Paeds ICM

Question 1

Differences in adults and paediatrics blood results?

Answer 1

Haemoglobin
WBC
ALP (slightly higher in infants; <400IU/L)

Question 2

Similarities in adults and paediatrics blood results?

Answer 2

Platelets
INR
CRP
D-dimer

Question 3

Why is urea level lower in children?

Answer 3

Urea is a protein that comes from muscle mass.

When babies are born, they have very low levels of muscle but more subcutaneous fat. So low protein levels.

Urea will increase when babies grow and be active.

Under 12 months:
urea < 5.5mmol/L

Adults:
ureas 2.0-7.8mmol/L

Creatinine increases with muscle mass. It reaches adult range at the age of 12.

Question 4

What is a newborn blood spot test (Guthrie card)?

Answer 4

Spots of blood sample are taken at/by day 5 of life (or day 8 if baby had transfused blood) using a heel-prick test.

Detects for life changing conditions, for e.g.:
- cystic fibrosis (immunoreactive trysinogen)
- sickle cell disease (high-powered liquid chromotography)
- congenital hypothyroidism (TSH)
- 6 types of inherited metabolic disorders
* Galctosemia
* Maple Syrup Disease (MSUD)
* medium chan acyl-coenzyme A dehydrogenase defienceicy (MCADD)
* Phyenylketonuria (PKU)
* Homocystinuria
(HSU)
* Glutaric Acidaemia Type 1 (GA1)
* Isovaleric Acidaemia (VA)

Positive test can be treated early, improving baby’s health and, in some cases, preventing severe disability or even death.

Question 5

Types of paediatric needles and cannulas when taking blood?

Answer 5

Lower the gauge number, larger the needle.

Child sizes:
24G
22G
20G

Neoflon (brand name) -yellow cannula; used in neonatal

Question 6

Other blood tests?

Answer 6

Capillary blood gas
- quick, minimally invasive, heel-prick
- useful if worried about pH, pCO2.
-not good for pO2

Question 7

Other phlebotomy techniques?

Answer 7

Drip from needle or cannula
Butterfly needle in bigger kids
Scalp veins in babies

Question 8

What to consider when deciding on paediatric investigations?

Answer 8

Will doing the test CHANGE your management?
Risk vs benefit?
Can it be avoided?
How to minimise invasive/traumatic experience?

Question 9

Common presentations in paediatrics?

Answer 9

Breathing difficulties
- high RR
- SOB
- cough
- increase in work of breathing

Fever
- temp > 37.5deg

GI changes
- diarrhoea
- vomiting

Rash

Question 10

Differential diagnosis for breathing difficulty?

Answer 10

Lower respiratory tract infection
Asthma
Pneumothorax
Blunt/penetrating trauma
Toxin ingestion
Airway obstruction

Question 11

Investigations for breathing difficulty?

Answer 11

Check airway is clear before considering other IVx.

Breathing concern (x-ray, blood tests, capillary blood gas)

Question 12

Differential diagnosis for fever, reduced feeds, and irritability?

Answer 12

Viral URTI
Teething
Bacterial infection e.g. UTI
Reflux

Question 13

Investigations for fever, reduced feeds, and irritability?

Answer 13

Fever in < 5months old:
- urine MC&S
- FBC
- CRP
- Blood culture

• CXR
• Stool culture (age < 3months + diarrhoea)
• Lumbar puncture
• U&Es (dehydrated, jaundice)
• LFTs (dehydrated, jaundice)

Question 14

When can you do CXR in children?

Answer 14

Age < 3months + respiratory signs

Age > 3months
- any ‘red’ flags
- fever of unknown source AND 1+ ‘amber’ flags + temp >39deg and WBC >20

Question 15

If a 2 month old presented with fever, what must you consider?

Answer 15

Reduced consciousness
Floppy
Parents think their child is ‘not quite right’

Possible sepsis or meningitis?

Consider meningitis in any child with fever and associated symptoms.

Start abx immediately for sepsis.

Question 15

When to consider lumbar puncture in children?

Answer 15

All pts with any ‘red’ flags

Age < 1year and ‘amber’ flags

Question 16

Classic meningitis signs?

Answer 16

Neck stiffness
Bulging Fontanelle
High-pitched cry/Irritable
Decreased level of consciousness
Convulsive status epilepticus

Question 17

Management of suspected UTI and fever in a child?

Answer 17

Send urgent urine MC&S and refer to specialist if:
- age < 3months + fever

Urine dipstick
if age > 3months

Question 18

How to obtain urine sample?

Answer 18

Clean catch urine (CCU) sample

1. Sterile container/catching method
   - sterile boric acid container
   - potty cleaned with boiled hot water to sterilise
   - urine collection bag
2. Encourage micturition
   - gentle pressure over bladder
   - hydration

Question 19

Management of urine dipstick results?

Answer 19

+ve leukocyte AND +ve nitrate
→start abx for UTI, send urine for culture

+ve leukocyte AND -ve nitrate
→start abx for UTI if good clinical evidence, send urine for culture

-ve leukocyte AND +ve nitrate
→start abx for UTI, send urine for culture

-ve leukocyte AND -ve nitrate
→ don’t start abx tx, explore other causes for illness

Question 20

When to send urine culture?

Answer 20

Age > 3 months
Dipstick +ve leukocyte OR nitrite
Serious illness
Suspected upper UTI (aka pyelonephritis)
Recurrent UTI
Not improving after 1-2. days of tx (and no previous urine sample)

Question 21

When to consider imaging in UTI?

Answer 21

USS KUB routine (within 6 weeks)
- if age < 6months
- recurrent UTI
- looking for structural issues

USS KUB during acute infection
- if age < 6months AND recurrent UTI
- atypical UTI any age

Question 22

What is atypical UTI?

Answer 22

Seriously ill
Poor urine flow
Abdominal or bladder mass
Raised creatinine
Septicaemia
Failure to respond to abx in 48hours
Non- E-coli infection

Question 23

What is recurrent UTI?

Answer 23

2+ episodes of acute pyelonephritis

1 episode pyelonephritis + 1+ cystitis (lower UTI)

3+ episodes cystitis/lower UTI

Question 24

Differentials for diarrhoea and vomiting of 4 year old girl?

Answer 24

Gastroenteritis
Traveller’s diarrhoea
Food poisoning
Bowel obstruction
Appendicitus
Septicaemia

Question 25

When to consider stool MC&S IVx for children?

Answer 25

Consider if:
- recent travel abroad
- diarrhoea > 7days
- want to rule out gastroenteritis

Definitely send a stool culture if:
- suspect sepsis
- blood or mucus in stool
- immunocompromised pt

Question 26

What must you do before starting antibiotics for sepsis?

Answer 26

Take a blood culture

Question 27

What must you check for before giving IV fluids?

Answer 27

Electrolytes and glucose
Sodium
Potassium
Chloride
Creatinine

This will indicate what else you need to give with the IV fluid.

Question 28

What does blanching rash mean?

Answer 28

Rash disappears when pressed on.

Question 29

Differential diagnosis for non-blanching red/pink rash spots over legs and buttocks in a 3 year old?

Answer 29

Viral illness
Niessera meningitidis
Henoch Schonlein Purpura (HSP)
ITP
Leukaemia or lymphoma
Other infections (Strep pneumonia, H influenza)

Question 30

IVx for purpuric rash?

Answer 30

FBC
Coagulation screen
CRP
Glucose
Blood gas
Blood MC&S
N meningitidis PCR

Question 31

When should you do CT head in a child?

Answer 31

CT head if:
- GCS <10
- focal neuro
- fluctuating consciousness

Question 32

Reasons for CT within 1 hour?

Answer 32

Suspect non-accidental injury (NAI)

Post-traumatic seizure (no PMHx of epilepsy)

GCS <14
1 year old and GCS <15
GCS <15 -2hrs after injury

Skull fracture or tense fontanelle

Focal neurological deficit

Age < 1year: bruise, swelling, laceration >5cm on the head

Witnessed loss of consciousness (LOC) > 5mins

Amnesia >5mins

Abnormal drowsiness

≥ 3 discrete episodes of vomiting

Dangerous mechanism of injury

If pt has one of the following from above second section, then observe for 4 hours.