Paeds 3 - Allergy/Neonates/Development etc Flashcards
what is impetigo?
highly infectious skin infection - common on face in infants and young children, esp in eczema etc.
caused by staph aureus - rarely can be caused by strep infection
what are the clinical features of impetigo?
erythematous macules develop into honey-crusted lesions.
how is impetigo treated?
topical antibiotics if only mild e.g. mupirocin
if more severe - fluclozacillin.
nasal carriage can cause reinfection - nasal cream containing chlorhexidine and neomycin can be used to eradicate.
what is infantile seborrhoeic eczema and how is it treated?
cradle cap - scaly, non-itchy rash on scalp, might spread.
treatment - emollients and mild topical steroids.
what is atopy?
predisposition to atopic disorders - eczema, asthma and hay fever.
genetic, confers abnormal immune response to environmental allergens. often a lot of FHx.
what are the clinical features of eczema?
dry, red, itchy rash - usually on extensor surfaces and face in infants and young children, and the flexures (inner elbow, back of knees) in older kids.
how is eczema managed?
need to hydrate skin and minimise inflammation.
- general measures - cotton clothing, non-biologic detergents, no parental smoking, pets etc
- emollients - 2-3 times a day, replace soap with aqueous cream.
- mild topical steroid - 1% hydrocortisone ointment/cream applied to affected areas twice daily - highly effective to get under control, then focus on emollients.
- new class - topical immunomodulators e.g. tacrolimus cream
what is Stevens-Johnson syndrome?
widespread erythema multiforme (target lesions ± macules/papules/bullae), often painful. often a drug reaction or infection (herpes simplex, mycoplasma, EBV).
supportive management, pain relief, may need ICU.
what is allergic rhinitis?
hay-fever! also dust, pet allergies. 20% of children will have it.
IgE mediated inflammation from allergen exposure to nasal mucosa - release of inflammatory mediatory from mast cells.
what are the symptoms of allergic rhinitis?
sneezing, pruritus, nasal discharge (bilateral), itchy red eyes.
how do you manage a patient with allergic rhinitis?
allergen avoidance.
antihistamines e.g. loratidine, cetirizine.
intranasal corticosteroid sprays e.g. fluticasone.
describe the pathology behind anaphylaxis
severe allergic reaction with respiratory difficulty (wheeze/obstruction) and/or cardiovascular symptoms (shock, hypotension, dizziness).
prior exposure to antigen-sensitising mast cells and basophils –> systemic release of inflammatory mediators –> capillary leak, mucosal oedema, smooth muscle contraction.
mediated by IgE.
common allergens - food (peanuts), insect venom (rare), latex, drugs (penicillin, vaccines - rare)
what are the symptoms/signs of anaphylaxis?
resp - cough, stridor, hoarseness, facial swelling, wheeze
cario - faint, dizziness, syncope, pallor, tachycardia
may also see uritcaria, GI signs etc - these aren’t as life threatening.
describe the management of an anaphylactic reaction
IM adrenaline 150/300/500 micrograms depending on age.
follow with IV or oral steroids and antihistamine - helps prevent protracted reaction.
what is urticaria?
transient, itchy, erythematous rash - raised welts (hives).
induced by mast cell degranulation - histamines etc released causing vasodilation and increased capillary permeability.
mostly due to viral infections, might be an allergy thing.
what is angioedema?
swelling of lips and eyes that sometimes accompanies utricaria
if lips are involve - emergency, tongue may get involved and then there’s a risk of respiratory obstruction.
how do you manage urticaria/angioedema?
urticaria - should resolve spontaneously, give antihistamine if itchy, avoid precipitating factors.
angioedema - go to hospital, ABCDE.
what is Henoch-Schonlein purpura?
multisystem vasculitis of small blood vessels.
follow UTRI or exposure to drug or allergen.
think it’s immune-mediated - IgA.
what are the clinical features of HSP?
skin - purpuric rash of legs and buttocks
GI - colicky abdo pain ± gross/occult bleeding
joints - pain and swelling of large joints
kidneys - glomerulonephritis - microscopic haematuria
how is HSP diagnosed and managed?
clinical diagnosis.
Rx - symptomatic/supportive. recover in 4-6 weeks.
what is achondroplasia?
autosomal dominant disorder - short limbs, large head, abnormal neurology.
gene on chromosome 4, fibroblast growth receptor gene (FGFR3).
what is Fragile X syndrome?
X linked disorder typically involving severe learning impairment, more common in males, associated with autism.
physical features - dysmorphic facial appearance (large forehead, long face, large prominent ears), macrocephaly, macro-orchidism.
briefly explain the genetics of Downs syndrome?
trisomy 21 - extra chromosome can come from non-dysjunction (the chromosome 21 pair fails to separate at meiosis, so one gamete has two copies), translocation or mosaicism (occurs during mitosis after formation of zygote, so some cells might be normal, may have milder phenotype).
risk increases with maternal age.
what are the clinical features of Down syndrome?
dysmorphic facial features - round face, epicanthis folds, flat nasal bridge, protruding tongue, small ears, Brushfield spots on iris.
other dysmorphic features - single palmar creases, flat occiput, incurved little fingers, sandal toe gap, small stature.
structural defects - cardiac defects, duodenal atresia.
neurology - hypotonia, developmental delay, mean IQ = 50
how is Down syndrome diagnosed and managed?
nuchal translucency on antenatal US.
chromosome analysis, FISH is faster.
support and education for parents.
what are the genetics in Turner syndrome?
only 1 normal X chromosome.
affects 1 in 2500 live born females.
might have 45, XO
or deletion of short arm of one X chromosome
some have mosaicism.
what are the clinical features of Turner syndrome?
hallmarks - short stature + primary amenorrhoea.
normal intelligence, specific learning difficulties.
dysmorphic features - neck webbing, widely spaced nipples (shield chest), wide carrying angle, short stature.
structural/functional - gonadal dysgenesis, congenital heart disease, renal anomalies
how is Turner’s syndrome identified/diagnosed?
prenatally on USS.
at birth - presence of puffy hands and feet.
in childhood - short stature
in adolescence - primary amenorrhoea.
diagnosis confirmed by peripheral blood karyotype.
how is Turner’s syndrome managed?
GH therapy improves final height.
oestrogen therapy at c.11 years to promote secondary sex characteristics.
towards end of puberty, progestogen added to maintain uterine health
what is Klinefelter’s syndrome?
47, XXY - males born with two X chromosomes.
primary features - infertility, small testicles.
lack of hair/general secondary sex characteristics, very tall and slim, gynaecomastia, learning disability.
what is Edwards syndrome?
trisomy 18 (full, mosaic, or partial).
usually picked up in antenatal screening - nuchal translucency thickness/hypolasia of nasal bone.
risk rises with maternal age.
facial dysmorphisms - Low-set and malformed ears, Micrognathia (small jaw), Prominent occiput, Small facial features, Microcephaly, Cleft lip and palate
other dysmorphic features - overriding fourth/fifth finger., rocker bottom feet, thumb aplasia.
congenital heart defects, GI/kidney abnormalities.
what is Patau’s syndrome?
trisomy 13.
often incompatible with life.
severe brain and CNS abnormalities.
mean life expectancy is 2.5 days.
what is Angelman’s syndrome?
genetic disorder featuring happy demeanour, easily provoked laughter, developmental delay from 6 months. often epileptic.
Chromosome 15
what is Prader Willi syndrome?
result of genetic imprinting.
hypotonia and developmental delay in infancy. obesity, LD and behavioural issues in childhood. narrow face, almond shaped eyes. hypogonadism. cryptorchidism.
chromosome 15
describe the normal gross motor development you’d see in a newborn baby?
limbs flexed, symmetrical posture.
marked head lag on pulling up.
at what age would you expect a baby to raise their head to 45 degrees whilst prone (look up whilst lying on front)?
6-8 weeks
at what age would you expect a baby to sit without support?
6-8 months.
with rounded back at 6 months.
with straight back at 8 months.
at what age would you expect a baby to start crawling?
8-9 months.
at what age would you expect a baby to start furniture cruising?
10 months.
at what age would you expect a baby to start walking (unsteadily)?
12 months.
at what age would you expect a child to start walking steadily?
15 months.
at what age would you expect a child to start running?
2 years.
at what age would you expect a child to start jumping / hopping / be able to do heel to toe?
3 / 4 / 5 years
at what age would you expect a child to be able to follow a moving object/face by turning their head?
6 weeks
at what age would you expect a child to be able to reach out for toys?
4 months
at what age would you expect a child to use a palmar grasp?
4-6 months
at what age would you expect a child to be able to transfer toys from one hand to another?
7 months
at what age would you expect a child to have a mature pincer grip?
10 months
at what age would you expect a child to be able to make marks with a crayon?
16-18 months
at what age would you expect a child to be able to build towers of: 3, 6, 8 blocks, a bridge, a set of steps?
3 blocks - 18 months 6 blocks - 2 years 8 blocks - 2.5 years bridge - 3 years steps - 4 years
at what age would you expect a child to be able to draw a: line, circle, cross, square, triangle/6 part person?
line - 2.5 years circle - 3 years cross - 3.5 years square - 4 years triangle/6 part person - 5 years
at what age would you expect a child to startle to loud noise?
newborn
at what age would you expect a child to vocalise alone/when spoken to, coos, laughs?
3-4 months
at what age would you expect a child to turn to soft sounds out of sight?
7 months
at what age would you expect a child to say dada/mama?
7-10 months
at 7 months - just saying them to make sounds
10 months - saying them to mean the parents
at what age would you expect a child to be able to say 2 or 3 words, other than mama/dada?
12 months
at what age would you expect a child to know 6-10 words, and show you 2 parts of the body?
18 months
at what age would you expect a child to use 2+ words to make simple phrases e.g. give me teddy, want more
18 months
at what age would you expect a child to talk constantly in 3-4 word sentences?
2.5-3 years
at what age would you expect a child to smile?
6 weeks
at what age would you expect a child to put food to mouth?
6-8 months
at what age would you expect a child to wave bye bye, play peek-a-boo?
10-12 months
at what age would you expect a child to drink from a cup with 2 hands?
12 months
at what age would you expect a child to hold a spoon and get food safely to mouth?
18 months
at what age would you expect a child to engage in symbolic play e.g. makes mummy a cup of tea?
18-24 months
at what age would you expect a child to be dry by day, able to take off some clothing?
2 years
at what age would you expect a child to engage in parallel play, take turns, start interactive play?
2.5-3 years
at what age would you expect a child to be able to put on a t shirt?
3 years
at what age would you expect a child to be able to dress independently?
4 years
what are the key limit ages to know for gross motor development?
head control - 4 months
sits unsupported - 9 months
stands independently - 12 months
walks independently - 18 months
what are the key limit ages to know for vision and fine motor development?
fixes and follows visually - 3 months
reaches for objects - 6 months
transfers - 9 months
pincer grip - 12 months
what are the key limit ages to know for hearing, speech and language development?
polysyllabic babble - 7 months consonant babble - 10 months says 6 words with meaning - 18 months joins words - 2 years 3 word sentences - 2.5 years
what are the key limit ages to know for social behaviour development?
smiles - 8 weeks fear of strangers - 10 months feeds self with a spoon - 18 months symbolic play - 2-2.5 years interactive play - 3-3.5 years
what immunisations are given at 8 weeks old?
diphtheria/tetanus/pertussis/polio/Hib/hep B
pneumococcal (PCV)
menB
rotavirus
what immunisations are given at 12 weeks old?
diphtheria/tetanus/pertussis/polio/Hib/hep B
rotavirus
what immunisations are given at 16 weeks old?
diphtheria/tetanus/pertussis/polio/Hib/hep B
PCV
MenB
what immunisations are given at 1 year old?
Hib and MenC
PCV
MMR
MenB booster
what immunisations are given at 3y 4m (preschool)?
diphtheria/tetanus/pertussis/polio
MMR
what immunisations are given to girls aged 12-13?
HPV - two doses 6-24 months apart
what immunisations are given at 14 years old?
tetanus/diphtheria/polio
MenACWY
when should the Apgar score be used?
typically at 1 and 5 minutes after birth
what are the 5 components of the Apgar score?
heart rate (absent / 100bpm / >100bpm) respiratory effort (absent or weak / irregular or gasping / normal) muscle tone (limp / some flexion / active movements) reflex response to stimulation (none / weak / cries) colour (blue or pale / extremities blue / pink)
each scores either 0, 1 or 2
what is the first step in neonatal resus?
dry the infant, call for help, keep warm
assess breathing/heart rate/colour/tone
describe the steps involved in neonatal resus if you have dried and assessed the infant and discover their breathing is still poor
- stimulate baby, open and clear airway, bag and mask ventilation (5 inflation breaths)
no improvement? - check HR, if >60 continue ventilation, consider intubating
if HR <60bpm - start CPR - 3 compressions to 1 breath, for 30 sec
if still not working - gonna need help, consider adrenaline IV via umbilical venous catheter or IO.
what is hypoxic-ischaemic encephalopathy?
the manifestations of the brain damage done by birth asphyxia
what is perinatal/birth asphyxia and what does it lead to?
gas exchanged is somehow compromised/stops altogether (either placental or pulmonary) –> cardiorespiratory depression –> hypoxia, hypercarbia, metabolic acidosis –> decreased cardiac output, decreased tissue perfusion –> hypoxic-ischaemia injury to brain and other organs
leads to hypoxic-ischaemic encephalopathy - disability or death.
what can cause birth asphyxia?
- failure of gas exchange across placenta = excessive/prolonged uterine contractions, placental abruption, ruptured uterus
- interruption of umbilical cord flow = cord compression, including shoulder dystocia, cord prolapse
- inadequate maternal placental perfusion, maternal hypo-/hypertension
- compromised foetus = anaemia, IUGR
- failure of cardiorespiratory adaptation at birth i.e. failure to start first breaths
what clinical features might you see in an infant with hypoxic-ischaemic encephalopathy?
usually appear at around 48 hours.
mild = irritable, staring of eyes, hyperventilation, impaired feeding
moderate = abnormal tone/movement, cannot feed, might have seizures
severe = no normal spontaneous movements or response to pain, fluctuating tone, prolonged/refractory seizures, multi-organ failure
how can you treat hypoxic-ischaemic encephalopathy?
damage is irreversible - skilled resus vital to minimise the damage occurring in the first place!
be worried about birth asphyxia if - “fetal distress” (abnormal fetal HR/decelerations), acidosis (seen on fetal scalp blood), meconium staining of liquor (asphyxiated infant passes meconium!)
what are the most common vertically-transmitted infections causing congenital abnormalities?
TORCH infections! T - toxoplasmosis O - other (syphilIs, VZV, parvovirus B19) R - rubella C - cytomegalovirus H - herpes
what clinical features might you see in a newborn affected by maternal varicella zoster infection?
if infected in first trimester: cicatricial skin lesions (scars) malformed digits cataracts CNS damage, chorioretinitis
issue is more when the woman is infected late in pregnancy, especially if within 5 days before and 2 days after birth - fetus has high viral load but no maternal antibodies - severe infection, may die.
how do you reduce the risks associated with maternal chickenpox infection?
exposed susceptible women can be given varicella zoster immunoglobulin (VZIG) and aciclovir.
can also treat infants with VZIG if exposed.
if lesion develop in the newborn can give VZIG.
what are the clinical features associated with a severe congenital cytomegalovirus infection?
- IUGR
- hepatosplenomegaly, jaundice, purpura
- microcephaly, chorioretinitis
- sensorineuronal hearing loss
- other long term issues - epilepsy, CP, LD
what are the features of neonatal herpes?
transmitted from genital tract of mum who’s often asymptomatic.
high mortality/morbidity.
generalised infection with pneumonia, hepatitis and encephalitis within first week of life.
Rx - high dose IV aciclovir.
if mum has active genital herpes when she goes into labour, can be indication for an elective C section.
what are the features associated with maternal parvovirus B19 infection?
transmitted to fetus, and causes hydrops fetalis (due to fetal anaemia and myocarditis), fetal death or spontaneous abortion
what are the clinical manifestations of congenital toxoplasmosis?
often asymptomatic (at birth at least). hydrocephalus intracranial calcification chorioretinitis neurological damange
what is meconium aspiration?
passing meconium into amniotic fluid is triggered by foetal distress in term/post-term infants.
infant might then inhale it –> respiratory distress, cyanosis, high mortality rate.
what can you at the point of delivery to reduce the risk associated with meconium aspiration syndrome?
suctioning the meconium from upper airway as soon as head is delivered –> then suction from trachea under direct vision after delivery
but really the severe cases where babies die are mostly due to in utero aspiration so suctioning doesn’t help too much.
what is bronchopulmonary dysplasia?
‘chronic lung disease of prematurity’ - requiring supplemental oxygen beyond 36 weeks gestation/28 days age (whichever is later)
when does bronchopulmonary dysplasia occur?
in newborns who require prolonged assisted ventilation with high pressures and high concentrations of oxygen.
common in VLBW infants and positive pressure ventilation
caused by volutrauma and barotrauma, leading to an inflammatory reaction
CXR shows widespread opacities with patchy translucent areas
how do you manage an infant with bronchopulmonary dysplasia?
- initial continued need for assisted ventilation/supplemental O2/continuous positive airways pressure
- dexamethasone helps weaning off ventilation but can cause neurodevelopmental problems so only used if severe
- pay attention to nutrition
basically I think you just have to wean them off slowly??
what are the characteristic features of respiratory distress in term infants?
tachypnoea
cyanosis
nasal flaring and recession
expiratory grunting
what are the pulmonary and non-pulmonary causes of respiratory distress in a term infant?
pulmonary: transient tachypnoea of the newborn pneumonia pneumothorax meconium aspiration persistent fetal circulation milk aspiration diaphragmatic hernia
non-pulmonary:
congenital heart disease
severe anaemia
metabolic acidosis
define pre vs post term?
preterm = <37 completed weeks post-term = >42 completed weeks
what is respiratory distress syndrome?
aka hyaline membrane disease, surfactant deficiency
premature infant has a deficiency of surfactant (immaturity of type II alveolar cells).
surfactant = lipoprotein that reduces surface tension in alveoli and prevents their collapse during expiration.
deficiency –> alveolar collapse and inadequate gas exchange.
uncommon in term infants but will occur in most born <30 weeks gestation.
what can you do to prevent / treat respiratory distress syndrome?
if preterm birth expected, give mother antenatal glucocorticoids to stimulate foetal surfactant production.
if haven’t had chance to do this then effective resus at birth is vital.
then:
- surfactant therapy - derived from calf/pig lung, given into lung via tracheal tube
- oxygen
- assisted ventilation (CPAP)
should resolve in 3-7 days but complications can persist
list some potential complications of surfactant deficiency
pulmonary: pneumothorax, interstitial emphysema, secondary infection, chronic lung disease
non-pulmonary: intraventricular haemorrhage, PDA
what are apnoeic attacks?
very small preterm infants have episodes of very shallow breathing/cessation of breathing
can be associate with bradycardia and desaturations
gentle physical stimulation should start breathing again, can be prevented with oral caffeine if they’re frequent, CPAP if they’re severe
what cardiac issue commonly affects preterm infants?
patent ductus arteriosus - can be associated with respiratory distress syndrome.
failure of closure due to gestation immaturity and hypoxia.
usually closes itself, but if ventilated/cardiac failure occurs then treat with a prostaglandin inhibitor (indomethacin or ibuprofen) to encourage closing.
what is necrotizing entercolitis?
NEC - necrosis of intestine, usually involves distal ileum or proximal colon. possibly due to bacterial invasion.
list some factors that predispose an infant to NEC
preterm birth polycythaemia PDA asphyxia early oral feeding with formula (early breastfeeding is protective)
what are the clinical features that might suggest NEC?
stops feeding, possible vomiting ± bile staining, distended abdomen, fresh blood in the stools - can progress to perforation
what are the features of NEC on an XR?
?distended loops of bowel and thickening of bowel wall, with intramural gas
how do you manage an infant with NEC?
stop oral feeds ± aspirate stomach broad-spectrum abx e.g. penicillin, gentamicin, metronidazole parenteral nutrition cardioresp support surgery if bowel perforates
if a baby appears jaundice at <24 hours old, is this likely to be physiological or pathological?
ALWAYS pathological.
usually haemolysis causing it - either haemolytic disease of the newborn or an intrinsic red cell defect (spherocytosis, G6PD deficiency etc)
can be due to congenital infection
list some causes of jaundice in a newborn between 24h and 2 weeks old
*physiological* breast milk jaundice infection e.g. UTI haemolysis (as for <24 hours) bruising polycythaemia Crigler-Najjar
what is physiological jaundice?
common cause of jaundice in the 2 days –> 2 weeks age.
peaks on 3rd day of life.
associated with unconjugated hyperbilirubinaemia
if a baby is jaundiced and has conjugated hyperbilirubinaemia, what does this suggest is the cause?
usually cholestasis due to hepatobiliary disease
list some causes of jaundice in a baby over 2 weeks old
unconjugated - physiological or breast milk jaundice, infection, hypothyroidism, haemolytic anaemia, high GI obstruction (e.g. pyloric stenosis)
conjugated - bile duct obstruction (e.g. biliary atresia), neonatal hepatitis
what is the main worry when a baby is jaundiced?
you need to prevent bilirubin encephalopathy (aka kernicterus) - occurs when unconjugated bilirubin is deposited on brain (esp. basal ganglia and cerebellum).
presents with lethargy, rigidity, eye-rolling and seizures - can lead to cerebral palsy, sensorineural deafness and LDs.
how do you manage a baby that appears jaundiced?
ensure adequate milk intake/hydration
needs a plasma bilirubin really - plot on chart to establish when to treat.
phototherapy - blue light converts bilirubin in skin/superficial capillaries into harmless water-soluble substances that are wee-d out. cover the eyes, give extra fluids.
exchange transfusion - if levels keep rising dangerously despite phototherapy.
why do babies get physiological jaundice?
increased red blood cell breakdown after birth (have loads of Hb in utero and now don’t need as much)
immature liver - can’t handle all that work
NB - can progress to pathological so still keep an eye on it (e.g. if prem, or excessive bruising like in an instrumental delivery)
what is early onset neonatal infection/sepsis and what causes it?
occurs <48h after birth.
bacteria have ascended from birth canal and invaded the amniotic fluid.
foetus secondarily infected because the foetal lungs are in indirect contact with infected amniotic fluid.
get a pneumonia and secondary bacteraemia/sepsis
how do you manage an infant with early onset neonatal infection?
immediate IV abx - benpen and gentamicin
give some risk factors for hypoglycaemia in the first 24h of life
IUGR or prematurity - these babies have lower glycogen stores
maternal DM - these babies have plenty of glycogen but hyperplasia of islet cells so lots of insulin
large-for-dates
hypothermic
polycythemic
ill for any reason
what clinical features might you see if a neonate is hypoglycaemic? also what range do you want their BMs in roughly?
jitteriness, irritability, apnoea, lethargy, drowsiness and seizures
want >2.6ish but not worried till <2
how do you prevent/manage neonatal hypoglycaemia?
prevent with early and frequent milk feeds
IV glucose given if needed.
when are cleft lips typically diagnosed? what about cleft palates?
cleft lip usually picked up on the anatomy scan (20 weeks).
isolated cleft palate difficult to see on USS so diagnosed at birth usually
how are cleft lips/palates treated?
surgical repair at 6-12 months for palate
for lips - either early (first week of life) or late (3 months old)
what is the pierre robin anomaly?
association of micrognatia, posterior displacement of the tongue and midline cleft of the soft palate.
need prone position to maintain airway until growth of mandible is established.
what is oesophageal atresia and how do you manage it?
tracheo-oesophageal fistula usually present, also often polyhydramnios seen on scans (as foetus can’t swallow)
before trying first feed, pass feeding tube into to stomach and check location on XR to establish diagnosis.
will need surgery.
what is gastroschisis?
congenital abnormality where bowel protrudes without any covering sac through a defect in anterior abdo wall, adjacent to umbilicus
what is exomphalmos?
abdo content herniate through umbilical ring and are covered with a sac formed by peritoneum and amniotic membrane.
what are the risks to the baby of gestational diabetes/maternal DM?
congenital malformations (3x risk) macrosomia - foetal insulin response to hyperglycaemia promotes excessive growth (difficult delivery).
neonatal problems:
hypoglycaemia - early feeding can prevent, usually transient
respiratory distress syndrome
polycythaemia
what are the risks involved in a pregnant mother with uncontrolled hyperthyroidism?
massively increased risks of pre-eclampsia and low birthweight
how does group B beta-haemolytic strep infection present in a neonate?
early (in first week) or late (after first week). early = worse prognosis.
diagnosis - sepsis screen (blood culture, urine culture, LP and CSF culture, swabs), rapid antigen testing on CSF and blood. gram stain CSF.
how do you treat group B strep (GBS) infection in an infent?
IV abx
what are the usual pathogens behind neonatal meningitis?
E coli
Group B strep
listeria monocytogenes
what is the traffic light assessment for the unwell child?
assess child on green/amber/red criteria to determine how unwell they are and the management
green = taking most feeds OK, normal colour, responds to social cues, alert or wakens quickly, lusty cry or playing, breathing calmly amber = taking 50% or less of feeds, pale, hard to wake, no smiling, tachnypnoea, sats <95, creps, nasal flaring (if <1 year), cap refill tie >3 secs red = pale/mottled/ashen/blue, decreased consciousness, reduced skin turgor, grunting, rib recession, retraction of sternomastoid, stridor, unequal/unresponsive pupils, T >38C (if <6 months, >39C if older)
how do you manage a feverish child rated “green” on the traffic light system?
at home, offer regular drinks etc
if amber/red then admit
what are the components of a septic screen?
bloods - culture, FBC, electrolytes, LFTs, CRP
gas - glucose + lactate
urine - test for UTI
LP - if clinically indicated (and NOT contra-indicated)
CXR - if resp symps/signs
how do you estimate dehydration % clinically?
0-5% (mild) = 5% wt loss in infants, 3% in children. dry mucous membranes, maybe reduced skin turgor, maybe reduced urine output
5-10% (moderate) = 10% wt loss infants, 6% children. decreased skin turgor, very dry mucous membranes, oliguric, raised HR, CRT >2 s, lethargy, hoarse cry.
>10% (severe) = wt loss 15% infants, 9% children. skin turgor reduced with tenting, mucous membranes parched, anuric, shock, hypotension, coma.
how would you manage a child with mild dehydration <5%?
oral fluids, get parents to give little and often e.g. 5mL every 5 min by syringe - manage at home.
how would you manage a child with moderate dehydration, 5-10%?
IV fluids - maintenance + deficit over 48h.
might be able to manage giving the above in water/oral rehydration salts (dioralyte) - by NG tube maybe.
measure and replace ongoing losses e.g. from bowel.
might do ‘rapid rehydration’ for first 4h - make sure nurses know to reduce rate after that!
how do you calculate maintenance fluid requirements in kids? and what solution should you prescribe?
For every kg up to 10kg = 100ml/kg/day
For every kg between 10- 20kg = 50ml/kg/day
For every kg > 20kg = 20ml/kg/day
Divide total by 24 to give rate in ml per hour
use 0.45% saline with 5% glucose (unless concerned about hyponatraemia)
how do you calculate fluids to replace a deficit?
% dehydration X weight (kg) X 10 = mL
give on top of maintenance requirements, over 48h
explain medical management of constipation in children
faecal impaction - treat with escalating dose of polyethylene glycol 3350 + electrolytes (movicol paediatric plain), once cleared reduce to maintenance dose.
if unsuccessful can add lactulose, then alternate-day senna.§
what does a ‘hot potato voice’ indicate?
peritonsillar abscess/quinsy? –> ENT review
what volume of fluids are used for fluid boluses in fluid resuscitation?
20ml/kg 0.9% normal saline
UNLESS - neonate, trauma, DKA = 10ml/kg
how do you calculate normal fluid requirements?
100ml/kg for first 10kg
50ml/kg for 10-20kg
20ml/kg for >20kg
/24 to get rate per hour!
use 0.9% saline + 5% glucose, might chuck some potassium in
how do you calculate fluid replacement for a dehydrated child?
"dehydrated" = 5% = +50 ml/kg, over 24 hours "shocked" = 10% = +100ml/kg, over 24 hours
