Paeds Flashcards
High Fever, IRRITABLE w/ poor feeding, mottled, CRT 3 seconds - rash developing.
What’s the diagnosis?
Meningococcal Septicaemia
Bug = Meningococcus (Nisseria Meningitides)
You suspect a child has Septicaemia - WHAT DO YOU DO?
Sepsis Screen:
- Blood Culture
- Urine Culture
- Lumbar Puncture
- CXR
Who do you treat as Sepsis until proven otherwise?
Baby under one month with Fever - gets a full septic screen and treated with ABx
What is the Sepsis 6?
- High flow oxygen
- IV/IO access + blood
a. blood culture
b. Blood Glucose
c. Gases + lactate, FBC, CRP - Broad Spectrum ABx - Cefotaxime + Amoxiciliin +/- Aciclovir
- Fluid Resus
- Senior Clinician involvement
- consider ionotropic support early
What Abx would you give for meningitis? at what dose?
Cefotaxime 50mg/kg every 8 hours.
What causes purpura seen in meningitis?
-purpura = bleeding into the skin or submucosa
-it’s secondary to disseminated intravascular coagulation. bleeding may be secondary to depletion of
platelets.
What measures would be used to stabilise a spesis patient being moved to PICU?
- Intubate = maintain airways and reduce metabolic demands
- Oxygen
- catheter - monitor fluid output
- Corticosteroids - some evidence to suggest it may prevent septic shock
- vasopressor Tx
How is Neisseria Meningitis passes on?
- 1/10 people carry it in their nose
- Passed on through contact with saliva and sputum
Define a close contact in relation to a communicable disease.
Prolonged close contact in a household type setting within 7 days before the onset of symptoms exposed directly to large droplets/secretions from the resp tract.
What investigations would you do for the limping child with other systemic features?
- Bloods
- urine culture (reactive arthritis)
- ultrasound suspected joint
- blood cultures
- Xray suspected joints
What are the different types of juvenile idiopathic arthritis (JIA)?
- oligo less than or equal to 4 joints
- poly greater than 4 joints
- enthesitis. HLA B27
- Psoriatic
- Systemic
How do you manage a child with JIA?
- analgesia
- DMARDS - methotrexate/sulfasalazine
- steroids
- Biologics - tocilizumab, abatacept
- ophthalmology (uveitis a complication that can cause sight loss), physio, OT, rheumatologist, pain tema, child psych, ortho.
What is the diagnostic criteria for Kawasaki’s disease?
4/5 of the following:
- mucous membrane changes (red, dry, cracked lips, strawberry tongue)
- Cervical lymphadenopathy
- Rash (polymorphic)
- Changes in extremities - redness, swelling, induration of fingers & toes
- Bilateral nonexudative conjunctivitis
How do you treat Kawasaki’s disease?
- prompt IVIG
- High dose aspirin
- consider second dose IVIG
- if fever remains persistent consider escalation - corticosteroids, infliximab or cyclosporin
Why is aspirin contraindicated in children apart from in Kawasaki’s disease?
-It can cause Reye’s Syndrome. A sever liver and brain damage which can be fatal
What’s the acronym for remembering Kawasaki disease Sx?
MyHEART
M(y)= muscosal involvement
H=hands and feet oedema
E=Eyes non-purulent bilateral conjunctivitis
A= Adenopathy often cervical unilateral enlargement
R=Rash usually truncal and pleomorphic
T= Temperature non remitting fever for at least 5 days
What is the long term prognosis of Kawasaki’s?
- 50% have cardiac impairment + mild murmur
- 15-25% have coronary artery aneurysms if untreated
- mortality low
- long term follow for cardiac complications.
Which diseases are covered in the childhood immunisation schedule?
- Diphtheria
- tetanus
- Pertussis (whooping cough)
- Polio
- Haemophilus influenza B
- Hep B (infanrix hexa @ 8, 12 & 16 weeks)
- Pneumococcal (8 & 16 weeks + booster @ 1 year.)
- Men B
- rotavirus
- Measles (only at one year or above)
- Mumps
- Rubella
Discuss some trends in uptake of childhood vaccinations?
- Rural area have higher uptake than urban areas
- North & midlands have higher uptake than south
- BME populations have lower uptake than others
- being more socioeconomically deprived decreases the vaccination uptake rate
Name 5 notifiable diseases?
- Acute encephalitis
- Acute hepatitis
- Acute meningitis
- Anthrax
- Botulism
- Cholera
- Diphtheria
- Food poisoning
- HUS
- Yellow fever
- Whooping cough
- Tetanus
- Scarlet fever
- Rubella
- Rabies
- Meningococcal septicaemia
Discuss the NICE traffic light guidance for the unwell child.
- Excludes life threatening illness
- Assessment of risk of serious illness
- look for signs/Sx of specific illness
Assesses:
- temp
- HR
- RR
- CRT
- Hydration
What causes a rash in Scarlet Fever?
- fever, malaise, headache
- tonsilopharyngitis - sore throat and swallowing difficulties
- Reaction to to Strep toxin - red and blotchy then becomes fine like sand paper
What does an impetigo rash look like?
- usually face, hands and forearms
- crusted, red, blistered and can ooze
- highly contagious
A child prevents with painful blisters in their mouth, palms of hands and soles of feet. What is the disease, prognosis and Tx?
- hand, foot and mouth disease caused by coxsackievirus
- pain and hydration management
- should clear up between 2-7 days
A patient has more than 5 cafe au lait spots. What condition would you think about investigating for? What are it’s other criteria?
-Neurofibromatosis T1
Diagnosis if 2 or more of other criteria met:
- > =2 neurofibromas
- freckling in the axillary or inguinal regions
- optic glioma
- > = 2 lisch nodules
- osseous lesions ie.e sphenoid dysplasia
- 1st degree relative with NF1
What are the 2 main DDx for a patient with a non-blanching rash?
- meningococcal septicaemia
- Henoch-Schonlein Purpura (HSP)
What is stridor?
Harsh musical inspiratory sound due to the partial obstruction of the upper airway
What’s the main difference between stridor and wheeze?
Wheeze is polyphonic expiratory sound and intrathoracic airway blockage. Stridor is inspiratory sound from the blocker of the upper airways.
A child has a barking cough, noisy breathing and a hoarse cry. She has been unwell for a few days. What’s the DDx?
Croup (viral larnygotracheobronchitis), epiglottitis, bacterial tracheitis, laryngeal or oesophageal foreign body, allergic angioedema.
What would make you think a presentation was more likely to be viral laryngotracheobronchitis (croup) compared to epiglottitis?
Epiglottitis comes on over hours. Croup comes on over days.
What is the most likely causative agent of croup?
Parainfluenza virus
What’s the most common age of presentation of croup at what time of year?
- 2 years old (6 months - 6 years)
- Autumn
What is the first line treatment for croup?
initial dose of 150 mcg/Kg of dexamethasone
First line Tx of croup doesn’t work, what do you do next?
nebulised adrenaline 1mg/ml in 0.9% saline
A 6 month old has difficulty breathing whilst eating, a dry cough and has been unwell generally for a couple of days. He’s breathing fast and has subcostal recession. What’s the DDx?
Bronchiolitis, pneumonia, CF, Viral induced wheeze.
What’s the most likely causative agent of bronchiolitis?
Respiratory syncytial virus (RSV) - causes 80% of Bronchs
What other viruses causes bronchiolitis?
parainfluenza, rhinovirus, adenovirus, metapneumonvirus
What increases a child’s risk of bronchiolitis?
- low birth weight
- CF
- Prematurity
- congenital heart disease
- indoor air pollution
- overcrowding
- malnourished
How do you treat bronchiolitis?
YOU DON’T
- supportive management
- O2 therapy - humidified via nasal canual
-IV fluids 100 ml/kg for 10kg, 50 ml/kg for 10kg, 20 ml/kg subsequently.
A child has recurrent bronchiolitis due to RSV virus. What can you offer them?
- Palivizumab - monoclonal antibody to respiratory syncytial virus.
- Given monthly IM reduces the risk in prems.
Define Child Development.
The Biological, psychological and emotional changes that occur between birth and adolescence as the individual progresses dependency to increasing autonomy. There is a predictable sequence but each child will have a unique course. Development is determined by an interplay of genes and environment.
Give 4 things that influences how a child develops.
- education
- exposure to substances
- medical conditions
- genetics
- prematurity
- parenting
- maternal nutrition
- domestic violence
- nutrition
- hearing and vision
- stimulating environment
What are the 4 domains a child’s development is assessed in?
- Gross motor
- fine motor & vision
- speech, language and hearing
- social interaction and self care skills
What is deemed normal gross motor development as a newborn, 3 months. 6 months, 9 months & 1 year?
newborn - flexed arms and legs w/ equal movements
3 months - lifts head whilst lying on tummy
6 months - chest up with arm support, rolls, sits unsupported
9 months - pulls to stand
1 year - walks
What is deemed normal fine motor development as a newborn, 4 months. 8 months, 1 year & 18 months?
4 months - grasps object, uses both hands
8 months - takes a cube in each hand
1 year - scribbles with a crayon
18 months - tower of 2 cubes
What is deemed normal speech language and hearing development as a newborn, 3 months, 9 months, 1 year and 2 years?
newborn - turns to loud noises 3 months - laughs and squeals 9 months - dada mama 1 year - 1 word 2 years - 2 word sentences, names body parts 5 years - knows meanings of nouns
What is deemed normal social/self care development as a 6 weeks, 6 months, 9 months & 1 year?
6 weeks - smiles spontaneously
6 months - finger feeds
9 months - waves bye bye
1 year - uses spoon/fork
What is the health child programme?
Goverment scheme aimed to encourage care that keeps children healthy and safe.
- protect from disease through screening and immunisations
- promotes healthy eating & exercise
What universal surveillance do children get on the healthy child programme?
- NIPE
- new baby interview (14 days old)
- 6-8 week baby examination
- 1 year meeting
- 2-2.5 year meeting
-at each point:
=growth & development checks
=discuss parental concerns
=risks identified
What is the role of the health visitor?
- see child in their own environment
- use developmental screening tools
- check parental concerns
- health and development promotion
- monitor growth
- refer to paediatricians if abnormalities detected
What are red flags for development?
- loss of skills (regression)
- poor health/growth
- signifcant family history of poor development
- examination finds - microcephaly, dysmorphic features
- safeguarding indicators
What would be abnormal gross motor development?
not sitting by 1
not walking by 18 months
What would be abnormal fine motor development?
hand preference before 18 months - sign of possible CP
What would be abnormal speech and language development?
- not smiling by 3 months
- no clear words by 18 months
What would be abnormal social development?
- no response to carers interactions by 8 weeks
- not interested in playing with peers by 3 years
Give 3 genetic conditions that would cause developmental delay.
chromosomal - downs syndrome
single gene disorders - Rett Syndrome, Duchennes
polygenic - ASD, ADHD
What factors in childhood would cause developmental delay?
- infections - menigitis
- chronic ill health - CF
- metabolic disorders
- acquired brain injury - accidental or not
- hearing impairment
- vision impairment
What environmental factors would cause developmental delay?
- abuse
- neglect
- low stimulation
If a boy isn’t walking by 18 months, why is this worrying and what would you do?
suspect Duchenne’s muscular dystrophy & check CK
Give 3 determinants of growth in childhood.
- parental pheno and genotype
- quality and duration of pregnancy
- nutrition
- specific system and organ integrity
- psycho-social environment
- growth promoting hormones and factors
Where do disorders of growth manifest most?
Growth plate
What factors affect the health of a growth plate?
- nutrition
- extracellular fluid - O2 deficiency, acidosis, toxins
- inflammatory cytokines
What diagnosis could you give from a child with short limbs but normal torso length?
Achrondroplasia - genetic condition that causes dwarfism
What could tell from someone with a short back and long legs?
delayed puberty
What is important about interpreting any measurements of growth?
- 1 single measurement is not helpful
- if they’re at a low centile but still within normal range do they stick to that centile whilst growing
- take averages from the mum & dads measurements to work a projected height etc
Describe the 3 growth phases of children?
- high velocity growth when an infant
- growing but not as fast in mid-childhood
- rapid increase in growth velocity when going through puberty
What’s the formula for working out a boys predict height from parental measurements?
Fathers height + (mothers height + 12.5) all over 2
Girls - swap gender positions & - 12.5
When does growth end?
fusion of the epiphyses - oestrogen effect
What are the 5 Tanner stages of puberty for boys?
- no pubic hair + testes length <2.5cm, volume M3.0 ml
- sparse growth of slightly curly pubic hairs mainly at dick base, Testes >3ml
- Thicker hair spreading to mons, growth of penis in width and length, balls still growing
- adult type pubes not yet of medial thighs. genitals still growing, darker scrotal skin
- hair on medial thighs now, adult shape & sized genitalia
What are the features of Klinefelter syndrome?
-affects 1/600 males
-genetic condition causing primary hypogonadism
-47 XXY
-azoospermia, gynaecomastia
reduced secondary sexual hair
-osteoporosis
-tall stature, reduced IQ in some cases
-massive increase risk in breast cancer
What, in the HPG, is dysfunctional in primary hypogonadism? And what effects would this have on the hormones involved?
- Gonads are underactive
- causes hypergonadotropic, increase GnRH + increased LH and FSH
- causes low gonadal sex hormones
What, in the HPG axis, is dysfunctional in secondary/tertiary hypogonadism? And what effects would this have on the hormones involved?
- hypothalamus or pituitary are dysfunctional
- causes hypogonadtropic, low GnRH, Low FSH & LH
- causes low gonadal sex hormones
Give 2 examples of hypogonadotropic hypogonadism (secondary/tertiary hypogonadism).
- Kallman’s syndrome - with or without anosmia
- tumours - germinomas, craniopharyngiomas, other germ cell tumours
- radiation therapy
- head trauma
- genetic disorders - prada willi syndrome
- sickle cells
- marijuana use
- diabetes
What are the 5 Tanner Stages of puberty for girls?
- nada - no pubes, no boobs
- sparse growth of long, straight hair minimally pigmented mainly on labia, breast bud noted, enlargement of areola
- darker coarser hair spreading over mons, further enlargement of breast buds and areola
- thick adult type hair not yet on medial thighs, projection of areola and papilla to form secondary mound above.
- adult type hair disturbed in inverse triangle, adult contour breast with projection of papilla only.
What are the features of turner syndrome?
- Genetic condition of females - 45 X0
- hypergonadatropic hypogonadism, streak gonads.
- cardiovascular abnormalities
- horseshoes kidneys
- short stature
- recurrent otitis media
- at birth - oedema of the dorsal hands and feet
- neck webbing, low posterior hair line, small mandible, prominent ears, high arched palate, broad chest.
What’s the first sign of puberty in boys and girls?
boys = testicular enlargement girls = breast buds
What’s deemed early and delayed puberty in boys?
early = <9 delayed = >14
What’s deemed early and delayed puberty in girls?
early = <8
delayed =>13
What factors effect birth weight?
- maternal smoking
- maternal size & weight
- gestational diabetes
- parity
What are common associations with weight loss in children?
- vomiting
- dysmorphic features
- diarrhoea
- poor social circumstances
What are some common causes of short stature?
- constitutional, slow maturation (genetic), delayed puberty
- idiopathic
- environmental - psycho-social
- nutrition - pre or postnatally
- physical disease
- skeletal disease
- turners syndrome
- endocrine
What chronic diseases can cause short stature?
- gastro - coeliac, IBD
- cardiovascular - congenital heart disease
- renal disease
- chronic severe anaemia
- CF, bronchopulmonary dysplasia
- chronic infection
What are some causes of overgrowth?
-congential adrenal hyperplasia
-precocious puberty
-hyperthyroidism
-GH excess
-marfan’s
klienfelter syndrome (XXY)
What are the features of psycho-social short stature?
- usually seen over 3 years
- emotional rejection is key
- physical/sexual abuse may be associated
- 50% show reversible GH deficiency
What’s the most common caused of paediatric hypothyroidism - worldwide? in the UK?
worldwide - iodine deficiency
UK - maldescent of the thyroid & arthryosis
What’s the triad criteria for a screening test?
- identifiable when latent/early stage
- treatable
- earlier management = better prognosis
What 3 screening tests are done post-nataly?
- newborn physical examination
- new-born hearing test
- New-born blood spot - hell prick test
What diseases are tested for in the new-born blood spot test?
- sickle cell
- cystic fibrosis
- congenital hypothyroidism
- Phenylketonuria
- MCAD
- MSUD
How do you test for hypothyroidism?
TFTs- very high TSH. low T3 T4
How would you treate congenital hypothyroidism?
- levothyroxine 10-15 micrograms daily adjusted according to growth
- assessing levels of T4
A neonate has low sodium, high potassium and is metabolically acidotic. What is likely to be happening?
Addisonian crisis.
congenital adrenal hypoplasia.
chromosome 6.
How would you treat someone presenting with congential adrenal hyperplasia for the first time? and longterm?
first presentation:
- high potassium correction with salbutamol infusion
- calcium gluconate to protect heart
- replace adrenal homrones
- hydrocortisone (replaces glucocorticoid)
- fludrocortisone (replaces mineralcorticoid)
long term - hydrocortisone + fludrocortisone
How may a baby girl present with CAH at birth?
-ambiguous genital - partially fused labia, enlarged clitoris, palpable testes like lumps.
If CAH is picked up antenatally what is the treatment?
administering dexamethasone to the foetus via the mother
What are the 3 core behaviours of ADHD?
- inattention
- impulsivity
- hyperactivity
A child needs 6/9 inattentive Sx + 6/9 Hyperactive/impulsive Sx and what other other criteria do they need to meet to be diagnosed with ADHD?
- present before 12
- developmentally inappropriate
- several symptoms in 2 or more settings
- clear evidence that Sx interfere with ADL + functioning
Give some inattentive Sx.
- easliy distracted
- does not apprear to be listening when spoken too
- avoids mentally demanding tasks
- finds difficult to organise tasks
- fails to give attention to detail/makes careless mistakes
- loses important items
- forgetful in daily activities
Give some hyperactive Sx.
- squirms + fidgets
- cannot remain seated
- runs and climbs excessively in inappropriate situations
- often on the go ‘driven by motor’
- talks excessively
- cannot perform leisure activities
What are impulsive Sx.
- blurts answers before questions have finished
- difficulty turn waiting
- interrupts or intrudes others
What are the proposed aetilogies of ADHD?
- neurochemical/anatomical differences
- genetics (strong family Hx found)
- environmental factors
- CNS insults (perinatal factors, infections)
What happens in Scarlet fever?
- 2-3 days of rash that starts on arms and upper chest then spreads to the whole body
- high fever and sore through
- caused by Group A strep
What would be the results of CSF analysis of Bacterial or viral meningitis?
Bacterial:
- low glucose to blood ratio
- high WBC - polymorphs
- high lactate
Viral:
- raised protein
- normal glucose
- mildly raised WBC - lymphocytes
