Paeds 2 Flashcards
At what age would the average child acquire the ability to sit without support?
6-8 months
At what age would the average child start to play alongside, but not interacting with, other children?
2 years
What scan can be done to look for renal scarring in VUR?
DMSA scan
1st line in paeds BLS if there are no signs of breathing on initial assessment?
Give 5 rescue breaths
Follow this with CPR 15:2
At what age would the average child acquire a good pincer grip?
12 months
Describe rash in chickenpox
The rash starts as a macular rash before quickly developing into vesicular lesions which later scab over and heal.
The rash is itchy and associated with constitutional symptoms such as a fever, headache, and general malaise.
Gastroschisis vs omphalocele?
Both are examples of congenital visceral malformations.
Gastroschisis –> refers to a defect lateral to the umbilicus
Omphalocele –> refers to a defect in the umbilicus instead
What can be provided to parents for prophylaxis of febrile seizures? (2)
1) Rectal diazepam
2) Buccal midazolam
In what situations would Abx be indicated in otitis media?
1) >4 days of illness
2) Systemically unwell
3) Perforation of TM
4) Bilateral otitis media ≤2 y/o
Mx of otitis media (if no indications for Abx)?
Supportive
Safetynetting advice –> if temperature rises in the next few days, the child deteriorates, or swelling behind the ear develops.
What are the complications of otitis media?
1) Perforation of TM
2) Mastoiditis
3) Meningitis
What is the most common cause of ambiguous genitalia in newborns?
Congenital adrenal hyperplasia
Head size in fragile X syndrome?
Typically larger than normal
What is a reflex anoxic seizure?
A syncopal episode (or presyncope) that occurs in response to pain or emotional stimuli.
Features of a reflex anoxic seizure?
- child goes very pale
- falls to floor
- 2ary anoxic seizures are common
- rapid recovery
What class of medication is alprostadil?
Prostaglandin E1
Cause of congenital adrenal hyperplasia (CAH)?
Absence of 21-hydroxylase enzyme.
This results in the underproduction of cortisol & aldosterone, and overproduction of androgens.
What is the role of 21-hydroxylase?
Responsible for converting progesterone into aldosterone and cortisol.
Progesterone is also used to create testosterone, but this conversion does NOT rely on the 21-hydroxylase enzyme.
Therefore, because there is extra progesterone floating about that cannot be converted to aldosterone or cortisol, it gets converted to testosterone instead.
How do females with CAH typically present?
Ambiguous genitalia
How do males with CAH typically present?
Salt losing:
- hyponatraemia
- vomiting
- excessive dehydration
- hypotension
- hypoglycaemia
How is a diagnosis of CAH made?
1) Elevated cortisone precursors (17-hydroxyprogsterone)
2) Steroid profile
Mx of early onset vs late onset sepsis?
Early onset –> IV benzylpenicillin + gentamicin
Late onset –> IV flucloxacillin or vancomycin + gentamicin
What is the most common organism causing late onset neonatal sepsis?
Coagulase-negative Staphylococci e.g. Staph. epidermidis
What are 2 ABSOLUTE contraindications to lumbar puncture in neonates?
1) GCS <8
2) Raised ICP e.g. bulging fontanelle
In which condition is there REDUCED functioning of UGT enzyme in liver?
Gilbert’s syndrome
In which condition is there NO functioning of UGT enzyme in liver?
Crigler-Najjar syndrome
Causes of prolonged neonatal jaundice?
1) Biliary atresia
2) Breast feeding jaundice
3) Hypothyroidism
4) Congenital infections e.g. CMV, toxoplasmosis
5) UTI
6) Prematurity
7) Galactosaemia
Which investigation is used to monitor bilirubin levels AFTER starting treatmnet?
Serum bilirubin
What is the 1st line managment option for biliary atresia?
Portoenterostomy (Kasai procedure)
Which investigation is used to monitor bilirubin levels in jaundiced neonates with a gestational age <35 weeks?
Serum bilirubin
What is involved in a Kasai procedure (portoenterostomy)?
Damaged bile ducts outside of liver are removed.
Loop of infant’s small intestine is used to replace the damaged bile ducts.
What happens in phototherapy in the management of neonatal jaundice?
Phototherapy converts unconjugated bilirubin (neurotoxic) into lumirubin (excreted in bile & urine).
What is unconjugated bilirubin converted into in phototherapy?
Lumirubin
Which investigation is used to monitor bilirubin levels in neonates that are jaundiced <24 hours of life?
Serum bilirubin
What is the key complication of neonatal jaundice?
Kernicterus (bilirubin encephalopathy) - unconjungated bilirubin is neurotoxic.
This can lead to cerebral palsy, cognitive impairment & sensorineural hearing loss.
When can phototherapy for neonatal jaundice be stopped?
When bilirubin level is >50 umol/l below the treatment line on the threshold graphs.
When should you check for REBOUND hyperbilirubinaemia after stopping phototherapy?
12-18 hours after stopping phototherapy
What is the gold standard diagnostic method for biliary atresia?
Percutaneous biopsy
When would serum bilirubin be used over transcutaneous bilirubinometry? (3)
1) Jaundice <24h after birth
2) Premature <35 weeks gestation
3) Monitoring bilirubin after treatment
What can be used as adjunct to intensified phototherapy in rhesus haemolytic disease or ABO haemolytic disease?
IV immunoglobulin
How does kernicterus present?
- lethargy
- hypotonia
- poor suck reflex
- seizures
How does biliary atresia present?
1) Prolonged conjugated jaundice
2) Pale stools
3) Dark urine
1st line investigation in jaundice <24h?
Coombs test
When are doses of anti D routinely given?
(2)
1) 28 weeks gestation
2) Within 24 hours after birth
Give 4 endocine or metabolic causes of unconjugated neonatal jaundice
1) Gilbert’s syndrome
2) Crigler-Najjar syndrome
3) Hypothyroidism
4) Galactosaemia
What is GAS also known as?
S. pyogenes
What is GBS also known as?
S. agalactiae
What is the Abx of choice for GBS prophylaxis?
Intrapartum IV benzylpenicillin
How quickly should bilirubin be measured in babies presenting with jaundice <24h after birth?
Urgent - within 2 hours
When would you conisder attempting to delay birth in women <24 weeks gestation?
1) Previous hitory of preterm birth
2) US demonstrating cervical lenght of ≤25mm
What are 2 options for delaying preterm birth in gestational age <24 weeks?
1) Prophylactic vaginal progesterone
2) Prophylactic cervical cerclage
At what gestation age should resuscitation not be performed in premature babies?
<23 weeks
What age gestation does RoP typically present?
<32 weeks gestation
What is a key risk factor for triggering retinopathy of prematurity?
High flow oxygen in premature infants
What length defines a short cervix on US?
<25mm before 24 weeks of pregnancy
Under what 2 circumstances would babies be screened for RoP?
1) Born <31 weeks gestation
2) Birth weight <1.5kg
What are the 2 mainstays of management of RoP?
1) Transpupillary laster photocoagulation
2) Anti-VEGF
Define tocolysis
Medications used to PREVENT premature labour
What is the role of nifedipine in premature labour?
Tocolytic
What are the 3 key complications of RoP?
1) Infections
2) Cataracts
3) Retinal detachment
What are 2 key risk factors for NEC?
1) Prematurity
2) Low birth weight
Role of laser therapy in the management of RoP?
This burning process prevents abnormal blood vessel proliferation.
What is the most common surgical emergency in neonates?
Necrotising enterocolitis (NEC)
What is NEC?
Inflammation & death of the bowel tissue –> perforation, peritonitis & shock.
What will U&Es show in NEC?
Hyponatraemia
What is the difference between pneumatosis intestinalis and pneumoperitoneum?
Pneumatosis intestinalis –> describes abnormal intramural gas of the digestive tract.
Pneumoperitoneum –> refers to the presence of gas in the peritoneal cavity, out of the digestive tract.
Define apnoea
Periods where breathing stops spontaneously for more than 20 seconds, or shorter periods with oxygen desaturation or bradycardia.
What criteria is used to stage NEC?
Bell’s staging criteria
What can be used to prevent apnoea and bradycardia in babies with recurrent episodes of apnoea of prematurity?
IV caffeine
AXR features in NEC?
1) Distended bowel loops
2) Thickened bowel wall (oedema)
3) Intramural gas (pneumatosis intestinalis)
4) Pneumoperitoneum: in the later stages due to bowel perforation
5) Gas in portal vein
What is retinal blood vessel development stimulated by?
Hypoxia (which is a normal condition in the retina during pregnancy).
At what age would the average child acquire the ability to walk unsupported?
13-15 months
Age of presentation of NEC vs intussusception?
NEC –> 2nd to 3rd week of life
Intussusception –> 5m to 12m
What is included in the 6 in 1 vaccine?
1) diptheria
2) tetanus
3) polio
4) pertussis
5) Hib
6) hepatitis B
What are the 2 most serious long-term health problems for women with Turner’s syndrome?
1) aortic dilatation
2) aortic dissection
Which organism is responsible for causing scarlet fever?
GAS
What triad is seen in shaken baby syndrome?
1) retinalhaemorrhages
2) subdural haematoma (due to shearing of bridging veins)
3) encephalopathy
When do all breech babies require USS for DDH?
At 6 weeks (regardless of mode of delivery)
What is the most likely cause of worsening neurological function in a premature infant born at 34 weeks gestation?
Intraventricular haemorrhage
What occurs in intraventricular haemorrhage?
There is bleeding into the ventricular system of the brain.
This is more common in premature infants due to fragility of their blood vessels.
This can lead to: hydrocephalus, cerebral palsy, and developmental delays.
Give some causes of obesity in childhood
1) Lifestyle
2) GH deficiency
3) Hypothyroidism
4) Down’s syndrome
5) Cushing’s syndrome
6) Prader-Willi syndrome
Between what ages do febrile convulsions typically occur?
6 months to 5 years
What is roseola infantum caused by?
HHV-6
At what age would the average child acquire the ability to crawl?
9 months
What is a complication of roseola infantum?
Febrile convulsion
What is considered 1st line pharmacological mx of enuresis?
Desmopressin
How does roseola infantum typically present?
High fever followed by maculopapular rash.
When should a child with suspected UTI be referred to specialist paediatrics services?
<3 months
Mx of scarlet fever?
10 days of oral penicillin V
Is the corrected gestational age taken into consideration when looking at milestones?
Yes - until the age of 2
What is the corrected age of a premature baby?
The age minus the number of weeks he/she was born early from 40 weeks.
What is the normal age at which a child should show a responsive smile?
6-8 weeks
What is the most common heart lesion associated with Duchenne muscular dystrophy?
Dilated cardiomyopathy
how long should a child with whooping cough/pertussis be excluded from school for following commencement of Abx?
48h
Describe the Barlow manouevre
attempted dislocation of a newborns femoral head
What is a poor prognostic factor for congenital diaphragmatic hernia?
The presence of the liver in the thoracic cavity
Which best describes the typical distribution of atopic eczema in a 10-month-old child?
Face & trunk –> infants
When do children require screening for DDH?
If breech position at ≥36 weeks gestation or delivery (if earlier) –> require US scans to screen for DDH.
Define small for gestational age in infants
<10th centile
Define large for gestational age in infants
> 90th centile
Define appropriate weight for gestational age in infants
10th - 90th centile
If a baby is small in NIPE, what should you perform?
Head circumference (see if weight is disproportionately low)
What is asymmetrical growth restriction (i.e. low weight, normal head) commonly due to?
Placental insufficiency
What is symmetrical growth restriction (i.e. small head and weight) commonly due to?
Fetal factors such as genetic abnormalities or intrauterine infection.
How are hypotonic infants often described as feeling?
Like a ‘rag doll’ due to floppiness.
Why do hypotonic infants often have difficulty feeding?
As their mouth muscles cannot maintain a proper suck-swallow pattern or a good breastfeeding latch.
What congenital condition is hypotonia common in?
Down’s syndrome
What is caput succedaneum?
A diffuse subcutaneous fluid collection with poorly defined margins (often crossing suture lines) caused by pressure on the presenting part of the head during delivery.
It does not usually cause complications and resolves over the first few days.
What may a bulging fontenelle suggest?
Raised ICP e.g. hydrocephalus
Meningitis
What may a sunken fontenelle suggest?
Dehydration
Give 3 examples of facial birthmarks
1) Salmon patch
2) Haemangioma
3) Port-wine stain
What are some causes of an absesnt fundal reflex in neonates? (3)
1) retinal detachment
2) vitreous haemorrhage
3) retinoblastoma
An absent fundal reflex or the presence of a white reflex requires immediate ophthalmology referral.
What is a cystic hygroma?
A congenital lymphatic lesion which is typically identified prenatally or at birth.
A cystic hygroma can arise anywhere but typically develops in the left POSTERIOR triangle of the neck.
Cystic hygromas are benign but can be disfiguring and typically require surgical treatment including drainage and use of sclerosing agents to prevent reaccumulation of lymphatic fluid.
Mx of 2ary bleeding post-tonsillectomy? (i.e. 5-10 days later)
1) ENT referral
2) Admit & Abx
What are 3 key complications of mastoiditis?
1) meningitis
2) hearing loss
3) facial nerve palsy
What does unilateral glue ear in an adult need to be investigated for?
Posterior nasal space tumour
What vaccine can help protect against otitis media?
Pneumococcal
What 2 conditions can predispose to otitis media?
1) CF
2) PCD / Kartagener’s syndrome
Due to affecting ciliary motility
What age is OM typically seen?
<4 y/o
What is the most common cause of hearing impairment in children?
Otitis media with effusion
How long must OM be present for to support a diagnosis of ‘chronic’?
3 months
Where does infection come from in OM?
Back of the throat and through the eustachian tube
How can OM be categorised? (2)
Duration: acute or chronic
Presence of effusion or not
Management of acute OM with perforation?
Oral amoxicillin for 5-7 days
What are the 2 most common organisms causing OM?
1) Strep. pneumoniae
2) Hib (reducing due to vaccine)
Chronic suppurative OM vs chronic OM with effusion?
Suppurative –> leakage of fluid from PERFORATED tympanic membrane
Effusion –> build up of fluid behind an INTACT tympanic membrane
What EXTRINSIC factors can predispose to otitis media?
1) passive smoking
2) not receiving pneumococcal vaccine
3) bottle feeding
4) daycare
How can bottle feeding increase the risk of otitis media?
1) The strong swallow required to feed from a BREAST induces a sizeable negative pressure in the infants oral cavity allowing eustachian tube insufflation.
2) Breast milk provides maternal antibodies against common OM pathogens
When should admission be considered in OM?
Fever >38 degrees in children <3 months
or
Fever >39 degrees in children 3-6 months
What does a flat waveform finding on tympanometry indicate?
Perforated TM or fluid in middle ear
What 2 congenital abnormalities would you refer to 2ary care in chronic OM with glue ear?
1) Down’s syndrome
2) Cleft palate
What hearing investigation is indicated in glue ear?
Pure tone audiometry
What are the most common pathogen causing OM/mastoiditis in young children prior to vaccination?
HiB
What is mastoiditis usually the result of?
OM
What is a bacterial infection of the middle ear often preceded by?
Viral URTI
Perforations in what area of TM are more likely to lead to mastoiditis?
Upper portion of drum
What pathogen can cause OM or mastoiditis in diabetics?
Pseudomonas aeruginosa
Abx of choice in mastoiditis?
1st line –> cephalosporins e.g. ceftriaxone
Which groups is it recommended to prescribe Abx in OM?
1) Children <2 y/o with bilateral OM
2) Children <3m with temp >38
3) OM with ear discharge
4) Systemically unwell
5) High risk of complications or immunosuppressed
1st line Abx in OM?
Amoxicillin
(erythromycin or clarithromycin in allergy)
What is the most common cause of bacterial tonsillitis?
GAS (S. pyogenes)
What are some risk factors for chronic suppurative OM?
- pollution
- poor hygiene
What branch of the facial nerve runs through the middle ear?
Corda tympani branch of facial nerve
What is the most common virus causing tonsillitis?
Rhinovirus
What investigation is useful as an aid for the diagnosis of middle ear conditions?
Tympanometry
What Abx is indicated in tonsillitis caused by group A streptococcus (Streptococcus pyogenes)?
Penicillin V (phenoxymethylpenicillin)
What FeverPAIN score would you consider prescribing Abx in tonsillitis? What Centor score?
FeverPAIN ≥4
Centor ≥3
Under what circumstances should Abx be prescribed immediately in acute OM?
1) Symptoms for 4 or more days / not improving
2) Systemically unwell (but not requiring admission)
3) Immunocompromised
4) <2 y/o with bilateral OM
5) OM with perforation and/or discharge
What are the NICE indications for Abx in tonsillitis?
1) features of marked systemic upset 2ary to the acute sore throat
2) unilateral peritonsillitis
3) history of rheumatic fever
4) an increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency)
5) 3 or more Centor criteria are present
1st line Abx in tonsillitis in penicillin allergy?
Clarithromycin
A history of what condition indicates the need for Abx in tonsillitis?
Rheumatic fever
Choice of Abx in quinsy?
Usually co-amoxiclav (broad spectrum)
When it is indicated, what test is used for the confirmation of GAS infection in tonsillitis?
1) Rapid antigen test for GAS
2) If negative –> throat culture
Active observation of children with OM with effusion is appropriate for how long?
6-12 weeks (as spontaneous resolution is common)
Mx of quinsy?
IV Abx and surgical drainage (and consideration of a tonsillectomy in 6 weeks)
What is the usual post-exposure prophylaxis against meningococcal infection?
Ciprofloxacin (single dose)
Patients with meningococcal meningitis are at risk of Waterhouse-Friderichsen syndrome.
What is this?
Failure of adrenals
What should be added to drug treatment of bacterial meningitis if there is a risk of penicillin-resistant pneumococcal infection (e.g. recent foreign travel or prolonged antibiotic exposure)?
Vancoymycin
Which types of meningitis are notifiable diseases to the UK Health Security Agency?
(2)
1) bacterial meningitis
2) meningococcal infection
When are pregnant women advised to have the whooping cough (pertussis) vaccine?
Between 16-32 weeks gestation
What are 2 options for prophylaxis for contacts of patients with meningococcal meningitis?
1) ciprofloxacin
2) rifampicin
both oral
What CSF result is indicative of Guillain Barre syndrome?
Isolated result of high protein in the CSF
What can parvovirus B19 infection in patients with a background of haemolytic anaemia (e.g. sickle cell) cause?
Aplastic anaemia
What is aplastic anaemia?
A deficiency of all types of blood cell caused by failure of bone marrow development.
An US should be organised when there are signs of an atypical UTI in infants under 6 months.
What are some features of an 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.
What may urinary problems in a man with a history of gonorrhoea be due to?
A urinary stricture
What nerve root is implicated in Horner’s syndrome?
T1
What nerve roots are affected in Erb’s palsy?
C5 & C6
What nerve roots are affected in Klumpke’s palsy?
C8 & T1
What is the main complication of a fractured clavicle at birth?
Injury to the brachial plexus with a subsequent nerve palsy.
What is key in mx of HIE?
Therapeutic cooling
CXR findings in neonate RDS?
Ground glass appearance
What are some causes of HIE?
(4)
1) Maternal shock
2) Intrapartum haemorrhage
3) Nuchal cord
4) Prolapsed cord
What support may premature neonates need to reduce RDS?
(4)
1) Intubation & ventilation
2) CPAP (keep lungs inflated whilst breathing)
3) Endotracheal surfactant
4) O2 (91-95% aim)
What are oxygen targets in preterm infants?
91-95%
Effect of meconium on surfactant?
Meconium inhibits surfactant
What is the key respiratory complication of MAS?
Respiratory distress
What Apgras score indicates the need for additional monitoring after birth?
≤8
What are 2 key risk factors for MAS?
1) Foetal hypoxia
2) Post-term
How can foetal hypoxia cause MAS?
Foetal hypoxia can stimulate colonic activity –> results in passage of meconium.
When is the Apgar score assessed?
1 and 5 minutes of age
Repeated at 10 mins if low score
What does the Apgar scores indicate?
0-3: very low (bad)
4-6: moderately low
7-10: good
What makes up the Apgar score?
Appearance (colour):
- pink all over (2)
- pink body, blue extremities (1)
- blue all over (0)
Pulse:
- >100 (2)
- <100 (1)
- absent (0)
Grimace (reflex irritability):
- crying on stimulation, sneezes, coughs (2)
- grimace (1)
- nil (0)
Activity (muscle tone):
- active movement (2)
- limb flexion (1)
- flaccid (0)
Respiratory effort:
- strong, regular cry (2)
- weak irregular (1)
- nil (0)
Management of MAS?
1) Supportive e.g O2, ventilation
2) Surfactant therapy
3) Abx
How long are babies kept in hospital for after birth if mothers were taking SSRIs?
48h
How long are babies kept in hospital for after birth if mothers were taking opiates?
72h
What is the medical treatment option for moderate to severe symptoms for opiate withdrawal in neonates?
Oral morphine sulphate
What is the medical treatment option for moderate to severe symptoms for non-opiate withdrawal?
Oral phenobarbitone
