paeds essential conditions Flashcards
How is bilirubin formed?
What % of term babies develop jaundice in first week of life?
What’s the difference between conjugated and unconjugated bilirubin?
Formation of Bilirubin:
Red blood cells –> Haem broken down —> Bilirubin = transported to liver as unconjugated bilirubin, bound to albumin—> conjugation in the liver = become water soluble —> conjugated bilirubin excreted in the bile into duodenum —> stercobilinogen = makes faeces brown
60% term babies develop jaundice in first week of life
Usually unconjugated cause (pre-hepatic) – conjugated would indicate a worrying post hepatic cause
DDx for neonatal jaundice:
< 24 hrs
- unconjugated? 2
- conjugated? 4
24hrs - 2 wks
- unconjugated? 3
- conjugated? 4
> 2 wks
- unconjugated? 4
- conjugated? 3
nb unconjugated is much more common!!
< 24 hrs UNCONJUGATED
- haemolytic disease (eg rhesus, HBO incompatibility, hereditary spherocytosis, G6PD deficiency)
- neonatal sepsis
< 24 hrs CONJUGATED (ie neonatal hepatitis)
- hepatitis A or B (also a1-antitrypsin)
- TORCH infections
- Inborn errors of metabolism (eg galactosaemia)
- CF
24hrs - 2wks UNCONJUGATED
- PHYSIOLOGICAL
- hypothyroidism
- haemolysis/sepsis
24hrs - 2wks CONJUGATED
- (as above - ie hep, torch, metabolism, CF)
> 2wks UNCONJUGATED
- breast milk jaundice (but should have resolved by now)
- haemolysis
- sepsis
- hypothyroidism
> 2wks CONJUGATED
- BILIARY ATRESIA
- choledochal cyst
- neonatal hepatitis
JAUNDICE IN FIRST 24hrs IS NEVER PHYSIOLOGICAL!
PHYSIOLOGICAL JAUNDICE:
- when does it appear? and when should it go by?
- pathophysiology?
- what four things exacerbate it? 4
Appears after 24hrs, peaks day 3-4
Usually self-resolving by 14 days
Presents and progresses in cephalic to caudal direction
Immaturity of hepatic bilirubin conjugation process
Breakdown of foetal haemoglobin
EXACERBATED BY:
- bruising (eg forceps)
- polycythaemia
- dehydration (eg caused by poor feeding)
- prematurity
Give four examples of haemolytic disorders which can result in neonatal jaundice? (briefly describe each)
What blood test is done to rule these out?
RHESUS-HAEMOLYTIC DISEASE: affected infants are usually identified antenatally and monitored and treated when necessary. If not identified early then children can be born with anaemia, hydrops and hepatosplenomegaly
ABO INCOMPATIBILITY: now more common than rhesus disease. Most ABO abs are IgM and so do not cross the placenta but some women who are group O have IgG abs which can cross the placenta and start breaking down the red cells of the group A infant. The jaundice can be striking but there are usually fewer other severe symptoms in ABO compared to RHESUS
G6PD DEFICIENCY - develop haemolytic anaemia and jaundice. Mainly affects male infants
HEREDITARY SPHEROCYTOSIS
tests for haemolytic antibodies should be done - COOMB’S TEST
NEONATAL JAUNDICE Hx
- most important question? (and two red flag answers to this)
- prenatal Qs to ask? 2
- Qs to ask about labour? 7 (which 3 of these are risk factors for neonatal sepsis)
- Qs to ask about post-natal? 6 (incl feeding, bowels etc)
- conditions to ask if FHx of? 2
- other FHx to ask? 2
AT WHAT AGE DID THE JAUNDICE DEVELOP?
- <24hrs = red flag
- > 2wks = red flag
PRENATAL
- full antenatal care received? (if not may have missed rhesus or other screening etc)
- get any infections in pregnancy? (or in contact with anyone - list torch)
INTRAPARTUM
- gestation born?
- method of delivery?
- any trauma to baby during delivery? (bruising/forceps etc)
- how long mebranes ruptured for? (>12hrs sepsis)
- any fever? (sepsis)
- any high foetal HR? (sepsis)
- have to stay in NICU for any period?
POST NATAL
- general behaviour (active/alert or lethargic/needing to be woken)
- how fed? (breast or bottle)
- any feeding difficulties?
- when pass meconium (>48 hrs could be CF)
- How stools been since (pale, chalky = red flag for biliary atresia)
- wet nappies (lack of could mean infection/dehydration)
FHx
- any previous children (any problems)
- cosanguinity? (inborm errors)
- CF
- spherocytosis
Exam for NEONATAL JAUNDICE:
- what looking for? 10
nb you effectively do a full NIPE exam! (maybe minus the hips)
- is baby alert / well
- how handle / tone (hypothyroid)
- extent of jaundice (norm spreads from head towards feet)
- does it blanch to pressure? (hard to see if non-white)
ANY SIGNS OF DEHYDRATION
- mucous membranes
- dry nappy
- sunken FONTANELLE)
ANY FEATURES OF TORCH
- petechiae
- anaemia
- hepatosplenomegaly
Investigations for neonatal jaundice:
- initial test for all?
- initial bloods? 4
- other tests to consider to help find cause? 4
- what further tests should be done if infant still jaundiced after 14 days? 2
Measure trans-cutaneous bilirubin
if high, need to find cause:
- FBC (shows anaemia, low or high WCC)
- LFTs (esp proportion conjugated or not)
- Group + save (compare w mothers)
- COOMBS TEST
OTHER TESTS
- TORCH screen
- Septic screen
- TFTs
- Urine metabolic scvreen (inborn errors)
IF STILL JAUNDICE AFTER 14 DAYS (look for biliary atresia)
- liver USS
- liver isotope scan
NEONATAL JAUNDICE:
- three symptomatic management options? when use each?
- what other management is needed?
1) DO NOTHING
- if unconjugated bilirubin is lower than line for phototherapy
- reasssure parents that it is self-limiting AND safety net
- encourage feeding if struggling
2) PHOTOTHERAPY
- if unconjugated bilirubin above line for phototherapy
- baby lies under UV light with eyes protected
- have breaks for feeding, changing nappies etc
- measure bilirubin every 4-6 hours during phototherapy
- stop phototherapy once levels of bilirubin have dropped to at least 50micromol/L below threshold for treatment
3) EXCHANGE TRANSFUSION
- if unconjugated bilirubin above line for exchange transfusion (though can try phototherapy first)
REMEMBER JAUNDICE <24hrs is ALWAYS pathological and needs further investigation
FIND AND TREAT UNDERLYING CAUSE!
- unless just physiological!
BILIARY ATRESIA
- what is it?
- management? 1
GALACTOSAEMIA:
- what it it?
- absence of intra or extra hepatic bile ducts
- causes conjugated hyperbilirubinaemia
- stool becomes clay coloured
- leads to liver failure and death
Kasai procedure within 6 weeks of life can achieve adequate biliary drainage
GALACTOSAEMIA
means you can’t break down galactose
can cause neonatal hepatitis and jaundice
nb these conditons have nothing to do with each other (except that they both cause jaundice) they’re just on the same card because I accidently deleted one
an inborn error of metabolism
What is the complication that can occur if there are high levels of unconjugated bilirubin in the neonate?
specific form of brain injury known as KERNICTERUS
This occurs because babies have very thin blood-brain barriers that are not that efficient at keeping things out (this is also why they are more prone to meningitis). As a result of this the high levels of unconjugated bilirubin in their blood crosses this barrier readily - the unconjugated bilirubin collect in the basal ganglia
This bilirubin can damage the brain and the spinal cord and this can be life-threatening for the baby
Initial symptoms
- Poor feeding
- Irritability
- High-pitched cry
- Lethargy
- Apnoea
- Hypotonia
- Seizures - late sign
- Muscle spasms - late sign
Child can go on to develop cerebral palsy, learning difficulties and hearing problems
nb this is very rare now as most jaundice is picked up
What vaccinations are babies given at:
- 8 weeks? 3
- 12 weeks? 3
- 16 weeks? 3
- 1 year? 4
- 2 years? 1
- 3yrs 4mnths? 2
- 12-13 years? 1
- 14 years? 3
nb number refers to the number of injections - some vaccines cover more than one infection - list these if applicable
8 WEEKS
- diptheria, tetanus, pertussis, polio, haem influenzae type B (HiB), hep B (6-in-1)
- rota virus (oral)
- Meningitis B
12 WEEKS
- pneumococcal
- 6-in-1 (2nd dose)
- rotavirus (oral) (2nd dose)
16 WEEKS
- 6-in-1 (3rd dose)
- Men B (2nd dose)
ONE YEAR
- Hib/Men C (1st dose)
- MMR (1st dose)
- pneumococcal (2nd dose)
- Men B (3rd dose)
2 YEARS
- flu vaccine (nasal) given EVERY year
3 YEARS 4 MONTHS
- MMR (2nd dose)
- 4-in-1 preschool booster (diptheria, tetanus, pertussis + polio)
12-13 YEARS
- HPV vaccine (1st dose)
14 YEARS
- HPV vaccine (2nd dose, 6-12 mnths after 1st)
- 3-in-1 teenage booster (tetanus, diptheria, polio)
- Meningococcal group A, C, W and Y disease (MenACWY)
nb injections are generally given in thigh up to 12mnths then generally arm older than that
nb don’t use alcowipes to wipe skin before immunisations!! as may affect vaccines
What additional vaccines should be offered to infants / children at risk?
when give?
Heb B (at birth)
BCG (any age from birth - 16yrs)
Which common vaccines are live attenuated? 4
other live attenuated vaccines? 3
who should these NOT be given to?
- rotavirus
- MMR
- intranasal influenza
- BCG
- oral polio
- oral typhoid
- yellow fever
SHOULD NOT BE GVEN IF IMMUNOCOMPROMISED
General contraindications to any childhood vaccines? 5
- if younger than schedule
- acutely unwell with fever
- has had anaphylactic reaction to previous dose
- undiagnosed neurodevelopmental condition
- live attenuated vaccines to immunocompromised
also if severe egg allergy, give certain immunisations (esp MMR) under controlled conditions
How is consent taken to give childhood vaccines?
where are childhood vaccines recorded?
written consent is taken at beginning of new schedule
- then verbal consent before each vaccine
record in red book
- record serial number and site of each injection
What diseases are covered in the 6-in-1 vaccine?
- common side effects? 4
- rare side effects? 2
- diptheria
- tetanus
- pertussis
- polio
- haem influenzae type B (HiB)
- hep B
COMMON
- swelling
- redness
- papule at site
- fever
RARE
- febrile convulsions
- anaphylaxis
MMR
- contraindications? 4
- side effect? 3
CONTRAINDICATIONS
- immunocompromised children (is live vaccine)
- pregnant girls
- children with neurological conditions
- severe egg allergy
SIDE EFFECTS
- rash
- fever in 5-10 days
- mild mumps at 14 days
What do these vaccine abbreviations stand for:
- DTaP
- IPV
- HiB
- Td
- DTaP = diptheria, tetanus, acellular pertussis
- IPV = inactivated polio vaccine
- HiB = Haemophilus influenzae type B
- Td = tetanus and diptheria
Causative organisms in meningitis in:
- neonates? 3
- infants / children? 4
- adolescents / adults? 2
NEONATES (ie first 4 wks)
- group B strep
- e. coli
- listeria
INFANTS / CHILDREN
- haemophilus influenzae
- neisseria meningitis
- strep pneumoniae
- viral
ADOLESCENTS / ADULTS
- neisseria meningitis
- strep pneumoniae
MENINGITIS IN NEONATES
- changes in vital signs? 3
- other symptoms/signs? 7
VITAL SIGNS
- fever
- low HR
- high BP
OTHER SIGNS
- irritable
- poor feeding
- lethargy / coma
- seizures (30%)
- respiratory distress
- bulging fontanelle (often meningococcal)
- non-blanching rash (meningococcal)
DO NOT GET CLASSICAL SIGNS OF MENINGISM (have a LOW threshold of suspision)
MENINGITIS IN INFANTS / CHILDREN
- signs of meningism? 3
- other symptoms? 4
- other signs/obs? 5
- clinical signs? (two, which is which)
- fever
- headache
- neck stiffness
^ from 2 years old
OTHER SYMPTOMS
- refusing food
- lethargy
- unsettled
- nausea + vomiting
OTHER SIGNS
- cold peripheries
- non-blanching rash (meningococcal)
- reduced GCS
- high BP
- low HR
CLINICAL SIGNS
Kernig’s sign (K for Knee)
= bend knee up and then extend knee -> pain / resistance
Brudzinski’s sign
= flex pt neck and then hips + knee will flex in response
^ both very specific and sensitive
MENINGITIS IN ADOLESCENTS / ADULTS
- Symptoms / signs? 7
- clinical signs? (two, which is which)
- fever
- headache
- neck stiffness
- photophobia
- muscle aches
- nausea + vomiting
- non-blanching rash (meningococcal)
CLINICAL SIGNS
Kernig’s sign (K for Knee)
= bend knee up and then extend knee -> pain / resistance
Brudzinski’s sign
= flex pt neck and then hips + knee will flex in response
^ both very specific and sensitive
If suspect meningococcal meningitis in community, what do you do immediately? (what to do if allergy?) and within how long?
Give IM BenPen IMMEDIATELY (within 30mins)
- if pen allergic, ceftriaxone
transfer to hospital immediately
Investigations for suspected meningitis:
- bedside? 2
- bloods? 9
- imaging? 1
lumbar puncture (unless CI)
urine analysis
bloods:
- FBC
- U+E
- LFT
- clotting
- CRP
- Blood cultures
- whole blood PCR
- Glucose (do compare w LP)
- VBG
CXR
Contraindications for performing an LP on someone with suspected meningitis? 6
- signs of raised ICP
- focal neuro signs / focal seizures
- shock or CV instability
- evidence of coagulopathy
- infection of skin at site of LP
- signs of meningococcal septicaemia
nb bulging fontanelle is NOT a contraindication for LP
What changes do you see (ie high, normal, low) on LP for bacterial, viral and TB meningitis on:
- neutrophils?
- lymphocytes?
- protein?
- glucose?
- appearance?
- opening pressure?
BACTERIAL MENINGITIS
- neutrophils = HIGH
- lymphocytes = normalish
- protein = HIGH
- glucose = LOW
- appearance = cloudy/purulent
- opening pressure = HIGH
VIRAL MENINGITIS
- neutrophils = normalish
- lymphocytes = HIGH
- protein = normalish
- glucose = normal
- appearance = cloudy / purulent
- opening pressure = normal
TB MENINGITIS
- neutrophils = normalish
- lymphocytes = HIGH
- protein = HIGH
- glucose = LOW
- appearance cloudy / purulent
- opening pressure = high or normal
nb mumps is unusual in being associated with a low glucose level in a proportion of cases. A low glucose may also be seen in herpes encephalitis
1st line empirical abx management of bacterial meningitis:
- aged <1 month? 2
- aged 1-3 months? 2
- aged >3 months? 1
- additional medication to add if over 3 months? 1
- what else needs to be done from a public health perspective if confirmed case of bacterial meningitis? 2
< 1 month
- gentamicin
- amoxicillin
1-3 months
- cefotaxime
- amoxicillin
> 3 months
- cefotaxime
ALWAYS SAY YOU WOULD CONSULT TRUST GUIDELINES THOUGH!!!
also if > 3 months
- steroids (to decrease likelihood of neuro sequelae)
PUBLIC HEALTH
- prophylactically treat contacts / household members
- inform public health
Potential complications of meningitis:
- immediate? 5
- long term? 4
IMMEDIATE
- sepsis
- seizures
- DIC
- cerebral oedema
- hydrocephalus (dt blockage of ventricle outlets)
LONG TERM
- hearing loss
- focal paralysis
- seizures
- cerebral palsy (if under 2 years)
What is meningococcal septicaemia?
normal causative organism?
what % also have meningitis?
which two age groups most common in?
acute bacteraemia with vasculitis
neisseria meninigtidis
60% also have meningitis
nb subtypes of N. Men are: A/B/C/W/Y
two waves of incidence:
- < 5 years
- adolescence
Signs of meningococcal septicaemia? 6
- fever
- mottling
- cold peripheries
- leg pain
- breathing difficulties
- non-blanching rash
What investigations make up a ‘septic screen’? 4
who should these always be performed in?
- blood cultures
- urine analysis
- CXR
- LP
(also stool culture, if loose stools)
always perform in child with fever of unknown origin aged < 3 months
blood tests to do if suspect meningococcal septicaemia? 8
Management? 6
- FBC
- U+E
- LFT
- clotting
- CRP
- blood cultures
- VBG
- glucose
manage using BUFALO
Non-blanching rash:
- what is the pathophysiology? (ie, why doesn’t it blanch)
- what are the three different names given to them? (depending on size)
Red/Purple non-blanching discolouration of the skin dt haemorrhage from small blood vessels under the skin
PETECHIAE
- < 2mm diameter
PURPURA
- 3-10mm fiameter
ECHYMOSIS
- > 1cm diameter
Causes of purpura in children:
- infective? 2
- iatrogenic? 1
- other causes? 5
INFECTIVE
- viral (most commonly enterovirus eg HFAM, coxsackie, polio)
- septicaemia (most commonly meningococcal)
IATROGENIC
- drug reactions
OTHER
- Acute lymphoblastic leukaemia
- Congenital bleeding disorders
- Immune thrombocytopenic purpura (ITP)
- Henoch-Schonlein purpura (or other vasculitis)
- Non-accidental injury (or accidental trauma)
nb raised superior vena cava pressure (e.g. secondary to a bad cough) may cause petechiae in the upper body but would not cause purpura
Investigations for purpura in children:
- bedside / obs? 2
- bloods? 4
- if signs indicative f sepsis? 6
- if likely caused by drugs?
- if diagnosis unclear?
nb also take full Hx and examine (don’t forget joints for HSP and abdo exam/organomegaly for cancers)
- BP
- urine-analysis (to look for HSP)
- FBC
- U+E
- clotting screen
- blood cultures
if suspect sepsis:
- BUFALO
- stop any potential causative drugs
if diagnosis unclear, consider skin biopsy
IRON DEFICIENCY ANAEMIA:
- three groups of causes? (with 3 example for 1st, 2 examples for 2nd and 4 examples for 3rd
- biggest source of iron for children?
- what can increase the absorption of iron?
INADEQUATE INTAKE
- vegetarien/vegan
- fussy eater
- over-reliance on cow’s milk
MALABSORPTION
- coeliac disease
- parasitic disease (eg hookworm)
BLOOD LOSS
- meckel’s diverticulum
- NSAIDs
- cysts / tumours
- oesophagitis
FORTIFIED BREAKFAST CEREALS have loads of iron in
vitamin C increases absorption
nb breast and cow’s milik is a poor source of iron - formula feed better , but this is why should wean at 6 months
IRON DEFICIENCY ANAEMIA:
- most common presentation?
- systemic symptoms? 4
- mood / behavioural symptoms? 3
normally asymptomatic!!
- most toddlers tolerate surprisingly low Hb
- easily tired
- slow feeding in infants
- pallor (conjunctiva, palmar creases, tongue)
- breathlessness
- mood changes / irritability
- reduced cognitive + psychomotor performance
- PICA (eating unusual items, eg soil, chalk, gravel)
also ask about blood loss and symptoms of malabsorption (eg vomiting, failure to thrive)
possible blood tests for iron-deficiency anaemia? 4
possible findings of these?
FBC
- low Hb
- low MCV
- low MCH
- low MCHC
U+E
- for anaemia of chronic disease, eg renal
FERRITIN
- low, low iron stores
BLOOD FILM
- microcytic hypochromic anaemia
can also test for coeliac is suspect
ANAEMIA IS NOT A DISEASE - IT IS A SIGN (ie look for underlying cause)
1st line management of iron deficiency anaemia:
- lifestyle?
- medication? 1
what to screen for if don’t respond? 2
encourage iron-containing food
- fortified formula
- fortified breakfast cereals
- mean
- green veg
- beans
- egg yolk
avoid prolonged cow’s milk consumption to detriment of solids intake
ORAL FERROUS SULPHATE
- dose depend on age and kg
IF NO RESPONSE AFTER 6 MONTHS, screen for:
- thalasaemmia
- coeliac disease
ASTHMA:
- pathophysiology?
- risk factor to always ask about?
Chronic airway inflammation, bronchial hyper-reactivity, reversible airway obstruction.
Mucosal oedema, bronchoconstriction, hyper-secretion of mucus
always ask about FHx and PNHx of atopy (ezcema, asthma, hayfever - also allergy)
How to differentiate between asthma and viral-induced wheeze?
- age?
- onset?
- timing?
- physical exam findings?
- FHx/PMHx?
what is the main difference in management in the acute setting?
AGE:
- asthma = normally diagnosed by age 5, but hard to diagnose in infants/toddlers
- viral-induced = normally under 5 (80% grow out of it)
ONSET:
- asthma = worse with triggers (see other flashcard)
- viral-induced = symptoms associated with co-existing URTI
TIMING:
- asthma = interval symptoms (ie worse at night and early in morning and following triggers)
- viral induced = no interval symptoms
PHYSICAL EXAM FINDINGS:
- asthma = wheeze found on auscultation (+ reduced PEFR)
- viral-induced = clinical findings less likely
FHx / PMHx
- asthma = strong FHx/PMHx of atopy
- viral-induced = Hx less likely
Don’t use steroids in acute management of viral-induced wheeze
nb both are responsive to bronchodilators
What two things should you always ask about in social hx of a child with a resp problem?
- do parents smoke?
- any pets?
Four main symptoms of asthma?
- wheeze
- cough
- difficulty breathing
- chest tightness
Triggers for asthma? 8
- exercise
- cold (or damp air)
- pets
- dust mites
- pollen
- mould
- tobacco smoke
- with emotions or laughter
Aside from viral-induced wheeze, what other DDx to exclude if suspect asthma? 5
- TB
- URTI
- recurrent aspiration
- CF
- congenital heart disease
FEATURES OF ACUTE ASTHMA:
- acute severe attack? 5
- life-threatening attack? 8
incl O2 sats and PEFR
ACUTE SEVERE ATTACK
- Sats < 92%
- PEFR 33-50% best or predicted
- can’t complete sentences in one breath (or too breathless to talk or feed)
- HR >125 (if >5 years) or >140 (if 2-5 years)
- RR >30 (if >5 years) or >40 (if 2-5 years)
LIFE-THREATENING ATTACK
- Sats < 92%
- PEFR < 33% best or predicted
- silent chest
- poor resp effort
- cyanosis
- hypotension
- exhaustion
- confusion
also look for signs of resp distress (eg accessory muscle use)
MANAGEMENT OF ACUTE ASTHMA (aged over 2 years)
- acronym? 7
- 1st line? 4
- 2nd line? 2
O SHIT ME
ESCALATE EARLY!
FIRST LINE
- Oxygen (driven through salbutamol nebs)
- Salbutamol nebs
- hydrocortisone IV (or oral prednisalone)
- ipraptropium bromide nebs
SECOND LINE
- Aminophylline IV (or IV salbutamol)
- Magnesium sulphate IV
DDx of asthma in children under 2? 5
under, wheeze is more likely due to another aetiology
- aspiration pneumonitis
- pneumonia
- bronchiolitis
- tracheomalacia
- complications of underlying conditions (eg congenital heart disease, CF)
Management options for acute suspected asthma in children under 2 years? 4
ONLY TREAT IF VERY UNWELL / SYMPTOMATIC
oxygen (if sats low)
pMDI + spacer + mask of salbutamol
consider inhaled iproatropium bromide if severe
if severe, consider steroids (nb be cautious if repeated episodes as can stunt growth)
LONG-TERM MANAGEMENT OF ASTHMA IN UNDER 5s
- lifestyle changes? 2
- 1st line?
- 2nd line?
- 3rd line?
- 4th line?
- when to go to next line of treatment?
- what additional device should always be given to children under 5?
- what to check at every appointment?
- stop parental smoking (if relevant)
- reduce pet / animal exposure (if relevant)
1st line = salbutamol inhaler PRN
2nd line = regular inhaled steroids (start low dose and build up) OR leukotrine receptor antagonist if steroids CI
3rd line = add leukotriene receptor antagonist (or refer if under 2)
4th line = refer to resp physician
NEXT LINE: if using >3 doses of SABA a week
ALWAYS GIVE SPACERS!! (different ones for diff sizes)
CHECK INHALER / SPACER TECHNIQUE AT EVERY APPT
LONG-TERM MANAGEMENT of ASTHMA in children aged 5-12 years
- lifestyle changes? 2
- 1st line?
- 2nd line?
- 3rd line?
- 4th line?
- 5th line? 2
- when to go to next line of treatment?
- what additional device should always be given to children under 5?
- what to check at every appointment?
- stop parental smoking (if relevant)
- reduce pet / animal exposure (if relevant)
1st line = salbutamol inhaler PRN
2nd line = regular inhaled steroids (start low dose and build up)
3rd line = add LABA
4th line = increase dose of ICS
5th line = add steroid tablet AND refer to resp physician
NEXT LINE: if using >3 doses of SABA a week
ALWAYS GIVE SPACERS!! (different ones for diff sizes)
CHECK INHALER / SPACER TECHNIQUE AT EVERY APPT
nb children aged > 12, treat as for adults
Side effects of steroids in children? 4
- impaired growth (height, hair, feet)
- adrenal suppression
- altered bone metabolism
- oral candidiasis
BRONCHIOLITIS
- most common causative organism?
- most common season?
- age range most affected?
- what increases chance of increased severity? 3 (what are these groups given? 1)
RSV = 70-80%
winter
under 2 years
- peak incidence is 3-6months
HIGH RISK
- premature babies w chronic lung disease
- children w CF
- congenital heart disease
^ give these groups monoclonal antibodies (palitvizumab) before they leave hospital after birth
BRONCHIOLITIS:
- resp signs / symptoms? 5
- other signs / symptoms? 2
- what other systems to always ask about? 2
- when to suspect secondary bacterial infection? 2
RESP
- corzyal symptoms (normally precede wheeze etc - eg runny nose, sneezing)
- high-pitched expiratorywheeze
- fine inspiratory crackles (not always present)
- dry cough
- SOB
OTHER
- low grade fever (< 39 deg)
- feeding difficulties
nb symptoms peak day 3-5, though cough may continue for 3 wks
nb viral induced wheeze more likely where solely wheeze and > 1 year
ASK ABOUT:
- bladder
- bowels (incl feeding)
SUSPECT BACTERIAL INFECTION IF:
- focal crackles
- temp > 39 deg
BRONCHIOLITIS:
- changes to vital signs? 6
- possible resp exam findings? 5
- aside from resp exam, what else should you examine for? 2
RR - raised HR - raised BP - norm Sats - should be norm Temp - mildly raised AVPU - A
RESP
- nasal flaring
- subcostal and intercostal recessions
- harsh cough
- wheeze
- cyanosis!
look in nappies
- no wet nappies for 12 hrs is sign of dehydration
look for other signs of dehydration
- eg fontanelle, skin turgor, mucous membranes etc
BRONCHIOLITIS:
- when to consider admitting into hosp? 3
- when to immediately admit (by ambulance) and probs to PICU? 6
CONSIDER ADMITTING TO HOSP
- RR > 60
- difficulty with breastfeeding or inadequate oral intake (50-75% of normal volume)
- clinical dehydration (eg no wet nappies for >12 hours)
ADMIT IMMEDIATELY TO HOSP / PICU
- apnoea (observed or reported)
- child looks seriously unwell (dr opinion)
- severe resp distress (eg grunting, marked chest recessions, RR >70)
- central cyanosis
- persistent sats <92% on air
- milk / fluid intake drops below 50%
basically the two indications for admitting someone is either:
- resp distress
- feeding problems
If admitted, what are the management options for bronchiolitis? 3
what investigations can you do if severe? 2
what investigations can you do is diagnosis is uncertain? 1
- humidified OXYGEN is given via a head box and is typically recommended if the sats are persistently < 92%
- nasogastric feeding may be needed if children cannot take enough fluid/feed by mouth
- suction is sometimes used for excessive upper airway secretions
if severe:
- capillary blood gas
- CXR
if diagnosis uncertain:
- nasal swab
CROUP:
- full latin name?
- age group norm affected?
- normal causative organism?
- what section of the history is really important not to miss with croup?
acute viral laryngotracheobronchitis
6 months - 6 years
parainfluenzae
vaccination history!
- to exclude epiglottitis cause by HiB
CROUP:
- common prodrome? 1
- symptoms / signs? 3
- when are symptoms worse?
prodrome = coryzal symptoms
- barking cough
- inspiratory stridor
- fever
symptoms worse at night
CROUP:
- what scale is used to assess severity?
features of mild, moderate and severe disease on these parameters:
- frequency of barking cough
- audible stridor
- supra and/or intercostal recession
- behaviour of child
other sign of severe disease
WESTLEY SCORE
MILD
- barking cough = occasional
- audible stridor = none at rest
- supra and/or intercostal recession = none
- behaviour = happy: can eat drink + play
MODERATE
- barking cough = frequent
- stridor = easily audible at rest
- supra and/or intercostal recession = yes
- behaviour = no / little distress or agitation, child can be placated + is interested in surroundings
SEVERE
- barking cough = prominent
- stridor = inspiratory (+ occasionally expiratory) at rest
- supra and/or intercostal recession = yes, marked
- behaviour = significant distress + agitation or lethargy or restlessness
- tachycardia!
CROUP:
- what severity of croup should be admitted to hosp?
- other criteria for admission? 3
severe AND moderate (ie stridor at rest and intercostal recessions)
other criteria for admission:
- < 6 months of age
- known upper airway abnormalities (eg laryngomalacia, down’s)
- uncertainty about diagnosis (see DDx flashcard)
also if other reasons, eg child looks toxic / cyanosed, dehydration, social situations meaning parent is struggling to look after,
DDx of croup? 4
which is most important to rule out?
- ACUTE EPIGLOTTITIS (drooling present)
- bacterial tracheitis
- peritonsilar abscess
- foreign body inhalation
CROUP:
- simple investigations to do, in addition to resp exam? 6
- what should you NOT do when examining? 2
just do obs (HR, BP, RR, sats, AVPU, temp) in addition to resp exam
- is a clinical diagnosis
- try to visualise back of throat
- distress the child (as this may worsen symptoms)
CROUP MANAGEMENT:
- medication for all?
- advice to parents if going home? 4
- features to tell parents about to bring child in for? 3
- features to tell parents to call ambulance for? 7
- additional management options if admitted? 2
single dose PO dexamethasone (or can give IM or inhaled steroid if can’t take oral)
if going home (ie mild):
- symptoms should resolve within 48hrs
- use paracetamol / ibuprofen if distressed dt fever
- encourage fluid intake
- check child regularly, incl at night
BRING TO HOSPITAL
- continuous stridor
- skin between ribs is pulling in with each breath
- child is restless or agitated
CALL AMBULANCE
- very pale, blue or grey (incl blue lips) for > few secs
- unusually sleepy or not responding
- real difficulty breathing (windpipe pulling in , flaring nostrils)
- really agitated, uncalmable
- can’t talk (if applicable)
- can’t swallow
- drooling
IF ADMITTED
- high flow oxygen
- nebulised adrenaline (if still not work then consider intubation)
remember everyone gets same single dose of steroids, regardless of severity
EPIGLOTTITIS:
- norm causative organism?
- biggest risk factor?
Haemophilus influenzae type B
unvaccinated children
EPIGLOTITTIS:
- speed of onset?
- key symptoms / features? 3
- other symptoms / features? 5
- what symptom is normally absent (that is present in DDx)? 1
rapid onset
- high temp, generally unwell
- stridor
- drooling of saliva
OTHER SYMPTOMS
- sore throat
- odynophagia (painful swallowing)
- muffled voice (‘hot potato’ voice)
- cervical lymphadenopathy
- tripoding (older kids)
kids with epiglottitis rarely have a cough (helping to differentiate it from croup)
EPIGLOTITTIS MANAGEMENT:
- what shouldn’t do? 1
- who do you need to manage? 2
- medication? 1
- what sign on lateral neck xray?
DON’T look in mouth!
- anaesthetist
- ENT
Abx (once airway secured)
lateral neck x-ray
- thumbprint sign
COMMON CAUSES OF PNEUMONIA IN KIDS:
- commonest cause overall?
- neonates? 2
- children < 5 years? 5
- children > 5 years? 3
- what to consider in all ages? 1
COMMONEST = STREP PNEUMONIAE
NEONATES
- Group b strep
- gram -ve enterococci
CHILDREN < 5 YEARS - VIRAL: RSV - strep pneumoniae - haem influenzae - bordetella pertussis - chlamydia trachomatis (also infrequent, but serious: staph aureus)
CHILDREN > 5 YEARS
- strep pneumoniae
- mycoplasma pneumoniae
- chlamydia pneumoniae
consider TB in all ages! (ask about foreign travel!)
nb hard to tell difference clinically between viral and bacterial pneumonia in kids - tend to treat as bacterial (as also can’t tell on CXR either)
nb don’t focus on learning all that much, just that strep pneumoniae is most common and organisms from mother’s genital tract most common in neonates
PNEUMONIA IN CHILDREN:
- resp symptoms / signs? 7
- other symptoms / signs? 4
RESP
- dyspnoea
- cough
- wheeze
- crackles
- reduced air entry (dull percussion)
- nasal flaring
- inter/sub costal recessions
OTHER
- lethargy
- poor feeding
- fever
- localised chest, abdo or neck pain (suggests bacterial cause)
PNEUMONIA IN CHILDREN:
- 1st line abx management? 1
- Abx if pen allergic or suspect atypical cause? 1
- Abx if severe? 1
- what to say in osce?
- other management options? 2
amoxicillin = 1st line
macrolides (norm clarithromycin) if atypical (mycoplasma or chlamydia) is suspected (or if pen allergic)
co-amoxiclav if severe (or associated with flu)
I WOULD LIKE TO CONSULT THE TRUST GUIDELINES
- encourage oral intake (IV fluids if necessary)
- maintain O2 sats above 92%
Causative organisms in URTI in children:
- pharyngitis? (3 viral, 1 bacterial)
- tonsillitis? (1 viral, 1 bacterial)
PHARYNGITIS:
- adenovirus
- enterovirus
- rhinovirus
- group A beta haemolytic strep
TONISILITIS
- ebstein-barr virus
- group A beta haemolytic strep
nb just learn that either viral or group A strep (strep pyogenes)
URTI (pharyngitis/tonsilitis)
- resp symptoms? 4
- other symptoms? 3
- signs that make bacterial cause more likely? 4 (name of criteria)
- what to always ask about in infants? 1
RESP
- painful throat
- wheeze
- blocked nose
- nasal discharge
OTHER
- fever
- ear ache
- abdo pain (mesenteric adenitis - common < 16 yrs - inflammation of abdo lymph nodes)
CENTOR CRITERIA (need 3 or more):
- tender cervical lymph nodes
- purulent exudate on tonsils
- fever
- absence of cough
always ask about feeding (and wet nappies) in infants
URTI:
- management for all? 2
- additional management if suspect bacterial cause? 1
- which abx should you NOT give? 1
- encourage oral intake
- analgesia (paracetamol, ibuprofen)
ANTIBIOTICS: penicillin (check this)
DO NOT give ampicillin or amoxicillin (as can get rash if cause is actually EBV)
nb amoxicillin and ampicillin are the same thing!
VIRAL-INDUCED WHEEZE:
- typical age?
- what is main two DDx to rule out?
- management options? 2
typically under 5
MAIN TWO DDX
- asthma (look at triggers, diurnal symptoms, age, hx of atopy)
- foreign body inhalation (ask hx, onset)
MANAGEMENT
- salbutamol inhaler (if over 6 months)
- oxygen, if sats < 92%
nb don’t gve steroids!!
CYSTIC FIBROSIS
- what % in UK are carriers?
- chance of CF if both parents carriers?
- which protein is the mutation in?
- neonatal screening? 1
1 in 25 are carrier
if both parents carriers:
- 1 in 4 will have CF
- 2 in 4 will be carriers
- 1 in 4 will be normal
mutation in CFTR protein (chloride channels)
- causes faulty exchange of chloride and sodium -> lots of mucus -> defective mucociliary clearance
CYSTIC FIBROSIS:
- neonatal screening? 1
- diagnostic test? 1
- findings on CXR? 3
- finding on lung function test? 1
screening: Day 5 blood spot test in all babies (tests trypsin levels)
(if screening comes back +ve or any FHx of CF, do sweat test)
diagnostic: sweat test (if CF, have abnormally high sweat chloride)
nb there are things that cause a false positive sweat test (but don’t bother learning)
nb genetic test is also normally done to confirm!
CXR
- hyperinflation
- peri-bronchial thickening
- bronchiectasis (signet ring sign)
lung function test = obstructive resp defect
CYSTIC FIBROSIS:
- common presentations? 4 (excl neonatal screening)
- what % are diagnosed aged over 18?
- what specific questions should you ask about if suspecting CF? 5
1) MECONIUM ILLEUS
- around 20%
- can include billous vomiting
- less commonly, prolonged jaundice
2) RECURRENT CHEST INFECTIONS
- around 40%
3) MALABSORPTION
- around 30%
- failure to thrive (despite huge appetite)
- steatorrhoea
4) OTHER FEATURES
- around 10%
- eg liver disease
most are picked up on newborn screening, but 5% are diagnosed after age 18
Qs to ask
- any delay in passing first meconium?
- jaundice as a neonate? (or now)
- number of chest infections?
- growth? (weight and height - plot it!)
- consistency of stools?
CYSTIC FIBROSIS:
- signs on examination? 7
- crackles
- chest deformity
- nasal polyps
- evidence of malnutrition
- finger clubbing
- firm enlarged liver + splenomegaly
- delayed puberty
CYSTIC FIBROSIS:
- main complications? 8
- bronchiectasis / chronic infections
- nasal polyps + sinus infections
- diabetes (not everyone gets it but, if they do, tend to develop it in teenage years)
- nutritional deficiencies -> poor growth
- liver problems
- fertility problems (men infertile, women subfertile)
- osteoporosis
- mental health problems (secondary to living with a chronic disease)
CYSTIC FIBROSIS MANAGEMENT:
- exercise? 1
- nutrition? 3
- prophylactic meds for infection? 3
- other medications? 3
- end-stage management option? 1
- regular (at least twice daily) chest physio
- high calorie diet (incl high fat intake)
- fat soluble vit supplements (ADEK)
- CREON (pancreatic enzymes) taken with food
- prophylactic antibiotics
- pneumococcal vaccine
- influenza vaccine
- mucolytics (nebulised enzymes, take during physio)
- steroids
- lumacaftor/ivacaftor - ie orkambi (now funded by NHS)
- heart + lung transplant
nb people w CF shouldn’t meet others w CF! for risk of sharing bugs!
