Random Passmed Flashcards
Infantile Colic
- Characterized by bouts of crying and pulling-up of legs (20% of infants).
Improves 3-4 months of age and resolves by 6 months. - Worse in evenings/nights.
- Commences around 6-8 weeks.
- Consult specialist if symptoms persisting over 5 months, parents unable to cope, symptoms worsening.
- If symptoms improving at 3-4 months, reassure and offer follow-up appointment in 1 month.
Gastroesophageal Reflux Disease (GORD)
- Differs from infantile colic.
- Symptoms include hoarse cry, chronic cough, feeding difficulties.
- Pyloric stenosis presents at 2-6 weeks of age.
Hypospadias
- Circumcision avoided as foreskin is used in corrective surgical procedure.
- Surgery typically done at 12 months
- Cyptorchidism in approx 10%
Neonatal Hypoglycemia
- Define
- In-utero risk factors
- Management
- When to stop hypoglycaemia protocol
- Defined as blood glucose <2.6 mmol/L.
- Common in the first 24 hours, usually not pathological.
- Maternal labetalol use during pregnancy increases the risk.
- Management: asymptomatic - normal feeding, monitor blood glucose; symptomatic - admit to neonatal unit, IV 10% dextrose.
- Maternal diabetes increases the risk due to fetal insulin release.
- Babies on hypoglycemia protocol - stopped when at least 3 blood glucose values >2.5 mmol/L.
Orofacial Clefts
- Associated with maternal smoking, benzodiazepine use, antiepileptics, rubella (maternal), trisomy 18, 13, 15 (fetal).
- Cleft lip repaired from 1st week of life to 3 months.
- Cleft palate repaired between 6-12 months.
Neonatal Respiratory Distress Syndrome
- Associated with maternal diabetes (insulin inhibits surfactant production).
- Ground glass appearance on x-ray, indistinct heart border.
- Treatment: maternal corticosteroids, O2, assisted ventilation, exogenous surfactant via endotracheal tube.
Chromosomal Abnormalities
- Pierre-Robin
- Patau
- Edwards
- Williams
- Pierre-Robin: palate (cleft), posterior tongue displacement, small chin.
- Patau (Trisomy 13): polydactyl, microcephaly, low-set ears, cleft palate.
- Edwards (Trisomy 18): widely spaced eyes, rocker bottom feet, overlapping fingers, ptosis, low set ears, short stature.
- Williams: sparkly personality, elvish features, CVD (supravalvular aortic stenosis), hypercalcemia, intellectual disability.
Hypoxic Ischemic Encephalopathy
- Therapeutic cooling (33-35 degrees for 72 hours) within 6 hours of birth/hypoxia-inducing event.
- Slows metabolic rate, allows more recovery time from hypoxic insult
Cause of slap cheek?
Cause and mx of scarlet fever?
Eczema presentation?
- Slap cheek caused by Parvovirus (5th disease).
- Presents with a slap cheek appearance.
- Scarlet fever: group A strep, punctate erythema on torso first, spares palms and soles.
- Oral penicillin V for 10 days; azithromycin if allergic.
Eczema: <2 extensor surfaces and face, >2 flexure surfaces and creases of the face and neck.
Respiratory - Cystic Fibrosis
- Infection with Burkholderia cepacia is a contraindication for lung transplants.
- Lumacaftor/Ivacaftor (Orkambi) used for those homozygous for delta F508 mutation
Ortho
- Definitive mx SUFE
- Growing pain sx
- Age for Osgood-Schlatter
- Definitive management SUFE: in situ fixation with cannulated screw
- Growing pain symptoms shouldn’t be present in the morning, often intermittent and worse after vigorous activity.
- Osgood-Schlatter: knee pain at 10-15 years old
ENT - Retinoblastoma
- Most common pediatric ocular cancer.
- Autosomal dominant.
- Absence of red reflex most common presenting symptom.
- Strabismus is common; treatment includes external beam radiation therapy, chemotherapy, photocoagulation, enucleation.
Cardio - Innocent Murmur
- Soft, systolic, short, symptomless.
- Standing/sitting (may vary with position).
- Epstein’s Anomaly: atrialization of the right ventricle, low insertion of the tricuspid valve, large right atrium, small right ventricle
When is the APGAR score assessed?
At 1 and 5 minutes of age
Pulse, resp effort, colour, muscle tone and reflex irritability
Higher score = good health (0-3 very low, 4-6 moderately low, 7-10 good health)
What are the next steps if the APGAR score is <5 at 5 minutes?
Repeat at 10, 15 and 30 minutes and umbilical cord blood gas sampling considered
What is Kocher’s criteria for septic arthritis?
- Inability to weight bear (1 pt)
- Fever >38 (1 pt)
- WBC >12 x10^9/L (1 pt)
- ESR >40mm/hr (1 pt)
What is the next step in treatment for constipation if Movicol is insufficient?
Add Senna (stimulant laxative)
Movicol = osmotic laxative
What is the management of umbilical hernias?
- Usually self resolve
- If large (>1.5cm)/ symptomatic perform elective repair at 2-3 years
- If small and unsymptomatic perform eletive repair at 4-5 years
What is the management for an umbilical hernia that incarcerates during the observation period?
Manually reduce and surgically repair within 24 hours
How and where should chest compressions be performed in paediatric BLS?
Lower 1/2 of the sternum using the heel of the hand
What is the rate of chest compressions in paediatric BLS?
100-120 bpm (1/3 sternal depression)
15:2
Where is the damage located in dyskinetic cerebral palsy?
Basal ganglia and substantia nigra
What are the classical symptoms of dyskinetic cerebral palsy?
- Athetoid movements
- Oro-motor problems
What do lesions in the amygdala produce?
Kluver-Bucy syndrome
- Hypersexuality
- Hyperorality (preoccupation with oral sensations and behaviours)
- Hyperphagia (excessive eating)
- Visual agnosia (impaired visual recognition)
What is the presentation of cow’s milk protein intolerance?
Presentation days-weeks after CMP ingestion
- Diarrhea
- Emesis
- Colic
- Rectal bleeding
Rapid onset
- Urticaria
- Wheezing
- Itching
- Angioedems
- Coughing/ sob
What is the presentation of congenital hypothyroidism?
- Hypotonia
- Macroglossia
- Umbilical hernia
- Reduced feeding
- Constipation
What is the heel prick test used to screen for?
5-8 days of life
- Phenylketonuria
- Hypothyroidism
- Cystic fibrosis
- Congenital adrenal hyperplasia
What is the mechanism of jaundice in pyloric stenosis?
Decreased hepatic glucuronosyltransferase activity
What is the inflammation pattern in Croup?
Laryngotracheobronchitis
What are the guidelines for children who are admitted to hospital with suicide attempt?
Admission and urgent CAMHS assessment before discharge
When is treatment for enuresis initiated?
Once the child has turned 5
When should toxic shock syndrome be suspected in a child?
When there’s an unwell child with an unhealed burn
Treatment involves intensive care department with paeds consultant and plastic surgeon input
Resus with cryoprecipitate may be necessary
What is erythema infectiosum?
5th disease aka slapped cheek
Parvovirus B19
Mild prodromal period lasting 1-3 days and incubation period of 1 week
Slapped cheek appearance fades after 2-4 days and is followed by macular rash on the extremities (mainly extensor surfaces)
No exclusion from school required
What are the risks with a pregnant person becoming infected with parvovirus B19?
Infection in the first trimester is associated with 19% fetal death
But risks at all stages of pregnancy
Which patients does necrotising enterocolitis most commonly affect?
Formula-fed preterm infants, most commonly in the first few weeks of life
Which areas of the bowel are most commonly affected in necrotising enterocolitis?
Terminal ileum and ascending colon
What is the presentation of necrotising enterocolitis?
Bloody stool
Vomiting
Abdominal distention
Purpuric rash
Lethary
Cardiovascular collapse
Apnoea
What is the most likely cause of unilateral wheeze in a child <3?
Inhaled foreign object
(Child should be systemically well)
Where do inhaled foreign objects tend to lodge?
At the bifurcation of the right main bronchus, as it is more vertical
Why is polyhydramnios associated with tracheoesophageal fistula?
Because the amniotic fluid isn’t passed into the GI tract (due to the fistula)
What is the presentation of a tracheoesophageal fistula?
Immediate vomiting of uncurdles milk, mother with polyhydramnios
Which children is PDA more likely to occur in?
Children with hyaline membrane disease and in those with a concurrent cyanotic congenital heart condition
The initial stimulus for physiological closure of the ductus arteriosis is high blood oxygen tension
What is the first step for managing a febrile, neutropaenic child?
IV abx (tazocin)
Neutropaenic sepsis
What is the double bubble sign on abdominal x-ray?
Duodenal atresia
What is biliary atresia?
Blind-ended biliary tree (associated with trisomy 21) suffer from indigestion due to bile sludging and impaired fat absorption
+ jaundice from bile retention
What should point to mesenteric adenitis in children with right iliac fossa pain?
History of viral URTI and enlarged neck nodes and high temperature
What kind of fever does appendicitis tend to present with?
Low grade fever
Are patients who have had a VSD closed at high risk of developing infective endocarditis?
No, once the defect has been surgically repaired they’re not considered high risk
What is the management of necrotising enterocolitis?
Stop enteral feeding and medications
- TPN if feeds stopped >24 hours
- Confirmed NEC stop feeds for 7 days
NG tube
- Drain fluid and gas from the gut
- Monitor hourly gastric aspirates
Broad spectrum IV abx
- Eg. cefotaxime and vancomycin
IV fluids
- Cardiovascular support (inotropes if they need)
Surgery
When is surgery indicated in necrotising enterocolitis?
- Perforation
- Failure to respond to medical tx
What surgery is performed in necrotising enterocolitis?
Laparotomy with resection of necrosed bowel with either a primary anastomosis or defunctioning stoma
What is the managment for asymptomatic neonatal hypoglycaemia?
- Confirm hypoglycaemia with blood glucose assay
- Support breast-feeding techniques
- Offer additional feed if willing (breast milk substitute or IV glucose)
- Buccal glucose gel may be used in conjunction with a feeding plan
- Neonatal doctor informed
How often should blood glucose be monitored when feeding interventions are introduced for neonatal hypoglycaemia?
Remeasure in 1 hour to ensure there’s a response
What is the management for neonatal hypoglycaemia if pre-feed glucose is <2mmol/L or symptomatic?
Immediate glucose IV infusion
- Initial bolus of 2ml/kg 10%
- Infusion of 3.5mL/kg/hr 10%
- Aim for 3-4mmol/L
If glucose <1mmol/L buccal glucose gel is used as an interim whilst arranging IV infusion
What is the management for neonatal hypoglycaemia secondary to hyperinsulinism?
- Glucagon infusion
- Diazoxide + chlorthiazide
- Somatostatin analogue
What is the management for neonatal hypoglycaemia if first-line feeding ineffective?
10% IV glucose infusion with levels re-tested within 15 minutes
What is the management for neonatal respiratory distress syndrome?
A-E resus
Resp support
- Intubation and ventilation (severe RDS)
- Endotracheal surfactant
- CPAP (keeps lungs inflated)
- Supplementary O2 (aim between 91-95%)
Fluids
IV abx
- Broad spectrum combination eg. benzylpenicillin and gentamycin
CXR
- ASAP unless there’s only mild respiratory distress where this can be delayed
What is the initial step in management if meningococcal meningitis is suspected (LP has been done)?
3rd generation cephalosporins (eg. cefotaxime, ceftriaxone) should be administered as quickly as possible after lumbar puncture
What is the managment of meningitis if LP can’t be performed within 30 mins of hospital admission?
Empirical treatment
When would a head CT be done before lumbar puncture in meningitis?
If there are clinical signs of raised ICP, not routinely performed
When is jaundice in a newborn considered pathological?
When it presents before 24 hours, or after 24 hours and persists for >2 weeks
What embryological abnormality causes tetrology of fallot?
Anterosuperior displacement of the infundibular septum
What is the mechanism of transposition of the great arteries?
Failure of the aorticopulmonary septum to spiral
When is it abnormal for a child to have a hand preference?
Before 12 months old
By what age should a child be able to walk?
18 months
When is it abnormal for a child to not be able to stand on one leg?
By 4 years old
When is it abnormal for a baby not to be able to set unsupported?
By 8 months old
What are the methods for securing the airway with acute epiglottitis?
Call ENT surgeon/ senior anaesthetist to secure airway
- Endotracheal intubation
- Nasotracheal intubation
- Tracheostomy
What are the cyanotic heart conditions?
Presenting in the first week of life (relies of the ductus arteriosus being patient and become apparent once it closes):
- Total pulmonary atresia
- Tricuspid atresia
- TGA
- Tricuspid regurgitation and Ebstein’s anomany with right to left shunt via ASD
After the first week of life:
- TOF
- Total anomalous pulmonary venous drainage
How can a congenital 5-alpha reductase deficiency present?
5-alpha reductase converts testosterone to DHT
Feminisation of the external genitalia, usually phenotypically female until puberty
Early detection allows for gender assignment with dihydrotestosterone treatment
Later detection may lead to female gender assignment with hormone therapy and preventive orchidectomy
What is the first line management for infantile haemangiomas in children aged 5 weeks - 5 months?
Oral propranolol
Only if the haemangioma causes troublesome symptoms eg. becomes large, ulcerated or impairs functions such as vision, hearing or breathing
What is the growth pattern of benign haemangiomas?
- Grow rapidly in the first 3 months
- Peak around the 5th month
- Then regress
Usually appear at 4-6 weeks of life
What is the management of asymptomatic haemangiomas?
Monitoring only:
- Medical photography and reassessment in 3 months
How does congenital hypothyroidism cause neonatal jaundice?
Reduced bilirubin conjugation, gut motility and feeding
What are the serum bilirubin levels for neonatal jaundice?
> 85micromoles/L
How many words should children be speaking by 2 years?
50 or more
What is the most common cerebellar neoplasm of childhood?
Astrocytoma
What is the management of acute otitis media with tympanic membrane perforation?
5 day course of oral amoxicillin and a review to ensure healing (can be done in primary care) in 6 weeks
When does autosomal recessive polycystic kidney disease present?
In the neonatal period, causing death perinatally and almost always within the first year of life
Common signs of NAI?
- Bite marks
- Torn frenulum (forced bottle feeding)
- Ligature marks
- Burns
- Scolds
Severe otitis externa management?
Topical acetic acid spray and oral antibiotics
If ear canal is swollen, wick placement to maximise topical ear drop solution
Abx treat deeper tissue infection (indicated by cervical lymphadenopathy), rarely used in umcomplicated otitis externa
Abx regimen for severe otitis externa?
7 day course of flucloxacillin
When are chest compressions started in a neonate?
After a total of 10 inhalation breaths and 30s of effective ventilation breaths
Which neonatal GI condition is more common in turner’s syndrome?
Pyloric stenosis
Signs of Erb’s palsy?
- Reduced Moro’s reflex
- Reduced tone
- Waiter’s position
Associated with shoulder distocia, usually unilateral
Management of Erb’s palsy?
Physiotherapy (self-resolving)
Medical management for conjucated hyperbilirubinaemia in neonate?
Ursodeoxycholic acid
What is the biochemical cause of achondroplasia?
Activation of fibroblast growth factor 3 (FGF3) receptor
Affects proliferation of chondrocytes
Indications for CT scan within one hour?
More than one of:
- LOC more than 5 minutes
- Abnormal drowsiness
- 3 or more episodes of vomiting
- Dangerous mechanism of injury
- Amnesia lasting more than 5 minutes
If they only have one feature:
- Observation for a minimum of 4 hours
When should surgery for gastroschisis be performed?
Within a few hours
What is otitis media with effusion referred to ENT?
If the patient has Down Syndrome or cleft palate
What is the initial treatment for pyloric stenosis?
- Correction of metabolic derrangements
- Surgery
What is a child in need plan?
A voluntary plan devised for children in need of:
- Extra support for health
- Extra support for safety
- Extra support for developmental issues
When is Becker muscular dystrophy typically diagnosed?
5-25 years
Prognosis: mid 40s
What is the management for a child <2 years old with ballooning of the foreskin?
Don’t routinely require referral for circumcision
What is the management for balanitis caused by:
- Non-specific dermatitis
- Irritant/ allergic dermatitis
- Candida
Non-specific
- Topical hydrocortisone 1% (until sx settle or 14 days)
- Imidazole cream (sx settle or 14 days)
Irritant/ allergic
- Avoid triggers
- Topical hydrocortisone
- Emoliants + soap substitute
Candida
- Imidazole cream
- Topical hydrocortisone if inflammation causing discomfort
Management for severe balanitis infection?
Oral phenoxymethylpenicillin 10 days
(oral clarithromycin for true penicillin allergy 7 days)
When is an urgent surgical referral for phimosis required?
The child is unable to pass urine
What is the management for paraphimosis?
Urgent urological emergency
Manual reduction:
- Firm compression bandage over oedematous area
- Leave 10-15 mins
- Remove bandage and attempt to reduce
- Repeat bandage for 15 mins and re-attempt
Surgical reduction
What is the gold standard investigation for cerebral palsy?
MRI head
Features include: periventricular leukomalacia
What is paediatric inflammatory multisystem syndrome?
A systemic inflammatory response associated with COVID-19
How is the length of aganglionic bowel determined in Hirschprungs?
- Anorectal manometry or
- Barium studies
What is the management of Hirschprungs?
- Bowel irrigation
- Anorectal pull-through
Initial colostomy followed by anstamosis of normally innervated bowel to anus
What is the surgical procedure for malrotation?
Ladd’s procedure
What is the RBC lifespan in neonates?
70 days
When is a serum bilirubin preferred over transcutaneous bilirubin in neonates?
- Serum: when jaundice has developed within 24 hours or neonate born <35/40
- Transcutaneous: >24 hours, >35/40
If transcutaneous >250, serum is indicated
What is opthalmia neonatorum?
Inflammation of the conjunctiva occurring within 28 days of life (umbrella term)
Often benign, with most cases clearing with saline irrigation
What are the main causes of neonatal conjunctivitis?
- Chlamydia trachomatis (5 days - 2 weeks pp)
- Neisseria gonorrhoea (24hrs - 5 days)
When bacterial infection is suspected, same-day referral to opthalmologist
What is the first line treatment for chlamydia neonatal conjunctivitis?
Oral erythromycin 14 days
Before culture results, topical chloramphenicol eye ointment
What is the first line treatment for gonoccocal neonatal conjunctivitis?
Single IV cefotaxime
(disseminated gonoccocal disease = IV cefotaxime x3 per day)
Where is the inflammation in epiglottitis?
Supraglottis and surrounding tissues
What is the organism responsible for most causes of epiglottitis in the UK?
Strep pyogenes
(Haemophilus influenzae historically most common cause, now reduced due to vaccination)
What is the management of acute epiglottitis?
- A-E (NO AIRWAY EXAMINATION)
- Blood cultures
- IV ceftriaxone 7-10 days
What are the investigations for children presenting to secondary care with seizures?
- ECG (undetected long QT syndrome)
- Brain imaging (exclude SOL)
- Metabolic panel
What can lamotrigine exacerbate?
Myoclonic seizures
What can exacerbate absence seizures?
- Carbamazepine
- Oxcarbazepine
What is the first line treatment for absence seizures?
- Ethosuximide
- Sodium valproate
What is the management of focal seizures?
- Carbamazepine
- Lamotragine
What is the genetic mutation for Wilm’s tumour?
Deletion of the wilm’s tumour suppressor gene (WT-1) on chromosome 11
What is WAGR syndrome?
- Wilm’s tumour
- Aniridia
- GU abnormalities
- Mental retardation
What is the most appropriate investigation modality for wilm’s tumour?
Abdominal USS with Doppler studies
(echogeneic. heterogenous mass arising from kidney)
What is the most common cause of hospital admissions in children <1?
Bronchiolitis
What is bronchopulmonary dysplasia?
Lung damage secondary to mechanical ventilation in neonates
What are the nail changes sometimes associated with alopecia?
Onycholysis and pitting
What is trichotillomania?
Compulsive hair pulling
When should suspected alopecia be referred to a dermatologist?
- Diagnosis uncertain
- Patient is a child
- Disease is extensive (>50%)
- Initial treatment fails
What is the management of general hair loss in a child?
- <50% watchful waiting
- Topical corticosteroids 3 month course (patient is distressed)
What does a raised fecal calprotectin suggest?
Intestinal inflammation
Why is there left axis deviation in tricuspid atresia?
Due to development of a small non-functional right ventricle
What is osteochondritis dissecans?
Disrupted blood supply to the cartilage within the knee joint
Symptoms include:
- Pain
- Swelling
- Locking of the joint following exercise
What is chondromalacia patellae?
Cartilage of the patella softening, resulting in anterior knee pain
Common in teenage girls
Pain worse:
- Climbing stairs
- Standing from sitting
When does GORD tend to resolve?
By 12 months
