Paeds Flashcards
Mid-parental height
Girls:Mother+(father-13)/2 –> girls have to shorter than father
Boys: (Mother+13)+father/2
Biological mid parental height rang- +/- 7.5-8
Gastro- how long vomiting and how long diarrhea
Vomiting usually settles within a couple of days but diarrhoea can last up to 10 days.
Fluid bolus- Should we count that in our fluids equation
No you should not
Degree of dehydration (deficit) plus Maintenance fluid requirements plus Ongoing losses
Replacement of deficits- should be done fast in which kids and slow in which kids
Replacement may be rapid in most cases of gastroenteritis (best achieved by oral or nasogastric fluids), but should be slower in diabetic ketoacidosis and meningitis, and much slower in states of hypernatraemia (aim to rehydrate over 48 hours, the serum sodium should not fall by >1mmol/litre/hour).
What is the cause of neonatal respiratory distress syndrome
Lung surfactant deficiency disorder
is a lung disorder in infants that is caused by a deficiency of pulmonary surfactant.
Transient tachypnea of the newborn (wet lung disease)
- can be made better
- who gets it
- treatment
Reversible respiratory disorder
Most commonly occurs in full-term neonates delivered by cesarean section. These infants often have fluid-filled lungs.
supportive care (e.g., supplemental oxygen, neutral thermal environment, adequate nutrition)
DDX for neonatal distress
1) Neonatal respiratory distress syndrome(NRDS)
2) TTPN
3) Congenital diaphragmatic hernia
4) Pneumothorax
5) Meconium aspiration syndrome
6) Neonatal pneumonia
What is bronchopulmonary dysplasia
chronic lung disease primarily found in premature infants exposed to prolonged mechanical ventilation and oxygen therapy for neonatal RDS
What is the cut off for corticosteroid administration is a fetus
35 weeks
Surfactant production occurs early, at around 20 weeks’ gestation. However, its distribution throughout the lungs begins around weeks 28–32 and does not reach sufficient concentration until week 35. Thus, any infant born before term is vulnerable to surfactant deficiency.
Failure to thrive kid who started losing weight just after introducing into solid food would be
Celiac disease until proven otherwise
What are some gastrointestinal symptoms of celiac disease
Chronic or recurring diarrhea steatorrhea Flatulence, abdominal bloating, and pain Nausea/vomiting Lack of appetite Constipation (rarely)
What are some extraintestinal symptoms and associations with celiac disease
Malabsorption symptoms: fatigue, weight loss, vitamin deficiency, iron deficiency anemia, osteoporosis, hypocalcemia
In children: failure to thrive, growth failure, delayed puberty
Dermatologic associations: dermatitis herpetiformis
Neuropsychiatric symptoms: peripheral neuropathies (numbness, burning and tingling of the hands and feet) , headache, ataxia, depression, irritability
What are the screening test for celiacs and what other immunological tests should be done
Gold standard: IgA (anti‑)tissue transglutaminase antibody (tTG)
Quantitative IgA test: In the case of an IgA deficiency, patients are tested for IgG-based antibodies.
IgG deamidated gliadin peptide (DGP) indications: year less than 2 it is better
Anti-endomysial antibody (EMA)
What is the confirmatory and diagnostic test for celiac
Duodenal biopsy
State 3 characteristics of the duodenal biopsy in a patient with celiac disease
Villous atrophy
Crypt hyperplasia
Intraepithelial lymphocytic infiltration
What are the
1) screening test
2) diagnostic test
3) Follow up
Other blood: Folate, iron. Decreased with the involvement of duodenum
Screening-
IgA (anti‑)tissue transglutaminase antibody (tTG), IgG anti-deamidated gliadin antibody, also always do total IgA because of potentially associated IgA deficiency.
Diagnosis- Duodenal biopsy- showing intraepithelial lymphocytes and villis blunting/atrophy
Monitoring- Repeat anti-body testing, can take 12 months for Ab levels to normalise, intestinal healing can take up to two years, therefore, repeat duodenal biopsy should now be performed following at least 12 months of gluten-free diet
Celiac disease
-Acute management(follow up)-within 6 weeks
-Long-term management
1) Join celiac organization
2) Visiting a dieticians
3) Family screening
4) Bone density scan
5) Screening for other genetically associated conditions
After 6 months
1) repeat coeliac serology blood tests
after 12 months
1) repeat blood
2) Duodenal biopsy
Red Flags of failure of thrive(FTT)
1) Signs of abuse or neglect
2) Poor carer understanding e.g. non-English speaking, intellectual disability
3) Signs of family vulnerability e.g. drug and alcohol abuse, domestic violence, social isolation, no family support
4) Signs of poor attachment
5) Parental mental health issues
6) Already/previously case managed by child protection services
7) Did not attend or cancelled previous appointment/s
8) Signs of dehydration
9) Signs of malnutrition or significant illness
What are the 5 causes of poor growth
1) Inadequate caloric intake/retention
2) Psychosocial factors
3) Inadequate absorption
4) Excessive caloric utilization
5) Other Medical Causes
What are the inadequate absorption causes of FTT we should think about-3
Coeliac disease
1) Chronic liver disease
2) Pancreatic insufficiency eg. Cystic fibrosis
3) Chronic diarrhoea
4) Cow milk protein intolerance
correct for prematurity (<37 weeks) until how long
How do you do it
until 24 months of age
Down syndrome features
Face: round face, flat nasal bridge, up slanted palpebral fissures and protruding tongue
Flat occiput
Hand- single palmar(siamese crease), clindodactyl
Foot–> wide “sandal” gap between 1st and 2nd toe
Fetal alcohol syndrome diagnostic criteria
-what are the three sentinel features of the face
Prenatal alcohol exposure
Face: 3 sentinel features:
1) Smooth philtrum
2) Thin upper lip
3) Short palpebral fissure
Impairment in neurodevelopment: cognition, attention, memory and coordination
Predn dose for asthma
1mg/kg for asthma
Failure to thrive question for psychological issues
Has it ever been hard to take care of your child recent?
any financial problems? issues at home? your feel like not bonding with the baby as you use to?
Febrile seizures new guidelines for simple
<10 minutes is a simple febrile seizure
6 months-5 years
Burst therapy
3 doses in 1 hour
3 most sensitive parameters for dehydration-CRT
C-CRT
R-RR
T-tissue turgor
Fluid deficit equation that is the fluid loss for the whole day
Dehydration % x weight in kg x 10
Need to divide this by 24hr
How is trial of fluids in ED include
Aim for 10-20 mls/kg fluid over 1 hour of ORS
What fluid for bolus
maintenance
DKA
Bolus: 0.9% normal saline
Maintenace- 0.9% normal saline+ dextrose 5%
0.9% sodium chloride +/- potassium
The definite initial episode of ARF
2 major
OR
1 major and 2 minor manifestations
plus evidence of a preceding GAS infection
The definite recurrent episode of ARF in a patient with known
past ARF or RHD
2 major or
1 major and 1 minor or
3 minor manifestations
plus evidence of a preceding GAS infection
Major criteria in ARF in the high-risk group
1) Carditis (INCLUDING subclinical evidence of rheumatic valvulitis on echocardiogram)
2) Polyarthritis†† or aseptic mono-arthritis or polyarthralgia
3) Chorea
4) Erythema marginatum¶
5 )Subcutaneous nodules
Minor criteria in ARF in the high-risk group
1) Monoarthralgia
2) Fever‡‡
3) ESR ≥30 mm/h or CRP ≥30 mg/L
4) Prolonged P-R interval on ECG§§
Major criteria in ARF in all other groups
1) Carditis (EXCLUIDNG subclinical evidence of rheumatic valvulitis on echocardiogram)
2) Polyarthritis††
3) Chorea
4) Erythema marginatum
5) Subcutaneous nodule
Minor criteria in ARF in all other groups
Fever
Polyarthralgia or aseptic monoarthritis
ESR ≥30 mm/h or CRP ≥30 mg/L
Prolonged P-R interval on ECG
Mnemic for ARF/RHD- JONES and CAFE PAL
Look at google image
Recommended antibiotic regimens for secondary prevention
BPG, benzathine penicillin G; im, intramuscular.
4 weekly, or 3 weekly for selected groups
Innocent Murmurs
Hallmarks: 7’s inoSSents
- Soft
- S1 and S2 Normal (Heart sounds normal)
- Symptomless
- Systolic
- Short
- Standing / sitting may vary (change with posture) 7. Special Tests Normal (ECG/CXR/ECHO normal)
…also commonly Left sternal edge ( no radiation)
Acyanotic murmurs
VSD > PDA > ASD
Most Common CHD
VSD
Continuous Machinery murmur
-treatment
PDA
- Indomethecin to close the PDA
- Prostaglandin E keeps PDA open (for TGA’s)
TOF- 4 features
CXR shows
Pulmonary stenosis (causing Large VSD),
Right ventricular hypertrophy (RVH). Overriding aorta.
VSD
Ejection systolic murmur – left the sternal edge
CXR – the boot-shaped heart. ECHO (increased right
ventricular size).
Down syndrome children are increased risk of-3
Increased risk of: – Duodenal Atresia – Squint – Hypothyroidism – Leukaemia – Hirschprung’s disease – Deafness
Kawasaki disease affects which vessel
Small and medium
Causes of stridor
- Croup,
- Epiglottitis,
- Anaphylaxis,
- Laryngomalacia,
- Foreign body inhalation
- Bacterial tracheitis,
- Smoke inhalation
- Obstructive Malignancy.
4D of epiglottitis
-treatment
Dysphagia
Dysphonia(hot potato voice)
Distress
Drooling
IV Antibiotics
Empiric therapy: third-generation cephalosporin
Outline the management of asthma
- in mild
- moderate
- severe
asthmatic patient
Look at Queensland children hospital guideline
Risk factors for severe asthma- what kind of questions would you ask
1) previous admissions to ICU
2) Past Hx of anaphylaxis
3) Multiple episodes
When can child roll over
3-6 months
What are the development facets we are looking at
Gross motor skills Fine motor skills Language skills Social development and cognition Vision and hearing
2 core features in the ASD criteria and give examples
Persistent impairment in communication and social interaction (inability to form relationships, abnormal language development, reduced empathy, difficulties in adjusting behaviour to social situations, and poor eye contact)
Restricted, stereotyped patterns of behaviour, interests, and activities (e.g., hand flapping, excessive touching/smelling, lining up toys, adverse response to sounds, and echolalia)
What kind of pointing do ASD kids have
Protoimperative pointing than protodeclerative pointing
What are conditions need to be ruled out with GERD
Chronic reflux due to diseases of neuro disorders such as Cerebral Palsy
Chronic lung disease of prematurity
Pyloric stenosis electrolyte distrubance
Hypokalaemic Hypochloraemic Metabolic alkalosis =low plamsa K+ due to vomit
What other condition can look like Gastro
DKA
Red flags of gastroenteritis
1) severe abdominal pain or abdominal signs
2) persistent diarrhoea (> 10 days)
3) blood in stool
4) very unwell appearance
5) bilious (green) vomit
6) vomiting without diarrhoea
DDx for child with a limp and give sentence
1) Transient synovitis
2) Perthe’s disease
3) SUFE
4) Septic arthritis
5) JIA
6) Fracture/Trauma
7) NAI
8) Osgood-Schlatter disease
9) DDH
DDX for non-epileptic seizures
1) Febrile convulsions
2) metabolic
3) head trauma–> could be a reflex anoxic seizure?
4) meningitis/ encephalitis
5) toxins/poisons–> did you see him ingesting something usual before this happened?
Reflex Anoxic seizures/Pallid breath holding
Non-epileptic, syncope due to sudden drop in cerebral perfusion due to shock eg. bump to head, falling over etc. May go pale. Rapid recovery.
Reflex Anoxic seizures/Pallid breath-holding
Non-epileptic, syncope due to sudden drop in cerebral perfusion due to shock eg. bump to head, falling over etc. May go pale. Rapid recovery.
5 important rashes you need to be aware of in paeds
1) Measles
2) Rubella
3) Mumps
4) Chickenpox
5) Erythema infectiousum/ fifth disease/slapped cheek syndrome
6) Scarlet fever
Cleft lip and palate- definition
- what maternal factors causes this?
- surgical repair
- what MDT is needed
- what sequence is associated and triad does it have
Failure of the fusion of frontonasal and maxillary processes
-mother taking ANTICONVULSANTS
6-12 month for the palate
1st week-3 month for lip
Most will need speech therapy
Pierre Robin sequence:
micrognathia, glossoptosis, and airway obstruction.
Neural tube defects
- tell the three types
- tell me features about each one
Look at that slide on the paeds review folder
Causes of obesity in children- what are the 4 categories you need to explore
Environmental
Hormonal
Genetic
Medications
Environmental
1) Excess energy intake
2) Decreased activity levels
Hormone problems
1) Under functioning thyroid
2) Problems with the production of growth hormone
3) High steroid levels
4) PCOS
5) Other hormonal problems
Medications
1) Behaviour-related medications (such as antidepressants
2) Medications for fits and seizures
3) Steroids
Genetic syndromes
1) Prader-Willi syndrome
2) Other genetic syndromes-turner syndrome
Intertrigo
OSA- due to fat- how is his sleep?
What are the baseline tests and other tests to consider in an obese child
Baseline:
1) Blood lipids
2) Liver function tests
3) FBC-> general health, anaemia, infections
Consider the following when clinically indicated
1) Blood sugar and insulin levels/OGTT
2) Hormone function, such as thyroid hormone levels
3) Vitamin and nutrient levels (such as Iron, vitamin D, Vitamin B12)
Causes of a child who has short stature but steady growth before centile
Constitutional(familial)short stature Maturational delay Turner's syndrome IUGR Skeletal dysplasia(Rare)--> achondroplasia
Causes of a child who is shortfall off in growth across centile(losing height)= so failure to thrive with losing height
Chronic illness- Crohn's disease and chronic renal insufficiency Acquired hypothyroidism Cushing's Growth deficiency Psychosocial
5210 RULE for obese children
5- at least 5 fruits or vegetables per day
2- no more than 2 hrs screen time per day(<2 years old no screen time)
1- 1hour physical activity
0-No sweetened drinks
Overweight percentiles
85th to 95th
Obese percentiles
> 95th
BMI calculation
Kg/m2
In a simple febrile seizure, once the seizure has terminated, the aim of the assessment is to
determine the cause of the fever
In an afebrile seizures(seizure) what should be looked at in the past medical history
Past history – previous seizures and anti-seizure medication (management plan if in place), neurological comorbidity (e.g. VP shunt, structural brain abnormality) renal failure (hypertensive encephalopathy), endocrinopathy (electrolyte disturbance)
evidence of underlying cause that may require additional specific emergency management. Underlying causes include: hypoglycaemia electrolyte disturbances meningitis drug/toxin overdose trauma stroke and intracranial haemorrhage
In seizure child, what other system history is very important(besides neuro)
CARDIO
Ask about:
aura, focal features level of awareness recent trauma, consider non-accidental injury focality of limb or eye movement post-ictal phase/hemiparesis Relevant past history
Family history of seizures or cardiac disorders/sudden death
History suggestive of absence seizures or myoclonic jerks, nocturnal events
Developmental history
DDx for seizure-4 as given for RCH
1) Arrhythmia
2) Breath-holding spell (episode occurs when the child is crying)
3) Vasovagal syncope with anoxic seizure (postural change, preceded by dizziness and nausea)
4) Non-epileptic paroxysmal disorder
Also on examination look for
Full neurological examination looking for any abnormal neurological findings, signs of meningitis or raised intracranial pressure
Cardiovascular examination including BP and look for any signs that suggest an underlying cause e.g. neurocutaneous stigmata, microcephaly
Red for a seizure child
- Head injury with delayed seizure
- Developmental delay or regression
- Headache prior to the seizure
- Bleeding disorder, anticoagulation therapy
- Drug/alcohol use
- Focal signs
Pre-term baby: corrected age formula
Corrected age = Actual age - number of weeks premature
It is recommended to correct age for prematurity for children born before 37 weeks until the age of 2 years
When plotting the growth chart what is the age you use- corrected or actual
Corrected
What areas are you looking for in a febrile child
Colour Activity Respiratory Circulation and hydration Neurological Others
Febrile child- Infants ≤ 28 days corrected age- 3 steps you must do
Should be assessed promptly and discussed with a senior doctor
FBE, CRP, blood culture, urine (SPA), LP ± CXR
Admit for empiric antibiotic
Which type of febrile child should not undergo a LP
LP should not be performed in a child with the impaired conscious state, focal neurological signs impaired coagulation or haemodynamic instability (see Lumbar puncture). In this circumstance, treatment for meningitis/encephalitis can be commenced and an LP can be performed when the patient is stable and there are no other contraindications present.
Septic children may present with cold shock features
-which children get it
cold shock characterised by a narrow pulse pressure and prolonged capillary refill. The underlying haemodynamic abnormality is septic myocardial dysfunction, which is more common in infants and neonates.
Septic children may present with warm shock features
-which children get it
warm shock characterised by a wide pulse pressure and rapid capillary refill. The underlying haemodynamic abnormality is vasoplegia, which is more common in older children and adolescents.
Which vasopressor drug for cold shock
Adrenaline
Which vasopressor drug for warm shock
Noradrenaline
Shock what blood test should be done
CRP and LACTATE
2 signs of encephalitis
1) altered conscious state
2) focal neurological signs
Abx for meningitis- less than 2 months
Cefotaxime+ Benzylpenicillin
nil steroids
Abx for meningitis- more than 2 months
Ceftriaxone+Dexamethasone
Treatment for encephalitis
Aciclovir
Why use steroids in meningitis
Current evidence suggests that steroids may reduce the risk of hearing loss in bacterial meningitis.
Steroids are not recommended in neonates due to concern regarding effects on neurodevelopment.
What follow-up is needed for children who had meningitis
Audiology
All children with bacterial meningitis should have a formal audiology assessment 6-8 weeks after discharge (earlier if there are concerns regarding hearing).
The life-threatening complication in DKA
Cerebral oedema
Potassium levels are ok in this DKA, we don’t need to worry right?
Children with DKA are depleted in total body potassium regardless of the initial serum potassium level.
When you administer Insulin the potassium gonna get shifted so it is not the true value represented there
Biochemical criteria for DKA
1) Serum glucose >11 mmol/L
2) Venous pH <7.3 or Bicarbonate <15mmol/L
3) Presence of ketonaemia/ketonuria
Physically they don’t look unwell at first and BANG they are deteriorating
What should we be careful in DKA children when the assessment of hydration is done
The degree of dehydration is often over-estimated in DKA, this may be compounded by peripheral shutdown due to acidosis.
Excessive fluid replacement may increase the risk of cerebral oedema.
The following bloods are part of a diagnostic workup for first presentation T1DM:
1) Insulin antibodies, GAD antibodies, ZnT8 antibodies
2) celiac screen (total IgA, anti-gliadin Ab, tissue transglutaminase Ab)
3) TSH and fT4.
DKA state what bloods you would order
1) Serum glucose
2) Urea, creatinine and electrolytes (sodium, potassium, calcium, magnesium, phosphate).
3) Venous gas (including bicarbonate).
4) FBE (haematocrit may be elevated as a marker of dehydration, WCC may be elevated as a stress response).
5) Blood ketones (bedside test, normal <0.6mmol/L).
Urine
Dipstick for ketones, glucose and FWT
Culture if clinical suspicion of UTI
Consider ECG if potassium results will be delayed
The 4 goals of treatment of DKA
- Correct dehydration
- Reverse ketosis, correct acidosis and glucose
- Monitor for complications of DKA and its treatment: Cerebral oedema, hypo/hyperkalaemia, hypoglycaemia
- Identify and treat any precipitating cause
ECG DKA what you worried about
ECG changes related to potassium levels
hyperkalaemia: peaked T waves, widened QRS
hypokalaemia: flattened or inverted T waves, ST depression, PR prolongation).
DKA question: what should you state according to Dr.Yates
Always follow the local DKA protocol
If rural setting: call someone who is an expert in peads DKA management
What is the cut-off to add potassium to fluid or not
Add 40mmol/L potassium chloride to this fluid if the serum potassium ≤ 5.5mmol/L and the child is passing urine.
If anuric or serum potassium >5.5 mmol/L, do not add potassium to the fluids until this has resolved.
Treatment for cerebral oedema in DKA
Nurse head up
Reduce fluid infusion rate by one-third
Give mannitol immediately if cerebral oedema suspected – do NOT wait for cerebral imaging.
Discuss with consultant on call and liaise with intensive care or paediatric retrieval service to discuss transfer.
If the child becomes hypoglycemia in DKA
A BGL of <4.0mmol/L should be treated with additional glucose as below.
Do NOT discontinue the insulin infusion.
Signs of increased work of breathing/child with respiratory distress
1) Retraction
(intercostal, suprasternal, costal margin)
2) Paradoxical abdominal breathing
3) Accessory muscle use
Nasal flaring
Sternomastoid contraction (head bobbing)
Forward posture
4) ALOC
2 conditions for wheeze
Asthma and bronchiolitis
2 conditions for stridor
Croup and Upper Airway Obstruction
Croup treatment
Dex/Pred and consider adrenaline
Signs of deterioration and indications for urgent intervention are: in resp distress(3)
1) Hypoxia - worried, unsettled appearance, restlessness.
2) Fatigue or decreasing conscious state.
3) Increasing work of breathing.
A harsh, barking cough in a febrile, miserable, but otherwise well child suggests
Croup
Absent cough with low pitched expiratory stridor (often snoring) and drooling suggest.
epiglottitis.
Sudden onset in an otherwise well child with coughing, choking and aphonia suggests an
inhaled foreign body.
Swelling of face and tongue, wheeze or urticarial rash suggests
Anaphylaxis
High Fever
Hyperextension of neck
Dysphagia, pooling of secretions in throat
epiglottitis
retropharyngeal / peritonsillar abscess
Note: There is a high degree of overlap in clinical presentation between epiglottitis, bacterial tracheitis and upper airway abscess.
“Toxic” appearing child
Markedly tender trachea
bacterial tracheitis
Upper airway obstruction of a kid management
Allow child to settle quietly on parent’s lap in the position the child feels most comfortable.
DONOT DO ANYTHING TO IRRITATE THE CHILD(MINIMAL HANDLING)
Observe closely with minimal interference.
Treat specific cause - refer to Croup, Anaphylaxis and Foreign Body in the Airway guidelines.
Call PICU if worsening or severe obstruction.
Oxygen may be given while awaiting definitive treatment. This can be falsely reassuring because a child with quite severe obstruction may look pink in oxygen.
Intravenous access should be deferred - upsetting the child can cause increasing obstruction.(***)
Minimal handling is particularly important in:
Respiratory conditions, such as croup, asthma
How do you calculate amount dehydrate(% which is a deficit in the formula)
Previous weight(baseline weight)-current weight/previous weight x100
Gastroenteritis-should we do rapid resus or just trial of fluids
Trial of fluid is ideal cause everybody gets gastro and if the child is able to tolerate the fluids orally it is good
If severe then we are worried and then rapid NGT resus can be done
When should insulin be administered in DKA
- what is insulin going to do in DKA
1-2 hours after the commencement of IV fluid therapy
Insulin therapy is required to normalize the BGLand suppress lipolysis and ketogenesis- however in moderate and severe DKA, insulin IV is required
Hypoglycemia in kids
< or equal to 2.6mmol/L
ABCDEFG
If breathing holding spell is suspected/ or lets say febrile convulsion, what needs to be ruled out
Iron deficiency needs to be ruled out
What big 3 needs to be ruled out in a seizure in kids
1) Trauma
2) Intracranial infection
3) Hypoglycemia
When is a preventer warranted in asthmatic
> 6 attacks per year
“Complicated pneumonia” occurs when there is a complication such as
parapneumonic effusion, empyema, lung abscess, or necrotising pneumonia.
Should we do blood test and other investigations for pneumonia in children
Blood tests and microbiological investigations are NOT recommended for routine use in the diagnosis and management of CAP.
CPAP in a child examination findings-5
hypoxaemia ( <92%) on pulse oximetry
crackles and bronchial breathing on auscultation
the elevated respiratory rate for age
chest wall indrawing, retractions, grunting, nasal flaring
apnoea
absent breath sounds and a dull percussion note suggest a pleural effusion
DDX for acute asthma
Inhaled FB GERD DKA Pneumonia Croup Anaphylaxis
MDI dose for asthma in QLD
<20kg: 6 puffs
>20kg: 12 puffs
Pred dose for asthma
1mg/kg
Hypothermia or temp instability can be a sign of _____ in a febrile child
SBI
When should I do a CXR in a child with pneumonia
-should I do other investigations too?
If they are been admitted then you can consider doing it
Investigations including CXR, are NOT recommended for routine use in the diagnosis and management of CAP, particularly in those with mild disease who are expected to be managed as an outpatient. A CXR (posteroanterior view) is recommended for patients who require admission or if severe or complicated pneumonia is suspected.
Initial management for pneumonia inpatient
Admission to hospital is required for
- oxygenation
- fluid therapy or
- moderate to severe work of breathing.
Check oxygen saturation and provide supplemental oxygen if saturations are ≤92%. Administer oxygen to maintain saturations >92%.
If giving NG or IV fluids as maintenance therapy limit fluids to ½ or ⅔ of normal maintenance fluids to avoid fluid overload.
Advice regarding antibiotic management is summarised in the algorithm below. There is good evidence showing the equivalence of oral amoxicillin and IV benzylpenicillin.
If hospital admission is not required, what should be done
Discharge on oral amoxicillin TDS x5
When is pneumonia considered severe
Severe pneumonia should be considered if:
There are clinical features of pneumonia and 2 or more of the following: Severe respiratory distress Severe hypoxaemia or cyanosis Marked tachycardia Altered mental state
OR
There are clinical features of pneumonia with empyema
The most important parameters in the assessment of the severity of acute childhood asthma are:
general appearance/mental state and;
work of breathing (accessory muscle use, recession)
Severe asthma protocol- RCH
Involve senior staff.
Oxygen as above
Salbutamol-burst therapy–> another burst–>
Ipratropium-1 dose every 20 minutes for 1 hour only.
oral pred- 1mg/kg
consider other agents if not improving
Aminophylline
Magnesium sulfate
if signs of anapylaxis-
Consider Adrenaline. 0.01mL/kg of 1:1000 (maximum 0.5mL) intramuscular, into lateral thigh which should be repeated after 5 minutes if the child is not improving.
Definiton of anaphylaxis
Anaphylaxis is a multi-system allergic reaction characterised by:
SKIN+ (resp/cardio/gastro OR acute onset of hypotension/bronchospasm)
RCH
1) Any acute onset illness with typical skin features (urticarial rash or erythema/flushing, and/or angioedema),
PLUS
(2) Involvement of respiratory and/or cardiovascular symptoms and/or persistent severe gastrointestinal symptoms
OR
3) Any acute onset of hypotension or bronchospasm or upper airway obstruction where anaphylaxis is considered possible, even if typical skin features are not present)
How long can an anaphylaxis reaction last for and when can reaction occur
Most reactions occur within 30 minutes of exposure to a trigger but can occur up to 4 hours.
1st 5 steps in anaphylaxis
Remove allergen Do not allow- stand or walk Call for help High flow O2 Administer IM adrenaline
After anaphylaxis reaction, should I admit the patient
All children with anaphylaxis should be observed for at least 4 hours in a supervised setting with facilities to manage deterioration.
Admission for a minimum 12 hour period of observation is recommended if:
1) Further treatment is required within 4 hours of last adrenaline administration (biphasic reaction)
2) Previous history of biphasic reaction
3) Poorly controlled asthma
4) The child lives in an isolated location with delay to emergency services
GOR: it is normal, should we investigate
- is common, affecting at least 40% of infants
- usually begins before 8 weeks of age, peaks at 4 months and resolves by 1 year of age in the majority of cases
- does not cause crying and irritability in healthy infants. Infant crying peaks at 6-8 weeks, and hence some babies with simple GOR may also be unsettled
-rarely require investigations
GOR vs GORD
Gastro-oesophageal reflux disease is when GOR causes vomiting with:
refusal to feed pronounced irritability with feeding aspiration chronic cough, wheeze poor growth haematemesis
What are other condition can present as GORD
Cow milk protein allergy (CMPA) can present with similar symptoms to GORD.
Blood and/or mucous in stool, chronic diarrhoea or atopic risk factors make this diagnosis more likely.
What are the general measures for GORD
1) Positioning
2) Thickened feeds–> “Anti-reflux” formulas are pre-thickened, or alternatively, a thickening agent can be added to a standard formula or expressed breast milk.
3) Optimise feeds –> Observation and assessment of feeds by an experienced lactation consultant or Maternal Child Health Nurse (MCHN) can be helpful.
If GORD is suspected, what other condition needs to be ruled out
Cow Milk Protein Allergy (CMPA)
Specific measure for GORD
1) Consider cow milk protein exclusion: 2 weeks strict trial of the hydrolyzed formula for formula-fed babies and mother needs to follow strict dairy avoidance plan(ASCIA)
2) Consider acid suppressant therapy: Omeprazole- 4-week trial
3) Gaviscon junior is not going to help
What are the red flags symptoms of GORD
And signs
Reconsider diagnosis if any of the following red flag features are present:
Symptoms:
Vomiting that is bilious; has onset >6 months of age; or is consistent and forceful
Significant diarrhoea or constipation
Fever or lethargy
Signs:
Abdominal rigidity
Hepatosplenomegaly
Bulging fontanelle and/or increasing head circumference
Croup (Laryngotracheobronchitis)-
mild and moderate treatment
severe treatment
Minimise distress to the child as this can worsen upper airway obstruction.
Consider early transfer and involvement of senior staff if concerns regarding worsening upper airway obstruction.
For severe and life-threatening croup use nebulised adrenaline.
Less severe cases can be managed with corticosteroids alone.
Common in 6 months to 6 years and worse at night
Croup- 6 points on seen the child
- Barking cough
- Inspiratory stridor
- Hoarse voice
- May have associated widespread wheeze
- Increased work of breathing
- May have fever, but no signs of toxicity
Indications for LP
1) Suspected meningitis or encephalitis–> Meningitis, febrile convulsion, fever
2) Suspected Sub-arachnoid haemorrhage with a normal CT
(A normal CT scan does not tell you that the patient does not have raised ICP)
Contraindications for LP-8
1) Chid is so sick your going to give Abx even if CSF was clear/normal
2) Strong suspicious of meningococcal infection
3) Signs of increased ICP
4) Resp/cardio compromise
5) Coma
6) Seizure now or in the past 30 minutes
7) Coagulopathy
8) Local infection (in the area where an LP would be performed)
9) Focal neurological signs or seizures
Complications of LP
1) Failure to obtain a specimen / need to repeat LP/ Traumatic tap (common)
2) Post-dural puncture headache (fairly common) - up to 5-15%
3) Transient/persistent paresthesiae/numbness (very uncommon)
3) Respiratory arrest from positioning (rare)
4) Spinal haematoma or abscess (very rare)
5) Tonsillar herniation (extremely rare in the absence of contraindications above)
Which needle gauge is used in LP
22G or 25G bevelled spinal needles with stylet
Where are you going to insert the needle in LP
Draw an imaginary line between the top of the iliac crests. This intersects the spine at approximately the L3-4 interspace
Aim for the L3-4 or L4-5 interspace
Acute meningococcal disease- what is the immediate thing to be
Blood cultures
IV ceftriaxone / cefotaxime should be given as soon as meningococcal disease is suspected. If unavailable, give penicillin.
If the rash is blanching you do not need to worry right
Note: a blanching rash does not exclude meningococcal disease (can initially be macular, maculopapular)
BASICALLY any rash you need to RULE OUT MENINGOCOCCAL INFECTION
Acute meningococcal disease-investigations
Investigations should not delay antibiotic administration.
Blood (or marrow) culture should be obtained prior to antibiotic administration if possible. Meningococcal PCR (separate EDTA tube, minimum volume 0.2mL) CSF: For Gram stain (Gram-negative diplococci), culture, and meningococcal PCR if suspected meningitis and no purpuric rash or other contraindication to lumbar puncture. DO NOT delay antibiotics to obtain CSF.
Chemoprophylaxis for adult exposed to Acute meningococcal disease is
ciprofloxacin
child affected needs to be isolated
Iron deficiency in a child, what test is the best one
Serum ferritin is the most useful screening test for assessing iron stores. A ferritin of <20 μg/L is taken to indicate borderline/low iron stores.
Management for IDA in a child
Suggest iron supplementation and dietary modification if low ferritin, with or without anaemia.
Dietary advice
Increase iron-rich foods and reduce cow’s milk consumption.
See Iron dietary advice
Cow’s milk should not be offered to children < 12 months and should be limited to <500ml/day in those older than 12 months.
Consider referral to a dietitian.
What other drink can be given to absorb iron better in children
Iron is better absorbed if taken with vitamin C (e.g. orange juice)
Pale child: physical examination findings- 5
Pallor Pale conjunctivae Tachycardia Cardiac murmur Lethargy Listlessness Poor growth Poor concentration Weakness Shortness of breath Signs of cardiac failure Signs of haemolysis include jaundice, scleral icterus, splenomegaly and dark urine
4 test for anaemic child
FBC
ferritin
reticulocyte count
vitamin b12 and folate
donot need iron studies per se
Iron studies or serum iron should not be requested to diagnose iron deficiency.
What are the red flags in anaemia-6
Hb < 60g/L (including iron deficiency)
Tachycardia, cardiac murmur or signs of cardiac failure
Features of haemolysis (dark urine, jaundice, scleral icterus)
Associated reticulocytopenia
Presence of nucleated red blood cells on blood film
Associated thrombocytopenia or neutropenia may indicate malignancy or an infiltrative disorder
Severe vitamin B12 or folate deficiency
Need for red cell transfusion: Where possible defer transfusion until a definitive diagnosis is made.
What is the DDx for microcytic anaemia
IDA and thalassemia minors
What is the DDx for noromocytic anaemia
Haemolysis or blood loss
Marrow hypoplasia, leukemia
What is the DDX for macrocytic anaemia
Vitamin b12 and folate deficiency
Characteristic blood film findings include teardrop red cells and hypersegmented neutrophils
Macrocytic anaemia
Bite and blister cells
G6PD deficiency–> G6PD assay
Clinical features of CP
1) Follow up of “at risk” infants, such as those born prematurely
2) Delayed motor milestones, particularly learning to sit, stand and walk
3) Asymmetric movement patterns, for example, strong hand preference early in life
4) Abnormalities of muscle tone particularly spasticity or hypotonia
5) Management problems, for example, severe feeding difficulties and unexplained irritability. Many other conditions present with these features.
Does not reach milestones Seizure disorder Intellectual disabled Muscle weakness and/or atrophy Scissor gait
When does hand preference become a red flag
Definite hand preference before 1 year of age, suggests a one-sided muscle weakness and is a red flag for hemiplegia!
State some associated conditions with CP
Visual problems (approx 40%) eg strabismus, refractive errors, visual field defects and cortical visual impairment
Hearing deficits (approx 3 - 10%)
Speech and language problems
Epilepsy (approx 50%)
Cognitive impairments. Intellectual disability, learning problems and perceptual difficulties are common. There is a wide range of intellectual ability and children with severe physical disabilities may have normal intelligence
Management of the associated disabilities, health problems and consequences of the motor disorder in CP
Need MDT involvement
Associated disabilities
- all CP children need hearing and visual assessment
- Anticonvulsants for epilepsy
- Formal cognitive assessment
Monitor health problems
- Monitor growth and development
- GORD
- Constipation
- Lung disease and increase risk of aspiration
- Monitor VP shunts
- Osteoporosis
- Monitor dental health
- Mental health
Common presentations to the Emergency Department with CP-3
1) Respiratory problems particularly pneumonia
2) Uncontrolled seizures / status epilepticus
3) Unexplained irritability - consider acute infections, oesophagitis, dental disease, hip subluxation, pathological fracture. Review medications.
Consequences of motor disease on CP-3
1) Drooling–> speech pathologist
2) Incontience
3) Orthopaedic problems–> regular Hip-X-ray
Investigations you can order for FTT
FBE, ESR UEC, LFT Iron studies Calcium, phosphate Thyroid function Blood glucose Urine for microscopy and culture Coeliac screen if on solid feeds containing gluten Stool microscopy and culture Stool for fat globules and fatty acid crystals
1st most commmon vasculitis in children
HSP
2nd most common vasculitis in children
Kawasaki’s disease
The most common cause of acquired heart disease in children in developed countries causing coronary artery aneurysms (CAA).
Kawasaki’s disease
Early treatment with intravenous immunoglobulin (IVIg) has been shown to reduce morbidity and mortality.
CRASH and BURN mnemonic for KD
Kawasaki Disease: Diagnostic criteria.
Fever persisting for at least 5 days, PLUS 4 of the 5 criteria:
Conjunctivitis-Bilateral, “dry” or non-purulent, painless. Preferentially bulbar in distribution.
Rash-Polymorphous, variable presentations such as urticarial, morbilliform, maculopapular, or resembling scarlet fever.
Adenopathy-Cervical, most commonly unilateral, tender. At least one node >1.5cm.
Strawberry tongue-Intense hyperaemia of lips leading to redness and cracking and/or diffuse erythema of oropharynx and Strawberry tongue.
Hands and feets-Hyperaemia and painful oedema of hands and feet that progresses to desquamation in the convalescent stage.
Perineal desquamation frequently associated.
KD has 3 drugs for treatment what are they
1) INTRAVENOUS IMMUNOGLOBULIN (IVIg)
2) CORTICOSTEROIDS
3) ASPIRIN:
3-5mg/kg as a daily dose until normal echo on follow up (minimum 6 weeks).
Orbital cellulitis- why is it an emergency
Orbital cellulitis is an emergency with serious complications including intracranial infection, cavernous sinus thrombosis and vision loss.
Urgent imaging and surgical consultation (ENT and ophthalmology) should be considered for any child with suspected orbital cellulitis.
Which cellulitis is worse orbital or periorbital
Orbital cellulitis
treatment for uncomplicated impetigo
(uncomplicated localised): wash crusts off - topical mupirocin 2% ointment 8H
If extensive / multiple lesions present / not responding to topical treatment: treat as for cellulitis
Difference between SJS and TEN vs SSSS
Stevens-Johnson syndrome and toxic epidermal necrolysis present with mucosal involvement, SSSS doesn’t!
Steroids are contraindicated, as the etiology of SSSS is infectious! (They are, however, indicated in SJS and TEN.)
Complications of SSSS
The complications faced by SSSS patients are similar to those of patients with burns, as both have a compromised skin barrier:
Fluid and electrolyte imbalances
Thermal dysregulation
Secondary infections (e.g., pneumonia, sepsis)
palpable skull fractures, signs of a fractured base of skull in children
haemotympanum, racoon eyes, Battle’s sign and for CSF leak
Investigations for Global Developmental Delay
Chromosomes including Fragile X
Thyroid function test
Urine metabolic screen in global developmental delay
Neuroimaging
Other investigations depending on history and
examination (e.g. s lead)
Hearing assessment is essential in speech delay
Vision assessment
FBC and Creatinine Kinase
Abdominal pain in neonates
Time critical ones Hirschprung’s enterocolitis Incarcerated hernia Intussusception-->Vomiting is usually a prominent feature (but bile stained vomiting is a late sign and indicates a bowel obstruction) Meckel’s diverticulum Necrotising enterocolitis Testicular torsion Volvulus
Less time critical
Irritable/unsettled infant
UTI
Important non-abdominal causes of abdominal pain to consider:
Pneumonia
DKA
Sepsis
Toxin exposure or overdose
-dont forget to look for hernia and testes in the physical examination
Must do this test for Intussusception
USS
Medical causes of constipation
Cow milk allergy
Coeliac disease
Hypercalcaemia
Hypothyroidism
Surgical causes of constipation
Hirschsprung disease
Meconium ileus
Anatomic malformations of anus
Spinal cord abnormalities
Constipation
-how much is normal or concerning
Breastfed babies may defaecate as infrequently as once a week. and ≤2 stools/week
Red flags of constipation
Infants presenting <6 weeks age
Delayed passage of meconium – most infants pass meconium in the first 24 hours of life (consider Hirschsprung disease or anorectal malformation).
Ribbon like stools - consider anorectal malformation.
Weight loss/poor growth, persistent vomiting or PR blood loss
Abdominal mass (not consistent with large faecal mass)
Management of constipation
Behaviour Modifications
- position
- timing
- diary
Dietary modification
Medications
Rectal treatment with suppositories or enemas should be avoided.
Only Ix needed for HSP
Urinalysis
Most cases are self-limiting and require only symptomatic management
Classic presentation of HSP
-4 Main points are
It is most commonly seen in children 2-8 years of age.
In ~50% of cases there is a history of a recent upper respiratory tract infection
HSP is characterised by palpable purpura with arthritis/arthralgia (~50-75%), abdominal pain (~50%) and/or renal involvement (~25-50%) (haematuria/proteinuria/hypertension)
discussion with a Renal specialist is recommended if there is: Hypertension Abnormal renal function Macroscopic haematuria for 5 days Nephrotic syndrome Acute nephritic syndrome Persistent proteinuria
UTI confirmation- can it be done by dipstick
Urinary dipstick is a useful screening test, but a positive urine culture with pyuria confirms the diagnosis.
–> Pyuria and bacteria seen on microscopy are suggestive of UTI, but a positive culture is required to confirm the diagnosis
Oral antibiotics are appropriate for most children with UTI. Children who are seriously unwell and most infants under 3 months usually require IV antibiotics.
Seriously unwell children, those with renal impairment, and boys <3 months of age should have a renal ultrasound prior to discharge to exclude renal tract obstruction.
DDx for NAI/Child abuse
ITP
HSP
Leukemia
oestegenesis imperfecta
NAI include– Shaken baby syndrome–> retinal haemorrhage
NAI red flags
drug history in the family
Mental health in the family
Pathognomonic for NAI
Classic metaphyseal fractures
Sepsis in a child, what is the most important blood test
Lactate–> produced by all cells
NAI presentations in children
Subdural haematoma
Retinal haemorrhages
Posterior rib fractures
Metaphyseal chip fractures(corner fracture)
Bucket handle fracture–> distal femur and proximal tibia
and proximal humerus
Skull fracture–> eggshell, crush fracture crossing suture lines
Vertebral compression fractue in a child–> NAI
Midshaft fractures–> straight and spiral fractures
What are the red flags for acute otitis media and will warrant for Abx at the initial consultation
1) AOM in the only hearing ear(if they are congenitally deaf)
2) Cochlear implants–> discuss with ENT for IV abx
3) ATSI children
Otoscopy: tympanic membrane (TM) evaluation in AOM
Early findings
Retracted and hypomobile
Loss of light reflex
Red bulging TM with loss of landmarks
Complications of AOM-3
Tympanic membrane perforation
Acute mastoiditis
Otitis Media with Effusion (OME)
Acute tonsilits–> GABHS
- Supprative complications
- 3 non-supprative complications
Suppurative complications Peritonsillar abscess Parapharyngeal abscess Otitis media Sinusitis Cervical lymphadenitis Mastoiditis
Nonsuppurative complications
Rheumatic fever
Scarlet fever
Poststreptococcal glomerulonephritis
Prevention in the context of ARF/RHD:
- Primordial prevention
- primary prevention
- secondary prevention
- tertiary prevention
•primordial prevention: broad social, economic
and environmental initiatives were undertaken to prevent
or limit the impact of GAS infection in a population
•primary prevention: reducing GAS transmission,
acquisition, colonisation and carriage, or
treating the GAS infection effectively to prevent the
development of ARF in individuals
•secondary prevention: administering regular
prophylactic antibiotics to individuals who have
already had an episode of ARF to prevent the
development of RHD, or who have established
RHD in order to prevent the progression of the disease
•tertiary prevention: intervention in individuals
with RHD to reduce symptoms and disability, and
prevent premature death
Antistreptococcal serology for ARF include:
both ASO and anti-DNase B titres, if available (repeat 10–14 days later if first test
not confirmatory)
Long-term preventive measures once the diagnosis of ARF confirmed
First dose of secondary prophylaxis
Notify case to ARF/RHD register, if available
Contact local primary care staff to ensure follow up
Referral to a medical specialist
Provide culturally-appropriate education to patient and family
Arrange dental review and ongoing dental care to reduce risk of endocarditis
Appropriate RHD care plan
