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An Overview of Paediatrics BY USMAN TARIQWhat we’ll cover today 1. Paediatric Illnesses 2. Paediatric GI Disorders 3. Meningitis 4. Immunisation Schedule 5. Causes of PetechiaePaediatric Illnesses 1. Croup 2. Bronchiolitis 3. Hand foot and mouth disease 4. Scarlet fever 5. Slapped cheek 6. Roseola infantum 7. Kawasaki 8. Mumps 9. Measles 10. Rubella 11. Chicken pox 12. PertussisCroup u An URTI see in infants and toddlers. u Majority of cases are caused by parainfluenza viruses. u Has a characteristic barking cough which is worse at night. It also presents with stridor, fever, coryzal symptoms. u Majority of croup is diagnosed clinically. X-rays can be done and if so; a PA view will show the steeple sign, which is subglottic narrowing. A lateral view will show the thumb sign, which is swelling of the epiglottis u Croup is managed via a single dose of oral dexamethasone (0.15mg/kg).Bronchiolitis u Bronchiolitis is a condition characterised by acute inflammation of the bronchioles. u 75-80% of bronchiolitis cases are caused by the Respiratory Syncytial Virus (RSV) u Typically presents with initially coryzal symptoms which progresses to a dry cough, increasing breathlessness, wheezing, fine inspiratory crackles and feeding difficulties. u Diagnosis is made clinically, but immunofluorescence of nasopharyngeal secretions may show RSV. u Management of bronchiolitis is largely supportive and humidified oxygen is recommended if the oxygen saturations are below 92%.Hand, foot, and mouth disease u Hand, foot, and mouth disease is a self-limiting condition affecting children. u It is caused by the intestinal viruses Coxsackie A16 and Enterovirus 71. u Typically presents with systemic manifestations initially such as a sore throat and fever. This is later followed by vesicles on the palms and soles of the feet. u It is managed via supportive treatment; advising about good hydration and pain relief and analgesia. u It is not a requirement for the children to be excluded from school, however, it is recommended that the children who are unwell should be kept off of school until they feel better.Scarlet Fever u Scarlet fever is usually caused by Streptococcus pyogenes. It is more common in children aged 2-6 years old. u Scarlet fever has an incubation period of 2-4 days and typically presents with; fever, malaise, headache, nausea/vomiting, sore throat, and strawberry tongue. u Scarlet fever also presents with a distinct rash. It is a fine, erythematous rash and the rash is more obvious in the flexures. It has a characteristic sandpaper texture. You also may find desquamation (skin peeling) around the fingers and toes, but this is a late feature. u Diagnosis is confirmed via a throat swab, however, treatment should be commenced immediately, before receiving the results. u Scarlet fever is managed via oral penicillin V for 10 days. Patients who are allergic to penicillin should be given azithromycin. u School exclusion is required, and children can return to school 24 hours after commencing antibiotics. Scarlet fever is also a notifiable disease.Slapped Cheek u Also known as erythema infectiosum u Generally consists of a mild feverish illness and then a noticeable rash which appears after a few days. The rose-red rash makes the cheeks appear bright red. The child usually feels better as the rash appears. u Most children recover and need no specific treatment. u School exclusion is unnecessary as the child is not infectious once the rash emerges.Kawasaki Disease u It is a type of vasculitis which is predominately seen in children. u It typically presents with high-grade fever which lasts for >5 days, The fever is characteristically resistant to antipyretics such as NSAIDs. Infection of the conjunctiva, bright red cracked lips, strawberry tongue, cervical lymphadenopathy, and red palms of the hands and the soles which later peel. u Kawasaki disease is a clinical diagnosis and there is no specific diagnostic test. u Management of Kawasaki disease is high-dose aspirin and IV immunoglobulin. Patients diagnosed with Kawasaki disease often require echocardiograms to rule out coronary artery aneurysms.Chicken Pox u Caused by primary infection with the varicella zoster virus. u Tends to present with fever initially and then an itchy, rash starting on head/trunk before spreading. Initially macular then popular then vesicular. Systemic upset is usually mild. u Management is usually supportive with calamine lotion and fluids. u School exclusion is necessary until all the lesions are dry and have crusted over. u NSAIDs may increase the risk of secondary bacterial infection of the lesions. In a small number of patients, this has presented as necrotizing faciitis/Pertussis (whooping cough) u Infectious disease caused by the gram-negative bacterium Bordetella pertussis. u Initially presents with symptoms similar to a viral upper respiratory tract infection and this phase lasts around 1-2 weeks. The cough then increases in severity. The coughing episodes are usually worse at night cyanosis. Has a characteristic inspiratory whoop which is usually present and is caused by a forced inspiration against a closed glottis. u Diagnosed via a nasal swab culture which can take a few days to come back, u Management is via an oral macrolide such as clarithromycin if the onset of the cough is within 21 days./ u Whooping cough is a notifiable disease and requires school exclusion 48 hours after commencing antibiotics.Question 1 u A mother arrives at the paediatric emergency department with her 4- year-old boy. He has a 5-day history of fever and she has noticed raised nodes on his neck. She has given him paracetamol and ibuprofen but his temperature is not reducing. His lips have become extremely dry and cracked and his tongue red and slightly swollen. She has noticed that his feet are also red and puffy now, and he is developing a widespread fine rash. What is the most likely diagnosis? 1. Hand, foot, and mouth disease 2. Kawasaki’s disease 3. Measles 4. Parovirus B19 5. Scarlet feverQuestion 1 u A mother arrives at the paediatric emergency department with her 4- year-old boy. He has a 5-day history of fever and she has noticed raised nodes on his neck. She has given him paracetamol and ibuprofen but his temperature is not reducing. His lips have become extremely dry and cracked and his tongue red and slightly swollen. She has noticed that his feet are also red and puffy now, and he is developing a widespread fine rash. What is the most likely diagnosis? 1. Hand, foot, and mouth disease 2. Kawasaki’s disease 3. Measles 4. Parovirus B19 5. Scarlet feverQuestion 2 u Charlotte is a 7-year-old girl brought in by her mother with a 2 day history of fever and sore throat. Today she has developed a rash on her torso. She is eating and drinking well, but has not been to school for the last 2 days and has been feeling tired. u On examination, Charlotte is alert, smiling and playful. She has a temperature of 37.8°C. Her throat appears red with petechiae on the hard and soft palate and her tongue is covered with a white coat through which red papillae are visible. There is a blanching rash present on her trunk which is red and punctate with a rough, sandpaper-like texture. 1. Kawasaki’s disease 2. Hand, foot, and mouth disease 3. Scarlet fever 4. Roseola infantum 5. BronchiolitisQuestion 2 u Charlotte is a 7-year-old girl brought in by her mother with a 2 day history of fever and sore throat. Today she has developed a rash on her torso. She is eating and drinking well, but has not been to school for the last 2 days and has been feeling tired. u On examination, Charlotte is alert, smiling and playful. She has a temperature of 37.8°C. Her throat appears red with petechiae on the hard and soft palate and her tongue is covered with a white coat through which red papillae are visible. There is a blanching rash present on her trunk which is red and punctate with a rough, sandpaper-like texture. 1. Kawasaki’s disease 2. Hand, foot, and mouth disease 3. Scarlet fever 4. Roseola infantum 5. BronchiolitisQuestion 3 u A 16-month-old girl is reviewed by her GP. She has a 3 day history of fever and coryzal symptoms. Overnight she has developed a harsh cough. On examination she has a temperature of 38ºC and inspiratory stridor is noticed although there are no signs of intercostal recession. What is the most likely diagnosis? 1. Bronchiolitis 2. Croup 3. Acute epiglottitis 4. Pertussis 5. PneumoniaQuestion 3 u A 16-month-old girl is reviewed by her GP. She has a 3 day history of fever and coryzal symptoms. Overnight she has developed a harsh cough. On examination she has a temperature of 38ºC and inspiratory stridor is noticed although there are no signs of intercostal recession. What is the most likely diagnosis? 1. Bronchiolitis 2. Croup 3. Acute epiglottitis 4. Pertussis 5. PneumoniaPaediatric GI Disorders 1. Biliary atresia 2. Pyloric stenosis 3. Intussusception 4. Hirschprung’s disease 5. Cow’s milk intolerance 6. Necrotising enterocolitisBiliary Atresia u Biliary atresia is a condition where there are defects in the extrahepatic biliary system which results in an obstruction in the flow of the bile. u Patients will typically present within their first few weeks of life with jaundice, dark urine and pale stools, and there will also be appetite and growth disturbance, u There would also be signs of hepatomegaly with splenomegaly and abnormal growth. u Investigations include serum bilirubin (both conjugated bilirubin and total bilirubin. u Definitive management of biliary atresia is surgical intervention which may include dissection of the abnormalities into distinct ducts and anastomosis creation.Pyloric Stenosis u Caused by the hypertrophy of the circular muscles of the pylorus. u Typically presents with projectile vomiting, typically 30 minutes after a feed. Constipation and dehydration may also be present. A palpable mass may be present in the upper abdomen. u Diagnosis is made via ultrasound. Bloods would show a hypocholoraemic, hypokalaemic alkalosis due to persistent vomiting. u Management is with Ramstedt pyloromyotomy.Intussusception u Describes the outpouching of one portion of the bowel into the lumen of the adjacent bowel. This most commons occurs around the ileo- caecal region. u Typically affects infants between 6-18 months old. Boys are affected twice as often as girls. u Typically presents with intermittent, severe, crampy, progressive abdominal pain. Inconsolable crying. During episodes, the infant will characteristically draw their knees up and turn pale. May find a sausage-shaped mass in the right upper quadrant. Red-currant jelly stool may be present, but this is typically a late sign. u Ultrasound is now the investigation of choice and may show a target- like mass. u Management is reduction by air insufflation under radiological control.Hirschsprung's Disease u Hirschsprung's disease is caused by an aganglionic segment of bowel due to a developmental failure of the parasympathetic Auerbach and Meissner plexuses. u Typically presents in the neonatal period with failure or delay to pass meconium. However, it can be missed and present in older children with constipation and abdominal distension. u The gold standard for diagnosis is rectal biopsy. u Managed initially via rectal washouts/bowel irrigation, however, the definitive management is surgery to the affected segment of the colon.Cow’s Milk Intolerance u Typically presents in the first three months of life in formula-fed infants. u Has features such as regurgitation and vomiting, diarrhoea, urticaria, atopic eczema, and rarely angioedema and anaphylaxis may occur. u Diagnosis is often clinical with improvement in condition with the elimination of cow’s milk. However, investigations can include skin prick/patch testing. u Management involves extensive hydrolysed formula. Second-line is amino acid-based formula. u This usually carries a good prognosis with it usually resolving by the age of 3 years.Necrotising Enterocolitis u One of the leading causes of death among premature infants. u Initial symptoms can include feeding intolerance, abdominal distension, and bloody stools. This can quicky escalate to peritonitis. u Abdominal x-rays are useful when diagnosing necrotising enterocolitis, as they can show; dilated bowel loops, bowel wall oedema, pneumatosis intestinalis, portal venous gas, pneumoperitoneum resulting from perforation.Question 4 u A 3-day-old male is admitted to the neonatal unit with bilious vomiting and reduced feeding. He was born at 30 weeks gestation via an uncomplicated delivery. An abdominal X-ray is requested that shows intramural gas. Oral feeding is stopped and he is started on broad-spectrum antibiotics. Which of the following is the most likely diagnosis? 1. Biliary atresa 2. Duodenal atresia 3. Hirschsprung’s disease 4. Intussusception 5. Necrotising enterocolitisQuestion 4 u A 3-day-old male is admitted to the neonatal unit with bilious vomiting and reduced feeding. He was born at 30 weeks gestation via an uncomplicated delivery. An abdominal X-ray is requested that shows intramural gas. Oral feeding is stopped and he is started on broad-spectrum antibiotics. Which of the following is the most likely diagnosis? 1. Biliary atresa 2. Duodenal atresia 3. Hirschsprung’s disease 4. Intussusception 5. Necrotising enterocolitisQuestion 5 u Charlie is a 7 month old baby boy who presents to you with poor weight gain (50th to 10th centile), on examination he has an erythematous, blanching rash over his abdomen, colicky abdominal pain and vomiting after feeds. He has been breast feeding with top ups of 'Aptamil' formula. What is the most likely diagnosis? 1. Pyloric stenosis 2. Eczema 3. Infantile colic 4. Cows’ milk protein intolerance 5. RefluxQuestion 5 u Charlie is a 7 month old baby boy who presents to you with poor weight gain (50th to 10th centile), on examination he has an erythematous, blanching rash over his abdomen, colicky abdominal pain and vomiting after feeds. He has been breast feeding with top ups of 'Aptamil' formula. What is the most likely diagnosis? 1. Pyloric stenosis 2. Eczema 3. Infantile colic 4. Cows’ milk protein intolerance 5. RefluxQuestion 6 u A 4-day-old girl who was diagnosed prenatally with Down's syndrome and born at 38 weeks gestation presents with bilious vomiting and abdominal distension. She is yet to pass meconium. What is the most likely diagnosis? 1. Duodenal atresia 2. Hirschsprung’s disease 3. Intussusception 4. Necrotising enterocolitis 5. Pyloric stenosisQuestion 6 u A 4-day-old girl who was diagnosed prenatally with Down's syndrome and born at 38 weeks gestation presents with bilious vomiting and abdominal distension. She is yet to pass meconium. What is the most likely diagnosis? 1. Duodenal atresia 2. Hirschsprung’s disease 3. Intussusception 4. Necrotising enterocolitis 5. Pyloric stenosisMeningitis – Causative Organisms and Presentation u Causative organisms; u Neonatal to 3 months; Group B Steptococcus, E.coli and other gram-negative organisms u 1 month to 6 years; Neisseria meningitidis, Streptococcus pneumoniae, haemophilus influenzae u Greater than 6 years; Neisseria meningitidis, streptococcus pneumoniae u Typically presents with fever and chills, irritability, lethargy, and reduction in feeding, and nappies. Quite vague symptoms.Meningitis – investigations and management u cultured. is typically made via lumbar puncture to obtain CSF samples to be u Contraindications to lumbar puncture include any signs of raised ICP; focal neurological signs, papilloedema, significant bulging of the fontanelle, disseminated intravascular coagulation, signs of cerebral herniation. u Instead, blood cultures and PCR should be obtained. u < 3 months: IV amoxicillin (or ampicillin) + IV cefotaxime. > 3 months: IV cefotaxime (or ceftriaxone) u NICE advise against giving corticosteroids in children younger than 3 months. following: frankly purulent CSF, CSF white blood cell count greater thanthe 1000/microlitre, raised CSF white blood cell count with protein concentration greater than 1 g/litre, and bacteria on Gram stain. u Public health needs to be notified and prophylactic antibiotics via ciprofloxacin are given to close contacts.Immunisation Schedule Age Recommended immunisations At birth BCG if risk factors (see below) 2 months '6-1 vaccine' (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B) Oral rotavirus vaccine Men B 3 months* '6-1 vaccine' (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B) Oral rotavirus vaccine PCV 4 months '6-1 vaccine' (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B) Men B 12-13 months Hib/Men C MMR PCV Men B 2-8 years Flu vaccine (annual) 3-4 years '4-in-1 pre-school booster' (diphtheria, tetanus, whooping cough and polio) MMR 12-13 yearHPV vaccination 13-18 year'3-in-1 teenage booster' (tetanus, diphtheria and polio) Men ACWYAcute Lymphoblastic Leukaemia (ALL) u Most common type of childhood malignancy and accounts for 80% of childhood leukaemia. Peak incidence is around 2-5 years old and boys are affected slightly more than girls. u Typically presents with; anaemia, lethargy and pallor; neutropenia, frequent or severe infections; thrombocytopenia, easy bruising and petechiae. Can have other features such as bone pain, splenomegaly, hepatomegaly. u Poor prognostic factors; age < 2 years old or > 10 years, WBC > 20 x 10^9 at diagnosis, non-white, and male sex.Immune Thrombocytopenic Purpura (ITP) u An immune-mediated reaction in the platelet count. It is an example of a type II hypersensitivity reaction. u Typically presents with bruising, a petechial or purpuric rash, bleeding is less common, but when it does occur it presents as epistaxis or gingival bleeding. u Investigated via FBC; this will show an isolated thrombocytopenia, and blood film, which should be normal in ITP. Bone marrow examinations are only required if there are atypical features; lymph node enlargement/splenomegaly, high/low white cells, or failure to respond to treatment. u Usually, no treatment is required as it generally resolves by itself. In the case of very low platelet count (<10 x 10^9), options include oral/IV corticosteroids or IV immunoglobulins.Thank you for listening!! TARIQMU@CARDIFF.AC.UK