Paeds SBAs Flashcards
The paediatric team is resuscitating a 3-month-old boy who is in Pulseless Electrical Activity (PEA). He was discovered to be blue and lifeless when his parents went to wake him in the morning. The airway has been secured and despite ventilation the child remains blue. An intra-osseous needle has been inserted and two boluses of normal saline have been given. The nurse reports that the temperature of the child is 35°C. You listen to the chest and can hear bilateral breath sounds.
Where is the most appropriate position on the chest to do cardiac compressions?
Midline between the nipples
1 finger breadth above the line between the nipples
1 finger breadth below the line between the nipples
None of the above
1 finger breadth below the line between the nipples
In an infant the heart is lower in relation to the external landmarks than in older children or adults. The area of compression over the sternum should be one fingerbreadth below an imaginary line between the nipples.
You are in the acute assessment unit and see David, a 15-month-old boy who has a fever of 38.5°C. He has had a runny nose, cough and a fever for 3 days. Since this morning he has slept and has been difficult to wake. His heart rate is raised. He has a rash scattered over his legs which does not disappear with pressure.
Which of the following is the most likely diagnosis?
NAI HSP ITP ALL Septicaemia
Septicaemia
He has a purpuric rash, with lesions of variable size. In a febrile child, meningococcal septicaemia is most likely. This may be accompanied by meningitis.
Henoch–Schönlein purpura although localized to the legs, is associated with abdominal pain and joint pain but not with fever.
With Idiopathic thrombocytopenia the children are usually well.
This is a relatively short history of the child being unwell. In acute lymphoblastic leukaemia you would expect a longer history.
A 3-year-old boy who is unconscious arrives in Accident and Emergency. You manage his Airway, Breathing and Circulation. His blood glucose is normal. On examination you note that he has bilateral pinpoint pupils. His temperature and other vital signs are otherwise normal.
What is the most likely cause?
3rd nerve lesion Severe hypoxia Hypothermia Tentorial herniation Opiate poisoning
Opiate poisoning
Bilateral, pin-point pupils with coma can be caused by a pontine lesion or opiate poisoning. Opiate poisoning may occur in homes with illicit substance abusers or adults on methadone.
Third nerve lesions and tentorial herniation would cause a unilaterally dilated pupil.
Severe hypoxia would cause dilated pupils.
With hypothermia the child’s temperature would be low and causes dilated pupils.
You are called to see a 3-year-old boy with a high fever. The nurse is worried that he is very sleepy. As you walk into the resuscitation room he makes no spontaneous response. You try calling his name but he makes no response. On stimulation, his eyes open, he moans and he raises his hand and pushes your hand away.
What is this child’s Glasgow Coma Score?
8 9 10 11 12
9
Eyes: React to pain - 2
Verbal: Moans to pain - 2
Motor: Localises pain - 5
Ryan, aged 10 months, is rushed to the Accident and Emergency department after being found submerged in the bath. His mother runs screaming into the department saying ‘help my baby, please’.
Which is the next most appropriate step?
Commence bag and mask ventilation
In managing his airway, his head should be in the neutral position
Commence chest compressions in a ratio of 15:2
Assess patient, call for help
Remove wet clothing/towels
Assess patient, call for help
All resuscitation algorithms ensure that patient is assessed in a sequential manner, first initial assessment and then management in an A,B,C approach. Calling for help early on in these situations is paramount as you need many people for resuscitation. This baby is going to need his airway managing in the neutral position, with bag and mask ventilation and cardiac compressions in a ratio of 15:2; the wet clothing will also need removing.
Mohammed, aged 8 months, has been vomiting and off his feeds for two days. Initially he had episodes of crying uncontrollably, drawing his legs up into his abdomen as if in pain, and appeared fractious. His mother gave him some oral rehydration solution, but his vomiting continued and he has become lethargic. On admission to hospital he is in shock.
What is the most likely diagnosis?
Gastroenteritis Malrotation Strangulated hernia Intussusception Meckel diverticulum
Intussusception
Intussusception is the most likely cause of the pain and shock. Although this could be a strangulated hernia, this should be evident on clinical examination.
Mohammed, aged 8 months, has been vomiting and off his feeds for two days. Initially he had episodes of crying uncontrollably, drawing his legs up into his abdomen as if in pain, and appeared fractious. His mother gave him some oral rehydration solution, but his vomiting continued and he has become lethargic. On admission to hospital he is in shock. Intussusception is suspected.
Mohammed is 8 months old and weighs 8 kg. He needs a bolus of normal saline 0.9% to treat his shock.
What volume of fluid would you give initially?
40ml 160ml 320ml 680ml 800ml
160ml
This is 20 ml/kg initially, repeated as necessary.
Mohammed, aged 8 months, has been vomiting and off his feeds for two days. Initially he had episodes of crying uncontrollably, drawing his legs up into his abdomen as if in pain, and appeared fractious. His mother gave him some oral rehydration solution, but his vomiting continued and he has become lethargic. On admission to hospital he is in shock. Intussusception is suspected.
Mohammed has received the fluid bolus of normal saline 0.9% which has improved his condition. From his presentation you suspect he is 10% dehydrated. You receive his laboratory results which reveal a plasma sodium of 138 mmol/L (within the normal range). His continuing fluid loss from vomiting is small and can be ignored. (The maintenance intravenous fluid requirement for a child of this age is 100 ml/kg/24 h.)
What is Mohammed’s total fluid requirement for the initial 24 hours? He weighs 8 kg.
160ml 320ml 800ml 880ml 1600ml
1600ml
Mohammed’s fluid requirement is calculated by adding: • Deficit: 10% of 8 kg = 800 ml • Maintenance: 100 ml/kg/24 h = 800 ml • Continuing losses: 0 ml Total = 1600 ml
You are called to the resuscitation room where there is a 6-year-old child who has arrived by ambulance. He is a known to have epilepsy and is on anti-epileptic treatment. The child has been having a generalised seizure for 15 minutes. The ambulance crew gave a dose of buccal midazolam 5 minutes ago. The emergency doctor has maintained the airway and has applied oxygen with a non-rebreathe mask. His capillary refill time is less than 2 seconds and his heart rate 120 beats/minute.
What is the next most appropriate management step?
Administer further anti-convulsant Gain iv access Check blood glucose level Check pupils Check conscious level
Check blood glucose level
This is the most appropriate next step as, if the patient is hypoglycaemic, the only treatment to stop the fit would be to administer glucose.
Seb, a 2-year-old boy, was at his cousin’s birthday party. His mother noticed that he has suddenly developed a widespread urticarial rash and has also become flushed in the face. His vital signs are normal and he has no respiratory compromise.
Which medication would you give?
im adrenaline Oral corticosteroid iv hydrocortisone oral antihistamine im antihistamine
Oral antihistamine
In children, the most common causes of acute food allergy are ingestion or contact with nuts, egg, milk or seafood. Urticaria and facial swelling are mild reactions. Immediate management is with an oral antihistamine (e.g. chlorpheniramine) and observed over 2 hours for possible
Jenny, a 3-year-old girl, was at a village fete. She suddenly developed swollen cheeks and lips and a widespread urticarial rash. She is rushed to the nearby general practice surgery, where it is noted that her breathing is very noisy. She is distressed and frightened. On auscultation she has widespread wheeze.
Which medication would you give first?
im adrenaline Oral corticosteroid iv hydrocortisone oral antihistamine im antihistamine
IM adrenaline
This child has anaphylaxis, which is life-threatening as she has upper airway obstruction and bronchoconstriction. Priority is to manage the airway and give oxygen via a non-rebreathe mask. The first medication to give would be intramuscular adrenaline.iv hydrocortisone should only be given after immediate treatment of the upper airway obstruction with intramuscular adrenaline. Also, her upper airway obstruction may be further compromised by the distress of establishing an intravenous cannula. It takes about 6 hours to have optimal effect.
This child is unlikely to be able to take oral medications and the antihistamine alone will not treat the upper airway obstruction and oral steroids would take too long to work.
im antihistamine would make the situation worse, as it is painful and will not directly treat the upper airway obstruction.
There has been a dramatic decline in the incidence of sudden infant death syndrome in the UK.
Which of the following is the single most important factor responsible for this decline?
Feet to foot of cot
Supine sleeping
Keeping baby in parent’s room until 6 months
Keeping room cool
Parents should not smoke in same room as infant
Supine sleeping
All the answers have helped reduce the risk of cot death, but the single most important factor is putting babies to sleep on their backs.
What is the most common cause of death in children aged 1–14 years in the UK?
Accidents Congenital heart disease Infectious diseases Malignant disease Respiratory disease
Accidents
This is now the commonest cause of death, followed by malignant disease.
Hamim, a boy aged 3 years, fell 3 metres from a first-floor balcony on to a concrete path. He presents to the Accident and Emergency department with his parents who are concerned that he has vomited several times since the episode. After the fall he immediately cried out in pain, but appeared to be all right. His mother reports that he did not lose consciousness. On examination he is found to be fully conscious but has a large bruise over the left parietal region. There are neither focal neurological signs nor any other injuries. His heart rate is 110 beats/minute, his respiratory rate is 25 breaths/minute and his blood pressure is 90/50 mmHg.
Which of the following would be the most serious clinical sign?
Nasal discharge since his fall Further enlargement of parietal bruise A fractured nose Laceration above the eye requiring suturing A unilateral black eye
Nasal discharge since his fall
This child has had a significant head injury. His vital signs are normal. A nasal discharge post head trauma is a significant sign. It may be leakage of cerebrospinal fluid (CSF) that can indicate a basal skull fracture.
Parietal bruising, a fractured nose or facial laceration are all distressing, but do not suggest significant brain or skull injury.
Black eyes (periorbital ecchymosis) are a significant sign if bilateral, as this can indicate a basal skull fracture.
Hamim, a boy aged 3 years, fell 3 metres from a first-floor balcony on to a concrete path. He presents to the Accident and Emergency department with his parents who are concerned that he has vomited several times since the episode. After the fall he immediately cried out in pain, but appeared to be all right. His mother reports that he did not lose consciousness. On examination he is found to be fully conscious but has a large bruise over the left parietal region. There are neither focal neurological signs nor any other injuries. His heart rate is 110 beats/minute, his respiratory rate is 25 breaths/minute and his blood pressure is 90/50 mmHg.
Eight hours after admission, the nurses note a change in his level of consciousness. He is now responsive only to painful stimuli; his left pupil is dilated although still responsive to light. His airway, breathing and circulation are satisfactory. A CT scan shows that there is a haemorrhage and a skull fracture. He is stabilized in the resuscitation room.
Which of the following is the most appropriate next step in his management?
Clotting studies EEG Skeletal survey Ophthalmology opinion Neurosurgical referral
Neuro referral
This child has sustained a potentially serious head injury and now has reduced level of consciousness and focal neurological signs, which are indications to be assessed by a neurosurgical specialist. The priority for this child is to prevent further secondary brain injury.
Chelsea is a 2-year-old girl who presented 6 months ago with a fractured femur which was felt to be accidental. She presents to Accident and Emergency having slipped in the bath whilst briefly being left alone. On examination there is swelling and bruising over Chelsea’s anterior right chest wall. She has some older bruises on her right thigh. She has no other medical problems and is not on any medication. The chest X-ray reveals rib fractures.
Select the most appropriate next management:
Genetic counselling Parental reassurance Child protection case conference Discharge home without follow up Health visitor home assessment
Child protection case conference
Even if you do not see the fractures on this X-ray, there are some features in this history which are very concerning. The child is left unsupervised in the bath; she has had a previous femur fracture and has bruises on her thigh. A child protection conference needs to be undertaken to assess the safest and most appropriate outcome for this child.
You are a junior doctor working on the paediatric ward. You are asked to take some bloods from Chloe, an 11-year-old girl. Her parents do not wish to be present. When rolling up her sleeve to look for a suitable place for venepuncture you note numerous bruises from strap marks to her upper arm. You ask her how she got the bruising. She replies that her uncle did it as she had been misbehaving.
What should you do with the information?
Ignore it; she was being disciplined for misbehaviour
Just document what was said in the notes including sketches and photographs
Document what was said in the medical notes including sketches and photographs and inform the Consultant on call.
Inform the health visitor and request a home assessment
Inform her mother what she said and suggest she asks the uncle about it
Document what was said in the medical notes including sketches and photographs and inform the Consultant on call.
This is a safeguarding issue, as the girl has alleged physical abuse and this needs to be taken seriously. Other agencies e.g. social services and school need to be contacted to identify any concerns, and the patient needs a full medical examination by a paediatrician trained in child protection.
Louise, aged 4 years, was hit by a car in the local supermarket car park. She is brought to the Accident and Emergency department by the paramedical team.
An initial assessment shows:
• Airway —neck collar in place, talking to mother
• Breathing —receiving oxygen via a rebreathing circuit, oxygen saturation 99%
• Breathing —air entry satisfactory and equal bilaterally, respiratory rate 30/min
• Circulation —pulse 160/minute, blood pressure 90/50, capillary refill time 3 sec
• Disability —alert, but frightened and agitated, moving all four limbs.
She has abrasions to her left flank and pain in her left shoulder.
What is the next intervention needed?
Intubation and ventilation IV access CXR Analgesia Blood glucose
IV access
Louise has cardiovascular compromise and urgently needs fluid resuscitation. She therefore needs intravenous access.
A chest X-ray is needed but this comes after ABC.
Analgesia and a blood sugar are important but not until she has some fluid.
Louise, a girl aged 4 years, was hit by a car in the local supermarket car park. She is brought to the Accident and Emergency department by the paramedical team.
An initial assessment shows:
• Airway —neck collar in place, talking to mother
• Breathing —receiving oxygen via a rebreathing circuit, oxygen saturation 99%
• Breathing —air entry satisfactory and equal bilaterally, respiratory rate 30/min
• Circulation —pulse 160/min, blood pressure 90/50, capillary refill time 3 sec
• Disability —alert, but frightened and agitated, moving all four limbs.
She has abrasions to her left flank and pain in her left shoulder.
Chest and abdominal X-rays show fractures of the 9th and 10th ribs on the left-hand side.
What is the most important investigation to perform to establish the cause of her condition?
Abdo US CT head Cervical spine X-ray FBC Blood creatinine, U&Es
Abdo US
The history and signs suggest hypovolaemic shock from splenic injury. She needs an urgent abdominal ultrasound scan (FAST scan, focused abdominal sonography in trauma).
Ronaldo is a 2½-year-old boy from Brazil. He pulled a chip pan off the cooker and has been extensively burnt. He is rushed to the nearest Accident and Emergency department. His airway, breathing and circulation are satisfactory. His burns are to his chest, abdomen and his right arm and hand. Most of the burnt area is now blistering and mottled in colour, with a few white areas. Intravenous analgesia is given.
What immediate management does Ronaldo require?
IV 0.9% saline Place in cold water Cover the burns with sterile dressings Intubation and artificial ventilation IV antibiotics
IV 0.9% saline
There will be significant fluid loss through the burnt areas, which needs replacing.
Jake is a 3-year-old boy. His brother spilt a pan of hot water over him and he has been extensively burnt. He is rushed to the nearest Accident and Emergency department. His airway and breathing are satisfactory. He is tachycardiac, his capillary refill time is 4 seconds and he has a low blood pressure. He has 20% burns involving his chest, abdomen and his right arm and hand.
What is the most important underlying cause for his tachycardia and a capillary refill of 4 seconds?
Shock secondary to his pain from his burns
Shock due to loss of blood plasma, because of damage to his blood vessel secondary to his burn
He has shock due to loss of red blood cells, because of damage to his blood vessels secondary to his burn
He has shock due to vasodilation of his blood vessels, secondary to his burn
He has shock due to vasodilation of his blood vessels, secondary to infection developing in his burn
Shock due to loss of blood plasma, because of damage to his blood vessel secondary to his burn
Jake has hypovolaemic shock secondary to the loss of blood plasma. This is secondary to loss of skin integrity.
Solomon, aged 3 years, has been found eating some of his pregnant mother’s iron tablets; up to 10 tablets are missing. Their general practitioner advised that he should be taken to hospital directly. On examination in the emergency department he is found to be talkative, with no obvious abnormalities. He has no other medical problems and is not normally on any medications.
What would be the first investigation you would perform?
Abdo Xray FBC Clotting Serum iron LFTs
Abdo Xray
An abdominal X-ray identifies if there is a significant number of tablets in his stomach.
The serum iron result will not be helpful at this stage as he will not have absorbed the medication.
Solomon, aged 3 years, has been found eating some of his pregnant mother’s iron tablets; up to 10 tablets are missing. Their general practitioner advised that he should be taken to hospital directly. On examination in the emergency department he is found to be talkative, with no obvious abnormalities. He has no other medical problems and is not normally on any medications.
Your investigation suggests a significant ingestion of iron.
Which of the following would you initiate?
IV acetylcusteine IV naloxone IV desferrioxamine Forced alkaline diuresis Intubate and hyperventilate
IV desferrioxamine
Intravenous desferrioxamine binds with iron in the blood excreting it in urine and faeces.
Pauline is a 6-year-old girl. Her teacher is concerned, as she has been rubbing herself ‘down below’ in the classroom and touching other girls. She later discloses to her teacher that her stepfather has hurt her with his ‘willy’. She is seen by the consultant paediatrician who notices some vulval soreness and so takes a swab which reveals gonococcus. She also notices that there is some bruising to the thighs. She plots her weight and finds it to be just above the 99th centile. She has no other medical problems.
Which of the following findings is the most suggestive of sexual abuse?
Bruising to the thighs Disclosure of event to teacher Gonococcus on swab Sexualised behaviour Vulval soreness
Gonococcus on swab
All of these could suggest sexual abuse but only the gonococcus on the swab can absolutely confirm it. Identifying a sexually transmitted infection in a child is highly suggestive of sexual abuse. It will not however inform you of whom the perpetrator is.
The disclosure is very useful and a police investigation would need to be undertaken. But only the gonococcus on the swab can absolutely confirm sexual abuse.
Bruising over the thighs is common in active children but it is more concerning if it is found in the inner thigh as this area is anatomically ‘protected’ and not often bruised accidentally. But only the gonococcus on the swab can absolutely confirm sexual abuse.
Mr and Mrs Walsh attend clinic with their new baby, Ophelia, who has Down syndrome. They are keen to have further children and want to know more about their future risk of having children with Down syndrome. What chromosomal abnormality is likely to have caused Ophelia to have Down syndrome?
Non-disjunction Translocation Mosaicism Point mutation Triplet repeat expansion
Non-disjunction
It is responsible for 94% of cases of Down syndrome. the pair of chromosome 21s fails to separate, so that one gamete has two chromosome 21s and one has none. related to maternal age.
Translocation (5%) - When the extra chromosome 21 is joined onto another chromosome (usually chromosome 14, but occasionally chromosome 15, 22 or 21), this is known as a Robertsonian translocation.
Mosaicism (1%) - In mosaicism, some of the cells are normal and some have trisomy 21. This usually arises after the formation of the chromosomally normal zygote by non-disjunction at mitosis but can arise by later mitotic non-disjunction in a trisomy 21 conception. The phenotype is sometimes milder in Down syndrome mosaicism.
Mr and Mrs David are seen by the geneticists as their baby, Sarah, has Down syndrome. Her chromosomes are examined. Three copies of chromosome 21 are seen, one of which is attached to chromosome 14. How would you describe this abnormality?
Non-disjunction Balanced Robertsonian translocation Unbalanced Robertsonian translocation Mosaicism Triplet repeat expansion
Unbalanced translocation.
This is important because there is an increased risk of recurrence as one of the parents is likely to have a balanced translocation whereby one of their copies of chromosome 21 is attached to chromosome 14.
Olive is a 10-day-old baby with Down syndrome. On examination, you hear a loud heart murmur. What is the most likely cause?
Patent ductus arteriosus Aortic stenosis Coarctation of the aorta Innocent murmur Atrioventricular septal defect
Atrioventricular septal defect.
This is the most common congenital cardiac anomaly in children with Down syndrome. 40% of children with Down syndrome have a congenital heart defect and therefore it is important that all children have an echocardiogram in the neonatal period.
Fiona is a well 4-year-old girl with Down syndrome. She attends her yearly follow-up appointment with her mother. There are no real problems other than constipation, for which her general practitioner has started treatment. When you plot Fiona on the Down syndrome growth chart, you notice that her height is starting to drift from the 75th to the 25th centile. Her weight, however, has gone from the 50th to the 75th centile.
Which of the following investigations would you perform?
FBC TFT Cytogenetic testing Coeliac screen U&Es
Thyroid function tests
Children with Down syndrome are at an increased risk of hypothyroidism. Growth failure and constipation are symptoms of hypothyroidism. Coeliac disease is more common in Down syndrome and it can cause short stature; however her weight would be falling.
Mary is an infant with Down syndrome. She was diagnosed soon after birth and this has been confirmed with a rapid karyotype. Her antenatal scans had been all normal and a routine echocardiogram on the neonatal unit shortly after birth was normal. She attends the community clinic for the first time at 4 weeks of age. She is now thriving and feeding well. Her parents have many questions about what is going to happen in the future. In particular, they have been reading that she is at increase risk of certain diseases because she has Down syndrome.
Out of the following, which is a higher risk to Mary, compared with the general population?
Duodenal atresia Ischaemic heart disease Pyloric stensosis Congenital heart disease Leukaemia
Leukaemia.
Children with Down syndrome are also at an increased risk of congenital heart disease and duodenal atresia. However Mary had a normal echocardiogram and duodenal atresia would have already presented with bile-stained vomiting within the first few days of life. Children with Down syndrome are not at an increase risk of ischaemic heart disease or pyloric stenosis.
Louise has Turner’s syndrome. What is her karyotype?
46, XO 46, XX 45, XO 45, XY 47, XXY
45, XO.
There are 22 pairs of autosomes, and only one sex chromosome, an X. This makes the total number of chromosomes 45.
Louise is a 14-year-old girl. She is attending the endocrinology clinic, as she is the shortest girl in her class and wants to know if there is treatment to make her taller. She is otherwise well and has no other medical complaints. She as always been the shortest girl in her class. Her clinical appearance is shown in the picture (round facies with short, webbed neck). Her height plots well below the 0.4th centile but her weight is on the 9th centile. Her karyotype is 46, XX.
Select the most likely cause of her short stature.
Normal variant Turner syndrome Noonan syndrome Cushing syndrome Down syndrome
Noonan syndrome.
She has a round facies with short, webbed neck and short stature since infancy, characteristic of Noonan syndrome. There is some overlap with the phenotype of Turner syndrome, but her karyotype is normal. Cushing syndrome – there is growth failure.
A mother has just found out she is pregnant and asks for advice about how to look after her health and nutrition during pregnancy and to provide the best possible care for her newborn baby. She smokes 15 cigarettes a day. You recommend she gives up smoking.
Select the problem that has been linked to smoking.
Increased risk of shoulder dystocia Increased risk of baby that is small for gestational age Increased risk of Vitamin A deficiency Increased risk of neural tube defects Increased risk of dysmorphic syndromes
Increased risk of baby that is small for gestational age
Smoking reduces birthweight and is associated with increased risk of stillbirths and miscarriages.
A mother has her routine 20-week antenatal scan. The sonographer finds the fetal abdominal and head circumference measurements are normal, but is concerned that there is an abnormally small amount of amniotic fluid (oligohydramnios).
Select the most likely cause for this.
Maternal diabetes Duodenal atresia Gastroschisis Poorly functioning kidneys Severe intrauterine growth restriction
Poorly functioning kidneys
Oligohydramnios, reduced or lack of amniotic fluid, may be associated with decrease fetal urine output because of abnormal kidneys.
Oligohydramnios may be associated with severe intrauterine growth restriction, but the sonographer has identified a normal head and abdominal circumference.
Duodenal atresia, Maternal diabetes may be associated with polyhydramnios (excess amniotic fluid).
Gastroschisis should not affect the volume of amniotic fluid.
A midwife is concerned that a mother who is at 32 weeks’ gestation has a symphysis-fundal height smaller than expected. An ultrasound confirms intrauterine growth restriction.
Select the feature that would concern the sonographer that there may be fetal compromise.
Reverse end diastolic flow in the umbilical artery Active fetal movements Accelerations of metal heart rate Normal amniotic fluid volume Fetal breathing movements seen
Reverse end diastolic flow in the umbilical artery
Absent or reversed flow velocity during diastole carries an increased risk of morbidity from hypoxic damage to the gut or brain, or of intrauterine death.
Fetal breathing movements, accelerations on the cardiotocography (CTG) trace, active fetal movements and a normal amniotic fluid volume are a normal sign.
A mother has just found out she is pregnant with twins. Her antenatal scan reveals dichorionic, diamniotic twins.
Select the risk which is increased because of her twin pregnancy.
Twin to twin transfusion Macrosomia Gestational diabetes Post-term gestation Congenital abnormalities
Congenital abnormalities
There is a higher rate of congenital abnormalities in twin pregnancies. These occur twice as frequently as in a singleton (but the risk is increased four-fold in monochorionic twins).
Twin-twin transfusion syndrome is found in monochorionic twins (with a shared placenta). She has dichorionic diamniotic twins and therefore they are not at risk of this as they will have two separate placentas.
Multiple births are at risk of intrauterine growth restriction (IUGR) rather than macrosomia.
Multiple births are at risk of pre-term rather than post-term births. The median gestation for twins is 37 weeks.
You perform a routine newborn examination on a baby who is 20 hours old.
Which one of the following is true?
An absent red reflex is an indication for routine ophthalmological referral as an outpatient
An undescended testis requires urgent surgical repair
A heart murmur is physiological on the first day of life
The palate should be assessed by palpation only
Breast enlargement in newborn babies of either sex does not require investigation
Breast enlargement in newborn babies of either sex does not require investigation
Breast enlargement can occur in either sex and a small amount of milk may be discharged. This resolves spontaneously and does not require investigation.
An absent red reflex could be caused by cataracts or a retinoblastoma and needs an urgent ophthalmological referral.
Urgent surgical opinion for an undescended testis is not indicated as most descend spontaneously in the first year of life and surgical repair is therefore delayed. The testis should be rechecked at several months of age.
Although many heart murmurs heard at the first day of life are innocent and will disappear, some are from congenital heart disease.
Examination to exclude a cleft palate should be by palpation and visualisation of the palate.
An Afro-Caribbean mother, who is not known to have diabetes mellitus, is found to have glycosuria at her midwife appointment at 32 weeks’ gestation. Her glucose tolerance test and fasting glucose is abnormal. She is given dietary advice to control her blood sugars.
What is her newborn baby at increased risk of?
Small for gestational age Respiratory distress syndrome Hyperglycaemia at birth Anaemia Type 1 DM
Respiratory distress syndrome
This mother has gestational diabetes which places the infant at increased risk of respiratory distress syndrome as lung maturation is delayed.
Transient hypoglycaemia is common during the first day of life due to fetal hyperinsulinism, which is a response to the high levels of maternal glucose crossing the placenta.
These newborn infants are at increased risk of polycythaemia (venous haematocrit >0.65) rather than anaemia.
There is no increased risk of type 1 diabetes mellitus in babies born to mothers with gestational diabetes.
In the fetus, the lungs are filled with fluid and oxygen is supplied by the placenta. To enable the baby to adapt to extrauterine life, the fetus undergoes physiological changes during labour and in the first few minutes of life.
Which of the following is not true?
Oxygenated blood flow through the ductus arteriosus causes closure
Lung liquid is drained during descent through the birth canal
Pulmonary vascular resistance increases at birth
Foramen ovale closes due to increased left atrial pressure
Tactile stimuli at birth help initiate breathing
Pulmonary vascular resistance increases at birth
This is not true. Pulmonary vascular resistance falls on inflation of the lungs. There is therefore increased blood flow through the lungs, which leads to increased left atrial filling. The increased pressure in the left atrium causes the foramen ovale to close.
Jonathon, a newborn Caucasian baby, is noted to have hepatosplenomegaly and a petechial rash. His red eye reflex is normal and there is no heart murmur. He fails his newborn screening hearing test. His mother is from the UK and her antenatal screening bloods were all normal.
What is the most likely congenital infection that has caused these symptoms?
CMV Rubella Varicella zoster Toxoplasmosis Syphilis
CMV
This is the most common congenital infection in the UK. Most babies born to mothers with CMV infection during pregnancy are normal at birth, but 5% have clinical features such as hepatosplenomegaly and petechiae. Most of these babies will go on to have neurodevelopmental disabilities.
Congenital rubella can cause similar signs but is often associated with cataracts and congenital heart disease as well as deafness; congenital rubella is extremely rare in the UK since the MMR vaccine was introduced, and all mothers are screened for rubella antibodies.
Babies whose mothers develop chickenpox in the first 20 weeks of pregnancy are at risk of severe scarring of the skin and possibly ocular and neurological damage.
Babies with toxoplasmosis can have some of the features described, with the addition of intracranial calcification, hydrocephalus and retinopathy, but this infection is extremely rare in the UK.
This is unlikely because mothers in the UK are screened for syphilis infection, and we know that this mother’s screening bloods were normal.
A newborn Caucasian girl is having her routine neonatal examination at 24 hours of age. She was born at term by normal vaginal delivery. Examination is normal including her tongue, which is pink, but her hands and feet are still blue.
What investigation do you need to do?
None Check O2 saturation Four limb blood pressures Echocardiogram Chest X-ray
None
Hands and feet being blue (peripheral cyanosis) is very common in the first days of life. If the rest of the examination is normal, especially that the tongue is pink (i.e. no central cyanosis), no investigations are indicated and the parents can be reassured.
Four limb blood pressures are useful for helping to detect coarctation of the aorta. Peripheral cyanosis is not a sign of this. In addition, examination of the baby (which must include auscultation of the heart and palpation of the femoral pulses) is normal.
This baby is not centrally cyanosed and has a normal examination. Therefore there is no sign of cardiac disease, and the baby does not need an echocardiogram.
A chest X-ray would detect cardiac or respiratory disease, and this baby has a normal examination with no central cyanosis. A chest X-ray is therefore not indicated.
Oxygen saturations are likely to be normal in this child who does not have central cyanosis.
You are asked to review a baby by a midwife who has recently started doing routine examinations of the newborn. The baby was an unexpected breech presentation but had no neonatal problems. When she examined the hips she felt the left hip was ‘clicky’. When you examine the hips, you find that both hips abduct fully and the head of femur is stable and was not dislocated or dislocatable. There is no family history of developmental dysplasia of the hip.
What investigation and follow up does this child need?
None
Hip US in 6 weeks as an outpatient
Hip US immediately
Hip US immediately and referral to orthopaedic surgeon
Hip US immediately and referral to physio
Babies with breech presentation or where there is a positive family history are at increased risk of developmental dysplasia of the hip (DDH). In many hospitals these infants are recommended to have a hip ultrasound at about 6 weeks of age.
Babies with a breech presentation are at an increased risk of developmental dysplasia of the hip and this should be looked for.
Although this baby is at risk of developmental dysplasia of the hip because of the breech presentation, the hips are stable on examination and investigations do not need to be completed urgently. ‘Clicky’ hips are a common and benign finding on examination.
A mother is known to have pre-eclampsia and her fetus has shown signs of intrauterine growth restriction on antenatal scans. He is delivered at 37 weeks and weighs 2.2kg. He is admitted to the Special Care Baby Unit because of his size. He appears well and has had a breast-feed.
What is he most at risk of?
Group B strep infection Hypoglycaemia Hypercalcaemia Anaemia Congenital cardiac abnormality
Hypoglycaemia
The baby has intrauterine growth restriction. These babies are liable to hypoglycaemia from poor fat and glycogen stores.
This baby has intrauterine growth restriction. However, this does not increase the baby’s risk of Group B streptococcus infection compared to babies of normal weight.
These babies are at risk of hypocalcaemia rather than hypercalcaemia.
These babies are at risk of polycythaemia rather than anaemia.
Congenital cardiac anomalies are not caused by intrauterine growth restriction.
Severe hearing impairment can be detected by screening newborns using evoked otoacoustic emission.
Which newborn infants should be tested?
All newborns
Only newborns with a FHx of deafness
Only newborns whose parents are worried about their hearing
No newborns, as hearing screening can be performed more reliably at 8 months of age
Only newborns who are found to have other abnormalities
All newborns
In the UK, all newborns are now routinely screened at birth or within the first few days of life.
All newborn babies have a heel-prick blood sample taken at 5–9 days of age for biochemical screening (Guthrie test).
Which of the following is not tested for?
Cystic fibrosis Phenylketonuria Hypothyroidism Sickle cell Duchenne muscular dystrophy
Duchenne muscular dystrophy
Callum, a two-day-old Caucasian infant, weighs 3.6 kg at birth. He was born by vaginal delivery with Apgar scores of 7 at 1 minute and 10 at 5 minutes. On day 2, he is reported to be jittery, crying inconsolably and feeding poorly. He sneezes and yawns, and is thought to have some abnormal movements, possibly seizures. No dysmorphic features are present and he is not jaundiced.
What is the most likely explanation for Callum’s problems?
Congenital rubella syndrome Fetal alcohol syndrome Birth asphyxia Kernicterus Maternal opiate use
Maternal opiate use
The clinical features are consistent with this condition.
Mohammed is a 24-hour-old baby. His mother develops chicken pox (varicella) one day after his delivery.
What is the most appropriate advice you would give?
Reassure and discharge home to avoid spread of infection
Neonatal infection is unlikely due to transplacentally acquired antibodies
There is a significant risk of serious neonatal infection
Breast-feeding is contraindicated
The infant’s varicella antibody status should be checked
There is a significant risk of serious neonatal infection
If the mother develops chickenpox from five days before until 2 days after delivery, there will be insufficient time for protective antibodies to develop and be transferred to the infant. A quarter of such infants become infected with a significant mortality.
The infant will not have received protective antibodies against varicella from the mother, and is therefore at risk of morbidity and mortality if discharged home.
The mother is unlikely to have antibodies to varicella, because she herself has developed chickenpox. Transplacental transfer of antibodies will therefore not have happened.
Antibodies acquired via breast-milk are important for an infant’s immunity, although they will not protect against this episode of varicella.
It is unlikely that the mother will have any antibodies to varicella, as she herself has developed chickenpox. Therefore transplacental transfer of antibodies cannot have occurred, and you can be sure that the infant is not immune to varicella.
You are called as an emergency to delivery suite just as a term baby boy is being delivered. There had been an abnormal CTG (cardiotocography) prior to delivery, and a severe antepartum haemorrhage. At birth the baby is not breathing, has a heart rate less than 60 beats/minute and is white. Resuscitation is commenced and his Apgar scores are 2 at 1 minute, 4 at 5 minutes, and 4 at 10 minutes of age. He is transferred to the neonatal unit where he requires ventilatory support as he is not breathing adequately. His limbs are hypotonic, he has a seizure at 12 hours and then a further one at 18 hours of age.
He fulfils the definition of birth asphyxia because his Apgar score at 1 minute of age was less than 3
His Apgar score at 10 minutes of age is associated with an increased risk of long-term disability
He is too small to have an MRI scan to determine long-term prognosis
His clinical features are those of moderate hypoxic ischaemic encephalopathy
This baby is representative of the commonest cause of cerebral palsy
His Apgar score at 10 minutes of age is associated with an increased risk of long-term disability
Hypoxic ischemic encephalopathy is the name of the condition assigned to a hypoxic insult before, during or after delivery resulting in injury to the brain. It is caused by compromised placental or pulmonary gas exchange that results in cardio-respiratory depression. This leads to hypoxia, hypercarbia and decreased cardiac output.
If the Apgar score remains low at 10 minutes of age the risk of long-term disability or mortality is nearly 50%.
A baby girl is delivered by caesarean section at 32 weeks’ gestation because of maternal pre-eclampsia. Her birth weight is 1.9 kg. No resuscitation is required. At 2 hours of age she develops respiratory distress, with a respiratory rate of 70 breaths/minute, grunting respirations and indrawing of her rib cage. Respiratory support with CPAP (continuous positive airway pressure) and 45% oxygen is required. What is the most likely diagnosis?
Meconium aspiration Pneumonia Resp. distress syndrome Transient tachypnoea of the newborn Pneumothorax
Respiratory distress syndrome
Caused by a deficiency of surfactant, produced by type II pneumocytes, mainly in pre-term infants. It results in ventilation-perfusion mismatch. The chest X-ray characteristically shows a diffuse granular or ‘ground glass’ appearance of the lung fields, an air bronchogram outlining the larger airways, and the heart border is indistinct.
Robert is a full-term baby boy, born 10 hours ago. His mother is blood group O negative, and her membranes ruptured 2 days before delivery. He is breast-feeding well but the midwife noticed he looks markedly jaundiced. On examination the baby is clinically well but markedly jaundiced.
What investigation should be performed first?
Bilirubin level Blood culture Congenital infection screen Direct antibody test Blood group
Bilirubin level
Jaundice starting at less than 24 hours of age is most likely due to haemolysis and may rapidly rise to dangerously high levels. It needs urgent assessment and close monitoring. The most urgent investigation is to measure the bilirubin level, as this will determine the management required.
Direct antibody test is positive with Rhesus disease and ABO incompatibility.
Blood group will inform if ABO incompatibility is a potential cause.
Congenital infection can cause early jaundice but there are usually clinical features and the jaundice is mild.
Blood cultures are taken to exclude infection but do not influence immediate management.
A 3-week-old baby boy, at home with his mother, is noted to be jaundiced by the midwife. He is exclusively breast-fed and is growing well. When you examine him you note he is jaundiced but otherwise the examination is normal.
What is the most important investigation to do first?
Abdo USS Unconjugated and conjugated bilirubin No investigation needed Unconjugated bilirubin alone Congenital infection screen
Unconjugated and conjugated bilirubin
Jaundice in babies over 2 weeks of age must be investigated. Those who are breast-fed are most likely to have unconjugated hyperbilirubinaemia secondary to ‘breast-milk jaundice’. However, it is extremely important to rule out a conjugated cause, especially biliary atresia, which needs prompt diagnosis. The first investigation would be to measure the unconjugated and conjugated bilirubin.
You are asked to review a newborn baby who is only 24 hours old and has developed very swollen eyelids with a purulent discharge. The eyes have been swabbed and the gram stain comes back as gram negative bacteria.
What treatment is required?
Clean with cool boiled water Reassure it will resolve spontaneously Topical antibiotic ointment alone IV antibiotics Oral antibiotics
IV antibiotics
Purulent discharge and eyelid swelling in the first 48 hours of life must be taken seriously. The gram stain makes gonococcal infection likely and this should be treated promptly, e.g. with a third-generation cephalosporin intravenously; as permanent loss of vision can occur. The most common cause of severe neonatal purulent conjunctivitis is Chlamydia trachomatis.
Isabelle was born at term weighing 4kg. At 6 hours of age she was noted to be breathing fast and have a low temperature. She was born by normal vaginal delivery and the membranes had ruptured 24 hours previously. Mother had a low-grade fever and there was fetal tachycardia prior to delivery. Isabelle has not breast-fed since birth and has had one vomit. On examination, her temperature is 35.5°C, respiratory rate 90 breaths/minute. Capillary refill time is 3 seconds. She is lethargic. Her oxygen saturation is 89% in air.
Her chest X-ray shows consolidation at the right base. The microbiologist has phoned to say her blood cultures are growing an organism.
What is the most likely organism?
Listeria monocytogenes Group B Streptococcus Escherichia coli Staphylococcus aureus Herpes simplex virus unfection
Group B Strep
Isabelle has early-onset sepsis and this can be caused by infection in the urine, chest or cerebrospinal fluid (meningitis). The most common organism causing early-onset sepsis in the UK is Group B streptococcus.
Listeria monocytogenes, E. coli and Staphylococcus aureus may cause early-onset sepsis but are less common causes in the UK.
James was born at 39 weeks’ gestation by elective caesarean section because of pre-eclampsia. His birth weight was 3.7 kgs. His mother breast-fed him as soon as she had recovered from general anaesthetic. He fed well, but is vomiting after every feed. He is now 18 hours old and after the last 2 feeds he ‘vomited everything up’ and it was greenish in colour. On examination his temperature is 36.5°C, and he is alert and hungry.
His abdomen is not distended. He has not yet passed meconium.
What is the most likely diagnosis?
Pyloric stenosis Duodenal atresia Meconium ileus Hirschprung disease Neonatal sepsis
Duodenal atresia
This is the most likely cause of persistent bilious vomiting on the first day of life.
Pyloric stenosis: the vomit is not bile-stained as the obstruction is above the ampulla of Vater and presents at about 6 weeks of age.
Hirschprung disease: as this affects the rectum and sometimes the colon, this distal bowel obstruction results in marked abdominal distension.
Meconium ileus: this affects the lower ileum, so there would be abdominal obstruction.
Neonatal sepsis: can cause vomiting, sometimes slightly bile-stained, but there are no risk factors from labour and delivery, and no other features on clinical examination.
Aaron was born at term, birth weight 3.2 kg. He is now 2 weeks old, and his mother is concerned that his umbilicus looks abnormal. A photo is shown in the figure below.
Select the most likely diagnosis.
Umbilical granuloma- In umbilical granuloma there is a pink, pedunculated lesion of granulation tissue as shown here.
In umbilical hernia there is protrusion of the umbilicus.
In exomphalos the abdominal contents protrude through the umbilical ring, covered by the amniotic membrane and peritoneum.
In umbilical infection (omphalitis) there is redness of the skin surrounding the umbilicus, and may be a purulent discharge on the umbilicus.
In gastroschisis the bowel protrudes through a defect in the anterior abdominal wall adjacent to the umbilicus.
Janine, a 9-month-old Caucasian girl, is seen by her family doctor because of concern that she is not growing fast enough. She is only on the 5th centile for height and 2nd centile for weight.
What is the greatest influence on her growth rate at her age?
Genes Nutrition Growth hormone Oestrogen Testosterone
Nutrition
Along with good health, well-being and thyroid hormones, infantile growth (from birth to 12 months of age) is dependent on good nutrition.
John, a 3-year-old boy, is referred to paediatric outpatients because of concern about the development of pubic and axillary hair. His testes are 1.5 ml in size (pre-pubertal). His blood pressure is 100/75. Gonadotrophin levels are normal for a pre-pubertal boy (undetectable) but his bone age is 5 years.
What is the most likely cause of his early pubertal development?
Adrenal tumour Brain tumour Idiopathic precocious puberty Testicular tumour Prader-Willi syndrome
Adrenal tumour
Premature sexual development in boys is uncommon and usually has an organic (rather than constitutional or familial) cause. With his pre-pubertal testes, hypertension and normal gonadotrophin levels, the abnormality is likely to be in his adrenal glands.
Chelsea, a 7-year-old girl, is brought by her mother to the paediatric clinic. Her mother is concerned about Chelsea’s early development of puberty. Chelsea has started to develop breasts and, more recently, some pubic hair. On examination she has breast development stage BIII and pubic hair development PHII. She has not started her periods, but has had a growth spurt recently. An ultrasound of her pelvis shows multicystic ovaries and enlarging uterus.
What is the most likely cause of her early pubertal development?
Brain tumour Ovarian tumour Idiopathic precocious puberty Turner syndrome Congenital adrenal hyperplasia
Idiopathic precocious puberty
Precocious puberty in females is usually due to premature onset of normal puberty. The sequence of puberty in this child is normal and there is also been an associated growth spurt, which makes an idiopathic cause for the precocious puberty more likely. The pelvic ultrasound findings are consistent with premature onset of normal puberty.
Turner syndrome is associated with delayed rather than precocious puberty.
In congenital adrenal hyperplasia, the sequence of pubertal changes is abnormal, with isolated pubic hair and virilisation of genitalia.
Sophia, an 18-month-old girl, is brought to outpatients by her mother, who is very worried as she has developed breasts. She is otherwise well and has been growing normally. On examination she has breast development BIII but no pubic or axillary hair. Her bone age is 20 months.
What is the most likely cause of her early pubertal development?
Idiopathic precocious puberty Premature thelarche Premature pubarche Brain tumour Congenital adrenal hyperplasia
Premature thelarche
Sophia has breast development and no other signs of puberty. She has premature thelarche.
Sophia does not have precocious puberty because she does not have axillary or pubic hair, nor has she had a growth spurt.
Congenital adrenal hyperplasia would cause premature pubarche rather than isolated breast development.
She has not developed pubic or axillary hair.
A brain tumour is unlikely as she has isolated breast development.
Hypoglycaemia
George, a 2-week-old Caucasian baby boy, presents to the Accident and Emergency department with vomiting, diarrhoea and poor feeding.
Investigations show:
• Sodium 112 mmol/L (normal range 133-145 mmol/L)
• Potassium 6.8 mmol/L (normal range 3.5–6.0 mmol/L)
• Urea 7.8 mmol/L (normal range 2.5–8.0 mmol/L)
• Creatinine 30 μmol/L (normal range 20–65 mmol/L)
• Blood glucose 1.7 mmol/L (normal range >2.4 mmol/L)
• Infection screen—negative
What is the most likely cause?
Congenital adrenal hyperplasia Acute renal failure Hypothyroidism Cushing syndrome Gastroenteritis
Congenital adrenal hyperplasia
The combination of hyponatraemia, hyperkalaemia and hypoglycaemia are suggestive of glucocorticoid deficiency, as seen in congenital adrenal hyperplasia.
Gastroenteritis can lead to hyponatraemic dehydration but the urea would be raised and the potassium normal.
An excess of glucocorticoids, as seen in Cushing syndrome, causes an intolerance to carbohydrates (hyperglycaemia), rather than the hypoglycaemia seen in this child.
Hyponatraemia may be a feature of acute renal failure, but this child has a normal plasma urea and creatinine.
A newborn baby has recently been delivered. The midwife requests an urgent paediatric review of the baby because she cannot tell if the baby is male or female. The parents are asking what sex their baby is.
What should you tell them?
You are unable to tell right now but will be able to assign a sex as soon as you get the baby’s chromosomes back
You are unable to tell right now and a detailed assessment of the baby including scans and blood tests will be needed before you can tell them
You feel it is likely to be a girl so tell them it is female
You feel it looks like boy so tell them he is male
You are unable to tell if the baby is male or female and tell the parents it is likely to be a mixture of both sexes i.e. ovotesticular disorder of sex development (DSD – or hermaphroditism).
You are unable to tell right now and a detailed assessment of the baby including scans and blood tests will be needed before you can tell them
A detailed assessment by medical, surgical and psychological specialists needs to be performed followed by a full discussion with the parents before the infant is assigned a sex
If there is abnormal sexual differentiation at birth, do not guess the infant’s gender. A detailed assessment needs to be performed.
A Caucasian infant is born with a disorder of sexual differentiation. Congenital adrenal hyperplasia is suspected.
What blood result would confirm the diagnosis?
A markedly raised plasma 17α-hydroxyprogesterone
A markedly lowered plasma 17 α-hydroxyprogesterone
A low testosterone
A markedly raised cortisol level
A raised blood sugar
A markedly raised plasma 17α-hydroxyprogesterone
Most children with congenital adrenal hyperplasia have 21-hydroxylase deficiency. The diagnosis is made by finding markedly raised levels of the metabolic precursor 17 α-hydroxy-progesterone.
In congenital adrenal hyperplasia the cortisol level would be low and the testosterone would be raised..
Babatunde, a 13-month-old black African boy, presents to the paediatric clinic with progressive bowing of his legs. He is still entirely breast-fed. He is miserable, and his wrists are noted to be swollen. An X-ray is taken of his wrists and is shown in the figure below. What is the most likely diagnosis?
Vit A deficiency Vit B1 deficiency Vit D deficiency Vit E deficiency Vit K deficiency
Vit D deficiency
He has Vitamin D deficiency resulting in rickets. This has caused bowing of his legs; also the ends of the radius and ulna are expanded and rarified, and cup-shaped. At 13 months of age, breast-milk alone does not provide adequate intake of vitamin D.
Sarah, a 9-year-old Caucasian girl, is referred by the school nurse to the paediatric clinic because of her weight. She weighs 43 kg (98th centile) and is 141 cm tall (91st centile). She has followed her height centiles for the last 9 months, but her weight centile has increased. Her BMI is on the 97th centile.
Which of the following statements is true?
Sarah is obese
Sarah’s main problem is that she has a low metabolic rate
A BMI remaining at this level places Sarah at an increased risk of an abnormal lipid profile and raised blood pressure in adult life
Sarah’s adreno–cortical axis should be checked to exclude Cushing syndrome
A crash diet is the treatment of choice
Sarah is overweight (BMI >91st centile) rather than obese (BMI >98th centile). It places her at increased risk of an abnormal lipid profile and raised blood pressure in adult life.
For clinical use, obese children are those with a BMI above the 98th centile of the UK 1990 reference chart for age and sex. Sarah is overweight (BMI >91st centile).
Cushing syndrome is rare and associated with a failure of linear growth.
Regarding the Barker hypothesis relating birthweight to diseases in adult life, which of the following newborns have the highest risk of cardiovascular disease in later life?
Birthweight
Birthweight
Which of the following is not correct regarding the advantages of breast-feeding over formula-feeding?
Higher interferon level in breast-milk
Decreased risk of gastrointestinal infections associated with breast-feeding
Closer mother-child relationship with breast-feeding
Higher vitamin K concentration in breast-milk
Lengthened time-period between children
Higher vitamin K concentration in breast-milk
The vitamin K concentration in breast-milk is lower. There is insufficient vitamin K in breast-milk to reliably prevent haemorrhagic disease of the newborn. This risk is minimised by recommending prophylactic vitamin K to all newborns.
Breast-feeding leads to an increased time period between children because of its contraceptive effect. However, it is not a fully effective form of contraception, and counselled regarding contraceptive methods should be given.
Breast-feeding enhances mother-child relationship.
Interferon is present in breast-milk and has an antiviral property.
Breast-feeding is life-saving in developing countries due to the association with fewer gastrointestinal infections.
Anil is a 2½-year-old boy who lives in India and attends the local health clinic for a routine check. Both his parents are subsistence farmers. He is asymptomatic. On examination, he is very thin, but his hair and skin appear normal, and there is no oedema or other clinical abnormalities. His height is on the 5th centile but his weight is well below the 4th centile.
What is the most likely diagnosis?
Sever gastro-oesophageal reflux Marasmus Kwashiorkor Rickets Normal child
Marasmus
In marasmus, severe protein-energy malnutrition, the weight for height more than –3 standard deviations below the median, corresponding to
Harry is a 13-year-old Caucasian boy who attends the paediatric clinic because of obesity. His height is on the 98th centile, and his weight is above the 99.6th centile.
Which of the following is NOT associated with obesity in later life?
Type 1 Diabetes Slipped upper femoral epiphysis Hypertension Asthma Low self esteem
Type 1 Diabetes
Obese children are more likely to have non-insulin-dependent diabetes mellitus (type 2 diabetes). Type 1 diabetes is an autoimmune disorder and is not related to a child’s weight.
Benjamin is a 14-month-old boy, who is seen in the paediatric emergency department. He has been vomiting and has had diarrhoea for 3 days. Today, he has eaten much less food than usual and has vomited after each feed. His stool is watery and foul-smelling but has no blood in it. He has not been out of the UK since he was born. Examination shows that he is slightly dehydrated, but is otherwise normal.
What is the most likely organism that has caused his symptoms?
Rotavirus Escherichia Coli Shigella Campylobacter Giardia lamblia
Rotavirus
Rotavirus is a common cause of foul-smelling, watery diarrhoea. E. coli, Shigella and Campylobacter also cause explosive watery diarrhoea but can be associated with blood in the stools.
Giardia lamblia is a parasitic infection and is usually acquired whilst travelling abroad, although there are rare cases in the UK.
