Paeds Key Flashcards
1
Q
Acute epiglottitis
◘ A rare but serious infection
◘ Caused by Haemophilus influenzae type B.
◘ Immediate recognition and treatment is essential as airway obstruction may
develop.
◘ Epiglottitis was generally considered a disease of childhood but in the UK, it
is now more common in adults due to the immunisation programme.
A
Causative organism of acute epiglottis
is haemophilus influenzae type B
2
Q
Features of acute epiglottis
And management
A
The incidence of epiglottitis has decreased since the introduction of the Hib
vaccine. (Hib = Hemophilus Influenza type B).
Features
√ rapid onset
√ high temperature,
√ generally unwell, toxic child
√ stridor
√ drooling of saliva
√ Muffling/ hoarse / Changing voice.
√ lateral neck X-ray → Thumb sign
◙ Rx
◙ Call (Summon) anaesthetist → Intubation “before airway obstruction occurs”
◙ Secure His Airways
Any of these two would be a valid answer in Acute epiglottitis
3
Q
Croup (Laryngotracheobronchitis)
◙ An upper respiratory tract infection seen in infants and toddlers.
◙ Commonest organism → Parainfluenza viruses.
A
◙ Features
√ stridor
√ barking cough (worse at night) “often the hint”
√ fever
√ coryzal symptoms
√ X-ray → Steeple sign.
4
Q
Severe croup symptoms
◙ If moderate to severe, we admit. Look at these features of severe croup:
A
♠ Frequent barking cough.
♠ Prominent inspiratory (and occasionally, expiratory) stridor at rest
.
♠ Marked sternal wall retractions.
♠ Significant distress and agitation, or lethargy or restlessness (a sign of
hypoxaemia).
♠ Tachycardia occurs with more severe obstructive symptoms and
hypoxaemia.
5
Q
◙ Management of Croup (important √)
A
√ A single dose of oral dexamethasone 0.15mg/kg to all children regardless of severity.
(Prednisolone is an alternative if dexamethasone is not available).
6
Q
A
7
Q
◙ Emergency treatment
A
high-flow O2
Nebulised adrenaline → In severe cases of croup.
√ The prognosis of most cases of barking cough (Croup) is:
→ natural resolution (complete recovery).
8
Q
Nocturnal Enuresis.
A
♦ The majority of children achieve day and night time continence by 3 or 4 YO.
♦ Enuresis → ‘involuntary discharge of urine by day or night or both, in a child ≥ 5
YO, in the absence of congenital or acquired defects of the nervous system or
urinary tract’
.
♦ Nocturnal enuresis can either be
:
Primary- the child has never achieved sustained continence before)
or,
secondary
(the child had been dry for at least 6 months before).
9
Q
A
10
Q
Management of Primary Enuresis
(The child has never achieved sustained continence before)
A
Management of Primary Enuresis
(The child has never achieved sustained continence before)
◙ If WITH Daytime enuresis (+) > 2 YO
→ Refer to 2ry care or enuresis clinic for further assessment.
This is the case here but he is already being seen in the 2ry care.
Important Causes (imp. √):
√ Urinary tract infections (need urine dipstick, urinalysis, possibly urine culture and
√ Urge incontinence (Overactive bladder):
Bladder retraining.
antibiotics).
- This is treated by →
- Another valid answer is →
1.- If Bladder retraining and or 2.Behavioural therapy are not given in the options or
tried but failed, go for → Oxybutynin or drugs (anticholinergics).
Behavioural Therapy.
Tolterodine, which are antimuscarinic
√ Others: congenital malformations, chronic constipation, neurological disorders.
11
Q
A
12
Q
◙ If WITHOUT Daytime symptoms (only night bedwetting)
A
• < 5 YO → Reassure (they may achieve continence soon).
• ≥ 5 YO:
◘ If infrequent (<2 times a week) → Reassure.
◘ If frequent (>2 times a week):
💕If Long-term control is required → (enuresis alarm)(
💕first-line)
Reward system
+ -
💕If short-term control of bedwetting is required (eg, the child is going to sleep at a
camp for 2 days) or > 7 YO → (
ie, for
💕temporary control and is also useful in overactive bladder ie urge incontinence).
Desmopressin -orally not intranasally- for temporary control
💕If after 2 complete courses of treatment with alarm, reward system, desmopressin,
they are still bedwetting → Refer to 2ry care.
13
Q
Management of 2ry Enuresis.
The child was dry for at least 6 months of his life and then started wetting
himself at night ± at daytime
→ Refer to a Paediatrician
A
√ Common causes of 2ry enuresis → Emotional upset (could be a result of child
abuse),
UTI, DM (polyuria), constipation. Therefore, a paediatrician needs to
investigate possible causes.
14
Q
General Points
√ Look for possible underlying causes/triggers (e.g. Constipation, diabetes mellitus,
UTI if recent onset, emotional upset).
√ Advise on fluid intake, diet and toileting behaviour.
√ Reward systems (eg, Star charts). NICE recommend these ‘should be given for
agreed behaviour rather than dry nights’ e.g. Using the toilet to pass urine before
sleep, give reward.
√ NICE advise: ‘Consider whether alarm or drug treatment is appropriate,
depending on the age, maturity and abilities of the child or young person, the
frequency of bedwetting and the motivation and needs of the family’ (Ass shown
above).
√ Generally:
◘ An enuresis alarm is first-line for children under the age of 7 years.
A
◘ desmopressin may be used first-line for children over the ago 7 years,
particularly
if short-term control is
needed or an enuresis alarm has been
ineffective/is not acceptable to the family.
15
Q
Reflux Nephropathy
• Urine goes back from bladder to ureters and kidneys (Vesico-Ureteric Reflux)
→ Dilated Pelvicalyceal system → Repeated UTIs → Progressive Renal Failure.
• Occurs mainly in the young (children).
♦ An important cause → Congenital abnormality of the insertion of ureters
into the urinary bladder (can be seen on US).
A
16
Q
Reflux Nephropathy
• Urine goes back from bladder to ureters and kidneys (Vesico-Ureteric Reflux)
→ Dilated Pelvicalyceal system → Repeated UTIs → Progressive Renal Failure.
• Occurs mainly in the young (children).
♦ An important cause → Congenital abnormality of the insertion of ureters
into the urinary bladder (can be seen on US).
A
Dx
√Initial
√Gold standard
√For parenchymal damage →
1.Renal Ultrasound (+) Urinalysis, urine culture and sensitivity.
2.→ Micturating Cystourethrogram. (Not done >3 years age).
(3. cortical scars) → Technetium Scan (DMSA).
17
Q
Reflux Nephropathy
• Urine goes back from bladder to ureters and kidneys (Vesico-Ureteric Reflux)
→ Dilated Pelvicalyceal system → Repeated UTIs → Progressive Renal Failure.
• Occurs mainly in the young (children).
♦ An important cause → Congenital abnormality of the insertion of ureters
into the urinary bladder (can be seen on US)
A
For Exam: Recurrent UTIs in children:
• First-step → US.
• Next step→ DMSA. (Not urgent, can be booked 4-6 month after acute UTI).
♦ Rx
√ Initially → Low-dose antibiotics prophylaxis (trimethoprim) daily.
√ Failed? Or Parenchymal damage? → Surgery (Ureters Re-implantation).
18
Q
◙ Branchial cyst → Lateral neck mass – Not-translucent.
◙ Lymphangioma → Lateral neck mass – Translucent.
Lateral = along or near sternocleidomastoid muscle.
◙ Painless, mobile lump in the anterior midline neck that moves up with
tongue protrusion ➔ Thyroglossal Cyst.
√ The most appropriate Ix → Ultrasound!
If suspicious → FNAC
A
Notes:
* Thyroglossal cyst is the commonest neck congenital anomaly.
* It may become painful if infected.
- A thyroglossal cyst moves up with tongue protrusion because it is
attached to the thyroglossal tract which attaches to the larynx by the
peritracheal fascia. - A neck midline lump that moves up with swallowing → Goitre?
- Fluctuant lump and transilluminate in the neck → Cystic hygroma?
19
Q
Suspect Non-Accidental Injury (Child Abuse) in Paediatrics if:
◙ Delayed presentation to medical care.
◙ Delay in attaining milestones (eg, low weight for age).
◙ Lack of concordance between proposed and actual mechanism of injury
(the carer gives a Hx which is not compatible with the signs and injuries
).
◙ Multiple injuries.
◙ Injuries/ Bruises at sites not commonly exposed to trauma.
◙ Bruises are often of varying degrees and colours.
◙ A child/ baby lives with a step-parent or a friend
A
◙ Irritable, crying, distressed baby with multiple bruises (in pain).
◙ The victim child is Not making eye contact.
Management
Admit to ward
→ relieve pain and treat underlying medical conditions
→ perform Skeletal Survey (Then)
→ inform local safeguarding
→ refer to social service
◙ Note that the answer can be a mix of two of the above.
For example, → Admit to general paediatrics ward + Refer to social service.
Skeletal Survey ◙ Also note that after giving analgesia, perform seek legal child protection (inform safeguarding, refer to social services).
and THEN
Note, do not get distracted by a “runny nose” in a baby with low weight for
age,
multiple bruises and irritability.
Runny nose might just be a result of
excessive crying 2ry to pain and abuse.
20
Q
A
21
Q
Other Distractors (DDx)
Bruises: (See haematology chapter)
• Haemophilia (X-linked recessive, so the affected individual is a boy mainly)
→ ↑ PTT + (Bleeding into muscles or joints or easily bleeds).
• Henoch-Schonlein Purpura (HSP)
HSP → PAAN: non-blanching Purpura ± Arthralgia, Abdominal pain,
Nephropathy (Hematuria, Proteinuria).
• Purpura is non-blanching and mainly on the buttocks and Lower Limbs.
• Precipitated by URTI – Sore Throat.
• All Blood Results are NORMAL “Normal Hb, WBCs and Platelets”.
• However, there might be ↑ ESR/ IgA/ Creatinine.
• One rare complication of HSP is → Intussusception (severe abdominal pain +
rectal bleeding in 6-36 months old. It can develop a few days after HSP)
• Idiopathic Thrombocytopenic Purpura (ITP)
Isolated Thrombocytopenia (low platelets) has to be given in a stem.
A
Fractures
• Osteogenesis Imperfecta
(Type 1- Autosomal dominant – collagen metabolism disorder → Brittle Bone Disease)
Other hints would be given, which are:
Blue Sclera ▐ Dental abnormalities ▐ Brittle bones - ▐ Multiple/
Unexplained fractures ▐ Hearing loss 2ry to Otosclerosis
→ Give Bisphosphonate
22
Q
Management of Acute Asthma Exacerbation in Paediatrics
1 ♦ O2
2 ♦ Salbutamol 3 ♦ Add Nebuliser (could be given back-to-back).
Nebuliser.
“Salbutamol and Ipratropium can be mixed in a solution and repeated)
Ipratropium Bromide 4
♦ Corticosteroids
√ Oral prednisolone (either liquid or crushed tablets dissolved in water)
√ OR IV hydrocortisone.
5 ♦ If still in asthma exacerbation, consider:
A
♠ IV Magnesium sulphate (MgSO4): tried first before the following 2 options.
♠ IV Salbutamol
♠ IV Aminophylline (unlikely to be the correct answer as it is given by seniors
in severe life-threatening asthma exacerbations that have failed to respond to
the max doses of bronchodilators and steroids)
◙ Once there is a Silent chest → Intubate.
Salbutamol is a short-acting beta2 agonist (SABA)
Ipratropium bromide is anticholinergic.
After giving O2, Salbutamol…etc, if the child develops tachypnea, SOP, drowsiness
Request → Arterial blood gas.
(To look for respiratory acidosis and manage accordingly)
23
Q
DDx of Stridor in paediatrics:
Acute epiglottitis and Croup are mentioned above.
A
Inhaled FB ♦ Symptoms depend on the site of impaction of foreign
body.
♦ Features are of sudden onset.
→ coughing, choking, vomiting, stridor.
→ Laryngoscopy
Laryngomalacia ♦ Congenital abnormality of the Larynx. √
♦ Typically presents at 4 weeks of age with → Stridor.
♦ Stridor can be worse on crying.
♦ Usually resolve within one year of life.
♦ Laryngomalacia is the most common congenital
airway disorder and the most common cause of stridor
in neonates.
Asked before:
What structure is not fully developed at birth?
→ Larynx.
24
Q
• Hx of travel, WATERY Diarrhea (Not-bloody), Weight Loss,
abdominal pain, foul-smelling flatulence, bloating → Giardiasis
A
♦ First line Investigation → ♦ Another investigation → Stool ELISA/ PCR
Stool microscopy “for ova and parasite
♦ First line Rx → Metronidazole + Hygiene.
25
Remember “from Infectious disease chapter”:
A patient came from Kenya (a country in Africa) develops watery diarrhea
with abdominal cramping.
The most likely organism → E. Coli.
A patient came from Kenya (a country in Africa) develops watery diarrhea
with abdominal cramping. He also has foul-smelling flatulence and weight
loss.
The most likely organism → Giardia.
◘ Traveller’s diarrhea that is usually of a short period and self-limited in 72
hours (especially Hx of a travel to Africa) → E. coli.
◘ Hx of travel, WATERY (Non-bloody) diarrhea, Weight Loss (If chronic
Giardiasis), abdominal pain and bloating (Symptoms for > 10 Days) → Giardia.
◘ Hx of travel → Prodrome: HIGH Fever (40 degrees), Headache, Myalgia →
Followed by BLOODY Diarrhea → Campylobacter jejuni.
26
Other Important Notes on Diarrhea:
- Bloody diarrhea → Campylobacter jejuni → Followed by Shigella.
- Traveller’s diarrhea → E. coli.
- Diarrhea in Paediatrics → Viral (Rota Virus).
- Diarrhea (GIT infection) + Weakness + Areflexia → Guillain-Barre Syndrome.
- Diarrhea + Renal Impairment + Hemolysis → Hemolytic Uremic Syndrome.
- Diarrhea followed by RUQ Pain → Amoeba.
- Watery Diarrhea after camping or long travel in Europe → Giardia.
- Diarrhea after long-term antibiotics → Clostridium Difficile
(Pseudomembranous colitis)
Rx → Oral Metronidazole or Oral Vancomycin.
- Diarrhea after eating Eggs or Chicken → Salmonella.
- Diarrhea just hours after a meal → Staph. Toxin.
- Diarrhea in a bedridden-patient (e.g. handicapped) with stony hard stools →
Fecal impaction.
Remember, bloody diarrhea → CSS → Campylobacter – Shigella – Salmonella.
27
Breath-Holding Spells → Reassure
A toddler (mainly 6 months – 2 years old)
(± Minor injury – pain – fear), followed by:
→ ± Crying → Loss of consciousness (for 1-2 minutes) → Rapid Recovery
Blue breath holding spells (the young child turns Blue and stops
√ Either → breathing).
√ Or → (= Reflex asystolic syncope) (= White breath
holding attacks) (
The young child stops breathing and turns Pale).
Reflex anoxic seizures HOWEVER, there is no
• Note, in Reflex anoxic seizures, a toddler is rigid and pale and may have
upward eye deviation + Colonic (Jerky) movements. biting of tongue.
• Reflex anoxic seizures do not cause Tongue Biting (an important point to
differentiate it from epilepsy).
• We do not usually need to differentiate blue breath-holding spells from
Reflex-anoxic seizures as the management is the same.
• Nonetheless, in the former (blue breath-holding spells), the toddler usually
cries vigorously and turns into blue
whereas, in the latter (Reflex anoxic seizure), he would attempt to cry
followed a minor injury (e.g. falling) but may not be able to cry, and he turns
to pale.
◙ Management in both cases:
√ Reassurance.
√ Advice parents to place their child in the recovery position until the episode
ends (usually less than 1-2 minutes).
√ Check Ferritin and treat iron deficiency anemia if present.
28
5-Week-old baby with prolonged jaundice presents with pale stool,
dark urine,
liver enlargement and
low weight for age.
→ Biliary Atresia.
Request → Direct “Conjugated” Bilirubin → Surgery.
These are features of obstructive jaundice (Pale stool, Dark Urine)
Biliary Atresia is a common cause of “Prolonged” Neonatal Jaundice.
8-Week-old baby presents with jaundice, Yellow stool
, Pale urine,
liver
enlargement,
low weight,
difficult feeding and Vomiting.
→ Galactosemia.
Here, pale urine → (not obstructive jaundice → not biliary atresia).
Vomiting, poor feeding, FTT and Prolonged jaundice → Galactosemia.
29
Causes of prolonged jaundice (persists for weeks “> 14 days”)
√ Biliary atresia
√ Congenital Hypothyroidism → “Obstructive Jaundice” → ↑ Conjugated “Direct” Bilirubin
→ Pale stool, Dark urine, hepatomegaly, FTT (Failure to Thrive).
→ Jaundice, Constipation, Cold mottled dry
skin, Hypoactive, Floppy muscles, FTT (Failure to Thrive), Protruded tongue,
flat nose, widely set eyes
→ Give Oral Levothyroxine until 2 years of age.
√ Breast milk jaundice
√ Galactosaemia
√ Urinary tract infection
√ Congenital infections → Vomiting, Difficulty feeding, Diarrhea, Jaundice, FTT.
(UTI)
e.g., CMV, toxoplasmosis
30
Duchenne Muscular Dystrophy (DMD)
◙ Diagnosis:
→ Initial test → CK “Creatine Kinase)
→ Muscle Biopsy
→ Genetic Testing (Obligatory after +ve muscle biopsy).
◙ Important Note:
DMD has a mutation defect in Dystrophin protein which lies in Striated muscles.
◙ X-linked Recessive Conditions:
DMD ▐ Haemophilia
◙ X-linked Recessive → a Male child has 50% to inherit the gene if his mother
is a carrier.
X-linked recessive only affects males
.
◙ For PLAB 1, criteria for DMD:
√ 4-8 YO ♂ (boy) who started to walk late (≥ 18 months instead of 12 months)
√ Gower’s sign → the boy uses his hands to push on his legs to stand.
√ Proximal Muscle weakness.
√ Waddling gait (he cannot run).
√ (↑) CK “Creatine Kinase”, ALT, AST.
√ (±) Respiratory and/or Cardiac manifestations.
31
32
Autosomal Recessive
If Both Parents are carriers
• 25% chance of a child to be affected
50% chance of a child
to be carrier
Cystic Fibrosis
Congenital Adrenal
Hyperplasia
(21-hydroxylase
Deficiency).
Thalassemia
Sickle Cell Anemia
33
X-Linked Recessive
Duchenne Muscular
Dystrophy (DMD)
Haemophilia
If Mother is Carrier
→ 50% chance of a Male child to be affected
34
Autosomal Dominant
Polycystic Kidney
Disease (ADPKD)
BRCA 1 gene
(Autosomal dominant
with incomplete
penetrance)
Huntington’s Disease
Autosomal dominant
with anticipation)
NF
If One parent is Affected
→ 50% chance of a child to be affected
💕25% chance of a
Grandchild to be
affected.
35
Very DDx of Abdominal Conditions
Case (1)
◙ Sudden onset of green, bilious vomiting in a neonate
(+) Blood per rectum.
(±) Double bubble sign on X-ray
→ Malrotation and Volvulus.
√ Dx → Abdominal X-ray, Barium enema.
√ Rx → ABCDE, NGT decompression, refer to paediatrics surgery for
laparotomy and resection
36
Case (2)
◙ Projectile, non-bilious vomiting “≈ 30 min” after a feed in a 3-8 weeks neonate
(±) Palpable Almond-seized mass in the upper abdomen
(±) hypochloraemic, hypokalaemic alkalosis (Metabolic alkalosis: ↓Cl-
, ↓ K+).
(±) A hungry baby who wants to feet regardless of the constant vomitin
→ Pyloric Stenosis.
Abdominal Ultrasound → Thickened pylorus
√ Dx → important √
√ CAREFULL! The most URGENT Next step → Serum Potassium (K+).
“Remember that repetitive projectile non-bilious vomiting especially after
feeding in can cause →
pyloric stenosis hypochloraemic hypokalemic alkalosis (low Cl-
, Low K+) which prompts urgent
correction.
♠ Therefore, if the question asks about the next step or the most URGENT step,
the answer would be → (measure serum K+),
37
Pyloric stenosis
whereas if the question asks about an investigation for Diagnosis, the answer
will be → “Abdominal Ultrasound”.
√ Rx → Correct dehydration and electrolytes.
→ NGT (Nasogastric tube).
→ Ramstedt Pyloromyotomy.
38
39
40
◙ Infants 6-36 months old with paroxysmal:
Severe abdominal colicky pain, + Irritable + CRYING
(±) bloodstained stool (rectal bleeding) –
‘red-currant jelly’
– late sign
(±) sausage-shaped mass in the right upper quadrant (ileocecal
).
.
→ Intussusception.
Abdominal Ultrasound √ Dx → → Target sign/ Doughnut sign.
√ Rx → Mechanical reduction (first line: reduction by 2nd: reduction by barium enema).
If fails→ Surgical reduction (laparotomy).
air enema insufflation.
• Important Note:
√ A rare complication of Henoch-Schonlein Purpura (HSP) is intussusception.
41
√ HSP → PAAN: non-blanching Purpura (mainly on buttocks and lower limbs ±
Arthralgia, Abdominal pain, Nephropathy (Hematuria, Proteinuria).
√ So, if a baby has pruritic rash (purpura), abdominal pain and arthralgia and then
develops severe abdominal pain, rectal bleeding and irritability:
Think → Intussusception (as a complication of Henoch-Schonlein Purpura HSP). √.
√ HSP → PAAN: non-blanching Purpura (mainly on buttocks and lower limbs ±
Arthralgia, Abdominal pain, Nephropathy (Hematuria, Proteinuria).
√ So, if a baby has pruritic rash (purpura), abdominal pain and arthralgia and then
develops severe abdominal pain, rectal bleeding and irritability:
Think → Intussusception (as a complication of Henoch-Schonlein Purpura HSP). √.
42
Painless bleeding per rectum in a Male child aged 2-3 YO
→ Meckel’s Diverticulum.
√ Dx – Initial modality → Radioisotope Scan.
√ Dx – Definitive → Laparotomy.
√ Rx → Surgical Resection.
√ Other hints for Meckel’s (Rule of 2):
2-3 YO “mainly male”
▐ 2 inches long
▐ 2 feet away from ileocecal valve.
Remember that in Intussusception and Volvulus → Painful.
43
Meconium ileus is present (not being passed in the first 2 days of life)
+ Bilious greenish vomiting + Abdominal distension + Crying
→ Hirschsprung’s disease. To confirm → X-ray or rectal biopsy.
Meconium ileus is present (not being passed in the first 2 days of life)
+ Bilious greenish vomiting +
Abdominal distension + Crying
→ Hirschsprung’s disease. To confirm → X-ray or rectal biopsy.
44
Viral Rashes in Paediatrics
Measles / Rubella / Roseola / Parvovirus B19 / Head, Foot and Mouth Disease
Treatment in all these cases → Supportive + Reassurance
Measles
(•) Fever, Irritability
(+) Rash “often itchy”
, begins on Face/ Neck and then spreads to body
(+) Koplik spots “red with white centre spots -grain of salt- on buccal mucosa”
(+) URTI (runny nose and sore throat)
(+) No cervical Lymphadenopathy
→ Measles = Rubeola
Note, Measles is also called “Rubeola” ▐ Rubella is also called “German Measles”
√ Mainly supportive (e.g. Paracetamol/ Ibuprofen for pain and fever).
√ A notifiable disease
√ If these are not given in options, pick → Reassurance (as no antibiotics or
steroids are required; it usually resolve spontaneously in a week or so).
Measles → ‘’K’’: Koplik spots, Cough, Coryza (runny nose, sore throat),
Conjunctivitis.
45
Rubella
(•) Low-grade fever
(+) Rash: maculopapular, initially on the face (before spreading to the whole
body), usually fades by the 3-5th day
(+) Lymphadenopathy: cervical, suboccipital and postauricular.
(±) Froschheimer’s Spots on “soft palate” [Red petechiae in the mouth]
Management → The same as measles.
Note, Rubella presents similar to Measles but with
√ Enlarged LNs.
√ Froschheimer’s Spots on “soft palate” not “buccal mucosa”.
46
Roseola (Roseola infantum)
HIGH Temperature Sudden followed
by spreads to body.
(√) asked in September 2019 Plab 1 exam.
non-itchy rash on CHEST or legs then
Erythema infectiosum = (fifth disease) = Parvovirus B19
Children: Slapped cheek appearance (bright red rash on both cheeks,
may
spread to body, may be itchy if involves the feet soles)
47
Hand, Foot and Mouth Disease.
Coxsackie Virus. “important √”
Painful ulcers on tongue (+) grey blisters on hands and feet.
The management of these Viral Rash Conditions is Supportive + Reassurance.
HOWEVER,
If you suspect Meningitis (rash, neck stiffness, photophobia, uncontrollable
fever), the management will be completely different!
48
49
♦ Urine Dipstick testing should be used for infants and children > 3 months
old with suspected UTI.
♦ If both leukocyte esterase and nitrite are negative: do not start antibiotic
treatment, and do not send a urine sample for microscopy and culture.
♦ If leukocyte esterase or nitrite, or both are positive
→ start antibiotic treatment and send a urine sample for culture
(Midstream catch if mature enough)
clean catch urine sample = Midstream catch
√ A urine collection recommended by NICE.
Do not be surprised if you have to choose “Clean catch urine sample for
is the method of choice for
culture” in a 2 YO child :D Good luck trying
√ If a clean catch urine sample is not possible (Not toilet-trained children):
♦ A collection bag attached to cleaned genitalia can be used. However, if the
genitalia are not cleaned and culture is delayed, there can be a high incidence
of false positive results (85-99%).
♦ Use other non-invasive methods such as urine collection pads but do not
use cotton wool balls, gauze or sanitary towels.
♦ Alternatively, a (urine catheter) sample or (Suprapubic Aspiration) SPA of
urine may be collected where sufficient experience and resources exist.
50
Paediatric Developmental Milestones
In the exam, if you see one of the following
→ Refer for “Developmental Milestones Assessment”
as they represent the age limit after which, it is considered abnormal.
• No smile by 8 weeks of age (2 months).
→ Delayed Social Development.
• No eye contact by 3 months of age.
→ Delayed Social Development.
• No holding objects placed in hand by 5 months of age.
→ Delayed Fine Motor Development.
No reaching for objects by 6 months of age.
→ Delayed Fine Motor Development.
• No transferring objects between hands by 9 months of age.
→ Delayed Fine Motor Development.
• Cannot sit unsupported by 12 months. (but if he cannot stand unsupported
by 12 months, it is still considered as normal).
→ Delayed Gross Motor Development.
• Cannot walk by 18 months.
→ Delayed Gross Motor Development.
• No single meaningful word by 18 months.
→ Delayed Verbal “Language” Development.
• Only says dada and mama at 24 months ▐
Not putting 2 or more words
together like (car seat), (Mama milk) in a sentence at 24 months:
→ Delayed Verbal “Language” “Speech” Development.
• Cannot run by 30 months (2.5 years)
51
Development milestone
→ Delayed Gross Motor Development.
√ If parents are concerned about speech at anytime
→ Refer for hearing test.
Otherwise → Reassure / Normal Development.
Remember,
The above are the commonly asked concerning milestones.
However, for your knowledge and interest, we have provided the
full Paediatric developmental
milestones (if you have time, go over them).
52
Gross Motor Development
Newborn
Limbs flexed, symmetrical pattern
Marked head lag on pulling up
6 – 8 weeks
Raises head to 45 degrees in prone (tummy-time)
6 – 8
Sits without support (initially with a round back, then
eventually with a straight back by 8 months)
months
Limit age: 9 months
8 – 9
months Crawling
10 months Stands independently
Cruises around furniture
Walks unsteadily – a broad gait, with hands apart
12 months
Limit age: 18 months
15 months Walks steadily
2.5 years Runs and jumps
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Vision and Fine Motor Development
Follows moving object or face by turning the head
(fixing and following)
6 weeks
Limit age: 3 months
4 months Reaches out for toys
Limit age: 6 months
4 – 6 months Palmar grasp
Transfers toys from one hand to another
7 months
Limit age: 9 months
10 months Mature pincer grip
Limit age: 12 months
16 – 18 months Makes marks with crayons
Tower of three – 18 months
14 months – 4
years
Tower of six – 2 years
Brick building
Tower of eight or a train with four bricks – 2.5 years
Bridge (from a model) – 3 years
Steps (after demonstration) – 4 years
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Development
Line – 2 years
2 – 5
Circle – 3 years
years Pencil
skills
Cross – 3.5 years
Drawing without
Square – 4 years
seeing how it is
done.
Triangle – 5 years
Can copy 6
months earlier.
Diamond – 6 years
55
Hearing, Speech and Language Development
❤️Newborn Startles to loud noises
❤️3 – 4
months Vocalises alone or when spoken to, coos and laughs “aa, aa”
❤️Turns to soft sounds out of sight
7 months
Polysyllabic babble (“babababa, lalalalala”)
❤️Sounds used indiscriminately at 7 months
7 – 10
Sounds used discriminately to parents at 10 months “Dada,
months
Mama”
❤️Two to three words other than ‘Dada’ or ‘Mama’
12 months
Understands name “Drink”
6-10 words
❤️18 months
Is able to show two parts of the body “Where is your nose?”
– Baby will point
❤️20 – 24
Joins two or more words to make simple phrases “Give me
months
teddy”
❤️Talks constantly in 3 – 4-word sentences
2.5 – 3
years
Understands 2 joined commands “Push me fast Daddy”
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Social, Emotional and Behavioural Development
Smiles responsively
6 weeks
Limit age: 8 weeks
6 – 8
months Puts food in their mouth
Waves bye-bye, plays peek-a-boo
10 – 12
months
12 months Drinks from a cup with two hands
18 months Holds spoon and gets food safely to mouth
Symbolic play
18 – 24
months
Limit age: 2 – 2.5 years
Toilet training: dry by day
2 years
Pulls off some clothing
Parallel play
2.5 – 3
Interactive play evolving
years
Takes turns
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Celiac Disease
- Autoimmune, Malabsorption disease, results due to sensitivity to the Gluten
(which is a protein).
- Eating gluten diet (eg, Rye, Wheat, Barley) → Villous atrophy of the GIT →
Malabsorption → Iron deficiency Anemia, Folic Acid and Vit. B12 Deficiency,
malabsorption of fat.
◙ Manifestations:
• Chronic or Intermittent Diarrhea.
• Steatorrhea (fatty stools “Smelly, difficult to flush” due to fat malabsorption).
• Stinking (bad-smell) stools
• Abdominal discomfort, Bloating - Distension-, Nausea and Vomiting.
• Wight Loss. (Failure to thrive) imp
√.
• Anemia Types:
Iron deficiency anemia (the most common. The baby is patient is pale), followed
by Folate deficiency then Vitamin B12 deficiency.
• Manifestations of anemia eg, Pallor, Fatigue.
◙ Complications: Osteoporosis / T-cell lymphoma (rare).
- Association not to be forgotten → Dermatitis Herpetiformis.
◙ Diagnosis:
• Positive TTG and IgA. (First Line)
(TTG= • Sometime, TTG will not be given in the options,
Pick → • Also, Tissue TransGlutaminase Antibodies) “First-line”
.
Anti-Endomysial Antibodies.
alpha-gliadin antibodies would be positive.
If TTG is positive, we need to confirm the diagnosis of Celiac disease by a Biopsy →
• Jejunal or Duodenal Biopsy.
- Villous Atrophy.
- Crypt hyperplasia.
- ↑ inter-epithelial lymphocytes.
Important: for the biopsy to be accurate, the patient should re-
introduce the gluten in his diet for 6 weeks before the biopsy.
◙ Treatment: → Gluten-free diet.
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A 24-year-old child (2-year-old) presents with his parents as he has been having a
smelly loose stools and abdominal distention for the past few months. He is not
being able to gain sufficient weight as well despite feeding well. He looks pale.
Steatorrhea (loose smelly stools) due to fat malabsorption, abdominal distension
and failure to thrive (not gaining weight sufficiently) are features of celiac disease.
Also, he is pale because of anemia (which is also prominent in celiac disease due to
malabsorption).
Dx → Celiac disease.
Ix → Tissue TransGlutaminase Antibodies
If not given → Anti-Endomysial Antibodies
Why not cystic fibrosis?
In CF, hints other than steatorrhea (malabsorption) would be given (eg, recurrent
respiratory infections,
repetitive cough over the past few months
± Delayed
growth and Abdominal distension).
In this case, CF would be suspected and (Sweat
chloride test would be requested).
◙ In the UK, there is a neonatal screening test for CF
(Guthrie test) using heel-prick test.
If positive → Confirm by Sweat test and Genetic
testing for CFTR.
◙ If CF was not diagnosed during neonatal period and it is suspected in an older
individual (eg, 1 YO) → Perform Sweat Test “First”
or Genetic testing for CFTR.
59
Cystic fibrosis
Important,
◙ Why are there repeated pulmonary problems in cystic fibrosis patients?
→ Due to higher Viscosity of mucous.
◙ What is the most commonly organism affecting Chest in Cystic fibrosis?
→ Staphylococcus aureus. Followed by Pseudomonas
Please note that the “Cystic fibrosis” topic is fully covered in the Genetic Chapter.
60
A child presents with repetitive cough, low percentile for weight and height
(Failure to thrive),
Steatorrhea (Greasy, bulky and smelly stools that float),
rectal prolapse (due to bulky stool), recurrent chest infections
.
→ Suspect Cystic Fibrosis and perform → chloride Sweat Test.
61
A child with multiple admissions to hospital with weight loss and infections
which recover after admission and re-occur when discharged.
Suspect → Neglect
The child is likely being neglected at home “no sufficient nutrition or care”.
62
A child has been recently diagnosed with type 1 DM. since then, he is sad, not
cooperating, socially isolated. Where to refer?
→ Psychologist
(He needs some talk therapy so he can accept his diagnosis of insulin
dependent diabetes and gets back to life).
63
Important Notes on Hernias
◙ Inguinal Hernia → ABOVE and Medial (some references say lateral) to the
pubic tubercle.
◙ Femoral Hernia → BELOW and lateral to the pubic tubercle.
◙ Inguinal Hernia → Impulse on cough, reducible
◙ Femoral Hernia → rarely impulse on cough + Irreducible as the femoral
canal is narrow.
◙ Strangulated and Incarcerated hernias → Irreducible, very painful, require
urgent surgery.
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√ Uncomplicated inguinal hernia treatment?
→ “Elective” surgery
√ If complicated “incarcerated, strangulated red painful irreducible”?
→ “Emergency” surgery.
♦ If
♦ If < 10 YO
> 10 YO
→ Herniotomy.
→ Herniorrhaphy (reinforcing the abdominal wall with a mesh).
◙ RFx of Inguinal Hernia → Male sex, Lifting heavy objects, old age, chronic
cough, previous abdominal surgery.
◙ Indirect inguinal hernia → Passes through the deep and the superficial
inguinal ring (Passes through the entire length of the inguinal canal) and lies
LATERAL to the inferior epigastric artery.
◙ Direct inguinal hernia canal “directly”.
→ Passes through the Posterior wall of the inguinal
It does not pass through the deep and then the superficial ring of the inguinal
canal as the indirect hernia does.
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◙ Signs of Strangulated Hernias
Pain / Fever / Inflammation / Nausea and Vomiting
Features of Intestinal Obstruction (Abdominal Pain, Distention, Constipation).
◙ Irreducible inguinal hernias in children warrant Emergency Surgery.
◙ Concomitant
Orchidopexy is required if one or both testes are impalpable
in scrotum or incarcerated.
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A child – Nasal Speech – Snores heavily at night – Breathing through mouth
√ Dx → Obstructive sleep apnea (OSA)
√ Since most cases of OSA in children are due to enlarged tonsils and adenoids
→ Refer to ENT Surgeon.
√ Ix of choice → Polysomnography.
Polysomnography is also called a sleep study, is a comprehensive test used to
diagnose sleep disorders.
Polysomnography records brain waves, oxygen level in blood, heart rate and
breathing, as well as eye and leg movements during the study.
Note, children with OSA may be active during the daytime while adults with
OSA (obsess) are usually fatigued during daytime and may fall asleep.
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A bite of psychiatry:
◙ Tourette’s syndrome → Repetitive multiple Tics (motor + vocal), 6-13 YO child.
• Examples:
√ Unable to sit still, constantly blinking, making grunting noises, rubbing
fingers.
√ A child yelling in class intermittently, shouting expletives.
√ ADHD “Attention Deficit Hyperactivity Disorder) frequently co-occurs in
children with Tourette Syndrome → inattentiveness at class.
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♠ Do you remember restless-leg syndrome the
CNS chapter?
♠ A person feels as if there are insects crawling over his lower limbs, and
when moving his legs, he gets a relief.
= (Willis-Ekbom Syndrome)
√ Try to link “insects”, “parasites” in both Ekbom and Willis-Ekbom; however,
they are different.
√ Remember, in Restless-leg syndrome (Willis-Ekbom Syndrome):
→ Check iron (ferritin)
♦ If low → Give iron supplements (even if Hb is normal, what matters is ferritin)
♦ If ferritin is normal → Give Dopamine agonist
Do not worry for now, these and more psychiatric conditions will be mentioned
and explained in more details and examples in the Psychia
Tics → Tourette
◙ Asperger Syndrome → Affects Social interactions + behavioural problem.
◙ Cotard’s syndrome → delusion of being already dead! (I’m dead)!
◙ Rett’s syndrome → Normal development until 2-3 YO. After that, a
Regression in motor, social, language, coordination skills occurs.
◙ Ekbom’s Syndrome → Delusion of Parasite infestation. (I am infested by
parasites).
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70
Kawasaki Disease → Febrile systemic vasculitis in children < 5 YO.
◙ No specific diagnostic Test
◙ Diagnosed clinically by:
√ High-grade fever (≥39 C) which lasts for > 5 days
Fever is characteristically resistant to antipyretics
(+) at least 4 of the following.
√ Bilateral, non-exudative Conjunctival injection (conjunctivitis)
√ Bright red, cracked lips
√ Strawberry red tongue
√ Painless Cervical lymphadenopathy
√ Red palms of the hands and the soles of the feet which later peel -desquamation-
√ Polymorphous Rash
Mnemonic → CRASH BURN.
-Conjunctivitis
– Rash
– Adenopathy
– Strawberry tongue
–Hand foot erythema
– Burning High Fever
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• It is important, for your general medical knowledge, to know that the use of
Aspirin should normally be avoided in children due to the risk of Reye’s
syndrome (Encephalitis + Liver damage).
• Kawasaki disease is one of the few indications for the use of aspirin in
children (to prevent Coronary Artery Aneurysm).
◙ Complications → Coronary Artery Aneurysm √ important “asked”
◙ Management → aimed at preventing aneurysm.
♦ High-dose aspirin. (Low dose aspirin is given after settling of fever).
♦ IV immunoglobulin. (If given early → ↓ risk of coronary artery aneurysm).
♦ Echocardiogram (rather than angiography) is used as the initial screening
test for coronary artery aneurysms
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Scarlet Fever
◙ The commonest organism → Group A Streptococcus Pyogenes. √
√ Sore throat ◙ Features:
√ Fever: typically lasts 24 to 48 hours
(a clincher to differentiate it from Kawasaki disease).
√ Rash – fine punctate erythema (‘pinhead’) = (Sandpaper-like rash). Rash
starts on trunk 12-48 hours after fever (not on palms or soles) and spreads to
body.
√ Others:
• Strawberry tongue.
• Cervical LNs.
• Tonsils may be covered with pale exudates with red macules (Forchheimer
spots)
Scarlet Fever
◙ The commonest organism → Group A Streptococcus Pyogenes. √
√ Sore throat ◙ Features:
√ Fever: typically lasts 24 to 48 hours
(a clincher to differentiate it from Kawasaki disease).
√ Rash – fine punctate erythema (‘pinhead’) = (Sandpaper-like rash).
Rash
starts on trunk 12-48 hours after fever (not on palms or soles) and spreads to
body.
√ Others:
• Strawberry tongue.
• Cervical LNs.
• Tonsils may be covered with pale exudates with red macules (Forchheimer
spots)
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Scarlet fever mng
◙ Management
√ Oral penicillin V for 10 days.
azithromycin.
√ If penicillin allergy → √ children can return to school 24 hours after commencing antibiotics.
√ scarlet fever is a notifiable disease.
◙ Some complications:
♦ Otitis media: the most common complication
♦ Rheumatic fever: typically occurs 20 days after infection
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Kawasaki vs scarlet fever
♦) Kawasaki disease is not an infection; it is Vasculitis. Hence, we treat it
using high dose aspirin and IV immunoglobulins for the fear of aneurysms.
(♦) Scarlet fever is bacterial infection (Strept. Pyogenes). Thus, we treat it
with oral penicillin V (or Azithromycin if there is penicillin allergy).
(♣) Kawasaki disease → Fever that does not respond to antipyretics and
lasts for 5 days or more + 4 of:
Conjunctivitis
+ Painless Cervical LNs +
Strawberry Tongue/ Red Cracked lips + Red palms and soles with a later
desquamation
+ Polymorphous Rash
(♣) Scarlet fever →
Fever + (SORE THROAT) ± [Sandpaper Rash,
No redness of palms or soles,
Painful Cervical LNs,
Tonsils covered with Pale
exudates]
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Do not forget the diagnostic modality of the following:
◙ Malrotation and Volvulus → Abdominal X-ray (Double bubble), Barium
enema
◙ Pyloric Stenosis → Abdominal Ultrasound “Important √ P-US”
◙ Intussusception → Abdominal Ultrasound → Target sign
Do not forget the diagnostic modality of the following:
◙ Malrotation and Volvulus → Abdominal X-ray (Double bubble), Barium
enema
◙ Pyloric Stenosis → Abdominal Ultrasound “Important √ P-US”
◙ Intussusception → Abdominal Ultrasound → Target sign
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If you remember from the infectious disease chapter, we would give Varicella
Zoster Immunoglobulin (VZIG) to an infant with a peri-partum exposure to a
varicella patient.
Important Elaboration
The meaning of (peri-partum exposure) is either 7 days before or 7 days after
the delivery.
Within this specified period, if a newborn comes in contact with
varicella patients (e.g., his mother), we should administer VZIG + isolation.
Important, what if the exposure was 8 days or more after delivery?
→ Observation + Advise the mother to continue caring for her baby.
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78
Chicken Pox → Varicella Zoster Virus.
♦ Very contagious (Mainly → via Respiratory “Airborne” route) (√)
However, Varicella zoster virus can also be transmitted via direct contact
with the vesicles.
Once the vesicles are dried and crusted → no transmission.
♦ Infectivity: 1-2 days Before the rash appears, until 5 days After the rash
first appeared (becomes non-infective when the rash dries and crusts).
♦ Presentation:
√ Fever (38-39 C).
√ Pruritic “itchy” Rash: macules → papules → vesicles → and then dry crusts,
starting on the face and spreading mainly on chest and back.
Q) When can a child with chicken pox return to a school?
A) After the rash and vesicles are dried and crusted (Usually around 5 days
after the onset of the rash).
◙ Management “Important” √
• Generally, in a healthy child < 12 YO → Reassurance + Supportive measures
(such as paracetamol for fever and sedating antihistamines and calamine
lotion for itching [Self-Limiting Disease]).
HOWEVER
• If superimposed infection is suspected (e.g. discharging pustules, redness
around the vesicles, pinkish fluid secreted from the lesions with High Fever)
→ Give Oral Antibiotics.
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80
VZIG is mainly reserved for neonates exposed within 7 days before or after
delivery, or when antivirals are contraindicated (e.g., due to absorption issues
or renal toxicity).
2. Aciclovir:
▪ Oral Aciclovir is the preferred treatment for pregnant women and
immunocompromised individuals exposed to chickenpox or shingles,
administered 7–14 days after exposure. Also, for those who develop
chickenpox.
▪ IV Aciclovir may be used in severe cases or when complications, such as
pneumonia, arise. In milder cases, oral Aciclovir is started within 24 hours of
rash onset to reduce severity.
√ This reflects the most recent updates, with Aciclovir replacing VZIG in many
cases and the use of oral or IV forms depending on the severity of the case. But
most cases receive aciclovir orally unless severe or complicated.
√ Remember that in children, non-complicated chickenpox
→ Reassure + Supportive treatment (self-limiting).
Updated UK Guidelines for Varicella-Zoster Immunoglobulin (VZIG)
and Aciclovir Use in Adults
1. Varicella-Zoster Immunoglobulin (VZIG):
▪ VZIG is no longer the first-line prophylaxis for pregnant women exposed to
chickenpox. Instead, oral Aciclovir is recommended for non-immune
pregnant women (VZV IgG negative) following exposur
81
◙ Seizure + Fever → Febrile seizure.
♦ (Commonly in children from 6 months to 6 years old)
♦ (Often with FHx of febrile convulsions)
♦ (Typical generalised tonic-clonic seizures)
♦ (Careful! Investigate for meningitis as a source of this fever)
◙ Management of Febrile Seizure:
√ If a febrile seizure lasts < 5 min → Antipyretics (e.g., Paracetamol).
√ If lasts > 5 min → Benzodiazepine (eg, Diazepam, buccal Midazolam).
(If IV line is inserted → IV lorazepam).
Note: If the question asks about a medication that would ((STOP)) the current
ongoing seizure, the answer is a benzodiazepine (eg, diazepam, lorazepam).
◙ Important:
√ 1/3 of cases with a Febrile convulsion → will have further episodes of febrile
convulsion (if they develop fever before the age of 6 years).
√ 1/3 of the cases who had Further episodes of Febrile seizure
→ will develop Epilepsy.
√ (≈ 10% of all complex febrile convulsion cases would develop epilepsy).
82
Points on hearing loss in paediatrics
√ Serous Otitis Media (=Glu ear) (=OM with effusion)
→ Conductive Hearing Loss.
√ Aminoglycosides (e.g. Gentamicin) ototoxicity
→ Sensorineural Hearing Loss (SNHL).
√ Congenital infections (e.g., Congenital Cytomegalovirus CMV)
→ Sensorineural Hearing Loss (SNHL).
83
Remember, the following points are “concerning” delayed milestones that
exceed the permit limit and thus we need to make a further step for the
management such as assessment of mile stones/ refer.
♦ Cannot sit unsupported at 12 months or more.
♦ Cannot walk at 18 months or more.
♦ No speech at all at 18 months or more (refer for hearing assessment ).
(Important, at any time, if there is a parental concern about hearing loss
→ refer for hearing assessment (Audiology test) even if before 18 months
old “e.g. 15 months old baby cannot say a single word including “dada”
“mama”). Remember that (Serous – Otitis media with effusion is common in
this age and it causes Conductive HL)
♦ Cannot run at 2.5 years (30 months) or more.
♦ Cannot Smile at 8 weeks or more.
♦ Cannot make eye contact at 3 months or more.
♦ Cannot hold objects placed in hand at 5 months or more.
♦ Cannot reach for objects at 6 months or more.
♦ Cannot transfer objects from a hand to another at 9 months or more.
84
85
86
87
Tricyclic Antidepressant Overdose (e.g. Amitriptyline)
potentially life-threatening
Dilated pupils – Dry mouth – Dry flushed skin – Drowsiness – Hypotension –
Urine retention – Severe Sedation – Tachycardia – Widened QRS
• ECG monitori–– is essential: Widened QRS, PR, QT and Broad
complex tachycardia.
◙ 2 popular Scenarios in the exam (Important √)
1) A child taking his grandparent’s medication and presented drowsy
lethargic and tachycardic ± with myoclonic twitches
2) An elderly with terminal illness and wants to end his life, presented
with dry skin and mouth, and dilated pupils.
◙ The most important immediate action → ECG Monitoring
◙ As the patient is in severe metabolic Acidosis
→ give an IV bolus of 250 ml Normal Saline (0.9%)
(+) Sodium Bicarbonate (50 mmol IV slowly of 8.4%).
♠ N.B. aim for pH of 7.5-7.55!
♠ Sodium bicarbonate will correct ECG changes and cardiac rhythm.
♠ Do not forget that in a patient with amitriptyline (TCA) overdose, if he is
acidotic, 2 steps to be done:
1) ECG monitoring.
2) IV fluids including Sodium Bicarbonate (HCO3)
88
ey
40
A prompt investigation is required in the following red flag
delayed developmental milestones:
• No smile by 8 weeks of age.
→ Delayed Social Development.
• No eye contact by 3 months of age.
→ Delayed Social Development.
• No holding objects placed in hand by 5 months of age.
→ Delayed Fine Motor Development.
• No reaching for objects by 6 months of age.
→ Delayed Fine Motor Development.
• No transferring objects between hands by 9 months of age.
→ Delayed Fine Motor Development.
• Cannot sit unsupported by 12 months. (but if he cannot stand unsupported
by 12 months, it is normal).
→ Delayed Gross Motor Development.
• Cannot walk by 18 months.
→ Delayed Gross Motor Development.
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• No single meaningful word by 18 months.
→ Delayed Verbal “Language” Development.
• Only says dada and mama on 24 months.
→ Delayed Verbal “Language” Development.
• No sentences composed of 2-3 words by 30 months (2.5 years).
→ Delayed Verbal “Language” Development.
• Cannot run by 30 months (2.5 years)
→ Delayed Gross Motor Development.
√ If parents are concerned about speech → refer for hearing test.
◙ Otherwise → Normal Development/ Reassure
90
Sudden Infant Death Syndrome (SIDS)
Sudden infant death syndrome is the commonest cause of death in the first
year of life. It is most common at 3 months of age.
Advice to Reduce the Risk of Sudden Infant Death Syndrome.
(Advice to reduce the risk of Cot Death).
Cot = a camp baby bed, particularly a portable, collapsible one.
• Avoid prone sleeping (baby should sleep on his back, not his front or side).
• Avoid parental smoking near infants.
• Avoid parental sedative medications or alcohol at the time a baby sleeps.
• Avoid duvet (soft bedding) or pillows; only use blankets or sheets.
• Blankets should not be higher than the infants’ shoulders.
• Do not heavily wrap a baby (avoid overheating).
• Avoid head covering.
• Place a baby on his back with his feet at the foot of the cot to sleep.
• Avoid sleeping with a baby on sofa or bed (avoid bed sharing).
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A child with severe asthma after receiving O2, Salbutamol…etc, if the child
develops tachypnea, SOP, Drowsiness
Request →
Arterial blood gas.
(to look for respiratory acidosis and manage accordingly)
A child with severe asthma after receiving O2, Salbutamol…etc, if the child
develops tachypnea, SOP, Drowsiness
Request
→ Arterial blood gas.
(to look for respiratory acidosis and manage accordingly)
92
Bronchiolitis
◙ The commonest organism → Respiratory syncytial virus (RSV).
◙ Bronchiolitis is the most common cause of a serious lower respiratory tract
infection in < 1 YO (90% are 1-9 months, with a peak incidence of 3-6 months).
◙ Maternal IgG provides protection to newborns against RSV
◙ Higher incidence in winter
◙ Features
√ Coryzal symptoms (including mild fever) precede:
√ Dry cough.
√ Increasing breathlessness.
√ Wheezing, fine inspiratory crackles (not always present).
√ Nasal flares.
√ Feeding difficulties associated with increasing dyspnoea are often the
reason for hospital admission.
◙ Management is largely → supportive
including humidified oxygen if low O2 saturation.
• If severe manifestations → admit for supportive Rx and observation
♠ Suspect bronchiolitis in infants < 1 YO (especially 3-9 months old) and
even young children (first 2 years of life) who have NO Hx of Asthma, and
present with cough, coryza, fever, SOB, WHEEZES and more importantly
difficulty feeding and breathing.
♠ Always bear in mind that Bronchiolitis is very common in infants and
young children. Supportive management is only required; No antibiotics!
Sometimes if it is a mild bronchiolitis, pick Reassure, No Rx required!
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After she has recently started taking horse-riding lessons, 8-
year-old girl presents with her mother complaining of the
presence of bright-red spots on her underpants.
The likely Dx → Perforated hymen.
The next step → Examine her genitalia in clinic.
Q) When should we examine her genitalia under general anaesthesia?
→ If the child refuses to be examined while the examination is critical such as
in a suspected case of bleeding, severe trauma, foreign body.
• So, we shall initially give an attempt for a normal examination at clinic.
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A lymph node that is increasing in size and ≥ 2 cm should be a worry even if
with no other suspicious features (e.g. fever, weight loss).
Thus, the step number 1 (initial step) to take is to request
→ Full Blood Count and blood film to look for any abnormalities that might
suggest leukemia, lymphoma such as low Hb, low WBCs and low platelets in
acute lymphoblastic leukemia.
The next step after FBC would be Ultrasound.
Some causes of enlarged LNs in children
√ Haematological malignancies → e.g. ALL, lymphoma.
√ CMV
√ EBV
√ Kawasaki disease
√ TB
95
Remember,
√ If a febrile seizure lasts < 5 min
→ Antipyretics (eg, Paracetamol + Observation)
√ If lasts > 5 min → Benzodiazepine (e.g., Diazepam, lorazepam, Midazolam).
Note: If the question asks about a medication that would ((STOP)) the current
ongoing seizure, the answer is a benzodiazepine (eg, diazepam, lorazepam).
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First 24 hours jaundice
♦ Jaundice in the first 24 hrs is always pathological
◙ Causes of jaundice in the first 24 hrs
√ Rhesus haemolytic disease (Rh incompatibility)
√ ABO haemolytic disease (ABO incompatibility)
√ Hereditary spherocytosis
√ Glucose-6-phosphodehydrogenase (G6PD) deficiency.
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◙ Jaundice in the neonate from the 2-14 days is common (up to 40%) and
usually physiological. It is more commonly seen in breast fed babies
Jaundice in the neonate from the 2-14 days is common (up to 40%) and
usually physiological. It is more commonly seen in breast fed babies
♦ If there are still signs of jaundice after 14 days of delivery, a prolonged
jaundice screen is performed, including
:
√ Conjugated and unconjugated bilirubin: the most important test as a raised
conjugated bilirubin could indicate Biliary atresia which requires urgent
surgical intervention
√ Direct antiglobulin test (Coombs’ test)
√ TFTs (Thyroid function tests) → e.g. Congenital hypothyroidism
√ FBC and blood film/ urine for Microscopy, C&S and reducing sugars/ U&Es
and LFTs
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Causes of prolonged jaundice (that persists for weeks “> 14 days”)
√ Biliary atresia
√ Congenital Hypothyroidism → “Obstructive Jaundice” → ↑ Conjugated “Direct” Bilirubin
→ Pale stool, Dark urine, hepatomegaly, FTT (Failure to Thrive).
Congenital hypothyroidism
→ Jaundice, Constipation, dry skin, FTT (Failure
to Thrive), Protruded tongue, flat nose, widely set eyes
√ Breast milk jaundice
√ Galactosaemia
√ Urinary tract infection
√ Congenital infections →
Vomiting, Diarrhea, Jaundice, FTT.
(UTI)
e.g., CMV, toxoplasmosis
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Example 1)
An infant with: prolonged neonatal jaundice (or family history of prolonged
neonatal jaundice),
Constipation, dry skin, FTT (Failure to Thrive),
Protruded
tongue, flat nose, widely set eyes
→ Congenital Hypothyroidism
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Example 1)
An infant with: prolonged neonatal jaundice (or family history of prolonged
neonatal jaundice),
Constipation, dry skin, FTT (Failure to Thrive),
Protruded
tongue, flat nose, widely set eyes
→ Congenital Hypothyroidism
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Example 2)
4-week-old baby having jaundice since few days after birth. She is healthy
and fully breastfed.
Her stool is creamy and yellow in colour. What is the
likely cause of jaundice among the following options?
◙ The jaundice that appears after the first 24 hours of life and persists for > 2
weeks is called (Prolonged Jaundice).
◙ The jaundice in this stem appeared a few days after birth and persisted for
around 4 weeks now. So, it is a case of “Prolonged jaundice”.
◙ Among the given options, both B and C are causes of prolonged Jaundice.
◙ Regarding B (Biliary atresia), there has to be a picture of obstructive
jaundice (ie, Pale stools, Dark urine) which is not the case here.
◙ So, the likely answer is C (Breast milk Jaundice).
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Example 3)
A 5-week-old infant is brought to the GP by their parents due to concerns
about prolonged jaundice.
The baby was born at term via an uncomplicated
vaginal delivery and has been thriving, with no issues related to feeding. The
infant is fully breastfed.
The parents have noticed that the baby's skin and the
whites of the eyes have remained yellow for the past few weeks. The baby’s
stools are described as normal in colour. On examination, the infant is alert,
active, and has appropriate weight gain for age.
There is no hepatomegaly or
other significant findings on physical examination. What is the most
appropriate next step?
Answer → B) Measure serum bilirubin levels and liver function tests.
For this 5-week-old infant presenting with prolonged jaundice,
it is vital to
perform tests to measure serum bilirubin (both conjugated and unconjugated)
and liver function tests (LFTs) to determine the cause of jaundice.
Although the lack of pale stools makes biliary atresia less likely, it should still
be considered.
Initiating with these tests helps refine the diagnosis and
identify the next steps.
Evaluation Steps
Serum Bilirubin Levels:
• Total Bilirubin: Measures the combined levels of unconjugated (indirect)
and conjugated (direct) bilirubin.
• Direct (Conjugated) Bilirubin: High levels suggest issues with the liver or
bile ducts, such as biliary atresia or neonatal hepatitis (due to intrahepatic
cholestasis).
• Indirect (Unconjugated) Bilirubin: Elevated in conditions like physiological
jaundice and breastfeeding jaundice.
Liver Function Tests:
• Alanine Aminotransferase (ALT) and Aspartate Aminotransferase (AST):
Raised levels indicate liver cell injury.
• Alkaline Phosphatase (ALP): High levels are often associated with
cholestatic liver diseases.
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In a child with (positive leucocyte esterase and/or nitrates on urinalysis)
→ Send urine sample for culture and sensitivity.
→ Commence prophylactic antibiotics while waiting the results.
If still feverish after 2 days of antibiotics?
→ URGENT Ultrasound
Or
to look for any bladder, ureters
anatomical problems or Vesicoureteral reflux (VUR).
So, if “urgent” Ultrasound is not in the options, pick → MCUG
→ Micturating Cystourethrogram (MCUG)
What if the child responds well to Antibiotics?
Ultrasound (within 6 weeks)
Be careful!
◙ In children with UTI who have been given Antibiotics (Abx)
√ If no response to Abx within 2 days → URGENT US (not within 6 weeks!) or
MCUG
If There is response to Antibiotics within 2 days → US (fine within 6 weeks)
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Murmurs in pd
Murmurs in Paediatrics:
◙ Preterm + continuous “machinery” murmur
→ PDA
◙ Cyanotic baby with ejection systolic murmur
→ TOF (Tetralogy of Fallot) “the ejection systolic murmur here is due to
pulmonary stenosis which is a feature of the 4 main criteria of TOF”.
Remember, TOF is one of the main causes of “cyanotic” congenital heart
disease.
◙ Progressive (Severe) Cyanosis + Poor feeding + Holosystolic (pansystolic)
murmur along the left sternal border → Tricuspid Atresia.
◙ Acyanotic, Pan-systolic murmur → VSD (Others: Poor feeding and poorly
gaining weight)
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Patent Ductus Arteriosus (PDA)
Overview
• A form of congenital heart defect
• Usually closes in 48 hours after birth in (Term) babies but remains open
in (Preterm) babies.
•
‘Acyanotic’
. (√)
• Connectio‘‘between ’’e pulmonary artery and descending aorta
• more common in premature (Preterm) babies. (√)
• May close spontaneously
Features
• left subclavicular thrill (sometimes rough systolic murmur along the left
sternal border)
• Continuous ‘machinery’ murmur (√) “best heard beneath the left clavicle”
• large volume, bounding, collapsing pulse
• wide pulse pressure
Diagnosis → Echo
Management
• Indomethacin (a NSAID) (ind=end=closes the duct) (inhibits
prostaglandin synthesis) → closes the connection in the majority of
cases. (√)
• If associated with another congenital heart defect amenable to surgery
then prostaglandin E1 is useful to keep the duct open until after surgical
repair.
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Diagnosis → Echo
Management
• Indomethacin (a NSAID) (ind=end=closes the duct) (inhibits
prostaglandin synthesis) → closes the connection in the majority of
cases. (√)
• If associated with another congenital heart defect amenable to surgery
then prostaglandin E1 is useful to keep the duct open until after surgical
repair.
PDA
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Hearing Tests in Children
The answer would always be → Arrange or refer for hearing assessment
(Audiology Test) in any of the following conditions:
• Any parental concern about hearing loss at any time (Despite
previously normal hearing tests).
• Professional (Doctor’s) Concern.
• Temporal bone fracture.
• Bacterial Meningitis.
• Severe Unconjugated Hyperbilirubinemia.
Delayed speech and language milestones.
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Delayed speech and language milestones.
Key
51 Careful not to mix things up!
◙ In cases of Croup
(Barking cough,
Stridor, Coryza,
Steeple sign…)
→ Oral Dexamethasone.
◙ If severe Croup → O2 + Nebulised adrenaline.
◙ Bronchiolitis (Wheezes, SOB, Cough, Coryza, Poor feeding, Fever…)
(including humified O2, NGT feeding if a child not
tolerating orally, Suction of excessive secretions) EVEN IF SEVERE.
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√ Note that (measles) and (Rubella) tend not to appear in children who are
Fully Immunised.
♦ Rx in these cases
→ Supportive (paracetamol/ ibuprofen) + Reassurance
IMPORTANT DDx
◙ Fever + irritable unwell child + red-brown blotchy rash “often itchy” on face
then spreads to body ± White centre spots on the oral cavity (Koplik spots)
→ Measles.
◙ Fever + cough, rhinorrhea (coryza) + conjunctivitis, “Koplik spots are not
always mentioned)
“Remember, scarlet fever always has sore throat”.
→ Measles.
◙ Mild Fever, Rash on the face initially eg, behind ear then spreads to body +
Lymphadenopathy (swollen LNs) + Red petechiae in mouth
→ Rubella.
◙ A sudden HIGH fever (>39) in a child followed by Rash on Chest/Trunk,
body, legs (BUT NOT ON HEAD and NECK)
(Roseola infantum)
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√ Note that (measles) and (Rubella) tend not to appear in children who are
Fully Immunised.
♦ Rx in these cases
→ Supportive (paracetamol/ ibuprofen) + Reassurance
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Remember,
Children > 2 YO who have Night bedwetting (+) Daytime symptoms
→ Refer to 2ry care or an enuresis clinic
Remember,
Children > 2 YO who have Night bedwetting (+) Daytime symptoms
→ Refer to 2ry care or an enuresis clinic
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(♦) Kawasaki disease is not an infection; it is Vasculitis. Hence, we treat it
using high dose aspirin and IV immunoglobulins for fear of aneurysms.
(♦) Scarlet fever is bacterial infection (Strept. Pyogenes). Thus, we treat it
with penicillin V (or Azithromycin if there is penicillin allergy).
(♣) Kawasaki disease → Fever that does not respond to antipyretics and
lasts for 5 days or more + 4 of: Conjunctivitis + Painless Cervical LNs +
Strawberry Tongue/ Red Cracked lips + Red palms and soles with a later
desquamation in kawasaki
(♣) Scarlet fever → Fever + (SORE THROAT) ± [Sandpaper Rash, No redness
of palms or soles, Painful Cervical LNs, Tonsils covered with exudates].
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Acute Lymphoblastic Leukemia (ALL)
• Children.
√ Low Hb → Anemia → Fatigue, Pallor…etc.
√ Low WBCs → Recurrent Infections.
√ Lowe Platelets → Thrombocytopenia → Bleeding, Bruises
• Bone Marrow Aspiration/Biopsy → • Pancytopenia
Numerous Blasts.
♦ In the exam, pancytopenia is either ALL or Aplastic Anemia. BM biopsy
can differentiate.
√ In the exam, all leukemia that occurs in children is ALL.
You will find the other types of leukemia in the hematology chapter.
Remember these clinchers:
Important Leukemia Clinchers: (The Age is Very Important)
ALL Child (Up to 15 YO), Pancytopenia, Blast cells.
AML Adult (20-30 YO), Auer rods, Blast cells.
CML Middle age (40-50 YO), Massive Splenomegaly, Philadelphia
chromosome, Granulocytes (Neutrophils, basophils, eosinophils)
without blast cell, in all stages of maturation (i.e. myelocytes,
metamyelocytes…)
CLL Old (> 60 YO), usually no splenomegaly, smudge cells, Cervical LNs,
Mature Lymphocytes.
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Remember, a child or infant with Prolonged/ Worsening Respiratory
symptoms (e.g. cough/ SOB) + Malabsorption (e.g. Abdominal distention/
Steatorrhea) ± Delayed development (e.g. Low weight for age)
→ Consider Cystic Fibrosis.
→ Sweat test
→ The reason → High viscosity of mucus secretions
Cystic fibrosis is an autosomal recessive disease (like thalassemia, SCA and
congenital adrenal hyperplasia “21-hydroxylase deficiency”).
This means that
If Both Parents are Carriers →
• 25% chance of a child to be affected.
25% chance of a child to be Healthy.
• 50% chance of a child to be a Carrier.
Newborn → From delivery – up to 28 days of age.
Infant → 1 month – 1 Year of age.
Toddler → 1-3 YO.
Pre-school → 3-5 YO.
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Weight at birth can be classified into three categories,
• Normal (birth weight ≥2.5 kg to < 4.0 kg),
• Low birth weight (birth weight < 2.5 kg)
• (Macrosomia) (birth weight ≥ 4.0 kg)
Please, note that corticosteroids are used after renal transplant for
immunosuppression “to prevent rejection”.
• Long-term use of steroids can lead to Cushing Syndrome (high cortisol).
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