Paeds Passmed Flashcards
What is the treatment for threadworm?
Single dose mebendazole for whole family (>6 months)
How do you check pulse on infants vs children?
Infants: Brachial + femoral
Children: Femoral
What valvular abnormalities are present in turners syndrome? And how do they present?
- Bicuspid aortic valve (ejection systolic upper right sternal border which radiates to the carotids
- Coarctation of the aorta (Systolic murmur that is loudest in the back below the left scapula)
- aortic root dilatation
What is turners syndrome?
Only affects females. Missing/partially missing x-linked chromosome. XO karyotype
How does turners present?
- Short stature
- Webbed neck + low set ears
- primary amenorrhea + poorly developed secondary characteristics
- High arched palate
- Raised FSH/LH + low oestradiol -> POF
- horseshow kidney
What chromosome is affected in pataus?
Trisomy 13. Not inheritied - nondisjunction or translocation
How does pataus present?
- microcephalic, small eyes
- cleft lip/palate
- polydactyly
- Scalp lesions
- Incompatible with life
What chromosome is affected in Edwards?
Trisomy 18
How does Edwards present?
- IUGR
- Micerognathia
- Overlapping fingers
- Rocker bottom feet
- Incompatible with life
- choroid plexus cysts
How does fragile x present?
- Learning difficulties/autism (lack of protein that causes brain to develop)
- Macrocephaly
- Long face
- Large ears
- Macro-orchidism
- mitral valve prolapse
3 Ms, 3 Ls
Trinucleotide disorder
How does Noonans present?
- Webbed neck
- Pectus excavatum
- short stature
- Pulmonary stenosis
- Wide spaced eyes + deep philtrum
What causes kleinfelters syndrome?
Having an addition X chromosome (not directly inherited). Only affects men.
How does Klinefelter’s present?
- Often asymptomatic till puberty
- infertility (small testes + primary testicular insufficiency)
- Taller, curved pinky, flat feet
- symptoms of low testosterone -> gynecomastia, decreased body hair
How is Klinefelter’s treated pharmacologically?
TRT
What chromosome is affected in prader-willi syndrome?
Loss of function of chromosome 15
How does prader-willi present?
- Excessive appetite/eating
- Hypotonia
- Hypogonadism
- Restricted growth
What chromosome is affected in williams syndrome?
Partial loss of chromosome 7
How does Willams present?
- Supravalvular aortic stenosis (not cyanotic)
- Intellectutal disability
- Friendly
- Broad forehead, strabimus, elfin facies
What are the 3 symptoms of shaken baby syndrome?
- Retinal haemorrhage
- Subdural haemorrhage
- Encephalopathy
Why should aspirin never be given to children?
Reyes syndrome
How does perthes disease present?
- Hip pain
- Limping
- Reduced range of motion
- Widening of joint spaces
- Leg shortening
What does a jittery and hypotonic newborn indicate?
Neonatal hypoglycaemia
What is the gold standard test for hirsphrungs?
Rectal biospy - lack of ganglionic nerve cells
What congential heart condtiion is associated with downs?
- Tetralogy of Fallot (overriding aorta, RVH, VSD, pulmonary stenosis -> Ejection systolic murmur )
- ASD: a systolic murmur is heard at
the upper left sternal edge which radiates to the back. (most common)
What GI condition is secondary to cystic fibrosis?
Meconium ileus - small bowel obstruction caused by thickened meconium
Symptoms of ALL?
- Easy bruising
- Hepatosplenomegaly
- SOB and systolic murmur
What is raised in biliary atresia?
- Conjugated billirubin - as it is normally released in bile
- Bile acids and aminotransferases are also typically raised, but cannot be used to differentiate between other causes of neonatal cholestasis and biliary atresia.
What is the treatment for biliary atresia ?
Kasai procedure
What makes a murmur innocent?
Soft, systolic, short, Symptomless, Standing/Sitting (vary with position)
Side effect of maternal anti-epileptic use?
Cleft lip
Where does inflammation occur in osgood-schatter
tibial tuberosity
Most common cause of primary amenorrhea?
Androgen insensitivity syndrome
How do you differentiate perthes vs transient synovitis?
Transient synovitis is usually following another infection and perthes more common in boys
Most common sign of neonatal sepsis?
Resp distress/grunting
What condition usually precedes ITP?
Viral infection
What is the treatment for croup?
- single dose of dexamethasone
- inhaled racemic adrenaline
What are the cyanotic congenital heart diseases?
- Tetralogy of fallot (a few months)
- Transposition of the great arteries (right after birth + diabetic mother)
- tricuspid atresia
- Total anomalous pulmonary venous return
- Truncus arteriosus
What is given in cyanotic CHD?
Prostaglandin E1 - to prevent closure of PDA to allow mixing of oxygenated and deoxygenated blood until surgical correction
Child with billous vomit, diarrhoea, reduced feeding, PROM?
Necrotising entercolitis - xray ( Dilated Bowel Loops, Bowel wall oedema, Pneumotitis Intestinalis: gas within the wall of the intestine)
What conditions is cystic fibrosis associated with?
- Diabetes
- Downs
- meconium illeus
Jaundice in the first 24 hours is always…
pathological - blood film analysis
Causes of jaundice in <24 hours?
- rhesus haemolytic disease
- positive coombs test
- normocytic anaemia with reticulocytosis and bilirubinaemia.
- nucleated red blood cells - ABO haemolytic disease
- hereditary spherocytosis
- negative coombs test - glucose-6-phosphodehydrogenase
What antibiotic is used for whooping cough?
Clarithomycin
How does hirshprungs present/diagnosed/treated?
- Delayed meconium passing (48 hours)
- Absence of ganglion cells from myenteric and submucosal plexuses
- associated with downs and MEN IIa
Diagnosis: Full-thickness rectal biopsy for diagnosis
Treatment: rectal washouts initially, after that an anorectal pull-through procedure/swenson
How does pyloric stenosis present/diagnosed/treated?
1 Projectile non bile stained vomiting at 4-6 weeks of life
2. hypochloraemic, hypokalaemic alkalosis due to vomiting
Diagnosis: test feed or USS
Treatment: Ramstedt pyloromyotomy (open or laparoscopic)
How does mesenteric adenitis present?
- Right lower quadrant pain secondary to an inflammatory condition of mesenteric lymph nodes (URTI)
Treatment: conservative management
How does intussusception present/diagnosed/treated?
- Telescoping bowel, proximal to or at the level of, ileocaecal valve
- 6-9 months of age
- Colicky pain, diarrhoea and vomiting, sausage-shaped mass, red jelly stool.
Diagnosis: ultrasound (target sign)
Treatment: reduction with air insufflation
How does intestinal malrotation present/diagnosed/treated?
- High caecum at the midline
- Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia
- May be complicated by the development of volvulus, an infant with volvulus may have bile stained vomiting
Diagnosis: upper GI contrast study and USS
Treatment: laparotomy, if volvulus is present (or at high risk of occurring then a Ladd’s procedure is performed (includes division of Ladd bands and widening of the base of the mesentery)
How does oesophageal atresia present?
- Associated with tracheo-oesophageal fistula and polyhydramnios
- May present with choking and cyanotic spells following aspiration
- VACTERL associations (Vertebral, anal atresia, cardiac defects, traceal anomalies, esophagel atresia, renal and radial thumb, limbs)
How does meconium ileus present/diagnosed/treated?
- Usually delayed passage of meconium and abdominal distension
- associated with cystic fibrosis
Diagnosis: X-Rays will not show a fluid level as the meconium is viscid, PR contrast studies may dislodge meconium plugs and be therapeutic
Treatment: Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs
How does biliary atresia present/treated?
- Jaundice > 14 days
- Increased conjugated bilirubin
Treatment: Urgent Kasai procedure (connection between liver and small intestine for bile drainage)
How does necrotising enterocolitis present/diagnosed/treatment?
- Prematurity is the main risk factor
- abdominal distension and passage of bloody stools
- billous vomit, diarrhoea, reduced feeding, PROM
- Increased risk when empirical antibiotics are given to infants beyond 5 days
Diagnosis: x-Rays may show pneumatosis intestinalis and evidence of free air (GAS CYSTS) or dilated bowel loops
Treatment: total gut rest and TPN, babies with perforations will require laparotomy + broad spectrum antibiotics
How does Meckel’s diverticulum present/diagnosed?
- abdominal pain mimicking appendicitis
- painless rectal bleeding (most common cause of painless GI bleed requiring transfusion in kids 1-2)
- intestinal obstruction: secondary to an omphalomesenteric band (most commonly), volvulus and intussusception
Investigation: Meckel/technetium scan
Treatment: wedge excision (if symptomatic)
How is kawasaki disease treated?
- High dose aspirin
- IV immunoglobulin
- Echo (cornoary artery aneurysm)
What triggers DIC?
major trauma, sepsis, severe obstetric disorders and malignancy
What kind of vaccine is the rotavirus? and when is it administered?
Oral, live, attenuated vaccine
Given at 2 and 3 months
Risk of intussusception if given at wrong time
What is the side effect of methylphenidate? and what is given if not tolerated
(dopamine/norepinephrine reuptake inhibitor)
cardiotoxic. Perform a baseline ECG before starting treatment
stunted growth - monitor every 6 months
lisdexamfetamine/dexafetamine
How does pierre-robin present?
- Micrognathia
- Posterior displacement of the tongue (may result in upper airway obstruction)
3.Cleft palate
When are unilateral undescended testes concerning?
> 3 months
bilateral: 24 hours
increased risk of testicular torsion, infertility, cancer
What are the NICE red flag symptoms?
- Moderate or severe chest wall recession
- Does not wake if roused
- Reduced skin turgor
- Mottled or blue appearance
- Grunting
- appears unwell to doctor
What is the treatment for PDA?
Indomethacin or ibuprofen
Which condition is associated with pulmonary hypoplasia?
Congenital diaphragmatic hernia
What is used to prevent RSV?
Palivizumab: monoclonal antibody
When should a child with fever be admitted?
< 3 months + > 38 degrees ALWAYS admit
How is meningitis treated?
> 3 months: IV cefritaxime/one + dexamethasone
< 3 months: IV cefritaxime + amoxicillin (listeria) -> no steroids
Add vancomycin if recent travel outside UK
How does transposition of the great arteries present?
no murmur but typically a loud single S2 is audible and a prominent right ventricular impulse is palpable on examination
What is the most common cause of stridor in infants?
Laryngomalacia - floopy epiglottis that fols in wards and worse when eating
When should an urgent referral be made with an acute limp?
< 3 years
What investigation do all breech babies require?
USS at 6 weeks
What is the recommended compression: ventilation ratio for the newborn?
3:1
How does a slipped capital femoral epiphysis present? diagnosed? treated?
- loss of internal rotation of the leg in flexion
- hip, groin, medial thigh or knee pain
Frog pose hip x-ray
Treatment: internal fixation: typically a single cannulated screw placed in the center of the epiphysis
What is the causative organism for roseola infantum?
human herpes virus 6
What is the causative organism for slapped cheek syndrome?
Parovirus B19
What is the causative organism for hand, foot and mouth disease?
Cosackie A16
How does rubella present?
1..pink maculopapular, initially on face before spreading to whole body, usually fades by the 3-5 day
2. Lymphadenopathy: suboccipital and postauricular
How is GORD treated?
2 week alginate -> 4 week PPI or H2 receptor antagonist (ranitidine) -< Nissan fundoplication
How does osgood-schatter present?
- Unilateral (but may be bilateral in up to 30% of people).
- Gradual in onset and initially mild and intermittent, but may progress to become severe and continuous.
- Relieved by rest and made worse by kneeling and activity, such as running or jumping.
Most common causative organism of acute epiglottis.
Haemophilus influenzae type B
How do you differentiate between seizure and psudoseizure?
Seizure - increased prolactin
Which vaccine would you offer for uni students?
Men ACWY
How do you differentiate between Kawasaki and scarlet fever?
Kawasaki has fever >5 days
What is one of the few indications for aspirin in children?
Kawasaki disease
Difference in metabolic disorders with vomiting vs diarrhoea?
Vomiting: hypochloremic, hypokalaemia metabolic alkalosis
Diarrhoea: metabolic acidosis
How is CMPA treated? and what is the prognosis?
- eHF
- AAF
IgE mediated resolves by 5
Non-IgE mediated resolves by 3
How are undescended testes managed?
Unilateral: wait till 3 months
Bilateral: 24 urgent refferal -> karyotping
What is Perthes disease?
avascular necrosis of femoral head - 4-8 years
What is exomphalos
the abdominal contents protrude through the anterior abdominal wall but are covered in an amniotic sac formed by amniotic membrane and peritoneum -> may have raised AFP
How is exomphalos managed?
c-section and staged repair
What is a late complication of downs syndrome?
- Alzheimers - chromosome 21 produces amyloid plaques
- ALL
- Hypothryodiism
- subfertility
How do you differentiate between caput succedaneum and cephalohematoma?
Caput crosses suture lines and present at birth
What cranial injuiry most commonly causes seizures after birth?
intracranial haemorrhage
1. Subarachnoid haemorrhages are common and may cause irritability and even convulsions over the first 2 days of life.
2. Subdural can following the use of forceps.
3. Intraventricular haemorrhage mostly affects pre-term infants and can be diagnosed by ultrasound examinations.
What complication of chicken pox causes systemic symptoms with peeling grey wound?
Group a step -> necrotising fasciitis
id not systemic symptoms -> cellulitis
How is vit K given to newborns?
one-off oral/IM dose to prevent HDN
How are immunisations given to preterm babies?
Acorrding to chronological age, not gestations
if <28 weeks give in hospital
How is symptomatic neonatal hypoglycaemia treated?
admit to nepnatual unit and 10% iV dextrose
What cardiac abnormality is seen with duchenne muscular dystrophy?
Dilated cardiomyopathy
How does JIA present?
- pyrexia
- salmon-pink rash
- lymphadenopathy
- arthritis
- Chronic anterior uveitis (There is a national screening programme for all children with JIA to have their eyes screened on a 3 monthly basis)
- anorexia and weight loss
How is JIA diagnosed?
- ANA may be positive, especially in oligoarticular JIA
rheumatoid factor is usually negative - <16 years and >6 months
How does cystic fibrosis present?
- Meconium ileus (neonatal)
- recurrant chest infections
- malabsoption/failure to thrive
- nasal polyps
- delayed puberty
- rectal prolapse
- diabetes mellitus
What are the hearing tests for each age group?
- Newborn - otoacoustic emmision test + auditory brainstem response test
- 6-9 months - distraction test
- 1.5-2.5 years - Recognition of familiar objects
- school age - pure tone audiometry
How does PDA present?
- left subclavicular thrill
- continuous ‘machinery’ murmur
- large volume, bounding, collapsing pulse
- wide pulse pressure
- heaving apex beat
What is TGA and how does it present?
Aorta connected to R ventricle instead of left - pumps deoxygenated blood to body
Pulmonary artery connected to L ventricel instead of R - pumps ocygenated blood to lungs
- cyanosis
- tachypnoea
- loud single S2
- prominent right ventricular impulse
- ‘egg-on-side’ appearance on chest x-ray
How do you manage children with unexplained mass (+ painless haematuria)?
48 hour paediatric referral - could be wilms tumours (nephroblastoma)
What are the complications of measles?
otitis media: the most common complication
pneumonia: the most common cause of death
encephalitis: typically occurs 1-2 weeks following the onset of the illness)
subacute sclerosing panencephalitis: very rare, may present 5-10 years following the illness
febrile convulsions
keratoconjunctivitis, corneal ulceration
diarrhoea
increased incidence of appendicitis
myocarditis
What is the treatment for cerebral palsy?
- oral diazepam
- oral and intrathecal baclofen
- botulinum toxin type A
How is cerebral palsy classifed?
- spastic (70%)
- subtypes include hemiplegia, diplegia or quadriplegia
- increased tone resulting from damage to upper motor neurons (pyramidal tracts/corticospinal0 - dyskinetic
- caused by damage to the basal ganglia and the substantia nigra
- athetoid movements and oro-motor problems - ataxic
- caused by damage to the cerebellum with typical cerebellar signs - mixed
Up to what age is bow legged normal?
< 3 years and usually resolves by 4
Barlow vs ortilani?
Barlow test: attempts to dislocate an articulated femoral head
Ortolani test: attempts to relocate a dislocated femoral head
How does HUS present?
- AKI
- Thrombocytopaenia
- normocytic anaemia
- brief gasteronentritis episode (e-coli)
What is a common complication when taking amoxicillin for infectious mono?
maculopapular pruritic rash
What would blood gas/blood tests for DKA show?
- metabolic acidosis
- hyperkalaemia (due to acidosis and lack of insulin meaning lots of potassium remains in the blood rather than being moved into cells)
- Hyperglycaemia
- ketonaemia
- Mildly raised creatinine
- Low bicarbonate (used by ketones)
- Slightly raised sodium (due to dehydration)
How does an adrenal crisis caused by CAH present?
- Hyperkalaemia and hyponaetremia
- metabolic acidosis
- Raised 17-hydroxyprogesterone
Most common organism that causes glandular fever? and how does it present
EBV
Fever
Sore throat/tonsillar exudate
Fatigue
Hepatomegaly and/or splenomegaly may sometimes be found on palpation
heterophile antibody ‘Paul Bunnell’ test
What is considered sanctuary sites for chemo?
CNS (due to BBB) and testes
What medications are used for sickle cell disease?
- Prophylactic penicillin due to splenectomy
- Hydroxycarbamide to prevent vaso-occulsive complications
Difference between haemophillia A vs B?
A: Factor VIII
B: Factor IX
What are the complications of Kawasaki disease?
- Coronary artery aneurysm
- Pericardia effusion
- Myocardial disease/valve damage
Do a transthoracic echo
How does Kawasaki present?
CRASH AND BURN
Conjunctivitis, Rash, Adneopathy,
Strawberry tongue, Hands (palmar erythema, swelling), Burn (fever >5 days)
What are the complications of shingles?
Ramsay hunt syndrome
What are the complications of mumps?
Pancreatitis
Orchitis
Meningitis
Sensorineural hearing loss
What are the notifiable diseases?
- MMR
- HUS
- Whooping cough
How is cancer treatment response monitored?
PET scan -> shows areas of high uptake and therefore malignancy
Which lymphoma is more common in childhood?
non-hodgkins
What are the B symptoms seen in lymphoma?
unexplained fever, unexplained weight loss, and drenching sweats (particularly at night)
What are the risk factors for DDH?
Female, Breech birth, high birth weight, oligohydramnios, and prematurity
What condition would you find a ‘double bubble’ sign-on x-ray? and what genetic condition is it associated with?
Dudodenal atresia - downs (has billous vomitting)
What are the typical features of down syndrome?
- Brushfield spots in the iris
- Delayed motor milestones
- Hypotonia
- Small ears
- Upslanted palpebral features
- obstructive sleep apnoea/hearing issues/CHD
7 atlanto-axial instability (check in active kids)
Why is an US conducted between 16-24 weeks with monochorionic twins?
Look for twin-to-twin transfusion
How does retinopathy of a newborn present?
- <32 weeks
- absent red reflex
- choroidal neovascularisation.
- free radical damage to retina
What is an ebstein abnormality?
low insertion of the tricuspid valve resulting in a large atrium and small ventricle
LINKED TO LITHIUM USE IN PREGNANCY
1. cyanosis
2. prominent ‘a’ wave in the distended jugular venous pulse,
3. hepatomegaly
4. tricuspid regurgitation : pansystolic murmur, worse on inspiration
5. Tricuspid stenosis : mid-diastolic murmur
5. right bundle branch block → widely split S1 and S2
6. right atrial hypertrophy
What is the antibiotic of choice for bacterial throat infections?
Phenoxymethylpenicillin for 5-10 days 500mg
Clarithomycin if intolerated
How does croup present?
inspiratory stridor (if at rest, admit)
barking cough (worse at night)
fever
coryzal symptoms
6 months - 3 years
When should a child with croup be admitted?
<6 months
What is rheumatic fever?
group A beta-haemolytic streptococcal (streptococcus pyogenes) causing tonsillitis. The immune system creates antibodies to fight the infection. These antibodies not only target the bacteria, but also match antigens on the cells of the person’s body, for example the muscle cells in the myocardium in the heart.
This results in a type 2 hypersensitivity reaction, where the immune system begins attacking cells throughout the body. This process is usually delayed 2 – 4 weeks after the initial infection.
How does rheumatic fever present?
- Joints : Migratory arthritis
- Heart : mitral stenosis (mid-diastolic murmur), pericardial rub
- Skin : Subcutaneous nodules + Erythema marginatum rash
- Nervous system : chorea
How is rheumatic fever diagnosed?
- Throat swab for bacterial culture
- ASO antibody titres
- Echocardiogram, ECG and chest xray can assess the heart involvement
- Jones criteria
What is the jones criteria?
JONES (major) FEAR (minor)
Joint involvement
Organ involvement
Nodules
Erythema marginatum
Sydenham chorea
Fever
ECG Changes (prolonged PR interval) without carditis
Arthralgia without arthritis
Raised inflammatory markers (CRP and ESR)
How is rheumatic fever treated?
- Tonnsilitis - 10 day course of phenoxymethypennicillin
- NSAIDs (e.g. ibuprofen) are helpful for treating joint pain
- Aspirin and steroids are used to treat carditis
- Prophylactic antibiotics (oral or intramuscular penicillin) are used to prevent further streptococcal infections and recurrence of the rheumatic fever. These are continued into adulthood.
How does rubella infection during pregnancy present?
<20 weeks
Classic features: cataract, deafness, cardiac abnormalities (PDA/pulmonary stenosis)
blueberry muffin rash
Other possible features: jaundice, hepatosplenomegaly, microcephaly, reduced IQ
DEAF, BLIND, CARDIAC
How does foetal varicella syndrome present?
<28 weeks
skin scarring, eye defects (small eyes, cataracts or chorioretinitis), neurological defects (reduced IQ, abnormal sphincter function, microcephaly)
How does maternal syphilis infection present?
Rhinitis, saddle shaped nose, deafness (sensorineural hearing loss) and Hutchinson’s incisors
Hepatosplenomegaly, lymphadenopathy, anaemia, jaundice
How does infection with parovirus B19 during pregnancy present?
Miscarriage or fetal death
Severe fetal anaemia
Hydrops fetalis (fetal heart failure)
Maternal pre-eclampsia-like syndrome
When can a child return to school with the different rashes?
- Scarlet fever : 24 hours after starting antibiotics
- Chicken pox : until all lesions have crusted over
- Hand, foot and mouth : school exclusion not needed
4.Measles : 5 days since rash - Mumps : 5 days since swollen glands
- whooping cough : 48 hours after antibiotics
- Roseola: no exclusion
- slapped cheek: no longer infectious once rash apperas
How is scarlet fever treated?
10 day course of penicillin v
Erythromycin if not tolerated
Notifiable disease
What are the complication associated with scarlet fever?
otitis media: the most common complication
rheumatic fever: typically occurs 20 days after infection
acute glomerulonephritis: typically occurs 10 days after infection
invasive complications (e.g. bacteraemia, meningitis, necrotizing fasciitis) are rare but may present acutely with life-threatening illness
What will chest radiograph show with NRDS?
diffuse ground glass lungs with low volumes and a bell-shaped thora
(IPF: ground glass to honeycombing)
How does roseola infantum present?
characteristic 3 day fever and then emergence of a maculopapular rash on the 4th day, following the resolution of the fever.
Nagayama spots: papular enanthem on the uvula and soft palate
6 months - 2 years
How is nocturnal enureisis managed?
< 5 years reassure and give advice
General advice -> reward system -> enuresis alarm -> desmopressin
How are febrile convulsions treated?
Rectal diazepam and oral midazolam
What is the chest compressions for BLS?
15:2 (30:2)
How is asthma managed?
SABA -> paediatric low-dose ICS or LTRA if <5 -> leukotriene receptor antagonist (LTRA) -> stop LTRA and start LABA
How is transient synovitis managed?
If fever - same day assessment
Afebrile - rest and analgesia
What age are medications for gastroenteritis contraindicated?
<5 years
How is whooping cough diagnosed?
Nasal swab
How is whooping cough managed?
- infants under 6 months with suspect pertussis should be admitted
- UK pertussis is a notifiable disease
- an oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread
- household contacts should be offered antibiotic prophylaxis
- antibiotic therapy has not been shown to alter the course of the illness
- school exclusion: 48 hours after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )
How does a congential diaphragmatic hernia present?
- dyspnoea and tachypnoea at birth.
- The auscultation findings are due to pulmonary hypoplasia and compression of the lung due to the presence of abdominal contents in the thoracic cavity (reduced breath sounds bilaterally)
- concave abdo wall
How does nephrotic vs nephritic syndrome present?
Nephrotic
1. Proteinuria (> 3g/24hr) causing
2. Hypoalbuminaemia (< 30g/L) and
3. Oedema
Nephritic
+ haematuria
What is the most common cause of nephortic syndrome in children?
Minimal change disease (treat with steroids) -> fused foot processes
What are the causes of nephritic syndrome?
1-2 DAY post infection -> igA (related to HSP)
1-2 week post infection -> post strep (test Antistreptolysin O antibody titres)
What is precocious puberty?
‘development of secondary sexual characteristics before 8 years in females and 9 years in males’
What is the treatment of infantile colic?
Reassurance and support
NICE do not recommend use of medicines such as infacol
When are APGAR scores checked?
1 and 5 mins
If score below 7, check 10 min intervals
What is part of the core child health programme?
Newborn
- Clinical examination of newborn
- Newborn Hearing Screening Programme e.g. oto-acoustic emissions test
- Give mother Personal Child Health Record
First month
- Heel-prick test day 5-9 - hypothyroidism, PKU, metabolic diseases, cystic fibrosis, medium-chain acyl Co-A dehydrogenase deficiency (MCADD)
Midwife visit up to 4 weeks*
Following months
- Health visitor input
- GP examination at 6-8 weeks
- Routine immunisations
Pre school
- National orthoptist-led programme for pre-school vision screening to be introduced
Ongoing
- Monitoring of growth, vision, hearing
- Health professionals advice on immunisations, diet, accident prevention
What condition is a contraindication for lumbar puncture?
Meningococcal septicaemia
What is the sepsis 6?
- lactate
- urine output hourly
- oxygen
- blood culture
- antibiotics
- fluids
How do you differentiate between gastroschisis and omaphacele?
Gastroschisis (surgery < 4 hours) and omphalocele present similarly, but gastroschisis refers to a defect lateral to the umbilicus whereas omphalocele refers to a defect in the umbilicus itself.
Why should ibuprofen not be given in chicken pox?
Increases risk of necrotising faciitis
What is the most common reversible cause of cardiac arrest?
Hypoxia
What are the symptoms of whooping cough
Paroxysmal cough.
Inspiratory whoop.
Post-tussive vomiting.
Undiagnosed apnoeic attacks in young infants.
When should dexamethasone be considered in bacterial meningitis?
- > 3 months
- frankly purulent CSF
- CSF white blood cell count greater than 1000/microlitre
- raised CSF white blood cell count with protein concentration greater than 1 g/litre
- bacteria on Gram stain
what is given for meningitis prophylaxis?
Ciprofloxacin
what is the treatment for hypoxic injury?
Therapeutic cooling (33.5 - 34.5ºC for 72 hours within a six hour window of the hypoxia inducing event/birth.)
What is a common complication of viral gastroenteritis (rotavirus)?
Transient lactose intolerance
What are the signs of retinoblastoma?
- absent red reflex + leukoria (most common)
- Strabimus (refer if still at 8 weeks)
- visual issues
How does alpha thalassemia present?
- 1- 2 alpha globulin alleles: hypochromic and microcytic, but the Hb level would be typically normal + asymptomatic
- 3 alpha globulin alleles: hypochromic microcytic anaemia with splenomegaly. This is known as Hb H disease
- 4 alpha globulin alleles: death in utero (hydrops fetalis, Bart’s hydrops)
How does beta thalassemia major present?
- Symptoms between 3-6 months after birth. Before this they still have HbF ‘protecting’ them
- Severe anemia and jaundice
- Failure to thrive
- Hepatosplenomegaly (due to increased haemolysis)
- Erythroid hyperplasia (chipmunk faces)
X-ray: Thumb vs steeple sign?
Thumb: acute epiglottis
Steeple: croup
Can you have male-to-male transmission with haemophillia?
NO - x linked
Each male child of a heterozygous female carrier has a 50% chance of being affected whilst each female child of a heterozygous female carrier has a 50% chance of being a carrier.
What increases mortality rates in patients with CF?
chronic infection with Burkholderia cepacia
What are the RF for NRDS?
male sex
diabetic mothers
Caesarean section
second born of premature twins
What is the APGAR score?
Activity: 0 (floppy), 1 (some flexion), 2 (flexed limbs that resist extension)
Pulse: 0 (absent), 1 (below 100), 2 (above 100)
Grimace: 0 (no response), 1 (minimal response), 2 (prompt response to stimulation)
Appearance: 0 (blue), 1 (pink, blue extremities), 2 (pink all over)
Resp: 0 (absent), 1 (slow/irregular), 2 (normal)
How does meconium aspiration present?
- thick meconium-stained amniotic fluid.
- cyanosed and tachypnoeic with chest wall retraction
- X-ray: patchy infiltrations and atelectasis.
What is the treatment of UTI?
- <3 months: admit and IV cefuroxime
- > 3 months old with an upper UTI should be considered for admission to hospital. If not admitted oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days
- > 3 months old with a lower UTI: trimethoprim, nitrofurantoin, cephalosporin or amoxicillin.
- Parents should be asked to bring the children back if they remain unwell after 24-48 hours
- antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs
Features of atypical UTI?
Seriously ill
Poor urine flow
Abdominal or bladder mass
Raised creatinine
Septicaemia
Failure to respond to treatment with suitable antibiotics within 48 hours
Infection with non-E. coli organisms.
What causes early stage neonatal sepsis <72 hours?
Streptococcus agalacticae + group b strep
s aureus >72
What height percentile should you be reviewed by paediatrician/GP?
GP <2nd centile
paediatrician < 0.4
how does Osteochondritis dissecans present?
locking and stiffening of knees
after exercise
How are mitochondrial diseases passed down?
Man = 0%
Woman = 100%
muscle biopsy classically shows ‘red, ragged fibres’
What does VSD increase the risk of?
- Endocarditis
- Pulmonary hypertension
- aneurysms of the ventricular septum,
Who do you report FGM to?
Police
What are the two innocent murmurs heard in kids?
Venous hums : continuous blowing noise heard just below the clavicles
Still’s murmur: Low-pitched sound heard at the lower left sternal edge
How do infantile spasms present?
- Poor prognosis
- the EEG shows hypsarrhythmia in two-thirds of infants
- M>F
- characteristic ‘salaam’ attacks: flexion of the head, trunk and arms followed by extension of the arms
- this lasts only 1-2 seconds but may be repeated up to 50 times
- progressive mental handicap
What is benign rolandic epilepy?
- seizures characteristically occur at night
- seizures are typically partial (e.g. paraesthesia affecting face/drooling) but secondary generalisation may occur (i.e. parents may only report tonic-clonic movements)
- EEG characteristically shows centro-temporal spikes
- Good prognosis
How is constipation in children treated?
- polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen (Macrogol laxative)
- add a stimulant laxative if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks e.g. senna
- substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if Movicol Paediatric Plain is not tolerated
What is the treatment of clinical dehydration?
IV fluids (0.9% NaCl 10ml/kg) + SC insulin (0.1units/kg/hr)
How does measles present?
Prodrome: irritable, conjunctivitis, fever
Koplik spots: white spots (‘grain of salt’) on buccal mucosa
Rash: starts behind ears then to whole body, discrete maculopapular rash becoming blotchy & confluent
How does HSP present?
vasculitis affecting children aged 3-10 years. As well as a rash
which has a typical distribution over the buttocks, extensor surface of limbs and ankles, there is often
joint and abdominal pain seen.
Monitor 1, 2 week then 1,3,6 months to look for nephritic syndrome
What is the vaccination schedule?
8 weeks: 6-in-1, Rotavirus, Men B
12 weeks: 6-in-1 (again), Rotavirus (again), Pneumococcal
16 weeks: 6-in-1 (again), Men B (again)
1 year- Men B (again) pneumococcal (again), HiB, Men C, MMR
What is the treatment of JIA?
- Intra-articular steroid injection (first line for oligoarticular)
- Anti-TNFa
- Methotrexate (reduced joint damage)
- Paracetamol
What are the milestone red flags
- > 3 months: strabismus
- > 6 months: no smile, not rolling, poor head control, no gestures, no grasp
- > 9 months: No response to words, not passing toys hand to hand, unable to sit/crawl without support
- <12 months: hand preference (cerebral palsy)
- > 12 months: unable to stand holding furniture, unable to pick up small items, unable to crawl or bottom shuffle, no babbled phrases
- > 18 months: uninterested in playing with others, no clear words, not able to hold crayon, not walking, unable to stack 2 blocks
- > 2 years: unable to climb stairs, no interest in feeding or dressing, <50 words
What are the complications of chickenpox?
Bacterial superinfection
Cerebellitis
Disseminated intravascular coagulation
Progressive disseminated disease
pneumonia
encephalitis
CSF results
Bacterial meningitis: turbid appearance, raised polymorphs, raised protein, low glucose
Viral meningitis: clear appearance, raised lymphocytes, normal/raised protein, normal/low glucose
Encephalitis: clear appearance, normal/raised lymphocytes, normal/raised protein, normal/low glucose
TB meningitis: turbid/clear appearance, raised lymphocytes, raised protein, low glucose
Fungal = high opening pressure
How does scarlet fever present?
- Reaction to erythrogenic toxins produced by Group A haemolytic streptococci
- Fever, malaise, tonsillitis
- ‘Strawberry’ tongue
- sandpaper Rash - fine punctate erythema sparing the area around the mouth (circumoral pallor)
What criteria is used for tonsillitis?
CENTOR criteria (fever <3 days, tender anterior cervical lymphadenopathy, tonsilar exudate, absence of cough)
>3 start antibiotics (phenoxymethylpenicillin as amoxicillin can cause rash if due to EBV) for 5 days
What is kallman syndrome?
- delayed onset of puberty- small penis, reduced testicle size and no facial or body hair. (hypogonadotropic hypogonadism)
- Poor sense of smell
- poor balance
- learning difficulties
Sporadic inheritance
Dietary advice for cystic?
High calorie, high fat with pancreatic enzymes for every meal
How does congenital CMV present?
Fetal growth restriction
Microcephaly
Hearing loss
Vision loss (containing spots within the retina, along with flame shaped haemorrhages -> Intraocular Ganciclovir and PO Valganciclovir)
Learning disability
Seizures
periventricular calcification
How does osteosarcoma show on x-ray?
sunburst
Treatment for urosepsis?
Cephalexin
Most common causative organisms for cystic fibrosis chest infections?
pseudomonas aeruginosa
Treatment of asthma attack
oral salbutamol -> nebulised salbutamol -> nebulised ipratropium bromide -> magnesium sulphate -> IV salbutamol -> aminophylline
DKA resuscitation fluid?
10ml/kg 0.9% NaCl for 15 mins (if shock)
10ml/kg 0.9% NaCl for 30 mins (no shock)
How is maintenance fluid calculated?
1st 10kg = 100ml/kg/day
Plus 50ml/kg/day for next 10kg
Plus 20ml/kg/day for each additional kg above 20kg
(up to a maximum of 80kg total body weight)
For DKA double as its over 48 hours
Communicating vs non-communicating hydrocephalus
non-communicating: something obstructs the flow through the ventricular system.
- a congenital malformation (e.g., stenosis of the aqueduct or a Chiari malformation)
- a tumour or vascular malformation in the posterior fossa
- an intraventricular haemorrhage (premature infants are particularly at risk)
communicating hydrocephalus: failure to reabsorb CSF occurs from an insult to the arachnoid villi
- meningitis and subarachnoid haemorrhage
How is hydrocephalus diagnosed?
Ultrasound
How does ewings sarcoma diagnosed?
X-ray: lamellated (onion skin) type periosteal reaction in proximal portion of the left tibia with reduced bone matrix.
MRI: Large mass with necrosis
Histology: Small blue round cells are present and have a clear cytoplasm on haematoxylin and eosin staining.
What test/treatment is done with HSP?
NSAIDs for analgesia and their anti-inflammatory effect
Antihypertensives may be needed to control blood pressure
After an episode of HSP, children should have regular urine dips for 12 months to check for renal impairment.
What complication is seen with SLE in mother?
Congenital heart block (presence of maternal anti-Ro and/or anti-La antibodies,)
Complication of artificial vs mechanical ventilation?
Artificial: retinopathy
Mechanical: pneumothorax
Congenital gonorrhoea px?
conjunctivitis - ophthalmic erythromycin
How does VSD present?
SOB (on exertion), pan systolic murmur lower left sternal edge, poor weight gain
What guidance is offered for glandular fever?
Avoid heavy lifting for a month due to splenic rupture
What bacteria most commonly affects those with CF?
Psudomonas
Croup differential diagnosis?
Bacterial tracheitis - doesn’t improve with meds
child has a high fever and has rapidly progressive airway obstruction with copious thick airway secretions -> Staphylococcus aureus
how are severe tet spells managed?
Phenylprine
how are severe tet spells managed?
Phenylprine
Why should oxygen be used cautiously in prematures?
Retinopathy of prematurity
What can eating cheese during pregnancy cause?
Listeria Monocytogene
- neonatal sepsis, meningitis, or respiratory distress due to aspiration of infected amniotic fluid
- treat with ampicillin and an aminoglycoside
Phototherapy guidelines?
If transcutaneous >250 check serum bilirubin. <6 hours if >24 hours and <2 hours if <24 hours
Starting
- if under 50 below threshold
Monitoring
During phototherapy:
- 4–6 hours after initiating phototherapy
- 6–12 hours when the serum bilirubin level is stable or falling
Stopping
- Stop phototherapy once serum bilirubin has fallen to a level at least 50 below the phototherapy threshold
- Check for rebound of significant hyperbilirubinaemia with a repeat serum bilirubin measurement 12–18 hours after stopping phototherapy.
Which diet is recommended in lennox-gastaut
Keto
What condition is HLA-DQ2 as
coeliac disease
How does coeliacs present in kids?
Short stature, wasting buttocks, weight loss, abdomen distension/pain
What is a complication in those with parvovirus b19?
Red cell aplasia
- Parvovirus infection also reduces erythropoiesis.
This is not significant for most patients; however, in vulnerable groups like those with conditions like sickle cell anaemia and hereditary spherocytosis that rely on erythropoiesis, infection can precipitate a severe anaemia, causing an aplastic crisis
-infection in the first half of pregnancy can also cause severe foetal anaemia that can precipitate hydrops foetalis and subsequent miscarriage
- Cardiomyopathy
What immunoglobulin provides passive immunity to child?
IgG
Treatment of anaphylactic shock?
3ooug IM adrenaline
What is eisenmenger syndrome?
reversal of a left-to-right shunt to a right-to-left shunt. It is thus an acquired right-to-left shunt.
How does congenital herpes present?
Local features include vesicular lesions on the skin, eye or oral mucosa, without internal organ involvement.
Disseminated features include seizures, encephalitis, hepatitis or sepsis. Symptoms commonly appear in the first week of birth but manifestation can be as late as the fourth week of life.
How deos slapped cheek present?
Initial stage: viral infection/headache
second stage: bright red rash over her cheeks and nose as well as a slightly more faded, lacy rash on her torso.
What is potters syndrome?
Renal agenesis leading to oligohydramnios (less room for baby)
How does potters syndrome present?
Flattened ‘parrot-beaked’ nose
Recessed chin
Downward epicanthal folds
Low-set, cartilage-deficient ears (known as ‘Potter’s ears’)
Pulmonary hypoplasia can result in the baby having respiratory distress at birth.
Which are the active vaccines?
Measles, mumps, rubella (MMR combined vaccine)
Rotavirus
Smallpox
Chickenpox
Yellow fever
What is meckels?
When a child’s small intestine was developing, a small pouch formed consisting of tissue from elsewhere in the body. Usually the pouch – also known as Meckel’s diverticulum – is formed from tissue similar to that found in the pancreas or stomach.
What is the classification of VUS? and treatment?
Grade 1 – into ureters only
Grade 2 – into pelvis causing no dilatation
Grade 3 – into pelvis causing mild dilatation
Grade 4 - into the pelvis causing moderate dilatation
Grade 5 – through to calyces
Prophylactic antibiotics for kidneys
What is used in ADHD if methylphenidate is not tolerated e.g. facial tics?
Lisdexafetamin ->Dexamfetamine -> Atomoextine
What 3 investigations are used for DKA?
- Serum ketones >3
- Blood gas ph<7.3 or bicarb <15
- Serum glucose >11
What is the treatment of DKA?
IV fluids followed by IV insulin
3 complications of DKA therapy?
- cerebral oedema
- hypokalaemia
- hypoglycaemia
- aspiration pneumonia
What can be used to manage cerebral oedema?
- Mannitol
- hypertonic saline
At what gestation is congenital rubella risk highest?
First trimester (beyond 20 rare)
First line for mild bleeding in ITP?
Tranexamic acid (or prednisolone)
AVOID ASPIRIN AND NSAIDS (lower platelets)
Treatment of asthma attack?
- oxygen
- Salbutamol + ipatropium
- steroids
Most common cause of UTI in kids
e-coli
Which of the following is a recommended first-line antibiotic for uncomplicated UTIs in children over 3 months old?
Trimethoprim
What imaging is needed after UTI if responded to antibiotics in 48 hours?
Renal USS in 6 weeks
What is another name for VSV?
HHV 3
What is another name for EBV?
HHV 4
Treatment of ottis media?
- Admit if < 3 months with a temp >38, or children with suspected acute complications of otitis media such as meningitis, mastoiditis or facial nerve palsy.
- Consider admitting any children who are very systemically unwell.
- pain and fever with paracetamol or ibuprofen.
- A delayed antibiotic prescribing strategy can also be appropriate. This involves asking patients/parents to start taking antibiotics if symptoms don’t improve within four days.
- Offer immediate antibiotic prescription to children who are systemically unwell (but don’t require admission) or those at high risk of complications (e.g. immunocompromised patients). (5 day amoxicillin or clarithromycin)
What is the treatment of ezcema herpeticum?
Acyclovir
What should all members of house exposed to meningitis receive?
Ciprofloxacin
What determines the level of cyanosis in TOF?
pulmonary stenosis
What maternal condition increased the babies risk of TGA?
Type 1 diabetes
What tests are done in pirmary practive when susoecting ovarian cancer?
- serum CA125 (>35 could be malignancy)
- if raised - an ultrasound of the abdomen and pelvis
These investigations may be bypassed and a direct referral to gynaecology made if physical examination identifies ascites and/or a suspicious abdominal or pelvic mass.
what are the types of hypersensitivity reactions?
Type 1: IgE immediate reaction (allergic asthma)
Type 2: IgG + IgM occurs in hours to days
Type 3: insect bites
Type 4: Delayed hypersensitivity/contact dermatitis
What markers are raised in JIA?
ESR high
RF+ANA low
How is perthes diagnosed?
x-ray ->MRI
What congenital infection is associated with hydrocephalus?
Rubella (aqueduct stenosis)
How does HIV present? and treated?
- fever and lymphadenopathy
- maculopapular rash, found commonly on the upper chest
- mucosal ulcers
cART
What is the honeymoon period in T1DM?
Residual functioning of beta cells after diagnosis/early in disease so low requirement of insulin
Risk of having second febrile seizure?
30-40%
What vitamins are those with CF lacking?
A,D,E,K (fat soluble)
First sign of puberty in girls vs boys?
Girls: breasts
Boys: Testes increase >4ml
What is a complication of broncholitis?
Broncholitis obliterans caused by adenovirus
What can be given in primary care when meningitis suspected?
IV/IM benzylpenicillin
What is the pathological process behind meningitis?
Intravascular coagulation
bacteria enters circulation, initiates inflammatory process leading to capillary leakage and intravascular thrombosis
How do you differentiate between orbital and preseptal cellutitis?
Both precipitated by bacterial sinus infection
orbital affects deeper structures so has visual symptoms and limits eye movements
How does ALL present?
- bone marrow failure (anaemia, neutropenia, thrombocytopenia)
- easy bruising + frequent infections
- hepatosplenomegaly
- bone pain
Bone marrow biopsy
Most likely cause of febrile seizures?
Roseola + viral infections
How long should you be kept in hospital after anaphalctic shock?
6 hours
What sign can indicate congestive cardiac failure in children?
Hepatomegaly
What are the complications associated with nephrotic syndrome?
- Frequent relapses
- Hypercholesterolaemia
- Hypovolaemia
- Infection (loss of immunoglobulins in urine)
- Thrombosis
- pleural effusion
How does acute ottis media vs with eddusion look on otoscopy?
Ottis media: red, hot , bulging
Effusion: grey + visible fluid behnd tymphanic membrane
How is acute mastoiditis treated?
Immediate referral to hospital for IV antibiotics and CT scan
What is another name for port wine stain? and what is the pathophysiology?
Naevus flammeus -> vascular malformation of the
capillaries in the dermis. Laser therapy can be used as a treatment.
What genetic conditions are more likely to get GORD?
- Downs
- cerebral palsy
Complications of gord?
Recurrent pulmonary aspiration + Sandifer syndrome
Treatment of glue ear?
Grommets/temporary hearing aids if > 3 months
Treatment of impetigo?
- lesions are localised and non-bullous: a short course of hydrogen peroxide cream is
- the lesions are near the eye: topical fusidic acid are given.
- rash is widespread and non-bullous/systemically unwell: flucloxacillin, or clarithromycin if penicillin-allergic.
What is the incubation period of chicken pox?
21 days
What test is used to determine if there’s shortening of tibia or femoral in DDH?
Gallaezi test
What is a common side effect of salbutamol?
Tachycardia
How does aplastic crisis in sickle cell present?
tachypnoea and tachycardia in the absence of pain?
What food should be avoided under 12 months?
Honey - botulism
What is von Willebrand disorder?
Dysfunctional platelet adhesion🡪 Impaired primary hemostasis
Which cancer is linked to EBV?
Hodgkins lymphoma and Burkitt lymphoma (non-hodgkins)
Hallmark sign in hodgkins?
reed-Sternberg cells
What staging is used for hodgkins?
Ann-arbor using CT/MRI
What is the ann-arbor staging?
1 – confined to single lymph node
2 – involves two or more nodal areas on the same side of the diaphragm
3 – involvement on both sides of the diaphragm
4 – spread beyond lymph nodes eg. to liver/bone marrow
Further staged as “A” or ”B”. If “B:” symptoms are present, then a B is added to the staging; eg. stage 3B
Treatment of hodgkins
ABVD (combination chemotherapy)
Adriamycin, Bleomysin, Vinblastine, Dacarbazine
What is seen with bloods in lymphoma?
High lactate dehydrogenase
Treatment of non-hodgkins?
R-CHOP (combined chemotherapy)
Rituximab, cyclophosphamide, hydroxy-daunorubicin, vincristine, prednisolone
How do you differentiate between partial androgen insensitivity and complete?
Partial ( like CAH) has ambiguous genetalia
Complete: high testosterone but being completely inactive so male internal genitalia or external genitalia do not develop. Sertoli cells are still present and produce anti-Mullerian hormone, so the Mullerian duct regresses meaning female internal genitalia are not produced. The lack of DHT (made from testosterone) causes female external genitalia to develop.
What is glue ear?
otitis media with an effusion
What is the most common congenital male reproductive disorder?
Cryptorchidism
How does molluscum contagious present?
firm, smooth, umbilicated papules, usually 2-5 mm in diameter and appear in “crops”. They may be the colour of skin, white, translucent or slightly yellow
What is seen on x-ray with multiple myeloma?
Punched out lesions
First line treatment for ITP?
Steroids
Which vitamin deficiency is associated with an increased risk of severe measles infection?
Vitamin A
Treatment of NRDS?
intratracheal instillation of artificial surfactant
Management of meconium aspiration?
Admission to NICU for oxygen and antibiotics
RF for cerebral palsy?
- Birth complications
- Maternal infection
- Maternal thyroid dysfunction
- prematurity
- low birth weight
Klumpke’s palsy
Involves the C8-T1 nerve roots with corresponding dermatomal sensory loss, and weakness of the intrinsic muscles of the hand. Uncommonly, T1 involvement may also result in an ipsilateral Horner’s syndrome.
Diaphragmatic hernia presentation? and treatment?
decreased air entry on the left side of his chest and a displaced apex beat. Abdominal examination demonstrates a scaphoid abdomen but is otherwise unremarkable. (L>R)
intubation and ventilation if needed
Treatment of mycoplasma pnemonia?
Erythromycin
Erbs palsy
c5-c6
When can a transcutaneous bilirubin monitor not be used?
baby < 24 hours -> serum bilirubin every 2 hours
Treatment for turners?
Growth hormone therapy
