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Pediatrics Wrap up lecture Dr Sweatha Ananthalingam West Midlands SouthoctorTable of Contents Development Neurology Hematology Rheumatology Endocrinology Questions and OSCE stationsFailure to Thrive o Poor physical growth and development o Faltering Growth? •>=1 centile spaces if b.w <9 centile •>=2 centile spaces if 9 < b.w < 91 centile st •>=3 centile spaces if b.w > 91 centile Causes of Failure to Thrive? *Plotting a growth chart* Causes Inadequate Nutritional Increased Energy Inability to process Intake DifficultyFeeding Malabsorption Requirements nutrition Maternal malabsorption+ Poor suck – Cerebral palsy CF Hyperthyroidism breastfeeding Inborn errors of Cleft palate Coeliac Disease Chronic disease - CHD Iron deficiency anaemia Genetic abnormalities IBD Malignancy metabolism Neglect T1DM Pyloric Stenosis Chronic Diarrhoea Chronic infections - HIV Availability of foodAssessment for Failure to Thrive •Pregnancy, birth, developmental and social history •Feeding or eating history •Mums physical and mental health •Parent-child interactions •BMI - < 2 centile •mid-parental height - more than 2 centiles below MPH ?inadequate nutrition/growth disorder *Failure to Thrive history*Management Routinely Urine dipstick & Coeliac screen is completed Further investigations is led by clinical concerns. MDT approach to managementhttps://mrcpch.paediatrics.co.uk/de velopment/development-videos/ *Describing domains of development from a video*Question 1 Which of the followingis NOT a red flag for developmental delay? 1. Not smilingat 6weeks 2. Not sittingunsupported by 12 months 3. Not walking by 18 months 4. Not knowing 2-6 words by 18 monthsQuestion 1 Which of the followingis NOT a red flag for developmental delay? 1. Not smilingat 6weeks 2. Not sittingunsupported by 12 months 3. Not walking by 18 months 4. Not knowing 2-6 words by 18 months Lost Devmilestonel No grip – 5 No words & no months interest inothers – 18 months Red Flags Not running - 2.5 Not sitting years unsupyeared – 1 Not walking Not standing indep2 yearsy – in18 monthsly –Enuresis Most children get control of Day-time urination by 2 years and Night-time by 3-4 years • Nocturnal Enuresis - Bed-wetting • Primary – Never managed to be dry at night. • Secondary – Child begins bed-wetting when has been dry for at least 6 months. More indicative of underlying pathologyPrimary Nocturnal Enuresis ❑ Commonly a normal variant < 5 years. Can have family history of delayed dry nights ❑ Fluid intake prior to bedtime (i.e fizzy drinks) ❑ Failure to wake (deep sleep and underdeveloped bladder signals) ❑ Psychological distress (low self esteem, stress) ❑ Overactive bladder. ❑ Secondary causes - chronic constipation, UTI, learning disability or cerebral palsy Primary Nocturnal Enuresis ❑ Reassurance < 5 years ❑ Lifestyle changes: reduced fluid intake in the evenings, pass urine before bed ❑ Encouragement and positive reinforcement. ❑ Treat any underlying causes or exacerbating factors,such as constipation ❑ Enuresis alarms – noise at 1 signs of bed-wetting. Consistent use for at least 3 months ❑ Medications • Desmopressin (ADH analogue) : Reduces volume of urine produced • Oxybutynin : Anticholinergic for overactive bladder *Communication station on discussing concerns around bed-wetting and how to manage it*Secondary Nocturnal Enuresis •UTI – ( repeated UTIs think about safeguarding) •Constipation •Type 1 diabetes •New psychosocial problems *Safeguarding* Treat underlying cause *Ethics Station*Febrile Convulsions o Seizure in children between 6 months and 5 years with “high fever” o Not caused by epilepsy or any other underlying pathology o Typical patient is 18-month child with 2-5 minutes seizure with underlying viral (or) bacterial illness o Generalized Tonic - Clonic seizures + < 15 minutes – Simple o Focal (or) Partial + > 15 minutes – Complex o Rule out other causes! – what other causes?Other causes of seizures •Epilepsy •Meningitis, encephalitis and another neurological infection •Intracranial space occupying lesions – i.e brain tumours •Syncopal episode •Electrolyte abnormalities •Trauma (Non accidental injury!) *History or history+explanation/reassurance station*Management o Child in a safe place in a recovery position o If > 5 minutes – call ambulance st o 1 seizure episode – ED visit always necessary o Manage underlying source of infection o Fever – with Paracetamol and Ibuprofen o 1 in 3 children will have another febrile convulsionQuestion 2 Which of the following is Least commonly associated with febrile convulsions? 1. Upper respiratory Tract Infections 2. Gastroenteritis 3. Otitis Media 4. Urinary Tract Infections 5. Lower Respiratory Tract InfectionsQuestion 2 Which of the following is Least commonly associated with febrile convulsions? 1. Upper respiratory Tract Infections 2. Gastroenteritis 3. Otitis Media 4. Urinary Tract Infections 5. Lower Respiratory Tract InfectionsQuestion 3 Which of the following is most suggestive of a diagnosis of Cerebral palsy? 1.Walking by 12 months 2.Hand dominance at 9 months 3.Smiling at 8 weeks 4.Sitting without support at 6 months 5.Head control at 6 weeksQuestion 3 Which of the following is most suggestive of a diagnosis of Cerebral palsy? 1.Walking by 12 months 2.Hand dominance at 9 months 3.Smiling at 8 weeks 4.Sitting without support at 6 months 5.Head control at 6 weeksNon-Blanching Rash Due to small bleeds beneath skin Petechiae: <5mm Purpura: 5-10mm Ecchymoses: >1cm diameter diameter diameter Non-Blanching Rash Differentials •Meningococcal sepsis •Leukemia* •Non-accidental injury •Henoch-Schönlein purpura* •Idiopathic thrombocytopenic purpura – self limiting, secondary to viral illness; low platelets; steroids •Haemolytic uraemic syndrome – Triggered by shiga toxin in E-coli(or)Shigella ; 1 week from onset of diarrhoea Haemolytic Anaemia+AKI+low platlets; Self resolving •Forceful coughing/vomiting *Non-blanching Rash history+ Data interpretation*Leukemia • Unregulated proliferation of a single type of abnormal WBCs : Myeloid (vs) Lymphoid • Acute (vs) Chronic; • In Children : Acute Lymphoblastic Leukemia(ALL) is the commonest; Proliferation of B-lymphocytes suppressing other cell-lines -> pancytopenia AML is the next most common Age of Incidence: ALL – 2 to 3 years AML - < 2 yearsLeukemia Risk factors • Radiation exposure • Down Syndrome • Klinefelter’s Syndrome • Noonan’s Syndrome • Fanconi’s AnemiaLeukemia Symptoms •Persistent fatigue •Petechiae and abnormal bruising (thrombocytopenia) •Unexplained fever •Unexplained bleeding (thrombocytopenia) •Failure to thrive •Abdominal pain •Weight loss •Generalised lymphadenopathy •Night sweats •Unexplained or persistent bone or joint pain •Pallor (anaemia) •Hepatosplenomegaly Usually presents with non-specific symptomsLeukemia Investigations •Urgent full blood count within 48 hours in suspected Leukemia •FBC – Pancytopenia (Anemia, Leukopenia, Thrombocytopenia) + High abnormal WBCs •Blood Film – Blast cells (AML – Auer rods in cytoplasm) •Bone Marrow and Lymph Node Biopsy •Other tests for staging : CXR, CT, Genetic analysis of abnormal cells *Data Interpretation station*Leukemia Management Pediatric MDT Oncology team Chemotherapy (+ Radiotherapy, Surgery, Bone Marrow Transplant) 80% cure rate for ALLbut prognosis varies based on patientQuestion 5 Which of these features is associated with abetter prognosis in ALL? 1. Male 2. Age 15at Diagnosis 3. CNS involvement 4. WCC<50 5. Age < 1 year at DiagnosisQuestion 5 Which of these features is associated with abetter prognosis in ALL? 1. Male 2. Age 15at Diagnosis 3. CNS involvement 4. WCC<50 5. Age < 1 year at DiagnosisHenoch Schoenlein Purpura o Iga vasculitis with purpuric rash on lower limbs and buttocks o Commonly occurs after a viral URTI (or) gastroenteritis o < 10 years o Symptoms: ▪ Purpura(100%) ▪ Joint Pain (75% - arthritis/arthralgia of knees and ankles) ▪ Abdominal Pain (50% - GI hemorrhage, introsusception, bowel infarction) ▪ IgA Nephritis ( 50% - hematuria,proteinuria +/- oedema)Henoch Schoenlein Purpura o Exclude serious pathology o FBC, U&Es,LFT, CRP, Urine dipstick, Urine protein: creatinine ratio, BP o Supportive management (with close monitoring of BP and Urine dip) o Steroids maybe used Kawasaki’s Disease • Medium Sized Vasculitis • Typical patient : <5 years, East Asian, Males • Persistently high fever > 5 days ; • Skin desquamation, bilateral conjunctivitis,cervical lymphadenopathy • Investigations: ▪ FBC - anaemia, leukocytosis and thrombocytosis ▪ LFT - hypoalbuminemia + elevated liver enzymes Maculopapular ▪ Raised ESR + CRP ▪ Urinalysis raised WBC w/o infection ▪ Echocardiogram can demonstrate coronary artery pathology Complication – Coronary Artery Aneurysm (subacute phase of 2-4 weeks after initially unwell. Can also have arthralgia and skin peeling then.)Kawasaki’s Management High dose Aspirin – thrombosis risk IV immunoglobulins – coronary artery aneurysm risk *Aspirin usually avoided in children due to risk of Reye’s syndrome*Question 6 A 4year old male child presentsto the emergency department with a history of fever for 10 days. The child also complains of loose stools, vomiting, and abdominal pain.He has bilateral redness in eyes. The child has a history of amild episode of COVID-19before 3 weeks. The child’s labs reveal lymphocytopenia, and an elevated C-reactive protein. Which condition would you suspect in this child? 1. Kawasaki’s Disease 2. Paediatric multisystem inflammatory syndrome 3. Toxic shock syndrome 4. Acute gastroenteritis 5. Non specific viral illnessQuestion 6 A 4year old male child presentsto the emergency department with a history of fever for 10 days. The child also complains of loose stools, vomiting, and abdominal pain.He has bilateral redness in eyes. The child has a history of amild episode of COVID-19before 3 weeks. The child’s labs reveal lymphocytopenia, and an elevated C-reactive protein. Which condition would you suspect in this child? 1. Kawasaki’s Disease 2. Paediatric multisystem inflammatory syndrome 3. Toxic shock syndrome 4. Acute gastroenteritis 5. Non specific viral illnessT1DM ▪ Autoimmune condition. Can be triggered by Coxsackie B virus and enterovirus ▪ 25-50% of patients present in DKA ▪ Remaining patients present with triad of Polyuria, Polydipsia, Weight loss ▪ Can present as secondary enuresis or recurrent infectionsDKA •Hyperglycaemia (i.e.blood glucose > 11 mmol/l) •Ketosis (i.e.blood ketones > 3 mmol/l) •Acidosis (i.e.pH < 7.3) THREATENING FEATURES : DEHYDRATION, K+ IMBALANCE AND ACIDOSIS*Data Interpretation of DKA*New Diagnosis of T1DM investigations •Baseline bloods - FBC, U&E and laboratory glucose •HbA1c •TFTs and TPO antibodies - associated autoimmune thyroid disease •Tissue transglutaminase (anti-TTG) antibodies - associated coeliac disease •Insulin, anti-GAD and islet cell antibodies to test for antibodies associated with destruction of the pancreas and the development of type 1 diabetesManagement Lifelong management 1.‘Basal-Bolus’ insulin regimen : Long acting(Lantus)+ Short acting(Actrapid) insulin (or) Insulin pumps 2.Blood sugar monitoring – Capillary blood glucose (or) Free-style Libre 3.Monitoring Complications : Coronary artery disease, Diabetic foot, Retinopathy, Peripheral neuropathy, Kidney Disease, Increased risk of infections *T1DM Explanation station*Question 8 Which of the following is not a feature of Duchenne’s Muscular Dystrophy? 1. Respiratory muscle failure 2. Gower’s sign 3. Hemiplegia 4. Waddling gait 5. ClumsinessQuestion 8 Which of the following is not a feature of Duchenne’s Muscular Dystrophy? 1. Respiratory muscle failure 2. Gower’s sign 3. Hemiplegia 4. Waddling gait 5. ClumsinessQuestion 9 Which of these is not an aspect of the Centor criteria? 1. Tonsillar Exudate 2. Lymphadenopathy or lymphadenitis 3. Absence of cough 4. Attend Rapidly 5. FeverQuestion 9 Which of these is not an aspect of the Centor criteria? 1. Tonsillar Exudate 2. Lymphadenopathy or lymphadenitis 3. Absence of cough 4. Attend Rapidly 5. FeverQuestion 10 A 3year old girl presents to her GP miserable, with 2 days of coryza and cough, alongside a fever.She has a papular erythematous rashperiorally, as well as on her buttocks and the soles of her feet. What is the most likely pathogen? 1. Coxsackie A16 2. Parvovirus B19 3. Mumps virus 4. Chlamydia Trachomatis 5. AdenovirusQuestion 10 A 3year old girl presents to her GP miserable, with 2 days of coryza and cough, alongside a fever.She has a papular erythematous rashperiorally, as well as on her buttocks and the soles of her feet. What is the most likely pathogen? 1. Coxsackie A16 2. Parvovirus B19 3. Mumps virus 4. Chlamydia Trachomatis 5. AdenovirusQuestion 11 Which of the followingantidepressants is recommended in under 16s? 1. Sertraline 2. Venlafaxine 3. Melatonin 4. Citalopram 5. FluoxetineQuestion 11 Which of the followingantidepressants is recommended in under 16s? 1. Sertraline 2. Venlafaxine 3. Melatonin 4. Citalopram 5. Fluoxetine