Passmed - Paeds Flashcards
Organism causing acute epiglottitis
Haemophilus influenzae type B
Acute epiglottitis signs and symtoms
rapid onset high temperature, generally unwell stridor drooling of saliva 'tripod' position: the patient finds it easier to breathe if they are leaning forward and extending their neck in a seated position
Epiglottitis dx
Diagnosis is made by direct visualisation (only by senior/airway trained staff, see below).
X-rays may be done, particularly if there is concern about a foreign body:
a lateral view in acute epiglottis will show swelling of the epiglottis - the ‘thumb sign’
in contrast, a posterior-anterior view in croup will show subglottic narrowing, commonly called the ‘steeple sign’
Epiglottitis mx
immediate senior involvement, including those able to provide emergency airway support (e.g. anaesthetics, ENT)
endotracheal intubation may be necessary to protect the airway
if suspected do NOT examine the throat due to the risk of acute airway obstruction
the diagnosis is made by direct visualisation but this should only be done by senior staff who are able to intubate if necessary
oxygen
intravenous antibiotics
Most common malignancy affecting children + peak incidence
Acute lymphoblastic leukaemia
Peak incidence - 2-5 years
ALL symptoms and signs
Bone marrow failure
- anaemia: lethargy and pallor
- neutropaenia: frequent or severe infections
- thrombocytopenia: easy bruising, petechiae
Other features
bone pain (secondary to bone marrow infiltration)
splenomegaly
hepatomegaly
fever is present in up to 50% of new cases (representing infection or constitutional symptom)
testicular swelling
ALL poor prognostic factors
age < 2 years or > 10 years WBC > 20 * 109/l at diagnosis T or B cell surface markers non-Caucasian male sex
Aetiology of alpha thalassaemia
Deficiency of alpha chains in Hb
2 separate alpha-globulin genes are located on each chromosome 16
Clinical severity of alpha thalassaemia
If 1 or 2 alpha globulin alleles are affected - hypochromic microcytic blood film, normal Hb
If are 3 alpha globulin alleles are affected - hypochromic microcytic anaemia with splenomegaly
This is known as Hb H disease
If all 4 alpha globulin alleles are affected (i.e. homozygote) then death in utero (hydrops fetalis, Bart’s hydrops)
Causes of ambiguous genitalia in children + basic physiology
Most common cause - CAH
Other causes
True hemaphroditism
maternal ingestion of androgens
initially gonads in fetus are undifferentiated on the Y chromosome there is a sex-determining gene (SRY gene) which causes differentiation of the gonad into a testis if absent (i.e. in a female) then the gonads differentiate to become ovaries
Apgar score
https://litfl.com/wp-content/uploads/2019/03/APGAR-score-Table-3.png
0-3 very low score
4-6 moderate low
7-10 baby is in a good state
Appendicitis in <4 presentation
Uncommon
Often presents with perforation
Asthma attack in children
severe vs life-threatening
SpO2 PEF HR RR Behaviour
Severe SpO2 <92% PEF 33-50% best or predicted HR >125 (>5y), >140(1-5y) RR >30 (>5y), >40 (1-5y) Behaviour Too breathless to talk or feed Use of accessory neck muscles
SpO2 <92% PEF <33% best or predicted Behaviour Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis Increasing CO2
Asthma attack in children mx
Emergency transfer to hospital if severe or life-threating
Children >5
mild to moderate acute asthma:
Bronchodilator therapy
Salbutamol via spacer (for a child < 3 years use a close-fitting mask)
give 1 puff every 30-60 seconds up to a maximum of 10 puffs
if symptoms are not controlled repeat beta-2 agonist and refer to hospital
Steroid therapy
should be given to all children with an asthma exacerbation
treatment should be given for 3-5 days
Usual prednisolone dose used ins steroid therapy for asthma attacks
BTS
2-5
20mg OD
> 5
30-40mg OD
cBNF -
1-2mg/kg OD
Asthma mx in children >5
1) SABA
2) SABA + low dose ICS
3) SABA + low dose ICS + LTRA
4) SABA + low dose ICS + LABA
5) SABA + MART
6) SABA + moderate dose ICS MART OR moderate dose ICS + LABA
7) SABA and
- high dose ICS or
- Trial of additional drug e.g. theophylline
- Seek advice
ICS doses = paediatric doses
Asthma mx in children <5
1) SABA
2) SABA + 8 week trial of moderate dose ICS
symptoms did not resolve - review dx
symptoms resolved then recurred within 4 weeks of stopping ICS - restart ICS at a paediatric low dose
symptoms resolved then recurred beyond 4 weeks of stopping ICS - repeat 8 week trial of paediatric moderate dose ICS
3) SABA + paediatric low dose ICS + LTRA
4) stop LTRA, refer to specialist
When do you decide to put a child on maintenance + reliever therapy rather than just reliever?
Symptoms at presentation that clearly indicate the need for maintenance therapy (e.g. asthma-related symptoms >3x/week or causing waking at night)
Asthma uncontrolled with SABA alone
When do you decide to trial a child <5 on a moderate dose paediatric ICS for asthma?
Symptoms at presentation that clearly indicate the need for maintenance therapy (e.g. asthma-related symptoms >3x/week or causing waking at night)
Asthma uncontrolled with SABA alone
• Paediatric Doses for CS in asthma (budesonide or equivalent)
o Low dose
o Moderate dose –
o High dose
• Paediatric Doses (budesonide or equivalent)
o Low dose - <200 mcg
o Moderate dose – 200-400 mg
o High dose - >400 mcg
ADHD features
Persistent symptoms
Developmental delay
<16 - 6 features have to be present
>= 17 - 5 features need to be present
Inattention
Does not follow through on instructions
Reluctant to engage in mentally-intense tasks
Finds it difficult to sustain tasks
Easily distracted
Finds it difficult to organise tasks or activities
Often forgetful in daily activities
Often loses things necessary for tasks or activities
Often does not seem to listen when spoken to directly
Hyperactivity/impulsivity
Unable to play quietly
Talks excessively
Does not wait their turn easily
Will spontaneously leave their seat when expected to sit
Is often ‘on the go’
Often interruptive or intrusive to others
Will answer prematurely, before a question has been finished
WIll run and climb in situations where it is not appropriate
ADHD management in children
- 10 week watch + wait
- refer to 2ndary care
- education and training programmes for parents
- drug therapy >5, last resort
- Methylphenidate
(6 week trial) - 1st line - lisdexamfetamine - 2nd line
- dexamfetamine - if lisdexamfetamine is beneficial but side effects cannot be tolerated
SE of medication used for ADHD
Methylphenidate - Abdominal pain, N, dyspepsia
weight + height should be monitored every 6 months
cardiotoxic
ECG before treatment
ASD autism sympotms and signs
Social communication impairments and repetitive behaviours are present during early childhood (typically evident before 2–3 years of age),
Impaired social communication and interaction:
Children frequently play alone and maybe relatively uninterested in being with other children.
They may fail to regulate social interaction with nonverbal cues like eye gaze, facial expression, and gestures.
Fail to form and maintain appropriate relationships and become socially isolated.
Repetitive behaviours, interests, and activities:
Stereotyped and repetitive motor mannerisms, inflexible adherence to nonfunctional routines or rituals are often seen.
Children are noted to have particular ways of going about everyday activities.
ASD is often associated with intellectual impairment or language impairment.
Attention deficit hyperactivity disorder (35%) and epilepsy (18%) are also commonly seen in children with ASD.
ASD is also associated with a higher head circumference to the brain volume ratio.
AR vs AD inheritance - what conditions do they cause?
AR - metabolic
AD - structural
AD conditions
Adult polycystic disease Antithrombin III deficiency Ehlers-Danlos syndrome Familial adenomatous polyposis Hereditary haemorrhagic telangiectasia Hereditary spherocytosis Hereditary non-polyposis colorectal carcinoma Huntington's disease Hyperlipidaemia type II Hypokalaemic periodic paralysis Malignant hyperthermia Marfan's syndromes Myotonic dystrophy Neurofibromatosis Noonan syndrome Osteogenesis imperfecta Peutz-Jeghers syndrome Retinoblastoma Romano-Ward syndrome tuberous sclerosis Von Hippel-Lindau syndrome Von Willebrand's disease*
*type 3 von Willebrand’s disease (most severe form) is inherited as an autosomal recessive trait. Around 80% of patients have type 1 disease
AR conditions
Congenital adrenal hyperplasia Cystic fibrosis Familial Mediterranean Fever Haemochromatosis Sickle cell anaemia Thalassaemias Wilson's disease
Beefy red well defined patches, especially in skin folds
Candida
Annular erythematous plaque that has advancing scaly edges and central clearing
Tinea corporis
Fungal cutaneous infection that can affect an infant’s torso
Murmurs in the following heart defects
ASD VSD Coarctation of the aorta PDA PS
ASD ejection systolic murmur and fixed splitting of the second heart sound
VSD pansystolic murmur in lower left sternal border
Coarctation of the aorta Crescendo-decrescendo murmumr in thr upper L sternal border
PDA diastolic machinery murmur in the upper left stenrnal border
PS Ejection systolic in the upper left sternal border
What murmur does the ASD produce and why?
Ejection systolic murmur with fixed splitting of the second heart sound
about the systolic nature of the murmur it is to ejection systolic murmur = increased flow through the pulmonary valve due to the left to right shunt, the fixed delay being caused by an increased loading pressure of the right ventricle delaying closure of the valve
Paramteres that need monitoring when the child is on mthylphenidate for ADHD
Methylphenidate, a stimulant, may suppress appetite and cause growth impairment in children
It is advised to monitor growth (weight + height) blood pressure pulse on a regular basis.
Neonatal resuscitation When do you start CPR on a newborn?
When HR <60 bpm
Neonatal resuscitation when do you suction their airways?
When there is thick maeconium causing obstruction as it can cause reflex bradycardia in babies
If the infant becomes bradycardic, positive pressure ventilation to aerate the lungs is indicated despite the prsesence of meconium
Neonatal resuscitation
DAM I ReCussitAte (RCA) Dry Access (APGAR) Meconium in mouth (suck if presence) Inflation breath 5 (via mask) ReAssess (APGAR) Compression (if HR<60) Adrenaline
Nephritic syndrome
1-2 days post infection
1-2 w post infection
1-2 days post infection igA nephropathy
1-2 w post infection post strep glomerulonephritis
Which one of the following is the most common cause of nephrotic syndrome in children?
Minimal change disease
Majority of cases are idiopathic + respond well to steroids
Why would NSAIDs like ibuprofen not be recommended in anchild with chickenpox?
NSAIDs can increase the risk of necrotising fasciitis in patients with chicken pox
A common complication is secondary bacterial infection of the lesions
NSAIDs may increase this risk
whilst this commonly may manifest as a single infected lesion/small area of cellulitis, in a small number of patients invasive group A streptococcal soft tissue infections may occur resulting in necrotizing fasciitis
Kawasaki disease main signs and symptoms
‘CRASH + Burn’
Conjunctivitis Rash Adenopathy (lymph) Strawberry tongue... the classic Hand swelling with desquamation
Burn - fever >5 days
Vaccinations in
premature babies
Babies <28
When should they be given?
Babies who were born prematurely should receive their routine vaccinations according to chronological age; there should be no correcting for gestational age. Babies who were born prior to 28 weeks gestation should receive their first set of immunisations at hospital due to risk of apnoea.
How do you calculate the correct Timing of milestones for a baby born prematurely?
Developmental milstones - Expected Age + (40 - gestational age at birth)
[Example for social smile: Usually expected at 6 weeks for a normal child. But would be expected by 14 weeks for a child born at 32 weeks. 6 + (40-32) = 14]
Roseola infantum infection characteristics
caused by human herpes virus 6
Roseola infantum is a common viral illness that causes a characteristic 3 day fever and then emergence of a maculopapular rash on the 4th day, following the resolution of the fever. The fever is typically rapid onset and can often predispose to febrile convulsions. The rash typically starts on the trunk and limbs (this is different to chickenpox which is typically a central rash). HHV6 is neurotropic (attacks the nervous system) and thus a rare complication is encephalitis and febrile fits (after cessation of the fever).
Mneumonic
6 looks like a rose
HHV 6 - 6th disease
3 days fever + 3 days rash (in total, that’s 6 days)
