Paeds Flashcards
What ages are the following classes of children?
- Neonate
- Infant
- Young Child
- Child
- Adolescent
- Neonate – birth to 1 month
- Infant – 1 month to 2 years
- Young Child – 2 -6 years
- Child – 6-12 years
- Adolescent – 12-18 years
Name some differentials for
- looks unwell
- Inspiratory expiratory Stridor at rest
- A dry barking cough is observed
- RR 48/min, nasal flaring, moderate tracheal tug, intercostal and subcostal recession.
- She appears pink in air
Croup (parainfluenza)
Epiglottitis (Haemophilus influenzae)
Bacterial tracheitis
Foreign body
Laryngomalacia
What are the signs of anaphylaxis?
- Hypotension - Pale and sweaty
- Bronchoconstriction - Wheeze
- Airway compromise - Stridor
What questions should you ask with a Hx of allergic reaction/ anaphylaxis?
- Does your child have Asthma?
- If they have Asthma what treatment do they take?
- Do they take a regular preventer inhaler?
- When they had the initial reaction how much of the foodstuff or allergen had they been in contact with?
Allergy - How does sensitisation occur and what are the underlying physiological mechanisms involved?
Following exposure to an antigen the protein causes cross binding of two bound IgE molecules on the Mast Cell or Basophil surface. This process results in degranulation of the Mast Cell.
What are the 4 effects of histamine?
- Endothelial Cell Separation
- Localised irritation
- Vasodilatation
- Bronchoconstriction
When would you prescribe an EpiPen?
What would you prescribe instead if none of these are present?
- History of Anaphylaxis
- Previous cardiovascular / Respiratory involvement
- Evidence of airway obstruction
- Poorly controlled Asthma requiring regular inhaled corticosteroids
- Reaction to a small amount of allergen
- Ease of allergen avoidance
In the absence of these risk factors anti-histamine
what kind of course does croup follow?
Viral croup often follows an undulating course with symptoms flaring at night.
Up to a month of age the minimum milk requirement to provide enough calories to grow is what?
150mls/kg/day.
what are the 3 areas of history always relavent in paediatric history? (BIG)
- Birth history; or example prematurity
- Immunisation history; risk for specific infections
- Growth and wellbeing;
What patterns of bruising would be suspicious for NAI?
- Face, back, buttock, TEN (Torso, Ears, Neck)
- Bruise outlines a particular object e.g. hand, belt
- Pattern of bruising e.g. fingertips
What fractures would be suspicious of NAI?
- Metaphyseal fractures (twisting force)
- Rib fractures (ribcage = v complient at young age)
- Fractures of different ages
- Complex skull fractures
- Long bone shaft fractures in non-mobile child
What history would be suspicious for NAI?
- No mechanism offered / mechanism not consistent with the injury
- Delay in reporting the injury / seeking medical attention
- Inconsistent histories from parents
- Inappropriate reaction of parents e.g. vague, elusive, unconcerned, excessively distressed, aggressive
- Recurrent injuries
- Injuries inconsistent with the child’s age, development, mobility e.g. bruising in non mobile babies
What burn pattern would be suspicious for NAI?
- Uniform shape e.g. cigarette burn
- Glove-stocking distribution
Consider what clinical features a baby with non-accidental head injury may show.
- Irritability
- Poor Feeding
- Increasing head circumference
- Seizures
- Reduced GCS
- Full fontanelle
- Anaemia
- Retinal Haemorrhages
What is abusive head trauma?
What is one of the most useful diagnostic signs?
Head injury may follow severe shaking, especially in children under 6 months. This may cause rupture to the small vessels crossing the subdural space, causing a subdural haemorrhage.
Retinal haemorrhage
What investigations should be done for NAIs?
CT head
Skeletal Survey
FBC
Coagulation studies incl. von Willebrand disease
What are toddler bruises like?
- anterior shins
- bony prominences
- Single circular bruises
What is the toxic trio?
- Domestic violence
- substance abuse
- Mental illness
What is pyloric stenosis?
How does it present?
- 2-8 weeks, more male than female, presents with projectile vomiting, dehydration and olive-shaped mass in RUQ
- Thickening of the pylorus of the stomach → obstruction
How does pyloric stenosis lead to electrolyte / blood gas changes?
- Thickening of the pylorus of the stomach → obstruction
- → vomiting
- →→ projectile vomiting
- →dehydration
- →→ ↓K+, ↓Cl- (loss of HCl)
- →→→ exchange of intracellular K+ for extracellular H+ → metabolic alkalosis
How do you test for pyloric stenosis?
How do you treat it? C-M-S
Test feed + USS
C - fluids and correct electrolytes
S - pyloromyotomy
What are some differentials of bile-stained vomit?
Potential emergency!
Intestinal obstruction:
intussusception, malrotation, strangulated inguinal hernia
What investigations might you need for severe GORD in a child?
- 24hr oesphageal pH study
- endoscopy
How do you manage GORD? C, M, S
Conservative - thicken feed
Medical - omeprazole / ppi or H receptor antagonist e.g. ranitidine
Surgical - RARE - fundoplication
How does intussusception present?
- Acute abdominal pain in 6-18 month year old
- Pain = guarding (!-peritonitis), worse with peristalsis, paroxysmal, colicky pain
- Pallor
- Vomiting - bile-stained (obstruction)
- Mass in abdomen - sausage or large mass (→volvulus)
- Red jelly stool
- Sy of sepis / shock!!
What are the 3 causes of intussusception?
- Infection (e.g. gastroenteritis) → increased size of peyer’s patches (lymph nodes) → act as leap point
- Meckel’s diverticulum inverts into ileum and acts as leap point
- Idiopathic (we no know)
What is the classic investigation finding for intususseption?
target sign on USS
What are the risk factors for intusussception?
- Malrotation
- Sibling with intusussception
- Past Hx of intusussception
Management of intusussception?
C: Fluid resuscitation
M: Barium or air enema, rectal air insufflation
S: Surgery to reverse it and remove obstruction
Name some red flags for abdominal pain in children
- Blood in the stools
- Symptoms regularly waking child from sleeep
- Poor growth
- Age <5 years
- Weight loss
What are the common causes of melena in children?
- Infective – bacterial diarrhea eg campylobacter, salmonella
- Inflammatory bowel disease
- Tearing from anal vein
- Polyp
- Intussusception – acutely unwell
Name 7 symptoms of coeliac disease
- Chronic or intermittent diarrhoea
- Failure to thrive or faltering growth (in children)
- Persistent or unexplained gastrointestinal symptoms including nausea and vomiting
- Prolonged fatigue (‘tired all the time’)
- Recurrent abdominal pain, cramping or distension
- Sudden or unexpected weight loss
- Unexplained iron-deficiency anaemia, or other unspecified anaemia
What kind of gastroenteritis is most likely with children?
Viral
Classically seen in young children, what is the trio found in children with HUS (haemolytic uraemic syndrome)?
What is it caused by on 90% of cases?
- acute kidney injury
- microangiopathic haemolytic anaemia
- thrombocytopenia
classically Shiga toxin-producing Escherichia coli (STEC) 0157:H7
List important features in the history for assessment of a child presenting with diarrhoea and vomiting:
- Duration, frequency/number, volume and colour of the vomitus
- Duration, frequency/number, volume of loose stools and any passage of blood in stools
- Current oral intake and usual feeding pattern
- Ask about passage of urine- number of wet nappies, if the nappies are as heavy as before and how long ago did the child have a wet nappy?
- History of fever and other red flag symptoms
- Recent contact with someone with diarrhoea and vomiting, ingestion of contaminated food or water and recent travel abroad
What are the signs of dehydration in an infant?
- reduced capillary refill time
- reduced skin turgor
- tachycardia
- hypotension
- tachypnoea
- dry mucous membrane
- Sunken anterior fontanelle
- oliguria
What are the common gastroenteritis-causing viruses in children?
- Rotavirus (most will develop immunity by 5yrs)
- Adenovirus
What is the most common bacterial cause of gastroenteritis?
Camplyobacter jejuni
What kind of fluid is used in acute fluid resus?
0.9 % saline
What is the normal age for the anterior fontanelle to close?
18-24 months
What are some concerning signs in C of ABCDE?
- Tachycardia
- Pallor
- Cool Peripheries
- Reduced urine output
What tests would you request on CSF samples?
Protein
Glucose (get BM beforehand too for comparison)
Microscopy and gram stain
Culture and sensitivity
PCR for virology, pneumococcus and meningococcus
What are the contraindications to lumbar puncture?
- Cardioresp. instability
- Focal neurological signs
- Signs of Raised ICP
- coma
- low HR
- high BP
- papilloedema
- Coagulopathy
- Thrombocytopenia
- Local infection at LP site
- If it causes undue delay in starting abx
A child over 3 months with suspected Meningitis should be treated with Intravenous ?
ceftriaxone
What are the most common bacterial causes of meningitis in
- neonates (<3mo)
- Young children (3 mo-5yrs)
- Children (5yrs+)
- Birth canal bugs:
- Group B strep
- E coli
- Listeria
- Niesseria mengitides, Strep pneumoniae, Haem influenza group B
- Niesseria mengitides, Strep pneumoniae
describe CSF changes in bacterial / viral / tb / fungal meningitis
Bacterial: Turbid, Lots of polymorphs/neutrophils, Low glucose, Raised protein
Viral: Clear, Lots of lymphocytes (initially could be polymorphs), normal protein / glucose
TB: Like bacterial but with lymphocytes instead of polymorphs
What virus group commonly cause meningitis?
enteroviruses (85%, especially coxsackie and echovirus)
When should you not give corticosteroids for meningitis?
What is the dose?
- If it is TB
- Below 3 months
- If it is mengococcal septicaemia
- More than 12 hours after starting antibiotics.
0.15 mg/kg to a maximum dose of 10 mg, four times daily for 4 days (high dose 0.6)
What are the indications for Dexamethasone in suspected/confirmed Meningitis?
- Frankly purulent pus
- CSF wcc > 1000/microlitre
- Raised CSF wcc with CSF Protein > 1g/l
- Bacteria on Gram stain
What are the layers of the meninges called?
DAP:
Dura mater
Arachnoid
Pia mater
Name some long term complications of meningitis
- Hearing impairment
- Local vasculitis - CN palsies, focal neurological lesions
- Local cerebral infarction → seizures, may → epilepsy
- Neuro impairment
- Learning difficulties
- Requiring surgery:
- Subdural effusion
- Hydrocephalus
- Cerebral abscess
What should happen after diagnosis and successful treatment of meningitis?
Rapid (2 week) hearing assessment (before calcification of the cochlea)
In Renal disease, what are the significant levels of proteinuria?
>20 mmol/ml - This may be significant, and may indicate tubular disease
>200 mmol/mg - This is nephrotic range
What is the most common nephrotic syndrome in children?
Minimal change nephrotic syndrome
What is the treatment for minimal change nephrotic syndrome
High dose steroids
Abx to prevent infection (strep, pnumococcal) → penicillin
What is the clinical triad for nephrotic syndrome?
- Massive proteinuria (>200g/L)
- ↓circulating albumin (<25g/L)
- oedema
What are risk factors for UTI in children?
↓ Flow:
- poor urine flow
- dysfunctional voiding
- ↑ bladder size
- constipation
- abdominal mass
Health:
- Prev UTI
- ↑ BP
- ↓growth
- recurrent fever of unknown origin
Renal:
- renal abnormality
- FHx of
- renal disease
- vesicoureteric reflux
What is the Definition of atypical UTI; increased risk of renal screening?
- Seriously ill
- Poor urine flow
- Abdominal or bladder mass
- Raised creatinine
- Septicaemia
- Failure to respond within 48 hours
- Non E coli
What is the definition of recurrent UTI?
requires investigations for an underlying cause
- 2 or more upper UTI
- 1 upper and 1 or more lower UTI
- 3 or more lower UTI
What clinical signs make an Upper UTI likely in kids?
- Bacteriuria and fever of 38*C or higher +/- loin tenderness
- Bacteriuria, loin pain/tenderness and fever of less than 38*C
- Age less than 3 months
What follow-up is required after UTI?
Renal US within 6 weeks
What scans should a child under 1 year have with atypical UTI to assess kidneys?
US scan
DMSA
MCUG (micturating cystourethrogram)
What is vesicoureteric reflux?
A developmental anomaly of the vesicoureteric junctions. The ureters enter directly into the bladder rather than at an angle → urine can reflux back into ureter.
Severe disease can lead to backflow of urine into renal pelvis → scarring risk if UTIs occur.
What is an MCUG?
Micturating cystogram
to identify any vesicoureteric reflux (VUR), bladder abnormalities and posterior urethral valves within a few weeks after treatment of UTI.
The technique consists of catheterizing the child in order to fill the bladder with a radio-contrast agent then taking x-rays as the infant voids urine..
When would you consider a MCUG?
- Infants younger than 6 months with atypical or recurrent UTI
- Consider in children older than 6 months if dilatation on ultrasound, poor urine flow, non-E coli infection or family history VUR
What is a DMSA and when would you do it?
DMSA in 4-6 months (after UTI). This is a radionucleotide scan used to assess renal function and identify any scarring of the kidneys due to the UTI. Healthy renal tissue takes up the isotope. Unhealthy or scarred tissue doesn’t take up the isotope and appears as a filing defect on DMSA scan.
DMSA may be inaccurate if performed shortly after an infection.
Indications:
All children with recurrent UTI
Children under 3 years with atypical UTI
You are asked to see a boy on the postnatal ward aged 1 day. The antenatal scan showed bilateral dilated kidneys. The child appears well and examination is normal. Nappies are wet.
What should you do?
Arrange ultrasound of kidneys within 24 hours
Need to exclude posterior urethral valves – this is a very serious condition which if untreated can cause renal failure due to obstruction.
If was just one side then outpatients is ok
What extra questions are important in fever or diarrhoea histories?
Contact - With other ill people - home or nursery, or with animals e.g. petting zoo
Travel - at risk areas, vaccination, contact with mosqitos, anyone ill on the plane?
When would you send a sample of stool for microscopy and culture?
NICE recommend sending stool for microbiology if you :
- suspect septicaemia,
- there is blood or mucus in the stool or
- the child is immunocompromised,
and to consider sending stool if
- there is a history of travel,
- the diarrhoea has persisted more than 7 days,
- or you are uncertain about the diagnosis of gastroenteritis.
What is the name for the classic red, expanding lesion with bright red outer spreading edge found in Lyme disease?
What is the infecting organism?
erythema migrans
caused by the spirochete b.burgdorferi
What are the 3 stages of Lyme disease?
- Early - skin lesion + fever-like symptoms: fever, malaise, myalgia, arthralgia, lymphadenopathy
- Dissemination (rare) - meningitis, cranial nerve palsies, arthritis, carditis
- Late - after weeks / months: neuro, cardio and joint manifestations:
- Neuro: meningoencephalitis, cranial (facial nerve normally) and peripheral neuropathies
- Cardiac: myocarditis, heart block
- Joint: arthralgia, oligoarthritis etc
How do you test for Lyme disease?
Testing early in the disease may not be useful, as seroconversion generally happens after the early stage.
→ Blood tests are indicated if symptoms persist and there is uncertainty about the diagnosis:
- enzyme-linked immunosorbent assay (ELISA) antibodies to Borrelia burgdorferi are the first-line test
- if this test is positive or equivocal then an immunoblot test for Lyme disease should be done
How do you treat Lyme disease?
> 12 yrs doxycycline
<12 yrs amoxicillin
What disease do reptiles sometimes carry?
Salmonella
What are the features of Kawasaki disease? x6
CRASH and BURN
- Burn = High temperature >5 days +4/5
- Conjunctivitis
- Rash- pleomorphic
- Adenopathy - Cervical lymphadenopathy
- Swollen red lips, tongue (strawberry)
- Hands - Peeling of skin of hands and feet
What is the most common cause of infective diarrhoea in children in the UK?
Rotavirus
How do you treat Kawasaki?
What is the main complication?
Aspirin (prevents clots) - the only time you prescribe aspirin in children due to risk of Reye’s syndrome
intravenous immunoglobulin
echocardiogram (rather than angiography) is used as the initial screening test for coronary artery aneurysms
What is the sequence of acute Seizure medications?
- No vascular access: 0.5mg / kg
- Rectal diazapam
- Buccal midazolam
- OR Vascular access 0.1 mh/kg lorazepam
- Still fitting: 0.1 mh/kg lorazepam
- Optional - give paraldehyde
- Confirm it’s still a fit!
- Sr Help, get anaethetics / ICU help
- Give 20mg/kg phenytoin or phenobarbitone over 20 mins (if already on phenytoin)
When is a child hypoglycaemic?
Glucose <2.6
Re-Check if between 2.6 and 3.5
What should you ask about in suspected seizure
- Pre-seizure
- During
- After
- Recent illness?
What is a complex febrile seizure?
- A focal, or generalized and prolonged seizure,
- of a duration of greater than 15min,
- recurring more than once in 24h,
- and/or associated with postictal neurologic abnormalities, more frequently a postictal palsy (Todd’s palsy),
- or with previous neurologic deficits
What are the indications for brain imaging in seizures?
Indications for urgent head CT or MRI:
- Encephalopathic or coma
- Suspected raised intracranial pressure
- Progressive neurological deficit
Indications for elective head MRI:
- In a child under 2 year of age at onset
- hard focal neurological signs
- a focal epilepsy
- associated significant learning difficulties
- an epilepsy resistant to full doses of 2 appropriate drugs
What points should you cover when reassuring a patient about febrile seizures?
- Counselling on recurrence risk of fever related seizures and risk of epilepsy.
- Parents need first aid training and what not to do in a convulsive seizure (especially not to put something into the child’s mouth or do chest compressions)
- They maybe considered for training to administer rescue medication, buccal midazolam for example, at 5 minutes.
- They need to be aware of when to call an ambulance (e.g. after 5 minutes of a convulsive seizure, or if rescue medication was ineffective after 5 minutes)
- Follow up arrangements, by either their Consultant, or a referral to an epilepsy specialist
What is the GMFCS?
Gross motor function classification system
- no limitations
- some limitations
- uses handheld assisting device
- self-mobility with limitations, may use powered mobility
- transported in a manual wheelchair
What are the causes of cerebral palsy?
- 80% antenatal:
- cerebral vascular damage / ischaemia
- ↓ development of brain in utero
- cortical migration disorders
- infection
- 10% hypoxic ischaemic injury
What is Periventricular leukomalacia (PVL)?
is a condition of underdeveloped white matter in the brain surrounding the ventricles.
It is the leading cause of CP in preterm infants.
Premature babies brains are at risk of what 2 pathologies?
The premature neonatal brain is susceptible to two main pathologies: intraventricular hemorrhage (IVH) and periventricular leukomalacia (PVL).
What is the definition of global developmental delay?
A child has global developmental delay if they have a significant delay in milestones in two or more areas (2 or more standard deviations below the mean).
What is the definition of Cerebral Palsy?
A disorder of tone, posture and movement, caused by a non-progressive brain lesion in a developing brain
What are the types of CP?
Spastic - ↑↑tone - clasp knife
Dyskinetic - involuntary movements
Ataxic - shaky movements, low tone, balance and spatial awareness ↓
What do the terms hemiplegia, diplegia, quadriplegia mean?
Hemiplegia – unilateral arm and leg involvement
Diplegia – symmetrical paralysis (may be of the legs, arms, face or combined thereof)
Quadriplegia – all four limbs involved.
What medications may help manage increased tone in CP?
Baclofen - antispasmodic
Diazepam - relaxant
Botulinum toxin - botox injections (Mr B)
What is Duchenne muscular dystrophy?
what is the test for DMD?
X-linked condition
characterised by progressive muscle weakness commencing in the legs and pelvis, then extending to other muscles of the body.
DMD should be considered in all boys who have delayed motor milestones and speech delay
Test creatinine phosphokinase ↑↑↑ (CK) level is nearly always at least five times as high as the maximum for unaffected people
How do you diagnose DKA?
Do blood glucose levels have to be high?
Diagnose DKA in children and young people who have
- acidosis (indicated by blood pH below 7.3 or plasma bicarbonate below 18 mmol/litre)
and
- ketonaemia (indicated by blood beta-hydroxybutyrate above 3 mmol/litre)
Blood glucose levels are generally high (above 11 mmol/l) but children and young people with known diabetes may develop DKA with normal blood glucose levels.
How do you classify DKA?
Children and young people with a pH of 7.1 or above have MILD or MODERATE DKA
Children and young people with a pH of less then 7.1 have SEVERE DKA
What is Hyperosmolar Hyperglycaemic State?
If a child is hyperosmolar with a very high bloog glucose level (>30 mmol/l), with little or no acidosis or ketones
How do you work out how much fluid a child in DKA needs?
Requirement = Deficit + Maintenance
Deficit:
- Mild DKA = 5%
- Severe DKA = 10%
Maintenance:
- if they weigh less than 10 kg, give 2 ml/kg/hour
- if they weigh between 10 and 40 kg, give 1 ml/kg/hour
- if they weigh more than 40 kg, give a fixed volume of 40 ml/hour.
What is kussmaul breathing?
Deep and Laboured breathing as a result of diabetic ketoacidosis - trying to blow off CO2
What is the worry with ↑fluids in DKA?
↑risk of cerebral oedema
The morbidity and mortality in childhood DKA is from cerebral oedema. The aim of therapy is very gentle and slow correction to avoid cerebral oedema
What is the rule for maintenance fluids outside of DKA?
1st 10kg = 100ml/kg/day
2nd 10 kg = 50ml/kg/day
Subsequent = 20ml/kg/day
What are the signs that a baby may have a congenital heart defect?
(top to bottom)
- Poor feeding
- Pale
- Breathless
- Failure to thrive
- Recurrent LRTIs
- Congestive heart failure symptoms
- ?cyanosis
How do you manage croup?
- Do not examine throat!
- Steroids - oral dexamethasone 0.15 mg/ kg as a single dose (can be repeated 12 hours later).
- Nebulised Adrenaline 5mls 1:1000
