Paeds Extras

Question 1

what is strabismus?

if untreated, what can it lead to?

Answer 1

misalignment of one or both of the eyes

high risk of amblyopia if constant and unilateral

Question 2

what are the 4 (8) types of strabismus?

Answer 2

esotropia - eye turned in
exotropia - eye turned out
hypertropia - eye turned up
hypotropia - eye turned down

tropia = manifest

phoria = latent (only elicited on covering eye) so double these

Question 3

difference between latent or manifest squints?

Answer 3

manifest squint is present when the eyes are open and being used (tropias)

latent squint the eye turns only when it is covered or shut (phorias)

Question 4

causes of stabismus in children?

Answer 4

hereditary

refractive error

neurological e.g retinoblastoma

known neuro defects (CP)

craniofacial synostosis

Question 5

what is amblyopia?

what is it also known as?

Answer 5

Defective visual acuity which persists after
correction of the refractive error (with glasses) and removal of any pathology

aka lazy eye

Question 6

what are the 3 main treatments for amblyopia and when should they be done by?

Answer 6

refractive adaptation - wear special glasses for a certain amount of time (16-18 weeks)

occlude the better eye - eye patch

dilate the better eye with eye drops (atropine)

should be done as early as possible as better prognosis but definitely by 7 if possible

Question 7

what are the possible treatments for childhood stabismus?

Answer 7

Conservative

• Optical – glasses / CL
• Prisms
• Orthoptic exercises

Surgery
Esotropia – bilateral medial rectus recession or medial rectus recession and lateral rectus resection
Exotropia – bilateral lateral rectus recession or lateral rectus recession + medial rectus resection
Vertical strabismus – surgery depends on the type and ocular movements

Botulinum Toxin- Inject muscle under ketamine anaethesia in children
Medial rectus in esotropia
Lateral rectus in exotropia

Question 8

when is it normal to have transient eye misalignments?

Answer 8

in first few months of life

that are:
transient
improving from age 2 months onwards
gone - ‘normal eye alignment’ – age 4 months onwards

Question 9

when should you urgently refer a strabismus?

Answer 9

sudden onset

or other neuro signs/symptoms

Question 10

whats the difference between concomitant and incomitant?

whats more common in children?

Answer 10

Concomitant (non-paralytic) where the size of the deviation does not vary with direction of gaze

Incomitant (paralytic) where the direction of gaze does affect the size, or indeed presence, of the squint.

Concomitant and begin early in childhood, typically between the ages of 2-4 years.

Incomitant strabismus occurs both in childhood and adulthood as a result of neurological, mechanical or myogenic problems affecting the muscles controlling eye movements.

Question 11

how does acute leukaemia present in children?

Answer 11

Signs/symptoms related to:

Bone marrow failure: anaemia, pallor, lethargy (dyspnoea, neutropenia), fever, thrombocytopenia, spontaneous bruising, blleding of gums etc

Organ infiltration – superficial lympathdenopathy, hepatosplenomegaly, bone pain (ALL only), skin infiltration (AML only), resp symptoms secondary to mediastinal lymphnodes

Question 12

whats the pneumonic to remember symptoms of kawasaki disease?

Answer 12

CRASH AND BURN

(burn is the temperature)

• C- conjunctivitis (non purulent)
• R- rash
• A – adenopathy
• S – strawberry tongue
• H – hands and feet desquamation

Question 13

what is the criteria used to diagnose kawasaki disease?

Answer 13

Kawasaki disease – 1 required criteria and 4 additional criteria

Required
- Fever for at least 5 days generally high and spiking, persisting for 1-2 weeks or longer
additional

• Changes in arms or legs – redness, swelling, induration of hands/feet, desquamation of fingers and toes may occur
• Polymorphic exanthem involving trunk and extremities (differen kinds of rash)
• Painless, non-exudative bilateral bulbar conjunctival injection
• Strawberry tongue, redness and cracking of lips, no mouth ulcers
• Cervical lympahdemopaly
• Rule out other diseases with similar findings

Question 14

what is kawasaki caused by?

what blood test results might you see?

Answer 14

caused inflammation of some of the arterties in body

raised ESR
thrombocytosis - increase platelet count

Question 15

What is the classic presentation of scarlet fever in a child?

Answer 15

when you have strep throat, can turn into this bacterial ilnesss.

Red rash over most of the body, red lines in the folds of skin, flushed face, high fever, sore throat, headache

Question 16

rash which started behind ears might be…

in an unwell child
in a well child

Answer 16

unwell child - measles

well child - rubella

Question 17

most common complication from kawasaki disease?

Answer 17

coronary artery aneurysm

Question 18

what investigation would you do after kawasaki disease?

Answer 18

cardiac echo

Question 19

what medication do you give children with kawasaki disease?

whats a bad side effect from it?

Answer 19

aspirin

Reyes – acute liver failure and encephalopathy

Question 20

what fluid bolus do you give to a shocked child:

most cases?
DKA or trauma?

Answer 20

20ml/kg of 0.9% NaCl

give 10ml/kg of 0.9% sodium chloride in DKA - cerebral oedema risk,
and same in trauma (first clot = best clot)

Question 21

when giving fluids in DKA, what period do you want to do it over? and why?

Answer 21

over 48 hours instead of 24 like normal

this is because of the risk of cerebral oedema

Question 22

how do you calculate manintence fluids in children?

what do you give them?

Answer 22

Weight Daily (ml/24h)
First 10 kg 100ml/kg
Next 10kg 50ml/kg
Next ..kg 20ml/kg

0.9% NaCl + 5% glucose (+/- KCL)

Question 23

how do you calculate fluid deficits in children?

Answer 23

5 or 10%

% x 10 x kg

so 5 x 10 x kg

or 10x10xkg

Question 24

what fluids and how much do you give to a neonate (first month of life)?

Answer 24

• Day 1: 60/ml/kg/day,
• day 2: 90ml/kg/day
• day 3 – 120 ml/kg/day
• day 4- 150ml/kg/day

0.9% NaCL + 10% glucose

Question 25

what does a HIGH TSH (thyroid stimulating hormone) indicate?

Answer 25

TSH is how much your pituitary is telling your thyroid to make thyroid hormone.

TSH will be high if there is no negative feedback loop to bring it back down – therefore your thyroid is not responding to it and you have hypothyroidism

(so high TSH doesn’t = hyperthyroidism, because its the stimulating hormone thats high not thyroid itself!)

Question 26

what are the diseases screened for on the newborn screening test?

Answer 26

congenital hypothyroidism, sickle cell, Cystic fibrosis

+ 6 metabolic diseases:
aceyclo coa dehydrogenase deficiency, homocystinuria, maple syrup urine disease, glutaria acidemia type 1, isovalerica acidemia

Question 27

what is the pathology in CAH?

Answer 27

In CAH there is no enzyme which produces aldosterone and cortisol (the sex hormone enzyme is still there though)

because there is excess of the substrate and the enzyme that makes the sex hormone is still there, LOADS Of sex hormones are made. so
testosterone there is masculisation of the genitals in girls (virilisation) = will have enlarged clit (so is normal in boys) - so girls are picked up from birth but boys can go undiagnosed

So no cortisol – no source of energy or compensatory mechanisms as this is the stress hormone, - drop BP and glucose
or aldosterone - can’t control fluid balance

so boys will present collapsed and shocked at a very young age normally