Paeds Flashcards
when to refer to paediatrician - weight loss after birth
more than 10% weight loss on day 3
(community MW will weigh on day 3, 5 and 10, at day 3 check most will have lost weight, aim to regain birth weight by day 14)
normal RR
<1 - 30-40
1-2 - 25-35
2-5 - 25-30
5-12 - 10-25
> 12 - 15-20
normal HR
<1 - 110-160
1-2 - 100-150
2-5 - 95-140
5-12 - 80-120
> 12 - 60-100
adjusting for prematurity on a growth chart
separate section for premature babies until 42w
then adjustment is done on normal growth chart for the first 2 years
(prematurity = <37w)
information on a growth chart and when to refer
height, weight, and also head circumference from 0-1 years
o Failure to thrive = growth that crosses 2 centile lines
o If they cross only one centile, then refer to GP or health visitor for surveillance (could have just been due to a minor illness)
<2nd centile = underweight (overweight = 98th or above)
reasons for dips in growth charts
note that acute illness can lead to sudden weight loss and a weight centile fall, but children generally recover to their normal centile within 2-3 weeks - is a SUSTAINED drop that we are worried about
crohns coecliac cf neglect hypothyroidism GH deficiency reflux - back arching cows protein allergy
causes of short stature
primary - Down’s, turner’s, russel-silver, IUGR with fialure to catch up, osteogenesis imperfecta, achondroplasia
secondary - deprivation, neglect, malabsorptive disease, anorexia, chronic disease of any form, GH/IGF-1 deficiency, Laron syndrome (defective GH receptors), hypothyroidism, medication like steroids, cushings
if worried - continue to review and can calculate growth veloicty - growth failure is defined as height velocity <25th centile over at least 18m
investigations for poor growth
x-ray of wrist and hand - can identify bone age which has a marked delay in hypothyroidism and GH deficinecy (moderate delay in constitutional and no delay in familial short stature) fbc - anaemia in coeliac/ibd bone profile tsh in hypothyroidism karyotype for turners and others bloods for coeliac crp/esr ibd GH provocation tests using insulin/glucagon to see if gh deficiency IGF-1 measurement dex suppression test in cushings mri head for tumours skeletal survey for scoliosis
causes of failure to thrive
o Inadequate intake due to impaired suck/swallow, cleft palate
o Inadequate retention due to vomiting and GORD
o Increased nutritional requirements due to chronic illness in general
o Failure to utilise nutrients e.g. syndromic disorders
o Impaired nutrient absorption
1 year milestones
GROSS MOTOR
walks unsteadily with broad based gait, or walks with one hand held
FINE MOTOR
throws objects away
scribble with crayon
has a mature pincer grip
HEARING SPEECH ANAD LANGUAGE
uses 2-3 words with meaning
SOCIAL EMOTIONAL AND BEHAVIOURAL
uses a spoon
drinks from a cup using 2 hands
when should reflexes go
moro - 2m
palmar - 6m
rooting - 4m
asymmetric tonic neck reflex - 6m
autism vs asperger’s
autism =
abnormalities in reciprocal social interactions - failure of eye contact, facial expression, lack of relationships, inappropriate response to others emotions, dont understnat humour
speech and language disorder - delay in speaking, difficult initiating or sustaining convos, odd volume of speech, echolalia
restricted/stereotyped/repitive behaviour - rituals, routine, no imagination, unusual movements
^at least one of these must be present before age of 3 for diagnosis
asperger’s = mild social impairements but near-normal speech and language (i.e. these skills are not delayed) - more mild than autism, normal intellegence (autism ma have lower iq), more likely to live independently, diagnosis is usually made later (7 vs 3)
persistent difficulties with or differences in social communication and social interaction
restricted and repetitive patterns of behaviours, activities or interests since early childhood, to the extent that these impact negatively on day to day life
type of therapy for autism
applied behavioural analysis
red/high risk signs in a febrile child
mottled or blue no response to you if roused does not stay awake weak, high pitched or continuous cry appears ill to a healthcare professional RR >60 grunting chest in-drawing between ribs when breathing in reduced skin turgor <3m with temp >38 non-blanching rash neck stiffness bulging fontanelle seizures or fits
pattern of rash in roseola infantum and its management
fever followed later by a maculopapular rash LATER
rash starts at trunk before spreading to limbs
non-itchy
diarrhoea and cough also commonly seen
infection should pass in a week - managed conservatively with anti-pyretics if irritable - once the fever has passed child can go back to school as that is when most contagious point has passed
cause of roseola infantum
HHV6
pattern of rash in pityraisis rosea and its management
o Herald patch - single pink or red oval patch of scaly skin appears at least 2 days before a more widespread rash
o The widespread rash does not usually involve the face
o Not painful but can be itchy
o Usually gets better without treatment in 12 weeks
o Conservative treatment involves emollients, steroid creams, antihistamines for itch
o Aetiology is not usually understood but is thought that HHV-7 may play a role
cause of slapped cheek
parvovirus b19
2 important health messages with slapped cheek
rarely can lead to aplastic crisis - usually in those seen with immunodeficiency or haemolytic anaemia
avoid pregnant ladies as can lead to hdyrops fetalis
measles pattern of rash and prodrome and management
prodrome - 3C’s = coryza, cough and conjunctivitis
starts with fever, sore eyes that are sensitive to light and grey spots inside the cheecks called Koplik’s spots
after a few days a red brown rash forms over head or neck then spreads to rest of body
- Usually improves in 7-10 days - stay away from school for at least 4 days when rash first appears
- Can use anti-pyretics, clean eyes with water, put a wet towel on warm radiator to moisten air to help with cough, warm drinks with lemon or honey
confirm with salivary swab or serum sample for measles specific immunoglobulin
complications include bronchopneumonia - return if breathing difficulties, encephalitis - return if headache, changing consciousness, or seizures (carries 15% mortality rate)
cause of scarlet fever
group a strep
treatment of scarlet fever
phenoxymethylpenicillin for 10 days
important to avoid rheumatic fever and rheumatic heart disease
scarlet fever symptoms
fever lasts 24-48 hours
pin prick rash
more in flexures
TENDER lympahdenopathy - in contrast to kawasaki which is painless
all the S’s
- Causes pink-red rash that feels like sandpaper and looks like sunburn
- Usually starts with a swollen/strawberry tongue, sore throat, headache and fever
- Starts at neck then trunk then extremities
- 7-10 days later can get desquamation - tell this to parents so they know what to expect
toxic shock syndrome symptoms, cause and management
- TSS occurs as a reaction to toxins produced by staphylococcal or group-A streptococcal (aka strep pyogenes) infections. It is suggested by fever >39, hypotension and a diffuse erythematous macular rash
- The toxin can also lead to mucositis, diarrhoea and vomiting, renal and liver impairment, and clotting abnormalities
- Management is with antibiotics. It is important to be aware that desquamation of the palms and soles will follow after around 2 weeks
Causes
- Tampons
- Female barrier contraceptives
- Cuts, burns, boils, insect bites, wounds following surgery
- Childbirth
- Nasal packing to treat a nosebleed
- Having staphylococcal infection or streptococcal infection such as throat infection, impetigo or cellulitis
phases of whooping cough/bordetella pertussis (mainly affects babies less than 6m who haavent had full vaccine 3x dose yet and teenagers where their vaccines have started to fade)
catarrhal phase - 1-2 weeks long
rhinitis, conjunctivitis, irritability, sore throat, low grade fever, dry cough (all mimic other URTI so rarely diagnosed at this stage)
paroxysmal phase - 2-8 weeks long
severe paroxysms of coughing followed by an inspiratory gasp producing the classic whoop sound (<3m the whoop is less common and apnoea is the more common feature)
the paryoxsysms are more common at night and often followed by vomiting
can be severe enough to cause cyanosis
convalescent phase - up to 3m
the cough gradually decreses in frequency and severity
notably - have no wheeze or crakes - rules out bronchiolitis and pneumonia
diagnosis of whooping cough
cough <2 weeks - per nasal swab culture for bordatella pertussis
cough >2 weeks - PCR and serology for anti-pertussis toxin IgG for <5 OR anti-pertussis toxin detection in oral fluid for 5-17
o A limitation of both serology and oral fluid testing is that a pertussis vaccine within the last year can produce a false positive
FBC will show leukocytosis
management of whooping cough
hopsital admission for <6months who is acutely unwell, or in those with significant breathing/feeding difficulties or any complications like pneumonia or sepsis
antibiotics can only be given within 3 weeks of cough onset
first line = clarithromycin <1 month, aznithromycin or clarithromycin >1 month
plus supportive care - paracetamol etc and fluids
parents should be advised that despite antibiotic treatment the cough may take 3 months to resolve
The child should avoid nursery or school until they have had the cough for 21 days or 48 hours after starting abx
exclusion of school for whooping cough
they should avoid school until they have had the cough for 21 days or 48 hours after commencing antibiotics
treatment of tetanus
tetanus immunoglobulin
fluid requirement based on weights - maintenance fluids
first 10kg = 100ml/kg/day
second 10kg = 50ml/kg/day
subsequent kg = 20ml/kg/day
used for day 5 onwards
rate = roughly this figure /24
use bags of 500ml rather than 1L as this gives better control
generally 0.9% NaCl with 5% glucose +/- 10mml potassium chloride
fluid resuscitation
20mlkg bolus over less than 10 minuttes
for neonates - 10-20ml/kg over 10 minutes (under 28 days)
seek expert advice (e.g. paediatric intensive care team) if 40-60ml/kg or more is needed as part of the initial fluid resuscitation
o Consider inotropes e.g. adrenaline
o Consider endotracheal intubation and ventilatory support
hypoglycaemia management in children
o In conscious child give oral glucose drink or gel e.g. 1 slice of bread or a banana
o In non-conscious
• 1U of glucagon if no IV access
• bolus of 2ml/kg 10% IV glucose if IV access
o In all
• Followed by continuous infusion of salt solution with 5-10% glucose (60ml/kg/day) e.g. 0.9% saline and 5% glucose
WETFLAG
The purpose of WETFLAG is to work out (quickly) appropriate weight based drugs and equipment for the child you are looking after
weight energy - 4 joules/kg tube fluids - 20ml/kg bolus lorazepam adrenaline glucose - 2ml/kg dextrose solution 10% (bolus needed in a hypo)
chest compressions ratio in cardiac arrest in a child
first give 5 rescue breaths (before even checking a pulse)
then 15:2
1-8 years - use heel of one hand over lower third of sternum
less than this - two thumbs over lower third of sternum or tips of two fingers
most causes of cardiac arrest = hypoxia
innocent murmurs
STILLS MURMUR mid-systolic murmur buzzing quality left lower sternal edge softens on standing - best heard supine PULMONARY FLOW MURMUR systolic murmur best heard at upper left sternal edge disappears with valsavas softens on standing - best heard supine VENOUS HUM supraclavicular continous murmur best heard standing NECK MURMUR innocent murmur/bruit in neck are common - best heard above clavicle PERIPHERAL PULMONARY STENOSIS upper left sternal border radiates to axilla
when to refer a murmur
loud
pansystolic
diastolic
continuous, unless a venous hum
NB heart murmurs in neonates are much more likely to indicate structural heart disease and should prompt specialist assessment. Less than 1% of newborns have a heart murmur but more than 50% of those with a murmur have structural heart disease
causes of ejection systolic murmurs in children
PATAT
pulmonar stenosis aortic stenosis tetrology of fallot ASD - a split double - split S2 truncus arteriosus
pan systolic murmurs in children
VSD - very systolic - pan systolic
mitral regurgitation
partial AVSD
continuous murmurs in children
venous hum
PDA
co-arctation
complications of kawasaki disease
coronary artery aneurysm
coronary thrombosis
MI
dysarrthymias
symptoms of kawasaki disease
fever >38.5 degrees present for at least 5 days with 4/5 of the following
CRASH
congestion of conjunctivae
rash - polymorphous rash
lymphAdenopathy
strawberry tongue (or general redness to mucus membranes)
hands and feet - oedema and/or erythema and periungual desquamation
investigatinos for kawasaki
diagnosis is clinical
- FBC - leukocytosis and neutrophilia
- CRP and ESR will be raised
- Platelets may be raised to start with but will decrease throughout second and third weeks of illness
- LFTs may be slightly deranged - albumin may be low (negative acute phase reactant)
- Urinalysis may show sterile pyuria +/- proteinuria
- ECG may show conduction abnormalities due to carditis
- Echo to assess for aneurysms - at onset, then 6-8 weeks then 12 months
management of kawasaki
usually cared for as inpatients and put on bed rest due to risk of myocardial events
high dose IV immunoglobulin (2g/kg as a single infusion over 10-12 hours - but may require a second dose if fever not resolving by 36 hrs later)
aspirin until fever resolves - how much is given depends on symptoms - but usually given high-dose aspirin until fever subsides, then may be prescribed low-dose until 6-8 weeks after the start of their symptoms when their next echo is due (NB has association with Reye syndrome –> rapidly progressive encephalopathy (vomiting, confusion, seizures, LOC))
refractor cases - steroids, anti-TNF, plasma exchange…
follow-up is very important for cardiac review e.g. echo - CV disease is a severe complication of Kawasaki disease- which most commonly presents as coronary artery aneurysms and can lead to arrythmias, MI and ultimately HF
cyanotic (right to left shunt) is due to all the Ts plus what else
pulmonary atresia
hypoplastic left heart
presentation of TOF
3 categories
mild-pink TOF - has mild pulmonary stenosis/RVF and usually asymptomatic, presents by 1-3 years
moderate-severe - cyanotic TOF - presents in first few weeks of life with cyanosis and respiratory distress - may have recurrent chest infections and failure to thrive
extreme - further divided into TOF w pulmonary atresia or absent pulmonary valves - presents in first few hrs of life
clubbing
low o2 sats
murmur - ejectinon systolic
hypoxic/tet spells - restless, cyanosed and can cause LOC (CO2 accumulates which stimulates fast deep respirations which worsens shunt - may be precipitated by dehydration, anaemia or prolonged crying - all cause tachycardia and reduced systemic vascular resistance which will worsen shunt and deoxygenation)
investigations for TOF
- ECG (RVH)
- CXR - boot shaped heart and reduced pulmonary vascular marking due to decreased blood flow
- Echocardiography - gold standard to diagnose
- Cardiac MRI pre- and post-operatively can be done - more so in tertiary centres
- Karyotyping if genetic syndromes suspected
management of TOF
MEDICAL
o Squatting - parents may observe infants squatting or keeping knees to their chest - this helps them improve venous return therefore increasing systemic resistance
o PG infusion to keep PDA open in more severe-extreme forms - must be started urgently following delivery
o BB - propranolol is commonly used in tet spells and prophylaxis in severe disease (decreases HR thus improved venous return so improved right ventricular outflow)
o Morphine - reduces respiratory drive therefore reduces the abnormal breathing that form tet spells
o Saline 0.9% bolus can be used in tet spells to increase pulmonary blood flow through right ventricular outflow tract
SURGERY
o Definitive treatment is with closure of the VSD and relief of the RVOT with placement of a graft between the right ventricle and pulmonary artery from 4 months onwards (or removal of muscle causing the obstruction)
FOLLOW-UP
o Due to risk of long-term complications, will require regular ECG, echo and in cases of exercise intolerance = cardiopulmonary exercise testing
in furture - may need pulmonary valve replacement due to pulmonary regurgitation as a result of TOF surgery
egg on a string vs boot shaped heart
boot shaped in TOF
egg on a string in transposition of great arteries
management of transposition of great arteries
prostaglandin to increase patency of ductus arteriosus
in some it may be necessary to do an early balloon atrial septostomy to reopen foramen ovale
eventually will require an arterial switch operation - usually done before the age of 4 weeks
management of VSD
Medical
o Increase calorie intake
o Diuretics like furosemide to relieve pulmonary congestion
o ACEi to reduce afterload - allows more blood through the aortic valve and less through the VSD
o Digoxin
Surgery
o Surgical repair may not be required for a small muscular VSD, as this will close on its own as the heart grows
o Large VSDs will require medical management up to the point of surgical repair at 3 – 4 months, this can be trans-catheter repair or open surgery
Long-term
o There is an increased risk of endocarditis so advised to maintain good dental hygiene
management of ASD
Conservative
o If <5mm should close within 12 months of birth
o In adults, if patient is presenting with no signs of right heart failure and a small defect, then monitor every 2 – 3 years with echocardiogram
Medical
o In children with HF, diuretics, ACEi, digoxin, higher calorie intake may be needed
Surgical repair - >1cm
o Via cardiac catheterisation or open
o This is usually performed at about 3 – 5 years’ old (complete AVSDs between 3-6m)
what does congenital diaphragmatic result in
pulmonary hypertension and pulmonary hypoplasia
because abdominal organs migrate up into chest cavity
usually diagnosed on us scans
can present soon after bith with cyanosis, tachypnoea, tachycardia, asymmetry of chest wall, absent breath sounds, bowel sounds over chest wall
investigations for coeliac disease
- Before testing, confirm that the person has eaten gluten-containing foods at least twice every day over the previous 6 weeks
- FIRST send-off serology (before any biopsy)
o Use IgA tTG and total IgA as first line. IgA EMA can be used if IgA tTG is unavailable.
(If IgA is deficient, this will cause a false-negative result so test for IgG tTG, IgG EMA or IgG DGP (deamidated gliadin peptide) instead) - FBC - IDA is a common presentation - could also do vitamin B12 and folate
- Small bowel – 2 biopsies of the bulb and at least 4 of the distal duodenum - will show presence of intra-epithelial lymphocytes, villous atrophy and crypt hyperplasia
- Skin biopsy
o In any patient with skin lesions suggestive of dermatitis herpetiformis
management of coeliac disease
gluten-free diet - consists of most dairy products, fruit and veg, meat and fish, potatoes, rice, gluten-free flours
vitamin replacement if deficient
consider annual blood testing
o Coeliac serology
o FBC and ferritin
o TFTs – to screen for autoimmune thyroiditis
o LFTs – to screen for autoimmune hepatitis
o Vitamin D, B12, red cell folate and serum calcium
o Electrolytes – for Addison’s
patients with coeliac disease often have functional hyposplenism - making it important they receive the pneumococcal vaccine and yearly influenza vaccines
what is infantile colic and how can it be treated
crying with no apparent cause in a healthy baby with drawing up of the knees
usually resolves by 4 months
may be due to sensitiesed pathways in the gut viscera
simethicone may help but has not been proven to give a wide benefit - is an anti-flatulent
what is hirschprungs disease
absence of parasympathetic ganglion cells in the myenteric and submucosal plexus of the rectum causing a functional obstruction
mesenteric adenitis vs appendicitis
mesenteric lymphadenitis = associated with a viral infection leading to inflammation of mesenteric lymph nodes
no loss of appetite and has a high-grade pyrexia around 39 whereas appendicitis is usually low grade around 38
also has more diffuse abdominal pain because there is no peritonism
also normally normal WCC and CRP in mesenteric adenitis
(usually no treatment needed - maybe abx if bacterial cause)
score to see how useful it is they have appendicitis
paediatric appendicitis score
investigations for food allergy
skin prick - swollen red bump will form if allergic
RAST testing to look for specific IgE antibodies
or ELISA - widely replaced RAST
in severe cases when allergen cannot be found - start a full elimination diet in which only have hypoallergenic foods for 1-2 weeks e.g. lamb, rice, water followed by retintroduction of food
lactose intolerance in children
often post-viral gastroenteritis e.g. rotavirus
most cases are short lasting - 4-6 weeks
management of cows protein allergy
o In exclusively breast-fed infants, this is achieved by a maternal exclusion diet to these proteins
o In formula fed infants feed with a hydrolysed formula (short peptides)
o If symptoms severe, or unresponsive to hydrolysed formula, then an elemental (amino acid) formula may be required
o After weaning, introduce a cow’s milk protein free diet (supplement with oral calcium if required)
o Consider a cow’s milk protein challenge after 6–12mths
follow-up after anaphylaxis
observe for 6-12 hours from onset of symptoms depending on response to emergency treatment - is due to possibility of a biphasic reaction
ofter referral to specialty allergy clinical - skin prick tests to identify allergen
inform person that a blood sample may be required at follow-up allergy clinic to establish what mast cell tryptase is at baseline
suggest a medicalert bracelt
offer an adnrelaine injector - 0.15mg in children, 0.3mg in adults
adrenaline IM dose in anaphylaxis in children and how much can be given
- 5mg >12
- 3mg in 6-12
- 15mg in <6
assess response after 5 minutes and repeat at 5 minute intervals until adequate response - people needing lots of repeat doses may need IV adrenaline - requires ICU physician help
when to measure mast cell tryptase in anaphylaxis
one as soon as possible after emergency treatment starts
second ideally within 1-2 hours, no later than 4
(should also monitor patient with pulse oximetry, BP and ECG)
management of GORD
thickened milk feeds in those that are formula fed
ensure not overfed - 150ml/kg/day max
small frequent meals
avoid food before sleep
gaviscon (alginate therapy) immediately after feeds
if no response after 2 weeks can try gastric acid reducing drugs like ranitidien or omeprazole
or prokinetic drugs like domperidone
surgery - fundoplication
what VBG will pyloric stensosi cause
hypochloraemic, hypokalaemia metabolic alkalosis (vomiting up Hcl and potassium)
surgery for pyloric stensosi
ramstedt pyloromyotomy
general investigations for diarrhoea
stool - microscopy, fat globules and faecal eslastase (low in pancreatitis), culture, pH (low in carb malasorption), fecal occlut blood (colitis)
bloods - FBC, UE, raised eosinophils in food hypersenstivity or parasties, raised CRP and ESR in inflammation, RAST in food allergy
AXR or US for NEC
hydrogen breath test for lactose malabsorption of H pylori
sweat test/genetics in CF
biopsy for coeliac and IBD
rectal biopsy in hirschprungs
