Paediatrics

Gwendoline TanLydia Akinola

For Peer Teaching Society21/9/15

What we will cover

• Viral/bacterial rashes in children• Difficulty breathing

Measles

• Prodrome: cough, coryza, conjunctivitis, Koplik spots, fever

• Maculopapular rash starts behind ears• Complications

– encephalitis– giant cell pneumonia– subacute sclerosing panencephalitis– febrile convulsions– keratoconjunctivitis, corneal ulceration

• MMR within 72h of measles contact for non-immunised child

Mumps

• Fever, malaise, parotitis • Becomes bilateral in 70%• Complications– Pancreatitis– Orchitis– Meningitis/encephalitis

Rubella

• Pink macular rash which starts on face and spreads to trunk

• Suboccipital and postauricular lymphadenopathy

• In utero– 1st to 4th week: eye anomaly– 4th to 8th week: cardiac abnormality– 8th to 12th week: deafness

Erythema infectiosum (fifth disease)

• Parvovirus B19 • Lethargy, fever, headache, ‘slapped-cheek'

rash on face and limbs• Can cause marrow to stop producing RBCs

aplastic crisis transfusions

Roseola infantum (sixth disease)

• HHV6• High fever and MP rash when fever subsides• Febrile convulsions (10-15%)• Can cause aseptic meningitis, hepatitis

Hand foot mouth disease

• Coxsackie A16/enterovirus 71• Sore throat, fever, oral ulcers then vesicles on

palms and soles

Chickenpox

• Varicella zoster virus (HHV3)• Can be caught from someone with shingles• Fever, rash often starting on back• Macule papule vesicle ulcer crust• Complications: purpura fulminans, necrotising

fasciitis, pneumonia, meningitis• VZV Ig + aciclovir if immunosuppressed

Herpes simplex

• Gingivostomatitis: vesicles on lips, gums, tongue, palate high fever, painful eating and drinking

• Cold sores – usually HSV1• Complications– Eczema herpeticum– Herpetic whitlows– Blepharitis/conjunctivitis– Aseptic meningitis– HSV encephalitis

Molluscum contagiosum

• Umbilicated papules caused by Pox virus• Spread by direct contact• More extensive in those with eczema/HIV• Usually resolves w/o treatment in 18mths

Scarlet fever

• Group A strep (S. pyogenes) – seen post-strep/impetigo

• Fever, sore throat, strawberry tongue, rash• Rash 12-48h after fever, feels like

sandpaper/goosebumps• Peeling skin in armpits/groin/fingers and toes• Complications: OM, post-strep GN, rheumatic

fever, septicaemia, pneumonia• Penicillin V PO

Impetigo

• Contageous staph/strep skin infection• Erythematous vesicular golden honey-

coloured crusted lesions• Topical mupirocin or fusidic acid if mild• Flucloxacillin or erythromycin if extensive

Meningococcal septicaemia

• Non-blanching purpuric rash, fever, unwell child, shock

• IM benzylpenicillin in community, IV ceftriaxone Age Organism

Neonate – 3m GBS, E. coli, Listeria monocytogenes

1m – 6y N. meningitidis, S. pneumoniae, H. influenzae

>6y N. meningitidis, S. pneumoniae

Nappy rash

• Ammoniac– Crease-sparing– Erythematous– Irritant dermatitis – barrier cream e.g. Sudocrem

• Candida– Creases involved– Satellite lesions– Treat with antifungal

Other rashes to revise

• Eczema• Dermatitis herpetiformis• Cellulitis/erysipelas• Henoch-Schonlein purpura• Tinea• Scabies• Don’t forget to consider NAI

Breathing difficulties

Airway Assessment

• Secretions or stridor• Foreign body• Unprotected airway

Breathing assessment

• Respiratory rate• Recession and use of accessory muscles• Oxygen saturations• Auscultation

Age < 1 year 1-2 years

2-5 years

5-12 years

> 12 years

Resp. Rate

30-40 25-35 25-35 20-25 15-20

WheezeCommon Rare

Infection – bronchiolitis, viral induced wheeze, whooping cough, pneumonia

Cystic fibrosis

Asthma (> 1 year of age) Cow’s milk protein intolerance

Foreign body inhalation External compression of airway

Gastro-oesophageal reflux Heart failure

Recurrent aspiration

Persistent coughCommon Uncommon

Post-infection Pertussis

Recurrent URTIs Foreign body

Post-nasal drip Gastro-oesophageal reflux

Asthma (exercise, night) Cystic fibrosis

Cigarette smoke Tuberculosis

Habit Immune deficiency

Respiratory distressSymptom Signs

Breathlessness Tachypnoea

Difficulty talking Tachycardia

Difficulty feeding Dyspnoea

Wheeziness Recession

Sweatiness Cyanosis

Nasal flaring

Use of accessory muscles

Expiratory grunting

Crackles

Downward displacement of the lung

Case

A 14 month old girl is seen with a 2 day history of a loud cough. She has a fever of 38.5°C, a respiratory rate of 35, stridor and marked intercostal and subcostal recession. She is playful and is feeding well.(taken from Paediatrics: Clinical Case Uncovered)

Asthma

Asthma

Features of episode that suggest asthma include:• Nocturnal symptoms• Recurrent cough, shortness of breathe, wheeze• Worse following exposure to trigger• Personal/family history of atopy• Widespread wheeze on auscultation• Improvement with treatment

Asthma

• What are the symptoms of life-threatening asthma?

• What might you find on examination?• What might you find on spirometry?

Asthma

What are the side effects of chronic treatment?

Cystic fibrosis

Cystic fibrosis

• Which other organs can be affected?• Name 3 ways that CF may present?• Name 5 people involved in CF MDT

CaseA 3 year old boy is in acute respiratory distress. There is no past history of note except he has not been immunised. He has a temperature of 40C, looks flushed and unwell, is drooling and has an inspiratory stridor. His cough is muffled. A colleague asks for help examining the boy’s throat. Which is the single most appropriate advice to give?(taken from Oxford Assess & Progress)

A – do not disturb the child, and call for senior help urgentlyB – give neb budesonide and then examine the throatC – go ahead and examine the throat, but have a laryngoscope and endotracheal tube to handD – go ahead and examine the throat straight away to help make diagnosisE – site an IV line and give a dose of cefotaxime first, then examine the throat

Airway inflammationCroup Epiglottis

Time course Days Hours

Prodrome Coryza None

Cough barking Slight if any

Feeding Can drink No

Mouth Closed Drooling saliva

Toxic No Yes

Fever < 38.5°C > 38.5°C

Stridor Rasping Soft Voice Hoarse Weak or silent

Croup

• Also known as acute laryngotracheobronchitis• https://www.youtube.com/watch?v=

XpPVYmALPoA• Most commonly caused by parainfluenza virus• What are the treatment options?

PneumoniaAge Pathogens

NeonatesGroup B streptococcus

Escherichia coli (and other enterococci)Chlamydia trachomatis

Infants

Respiratory virus (e.g. RSV, adenovirus)Streptococcus pneumoniae

Haemophilus influenzaeBordetella pertussis

Staphylococcus aureus (RARE)

Children Streptococcus pneumoniae

Haemophilus influenzaeGroup A streptococcus

AdolscentsAs above

Mycoplasma pneumoniaeChlamydia pnuemoniae

Whopping cough

• http://www.parents.com/videos/v/97819228/what-does-whooping-cough-sound-like.htm

Case

A 6 week old is seen in the ‘failure to thrive’ clinic. For 3 weeks her feeding has been poor with only 30-60 ml of milk taken each feed, in several short bursts. There is no cough. Her respiratory rate is 60/min she has mild recession and inspiratory crackles.(taken from Paediatrics: Clinical Case Uncovered)

Other conditions to revise

• Bronchiolitis• URTIs include acute otitis media• Chronic lung disease of prematurity