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Paediatrics > Respiratory, GI, Growth, Metabolic > Flashcards

Respiratory, GI, Growth, Metabolic Flashcards

1
Q

Key investigations for asthma

A

PEFR
Spirometry + Reversibility testing
FeNO test

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2
Q

Respiratory symptoms/signs increasing the likelihood of asthma over other resp diseases

A

Cough and Wheeze
Hx atopy
Wheeze on auscultation
Responsive to therapy

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3
Q

Features of acute severe asthma exacerbation

A 
SpO2<92%
PEFR 33-50%
Tachycardia and Tachypnoea 
Can't complete sentences in one breath
Too SoB TO SPEAK
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4
Q

Features of life-threatening asthma

A 
SPO2<92%
PEFR<33%
Silent, poor effort, exhaustion
Hypotension
Confusion 
Normal or raised PCO2
Cyanosis
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5
Q

For mild asthma exacerbation what can you give?

A

6-8 puffs of salbutamol inhaler
1puff= 100mcg
If tolerated then go home on this for 48 hours

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6
Q

What is the maximum number of salbutamol puffs recommended for home in ?Acute asthma

A

2-4 puffs

6+ then they need to come hospital

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7
Q

Acute asthma management (>5 years)

A

Nebulised salbutamol 5mg BTB
Nebulised ipratropium 250mcg every 5 mins
Prednisolone 30-50mg 3 days (or hydracortisone 100mg IV)
MGSO4 added to Salbutamol
Aminophylline or IV salbutamol

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8
Q

What time between inhalers after an acute exacerbation of asthma would indicate it is safe to discharge

A

> 4 hours apart

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9
Q

Aims of asthma control

A

No waking at night
No need for reliever therapy
No limitations on activity
Step down therapy once objectives are achieved

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10
Q

How many uses of SABA a week would suggest asthma therapy needs to be intensified

A

> /=3

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11
Q

BTS Asthma guidelines

A

1) SABA
2) Low dose ICS
LTRA if <5
3) Increase ICS or add LTRA or LABA
4)Oral steroids, theophylline

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12
Q

NICE Asthma guidelines

A

SABA-> + ICS low dose -> +LTRA -> Stop LTRA IF NOT HELPING -> +LABA/MART

If <5 years then SABA + 8 WEEK TRIAL of ICS then consider LTRA

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13
Q

Example of a LTRA

A

Monteleukast

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14
Q

Example of a low dose ICS

A

Clenil Modulite

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15
Q

What is Maintenance and Reliever Therapy

A

LABA and ICS In one inhaler

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16
Q

Indications for starting an asthmatic child on both SABA and ICS (According to NICE)

A

If symptoms > 3X a week or waking at night

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17
Q

Peak age for Bronchiolitis

A

3-6 months

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18
Q

Cause of Bronchiolitis

A

RSV (Maybe other viruses)

Inflammation and narrowing of airways in lungs because of infection

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19
Q

Presentation of bronchiolitis

A

Harsh cough, Fever, High pitched wheeze bilaterally, Fine inspiratory crackles, SOB, Poor feeding
YOUNG <2 Years

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20
Q

When do the symptoms of Bronchiolitis peak

A

4-5 days from onset

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21
Q

Indications for admission of bronchiolitis

A

THINK FEEDING OR OXYGEN SUPPORT

Dehydration- No wet nappy for 12 hours
Marked recessions/grunting
Apnoeic 
Milk/Fluids<50% normal
Exhausted
Spo2<92%
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22
Q

Management of moderate Bronchiolitis

A

NG feed
Nasal cannula-> CPAP-> Intubate
+/- Fluids

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23
Q

Management of severe Bronchiolitis

A

HDU/PICU

CPAP/Ventilation/IV fluids

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24
Q

Severe bronchiolitis

A 
Worsening respiratory distress
Respiratory acidosis
Apnoea 
Dehydration
Risk Factors
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25
Q

Palivizumab

A

MAb to RSV
Passive immunity provided to at risk babies: Premature/CF/Congential HD/Lung disease

Reduces INFECTIONS
IM monthly for 6/12

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26
Q

Safety netting for Bronchiolitis when sending a mild case home

A 
Struggling to breath or irregular breathing 
Blue lips
Unresponsive
No wet nappy >12 hours
Pauses in breathing
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27
Q

Peak age for croup

A

6 months to 6 years

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28
Q

Causes of croup

A

Parainflueza virus mostly

Can be other viruses like RSV/Adeno/Influenza

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29
Q

What is Croup

A

Acute viral Layngotracheobronchitis (URTI)

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30
Q

Presentation of croup

A 
~Acute abrupt onset
Stridor 
Barking cough 
Respiratory distress
Worse at night 
IC recessions
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31
Q

Commonest cause of stridor in children

A

Croup

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32
Q

What is contraindicated in Croup

A

Throat exam as can potentiate airway obstruction

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33
Q

Epiglottitis vs Croup

A

In Epiglottitis there is drooling, mouth open with muffled voice and they cannot drink
ONSET IS VERY RAPID mins- hrs

Croup has barking cough and no drooling

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34
Q

Indications for admission in croup

A

< 6 months old
Poor oral intake
Severe obstruction
Immunocompromised

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35
Q

Mild vs Moderate croup presentation

A

Mild has occassional barking but no stridor and no Resp Distress

Barking and stridor is intermittent in moderate croup, chest wall retraction

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36
Q

Signs of severe croup

A

Frequent barking
Severe RDS
Stridor is prominent and there at rest
Tiredness and confusion

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37
Q

Treatment of croup

A 
Keep upright 
Oral Dexamethasone 0.15mg/kg (or Neb Budesonide or IM Dex)
Neb Adrenaline if Mod-Sev
HF O2 if severe
ENT help?
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38
Q

How do you assess the severity of Croup

A 
Stridor
Recessions
Air entry
02 sats
Conscious level
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39
Q

What is Pneumonia

A

Inflammation of the lungs primarily affecting the alveoli

Induced by infection

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40
Q

Bacterial causes of pneumonia

1) Neonates
2) Infants
3) Children

Viral causw

A

1) GBS, E.coli, Listeria, Chlamydia
2) S.Pneum, H.Influ, Pertussis
3) S.Pneum, H.Influ, GAS, Mycoplasma

RSV, PIV, AV, Rhino (1/3rd are viral!)

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41
Q

Presentation of Pneumonia?

What abdominal sign is important not to forget?

A 
Recent URTI
Cough +/- Sputum 
Respiratory distress
Feeding is reduced
Pleuritic chest pain
Wheeze, crackles, reduced AE, Bronchial Breathing

UPPER ABDO TENDERNESS

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42
Q

Investigations for Pneumonia?

When is a CXR indicated?

A

FBC, U&Es, CRP, Sputum ?Blood culture
?Septic screen

CXR if not responding to treatment or complications are suspected

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43
Q

Admission of pneumonia

A

If Moderate to severe

- Respiratory distress, Poor fluid intake, Dehydration, Diffuse chest signs, RR>70 infants, RR>50 Children

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44
Q

Treatment of Mild Pneumonia

CXR follow up?

A

Send home, fluids advice and temp control
Oral Amoxicillin +/- Macrolides
NO CXR follow up

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45
Q

Treatment of mod-sev pneumonia

A

0xygen support to maintain sats >92%
IV Co-Amoxiclav +/- Cefotaxime/Cefuroxime
Fluids

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46
Q

Follow up CXR in Pneumonia

A

Not routinely indicated in paediatrics

Unless: Atelectasis, Volume loss, Lymphadenopathy

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47
Q

What signs indicate a bacterial tonsillitis

A

Tender Cervical Lymphadenopathy

Purulent exudate on tonsils (ESPECIALLY GAS)

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48
Q

Common causes of pharyngitis

A

Viral- Adeno, Entero, Rhino

GAS can be a cause in older children

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49
Q

Centor Criteria

A

> 3= Bacterial likely

Tonsillar exudate, Tender anterior cervical lymphadenopathy, Hx feverm No cough

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50
Q

URTI advice

A

Should only last a week
Ibuprofen and paracetamol
Lots of fluids

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51
Q

Abx indications for URTI

A

> 3 centor
Immunodeficiency
Rheumatic fever
Marked systemic upset

1st line is Phenoxymethylpenicillin 7-10 days or erythromycin if allergic

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52
Q

Amoxicillin and EBV

A

Causes a rash

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53
Q

Complications of tonsillitis

A

Otitis media
Quinsy
Post-strep glomerulonephritis

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54
Q

Tonsillectomy indications

A

> 5 episodes a year
Disabling
Quinsy
Obstructive- Apnoea, Dysphagia

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55
Q

Viral induced wheeze

A

URTI associated
< 5 years
No Hx of atopy
May have had it before but admission unlikely

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56
Q

Wheeze vs Stridor

A

Wheeze- High-pitched largely expiratory breath sound; intrathoracic airway narrowing

Stridor- Upper airway obstruction, arises acutely and paitent is in respiratroy distress, Inspiratory noise

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57
Q

Treatment of wheeze

A

Ensure it isnt stridor

SABA or Anticholinergic via spacer +/- LTRA/ICS

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58
Q

Different modalities of airway compression that can cause wheeze

A

Extrinsic- Lung parenchyma, Vascular, Lymphatic
Intrinsic- CF, Bronchiolitis, Polyps
Intraluminal- Aspiration, Reflux

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59
Q

Genetics and pathophysiology of CF

A

Autosomal recessive

CFTR defect, codes Cl- channel

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60
Q

Neonatal features of CF

A

Meconium ileus= Obstruction (Distended coils of bowel on CXR)
Prolonged jaundice

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61
Q

GI manifestations of CF

A 
Failure to thrive
Bulky, pale, offensive stools
Wx loss
Rectal prolapse
DM- PANCREATIC INSUFFICIENCY
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62
Q

Respiratory manifestations of CF

A

Bronchiectasis
Recurrent infections
Chest deformity
Crackles on auscultation

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63
Q

Key complications of CF

A 
Subfertility +/- Delayed puberty
Bone disease
Malabsorption 
DM
Liver disease as sluggish bile flow induces Portal HTN
Excess salt loss
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64
Q

Gold standard test for CF

A

Sweat test- Cl- >60mmols

Need 2 abnormal tests

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65
Q

False -ve sweat tests for CF

A

Skin oedema, adrenal/thyroid problems, Nephrogenic DI

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66
Q

Newborn screening for CF

A

Heel prick

Increased immunoreactive trypsinogen on newborn bloodspot card

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67
Q

CF on a CXR

A

Dilated TRAMLINE airways
Lymphadenopathy
Interstitial pattern because of scarring
Mottled ground glass appearance

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68
Q

MDT management of CF

A 
6-8 week outpatient appointment 
Specialist nurses
Pysiotherapy- 2X daily with Neb DNAase
High calorie diet + Vit ADEK + Salt (Dietician)
Isolate from other CF patients
?Sputum sample if infections + Dilators + Abx
PORTACATH 
Fertility/Endocrine support
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69
Q

Best measure of the progression of CF

Prognosis

A

Lung function tests

Half live to at least 48 years

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70
Q

What enzyme supplementation are CF patients given

A

Creon with all meals

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71
Q

Causes of a chronic cough >8 weeks

A 
Tonsillitis
Post-nasal Drip
GORD
Pertussis
TB
Bronchiectasis
PCD
Tourette's
Psychogenic
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72
Q

Cough red flags

A 
Haemoptysis
Dyspnoea
Pleuritic chest pain
Stridor
Respiratory distress
Cyanosis
Hypoxia
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73
Q

Classification of the causes of SoB

A 
Pulmonary
-Hypoxia
-Obstruction
-Abnormal lung mechanisms
Cardiac
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74
Q

Larynx obstruction

A

Hoarseness, Cough, Stridor, SOB, Cyanosis

Apnoea= complete

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75
Q

Oesophageal obstruction

A

Drooling, Dysphagia, Vomiting, Tracheal compression

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76
Q

Otitis Media causes

A

S.Pneum/H.Influ/RSV/Other viruses

+/- Eustachian tube dysfunction

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77
Q

Causes of Eustachian Tube Dysfunction

A

Results from many URTIs
Obstruction from large adenoids
Cleft palate and Down’s increase risk

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78
Q

Tympanic membrane in Otitis Media

A

Red, Inflamed, Bulging, Purulent discharge Loss of light refelx

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79
Q

Otitis media with effusion (GLUE EAR)

A

Peak 2 years
Thick middle ear exudate
Tympanic Membrane changes- Thick, Retracted, no light reflex
Hearing loss +/- Speech and language delay

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80
Q

Treatment of Glue Ear

A

Grommets (VENTILATION TUBES)
Lasts months to years
Indicated if language delay

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81
Q

Treatment of simple otitis media

A

Try Paracetamol for 72 hours- Spontaneous resolution

> 4 days/Systemic upset/immunocompromised/Bil + <2 years/Perforated drum= AMOXICILLIN 5/7

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82
Q

Mastoiditis

A

Can be secondary to OM

Otalgia, Swelling, Erythema, Tenderness, External ear protrudes forwards

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83
Q

Number one cause of stridor in neonates

A

Laryngomalacia

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84
Q

Presentation of Layngomalacia

A

Presents at birth and resolves by 12-18 months
Symptoms are increased when lying flat/eating
Otherwise well

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85
Q

Causes of Stridor

A 
Layngomalacia
Epiglottitis (esp 2-4 years)
Sinusitis/Rhinitis
Choanal atresia
Layngeal web/cleft
Croup 6 months to 6 years
Abscess/Cyst
Tracheomalacia
Fistula
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86
Q

Where is TB endemic

A

Asia, Latin America, Eastern Europe, Africa

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87
Q

Cause of TB

A

Mycobacterium tuberculosis
Acid fast bacilii
Induces a T4 Hypersensitivity reaction (Delayed and T-cell response)
Adults not children usually infectious

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88
Q

Presentation of TB

A

Cough, Fever, Wx loss, Night sweats, Haemoptyisis
< 4 years= Meningitis
Hilar lymphadenopathy +/- Bronchial obstruction

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89
Q

BCG vaccine

A

Parent/Guardian from high risk area

Then offered to Babies up to 1 year of age

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90
Q

Whooping cough classical presentation

A

Paradoxical expiratory cough spasms followed by a sharp inspiratory breath (Whooping)
Apnoeas/Post-tussive vomiting/Coryzal symptoms
Insp. whoop may be absent in younger patients

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91
Q

Diagnosis of Whooping Cough/Pertussis

A

Clinical
Ask immunisation status (6 in 1 vaccine)
Per-nasal swab culture if within 2/52 of cough
?Serum PCR

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92
Q

FBC in whooping cough

A

Significant lymphocytosis

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93
Q

Management of Whooping cough

A

Within 3/52 of onset= Give Abx
1) > 1month old= Azithromycin
< 1month = Claithromycin
Pregnant= Erythromycin

< 6months= Admit

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94
Q

Whooping cough and school exclusion

A

Avoid 48 hours post Abx

3 weeks if no treatment

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95
Q

Constipation- Acute vs Chronic

A

Acute- < 3 complete stools a week

Chronic if 6-8 weeks particularly abnormal if > 5 years old, incidence peaks at 2-4 years

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96
Q

Feacal impaction

A

No bowel movement in days, large faecal mass compacted in rectum
Overflow soiling
Severe constipation

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97
Q

Soiling

A

Faecal staining of underwear as there is leakage around impaction
Mistaken for diarrhoea
Abnormal of > 4 years!

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98
Q

Encopresis

A

Involuntary passage of whole stools
Overflow or Psych
CHILD MUST BE MATURE ENOUGH TO BE CONTITNENT

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99
Q

Presentation of constipation

A 
Excessive straining- Back arching, straight legs, tiptoed
Pain 
Soiling 
Overflow incontinence 
Neuro exam may be abnormal...
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100
Q

Constipation reg flags

A 
Present from birth
Thin Ribbon stools (?Anal stenosis)
Delayed meconium (>48 hours)
Abd distension and vomiting 
Leg weakness, locomotor delay
Abnromal leg reflexes
Sacral dimple, Gluteal agenesis 
Perianal fistula/Abscess 
Bruising around anus
(FTT is amber flag)
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101
Q

Causes of constipation

A

Number 1= IDIOPATHIC

Dehydration, Low fibre diet, Opiates, Learning difficulties, Post-illness, Abuse, Hypothyroidism, Hypercalcaemia, Routine change, Hirschsprungs’s, Coeliac’s

Toilet training is a precipitant

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102
Q

ROME criteria for constipation

A

2 or fewer defecations per week
At least 1 episode of weekly faecal incontinence
Hx of excessive stool retention

Need at least 2 for Dx

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103
Q

Hirschsprung’s disease

A

Absence of ganglion cells in the bowel wall plexus

Increased in Boys and Down’s syndrome

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104
Q

Hirschsprung’s disease presentation and Dx

A

Newborn + Delayed meconium + Distension

Dx= Biopsy

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105
Q

Pharmacological Management of idiopathic constipation

A

Disimpaction with Movicol for at least 2 weeks (may increase soiling and pain initially)
Then switch to Maintenance therapy with movicol (lower dose)

If disimpaction doesn’t work then + Senna Stimulant or + Laculose softner

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106
Q

Advice for constipation

A 
Always use advice + Laxative 
Increase water, Limit squash/fizzy drinks/Caffeine
Increase fibre, fruit, beans, nuts
Non-punitive regular toileting 
Regular set toilet times- sit 20 mins 1-3x a day
Footrest
Bowel diary 
?Reward system 
Massage abdomen if not weaned
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107
Q

Examples of osmotic, Stimulant and softener laxatives

A

Osmotic- Movicol

Stimulant- Senna, Bisacodyl

Softener- Lactulose

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108
Q

Length of Laxative maintenance therapy for constipation

A

3-6 months and keep them on it for weeks after resumption of normal bowel movements

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109
Q

NICE clinical features of Gastroenteritis

A

Diarrhoea 5-7/7
Worrying if > 2 weeks
Vomiting 1-2/7 stops within 3 days
+/- Fever, Abdo pain, Nausea

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110
Q

Causes of Gastroenteritis

A

ROTAVIRUS most common, also Adeno/Norovirus

Salmonella, Shigella, Campylobacter, E.Coli 0157

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111
Q

Bacterial vs Viral Gastroenteritis

A

Viral is watery smelly stools

Bacterial is usually bloody mucous stained stools

Not infallible

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112
Q

When is a stool sample indicated in gastroenteritis

A 
Blood and mucous in stools 
?Sepsis
Immunocompromised
Recently abroad
Diarrhoea not improving by D7
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113
Q

Key DDx for Gastroenteritis

A

INTUSSUSCEPTION
Associated with viral gastroenteritis
Episodic screaming, vomiting, paroxysmal drawing up of legs, shock, sausage shaped mass in RUQ, Jelly stool

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114
Q

Signs of Clinical dehydration 6-10%

A 
Sunken eyes
Sunken Fontanelle 
Decreased Skin turgor 
Tachycardia, Tachypnoea 
CRT normal, Warm extremities,Normal periph pulses
Irritable, Lethargic
115
Q

Signs of shock/10+% Dehydration

A 
Decreased Consciousness
Col peripheries
Pale, Mottled
HR/RR inc + Acidotic
Hypotension (Late)
Central CRT >5s
116
Q

When are Bloods indicated in gastroenteritis (especially urea and electrolytes)

A

If IV fluids needed

?Hypernatraemia (Won’t look dehydrated)

117
Q

Hypernatraemic dehydration presentation and management

A

Jittery, Increased tone, Hyperreflexia, Convulsions, Coma

Senior input, replace fluids slowly over 48 hours

118
Q

Management of dehydration with nil/Mild dehydration

A

Continue feeding
Discourage fruit juices and carbonated drinks
Oral challenge 5 mls every 5 mins +/- ORS if high risk
Can try oral fluids 2ml/kg/10 mins slow and steady if dehydrated
Home and safety net

119
Q

Management of clinical dehydration (6-10%) secondary to gastroenteritis

A

50ml/Kg ORS over 4 hours
Continue breastfeeding
?NGT if vomiting or not tolerating drinks

120
Q

Indications for escalating ORS therapy to IV therapy when treating dehydration

A 
Deterioration in state
Decreasing responsiveness 
Decreasing skin turgor
Persistent vomiting 
Adverse haemodynamic changes
121
Q

Management of clinical shock (10+% dehydration)

A

1) Rapid IV bolus NaCl 0.9% 20ml/kg
2) Repeat
3) Then ?PICU

If resolution then switch to IV maintenance therapy

122
Q

IV fluid maintenance therapy for dehydration

A

0/9% Saline + 5% Dextrose

1st 10kg= 100ml/kg/24rs
2nd 10kg= 50ml/kg/24hrs
>20kg= 20ml/kg/24hrs

+ 100ml/kg/24hrs if shocked
OR +50ml/kg/24hrs if clinically dehydrated

+ Zn if malnourished +K once potassium known (20mmol/l)
Continue breastfeeding

123
Q

Switching from IV maintenance fluids to ORT

A

Gradually introduce ORT early and if tolerated then switch

124
Q

Signs of late decompensated shock

A 
Hypotension
Bradycardia
Acidotic
Kussmal Breathing 
Blue
Absent UO
125
Q

Indications for Abx in Gastroenteritis

A 
C.Diff
Cholera
Giardiasis
Septicaemia
< 6/12 + Salmonella
Malnourished
Immunosuppressed
126
Q

Triad seen in Haemolytic Uraemic Syndrome

A

Consumption thrombocytopenia
Acute renal failure
Microangiopathic haemolytic anaemia

127
Q

Causes of HUS

A

Often follows bloody diarrhoea after E.Coli 0157
Shiga toxin damages Renal endothelium, leads to platelet aggregation, occlusion of micro-circulation and shredding of red cells

128
Q

HUS on a blood film

A

Schistocytes (Fragmented RBCs)

129
Q

Complications of Gastroenteritis

A 
Metabolic acidosis as Bicarb is lost
HUS
Guillain-Barre syndrome 
Reactive arthropathy 
Haemorhaggic colitis 
Paralytic Ileus as K+ is lost
Post-GE syndrome
130
Q

Post-Gastroenteritis syndrome

A

Introduction of a normal diet leads to diarrhoea
Temporary lactose intolerance

24 hour return to ORS then try normal diet again
Increasing yoghurt may help to increase lactase

131
Q

Significant abnormalities in height as depicted by centiles

A

<0.4th centile
>99.6th centile
or Markedly discrepant from weight

132
Q

The 4 phases of growth that determine adult height

A

Fetal 30%- Uterine
Infant- 15% Nutrition, Happiness, Thyroid
Childhood 40%- Genes, Happiness, Growth & Thyroid hormones
Pubertal 15%- Tes, Oes, Growth hormones

133
Q

A drop in how many centile lines is worrying when reviewing growth

A

> 2

134
Q

Causes of short stature

A

Familial
IUGR/Prematurity
Constitutional delay of growth and puberty
Endo (Hypothyroidism, GH deficiency, Steroid excess, IGF-1 deficiency)
Nutritional/GI (Crohn’s, Coeliacs)
Turner’s
Skeletal Dysplasia

135
Q

How does an endocrine cause of growth delay look on a growth chart?

A

Fall off height centile
Wx> Height centile
Delayed bone age

136
Q

How does a nutritional/GI cause of growth delay look on a growth chart?

A

Fall of height centiles
Height centile> Wx centile (unlike endo causes!)
Delayed bone age

137
Q

Familial and constitutional causes of reduced growth on a growth chart

A

Will follow a growth centile likely <0.4th

Rate may drop off if delayed puberty

138
Q

Measuring the Height of a baby

A

Baby supine

Head to Heel

139
Q

What age does GORD usually begin in children?

A

Likely <8 weeks

V common!

140
Q

Colic presentation

A

< 3 months of age
Pulls legs up, Arches back, Screams POST FEED
3 hrs a day, 3 times a day
Inconsolable

141
Q

Advice for colic

A

Reassure- BENIGN

?Anti-flatulents ?Venting pole on bottle

142
Q

Colic vs spasms in presentation

A

In infantile spasms there is distress in-between the spasms whereas in colic child is usually fine in-between episodes

143
Q

GORD presentation

A

Non-forceful vomiting/regurgitation post-feed
Coughing
Sleep disturbance
Refuses feed + Post-feed irritability/resistance
Inconsolable crying
Apnoea

144
Q

GOR vs GORD

A 
GORD= Reflux + Significant symptoms 
GOR= Reflux + No Pain + No FTT
145
Q

Diagnosis of GORD

A

Clinical +/- FBC

+/- 24hr PH study if not responding initially
+/- Barium Swallow +/- Endoscopy

146
Q

Red flags in ?GORD

A 
FTT
Lethargy
Onset > 6 months 
Carries on beyond 12 months
Fever
147
Q

When does GOR/GORD typically resolve by?

A

12-18 months

148
Q

Step-wise Management of GORD

A

Reassure- most gone by 18 months

1) Small regular feeds, wind baby during, keep upright 30 degrees, Add thickeners or anti-reflux milk
2) Stop thickeners and 4 week trial of Gaviscon
3) Omeprazole/Ranitidine
4) Nissen’s Fundoplication

149
Q

Causes of Bilious vomiting in Neonates

A 
Duodenal atresia
Malrotation with volvulus 
Jejunal/Ileal Atresia 
Meconium Ileus 
NEC
150
Q

Feeding requirement for a Infant

A

150mls/kg/day

151
Q

Causes of Acute vomiting

A 
Infection
Pyloric Stenosis
Obstruction
Aresia
Adverse food reaction
Raised ICP
Endocrine 
Poisoning 
Overfeeding
152
Q

When would Duodenal Atresia typically present? What is the X-ray sign?

A

Few hours post-birth

Bubble sign

153
Q

When would Malrotation typically present

A

3-5 days post-birth

154
Q

Key causes of Meconium Ileus

A

Hirschsprung’s

CF

155
Q

Mesenteric Adenitis

A

Lymph glands swollen in abdo

Recent Viral illness, not peritonitic, Pain mimics Appendicitis

156
Q

Abdo pain causes

A

Adenitis, Appendicitis, UTI, Pneumonia, Constipation, DKA, Calculi, HSP, Malrotation, NEC, IBD, Intussusception, Obstruction

157
Q

At what age is appendicitis common and uncommon?

A

Common > 5 years

Uncommon if < 4 years, Very rare < 1 year

158
Q

McBurney’s Triad of symptoms common in appendicitis

Associated symptoms

A

RIF pain, Low grade fever N&V

Constipation, reduced appetite, reluctance to move

MAY BE ATYPICAL IF YOUNG

159
Q

Blood results seen in Appendicitis?

Indications for a USS/CT in ?Appendicitis

A

Leucocytosis, Neutrophilia but WCC may be normal

Diagnosis uncertain or ?Abscess

160
Q

Treatment of Appendicitis

A

Appendectomy

+/- IV Abx if unwell with perforation/Abscess

161
Q

Diagnosis of a Appendicitis induced perforation

A

Abdominal lavage

162
Q

Common age of Coeliac’s presentation

A

Before 2 years

163
Q

Pathophysiology of Coeliac’s

A

Repeated Gluten exposure induces a non-IGE mediated immune response that causes vilious atrophy and malabsorption

Not Atopy because atopy is IGE specific

164
Q

1st choice investigation to diagnose Coeliac’s

A

Tissue Transglutaminase antibody (TTG)
Coeliac anti-endomysial Ab also useful

DEFINITIVE= Subtotal vilious atrophy in jejunal biopsy with crypt hyperplasia

165
Q

Presentation of Coeliac’s

A 
FTT
Anorexia
Vomiting, Diarrhoea, Pain, Fatigue
Distension, Wasted buttocks, Pallor
PALE FOUL SMELLING STOOL- Steatorrhoea
166
Q

Description of stools in Coeliac’s

A

Pale and Foul smelling (Steatorrhoea)

167
Q

Management of Coeliac’s

A

Gluten free diet induces a quick resolution of symptoms
The diet is continued indefinitely
Pneumococcal vaccine
Check for Iron deficiency anaemia
Gluten rechallenge can be considered after 2 years

168
Q

What 4 causes are important to consider when a child presents with feeding problems

A

Quantity of food
Kind of food- e.g milk changing
Technique
Congential problem e.g cleft palate

169
Q

Complications of GORD

A 
Aspiration Pneumonia 
Oesophagitis 
Bronchiectasis
FTT
Frequent Otitis Media
DYSTONIC NECK POSTURING/SANDIFER SYNDROME
170
Q

Managing feeding problems

A

Food diary

Turn off TV, 1 meal for whole family, Offer child only 2 choices, Allow them to help in preparation

Present food at pre-agreed time and then remove

Ignore -ves and Praise +ves

171
Q

Weaning advice

A

Start from 6 months
Puree fruit/veg or baby rice then Mashed food then gradually mash up less
Use alongside milk until 8 months
Cow’s milk and normal food at 12 months

Spoon feeding -> Finger feeding -> Feeding themselves
A mess is okay, small helpings, eat together, do not pressure them into eating
Remember that eating habits may be unpredictable could switch from eating huge amounts to little

172
Q

Advice about foods to avoid when weaning

When do you start certain foods?

A

Avoid: Low fat sugary salty foods, soft cheese

Honey and Cow’s milk fine AFTER 12 months
Full fat milk until 5 years, can switch to semi at 2 if needed
Nuts okay if ground but allergies are common
Shellfish allergies also common
No soya before 12 months

173
Q

Presentation of Inguinal hernia

A

Swelling likely right inguinal region +/- Groin
Increases when crying
Painless (unless incarcerated)
NO TRANSILLUMINATION
Testis palpable and distinct from swelling
Reducible

174
Q

Risk factors for inguinal hernia

A

Male

Preterm

175
Q

Most common type of inguinal hernia

A

Indirect

Direct is rare

176
Q

Key complications of inguinal hernias

A

Incarceration +/- Strangulation +/- Obstruction

Testicular infarction

177
Q

Indications for an urgent surgical referral for a inguinal hernia

A

Irreducible, Hard, Tender, Vomiting

This indicates incarceration and strangulation

178
Q

Management of an inguinal hernia

A

Surgery within weeks of diagnosis because the incarceration risk is high

This risk decreases after age of 1 year

179
Q

Management of an umbillical hernia

A

Fixed around 4/5 years for cosmetic reasons

Note People of Black ethnicity are at increased risk

180
Q

Hydrocele

A

Painless testicular swelling that Transilluminates
Not reducible
Spontaneously resolves by 12 months

181
Q

Epidemiology of intussusception

A

Infants 6-18 months
Peak is at 9 months

Males 2x more at risk

182
Q

Causes of intussusception

A

Proximal bowel telescopes into distal bowel, likely Ileum/Caecum

Common post-viral illness as Peyer’s patches become inflammed

Polyps and Meckel’s can cause this in older children

183
Q

Presentation of Intussusception

A

Episodic screaming- Cycles from agony to sleep
Paroxysmal drawing up of legs and knees
Pallor, Vomiting, Lethargy
May appear well inbetween episodes
Red current jelly stools
Sausage shaped mass in midline RUQ
HX of recent viral illness or vaccinations

184
Q

Diagnosis of Intussusception

A

USS- Target sign usually RLQ

185
Q

Management of Intussusception

A

Fluid resus, Abx and Analgesia

Air insufflation under radiological control then barium enema if this fails

Laparotomy if Peritonitis or above fails

186
Q

Causes of increased unconjugated bilirubin

A

Haemolysis- Spherocytosis, G6PD deficiency, SC anaemia, Thalass, HUS

Defective conjugation- Gilbert’s

187
Q

Causes of cholestatic jaundice (Raised conjugated fraction)

A 
Biliary atresia
Choledochal cyst 
CF
Cholangitis
Cholecystitis 
Tumours/Cysts
188
Q

Presentation of Kernicterus

A

Irritability, High pitched cry, Coma, Athetoid CP

189
Q

Causes of Intrahepatic cholestasis

A

Infection, Toxins, Wilson’s AATD, Biliary hypoplasia, RHF, Budd-Chiari

190
Q

Epidemiology of Pyloric stenosis

A

Mostly 2-8 weeks old with 6 weeks being the peak
Newborn infants
Uncommon

191
Q

Presentation of Pyloric stenosis

A

Recurrent projectile post-feed vomiting increasing in intensity
Infant hungry
Wx loss, Dehydration, Small for age, Irritable
Hard, olive shaped right epigastric mass
Visible peristaltic waves over stomach

192
Q

Diagnosis of Pyloric stenosis

A

USS showing thickened elongated pyloric muscle

193
Q

Blood results seen in Pyloric stenosis

A

Hypochloremic hypokalaemic metabolic alkalosis

194
Q

Management of Pyloric stenosis

A

Consider a test feed
Rehydration in preparation for surgery
Pyloromyotomy- Ramstedt’s procedure (Open) or Laparoscopic

195
Q

Presentation of testicular torsion

A 
Sudden severe scrotal pain +/- Referred to the lower abdomen 
Testis are retracted upwards
Red and Oedematous skin 
No Cremasteric reflex
Elevation does not ease pain 
'Walk like a cowboy'
196
Q

Epididymitis vs Testicular Torsion

A

Epidid= +ve Cremasteric reflex, Urinary symptoms and elevation relieves pain (Prehn’s +ve)

197
Q

Management of Testicular Torsion

A

Immediate scrotal exploration and fixing of testis
Treat contralateral as torsion risk is 50%

6 hrs from seeing there must be untangling!

If necrotic then remove

198
Q

Torted Hyatid

A

Like torsion but blue dot seen
< 10 years
Remanent of obliterated Mullerian ducts

199
Q

Classification of Crpytorchidism

A

Palpable undescended testis 70%- Can still descend

Impalpable 30%- Intra-abdomen, Inside canal or absent

200
Q

Complications of Crpytorchidism

A

Malignant deterioration especially if intra-abdominally

Increased Testicular cancer risk

201
Q

Risk factors for Crpytorchidism

A

Preterm
FHx
Low birth Wx

202
Q

Management of Crpytorchidism

A

Consider referral from 3 months, should be seen by a urology surgeon by 6 months corrected gestational age

If Bilateral and Non-palpable then 24hr urgent referral for Endo/Genetic evaluation alongside an examination under Anaesthesia-> THEN ORCHIOPEXY

Major surgeries usually done around 1 year

203
Q

Biliary atresia presentation

A

Persistent jaundice >14 days
Conjugated Hyperbilirubinaemia developing over several weeks

Pale, Chalky stools, Dark urine
Bruising and Hepatomegaly

204
Q

Biliary atresia Management

A

Urgent referral

Hepatoportoenterostomy if detected within 6 weeks

205
Q

Causes of Hepatitis

A

TORCHES, Hepatitis virus (esp. if mum Hep B Ag +ve, Hep is is Faecal Oral)

206
Q

Presentation of Hirschsprung’s

A 
Usually in the newborn period 
- Delayed meconium >48 hrs
-Distension and vomiting 
FTT 
Constipation
207
Q

What is Hirschsprung’s disease

A

Congential aganglionosis in bowel walls
Neural crest cells fail to migrate
Averbach and Meissner Plexuses fail

Inc in boys and those with Down’s syndrome

208
Q

Diagnosis of Hirschsprung’s disease

A

Rectal biopsy is definitive

209
Q

Hirschsprung’s disease on an AXR

A

Faecal loading, Dilated bowel loops, Air fluid levels

210
Q

Management of Hirschsprung’s disease

A

Resection of abnormal bowel and end to end anastamoses

Removal of aganglionic segment + Colostomy bag

Management of symptoms

211
Q

Crohn’s vs UC

A

Crohn’s is mouth to anus, UC is Colon

UC- Nothing inflammed beyond the submucosa, Inflammation seen in all layers in Crohn’s

212
Q

Toddler’s diarrhoea

A 
6 months to 5 years
Food particles in stool
Excessive fruit juice consumption
Child is generally well
Child must be thriving
213
Q

What is a volvulus

A

Torsion of the mal-rotated intestine around its mesenteric axis
More common in males

214
Q

What age is a volvulus most common?

A

6- 36 months

Rare in < 3 months

215
Q

Presentation of volvulus

A

Bilious vomiting
Acutely unwell, Haemodynamically unstable and collapse
Scaphoid abdomen (Malnutrition)
Peritonitic

216
Q

Volvulus Diagnosis

A

Upper GI contrast (Drink water with soluble contrast) showing corkscrew jejunum and DJ flexure to the right of the midline

(AXR also gasless)

217
Q

Management of a volvulus

A

Urgent surgery- Laparotomy- Ladd’s procedure to twist volvulus and treat underlying malrotation

218
Q

What congential conditions are associated with volvulus

A

Congential diaphragmatic gernia and exomphalos are associated with malrotation and thereby volvulus

219
Q

Average birth weight

A

3.3kg/7 pounds 4 ounces

Doubles by 5/12 and triples by 12/12

220
Q

Average head circumference at birth

A

35cm

221
Q

Immediate management of an infant with faltering growth

A

High energy 120mls/kg/day formula

?Admit for NG feeding

222
Q

When do teeth develop?

A 
Primary= 6/12- 2 years
Permanents= 6-12 years
Molars= 20 years
223
Q

How do you plot the weight of preterm babies on a growth chart?

A

Corrected Gestational Age until 2 years

Actual Age - Number of weeks the baby was preterm

224
Q

What constitutes a Failure to Thrive?

A

Lack of progress in Growth, Emotionally and Developmentally

During the 1st 3 years of life

225
Q

Causes of FTT

A

Psychological (most common)- Problems at home, abuse, eating difficulties

Malabsorption- Coeliac’s, CF

Chronic illness

Familial- ?Constitutionally small

226
Q

Peaks of T1DM

A

5-7 years
Puberty

Both as the body’s insulin requirements increase

227
Q

Diagnosis of T1DM

A

Random Blood Glu >11.1mmol/l + Symptoms
or…

6 hr Fasting Glu> 7mmol/l
or…

OGTT 2hr level >11.1mmol/l

228
Q

Basal Bolus insulin regime for T1DM

A

Fixed dose of long acting insulin lasting 24 hrs
Pre-meal short acting insulin with onset 20-30mins
Carb counting

THIS IS THE BASAL BOLUS REGIME

229
Q

Advice to parents in reference to insulin therapy in T1DM

A

Check sugars 4x/day before meals and bed
Increase checking if frequent hypos
Explain significance of taking insulin
Illness- Never stop insulin, ?More, Frequent drinks, check ketones, sip fizzy drinks if poor appetite

230
Q

Blood glucose targets for T1DM

A

FBG 4-7mmol/l

HBA1C<48 mmol/l (check every 3-6 months)

231
Q

Insulin pumps

A

Use rapid acting insulin
Improve compliance by decreasing need for injections
Expensive and technical issues though

232
Q

Diagnosis of DKA

A

1) +ve Glucose on dipstick
2) Ketones >3 on monitor or 3+ on dipstick
3) PH <7.3 (Bicarb<18) <7.1 is severe

233
Q

Indications for an NG tube when a patient is acutely unwell

A

Decreased GCS

Aspiration risk

234
Q

Fluid bolus in DKA when a patient is shocked

A

10ml/kg 0.9% NaCl + 20mmol/l K+

Then start maintenance

235
Q

Fluid resuscitation in a non-shocked DKA patient

A 
<10kg= 2ml/kg/hr
10-40kg= 1ml/kg/hr
40+kg= 40ml/hr

+ REPLACE DEFICITS (%Deficit X Wx X 10)- NOTE PH<7.1 IS SEVERE SO 10% Deficit (5% if PH>7.1)
+ 40mmol/l K+ given

236
Q

In DKA what is done after fluid Resuscitation

A

0.05-0.1 UI/kg/hour IV insulin

237
Q

Injection sites for insulin

A

Upper arms, Outer thighs, Abdomen

238
Q

Definition of hypoglycaemia

A

Technically when Blood glucose is <3mmol/l but pathology appears when <2.6mmol/l

239
Q

Causes of hypoglycaemia

A

D&V, Miscalculate insulin (common when just starting), Alcohol, Exercise, Stress, Puberty, Illness

240
Q

Symptoms of hypoglycaemia

How does this present in a Neonate

A

Faint/Dizzy, Sweaty, Lethargy, Seizure, Coma

Neonate= Jittery, Hypotonic

241
Q

In hospital when would you treat hypoglycaemia

A

Any glucose <4mmol/l + Symptoms

242
Q

Management of hypoglycaemia

A

Try Glucogel (E.G 15g in 85ml H20 for a 50kg child), Sugary drinks and bread then recheck in 15 minutes

If symptoms then: IV Glucose or IM glucagon

243
Q

Transient hypoglycamia if the newborn

A

Common if MDM
Monitor and encourage feeding

If CBG is <2 mmol/l on 2x readings despite the above then IV dextrose

244
Q

MODY

A

Very strong FHx
Monogenetic AD gene defect

Relatively thin, Recurrent infection, Frequent urination, Polydipsia, Wx loss

245
Q

When do you screen for T2DM

A

FHx, High risk ethnicity (S.Asian), HTN, PCOS, Acanthosis Nigricans

246
Q

T2DM presentation

A

Insidious onset

Polyuria, Polydipsia, Skin changes (Acanthosis Nigricans), Infection, Lethargy, Glycosuria

247
Q

Management of T2DM

A

Exercise and lifestyle changes

Then Try Metformin

248
Q

Causes of Primary Acquired Hypothyroidism

A

Hashimoto’s, Thyroiditis, Iodine deficiency, drugs

249
Q

Congenital hypothyroidism

How is it screened for?

A

Thyroid dysgenesis= Prolonged jaundice, Constipation, Hypotonia + other hypo symptoms

Picked up by Heel Prick in 1st few days of life and then USS to establish dysgenesis

250
Q

Causes of secondary hypothyroidism

A

Pituitary/Hypothalamic dysfunction

Intracranial masses. RT, Surgery

251
Q

Blood results for primary and secondary hypothyroidism

A

Primary Raised TSH and Low T3/4

Secondary Low everything

252
Q

Presentation of hypothyroidism

A

SHORT STATURE AND DEVELOPMENTAL DELAY OR DROP IN SCHOOL PERFORMANCE

Constipation, Pubertal delay, Wx gain, Fatigue, Slipped upper femoral epiphysis (Limp/Hip pain), Delayed bone age

253
Q

Management of hypothyroidism

A

Lifelong levothyroxine
TFTs every 4-6 months
Monitor growth and neurodevelopment
Good prognosis

254
Q

What BMI percentile chart indicates overweight or obesity?

A

> 85th centile= Overweight

91-98th= Obese

255
Q

Lifestyle changes for obesity

A

1hr/day of exercise for 7 days a week
3 meals a day with healthy snacks
Decrease calorie intake
Education and behavioural change

256
Q

Indications for checking glucose tolerance

A 
>98th centile on BMI percentile chart
PCOS
HTN
FHx
Symptoms of DM
257
Q

PKU pathophysiology

A

Defect in Phenylalanine hydroxylase so cannot convert phenylalanine to tyrosine

AR chr 12 gene

If left untreated it causes impaired brain development

258
Q

Presentation of PKU

A

6 months= DEVELOPMENTAL DELAY

Fair haired and blue eyed + FHx

Learning difficulties, Eczema, Seizures, musty odour to sweat

259
Q

Guthrie test

A

Day 5-9 Heel Prick

PKU, Congential Hypothyroidism, CF

260
Q

Management of PKU

A

Avoid Meat, Eggs and Dairy, Aspartame
High-tyrosine dietary substitution

Regularly assess plasma phenylalanine levels to reflect treatment response

261
Q

Leading cause of pseudo-hermaphroditism

A

Congential Adrenal Hyperplasia

262
Q

Congential Adrenal Hyperplasia

A

Likely 46xx karyotype but absence of 2-1-hydroxylase commonly leads to male phenotype

Inadequete cortisol production = Inc ACTH and adrenal hyperplasia and androgen overproduction (=Ambiguous Genitalia)

263
Q

Causes of Ambiguous Genitalia

A

Congential Adrenal Hyperplasia (MOST COMMON)
Androgen Insensitivity syndrome (46xy)
5-Alpha Reductase Deficiency

264
Q

Androgen Insensitivity syndrome

A

46XY Male Genotype; Female Phenotype
Testes there but external genitalia are ambiguous
No uterus, Tes/Oes/LH all raised

265
Q

5-Alpha Reductase Deficiency

A

46XY
AR disease
Cannot convert Testosterone to Dihydrotestosterone leading to ambiguous genitalia and hypospadias

266
Q

Definition of Precocious Puberty

A

Female <8 years (Idiopathic/Familial)

Male <9 years (Uncommon, Organic cause)

267
Q

Hypothalamic-Pituitary-Gonadal axis

A

Hypothalamus release GnRH
Anterior Pituitary then release FSH/LH
This acts on the testis and ovaries to induce Testosterone and/or Oestrogen release
This then induces a negative feedback loop

268
Q

Gonadotrophin dependent Precocious Puberty

A

Central/True- FSH/LH raised
Can be caused by intracranial pathology
Testicular enlargement will be bilateral
Gonadotrophin agonists to treat via negative feedback

269
Q

Gonadotrophin independent Precocious Puberty

A

Peripheral/False- FSH/LH low
Adrenal/Testicular/Ovarian pathology

Unilateral testicular enlargement if gonadal, Small Testes if Adrenal

Ketoconazole or Cyproterone to treat

270
Q

Definition of delayed puberty

A

Female>13 yrs

Male>14 yrs

271
Q

Functional causes of Delayed Puberty

A

Constitutional delay
Malnutrition
Excessive exercise

272
Q

Causes of Delayed puberty with short stature

A

Turners (45XO)
Prader-Wili
Noonan’s

273
Q

Causes of Delayed puberty with normal stature

A

PCOS
Kallmann’s (Hypogonadotrophic hypogonadism)
Kilnefelters (47xxy)
Androgen insensitivity

274
Q

Delayed Puberty- Kallmann’s syndrome

Hypogonadotrophic Hypogonadism

A

X linked recessive pattern of inheritance
GNRH neurones fail to migrate to hypothalamus LH/FSH/Tes low

Small gonads, Poor smell, Cryptorchidism, Delayed puberty

275
Q

Precocious puberty- Androgen insensitivity

A

X-linked recessive
46xy but female phenotype
Primary Amenorrhoea, Bilateral Orchidectomy, Raise as female

276
Q

Precocious Puberty- Klinefelter’s

A 
47xxy 
No secondary sexual characteristics 
Small firm testis and Gyaecomastia 
Tall
Raised LH, Low Testosterone
277
Q

Short stature Definition

A

> 2 SDs below the 2nd centile

Height, Weight and Head circumference

278
Q

Investigating short stature

A

Biochemistry- FBC, TFTs, U&Es, VitD,Ca, Fe, B12, Folate, Coeliacs screen, GH levels post glucagon stimulation

Karyotype?

Dex suppression test, Synacthen test (prim adrenal)

Growth chart- Normal velocity= Healthy short

X-ray wrist for bone age

Uterus/ovary USS

279
Q

Turner’s syndrome (45XO)

A

No pubertal signs B/C Gonadal dysgenesis
Neck webbing, low set ears, Hypertelorism, shield chest, low hairline, short 4th metacarpal

Biscuspid Aortic valve and coarctation of aorta

280
Q

Presentation of congential diaphragmatic hernia

A

Born in respiratory distress alongside pulmonary HTN
Can be detected later

Postero-lateral most common

281
Q

Exompholos

A

Abd contents in sac at umbillicus

Carefully and gradually put back in

282
Q

Gastroschisis

A

Uncovered abdominal contents outside cavity at umbillicus

Atresia risk as bowel thickens

283
Q

When is surgery considered for an umbilical hernia?

A

> 2 years old if symptomatic

if <1 cm most close by age 5 (>1.5cm ?Repair)

284
Q

X-ray changes in CF

A

Dilated tramline airways
Lympthadenopathy
Interstitial pattern because of scars

Paediatrics (6 decks)

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