Paediatrics & Adolescents Quiz

A nurse asks you to chart a bag of fluid to maintain patency of a cannula in a 4 year old child. What will you chart? 1. Sodium Chloride 0.45% (77 mmol/L) with Glucose 5% +/- Potassium Chloride 20 mmol/L. 2. Sodium Chloride 0.9% (154 mmol/L) + Glucose 5% at 20 ml/hr 3. Sodium Chloride 0.45% (77 mmol/L) with Glucose 5% + Potassium Chloride 20 mmol/L at 5 ml/hr 4. Sodium Chloride 0.45% (77 mmol/L) with Glucose 5% + Potassium Chloride 100 mmol/L at 10 ml/hr

1. at 10ml/hr

A 7-year-old boy is brought to the Emergency Department with a 1-day history of worsening vomiting. Over the last few hours parents report that he has been much less responsive and is now not talking but only making moaning noises. He has had bedwetting over the last 2 weeks having previously been dry at night from age 3. On examination he is pale, dehydrated, making laboured respiratory effort, rate of breathing is 50/min. He is lying in his mother's arms, opens his eyes when his name is called, movement is reduced but he will move his arm away from a painful stimulus. Q. Which of the following diagnoses is most likely? (1) Ingestion of poisonous drug/ chemical; (2) Intracerebral haemorrhage; (3) Meningitis; (4) Diabetic ketoacidosis; (5) Gastroenteritis.

4 Diabetic ketoacidosis is suggested by the pattern of breathing, which indicates metabolic acidosis, and the history of nocturnal enuresis.

What type of fluid is most appropriate for a day 1 neonate unable to feed? 1. Sodium Chloride 0.45% + Glucose 5% IV 2. Nasogastric (enteral) feed eg Neonatal Ensure Plus 3. Glucose 10% and Sodium Chloride 0.45% and Potassium Chloride 10 mmol IV 4. Glucose 10% IV

4.

Choose the correct IV fluid and volume for a 42kg child fasting (otherwise well) for surgery: 1. Sodium Chloride 0.9% (154 mmol/L) + Glucose 5%. 120ml/hr 2. Hartmanns solution 42 ml/hr 3. Sodium Chloride 0.9% (154 mmol/L). 80 ml/hr 4. Sodium Chloride 0.45 % (77mmol/l) 80ml/hr

42kg = 60 + 1x(42-20) = 60 + 22 = 82ml/hr 3

Which one of the following organism is a common cause of urine infection? (a) Escherichia Coli (b) Staphylococcus aureus (c) Lactobacillus acidophilus (d) Pseudomonas aeruginosa (e) Candida albicans

A

The following features of bruises are suspicious of inflicted abusive injury EXCEPT (a) Multiple bruises to the shins of the lower legs in toddler age children (b) Bruises to the lower back in preschool age children (c) Bruises to the ears (d) Bruises in multiple areas (e) Bruises in infants <9 months of age

A Bruises are a frequent finding in children who have been physically abused. Many preschool children develop bruises to the shins, elbows and forehead areas through accidental falls as they learn to walk. Bruises to areas of the body that do not make contact with the ground in falls are more suspicious of an abusive cause. Young babies should not have any bruises as they are not independently mobile. Bruises to the ears can be caused by punching or slapping as the ear is hit against the side of the head, leaving marks, sometimes within or on the inner aspect of the pinna.

Acute diarrhoea in children: (a) Often requires careful attention to fluid intake to prevent dehydration (b) Is usually bacterial and therefore requires antibiotic treatment( c) Is very rarely infectious to other children (d) Is a cause of failure to thrive (e) Typically presents with blood in the stools

A. Diarrhoea can lead to dehydration unless fluid intake is not maintained. In a child presenting with dehydration you will need to carefully rehydrate them. Most gastroenteritis is viral and highly infectious. Weight loss in acute diarrhoea is usually due to dehydration (loss of body water) and only chronic or recurrent diarrhoea causes failure to thrive in the longer term.

In a 15 year old girl with recurrent abdominal pain (a) An abdominal ultrasound may be useful to exclude ovarian pathology (b) An abdominal X-ray is useful to exclude constipation (c) A pregnancy test is not necessary if the child denies sexual activity (d) Is likely to be due to irritable bowel syndrome, even if the stool pattern is normal (e) The child should be examined alone, to allow them to disclose any potential sexual abuse

A. Gynaecological causes of the pain are possible, but other causes should be sought also. Abdominal X-ray should not be performed if there is any possibility of pregnancy. Pregnancy test is useful and should be encouraged in all girls of this age. Whilst irritable bowel syndrome is a possibility there is by definition altered bowel habit. The child should be spoken to alone if possible, but not examined without a parent or chaperone present.

Which one of the following conditions causes growth to fall off across centile lines before the onset of puberty? (a) Hypothyroidism (b) Constitutional short stature (c) Turner's syndrome (d) A child with a history of Intrauterine growth retardation (IUGR) (e) Achondroplasia

A. Hypothyroidism can have a profound effect on growth in the childhood years. The other conditions cause short stature with growth below or on a low centile line.

Most of the causes of global developmental delay and intellectual disability cannot be reversed by treatment. However one of the following conditions is reversible by early identification and treatment. Which one? (a) Phenylketonuria (b) Fetal alcohol syndrome (c) Tuberous sclerosis (d) Fragile X (e) Neurofibromatosis

A. Most congenital causes of severe intellectual disability are irreversible. The two exceptions are phenylketonuria (PKU) and congenital hypothyroidism, both identified through the neonatal screening programme. Treatment (with a phenylalanine free diet and thyroid hormone respectively) has allowed affected individuals to lead entirely normal lives. The other conditions in the list cannot be reversed, although the outcome can be improved with early referral and intervention through a Child Development Centre.

The health visitor has asked you to see an 8-month-old baby girl as she has not been gaining weight recently. Her weight at the age of 6 months was on the 25th centile and it is now on the 2nd. She had an episode of gastroenteritis when she was 26 weeks old. She has recovered but still has loose stools. Her mother says that she has become rather irritable, and is not feeding as well as she used to. On examination her length is on the 50th centile, as is her head circumference. She looks thin, and her abdomen protrudes somewhat. Otherwise her physical examination is normal. How would you manage this baby?

Admission to hospital FBC, UEC, LFT, BSL, TFT, iron studies, Vitamin B12, CMP, Coeliac serology, Faecal calprotectin +/- faecal PCR/MCS, Urinalysis and MC&S Involvement of nutritionist and dietician to assess feeding Elimination of lactose

Which of the following are diagnostic features of Autism spectrum disorder? A. Inattention, impusivity and hyperactivity B. Impaired social communication, speech, repetitive motor mannerisms and lack of shared play C. Lack of empathy, rule breaking and aggressive behaviour.

B

Which one of the following conditions can present with poor growth before the classic symptoms of the disease become apparent? (a) Congenital heart disease (b) Crohn's disease (c) Asthma (d) Nephrotic syndrome (e) Juvenile idiopathic arthritis

B Any chronic condition can affect growth, but evidence of the disease process precedes the slow down in growth. The exceptions are Crohn's disease, chronic renal failure and coeliac disease which can all present with poor growth in advance of other symptoms.

Which one of the following babies with IUGR (intrauterine growth retardation) has the best prognosis for growth? (a) A baby with a genetic syndrome (b) A baby whose birth weight is <10th centile and length on the 25th centile (c) A baby whose weight, length and head circumference at birth are <10th centile (d) A baby born to short parents who are themselves on the 2nd centile (e) A baby with features of TORCH

B Baby b's weight but not his length was affected by intrauterine growth retardation. The adverse influences therefore occurred towards the end of the pregnancy and the prognosis for growth is good. All of baby c's growth parameters are affected indicating that the adverse conditions were present early on in the pregnancy and so growth potential is likely to be reduced. The other conditions are all associated with short stature.

Which one of the following features is NOT correct regarding Turner's syndrome? (a) XO karyotype (b) Advanced bone age (c) Short stature (d) Absent signs of puberty (e) Shield shaped chest and wide spaced nipples

B Girls with Turner's syndrome are short, however bone age is usually appropriate for age. Advanced bone age is associated with increased growth and early onset of puberty.

In chronic renal failure (a) Renal transplantation is performed after a child is stabilised on haemodialysis (b) Vitamin D is given to raise plasma calcium and lower parathyroid hormone levels which improves bone mineral density (c) Hypertension is caused by the primary renal disease in advanced chronic renal failure (d) Anaemia is caused by iron deficiency (e) Most children on dialysis receive haemodialysis

B If a child is followed through a gradual deterioration in renal function it may be possible to perform a renal transplant before dialysis is needed. This is rare but has the advantage of avoiding any period on dialysis. Hypertension may be due to the original renal disease but is commonly an effect of fluid and sodium retention. Anaemia is caused by insufficient erythropoietin production. Most children are managed with peritoneal dialysis.

In a 12.5 kg child with 10% dehydration: (a) The maintenance fluid requirements over 24 hours are 12.5 kg (12500 mLs) × 10% = 1.25 L (b) The maintenance fluid requirement is 1.125 L (c) The total fluids required over 24 hours = fluid deficit + 10% of maintenance (d) The fluid deficit is 1.125 L (e) The maintenance fluid volume should be given via NG tube but the deficit fluid volume should be given as intravenous saline (0.9%) over 4 hours

B Maintenance = 100 ml × 10 kg plus 50 ml × 2.5 kg = 1125 mLs. The child will of course also need the deficit (10% × 12.5 kg = 1.25 L) replacing over 24 hours, and the safest way to do this is orally, via an NGT.

he following commonly cause bilateral swellings in the neck except for: (a) Mumps (b) mastoiditis (c) infectious mononucleosis (d) cervical adenitis caused by beta haemolytic streptococcus (e) viral pharyngitis

B Mastoiditis is a serious condition and is a complication of otitis media. It causes unilateral swelling, tenderness and erythema of the mastoid bone, pushing the ear out. The other conditions usually cause bilateral swellings.

Which of the following is NOT helpful for the initiation of successful breastfeeding (a) Ensuring the baby latches on well and has the nipple and the areolar in its mouth (b) Ensuring the mother has a rest immediately following delivery before putting the baby to the breast (c) Including breastfeeding guidance in antenatal programmes (d) Avoiding 'top ups' with formula to give the mother a rest (e) Milk company sponsorship of patient information leaflets

B The baby should be put to the breast soon after delivery to stimulate milk production. WHO baby friendly initiative discourages availability of formula milk and any advertising or promotion of formula milk in hospitals.

In malabsorption due to coeliac disease, which one of the following is true? (a) Weight gain is poor from birth(b) Weight gain begins to fall off after 6 months(c) Length is unaffected(d) Weight and height fall off simultaneously(e) Growth is only affected when gastrointestinal symptoms are severe

B n coeliac disease weight gain tends to fall off after the introduction of gluten to the diet, but growth from birth to weaning is satisfactory. Poor weight gain is usually the first measure to be affected and only subsequently length/height fall off. Children with later onset coeliac disease can present with poor growth alone without significant gastrointestinal symptoms.

Which one of the following is true of children with autistic spectrum disorder (ASD)? (a) Generally have high intelligence but poor social communication (b) Can present with poor social responses before 6 months of age (c) There is little evidence of genetic factors in the aetiology of ASD (d) Those children diagnosed <3 years of age will not develop speech (e) If speech is not developing then children will not be able to communicate

B Most children with ASD do not have high intelligence. An increasing number of genetic abnormalities are being discovered in children with ASD and investigations such as array CGH should be considered in the assessment of children with this pattern. Speech therapy can be effective in encouraging speech in many children with ASD. Those that don't develop speech may achieve some communication using strategies such as the Picture Exchange system.

What is 'catch down' growth? (a) When a baby loses weight as a result of neglect(b) When a baby born large for gestational age crosses to a lower centile line(c) When an obese baby loses puppy fat(d) When weight gain is poor due to malabsorption(e) When a child crosses centile lines due to growth hormone deficiency

B.

Which of the following are true of Necrotizing enterocolitis (NEC)? (a) NEC can be entirely prevented by using breast milk instead of formula milk (b) NEC is twice as likely in babies fed formula milk compared with breast milk( c) NEC is best diagnosed by careful abdominal examination (d) NEC only occurs in preterm babies <28 weeks (e) If a baby develops NEC they will need surgery to remove the affected bowel.

B. Babies given breast milk have half the incidence of formula fed babies but it still cannot be entirely prevented. There is evidence that probiotics such as bifidobacter and lactobacillus can further reduce the risk, even in breast-milk fed babies.

Which of the following are true of an inguinal hernia? (a) It is very unlikely to strangulate so does not need surgery (b) If bilateral in a female this may be an undervirilized male with undescended testes (c) If present in a preterm baby it will probably resolve spontaneously with time (d) It tends to disappear on coughing and appear on lying down (e) It transilluminates easily, especially on coughing.

B. Bilateral hernias can occur in either sex, but beware of the fact that a baby boy with a disorder of sexual differentiation and undescended testes may have the phenotypic appearance of a girl with bilateral inguinal hernias. Inguinal hernias should always be repaired, even in preterm babies as they carry a high chance of strangulation compared with umbilical hernias, which are also common in the preterm baby. Hernias do not usually transilluminate.

Which of the following are true of Coeliac disease? (a) Is an autosomal dominant inherited disorder (b) Is an auto-immune disorder associated with type 1 diabetes mellitus (c) Is an auto-immune disorder caused by antibodies which destroy the villi within the colon (d) Is due to a lack of pancreatic exocrine enzyme function (e) Can be reliably diagnosed by excluding gluten for a week and seeing if symptoms resolve

B. Coeliac disease is an autoimmune disorder associated with IgA anti-tissue transglutaminase enzymes. It is nothing to do with the pancreas, although it can lead to failure to thrive and steatorrhoea in a similar way to pancreatic enzyme deficiency. It requires a jejunal biopsy to look at the villi under the microscope, whilst on a diet containing gluten.

Which of the following are typical of gastritis or peptic ulcer pain? (a) Pain worse on drinking warm milk (b) Pain which wakes the child from sleep (c) Pain worse first thing in the morning and relieved by eating (d) Pain going through to the back (e) Pain worse after antacids such as H2 receptor antagonists

B. The pain is usually made worse by hot, spicy or acidic foods or drinks and relieved by antacids and milk. Pain may cause severe epigastric pain that can even be perceived as cardiac- hence the term 'heart burn'. Peptic ulcer pain often causes the child to be woken from sleep.

Which one of the following is true of weight loss in the first week of life (a) Weight loss of up to 12.5% birth weight is to be expected in breast fed babies (b) Breast fed babies usually lose a little more weight than formula fed babies (c) Weight loss of >12.5% is often associated with hyponatremic dehydration (d) Weight loss of > 5% birth weight is an indication for a feeding assessment (e) Weight loss >12.5% in a breast fed baby is an indication to switch to formula feeds

B. Weight loss >12.5% is serious and needs careful assessment and investigation, usually in hospital. It may be associated with hypernatremia. Expressed breast milk may be given via a nasogastric tube or bottle to correct dehydration. Occasionally formula feeds or iv fluids will be needed but this must be undertaken carefully.

Which one of the following is a sign of abnormal social development (a) Points to indicate something wanted at 12 months (b) No stranger anxiety with unfamiliar adult at 12 months (c) Puts objects in mouth at 6 months (d) Waves 'bye-bye' at 10 months (e) Eats with spoon and fork at age 2 years

B. Babies generally develop stranger anxiety at around 7 months of age. Failure to do this may indicate learning disability or abnormal social development.

Which of the following statements regarding measuring and plotting children's growth is true? (a) The measurement should be marked on the growth chart with a cross (b) Correction for prematurity should be made up to the age of 6 months at least (c) It is normal for an infant's weight to cross centiles in the first year (d) Final height usually approximates the father's height (e) Once a child is 5 years old height does not usually deviate from the centile line

C

Which of the following is likely to be a hydrocele? (a) A painless mobile mass on the left side of the scrotum that you can get above on palpation (b) A mass in the scrotum and groin that transilluminates and is tender to palpation, with the testes clearly palpable within it (c) A scrotal swelling that transilluminates but in which you cannot feel the testes (d) A red, tender mass in the scrotum that does not transilluminate (e) A mass that is tender but can be reduced by pressure over the swelling

C A hydrocele is typically painless, although if large may cause some discomfort. It usually transilluminates easily and it is difficult to feel the testes within a tense hydrocele. A tender mass that does not transilluminate may be a torted testicle. A reducible mass is probably an inguinal hernia.

Targeted more detailed follow up after routine newborn hearing screening is recommended for the following groups EXCEPT (a) Babies who have had high gentamicin levels (b) Babies who have failed the otoacoustic emission test (c) Babies with a family history of sensorineural deafness (d) Babies with cleft palate (e) When there has been a history of cytomegalovirus infection in the pregnancy

C Babies with a family history of deafness are no longer routinely recalled for more detailed testing if the standard otoacoustic emissions test shows a clear pass in both ears. However if there is any parental concern that babies are not responding to sound or not developing speech then hearing should be retested.

Which one of the following statements is correct regarding physical abuse in children? (a) Investigations showing the child has a coagulation disorder proves that a hand-slap outline bruise on the face is not abusive (b) Bite mark bruising is usually caused by other preschool children in nursery—further study of the bite pattern is not helpful (c) Young children suffer scalding injuries from hot drinks at home usually present with minor burns to the face and trunk (d) Dog bites in young children are common and not a sign of abuse (e) The colour of a bruise can be used to accurately estimate the timing of the injury

C Children with coagulation disorders may still suffer abusive injuries and need safeguarding, finding a coagulation disorder can help understand the level of force used or may be an explanation for multiple innocent bruises in a child. Specialists in forensic dentistry can review bite marks and it can be possible to discriminate an adult bite mark from a young child's. Dog bites can be a sign of neglect if parents have failed to supervise their young children safely or have exposed them to an aggressive dog. The colour of bruises are highly variable and cannot accurately date the time of an injury as they may be as much as 2 weeks or as little as 1 day old. Scalding injuries from hot drinks do tend to cause facial and trunk burns—but not burns to areas that are covered by clothes as the drink falls on the child. Abuse still needs to be considered in the differential diagnosis. Immersion injuries are usually well demarcated.

Which of the following are true of lactose intolerance in a 4 year old? (a) Is likely to cause blood and mucous in the stools, as mucosal cells are sloughed off (b) Is usually due to a genetic deficiency of intestinal lactase enzyme (c) Is most likely temporary, secondary to acquired lactase deficiency (d) Is exacerbated by intake soya milk, cow's milk or breast milk (e) Leads to excessive lactic acid (lactate) in the blood, causing acidosis

C. Lactase deficiency is usually acquired and follows an episode of gastroenteritis that damages the lactase containing mucosal cells. This causes diarrhoea and wind but not a full-blown colitis.

The following are more common in preterm babies than full term babies (a) Hyperthermia (b) Erythema toxicum (c) Periventricular leucomalacia (PVL) (d) Hypoxic-ischaemic encephalopathy (e) Transposition of the great arteries

C. The preterm white matter seems to be especially sensitive to ischaemic injury and this is further exacerbated if there is an inflammatory response present secondary to infection (e.g. chorioamnionitis) or inflammation (e.g. NEC). Hypoxic ischaemic injury is possible at any gestation but more common in term babies due to complications of labour.

In a full term baby who has a respiratory rate of 80 breaths/min, subcostal recession and oxygen saturations of 91% in air at 2 hours of age. (a) Antibiotics are not indicated unless there is a positive blood culture (b) A chest X-ray will rarely be useful (c) A pneumothorax should be ruled out using a cold light or chest X-ray (d) Provided the baby is feeding well they should just be observed (e) If there was a history of meconium stained liquor then meconium aspiration syndrome is the most likely diagnosis

C. This baby has respiratory distress which must be investigated, with a chest X-ray. A pneumothorax is one of the possible problems, but meconium aspiration, transient tachypnea of the newborn (TTN), pneumonia and congenital airway or lung abnormalities are also possible.

The term global developmental delay implies that all four developmental areas are affected. However it is not unusual for one developmental area to be spared. Which one? a) Speech and language (b) Fine motor (c) Gross motor (d) Social skills

C. The other three areas are more reflective of intellectual abilities and so delay in those areas are more concerning. A child with significant learning disabilities may still attain their gross motor milestones at a normal age.

A 3-month-old baby boy is referred by the GP who noticed a number of bruises when the baby was seen for their routine immunizations. The baby attends with both parents. There is a 1-cm circular bruise to the left cheek and two similar-size bruises to the abdomen. The baby is a little quiet and it is mentioned that his feeds have reduced that day but he is otherwise well. There is no history of any injury. What investigations should be performed? What safeguarding process should occur?

Coagulation studies Bone scan Brain imaging Nutritional work up: iron studies, Vitamin B12 and folate, FBC, CMP, TFTs. Photograph and document each finding In the case of an NAI -> mandatory reporting report to child protection services or gateway services Involve social work and police

Which of the following are typical of toddler diarrhoea? (a) Failure to thrive due to malabsorption (b) Going red in the face, then blue, then breath-holding (c) Blood and mucous in the stools (d) Passing undigested food in the stool (e) Drinking excessive volumes of milk

D There is a fast gut transit time and so some food may come out in the stool relatively undigested. Toddler diarrhoea is associated with drinking lots of fluid but usually juice- over consumption of milk tends to cause constipation. Typically with toddler diarrhoea the child is well and thriving.

Patients with nephrotic syndrome (a) Have high serum albumin levels (b) Are likely to be hypertensive (c) Need a renal biopsy to define cause (d) Should have pneumococcal vaccination when in remission (e) Stay on life-long penicillin prophylaxis

D n nephrotic syndrome serum albumin levels are low as protein is lost in the urine. Hypertension can occur but is unusual in most uncomplicated patients. Patients with uncomplicated idiopathic nephrotic syndrome do not need a renal biopsy—if the presentation is typical then it is recommended to start steroid treatment and assess response. Biopsy may be indicated if there are atypical features or fail to respond to steroids. Pneumococcal vaccination is recommended in remission in case of recurrence. Penicillin is taken whilst the nephrotic syndrome is active.

All the following measures reduce the risk of recurrent urinary tract infection except one. Select the FALSE answer: (a) Prescribe regular long term prophylactic antibiotics(b) Treat for constipation(c) Advice to children to go to the toilet promptly when they sense the urge to pass urine(d) Perform renal ultrasound scan(e) Advice to children to drink water regularly through the day

D

Children should be measured lying down until which age? (a) 9 months (b) 12 months (c) 18 months (d) 24 months (e) 30 months

D

All but one of the following are important findings in a child with global developmental delay as they provide pointers to an underlying cause. The exception is: (a) Dysmorphic facial features (b) Hepatosplenomegaly (c) Café au lait spots (d) Hypospadias (e) Microcephaly

D Hypospadias is the diagnostic term when a baby is born with the external urinary meatus opening on the ventral side of the penis. It is correctable surgically and is not associated with developmental abnormality. Dysmorphic facial features are characteristic of most congenital syndromes causing intellectual disability; café au lait spots are found in neurofibromatosis; microcephaly can result from intrauterine infection, perinatal trauma or as part of a congenital syndrome; hepatosplenomegaly is a feature of some congenital metabolic disorder

When intrauterine growth retardation occurs early in gestation which one of the following growth patterns is usually evident at birth? (a) Low birth weight, normal length, normal head circumference (b) Short length, normal weight, normal head circumference (c) Small head circumference, normal length, normal weight (d) Small head circumference, short length and low birth weight (e) Normal weight, normal length, normal head circumference

D Intrauterine growth retardation starting early in pregnancy affects head, length and weight measures. If it occurs later in pregnancy when most of a baby's linear growth has been achieved, weight alone is affected.

Which one of the following applies to a UK child protection safeguarding conference? (a) It is organized by the hospital paediatrician (b) The parents of the child are not invited to contribute their views (c) The conference makes the decision to remove a child from their carers if there is risk of serious harm (d) Reports on the child's vaccination status are considered (e) The conference reviews the medical evidence including any X-rays, CT scans or photographs of injuries

D Paediatricians refer concerns to social services and work together with social services staff to understand the level of risk to a child. Safeguarding conferences are chaired by social services staff. The local authority has a legal obligation to coordinate the process and take action in a set time period. Parents are usually invited to attend the conference and give their views on how their child's safety should be safeguarded in the future but this will be considered along with the views of professionals at the meeting before a decision is made. If there is concern of serious risk of harm to a child then the decision of the conference may be that the local authority should apply to the family court to request a court order that a child should be removed from parent's care. The paediatrician prepares a report for the conference that summarises the history, examination and investigations and gives an opinion on the likelihood of any injuries being inflicted/risk of abuse based on their involvement. The individual investigations are not reviewed in the conference. Reports on general health, growth, GP attendance, immunization, dental health and school progress make an important contribution to understanding a child's general level of care.

A child presents with swollen cervical glands. You might consider doing all the following tests except: (a) Full blood count (b) Biopsy (c) EBV screen (d) T4 and TSH levels (e) Throat culture

D T4 and TSH may be abnormal in thyroiditis, but the thyroid is a midline swelling, whereas cervical glands lie laterally in the anterior or posterior cervical angles delineated by the sternoid mastoid muscle. The other tests can be considered if the child is very sick or the glands persist.

Which of the following are true of swellings in the neck? (a) Mumps causes a swelling behind the ear (b) Thyroiditis causes a swelling at the angle of the jaw (c) Cervical adenitis causes a midline anterior swelling (d) Mastoiditis causes a swelling behind the ear (e) Lymphoma usually causes swellings in the cervical chain bilaterally

D.

Babies born at 25 weeks: (a) Have an 80% chance of disability (b) Cannot be fed breast milk until 34 weeks (c) Have a 20% chance of blindness from retinopathy of prematurity (d) Have a 65-70% chance of survival if admitted to a NICU (e) Do not develop respiratory distress syndrome as their lungs are too immature to produce surfactant

D. 62% of those alive at the onset of labour and nearly 70% of babies admitted alive will survive to discharge but disability free survival is about 45% (i.e. 55% will have some disability). Breast-feeding can often start as early as 32 weeks and before that expressed breast milk can be used via a nasogastric tube. The chance of retinopathy at 25 weeks is about 25-30% but less than 20% of those treated will develop visual loss. Overall risk of blindness is <1%. Babies at 25 weeks have reduced surfactant production and so they DO develop RDS.

In a breast fed four week old baby the following are all normal except one—choose the abnormal one: (a) Passing runny yellow stool 6 times a day (b) Passing green stool once a day (c) Passing a smooth, soft stool once a week (d) Passing a stool with a little blood on the surface (e) Passing a seedy stool with a mixture of lumps and liquid

D. Babies should never pass blood in their stool—this may reflect constipation with an anal fissure, cow's milk protein allergy with allergic colitis or a bleeding disorder such as Vitamin K deficient bleeding.

Which of the following is true about streptococcal tonsillitis? (a) It is common in children aged under 2 years (b) Treatment with phenoxymethylpenicillin is required (c) White tonsillar exudates are a reliable sign of bacterial infection (d) Glomerulonephritis is a rare complication (e) Cervical adenitis is a rare but important sign

D. Bacterial tonsillitis is rare in babies and toddlers, although they may have viral tonsillitis. Both exudates and cervical adenitis are common findings in tonsillitis and occur in bacterial and viral infection. Post streptococcal glomerulonephritis is a rare but important complication. In countries where rheumatic fever is rare children can be treated symptomatically without antibiotics.

Which of the following is NOT an age-appropriate test for hearing in young children: (a) Speech discrimination test at age 2½ years (b) Distraction hearing test at age 12 months (c) Child responds to name at age 9 months (d) Pure tone audiogram at age 2 years (e) Oto-acoustic emissions test in newborn babies

D. Children need to understand the complex process of listening for a sound and indicating that they hear it in order to perform an audiogram test. This is usually possible from around three years of age onwards.

Which of the following apply to Vesicoureteric reflux? (a) It needs corrective surgery to prevent further infection and renal damage (b) It is linked to renal damage through the pressure effect of urine backflow (c) It is commonly found in teenagers presenting with their first urine infection (d) It has a familial association (e) It is detected on antenatal scanning of the kidneys and bladder

D. Many cases of vesicoureteric reflux do not need corrective surgery and can be managed conservatively with avoidance of infection and often there is spontaneous resolution through pre-school years. Kidney damage is caused by the combination of reflux and infection. Most patients with vesicoureteric reflux present in early childhood. Most patients with vesicoureteric reflux are not found to have any anomaly on antenatal ultrasound scanning.

In a well child with intermittent abdominal pain for a month, that mostly occurs on school days: (a) The pain is typically in the right iliac fossa (b) Serious pathology can always be excluded by the history alone (c) A trial of stopping school for a week will be useful to make the diagnosis of school-related anxiety (d) It is likely the child actually feels pain, rather than putting it on (e) Sexual abuse is the likely cause

D. Whilst idiopathic or recurrent abdominal pain often occurs in sensitive high-achieving children who are anxious, they are usually not malingering and do feel the pain as pain. Serious pathology is unlikely but you keep an open mind and only exclude this if the child is thriving, has no abnormal signs and is well in between. Basic investigations such as a blood sugar and urine culture may be useful. Abuse is unlikely but should be considered.

Which of the following is a sign of abnormal gross motor development: a) Running at age 2 years (b) Climbing and descending stairs at age 2 years (c) Changing from lying to sitting position at age 9-12 months (d) Crawling at age 18 months (e) Pedalling a tricycle at age 3 years

D. 90% of babies can crawl at 9 months of age. An exception to this are those babies that 'bottom-shuffle' who may not crawl until age 2 years but otherwise develop normally.

Which of the following findings would be concerning in children with a fever: A. Wheezes & mild WOB B. Low urine ouput and dry mucous membranes C. Increased stool frequency D. Elevated WCC, tachycardia, Febrile and increased RR

D. SIRS

Which one of the following is true of Autosomal Dominant conditions? a) They are more common in cousin-cousin marriages (b) The condition or disease usually skips a generation (c) Boys are affected twice as often as girls (d) At least one parent must always carry the abnormal gene (e) 50% of the offspring will be affected

E. Only one copy of the gene is needed so 50% of the offspring are likely to be affected and 50% will not be affected and will not pass on the gene. New mutations are quite common so the affected individual may be the first in their family to express the phenotype. Cousin-cousin marriages usually increase the chances of autosomal recessive disorders.

Case. A 5-week-old baby has been vomiting for the last 48 hours. Initially he was keeping some feeds down but now he is vomiting after every feed. He was breast-fed initially but for the last week has been given formula milk via a bottle because his mother, who is only 17, developed a breast abscess and decided to stop breast-feeding. Q. His mother is carrying her child health record (red book). How can you establish exactly the degree of dehydration?

Determine his weight In fact this baby weighed 3.3 kg a week ago. He has therefore lost 300 g. If we assume all this weight loss is due to fluid loss, this represents 9% dehydration.

A 9-year-old boy is at home with his parents when he suddenly complains of a pain in his right groin. He has been playing football all afternoon. As a baby he had a hydrocele on the right side of his scrotum but this disappeared when he was about 12 months old. His father has a look at his groin area and noticed the right side of his scrotum is swollen and extremely tender. He telephones the family doctor for advice as to what he should do next. The GP sends the boy to the local hospital for review by a paediatric surgeon. The surgeon finds a tense red swelling in the right scrotum and inguinal canal. It is difficult to 'get above it' and the testis is not easily palpable on that side. The swelling is not reducible. What is the diagnosis and what is the treatment? (e) What is the danger of delaying treatment?

Dx- incarcerated inguinal hernia Tx- surgical closure of the patent processus vaginalis with meshing Delayed treatment increases the risk of volvulus and ischemic bowel

A 2 day old baby who is at home and looks visibly jaundiced should (a) Be admitted to hospital for exclusion of sepsis (b) Have phototherapy in hospital (c) Be placed in the sunlight, which converts unconjugated bilirubin to a safer form (d) Be placed under phototherapy which converts unconjugated to conjugated bilirubin (e) Should have their bilirubin measured

E The total bilirubin should be measured, either with a blood test or a transcutaneous bilirubinometer. Visual assessment is not accurate. The level should be compared with a treatment threshold graph or table and treatment started if it exceeds this level. The baby should also be assessed clinically to check they are feeding well and do not have any signs of infection.

In a 5 year old with severe constipation (painful rock hard faeces and pellets passed every 5-6 days) which treatment plan makes the most sense? (a) Changing to wholewheat bread and encouraging more orange juice in the diet (b) Starting an iso-osmotic laxative followed by a stimulant laxative after a week (c) Starting a stimulant laxative followed by bulking agents (d) Starting an iso-osmotic laxative followed by a stool softener for 1 week (e) Starting an iso-osmotic laxative and re-evaluating after a week

E. C and d may also be appropriate but require evaluation of the child and the response to the first treatment before starting. In the longer term a change in diet will be required.

Which of the following would make the diagnosis of Hirschsprung's disease more likely? (a) A history of passing meconium at birth but then no other stool for 36 hours (b) A history of abdominal pain and constipation from the age of 8 years (c) A child with failure to thrive, hepatomegaly and a distended abdomen (d) Features of Turner's syndrome on examination (e) Parents remember the first meconium after birth was at 3 days

E. There is delay in passage of meconium for >48 hours and often abdominal distension and vomiting. It can present with constipation in older children, but usually presents well before 8 years.

A 7-year-old boy is brought to the Emergency Department with a 1-day history of worsening vomiting. Over the last few hours parents report that he has been much less responsive and is now not talking but only making moaning noises. He has had bedwetting over the last 2 weeks having previously been dry at night from age 3. On examination he is pale, dehydrated, making laboured respiratory effort, rate of breathing is 50/min. He is lying in his mother's arms, opens his eyes when his name is called, movement is reduced but he will move his arm away from a painful stimulus. (b) What is the Glasgow Coma Score of this patient?

Eyes: 3 Movements: 4 Speech: 2 = 9

Which one of the following is correct regarding Fragile X syndrome? (a) Does not affect girls (b) Is more common with increasing maternal age (c) Children with fragile X syndrome have a greater risk of autoimmune hypothyroidism (d) Should be tested in all boys with moderate or severe learning difficulties (e) Is due to trisomy of the sex chromosomes

Fragile X is one of the commonest causes of learning disability affecting 1 in 400 boys and 1 in 8000 girls. Boys are usually more severely affected. It is more common with increasing paternal age. Children with Down's syndrome have higher rates of autoimmune disease.

Suzie is 24 months old. Her health visitor has referred her for a check-up as she is concerned that Suzie is not yet beginning to talk. Suzie's mother is not too worried, as her mother told her that she was a slow developer herself. You take a developmental history and discover that Suzie walked at 13 months, and is now able to run. You settle down to play with Suzie and find that she can build a tower of three bricks when she is shown how. She readily takes a crayon but does not know how to scribble. She babbles happily to herself but does not have any words yet. Her mother tells you that she waves bye-bye, eats with her fingers and drinks from a bottle. She has been offered a spoon, but has shown no interest in using it. Q. What do you think of the milestones she has attained? Show Answer

GM: walking at 13mo & running FM: drinks from a bottle, tower of 3 blocks (18mo) S&L: Babbles, waves (9mo) Suzie has significant developmental delay in all areas other than her gross motor skills, which are appropriate for her age. Her fine motor skills are delayed—at the age of 2 years she should be able to build a tower, and scribble freely. Her language skills are delayed—first words appear at around 12 months. Her social skills are also delayed—finger feeding starts at around 7 months and waving bye-bye at 9 months. By 15 months she should have managed a spoon and a cup. This degree of delay is very worrying and suggests that she is likely to have a significant learning disability.

A 3-month-old baby boy is referred by the GP who noticed a number of bruises when the baby was seen for their routine immunizations. The baby attends with both parents. There is a 1-cm circular bruise to the left cheek and two similar-size bruises to the abdomen. The baby is a little quiet and it is mentioned that his feeds have reduced that day but he is otherwise well. There is no history of any injury. What signs should be looked for on examination?

General: BMI, Trauma and swelling over the scalp region Retinal haemorrhages with fundoscopy Trauma to the oral cavity Pain and tenderness over the abdomen, ribs, humerus, femur and tibia Asymmetry between the limbs and growth Other signs of bruising, scaring and burns

Which one of the following blood disorders is a cause of chronic haemolysis and episodes of jaundice through childhood? (a) Haemochromatosis (b) Sickle cell disease (c) Sickle cell trait (d) Hereditary spherocytosis (e) Gilbert's syndrome

Haemochromatosis can cause skin discolouration as iron accumulates over time. Progressive liver damage can occur. Symptoms usually start when patients are30-50 years age. Sickle cell disease can cause anaemia but this is not a haemolytic process. Gilbert's syndrome is common and usually does not cause significant problems although there is a higher rate of some gastrointestinal symptoms such as irritable bowel syndrome. There is a normal process of red cell breakdown but a problem with clearance of the bilirubin leading to jaundice. In hereditary spherocytosis episodes of haemolysis occur which can cause jaundice and anaemia. There is a risk of gallstones and splenomegaly. Patients who have severe anaemia requiring repeated transfusions may benefit form splenectomy.

Case. A 5-week-old baby has been vomiting for the last 48 hours. Initially he was keeping some feeds down but now he is vomiting after every feed. He was breast-fed initially but for the last week has been given formula milk via a bottle because his mother, who is only 17, developed a breast abscess and decided to stop breast-feeding. Following your examination you decide to admit the child and undertake some blood tests. These are the results: Sodium 130 mmol/L; Potassium 2.8 mmol/L; Chloride 90 mmol/L; Bicarbonate 32 mmol/L; Creatinine 90 mol/L; Urea 6.7 mmol/L; Glucose 5.5 mmol/L; pH 7.53; PCO2 5.5 KPa; PO2 14 KPa; Base excess +7 mmol/L Q. Which of the following is the most likely diagnosis? (1) Acute renal failure; (2) Inborn error of metabolism; (3) Aspirin poisoning; (4) Administration of hyperconcentrated milk feeds; (5) Pyloric stenosis; (6) Severe gastroenteritis; (7) Diabetic ketoacidosis.

Hyponatraemic Hypokalaemic Bicarbonate elevated Alkalosis (5) Pyloric stenosis. There is a metabolic alkalosis and hypokalaemia due to depletion of H+ in the vomit. The timing (4-6 weeks), male sex, increasing vomiting and constipation, lack of bile and irritability are typical features. Acute renal failure would show a higher creatinine and hyperkalaemia. Concentrated feeds would cause hypernatraemia Most of these conditions cause acidosis. The normal glucose excludes diabetic ketoacidosis. This child is too young to have accidentally ingested aspirin. Aspirin poisoning typically causes a respiratory alkalosis due to hyperventilation, then progresses to a metabolic acidosis.

Which one of the following blood group combinations in a mother and baby gives the highest risk of jaundice due to haemolytic disease of the newborn? (a) Mother group A Rh+ baby group A Rh− (b) Mother group AB Rh+ baby group O Rh− (c) Mother group O Rh+ baby group A Rh+ (d) Mother group O Rh− baby group A Rh+ (e) Mother group A Rh− baby group O Rh+

If mother is group O Rh− she may produce IgG antibodies to both group A and to Rhesus antigens from the foetal blood if the baby is group A Rh+. These antibodies can cross the placenta and cause haemolysis before and after the delivery.

The health visitor has asked you to see an 8-month-old baby girl as she has not been gaining weight recently. Her weight at the age of 6 months was on the 25th centile and it is now on the 2nd. She had an episode of gastroenteritis when she was 26 weeks old. She has recovered but still has loose stools. Her mother says that she has become rather irritable, and is not feeding as well as she used to. On examination her length is on the 50th centile, as is her head circumference. She looks thin, and her abdomen protrudes somewhat. Otherwise her physical examination is normal. What are the possible causes of her poor weight gain?

Increased caloric requirements Hyperthyroidism T1DM UTI Decreased caloric intake Neglect and abuse Financial insecurity IBD Coeliac disease Cow's milk protein intolerance Cystic fibrosis with pancreatic insufficiency

Case. A 5-week-old baby has been vomiting for the last 48 hours. Initially he was keeping some feeds down but now he is vomiting after every feed. He was breast-fed initially but for the last week has been given formula milk via a bottle because his mother, who is only 17, developed a breast abscess and decided to stop breast-feeding. You examine the baby. His temperature is 36.8 °C. He has sunken eyes, a slightly sunken fontanelle and dry mucous membranes. The nappy is dry and empty. His pulse is 160 beats/min, blood pressure is 70/40 and his capillary refill time 3 seconds. He weighs 3.0 kg. He is irritable. As you examine him he vomits milk on to your shoe. Q. Do you think he is dehydrated? If so, to what degree?

Moderate MINIMAL <5% • Normal capillary refill time (1-2 sec) • Skin pinch retracts immediately • Normal respiratory pattern • Normal conscious state • Normal drinking • Normal urine output MODERATE 5-10% • Delayed capillary refill (3-4 sec) • Skin pinch retracts slowly (1-2 sec) • Increased respiratory rate • Restless, irritable • Tachycardia • Drinks eagerly, increased thirst SEVERE >10% • Very delayed capillary refill (greater than 4 sec), mottled skin • Skin pinch retracts very slowly (greater than 2 sec) • Deep, acidotic breathing • Lethargic, unconscious • Deeply sunken eyes • Unable to drink • Hypotensive

A 9-year-old boy is at home with his parents when he suddenly complains of a pain in his right groin. He has been playing football all afternoon. As a baby he had a hydrocele on the right side of his scrotum but this disappeared when he was about 12 months old. His father has a look at his groin area and noticed the right side of his scrotum is swollen and extremely tender. He telephones the family doctor for advice as to what he should do next. If the boy had complained of a headache, a swollen face and a fever in the preceding days, what other condition might you consider?

Mumps

Case. A 5-week-old baby has been vomiting for the last 48 hours. Initially he was keeping some feeds down but now he is vomiting after every feed. He was breast-fed initially but for the last week has been given formula milk via a bottle because his mother, who is only 17, developed a breast abscess and decided to stop breast-feeding. Your senior colleague reviews the child and decides that he is 8% dehydrated and needs rehydration. Q. What fluid would you use to rehydrate him and by what route? Can you calculate his fluid deficit in millilitres?

Normally, oral rehydration solution is the safest way to rehydrate this degree of dehydration, but as the child is likely to have pyloric stenosis this will not be absorbed. Intravenous dextrose-saline fluids are indicated, with added potassium to correct the hyperkalaemia. If this child is 8% dehydrated and weighs 3 kg then his fluid deficit is approximately 8% of 3 L. For this child, this would be (3300 mL /100) × 8 = 264 mL. The fluid prescription should include the child's maintenance fluid requirement and this deficit, given over 24 hours. The maintenance fluid requirement is 100 mL/kg (for the first 10 kg), which 3.3 × 100 = 330 mL. The total fluids (over 24 hours) is therefore 330 + 264 = 594 mL (= approx. 25 mL/h).

The health visitor has asked you to see an 8-month-old baby girl as she has not been gaining weight recently. Her weight at the age of 6 months was on the 25th centile and it is now on the 2nd. She had an episode of gastroenteritis when she was 26 weeks old. She has recovered but still has loose stools. Her mother says that she has become rather irritable, and is not feeding as well as she used to. On examination her length is on the 50th centile, as is her head circumference. She looks thin, and her abdomen protrudes somewhat. Otherwise her physical examination is normal. What suggests an organic rather than psychosocial cause?

Ongoing loose stools Irritability Previously good growth his baby has loose stools and a protruding abdomen, which should raise your suspicion that she may have an organic cause. Problems in any organ system can be associated with poor weight gain so she needs a thorough history and physical examination, especially focusing on evidence of chest infections, heart murmur, vomiting, recurrent fever, developmental delay, hepatosplenomegaly and neurological signs. It is important too to look for non-organic symptoms (rather than consider this as a diagnosis of exclusion). Enquire about eating difficulties, difficulties in the home, limitations in the parents, disturbed attachment between mother and child, and maternal depression or psychiatric disorder. Uncommonly, neglect might be a factor.

A 3-month-old baby boy is referred by the GP who noticed a number of bruises when the baby was seen for their routine immunizations. The baby attends with both parents. There is a 1-cm circular bruise to the left cheek and two similar-size bruises to the abdomen. The baby is a little quiet and it is mentioned that his feeds have reduced that day but he is otherwise well. There is no history of any injury. a) What further history is needed?

Psychosocial Family safety and financial security History of substance abuse Presenting complaint Mechanism of obtaining the bruises Attendance of previous appointments Previous notifications to child protection services Other children and hx of domstive violence History of coagulopathy

Regarding strabismus (squint), which of the following is true? (a) Strabismus <12 months is common and does not need investigating (b) Strabismus is an early sign of raised intracranial pressure in children with brain tumours (c) Amblyopia can result from failure to detect strabismus in young children and this is a common cause of severe visual impairment in adults (d) Strabismus is assessed with cover test at the 6 week baby check (e) Strabismus is tested with the cover test that shows a squinting eye remain out of position when the good eye is covered

Strabismus persisting beyond 2 months should be referred for assessment including fundoscopy. Strabismus is a late sign of raised intracranial pressure in children with brain tumours. Strabismus is not tested at 6 week check but eye movements are reviewed to make sure there are not signs of fixed, permanent strabismus. In the cover test a squinting eye moves into the correct position when the good eye is covered. Unilateral amblyopia is a common cause of severe visual impairment in adults because amblyopia is very common and overall impairment can result if there is any subsequent problem with the other eye.

A 9-year-old boy is at home with his parents when he suddenly complains of a pain in his right groin. He has been playing football all afternoon. As a baby he had a hydrocele on the right side of his scrotum but this disappeared when he was about 12 months old. His father has a look at his groin area and noticed the right side of his scrotum is swollen and extremely tender. He telephones the family doctor for advice as to what he should do next. (a) List four conditions that should be in the GP's differential diagnosis for this presentation?

Testicular torsion Incarcerated inguinal hernia Epidimorchitis Varicocele or hydrocele

In a patient with newly presenting type 1 diabetes (a) A blood pH < 7.30 indicates severe ketoacidosis (b) It is more common to see diabetic ketoacidosis in children <5 years and teenagers than children age 5-11 years (c) Blood ketones are low when insulin levels are low in ketoacidosis (d) A random blood glucose >7 mmol/L is diagnostic of type 1 diabetes (e) Autoantibodies to islet cells are seen in all patients with type 1 diabetes

The correct answer is (b) Blood pH < 7.30 is mild acidosis, pH < 7.20 is moderate acidosis, pH < 7.10 is severe acidosis. Blood ketones are high with low insulin levels. Random blood glucose >11.1 mmol/L is suggestive of diabetes, fasting level >7 mmol/L. Autoantibodies can be absent and can also be seen in patients with type 2 diabetes. Very young children are more likely to have ketoacidosis as their presentation with symptoms of diabetes is less obvious for families and health professionals to notice. Teenagers are more likely to have ketoacidosis as there are greater numbers of teenagers with diabetes than younger children and because compliance is often less good with independent control.

What are possible causes of Suzie's developmental delay?

The possible causes of Suzie's developmental picture include: • Idiopathic causes• Central nervous system malformation• Chromosomal abnormalities• Neurodegenerative disorders• Pre-, peri- or postnatal natal injury• Metabolic defects

You are asked to review a full-term baby on the postnatal ward who is 12 hours old. The midwife is concerned that the baby looks jaundiced. You go to see the baby who is jaundiced and has yellow sclera but is alert and has just completed a breast feed. You review his history including the history of the recent pregnancy.

This is early-onset jaundice ( < 24 h) and is therefore pathological and has to be taken seriously. You need to establish whether there are any risk factors for infection such as prolonged rupture of membranes or known maternal infection (high CRP, positive urine or HVS culture). It is also important to know the mother's blood group as this may be haemolytic disease of the newborn.

A 7-year-old boy is brought to the Emergency Department with a 1-day history of worsening vomiting. Over the last few hours parents report that he has been much less responsive and is now not talking but only making moaning noises. He has had bedwetting over the last 2 weeks having previously been dry at night from age 3. On examination he is pale, dehydrated, making laboured respiratory effort, rate of breathing is 50/min. He is lying in his mother's arms, opens his eyes when his name is called, movement is reduced but he will move his arm away from a painful stimulus. Q. Is there a need for any resuscitation intervention?

Yes. Altered conscious level is potentially life threatening as impaired consciousness means that the airway can be compromised. If a partially conscious patient vomits they may aspirate and risk respiratory arrest. Intervention to protect the airway includes positioning of the neck and chin and consider whether nasogastric tube should be placed to aspirate stomach contents. Call anaesthetist as airway intubation may be needed.

You are asked to review a full-term baby on the postnatal ward who is 12 hours old. The midwife is concerned that the baby looks jaundiced. You go to see the baby who is jaundiced and has yellow sclera but is alert and has just completed a breast feed. You review his history including the history of the recent pregnancy.

You should take blood to measure the serum bilirubin level and the babies blood group. A direct Coomb's test will establish whether there is maternal IgG antibody attached to the baby's red blood cells. A full blood count may show signs of anaemia and haemolysis and may show a leucocytosis if there is infection. CRP and blood culture should be performed.

Regarding Down's syndrome which of the following is correct? (a) Most cases are caused by unbalanced translocation of chromosomes 14 and 21 (b) Girls with Down's syndrome are infertile due to their trisomy 21 (c) 88% of cases of non-disjunction arise from the maternal gamete and 5% from paternal gamete (d) Children with mosaic Down's syndrome do not have the characteristic heart defects of children with full trisomy 21 (e) Most babies with Down's syndrome are born to mothers age >35

c <2% are caused by translocation (which has a higher risk of recurrence) with most cases arising from non-disjunction. Girls with Down's syndrome may be fertile and can pass on trisomy 21 if they become pregnant. Most cases arise from maternal non-disjunction which increases with maternal age. Most pregnancies with Down's syndrome occur in older women but more babies with Down's syndrome are born to younger mothers as antenatal screening is targeted at older mothers. People with the mosaic Down's syndrome genetics can have all the features of the more typical full trisomy 21 although overall the group have less severe learning difficulties.

Babies who are born prematurely are expected to have delayed developmental milestones. By what age does catch up usually occur (if the baby has not incurred neurological damage)? (a) 6 months (b) 1 year (c) 2 years (d) 3 years

c Many premature babies show catch up in their developmental milestones within the first year, and if catch up has not occurred by the age of 2 years it is worrying. Guidance recommends that babies' development should be 'corrected for age' up to the age of 2 years.

A 6 year old child presents with fever, pain and a bulging red tympanic membrane. A diagnosis of acute otitis media is made. Which of the following statements is correct? (a) The child should receive a course of amoxicillin (b) Grommets are indicated if the episodes become recurrent (c) Paracetamol should be given for 3 days before considering antibiotics (d) Otitis media is commoner in autism (e) Prognosis is poor if perforation of the tympanic membrane occurs

c. Otitis media is a common problem in childhood. It occurs more commonly where there is Eustachian tube dysfunction and in Down's syndrome. It is advisable to treat with analgesia before considering a course of antibiotics. Perforation of the eardrum is not uncommon and has a good prognosis. Grommets are controversial and considered where there is language delay secondary to glue ear.

Which of the following statements is correct regarding pyrexia of unknown origin (PUO)? a) PUO is defined as fever of >2 week in young children (b) Blood cultures should be taken when the fever breaks (c) PUO is usually due to an atypical presentation of a common illness (d) Absence of fever and sweating is a sign of occult disease (e) Antipyretics should be given as the fever rises to make the patient more comfortable

c. PUO is usually due to an atypical presentation of a common illness such as urine infection or pneumonia. In adolescents PUO is defined as a fever for more than 2-3 weeks, but in young children the definition is fever for more than one week. The absence of fever and sweating suggests factitious fever rather than organic disease. Blood cultures should be obtained at the peak of fever as the yield is then higher. During the investigation phase of PUO antipyretics should be avoided as they will obscure the pattern of the fever.

The following features in a history or physical examination would alert you to the possibility of infective endocarditis as a cause for PUO except: a) Congenital heart disease (b) An indwelling catheter for parenteral nutrition (c) Splinter haemorrhages and clubbing (d) Disappearance of a pre-existing heart murmur (e) Microscopic haematuria

d.

Patients with haematuria (a) Haematuria at the time of an upper respiratory tract infection is typical of post-streptococcal glomerulonephritis (b) The commonest cause of macroscopic haematuria is post-streptococcal glomerulonephritis (c) Children need referral to paediatric nephrology to consider renal biopsy following an episode of macroscopic haematuria (d) Serum immunoglobulin A level is the most sensitive test for IgA nephropathy (e) Renal cysts on ultrasound scan suggest autosomal dominant polycystic kidney disease even if there is no family history

e. Haematuria tends to follow 1-2 weeks after streptococcal infection. The commonest cause of macroscopic haematuria is urinary tract infection. Renal biopsy is indicated if there is evidence of impaired renal function, proteinuria or hypertension at presentation. IgA nephropathy is diagnosed by finding IgA deposits in the glomerular mesangium, serum IgA is raised in <20% of children. Polycystic kidney disease is autosomal dominant but the previous generation may have not yet demonstrated any signs.

Which one of the following statements is true regarding breast milk jaundice in a 14 day old baby? (a) Investigation is not required if the baby is breast fed and otherwise well (b) A high conjugated bilirubin is typical of breast milk jaundice (c) The baby's faeces should be pale, grey/white in breast milk jaundice (d) Parents should be advised to change to formula milk feeds (e) Jaundice can persist beyond 2 months of age

e. All babies with jaundice should have investigation at 14 days (21 days if premature) to check that the pattern of jaundice is elevated unconjugated hyperbilirubinaemia, typical of breast milk jaundice. Conjugated hyperbilirubinaemia and pale faeces indicate that the baby may have biliary atresia which needs urgent investigation. Breast milk jaundice usually settles over a few weeks but occasionally persists for 3 months. No treatment is needed. Mothers should be advised to continue breast feeding.

A young child is referred with regression of previously acquired developmental milestones. Which of the following conditions could be a cause? (a) Fragile X (b) Down syndrome (c) Fetal alcohol syndrome (d) Neurofibromatosis (e) Chronic subdural haematoma

e. Subdural haematomas classically occur as a result of shaking injuries, and developmental regression can occur. Other causes of regression are the neurodegenerative diseases where a previously normal baby loses their developmental skills. The other conditions in the list are all congenital and cause developmental delay rather than regression.

Continuous subcutaneous insulin infusion pump systems for patients: Which statement is correct? (a) Are set to give basal insulin infusion plus 3 boluses per day to match mealtime carbohydrate intake (b) Are set to give constant background basal insulin (c) Are removed at night during sleep (d) Measure blood glucose and deliver insulin according to need (e) Cannula remains at injection site for 3-4 days

e. The pump systems deliver a basal insulin infusion which can be programmed to vary through the 24 hour period—some patients have a higher basal insulin requirement just before waking in the morning and later in the day than at midday. Boluses of insulin can be given more than 3 times a day to match carbohydrates at snacks and meals and also as an extra correction if glucose levels are high. Pumps do not currently measure blood glucose—patients still need to check capillary blood tests or a separate continuous glucose monitor. This question is not clear that there is one correct answer. I may be wrong but I thought the wording might be improved (I was concerned that for many patients they do give three boluses and that the background insulin is constant.

Which of the following statement is true for fever in childhood? (a) The definition of fever is a temperature above 37.0° (b) Antipyretics should be given when the fever is above 38° (c) Aspirin, ibuprofen or paracetamol are suitable antipyretics (d) The height of the fever correlates with the severity of illness (e) Fever in infants less than 8 weeks requires a CXR and LP

e. Fever in infants less than 8 weeks old must be taken seriously as signs of sepsis at this age can be nonspecific. Fever is usually defined as a temperature above 37.5°C; rectal temperatures are higher as they are closer to core temperature. Children need only be given antipyretics if they are in discomfort. There is some evidence that fever is part of the body's defense against infection. The height of the fever does not differentiate between viral and bacterial causes of infection nor does it correlate with severity

Calculate the fluid rate in ml/hr for an 18kg child: 1. 42 2. 112 3. 56 4. 10

formula = 40 + 2 x(18-10) = 40 + 2 x 8 = 40 + 16 = 56ml/hr answer 3

Case. A 5-week-old baby has been vomiting for the last 48 hours. Initially he was keeping some feeds down but now he is vomiting after every feed. He was breast-fed initially but for the last week has been given formula milk via a bottle because his mother, who is only 17, developed a breast abscess and decided to stop breast-feeding. Q. You are worried about this baby, who seems quite ill. What further information do you need from the history?

ou need to establish the cause of the vomiting. Is it associated with diarrhoea, which would make gastroenteritis more likely, or is it associated with constipation, which may suggest a bowel obstruction? Is the vomiting bile stained, which suggests a serious bowel obstruction, or is it just curdled milk? Is the vomiting minor posseting, suggestive of gastro-oesophageal reflux, or is it projectile, as occurs in pyloric stenosis? Finally, the baby has recently changed feeds so you might want to ask how this young mother is making up the feeds—non-sterile water may cause gastroenteritis, or over-concentrated feeds may cause electrolyte imbalance.

A 9-year-old boy is at home with his parents when he suddenly complains of a pain in his right groin. He has been playing football all afternoon. As a baby he had a hydrocele on the right side of his scrotum but this disappeared when he was about 12 months old. His father has a look at his groin area and noticed the right side of his scrotum is swollen and extremely tender. He telephones the family doctor for advice as to what he should do next. What features on examination differentiate between a hydrocele, inguinal hernia, testicular torision and trauma to the testes?

• A hydrocele will transilluminate light from a pen-torch or otoscope, due to the presence of fluid around the testes. It is unusual for a hydrocele to recur having resolved in early childhood. • An inguinal hernia will become more prominent on coughing and it is difficult to delineate the upper margin of the swelling. It is not normally painful unless incarcerated. • Testicular torsion tends to occur in teenage boys and is acutely painful with a red tender mass present in the scrotum. • Trauma may be caused by a direct blow to the scrotum, although there would normally be a clear history of this. • Mumps is a viral infection that is now rare due to the MMR (mumps, measles, rubella) vaccine. It presents with malaise, fever and parotid swelling. It can be associated with orchitis (testicular inflammation) and can lead to subfertility.