Paeds V Flashcards
TOM TIP: With neonate sepsis, the organism to remember for your exams is [] This is a common bacteria found in the vagina. It does not cause any problems for the mother, but can be transferred to the baby during labour and cause neonatal sepsis.
TOM TIP: The organism to remember for your exams is group B strep (GBS) = Streptococcus agalactiae This is a common bacteria found in the vagina. It does not cause any problems for the mother, but can be transferred to the baby during labour and cause neonatal sepsis. Prophylactic antibiotics during labour are used to reduce the risk of transfer if the mother is found to have GBS in their vagina during pregnancy.
How do you treat for presumed sepsis in neonate? [7]
- If there is one risk factor or clinical feature, monitor the observations and clinical condition for at least 12 hours
- If there are two or more risk factors or clinical feature of neonatal sepsis start antibiotics
- Antibiotics should be started if there is a single red flag
- Antibiotics should be given within 1 hour of making the decision to start them
- Blood cultures should be taken before antibiotics are given
- Check a baseline FBC and CRP
- Perform a lumbar puncture if infection is strongly suspected or there are features of meningitis (e.g. seizures)
Always check your local antibiotic policy. The NICE guidelines (2012) recommend [2] as first line antibiotics for neonatal sepsis [2]
Alternatively [1] may be given as an alternative in lower risk babies.
Always check your local antibiotic policy. The NICE guidelines (2012) recommend benzylpenicillin and gentamycin as first line antibiotics.
Alternatively a third generation cephalosporin (e.g. cefotaxime) may be given as an alternative in lower risk babies.
When do you check CRP for ongoing neonate sepsis management? [3]
Initial treatment:
* Check CRP at 24hrs
* Check blood culture results at 36 hours
* Consider stopping the abx if baby is clinically well and blood cultures are negative 36hrs after taking AND both CRPs are < 10.
Check CRP again at 5 days if still on tx:
- Consider stopping antibiotics if the baby is clinically well, the lumbar puncture and blood cultures are negative and the CRP has returned to normal at 5 days.
Neonatal sepsis:
Consider [investigation] if any of the CRP results are more than 10.
Consider performing a lumbar puncture if any of the CRP results are more than 10.
The causes of neonatal jaundice can be split into increased production or decreased clearance.
What are 5 causes of increased production of bilirubin in neonates? [5]
Haemolytic disease of the newborn
ABO incompatibility
Haemorrhage
Intraventricular haemorrhage
Cephalo-haematoma
Polycythaemia
Sepsis and disseminated intravascular coagulation
G6PD deficiency
The causes of neonatal jaundice can be split into increased production or decreased clearance.
What are 5 causes of decreased clearance of bilirubin in neonates? [5]
Decreased clearance of bilirubin:
* Prematurity
* Breast milk jaundice
* Neonatal cholestasis
* Extrahepatic biliary atresia
* Endocrine disorders (hypothyroid and hypopituitary)
* Gilbert syndrome
Why does jaundice occur in premature babies? [1]
This increases the risk of complications, particularly [1].
Explain this complication [1] and how it presents [2]
In premature babies, the process of physiological jaundice is exaggerated due to the immature liver. This increases the risk of complications, particularly kernicterus.
Kernicterus is brain damage due to high bilirubin levels. Bilirubin levels need to be carefully monitored in premature babies, as they may require treatment.
- Bilirubin can cross the BBB and in XS can damage the CNS
- The damage to the nervous system is permeant, causing cerebral palsy, learning disability and deafness. Kernicterus is now rare due to effective treatment of jaundice.
When is jaundice always pathological? [1]
Jaundice is “prolonged” when it lasts longer than would be expected in physiological jaundice. This is:
More than [] days in full term babies
More than [] days in premature babies
Always pathological in first 24 hrs
Jaundice is “prolonged” when it lasts longer than would be expected in physiological jaundice. This is:
More than 14 days in full term babies
More than 21 days in premature babies
Prolonged jaundice should prompt further investigation to look for an underlying cause.
These are particularly looking for conditions that will cause jaundice to persist after the initial neonatal period, such as [4]
Prolonged jaundice should prompt further investigation to look for an underlying cause. These are particularly looking for conditions that will cause jaundice to persist after the initial neonatal period, such as biliary atresia, hypothyroidism and G6PD deficiency.
What is involved in a prolonged jaundice screen? [+]
conjugated and unconjugated bilirubin:
- the most important test as a raised conjugated bilirubin could indicate biliary atresia which requires urgent surgical intervention
direct antiglobulin test (Coombs’ test)
- for haemolysis
TFTs:
- for hypothyroid
FBC and blood film
- polycythaemia or anaemia
urine for MC&S and reducing sugars
- suspected sepsis
Glucose-6-phosphate-dehydrogenase (G6PD) levels
- for G6PD deficiency
Describe the management of neonatal jaundice [2]
In jaundiced neonates, total bilirubin levels are monitored and plotted on treatment threshold charts. These charts are specific for the gestational age of the baby at birth. The age of the baby is plotted on the x-axis and the total bilirubin level on the y-axis. If the total bilirubin reaches the threshold on the chart, they need to be commenced on treatment to lower their bilirubin level.
Phototherapy is usually adequate to correct neonatal jaundice.
- If within 50umol of exchange line then use double phototherapy
Extremely high levels may require an exchange transfusion. Exchange transfusions involve removing blood from the neonate and replacing it with donor blood.
Define apnoeas in newborns [1]
What are they often associated with? [1]
Apnoea are defined as periods where breathing stops spontaneously for more than 20 seconds, or shorter periods with oxygen desaturation or bradycardia.
- They are often accompanied by a period of bradycardia.
How do you manage apnoeas in neonatal units? [2]
Neonatal units attach apnoea monitors to premature babies.
These make a sound when an apnoea is occurring. Tactile stimulation is used to prompt the baby to restart breathing.
Intravenous caffeine can be used to prevent apnoea and bradycardia in babies with recurrent episodes.
Describe risk factors for jaundice in neonates [+]
- Premature infants, LBW
- Asian ethnicity
- Male infants
- G6PD or ABO incompatbility
- Previous sibling
- Exclusive breastfeeding
- Cephalohaematoma
Describe the presentation of acute bilirubin encephalopathy
and chronic encephalopathy (what are the two types?)
Acute encephalopathy;
- Lethargy
- Decreased feeding
- Tone abnormalities
- High pitched crying
- Torticollis
- Opisthotons
- Seizures
Chronic:
Kernicterus:
- Movement disorders
- Auditory dysfunction
- Oculomotor impairment
- Dental dysplasia
Bilirubin induced neurological dysfunction (BIND):
- More subtle neurological impact on vision, hearing and cognitinve behaviourhal impairments
What are causes of neonatal jaundice < 24hrs? [3]
Haemolytic disease of the newborn
Infection - TORCH or sepsis
- Start Abx within 24hrs of birth
G6DP deficiency
How do you test for haemolytic disease of the newborn? [1]
Explain this test [1]
How do you treat DAT+ve babies [2]
Direct antiglobulin test (DAT)
- Get babys blood and mix with reagant with anti IgG antibodies. If babies blood cells are covered in maternal IgG then will clump
DAT +ve babies:
- Give folic acid supplementation for 6-8 weeks
- Follow up appointment to monitor for haemolytic anaemia
Describe how you measure bilirubin levels [2]
How do you interpret them? [+] Include when tx
TCB - Transcutaneous bilirubinometer:
- > 35 weeks gestation
- > 24 hrs old
Serum bilirubin
Interpretation:
- Plot total bilirubin
- If crosses phototherapy line, then tx
- If rises by > 8.5 / hr then treat
- Can stop treatment if 5 boxes below phototherapy threshold
- Check guideline
A neonate presents with jaundice. Which first line investigations would you perform? [3]
Which further ones might you consider? [2]
First line:
* Total bilirubin
* FBC
* Group and DAT
Consider:
- CRP and blood cultures
- Blood film and G6PD testing
When do you stop phototherapy treatment for jaundice? [1]
When bilirubin is below > 50 umol/L/ phototherapy line
- BUT: be careful of rebound bilirubin 12-18 hrs after
If a baby has prolonged jaundice, what is the main aim of subsequent investigations? [1]
Main aim of initial investigations is to confirm whether it is a conjugated hyperbilirubinaemia:
* Direct bilirubin of >25 umol/L, or if >20% of total bilirubin
The majority of babies will have an uncomplicated isolated unconjugated hyperbilirubinaemia
What is an important anatomical reason for jaundice? [1]
Biliary atresia:
* Intra +/- extra-hepatic bile duct atresia
Typical features in the history and examination that suggest constipation are: [+]
- Less than 3 stools a week
- Hard stools that are difficult to pass
- Rabbit dropping stools
- Straining and painful passages of stools
- Abdominal pain
- Holding an abnormal posture, referred to as retentive posturing
- Rectal bleeding associated with hard stools
- Faecal impaction causing overflow soiling, with incontinence of particularly loose smelly stools
- Hard stools may be palpable in abdomen
- Loss of the sensation of the need to open the bowels
Describe the process of desensitisation of the rectum [5]
Often patients develop a habit of not opening their bowels when they need to and ignoring the sensation of a full rectum.
Over time they loose the sensation of needing to open their bowels, and they open their bowels even less frequently.
They start to retain faeces in their rectum. This leads to faecal impaction, which is where a large, hard stool blocks the rectum.
Over time the rectum stretches as it fills with more and more faeces. This leads to further desensitisation of the rectum.
The longer this goes on, the more difficult it is to treat the constipation and reverse the problem.
Describe the management plan for constipation [+]
NICE produced guidelines in 2010 on the diagnosis and management of constipation in children. A diagnosis of constipation is suggested by 2 or more of the following:
Stool pattern
Symptoms associated with defecation
History
Describe how these may present in children < 1 [3]
Stool pattern:
- Fewer than 3 complete stools per week
- Hard large stool
- ‘Rabbit droppings’ (type 1)
Symptoms associated with defecation
- Distress on passing stool
- Bleeding associated with hard stool
- Straining
History
- Previous episode(s) of constipation
- Previous or current anal fissure
NICE produced guidelines in 2010 on the diagnosis and management of constipation in children. A diagnosis of constipation is suggested by 2 or more of the following:
Stool pattern
Symptoms associated with defecation
History
Describe how these may present in children > 1 [3]
Stool pattern:
- Fewer than 3 complete stools per week
- Overflow soiling (commonly very loose, very smelly, stool passed without sensation
- ‘Rabbit droppings’ (type 1)
- Large, infrequent stools that can block the toilet
Symptoms associated with defecation
* Poor appetite that improves with passage of large stool
* Waxing and waning of abdominal pain with passage of stool
* Evidence of retentive posturing: typical straight-legged, tiptoed, back arching
* posture
* Straining
* An**al pain
History
- Previous episode(s) of constipation
- Previous or current anal fissure
- Painful bowel movements and bleeding
How do you treat constipation of fecal impaction is present [4]
- polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen as the first-line treatment
- add a stimulant laxative if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks
- substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if Movicol Paediatric Plain is not tolerated
- inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain
Describe the maintenence treatment plan for constipation [4]
- first-line: Movicol Paediatric Plain
- add a stimulant laxative if no response
- substitute a stimulant laxative if Movicol Paediatric Plain is not tolerated. Add another laxative such as lactulose or docusate if stools are hard
- continue medication at maintenance dose for several weeks after regular bowel habit is established, then reduce the dose gradually
Why are ribbons stools a red flag? [2]
Explain why the above pathologies cause ribbon stools [2]
Ribbon stools, also known as pencil-thin or narrow stools, are a red flag symptom because they may indicate a significant underlying condition such as Hirschsprung’s disease or an intestinal obstruction.
- Hirschsprung’s disease is a congenital disorder characterised by the absence of ganglion cells in the myenteric and submucosal plexuses of the distal bowel. This results in functional obstruction and severe constipation. Ribbon stools occur due to the partial blockage of the large intestine, which forces stool to become thin in order to pass through.
- Another cause could be an intestinal obstruction like a tumour or polyp. The presence of these masses can physically reduce the diameter of the colon, resulting in ribbon-like stools.
It is normal for babies to have some reflux after larger feeds. It becomes more troublesome when this causes them to become distressed. Signs of problematic reflux include:
- Chronic cough
- Hoarse cry
- Distress, crying or unsettled after feeding
- Reluctance to feed
- Pneumonia
- Poor weight gain - need to plot weight gain
- Children over one year may experience similar symptoms to adults, with heartburn, acid regurgitation, retrosternal or epigastric pain, bloating and nocturnal cough.
What are the features of GOR in children [4]
Features:
typically develops before 8 weeks,
vomiting/regurgitation
* milky vomits after feeds
* may occur after being laid flat
excessive crying, especially while feeding
If a baby is not losing weight and you don’t suspect serious pathology causing GOR, what advise can you give parents to help? [4]
advise regarding position during feeds - 30 degree head-up
ensure infant is not being overfed (as per their weight) and consider a trial of smaller and more frequent feeds
a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum)
a trial of alginate therapy e.g. Gaviscon. Alginates should not be used at the same time as thickening agents
NICE do not recommend a proton pump inhibitor (PPI) to treat overt regurgitation in infants and children occurring as an isolated symptom. A trial of one of these agents should be considered if 1 or more of the following apply: [3]
- unexplained feeding difficulties (for example, refusing feeds, gagging or choking)
- distressed behaviour
- faltering growth
Describe what is meant by Sandifer’s Syndrome [1]
What are the key features? [2]
This is a rare condition causing brief episodes of abnormal movements associated with gastro-oesophageal reflux in infants. The infants are usually neurologically normal. The key features are:
Torticollis:
- forceful contraction of the neck muscles causing twisting of the neck
Dystonia:
- abnormal muscle contractions causing twisting movements, arching of the back or unusual postures
The condition tends to resolve as the reflux is treated or improves. Generally the outcome is good.
TOMTIP: Sandifer’s syndrome.
It is worth referring patients with these symptoms to a specialist for assessment, as the differential diagnosis includes more serious conditions such as [2]
It is worth referring patients with these symptoms to a specialist for assessment, as the differential diagnosis includes more serious conditions such as infantile spasms (West syndrome) and seizures.
How do you manage pyloric stenosis? [1]
Management is with Ramstedt pyloromyotomy.
- laparoscopic pyloromyotomy (known as “Ramstedt’s operation“). An incision is made in the smooth muscle of the pylorus to widen the canal allowing that food to pass from the stomach to the duodenum as normal. Prognosis is excellent following the operation.
Describe the features of intussusception
- intermittent, severe, crampy, progressive abdominal pain
- inconsolable crying
- during paroxysm the infant will characteristically draw their knees up and turn pale
- vomiting
- bloodstained stool - ‘red-currant jelly’ - is a late sign
- sausage-shaped mass in the right upper quadrant
TOM TIP: Look out for the “redcurrant jelly stool” in your exams as this indicates intussusception as a diagnosis. The other classic feature is the sausage-shaped mass in the abdomen. The typical child in the exam will have had a viral upper respiratory tract infection preceding the illness and will have features of intestinal obstruction (vomiting, absolute constipation and abdominal distention). .
What are two possible complications of intussusception? [2]
If the bowel becomes gangrenous (due to a disruption of the blood supply) or the bowel is perforated
Describe what is meant by abdominal migraine [1] and the clinical features [5]
Abdominal migraine presents with episodes of central abdominal pain lasting more than 1 hour. Examination will be normal.
Features:
* Nausea and vomiting
* Anorexia
* Pallor
* Headache
* Photophobia
* Aura
Describe how you treat abdominal migraine
- treating the attack [4]
- preventative medications [4]
Management of abdominal migraine is similar to migraine in adults. Careful explanation and education is important. It involves treating acute attacks and preventative measures. Preventative medications are initiated by a specialist.
Treating the acute attack:
* Low stimulus environment (quiet, dark room)
* Paracetamol
* Ibuprofen
* Sumatriptan
Preventative medications:
* Pizotifen, a serotonin antagonist
* Propranolol, a non-selective beta blocker
* Cyproheptadine, an antihistamine
* Flunarazine, a calcium channel blocker
TOMTIP:
Pizotifen is the main preventative medication to remember for abdominal migraine. It needs to be withdrawn slowly when stopping as it is associated with withdrawal symptoms such as depression, anxiety, poor sleep and tremor.
TOMTIP:
[] is the main preventative medication to remember for abdominal migraine.
How do you instruct how to manage this medication? [1]
Pizotifen is the main preventative medication to remember for abdominal migraine. It needs to be withdrawn slowly when stopping as it is associated with withdrawal symptoms such as depression, anxiety, poor sleep and tremor.
Describe what is meant by mesenteric adenitis [1] and how it can present [1]
Mesenteric adenitis is inflamed lymph nodes within the mesentery.
It can cause similar symptoms to appendicitis and can be difficult to distinguish between the two. It often follows a recent viral infection and needs no treatment
NB: Keep in mind could still be appendicitis
In a clinical examination of appendicitis, what is important to assess? [1]
Full Assessment - including ENT. Look at throat
Describe what is meant by an oesophageal atresia (OA) [1]
Which is the most common type? [1]
Oesophageal atresia (OA) and tracheo-oesophageal fistula (TOF) are congenital malformations that result from the defective separation of the common embryologic precursos to both the oesophagus and trachea.
The most common type is a blind-ending upper oesophageal pouch with a fistulous connection between the distal oesophageal segment and the trachea.
What is the treatment plan for OA? [3]
NG tube placement
Abx
Referal to surgery
Dx of OA? [3]
BMJ BP
One - US: A part of routine antenatal screening or in cases of suspected chromosomal anomaly or familial syndrome. If evidence of polyhydramnios, fetal MRI is also recommended.
- Result: polyhydramnios and a small or no stomach bubble
Two - Fetal MRI can assist in confirming the diagnosis and determining other congenital anomalies.
- oesophageal pouch and small stomach
Three - CXR & AXR
- Evidence of respiratory distress or poor handling of secretions, or an inability to pass a nasogastric tube warrants an x-ray. An x-ray of the chest and abdomen with a nasogastrc tube in place should also be obtained immediately after birth in patients who are suspected to have an oesphageal atresia/tracheo-oesophageal fistula on antenatal ultrasound
How would OA likely to present? [4]
presence of risk factors - including trisomy 21
maternal history of polyhydramniosis
inability to swallow secretions
inability to pass a nasogastric tube
What is midgut malrotation? [1]
When does it present? [1]
Congenital problem in which the midgut remains unfixed and suspended on a narrow based mesentery due to abnormal rotation in utero
Presents in first 6 months of life
How does midgut malrotation present? [3]
Malrotation: Presentation:
* Acute strangulating obstruction: Shocked, bilious vomiting, tender, dark blood PR
* Recurrent episodes of subacute obstruction: bile-stained vomiting, forewarning of volvulus
* Intermittent vomiting, occasionally bile stained, intermittent abdominal pain and malabsorption
How is midgut dx [1] and malrotation mx ? [2]
1st line: upper gastrointestinal contrast series
- Diagnostic standard test for malrotation
- DJ flexion to the right
- right-sided duodenum (malrotation); duodenum courses inferior or medial to normal (malrotation); bird-beak cut-off of duodenum (volvulus); corkscrew of duodenum (volvulus); a web in the duodenum (duodenal atresia)
Management:
* urgent / emergency surgery (if ischaemic or not): open laparotomy and Ladd’s procedure
* Nasogastric tube, antibiotic coverage for gram-negative organisms (e.g., cefoxitin), and aggressive intravenous fluid resuscitation should be performed en route to the theatre
Why can pyloric stenosis be difficult to treat with regards to anaesthesia? [1]
Gas needs to be corrected.
Often alkalotic - if not corrected and given anaesthestic the respiratory system can fail to make you breath
