WEEK 7 – GASTRO-URO & SURGICAL Flashcards
6 Key Points?
- 6 Red Flags of Abdominal Pain presentations in children?
- Which investigation must you always do?
Key Symptom Presentations & Associated Diagnoses (an incomplete simplification)
- 6 Vomiting differentials?
- 5 Dysuria differentials?
- 3 Haematuria differentials?
- 8 Abdo Pain differentials?
- 5 Abdominal Mass differentials?
- 2 Proteinuria differentials?
CAHS Guidelines - Jaundice
- Risk if not correctly identified in a timely manner?
- How common is jaundice in newborns?
- When is it considered pathological?
- How is it usually managed?
- ## If not recognised, monitored and managed appropriately jaundice can lead to bilirubin encephalopathy and kernicterus. This may result in chronic neurological impairment, neuro-cognitive delay, dysfunction of motor control and tone and sensory-neuronal hearing loss.
CAHS Guidelines - Jaundice
- What is Acute Bilirubin Encephalopathy?
- 4 acute manifestations of bilirubin toxicity observed in the first weeks of life? Progression of symptoms?
- What is Bilirubin Induced Neurological Dysfunction (BIND)?
- How is BIND managed?
CAHS Guidelines - Jaundice
- What is Chronic Bilirubin Encephalopathy (Kernicterus)?
- 6 Neurological features?
CAHS Guidelines - Jaundice
- Outline the diagnostic evaluation of Early onset (< 24 hours) and Aggressive Jaundice?
- 7 Causes of early jaundice?
Causes of early jaundice include:
Haemolysis:
1. Rhesus Iso-immunisation.
2. Minor red cell antigen incompatibility.
3. ABO incompatibility.
Sepsis.
Rarer causes:
4. Red cell enzyme defects (e.g. G6PD).
5. Red cell membrane defects (e.g. hereditary spherocytosis).
6. Crigler-Najjar Syndrome.
CAHS Guidelines - Jaundice
- Is Jaundice between 24 hours and 14 days to be a concern?
- 5 Causes?
Jaundice between 24 hours and 14 days:
- Jaundice occurring after the first 24 hours and lasting less than 14 days is most commonly physiological in nature.
- Causes of hyperbilirubinaemia with onset during this period include:
1. Physiological jaundice
2. Haemolysis.
3. Breakdown of extravasated blood.
4. Sepsis
5. Polycythaemia.
CAHS Guidelines - Jaundice
- Outline the Diagnostic Evaluation of Prolonged or Late Onset Jaundice (> 10-14 days)?
- 4 Causes of prolonged or late-onset jaundice?
- 6 Causes of jaundice characterised by either conjugated hyperbilirubinemia or mixed conjugated and unconjugated hyperbilirubinemia?
Prolonged or Late Onset Jaundice (> 10-14 days):
Jaundice in which the onset is relatively late (i.e., > 10 days), or is prolonged should be considered pathological until possible aetiological factors have been excluded. Unconjugated hyperbilirubinemia may occur in isolation, or in association with elevated conjugated bilirubin (e.g. idiopathic neonatal hepatitis, TORCH infections).
CAHS Guidelines - Jaundice
- How often should a newborn be assessed for jaundice?
- Which Rule can be useful to determine the severity of jaundice clinically?
- What should all infants in whom the severity of jaundice is in question have instead?
Clinical Assessment
- All newborns should be assessed at least every 12 hours for jaundice.
- Appearance and progression tends to occur in a cephalo-caudal manner.
- Kramer’s Rule provides a mechanism for the clinical assessment of jaundice severity by the proportion of the skin involved. Whilst this provides a useful guide, visual estimation of jaundice severity is prone to error, and is particularly difficult in darkly pigmented infants.
- All infants in whom the severity of jaundice is in question, especially those with risk factors, should have a transcutaneous bilirubin or serum bilirubin measurement performed.
CAHS Guidelines - Jaundice
- Which 8 Investigations should be performed for Infants at a child at HIGH RISK for early/aggressive jaundice?
Infants at HIGH RISK for early/ aggressive jaundice
- Infants at high risk for early and / or aggressive jaundice include those with raised antibody titres to red cell antigens, especially Rhesus and some minor group antigens.
- Women who are Rh(-) or in whom red cell antibodies have been detected have generally been monitored during pregnancy. Repeated titre results may be available.
- In severe cases of Rhesus isoimmunisation, intra-uterine blood transfusion may have been administered. These infants are at increased risk for unconjugated
hyperbilirubinaemia.
CAHS Guidelines - Jaundice
- Which Investigations should be performed for Infants with risk factors for non-physiological or jaundice potentially resistant to phototherapy?
CAHS Guidelines - Jaundice
- Which Investigations should be performed for Infants at risk of G6PD deficiency?
- 5 Instances when G6PD enzyme level should be tested for in infants?
G6PD enzyme level should be tested for when:
1. response to phototherapy is poor
2. SBR levels are very high
3. haemolysis is suspected
4. there is a relevant family history
5. there is a relevant ethnic/geographic history
CAHS Guidelines - Jaundice
- What is a Transcutaneous Bilirubin (TcB) Measurement?
- Which infants get it?
- When does it become unreliable?
Transcutaneous Bilirubin (TcB) Measurement
- Transcutaneous measurement of bilirubin in this hospital uses a JM-103 bilirubinometer. TcB measurements may be performed as an initial screen for jaundice in the well, term or late preterm (>35 weeks) infant who is greater than 24 hours of age.
- Infants in whom jaundice presents less than 24 hours of age, or where other risk factors are present (e.g. preterm, maternal antibodies, possible sepsis, G6PD risk, etc.) should have an SBR performed in the first instance.
CAHS Guidelines - Jaundice
- Outline the management of Infants with Aggressive/Haemolytic Jaundice?
CAHS Guidelines - Jaundice
- Outline the management of Infants with Physiological Jaundice?
- Outline an approach to Jaundice in the Infant >35 Weeks Gestation?
Infants considered to have physiological jaundice, who are feeding appropriately and have weight loss within acceptable limits (i.e. less than 10% below birthweight) may be discharged without ongoing monitoring of SBR. Monitoring of skin colour, feeding, weight gain and lethargy should be performed by a Visiting Midwife (VMS) or Child Health Nurse.
CAHS Guidelines - Jaundice
- Outline the causes of neonatal jaundice?
PCH ED Guidelines -Neonatal Jaundice
- Background?
- 5 Key points?
PCH ED Guidelines -Neonatal Jaundice
- 6 Maternal Risk factors for neonatal jaundice?
- 7 Neonatal risk factors?
PCH ED Guidelines -Neonatal Jaundice
- 6 Red flags for pathological jaundice?
- 7 Features to ask on history?
- 5 Clinical Features on examination?
Red flags for pathological jaundice
1. Jaundice that occurs in the first 24 hours of life
2. Associated anaemia and hepatomegaly
3. Rapidly rising total serum bilirubin (> 85 micromol/L per day)
4. Elevated conjugated bilirubin level > 10% total serum bilirubin, or >20micromol/L – neonatal cholestasis (e.g. biliary atresia)
5. Prolonged jaundice > 14 days in term, >21 days in preterm infants.1,2
6. Notably, 10% of breastfed babies are still jaundiced at 1 month, but breastmilk jaundice remains a diagnosis of exclusion.
PCH ED Guidelines -Neonatal Jaundice
- 10 Initial ED investigations?
- Overview of initial investigations and management of neonatal jaundice in an Unwell, Well Neonate, those with Conjugated hyperbilirubinaemia?
Initial ED investigations
1. Transcutaneous biliometry (TcB) (if available) for immediate estimate of bilirubin. Very difficult to assess level of jaundice by eye alone.
2. Serum Bilirubin (SBR) conjugated and unconjugated
3. Blood group if not previously done
4. Direct Coombs if not previously done
4. Full Blood Count (FBC) (add reticulocyte count if anaemic)
5. Liver Function Tests (LFTs) + albumin
6. Urine culture
7. + / - Thyroid Function Test (TFT) (check if infant has had normal neonatal screening)
8. +/- Glucose-6-phosphate -dehydrogenase deficiency (G6PD)
9. +/- Urine for reducing substances
PCH ED Guidelines -Neonatal Jaundice
- Outline the use of Phototherapy in the management of neonatal jaundice?
Management - Phototherapy
- Plot SBR level on graph below.
- Admit for phototherapy if bilirubin level is over the line as per the graph.
- If significantly above the treatment line consider possibility of requiring exchange transfusion. Plot on exchange graph and consult early with neonatology/intensive care.
- Phototherapy should be commenced in the Emergency Department if there is a delay in transfer to an inpatient ward.
PCH ED Guidelines -Neonatal Jaundice
- What is Breast Milk Jaundice?
- Disposition?
Breast milk jaundice
- Breast milk jaundice is common and is a diagnosis of exclusion.
- Breast milk jaundice usually appears between day 5-10, the infant is generally thriving, and no intervention is required.
- Breast feeding should continue to be encouraged and supported. Breast milk jaundice may last 3-12 weeks.
CAHS Guidelines - Gastro-Oesophageal Reflux
- Background - What is GORD?
CAHS Guidelines - Gastro-Oesophageal Reflux
- How does GORD present in an infant? (7)
CAHS Guidelines - Gastro-Oesophageal Reflux
- Investigation and Diagnosis?
CAHS Guidelines - Gastro-Oesophageal Reflux
- Barium Swallow Study?
- The 24-hour pH study?
- Endoscopy, manometry & radionuclide milk scans?
Barium Swallow Study - There is insufficient evidence to support the use of a barium contrast study or Ultrasonography for the primary diagnosis of GORD in infants and children. Contrast studies are useful to rule out other structural problems.
The 24-hour pH study - pH probe measurements or multichannel intra-oesophageal impedance may provide
information about the quantity and character of reflux. However, those events do not correlate well with clinical symptoms.
Endoscopy, manometry & radionuclide milk scans - Rarely required in a neonatal setting.
CAHS Guidelines - Gastro-Oesophageal Reflux
- Outline the management of GORD in children?
- 4 Feeding/Sleeping changes?
- Use of Prokinetic agents?
- Use of Sodium alginate preparations?
- Use of Trans pyloric tube feeds?
- Use of Fundoplication?
- Use of PPIs?
- Prokinetic agents should not be used in GOR. Many studies have failed to show any clear benefit in the neonatal population. Prokinetic agents have the
potential for significant adverse effects. - Erythromycin is associated with a higher risk of infantile pyloric stenosis and cardiac arrhythmia.
- Domperidone and Metoclopramide have been associated with neurologic side effects.
- Sodium alginate preparations have been found to be effective in decreasing the number of GOR events. However, the long-term safety of these agents in preterm infants is not known.
- Trans pyloric tube feeds have occasionally been useful in the interim for neonates with other conditions who can’t tolerate feeds due to significant GOR.
CAHS Guidelines - Gastro-Oesophageal Reflux
- Use of Feed thickeners?
- Algorithm for Using Guar Gum-Based Thickener (Supercol) to thicken breast milk and formulas for Neonates <44 weeks Gestation?
- In KEMH NICU and PCH NICU (3B), minimal amounts of a guar gum thickening agent can be used to thicken breast milk, term formula and infant
formulas used for medical nutrition therapy. Two levels of guar-gum thickened feeds are available.
1. Half Thick (0.1% Supercol) should be considered as first option if clinically indicated and ordered by the neonatologist.
2. Level 1 Thick (0.27% Supercol)
BetterHealth Victoria - Vomiting in Neonates
- List 11 instances when vomiting in a neonate may be clinically significant?
Vomiting may be clinically significant if:
1. vomit contains blood (red or black, the colour of the blood will depend upon how long the blood has been in the stomach)
2. the vomit is bile (green, not yellow)
3. the baby is projectile vomiting
4. the baby is unwell
5. the baby is failing to thrive
6. the baby has gastrooesophageal reflux and could be aspirating
7. the baby also has diarrhoea
8. the abdomen is distended
9. delay in passage of meconium
10. the baby is dehydrated (dry mouth,
11. decreased wet nappies, hypotonic).
BetterHealth Victoria - Vomiting in Neonates
- What type of vomit is this in a neonate?
If none of the above clinical scenarios apply, the vomiting is unlikely to be clinically significant. Small, frequent vomits are referred to as ‘possets’. In a breastfed baby a small amount of yellow vomiting as opposed to (lime) green vomiting may be due to colostrum rather than bile and is usually benign if the amount and frequency are small.
BetterHealth Victoria - Vomiting in Neonates
- What is the most common cause. of blood containing vomit in a neonate?
- Blood swallowed during birth normal?
- Should we be concerned about Blood swallowed during breastfeeding?
Vomit contains blood -The commonest cause of vomit containing blood is swallowed maternal blood. Swallowed blood often irritates the stomach and causes vomiting. Blood may be swallowed during: birth or breastfeeding.
Blood swallowed during birth
- No birth is bloodless, whether vaginal or Caesarean, and hence there is the opportunity to swallow blood at birth.
- However, the largest amount of blood will be swallowed if there is an antepartum haemorrhage associated with bleeding into the amniotic fluid for at least several hours before birth. This blood may then take several days after birth to clear the gastrointestinal tract (GIT).
- Under these circumstances, as well as vomiting blood, the baby may pass malaena stools, rather than meconium.
BetterHealth Victoria - Vomiting in Neonates
- Other than blood swallowed during birth or breastfeeding, what are 2 other causes of bloody vomit in neonate?
Baby is bleeding - Less commonly, the baby is bleeding. Causes may include:
1. Haemorrhagic disease of the newborn (HDN) - this rarely occurs with adequate vitamin K prophylaxis. Babies whose mothers have been taking medications that interfere with vitamin K metabolism (such as anticonvulsants or oral anticoagulants) or babies with liver disease or consumption of clotting factors are at higher risk.
2. Stress ulceration - babies who are very sick can have stress ulceration of the stomach, as can those treated with drugs such as corticosteroids and indomethacin.
BetterHealth Victoria - Vomiting in Neonates
- What should you immediately suspect if a child is vomiting green bile? 3 Causes?
- 3 other signs of obstruction?
- 2 findings on supine abdominal x-ray?
- Treatment of bowel obstruction?
Look for other signs of obstruction
- Other signs of obstruction, including bloody diarrhoea, abdominal distention and imperforate anus should be sought. The anus should be carefully inspected for patency to rule this out.
- A supine abdominal x-ray will usually reveal an abnormal gas pattern, for example:
1. paucity of gas and distention of the stomach and proximal duodenum in volvulus
2. more gaseous distention with lower obstructions and a lateral decubitus x-ray will reveal fluid levels.
BetterHealth Victoria - Vomiting in Neonates
- What 2 differentials should you consider in a child with projectile vomiting?
- When do children with Pyloric stenosis usually present?
- What type of metabolic derangement is often associated with Pyloric stenosis?
- Commonest cause of duodenal obstruction? Which syndrome is it associtated with?
- Classical abdominal xray sign of duodenal atresia?
Consider pyloric stenosis
- Pyloric stenosis usually presents at two to six weeks of age after most babies have been discharged home, rarely presenting after 12 weeks.
- However, it occasionally occurs in the convalescing preterm infant before discharge home.
- Ultrasound will often help to make the diagnosis.
- The baby will often have a hypochloraemic metabolic alkalosis.
BetterHealth Victoria - Vomiting in Neonates
- 6 Differentials to consider in an unwell baby that is vomiting?
- 3 Helpful clues?
If an unwell baby is vomiting, consider:
1. infection
2. inborn errors of metabolism (urea cycle disorders)
3. congenital adrenal hyperplasia
4. oesophageal atresia
5. tracheo-oesophageal fistula
6. imperforate anus.
Helpful clues include:
1. Other signs of sepsis (including NEC) excessive weight loss (including dehydration)
2. Disordered conscious state
3. Metabolic derangements, including: Metabolic acidosis and electrolyte disturbances (high potassium and low sodium in congenital adrenal hyperplasia).
BetterHealth Victoria - Vomiting in Neonates
- 3 Causes of Vomiting with failure to thrive?
- 7 Characteristics of GOR in neonates?
- Treatment of GOR in neonates?
Vomiting with failure to thrive - Causes
1. Gastro-oesophageal reflux (GOR)
2. Sepsis
3. Inborn errors of metabolism.
Treatment of GOR: Treatment includes thickening the baby’s feeds; smaller, more frequent feeds; minimal handling after feeds.
BetterHealth Victoria - Vomiting in Neonates
- 6 Issues to note about vomiting that causes choking in neonates?
- Why is Gastroenteritis is less common during primary hospitalisation? (3)
Gastroenteritis is less common during primary hospitalisation due to:
1. Higher breastfeeding rates
2. More rooming-in (less care of babies in communal nurseries, where infectious agents such as rotavirus can spread easily) hand hygiene practices.
3. Gastroenteritis can, however, still cause vomiting and diarrhoea in newborn infants leading to dehydration and shock if unrecognised or treated.
CAHS Guidelines - Inguinal Hernia: Non-Strangulated and Strangulated
- What is a Non-Strangulated (Non-Obstructed) Inguinal Hernia?
- Clinical Presentation in children?
- Differential dianosis?
Non-Strangulated (Non-Obstructed) Inguinal Hernia
Inguinal hernia repair is the most common operation performed on premature infants. If it is easily reducible and causing no other problems, it is recommended that it is operated on shortly before the infant’s discharge home.
CAHS Guidelines - Inguinal Hernia: Non-Strangulated and Strangulated
- Outline the Management of Non-Strangulated (Non-Obstructed) Inguinal Hernia in Children?
CAHS Guidelines - Inguinal Hernia: Non-Strangulated and Strangulated
- What is a Strangulated (Obstructed) Inguinal Hernia?
- Clinical Presentation in a child? (4)
- Management?
Strangulated (Obstructed) Inguinal Hernia - A loop of small bowel becomes trapped in the hernial sac. Early reduction is important to
save the trapped bowel and also the testis on the same side. The testicular vessels can be severely comprised by a tense hernia in infants.
Clinical Presentation
1. Inconsolable crying and a lump in the inguinal region.
2. The lump is often tense, tender and not reducible.
3. There may be vomiting and abdominal distension.
4. The infant may deteriorate so careful monitoring and prompt intervention is
necessary.
CAHS Guidelines - Inguinal Hernia: Non-Strangulated and Strangulated
- Pain relief suggested for management of Inguinal hernia in a child?
- Changes to Feeding?
- Outline the Pre-Operative Care (3), Post-Operative Care (5), and Wound Care Management of a Strangulated (Obstructed) Inguinal Hernia in a child?
Pre-Operative Care
1. Routine Pre-Operative Care.
2. Insert peripheral IV to assist with pre anaesthetic care.
3. Fast 4 hours from formula and 3 hours EBM.
Post-Operative Care - Routine Post-Operative Care on return from theatre, include:
1. Full cardiac and oxygen saturation monitoring for 24 hours.
2. Hourly temperature for 4 hours or until stable, then 4 hourly.
3. Hourly blood pressure for 4 hours or until stable, then 4 hourly.
4. Blood gas on return from theatre, thereafter as per medical orders.
5. After 24 hours observation should be according to the infant’s general condition.
CAHS Guidelines - Testes Assessment
- What is the Risk if undescended testes are not detected and treated effectively?
- What is UDT? How does it occur?
- Epidemiology?
Risk - If undescended testes (UDT) are not detected and treated effectively, there is an increased risk of subfertility and testicular malignancy.
CAHS Guidelines - Testes Assessment
- List 5 Risk factors for congenital UDT?
- What is the optimal time for detection and surgical correction of UDT?
Risk factors for congenital UDT include:
1. Prematurity
2. Low birth weight for gestational age
3. Family history
4. Maternal tobacco use
5. Placental insufficiency.
CAHS Guidelines - Testes Assessment
- Outine the procedure for clinically examining a baby/infant for UDT?
CAHS Guidelines - Testes Assessment
- Which children should be referred to a medical practitioner after clinical examination for UDT?
- Process?
CAHS Guidelines - Testes Assessment
Define the following:
1. Maldescended testis?
2. Undescended testis (UDT)?
3. Acquired Undescended Testes? Optimum time for orchidopexy?
Maldescended testis - This term refers to any abnormality in testicular descent that is not a normal variant.
CAHS Guidelines - Testes Assessment
Define the following:
1. Retractile Testes?
2. Impalpable testis?
3. Bilateral non-palpable testes?
4. Testicular Torsion?
5. Hydrocele?
Testicular torsion
- Testicular torsion is a rotation of the testis with resultant strangulation of its blood supply. It most commonly occurs in infancy and between 12 and 18 years of age and affects the left testis more often than the right.
- Symptoms include acute scrotal pain and swelling, nausea and vomiting, followed by scrotal oedema.
- Acute scrotal pain requires urgent surgical review.
Hydrocele
- A hydrocele is a non-tender, soft, fluctuant scrotal swelling commonly found in infants (congenital) although in may develop later (acquired). Most congenital hydroceles will resolve spontaneously within the first two years of life, without intervention. Refer if hydrocele:
- is causing pain or enlarging, OR
- is still present after 2 years of age.
PCH ED Guidelines - Acute Abdominal Pain
- Definition?
- Background?
- 7 Features that may suggest a serious underlying cause?
- Assessment?
Abdominal pain is a symptom and can be due to numerous underlying aetiologies across many different organ systems.
Features that may suggest a serious underlying cause:
1. Increasing severity of pain, pain becoming constant, inconsolable infants.
2. Re-presentation to hospital.
3. Requiring opiate analgesia.
4. Localised pain in the abdomen.
5. Signs of peritonism.
6. Associated shock.
7. Any vomiting.
PCH ED Guidelines - Acute Abdominal Pain
- 19 Features on History?
- 13 Features on Examination?
PCH ED Guidelines - Acute Abdominal Pain
- 10 Investigations to consider and their possible indications?
PCH ED Guidelines - Acute Abdominal Pain
- Differential diagnosis: conditions causing abdominal pain in children of varying ages?
- Management - Should you give analgesia?
Management - Always give analgesia - this will not mask the underlying cause.
PCH ED Guidelines - Acute Abdominal Pain
- Initial Management?
- 10 Reasons to Consider a surgical consultation?
PCH ED Guidelines - Chronic/Recurrent Abdominal Pain
- Initial Management?
- 10 Reasons to Consider a surgical consultation?
- 4 Pre-referral Investigations?
- Pre-referral management?
- When to refer?
- How to refer?
- Chronic /recurrent abdominal pain is common, affecting up to 10% of all children.1,2,3 In the majority of cases, it gets better with time and without any specific treatment.
- Features that suggest a more sinister cause include: pain consistently waking the child from sleep, weight loss, significant vomiting or diarrhoea, blood in stools.
Pre-referral investigations
1. FBC, ESR, CRP, U&E’s, LFT
2. Coeliac serology
2. Urine MC&S
3. Stool MC&S, virology, parasites/ oocytes
4. Consider checking lipase and/or H Pylori urea breath test/ (NB positive serology does not indicate active infection)
PCH ED Guidelines - Appendicitis
- What is it?
- History - Typical progression of symptoms? (6)
- 8 Features on Examination?
- What is the Rovsing sign?
- What is the Psoas sign?
- What is the Obturator sign?
History - The “classic” progression of symptoms is:
1. loss of appetite
2. dull periumbilical pain followed by
3. nausea
4. migration of the pain to the right iliac fossa (RIF)
5. vomiting
6. occasionally loose stools and fever
However, very young children with appendicitis may lack this history of progression and migration of pain and have a tendency towards early perforation and systemic illness. This finding also applies to those with communication difficulties such as autism and developmental delay.
Likewise, the differential diagnostic possibilities are increased in the adolescent female who has started menses.
PCH ED Guidelines - Appendicitis
- 5 Investigations?
PCH ED Guidelines - Appendicitis
- Initial Management?
- Further Management?
PCH ED Guidelines - Cervical lymphadenitis
- Are palpable cervical LNs always pathologicals in children?
- 8 Features to look for on Clinical Examination?
- Enlarged lymph node in the neck.
- Cervical lymph nodes (LN) are commonly palpable in children even if not unwell.
- Can be reactive, or infective: caused by viruses and bacteria.
- May be tender and inflamed.
PCH ED Guidelines - Cervical lymphadenitis
- When are investigations indicated? Which ones would you perform?
- What is a Reactive lymph node (LN) and how is it managed?
- What is Acute bacterial cervical lymphadenitis and how is it managed?
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.
- Full blood count, C-Reactive Protein (CRP) and blood cultures are indicated in the unwell or septic appearing child.
- Refer to Sepsis Recognition and Management (ED Guidelines).
- Ultrasound may be considered if atypical or clinical doubt about drainable collection.
PCH ED Guidelines - Balanitis
- What is it? Definition?
- 2 Features on Assessment?
- Investigations required?
- 1 Differential?
- Management - if the patient is able to void urine? Which 2 Abs? (4)
- Management - if the patient is unable to void urine? (6)
Definition - Balanitis is an irritation and inflammation of the foreskin and glans, often associated with poor hygiene. There is usually an infective component to the condition, and there may be an associated nappy rash.
Assessment
- Mild to severe swelling of the foreskin and glans.
- Erythema
Investigations - No investigations are required.
Differential diagnoses - Paraphimosis
PCH ED Guidelines - Constipation
- Bristol Stool Chart?
- What is it? Definition?
- Most common cause in children?
- 6 Ways it may present in children?
- Normal Stool Pattern for a child?
- Constipation is a symptom not a disease. Constipation refers to infrequent bowel movements or hard to pass faeces.
- Constipation in children is most commonly due to a functional cause (95%).
- Although rare, some causes of constipation are potentially life threatening.
Constipation can present as:
1. History of infrequent stools (< 3 stools per week)
2. Large and/or hard stool associated with painful defaecation
3. Intermittent abdominal pain
4. Incomplete evacuation of rectal content
5. Involuntary soiling
6. Inability to pass stool.
PCH ED Guidelines - Constipation
- 8 Features to question about on History?
- 6 Features to consider on examination?
History
1. Delayed passage of meconium for more than 48 hours.
2. Constipation present from birth or early infancy.
3. Failure to thrive, significant weight loss.
4. Abdominal distention, bilious vomit or ileus.
5. Child is systemically unwell, fever, vomiting.
6. Fatigue, polyuria, polydipsia
7. Urinary incontinence
8. Extraintestinal symptoms.
PCH ED Guidelines - Constipation
- Management?
- Risks in Management?
- Disimpaction?
- Rectal disimpaction with glycerol?
Disimpaction
- The oral approach to disimpaction is not invasive and gives a sense of power to the child, but adherence to the treatment regimen may be a problem.
- The rectal approach to disimpaction is faster but is invasive.
- The oral and rectal approach may both be required.
- The choice of treatment is best determined after discussing the options with the Emergency Department Senior Doctor and the family.
- Ensure the patient is provided with a Constipation Management Plan, completed using the information below.
PCH ED Guidelines - Constipation
- Role of Enemas in the mangement of constipation in a child?
- 2 Types/Formulas?
PCH ED Guidelines - Constipation
- Oral Disimpaction?
- When would you add a stimulant laxative?
- Movicol Junior dosage for disimpaction?
- Movicol Adult strength dosage?
Oral disimpaction
- Macrogol-containing products (available as Movicol®, Macrovic® and many other brands) are the recommended laxative.
- Movicol® Adult (13.125g of Macrogol 3350 per sachet) is equivalent to two Movicol Junior® sachets.
- Palatability is improved by adding flavour e.g. cordial
- Disimpaction usually takes 3-5 days but may take longer. If taking longer than 7 days, continue with day 7 dose until disimpaction occurs.
- Add a stimulant laxative after 2 weeks if disimpaction has not been achieved.
- Stop once disimpaction occurs and then commence maintenance dose.
PCH ED Guidelines - Constipation
- When would you consider admission for oral or nasogastric colonic lavage?
PCH ED Guidelines - Constipation
- Maintenance Treatment?
- Osmotic Agents? (3)
- Stool softeners? (2)
Maintenance Treatment
First Line Laxative treatment
- Children < 2 years, stool softener and/or osmotic laxative
- Children > 2 years, osmotic laxative
- A macrogol-based preparation (such as Movicol®) is the recommended laxative.
- Long term treatment needs to be under the supervision of the child’s local doctor.
PCH ED Guidelines - Intussusception
- What is it? Definition?
- Where does it most commonly occur?
- Peak age?
- 4 Complications?
- 5 Features to ask about on History?
- Intussusception occurs when a section of bowel invaginates into the lumen of the immediately distal bowel, resulting in ischaemia and gangrene of the inner bowel.
- It most commonly occurs at the ileocaecal junction.
- Peak age 5-10 months (may occur from 3 months to 5 year old)
- Most common cause of acute intestinal obstruction in children 6-36 months
- 60% of cases are < 1 year old and 80-90% are < 2 year old.
Complications
1. Perforation of bowel, with peritonitis
2. Necrosis of bowel requiring bowel resection
3. Shock and sepsis
4. Re-intussusception after spontaneous or active reduction.
PCH ED Guidelines - Intussusception
- How may the child present? (6)
- 3 Types of Investigations? Diagnostic investigation of choice?
- Classic sign on US?
- 4 Signs of intussusception on Abdo Xray?
The child can present as:
1. Pale, lethargic and hypovolemic
2. Abdomen may be distended and tender
3. Palpable abdominal mass (sausage shaped) in the right upper quadrant.
4. Dehydration or shock develops as symptoms progress.
5. Vomiting (may become bile-stained if bowel obstruction has occurred)
6. ‘Red currant jelly’ stool (blood and mucous in stool) is a late sign.
PCH ED Guidelines - Intussusception
- Outline the management?
PCH ED Guidelines - Inguinal Hernia
- How may it present in a male?
- Incidence?
- Assessment?
- Inguinal hernias may present in children of any gender and may present insidiously or as an emergency.
- Any acute swelling or pain of the scrotum warrants urgent review by a surgeon since torsion of the testis and incarcerated hernia are both surgical emergencies.
Incidence
- Ranges between 1-5%
- Incidence is higher in premature infants: 15-25%.
- Boys are affected 9 times more than girls.
- Right sided predominance is well established (60% vs 30%).
- 10% are bilateral in full term infants and nearly 50% in premature & low-birth-weight infants.
PCH ED Guidelines - Inguinal Hernia
- What is the management if the bowel is compromised?
- What is the management if the bowel is not compromised and the child is less than one month of age?
- What is the management if the bowel is not compromised and the child is greater than one month of age?
PCH ED Guidelines - Pyloric stenosis
- In which patients should you suspect pyloric stenosis?
- Typical age range?
- Incidence?
- % of male cases?
- Assessment?
- 4 Features on history?
- Hypertrophic pyloric stenosis should be suspected in infants 3 to 6 weeks old with non-bilious vomiting after meals.
- Projectile vomiting is not always present.
- The typical age range is 3 to 6 weeks of age, but it is rare less than 10 days old and greater than 11 weeks
- The incidence is 1:450
- Males account for 85% of cases.
PCH ED Guidelines - Pyloric stenosis
- 3 Features on Clinical Examination?
- 5 Investiations?
- What will a VBG show?
- US findings?
- 5 Differential diagnoses?
Investigations
1. Venous blood gas (VBG) - shows a metabolic alkalosis (hypochloraemic, hypokalemic, hyponatraemic alkalosis) in those with metabolic derangement.
2. U&Es
3. FBC
4. BGL
5. Abdominal ultrasound will usually confirm the diagnosis. Where this is not readily available, plain abdominal films may show the ‘single bubble’ of gastric dilatation (with little or no air beyond the pylorus) although this is not routinely done.
PCH ED Guidelines - Pyloric stenosis
- Initial & Further Management?
PCH ED Guidelines - Nephrotic Syndrome Management
- Define: Nephrotic Syndrome (NS)?
- Define: Complete remission of NS?
- Define: Relapse of NS?
PCH ED Guidelines - Nephrotic Syndrome Management
- Define: Nephrotic Syndrome (NS)?
- Define: Complete remission of NS?
- Define: Relapse of NS?
- Risks of failing to diagnose?
- Risk of side effects of tx?
- What is the treatment? How long?
Risks
- Delays in recognition and initiation of treatment can place children at increased risk of developing a life-threatening infection which remains the leading cause of mortality in children with NS, currently at around 3%.
- The effects of treatment itself can place children at risk for adverse outcomes if not appropriately and carefully managed. Prolonged use of high dose corticosteroids has well known side effects including immunosuppression, increasing the risk of infection; cataracts; and osteoporosis.
- A standardised approach and rationalised corticosteroid regimen aims to minimise these risks.
PCH ED Guidelines - Nephrotic Syndrome Management
- 6 things you need to assess for?
PCH ED Guidelines - Nephrotic Syndrome Management
- 10 Investigations?
- When would you consider imaging?
PCH ED Guidelines - Nephrotic Syndrome Management
- General Ward Management?
- Restrict fluids whilst in nephrotic state?
- Which additional vaccinations do children with nephrotic syndrome require? When?
PCH ED Guidelines - Nephrotic Syndrome Management
- First presentation Treatment Protocol? (3 components)
- Relapse treatment protocol?
PCH ED Guidelines - Nephrotic Syndrome Management
- Managing acute complications - Hypovolaemia / Severe Oedema?
- Hypertension?
PCH ED Guidelines - Nephrotic Syndrome Management
- When should a referral to a paediatric nephrologist should be made?
- 3 Atypical signs and symptoms?
- 4 Extra-renal symptoms?
PCH ED Guidelines - Nephrotic Syndrome Management
- Discharge planning & Education?
- Outpatient schedule?
- Which side effect of treatment needs to be monitored? By who?
Ophthalmology
- There is risk of developing cataracts with prolonged, repeat dosing of corticosteroids.
- Children who have two or more relapses in one year should be referred for an ophthalmology assessment.
PCH ED Guidelines - Urinary tract infection
- What is a UTI? Definition?
- UTI Management flowchart - Infant <3months vs. >3months?
- Urinary tract infection (UTI) refers to a bacterial infection in the bladder (cystitis), or kidneys and ureters (pyelonephritis).
- Urinary tract infections in childhood are common and can be potentially serious in the first few years of life.
- The diagnosis of UTI should be considered in all febrile infants and young children, and in all infants with fever without focus.
PCH ED Guidelines - Urinary tract infection
- Assessement?
- How to collect the urine for MC&S?
- 6 Features on history?
History
1. Fever may be present, particularly fever without apparent source.
2. Irritability
3. Poor feeding
4. Vomiting
5. Jaundice (in neonates)
6. In older children symptoms can include dysuria, urinary frequency, and urinary incontinence.
PCH ED Guidelines - Urinary tract infection
- 6 Investigations - Birth to 3 Months of Age?
- Investigations - >3 Months of Age & Unwell? Well?
PCH ED Guidelines - Urinary tract infection
- Management - Birth to 3 Months of Age?
- Management - >3 Months of Age & Unwell? Well?
PCH ED Guidelines - Urinary tract infection
- Oral antibiotic choices for patients ≥ 3 months old who are being discharged from the emergency department (e.g. are systemically well)?
- Intravenous antibiotic choices for children being admitted to hospital?
- Which children should have a renal tract ultrasound after discharge from ED? (4)
The following children should have a renal tract ultrasound after discharge from ED:
1. Less than 3 years old with a first UTI
2. Recurrent UTIs
3. Atypical organism (e.g. Pseudomonas)
4. Not responding to 48 hours of appropriate antibiotics
PCH ED Guidelines - Urinary tract infection
- When is a Renal Tract Ultrasound (US) warranted for children less than 3 years of age?
- When is a Renal Tract Ultrasound (US) warranted for children older than 3 years of age?
- What is a Micturating Cystourethrogram (MCUG) and when would you consider ordering one?
PCH ED Guidelines - Urinary tract infection
- What is a Dimercaptosuccinic Acid Scan (DMSA scan) and when would you consider ordering one?
- What is a Mercaptoacetyltriglycine scan (MAG 3 scan) or Diethylene Triamine Pentacaetic Acid scan (DTPA scan) and when would you consider ordering one?
PCH ED Guidelines - Vulvovaginitis
- What is it? Definition?
- How common is it?
- Causal factors of non-specific vulvovaginitis in prepubertal child?
- 3 Signs & 3 Symptoms?
- Vulvovaginitis is the general term which refers to many types of vaginal/vulva inflammation or infection.
- In prepubertal girls usually 2-8 years, non-specific vulvovaginitis is responsible for 25-75% of vulvovaginitis.
Causal factors of non-specific vulvovaginitis in prepubertal child:
1. Unoestrogenised thin vaginal mucosa with lack of labial development.
2. More alkaline pH (pH 7) than post-menarchal girls.
3. Moisture to area (aggravated by synthetic fibre underwear, tight clothing, wet bathers, obesity, poor hygiene).
4. Irritants (e.g. bubble baths, shampoos, soaps, antiseptics).
PCH ED Guidelines - Vulvovaginitis
- Examination?
- Investigations?
- 8 Differentials?
Differential diagnosis - If persistent, offensive or bloody discharge, consider the following:
1. Threadworm - if pruritus (vulval and/or perianal) is prominent especially at night.
2. Foreign body - if chronic vaginal discharge, intermittent bleeding, offensive odour. Toilet paper commonest foreign body. Refer to paediatric gynaecologist as required.
3. Specific organisms if discharge is profuse/offensive take an introital swab.
PCH ED Guidelines - Vulvovaginitis
- Management?
List 5 Key Points regarding UTIs in children?
- PAED UTI - Definition & classification?
PAED UTI - TAKE HOME MESSAGES
1. Paed UTI is common, do URINALYSIS on ALL febrile infants and all febrile children (and send for MCS) where you’re unsure of the source.
2. DO NOT USE Urine bags to diagnose UTI - high false positive rate.
3. Resistance to amoxycillin common - use something else when commencing empirical antibiotic (refine once sensitivities known)
4. Consider other sites of infection - especially in young infants (eg meninges)
5. Children less than 3y should get renal tract USS after first UTI, and selected children >3y
Paediatric UTI
- Epidemiology?
- Which bacteria?
- History/Clinical presentation?
- 7.0% of febrile children <24m old
- possibly higher relative prevalence in uncircumcised boys
- 2% boys and 8% girls by 7y age
- E. coli was the most common uropathogen overall but the prevalence of E. coli was higher among females (83%) than males (50%, p <0.001).
- Other common species among males were: Enterococcus (17%), Proteus mirabilis (11%) and Klebsiella (10%). These uropathogens each accounted for 5% or less of female isolates (p <0.001).
Paediatric UTIs
- Diagnosis/Investigations?
- Suprapubic Aspirate Technique?
- ALWAYS GET A CLEAN URINE SAMPLE
- Clean Catch Urine (not toilet trained)
- Mid Stream Urine (toilet trained)
- Supra-Pubic Aspirate (<6m)
- Catheter Specimen Urine (any age)
- DO NOT USE URINE BAGS
A 3 month female presents with fever 38.5C and not feeding well. What is the best management to initiate?
Also oliguric. No previous history. Looks pale and seems irritable in a lethargic kind of way.
- A. Do bloods & wait
- B. Do bloods, MC&S, CSF, antibiotics – obviously septic child
- C. Do bloods, MC&S, CSF, wait
- D. Do bloods, MC&S, antibiotics
- E. Do bloods, MC&S, wait
= B. Do bloods, MC&S, CSF, antibiotics – obviously septic child
A 6 month male presents with T37.5C, malaise, and vomiting. What management?
- A. Bloods, Urine MC&S, Wait
- B. Bloods, Urine MC&S, Oral Abs
- C. Bloods, Urine MC&S, CSF, IV Abs
- D. Urine MC&S, Oral Abs, Review 24hrs
- E. Urine MC&S, observe inpatient
= not quite the septic picture (CSF not indicated)
B. Bloods, Urine MC&S, Oral Abs
OR
D. Urine MC&S, Oral Abs, Review 24hrs
18 month female 3/7 vomiting, mild pain and no fever. What management?
- A. MC&S, Oral Abs
- B. MC&S, IV Abs
- C. MC&S, USS, consider Abs – USS maybe at follow up but wouldn’t change the management in ED
- D. MC&S, bloods, USS, IV Abs
- E. MC&S, IM Cef stat. then PO Abs – not routine practice
A. MC&S, Oral Abs
3-year-old female acute onset of profuse vomiting. Fever 38.5C. What management?
Alert and grumpy with no neck stiffnesss, CR 2-3S. Intermittent tummy pain, soft abdomen with lots of bowel sounds.
- A. MC&S, Oral Abs
- B. Oral rehydration trial
- C. MC&S, bloods, CSF, observe.
- D. NG rapid rehydration – management of moderately dehydrated child with gastro in ED
- E. Bloods, MC&S, IV rehydration
= Gastroenteritis picture
B. Oral rehydration trial OR
D. NG rapid rehydration – management of moderately dehydrated child with gastro in ED
6-year-old female, previous UTIx3. Vomiting. Fever 39.7. Loin pain. What management?
- A. MC&S, bloods, Oral Abs
- B. MC&S, bloods, Wait
- C. MC&S, bloods, IV ABs
- D. MC&S, USS, bloods, IV ABs
- E. MC&S, IV ABs
= D. MC&S, USS, bloods, IV ABs
Diagnosis of Non-Organic Abdominal Pain in Children
- Definition?
- Rome IV Criteria?
- Sleep pattern?
Diagnosis of Non-Organic Abdominal Pain in Children - Definition
“At least 3 bouts of pain, severe enough to affect his/her activities over a period of not less than three months.
Sleep Pattern - Often worse on going to bed and keeps child from going to sleep BUT Rarely awakens from sleep.
List 5 Differentials for Chronic Abdominal Pain in a child other than a Functional Somatic Disorder.
- List 9 Warning Signs for an Organic cause of the pain?
Differentials – Minimal
1. Coeliac – varied presentation
2. Inflammatory bowel disease – Crohns/UC - unusual, but possible (more so in the adolescent child), often associated with weight loss
3. Constipation – more discomfort
4. Malignancy – very rare but not impossible
5. Infection transient – eg. Giardia
- Why are Functional Somatic Disorders a public health issue?
- Describe the Disability associated with functional symptoms
- Examples of Functional Somatic Syndromes by Specialty?
**Functional Somatic Symptoms **
- Are common and persistent.
- Associated with significant disability.
- Unnecessary expenditure of scare resources.
Functional symptoms – disability
* Emotional distress/disorder higher in patients with IBS than IBD
* Disability more marked in chronic fatigue than heart failure patients
* School absence in children with recurrent abdominal pain greater than IBD
Treatment of Chronic Abdominal Pain in Children?
- Ixs?
A 3 week old infant presents with acute lethargy, bilious (bright green) vomiting, and a lump in the groin to a regional Australian town. How would you manage a presentation like this?
Analysis: This is a neonate, and bilious vomiting implies serious obstructive aetiology. The lump in the groin probably insinuates an inguinal hernia, so this may well be an obstructed inguinal hernia. But it probably is worth being a bit careful, and consider a variety of causes of neonatal vomiting.
Answer: First, it is necessary to refine a diagnosis in order to manage this infant. The likely diagnosis is obstructed inguinal hernia, but alternative diagnoses may be considered depending on what other symptoms are in the history, and what else is found on physical examination:
Describe the management of chronic constipation in a 3 year old child, including the use of medications, compliance and follow up.
Analysis: Well, management, as usual, is a broad question which includes the processes of diagnostic refinement, as well as treatments, education, prognosis and follow-up. Diagnostic refinement needs to consider the age of the child. This is for a three year old, so the likelihood of this being a congenital constipation syndrome (Hirschprung, congenital megacolon) is very low/negligible, meaning the diagnosis is likely to be either functional constipation (most common) or slow transit constipation. The important (potentially disabling or life threatening) causes of constipation are rare and freaky e.g. pelvic tumour, lumbar spine malformation, neurological lesion could be considered if it is an infant or if there are other “red flags” on the history & examination. Management might also consider the need to differentiate the acute (i.e. disimpaction) phase from the maintenance phase of treatment.
Which investigations would be appropriate (assuming none had already been done) for an 8 year old who has had intermittent generalised abdominal pain for the past 4 months, resulting in missing school an average of 1 day per week?
a. Suggest some treatment options.
Analysis: This question is specifically asking about investigations. It’s a bit tricky because there is no other mention of further detail with regard to the history, and no description of the physical examination. You cannot really make a diagnosis informed comment about investigation, so the issue might rather be: what is the most likely cause of four months of abdominal pain. Evidently, it is not an acute problem, so it is unhelpful to consider the acute abdominal pain guidelines.
A 2 year old presents with a neck lump, present for several weeks. What range of conditions are important to consider?
Analysis: Two year olds are vulnerable to a range of intercurrent illnesses as they socialise more (compared with infancy) and are often still a little immune-naïve (potentially depending on whether they started daycare earlier). This question is about having a ready list of differentials when you meet a young child with a neck lump, which has not previously been there (ie. we can rule out congenital conditions).
A neonate is examined as part of a routine post-natal discharge check. It is noted to have bilaterally non-palpable testes. What is the range of diagnoses a clinician should consider, and are there any investigations necessary to refine the diagnosis?
- What is the treatment for any infant <3mo with suspected UTI?
- What is the treatment for any infant >3mo with suspected UTI?
- All infants <3m with suspected UTI should be admitted for IV antibiotics - amoxycillin + gentamicin
- Consider sepsis and meningitis in young infants (<3m) – strongly consider lumbar puncture and blood culture
Clinical Imaging pathway for Paediatric UTI:
- First episode?
- Recurrent/Atypical UTI?
- All children with first UTI aged <3years should have renal tract USS
- Children >3years should only have renal tract USS if recurrent, atypical features or not responding to treatment
- Strongly consider inpatient ultrasound if seriously unwell, not responding to treatment or in males <3m
- Further imaging is decided on clinical suspicion based on US, recurrent/ atypical UTI, age or family history of vesico-ureteric reflux (VUR)
What does this USS show?
- Right: Severe VUR with filling of a grossly dilated and tortuous right ureter.
- These appearance are consistent with Grade V reflux.
- Left: filling of a non-distended renal collecting system with normal appearing calyces. Early tortuosity of left ureter.
- The bladder contour is within normal limits.
PAED UTI - how to manage – follow-up?
