A 5-year-old girl with asthma presents to the emergency department with wheeze and breathlessness that started 4 hours ago. She uses a salbutamol inhaler as required. On examination, she is speaking in sentences, respiratory rate is 32 breaths/minute, heart rate 115 bpm, oxygen saturation 94% on air. She has widespread polyphonic wheeze throughout both lung fields. Peak expiratory flow rate is 65% of her predicted value. What is the most appropriate initial management?
Q112
A 3-year-old boy presents with fever of 39.4°C for 48 hours. His mother reports he has been drinking less than usual but is still passing urine. On examination, he is alert and interactive. Heart rate is 130 bpm, respiratory rate 28 breaths/minute, capillary refill time 2 seconds centrally. He has bilateral cervical lymphadenopathy and an erythematous throat with white exudate on the tonsils. A rapid antigen detection test for Group A Streptococcus is positive. What is the most appropriate management?
Q113
A 14-month-old child presents with a 24-hour history of fever to 39.1°C and irritability. The parents report the child has had decreased wet nappies. On examination, the child is alert but irritable, temperature 38.7°C, heart rate 155 bpm, respiratory rate 38/min, capillary refill time 2 seconds. Fontanelle is normal. Chest is clear, no rash, throat appears normal, and ears are normal. A urine sample obtained by clean catch shows: leucocytes +, nitrites negative, protein trace. What is the most appropriate next management step?
Q114
A 4-year-old boy presents with fever of 38.2°C, cough, and increased work of breathing. On examination, he has respiratory rate 45/min, heart rate 125 bpm, oxygen saturations 94% on air, and widespread expiratory wheeze. The mother reports he has never wheezed before. He has a background of eczema and the family history includes maternal asthma. The GP started him on salbutamol inhaler yesterday with minimal improvement. What best explains the most appropriate underlying pathophysiological classification of his wheeze?
Q115
A 9-year-old girl with known asthma presents with acute breathlessness and wheeze. She is unable to complete sentences, has a respiratory rate of 38/min, heart rate 135 bpm, and oxygen saturations of 90% on air. She is started on high-flow oxygen, back-to-back salbutamol and ipratropium nebulisers, and oral prednisolone. Peak flow cannot be measured reliably due to poor effort. She has had two previous admissions to PICU for asthma. What additional factor most significantly increases her risk of a fatal asthma attack?
Q116
A 20-month-old child presents with a 4-day history of fever up to 39.7°C. On examination, there is bilateral non-purulent conjunctivitis, a maculopapular rash on the trunk and limbs, strawberry tongue, and indurated swelling of both hands and feet. Blood tests show: WBC 18.5 × 10⁹/L, neutrophils 14.2 × 10⁹/L, CRP 145 mg/L, ESR 78 mm/hr, albumin 32 g/L, ALT 65 U/L, platelets 298 × 10⁹/L. There is no cervical lymphadenopathy. How should this patient be classified and managed?
Q117
An 8-year-old boy presents to the emergency department with acute asthma. He has respiratory rate 35/min, oxygen saturations 93% on air, heart rate 125 bpm, and peak flow 55% of his best. He is speaking in short phrases. He receives back-to-back salbutamol and ipratropium nebulisers with oxygen, and oral prednisolone. After 1 hour, his observations are: respiratory rate 32/min, oxygen saturations 94% on 2L oxygen, heart rate 118 bpm, peak flow 60% predicted. What is the most appropriate next step?
Q118
A 6-year-old girl presents with a 5-day history of fever (maximum 40.1°C), rash, bilateral non-purulent conjunctivitis, red cracked lips, and cervical lymphadenopathy. Echocardiography shows coronary artery dilation with Z-score of +3.5. She has already received one dose of intravenous immunoglobulin (IVIG) 2 g/kg 36 hours ago but remains febrile at 38.9°C. CRP remains elevated at 92 mg/L. What is the most appropriate next step in management?
Q119
A 3-year-old child with asthma is being assessed following an acute exacerbation that required hospital admission. The parents report that before this episode, the child was waking at night with cough 3-4 times per week and needed salbutamol inhaler most days. The child is currently on salbutamol as needed only. What is the most appropriate modification to the treatment plan according to BTS/SIGN guidance?
Q120
A 5-month-old infant is brought to the emergency department with fever of 38.8°C for 8 hours. The baby appears well, is feeding normally, and examination is entirely normal apart from the fever. A clean-catch urine sample shows: leucocytes ++, nitrites +, protein +, and blood +. The parents are anxious and want to take the baby home. What is the most appropriate management?
Acute Paediatrics UK Medical PG Practice Questions and MCQs
Question 111: A 5-year-old girl with asthma presents to the emergency department with wheeze and breathlessness that started 4 hours ago. She uses a salbutamol inhaler as required. On examination, she is speaking in sentences, respiratory rate is 32 breaths/minute, heart rate 115 bpm, oxygen saturation 94% on air. She has widespread polyphonic wheeze throughout both lung fields. Peak expiratory flow rate is 65% of her predicted value. What is the most appropriate initial management?
A. Administer 10 puffs of salbutamol via spacer, assess response after 15 minutes (Correct Answer)
B. Administer nebulised salbutamol 2.5mg with oxygen and oral prednisolone 20mg
C. Give oral prednisolone 20mg and reassess in 4 hours
D. Administer intravenous salbutamol and oral prednisolone 30mg
E. Give nebulised ipratropium bromide 250 micrograms as monotherapy
Explanation: ***Administer 10 puffs of salbutamol via spacer, assess response after 15 minutes***- This patient presents with a **moderate asthma exacerbation**, defined by PEFR >50%, ability to **speak in sentences**, and oxygen saturation ",=" 92%.- For moderate cases, **inhaled beta-2 agonists** (salbutamol) delivered via a **pressurized metered-dose inhaler (pMDI) and spacer** are as effective as nebulizers and are the gold standard for initial management.*Administer nebulised salbutamol 2.5mg with oxygen and oral prednisolone 20mg*- **Nebulized therapy** is specifically indicated for **severe** (e.g., PEFR <50%, saturations <92%, or inability to complete sentences) or life-threatening asthma.- While the prednisolone dose is correct for her age, the delivery method of salbutamol via **oxygen-driven nebulization** is unnecessary for a moderate exacerbation.*Give oral prednisolone 20mg and reassess in 4 hours*- Waiting four hours for reassessment without providing an immediate **bronchodilator** is unsafe and does not address the patient's current **polyphonic wheeze**.- While **oral corticosteroids** are essential to reduce airway inflammation, they take several hours to act and must be paired with immediate-acting **bronchodilation**.*Administer intravenous salbutamol and oral prednisolone 30mg*- **Intravenous salbutamol** is a high-level intervention reserved for **life-threatening asthma** that has failed to respond to continuous nebulized treatment.- The dose of **prednisolone 30mg** is typically reserved for children older than 5 years; for a 5-year-old child, **20mg** is the standard dose.*Give nebulised ipratropium bromide 250 micrograms as monotherapy*- **Ipratropium bromide** should never be used as **monotherapy** in acute asthma flares as it is less effective than beta-2 agonists.- It is typically added to salbutamol only in **severe or life-threatening** exacerbations to provide additional bronchodilation via a different pathway.
Question 112: A 3-year-old boy presents with fever of 39.4°C for 48 hours. His mother reports he has been drinking less than usual but is still passing urine. On examination, he is alert and interactive. Heart rate is 130 bpm, respiratory rate 28 breaths/minute, capillary refill time 2 seconds centrally. He has bilateral cervical lymphadenopathy and an erythematous throat with white exudate on the tonsils. A rapid antigen detection test for Group A Streptococcus is positive. What is the most appropriate management?
A. Administer intravenous fluids and await blood culture results before starting antibiotics
B. Prescribe oral phenoxymethylpenicillin for 10 days and provide safety-netting advice (Correct Answer)
C. Admit for intravenous benzylpenicillin due to decreased oral intake
D. Prescribe oral amoxicillin and arrange follow-up in 48 hours
E. Advise symptomatic treatment only as most cases resolve spontaneously
Explanation: ***Prescribe oral phenoxymethylpenicillin for 10 days and provide safety-netting advice***- The child's presentation (fever, cervical lymphadenopathy, exudative tonsillitis) with a **positive rapid antigen detection test for Group A Streptococcus (GAS)** confirms **streptococcal pharyngitis**. **Oral phenoxymethylpenicillin (Penicillin V)** is the first-line antibiotic.- A **10-day course** is crucial for **GAS eradication** to prevent **acute rheumatic fever** and other **non-suppurative complications**. Safety-netting ensures parents know when to seek further medical attention.*Administer intravenous fluids and await blood culture results before starting antibiotics*- The child is **alert and interactive**, has a **capillary refill time of 2 seconds**, and is **passing urine**, indicating he is **well-perfused** and not requiring **intravenous fluids** for dehydration or shock.- For an uncomplicated, localized **streptococcal pharyngitis** in a stable child, **blood cultures** are not routinely indicated, and delaying antibiotics for results is inappropriate given the risk of **rheumatic fever**.*Admit for intravenous benzylpenicillin due to decreased oral intake*- Despite drinking less, the child shows no signs of **severe dehydration** or **systemic toxicity** requiring hospital admission or **intravenous antibiotics**. He is alert and interactive.- **Intravenous benzylpenicillin** is reserved for severe infections, inability to tolerate oral medications, or signs of **sepsis**, which are not present in this stable patient.*Prescribe oral amoxicillin and arrange follow-up in 48 hours*- While **amoxicillin** is effective against GAS, it is typically avoided for suspected streptococcal pharyngitis before confirmation, as it can cause a **maculopapular rash** if the underlying infection is **infectious mononucleosis (EBV)**.- A **10-day course** of antibiotics is standard for GAS; a 48-hour follow-up without specifying the full course is insufficient for eradication and prevention of complications.*Advise symptomatic treatment only as most cases resolve spontaneously*- Although many viral pharyngitis cases resolve spontaneously, a **confirmed positive rapid antigen test for Group A Streptococcus** necessitates antibiotic treatment.- **Antibiotic therapy** for GAS is essential not only to reduce the duration and severity of symptoms but, more importantly, to prevent serious **non-suppurative complications** like **acute rheumatic fever** and **post-streptococcal glomerulonephritis**.
Question 113: A 14-month-old child presents with a 24-hour history of fever to 39.1°C and irritability. The parents report the child has had decreased wet nappies. On examination, the child is alert but irritable, temperature 38.7°C, heart rate 155 bpm, respiratory rate 38/min, capillary refill time 2 seconds. Fontanelle is normal. Chest is clear, no rash, throat appears normal, and ears are normal. A urine sample obtained by clean catch shows: leucocytes +, nitrites negative, protein trace. What is the most appropriate next management step?
A. Discharge with safety-netting advice as nitrites are negative
B. Send urine for microscopy and culture; start oral antibiotics empirically (Correct Answer)
C. Admit for intravenous antibiotics pending urine culture
D. Repeat urine sample via catheter or suprapubic aspirate
E. Perform full septic screen including blood cultures and lumbar puncture
Explanation: ***Send urine for microscopy and culture; start oral antibiotics empirically***- In a 14-month-old child with fever, irritability, decreased wet nappies, and **positive leucocytes** on urine dipstick, a **Urinary Tract Infection (UTI)** is highly suspected, necessitating a definitive **urine culture**.- Given the child is alert, has a normal capillary refill time, and is over 3 months old, **oral antibiotics** are appropriate for empirical treatment while awaiting culture results, following general paediatric guidelines for uncomplicated UTIs.*Discharge with safety-netting advice as nitrites are negative*- **Negative nitrites** do not reliably rule out a UTI in young children, especially if they void frequently or if the infection is caused by organisms that do not reduce nitrates.- The presence of **leucocytes** and clinical symptoms such as fever, irritability, and decreased wet nappies indicates a likely infection that requires investigation and treatment, not just discharge.*Admit for intravenous antibiotics pending urine culture*- **Intravenous antibiotics** are generally reserved for infants younger than 3 months with fever, children who are systemically unwell (e.g., signs of sepsis), or those with suspected **pyelonephritis** and inability to tolerate oral intake.- This child is 14 months old and clinically stable (alert, CRT 2s), making empirical **oral antibiotics** a suitable first-line approach in the outpatient setting.*Repeat urine sample via catheter or suprapubic aspirate*- While catheterization or suprapubic aspirate yields the most accurate samples, a properly collected **clean catch** urine sample showing evidence of infection is sufficient to guide initial management in a non-critically ill child.- More invasive collection methods are typically reserved for situations where clean catch is impossible, a non-invasive sample is contaminated, or a rapid, definitive diagnosis is crucial in a severely unwell child.*Perform full septic screen including blood cultures and lumbar puncture*- A **full septic screen** (including blood cultures and lumbar puncture) is indicated for infants <3 months with fever or older children showing signs of severe sepsis, meningitis (e.g., bulging fontanelle, neck stiffness), or altered consciousness.- This child has a potential source of infection (UTI) and does not exhibit red flags for severe bacterial infection or meningitis, therefore, a full septic screen is not immediately warranted.
Question 114: A 4-year-old boy presents with fever of 38.2°C, cough, and increased work of breathing. On examination, he has respiratory rate 45/min, heart rate 125 bpm, oxygen saturations 94% on air, and widespread expiratory wheeze. The mother reports he has never wheezed before. He has a background of eczema and the family history includes maternal asthma. The GP started him on salbutamol inhaler yesterday with minimal improvement. What best explains the most appropriate underlying pathophysiological classification of his wheeze?
A. Multi-trigger wheeze due to multiple sensitisations and airway hyperresponsiveness (Correct Answer)
B. Episodic viral wheeze due to viral infection causing airway inflammation
C. Bronchiolitis due to respiratory syncytial virus infection
D. Foreign body aspiration causing unilateral wheeze and respiratory distress
E. Allergic asthma triggered by environmental allergen exposure
Explanation: ***Multi-trigger wheeze due to multiple sensitisations and airway hyperresponsiveness***
- The child's history of **eczema** and **maternal asthma** strongly indicates an underlying atopic predisposition and **airway hyperresponsiveness**, a key feature of this classification.
- This phenotype explains wheezing triggered by various stimuli (including viral infections, as suggested by fever and cough) and often represents a precursor to **asthma** in young children.
*Episodic viral wheeze due to viral infection causing airway inflammation*
- This classification is typically applied to children who **only wheeze during viral infections** and lack significant atopic features or a family history of asthma.
- The presence of **eczema** and **maternal asthma** in this patient suggests a more complex underlying predisposition than simple episodic viral wheeze.
*Bronchiolitis due to respiratory syncytial virus infection*
- **Bronchiolitis** primarily affects **infants under 12 months** of age, making it an unlikely diagnosis for a 4-year-old.
- While it causes wheeze, the typical age and overall clinical presentation in this case are more consistent with a **reactive airway disease** in an older child.
*Foreign body aspiration causing unilateral wheeze and respiratory distress*
- Foreign body aspiration usually presents with a **sudden onset** of symptoms and often causes a **unilateral wheeze** or focal signs, which are not present here.
- The patient's **fever** and **widespread expiratory wheeze** are inconsistent with mechanical obstruction and suggest a diffuse inflammatory process.
*Allergic asthma triggered by environmental allergen exposure*
- While the child has **atopic features**, the current episode is associated with **fever and cough**, indicating a **viral trigger** rather than purely environmental allergen exposure.
- **Multi-trigger wheeze** is a more comprehensive classification for a preschool child with atopic sensitization whose wheezing episodes are provoked by both infections and potentially allergens.
Question 115: A 9-year-old girl with known asthma presents with acute breathlessness and wheeze. She is unable to complete sentences, has a respiratory rate of 38/min, heart rate 135 bpm, and oxygen saturations of 90% on air. She is started on high-flow oxygen, back-to-back salbutamol and ipratropium nebulisers, and oral prednisolone. Peak flow cannot be measured reliably due to poor effort. She has had two previous admissions to PICU for asthma. What additional factor most significantly increases her risk of a fatal asthma attack?
A. Age over 8 years with poorly controlled asthma
B. Previous history of PICU admissions for asthma (Correct Answer)
C. Current inability to measure peak flow reliably
D. Presence of tachycardia above 125 bpm
E. Requirement for high-flow oxygen therapy
Explanation: ***Previous history of PICU admissions for asthma***- A history of **near-fatal asthma** or previous **PICU admission** is the most significant predictor of future risk for a fatal asthma attack.- This background indicates a phenotype of disease that is prone to **respiratory failure** and suggests a lower threshold for clinical deterioration.*Age over 8 years with poorly controlled asthma*- While poor control is a risk factor, specific **age thresholds** like being over 8 years are not as significant as the severity of previous exacerbations.- Clinical guidelines prioritize **asthma severity markers** and past life-threatening events over age when assessing fatality risk.*Current inability to measure peak flow reliably*- Inability to perform **peak expiratory flow (PEF)** is a marker of the severity of the **current acute episode**, categorizing it as life-threatening.- It does not carry the same long-term **prognostic weight** for mortality as a documented history of intensive care requirements.*Presence of tachycardia above 125 bpm*- Tachycardia (in this age group, >125 bpm) is a clinical sign used to classify an **acute severe asthma** attack.- While important for immediate management decisions, it is a **transient physiological response** rather than a longitudinal risk factor for death.*Requirement for high-flow oxygen therapy*- The need for oxygen reflects **hypoxia (SpO2 <92%)**, which is a criterion for **life-threatening asthma** in the acute setting.- It indicates the severity of the **presenting episode** but is not as strong an indicator of underlying fatal risk as prior **mechanical ventilation** or PICU care.
Question 116: A 20-month-old child presents with a 4-day history of fever up to 39.7°C. On examination, there is bilateral non-purulent conjunctivitis, a maculopapular rash on the trunk and limbs, strawberry tongue, and indurated swelling of both hands and feet. Blood tests show: WBC 18.5 × 10⁹/L, neutrophils 14.2 × 10⁹/L, CRP 145 mg/L, ESR 78 mm/hr, albumin 32 g/L, ALT 65 U/L, platelets 298 × 10⁹/L. There is no cervical lymphadenopathy. How should this patient be classified and managed?
A. Incomplete Kawasaki disease; treat with IVIG and aspirin immediately (Correct Answer)
B. Atypical viral infection; treat supportively and observe
C. Complete Kawasaki disease; treat with IVIG and aspirin immediately
D. Possible Kawasaki disease; await day 5 of fever before treatment
E. Drug reaction; stop any medications and give antihistamines
Explanation: ***Incomplete Kawasaki disease; treat with IVIG and aspirin immediately***
- The child presents with fever for 4 days and four out of five principal features (conjunctivitis, rash, oral changes, and extremity changes), but lacks **cervical lymphadenopathy**, fitting the criteria for **incomplete Kawasaki disease**.
- Highly elevated **inflammatory markers** (CRP 145 mg/L, ESR 78 mm/hr, leukocytosis, hypoalbuminemia) strongly support the diagnosis and necessitate immediate treatment with **IVIG and aspirin** to prevent **coronary artery aneurysms**.
*Atypical viral infection; treat supportively and observe*
- The specific constellation of symptoms, including **strawberry tongue**, **indurated hand and foot swelling**, and markedly elevated **inflammatory markers**, goes beyond what is typically seen in an atypical viral infection.
- Observing without treatment carries a significant risk of **cardiac complications**, which is unacceptable given the high suspicion for Kawasaki disease.
*Complete Kawasaki disease; treat with IVIG and aspirin immediately*
- **Complete Kawasaki disease** requires at least **5 days of fever** along with 4 out of 5 principal diagnostic criteria; this child has only had fever for 4 days.
- While the treatment approach (IVIG and aspirin) would be correct, the classification of **complete Kawasaki disease** is inaccurate based on the fever duration and number of criteria.
*Possible Kawasaki disease; await day 5 of fever before treatment*
- Given the significant clinical findings (4 criteria) and alarming **laboratory evidence** of systemic inflammation, the diagnosis is more than just
Question 117: An 8-year-old boy presents to the emergency department with acute asthma. He has respiratory rate 35/min, oxygen saturations 93% on air, heart rate 125 bpm, and peak flow 55% of his best. He is speaking in short phrases. He receives back-to-back salbutamol and ipratropium nebulisers with oxygen, and oral prednisolone. After 1 hour, his observations are: respiratory rate 32/min, oxygen saturations 94% on 2L oxygen, heart rate 118 bpm, peak flow 60% predicted. What is the most appropriate next step?
A. Discharge home with asthma action plan and steroid course
B. Transfer immediately to paediatric intensive care unit
C. Admit to paediatric ward for continued nebulised bronchodilators (Correct Answer)
D. Administer intravenous salbutamol infusion
E. Give intravenous aminophylline loading dose
Explanation: ***Admit to paediatric ward for continued nebulised bronchodilators***
- Admission is necessary because the patient still requires **supplemental oxygen** to maintain saturations and has a peak flow below **75% of predicted/best** after initial therapy.
- He remains in the **acute severe asthma** category despite initial nebulizers, requiring transition to a tapering schedule of **nebulised bronchodilators** (e.g., every 1
4 hours).
*Discharge home with asthma action plan and steroid course*
- Discharge is inappropriate as the child is still **oxy-dependent** and has not achieved a stable peak flow of >75% for at least 4 hours.
- Home management is only safe once the patient can maintain **saturations >94% on air** and has transitioned successfully to **spacer-delivered inhalers**.
*Transfer immediately to paediatric intensive care unit*
- PICU transfer is reserved for **life-threatening** features such as **silent chest**, cyanosis, exhaustion, or **SpO2 <92%** despite high-flow oxygen.
- This patient is **speaking in phrases** and shows a partial response to treatment, indicating he does not currently meet criteria for intensive care.
*Administer intravenous salbutamol infusion*
- **Intravenous salbutamol** is a second-line therapy for patients with **life-threatening asthma** or those failing to respond to repeated nebulized therapy.
- The patient is currently showing a **positive response** to nebulizers (improved peak flow and heart rate), so escalating to IV bronchodilators is not yet indicated.
*Give intravenous aminophylline loading dose*
- **Aminophylline** is typically considered in children who are **unresponsive** to repeated nebulized bronchodilators and IV magnesium sulfate.
- Due to its **narrow therapeutic index** and the patient
clinical improvement on standard therapy, it is not the most appropriate next step.
Question 118: A 6-year-old girl presents with a 5-day history of fever (maximum 40.1°C), rash, bilateral non-purulent conjunctivitis, red cracked lips, and cervical lymphadenopathy. Echocardiography shows coronary artery dilation with Z-score of +3.5. She has already received one dose of intravenous immunoglobulin (IVIG) 2 g/kg 36 hours ago but remains febrile at 38.9°C. CRP remains elevated at 92 mg/L. What is the most appropriate next step in management?
A. Administer second dose of IVIG 2 g/kg (Correct Answer)
B. Start oral aspirin at anti-inflammatory dose only
C. Give intravenous methylprednisolone
D. Commence infliximab therapy
E. Continue current management and observe for further 24 hours
Explanation: ***Administer second dose of IVIG 2 g/kg***
- This patient has **IVIG-resistant Kawasaki disease**, defined as persistent or recurrent fever at least **36 hours** after the completion of the initial IVIG infusion.
- Retreatment with a **second dose of IVIG** (2 g/kg) is the standard first-line recommendation to reduce the risk of further **coronary artery aneurysm** progression.
*Start oral aspirin at anti-inflammatory dose only*
- While aspirin is a component of Kawasaki management, it is primarily used for its **anti-thrombotic** and anti-inflammatory properties and cannot alone resolve **IVIG resistance**.
- Relying solely on aspirin in the presence of **coronary artery dilation** (Z-score +3.5) would be insufficient to prevent progressive vasculitis.
*Give intravenous methylprednisolone*
- Pulse **methylprednisolone** is often reserved as a second-line or third-line option if the patient fails to respond to a **second dose of IVIG**.
- Although used earlier in high-risk patients by some protocols, standard guidelines prioritize the **IVIG retreatment** before transitioning to systemic steroids.
*Commence infliximab therapy*
- **Infliximab** (a TNF-alpha inhibitor) is an effective adjunctive therapy for refractory cases but is typically used after **IVIG retreatment failure**.
- It is not the universal first step for initial resistance unless specific institutional protocols or contraindications to more IVIG exist.
*Continue current management and observe for further 24 hours*
- Delaying treatment in a child with **persistent fever** and a high **CRP** (92 mg/L) increases the risk of worsening **coronary artery lesions**.
- Observation is inappropriate once the 36-hour mark from the first IVIG dose has passed and the patient remains clinically symptomatic.
Question 119: A 3-year-old child with asthma is being assessed following an acute exacerbation that required hospital admission. The parents report that before this episode, the child was waking at night with cough 3-4 times per week and needed salbutamol inhaler most days. The child is currently on salbutamol as needed only. What is the most appropriate modification to the treatment plan according to BTS/SIGN guidance?
A. Add montelukast as the first-line preventer therapy
B. Start paediatric low-dose inhaled corticosteroid (Correct Answer)
C. Add long-acting beta-agonist to current therapy
D. Increase salbutamol to regular four times daily dosing
E. Start oral prednisolone maintenance therapy
Explanation: ***Start paediatric low-dose inhaled corticosteroid***
- Inhaled corticosteroids (ICS) are the **first-line preventer therapy** for children with symptoms requiring regular treatment or those who have had a recent **hospital admission** due to asthma.
- This child's symptoms (nocturnal cough 3-4 times/week, salbutamol most days) and recent hospitalization indicate **poorly controlled asthma**, necessitating daily controller therapy.
*Add montelukast as the first-line preventer therapy*
- **Leukotriene receptor antagonists (LTRAs)** like montelukast are generally considered **second-line** preventer therapy or an alternative for specific phenotypes, such as viral-induced wheeze, according to BTS/SIGN guidelines.
- While effective for some, **ICS** are more consistently efficacious and recommended as the initial controller medication for most children with persistent asthma.
*Add long-acting beta-agonist to current therapy*
- **Long-acting beta-agonists (LABAs)** should not be used as monotherapy and are typically added to **inhaled corticosteroids** if asthma remains uncontrolled on ICS alone.
- As the child is currently only on a short-acting beta-agonist (SABA) as needed, initiating a LABA without prior ICS is not in line with the **step-wise management** of asthma.
*Increase salbutamol to regular four times daily dosing*
- **Salbutamol** is a **short-acting reliever medication** and should only be used on an **as-needed basis** to alleviate acute symptoms.
- Regular, fixed-dose use of salbutamol does not address the underlying **airway inflammation** in asthma and is associated with poor disease control and increased risk of exacerbations.
*Start oral prednisolone maintenance therapy*
- **Oral corticosteroids** are reserved for the management of **severe refractory asthma** and for short courses during acute exacerbations.
- They are not appropriate for initial or routine maintenance therapy in a child with this presentation, particularly when **inhaled corticosteroids** have not been tried.
Question 120: A 5-month-old infant is brought to the emergency department with fever of 38.8°C for 8 hours. The baby appears well, is feeding normally, and examination is entirely normal apart from the fever. A clean-catch urine sample shows: leucocytes ++, nitrites +, protein +, and blood +. The parents are anxious and want to take the baby home. What is the most appropriate management?
A. Discharge with safety-netting advice and await urine culture results
B. Prescribe oral trimethoprim and arrange outpatient follow-up
C. Admit for intravenous antibiotics and full septic screen (Correct Answer)
D. Repeat urine sample to confirm the findings before treatment
E. Prescribe oral amoxicillin and arrange paediatric outpatient review
Explanation: ***Admit for intravenous antibiotics and full septic screen***
- For infants aged **3 to 6 months** who present with a **febrile urinary tract infection (UTI)**, guidelines recommend serious consideration for **hospital admission** and parenteral treatment.
- A **full septic screen** (including blood cultures) is required due to the increased risk of **bacteremia** and potential for rapid clinical deterioration in young infants.
*Discharge with safety-netting advice and await urine culture results*
- Discharging a young infant with a **positive dipstick** (leucocytes and nitrites) and fever is unsafe as it delays necessary treatment for a potential acute infection.
- Waiting for **culture results** without starting empiric therapy increases the risk of **renal scarring** and systemic sepsis in this age group.
*Prescribe oral trimethoprim and arrange outpatient follow-up*
- While oral antibiotics are used for older children, febrile infants under **6 months** often require **IV antibiotics** initially to ensure adequate serum levels.
- **Trimethoprim** has significant resistance rates and is not considered first-line for an empiric **febrile UTI** where parenteral therapy is indicated.
*Repeat urine sample to confirm the findings before treatment*
- The initial **clean-catch sample** was already positive for both **nitrites and leucocytes**, which has high specificity for a UTI.
- Delaying treatment to repeat the sample is unnecessary and risky given the infant's **pyrexia** and age.
*Prescribe oral amoxicillin and arrange paediatric outpatient review*
- **Amoxicillin** is generally avoided as empiric monotherapy due to high rates of **E. coli resistance**.
- Outpatient review is inappropriate for a febrile 5-month-old with suspected **pyelonephritis** or systemic involvement requiring urgent inpatient stabilization.
