Paeds Flashcards
Gross motor milestones
3 months
Little or no head lag on being pulled to sit
Lying on abdomen, good head control
Held sitting, lumbar curve
Gross motor milestones
6 months
Lying on abdomen arms extended Lying on back, lifts and grasps feet Pulls self to sitting Held sitting, back straight Rolls front to back
Gross motor milestones
7-8m
Sits without support
Refer at 12m
Gross motor milestones
9 months
Pulls to standing
Crawls
Gross motor milestones
12m
Cruises
Walks with one hand held
Gross motor milestones
13-15m
Walks unsupported
Refer at 18m
Gross motor milestones
2y
Runs
Walks upstairs and downstairs holding onto rail
Pyloric stenosis presentation:
Pyloric stenosis typically presents in the second
to fourth weeks of life with vomiting, although
rarely may present later at up to four months. It
is caused by hypertrophy of the circular
muscles of the pylorus
Features of Py Sten
‘projectile’ vomiting, typically 30 minutes after
a feed
constipation and dehydration may also be
present
a palpable mass may be present in the upper
abdomen
hypochloraemic, hypokalaemic alkalosis due to
persistent vomiting
Dx of py sten
USS
Ramstedt pylorotomy
Used in management of py sten
Excision of the hypertrophied circular muscles
of the pylorus
Def intussuception
Intussusception describes the invagination of
one portion of bowel into the lumen of the
adjacent bowel, most commonly around the
ileo-caecal region.
Intussusception usually affects infants between
6-18 months old. Boys are affected twice as
often as girls
Features of intussuception
paroxysmal abdominal colic pain during paroxysm the infant will characteristically draw their knees up and turn pale vomiting blood stained stool - 'red-currant jelly' sausage-shaped mass in the right lower quadrant
Ix intussuception
uss
Mx of intussuception
Air insuffation under radiological control
If the child has signs of peritonitis or the air
insufflation fails, Sx
A 2-month-old boy is brought to the afternoon
surgery by his mother. Since the morning he
has been taking reduced feeds and has been
‘not his usual self’. On examination the baby
appears well but has a temperature of 38.7ºC.
What is the most appropriate management?
Advise regarding antipyretics, to see if not
settling
IM benzylpenicillin
Advise regarding antipyretics, booked
appointment for next day
Admit to hospital
Empirical amoxicillin for 7 days
Any child less than 3 months old with a
temperature > 38ºC is regarded as a ‘red’
feature in the new NICE guidelines, warranting
urgent referral to a paediatrician. Although
many experienced GPs may choose not to
strictly follow such advice it is important to be
aware of recent guidelines for the exam
Assessment of febrile children?
T: electronic thermometer in the axilla if <4w or with infra-red tympanic thermometer HR RR CRT Signs of dehydration: skin turgor
Mx of child at “green” on risk stratificiation for
feverish illness?
Managed at home with appropriate care
advice, including when to seek further help
Mx of child at “amber” on risk stratificiation for
feverish illness?
Safety net or refer to paediatric specialist for
further assessment
Safety net: verbal/written info about warning
symptoms and how to access further care
Mx of child at “red” on risk stratificiation for
feverish illness?
Admit to hospital
A 3-year-old girl is brought in by her mother.
Her mother reports that she has been eating
less and refusing food for the past few weeks.
Despite this her mother has noticed that her
abdomen is distended and she has developed a
‘beer belly’. For the past year she has opened
her bowels around once every other day,
passing a stool of ‘normal’ consistency. There
are no urinary symptoms. On examination she
is on the 50th centile for height and weight.
Her abdomen is soft but slightly distended and
a non-tender ballotable mass can be felt on the
left side. Her mother has tried lactulose but
there has no significant improvement. What is
the most appropriate next step in
management?
Switch to polyethylene glycol 3350 +
electrolytes (Movicol Paediatric Plain) and
review in two weeks
Speak to a local paediatrician
Reassure normal findings and advise Health
Visitor review to improve oral intake
Prescribe a Microlax enema
Continue lactulose and add ispaghula husk
sachets
The 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. Whilst
an adult with such a ‘red flag’ symptom/sign
would be fast-tracked it is more appropriate to
speak to a paediatrician to determine the best
referral pathway, which would probably be
clinic review the same week.
Wilms’ tumour
Wilms’ nephroblastoma is one of the most
common childhood malignancies. It typically
presents in children under 5 years of age, with
a median age of 3 years old
Features of Wilm’s tumour
Abdominal mass (most common PC) Painless haematuria Flank pain Anorexia, fever Unilateral in 95% Mest found in 20%
Mx of Wilm’s
Management nephrectomy chemotherapy radiotherapy if advanced disease prognosis: good, 80% cure rate
Features of pertussis
Caused by Bordetella pertussis
10-14d incubation
Infants rountely immunised at 2,3,4m and 3-5y.
Pregnant women also immunised
Clinical features of pertussis
Coughing bouts: usually worse at night and
after feeding, may be ended by vomiting and
associated central cyanosis
inspiratory whoop (not always present), caused
by forced inspriration against a closed glottis
Persistent coughing may cause subconjunctival
haemorrhages or anorexia, leading to syncope
and seizures
Symptoms may last 10-14w and tend to be
more severe in infants
Lymphocytosis
Dx of pertussis
Per nasal swab culture for B. pertussis
PCR and serology may also be used
Mx of pertussis
Oral erythromycin to eradicate organism and
reduce spread
Has not been shown to alter the course of the
illness
A mother presents to your GP surgery with her
six month old daughter. She has been struggling
to feed her daughter, and her health visitor
found that she was small for her age. Her
mother is exhausted as she says her daughter
sleeps poorly.
On examination, the baby is just below the 3rd
centile in length. She has epicanthic folds and
low set ears. Her neck appears short and she
has micrognathia. You hear an ejection systolic
murmur on auscultation.
What is the most likely diagnosis?
Fragile X syndrome
Down’s syndrome
Patau syndrome
Klinefelter’s syndrome
Turner’s syndrome
Turner’s syndrome is a genetic condition due to
a loss or abnormality of one X chromosome. In
infancy, children often have difficulty with
feeding which contributes to poor weight gain,
although the often have short stature too when
older. Babies with Turner’s syndrome often
have multiple dysmorphic features, but a
webbed neck is often classical. It is also
associated with cardiac abnormalities, in this
question aortic stenosis although others are
also common. Chromosome analysis would be
needed to confirm the diagnosis.
While Down’s syndrome babies would have
many of the dysmorphic features, they would
not usually have a webbed neck or
micrognathia. They may have loose skin at the
nape of the neck but not webbing. It is caused
by Trisomy 21.
Klinefelter’s syndrome is caused by having an
extra X chromosome. They are often tall in
stature with small testes and gynaecomastia.
They do not tend to have the dysmorphic
features.
Fragile X syndrome is due to a CGG repeat on
the X chromosome. They tend to have learning
difficulties, long ears, mitral valve prolapse and
a large forehead and jaw.
Patau’s syndrome is caused by trisomy 13. They
do tend to have intrauterine growth restriction
leading to low birth weight, and can have
congenital heart defects and ear abnormalities.
However, they do not have webbing of the
neck, and eye dysmorphic features tend to be
microphthalmia or anophthalmia. They
typically have rocker bottom feet and
polydactyly
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Features of Turner’s syndrome
45XO Short stature Shield chest, widely spaced nipples Webbed neck Cardiac: bicuspid aortic valve, coarctation Primary amenorrhoea Cystic hygroma High-arched palate Short fourth metacarpal Multiple pigmented naevi Lymphoedema Increased incidence of autoimmune disease: thyroiditis and Crohn's especially
A 2 year old boy presents to the GP with his
mother. She is worried that he is not growing at
the same rate as the other children at his play
group. His mother describes foul smelling
diarrhoea about 4-5 times a week,
accompanied by abdominal pain.
On examination he has a bloated abdomen and
wasted buttocks. He has dropped 2 centile lines
and now falls on the 10th centile.
What is the most appropriate initial investigation? Stool sample IgA TTG antibodies Hydrogen breath test Endoscopy Abdominal xray
The most likely diagnosis here is coeliac
disease, diagnosed using IgA TTG antibodies, as
explained below.
A stool sample would be diagnostic for
gastroenteritis, in order to dictate which
antibiotic should be used.
The hydrogen breath test is used to diagnose
irritable bowel syndrome or some food
intolerances.
Endoscopy is more commonly used in adults
where cancer is suspected.
An abdominal X-ray may be useful where
obstruction is suspected.
Coeliac disease is a digestive condition which is
becoming increasingly common, and describes
an adverse reaction to gluten. gluten is a
protein found in wheat, barley and rye.
Features of coeliac in children?
May coincide with the introduction of cereals FTT Diarrhoea Abdominal distension Older children may present with anaemia May not be dxed until adulthood
Hirschprung’s features
Hirschsprung’s disease is caused by an
aganglionic segment of bowel due to a
developmental failure of the parasympathetic
Auerbach and Meissner plexuses. Although rare
(occurring in 1 in 5,000 births) it is an important
differential diagnosis in childhood constipation
Possible presentations neonatal period e.g. failure or delay to pass meconium older children: constipation, abdominal distension Associations 3 times more common in males Down's syndrome
Erb’s palsy
Erb’s palsy occurs due to damage to the upper
brachial plexus most commonly from shoulder
dystocia. Damage to these nerve roots results
in a characteristic pattern: adduction and
internal rotation of the arm, with pronation of
the forearm. This classic physical position is
commonly called the ‘waiter’s tip’.
Klumpke’s palsy
Klumpke’s palsy occurs due to damage of the
lower brachial plexus and commonly affects the
nerves innervating the muscles of the hand.
A male child from a travelling community is
diagnosed with measles. Which one of the
following complications is he at risk from in the
immediate aftermath of the initial infection?
Arthritis
Pancreatitis
Infertility
Subacute sclerosing panencephalitis
Pneumonia
Subacute sclerosing panencephalitis is seen but
develops 5-10 years following the illness.
Pancreatitis and infertility may follow mumps
infection
Pneumonia
Measles clinical features
Prodrome: irritable, conjunctivitis, fever
Koplik spots: grains of salt, on buccal mucosa
Rash: starts behind ears, then to whole body,
discrete maculopapular rash becoming blotchy
and confluent
Cxs of measles
encephalitis: typically occurs 1-2 weeks
following the onset of the illness)
subacute sclerosing panencephalitis: very rare,
may present 5-10 years following the illness
febrile convulsions
giant cell pneumonia
keratoconjunctivitis, corneal ulceration
diarrhoea
increased incidence of appendicitis
myocarditis
Mx of measles contacts
if a child not immunized against measles comes
into contact with measles then MMR should be
offered (vaccine-induced measles antibody
develops more rapidly than that following
natural infection)
this should be given within 72 hours
Def: nephrotic syndrome
Nephrotic syndrome is classically defined as a triad of proteinuria (> 1 g/m^2 per 24 hours) hypoalbuminaemia (< 25 g/l) oedema
Nephrotic syndrome in children
In children the peak incidence is between 2 and
5 years of age. Around 80% of cases in children
are due to a condition called minimal change
glomerulonephritis. The condition generally
carries a good prognosis with around 90% of
cases responding to high-dose oral steroids.
Other features include hyperlipidaemia, a
hypercoagulable state (due to loss of
antithrombin III) and a predisposition to
infection (due to loss of immunoglobulins)
Features of acute epiglottitis
Acute epiglottitis is rare but serious infection
caused by Haemophilus influenzae type B.
Prompt recognition and treatment is essential
as airway obstruction may develop. Epiglottitis
was generally considered a disease of
childhood but in the UK it is now more
common in adults due to the immunisation
programme. The incidence of epiglottitis has
decreased since the introduction of the Hib
vaccine
Clinical features of epiglottit
Features rapid onset high temperature, generally unwell stridor drooling of saliva
A 7-year-old boy is brought in to the GP surgery
with an exacerbation of asthma. On
examination he has a bilateral expiratory
wheeze but there are no signs of respiratory
distress. His respiratory rate is 36 / min and PEF
around 60% of normal. What is the most
appropriate action with regards to steroid
therapy?
Oral prednisolone for 3 days
Admit for intravenous steroids
Give a stat dose of oral dexamethasone
Double his usual beclometasone dose
Do not give steroids
Oral prednisolone for 3 days
Mx of mild-moderate acute asthma
Bronchodilator:
Beta-2 agonist via a spacer (<3y use a closefitting
mask)
1 puff every 15-30secs, up to a maximum of 10
puffs, repeat dose after 10-20 mins if
necessary
If symptoms are not controlled, repeat beta-2
and refer to hospital
Steroid therapy:
should be given to all children with asthma
exacerbation
Treatment for 3-5d
A 9-year-old boy is brought to surgery with recurrent headaches. What is the most common cause of headaches in children? Migraine Depression Refractive errors Tension-type headache Cluster headache
Migraine
Features of Hand foot and mouth disease?:
Hand, foot and mouth disease is a self-limiting
condition affecting children. It is caused by the
intestinal viruses of the Picornaviridae family
(most commonly coxsackie A16 and enterovirus
71). It is very contagious and typically occurs in
outbreaks at nursery
Clinical features
mild systemic upset: sore throat, fever
oral ulcers
followed later by vesicles on the palms and
soles of the feet
Mx of hand foot and mouth?
Management
general advice about hydration and analgesia
reassurance no link to disease in cattle
children do not need to be excluded from
school*
*The HPA recommends that children who are
unwell should be kept off school until they feel
better. They also advise that you contact them
if you suspect that there may be a large
outbreak.
Features of Croup?
Croup is a form of upper respiratory tract
infection seen in infants and toddlers. It is
characterised by stridor which is caused by a
combination of laryngeal oedema and
secretions. Parainfluenza viruses account for
the majority of cases.
Epidemiology
peak incidence at 6 months - 3 years
more common in autumn
Features
stridor
barking cough (worse at night)
fever
coryzal symptoms
Mx of croup
Single dose of oral dexamethasone (0.15mg/kg) Emergency: High flow O2 Nebulised adrenaline
The parents of a 14-month-old girl present to
their GP. They have noticed that in some
photos there is no ‘red eye’ on the left hand
side. When you examine the girl you notice an
esotropic strabismus and a loss of the redreflex
in the left eye. There is a family history of
a grandparent having an enucleation as a child.
What is the most likely diagnosis?
Congenital hypertrophy of the retinal pigment
epithelium
Uveal malignant melanoma
Neuroblastoma
Retinoblastoma
Congenital cataract
A congenital cataract may cause a loss of the
red-reflex but is likely to have been detected at
birth or during the routine baby-checks. It
would also not explain the family history of
enucleation.
Retinoblastoma
Features of retinoblastoma
Retinoblastoma is the most common ocular malignancy found in children. The average age of diagnosis is 18 months. Pathophysiology caused by a loss of function of the retinoblastoma tumour suppressor gene on chromosome 13 around 10% of cases are hereditary Possible features absence of red-reflex, repalced by a white pupil (leukocoria) - the most common presenting symptom strabismus visual problems
Mx of retinoblastoma
Management
enucleation is not the only option
depending on how advanced the tumour is
other options include external beam radiation
therapy, chemotherapy and photocoagulation
Prognosis
excellent, with > 90% surviving into adulthood
What differentiates between NRDS and TTN?
Neonates with NRDS usually present with
respiratory distress shortly after birth which
usually worsens over the next few days. In
contrast, TTN usually presents with tachypnoea
shortly after birth and often fully resolves
within the first day of life. A chest radiograph
can be useful
CXR in NRDS?
Diffuse ground glass lungs
Low volumes
Bell shaped throax
CXR in TTN
Heart failure type pattern Intersitital oedema PLeural effusions But normal heart size in contrast to congenital heart disease
Features of Surfactant lung disease?
Surfactant deficient lung disease (SDLD, also
known as respiratory distress syndrome and
previously as hyaline membrane disease) is a
condition seen in premature infants. It is
caused by insufficient surfactant production
and structural immaturity of the lungs
The risk of SDLD decreases with gestation
50% of infants born at 26-28 weeks
25% of infants born at 30-31 weeks
Other risk factors for SDLD include
male sex
diabetic mothers
Caesarean section
second born of premature twins
Clinical features are those common to
respiratory distress in the newborn, i.e.
tachypnoea, intercostal recession, expiratory
grunting and cyanosis
Chest x-ray characteristically shows ‘groundglass’
appearance with an indistinct heart
border
Mx of SDLD?
Management
prevention during pregnancy: maternal
corticosteroids to induce fetal lung maturation
oxygen
assisted ventilation
exogenous surfactant given via endotracheal
tube
What timing indicates idiopathic constipation?
Starts after a few weeks of life
Obvious precipitating factors coinciding with
the start of symptoms: fissure, change of diet,
timing of potty/toilet training or acute events
such as infections, moving house, starting
nursery/school, fears and phobias, major
change in family, taking medicines
Mx of feacal impaction
Polyethylene glycoe 3350 + electroyles (using
an escalating dose) is first line
Stimulant laxative can be addied if first line
does not lead to disimpaction after 2 weeks.
Subsititue a stimulant laxative singly or in
combination with an osmotic laxative such as
lactulose if Movicol Paediatric plan is not
tolerated.
Inform families that disimpaction treatment
can initially increase symptoms of soiling and
abdominal pain
General points in Mx of constipation?
do not use dietary interventions alone as firstline
treatment although ensure child is having
adequate fluid and fibre intake
consider regular toileting and non-punitive
behavioural interventions
for all children consider asking the Health
Visitor or Paediatric Continence Advisor to help
support the parents.
Mx of infants not yet weaned with
constipation
bottle-fed infants: give extra water in between
feeds. Try gentle abdominal massage and
bicycling the infant’s legs
breast-fed infants: constipation is unusual and
organic causes should be considered
Features of:
Chickenpox
Fever initially
Rash starting on head/trunk before spreading
Initially macular, then papular, then vessciular
Normally mild systemic upset
Features of mumps
Fever, malaise, muscular pain
Parotitis initially unilateral becoming bilateral in
70%
Features of measles
Prodrome: irritable, conjuncitivits, fever
Koplik spots
Rash starting behind ears, spreading to the
whole body
Initially discrete maculopapular rash that
becomes blotchy and confluent
Features of Rubella
Pink maculopapular rash initially on face before
spreading to the whole body, usually faind by
the 3-5th day
Suboccipital and postauricular
lymphadenopathy
Features of erythema infectiosum
AKA slapped cheek syndrome Caused by parvovirus B19 Lethargy, fever, headache Slapped cheek rash spreading to proximal arms and extensor surfaces
Features of Scarlet fever
Reaction to erythrogenci toxins produced by group A haemolytic strep Fever, malaise, tonsilitis Strawberry tongue Fine punctate erythema sparing face
Features of hand, foot and mouth disease
Caused by coxsackie A16 virus
Mild systemic upset: sore throat, fever
Vesciles in the mouth and on the palms and
soles of the feet
Scarlet fever features
Scarlet fever is a reaction to erythrogenic toxins
produced by Group A haemolytic streptococci
(usually Streptococcus pyogenes). It is more
common in children aged 2 - 6 years with the
peak incidence being at 4 years.
Scarlet fever has an incubation period of 2-4
days and typically presents with:
fever
malaise
tonsillitis
‘strawberry’ tongue
rash - fine punctate erythema (‘pinhead’) which
generally appears first on the torso and spares
the face although children often have a flushed
appearance with perioral pallor. The rash often
has a rough ‘sandpaper’ texture.
Desquamination occurs later in the course of
the illness, particularly around the fingers and
toes
Dx of scarlet fever
Throat swab usually taken but antibiotic
treatment should be commenced immediately
Mx of scarlet fever
Oral penicillin V (penallergic: azithromycin)
Children can return to school 24h after
commencing antibiotics
Notifiable disease
Cx of Scarlet fever?
Otitis media: most common
Rheumatic fever: typically 20d after infection
Acute GN
Characteristic symptoms in ADHD?
Extreme restlessness
Poor concentration
Uncontrolled activity
Impusliveness
Patau syndrome (trisomy 13)
Microcephalic, small eyes
Cleft lip/palate
Polydactyly
Scalp lesions
Edward’s syndrome (trisomy 18)
Micrognathia
Low-set ears
Rocker bottom feet
Overlapping of fingers
Fragile X
Learning difficulties Macrocephaly Long face Large ears Macro-orchidism
Noonan syndrome
Webbed neck
Pectus excavatum
Short stature
Pulmonary stenosis
Prader-Willi syndrome
Hypotonia
Hypogonadism
Obesity
William’s syndrome
Short stature Learning difficulties Friendly, extrovert personality Transient neonatal hypercalcaemia Supravalvular aortic stenosis
What Ixs should be performed in infants <3m
old with fever?
FBC Blood culture CRP Urine dip CXR if respiratory signs are present Stool culture if diarrhoea is present
What are hte criteria for admission in
bronchiolitis?
Apnoea (observed or reported)
Persistent oxygen saturation of <92% in air
Inadequate oral fluid intake (<50% of normal
fluid intake)
Persisting severe respiratory distress, for
example grunting, marked chest recession, or a
respiratory rate of over 70 breaths/minute.
Mx of RSV
Admit if fulfils criteria
Deliver humidifed oxygen best through head
box. Level can be determiend with pulse
oximetry.
Fluids and feed may need to be given by NG
tube or IV.
Only 5% require venitlation.
A 2-year-old girl is brought to her GP because
her mother has noticed she is constantly itching
her bottom at night. Her mother says she has
noticed some strange looking white bits when
she wipes her daughters bottom following a
bowel motion. What is the most appropriate
management option?
Prescribe 14 days of daily miconazole for whole
household and issue hygiene advice.
Issue hygiene advice only.
Prescribe a single dose of mebendazole for the
daughter and issue hygiene advice.
Prescribe a single dose of mebendazole for the
whole household and issue hygiene advice
This child is highly likely to have a threadworm
infection with symptoms of perianal itching
that is worse at night. It is also possible to see
threadworms, described as small threads of
slowly-moving white cotton either around the
anus or in the stools.
The risk of transmission in families is as high as
75%, and asymptomatic infestation is common.
For this reason an anthelmintic drug
(mebendazole) should be given as a single dose
to all household members.
64
Features of threadworm infection
Asymptomactic in 90%
Perianal itching, particulrly at night.
Girls may have vulval symptoms.
Dx can be made by applyoing sellotape to the
perianal area and sending it to the laboratory
for microscopy to identify the eggs.
A mother comes to surgery with her 6-year-old
son. During the MMR scare she decided not to
have her son immunised. However, due to a
recent measles outbreak she asks if he can still
receive the MMR vaccine. What is the most
appropriate action?
Arrange for measles immunoglobulin to be
given
Cannot vaccinate at this age as live vaccine
Give separate measles vaccine
Give MMR with repeat dose in 3 months
Give MMR with repeat dose in 5 years
The Green Book recommends allowing 3
months between doses to maximise the
response rate. A period of 1 month is
considered adequate if the child is greater than
10 years of age. In an urgent situation (e.g. an
outbreak at the child’s school) then a shorter
period of 1 month can be used in younger
children.
Transient synovitis
Acute onset
Usually accompanies viral infections, but the
child is well or has a mild fever
More common in boys, aged 2-12 years
Septic arthritis/osteomyelitis
Unwell child, high fever
