Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Paediatrics 1 5/6/2025, Dr Alexander Wallace and Dr Katherine WostenholmeLearningObjectives ● Neonatal jaundice: Types, causes, management ● Common pediatric infections: Otitis media, gastroenteritis, URTI ● Growth and development milestones: Assessment and red flags ● Pediatric asthma: Diagnosis, management, and exacerbations ● Pediatric emergency: Anaphylaxis, seizures ● Vaccination schedule and recommendationsQuestion 1 What is the most appropriate management? A 3-day-old term male infant is brought to the postnatal clinic with yellowing of A. Start phototherapy the skin and sclera. He was born by B. Start exchange transfusion normal vaginal delivery at 39 weeks' C. Repeat bilirubin level in 6 hours gestation, with no complications. He is feeding well and has passed urine and D. Discharge the baby home E. Start antibiotics meconium. On examination, he is alert and well-appearing, with jaundice visible up to his abdomen. There is no hepatosplenomegaly or signs of sepsis. A bilirubin level is checked and shows: ● Total serum bilirubin: 210 µmol/L The NICE threshold for phototherapy at this age and gestation is 255 µmol/L.Answer 1 A 3-day-old term male infant is brought to the postnatal clinic with yellowing of the skin and sclera. He was born by normal What is the most appropriate management? vaginal delivery at 39 weeks' gestation, with no complications. He is feeding well and A. Start phototherapy has passed urine and meconium. On B. Start exchange transfusion examination, he is alert and well-appearing, with jaundice visible up to his abdomen. C. Repeat bilirubin level in 6 hours There is no hepatosplenomegaly or signs of D. Discharge the baby home sepsis. E. Start antibiotics A bilirubin level is checked and shows: ● Total serum bilirubin: 210 µmol/L The NICE threshold for phototherapy at this age and gestation is 255 µmol/L.Neonatal jaundice Increased bilirubin: - Unconjugated converted to conjugated in the liver -> excreted bybiliarysystem and urine - Fetus & neonate have higher concentrations and fragile RBC= increase breakdown - Less developed liver function - Fetus bilirubin excretion via placenta - = build up (physiological between 2-10 days) - <24hrs = pathological (urgent investigation) Kernicterus: excessive bilirubin crossing the BBB causes CNS damage: CP,LD,deafnessNeonatal jaundice Causes: - Increased production: - Haemolyticdisease of the newborn: rhesus antigen mother (-) & 2nd fetus (+) - Sepsis - G6PD deficiency - Decreased clearance: - Prematurity - Breast milkjaundice - Extrahepaticbiliaryatresia - Endocrine disorders (hypothyroid and hypopituitary)Neonatal jaundice Investigations: - FBC - LFTs -bilirubin (^ conjugated = hepatobiliarycause (biliaryatresia)) - Blood group testing - Direct Coombs (haemolyticdisease of the newborn) - TFTs - Infection screen ?sepsis - G6PD levels Management: - Plot total bilirubin levels vs.age (hours) on a chart = treatment threshold - Phototherapy(unconjugated bilirubin to excreatable compound without needing liver conjugation) - Exchange transfusionQuestion 2 A 2-year-old girl is brought to the GP with a 2-day history of fever, What is the most appropriate next step in management? irritability, and tugging at her right ear. She has had no vomiting or A. Prescribe amoxicillin for 5 days diarrhoea. On examination, her B. Prescribe topical ear drops C. Admit to hospital for intravenous antibiotics temperature is 38.6°C, and otoscopy D. Provide safety netting advice and no antibiotics for now reveals a red, bulging tympanic membrane on the right with loss of E. Arrange outpatient ENT follow-up the light reflex. The left ear appears normal. She is otherwise well, playing in the room, and her parents report she is eating and drinking adequately.Answer 2 A 2-year-old girl is brought to the GP with a 2-day history of fever, What is the most appropriate next step in management? irritability, and tugging at her right A. Prescribe amoxicillin for 5 days ear. She has had no vomiting or B. Prescribe topical ear drops diarrhoea. On examination, her C. Admit to hospital for intravenous antibiotics temperature is 38.6°C, and otoscopy D. Provide safety netting advice and no antibiotics for now reveals a red, bulging tympanic E. Arrange outpatient ENT follow-up membrane on the right with loss of the light reflex. The left ear appears normal. She is otherwise well, playing in the room, and her parents report she is eating and drinking adequately.Common paediatricinfections-Ear Otitis media: - Step. pneumonia, Haemophilus, Moraxella - red + bulging TM - on day 3 = amoxicillin (7 days) or clarithromycin (if penicillin allergy) - complications: mastoiditis (pushes ear outwards), chronic suppurative OM: TM perforation >6wks + discharge (active or inactive) - TM perforation >3 months = surgical repair Otitis externa: - Pseudomonas (freshwater swimming), Staph aureus - tx: ○ 1st: acetic acid (ear calm) & topical abx (ciprofloxacin) + steroid drops ○ oral flucloxacillin (1st line for diabetics, refer) - complication: malignant otitis externa (temporal bone osteomyelitis)Question 3 A 15-month-old boy is brought to the What is the most appropriate management? Emergency Department with a 2-day history of vomiting and diarrhoea. He A. Discharge with reassurance and no has had 6 episodes of watery stool and treatment 3 episodes of vomiting in the last 24 B. Start IV fluids for rehydration hours. He is still taking small amounts of C. Start oral rehydration solution and continue breast milk. On examination, he is alert breastfeeding but quieter than usual. His capillary refill D. Prescribe loperamide time is under 2 seconds, heart rate is E. Start empirical antibiotics 120 bpm, and he has slightly dry mucous membranes. His skin turgor is normal. He has no signs of shock.Answer 3 A 15-month-old boy is brought to the What is the most appropriate management? Emergency Department with a 2-day history of vomiting and diarrhoea. He A. Discharge with reassurance and no treatment has had 6 episodes of watery stool and B. Start IV fluids for rehydration 3 episodes of vomiting in the last 24 C. Start oral rehydration solution and continue hours. He is still taking small amounts of breastfeeding breast milk. On examination, he is alert D. Prescribe loperamide but quieter than usual. His capillary refill E. Start empirical antibiotics time is under 2 seconds, heart rate is 120 bpm, and he has slightly dry mucous membranes. His skin turgor is normal. He has no signs of shock.Common paediatricinfections-Gastroenteritis Viral: Rotavirus and norovirus E.coli: E. coli 0157 = Shiga toxin = haemolytic uraemic syndrome (Shigella cause produced Shiga toxin) Campylobacter Jejuni: raw poultry, untreated water, unpasteurised milk. Bloody diarrhoea. Yersinia Enterocolitica: pork, lymphadenopathy and mesenteric lymphadenitis Management principles: - Off school until 48 hours after symptoms resolve - Stool MCS - Ensure hydration: fluid challenge, rehydration solutions (dioralyte), IVF - Antidiarrhoeal and antiemetic medications NOT advised (especially: E. coli 0157, Shigella and bloody diarrhea) - Antibiotics only given once microbe has been identified Complications: - Lactose intolerance - IBS - Reactive arthritis - Guillain-Barre syndrome (Campylobacter)Common paediatricinfections-Respiratory Tonsillitis (GAS - strep pyogenes): - CENTOR (≥3), FeverPAIN (≥4) = Penicillin V (10 days) or clarithromycin - Quinsy (peritonsillar abscess): trismus (<3cm), red around tonsil, hot potato voice - Tonsillectomy Bronchiolitis: expiratory wheeze, RSV, <1yrs, palivizumab vaccine Viral induced wheeze: expiratory wheeze, <3yrs, tx (acute asthma) Croup (parainfluenza): barking cough, tx=dexamethasone Epiglottitis (Haemophilus influenza B): tripod, CXR = thumbprint sign tx = sit up, do NOT examine throat, endotracheal intubation, oxygen, IVabx Whooping cough (Bordetella pertussis - notifiable): vaccine: pregnant women (wk16) + children, tx = macrolide (21 days), prophylaxis abx household Pneumonia: tx = amoxicillin + macrolideQuestion 4 A 2-year-old boy is brought to the health What is the most appropriate next step? visitor for a routine developmental check. His mother is concerned that he A. Refer urgently to paediatric neurology is not speaking much. He walks B. Reassure and review again in 6 months independently, can feed himself with a C. Refer to speech and language therapy spoon, and engages in pretend play. He D. Start a course of antibiotics says only two words: “mama” and “ball”. E. Arrange urgent hearing test He follows simple instructions but does not combine words. There are no concerns about other aspects of his development.Answer 4 A 2-year-old boy is brought to the health visitor for a routine developmental What is the most appropriate next step? check. His mother is concerned that he is not speaking much. He walks A. Refer urgently to paediatric neurology independently, can feed himself with a B. Reassure and review again in 6 months spoon, and engages in pretend play. He C. Refer to speech and language therapy says only two words: “mama” and “ball”. D. Start a course of antibiotics He follows simple instructions but does E. Arrange urgent hearing test not combine words. There are no concerns about other aspects of his development.Developmental Milestones Summary Milestones (1mos, 6mos, 12mos, 24mos): - 1mos: lift head - track objects - coo - recognise parents - 6mos: sit up - palmar grip - babble - recognise strangers - 9mos: crawl - inferior pincer grip - mamma/dad - plays peek-a-boo - 12mos: walk - pincer grip - words - imitates - 24mos: up 2 steps - use 2 hands - 2-word sentence - stack blocks *Younger siblings walk later than older onesDevelopmental Milestones Red Flags Any regression = pathological Gross: unsupported by 12m, no walking by 18m, not running by 2yrs Speech: not speaking by 2yr Communication: no smile by 10wks Fine: hand preference before 18m Weight red flags: ○ below 2 centile ○ drop of 1 centile in bottom (1) decile ○ drop of 2 centiles in the middle (1-9) deciles ○ drop of 3 centiles in top decile (9)Question 5 A 7-year-old boy presents with a history of wheezing and shortness of breath triggered by exercise and cold weather. His symptoms are worse at night. What is the most appropriate initial investigation to support the diagnosis of asthma? A. Chest X-ray B. Peak expiratory flow variability C. Spirometry with bronchodilator reversibility D. Skin prick testing E. Fractional exhaled nitric oxide (FeNO)Question 5-Answer A 7-year-old boy presents with a history of wheezing and shortness of breath triggered by exercise and cold weather. His symptoms are worse at night. What is the most appropriate initial investigation to support the diagnosis of asthma? A. Chest X-ray B. Peak expiratory flow variability C. Spirometry with bronchodilator reversibility D. Skin prick testing E. Fractional exhaled nitric oxide (FeNO)Question 5-Explanation In children ≥5 years, spirometry with bronchodilator reversibility is the first-line test to support a diagnosis of asthma. FeNO can be used as a second-line test. Chest X-ray is not routinely required unless another diagnosis is suspected. The diagnosis of asthma in children aged 5 years and older should be supported by objective evidence of variable airflow obstruction, in accordance with NICE and BTS/SIGN guidelines. Spirometry measures FEV₁ (Forced Expiratory Volume in 1 second) and FVC (Forced Vital Capacity). A diagnosis of asthma is supported by: • FEV₁/FVC < 70%, and • Reversibility of ≥12% in FEV₁ after administration of a short-acting beta-agonist (e.g., salbutamol).Question 6 A 5-year-old boy with asthma is brought to A&E with an exacerbation. He is talking in full sentences, oxygen saturations are 96%, RR is 26, and there is widespread wheeze. What is the most appropriate initial management? A. Intravenous hydrocortisone and aminophylline B. Oral prednisolone and nebulised salbutamol C. High-flow oxygen and IV salbutamol D. Inhaled salbutamol via spacer and oral prednisolone E. Adrenaline IM and IV fluidsQuestion 6-Answer A 5-year-old boy with asthma is brought to A&E with an exacerbation. He is talking in full sentences, oxygen saturations are 96%, RR is 26, and there is widespread wheeze. What is the most appropriate initial management? A. Intravenous hydrocortisone and aminophylline B. Oral prednisolone and nebulised salbutamol C. High-flow oxygen and IV salbutamol D. Inhaled salbutamol via spacer and oral prednisolone E. Adrenaline IM and IV fluidsAsthma Exacerbation SeverityCriteriaTreatment Immediate Management • Oxygen- Give high-flow O₂ if sats less thn 94% - aim for (94–98%) • Bronchodilators - Inhaled SABA (e.g., salbutamol) • Use spacer + inhaler if mild/moderate • Use nebuliser if severe • Add Ipratropium bromide if poor response to SABA • Corticosteroids- Oral prednisolone for 3 days (Oral dexamethasone is an alternative, often used practically) • Consider IV hydrocortisone if vomiting or too unwell Second-Line Management (Specialist Input) • IV salbutamol (monitor for toxicity) • IV magnesium sulphate (bronchodilator effect)Safe discharge criteria post exacerbation • Salbutamol via spacer every ≥4 hours (e.g. 6 puffs 4-hourly PRN) • SaO₂ >94% on room air • Inhaler technique reviewed and taught • Written asthma plan given & explained • GP notified within 24h • Follow-up arranged within 2 working daysQuestion 7 A 9-year-old girl with epilepsy is having a tonic-clonic seizure in the emergency department. The seizure has lasted 6 minutes. What is the most appropriate next step in management? A. Wait another 4 minutes before treatment B. Give IV lorazepam C. Administer buccal midazolam D. Start phenytoin infusion E. Administer rectal paracetamolQuestion 7 -Answer A 9-year-old girl with epilepsy is having a tonic-clonic seizure in a GP surgery waiting room. The seizure has lasted 6 minutes. What is the most appropriate next step in management? A. Wait another 4 minutes before treatment B. Give IV lorazepam C. Administer buccal midazolam D. Start phenytoin infusion E. Administer rectal paracetamolQuestion 7 -Explanation For a seizure lasting >5 minutes, buccal midazolam is the first-line treatment. IV lorazepam can be used if IV access is already in place, but buccal midazolam is preferred for rapid action.Question 8 A 6-year-old boy with a known peanut allergy suddenly develops widespread urticaria, facial swelling, hoarse voice, wheeze, and a BP of 82/45 mmHg after eating a biscuit at a party. He is drowsy and has a capillary refill time of 4 seconds. What is the most appropriate immediate management step? A. Intramuscular adrenaline 1:1000, 300 micrograms B. Intravenous hydrocortisone and chlorphenamine C. Nebulised salbutamol and oxygen D. Oral antihistamines and observe for response E. Intramuscular adrenaline 1:1000, 150 microgramsQuestion 8-Answer A 6-year-old boy with a known peanut allergy suddenly develops widespread urticaria, facial swelling, hoarse voice, wheeze, and a BP of 82/45 mmHg after eating a biscuit at a party. He is drowsy and has a capillary refill time of 4 seconds. What is the most appropriate immediate management step? A. Intramuscular adrenaline 1:1000, 300 micrograms B. Intravenous hydrocortisone and chlorphenamine C. Nebulised salbutamol and oxygen D. Oral antihistamines and observe for response E. Intramuscular adrenaline 1:1000, 150 microgramsQuestion 8-Explanation This child is exhibiting life-threatening anaphylaxis, with airway compromise (hoarse voice), respiratory distress(wheeze), circulatory collapse (hypotension, prolonged CRT), and CNS involvement (drowsiness). • The first-line and only life-saving treatment is IM adrenaline. • In children aged 6 months to <6 years, the correct dose is 150 micrograms (0.15 mL of 1:1000) IM, into the anterolateral thigh. • Adrenaline should be administered immediately, even before IV access, oxygen, or antihistamines.Anaphylaxis-IMAdrenaline dosage byageQuestion 9 A 13-year-old girl is due to receive the HPV vaccine. Which of the following best describes the current UK recommendation? A. One dose for boys only B. One dose for girls only C. Two doses for girls aged 12–13 D. Three doses for all teenagers E. Two doses for both girls and boys aged 12-13Question 9-Answer A 13-year-old girl is due to receive the HPV vaccine. Which of the following best describes the current UK recommendation? A. One dose for boys only B. One dose for girls only C. Two doses for girls aged 12–13 D. Three doses for all teenagers E. Two doses for both girls and boys aged 12-13Question 9-Explanation The HPV vaccine is given as two doses to boys and girls aged 12–13 years in the UK. It protects against cervical cancer and other HPV-related diseases.Question 10 A 4-year-old child presents with a rash and fever. The mother refuses the MMR vaccine due to misinformation. What is the most appropriate next step? A. Report to social services immediately B. Call the police due to safeguarding concerns C. Respect the mother’s decision and provide accurate information D. Administer the vaccine without consent E. Inform the school to suspend the childQuestion 10-Answer A 4-year-old child presents with a rash and fever. The mother refuses the MMR vaccine due to misinformation. What is the most appropriate next step? A. Report to social services immediately B. Call the police due to safeguarding concerns C. Respect the mother’s decision and provide accurate information D. Administer the vaccine without consent E. Inform the school to suspend the childQuestion 10 MMR (measles, mumps, rubella) is a routine childhood vaccine given at 12 months and again at 3 years 4 months in the UK. Refusal of MMR is often driven by misinformation, particularly fears linking it to autism — a myth debunked by extensive research. Vaccine refusal is not a safeguarding issue unless there’s evidence of neglect. Informing the school is not necessary as there is no legal requirement to have MMR Vaccination to attend school and would break confidentiality. The best approach is shared decision-making and correcting misinformation with empathy. SEEYOUNEXT https://linktr.ee/medtic.teaching THURSDAY! Sign up to our next session on MedAll Take part in our research survey See all our upcoming events www.medticteaching.com | Email: medticteaching@gmail.com | Youtube @medtic | Instagram @medtic.teaching | Tiktok @medticteaching