Paeds Mx Flashcards
Indicates a life-threatening asthma attack
SpO2 <92% Silent chest Poor respiratory effort Altered consciousness Cyanosis PEFR <33%
Asthma Advice
Advise influenza immunisation every autumn
Inhaler technique
Record peak flow readings
Peak flow reading technique
- Put the marker to zero.
- Take a deep breath.
- Seal your lips around the mouthpiece.
- Blow as hard and as fast as you can into the device.
- Note the reading.
- Repeat three times.
Asthma questions
Exercise tolerance? Sports? Hospitalised before? Worse at Night? Controlled by inhalers? School absence? Parents smoke?
DKA Ix
Examination - reduced skin turgor, dry membranes, sunken eyes
Blood glucose
Urine dip
Venous blood gas
ECG
Mx of severe DKA
Assess level of dehydration
20ml/kg bolus of 0.9% Saline
0.05 - 0.1 U/kg per hr Insulin
5% Dextrose once glucose <14mmol/L
20mmol KCL
Mannitol if signs of cerebral oedeme
Simple vs Complex Febrile Convulsion
Simple <15 mins Don’t Recur Tonic Clonic < 1 year old
Complex > 15 mins Recur within 24hrs/same illness Partial/Focal Incomplete recovery at 1 hr
Seizure questions?
Warning?
Upset/breathholding?
How long? Limb jerking? Loss of consciousness? Stiff or floppy? Tongue biting? Incontinence? Change in colour? Trauma?
How long to wake up?
Fast or slow recovery?
When would EEG be recommended in seizures
Recurrent and focal
Epilepsy Mx
Carbamazepine (partial) Sodium Valproate (generalised)
Head control?
4 months
Autism screening questions?
Does your child have problems interacting with other children/people?
Does he make eye contact?
Do you find he is overly obsessed
with a certain hobby/toy?
Hypothyroid signs in children?
Floppy
Umbilical Hernia
Heel prick test results
Abx Tx in meningococcal septicaemia
< 3 months: IV amoxicillin + IV cefotaxime
> 3 months: IV cefotaxime
if > 1 month and Haemophilus influenzae then give dexamethasone
Abx prophylaxis for contacts of meningococcal septicaemia
Rifampicin
Meningitis complications?
Hearing loss (most common) Learning problems Epilepsy Kidney problems Joint/bone problems
MMR side effects
Fever 1 in 10
Febrile convulsion 1 in 1000
WHO have categorically stated there is no risk of autism
The doctor who published the paper Dr Andrew Wakefield has subsequently, been struck off the medical register. Dr Wakefield had shares in a pharmaceutical company that was trying to market an alternative MMR vaccine
Signs of NAI
Retinal haemorrhages Poor dentition (neglect) Torn frenulum Bruising Spiral fracture
Development questions to ask?
Gross: Sit unsupported, walk
Vision + Fine Motor; Pincer Grip (12 months), transfer between hands (9 months)
Hearing + Speech: No. of words, hearing concerns
Social + Behaviour: Smile (10 weeks), Spoon (18 months)
Status epilepticus Mx
Call Paediatric SpR Secure airway Apply facial oxygen and sat monitor Check glucose and give IV 10% glucose 3-5ml/kg if hypoglycaemic Antipyretic if fever
- Lorazepam IV 0.1mg/kg IV, to maximum 4g
If no response or seizure recurs within 10 minutes then:
2. Lorazepam IV 0.1mg/kg
If no response or seizure recurs within 10 minutes then:
3. Phenytoin 18mg/kg infusion over 20 minutes under ECG monitoring IV or if no access via IO
CALL ANAESTHETISTS
If no response or seizure recurs within 10 minutes then:
4. Rapid sequence induction using Thiopentone, intubation and ventilation, and transfer to PICU
Epilepsy counselling
Outlook a lot better than many people realise
About 5 in 10 people with epilepsy will have no seizures at all over a five-year period.
About 3 in 10 people with epilepsy will have some seizures in this five-year period but far fewer than if they had not taken medication
In total, with medication, about 8 in 10 people with epilepsy are well controlled with either no, or few, seizures.
% of children bedwetting
10% of 5 year olds.
5% of 10 year olds.
1% of 18 year olds.
Causes of bedwetting
Very deep sleep, insufficient ADH
Bedwetting Mx
1st
Rewards for agreed behaviour not for dry nights. Don’t drink before bed + go toilet
2nd
Offer bell and pad alarm <7 year olds.
3rd (or short term)
Desmopressin
4th
Refer to Paeds Specialist - Imipramine or Oxybutinin
MMR Vaccine age
1 y/o
3 years + 4 months (40 months)
Vaccines at 3 months
6-in-1
Rotavirus
PCV (pneumococcal)
Vaccines at 1 year
MMR HiB Men B Men C PCV (pneumococcal)
Fluid resuscitation targets?
Bolus – 0.9% NaCl stat
• 20ml/kg under 10 mins – children
• 10ml/kg under 10 mins – neonates
ORS target?
75ml/kg over 4 hours
DKA fluid resuscitation
1) Bolus: 10ml/kg over 30 mins and subtract from total fluid deficit.
If shocked, bolus 20ml/kg and do not subtract.
2) Deficit: % deficit x weight x 10
Mild, Moderate, Severe DKA?
Mild pH < 7.3 (<5% deficit)
Moderate < 7.2 (5-10% deficit)
Severe < 7.1 (>10 deficit)
Paediatric pulse to assess?
- Infant < 1y: brachial or femoral
* Child >1y: use carotid or femoral
Choking algorithm
Encourage cough
- If conscious: 5 back blows, 5 thrusts (chest if < 1 year, abdominal if > 1 year)
- If unconscious: open airway, 5 rescue breaths, start CPR
BLS if shockable rhythm
i. 1 shock (4 J/kg).
ii. Immediately resume CPR for 2 mins
iii. If still VT/pVF, give 2nd shock.
iv. Resume CPR for 2 mins.
v. If still VT/pVF, give 3rd shock.
vi. Resume CPR.
vii. Give adrenaline IV/IO 10mcg/kg (0.1ml/kg of 1 in 10,000 solution) and amiodarone 5mg/kg after 3rd shock, repeat adrenaline every 3-5 mins/alternate cycles
viii. give 2nd amiodarone dose after 5th shock.
ix. Continue until signs of life/organised electrical activity or switch to non-shockable rhythm algorithm if PEA/asystole.
BLS for non-shockable rhythm
i. Continue CPR rate 15:2, ventilate with high flow oxygen, continuous chest compressions if intubated.
ii. Reassess rhythm briefly every 2 mins.
iii. Give adrenaline IV/IO 10mcg/kg (0.1ml/kg of 1 in 10,000 solution) every 3-5 mins
Current febrile convulsion Mx
Monitor duration
Protect head from injury (remove harmful objects nearby)
Check airway
Place in recovery position
> 5 mins – call ambulance and give buccal midazolam or rectal diazepam
Repeat in 10 mins if 1st dose not stopped it
What indicates hospital assessment by paediatrician in febrile convulsion (5)
1st seizure <18 months old Complex signs Decreased GCS post seizure Recent Abx prescription
Febrile convulsion counselling?
> 5 mins call ambulance
If child develops a non-blanching rash or loses consciousness, becomes dehydrated, fever lasting longer 5 days, or if you have any concerns then please come back.
Paracetamol for temperature/pain
Regular fluids
Keep off school till recovered
Paediatric Sepsis 6
Give O2, Fluids, Abx
Take Blood culture
Involve senior clinicians early
Consider inotropic support
Sepsis Mx
Community: IM Benzylpenicillin
Admit to hospital
In hospital: Sepsis 6
Review hourly
Iv ceftriaxone
or IV Benzylpenicillin+gentamicin in neonates
Review within 48 hours of commencing
Diabetes education + support
Foods with a low glycaemic index
Attend clinic 4 times a year, measure height and weight
Medic Alert Bracelets
Diabetes Mx
- Offer multiple daily injection basal-bolus insulin regimen with rapid acting insulin to be injected before eating
Explain that patients may have a partial remission phase (honeymoon period) upon starting insulin.
- For young people using twice daily injection regimens, encourage them to adjust insulin according to the general trend in their pre-meal, bedtime and occasional night-time blood glucose.
- Advise young people to routinely perform at least 5 capillary blood glucose tests daily. Advise that more frequent testing is needed during intercurrent illness or exercise.
• Explain to young people that they should always have access to immediate fast-acting glucose and blood glucose monitoring equipment. Equip carers and nurses to give IM glucagon for emergencies.
Severe hypoglycaemia Mx
Community: Oral glucose solution if conscious
IM Glucagon
If in hospital give: 10% dextrose 5ml/kg
Initial fluid bolus in patients with DKA (2)
- For young people clinically dehydrated but not in shock: initial IV bolus 10ml/kg 0.9% NaCl over 30 mins. Discuss with senior before giving another bolus. Subtract the bolus volume from the total fluid deficit.
- For young people with signs of shock: initial IV bolus 20mol/kg 0.9% NaCl. Do not subtract this from total fluid deficit.
Mx of DKA
Fluid Bolus
Calculate fluid deficit
Calculate fluid maintenance
+40mmol/L KCL
IV insulin
< 14mmol/L - start 5% dextrose
Start SC insulin 30 mins before stopping IV insulin
Monitor GCS every 30 mins and medically review 4 hourly
Complications of DKA Tx? (3)
How are they managed?
Cerebral Oedema - give mannitol
Hypokalaemia - KCL
Increased risk of VTE
Diabetes diagnosis counselling points?
Not curable
Good blood sugar control important to prevent kidney/vision problems
Teach you to self-inject into tummy or thigh
Target 4-7 or <9 2 hours after a meal
Count carbohydrates in meals to calculate amount of insulin given
Might need more insulin when ill
Teach you to use finger prick device
Medic alert bracelet
Healthy diet: high in protein, low in fat
60 mins of exercise a day
Diabetes UK
See GP within 2 days of discharge
Safety net:
Drink a sugary energy drink if feeling very tired, dizzy, shaky, lips tingling or heart is pounding. (hypoglycaemia)
If you experience blurred vision, tummy pain or nausea and vomiting (hyperglycaemia) you should inject insulin according to your nurse’s advice.
Call 999 if your breathing is affected
Call 999 if insulin doesn’t help symptoms
When is EEG used in epilepsy diagnosis?
Performed only after the second seizure to determine type and epilepsy syndrome for prognostic reasons
Epilepsy Mx
Specialist initiates AED
Review every 3-12 months
Monitor AED blood levels
Can withdraw over a 3 month period if seizure free for 2 years
Drug Tx for most type of epileptic seizures
Lamotrigine (girls) Sodium Valproate (boys)
(if it’s not lamotrigine it is usually topiramate)
Status Epilepticus Mx
- Secure airway, give high-flow oxygen, assess cardiac and respiratory function.
- Secure IV access with large bore and check blood glucose.
- Give IV lorazepam 0.1mg/kg (IV diazepam or buccal midazolam if unable to secure IV access).
- After 10 mins, give a second dose of lorazepam. Alert senior to the possibility of refractory convulsive status epilepticus.
- After 10 mins, give IV phenytoin 20mg/kg over 20m. Measure blood levels of AEDs. Inform PICU and anaesthetist.
- Rapid induction sedation with IV thiopental 4mg/kg.
Counselling epilepsy
Try and record a future seizure
Do not restrain them. Protect their head from hitting anything
>5 mins - amublance
Avoid swimming, unsupervised bath
Asthma Ix
- Spirometry (FEV1/FVC<70% expected)
* Bronchodilator reversibility test (FEV1 improvement >12% after beta agonist)
Asthma <5 y/0 Mx?
- Offer SABA as reliever
- 8 week trial of ICS at paediatric moderate dose with symptoms >3 times a week
- Stop ICS after 8 weeks and monitor symptoms:
• If symptoms did not resolve: consider alternative diagnosis
• If symptoms resolved but recurred within 4w of stopping ICS: restart ICS at paediatric low dose
• If symptoms resolved but recurred beyond 4w of stopping ICS: repeat 8-week moderate dose ICS trial. - Consider adding LTRA to ICS maintenance therapy.
- Stop LTRA and refer to specialist.
Asthma Mx > 5 y/o
- Offer SABA as reliever therapy.
- Offer paediatric low dose ICS in children with symptoms that indicate need for maintenance therapy (symptoms >3 times per week).
- Consider adding LTRA to ICS maintenance therapy and review in 4-8w.
- Consider stopping LTRA and starting LABA.
- Consider changing ICS and LABA maintenance therapy to a MART regimen, with paediatric low dose ICS. Continue SABA.
- Consider increasing ICS to paediatric moderate dose.
- Refer to specialist. Omalizumab (IgE monoclonal antibody) may be used if > 6y/o
Acute Asthma Mx (not requiring admission)
Take up to 10 puffs of salbutamol every 10-20 minutes
Prescribe 3-7d course of oral prednisolone
Advice patient to use SABA as required up to 4 times daily on a 4 hourly basis
Monitor Peak Flow
Indications for admission with bronchiolitis?
RR > 60 Inadequate fluid/food intake (<50%) Central cyanosis Apnoea O2 < 92% Clinical dehydration
Bronchiolitis counselling
Plenty of fluid to avoid dehydration.
You can give paracetamol or ibuprofen to bring down their temperature but don’t mix the two and don’t give aspirin.
At home, you should wash you and your child’s hands frequently and wipe surfaces and toys.
Avoid smoking in the house and keep your child away from other children where possible.
Check on him throughout the night.
• Safety net: call 111 if your child takes less than half their usual amount in the last 3 feeds or has a dry nappy for 12hrs or if he has a persistent temperature of 38C or above or seems very irritable or drowsy.
Call 999 if your baby’s tongue or lips are blue or there are pauses in breathing or it seems like he is using a lot of energy to breathe
Croup Mx
Administer 0.15mg/kg dexamethasone PO
(IM dexamethasone if unable to swallow)
If mild advise parents that symptoms resolve within 48hrs
If severe and dexamethasone is ineffective, consider nebulised adrenaline solution 1/1000 with close monitoring.
Croup safety net
• Safety net: call 111 if your child takes less than half their usual amount in the last 3 feeds or has a dry nappy for 12hrs or if he has a persistent temperature of 38C or above or seems very irritable or drowsy.
Call 999 if your baby’s tongue or lips are blue, there is drooling or difficulty breathing or swallowing, if he is unusually quiet and still or suddenly gets a very high temperature
Whooping cough Mx
Admission if < 6 months and acutely unwell
Clarithromycin
Bed rest, stay off school till 48h Abx
Azithromycin prophylaxis for close contacts
Pneumonia Mx
7-14d amoxicillin
O2 if < 92%
Advise giving paracetamol or ibuprofen for fever
Recommend good hygeine + safety net
TB Mx
RI (6) PE (2)
Use a dosage regimen of at least 3x per week
TB treatment team will help you
Offer Mantoux and BCG vaccine to recent/close contacts
Cystic Fibrosis Mx
Provide weekly reviews <1m, monthly 1-12m, 8 weekly 1-5y, 12 weekly >5y, every 3m as adults
Encourage increased calorie intake with pancreatic enzyme replacement therapy and fat-soluble vitamins
Airway physiotherapy (clearance techniques)
Abx to Tx airway infections
Annual Flu vaccine
Meningitis Mx
IV ceftriaxone
Observe RR, HR, BP, GCS/AVPU, CRT and saturations hourly for 4-6hrs.
Give 0.15 mg/kg dexamethasone to a maximum dose of 10 mg, four times daily for 4 days to children over 3m if bacterial
Offer formal audiological assessment within 4w
Test for complement deficiency if recurrent
Encephalitis Mx
ABCDE
Intubation
Antiviral
Intensive inpatient rehabilitation therapy after hospital discharge with monitoring for development of seizure disorders
Parvovirus B19 counselling?
Should clear up in 3 weeks Plenty of fluids Antipyretics Moisturiser if itchy Safety net
Infectious for 7-10 days before the rash develops, so let anyone who is immunocompromised or pregnant to seek medical advice if they have had significant contact with your child
Impetigo Mx
Refer to dermatology 5 days (TDS) topical Fusidic Acid
Can use oral flucloxacillin if widespread instead of topicals
Measles Mx
Paracetamol
Plenty of fluids
Infectious till 4 days after the rash appears (keep off school)
Kawasaki Ix?
Temp
Hydration
Echocardiogram
Consider Sepsis Screen
Kawasaki Mx
Give PO high-dose aspirin 7.5-12.5mg/kg QDS for 2w or until afebrile, then 2-5mg/kg OD for 6-8w.
Aspirin may be continued depending on results from echocardiogram.
Give IVIG 2g/kg single dose
(Paracetamol for fevers)
Rheumatic fever Ix?
- Jones criteria
- FBC, U&E, LEFT, ESR/CRP
- Blood culture
- ECG
- CXR
- Throat culture and rapid antigen testing for GAS
- Anti-streptolysin O titre serology
Rheumatic fever Mx?
Give benzylpenicillin (450mg IM single dose <27kg, 900mg IM single dose >27kg)
If chorea puts the person at risk of injury, give carbamazepine or valproate
Following acute treatment, give benzylpenicillin 450-900mg IM monthly for 10 years or until the age of 21
Infective endocarditis Mx
Admit
Take 3 blood cultures
IV Abx
Continue Abx for up to 6 weeks
Complicated Otitis Media Mx
5-7d amoxicillin
(just anti-pyretics if uncomplicated)
Prevent recurrence by avoiding the use of dummies and flat positional feeding
Epiglottitis Mx
Secure airway
IV cefotaxime
Recommend immunisations
Scarlet fever Mx
Phenoxymethylpenicillin QDS 10d
School exclusion until 24 hours Abx
Tonsillitis Mx
CENTOR
Phenoxymethylpenicillin
School exclusion until 24 hours Abx
Refer to ENT fo tonsillectomy if:
>7 in a year
5 per year for 2 years
3 per year for 3 years
Urticaria or “hives” Mx
(Mild is self limiting)
Cetirizine
+prednisolone 7d OD if severe
Safety net: return if difficulty breathing or swallowing
If Sx improve, prescribe daily antihistamine for 3-6 months
Eczema Mx
mild
Assess severity
Mild:
Emollient with frequent and generous application
Hydrocortisone 1% until 48 hours after resolved
Avoid scratching + triggers
Give steroid first then wait 15-30 minutes to apply emollient
Mx of moderate eczema
Moderately potent steroid: betamethasone valerate 0.025%. Continue until 48hrs after flare resolved
Mild potency steroid for face and sensitive areas: hydrocortisone 1% (max 5 days)
Occlusive dressings or dry bandages considered
Consider cetirizine if severe itch, urticaria
Consider topical corticosteroids maintenance regimen if recurrent flares
Review every 3-6 months
Specialist may offer calcineurin inhibitors (tacrolimus)
Severe eczema Mx
Potent topical corticosteroid, betamethasone valerate 0.1% on inflamed areas.
Moderate potency steroid on face and flexures: betamethasone valerate 0.025%
Occlusive dressings or dry bandages considered
Consider cetirizine if severe itch, urticaria
Consider topical corticosteroids maintenance regimen if recurrent flares
Review every 3 months
Specialist may offer calcineurin inhibitors (tacrolimus)
Infected eczema Mx
Swab skin Oral antibiotics (flucloxacillin)
Topical antibiotics for localised infection – can be combined with steroid PRN for 2w.
Discard old emollients and steroids due to contamination, prescribe new.
Consider topical antiseptic preparation
Urgent 2w referral to dermatology if infected eczema fails to respond.
Eczema counselling points
Don’t itch/scratch
Keep fingernails short to avoid scratching
Apply creams to clean skin and use pump dispensers to ensure the cream isn’t infected.
Safety net: If the rash starts to blister and are filled with fluid or pus, become very painful and spread to other parts of the body then take your child to A&E immediately
Nappy rash Mx
Use high absorbency pads and changing the nappies frequently (at least every 3-4 hours)
Avoid skin irritants (baby wipes)
OTC barrier cream
Topical hydrocortisone 1% if needed
Imidazole cream if candida
Flucloxacillin if bacterial
Scabies Mx
Topical permethrin - apply to whole body, especially between fingers/toes
Wash off after 8-12 hours
2nd application after one week
Also treat close contacts
Cow’s milk protein allergy Mx
Maternal exclusion of cow’s milk protein from diet with vitamin D and calcium supplements.
(for 6 months, or at least 9 months old)
Dietician
Extensively hydrolyzed formula
Allergy UK
How to diagnose Cow’s milk protein allergy
Non-IgE = re-intrdouce cows milk in 4 weeks
IgE mediated skin prick/serum specific IgE (retest after 12 months)
Allergic rhinitis Mx
Nasal irrigation with saline spray
Avoid triggers for pollen
Review in 2-4 weeks
If persistent consider:
Intranasal decongestant
Intranasal antihistamine
Intranasal corticosteroid
CAH Ix
Serum 17-hydroxyprogesterone
FBC U&E, sodium, potassium, calcium
Rapid ACTH stimulation test
CAH Mx
Salt losing crisis: IV 0.9% NaCl, IV hydrocortisone 200mg, IV dextrose
- Prescribe lifelong hydrocortisone. Monitor adrenal androgens and 17-hydroxyprogesterone to inform dose titration.
- Consider fludrocortisone and salt supplementation where there is lack of aldosterone production
Females may require surgical correction for external genitalia at puberty
Cyanotic heart disease Ix
- Pulse oximetry
- Echocardiogram
- ECG
- CXR
- Hyper-oxygenation test (consider if TOF is likely)
Cyanotic heart disease Mx
Stabilise airway
Place umbilical venous or arterial catheter and give prostaglandin E1 0.05mcg/kg/min infusion.
Monitor for apnoea, jitteriness, seizures, flushing, vasodilation, hypotension
Start IV antibiotic prophylaxis with cefalexin or amoxicillin 50mg/kg orally or ampicillin 50mg/kg IV or IM.
Surgical repair
Tetralogy of Fallot Ix
Pulse oximetry ECG CXR Hyper-oxygenation test ECHO
Tetralogy of Fallot Mx?
Weight gain monitoring
Surgery before 1 y/o
Paediatric cardiologist follw up
Tet Spells Mx
- Calm the child and perform manoeuvres to increase the amount of blood exiting the right ventricle (knees to chest to increase venous return).
- Medical therapy
• Morphine
• Beta-blockers
• Phenylephrine
• Prostaglandins to maintain PDA patency
Neonatal jaundice Ix
Bilirubin levels FBC Blood film G6PD blood level LFTs Hydration level DAT
Consider: septic screen, urine dip
Mx of neonatal jaundice
Phototherapy
Exchange transfusion
Repeat serum bilirubin every 4-6hrs after initiating phototherapy and every 6–12 hours when the serum bilirubin level is stable or falling.
Stop phototherapy once serum bilirubin has fallen to a level at least 50 mmol/litre below the phototherapy threshold.
Check for rebound by repeat serum bilirubin measurement 12–18 hours after stopping phototherapy
If baby is clinically well, >24hrs old or >38w, bilirubin below phototherapy threshold but within 50mmol/L of threshold, then repeat bilirubin within 18hrs if there are risk factors, within 24hrs if no risk factors
Down Syndrome Ix (6)
Karyotype
ECHO AXR Hearing test TFTs FBC
Downs Mx
MDT approach
Maximise indepence: physiotherapy, occupational therapy, SALT
Education + Support
Regular follow up
Genetic counselling for future pregnancies
GORD Mx
if breastfed
- Consider 2w trial of alginate therapy.
- If symptoms improve, continue. Advise parents to stop treatment every 2w to see if symptoms have improved and if it is possible to stop treatment completely.
- If symptoms remain, consider prescribing 4w trial of PPI (omeprazole suspension, oral ranitidine no longer licensed).
- Refer to paediatric gastroenterologist and consider endoscopy.
GORD Mx if formula fed
- Review feeding history
- Reduce volume of feeds if excessive (150ml/kg/24hrs).
- Offer 2w trial of smaller, more frequent feeds while maintaining adequate volume.
- Offer 2w trial of pre-thickened formula (Enfamil, SMA Staydown for 6m max) or added thickener (Carobel).
- Stop the thickened formula and offer 2w trial of alginate therapy.
- If symptoms improve, continue. Advise parents to stop treatment every 2w to see if symptoms have improved and if it is possible to stop treatment completely.
- If symptoms remain, consider prescribing 4w trial of PPI
Intussusception Mx
ABCDE
Nil by mouth
Clindamycin + Gentamicin for 1 hour before Sx and 48 hours after
Contrast enema reduction
2nd line = pneumatic reduction
Laparoscopic surgical reduction if ^ unsuitable
Absolute contraindications to contrast enema in intussusception (4)
Peritonitis
Perforation
Toxic Colitis
Hypovolaemic Shock
Biliary Atresia Mx
Kasai hepatoportoenterostomy
Antibiotic prophylaxis with co-trimoxazole or neomycin for the first year of life to prevent cholangitis
Liver transplantation if HPE is unsuccessful or extensive liver damage at the time of diagnosis
Ulcerative Colitis Ix
- Faecal calprotectin
- Truelove and Witts’ severity index
- Paediatric Ulcerative Colitis Activity Index
Ulcerative Colitis Mx
Diet advice
1) Topical aminosalicylate for 4 weeks
+ oral aminosalicylate if ineffective
2) Offer short term topical steroid
+ Offer short-term oral steroid if ineffective
Ustekinumab
Monitor height/weight every 3-6 months before puberty, every 6 month during puberty and every 12 months after
Screened for bowel cancer 10 years post-diagnosis
Crohn’s Mx
Steroids or aminosalicylate
Add Azathioprine if 2+ yearly exacerbations
Azathioprine also used to maintain remission
Screened for bowel cancer 10 years post-diagnosis
Infliximab
Coeliac counselling
Gluten is found in 3 types of cereal- wheat, barley and rye. Foods containing these include pasta, cakes, most bread, certain sauces and breakfast cereals.
There is no cure for coeliac disease, but a gluten-free diet should control symptoms and prevent complications. Even if your symptoms are mild, you should change your diet because continuing to eat gluten can lead to serious complications such as weak bones, anaemia and bowel cancer.
Review in a month
Coeliac UK
Constipation Ix
Bristol stool form scale
DRE (if suggestive of Hirschsprung’s
Constipation Mx
Advice on scheduled toileting, reward systems and high fibre diet
Movicol - initially increases abdo pain and soiling
If this fails after 2 weeks add Senna
Maintenance with Movicol (half the disimpaction dose)
Enuresis Mx > 5 y/o
Reduce fluids (+caffeine), Toiletting patterns, Reward system, Avoid Punishment
Enuresis Alarm purchased OTC
Assess response after 4 weeks, stop if no response at all. Continue until minimum of 2 weeks uninterrupted dry nights
Desmopressin
If not completely dry after 2 weeks you can double dose
(can continue for up to 6 months)
Enuresis Clinic
When to refer to secondary care with enuresis
Primary enuresis with daytime symptoms
```
Secondary enuresis
if can’t be treated as a UTI or constipation
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AKI severity scale?
KDIGO
- Stage 1: creatinine rise of 26 micromol or more within 48 hours, creatinine rise of 50–99% from baseline within 7 days (1.50–1.99 x baseline) or UO < 0.5 mL/kg/h for more than 6 hours.
- Stage 2: 100–199% creatinine rise from baseline within 7 days* (2.00–2.99 x baseline), UO** < 0.5 mL/kg/hour for more than 12 hours.
- Stage 3: 200% or more creatinine rise from baseline within 7 days* (3.00 or more x baseline), creatinine rise to 354 micromol/L with acute rise of 26 micromol/L or more within 48 hours or 50% or more rise within 7 days, or OU < 0.3 mL/kg/hour for 24 hours or anuria for 12 hours.
Mx of AKI?
Admit
Stage disease
Fluid restriction (or diuretics if overloaded)
Refer to specialist - monitor eGFR
Follow up for 3 years to assess for HTN and kidney damage
UTI Mx (3 categories)
< 3 months - Admit + IV co-amoxiclav 5-7 days
> 3 months Upper UTI - admission, 7-10 days co-amoxiclav
> 3 months Lower UTI - 3d oral trimethoprim
US if atypical infection immediately if <6 months or recurrent
Done within 6 weeks if older/not recurrent
MCUG if atypical or recurrent
+ DMSA within 4-6 months
Prophylactic Trimethoprim if recurrent
Mx of recurrent UTI
US immediately
MCUG, give Abx for procedure
DMSA in 4-6 months
Prophylactic Trimethoprim if recurrent, review every 6 months
CKD Mx?
Stop nephrotoxic drugs
Monitor serum creatinine, eGFR, ACR
FBC (renal anaemia), serum calcium, phosphate, vitamin D and PTH levels.
Nephrology specialist referral.
If hypertensive treat with ARB/ACEi/diuretics.
Calorie supplements or NG/gastrostomy feeding often necessary to optimise growth
Salt supplements
Minimal change disease Ix
Urine protein:creatinine ratio FBC, ESR, U+Es GFR BP Complement levels Consider ultrasound
Minimal change disease Mx
OD oral prednisolone for 6 weeks, then on alternate days for 6 weeks
Fluid restriction, low-salt diet
Biopsy if no response to steroids
- give tacrolimus
Mx of undescended testis?
Unilateral: re-examine at 6-8 weeks and at 4-5 months
Refer to paediatric surgery if still undescended at 4-5 months to be seen by 6 months age
Bilateral >6 weeks old - urgent 2 week referral
G6PDD Mx?
Transfusions and IVIG in acute haemolysis
Avoid triggers (fava, mothballs, henna beans, aspirin, rasburicase)
Vaccinations
Folate supplementation
Genetic counselling for parents
Sickle cell disease Mx
Daily penicillin
Daily folic acid
Hydroxycarbamide for recurrent painful crises
Minimise exposure to cold. excessive exercise, hypoxia, dehydration.
Secondary care follow-up every 3m until 2y, every 6m 3-5y, annually over 5y
Immunisations + annual flu vaccine + pneumococcal vaccine every 5 years (1st at 2y/o)
Safety net: teach to recognise an enlarged spleen, signs of pallor
Acute crises: exchange transfusion
Thalassaemia Mx
- Regular blood transfusions, maintain Hb>100 g/L
- Iron monitoring and chelation with desferrioxamine
- Splenectomy (if enlarged)
- Bone marrow transplant (in major) if HLA-matched sibling
Genetic counselling
Haemophilia Ix
APTT (prolonged)
Factor 8 and 9 assays
FBC (usually normal)
PT (normal)
Haemophilia Mx
Regular tranfusions.
Recombinant factor 8 concentrate for haemophilia A. Recombinant factor 9 concentrate for haemophilia B.
Avoid IM injections, aspirin, NSAIDS - use paracetamol for pain
ITP Mx?
- Resolves spontaneously in 6-8 weeks for most children.
Conservative management with repeat FBC in 5-7 days. - Treatment if major bleeding occurs with IVIG + steroids + anti-D Ig.
- In chronic disease, consider mycophenolate mofetil or rituximab
Safety net: Bring to A&E if they have an severe injury leading to significant blood loss
ALL Ix?
FBC
Clotting screen (10% DIC)
Peripheral blood smear
Baseline bloods: LFTs U*Es
BM biopsy and flow cytometry is diagnostic
ALL Mx?
Refer for immediate specialist assessment
Stage disease
Induction chemotherapy with prednisolone, vincristine doxorubicin (adriamycin)
Prophylactic Abx
Chemo needed for 2 years in girls, 3 years in boys on average
Mx of acute osteomyelitis?
Immobilise affected limbs
< 3 months - IV cefotaxime
< 5 y/o - IV cefuroxime
>6 y/o - IV flucloxacillin
Penicllin allergy - clindamycin
Staging of chronic osteomyelitis?
Tx?
Cierny-Mader classification
Surgical debridement
IV Abx + analgesia
Ix of osteomyelitis?
- Blood cultures
- FBC, ESR/CRP
- Plain X rays of affected areas with joint above and below affected area
Septic Arthritis Ix?
• Synovial fluid joint aspiration under US for stain, microscopy, MCS, WCC
Plain X-rays to exclude trauma
WCC, CRP, ESR, U&E, LFT
Blood Culture
Septic Arthritis Mx?
Admit Joint aspiration IV Flucloxacillin (g +ve) IV Ceftriazone (g -ve)
Home with 4 weeks oral Abx
Start to mobilise joint to prevent stiffness
Perthe’s Ix?
- X-rays AP and lateral of both hips. If normal but symptoms persist, repeat X-ray.
- MRI both hips if X-rays normal
- Catterall staging
Perthe’s Mx?
- Acute pain: supportive care, rest, paracetamol or ibuprofen.
- Containment and/or surgery depending on age:
• < 5y: mobilisation and monitoring, non-surgical containment with splits
• 5-7y: mobilisation and monitoring, surgical containment (femoral and/or pelvic osteotomy)
• 7-12y: surgical containment, salvage procedure if stage 3-4 (containment contraindicated, instead need to remodel the acetabulum)
• > 12y: salvage procedure (if no arthritis), replacement arthroplasty after skeletal maturity (if has arthritis)
SUFE Ix
Bilateral AP hip X ray including frog lateral views
SCFE Mx? (2)
Unstable - Urgent surgical repair (decompress hip joint, initial reduction, stabilise with 1 or 2 screws fixed through growth plate to the femoral head).
Stable - In situ fixation with 1 screw
2nd line - open reduction and internal fixation
Consider prophylactic fixation of contralateral hip if there is an underlying endocrinopathy
May need crutches, can refer to physiotherapy
DDH Ix
Barlow & Ortolani tests
Ultrasound 6 weeks old
> 6 months old: X-ray
DDH Mx
Usually, unstable hips spontaneously resolve by 3-6weeks of age.
Serial examinations and US every month
Pavlik harness (keeps hips flexed and abducted)
• Advise parents not to remove when changing nappies or cleaning
• Progress monitored by repeat ultrasound or X-ray
• Evaluation at 6 months of age
Surgery if conservative measures fail or if diagnosed in older child (> 6 months)
• Reduction surgery (open or closed) with spica casting
> 6 years old = salvage osteotomy
Juvenile idiopathic arthritis Mx
Refer to specialist
NSAIDs for pain+stiffness
Corticosteroids (adjunct while waiting for DMARDs affect)
DMARDs - methotrexate (1st) sulfasalazine (2nd)
Etanercept or Tocilizumab
NAI Ix
- Skeletal survey
- CT head scan
- Bloods and bone profile (rule out leukaemia, ITP etc)
- Fundoscopy (retinal haemorrhages – shaken baby)
- Consider whether other children are in danger e.g. siblings
NAI Mx
Safeguarding (admit if needed)
Child Abuse Investigation Team
Record exactly what is observed and/or heard from whom and when. Document concerns and actions. Inform parents of safeguarding referral unless this would pose risk to child- you do not ned parental consent
NSPCC
