Paeds two Flashcards
How do you treat ADHD?
- EDUCATION
- parenting programme
- school support & liason
- medications - methylphenidate
What are the 3 main symptom groups in ASD?
- communication difficulties
- Social interactions
- Behavioural, poor imagination, rigidity
What are some communication difficulties observed in ASD?
- lack of desire to communicate
- delayed or disordered language (echolalia)
- poor non-verbal communication
- good language but unable to start or keep a conversation going
What are some social interaction difficulties observed in ASD?
- doesn’t understand unspoken social rules (personal space)
- touches inappropriately
- plays alone
- poor eye contact
- turn taking hard
- stressful being around other people
What are some of the rigidity/lack of imagination Sx of ASD?
- inability to play imaginatively
- resist change
- obsessions/rituals
- plays the same game over and over
- follows rules exactly
- learning by rote and not understanding
- asks same question even when answer given
How do you manage ASD?
- comunication aids - something to distract them with
- Visual planners - words and pictures
- special schools
- parental education
what presentations can RSV cause?
- VIW
- bronchiolitis (80+%)
- croup
- pneumonia
- wheezy bronchitis
What causes croup?
-virus - usually para flu
What time of year does croup present?
Spring/autumn
What is the typical presentation of croup?
- barking seal like cough
- stridor
- recession
- worse at night
- self limiting
How do you treat croup?
- oral or injected dexamethasone
- if stats don’t improve - nebulised adrenaline
What causes acute epiglottitis?
-Haemophilus influenza type b
How does epiglottitis present?
- severe acute illness
- high pitched stridor
- sat up not moving much at all
- drooling
Define pneumonia.
Respiratory disease characterizd by inflammation of the lung parenchyma (excluding bronchi) with congestion caused by viruses or bacteria or irritants.
What is the diagnostic criteria for pneumonia?
- Hx of cough and/or difficulty breathing for <14 days
- w/ increased respiratory rate (defined for age)
What would expect a CXR to look like for someone with pneumonia?
- dense fluffly opacity that occupies a portion or whole love or lung
- may or may not contain an air bronchograms
What is the leading cause of pneumonia in the UK?
pneumococcus 30-50%
Other than pneumococcus, what other bacteria can cause pneumonia?
- HiB
- S. aureus
- K. pneumoniae
- mycobacterium tuberculosis
What causes whooping cough?
Bordetella Pertussis
What is the typical presentation of Whooping cough (pertussis infection)?
3 phases
- 1st - coryzal mild resp infection like - mild fever, dry cough, nasal discharge, sore throat, malaise
- 2nd - dry hacking cough - prolonged episodes followed by characteristic whoop, reddened face, bulging eyes, post coughing vomiting, may be severe enough to cause cyanosis
- 3rd - persistent cough goes on long after infection - can be months.
How do you treat whopping cough?
Macrolide Tx - Clarithromycin/azithromycin/erythromycin
- supportive and symptomatic relief
- INFORM PHE
What CSF findings indicate a bacterial meningitis?
- raised cell count
- raised protein
- low glucose
- bacteria in CSF/blood/PCR
What CSF findings indicate a viral meningitis?
- raised cell count
- normal protein
- normal glucose
- virus identified in blood/throat/still/CSF
What bacteria would you suspect causing Meningitis in a baby under 3 months? why are they different to babies over 3 months?
- Group B strep, E.coli, listeria, pneumococcus, meningococcus
- picked up from maternal vaginal flora during birth
What are some signs of primary immune deficiency?
- failure to thrive
- reccurent infections (x4 in a year)
- infection with abnormal bacteria
- little response to antibiotics
- persistent thrush in mouth or fungal infection on skin
What would you expect to see on blood test results of a child with immune deficiency?
- low IgG
- low IgA
- Low IgM
- increase WBC
- raised inflammation markers
How do you treat someone with primary immune deficiency?
- antibacterial/viral prophylaxis
- prompt infection Tx
- replacement of immunoglobulins
- bone marrow transplant
How do vaccines work?
- induce immunity: T and B cell specific for organism/toxin
- induce immunological memory
- Antibodies (B cell memory): measurable
- herd immunity
- specific T cell memory
What are babies at risk of if born prematurely?
- Respiratory distress syndrome
- sepsis
- pneumothorax
- pulmonary oedema
- congenital heart defect
How do you treat neonatal hypoglycaemia in a pre term/low birth weight?
- IV bolus 2.5ml/kg 10% dex
- 10% dex infusion or parentral nutrition for maintenance
Why does neonatal hypoglycaemia happen?
-preterms/growth restricted babies have poor glycogen stores
how does neonatal hypoglycaemia present?
- within the first 24 hours of life
- jitteriness, irritability, apnoea
- lethargy, seizures, drowsiness
What screening is done on preterm neonates?
- Eyes - retinopathy of prematurity
- Lungs - chronic lung disease/bronchopulmonary dysplasia
- brain - intraventricular haemorrhage
- hearing - increased risk of hearing impairment
What is the best form of nutrition for neonates and why?
BREAT IS BEST!
- maternal immunity boost
- decrease risk on necrotising enterocolitis
How does necrotising enterocolitis present?
- seen in prematurity within the first few weeks of life
- initially - feed intolerant, vomiting which may be bile stained, distended abdomen, fresh blood in stool (sometimes)
- later - Sx of shock - worsening of abdomen distension
What radiological features would confirm necrotising enterocolitis?
- distended loops of bowel
- thickening of the bowel wall w/ intramural gas
- gas in portal venous tract
- air under diaphragm due bowel perforation
How does one treat necrotising enterocolitis?
- stop oral feed
- treat with broad spec Abx for both aerobic and anaerobic organisms
- parenteral nutrition always required
- mechanical ventilation
- circulatory support (I assume this means fluids)
What is the prognosis of a child with NEC?
- 20% mortality rate
- long term bowel dysfunction;
- strictures
- malabsorption problems if large resection has been necessary
- greater risk of poor neurodevelopment
What are some causes of jaundice in the first 24 hours of life?
-Haemolytic disorders
~Rhesus haemolytic disease
~ABO incompatibility
-G6PD deficiency - male dominant middle-eastern/African
-Spherocytosis - FHx common, diagnosed by presence of spherocytes on blood film
What are some causes of jaundice in neonates ages 2 days - 2 weeks?
- physiological - neonate adapting to transition from fetal life
- breast milk jaundice
- dehydration
- infection
What are the causes of jaundice in a neonate older than 2 weeks of age?
prolonged Unconjugated:
- breast milk
- infection - particulary UTI
- congenital hypothyroidism
Conjugated:
- neonatal hepatitis
- biliary atresia
What clinical signs may be present in a neonate with biliary atresia?
- dark urine
- unpigmented pale stools
- hepatomegaly
- poor weight gain
What investigations should be done in neonatal jaundice?
- clinically assess - press on babs chest
- serial measurement of transcutaneous bilirubin
- check if conjugated or un
- plot on bilirubin chart to assess changes in levels and indications for intervention
How do you manage neonatal jaundice?
depends on aetiology.
- correct dehydration/poor breast feeding with supplementary milk
- phototherapy - 450nm blue-green light indicated if rapidly rising or reached high level
- exchange transfusion - bilirubin levels dangerously high - neonates blood removed and replaced with twice the volume of donor blood
What is the worrying complication of neonatal jaundice?
-kernicterus
-unconjugated bilirubin deposits in the basal ganglia
-can cause various Sx:
~lethargy & poor feeding
~irritability, increased muscle tone
~seizures
~coma
How do you treat biliary atresia? what complication do you risk if left untreated?
- Kasia procedure (hepatoporto-enterostomy)
- liver cirrhosis
What’s the difference between wheeze and stridor?
- wheeze expiratory vs stridor inspiratory
- wheeze LRT (intrathoracic airways) vs stridor URT
- polyphonic vs monophonic
What is the other name for croup?
viral laryngotracheobronchitis
What the monoclonal antibody treatment for recurrent/at risk bronchiolitis patients?
- palivizumab - Mab to RSV
- given monthly IM
- reduces number of hospital admissions for those at risk. prems & immune deficient
what 2 tests can pick up cystic fibrosis?
- new born blood spot test (heel-prick test)
- sweat test - detects increased levels of chlorine in sweat
What is the inheritance pattern of cystic fibrosis?
Autosomal recessive
Describe the pathophysiology of cystic fibrosis of the airways?
- defect in the CF transmembrane conductance regulator (CFTR) protein
- CFRT = cAMP dependent Chloride ion channel membrane found in cell membranes all around the body
- F508 most common gene disruption
- leads to defect in ion transport across epithelial cells
- airways = reduces airway surface liquid layer, impaired ciliary function and therefore retention of mucoplurent secretions.
describe the extra-airway manifestations of cystic fibrosis?
- pancreas - ducts can become blocked leading to enzyme deficiency and malabsorption
- meconium ileus - bowel obstruction form the premature faeces being bare sticky
- liver disease - cirrhosis
- testicular insufficiency
Give some causes of heart failure in neonates and infants?
- ASD
- VSD
- PDA
- tetralogy of Fallot
- transposition of the great arteries
- AVSD
- Aortic stenosis
- Pulmonary stenosis
- Adult type coarctation
how do you treat children with heart failure?
- treat underlying cause
- diuretics
- captopril (ACE-I)
What 3 indications would you give 10ml/kg bolus instead of 20ml/kg?
DKA
Trauma
Primary cardiac pathology e.g. heart failure
Child has pneumonia symptoms with a red circular rash. What is this pathognomonic of?
Mycoplasma pneumoniae
What are risk factors for Surfactant Deficient Lung Disease?
- prem
- male
- second twin born
- maternal diabetes
- C section
What CXR features would you see in a newborn with surfactant deficient lung disease?
-ground glass appearance with indistinct hear border
How do you treat surfactant deficient lung disease?
- maternal corticosteroids - is prenatally suspected (prem delivery, maternal DM)
- O2 therapy
- assisted ventilation
- exogenous surfactant via endotracheal tube
What’s the triad of shaken baby syndrome?
- retinal haemorrhage
- subdural haematoma
- encephalopathy
What is the other name for croup?
Viral laryngotracheobronchitis
What are the typical features of croup?
- low grade fever
- Barking cough
- harsh stridor
What is the most common causative agent of croup?
Parainfluenza
How do you treat Croup?
- oral dexamethasone 150mg/kg
- O2 where indicated
- nebulised adrenaline if necessary
What are the risk factors for a baby developing bronchiolitis?
- parental smoking
- pre
- Chronic lung disease
- underlying lung condition - CF
What is the causative agent of bronchiolitis?
-RSV in 80% (respiratory syncytial virus)
What is a typical presentation of bronchiolitis?
- dry cough
- difficulty breathing whilst feeding
- coryzal symptoms
- wheeze
- recession of varying degrees
- low grade temperature
How do you treat a infectious exacerbation of CF? that was
- IV Abx
- give antibody for RSV
- mucous clearance
What signs would you expect to see on a baby with a VSD?
- worsening wheeze
- palpable thrill
- pansystolic murmur @ left sternal edge
- fine creps bilaterally
- liver may be palpable
What investigations would you undergo a child query heart failure?
- Echo
- ECG
- CXR
What medications would you use to treat heart failure in children?
- Diuretics - spironolactone
- ACEi - captopril
What features of a history would make you think a child had Viral Episodic Wheeze?
- preceded by coryzal Sx/URTI
- no interval symptoms
- no excess atopy
- starts after 3 resolves by 6
What is the management of an acute asthma attack?
- O2 if needed
- 10 puffs of salbutamol every 2 hours
- Oral or IV steroids 1mg/kg
- IV salbutamol bolus
- aminophylline/MG2+/salbutamol infusion take ya pick
what is the stepwise approach to managing asthma long term?
Step 1:
-SABA - salbutamol PRN - remember at this stage to council on environment, self management plans
Step 2:
-Add ICS 200mcg/day (2 puffs morning and night)
Step 3:
-Add LABA - salmeterol
-Assess control - if LABA doesn’t work increase ICS to 400 mcg/day
-if still inadequate add leukotriene receptor antagonist - Montelukast
Step 4:
-Increase ICS to 800 mcg/day
Step 5:
-refer to paediatrician
-use daily steroid tablet
What must you consider if a child with asthma fails to respond to treatment?
ABCDE
- Adherence (compliance)
- Bad disease
- Choice of drugs/devices
- diagnosis may be wrong
- environmental changes may be necessary
What gross and fine motor skills should a baby have by 6 months?
Gross - can sit up unassisted, can roll over
Fine - palmar grasp
How would you classify causes of failure to thrive?
- inadequate intake
- inadequate retention
- malabsorption
- failure to utilize movements
- increased requirements
A baby is feeding well, has normal stools and doesn’t have any resp symptoms. However, his growth has faltered and is posseting more. What are the possible causes of the baby’s failure to thrive?
- failure to utilize nutrients ~ Down’s metabolic disorders
- inadequate retention ~ GORD, vomiting
- malabsorption
What organisms can cause UTI in a child?
- E. Coli
- Klebseilla
- Enterococcus
What Abx treatment would you give for a UTI in a child?
Trimethoprim
What further investigations would you do for a child presenting with a UTI?
-MC&S - resistance and sensitivity
-USS
-MCUG
-DMSA
(last 3 detect for abnormalities that predispose to a UTI)
What’s the DDx for a child with diarrhoea?
- gastroenteritis
- coeliac disease
- inflammatory bowel disease
- overflow incontinence
- antibiotic use
How do you treat constipation?
-firstly encourage increase in oral fluids and better toileting habits
-polyethylene glycol + electrolyte regime (low dose or high dose depending of impaction or not)
+/- stimulant laxative
-continue for 6 months following to ensure passing of regular soft stool
What are causes of proteinuria in children?
- orthostatic proteinuria
- glomerular abnormalities ~ minimal change disease, glomerlonephritis, familial nephritides
- increased glomerular filtration pressure
- reduced renal mass in CKD
- HTN
- Tubular proteinuria
What investigations would you undergo for a child with nephrotic syndrome?
-Renal biopsy - light microscopy normal - electron foot process effacement
-urine analysis - protein/lipiduria
-bloods:
~FBC, ESR
~U and Es - albumin
~complement levels
What are the symptoms of nephrotic syndrome?
- periorbital oedema
- scrotal/vulval/leg/ankle oedema
- ascites
- breathless due to pleural effusion
- infection such as septic arthritis, septic arthritis or sepsis due to loss of IgA
What is the treatment for nephrotic syndrome?
-oral prednisolone 60mg/m^2 per day for 4 weeks
ween to 40mg/m^2 alternately
then ween to stop
What’s the prognosis of nephrotic syndrome?
- 1/3 resolve directly
- 1/3 relapse infrequently
- 1/3 steroid dependent because of frequent relapses
Describe some primitive reflexes and when you should loose them?
- rooting reflex - mouth stroke and head turns to stimulus, aids in feeding - lost around 4 months
- suck reflex - roof of mouth stimulation causes sucking
- Moro reflex - in response to loud stimulus or dropping, opens arms + throws head back + cries = then brings are bought back - lost around 2 months
- Tonic neck reflex - head turned to one side arm extends - 5-7 months lost
- Grasp reflex -stroke palm and baby’s hand closes to grab - 9-12 months lost
- Stepping reflex - as you can imagine - 2 months
Define Cerebral palsy
non progressive brain lesion that affects tone and movement that is caused pre, ante and postnatally.
What are the subtypes of cerebral palsy?
-spastic, dyskinetic, ataxic
What are some prenatal causes of cerebral palsy?
- Infection
- hypoxia
- congenital
- haemorrhage
What are some antenatal causes of cerebral palsy?
- Infection
- hypoxia
- haemorrhage (inc. PVL)
What are some post natal causes of cerebral palsy?
- Infection
- hypoxia
- trauma (inc NAI)
- Haemorrhage
A 6 year old girl is having increasing frequency of daydreaming episodes at school and at home. Suggest a DDx?
- Absence Seizures
- ADHD
- Hearing problems
- daydreaming
What investigations should be done for a DDx of absence seizures?
-EEG
What would an EEG of someone with absence seizures look like?
-3Hz spike and wake
Hypsarrythmia is pathognomic of what?
- infantile spasms
- criteria for west sydnrome + developmental regression
How do you treat absence seizures?
- ethosuximide
- second line lamotrigine
What may absence seizures be linked to in older age?
-juvenile myoclonic epilepsy
What’s the treatment for JME? What’s lifelong, good control
- sodium valporate
- 2nd Lamotrigine
- 3rd levetiracetam
Wha’s the difference between tropia strabismus and a phoria strabismus?
- tropia is manifest
- phoria is latent - evident on one eye covering
How do you manage Strabismus?
- Botox into ocular muscles
- surgery to correct length of muscles - resection or recession
- glasses/prisms/patches
- orthoptic exercises
