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Paediatrics
🦠 Infection
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Name the key features of a child that is:
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- Appearance
- Colour: Pale
- Activity: Not responding normally to social cues, wakes only with prolonged stimulation
- Breathing
- Nasal flaring
- Tachypnoea (but ≤ 60 breaths/min)
- Circulation
- Tachycardia
- CRT ≥ 3 seconds
- Dry mucous membranes
- Everything else
- Aged 3-6 months with temperature ≥ 39°C
- Fever ≥ 5 days
- Rigors
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- Appearance
- Colour: Pale/mottled/blue
- Activity: No response to social cues, doesn't wake or if roused doesn't stay awake
- Breathing
- Grunting
- Tachypnoea > 60 breaths/min
- Circulation
- Reduced skin turgor
- Everything else
- Aged < 3 months with temperature ≥ 38°C
- Non-blanching rash
- Bulging fontanelle
- Neck stiffness
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- Ataxic telangiectasia
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- Total IgA - They may have a selective IgA deficiency, in which case they need to test for IgG anti-TTG & tissue biopsy
- Opportunistic infections - Commonly LRTIs
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- DiGeorge syndrome - Microdeletion of chromosome 22
- Congenital HD
- Abnormal facies
- Thymus incompletely developed
- Cleft palate
- Hypoparathyroidism → Hypocalcaemia
- 22nd chromosome abnormality
- Incomplete thymus development → T-cell immunodeficiency
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CATCH-22
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- Complement proteins - C2 deficiency most common
- HiB
- S. pneumonia
- N. meningitidis
- SLE
- Vaccination against encapsulated organisms
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Encapsulated organisms:
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- Severe combined immunodeficiency
- X-linked recessive genetic disease causing immunodeficiency resulting in dysfunctional B-cells & T-cells
- JAC3 gene mutation → Adenosine deaminase deficiency
- Atypical infections - Pneumocystis, CMV
- Unwell after live vaccines
- Immunoglobulin therapy
- Sterile environment
- Haematopoietic stem cell transplant
- SCID
- Erythroderma - Red scaly, dry rash
- Alopecia
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No immune response leads to:
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Manage infection risk:
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- C4 levels (↓)
- Hereditary angioedema - C1 esterase deficiency
- Bradykinin is part of the inflammatory response causing increased vascular permeability & BV dilatation
- C1 esterase inhibits bradykinin normally so its deficiency causes angioedema (lip swelling) following infection due to unopposed bradykinin
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Dehydration severity | Deficit (ml/kg) | Clinical features | Management |
Mild | 50ml/kg
(5% body weight) | Slightly dry mucus membranes, increased thirst, slightly decreased urine output. | Oral/NG rehydration solution (1-1.5x maintenance)
OR: IV maintenance |
Moderate | 100ml/kg
(10% body weight) | Dry mucus membranes, tachycardia, reduced urine output, loss of skin turgor, sunken eyes/fontanelle. | IV bolus
OR: NG fluids at 25ml/kg/h for first 4 hours; oral
rehydration solution |
Severe | 150ml/kg
(15% body weight) | As in moderate but also:
pronounced tachycardia, weak pulse, hypotension, delayed capillary refill, mottled skin/cyanosis, dyspnoea. | IV bolus (may need multiple) |
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- 220-440ml over 15 mins
- 10-20 ml/kg STAT
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- 22kg: 1000ml + 500ml + 40ml = 1540ml/day
- 1540 ÷ 24 = 64 ml/hr
First 10kg of bodyweight | 100ml/kg/day |
Second 10kg of bodyweight | 50ml/kg/day |
Remainder of bodyweight | 20ml/kg/day |
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- K⁺ - 1mmol/kg/day
- Glucose - 50-100 g/day
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- NaCl (0.9%) + 5% dextrose + 10mmol KCl
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A exanthem is an eruptive widespread rash.
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- Measles virus
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- Fever
- Coryzal symptoms
- Conjunctivitis
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- 3-5 days following fever onset: Erythematous macular rash that starts behind the ears then spreads to the rest of the body
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- Koplik spots in the mouth (buccal mucosa)
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- Conservative: Self-resolving after 7-10 days
- Report to public health
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- 5 days after the rash has cleared up
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- Acute otitis media (most common)
- Bronchopneumonia
- Encephalitis
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- Toxin produced by Strep. pyogenes (group A strep) - Often assoiated with tonsillitis
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- 'Strawberry' tongue
- Fever (1-2 days)
- Malaise
- Tonsillitis
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- Fine punctate erythema ('pinhead') starting on the trunk and spreads outwards
- Rough sandpaper texture, desquamation (skin peeling)
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- Penicillin V (10 days)
- Report to public health
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- Otitis media
- Post-strep GN
- Acute rheumatic fever
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- Rubella virus
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- Erythematous macular rash starting on the face then spreading to the rest of the body
- Classically lasts 3 days
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- Conservatively
- Report to public health
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- Thrombocytopenia
- Encephalitis
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- Parvovirus B19
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- Diffuse bright red rash on both cheeks.
- A few days later: Reticular (net-like) mildly erythematous rash affecting the trunk and limbs appears that can be raised and itchy.
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- Conservative (1-2 weeks)
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- When the rash appears
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- Immunocompromised patients
- Pregnant women
- Haematological conditions: Sickle cell, thalassaemia, haemolytic anaemia
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- Aplastic anaemia - FBC, reticulocyte count
- Serological test to confirm parvovirus presence
- Especially in patients with sickle cell
- Encephalitis/meningitis
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- Infection in the first 20 weeks → Hydrops fetalis
- Placental thickening
- Excess amniotic fluid
- General oedema
- Abnormal fluid in the abnormal cavity, heart, or lungs
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- HHV-6 (human herpes virus)
- 6 months - 2 years
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- High fever (up to 40°C) that comes on suddenly and goes in 3-5 days
- Febrile convulsions
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- Mild erythematous macular rash across the arms, legs, trunk & face
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- Conservative - Antipyretics
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- Varicella zoster virus (VCV) - Human herpes virus 3 (HHV-3)
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- Fever, itch and general fatigue
- Widespread, erythematous, vesicular rash with blistering lesions
- Infective 3 days prior to and 5 days after rash appears
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- Stay off school until 5 days after the rash appeared
- OR until all lesions have crusted over
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- Conservative in most
- Fever: Paracetamol
- Itch: Chlorphenamine (antihistamine), calamine lotion
- Aciclovir in immunocompromised
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- Bacterial superinfection (common)
- Conjunctival lesions
- Pneumonia
- Encephalitis → Ataxia
- Shingles in later life (or Ramsay hunt syndrome)
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- < 28 weeks gestation → Congenital varicella syndrome (developmental abnormalities)
- Varicella zoster immunoglobulins
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- Coxackie A16
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- Vesicular rash in the mouth and on the palms and soles of the feet
- Mild systemic upset: Sore throat, fever
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- Conservative
- Don't share towels & bedding as highly contagious
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- No - Only if they feel unwell, not compulsory
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- Molluscum contagiosum virus (poxvirus)
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- Flesh coloured papules with central dimples, typically appearing in "crops" of multiple lesions
- Spread through direct contact
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- Conservative
- Immunocompromised: Topical KOH or surgical removal & cryotherapy
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- HHV-6/7
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- Herald patch
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- Herald patch (shown above) appears ≥ 2 days before the rest of the rash
- Faint red/pink oval shaped (discoid) lesions smaller than herald patch
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- Conservative (rash resolves within 3 months)
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- Vasculitis affecting medium-sized blood vessels
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- > 5 days with high, resistant fever (≥ 40°C)
- Often < 5 years old
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- Mouth (strawberry tongue & red, cracked lips) & eyes (conjunctivitis)
- Erythema of the palms of hands and soles of feet which later peel
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- High dose aspirin & echocardiogram
- Risk of coronary artery aneurysm
- Reye's syndrome → Encephalopathy & liver damage
- IV immunoglobulins: Reduce fever and the risk of heart problems
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- Fungal infection of the skin
- Common fungus: trichophyton
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- Scalp
- Causes hairloss
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- Athlete's foot
- White or red, flaky, cracked, itchy patches between the toes
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- Groin
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- Body
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- Nail
- Thickened, discoloured and deformed nails
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- Itchy, erythematous, scaly and well-demarcated rash
- If they have a skin infection it may have spread from toenails so always check them
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- Scrape off scales and send for microscopy & culture
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- Lifestyle: Stopping warm, moist environments will stop growth
Most:
- Topical: Clotrimazole/miconazole
- PO: Fluconazole/griseofulvin/itraconazole
Nail:
- Amorolfine nail lacquer
- PO terbinafine
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- Sarcoptes scabei
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- Incredibly itchy red spots classically between finger webs
- Track marks where the mites have burrowed
- Crusted scabies: Scaly plaques (differential for psoriasis) typically in immunocompromised
- Very serious condition due to lack of immune response
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Treat everyone in household as very contagious, even if asymptomatic. Was all clothes, towels, bedsheets, etc.
- Permethrin cream left on for 8-12 hours then washed off
- Repeat 1W later
- PO ivermectin (if not working or crusted scabies)
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- S. aureus → "Golden crust"
- S. pyogenes
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- Non-bullous (nose/mouth)
- "Golden crust" from dried exudate
- Bullous
- 1-2cm fluid filled bullae form on the skin, when they burst they also form a golden crust.
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- TOP fusidic acid/antiseptic cream (hydrogen peroxide)
- PO flucloxacillin for:
- Widespread/severe infection
- Bullous
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- All lesions have crusted over OR
- 48h after treatment has started
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- Staphylococcal scalded skin syndrome
- IV flucloxacillin & topical fucidic acid
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- Bleeding under the skin, 3 types:
- Petechiae (burst capillaries) < 3mm
- Purpurae (leaking of blood from vessels): 3-10mm
- Ecchymosis > 10mm
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Think: Anything that puts you at ↑ risk of bleeding
- Meningococcal septicaemia (DIC)
- Feverish, unwell child
- HSP (IgA vasculitis)
- Purpuric rash on legs and buttocks
- ITP (idiopathic thrombocytopenic purpura)
- Acute leukaemias
- Often have petechiae w/ other systemic signs
- HUS
- Oliguria & signs of anaemia, often after recent diarrhoea
- Traumatic: Non-accidental injury (e.g. tight pressure on the skin)
- Viral illness (diagnosis of exclusion)
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- Bedside:
- BP
- Urinalysis: UTI
- Bloods:
- FBC: Hb, platelets, WCC
- U&E: Urea, creatinine
- Coagulation
- CRP
- Blood culture
- Lumbar puncture
- Imaging:
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- Inactivated: Dead pathogen
- Subunit/conjugate: Parts of the pathogen
- HPV, shingles
- Live attenuated: Weakened but live pathogen
- MMR, BCG, chickenpox, rotavirus
- Toxin
- Diphtheria, tetanus
Schedule:
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- 6-in-1, MenB, Rotavirus, Pneumococcal, 2-in-1, MMR
- Diphtheria, tetanus, pertussis, polio, HiB and HepB
- 2, 3 & 4 months
- 6-in-1
- Rotavirus
- MenB
- 6-in-1
- Rotavirus
- Pneumococcal
- 6-in-1
- MenB
- 2-in 1
- HiB
- MenC
- MMR
- Pneumococcal
- MenB
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6-RM
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6-RP
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6-M
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2-MPM
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- 4-in-1
- Diphtheria
- Tetanus
- Pertussis
- Polio
- MMR (second dose)
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DTPP
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- 12-13 years (2 doses 6-24M apart)
- Needs to be given before they're sexually active to protect them from genital warts and cervical cancer
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- MEN ACWY
- 3-in-1: Diphtheria, tetanus, polio
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- High risk individuals: Urban areas with high TB prevalence or children arriving from high risk areas
- Given at birth or whenever the child presents if not born in UK
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- Nitrous oxide (NO)
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- Mast cells release cytokines → ↑ endothelial permeability → Fluid leakage into extracellular space → Oedema & ↓ blood volume
- Oedema → ↓ perfusion to tissues → Anaerobic respiration → ↑ lactate
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- Coagulation activation → Widespread formation of small clots → Consumption of platelets & coagulation factors → Thrombocytopenia (DIC)
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Symptoms:
- Not feeding
- High pitched crying
- Reduced tone
Signs:
- Skin colour change (mottled, pale, cyanosed)
- Low BP, raised HR
- Prolonged CRT
- Pyrexia
- Reduced GCS
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BUFALO
- Blood cultures
- Urine output
- Fluids IV/IO
- 20ml/kg - Children
- Intraosseous
- Used when IV access isn't possible
- Antibiotics IV (within 1 hour)
- Child oldern than 1M: IV cefotaxime
- Alter when the MC&S arrives back
- Lactate (ABG/VBG)
- FBC, U&E, CRP, INR
- Oxygen (If shock or SpO2 < 94%)
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Identify the underlying cause:
- CXR → Pneumonia
- Sputum culture → Pneumonia
- Urine MC&S → UTI
- LP → Meningitis
🧬 Genetics, Neonates & Growth
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- Involves looking at the number of chromosomes, their size & basic structure.
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Structural changes:
- Huntington's chorea
- Marfan's/Ehlers-Danlos
- Adult polycystic kidney disease (AD-PKD)
- Von Willebrand's disease
- Hereditary non-polyposis colorectal cancer (HNPCC)
- Familial adenomatous polyposis (FAP)
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Metabolic:
- Cystic fibrosis
- Sickle cell anaemia
- Haemochromatosis
- Thalassaemia
- Wilson's disease
- Congenital adrenal hyperplasia
- Gilbert syndrome
- Childhood polycystic kidney disease (ARPKD)
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- Haemophilia A/B
- Duchenne's muscular dystrophy
- Becker muscular dystrophy
- G6PD deficiency
- Androgen insensitivity syndrome
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Name the condition and the genetic abnormality for the following cases:
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- Fragile X syndrome: Trinucleotide repeat in the FMR1 gene. X-linked (unclear whether dominant or recessive).
- Mutation in the FMR1 gene coding for a protein that plays a role in cognitive development
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- William syndrome: Deletion mutation on chromosome 7
- Supravalvular aortic stenosis (narrowing just above aortic valve)
- Hypercalcaemia
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- Patau syndrome: Trisomy 13
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- Noonan syndrome: Multiple mutations cause this (PTPN11, SOS1, RAF1 and RIT1 genes) but they won’t be tested.
- Autosomal dominant
- Wide space between the eyes
- Risk of pulmonary stenosis, HOCM & ASD
- Cryptorchidism
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- Marfan syndrome: Defects or deletions of the fibrillin-1 (FBN1) gene → Abnormal formation of fibrillin → Abnormal connective tissue
- Autosomal dominant
- Ehlers-Danlos
- Aortic/mitral regurgitation
- Aortic aneurysms
- Pneumothorax
- Minimise BP to reduce risk of cardiac abnormalities
- High risk in pregnancy due to hypertension
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- Prader-Willi syndrome: Absence of paternally expressed genes on chromosome 15 due to paternal deletion.
- Growth hormone to improve muscle development
- Dieticians
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- Edwards syndrome: Trisomy 18
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- Angelman syndrome: Genetic mutation on chromosome 15 (UBE3A).
Common cases:
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- Trisomy of chromosome 21
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- Facial:
- Brachycephaly (small head with a flat back)
- Prominent epicanthic folds
- Upward sloping palpebral fissures
- Brushfield spots in the eyes
- Body:
- Hypotonia
- Single palmar crease
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- Brain: Learning disability, Early-onset Alzheimer's
- Ear: Recurrent otitis media & deafness
- Eye: Myopia, strabismus, cataracts
- Heart (1 in 3): ASD, VSD, PDA & TOF
- Hypothyroidism
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- Combined test at 11-14W
- USS looking at nuchal translucency (thickness of the back of the fetal neck): Down's > 6mm
- Bloods: ↑ β-hCG & ↓ PAPPA: High risk
- Results: Risk score.
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- Referred for these tests when the screening comes back as high risk.
- Methods:
- CVS: USS guided biopsy of placenta (Cases < 15 weeks)
- Amniocentesis: USS guided aspiration of amniotic fluid (Cases > 15 weeks)
- NIPT: Fetal blood cells are separated from maternal and karyotyped
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- MDT approach to manage the wide array of problems arising
- Doctors (paediatrician & GP), nurses, speech & language therapist, occupational therapist, physiotherapist
- Regular TFTs, echocardiogram, audiometry, eye checks
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- Single X chromosome (45XO)
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- Female because all humans lacking a Y chromosome are.
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- Short stature
- Webbed neck
- Widely spaced nipples
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- Ear: Recurrent otitis media
- Heart:
- Bicuspid aortic valve (most common)
- Aortic coarctation
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- Growth hormone therapy
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- Oestrogen & progesterone replacement
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- Fertility treatment
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- 47 XXY
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- Appear as normal males until puberty then develop features
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- The additional X chromosome results in primary male hypogonadism → Testosterone deficiency
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- MSK: Taller height, wider hips, weaker muscles
- Hormonal:
- Gynaecomastia
- Small testicles
- Reduced libido
- Infertility
- Speech & language difficulties
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- Testosterone injections
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- Breast reduction surgery
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- Advanced IV fluids techniques have the potential to allow fertility
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- Prematurity
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- Warm the baby
- Calculate the APGAR score
- Used to check a baby's health: 7-10 is normal
- Appearance, Pulse, Grimace, Activity & Respiration. 0-2 for each
- Low = Bad. High = Good.
- Stimulate breathing - Drying vigorously
- Inflation breaths - If gasping or not breathing
- Chest compressions - If HR < 60 despite resuscitation
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Finding | 0 | 1 | 2 |
Appearance (Skin colour) | Blue / centrally pale | Blue extremities | Pink |
Pulse | Absent | < 100 | > 100 |
Grimmace (Response to stimulation) | No response | Little response | Good response |
Activity | Floppy | Flexed arms & legs | Active |
Respiration | Absent | Slow / irregular | Strong / crying |
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- 5 rescue breaths, then
- 3:1
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- Day 5-9 of life
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- Sickle cell disease
- Hypothyroidism
- Cystic fibrosis
- Phenylketonuria
- Medium-chain acyl-CoA dehydrogenase deficiency (MCADD)
- Maple syrup urine disease (MSUD)
- Isovaleric acidaemia (IVA)
- Glutaric aciduria type 1 (GA1)
- Homocystin
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They are both collections of fluid resulting from trauma during birth.
- Caput succaneum: Fluid collecting outside of the periosteum on the scalp, meaning it is able to cross suture lines
- Cephalohaematoma: Subperiosteal haematoma, confined to the suture lines of the skull. Blood can also cause bruising of the affected area.
- Cephalo - Head, therefore the collection is within the skull
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- Weakness of shoulder abduction, external rotation, arm flexion & finger extension
- C5/6 nerve root damaged during shoulder dystocia or traumatic delivery
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- Apnoea
- > 20 seconds
- Immaturity of the autonomic nervous system, therefore more common in premature neonates
- Infection
- Anaemia
- Seizures/intracranial haemorrhage
- GORD
- Apnoea monitors
- Tactile stimulation to prompt restarting of breathing
- IV caffeine to prevent recurrent apnoea
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- TORCH syndrome
- Toxoplasmosis (flu-like illness)
- Other agents
- Rubella
- CMV
- HSV
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- Transient tachypnoea of the newborn → Treat with O₂
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- Neonatal abstinance syndrome
- Opiates
- Diazepam
- SSRIs
- Alcohol
- PO morphine sulphate for opiate withdrawal
- PO phenobarbitone for non-opiate withdrawal
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- Foetal alcohol syndrome
- Learning difficulties
- Microcephaly
- Cardiac malformations
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- Congenital rubella syndrome (Classic triad)
- MMR vaccine before getting pregnant
- Vaccine cannot be given antenatally as it is a live vaccine but should be offered after they have given birth
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- Congenital varicella syndrome: Chorioretinitis → Cataracts & eye inflammation
- IgG antibodies against varicella
- IV varicella immunoglobulins
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- Congenital HSV
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- Antenatal CMV infection
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- Congenital Zika syndrome
Key neonatal conditions:
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- Within 24 hours of birth
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- Mild yellowing of the skin & sclera at 2–7 days of age, resolving by day 10
- Caused by fragile RBCs and underdeveloped liver
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Increased production of bilirubin:
- Haemolytic disease of the newborn (Rhesus incompatibility)
- ABO incompatibility
- Trauma: Cephalohaematoma, haemorrhage
- Sepsis/DIC
- G6PD deficiency
Decreased clearance of bilirubin:
- Prematurity → Underdeveloped liver
- Breast milk jaundice → Baby more likely to be dehydrated
- Neonatal cholestasis
- Biliary atresia
- Hypothyroidism/hypopituitarism
- Gilbert syndrome
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- CNS damage caused by high levels of unconjugated bilirubin → Cerebral palsy, learning difficulties and/or deafness
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- FBC: Polycythaemia/anaemia
- Conjugated bilirubin: ↑ in HPB cause
- Blood type: ABO/Rhesus abnormalty
- Direct Coombs test: Haemolysis
- TFT: Hypothyroidism
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- Phototherapy: Converts unconjugated bilirubin into isomers that can be excreted by the body
- Exchange transfusion
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- Group B streptococci (GBS)
- E. coli
- Listeria
- Klebsiella
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- Vaginal GBS colonisation
- Previous GBS infection in pregnancy
- Chorioamnionitis or pyrexia
- Prematurity (< 37 weeks)
- Preterm premature rupture of the membranes (PPROM)
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- Maternal sepsis
- Signs of shock
- Seizures
- Respiratory distress starting > 4 hours after birth
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- 1 risk factor → Monitor carefully for 12 hours
- > 1 risk factor / 1 red flag → Start antibiotics
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- Benzylpenicillin & gentamicin
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- Lack of blood supply to the brain → Ischaemia of the brain tissue → Brain malfunction → Cerebral palsy/Death
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- Maternal shock
- Intrapartum haemorrhage
- Prolapsed cord/cord compression
- Nuchal cord (wrapped around baby's neck)
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- Poor feeding
- Hypotonia
- Seizures
- Apnoea → Cyanosis
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- Supportive care with ventilation & resuscitation
- Therapeutic hypothermia (33-34°C) to reduce the inflammation and neuron loss in the brain
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- Child < 32 weeks → Inadequate surfactant → High surface tension → Atelectasis → Hypoxia, hypercapnia, ARDS
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- Antenatal dexamethasone to stimulate surfactant production
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Short-term:
- Pneumothorax
- Infection
- Apnoea
- Intraventricular hemorrhage (IVH)
Long-term:
- Chronic lung disease of prematurity
- Retinopathy of prematurity
- Neurological, visual & hearing impairment
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- Bowel necrosis in premature neonates with unknown cause → Can cause perforation & peritonitis
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- Prematurity
- Formula feeding
- Respiratory distress
- Sepsis
- Congenital heart disease: PDA
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- Intolerance of feeds, vomiting with green bile, distended abdomen
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- Dilated bowel loops, bowel wall oedema
- Pneumatosis intestinalis: Gas in the bowel wall
- Free gas in peritoneal cavity → Perforation
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- NBM
- TPN feeding
- Antibotics
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- Laparotomy to remove necrotic bowel tissue
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- Prematurity → Incomplete retinal blood vessel development → Hypoxia, neovascularisation & scarring → Retinal detachment & blindness
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- The vessels grow from the middle of the retina outwards
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- Assess how far the vessels have grown in the retina. When they reach zone 3 they don't need assessing anymore.
- Disease is staged:
- Stage 1: A demarcation line that separates normal from premature retina.
- Stage 2: A The demarcation line widens and thickens forming a ridge.
- Stage 3: Growth of fragile new abnormal blood vessels. As ROP progresses the blood vessels may engorge and become tortuous.
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- Babies born < 32 weeks gestation or under 1.5kg
- Every 2 weeks until vessels are in zone 3
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- Transpupillary laser photocoagulation → Stops neovascularisation
- Anti-VEGF medications
- Surgery for retinal detachment
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- Free
- Overfeeding is less common with breast feeding
- Breast feeding contains antibodies
- Reduced risk of sudden infant death syndrome
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- 150 ml/kg/day
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- Feeding on demand
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- Breast: 10%
- Formula: 5%
- Day 10
- Dehydration due to under feeding
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- The gradual transition from milk to normal food
- ~ 6 months
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An infant or child who does not gain weight at the expected rate.
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- One or more centile spaces if birthweight was < 9th centile
- Two or more centile spaces if between 90th & 91st percentile
- Three or more centile spaces if > 91st percentile
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- The distance between the two centile lines on a growth chart (e.g. between 75th & 50th centile)
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- Inadequate nutritional intake
- Neglect
- Iron deficiency anaemia
- Maternal malabsorption if breastfeeding
- Difficulty feeding
- Poor suck (e.g. due to hypotonia)
- Cleft palate
- Increased energy requirements
- Hyperthyroidism
- Chronic disease, e.g. congenital HD, CF
- Malignancy
- Immunodeficiency (HIV)
- Infection
- Malabsorption
- Cystic fibrosis
- Coeliac disease
- Cow's milk protein intolerance
- Inflammatory bowel disease
- Inability to process nutrition
- Type 1 diabetes mellitus
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History:
- Neglect: Parents’ physical/mental health
- Feeding history: Breast/bottle, volume, frequency, keep food diary
- Family history: CF, IBD or coeliac disease
Examination:
- Growth chart plotting: Height & weight
- Cardiac: BP, HR, murmurs
- Respiratory: Breath sounds (CF)
- Gastrointestinal: Palpate (Pyloric stenosis)
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MDT approach:
- Breast feeding technique advice
- Dietician
- Energy dense foods to boost calories
- Nutritional supplement drinks
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Height ≥ 2 SDs below the average for their age and sex
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- Constitutional delay in growth & development
- A variation on normal development leading to short stature in childhood but this is compensated for with a large growth spurt in puberty
- They ultimately reach their predicted adult height
- Delayed bone age
- X-ray hand & wrist to assess bone age
- Familial short stature
- Endocrine: Hypothyroidism
- Genetic: Down's syndrome
- Nutritional: Malabsorption (coeliac/IBD/CF), neglect
- Chronic disease: Congenital heart disease
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4 domains:
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- Not sitting unsupported at 12 months
- Not standing independently at 18 months
- Not walking independently at 24 months
- Not running at 2.5 years
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- Supports head when lying on abdomen
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- Sit with support
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- Sit unsupported (refer at 12 months)
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- Stand with aid & cruises using furniture
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- Walk unaided
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- Squat & pick things up from floor
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- Run & kick a ball
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- Climb stairs 1 foot at a time
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- Climb stairs like an adult
- Hop
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- Hand preference before 12/18 months (may indicate CP)
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- Fix & follow
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- Palmar grasp
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- Scissor grasp
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- Pincer grasp
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- Clumsily use a spoon & bring food to mouth
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- Drawing
- Vertical: 2 years
- Horizontal: 2.5 years
- 3 years
- Tower of bricks
- 14 months → 2 bricks
- 18 months → 4 bricks
- 24 months → 8 bricks
- 30 months → 12 bricks
- 3 years
- Pencil grasps
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Age | Grip | Description |
1–2 years | Fisted grip | Hold it like a dagger. |
2–3 years | Digital pronate grip | All fingers holding the pen, palm facing down, movement mostly from elbow. |
3–4 years | 4 finger grip | 4 fingers on pen, movement mostly from the wrist. |
4–6 years | Static tripod grip | |
6–7 years | Dynamic tripod grip |
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- No words at 18 months
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- Double syllables 'adah'
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- Polysyllabic babbles
- Mama/dada
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- Knows & responds to their name
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- Knows 2-6 words (refer at 18 months)
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- Combine 2 words
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- Talks in 3-5 word sentences
- Asks 'what' & 'who' questions
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- Asks 'why' & 'how' questions
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- Doesn't smile by 10 weeks
- No interest in others at 18 months
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- Smiles
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- Curious & engaged with people
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- Stranger danger
- Takes everything to mouth
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- Waves bye bye
- Claps hands
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- Imitates activities: Play kitchen, cooking, etc.
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- Parallel play (II - Parallel)
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- Interactive play
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- Imaginative play
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- Down's syndrome
- Fragile X syndrome
- Foetal alcohol syndrome
- Metabolic disorders
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- Cerebral palsy
- Myopathy
- Spina bifida
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- Dyspraxia (Caused by prematurity/low birth weight): Developmental co-ordination disorder
- Cerebral palsy
- Muscular dystrophy
- Visual impairment: Cataracts
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- Hearing impairment: Otitis media
- Learning difficulties
- Neglect
- Autism
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- Neglect
- Autism
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- Female: 8-14 years
- Male: 9-15 years
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- Boys: Increased testicular volume
- Girls: Breast development
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- ~ 4 years from start to finish
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- Tanner staging: Based on pubic hair, breast development, testicular volume, genital size
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LH | Testosterone | Diagnosis |
↓ | ↓ | A |
↑ | ↓ | B |
↑ | ↔︎/↑ | C |
↓ | ↑ | D |
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- Hypogonadotrophic hypogonadism
- Kallman's syndrome
- Anosmia - Reduced or absent sense of smell
- Hyperprolactinaemia
- GH deficiency
- Pituitary damage: Trauma/surgery
- Excessive exercise: Delays menarche in girls
- Hypothyroidism
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- Primary hypogonadism
- Gonad damage: Torsion, cancer, infection (mumps)
- Cryptorchidism
- Klinefelter's syndrome
- Turner's syndrome
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- Androgen insensitivity syndrome
- X-linked recessive genetic condition where there is end-organ resistance to testosterone
- Genotypical (46XY) male has a female phenotype
- Primary amenorrhoea
- Undescended testes causing groin swellings
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- Testosterone secreting tumour
👨👨👦 Core Medical
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- Fetus: Veins carry oxygenated blood, arteries carry deoxygenated blood
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- From the internal iliac arteries to the placenta
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- The placenta supplies oxygen and nutrients in the fetus, not the lungs
- They allow more blood to reach the systemic circulation & tissues, bypassing the liver & lungs (diagram below)
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- Ductus venosus
- From umbilical vein to IVC - Bypass liver
- Foramen ovale
- From right atrium to left atrium - Bypass lungs
- Ductus arteriosus
- From pulmonary artery to aorta - Bypass lungs
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- Foramen ovale: Baby breathes → Alveoli expansion → ↓ pulmonary vascular resistance → ↓ RA pressure → Closure of the foramen ovale
- Becomes fossa ovalis
- Ductus arteriosus: ↓ circulatory prostaglandins → Closure of ductus arteriosus
- Becomes ligamentum arteriosum
- Ductus venosus: No flow through umbilical veins → Duct closure
- Becomes ligamentum venosum
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Formulating differentials:
‣
- Not pathological. Caused by fast blood flow through various areas of the heart during systole
- All the S’s:
- Soft
- Short
- Systolic
- Symptomless
- Situation dependent (quieter when standing)
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- S2: Closure of the aortic and pulmonary valves
- On inspiration the right side of the heart fills faster than the left → Takes longer for RV to empty due to increased volume → Pulmonary valve closes after the aortic
- Splitting of the second heart sound is normal in children if it is only on insipration
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Constant volume throughout
- Mitral/tricuspid regurgitation
- VSD (left lower sternal border)
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Crescendo-decrescendo murmur (loud)
- Aortic stenosis
- Pulmonary stenosis (caused by TOF)
- ASD (mid-systolic)
- HOCM (fourth intercostal space LSE)
- Coarctation of the aorta
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- Mid-systolic crescendo-decrescendo murmur in second intercostal space LSE
- Atria are filling during ventricular contraction
- Fixed split second heart sound (on inspiration & expiration)
- Shunt from LA → RA causing overfilling of RV, taking londer to empty
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- Continuous "machinery" murmur
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- Ejection systolic due to pulmonary stenosis
Investigations & management:
‣
- Wait 24 hours & inform senior then review again:
- If still present refer for for ECHO
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- Louder than 2/6
- Diastolic
- Louder on standing
- Other symptoms: FTT, feeding difficulty, SOB, cyanosis
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- ECG
- CXR
- Echocardiogram
Cyanotic vs Acyanotic:
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A heart defect that allows blood to bypass the lungs and enter the systemic circulation → Recirculation of deoxygenated blood.
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- Right side of the heart pumps into the aorta & left side pumps into pulmonary vein.
- This results in no blood flow from the lungs into the systemic circulation
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- VSD
- Coarctation of aorta
- Pulmonary stenosis
- Maternal T1DM/T2DM but not gestational diabetes
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- No effect on development as aorta supplies placental blood to systemic tissues.
- After birth it is fatal if not corrected, there is no oxygenated blood reaching tissues → Cyanosis
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- Antenatal USS usually
- Cyanotic child at or within a few days of birth
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- VSD or PDA as they allow for oxygenated blood to travel into the systemic circulation
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- Immediate:
- VSD: No medication needed
- No VSD: Prostaglandin infusion (alprostadil) to maintain the ductus arteriosus
- Definitive:
- Open heart surgery to perform an "arterial switch" while the patient is on cardiopulmonary bypass
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- Ventricular septal defect
- Overriding aorta: Aortic valve is further right than normal above the VSD.
- Pulmonary stenosis
- RV hypertrophy: Results from the left-to-right shunting and pulmonary stenosis
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- Pulmonary stenosis results in less pulmonary blood flow (main factor)
- Overriding aorta is positioned further right so receives deoxygenated blood from the contracting RV
- The RVH causes a right-to-left shunt
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- Rubella infection
- Mother > 40 years
- Alcohol consumption in pregnancy
- Diabetic mother
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- Can be picked up on antenatal scans or with an ejection systolic murmur on newborn baby check.
- Typically presents within around 1-2 months with cyanosis and/or an ejection systolic murmur in the 2nd intercostal space RSE & tet spells.
- Others: Clubbing, poor feeding
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- Intermittent symptomatic periods where the right-left shunt becomes worsened causing a cyanotic episode.
- Pathophysiology: Exertion (walking, crying) → ↑ CO2 → Systemic vasodilation → Pulmonary vascular resistance > systemic → More deoxygenated RV blood enters the aorta
- Management:
- Squat: Increases SVR encouraging pulmonary blood flow
- O2, β-blockers, IV fluids, morphine
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- Echocardiogram: Establish diagnosis
- Doppler flow studies: Uses colour to demonstrate the flow through the heart
- CXR: ‘Boot shaped’ heart due to RVH
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- Neonatal: Prostaglandin (alprostadil) infusion to maintain the ductus arteriosus
- Definitive: Open heart surgery (5% mortality)
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- Tricuspid valve is set lower in the right side of the heart causing a bigger RA and smaller RV
- Poor blood flow to pulmonary vessels
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- When they also have an ASD as it leads to a right-left shunt
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- With ASD: A few days after birth they present with cyanosis, gallop rhythm, SOB and oedema
- Without ASD: Present later with a pan-systolic murmur (due to tricuspid incompetence)
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- ECG: Arrhythmias, RBBB, LAD
- CXR: Cardiomegaly, right artial enlargement
- Echocardiogram
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- Wolff-Parkinson white (slurred upstroke)
- More likely to have an accessory pathway due to the malformation of the endocardial cushion
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- Treat arrhythmias & HF.
- Definitive: Surgical correction
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- Patient has an:
- atrial septal defect, and either a;
- ventricular septal defect or a patent ductus arteriosus
- Pulmonary pressure is higher than systemic pressure → Right-to-left shunt → Cyanosis
- Patients with the defects above only get cyanosed if they have this syndrome
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- Anatomical defect (ASD/VSD/PDA) → Left-to-right shunt
- ↑ Pulmonary vascular resistance & ↑ left-sided preload → RVH & LVH → HF
- ↓ cardiac output → Pulmonary pressure higher than systemic pressure
- Right-to-left shunt → Cyanosis
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- Cyanosis
- Plethoric (red) complexion
- Hypoxia → ↑ EPO → Polycythaemia
- Clubbing
- Dyspnoea
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- Medical:
- Sildenafil → Dilates pulmonary vessels
- Venesection for polycythaemia
- Anticoagulation
- Prophylactic antibiotics to prevent IE
- Surgical (definitive):
- Heart-lung transplant
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A heart disease which causes oxygenated blood to be pumped around the body abnormally.
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- Septum primum & septum secondum grow downwards towards endocardial cushion & fuse.
- Each septa form holes within them, allowing blood to travel from RA to left, but not the other way
- Lower septum primum blocks the flow from left to right
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- ↑ RA & RV pressure → ↑ Pulmonary vascular resistance → RV & LV hypertrophy → HF
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- Eisenmenger syndrome
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From most to least common:
- Ostium secondum: Septum secondum doesn't fully close
- PFO (although not strictly classed as an ASD)
- Ostium primum: Septum primum doesn't fully close → AV valve defects → Atrioventricular septal defect
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- Small & asymptomatic: Watch & wait
- Large: Transvenous catheter closure/open heart surgery
- Anticoagulants (DOAC/warfarin) to reduce clot, and potential subsequent stroke, risk.
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- Stroke: DVT thrombus goes to brain instead of lung
- Heart failure
- Eisenmenger syndrome
- AF or atrial flutter
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- Congenital hole in the septum between the two ventricles, varying in size from very small to the entire septum
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- Down's syndrome
- Turner's syndrome
- Tetralogy of Fallot
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- Picked up on antenatal USS
- Pan-systolic murmur in LLSE & loud P2 (↑ flow into pulmonary artery) heard on newborn baby check
- Later with cyanosis due to Eisenmenger syndrome
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- All: Risk of IE → Consider antibiotic prophylaxis
- Mild (No symptoms or evidence of severe disease): Watch & wait, they often close spontaneously
- Severe (Pulmonary hypertension, cyanosis, big defect): Transvenous catheter closure or open heart surgery
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- Prematurity
- Maternal rubella infection
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- From aorta into pulmonary vessels → Pulmonary hypertension
- ↑ pulmonary vascular resistance → Right heart strain → RV hypertrophy
- ↑ blood returning to left side of heart → ↑ preload → LVH
- Heart failure due to RVH & LVH
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- Echocardiogram
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- < 1 year: Monitor using echocardiogram, waiting for spontaneous closure
- > 1 year: Trans-catheter or surgical closure
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- Indomethacin - Inhibits prostaglandin synthesis, closing the duct
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- Narrowing of the aortic arch
- Usually around the ductus arteriosus
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- Turner's syndrome
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This depends on where the narrowing is on the arch:
- Reduced blood pressure distal to the narrowing → Femorals
- Increased pressure proximal to narrowing → Arms & head
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- Neonate: Weak femorals
- 4 limb BP: High in arms, low in legs
- Left infraclavicular systolic murmur
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- Severity varies, some need emergency surgery after birth and some can be asymptomatic until adulthood.
- Critical coarctation: Prostaglandin infusion & open heart surgery
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- Narrowing of the aortic valve caused by thickening & calcification of the leaflets
- Can have 2-4 leaflets on the valve
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- Mild: Incidental murmur on routine examination
- Severe: Fatigue, SOB, dizziness & syncope, worse on exertion
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- Ejection systolic murmur
- Palpable thrill
- Narrow pulse pressure
- Slow rising pulse
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- ECG
- Echocardiogram
- Exercise testing: Monitor disease progression
‣
- Percutaneous balloon valvuloplasty
- Surgical valvulotomy
- Valve replacement
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- Tetralogy of Fallot
- William syndrome
- Noonan syndrome
- Congenital rubella syndrome
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- Same as aortic stenosis
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- Parainfluenza infection → Upper airway oedema & obstruction
‣
- 6 months - 2 years
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- Bacterial tracheitis caused by S. aureus
‣
- Simple supportive treatment: Fluids & rest
‣
Stepwise approach:
- PO dexamethasone (& O₂)
- Nebulised adrenaline & budesonide
- Intubation & ventilation
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- Haemophilus influenza type B (HiB)
‣
- HiB vaccination
‣
- Not needed in acute epiglottitis - Treat immediately
- If unsure: Lateral XR of the neck
- "Thumbprint sign" - Oedematous & swollen epiglottis
‣
- Secure airway - Don't distress the patient as closes airway. Inform anaesthetist & paediatrician immediately
- Intubation/tracheostomy may be needed but often isn't
- IV antibiotics & PO steroids
- Ceftriaxone
- Dexamethasone
- Prophylactic antibiotics for all in the household
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- Epiglottic abscess: Collection of pus around epiglottis presenting in a similar way
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- Bordatella pertussis (gram negative)
‣
- Present with apnoea
‣
- Pneumothorax, fainting or vomiting
‣
- Nasal swab with PCR testing/culture
- Cough > 2 weeks: IgG against pertussis toxin
‣
- Supportive care
- Antibiotics: Azithromycin/Co-trimoxazole
- Prophylactic antibiotics to all those in the household
- Notify Public Health England (PHE)
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- Yes - Exclusion until 48 hours after commencing antibiotics
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- Bronchiectasis - Damage, widening & thickening of the bronchi
- Hypoxic brain injury
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- Structural laryngeal abnormality where the supraglottic larynx causes partial airway obstruction → Chronic stridor
- Aryepiglottic folds are shortened pulling the epiglottis into an "omega" shape
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- No interventions required usually, as it grows the larynx is better able to support itself
- If upper airway obstruction then may need tracheostomy
Cases: Name the diagnosis & cause.
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- Whooping cough
- Bordatella pertussis (gram negative)
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- Acute epiglottitis
- Haemophilus influenza type B (HiB)
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- Laryngomalacia
- The exact cause of laryngomalacia unknown. Relaxation or a lack of muscle tone in the upper airway may be a factor.
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- Croup (laryngotracheobronchitis):
- Parainfluenza infection → Upper airway oedema & obstruction
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- Respiratory syncytial virus (RSV)
‣
- 0-1 year
- RSV cause inflammation & oedema in the airways, adult airways are wide enough for this not to affect their function but it can cause occlusion of children's airways
‣
- Ex-premature children with chronic lung disease
- CF
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- Cyanosis
- Nasal flaring
- Head bobbing
- Tracheal tug
- Intercostal & subcostal recession
- Use of accessory muscles
- Abnormal airway noises
- Raised RR
‣
- Grunting - Exhaling against a partially closed glottis to maintain more residual volume
- Wheeze
- Stridor - Less likely here.
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- Viral-induced wheeze
‣
- Day 5-7 of the infection
‣
- Hyponatraemia
‣
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Most are managed at home, except those with the following:
- Aged < 3 months or with any pre-existing condition (Down's, CF, prematurity)
- Not feeding (> 50% less than normal) / clinical dehydration
- Fluid challenge - Can they drink water?
- Clinical dehydration - Mucous membranes, skin turgor
- RR > 70, SpO2 < 92%
- Signs of severe respiratory distress
‣
- Adequate fluid intake & nutrition - PO/IV
- Oxygen therapy
- Ventilatory support
‣
- High-flow humidified O₂ (Airvo) - Adds positive end-expiratory pressure keeping airways patent
- CPAP
- Intubation & ventilation - Insertion of ET tube
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- ABG/VBG looking for pO₂, pCO₂ & lactate
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- Ex-premature children with chronic lung disease & children with congenital heart disease
- Palivizumab monthly injections
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- Can be bacterial or viral.
‣
- Bronchial breath sounds - Inspiration & expiration are a similar length
- Focal coarse crackles - Air passing through sputum
- Dullness to percussion - Tissue collapse or consolidation
‣
- Bacterial
- S. pneumonia
- S. pyogenes (group A strep)
- Group B strep (birth)
- S. aureus - Cavitating
- H. influenzae - Unvaccinated
- Mycoplasma
- Viral
- RSV
- Parainfluenza virus
- Influenza
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- Bedside:
- Sweat test → CF
- Bloods:
- FBC → WCC (leukaemia, other malignancy), Hb, platelets
- Sputum culture → Organism could indicate condition (e.g. P. aeruginosa)
- HIV testing
- Radiology:
- CXR → Structural change & scarring
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- Typical: Amoxicillin
- Atypical: Amoxicillin & clarithromycin
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This is chronic lung disease of prematurity.
‣
- Hypoxia at birth: Capillary wall damage → Leakage of interstitial fluid & pulmonary oedema → Bronchiolar necrosis & loss of ciliated epithelium
- Hyperexpansion & atelectasis
‣
- Increased opacification of the lung tissue representing thickened tissue and less air
- Atelectasis
- Cardiomegaly (from pulmonary hypertension)
- Hyperinflated lungs
‣
- Formal sleep study assessing their SpO2 during sleep supports the diagnosis & guides management
- Nasal cannulae providing O2 while sleeping
- RSV prophylaxis with palivizumab
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Genetics & pathophysiology:
‣
- Mutation of the CFTR gene on chromosome 7
- Most common is 𝜹-F508 mutation
- Autosomal recessive inheritance
‣
- Chloride channels
- Pancreas, airways & bowel
‣
- Pancreatitis: Thick pancreatic secretions block the ducts
- LRTI: Loss of airway surface liquid → Thick secretions → Mucociliary escalator dysfunction → Bacterial colonisation
- Male infertility: Congenital absence of vas deferens in males
Presentation, investigations & management:
‣
- Newborn bloodspot screening
- Meconium ileus: Meconium is not passed in the first 24 hours due to being thick & sticky → Bowel blockage → Distension & vomiting
- AXR: 'Bubbly' appearance of the intestines with a lack of air-fluid levels
- Recurrent LRTI, pancreatitis & FTT in later childhood
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- Congenital heart disease
- Malignancy
- Tuberculosis
- Liver cirrhosis
- IBD
‣
- Sweat test (Gold standard): Excessive NaCl in sweat due to low fluid secretion
- Pilocarpine is applied to the skin inducing sweating at the site
- Electrodes run a current through this and also induce sweating
- Sweat is collected on gauze & tested for Cl⁻ concentration
- > 60 mmol/L → CF
- Genetic testing for CFTR gene mutation
- Raised immuno-reactive trypsinogen
‣
‣
- S. aureus
- Prophylactic flucloxacillin
- P. aeruginosa
- Nebulised tobramycin
- PO ciprofloxacin
- Others: H. influenzae, Klebsiella, E. coli, Burkhodheria
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‣
‣
MDT approach:
- Chest physiotherapy
- High calorie diet due to malabsorption
- Creon tablets (given pancreatic impairment)
- Prophylactic flucloxacillin
- Salbutamol
- Nebulised DNase (makes respiratory secretions thinner)
- Vaccinations
‣
- Diabetes due to pancreatitis
- Osteoporosis due to calcium malabsorption
- Vitamin D deficiency due to liver dysfunction
- Liver failure
Case:
‣
- Both parents are carriers so have the Cc genotype
- Child cannot be cc because they would have the disease so the remaining options are CC, Cc or cC.
- Carrier likelihood: 2/3
‣
‣
- Paranasal sinusitis
- Bronchiectasis
- Situs inversus
‣
- Autosomal recessive genetic condition → Ciliary dysfunction throughout the body (esp. in respiratory tract) → Mucus buildup
- Associated with consanguinity (incest)
‣
- All internal organs are switched to the opposite side, hence heart is on the right & liver is on the left.
- Present in 50% of cases of Kartagener's
‣
- Infertility due to fallopian tube cilia problems in women & sperm flagella (tail) problems in men
‣
- Sample of ciliated epithelium is taken from the upper airway by nasal brushing or bronchoscopy
- Cilia are examined
‣
- Similar to CF & bronchiectasis
Name the diagnosis & cause based on the following presentations:
‣
- Bronchiolitis
- RSV
‣
- Kartagener's syndrome (Primary ciliary dyskinesia)
- Autosomal recessive genetic condition → Ciliary dysfunction throughout the body (esp. in respiratory tract) → Mucus buildup
‣
- Chronic lung disease of prematurity (Bronchopulmonary dysplasia)
- See notes above for mechanism.
‣
- Cystic fibrosis
- Mutation of the CFTR gene on chromosome 7
‣
- Pneumonia
- Causes: Bacterial or viral
‣
- Viral-induced wheeze or asthma
- Viral: < 3 years, no atopy, only presents when other viral symptoms are present
- Asthma: Can be worsened by viral infection but signs will be present in its absence as well. Triggered by exercise, cold, dust & emotion. Atopic history
- Virus causes airway inflammation & oedema causing turbulent flow, this is heard more loudly on expiration
- Tumour
- Inhaled foreign body
- Pneumonia
- Same as acute asthma in children
‣
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‣
‣
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- Constipation
- UTI
- Coeliac disease
- IBD
- IBS
- Mesenteric adenitis
- DKA
- Abdominal migraine
- Pancreatitis
- Adolescent girls: Dysmenorrhoea, Mittelchmerz, ectopic pregnancy, pregnancy, PID, ovarian torsion
‣
- Appendicitis
- Meckel's diverticulum
- Pyloric stenosis
- Intusussception
- Bowel obstruction
- Testicular torsion
‣
- Persistent bilious vomiting → Obstruction
- RIF pain, guarding & rigidity
- Rectal bleeding
- Failure to thrive
- Dysphagia
‣
Bedside:
- Urinalysis → UTI
- Faecal calprotectin → IBD
Bloods:
- FBC: Anaemia → IBD/Coeliac/Blood loss
- ESR/CRP → IBD
- Anti-TTG/EMA → Coeliac
Upper GI vs Lower GI:
‣
‣
Immune-mediated allergic response to casein and whey, naturally-occurring milk proteins.
‣
- IgE mediated: Type-I hypersensitivity reaction, with B-cells producing IgE antibodies agains cow’s milk protein. Rapid reaction over ~ 2 hours (anaphylaxis is rare).
- Non-IgE mediated: T-cell activation against cow’s milk protein. Reactions are less severe and occur over several days.
‣
- < 1 year of age, often when weaned from breast to formula milk but can be in breastfed if mother is drinking dairy products.
- Gastrointestinal symptoms:
- Bloating/wind
- Abdominal pain
- Diarrhoea & vomiting
- Allergic symptoms:
- Urticaria
- Angioedema
- Cough/wheeze
‣
- Usually a clinical diagnosis is sufficient.
- IgE antibody blood test to cows milk protein can be useful. This has a high sensitivity but low specificity leading to false positives. They may be sensitised (have the IgE), but not be allergic.
‣
- Mild: Breast feeding mothers avoid dairy products
- Mild: Extensively hydrolysed formulas (casein and whey have been broken down so won't trigger a response).
- This is the first-line, cheaper, formula made from cow’s milk. They break down the casein and whey into smaller peptides which are less immunogenic.
- Severe: Amino acid formulas (neocate)
- This is the second-line, more expensive, formula for those who still have symptoms with eHF (10% of children).
‣
- Patients have the same GI symptoms but no symptoms suggestive of allergy.
- They grow out of the intolerance by 2-3 years.
- Managed the same but after 1 year they are started on the milk ladder.
‣
Gluten is broken down to gliadin in the small intestine → Inflammatory response → Cell destruction → Malabsorption.
‣
- IgA anti-TTG antibodies
- Total IgA because if there's an IgA deficiency then the test will be negative but the disease may still be present
- IgG anti-TTG/anti-EMA
- Anti-EMA antibodies
‣
‣
‣
- Villous atrophy
- Crypt hypertrophy
‣
- Common: T1DM & thyroid - All of these patients are tested for coeliac disease
- Other autoimmune: Autoimmune hepatitis, PBC, PSC
‣
- Lifelong gluten-free diet
- Dapsone antibiotic for dermatitis herpetiformis
‣
‣
- Immaturity of the lower oesophageal sphincter → Easily allows reflux into the oesophagus.
- Normal up to 1 year and can be physiological if all other variables are normal.
‣
- Overfeeding
- Pyloric stenosis
- Gastritis/gastroenteritis
- Appendicitis (pain)
- Obstruction
‣
- Not keeping down any feed
- Vomiting - Projectile / forceful vomiting / bile stained / blood
- Melaena
- Abdominal distention
- Rash, angioedema & signs of allergy
‣
- Small, frequent meals. Don't overfeed
- Keep baby upright after feeding
- Gaviscon with feeds, thickened milk
- Ranitidine
- Omeprazole
‣
- Sandifer's syndrome
- Neck: Torticollis
- Back: Dystonia → Twisting & arching
‣
Pyloric sphincter hypertrophy → Pylorus narrowing → Powerful stomach peristalsis to try to push stomach contents through → Projectile vomiting.
‣
- Hypochloric metabolic alkalosis (vomiting HCl from the stomach).
‣
- USS
‣
- Laparoscopic pyloromyotomy (Ramstedt's operation).
Cases:
‣
‣
- Coeliac disease
‣
- Dermatitis herpetiformis (pruritic vesicles on the extensor surfaces)
- Anaemic due to malabsorption of B12/folate
‣
- Pyloric stenosis
‣
- GORD
‣
- Conjugated & unconjugated bilirubin levels
- Biliary atresia - Narrowing/absence of the bile duct → Cholestasis
- 2-8 weeks old
- Surgery: Kasai portoenterostomy (somewhat successful but they often require a full liver transplant).
‣
‣
‣
‣
- Cow's milk protein allergy (IgE-mediated)
‣
- Transient lactose intolerance following infection
‣
‣
‣
- Absolute constipation
- Bilious vomiting
- Tinkling bowel sounds
‣
- Meconium ileus (CF)
- Hirshprung's disease
- Pyloric stenosis
- Surgical adhesions
- Intusussception
- Imperforate anus
- Volvulus
- Strangulated hernia
- Abdominal mass
‣
- Depends on the cause - treatment would be tailored to the cause.
- Refer to paediatric surgical unit
- NBM
- Drip & suck - IV fluids & NG tube insertion
‣
Congenital condition where the myenteric (Auerbach's) plexus of the bowel is absent → No large bowel peristalsis → No passing of meconium.
‣
- Parasympathetic ganglion cells are missing as they usually migrate down from higher in the GI tract but they don't here.
‣
- Dilated loops of bowel with fluid levels (meconium ileus - no fluid levels)
‣
- RF: Family history
- Associations: Down's, neurofibromatosis, MEN II
‣
- AXR: Obstruction
- Rectal biopsy → Absence of ganglionic cells
‣
- Fluid resuscitation
- Bowel irrigation/washouts
- Definitive: Surgical removal of aganglionic section of bowel
‣
- Hirschprung-associated enterocolitis
- Management: Fluids, antibiotics & decompression of obstructed bowel
‣
Bowel invaginates (folds) into itself → Decreased bowel lumen size causing obstruction.
‣
‣
- 6 months - 2 years (more common in boys).
‣
- Preceding viral illness (Common)
- Henoch-Schönlein purpura (HSP)
- Cystic fibrosis
- Meckel's diverticulum
‣
- Abdominal USS
‣
- Therapeutic enemas - Pump contrast/water/air into colon to force the folded bowel out
- Surgical reduction
- Surgical resection of gangrenous/perforated bowel
‣
‣
- Rabbit dropping stools
- Abnormal posture - Retentive posturing
- Faecal impaction causing overflow soiling
- Tenesmus - Always feeling like you need to go
- Abdominal pain
‣
- Faecal incontinence - Not pathological until 4 years.
- Commonly a sign of chronic constipation causing stretching and desensitisation of the rectum
- Rarer causes: Spina bifida, Hirschprung's, CP
‣
- Hirschprung's disease
- Hypothyroidism
- Cystic fibrosis - Meconium ileus
- Spinal cord lesions
- Cow's milk intolerance
‣
- Not passing meconium in the first 24 hours
- Failure to thrive
- Acute abdominal pain/bloating
- Vomiting - Bilious, projectile
- Neurological signs
‣
- Plenty of fluids & high fibre diet
- Laxatives
- Movicol
- Bowel diary & encouragement to go to the toilet
‣
‣
‣
‣
- Abdominal pain, blood diarrhoea, mouth ulcers, other autoimmune conditions, WL, anaemia
- Systemically unwell during flares
‣
‣
- No/less blood or mucus in stool
- Entire bowel is affected
- Skip lesions
- Terminal ileum most affected & Transmural thickness inflammation
- Smoking makes it worse
‣
- Continuous inflammation
- Limited to colon & rectum
- Only superficial mucosa affected
- Smoking protective
- Excrete blood & mucus
- Use aminosalicylates
- Primary sclerosing cholangitis
‣
- Finger clubbing
- Erythema nodosum
- Pyoderma gangrenosum
- Episcleritis/iritis
- PSC in UC
‣
‣
‣
- Rectum
‣
- Skin: Erythema nodosum, pyoderma gangrenosum
- Primary sclerosin cholangitis (independent of flares)
- Eyes: Episcleritis, scleritis, anterior uveitis
- Osteoporosis (malabsorption)
- Peripheral neuropathy (B12)
‣
Disease is limited to the mucosa, showing:
- Crypt abscesses
- Goblet cell depletion
- Mucin depletion
- Mucosal ulcers
‣
- 'Lead pipe sign' - Loss of haustral markings on the bowel
‣
- Toxic megacolon: AXR to investigate
- ACR (colon dilation), Temp > 38.6°C, HR > 120bpm, anaemia, ↑ neutrophils
‣
‣
Age of onset is bi-modal:
- 15-40 years: Majority
- 60-80 years: Small second peak
‣
- Distal ileum
- Proximal colon
‣
- Abdominal pain (potentially colicky)
- Diarrhoea (often chronic)
- Oral aphthous ulcers (can be painful)
- Perianal disease
‣
- Bedside: Faecal calprotectin
- Bloods: FBC (macrocytic anaemia), LFT (PSC).
- Radiology: USS/CT/MRI (fistulae, abscesses, strictures)
- Endoscopy: OGD & colonoscopy
- Take biopsies to look for microscopic features.
- If active disease only do flexible sigmoidoscopy because of risk of perforation in colonoscopy.
- If colonoscopy is negative in Crohn's, use MRI to assess the small bowel.
‣
- Induce remission
- Steroids - PO prednisolone (mild-moderate) / IV hydrocortisone (severe)
- Add azathioprine/mercaptopurine
- Refractory: Infliximab
- Aminosalicylate - Mesalazine (mild-mod)
- Suppository/enema first
- PO if extensive disease
- Steroids - PO prednisolone (mild-mod) / IV hydrocortisone (severe)
- IV ciclosporin (severe)
- Maintain remission
- Azathioprine/Mercaptopurine
- Methotrexate
- Infliximab
- Adalimumab
- If only affecting one area of bowel severely, surgery will be considered.
- Aminosalicylate - Mesalazine (PO/PR)
- Azathioprine
- Mercaptopurine
- Panproctocolectomy: Surgery to remove the colon & rectum. May have hemicolectomy, depends on case.
- Patient has either a permanent ileostomy or ileo-anal anastomosis (J-pouch).
‣
‣
‣
Medical:
Surgical:
‣
Medical:
Surgical:
Cases:
‣
- Omphalocele
- Gastroschisis - No peritoneal covering
- Omphalocele - Staged closure starting immediately and ending at 9-12M (to prevent respiratory complications)
- Gastroschisis - Immediate closure
‣
‣
‣
- Hirschprung's disease
‣
- Meconium ileus
‣
- Intussusception
👧 Speciality
‣
‣
‣
Vagus nerve receives a strong stimulus → Parasympathetic activation → blood vessel dilatation → Brain hypoperfusion → Syncope
‣
Primary (simple):
- Vasovagal: May occur following pain, sudden surprise or sight of blood
- Dehydration
- Missed meals
- Extended standing in warm environment
Secondary:
- Hypoglycaemia
- Anaemia
- HOCM/aortic stenosis
- Infection
- Anaphylaxis
‣
- Lightheadedness, sweating, blurred vision before the event
- Reduced tone during episode
- Return to consciousness shortly after falling
- No post-ictal period, although may feel groggy in this time
‣
- Injuries secondary to the fall
- Concurrent illnesses causing the faint
- Cardiac examination: Murmurs
- Lying & standing BP
- Neurological examination
‣
- Bedside:
- BM
- ECG → Arrhythmia
- 24h ECG → Paroxysmal arrhythmia
- Echocardiogram → Structural HD
- Bloods:
- FBC → Anaemia, infection
- U&E → Electrolyte abnormalities → Arrhythmia/seizure
‣
- Stay hydrated, don't miss meals, don't stand for long periods
- When having prodromal symptoms: Sit/lie down to maintain cerebral perfusion
‣
Transient episodes of abnormal electrical activity in the brain.
‣
‣
- Aura (smell/taste/deja vu)
- Tonic-clonic activity
- Tongue biting
- Cyanosis
- Post-ictal confusion
‣
- EEG: Only after the second tonic-clonic seizure)
- MRI brain: Structural problems (Seizure < 2y, focal seizures, don't respond to first-line meds)
- Consider: ECG, electrolytes, glucose, blood cultures
‣
- To be seizure free on the minimum anti-epileptic medications.
‣
‣
‣
- Loss of consciousness
- Tonic: Muscle tensing (typically first)
- Clonic: Muscle jerking movements
- Associated symptoms: tongue biting, groaning and incontinence
- Post-ictal period: Confusion, drowsiness and irritability
‣
- Sodium valproate
- Lamotrigine / carbamazepine
‣
‣
- Temporal lobes → Affect hearing, speech, memory and emotions
‣
- Hallucinations
- Memory flashbacks
- Déjà vu
‣
- Simple (maintained consciousness)
- Complex (lost consciousness)
- Secondary generalised
‣
- Carbamazepine / lamotrigine
- Sodium valproate / levetiracetam
‣
‣
10–20 seconds of:
- Appearing blank, staring out into space and then abruptly returning back to normal.
- Complete unawareness during the episode and unresponsive
‣
- Sodium valproate / ethosuximide
‣
‣
- Brief lapses in muscle tone lasting no more than around 3 minutes. They typically begin in childhood
‣
- Lennox-Gastaut syndrome
‣
- Sodium valproate
- Lamotrigine
‣
‣
- Sudden brief muscle contractions, like a sudden “jump”
- Patient remains aware throughout
‣
- Juvenile myoclonic epilepsy
‣
- Sodium valproate
- Lamotrigine, levetiracetam / topiramate
‣
‣
Hypsarrhythmia:
‣
- Prednisolone
‣
‣
- Seizures occurring secondary to fever in a child.
- There is no underlying neurological pathology
‣
- Children aged 6 months – 5 years
‣
- Antipyretics: Paracetamol
- Treat underlying infection
What seizure has occurred based on the following features:
‣
- Tonic-clonic seizure
‣
- Focal seizure
‣
- Absence seizures
‣
- Atonic seizures
‣
- Juvenile myoclonic epilepsy
‣
- Infantile spasms (West syndrome)
‣
- ABCDE
- Hospital: IV lorazepam (Repeat after 10 mins). Community: Buccal midazolam/rectal diazepam
- IV phenobarbital/phenytoin
- Intubate & ventilate (PICU)
‣
- Febrile convulsions
‣
Name the type of headache.
‣
- Tension
‣
- Migraine with visual aura
- Sumatriptan
- Paracetamol/ibuprofen
- Domperidone - Nausea
- Propranolol (CI in asthma)
- Pizotifen
- Topiramate (teratogen - ensure on contraception)
- Recurrent central abdominal pain → Abdominal migraine
‣
‣
‣
‣
- Trauma: Head injury/bleed
- Infection: Meningitis, sinusitis, URTI, encephalitis
- Neoplasia: SOL
- Drugs: Medication overuse headache
‣
‣
- Antenatal
- Infection: Chorioamionitis
- Trauma
- Perinatal
- Preterm birth
- Birth asphyxia - Premature placental separation, prolonged delivery, cord prolapse/nuchal cord, maternal hypotension
- Postnatal
- Kernicterus
- Meningitis
- Intraventricular haemorrhage
‣
- Pyramidal tract (UMN lesion)→ Spastic CP (hypertonia)
- Basal ganglia → Dyskinetic CP (athetoid and oro-motor problems)
- Cerebellum → Ataxic CP (poor coordination)
‣
- Monoplegia
- Hemiplegia - One side of the body is affected
- Diplegia - All 4 limbs are affected but legs are worse
- Quadriplegia - All 4 limbs are severely affected
‣
‣
- Hemiplegic/diplegic
‣
- Broad-based/ataxic
‣
- High stepping
‣
- Waddling
‣
- Antalgic (limp)
‣
MDT approach:
- Allied health professionals: PT/OT, SALT.
- Dietitians
- Paediatricians
- Muscle relaxants
- Anti-epileptics
- Glycopyrronium bromide for excessive drooling
‣
‣
Abnormal buildup of CSF within the ventricles. Caused by either:
- Excessive CSF production
- Blockage of the drainage/absorption of CSF
- Aqueductal stenosis (most common cause)
- Arachnoid cysts
- Arnold-Chiari malformations
- Chromosomal abnormalities causing congenital malformations
‣
‣
- Enlarged rapidly increasing occipito-frontal circumference
- Bulging anterior fontanelle
- FTT
‣
- Rubella
‣
- VP shunt: Drains CSF into the peritoneal cavity using a catheter
- IVH
- Infection
- Blockage
- Outgrowing them
‣
‣
‣
‣
‣
- Neisseria meningitidis (meningococcus)
- They are circular bacteria (cocci) that occur in pairs (diplo-)
- S. pneumoniae (pneumococcus)
‣
Gram negative diplococcus
‣
- Group B strep (GBS)
- Bulging fontanelle
‣
- HSV
- VZV
- Enterovirus
‣
‣
- Appearance: Pale/mottled, reduced responsiveness
- Fever, neck stiffness, fatigue, vomiting, headache
- Non-blanching rash, seizures
- N. meningitidis is the underlying cause
‣
‣
- Kernig's:
- Patient lying supine, flex one hip & kneethen slowly straighten the knee while keeping the hip flexed
- Positive: Causes pain/resistance
- Brudzinski's:
- Patient lying supine, bring chin to chest
- Positive: Involuntary flexion of hips & knees
‣
‣
- Suspected bacterial meningitis with non-blanching rash
- IM benzylpenicillin & urgent hospital transfer
‣
- Lumbar puncture (LP) & bloods (usuals and meningococcal PCR)
- TB meningitis
- Viral meningitis
- Bacterial meningitis
- N. meningitidis
- S. pneumoniae
- IV antibiotics:
- < 3M: Cefotxime & amoxicillin
- > 3M: Ceftriazone
- Inform PHE as it's a notifiable disease
‣
‣
‣
‣
‣
‣
‣
- Dexamethasone to reduce risk of deafness & neurological deficit
‣
- Ciprofloxacin
‣
‣
- Infective (Viral)
- HSV - Cold sore
- VZV - Chickenpox
- CMV - Immunosuppressed
- EBV - Glandular fever
- Non-infective
- Autoimmune
‣
- Function: Seizures/altered consciousness or cognition
- Pressure: Vomiting, headache
- Systemic: Fever
‣
- LP
- ? Raised ICP due to cerebral mass → Coning
- Coagulopathy
- Spinal cord trauma
- Skin infection near the site of LP
- MRI brain
- EEG
- Swabs - Identify organism
- HIV PCR - Immunosuppression
‣
‣
‣
- Aciclovir (not effective for other viruses)
‣
- Ganciclovir
‣
‣
- Flattening of one area of the baby’s head in otherwise normal healthy babies
- Exclude craniosynostosis, congenital muscular torticollis (could be why the child is always resting on that side)
- Management: Plagiocephaly helmets (but not available on NHS)
‣
- Premature closing of the skull sutures resulting in abnormal head shapes & raised ICP if untreated
- Investigated with a skull XR
- Managed with surgical skull reconstruction
‣
- Flattening of the back of the head (commonly seen in Down's syndrome)
- Investigations & management same as plagiocephaly
Case:
‣
- Shaken baby syndrome
- Retinal haemorrhages
- Subdural haematoma
- Encephalopathy
‣
‣
‣
‣
‣
- ~ 5 years old
‣
- Gower sign - Child uses arms to stand from squatted position
‣
- Frameshift deletion mutation in the dystrophin gene (severe)
- X-linked recessive
‣
- Malformation of dystrophin, a protein that connects the muscle membrane to actin → Muscle is unable to contract due to unstable actin
‣
- PO steroids → Slow muscle weakness progression
- Creatine supplements → Improves muscle strength
‣
- Wheelchair in teenage years
- Life expectancy: 25-35 years
‣
‣
- 10–12 years old
‣
- Calf pseudohypertrophy: Abnormal muscle tissue makes calves large
‣
- Non-frameshift insertion in dystrophin gene → Less severe than Duchenne's
- X-linked recessive
‣
- Wheelchair in 20s or 30s
- Live much longer than Duchenne's
‣
‣
- Trinucleotide repeat disorder
‣
- 20-30 years
‣
- Episodes of weakness
- When you shake their hand they are unable to let go
- Cataracts
- Cardiac arrhythmias (heart block)
‣
‣
- Type I: Severe form leading to death within 2 years due to affecting respiratory muscles
- Type II: Onset in first 18M, never walk
- Type III: Onset after 1 year, most walk with support
- Type IV: Onset in 20s
‣
- Autosomal recessive genetic condition causng a progressive loss of lower motor neurons → Progressive muscular weakness
Diagnose the patient based on the following presentations:
‣
- Myotonic dystrophy
‣
- Becker muscular dystrophy.
- Age tells you it's Becker (8-12 years) not Duchenne's (~ 5 years).
‣
- Duchenne muscular dystrophy
‣
- Spinal muscular atrophy type I
‣
‣
- Autosomal dominant
‣
- Absent red reflex around 18 months
- Strabismus
- Visual problems
‣
- Enucleation
- External beam radiation therapy, chemotherapy and photocoagulation
‣
‣
‣
‣
- Autosomal recessive congenital deficiency of the 21-hydroxylase enzyme
‣
- Underproduction of cortisol & aldosterone
- Overproduction of androgens
‣
Severe:
- Female with ambiguous genitalia at birth
- Hyponatraemia, hyperkalaemia & hypoglycaemia → Vomiting, poor feeding, dehydration
Mild (affected during childhood or after puberty):
- Female: Tall, facial hair, primary amenorrhoea, deep voice
- Male: Tall, deep voice, large penis, small testicles
‣
- ↓ cortisol → ↑ ACTH → Converted to MSH → Hyperpigmentation
‣
- Hydrocortisone & fludrocortisone
‣
‣
Excessive production and secretion of thyroid hormones by the thyroid gland.
‣
- Graves disease: Non-tender goitre.
- Toxic multinodular goitre.
- Solitary toxic thyroid nodule.
- De Quervain's thyroiditis (in subacute hyperthyroid phase of disease): Tender goitre.
- Neonatal hyperthyroidism (transplacental transfer of maternal TRAb to the foetus).
- hCG-secreting tumour (hCG has a similar structure to TSH).
- Functioning pituitary adenoma → TSH.
‣
‣
- Excessive quantity of thyroid hormone in the body
‣
- An autoimmune condition where TSH receptor antibodies cause a primary hyperthyroidism
‣
- Nodules develop on the thyroid gland that act independently of the normal feedback system and continuously produce excessive thyroid hormone.
‣
- Severe presentation of hyperthyroidism with pyrexia, tachycardia & delirium
- Infection, thyroid surgery, trauma
‣
‣
‣
- Sweating & heat intolerance
- Weight loss
- Fatigue
- Anxiety & irritability / restlessness
‣
- Tachycardia
- Tremor
- Palmar erythema
- Lid lag & retraction
- Diffuse goitre
‣
- Thyroid acropachy
- Exophthalmos - TSH antibodies cause eye muscle inflammation, swelling & hypertrophy
- Ophthalmoplegia
- Pretibial myxoedema
‣
- TFTs
- TSH receptor stimulating antibody → Graves
- Anti-TPO antibody → Graves
- USS +/- biopsy → Tumour
Management:
‣
- Carbimazole
- Stops I₂ from being converted to I⁻ reducing thyroid hormone formation.
- Agranulocytosis
- Teratogenic
- Propylthiouracil
- Similar mechanism to carbimazole
- Stops I₂ from being converted to I⁻ reducing thyroid hormone formation.
- Pregnancy & thyroid storm
- Risk of severe hepatic reaction → Death
- Radioiodine (Lugol's iodine)
- Taken up by thyroid cells and the radiation kills them
- Pregnancy
- Age < 16y
- Thyroid eye disease (worsens it)
- Hypothyroidism
‣
‣
‣
‣
‣
‣
‣
‣
‣
- Total thyroidectomy
‣
- Propylthiouracil
- Beta blocker (IV propranolol) - Tachycardia
- Antiarrhythmics
- Prednisolone - Reduces conversion of T4 to T3
‣
‣
- Weight gain, lethargy
- Dry skin, coarse hair, loss of lateral eyebrow
- Menorrhagia
- Constipation
- May have amenorrhoea because TRH stimulates prolactin release
‣
- Congenital: Thyroid dysgenesis (underdevelopment - iodine deficiency), thyroid dyshormonogenesis (fully developed but doesn't produce enough hormone).
- Newborn blood spot screening test
- Thyroid descends from the tongue into the neck, if this doesn't happen a lingual thyroid causes macroglossia
- Acquired: Hashimoto's (most common), De Quervain's (subacute) thyroiditis
- Child/adolescent
- Thyroid function tests (TFTs)
- Antibodies:
- Anti-TPO
- Antithyroglobulin
- Other autoimmunity:
- BM (T1DM)
- Anti-TTG antibodies (coeliac disease)
- Thyroid USS
‣
‣
‣
‣
‣
- TFTs
‣
‣
- 50-100 micrograms
‣
- Serum TSH (keep in normal range)
‣
- Increase it by 25-50 micrograms
‣
- Hyperthyroidism
- Reduced bone mineral density
- Can worsen angina
- Atrial fibrillation
‣
- Iron (reduces absorption), give them 2 hours apart
‣
‣
Severe hypothyroidism leading to low everything: Consciousness, HR, BP, temperature.
- Confusion
- Bradycardia
- Hypotension
- Hypothermia
‣
- IV levothyroxine
- IV hydrocortisone: Assume that the low thyroid has lead to adrenal insufficiency
‣
‣
‣
- Acetone
- Acetoacetate
- β-hydroxybutyrate
‣
- Infection
- Missed insulin
- MI
‣
- Abdominal pain
- Polyuria
- Polydipsia
- Kussmaul's respiration - trying to breathe out CO2 due to acidosis
- Pear drop breath
‣
- Acidosis: pH < 7.3 or plasma bicarbonate below 15mmol/litre.
- Ketonaemia: Ketones (beta-hydroxybutyrate) > 3 mmol/litre.
- Blood glucose is generally high (> 11mmol/litre), but children can develop DKA with normal glucose.
‣
‣
- IV fluids → NaCl 500mL 0.9%
‣
- Fixed rate insulin infusion → 0.1 unit/kg/hr (80kg = 8 units/hr)
- Continue long-acting insulin, stop short acting
‣
- Potassium: Risk of hypokalaemia
- K⁺ 3.5-5.5 → Add 40mg KCl into IV fluids
- Sodium: Risk of cerebral oedema if going from aggressive fluid resuscitation
‣
‣
- Blurred vision
- Weakness
- Recurrent headaches
‣
- EXogenous drugs - insulin, sulphonylureas
- Pituitary dysfunction
- Liver failure
- Addison's disease
- Insulinoma
- Non-pancreatic neoplasms
‣
- Serum C-peptide → High in endogenous production as it's a by-product of the synthesis
- Give insulin: Normally C-peptide will fall, in insulinoma it will remain the same
‣
- Conscious (both): Lucozade drink
- Unconscious:
- Hospital: 200ml 10% IV dextrose
- GP: IM glucagon
‣
‣
- Two separate infusions, one of glucose and one of insulin
- Rates can be easily adjusted based on BM results so used in medical management of diabetic inpatients
‣
- Temporary treatment for ≤ 3 months or less
- GDM that are taking insulin for < 3 months post-delivery
Give an example of each of the following:
‣
- Novorapid
‣
- Actrapid
‣
- Isophane
‣
- Levemir / Lantus
Cases:
‣
- Congenital hypothyroidism
‣
- Growth hormone deficiency
- Congenital: Genetic mutation of GH1/GHRHR genes
- Acquired: Secondary to infection, trauma, surgery
- XR wrist → Look for delayed skeletal age
- Serum IGF-1 → Low
- GH stimulation test (diagnostic):
- Give glucagon/insulin, this should stimulate GH production.
- Instead the GH stays low (< 10 mcg/L).
- Daily subcutaneous GH supplementation
‣
‣
‣
‣
‣
This occurs when the blood supply to the rounded head of the femur is temporarily disrupted, causing avascular necrosis. The cause is unknown.
‣
- Age ~ 4–10 years.
- 5 times more common in boys than girls.
- In 10–15% of cases, both hips are affected.
‣
- Necrosis (First months): Blood supply to the femoral head is disrupted causing AVN. Child may limp or walk differently.
- Fragmentation (1–2 years): The body removes the dead bone beneath the articular cartilage, replacing it with softer bone. This weak bone is more likely to collapse into a flatter position.
- Reossification (3-5 years): New, stronger bone develops in the head of the femur. The reossification stage is often the longest stage of the disease and can last a few years.
- Healed: Bone regrowth is complete. How close the shape is to round will depend on the extent of the damage in the fragmentation stage and the child’s age at disease onset.
‣
- Hip XR
- Hip MRI (AVN may not be visible on XR)
‣
- < 6 years: Observation
- > 6 years: Surgical repair
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Abnormal development and formation of the acetabulum in-utero.
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- Female (6X)
- Breech
- Family history
- Oligohhydramnios
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- Newborn examination
- Bilateral hip USS at 6 weeks
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This is a hip condition developing in growing teens where the head of the femur slips off the neck in a backward direction causing pain, stiffness, and instability in the affected hip.
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- Hip X-ray
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- Surgery: Internal fixation
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- Rapid degeneration of the femoral head
- Arthritis in the hip joint
What’s the cause based on the following presentations:
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- Slipped capital femoral epiphysis
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- Developmental dysplasia of the hip
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- Perthes' disease causing AVN of the femoral head
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