Zero to Finals: PAEDS

whooping cough: management

* <6months should be admitted * notifiable disease * oral macrolide (e.g. clarithromycin, azithromycin, erythromycin) indicated if the onset of cough is within previous 21 days (to eradicate organism) * household contacts offered AB prophylaxis

surfactant deficient lung disease: management

* prevention during pregnancy: maternal corticosteroids to induce fetal lung maturation * oxygen * assisted ventilation * exogenous surfactant given via endotracheal tube

acute asthma: mild to moderate management

- B-2 agonist via a spacer (child <3 years use close-fitting mask) - 1 puff every 30-60s up to a max of 10 puffs - symptoms not controlled, repeat beta-2 agonist and refer to hospital - steroid therapy - all children with asthma exacerbation (3-5 days) - 2-5 years: 20mg od - >4 years: 30-40mg od

cystic fibrosis: symptoms

- Chronic cough - Thick sputum production - Recurrent respiratory tract infections - Loose, greasy stools (steatorrhoea) - Abdominal pain and bloating - Parents may report the child tastes particularly salty when they kiss them - Poor weight and height gain (failure to thrive)

cystic fibrosis: signs

- Low weight or height on growth charts - Nasal polyps - Finger clubbing - Crackles and wheezes on auscultation - Abdominal distention

cystic fibrosis: presentation

- screened for at birth with the newborn bloodspot test - meconium ileus (not passing meconium within 24 hrs, abdominal distention, vomiting) - CF is not diagnosed shortly after birth, later in childhood with recurrent lower respiratory tract infections, failure to thrive of pancreatitis

episodic viral wheeze: management 1st line 2nd line

- symptomatic - b-2 agonist (e.g. salbutamol) or anticholinergic - intermittent leukotriene receptor antagonist (montelukast), intermittent ICS or both (little role for oral prednisolone in children who do not require hospital treatment)

cystic fibrosis: consequence of CF mutation (3)

- thick pancreatic + biliary secretions (blockage of the ducts resulting in lack of digestive enzymes e.g. lipase) - low volume, thick airway secretions (bacterial colonisation + susceptibility to infections) - congenital bilateral absence of the vas deferens (infertility)

viral induced wheeze: presentation

1-2 history of viral symptoms (fever, cough, coryzal symptoms) SOB respiratory distress expiratory wheeze throughout chest

viral induced wheeze: most common in children of what age?

1-3

chronic asthma: management <5

1. SABA 2. SABA + 8-week trial of paeds mod-dose ICS (newly diagnosed asthma with >/=3/weeks or night time waking) - stop after 8 weeks and monitor symptoms - if symptoms resolved then reoccurred within 4 weeks of stopping ICS, restart at low dose - symptoms resolved then reoccurred beyond 4 weeks of stopping ICS, repeat 8-week trial 3. SABA + paeds low-dose ICS + LTRA (montelukast) 4. stop LTRA + referral

chronic asthma: management 5-16

1. SABA 2. SABA + ICS (paediatric low-dose) (newly diagnosed asthma with >/=3/weeks or night time waking) 3. SABA + ICS + LTRA 4. SABA + ICS + LABA 5. SABA + paediatric low dose ICS/ LABA (MART) 6. SABA + paeds mod dose ICS/ LABA (MART) 7. SABA + any of the following - increase ICS to paeds high-dose - additional drug e.g. theophylline - referral

bronchiolitis: can rarely be diagnosed in children up to what age?

2 (particularly in ex-premature babies with chronic lung disease)

whooping cough: features

2-3 days coryza precede onset of: - coughing bouts (worse at night + after feeding; may be ended by vomiting & associated with central cyanosis) - inspiratory whoop (not always present; forced inspiration against closed glottis) - apnoea in infants - persistent coughing may cause subconjunctival haemorrhages or even anoxia leading to syncope & seizures - symptoms may last 10-14 weeks (more severe in infants) - marked lymphocytosis

RSV: chest symptoms are generally at their worst on day ___

3/4

bronchiolitis: generally considered to occur in children of what age? 90% of cases are within which age group? peak incidence? higher incidence during what time of year?

<1 1-9 months (90%) 3-6 months (peak incidence) (maternal IgG gives protection to newborns) winter

asthma: most common in children of what age?

>4

cystic fibrosis: define

AR disorder causing increased viscosity of secretions (e.g. lung an pancreas) caused by a defect in the CF transmembrane conductance regulator gene (CFTR) which codes a cAMP- regulated chloride channel 80% of cases due to delta F508 mutation

whooping cough: causative organism, gram -ve or +ve?

Bordetella pertussis gram-ve

surfactant deficient lung disease: define

also known as respiratory distress syndrome. condition seen in premature infants caused by insufficient surfactant production and structural immaturity of the lung.

pneumonia: tests which can be done to investigate recurrent LRTI?

FBC (check levels of WBC) CXR (structural abnormality/ scarring) serum immunoglobulins (selective antibody deficiency) immunoglobulin G levels (immunoglobulin class-switch recombination deficiency) sweat test (CF) HIV test (especially if mothers status is unknown/ positive)

pneumonia: management when there is sepsis or a problem with intestinal absorption

IV antibiotic

epiglottitis: features

rapid onset high temperature, generally unwell stridor drooling of saliva (no cough)

bronchiolitis: NICE recommend clinicians 'consider' referring to hosptial if any of the following apply

RR >60/min difficulty with breastfeeding or inadequate fluid intake (50-75% of usual volume) clinical dehydration

pneumonia: causative agents (viral) (45%)

RSV parainfluenza virus influenza virus

viral induced wheeze: common organism

RSV rhinovirus

acute asthma: severe attack

SpO2 < 92% PEF 33-50% best or predicted Too breathless to talk or feed Heart rate - >125 (>5 years) - >140 (1-5 years) Respiratory rate - >30 breaths/min (>5 years) - >40 (1-5 years) Use of accessory neck muscles

acute asthma: life-threatening

SpO2 <92% PEF <33% best or predicted Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis

acute asthma: moderate attack

SpO2 > 92% PEF >50% best predicted No clinical features of severe asthma

cystic fibrosis: organisms which may colonise CF patients

Staphylococcus aureus Pseudomonas aeruginosa Burkholderia cepacia* Aspergillus

croup: CKS criteria to grade severity: moderate

frequent barking cough easily audible stridor at rest suprasternal + sternal retraction at rest no/ little distress or agitation child can be placated and interested in surroundings

croup: define

URTI seen in infants and toddlers. characterised by stridor cause by a combination of laryngeal oedema and secretions. parainfluenza viruses account for the majority of cases.

URTI caused by Bordetella pertussis (a gram negative bacteria).

Whooping cough (pertussis)

pneumonia: management (1st line) what can be added if there is no response to therapy? what will cover mycoplasma if suspected? if associated with influenza what is recommended?

amoxicillin macrolide macrolide co-amoxiclav

bronchiolitis: NICE recommend immediate referral (by 999 ambulance) if they have any of the following

apnoea (observed or reported) child looks unwell to a healthcare professional severe respiratory distress (e.g. grunting, marked chest recession, RR> 70) central cyanosis persistent low sats of <92% on air

pneumonia: characteristic chest signs of pneumonia

bronchial breath sounds (harsh breath sounds, equally loud on inspiration and expiration) focal coarse crackles dullness to percussion

7 month old boy bought into ED 12hr Hx of difficulty breathing he has had "a cold" since yesterday generally miserable all day and has refused 1/2 of his usual feeds. OEx: bilateral expiratory wheeze + crackles + moderate subcostal recession RR: 62 Sats: 90% HR: 152 CRT: <2s What is the diagnosis + most appropriate management?

bronchiolitis admit for O2 therapy, consider NG tube feeds

what is useful in severe respiratory distress and in monitoring children who are having ventilatory support?

capillary blood gases

epiglottitis: management ABx (once airway is secure)

ceftriaxone cefotaxime (broad spec to cover Haemophilus influenza + staph aureus)

epiglottitis: what investigations should be performed

clinical diagnosis (if pt is acutely unwell, Ix should not be performed)

croup: investigations

clinical diagnosis (vast majority) CXR (posterior- anterior view sill show subglottic narrowing- Steeple sign; lateral view will show epiglottis swelling- Thumb sign)

bronchiolitis: presentation

coryzal symptoms (including mild fever) precede: - dry cough - increasing breathlessness - wheezing, fine inspiratory crackles (not always present) - feeding difficulties associated with increasing dyspnoea are often the reason for hospital admission

pneumonia: presentation

cough (wet + productive) high fever (>38.5ºC) tachypnoea tachycardia increased work of breathing lethargy delirium (acute confusion associated with infection)

whooping cough: diagnostic criteria

cough lasting for >/=14 (without another apparent cause) * paroxysmal cough * inspiratory whoop * post-tussive vomiting * undiagnosed apnoeic attacks in young infants

what is shown here?

croup thumb-print sign

what is shown here?

croup Steeple sign

croup: CKS criteria to grade severity: severe

frequent barking cough prominent inspiratory stridor at rest marked sternal wall retractions significant distress + agitation or lethargy or restlessness (sign of hypoxaemia) tachycardia (more severe obstructive symptoms + hypoxaemia)

croup: management (all cases) emergency treatment

dexamethasone (0.15mg/Kg) to all children regardless of severity (prednisolone is an alternative) high-flow oxygen + nebulised adrenaline

epiglottitis: management

do not distress patient alert senior paediatrician + anaesthetist ensure secure airway (most pts do not require intubation, however there is a risk of sudden airway closure so preparation need to be made to perform intubation at any time) intubation tracheostomy (if airway completely closes) ICU IV Abx (ceftriaxone) steroids (dexamethasone) O2 + IV fluid

A 4-year-old boy presents to the emergency department with complaints of dysphagia, fever, drooling, and muffled voice. Symptoms have progressively worsened over the course of the day. He is toxic-appearing, and leans forwards while sitting on his mother's lap. He is drooling, and speaks with a muffled 'hot potato' voice. The parents deny trauma or evidence of foreign-body ingestion. They have no recollection of the child receiving a Haemophilus influenzae type B (Hib) vaccine. what is the diagnosis?

epiglottitis

inflammation and swelling of the epiglottis caused by infection. Life threatening emergency.

epiglottitis

unvaccinated child, fever, sore throat, difficulty swallowing, sitting forward, drooling

epiglottitis

epiglottitis: difference between epiglottitis and croup

epiglottits has more rapid onset

pre school wheeze: classification into two groups

episodic viral wheeze (only wheezes when has a viral URTI and is symptom-free in-between episodes) multiple trigger wheeze (as well as viral URTI, other factors appear to trigger the wheeze e.g. exercise, allergens and cigarette smoke. more likely to develop asthma)

grunting: define

exhaling with the glottis partially closed to increase positive end-expiratory pressure

surfactant deficient lung disease: CXR

ground-glass appearance on CXR indistinct heart border

sound caused by exhaling with the glottis partially closed to increase positive end-expiratory pressure (prevent collapse of alveoli)

grunting

epiglottitis: typical causative agent

haemophilus influenza type B

signs of respiratory distress:

increased RR use of accessory muscles of breathing (sternocleidomastoid, abdominal, intercostal muscles) intercostal + subcostal recessions nasal flaring head bobbing tracheal tugging cyanosis abnormal airway noises (wheezing, grunting, stridor)

whooping cough: who are vaccinated against pertussis?

infants (2, 3, 4 months and 3-5 years) pregnant women (newborns are particularly vulnerable, 20-32 weeks)

focal wheeze: what could it be?

inhaled foreign body tumour

acute asthma: bronchodilator step up

inhaled/ nebulised salbutamol inhaled/ nebulised ipratropium bromide IV magnesium sulphate IV aminophylline

another name for croup

laryngotracheobronchitis

croup: CKS criteria - who should be admitted? features which should prompt admission?

moderate + severe croup * < 6 months of age * known upper airway abnormalities (e.g. Laryngomalacia, Down's syndrome) * uncertainty about diagnosis (important differentials include acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation)

epiglottitis: prognosis

most recover without intubation pt who are intubated can be extubated after few days death in cases without prompt management

bronchiolitis: other pathogens

mycoplasma adenovirus

pneumonia: atypical bacterial cause with extra-pulmonary manifestations e.g.___

mycoplasma pneumoniae erythema multiforme

wheezing: define

narrowed lower ariways during expiration (can happen inspiration or both)

stridor: define

narrowed upper airway high pitched inspiratory noise (can happen expiration or both)

croup: CKS criteria to grade severity: mild

occasional barking cough no audible stridor at rest no/ mild suprasternal recession and/ intercostal recession happy child (eating, drinking, playing)

a monoclonal antibody that targets RSV. It's a monthly injection given to high risk babies as prevention against bronchiolitis.

palivizumab

croup: classic cause for croup

parainfluenza virus

croup: epidemiology (2)

peak incidence at 6 months - 3 years more common in autumn

whooping cough: diagnosis

per nasal swab culture for Bordetella pertussis (several days or weeks to come back) PCR and serology

infection of the lung tissue which can be seen as consolidation on CXR.

pneumonia

when should palivizumab be given to children?

premature chronic lung disease congenital heart disease immunodeficient

surfactant deficient lung disease: risk factors

prematurity male sex diabetic mothers Caesarean section second born of premature twins

pneumonia: what could lead to a child having recurrent admissions requiring antibiotics for LRTI?

reflux aspiration neurological disease heart disease asthma CF primary ciliary dyskinesia immune deficiency

epiglottitis: clinical triad

respiratory distress dysphagia drooling

bronchiolitis: most common causative agent (75-80%)

respiratory syncytial virus (RSV)

coryzal symptoms

rhinorrhoea sneezing mucus in throat watery eyes

the most helpful signs of poor ventilation: (2)

rising pCO2 falling pH (type 2 respiratory failure)

moderate to severe acute asthma: management (stepwise approach)

salbutamol inhaler via spacer (10 puffs every 2 hrs) nebulised salbutamol/ ipratropium bromide IV hydrocortisone IV magnesium sulphate IV salbutamol IV aminophylline put out a paeds peri-arrest call

acute asthma: ominous sign

silent chest (airways too tight to produce a wheeze, reduced respiratory effort, fatigue, life threatening)

pneumonia: investigations

sputum cultures + throat swabs for bacterial culture and viral PCR (establish causative organism and guide treatment) blood cultures (if septic)

pneumonia: most common causative agent of a bacterial pneumonia in children other causes of bacterial pneumonia (5)

streptococcus pneumoniae group A strep (Strep. pyogenes) group B strep (occurs in pre-vaccinated infants, contracted during birth) staph aureus haemophilus influenza mycoplasma pneumonia

is a high pitched inspiratory noise caused by obstruction of the upper airway, for example in croup

stridor

croup: features (4)

stridor barking cough (worse at night) fever coryzal symptoms

whooping cough: complications (4)

subconjunctival haemorrhage bronchiectasis pneumonia seizures

bronchiolitis: typical management

supportive management - humidified O2 via a headbox is recommended (if <92%) - nasogastric feeding (if inadequate fluid intake) - suction (for upper airway secretions) - ventilatory support (if required)

pneumonia: signs which may indicate sepsis secondary to pneumonia

tachypnoea tachycardia hypoxia hypotension fever confusion

surfactant deficient lung disease: features

tachypnoea intercostal recession expiratory grunting cyanosis

what does this lateral neck Xray show? what does this sign suggest? what can be excluded in a neck Xray?

thumbprint sign epiglottitis foreign body

multiple trigger wheeze: management

trial of ICS or leukotriene receptor antagonist (montelukast) fo 4-8 weeks

epiglottitis: why is it now rare

vaccination against haemophilus influenza

Children who have had bronchiolitis as infants are more likely to have ___ during childhood.

viral induced wheeze

an acute wheezy illness caused by a viral infection. Typically affects children <3 years.

viral induced wheeze

define bronchiolitis:

viral inflammation and infection of the small airways (occurs in children <1 year)

whistling sound caused by narrowed airways, typically heard during expiration

wheezing

acute asthma: when can discharge be considered?

when a child is well on 6 puffs 4 hrly of salbutamol (finish course of steroids if started, 3 days normally, safety net, asthma action plan)