A 7-year-old girl with asthma presents to the emergency department with wheeze and breathlessness. She is on beclometasone 400 micrograms twice daily and uses salbutamol as needed. On examination, she has a respiratory rate of 28/min, heart rate 110/min, oxygen saturation 96% on air, and is able to complete full sentences. There is polyphonic expiratory wheeze throughout both lung fields. Peak expiratory flow is 65% of her predicted value. How should this exacerbation be classified and managed?
Q22
A 15-month-old child is brought to the GP with a 36-hour history of fever to 39.3°C and coryzal symptoms. The parents report the child had a brief episode this morning where they became stiff, their eyes rolled back, and their limbs jerked rhythmically for approximately 2 minutes. The child was drowsy afterwards for 10 minutes but has since returned to their usual self. Examination reveals a febrile child with temperature 38.6°C, clear chest, and normal neurological examination. What is the most appropriate management?
Q23
A 3-year-old boy presents with a 4-day history of fever ranging from 38.7°C to 40.1°C. He has bilateral non-purulent conjunctivitis, erythematous cracked lips, a polymorphous rash on his trunk, and mild cervical lymphadenopathy. His hands and feet appear oedematous and erythematous. Blood tests reveal WCC 17.5 × 10⁹/L with neutrophilia, CRP 145 mg/L, ESR 88 mm/hr, albumin 28 g/L, and platelet count 580 × 10⁹/L. What is the most important immediate investigation to perform?
Q24
A 10-month-old infant with bronchiolitis has been admitted for observation. On assessment, the respiratory rate is 65/min, oxygen saturation 90% on air, with moderate subcostal and intercostal recession. The infant is alert, taking 30% of normal feeds orally, and has passed adequate urine. Which of the following represents the most appropriate immediate management?
Q25
A 2-year-old girl presents with a 3-day history of fever up to 39.8°C. She has been increasingly irritable and refusing to bear weight on her right leg for the past 24 hours. On examination, her temperature is 38.9°C, heart rate 145/min. She has marked tenderness and restricted range of movement of the right hip with pain on passive movement. There is no overlying erythema or swelling. Blood tests show WCC 16.2 × 10⁹/L, CRP 78 mg/L, ESR 62 mm/hr. What is the most appropriate next investigation?
Q26
What is the recommended first-line add-on therapy for a 7-year-old child with asthma who remains poorly controlled on a paediatric low-dose inhaled corticosteroid (beclometasone 200 micrograms daily equivalent)?
Q27
A 4-month-old infant presents to the emergency department with a 2-hour history of fever reaching 38.9°C. The baby was born at term with no perinatal complications and has been well until now. On examination, the infant is alert, feeding normally, has good peripheral perfusion, and no focal signs are identified. Capillary refill time is 2 seconds. The parents are concerned but the baby appears comfortable. What is the most appropriate immediate management?
Q28
A 10-month-old infant born at 32 weeks gestation with chronic lung disease presents with a 3-day history of coryzal symptoms, followed by rapid onset of respiratory distress. Examination shows respiratory rate 68/min, heart rate 162/min, oxygen saturation 88% on air, temperature 37.8°C, marked subcostal and intercostal recession, grunting, and bilateral fine crepitations with wheeze. He is taking only half his usual feeds. What is the single most important immediate management priority?
Q29
A 3-year-old girl with asthma on beclometasone 200 micrograms twice daily presents with acute wheeze. She receives salbutamol nebuliser and oral prednisolone in the emergency department. One hour after treatment, she has oxygen saturation 96% on air, respiratory rate 28/min, heart rate 110/min, and can speak in full sentences with occasional wheeze audible. What is the most appropriate management plan?
Q30
A 16-month-old child presents with a 5-day history of fever peaking at 40.3°C, extreme irritability, and refusal to walk. Examination reveals bilateral bulbar conjunctival injection without discharge, strawberry tongue, erythema and oedema of hands and feet, a polymorphous rash, and right-sided cervical lymphadenopathy >1.5 cm. Initial echocardiogram shows small coronary artery ectasia (Z-score +2.8). She has received one dose of IVIG 2 g/kg. After 48 hours, she remains febrile at 39.1°C. What is the most appropriate next management step?
Acute Paediatrics UK Medical PG Practice Questions and MCQs
Question 21: A 7-year-old girl with asthma presents to the emergency department with wheeze and breathlessness. She is on beclometasone 400 micrograms twice daily and uses salbutamol as needed. On examination, she has a respiratory rate of 28/min, heart rate 110/min, oxygen saturation 96% on air, and is able to complete full sentences. There is polyphonic expiratory wheeze throughout both lung fields. Peak expiratory flow is 65% of her predicted value. How should this exacerbation be classified and managed?
A. Acute severe asthma - give high-flow oxygen, nebulised salbutamol, ipratropium bromide, and oral prednisolone
B. Moderate acute asthma - give salbutamol via spacer (10 puffs) and oral prednisolone, observe for 1 hour (Correct Answer)
C. Life-threatening asthma - give high-flow oxygen, continuous nebulised salbutamol, ipratropium, IV magnesium sulphate, and call ICU
D. Moderate acute asthma - give salbutamol via spacer (10 puffs), observe for 1 hour, discharge if improved
E. Acute severe asthma - give high-flow oxygen, nebulised salbutamol, oral prednisolone, and prepare for possible escalation
Explanation: ***Moderate acute asthma - give salbutamol via spacer (10 puffs) and oral prednisolone, observe for 1 hour***
- This patient is classified as having **moderate acute asthma** because she is able to **complete full sentences**, has **oxygen saturations ≥92%** (96%), and a **PEFR >50%** (65%).
- Management for moderate exacerbations in children involves using a **pressurized metered-dose inhaler (pMDI) with a spacer** for bronchodilation and a course of **oral prednisolone** to reduce airway inflammation.
*Acute severe asthma - give high-flow oxygen, nebulised salbutamol, ipratropium bromide, and oral prednisolone*
- This classification is incorrect as **severe asthma** typically presents with a **PEFR 33-50%**, inability to complete sentences, or a heart rate >125/min (for children over 5).
- **Nebulized therapy** and **ipratropium bromide** are escalated treatments reserved for patients who meet severe criteria or fail to respond to initial treatment.
*Life-threatening asthma - give high-flow oxygen, continuous nebulised salbutamol, ipratropium, IV magnesium sulphate, and call ICU*
- **Life-threatening** features such as **SpO2 <92%**, **silent chest**, cyanosis, exhaustion, or **PEFR <33%** are absent in this case.
- Intervention with **IV magnesium sulphate** and ICU consultation is only indicated for patients with deteriorating clinical status or persistent severe symptoms.
*Moderate acute asthma - give salbutamol via spacer (10 puffs), observe for 1 hour, discharge if improved*
- While the classification of moderate acute asthma is correct, this option is incomplete as it lacks the essential administration of **oral prednisolone**.
- **Oral corticosteroids** are mandatory in the management of acute moderate asthma to prevent **late-phase relapse** and improve recovery rates.
*Acute severe asthma - give high-flow oxygen, nebulised salbutamol, oral prednisolone, and prepare for possible escalation*
- This patient does not meet the **severe asthma** thresholds, specifically maintaining a **heart rate <125/min** and **respiratory rate <30/min** (for a 7-year-old).
- High-flow **oxygen** is unnecessary in this scenario as the patient's saturations are stable at **96% on air**.
Question 22: A 15-month-old child is brought to the GP with a 36-hour history of fever to 39.3°C and coryzal symptoms. The parents report the child had a brief episode this morning where they became stiff, their eyes rolled back, and their limbs jerked rhythmically for approximately 2 minutes. The child was drowsy afterwards for 10 minutes but has since returned to their usual self. Examination reveals a febrile child with temperature 38.6°C, clear chest, and normal neurological examination. What is the most appropriate management?
A. Arrange urgent hospital admission for investigation including lumbar puncture
B. Prescribe rectal diazepam to be used if further seizure lasts more than 5 minutes and provide safety-netting advice (Correct Answer)
C. Arrange urgent CT brain scan
D. Prescribe prophylactic daily anticonvulsant medication
E. Refer to paediatric neurology for EEG
Explanation: ***Prescribe rectal diazepam to be used if further seizure lasts more than 5 minutes and provide safety-netting advice***
- This child presented with a **simple febrile seizure** (generalized, <15 minutes, single episode in 24 hours), which is common and benign in children aged **6 months to 5 years**.
- Standard management involves **reassurance**, education on fever management, and providing **rescue medication** like rectal diazepam or buccal midazolam for prolonged future episodes.
*Arrange urgent hospital admission for investigation including lumbar puncture*
- Admission and **lumbar puncture** are not indicated for a simple febrile seizure in a child who has fully recovered and shows no signs of **meningism** or sepsis.
- This child has a clear viral source (**coryzal symptoms**) and a **normal neurological examination**, making intracranial infection highly unlikely.
*Arrange urgent CT brain scan*
- **Neuroimaging** is not routinely recommended for simple febrile seizures as they do not indicate underlying **structural brain abnormalities**.
- A scan would only be considered if there were persistent focal neurological deficits or signs of **raised intracranial pressure**.
*Prescribe prophylactic daily anticonvulsant medication*
- **Prophylactic anticonvulsants** are not indicated for simple febrile seizures because they have significant side effects and do not prevent future epilepsy.
- The risks of daily medication outweigh the benefits for a **benign, self-limiting condition** with an excellent long-term prognosis.
*Refer to paediatric neurology for EEG*
- An **EEG** is not useful in the routine workup of simple febrile seizures as it does not predict the recurrence of seizures or the risk of **epilepsy**.
- Referral is usually reserved for **complex febrile seizures** (focal, >15 minutes, or multiple episodes) or if there is developmental regression.
Question 23: A 3-year-old boy presents with a 4-day history of fever ranging from 38.7°C to 40.1°C. He has bilateral non-purulent conjunctivitis, erythematous cracked lips, a polymorphous rash on his trunk, and mild cervical lymphadenopathy. His hands and feet appear oedematous and erythematous. Blood tests reveal WCC 17.5 × 10⁹/L with neutrophilia, CRP 145 mg/L, ESR 88 mm/hr, albumin 28 g/L, and platelet count 580 × 10⁹/L. What is the most important immediate investigation to perform?
A. Throat swab for bacterial culture
B. Blood culture and viral PCR panel
C. Chest X-ray and ECG
D. Echocardiography (Correct Answer)
E. Lumbar puncture
Explanation: ***Echocardiography***- The patient presents with clinical features of **Kawasaki disease**, including high fever, **conjunctivitis**, **cracked lips**, **extremity oedema**, and **polymorphous rash**; echocardiography is vital to screen for **coronary artery aneurysms**.- It serves as the baseline assessment for cardiac function and helps identify early **myocarditis** or pericardial effusion, which significantly impacts prognosis.*Throat swab for bacterial culture*- While useful to rule out **Scarlet fever**, this investigation does not address the primary life-threatening complications of the clinical picture presented.- **Kawasaki disease** is a clinical diagnosis and is not confirmed or excluded by the presence or absence of a bacterial throat infection.*Blood culture and viral PCR panel*- These tests are often performed to investigate **fever of unknown origin**, but they will not provide the immediate structural cardiac assessment needed here.- Elevated **inflammatory markers** (CRP, ESR, Neutrophilia) and **thrombocytosis** in this context point towards an inflammatory vasculitis rather than a simple viral or bacterial infection.*Chest X-ray and ECG*- An **ECG** is a supportive test that can show tachycardia or arrhythmia, but it lacks the sensitivity of **echocardiography** to visualize the **coronary arteries**.- A **chest X-ray** may show cardiomegaly if heart failure is present, but it is not the most important immediate tool for diagnosing specific vascular complications.*Lumbar puncture*- This is primarily used to investigate **meningitis** or **sepsis**, which can present with fever and rash, but the specific mucocutaneous findings here suggest a different pathology.- Performing a lumbar puncture would delay the critical **cardiac imaging** and the initiation of **IVIG** therapy required for Kawasaki disease.
Question 24: A 10-month-old infant with bronchiolitis has been admitted for observation. On assessment, the respiratory rate is 65/min, oxygen saturation 90% on air, with moderate subcostal and intercostal recession. The infant is alert, taking 30% of normal feeds orally, and has passed adequate urine. Which of the following represents the most appropriate immediate management?
A. Start supplemental oxygen via nasal cannula to maintain saturations above 92%
B. Insert nasogastric tube for feeding and start supplemental oxygen to maintain saturations above 92% (Correct Answer)
C. Commence high-flow humidified oxygen therapy via nasal cannula
D. Start nebulised salbutamol and reassess response
E. Commence CPAP (continuous positive airway pressure) ventilation
Explanation: ***Insert nasogastric tube for feeding and start supplemental oxygen to maintain saturations above 92%***- This infant meets the criteria for both **supplemental oxygen** (saturation <92%) and **fluid support** (oral intake <50% of normal) according to NICE guidelines for **bronchiolitis**.- **Nasogastric feeding** is the preferred method of hydration over IV fluids in these patients as it allows for continued use of the gut and is usually better tolerated.*Start supplemental oxygen via nasal cannula to maintain saturations above 92%*- While oxygen is necessary to treat the **hypoxia** (90% saturation), this approach fails to address the **inadequate oral intake** of only 30%.- Correct management must involve dual intervention when both **respiratory** and **hydration** thresholds are compromised.*Commence high-flow humidified oxygen therapy via nasal cannula*- **HFNC therapy** is generally reserved for patients who do not respond to standard low-flow oxygen or show signs of **looming respiratory failure**.- This infant is alert and has only moderate recession, making **standard supplemental oxygen** the more appropriate first-line respiratory support.*Start nebulised salbutamol and reassess response*- **Bronchodilators** like salbutamol are not recommended in the management of bronchiolitis because the underlying pathology is **airway edema** and mucus, not bronchospasm.- Clinical trials have shown that **salbutamol** does not significantly reduce the rate of hospitalization or the duration of stay.*Commence CPAP (continuous positive airway pressure) ventilation*- **CPAP** is an advanced intervention for infants with **impending respiratory failure**, exhaustion, or recurrent **apnea**.- This infant's clinical status (alert and moderate recession) does not yet justify the use of **non-invasive ventilation**.
Question 25: A 2-year-old girl presents with a 3-day history of fever up to 39.8°C. She has been increasingly irritable and refusing to bear weight on her right leg for the past 24 hours. On examination, her temperature is 38.9°C, heart rate 145/min. She has marked tenderness and restricted range of movement of the right hip with pain on passive movement. There is no overlying erythema or swelling. Blood tests show WCC 16.2 × 10⁹/L, CRP 78 mg/L, ESR 62 mm/hr. What is the most appropriate next investigation?
A. Plain radiograph of the hip followed by ultrasound if normal
B. MRI scan of the hip and femur
C. Urgent ultrasound of the hip followed by aspiration if effusion present (Correct Answer)
D. Blood culture and start empirical intravenous antibiotics immediately
E. CT scan of the pelvis and hip
Explanation: ***Urgent ultrasound of the hip followed by aspiration if effusion present***- The clinical presentation of high fever, refusal to bear weight, and elevated inflammatory markers (CRP 78 mg/L, ESR 62 mm/hr) strongly suggests **septic arthritis**, which is a medical emergency that requires prompt diagnosis and management.- **Urgent ultrasound** is the most sensitive and rapid investigation for detecting a hip joint **effusion** in a child, and if present, **aspiration** of the fluid is crucial for definitive diagnosis via cell count and culture before initiating targeted antibiotic therapy.*Plain radiograph of the hip followed by ultrasound if normal*- **Plain radiographs** are frequently normal in the early stages of septic arthritis and therefore should not delay more sensitive and urgent investigations like ultrasound.- While useful to exclude **fractures** or other bony pathologies, they cannot definitively rule out an infected joint space, making them a less appropriate first step when septic arthritis is highly suspected.*MRI scan of the hip and femur*- **MRI** is highly sensitive for detecting early osteomyelitis and soft tissue changes, but it is a time-consuming procedure and often requires **sedation** in a 2-year-old, delaying immediate diagnosis and intervention for septic arthritis.- It is not the practical first-line emergency investigation for suspected **septic arthritis** when rapid assessment and intervention (like joint aspiration) are paramount and ultrasound is readily available.*Blood culture and start empirical intravenous antibiotics immediately*- While **blood cultures** and **empirical intravenous antibiotics** are essential components of managing suspected septic arthritis, the most critical step is to obtain a **synovial fluid sample** through aspiration to identify the causative pathogen.- Initiating antibiotics without first collecting joint fluid cultures can significantly reduce the diagnostic yield, making **aspiration** a priority before empirical treatment, unless the patient is critically unstable.*CT scan of the pelvis and hip*- **CT scans** are generally not indicated as a first-line investigation for suspected septic arthritis in children due to significant **radiation exposure** and inferior soft tissue detail compared to ultrasound or MRI for joint effusions.- Furthermore, CT does not provide the therapeutic and diagnostic benefit of **joint aspiration**, which is crucial for managing an infected hip joint.
Question 26: What is the recommended first-line add-on therapy for a 7-year-old child with asthma who remains poorly controlled on a paediatric low-dose inhaled corticosteroid (beclometasone 200 micrograms daily equivalent)?
A. Increase inhaled corticosteroid to moderate dose
B. Add a leukotriene receptor antagonist (Correct Answer)
C. Add a long-acting beta-2 agonist
D. Add theophylline
E. Add oral prednisolone maintenance therapy
Explanation: ***Add a leukotriene receptor antagonist***
- According to **NICE guidelines** for children aged 5–16 years, if asthma is uncontrolled on **low-dose ICS**, the next step is adding a **leukotriene receptor antagonist (LTRA)** like **montelukast**.
- This approach is prioritized in this age group to improve control before introducing long-acting bronchodilators or increasing steroid doses.
*Increase inhaled corticosteroid to moderate dose*
- Increasing to a **moderate dose ICS** is typically reserved for children who remain uncontrolled even after trials of **add-on therapies** like LTRAs or LABAs.
- Routine escalation of steroids is avoided early in children to minimize the risk of **systemic side effects** such as growth suppression.
*Add a long-acting beta-2 agonist*
- While previously recommended first-line, current **NICE guidance** for this age group suggests a trial of an **LTRA** before adding a **long-acting beta-2 agonist (LABA)**.
- If an LTRA is ineffective or not tolerated, the clinical pathway then moves toward **LABA therapy** in combination with ICS.
*Add theophylline*
- **Theophylline** is considered a **fourth-line** or specialist-initiated therapy for severe asthma that is refractory to standard treatments.
- It requires **therapeutic drug monitoring** due to its narrow therapeutic index and significant side-effect profile.
*Add oral prednisolone maintenance therapy*
- **Oral prednisolone maintenance** is the final step in the management ladder, used only for **severe, refractory asthma**.
- This treatment is managed exclusively by **specialist pediatric respiratory clinics** due to the high risk of adrenal suppression and other long-term steroid complications.
Question 27: A 4-month-old infant presents to the emergency department with a 2-hour history of fever reaching 38.9°C. The baby was born at term with no perinatal complications and has been well until now. On examination, the infant is alert, feeding normally, has good peripheral perfusion, and no focal signs are identified. Capillary refill time is 2 seconds. The parents are concerned but the baby appears comfortable. What is the most appropriate immediate management?
A. Discharge home with safety-netting advice and paracetamol as needed
B. Perform a full septic screen including blood culture, urine culture, and lumbar puncture, then start intravenous antibiotics (Correct Answer)
C. Observe in hospital for 4 hours with repeat observations and reassess before discharge
D. Prescribe oral antibiotics and arrange follow-up in 24 hours
E. Perform blood tests including full blood count, C-reactive protein, and blood culture, then await results
Explanation: ***Perform a full septic screen including blood culture, urine culture, and lumbar puncture, then start intravenous antibiotics***- According to **NICE guidelines (NG143)**, infants 3-6 months with a temperature ≥39°C are at high risk for **serious bacterial infection (SBI)**, even if appearing well.- Despite appearing comfortable, these infants require a mandatory **septic screen** and immediate **intravenous antibiotics** because they can deteriorate rapidly and clinical signs of meningitis or sepsis are often subtle.*Discharge home with safety-netting advice and paracetamol as needed*- Discharging a febrile infant of this age without investigations is unsafe due to the risk of **occult bacteremia** and **meningitis**.- Home management is only appropriate for older children with a **low-risk (green)** traffic light classification and an identifiable focus of infection.*Observe in hospital for 4 hours with repeat observations and reassess before discharge*- Observation alone is insufficient for an infant in this age group with a high fever as it delays the diagnosis and treatment of potential **serious bacterial infection**.- Clinical appearance is often an unreliable indicator of health status in **young febrile infants**, who can mask severe illness.*Prescribe oral antibiotics and arrange follow-up in 24 hours*- **Oral antibiotics** are inappropriate for initial management when **serious bacterial infection** is a concern in an infant under 6 months old.- Management must involve **parenteral antibiotics** (usually intravenous) until cultures return negative or a specific focus is identified.*Perform blood tests including full blood count, C-reactive protein, and blood culture, then await results*- Awaiting laboratory results before starting treatment is incorrect as it introduces dangerous delays in treating potential **sepsis** or **meningitis**.- **Empirical intravenous antibiotics** must be administered immediately after the septic screen samples are obtained in this high-risk age group.
Question 28: A 10-month-old infant born at 32 weeks gestation with chronic lung disease presents with a 3-day history of coryzal symptoms, followed by rapid onset of respiratory distress. Examination shows respiratory rate 68/min, heart rate 162/min, oxygen saturation 88% on air, temperature 37.8°C, marked subcostal and intercostal recession, grunting, and bilateral fine crepitations with wheeze. He is taking only half his usual feeds. What is the single most important immediate management priority?
A. Provide supplemental oxygen to maintain saturations ≥92% (Correct Answer)
B. Commence nasogastric feeding to maintain hydration and nutrition
C. Administer trial of nebulised salbutamol
D. Obtain nasopharyngeal aspirate for RSV testing
E. Commence intravenous antibiotics for suspected bacterial pneumonia
Explanation: ***Provide supplemental oxygen to maintain saturations ≥92%***- The infant presents with severe **hypoxia (88% oxygen saturation)** and marked **respiratory distress**, making immediate **oxygen supplementation** the most critical priority to prevent respiratory failure.- Given the history of prematurity and **chronic lung disease**, this infant is at high risk for severe bronchiolitis, and maintaining oxygen saturations **≥92%** is crucial as per current guidelines.*Commence nasogastric feeding to maintain hydration and nutrition*- While the infant is taking only **half of the usual feeds**, addressing the life-threatening **hypoxia** and respiratory compromise takes absolute precedence over nutritional support.- Initiating **nasogastric feeding** in a severely dyspneic infant carries a risk of aspiration and can further increase respiratory effort, which is contraindicated before respiratory stabilization.*Administer trial of nebulised salbutamol*- Clinical evidence overwhelmingly shows that **bronchodilators** like salbutamol are largely ineffective in **bronchiolitis**, as the pathology is primarily inflammation and edema of the small airways, not bronchospasm.- Routine use of **salbutamol** is therefore not recommended in standard guidelines for infants presenting with bronchiolitis.*Obtain nasopharyngeal aspirate for RSV testing*- While identifying the viral etiology (e.g., **RSV**) through a **nasopharyngeal aspirate** is useful for infection control and surveillance, it is not an immediate therapeutic intervention.- This diagnostic step should not delay the **stabilization** of the patient's airway and breathing, which is the immediate management priority.*Commence intravenous antibiotics for suspected bacterial pneumonia*- The clinical picture of preceding **coryzal symptoms**, followed by rapid onset of respiratory distress with **wheeze** and **crepitations**, is highly characteristic of **viral bronchiolitis**.- **Antibiotics** are not indicated for viral infections and should only be considered if there is strong evidence of a **secondary bacterial infection**, such as persistent high fever or specific radiographic findings suggestive of pneumonia.
Question 29: A 3-year-old girl with asthma on beclometasone 200 micrograms twice daily presents with acute wheeze. She receives salbutamol nebuliser and oral prednisolone in the emergency department. One hour after treatment, she has oxygen saturation 96% on air, respiratory rate 28/min, heart rate 110/min, and can speak in full sentences with occasional wheeze audible. What is the most appropriate management plan?
A. Discharge immediately without follow-up as symptoms have resolved
B. Increase beclometasone to 400 micrograms twice daily and discharge
C. Discharge home with advice to continue salbutamol 4-6 hourly and complete 3-day course of prednisolone (Correct Answer)
D. Admit for overnight observation and continue nebulised salbutamol 4-hourly
E. Observe for a further 2 hours and repeat salbutamol nebuliser before discharge
Explanation: ***Discharge home with advice to continue salbutamol 4-6 hourly and complete 3-day course of prednisolone***
- The patient shows signs of a **good clinical response** following treatment, including **SpO2 ≥94%**, normal respiratory rate for her age, and ability to speak in **full sentences**.
- Standard management for resolving acute asthma involves finishing a **3-day course of prednisolone** and weaning **salbutamol via a spacer** to prevent early relapse.
*Discharge immediately without follow-up as symptoms have resolved*
- Immediate discharge without a clear **management plan** or follow-up is unsafe; patients require a **GP review within 2 working days** after an acute exacerbation.
- Neglecting the completion of **oral corticosteroids** significantly increases the risk of a rebound exacerbation.
*Increase beclometasone to 400 micrograms twice daily and discharge*
- Adjustments to **preventer therapy (ICS)** are usually made at a follow-up appointment after investigating the patient's usual **asthma control** and technique.
- Doubling the dose of inhaled steroids is no longer recommended as an acute strategy during the **exacerbation recovery phase** over oral steroids.
*Admit for overnight observation and continue nebulised salbutamol 4-hourly*
- Admission is not indicated because the child is **hemodynamically stable**, maintains **saturations >94% on air**, and does not require frequent nebulizers.
- **BTS/SIGN guidelines** allow for discharge if the patient is stable for at least **one hour** post-treatment and the parents can manage at home.
*Observe for a further 2 hours and repeat salbutamol nebuliser before discharge*
- Further **observation** is unnecessary as the child has already met clinical stability criteria and can transition to **spacer-delivered salbutamol**.
- Repeated **nebulization** is not required for a child who is clinically well and able to speak in full sentences with minimal wheezing.
Question 30: A 16-month-old child presents with a 5-day history of fever peaking at 40.3°C, extreme irritability, and refusal to walk. Examination reveals bilateral bulbar conjunctival injection without discharge, strawberry tongue, erythema and oedema of hands and feet, a polymorphous rash, and right-sided cervical lymphadenopathy >1.5 cm. Initial echocardiogram shows small coronary artery ectasia (Z-score +2.8). She has received one dose of IVIG 2 g/kg. After 48 hours, she remains febrile at 39.1°C. What is the most appropriate next management step?
A. Start intravenous methylprednisolone 30 mg/kg/day for 3 days
B. Increase aspirin dose to 100 mg/kg/day in divided doses
C. Add oral ciclosporin and continue high-dose aspirin
D. Administer a second dose of IVIG 2 g/kg (Correct Answer)
E. Give infliximab 5 mg/kg as a single infusion
Explanation: ***Administer a second dose of IVIG 2 g/kg***
- This patient meets criteria for **refractory Kawasaki disease**, defined by persistent or recrudescent fever at least 36–48 hours after the initial **IVIG** infusion.
- A **second dose of IVIG** (2 g/kg) is the standard recommended first-line therapy for IVIG resistance to reduce the risk of further **coronary artery ectasia**.
*Start intravenous methylprednisolone 30 mg/kg/day for 3 days*
- While **pulse steroids** are used in refractory cases, they are typically reserved for patients who fail a second dose of IVIG or as an adjunct in very high-risk situations.
- Current guidelines prioritize a repeat of the **IVIG** before escalating to high-dose systemic corticosteroids in most treatment algorithms.
*Increase aspirin dose to 100 mg/kg/day in divided doses*
- High-dose **aspirin** has anti-inflammatory properties but does not independently resolve **IVIG resistance** or reduce the incidence of **coronary artery abnormalities**.
- Management focuses on immunomodulation rather than simply increasing salicylate dosage, which also carries a risk of **Reye syndrome** or toxicity.
*Add oral ciclosporin and continue high-dose aspirin*
- **Ciclosporin** is an immunosuppressant typically reserved for highly refractory cases or specialized rescue therapy, not as the immediate next step.
- It is not considered first-line for **IVIG-resistant** Kawasaki disease until more established therapies have failed.
*Give infliximab 5 mg/kg as a single infusion*
- **Infliximab** (a TNF-alpha inhibitor) is an effective alternative for refractory disease, but it is generally considered after or alongside a second dose of **IVIG**.
- Although some centers use it earlier in high-risk patients, repeat **IVIG** remains the most widely accepted and conventional next management step.
