Paediatrics revision slides

Paediatrics revision slides
Chris Mayo and Henry Greenslade The Peer Teaching Society is not liable for false or misleading information…

Things to cover Neonatal stuff Congenital conditions (incl. cardiac)
Respiratory MSK Infections GI The Peer Teaching Society is not liable for false or misleading information…

Case 1 Jack is a one-day old neonate who is admitted to NICU after he was born prematurely at 27 weeks of age. What problems can premature babies develop? The Peer Teaching Society is not liable for false or misleading information…

Neonatal problems Respiratory distress syndrome Jaundice
Necrotising enterocolitis Patent ductus arteriosus Brain injury Hypothermia Nutritional issues And lots more… The Peer Teaching Society is not liable for false or misleading information…

Respiratory distress syndrome
What is the pathophysiology of RDS? Not enough surfactant = alveolar collapse You are looking after a pregnant woman who is likely to give birth prematurely – what drug can you give to a) mother and b) the child? a) corticosteroids b) surfactant (intratracheal) What is a possible complication of RDS? Pneumothorax, chronic lung disease also - transient tachypnoea of the newborn - typically too much fluid in the lungs - c-section is a risk factor Not enough surfactant production - starts from about 20 weeks and increases - even babies born at 31 weeks have a 50% risk of RDS Signs of RDS include tachypnoea, intercostal recession, nasal flaring, tracheal tug The Peer Teaching Society is not liable for false or misleading information…

Jaundice – key points Any jaundice that occurs <24 hours post birth is abnormal – e.g. haemolysis, infection After 24h = normal, dehydration, breast milk, bruising, bile duct obstruction, neonatal hepatitis Investigation? What complication are we looking to avoid? Name two treatments and how we decide who needs them? Jaundice is common - 50% of all neonates - due to liver immaturity and increased RBC breakdown The Peer Teaching Society is not liable for false or misleading information…

NICE clinical guideline 98 - Jaundice in newborn babies under 28 days
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A quick bit on NEC Bacterial invasion of ischaemic bowel wall
Typically seen in premature infants Vomiting, poor feeding, distended abdomen, blood in stool May progress to shock, perforation IV antibiotics, TPN, ITU The Peer Teaching Society is not liable for false or misleading information…

Chromosomal abnormalities
The key condition to focus on here is Down’s syndrome There are others to be aware of e.g. Patau - trisomy 13 and Edward’s - trisomy 18 These will more likely be assessed via SBAs than a SAQ The Peer Teaching Society is not liable for false or misleading information…

Down’s syndrome - features
Craniofacial appearance - epicanthic folds, flat nasal bridge, Brushfield spots Congenital heart defect (e.g. AVSD), duodenal atresia. Long term complications - leukaemia/solid tumour risk, hearing impairment, increased risk of Alzheimer’s, epilepsy The Peer Teaching Society is not liable for false or misleading information…

Congenital heart conditions
Typically picked up during antenatal ultrasound screening Most common - Ventricular septal defect, PDA, ASD Lots to think about - but you can recognise the most common murmurs thinking through the pathology The Peer Teaching Society is not liable for false or misleading information…

A child with a murmur Is the child cyanotic?
If yes - it will either be ToF, or TGA 2.Is the child unwell? Typically - ASD’s are asymptomatic, large VSD’s can present with FTT and heart failure. 3.When do you hear the murmur? Systolic/diastolic/“machinery” murmur The Peer Teaching Society is not liable for false or misleading information…

Common murmurs Atrial septal defect What causes the murmur in ASD?
= ↑ flow across the pulmonary valve - ULSE murmur (systolic) How do we treat this? And does everyone need treatment? Talk about risk of paradoxical embolisation if ASD remains patent in later life = treatment is with closure of ASD. Only patients with right ventricle compromise need treatment. The Peer Teaching Society is not liable for false or misleading information…

VSD Where is the murmur? Lower left sternal edge (generally) - quieter the murmur - the larger the defect Why is a large VSD a problem? Large VSD’s are larger than the aortic valve - results in heart failure What do we need to avoid in these patients? Eisenmenger syndrome (R->L shunting) The Peer Teaching Society is not liable for false or misleading information…

Persistent ductus arteriosus
What does this sound like? A constant murmur, heard below left clavicle What is the treatment? Either NSAID treatment (inhibit prostaglandins) or closure of the duct with a coil at around 1 year of age The Peer Teaching Society is not liable for false or misleading information…

Tetralogy of Fallot What might you see on X-ray?
Name the four problems in ToF? Pulmonary stenosis Overriding aorta Right ventricular hypertrophy Ventricular septal defect What might you see on X-ray? A boot shaped heart - due to RVH The Peer Teaching Society is not liable for false or misleading information…

TGA Vessels are the wrong way round - and there are two parallel circulations going on Cyanosis, may not have a murmur Need to maintain PDA and do urgent surgery The Peer Teaching Society is not liable for false or misleading information…

Respiratory stuff Things to know Asthma, and acute attacks
Cystic fibrosis Respiratory infections (URTI’s, LRTI’s) The Peer Teaching Society is not liable for false or misleading information…

Case 2 Jill is a 7 year old girl, and has been brought into A+E after becoming very short of breath playing football. She is known to have asthma. You do a quick A->E assessment and you find - A - Speaking in short sentences, airway patent B - RR 32, equal expansion, bilateral wheeze, use of accessory muscles, 91% O2 on air C - BP 110/65, CRT <2s, HR 130 D - PEARL, GCS 15/15, BM 5.5 E - no rashes, temp 37.5 The Peer Teaching Society is not liable for false or misleading information…

Acute asthma What do you want to next? (3 things)
Oxygen - 15/L via NRB Assess peak flow Salbutamol nebulisers Steroids What are some features of life threatening asthma ? Silent chest PEF < 33% Poor respiratory effort Hypotension Exhaustion The Peer Teaching Society is not liable for false or misleading information…

Cystic fibrosis Pseudomonas aeruginosa
Can you name 3 organs involved in CF? GI - malabsorption, Lungs - recurring infections, Do we screen babies for CF? Immunoreactive trypsinogen How do we diagnose CF ? Sweat test Can you name a bacteria that can commonly cause chronic infection in CF? Pseudomonas aeruginosa The Peer Teaching Society is not liable for false or misleading information…

Respiratory infections
Important things to know for URTI/LRTI’s Typical age What organism is involved Symptoms - look for buzzwords e.g. “barking cough” for croup Investigations - anything specific, also know ABCDE Management - first line treatments The Peer Teaching Society is not liable for false or misleading information…

Bronchiolitis Croup Epiglottitis Whooping cough The Peer Teaching Society is not liable for false or misleading information…

Bronchiolitis Age - 90% occur before 1 year of age
Organism typically involved? Respiratory syncytial virus Symptoms - breathing difficulties, following coryzal symptoms Investigations - RSV swab, O2 saturation Treatment - mainly supportive The Peer Teaching Society is not liable for false or misleading information…

Croup Age - 6 months to 6 years old
Organism - most typically parainfluenza virus Symptoms - barking cough, stridor, worse at night Investigations - Sats, avoid examination of the throat Management - Oral corticosteroids, oxygen therapy, intubation in airway obstruction (rare) The Peer Teaching Society is not liable for false or misleading information…

Epiglottitis Age - 1 - 6 years
Organism - most commonly H.influenzae (rare in vaccinated children) Symptoms - child appears toxic, high grade fever, soft stridor, absent cough, rapid onset. Child is often sitting upright to optimise airway Investigations - similar to croup Management - Intubation under GA -> followed by cultures and antibiotics The Peer Teaching Society is not liable for false or misleading information…

Pertussis Age - In the UK - peak age is typically infants that have not had first jab (e.g. < 4 months) Organism - Bordetella pertussis Symptoms - week of coryzal symptoms followed by paroxysmal coughing phase - lasts up to 6 weeks. - Whooping follows cough Investigations - per-nasal swab to identify Management - Erythromycin eradicates B.pertussis and prevents spread The Peer Teaching Society is not liable for false or misleading information…

Case #3 - child with a limp
Jack is now 4 and is is carried into your GP surgery by mum - he is refusing to walk and looks very upset. When you examine his hip you find that the right hip joint appears red and is tender and warm to touch. What do you need to rule out ? The Peer Teaching Society is not liable for false or misleading information…

Septic arthritis Acute inflammation of the joint - need to treat quickly to prevent joint damage Typically caused by S.aureus What investigations would you like to do? Blood cultures, joint aspiration (+culture) What management would you like to do? IV antibiotics (probably Fluclox) The Peer Teaching Society is not liable for false or misleading information…

Important things for limp
What is the age of the patient? There is a specific hip pathology for each age group e.g. DDH in infants, Perthes disease in 4-10, SUFE in teenagers Is the patient unwell? If yes, more likely to be septic arthritis/osteomyelitis Does it affect only one joint? Onset - infective is typically quick onset e.g. 1 day Associated symptoms - e.g. prolonged fever suggests JIA/malignancy, associated The Peer Teaching Society is not liable for false or misleading information…

Other causes of limp Transient Synovitis Osteomyelitis Perthes disease
Developmental dysplasia of the hip Slipped capital femoral epiphysis Juvenile idiopathic arthritis Also - malignancy, NAI The Peer Teaching Society is not liable for false or misleading information…

GI Case History Henry, a 6 week old baby boy, has seen a multiple doctors over the past 2 weeks because of vomiting. He has been started on omeprazole and thickened feeds to treat a presumptive diagnosis of reflux. His parents are concerned as he remains unwell. They bring him to A+E for another review. His vomiting is worse and occurs after every feed. He has less wet nappies, lethargy and some weight loss. The Peer Teaching Society is not liable for false or misleading information…

Vomiting Differential Diagnosis
Surgical sieve: V: Intracranial haemorrhage I: UTI*; Gastroenteritis*; Meningitis; Otitis media T: Trauma; NAI A: Coeliac M: GORD*; Pyloric stenosis*; Intussusception; Hirschprung’s I: Overfeeding N: Intracranial tumour D: Malrotation of midgut GORD, pyloric stenosis, infection (UTI/gastroenteritis) The Peer Teaching Society is not liable for false or misleading information…

He projectiles vomits on you, what is the likely diagnosis?
Peak incidence? What would be the classical features of this? What would you see on a blood gas? 3-6/52 Pyloric stenosis Vomiting during/after feeds, increasing in freq and force, projectile, Hunger (after feeds), Wt loss. Hypochloraemic, hypokalaemic metabolic alkalosis [The pylorus is normal at birth. There is progressive hypertrophy of the pyloric muscle resulting in gastric outlet obstruction. This manifests as vomiting and results in the loss of HCl and hypovolemia. The kidneys attempt to compensate for the loss of acid by retaining protons in exchange for potassium.] Test feeding demonstrating peristatic massed for left to right; Olive shaped mass on USS The Peer Teaching Society is not liable for false or misleading information…

Hypochloraemic Hypokalaemic Metabolic Alkalosis
Blood gas shows picture of hypochloraemic, hypokalaemic metabolic alkalosis What does this mean? pH = raised pCO2 = often raised as body tries to compensate for alkalosis HCO3 = raised – tells you this is a metabolic alkalosis Often a raised base excess Low electrolytes (K and Cl) The Peer Teaching Society is not liable for false or misleading information…

Investigations? Management?
Test feeding demostrating peristatic massed for left to right; Olive shaped mass on USS Ramstedt's pyloromyotomy is easily performed and is associated with minimal complications. Stabilise intially with fluids (0.45% saline + 5% dextrose) w/ supplemental KCl if needed The Peer Teaching Society is not liable for false or misleading information…

GORD Aetiology: More significant GOR is also common in infancy (at least 40% of infants), usually begins before the infant is 8 weeks old, may be frequent (5% of those affected have six or more episodes each day) and usually becomes less frequent with time (resolves in 90% of affected infants before aged 1 year) Symptoms: Recurrent regurgitation or vomiting (after meals); Witnessed episode of choking or apparent life-threatening event can sometimes occur; Respiratory problems (eg, cough, apnoea, recurrent wheeze and, less commonly, aspiration pneumonia); Feeding and behavioural problems; Failure to thrive. Investigation: Usually not needed; pH study; Imaging of upper GIT More significant GOR is also common in infancy (at least 40% of infants), usually begins before the infant is 8 weeks old, may be frequent (5% of those affected have six or more episodes each day) and usually becomes less frequent with time (resolves in 90% of affected infants before aged 1 year) The Peer Teaching Society is not liable for false or misleading information…

GORD Management: May not require any treatment – frequency should reduce – Reassure Review feeding history and assess breast feeding technique and prevent over-feeding Try smaller, more frequent feeds Try thickened feeds Add a trial of alginate therapy Add in PPIs with overt regurgitation/ failure to thrive/ distressed behaviour More significant GOR is also common in infancy (at least 40% of infants), usually begins before the infant is 8 weeks old, may be frequent (5% of those affected have six or more episodes each day) and usually becomes less frequent with time (resolves in 90% of affected infants before aged 1 year) The Peer Teaching Society is not liable for false or misleading information…

Intussusception Pathology: Telescoping of one portion of the bowel into an immediately adjacent segment  Restriction of BS and oedema of the bowel wall rapidly leads to obstruction and potential gangrene/ perforation. Aetiology: Most commonly 3-12 months Symptoms: Paroxysmal colicky abdominal pain; Bile stained vomiting; Redcurrant jelly stools Signs: Shock; Palpable sausage shaped mass in RUQ; Redcurrant jelly on PR Investigation: Target sign on USS; Proximal dilation on AXR Management: Resuscitate with fluid and place NG tube. Reduction w/ air enema. Laparotomy with failure. The Peer Teaching Society is not liable for false or misleading information…

Hirschprung’s Disease
Pathology: Congenital agenesis of the colonic ganglion  function GI obstruction, constipation and mega colon. 1 in 5000 births. M:F = 4:1 Aetiology: Mainly neonatal; may present in older children with chronic constipation Symptoms: Abdominal distention, failure of passage of meconium within the first 48 hours of life and repeated vomiting. Signs: Abdomen distended with faeces. PR = Tight anal sphincter; Explosive discharge of stools and gas Investigation: AXR (dilated lower bowel); Suction biopsy of the aganglionic segment. Management: Excision of the aganglionic segment +/- colostomy What is the other important cause of failure to pass meconium? Cystic fibrosis The Peer Teaching Society is not liable for false or misleading information…

Infection Case history
Chris, a 4 year-old boy is brought to the emergency department by his parents with a history of increasing numbers of red spots on his legs over the past 6 days. They took him to two different family doctors and have tried various creams. The spots have spread to his buttocks and his arms, and now his legs are sore and look swollen. He has also had abdominal pains. On examination he looks well with age-appropriate vital signs, but he is reluctant to move his lower limbs. His rash looks like this: The Peer Teaching Society is not liable for false or misleading information…

Petechial rash The Peer Teaching Society is not liable for false or misleading information…

Neonates What is the likely diagnosis?
What investigations may you do to exclude complications? What is the natural history of the disease? How is it managed? HSP is an autoimmune, self-limiting, immunoglobulin A-mediated, small-vessel vasculitis. It typically affects children aged 2-8 years and is the most common vasculitis affecting children. It is often preceded by upper respiratory tract symptoms (occuring 1-3 weeks earlier). The diagnosis is likely in the presence of the triad of: purpuric rash on the limbs (mainly lower) and buttocks (especially the dependent surfaces) joint pain/ swelling abdominal pain NHx: upper respiratory tract infection may precede the onset of symptoms by 1-3 weeks. joint pain usually lasts <48h abdominal pain usually lasts <72h resolution of rash by 4-6 weeks Supportive management with treatment of renal complications HOME | Medical Specialty | Emergency Medicine | Horrible Spots and Pain Horrible Spots and Pain by Chris Nickson aka Pediatric Perplexity 014 A 4 year-old boy is brought to the emergency department by his parents with a history of increasing numbers of red spots on his legs over the past 6 days. They took him to two different family doctors and have tried various creams. The spots have spread to his buttocks and his arms, and now his legs are sore and look swollen. He has also had abdominal pains. On examination he looks well with age-appropriate vital signs, but he is reluctant to move his lower limbs. His rash looks like this: Photo by okwikikim – click image for source A urine dipstick shows 2+ RBCs. Questions Q1. What is the likely diagnosis? Answer and interpretation Henoch-Schonlein Purpura The rash may not appear until after the onset of the other symptoms. It starts as erythematous papules quickly followed by palpable purpura, which are visible, unblanching hemorrhages in the skin and mucous membranes, up to 10 mm in diameter. The rash may also resemble urticaria. Although named for Eduard Heinrich Henoch and Johann Lukas Schönlein, HSP was actually first described by the brilliant English physician William Heberden in 1802. HSP can occur in adults (sometimes associated with drugs or malignancy) and there is also an infantile form. Check U+Es Renal function should be assessed if there is evidence of hematuria (90% of cases) or hypertension. About half of cases will develop nephritis, but only 1% will have longterm renal failure. Other investigations may not be required. Sometimes the cause of purpura may be uncertain. In this case the patient should be investigated as discussed in Pediatric Perplexity 007 (e.g. FBC, blood culture). In HSP, there is no thrombocytopenia or coagulopathy. The Peer Teaching Society is not liable for false or misleading information…

The unwell child with petichae
Unwell if: Irritable/ lethargic Abnormal vital signs Poor peripheral circulation OR: the petechiae progress in extent during the 4 hours of observation in the emergency department purpura (lesions >2 mm) develop — however, the child may be treated for HSP if he or she is well with palpable purpura in the classic distribution (buttocks and lower limbs) with or without arthralgias or abdominal pain. abnormal laboratory parameters — WBC <5 or >15 x 10E6/L or CRP>8 the child is irritable or lethargic the child has abnormal vital signs — tachycardia, tachypnea or SpO2 desaturation, hypotension or abnormal pulse pressure the child has poor peripheral circulation — cool peripheries, capillary return time > 2 seconds It’s probably reasonable to add: if the doctor, nurse or the parents think the child is unwell regardless of the above… the petechiae progress in extent during the 4 hours of observation in the emergency department purpura (lesions >2 mm) develop — however, the child may be treated for Henoch-Schonlein purpura if he or she is well with palpable purpura in the classic distribution (buttocks and lower lower limbs) with or without arthralgias or abdominal pain. abnormal laboratory parameters — WBC <5 or >15 x 10E6/L or CRP>8 The Peer Teaching Society is not liable for false or misleading information…

The unwell child with petechiae
Holly, a 3/52 old child, comes in with to A+E with a non blanching rash that looks like this. She is less responsive than normal, tachpnoeic and tachycardic and her capillary refill is 4 seconds peripherally What is the likely causative organism? What is your management plan? Name 5 complications of this condition What would you give to close contacts as prophylaxis? Neonates: group B streptococci, Listeria monocytogenes, Escherichia coli. Infants and young children: H. influenzae type b, if younger than 4 years and unvaccinated; Neisseria meningitidis, Streptococcus pneumoniae. Adults and older children: S. pneumoniae, H. influenzae type b, N. meningitidis, Gram-negative bacilli, staphylococci, streptococci and L. monocytogenes. Children 3 months and older and young people should be given intravenous ceftriaxone as empirical treatment before identification of the causative organism. If calcium-containing infusions are required at the same time, cefotaxime is preferable. Children younger than 3 months should be given intravenous cefotaxime plus either amoxicillin or ampicillin. NB: ceftriaxone should not be used in premature babies or in babies with jaundice, hypoalbuminaemia or acidosis, as it may exacerbate hyperbilirubinaemia. Immediate: septic shock, including disseminated intravascular coagulation, coma with loss of protective airway reflexes, cerebral oedema and raised intracranial pressure,septic arthritis, pericardial effusion and haemolytic anaemia (H. influenzae). Subdural effusions: reported in 40% of children aged 1-18 months with bacterial meningitis. Risk factors include young age, rapid onset of illness, low peripheral white cell count and high CSF protein. Syndrome of inappropriate antidiuretic hormone secretion (SIADH). Seizures: occur more commonly during the acute stage of the disease. Studies reported that this occurred in 47% of children and 17% of adults with acute bacterial meningitis.[20][21] Delayed: decreased hearing, or deafness; other cranial nerve dysfunction, multiple seizures, focal paralysis, subdural effusions, hydrocephalus, intellectual deficits, ataxia, blindness, Waterhouse-Friderichsen syndrome and peripheral gangrene. The Peer Teaching Society is not liable for false or misleading information…

More infections …. A mother noticed lesions in her child’s mouth and then a rash. The child had coryzal symptoms and conjunctivitis last week…. The Peer Teaching Society is not liable for false or misleading information…

Measles Pathology: It is one of the most contagious infectious diseases; Transmission is airborne via respiratory droplets. Signs and Symptoms Prodrome: cough, coryza, conjunctivitis, Koplik spots, fever Rash: starts behind ears then to whole body, discrete maculopapular rash becoming blotchy & confluent Management: Supportive + vaccinate contacts Complications encephalitis giant cell pneumonia subacute sclerosing panencephalitis (5-10y later) febrile convulsions keratoconjunctivitis, corneal ulceration Features Prodrome: irritable, conjunctivitis, fever Koplik spots (before rash): white spots ('grain of salt') on buccal mucosa Rash: starts behind ears then to whole body, discrete maculopapular rash becoming blotchy & confluent Complications Encephalitis subacute sclerosing panencephalitis: very rare, may present 5-10 years following the illness Treatment Symptomatic treatment The Peer Teaching Society is not liable for false or misleading information…

More …. Child presents with a rash, low grade fever and suboccipital and postauricular lymphadenopathy… The Peer Teaching Society is not liable for false or misleading information…

Rubella Pathology: Transmission is airborne via respiratory droplets.
Signs and Symptoms Prodrome of low grade fever or none at all Maculopapular rash often first sign of infection Initially on face then spreading to whole body Lymphadenopathy (suboccipital and postauricular nodes) Management: Supportive + vaccinate contacts Complications Encephalopathy and arthralgia occur rarely What complication do you need to be cautious of and what do you need to do? In utero 1st to 4th week: eye anomaly 4th to 8th week: cardiac abnormality 8th to 12th week: deafness The Peer Teaching Society is not liable for false or misleading information…

More …. 16 year old presents with fever, malaise and a facial swelling
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Mumps Pathology: Transmission is airborne via respiratory droplets.
Signs and Symptoms Fever Malaise Parotitis Management: Supportive + vaccinate contacts Complications Pancreatitis Orchitis Meningitis/encephalitis Clinical features Fever Malaise Parotitis Infectivity up to 7d after onset of parotid swelling Illness generally mild and self limiting Complications: Viral meningitis and encephalitis; Orchitis The Peer Teaching Society is not liable for false or misleading information…

More …. A 2-year-old who has had a fever for the past 7 days is noted to have conjunctivitis, erythema and oedema of the hands and feet, cracked lips and a strawberry tongue The Peer Teaching Society is not liable for false or misleading information…

Kawasaki’s Disease Pathology: Peak is between 6 months to 5 years; M>F; Commoner in far east populations Signs and Symptoms high-grade fever (> 5 days) conjunctival injection bright red, cracked lips strawberry tongue cervical lymphadenopathy red palms of the hands and the soles of the feet which later peel Management: Aspirin + IV Ig What important complication does this disease have? How would you investigate? The Peer Teaching Society is not liable for false or misleading information…

Look your vaccination schedules and notifiable diseases!
Thank you and good luck! The Peer Teaching Society is not liable for false or misleading information…

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