1
Q
Coeliac’s disease has a prevalence of 1% in children (1:100). What is the pathophysiology of coeliac’s disease?
A
Autoimmune condition where exposure to gluten causes an immune reaction that creates inflammation in the small intestine
Autoantibodies (Anti-TTG and anti-EMA) are created in response to gluten that target the epithelial cells of the intestine and lead to inflammation
Usually in jejunum, causes atrophy of the intestinal villi so malabsorption
2
Q
What are some associations with coeliac disease?
A
- Down’s syndrome
- Type 1 diabetes
- Thyroid disease
- Other autoimmune conditions e.g RA, Addison’s
3
Q
How may coeliac disease present in a child?
A
Younger children tend to have GI symptoms but older children have extra GI symptoms. Can present at any age
- Asymptomatic
- Failure to thrive
- Diarrhoea/Steatorrhea
- Weight loss
- Abdominal pain
- Fatigue
- Mouth ulcers
- Anaemia secondary to iron, B12 or folate deficiency (in older children)
- Dermatitis herpetiformis
4
Q
What are some differentials for coeliac’s?
A
Think of other malabsorption conditions
- Cystic fibrosis
- Inflammatory bowel disease
- Post – gastroenteritis
- Autoimmune enteropathy
- Eosinophilic enteritis
5
Q
What genetic associations are found in coeliac’s and what auto-antibodies are found?
(image important)
A
Genetic
- HLA-DQ2 gene (90%)
- HLA-DQ8 gene
Auto-antibodies (ALWAYS TEST FOR TOTAL IGA TOO)
- Tissue transglutaminase antibodies (anti-TTG)
- Endomysial antibodies (EMAs)
- Deaminated gliadin peptides antibodies (anti-DGPs)
6
Q
What investigations are done to diagnose coeliac’s disease?
A
Patient must remain on gluten diet during investigations for at least 6 weeks before as otherwise may not detect antibodies
- Total immunoglobulin A levels: to exclude IgA deficiency
- Anti-TTG antibodies (first choice)
- Anti-endomysial antibodies
- Endoscopy and intestinal biopsy: If positive serology. Crypt hypertrophy and villous atrophy
7
Q
What are the indications for coeliac serology in children?
A
- Persistent unexplained abdominal or gastrointestinal symptoms
- Faltering growth
- Prolonged fatigue
- Unexpected weight loss
- Severe or persistent mouth ulcers
- Unexplained iron, vitamin B12 or folate deficiency
- Type 1 diabetes, at diagnosis
- Autoimmune thyroid disease, at diagnosis
- First‑degree relatives of people with coeliac disease
8
Q
How is coeliac disease managed in children?
A
- Life-long gluten free diet
- Annual follow up to check for symptoms, diet compliance, development, growth and long term complications
9
Q
What are some complications of coeliac’s disease if left unmanaged?
A
- Anaemia
- Osteoporosis
- Malignancy (Non Hodgkin Lymphoma, EATL, Small bowel adenocarcinoma)
- Infertility
10
Q
What is the epidemiology and pathophysiology of GORD in children?
A
Only GORD if symptomatic, can be asymptomatic which is physiological called GOR
Epidemiology
- Occurs in 40% of infants in first 2 weeks as LOS still developing until 6 months
- 1% of children under 13 have it
Pathophysiology
- Low tone of lower oesophageal sphincter so reflux out of stomach to oesophagus
11
Q
What are some risk factors for GORD in children?
A
- Prematurity
- Parental history of heartburn
- Obesity
- Hiatus hernia
- History of congenital diaphragmatic hernia
- History of congenial oesophageal atresia
- Neurodisability (eg. cerebral palsy)
12
Q
How may GORD present in children?
A
Frequent effortless regurgitation of feeds is normal
- Chronic cough
- Hoarse cry
- Back arching
- Drawing knees to chest
- Excess crying or unsettled after feeding
- Reluctance to feed
- Pneumonia
- Poor weight gain
13
Q
What are some differentials for GORD in infants?
A
If onset is >6 months of age or symptoms persist beyond 1 year then reflux is unlikely
- Pyloric stenosis: Frequent, forceful (projectile) vomiting in <2 month olds
- Intestinal obstruction: bile-stained vomit,
- Upper GI bleed: haematemesis
- Sepsis
- Raised ICP: rapidly increasing head circumference (>1cm per week), persistent headache and vomiting following periods of recumbence
- UTI
- CMPA
- Possetting
- Overfeeding
14
Q
How is GORD investigated and managed?
A
Ix
- No investigation if feeding and gaining weight
- Rule out other causes e.g urine dipstick
Mx
- Conservative (advice on keeping baby upright, burping after feeds, thickened formula)
- Medical (Infant gaviscon, omeprazole)
- Surgical in severe cases (fundoplication)
15
Q
What is the medical management for GORD in infants?
A
- Alginate mixed with water and feed (Gaviscon)
- If not resolved with this in 2 weeks then trial PPI (Omeprazole) or H2 antagonist (Ranitidine)
16
Q
If GORD is severe, what investigation is done before fundoplication?
A
- Barium Meal
- Endoscopy
Only do fundoplication if failure to thrive or apneas
17
Q
What are some complications with GORD?
A
90% of infants will spontaneously resolve within the first year of life as they change diet and start to sit upright
- Reflux oesophagitis
- Recurrent aspiration pneumonia
- Recurrent acute otitis media (>3 episodes in 6 months)
- Dental erosion (especially in children with neurodisability)
- Apnoea
- Apparent life-threatening events (ALTE): apnoea, colour change, change in muscle tone, choking and gagging
18
Q
What is Sandifer’s syndrome?
A
Brief episodes of abnormal movements associated with GORD in infants. The infants are usually neurologically normal
- Torticollis: forceful contraction of the neck muscles causing twisting of the neck
- Dystonia: abnormal muscle contractions causing twisting movements, arching of the back or unusual postures
Tends to resolve as reflux resolves but refer to rule out infantile spasms and seizures
19
Q
What are some red flags that point away from GORD to another diagnosis?
A
- Frequent, forceful (projectile) vomiting
- Bile-stained (green or yellow-green) vomit
- Abdominal distension, tenderness, or palpable mass
- Blood in vomit
- Bulging fontanelle or altered responsiveness (for example lethargy or irritability)
- Rapidly increasing head circumference (more than 1 cm each week); persistent morning headache and vomiting worse in the morning
- Blood in the stool
- Chronic diarrhoea
- Dysuria
- Appearing unwell or fever
- Onset of regurgitation and/or vomiting after 6 months of age or persisting after 1 year of age
20
Q
What is important to ask in the history if you suspect GORD?
A
Feeding history
21
Q
When should a baby with GORD be admitted?
A
- Haematemesis
- Malena
- Dysphagia
22
Q
What are the differences between UC and Crohn’s, both being forms of IBD with periods of exacerbation and remission?
A
NESTS
UC-CLOSE UP
23
Q
How does IBD tend to present in children?
A
- Poor growth
- Diarrhoea
- Abdominal pain
- Bleeding
- Weight loss
- Anaemia
- Fever
24
Q
What are some extra-intestinal manifestations of IBD in children?
A
- Finger clubbing
- Erythema nodosum
- Pyoderma gangrenosum
- Episcleritis and iritis
- Inflammatory arthritis
- Primary sclerosing cholangitis (UC)
25
What investigations are done for IBD in children?
* ***Blood tests*** for anaemia, infection, thyroid, kidney and liver function. A raised CRP indicates active inflammation
* ***Faecal calprotectin***
* ***Endoscopy*** ***(OGD and colonoscopy) with biopsy:*** gold standard
* ***Imaging*** ***with ultrasound, CT and MRI*** can be used to look for complications such as fistulas, abscesses and strictures
26
How is IBD generally managed in children?
* Any child presenting with symptoms of IBD should be referred to secondary care for specialist assessment and management with **MDT**
* **Monitor growth and pubertal development** especially when treated with steroids. Get dietician input
* **Inducing remission during flares and maintaining remission**
27
What is the medical management for Crohn's?
**_Inducing Remission_**
* **Steroids:** First line e.g. oral prednisolone or IV hydrocortisone).
* **Immunosupressants:** if above doesn't work
**_Maintaining Remission_**
* **First line:** Azathioprine or Mercaptopurine
* Second Line: Methotrexate, Infliximab, Adalimumab
28
When should children with Crohn's be referred for surgery?
* If just affects **distal ileum t**hen **resect**
* Surgery can also be used to treat **strictures** and **fistulas** secondary to Crohn’s
29
What is the medical management for UC?
**_Inducing Remission_**
**Mild to moderate disease**
* **First line:** aminosalicylate (e.g. mesalazine oral or rectal)
* **Second line:** corticosteroids (e.g. prednisolone)
**Severe disease**
* **First line:** IV corticosteroids (e.g. hydrocortisone)
* **Second line:** IV ciclosporin
**_Maintaining Remission_**
* Aminosalicylate (e.g. mesalazine oral or rectal)
* Azathioprine
* Mercaptopurine
30
What surgery can be done for UC?
* **Panproctocolectomy:** left with either a permanent ***ileostomy*** or something called an ***ileo-anal anastomosis*** (***J-pouch***)
31
What monitoring needs to be done for children with UC?
* Bone health
* Height and body weight plotted on growth chart
* Pubertal development
32
What is the definition of constipation in children and some of the causes for this?
Less than 3 stools per week or significant difficulty passing stool
* **Idiopathic** (most common, lifestyle issues e.g lack of fibre, dehydrated)
* **Hirschprung's**
* **CF**
* **Hypothyroidism**
* **Cow's milk intolerance**
* **Anal stenosis**
* **Sexual abuse**
33
What are some typical features in the history for constipation in children?
* Hard stools that are difficult to pass
* Rabbit dropping stools
* Straining and painful passages of stools
* Abdominal pain
* Holding an abnormal posture, referred to as retentive posturing
* Rectal bleeding associated with hard stools
* Overflow soiling
* Hard stools may be palpable in abdomen
34
What is encopresis?
Faecal incontinence, usually a **sign of chronic constipation** where the rectum becomes stretched and loses sensation. Not pathological until 4 years
Other rarer causes of encopresis include:
* Spina bifida
* Hirschprung’s disease
* Cerebral palsy
* Learning disability
* Psychosocial stress
* Abuse
35
What are some lifestyle factors in children that lead them to become constipated?
* Habitually not opening the bowels so lose sensation
* Low fibre diet
* Poor fluid intake and dehydration
* Sedentary lifestyle
* Psychosocial problems such as a difficult home or school environment
* Pain or anal fissure
36
What are some red flags in children when they have constipation that point away from a diagnosis of idiopathic constipation?
* **Not passing meconium** **within 48 hours of birth:** CF or Hirschsprung's
* **Neurological** **signs or symptoms:** cerebral palsy or spinal cord lesion
* **Vomiting:** intestinal obstruction or Hirschsprung’s
* **Ribbon stool:** anal stenosis
* **Abnormal anus:** anal stenosis, IBD or sexual abuse
* **Abnormal lower back or buttocks:** spina bifida
* **Failure to thrive:** coeliac disease, hypothyroidism or safeguarding
* **Acute abdominal pain and bloating:** obstruction or intussusception
37
What might you find on examination of a child with constipation?
* Distended abdomen
* Hard mass in abdomen (faeces)
* Anal fissure
* Haemorrhoids
38
Before treating a child with constipation what needs to be done?
Assessed for faecal impaction:
* Symptoms of severe constipation
* Overflow soiling
* Faecal mass palpable in the abdomen (only specialist can do DRE)
39
What are the general points of management in idiopathic constipation?
* **Correct any reversible factors,** e.g high fibre diet and good hydration
* **Start maintenance laxatives**
* **Disimpaction regime** if faecal impaction
* **Good toilet habits** e.g praise, toilet scheduling, star charts
40
What lifestyle changes can parents make for children with idiopathic constipation?
ERIC PROGRAMME
* High fibre diet
* High fluid intake
* Regular toileting e.g after meals, before bed
* Toilet positioning
* Exercise
* Praise for going to toilet
41
What is the disimpaction regime?
* Escalating doses of polyethene glycol 3350+electrolytes (Movicol)
* If no disimpaction after 2 weeks add a stimulant laxative
* Warn parents will make it worse before better and may have soiling
42
What is the maintenance regime for constipation?
* **Movicol** first line
* **Stimulant** added if above not working
* Stay on laxative for a few weeks after regular bowel habit established then slowly reduce
43
What are some examples of functional GI disorders in children?
Always be careful not to miss diagnoses like IBD, always recheck for them every few months, especially if growth issues
44
What is the pathophysiology of functional GI disorders in children and how can this guide our treatment?
Psychological intervention is important
45
What is the criteria for abdominal migraine in children?
May occur in young children before they develop traditional migraines as they get older
Episodes of ***central abdominal pain*** lasting ***more than 1 hour***. Examination will be normal.
There may be:
* Nausea and vomiting
* Anorexia
* Pallor
* Headache
* Photophobia
* Aura
46
How does mesenteric adenines present?
**Diffuse central abdominal pain** in the context of a **previous URTI**
US abdo will show enlarged mesenteric lymph nodes with a normal appendix.
**Will improve spontaneously,** appendicitis will not
47
What is oesophageal atresia?
* Blind-ending oesophagus
* Associated with tracheooesophageal fistula
* More common in trisomies – Downs/Pataus/Edwards
* VACTERL
48
How may oesophageal atresia present?
* **Polyhydramnios**
* **Difficulty feeding**
* Overflow saliva and blowing bubbles
* Choking and cyanotic spells
49
How is oesophageal atresia diagnosed and managed?
* Inability to pass a catheter into the stomach, X-rays show it coiled in the oesophagus
* Stop feeding and suck out any oesophageal pouch
* Primary surgical repair and look for other anomalies (50% have VACTERL)
50
What is gastroschisis and how is it managed?
Anterior abdominal wall defect to the ***side of the umbilicus*** with ***evisceration of the bowel*** and ***no covering of the bowel***
**_Management_**
* Vaginal delivery may be attempted
* At delivery, cover exposed bowel in clingfilm, keep the baby warm and hydrated and aim to close the defect surgically as soon as possible, may be staged procedure
* Need TPN for few weeks
51
What is exomphalos and how is it managed?
Abdominal contents protrude through the anterior abdominal wall but are covered in an amniotic sac formed by amniotic membrane and peritoneum
**_Associations_**
* Beckwith-Wiedemann syndrome
* Down's syndrome
* Cardiac and kidney malformations
**_Management_**
* C-section to reduce the risk of sac rupture
* Staged repair with loose elastic bandage at 6-12 months, harder than gastroschisis
52
How may an infant with hepatitis present?
* Asymptomatic
* Jaundice
* Poor growth
* Splenomegaly
* Enlarged liver
53
How do you distinguish hepatitis from biliary atresia in children?
In biliary atresia baby is growing normally and does not have enlarged spleen but this is opposite in hepatitis
Also blood tests and liver biopsy can help tell the difference
54
What are some causes and how is hepatitis treated in children?
(image important)
* Vitamin supplements
* Phenobarbital to control seizures but also stimulates liver to excrete additional bile
* Hepatitis A virus usually resolves itself within six months
* If cirrhotic then liver transplant
55
Can a mother with Hep B or C breastfeed?
Yes - vaccinate baby for Hep B at 2, 3, 4 months but no vaccine for Hep C
56
What is the criteria for acute liver failure in children?
Rapid ***decline of hepatic function, jaundice, coagulopathy (***INR \>1.5) and ***hepatic encephalopathy*** in patients with no evidence of previous liver disease.
57
What are some causes of acute liver failure in children?
**Viral and bacterial infections**: CMV, EBV, Herpes, Parvovirus, Hep B/C
**Metabolic disorders:** mitochondrial disorder, galactosemia and tyrosinemia
**Toxic hepatitis:** mushrooms, acetaminophen, valproate or fluconazole
58
What investigations are done for acute liver failure in children?
* **FBC**
* **G+S**
* **U+Es and CRP**
* **LFTs, GT and conjugated bilirubin**
* **Blood glucose**
* **Arterial blood gas**
* **Blood for toxicology** (including paracetamol level)
* **Urine metabolic screen** (less than 5 years)
* **Autoantibodies** ANA/SMA/LKM
* **Coeliac** (EMA and TTGA)
* **Serology** (Hep A,B,C, E)
* **Opthalmology** (Kayser-Fleischer rings, chorioretinitis, cataracts, specific signs of metabolic disorders)
59
What is the management for acute liver failure in children?
**_General_**
* **Daily IV Vit K**
* **Ranitidine IV** or orally/NG
* **Lactulose** TDS to achieve BO 3-4x per day
* **If signs of encephalopathy** nurse with head elevated at 10-20 degrees
* **If encephalopathy grade 3 or above** requires ventilation and sedation
* **Maintain circulating volume** and avoid fluid overload
* **Make sure fluids have glucose** in to keep blood glucose \>4.5
60
What are the criteria for liver transplant in children?
Always be thinking about encephalopathy
61
What are causes of diarrhoea in children?
(image important)
Diarrhoea usually lasts for 5-7 days and stops within 2 weeks. If \>2 weeks it is chronic
* **Sepsis**
* Infections: Viral (Rotavirus), Parasitic, HUS
* IBS
* IBD
* Coeliac's
* NEC
* Food intolerance (Cow's milk)
* Toddler's Diarrhoea (contains undigested food)
* Thyrotoxicosis
* Post gastroenteritis lactose intolerance
62
It is rare to do tests for acute diarrhoea in children but a stool culture may be done. When do you need to do a stool culture for diarrhoea in children?
* Suspect sepsis
* Blood or mucus in stool
* Child is immunocompromised
You should consider doing a stool culture if:
* Recent travel abroad
* Not stopped by day 7
63
What is the most important thing to assess when a child has diarrhoea?
DEHYDRATION
Assess hydration status as normal, dehydrated or shocked
64
What children with diarrhoea are at risk of being dehydrated?
65
How is acute diarrhoea in children managed?
* **Increased fluid intake:** admit for IV fluids if clinically dehydrated
* **Avoid antidiarrhoeals**
* **Avoid fruit juice and carbonated drinks**
* **Hygiene advice:** hand washing, avoid nursery for 48 hours after last episode, do not go swimming
66
If a child has chronic diarrhoea what do you need to be considering?
* Coeliac's
* Lactose intolerance
* Toddler's diarrhoea (limit fruit juice)
* IBD
* IBS
* Parasitic infection
67
What are some causes of vomiting in children?
* **Posseting:** effortless and normal after feeds
* **GORD**
* **Over-feeding** (150mL/kg/day is normal)
* **Pyloric stenosis** (projectile, at ~8 weeks old)
* **Any infection,** eg UTI
* **Adverse food reaction**
* **Infective gastroenteritis**
* **Pharyngeal pouch**
* **Raised intracranial pressure**
* **Intestinal obstruction**
68
What are some general and specific red flags for vomiting in infants?
**_General_:** signs of dehydration e.g drowsy or floppy, dry mucous membranes and sunken eyes
**_Specific_**
* **Projectile vomiting around 6-8 weeks of age**
* **Bile-stained vomit and abdominal distention:**
* **Bloody stool with vomiting**
* **Paroxysmal coughing to the point of vomiting**
* **Seizures/bulging fontanelle with vomiting:** raised intracranial pressure
69
What is very important to assess in vomiting children?
Are they dehydrated? Do they need IV fluids?
70
What are some medical causes of abdominal pain in children?
71
What are some surgical causes of abdominal pain in children?
* Appendicitis
* Intususseption
* Bowel obstruction
* Testicular torsion
72
What are some red flags for serious pathology behind abdominal pain in children?
* Persistent or bilious vomiting
* Severe chronic diarrhoea
* Fever
* Rectal bleeding
* Weight loss or faltering growth
* Dysphagia
* Nighttime pain
* Abdominal tenderness
73
Recurrent abdominal pain with no underlying cause is common in children, especially during stressful life events e.g loss of a relative or bullying. The leading theory for the cause is increased sensitivity and inappropriate pain signals from the visceral nerves in response to normal stimuli.
How can this be managed?
* **Distract child** from pain with other activities
* **Encourage parents not to ask about** or focus on the pain
* **Advice about sleep, regular meals, healthy balanced diet**, staying hydrated, exercise and reducing stress
* **Probiotic supplements**
* **Avoid NSAIDs** such as ibuprofen
* **Address psychosocial triggers** and exacerbating factors
* **Support from a school counsellor** or child psychologist
74
How is abdominal migraine managed?
Similar to adult migraines, managing acute attacks and prevention
**_Treating the acute attack:_**
* Low stimulus environment (quiet, dark room)
* Paracetamol
* Ibuprofen
* Sumatriptan
**_Preventative medications:_**
* ***Pizotifen***, a serotonin agonist.
* Propranolol,
* Cyproheptadine
* Flunarazine
75
What is the issue with taking Pizotifen for abdominal migraines?
**Withdrawal symptoms**
e.g depression, anxiety, poor sleep, tremor
Need to withdraw slowly
Y4 Paediatrics
flashcards
Decks in class (31)
# Cards
-
1 - History Taking and Communications with the Child33
-
2 - Examination and Practical Procedures52
-
3 - Genetics62
-
4 - Neonatology90
-
5 - Surveillance and Development60
-
6 - Community Paediatrics 177
-
7 - Safeguarding33
-
8 - Respiratory 172
-
9 - Respiratory 288
-
10 - Cardiology83
-
11 - ENT76
-
12 - Endocrinology76
-
13 - Puberty58
-
14 - Allergy and Immunology75
-
15 - Dermatology65
-
16 - Nephrology91
-
17 - Haematology79
-
18 - Oncology52
-
19 - Orthopaedics67
-
20 - Rheumatology45
-
21 - Neurology 155
-
22- Neurology 250
-
23 - Gastroenterology75
-
24 - Paediatric Surgery69
-
25 - Paediatric Surgery 251
-
26 - Infectious Diseases 184
-
27 - Infectious Diseases 280
-
28 - Recognition and Management of the Sick Child19
-
29 - Emergency Paediatrics 174
-
30 - Emergency Paediatrics 261
-
31 - Prescribing for Children29
