Paeds

Question 1

What causes Hand, foot and mouth?
How is it managed, including return to school advice?

Answer 1

W:
- Coxsackie virus, spread from blisters. Stool and saliva for weeks
- <5s, summer/early-autumn

S: fever, sore throat, loss of appetite
Cx: dehydration, nail changes, severe infection -> meningitis etc
Dx: clinical +/- viral PCR from throat

Mx:
- analgesia, mouthwashes, hydrate
- leave blisters
- School if well enough with hygeine
- Complete resolution 7 days

Question 2

Co-sleeping advise

Answer 2

Not recommended but ways to make it safer:
- Not after drinking or if drowsy
- On back, no pillow near, no covers
- Bed not up against well
- No other kids or pets in bed
- No swaddling, approved sleep bag
- No smoking

Question 3

What ADHD assessment forms are there?

Answer 3

Weiss
SNAP-IV
CADDRA teacher and patient form
Vanderbilt
ASRS (adult self report only)

Question 4

DMD

Answer 4

W: boys 2-6, progressive
- X-linked recessive. 1/3 de-novo
- >CK level -> DNA for dystrophin or muscle biopsy

Sx: weakness
- initially n but delayed milestones
- mild hypotonia, poor head control
- gait abnormal 2-3, waddling
- can aspirate, nasal voice
- calf hypertrophy, scoliosis, contractures, CM, encephalopathy
Gower’s: uses legs to get up
Trendelenburg gait

Mx:
- Steroids < sx, reduce progression
- ACE/ARB slow CM/CHF
- Pulm rehab
- Much improved prog with steroids

Question 5

Advice for contact irritation from food?

Answer 5

Can still spoon feed
Bib to prevent contact w body
Can continue with the food
Apply barrier cream around mouth

Question 6

What are the features of OME?
When is treatment required?

Answer 6

Dullness, retraction, effusion seen
Type B on tymp (A normal, C ETD)
Hearing loss, sleep/balance issue

Mx:
- W&W 3m, r/w at 4 weeks
- ENT >3m ?grommet
- Audiology/SLT if issue >2.5y

Question 7

CSOM

Answer 7

Discharge 2-6w, ?hearing loss
Tropical drops (ciproxin best) 5d
Swab x work -> swab and d/w ENT
Ear toilet

ENT advice if still discharging after 2w treatment

If microsuction is indicated, refer to a child ear clinic via public health nurses, or a private community ear clinic.

Question 8

Concussion

Answer 8

Rest 24-48hrs
- AVOID reading, TV, phone, ET
Build up
- walking, music, reading
- drop intensity if > symptoms
Self-care
- Hydration, avoid trigger, no ETOH

Paracetmol yes
No NSAID in first 48hrs

Work/school after 48rs
- ACC45 and ACC18 to support
- Driving x 48hr and x sx. CLEAR 1st
- Trial home-based first, part days

Sports:
- after 14d can start training IF fully returned to school/work, no Sx
- 21d before competing, IF fully training and at school/work, no Sx

FU 7-10d, repeat score, advice, ?ref

Question 9

General behaviour tips

Answer 9

Reward good behaviour
Remove privilages for bad/ time out
Compliment attitudes / kindness
Don’t give attention 2 bad aspects
No screens in room, suggest toys
- Under 2 years: no screens
- 2 to 8 years: 1 hour
- Over 5 years: 2 hours

For appropriate media:
commonsensemedia.org

Being active:
- 60 minutes moderate exercise/day
- 6x short 10min can be just as good
- Give active chores, veggie patch
- Active games. Be active together

Sleep:
- Naps until 3-5yo, good routine
- 12hrs until 5, then 11, 9hrs by 12

Question 10

Indictors of neglect / abuse

Answer 10

FLAGS
- Any injury to non-ambo child
- Poor explanation, delay
- LOC, persistent vomiting, bleeds
- Harsh, name calling, harm something important to child, threaten abandoning them, mock

1. Physical - poor growth in babies 2. Neglectful - home alone, or without someone safe l
2. Emotional
3. Medical
4. Educational - truancy, x enrol

Good questions:
“I notice these injuries, ONE possible explanation is that these injuries could have come about from someone harming ____, are you worried that….” then “I hear that you are/not worried, given that is a possibility I am required to make a referral” “Both want ___ to be safe”
“They will want to chat with you/parents, offer to phone parents if not here +/- investige”
“OT may want to do Ax, may include visit to work out how things work at home” call/email
- Ask questions whenever or cultural support whenever

“Looking after kids can be stressful, how is it for you”
“Is there any way we can support you to get to appointments”
“how are you supported”
“do you think your problems are affecting them”
“what happens when things go wrong in your house”
“what happens when parents are angry with you”
“what happens if you break the rules”

Injuries of concern:
- Head, fractures, burns, clusters

Mx:
- Document. Report: identification (carers, siblings), concern/context, +/- factors, LT effect
- FLAGS / asap protection + co-op parents: paeds
- Clear non-accident + un-co-op parent -> OT and police
- Unclear: explain concerns but not expert and it is policy to refer for full assessment
- Unsupervised imjury: explain concerns, OT, paeds or CPS
- Low risk: support services
- High risk: OT

“It seems like you have a lot on your plate at the moment. I think it might be helpful for me to organise for someone to visit you and see what other support we can put in place.”

Question 11

What groups are there for parenting support?

Answer 11

Barnados:
- Parents in charge (16-18yo)
- Separation courses
- Feeling safe (4-11 + violence)
- Triple P: 8/52 difficult behaviour

Family Start
- Home visits. Growth, learning, family, environmental safety

Group programmes:
- Incredible years: high intensity, 2.5hrs / 14wks, evidence based, 3-8 MOST effective. Severe behaviours
- Toolbox: less intense, milder

Monitored, for young adults:
- SPARX: 12-19 mild to mod mood. Game-based. 7 levels 30 mins each. Info in starting on H.P.
- Beating the blues: 18y older. Dr needs to register. 8 x 50 mins. Dr receives progress report.
- Just a thought - 16+ asap CBT

Unmonitored:
- CALM
- Aunty Dee (MAPAS)

Helplines:
- 1737: 24/7 counselling
- Derpression helpline
- Gambling helpline
- Lifeline / Tautoko suicide
-

Question 12

Weight management in children

Answer 12

W: 1/3 are overweight b4 school
- MAPAS

IX:
- Use growth charts

Hx:
- FH: BMI, CVD, chol, DM, OSA
- Cx: T2DM, snoring, poor sleep, wetting, thirst, asthma/OSA, SUPHE, psychological,
- Diet: what, when, size, snacks, f+v
- Activity: physical, sedentary

Ex:
- BP - R arm, then compare to charts on HP
- ENT, abdomen, gait
- dysmoprhic, syndromic, acantho

Mx:
Risks (HTN, acanthosis, FH, PCOS, snoring >2) / indicated by exam
- OSA questionnaire yearly >2
- BP yearly for >10 (abn >95th 4 age)
- HbA1c, fasting lip 2 yearly from 10
- ACR if either above abn (3x if abn)
- LFT 2 years from age 5

Referral:
- BP >95th
- HbA1c >40, symptoms
- lipids still high after 6m lifestyle
- LFT still high after 3m lifestyle
- ENT if +ve OSA questionnaire
-> Recall every 3-6months

Discuss with child if >10
- show growth chart
- trying to achieve healthy growth
- focus on growing into weight
- DIETING never healthy
- SLEEP very important
- Healthy eating habbits
- >physical activity, <sedentary
- Consider healthy lifestyle program

Paeds:
- very unhealthy range + comorbid
- BP >95th
- HbA1c >40
- Abnormal lipids >6m lifestyle
- Abnormal lipids >3m lifestyle
- Underlying cause
- Advice via phone 3x abn ACR
- OSA -> ENT
- MH stress -> paeds MH
- CPS -> OT

https://aucklandregion.communityhealthpathways.org/Resources/SummaryBeSmarter-45235.pdf

Question 13

HSP

Answer 13

W: 2-10yo, 6 most common, M=F
- Usually after URTI, inc GAS

Sx:
- Rash: petechial, symmetrical, leg extensors, buttocks +/- arm/face
- Arthritis: oligoarticular (a few), swollen/tender, self-limiting
- Abdo pain: diffuse, n+v, GI bleeding, 3-4% interssuception
- Nephritis: can be nephrotic/itic, HTN

Ix: Ht/Kg, BP, urinalysis (ACR if positive)

Mx: supportive, paracetamol, NSAID if Cr okay
- usually recover 4-8wk
- 30% reccurrence within 6m
- small develop renal issues
- FU closely as nephritis can be delayed

Refer:
- Discuss: BP 95th, macroscopic haematuria, 2+ protein,
- Neph: nephrotic (odema + low albumin, >PCR), HTN, renal function, persisting macro haematuria, persisting proteinuria

Question 14

Diets in children?

Answer 14

• Vegetarian and vegan can be healthy options BUT risk deficiency e.g. B12
• Greater risk in vegan so x recommended
• Alternative milks not good
• Expose to allergens before 12m. Recc to still introduce

Diets:
- Lacto-ovo
- Lacto
- Vegan

Pro:
- limited data BUT may be leaner, less obese, DM, CVD, HTN

Risks:
- B12, iron, calcium, zinc, iodine, O3, vit D
- <BMD if <of above

Question 15

Dietary sources of elements

Answer 15

Iron
- meat, poulty, sea, green vege, cereals
- plant not as easily absorbed (need x2)
- ZINC v similar
- no tea/coffee as tannin inhibit absorb

B12
- animal, dairy, eggs
- fortified soy, cereals

Vit D
- sun, fortified daity
- Rickets: swelling, late teeth, motor, <ca, <ht

Calcium
- Legumes, dairy, fortified soy

Iodine
- fish, meat, eggs, milk
- dried seaweed, iodised salt (cautious)

Protein
- Non meat :nuts, beans, grains, seeds, leafy green veges
- kids need BD pre/school age. 3-4x young adult

Question 16

Breast feeding / formula feeding and nutrition

Answer 16

BREAST
6m to 1year, only source until 6m. If plant-based diet, increase to 2year

If mother’s diet is good, should be fine

Supplement with B12 IF VEGAN + fortified
- oral xfund, IM fund

FORMULA
- Cows milk formula, continue until 1y, or 2 if on vegan diet
- 500ml /day enough VitD
- Fortified soy only recommended >6m, ideally >1year
- No other alternatives

SOLIDS
- From 6m to help with iron stores. More if only plant based

Question 17

Kawasaki

Answer 17

W: 2nd most common vasculitis after HSP
- Asian, 75% <5

D: 5 day fever PLUS 4/5 of:
- Conjunctival BL
- Rash, mac-pap
- Red tongue, cracking
- Red, fluid hand/feet, desquamate 2nd wk
- lymphadenopathy

Mx:
- Refer
- ECHO 0w, 2w, 6w
- Bloods, ECG
- IvIG, aspirin, steroid

Question 18

When does eye screening start for T1 diabetics

Answer 18

5YR AFTER DX or at age 10

Question 19

What can be used for cough?

Answer 19

Honey, paracetamol, fluids, lozenges (can reduce irritation but not severity/duration)

Question 20

Bronchiectasis

Answer 20

D: wet cough >3x year lasting >4wks
W: ANY age. initial trigger -> dilation -> reduced clearance -> inflam -> chronic wet cough
R: MAPAS, crowding, cold/damp, smoke, <access to care, hosp with resp illness <2y, CF, <immune, FB asp

IX:
- sample if poss (>6)
- CXR all if given abx, ideally when well -> refer paeds if abnorm

MX:
- Prevent: hygiene, housing, education
- Smoking cessation
- Imms (flu if high risk, 4th pneum if resp dx)
- >4w -> 2w Abx
-> further 2w + ref
-> better after 1x course then label as protracted bronchitis

Confirmed:
- Exac: Augmentin 2w
- Chest PT, BD if well

Ref:
- 2x 2week courses
- 3x eps/year
- symp/sign chronic dx
- abnormal CXR

Whilst waiting
- Immunoglobulin
- Sputum
- CXR
- Spirometry if poss

Question 21

Asthma

Answer 21

<1 - bronchiolitis, nil steroid or inhalers

1-5 IF frequent/sx in between viruses
1. SABA
2. low dose ICS via MDI and spacer
3. + montelukast
4. Refer’

5-11
1. SABA
2. Low dose ICS
3. Low dose ICS/LABA
4. Standard dose +/- referral + monte
5. High dose + referral + monte

12+
1. PRN symbi
2. 1 BD or 2 OD
3. 2 BD +/- monte
4. Referral

Question 22

Food allergy

Answer 22

W: 10% parents report preschool age children
- common: milk, egg and peanut 75%, tree nut increasing, cashew most common. Note cashew and pistacio related. Peacan and walnut similar. Warn parents. Still good to try. Anaphylaxis RARE. Try in safe environment if well.
- Most outgrow
- Most IgE-mediated, FPIES (food protein, non-IGE mediated, couple of hours later with d+v)
- food intolerance - not immunologically mediated - often removed!

Sx
- IgE: 10-20min, ALWAYS <2HR. Skin, GI, resp, generalised anaphylaxis
- In insect sting: VOMITING + AP are sign of anaphylaxis!!!
- Usually have ingest. Contact usually only mild (less likely allergy) except for fish

Hx
- What food? quantity? symptoms?
- >/< 2hrs (uriticaria >6hrs then very unlikely allergy)
- Have previous ingestions resulted in symptoms? Unlikely if OK before.
- Eczema or asthma? MOST HAVE, can be mild
- Anaphylaxis is very rarely biphasic

Ix
- Can be on >6m. Wait if <6m as likely to milk - avoid and test at 6 months.
- NOT painful. Virtually no risk anaphylaxis. If so, wait 6w. Stop antihist 72hr. x eczema all over.
- size of wheel not proportionate to reaction
- positive test without positive history = sensitisation, not allergy. SO DON’T REQUEST PANNEL as ends up needing food challenge
- always request test if suspicion of IgE allergy
- eliminating foods with sensitisation can later produce allergy years later
- can request specific test but must go through paeds / immunology
- serum specific IGE (“RAST”) only if skin conditions / long-term antihistamine preclude skin test

Mx
- OD antihistamine
- Epipen: SA (anaphylaxis to ED/hospital, significant risk, NOT more than two devices on Rx)

EGG
Ladder
- 1 baked in flour matric
- 2 baked in other foods
- 3 well cooked whole egg
- 4 lightly cooked
- 5 raw in mayonnaise
Mx: if allergy to egg and tolerated lower down ladder then can continue that but stop at rung of ladder that caused symptoms IF prick <8
-> refer and skin prick test
-> early baked egg then usually 50% resolved in 2yrs of age

Peanut allergy
- Retest at school age (25% resolve)
- Consider challenge if same result or less. High result (>8mm) then likely persisting

Allergy.au.org
- Has allergic reaction plan and anaphylaxis plan
Nip allergies in the bud
Eczema action plan off of starship

Allergy + eczema
- atopy risk factor but not to specific foods apart from egg and peanut. NO BENEFIT TO exclude
- food allergy does not cause eczema. AVOID skin testing. Can cause problems.
- refer if eczema management challenging - HAVE TIME

Question 23

Anaphylaxis

Answer 23

ABCDE
- Lie down/reclining. Upright risk factor for fatal anaphylaxis.
- IM adrenaline 0.01ml/kg 1:1000
- Ambo

Risk factors fatal anaphylaxis: asthma (poor control), adolescent, nut allergy, eating away from home, sitting or standing, delayed adrenaline

Cows Milk Protein Allergy CMPA
- <6m extensively hydrolysed pepti junior with SA (smaller NECKLACE of amino acids)
- >6m then try soy
- if anaphylaxis: amino acid based. Neocate or Elecare. Taste gross. (individual BEADS)
- AVOID goat milk. Cross-reactive and very expensive. No role partially hydrolysed

Rice milk not rec <5. Need fortified
Other nut milks not recommended

Question 24

Developmental assessment

Answer 24

FOCUS on first 2years for exams

Ax USE DENVER
- General obs, dysmorphism
- big or small head
- quality of movements
- asymmetry
- visual regard
- response to sound

Eyes
- red reflex, conjugate movements - move toy around
- newborn, blinks to flash, fixes briefly
- 6-8 weeks, fixes and follows near face horizontally
- 3 months, + vertically
- 6 months circle
- 1yr 6/6 vision

Any issues with development not reliable enough?

Hearing: difficult -> screen if concerned

Gross motor
- how does your child move around?
- pull to sit very useful, hypotonia if lots of head lag, legs less flexed, rag-doll

3m head control - no head lag on pull to sit, head steady when upright, ok on tummy
4-5m - good with pull to sit, anticipates, up on wrists when prone on tummy, rolls F->B first
6m trunk control, sit unsupported
8m crawling but not all. Different styles. Check lower limb tone if just using arms
12m leg control
Walking 10-18m. often bow-legged initially

18m running
24m jump, kick a ball
3yr, pedal a tricycle
4yr, skip and hop

Fine motor
- what does your chlid do with their hands?
- 3m: hold rattle placed in hand, hands open from closed
- 3-4m: plays with own hands
- 5m: reaches both hands
- 6m: reaches one hand
- 9m: immature pincer (3 fingers) raisin
- 11m: mature pincer
- 12m: mark with crayon
- 18m: scribbes, 3 tower block
- 24m: 6blocks

Language - think hearing issue
- what noises do they make / what words do they say?
- do they understand you when they talk to them?
- receptive before expressive. Isolated or combined delay. More concerning if both. ?AD

Expressive:
- 6-8w smiling
- 3m coo
- 4m laugh
- 5m raspberries
- 6m hard babble
- 9m jargoning, mama
** 12m one word, points
** 18m few single words
** 2 = 2 word combos, 50% understandable
** 3 = 3 word combos
- 4 = sentences, should be understanding 100%

Receptive
- 6w: quietens to familiar voice
- 5m: turns to voice
** NINE = NO & NAME
** 1yr 1 step command
18m points to named bodyparts
*** 2 yr 2 step command

Personal-social
- how does your child play? what do they like to play with?

Delays
- isolated versus global delay
- tests? Ck, reflexes, b12, hypothyroid, cerebral palsy. Xray if delayed walking DDH
- can take a long time to see (e.g. 1yr in paeds)
- in the meantime: ministry of education early intervention, audiology, SLT
- limit screentime, play with children, if kid says fish then repeat word 3x to reinforce

FLAGS
- 3M: Head, smile, vocalise
- 5M: Not holding object
- 9M: Can’t sit
- 10M: Babble
- 12M: hand preference
- 18M: Walking, clear word, not responding to name
- 2Y: no pretend play, repetitive play
- 2.5Y: 2 words together
- 3Y: not understandable
- 3-4Y: x play with others

Question 25

Wilms tumour

Answer 25

• B>G
• abdo pain, reduced appetite, fevers, FTT
• 20% of all childhood malignancies
• 50% of all malignancies during infancy
• 80% <5, peak 2-3 years.
• 10% bilateral (ALL inherited) 15% of UL also

Question 26

JIA

Answer 26

W:
- 2+ joints
- >6w
- <16yo
- Other causes excluded

Oligo 4 or less
Poly 5 or more
+/- enthesitis, systemic, PA

SX: MAPAS >cervical envolvement, erosive change, narrowing, rheumatoid factor +ve

EX: PGALS

Diff:
- Infection: viral, OM, septic, TB, mycolpasma, cat scratch
- RA (STI, GI), RF
- AI: sarcoid, CTD
- Vasc: Kawa, HSP, Bechets
- Chronic: IBD, coeliac
- Malignancy: blood, bone

IX:
- Ortho if ?infection
- If JIA suspected: ANA, FBC, CRP/ESR
- RF / CCP prognostic
- HLAB27 if enthesitis

MX:
- NSAIDS, paracetamol
- Paed rheum within 4w
- May need steroid or DMARD (MTX)
- Ophthalm review

Question 27

Colic

Answer 27

W: 2-16w (4m)

P: peak 8w
U: unpredictable
R: resistant to soothing
P: pained look (fists, legs)
L: long bouts (hours)
E: evening (afternoon)

Can end @ BM/gas/sleep

NOT HARMFUL
NO PROVEN CAUSE
??reflux, intolerance, cow milk allergy

Baby Mx:
- Hold upright
- ?avoid foods if connected
- change formula/bottle
- hold, soothing sounds
- dim lights
- sway or pushing in pram
- front pack/sling 4 tasks
- warm bath
- gentle stomach rub

Mum Mx:
- Keep hours free during bad time periods
- hydration, snack before
- Plunket

Question 28

Reflux

Answer 28

W: 50%, gets better alone
- 40% regurgitate OD
- <8w,16w (4m) peak - 1yr
- looser, liquids, lying

Sx:
- burp, belch, swallow hard
- swallowed or back up

GORD in very small no
= complication of above
- KEY: >5 regurg per day OR persisting feed issues
- crying +++
- blood
- back arching after feed
- poor sleep/kg gain
- cough/wheezy breathing

Ix: ?GORD - Ba swallow, pH monitoring OVER 24hrs.

Mx:
- calm, relaxed
- burp during feeds
- smaller more frequent
- check teet size if bottle
- hold upright after
- may need feeding sooner
- thickener to milk

Dr if forceful, blood, >1yr

Paeds: excessive relux +
- faulure of above
- FTT
- oesophagitis
- uncertainty
- extreme anxiety

Gaviscon infant best medication

Question 29

Vaccines

Answer 29

DO NOT adjust for pre-term birth

Question 30

ADHD

Answer 30

diagnosis requires function impairment

9% childhood

innatention, hyerpactive, impulsive or combo

2 domans generally

Rx -> large QoL improvement

Question 31

Vaccines

Answer 31

6w
- Rota
- Infanrix
- Pneuo

3m
- Rota
- Infanrix
- MenB

5m
- Infanrix
- Pneumo
- Men B

12m
- MMR
- Pneumo
- Men B

15m
- Varicella
- Hib
- MMR

4yr
- Infanrix-IPV

11yr
- Boostrix
- HPV 2 doses 6-12m apart, 3, with 1x @1m, 1x @6m
45 - boostrix

Flu and boostrix in preg

65 - boostrix, Shingrex

TB
- <5 + living with someone with TB or Hx of
- Parents in high risk country for <6m last 5yr
- Living in high risk country for 3m within first 5 year

Answer 32

50% will have murmur some stage. <1% CHD

Congenital HD
1. VSD
2. ASD
3. PDA

I barely
II soft
III audible wo thrill
IV audible w thrill
V loud
VI audible off chest

Benign
- 3 or less, louder with exercise or fever, <Hb
- More audible supine
- No associated symptom

ASD
- usually asymptomatic
- wide and split 2nd sound
- usually fix as > stroke

VSD
- small often x Sx

PDA
- Continuous machinery
- L to R shunt (>a:p mmHG)
- ALL Closed

ToF
- RVOT obstruction + RVH, VSD, aortic override
- Boot-shaped heart
- Correct all. Some asym if minor RVOT issue

Refer
- <3m ANY murmur
- ARF/RHD
- Pathological murmur
- FH of concern
- FTT/growth/feeding
- Clubbing, cyanosis