Paeds Corrections Flashcards
What is the ‘traffic light system’ for feverish illness?
Guidlines for risk stratification of children under the age of 5 years presenting with a fever.
What 4 observations should be recorded in all febrile children?
1) Temp
2) HR
3) RR
4) CRT
If the child is <4 weeks old, how should temperature be measured?
With an electronic thermometer in the axilla
or
With an electronic/chemical dot thermometer in the axilla
or
With an infra-red tympanic thermometer.
What RR is a ‘red flag’ in febrile illness in children <5?
> 60
How should immunisation dates be adjusted for babies born prematurely?
Give as per normal timetable (i.e. all babies, including those born prematurely, should receive their first set of vaccinations at 8 weeks from birth).
Why are immunisations given as per normal timetable in premature babies?
As premature babies are at higher risk of infections and therefore need protection provided by vaccines as soon as possible.
What is roseola infantum ((also known as exanthem subitum?
A common disease of infancy caused by the human herpes virus 6 (HHV6).
Features of roseola infantum?
1) high fever: lasting a few days, followed later by a
2) maculopapular rash
3) Nagayama spots: papular enanthem on the uvula and soft palate
4) febrile convulsions occur in around 10-15%
5) diarrhoea and cough are also commonly seen
Is school exclusion required for roseola infantum?
No
If a formula-fed baby is suspected of having mild-moderate cow’s milk protein intolerance, what is the 1st line management step?
Trial of extensively hydrolysed formula
What is scarlet fever?
A reaction to erythrogenic toxins produced by Group A Strep.
How is scarlet fever spread?
Via the respiratory route by inhaling or ingesting respiratory droplets or by direct contact with nose and throat discharges, (especially during sneezing and coughing).
What is the peak age incidence for scarlet fever?
4 years
Features of scarlet fever?
1) Fever: lasts 24-48h
2) Malaise, headache, N&V
3) Sore throat
4) ‘Strawberry’ tongue
5) Rash
What texture is the rash in scarlet fever often described as having?
A rough ‘sandpaper’ texture
Where does the rash in scarlet fever typically affect?
Generally appears first on the torso and spares the palms and soles.
Describe the rash in scarlet fever
1) Fine punctate erythema (‘pinhead’).
2) Generally appears first on the torso and spares the palms and soles.
3) Children often have a flushed appearance with circumoral pallor.
4) The rash is often more obvious in the flexures.
5) It is often described as having a rough ‘sandpaper’ texture.
6) Desquamination occurs later in the course of the illness, particularly around the fingers and toes.
How is a diagnosis of scarlet fever made?
A throat swab is normally taken but Abx treatment should be commenced immediately, rather than waiting for the results.
1st line management of scarlet fever?
Oral penicillin V for 10 days (azithromycin in pencillin allergy).
When can children with scarlet fever return to school?
24h after starting Abx
Is scarlet fever a notifiable disease?
Yes
What is the most common complication of scarlet fever?
Otitis media
Give some complications of scarlet fever
1) Otitis media
2) Rheumatic fever
3) Acute glomerulonephritis
4) Invasive complications e.g. bacteraemia, meningitis, necrotising fasciitis (rare)
How soon after scarlet fever can rheumatic fever occur?
20 days after infection
When is the meningitis B vaccine given?
At 2, 4 and 12-13 months.
What are the 3 most common fractures associated with child abuse?
1) Radial
2) Humeral
3) Femoral
If a newborn baby has an abnormal hearing test at birth, what are they offered next?
Auditory brainstem response test
When is bow legs in a child a normal variant?
<3
Usually resolves by the age of 4
What can be prescribed as rescue medication for recurrent febrile seizures?
Rectal diazepam or buccal midazolam
What is the first-line treatment for developmental dysplasia of the hip (DDH) in infants under six months of age?
Pavlik harness (dynamic flexion-abduction orthosis).
A common complication of chickenpox is 2ary bacterial infection of the lesions.
What increases this risk?
NSAIDs
How may 2ary bacterial infection of chickenpox present?
Whilst this commonly may manifest as a single infected lesion/small area of cellulitis, in a small number of patients invasive group A streptococcal soft tissue infections may occur resulting in necrotizing fasciitis
What are 4 rare complications of chickenpox?
1) pneumonia
2) encephalitis (cerebellar involvement may be seen)
3) disseminated haemorrhagic chickenpox
4) arthritis, nephritis and pancreatitis may very rarely be seen
What is Epstein’s pearl?
A congenital cyst found in the mouth.
They are common on the hard palate, but may also be seen on the gums where the parents may mistake it for an erupting tooth.
Management of Epstein’s pearl?
No treatment is generally required as they tend to spontaneously resolve over the course of a few weeks.
Mx of head lice?
A choice of treatments should be offered - malathion, wet combing, dimeticone, isopropyl myristate and cyclomethicone
1st line management of meningitis in children <3 months?
IV amoxicillin + IV cefotaxime
What is the positive result for CF in a newborn heel prick test?
Raised immunoreactive trypsinogen (IRT)
What organism causes perianal itching?
Enterobius vermicularis (i.e. threadworms)
1st and 2nd line management of viral induced wheeze?
1st –> SABA
2nd –> oral montelukast or inhaled corticosteroid
When should serum bilirubin be measured in babies <24 hours old if they are high risk for developing severe hyperbilirubinaemia?
Within 2 hours
Steps for newborn resuscitation?
1) Dry the baby, maintain temperature & start the clock
2) Assess tone, breathing & HR
3) If gasping or not breathing –> open airway and give 5 inflation breaths
4) Reassess for increase in HR
5) If the chest is not moving you assume the inflation breaths are inadequate and recheck head position, consider 2-person airway control and other manoeuvers and repeat inflation breaths then look for a response.
6) If the chest is moving but the heart rate is still undetectable or less than 60 beats per minute you start chest compressions at a ratio of 3 compressions to 1 inflation breath (3:1).
7) You reassess heart rate every 30 seconds, and if it is still undetectable or very slow, you consider IV access and drugs.
What is William’s syndrome?
An inherited neurodevelopmental disorder caused by a microdeletion on chromosome 7.
Features of William’s syndrome?
1) elfin-like facies
2) characteristic like affect - very friendly and social
3) learning difficulties
4) short stature
5) transient neonatal hypercalcaemia
6) supravalvular aortic stenosis
What are elfin facies?
Characterised by a prominent forehead, widely spaced eyes, an upturned nose, an underdeveloped mandible, dental hypoplasia, and patulous lips.
What syndrome is rocker-bottom feet associated with?
Edward’s
All newborns should be tested as part of the Newborn Hearing Screening Programme.
What test is used?
Otoacoustic emission test:
A computer-generated click is played through a small earpiece. The presence of a soft echo indicates a healthy cochlea.
What hearing test is done at school entry in most areas of the UK?
Pure tone audiometry
What hearing test can be if otoacoustic emission test is abnormal?
Auditory brainstem response test
What is the 1st line therapy for treatment of threadworm?
Oral mebendazole
What causes threadworm?
Enterobius vermicularis
What is exomphalos (AKA omphalocoele)?
When he abdominal contents protrude through the anterior abdominal wall but are covered in an amniotic sac formed by amniotic membrane and peritoneum.
Mx of exomphalos?
1) C-section is indicated to reduce the risk of sac rupture
2) A staged closure (starting immediately with completion at 6-12 months)
What investigations should be done in infants <3 months with a fever?
1) FBC
2) Blood culture
3) CRP
4) Urine testing for UTI
5) CXR (if respiratory signs are present)
6) Stool culture (if diarrhoea present)
What organism causes scarlet fever?
GAS
IV fluid resuscitation in children?
Bolus of 20ml/kg 0.9% NaCl over <10 mins
What RR is a red flag in paeds at ANY age?
> 60
Mx of threadworms?
Treatment of patient and ALL household contacts (even if have no symptoms) –> oral mebendazole
In what 3 situations may bronchiolitis cause a more severe infection?
1) bronchopulmonary dysplasia (e.g. premature)
2) congenital heart disease
3) CF
In paediatric BLS, how many rescue breaths are given?
5 rescue breaths, then 15 chest compressions to every 2 ventilation breaths.
Features of fragile X syndrome?
- learning difficulties
- large low set ears, long thin face, high arched palate
- macroorchidism
- hypotonia
- autism is more common
- mitral valve prolapse
What heart defect is fragile X syndrome associated with?
Mitral valve prolapse
What heart defect is William’s syndrome most associated with?
Supravalvular aortic stenosis
Inheritance of haemaphilia?
X-linked conditions
X-linked recessive conditions are only passed on from mothers (carriers) to sons. The father can only pass on the gene to his daughters who will become carriers and he cannot pass on the gene to his sons as they inherit the Y-chromosome from him.
Where is nasal flaring on the paediatric traffic light system?
Amber
Where is intercostal recession on the paediatric traffic light system?
Red
What is palivizumab given for?
Monoclonal Ab given to prevent RSV (in children who are at increased risk of severe disease).
Those at risk:
- premature infants
- infants with lung or heart abnormalities
- immunocompromised infants
What organism causes bronchiolitis?
RSV
What organism causes croup?
Parainfluenza virus
The testes can help detemine cause of precocious puberty in males.
What do the following indicate as a cause:
1) bilateral enlargement
2) unilateral enlargement
3) small testes
1) gonadotrophin release from intracranial lesion
2) gonadal tumour
3) adrenal cause (tumour or adrenal hyperplasia)
What should bowel sounds in a respiratory exam of a neonate make you think of?
Congenital diaphragmatic hernia
Management of a congenital diaphragmatic hernia?
1) Insertion of NG tube (with aim of keeping air out of gut)
2) Intubation & ventilation
3) Surgical repair
What can be done to reduce hypoxic ischemic encephalopathy (HIE)?
Therapeutic cooling
Crossing the suture lines - cephalohaematoma vs caput succedaneum?
Cephalhaematoma –> does not cross suture lines
Caput succedaneum –> does cros suture lines
What does Hodgkin’s lymphoma show on blood tests?
Does NOT cause an increase in the lymphocytes, but it can cause normocytic anaemia and eosinophilia.
What are the 2 key risk factors for HL?
1) HIV
2) EBV
WHat is the most common presenting complaint of HL?
Lymphadenopathy –> usually painless, non-tender, asymmetrical.
Most commonly in the neck (cervical/supraclavicular).
When may lymph nodes be painful in HL?
Alcohol-induced lymph node pain is characteristic of Hodgkin’s lymphoma but is seen in less than 10% of patients.
What characterises CML?
- anaemia
- splenomegaly
- an increase in granulocytes at different stages of maturation
- occasionally accompanied by thrombocytosis
Is non-HL or HL more common?
Non-HL is much more common than HL
What can blood film show in EBV?
Atypical lymphocytes
Lymphadenopathy in tonsillitis vs EBV?
Tonsillitis –> upper anterior cervical chain
EBV –> anterior and posterior triangles of the neck
Classic triad of symptoms in infectious mono?
1) sore throat
2) lymphadenopathy (may be present in the anterior and posterior triangles of the neck)
3) pyrexia
What is 1st line treatmennt for CML?
Tyrosine kinase inhibitor e.g. imatinib
What cancer is Hashimoto’s thyroiditis associated with the development of?
MALT lymphoma
What are the poor prognostic factors in ALL?
1) age < 2 years or > 10 years
2) WBC > 20 * 109/l at diagnosis
3) T or B cell surface markers
4) non-Caucasian
5) male sex
What is Ann Arbor staging system used in?
HL
Describe stage IV of the Ann Arbor staging system
Diffuse or disseminated involvement of one or more extralymphatic organs, with or without associated lymph node involvement.
What are the risk factors for surfactant deficient lung disease? (AKA respiratory distress syndrome)
1) Prematurity (key risk factor)
2) Male sex
3) Diabetic mother
4) C-section
5) 2nd born of premature twins
What does CXR typically show in surfactant deficient lung disease?
‘Ground glass’ appearance with an indistinct heart border
What is often seen on blood smears in thrombotic thrombocytopaenic purpura (TTP)?
Schistocytes
At what age should undescended testes be reviewed?
3 months
1st and 2nd line management of episodic viral induced wheeze?
1st –> SABA (e.g. salbutamol) or anticholinergic via a spacer
2nd –> oral montelukast or ICS (or both)
School exclusion in hand, foot & mouth disease?
Does not require exclusion from a childcare setting or school if child feels well
Describe cough in whooping cough/pertussis
coughing bouts are usually worse at night and after feeding, may be ended by vomiting & associated central cyanosis
inspiratory whoop: not always present (caused by forced inspiration against a closed glottis)
1st line mx of whooping cough?
An oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread.
Household contacts should be offered antibiotic prophylaxis.
What is the initial management in Hirschprung’s disease?
Rectal washouts/bowel irrigation
Transient hypoglycaemia in the first hours after birth is common.
What is a key risk factor for persistent/severe hypoglycaemia?
Prematurity
Mx of bronchiolitis?
Supportive measures only
(note - salbutamol is not given, even if wheeze is present)
What is considered the gold standard for detecting renal parenchymal defects, such as scarring due to vesicoureteric reflux?
Radionuclide scan using dimercaptosuccinic acid (DMSA)
Precocious puberty in females may be defined as the development of secondary sexual characteristics before what age?
8 years
Which vaccines do young people usually receive between the ages of 13 - 18 years?
1) ‘3-in-1 teenage booster’ (tetanus, diphtheria and polio)
2) Men ACWY
Which vaccines do children usually receive between the ages of 3-4 years?
1) ‘4-in-1 pre-school booster’ (diphtheria, tetanus, whooping cough and polio)
2) MMR
What does grunting in infants indicate?
Severe respiratory distress –> hospital admission
In which part of the brain/nervous system has damage occurred in spastic cerebral palsy?
UMN in the periventricular white matter.
This results in increased tone.
Features of congenital CMV infection?
1) Low birth weight
2) Purpuric skin lesions
3) Sensorineural deafness
4) Microcephaly
What is is transient synovitis typically seen in?
Children aged 3-8 y/o
What age infants with suspected conjunctvitis should be referred for same-day ophthalmology/paediatric assessment?
<28 days –> risk of ophthalmia neonatorum
What are the 2 organisms responsible for ophthalmia neonatorum?
1) Chlamydia trachomatis
2) Neisseria gonorrhoeae
1st line management of cradle cap (seborrhoeic dermatitis)?
Baby shampoo + baby oil/emollients
What characterises benign rolandic epilepsy?
Partial seizures at night
What is the characteristic EEG finding in benign rolandic epilepsy?
Centrotemporal spikes
Prognosis of benign rolandic epilepsy?
The prognosis is excellent, with seizures stopping by adolescence.
What is the first sign of puberty in boys?
Increase in testicular volume
What is a low, moderate and good APGAR score?
0-3 –> very low
4-6 –> moderate low
7-10 –> baby in a good state
When should babies be assessed with the APGAR score?
1 and 5 minutes of age.
If the score is low then it is again repeated at 10 minutes.
What makes up the APGAR score?
1) Appearance (colour)
- Pink (2)
- Body pink, extremities blue (1)
- Blue all over (0)
2) Pulse
- 100-160 (2)
- <100 (1)
- Absent (0)
3) Grimace (reflex irritability)
- Cries on stimulation/sneezes, coughs (2)
- Grimace (1)
- Nil (0)
4) Activity (muscle tone)
- Active movement (2)
- Limb flexion (1)
- Flaccid (0)
5) Respiratory effort
- Strong, crying (2)
- Weak, irregular (1)
- Nil (0)
James is a 5-year-old boy that needs a blood transfusion. His condition is life threatening and he needs immediate resuscitation.
James has lost a lot of blood and will die without a transfusion.
However, both of his parents are present and are Jehovah’s Witnesses. They refuse to give consent for James’ blood transfusion.
What is the best way to proceed?
Give the blood transfusion because it is a life-threatening situation and it is in James’ best interest.
In an emergency, you can provide treatment that is immediately necessary to save life or prevent deterioration in health without consent or, in exceptional circumstances, against the wishes of a person with parental responsibility.
When does bow legs in a child usually resolve?
Bow legs in a child < 3 is a normal variant and usually resolves by the age of 4 years
Features of patent ductus arteriosus?
1) left subclavicular thrill
2) continuous ‘machinery’ murmur
3) large volume, bounding, collapsing pulse
4) wide pulse pressure
5) heaving apex beat
Mx of patent ductus arteriosus?
indomethacin or ibuprofen given to neonates
Role of indomethacin in patent ductus arteriosus?
inhibits prostaglandin synthesis –> closes the connection in the majority of cases
What is the management of pyloric stenosis?
Ramstedt pyloromyotomy –> involves dividing the pyloric muscle to increase the diameter of the gastric outlet.
What are some factors that point towards child abuse?
1) story inconsistent with injuries
2) repeated attendances at A&E departments
3) delayed presentation
4) child with a frightened, withdrawn appearance - ‘frozen watchfulness’
Why do children experiencing child abuse have repeated attendances at A&E departments?
Frequent attendance to the A&E department, rather than GP, may point towards child abuse as parents presume they will see a different doctor each time, making it less likely suspicions will be aroused
Mx of scarlet fever?
10 days of oral penicillin V
Safe to return to school after 24h
Which 2 conditions in children is throat examination contraindicated due to risk of airway obstruction?
1) Epiglottitis
2) Croup
What type of vaccine is the rotavirus?
Oral, live attenuated vaccine
When are rotavirus immunisations given?
2 months & 3 months
What is the most appropriate method to ascertain how obese a child is?
BMI percentile adjusted to age and gender
What are some features of childhood sexual abuse?
- pregnancy
- STIs, recurrent UTIs
- sexually precocious behaviour
- anal fissure, bruising
- reflex anal dilatation
- enuresis and encopresis
- behavioural problems, self-harm
- recurrent symptoms e.g. headaches, abdominal pain
When is the BCG vaccination recommended?
BCG vaccination is recommended for babies up to one year of age who:
1) are born in areas of the UK with high rates of TB
2) have a parent or grandparent who was born in a country with high rates of TB
Is scarlet fever a notifiable disease?
Yes
What pulse abnormality is most associated with a patent ductus arteriosus?
Collapsing pulse
PDA results in a left-to-right shunt from the aorta to the pulmonary artery, leading to increased stroke volume and subsequently a rapid rise and fall of arterial pressure - hence a collapsing pulse.
Rash in Kawasaki disease vs scarlet fever?
Kawasaki disease –> erythematous polymorphous rash
Scarlet fever –> coarse, rough ‘sandpaper’ texture
Do you XR the affected hip or both hips in SUFE?
Both hips
Mx of children aged 5-16 years with asthma not controlled by a SABA + paediatric low-dose ICS + LTRA?
Add a LABA and stop LTRA
Inheritance of thalassaemia?
Autosomal recessive
How long should a child with impetigo be excluded from school for?
until the lesions are crusted and healed or 48 hours after commencing antibiotic treatment
Cyanotic congenital heart disease presenting within the first days of life vs 1-2 months of age?
First days of life –> TGA
1-2 months –> ToF
Mx of SUFE?
Surgery –> in situ fixation with a cannulated screw
What is the triad of shaken baby syndrome?
1) retinal haemorrhages
2) subdural haematoma
3) encephalopathy
When does a cephalohaematoma vs caput succedaneum appear?
Cephalohaematoma –> develops after birth
Caput succedaneum –> develops during birth
What is a subaponeurotic haemorrhage?
A serious condition caused by bleeding in the potential space between the periosteum and subgaleal aponeurosis.
Typically there is a boggy swelling that grows insidiously and is not confined to the skull sutures.
Neonate may present with haemorrhagic shock.
How may a neonate with a subaponeurotic haemorrhage present?
With haemorrhagic shock
Exam findings in TGA?
1) No murmur
2) Loud single S2
3) Prominent RV impulse
What are the 2 innocent murmurs heard in children?
1) Venous hums
2) Still’s murmur
What causes a venous hums?
Due to the turbulent blood flow in the great veins returning to the heart.
Describe a venous hums
A continuous blowing noise heard just above the clavicles.
Describe a Still’s murmur
Low pitched sound heard at the lower left sternal edge.
Characteristics of an innocent ejection murmur?
1) soft blowing murmur in pulmonary area or short buzzing murmur in aortic area
2) may vary with posture
3) localised with no radiation
4) no diastolic component
5) no thrill
6) no added sounds (e.g. clicks)
7) asymptomatic child
8) no other abnormality
School exclusion for scarlet fever?
24h after starting Abx
School exclusion for whooping cough?
2 days after starting Abx (or 21 days from onset of symptoms if no Abx)
1st line Abx for whooping cough?
Macrolide e.g. azithromycin
School exclusion for measles?
4 days from onset of rash
School exclusion for chickenpox?
Until all lesions crusted over
What delayed motor milestones should elicit suspiscion of cerebral palsy? (4)
1) Not sitting by 8 months (corrected for gestational age)
2) Not walking by 18 months (corrected for gestational age)
3) Hand preference before 1 year
4) Persistent toe walking
Mx of asymptomatic hypoglycaemia in neonates?
Common in first few hours, encourage feeding and monitor blood glucose.
Mx of symptomatic hypoglycaemia in neonates?
IV dextrose 10%
Give 4 causes of neonatal hypoglycaemia
1) Prematurity
2) Maternal diabetes
3) Hypothermia
4) IUGR
Paeds BLS, what pulse should you start CPR?
<60
Triad of symptoms of NEC?
1) Abdo distension
2) Feeding intolerance
3) Bloody stool
Key investigation in NEC?
AXR
What will AXR show in NEC?
Distended bowel loops, pneumatosis intestinalis
Mx of NEC?
1) Abx
2) Gut rest
3) TPN
What is the most common cause of stridor in infants?
Laryngomalacia
Mx of bronchiolitis?
Supportive
What is given as prophylaxis for LTRIs?
Palivizumab
What number of episodes of vomiting in paeds indicates need for ugent head CT (<1 hour)?
≥3
At what age should ALL children with an acute limp be referred urgently for assessment?
≤3 y/o –> increased risk of NAI and septic arthritis
What does grunting indicate?
Severe respiratory distress
What is the most common cause of death with measles?
Pneumonia
When does biliary atresia typically present?
Symptoms of cholestasis around 14 days after birth
What genetic syndrome is there an increased risk of autism?
Fragile X syndrome
Testicles in Fragile X syndrome?
Macroorchidism (large testes)
Mx of PDA?
Echo a few days after birth –> indomethacin
What is the nitrogen hyperoxia test?
The initial method to distinguish cyanotic congenital heart disease from pulmonary disease.
What does the nitrogen hyperoxia test involve?
Measure pO2 using ABG before and after 15 mins of 100% inspired O2.
Test positive if pO2 <15kPa after 15 mins of 100% O2.
Which syndrome is there Elfin facies?
William’s syndrome
Which syndrome is there Rocker bottom feet?
Edward’s
Stepwise management of GORD in infants?
1) thickened formula
2) alginate therapy e.g. Gaviscon
3) PPI trial
Colonisation with what bacteria in CF is a contraindication for lung transplant?
Burkholderia cepacia
What is a key risk factor for meconium aspiration?
Post-term
Normal RR and HR for infants?
RR: 30-60
HR: 100-160
What investigations are done in suspected DDH/those at risk of DDH?
1) Barlows & Ortolani test
2) US of hip
What investigations are done in suspected Perthe’s?
XR then MRI
2nd line investigation in Perthe’s after XR?
MRI
Stepwise management of paeds constipation?
Movicol (osmotic lax) then + senna
Fluids used in paeds resus?
0.9% saline 20ml/kg bolus over 10 mins
What investigation is used in Meckel’s diverticulum?
Technetium scan –> mucoid cells in protrusion accumulate in technetium.
Are innocent murmurs ejection or systolic?
Always ejection
Mx of croup?
Single dose of oral dex (0.15mg/kg)
What vaccines do infants receive at age 12m?
1) Hib/men C
2) MMR
3) Men B
4) PCV
What is used for definitive diagnosis of Duchenne’s muscular dystrophy?
Genetic testing
CK levels in Duchenne’s?
Raised
What is a key cardiac complication of Duchenne’s?
Dilated cardiomyopathy
Features of Kawasaki disease (6)
1) Fever >5 days
2) Peeling skin on hands and feed
3) Bilateral conjunctivitis
4) Cervical lymphadenopathy
5) Red rash over trunk
6) Dry cracked lips
