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
