Paediatrics:
- common conditions for finals.
Dr Katie Green
FY2 Paediatrics
What we’ll cover
• Additional topics – infection, syndromes,
miscellaneous, child abuse
• Quizes and Questions throughout
• Summary of finals topics at end!
Cardiovascular Topics
• Murmurs- Innocent vs pathological
• Congenital heart disease
– Down’s syndrome
• Kawasaki’s disease
• Rheumatic Fever
Homework… cardio exam of a child
• Wash hands, introduce yourself….play the game!
• Look- bedside clues, scars, clubbing, on oxygen?
• Feel- pulses, praecordium (heaves),
hepatomegaly, peripheral oedema
• Listen- heart sounds, lung bases
• Thank child and wash hands
• Present your findings and summarise
• It’s paeds- go with the flow, examine in whatever
order you like
Innocent Murmurs
Can be louder / exaggerated in periods of illness
Hallmarks: 7’s inoSSents
1. Soft
2. S1 and S2 Normal (Heart sounds normal)
3. Symptomless
4. Systolic
5. Short
6. Standing / sitting may vary (change with posture)
7. Special Tests Normal (ECG/CXR/ECHO normal)
…also commonly Left sternal edge ( no radiation)
Acyanotic murmurs
VSD > PDA > ASD
Left to right shunts
No cyanosis (oxygenated blood being shunted)
Can all cause pulmonary HTN  Eisenmenger’s
syndrome
Left to right shunts (Acyanotic)
VSD
•Most Common CHD
•Murmur reversely proportional to size of hole
Presents –
SMALL: asymptomatic. Thrill over the lower sternal edge. Loud
pansystolic murmur at lower left sternal edge. Quiet 2nd heart sound.
LARGE – HF, Failure to thrive, chest infections after 1 week of age. Soft
pansystolic or no murmur. Loud second heart sound
Tests – Small: ECHO Large: CXR, ECG, ECHO
Management:
– SMALL: most close spontaneously
– LARGE: HF with diuretics and captopril. Definitive surgical closure.
•Dental propylaxis controversial – not these days but still in books!
Left to right shunts
PDA
• “Continuous Machinery murmur” beneath the
left clavicle = Burrrr Durrrrrr
•Tests: Echo
•Management –
1. Asymptomatic must close to reduce endocarditis risk. 1 yr
done via catheter.
2. Symptomatic: close immediately.
•Indomethecin to close the PDA
•Prostaglandin E keeps PDA open (for TGA’s)
Acyanotic = Left to right shunts
ASD
• May be asymptomatic. If severe HF, Recurrent
chest infections.
• Signs: wide fixed splitting 2nd heart sound +/ejection systolic murmur.
• Investigations : CXR, ECG, ECHO
• Management: Surgery
• Risk of arrhythmias as adults (AF/SVT)
Outflow obstructions
• Aortic stenosis (Ejection systolic murmur)
• Pulmonary stenosis (Ejection systolic murmur)
• Coarctation (radiofemoral delay)
Turner’s Syndrome
Outflow obstruction
Coarctation
•Uncommon
•Turner’s syndrome (XO)!
•Presents – ejection systolic murmur at the L
upper sternal edge. High BP in the right arm.
•Rib notching on CXR= ‘3 sign’.
•Management: Stent if severe.
Coarctation
Murmurs…in summary
Murmur Heard
• Wide fixed splitting of S2
“Lub splat”
• Pansystolic murmur
“Burrrrr”
• Ejection systolic murmur
“Burr de”
• Continuous machinery
murmur
“BurrrrDurrrrr”
Pathology
• ASD
• VSD, Mitral regurg
• Aortic stenosis, Pul stenosis
• Patent Ductus Arteriosus
Murmurs in summary….
Oh murmur, where art thou…?
www.askdoctorclarke.com
Cyanotic murmurs
TOF / AVSD / TGA
Truncus Arteriosus / Pulmonary Atresia / Hypoplastic left heart
Right to Left Shunts
Cyanosis (de-oxygenated blood being shunted)
4 cardinal features:
TOF
Pulmonary stenosis (causing Large VSD),
Right ventricular Hypertrophy (RVH).
Overriding aorta.
VSD
Ejection systolic murmur – left sternal edge
•Present cyanosis on exercise / 2+ days of life. Clubbing. Right parasternal
heave
•Cyanotic spells when upset
•Investigations: CXR – boot shaped heart. ECHO (increased right
ventricular size).
•Management:
•Beta blockers for hypoxic spells. Palliative surgery = blalock-taussig shunt.
Total surgical repair around 6 months.
Transposition great arteries
• Present – cyanosis (only cyanotic condition that can
present from birth).
• Aorta comes off right ventricle, PA off left ventricle
• Profound and life threatening. Less severe if VSD as
mixing of the blood. Clubbing. Usually no murmur.
PDA.
• Tests- x ray shows ‘egg on side appearance’. ECHO
• Management – prostaglandin infusion to maintain
PDA (allows blood mixing). Balloon atrioseptostomy
– tears atrial septum to essentially make an ASD.
Graft surgery.
Congential murmurs and
syndromes
Downs: AVSD, VSD, ASD.
Turners: Atrial stenosis and Coarctation
Trisomy 13 + 18 : complex septal defects
Williams: elfin features + supravalvular aortic stenosis
Noonans : tricuspid stenosis and septal defects
William’s Syndrome
• Elfin features
• Supravalvular Aortic stenosis
Down’s Syndrome
• Trisomy 21
• 50% have cardiac abnormality
• AVSD, ASD, VSD, MR, TR
Increased risk of:
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Duodenal Atresia
Squint
Hypothyroidism
Leukaemia
Hirschprung’s disease
Deafness
Kawasaki’s Disease
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6m to 4 years
More common in Japanese children
Unknown aetiology ? superantigen
Systemic vasculitis – small and medium vessels
Clinical features
– Fever for >5 days
– Four of: conjuncivitis, red mucous membranes, cervical LNs,
rash, palm changes
• Complications in 1/3 of cases; follow-up echos (risk of
coronary artery aneurysms)
• Prompt treatment with IVIGs and aspirin for 6 months
(↓ thrombosis)
Homework 2…the fetal heart
Diagrams from (the amazing)
www.askdoctorclarke.com
Rheumatic Fever
• 2-6 weeks after strep pyogenes infection (Group A
Beta haemolytic strep)
• >50% get ACUTE CARDITIS = pericardial rub
• Often get Mitral Stenosis or Aortic Regurg years
later as teen / adults
• Diagnosed by strep positive throat swab/ASO titre
and Duckett Jones major/minor criteria
Sore throat / Arthralgia / Fever / Erythema
Marginatum / Arthritis / Nodules / Chorea / New
mitral diastolic murmur
Rheumatic Fever
Diagnosis requires:
• 2 major criteria OR
• 1 major criteria and 2 minor criteria
Eisenmenger’s syndrome
• SHUNT REVERSAL
• Initially (large) left to right shunt
• Due to blood shunted right, develop pulmonary artery
hypertension to the point of right pressure exceeding
left = shunt reversal = cyanosis
• “Acquired Cyanotic Heart Disease” = acquired R L shunt
• Poor prognosis – no management /reversal options
• Heart-lung transplant is only hope
Cyanosis
• Cyanotic from birth = TGA’s
• Cyanotic without murmur = TGA’s
• Cyanotic on crying / day 2-3 of life = TOF
• Cyanosis with Down’s syndrome = AVSD
• Acquired Cyanotic heart disease = Eisenmenger’s
syndrome
CARDIO RECAP
1. What are the murmurs of:
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VSD
PDA
ASD
Aortic stenosis
2. Classification of Congenital Heart Disease
– Acyanotic
– Cyanotic
3. Cardiovascular abnormalities of Down’s
syndrome?
4. 5 diagnostic criteria of Kawasaki’s ?
Respiratory
• Infections
• Cystic fibrosis
• Asthma
Bronchiolitis
• Nearly always <18m
• Viral infection (RSV) → small airway obstruction
– Wheeze, harsh cough, fever, ↑hr and rr, nasal flaring, s/c &
i/c reccession
– Fine insp. crackles and expiratory wheeze
– 9 day illness: 3 stable, 3 worse, 3 better – resolved!
• Those at risk (prem, chronic resp conditions, CHD
cardiac pts) = PAVALIZUMAB monoclonal antibody
• Investigation only needed in severe cases
– Capillary blood gas, CXR, nasopharyngeal aspirate (RSV)
• Essentially Supportive Management : humidified
oxygen, saline / bronchodilator nebs if severe.
Management of Bronchiolitis
Assess the clinical severity!!
1.Mild: feeding well, minimal RD, no RFs, no O2
needed – HOME with advice on when to return
2.Moderate: ↑ work of breathing, poor feeding, low
sats, RFs – admit for feeding support +/- O2
3.Severe: worsening RD, respiratory acidosis,
apnoea, dehydration, RFs – HDU, CPAP,
ventilation, IV fluids
Pneumonia
• Up to 1/3 are viral (RSV, parainfluenza, adenovirus,
rhinovirus) – wheeze more common
• Usual Signs and symptoms
• Mild – home with oral Abs and advice
• Moderate to severe (unwell child, RD, needs O2, poor fluid
intake) – admit, O2, IV Abs/fluids
Croup and epiglottitis
• Croup = Acute viral laryngotracheobronchitis
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Hoarse voice, barking cough, harsh stridor, possible RD
Age 6m to 6y
Parainfluenza virus
Mx: mild (RD disappears at rest)/moderate/severe
• Epiglottitis (H. influenzae): very unwell, drooling, leave
alone and ask ENT to r/v immediately. Leave alone!
Croup .vs. Epiglottitis
Croup
Epiglottitis
Onset
Over days
Over hours
Preceding cold
Yes
No
Cough
Severe, barking
Absent/slight
Able to eat and drink
Yes
No
Drooling saliva
No
Yes
Appearance
Unwell
Toxic, very ill
Fever
<38.5°C
>38.5°C
Stridor
Harsh, rasping
Soft, whispering
Voice and cry
Hoarse
Muffled, reluctant to speak
Bronchitis
• Inflammation of the bronchi
• Cough and fever are the main Sx ?wheeze
• Lasts for approx. 2 weeks (longer if pertussis)
• Whooping cough
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Highly infectious form of bronchitis
Bordetella pertussis
Catarrhal phase – coryzal Sx
Paroxysmal phase – cough followed by inspiratory whoop
Apnoea in infants
Epistaxes and subconj. Haemorrhages can occur
Ix: nasal swab, lymphocytosis
Immunisation crucial - pregnant women
Cystic Fibrosis
• Autosomal recessive inheritance (gene on
chromosome 7 codes for CFTR)
• 1 in 25 are carriers in the UK
– Mutation (ΔF508) → abnormal ion transport →
thick secretions
• Pancreatic insufficiency – DM and malabsorption (FFT,
steatorrhoea – low elastase levels)
• Recurrent chest infections and bronchiectasis
Most present with
malabsorption and
FFT from birth
Cystic Fibrosis
• Clinical features
– Newborn – screening (IRT/genetic testing)
– Infancy – meconium ileus, jaundice, FFT
– Child – rectal prolapse and nasal polyps
– Older child – ABPA, DM, cirrhosis and portal
hypertension, obstruction, pneumothorax, sterility.
• Investigations – the sweat test (pilocarpine-PNS)
– High Chloride levels (>60)
– Usually high Na+ levels too
• Managment
– MDT – mostly respiratory and nutrition
Asthma
• Not diagnosed until >4 yrs
• Reversible airway disease
• Tends to be worse in mornings and at night = “diurnal
variation”
• Triggers- exercise, allergens, cold weather, stress /
emotion.
• Assoc with eczema and rhinitis (Atopy)
• Tend to have: generalised expiratory polyphonic wheeze,
tachypnoea, hyperinflated lungs on CXR
• Rule of 3’s:
1/3 grow out of it, 1/3 improve in teens for it to return in
adulthood, 1/3 have asthma throughout life.
Asthma Management
1. Acute Management:
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Oxygen, nebulized salbutamol + ipratropium, IV
hydrocortisone, IV magnesium sulphate (need senior r/v by
now)
10 puffs of salbutamol with spacer is as effective as nebuliser =
“just get salbutamol into them however and keep giving it”
approach!!
Be aware of the silent chest – wheeze that disappears without
treatment is a disaster and not a miracle!!
2. Chronic Management:
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Avoid allergens, peak flow and symptom diary
MDT involvement – specialist nurses are great
Stepwise management
<2 years: MDI with spacer and mask, 2-7 years: MDI with
spacer, >7 years MDI
Individual action plan
Stepwise management of asthma
Steps
Treatment
STEP 1: Mild intermittent asthma
Short acting beta agonist: salbutamol
+/- ipratropium
STEP 2: Requires >3 puffs of beta agonist
per week
Inhaled steroid e.g. Budesonide or
beclometasone
STEP 3: Poorly controlled on inhaled
steroids
Long acting beta agonist:
salmeterol/formoterol
STEP 4: Persistent poor control
Increase inhaled steroid dose
Leukotriene receptor antagonist
STEP 5: Chronic severe asthma
Daily oral steroids
Start where is appropriate, not necessarily from step 1.
Causes of Stridor
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Croup,
Epiglottitis,
Anaphylaxis,
Laryngomalacia,
Foreign body inhalation,
Bacterial tracheitis,
Smoke inhalation
Obstructive Malignancy.
RESP RECAP
1.
2.
3.
4.
5.
How are babies with CF likley to present?
Which children are at risk of bronchiolitis?
Name 4 causative ‘agents’ of pneumonia?
How do you manage epiglottitis?
Describe the stepwise treatment of asthma
Gastrointestinal
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Diarrhoea
Abdominal pain
Coeliac’s disease
Pyloric stenosis
Intussusception
Growth Charts
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Correct prematurity until 2 years old (<36+6)
Plot as dots and not crosses
Coeliac- fall off in weight begins as weaning begins (6 months)
IUGR- low birthweight baby, may catch up. Early IUGR if head
circ and length also affected. May have reduced growth
potential.
Hydrocephalus = head circ much greater than length and
weight and suddenly shoots up. Tumours / IVH
Turner’s = poor growth from young age and absence of
pubertal growth spurt. Short stature.
GH deficiency = fall off in height- can be congenital but if
sudden fall off likely to be pituitary deficiency (pit adenoma /
tumour?). Aquired hypothyroidism has similar pattern.
CF- failure to thrive, difficult to gain weight, weight always on
lower centiles. Hx likely to suggest recurrent LRTI’s.
Types of Vomiting (yay!)
• Bile stained – intestinal obstruction
• Blood in vomit – oesophagitis, peptic ulcer,
oral/nasal bleed, malrotation
• Projectile vomit- pyloric stenosis
• Vomiting at end of paroxysmal coughing –
whooping cough
• Abdo distension- lower intestinal obstruction
Gastro-oesophageal reflux
• Mainly due to LOS immaturity and inappropriate
relaxation.
• Usually resolved by 1 year.
• Chronic reflux due to diseases of neuro disorders
such as Cerebral Palsy, chronic lung disease of
prematurity
• Symptoms- crying after feeds, vomiting after feeds,
not wanting to lie down, reflux, anxious mother
• Investigations: clinical assessment. Barium swallow,
pH monitoring (24hrs), trial meds
• Management: thickened feeds, positioning during
feeds, PPIs, Surgery. Reassure mother this is common
and usually self-resolves with age.
GORD Treatment
• GORD =
Gaviscon
Omeprazole
Ranitidine
Domperidone.
• Surgery (Nissen’s Fundlopication)
Pyloric Stenosis
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Hypertrophy of pylorus that causes outflow obstruction.
2-7 weeks. Boys > girls.
Surgical Emergency
Projectile vomiting which gets worse overtime. Constant
hunger, weight loss, “scaphoid abdomen”, upset baby.
Hypokalaemic Hypochloraemic Metabolic alkalosis =low
plamsa K+ due to vomit
Diagnosis – clinical olive on abdo. Oserve feed for visible
peristalsis (mind out for vomit!)
Ix = USS or barium meal
Tx- correct electrolytes +fluids. NBM. Surgery
Gastroenteritis
• Infective vomiting and diarrhoea.
• Rotavirus commonest in developing world. Worse winter.
• Bacteria – campylobacter jejuni commonest but overall rare. Shigella
and salmonella cause dysenteric infection.
• Have a low threshold for admitting as many things can look like
gastroenteritis (DKA)
• Look out for dehydration – reduced conciousness, sunken
fontanelle, dry mucus membranes, tachypnoea, tachycardia.
Prolonged cap refill, weight loss, reduced skin turgor.
• Investigations:- nil unless
Septicaemia is suspected.
There is blood and/or mucus in the stool.
The child is immunocompromised.
The child has recently been abroad.
The diarrhoea has not improved by day 7.
There is uncertainty about the diagnosis of gastroenteritis.
Gastroenteritis
Management = fluids fluids fluids!!
•<5% Mild: feed replacement. Glucose +
electrolyte until subsides
•5-10 severe: 6hr 100ml/kg
•>10% IV rehydration
•Beware of hypernatraemic dehydration
•Rehydration is mainstay of treatment
•Beware outbreaks of e.coli O157 (haemolytic
uraemic syndrome)
Causes of Acute Abdo pain…
Your Turn….!
Birth-1 year
•Medical causes Gastroenteritis, Constipation UTI
•Surgical causes: Intussusception, Volvulus Incarcerated hernia
•Other causes: Infantile colic Hirschsprung's disease
2-5 years
•Medical, Gastroenteritis, Constipation, UTI
•Surgical: Appendicitis, Intussusception, Volvulus, Trauma
•Others: Mesenteric lymphadenitis, Henoch-Schönlein purpura, Sickle cell crises
6-11 years
•Medical: Gastroenteritis, Constipation, UTI
•Surgical: Appendicitis, Trauma
•Other: Mesenteric lymphadenitis, Henoch-Schönlein purpura, Sickle cell crises, Pneumonia,
Functional pain
12-18 years
•Medical: Gastroenteritis, Constipation
•Surgical: Appendicitis, Trauma, Ovarian/testicular torsion
•Other: Dysmenorrhoea, Mittelschmerz, Threatened abortion, Ectopic pregnancy, Pelvic
inflammatory disease
Appendicitis
• Acute appendicitis doesn’t really occur in
children under 3 yrs.
• Presents- anorexia, vomiting, abdo pain.
Flushed face. Oral fetor. 37.2-38 C. Guarding
• Watch out- kids can perf suddenly = low
threshold for theatre
• Treat – NBM, IV fluids, appendicectomy, iv
antibiotics.
Intussusception
• Invagination of the proximal bowel into the distal segment.
Commonest involves ileum into caecum.
• COMMONEST postnatal cause of intestinal obstruction in
infants. 2months-2 years.
Presents: paroxysmal, severe colicky pain and pallor. Sausage
shaped mass palpable in abdomen. Red current current jelly
stool (late sign). Abdo distension + shock.
Ix: Xray distended loops bowel. USS diagnosis and checking
insufflation
Tx - 75% reduced by air insuffation (NG tube). 25% reduced
by surgery
Malrotation
• Ileocaecal and duodenaljejunal flexure are
predisposed to volvulus due to short base.
• Presents as obstruction +/- compromised
blood flow. Bile or blood stained vomit.
Perotinitis. Ischaemic bowel.
• Usually 1-3 days with Ladds band obstructing
duodenum
• Surgical emergency = NBM, NG tube, Surgical
management
Henoch-Schonlein Purpura
• Usually occurs post streptococcal infection
• Small vessel Vasculitis
• Preceded by infections: Group A streptococci,
mycoplasma, Epstein-Barr virus. Vaccinations.
Environmental exposures: for example, drug and
food allergens pesticides, cold exposure, insect
bites
• Occurs more in the winter usually.
• Macular rash is preceded by low grade fever and
abdo pain. Can have bloody diarrhoea and swollen
painful joints.
• The rash is macula that progresses to papulae in a
classic buttock and back of leg location.
• Renal involvement in 50% of older but only 10%
significant with 1% going to ESRF
• Supportive management – steroids of really severe
and if renal and joint involvement
Purpuric rash!
Abdo pain - Tips
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In females always consider gynaecological disorders and
pregnancy-related disorders (you may need to speak to the
patient alone)
Male patients - always consider torsion of the testes
Consider illicit drug use
Is there a possibility of child abuse? In exams children being
abused invariably have abdominal pain!!!
Refer patient if you are unsure or concerned
Repeat physical examination may help
Use analgesia as required - it does not affect diagnostic
accuracy
Exclude medical causes such as pylenephritis, DKA,
pneumonia, UTI
Malabsorption
Presents :
–abnormal stools.
–Failure to thrive. Or poor growth in most, not all cases =
dropping centiles.
–Specific nutrition deficiencies.
–Difficult stools to flush and that have offensive pervading
odour.
• All must have diabetic assessment
Coeliac Disease
• Autoimmune disease- HLA B8.
• Gluten causes damage to the villi in the intestinal
mucousa causing it to become flat = crypt hypertrophy.
• Presents: Failure to thrive in first few years (commences
at 6 months when weaning begins). Irritable. Loose
stools. Abdo distension. Wasting esp buttocks.
Dermatitis herpetiformis.
• Diagnosis: transglutaminase ab and anti-endomysial
antibodies. Check IgA levels. Jejunal biopsy is gold
standard (when eating gluten!!!)
• Management: remove gluten from the diet. It before 2
years then must do a gluten challenge later in life to see
if still susceptible to damage.
• Free prescriptions for gluten free food!
Diarrhoea
• ‘transient dietary protein intolerances’ –
usually presents with diarrhoea, eczema.
• Acute colitis.
• Abdominal Migraine.
• Toddler diarrhoea – carrots and peas
diarrhoea. Grow out of by ~5 yrs. NORMAL!
Constipation
This is common in breast fed children. Again in young children
constipation and painful stools. Can follow febrile illness or superficial
fissure causing refrainment from defecation. Bad potty training.
Psychological stress. This causes faecal loading, reduced sensation of
internal sphincter and finally soiling as the internal sphincter is
overcome.
Organic causes. Constipation. Hypothyroidism. Hypercalcemia. UTI.
Hirshsprung
Management.
•Mild – increase dietary fibre. Stool softners (lactulose, docusate).
stimulate ( senna).
•Severe – evacuate the overload. Followed by 1-2 weeks of stool
softners. Large doses of powerful laxatives.
Encouragement by family is essentially
Enemas are best avoided
Hirschsprung’s Disease
• Absence of of ganglion cells from mysenteric and submucosal plexuses.
Results in narrow contracted segments. Abnormal bowel from rectum
progressing upwards until you get a dialted uninnervated bowel.
• Presents – failure to pass meconium and bowel distension. Later bile
stained vomit.
• PR – narrow segment and gush of poo and flatulence on removal.
Temporary removal of obstruction can delay diagnosis
• Can get associated hirschsprungs enterocolitis in first couple of weeks of
life. Later life you get chronic constipation without overflow soiling
• Diagnosis – demonstrate ganglion absence. Large acetyl-cholinesterase –
ve positive nerve trunks on a rectal biopsy. Anorectal manometry or
barium studies may be useful for surgery.
• Tx surgery – remove bad section and reattach normal bit to the anus
Misc Paeds
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DKA
Meningitis
Imms
Rashes
Safeguarding / child protection
Child with a limp
Kidneys and UTIs
• Triad:
DKA
1. Hyperglycaemia
2. Ketosis (urine and serum ketones)
3. Acidosis (pH <7.3)
• 30% of new diabetics present this way = Commonest
new presentation
• Risk factors = fhx diabetes, poor social circumstances,
<5 yrs, adolescent girls, previous DKA
• Serious = hypokalaemia, hypoglycaemia, dehydration,
hypovolaemia, renal failure, cerebral oedema.
• Be aware of gastroenteritis, dehydration with excess
urine output and resp distress with no chest signs
DKA
Child abuse
Risk Factors
Physical
– Bruises, bites, lacerations, burns, #, fabricated
illness
– Accidental, osteogenica imperfecta, coagulation
disorders, SSS, mongolian blue spot (melanocytosis)
Emotional
– Aggressive behaviour, poor self esteem
Sexual abuse
– Involve senior paediatrician and avoid repeated examinations
Neglect
– Often manifests in developmental delay
Management: SMACK
Safety of the child is the priority
Manage the medical problem
Always discuss concerns with senior
Contact social care
Keep clear notes
Non-accidental injury: NICE guidelines
LISTEN and observe: history, examination and investigations.
Seek an EXPLANATION: is it plausible, adequate and consistent?
RECORD exactly who said what and when.
DISCUSS the case with a senior experienced in child protection.
Are you CONSIDERING or SUSPECTING child maltreatment?
CONSIDERING: maltreatment is
included in the differential
diagnosis. Look into past history,
talk to other agencies, arrange a
prompt review of the situation.
SUSPECTING: serious level of
concern about maltreatment but
no proof. Refer urgently to social
services.
Immunisationsgood old parrot fashion: learn and regurgitate!
Age
Vaccines
2 months
Diphtheria, tetanus, pertussis, polio and Hib + pneumococcal
3 months
Diphtheria, tetanus, pertussis, polio and Hib + meningitis C
4 months
Diphtheria, tetanus, pertussis, polio and Hib + pneumococcal +
meningitis C
12 months
Hib + meningitis C
13 months
MMR + pneumococcal
3 years and 4
months – 5 years
Diphtheria, tetanus, pertussis, polio and Hib + MMR
Girls 12-13 years
HPV 16 and 18
13-18 years
Tetanus, diphtheria and polio
Case: The febrile child
Mikey is a 4 year old boy who is rushed
straight into resus because his parents are
unable to rouse him. They tell you that he has
had a fever for a few hours, then complained
of a headache and vomited. On the way to the
hospital they noticed a rash on his tummy, and
he then started to become drowsy.
Questions
1.
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3.
4.
5.
What is the most likely diagnosis?
What is a septic screen?
What is the most likely organism in this case?
How would you manage this condition?
Is this a notifiable disease?
Answers
1. Meningitis
2. Septic screen: blood cultures, urine culture,
chest x-ray and lumbar puncture.
3. Neisseria meningitidis
– Neonates: Group B strep, e.coli and Listeria.
– 1 month- 6 years: Neisseria meningitidis, Strep
pneumonia and Haemophilus influenzae.
– More than 6 years: Neisseria meningitidis and Strep
pneumoniae.
4. Call for senior help, IV fluids, IV
cefotaxime/ceftriaxone, rifampicin for close
contacts and check immunisation history.
5. Yes!
Notifiable Diseases…
Acute encephalitis
Acute infectious hepatitis
Acute meningitis
Acute poliomyelitis
Anthrax
Botulism
Brucellosis
Cholera
Diphtheria
Enteric fever (typhoid or paratyphoid
fever)
Food poisoning
Haemolytic uraemic syndrome (HUS)
Infectious bloody diarrhoea
Invasive group A streptococcal disease
Legionnaires’ Disease
Leprosy
Malaria
Measles
Meningococcal septicaemia
Mumps
Plague
Rabies
Rubella
SARS
Scarlet fever
Smallpox
Tetanus
Tuberculosis
Typhus
Viral haemorrhagic fever (VHF)
Whooping cough
Yellow fever
Child with a limp
• Perthe’s Disease- 4-8yrs, often boys, avascular necrosis
femoral head.
• SUFE’s – Obese, young teen, often boys, often have assoc
groin pain.
• Septic Arthritis- needs Abs ASAP = SAUPO
• Juvenile Idiopathic Arthritis – erythematous, swollen joint,
limited mobility, often fixed in position.
• Fracture / Trauma
• NAI
• Osgood Schlatter Disease – usually young teens, athletic
(gymnasts!)
• Developmental dysplasia of hips
The Child With a Limp
Septic arthritis
Features of septic arthritis:
• Systemically unwell child
• Erythematous warm joint
• Pseudoparalysis due to pain
Management:
• Give IV antibiotics NOW
• Initiate basic investigations:
FBC, CRP, U+E, x-ray of the
affected limb
• Aspirate under US guidance
and do cultures
• Look for an underlying cause e.g.
immunodeficiency
Duchenne Muscular Dystrophy
• Proximal muscle weakness
• Affects boys
• Life limiting (most die in
teens)
• Gower’s sign
Epilepsy & Seizures
A clinical event in which there is a sudden disturbance of
neurological function due to an abnormal/ excessive
neuronal discharge.
• Largely a clinical diagnosis
Classification of epilepsy:
1. GENERALIZED (ONSET in both hemispheres): absence,
myoclonic, tonic, tonic-clonic, and atonic.
2. FOCAL (ONSET in one hemisphere):
• simple partial seizure (consciousness unimpaired),
• complex partial seizure (consciousness impaired),
• partial seizure with secondary generalisation.
Seizures
Seizures
Non-epileptic: febrile convulsions, metabolic , head trauma,
meningitis/encephalitis, toxins/poisons.
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Reflex Anoxic seizures- non-epileptic, syncope due to sudden drop in
cerebral perfusion due to shock eg. bump to head, falling over etc. May
go pale. Rapid recovery.
Breath Holding Attacks- episodic apnoea, most common 12-18 months,
frightening but reassure parents not dangerous. Child will outgrow.
Pseudoseizures (exclude safeguarding issues). Diagnosis exclusion.
Epileptic: idiopathic (70-80%). Also consider congenital cerebral
abnormalities, encephalitis/meningitis, cerebral tumour, neurocutaneous
syndromes.
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Absence seizure- 3Hz spike and wave. Treat with Ethosuximide! (NOT
VALPROATE). Can be bought on by hyperventillation.
Grand Mal seizure- Tonic clonic (ask about tongue biting, incontinence,
noises, pre and post-ictal phases, triggering activity).
Partial Seizure- Focal seizures – simple = no unconsciousness, complex =
loss of consciousness
General Epilepsy Management
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MDT
Involve the parent and child in decision making
Family education
Drug treatment: valproate for generalized and
carbamazepine for focal seizures. Monitor levels and
for side effects.
Rescue medication (buccal midazolam/PR diazepam).
Consider tapering off medications if patients are
seizure free for 2 years.
Remember DVLA for older teens
Surgery for refractory epilepsy
Cerebral Palsy
Developmental Assessment
Rashes
The child with a rash:
Name the rash……..
A long-standing rash
in a 6 year old girl
with asthma and a
peanut allergy.
The child with a rash:
Name the rash…..
Eczema
Case: The child with a rash:
Name the rash…
A 5 year old boy
develops small red
macules that then
develop into blisters.
Case: The child with a rash:
Name the rash
Chickenpox
Case: The child with a rash:
Name the rash…..
A 1 year old boy develops
blisters on his face that
burst and form
erythematous areas with
honey-coloured scabs.
Case: The child with a rash:
Name the rash……
Impetigo
ADHD
• Attention deficit hyperactivity disorder
• Inattention, poor impulse control and motor overactivity.
• Management:
1. Exclude other causes of the behaviour: chronic illness,
sleep disorders, depression, problems at home.
2. Behaviour rating scales to establish severity
3. Psychosocial interventions: educate the family about
ADHD and coping strategies
4. Behaviourally oriented treatments: to rectify problem
behaviours
5. Medications: methylphenidate or dextroamphetamine
(stimulants). Monitor growth and blood pressure.
The Kidneys
Kidney Abnormalities:
Solitary kidney- unilateral renal agenesis. No treatment necessary if other kidney is
normal
Ectopic kidney- abnormal migration during embryogenesis = pelvic kidney or
horse-shoe kidney. Associated with Turner’s. DMSA scan detects
Multicystic dysplastic kidney- ureteric bud abnormality or proximal ureteric
atresia. kidney non-functioning and usually disappears
Autosominal dominant polycystic kidney disease-small cysts throughout kidney.
Associated with tuberous sclerosis, ovarian cysts, cerebral artery aneurysm
Autosomal recessive polycystic kidney disease- large cystic kidneys don’t
produce adequate urine = reduced amniotic fluid and pulmonary dysplasia. Develop
renal failure early childhood. Associated cystic liver disease. Detected fetally usually.
UTI’s
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Girls > Boys
Can present very vaguely- any unwell child potentially has UTI!
Dip urine of ALL unwell children
Can cause nocturnal enuresis
Always think diabetes (polyuria)
May have underlying vesico-ureteric reflux = kidney “scarring”
Leukaemia
• ALL is the commomest malignancy of childhood
• Proliferation of immature white blood cells
(blasts)
• Symptoms due to bone marrow failure = bruising,
anaemia, lymphadenopathy, bone pain,
hepatosplenomegaly, neutropaenic infection
• Diagnosed by bone marrow aspiration =
replacement of normal cells by blast cells
• Features of good prognosis = common subtype,
female sex (males get 2 yrs chemo, females 1
yr), low WCC count,
• Overall Good prognosis - >65% cured
Cleft Lip & Palate
Neural Tube Defects
Autism
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Hot OSCE topics
• Explaining
– Inhalers, Down’s syndrome, CF, diabetes, screening in
pregnancy, DMD.
• Examinations
– Neonate or child (incl. head circumference and hips),
developmental delay (growth charts)
• History or examination or management
– Common GI/resp/CV conditions, child abuse, Abdo
pain, febrile convulsions, seizures,
constipation/soiling/bed wetting, recurrent UTIs, reflux
• Videos
– Developmental assessment, CF, cerebral palsy
Questions?
That’s it folks!
Test Yourself QUIZ!!
1. Would you be concerned if you saw these
patients at your GP surgery?
QUIZ
2. A 10 month old child is admitted with difficulty in
breathing and a cough. O/e they have fine
inspiratory crackles and a wheeze and you notice
slight intercostal reccession
- What is the diagnosis and causative organism?
Their mother says that in addition to finding it hard to
breathe, and they haven’t been feeding well. Their
sats are 93% OA.
- Would you admit them?
- How would you treat them?
Management of bronchiolitis
Assess the clinical severity!!
1.Mild: feeding well, minimal RD, no RFs, no O2
needed – HOME with advice on when to return
2.Moderate: ↑ work of breathing, poor feeding, low
sats, RFs – admit for feeding support +/- O2
3.Severe: worsening RD, respiratory acidosis,
apnoea, dehydration, RFs – HDU, CPAP,
ventilation, IV fluids
QUIZ
3. A child presents to A&E with a likely fractured
arm. The X ray shows a fractured radius. You
notice she has had multiple fractures in the past
so go back to examine the child and find this
o/e:
What is the diagnosis?
If you suspected child abuse, what would you do?
S safety of the child is the priority
M manage the medical problem
A always discuss concerns with senior
C contact social care
K keep clear notes
QUIZ
4. List 5 causes of abdominal pain in children
– Which factors would make you suspect a psychological cause?
5. You see a 2 year old girl in A&E who looks extremely
unwell. She is holding her throat with her mouth open.
You notice she is drooling and has soft inspiratory
stridor. She is not coughing. Her temperature is 39°C.
Her mother is desperate that you examine her throat as
she thinks she is choking.
– How would you manage this patient; would you examine her?
Case
• 6 week old baby boy – Tyrone
• Mum’s first child present with episodes of vomiting. And is a
little worried as he is not keeping anything down though still
eager to eat.
• The vomiting has been present for the last week or so and can
be quite vigorous, often hitting the wall. No blood. Brings up
what is eaten.
• O/e Tyrone looks fatigued. He has some dry mucus
membranes. And you notice an olive like mass in the LUQ.
• Investigations – U+Es, USS, barium swallow
• Tx – fluid and electrolyte resus. Pylorotomy
Case: The blue baby
Kevin is a 3 week old baby who is brought to
see the GP because his mum has noticed that
he is going a bit purple around the lips. He
also has crying spells where he is inconsolable
and goes very pale. On examination you note
cyanosis and a loud harsh ejection systolic
murmur at the left sternal edge, radiating to
the back.
His chest x-ray
Questions
1. What is the most likely diagnosis?
2. What are the key abnormalities in this
condition?
3. How do you distinguish between cardiac and
respiratory causes of cyanosis?
4. What are the crying episodes, and how would
you manage them?
Answers
1. Tetralogy of Fallot
2. 4 key abnormalities: a large VSD, over-riding
aorta, subpulmonary stenosis, and right
ventricular hypertrophy.
Answers
3. Put the baby in a chamber with 100% oxygen and if
the partial pressure of oxygen remains low then the
heart and not the lungs is the problem.
4. Hypercyanotic episodes: there is an increase in
cyanosis, inconsolability due to hypoxia, shortness of
breath and pallor. If they last more than 15 minutes
then urgent treatment is required as the infant is at
risk of MI and stroke. Give sedation, morphine, IV
propranolol and fluids.
Key Revision Topics
• Cardiac- basic murmurs (VSD, ASD, TOF, PDA, TGA, coarctation) and SVT
• Resp- Asthma, C.F, Viral wheeze, croup, epiglottitis, Anaphylaxis, bronchiolitis,
Pneumonias, Ear infections (Otitis externa, otitis media, glue ear)
• GI- Coeliac disease, IBD (Crohn’s >UC), Constipation, Gastroenteritis,
Intussusception
• Psych / Developmental- Autism, Developmental milestones, Cerebral palsy
• Infectious Diseases- Kawasaki, Rheumatic fever, Endocarditis, Meningitis
• MSK- JIA, Lupus, Perthe’s disease, septic arthritis, SUFE
• Hepatic- neonatal jaundice
• Haem / Onc- Leukaemias (ALL), ITP, sickle cell,
• Paediatric rashes – chicken pox, rubella, mumps, measles, HSP, slapped cheek
• Syndromes- Down’s, Edwards, Patau’s, Turner’s, Klinefelter’s,
• Neonatal- NEC, streptococcal sepsis, Pyloric stenosis,
• NAI and differentials (Mongolian blue spots, osteogenesis imperfecta, scalded
skin syndrome)
• Emergencies- Anaphylaxis, Meningitis, Choking, DKA,
• Immunisations and growth charts
• Know how to take a basic structured history, structured examination, and
formal developmental assessment.