Paediatrics

Question 1

State the paediatric milestones

6wks

6months

9 months

12months

18months

2yrs

2.5yrs

3yrs

3.5yrs

4yrs

Answer 1

Gross motor: 6m sit withought support

Fine Motor: 6m hand to hand, palmar grasp

speech: 6m turns head to loud sounds, babbles

Social: 6ick smile, 6 mouth, 9 strangers, 12 bye stranger, 18imitates, 2spoon, 3 fork, 4 best friend, 4.5 bladder control, 5 handles knife

Question 2

The NHS NIPE Screening Programme aims to reduce morbidity and mortality by:

Newborn and infant physical examination screening programme

Answer 2

identifying and referring all children born with congenital abnormalities of the eyes, heart, hips, and testes, where these are detectable, within 72 hours of birth

identifying those abnormalities that may become detectable by 6 to 8 weeks of age, at the second physical examination

Question 3

Examination of the eyes:

1. Main concern?
2. RF
3. Bilateral examination covers:
4. Screen negative – newborn and 6-8 week infant examination:
5. Screen positive

Answer 3

1. Congenital cataracts
2. FHx of congenital or hereditary cataracts (first degree relative)

Prematurity

Children with trisomy 21

Maternal exposure to viruses during pregnancy, including rubella and cytomegalovirus

(aniridia, colobomata and retinoblastoma)

3. eye opening – presence of eyes

position and symmetry

size and colour

presence of red reflex (a reflection from the back of the eye that is similar to the red eye effect sometimes seen in flash photography)

4. transfer care to the Healthy Child Programme
5. The absence of red reflex - congenital cataract.

A white reflex (leukocoria) - a tumour of the eye (retinoblastoma)

Screen positive following newborn examination -> attend an assessment appointment by 2 weeks of age

Screen positive following 6 to 8 week infant examination - seen by 11 weeks of age

Question 4

Examination of the heart

1. Main concern
2. RF
3. Undertaking the examination

Answer 4

1. Congenital heart abnormalities can be categorised as:

critical CHD: includes all potentially life threatening duct-dependent conditions and those conditions that require procedures within the first 28 days of life

major serious CHD: those defects not classified as critical but requiring invasive intervention in the first year of life

lesions may be detected during pregnancy as part of the fetal anomaly screening programme (FASP)

2.

• FHx of CHD (first degree relative)
• fetal trisomy 21
• cardiac abnormality suspected from the antenatal scan
• maternal exposure to viruses, for example, rubella during the first trimester of pregnancy,
• maternal conditions, such as diabetes (type 1), epilepsy, systemic lupus erythematosis (SLE)
• drug-related teratogens during pregnancy, for example, antiepileptic and psychotrophic5 drugs

3. Parents should be asked if:

• the baby ever gets breathless or changes colour at rest or with feeding
• the baby’s feeding behaviours and energy levels are normal
• the baby is ever too tired to feed, quiet, lethargic, or has poor muscle tone

Question 5

Examination of the hips

1. Main concern
2. RF
3. Examination
4. screen positive

Answer 5

1. developmental dysplasia of the hips (DDH)

undetected/delayed treatment may lead to:

• impaired mobility and pain
• OA of the hip and back

2. First degree family history of hip problems in early life.

Breech presentation

3. Observation covers:

symmetry of leg length

level of knees when hips and knees are both flexed

symmetry of skin folds in the groin when baby is in ventral suspension6

if legs can be fully abducted

Manipulation

Undertake both the Ortolani and Barlow manoeuvres on each hip separately to assess hip stability.

Ortolani manoeuvre is used to screen for a dislocated hip.

Barlow manoeuvre is used to screen for dislocatable hip.

4.

Screen positive

Screen positive results are:

difficulty in abducting the hip to 90 degrees

difference in leg length

knees at different levels when hips and knees are bilaterally flexed

asymmetry of groin skin folds

palpable ‘clunk’ when undertaking either the Ortolani or Barlow manoeuvres

These babies should be referred and undergo hip ultrasound within 2 weeks of birth.

Question 6

Examination of the testes

1. Main concern?
2. Associated risk factors
3. Examination

Answer 6

1. Cryptorchidism

associated with:

• a significant increase in the risk of testicular ca (primarily seminoma)
• reduced fertility when compared with normally descended testes
• other urogenital problems such as hypospadias and testicular torsion

2. a first degree family history of cryptorchidism (baby’s father or sibling)

low birth weight

small for gestational age or preterm birth

3. Observe scrotum for symmetry, size and colour

Palpation of scrotal sac to determine location of testes bilaterally

If testes are not located in the scrotal sac, palpation of the inguinal canal should be undertaken.

Question 7

Chickenpox

1. Cause:
2. O/e:
3. Management:

Answer 7

Fever initially
Itchy, rash starting on head/trunk before spreading.

Initially macular then papular then vesicular

Systemic upset is usually mild

1. VZV
2. vesicular itchy rash, aches, fever, loss of appetite

250-500 itchy blisters over the entire body OR

Sometimes 50 or fewer red bumps that rarely evolve to blisters

last for 5-7 days and heal with scabs

3. avoid nursery or work for 5 days, fluid, paracetamol, socks of hands, cut child’s nails, cooling creams, bathe in cool water & pat skin dry, ?antihistamine, loose clothes

Takes 1-3 weeks from time you have been infected for spots to start appearing

DO NOT use ibuprofen

DO NOT give aspirin <16 = possible links to a rare disease that attacks the brain and liver

Question 8

Croup

Signs and symptoms:

Answer 8

viral infection in the upper airways

barking cough, stridor, hoarse voice, difficulty breathing

Croup usually gets better within 48h

Management:

• paracetamol or ibuprofen -> sore throat and temperature
• Sit your child upright and comfort them if they are distressed. Crying can make the symptoms worse.
• fluids - enough so they are weeing
• DO NOT put any objects in your child’s mouth. This can trigger a spasm in the airway.

Question 9

Measles

1. Cause/ spread
2. How long does it take to recover
3. Symptoms
4. Measles by:
5. Prevented
6. treatment?
7. prodrome? Koplik spots: Rash:

Answer 9

1. viral/ coughs or sneezes as well as through contact with a surface or object that has been contaminated
2. 7 - 10 days

3.

• cold-like symptoms: runny nose, sneezing and a cough
• sore, red eyes that may be sensitive to light
• a high temperature (fever), which may reach around 40C (104F)
• small greyish-white spots on the inside of the cheeks

4. lungs (pneumonia) and brain (encephalitis)

5.

• breathing in these droplets
• touching a surface the droplets have settled on and then placing your hands near your nose or mouth (the virus can survive on surfaces for a few hours)

6. measles, mumps and rubella (MMR) vaccine

7.

• taking paracetamol or ibuprofen to relieve fever, aches and pains (aspirin should not be given to children <16yo)
• drinking plenty of water to avoid dehydration
• closing the curtains to help reduce light sensitivity
• using damp cotton wool to clean the eyes
• staying off school or work for at least 4 days from when the rash first appears

8. Prodrome: irritable, conjunctivitis, fever

Koplik spots: white spots (‘grain of salt’) on buccal mucosa

Rash: starts behind ears then to whole body, discrete maculopapular rash becoming blotchy & confluent

Question 10

Chicken pox vs measles

Answer 10

Question 11

Mumps

1. Appearance?
2. Symptoms
3. spread?
4. prevent
5. Rx

Answer 11

1. swellings at the side of the face under the ears (the parotid glands), giving a person with mumps a distinctive “hamster face” appearance
2. headaches, joint pain and a high temperature, which may develop a few days before the swelling of the parotid glands.
3. droplets
4. MMR vaccine

1 dose when they are around 12-13 months

Second booster dose at 3 years and 4 months

5.

• getting plenty of bed rest and fluids
• using painkillers, such as ibuprofen and paracetamol – aspirin shouldn’t be given to children under 16
• applying a warm or cool compress to the swollen glands to help relieve pain

Fever, malaise, muscular pain

Parotitis (‘earache’, ‘pain on eating’):

unilateral initially then becomes bilateral in 70%

Question 12

How does Parvovirus B19 present?

Answer 12

slapped-cheek syndrome = erythema infectiosum

coryza

fever

red rash = body = lace like rash

Question 13

Rubella

1. Rash:
2. Rubella can also cause:

Answer 13

1. pink maculopapular,

initially on face before spreading to whole body,

goes within a week

2. Lymphadenopathy: suboccipital and postauricular

aching fingers, wrists or knees

a high temperature of 38C or above

coughs

sneezing and a runny nose

headaches

a sore throat

sore, red eyes

Question 14

Erythema infectiosum

1. Also known as ?
2. Caused by?
3. other features

Answer 14

1. fifth disease or ‘slapped-cheek syndrome’
2. parvovirus B19
3. Lethargy, fever, headache
   ‘Slapped-cheek’ rash spreading to proximal arms and extensor surfaces

Question 15

Scarlet fever

1. Cause?
2. Features:
3. Rx

Answer 15

1. Reaction to erythrogenic toxins produced by Group A haemolytic streptococci
2. Fever, malaise, tonsillitis
   ‘Strawberry’ tongue
   Rash - fine punctate erythema sparing the area around the mouth (circumoral pallor)

3.

Antibiotics

You can relieve symptoms of scarlet fever by:

drinking cool fluids

eating soft foods if you have a sore throat

taking painkillers like paracetamol to bring down a temperature (do not give aspirin to children under 16)

using calamine lotion or antihistamine tablets to stop itching

Question 16

Hand, foot and mouth disease

1. The first signs of hand, foot and mouth disease can be:
2. How long does it take to resolve?
3. Cause?

Answer 16

1. a sore throat

a high temperature, above 38C

not wanting to eat

After a few days mouth ulcers and a rash will appear

2. better in 7 to 10 days
3. Coxsackie A16 virus

Question 17

Rash with itching DD?

Answer 17

1. small red spots known as prickly heat or heat rash

itchy, red, dry and cracked may be eczema. It’s common behind the knees, elbows and neck

Raised, itchy red rash (hives) can appear as an allergic reaction to things like stings, medicines or food. It usually clears up within a day or 2.

Question 18

besides the heart, hip, genitalia and eyes what else can you check?

Answer 18

fontanelles

spine

feeding

abdomen

Question 19

What is this image showing?

Answer 19

Cradle cap is when a baby gets yellowish, greasy scaly patches on their scalp.

It usually gets better without treatment in a few weeks or months.

Gently washing your baby’s hair and scalp with baby shampoo may help prevent more patches.

Question 20

What is this image showing

Answer 20

Baby acne can appear within a month after birth but usually clears up after a few weeks or months.

Washing your baby’s face with water and a mild moisturiser can help.

Do not use acne medicines intended for older children and adults.

Question 21

what does this show?

Answer 21

Small, firm, raised spots that can appear anywhere on the body are common in children and known as molluscum contagiosum.

Rx: isn’t recommended because the spots clear up on their own, although it can take more than a year.

Question 22

What does this image show?

Answer 22

Raised red, yellow and white spots (erythema toxicum) can appear on babies when they’re born. They usually appear on the face, body, upper arms and thighs.

The rash can disappear and reappear.

It should clear up in a few weeks without treatment.

Question 23

what is this image showing?

Answer 23

Small white spots (milia) often appear on a baby’s face when they’re a few days old.

They usually clear up within a few weeks and don’t need treatment.

Question 24

1. Scabies symtoms?
2. Rash?
3. For children over the age of two months, and adults with non-crusted scabies, prescribe:

Answer 24

1. intense itching, especially at night
2. silvery lines -> between fingers -> spreads tiny red papules

<2 GP

3. topical insecticide:
   1st: Permethrin 5% cream 8-12hrs then wash

second application is required one week after the first

Treat post-scabietic itch with crotamiton 10% cream

wash clothes above 60 degrees

Question 25

What does this show?

Answer 25

blotchy red rash with associated yellowish pustules. Settles with no treatment.

Question 26

Milia–

Answer 26

benign keratin filled cysts

Question 27

Birthmarks

Answer 27

Mongolian blue spots – particularly over the sacrum / buttocks are extremely common. Small port wine naevi and Strawberry naevi generally require no treatment. They grow for 6-12 months before gradually fading within 5-8 years Large unilateral port wine stains can be associated with intracranial vascular anomalies2and further imaging/review may be required.

Question 28

Neurological

Answer 28

* Inspect spine for sacral dimples / hairy patches. If unable to identify base of dimple refer for spinal USS2. * Tone – when pulling babies to sit from supine, babies should be able to attempt to raise their head. * Social smile / normal cry * Hearing – startles to noise

Question 29

Facial features

Answer 29

* Measure head circumference. Is it a normal shape? * Eyes – check for bilateral red reflex (retinoblastoma) * Cleft lip/palate – refer cleft coordinator LGI * Ears – pre auricular skin tags – plastic surgeons * Neonatal tooth – orthodontist

Question 30

Cardiovascular/Respiratory system

Answer 30

* Rule out congenital heart disease. * Inspect for cyanosis or respiratory distress. * Palpate apex for displacement. * Listen for murmurs & check for equal air entry. * Palpate for femorals– diagnose coarctation of the aorta

Question 31

Hands Abdomen / hernias

Answer 31

* Polydactyly– if bilateral can be associated with renal abnormalities so a renal US should be arranged * Syndactyly– if there is fusion of the bone refer to a hand specialist / if not refer to the plastic surgeons * Umbilical hernia – common and usually resolves by 18/122. Inguinal hernias are rare in term, newborn infants. If diagnosed they need early surgical intervention as they are at increased risk of incarceration

Question 32

Developmental dysplasia of the hip

Answer 32

Risk factors: breech presentation, FHx of DDH require USS of the hips Barlows– flex and adduct each hip then push the hip posteriorly keeping your fingertips on the greater trochanter. Feel for the femoral head slipping out of socket. Ortolani’s – gently abduct the hip fully – feel for the femoral head slipping back into joint.

Question 33

Genitalia

Answer 33

* Ambiguous genitalia – don’t guess! Refer to a consultant paediatrician. * Undescended testes – most will descend in the first few weeks post delivery. If undescended by 1 year old referral to surgeons is needed. * Hypospadias – urethral meatus opens in an abnormal position. Ensure that baby can pass a good stream of urine. Need referral to paediatric urologist.

Question 34

Development /health promotion

Answer 34

* Review feeding and weight gain. * Plot on growth chart length, weight and HC. * Note centiles. * Take the opportunity to discuss - Immunisations - Reducing risk of sudden infant death - Dangers of passive smoking - Car safety - Dental health

Question 35

Seven classic childhood exanthems (Fever with a rash) • Adenoviruses and Bacteria – conjunctivitis (also allergic causes) • Staphylococcus aureus – styes & orbital cellulitis • Streptococcus – orbital cellulitis UTI Proteus and Pseudomonas infections suggest an underlying urinary tract structural abnormality in 50% of cases and so radiological imaging is indicated, unlike 5% in E Coli infections Group A beta-haemolytic streptococcus (GABHS:Streptococcus pyogenes) is the most likely cause of bacterial tonsillitis • This can lead to a systemic infection and resultant rheumatic fever, scarlet fever and acute glomerulonephritis. RSV (Respiratory Syncytial Virus) causing Croup and Bronchiolitis * Human Papilloma Virus and association with carcinoma of the cervix * Vaccines; Gardasil and Cervarix WhealUrticaria

Answer 35

* First disease - Measles (forehead rash, eyes effected) * Second Disease - Scarlet fever (sandpaper rash, strawberry tongue) * Third disease – Rubella (G Measles) * Fourth Disease - Dukes-Filatov disease * \*Fifth Disease – “Slapped Cheek” * Sixth Disease - Roseola infantum * \*Seventh Disease - Kawasaki’s disease