Paeds Flashcards
Newborn resuscitation guidelines
- Dry baby and maintain temperature
- Assess tone, respiratory rate, heart rate
- If gasping or not breathing give 5 inflation breaths*
- Reassess (chest movements)
- If the heart rate is not improving and <60bpm start compressions and ventilation breaths at a rate of 3:1
Most common cause of arrest in children?
Respiratory - likely foreign body
What does this image show?
Pyloris stenosis - target mass on USS
Bloods will show hypochloraemic hypokalaemic metabolic alkalosis
causative organism of croup
parainfluenza
Other name for croup
Laryngeotracheobronchitis
Treatment of meningitis
Antibiotics
< 3 months: IV amoxicillin (or ampicillin) + IV cefotaxime
> 3 months: IV cefotaxime (or ceftriaxone)
Initial management of cyanotic heart disease
Prostaglandin E1, then surgery
When do cyanotic heart disease present/
ToF - months, weeks, days
TGA - hours
TA - minutes
Basic anatomical changes in TGA
aorta leaves the right ventricle
pulmonary trunk leaves the left ventricle
CXR appearance of TGA
‘egg-on-side’ appearance on chest x-ray
Murmurs heard on TGA
NO MURMUR
loud single S2
prominent right ventricular impulse
Echocardiogram sign of TGA
parallel aorta and pulmonary trunk
Prostanglandin name
Alloprostadil
Red flags that would warrant admission in bronchiolitis
grunting noises, cyanosis, use of accessory muscles for respiration, a respiratory rate exceeding 70 breaths per minute, oxygen saturations below 92% on room air or episodes of apnoea
cuase of bronchiolitis
RSV
Management of bronchiolitis
supportive
What can cause bronchiolitis to be more severe?
CHD
Monoclonal AB that can be used in RSV
Palivizumab
Neonatal hypoglycaemia cut off
<2.6
Management of neonatal hypoglycaemia
asymptomatic
encourage normal feeding (breast or bottle)
monitor blood glucose
symptomatic or very low blood glucose
admit to the neonatal unit
intravenous infusion of 10% dextrose
Most common cause of nappy rash
Irritant dermatitis, typically spares creases
Pattern of nappy rash in candida dermatitis
involves flexures and has satellite lesions
High fever lasting >5 days, red palms with desquamation and strawberry tongue
Kawasaki
Management of Kawasaki
high-dose aspirin
intravenous immunoglobulin
echocardiogram (rather than angiography) is used as the initial screening test for coronary artery aneurysms
Complication of Kawasaki that needs screening for, how?
Coronary artery aneurysm, Echo
When should infantile colic resolve by?
6 months
Features that suggest infantile colic
baby’s age (colic starts in the first few weeks of life and resolves around 3-4 months of age), the timing of the crying (most often occurs in the late afternoon or evening), and arching of the back (babies often draw their knees up to their abdomen or arch their backs when crying).
when is APGAR score measured
NICE recommend that it is assessed at 1, and 5 minutes of age. If the score is low then it is again repeated at 10 minutes
APGAR score interpretations
A score of 0-3 is very low score, between 4-6 is moderate low and between 7 - 10 means the baby is in a good state
Visible peristalsis in abdomen with non-bilious vomiting
Pyloric stenosis
Electrolyte abnormality in pyloric stenosis
Hypochloraemic Hypokalaemic Metabolic Alkalosis
Criteria to assess probability of septic arthritis in children, how to calculate and interpret?
Non-weight bearing - 1 point
Fever >38.5ºC - 1 point
WCC >12 * 109/L - 1 point
ESR >40mm/hr
The probabilities are calculated thus:
0 points = very low risk
1 point = 3% probability of septic arthritis
2 points = 40% probability of septic arthritis
3 points = 93% probability of septic arthritis
4 points = 99% probability of septic arthritis
Most important investigations in septic arthritis
joint aspiration: for culture. Will show a raised WBC
raised inflammatory markers
blood cultures
What should be given to all children who an asthma attack/exacerbation? How long for?
Oral steroids for 3-5 days
groin swelling and primary amenorrhoea
androgen insensitivity, groin swellings are undescended testis
genetically male (46XY), but phenotypically female
Table showing disorders of sex hormones
Cause of primary hypogonadism, give karyotype and features
Klinefelter’s syndrome is associated with karyotype 47, XXY
Features
often taller than average
lack of secondary sexual characteristics
small, firm testes
infertile
gynaecomastia - increased incidence of breast cancer
elevated gonadotrophin levels
Diagnosis is by chromosomal analysis
Cause of hypogonadotropic hypogonadism, give features
Kallman syndrome, X-linked
Features
‘delayed puberty’
hypogonadism, cryptorchidism
anosmia
sex hormone levels are low
LH, FSH levels are inappropriately low/normal
patients are typically of normal or above average height
lack of smell (anosmia) in a boy with delayed puberty
Kallman
Management of androgen insensitivity syndrome
counselling - raise child as female
bilateral orchidectomy (increased risk of testicular cancer due to undescended testes)
oestrogen therapy
When can a child with scarlet fever return to school?
24 hours after commencing ABx
When can a child with measles return to school>
4 days from onset of rash
When can child with whooping cough return to school?
48 hours after commencing ABxWh
When can child with rubella return to school?
5 days from onset of ras
When can child with D+V return to school?
48 hours after symptoms settled
causative organism of scarlet fever
Group A haemolytic streptococci (usually Streptococcus pyogenes)
sandpaper rash
Scarlet fever
Management of scarlet fever
oral penicillin V for 10 days
patients who have a penicillin allergy should be given azithromycin
children can return to school 24 hours after commencing antibiotics
scarlet fever is a notifiable disease
Most common complication of scarlet fever
otitis media: the most common complication
Child with a limp/hip pain and fever mx
Refer for same day assessment even if a diagnosis of transient synovitis suspected
Main cause of painless massive GI bleeding
Meckels
Rule of 2s for Meckles
occurs in 2% of the population
is 2 feet from the ileocaecal valve
is 2 inches long
How can meckels present?
Presentation (usually asymptomatic)
abdominal pain mimicking appendicitis
rectal bleeding
Meckel’s diverticulum is the most common cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years
intestinal obstruction
secondary to an omphalomesenteric band (most commonly), volvulus and intussusception
Differential for appendicitis
Meckels
Investigation for Meckels
99m technetium pertechnetate, which has an affinity for gastric mucosa
What is meckels?
remnant of the omphalomesenteric duct (also called the vitellointestinal duct) and contains ectopic ileal, gastric or pancreatic mucosa.
Child <3 with acute limp
Urgent paediatric assessment
Acute cough and stridor following fever and coryza in a child aged 6 months to 3 years
Croup
Barking cough
Croup
What does stridor suggest?
upper airway obstruction, caused by inflammation and oedema of the larynx, trachea, and bronchi
Croup is more common in which season
autumn
most likely result if a fetus is homozygous for alpha-thalassaemia
hydrops fetalis
what is anencephaly, cause?
serious birth defect in which a baby is born without parts of the brain and skull
folic acid deficiency
Management of formula fed cows milk protein allergy
extensive hydrolysed formula (eHF) milk is the first-line replacement formula for infants with mild-moderate symptoms
amino acid-based formula (AAF) in infants with severe CMPA or if no response to eHF
around 10% of infants are also intolerant to soya milk
Management of breast fed cows milk protein allergy
continue breastfeeding
eliminate cow’s milk protein from maternal diet. Consider prescribing calcium supplements for breastfeeding mothers whose babies have, or are suspected to have, CMPI, to prevent deficiency whilst they exclude dairy from their diet
use eHF milk when breastfeeding stops, until 12 months of age and at least for 6 months
What occurs in testicular torsion?
testis turns on the remnant of the processus vaginalis
acutely severe testicular pain often with associated nausea and vomiting
torsion
Signs associated with torsion
The cremaster reflex may also be absent on the affected side.
Prehn’s sign - Elevation of the testicle often results in worsening of the pain.
Features of Innocent murmur
Soft, Systolic, Short, Symptomless, Standing/Sitting (vary with position)
Venous hums
Innocent murmurs that is due to the turbulent blood flow in the great veins returning to the heart. Heard as a continuous blowing noise heard just below the clavicles
Still’s murmur
Innocent murmur that is a Low-pitched sound heard at the lower left sternal edge
murmur in aortic coarctation
ejection systolic murmur which can be heard through to the back
murmur does not change on position
Examination finding of aortic coarctation
Radio-femoral delay
difference between blood pressure in the arms and legs is detected
Murmur thats seen in VSD
pansystolic
Murmur seen in ASD
ejection systolic murmur but is often associated with fixed splitting of the 2nd heart sound
Murmur seen in pulmonary stenosis
ejection systolic murmur heard at the left upper parasternal edge
Components of APGAR score
Pulse Respiratory effort Colour Muscle tone Reflex irritability
A 5-day-old baby has her heel prick test done, and it comes back that she has a raised level of immunoreactive trypsinogen (IRT). What next?
Sweat test
normal value < 40 mEq/l, CF indicated by > 60 mEq/l
Fluid resus guidelines
Start IV fluid resuscitation in children or young people with a bolus of 10 ml/kg over less than 10 minutes
Major RF for NRDS
Prematurity
Major RF for TTN
C section
Major RF for aspiration pneumonia
Meconium staining
CXR finding on NRDS
diffuse ground glass lungs with low volumes and a bell-shaped thorax
CXR finding of TTn
heart failure type pattern (e.g. interstitial oedema and pleural effusions
NOTE: key distinguishing features from congenital heart disease are a normal heart size and rapid resolution of the failure type pattern within days.
NRDS AKA
Surfactant deficienct lung disease
Management of NRDS
prevention during pregnancy: maternal corticosteroids to induce fetal lung maturation
oxygen
assisted ventilation
exogenous surfactant given via endotracheal tube
Infant with bilious vomiting & obstruction
Intestinal malrotation
Signs of obstruction
distended abdomen and absent bowel sounds
What type of vaccine is rotavirus?
oral, live attenuated vaccine
Dose of dex to be given in croup
Croup - A single dose of oral dexamethasone (0.15 mg/kg) is to be taken immediately regardless of severity
Initial management of Hirchsprung’s
rectal washouts/bowel irrigation
Definitive management of Hirchpsrung’s
Anorectal pull through
Absence of in Hirchsprung
parasympathetic Auerbach and Meissner plexuses
Hirchsprung association
Down’s
Gold standard for Hirchsprung
Full thickness rectal biopsy
Failure or delay to pass meconium
Hirchsprung
prodrome of fever, irritability and conjunctivitis
Measles
Koplik spots
white spots (‘grain of salt’) on buccal mucosa
seen in measles
Presentation of chickenpox
Fever initially
Itchy, rash starting on head/trunk before spreading. Initially macular then papular then vesicular
How does rash present in measles?
Rash: starts behind ears then to whole body, discrete maculopapular rash becoming blotchy & confluent
How does rash present in rubella?
Rash: pink maculopapular, initially on face before spreading to whole body, usually fades by the 3-5 day
How to differentiate between measles and rubella?
Measles has a prodrome of irrtability, conjunctivitis and fever
Rubella has Lymphadenopathy: suboccipital and postauricular
Complication of mumps
Orchitis and eventually subfertility
Parotitis (earache/pain on eating)
Mumps
Erythema Infectiosum AKA, cause?
Also known as fifth disease or ‘slapped-cheek syndrome’
Caused by parvovirus B19
Rash in erythema infectiosum
‘Slapped-cheek’ rash spreading to proximal arms and extensor surfaces
Rash in scarlet fever
fine punctate erythema sparing the area around the mouth (circumoral pallor)
Sandpaper like
Cause of hand, foot and mouth disease
coxsackie A16 virus
Vesicles in the mouth and on the palms and soles of the feet
Hand, foot and mouth disease
Short stature + primary amenorrhoea
Turners
Karyotype of Turners
45,XO or 45,X.
Presentation of Turners
short stature
shield chest, widely spaced nipples
webbed neck
bicuspid aortic valve (15%), coarctation of the aorta (5-10%)
primary amenorrhoea
Projectile non bile stained vomiting at 4-6 weeks of life
Pyloric stenosis
Treatment of pyloric stenosis
Ramstedt pyloromyotomy (open or laparoscopic)
Colicky pain, diarrhoea and vomiting, sausage-shaped mass, red jelly stool.
Intusussception
Treatment of intusussception
reduction with air insufflation
Treatment of volvulus
Ladd’s procedure
Associations of oesophogael atresia
Associated with tracheo-oesophageal fistula and polyhydramnios
VACTERL associations - vertebrae, anus, cardia, trachea, esophagus, renal and limbs
VACTERL associations
vertebrae, anus, cardia, trachea, esophagus, renal and limbs
Seen in oesophogael atresia
Jaundice >14 days with increased conjugated bilirubin
Biliary atresia
Management of biliary atresia
Kasai
What blood test finding in biliary atresia?
Increased conjugated bilirubin
XR finding of nec enterocolitis
pneumatosis intestinalis
abdominal distension and passage of bloody stools in a premature infant
Nec enterocolitis
meconium ileus associated with
CF
What can be done to reduce chances of severe brain damage in neonates with hypoxic injury?
Therapeutic cooling at 33-35 degrees
normal pCO2 in an acute asthma attack indicates
Life threatening attack
Features of severe astham attack
SpO2 < 92% (unlike in adults, SpO2 < 92% may be consistent with a ‘severe’ attack in children)
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
Features of life threatening asthma attack
SpO2 <92%
PEF <33% best or predicted
Silent chest
Poor respiratory effort
Agitation
Altered consciousness
Cyanosis
Most common fractures associated with child abuse
- Radial
- Humeral
- Femoral
Treatment of ITP
usually, no treatment is required
ITP resolves in around 80% of children with 6 months, with or without treatment
What type of rash in ITP
petechial or purpuric rash
Best investigation for VUR
micturating cystourethrogram
Why do a DMSA scan
look for renal scarring
Infantile spasms AKA
West syndrome
Features of West syndrome
characteristic ‘salaam’ attacks: flexion of the head, trunk and arms followed by extension of the arms
this lasts only 1-2 seconds but may be repeated up to 50 times
progressive mental handicap
Prognosis of infantile spasms
BAD
EEG findings of West syndrome
hypsarrhythmia
1st line medication for infantile spasms
vigabatrin is now considered first-line therapy
Fever followed later by rash
Roseola infantum
Roseola infantum AKA, caused by?
Roseola infantum (also known as exanthem subitum, occasionally sixth disease) is a common disease of infancy caused by the human herpes virus 6 (HHV6)
Common association of roseola infantum
Febrile convulsions
What can NSAIDs cause in patients with chicken pox?
Nec fascitis
baby is born with micrognathia, low-set ears, rocker bottom feet and overlapping of fingers
Edward’s (trisomy 18)
cleft lip or palate, polydactyly (extra digits), microphthalmia (small eyes), scalp defects, and congenital heart disease
Patau (trisomy 13)
elfin’ facies (distinctive facial features such as a wide mouth, small nose, and full lips), cardiovascular disease (especially supravalvular aortic stenosis), hypercalcemia (high calcium levels in the blood), intellectual disability and an outgoing personality
William syndrome
Deletion on chromosome 7
intellectual disability ranging from learning difficulties to severe cognitive impairment along with characteristic long face, large ears, hyperextensible joints especially fingers and behavioural problems like ADHD or autism spectrum disorder
Fragile X
anomalies of the facial structures leading to micrognathia (undersized jaw), glossoptosis (downward displacement or retraction of the tongue) and often cleft palate
Pierre-Robin syndrome
Webbed neck
Pectus excavatum
Short stature
Pulmonary stenosis
Noonnan syndrome
Hypotonia
Hypogonadism
Obesity
Prader-Willi syndrome
Deletion on chromosome 5
Characteristic cry due to larynx and neurological problems
Feeding difficulties and poor weight gain
Learning difficulties
Microcephaly and micrognathism
Hypertelorism
Cri du chat syndrome (chromosome 5p deletion syndrome)
THINK: CRY du chat
Management of hand, foot and smouth disease
symptomatic treatment only: general advice about hydration and analgesia
reassurance no link to disease in cattle
children do not need to be excluded from school
This child has had what was a likely viral illness in the past week and is now suffering with abdominal pain, How to differ mesenteric adenitis from other conditions?
He is eating and drinking normally, unlikely in appendicitis.
He is passing normal stools, unlikely in constipation.
He is not vomiting, unlikely in gastroenteritis.
1st line laxative in constipation
Osmotic - polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain
Then stimulant
children with an unexplained enlarged abdominal mass in children
possible Wilm’s tumour - arrange paediatric review with 48 hours
Most common complication of measles
otitis media
Pneumonia also a complication
When to start medication in whooping cough? What medication?
azithromycin or clarithromycin if the onset of cough is within the previous 21 days
Causative organism of whooping cough
Bordetella pertussis
Diagnostic criteria for whooping cough
Whooping cough should be suspected if a person has an acute cough that has lasted for 14 days or more without another apparent cause, and has one or more of the following features:
Paroxysmal cough.
Inspiratory whoop.
Post-tussive vomiting.
Undiagnosed apnoeic attacks in young infants.
Diagnosis of whooping cough done via
per nasal swab culture for Bordetella pertussis - may take several days or weeks to come back
Who should be admitted in whooping cough?
infants under 6 months with suspect pertussis should be admitted
Is whooping cough a notifiable disease?
Yes
Main complication of whooping cough
subconjunctival haemorrhage
Triad of shaken baby syndrome
Retinal haemorrhages, subdural haematoma and encephalopathy
Common presenting features of neonatal sepsis
grunting, nasal flaring, tachypnoea and the use of accessory respiratory muscles.
Cause of early onset neonatal sepsis
GBS
Cause of late onset neonatal sepsis
Coag negative staph e.g. satph epidermis
1st like medication in confirmed neonatal sepsis
intravenous benzylpenicillin with gentamicin
Risk of further febrile convulsion
1 in 3
Management of febrile convulsions
parents should be advised to phone for an ambulance if the seizure lasts > 5 minutes
regular antipyretics have not been shown to reduce the chance of a febrile seizure occurring
1st line medication for febrile convulsion that don’t teriminate
rectal diazepam or buccal midazolam
Why is gestational diabetes a risk factor for NRDS?
insulin inhibits surfactant production and maturation of the fetal lungs.
Rate of chest compressions in children
100-120 per minute
What age should babies who were born prematurely receive their routine vaccines according to?
Chronological, no adjustment for gestation
Under what centile for height should children be reviewed by a paediatrician?
Children below 0.4th centile for height should be reviewed by a paediatrician
What murmur in PDA?
Gibson murmur - continuous machinery murmur
Features on examination of PDA
left subclavicular thrill
continuous ‘machinery’ murmur
large volume, bounding, collapsing pulse
wide pulse pressure
heaving apex beat
Management of PDA
indomethacin or ibuprofen
most common cardiac condition in Down’s
AVSD
Associations of down’s syndrome
congenital heart defects - AVSD, VSD
duodenal atresia
Hirschsprung’s disease
Complications of Down’s
Subfertility
Short stature
Recurrent infections
acute lymphoblastic leukaemia
hypothyroidism
Alzheimer’s disease
atlantoaxial instability
Hand preference before when is abnormal?
12 months
Presentation of ALL
anaemia, neutropaenia and thrombocytopaenia
testicular swelling in a child
Exclude ALL
Hepatosplenomegaly and the presence of bruising together with the symptoms of anaemia (soft systolic murmur and shortness of breath on exertion)
ALL
management of unilateral undescened testicle
Unilateral undescended testicle - review at 3 months - if persistent refer
Management of bilateral undescended testis
Should be reviewed by a senior paediatrician within 24hours as the child may need urgent endocrine or genetic investigation
when to consider a diagnosis of pneumonia over bronchiolitis?
high fever (over 39°C) and/or
persistently focal crackles.
anterior knee pain on walking up and down stairs and rising from prolonged sitting
Chondromalacia patellae
Pain, tenderness and swelling over the tibial tubercle
Osgood-Schlatter disease
Pain after exercise
Intermittent swelling and locking
Osteochondritis dissecans
Where may referred pain in the knee come from?
hip problems such as slipped upper femoral epiphysis
When to admit a child with group?
moderate or severe croup
< 3 months of age
known upper airway abnormalities (e.g. Laryngomalacia, Down’s syndrome)
uncertainty about diagnosis (important differentials include acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation)
child with croup and stridor at rest, mx?
admit as stridor at rest is a feature of moderate croup along with sternal wall retraction
At what age would the average child acquire the ability to sit without support?
The answer (6-8 months) includes the 6 months as stated in the MRCPCH Development Guide.
Evidence of bowel sounds in a respiratory exam of a neonate in respiratory distress
diaphragmatic hernia
Difference in presentation of cyanotic heart disease
Cyanotic congenital heart disease presenting within the first days of life is TGA.
Cyanotic congenital heart disease presenting at 1-2 months of age is TOF
After how long is passage of meconium classed as a red flag?
48 hours
Cardiac compplication associated with fragile X
mitral valve prolapse
Most common cardiac abnormality in Turners
Bicuspid aortic valve
What condition is a contraindication to LP? How does it present?
Meningococcal septicaemia, purpuric rash
Cyanotic heart disease with no murmur but typically a loud single S2 is audible and a prominent right ventricular impulse is palpable on examination
ToGA
How to differentiate between cyanotic cardiac and respiratory causes?
Administer 15 mins of 100% oxygen - nitrogen (hyperoxia) test
>15 - resp e.g. TTN, meconium aspiration, NRDS
<15 –> heart e.g. TA, TOGA, ToF
Types of cerebral palsy
spastic (70%)
subtypes include hemiplegia, diplegia or quadriplegia
increased tone resulting from damage to upper motor neurons
dyskinetic
caused by damage to the basal ganglia and the substantia nigra
athetoid movements and oro-motor problems
ataxic
caused by damage to the cerebellum with typical cerebellar signs
mixed
Damage occurs where in the brain cerebral palsy
pyramidal tracts
Causes of cerebral palsy
antenatal (80%): e.g. cerebral malformation and congenital infection (rubella, toxoplasmosis, CMV)
intrapartum (10%): birth asphyxia/trauma
postnatal (10%): intraventricular haemorrhage, meningitis, head-trauma
Non-motor associations of cerebral palsy
learning difficulties (60%)
epilepsy (30%)
squints (30%)
hearing impairment (20%)
At what age would the average child acquire the ability to walk unsupported
On average, most children start to walk unsupported between the ages of 13 and 15 months
what age do you grow out of febrile convulsions?
5 years
A boy with learning difficulties is noted to be extremely friendly and extroverted. He has short for his age and has supravalvular aortic stenosis
Williams
Cardiac defect most associated with Williams
supravalvular aortic stenosis
A child aged < 3 months with a fever > 38ºC, management?
same day paediatric assessment
At what age would the average child start to smile?
6 weeks
What position may patiennts with acute epigolittis adopt?
tripod position
drooling and respiratory distress
acute epiglottitis
what sign on X ray in epiglottitis
Thumb si
Causative agent of acute epiglottitis
Hib
Management of acute epiglottitis
immediate senior involvement, including those able to provide emergency airway support (e.g. anaesthetics, ENT)
endotracheal intubation may be necessary to protect the airway
if suspected do NOT examine the throat due to the risk of acute airway obstruction
oxygen
intravenous antibiotics
most common cause of microcephaly
foetal alcohol syndrome
Presentation of foetal alcohol syndrome
short palpebral fissure
thin vermillion border/hypoplastic upper lip
smooth/absent filtrum
learning difficulties
microcephaly
growth retardation
epicanthic folds
cardiac malformations
what signs can be indicative of sexual abuse?
Anal fissures and recurrent UTIs in children
Cause of slapped cheek syndrome
Parvovirus B19
Distinguishing features between cephalhaematoma and caput succedaneum
Distinguishing features of a cephalhaematoma are that they usually develop after birth and do not cross the suture lines of the skull as the blood is confined between the skull and periosteum.
crosses suture lines
caput succedcaneum
Infant < 8 weeks, presents with milky vomits after feeds, often after being laid flat, excessive crying
GORD
When is indomethacin given to child with PDA?
indomethacin is given to the neonate in the postnatal period, if the echo shows PDA one week after delivery
When should a PPI be trialed in GORD?
PPI should be trialled in infants with GORD who do not respond to alginates/thickened feeds and who have 1. feeding difficulties, 2. distressed behaviour or 3. faltering growth
At what age would the average child acquire the ability to crawl?
9 months
In tetralogy of Fallot, what determines the degree of cyanosis and severity?
the severity of the right ventricular outflow tract obstruction (pulmonary stenosis) determines the degree of cyanosis and clinical severity
Age of palmar grasp
5-6 months
Age to draw a circle
3 years
Age for a tower of 3-4 blokcs
18 months
Most common cause of stridor in neonate
laryngomalacia
greasy, yellowish rash with flaky scales, most commonly on the scalp
cradle cap - seborrhoeic dermatitis - malazzesia
Management of seborrhoeic dermatitits
reassurance that it doesn’t affect the baby and usually resolves within a few weeks
massage a topical emollient onto the scalp to loosen scales, brush gently with a soft brush and wash off with shampoo.
if severe/persistent a topical imidazole cream may be tried
At what age would the average child start to say ‘mama’ and ‘dada’?
9-10 months
webbed neck, pulmonary stenosis, ptosis and short stature. The karyotype is normal
Noonan syndrome
bossing of the forehead, bowing of his legs, widening of joints and significant kyphoscoliosis of the spine.
Rickets
child presents in first few weeks of life with jaundice, appetite and growth disturbance
biliary atresia
When is bow legs in a child normally?
Bow legs in a child < 3 is a normal variant and usually resolves by the age of 4 years
Effective treatment option for head lice
Wet combing
How does hypernatraemic dehydration present?
jittery movements
increased muscle tone
hyperreflexia
convulsions
drowsiness or coma
Features of atypical 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.
Emergency treatment of croup
high-flow oxygen
nebulised adrenaline
Causes of jaundice in the first 24 hours
ALWAYS PATHOLOGICAL
Causes of jaundice in the first 24 hrs
rhesus haemolytic disease
ABO haemolytic disease
hereditary spherocytosis
glucose-6-phosphodehydrogenase
How quick should serum bilirubin be measured when jaundice occurs within the first 24 hours of life?
Within 2 hours
small, red growth of tissue in the centre of the umbilicus, covered with clear mucus
Umbilical granuloma
size of testes in fragile X
macroorchidism
size of head in Fragile X syndrome
MASSIVE HEAD
mode of inheritance in Prader willi
Imprinting
loss of red reflex in eye
Retinoblastoma
UTI in <3 month mx
Refer immediately to hospital
atrialisation of right ventricle
Ebstein’s anomaly
Associations of Ebstein’s anomaly
patent foramen ovale (PFO) or atrial septal defect (ASD) is seen in at least 80% of patients, resulting in a shunt between the right and left atria
Wolff-Parkinson White syndrome
Clinical features of Ebstein’s anomaly
cyanosis
prominent ‘a’ wave in the distended jugular venous pulse,
hepatomegaly
tricuspid regurgitation
pansystolic murmur, worse on inspiration
right bundle branch block → widely split S1 and S2
Commonly associated conditions with malrotation
Exomphalos and diaphragmatic hernia
Is school exclusion needed for head lice?
No
infrahyoid cyst that rises on protrusion of tongue
Thyroglossal cyst
Palivizumab type of medication and indication
monoclonal antibody used to prevent RSV
most common cause of childhood hypothyroidism in the UK
AI thyroiditis
Most common cause of nephrotic syndrome in children
Minimal change disease
eczema distribution in a 10 month child
face and trunk
What type of pulse with PDA?
large volume, bounding, collapsing pulse
What causes nec fascitis in patients with chicken pox?
Invasive group A Streptococcus, a β-haemolytic Streptococcus
When is an immediate CT scan warranted in head injury?
Loss of consciousness lasting more than 5 minutes (witnessed)
Amnesia (antegrade or retrograde) lasting more than 5 minutes
Abnormal drowsiness
Three or more discrete episodes of vomiting
Reduced GCS
Most common causative agent of bacterial pneumonia in children
S.Pneumoniae
Sign of late decompensated shock compared to earlly
Hypotension in late
Table showing differences between early and late shock
Opthalmia neonatorum mx
referred for same-day ophthalmology/paediatric assessment.
Causative agents of opthalmia neonatorum and how they differ
Chlamydia trachomatis - few weeks after birth
Neisseria gonorrhoeae - few days after birth
When should parents be advised to call an ambulance in a febrile convulsion?
If it lasts>5 mins
Healthy resp rate and pulse rate for infants
Healthy infants should have a respiratory rate between 30-60 breaths per minute, a regular pulse between 100-160 beats per minute in a newborn, temperature of around 37 Celsius, and pass urine and stool regularly.
Treatment of pityriasis versiocolor
Ketoconazole 2% shampoo
You are seeing a 15-year-old boy who has developed a widespread rash over the last week. It seemed to start from a single patch on his abdomen that he first noticed 10 days ago.
On examination, he has a symmetrically distributed rash consisting of discrete pink/red lesions which are 0.5-1cm in diameter. Most are flat, but some appear slightly raised. Some have fine scales along the edges. They are not painful or itchy.
He is otherwise well and his observations are normal. Dx? Mx?
Pityriasis rosea, supportive
ESM and fixed splitting of second heart sound in an asymptoamtic child
ASD
VSD murmur
Pansystolic murmur in lower left sternal border
Coaractation of aorta murmur
Crescendo-decrescendo murmur in the upper left sternal border
PDA murmur
Diastolic machinery murmur in the upper left sternal border
Pulmonary stenosis murmur
Ejection systolic murmur in the upper left sternal border
a ballotable mass associated with abdominal distension, Hx of passing stools every other day, mx?
history of constipation is not particularly convincing. A child passing a stool of normal consistency every other day is within the boundaries of normal. The key point to this question is recognising the abnormal examination finding - a ballotable mass associated with abdominal distension.
Management of viral induced wheeze
treatment is symptomatic only
first-line is treatment with short acting beta 2 agonists (e.g. salbutamol) or anticholinergic via a spacer
next step is intermittent leukotriene receptor antagonist (montelukast), intermittent inhaled corticosteroids, or both
What should be offered to breafeeding mothers whoa are trying to exclude calcium from their diet?
Calcium and vitamin D
What is the most esrious long term health problems for women with Turner’s?
Aortic dilatation and dissection
most common cause of ambiguous genitalia in newborns
CAH
What can bruising cause in the newborn?
Jaundice due to haemolysis
What may infants present with instead of whoops in whooping cough?
Periods of apnoea
Should whooping cough be notified?
Yea
Most common heart lesion associated with duchenne
Dilated cardiomyopathy
A 9-week-old infant is brought to the Emergency department by her father. She has been very unsettled for the past 24 hours, high pitched crying and poorly feeding. On examination her temperature is 38.1C and her right tympanic membrane appears red and inflamed. A diagnosis of acute otitis media without effusion is made. Which one of the following is the most appropriate management in the emergency department?
Admit
According to the guidelines, this child has one medium risk factor (poor feeding) and two high risk factors (high pitched cry, temperature greater than 38C in an infant under 3-month-old). Any child with a high risk factor should be referred urgently to the paediatric team for assessment.
What may be needed to protect the airway in epiglottitis?
Endotracheal intubation
What test may be done in newborns if the otacoustic emission test is abnormal?
Auditpory brainstrem response test
When is bow legs in a child a normal variant? When does it resolve by?
Bow legs in a child < 3 is a normal variant and usually resolves by the age of 4 years
Difference between gastroschisis and omphalocele and how they present
Gastroschisis and omphalocele present similarly, but gastroschisis refers to a defect lateral to the umbilicus whereas omphalocele refers to a defect in the umbilicus itself.
Gastroschisis does not have a covering, omphalocele does
How to differentiate between reflex anoxic seizures and epilepsy?
Reflex anoxic seizures have a rapid recovery unlike epileptic seizures
How should impetigo be managed?
A child with impetigo should be excluded from school until the lesions are crusted and healed or 48 hours after commencing antibiotic treatment
Topical hydrogen peroxide 1% cream can also be used
When is bone marrow biopsy required in children with ITP?
Splenomegaly
Inheritance of Hungtindons
AD
What does VSD increase the risk of?
Endocarditis
When to offer surgeries for umbilical hernias?
4-5 years of age
Usually self-resolve, but if large or symptomatic perform elective repair at 2-3 years of age. If small and asymptomatic peform elective repair at 4-5 years of age.
Management of babies with absent or weak femoral pulses at 6-8 week baby check? Suggestive of?
same day discussion with paediatrics is the correct answer. Absent or weak femoral pulses are suggestive of a major defect such as coarctation of the aorta and thus would best be discussed with and referred to the appropriate paediatrics team.
What do small testes in precocoious puberty indicate?
an adrenal cause of the symptoms
A baby is noted to have micrognathia and a cleft palate. He is placed prone due to upper airway obstruction. There is no family history of similar problems
Pierre-Robin syndrome
What genetic condition causes neonatal hypotonia?
Prader-Willi syndrome
An older child presenting with a Trendlenberg gait and leg length discrepancy
missed DDH
How to adjust development milestones if premature?
The corrected age of a premature baby is the age minus the number of weeks he/she was born early from 40 weeks
What MSK condition are people with Down syndrome most at risk of? How to reduce risk =?
Screen for atlanto-axial instability in people with Down syndrome who participate in sports that may carry an increased risk of neck dislocation (e.g. trampolining, gymnastics, boxing, diving, rugby and horse riding)
Next step in management of head lice following wet combing
malathione
How to remember which conditions are autosomal dominant and recessive
Autosomal recessive conditions are ‘metabolic’ - exceptions: inherited ataxias
Autosomal dominant conditions are ‘structural’ - exceptions: Gilbert’s, hyperlipidaemia type II
bicuspid aortic valve murmur
ESM
What genetic condition are nasal polyps associated with?
Cystic fibrosis
What do mitochondrial diseases follow?
A maternal inheritance pattern
How does neonatal sepsis most commonly present?
Gruntin and other signs of respiratory distress
What is the mainstay of treatment in unvomplicated TTN
Observation and supportive care +/- oxygen
What area of brain is affected in dyskinetic cerebral palsy?
Basal ganglia
What area of brain is affected in spastic cerebral palsy?
Pyramidal tracts
Mx of otitis media with effusion?
refer to ENT - to avoid risk of delays in their development
Who is a PDA more lilely to occur concurrently in?
children with hyaline membrane disease and in those with a concurrent cyanotic congenital heart condition
What is used as the treatment for conjugated hyperbilirubinaemia in children in the neonatal period?
First phototherapy, then ursdeoxycholic acid
Genetic inheritance of DMD
X linked recessive
resence of hepatosplenomegaly, lymphadenopathy and new-onset bruising
malignancy
anaemia, thrombocytopenia, and neutropenia
ALL
Definitive diagnosis of ALL
bone marrow aspirate and biopsy
How does congenital hypothyroidism cause neonatal jaundice?
by reducing bilirubin conjugation, gut motility, and feeding.
What disorders can present with bleeding problems with normal haematological values?
Connective tissue disorders like Ehler Danlos SYndrome
What are infants of diabetic mothers at greater risk of developing?
NRDS
‘double bubble’ in the abdomen
Duodenal atresia
Unilateral wheeze in a child under three years old is usually associated with
Inhalation of a foreign body until proven otherwise. The latter tend to lodge at the bifurcation of the right main bronchus, as it is more vertical. Foreign body inhalation explains the unilateral wheeze, as the latter results from partial or complete airway obstruction by the foreign body.
What GI condition are those with TUrner’s at risk of?
Pyloric stenosis
bony deformities, blue sclera, teeth, deafness and heart valve abnormalities.
osteogenesis imperfecta
Severely dehydrated children exhibit symptoms of clinical shocks, such as? What do they require?
Decreased consciousness, pale or mottled skin, cold extremities, tachycardia, rapid breathing, low blood pressure, weak peripheral pulses, and prolonged CRT. Children experiencing clinical shock require immediate admission and treatment, including intravenous fluid rehydration and electrolyte supplementation to restore normal fluid balance.
What is impetigo due to? How does it present?
Impetigo is a superficial infection with Staphylococcus or Streptococcus bacteria. It gives fluid-filled blisters or sores that burst to leave a yellow crust.
waiter’s tip position
Erb’s palsy
Management of Erb’s palsy
physiotherapy involvement, and exercises are given to the parents to help strengthen the arm. Erb’s palsy is self-resolving.
How can coarctation of aorta be treated?
surgical repair or balloon angioplasty and/or stenting.
chest X-ray may show rib notching
Aortic coarctation
absent femoral pulses in a cardiac ocnditon, or radiofemoral delay
Aortic coarctation
musty odour of the skin and urine. Examination reveals hypopigmentation and eczema. Genetic testing revealed an autosomal recessive genetic disorder.
Phenylketonuria, due to a defect in phenylalanine hydroxylase
What is Erb’s palsy due to?
trauma to the upper trunk of the brachial plexus
What is tracheoesophagael fistula associated with?
Polyhydramnios in pregnancy
Potential complciations of pavlik harness
Avascular necrosis and temporary femoral nerve palsy
When should CT scan be done in head injuries? If not CT scan then what?
f a child has more than one of the specified features such as loss of consciousness for more than five minutes, abnormal drowsiness, three or more episodes of vomiting, a dangerous mechanism of injury, or amnesia lasting more than five minutes, a CT scan should be done within one hour. If they have only one of these features, observation for a minimum of four hours is recommended.
loss of red reflex on child
Retinoblastoma
Gene and mutation of retinoblastoma
RB1 gene on chromosome 13
Mx of bacterial superinfection of chicken pox
Fluclox and aciclovir both IV
Most common cyanotic heart disease on first day
TGA
Difficult to differentiate between tricuspid atresia, TGA has no murmur. If in doubt put TGA
How tpo differentaite between epididymitis and epididymal-orchitis? Management?
epididymitis. The testicles are not inflamed, and as such, this patient does not have epididymal-orchitis. This typically presents with tenderness and swelling of the scrotum, plus a gradual build-up of pain and fever. Among sexually active men, acute epididymitis is most frequently caused by Chlamydia trachomatis and Neisseria gonorrhoeae. Treatment is a single shot of ceftriaxone 1 g, followed by doxycycline 2 × 100 mg/day for two weeks.
boot shaped heart
ToF
Anatomical features of ToF
right ventricular hypertrophy, right ventricular outflow tract obstruction due to pulmonary stenosis, a ventricular septal defect causing the murmur, and an overriding aorta
An unwell child with an unhealed burn must be treated for?
toxic shock syndrome until proven otherwise. Treatment will require management in the intensive care department with input from a paediatric consultant and the plastic surgery team. Circulatory support with cryoprecipitate may be necessary.
Which is the most common cerebellar neoplasm of childhood?
Cerebellar astrocytoma is one of the commonest brain tumour in the paediatric population. They are classed as a type of glioma as they originate from astrocytes which are a type of glial cells, others being microglia and ependymal cells.
fluid-filled cystic mass that is continuous with the spinal cana
meningocele due to spina bifida
Manifestations of spina bifida and they range in severity
mild, as in spina bifida occulta, to severe, involving the spinal cord and meninges, as in meningomyelocele
What is spina bifida caused by?
failure of the neural tube to close during development, owing to insufficient maternal folate, a vitamin necessary in nucleic acid synthesis
What defect is associated with ToF?
VSD
What do NICE guidelines say to do urgently in children younger than 6 months of age with an atypical UTI? What to do after?
Urgent USS is required during the acute infection, looking for any structural abnormalities in the urinary tract. Once the acute infection has resolved, 4–6 months later, a routine DMSA is performed (looking for a scar in the kidney, renal agenesis or a duplex system) and an MCUG (looking for vesico-ureteric reflux or a posterior urethral valve).
Gene and mutation affected in achondroplasia
autosomal dominant inheritance, fibroblast growth factor receptor (FGFR3)
What mutation and inheritance in Marfan syndrome?
Mutations in the fibrillin-1 gene cause Marfan syndrome, an autosomal dominant connective tissue disorder.
‘egg-on-side’ appearance of the cardiac shadow
Transposition of the great arteries
Biggest complication of untreated ToF
Eisenmenger syndrome
In ventricular septal defect (VSD), there is a shunt of blood from the left ventricle to the right ventricle caused by an opening in the membranous region of the septum (90% of cases). Newborns with a VSD will become cyanotic at a later age when the demand for oxygen increases. It is important to correct the defect because uncorrected VSD can cause compensatory pulmonary vascular hypertrophy, leading to pulmonary hypertension and shunt reversal (right to left shunt, known as Eisenmenger’s syndrome). In turn, pulmonary hypertension will lead to congestive heart failure.
Management of a child who has made a serious attempt at committing suicide
admission and urgent CAMHS assessment for all children who self-harm.
What is infantile hemangioma? How does it present?
benign lesion caused by abnormal blood vessel growth in the skin and deeper tissues. Hemangiomas typically appear shortly after birth, with the highest incidence around the fourth to sixth week of life. They can be superficial (red, raised areas) or affect deeper structures (bluish tinge). Most hemangiomas grow rapidly in the first three months, peak around the fifth month, and then regress.
child with febrile nutropenia indicates what?
Neutropenic sepsis
Management of neutropenic spesis
IV tazocin (covers for pseudomonas)
What renal syndrome does HSP occur alongside?
IgA Vasculitis
Get a rash over buttocks
A six-week-old female is taken to see the General Practitioner. She has been struggling to feed for a few days, seems to be working harder with her breathing and has not gained weight in two weeks. On examination, a parasternal heave and a loud systolic murmur are heard at the lower left sternal border. Dx?
VSD
Mx of acute otitis media with perf
five-day course of oral amoxicillin and a review to ensure healing, which can be done in primary care.
What is the preferred investigative method in caput succadenum?
Cranial US scan
what type of biopsy is needed in Hirchsprung?
Suction assissted full thickness
antispasmolytic used in cerebral palsy
Baclofen
