Acute Paediatrics

Acute Paediatrics UK Medical PG Question 1: According to the NICE traffic light system for assessing febrile illness in children under 5 years, which of the following features would place a child in the high-risk 'red' category requiring urgent specialist assessment?

• A. Temperature greater than 39°C in a child aged 6-12 months
• B. Non-blanching rash appearing during the consultation (Correct Answer)
• C. Capillary refill time of 2 seconds centrally
• D. Respiratory rate of 55 breaths per minute in a 6-month-old infant
• E. Reduced activity and not responding normally to social cues

Acute Paediatrics Explanation: ***Non-blanching rash appearing during the consultation*** - A **non-blanching rash** is a critical **high-risk (red)** feature in the **NICE traffic light system** as it is a strong indicator of serious invasive bacterial infection, such as **meningococcal disease**. - Its appearance or progression during observation necessitates **urgent specialist assessment** and immediate medical intervention. *Temperature greater than 39°C in a child aged 6-12 months* - A temperature of **39°C or greater** in a child aged **6-12 months** is classified as an **intermediate-risk (amber)** feature, not a high-risk (red) feature. - A high temperature (38°C or above) in infants **under 3 months** is, however, considered a **high-risk (red)** feature. *Capillary refill time of 2 seconds centrally* - A **capillary refill time (CRT)** of **2 seconds** is considered normal and does not indicate a high-risk status. - The NICE traffic light system defines a CRT of **3 seconds or more** as a **high-risk (red)** feature, suggesting poor perfusion. *Respiratory rate of 55 breaths per minute in a 6-month-old infant* - For a 6-month-old infant, a respiratory rate of **55 breaths per minute** is within the normal physiological range, which is typically **25-60 breaths per minute**. - Tachypnoea is considered a **high-risk (red)** feature only if the respiratory rate is **>60 breaths per minute** in any age group, or if there is moderate or severe **chest indrawing** or **grunting**. *Reduced activity and not responding normally to social cues* - **Reduced activity** and **not responding normally to social cues** are classified as **intermediate-risk (amber)** features in the NICE traffic light system. - High-risk (red) neurological features include **decreased conscious level**, **bulging fontanelle** in infants, or **neck stiffness**.

Acute Paediatrics UK Medical PG Question 2: A 6-month-old baby presents with failure to thrive, chronic diarrhea, and recurrent respiratory infections. Sweat chloride test is 70 mmol/L (normal <40). What is the most likely diagnosis?

• A. Celiac disease
• B. Cystic fibrosis (Correct Answer)
• C. Immunodeficiency
• D. Inflammatory bowel disease
• E. Lactose intolerance

Acute Paediatrics Explanation: ***Cystic fibrosis***- The constellation of **failure to thrive**, chronic **malabsorptive diarrhea** (due to **pancreatic insufficiency**), and recurrent **respiratory infections** (due to thick mucus) is classic for **Cystic fibrosis**.- A sweat chloride level of 70 mmol/L is diagnostic for **Cystic fibrosis** in an infant (cut-off is typically >60 mmol/L), confirming the defect in the **CFTR channel**.*Celiac disease*- While a cause of failure to thrive and chronic diarrhea, symptoms typically manifest after the introduction of **gluten** (usually after 6 months of age) and often involve abdominal distension.- It does not cause recurrent respiratory infections as a primary feature, nor is it associated with an elevated **sweat chloride** level.*Immunodeficiency*- This could explain **recurrent respiratory infections** and failure to thrive, but it typically does not cause the specific syndrome of chronic steatorrhea due to **pancreatic insufficiency**.- Immunodeficiency conditions do not result in an abnormally high **sweat chloride** test result.*Inflammatory bowel disease*- IBD rarely presents in early infancy (6 months) and usually causes features like **bloody diarrhea** and **abdominal pain** rather than the typical **steatorrhea** associated with pancreatic insufficiency.- IBD is not associated with an elevated **sweat chloride** test or recurrent sino-pulmonary infections driven by mucus accumulation.*Lactose intolerance*- This causes osmotic diarrhea and potentially failure to thrive, but the symptoms are strictly gastrointestinal and often improve when **lactose** is removed from the diet.- It does not explain the hallmark triad of pulmonary disease, malabsorption, and the pathognomonic **elevated sweat chloride**.

Acute Paediatrics UK Medical PG Question 3: A 8-year-old child presents with fever, sore throat, and a sandpaper-like rash over the trunk and limbs. The tongue appears red with prominent papillae ("strawberry tongue"). What is the most likely diagnosis?

• A. Viral exanthem
• B. Scarlet fever (Correct Answer)
• C. Kawasaki disease
• D. Measles
• E. Erythema infectiosum

Acute Paediatrics Explanation: ***Scarlet fever*** - The presentation of fever, sore throat (streptococcal pharyngitis), and a generalized fine papular, **sandpaper-like rash** is pathognomonic for scarlet fever. - The finding of a **strawberry tongue** (red, prominent papillae) is also highly characteristic, resulting from the systemic effects of circulating **pyrogenic exotoxins** produced by *Streptococcus pyogenes*. *Viral exanthem* - While many **viral exanthems** cause fever and rash, they typically lack the characteristic fine, **sandpaper texture** or the associated severe pharyngitis. - The combination of sore throat, sandpaper rash, and specific **strawberry tongue** makes a common viral rash diagnosis highly unlikely. *Kawasaki disease* - This disease presents with high fever unresponsive to antipyretics and signs like **bilateral non-exudative conjunctivitis**, cracked lips, and **cervical lymphadenopathy**. - The specific **sandpaper rash** and severe pharyngitis seen in the patient are not typical features of Kawasaki disease, which carries a risk of **coronary artery aneurysms**. *Measles* - Measles is characterized by the prodrome of cough, coryza, and conjunctivitis, followed by a maculopapular rash that starts on the face and spreads downwards. - The presence of **Koplik spots** (small white spots on the buccal mucosa) precedes the rash in measles, and the rash appearance differs from the fine 'sandpaper' texture. *Erythema infectiosum* - This disease (Fifth Disease, caused by **Parvovirus B19**) is clinically recognized by the initial **slapped cheek appearance**. - The rash then spreads to the extremities, developing a distinct **lacy, reticular pattern**, which contrasts sharply with the generalized, fine, sandpaper rash of scarlet fever.

Acute Paediatrics UK Medical PG Question 4: A 8-year-old child presents with fever, sore throat, and a fine sandpaper-like rash. The tongue appears red with prominent papillae. What is the most likely diagnosis?

• A. Viral exanthem
• B. Scarlet fever (Correct Answer)
• C. Kawasaki disease
• D. Measles
• E. Erythema infectiosum

Acute Paediatrics Explanation: ***Scarlet fever*** - The classic clinical presentation of **fever**, **sore throat**, a **fine, erythematous, sandpaper-like rash**, and a **red tongue with prominent papillae** (often called **strawberry tongue**) is highly characteristic of scarlet fever. - This condition is caused by **Group A *Streptococcus*** (*S. pyogenes*) releasing **pyrogenic exotoxins** (erythrogenic toxins) which are responsible for the distinctive rash and tongue appearance. *Viral exanthem* - This is a generic term for a rash accompanying a viral infection, but it typically lacks the very specific combination of a **sandpaper rash** and **strawberry tongue** seen in this case. - Viral exanthems generally do not present with the severe **pharyngitis** and the characteristic toxin-mediated rash of scarlet fever. *Kawasaki disease* - Key diagnostic criteria for Kawasaki disease include persistent fever for at least 5 days, **conjunctival injection**, oral changes (e.g., cracked lips, but **strawberry tongue** is less specific), and often **polymorphous rash**, but not typically a **sandpaper-like rash**. - While it can cause oral changes, it is not preceded by **streptococcal pharyngitis** and does not feature the specific sandpaper rash caused by streptococcal exotoxins. *Measles* - Measles (Rubeola) is characterized by the 3 Cs: **cough, coryza, and conjunctivitis**, followed by a descending, **maculopapular rash** that is distinct from a sandpaper rash. - Unlike scarlet fever, measles classically presents with **Koplik spots** (small white spots on the buccal mucosa) before the rash appears and does not cause a sandpaper rash or a typical strawberry tongue. *Erythema infectiosum* - Also known as Fifth Disease, it is caused by **Parvovirus B19** and classically presents with a distinctive **

Acute Paediatrics UK Medical PG Question 5: A 8-year-old child presents with fever, irritability, and a widespread petechial rash that doesn't blanch with pressure. The child appears unwell and has neck stiffness. What is the most appropriate immediate management?

• A. Oral antibiotics
• B. IV benzylpenicillin (Correct Answer)
• C. Lumbar puncture
• D. Blood cultures
• E. CT head

Acute Paediatrics Explanation: ***IV benzylpenicillin***- The constellation of fever, irritability, widespread non-blanching petechial rash, unwell appearance, and neck stiffness is highly suggestive of **meningococcal disease** (meningitis with or without septicaemia), a medical emergency.- **Immediate empirical intravenous antibiotics**, such as **benzylpenicillin**, are critical to reduce mortality and morbidity in suspected meningococcal disease and should not be delayed by investigations. *Oral antibiotics*- The child presents with severe symptoms, including an **unwell appearance** and **non-blanching rash**, indicating a life-threatening infection requiring urgent intervention.- **Oral antibiotics** are inadequate for treating severe, rapidly progressing infections like meningococcal disease due to potentially slow absorption and insufficient blood-brain barrier penetration.*Lumbar puncture*- While a **lumbar puncture** is crucial for definitive diagnosis of meningitis, it must **not delay the immediate administration of IV antibiotics** in suspected meningococcal disease.- In a critically unwell child with signs of increased intracranial pressure (e.g., severe irritability, neck stiffness in context of severe illness), a lumbar puncture carries a risk of **herniation** and should be deferred until after antibiotics are given and/or a CT head rules out a space-occupying lesion.*Blood cultures*- **Blood cultures** are important for identifying the causative organism and guiding specific antibiotic therapy, but they should be taken **concurrently with or immediately after administering the first dose of IV antibiotics**.- Delaying antibiotic administration to obtain blood cultures can have severe consequences in a rapidly deteriorating patient with suspected **meningococcal septicaemia**.*CT head*- A **CT head** may be indicated to rule out complications like **cerebral edema** or **abscess** before a lumbar puncture, especially if there are signs of raised intracranial pressure.- However, like other investigations, a **CT head should not delay the immediate administration of life-saving IV antibiotics** in a child with suspected meningococcal disease, where time to treatment directly impacts prognosis.

Acute Paediatrics UK Medical PG Question 6: A 4-year-old child presents with fever, irritability, and neck stiffness. Lumbar puncture shows: opening pressure 25 cmH₂O, WCC 800/μL (90% neutrophils), protein 2.8 g/L, glucose 1.2 mmol/L (serum glucose 6.0 mmol/L). What is the most likely diagnosis?

• A. Viral meningitis
• B. Bacterial meningitis (Correct Answer)
• C. Tuberculous meningitis
• D. Fungal meningitis
• E. Normal CSF

Acute Paediatrics Explanation: ***Bacterial meningitis***- The constellation of **fever**, **neck stiffness**, severely elevated CSF **protein** (2.8 g/L), and profoundly low CSF **glucose** (ratio 0.2) is classic for acute bacterial infection.- The marked CSF pleocytosis (800/μL) with a predominant population of **neutrophils** (90%) indicates a rapidly progressive, pyogenic process.*Viral meningitis*- Characterized by **lymphocytic pleocytosis** (predominant lymphocytes) rather than the neutrophilic dominance seen here.- CSF glucose levels are typically **normal** or only mildly reduced, unlike the severe hypoglycemia reported in this patient.*Tuberculous meningitis*- While associated with low CSF glucose and high protein, it generally presents **subacutely** or chronically over weeks, not acutely.- CSF pleocytosis is usually **lymphocytic** or monocytic, not the acute neutrophilic predominance found in this sample.*Fungal meningitis*- This is rare in immunocompetent children, usually follows an indolent or **chronic** course, and typically presents with **lymphocytic** pleocytosis.- The acute presentation with fever, irritability, and prominent neutrophilia points strongly away from a fungal etiology.*Normal CSF*- Normal CSF findings include an opening pressure < 18 cmH₂O, WCC < 5/μL, and a CSF/serum glucose ratio > 0.6.- All measured parameters (pressure 25, WCC 800, glucose ratio 0.2) are significantly **abnormal**, definitively ruling out normal CSF.

Acute Paediatrics UK Medical PG Question 7: A 3-year-old child presents with a barking cough, inspiratory stridor, and hoarse voice. The symptoms are worse at night. The child is alert and playful. What is the most likely diagnosis?

• A. Epiglottitis
• B. Croup (Correct Answer)
• C. Bronchiolitis
• D. Pneumonia
• E. Foreign body aspiration

Acute Paediatrics Explanation: ***Croup*** - The presentation of a **barking cough**, **inspiratory stridor**, and **hoarse voice** in a 3-year-old is the classic triad for **Croup** (laryngotracheobronchitis), typically caused by the **Parainfluenza virus**. - Symptoms are typically worse at night due to increased **vagal tone** and decreased ambient humidity, yet the child remains alert and non-toxic, which is characteristic of mild-to-moderate croup. *Epiglottitis* - This condition presents as a medical emergency with rapid onset of **high fever**, severe **dysphagia**, drooling, and a **muffled voice**, but usually lacks the characteristic **barking cough**. - The child with epiglottitis typically appears **toxic**, apprehensive, and prefers the **tripod position**, unlike the alert and playful child described. *Bronchiolitis* - Bronchiolitis is an infection of the small airways, primarily causing **wheezing**, **tachypnea**, and signs of **lower respiratory distress**, usually without stridor or the specific barking cough. - It predominantly affects infants under 2 years of age and is most often caused by **Respiratory Syncytial Virus (RSV)**. *Pneumonia* - This is an infection of the lung parenchyma, presenting with fever, **tachypnea**, and often a productive cough accompanied by focal findings like **crackles** or **dullness** on chest exam. - Pneumonia does not typically cause prominent **inspiratory stridor** or the characteristic **barking cough** associated with upper airway swelling. *Foreign body aspiration* - This diagnosis usually involves a sudden onset of **choking** or coughing, and if the object is lodged in the larynx or trachea, it causes stridor, but the symptoms do not typically fluctuate and worsen specifically **at night**.

Acute Paediatrics UK Medical PG Question 8: A 2-year-old child presents with a 3-day history of cough, wheeze, and difficulty breathing. The symptoms started gradually and the child has been feeding poorly. On examination, there are widespread fine crackles and wheeze. What is the most likely diagnosis?

• A. Asthma
• B. Pneumonia
• C. Bronchiolitis (Correct Answer)
• D. Croup
• E. Foreign body aspiration

Acute Paediatrics Explanation: ***Bronchiolitis*** - This diagnosis is strongly suggested by the patient's age (2 years), gradual onset of cough, wheeze, and difficulty breathing over 3 days, combined with **poor feeding** and widespread **fine crackles** and **wheeze** on examination, which are classic features of this viral lower respiratory tract infection. - It is the most common cause of lower respiratory tract infection in infants and young children, often caused by **Respiratory Syncytial Virus (RSV)**, leading to inflammation and obstruction of the small airways. *Asthma* - While asthma presents with cough and wheeze, a first presentation in a 2-year-old with a 3-day gradual onset including **poor feeding** and widespread **fine crackles** is less typical, as asthma usually involves recurrent episodes or specific triggers. - The characteristic widespread fine crackles alongside wheeze, especially with a history of poor feeding and a clear acute illness, point away from asthma as the primary diagnosis in this context. *Pneumonia* - Pneumonia usually presents with more localized findings (e.g., **dullness to percussion**, **bronchial breath sounds**), **coarse crackles**, and often higher fever or more significant systemic illness, differentiating it from the generalized wheeze and fine crackles of bronchiolitis. - The description of widespread wheeze is not a typical predominant finding in uncomplicated pneumonia in this age group. *Croup* - Croup is characterized by a distinctive **barking cough** and **inspiratory stridor**, indicating upper airway obstruction, which are absent in the clinical presentation provided. - The widespread wheeze and fine crackles point to lower airway involvement, not the laryngeal and tracheal inflammation seen in croup. *Foreign body aspiration* - Foreign body aspiration typically has a **sudden onset** of choking or coughing, which contrasts with the gradual 3-day history described. - While it can cause wheeze, it is often unilateral or localized and usually lacks the widespread **fine crackles** and history of poor feeding associated with a viral illness.

Acute Paediatrics UK Medical PG Question 9: A 9-year-old boy with known asthma presents to the emergency department with an acute exacerbation. Following administration of oxygen, nebulized salbutamol, ipratropium bromide, and oral prednisolone, he remains in respiratory distress with oxygen saturation 92% on high-flow oxygen, peak flow 30% of predicted, and poor respiratory effort. What is the appropriate dose and route of magnesium sulphate administration in this clinical scenario?

• A. 40 mg/kg (maximum 2 g) intravenous infusion over 20 minutes (Correct Answer)
• B. 25 mg/kg (maximum 1 g) intravenous bolus over 5 minutes
• C. 40 mg/kg nebulized with salbutamol
• D. 50 mg/kg (maximum 2.5 g) intravenous infusion over 30 minutes
• E. 150 mg nebulized with ipratropium bromide

Acute Paediatrics Explanation: ***40 mg/kg (maximum 2 g) intravenous infusion over 20 minutes*** - This patient presents with a **severe acute asthma exacerbation** (peak flow 30% predicted, poor respiratory effort, poor response to initial therapies), necessitating adjunctive intravenous magnesium sulphate. - Current guidelines recommend **intravenous magnesium sulphate** at **40 mg/kg** (maximum 2 g) administered as a slow **infusion over 20 minutes** for children with severe refractory asthma. *25 mg/kg (maximum 1 g) intravenous bolus over 5 minutes* - This **dose (25 mg/kg)** is below the recommended concentration for treating **severe pediatric asthma exacerbations**, which typically calls for 40 mg/kg. - Administering magnesium as a rapid **intravenous bolus over 5 minutes** significantly increases the risk of adverse effects like **hypotension** and cardiac arrhythmias. *40 mg/kg nebulized with salbutamol* - While **nebulized magnesium sulphate** has been studied, its efficacy for **life-threatening asthma exacerbations** is not as well-established as the intravenous route, especially after failure of initial nebulized bronchodilators. - For severe, refractory asthma, **systemic (intravenous) administration** is preferred as it ensures better absorption and clinical effect compared to nebulized delivery. *50 mg/kg (maximum 2.5 g) intravenous infusion over 30 minutes* - This dose of **50 mg/kg** exceeds the standard **maximum recommended dose of 2 g** for intravenous magnesium sulphate in pediatric asthma, raising concerns for increased toxicity without additional therapeutic benefit. - Although a slow infusion, the **recommended duration** is typically 20 minutes for managing acute asthma effectively while minimizing side effects. *150 mg nebulized with ipratropium bromide* - The dose of **150 mg** is an incorrect fixed dose for nebulized magnesium sulphate in children; dosing is typically **weight-based**, and this combination with ipratropium bromide is not standard. - In a **life-threatening asthma exacerbation** with poor respiratory effort, **systemic (intravenous) magnesium sulphate** is the indicated adjunctive treatment, as nebulized delivery is less effective in this critical scenario.

Acute Paediatrics Flashcard 1 of 10

Question: What is the management of measles? _____ & school exclusion for 4 days after rash onset

Answer: Supportive care (e.g. fluids, simple analgesia, rest)

Acute Paediatrics Flashcard 2 of 10

Question: What is the mangement of a child's first febrile seizure, complex febrile seizure, or suspected CNS infection? _____

Answer: Seek paediatric opinion and assessment

Acute Paediatrics Flashcard 3 of 10

Question: _____ are seizures triggered by a fever (>38ºc)affecting children aged 6 months to 5 years in the absence of CNS infection

Answer: Febrile convulsions

Acute Paediatrics Flashcard 4 of 10

Question: Features of Threadworm infestation includes: _____ vulval symptoms

Answer: perianal itching (particularly at night)

Acute Paediatrics Flashcard 5 of 10

Question: What is the taxanomical name for Threadworms? _____

Answer: Enterobius vermicularis

Acute Paediatrics Flashcard 6 of 10

Question: Diagnosis of threadworms is made by applying _____ to the perianal area and sending it to the laboratory for microscopy to se the eggs

Answer: Sellotape

Acute Paediatrics Flashcard 7 of 10

Question: Management for Threadworms includes: _____ Anthelmintic with hygiene measures for all members of the household

Answer: Mebendazole

Acute Paediatrics Flashcard 8 of 10

Question: Threadworm infestation are asymptomatic in _____ of cases

Answer: 90%

Acute Paediatrics Flashcard 9 of 10

Question: Ostium Primum present earlier than _____

Answer: ostium secundum defects

Acute Paediatrics Flashcard 10 of 10

Question: The only exception of Aspirin use in under 16s is in _____

Answer: Kawasaki Disease