PAEDS ILA 3 and 4 Flashcards
what is stridor?
a high pitched wheezing sound caused by disrupted airflow
usually inspiratory
most common cause is croup
how is stridor different from a wheeze?
wheeze is usually expiratory lung sounds that are high-pitched whistling sounds
stridor is a special kind of wheeze which is described as a loud musical sound of constant pitch
stridor is extra-thoracic airway obstruction in the trachea or larynx
wheeze is a result of lower airways narrowing
barking cough noisy breathing hoarse cry harsh stridor intermittent barking cough low grade fever reduced oxygen sats
what are the differentials?
croup epiglottitis (caused by H-influenza) inhaled foreign body bacterial tracheitis angioedema
what is the natural course of symptoms in croup
coryza –> barking cough –> stridor
what is the common cause an time of year for croup to present and what age group is it common in?
classically parainfluenza virus (rhinovirus, rsv and influenza can produce a similar picture)
usually in autumn and early winter
6 months to 6 years but peak is in 2nd year of life
when examining a child with croup what must you not do and why?
do not distress the child, let them be in a comfortable position
do not examine the throat - it can agitate them and worsen the obstruction
clinical diagnosis - do not perform CXR, blood or cannula just keep child as comfortable as possible
what is the management for croup?
if sats continue to drop after initial management what is the plan?
steroid - oral dexamethasone or nebuliser budesonide
keep calm
if getting worse - oxygen and adrenaline
very occasionally intubation will be needed.
Jake is a six month old child who has been referred by his GP with difficulty in feeding and breathing and a dry cough with coryza. He has been unwell for the past two days but has become worse overnight. He was born at term with no difficulties. His birth weight was 3.2kg.
On examination, Jake has a low grade fever of 37.8oC and peripheral cyanosis, with oxygen
saturations of 88% in air. He has a hyper-inflated chest with tachypnoea and intercostal recession.
There are widespread crepitations and wheeze bilaterally on auscultation.
what are the DD and the most likely diagnosis?
DD - bronchiolitis, LRTI - pneumonia, heart failure (if you can palpate liver), GORD
most likely - bronchiolitis
what are the possible causative organisms of bronchiolitis and which is the most common
Classically RSV,
others rhinovirus, parainfluenza, adenovirus
how does bronchiolitis usually present?
coryza, increasing SOB, decreased feeds
what factors increase the risk of bronchiolitis?
chronic lung disease significant congenital heart disease under age of 2 prematurity neuromuscular disorders immunodeficiency
how would you diagnose bronchiolitis?
clinical diagnosis
nasopharyngeal aspirate - useful to avoid other investigations
CXR if worsening and not improving day 5 or if they have high spiking temperatures
how is bronchiolitis treated?
supportive treatment
oxygen if sats are low
CPAP/high flow oxygen if normal oxygen doesn’t work, if this does not work then they may need intubation
if not feeing give small regular feeds,
how can bronchiolitis be prevented and who should be given the prophylaxis?
palivizumab - it is a monoclonal antibody to RSV
should be given to preteen babies, babies with chronic lung disease, congenital heart defects or in the immunocompromised.
IM injection for 5 months in winter
what test confirms CF in neonates ?
new born screening blood spot test
screening for raised immunoreactive trypsinogen (IRT) and CFTR deletions from blood spot analysis
what other conditions are picked up on the newborn screening test?
Sickle cell disease
Cystic fibrosis
Congenital hypothyroidism
Inherited metabolic disorders:
–PKU
–Medium-chain acyl Co-A dehydrogenase deficiency (MCADD,
–Maple syrup urine disease, isovaleric acidemia,
–Glutaric aciduria type 1, homocystinuria
what is the pattern of inheritance for CF?
AR
what organs does CF affect?
defective ion transport in exocrine glands lungs pancreas liver male fertility digestive system
Jessie, a six-week-old infant is referred to hospital with a three week history of progressive wheeze, poor feeding, and poor weight gain. She now appears short of breath especially towards the end of feeds.
what are the differentials?
bronchiolitis
LRTI
heart failure due to congenital heart disease
pneumonia
There is a palpable thrill on the chest wall and on auscultation, there is a harsh pansystolic murmur, loudest at the left sternal edge. Jessie is tachypnoeic with some intercostal and sternal recession. There are fine crepitations audible in both lung fields. The liver is just palpable at 3cm below the costal margin
what is the likely diagnosis?
heart failure secondary to a VSD
what investigations would you perform on an infant presenting with hear failure?
blood tests - FBC, U&E
CXR - cardiomegaly, enlarged pulmonary arteries, increased pulmonary vasculature, pulmonary oedema
ECG - biventricular enlargement
echo - will demonstrate the anatomy of the defect
how do you manage congenital heart disease causing heart failure in infants?
diuretics +/- ACE inhibitors to control congestive cardiac failure and prevent pulmonary vascular disease
if the defect is small - just leave it and have follow ups
if moderate - medical management with the drugs mentioned above
large defect - stabilisation and surgical correction
sometime pulmonary artery banding can be done to allow the baby to grow before surgery
what are some causes of heart failure in neonates and infants
cardiac arrhythmias volume overload ( structural heart disease, anaemia) pressure overload - structural heard disease (AS or coarctation), hypertension systolic ventricular dysfunction - myocarditis, dilated cardiomyopathy, ischaemia diastolic ventricular dysfunction - hypertrophic cardiomyopathy, pericarditis, cardiac tamponade
how could you classify faltering growth?
poor intake (poor breast feeding technique, persistent vomiting)
malabsorption - coeliac disease, liver disease, CF. diarrhoea - lactose intolerance, cow’s milk protein intolerance
digestive tract disease
increased energy expenditure - malignancy, chronic ilness, thyroid problem
4 month old, poor weight gain, exclusively breast fed. possessing frequently, gradually unsettles.
normal stools no resp problems
DD?
investigations?
DD GORD, blockage, pyloric stenosis, infection, cardiac problems, cow’s milk protein allergy
blood tests
urine culture
4 month old is found to have large amounts of nitrites and leucocytes in urine, what are the possible causes?
E.coli is the most common causes
how do you manage children with UTI?
less than 3 months - refer to specialist
children aged more than 3 months old with an upper UTI should be considered for admission to hospital.
If not admitted oral antibiotics such as cephalosporin (cefiximie) or co-amoxiclav should be given for 7-10 days
children aged more than 3 months old with a lower UTI should be treated with oral antibiotics for 3 days according to local guidelines, usually trimethoprim, nitrofurantoin, cephalosporin or amoxicillin. Parents should be asked to bring the children back if they remain unwell after 24-48 hours
what further investigations could you perform for children with UTIs?
USS KUB
DMSA scan
what are the possible causes if diarrhoea in children ?
infection (viral, bacterial, fungal, protozoal)
malabsorption (coeliac, IBD, CF)
food intolerance (cow’s milk protein intolerance, lactose intolerance)
drugs - laxative or antibiotics
endocrine - hyperthyroidism
toddler’s diarrhoea
overflow secondary to constipation
what is overflow secondary to consipation?
• Soiling, overflow incontinence, or fecal incontinence, is when liquid or formed stool leaks into the child’s underpants. The child has no control over this leakage. It usually happens when a big, hard blockage of stool from constipation is blocking the rectum. This is called an impaction. When a child has impaction, stool can leak around the blockage into the underpants.
how would you manage overflow incontinence ?
disimpaction regimen with movicol
if not improvement after 2 weeks, add stimulant laxative (e.g. sodium pico sulphate)
if still no improvement add/substitute with osmotic laxative (lactulose)
A four year old boy is referred to the paediatric ward because he has developed swelling around the face, scrotum and ankles. About 2 months ago he had a minor coryzal illness, but has been otherwise fit and well. On examination he has swelling of the eyes, scrotum and ankles. He is afebrile. His abdomen is slightly distended and there is no rash. Urinalysis is performed and large amounts of protein are found but no blood. His weight is 17kg.
what is the likely diagnosis?
Nephrotic syndrome
minimal change nephrotic syndrome
what are the causes proteinuria in children?
physical exercise glomerularnephritis UTI nephrotic syndrome diabetes renal tubular disease chronic renal disease
what are the specific diagnostic criteria for minimal change nephrotic syndrome?
proteinuria
hypoalbuminema
peripheral oedema
what investigations would you perform for nephrotic syndrome?
urine for protein, blood, protein/creat ratio FBC, U&E bone profile including albumin varicella titres blood pressure consider need for - autoantibodies, hepatitis B serology, immunoglobulins, complement levels - renal USS - renal biopsy
what are the possible causes of nephrotic syndrome?
primary
secondary: DM, SLE, amyloidosis
how would you manage nephrotic syndrome?
fluid balance
fluid restriction
prednisolone
penicillin prophylaxis
pneumococcal vaccination
consider albumin infusion, diuretics with albumin
prognosis - 80% respond to prednisolone 70% relapse
