PAEDS ILA 3 and 4

Question 1

what is stridor?

Answer 1

a high pitched wheezing sound caused by disrupted airflow
usually inspiratory
most common cause is croup

Question 2

how is stridor different from a wheeze?

Answer 2

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

Question 3

barking cough 
noisy breathing 
hoarse cry
harsh stridor 
intermittent barking cough 
low grade fever 
reduced oxygen sats 

what are the differentials?

Answer 3

croup 
epiglottitis (caused by H-influenza)
inhaled foreign body 
bacterial tracheitis 
angioedema

Question 4

what is the natural course of symptoms in croup

Answer 4

coryza –> barking cough –> stridor

Question 5

what is the common cause an time of year for croup to present and what age group is it common in?

Answer 5

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

Question 6

when examining a child with croup what must you not do and why?

Answer 6

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

Question 7

what is the management for croup?

if sats continue to drop after initial management what is the plan?

Answer 7

steroid - oral dexamethasone or nebuliser budesonide
keep calm

if getting worse - oxygen and adrenaline
very occasionally intubation will be needed.

Question 8

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?

Answer 8

DD - bronchiolitis, LRTI - pneumonia, heart failure (if you can palpate liver), GORD

most likely - bronchiolitis

Question 9

what are the possible causative organisms of bronchiolitis and which is the most common

Answer 9

Classically RSV,

others rhinovirus, parainfluenza, adenovirus

Question 10

how does bronchiolitis usually present?

Answer 10

coryza, increasing SOB, decreased feeds

Question 11

what factors increase the risk of bronchiolitis?

Answer 11

chronic lung disease 
significant congenital heart disease 
under age of 2 
prematurity 
neuromuscular disorders
immunodeficiency

Question 12

how would you diagnose bronchiolitis?

Answer 12

clinical diagnosis
nasopharyngeal aspirate - useful to avoid other investigations
CXR if worsening and not improving day 5 or if they have high spiking temperatures

Question 13

how is bronchiolitis treated?

Answer 13

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,

Question 14

how can bronchiolitis be prevented and who should be given the prophylaxis?

Answer 14

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

Question 15

what test confirms CF in neonates ?

Answer 15

new born screening blood spot test

screening for raised immunoreactive trypsinogen (IRT) and CFTR deletions from blood spot analysis

Question 16

what other conditions are picked up on the newborn screening test?

Answer 16

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

Question 17

what is the pattern of inheritance for CF?

Answer 17

AR

Question 18

what organs does CF affect?

Answer 18

defective ion transport in exocrine glands 
lungs 
pancreas 
liver
male fertility 
digestive system

Question 19

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?

Answer 19

bronchiolitis
LRTI
heart failure due to congenital heart disease
pneumonia

Question 20

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?

Answer 20

heart failure secondary to a VSD

Question 21

what investigations would you perform on an infant presenting with hear failure?

Answer 21

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

Question 22

how do you manage congenital heart disease causing heart failure in infants?

Answer 22

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

Question 23

what are some causes of heart failure in neonates and infants

Answer 23

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

Question 24

how could you classify faltering growth?

Answer 24

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

Question 25

4 month old, poor weight gain, exclusively breast fed. possessing frequently, gradually unsettles.
normal stools no resp problems

DD?
investigations?

Answer 25

DD GORD, blockage, pyloric stenosis, infection, cardiac problems, cow’s milk protein allergy

blood tests
urine culture

Question 26

4 month old is found to have large amounts of nitrites and leucocytes in urine, what are the possible causes?

Answer 26

E.coli is the most common causes

Question 27

how do you manage children with UTI?

Answer 27

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

Question 28

what further investigations could you perform for children with UTIs?

Answer 28

USS KUB

DMSA scan

Question 29

what are the possible causes if diarrhoea in children ?

Answer 29

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

Question 30

what is overflow secondary to consipation?

Answer 30

• 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.

Question 31

how would you manage overflow incontinence ?

Answer 31

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)

Question 32

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?

Answer 32

Nephrotic syndrome

minimal change nephrotic syndrome

Question 33

what are the causes proteinuria in children?

Answer 33

physical exercise 
glomerularnephritis
UTI
nephrotic syndrome 
diabetes 
renal tubular disease 
chronic renal disease

Question 34

what are the specific diagnostic criteria for minimal change nephrotic syndrome?

Answer 34

proteinuria
hypoalbuminema
peripheral oedema

Question 35

what investigations would you perform for nephrotic syndrome?

Answer 35

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

Question 36

what are the possible causes of nephrotic syndrome?

Answer 36

primary

secondary: DM, SLE, amyloidosis

Question 37

how would you manage nephrotic syndrome?

Answer 37

fluid balance
fluid restriction
prednisolone
penicillin prophylaxis
pneumococcal vaccination
consider albumin infusion, diuretics with albumin
prognosis - 80% respond to prednisolone 70% relapse