Paeds Flashcards
name the 3 shunts in foetal circulation
foramen ovale
ductus arteriosus
ductus venosus
name the 4 left to right shunts
atrial septal defect
ventricular septal defect
atrio-ventricular septal defect
patent ductus arteriosus
describe an ASD and what are the most common types
hole connecting the 2 atria = leads to a shunt of blood moving from LA to RA = high pressure blood to lungs = RH failure and overload + pulmonary hypertension
ostium secundum = 80%
ostium primum = partial ASD
what are the symptoms of ASD
often asymptomatic in childhood or:
- sob
- difficulty feeding
- poor weight gain
older:
- recurrent chest - infections/wheeze
- heart failure
what are the clinical signs of ASD
fixed and widely split 2nd heart sound = pulmonary/aortic valves close at different times
ejection systolic murmur at left sternal edge in pulmonary area
possible palpitations
what investigations for ASD
chest XR = cardiomegaly wiht dilatation of pulmonary arteries
ECG = partial RBBB + right axis deviation
(partial ASD = left axis deviation)
echoCG = mainstay = shows anatomy
what is the management of ASD
small/asym = W&W
surgical closure/catheter closure
Anticoags in adults to prevent stroke complication
what is the most common cause of meningitis in the UK
neisseria meningitidis
what are the sepsis 6
WITHIN AN HOUR
1. high flow oxygen
2. blood cultures
3. obtain IV access + give IV ceftriaxone 80mg/kg
4. fluid resus of 20ml/kg 0.9% saline
5. measure lactate
6. measure urine
what is klinefelter syndrome and what are its features
XXY chromosomes = primary hypogonadism
- azoospermia + gynaecomastia
- reduced secondary sexual characteristics
- osteoporosis
- tall
- reduced IQ
** increased risk breast cancer
what is hypogonadotrophic hypogonadism
deficiency of LH and FSH
what is hypergonadotrophic hypogonadism
lack of response to LH/FSH by the gonads
what is the cause of hypOgonadotrophic hypogonadism and name some causes
= abnormal hypothalamus/pituitary function
- damage
- GH deficiency
- hypothyroidism
- hyperprolactinaemia
- serious chronic conditions (IBD/CF)
- excessive diet/exercise
- Kallman syndrome
what is the cause of hypERgonadotrophic hypogonadism
= gonads no response = no negative feedback = increased LH/FSH
- previous gonad damage
- congenital absence of gonads
- kleinfelters syndrome XXY
- turners syndrome XO
what is kallman’s syndrome
hypogonadotrophic hypogonadism
anosmia (no smell)
visual problems
craniofacial abnormalities
what is turners syndrome
45 X0
- often results in miscarriage
- lymphoedema hands/feet in neonate
- short stature (height 20cm below normal)
- gonadal failure
- webbing of neck/low hairline/big ears/high arched palate
- CVS malformations
- horseshoe kidney
name the causes of short stature
familial
constitutional delay in growth and development
malnutrition
chronic disease (IMD/CHD)
endocrine (hypothyroidism)
genetics (downs/turners)
skeletal dysplasia
how is constitutional delay in growth and puberty (CDGP) diagnosed
history/examination
XR of hand/wrist
bone age compared to actual age
name the causes of overgrowth with impaired final height
precocious puberty
congenital adrenal hyperplasia
hyperthyroidism
mcAlbright
name the causes of overgrowth with increased final height
androgen deficiency/oestrogen resistance
GH excess
Kleinfelter sydrome XXY/Marfan syndrome
what is psycho social short stature
seen over 3
emotional rejection/abuse associated
50% show reversible GH deficiency
what growth centile constitutes overweight and obese
overweight = BMI above 85th percentile
obese = BMI above 95th percentile
describe puberty in girls
breast bud first sign
early = under 8
late = over 13
describe puberty in boys
testicular enlargement first sign in boys
early = under 9
late = over 14
what genetic syndromes can cause short stature
turners
noonans
downs
russel-silver
causes of microcephaly
= familial
= autosomal recessive condition
= congenital infection
= acquired after insult to brain e.g. meningitis
causes of macrocephaly
= familial
= raised intercranial pressure
= hydrocephalus
= chronic subdural heamatoma
= tumour
= neurofibromatosis
causes of precocious puberty in girls vs boys
girls = usually early onset of normal puberty
boys = organic cause
- intracranial tumours
- adrenal cause
what is congenital adrenal hyperplasia
autosomal recessive
classic CAH = salt wasting type in boys 7-10 days = adrenal crisis
ambiguous genitalia = cliteral hypertrophy and labial fusion
describe the important causes of vomiting in neonates (5)
malrotation/volvulus = bilious
hirshprungs disease/meconium ileus = bilious
NEC = bilious
infection
describe the important causes of vomiting in infants (7)
GORD = feed associated
food intolerance = change in stools
pyloric stenosis = projectile
intussusception = 3-36 months/colicky, red currant jelly stools
strangulating hernia/obstruction = bilious
raised ICP = early morning
infection
describe the important causes of vomiting in older children (9)
appendicitis
strangulated hernia
pancreatitis
DKA - diabetes symptoms
meds/alcohol/drugs
post-op pain
psychiatric/eating disorder
pregnancy
infection - pyrexia
describe the investigations for acute vomiting
U&E
stool virology
abdo XR
surgical consultation
exclude systemic disease
describe the investigations for chronic vomiting
FBC
ESR/CRP
U&E
LFT
H.pylori serology
urinalysis
upper GI endoscopy
abdo USS
small bowel enema
brain imaging
test feed = pyloric stenosis
describe the investigations for cyclic vomiting
same as chronic +:
amylase
lipase
glucose
ammonia
what presentation is typical of pyloric stenosis
projectile vomiting at 2-7 weeks of age
what does bile stained vomiting suggest
intestinal obstruction
intessuseption
malrotation
strangulated inguinal hernia
what are the complications of vomiting
K deficiency
alkalosis
Na depletion
nutritional deficiency
FTT
anaemia
malloey-weiss tear
tear of small arteries
dental erosions and caries
oesophageal stricture/barrets oesoph
describe GORD in children
normal <12 months due to lower oesophageal sphincter immaturity
increased risk in neuromuscular kids (cerebral palsy)
effortless regurgitation
usually self-resolving
what is the best diagnostic test for GORD
24hr oesophageal pH monitoring
describe the management for GORD
upright position
feed thickeners
medication = antacid/H2 blocker/PPI
fundoplication if serious (rare)
what are the most common food allergens
cows milk
eggs
peanuts
wheat
soya
fish
shellfish
tree nuts
what are the clinical features of food allergy/intolerance
diarrhoea +/- bloody/mucus
vomiting
abdo pain
FTT
eczema
urticaria
red rash, particularly around mouth
asthma sympts/anaphylaxis if severe
what is the difference between a food allergy and an intolerance
food allergy = immunological response to food
intolerance = adverse reaction mediated by NON-immunological response = more common
describe cow’s milk protein allergy
most common allergy in infancy
Sx depend on site of inflammation:
upper GI = vomiting, pain
small intestine = diarrhoea, pain, FTT
large intestine = diarrhoea, acute colitis blood/mucus
what is the management of CMPA
limit cows milk protein intake *for mother if breastfeeding
give formula if bottle fed
dont give soya milk
after 6-12months consider cows milk challenge
what is toddler diarrhoea
commonest cause of loose stool in preschool children
undigested veg in stool common
children are well and thriving
no treatment
what is encoporesis
involuntary faecal soiling or incontinence
= emotional disorder
= more common in boys
= can be secondary to constipation
what pattern indicates constipation
less than 3 stools per week
hard, large stool
what is hirsprungs disease
absence of meyenteric plexus of rectum and colon
usually presents in newborn as intestinal obstruction + delay in passing meconium w/n 24hr
diagnose with suction rectal biopsy
management is surgical
describe the red flags for constipation
no meconium w/n 48hrs = hirsprung/CF
neurological signs
vomiting = obstruction/hirscprungs
ribbon stool = anal stenosis
abnormal anus
abnormal lower back/buttocks
FTT
acute severe abdo distention/pain/bloating
what is the most common cause of a UTI
E.coli
what would pseudomonas on a urine microscopy result suggest
structural abnormality
what is foaming urine indicative of
heavy protein loss in urine
name the acyanotic congenital heart diseases
left to right shunts:
- atrial septal defect
- ventricular septal defect
- atrioventricular septal defect
- patent ductus arteriosus
Outflow obstruction:
- coarctation of aorta
- aortic stenosis
- pulmonary stenosis
name the cyanotic congenital heart diseases
transposition of the great arteries
tetralogy of fallot
tricuspid atresia
describe the diagnostic criteria for anorexia nervosa
- deliberately keeping weight below 85% expected = eating/exercise
- dread of getting fat
- endocrine effects = delayed menarche/menstruation stops
describe the epidemiology of anorexia nervosa
1 in 250 female
1 in 2000 males
mean age of onset 16-17
describe the aetiology of anorexia nervosa
social pressure
perfectionist character traits
low self esteem
reversing/halting effects of puberty
family attitudes
some genetic links
depression/anxiety
occupation (ballet)
past or present events
describe the screening tool for eating problems
SCOFF
do you make yourself SICK because uncomfortably full
do you worry youve lost CONTROL over eating
have you lost more than ONE stone in 3 months
do you believe youre FAT when others say youre thin
does FOOD dominate your life
describe the clinical signs of anorexia nervosa
dry skin
lanugo hair
orange skin/palms
cold hands/feet
bradycardia
oedema
postural hypotension
weak proximal muscles
what is the mneumonic for appendicitis
MAGNET
Migration of pain to RIF
Anorexia
Guarding
Nausea
Elevated temp
Tenderness in RIF
what are the 2 most common causes of acute abdominal pain in children
non-specific pain
appendicitis
how does malrotation typically present
within first few days of life (but can at any stage of life)
obstruction
green bilious vomiting
blood in vomit = ischaemic bowel
abdominal pain
what are the investigations and management for malrotation
urgent upper GI contrast study = barium meal
treatment is urgent surgical correction (Ladd’s procedure)
what is indicated with bilious or bloody vomiting in children
upper GI contrast study is needed
describe the presentation of intussuseption
2 months - 2 y/o
paroxysmal/severe colicky pain
pallor during pain episodes
sausage shaped mass on examination
redcurrant jelly stool - later presentation
abdominal distension and shock
what is the most common cause of intestinal obstruction in infants after neonatal period
intussuseption - ileocaecal most common
what route for fluids if iv access cant be abtained
interosseous (into femur)
what antibiotic can you not give to neonates and why
ceftriaxone = causes jaundice
what causes purpura
skin microvessel thrombosis leading to heamorrhagic necrosis
peripherals effected due to reduced perfusion to distal tissue in shock
what is the 1st line prophylaxis for meningitis
ciprofloxacin
rifampicin also acceptable
describe the contraindications/complications for rifampicin
effect oral contraceptives
cause jaundice
person on anticoagulants
person on seizure medication
what types of fluids can be used for maintenance in children
0.45% sodium chloride + 5% dextrose
0.9% sodium chloride + dextrose
what is the rate for maintenance fluids in children
100ml/kg for first 10kg
50ml/kg for next 10kg
20mls/kg for the rest
what fluid maintenance is given to babies on day 0
10% dextrose only
when is a fluid bolus given
hypoglycaemia - 10% dextrose 2ml/kg STAT
hypovolaemia (shock) - 0.9% saline (even in neonate) 20mls/kg STAT
how is the deficit calculated for dehydration fluids
% dehydrated x 10 x weight in kg
advantages of breast feeding
macronutrients for baby
free antibodies for infection
free
maternal bonding
reduce NEC risk in preterm
reduce risk of post menopausal breast cancers
disadvantages of breast feeding
unknown intake
mother has to do all
breast milk jaundice
transmission of drugs/infections
insufficient vit D/K in breastmilk
why is important to refeed slowly in anorexia
refeeding syndrome = body take up glucose and excrete sodium/potassium
refeeding hepatitis
describe the diagnostic criteria for ADHD in under 17 year olds
6/9 inattentive symptoms
6/9 hyperactive/impulsive symptoms
- present before 12 yr old
- developmentally inappropriate
- several symptoms in 2 or more settings
- clear evidence symptoms intefere/reduce QoL (social/academic etc)
describe some features of inattentive symptoms
easily distracted
not listening
difficulty sustaining attention during activities
forgetful in activities
difficult to follow instructions
difficult to organise tasks
describe some features of hyperactive symptoms
squirms/fidgets
cant remain still
run/climbs excessively
‘on the go’
talks excessively
cannot do tasks quietly
describe some features of impulsive symptoms
blurts out answers to questions
cannot wait their turn
interrupts or intrudes on others
describe the epidemiology of ADHD
4-7% school age children
males: females 4:1
overlaps with many other mental disorders
what are some risk factors for ADHD
foetal oxygen deprivation
maternal smoking
low birth weight
prematurity
heroin use in pregnancy
genetic component
low socioeconomic status
other psychiatric disorders - aspergers/odd/tics
describe the non drug management of ADHD
parent education and training
CBT to support social skills etc
regular routines
rewards and targets to reach for
school support
describe the drug management of ADHD
stimulants (increase dopamine) = as needed:
- ritalin = short acting
- delmosart = long acting
- elvanse
non stimulants (breakdown norepinephrine) = regular taking:
- atomoxetine (SNRI)
- guanfacine
** or combination **
what is the efficacy of ADHD drugs
70% benefit of stimulant medication
significant side effects - cardiac/anorexia/anxiety/depression
describe the prognosis of ADHD
30% grow out of it
15% remain meeting criteria by 25
describe the epidemiology of ASD
1 in 100
500,000 in UK
boys x4 to girls
what are the cardinal symptoms of Autism SD
combination of difficulties of:
1. communication/speech and language
2. social interaction
3. behaviour rigidity/routines/rituals
describe some of the communication features of ASD
lack of desire to communicate
communicate needs only
disordered/repeated speech
poor non verbal comms
no social awareness
describe some of the social interaction features of ASD
no desire to interact
lack of motivation to please others
affectionate on own terms
no understanding of social cues
inappropriate touching/eye contact
plays alone/stressful to be with others
describe some of the rigidity/imagination features of ASD
use toys as objects
cannot play imaginatively
resist change
playing same game over/obsessions
learn by rote not by understanding
follows rules exactly
inability to see others point of view
describe the management of ASD
education/information
parenting workshops - timetables etc
school liaison/support
manage comorbidities
what are the features of an ‘innocent’ murmur
4 S’s
Soft blowing murmer
aSymptomatic
left Sternal edge
Systolic murmur
short duration
name the congenital infections to be aware of
CHRISTS
CMV
HSV
Rubella
hIV
Syphillus
Toxoplasmosis
what do you give a pregnant lady with syphillis
IM benzylpenecillin
how do you treat toxoplasmosis in pregnancy
spiromycin
what causes epiglottitis and what are some red flag signs
haemophilus B
high fever
drooling saliva
soft stridor
tripod stance/mouth open
how is epioglottitis managed
do not examine throat
paeds emergency!!!!!
anaesthetis and ENT surgeon needed
keep child calm
prepare for intubation
once airway secures = blood cultures
TX: cefuroxime
3-5 day abx
what is prophylaxis for epiglottitis
rifampicin for household contacts
what is the treatment for croup
1st line = oral dose dexamethasone
severe:
nebulised adrenaline
oral prednisolone
nebs steroids
what age group does bronchiolitis effect
up to 1 year old
rare after 1
what preventative treatment is given for bronchiolitis
pavlizumab = for high risk
- premy
- CF
- chronic heart/lung disease
what are the most common causes of pneumonia in newborn
group B strep
gram negative enterococci
= from mothers genital tract
what are the most common causes of pneumonia in infants/young kids
bacterial
= strep. pneum
= h.influenza
= bordatella pertussis
= chlamydia
= s.aureus
viral
= RSV
= rhinovirus
most common causes pneumonia in over 5s
strep. pneumonia
chlamydia pneumoniae
klebsiella
mycoplasma
most common cause of pneumonia in immune comprpmised
pneumocystitis jiroveci
TB
describe the indications for hospitalisation in pneumonia
sats <93%
severe tachypnoea/difficult breathing
grunting
apnoea
not feeding
family unable to provide care
describe the antibiotic treatment for pneumonia
newborn = broad spec (benpen + gentamycin)
older children = oral amoxicillin/erythromycin
describe the presentation of otitis media and what are the typical causative pathogens
irritable/miserable child
pulling at ear
6 months - 12 months most common
RSV
rhinovirus
pneumococcus
h.influenzae
describe the examination findings of tympanic membrane for otitis media +/- effusion
red
bulging
lack of light reflection
+effusion:
= dull and retracted
= visible fluid level
how is otitis media treated
simple analgesics
80% spontaneous resolution
possible amoxicillin
what is glue ear and how is it treated
otitis media with effusion
recurrent OM infections = reduce hearing
most common cause conductive hearing loss in children
no Tx or grommets
what are the most common causes of tonsillitis
viral
group A beta haemolytic strep
what indicates more likely bacterial tonsilitis
headache
apathy
abdo pain
tonsillar exudate/pus
cervical lymphadenopathy
what are the causes of proteinuria in children
transient
orthostatic
increased glomerular perfusion pressure
reduced renal mass
hypertension
tubular proteinuria
glomerular abnormalities: GN, minimal change, abnormal BM
what is the most common cause of nephrotic syndrome in children + name 4 other causes
- minimal change disease
- HSP/vasculitis
- SLE
- infections
- allergens
what are the 3 categories of nephrotic syndrome and who is high risk for each
congenital - finnish people
steroid sensitive - boys/asian/atopic
steroid resistant
describe congenital nephrotic syndrome
first 3 months of life
rare but very serious
end stage renal failure and dialysis needed
high mortality
what are the features suggesting steroid sensitive nephrotic syndrome
age 1-10
no macroscopic haematuria
normal BP
normal complement
normal renal function
often resp infections precipitate
how is steroid sensitive nephrotic syndrome managed and what is the prognosis
60mg/m squared/day prednisolone 4 weeks every day
40mg/m squared/day 4 weeks alternate days
relapses can occur
if continue to adulthood may need methotrexate
what is the prognosis of steroid RESISTANT nephrotic syndrome
30% go to ESRF in 5 years
20% respond to cytotoxic meds
most spontaneously remit in 5 years
describe the classification for FTT
mild = fall across 2 centile lines
severe = fall across 3 centile lines
name the classification of causes of FTT
inadequate intake
difficulty feeding
malabsorption
increased energy requirements
inability to process nutrients
what are some organic causes of FTT
impaired suck/swallow - cleft palate/neuromotor dysfunction
cardiac disease = breathlessness
malabsorption = coeliac/CF/intolerance
chronic illness = liver/heart/renal
excessive calorie loss = vomiting/protein loss
increased calorie need = malginancy/CF
chromosomal = downs
what investigations for FTT
FBC
U&E
inflamm markers
coeliac antibodies
chest XR/sweat test for CF
what is the acute treatment for paediatric UTI
trimethoprim 3 day course
or
co-amoxiclav 5 day course
fluids
analgesia
adjust abx once sensitivities return
what are the fraser guidelines
used to assess if underage person is competent to consent to treatment:
1. can understand advice
2. cannot be persuaded to inform parents
3. likely to continue sexual intercourse without protection
4. physical and mental health suffer if dont get contraception
5. its in her best interest to receive contraception wihtout parental consent
what is the definition of osteoporosis in children
1 + vertebral crush fractures
2+ long bone fractures by 10
3+ by 19
bone density <2.5 SD below mean
describe the causes of osteoporosis in children
inherited:
- osteogenesis imperfecta
- haematological
acquired:
- drugs (steroids)
- endocrine disorder
- malabsorption
- inflammation/immobility
describe the pathophysiology of osteogenesis imperfecta
autosomal dominant
type 1 collagen defect
different types:
type 2 fatal
chest too small to allow breathing/multiple rib fractures/no lung function
= brittle bones
= fragiel bones
how does osteogenesis imperfecta present
bone fragility/fractures/deformity
bone pain
impaired mobility
poor growth
deafness/hernia/valvular prolapse
what is a distinctive feature of osteogenesis imperfecta
blue tinted sclera
describe the XR features of osteogenesis imperfecta
wormian bones (wiggly black lines in skull) = bubble wrap feeling
bent bones
bowing of femur
complete chest collapse in type 2 fatal
what is the treatment for osteogenesis imperfecta
- bisphosphonates = pamidronate
- prefer given IV
- increase lumbar spine/total body bone mass - vitamin D supplements
- specialist MDT
describe the types of OI
type 1 mild
type 2 fatal
type 3 severe
type 4 moderate
describe the role of vitamin D
- inreases Ca absorption from gut
- increases Ca release from the bone
- decreases Ca excretion by kidney
- role in immune function
what is rickets and what are the risk factors
soft bones due to vitamin D or calcium deficiency
can be genetic (X linked)
insufficient vit D in pregnancy
lack of sunlights
dark skin
lack of dietary vitamin D
how does rickets present
bowed leg
hypocalcaemia convulsions
gross motor delay
swollen ankle
carpopedal spasm
incidental XR finding = splayed/frayed metaphyses
how is rickets/vitamin D deficiency treated
vit D supplement 400mg per day reccomended
inactive form because they can convert it themselves
how is estimated weight calculated
under 12 months = (age in months +9)/2
1-5 =(age in years +4) x 2
5-14 = age in years x4
what is the wet flag mneumonic and what are the equations
Weight = (age+4)x2
Energy = 4J per kg
Tube diameter = (age/4)+4
Fluid = 20ml x weight in medical, 10ml x weight in trauma
Lorazepam = 0.1mg x weight
Adrenaline = 0.1ml x weight of 1:10,000
Glucose = 2ml x weight of 10% dextrose
what are some causes of seizures in children
epilepsy
febrile convulsions
hypoglycaemia/hypocalcaemia
head trauma
infection (meningo/enceph/abcess)
amphetamines/stimulants
describe febrile convulsions
6 months - 6 years
high fever
simple = <15 mins
complicated = >15 mins
may reoccur, no lasting damage
what are some causes of funny turns in children
breath holding attack
reflexive anoxic seizures
syncope
migrain
vertigo
arrythmias
fabricated by parent
describe the distinctive features of temporal lobe seizures
strange warning feelings/aura
automatisms = lip smakcing/pacing
deja vu and jamais vu
impaired consciousness longer than absence
how are seizures investigated
witness history/video
thorough history incl family history
EEG
blood tests
metabolic investigations
what EEG features suggest absence seizures
3hrts spike and wave
what is the treatment for absence seizures
- sodium valproate/ethosuximide
- lamotrogine
what AED should be avoided in absence and myoclonic seizures
carbamezapine
what are the blood result criteria for DKA
BM over 11
bicarb under 15
ketones over 3
when are children’s hearing checked
newborn
starting school
if parents are concerned
what are the 2 categories of hearing loss and the underlying pathology
conductive = obstruction in ear canal preventing sound from getting through, can be reversible
sensorineural = nerve damage, irreversible
name some causes of conductive hearing loss in children (6)
congestion with cold most common
glue ear
ear wax
middle ear infection
perforated ear drum
structural abnormality
name 3 risk factors of conductive hearing loss
down’s syndrome
craniofacial syndromes
cleft palate
what is the exam finding of conductive hearing loss and how is it managed
better hearing through bone conduction
self limiting
ENT referral = grommets
hearing aids if permanent cause
what are some causes of sensorineural hearing loss (7)
many unknown
genetic/syndromal
perinatal trauma/infection/hypoxia
CMV/rubella in pregnancy
meningitis
premature babies
what is the examination findings in sensorineural hearing loss and how is it managed
hearing NOT better through bones
on audiology higher frequencies worst heard
= hearing aids
= cochlear implants
= aim to raise hearing so speech is audible
which cases are cochlear implants reserved for
profound hearing loss
high frequency
bilateral loss
meningitis loss
what are some long term affects of hearing loss
developmental delay
behavioural problems
impact on education/friendships/social life
name 3 syndromes associated with hearing loss
ushers syndrome (sensorineural)
wardenbergs syndrome (sensorineural)
treacher-collins (conductive)
what congenital infection most commonly causes hearing loss
cytomegalovirus
also:
rubella
syphillis
herpes
when does hearing need to monitored
chemotherapy
cystic fibrosis treatment
CMV
head trauma
cleft lip/palate
any of the syndromes associated with hearing loss
what is the difference between cyanotic breath holding spells and reflex anoxic seizures
cyanotic breath holding = stop breathing become blue and lose consciousness
= after crying
= involuntary
= tired/lethargic afterwards
reflex anoxic seizures = vagus nerve tells heart to stop beating = pale/unconscious/muscle twitches
= regain conc within 30 secs
= happens when child is startled/scared
up to what age is a squint normal
up to 12 weeks
what is strabismus and name some causes
misalignment of the visual axis
refractive errors = most common
cataracts
retinoblastoma
intra-occular problems
what are the 2 types of squint
non-paralytic/concomintant = refractive error
paralytic = due to paralysis of motor nerves (rare)
what tests can be done to detect a squint
corneal light reflex test = reflection of light should be in same position in both eyes
cover test = cover good eye and squinting eye will move
name the 3 refractive errors seen in childhood
hypermetropia (long sighted)
myopia (short sighted)
amblyopia (lazy eye)
what causes amblyopia and how is it treated
squint
refractive errors
ptosis
cataracts
treat early!! before 7 y/o
= glasses
= patching
how is strabisumus treated
glasses
orthoptic exercises
surgery = strengthen or weaken
botox injections
what infection most commonly presents with neonatal jaundice + investigations
= UTI
urine sample
blood cultures
CXR
FBC
what type of jaundice in neonates is most worrying
persistent/prolonged
what features suggest biliary atresia
pale stools
dark urine
off feeds/unwell
itching/scratch marks
what is the gold standard investigation for suspected biliary atresia
ultrasound liver
what counts as prolonged jaundice
> 14 days in term babies
21 days in premature
what is an important complication of jaundice
kernicterus
excess bilirubin causes brain damage
non responsive/floppy/drowsy baby
permanent damage = cerebral palsy/learning difficulties/deafness
what are the risk factors for neonatal hypoglycaemia
preterm
IUGR
diabetic mothers
large babies
polycythaemia
unwell babies
how does neonatal hypoglycaemia present
jitters
irritable
apnoea
lethargy/drowsiness
seizures
how is neonatal hypoglycaemia managed
regular blood glucose bedside monitoring
early and frequent milk feeding
if need top up = IV dextrose via central venous catheter
describe an APGAR score
between 1 and 10
7-10 normal
cardio
resp
colour
reflexes
tone
how does group B strep present in neonates and what is the mortality
pneumonia
septicaemia
meningitis (not as common)
mortality = 10%
which women are high risk for GBS and are screened
pre-term delivery
previous baby with GBS
prolonged rupture of membranes
fever over 38 in labour
postpartum Abx given to high risk ladies
how is conjunctivits in the newborn managed
usually just water/saline
if troublesome discharge could staph/strep = neomycin eye ointment
gonococcal infection (48hrs after birth)= treat with penicillin or cephalosporin, cleanse frequently
chlamydia (2 weeks after birth) = oral erythromycin for 2 weeks
what are the features of juvenile myoclonic seizures
occurs in the teen years
early morning sudden myoclonic jerks = clumsy?
triggered by lack of sleep
often later develop generalised tonic-clonic (GTC) seizures
may be inherited as autosomal dominant
40% with absence seizures will develop JME
a teenager spills their cereal every morning - what is this an indicator of
juvenile myoclonic epilepsy
what are the side effects of sodium valproate
teratogenic
weight gain
what is ebstein’s anomaly and when does it present
tricuspid valve is lower = larger RA, smaller RV
= poor flow to pulmonary vessels
associated with ASD = right to left shunt = cyanosis
presents couple days post natal = when PDA closes
what are the clinical findings for ebsteins anomaly
ECG
= arrhythmia
= RBBB
= left axis deviation
CXR = cardiomegaly/RA enlarge
echocardiogram = definitive diagnosis
how is ebsteins anomaly treated
treat arrythmia
treat heart failure
abx prophylaxis for IE
surgical to correct
what findings are suggestive of a UTI
positive nitrites positive leucocytes
just positive nitrites
nitrites = better indicator of infection
describe the treatment of a UTI in an infant
all <3 months old with fever = IV abx and sepsis screen
oral abx if over 3 months and well:
- trimethoprim
- nitrofurantoin
- cefalexin
- amoxicilin
describe the need for ultrasound for UTI
all under 6 months first UTI = abdo USS within 6 weeks
children with recurrent UTI = abdo USS within 6 weeks
children with atypical UTI = abdo USS during the illness
describe the risk factors for DDH
1st child
breech presentation from 36 weeks
breech at birth
multiple pregnancy
name the tests to screen for DDH
ortolani test = abduct hips to see if hips dislocate anteriorly
barlow test = pressure on knees/femur to see if femoral head dislocate posteriorly
clicking = normal
clunking = need ultrasound
how is DDH investigated
ultrasound of hips for all children with findings or risk factors
XR useful in older children
describe the management for DDH
pavlik harness if under 6 months = keeps hips flexed and abducted
regular review
surgery if harness fails or >6 months old
describe the features of ulcerative colitis (CLOSE UP)
Continuous inflammation
Limited to colon/rectum
Only superficial mucosa
Smoking is protective
Excrete blood/mucus
Use AMINOSALICYCLATES
Primary sclerosing cholangitis
describe the features of Crohns (NESTS)
No blood/mucus
Entire GI tract
Skip lesions
Terminal ileum most common and Transmural
Smoking risk factor
what is pyloric stenosis and how does it present
hypertrophy and narrowing of pylorus = peristalsis of the stomach sends contents up oesophagus = vomiting in first few weeks of life
- thin
- pale
- FTT
- hungry
- PROJECTILE vomiting
firm round mass in upper abdomen (olive-like)
metabolic alkalosis from loss of stomach acid
how is pyloric stenosis managed
Dx = abdominal USS
laparoscopic pyloromyotomy (Ramsted’s operation) = widens pylorus
what is gastroenteritis and what are the most common causes
inflammation from stomach to intestines with nausea, vomiting and diarrhoea
most common causes = viral:
rotavirus
norovirus
what is biliary atresia and how is it treated
narrow or absent bile duct = cholestasis = no bile excreted = buildup of conjugated bilirubin = jaundice >14 days (term bb) >21 days (prem bb)
treat with surgery = Kasai portoenterostomy = attach small intestine to liver
often need full liver transplant
what is oesophageal atresia
congenital abnormality = blind ending oesophagus
can have >1 fistulae connecting trachea as well = tracheo-oesophageal fistulae (TOF)
associated with other anomalies = VACTERL syndrome
how does oesophageal atresia +/- TOF present
first few hours from birth:
respiratory distress
choking
feeding difficulties
frothing at mouth
NG tube not possible
overflow of saliva
aspiration can occur
how is oesophageal atresia investigated and treated
CXR to assess lung fields + if theres TOF
imaging renal tract = assess urogenital tract
‘gap-o-gram’ to assess length of oesophagus
Mx: correct abnormality
= surgery
= supportive feeding and hydration
what is duodenal atresia and how does it present
gap or narrowing in duodenum
present with bile green vomiting after feeds within first few days of life
association with downs syndrome
how is duodenal atresia diagnosed and treated
abdo XR = 2 large air sacs (double bubble)
surgical management
describe the causes of clubbing in children
hereditary
infective endocarditis
cyanotic heart disease
cystic fibrosis
liver cirrhosis
IBD
TB
what are the most common causative organisms for chest infections in cystic fibrosis
staph aureus = flucloxacillin long term to prevent
pseudomonas = hard to treat, worse prognosis
= tobramycin or ciprofloxacin
describe the management of hypoglycaemia in T1DM
too much insulin = low blood sugar
pale/irritable/hungry/tremor/sweating
treat with rapid acting insulin (lucozade) followed by long acting (toast/biscuits)
severe = IM glucagon and IV dextrose
nocturnal hypoglycaemia very common
describe the complication of hyperglycaemia in T1DM
BM too high but not DKA = alter insulin regimen
what is mesenteric adenitis
inflammation of lymph glands of the mesentery = umbilical/RIF abdominal pain
common in children/teenagers
fever/nausea/diarrhoea/cold sympts just before
painkillers and supportive care
describe the pathophysiology of viral induced wheeze
children under 3 have smaller airways, smaller diameter
virus = oedema and inflammation = airways constrict and narrow
wheeze + lack of ventilation = respiratory distress
what is the difference between viral wheeze and asthma
viral wheeze:
children <3
no atopic history
only during viral infections
what is the presentation and management of viral induced wheeze
coryzal sympts roughly 2 days before wheeze
shortness of breath
signs of respiratory distress
widespread expiratory wheeze
management same as acute asthma management
what causes whooping cough and how does it present
bordatella pertussis gram neg bacteria
coryzal sympts and dry cough then develop paroxysmal coughing attacks with loud inspiratory whoop
coughing can cause fainting, vomiting, pneumothorax
children may not make whooping sound
how is whooping cough diagnosed and treated
nasal/nasopharyngeal swab PCR tested/cultured
cough >2 weeks = can test for anti-pertussis toxin IgG
notify public health
supportive care
macrolides good in vulnerable people (erythromycin/clarithromycin etc)
contact tracing
what is diptheria and how does it present
cornyebacterium diptheria causes mucosal membrane inflammation
severe sore throat
mild pyrexia
lymphadenopathy
tachypnoea
grey membrane over tonsils
how is diptheria diagnosed and treated
throat swab = irregular gram +ve rods
treat with antitoxin
isolation for the individual to prevent spread
what is scarlet fever
disease caused by strep pyogenes (group A strep)
highly contagious - aerosol or direct contact spread
most common ages 2-8
how does scarlet fever present
sore throat/fever/nausea/vomiting
pin point sandpaper-like blanching rash on trunk developing 12-48 hours after initial sympts - spreads to rest of body
possible strawberry tongue + cervical lymphadenopathy
how is scarlet fever diagnosed and managed
clinical diagnosis
oral antibiotics e.g. phenoxymethylpenicillin for 10 days
notify public health
isolation
describe the complications of scarlet fever
otitis media
peritonsillar abcess
acute sinusitis
rheumatic fever
acute post strep GN
what is congenital diaphragmatic hernia
birth defect of diaphragm = abdominal organs pushed into chest cavity = pulmonary hypoplasia and pulmonary HTN
causes severe respiratory distress at birth
Bochdalek most common type
treated surgically to repair hernia while child is intubated
40-62% mortality rate
what is meconium aspiration syndrome
respiratory distress in newborn due to presence of meconium in the trachea
if born in meconium stained amniotic fluid = at risk of developing
diagnosis confirmed through CXR
management is supportive
ECMO and NO may be needed if persistent pulmonary HTN
what are some risk factors for meconium aspiration syndrome
gestation >42 weeks
maternal Hx of HTN/preeclampsia/smoking/substance abuse
foetal distress
oligohydramnios
describe retinopathy of the newborn
retinal vessel growth stimulated by hypoxia
if exposed to too much oxygen = excessive abnormal blood vessels and scar tissue form = causes retinal detachment
describe the diagnosis of retinopathy of the newborn
screening for all born <32weeks or <1.5kg
performed by opthalmologist at 30-31 wk gestational age if born <27wks
4-5wk of age if born >27wk
happen every 2 weeks until around 36 weeks gestation
examination = retinal vessels and signs of plus disease
how is retinopathy of the newborn treated
transpupillary laser photocoagualation = stops new blood vessels developing
cryotherapy also option
describe transient tachypnoea of the newborn
newborns present with tachpnea and respiratory distress due to delayes absorption of lung fluid following birth
risk factors:
- C sections
- maternal asthma and smoking
- premature infants
- male sex
- PROM
frequently resolves within 72 hours
how is transient tachypnoea of the newborn diagnosed and treated
clinical diagnosis
ABG to assess gas exchange
pulse oximetry
supportive treatment for resp distress
rule out pneumonia and meconium aspiration
describe the causes of primary nocturnal enuresis
= child has never had a dry night
overactive bladder
fluid intake prior to bedtime
failure to wake due to deep sleep/weak signals
psychological distress and stress
secondary
what is the management for primary enuresis
reassurance - probably resolve
lifestyle changes - less fluid b4 bed etc
encouragement and positive reinforcement
treat underlying factors
pharmacological tx
what is secondary enuresis and what are the causes
= child begins wetting bed after dry period of at least 6 months
UTI
constipation
T1DM
new psychosocial stress
maltreatemnt
abuse/safeguarding
describe the pharmacological treatments for enuresis
desmopressin = ADH = reduces volume of urine produced by kidneys
oxybutinin = anticholinergic reducing contractility of bladder
imipramine = tricyclin antidepressant may relax the bladder
what is nephritis and what is it caused by and what are the features
inflammation of nephrons
caused by post strep GN and IgA nephropathy
= nephritic syndrome
1. reduction in kidney function
2. haematuria
3. proteinuria (not as much as nephrotic syndrome)
describe the diagnosis and treatment of post strep glomerulonephritis
1-3 weeks post Beta strep infection e.g. tonisilitis
supportive management with 80% full recovery
impaired renal function = may need antihypertensives and diuretics for oedema
describe the diagnosis and treatement of IgA nephropathy causing nephritis
aka Berger’s disease
related to HSP
renal biopsy will show IgA deposits
usually teenagers/YA
supportive management and immunosuppressent medications (steroids/cyclophosphomides)
what is status epilepticus and how is it managed
medical emergency = seizure >5 mins or >3 in and hour
ABCD approach:
- secure airway
- oxygen
- cardiac/resp functino
- blood glucose
- IV lorazepam
- IV phenobarbital/phenytoin
- transfer ITU
describe junior myoclonic epilepsy
occurs in teen years
triggered by lack of sleep
early morning myoclonic jerks (arms/shoulders)
often later develop GTC seizures
may be autosomal dominant inheritance
describe petit mal seizures
brief staring spells lasting a few seconds at a time
abrupt onset and termination
child may be unaware
1/3rd will have 1+ tonic clonic convulsions
describe acute chest syndrome and how it is managed
- fever/resp sympts
- new infiltrates seen on CXR
can be infective or non infective cause
= medical emergency with high mortality
treat underlying cause:
- antibiotics/antivirals
- blood transfusions
- incentive spirometry
- artificial ventilation
whats the most common cause of meningitis in neonates
group B strep contracted during birth
how might meningitis present in a neonate/baby
non specific
hypotonia
poor feeding
lethargy
hypothermia
bulging fontanelle
how is meningitis investigated
clinical examination
kernig’s test = lift bent leg then straighten from knee = pain
brudzinski’s test = gently lifting head and neck off bed = involuntary hip/knee flexion
lumbar puncture
what level is a LP performed at
L3-L4 intervertebral space
describe the causes of acute glomerulonephritis
common:
post infectious GN
HSP
IgA nephropathy
less common:
SLE
Membranoproliferative GN
focal segmental glomerulosclerosis
name the causes of headaches in children
tension
migraines
ENT infection
analgesic headache
vision problems
raised intracranial pressure
brain tumours
meningitis/encephalitis
carbon monoxide poisoning
describe tension headaches
very common in children
band-like, symmetrical, gradual occur and resolve
NO visual problems
resolve within 30 mins
triggered by stress/dehydration/hunger
how are migraines managed in children
rest/fluids/low stimulus environment
paracetamol/ibuprofen
sumatriptan
antiemetics
prophylaxis in severe cases:
propranolol (CI in asthma)
pizotifen (cause drowsy)
topiramate (teratogenic)
what is abdominal migraine
common in young children - go on to develop migraines
central abdo pain >1 hour
normal examination
nausea/vom
anorexia
headache
pallor
what is gowers sign and when is it seen
to stand from lying down, child pushes hips up and out like downward dog and walks hands up legs = due to proximal muscle weakness in muscular dystrophy
what causes duchennes muscular dystrophy
defective gene for dystrophin on X chromosome = X linked recessive inheritance
describe DMD
boys around 3-5 with weakness around pelvis muscles
progressive weakness
life expectancy 25-35
cardiac and respiratory complications
describe beckers muscular dystrophy
dystrophin less severely affected
presentation at 8-12 yr old
longer life expectancy
describe myotonic dystrophy
genetic disorder presenting into adulthood
progressive muscle weakness
prolonged muscle contractions (unable to let go shaking hand)
cataracts
cardiac arrhythmias
what is facioscapulohumeral muscular dystrophy
progressive weakness around face, shoulders, arms
sleep with eyes slightly open and unable to purse lips
what is emery dreifuss muscular dystrophy
presents in childhood
contractures elbows/ankles
progressive weakness/wasting of muscles starting in upper arms/lower legs
what is west syndrome
= infantile spasms
rare disorder
onset around 6 months old
cluster of full body spasms
ppor prognosis = 1/3rd die by 25
treat with prednisolone and vigabatrin
what is friedreich’s ataxia
autosomal recessive neurodegenerative disease
associated with cardiomyopathy/diabetes
onset before adolescence
- progressive ataxia
- ascending weakness and loss - of vibration/proprioception
- scoliosis
- cardiomyopathy/arrhythmias
what presents identically to friedreichs ataxia
vitamin E deficiency
how is freidreichs ataxia diagnosed and managed
nerve conduction studies
ECG/echocardiogram
exclude vitamin E deficiency
MDT treatment - mainly supportive with physios and occupational therapists
treatment of cardiac issues
life expectancy 40-50
what is neurofibromatosis and what is the difference between type 1 and 2
autosomal dominant genetic disorder causing tumours to form on nerve tissue
type 1 (more common) = recklinghausens disease = neurofibromas grow on nerves and compress nerves/tissue
type 2 = bilateral acoustic neuromas develop causing hearing loss
describe the difference in presentation between neurofibromatosis 1 and 2
type 1
cafe au lait spots
freckling
dermal fibromas
nodular neurofibromas
lisch nodules (eyes)
short stature/microcephaly
type 2
cafe au lait spots
deafness
vertigo
tinnitus
signs of raising ICP
how is neurofibromatosis managed
supportive and monitoring progress in all areas
treat comlications e.g. HTN/epilepsy/ADHD
describe some risk factors for neural tube defects
family history
chromosomal disorders
inadequate folate intake
folic acid antagonists (methotrexate)
anti-epilepsy drugs
describe the types of neural tube defect
anencephaly = absence of major portion of brain, skull and cap = cranial end of neural tube fails to close
cephaloceles = brain matter herniate through skull
spina bifida occulta (most common) = neural tube fail to close at caudal end but isolated laminar effects = usually only tuft of hair etc
spina bifida cystica = defect of lumbar/sacral vertebrae = can be incidental/myelomeningocele/asymmetrical LMN weakness and wasting and limb deformity
how are neural tube defects diagnosed
MRI/CT scan
USS antenatally
prenatal screening = measure maternal alpha fetoprotein
second trimester USS most accurate
what is tuberous sclerosis and how does it present
wideranging multisystem disorder = harmatomas in many organs
commonly brain/skin/kidney
commonly present in childhood with SKIN changes and EPILEPSY
renal angiomyolipomas/lung tumours
cognitive and behavioural problems
treat and support each problem individually
describe extradural haemorrhage in children
rare due to plasticity of skull
= bleeding between dura and skull
due to fractured temporal/parietal bone damaging middle meningeal artery
history of trauma/head injury with loss of consc followed by lucid period before deterioration
headahce/nausea/vomiting
CT = lemon shape
avoid LP
may need mannitol to reduce intracranial pressure
may need burr holes
describe subdural haemorrhage in children
bleeding between dura and arachnoid mater due to tearing of bridging veins between cortex
often due to acceleration-deceleration of head/blunt head trauma = shaking baby/abuse
headache/possible loss of conc
CT (with contrast) = banana shape
opthalmology for retinal haemorrhages if shaken baby suspected
mannitol/burr holes/surgery
craniotomy/clot evacuation
describe subarachnoid haemorrhage in children
rare!
caused by trauma = ?child abuse
severe headache sudden onset
nausea/vomiting/loss of consc/neuro deficits
CT = star shaped
surgical intervention
what is hereditary spherocytosis and how does it present
RBC sphere shaped = autosomal dominant
common in northern europe
jaundice
anaemia
gallstones
splenomegaly
haemolytic crises = symptoms more severe
aplastic crises = parvovirus = no bone marrow response so severe anaemia/jaundice
how is hereditary spherocytosis diagnosed and managed
family history and clinical features
blood film = spherocytes
MCHC = raised
reticulocytes = raised due to rapid RBC turnover
Tx: folate supplement and splenectomy
removal of GB if stones persistant problem
transfusions during severe crises
what is G6PD deficiency
= defect in G6PD enzyme
more common mediterranean/middle east/african
X linked recessive pattern = males affected
causes crises triggered by:
infections
medications
fava beans
crises = RBC attacked by reactive oxygen species = haemolysis
how does G6PD deficiency present and diagnosed
** neonatal jaundice **
anaemia
intermittent jaundice
gallstones
splenomegaly
Heinz bodies on blood film = denatured Hb within RBC
G6PD enzyme assay for diagnosis
how is G6PD managed
avoid triggers:
antimalarial
ciprofloxacin
nitrofurantoin
trimethoprim
what is thalassaemia
autosomal recessive genetic defect in protein chains of Hb
alpha (chrom 16)
= depletion of alpha chains
= more severe if more genes affected
= african/asian pop
beta (chrom 11)
= depletion beta chains
= no. genes affects NOT = severeity
= european pop
how can thalassaemia present
microcytic anaemia (low MCV)
fatigue
pallor
jaundice
gallstones
splenomegaly (increased RBC breakdown)
pronounced forehead/malar eminences (bone marrow expands to produce extra RBC)
how is thalassaemia diagnosed
FBC = microcytic anaemia
haemoglobin electrophoresis = globin abnormalities
DNA testing for genetic abnormality
how is alpha thalassaemia managed
monitor for FBC and complications
blood transfusions
splenectomy
bone marrow transplant
how is beta thalassaemia managed
minor = monitor mild microcytic anaemia
intermedia = significant anaemia = blood transfusions, may require iron chelation
major = 2x deletion genes = severe anaemia and FTT = regualr transfusion/iron chelation/splenectomy/BM transplant
what is a common complication of thalassaemia
iron overload
= monitor ferritin levels
= limit transfusions and perform iron chelation
effects:
fatigue
liver cirrhosis
infertility
impotence
heart failure
arthritis
diabetes
what is haemophilia
inherited condition X linked recessive
type A = more common = lack of factor VIII
type B = lack of factor IX
prothrombin time normal
partial thromboplastin time increased
presents with bleeding/bruising/haematomas e.g. prolonged umbilical bleeding in neonate
mild to severe disease presentation
how is haemophilia managed
replace missing clotting factors with regular infusion
type A = factor VIII
type B = factor IX
what is idiopathic thrombocytopenic purpura ITP
spontaneous low platelet count causing purpuric rash
caused by type 2 hypersensitivity reaction = antibodies destroy platelets
can be triggered
presentation:
bleeding
bruising
petechial/purpuric rash (non blanching)
how is ITP managed
urgent FBC for plt count = confirm Dx
exclude other causes e.g. leukemia
usually no treatment required
plt <10 or actively bleeding:
prednisolone
IV Ig
blood transfusions
platelet transfusion (only temporary)
what are the complications and advice for ITP
chronic ITO
anaemia
intracranial and subarachnoid haemorrhage
GI bleeding
= avoid contact sports
= avoid NSAIDs/blood thinners/bleeding procedures
what is perthes disease
disruption of bloodflow to femoral head = avascular necrosis = affects epiphysis of femur
4-12 y/o with common 5-8y/o
no clear cause
revascularisation + healing of femoral head can lead to soft and deformed femoral head = early OA
how does perthe’s disease present and how is it diagnosed
slow onset + no Hx of trauma
pain in hip/groin
limp
restricted movement
referred pain to knee
- XR (can appear normal)
- bloods to exclude other causes
- technetium bone scan
- MRI
how is perthes disease managed
severity varies
conservative Mx in younger/milder
bed rest
traction
crutches
analgesia
= reduce risk of damage/deformity when healing
= physio/regular XR/surgery in severe cases
describe slipped upper femoral epiphysis and its presentation
head of femur displaced along the growth plate
8-15y/o (12y/o common) and boys>girls
Px
adolescent obese male undergoing growth spurt with Hx minor trauma
- hip/groin/knee pain disproportionate to minor trauma
- RoM hip
- painful limp
examination = prefer external rotation of hip with PAIN with internal rotation of hip
how is SUFE diagnosed and managed
bloods = normal/to exclude
xr of both hips AP and frog leg
= in situ fixation with cannulated screw
= internal fixation across growth plate
describe osgood-schlatter disease
inflammation at tibial tuberosity at patella tendon insertion due to stress from activity and exercise
= multiple small avulsion fractures = cause visible lump below knee = tender and inflamed
pain in anterior knee
pain worse by activity/pressure
once healed = non tender and hard lump
how is osgood-schlatter disease managed
reduction in physical activity
ice
NSAIDs
stretching/physiothreapy
symptoms usually resolve - may have small lump under knee
what is chondromalacia patellae
= softening of articular cartilage of patella seen on MRI
= patellofemoral pain syndrome
inflammation and pain in and around patella
caused by compressive forces from exercise or long periods of knee flexion
common in sporty and active adolescents/YA
treat with physio/analgesia
what is patellar tendonitis
= ‘jumpers knee’
inflammation at patellar tendon due to overuse
adolescents = sinding-larsen johansson disease = chronic stress injury
= anterior knee pain and tenderness
XR may be normal
USS examination of choice = shows swelling
rest/analgesia/physio to treat
what is osteochondritis dissecans
pathological process affecting subchondral bone of children with open growth plates
affects knee mainly
trauma/male/overuse/family hx = risk factors
= vague aching pain/oedema/formation of loose bodies in joint/latching and catching joint
XR show loose body
USS/CT showing lesions
MRI best for evaluation
Tx = analegesia/physio/surgery
what is achondroplasia
= dwarfism
= FGFR3 gene on chromosome 4
= autosomal dominant inheritance
homozygous gene mutation = fatal in neonatal period
what are the features of achondroplasia
disproportionate short stature (4 ft)
short limbs
short digits
bow legs
disproportionate skull
foramen magnum stenosis (cervical cord compression/hydrocephalus)
recurrent otitis media due to cranial abnormalities
obesity
obstructive sleep apnoea
what is molluscum contagiosum
viral skin infection caused by type of poxvirus
small flesh coloured papules with central dimple
appear in crops of lesions
spread through direct contact/shared linens
avoid scratching/breaking skin as can cause additional infection
clear up spontaneously up to 18months
can treat with potassium hydroxide/benzoyl peroxide/imiquimod
surgical removal is option but can cause scarring
describe scabies
tiny mites (sarcoptes scabiei) burrow under skin cauing intense itching and small red dots rash
finger webs common area
easily spread so ask about contacts with itching
treat with permethrin cream = need to be applied to entire body and left for 8-12 hours then washed off
= repeat after a week
oral ivermectin single dose option for difficult to treat
all household needs treatment and deep clean all linens and carpets
crotamiton cream for itching
what are crusted scabies
norwegian scabies
serious infestation with scabies in immunocompromised
can present like psoriatic plaques with no ithcing
may require hospital treatment and isolation
what is impetigo
superficial bacterial skin infection
caused by staph aureus
also can be caused by strep pyogenes
VERY infectious = no school during infection
what is non-bullous impetigo
occur around nose/mouth
exudate dries = golden crust
treat with topical fusidic acid
oral flucloxacillin to treat more widespread
advise measures to avoid spread
what is bullous impetigo
always caused by staph aureus = epidermolytic toxins that break down skin proteins = fluid vesicles form then burst = golden crust
painful and itchy
more common neonates + <2y/o
can have systemic symptoms
swabs to confirm Dx
flucloxacillin treatment
very contagious = isolation needed
what are the complications of impetigo
cellulitis
sepsis
scarring
post strep GN
staph scalded skin syndrome
scarlet fever
what is erythema multiforme
erythematous rash caused by hypersensitivity reaction
caused by viral infections and medications e.g. HSV/mycoplasma pneumonia
widespread itchy red rash with target lesions
sypmts abrupt onset + mild fever/stomatitis/muscle aches/flu-like sympts
Tx underlying cause
mild and should resolve spontaneously
what is staphylococcus scalded skin syndrome (SSSS)
staph aureus release toxins break down skin proteins = infection
affects children <5
generalised patches of erythema –> fluid blisters (bullae) –> burst and scar = scalded
Nikolsky skign = gentle rubbing of skin causes it to peel away = confirm SSSS
+ systemic symptoms
tx by hospital admission + IV fluids and IV Abx
what is ringworm and what are the different types
fungal infection
aka tinea or dermatophytosis
tinea capitis = on scalp
tinea pedis = foot/athletes foot
tinea corporis = body
tinea cruris = groin
onchomycosis = fungal nail
how does ringworm present
itchy/erythmatous/scaly/well demarcated rash
capitis = hair loss/dryness
pedis = between toes
** check toes if ringworm = athletes foot common**
how is ringworm diagnosed and managed
clinical diagnosis + response to antifungals
possible to scrape and culture
treat with antifungals
- clotrimaxole
- miconazole
- ketoconazole
mild topical steroid help with inflammation and itching
advice to avoid/prevent future infections
what is tinea incognito
more extensive fungal skin infections
caused by use of steroids to treat fungal infection = suppresses immune response = infection grows
what causes chicken pox and how does it present
varicella zoster virus = highly contagious
presents with fever first
itch
general fatigue/malaise
rash - widespread/red/raised/vesicular
once scabbed = not contagious
how is chicken pox spread
highly contagious
spread through direct contact with lesions or infected droplets from cough/sneeze
symptomatic 10 days03 weeks after exposure
what are the complications of chicken pox
bacterial superinfection
dehydration
conjunctival lesions
pneumonia
encephalitis
virus can lay dormant in sensory dorsal root ganglion cells = later = shingles or ramsay hunt syndrome
how is chicken pox managed
mild/self-limiting
aciclovir considered in immunocompromised patients/>14 presenting <24hr/neonate
itching = calamine lotion/antihystamine
what causes hand foot and mouth disease and how does it present
coxsackie A virus
3-5 day incubation
upper resp tract symptoms and fever
1-2 days = small mouth ulcers with blistering red spots across body (hand/foot/mouth)
painful mouth ulcers + on tongue
how is hand foot and mouth disease managed and what are the complications
diagnosis = clinical appearance
supportive management
resolve in week-10 days
highly contagious = careful
dehydration/bacterial superinfection/encephalitis
what is roseola infantum
sixth disease/3 day rash
caused by herpesvirus 6/7
high fever sudden development
rash over body excluding face (often after fever subsides)
sore throat
lymphadenopathy
supportive management
what is erythema infectiosum
aka slapped cheek syndrome
caused by parvovirus B19
can be passed from mother to baby via placenta
may be asymptomatic or non specific coryzal sympts
symptom free 7-10 days then rash appear on cheeks
can present with arthropathy
management = symptomatic
what are the complications of erythema infectiosum
transient aplastic crisis in those with sickle cell/thalassaemia/hereditary spherocytosis/iron deficiency anaemia
can cause immunocytopenia in immunodeficient patients
can cause meningoencephalitis in immunocompromised
DANGEROUS IN PREGNANCY
what are the features of osteosarcoma
= bone cancer
10-20 y/o
most commonly femur (tibia/humerus)
** persistent bone pain, especially at night **
bone swelling/palpable mass/RoM
describe the diagnosis of osteosarcoma
very urgent direct access XR in 48 hours if unexplained bone pain/swelling
if XR suggest osteosarcome - urgent specialist assessment 48hrs
blood test = raised ALP
CT
MRI
bone scan
PET scan
bone biopsy
describe the features of osteosarcoma on XR
poorly defined lesions in bone
destruction of normal bone
fluffy appearance
periosteal reaction = sunburst appearance
how is osteosarcoma managed
surgical resection of lesion with limb amputation
adjuvant chemo
MDT team
main complication = pathological bone fractures and metastasis
what is a wilm’s tumour and how does it present
= nephroblastoma = cancer of kidneys
presents 0-5 y/o
asymptomatic abdo mass
adbo pain
haematuria
UTI
HTN
how is wilm’s tumour diagnosed and managed
FBC
renal function
electrolytes
urinalysis
USS show distortion of renal pelvis
renal angiography
CT/MRI for staging
Tx = nephrectomy followed by chemo
routine postop radiotherapy is stage 3
prognosis = 90% survive long term
increased risk of second tumours in wilms survivors
what is a rhabdomyosarcoma
malignancy of connective tissue where abnormal cells arise from primitive muscle cells
most common around head/neck
bladder (20%)
muscles/limbs/chest (15-20%)
= highly malignant and grow rapidly
87% patients are <15 (rarely affect adults)
what are the risk factors of rhabdomyosarcoma
neurofribromatosis
fetal alcohol syndrome
parental use of marijuana/cocaine
exposure to XR
how does rhabdomyosarcoma present
expanding lump/swelling = may be painful
nose - nasal obstruction/discharge
eyes = swelling eyeball
adbdomen = pain/change in bowel habit
bladder = haematuria
how is rhabdomyosarcoma diagnosed
non resolving lumps in children = investigated for cancer
bloods = anaemia/raised ALT
urinalysis = haematuria
XR/CT/MRI
bone scan look for mets
how is rhabdomyosarcoma managed
surgery for all lesions if possible
chemo (vincristine/cyclophosphamide etc)
post-op radiotherapy
prognosis = 60% children/teens cured
describe retinoblastoma
embryonal tumour of retina = most common eye malignancy in children
inutero-5 y/o onset
40% = hereditary (AD)
how does retinoblastoma present and what are the key differentials
abnormal pupil (leukocoria)
strabismus
deterioration of vision
red/irritated eye
Ddx:
cataracts
hamartomas
choroiditis
how is retinoblastoma diagnosed and managed
any child showing indication = red reflex performed
exam under anaesthesia
bidimensional ocular USS/MRI
evaluate presence of mets
genetic counselling
Mx: urgent opthamology referral
1. surgery
2. chemo
3. radiation
99% survival in UK
invasion of optic nerve most significant prognostic factor
what are the most common types of brain cancer in children
astrocytoma most common = most are low grade, slow spread
medullablastoma = most common high grade, fast spreading
