Paeds - ILAs Flashcards
What is stridor?
harsh monophonic noise on breathing, primarily during inspiration, caused by turbulent airflow in the upper airway
from the THORACIC INLET UPWARDS
What are the causes of stridor
3 broad categories
Narrowing of airway:
- Croup
- Epiglottitis
- Bacterial tracheitis
- Anaphylaxis
Inhaled foreign body
Congenital airway abnormalities
What is wheeze?
Polyphonic expiratory whistling noise due to turbulent flow in the lower airway
(if severe it can be on inspiration too)
CASE:
2 year old child with coryza
Then barking cough, noisy breathing, hoarse cry
Healthy and up to date with immunisations
Diagnosis?
Croup
Diagnostic features of croup (symptoms)
Barking cough
Hoarse voice
Stridor
Preceded by coryzal symptoms and fever
What is epiglottitis
Intense swelling of epiglottis and surrounding tissue associated with sepsis
What is the causative pathogen for epiglottitis?
HiB - haemophilus influenzae B
What is the causative pathogen for croup?
Parainfluenza
+ can be:
Influenza
RSV
Human metapneumovirus
What is the typical age for a child with croup?
6 months to 6 years
Peak in second year of life
Classical presentation of a child with epiglottitis
Very unwell - toxic looking
Painful throat
Stridor
Unable to swallow - so drooling / dribbling
Immobile and upright - trying to keep airway open
Distinguishing features between croup and epiglottitis
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
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?
Acute epiglottitis
How do you treat epiglottitis?
General management
Medication
Prophylaxis for close contacts
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
Why shouldn’t you examine the throat in a child with stridor?
Could cause a partial obstruction to become a full obstruction
If epiglottitis - due to laryngospasm
What is the first line treatment for croup?
+ DOSE
Oral dexamethasone - 0.15mg/kg stat dose
If none - prednisolone
If unable to take oral:
- Nebulised budesonide
- IM dexamethasone
How would you manage a child with croup who’s developing respiratory depression?
Call anaesthetist - get ready to intubate + ICU
High flow oxygen
Nebulised adrenaline
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
6 months = bronchiolitis (up to 1 year)
2 years = viral induced wheeze (1 - 3.5 years)
What are the causative pathogens for bronchiolitis?
RSV most common Parainfluenza Influenza Adenoviruses Rhinoviruses Metapneumovirus Chlamydia Mycoplasma pneumoniae
What are the risk factors for bronchiolitis?
Child <1 year of age Chronic lung disease of prematurity Congenital heart disease Immunodeficiency Other lung disease eg cystic fibrosis
What is the diagnostic investigation for bronchiolitis?
PCR nasal secretions
Maybe chest x ray - unsure tbh
How would you treat a child with bronchiolitis?
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
How would you prevent bronchiolitis?
+ what groups of people would you do this for
Pavilizumab
IM injection for 5 months starting October
Preterm babies
Oxygen dependent infants at risk of RSV infection
Chronic lung disease eg cystic fibrosis
What is used in newborns to diagnose cystic fibrosis?
Heel prick test - Guthrie
What conditions are picked up on the newborn heel prick screening test?
Many Children Can Present More Severely Maple syrup urine disease Cystic fibrosis Congenital hypothyroidism Phenylketonuria MCADD Sickle cell disease
What is the pattern of inheritance for cystic fibrosis?
Autosomal recessive
Which gene is affected in Cystic fibrosis and what chromosome is this gene on?
CFTR - cystic fibrosis transmembrane regulator
Chromosome 7
Which organ systems are affected in cystic fibrosis? (6)
Lungs Liver Skin Pancreas GI Reproductive
How would an infant present with cystic fibrosis? (5)
Delayed passage of meconium Prolonged jaundice Failure to thrive Recurrent infections Malabsorption and steatorrhoea
How would a young child present with cystic fibrosis? (4)
Bronchiectasis
Rectal prolapse
Nasal polyps
Sinusitis
How would an older child present with cystic fibrosis? (6)
ABPA (allergic bronchopulmonary aspergillosis) Diabetes mellitus Cirrhosis / portal hypertension Distal intestinal obstruction Pneumothorax / recurrent haemoptysis Sterility in males
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?
Heart failure Bronchiolitis Pneumonia Cystic fibrosis GORD Foreign body
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?
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
What medications would you give to a baby with heart failure?
Diuretics - furosemide
ACE inhibitor
How would you treat a baby with heart failure?
Medications - diuretics and ACE inhibitors
Surgical repair of VSD - at 3 months
Additional calorie input to make them bigger for surgery
What are the causes of heart failure in neonates? (4)
Hypoplastic left heart syndrome
Critical aortic stenosis
Severe coarctation of the aorta
Interruption of the aortic arch
What are the causes of heart failure in infants? (3)
VSD
AVSD
Large persistent ductus arteriosus
What are the causes of heart failure in older children? (3)
Rheumatic heart disease
Eisenmengers
Cardiomyopathy
What are the components of the septic screen?
Bloods
- FBC
- U&E
- CRP
- Cultures
- PCR (viral cause)
Urine
- Dipstick
- Microscopy
- Culture
- Virology
CXR Sputum culture Stool culture Lumbar puncture Rapid antigen test
What does the rapid antigen test identify?
Group A strep
What would you look for on a lumbar puncture in a septic child? (4)
Appearance
WBC
Glucose
Protein
What are the contraindications for a lumbar puncture in a septic child? (6)
Signs of raised ICP Reduced conscious level Local infection at site of LP Thrombocytopaenia Focal neurological signs Cardiac instability
Lumbar puncture results: Turbid appearance Increased polymorphs Increased protein Decreased glucose
Likely diagnosis?
Bacterial meningitis
What are the signs of raised ICP in a child? (5)
Coma High BP Low heart rate Papilloedema Bulging fontanelle
Lumbar puncture results: Clear appearance Increased lymphocytes Normal glucose Normal protein
Likely diagnosis?
Viral meningitis
Lumbar puncture results: Viscous appearance Increased lymphocytes Increased protein Decreased glucose
Likely diagnosis?
TB meningitis
Lumbar puncture results: Clear appearance Normal WCC Increased protein Decreased glucose
Likely diagnosis?
Encephalitis
What does the rash look like for meningococcal septicaemia?
Purpuric
Non-blanching
What is the likely diagnosis in a child with purpuric rash and fever?
Meningococcal sepsis
How would you immediately manage a child with meningococcal sepsis?
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
What medical treatment would you give to child with suspected meningococcal sepsis if you were in primary care?
+ dose
+ route
IM benpen
300mg up to 1 year
600mg 1-9 years
1.2g >10 years
What medical treatment would you give to a child with suspected meningococcal sepsis in secondary care?
+ dose
+ route
Ceftriaxone 50-80mg/kg/day IV infusion
If <3 months cefotaxime + amoxicillin 50mg/kg qds
What measures would you use to monitor a child with meningococcal sepsis?
Pulse BP Resp rate Consciousness level WCC Platelets
How is N. Meningitidis carried?
Carried in the throat
How is N. Meningitidis passed on?
And who to?
Person-to-person through droplets of respiratory or throat secretions
Close and prolonged contact (kissing, sneezing, coughing) or living in close quarters
What is the definition of a close contact?
Household member or 8 or more hours of contact
What is the prophylactic treatment for meningococcal sepsis?
+ dose and how many
Rifampicin 4 doses orally, 12 hourly 5mg/kg <1 year 10mg/kg 1-12 years 600mg >12 years
What are the contraindications for Rifampicin? (4)
Liver disease
Diabetes
Porphyria
On antiretrovirals
What are the side effects for Rifampicin to warn people about? (4)
Turns urine red
Can stain contact lenses
Flu-like symptoms
Interacts with OCP + other P450 drugs eg Warfarin
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?
Kawasaki disease
Scarlet fever
Staph scalded skin
Toxic shock syndrome
What are the diagnostic criteria for Kawasaki disease?
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)
What would you see in the bloods of a child with Kawasaki disease? (8)
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
What is the first line management for Kawasaki disease?
+ doses
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
How would you follow up a child with Kawasaki disease?
Serial ECHO from 6 weeks
If aneurysm –> warfarin
What are the complications with first line treatments for Kawasaki disease?
Infections from IVIG eg Hep C Reyes syndrome - aspirin Anaphylaxis / allergic reaction Acute renal failure Thrombosis Aseptic meningitis
What is the initial drug treatment for JIA?
NSAIDs - ibuprofen, diclofenac, naproxen
Other than NSAIDs, what types of medication can be used in the treatment of JIA? (4)
Methotrexate
Etanercept (anti-TNF)
Tocilizumab (anti-IL6)
Intra-articular steroid injections - Triamcinolone
What should be included in the follow up for a patient with JIA?
Regular screening for uveitis
Measuring growth
CASE
Child with weight loss, drinking and weeing a lot, unresponsive, stomach ache
GCS 8
Dehydrated
Diagnosis?
DKA
How would you immediately resuscitate a child in DKA?
ABCDE IV access Intubate if GCS 8 or below Boluses of 0.9% saline 10ml/kg - NOT TWENTY AS DKA
How do you calculate fluid requirements? (equation)
Overall fluid requirement = maintenance + deficit + ongoing losses
How do you calculate maintenance fluids?
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
How do you calculate fluid deficit?
Fluid deficit = current weight (kg) x % deficit x 10
How long is fluid deficit given over?
Normally = 24 hours
In DKA = 48 hours
How do you treat shock? (fluids)
Normal child = 20ml/kg boluses of 0.9% saline
DKA = 10ml/kg boluses of 0.9% saline
Outline the management of a child in DKA
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
What would you monitor while treating a child in DKA? (8)
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
When should you stop the insulin infusion when treating a child in DKA?
1 hour after first subcut insulin given
Why should you give the correction of fluid deficit over 48 hours in a child with DKA?
To prevent cerebral oedema
How do you make a diagnosis of DKA - from the bloods? (5)
Hyperglycaemia
Blood gas:
- Low pH
- Low HCO3 - METABOLIC
- Low pCO2 - respiratory compensation
Ketones
CASE
A neonate with high TSH on screening
Diagnosis?
Congenital hypothyroidism
Which axis is involved in the production of thyroid hormones?
Hypothalamo-pituitary-thyroid axis
What is the most common cause of hypothyroidism worldwide?
Iodine deficiency - poor intake
What is the most likely cause of hypothyroidism in a child in the UK?
Thyroid dysgenesis:
- Aplasia
- Hypoplasia
- Ectopic thyroid
What is the biosynthetic cause of hypothyroidism in children?
Consanguineous pedigree - thyroid hormone biosynthetic defect (truncated TSH)
Clinically, how would you differentiate between thyroid dysgenesis and a biosynthetic thyroid defect and what are you looking for?
Thyroid imaging - USS to see aplasia / hypoplasia
Radionucleotide scanning - for location of thyroid as
- Dysgnesis is anatomical
- Biosynthetic would appear normal
What is the treatment for congenital hypothyroidism?
+ route
+ dose
Levothyroxine
Oral
10-15mcg/kg/day
What are the symptoms of hypothyroidism? (10)
Prolonged jaundice Umbilical hernia Pallor Hypothermia Macroglossia Hypotonia Dry skin Constipation Goitre Cretinism
CASE
10 day old baby
Collapsed and shocked
Differential diagnoses? (7)
Hypovolaemia - dehydration, sepsis, DKA, blood loss Infection - meningitis, GBS, septicaemia Thyrotoxicosis Congenital heart defects Hypoglycaemia / other metabolic NAI NEC
What is your immediate management for a shocked and collapsed neonate? (7)
ABCDE Neonatal unit Vascular access Bolus 0.9% saline 10-20ml/kg if circulatory compromise Bloods Septic screen Start broad spectrum abx
Which blood tests would you do for a collapsed and shocked neonate and what are you looking for? (4)
Glucose - hypoglycaemia
FBC - anaemia / blood loss / infection
U&E - metabolic shit / dehydration
Blood gas - self explanatory
What do the bloods show in a child in salt losing crisis (congenital adrenal hyperplasia)?
Hyponatraemia Hyperkalaemia Hyperuraemia Decreased bicarb Low pH Low CO2 if respiratory compensation Hypoglycaemia
(metabolic acidosis)
How would you initially manage a child with salt losing crisis / congenital adrenal hyperplasia?
ABCDE
Fluid resuscitation
Glucose etc
IV:
- Hydrocortisone
- Saline
- Glucose
What enzyme are children with congenital adrenal hyperplasia deficient in?
21-hydroxylase
Describe the pathophysiology of why children with 21-hydroxylase deficiency present the way they do
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
What is the long term management for congenital adrenal hyperplasia?
Glucocorticoids - hydrocortisone (suppresses ACTH and so testosterone)
Mineralocorticoids - fludrocortisone (salt loss)
Referral to endocrinologist
How may females present with congenital adrenal hyperplasia?
Ambiguous genitalia (giant clit) (less likely to get salt-losing crisis)
How do you classify the causes of faltering growth?
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)
How would you investigate a 4 month old baby, exclusively breast fed, who has faltering growth and is possetting more but nothing else?
Check how much the mother is expressing
Bloods:
- U&Es (dehydration, electrolytes)
- TFTs
- Coeliac antibodies
- LFTs (CF)
Urinalysis
What are the causative organisms for UTI?
E coli
Klebsiella
Proteus
Pseudomonas
Which antibiotic would you prescribe for a 4 month old with a UTI (from urinalysis)?
IV cefotaxime / cefuroxime / gentamicin
Which oral antibiotics would you prescribe for a 4 month old with a UTI?
Trimethoprim
Nitrofurantoin
Co-amoxiclav
What further investigations would you perform on a small child who has had a UTI?
+ what do you look for
USS - obstruction
DMSA - renal scarring / kidney function
Micturating cysterourethrogram - retrograde flow of urine
What would increase your likelihood of investigating a child with a UTI?
Whether they respond to abx in 48 hours
Previous UTI
Any child under 6 months with UTI
Atypical organism (non-E coli)
What are the possible causes of diarrhoea in children?
Toddler’s diarrhoea
Overflow diarrhoea
Gastroenteritis
Inflammatory bowel disease
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?
Overflow diarrhoea
How would you explain overflow diarrhoea to the parents of a child who has it?
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
How would you manage a child with overflow diarrhoea?
Movicol
Loads of it
What are the causes of proteinuria in children?
Minimal change disease
Infection, exercise, orthostatic
Hypertension
Reduced renal mass
What are the specific diagnostic criteria for nephrotic syndrome?
Heavy proteinuria = 1g/m2/24 hours Hypoalbuminaemia <25g/L Oedema (clinical) High protein:creatinine ratio Hyperlipidaemia
What initial investigations would you do in a patient with nephrotic syndrome?
FBC U&E LFTs Immunoglobulins Complement levels Varicella titres
Hep B+C serology
Consider renal USS / biopsy
What are the possible causes of nephrotic syndrome?
Minimal change disease
Focal segmental glomerulosclerosis
Membranous nephropathy
Secondary to Hep B / SLE / diabetes
How would you manage a child with nephrotic syndrome?
Oral prednisolone
60mg/m2 for 4 weeks
then 40mg/m2 on alternate days for 4 weeks
then wean over 4 months
Why do you wean children with nephrotic syndrome off of their steroids?
To avoid adrenal crisis
What are children with nephrotic syndrome prone to?
Infections with capsulative organisms as depleted of IG and complement
What is the prognosis for nephrotic syndrome?
1/3 resolve
1/3 relapse
1/3 become steroid resistant
What are the clinical features of adrenal crisis / insufficiency / Addison’s crisis?
Circulatory collapse
Dehydration
Hypertension
What are the features in the blood of a child in adrenal crisis?
Hyperkalaemia Hypercalcaemia Hyponatraemia Hypoglycaemia Hypothyroid
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?
Daydreaming
Deafness
Absence seizures
Inattentive ADHD
How could you investigate a child who is zoning out a lot of the time and is otherwise normal?
ECG (arrhythmias)
Connor’s questionnaire (inattentive ADHD)
EEG + hyperventilation (3/s spike and wave, in all 4 quadrants as generalised)
MRI + CT
Metabolic tests
How do you treat absence seizures? + side effects
Sodium valproate Vomiting Appetite increase Liver failure Pancreatitis Regrowth of hair curly Oedema Ataxia Thrombocytopaenia / teratogenicity / Encephalopathy
What medication would you NOT give in absence seizures?
Carbamazepine
CASE
A child with previous absence seizures has a generalised tonic clonic a few years later and she is clumsy in the mornings
Diagnosis?
Myoclonic jerks / juvenile myoclonic seizures
How do you treat juvenile myoclonic epilepsy?
Lamotrigine / valproate (but if approaching childbearing age then would stop valproate)
What is the long term prognosis of childhood absence seizures?
80% go on to remain seizure-free
20% develop either juvenile absence epilepsy or juvenile myoclonic epilepsy
What are the four fields of development?
Gross motor
Fine motor
Speech, language, hearing
Social
What developmental milestones would you expect a 6 month old child to have achieved?
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
What developmental milestones would you expect a child to have reached by 12 months?
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
What is the Moro reflex?
STARTLE REFLEX
sudden extension of head causing symmetrical extension then flexion of the arms
What is the significance of abnormal persistence of primitive reflexes?
Abnormal development of the brain
UMN lesion
What are the primitive reflexes? (6)
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)
What is cerebral palsy?
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
What happens if a child get a non-progressing abnormality of the brain after 2 years of age?
ie what is it called
Acquired brain injury
What causes cerebral palsy?
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
What predisposes children to the causes of cerebral palsy?
Prematurity
Why do the clinical signs of cerebral palsy change over time?
When peers are developing normally, they aren’t acquiring the same skills so looks like more are forming progressive motor dysfunction
What are the types of cerebral palsy?
Spastic (90%) - unilateral or bilateral (bilateral = diplegia / quadriplegia)
Dyskinetic (floppy, chorea, dystonia)
Ataxic (cerebellar - genetically determined)
What are the features of a spastic cerebral palsy?
UMN
Hypertonia
Brisk deep tendon reflexes
Clasp knife shit
What investigations would you perform to confirm a diagnosis of cerebral palsy?
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
Which specialists are involved in the care of a child with cerebral palsy?
Doctor (paediatrician) Specialist nurse Speech and language therapist Physiotherapist Occupational therapist Dietician Psychologist
When would botox be prescribed in a child with cerebral palsy?
Excessive spasticity
CASE
A kid with a squint - left eye pointing outwards but moves inwards when the other eye is covered
Diagnosis?
Exotropia
Non-paralytic as moves back when the other eye is covered
What are the causes of a exotropic wang eye?
Congenital
Difference in visual acuity
Space occupying lesion (if paralytic)
How would you treat a child with an exotropic wang eye?
Patch on good eye
Frosted glass in glasses on good eye side
Surgery to correct (to prevent amblyopia)
What is the complication associated with long term untreated exotropic wang eye?
Amblyopia (blindness in affected eye)
How would you investigate a paralytic squint?
Imaging of the head and orbit (MRI)
To look for tumours
How would you treat status epilepticus?
Benzodiazepine 2nd dose benzodiazepine Paraldehyde IV phenytoin Rapid sequence induction - intubation + general anaesthesia - usually makes it stop
How do you define status epilepticus?
Seizure lasting 30 mins or longer
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?
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
Outline the pathophysiology of respiratory distress syndrome
Surfactant deficiency
Leads to:
- Alveolar collapse
- Increased work of breathing
- Hypoxia
How would you manage a child with respiratory distress syndrome?
Oxygen with CPAP
Surfactant - intubate and inject into the lungs - improves in one minute
+ antenatal steroids usually
What are the clinical features of respiratory distress syndrome?
Tachypnoea over 60bpm
Sternal or subcostal recession
Grunting
Cyanosis if severe
Within FOUR HOURS OF BIRTH
What antibiotics would you use if you suspected GBS infection in a newborn? (+ route)
IV benpen + gentamicin
What are the possible reasons why a premature neonate could develop hypoglycaemia in the hours after birth?
Prematurity - increased risk of hypoglycaemia (due to decreased glycogen storage)
Not been fed
Glucose usually dips in the first few hours after birth anyway
How would you manage a premature baby who has developed hypoglycaemia after birth?
Feed
Keep warm
2ml/kg 10% dextrose bolus
20ml/kg 0.9% saline bolus
How would you feed a premature baby?
If <34 weeks - don't have suck and swallow so feed via NG tube Otherwise enterally (normally)
Start slowly and build
Why would you not build up feeds to quickly?
Risk of NEC
How do you monitor the adequacy of nutrition given to babies?
Plot height and weight on centile chart and correct for gestational age
What are the differentials for sudden deterioration / looking pale in a premature baby?
Shock:
- Sepsis
- Hypoxia
- Hypovolaemia - IVH
How would you identify interventricular haemorrhage in a premature baby?
Cranial ultrasound - through anterior fontanelle
What are the long term problems associated with prematurity?
Retinopathy of prematurity
Hearing loss
Respiratory distress syndrome and chronic lung disease
Intracranial haemorrhage
How do you assess jaundice clinically?
Looking where it starts and progresses - usually starts at head and progresses down to the feet
What investigations would you perform in a baby who is jaundiced?
Blood bilirubin level - assess conjugated vs unconjugated
Blood typing
G6PD
Blood film
Direct Coombs test - haemolytic disease of the newborn basically
How do you know when to treat a baby who is jaundiced?
Look at the level
Under 24 hours - usually need to treat as not physiological
How would you treat a baby with jaundice?
Phototherapy
Antibiotics if suspected infection
What is the harmful complication of jaundice?
Kernicterus - encephalopathy due to deposition of unconjugated bilirubin in the basal ganglia
When unconjugated bilirubin exceeds albumin binding capacity
What are the causes of jaundice that occur within the first 2 days of life?
Haemolysis
- Rhesus incompatibility
- ABO incompatibility
- G6PD deficiency
- Spherocytosis
- Pyruvate kinase deficiency
- Congenital infection
What are the causes of jaundice that occur within 2-14 days of life?
Physiological
Breast milk jaundice
Could be infection
What are the causes of jaundice lasting longer than 2 weeks?
BILIARY ATRESIA Infection Polycythaemia Crigler-Najjar syndrome Hypothyroidism Pyloric stenosis Bile duct obstruction Neonatal hepatitis
How would you investigate a neonate with prolonged jaundice (>2 weeks)?
HIDA scan - isotope scan showing the structure of the biliary tree - for biliary atresia
What disease is important to identify in a baby with prolonged jaundice?
Biliary atresia - as can lead to cirrhosis, portal hypertension, liver failure
What are the differentials in an inconsolable neonate who is not moving a limb?
NAI
Osteogenesis imperfecta
What features would you look out for on an examination of a child with an inconsolable neonate who is not moving a limb?
Bruising / marks (NAI)
Blue sclera - for OI
How would you investigate a child with a suspected fracture / immobile limb?
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)
What is the mode of inheritance of osteogenesis imperfecta?
Autosomal dominant
What other agencies would need to be involved if NAI was suspected?
Police
Social services
What would be appropriate analgesia for a fracture in a neonate?
Calpol - paracetamol
Sucrose
Feeding
How would you treat osteogenesis imperfecta?
Bisphosphonates
