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Phase 3a > Paeds - ILAs > Flashcards

Paeds - ILAs Flashcards

1
Q

What is stridor?

A

harsh monophonic noise on breathing, primarily during inspiration, caused by turbulent airflow in the upper airway
from the THORACIC INLET UPWARDS

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2
Q

What are the causes of stridor

3 broad categories

A

Narrowing of airway:

  • Croup
  • Epiglottitis
  • Bacterial tracheitis
  • Anaphylaxis

Inhaled foreign body

Congenital airway abnormalities

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3
Q

What is wheeze?

A

Polyphonic expiratory whistling noise due to turbulent flow in the lower airway
(if severe it can be on inspiration too)

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4
Q

CASE:
2 year old child with coryza
Then barking cough, noisy breathing, hoarse cry
Healthy and up to date with immunisations

Diagnosis?

A

Croup

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5
Q

Diagnostic features of croup (symptoms)

A

Barking cough
Hoarse voice
Stridor
Preceded by coryzal symptoms and fever

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6
Q

What is epiglottitis

A

Intense swelling of epiglottis and surrounding tissue associated with sepsis

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7
Q

What is the causative pathogen for epiglottitis?

A

HiB - haemophilus influenzae B

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8
Q

What is the causative pathogen for croup?

A

Parainfluenza

+ can be:
Influenza
RSV
Human metapneumovirus

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9
Q

What is the typical age for a child with croup?

A

6 months to 6 years

Peak in second year of life

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10
Q

Classical presentation of a child with epiglottitis

A

Very unwell - toxic looking
Painful throat
Stridor
Unable to swallow - so drooling / dribbling
Immobile and upright - trying to keep airway open

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11
Q

Distinguishing features between croup and epiglottitis

A

Croup = days, epiglottitis = hours
Croup = coryzal prodrome
Cough - barking in croup, minimal in epiglottitis
Mouth closed in croup, drooling and dribbling in epiglottitis
Keeping upright in epiglottitis
Fever - mild in croup, high fever in epiglottitis

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12
Q

CASE:
5 year old girl
Sore throat, drooling of saliva, high fever
Increasing difficulty with breathing over 8 hours
Not up to date with immunisations

Diagnosis?

A

Acute epiglottitis

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13
Q

How do you treat epiglottitis?

General management
Medication
Prophylaxis for close contacts

A

Hospital admission
Call anaesthetist / paediatrician / ICU
Take cultures after airway secure / intubated

IV cephalosporin for 7-10 days
Cefuroxime, Ceftriaxome or Cefotaxime

+ prophylaxis for close contacts = Rifampicin

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14
Q

Why shouldn’t you examine the throat in a child with stridor?

A

Could cause a partial obstruction to become a full obstruction
If epiglottitis - due to laryngospasm

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15
Q

What is the first line treatment for croup?

+ DOSE

A

Oral dexamethasone - 0.15mg/kg stat dose
If none - prednisolone

If unable to take oral:

  • Nebulised budesonide
  • IM dexamethasone
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16
Q

How would you manage a child with croup who’s developing respiratory depression?

A

Call anaesthetist - get ready to intubate + ICU
High flow oxygen
Nebulised adrenaline

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17
Q 
CASE:
Child with
Difficulty breathing
Difficulty feeding
Dry cough
Coryza
Unwell for 2 days but worse overnight

+ signs of respiratory depression
Widespread crepitations
Wheeze

DIAGNOSIS
Child who is 6 months
Child who is 2 years

A

6 months = bronchiolitis (up to 1 year)

2 years = viral induced wheeze (1 - 3.5 years)

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18
Q

What are the causative pathogens for bronchiolitis?

A 
RSV most common
Parainfluenza
Influenza
Adenoviruses
Rhinoviruses
Metapneumovirus
Chlamydia
Mycoplasma pneumoniae
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19
Q

What are the risk factors for bronchiolitis?

A 
Child <1 year of age
Chronic lung disease of prematurity
Congenital heart disease
Immunodeficiency
Other lung disease eg cystic fibrosis
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20
Q

What is the diagnostic investigation for bronchiolitis?

A

PCR nasal secretions

Maybe chest x ray - unsure tbh

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21
Q

How would you treat a child with bronchiolitis?

A 
Supportive treatment
Oxygen to get sats above 92%
Fluids
CPAP / mechanical ventilation
Infection control
Bronchodilator for wheeze
Antivirals if immunodeficient / underlying heart or lung disease
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22
Q

How would you prevent bronchiolitis?

+ what groups of people would you do this for

A

Pavilizumab
IM injection for 5 months starting October

Preterm babies
Oxygen dependent infants at risk of RSV infection
Chronic lung disease eg cystic fibrosis

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23
Q

What is used in newborns to diagnose cystic fibrosis?

A

Heel prick test - Guthrie

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24
Q

What conditions are picked up on the newborn heel prick screening test?

A 
Many Children Can Present More Severely
Maple syrup urine disease
Cystic fibrosis
Congenital hypothyroidism
Phenylketonuria
MCADD
Sickle cell disease
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25
Q

What is the pattern of inheritance for cystic fibrosis?

A

Autosomal recessive

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26
Q

Which gene is affected in Cystic fibrosis and what chromosome is this gene on?

A

CFTR - cystic fibrosis transmembrane regulator

Chromosome 7

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27
Q

Which organ systems are affected in cystic fibrosis? (6)

A 
Lungs
Liver
Skin
Pancreas
GI
Reproductive
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28
Q

How would an infant present with cystic fibrosis? (5)

A 
Delayed passage of meconium
Prolonged jaundice
Failure to thrive
Recurrent infections
Malabsorption and steatorrhoea
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29
Q

How would a young child present with cystic fibrosis? (4)

A

Bronchiectasis
Rectal prolapse
Nasal polyps
Sinusitis

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30
Q

How would an older child present with cystic fibrosis? (6)

A 
ABPA (allergic bronchopulmonary aspergillosis)
Diabetes mellitus
Cirrhosis / portal hypertension
Distal intestinal obstruction
Pneumothorax / recurrent haemoptysis
Sterility in males
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31
Q

CASE
6 week old
3 week history of progressive wheeze, poor feeding, poor weight gain
Now appears short of breath, especially at end of feeds
Born at term with no difficulties
Neonatal exam normal

Differential diagnoses?

A 
Heart failure
Bronchiolitis
Pneumonia
Cystic fibrosis
GORD
Foreign body
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32
Q

How would you investigate a child with wheeze, poor feeding, poor weight gain, respiratory distress, harsh pansystolic murmur loudest at left sternal edge, palpable liver, creps in lungs?

A

ECG - upright T wave = pulmonary hypertension
CXR - for cardiomegaly and pulmonary vascular markings
ECHO - to look for congenital heart disease
Blood pressure in limbs - for coarctation of aorta
Pre and post ductal sats - for PDA

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33
Q

What medications would you give to a baby with heart failure?

A

Diuretics - furosemide

ACE inhibitor

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34
Q

How would you treat a baby with heart failure?

A

Medications - diuretics and ACE inhibitors
Surgical repair of VSD - at 3 months
Additional calorie input to make them bigger for surgery

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35
Q

What are the causes of heart failure in neonates? (4)

A

Hypoplastic left heart syndrome
Critical aortic stenosis
Severe coarctation of the aorta
Interruption of the aortic arch

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36
Q

What are the causes of heart failure in infants? (3)

A

VSD
AVSD
Large persistent ductus arteriosus

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37
Q

What are the causes of heart failure in older children? (3)

A

Rheumatic heart disease
Eisenmengers
Cardiomyopathy

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38
Q

What are the components of the septic screen?

A

Bloods

  • FBC
  • U&E
  • CRP
  • Cultures
  • PCR (viral cause)

Urine

  • Dipstick
  • Microscopy
  • Culture
  • Virology
CXR
Sputum culture
Stool culture
Lumbar puncture
Rapid antigen test
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39
Q

What does the rapid antigen test identify?

A

Group A strep

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40
Q

What would you look for on a lumbar puncture in a septic child? (4)

A

Appearance
WBC
Glucose
Protein

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41
Q

What are the contraindications for a lumbar puncture in a septic child? (6)

A 
Signs of raised ICP
Reduced conscious level
Local infection at site of LP
Thrombocytopaenia
Focal neurological signs
Cardiac instability
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42
Q 
Lumbar puncture results:
Turbid appearance
Increased polymorphs
Increased protein
Decreased glucose

Likely diagnosis?

A

Bacterial meningitis

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43
Q

What are the signs of raised ICP in a child? (5)

A 
Coma
High BP
Low heart rate
Papilloedema
Bulging fontanelle
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44
Q 
Lumbar puncture results:
Clear appearance
Increased lymphocytes
Normal glucose
Normal protein

Likely diagnosis?

A

Viral meningitis

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45
Q 
Lumbar puncture results:
Viscous appearance
Increased lymphocytes
Increased protein
Decreased glucose

Likely diagnosis?

A

TB meningitis

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46
Q 
Lumbar puncture results:
Clear appearance
Normal WCC
Increased protein
Decreased glucose

Likely diagnosis?

A

Encephalitis

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47
Q

What does the rash look like for meningococcal septicaemia?

A

Purpuric

Non-blanching

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48
Q

What is the likely diagnosis in a child with purpuric rash and fever?

A

Meningococcal sepsis

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49
Q

How would you immediately manage a child with meningococcal sepsis?

A 
ABCDE
Protect the airway
Give high flow O2
Set up IVI
If in shock give boluses of 0.9% saline (20ml/kg)
If shock persists - intubate
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50
Q

What medical treatment would you give to child with suspected meningococcal sepsis if you were in primary care?
+ dose
+ route

A

IM benpen
300mg up to 1 year
600mg 1-9 years
1.2g >10 years

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51
Q

What medical treatment would you give to a child with suspected meningococcal sepsis in secondary care?
+ dose
+ route

A

Ceftriaxone 50-80mg/kg/day IV infusion

If <3 months cefotaxime + amoxicillin 50mg/kg qds

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52
Q

What measures would you use to monitor a child with meningococcal sepsis?

A 
Pulse
BP
Resp rate
Consciousness level
WCC
Platelets
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53
Q

How is N. Meningitidis carried?

A

Carried in the throat

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54
Q

How is N. Meningitidis passed on?

And who to?

A

Person-to-person through droplets of respiratory or throat secretions
Close and prolonged contact (kissing, sneezing, coughing) or living in close quarters

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55
Q

What is the definition of a close contact?

A

Household member or 8 or more hours of contact

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56
Q

What is the prophylactic treatment for meningococcal sepsis?

+ dose and how many

A 
Rifampicin
4 doses orally, 12 hourly
5mg/kg <1 year
10mg/kg 1-12 years
600mg >12 years
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57
Q

What are the contraindications for Rifampicin? (4)

A

Liver disease
Diabetes
Porphyria
On antiretrovirals

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58
Q

What are the side effects for Rifampicin to warn people about? (4)

A

Turns urine red
Can stain contact lenses
Flu-like symptoms
Interacts with OCP + other P450 drugs eg Warfarin

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59
Q

CASE
3 year old with 7 day history of high fevers, red eyes, diffuse maculopapular rash, sore mouth and throat, cervical swelling, swollen palms

Differential diagnoses?

A

Kawasaki disease
Scarlet fever
Staph scalded skin
Toxic shock syndrome

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60
Q

What are the diagnostic criteria for Kawasaki disease?

A

Fever for >5 days with no other explanation
+ 4/5 of:
Conjunctivitis
Changes of mucous membranes of mouth - cracked lips, strawberry tongue
Swollen hands and feet –> peeling
Diffuse maculopapular rash (polymorphous exanthem)
Cervical lymphadenopathy >1.5cm (non-suppurative)

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61
Q

What would you see in the bloods of a child with Kawasaki disease? (8)

A 
FBC
- leucocytosis initially
- thrombocytosis
- normocytic, normochomic anaemia
Increased coagulability
Raised ESR (mainly, beyond fever) / CRP
Raised LFTs
Hypoalbminaemia
B cell / circulating monocyte and macrophage activation
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62
Q

What is the first line management for Kawasaki disease?

+ doses

A

High dose IVIG
2g/kg over 12 hours single infusion

Aspirin
30-50mg/kg/day
When fever resolves - 3-5mg/kg/day for 6 weeks

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63
Q

How would you follow up a child with Kawasaki disease?

A

Serial ECHO from 6 weeks

If aneurysm –> warfarin

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64
Q

What are the complications with first line treatments for Kawasaki disease?

A 
Infections from IVIG eg Hep C
Reyes syndrome - aspirin
Anaphylaxis / allergic reaction
Acute renal failure
Thrombosis
Aseptic meningitis
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65
Q

What is the initial drug treatment for JIA?

A

NSAIDs - ibuprofen, diclofenac, naproxen

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66
Q

Other than NSAIDs, what types of medication can be used in the treatment of JIA? (4)

A

Methotrexate
Etanercept (anti-TNF)
Tocilizumab (anti-IL6)
Intra-articular steroid injections - Triamcinolone

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67
Q

What should be included in the follow up for a patient with JIA?

A

Regular screening for uveitis

Measuring growth

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68
Q

CASE
Child with weight loss, drinking and weeing a lot, unresponsive, stomach ache
GCS 8
Dehydrated

Diagnosis?

A

DKA

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69
Q

How would you immediately resuscitate a child in DKA?

A 
ABCDE
IV access
Intubate if GCS 8 or below
Boluses of 0.9% saline 
10ml/kg - NOT TWENTY AS DKA
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70
Q

How do you calculate fluid requirements? (equation)

A

Overall fluid requirement = maintenance + deficit + ongoing losses

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71
Q

How do you calculate maintenance fluids?

A

First 10kg = 100ml/kg daily
11-20kg = 50ml/kg daily
Over 20kg = 20mg/kg daily

So 100/50/20 per day
Or 4/2/1 per hour

72
Q

How do you calculate fluid deficit?

A

Fluid deficit = current weight (kg) x % deficit x 10

73
Q

How long is fluid deficit given over?

A

Normally = 24 hours

In DKA = 48 hours

74
Q

How do you treat shock? (fluids)

A

Normal child = 20ml/kg boluses of 0.9% saline

DKA = 10ml/kg boluses of 0.9% saline

75
Q

Outline the management of a child in DKA

A

First 12 hours = 0.9% saline + 40mmol/L KCL
+ insulin infusion 0.1 units/kg/hour after 1 hour
+ when glucose is <14mmol/L add 5% glucose

After 12 hours - if plasma sodium stable - 0.45% saline + 5% glucose + 40mmol/L KCL

+ treat precipitating cause

76
Q

What would you monitor while treating a child in DKA? (8)

A 
Fluid input/output
Blood glucose (hourly)
Blood ketones (1-2 hourly)
Electrolytes - sodium, potassium, calcium (2-4 hourly)
Creatinine (dehydration) (2-4 hourly)
Acid base status (2-4 hourly)
\+ continuous cardiac monitoring until potassium stable
\+ neurological state
77
Q

When should you stop the insulin infusion when treating a child in DKA?

A

1 hour after first subcut insulin given

78
Q

Why should you give the correction of fluid deficit over 48 hours in a child with DKA?

A

To prevent cerebral oedema

79
Q

How do you make a diagnosis of DKA - from the bloods? (5)

A

Hyperglycaemia

Blood gas:

  • Low pH
  • Low HCO3 - METABOLIC
  • Low pCO2 - respiratory compensation

Ketones

80
Q

CASE
A neonate with high TSH on screening

Diagnosis?

A

Congenital hypothyroidism

81
Q

Which axis is involved in the production of thyroid hormones?

A

Hypothalamo-pituitary-thyroid axis

82
Q

What is the most common cause of hypothyroidism worldwide?

A

Iodine deficiency - poor intake

83
Q

What is the most likely cause of hypothyroidism in a child in the UK?

A

Thyroid dysgenesis:

  • Aplasia
  • Hypoplasia
  • Ectopic thyroid
84
Q

What is the biosynthetic cause of hypothyroidism in children?

A

Consanguineous pedigree - thyroid hormone biosynthetic defect (truncated TSH)

85
Q

Clinically, how would you differentiate between thyroid dysgenesis and a biosynthetic thyroid defect and what are you looking for?

A

Thyroid imaging - USS to see aplasia / hypoplasia
Radionucleotide scanning - for location of thyroid as
- Dysgnesis is anatomical
- Biosynthetic would appear normal

86
Q

What is the treatment for congenital hypothyroidism?
+ route
+ dose

A

Levothyroxine
Oral
10-15mcg/kg/day

87
Q

What are the symptoms of hypothyroidism? (10)

A 
Prolonged jaundice
Umbilical hernia
Pallor
Hypothermia
Macroglossia
Hypotonia
Dry skin
Constipation
Goitre
Cretinism
88
Q

CASE
10 day old baby
Collapsed and shocked

Differential diagnoses? (7)

A 
Hypovolaemia - dehydration, sepsis, DKA, blood loss
Infection - meningitis, GBS, septicaemia
Thyrotoxicosis
Congenital heart defects
Hypoglycaemia / other metabolic
NAI
NEC
89
Q

What is your immediate management for a shocked and collapsed neonate? (7)

A 
ABCDE
Neonatal unit
Vascular access
Bolus 0.9% saline 10-20ml/kg if circulatory compromise
Bloods
Septic screen
Start broad spectrum abx
90
Q

Which blood tests would you do for a collapsed and shocked neonate and what are you looking for? (4)

A

Glucose - hypoglycaemia
FBC - anaemia / blood loss / infection
U&E - metabolic shit / dehydration
Blood gas - self explanatory

91
Q

What do the bloods show in a child in salt losing crisis (congenital adrenal hyperplasia)?

A 
Hyponatraemia
Hyperkalaemia
Hyperuraemia
Decreased bicarb
Low pH 
Low CO2 if respiratory compensation
Hypoglycaemia

(metabolic acidosis)

92
Q

How would you initially manage a child with salt losing crisis / congenital adrenal hyperplasia?

A

ABCDE
Fluid resuscitation
Glucose etc

IV:

  • Hydrocortisone
  • Saline
  • Glucose
93
Q

What enzyme are children with congenital adrenal hyperplasia deficient in?

A

21-hydroxylase

94
Q

Describe the pathophysiology of why children with 21-hydroxylase deficiency present the way they do

A

Less progesterone can turn into aldosterone and cortisol as 21-hydroxylase is the enzyme needed for this
So more is turned into 17-hydroxyprogesterone and then adrenal androgens

95
Q

What is the long term management for congenital adrenal hyperplasia?

A

Glucocorticoids - hydrocortisone (suppresses ACTH and so testosterone)
Mineralocorticoids - fludrocortisone (salt loss)
Referral to endocrinologist

96
Q

How may females present with congenital adrenal hyperplasia?

A 
Ambiguous genitalia (giant clit)
(less likely to get salt-losing crisis)
97
Q

How do you classify the causes of faltering growth?

A

Non-organic = not getting enough in (maternal depression, neglect, insufficient breast milk)

Organic = stuff to do with the baby

  • Impaired suck / swallow
  • Bringing it up - vomiting, GORD
  • Chronic disease (CKD< anaemia, CF, Crohn’s)
  • Malabsorption (CF, Crohn’s)
  • Increased requirements (chronic infection, cancer, thyrotoxicosis)
  • Failure to utilise nutrients (hypothyroidism, infection, chromosomal abnormalities, IUGR)
98
Q

How would you investigate a 4 month old baby, exclusively breast fed, who has faltering growth and is possetting more but nothing else?

A

Check how much the mother is expressing

Bloods:

  • U&Es (dehydration, electrolytes)
  • TFTs
  • Coeliac antibodies
  • LFTs (CF)

Urinalysis

99
Q

What are the causative organisms for UTI?

A

E coli
Klebsiella
Proteus
Pseudomonas

100
Q

Which antibiotic would you prescribe for a 4 month old with a UTI (from urinalysis)?

A

IV cefotaxime / cefuroxime / gentamicin

101
Q

Which oral antibiotics would you prescribe for a 4 month old with a UTI?

A

Trimethoprim
Nitrofurantoin
Co-amoxiclav

102
Q

What further investigations would you perform on a small child who has had a UTI?
+ what do you look for

A

USS - obstruction
DMSA - renal scarring / kidney function
Micturating cysterourethrogram - retrograde flow of urine

103
Q

What would increase your likelihood of investigating a child with a UTI?

A

Whether they respond to abx in 48 hours
Previous UTI
Any child under 6 months with UTI
Atypical organism (non-E coli)

104
Q

What are the possible causes of diarrhoea in children?

A

Toddler’s diarrhoea
Overflow diarrhoea
Gastroenteritis
Inflammatory bowel disease

105
Q

CASE

A 5 year old girl, previously continent of faeces, now soiling herself, is small amounts of loose stool, unaware that she is doing it.
O/E mass in left iliac fossa

Diagnosis?

A

Overflow diarrhoea

106
Q

How would you explain overflow diarrhoea to the parents of a child who has it?

A

Explain that she is chronically constipated - this is blocking the lumen of the bowel
So everything else ie water has to go round it and just comes out

107
Q

How would you manage a child with overflow diarrhoea?

A

Movicol

Loads of it

108
Q

What are the causes of proteinuria in children?

A

Minimal change disease
Infection, exercise, orthostatic
Hypertension
Reduced renal mass

109
Q

What are the specific diagnostic criteria for nephrotic syndrome?

A 
Heavy proteinuria = 1g/m2/24 hours
Hypoalbuminaemia <25g/L
Oedema (clinical)
High protein:creatinine ratio
Hyperlipidaemia
110
Q

What initial investigations would you do in a patient with nephrotic syndrome?

A 
FBC
U&amp;E
LFTs
Immunoglobulins
Complement levels
Varicella titres

Hep B+C serology
Consider renal USS / biopsy

111
Q

What are the possible causes of nephrotic syndrome?

A

Minimal change disease
Focal segmental glomerulosclerosis
Membranous nephropathy

Secondary to Hep B / SLE / diabetes

112
Q

How would you manage a child with nephrotic syndrome?

A

Oral prednisolone
60mg/m2 for 4 weeks
then 40mg/m2 on alternate days for 4 weeks
then wean over 4 months

113
Q

Why do you wean children with nephrotic syndrome off of their steroids?

A

To avoid adrenal crisis

114
Q

What are children with nephrotic syndrome prone to?

A

Infections with capsulative organisms as depleted of IG and complement

115
Q

What is the prognosis for nephrotic syndrome?

A

1/3 resolve
1/3 relapse
1/3 become steroid resistant

116
Q

What are the clinical features of adrenal crisis / insufficiency / Addison’s crisis?

A

Circulatory collapse
Dehydration
Hypertension

117
Q

What are the features in the blood of a child in adrenal crisis?

A 
Hyperkalaemia
Hypercalcaemia
Hyponatraemia
Hypoglycaemia
Hypothyroid
118
Q

CASE

A girl who is basically zoning out at home and school.
Her work is deteriorating at school. Everything else - neuro exam, development is normal.

Differentials?

A

Daydreaming
Deafness
Absence seizures
Inattentive ADHD

119
Q

How could you investigate a child who is zoning out a lot of the time and is otherwise normal?

A

ECG (arrhythmias)
Connor’s questionnaire (inattentive ADHD)
EEG + hyperventilation (3/s spike and wave, in all 4 quadrants as generalised)
MRI + CT
Metabolic tests

120
Q

How do you treat absence seizures? + side effects

A 
Sodium valproate
Vomiting
Appetite increase
Liver failure
Pancreatitis
Regrowth of hair curly
Oedema
Ataxia
Thrombocytopaenia / teratogenicity / 
Encephalopathy
121
Q

What medication would you NOT give in absence seizures?

A

Carbamazepine

122
Q

CASE

A child with previous absence seizures has a generalised tonic clonic a few years later and she is clumsy in the mornings

Diagnosis?

A

Myoclonic jerks / juvenile myoclonic seizures

123
Q

How do you treat juvenile myoclonic epilepsy?

A

Lamotrigine / valproate (but if approaching childbearing age then would stop valproate)

124
Q

What is the long term prognosis of childhood absence seizures?

A

80% go on to remain seizure-free

20% develop either juvenile absence epilepsy or juvenile myoclonic epilepsy

125
Q

What are the four fields of development?

A

Gross motor
Fine motor
Speech, language, hearing
Social

126
Q

What developmental milestones would you expect a 6 month old child to have achieved?

A

Gross motor - hold head up, sit without support (with round back)

Fine motor - grip with whole palm, hold objects with both hands and bang together, transfer objects between hands

  • Newborn - fix and follow
  • 6 weeks - turn head 90 degrees to follow object
  • 3-4 months spend time watching hands

Speech and language - use consonant monosyllables, turns to sounds out of sight

  • Newborn - quieten to voices and startle to loud noises
  • 6 weeks - respond to mothers voice
  • 12 weeks - vocalise when spoken to, coo and laugh

Social - smile, become more socially responsive, put food in mouth

127
Q

What developmental milestones would you expect a child to have reached by 12 months?

A

Gross motor - cruising round edge of furniture or walking

Fine motor - pincer grip using thumb and index finger, use index finger to point to objects

Speech and language - non-specific two syllable babble (mama, dada), maybe use two syllable words appropriately and understanding of other single words (drink, no)

Social - separation anxiety, wave goodbye, feed self using fingers and drink from a cup

128
Q

What is the Moro reflex?

A

STARTLE REFLEX

sudden extension of head causing symmetrical extension then flexion of the arms

129
Q

What is the significance of abnormal persistence of primitive reflexes?

A

Abnormal development of the brain

UMN lesion

130
Q

What are the primitive reflexes? (6)

A 
Moro
Sucking reflex
Grasp reflex
Rooting reflex (turn head to nipple)
Stepping response
Asymmetrical tonic neck reflex (look out to one side and throw the arm out)
131
Q

What is cerebral palsy?

A

Umbrella term for a permanent disorder of movement and/or posture and of motor function due to a non-progressive abnormality in the brain before 2 years of age

132
Q

What happens if a child get a non-progressing abnormality of the brain after 2 years of age?
ie what is it called

A

Acquired brain injury

133
Q

What causes cerebral palsy?

A 
Antenatal (80%)
- Cerebrovascular haemorrhage
- Ischaemia
- Cortical migration disorder
- Structural maldevelopment of the brain
Perinatal
- Hypoxic ischaemic injury
Postnatal (10%)
- Meningitis / encephalitis
- Head trauma
- NAI
- Symptomatic hypoglycaemia
- Hydrocephalus
- Hyperbilirubinaemia
134
Q

What predisposes children to the causes of cerebral palsy?

A

Prematurity

135
Q

Why do the clinical signs of cerebral palsy change over time?

A

When peers are developing normally, they aren’t acquiring the same skills so looks like more are forming progressive motor dysfunction

136
Q

What are the types of cerebral palsy?

A

Spastic (90%) - unilateral or bilateral (bilateral = diplegia / quadriplegia)
Dyskinetic (floppy, chorea, dystonia)
Ataxic (cerebellar - genetically determined)

137
Q

What are the features of a spastic cerebral palsy?

A

UMN
Hypertonia
Brisk deep tendon reflexes
Clasp knife shit

138
Q

What investigations would you perform to confirm a diagnosis of cerebral palsy?

A

None as clinical diagnosis

But MRI can show where the injury is depending on the cause + if spasticity then look at corticospinal tracts for damage

139
Q

Which specialists are involved in the care of a child with cerebral palsy?

A 
Doctor (paediatrician)
Specialist nurse
Speech and language therapist
Physiotherapist
Occupational therapist 
Dietician
Psychologist
140
Q

When would botox be prescribed in a child with cerebral palsy?

A

Excessive spasticity

141
Q

CASE

A kid with a squint - left eye pointing outwards but moves inwards when the other eye is covered

Diagnosis?

A

Exotropia

Non-paralytic as moves back when the other eye is covered

142
Q

What are the causes of a exotropic wang eye?

A

Congenital
Difference in visual acuity
Space occupying lesion (if paralytic)

143
Q

How would you treat a child with an exotropic wang eye?

A

Patch on good eye
Frosted glass in glasses on good eye side
Surgery to correct (to prevent amblyopia)

144
Q

What is the complication associated with long term untreated exotropic wang eye?

A

Amblyopia (blindness in affected eye)

145
Q

How would you investigate a paralytic squint?

A

Imaging of the head and orbit (MRI)

To look for tumours

146
Q

How would you treat status epilepticus?

A 
Benzodiazepine
2nd dose benzodiazepine
Paraldehyde
IV phenytoin
Rapid sequence induction - intubation + general anaesthesia - usually makes it stop
147
Q

How do you define status epilepticus?

A

Seizure lasting 30 mins or longer

148
Q

CASE

Infant born at 27 weeks gestation, following SROM 48 hours before. He is dependent on oxygen to maintain his saturations in the normal ranges, and is working hard to breathe.

Differentials?

A 
Respiratory distress syndrome
Infection - sepsis, pneumonia
Heart disorders - PDA, VSD, ToF
Blood disorders eg sickle cell
Meconium aspiration
Diaphragmatic hernia
Persistent pulmonary hypertension of the newborn
149
Q

Outline the pathophysiology of respiratory distress syndrome

A

Surfactant deficiency

Leads to:

  • Alveolar collapse
  • Increased work of breathing
  • Hypoxia
150
Q

How would you manage a child with respiratory distress syndrome?

A

Oxygen with CPAP
Surfactant - intubate and inject into the lungs - improves in one minute
+ antenatal steroids usually

151
Q

What are the clinical features of respiratory distress syndrome?

A

Tachypnoea over 60bpm
Sternal or subcostal recession
Grunting
Cyanosis if severe

Within FOUR HOURS OF BIRTH

152
Q

What antibiotics would you use if you suspected GBS infection in a newborn? (+ route)

A

IV benpen + gentamicin

153
Q

What are the possible reasons why a premature neonate could develop hypoglycaemia in the hours after birth?

A

Prematurity - increased risk of hypoglycaemia (due to decreased glycogen storage)
Not been fed
Glucose usually dips in the first few hours after birth anyway

154
Q

How would you manage a premature baby who has developed hypoglycaemia after birth?

A

Feed
Keep warm
2ml/kg 10% dextrose bolus
20ml/kg 0.9% saline bolus

155
Q

How would you feed a premature baby?

A 
If <34 weeks - don't have suck and swallow so feed via NG tube
Otherwise enterally (normally)

Start slowly and build

156
Q

Why would you not build up feeds to quickly?

A

Risk of NEC

157
Q

How do you monitor the adequacy of nutrition given to babies?

A

Plot height and weight on centile chart and correct for gestational age

158
Q

What are the differentials for sudden deterioration / looking pale in a premature baby?

A

Shock:

  • Sepsis
  • Hypoxia
  • Hypovolaemia - IVH
159
Q

How would you identify interventricular haemorrhage in a premature baby?

A

Cranial ultrasound - through anterior fontanelle

160
Q

What are the long term problems associated with prematurity?

A

Retinopathy of prematurity
Hearing loss
Respiratory distress syndrome and chronic lung disease
Intracranial haemorrhage

161
Q

How do you assess jaundice clinically?

A

Looking where it starts and progresses - usually starts at head and progresses down to the feet

162
Q

What investigations would you perform in a baby who is jaundiced?

A

Blood bilirubin level - assess conjugated vs unconjugated
Blood typing
G6PD
Blood film
Direct Coombs test - haemolytic disease of the newborn basically

163
Q

How do you know when to treat a baby who is jaundiced?

A

Look at the level

Under 24 hours - usually need to treat as not physiological

164
Q

How would you treat a baby with jaundice?

A

Phototherapy

Antibiotics if suspected infection

165
Q

What is the harmful complication of jaundice?

A

Kernicterus - encephalopathy due to deposition of unconjugated bilirubin in the basal ganglia

When unconjugated bilirubin exceeds albumin binding capacity

166
Q

What are the causes of jaundice that occur within the first 2 days of life?

A

Haemolysis

  • Rhesus incompatibility
  • ABO incompatibility
  • G6PD deficiency
  • Spherocytosis
  • Pyruvate kinase deficiency
  • Congenital infection
167
Q

What are the causes of jaundice that occur within 2-14 days of life?

A

Physiological
Breast milk jaundice
Could be infection

168
Q

What are the causes of jaundice lasting longer than 2 weeks?

A 
BILIARY ATRESIA
Infection 
Polycythaemia
Crigler-Najjar syndrome
Hypothyroidism
Pyloric stenosis
Bile duct obstruction
Neonatal hepatitis
169
Q

How would you investigate a neonate with prolonged jaundice (>2 weeks)?

A

HIDA scan - isotope scan showing the structure of the biliary tree - for biliary atresia

170
Q

What disease is important to identify in a baby with prolonged jaundice?

A

Biliary atresia - as can lead to cirrhosis, portal hypertension, liver failure

171
Q

What are the differentials in an inconsolable neonate who is not moving a limb?

A

NAI

Osteogenesis imperfecta

172
Q

What features would you look out for on an examination of a child with an inconsolable neonate who is not moving a limb?

A

Bruising / marks (NAI)

Blue sclera - for OI

173
Q

How would you investigate a child with a suspected fracture / immobile limb?

A 
Skeletal survey - rib fractures in OI
Clotting screen if bruising
CT head to look for haemorrhage - NAI
Skin biopsy for OI
Ophthalmology - retinal haemorrhages (shaken baby)
174
Q

What is the mode of inheritance of osteogenesis imperfecta?

A

Autosomal dominant

175
Q

What other agencies would need to be involved if NAI was suspected?

A

Police

Social services

176
Q

What would be appropriate analgesia for a fracture in a neonate?

A

Calpol - paracetamol
Sucrose
Feeding

177
Q

How would you treat osteogenesis imperfecta?

A

Bisphosphonates

Phase 3a (11 decks)

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