Paeds hard to recall Flashcards
What abx do you start immediately in suspected sepsis?
Neonates
Children 72hrs - 1 month
Children >1 month
neonates: benzylpenicillin 25mg/kg 12 hourly + gentamicin 5mg/kg
children 72 hours - 1 month: ampicillin 200mg/kg/day + gentamicin 5mg/kg
children >1 month: cefotaxime 200mg/kg/day OR ceftriaxone 100mg/kg/day (use piptaz if neutropenic)
CXR findings of TGA?
Egg on side appearance of heart shadow Narrow mediastinum
What is Eisenmenger syndrome, when does it present and why does it occur?
Cyanotic heart lesion (usually VSD) Later in life (20-40yrs) RV hypertrophy causes reversal of flow across VSD so it becomes right to left
Causes of true precocious puberty? What is the main feautre?
It is gonadotrophin dependent: Idiopathic Intracranial pathology - tumours, haemorrhage, hydrocephalus, NF, CP and primary hypothyroidism
Consonant i.e. follows normal sequence of puberty
Causes of pseudo precocious puberty? Main feature and who is it usually pathological in?
Gonadotrophin independent - dissonant i.e. follows abnormal sequence - often pathological in boys:
- CAH
- Adrenal virilising tumours
- Cushing syndrome
- Testicular/ovarian malignancy
- Gonadotrophin-secreting tumours (hepatoblastoma)
Features of McCune Albright syndrome?
Precocious puberty (primary ovarian cysts) Cafe-au-lait spots Polyostotic fibrous dysplasia
Define premature pubarche
Pubic hair with no other signs of puberty
Define premature thelarche
Breast tissue appearance without darkening or thickening of areola with no other signs of puberty
How to differentiate between mild and moderate dehydration?
In moderate you will have the following features: Tachycardia May be slightly cool peripherally Orthostatic hypotension Slightly reduced skin turgor Dry mucous membranes Oliguria
Define an effective cough in a child who is choking on an inhaled foreign object
If child is able to speak/cry/take breaths between coughs
What vitamin supplements are breastfeeding women recommended to take?
Vit D
What type of disorder are petechiae more suggestive of?
Platelet disorders e.g. ITP
Criteria for JIA?
Occurs before 16 years old
Symptoms last at least 6 weeks
Other known conditions excluded
Types of JIA?
Which is most common?
Monoarticular (single joint)
Oligoarticular aka pauciarticular (<4 joints) - MOST COMMON
Polyarticular (4+ joints) - seronegative or seropositive
Difference between oligoarticular and polyarticular JIA?
Oligoarticular: <4 joints, asymmetrical, Elbows, knees, ankles and wrists, Anterior uveitis, strong ANA association, Under 6yrs
Polyarticular: 4+ joints, symmetrical, Small joints of hands and feet, cervical and TMJ, RF positive, Older girls
Systemic JIA features aka Still’s disease?
Quotidian fever for 2 weeks
Salmon pink rash on trunk and proximal limbs
Splenomegaly
Hepatomegaly
Lymphadenopathy
Serositis (pericarditis and pleurisy)
Triad in HUS?
MAHA Thrombocytopenia Acute renal failure
What does the Guthrie test screen for?
PKU Congenital Hypothyroidism CF Sickle cell disease Thalassaemia MCADD
Cardinal features of galactosaemia?
Hepatomegaly Cataracts Jaundice
When is C-spine immobilisation appropriate for a head injury?
GCS <15 Neck tenderness/pain Focal neurological deficit Paraesthesia Clinical suspicion of injury
Solo Indications for CT head within 1 hour following head injury in under 16s?
Suspected NAI Post-traumatic seizure but no epilepsy GCS <14 in ED GCS <15 2 hours after injury Raccoon eyes Battle’s sign Haemotympanum Sign of basal skull fracture CSF from nose or ears Focal neuro deficit
Indications for CT head following head injury in under 1s?
GCS <15 in ED Presence of bruise, swelling or laceration >5cm on head
When to consider abx in acute otitis media?
Children <2 years with bilateral AOM Perforation or discharge in ear canal
How long should a course of abx be in acute otitis media?
5 days
Glucose targets pre-prandially and post-prandially?
Pre: 4-8mmol/L Post: 10mmol/L
What type of inguinal hernia is more common in children and why?
Indirect Due to a patent processus vaginalis
Syndromes leading to hypotonia in newborns?
Hypothyroidism Prader-Willi
Features of babies with fetal alcohol syndrome?
Microcephaly
Thin top lip
Short nose
Small eyes
Hypertelorism (wide gap between eyes)
Smooth philtrum
What type of gait is seen in diplegic cerebral palsy?
Scissor gait Tip toe walking Equinovarus feet (plantar flexed and turned inwards)
What may be seen on MRI head of kids with diplegic CP?
Periventricular leukomalacia
Features of growth hormone deficiency?
Neonatal hypoglycaemia Jaundice Doll-like face Delayed bone age Normal growth rate until 6-12 months then tails off
Syndromes associated with short stature?
Turner Prader Willi Noonan’s Down’s Russel Silver Achondroplasia Spondyloepiphysial dysplasia
How should salbutamol be adminstered during a moderate asthma attack?
Via spacer
What does coeliac disease increase the risk of?
Enteropathy associated T cell lymphoma (EATL) Non-hodgkin lymphoma Vitiligo Thyroid disease
Describe the grading of heart murmurs
What syndromes is pulmonary stenosis associated with?
Noonan
Alagille syndrome
TOF
Features of Alagille syndrome?
Jaundice
Xanthomas
Congenital heart defects
Butterfly-shaped vertebrae
Dysmorphic faecies
Why does constitutional delay cause a delay in puberty?
Due to low gonadotrophin release (LH and FSH)
What is Prehn’s sign?
Helps to differentiate between epididymitis and testicular torsion.
You lift the testes and in epididymitis it will decrease the pain but in testicular torsion it will increase the pain
What is torsion of the hydatid of Morgagni?
Torsion of a small embryological remnant at upper lobe of the testes
Which age group is testicular torsion more common in and which group is torsion of hydatid of morgagni?
Which is more painful
Testicular - adolescents
Hydatid of morgagni - boys aged 7-12 years
Features of torsion of hydatid of morgagni?
Pain onset over a few days
Pain localised to upper pole of testes
Cremasteric reflex preserved
Blue dot may be visible when scrotum is transilluminated
Mx of testicular torsion
Surgical exploration and untwisting of testicle
Bilateral fixation of testes to tunica vaginalis
What is AML associated with?
Down syndrome
Bloom syndrome
NF
Features of benign rolandic epilepsy?
Age 7-10 years
Male
Partial seizures in early morning
High amplitude spikes in left centrotemporal region on EEG
Describe a rolandic seziure
What do you see on EEG?
Usually nocturnal
Involve mouth and face but can progress to generalised seizure
Twitching of mouth and then rest of ipsilateral face - can be drooling, grunting and slurred speech
EEG: centrotemporal spikes
When does juvenile myoclonic epilepsy typically start and what can precipitate it?
When might they occur?
Puberty
Precipitated by alcohol
Typically occur on waking
What age and who typically gets absence seizures?
Girls aged 2-10 years
EEG of absence seizures?
3 spike-wave complexes per second
Features of Lennox-Gastaut type epilepsy? What would you see on EEG?
Presents between 1-4 years
Daily seizures
Status epilepticus
Slow psychomotor development
Behavioural disorders
Slow abnormal spike waves
In a split bilirubin what are you looking at?
Conjugated and total bilirubin levels
>20% (18 micromol/l) means referral to paediatric liver centre is needed
UTI tx in under 3 months?
IV abx and admit
What usually triggers guttate psoriasis?
Strep infection
Steps of movicol disimpaction regime?
- 2 sachets on day 1
- Increase no. of sachets by 2 every 2 days
- Until max 8 sachets per day
- Continue until impaction has resolved or for max 7 days
NB. If it doesn’t work after 2 weeks add senna
How to differentiate between alpha and beta thalassaemia trait?
Beta trait shows increase in HbA2 and HbF whereas alpha trait does not
During a sickle cell crisis what are the first things you should do?
- Remove the precipitant stress e.g. hypoxia
- Opioid and non-opioid analgesia within 30mins of arrival
- Fluid balance chart
- If infection suspected then start on broad spectrum abx
3 core symptoms of ADHD?
Inattention
Impulsivity
Hyperactivity
How long must symptoms be present for an ADHD diagnosis?
6 months
Non-core criteria for ADHD diagnosis?
The behaviour should have persisted for at least 6 months
The behaviour should be inconsistent with the child’s developmental age
There must be clinically significant impairment in social or academicdevelopment
The symptoms should occur in more than one setting
There should be no other explanation for the symptoms
Causes of cranial DI?
Meningitis
Head injury/surgery
Sarcoidosis
DIDMOAD syndrome
Features of DIDMOAD syndrome
DM
Diabetes insipidus
Optic atrophy
Deafness
Causes of nephrogenic DI?
Hypokalaemia
Hypercalcaemia
Lithium
Demeclocycline
Genetic defects
Heavy metal poisoning
In bacterial meningitis what would you expect to see in CSF glucose readings?
<50% of blood glucose levels
What score is used to assess severity of croup and what defines them?
Westley croup score
Mild <3
Moderate 3-6
Severe >6
What are the best predictors of long-term function in autism?
Language skills and IQ
In a pH study for GORD what is suggestive of reflux?
pH <4 for more than 4 hours
Causes of erythema multiforme?
Infection - HSV (MOST CASES), mycoplasma, coxsackie
Drugs - NSAIDs, antiepileptics, sulphonamides, penicillins, barbiturates
Pregnancy
Which vaccines should children with HIV not receive?
Yellow fever
BCG
Hypersensitivity to egg is a contraindication for which vaccines?
Influenza
Yellow fever
Tick-borne encephalitis
How long are kids treated with high dose steroids immunocompromised for?
3 months
Diagnostic criteria for kawasaki?
5 day+ fever & 4/5 of the following:
Bilateral conjunctival injection
Oral mucosal erythema
Polymorphous rash
Extremity changes: peripheral oedema/erythema and periungual desquamation
Cervical lymphadenopathy
For a child with T1DM, which regimen allows them to get tight control but not inject in school?
Three times daily injection
Mixed insulin in morning
Rapid acting at dinner time
Long-acting at night
RF for severe bronchiolitis?
Premature
Age <12 weeks
Chronic lung disease
CHD
Structural defects in airways
Immunodeficiency
Which organisms are children with nephrotic syndrome at higher risk from and why?
Encapsulated bacteria e.g. pneumococcus
Due to renal loss of IgG
Tx of minimal change disease?
prednisolone: 60 mg/square metre of body surface area/day orally for 6 weeks, followed by 40 mg/square metre of body surface area/day orally on alternate days for 6 weeks
First line Ix for global developmental delay?
Chromosomal testing
fragile-X testing
CK
U&Es
TFTs
lead level
FBC and ferritin
biotinidase
urate
Features of Landau-Kleffner syndrome?
Sudden or gradual aphasia
abnormal EEG
Causes of erythema nodosum?
Infection - group A strep, TB
Drugs - sulphonamides, OCP, barbiturates
IBD
SLE
Sarcoid
2 most important reasons to perform orchidopexy for cryptorchidism?
Psychological impact
Prevention and early detection/tx of testicular cancer
What Ix should all children who have a non-febrile seizure have?
ECG - exclude a prolonged QTc interval
Indications for MRI in non-febrile convulsive seizure?
Child <2 years
Focal seizure
Seizures continuing despite meds
SE of valproate?
Transient hair loss
Weight gain
Liver damage
Blood dyscrasias
SE of carbamazepine?
Allergic skin reactions
Blurred vision
Ataxia
Nausea
Hepatic enzyme inducer
SE of phenytoin?
Gum hyperplasia
Hirsutism
Coarse facial features
Ataxia
Slurred speech
Septic arthritis immediate Mx?
Joint aspiration followed by 4-6 weeks IV abx
Recommended imaging in kids <6 months with UTI?
Simple UTI which responds to abx: outpatient USS in 6 weeks –> if abnormal then MCUG
Atypical/recurrent UTI: inpatient USS and outpatient DMSA and MCUG
Recommended imaging in kids 3 months - 3 years with UTI?
Only if atypical: urgent USS followed by outpatient DMSA
If recurrent UTI: USS within 6 weeks followed by outpatient DMSA
MCUG indicated if: recurrent/atypical UTI in <6 month old
Consider MCUG if: dilation on USS, non E. coli, poor urine flow, FH of VUR
Recommended imaging in kids >3 years with UTI?
Atypical UTI: inpatient USS
Recurrent: Outpatient USS and DMSA
What is seen on xray of Perthes?
Collapsed, irregular and sclerotic femoral head
Increased joint space
Ix for primary enuresis?
LL neuro exam - rule out spina bifida and CP
BP - if elevated may indicate renal disease
Urinanalysis not needed unless indicated
Define polycythaemia in a baby?
Central venous HCT >0.65
What is the nitrogen washout test?
- Take a preductal ABG
- Repeat after 10-15mins of 100% oxygen therapy
PaO2 <20kPa suggests fixed right to left shunt
What period of time should a child with DKA be rehydrated?
48 hours
Features of C1 esterase deficiency?
Random episodes of urticaria not precipitated by things
May be FH
Which antibodies can be transferred in the breast milk?
IgG
Typical features on EEG of absence seizures?
3 spike waves per second activity in all leads
Complications of GOR?
Apnoeas
Failure to thrive
Oesophagitis
Aspiration
Sandifer’s syndrome (dystonic movements of head and neck that resemble seizures)
What are wormian bones and what condition are they seen in?
Osteogenesis imperfecta
Irregular isolated bones found within skull sutures
Features of osteogenesis imperfecta?
Recurrent fractures
Blue sclera
Conductive hearing loss
Aortic regurgitation
3 year old with 2 day history of fevers at 38.3. She is drowsy and has a seizure causing twitching of the right side of her body for 4 mins. RR = 30 and sats 98%. What is the diagnosis?
Viral encephalitis
What does a young child with fever who is refusing to walk suggest?
Osteomyelitis or septic arthritis
Features of Prader Willi in neonatal period?
Hypotonia
Poor feeding
Features of prader willi when older?
Hyperphagia
Obesity
Hypogonadism
Strabismus
Low IQ
Face - narrow forehead, olive eyes, anti-mongoloid slant, carp-shaped mouth
Features of Laurence-Moon-Biedl syndrome?
Learning difficulties
Progressive visual impairment
Polydactyl, syndactyl
Hypogenitalism
Nephropathy
Murmur in VSD?
LLSE pansystolic
Most common cause of mitral stenosis?
Rheumatic fever
Causes of splenic atrophy in children? What would you see on blood film?
Surgical removal
Sickle cell disease
Coeliac
Howell Jolly bodies
Which malignancy are patients with Down’s most at risk of?
AML
What day is bronchiolitis worst?
Day 4
Which inotrope should be used for cold shock vs warm shock?
Cold shock: Adrenaline
Warm shock: noradrenaline
Which neonates should not receive ceftriaxone for suspected sepsis/meningitis?
Premature
Jaundice
Acidotic
Hypoalbuminaemia
Tx for group B strep meningitis?
IV cefotaxime for 14 days
Tx for l monocytogenes meningitis?
IV amoxicillin/ampicillin for 21 days
Gentamicin for 7 days
Bacterial meningitis due to gram -ve bacilli tx?
IV cefotaxime for minimum 3 weeks
Tx for strep throat?
Penicillin V
How much milk should infants take per day?
150-180ml/kg/day
How is duodenal atresia diagnosis confirmed?
Double bubble on abdo xray
Meckel’s diverticulum rule of 2s?
found 2 feet proximal to iliocaecal junction
2 inches in length
occurs in 2% of population
List 2 pathological causes of genu varus
Ricket’s
Blount’s disease
Most likely diagnosis in a child <3 years with fever and RR >50?
Pneumonia
Which syndrome presents with swollen hands and feet in the newborn?
Turner’s
Complications of JIA?
Chronic anterior uveitis
Flexion contraction of joints
Amyloidosis
Features of enteropathic arthritis
Asymmetrical oligarticular arthritis
Mainly large joints in lower limbs
Occurs with underlying IBD
Most important diagnosis to rule out in a neonate with pale stools and jaundice? How would confirm this diagnosis?
Biliary atresia
USS
Complications of chicken pox?
Secondary bacterial infection
Pneumonitis
Conjunctival lesions
Post-infectious ataxia
Purpura fulminans
What infection causes a rash and fever which start on the same day?
Chicken pox
Complications of measles?
Otitis media
Pneumonitis
Mycocarditis
Encephalitis
subacute sclerosing panencephalitis (5-10 years later)
Complications of coxsackie virus?
pericarditis/myocarditis
Complications of parvovirus B19?
Arthralgia
Aplastic anaemia
How to diagnose giardiasis?
Motile trophozoites and villous atrophy of duodenal biopsy
When does stress haematuria occur?
After vigorous exercise
Causes of glomerulonephritis?
post infectious glomerulonephritis
IgA nephropathy
Alport’s syndrome
HUS
Features of Alport’s syndrome?
GBM degeneration
Sensorineural deafness
Ocular abnormalities
What suggests nephritic rather than nephrotic syndrome in a child?
Haematuria
HTN
May be oliguria
Blood findings with lead poisoning?
Microcytic hypochromic anaemia
Basophilic stippling
Tx of lead poisoning?
EDTA chelation
What is pica and what can it be a sign of or cause for?
Eating non-nutritive substances
Lead poisoning
Mx of meconium ileus in infants with CF?
Gastrograffin enema
Prophylactic fluclox
If peritonitic: laparotomy and bowel resection
Sweat test at 6 weeks
amino acid substitution in sicke cell?
Glutamine –> valine
When can a baby follow an object through a horizontal plane for 180 degrees?
3 months
90 degrees at 6 weeks
Tx of nephrotic syndrome?
Prednisolone
Salt restriction
Fluid replacement
Human albumin solution
Tx of salt losing crisis?
IV fluid resuscitation
IV hydrocortisone
SIADH tx?
Fluid restriction
What can frequent yawning in a newborn be a sign of?
Withdrawal after maternal drug use
How to differentiate between a hernia and a hydrocele?
Hernia transmits a cough impulse
You can get above a hydrocele
A hydrocele transilluminates
Tx of epididymo-orchitis?
Bed rest
6 weeks oral ciprofloxacin
Skin lesions of TB?
Erythema nodosum
Lupus vulgaris
Which conditions have an inheritance of uniparental disomy?
Prader willi
Angelman
Which conditions arise from microdeletions?
William’s Syndrome
DiGeorge
Cri-du-chat
Tx for labial adhesions?
Topical oestrogen
Why is cipro generally avoided in kids?
Risk of arthropathy
Phimosis vs paraphimosis?
Phimosis = inability to retract prepuce - no mx usually
Paraphimosis = retraction of tight foreskin over glans causing oedema of glans - formal circumcision needed
GH deficiency features?
Neonatal hypoglycaemia and prolonged jaundice
Short stature/failure to thrive
Features of congenital hypothyroidism?
Large tongue
Umbilical hernia
Prolonged jaundice
Feeding difficulties
Lethargy
Constipation
Floppy
Large fontanelle
Pathophys of ITP?
Auto-Ab to glycoprotein IIb/IIIa
Features of Wiskott-Aldrich syndrome?
Thrombocytopenia
Immunodeficiency
Eczema
Predisposed to haem malignancies
Features of Fanconi anaemia?
Aplastic anaemia
Short stature
Skeletal abnormalities
Predisposed to haem malignancies
Best marker of DIC?
Fibrinogen
Ix for gynaecomastia in a teenage boy?
Nothing if other signs of puberty present - transient gynaecomastia is a normal finding
Features of galactosaemia?
Occurs with lactose-containing milks:
Vomiting
Cataracts
Recurrent E. coli sepsis
How does myotonic dystrophy present most commonly?
Muscle weakness and wasting starting in adulthood
Congenital form can present with hypotonia from birth centrally and peripherally
Features of VACTERL?
Vertebral malformation
Anal imperforation
Cardiac problems
Tracheo-oesophageal fistula
Renal abnormalities
Limb abnormalities
Features of CHARGE syndrome?
Coloboma
Heart defects
Atresia choanae
Retardation of growth and development
Genitourinary abnormalities
Ear anomalies
Causes of asymmetrical IUGR?
Placental insufficiency
Maternal DM
Pre-eclampsia
Causes of symmetrical IUGR and low birth weight?
Chromosomal anomaly
Maternal smoking
Congenital infection
Maternal alcohol use
Mx of Hep A if child is well?
Supportive
Try not to admit them to reduce chance of spread
Report to Health Protection Agency
Best way to detect DiGeorge microdeletion?
FISH
2 examples of encapsulated bacteria children with asplenia or SCD are at risk from?
Strep pneumoniae
H. influenzae
Children with C5-9 complement deficiency are most at risk from which organism?
Neisseria meningitides
Most common causative organism of pneumonia in 1-4 year olds?
Strep pneumoniae
Most common causative organism of pneumonia in >4 year olds?
Mycoplasma pneumoniae
Complications of PCD?
Infertility
Sinusitis
Bronchiectasis
Dextrocardia
Situs inversus
Define chronic lung disease
Oxygen requirement at 36 weeks corrected gestation OR at 28 days post term
Which lobe of the lung is most likely to be the location of foreign body inhalation?
Right middle lobe
What does the Guthrie test for to detect CF? and what happens if it is positive?
Immune reactive trypsin
Sent for genetic analysis to identify mutation
Child then receives confirmatory sweat test
Blood gas findings if a child has increased work of breathing and has begun to tire?
Type 2 respiratory failure
Hypoxia
Hypercapnia
Respiratory acidosis
What pattern of respiratory disease is seen in muscular dystrophy?
Restrictive picture - low FVC, normal FEV1/FVC ratio
What pattern of respiratory disease is seen in asthma?
Obstructive picture:
Normal FVC
Low FEV1/FVC ratio
Morning dips
What conditions would you expect to see a flattened diaphragm in?
Hyperinflation and air trapping e.g. bronchiolitis
Most common congenital heart defects in order
- VSD
- PDA
- ASD/coarctation/TOG
Steps for cardioverting a child?
- Vagal manouvres
- Adenosine
- Sedated synchronised cardioversion
How would Eisenmenger’s present?
Teenagers: right to left shunt
Cyanotic and breathless
Pulmonary hypertension
Bi-basal fine creps
Soft pansystolic murmur
Displaced apex
What is required for a definitive dx of UTI?
Urine culture growing >105 colony forming units per mm of a single organism
I.e. in a baby with leukocytes in the urine you still need to do a full septic screen in case
Causes of HTN in children?
- Essential
- Renal - renal artery stenosis, CKD, Wilm’s
- Cardiac - coarctation of aorta
- Endocrine - Cushing’s, phaeo, neuroblastoma
- Metabolic - hyperaldosteronism, CAH
Features of henoch schonlein purpura?
Few weeks after viral infection
Arthralgia
Purpuric rash behind legs
Abdo pain
Renal involvement (nephrotic syndrome)
Best imaging modality for posterior urethral valves? What would you see?
Micturating cystourethrogram
Dilated and elongated posterior urethra
2 types of polycystic kidney disease and their features?
Autosomal recessive:
- Presents in childhood
- Bilateral renal masses
- Pulmonary hypoplasia
- Congenital hepatic fibrosis
Autosomal dominant:
- Presents in older children/adults
- Renal, liver and cerebral vasculature has cysts
Why do you usually not give platelets in ITP unless life threatening bleed?
Platelet infusion will be destroyed by immune system too
Inheritance of vWD?
AD
Features of Sturge Weber?
Port wine stain
Seizures (secondary to vascular malformation)
Developmental problems
When do strawberry naevi or cavernous haemangiomas appear?
After first month of life
Appearance of erythema toxicum?
Erythematous rash with small pustules
Why might a child with congenital hypothyroidism test negative on the Guthrie test?
Guthrie tests for high TSH but in kids with panhypopituitarism there is a low TSH and hence a low thyroxine
Features of Marfan’s?
High arched palate
Myopia
Lens dislocation
Arachnodactyl
Arm span > height
Hypermobility
Aortic arch abnormalities
Mitral valve prolapse
Chest wall deformity
What Ix is most important if a child presents with Addisonian crisis?
Kidney function with U&Es to asses hyponatraemia and hyperkalaemia
Most common surgical mx of SUFE?
Internal fixation
Difference between a torus fracture and a greenstick fracture?
Torus = cortex buckles on one side of long bone only
Greenstick = cortex buckles on one side of long bone and cortex is interrupted on the opposite side
What is a salter-harris fracture?
Fracture through the growth plate
Most appropriate mx if a baby is positive for DDH on ortolani and barlow’s?
Outpatient USS at 6 weeks of age
MRI findings of osteomyelitis?
Periosteal reactions
Soft tissue swelling
When must you always rule out meningitis in a febrile convulsion?
Children <1 year old
Differences between moderate and mild HIE?
Moderate has seizures and altered tone movement in addition to mild: irritability, startle responses, poor feeding and hyperventilation
MRI findings in MS?
Multiple hyperintense, inflammatory white matter lesions
MRI findings in tuberous sclerosis?
Subependymal calcifications
Hypointense white matter lesions/tubers
Features of neurofibromatosis type 1?
6 or more café-au-lait macules — flat light brown birthmarks
Freckling in skin folds
Lisch nodules in the iris of the eye
Optic gliomas
Multiple neurofibromas — tumours that hang off the skin
Sphenoid dysplasia
Features of NF2?
Bilateral acoustic neuromas and schwannomas
Meningiomas
Spinal cord ependymomas
What are slow relaxing reflexes a sign of?
LMN lesions - Guillain Barre
Hypothyroidism
Eye signs of raised ICP?
Papilloedema
Sunset eyes
Causes of West syndrome?
trauma
brain malformations such as hemimegalencephaly or cortical dysplasia
infections
Down syndrome
tuberous sclerosis (MOST COMMON)
Sturge Weber
PKU
Maple syrup urine disease
Skin manifestations of tuberous sclerosis?
Ash leaf macules
Shagreen patches (rough skin over lumbar spine)
Angiofibromata in butterfly distribution over nose and cheeks
Fibromas under nail beds
Features of Tay-Sach’s?
seizures
developmental regression
deafness
progressive loss of motor function and increased tone
Ashkenazi Jews
What is a toddler’s fracture and how does it happen?
aka childhood accidental spiral tibial fracture or CAST fracture
caused by a twisting injury while tripping, stumbling, or falling.
What are the 3 types of incomplete fracture seen in children?
Buckle (torus)
Greenstick
Bowing
How are fractures through the growth plate classified?
Salter-Harris classification
Mnemonic to remember salter-harris classification?
SALTER:
S – straight across the joint (type I)
A – above the joint (type II)
L – lower (type III)
TE – through everything (type IV)
R – ruined or rammed (type V)
Which type of salter harris fracture is most common?
Type 2
Which type of fractures may lead to limb length discrepancies, progressive angular deformities or joint incongruity?
Growth plate (physeal) injuries
1st line Tx for localised impetigo?
Topical fusidic acid
Which abx for whooping cough and when does it help?
Macrolide e.g. azithromycin
Within 21 days of symptoms
3 main complications of minimal change disease?
Increased risk of thrombosis
Increased infection risk
Hypercholesterolaemia
Symptoms of chondromalacia patellae? Who is it common in?
Anterior knee pain worse on walking up and down stairs and rising from prolonged sitting
Extension produces a grating feeling
Crepitus or small effusion may be palpable
Common in teenage girls
What does the WHO recommend for clinical dehydration without shock?
Rehydration with ORS at 75ml/kg every 4 hours
Caput succedaneum vs cephalohaematoma?
Caputs cross sutures (subcut fluid in scalp)
Resolves in a few days
Cephalohaematomas do not (haemorrhage between periosteum and skull)
Resolves in a few months
Where is the bleeding in a subgaleal haemorrhage?
Between scalp aponeurosis and periosteum
DDH ix?
Newborn and 6 week check: screen with ortolani + barlow –> then USS
6 weeks - 6month: USS
6 months and older: X-ray
What is bronchopulmonary dysplasia?
Pathological lung changes in infants following prolonged artificial ventilation
Where is the lesion in dyskinetic CP and features?
Basal ganglia
Variable muscle tone
Chorea
Athetosis
Dystonia
Where is the lesion in ataxic CP and features?
Cerebellum
Lack of voluntary coordination of muscle movements
Intention tremor
Ataxic gait
Speech abnormalities
Where is the lesion in spastic CP?
Motor cortex
Features of TTP?
MAHA
AKI
Thrombocytopenia
Fever
Neurological symptoms
How to tell the difference between HSP and IgA nephropathy?
IgA nephropathy presents 1-2 days after URTI
HSP presents 1-3 weeks after strep throat
What type of hypogonadism is Klinefelter’s?
hypergonadotrophic hypogonadism
Which influenza vaccine should kids with asthma or T1DM be offered?
IM influenza vaccine
Ix for neuroblastoma?
Urinary catecholamines and HVA and VMA high
Biopsy for definitive dx
MIBG scan for mets
What is the most common primary bone malignancy of childhood? What is the second most common?
- Osteosarcoma
- Ewing sarcoma
Which diarhhoeal diseases in children should be reported to the local health authority?
Campylobacter jejuni
Listeria
E coli
Shigella
Salmonella
3 stages of Rett syndrome?
- Develop normally for first 6-12 months then regression
- Plateau
- Movement deterioration - scoliosis, weakness, spasticity and loss of ability to walk
Features of atypical UTI?
Poor urine flow
Abdo or bladder mass
Raised creatinine
Sepsis
Failure to respond to abx within 48 hours
Non E. coli organism
Recommended imaging in kids >3 years with UTI?
USS during acute infection only if atypical UTI
USS within 6 weeks if recurrent
DMSA if recurrent
MCUG not indicated in this age group
Define recurrent UTI?
2 or more episodes of UTI with acute pyelonephritis/upper urinary tract infection, or
1 episode of UTI with acute pyelonephritis/upper urinary tract infection plus one or more episode of UTI with cystitis/lower urinary tract infection, or
3 or more episodes of UTI with cystitis/lower urinary tract infection
In boys with precocious puberty what does examination of testes suggest?
Bilateral enlargement = Gonadotrophin dependent
Atrophic testes = gonadotrophin independent
Unilateral enlargement = tumour
What is an appendicular mass?
A complication of appendicitis
Inflamed appendix had adherent covering of omentum and small bowel
Presents like appendicitis but more gradual and might be RIF mass on palpation
Tx for tinea capitis vs mild ring worm?
Mild ring worm = topical terbinafine/itraconazole
Tinea capitis = oral terbinafine
What is herpangina and what is it caused by?
Prominent fever and painful ulcers on soft palate, tonsils, uvula and pharynx
Cause = Coxsackie A16
What are nagayama spots?
Rash on soft palate in HHV6
Mx of acute crisis in SCD?
Analgesia within 30 mins
Oxygen therapy if sats <95%
When does post-infectious IBS most commonly occur?
After gastroenteritis with Campylobacter jejuni
Which bug is mesenteric adenitis most commonly associated with?
Yersinia enterocolitica
Description of eczema herpeticum?
Widespread blisters and punched-out erosions
Metabolic features of a salt losing crisis in CAH?
Hyponatraemia
Hyperkalaemia
Hypoglycaemia
Metabolic acidosis (in proximal convoluted tubule, sodium is secreted in exchange for hydrogen ions)
Most common causative organisms of reactive arthritis?
GI - campylobacter
Urogenital - chlamydia
Definitive dx in G6PD deficiency and when can it be done?
Enzyme assay
2-3 months after a crisis
Features of diamond blackfan anaemia?
AD
Presents at 2-3 months - red cell aplasia causes low RBCs and reticulocytes
Microcephaly
Absent thumbs
Cleft palate
3 cardinal features of macrophage activation syndrome?
Cytopenia
Liver dysfunction
Coagulopathy
What is macrophage activation syndrome a complication of?
Any rheumatic disease
Systemic JIA
Kawasaki disease
Main cause of recurrent intussusception and how can you investigate it?
Meckel’s diverticulum
Technetium-99m scan
Where does erythema multiforme typically start?
Hands and feet then spreads up limbs to torso
1st line ix in suspected testicular torsion?
doppler USS to assess testicular bloow flow
Tx for talipes equinovarus?
Ponseti method
Fixing feet into correct position with a cast - repeat every week for 5-8 weeks
Followed by minor operation to loosen Achilles tendon
What is pes planus associated with?
CP
SPina bifida
Muscular dystrophy
What is pes cavus associated with?
charcot-marie-tooth
Another name for vertical talus?
Rocker bottom feet
What is Sandifer syndrome and features?
Spasmodic condition associated with GOR
Torticollis of neck and arching of back
Topical steroids for eczema mild, moderate, potent and very potent?
Mild
- Hydrocortisone 1%
Moderate
- Betamethasone valerate 0.025%
- Clobetasone butyrate 0.05%
Potent
- Betamethasone valerate 0.1%
- Mometasone furoate 0.1%
Very potent
- Clobetasone proprionate 0.1%
Blood film findings in EBV in children >12 years in second week of illness?
>20% atypical lymphocytes
Tx of scabies?
Permethrin 5% cream
Head lice Tx?
- Wet combing 5 times over 3 weeks
- Dimeticone 4% or malathion 0.5% applied twice, 7 days apart
- Check at the end with wet combing for both
Most common cause of pneumonia in under 1 year olds?
RSV
When to admit a child with pneumonia?
Oxygen sats <92%
Grunting, marked chest recession, cyanosis
RR >60
1st line tx in pneumonia?
Amoxicillin
If no response add a macrolide
Surgical mx for OME?
Myringotomy followed by insertion of grommets which stay in for 6-12 months
OME mx?
Actively observe for 6-12 weeks
2x hearing tests with pure tone audiometry and tympanometry during this time
Refer to ENT if persistent
Typical presentation of spina bifida occulta?
Insidious onset
Lower back pain that worsens with activity
Gait disturbance
Scoliosis
High-arched feet
Neuro dysfunction - numb/weak, bladder and bowel dysfunction
Causes of macrocephaly?
Fragile X
NF type 1
Tuberous sclerosis
What head shape is:
Plagiocephaly
Brachycephaly
Craniosynostosis?
Plagiocephaly - unilateral occipital flattening
Brachycephaly - bilateral occipital flattening
Craniosynostosis - premature fusion of cranial sutures leads to distortion
What fluids to use in DKA resuscitation?
0.9% saline + 40mmol/L KCl
Once glucose <14 add 5% dextrose
Tx for umbilical stump infection?
IV flucloxacillin + gentamicin
What is blount’s disease? 2 types?
Abnormality of medial proximal tibial growth plate - bowed legs
Type 1: infantile + bilateral
Type 2: adolescent + unilateral + femur
Newborn hearing tests?
Automated otoacoustic emission test
If abnormal then automated auditory brainstem response test
What test is used to assess hearing with otitis media with effusion?
Tympanometry
HTN in Turner’s why?
Co-arctation of aorta
What is bronchomalacia and how does it present?
Cartilage supporting bronchi is weak
Presents in first few weeks of life with a wheeze
Most outgrow it by age 2 years
Acne mx?
- Benzoyl peroxide, adapalene or azelaic acid
- PO abx for 3 months - lymocycline/doxycycline
- Alternative abx
- Isotretinoin
What does a prolonged jaundice screen involve? When to do it?
If jaundice lasts >14 days and serum bilirubin >100
- FBC
- Conjugated bilirubin level
- Group and save
- Coomb’s
- Urine culture
- Metabolic screen
In BLS where should the pulse be felt in an under 1?
Femoral or brachial
What is epstein’s pearl?
A congenital cyst found in the mouth
Usually on the hard palate but can be on gums
Resolves spontaneously within a few weeks
Features of hypernatraemic dehydration?
jittery movements
increased muscle tone
hyperreflexia
convulsions
drowsiness or coma
When should you do a stool culture?
you suspect septicaemia or
there is blood and/or mucus in the stool or
the child is immunocompromised
the child has recently been abroad or
the diarrhoea has not improved by day 7 or
you are uncertain about the diagnosis of gastroenteritis
Mx for clinical dehydration?
give 50 ml/kg low osmolarity oral rehydration solution (ORS) solution over 4 hours, plus ORS solution for maintenance, often and in small amounts
Mx if exomphalos diagnosed antenatally?
What happens once born?
Elective C section
Staged closure starting at birth with completion at 6-12 months
Common referral points for developmental milestones?
doesn’t smile at 10 weeks
cannot sit unsupported at 12 months
cannot walk at 18 months
cannot say 2-6 words at 18 months
How are cyanotic spells in TOF managed?
b-blockers (to reduce infundibular spasm and thus prevent worsening of RV outflow obstruction)
What murmur is usually heard in TOF?
ejection systolic murmur due to pulmonary stenosis (the VSD doesn’t usually cause a murmur)
Muscle biopsy findings of mitochondrial diseases?
‘red, ragged fibres’ due to increased number of mitochondria
Most common fractures associated with child abuse?
Radial
Humeral
Femoral
How does TOG present on ausculation?
no murmur but typically a loud single S2 is audible and a prominent right ventricular impulse is palpable on examination
Features of androgen insensitivity syndrome?
X-linked recessive condition due to end-organ resistance to testosterone causing genotypically male children (46XY) to have a female phenotype
‘primary amenorrhoea’
undescended testes causing groin swellings
breast development may occur as a result of conversion of testosterone to oestradiol
When can transcutaneous bilirubinometer not be used?
<24 hours old
Features of Osteochondritis dissecans?
Pain after exercise
Intermittent swelling and locking
Features of Patellar subluxation?
Medial knee pain due to lateral subluxation of the patella
Knee may give way
Features of Patellar tendonitis?
More common in athletic teenage boys
Chronic anterior knee pain that worsens after running
Tender below the patella on examination
Tx for spasticity in CP?
oral diazepam, oral and intrathecal baclofen, botulinum toxin type A, orthopaedic surgery and selective dorsal rhizotomy
What CO2 level is a life-threatening sign of asthma?
Normal pCO2 of 4.8-6 kPa
Indications for dexamethasone in meningitis?
Not used if <3 months
Dexamethasone may be given if the following are seen on CSF analysis:
- Frankly purulent CSF
- CSF WBC > 1000/µL
- Raised CSF WBC + protein concentration > 1 g/L
- Bacteria on Gram stain
NOTE: steroids should NOT be used in meningococcal septicaemia, unless ICU says so
Symptoms of posterior urethral valves?
In utero: oligohydramnios and lung hypoplasia
Recurrent UTI
Bilateral hydronephrosis
Tx for posterior urethral valves?
Transurethral catheter ablation
What neurodevelopmental condition is fragile X associated with? What heart problem?
Autism
Mitral valve prolapse
Mx of hypoglycaemia in a neonate?
asymptomatic:
- encourage normal feeding (breast or bottle)
- monitor blood glucose
symptomatic or very low blood glucose (<1mmol/L)
- admit to the neonatal unit
- intravenous infusion of 10% dextrose
When can hypoglycaemia protocols be stopped in babies born to mother’s with DM?
at least 3 blood glucose values >2.5 mmol/L and are feeding appropriately
Approximate definition of neonatal hypoglycaemia?
<2.6mmol/L
When do NICE suggest a dx of pneumonia should be considered?
high fever (over 39°C) and/or
persistently focal crackles.
Mx of umbilical hernia?
Usually self-resolve, but if large or symptomatic perform elective repair at 2-3 years of age
If small and asymptomatic peform elective repair at 4-5 years of age.
Causes of HTN in children?
- renal parenchymal disease
- renal vascular disease
- coarctation of the aorta
- phaeochromocytoma
- congenital adrenal hyperplasia
- essential or primary hypertension (becomes more common as children become older)
What prophylaxis is preferred for meningococcal septicaemia contacts?
Ciprofloxacin over rifampicin
Mx for bilateral undescended testes?
Should be reviewed by a senior paediatrician within 24hours as the child may need urgent endocrine or genetic investigation
Peak incidence of bronchiolitis?
3-6 months
Features O/E of PDA?
large volume, bounding, collapsing pulse
wide pulse pressure
machinery continuous murmur
heaving apex
left subclavicular thrill
What rash is associated with being in the sun? What does it look like? tx?
Pityriasis versicolor
large number of light brown macules and confluent patches affecting most of his back and chest
Ketoconazole 2% shampoo
Which rash has a herald patch?
pityriasis rosea
When are babies at risk of meconium aspiration?
Thick/lumpy meconium - monitor until 12 hours postnatal
Thin meconium - monitor baby at 1 and 2 hours postnatally
Mx of perthes?
- <6 years: reassure and follow up
- >6 years/severe deformity of limb or joint: surgery
Perthes staging?
Caterall staging
When do NICE recommend admitting a child with croup?
- Signs of moderate/severe disease
- < 6 months of age
- Known upper airway abnormalities (e.g. Laryngomalacia, Down’s syndrome)
- Uncertainty about diagnosis (important differentials include acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation)
Causes of cleft palate?
events in pregnancy: smoking, BDZ use, anti-epileptic use, rubella infection
syndromic disorders affecting baby: trisomies 18, 13 and 15
Hypospadias mx?
once hypospadias has been identified, infants should be referred to specialist services
corrective surgery is typically performed when the child is around 12 months of age
it is essential that the child is not circumcised prior to the surgery as the foreskin may be used in the corrective procedure
Definitions of low dose and moderate dose ICS in children?
- <= 200 micrograms budesonide or equivalent = paediatric low dose
- 200 micrograms - 400 micrograms budesonide or equivalent = paediatric moderate dose
- > 400 micrograms budesonide or equivalent= paediatric high dose
What 2 things is prognosis of congenital diaphragmatic hernia based off?
- Liver position
- Lung-to-head ratio (>1 is good prognostically)
Most common cardiac abnormalities in Turner’s in order?
- Bicuspid aortic valve
- Aortic root dilatation
- Coarctation of the aorta
Electrolyte results in pyloric stenosis?
High bicarb
Low chloride
Low potassium
3 types of biliary atresia and which is most common?
- Type 1: The proximal ducts are patent, however, the common duct is obliterated
- Type 2: There is atresia of the cystic duct and cystic structures are found in the porta hepatis
- Type 3: There is atresia of the left and right ducts to the level of the porta hepatis, this occurs in >90% of cases of biliary atresia
Initial Tx for Hirschprung’s?
rectal washouts/bowel irrigation
Midline cyst below hyoid bone and moves up on tongue protrusion?
Thyroglossal cyst
Cyst located anterior to the sternocleidomastoid near the angle of the mandible?
Branchial cyst
Normal value for sweat test? What value indicates CF?
normal value < 40 mEq/l
CF indicated by > 60 mEq/l
What conditions are patients with Turner’s at risk of?
X linked (since only one X chromosome)
Average age of dx for retinoblastoma? Most common presentation? Prognosis?
18 months
Leukocoria
>90% children survive to adulthood
Mx of retinoblastoma?
Enucleation
depending on how advanced the tumour is other options include external beam radiation therapy, chemotherapy and photocoagulation
Red flag RR needing immediate hospital assessment?
RR>60
When to assess APGARs?
1, 5 and 10 mins
Bronchiolitis immediate referral to hospital vs consider referral to hospital?
Immediate:
- apnoea (observed or reported)
- child looks seriously unwell to a healthcare professional
- severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute
- central cyanosis
- Sats <92% in air
Consider:
- RR >60 breaths/minute
- difficulty with breastfeeding or inadequate oral fluid intake (50-75% of usual volume ‘taking account of risk factors and using clinical judgement’)
- clinical dehydration
What organism is likely to cause superimposed infection of chicken pox lesions?
Group A strep causing nec fasciitis
Biggest cause of massive painless bleeding needing a transfusion in children aged 1-2 years?
Meckel’s diverticulum
Heart abnormalitis in Turner’s?
bicuspid aortic valve (15%)
coarctation of the aorta (5-10%)
What is the Ponseti method?
process of serial manipulation and casting over a few weeks used to treat clubfoot
SUFE surgical mx?
Internal fixation across growth plate
How to remember primitive reflexes and when they disappear?
Some - Stepping - 2m
Meaningless - moro -3-4m
Reflexes - rooting - 4m
Go - grasp 4-5
Umbilical granuloma presentation and mx?
Presentation:
- First few weeks of life - small, red growth of tissue seen in centre of umbilicus –> usually wet and leaks small amounts of clear or yellow fluid
Mx:
- Regular application of salt
- Cauterise with silver nitrate
RFs for neonatal hypoglycaemia?
- preterm birth (< 37 weeks)
- maternal diabetes mellitus
- maternal labetalol use
- IUGR
- hypothermia
- neonatal sepsis
- inborn errors of metabolism
- nesidioblastosis
- Beckwith-Wiedemann syndrome
Triad in shaken baby syndrome?
Retinal haemorrhages
Subdural haematoma
Encephalopathy
Tx for biliary atresia?
Kasai procedure - the blocked bile ducts are removed and replaced with a segment of the small intestine. This restores bile flow from the liver to the proximal small bowel.
How to determine cause of precocious puberty in boys by testes size?
- bilateral enlargement = gonadotrophin release from intracranial lesion
- unilateral enlargement = gonadal tumour
- small testes = adrenal cause (tumour or adrenal hyperplasia)
How to differentiate between thyroglossal and dermoid cyst?
Both usually above hyoid bone
USS of dermoid: heterogenous and multiloculated mass
USS of thyroglossal: Thin walled and anechoic
If MMR missed in normal vaccine schedule when can you give it?
Any time - give 3 months in between doses
A period of 1 month is considered adequate if the child is greater than 10 years of age. In an urgent situation (e.g. an outbreak at the child’s school) then a shorter period of 1 month can be used in younger children.
What condition is trident hand deformity seen in?
Achondroplasia
Kocher’s criteria septic arthritis?
- temperature >38.5C,
- refusal to bear weight on affected limb
- raised inflammatory markers (erythrocyte sedimentation rate >40 mm/hour and CRP > 20.0 mg/litre)
- a peripheral white cell count of > 12.0 x 109 (normal range 3.5 – 10.5 x 109 cells per cubic litre)
Most common type of headache in children?
- Migraine
- Tension type headache
When to admit child with UTI?
- infants <3 months old - refer immediately to a paediatrician
- children >3 months old with an upper UTI -consider for admission to hospital. If not admitted oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days
- children >3 months old with a lower UTI - oral antibiotics for 3 days (trimethoprim, nitrofurantoin, cephalosporin or amoxicillin) Parents should be asked to bring the children back if they remain unwell after 24-48 hours
What conditions are associated with malrotation/volvulus?
How might it present?
exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia
scaphoid abdomen in early stages which becomes distended and bilious vomiting
What is the recommended compression: ventilation ratio for the newborn?
And for a child?
Newborn: 3:1
Child:15:2
Effect of growth hormone deficiency in kids?
Obesity
Mx for recurrent nosebleeds and no indication of bleeding disorder?
Topical treatment with an antiseptic preparation to reduce crusting and vestibulitis.
Prescribe Naseptin® (chlorhexidine and neomycin) cream to be applied to the nostrils four times daily for 10 days. If compliance is a problem, advise that it can be used twice daily for up to 2 weeks.
What should you do if a child <3 years presents with a limp?
Urgent hospital assessment
most common presentation of neonatal sepsis?
Grunting and other signs of respiratory distress
List the women who need a 5mg dose of folic acid
Previous child with NTD
Diabetes mellitus
Women on antiepileptic
Obese (body mass index >30kg/m²)
HIV +ve taking co-trimoxazole
Sickle cell
What diet may be advised in children with drug-resistant epilepsy?
High-fat ketogenic diet
Define epilepsy
Two or more seizures unprovoked by any immediately identifiable cause
1st line tx for generalised seizures?
sodium valproate
1st line tx for focal/partial seizures?
Carbamezapine or Lamotrigine
Which syndrome is associated with supravalvular aortic stenosis?
William’s syndrome
Examination findings TOG?
a loud single S2 is audible and a prominent right ventricular impulse
Indicators of life threatening asthma attack?
Cyanosis
Poor respiratory effort (PCO2 in normal range)
Peak expiratory flow rate < 33%
Silent chest
Altered level of consciousness
Acne Tx?
Mild:
- Topical retinoid - adapalene
- Benzoyl peroxide
- Azeleic acid
Moderate:
- PO abx - doxycycline or lymecycline for 3 month
- COCP
Severe:
- Isotretinoin
How long should acne tx be continued if successful?
at least 12 weeks
Tx for nappy rash with flexural sparing?
Zinc barrier cream
Tx for impetigo?
- Topical hydrogen peroxide 1% (localised)
- Topical fusidic acid 2%
- PO flucloxacillin
Diagnostic tools for autism?
- Autism Diagnosis Interview – Revised (ADI-R): 18 months & above
- Autism Diagnostic Observation Schedule – Generic
- Childhood Autism Rating Scale (CARS): 2 years & above
When to carry out autism diagnostic assessment? I.E refer directly to autism team
if there is regression in language or social skills in a child younger than 3 years
Factors associatd with increased prevalence of autism?
- Sibling with autism
- CNS Birth defects including cerebral palsy
- Gestational age <35 weeks
- Parental schizophrenia-like psychosis or affective disorder
- Sodium valproate in pregnancy
- Learning (intellectual) disability
- ADHD
- Neonatal encephalopathy or epileptic encephalopathy, including infantile spasms
- Chromosomal disorders - Down’s syndrome
- Genetic disorders - fragile X
- Muscular dystrophy
- Neurofibromatosis
- Tuberous sclerosis
When to refer to first to a paediatrician or paediatric neurologist in suspected ASD?
older than 3 years with regression in language
of any age with regression in motor skills.
What signs are you looking for in particular on physical exam of a kid with ?ASD
skin stigmata of neurofibromatosis or tuberous sclerosis using a Wood’s light
signs of injury, for example self-harm or child maltreatment
congenital anomalies and dysmorphic features including macrocephaly or microcephaly
Who should be screened for retinopathy of prematurity? How often?
All babies less than 32 weeks gestational age (up to 31 weeks and 6 days) or less than 1501g birthweight
Every week/2 weeks
1st line Tx for ROP?
Transpupillary diode laser therapy
Murmur in coarctation of aorta?
ejection systolic murmur is often present at the upper left sternal border
Loudest at left interscapular area
Ix to confirm oesophageal atresia +/- tracheo/oesophageal fistula?
How can you check clinically before doing this ix?
Gastrograffin swallow
Pass an NG tube into stomach and try to aspirate contents
What is the most comon form of oesophageal atresia?
Atresia with lower pouch tracheal fistula
Mx of haemangioma?
- Photograph and reassess in 3 months
- PO beta-blocker e.g. propranolol
- Topical/intralesional steroids
- Surgery
Presentation of haemangioma?
Appear shortly after birth (peak 4-6 weeks)
Grow fast for first 3 months
Regress by 5 months
Red, raised well demarcated firm papule with a pale halo
What are you worried about if a haematoma crosses the sutures in a newborn? What would you do?
Subgaleal haemorrhage
Cranial USS
How does a congenital bile duct cyst present?
Jaundice (conjugated bilirubin)
Abdo pain
Abdo mass
Define acute otitis media and its most common causes?
Acute inflammation of middle ear <3 weeks
Hib
Strep pneumonia
RSV
Where do Ewing’s sarcoma usually affect and what do you see on Xray?
Diaphysis/metaphysis of long bones
onion skinning of perioesteum
subperiosteal new bone formation
areas of bone destruction
Characteristics facies of diGeorge?
High and broad nasal bridge
Narrow palpebral fissures
Micrognathia
Microcephaly
Long face
Cleft palate
How is DiGeorge diagnosed?
FISH - TUPLE1 gene looking for 11.22.2 chromosome deletion
Features of congenital CMV
90% asymptomatic
Jaundice
Thrombocytopenia
Microcephaly
Periventricular calcification
Features of congenital toxoplasmosis?
Classic triad = hydrocephalus + chorioretinitis + intracranial calcifications (tram-like)
IUGR
Jaundice
Hepatosplenomegaly
Hydrocephalus
Microcephaly
Seizures
Rashes
Features of congenital syphilis?
Miscarriage/stillbirth
Rash
Blood stained rhinitis
Hepatosplenomegaly
Glomerulonephritis
Meningitis
OSteochondritis
Hutchinson’s teeth
Frontal bossing of skull
Saddle nose
Saber shins
Clutton’s joints
What is Gaucher disease?
inherited metabolic disorder in which deficiency of the enzyme glucocerebrosidase results in the accumulation of harmful quantities of certain lipids (glucocerebroside) throughout the body especially within the bone marrow, spleen and liver
Which empirical abx for child with leukaemia with febrile neutropenia?
IV Tazocin
Features of congenital cmv?
LBW
jaundice
microcephaly
sensorineural deafness
seizures
What to do if down’s child with AOM with effusion?
Refer to ENT
Complications of pavlik harness?
Avascular necrosis of femoral head
Temporary femoral nerve palsy
Presentation of Tay Sach’s and where is the deficiency?
Cherry red spot on macula
Progressive neurodegeneration
Hexosaminidase A deficiency
Tx in haemophilia?
Acute mild-moderate bleed: Desmopressin
Acute severe bleed: Recombinant Factor VIII or IX (if recurrent can also give as prophylaxis)
CXR findings in surfactant deficiency?
ground glass
CXR on meconium aspiration?
hyperinflated lungs, asymmetric patchy pulmonary opacities, pleural effusions, multifocal consolidation, pneumothorax
What is Congenital diaphragmatic hernia associated with in utero?
Polyhydramnios
Ix for biliary atresia
- USS
- Liver biopsy = GOLD STANDARD
Features of mastoiditis?
Fever
Otalgia
Hearing loss
Forward displacement of ear
When to temporarily defer vaccines?
Acutely unwell (fever >38.5)
If another live vaccine given within 4 weeks
Immunoglobulin tx (wait 3 months)
1st and 2nd line for procedural sedation?
- PO or intranasal midazolam/inhaled NO
- Ketamine
CXR findings with coarctation of aorta?
Rib notching
When should children be given VZIG after exposure?
- Neonates born to mothers who were infected 1 week before - 1 week after delivery
- Neonates born to mothers with negative varicella immune status
- Prem born at <28 weeks
- LBW
- Children on immunosuppressants
Most common intracranial tumour in kids?
Cerebellar astrocytoma
Ependymoma
Most common extracranial solid tumour in kids?
neuroblastoma
2 X ray views needed for NEC diagnosis?
AP
left lateral decubitus
Staging system used for NEC tx?
Bell staging
What are the 3 main categories of unconjugated hyperbilirubinemia associated with breastfeeding?
Physiologic jaundice: occurs between 1 and 7 days of life and peaks at 3–5 days.
Breastfeeding jaundice (BFJ): exaggerated physiologic jaundice associated with inadequate milk intake.
Breast milk jaundice (BMJ): occurs between 1 and 12 weeks in thriving breast milk–fed infant.
Important differential for babies who are difficult to wean off ventilators?
PDA
Multiple indications (2+) for CT head within 1 hour after head injury?
LOC >5 mins
Abnormal drowsiness
3+ vomits
High impact/dangerous mechanism
Amnesia >5 mins
Head injury but no CT head indicated immediately?
Observe 4 hours minimum
Features of hyper IgE syndrome?
Recurrent respiratory infections (staph/haemophilus)
Chronic eczema
Cold abscesses
Mucocutaneous candidiasis
Coarse facial features
Duchenne Muscular dystrophy vs Becker muscular dystrophy?
Duchenne is a frameshift mutation - both binding sites on dystrophin protein lost
Becker - non-frameshift insertion in the dystrophin gene resulting in both binding sites being preserved leading to a milder form
Duchenne develops at 5 years, Becker at 10 years
Intellectual impairment in 30% of Duchenne
Features of glycogen storage diseases? Give an example
Muscle cramps and weakness after first few minutes of exercise
After 10mins of ongoing exercise might get ‘second wind’ of energy
Myoglobinuria after exercise
McArdle disease or Von Gierke’s
What would you see on CXR of inhaled foreign object?
Hyperinflated lung in lung affected
Clinical presentation of G6P deficiency?
Presents at 3-4 months
Hypoglycaemia + poor tolerance to fasting
Hepatomegaly
Growth retardation
Tendency to infection
What does finding reducing substances in the urine suggest?
Galactosaemia
What is an arterial partial pressure of oxygen <50mmHg after administration of 100% oxygen consistent with?
Cyanotic congenital heart lesion
Most common cause of trisomy 21?
Meiotic non-dysjunction
RFs for significant hyperbilirubinaemia in a neonate? What should you do if they don’t reach treatment threshold? What should you do if they don’t have these RFs?
Exclusively breast fed
Gestational age <38 weeks
Previous sibling needing phototherapy
Visible jaundice within 24 hours of life
Recheck within 18 hours
If no RFs recheck in 24 hours
DKA diagnostic values?
Ketonaemia: 3mmol/L and over
Blood glucose over 11mmol/L
Bicarbonate below 15mmol/L or venous pH less than 7.3
CENTOR criteria for tonsillitis?
Tonsillar exudate
Tender anterior cervical lymphadenopathy
Fever over 38
Absence of cough
Mx of bacterial tonsillitis?
A Centor criteria score of 3/4 would warrant prescribing antibiotics or evidence of systemic upset/immunosuppression would warrent a course of antibiotics:
1st line: Penicillin V 500mg PO QDS for 5-10 days
Alternative in pen allergy: Clarithromycin/Erythromycin 250-500mg PO BD for 5 days
Incubation period for chicken pox?
Up to 3 weeks
RFs for sepsis?
Age less than 1 year
Impaired immune function (e.g. diabetes, splenectomy, immunosuppressant medication, cancer treatment)
Recent surgery in the last six weeks
Breach of skin integrity (burns/cuts/skin infections)
Presence of an indwelling catheter or line
NICE criteria that children are at increased risk of death from sepsis?
If a child is not rousable, or does not stay awake when roused
Bradycardia or tachycardia for age
Bradypnoea or tachypnoea for age
Mottled skin
Peripheral or central cyanosis
Non-blanching rash
Mx of meconium aspiration syndrome?
Admission to NICU for oxygen and abx
Tanner Staging girls breasts?
B1 Prepubertal
B2 Breast bud
B3 Juvenile with smooth contour
B4 Areola and papilla project above breast
B5 Adult
Tanner staging boys genitals?
G1 Prepubertal, testicular volume <1.5ml
G2 Penis grows in length only, testicular volume 1.5-6ml
G3 Penis grows further in length and circumference, testicular volume 6-12ml
G4 Development of glans penis, darkening of scrotal skin, testicular volume 12-20ml
G5 Adult genitalia, testicular volume >20ml
Tanner staging pubic hair?
PH1 Pre-adolescent no sexual hair
PH2 Sparse, pigmented, long, straight, mainly along labia or at base of penis
PH3 Dark, coarser, curlier
PH4 Filling out towards adult distribution
PH5 Adult in quantity and type with spread to medial thighs in males
RFs for SUFE?
Onset of puberty
Obesity
Endocrine disorders: hypothyroidism, panhypopituitarism, renal osteodystrophy, and growth hormone deficiency are all associated with SCFE.
Male gender
Afro-Caribbean or Hispanic ethnicity
Previous radiotherapy
Testicular torsion mx plan?
- Contact urology for urgent surgical exploration
- Doppler USS (can be delayed as long as urology have been contacted)
What is Autoimmune encephalitis? Symptoms?
noninfectious neuroinflammation that has become an increasingly recognized cause of acute/subacute progressive mental status change
confusion, seizures, movement disorders, behavioural changes, emotional lability, psychosis, cognitive impairment and reduced conscious level in young people
What does partial closure of the vitelline duct cause?
Meckel’s diverticulum
What is a tumour of Rathke’s pouch and what symptoms does it cause?
Craniopharyngioma
Bitemporal hemianopia
Growth failure
Causes of HIE?
Failure of gas exchange across the placenta (excessive or prolonged uterine contractions, placental abruption, ruptured uterus)
Interruption of umbilical blood flow (e.g. cord compression including shoulder dystocia, cord prolapse)
Inadequate maternal placental perfusion, maternal hypotension and hypertension
Compromised foetus (anaemia, IUGR)
Failure of cardiorespiratory adaptation at birth (failure to breathe)
Eligibility criteria for therapeutic cooling in HIE?
- Gestational age ≥ 36 weeks and ≤6 hours of age
- Metabolic or mixed acidosis with a pH of ≤7.0 or a base deficit of ≥ 16mmol/L in a sample of umbilical cord blood or any blood obtained within first hour after birth
- One of the following:
- 10 minute Apgar score of ≤ 5
- Ongoing resuscitation initiated at birth and continued for at least 10 minutes
- Moderate to severe encephalopathy on clinical examination
Most common cardiac defect in mothers with T1DM and T2DM?
TGA
Different types of spastic CP?
Spastic hemiplegia: Arm>leg, early hand preference
Spastic quadriplegia: Most severe, Associated with seizures, leg>arm
Spastic monoplegia: paralysis of 1 limb, usually an arm
Spastic diplegia: Associated with periventricular damage and scissor walking
Risks of ceftriaxone tx in neonate?
Biliary sludging
Kernicterus
How to monitor response to sepsis tx?
CRP 18-24 hours after abx started
When to do an LP in a child with sepsis?
- infants younger than 1 month
- all infants aged 1–3 months who appear unwell
- infants aged 1–3 months with a white blood cell count less than 5×109 /litre or greater than 15×109 /litre
When should immediate IV abx be given in a child presenting with a fever?
Shocked
Unrousable
Signs of meningococcal disease
Time frame for adminstering abx in suspected sepsis?
1 hour
When to consider UTI in a child with a fever <3 months?
When to consider it in a child over 3 months?
Always in under 3 months
In a child >3 months:
- vomiting
- poor feeding
- lethargy
- irritability
- abdominal pain or tenderness
- urinary frequency or dysuria
Physiological murmur findings:
Soft
Systolic
Short
S1 and S2 normal
Symptomless
Sitting/standing (vary with position)
Common causative organisms of pneumonia in CF?
Pseudomonas
Staph aureus
Haemophilus influenza
AVSD murmur?
Pan-systolic LLSE
Murmur in ASD?
Ejection systolic with fixed split S2
Bloods in post strep glomerulonephritis?
Low C3
High ASOT
What do you see on CT chest/abdo in a wilm’s tumour?
Claw sign
Tx for steroid sensitive nephrotic syndrome?
60mg/m2 per day of prednisolone for 4 weeks
4 further weeks of reducing dose
What is seen on electron microscopy of minimal change disease?
Fusion of epithelial podocytes
HSP follow up
Patients should be followed for at least 6 months with periodic urinalysis and BP monitoring.[24] An abnormality on urinalysis should be followed by a serum creatinine to assess renal function.
Diagnostic ix in periorbital cellulitis?
CT sinus and orbits with contrast medium
When to refer a neonate with a squint?
Fixed squint
Persists beyond 8 week baby check
Symptoms of salbutamol toxicity?
tremor, tachycardia, agitation, metabolic acidosis, hyperglycaemia, and hypokalaemia –> arrhythmia
Indications to not give ceftriaxone in a child?
Cholestatic jaundice
Acidosis
Hypoalbuminaemia
How can the weight of children between the ages of 1 and 10 years can be safely estimated?
weight=2 × (age +4)
Depth of chest compressions in resuscitation?
One third of depth of chest
What does a wall to wall heart on CXR suggest?
Ebstein’s anomaly
Murmur in ebstein’s anomaly?
Pansystolic due to tricuspid regurge
What does a figure of 3 sign of cxr suggest?
CoArctation of the aorta
Which heart defect is associated with Edward’s syndrome?
VSD
Mx of atrial septal defect?
closure at 3-5 years, 90% device closure in catheter laboratory or uncommonly surgical closure if very large
Mx of VSD?
Small VSDs are managed conservatively with regular echocardiograms
Large VSDs are usually treated with medical therapy – diuretics, captopril and added calories
Minor criteria in revised Jones criteria for rheumatic fever
Minor criteria:
- fever > 38.5
- Arthralgia
- ESR > 30 and/or CRP > 3
- prolonged PR interval
Revised Jones criteria for rheumatic fever?
- 2 major criteria or 1 major criterion + 2 minor criteria
- evidence of preceding streptococcal infection
Formal indications for tonsillectomy?
An episode frequency of:
> 7 / year
> 5 / year in each of the previous 2 years
>/= 3 / year in each of the previous 3 years
painless otorrhoea > 6 weeks causes in an adolescent? What is the pathophsy and what might be seen on examination?
chronic suppurative otitis media (CSOM)
Pathophys: recurrent AOM or trauma perforates tympanic membrane with subsequent bacterial infection
O/E: perforated tympanic membrane +/- cholesteatoma
What does retraction of tympanic membrane with bright white calcification o/e suggest?
Tympanosclerosis – can cause significant hearing loss but unlikely to be associated with discharge
What rash does a strep infection precipitate?
Guttate psoriasis
Which rash may precede an URTI?
Pityriasis rosea
Normal feeding requirements of a newborn?
Normal feeding requirements of a newborn
- Day 1: 60ml/kg/day
- Day 2: 90ml/kg/day
- Day 3: 120ml/kg/day
- Day 4 onwards: 150ml/kg/day
What is a MAG3 scan used for and in who?
Radionucleotide scan used in children >2 years old (instead of MCUG in young kids)
What is seen on AXR of meconium ileus?
Ground glass shadowing
Dilated bowel loops
In children and young people with suspected meningitis or suspected meningococcal disease, perform a lumbar puncture unless any of which contraindications are present?
signs suggesting raised intracranial pressure:
- reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 or more)
- relative bradycardia and hypertension
- focal neurological signs
- abnormal posture or posturing
- unequal, dilated or poorly responsive pupils
- papilloedema
- abnormal ‘doll’s eye’ movements
shock
extensive or spreading purpura
after convulsions until stabilised
coagulation abnormalities:
- coagulation results (if obtained) outside the normal range
- platelet count below 100 x 109/litre
- receiving anticoagulant therapy
local superficial infection at the lumbar puncture site
respiratory insufficiency (lumbar puncture is considered to have a high risk of precipitating respiratory failure in the presence of respiratory insufficiency)
Innocent murmurs in children? Where and when are they heard?
- Still’s murmur - short soft midsystolic murmur with a characteristic buzzing quality LLSE (gets quiet on standing)
- Pulmonary flow murmur - soft systolic murmur but harsher and higher pitched than Still’s (disappears on Valsava and loudest on back)
- Venous hum - continuous murmur heard beneath the clavicles (still heard on standing)
What is the most common cause of heart failure in neonates? (2 days of life)
Obstructed systemic circulation e.g. hypoplastic left heart, critical aortic valve stenosis, severe coarctation
What is the most common cause of heart failure in infants? (age 1-12 months)
Left-to-right shunt e.g. VSD, AVSD, large PDA.
What is the definitive treatment for partial atrioventricular septal defect (pAVSD)?
Surgery, usually at 3-5y old.
In term infants, what is the normal range for haemoglobin at birth?
145-215 g/L
What is the definition of anaemia in a neonate?
<140 g/L
