rando Flashcards
non accidental injury red flags
any # in immobile child, multiple #s of different ages, spiral #s brusing in shape of hand or object, on neck, around wrists, buttocks any burn in non mobile child always do a full development assessment to see if child is able to do what parent said child did
non accidental injury investigations
full skeletal survey
bruising differentials
NAI trauma coagulation disorders ALL Mongolian blue spot (back of thigh and buttocks)
differentials
NAI osteogenesis imperfecta
presyncopal symptoms?
faint dizzy feeling nausea feeling hot/ cold/ sweaty rushing noise in the ears
risk factors predisposing to vasovagal syncope?
tired hungry stressed crowded place frightened unwell anaemic dehydrated standing suddenly
2 month immunisations?
6 in 1: DTaP/IPV(polio)/Hib/HepB + Rotavirus (oral) + MenB
3 month immunisations?
6 in 1: DTaP/IPV(polio)/Hib/HepB + Rotavirus (oral) + PCV
4 month immunisations?
6 in 1: DTaP/IPV(polio)/Hib/HepB + MenB
12-13 month immunisations?
Hib/MenC + MMR + PCV + MenB
preschool immunisations? aka 3-4 years
4 in 1 (Diphtheria, tetanus, pertussis, polio) + MMR
14 year immunisations?
Td/IPV(polio) booster + Men ACWY
immunisations given to only those at high risk? + live
BCG
Fraser guidelines?
UPSSI understands advice cannot be persuaded to tell parents likely to continue having sex physical or mental health likely to suffer in the young persons best interests
consent in children
patients less than 16 years old may consent to treatment if they are deemed to be competent (an example is the Fraser guidelines, previously termed Gillick competence), but cannot refuse treatment which may be deemed in their best interest between the ages of 16-18 years it is presumed patients are competent to give consent to treatment patients 18 years or older may consent to treatment or refuse treatment
Causes of neonatal jaundice presenting within 24 h of life
ALWAYS pathological! Haemolytic disease of newborn (rhesus/ ABO incompatibility), G6PD deficiency, Hereditary spherocytosis, pyruvate kinase deficiency. Congenital infection e.g. CMV, rubella, toxoplasmosis
Causes of neonatal jaundice that occurs after 24 h of life but is not yet prolonged (under 2 wks)
physiological, breast milk jaundice, dehydration, infection e.g. UTI, haemolytic disorders, bruising, polycythaemia
why do neonates become jaundiced physiologically?
High [Hb] at birth which undergo marked breakdown in the following days red cell life span markedly shorter than adult RBCs (70 days) hepatic bilirubin metabolism less efficient in the first few days of life.
causes of prolonged neonatal jaundice (>2 wks)
unconjugated - breast milk jaundice, infection esp UTI, hypothyroidism, haemolytic anaemia, Crigler-Najjar conjugated - biliary atresia, bile duct obstruction by cyst, neonatal hepatitis e.g. by congenital infection, inborn errors of metabolism, etc. intrahepatic biliary hypoplasia
Biliary Atresia - presentation - Ix -mx
progressive disease, destruction or absence of extrahepatic biliary tree and intrahepatic biliary ducts -> chronic liver failure and death unless surgery is performed. pale stools dark urine. FTT. neonatal jaundice hepatosplenomegaly - secondary to portal HTN Ix: Fasting Abdo USS may show absent/ contracted gallbladder Liver biopsy shows features of extrahepatic biliary obstruction. Diagnosis confirmed at laparotomy by operative cholangiography Tx- Kasai procedure. if surgery unsuccessful, consider liver transplantation
mx of hepatitis A
supportive: rest and hydration close contacts given prophylaxis with human normal Ig or vaccinated within 2 wks of illness onset Admit if severe vomiting and dehydration, deranged liver function (abnormal clotting) and hepatic encephalopathy
Hep A presentation
acute mild illness, jaundice, gastroenteritis, abdo discomfort some may develop prolonged cholestatic hepatitis (self limiting) or fulminant hepatitis diagnosis confirmed by detecting IgM antibody to the virus
Tx of Hep C infection in children
Pegylated IFNa and ribavarin success rate depends on viral genotype tx not undertaken before 4 years, as it may resolve spontaneously following vertically acquired infections
Tx of Hep B infection in children
all babies born to HBsAg+ mother should receive a course of hep B vaccination. Pegylated IFNa usually taken for 48 wks
To perform a jejunal biopsy on a suspected coeliac patient who is on a gluten free diet, what is the recommendation?
recommendation is to eat some gluten in more than one meal every day for at least 6 weeks before testing.
causes of acute liver failure (fulminant hepatitis) in children
viral: Hep A, B, C poisons/ drugs - paracetamol, isoniazid metabolic - wilsons, reye syndrome, Autoimmune hepatitis
presenting within hours / weeks with jaundice, encephalopathy, coagulopathy, hypoglycaemia, electrolyte imbalance. encephalopathy may present as alternating periods of irritability and confusion w drowsiness.
Acute liver failure *impt to monitor acid-base balance (ABG/ VBG), blood glucose and coagulation times
acute liver failure diagnosis
LFTS: transaminases greatly elevated. ALP increased Clotting abnormal Plasma ammonia elevated. EEG shows acute hepatic encephalopathy and CT may demonstrate cerebral oedema
Complications of Acute liver failure
cerebral oedema haemorrrhage from gastritis or coagulopathy sepsis and pancreatitis
Mx of acute liver failure
maintain blood glucose >4 with IV dextrose, prevent sepsis w abx and antifungal prophylaxis, preventing haemorrhage with FFP, cryoprecipitate, Vit K, and PPI or H2 blocking drugs, treat cerebral oedema by fluid restriction and mannitol diuresis, URGENT transfer to specialist liver unit.
where is gluten commonly found?
wheat, barley and rye
retinal haemorrhages in an infant?
shaken baby syndrome caused by intentional shaking of a child. Triad of retinal haemorrhages, subdural haematoma, and encephalopathy.
large abdo mass often found incidentally. may sometimes be accompained by abdo pain, anorexia, anaemia (haemorrhage into mass), haematuria and hypertension.
wilms tumour nephroblastoma.
Ix of suspected wilms tumour
USS or CT/MRI then staging for metastases (usually lung), initial tumour resectability and function of other kidney
pulmonary hypoplasia - what are some common causes?
oligohydramnios + congenital diaphragmatic hernia. It is believed that oligohydramnios decreases the size of the intrathoracic cavity, thus preventing foetal lung growth
Mx of wilms tumour
initial chemo followed by delayed nephrectomy. Radiotherapy restricted to those w advanced disease
persistent localised bone pain, commonly in limbs. - likely diagnosis? - investigations? - mx?
osteosarcoma Plain Xray followed by MRI and bone scan Xray shows codmans triangle - lifted periosteum and destruction of bone. In Ewings’ there is often a substantial soft tissue mass. CXR for lung mets and BM sampling to exclude BM involvement. Mx in Osteosarcoma (& Ewings) - combination chemo before surgery. if resection is impossible or incomplete e.g. pelvic or axial skeleton, radiotherapy used for local disease in Ewings
Retinoblastoma presentation
red reflex absent/ squint IX- MRI and examination under anaesthetic. Tx- to cure, yet preserve vision. enucleation of eye may be necessary for more advanced disease. Chemo used (esp if bilateral) to shrink the tumour followed by local laser to the retina. Radiotx may be used in advanced, but more often reserved for tx of recurrence.
most common type of solid tumour in children?
CNS tumours e.g. astrocytoma (40%), medulloblastoma (20%), ependymoma (8%), brainstem glioma (6%), craniopharyngioma (4%)
most common type of CNS tumour in child?
astrocytoma ranges from benign to highly malignant (glioblastoma multiforme)
clinical features of CNS tumour
raised ICP + focal neuro signs dependent on site of tumour. headache, vomiting, behaviour/ personality change, visual disturbance and papilloedema. Infants- vomiting, tense fontanelle, increased head circumference, head tilt, developmental delay
medical indications for circumcision?
phimosis - inability to retract foreskin. whitish scarring of the foreskin. due to localised skin disease known as balanitis xerotica obliterans. Recurrent balanoposthitis - redness + inflammation of foreskin, sometimes w dischage. Recurrent UTI
sudden onset severe pain in groin/ lower abdomen/ scrotum. *cremasteric reflex absent
testicular torsion testis always tender if testicular torsion. must be relieved within 6-12 h for there to be good chance of testicular viability.
testicular torsion mx?
surgical exploration. if confirmed, fixation of contralateral testis is essential because there may be anatomical predisposition to torsion.
what increases risk of testicular torsion and risk of delayed diagnosis?
cryptorchidism
epididymitis
feverish, +/- freq/ dysuria. Prehn’s sign: tenderness relieved by elevating the scrotum.
most common cause of acute scrotum in child. pain, testicle red/ swollen. blue dot sign on transillumination
torsion of hydatid of Morgagni. aka torsion of testicular appendage.
cryptorchidism risk factors
more common in preterm infants because testicular descent through inguinal canal occurs in 3rd trimester. may descend in the first 3 months of life.
classification of cryptorchidism
retractile - can be manipulated to the bottom but subsequently retracts, pulled up by the cremasteric muscle. with age, testis resides permanently in scrotum but follow up is advisable. Palpable - testes can be palpated but not manipulated into scrotum. Impalpable - no testis felt. may be in the inguinal canal, intra abdo or absent.
IX of cryptorchidism
USS - to verify internal pelvic organs Hormonal - inject hCG for rise of testosterone to confirm presence of testicular tissue Laparoscopy - investigation of choice for impalpable testes.
Mx of cryptorchidism
surgical placement of testis in scrotum (orchidopexy) for: fertility- optimal temp for spermatogenesis. malignancy- increased malignancy risk. scrotal testes more easily examinable and can be picked up earlier. Cosmetic and psyschological reasons. *if bilateral impalpable testes, usually sterile. if unilat, fertility close to normal.
intermittent swelling in groin or scrotum on crying or straining. swelling may become visible on raising intra abdo pressure by gently pressing abdo. may also present as irreducible lump which is firm and tender.
inguinal hernia. due to patent processus vaginalis.
mx of inguinal hernia
incarcerated- emergency surgery irreducible but stable- opioid analgesia + sustained gentle compression may be able to reduce hernia. surgery delayed for 24-48 h to allow resolution of oedema
acute renal failure (uraemia), thrombocytopenia, MAHA. usually secondary to GI infection. prodrome of bloody diarrhoea
Haemolytic Uraemic Syndrome early supportive therapy including dialysis. follow up is necessary as there may be persistent proteinuria and HTN and declining renal function in subsequent years.
if metabolic acidosis due to acute renal failure- mx?
sodium bicarbonate
if hyperphosphataemia due to acute renal failure- mx?
calcium carbonate + dietary restriction
if hyperK due to acute renal failure- mx?
calcium gluconate, salbutamol, glucose+ insulin, dietary restriction, dialysis
when is dialysis indicated?
failure of conservative mx, hyperK, severe acidosis, severe hypo/hyperNa, pulmonary oedema or HTN, multisystem failure,
Staging of Perthes Disease
Stage 1: clinical and histological features only Stage 2: sclerosis with or without cystic changes and preservation of the articular surface Stage 3: loss of structural integrity of the femoral head Stage 4: loss of acetabular integrity.
monitoring of growth of children below 0.4 gentile for height
should be reviewed by a paediatrician
monitoring of growth of children below 2nd centile
reviewed by GP
1st hearing test in newborn
automated otoacoustic emissions test’ or ‘evoked otoacoustic emissions test’
if automated otoacoustic emissions test is +ve, what test do you do?
automated auditory brainstem response test
what hearing test may be performed on a 6-9 month old?
distraction test
what hearing test may be performed in those >3 yrs
pure tone audiometry
congenital diaphragmatic hernia
birth defect of the diaphragm. malformation of the diaphragm allows the abdominal organs to push into the chest cavity, hindering proper lung formation. -> pulmonary hypoplasia and pulmonary HTN
Choanal atresia
congenital disorder where the back of nasal passage is blocked. may present as cyanosis while baby is feeding, because the oral air passages are blocked by the tongue. cyanosis may improve when the baby cries, as the oral airway is used at this time. - may require resuscitation. assoc w other congenital malformations e.g. coloboma babies w bilateral disease are obligate mouth breathers. tx w fenestration procedures designed to restore patency.
intraventricular haemorrhage
Intraventricular haemorrhage is a haemorrhage that occurs into the ventricular system of the brain. It is relatively rare in adult surgical practice and when it does occur, it is typically associated with severe head injuries. In premature neonates it may occur spontaneously. The blood may clot and occlude CSF flow, hydrocephalus may result. In neonatal practice the vast majority of IVH occur in the first 72 hours after birth, the aetiology is not well understood and it is suggested to occur as a result of birth trauma combined with cellular hypoxia, together the with the delicate neonatal CNS.
Tx of intraventricular haemorrhage
Is largely supportive, therapies such as intraventricular thrombolysis and prophylactic CSF drainage have been trialled and not demonstrated to show benefit. Hydrocephalus and rising ICP is an indication for shunting.
Mx of croup
Oral dexamethasone 0.15mg/ kg (or prednisolone) Emergency tx if severe: high flow O2, nebulised adrenaline.
The mother of a 6-week-old baby girl born at 32 weeks gestation asks for advice about immunisation. What should happen regarding the first set of vaccines?
Give as per normal timetable.
recommended period to be kept away from school for chickenpox
5 days from start of eruption. but all lesions should be crusted over by then.
the majority of children crawl on all fours before walking but some children ‘bottom-shuffle’.
This is a normal variant and runs in families
1st line for constipation in children
movicol paediatric plain
Mx for constipation in children
first-line: Movicol Paediatric Plain add a stimulant laxative (Senna) 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 dose gradually
constipation in breast fed infants
unusual and organic causes should be considered
social hx in paeds?
social services?
who lives at home?
coping?
smoking in the household?
if older child: ask about school/ any problems
progressive weight loss, constipation, muscular atrophy, loss of skin turgor, hypothermia and possible, oedema.
in advanced disease, affected infants are lethargic and can have starvation diarrhoea, with small, mucus-containing stools.
these children appear emaciated and cachetic.
marasmus
(infantile atrophy)
due to inadequate caloric intake that can be linked w factors such as insufficient food resources, poor feeding techniques, metabolic disorders and congenital anomalies.
autosomal dominant disorder, distinctive white forlock, heterochromia irides, unilateral or bilateral congenital deafness and lateral displacement of the inner canthi.
waardenburg syndrome
autosomal dominant, tall stature, long slender limbs, hypermobile joints, lens subluxation and myopia, and mitral valve prolapse.
aortic dilatation and dissection are potential complications.
Marfans syndrome
iron toxicity in infants
as few as 3 tablets can cause severe symptoms and as few as 10 can be lethal.
symptoms occur in two phases: GI symptoms such as bloody vomiting or diarhhoea and abdo pain, followed by a
latent period of up to 12h or more and terminating w CV collapse.
Desferrioxamine given
sacral agenesis assoc w ?
maternal diabetes mellitus
also higher risk of cardiac defects e.g. TGA, VSD, renal defects
and anencephaly
use of antivconvulsants phenytoin and valproate during pregnancy assoc w?
fetal hydantoin syndrome
IUGR, hypoplasia of distal phalanges and nails, alterations in CNS performance.
with valproate, increased risk of neural tube defects in the first trimester
neonatal lupus erythematosus
skin lesions
AV block (permanent) -> heart block*
TGA
valavular and septal defects.
scabies in children tx
permethrin 5% cream
what vit should be given to all children w measles?
in communities where this vit deficiency is prtevalent
vit A.
What Vit is given to newborns to prevent haemorrhagic disease of the newborn?
Vit K
lack of free Vitamin K in the mother and the absence of bacterial intestinal flora that synthesizes vit K result in a transient deficiency in vit k depenedent factors.
what is short stature defined as?
and when is it abnormal?
height below the 2nd or 0.4th centile.
abnormal if child is falling across centile lines.
Height velocity should be calculated.
height must be compared to weight centile and estimate of genetic target centile, which is calculated as mean of fathers and mothers height, with 7cm added for boy and 7cm subtracted for a girl.
how to calculate height velocity?
2 accurate measurements of height velocity at least 6 months (but preferably 1 year) apart.
calculated as cm/ year.
If height velocity is persistently below 25th centile -> abnormal and child will eventually be short.
causes of short stature
familial- short parents
IUGR - born w severe IUGR or extremely preterm (GH tx may be indicated)
Endocrine - hypothyroid, GH deficiency, steroid excess (usually weight centile > height centile)
Constitutional delay
Chronic illness (e.g. coeliac)
restricted diet, psychosocial deprivation
chromosomal abnormalities
Ix of short stature
Growth charts
with clinical features usually allows diagnosis.
Bone age may be indicated. (X ray of hand and wrist for bone age)
Constitutional delay
presentation
more common in males.
often familial.
variation of normal timing of puberty.
may also be due to dieting or excessive excercise.
will have delayed sexual changes compared to peers, and bone age would show moderate delay. (legs will be long in comparison to back).
Eventually target height is reached.
Ix of constitutional delay
If puberty abnormally late,
bone age measurement from hand/ wrist Xray - usually delayed.
in females: pelvic USS can help determine uterine size and endometrial thickness.
Mx of constitutional delay
onset of puberty can be induced w short course of androgens or oestrogens.
what syndromes may cause tall stature?
marfan, homocystinuria, klinefelters.
when is puberty considered to be delayed in females? and males?
>14 for females
>16 for males
Causes of pubertal delay
constitional delay of puberty and growth
hypogonadotrophic hypogonadism-
e.g. kallmanns, congenital hypopituitarism, isolated LH/FSH deficiency, intracranial tumours, anorexia nervosa, excessive exercise, chronic illness.
Primary gonadal failure-
chromosomal, LH resistance, chemotherapy, gonadal irradiation/ infection/ trauma
examination for delayed puberty
height, weight, HC - growth charts
measure parents heights and midparental height
puberty staging
Ix in delayed puberty
LH, FSH. oestrogen/ testosterone levels
karyotype if any dysmorphic features or suspicion.
TFTs, routine biochemistry and CRP/ESR.
Bone age xray, Pelvic USS for ovarian morphology or intra abdo testes.
specific test to measure for levels of testosterone?
hCG stimulation test
- measurement of testosterone pre and post HCG
special test for LH and FSH in delayed puberty?
GnRH test
- measurement of basal LH/FSH and post GnRH to measure gonadal function.
Abx for upper UTI?
Cefotaxime
if <3 months: IV for sure.
>3 mths: IV/ Oral for 10 days
if >3 months: ceftriaxone / co-amoxiclav.
Abx for lower UTI?
oral 3 day course
trimethoprim, nitrofuratoin, cefotaxime.
what is McBurney’s point?
found 1/3 of the way between the ASIS and the umbilicus
pain over mcburneys point seen in appendicitis
What is the Rovsing’s sign?
palpation over the LIF causes pain in RIF
Seen in acute appendicitis
common causes of mesenteric adenitis
inflammation of mesenteric lymph nodes
commonly following viral URTI, or with tonsillitis/ otitis media.
symptoms of DKA
poyluria, polydipsia
lethargy
weight loss
abdo pain
n+v
laboured breathing (resp compensation for the acidosis)
what does a full septic screen involve?
blood cultures, urine cultures, lumbar puncture for CSF
CXR
FBC, U+Es + glucose
usually for <3 months with high fever
Complications of gastro oesophageal reflux
apnoea
failure to thrive
aspiration
oesophagitis -> Pain, bleeding, iron deficiency
Sandifer’s syndrome -> dystonic movements of head and neck and arching of back that resembles seizures
ABC DEFG
ABC
dont ever forget glucose
neonatal hypoglycaemia
symptoms
may be asymptomatic
or jittery, convulsions, hypotonia, lethargy, apnoea
Risk factors for neonatal hypoglycaemia
preterm (<37), babies <2.5kg, IUGR
babies of mothers with GDM/ on BB for preeclampsia
prolonged, symptomatic hypoglycaemia can cause permanent neurological disability.
Signs of shaken baby syndrome
Non accidental injury
retinal haemorrhages
skull fractures
swelling of the brain
subdural haematomas
rib and long bone fractures
bruises around the head, neck, or chest
torn frenulum
Live attenuated vaccine given intradermally to at risk infants
BCG
inactivated virus given at 2, 3, 4 months, preschool booster and again at 13-18 yrs
to prevent muscle paralysis.
Polio
(Salk)
When is Men C given to children?
12-13 months
with Hib Vaccine
+ MMR + PCV + MenB
when are Men B + PCV given?
2, 4 and 12-13 months
Pertussis - when is the vaccine given?
2, 3, 4 months, preschool booster.
vaccine that is given 2, 3, 4 months, preschool and again at 13-18 yrs to prevent disease that causes thick gray coating in the back of throat/ nose (‘pseudomembrane’)
Diphtheria
thick gery-white coating at back of throat
high fever
malaise
sore throat
headache
swollen cervical LNs
difficulty breathing and swallowiing
cutaneous - pus filled blisters, large ulcers
what factors should initiate a higher level of suspicion of non accidental injury?
discrepancy between injury/ presentation and hx given
change in hx over time or between different ppl
delay in presentation
unusual reaction to the injury
repeated injuries
hx of NAI/ suspicious injury in sibling
other signs of neglect / FTT
osteogenesis imperfecta
features
bony fragility -> recurrent fractures and deformity
wormian bones may be seen on skull Xray
(irregular, isolated bones found within skull sutures- not fractures)
sclerae are blue
assoc w conductive hearing deafness and
aortic valve regurgitation - Diastolic mumur
e.g.s of short acting beta2 agonists for asthma
salbutamol
terbutaline
e.g.s of inhaled steroid
in asthma
budesonide
fluticasone
how to administer leukotriene receptor antagonists in children w asthma
oral
can be sprinkled onto foods such as yoghurt or cereal
eg. of long acting b2 agonist in asthma
salmeterol
formoterol
features of severe asthma
pt too breathless to talk or feed
PEF <50% predicted or best
RR >50
Pulse >140
Features of life threatening exacerbation of asthma
silent chest
poor resp effort
PEF <33% predicted or best
decreasing consciousness
fatigue/ exhaustion
Mx of life threatening asthma
Oxygen
Nebulised salbutamol (back to back + cardiac monitoring)
oral/ Iv steroids
may need IV salbutamol +/- IV aminophylline
or transfer to ITU
if >5 yrs, IV mg so4 can be used
Gold standard for how to get a urine sample in a child
clean catch urine
learning difficulties, progressive visual impairment due to retinal changes, polydactyly and syndactyly, hypogenitalism and nephropathy
Laurence Mood Biedl syndrome
coarse facial features, large tongue, hoarse cry, hypotonia, lethargy, umbilical hernia, constipation and prolonged jaundice
congenital hypothyroidism
rarely made as a clinical diagnosis now due to screening using the Guthrie card
pansystolic murmur in the 5th intercostal space, left of the sternum
VSD
murmur caused by shunting of blood from the high pressure L ventricle to the low pressure R ventricle
Mitral stenosis murmur
end diastolic in the 5th intercostal space, left side (apex)
almost always caused by rheumatic fever
ejection systolic murmure
Upper Right Sternal Edge
Aortic stenosis
If critical, HF will ensue rapidly after birth.
there may be an ejection click and radiation to the carotids
ejection systolic murmur
upper left sternal edge
pulmonary stenosis
critical stenosis will present rapidly when the ductus arteriosus closes
mx is w dilatation of stenosis w balloon or surgical correction
machinery murmur (in both systolic and diastolic)
inferior to left clavicle
patent ductus arteriosus
first line mx in bacterial gastroenteritis
Oral rehydration.
toddlers diarrhoea
common between 1-5 yrs
often description of food in the diarrhoea
in otherwise well child
e.g.s of osmotic laxatives
movicol (a macrogol- polyethylene glycol)
lactulose
signet ring inclusions
malaria
Mx of incarcerated inguinal hernia
treat the severe dehydration
reduction of hernia and possible resection of necrotic bowel
what is an antacid we can use in gastrooesophageal reflux?
gaviscon
what is a promotility drug we can use in gastrooesophageal reflux
erythromycin
domperidone
metoclopramide
Proton pump inhibitors we can use in gastrooesophageal reflux
omeprazole
H2 receptor antagonists that we can use in gastrooesophageal reflux
ranitidine
double bubble sign on abdo xray
- presence of air in the stomach and proximal duodenum only, and not in the distal intestines
Duodenal atresia
about 1/3 have Downs
present at birth w bilious vomiting and abdo distension
tx by duodeno-duodenostomy
gastroschisis
defect in ant abdo wall adjacent to umbilicus
abdo contents can herniate through this defect, but there is no sac covering the contents
Mx: immediately covering the exposed viscera w cling film, followed by surgical repair.
Exomphalos
herniation of abdo contents through umbilicus
herniated viscera surrounded by a sac and this structure known as an omphalocele
surgical closure is required.
assoc w other congenital malformations such as trisomies and cardiac defects
Meckel’s diverticulum
congenital diverticulum that contains gastric-type mucosa
usually found 2 feet proximal to ileocaecal junction, 2 inches in length and occurs in 2% of population
most common presentation- painless rectal bleeding
some may present w acute inflammation similar to acute appendicitis.
Dx by technetium-99m scan
Tx by resection if required.
complications of septic arthritis
joint destruction leading to arthritis
spread of infection to bone - osteomyelitis
ankylosis- bony fusion across the joint
talipes equinovarus
= clubfoot
foot is inverted and plantar flexed
talipes is the most common congenital abnormality
half of the cases are bilateral.
may be secondary to intrauterine compression (oligohydramnios) or a neuromuscular disorder (such as spina bifida)
mx: passive stretching and strapping.
if deformity is severe, then corrective surgery required.
genu varus
bowlegs
congenital disorder w lymphoedema of hands and feet in the neonatal period, coarctation of the aorta (femoral pulses hard to palpate)
45XO turners syndrome
Stills diseae
systemic form of Juvenile arthritis
autoimmune
intermittent high pyrexia and salmon pink rash w aches and pains of the joints and muscles
+ hepatosplenomegaly, lymphadenopathy and pericarditis.
CRP raised.
Mx includes physiotherapy, resting splints, NSAIDs, DMARDs e.g. methotexate, ciclosporin, and steroids.
why does rheumatic fever occur following strep infections?
ususally 2-4 wks after group A strep
in susceptible individuals, antibodies formed against the bacterial carbohydrate cell wall cross react w antigens in the heart, joints and skin in a process known as molecular mimicry,
Diagnosis of Rheumatic fever
2 major or 1 major + 2 minor + evidence of strep infection
Major:
Pancarditis - myocarditis, pericarditis, endocarditis
Polyarthritis
Sydenhams chorea (St vitus’ dance)
erythema marginatum
subcutaneous nodules
Minor:
fever
arthralgia
high ESR/ WCC
heart block
Serial ASOT titres
what are the major criteria for rheumatic fever
Pancarditis - myocarditis, pericarditis, endocarditis
Polyarthritis
Sydenhams chorea (St vitus’ dance)
erythema marginatum
subcutaneous nodules
Minor criteria for Rheumatic fever
fever
arthralgia
high ESR/ WCC
heart block
Pancarditiis in rheumatic fever can present w?
murmurs - incl mitral stenosis, mitral regurgitation, aortic regurgitation
Carey Coombs murmur (soft mid diastolic murmur tt ocurs due to nodule development on mitral valve leaflets)
pericarditis
myocarditis
endocarditis
Mx of rheumatic fever
Penicilliin
analgesia
NSAIDs
bed rest
if severe, steroids
following acute phase, patients require prophylactic abx prior to invasive procedures such as tooth extraciton in order to protect against bacteraemia and subsequent bacterial endocarditis.
TORCH screen?
Toxoplasmosis
Other - Syphilis
Rubella
CMV- most common
HSV
Mx of patent ductus arteriosus w subsequent heart failure
HF should be treated w duretics, such as frusemide and spironolactone
patent ductus arteriosus then plugged via catheter inserted into the femoral artery.
only if this fails should open cardiothoracic surgery be performed
same presentation as coeliac
biopsy shows villous atrophy and motile trophozoites
Giardiasis
chronic infection causes malabsorption, particularly of carbohydrates and fat
deficiency of fat soluble Vit A D E K
stool cultures may be taken to look for cysts
tx - oral metronidazole
tx of giardiasis
oral metronidazole
haematuria after vigorous forms of exercise?
stress haematuria
aka
exercise induced haematuria
painless and of short duration
later repeated samples will be clear
IgA nephropathy
assoc w Henoch schonlein purpura
causes haematuria 2 days after an URTI
Triad of glomerual BM degeneration, sensorineual deafness, and ocular abnormalities
Alports syndrome
second most common inherited cause of chronic renal failure (after polycystic disease)
an x linked mutation causes degeneration of type IV collagen, found in the BM, cochlea and eye
haematuria after prolonged surgery?
rhabdomyolysis
- breakdown of muscle fibres w release into the blood of myoglobiin which is excreted into the urine.
tx w IV rehydration to aid excretion of myoglobin and prevent renal failure.
Immediate mx of Crohns with anal fissure and anal tags?
Tx underlying constipation w laxatives.
2nd line: topical preparations that relax the anal sphincter can be used, such as glyceryl trinitrate or diltiazem pastes.
pica
nervous, GI and haem systems affected
abdo pain, constipation, headaches
encephalopathic signs
hypochromic microcytic anaemia
blood film demonstrates basophilic stippling
Lead poisoning
examination may reveal a bluish line along the gums.
lead found in paint.
Ix: measure blood lead levels
tx: chelation of lead using EDTA (ethylenediamine tetraacetic acid)
meconium ileum in CF
mx?
initial mx is with gastrograffin enema, which is both diagnostic and therapeutic.
if child is peritonitic -> gastrograffin enema is contraindicated and a laparotomy and bowel resecetion should be performed
start immediately on prophylactic flucloxacillin to protect lung function
Diagnosis of sickle cell disease
blood film appearance,
haemoglobin electrophoresis
Mx of inhalation of foreign body
CXR may locate the foreign object
but needs to removed by rigid bronchoscopy under anaesthesia.
retropharyngeal abscess
presentation
fever, drooling, dysphagia, stridor
similar to acute epiglottitis but air entry still fine.
occasionally, head tilted to one side and neck may be stiff (torticollis)
Mx: abscess needs to be drained with antibiotic cover
what age would a child be walkinging alone, feet apart, arms assisting balance?
15 months
at what age would a child be able to draw squares and triangles?
5 years
at what age will a child be able to walk on a narrow line?
5 yrs
at what age can a child fix and follow 180 through the horizontal plane?
and fix and follow 90?
180 degrees- 3 months
90 degrees- 6 wks
at what age can a child hop on one foot?
4 years
hereditary angioedema
- what deficiency?
C1 esterase inhibitor deficiency
C1 esterase inhibitor acts as a mediator of complement proteins of the immune system. Lack of this protein -> complement system goes unchecked + accumulation of vasoactive inflammatory mediators.
Angioedema
- presentation
intermittent itchy swelling of the face, lips, pharynx and limbs, along with abdo pain, vomiting and diarrhoea.
attacks of herediatry angioedema can be mistaken for anaphylaxis.
there is often no identifiable trigger for attacks of hereditary angioedema, although recognized precipitators include minor trauma and strenuous exercise.
laryngeal oedema is the most concerning complication, and can be fatal
Mx of acute episode of angioedema
IV C1 esterase inhibitor concentrate
long term mx with anabolic steroids e.g. danazol
helps promote synthesis of C1 esterase inhibitor.
Nephrotic syndrome complications
ascites -> can become infected (peritonitis)
pulmonary oedema
loss of immunoglobulins in the urine-> high risk of pneumococcal and haemophilus infections
Mx of nephrotic syndrome
prednisolone to induce remission
salt restriction and replacement of fluids with human albumin solution may be required.
Prophylactic penicillin.
Congenital adrenal hyperplasia
- enzyme deficiency
- what accumulates?
21 hydroxylase (autosomal recessive deficiency)
excess 17-hydroxyprogesterone
Mx of SIADH
restrict total intake of fluids
monitor daily - electrolytes, serial serum and urine osmolality
in severe cases: hypertonic saline and concurrent furosemide.
CXR - boot shaped heart, where the normally convex-shaped pulmonary artery on the L heart border becomes a concavity.
tetralogy of fallot
neonatal teeth mx
neonatal teeth are often removed, as there is a risk of aspiration and they can cause problems w breastfeeding.
infantile colic
description of a baby who cries for more than a total of 3 h in any 3 days of 3 consecutive wks
tx is supportive, and the baby w colic usually settles by the fourth month of life.
Mx of tetany
anti tetanospasmin Immunoglobulins
Fever, malaise, pharyngitis, tonsillitis, lymphadenopathy.
Petechiae on the soft palate, jaundice, splenomegaly and hepatomegaly
Administration of amoxicillin/ ampicillin causes widespread maculopapular rash.
Infectious mono (glandular fever)
Caused by EBV
Diagnosis via monospot test/ Paul Bunnell test
Tx is symptomatic.
*Administration of amoxicillin/ ampicillin in infectious mono causes widespread maculopapular rash.
This rash can scar.
Better to administer penicillin instead if wanting to tx for bacterial tonsillitis but cannot rule out Infectious mono.
Ddx of acute epiglottitis
Retropharyngeal abscess
Often preceded by an URTI
Presents w fever, drooling, dysphagia and stridor.
Head may be tilted to one side and neck may be stiff.
unvaccinated child
flu-like illness associated w muscle pain, flaccid paralysis and areflexia.
cranial n dysfunction-> deafness, blindness, dysarthria and dysphagia.
Poliomyelitis
acute disorder of the anterior horn cells caused by the highly contagious RNA poliovirus.
affects lower motor neurones.
paralysis of the resp muscles warrant mx w non invasive negative pressure ventilator.
Severe dysphagia, earache and trismus (lockjaw)
Inspection of the pharynx shows a unilateral bulge of the soft palate, w deviation of the uvula to the opposite side.
Tonsils inflamed + halitosis
Peritonsillar Abscess (Quinsy)
Collection of pus outside the tonsil – complication of tonsillitis
White plaques in mouth
May be immunosuppressed/ recently used antibiotics
Dysphagia, odynophagia and hoarse voice
Candida.
Oesophageal candidiasis can be treated w antifungals such as fluconazole, nystatin or amphotericin.
skin lesions of TB
erythema nodosum - painful inflamed rash on the lower limbs
lupus vulgaris - painful, nodular, disfiguring lesions, predominantly on the face
recurrent fevers on uncertain origin + erythema nodosum
TB
wound on the back of hand there for 7-14 days
painful, hot, regional lymphadenitis and flu like symptoms.
fever
if severe, altered mental state and convulsions
cat scratch fever
infection w gram negative bacterium bartonella henselae
tx w antibiotics.
Prader- Willi syndrome
Angelman syndrome
- inheritance pattern?
imprinting
- gene required for normal function comes from only one parent
syndrome ensues when gene is deleted or both genes come from the other parent (uniparental disomy)
williams syndrome
short stature, elf like faces, transient hypercalcaemia as infants, supravalvular aortic stenosis and mild to moderate learning difficulties
inheritance pattern?
microdeletion
at chr 7q11
Tx of acute sinusitis
antibiotics if bacterial infection is suspected
analgesia
vasoconstricting nose drops (1% ephedrine) aid drainage of the sinus
Labial Adhesions
relatively common in prepubertal girls
caused by recurrent irritation, trauma or infection
prepubescent labia are prone to adhesions due to lack of oestrogenized epithelium.
bleeding and dysuria are common.
most cases will require no tx
tx required if pt is symptomatic w dysuria or freq vulval or vaginal infections.
most cases respond w topical oestrogen tx.
if unsuccessful, symptomatic cases need surgical intervention.
Mx of phimosis
No treatment needed
Only if prepuce remains non retractile or he has UTI/ balanitis secondary to phimosis, should surgical correction be performed.
Mx of paraphimosis
Administer local anaesthetic ring block to the glans followed by simultaneous squeezing of the glans and reduction of the foreskin.
After paraphimosis, formal circumcision should be performed to prevent recurrence.
urological emergency. Paraphimosis is caused by retraction of a tight foreskin over the glans. The foreskin then acts as a tight band, making it more difficult to reduce the skin. may cause necrosis/ gangrene.
Petechiae vs purpura?
Petechiae are pinpoint, flat, red lesions that do not blanch on pressure. Caused by capillary bleeding into the skin.
Purpura comprises larger lesions that are red, brown or purple. They do not blanch w pressure, are raised and may be palpable.
Henoch Schonlein purpura
What features?
Often preceded by URTI esp strep infections
Non thrombocytopenic palpable purpura (usually on buttocks and extensor surfaces of lower limbs), arthralgia, periarticular oedema, colicky abdo pain and glomerulonephritis.
Rash is initially uritcarial, rapidly becoming purpuric.
Tx is symptomatic.
Why may a child w pertussis cause petechiae in the upper limbs/ face?
Both coughing and vomiting can cause increased pressure in the SVC region, resulting in bleeding from the superficial capillaries into the skin.
thick yellow scale and crust on the scalp of a young child
seborrhoeic dermatitis
prophylactic tx for migraines in children?
topiamate and propranolol
(>12 yrs old)
CKD does not recommend preventative tx in primary care unless the HCP has a specialist interest in headaches (consider expert advice/ referral).
what is given alongside iv antibiotics in bacterial meningitis, to reduce the incidence of neuorlogical complications?
IV dexamethasone
1st thing to do when a premature infant is born?
put a hat on the babys head and a plastic bag over his body
what are oesophageal atresias assoc with?
92% assoc w tracheo-oesophageal fistula
catch-up growth for weight in early childhood is a risk factor for obesity
e.g. when a child is in 0.4th centile at term birth but then 50th centile at 2 yrs old.
strawberry naevus
bright red and irregular
enlarge in size initially and then shrink and disappear by the age of 4 to 5 years.
epstein pearls
seen in over half of newborns and caused by entrapment of fluid during development of the palate
they disappear within a few wks and are harmless.
erythema toxicum neonatorum
baby acne
seen in about half of newborns and despite the name, is completely harmless.
classically, there are small pustule like spots on a red base and the fleeting nature is characteristic.
white flecks on the iris in Downs
brushfield spots
newborn with macroglossia, macrosomia, microcephaly, midline abdominal wall defects (omphalocele/ exomphalos, umbilical hernia), ear creases, nenonatal hypoglycemia
Bechwith-Wiedemann syndrome
a 10 yr old boy with T1DM has recurrent abdo pain, oily loose stools and recurrent episodes of hypoglycemia.
what is the cause of the abdo pain?
coeliac disease
T1DM is an autoimmune condition and there is an increased risk of other immune-mediated diseases, such as coeliac disease, which is characterized by features of malabsorption.
3 month old boy has had severe gastroenteritis, for which he has required intravenous rehydration. On reintroduction of feeds, his diarrhoea has worsened and he has increasing abdominal discomfort and distension and borborygni.
what is the cause of abdo pain?
transient lactose intolerance
following gastroenteritis, the gut can take some time to heal completely, and there may be a transient lactose intolerance.
this will cause symptoms of malabsorption.
orange-red stains in nappy
urate crystals
may be noticed in the first couple of days after birth.
often mistaken for blood.
a sign of overconcentrated urine.
if there is any doubt, the red area can be eluted into some water in a specimen pot and tested with a urine dipstick. it will be negative if urate crystals are the cause,
episodes that occur on waking
tingling on one side of the mouth, and then makes a gurgling noise and cannot speak properly.
he finally makes small jerking movements, which spread from his arm to his leg on the left side.
afterwards he is sleepy for several hours.
beinign rolandic epilepsy
double bubble sign
duodenal atresia
which feature of downs syndrome occurs most frequently?
intellectual impairment
In the U.K., the perinatal mortality rate is approximately 6 per 1000 births. The World Health Organization (WHO) defines the Perinatal mortality rate as
The number of stillbirths (of at least 22 completed weeks of gestation) plus the number of neonatal deaths within the first 7 days of life per 1000 births.
nephrotic syndrome ix?
lipids: cholesterol and triglyceride levels (elevated in nephrotic syndrome)
ASOT titre + C3/4 levels (post strep GN)
ANA (vasculitides e.g. SLE)
Hep B antibodies of at risk population - rare cause of nephrotic syndrome
measles and VZ antibodies (impt to know as children on immunosuppressive therapy such as steroids are more vulnerable to these conditions)
blood culture if febrile
Urine- Dip + MCS + Spot Protein.creatinine ratio (should be >2 in nephrotic syndrome)
mx of nephrotic syndrome
prednisolone as a single morning dose for 4 wks follwed by a prolonged reducing regime.
+ prophylactic penicillin (due to increased risk of bacterial infections- immunosuppression + loss if Ig in the urine)
assess fluid balance of child, esp if hypoabluminaemia or vomting/ diarrhoea.
if hypovolaemic -> IV fluids, or IV albumin
what % of patients w nephrotic syndrome will relapse again?
70%
Complications of nephrotic syndrome
- hypovolaemia -> iv fluids/ albumin
- bacterial sepsis - most common strep pneumoniae and bacterial peritonitis.
- thromboembolic events due to hyperviscosity e.g. PE/ DVT/ renal vein thrombosis
examination of a bedwetter
gentalia and spine inspected for abnormalities,
assess lower limb neurology
DDx of primary nocturnal enuresis
lack of arousal from sleep - enuresis alarm w star chart
bladder instability - bladder retraining, anticholinergic medication
low functional bladder capacity
most common cause of hypertension in pubertal children?
essential (idiopathic) HTN - usually assoc w obesity.
*if prepubertal- there is often a cause
Idiopathic HTN Mx
BP repeated at least 3 x at weekly intervals
- to determine if elevation is sustained.
plot BP on centile chart.
Lifestyle changes.
referral to dietician + advice about low salt/ low fat diet
total of 1 hr of exercise a day is recommended
if the raised BP is confirmed, a BB/ CCB may be used.
causes of HTN
CREED
Cardiological - e.g. coarctation of the aorta
Renal - e.g. GN, renal artery stenosis
Essential
Endocrine e.g. Cushings, thyrotoxicosis, phaeochromocytoma
Drugs e.g. steroids, COCP, amphetamines
Ix of HTN in an adolescent
24 hr ambulatory BP monitoring to confirm diagnosis
renal USS - renal disease?
ECG - cardiac pathology?
Fasting Glucose (to rule out T2DM- potential consequence of obesity)
Lipids: cholesterol and triglyceride levels
complications of measles
pneumonia
suppurative otitis media
corneal ulceration
gastroenteritis
febrile convulsions
encephalomyelitis
encephalitis
subacute sclerosing panencephalitis
lymph node features in bacterial vs viral vs TB infection?
bacterial infections -
overlying skin is usually erythematous and lump is warm and tender.
occasionally, the swelling may become fluctuant and this is indicative of pus formation and an abscess -> referral to surgeon for incision and drainage.
viral infections-
nodes are tender but not usually warm/ erythematous.
TB infection
lump usually cold and non tender
lymphoma-
non tender, tends to be firmer than inflammatory nodes and may be adherent to the overlying skin or underlying structures.
characteristic Xray features of osteosarcoma
bone destruction
gross swelling
elevation of the periosteum w creation of codmans triangle
sunray spicules of new bone visible in the muscle and subcut tissues.
Mx of osteosarcoma
a senior paediatrician should break the news to the girl and her family.
onward referral to specialist paediatric oncology centre
MDT care- oncology, specialist nurses
first step- analgesia.
screened for metastases - Chest CT scan and bone scan + MRI scan of shoulder to guide future surgery.
Biopsy should be taken
Initial chemo to reduce tumour bulk
then surgery
then further chemotx
what factors contribute to increased risk of infection in children w cancer?
neutropenia
mucositis - following chemo/ radiotx (poor mucus protection_
indwelling central lines
frequent hospital admissions
poor nutrition
generalized immunosuppression.
Ix of temperature in neutropenic chemo kid?
blood cultures, FBC, WCC, CRP, U+Es
swabs from any suspected sites of infection
+ urine/ stool samples
CXR if resp signs
Mx of fever in neutropenic chemo kid?
gram -ve sepsis is the real threat.
febrile neutropenia in an immunocompromised child is a medical emergency.
admit and immediate IV Abx broad-sepctrum.
careful monitoring and frequent re evaluation, changing the regimen according to response and culture results.
if still febrile and neutropenic after 5 days, add antifungal agents.
may need blood/ platelet transfusions if active bleeding or v low numbers.
Endocrine associations of Downs syndrome
Hypothyroidism
Addisons
T1DM
Ocular assoc w Downs
cataracts
IBD in a younger child more likely to be?
Crohns
Mx of epileptic fit worsened due to concurrent febrile illness
IV fluids.
IV ceftriaxone, clarithromycin, aciclovir. (empirical abx/ antivirals if high temp and cant rule out meningitis/ encephalitis)
antipyretics if temp v high.
measure blood glucose to rule out hypoglycaemia.
when performing examination of large head, what to consider?
shape of head, size/ shape/ patency of the fontanelles and cranial sutures.
dysmorphic features, or other congenital abnormalities.
full neuro/ developmental assessment.
plot weight/ heigh and head circumferences on centile chart.
causes of macrocephaly
familial
hydrocephaly -> tense fontanelle, distended scalp veins
SOL - tumour, vascular malformations, subdural haematoma (NAI)
fragile X syndrome -> large ears, developmental delay
overgrowth syndrome e.g. developmental delay, large hands/ feet
neurofibromatosis - cafe au lait patches, axillary freckles
DDx of coma in children
hypoxic ischaemic brain injury
epileptic seizure/ post ictal state
trauma e.g. intracranial haemorrhage, cerebral oedema
infections e.g. meningitis, encephalitis, abscess
metabolic - renal and hepatic failure, hypoglycemia, DKA, inborn errors
poisoning
vascular lesions e.g. stroke
mx of subdural haemorrhage causing raised intracranial pressure in infant
urgent transfer to neurosurgical unit/ PICU.
sitting infant at 30 degree angle
restricting fluids to two thirds maintenance
elective intubation and ventilation
control oxygenation/ maintain normoglycaemia
urgent discussion w regional neurosurgical centre
decrease ICP - can be done w mannitol/ hypertonic saline
arrange for urgent neurosurgical assessment to determine whether surgery required to evacuate the haematoma.
contact social services and follow child protection procedures.
causes of delayed walking
generalized developmental delay: e.g. downs syndrome, fragile X
neuromuscular cause: cerebral palsy, Duchenne muscular dystrophy
MSK: DDH
normal late walker: majority of cases
contributing factors in learning difficulties?
hearing impairment
visual impairment
chronic medical condition
epilepsy
autism spectrum disorder
dyspraxia
neglect
commonest cause of acute childhood stroke
sickle cell disease
causes of acute stroke in childhood
haem- sickle cell, polycythaemia, leukaemia
cardiac- embolic, kawasaki
infection- meningitis
intracerebral vascular- ruptured aneurysm, arteriovenous malformation
autoimmune- JIA, SLE
metabolic- homocystinuria
trauma
Ix of Stroke
CT/MRI head
- to distinguish between ischaemia/ haemorrhagic
all children w arterial ischaemic stroke:
MRI angiography of the cervical and proximal intracranial arterial vasculature
cardiac echo
ix for prothrombic tendency e.g. protein C deficiency
if intracerebral haemorrhage:
clotting studies and pl count
mx of stroke in childhood
refer to neurology
regular neuro observations
urgent scanning/ admission to PICU if there is deterioration.
if ischaemic stroke and haemorrhage / SCD excluded- start aspirin
long term mx involves MDT
features of common migraine
recurrent headache w symptom-free intervals
unilateral, typically throbbing, n+v
abdo pain is common
over 90% have family history
auras: visual, small areas of visual loss in a visual field (scotoma) and brilliant white zig zag lines
DDx of chronic headaches
tension headache
sinusitis
refractive errors - check vision
raised ICP - pain worse on lying down/ change in behaviour, papilloedema
solvent/ drug abuse
HTN- blood pressure must be checked
mx of migraine
migraine diary - identify possible triggers (common stress/ tiredness/ anxiety)
reassurance that there is no serious intracranial pathology
lifestyle changes
avoid blanket exclusion diets
explore social stressors- e.g. bullying
if all else fails, school attendance is affected, migraines are unacceptably intrusive, prevention w drugs. e.g. propranolol, pizotifen, topiramate but all have side effects
Bells palsy
lower motor neurone palsy of the facial n
whole side of the face is weak.
taste on the anterior 2/3 of the tongue on the involved side may be lost
+ facial numbness
lower vs upper motor neuron lesion of facial n
how to differentiate
in upper motor neurone facial n palsies:
preserved facial power and eye closure
why may bells palsy occur following infection
occurs due to oedema of the facial n as it crosses the facial canal in the temporal bone
it may occur 2 wks after a viral infection
herpes simplex and varicella zoster are causative + EBV, lyme disease and mumps
causes of acute bells palsy
HSV
VZV
EBV
lyme disease
mumps
consider chronic cases of bells palsy
otitis media
HTN
tumours
leukaemia
trauma
mx of bells palsy
if presenting within 1 wk:
steroid tx with prednisolone for 7 days
eye care impt - if child cannot close eye, tx w artificial tears such as hypromellose eye drops and taping of the eye at night
most pts recover within a few wks
10% left with mild facial weakness
5% are left w permanent significant facial weakness
recovery may take up to 6 months
DDx of back pain in children
developmental abnormalities - spondylolysis, scoliosis
traumatic- verterbral stress fractures, muscle spasm due to overuse e.g. in athletes/ gymnasts, prolapsed intervertebral disc
neoplastic - metastases
infection - discitis, verterbral osteomyelitis
rheumatological - ank spond, psoriatic arthritis
back pain in child- screen for?
persistent or worsening pain
systemic features: FLAWS
neuro symptoms/ signs
sphincter dysfunction
young age
mx of back pain in child
with neuro signs: hypotonia/ absent reflexes
medical emergency
urgent investigation and intervention to reduce cord compression
MRI
refer immediately to a paediatric neurosurgery centre
spinal cord tumours: intramedullary, extramedullary intradural, extramedullary extradural
west syndrome
epilepsy syndrome characterized by infantile spasms, developmental regression and hypsarrhythmia on EEG
usually starts in first year of life and can have a variety of underlying causes including structural brain abnormalities, neurometabolic disease, neurocutaneous syndromes and acquired brain injury
causes of developmental regression
acquired brain injury: hypoxia, meningitis
seizure disorders: west syndrome
neurodegenerative: mitochondrial disorders, Tay-Sachs disease
toxic substances: lead poisoning
infectious: subacute sclerosing panencephalitis, prion disease
pervasive developmental disorder: autism, rett’s syndrome
Ix of developmental regression
MRI scan
EEG - seizure disorder?
FBC, renal function, liver function tests, U+Es, lactate/ ammonia
urine for urine amino and organic acids
depigmented patches on skin?
possible ash leaf macules
tuberous sclerosis
tuberous sclerosis presentation
hamartomas in multiple organs including brain, skin, eyes, kidneys, heart.
ash leaf macules
seizures common.
chronic otitis media w effusion
‘glue ear’
presentation and signs
conductive hearing loss
snoring (partial upper airway obstruction)
tympanic membranes have dull retracted appearance w loss of light reflex and some bubbles visible behind the membrane
why are children w Downs particularly vulnerable to Otitis media w effusion?
large adenoids, small nasopharynx and narrow eustachian tubes
making aeration of the middle ear less efficient.
mx of conductive hearing loss
causes: glue ear, congenital ear abnormalities
conservative
use grommets
sensorineural deafness
causes
genetic
infection: congenital/ postnatal
birth asphyxia
head injury
Mx of sensorineural hearing loss
hearing aid
cochlear implant
mx of downs syndrome w glue ear
refer to paediatric audiology clinic + regular follow up
hearing assessment
tympanometry to confirm negative middle ear pressures typical of OME
if pt has sleep apnoea -> may necessitate an adenotonsillectomy
what is a convergent squint?
appearance of one eye not looking in the same direction as the other
ie. right convergent squint means that the right eye is turned in towards the nose when the left eye is looking directly at the target
squint: types
paralytic or concomitant
paralytic squints are caused by dysfunction of the motor nerves controlling eye movements (III, IV, VI) -> may be the 1st sign of a brain tumour/ neuro disorder
concomitant squints are common - usually due to extraocular muscle imbalance in infants, or refractive errors after infancy.
what simple assessment to assess for squint?
testing corneal light reflex-
looking at position of reflection on each eye.
Ix of squint
corneal light reflex
visual fields
range of eye movement tested
red reflexes tested w ophthalmoscope - absence of the red reflex indicates ocular pathology such as cataract or retinoblastoma
cover test: when fixing eye is covered, the squinting eye will move to take over fixation
Mx of squint
refer to paediatric Opthalmology
aim to detect any serious underlying pathology and to prevent development of amblyopia.
in the developing brain- the image from the squinting eye is suppressed to avoid diplopia.
in untreated squint- leads to irreversible suppression of the visual pathways, visual impairment in that eye and possible blindness. (amblyopia)
correction of refractive errors w glasses
patching of good eye to force use of the other eye
surgery on the extraocular muscles
triad in autism
impairment of social communication, social interaction and rigidity of thought and behaviour
what comorbidities to consider with autism?
hearing difficulties
learning disability
assessment of suspected autism spectrum disorder?
refer to CAMHS for assessment or paediatrician w interest in autism spectrum disorders
usually involves a clinical psychologist + MDT
hearing test arranged
detailed developmental, medical, family and social histories taken
social skills, communication and behaviour observed in a standardized way
criteria for ADHD
inattention, hyperactivity, impulsiveness
excessive for the childs developmental age and cause significant social/ academic problems
present in more than one setting
begun < 7 yrs of age
present for > 6months
causes of injury to fetal brain:
antenatal (80%)
vascular occlusion
structural maldevelopment of the brain
genetic syndromes
congenital infection
causes of injury to fetal brain
perinatal
hypoxic ischaemic injury during delivery
causes of postnatal brain injury (10%)
meningitis
encephalitis
encephalopathy
head trauma
hypoglycaemia
hydrocephalus
kernicterus
neonatal stroke
clinical presentation of cerebral palsy
abnormal limb/ trunk posture and tone
delayed motor milestones
feeding difficulties w oromotor incoordination
abnormal gait once walking
asymmetric hand function < 12 months
primitive reflexes may persist and become obligatory
diagnosis of cerebral palsy
clinical examination of posture/ tone/ hand function and gait
Hemiplegic Spastic Cerebral Palsy
increased spasticity with brisk deep tendon reflexes and extensor plantar responses.
unilateral arm and leg affected.
arm more affected/ face spared.
flexed arm, pronated forearm, asymmetric hand function, tiptoe walk on affected side (due to contracted calf)
Quadriplegic spastic cerebral palsy
increased spasticity with brisk deep tendon reflexes and extensor plantar responses.
all 4 limbs affected, often severely.
trunk - extensive posturing
poor head control
low central tone
more severe- seizures, microcephaly, intellectual impairment
may have hx of perinatal HIE
diplegic spastic cerebral palsy
increased spasticity with brisk deep tendon reflexes and extensor plantar responses.
all 4 limbs affected, but legs much more.
hand fn releatively normal but abnormal gait.
assoc w preterm birth due to periventricular brain damage
dyskinetic cerebral palsy
involuntary, uncontrolled movements
variable muscle tone
primitive reflexes predominated
chorea, athetosis and dystonia
signs are due to basal ganglia/ extrapyramidal injury
commonest cause: HIE at term/ kernicterus
ataxic (hypotonic) cerebral palsy
most genetically determined
early trunk and limb hypotonia, poor balance
delayed motor development
incordinate movements
intention tremor
ataxic gait
mx of cerebral palsy
MDT approach - SALT, physio, OT to support child development + neurologists
stretching exercises, orthoses etc for posture/ movement
surgery last resort
communication - speech aids/ therapy
cognition and learning- special education
tx for spasticity: oral diazepam, oral/ intrathecal baclofen, etc
paediatric emergency
ABCDE protocol
AVPU/ GCS score
BLS to resuscitate seriously ill child
fluid requirements: first 10 kg - 4ml/kg/hr
subsequent 10kg - 2 ml/kg/hr
subsequent 10 kg - 1ml/kg/hr
Bolus - 0.9% saline, 20ml/kg
1st line treatment for seizure if IV access alr established
IV lorazepam
- in hospital setting.
can give twice
advice regarding prevention of sudden infant death syndrome
put to sleep on back
avoid overheating by heavy wrapping
immediate mx for premature baby birth
immediately dried and covered (head + body), or placed in a plastic bag under a radiant heater
assess APGAR
airway positioned optimally
baby will need resp support, which may be CPAP or intubation
surfactant may need to be delivered
transfer to neonatal unit
complications of premature birth
lungs- RDS, apnoea, pneumothorax
brains - periventricular haemorrhage, periventricular leukomalacia
heart- PDA
GI - NEC, GORD
infection
metabolic- hypoglycaemia, jaundice
Vesicoureteric reflux (VUR) is the abnormal backflow of urine from the bladder into the ureter and kidney. It is relatively common abnormality of the urinary tract in children and predisposes to urinary tract infection (UTI), being found in around 30% of children who present with a UTI. As around 35% of children develop renal scarring it is important to investigate for VUR in children following a UTI
perform DMSA scan to identify renal scarring
maternal labetalol may lead to what in a neonate?
neonatal hypoglycaemia
measure blood glucose
elfin like facies, v friendly and social, learning difficulties, supravalvular aortic stenosis
williams syndrome
diagnosis by FISH
signs of achondroplasiatrident hand deformity (short, stubby fingers with separation between the middle and ring fingers), other physical features include: short limbs (rhizomelia), lumbar lordosis and midface hypoplasia.
short limbs (rhizomelia) with shortened fingers (brachydactyly)
large head with frontal bossing and narrow foramen magnum
midface hypoplasia with a flattened nasal bridge
‘trident’ hands
lumbar lordosis
fetal risk if SSRI use during third trimester?
persistent pulmonary hypertension of the newborn
by what age can a child squat to pick up a toy?
18 months
term neonate
VBG: severe metabolic acidosis
absence of risk factors/ signs of sepsis
lethargic baby
strong odour
ketones +++ in urine
lactate 2.1 glucose 5.2
inborn error of metabolism
e.g. organic acidurias
isovaleric acidaemia, maple syrup urine disease
mx of baby w severe metabolic acidosis from inborn error of metabolism
call for help from senior paediatrician
stop feeds and start infusion of 10% dextrose
may need intubation and ventilation
sodium bicarb to correct the acidosis
blood should be sent for ammonia, plasma ammino acid profile and urine for amino and organic acid profiles.
transfer to regional metabolic unit
what are dysmorphic features
abnormal body characteristics
characteristic dysmorphic features of t21
hypotonia
flat face
upward slanting palpebral fissures
epicanthic folds
white speckles on iris (brushfield spots)
short broad hands
single palmar and plantar fissures (simian crease)
ix in one with downs syndrome
chromosomal analysis - to confirm diagnosis, look for mosaicism (that might alter the prognosis), to exclude a translocation
cardiac echo - even if no murmurs are heard
breaking bad news about downs syndrome
should be done by senior paediatrician and midwife who knows them well
discussion needs to take place in a private room w plenty of time allowed
avoid jargon and use diagrams to help explanations.
expect distress/ anger - any emotion
written material is available from downs syndrome charities and their websites
approach to a fitting child
ABC
give high flow oxygen
place on cardiac monitor
obtain intravenous access
send relevant tests
check blood glucose
in a neonate, though it may seem unlikely- give iv broad spectrum abx to cover for sepsis
control the seizure with anticonvulsants
what anticonvulsant to use in a neonate
usually a loading dose of phenobarbital
followed by- if necessary- maintenance
causes of hypoCa in infancy
prematurity
hypoxic ischaemic encephalopathy
hypoPTH (e.g. diGeorges)
hypoMg - Mg facilitates release of PTH
exchage trnafusion - citrate in transfused blood chelates ca to prevent clotting
maternal hyperCa- suppresses fetal PTH
maternal vit D deficiency
what does the Xray show
Xray shows a mid shaft spiral fracture of the left femur.
spiral fracture suggests a twisting injury - unlikely in a non weight bearing infant.
NAI Ix
Full skeletal survey
Brain CT scan - exclude any injuries such as subdural haemorrhage
if there is bruising -> FBC, clotting screen
mx of spiral fracture in child
admit to manage the fracture and as place of safety
pain relief and immobilization in traction
check child protection register
document, date, sign hx, examination, investigations
inform senior paediatrician, who will confirm the findings and explain openly and non judgmentally why there are concerns, what is going to happen next and who will be involved
refer immediately to social care/ safeguarding lead
aim is to act in childs best interest
vulvovaginitis
causes
due to UTI
poor perineal hygiene - often after girls have started self toileting
masturbation
pinworms - assoc w perianal itching, esp at night (20% assoc vulvovaginitis)
herpes infection
possibility of sexual abuse
advice on hygiene for vulvovaginitis
cleaning oneself from front to back after bowel motion
use loose fitting cotton knickers
having daily baths/ showers using simple soaps
allowing area to dry
what is this?
positional plagiocephaly
occurs when asymmetricael pressure on the developing occiput/ skull base results in oblique flattening of the posterior skull.
plagiocephaly causes
asymmetrical sleeping position
- may be normal or may have underlying neuromuscular disorder
torticollis
cervical spine abnormalities
typical presentation of positional plagiocephaly
baby born with/ develops an abnormal head shape sometime after birth
which then improves with time
as mobility increases, the likelihood of persistent asymmetrical pressure decreases, and in most cases head shape will return to normal.
threadworms presentation
perianal itching, particularly at night
girls may have vulval symptoms
asymptomatic in around 90% of cases
Infestation with threadworms (Enterobius vermicularis, sometimes called pinworms) is extremely common amongst children in the UK.
occurs after swallowing eggs that are present in the environment.
diagnosis of threadworms
apply sellotape to perianal area
send to lab for microscopy to visualize eggs
However, most patients are treated empirically and this approach is supported in the CKS guidelines.
mx of threadworms
CKS recommend a combination of anthelmintic with hygiene measures for all members of the household
1st line for >6 month old: mebendazole
newborn with growth retardation, sensorineual deafness, purpuric skin lesions, seizures
CMV
characteristic features: growth retardation/ purpuric skin lesions
other features: hepatosplenomegaly, jaundice, anaemia, pneumonitis, cerebral palsy
rubella: SHE, purpuric skin lesions and ‘salt and pepper’ chorioretinitis
DDx of plagiocephaly
craniosynostosis
what is craniosynositis?
premature fusion of one or more sutures of the skull, resulting in abnormal skull shape.
deformity often present at birth, is progressive and does not improve spontaneously.
can result in raised ICP and developmental delay
atlantoaxial instability assoc w?
Downs
neck instability
precocious puberty + cafe au lait spots + polyostotic fibrous dysplasia
mcCune-Albright syndrome
what atrial septal defect is most common in Downs
secundum ASD
at what age is the average child able to draw a staight line
2.5 years
at what age can a child build a tower of 6 blocks
2 years
at what age has an average child developed a pincer grip
9/10 months
at what age does early babbling start - with double syllables?
6 months
at what age can a child turn towards sound
3 months
at what age can a child understand no
9 months
at what age does a child know and respond to own name
1 year
what type of ovarian tymour is assoc with Meigs syndrome
fibroma
triad of ascites, pleural effusion and benign ovarian tumour)
complications of craniosynositis
increased ICP
developmental delay
permanent abnormal head shape
sagittal synostosis results in what appearance?
narrow head with enlarged anteroposterior dimension
lambdoid synostosis
appearance?
similar to plagiocephaly
unilateral flattening of the occiput but less frontal asymmetry (compared to plagiocephaly)
resulting in rhomboid head shape
also, ear ipsilateral to flattened occiput is displaced posteriorly and inferiorly
a ridge may be palpable in the area of the fused suture
differentiating between plagiocephaly and lambdoid craniosynostosis
plagiocephaly: parallelogram head shape, unilateral flattening of occipital area with ipsilateral bossing of the frontal and parietal bones
Lambdoid synostosis: rhomboid shape, unilat flattening of occiput but less frontal asymmetry
ear
plagiocephaly: ear ipsilateral to flattened occiput is displaced anteriorly
lambdoid synostosis: ear is displaced poisteriorly and inferiorly
in craniosynostosis, ridge often palpable on area of fused suture
imaging
CXR/ CT scan can be used to assess sutures
mx of plagiocephaly
will improve spontaneously
even if it does not completely return to normal, hair growth will disguise much of the abnormal appearance
if problem is severe or continues to worsen then tx may be indicated.
helmet moulding may have some benefit by rebalancing growth of skull
it most severe cases- surgical intervention may be warranted
mode of action of emergency contraception levonorgestrel
inhibits ovulation
what heart defects assoc w turners syndrome?
bicuspid aortic valve (15%)
coartaction of the aorta (5-10%)
when is a child able to build a tower of 3-4 blocks
18 months
mode of action of desogestrel POP
inhibits ovulation
+ thickens cervical mucus
classical history for iron toxicity
iron is corrosive to GI mucosa -> abdo pain, nausea, vomiting, diarrhoea w haematemesis and bloody diarrhoea (dark) in more severe toxicity
interlude w apparent recovery for abour 8-16h
third stage: progressive systemic involvement due to vasodilator effects of iron and mitochondrial poisoning
mx of iron poisoning
Oxygen and IV fluids to manage poor perfusion
treat hypoglycaemia
send family to check for missing drugs - identify other possible drug toxicity
Abdo Xray- can confirm ingestion of iron tables which are radio opaque
if taken with 1 hr of presentation or tablets visible in stomach on xray -> consider gastric lavage with wide bore tube
measure serum Iron urgently- it may be spuriously low if taken >8h post ingestion
discuss w national poisons info service to discuss tx w desferrioxamine
discuss w specialist liver unit
at what age does a child wave bye bye
1 year
same time they know and respond to their own name
and develop a good pincer grip
inheritance of retinoblastoma
autosomal dominant
by what age should a child be able to smile
6 weeks
when to intubate a child?
airway of any child w GCS <8 is at risk
an anesthetist should be called urgently to monitor airway/ breathing
and potentially may need to be intubated.
alcohol poisoning
unconscious teen
ix?
blood alcohol level
blood glucose
U+Es, LFTs, Blood gas
CT head - may have sustained head injury
Mx of alcohol poisoning
ABC
maintenance IV fluids (0.45% saliine, 5% dextrose)
hourly GCS observations
social services
contact childs family
consider doing urine toxicology
may need further psychiatric/ social work input and follow up
Questions to ask in social history when considering neglect?
who else is at home?
does the mother have a partner? is the partner father of child?
is there hx of drug/ alcohol abuse?
are there other children?
is family known to social care?
Pica is assoc w?
iron deficiency anaemia and
lead poisoning - basophilic stippling
symptoms of lead poisoning
colicky abdo pain
constipation
headache
drowsiness
fits
coma -> lead encephalopathy
mx of lead poisoning
urgent referral to hospital
measure blood lead
seek advice from national posions info service about need for chelating agents
check blood ferritin and haemoglobinathy screen
measure bone biochemistry and vit D -> tx w Vit D to minimize lead absorption
mx of neglect
referral to social care for multidisciplinary assessment of whole family
referral to child and family therapy service for behaviour management
emergency mx of anaphylaxis
IM adrenaline 1:1000
ABC
high flow oxygen
nebulized salbutamol
(if stridor does not improve- call for anaesthetist)
IV fluids: Bolus 20ml/kg + maintenance
dose of antihistamine e.g. chlorpheniramine
Mx of anaphylaxis?
find culprit food
skin prick testing and or total IgE/ RAST to specific foods
lifelong exclusion
epipen on him at all times + family taught how to use it + supply of oral antihistamine
referral to dietician
to determine whether a relationship presents a risk that needs referral to social care and or police:
GP needs to consider?
whether pt is competent to understand and consent to sexual activity (ALL children <13 not competent to consent)
power imbalances - difference in age/ development e.g. teacher/ youth worker
aggression/ manipulation/ bribery - use of drugs/ alcohol
attempts to secure unreasonable secrecy
whether partner is known by agencies to have worrying relationships w other young ppl
evidence of parental neglect/ lack of supervision in child <13
grooming behaviour? sexual exploitation
what does advanced paediatric life support involve?
asystole in child
->
ventilate w high concentration O2
intubation
IV access -> give IV 1:10000 adrenaline
4 min CPR
consider 4 Hs:
hypothermia, hypovolaemia, hypoxia, hypoK/hyperK
consider 4 Ts:
cardiac tamponade, tension pneumothorax, toxic substances, thromboemolic phenomena
consider giving IV bicarb
mx of sudden infant death syndrome
refer to coroner
baby by law requires postmortem
police automatically informed
child protection register check
bereavement counselling offered
ix in patients with suspected chronic fatigue syndrome
investigations to rule out active infection, inflammation, endocrine problems, malignancy
FBC, WCC, CRP, ESR
Blood film
Ur, Cr
Glucose and U+Es
Liver function, thyroid function
urine dipstick
Mx of chronic fatigue syndrome
MDT approach:
support w physiotherapy, occupational therapy and CAMHS
assessment of baseline fn using activity diary
supportive tx- allieviate symptoms, improve nutrition and sleep patterns
graded programme of return to activity
occasionally - inpatient mx required
fabricated or induced illness
perpertrator may
- fabricate medical hx
- cause symptoms by repeatedly exposing child to toxin, medication, infectious agent, physical trauma
- alter lab samples/ temp measurements
consider in children who have recurrent unexplained symptoms
- almost always the mother. sadly the disturbed parent seems to obtain a perverse satisfaction from the close association w hospital care and staff.
mx of suspected fabricated/ induced illness
obtain second opinion from another consultant paediatrician
referred to social care
child protection register check
health visitor contacted for further info
3 day history of puffy eyes, unwell with coryzal illness last wk.
O/E generalized oedema and scrotal oedema.
tachycardic + cool peripheries
diagnosis?
nephrotic syndrome with hypovolaemia
tachycardia and cool peripheries suggest hypovolaemia, due to increased interstitial fluid collection due to reduced oncotic pressure.
how to diagnose posterior urethral valves?
micturating cystourethrogram
post urethral valves may cause vesicoureteric reflux
NSAIDs e.g. diclofenac in renal impairment?
Do not use
as it is nephrotoxic
inheritance pattern of PCKD that presents in childhood with bilateral renal masses?
and of PCKD that presents in older children/ adults.
auto recessive- presents in childhood w bilateral renal masses, resp distress due to pulmonary hypoplasia and chronic hepatic fibrosis w pulmonary HTN.
due to tubular dilation of the distal collecting system. Renal function is impaired and progressively deteriorates, requiring renal replacement therapy (dialysis/ transplant).
the auto dominant type presents in older child/ adult. the cysts are grossly dilated nephrons which compress normal renal tissue. it affects renal, liver and cerebral vasculature.
what is considered a mild Learning disability?
IQ 50-70
moderate learning disability?
IQ 35-50
severe learning disability?
20-35
mx of umbilical hernia
if small and asymptomatic
perform elective repair at 4-5 yrs of age.
Umbilical hernias are relatively common in newborn children, and in 80% will spontaneously close by 4-5 years of age.
after this age, it should be managed due to risk of incarceration.
mx of large (>1.5cm) or symptomatic umbilical hernia
elective repair at 2-3 yrs of age
hernias may cause pain/ intermittent symptoms of incarceration.
mx of incarcerated umbilical hernia
should be manually reduced with pressure and surgically repaired within 24 hours.
if it can’t be reduced, an emergency operation is required.
how does ovarian cancer spread
by local invasion
what is considered a raised CA125
35 IU/mL or greater
what is infantile colic?
Infantile colic describes a relatively common and benign set of symptoms seen in young infants.
typically occurs in infants < 3 months old
characterised by bouts of excessive crying and pulling-up of the legs, often worse in the evening
cause unknown
occurs in up to 20% of infants
what investigations do you perform in infant < 3m w fever?
Full blood count
Blood culture
C-reactive protein
Urine testing for urinary tract infection
Chest radiograph only if respiratory signs are present
Stool culture, if diarrhoea is present
when can a child ask what and who questions?
3 years
when can a child count to 10
3 years
when can a child ask why when and how qns
4 years
most common fractures assoc w child abuse
radial
humeral
femoral
when can a child start to play alongside, but not interacting with, other children? (parallel play)
2 years
when does a child start to laugh and enjoy friendly handling?
3 months
when does a child start to be shy and take everything to the mouth
9 month
Lactational Amenorrhoea method
what % of the babys feeds have to be from moms breastfeeding?
85% feeds from breast milk
mx of seborrhoeic dermatitis
regular washing of scalp w baby shampoo followed by gentle brushing w soft brush
softening scales w baby oil first then gentle brushing and washing off w baby shampoo
if simple measures not effective: topical imidazole cream.
features of growing pains
never present at the start of the day after the child has woken
no limp
no limitation of physical activity
systemically well
normal physical examination
motor milestones normal
symptoms are often intermittent and worse after a day of vigorous activity
normal heart rate in infants <1
110-160
normal resp rate in infants <1
40
toddlers 1-2 yrs normal heart rate
100-150
toddlers 1-2 yrs normal resp rate
35
preschool 3-4 yrs normal heart rate
95-140
preschool 3-4 yrs normal resp rate
30
5-11 yr olds normal heart rate
80-120
5-11 yr olds normal resp rate
25
how to estimate weight in child 1 yr and over?
(age +4) x2
tricuspid valve leaflets are attached to the walls and septum of the right ventricle
resulting in a large atrium and small ventricle.
ebsteins anomaly
mx of pertussis in child < 1 month of age
clarithromycin
mx of pregnant woman with pertussis
erythromycin
complications of pertussis
subconjunctival haemorrhage
pneumonia
bronchiectasis
seizures
in infants with GORD who do not respond to alginates/thickened feeds and who have 1. feeding difficulties, 2. distressed behaviour or 3. faltering growth
mx?
proton pump inhibitor (PPI) or H2 receptor antagonists (H2RA) e.g ranitidine
painless fluid filled lesion posterior to the sternocleidomastoid
cystic hygroma
atopic eczema in infant
what areas are often affected
face and trunk
what type of vaccine is the rotavirus?
oral, live attenuated vaccine
scaphoid abdomen and bilious vomiting
intestinal malrotation and volvulus
When does moro reflex disappear?
from birth to around 3-4 months
when does grasp reflex disappear?
from birth to 4-5 months of age
when does stepping reflex disappear?
birth til 2 months
when does rooting reflex disappear?
from birth til around 4 months
mx of any chidld <2 w acute limp
urgent hospital assessment
as they are at higher risk of septic arthritis and child maltreatment
what term is used to describe the fetal head in relation to the ischial spine
station
0 - directly at lvl of the ischial spines
-2 -> 2cm above the ischial spines
+2 -> 2 cm below the ischial spines
molar pregnancy
what do you expect of BHCG, TSH and T4 levels
BHCG high
TSH low
T4 High
What is Kocher’s criteria?
Non-weight bearing - 1 point
Fever >38.5ºC - 1 point
WCC >12 * 109/L - 1 point
ESR >40mm/hr
What is Kocher’s criteria used for?
