediated cows milk allergy
one or more symptoms such as gastro-oesophageal reflux disease, abdominal discomfort, constipation, diarrhoea, or atopic eczema, particularly if symptoms are treatment-resistant.
In cows milk protein intolerance/allergy, how long should mother/infant trial elimination of all cows milk from diet to diagnose?
2-4w then reintroduction of cows milk to confirm diagnosis if clear improvement
In cows milk protein intolerance/allergy, how long should mother/infant eliminate all cows milk from diet?
until child is 9-12m old and for at least 6m; then reintroduction using milk ladder if non-IgE mediated
What if in suspected cows milk allergy, allergy testing does not correspond with clinical history?
oral food challenge under medical supervision is gold standard
Cows milk protein allergy (intolerance)= following cows milk-free diet, what is then advised?
planned home reintroduction or supervised challenge of cow’s milk is necessary to determine if tolerance has been acquired.
if current atopic eczema/immediate onset symptoms then refer to specialist for allergy testing and ongoing Mx
if not then reintroduction using ‘milk ladder’
Cows milk protein allergy= milk ladder?
reintroduces baked milk products first as heating reduces allergenicity. Once tolerance is established, greater exposure to less processed milk should be gradually encouraged, ending in the reintroduction of fresh cow’s milk. The iMAP Milk Allergy Guideline Milk ladder and Milk ladder recipes leaflets may be helpful for parents/carers.
have oral antihistamines available at home, in case there is a return of symptoms on reintroduction.
If symptoms return on reintroduction of cow’s milk, a cow’s milk-free diet should be continued, and the child should be re-evaluated after a further 6 to 12 months.
IgE mediated vs non-IgE mediated cows milk protein allergy?
IgE= rapid onset (within mins, up to 2hrs); acute angioeodema, acute urticaria, atopic eczema (acute flare), erythema, pruritus; colickly abdo pain, diarrhoea, nausea, vomiting; wheezing, SOB, cough, nasal itching, cogestion; signs of anaphylaxis
non-IgE= delayed onset (2-72hrs); atopic eczema, erythema, pruritus; abdo pain; blood +/or mucus in stool; faltering growth; GORD, vomiting, colic, loose/frequent stools; pallor & tiredness, perianal redness; wheeze, SOB, cough
Causes of haematuria?
- trauma= renal tract, ureter, bladder
- infection= TB
- malignancy= RCC, urothelial (TCC), SCC, prostate ca, penile ca (SCC)
- renal disease= golmerulonephritis
- stones= microscopic haematuria
- structural abnormalities= BPH, cystic renal lesions, vascular malformations, renal vein thrombosis due to RCC
- coagulppathy
- drugs
- benign= exercise
- gynae= endometriosis
- iatrogenic= catheterisation, radiotherapy
- pseudohamaturia
What drugs may cause haematuria?
cause tubular necrosis or interstitial nephritis= aminoglycosides, chemotherapy
interstitial nephiritis= penicillin, sulphonamides, NSAIDs
anticoags
Another name for failure to thrive?
faltering growth
Faltering growth (failure to thrive) Cx?
impairment of long term growth
cognitive, immune, cardiac and GI impairment
Faltering growth (failure to thrive) can be split into what?
weight loss in 1st few days of life and weight loss following the 1st few days of life
Weight loss in 1st few days of life?
normal, usually stops by day 3-4 and by 3w should have regained their birthweight
due to body fluid adjustment
By what age should babies have regained their birthweight?
by 3w of age
When is weight loss in the 1st few days of life (up until around 3-4 days) concerning?
if lose >10% of birth weight in early days of life or fail to regain birth weight by 3w
refer to paeds eg. illness, marked weight loss, failure to respons to feeding support
How to recognise faltering growth (failure to thrive) after the first few days of life?
assessment of childs weight +/- height/length
plotted on growth charts in red book
Growth charts?
growth standards and UK birth and preterm growth statistics
lines on the chart called centiles, which mark the weight or height below which a specified percentage of age and gender-matched children will fall.
Eg 50% of children are below the 50% centile.
Head circumference, weight, and height/length are plotted over time to visually represent growth.
A healthy child will normally approximately follow the centile they are born on as they grow, but if a child fails to gain weight in this way they will begin to drop through the centiles.
When to be concerned about growth in infants and children?
A fall across 1 or more weight centile spaces, if birthweight was below the 9th centile.
A fall across 2 or more weight centile spaces, if birthweight was between the 9th and 91st centiles.
A fall across 3 or more weight centile spaces, if birthweight was above the 91st centile
When current weight is below the 2nd centile for age, whatever the birthweight.
How to assess growth in children?
<2yrs= growth chart
> 2yrs= BMI
When to suspect faltering growth (FTF) in children >2yrs?
BMI is below the 2nd centile (can be due to undernutrition or a small build).
BMI is below the 0.4th centile (suggests probable malnutrition).
What to measure if there is concern about faltering growth?
their length (if <2 years old) or height (if >2 years old).
Factors that may contribute to faltering growth?
often multifactorial
1) inadequate intake of nutrients
2) inadequate absorption of nutrients
3) XS energy output due to an underlying condition
Factors that may contribute to faltering growth= inadequate intake of nutrients?
Decreased availability of nutritious food.
Lack of knowledge of appropriate healthy food.
Feeding issues, eg breastfeeding problems, cleft lip/palate, poor appetite and weaning struggles.
Child maltreatment.
Developmental delay.
Eating disorders.
Factors that may contribute to faltering growth= inadequate absorption of nurtients?
Troublesome vomiting, eg due to reflux, obstruction, side effects to medication, food sensitivities/allergy, underlying metabolic disease or central nervous system disease.
Malabsorption due to bowel disease, eg chronic diarrhoea, food allergy/sensitivity, coeliac disease, inflammatory bowel disease, or protein-losing enteropathy.
Factors that may contribute to faltering growth= XS energy output due to an underlying condition?
Immunodeficiency such as severe combined immune deficiency (SCID).
Genetic conditions such as Down’s syndrome.
Malignancies.
Cardiac disease such as congenital heart disease.
Respiratory disease such as cystic fibrosis or more commonly laryngomalacia.
Endocrine disease such as diabetes or hyperthyroidism.
Metabolic disease such as inborn errors in metabolism.
Renal disease such as renal tubular acidosis.
What is associated with improved prognosis and fewer long-term Cx in faltering growth?
prompt diagnosis and establishing underlying cause and initiating correct Tx quickly
If weight loss is more than 10% of birth weight in the early days of life or the infant has not returned to their birth weight by 3 weeks of age= what should we do?
assess the baby for signs or symptoms of an underlying disease causing faltering growth.
Discuss or refer to paediatrics (urgency dependent on the individual situation) all babies with:
- symptoms or signs suggestive of an acute or chronic underlying condition.
- rapid weight loss or severe under-nutrition.
- safeguarding concerns.
- slow linear growth or unexplained short stature.
If weight loss is more than 10% of birth weight in the early days of life or the infant has not returned to their birth weight by 3 weeks of age= what to do if no need to refer to paeds?
- feeding support eg. by midwife
- direct observation and training eg. breastfeeding support workers
- support to continue breastfeeding
- advise to express milk to promote supply and give breast milk first before any formula top ups
- follow up to review growth and weight (no more than once daily)
Follow up in faltering growth?
Weight should be measured again at appropriate intervals (no more than once daily if less than 1 month old) ‘ record all measurements in the parent or carer-held Personal Child Health Record.
If an infant with faltering growth develops new clinical symptoms or signs after the initial assessment, develops marked weight loss or fails to respond to feeding support consider referral to paediatrics.
Mx for faltering growth outside the first few days of life?
- refer to paeds if needed
- eating solids= do they have interest in food, mealtime arrangements and practices eg. do family all eat together; what food is being offered and is it appropriate; any food aversion or avoidance; does caregiver respond to childs mealtime cues
- encourage relaxed mealtimes not too short or long eg. 20-30mins
- nutrient rich healthy food appropriate for developmental age, size of portion, texture
- avoid too many high energy drinks eg. milk as can reduce appetitie
- routine eg. 3 meals a day 2 snakcs
- encourage child to explore food, feed themselves, be messy
- refer depending on the individual situation eg a dietician, psychologist, occupational therapist, school nurse or social services.
Follow up for faltering growth in child outside of 1st few days of life?
monitor the child’s growth but the frequency of this will be dependent on the individual clinical situation. Normally, no more than:
Monthly from 1 year of age.
Fortnightly if between 6-12 months.
Weekly if between 1-6 months.
Daily if less than 1 month old.
Faltering growth= weight gain normally takes how long to show after a successful intervention?
at least 4-8w
Causes of learning difficulties?
genetic
congenital infections
birth
metabolic disorders?
Causes of learning difficulties= genetic?
fragile X
Downs
Causes of learning difficulties= congenital infections?
cytomegalovirus
toxoplasmosis
rubella
Causes of learning difficulties= birth?
hypoxia
rhesus haemolytic disease
intraventricular haemorrhage
Causes of learning difficulties= metabolic disorders?
PKU
maple syrup urine disease
homocystinuria
Causes of limping child?
- transient synovitis
- septic arthritis/osteomyelitis
- juvenile idiopathic arthritis
- trauma
- developmental dysplasia of hip
- perthes disease
-slipped upper femoral epiphysis (SUFE)
Causes of limping child=
- Acute onset
- Usually accompanies viral infections, but the child is well or has a mild fever
- More common in boys, aged 2-12 years
transient synovitis
Causes of limping child= unwell child, high fever
septic arthritis/osteomyelitis
Causes of limping child= limp may be painless?
juvenile idiopathic arthritis
Causes of limping child= history is usually diagnostic?
trauma
Causes of limping child= usually detected in neonates, 6x more common in girls?
developmental dysplasia of the hip
Causes of limping child= more common at 4-8yrs; due to avascular necrosis of the femoral head
perthes disease
Causes of limping child= 10-15yrs; displacement of the femoral head epiphysis postero-inferiorly
slipped upper femoral epiphysis
What does SUFE stand for?
slipped upper femoral epiphysis
Define limp?
asymmetric gait, and is a deviation from a normal age-appropriate gait pattern. eg. antalgic gait
Red flags in a limping child?
- pain waking child up at night= ?malignancy
- red, swelling, stiffness= infection or inflam joint disease
- weight loss, anorexia, fever, night sweats, fatigue= malignancy, infection, inflam
- unexplained rash or bruising= haem or inflam joint disease; child maltreatment
- limp and stiffness worse in the morning= inflam joint disease
- unable to bear weight or painful limitation of range of motion= trauma or infection
- severe pain, anxiety, agitation after traumatic injury= neurovasc compromise or impending compartment syndrome
- palpable mass= malignancy or infection
Referral for urgent specialist assessment should be arranged if limping child and…?
- has fever/red flags
- maltreatment
- <3yrs
- > 9yrs with painful or restricted hip movements (in particular internal rotation)= exclude SUFE
Why urgent assessment if child has a limp and is <3yrs?
transient synovitis is rare in this age group, septic arthritis more common
Why urgent assessment if child has a limp, is >9yrs and has painful or restricted hip movements (in particular internal rotation)?
to exclude SUFE
Children with working diagnosis of transient synovitis can be managed in primary care, what to do?
rest and simple analgesia
A&E if unable to weight bear, become unwell, develop fever
if improving within 48hrs then review 1w from symptom onset to confirm complete symptom resolution
Child with limp history of trauma or focal bony tenderness on examination?
an X-ray should be arranged.
A child with persistent limp and normal initial X-ray should be referred to paediatric orthopaedics or paediatric rheumatology department (the urgency depending on clinical judgement) for further investigation.
In infants, pain during nappy changes causing back flexion may indicate
discitis
Differential diagnosis for child with limp who is younger than 3yrs?
- fracture or soft tissue injury
- DDH
Differential diagnosis for child with limp who is 3-10yrs?
- transient synovitis
- fracture or soft tissue injury
- Perthes disease (Legg-Calve-Perthes disease)
Summarise transient synovitis?
self-limiting inflammatory disorder of the hip.
It is more common in boys than in girls and is rare in children aged younger than 3 years.
It presents acutely with mild to moderate hip pain and limp, and there is no (or mild) restriction of hip movements, especially abduction and internal rotation. Children are otherwise well and afebrile.
There is usually a history of viral illness, but the absence of a viral illness does not rule out the possibility of synovitis.
The diagnosis of transient synovitis is one of exclusion, after other causes of hip pain and limp have been ruled out.
Summarise perthes disease?
An idiopathic avascular necrosis of the developing femoral head.
It is more common in boys than in girls.
Onset is usually over weeks, and the child will typically present with limitation of hip rotation and a subacute limp sometimes with referred pain to the groin, thigh, or knee. It is typically unilateral, though bilateral involvement is present in 10% of cases.
The child is systemically well with no other joint involvement and no evidence of joint inflammation.
Most children with Perthes’ disease have good outcomes, but long-term complications may include chronic pain and osteoarthritis.
An idiopathic avascular necrosis of the developing femoral head
perthes disease
Differential diagnosis for child with limp who is 10-19yrs?
- fracture or soft tissue injury
- SUFE
- perthes
- Osgood-Schlatter disease
- Sever’s disease
- Osteochondritis dissecans
- Chondromalacia patellae
Toddler fracture?
subtle undisplaced spiral fracture of the tibia typically seen in pre-school children. It is usually caused by a sudden twist, often after an unwitnessed fall. Affected toddlers (often new walkers) present with difficulty or refusal to bear weight.
Summarise SUFE?
A displacement of the proximal femoral epiphysis from the metaphysis.
It is slightly more common in boys than girls and in children who are overweight.
It can present with an acute/insiduous onset of pain (hip, thigh, or knee), and the child may walk with an antalgic gait out-toeing, with shortening of the affected limb. It is sometimes associated with endocrine abnormalities, such as hypothyroidism, and in children being treated for growth hormone deficiency or with a history of radiotherapy treatment.
Prompt diagnosis is crucial to avoiding further displacement and the development of avascular necrosis.
Summarise Osgood-Schlatter disease?
An overuse injury caused by multiple small avulsion fractures within the ossification centre (apophysis) of the tibial tuberosity at the inferior attachment of the patellar ligament.
It is a usually self-limiting disorder causing anterior knee pain during adolescence.
Summarise Sever’s disease?
An overuse injury thought to be caused by repetitive microtrauma from the pull of the Achilles tendon on the unossified apophysis.
It is most common in boys aged 10–12 years who are active in sports, such as running and football, and produces heel pain as a result of inflammation of the calcaneal apophysis.
It often resolves within 2 weeks to 2 months, but a child may have recurrent symptoms until skeletal maturity.
Summarise osteochondritis dissecans?
Occurs when a small piece of subchondral bone begins to separate from its surrounding area due to a disturbance of the local blood supply. This bone and the cartilage covering it may break loose, causing pain and possibly hindering joint motion.
It is the most common cause of a loose body in the joint space, typically affecting the knee between the ages of 10–19 years.
The aetiology is uncertain but trauma, vascular abnormalities, defects in ossification, and genetics have all been suggested as possible causes. Clinical findings are subtle and a small effusion or limited range of joint movement may be the only sign. Locking or instability suggest a loose body in the joint.
Summarise chondromalacia patellae?
Describes anterior knee pain typically felt when walking up or down stairs.
Affects children between the ages of 10–19 years in a ratio of three girls to two boys.
Differential diagnosis for limp in child at any age?
- septic arthritis and osteomyelitis
- other infections eg. discitis
- malignancy= primary bone tumours, soft tissue sarcoma, leukaemia and lymphoma
- Non-malignant haematological disease eg. sickle cell and haemophilia
- metabolic disease eg. rickets
- inflam muscle or joint disease eg. JIA and Lyme arthritis
- neuromusc disease eg. cerebral palsy or spina bifida
- muscular dystrophies
- primary anatomical abnormality eg. limb length discrepancy
- intra-abdo pathology eg. inguinal hernia and appendicitis; inguinoscrotal disorders eg. testicular torsion
Summarise septic arthritis?
Infection of the synovium and joint space. It can present in any joint but most commonly affects the lower limbs, and can lead to joint destruction, permanent loss of joint function, and sepsis. Clinical features include refusal to bear weight and fever. There may be evidence of joint inflammation.
Summarise osteomyelitis?
infection of the bone. It usually involves a single bone but may rarely affect multiple sites, and can lead to inflammation and bone destruction. The most common presenting signs are pain with palpation and decreased limb use.
CP of septic arthritis and osteomyelitis may mimic what?
transient synovitis.
However, transient synovitis is rare in children younger than 3 years of age.
Four independent predictors have been proposed and validated to aid in the differentiation of transient synovitis and septic arthritis?
1) fever
2) non-weight bearing on affected side
3) ESR >40
4) WCC >12,000
Summarise discititis?
inflammation of the disc space and adjacent vertebral endplates that typically affects the lumbar spine.
It is more common in neonates and young children.
Presentation can be very non-specific, and a high index of suspicion is required for diagnosis. Clinical presentation ranges from refusal to walk or bear weight to irritability on spine immobility. Point tenderness over the spine can aid in the diagnosis. It may also present with unusual symptoms, such as abdominal pain, limp, hip or leg pain.
Limited spinal flexion, stiff posture, and local tenderness on spine examination are also suggestive of discitis.
Most common bone tumour in children?
osteosarcoma, peaks after 10yrs
Most common non-bone tumours in children?
leukaemia and neuroblastoma
CP that may indicate malignancy as the cause of limp in child?
night pain, hepatosplenomegaly, lymphadenopathy, or pathological fractures.
Sickle cell disease in children as a cause for limp?
Sickle cell disease encompasses a group of inherited conditions that have the inheritance of sickle haemoglobin in common. It can cause a limp through avascular necrosis of the hip, increased susceptibility to infections (including osteomyelitis), and stroke (about 10% of children with sickle cell disease are at risk of stroke, which may present as sudden onset of a limp)
Haemophilia as a cause of child limp?
Haemophilia may result in easy bruising, bleeding after dental procedures, haemarthrosis, soft-tissue/muscle haematomas in toddlers, and swollen joints in active toddlers (usually boys). May be related to family history of bleeding disorders.
Summarise rickets?
Osteomalacia (called rickets in children) is due to a lack of vitamin D or problems with its metabolism.
When osteomalacia affects the growing skeleton, it is referred to as rickets. Clinical features of rickets include bone pain and tenderness, skeletal deformity (such as bowing of the legs) and kyphoscoliosis, and proximal muscle weakness.
JIA?
JIA encompasses a group of disorders presenting with inflammatory joint disease in children. It is characterized by joint pain, swelling without a large effusion, and morning stiffness that persists for longer than 6 weeks, and has no known cause. It can affect single or multiple joints. Systemic symptoms of lethargy and anorexia may be present. Eye involvement in the form of uveitis is also commonly noted. Often children with JIA are otherwise well and blood tests and X-rays may be normal.
Lyme arthritis?
second most common symptom to the classic rash associated with Lyme disease. In cases where the erythema migrans rash (commonly called the bull’s eye rash) does not appear or goes unnoticed, Lyme arthritis may be the first clinical sign. It typically presents without a fever. The child will bear partial weight and present with a limp.
Perthes disease?
degenerative condition affecting the hip joints of children, typically between the ages of 4-8 years.
Perthes disease typically affects what age?
4-8yrs
Cause of Pethes disease?
due to avascular necrosis of the femoral head, specifically the femoral epiphysis. Impaired blood supply to the femoral head causes bone infarction
Perthes disease more common in what gender?
5x more in boys
10% cases are bilateral
Features of perthes?
hip pain: develops progressively over a few weeks
limp
stiffness and reduced range of hip movement
X-ray findings in perthes?
early changes include widening of joint space, later changes include decreased femoral head size/flattening
Diagnosis of perthes?
plain x-ray
technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist
Cx of perthes?
osteoarthritis
premature fusion of the growth plates
Staging for perthes?
Catterall staging
1= Clinical and histological features only
2= Sclerosis with or without cystic changes and preservation of the articular surface
3= Loss of structural integrity of the femoral head
4= Loss of acetabular integrity
Mx for perthes?
To keep the femoral head within the acetabulum: cast, braces
If less than 6 years: observation
Older: surgical management with moderate results
Operate on severe deformities
Perthes disease prognosis?
Most cases will resolve with conservative management. Early diagnosis improves outcomes.
Transient synovitis?
irritable hip.
It generally presents as acute hip pain following a recent viral infection.
It is the commonest cause of hip pain in children.
Typical age group for transient synovitis?
3-8yrs
Features of transient synovitis?
- acute hip pain following recent viral infection
- limp/refusal to weight bear
- groin or hip pain
- low grade fever in minority; if high grade then ?septic arthritis
Exclude transient synovitis vs septic arthritis?
fever is a red flag, indicating the need for urgent
specialist assessment
children may be monitored in primary care (with a presumptive diagnosis of transient synovitis) ‘If the child is aged 3-9 years, well, afebrile, mobile but limping, and has had the symptoms for less than 72 hours
Mx for transient synovitis?
self-limiting, rest and analgesia
Peak incidence for ALL?
2-5yrs
Poor prognostic factors for ALL?
age < 2 years or > 10 years
WBC > 20 * 109/l at diagnosis
T or B cell surface markers
non-Caucasian
male sex
anaemia: lethargy and pallor
neutropaenia: frequent or severe infections
thrombocytopenia: easy bruising, petechiae
bone pain (secondary to bone marrow infiltration)
splenomegaly
hepatomegaly
fever is present in up to 50% of new cases (representing infection or constitutional symptom)
testicular swelling
ALL
Types of ALL?
common ALL (75%), CD10 present, pre-B phenotype
T-cell ALL (20%)
B-cell ALL (5%)
Lymphadenopathy
condition of enlarged lymph nodes, typically indicating an immune response to an infection or malignancy
Lymphadenopathy pathophysiology?
The lymphatic system, comprising lymph vessels, nodes, and other tissues, plays a critical role in body’s immunity.
Lymph nodes are small, bean-shaped structures that produce and store cells that fight infection and disease.
They filter the lymph fluid as it flows through them, trapping bacteria, viruses, and other foreign substances to be destroyed by white blood cells.
Lymphadenopathy usually occurs when these nodes produce more cells or become filled with debris from a destroyed cell.
Differential diagnosis for generalised lymphadenopathy?
infective
neoplastic= leukaemia and lymphoma
autoimmune= SLE, RA
graft versus host disease
sarcoidosis
drugs
Infective causes of generalised lymphadenopathy?
infectious mononucleosis
HIV, including seroconversion illness
eczema with secondary infection
rubella
toxoplasmosis
CMV
tuberculosis
roseola infantum
What drugs may cause generalised lymphadenopathy?
phenytoin and to a lesser extent allopurinol, isoniazid
Neoplastic causes of generalised lymphadenopathy?
leukaemia and lymphoma
Sudden infant death syndrome (SIDS)?
the sudden, unexpected and unexplained death of an apparently healthy baby
commonest cause of death in 1st yr of life
What age is SIDS most common?
3m
Major RFs for SIDS?
putting the baby to sleep prone
parental smoking: increases the risk up to 5 fold
prematurity: 4-fold increased risk
bed sharing: odds ratio 5.1
hyperthermia (e.g. over-wrapping) or head covering (e.g. blanket accidentally moves)
other= male; multiple births; social classes IV and V; maternal drug use; winter
Protective factors for SIDS?
- breastfeeding
- room sharing (NOT bed sharing)
- use of dummies
SIDS= following a cot death, what should be done?
siblings should be screened for potential sepsis and inborn errors of metabolism.
Inborn errors of metabolism?
genetic disorders caused by enzyme defects in metabolic pathways, leading to toxic metabolite accumulation or deficiency. eg…
- Disorders of Carbohydrate Metabolism= Hereditary Fructose Intolerance: (Deficiency of aldolase B; triggers hypoglycemia and vomiting after fructose ingestion.)
- Disorders of Amino Acid Metabolism= Maple Syrup Urine Disease (Defective metabolism of branched-chain amino acids; presents with lethargy and a sweet-smelling urine) and Phenylketonuria (PKU): (Deficiency of phenylalanine hydroxylase; causes intellectual disability if untreated.)
many more
Management involves dietary restrictions, supplements, and sometimes enzyme replacement. Early diagnosis via newborn screening is critical.
Most common nutritional disorder of childhood?
iron def anaemia
10% of children in the UK.
The prevalence is higher in Asian, Afro-Caribbean and Chinese children
Causes of iron def anaemia in children?
socioeconomic - iron supplemented milk formulas may be more expensive
unmodified cow’s milk - a poor source of iron due to it being in a form that is not absorbed well, therefore should be introduced after 1 year of age (breast milk is relatively low in iron but it is present in a form that is easily absorbed)
ethnic origin - e.g. Asian mothers may introduce solids later
Prevention of iron def anaemia in children?
supplementary iron in milk
dietary education
free formulas for at risk infants
Risks of prematurity?
necrotizing enterocolitis
increased mortality depends on the gestation
respiratory distress syndrome
intraventricular haemorrhage
chronic lung disease,
hypothermia, feeding problems, infection, jaundice
retinopathy of prematurity
hearing problems
Retinopathy of prematurity?
important cause of visual impairment in babies born before 32 weeks gestation
the cause is not fully understood and multivariate. One of the contributing factors is thought to be over oxygenation (e.g. during ventilation) resulting in a proliferation of retinal blood vessels (neovascularization)
screening is done in at-risk groups
First sign of puberty in males?
testicular growth at around 12 years of age (range = 10-15 years)
What indicated the onset of puberty in males/
testicular volume >4ml
Puberty in males= height spurt?
max height spurt at 14
Typical age of puberty in males?
12yrs
range 10-15yrs
Typical age of puberty in females?
11.5yrs
range= 9-13yrs
First sign of puberty in females?
breast development at around 11.5 years of age (range = 9-13 years)
Puberty in females= height spurt?
height spurt reaches its maximum early in puberty (at 12) , before menarche
increase of only about 4% of height following menarche
Puberty in females= when is menarche?
13yrs (11-15yrs)
Normal changes in puberty?
gynaecomastia may develop in boys
asymmetrical breast growth may occur in girls
diffuse enlargement of the thyroid gland may be seen
Torsion of the appendix testis or appendix epididymis?
This condition is related, but distinct from classic testicular torsion. It classically occurs in boys aged 8-11 years.
Torsion of the appendix testis or appendix epididymis= structures?
small vestigial remnants:
- appendix testis: a small structure on the anterosuperior aspect of the testis (an embryologic remnant of the Mullerian duct system)
- appendix epididymis: a small remnant of the Wolffian duct located at the head of the epididymis
Torsion of the appendix testis or appendix epididymis= features?
similar, but often less severe symptoms to testicular torsion, i.e.:
sudden-onset testicular pain
the testicular body itself is usually non-tender but there is a tender mass palpable
a ‘blue-dot’ sign may be seen through the scrotum
the testicular body itself is usually non-tender but there is a tender mass palpable
a ‘blue-dot’ sign may be seen through the scrotum
Torsion of the appendix testis or appendix epididymis
Diagnosis of torsion of the appendix testis or appendix epididymis?
usually clinical although Doppler ultrasound scans may be helpful
Mx of of torsion of the appendix testis or appendix epididymis?
conservative treatment is possible, but many children will have an exploratory operation to exclude classic testicular torsion, given the consequences of a missed diagnosis.
Acute scrotal disorders in children?
1) testicular torsion= most common around puberty
2) irreducible inguinal hernia= most common in children <2yrs
3) epididymitis= rare in prepubescent children
When is infant/child considered to have a fever?
38°C or higher
What should be used to stratify risk of serious illness in children <5yr presenting with a fever?
traffic light system
Traffic light system for fever= what if any red features suggesting serious or life threatening cause of febrile illness?
emergency ambulance to A&E
Traffic light system for fever= what if any non-life threatening red features?
urgent face-toface assessment within 2hrs
Traffic light system for fever= what if any amber features?
face to face assessment (urgency depending on clinical judgement
Traffic light system for fever= what if green features but no amber or red?
child can be managed at home
Mx of infant or child with fever- advice to parent/carer?
- look for signs of dehydration
- regular fluids
- continue breastfeeding
- do not underdress or over wrap to prevent overcooling or overheating
- avoid using cool water sponging to lower temp
- check child regularly incl during the night
- keep away from nursery/school until recovered
Advice on use of antipyretics for children with fever for parents?
paracetamol or ibuprofen initially and consider to switching to ibuprofen is paracetamol alone is ineffective and vise vera
Safety-netting advice to parents/carers on warning symptoms and signs of when to arrange urgent medical review in a child with fever?
- non-blanching rash/signs of CNS infection
- seizure
- dehydrated
- fever >5d
- becomes more unwell
- distressed that unable to look after child at home
How to assess child with fever?
- traffic light system
- appearance, temp, HR, RR, CRT, fluid status
- BP if HR or CRT abnormal
- height and duration of fever, method of measurement, associated symptoms eg. cough, pain, SOB, itch, rash, confusion, swelling, N&V
- any perinatal Cx= maternal fever, prematurity (these are RFs for serious bacterial infection in <3m)
- ?medical conditions eg. immunosuprression/def
- recent med use
- foreign travel
How to check body temp in children?
<4w= electronic thermometer in axilla
4w-5yrs= electronic thermometer or chemical dot thermometer in the axilla, or an infra-red tympanic thermometer.
NICE traffic light system: how many things do they need to fall under amber or red risk categorgy?
if they have ANY of the relevant clinical features (only need 1 to be in that category)
NICE traffic light system: different categories? (5)
1) Colour (skin, lips, tongue)
2) Activity
3) Respiratory
4) Circulation and hydration
50 Other
NICE traffic light system: GREEN (low risk)?
1) Colour= normal
2) Activity= responds normally to social cues; content or smiles; stays awake or awakens quickly; strong normal cry or not crying
3) Resp= /
4) Circulation and hydration= normal skin and eyes; moist mucus membranes
5) Other= none of amber or red signs or symptoms
NICE traffic light system: AMBER (intermediate risk)?
1) Colour= pallor reported by parent/carer
2) Activity= does not respond normally to social cues; no smile; wakes only with prolonged stimulation; decreased activity
3) Resp= nasal flaring; tachypnoea: 6-12m with RR >50; >12m with RR >40; O2 sats ≤ 95% on air; crackles on auscultation
4) C&H= tachycardia; <12m and >160bpm; 12-24m and >150bpm; 2-5yrs and >140 bpm; poor feeding in infants; dry mucous membranes; CRT 3secs or more; reduced urine output (wet nappies in infants)
5) T ≥ 39°C if 3-6m; fever 5d+; rigors; swelling of limb or joint; non-weight bearing limb or not using an extremity
NICE traffic light system= RED (high risk)?
1) Colour= pale, mottled, ashen or blue
2) Activity= no response to social cues; appears ill to healthcare professional; does not wake or if roused does not stay awake; weak, high-pitched or continuous crying
3) Resp= grunting; tachypnoea: RR 60 or more; moderate or severe chest indrawing
4) C&H= reduced skin turgor
5) T ≥ 38°C if <3m; non-blanching rash; bulging fontanelle; neck stiffness; focal neuro signs; focal seizures; status epilepticus
Some vaccinations may induce fever in children how old?
<3m
What illnesses to consider in children with fever?
- meningococcal disease
- bacterial meningitis
- herpes simplex encephalitis
- pneumonia
- UTI
- septic arthritis or osteomyelitis
- Kawasaki disease
Fever= paracetamol dosing?
dose every 4-6hrs if needed (max 4 doses in 24hrs)
1-2m= 30-60mg (every 8hrs, max 60mg/kg per day)
2-5m= 60mg
6-23m= 120mg
2-3yrs= 180mg
4-5yrs= 240mg
6-7= 240-250mg
8-9= 360-375mg
10-11= 480-500mg
12-15= 480-750mg
16yrs+= 500mg-1000mg (1g)
(oral)
Fever= ibuprofen dosing?
1-2m= 5 mg/kg 3–4 times a day (off-label indication under 3 months of age or body weight less than 5 kg)
3-5m= 50mg 3xd
6-11m= 50mg 3-4x a day
1-3yrs= 100mg 3xd
4-6yrs= 150mg 3xd
7-9= 200mg 3xd
10-11yrs= 300mg 3xd
12-17yrs= 300-400 3-4x d
What should be recorded in ALL febrile children?
1) T
2) HR
3) RR
4) CRT
Also look for signs of dehydration eg. reduced skin turgor and cool extremities
Traffic light system= Mx if green?
Child can be managed at home with appropriate care advice, including when to seek further help
Traffic light system= Mx if amber (only need 1 criteria to be filled)?
safety net or refer to a paediatric specialist for further assessment
a safety net includes verbal or written information on warning symptoms and how further healthcare can be accessed, a follow-up appointment, liaison with other healthcare professionals, e.g. out-of-hours providers, for further follow-up
Traffic light system= Mx if red (only need 1 criteria to be filled)?
refer child urgently to a paediatric specialist
Child with fever: 2 key points to remember?
1) oral Abx should not be prescribed to children with fever without apparent source (unless ?sepsis for example)
2) if suspect pneumonia but child not going to hospital then do not routinely need CXR
Nocturnal enuresis aka
bedwetting
What age do most children achieve day and night time continence?
by 3-4yrs
Enuresis definition?
‘involuntary discharge of urine by day or night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract’
Nocturnal enuresis can be defined as what?
either primary (the child has never achieved continence) or secondary (the child has been dry for at least 6 months before)
Possible underlying causes/triggers for nocturnal enuresis?
constipation, DM, UTI if recent onset
Mx for nocturnal enuresis?
1) look for underlying cause/trigger
2) general advice= fluid intake; toilet patterns (encourage empty bladder regularly during day and before sleep); lifting and waking
3) Reward system eg. star charts= give for agreed behaviour rather than dry nights eg. using toilet to pass urine before sleep
4) Enuresis alarm (have sensor pads that sense wetness; high success rate)
5) Desmopressin= short term eg. sleepovers or if alarm ineffective
What can be given to a child with nocturnal enuresis short term eg. if going on sleepover?
desmopressin
How to use reward systems eg. star charts for nocturnal enuresis?
‘should be given for agreed behaviour rather than dry nights’ e.g. Using the toilet to pass urine before sleep
3 ways bedwetting can be classified?
primary bedwetting without daytime symptoms
primary bedwetting with daytime symptoms
secondary bedwetting
Primary bedwetting without daytime symptoms? Causes?
never achieved sustained continence at night and does not have daytime symptoms.
This is thought to be caused by sleep arousal difficulties, polyuria, and/or bladder dysfunction.
Primary bedwetting with daytime symptoms? Causes?
ever achieved sustained continence at night and has daytime symptoms, such as wetting, urinary frequency, or urgency.
This may be caused by an overactive bladder, congenital malformations, neurological disorders, urinary tract infection (UTI), or chronic constipation.
Secondary bedwetting? Causes?
bedwetting occurs after the child or young person has been previously dry at night for more than 6 months.
This is usually due to an underlying cause, such as diabetes, UTI, constipation, psychological problems (for example behavioural or emotional problems), or family problems (vulnerable child or family).
RFs for bedwetting?
- FHx
- m>f (2:1)
- delay in attaining bladder control
- obesity
- psycho or behavioural disorders eg. ADHD, autism, anxiety, depressive and conduct disorders
Assessing child with bedwetting, important to determine the type by asking what?
There are any daytime symptoms.
The child has previously been dry at night without assistance for 6 months.
Mx of bedwetting without daytime symptoms?
1) advice= reward system, toilet patterns, fluid intake
2) <5yrs= reassure that many children that age wet bed and normally resolves without Tx
3) 5yrs+= if <2x a week then reassure and wait-and-see; if Tx needed then positive reward system + enuresis alarm; may need desmopressin
Mx of bedwetting with daytime symptoms?
- refer to enuresis clinic or secondary care for Ix
- > 2yr and despite awareness of toileting needs and showing appropriate toileting behaviour, are struggling to not wet themselves during the day as well as the night= assessment and Ix for specific medical problem
Mx of secondary bedwetting?
manage underlying cause or arrange referral to paeds/enuresis clinic if can’t be identified or managed in primary care
What groups will need BCG vaccine?
all infants (aged 0 to 12 months) living in areas of the UK where the annual incidence of TB is 40/100,000 or greater
all infants (aged 0 to 12 months) with a parent or grandparent who was born in a country where the annual incidence of TB is 40/100,000 or greater. The same applies to older children but if they are 6 years old or older they require a tuberculin skin test first
previously unvaccinated tuberculin-negative contacts of cases of respiratory TB
previously unvaccinated, tuberculin-negative new entrants under 16 years of age who were born in or who have lived for a prolonged period (at least three months) in a country with an annual TB incidence of 40/100,000 or greater
healthcare workers
prison staff
staff of care home for the elderly
those who work with homeless people
BCG vaccine?
Bacille Calmette-Guerin (BCG) to protect against TB
Who is the BCG vaccine given to (protect against TB)?
to high-risk infants
What does the BCG vaccine contain?
live attenuated Mycobacterium bovis.
Protects against TB.
It also offers limited protection against leprosy.
How is the BCG vaccine administered?
any person being considered for the BCG vaccine must first be given a tuberculin skin test. The only exceptions are children < 6 years old who have had no contact with tuberculosis
given intradermally, normally to the lateral aspect of the left upper arm
Can the BCG vaccine be given at the same time as other live vaccines?
yes but not administered simultaneously there should be a 4 week interval
Contraindications to the BCG vaccine?
previous BCG vaccination
a past history of tuberculosis
HIV
pregnancy
positive tuberculin test (Heaf or Mantoux)
BCG vaccine is not given to anyone over what age?
over the age of 35, as there is no evidence that it works for people of this age group.
HPV infects what?
keratinocytes of the skin and mucous membranes and it is carcinogenic.
What does HPV stand for?
hyman papullomavirus
Dozens of strains of HPV but what are the important ones to remember?
6 & 11= genital warts
16 & 18= linked to cervical ca and other ca
HPV infection is linked to what?
> 99.7% cervical ca (HPV testing integral to cervical ca screening; samples first tested for HPV and only if they are +ve then cytology is performed)
85% anal ca
50% vulval and vaginal ca
20-30% mouth and throat ca
RFs for cervical ca?
HPV
smoking
COCP
high parity
HPV vaccination programme protects against what strains?
16 & 18 (oncogenic) and the strains that cause genital warts (6 & 11)
Who is offered the HPV vaccine?
12-13 years olds, both girls and boys
also offered to gay, bisexual, and other men who have sex with men (GBMSM) to protect against anal, throat and penile cancers.
When and who to is given the HPV vaccine?
All 12 and 13 yr old GIRLS AND BOYS in year 8
- given at school
- one dose
Other groups who get HPV vaccine?
eligible GBMSM under the age of 25 also receive 1-dose, offered through sexual health clinics
eligible GBMSM aged 25 to 45 years receive a 2-dose schedule, offered through sexual health clinics
eligible individuals who are immunosuppressed or those known to be HIV-positive receive a 3-dose schedule
General contraindications to immunisation?
- confirmed anaphylactic reaction to previous dose of vaccine containing same antigens
- confirmed anaphylactic reaction to another component contained in the relevant vaccine eg. egg protein
Situations where vaccines should be delayed?
febrile illness/intercurrent infection
Contraindications to live vaccines (2)?
pregnancy
immunosuppression
DTP vaccine should be deferred in children with what?
an evolving or unstable neuro condition
What things are NOT contraindications to immunisation?
asthma or eczema
history of seizures (if associated with fever then advice should be given regarding antipyretics)
breastfed child
previous history of natural pertussis, measles, mumps or rubella infection
history of neonatal jaundice
family history of autism
neurological conditions such as Down’s or cerebral palsy
low birth weight or prematurity
patients on replacement steroids e.g. (CAH)
Immunisation schedule?
At birth= BCG if RFs
2m= 6 in 1; oral rotavirus; Men B
3m= 6 in 1; oral rotavirus; PCV
4m= 6 in 1; Men B
12-13m= Hib/MenC; MMR; PCV; Men B
2-8yrs= annual flu
3-4yrs= 4 in 1 pre-school booster; MMR
12-13yrs= HPV
14yrs (Year 9)= 3 in 1 teenage booster; Men ACWY
New uni students (up to 25yrs)= Men ACWY
When should BCG vaccine be given at birth?
if baby deemed at risk of TB eg. TB in family in past 6m
6 in 1 vaccine?
Diphtheria
Tetanus
Whooping cough
Polio
Hib
Hep B
MMR vaccine?
measles
mumps
rubella
4 in 1 pre-school booster?
diphtheria
tetanus
whooping cough
polio
3 in 1 teenage booster?
Tetanus
Diphtheria
Polio
When is 6 in 1 vaccine given?
2m, 3m, 4m
When is BCG vaccine given?
at birth if RFs for TB
When is oral rotavirus vaccine given?
2m, 3m
When is PCV vaccine given?
3m
12-13m
When is the Men B vaccine given
4m
12-13m
When is the Hib/Men C vaccine given?
12-13m
(Hib also in 6 in 1)
When is the MMR vaccine given?
12-13m
2-4yrs
When is the flu vaccine given?
2-8yrs annual
When is the 4 in 1 preschool booster given?
3-4yrs
When is the HPV vaccine given?
12-13yrs
When is the 3 in 1 teenage booster given?
13-18yrs ( 14yrs in Year 9 normally)
When is the Men ACWY vaccine given?
13-18yrs
New uni students (up to 25yrs)
How do adolescents get the Men ACWY vaccine?
GP practices will automatically send letters inviting 17-and 18-year-olds in school year 13 to have the Men ACWY vaccine.
Students going to university or college for the first time as freshers, including overseas and mature students up to the age of 25, should contact their GP to have the Men ACWY vaccine, ideally before the start of the academic year’
Hib?
Haemophilus influenzae B vaccine
PCV?
Pneumococcal Conjugate Vaccine
Men B?
Meningococcal B vaccine
Men C?
Meningococcal C vaccine
Men ACWY?
Meningococcal vaccine covering A, C, W and Y serotypes
HPV vaccine?
Human Papilloma Vaccine
Hib/Men C?
H. influenzae type b and meningococcal group C (Hib/MenC) booster.
Flu vaccine in children according to NICE?
At 2–11 years of age = each year from September:
Live attenuated influenza vaccine (LAIV — Fluenz Tetra®). If LAIV is unsuitable and the child is in a clinical risk group, use inactivated flu vaccine.
When are children considered to be at high risk of exposure to hep B and may need the vaccine?
Born to a mother or living with parents or close household contacts known to have hepatitis B.
Whose parents are people who inject drugs.
Who receive regular blood transfusions (for example for haemophilia).
In residential or day care for people with severe learning disability (decisions on immunization should be made on the basis of a local risk assessment).
Who are at high risk of requiring medical or dental procedures when travelling to visit relatives in countries where there is a moderate or high prevalence of hepatitis B.
When may child need chicken pox vaccine?
vaccination is recommended for non-immune children who are close contacts of people who are immunocompromised (for example they have a sibling or parent with leukaemia or undergoing chemotherapy).
For children aged 1 year or older, give two doses of varicella vaccine (Varivax® or Varilrix®) spaced 4–8 weeks apart.
The varicella vaccine and the measles, mumps, and rubella (MMR) vaccine should be spaced 4 weeks apart if they are not administered on the same day.
Additional vaccines required for pt with= Asplenia or splenic dysfunction (including due to sickle cell and coeliac disease)?
MenACWY, MenB, PCV13 or PPV23, annual flu vaccine
Additional vaccines required for pt with= cochlear implants?
PCV13 or PPV23
Additional vaccines required for pt with= chronic resp and heart conditions eg. severe asthma, COPD, HF?
PCV13 or PPV23
Annual flu
Additional vaccines required for pt with= chronic neuro conditions eg. Parkinsons, MND or learning disability?
PCV13 or PPV23
Annual flu
Additional vaccines required for pt with= DM?
PCV13 or PPV23
Annual flu
Additional vaccines required for pt with= CKD incl haemodialysis?
PCV13 or PPV23
Annual flu
Hep B
Additional vaccines required for pt with= Chronic liver conditions?
PCV13 or PPV23
Annual flu
Hep A & B
Additional vaccines required for pt with= haemophillia?
Hep A and B
Additional vaccines required for pt with= immunosuppression due to disease or Tx?
PCV13 or PPV23
Annual flu
Additional vaccines required for pt with= completement disorders (incl those receiving complement inhibitor therapy)?
PCV13 or PPV23
Annual flu
MenACWY
Men B
PCV13 and PPV23?
Pneumococcal conjugate vaccine (PCV13) can be administered to children aged up to 10 years. Pneumococcal polysaccharide vaccine (PPV23) can be administered to children aged 2 years and over.
Contraindications to MMR vaccine?
severe immunosuppression
allergy to neomycin
children who have received another live vaccine by injection within 4 weeks
pregnancy should be avoided for at least 1 month
following vaccination
immunoglobulin therapy within the past 3 months (there may be no immune response to the measles vaccine if antibodies are present)
Adverse effects of MMR vaccine?
malaise, fever and rash may occur after the first dose of MMR. This typically occurs after 5-10 days and lasts around 2-3 days
Rotavirus vaccine type?
oral, live attenuated vaccine
Oral rotavirus vaccine- when given and how many doses required?
2 doses are required, the first at 2 months, the second at 3 months
the first dose should not be given after 14 weeks + 6 days and the second dose cannot be given after 23 weeks + 6 days due to a theoretical risk of intussusception
Effectiveness of oral rotavirus vaccine?
around 85-90% effective and is predicted to decrease hospitalisation by 70%
offers long-term protection against rotavirus
Tetanus vaccine?
a cell-free purified toxin that is normally given as part of a combined vaccine.
How many doses of tetanus vaccine needed to provide adequate long-term protection?
5
When is tetanus vaccine given?
5 doses in total:
2m
3m
4m
3-5yrs
13-18yrs
3 types of wound?
- clean wound
- tetanus prone wound
- high-risk tetanus prone wound
Mx of wounds summary?
1) classify wound eg. clean or tetanus prone
2) ? tetanus vaccine +/- tetanus immunoglobulin
What is a ‘clean wound’?
Wounds less than 6 hours old, non-penetrating with negligible tissue damage
Tetanus prone wound?
puncture-type injuries acquired in a contaminated environment e.g. gardening injuries
wounds containing foreign bodies
compound fractures
wounds or burns with systemic sepsis
certain animal bites and scratches
High-risk tetanus prone wound?
heavy contamination with material likely to contain tetanus spores e.g. soil, manure
wounds or burns that show extensive devitalised tissue
wounds or burns that require surgical intervention
Mx of wounds= pt has had full course of tetanus vaccines with the last dose <10yrs ago?
no vaccine nor tetanus immunoglobulin is required, regardless of the wound severity
Mx of wounds= pt has had full course of tetanus vaccines with the last dose >10yrs ago?
if tetanus prone wound: reinforcing dose of vaccine
high-risk wounds (e.g. compound fractures, delayed surgical intervention, significant degree of devitalised tissue): reinforcing dose of vaccine + tetanus immunoglobulin
Mx of wounds= tetanus vaccination history incomplete or unknown?
reinforcing dose of vaccine, regardless of the wound severity
for tetanus prone and high-risk wounds: reinforcing dose of vaccine + tetanus immunoglobulin
Clostridium tetani?
tetanus
What are live attenuated vaccines?
utilise a weakened form of the pathogen to stimulate an immune response akin to a natural infection without causing the disease
Live attenuated vaccines are typically not recommended in who?
immunocompromised due to live nature of the vaccines
7 examples of live attenuated vaccines?
BCG
measles, mumps, rubella (MMR)
influenza (intranasal)
oral rotavirus
oral polio
yellow fever
oral typhoid
Name 6 types of vaccines (categories)?
- live attenuated
- Inactivated preparations
- Toxoid (inactivated toxin)
- Subunit and Conjugate vaccines
- Messenger RNA (mRNA) vaccines
- Viral vector vaccines
- can also be monovalent (specific to one antigen/strain/subtype of pathogen) or multivalent/polyvalent (various)
Why is it important to know which vaccines are live-attenuated type?
as may pose a risk to immunocompromised pts
What are inactivate preparations vaccines?
employ pathogens that have been killed, often by heat or chemicals, to elicit an immune response
might require booster doses to maintain immunity as the induced immune response is generally weaker than live attenuated vaccines
What type of vaccines may need a booster?
inactivated preparations= to maintain immunity as the induced immune response is generally weaker than live attenuated vaccines
also toxiod
Vaccines= 3 examples of inactivated preparations?
rabies
hep A
influenza (IM)
Toxoid (inactivated toxin) vaccines?
these vaccines are designed around the toxins produced by certain bacteria. The toxins are rendered harmless (detoxified) and used as antigens in the vaccine. When the immune system encounters these non-toxic toxoids, it learns to combat the natural toxins the bacteria produce, providing immunity against the toxic effects of infections
toxoid vaccines often require booster doses to maintain immunity since, like inactivated vaccines, the immune response they induce can wane over time
3 examples of toxoid (inactivated toxin) vaccines?
tetanus
diphtheria
pertussis (whooping cough)
Subunit and conjugate vaccines?
subunit and conjugate vaccines are often grouped together.
Subunit means that only part of the pathogen is used to generate an immunogenic response.
A conjugate vaccine is a particular type that links the poorly immunogenic bacterial polysaccharide outer coats to proteins to make them more immunogenic
5 examples of subunit and conjugate vaccines?
pneumococcus (conjugate)
haemophilus (conjugate)
meningococcus (conjugate)
hepatitis B
human papillomavirus
mRNA vaccines?
introduce a piece of mRNA into cells which then produce a protein to trigger an immune response.
Example of mRNA vaccine?
some COVID-19 vaccines
Viral vector vaccines?
use a harmless virus (different from the target pathogen) to deliver critical parts of the target pathogen to stimulate an immune response
can be produced more rapidly in response to emerging threats
Examples of viral vector vaccines?
some Ebola and COVID-19 vaccines
Types of vaccines= influenza?
different types are available, including whole inactivated virus, split virion (virus particles disrupted by detergent treatment) and sub-unit (mainly haemagglutinin and neuraminidase)
Types of vaccines= cholera?
contains inactivated Inaba and Ogawa strains of Vibrio cholerae together with recombinant B-subunit of the cholera toxin
Types of vaccines= hep B?
contains HBsAg adsorbed onto aluminium hydroxide adjuvant and is prepared from yeast cells using recombinant DNA technology
Valency of vaccines meaning?
‘valency’ in vaccinology denotes the number of distinct antigenic components or serotypes a vaccine can protect against.
Essentially, it specifies the extent of a vaccine’s antigenic reach.
Monovalent vaccines?
contain a singular antigenic component, conferring immunity against one strain or subtype of a pathogen
Monovalent vaccines= example?
measles vaccine
Multivalent or polyvalent vaccines?
these vaccines comprise multiple antigenic components, safeguarding against various strains or subtypes of a pathogen or, occasionally, multiple pathogens
Example of multivalent or polyvalent vaccines?
quadrivalent influenza vaccine, protective against four distinct virus strains
Who are annual influenza vaccines recommended for?
- > 65yrs
- chronic respiratory disease (including asthmatics who use inhaled steroids)
- chronic heart disease (HF, IHD, including HTN if associated with cardiac Cx)
- CKD (at stages 3, 4 or 5, chronic kidney failure, nephrotic syndrome, kidney transplantation)
- chronic liver disease: cirrhosis, biliary atresia, chronic hepatitis
- chronic neurological disease: (e.g. Stroke/TIAs)
- DM (including diet controlled)
- immunosuppression due to disease or treatment (e.g. HIV)
- asplenia or splenic dysfunction
- pregnant women
- health and social care staff directly involved in patient care (e.g. NHS staff)
- those living in long-stay residential care homes
- carers of the elderly or disabled person whose welfare may be at risk if the carer becomes ill (at the GP’s discretion)
Pneumococcal polysaccharide vaccine (Pneumococcal vaccine) is offered to who?
- > 65yrs
- asplenia or splenic dysfunction
- chronic respiratory disease: COPD, bronchiectasis, CF, interstitial lung disease. Asthma is only included if ‘it requires the use of oral steroids at a dose sufficient to act as a significant immunosuppressant’
- chronic heart disease: IHD if requiring medication or follow-up, HF, congenital heart disease. Controlled HTN is not an indication for vaccination
- CKD (at stages 4 and 5, nephrotic syndrome, kidney transplantation)
- chronic liver disease: including cirrhosis and chronic hepatitis
- DM if requiring medication
- immunosuppression (either due to disease or treatment). This includes patients with any stage of HIV infection
- cochlear implants
- patients with CSF leaks
Achondroplasia?
autosomal dominant disorder associated with short stature.
Results in abnormal cartilage
What causes Achondroplasia?
autosomal dominant
Caused by a mutation in the fibroblast growth factor receptor 3 (FGFR-3) gene
CP of achondroplasia?
abnormal cartilage giving rise to:
- short limbs (rhizomelia) with shortened fingers (brachydactyly)
- large head with frontal bossing and narrow foramen magnum
- midface hypoplasia with a flattened nasal bridge
- ‘trident’ hands
- lumbar lordosis
RFs for achondroplasia?
- 70% sporadic mutation
- advancing parental age at time of conception
- once present it is inherited in autosomal dominant fashion
Tx for achondroplasia?
- no specific
- limb lengthening procedures= application of Ilizarov frames and targeted bone fracture
Basic physiology for genitalia development?
initially gonads in fetus are undifferentiated
on the Y chromosome there is a sex-determining gene (SRY gene) which causes differentiation of the gonad into a testis
if absent (i.e. in a female) then the gonads differentiate to become ovaries
Causes of ambiguous genitalia in newborns?
congenital adrenal hyperplasia
true hermaphroditism
maternal ingestion of androgens
Most common cause of ambiguous genitalia in newborns?
congenital adrenal hyperplasia
What is the apgar score?
assesses health of newborn baby
When is the Apgar score assessed?
1 and 5mins of age
if score is low then repeated at 10mins
Apgar score stands for?
Appearance
Pulse
Grimace (reflex irritability)
Activity (muscle tone)
Respiratory effort
Apgar score= pulse?
> 100= 2
<100= 1
absent= 0
Apgar score= respiratory effort?
strong crying= 2
weak, irregular= 1
nil= 0
Apgar score= appearance?
pink= 2
body pink, extremities blue= 1
blue all over= 0
Apgar score= activity (muscle tone)?
active movement= 2
limb flexion= 1
flaccid= 0
Apgar score= grimace (reflex irritability)?
cries on stimulation/sneezes, coughs= 2
grimace= 1
nil= 0
Apgar score= what do the scores mean?
0-3 is very low
4-6 moderate low
7-10 means baby is in good state
Autosomal dominant diseases= who manifests the disease?
both homozygotes and heterozygotes manifest disease (there is no carrier state)
both males and females affected
Autosomal dominant diseases= disease is passed on to who?
passed on to 50% of children
only affected individuals can pass on disease
normally appears in every generation
risk remains the same for each successive pregnancy
Autosomal dominant disease= complicating factors?
non-penetrance: lack of clinical signs and symptoms (normal phenotype) despite abnormal gene. E.g. 40% otosclerosis
spontaneous mutation: new mutation in one of gametes e.g. 80% of individuals with achondroplasia have unaffected parents
Autosomal recessive conditions are thought to be what?
Compared to autosomal dominant?
Recessive= metabolic
Dominant= structural
some exceptions
Exceptions when autosomal recessive conditions are not metabolic and dominant are not structural?
some ‘metabolic’ conditions such as Hunter’s and G6PD are X-linked recessive whilst others such as hyperlipidaemia type II and hypokalaemic periodic paralysis are autosomal dominant
some ‘structural’ conditions such as ataxia telangiectasia and Friedreich’s ataxia are autosomal recessive
List autosomal dominant conditions?
Achondroplasia
Acute intermittent porphyria
Adult polycystic disease
Antithrombin III deficiency
Ehlers-Danlos syndrome
Familial adenomatous polyposis
Hereditary haemorrhagic telangiectasia
Hereditary spherocytosis
Hereditary non-polyposis colorectal carcinoma
Huntington’s disease
Hyperlipidaemia type II
Hypokalaemic periodic paralysis
Malignant hyperthermia
Marfan’s syndromes
Myotonic dystrophy
Neurofibromatosis
Noonan syndrome
Osteogenesis imperfecta
Peutz-Jeghers syndrome
Retinoblastoma
Romano-Ward syndrome
tuberous sclerosis
Von Hippel-Lindau syndrome
Von Willebrand’s disease (type 3-most severe is recessive)
Huntington’s disease autosomal dominant or recessive?
dominant
Marfan’s syndrome autosomal dominant or recessive?
dominant
osteogenesis imperfecta autosomal dominant or recessive?
dominant
Retinoblastoma autosomal dominant or recessive?
dominant
Von Willebrands disease autosomal dominant or recessive?
dominant (80% type 1)
type 3 most severe form is recessive
Autosomal recessive inheritance?
only homozygotes are affected
males and females are equally likely to be affected
not manifest in every generation - may ‘skip a generation’
Autosomal recessive conditions= 2 heterozygote parents?
25% chance of having an affected (homozygote) child
50% chance of having a carrier (heterozygote) child
25% chance of having an unaffected (i.e. genotypical) child
Autosomal recessive conditions= 1 affected parent (homozygous for gene) and 1 unaffected (not affected or a carrier)?
all children will be carriers
Type of conditions in autosomal recessive disorders vs dominant?
Autosomal recessive disorders are often metabolic in nature and are generally more life-threatening compared to autosomal dominant conditions
List come autosomal recessive conditions?
Albinism
Ataxic telangiectasia
Congenital adrenal hyperplasia
Cystic fibrosis
Cystinuria
Familial Mediterranean
Fever
Fanconi anaemia
Friedreich’s ataxia
Gilbert’s syndrome
Glycogen storage disease
Haemochromatosis
Homocystinuria
Lipid storage disease: Tay-Sach’s, Gaucher, Niemann-Pick
Mucopolysaccharidoses: Hurler’s
PKU
Sickle cell anaemia
Thalassaemias
Wilson’s disease
CF autosomal dominant or recessive?
recessive
Gilbert’s syndrome autosomal dominant or recessive?
recessive (some say dominant)
PKD autosomal dominant or recessive?
90% dominant
Haemochromatosis autosomal dominant or recessive?
recessive
Sickle cell anaemia autosomal dominant or recessive?
recessive
Thalassaemias autosomal dominant or recessive?
recessive
Wilsons autosomal dominant or recessive?
recessive
Benign rolandic epilepsy?
form of childhood epilepsy that typically occurs between the age of 4 and 12 years.
Features of benign rolandic epilepsy?
seizures characteristically occur at night
seizures are typically partial (e.g. paraesthesia affecting the face) but secondary generalisation may occur (i.e. parents may only report tonic-clonic movements)
the child is otherwise normal
EEG findings in benign rolandic epilepsy?
centrotemporal spikes
EEG showing centrotemporal spikes?
?benign rolandic epilepsy
Prognosis of benign rolandic epilepsy?
excellent, stops by adolescence
Seizures occuring at night in otherwise normal child?
benign rolandic epilepsy
Caput succedaneum?
oedema of scalp at presenting part of the head, typically vertex
Causes of Caput succedaneum?
may be due to mechanical trauma of the initial portion of the scalp pushing through the cervix in a prolonged delivery or secondary to the use of ventouse (vacuum) delivery.
Features of Caput succedaneum?
soft puffy swelling due to localised oedema
crosses suture lines
Tx for Caput succedaneum?
none needed
usually resolves in few days
Which crosses suture lines= Caput succedaneum or cephalohaematoma?
Caput succedaneum (C.S= crosses suture lines)
Caput succedaneum vs Cephalohaematoma?
CS= present at birth; typically forms over vertex and crosses suture lines; resolves within days
CH= typically develops several hrs after birth; most commonly in parietal region; doesn’t cross suture lines; may take months to resolve
Both= swelling on head of newborn, more common following prolonged difficult deliveries; Mx conservative
Cephalohaematoma?
swelling on newborns head
Cause of cephalohaematoma?
develops several hrs after delivery and is due to bleeding between the periosteum and skull
Most common site affected in Cephalohaematoma?
parietal region
What may develop in newborn with Cephalohaematoma as a Cx?
jaundice
Tx for Cephalohaematoma?
none
may take 3m to resolve
When is child health surveillance carried out?
1) antenatal
2) newborn
3) 1st month
4) following months
5) pre school
6) ongoing
Child health surveillance= antenatal?
Ensure intrauterine growth
Check for maternal infections e.g. HIV
Ultrasound scan for fetal abnormalities
Blood tests for Neural Tube Defects
Child health surveillance= newborn?
Clinical examination of newborn
Newborn Hearing Screening Programme e.g. oto-acoustic emissions test
Give mother Personal Child Health Record
Child health surveillance= 1st month?
Heel-prick test day 5-9 - hypothyroidism, PKU, metabolic diseases, cystic fibrosis, medium-chain acyl Co-A dehydrogenase deficiency (MCADD)
Midwife visit up to 4 weeks (usually health visitor takes over at 2w)
Child health surveillance= following months?
Health visitor input
GP examination at 6-8 weeks
Routine immunisations
Child health surveillance= pre school?
National orthoptist-led programme for pre-school vision screening to be introduced
Child health surveillance= ongoing?
Monitoring of growth, vision, hearing
Health professionals advice on immunisations, diet, accident prevention
When do children with coeliac disease normally present?
<3yrs following intro of cereals (i.e gluten) into diet
Features of coeliac disease in <3yr old following intro of gluten?
failure to thrive
diarrhoea
abdominal distension
older children may present with anaemia
many cases are not diagnosed to adulthood
Diagnosis of coeliac disease?
jejunal biopsy showing subtotal villous atrophy
IgA Tissue Transglutaminase antibodies (tTG)
Congenital diaphragmatic hernia (CDH)?
herniation of abdominal viscera into the chest cavity due to incomplete formation of the diaphragm. This can result in pulmonary hypoplasia and hypertension which causes respiratory distress shortly after birth.
Congenital diaphragmatic hernia (CDH) pathophysiology?
usually represents a failure of pleuroperitoneal canal to close completely
Most common type of Congenital diaphragmatic hernia (CDH)?
left-sided posterolateral Bochdalek hernia which accounts for around 85% of cases.
Prognosis of Congenital diaphragmatic hernia (CDH)?
Only around 50% of newborns with CDH survive despite modern medical intervention.
Examples of 3 congenital infections?
rubella, toxoplasmosis and cytomegalovirus
Most common congenital infection in UK?
cytomegalovirus
maternal infection is usually asymptomatic
Congenital infections= features of rubella?
1) Sensorineural deafness
2) Congenital cataracts
3) Congenital heart disease (e.g. patent ductus arteriosus)
4) Glaucoma
Growth retardation
Hepatosplenomegaly
Purpuric skin lesions
‘Salt and pepper’ chorioretinitis
Microphthalmia
Cerebral palsy
Congenital infections= features of toxoplasmosis?
1) Cerebral calcification
2) Chorioretinitis
3) Hydrocephalus
Anaemia
Hepatosplenomegaly
Cerebral palsy
Congenital infections= features of cytomegalovirus?
1) Low birth weight
2) Purpuric skin lesions
3) Sensorineural deafness
4) Microcephaly
Visual impairment
Learning disability
Encephalitis/seizures
Pneumonitis
Hepatosplenomegaly
Anaemia
Jaundice
Cerebral palsy
Consent laws in children?
patients less than 16 years old may consent to treatment if they are deemed to be competent (an example is the Fraser guidelines, previously termed Gillick competence), but cannot refuse treatment which may be deemed in their best interest
between the ages of 16-18 years it is presumed patients are competent to give consent to treatment
patients 18 years or older may consent to treatment or refuse treatment
With regards to the provision of contraceptives to patients under 16 years of age the Fraser Guidelines state that all the following requirements should be fulfilled:
the young person understands the professional’s advice
the young person cannot be persuaded to inform their parents
the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment
unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer
the young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent
Law for consent in terms of the provision of contraception to pts under 16?
Fraser Guidelines
Guidelines on obtaining consent in children?
at 16 years or older a young person can be treated as an adult and can 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*
*in Scotland those with parental responsibility cannot authorise procedures a competent child has refused
Gillick or Fraser?
Some doctors use the term Fraser competency when referring to contraception and Gillick competency when referring to general issues of consent in children
Is cyanosis common in neonates?
peripheral cyanosis eg. hands and feet very common in 1st 24hrs of life, may occur when child is crying or unwell from any cause
Cyanosis in neonatal period= when can central cyanosis be recognised clinically?
when the concentration of reduced haemoglobin in the blood exceeds 5g/dl
Cyanosis in the neonatal period= what can be used to differentiate between cardiac from non-cardiac causes?
The nitrogen washout test (also known as the hyperoxia test)
the infant is given 100% oxygen for ten minutes after which arterial blood gases are taken. A pO2 of less than 15 kPa indicates cyanotic congenital heart disease
Initial management of suspected cyanotic congenital heart disease?
supportive care
prostaglandin E1 e.g. alprostadil
- used to maintain a patent ductus arteriosus in ductal-dependent congenital heart defect
- this can act as a holding measure until a definite diagnosis is made and surgical correction performed
Acrocyanosis?
often seen in healthy newborns and refers to cyanosis around the mouth and the extremities such as the hands and feet. It is differentiated from other causes of peripheral cyanosis with significant pathology as it occurs immediately after birth in healthy infants. It is a common finding and may persist for 24 to 48 hours.
Cutaneous dermoid cyst may develop where?
sites of embryonic developmental fusion
Where are dermoid cysts most common?
midline of the neck, external angle of the eye and posterior to the pinna of the ear. They typically have multiple inclusions such as hair follicles that bud out from its walls. They may develop at other sites such as the ovary and in these sites are synonymous with teratomas.
Desmoid tumour?
may be classified either as low grade fibrosarcomas or non aggressive fibrous tumours.
They commonly present as large infiltrative masses. They may be divided into abdominal, extra abdominal and intra abdominal. All types share the same biological features.
Extra abdominal desmoids have an equal sex distribution and primarily arise in the musculature of the shoulder, chest wall, back and thigh. Abdominal desmoids usually arise in the musculoaponeurotic structures of the abdominal wall.
Intra abdominal desmoids tend to occur in the mesentery or pelvic side walls and occur most frequently in patients with familial adenomatous polyposis coli syndrome.
Most common cause of gastroenteritis in children?
rotavirus
Clinical features of gastroenteritis in children?
diarrhoea usually lasts for 5-7 days and stops within 2 weeks
vomiting usually lasts for 1-2 days and stops within 3 days
How to categorise hydration status in children?
normal, dehydrated or shocked
Clinical dehydration in child?
Appears to be unwell or deteriorating
Decreased urine output
Skin colour unchanged
Warm extremities
Altered responsiveness (for example, irritable, lethargic)
Sunken eyes
Dry mucous membranes
Tachycardia
Tachypnoea
Normal peripheral pulses
Normal capillary refill time
Reduced skin turgor
Normal blood pressure
Clinical shock in child?
Decreased level of consciousness
Cold extremities
Pale or mottled skin
Tachycardia
Tachypnoea
Weak peripheral pulses
Prolonged capillary refill time
Hypotension
What children are at risk of dehydration?
children younger than 1 year, especially those younger than 6 months
infants who were of low birth weight
children who have passed six or more diarrhoeal stools in the past 24 hours
children who have vomited three times or more in the past 24 hours
children who have not been offered or have not been able to tolerate supplementary fluids before presentation
infants who have stopped breastfeeding during the illness
children with signs of malnutrition
Features suggestive of hypernatraemic dehydration in child?
jittery movements
increased muscle tone
hyperreflexia
convulsions
drowsiness or coma
Diarrhoea and vomiting in child: when to do a stool culture?
- you suspect septicaemia or
- there is blood and/or mucus in the stool or
- the child is immunocompromised
consider if:
- the child has recently been abroad or
- the diarrhoea has not improved by day 7 or
- you are uncertain about the diagnosis of gastroenteritis
Diarrhoea and vomiting in child= Mx if clinical shock suspected?
Admit for IV rehydration
Diarrhoea and vomiting in child= Mx if no evidence of dehydration?
continue breastfeeding and other milk feeds
encourage fluid intake
discourage fruit juices and carbonated drinks
Diarrhoea and vomiting in child= Mx if dehydration suspected?
give 50 ml/kg low osmolarity oral rehydration solution (ORS) solution over 4 hours, plus ORS solution for maintenance, often and in small amounts
continue breastfeeding
consider supplementing with usual fluids (including milk feeds or water, but not fruit juices or carbonated drinks)
Fluid requirements for child 0-10kg?
child needs 100 mL/kg fluids per day.
For example, if a child weighs 5 kg, the maintenance fluid volume is 500 mL/day.
Fluid requirements for child 10-20kg?
child needs 1000 mL plus 50 mL/kg for each kg over 10 kg per day.
For example, if a child weighs 15 kg, the maintenance fluid volume is 1250 mL/day.
Fluid requirements for child >20kg?
child needs 1500 mL plus 20 mL/kg for each kg over 20 kg per day.
For example, if a child weighs 25 kg, the maintenance fluid volume is 1600 mL/day.
How to give low-osmolarity oral rehydration salt (ORS) solution to rehydrate a child?
(240–250 mOsm/L)
Age 5 years or younger= give 50 mL/kg body weight for fluid deficit replacement, as well as maintenance volume of ORS solution, over 4 hours.
Note: breastfeeding can continue, but do not routinely give oral fluids other than ORS solution.
Age 5–11 years: give 200 mL ORS solution after each loose stool, in addition to the child’s normal fluid intake.
Age 12–16 years: give 200–400 mL ORS solution after every loose stool, dose according to fluid loss
After rehydration, for children at increased risk of dehydration: give 5 mL/kg body weight after each large watery stool, to prevent recurrence of dehydration.
Mx of child with gastroenteritis= confirmed salmonella after stool culture and sensitivity testing?
- advice from local health protection team
- esp if <6m or malnourished or immunocompromised
Mx of child with gastroenteritis= confirmed Shiga toxin-producing Ecoli (STEC) after stool culture and sensitivity testing?
- do not give Abx
- specialist monitoring for Cx= haemolytic uraemic syndrome
Mx of child with gastroenteritis= confirmed giardiasis after stool culture and sensitivity testing?
- specialist advice for metronidazole Tx
- don’t go swimming for 2w after last diarrhoea episode
Mx of child with gastroenteritis= confirmed dysenteric shigellosis after stool culture and sensitivity testing?
Abx not needed unless severe or immunocompromised
Mx of child with gastroenteritis= confirmed dysenteric amoebiasis after stool culture and sensitivity testing?
drug Tx needed
specialist advice for microbio clearance to confirm Tx success 1w after finishing Tx
Mx of child with gastroenteritis= confirmed camplyobacteriosis after stool culture and sensitivity testing?
Abx not needed as self-limiting
UNLESS severe, immunocompromised or worsening
Mx of child with gastroenteritis= confirmed cryptosporidiosis after stool culture and sensitivity testing?
dont go swimming 2w after last episode of D
specialist advice if immunocompromised
When to arrange emergency hospital admission for child with gastroenteritis?
child is systemically unwell and/or there are clinical features suggesting severe dehydration and/or progression to shock.
There is intractable or bilious vomiting.
There is acute-onset painful, bloody diarrhoea in previously healthy children, or confirmed Shiga toxin-producing Escherichia coli (STEC) infection
There is a suspected serious complication, such as haemolytic uraemic syndrome or sepsis.
Rotavirus in children?
most common cause of gastroenteritis
diarrhoea, fever and vomiting for the first 2 days. The diarrhoea may last up to a week
main risk is severe dehydration
Tx is rehydration
Chronic diarrhoea causes in infants?
most common cause in the developed world is cows’ milk intolerance
toddler diarrhoea: stools vary in consistency, often contain undigested food
coeliac disease
post-gastroenteritis lactose intolerance
Primary hypogonadism (Klinefelter’s syndrome)= LH and FSH?
LH= high
Testosterone= low
LH high and testosterone low
?Primary hypogonadism (Klinefelter’s syndrome)
Hypogonadotrophic hypogonadism (Kallman’s syndrome)= LH and testosterone?
LH= low
Testosterone= low
LH low and testosterone low
?Hypogonadotrophic hypogonadism (Kallman’s syndrome)
Androgen insensitivity syndrome= LH and testosterone?
LH= high
testosterone= normal/high
LH high and testosterone normal/high
Androgen insensitivity syndrome
Testosterone-secreting tumour= LH and testosterone?
LH= low
Testosterone= high
LH low and testosterone high
?Testosterone-secreting tumour
Klinefelter’s syndrome is associated with what karyotype?
47,XXY
Karyotype 47,XXY
Klinefelter’s syndrome
Diagnosis of Klinefelter’s syndrome?
chromosomal analysis
Features of Klinefelter’s syndrome?
often taller than average
lack of secondary sexual characteristics
small, firm testes
infertile
gynaecomastia - increased incidence of breast cancer
elevated gonadotrophin levels
often taller than average
lack of secondary sexual characteristics
small, firm testes
infertile
gynaecomastia - increased incidence of breast cancer
elevated gonadotrophin levels
?Klinefeleters
Kallman’s syndrome?
cause of delayed puberty secondary to hypogonadotrophic hypogonadism
Cause of Kallman’s syndrome?
X-linked recessive trait inheritance
failure of GnRH-secreting neurons to migrate to hypothalamus
Lack of smell (anosmia) in boy with delayed puberty?
Kallman’s syndrome
Features of Kallman’s syndrome?
‘delayed puberty’
hypogonadism, cryptorchidism
anosmia
sex hormone levels are low
LH, FSH levels are inappropriately low/normal
patients are typically of normal or above average height
Cleft lip/palate and visual/hearing defects are also seen in some patients
hypogonadotrophic hypogonadism aka
Kallman’s syndrome
Androgen insensitivity syndrome?
X-linked recessive condition due to end-organ resistance to testosterone causing genotypically male children (46XY) to have a female phenotype
(complete androgen insensitivity syndrome= testicular feminisation syndrome)
Androgen insensitivity syndrome features?
‘primary amenorrhoea’
undescended testes causing groin swellings
breast development may occur as result of conversion of testosterone to oestradiol
Diagnosis of Androgen insensitivity syndrome?
buccal smear or chromosomal analysis to reveal 46XY genotype
Mx of Androgen insensitivity syndrome?
counselling- raise child as female
bilateral orchidectomy (as increased risk of testicular ca due to undescended testes)
oestrogen therapy
Genotype of Androgen insensitivity syndrome?
46XY (male)
Look female but genetically male?
Androgen insensitivity syndrome
Ebstein’s anomaly?
congenital heart defect characterised by low insertion of the tricuspid valve resulting in a large atrium and small ventricle. It is sometimes referred to as ‘atrialisation’ of the right ventricle.
Ebstein’s anomaly cause?
exposure to lithium in utero
Ebstein’s anomaly associations?
patent foramen ovale (PFO) or atrial septal defect (ASD) is seen in at least 80% of patients, resulting in a shunt between the right and left atria
Wolff-Parkinson White syndrome
Ebstein’s anomaly clinical features?
cyanosis
prominent ‘a’ wave in the distended jugular venous pulse,
hepatomegaly
tricuspid regurgitation=
pansystolic murmur, worse on inspiration
right bundle branch block → widely split S1 and S2
Ebstein’s anomaly murmur?
tricuspid regurgitation=
pansystolic murmur, worse on inspiration
right bundle branch block → widely split S1 and S2
Epstein’s pearl
congenital cyst found in the mouth.
They are common on the hard palate, but may also be seen on the gums where the parents may mistake it for an erupting tooth.
No treatment is generally required as they tend to spontaneously resolve over the course of a few weeks.
When does eczema typically present?
before 2 years but clears in around 50% of children by 5 years of age and in 75% of children by 10 years of age
Features of eczema?
itchy, erythematous rash
repeated scratching may exacerbate affected areas
in infants the face and trunk are often affected
in younger children, eczema often occurs on the extensor surfaces
in older children, a more typical distribution is seen, with flexor surfaces affected and the creases of the face and neck
Mx of eczema in children?
- avoid irritants
- simple emollients
- topical steroids
- wet wrapping
- severe= oral ciclosporin
Emollients for eczema?
large quantities should be prescribed (e.g. 250g / week), roughly in a ratio of with topical steroids of 10:1
if a topical steroid is also being used the emollient should be applied first followed by waiting at least 30 minutes before applying the topical steroid
creams soak into the skin faster than ointments
emollients can become contaminated with bacteria - fingers should not be inserted into pots (many brands have pump dispensers)
Wet wrapping in eczema?
large amounts of emollient (and sometimes topical steroids) applied under wet bandages
Fetal alcohol syndrome= what may happen at birth?
baby may show symptoms of alcohol withdrawl at birth eg. irritable, hypotonic, tremors
Features of fetal alcohol syndrome?
short palpebral fissure
thin vermillion
border/hypoplastic upper lip
smooth/absent filtrum
learning difficulties
microcephaly
growth retardation
epicanthic folds
cardiac malformations
Fragile X syndrome is what type of disorder?
trinucleotide repeat
X linked dominant
Features of fragile X in males?
learning difficulties
large low set ears, long thin face, high arched palate
macroorchidism
hypotonia
autism is more common
mitral valve prolapse
Features of fragile X in females (who have one fragile chromosome and one normal X chromosome)?
range from normal to mild
Diagnosis of fragile X?
can be made antenatally by chorionic villus sampling or amniocentesis
analysis of the number of CGG repeats using restriction endonuclease digestion and Southern blot analysis
2 examples of congenital visceral malformations
Gastroschisis and exomphalos
Gastroschisis?
congenital defect in the anterior abdominal wall just lateral to the umbilical cord.
Gastroschisis Mx?
vaginal delivery may be attempted
newborns should go to theatre as soon as possible after delivery, e.g. within 4 hours
Exomphalos (omphalocoele)?
the abdominal contents protrude through the anterior abdominal wall but are covered in an amniotic sac formed by amniotic membrane and peritoneum.
Exomphalos (omphalocoele) associations?
Beckwith-Wiedemann syndrome
Down’s syndrome
cardiac and kidney malformations
Exomphalos (omphalocoele) Mx?
c-section is indicated to reduce the risk of sac rupture
a staged repair may be undertaken as primary closure may be difficult due to lack of space/high intra-abdominal pressure
- if this occurs the sacs is allowed to granulate and epithelialise over the coming weeks/months
- this forms a ‘shell’
- as the infant grows a point will be reached when the sac contents can fit within the abdominal cavity. At this point the shell will be removed and the abdomen closed
child complaining of pain in the legs with no obvious cause. Such presentations, in the absence of any worrying features, are often attributed to as what?
growing pains
Growing pains?
often not related to growth so current term is benign idiopathic nocturnal limb pains of childhood
Growing pains typically affect who?
boys and girls 3-12yrs
Growing pains features?
- nocturnal limb pain
never present at the start of the day after the child has woken
no limp
no limitation of physical activity
systemically well
normal physical examination
motor milestones normal
symptoms are often intermittent and worse after a day of vigorous activity
3 types of growth in children?
Infancy (birth to 2-years-old)
Childhood (3 to 11-years-old)
Puberty (12 to 18-years-old)
Factors which affect fetal growth?
environmental: this is the most important factor affecting fetal growth e.g. maternal nutrition and uterine capacity
placental
hormonal
genetic: predominately maternal
What are major drives of growth in infancy?
nutrition and insulin
not dependent on growth hormone as they have a low amount of receptors and finally growth isn’t affected by hypopituitarism and there is no effect of the thyroid
What drives growth in children and what drives puberty?
In childhood growth is driven by growth hormone and thyroxine and in puberty growth is driven by growth hormone and sex steroid, high amount of growth hormone is important in growth spurts.
Genetic factors are the most important determinant of final adult height.
Monitoring of growth in children?
infants aged 0-1 years should have at least 5 recordings of weight
children aged 1-2 years should have at least 3 recordings of weight
children older than 2 years should have annual recording of weight
children below 2nd centile for height should be reviewed by their GP
children below 0.4th centile for height should be reviewed by a paediatrician
Most common cause of primary headache in children?
migraine without aura
IHS criteria for paediatric migraine without aura?
A= >= 5 attacks fulfilling features B to D
B= Headache attack lasting 4-72 hours
C= Headache has at least two of the following four features:
- bilateral or unilateral (frontal/temporal) location
- pulsating quality
- moderate to severe intensity
- aggravated by routine physical activity
D= At least one of the following accompanies headache:
- nausea and/or vomiting
- photophobia and phonophobia (may be inferred from behaviour)
Acute Mx of migraine in children?
ibuprofen
triptans if >=12yrs but follow up needed (sumatriptan nasal spray but poorly tolerated due to bad taste)
oral triptans not licensed <18yrs
Side effects of triptans?
tingling, heat and heaviness/pressure sensations
2nd most common cause of headache in children?
tension type headache
IHS criteria for tension type headaches in children?
A= At least 10 previous headache episodes fulfilling features B to D
B= Headache lasting from 30 minutes to 7 days
C= At least two of the following pain characteristics:
- pressing/tightening (non/pulsating) quality
- mild or moderate intensity (may inhibit but does not prohibit activity)
- bilateral location
- no aggravation by routine physical activity
D= Both of the following:
- no nausea or vomiting
- photophobia and phonophobia, or one, but not the other is present
What hearing test is done in all newborns?
Otoacoustic emission test
A computer-generated click is played through a small earpiece. The presence of a soft echo indicates a healthy cochlea
What hearing test is done if the otoacoustic emission test in newborn is abnormal?
Auditory brainstem response test (in newborns and infants)
What hearing test can be done in 6-9 month olds?
Distraction test
performed by health visitor, requires 2 trained staff
What hearing test can be done in child 18m-2.5yrs?
recognition of familiar objects
Uses familiar objects e.g. teddy, cup. Ask child simple questions - e.g. ‘where is the teddy?’
What hearing test can be done in child >2.5yrs?
Performance testing
or
Speech discrimination tests - Uses similar-sounding objects e.g. Kendall Toy test, McCormick Toy Test
What hearing test can be done in child >3yrs?
Pure tone audiometry
What hearing test is done at school entry in most areas of UK?
Pure tone audiometry
As well as hearing tests in children, what else is done by the parent?
questionnaire in the Personal Child Health Records- ‘Can your baby hear you?’
Homocystinuria?
rare autosomal recessive disease caused by a deficiency of cystathionine beta synthase. This results in severe elevations in plasma and urine homocysteine concentrations.
Homocystinuria features?
often patients have fine, fair hair
MSK= Marfanoid body habitus: arachnodactyly etc;
osteoporosis; kyphosis
neuro: may have learning difficulties, seizures
ocular= downwards (inferonasal) dislocation of lens; severe myopia
increased risk of arterial and venous thromboembolism
also malar flush, livedo reticularis
Ix for Homocystinuria?
increased homocysteine levels in serum and urine
cyanide-nitroprusside test: also positive in cystinuria
Tx for Homocystinuria?
vitamin B6 (pyridoxine) supplements.
Hypospadias?
congenital abnormality of the penis
genetic element
usually identified on newborn baby check; if missed parents may notice abnormal urine stream
Hypospadias is characterised by what?
a ventral urethral meatus
a hooded prepuce
chordee (ventral curvature of the penis) in more severe forms
the urethral meatus may open more proximally in the more severe variants. However, 75% of the openings are distally located.
Hypospadias most commonly occurs as an isolated disorder. However, associated conditions include
cryptorchidism (present in 10%) and inguinal hernia.
Mx of hypospadias?
refer to specialist services
corrective surgery is typically performed when the child is around 12m
it is essential that the child is NOT circumcised prior to the surgery as the foreskin may be used in the corrective procedure
in boys with very distal disease, no treatment may be needed.
most common cause of hypothyroidism in children (juvenile hypothyroidism)?
autoimmune thryoiditis
Causes of hypothyroidism in children (juvenile hypothyroidism)?
autoimmune thyroiditis
post total-body irradiation (e.g. in a child previous treated for acute lymphoblastic leukaemia)
iodine deficiency (the most common cause in the developing world)
Hypotonia associated with encephalopathy in the newborn period is most likely caused by?
hypoxic ischaemic encephalopathy
Central causes of hypotonia?
Down’s syndrome
Prader-Willi syndrome
hypothyroidism
cerebral palsy (hypotonia may precede the development of spasticity)
Neuro and muscular causes of hypotonia?
spinal muscular atrophy
spina bifida
Guillain-Barre syndrome
myasthenia gravis
muscular dystrophy
myotonic dystrophy
Causes of hypotonia?
- acutely ill child eg. septicaemic
- central causes
- neuro and muscular causes
Infantile spasms aka?
West syndrome
Infantile spasms (West syndrome)?
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 of infantile spasms (West syndrome)?
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
Ix for infantile spasms (West syndrome)?
the EEG shows hypsarrhythmia in two-thirds of infants
CT demonstrates diffuse or localised brain disease in 70% (e.g. tuberous sclerosis)
Mx of infantile spasms (West syndrome)?
poor prognosis
vigabatrin 1st line
ACTH also used
Name 3 innocent murmurs in children?
- ejection murmurs
- venous hums
- Still’s murmur
Innocent murmurs in children= ejection murmurs?
due to turbulent blood flow at the outflow tract of the heart
Innocent murmurs in children= venous hums?
due to the turbulent blood flow in the great veins returning to the heart
heard as continuous blowing noise heard just below the clavicles
Innocent murmurs in children= Still’s murmur?
low-pitched sound heard at the lower left sternal edge
Characteristics of innocent ejection murmur?
soft-blowing murmur in the pulmonary area or short buzzing murmur in the aortic area
may vary with posture
localised with no radiation
no diastolic component
no thrill
no added sounds (e.g. clicks)
asymptomatic child
no other abnormality
Intraventricular haemorrhage?
haemorrhage that occurs into the ventricular system of the brain.
It is relatively rare in adult surgical practice and when it does occur, it is typically associated with severe head injuries.
In premature neonates it may occur spontaneously. The blood may clot and occlude CSF flow, hydrocephalus may result.
In neonatal practice the vast majority of IVH occur in the first 72 hours after birth, the aetiology is not well understood and it is suggested to occur as a result of birth trauma combined with cellular hypoxia, together the with the delicate neonatal CNS.
Tx for intraventricular haemorrhage?
largely supportive, therapies such as intraventricular thrombolysis and prophylactic CSF drainage have been trialled and not demonstrated to show benefit.
Hydrocephalus and rising ICP is an indication for shunting.
When is jaundice in newborn period pathological?
in 1st 24hrs or after 14d
When is jaundice in the newborn physiological (normal) and happens in up to 40% neonates?
jaundice from 2-14d
Name 4 causes of jaundice in the first 24hrs of life (always pathological)?
rhesus haemolytic disease
ABO haemolytic disease
hereditary spherocytosis
glucose-6-phosphodehydrogenase def
Causes of physiological jaundice (2-14d of life)?
due to a combination of factors, including more red blood cells, more fragile red blood cells and less developed liver function.
It is more commonly seen in breastfed babies
When is jaundice in newborn classed as prolonged?
after 14d (or 21d if premature)
Ix if jaundice at 14d (21d if premature)-prolonged jaundice?
conjugated and unconjugated bilirubin: the most important test as a raised conjugated bilirubin could indicate biliary atresia which requires urgent surgical intervention
direct antiglobulin test (Coombs’ test)
TFTs
FBC and blood film
urine for MC&S and reducing sugars
U&Es and LFTs
Causes of prolonged jaundice in newborn?
biliary atresia
hypothyroidism
galactosaemia
urinary tract infection
breast milk jaundice
prematurity (due to immature liver function;
increased risk of kernicterus)
congenital infections e.g. CMV, toxoplasmosis
Breast milk jaundice?
Can be physiological or be a cause for prolonged jaundice (>14d)
jaundice is more common in breastfed babies
mechanism is not fully understood but thought to be due to high concentrations of beta-glucuronidase → increase in intestinal absorption of unconjugated bilirubin
Jaundice is more common in what babies?
breastfed
Cause of McCune-Albright syndrome?
not inherited; it is due to random, somatic mutation in GNAS gene
Features of McCune-Albright syndrome?
precocious puberty
cafe-au-lait spots
polyostotic fibrous dysplasia
short stature
precocious puberty
cafe-au-lait spots
polyostotic fibrous dysplasia
short stature
McCune-Albright syndrome
Meconium aspiration syndrome?
resp distress in newborn as a result of meconium in the trachea
occurs in the immediate neonatal period
When does meconium aspiration syndrome occur?
in immediate neonatal period
Resp distress occurring immediately in post-term delivered baby?
?meconium aspiration syndrome
RFs for meconium aspiration syndrome?
- post term delivery= 44% in babies born >42w
- Hx of maternal HTN, pre-eclampsia, chorioamnionitis, smoking or substance abuse
Mesenteric adenitis?
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
Mesenteric adenitis Tx?
none
Microcephaly definition?
occipital-frontal circumference < 2nd centile
Causes of microcephaly?
normal variation e.g. small child with small head
familial e.g. parents with small head
congenital infection
perinatal brain injury e.g. hypoxic ischaemic encephalopathy
fetal alcohol syndrome
syndromes: Patau
craniosynostosis
How can some diseases be inherited from mitochondria?
most DNA found in nucleus but small amount in mitochondria
It encodes protein components of the respiratory chain and some special types of RNA
Characteristics of mitochondrial inheritance?
inheritance is only via the maternal line as the sperm contributes no cytoplasm to the zygote
none of the children of an affected male will inherit the disease
all of the children of an affected female will inherit the disease
generally, encode rare neurological diseases
poor genotype:phenotype correlation - within a tissue or cell there can be different mitochondrial populations - this is known as heteroplasmy
How many children of an affected male with mitochondrial disease will inherit?
0
How many children will inherit the disease if the female has mitochondrial disease?
all children will get the disease
Mitochondrial inheritance is only via who?
affected female can only pass on disease not male
Generally what type of diseases are mitochondrial diseases?
rare neuro disease
Histology for mitochondrial disease?
muscle biopsy classically shows ‘red, ragged fibres’ due to increased number of mitochondria
Examples of mitochondrial disease?
Leber’s optic atrophy= symptoms typically develop at around the age of 30 years; central scotoma → loss of colour vision → rapid onset of significant visual impairment
MELAS syndrome= mitochondrial encephalomyopathy lactic acidosis and stroke-like episodes
MERRF syndrome= myoclonus epilepsy with ragged-red fibres
Kearns-Sayre syndrome= onset in patients < 20 years old, external ophthalmoplegia, retinitis pigmentosa. Ptosis may be seen
sensorineural hearing loss
Napkin rash aka?
nappy rash
5 causes of nappy rash?
irritant dermatitis
candida dermatitis
seborrhoeic dermatitis
psoriasis= less common
atopic eczema= other areas also affected
Most common cause of nappy rash?
irritant dermatitis
Nappy rash= irritant dermatitis?
most common cause
due to irritant effect of urinary ammonia and faeces
creases are spared
Nappy rash= candida dermatitis?
erythematous rash which involve the flexures and has characteristic satellite lesions
Nappy rash= seborrhoeic dermatitis?
erythematous rash with flakes; may coexist with scalp rash
General Mx for nappy rash?
- disposable nappies not towel
- expose napkin area to air when possible
- apply barrier cream eg. Zinc and castor oil
- mild steroid cream eg. 1% hydrocortisone if severe
- Suspected candidal= topical imidazole; stop barrier cream until candida settled
Name some neck masses in children?
- thyroglossal cyst
- brachial cyst
- dermoids
- thyroid gland= rare; cysts or lymphoma
- lymphatic malformations
- infantile haemangioma
- lymphadenopathy
Neck masses in children= thyroglossal cyst?
Located in the anterior triangle, usually in the midline and below the hyoid (65% cases)
Derived from remnants of the thyroglossal duct
Thin walled and anechoic on USS (echogenicity suggests infection of cyst)
Neck masses in children= brachial cyst?
Six branchial arches separated by branchial clefts
Incomplete obliteration of the branchial apparatus may result in cysts, sinuses or fistulae
75% of branchial cysts originate from the second branchial cleft
Usually located anterior to the sternocleidomastoid near the angle of the mandible
Unless infected the fluid of the cyst has a similar consistency to water and is anechoic on USS
Neck masses in children= dermoids?
Derived from pleuripotent stem cells and are located in the midline
Most commonly in a suprahyoid location
They have heterogeneous appearances on imaging and contain variable amounts of calcium and fat
Neck masses in children= lymphatic malformations?
Usually located posterior to the sternocleidomastoid
Cystic hygroma result from occlusion of lymphatic channels
The painless, fluid filled, lesions usually present prior to the age of 2
They are often closely linked to surrounding structures and surgical removal is difficult
They are typically hypoechoic on USS
Neck masses in children= infantile haemangioma?
May present in either triangle of the neck
Grow rapidly initially and then will often
spontaneously regress
Plain x-rays will show a mass lesion, usually containing calcified phleboliths
As involution occurs the fat content of the lesions increases
Neck masses in children= lymphadenopathy?
Located in either triangle of the neck
May be reactive or neoplastic
Generalised lymphadenopathy usually secondary to infection in children (very common)
Necrotising enterocolitis?
one of the leading causes of death among premature infants
Necrotising enterocolitis features?
Initial symptoms can include feeding intolerance, abdominal distension and bloody stools, which can quickly progress to abdominal discolouration, perforation and peritonitis.
Necrotising enterocolitis diagnosis?
abdo x-ray
What does abdo x-ray in Necrotising enterocolitis show?
dilated bowel loops (often asymmetrical in distribution)
bowel wall oedema
pneumatosis intestinalis (intramural gas)
portal venous gas
pneumoperitoneum resulting from perforation
air both inside and outside of the bowel wall (Rigler sign)
air outlining the falciform ligament (football sign)
Mx for necrotising enterocolitis?
- Nil per os (NPO): The patient is kept without food or drink to rest the bowel.
- Nasogastric decompression: A tube is inserted through the nose into the stomach to relieve gas and fluid.
- Parenteral nutrition: Nutritional needs are met intravenously since oral feeding is stopped.
- Broad-spectrum antibiotics: To treat potential bacterial infections that might be causing or complicating NEC.
- Fluid resuscitation and electrolyte correction: As NEC can lead to dehydration and electrolyte imbalance.
- Close monitoring
SURGERY IF SEVERE
Mx for necrotising enterocolitis= Abx?
First-Line Antibiotics:
Amoxicillin: To cover Gram-positive bacteria.
Gentamicin: To cover Gram-negative bacteria.
Metronidazole: To cover anaerobic bacteria.
When is the neonatal blood spot screening test (Guthrie test or ‘heel-prick test’)?
5-9 days of life
What conditions are screened for in the neonatal blood spot screening test (Guthrie test or ‘heel-prick test’)?
congenital hypothyroidism
cystic fibrosis
sickle cell disease
phenylketonuria
medium chain acyl-CoA dehydrogenase deficiency (MCADD)
maple syrup urine disease (MSUD)
isovaleric acidaemia (IVA)
glutaric aciduria type 1 (GA1)
homocystinuria (pyridoxine unresponsive) (HCU)
Is hypoglycaemia normal in newborns?
yes in the 1st 24hrs of life but without any consequence as they can use alternative fuels like ketones and lactate
Definition of neonatal hypoglycaemia?
< 2.6 mmol/L
Transient hypoglycaemia in newborn is common when?
in the 1st few hours after birth
Persistent/severe hypoglycaemia in newborns may be caused by what?
preterm birth (< 37 weeks)
maternal diabetes mellitus
IUGR
hypothermia
neonatal sepsis
inborn errors of metabolism
nesidioblastosis
Beckwith-Wiedemann syndrome
Features of neonatal hypoglycaemia?
- may be asymptomatic
- autonomic (hypoglycaemia → changes in neural sympathetic discharge)
- neuroglycopenic
- apnoea
- hypothermia
Autonomic features of neonatal hypoglycaemia?
‘jitteriness’
irritable
tachypnoea
pallor
Neuroglycopenic features of neonatal hypoglycaemia?
poor feeding/sucking
weak cry
drowsy
hypotonia
seizures
Mx of hypoglycaemia in newborn depends on what?
severity of hypoglycaemia and if newborn is symptomatic
Mx of hypoglycaemia in newborn?
asymptomatic= encourage normal feeding (breast or bottle); monitor blood glucose
symptomatic or very low blood glucose= admit to neonatal unit; IV infusion of 10% dextrose
When is IV dextrose given to neonate with hypoglycaemia?
Pre-Feed Glucose <1.0mmol/l OR Clinical Signs Consistent with Hypoglycaemia at a higher blood glucose concentration
Causes of neonatal hypotonia?
neonatal sepsis
Werdnig-Hoffman disease (spinal muscular atrophy type 1)
hypothyroidism
Prader-Willi
Neonatal hypotonia= maternal causes?
maternal drugs e.g. benzodiazepines
maternal myasthenia gravis
Noonan syndrome?
‘male Turner’s’
autosomal dominant condition associated with a normal karyotype. It is thought to be caused by a defect in a gene on chromosome 12
Noonan syndrome features?
Turner’s syndrome (webbed neck, widely-spaced nipples, short stature, pectus carinatum and excavatum)
cardiac: pulmonary valve stenosis
ptosis
triangular-shaped face
low-set ears
coagulation problems: factor XI deficiency
Cardiac feature in Noonan syndrome?
pulmonary valve stenosis
Normal lower limb variants in children?
- Flat feet (pes planus)= all ages
- In toeing= 1st yr
- Out toeing= all ages
- Bow legs (genu varum)= 1-2nd yr
- Knock knees (genu valgum)= 3-4th yr
Normal lower limb variants in children= flat feet (pes planus)?
All ages
Absent medial arch on standing
Typically resolves between the ages of 4-8 years
Orthotics are not recommended
Parental reassurance appropriate
Normal lower limb variants in children= in toeing?
1st year
Possible causes:
- metatarsus adductus: abnormal heel bisector line. 90% of cases resolve spontaneously, severe/persistent cases may require serial casting
- internal tibial torsion: difference the thigh and foot ankle: resolves in the vast majority
- femoral anteversion: ‘W’ sign resolves in around 80% by adolescence, surgical intervention in the remaining not usually advised
Normal lower limb variants in children= out toeing?
All ages
Common in early infancy and usually resolves by the age of 2 years
Usually due to external tibial torsion
Intervention may be appropriate if doesn’t resolve as increases risk of patellofemoral pain
Normal lower limb variants in children= bow legs (genu varum)?
1st-2nd year
Increased intercondylar distance
Typically resolves by the age of 4-5 years
Normal lower limb variants in children= knock knees (genu valgum)?
3rd-4th year
Increased intermalleolar distance
Typically resolves spontaneously
Ophthalmia neonatorum?
infection of newborn eye
Suspected Ophthalmia neonatorum?
refer for same-day opthalmology/paeds assessment
Causes of Ophthalmia neonatorum?
Chlamydia trachomatis
Neisseria gonorrhoeae
Tx for necrotising enterocolitis?
Treatment is with total gut rest and TPN, babies with perforations will require laparotomy
Summarise mesenteric adenitis?
Central abdominal pain and URTI
Conservative management
Intestinal malrotation?
High caecum at the midline
Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia
May be complicated by the development of volvulus, an infant with volvulus may have bile stained vomiting
Intestinal malrotation diagnosis?
upper GI contrast study and USS
Intestinal malrotation Tx?
laparotomy, if volvulus is present (or at high risk of occurring then a Ladd’s procedure is performed (includes division of Ladd bands and widening of the base of the mesentery)
Summarise Hirschsprungs disease?
Absence of ganglion cells from myenteric and submucosal plexuses
Occurs in 1/5000 births
Full-thickness rectal biopsy for diagnosis
Delayed passage of meconium and abdominal distension
Treatment is with rectal washouts initially, after that an anorectal pull through procedure
Oseophageal atresia?
Associated with tracheo-oesophageal fistula and polyhydramnios
May present with choking and cyanotic spells following aspiration
VACTERL associations
Summarise meconium ileus?
Usually delayed passage of meconium and abdominal distension
The majority have cystic fibrosis
X-Rays will not show a fluid level as the meconium is viscid, PR contrast studies may dislodge meconium plugs and be therapeutic
Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs
Summarise biliary atresia?
Jaundice > 14 days
Increased conjugated bilirubin
Urgent Kasai procedure
Summarise intussusception?
Telescoping bowel
Proximal to or at the level of, ileocaecal valve
6-9 months of age
Colicky pain, diarrhoea and vomiting, sausage-shaped mass, red jelly stool.
Treatment: reduction with air insufflation
List some paeds GI disorders?
- pyloric stenosis
- acute appendicitis
- mesenteric adenitis
- intussusception
- intestinal malrotation
- Hirschsprungs disease
- Oesophageal atresia
- Meconium ileus
- Biliary atresia
- Necrotising enterocolitis
Tx for developmental dysplasia of hip?
Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revision
How does developmental dysplasia of hip present?
Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies.
Radiology for developmental dysplasia of hip?
Initially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arc
How does perthes present?
Hip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%.
Perthes Tx?
Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly.
Perthes radiology?
X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment.
What does SUFE stand for?
Slipped upper femoral epiphysis
How does Slipped upper femoral epiphysis present?
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%.
Tx for SUFE?
Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required.
Radiology for SUFE?
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
Development of the umbilicus?
During development the umbilicus has two umbilical arteries and one umbilical vein. The arteries are continuous with the internal iliac arteries and the vein is continuous with the falciform ligament (ductus venosus). After birth, the cord dessicates and separates and the umbilical ring closes.
Umbilical hernia?
Up to 20% of neonates may have an umbilical hernia, it is more common in premature infants. The majority of these hernias will close spontaneously (may take between 12 months and three years). Strangulation is rare.
Paraumbilical hernia?
due to defects in the linea alba that are in close proximity to the umbilicus. The edges of a paraumbilical hernia are more clearly defined than those of an umbilical hernia. They are less likely to resolve spontaneously than an umbilical hernia.
Omphalitis?
infection of the umbilicus. Infection with Staphylococcus aureus is the commonest cause. The condition is potentially serious as infection may spread rapidly through the umbilical vessels in neonates with a risk of portal pyaemia, and portal vein thrombosis. Treatment is usually with a combination of topical and systemic antibiotics.
Umbilical granuloma?
These consist of cherry red lesions surrounding the umbilicus, they may bleed on contact and be a site of seropurulent discharge. Infection is unusual and they will often respond favourably to chemical cautery with topically applied silver nitrate.
Persistent urachus?
characterised by urinary discharge from the umbilicus. It is caused by persistence of the urachus which attaches to the bladder. They are associated with other urogenital abnormalities.
Persistent vitello-intestinal duct?
typically present as an umbilical discharge that discharges small bowel content. Complete persistence of the duct is a rare condition. Much more common is the persistence of part of the duct (Meckel’s diverticulum). Persistent vitello-intestinal ducts are best imaged using a contrast study to delineate the anatomy and are managed by laparotomy and surgical closure.
Average HR for children <1yr to >12yrs?
<1= 110-160
1-2= 100-150
2-5= 90-140
5-12= 80-120
>12= 60-100
Average RR for children <1 to >12yrs?
<1= 30-40
1-2= 25-35
2-5= 25-30
5-12= 20-25
>12= 15-20
Patent ductus arteriosus?
- congenital heart defect
- classed as acyanotic but intreated can be cyanotic as eventually result in late cyanosis in lower extremities
- connection between pulmonary trunk and descending aorta
connection between pulmonary trunk and descending aorta
patent ductus arteriosus
When does the ductus arteriosus usually close?
with the first breaths due to increased pulmonary flow which enhances prostaglandins clearance
When is patent ductus arteriosus more common?
premature
born at high altitude
maternal rubella infection in 1st trimester
Features of patent ductus arteriosus?
left subclavicular thrill
continuous ‘machinery’ murmur
large volume, bounding, collapsing pulse
wide pulse pressure
heaving apex beat
Mx of patent ductus arteriosus in preterm infants?
- expectant supportive care as often spontaneous closure
- is haemodynamically unstable or ventilator dependent after 1w of age= ibuprofen, indomethacin or paracetamol
How does ibuprofen/indomethacin work to close patent ductus arteriosus?
inhibits prostaglandin synthesis
given to the infant, not to the mother in the antenatal period
closes the connection in the majority of cases
indomethacin use is declining due to increased side-effect profile compared to other drugs
Mx of patent ductus arteriosus in term infants and children?
- closure if= moderate/large; prior episode of endocarditis or small audible PDA
- technique= transcatheter ΡDA closure (pharmacological not effective in term infants)
Mx if PDA + another congenital heart defect amenable to surgery?
Prostaglandin E1 to keep PDA open until after surgical repair
Phenylketonuria (PKU)?
autosomal recessive condition caused by a disorder of phenylalanine metabolism
Cause of Phenylketonuria (PKU)?
usually due to defect in phenylalanine hydroxylase, an enzyme which converts phenylalanine to tyrosine. In a small number of cases the underlying defect is a deficiency of the tetrahydrobiopterin-deficient cofactor, e.g. secondary to defective dihydrobiopterin reductase.
High levels of phenylalanine lead to problems such as learning difficulties and seizures.
The gene for phenylalanine hydroxylase is located on chromosome 12.
Features of Phenylketonuria (PKU)?
usually presents by 6 months e.g. with developmental delay
child classically has fair hair and blue eyes
learning difficulties
seizures, typically infantile spasms
eczema
‘musty’ odour to urine and sweat (secondary to phenylacetate, a phenylketone)
Diagnosis of Phenylketonuria (PKU)?
Guthrie test: the ‘heel-prick’ test done at 5-9 days of life - also looks for other biochemical disorders such as hypothyroidism
hyperphenylalaninaemia
phenylpyruvic acid in urine
Mx of Phenylketonuria (PKU)?
poor evidence base to suggest strict diet prevents learning disabilities
dietary restrictions are however important during pregnancy as genetically normal fetuses may be affected by high maternal phenylalanine levels
Phimosis?
non-retractable foreskin
Mx of phimosis?
if non-retractile foreskin and/or ballooning during micturition in <2yrs= expectant approach as will resolve over time
AVOID forcible retraction as can cause scar formation
personal hygiene important
if >2yrs and recurrent balanoposthitis or UTI then consider Tx
Most likely cause of pneumonia in children?
s.pnuemoniae
Mx of CAP in children?
1st line= amoxicillin
no respone= + macrolide
suspected mycoplasma or chlamydia= use macrolide
associated with influenzae= co-amoxiclav
Types of pre-school wheeze?
episodic viral wheeze: only wheezes when has a viral upper respiratory tract infection (URTI) and is symptom free inbetween episodes
multiple trigger wheeze: as well as viral URTIs, other factors appear to trigger the wheeze such as exercise, allergens and cigarette smoke
epsiodic wheeze= no risk of asthma
trigeer wheeze= risk of asthma
Mx of episodic viral wheeze?
- symptomatic
- 1st line= SABA via spacer
- montelukast or ICS or both
Mx of multiple trigger wheeze?
ICS or montelukast trial for 4-8w
Definition of precocious puberty?
‘development of secondary sexual characteristics before 8 years in females and 9 years in males’
more common in females
Thelarche?
first stage of breast development
Adrenarche?
first stage of pubic hair development
Precocious puberty can be classified into what?
1) Gonadotrophin dependent (‘central, true’)
2) Gonadotrophin independent (‘pseudo, false’)
Precocious puberty= gonadotrophin dependent?
due to premature activation of hypothalamic-pituitary-gonadal axis
FSH and LH raised
Precocious puberty= gonadotrophin independent?
due to XS sex hormones
LH and FSH low
Precocious puberty= FSH and LH raised?
gonadotrophin dependent
Precocious puberty= FSH and LH low?
gonadotrophin independent
XS sex hormones
Precocious puberty= in males?
uncommon and usually has organic cause
Precocious puberty= cause in males if there is bilateral enlargement of testes?
gonadotrophin release from intracranial lesion
Precocious puberty= cause in males if unilateral enlargement of testes?
gonadal tumour
Precocious puberty= cause in males if small testes?
adrenal cause (tumour or adrenal hyperplasia)
Precocious puberty= females?
usually idiopathic or familial and follows normal sequence of puberty
Precocious puberty= causes in females?
usually idiopathic or familial
organic causes rare= associated with rapid onset, neuro symptoms and dissonance eg. McCune Albright syndrome
Pulmonary hypoplasia?
newborn infants with underdeveloped lungs
eg. due to oligohydramnios or congenital diaphragmatic hernia
Reflex anoxic seizure?
syncopal episode (or presyncope) that occurs in response to pain or emotional stimuli.
typically in 6m-3yrs
Reflex anoxic seizure cause?
caused by neurally-mediated transient asystole in children with very sensitive vagal cardiac reflexes
Reflex anoxic seizure features?
child goes very pale, falls to floor, secondary anoxic seizures common, rapid recovery
Reflex anoxic seizure Tx?
none and prognosis excellent
Retinoblastoma?
most common ocular malignancy found in children
average age of diagnosis 18m
Retinoblastoma pathophysiology?
autosomal dominant
10% hereditary
caused by loss of function of the retinoblastoma tumour suppressor gene on chromosome 13
Retinoblastoma possible features?
absence of red reflex, replaced by white pupil (leukocoria)- most common
strabismus
visual problems
Mx of retinoblastoma?
- enucleation
- or chemo, external beam radiation therapy or photocoagulation (depending on how advanced)
> 90% survive into adulthood
Rickets?
inadequately mineralised bone in developing and growing bones= results in soft and easily deformed bones
usually due to vit D def
called osteomalacia in adults
Predisposing factors to rickets?
dietary deficiency of calcium, for example in developing countries
prolonged breastfeeding
unsupplemented cow’s milk formula
lack of sunlight
Features of rickets?
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
Ix for rickets?
- low vit D
- reduced seru calcium (may get symptoms from hypocalcaemia)
- raised ALP
Mx for rickets?
oral vit D
School exclusion for scabies?
until treated
School exclusion for influenzae?
until recovered
What conditions do not need school exclusion?
Conjunctivitis
Fifth disease (slapped cheek)
Roseola
Infectious mononucleosis
Head lice
Threadworms
Hand, foot and mouth
School exclusion for D & V?
until symptoms have settled for 48hrs
Shaken baby syndrome triad?
retinal haemorrhages, subdural haematoma and encephalopathy
retinal haemorrhages, subdural haematoma and encephalopathy?
shaken baby syndrome
Cause of shaken baby syndrome?
intentional shaking of a child (0-5yrs)
sometimes hard to determine whether mechanism of injury is definitely intentional shaking so hard for courts to convict suspects
Name 2 skull problems in children?
plagiocephaly
craniosynostosis
Skull problems in children= plagiocephaly?
parallelogram shaped head
the incidence of plagiocephaly has increased over the past decade. This may be due to the success of the ‘Back to Sleep’ campaign
Skull problems in children= craniosynostosis?
premature fusion of skull bones
SUFE aka?
slipped upper femoral epiphysis or slipped capital femoral epiphysis
SUFE?
rare hip condition, classically seen in obese boys
displacement of the femoral head epiphysis postero-inferiorly
displacement of the femoral head epiphysis postero-inferiorly
SUFE
SUFE typically seen in who?
obese boys, 10-15yrs
loss of internal rotation of leg in flexion?
SUFE
Features of SUFE?
acute following trauma or more common chronic with persistent symptoms
hip, groin, medial thigh or knee pain
loss of internal rotation of leg in flexion
bilateral slip in 20%
Ix for SUFE?
AP and lateral (typically frog-leg) views x-ray diagnostic
Mx for SUFE?
internal fixation= single cannulated screw placed in centre of epiphysis
Cx of SUFE?
osteoarthritis
avascular necrosis of femoral head
chondrolysis
leg length discrepancy
Causes of snoring in children?
obesity
nasal problems= polyps, deviated septum, hypertrophic nasal turbinates
recurrent tonsillitis
Downs
hypothyroidism
Name 4 causes of stridor in children?
- croup= 6m-3yrs
- acute epiglottitis= 2-6yrs
- inhaled foreign body
- laryngomalacia= 4w; congenital abnormality of larynx
Other names for surfactant deficient lung disease (SDLD)?
respiratory distress syndrome or hyaline membrane disease
SDLD/resp distress syndrome?
condition seen in premature infants caused by insufficient surfactant production and structural immaturity of lungs
RFs for SDLD/resp distress syndrome?
prematurity (50% born 26-28w; 25% born at 30-31w)
male
diabetic mothers
c-section
2nd born of premature twins
Features SDLD/resp distress syndrome?
common to resp distress in newborn eg. tachypnoea, intercostal recession, expiratory grunting and cyanosis
Ix for SDLD/resp distress syndrome?
CXR= ground glass appearance with indistinct heart border
Mx for SDLD/resp distress syndrome?
- prevention during preg= maternal corticosteroids to induce fetal lung maturation
- oxygen
- assisted ventilation
- exogenous surfactant given via endotracheal tube
Therapeutic cooling used in who?
pts who have had cardiac arrest, traumatic brain injury or neonatal hypoxic-ischaemic encephalopathy
How does therapeutic cooling work?
slows down metabolic rates of cells so reduces demand for O2 and production of harmful by-produccts that can lead to cell death
Main mechanisms in therapeutic cooling?
Reduction of Metabolic Rate: Hypothermia decreases the metabolic rate by approximately 5-7% per degree Celsius reduction in body temperature, thereby conserving ATP and limiting the accumulation of lactic acid.
Inhibition of Apoptosis: Cooling can reduce the activity of enzymes involved in programmed cell death (apoptosis), thus preserving cellular integrity.
Reduction of Inflammatory Response: Hypothermia suppresses the inflammatory response, including the reduction of cytokine release, which can mitigate further tissue damage.
Decreased Free Radical Production: By slowing metabolic processes, hypothermia reduces the production of free radicals, which can cause oxidative stress and damage cellular components.
Post-cardiac arrest patients who remain comatose after the return of spontaneous circulation (ROSC) can benefit from what to improve neuro outcomes?
therapeutic cooling
Methods of induction for therapeutic cooling?
Surface Cooling: Utilises cooling blankets, ice packs, or cooling helmets. These devices are applied externally and provide a non-invasive method to lower body temperature.
Endovascular Cooling: Involves the insertion of a catheter into a large vein (e.g., femoral vein), through which cold saline or other cooling fluids circulate, directly cooling the blood.
Cold Fluid Infusion: Rapid infusion of cold intravenous saline can be used to quickly lower the body temperature.
Therapeutic cooling target temp and duration?
32-26C
24-72hrs the gradual rewarming period to avoid rapid T fluctuations that can cause rebound hyperthermia or Cx
Therapeutic cooling monitoring and Mx?
Temperature Monitoring: Core temperature should be continuously monitored using an oesophageal, bladder, or intravascular thermometer.
Haemodynamic Stability: Patients undergoing therapeutic cooling require close monitoring of blood pressure, heart rate, and cardiac output, as hypothermia can induce bradycardia and hypotension.
Electrolyte Management: Regular monitoring and correction of electrolytes, especially potassium, magnesium, and phosphate, is crucial due to shifts that occur during cooling and rewarming.
Coagulation: Hypothermia can impair coagulation pathways, so coagulation profiles should be regularly assessed.
Infection Control: The immune response is suppressed at lower temperatures, increasing the risk of infection. Prophylactic antibiotics may be considered in some cases.
Cx of therapeutic cooling?
Cardiovascular: Bradycardia, arrhythmias, hypotension.
Coagulopathy: Increased risk of bleeding due to impaired platelet function and clotting enzyme activity.
Infection: Increased susceptibility to infections due to immunosuppression.
Electrolyte Imbalance: Hypokalaemia during cooling and hyperkalaemia during rewarming.
Shivering: Can increase metabolic rate and counteract the cooling process.
sedation, neuromuscular blockade, or specific anti-shivering protocols.
Therapeutic cooling= rewarming phase?
conducted slowly, typically at a rate of 0.25-0.5°C per hour, to minimise the risk of complications such as electrolyte imbalances, hypotension, and rebound hyperthermia. Continuous monitoring and supportive care are essential during this phase.
Cause of threadworms?
(Enterobius vermicularis, sometimes called pinworms)
Infestation occurs after swallowing eggs that are present in the environment.
Features of threadworms?
90% asymptomatic
- perianal itching, esp at nigjt
- girls may have vulval symptoms
Diagnosis of threadworms?
just treat empirically
can apply sellotape to perianal area and send to lab for micro to see eggs
Mx for threadworms?
hygiene measure and single dose mebendazole for all members of household (>6m; may need more if infestation persists)
Most common cause of respiratory distress in newborn period?
TTN
What is transient tachypnoea of newborn (TTN)?
cause of resp distress
caused by delayed resoption of fluid in the lungs
When is transient tachypnoea of the newborn (TTN) more common?
following c-section, may be due to the lung fluid not being ‘squeezed out’ during passage through birth canal
Transient tachypnoea of the newborn (TTN) CXR findings?
hyperinflation of lungs and fluid in horizontal fissure
CXR in newborn showing hyperinflation of lungs and fluid in horizontal fissure?
?Transient tachypnoea of the newborn (TTN)
Mx of Transient tachypnoea of the newborn (TTN)?
observation and supportive care
may need supp O2 to maintain sats
usually settles within 1-2d
Tumour suppressor genes?
genes which normally control the cell cycle
loss of function results in an increased risk of cancer
both alleles must be mutated before cancer occurs
Examples of tumour suppressor genes and their associated ca?
p53= Common to many cancers, Li-Fraumeni syndrome
APC= Colorectal cancer
BRCA1 & BRCA2= Breast and ovarian cancer
In men, there is an increased risk of breast cancer and prostate cancer
NF1= Neurofibromatosis
Rb= Retinoblastoma
WT1= Wilm’s tumour
Multiple tumor suppressor 1 (MTS-1, p16)= Melanoma
Tumour suppressor genes vs oncogenes?
Tumour suppressor genes - loss of function results in an increased risk of cancer
Oncogenes - gain of function results in an increased risk of cancer
Summarise umbilical hernia in children?
relatively common in children and may be found during the newborn exam.
Usually no treatment is required as they typically resolve by 3 years of age
Associations:
- Afro-Caribbean infants
- Down’s syndrome
- mucopolysaccharide storage diseases
Undescended testses?
2-3% term male infants but more common in preterm
25% bilateral
Cx of undescended testes?
- infertility
- torsion
- testicular ca
- psychological
Mx for undescended testes?
Unilateral undescended testis:
- referral should be considered from around 3 months of age, with the baby ideally seeing a urological surgeon before 6 months of age
- orchidopexy: Surgical practices vary although the majority of procedures are performed at around 1 year of age
Bilateral undescended testes:
- Should be reviewed by a senior paediatrician within 24hours as the child may need urgent endocrine or genetic investigation
Vesicoureteric reflux (VUR)?
abnormal backflow of urine from the bladder into the ureter and kidney.
It is a relatively common abnormality of the urinary tract in children and predisposes to urinary tract infection (UTI), being found in around 30% of children who present with a UTI.
As around 35% of children develop renal scarring it is important to investigate for VUR in children following a UTI
Vesicoureteric reflux (VUR) pathophysiology?
ureters are displaced laterally, entering the bladder in a more perpendicular fashion than at an angle
therefore shortened intramural course of the ureter
vesicoureteric junction cannot, therefore, function adequately
Vesicoureteric reflux (VUR) possible presentations?
antenatal period: hydronephrosis on ultrasound
recurrent childhood urinary tract infections
reflux nephropathy=
- term used to describe chronic pyelonephritis secondary to VUR
- commonest cause of chronic pyelonephritis
- renal scar may produce increased quantities of renin causing hypertension
Vesicoureteric reflux (VUR) Ix?
Ix (USS renal tract) if <6m after 1st episode or >6m after 3 lower UTI
diagnosed following a micturating cystourethrogram
a DMSA scan may also be performed to look for renal scarring - this is typically located at the upper and lower pole and is associated with cortical thinning
Vesicoureteric reflux (VUR) grading?
I= Reflux into the ureter only, no dilatation
II= Reflux into the renal pelvis on micturition, no dilatation
III= Mild/moderate dilatation of the ureter, renal pelvis and calyces
IV= Dilation of the renal pelvis and calyces with moderate ureteral tortuosity
V= Gross dilatation of the ureter, pelvis and calyces with ureteral tortuosity
Vesicoureteric reflux (VUR) Mx?
Conservative management is often the first line of treatment, especially in low-grade VUR. This involves long-term, low-dose antibiotic prophylaxis to prevent urinary tract infections (UTIs), which can lead to renal scarring. Regular monitoring with renal ultrasound and micturating cystourethrogram (MCUG) or direct radionuclide cystogram (DRNC) is also recommended to assess progress.
Surgical intervention may be considered if there’s persistent high-grade reflux, breakthrough UTIs despite prophylaxis, or evidence of renal damage. Several surgical options exist including endoscopic injection of bulking agents (Deflux), open ureteric reimplantation or laparoscopic robot-assisted ureteric reimplantation.
William’s tumour?
inherited neurodevelopmental disorder caused by microdeletion on chromosome 7
child with elfin-like facies, very friendly and social, short, transient neonatal hypercalc, supravalvular aortic stenosis and learning difficulties?
William’s syndrome
Diagnosis of William’s syndrome?
FISH studies
Features of William’s syndrome?
elfin-like facies
characteristic like affect - very friendly and social
learning difficulties
short stature
transient neonatal hypercalcaemia
supravalvular aortic stenosis
Wilm’s neohroblastoma (Wilm’s tumour)?
one of most common childhood malignancies
<5yrs, meadian age 3yrs
Wilm’s neohroblastoma (Wilm’s tumour) associations?
Beckwith-Wiedemann syndrome
as part of WAGR syndrome with Aniridia, Genitourinary malformations, mental Retardation
hemihypertrophy
around one-third of cases are associated with a loss-of-function mutation in the WT1 gene on chromosome 11
Wilm’s neohroblastoma (Wilm’s tumour) features?
abdominal mass (most common presenting feature)
painless haematuria
flank pain
other features: anorexia, fever
unilateral in 95% of cases
metastases are found in 20% of patients (most commonly lung)
Wilm’s neohroblastoma (Wilm’s tumour) referral?
children with an unexplained enlarged abdominal mass in children - possible Wilm’s tumour - arrange paediatric review with 48 hours
Wilm’s neohroblastoma (Wilm’s tumour) Mx?
nephrectomy
chemotherapy
radiotherapy if advanced disease
prognosis: good, 80% cure rate
Wilm’s neohroblastoma (Wilm’s tumour) histology?
epithelial tubules, areas of necrosis, immature glomerular structures, stroma with spindle cells and small cell blastomatous tissues resembling the metanephric blastema
Child with unexplained enlarged abdo mass?
?Wilms tumour so paeds review within 48hrs
X-linked dominant conditions examples?
Alport’s syndrome (in around 85% of cases - 10-15% of cases are inherited in an autosomal recessive fashion with rare autosomal dominant variants existing)
Rett syndrome
Vitamin D resistant rickets
pseudohypoparathyroidism was previously classified as an X-linked dominant condition but has now been shown to be inherited in an autosomal dominant fashion in the majority of cases
X-linked recessive inheritance only affects who?
males, females can only be carriers
EXCEPT in turners syndrome= affected due to only having 1 X chromosome
How are X-linked recessive disorders transmitted?
by heterozygote females (carriers) and male-to-male transmission is not seen. Affected males can only have unaffected sons and carrier daughters.
Chances of being affected by X-linked recessive condition?
Each male child of a heterozygous female carrier has a 50% chance of being affected whilst each female child of a heterozygous female carrier has a 50% chance of being a carrier.
The possibility of an affected father having children with a heterozygous female carrier is generally speaking extremely rare. However, in certain Afro-Caribbean communities G6PD deficiency is relatively common and homozygous females with clinical manifestations of the enzyme defect are seen.
List some X-linked recessive conditions?
Androgen insensitivity syndrome
Becker muscular dystrophy
Colour blindness
Duchenne muscular dystrophy
Fabry’s disease
G6PD deficiency
Haemophilia A,B
Hunter’s disease
Lesch-Nyhan syndrome
Nephrogenic diabetes insipidus
Ocular albinism
Retinitis pigmentosa
Wiskott-Aldrich syndrome
Becker and Duchenne muscular dysrophy inheritance?
X-linked recessive
G6PD def inheritance?
X-linked recessive
Haemophilia A, B inheritance?
X-linked recessive
Androgen insensitivity syndrome inheritance?
X-linked recessive
Colour blindness inheritance?
X-linked recessive
What disease has varying patterns of inheritance, with the majority being X-linked recessive?
Chronic granulomatous disease (in > 70%)
