WEEK 4 - SKIN & MSK & CHILD PROTECTION Flashcards
WEEK 4 - SKIN & MSK & CHILD PROTECTION
- 6 Key Points?
- 6 Key Symptom Presentations & their Associated Diagnoses?
RCH Guidelines - Neonatal Skin Care
- Layers of the skin?
- What is Vernix Caseosa?
Vernix Caseosa - Waxy white substance on newborn skin
RCH Guidelines - Neonatal Skin Care
- 4 Key Differences in Infants Skin?
- Infants born at term have a well-developed stratum corneum containing 10-20 layers. The epidermis is the outermost layer and provides an important barrier function. In preterm infants the stratum corneum may only have 2-3 layers. This deficiency and immaturity of the stratum corneum results in increased fluid and heat loss leading to electrolyte imbalance, reduced thermoregulation and increased infection risk.
- Cohesiveness of the epidermis to the dermis differs in preterm and term infants. Fibrils providing the cohesion between the epidermis and dermis are fewer in number and are more widely spaced in preterm infants. This decreased cohesion increases the risk of skin injury. If the adhesive used forms a stronger bond with the epidermis than that of the epidermis to the dermis, skin breakdown is likely
RCH Guidelines - Neonatal Skin Care
- Assessment - What is The Neonatal Skin Condition Score (NSCS?
Interpretation of the Results - The relevant medical team must be notified if a neonate scores a single score of 3 in one area or a combined score of 6 and above. A dermatology referral may also be appropriate.
RCH Guidelines - Neonatal Skin Care
- Nappy Care?
- Preterm infant considerations?
- Product Examples?
RCH Guidelines - Neonatal Skin Care
- Eye Care?
- Oral Care?
RCH Guidelines - Neonatal Skin Care
- General Bathing Principles?
- Swaddle immersion?
- First Sponge Bath?
RCH Guidelines - Neonatal Skin Care
- Routine Bathing Principles?
- Preterm Infant Considerations?
- Product Suggestions?
RCH Guidelines - Neonatal Skin Care
- Common newborn rashes - What is Erythema Toxicum Neonatorum?
- Clinical Features?
- Treatment?
Erythema Toxicum Neonatorum - A common condition affecting as many as half of all full term neonate neonates. Most prominent on day 2, although onset can be as late as two weeks of age. Often begins on the face and spreads to affect the trunk and limbs. Palms and soles are not usually affected.
Clinical features - Erythema Toxicum is evident as various combinations of erythematous macules (flat red patches), papules (small bumps) and pustules. The eruption typically lasts for several days however it is unusual for an individual lesion to persist for more than a day.
Treatment - The neonate is otherwise well and requires no treatment.
RCH Guidelines - Neonatal Skin Care
- Common newborn rashes - Neonatal Milia?
- Clinical Features?
- Treatment?
Neonatal Milia
- Affects 40-50% of newborn babies.
- Few to numerous lesions.
- Clinical features: Harmless cysts present as tiny pearly-white bumps just under the surface of the skin. Often seen on the nose, but may also arise inside the mouth on the mucosa (Epstein pearls) or palate (Bohn nodules) or more widely on scalp, face and upper trunk.
- Treatment: Lesions will heal spontaneously within a few weeks of birth.
RCH Guidelines - Neonatal Skin Care
- Common newborn rashes - Miliaria (Heat Rash)?
- Clinical Features?
- Treatment?
RCH Guidelines - Neonatal Skin Care
- Common newborn rashes - Pityrosoprum Folliculitis?
- Clinical Features?
- Treatment?
CAHS Guidelines - Developmental Dysplasia of the Hips (DDH)
- What is it?
- 4 Types?
- Epidemiology?
- Consequences?
- Investigation?
Developmental Dysplasia of the Hips (DDH) is a condition with a range of anatomical abnormalities of the hip joint in which the femoral head has an abnormal relationship with the acetabulum. This includes:
1. Dysplastic hip - there is an inadequate acetabulum formation (may not be clinically noted).
2. Subluxable hip - occurs if the femoral head can be partially displaced out of the acetabulum.
3. Dislocatable hip - when the femoral head may be displaced from the acetabulum with manoeuvres.
4. Dislocated hip - the femoral head is completely outside the acetabulum.
CAHS Guidelines - Developmental Dysplasia of the Hips (DDH)
- Risk factors for DDH?
- Screening for DDH? (4)
CAHS Guidelines - Developmental Dysplasia of the Hips (DDH)
- What is the Ortolani Test?
- What is the Barlow Test?
CAHS Guidelines - Developmental Dysplasia of the Hips (DDH)
- When is an Orthopaedic referral required? (3)
CAHS Guidelines - Subgaleal Haemorrhage (SGH) Detection and
Management in the Newborn
- What is a Subgaleal Haemorrhage (SGH)?
- Pathophysiology?
- Risk?
- 4 Maternal & 5 Fetal Risk Factors?
Subgaleal Haemorrhage (SGH) is an accumulation of blood in the loose connective tissue of the subgaleal space.
Pathophysiology - Tractional and rotational forces with the use of vacuum extraction can result in rupture
of veins and haemorrhage into different layers of the scalp. Most significantly, SGH may result from rupture of emissary veins into the subgaleal space. May (62-72% cases of SGH) may be associated with perinatal hypoxia
Risk - Most catastrophic complication of instrumental delivery and, while rare, is associated with significant morbidity and mortality. Early recognition with a low threshold of suspicion is essential to initiate timely and effective management.
CAHS Guidelines - Subgaleal Haemorrhage (SGH) Detection and
Management in the Newborn
- 3 Differential Diagnoses?
- 5 Local Signs?
- Systemic Signs?
CAHS Guidelines - Subgaleal Haemorrhage (SGH) Detection and
Management in the Newborn
- Level 1 surveillance?
- Level 2 surveillance?
- Level 3 surveillance & Immediate Investigations?
- What must you administer as soon as possible?
Administer intramuscular vitamin K as soon as possible.
RCH Guidelines - Child Abuse
- 6 Key Points?
- Assessment?
- Consent?
- Documentation?
Key points
1. Discuss all concerns about possible child abuse with a senior clinician.
2. Report all suspected cases in accordance with mandatory reporting obligations.
3. Child abuse is a possible cause for many different presentations. Children who attend with injury or suspected abuse must be assessed top-to-toe.
4. Suspected inflicted head injury, recent (<72 hours) sexual assault and poisoning often require time-critical investigations. Consult specialist services urgently.
5. Child sexual assault requires specialist service responses with trained medical forensic examiners.
6. Use of clinical decision tools, body diagrams and clinical photographs are recommended.
RCH Guidelines - Child Abuse
- History?
- List 10 circumstances when you might suspect child abuse?
RCH Guidelines - Child Abuse
- Examination?
- Red flag examination findings?
Examination - All children require a top-to-toe physical examination. This includes:
1. Recording height, weight, head circumference on percentile charts
2. ENT examination (including ear drums, nostrils, frenulum, teeth)
3. Fundoscopy
4. Complete skin check including neck and joint creases, palms of the hands, soles of the feet, inside the mouth, and areas underneath the nappy.
Behaviours observed between the child and carer during the consultation should be documented. When possible, the assessment should be performed with a colleague present (eg specialist counsellor, social worker) who can support the patient and family.
RCH Guidelines - Child Abuse
- Forensic investigation of bruising - Which 8 findings are concerning?
- What is the TEN 4 FACES Clinical Decision Rule?
- Laboratory investigations for underlying causes of bruising - 4 First line? 5 Second line?
The following findings are concerning:
1. Bruising in children who are not cruising or independently mobile.
2. Bruising on torso (including chest, abdomen, back, buttocks and genitalia), ears and neck. Under certain circumstances, bruising on upper arms or anterior thighs might also raise suspicion for abuse.
4. Bruising that is not on the front of the body or over a bony prominence.
5. Bruising that is abnormally large or multiple bruises.
6. Bruising that is clustered or patterned.
7. Bruising with petechiae.
8. Bruising that does not fit with the mechanism described.
- The age of a bruise cannot be determined on the basis of its colour.
- Multiple bruises that appear different may have been sustained at the same time.
- The possibility that the child has a bleeding disorder should be considered although it should be remembered that children who have bleeding disorders can also sustain inflicted injuries.
RCH Guidelines - Child Abuse
- Red flag features on examination?
PCH ED Guidelines - Burns
- Background?
- Assessment?
- History?
- Examination?
History
- Time and place the burn occurred
- Type of burn: thermal (most common), electrical, chemical (the substance causing the burn, duration of contact), radiation or friction
- First aid done at the scene
- Any further treatment prior to arrival in hospital
- Other injuries
- Immunisation status: tetanus
BURNS SURFACE AREA
SHEET - Infant & Child?
PCH ED Guidelines - Burns
- Which burns are considered major or of high concern?
- Resuscitation?
- First aid?
- Analgesia?
Resuscitation
- Airway: consider early intubation for inhalation burns, remember C-spine precautions in trauma.
- Breathing: always give oxygen in severe or inhalation burns.
- Circulation: If signs of shock, resuscitate with Sodium Chloride 0.9%, 10-20mL/kg bolus. Reassess after first fluid bolus and repeat as required.
- Consult Intravenous Fluid Therapy.
PCH ED Guidelines - Cellulitis and necrotising fasciitis
- When are investigations indicated? Which ones? (5)
- Management of Cellulitis, erysipelas or soft tissue infection <1 month of age?
- Management of Mild cellulitis or erysipelas ≥1 month of age?
- Management of Moderate cellulitis, erysipelas or soft tissue infection ≥ 1 month of age?
- Management of Severe skin and soft tissue infection (rapidly progressive cellulitis, cellulitis with persisting fever or tachycardia despite 24 hours of therapy)?
Investigations - The majority of children have mild disease and require no investigations. Indicated only if systemic symptoms, suspicion of underlying infection or in immunocompromised patient.
1. FBC, CRP and blood cultures are indicated in the unwell child who appears septic.
2. X-Ray if cellulitis in close proximity to bone (osteomyelitis, septic arthritis).
3. Swab microculture & sensitivity (MC&S) if discharge.
4. Consider HSV PCR test if suggestive of herpes.
5. Consider biopsy in the immunocompromised patient or if the infection is subacute or chronic.
PCH ED Guidelines - Cellulitis and necrotising fasciitis
- Management of Suspected Or Proven Necrotising Fasciitis?
PCH ED Guidelines - Impetigo
- What is Impetigo? 2 General types?
- Pathogens?
- 7 Complications?
- Examination?
- Investigations?
- 4 Differential diagnoses?
Pathogens - Staphylococcus aureus and Streptococcus pyogenes (either individually or in combination). Consider MRSA.
Complications - These are relatively uncommon but include:
1. Lymphadenitis
2. Scarlet fever
3. Osteomyelitis
4. Septic arthritis
5. Pneumonia
6. Septicaemia
7. Post-streptococcal glomerulonephritis - rarely and does not appear to be influenced by antibiotic treatment.
Impetigo often spreads rapidly, and the infection is generally more severe in children suffering atopic dermatitis (and other dermatological conditions).
PCH ED Guidelines - Impetigo
- Management?
- Hygiene issues?
- Exclusion from School/Day-care? Isolation?
Single-room isolation is not required for skin infections.
RCH Guidelines - Molluscum Contagiosum
- 4 Key Points?
- Background?
- Assessment - characteristic appearance of the lesions?
- 2 Complications?
- Management?
Key points
1. Molluscum Contagiosum Virus (Molluscum) is a common viral infection of childhood that causes a self-limiting infection of the skin.
2. Investigations are not required and most children do not require treatment.
3. Most cases resolve spontaneously within 6-9 months, but lesions can persist for more than a year. Exclusion from day care or school is not required.
4. Development of eczema in the surrounding skin is common and should be treated with usual eczema management
Background
- Molluscum is a common viral infection of childhood that causes a benign and self-limiting infection of the skin.
- Lesions can occur anywhere on the body and a child may develop a few or many lesions.
- Molluscum is spread by direct skin-to-skin contact, fomites (eg towels) or auto-inoculation by scratching or touching a lesion.
PCH ED Guidelines - Limp and hip pain
- Where could limping be referred pain from?
- History? (9)
- Examination - General? (3)
- Examination - Gait?
- Examination - Standing?
- Examination - Supine?
Limping may be due to pain referred from elsewhere:
- pain from the hip may refer to the thigh or knee
- pain from the spine or genitalia may refer to the hip
- always consider the possibility of non-accidental injury (NAI)
- limping for less than 3 days without any red flags does not require investigation.
PCH ED Guidelines - Limp and hip pain
- Investigations In a well child with < 3 days history of limp?
- Investigations in a Sick child?
- Investigations in In children with fever or severe hip pain/spasm?
- Outline 3 Differential Diagnoses?
PCH ED Guidelines - Limp and hip pain
- Management?
- Well children?
- Sick children?
- Septic arthritis/osteomyelitis?
- Perthes disease?
- SUFE?
PCH ED Guidelines - Torticollis
- 2 Groups?
Background
- The term torticollis (or wry neck), from the Latin for ‘twisted neck’, refers to a characteristics position where the head is held tipped to one side with the chin rotated toward the other.
- It is a physical sign, not a condition, and can be caused by a wide range of problems.
- Can be divided into 2 groups:
PCH ED Guidelines - Torticollis
- Investigations?
- Management?
Investigations
- If infective or inflammatory thought to be unlikely or if their is a history of trauma, cervical spine X-Rays should be taken.
- A full neurological examination including ophthalmological examination should be performed.
The Critically Ill Infant - THE MISFITS acronym?
Which emollients are effective and acceptable for eczema in children?
- Advantages of Thinner vs. Thicker emollients?
Non-Accidental Fractures in Kids
- Which fractures are of more concern?
- Common & Rare Highly Specific Injuries?
PCH ED Guidelines - Pulled Elbow
- What is it?
- Assessment?
- Investigations?
- History?
- Examination?
- A pulled elbow is where there is partial subluxation of the radial head, with the orbicular ligament slipping off the end of the radius.
- This is a common injury in toddlers 2-3 years of age (reported age range = 6 months - 7 years).
Assessment
- The history is central to the diagnosis
- The child is often undistressed, but reluctant to use the arm, and cries if the arm is moved.
- The child usually holds the affected arm motionless, in a mid-prone position in front of the chest, kept still by the opposite hand.
Investigations - No X-rays are required unless the history is atypical.
PCH ED Guidelines - Pulled Elbow
- Reduction - 2 Methods?
Reduction
- First explain to the parents that there will be a brief moment of pain followed by complete relief of pain. Sit the child on the parent’s knee.
- Consider and offer oral analgesia 30-60 minutes prior to the reduction.
PCH ED Guidelines - Eczema
- Diagnostic Criteria?
- What tool can be used to measure the extent and severity of eczema?
Background
- Eczema is a dry, itchy chronic inflammatory skin condition, which typically begins in early childhood.
- Eczema affects 1 in 4 Australian children.
- Usually starts at less than 12 months of age.
- It follows a remitting and relapsing course.
- Eczema tends to resolve in most children by the time they start school.
PCH ED Guidelines - Eczema
- Investigations?
- 7 Differential Diagnoses?
- Everyday management?
- Bathing?
- Moisturiser?
Investigations
- Skin swabs for bacterial or viral infections if required.
- Swabs of potential Staphylococcus aureus carriage sites should be considered in patients with recurrent skin infection. Suggested sites are nose, throat, axilla and wound.
Differential diagnoses
1. Psoriasis
2. Histiocytosis
3. Zinc deficiency (if perioral or perianal distribution)
4. Scabies
5. Malaria
6. Tinea
7. Immunodeficiency.
PCH ED Guidelines - Eczema
- Management of Active eczema?
- Topical steroids?
- Topical calcineurin inhibitors for troublesome facial eczema?
- Wet dressings?
- Antihistamines?
PCH ED Guidelines - Eczema
- Management of Infected Eczema or skin prone to infection? (2)
PCH ED Guidelines - Eczema
- Recommended general measures for all children with eczema?
- Treatment of Very Mild, Mild, Moderate to severe, and unresponsive treatment?
RCH Guidelines - The limping or non-weight bearing child.
- 4 Key points?
- History - 7 Red Flag features?
- Examination?
Key points
1. Most children presenting with a limp do not require investigations.
2. Observing the child’s gait may help localise the problem and narrow the differential diagnosis.
3. Acute inability to walk or weight-bear is a red flag.
4. Septic arthritis is an orthopaedic emergency and should be considered in all limping children with severe localised joint pain and fever.
Background
- Transient synovitis, acute myositis and minor trauma are common causes of limp in children, but serious pathology should be excluded.
- Pain causing limp can be referred.
- Therefore, a thorough assessment of joints above and below (including the spine and other relevant body systems) is essential to accurately localise the source.
RCH Guidelines - The limping or non-weight bearing child.
- 4 Common differentials for a Toddler (0-4 years)?
- 4 Common differentials for a Child (5-10 years)
- 3 Common differentials for an Adolescent (>10 years)?
- 8 Common differentials for all ages?
RCH Guidelines - The limping or non-weight bearing child.
- Investigations?
- Treatment?
- Algorithm for a child presenting with a limp?
Treatment
- Definitive management is determined by the working diagnosis.
- Simple analgesia - paracetamol +/- NSAID. Escalation of analgesia may be required but should prompt reassessment for red flags.
- Child-directed limitation of activity.
- Splint suspected fractures and manage accordingly.
- Septic arthritis is an orthopaedic emergency - consult local orthopaedic specialist ASAP.
- For infective causes, refer to the appropriate sub-specialist team and consult local antibiotic guidelines. If the child is stable and access to surgery will not be delayed, obtaining a surgical sample prior to antibiotic treatment is preferable. If the child is unwell do not delay treatment
RCH Guidelines - The limping or non-weight bearing child.
- Kocher Criteria for Hip Pain?
Kocher Criteria
In a child with hip pain, presence of the following 4 criteria increases the likelihood of septic arthritis:
1. fever >38.5°C
2. non weight-bearing
3. leucocytosis >12.0 x 109/L
4. ESR >40 mm/h (or CRP >20 mg/L)
RCH Guidelines - The acutely swollen joint
- 4 Key Points?
- History?
- Examination?
Key points
1. There are many causes of an acutely swollen joint. The aim of initial assessment is to identify and treat serious ones.
2. Acute inability to walk or weight bear is a red flag.
3. Septic arthritis is an orthopaedic emergency and should be suspected in any child presenting with localised severe joint pain and swelling, especially with fever.
4. Children discharged with an unclear diagnosis require early follow up
Background
- Joint swelling is a common feature in many conditions that affect children.
- History, examination, and tailored investigations will help to differentiate serious from benign causes.
RCH Guidelines - The acutely swollen joint
- Common differential diagnoses?
RCH Guidelines - The acutely swollen joint
- Acute joint swelling algorithm?
WA Guidelines for Protecting Children
- Physical Abuse Definition?
- Physical Indicators in child of physical abuse?
- Child’s behaviour Indicators of physical abuse?
- Parent/Carer behaviour Indicators of physical abuse?
WA Guidelines for Protecting Children
- Sexual Abuse Definition?
- Physical Indicators in child of Sexual abuse?
- Child’s behaviour Indicators of Sexual abuse?
- Parent/Carer behaviour Indicators of Sexual Abuse?
WA Guidelines for Protecting Children
- Emotional Abuse Definition?
- Physical Indicators in child of Emotional abuse?
- Child’s behaviour Indicators of Emotional abuse?
- Parent/Carer behaviour Indicators of Emotional Abuse?
WA Guidelines for Protecting Children
- Neglect Definition?
- Physical Indicators in child of Neglect?
- Child’s behaviour Indicators of Neglect?
- Parent/Carer behaviour Indicators of Neglect?
WA Guidelines for Protecting Children
- Medical Child Abuse Definition?
- Physical Indicators in child of Medical Child Abuse?
- Child’s behaviour Indicators of Medical Child Abuse?
- Parent/Carer behaviour Indicators of Medical Child Abuse?
Outline the WA health system guide to reporting child abuse.
What is an Erythematous Rash?
- How can it be distinguished from other rashes?
- Most common cause?
- 3 Examples?
How can you differentiate an erythematous rash to a petechial rash? = Erythematous rashes blanche
Define:
- Macular?
- Papular?
- Maculopapular?
- Coalescent?
- Discreet?
- Intense?
What do you need to consider as part of the history of a rash?
What are the principle of diagnosis of a rash in a child? Is it necessary to have a microbiological diagnosis?
Describe this rash/child?
This is a well looking child who is alert. The rash is erythematous, maculopapular with a discrete pattern. The distribution of the rash includes the child’s face and trunk and even on his hands = widespread.
Hx? - fever.
= Roseola infantum
What is Roseola Infantum?
- 5 Clinical features?
Describe the 3 rashes below.
- Child with an erythematous maculopapular rash which has coalescing.
- Maculopapular coalescing erythematous rash involving the face, limbs & trunk.
- Areas of desquamation = latter presentation of the same condition.
Hx = febrile, miserable, irritable, cough? immunisation status?
Dx = Measles (Rubella)
7 Clinical features of Measles?
8 Clinical features of Rubella?
What is this rash?
- 8 Clinical features?
What is this rash?
- Causative agent?
- 5 Clinical features?
- Management? (3)
What is this disease?
- 6 Clinical features/dx?
- Differentials?
KAWASAKI = CRASH & BURN
- C = Conjuncitivitis
- R = Rash (polymorphyous)
- A = Adenitis
- S = Strawberry tongue
- H = Hands & Feet odema
Complications & Management of Kawasaki disease?
Give 5 differentials for an erythematous rash?
Give an example of an erythematous rash that is:
- Common?
- Preventable?
- Treatable?
- Unforgettable?
4 Red flags for non-accidental injury?
What is the Bruising Clinical Decision Rule?
What is tramline bruising and why is it concerning when seen in a child?
What is Eczema?
What percentage of children get it?
Pathophysiology?
Consequences?
What is eczema?
- Chronic inflammatory skin condition
- Genetic – usually family history of atopy (asthma, eczema, hay fever, allergies) Worsened by triggers
- Affects 30% of Australian children
- 50% of children grow out of their eczema by 2 years old
- 85% by 5 years
- It is also called atopic eczema or atopic dermatitis
- Eczema = 1 in 4 babies/children Under 5
How does the distribution of eczema differ in infants vs. toddlers?
- 9 Eczema triggers?
Eczema triggers
1. Heat
2. Climate (low humidity)
3. Soap products
4. Saliva/drooling
5. Allergies
6. Rough clothing
7. Sand
8. Grass
9. Perfumes
What is the mainstay of treatment for eczema?
Moisturisers produce better results when used with active treatments, including prolonging the time to flare, reducing the number of flares, and reducing the quantity of TCS used.
opical
Corticosteroids (TCS) for eczema flare
- Start the steroid as soon as you see eczema.
- Apply enough steroid to cover ALL the eczema, not just the worst areas.
- Stop the steroid when skin is clear (once skin is soft, not rough or raised and not itchy).
- Weaker steroid is used on the face (face = eyebrow to chin) e.g. hydrocortisone 1%
- Stronger steroid is for the body (body = forehead and rest of body) e.g. methylprednisolone aceponate 0.1%
What is this?
= DDx of Eczema: Neonatal cephalic pustulosis
* Also known as Infantile acne. Due to increased activity of the newborns’ sebaceous glands causing inflammation and folliculitis.
* Clinical features: pustular eruption arising on the face and/or scalp of newborn babies, often during the third week.
* Treatment: None/Topical antifungal.
What is this?
DDx of Eczema: Neonatal milia
* Affects 40-50% of newborns. Few to numerous lesions. Also called ‘milk spots’.
* Clinical features: Harmless pearly-white bumps just under the skin. On the nose, inside the mouth on the mucosa (Epstein pearls) or palate (Bohn nodules) or more widely on scalp, face and upper trunk.
* Treatment: None
What is this?
DDx of Eczema: Erythema toxicum neonatorum
- Up to 50% of newborns. Most prominent on day 2, but up to two weeks of age. Often begins on the face and spreads to trunk and limbs.
- Clinical features: Combinations of erythematous macules (flat red patches), papules (small bumps) and pustules. The eruption typically lasts for several days.
- Treatment: None.
What is this?
DDx of Eczema: Seborrhoeic dermatitis
* Seborrheic dermatitis (cradle cap) Common in babies under 3 months of age.
* Clinical features: diffuse, greasy scaling on scalp.
* Crossover with eczema – often confused. Both can be relapsing
* Treatment: Depends on your view!
What is the POEM scoring system for Eczema?
A baby is investigated for jaundice at age 24 hours, with SBR 240mmol/L, what are the differential diagnoses and management?
a. How would this approach differ for a child who is 24 days old?
In an infant presenting with an erythematous maculo-papular rash, which clinical features (on history and/or examination) are useful in differentiating a serious condition (major morbidity or mortality) from a benign condition?
In a child presenting with purpura, describe a clinical and investigational approach which differentiates the important differential diagnoses.
Analysis: Important here, to distinguish different sizes of non-blanching purple coloured lesions. Clinical means history and examination. Investigational implies investigations are often necessary to refine the diagnosis.
How does the examination approach and differential diagnosis of hip conditions change from the neonatal period through to adolescence?
Analysis: Hip problems are collectively one of the more common (aside from trauma) MSK presentations in child health, and again, categorisation according to age of presentation can be useful in diagnostic reasoning.
What is the approach to managing a spectrum of trauma (bruises, fractures, other) in a pre-verbal infant or child?
Analysis: Trauma is common in mobile children, but uncommon during infancy generally. In this scenario, management is about vigilance for inflicted injury (a.k.a. “non-accidental injury”).
What are the fluid requirements of a newborn/2 week old?
Newborn - 60ml per kilo per day
2 Weeks - 150ml per kilo per day
Which components of the neonatal discharge check should be signposted as they require referral?
What is PURPLE Crying?
How Long Does PURPLE Crying Last?
The period of PURPLE crying is just that: a period. Even though it can be very frustrating for parents, it’s important to remember that your baby will eventually grow out of it.
When does PURPLE crying start Newborns start going through PURPLE crying at about two weeks old. When it starts, your baby will cry and sob even though they aren’t sick or in pain. It can be a frustrating time for parents since newborns resist soothing and consolation during this period. It’s important to remember that if you can’t get your baby to calm down, it’s okay. Even though it’s tiring and can make you feel guilty as a parent, you aren’t doing anything wrong. This is just a normal stage of growth.
What is this rash?
= Urticarial erythema multiforme
Urticaria multiforme is a benign cutaneous hypersensitivity reaction seen in pediatric patients that is characterized by the acute and transient onset of blanchable, annular, polycyclic, erythematous wheals with dusky, ecchymotic centers in association with acral edema. It is most commonly misdiagnosed as erythema multiforme, a serum-sickness-like reaction, or urticarial vasculitis. Since these three diagnoses represent distinct clinical entities with unique prognoses and management strategies, it is important that physicians distinguish urticaria multiforme from its clinical mimics in order to optimize patient care. By performing a thorough history and physical examination, the astute clinician can make the correct diagnosis and develop an appropriate, effective treatment plan while avoiding unnecessary biopsies and laboratory evaluations.
This child has a fine, sand-paper feeling rash and symptoms of an URTI. What is the diagnosis?
- Pathogen?
- Route of transmission?
- Diagnosis?
- Treatment?
- Clinical features: 3 phases?
= Scarlet fever
Pathogen
- Group A β‑hemolytic streptococci (Streptococcus pyogenes) produce erythrogenic exotoxin A, B, or C
- Route of transmission: aerosol
Diagnostics = Clinical diagnosis
- Elevated antistreptolysin O (ASO) and anti‑deoxyribonuclease B (ADB) titers
Treatment - oral penicillin V
What are these Classic pediatric exanthem diseases?
- Measles: Patients present with a dark red, erythematous, maculopapular, partially confluent exanthem, which spreads from behind the ears to the rest of the body.
- Scarlet fever: Patients present with a fine, light red, maculopapular rash. The exanthem begins on the neck and disseminates to the whole body. The patient’s face may be red with perioral sparing. After 1–2 days, the exanthem becomes scarlet-colored, and partially confluent. The rash is most pronounced in the axilla and groin. Nonblanching petechiae (Pastia lines) may be present.
- Rubella (German measles): Patients typically present with a nonconfluent, pink, maculopapular exanthem, which, like measles, extends from behind the ears to the rest of the body.
- Erythema infectiosum (fifth disease): A confluent, maculopapular rash appears only in ¼ of patients. It may take on a lace-like, reticular appearance over time. Additionally, patients present with diffuse redness of the face with perioral sparing (slapped-cheek rash).
- Roseola infantum (sixth disease): Three days of high fever are followed by a sudden decrease in temperature and development of a patchy, rose-pink, macular exanthem. The rash originates on the trunk and neck, and may spread to the face and extremities in some cases.
- Varicella (chickenpox): The exanthem affects the whole body, typically spreading to the scalp as well. Various stages of the rash occur simultaneously, which leads to the characteristic clinical finding known as “starry sky.”
What is the typical lesion of Erythema Multiforme?
IgA Vasculitis/Henoch-Schonlein Purpura
- What is it?
- Clinical Features?
IgA vasculitis (IgAV), previously referred to as Henoch-Schonlein purpura (HSP), is an acute immune complex-mediated small vessel vasculitis that most commonly occurs in children. Onset is often preceded by an upper respiratory tract or gastrointestinal infection; IgAV in adults may be idiopathic. Affected individuals typically develop palpable purpura, arthritis and/or arthralgia, and abdominal pain. Renal involvement (i.e., IgAV nephritis) is more common and usually more severe in adults than in children, typically manifesting with hematuria. While IgAV is a clinical diagnosis, laboratory studies are used to identify organ involvement and exclude differential diagnoses, and skin biopsy can confirm the diagnosis in patients with atypical presentations. IgAV is usually self-limited; treatment is generally supportive. Systemic glucocorticoids may be required depending on severity of manifestations (e.g., in IgAV nephritis, orchitis). IgAV has an excellent prognosis in children, usually resolving within one month when not complicated by IgAV nephritis. Adults often manifest with more severe features and have lower remission rates. All patients require follow-up assessments to rule out the development of chronic renal disease.
IgA Vasculitis/Henoch-Schonlein Purpura
- Aetiology?
- Pathophysiology?
- Clinical Features? (4)
IgA Vasculitis - Aetiology
- Preceding infection - preceded by viral or bacterial infection 1–3 weeks prior.
- Most commonly an upper respiratory tract infection caused by group A Streptococcus.
- IgA nephropathy
Pathophysiology - deposition of IgA immune complexes in vascular walls (e.g., in the skin, GI tract, joints, kidneys) → activation of complement → vascular inflammation and damage
Diagnostic Criteria for Henoch-Schönlein Purpura/IgA Vasculitis?
Kawasaki Disease
- Epidemiology?
- CRASH & BURN?
- 7 Clinical features?
Kawasaki Disease
Epidemiology
- Age: primarily children < 5 years
- Prevalence: Highest rate in children of Asian and Pacific-Islander descent.
Clinical features
“CRASH and BURN”: Conjunctivitis, Rash, Adenopathy, Strawberry tongue, Hands and feet, and BURN (fever ≥ 5 days) are the most common features of Kawasaki disease.
1. Fever for at least 5 days
2. Erythema and edema of hands and feet, including the palms and soles (the first week)
3. Possible desquamation of fingertips and toes after 2–3 weeks
4. Polymorphous rash, originating on the trunk
5. Painless bilateral “injected” conjunctivitis without exudate
6. Oropharyngeal mucositis - Strawberry tongue & Cracked and red lips
7. Cervical lymphadenopathy (mostly unilateral)
Kawasaki Disease
- Diagnostics? (1)
- Treatment? (2)
- Complications? (5)
Kawasaki Disease
Diagnostics
- Echocardiography: For evaluating coronary artery aneurysms
Treatment
1. IV immunoglobulin (IVIG) - High single-dose to reduce the risk of coronary artery aneurysms
2. High-dose oral aspirin - To avoid the risk of Reye syndrome, children should not be treated with aspirin, especially if a viral infection is suspected. Kawasaki disease is an exception to this rule.
What does this baby have?
= Facial impetigo
- Yellow staph golden aureus
Pathogens: superficial bacterial skin infection
- Staphylococcus aureus: ∼ 80% of cases: Causes both bullous impetigo and nonbullous impetigo
- Streptococcus pyogenes (GAS); causes nonbullous impetigo only & S. aureus and GAS coinfection
List 4 Differential diagnosis of pediatric hip pain.
Transient synovitis (toxic synovitis) of the hip
Epidemiology
- Peak incidence: 3–8 years of age
- Sex: ♂ > ♀
Aetiology - Associated with recent upper respiratory infection
Pathophysiology: nonspecific inflammation and hypertrophy of the synovial membrane.
Clinical features
1. Transient acute unilateral and transient hip or groin pain
2. Recent upper respiratory tract infection in approx. 70% of the patients
Treatment: symptomatic (e.g., rest, NSAIDs)
A 4yo presents with spreading lesions on her trunk (pictured). What is the most appropriate treatment?
A. Topical steroids
B. Cryoablation
C. Enucleation with curette
D. Topical imiquimod
E. Keep them covered
= E. Keep them covered
= papular with central umbilication
= Molluscum contagiosum = viral – direct contact spread
- Self-resolved
- Relative of the wart virus but not a papilloma virus
A 6yo presents with limping for 10 days. What is the diagnosis and management?
A. Transient synovitis, supportive
B. SUFE, surgical referral
C. Legg-Calve Perthes disease, surgical referral
D. Developmental dysplasia of the hips, surgical referral
E. Juvenile Idiopathic Arthritis, Steroids
= C. Legg-Calve Perthes disease, surgical referral
AP view of the pelvis
Flattened
Bilateral process that is degenerative
SUFE – usually affects older children, also it’s a subacute presentation
Transient synovitis = not this degree of degenerative
Developmental dysplasia of the hips – would have been symptomatic for the 5 years they have been walking
JIA = pain for more than 6 weeks, not radiological changes
A. Septic arthritis
B. SUFE
C. Transient synovitis
D. JIA
E. Perthe’s disease
The child also has pain on internal and external rotation of the knee.
If you suspected septic arthritis, what anitbiotic would you use?
= Transient synovitis
- No pathological changes on XRAY
If suspect septic arthritis = IV Flucloxacillin then if fails go to vancomycin = MRSA
Co-trimoxazole (Bactrim) – Oral
