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Paediatrics for the AMK
By Dr Eva Wooding
+ Learning Objectives
Revise key Indicative Presentations for the AMK including…
Paediatric emergencies (“what would you do first?”)
Common inherited conditions
Community Paediatrics (normal development,
vaccinations)
Common childhood infections and their management
Fractures and common injuries
+ Q: Febrile Child
A mother from Totnes brings her 22 month old daughter to ED. She has been off colour for 5 days and visibly unwell for 48 hours with a coryzal illness, pyrexia and lethargy. She had Calpol 2 hours ago. O/E: HR 165, RR 35, Sats 97% on air, BP 90/60, Cap Refill 3 secs, Temp 37.6oC. A maculopapular rash visible on the face, mild cervical lymphadenopathy and conjunctivitis. The child has not had any regular vaccinations. She is looked after at home, but attended a playgroup until 2 weeks ago.
What’s your primary diagnosis?
A: Bacterial Meningitis
B: Kawasaki Disease
C: Fifth Disease
D: Chickenpox
E: Rubella
+ Q: Febrile Child
A mother from Totnes brings her 22 month old daughter to ED. She has been off colour for 5 days and visibly unwell for 48 hours with a coryzal illness, pyrexia and lethargy. She had Calpol 2 hours ago. O/E: HR 165, RR 35, Sats 97% on air, BP 90/60, Cap Refill 3 secs, Temp 37.6oC. A maculopapular rash visible on the face, mild cervical lymphadenopathy and conjunctivitis. The child has not had any regular vaccinations. She is looked after at home, but attended a playgroup until 2 weeks ago.
What’s your primary diagnosis?
A: Bacterial Meningitis
B: Kawasaki Disease
C: Fifth Disease
D: Chickenpox
E: Rubella
+ Common Childhood Infections
Meningitis
Rash associated with bacterial septicaemia (non-blanching, maculopapular). Expect higher fever
Immediate Management?
Rubella
Respiratory spread, 14-21 day incubation.
Fever, then spreading maculopapular rash
(face to trunk) which fades in 3-5 days.
!! Pregnancy !!
Fifth Disease
Aka ‘Slapped Cheek’ caused by Parvovirus. Painless rash on one/both cheeks. Mild fever, usually self-limiting. Peak incidence April/May
Chickenpox
Respiratory spread. 10-21 day incubation. Clusters of vesicles over head/neck/trunk. Intensely itchy. Papule Vesicle Pustule Crust + Scratch marks
Kawasaki’s (vasculitis)
Fever >5 days + Strawberry tongue, peeling skin (desquamation) ,
cervical lymphadenopathy, bilateral conjunctivitis. Complications:
myocardial ischaemia and sudden death
+ Rashes of Childhood Diseases
+ Normal Reference Ranges in Children
They are different!
+ Q: Abdominal Pain
A 2 year old boy is brought to his GP with intermittent screaming
and pain, followed by periods where he is quiet and withdrawn.
He has had one loose, jelly-like stool passed today. O/E there is a
mass palpable in his abdomen.
A: Meckel’s Diverticulum
B: Gastroschisis
C: Intussusception
D: Sigmoid volvulus
E: Appendicitis
+ Q: Abdominal Pain
A 2 year old boy is brought to his GP with intermittent screaming
and pain, followed by periods where he is quiet and withdrawn.
He has had one loose, jelly-like stool passed today. O/E there is a
mass palpable in his abdomen.
A: Meckel’s Diverticulum
B: Gastroschisis
C: Intussusception
D: Sigmoid volvulus
E: Appendicitis
+ Paediatric Acute Abdomen
Intussusception
Cause of 25% of acute abdomen
in children <5. Male: female 3:2.
Usually sudden onset, colicky in
nature. ‘Sausagey mass’,
‘redcurrant jelly stool’
Meckel’s Diverticulum
Embryological remnant of vitellointestinal tract. Presents with intermittent, painless blood PR. Dx via Technetium scan to find ectopic gastric mucosa
Gastroschisis
Where abdomen is not covered by peritoneum.
This is found prenatally or postnatally and repaired surgically
Appendicitis
Rarer cause of acute abdomen for age group (usually 10-20y/o).
Migratory pain, not colicky. O/E usually no mass to palpate
+ Q: Respiratory Distress
A 6 year old African-Caribbean girl comes to ED with her
father. She appears lethargic and is sat quietly, but clearly
struggling to breathe. She has been unwell for around 6
hours and is sat forward dribbling. What is the diagnosis?
A: Epiglottitis
B: Croup
C: Bronchiolitis
D: Foreign body inhalation
E: Sickle cell crisis
+ Q: Respiratory Distress
A 6 year old African-Caribbean girl comes to ED with her
father. She appears lethargic and is sat quietly, but clearly
struggling to breathe. She has been unwell for around 6
hours and is sat forward dribbling. What is the diagnosis?
A: Epiglottitis
B: Croup
C: Bronchiolitis
D: Foreign body inhalation
E: Sickle cell crisis
+ So you think it’s Epiglottitis…
What do you do next?
A: Start broad spectrum antibiotics
B: Examine the throat for site of obstruction
C: Start high flow Oxygen
D: Call the anaesthetist
E: Order a Chest X-ray
+ So you think it’s Epiglottitis…
What do you do first?
A: Start broad spectrum antibiotics
B: Examine the throat for site of obstruction
C: Start high flow Oxygen
D: Call the anaesthetist
E: Order a Chest X-ray
+ Respiratory Tract Infections
Epiglottitis
Causes severe life-threatening stridor quickly due to H. Influenzae infection. If suspected, don’t delay urgent GA and upper airway endoscopy needed
Croup
Usually mild, viral illness. Also causes stridor and a barking cough (like a sealion). May have fever and develops more slowly.
Usually affects children 6m to 5yrs
Bronchiolitis
Viral RTI affecting children under 2 years (peak 3-6m). Seasonal illness (winter). Usually caused by Respiratory Syncytial Virus (RSV). Treat with fluids, O2
Foreign Body
Sudden onset of SOB ± history of
aspiration from observer.
Unilateral signs
(wheeze/reduced air entry). RHS
more common
+ Q: Childhood Injuries
A 10 month old boy presents to ED crying and clutching his right arm. He cries out when you attempt examination. His mother describes an accurate method of injury (fall from side of cot onto tiled floor) and brought the child immediately to ED. X-ray demonstrates
What part of the history will be most helpful for
informing on going management?
A: Family history
B: Past Medical history
C: Dietary history
D: Developmental history
E: Drug history
+ Q: Childhood Injuries
A 10 month old boy presents to ED crying and clutching his right
arm. He cries out when you attempt examination. His mother
describes method of injury (fall from side of cot onto tiled floor)
and brought the child immediately to ED. X-ray demonstrates
What part of the history will be most helpful for
informing on going management?
A: Family history
B: Past Medical history
C: Dietary history
D: Developmental history
E: Drug history
+
+ Highly Suspicious Injuries
Long bone fractures in non-ambulatory children
Any fracture under 6 months
Spiral fractures
Rib fractures in infant (Shaken baby) esp. Posterior
Depressed skull fractures
NB. Safeguarding!
+ Q: Vaccinations
A 3 1/2 year old girl from Exeter attends her practice nurse with her pregnant mother for her MMR vaccine. She is usually fit and well except for Asthma. She recently had a RTI but is now afebrile following a 1 week course of steroids. She is allergic to eggs. Her brother has previously had a reaction to the MMR vaccine.
What is the contraindication to having her MMR today?
A: Egg allergy
B: Recent steroids
C: Family History of vaccine reaction
D: Recent infection
E: Mother’s pregnancy
+ Q: Vaccinations
A 3 1/2 year old girl from Exeter attends her practice nurse with her pregnant mother for her MMR vaccine. She is usually fit and well except for Asthma. She recently had a RTI but is now afebrile following a 1 week course of high dose steroids. She is allergic to eggs. Her brother has previously had a reaction to the MMR vaccine.
What is the contraindication to having her MMR today?
A: Egg allergy
B: Recent steroids
C: Family History of vaccine reaction
D: Recent infection
E: Mother’s pregnancy
+ Childhood Vaccinations
Live Vaccines
• MMR
• BCG
Inactivated/Polysaccharide/
Toxoid Vaccines
• DTaP/IPV/Hib (Pediacel)
• Tetanus
• Influenza
• Pneumococcus
True Contraindications to
Vaccination
• Egg anaphylaxis (influenza,
yellow fever)
• Prednisolone 2/mg/kg/day
for >6 days
• Impaired immunity
• Chemo/RadioRx in last 6 wks
• Bone marrow transplant in
last 6 months
• Immunosuppression with
cytotoxic drugs
+ Q: Mobility Problems
A 4 year old boy attends Paediatric Outpatient Clinic with
difficulty walking, and trips. Developmentally, he sat up by 9
months and was walking by 20 months. His mother has noticed a
limp. O/E he has unsteady gait and poor balance.
The doctor diagnoses Muscular Dystrophy. How is this inherited?
A: Autosomal Dominant
B: X-linked Recessive
C: Autosomal Recessive
D: Polygenic Inheritance
E: X-linked Dominant
+ Q7: Mobility Problems
A 4 year old boy attends Paediatric Outpatient Clinic with
difficulty walking, and trips. Developmentally, he sat up by 9
months and was walking by 20 months. His mother has noticed a
limp. O/E he has unsteady gait and poor balance.
The doctor diagnoses Muscular Dystrophy. How is this inherited?
A: Autosomal Dominant
B: X-linked Recessive
C: Autosomal Recessive
D: Polygenic Inheritance
E: X-linked Dominant
+ Heritance Patterns
Autosomal Dominant
Familial hypercholesterolaemia – 1
in 500
Polycystic kidney disease – 1 in 1250
Marfan Syndrome – 1 in 4000
Huntington Disease – 1 in 15 000
X-Linked (recessive)
Red-Green colour-blindness
Duchenne’s and Becker’s Muscular
Dystrophies
Fragile X syndrome
Haemophilia A and B
Autosomal Recessive
Sickle cell disease – 1 in 625 (Black
African-Caribbeans)
Cystic fibrosis – 1 in 2500
(Caucasians)
Tay-Sacs disease – 1 in 3000
(Ashkenazi Jews)
Others
X-linked (Dominant): Vitamin D resistance Rickett’s
Mitochondrial (passed by mother)
Polyfactorial (congenital or acquired) e.g. Diabetes, Epilepsy…
+ Punnett Square
Which/who is the…?
Heterozygote
Homozygote
Dominant allele?
Affected child?
Unaffected?
What type of heritance is this?
+
Bonus Question What are the names of the two hip tests we carry out to look for
congenital hip disorders in neonates?
+ Congenital Hip Malformations
Ortolani’s
Flex hip to 90o then
move hips OUT
Tests for posterior
disclotion
Barlow’s
Move hips inwards
Tests for posterolateral dislocation
+ Q: Managing Epilepsy
A 7 year old child with known Epilepsy is having a seizure in
a GP’s waiting room. You are called to assess them. This
seizure has continued for 5 minutes. What should you do first?
A: Secure the airway
B: Call an ambulance
C: Remove objects from around the child e.g. chairs
D: Give Midazolam
E: Give Diazepam
+ Q: Managing Epilepsy
A 7 year old child with known Epilepsy is having a seizure in
a GP’s waiting room. You are called to assess them. This
seizure has continued for 5 minutes. What should you do first?
A: Secure the airway
B: Call an ambulance
C: Remove objects from around the child e.g. chairs
D: Give Midazolam
E: Give Diazepam
+ Seizures and their management
Emergency Management for seizures lasting >5 mins:
Call 999
Give buccal Midazolam in the community, IV Lorazepam if IV
access available (or PR Diazepam)
Status Epilepticus = seizure (or cluster of seizures) lasting >10
mins.
Treated with Benzodiazepines Phenobarbitol Phenytoin
+ Summary and Top Tips
If it’s obvious, go for it; they’re probably not trying to trick you!
Read the vignettes carefully looking for key words. Bring a
highlighter if that helps
Write things out if that works for you, especially for genetics
questions
If the question asks what you’d do FIRST… it’s probably “high flow
oxygen”
Don’t get too bogged down with details, remember the big stuff
and the common stuff and you’ll be fine!
+ Some Key Words/Phrases
Strawberry tongue and
‘desquamation’ of palms =
Kawasaki’s
Redcurrant jelly
stool/sausagey mass =
Intussusception
Sick child sat forward and
drooling = epiglottitis
Barking cough = Croup
Spiral fracture = Non-accidental
injury
+ Learning Objectives
Revise key Indicative Presentations for the AMK including…
Paediatric emergencies (“what would you do first?”)
Common inherited conditions
Community Paediatrics (normal development,
vaccinations)
Common childhood infections and their management
Fractures and common injuries
+ Further Reading and References
Etheridge, L (ed.) Oxford Assess and Progress: Clinical Specialties 2010 OUP: Oxford.
Core Clinical Cases in Paediatrics 2nd ed. Ewer A, Gupta R, Barrett T, Gupta J. 2011 Hodder Arnold: London.
Orekunrin O, Chaplin H. Revision Questions for Paediatrics. 2010 Radcliffe: Oxford.
Patient UK, 2013. Accessed online: http://www.patient.co.uk/doctor/Paediatric-Examination.htm (accessed 08/10/13).
University of Texas, 2013. Accessed online: http://www.utmb.edu/pedi_ed/CORE/Abuse/page_08.htm (accessed 08/10/13).
Almost A Doctor: Mind Maps, 2013. Accessed online: http://almostadoctor.co.uk/sites/all/MindMaps/409.pdf (accessed 08/10/13)
+ Picture References
Pictures are copyright and royalty free unless referenced
Chickenpox http://www.theintellectualdevotional.com
Kawasaki’s disease:http://en.wikipedia.org/wiki/File:Kawasaki_symptoms_B.jpg
Meningococcal septicaemia: http://www.wales.nhs.uk/sites3/page.cfm?orgId=457&pid=32261
Spiral Fracture: http://www.utmb.edu/pedi_ed/CORE/Abuse/page_08.htm
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/204061/DoH_Imm_schedule_poster_A4_2013_07_accessible.pdf
Punnett Square: http://upload.wikimedia.org/wikipedia/commons/2/22/Punnett_Square.svg
Ortolani/Barlow’s Manoeuvre http://www.cssd.us/body.cfm?id+512
