The Sick Child Flashcards
Describe the trends in HR, RR and BP of children
HR and RR start off much higher than adult values and get lower with age
BP starts off low and gets higher
What are the main anatomical differences in children
Large head and prominent occiput
High anterior larynx and floppy epiglottis - important in CPR and intubation
Relatively large surface area to volume - significant in burns cases
Flexible ribs - ‘sucking’ sign when in resp distress
Lower blood volume - bleed out fast
What are some of the most common illnesses that children present with
Bronchiolitis URTI Croup Gastroenteritis Seizures Pneumonia/ LRTI Asthma Viruses Head injury Abdominal pain UTI
What is the most common reason for acute illness in kids
Sepsis
Overwhelming infection
Describe the presentation of bronchiolitis
Starts with coryzal symptoms - cough (wet sounding), wheeze, runny nose, sometimes a temperature
Congestion causes breathing difficulty
Kids will struggle with feeding due to breathing difficulty - leads to dehydration
Widespread fine crackles in all areas
May cause apnoea’s
Describe the presentation of croup
Most common in toddlers - will be miserable and have a temp
Get stridor due to narrowing of upper airway
Hoarseness and barking cough
Increased WOB
Will get worse when they are upset and crying - keep calm
List potential causes of stridor
Anything that causes upper airway obstruction Bacterial tracheitis Croup Epiglottitis Inhaled foreign body
Describe asthma presentation and treatment in young kids
Not every kid who wheezes has asthma
Prolonged expiration is also a sign of asthma in children
Young kids cannot do peak flow
Treat with O2, bronchodilators and steroids (not in under 2s)
What CNS disease can kids present with
Meningitis: bacterial and viral
- varied symptoms
Encephalitis: commonly viral (coxsackie)
What would make you suspect meningitis and what would you do
Obvious signs like rash - not always there
Headache and photophobia not common complaints until about age 6
May have an unusual cry
Vomiting and fits
Generalised symptoms such as high temp and ‘not themselves’
Children are often irritable, hard to console
Treat as if they have meningitis - lumbar puncture, bloods and antibiotics
What type of meningitis causes the classic rash
Meningococcus meningitis
Rash is purpuric and doesn’t blanche
What can cause fits in children
Febrile seizures - reaction to temp
Vasovagal episode - fainting
Reflex anoxic seizure - stop breathing when they get a fright
Breath holding attack
Behavioural - looks like they’re blacking out but may just not be listening
Epilepsy
Arrhythmia
List signs of non-accidental injury
Broken ribs - kids have flexible ribs so have to really be damaged to break
Bruising in odd places
Retinal haemorrhages - sign of shaking
List common GI and urogenital presentations in kids
Viral gastroenteritis GI obstruction - pyloric stenosis, volvulus, intussusception Appendicitis UTI Testicular torsion
Describe pyloric stenosis
Presents at around 4-6 weeks -purely a paediatric problem
Kids will be skinny, undernourished and get dehydrated quickly
They omit every time they try and eat – projectile, milky
Caused by thickened stomach wall at the pylorus which causes obstruction
What heart conditions might you see in young children
Congenital heart disease
Arrhythmias - SVT’s
Cardiac issues very rare in kids
What are some of the most common but vague symptoms that kids present with
Difficulty breathing Poor feeding Fever Rash Lethargy / depressed conscious level dehydration
What is the most common cause of arrest in children
Respiratory failure leading to respiratory arrest
Cardiac arrest may occur secondary to resp but rarely primary in children
What has a better prognosis - respiratory or cardiac arrest
Respiratory
Why cant you do a full head tilt, chin lift in a young child
Kids have a high anterior larynx so tilting their head back like in adult BEC you can compress their airway
List signs of breathing difficulty in young children
Grunting - baby basically giving themselves CPAP
Nasal flaring
Use of accessory muscles - head will bob, abdominal breathing
Recession - chest moves inwards
You get sternal. subcostal and intercostal
Tracheal tug
Why might young children make a grunting noise
Cold
Hypoglycemia
Breathing problems - basically giving themselves CPAP by closing glottis
Is low blood pressure normal in a child?
NO
Children are really good at maintaining their BP so if it drops they are very unwell
This is because they have really good peripheral vasoconstriction to compensate
Pre-terminal sign
Where do you perform cap refill on a child
Centrally by pressing on the sternum
If a child is in shock, how do you treat them
Fluids - based on body weight
Saline is best
Give blood if it is a trauma case
List the key signs of dehydration
Dry mucous membranes, eyes or fontanelle Decreased skin turgor Low urine output Shock Lethargy Altered conscious level - severe
What is posturing
It describes abnormal movements made in fits
It means there is something wrong with the brain stem
Decorticate - hands pulled up to chest
Decerebrate - arms by sides, palm rotated to ground - more severe
How do you treat pyloric stenosis
Surgery
Pyloromyotomy - cut out the thickened muscle in the wall to reduce obstruction
What is intussusception
Part of the bowel folds in on itself like a telescope
List symptoms of intussusception
Blood in nappy - red currant jelly sign
Vomiting - comes in waves
Colicky pain - child will settle in between bouts
Floppy baby
Sausage like mass in abdomen - often right side
How does intussusception appear on US
When ‘face on’ it looks like a target or tree rings
From the side it looks like a kidney - pseudokidney
How do you treat intussusception
Place a tube into the bowel via back passage and blow air up it to try and push it back into place – works in 70-80%
If this doesn’t work, it will require surgery
How will appendicitis in a child appear on US
Usually just being able to see the appendix on US in a child means that it is inflamed
What is the jump test for appendicitis
If they get up and are more than happy to jump around then they probably don’t have peritonitis
If they are too sore, they do and will need surgery
If a baby is vomiting up green stuff, what diagnosis must be excluded
Malrotation with midgut volvulus
It is a surgical emergency and if not caught in time then the gut and baby can die
Describe the normal fixed position of the gut
There are 2 fixed points in the normal abdomen
Distance between these is the longest distance in the abdomen
Blood supply in the middle of this is the superior mesenteric artery
What can cause a malformation with midgut volvulus
Congenital malformation where the fixed points of the gut are not in the correct place
Distance is shorter, as is blood supply so gut is more unstable and likely to twist
List causes of acute scrotum problems
Testicular torsion - surgical emergency
Inflammation of the epididymis
Torsion of the hydatid - small area of necrosis on top of testicle (most common)
What is BXO
Abnormality of the penis
White scarring on the head around the urethral opening
Requires circumcision
Urological system is a common site of congenital malformation - true or false
TRUE
What is hypospadias
Abnormal opening in penis - e.g. urethra comes out below penis
What do you do if a testicle is stuck in the groin
Must be located and moved down to the scrotum
This puts it in a place where it can be examined which is important for cancer risk in later life
How do you treat an absent testicle
You don’t
There is no need to move anything as nothing there to cause cancer risk
How do you move a testicle from the groin to scrotum
2 phase operation
Cut the testicular artery to free the testicle
Leave to let heal and aim for the blood supply from below to take over
If blood supply is successful then push the testicle through the deep ring into the scrotum
In an ABCDE situation, what differences must be done in Airway in a child
DO NOT do a full head tilt chin lift
Just tilt head slightly so that head is parallel to the surface it is on
This is because children have floppier airways and a high anterior larynx that make it easy to occlude the child’s airway by tilting back too far
In an ABCDE situation, if a child is not breathing what do you do (only breathing tasks)
Give 5 rescue breaths
Check for chest rising with each breath
In an ABCDE situation, if a child is not breathing and the rescue breaths are ineffective - what do you do
If no signs of life give 15 chest compressions
Feel for brachial pulse
Anything below 100bpm is abnormal
Start CPR at a rate of 15:2
How do you treat a choking child (older)
Encourage them to cough
Give 5 back blows - check for object removal after each
Then go onto Heimlich manoeuvre
Repeat until it clears or until they fall unconscious
How do you treat a choking child (infant)
5 back blows with them pointing downwards - check for object removal after each
Then do 5 strong chest compressions
Repeat until it clears or until they fall unconscious
Why cant you do the Heimlich manoeuvre on infants
High risk of rupturing abdominal organs
What is the WETFLAG procedure for a child in arrest situation
Weight - allows you to work out doses Energy Tube Fluids Lorazepam Adrenaline Glucose
List common signs of hypoglycemia in children
Tiredness Feeling shaky Lips tingling Feeling tearful or irritable Blurry vision Lack of concentration Going pale Sweating Headache Feeling hungry
Children who are decompensating often appear well - true or false
True
Children are very good at compensating for illness
They are often severely unwell by the time they present as such
List the steps in the 3 minute exam for children
ABCDETT
Airway - secretions, stridor, foreign body
Breathing - RR, WOB, O2 sats, auscultation
Circulation - colour, HR, cap refill, temp of hands and feet
Disability - pupils, limb tone and movement, AVPU, glucose if very unwell or drowsy
ENT exam - look in ears and throat
Temperature
Tummy - soft, distended, tender, bowel sounds etc
How can you determine if a child has an unprotected airway
Test their gag reflex
Try and place an artificial airway and see how they react = they should cough and not tolerate
If they tolerate it then they are at risk of unprotected airway - maintain a jaw thrust and call anaesthetist
At what stage of hypoxia does cyanosis present
Roughly below 85%
Why might a sats probe give artificially low readings in children
If the child is moving and you don’t get good contact with the probe
Where do you place the sats probe on a small child
O2 sats taken from foot or whole hand on a baby as their fingers are too small
What is the target O2 sats for a child
Should have sats of 98% or more
94% or less is hypoxia
Once sats get down to 90% there is a more rapid deterioration - best to catch early
Auscultation is less useful in children than in adults - true or false
True
Children have much smaller chests so the noises will transmit across the whole chest - harder to localise
What is mottling a sign of
Poor perfusion
What affect can crying have on the obs
A distressed child will have an increased HR
What conditions can lead to poor perfusion
Sepsis
Dehydration
Why is central cap refill more reliable than peripheral
It is not affected by environmental temperature
List signs of poor perfusion in children
Poor cap refill - peripheral affected first, then central
Mottled skin
Cold hands and feet
What does asymmetrical pupils suggest
SOL in the brain
This includes haemorrhage
What condition can lead to sluggish pupils
Fits
Drug overdose
Changing pupil size is suggestive of what
May suggest an ongoing fit even if there is no tonic clonic movements
What is true irritability and what does it suggest
When a baby truly cannot be consoled or distracted
It is suggestive of raised ICP or meningitis
Why do boys with abdominal pain need a testicular exam
To exclude testicular torsion - emergency
Should also look in groin for hernias
Persistant drowsiness is a red flag sign - true or false
True
Often seen after fits or in fever
What type of thermometer is used on a young baby
Axillary thermometers are used in babies if ear too small for tympanic
List common causes of breathlessness in children
Asthma
Bronchiolitis
Pneumonia
Croup
Most severe resp infections usually occur in the first 3 years of life - true or false
True
Includes strep pneumo, Hib, pertussis
A prolonged expiration phase is seen in which conditions
Asthma
Bronchiolitis
B-agonists less effective for the treatment of asthma in children under 1 - true or false
True
This is because asthma in this age group is usually atypical
How do you treat croup
Responds really well to steroids - oral or inhaled
Usually a single dose of dexamethasone
In severe cases, nebulised adrenaline is used alongside O2 for immediate relief
How do you treat bronchiolitis
Supportive treatment only as it is viral
May need O2 and feeding support if severe
What caused croup
It is typically caused by parainfluenza
It is technically laryngotracheobronchitis
What causes bronchiolitis
Typically RSV
Leads to acute inflammatory injury of the bronchioles - LRTI
How does pneumonia present in kids
Present with non-specific symptoms compared to adults
Diagnosis is often based on general signs of infection as this is what kids present with - tachycardia, fever, lethargy, low O2 sats , resp distress
Will be more lethargic with a higher temp than with viruses
They often refuse food/drink
Cough is a less reliable symptom in kids, may be absent
-
Children may have persistent wheeze following pneumonia - true or false
True
Common for a few months after illness
Should grow out of it by age 2
List risk factors for respiratory illness in children
Prematurity
Required neonatal care
Exisiting cardio or resp disease
Respiratory distress can lead to dehydration in children - true or false
True
The breathing difficulty makes it hard for them to feed properly leading to dehydration
Kids become more distressed as they decompensate - true or false
False
They become less distressed as they become very tired/drowsy
Wheeze is an upper airway noise - true or false
False it is a lower airway noise
Heard in asthma and bronchiolitis
Stridor is an upper airway noise - true or false
True
Occurs on inspiration
Stridor is heard in which conditions
Heard in croup, foreign body aspiration, epiglottis etc.
Chest recessions are more common in younger children - true or false
True
They have softer smaller chests so less effort needed to indraw
Older kids with recessions are very sick
Intercostal and subcostal recession usually occur together - true or false
True
They have the same clinical significance
Which type of chest indrawing most indicates severe respiratory distress and why
Sternal indrawing
Lot of effort is needed to move such a large bone
Why do children in respiratory distress bob their heads
Head bob caused by pulling on sternocleidomastoid - they are using their accessory muscles
At which O2 saturation should you give a child supplemental oxygen
Give O2 if sats are below 92% - should get up to 100% quickly on high flow
Where might you hear bronchial breathing in a child
Heard just over an area of consolidation - harsh breathing noise
How would a child present if they have swallowed an foreign object
They will be very uncomfortable
Will be drooling due to swallowing difficulty
Which is more common, children swallowing foreign bodies or inhaling them
Swallowing is more common
List the potential outcomes of an inhaled foreign body
Coughed up
Brought up by Heimlich
Can go down into the bronchi = will present with wheeze
Life threatening choking cases are rare - hypoxic and LOC
A foreign body causing discomfort is most likely where - oesophagus or trachea
Oesophagus
How may children appear during an apnoea
May go floppy and cyanosed
In young infants (1-4 months old) apnoeas are a sign of what
Usually due to another underlying illness
Not necessarily respiratory in origin
Must be sent to hospital
Describe the difference in whooping cough presentation between older and younger kids
Older kids present with the classic whooping cough
Younger kids may present with apnoeas
Tachycardia can be an indicator for respiratory distress - true or false
True
How do you manage status asthmaticus
Requires intubation and ventilation to take over breathing
Can lead to respiratory failure without it
If a child has a silent chest, what must you do
You must call for intensive care
It is a sign of severe respiratory distress
What is the most common cause of fever in children
Most are caused by mild viral illnesses which get better on their own
Why are infants more vulnerable to infection
They still have an immature immune system
Takes around 2 years for the immune system to mature = thymus and spleen developing
The younger the child, the higher the risk of a local infection becoming sepsis - true or false
True
This is due to their immature immune system
Children are more likely to present with non-specific infection symptoms than adults - true or false
True
Why is CRP not a useful blood test in the acute setting
It takes time for levels to rise so doesn’t provide an accurate picture in the acute setting
What causes the purpuric rash seen in meningitis
It is caused by the release of endotoxin by the meningococcus bacteria
It makes the blood vessels leaky and blood escapes to the skin leading to the purple areas
Which blood tests should you perform on a child with suspected sepsis
Venous blood gas
WCC
Can also check lactate - significant if >3
The degree of the fever is a great predictor of illness severity - true or false
False
It is a poor predictor
Still important to ask about the degree and duration of the fever
At which point does a temperature becoming concerning in a child
Particularly concerning if temp is over 39.5C
Though in those under 3 months 38 is considered significant
Which children are at particularly high risk of infection
Cerebral palsy
Prematurity
Those on steroids
History of leukaemia
How does fever influence HR and RR
Fever itself can increase HR and RR
Rule is an increase of 10bpm for each degree of fever
They should both fall in response to anti-pyrectics
How should a fever respond to anti-pyrectics
Should fall into an up and down pattern - goes down after dose and then rises again
This is a reassuring sign
What does tachypnoea without signs of resp distress suggest
It is a sign of sepsis
Which examinations would you do to find an infection focus in a child
Typical ABCDE
Check all over for rash (include glass test)
Check fontanelles
Check for photophobia
ENT exam - look for runny nose
Abdominal exam
Check a urine sample if no obvious focus
Use the NICE traffic light system to determine next steps
What signs are required for a diagnosis of ear infection in children
Redness alone isn’t enough - can be a general/non-specific sign
Only diagnose if there’s a fluid level behind it, if it’s dull or non-reflective or if its different from the other ear
How can fever affect the findings on ENT exam
Temp can make the eardrums pink/flushed - does not mean it’s an ear infection
Same with the tonsils
How will the tonsils appear in true tonsillitis
They will be large with a whitish exudate
May be red - not enough on its own
Babies sometimes present with hypothermia in response to infection - true or false
True
Babies under 8 weeks old often present without a fever even with a severe infection - may drop their temp instead
Hypothermia is a red flag
Good fever control can prevent a febrile convulsion - true or false
False
There is no evidence of this
When would a child be sent for a chest X-ray
CXR done in those under 3 with signs of sepsis or a raised RR
How do you diagnose a UTI in children
Get a clean catch urine if not toilet trained
Parents given a pot and baby left without nappy to catch urine
When should you suspect a UTI in children
Should be considered if you have a fever of unknown source
Children often present without the classic symptoms - more non-specific
Can rapidly turn to sepsis in babies
List signs of bone or joint infection in children
Reluctance to use limb or limping (atraumatic limp)
Joint may be warm and red
General signs of infection
Consider osteomyelitis or septic arthritis
How does Kawasaki disease present
Child will be very irritable and unwell
High temp goes on for several days
Non-specific rash - usually maculopapular
Red eyes and sore mouths
Large lymph node on one side of neck
Rash fades then peeling of fingers and toes occurs
Kawasaki disease is a disease of childhood - true or false
True
Most common in the under 2’s
Kawasaki disease can lead to complications with which major organ
The heart
Can also affect the coronary arteries
Kawasaki disease can lead to complications with which major organ
The heart
Can also affect the coronary arteries
Kawasaki disease can lead to complications with which major organ
The heart
Can also affect the coronary arteries
How do children with influenza present
Headache, muscle ache, tiredness, fever, may have a cough
Babies have less specific symptoms - D&V and rash
Sepsis caused by meningitis is more fatal than meningitis alone - true or false
True
How do you treat a child with suspected bacterial meningitis (immediate treatment)
Give empirical penicillin or ceftriaxone to any older child with suspected meningitis
Viral meningitis can have a mild presentation - true or false
True
Can occur alongside viruses - mild and presents with headache
Its the bacterial one that’s severe
List possible causes of rash in children
Allergies Med reaction Stings and insect bites Chemical reactions Infection Systemic disease
A rash combined with a cough and sore throat is suggestive of what
Measles
A rash combined with sore/red eyes is suggestive of what
Kawasaki disease
A rash combined with abdominal pain is suggestive of what
HSP
A rash combined with a recent burn is suggestive of what
Toxic shock syndrome
A rash combined with a bleeding gums, bruising, joint pain and lethargy is suggestive of what
Leukemia
Meningitis will always present with a non-blanching rash - true or false
False
Can have a blanching erythematous rash to start with so don’t rule it out
What is erythema toxicum neonatorum
A transient rash seen in babies under the age of 1
Appears as raised, red, blotchy areas
Which common childhood rashes present as macules or papules
Mild viral rashes, measles, rubella and Kawasaki disease
Macular - splotchy but under skin so cant feel
Papular is the same but with raised area
May be combined as maculopapular
Which common childhood rashes appear as vesicles
Vesicles - small blisters
Chickenpox, herpes simplex, shingles
Which common childhood rashes appear as pustules
Pustules - pus filled blisters
Strep or staph infections
Which common childhood rashes appear as petichiae or purpura
HSP
Meningococcal sepsis
What is the difference between petichiae and purpura
Petechiae - 1mm or less in size and flat
Purpura - purple areas 2mm or larger
Which conditions can cause an urticariral rash in children
- Allergy and anaphylaxis
- Can come up and down again
What is cradle cap
Seborrheic dermatitis on the head causing flaky scalp
Common in babies
List common sites for eczema in children
Necks, elbows, knees, armpits and face
How does eczema appear when there is a secondary bacterial infection in it
Will be weepy with scabs
How does Neisseria meningitidis spread
Neisseria meningitidis can be found in the nose of carriers
In some people it spreads to the bloodstream then the brain
Most common in children under 5
How does Stevens Johnsons syndrome present in children
Rash and blistering of mucous membrane
Rash is target lesions
Children tend to be miserable and need admission if they need fluids (wont want to drink due to blistering)
What causes toxic shock syndrome in children
Caused by toxin secreting bacteria like strep or staph
Can occur after minor burn
How do you treat toxic shock syndrome
Immediate antibiotic treatment
How does toxic shock present following a burn
Burn looks normal but kid has a fever, diarrhoea, erythematous rash and generally unwell
Can become critically unwell very fast
What is HSP
It is an immune disease causing bleeding into the skin
How does HSP present in children
Child is usually well - obs normal
Presents with the purpuric rash - worst on back of legs and bum
List some of the main complications of HSP
Can cause bleeding in intestinal wall which causes abdo pain, may lead to intussusception
Can lead to kidney disease so check BP and urinalysis
Can also cause bleeding into joints causing pain
What is idiopathic thrombocytopenic purpura
Immune disease which affects platelets and therefore clotting - shows up on FBC
Child will be completely well but have a petechial rash
How do you treat idiopathic thrombocytopenic purpura
May need steroid treatment
Why should you do a FBC in kids with a petichial/purpura
Have to exclude cancer as leukaemia can present like this
Will be clinically anaemic
What is the more common type of fit - generalised or focal
Generalised
What is the most common cause of fits in children
Temperature - febrile convulsions in younger children
In older children it is more likely a non-febrile epileptic fit in someone with known epilepsy
List potential causes of fits in children
Fever - febrile seizures Acute brain injury Epilepsy NAI - if head injury included Encephalitis/meningitis Metabolic causes (particularly high/low sodium, low calcium, low glucose) Reflex anoxic seizure Drug and alcohol overdose/withdrawal
What event happens with warning symptoms a fit or a faint
A faint
Will have symptoms like dizziness, feeling hot, hearing and visual changes
Fits happen without warning
What should you include in a seizure history
Try and get a step by step eyewitness account of the fit itself
Any warning signs
Was there any preservation of consciousness
The appearance of the child during - movement, eyes, colour changes, incontinence
Duration of fit and recovery
Post event headache?
Jerking movements means that it is definitely a seizure - true or false
False
May see jerking movements or incontinence in faints too
What are the main differences between a faint and a fit
Fits happen without warning whereas faints usually have warning signs
The main difference is a fast recovery - should be back to normal within minutes
Faints are more common in older children
When does cardiac syncope typically occur
Due to an arrhythmia - may not feel it
Occurs out of the blue or during exercise
How can breath holding attacks lead to convulsive episodes
Children sometimes hold their breath in response to to pain or emotion
Can occur after a bump to the head as well
They hold it for so long they can pass out
Severe attacks can lead to reflex anoxic seizures in response to an asystole - true seizure
Febrile convulsions are usually which type of seizure
Febrile convulsions are usually generalised seizures
Most recover quickly
First time febrile convulsions are rare in those over the age of 3 - true or false
True
If a fever triggers a fit in a known epileptic is it considered a febrile seizure
Not a true one
How do most children present after a true seizure
Children are typically sleepy for 10-30 mins after a fit, they then develop a headache and may become irritable
Headache is a good sign they have had a true fit
How likely is it for a child to have another febrile seizure after their first presentation
50/50 chance of having another before they grow out of it
How do you manage a seizure
Time seizures - call for help if longer than 5 mins
Give O2 immediately, can insert an NP airway to hold it open
Then give IV drugs if you get access - e.g lorazepam
If no access the buccal route can be used - medazolam
Parents of known epileptic often have this at home for emergencies
How does a focal seizure present
Child will be awake and usually aware
The fit will affect a specific part of the body
How does a general seizure present
Child will be unaware of their surrounding - LOC
Includes tonic clonic seizures (jaw and fists clench, eyes roll back, may make grunting noises)
Also absence seizures
How do you manage a child in the post-ictal period
Give paracetamol after seizure to treat the headache
Then need to assess for fit complications and then the cause of it
Put in recovery position
Do a full neuro exam after they are awake
Check blood glucose to exclude that as a cause
Fits in infants only a few months old often look atypical - true or false
True
May present with odd posturing of arms, stiffness etc whilst some just go floppy
List signs of aspiration post-seizure
Signs include a drop in O2 sats, high RR or resp distress following a seizure event
What is status epilepticus
A fit lasting over 30 mins or when there is incomplete recovery between fits
Usually in severe epilepsy or severe underlying cause
Why would a small baby be jittery
Small babies become ‘jittery’ if they have low sugars - shaky but not a true fit
What is the most common cause of dehydration in children
Gastroenteritis - most often viral
Usually has to be severe for it to lead to dehydration
Children with chronic diseases are more vulnerable
How do you manage viral gastroenteritis in children
Oral rehydration sachets (e.g diorylite) are used for an oral fluid challenge
Oral fluid challenge can be observed - get parents to note down intake and output
IV fluids needed for more severe case such as DKA or if oral management not working
Which children are more vulnerable to dehydration
Children with chronic diseases
What typically comes first in viral gastroenteritis, diarrhoea or vomiting
Vomiting usually precedes diarrhoea
Diarrhoea and vomiting in children can be a sign of almost any illness, not just GI conditions - true or false
True
Many children will have 1 or 2 episodes of D&V with any illness so should run through other symptoms
How would a child with campylobacter infection typically present
Gastroenteritis with abdominal cramps
Why might appendicitis present with diarrhoea in children
It increases bowel motility = diarrhoea
Same with bowel obstruction
What can cause bloody stools in children
Salmonella or shigella infection
Can also be a sign of intussuception - red current jelly sign
In terms of nappies, when would you be worried about dehydration in a child
If no wet nappies for 12 hours
List signs of severe dehydration in children
Sunken eyes or fontanelle (ask parents if abnormal for them) Dry mucous membranes Mottling Cool peripheries Poor cap refill (poor perfusion due to dehydration) Poor skin tugor Oliguria Tachycardia Hypotension Persistent drowsiness
What is hypernatreamic dehydration
A type of dehydration specific to babies
Caused by their immature kidneys
If they get dehydrated (e.g. due to poor feeding or D&V) the kidneys cannot compensate properly by retaining water
Leads to a high sodium (imbalance due to water loss)
How does hypernatraemic dehydration present
Drowsiness - wont wake up to feed
Skin eyes and fontanelles NOT sunken
High HR and RR
Diagnose by blood test - high Na
Which children are at risk of hypernatraemic dehydration
Seen in first weeks of life when breastfeeding hasn’t been established properly or in bottle fed babies if feeds not made up properly
Also seen in those with severe watery diarrhoea
How does DKA present
High glucose and ketones cause dehydration
High RR caused by acidosis
Polyuria, excessive thirst and dehydration
List common abdominal causes of abdominal pain in children
Colic, intussuception, mesenteric adenitis, constipation, IBS (usually Crohns), coeliac, bowel obstruction, appendicitis
List common causes of abdominal pain in children that originate outwith the abdomen
Migraines DKA, Psych issues - stress UTI Testicular torsion Ovarian cysts or torsion Malignancy Infections elsewhere can cause abdominal pain
Appendicitis is hard to diagnose in children under 5 - true or false
True
Common for appendix to rupture before diagnosis
List common causes of chronic abdominal pain in children
Constipation
IBD
Malignancy
List common causes of acute abdominal pain in children
UTI
DKA
Surgical issue (obstruction, appendicitis etc)
Bilious vomiting is suggestive of what type of pathology
Bowel obstruction
Investigate by AXR, bloods and surgical opinion
List common symptoms of surgical bowel issues such as obstruction or appendicitis
Not eating
Severe pain
Worse on movement
Vomiting (particularly bilious = obstruction)
List some red flag features of abdominal pain in children
Faltering growth/failure to thrive is a sign of more serious pathology
So is being woken from sleep by the pain
List red flags for cervical lymphadenopathy
- Persistent fever (> 2 weeks)
- Weight loss
- Night sweats
- Pruritis
- Lymph nodes in the supraclavicular region
- Hepatomegaly
- Splenomegaly
- Anaemia
- Excessive bruising
- Fatigue
- Shortness of breath
- Bone pain
What is the most common cause of lymphadenopathy in children
Mostly due to benign self-limiting viral illness
Increased numbers of immune cells collect in the nodes, enlarging them
What is the first line treatment for lymphadenitis in children
Oral co-amoxiclav
List common signs and symptoms of lymphoma
Painless, enlarged nodes May grow rapidly or wax and wane Intermittent fever and night sweats Weight loss Difficulty in breathing (seen if there's a large mediastinal mass
How do you stage lymphoma
- LP
- CT chest, abdo and pelvis
- Bone marrow biopsy
What is tumour lysis syndrome
A potentially life threatening complication of cancer
Especially common in the early stages of chemotherapy treatment.
The tumours release their intracellular contents
Cancers with high proliferation rates (such as haem) re at an increased risk due to high cell turnover
Describe stage 1 lymphoma
One group of lymph nodes is affected, or there’s a single extranodal tumour.
Describe stage 2 lymphoma
Two or more groups of nodes are affected
Or there is a single extranodal tumour that has spread to nearby lymph nodes
Or there are two single extranodal tumours, but only on one side of the diaphragm.
Describe stage 3 lymphoma
There is lymphoma on both sides of the diaphragm (either in two or more groups of nodes)
Or there are two single extranodal tumours
Or the lymphoma is affecting the chest.
Describe stage 4 lymphoma
The lymphoma has spread beyond the lymph nodes to other organs of the body such as the bone marrow or nervous system
List the key features of tumour lysis syndrome
Hyperkalaemia - usually happens first)
Hyperphosphataemia which then causes the hypocalcaemia and hyperuricaemia.
AKI - happens for many reasons - hyperhydration before chemo, obstruction by uric acid and calcium phosphate
What is screened for in the newborn heel prick test
Cystic Fibrosis, Congenital Hypothyroidism, Phenylketonuria, MCADD, Sickle Cell Disease, Maple Syrup Urine Disease, Homocystinuria, Glutaric Aciduria type 1 and Isovaleric Aciduria
How is Cystic Fibrosis screened for in the UK
Part of the newborn heel prick test
Describe the early management of CF
Monitor feeding and growth
Give pancreatic enzyme replacement to prevent malabsorption, particularly of fats
Fat soluble vitamin supplements required as not properly absorbed- ADEK
Also treated with regular physiotherapy and prophylactic antibiotics
How is faecal elastase used in monitoring of CF
Faecal elastase is a marker of exocrine pancreatic function so CF kids may get it measured
This function is usually decreases in CF
Why is pancreas function reduced in CF
The pancreatic ducts get obstructed by thickened secretions, reducing function
Both exocrine and endocrine functions are
Leads to malabsorption and diabetes
How can CF present
Recurrent respiratory infections - can lead to bronchiectasis)
Failure to thrive
Pale/offensive stool - due to pancreatic insufficiency and malabsorption
Meconium ileus - bowel obstruction due to sticky stool
What are the two main nutritional challenges seen in cystic fibrosis
Pancreatic dysfunction results in malabsorption of energy dense fats The chronic respiratory infection results in an increased calorie requirement
How do you treat the nutritional deficiencies associated with CF
Counteracted with enzyme replacement and calorie dense diet
Sometimes overnight gastrostomy or NG feeds are used
List some of the complications of CF
Bronchiectasis, diabetes, distal intestinal obstruction syndrome, cirrhotic liver disease and infertility
A normal respiratory rate in a child with respiratory distress may be falsely reassuring - true or false
True
Can be a sign of a tiring child
Why should you note if a child was distressed during an examination
Distress can make them tachycardic etc. so may be a false sign
Important to note down
How do you correct for gestation on a growth chart
Should correct for gestation on growth chart if born before 37 weeks - measurements plotted at their actual age (i.e. as though born at 40 weeks) and then a line (with an arrow pointing left) should be drawn back the number of weeks the infant was premature
Until what age do you correct for gestation on the growth chart
Until they are 1 year old
What causes slapped cheek syndrome
Human Parvovirus B19 or Fifth Disease
What is the risk of catching parvovirus/slapped cheek syndrome in pregnancy
Infection in pregnancy can lead to fetal anaemia, ‘hydrops fetalis’ and miscarriage
What are the symptoms of slapped cheek syndrome
Fever
Headache
Runny nose
Followed by a rash on the arms and legs and middle of the body
The child may develop bright-red cheeks/”slapped-cheek” rash.
Describe the rash seen in slapped cheek syndrome
Bright red cheeks
The rash is seen on the arms and legs and middle of the body
It fades from the centre outwards, so it looks lacy.
Usually lasts around 2 weeks
Which children are at high risk if they catch slapped cheek syndrome
Children with sickle cell disease as can cause aplastic crisis
What is involved in a septic screen in children
LP, urine culture (clean catch), CXR when resp signs
When would you do a septic screen in a child
In all infants with fever under 6 weeks of age.
It is highly advisable in febrile infants between 6 weeks and 3 months, especially when the child is clinically unwell or the white cell count is abnormal
List contraindications for LP in children
Coma
Signs of raised ICP
Cardio or resp compromise
Focal neuro signs or seizures
Recent seizure (within 30 mins or not returned to normal)
Coagulopathy/thrombocytopenia
Local infection (in the area where an LP would be performed)
The febrile child with purpura where meningococcal infection is suspected.
List some potential complication of LP in children
Failure to obtain a specimen / need to repeat LP/ Traumatic tap (common)
Post-dural puncture headache - fairly common
Transient/persistent paresthesiae/numbness (very uncommon)
Respiratory arrest from positioning (rare)
Spinal haematoma or abscess (very rare)
Tonsillar herniation (extremely rare in the absence of contraindications above)
How do you prescribe fluids in children
For the 1st 10kg prescribe 100ml/kg
For the 2nd 10kg prescribe 50ml/kg
For every kg above 20kg prescribe 20ml/kg
Lower lobe pneumonias can present with abdominal pain in children - true or false
True
What signs of constipation may be found on abdominal exam
Hard faeces may be felt in the left iliac fossa
What is the most common cause of peritonitis in children
Perforated appendix
How does peritonitis present
Leads to widespread tenderness and guarding
Will also cause pain on movement
How can extra-abdominal infections lead to intussuception
Due to swelling of Peyer’s patches (lymph node collections) in the bowel wall in response to the infection
Bowel folds around this
May be seen with tonsillitis or ear infections
List some potential causes of abdominal masses in children
Neuroblastoma and Wilms tumour
Appendix abscess
Constipation
How might testicular torsion present
Swelling in scrotum
Tenderness or pain
Abdominal pain
Colour change
Testicular torsion is common in which age group
Torsion is most common in boys over 12 but should be considered in all boys
What is more common falling head injury in children - diffuse brain injury or haemorrhage
Diffuse brain injury - cerebral oedema
Usually occurs over the 24hrs after the injury
List red flag symptoms that suggest a serious head injury in children
Persistent drowsiness - more than 2 hours
Persistent headache
Persistent vomiting
What key factors should be covered in a head injury history
Mechanism of injury Risk of NAI? Behaviour at time of injury and since then Ages LOC (means injury was significant)
What is considered a significant fall in a child
Anything from their height or above
Which consequences of head injury can lead to true irritability in children
Cerebral oedema, contusions and haemorrhage
Which consequences of head injury can lead to true irritability in children
Cerebral oedema, contusions and haemorrhage
What are the indications for CT scan following head injury
LOC for more than 1 min Head injury with seizure Persistent drowsiness - over 2 hours Headache Vomiting
Brain haemorrhage almost always causes a headache = true or false
True
Following head injury behavioural changes usually occur after focal signs present - true or false
False
Behavior usually changes first
Which type of head injuries are common signs of NAI
Skull fracture and subdural haemorrhage
Injuries around the eye and ear may also be suspicious
Facial bruising in a non-walking infant is suspicious of NAI
How does the AVPU scale correlate to GCS
P on AVPU is roughly GCS 8
Which scalp signs suggest an underlying skull fracture
Soft, boggy or large swelling on scalp may suggest underlying fracture
Boggy haematoma
Facial bone fractures are common in children - true or false
False
Only really happens with a direct blow or high power injury like unrestrained RTA
What is mesenteric adenitis
Inflammation of the abdominal lymph nodes
Typically caused by viral infection
Causes abdominal pain in children
How do you differentiate between reflux and GORD in children
All kids get reflux but GORD is when the reflux causes faltering growth or signficant distress
Why should you not examine the throat in suspected croup
There is a risk of epiglottitis and if you irritate this it can lead to airway closure
What symptoms may be caused by administration of salbutamol
Tachycardia
Tremor
What is the minimum amount you want a child to be feeding per day
100ml per kg is the minimum you want
150ml per kg per day is normal feed
How does HUS present
Bloody diarrhoea - acute
Common cause of AKI in children
Microangiopathic Haemolytic Anaemia
Red cell fragmentation on Blood Film
What is HUS
Haemolytic uraemic syndrome
Consequnce of an e.coli 0157 infection
How do you manage HUS
Send stool sample
If well discharged with worsening advice
If unwell admit and give IV fluids
List signs of uncontrolled asthma
Symptoms every day
Symptoms disturbing sleep
Using reliever inhaler once a day or more
Symptoms triggered by simple exertion such as walking up stairs
Frequent absence from school due to asthma
List signs of poorly controlled asthma
Any asthma symptoms three times a week or more
Waking in the night because of asthma, one night a week or more
Any limitation on activities - exercise, leisure activities, school attendance
Using reliever inhaler three times a week or more
What is the main difference between the administration of aerosol and dry powder inhalers
Aerosol inhalers are inhaled slowly and deeply, but dry powder inhalers should be inhaled fast and forcefully
Why do children have higher resp rates than adults
Smaller people have smaller tidal volumes
RR higher to keep minute ventilation
Why do children have higher heart rates than adults
Smaller people have smaller stroke volumes
HR higher to maintain a sufficient cardiac output
What signs suggest severe croup
Severe respiratory distress
Cyanosis
Exhaustion
How do you manage GORD In children
Conservative measures
Thickening feed (eg. Gaviscon)
Reducing stomach acid (eg. PPI / H2 antagonist)
Emptying stomach faster (eg. Domperidone)
Early weaning can be useful
How does transient synovitis present
Painful joint - usually hip
Child will be otherwise well and afebrile
Preceded by viral illness in approximately 50%
How do you manage transient synovitis
Usually resolves by itself in 7-14 days
What is Perthes disease
Avascular necrosis of the capital femoral epiphysis
Typically occurs in those aged 3-9
How does Perthes disease present
Onset occurs over weeks
Child will be systemically well
No other joint involvement (just hip) and no signs of joint inflammation
How does septic arthritis present in children
Most commonly affects lower limbs
Usually unwell with fever / malaise and evidence of joint inflammation
Pain is usually severe
Hold the affected limb flexed or completely stop using the limb
How do you manage septic arthritis in children
Early involvement of orthopaedics as joint destruction can occur within 24 hours
Which children are most affected by SUFE
Usually late childhood / adolescence
M>F 2:1
Often weight >90th centile
How does SUFE present
Antalgic gait and apparent leg length discrepancy
Severe eczema can impact on development - true or false
True
All time and energy goes into skin
Miss out on opportunities and education
How can eczema lead to fluid loss
If severe you get leaking of serous fluid through broken skin - loss of fluid
The vast majority of children have which type of diabetes
Type 2
Even with rising obesity, the rate of type 2 in children isn’t as high
Good glycaemic control early on can reduce risk of complications further down the line - true or false
True
This is why paediatric diabetes is so important to control
The level of response to insulin changes as the child ages - true or false
True
Honeymoon period when first started on treatment where they are really responsive
Become less responsive to insulin in puberty - though to be due to hormone change etc
Why would a family history of thyroid problems be relevant to a child with suspected diabetes
Both are autoimmune conditions and can therefore be related/run in families
How might DKA present in a child
History of polyuria, polydipsia and tiredness
Tummy pain
Breathing issues - Kussmaul’s breathing
Symptoms of dehydration
How might DKA present in a child
History of polyuria, polydipsia and tiredness
Tummy pain
Breathing issues - Kussmaul’s breathing
Symptoms of dehydration
How do you diagnose DKA
Urinalysis NPT – glucose and ketones Bloods – FBC, U&E, Glucose, CRP, +/-Culture, HbA1c, Anti-GAD antibodies Blood gas Additional Ix on basis of presentation
How do you diagnose DKA
Urinalysis NPT – glucose and ketones Bloods – FBC, U&E, Glucose, CRP, +/-Culture, HbA1c, Anti-GAD antibodies Blood gas Additional Ix on basis of presentation
How do you manage DKA
Treat shock - IV access and fluids
Switch off ketosis - rehydrate then commence replacement insulin
O2 if required (sats<94%)
Monitor Electrolyte shifts (Na, K, Cl & HCO3)
Convert to S/C insulin once ketosis reversed and patient feeling better.
Describe how fluids are replaced in a patient with DKA
Initial bolus of 0.9% NaCl given to treat shock if present - 10ml/kg
After this you move to maintenance fluids which are given much slower - aiming to replace the fluid deficit
Subtract the initial bolus from the calculated deficit to get the dose of fluid needed
Why would you need K+ replacement in a patient being treated for DKA
Administration of insulin will cause your K+ to drop so will need replaced – quite hard to replace so catch it early
If a known diabetic patient presents with DKA you should stop their insulin - true or false
False
Long acting insulin should never be stopped – if they come in with DKA you should still give them it at night
What can cause fluid loss in a child
Blood loss
Gastroenteritis - D&V
Burns
What are the main reasons for requiring resuscitation in children
Respiratory Arrest = 85% of paediatric resus are hypoxia related
CARDIAC ARREST – 15% of paediatric resus are SHOCK related
Much more likely to survive respiratory arrest
Which conditions can cause fluid maldistribution
Septic shock
Cardiac disease
Anaphylaxis
How do you perform CPR in a child
Open airway - neutral head in infants, sniffing in children (not full head tilt)
Can lift chin or do jaw thrust if ineffective
If not breathing properly give 5 rescue breaths
Then move to 15 chest compression with 2 rescue breaths - 1/3 of chest depth
2 fingers or hand encircling in infants, one hand in young children
What is the biggest cause of mortality in children worldwide
Neonatal death
Then diarrhoael diseases then pneumonia
What is the most common thing for children to present with
Respiratory illness
How do you recognise sepsis in a child
Any child with suspected or proven infection and at least 2 from:
- Core temp <36C or >38C
- Inappropriate tachycardia
- Altered mental state (sleepiness, irritability, lethargy, floppiness)
- Reduced peripheral perfusion
Which children at at higher risk of sepsis and therefore have a lower threshold for treatment
Infants below 3 months old Immunosuppressed or comprimised Recent surgery Indwelling devices/lines Complex neurodisability or long term condition High index of clinical suspicion High parental concern
What is the paediatric sepsis 6
Give high flow O2
Takes bloods - cultures, glucose, lactate
Give IV or IO antibiotics
If shocked:
- Consider fluid resus
- Inotrophic support early - adrenaline or dextrose
- Involve seniors/specialists early
How does tonsillitis present in children
Fever Poor oral intake Drooling Halitosis Rash/perioral pallor
How do you deal with a choking child
If they have an effective cough - encourage them to cough until they clear the obstruction or deteriorate
If ineffective cough but conscious - do 5 back blow followed by 5 thrusts (on chest for infant and abdomen for child over 1)
If ineffective cough but unconscious - open airway, give 5 breaths and then start CPR
List the reversible causes of cardiac arrest
Hypoxia
Hypovolaemia
Hypo/hyperkaelameia (or other metabolic)
Hypothermia
Tension pneumothorax
Tamponade
Toxins
Thromboembolism
What are the shockable rhythms
VF
Pulseless VT
What are the non-shockable rhythms
Pulseless electrical activity
Asystole
What is the resus protocol for a newborn
If all is normal - clear airway, keep warm and dry
If not crying - reposition and stimulate
If apneoic or HR< 100 bpm then give positive pressure ventilation
If HR<60 then ensure effective lung inflation and add chest compression
If this does not work consider adrenaline
How do you get intraosseous access
Go in on the medial aspect of tibia, around 1-2 fingers below tibial tuberosity
Perpendicular to flat surface of bone
Push until gives
Which type of fluid should be used for fluid resus in children
Use ISOTONIC solutions - 0.9% saline or 4.5% albumin
Hypotonic will cause cerebral oedema and may cause coning
DO NOT use dextrose as volume replacement
What volume of fluid needs to be lost for signs of shock to present
Around 25% of circulating volumes
How would you use a spacer with a pressurized metered dose inhaler
Long, slow breaths in and out of the spacer – 10 for young children (5 for older children)
Which types of inhaler can be used with a spacer
Pressurised metered dose inhaler
What is a PMDI
Pressurised metered dose inhaler
e.g. salbutamol or seretide evohaler
Classic blue ‘puffer’
Must breath in, press down inhaler and continue to inhaler - one action
Why is it important to clean spacers
The build up of drug inside spacer makes it less effective
What is a breath actuated inhaler
Inhaler where the delivery of drug is triggered by the patient breathing in
Convenient as easy to use but does not require a spacer
What is a dry powder inhaler
Where drug is delivered as a powder - obviously
Need to breath in hard and fast - not pressurised so patient has to do the work
PMDIs can be used by all age groups - true or false
True
Younger children will likely need a spacer
List signs of a true seizure
Tonic – stiffness Clonic – movements Eye rolling Loss of consciousness If they are a known epileptic Incontinence Heart rate increases Hypoxia Post-ictal period – takes some time to recover, drowsy
Focal seizures can progress into a generalised ones - true or false
True
If breathing regular/relaxed it’s unlikely to be a seizure - true or false
True
Flashing lights is a common trigger of seizure in children - true or false
False it is rare
Neonatal seizure are very rare - true or false
True
Can be very difficult to diagnose the cause
List some potential causes of seizures in neonates
Myoclonus of infancy
Reflux - sandiffer syndrome, contort due to reflux discomfort
Normal baby movements
Jitters
Infantile spasms
West syndrome - causes seizures in small babies, associated with developmental regression, has a distinctive EEG
Every child who comes in with a syncope/funny turn needs an ECG - true or false
True
May be due to an arrhythmia
Some kids make fitting movements when collapsed
What is gratification
Unconscious movements which are done because they feel good
Can appear unresponsive or seizure like
What can be done to avoid febrile seizures
Nothing
It just happens to some children in response to temperature (>38C)
What must be excluded before a diagnosis of febrile seizure can be made
CNS infection
If the infection is meningitis then it is not a febrile convulsion, it is due to the brain infection itself
Which types of epilepsy are specific to childhood
Childhood absence epilepsy
Benign epilepsy of childhood with centro-temporal spikes
Juvenile myoclonic epilepsy develops in adolescence
EEGs can be used to diagnose epilepsy - true or false
False
It is not a diagnostic test but used with history to corroborate
When would a MRI brain be requested for a child who had a seizure
If there was a focal onset
When would genetic tests be carried out on a child presenting with seizure
Particularly if early onset < 3yo
Intractable
Strong family history
When is epilepsy considered to have resolved
In those who had an age-dependent syndrome but are now past the applicable age
Those who have remained seizure free for the past 10 years with no seizure medication for the last 5
What is the diagnostic criteria for epilepsy
At least 2 unprovoked seizures occurring more than 24hrs apart
Or one unprovoked seizure and a probability of another that is similar to the general recurrence risk after 2 unprovoked over the next 10 years
Which signs are suggestive of an UMN lesion
Weakness accompanied by increased tone and hyper-reflexia
Which signs are suggestive of a LMN lesion
Flaccid weakness with absent reflexes,
Look for bowel and bladder involvement or a sensory level to locate level of a spinal cord injury
May affect one limb (Nerve entrapment)
May be ascending as in Guillain Barre
Or intermittent, relapsing and “sounds unusual” as in periodic paralysis
List the main indications for urgent brain imaging in children
Altered Conscious level (CT)
Focal seizures as discussed (CT)
Cranial nerves involvement or Focal neurology ( ? Brain, spine or both) (CT)
Raised ICP – bradycardia, hypertension, papilloedema (CT)
Spinal cord injury/ compression – ONLY INDICATION FOR AN out of hours MRI
Combination of signs
Angular chelitis may be caused by which conditions
IBD Infection Candida Drooling Atopic eczema Poor nutrition
Mouth ulcers may be seen in which conditions
Often a sign of Crohn’s
Sometime seen in coeliac
Pigmented or freckled lips are a sign of which condition
Peutz-Jegher’s syndrome
A cancer syndrome - GI, breast, ovaries, pancreas
How far down can you visualise with an endoscope
Down to the 2nd part of the duodenum
All endoscopies in children are carried out under GA - true or false
True
At least in the UK
List symptoms of GORD in children
Retrosternal pain/heartburn
Vomiting
Back arching
Cough/aspiration pneumonia
If it leads to severe oesophagitis and erosion you may see melaena/anaemia
How might eosinophilic oesophagitis present in children
Difficulty swallowing (dysphagia) Painful swallow Food bolus obstruction
Gastric ulcers rarely present in children under what age
Rare before the age of 2
Typically due to H/pylori infection
Presents with pain, vomiting and melaena
Children have much higher calorie requirements per kg than adults - true or false
True
They have to consistently gain weight and grow
This is why bowel disorders can lead to failure to thrive/grow
What is the most common cause of rectal bleeding in children
Constipation and passage of hard stools
This can lead to fissures as well
Erythema nodusum is associated with which GI condition
Crohn’s
It is confined to arms and legs
Nodular and painful
Pyoderma gangrenosum is assocated with which GI condition
Crohn’s and UC
Confined to arms and legs
Looks like an infected ulcers but doesn’t respond to antibiotics
Dermatitis herpetiformis is associated with which GI condition
Coeliac disease
Rarer in children than adults
Can appear anywhere on the body and looks like eczema
What are the most common causes of viral diarrhoea
Noravirus, adenovirus, (rotavirus in countries without rotavirus vaccine)
What is the most common cause of diarrhoea in children, virus, bacteria or parasite
Viral
what are the most common bacterial causes of diarrhoea in children
E-coli 0157 (associated with Haemolytic Uraemic Syndrome), clostridium difficile, campylobacter, salmonella, cryptosporidium
More likely to present with blood in stool
what are the most common parasitic causes of diarrhoea in children in the UK
Giardia
Most other causes found abroad
How do you treat viral gastroenteritis in children
Trial of oral rehydration with oral rehydration solution (Dioralyte, Rehydrat)
Consider 1 dose ondansetron
Use syringe and give 5 ml every 2 minutes, consider NG tube if refusing to take solution
Intravenous fluids- admission with attention to fluid balance
List potential causes of diarrhoea in children
Infection most common cause
Inflammatory bowel disease
Malabsorption/enteropathies
Which conditions can cause malabsorption in children
Coeliac Disease Crohn’s disease Cystic fibrosis Food allergies Lactose intolerance Other rarer causes
What is Toddler’s diarrhoea
A benign condition thought to be caused by bowel immaturity
Typically self-limiting and improves by age 5-6
Can have up to 10 stools per day
No other abdominal symptoms, thriving child
How do you manage Toddler’s diarrhoea
Rule out other causes - FBC, U&E, LFT, Coeliac screen
Reduce excessive fruit juice
Increase fat if on low fat diet
Keep fibre content normal
May rarely need Loperamide to help with toilet training
GORD in children is typically benign and self-limiting - true or false
True
~ 98% resolved by 2 years
How do you manage GORD in a child
Assess for overfeeding
Reassurance
Consider cow’s milk protein allergy and trial of hydrolysed formula
Carobel or Gaviscon added to feed as thickener
Consider use of PPI
Further investigate if loosing weight/red flag signs
How does coeliacs disease present
Diarrhoea Pale Stools Bloating Growth failure Anaemia - asymptomatic
How do you screen for coeliac disease
tissue transglutaminase (TTG) anti- endomesial antibodies (EMA)
Should also check FBC, U&Es, LFTs, CRP, Iron studies, Ferritin, stool cultures, consider faecal calprotectin
What is the gold standard for coeliac diagnosis
endoscopy with duodenal biopsy
Children can be diagnosed with coeliac based on blood tests alone - true or false
True
Although only if classical symptoms
AND
TTG > 10 x upper limit of normal (varies between labs)
How does coeliac appear on histology
Crypt hyperplasia
Flattening of villi
Lymphocytic infiltration
Coeliac disease can be associated with which other conditions
Diabetes Mellitus type1
Autoimmune thyroid disease
Juvenile Chronic Arthritis
Other autoimmune diseases
Down’s syndrome
Turner syndrome
Williams syndrome
List some complications of coeliac disease
Osteoporosis Anaemia Short stature Delayed puberty Female infertility Intestinal malignancies (t-cell lymphoma)
How does Crohn’s present
Diarrhoea (with blood in Crohn’s colitis) Weight loss Anaemia Abdominal pain Peri-oral or perianal lesions
extra-intestinal signs in liver, eyes and skin
How does Crohn’s present on histology
skip lesions oedema, Inflammation Cryptitis Abscesses only 30% have granulomas
How do you investigate suspected Crohn’s disease
FBC, U&Es, LFTs, CRP (ESR), ferritin, coeliac screen, plasma viscosity (if >10years)
Faecal Calprotectin
Stool cultures x 3 - including C.diff.
Upper and lower GI endoscopy
MRI small bowel study - barium study in younger children
List potential complications of Crohn’s disease
Perforation Fistulae Colon CA in colitis Sclerosing cholangitis Autoimmune hepatitis Small increased risk of malignancies - increased by immunosuppressive meds
How do you manage Crohn’s in children
Induce remission
- Elemental diet for 6-8 weeks (for upper GI disease)
- Steroids (Prednisolone)
Maintenance
initially azathioprine
step up to methotrexate +/- infliximab or adalimumab
Avoid surgery if possible
Nutrition
Diet rich in calories
Low in bulk to avoid obstruction
What is the definition of constipation
Must include two from:
Less than three defecations per week
At least one episode per week of faecal incontinence (after the child has acquired toileting skills)
A history of excessive stool retention or retentive posturing
A history of painful or hard bowel movements
Presence of a large faecal mass in the rectum
A history of stools with large diameter that may obstruct the toilet
Recurrent rectal prolapse in children can be an indicator for which condition
CF
Explosive passing of stool following rectal examination suggests which condition
Hirschsprung’s disease
What typically causes rectal/anal skin tags in children
Usually caused by healed fissures
These can be caused by Crohn’s or sexual assault
List risk factors for constipation in children
Low fibre intake Low fluid intake Excessive dairy products Lack of exercise Obesity Problems with toilet training
How can you treat constipation in children
Softeners - e.g. Magrocol such as Laxido, Movicol
May need Laxido clear out if faecal impaction +/- soiling
May need to add stimulant such as Docusate or Senna
Adjust dose to achieve bristol stool chart goal
Long term use of laxatives will harm the bowel - true or false
False
Laxatives DO NOT make the bowel lazy- longstanding constipation harms the bowel
Why do children with constipation sometimes soil themselves
Faecal impaction causes overflow diarrhoea
Patient often not aware of soiling or smell
What is Infant Dyschezia
Problem in learning to defaecate with poor coordination of straining on stool and opening of the external anal sphincter
Babies appear in pain when trying to pass stool and settle when stool is passed
Stools are soft when passed-this is not constipation and laxatives will not help
Generally resolves after 2-4 weeks, no treatment is required
How is UC graded
Mild
Distal colon only, <3 stools/day, little blood, no fever, no weight loss
Moderate
3-5 stools/day, bloody, abdo pain + cramps, low grade fever, mild anaemia, weight loss
Severe
>5 stools/day, frank blood, fever, anaemia, leukocytosis, hypoalbuminiaemia, pain, risk of toxic megacolon and perforation (requires admission and urgent assessment with endoscopy)
Most children with UC present with which grade of disease
moderate to severe pancolitis
How do you manage toxic megacolon
‘Drip and suck’
IV antibiotics
Early surgical review
List some complications of UC
Long term risk of Colon Cancer
Extra intestinal manifestations
growth failure
arthropathy
episcleritis
skin (erythema nodosum/pyoderma gangraenosum)
auto-immune liver disease (more common in males, can progress to primary sclerosing cholangitis)
How does UC appear on histology
polymorph nuclear leucocytes near base of crypts
crypt abscesses
NO granulomas
How do you manage UC
Steroids to induce remission
Maintenance therapy
Mild - Mesalazine only
Moderate to severe - Mesalazine + Azathioprine,
Non responders - Mezalazine+ Azathioprine+ Infliximab or Adalimumab
CURE = Colectomy
How do you manage UC
Steroids to induce remission
Maintenance therapy
Mild - Mesalazine only
Moderate to severe - Mesalazine + Azathioprine,
Non responders - Mezalazine+ Azathioprine+ Infliximab or Adalimumab
CURE = Colectomy
What is eosinophilic oesophagitis
Immune condition characterised by eosinophilic infiltration of the oesophageal mucosa
2nd most common cause of oesophagitis after GORD
How does eosinophilic oesophagitis present
Clinical presentation with difficulty swallowing or food bolus obstruction
How does eosinophilic oesophagitis present
Clinical presentation with difficulty swallowing or food bolus obstruction
How do you treat eosinophilic oesophagitis
1st line dietary management top 6 food elimination (seafood, nuts, dairy, eggs, wheat, soya, 80% successful)
2nd line topical viscous budesonide
List potential causes of vomiting due to obstruction
Pyloric stenosis
Intestinal volvulus
Intussusception
Adhesions after previous surgery
