A 4-year-old girl with asthma presents to the emergency department with an acute exacerbation. She has received three doses of salbutamol nebulisers and one dose of ipratropium bromide, alongside oral prednisolone. Two hours after initial treatment, she remains breathless with oxygen saturation of 91% on 15L oxygen via non-rebreathe mask, respiratory rate 45/min, and is now speaking only in words. She has reduced air entry bilaterally with poor respiratory effort. What is the next most appropriate treatment?
Q72
A 9-month-old infant presents with a 48-hour history of fever up to 39.8°C. The child appears miserable when examined but is consolable when picked up by the mother. Respiratory rate is 35/min, heart rate 145/min, and capillary refill time 2 seconds centrally. There is no rash, the chest is clear, tympanic membranes appear normal, and throat examination is unremarkable. Urine dipstick shows leucocytes 2+, nitrites positive, and trace protein. What is the most appropriate initial management?
Q73
A 7-year-old boy with known asthma presents to the emergency department with acute breathlessness and wheeze. His respiratory rate is 28/min, heart rate 115/min, and oxygen saturation 94% on room air. He is able to speak in sentences and has widespread polyphonic wheeze on auscultation. Peak expiratory flow is 65% of his predicted best. What is the most appropriate classification of this asthma exacerbation?
Q74
A 14-month-old child presents to the emergency department with a 6-day history of persistent fever (38.9-40.1°C daily). The parents report the child has been increasingly irritable with decreased activity and reduced oral intake. There is no cough, vomiting, diarrhoea, or rash. On examination, temperature 39.7°C, heart rate 158/min, respiratory rate 34/min, capillary refill time 2 seconds. The child appears miserable and irritable even when held by parents. There is bilateral non-purulent conjunctival injection, strawberry tongue, cracked lips, and a maculopapular rash on trunk and limbs. Hands and feet appear erythematous and swollen. No palpable lymphadenopathy. Which investigation finding would most strongly support the need for urgent echocardiography in this child?
Q75
An 8-year-old girl with known asthma presents with acute breathlessness after playing football. She uses her salbutamol inhaler 6 puffs via spacer with minimal improvement. On examination, she speaks in full sentences, respiratory rate 32/min, heart rate 118/min, oxygen saturation 95% in air. Chest examination reveals bilateral expiratory wheeze with good air entry. Peak expiratory flow rate (PEFR) is 165 L/min (65% of her predicted best). She receives 10 puffs of salbutamol via spacer. After 15 minutes, she feels better with PEFR improved to 210 L/min (82% of predicted). Understanding the pathophysiology of her condition, which mechanism best explains the immediate bronchodilator effect of salbutamol?
Q76
A 5-year-old girl presents to the emergency department with a 4-day history of high fever (maximum 40.2°C), lethargy, and reduced oral intake. She initially had a sore throat that has now resolved. On examination, temperature is 39.6°C, heart rate 142/min, respiratory rate 28/min, blood pressure 98/58 mmHg. She has shotty cervical lymphadenopathy, splenomegaly (3 cm below costal margin), and small petechiae on the soft palate. There is no tonsillar enlargement or exudate. Blood tests show: Hb 118 g/L, WCC 18.4 × 10⁹/L (lymphocytes 12.2 × 10⁹/L, with 35% atypical lymphocytes), platelets 168 × 10⁹/L, CRP 24 mg/L. Liver function tests show ALT 156 U/L, AST 142 U/L. What is the most likely diagnosis?
Q77
A 3-year-old boy is reviewed in the emergency department 30 minutes after presenting with acute wheeze. He has had two previous similar episodes associated with viral upper respiratory tract infections, both of which resolved with salbutamol. He is not on any regular medication. He received 10 puffs of salbutamol via spacer on arrival. Current observations: respiratory rate 36/min, heart rate 128/min, oxygen saturation 96% in air. He is talking in sentences, has mild expiratory wheeze, and no recession. His parents are confident in managing him at home. What is the most appropriate management plan for discharge?
Q78
A 10-month-old infant with a 2-day history of coryzal symptoms and cough is brought to hospital with increased work of breathing. Temperature is 37.8°C, respiratory rate 68/min, heart rate 162/min, oxygen saturation 93% in air. There is subcostal recession and bilateral fine inspiratory crackles with occasional wheeze. The infant is taking approximately 50% of normal feeds. A clinical diagnosis of bronchiolitis is made. Which of the following factors would be the strongest indication for admission to hospital in this infant?
Q79
A 13-month-old child presents with a 4-day history of persistent fever ranging from 38.8-39.9°C. The parents report no specific symptoms apart from irritability and reduced appetite. On examination, the child is miserable but consolable, temperature 39.3°C, heart rate 148/min, respiratory rate 32/min, capillary refill time 2 seconds. Examination reveals bilateral non-purulent conjunctivitis, dry cracked lips, and a polymorphous rash on the trunk. Cervical lymphadenopathy is noted with one node measuring 1.8 cm. Extremities show mild erythema of palms and soles. Blood tests reveal: Hb 102 g/L, WCC 16.8 × 10⁹/L, platelets 512 × 10⁹/L, CRP 98 mg/L, albumin 28 g/L. What is the most appropriate definitive treatment?
Q80
A 7-year-old boy with known moderate persistent asthma on beclometasone 400 micrograms twice daily and salmeterol presents with an acute severe exacerbation. He has received back-to-back salbutamol nebulisers with oxygen and oral prednisolone 30mg. After 15 minutes his oxygen saturation remains 90% in high-flow oxygen, respiratory rate is 44/min, heart rate 148/min, and he can only speak 2-3 words at a time. Chest examination shows poor air entry bilaterally with no wheeze audible. What is the single most important immediate next step?
Acute Paediatrics UK Medical PG Practice Questions and MCQs
Question 71: A 4-year-old girl with asthma presents to the emergency department with an acute exacerbation. She has received three doses of salbutamol nebulisers and one dose of ipratropium bromide, alongside oral prednisolone. Two hours after initial treatment, she remains breathless with oxygen saturation of 91% on 15L oxygen via non-rebreathe mask, respiratory rate 45/min, and is now speaking only in words. She has reduced air entry bilaterally with poor respiratory effort. What is the next most appropriate treatment?
A. Intravenous magnesium sulphate (Correct Answer)
B. Intravenous aminophylline infusion
C. Intravenous salbutamol infusion
D. Continue back-to-back nebulisers and reassess in 15 minutes
E. Prepare for intubation and mechanical ventilation
Explanation: ***Intravenous magnesium sulphate***- This patient demonstrates features of **life-threatening asthma**, including oxygen saturations **<92%** on high-flow oxygen, poor respiratory effort, and the ability to speak only in words.- According to **BTS/SIGN guidelines**, intravenous magnesium sulphate is the first-line intravenous therapy for children who do not respond to initial inhaled **bronchodilators and steroids**.*Intravenous aminophylline infusion*- This is generally considered a **second-line intravenous treatment** and is added if magnesium sulphate or salbutamol infusions fail to show improvement.- It requires careful **therapeutic drug monitoring** due to its narrow therapeutic index and significant cardiovascular side effects.*Intravenous salbutamol infusion*- IV salbutamol is usually reserved as a **third-line escalation** or an alternative when magnesium sulphate is ineffective or there is a rapid decline.- It carries a risk of **tachycardia** and **electrolyte imbalances** (hypokalaemia), making earlier interventions like magnesium sulphate preferable.*Continue back-to-back nebulisers and reassess in 15 minutes*- This patient already presents with **reduced air entry** and poor effort, indicating that inhaled medication is likely not reaching the distal airways effectively.- Delaying escalation in the presence of **life-threatening features** and failing oxygen levels significantly increases the risk of respiratory arrest.*Prepare for intubation and mechanical ventilation*- While PICU should be alerted and preparations made, medical therapy with **IV bronchodilators** should be attempted first unless there is imminent respiratory collapse.- **Mechanical ventilation** in asthma is technically difficult and high-risk due to air-trapping, making it a last-resort intervention.
Question 72: A 9-month-old infant presents with a 48-hour history of fever up to 39.8°C. The child appears miserable when examined but is consolable when picked up by the mother. Respiratory rate is 35/min, heart rate 145/min, and capillary refill time 2 seconds centrally. There is no rash, the chest is clear, tympanic membranes appear normal, and throat examination is unremarkable. Urine dipstick shows leucocytes 2+, nitrites positive, and trace protein. What is the most appropriate initial management?
A. Oral antibiotics and arrange follow-up in 24 hours
B. Send urine for microscopy and culture, discharge with safety-netting advice
C. Admit for intravenous antibiotics and further investigation (Correct Answer)
D. Perform blood cultures and lumbar puncture before starting antibiotics
E. Prescribe oral antibiotics only if urine culture confirms infection
Explanation: ***Admit for intravenous antibiotics and further investigation***- This 9-month-old infant with a **high fever (39.8°C)**, appearing **miserable**, and showing a positive urine dipstick (**leucocytes 2+, nitrites positive**) is highly suggestive of a **urinary tract infection (UTI)**.- In infants under 1 year with suspected UTI and fever, or those who appear unwell, immediate admission for **intravenous antibiotics** and further investigation (e.g., urine culture, renal imaging) is crucial to prevent complications like **renal scarring**.*Oral antibiotics and arrange follow-up in 24 hours*- Given the infant's **age (9 months)**, **high fever**, and **unwell appearance**, oral antibiotics alone are insufficient and potentially dangerous as initial management.- This approach risks inadequate treatment for a possible **pyelonephritis**, leading to clinical deterioration and **long-term renal damage**.*Send urine for microscopy and culture, discharge with safety-netting advice*- Discharging a febrile 9-month-old with clear signs of a UTI (**positive nitrites and leucocytes**) is unsafe due to the high risk of **urosepsis** and renal complications.- While urine collection for microscopy and culture is essential, it does not replace the need for immediate empirical antibiotic treatment and inpatient monitoring.*Perform blood cultures and lumbar puncture before starting antibiotics*- While **blood cultures** are indicated in a febrile infant to rule out **bacteraemia**, a **lumbar puncture** is typically reserved for those with neurological signs or infants under 1-3 months of age without a clear source.- Delaying antibiotic initiation to perform a lumbar puncture in an infant with a clear focus of infection (UTI) is not the most appropriate initial step.*Prescribe oral antibiotics only if urine culture confirms infection*- Withholding empirical antibiotic treatment until **urine culture results** are available (which takes 24-48 hours) is unsafe for a febrile, unwell infant with a strong likelihood of UTI.- The presence of **nitrites** on urine dipstick has high specificity for UTI and, combined with clinical findings, warrants prompt initiation of antibiotics to prevent morbidity.
Question 73: A 7-year-old boy with known asthma presents to the emergency department with acute breathlessness and wheeze. His respiratory rate is 28/min, heart rate 115/min, and oxygen saturation 94% on room air. He is able to speak in sentences and has widespread polyphonic wheeze on auscultation. Peak expiratory flow is 65% of his predicted best. What is the most appropriate classification of this asthma exacerbation?
A. Mild asthma exacerbation
B. Moderate acute asthma (Correct Answer)
C. Acute severe asthma
D. Life-threatening asthma
E. Near-fatal asthma
Explanation: ***Moderate acute asthma***- A **moderate acute asthma** exacerbation in children >5 years is defined by a **Peak Expiratory Flow (PEF)** between **50-75%** of predicted and the ability to **speak in sentences**.- This patient's clinical markers (HR 115/min, RR 28/min, and **SpO2 94%**) fall within the parameters for moderate severity as they do not meet the criteria for severe or life-threatening status.*Mild asthma exacerbation*- Mild episodes typically feature a **PEF >75%** of the patient's best or predicted value and minimal clinical distress.- The **PEF of 65%** and the presence of widespread polyphonic wheeze shift the classification toward a **moderate** presentation.*Acute severe asthma*- In children aged >5 years, **severe asthma** criteria include a **PEF <50%**, a **heart rate >125/min**, or a **respiratory rate >30/min**.- Since this patient can **speak in sentences** and has a heart rate of 115/min, he does not meet these severity thresholds.*Life-threatening asthma*- This category is identified by clinical signs like a **silent chest**, cyanosis, **exhaustion**, or a **PEF <33%** of predicted.- The patient's **SpO2 of 94%** and normal level of consciousness help exclude this life-threatening classification.*Near-fatal asthma*- Near-fatal asthma is characterized by a **raised PaCO2** level or the requirement for **mechanical ventilation**.- There is no evidence of hypercarboxia or **respiratory failure** in this clinical scenario.
Question 74: A 14-month-old child presents to the emergency department with a 6-day history of persistent fever (38.9-40.1°C daily). The parents report the child has been increasingly irritable with decreased activity and reduced oral intake. There is no cough, vomiting, diarrhoea, or rash. On examination, temperature 39.7°C, heart rate 158/min, respiratory rate 34/min, capillary refill time 2 seconds. The child appears miserable and irritable even when held by parents. There is bilateral non-purulent conjunctival injection, strawberry tongue, cracked lips, and a maculopapular rash on trunk and limbs. Hands and feet appear erythematous and swollen. No palpable lymphadenopathy. Which investigation finding would most strongly support the need for urgent echocardiography in this child?
A. Platelet count of 682 × 10⁹/L
B. C-reactive protein of 156 mg/L
C. Albumin level of 26 g/L (Correct Answer)
D. White cell count of 19.4 × 10⁹/L
E. Erythrocyte sedimentation rate of 88 mm/hr
Explanation: ***Albumin level of 26 g/L***
- **Hypoalbuminemia** (≤30 g/L) is a critical laboratory marker indicating **increased vascular permeability** and severe systemic inflammation in Kawasaki disease (KD).
- It is a recognized independent risk factor for **intravenous immunoglobulin (IVIG) resistance** and a higher likelihood of developing **coronary artery aneurysms (CAAs)**, thus strongly warranting urgent echocardiography.
*Platelet count of 682 × 10⁹/L*
- **Thrombocytosis** is a characteristic feature of the **subacute phase** of KD, typically peaking in the second to third week of illness, not the acute phase described.
- While supportive of KD, it is not an early predictor of **coronary artery complications** that would necessitate urgent echocardiography during the acute febrile stage.
*C-reactive protein of 156 mg/L*
- An elevated **CRP** is a common indicator of acute inflammation in KD and is part of the diagnostic criteria for **incomplete Kawasaki disease**.
- Although it reflects disease activity, it is a non-specific marker of inflammation and does not carry the same specific prognostic weight for **cardiac risk** as severe hypoalbuminemia.
*White cell count of 19.4 × 10⁹/L*
- **Leukocytosis** with neutrophilia is frequently observed in the acute febrile phase of KD, indicating an active inflammatory response.
- This finding is common in many childhood infections and does not specifically stratify a patient's risk for **coronary artery abnormalities** or dictate the urgency for echocardiography compared to other specific markers.
*Erythrocyte sedimentation rate of 88 mm/hr*
- A significantly raised **ESR** is a hallmark of systemic inflammation in KD and is used both for diagnosis and monitoring treatment response.
- Similar to CRP, while it reflects high systemic inflammation, it is not as strong or specific an independent predictor of **coronary artery abnormalities** requiring urgent echocardiography as hypoalbuminemia.
Question 75: An 8-year-old girl with known asthma presents with acute breathlessness after playing football. She uses her salbutamol inhaler 6 puffs via spacer with minimal improvement. On examination, she speaks in full sentences, respiratory rate 32/min, heart rate 118/min, oxygen saturation 95% in air. Chest examination reveals bilateral expiratory wheeze with good air entry. Peak expiratory flow rate (PEFR) is 165 L/min (65% of her predicted best). She receives 10 puffs of salbutamol via spacer. After 15 minutes, she feels better with PEFR improved to 210 L/min (82% of predicted). Understanding the pathophysiology of her condition, which mechanism best explains the immediate bronchodilator effect of salbutamol?
A. Inhibition of phosphodiesterase leading to increased cyclic AMP
B. Stimulation of beta-2 adrenergic receptors causing smooth muscle relaxation (Correct Answer)
C. Blockade of muscarinic receptors reducing bronchoconstriction
D. Inhibition of mast cell degranulation preventing mediator release
E. Reduction of airway inflammation through suppression of cytokine production
Explanation: ***Stimulation of beta-2 adrenergic receptors causing smooth muscle relaxation***- **Salbutamol** is a short-acting **beta-2 adrenergic agonist (SABA)** that binds to **beta-2 receptors** on **bronchial smooth muscle cells**.- This binding activates **adenylyl cyclase**, leading to an increase in intracellular **cyclic AMP (cAMP)**, which ultimately causes **smooth muscle relaxation** and **bronchodilation**, explaining the immediate improvement in **PEFR**.*Inhibition of phosphodiesterase leading to increased cyclic AMP*- This mechanism is characteristic of **theophylline** and **aminophylline**, which prevent the breakdown of **cAMP**.- **Salbutamol** primarily increases **cAMP** levels by stimulating its production rather than inhibiting its degradation.*Blockade of muscarinic receptors reducing bronchoconstriction*- This describes the action of **anticholinergic** medications like **ipratropium bromide**, which block the effects of **acetylcholine**.- While used in asthma, this is not the mechanism by which **salbutamol** exerts its bronchodilator effect, as **salbutamol** is an **agonist**, not an **antagonist**.*Inhibition of mast cell degranulation preventing mediator release*- This is the mechanism of **mast cell stabilizers** such as **sodium cromoglicate**, used for **prophylaxis** in asthma.- These agents do not provide **immediate bronchodilation** and are ineffective for **acute asthma exacerbations**.*Reduction of airway inflammation through suppression of cytokine production*- This describes the action of **corticosteroids** (e.g., prednisolone), which work to reduce **airway inflammation** by altering gene expression.- **Corticosteroids** have a delayed onset of action and do not provide the **immediate** bronchodilator relief seen with **salbutamol**.
Question 76: A 5-year-old girl presents to the emergency department with a 4-day history of high fever (maximum 40.2°C), lethargy, and reduced oral intake. She initially had a sore throat that has now resolved. On examination, temperature is 39.6°C, heart rate 142/min, respiratory rate 28/min, blood pressure 98/58 mmHg. She has shotty cervical lymphadenopathy, splenomegaly (3 cm below costal margin), and small petechiae on the soft palate. There is no tonsillar enlargement or exudate. Blood tests show: Hb 118 g/L, WCC 18.4 × 10⁹/L (lymphocytes 12.2 × 10⁹/L, with 35% atypical lymphocytes), platelets 168 × 10⁹/L, CRP 24 mg/L. Liver function tests show ALT 156 U/L, AST 142 U/L. What is the most likely diagnosis?
A. Acute lymphoblastic leukaemia
B. Infectious mononucleosis (Correct Answer)
C. Kawasaki disease
D. Acute bacterial tonsillitis
E. Cytomegalovirus infection
Explanation: ***Infectious mononucleosis***- The constellation of **high fever**, **splenomegaly**, **shotty cervical lymphadenopathy**, and **palatal petechiae** in a child, following a sore throat, is highly suggestive of **Epstein-Barr virus (EBV)** infection, which causes infectious mononucleosis.- The laboratory findings of marked **atypical lymphocytosis** (35%) and elevated **transaminases** (ALT 156 U/L, AST 142 U/L) are classic diagnostic markers for this condition.*Acute lymphoblastic leukaemia*- While leukaemia can present with fever and organomegaly, it typically features more pronounced **pancytopenia** (severe anemia, thrombocytopenia) and the presence of **blast cells**, not predominantly atypical lymphocytes.- This patient's **hemoglobin** and **platelet count** are relatively preserved, making acute lymphoblastic leukaemia less likely than a viral cause for this picture.*Kawasaki disease*- This diagnosis requires at least 5 days of fever along with specific clinical criteria such as **bilateral conjunctivitis**, **strawberry tongue**, or **extremity changes** (e.g., desquamation), which are not described here.- While there is fever and lymphadenopathy, the **CRP** of 24 mg/L is relatively low for typical Kawasaki disease, which usually shows a much higher systemic inflammatory response.*Acute bacterial tonsillitis*- Acute bacterial tonsillitis typically presents with **neutrophilia** and often **tonsillar exudates**, which are explicitly stated to be absent in this patient.- It does not account for the significant **splenomegaly**, **palatal petechiae**, or the marked elevation in **liver enzymes** observed in this case.*Cytomegalovirus infection*- **Cytomegalovirus (CMV)** can cause a mononucleosis-like syndrome with similar lab abnormalities like atypical lymphocytosis and elevated transaminases, but it is generally less common than EBV in immunocompetent children.- CMV infection often lacks the prominent **pharyngitis** and **palatal petechiae** that are characteristic of EBV-induced infectious mononucleosis.
Question 77: A 3-year-old boy is reviewed in the emergency department 30 minutes after presenting with acute wheeze. He has had two previous similar episodes associated with viral upper respiratory tract infections, both of which resolved with salbutamol. He is not on any regular medication. He received 10 puffs of salbutamol via spacer on arrival. Current observations: respiratory rate 36/min, heart rate 128/min, oxygen saturation 96% in air. He is talking in sentences, has mild expiratory wheeze, and no recession. His parents are confident in managing him at home. What is the most appropriate management plan for discharge?
A. Salbutamol inhaler with spacer as needed, return if deteriorates (Correct Answer)
B. Salbutamol inhaler with spacer 2 puffs four times daily for 5 days
C. Salbutamol inhaler with spacer as needed and commence beclometasone inhaler 100 micrograms twice daily
D. Salbutamol inhaler with spacer as needed and prednisolone 20mg once daily for 3 days
E. Salbutamol inhaler with spacer as needed and montelukast 4mg once daily
Explanation: ***Salbutamol inhaler with spacer as needed, return if deteriorates***
- The child presents with **viral-induced wheeze** that has responded well to initial **salbutamol**, showing clinical stability with good oxygen saturation and no severe distress. This indicates **symptom-triggered** management is appropriate for discharge.
- According to **NICE** and **BTS/SIGN guidelines** for pre-school wheeze, if the child is stable and improving after a mild to moderate exacerbation, **short-acting beta-agonists (SABA)** should be prescribed **as needed** for symptomatic relief, with clear instructions on when to return.
*Salbutamol inhaler with spacer 2 puffs four times daily for 5 days*
- **Fixed-dose** or regular use of salbutamol is generally not recommended for **episodic viral wheeze** in pre-school children once the acute episode has resolved, as it can lead to unnecessary side effects like **tachycardia** or tremor.
- Management should be guided by **symptoms**; a rigid 5-day course does not account for individual variability in recovery or the risk of over-treatment.
*Salbutamol inhaler with spacer as needed and commence beclometasone inhaler 100 micrograms twice daily*
- **Inhaled corticosteroids (ICS)** are typically reserved for **persistent asthma** or **multi-trigger wheeze** where symptoms occur frequently (e.g., at least 3 times a week) or are severe, which is not indicated in this case of episodic viral wheeze.
- Starting a regular **preventer inhaler** like beclometasone is not indicated for an isolated, well-managed episode of viral-induced wheeze, especially without evidence of **frequent exacerbations** or **atopic features**.
*Salbutamol inhaler with spacer as needed and prednisolone 20mg once daily for 3 days*
- **Oral corticosteroids** such as prednisolone are usually reserved for **severe asthma exacerbations** or **viral-induced wheeze** not responding to bronchodilators, or in cases of significant respiratory distress.
- This child's current observations and clinical status (talking in sentences, mild wheeze, no recession, good sats) do not meet the criteria for requiring **systemic steroids** upon discharge.
*Salbutamol inhaler with spacer as needed and montelukast 4mg once daily*
- **Montelukast** is a **leukotriene receptor antagonist** used as an alternative or add-on therapy, often considered for children with **frequent viral-induced wheeze** or those with **exercise-induced asthma**.
- Initiating montelukast after a single, well-controlled mild episode is not standard practice for immediate discharge management unless there's an established pattern of **frequent** or **difficult-to-manage** symptoms warranting a preventative agent.
Question 78: A 10-month-old infant with a 2-day history of coryzal symptoms and cough is brought to hospital with increased work of breathing. Temperature is 37.8°C, respiratory rate 68/min, heart rate 162/min, oxygen saturation 93% in air. There is subcostal recession and bilateral fine inspiratory crackles with occasional wheeze. The infant is taking approximately 50% of normal feeds. A clinical diagnosis of bronchiolitis is made. Which of the following factors would be the strongest indication for admission to hospital in this infant?
A. Age less than 12 months
B. Oxygen saturation 93% in air (Correct Answer)
C. Respiratory rate 68/min
D. Taking 50% of normal feeds
E. Presence of subcostal recession
Explanation: ***Oxygen saturation 93% in air***- While **NICE guidelines** often use a threshold of **persistent oxygen saturation <92%** as a primary indication for admission in bronchiolitis, 93% is borderline and signifies a critical level requiring close observation for deterioration.- **Hypoxia** is a direct and objective measure of compromised respiratory function, and even mild desaturation in an infant with increased work of breathing indicates significant risk and is a stronger indicator than other signs alone.*Age less than 12 months*- While infants **under 3 months** are considered high-risk for severe bronchiolitis and admission, a 10-month-old infant, though young, doesn't automatically require admission solely based on age without other severe clinical signs.- Many 10-month-old infants with mild-to-moderate bronchiolitis can be safely managed at home if other **red flag symptoms** are absent and oxygenation is adequate.*Respiratory rate 68/min*- An elevated **respiratory rate** indicates increased work of breathing, but guidelines often specify rates **above 70/min** as a more definitive threshold for admission in infants of this age.- While concerning, a high respiratory rate alone is often secondary to the airway inflammation and is less critical than **hypoxemia** as an immediate admission criterion.*Taking 50% of normal feeds*- Reduced fluid intake is a concern for **dehydration**, and admission is typically considered when intake is consistently **below 50-75%** of normal, or there are signs of **clinical dehydration**.- However, compared to a borderline oxygen saturation, reduced feeding, without overt signs of severe dehydration, is generally a less acute and immediate indication for hospitalization.*Presence of subcostal recession*- **Subcostal recession** is a common sign of increased **work of breathing** in bronchiolitis and can be mild to moderate.- Admission based on recession is usually for **severe recession**, nasal flaring, grunting, or other signs of significant respiratory distress that indicate impending respiratory failure, which is not as acutely critical as compromised oxygenation.
Question 79: A 13-month-old child presents with a 4-day history of persistent fever ranging from 38.8-39.9°C. The parents report no specific symptoms apart from irritability and reduced appetite. On examination, the child is miserable but consolable, temperature 39.3°C, heart rate 148/min, respiratory rate 32/min, capillary refill time 2 seconds. Examination reveals bilateral non-purulent conjunctivitis, dry cracked lips, and a polymorphous rash on the trunk. Cervical lymphadenopathy is noted with one node measuring 1.8 cm. Extremities show mild erythema of palms and soles. Blood tests reveal: Hb 102 g/L, WCC 16.8 × 10⁹/L, platelets 512 × 10⁹/L, CRP 98 mg/L, albumin 28 g/L. What is the most appropriate definitive treatment?
A. Intravenous immunoglobulin 2 g/kg as a single dose (Correct Answer)
B. High-dose aspirin 80-100 mg/kg/day until fever settles
C. Intravenous ceftriaxone 80 mg/kg/day for 7 days
D. Oral prednisolone 2 mg/kg/day for 5 days
E. Supportive care with fluids and antipyretics only
Explanation: ***Intravenous immunoglobulin 2 g/kg as a single dose***
- The child presents with classic criteria for **Kawasaki disease**, including persistent high fever for >4 days, bilateral **non-purulent conjunctivitis**, dry cracked lips, a **polymorphous rash**, **cervical lymphadenopathy**, and extremity changes (erythema of palms/soles).
- **IVIG** is the cornerstone definitive treatment for Kawasaki disease, administered to reduce the risk of potentially life-threatening **coronary artery aneurysms** from approximately 25% to under 5% when given within the first 10 days of illness.
*High-dose aspirin 80-100 mg/kg/day until fever settles*
- **Aspirin** is an important part of Kawasaki disease treatment for its **anti-inflammatory** (high dose initially) and **anti-platelet** (low dose later) effects, but it is not sufficient as a standalone definitive therapy.
- It is used **adjunctively with IVIG**; aspirin alone does not adequately prevent the development of coronary artery aneurysms.
*Intravenous ceftriaxone 80 mg/kg/day for 7 days*
- This is an **antibiotic** regimen typically used for serious bacterial infections. The constellation of symptoms (mucocutaneous findings, prominent inflammation) points strongly towards a **vasculitic process** rather than a bacterial infection.
- Administering antibiotics would delay the necessary immunomodulatory treatment for **Kawasaki disease**, which is not caused by bacteria.
*Oral prednisolone 2 mg/kg/day for 5 days*
- **Corticosteroids** are sometimes used in Kawasaki disease, particularly in high-risk patients or those who are **refractory** to initial IVIG therapy.
- However, they are generally not considered first-line definitive treatment and are used as an **adjunct** rather than a primary therapy to prevent coronary artery damage.
*Supportive care with fluids and antipyretics only*
- **Kawasaki disease** is a serious systemic vasculitis that requires specific intervention to prevent severe cardiac complications, including **coronary artery aneurysms** and myocardial infarction.
- Relying solely on **supportive care** would leave the child at high risk for irreversible cardiac damage and is therefore inappropriate as definitive management.
Question 80: A 7-year-old boy with known moderate persistent asthma on beclometasone 400 micrograms twice daily and salmeterol presents with an acute severe exacerbation. He has received back-to-back salbutamol nebulisers with oxygen and oral prednisolone 30mg. After 15 minutes his oxygen saturation remains 90% in high-flow oxygen, respiratory rate is 44/min, heart rate 148/min, and he can only speak 2-3 words at a time. Chest examination shows poor air entry bilaterally with no wheeze audible. What is the single most important immediate next step?
A. Arrange immediate intubation and mechanical ventilation
B. Administer intravenous magnesium sulphate 40 mg/kg over 20 minutes
C. Add ipratropium bromide 250 micrograms to nebuliser and repeat salbutamol
D. Commence aminophylline infusion after loading dose
E. Request immediate senior paediatric and anaesthetic review (Correct Answer)
Explanation: ***Request immediate senior paediatric and anaesthetic review***- The child exhibits **life-threatening asthma** features, specifically a **'silent chest'** (poor air entry/no wheeze) and persistent **hypoxia** (SpO2 90%), indicating impending respiratory failure.- Standard emergency protocols dictate that for any child with life-threatening features not responding to initial treatment, **immediate senior support** is the priority to manage potential airway intervention and intensive care.*Arrange immediate intubation and mechanical ventilation*- While this may be required, it is a high-risk procedure in asthma due to **dynamic hyperinflation** and should only be performed by senior experts.- Clinical stabilization with **intravenous bronchodilators** is typically attempted first unless there is an absolute respiratory arrest, and the decision for intubation should be made by senior personnel.*Administer intravenous magnesium sulphate 40 mg/kg over 20 minutes*- **IV Magnesium** is an appropriate second-line treatment for severe asthma that does not respond to nebulizers, but it does not take precedence over securing **senior help** in a life-threatening scenario.- This pharmacological intervention is part of the escalation of care that should occur concurrently with or after **expert review**.*Add ipratropium bromide 250 micrograms to nebuliser and repeat salbutamol*- Adding **ipratropium bromide** is standard in acute severe asthma, but the presence of a **silent chest** suggests the patient has surpassed the level where nebulized therapy alone is sufficient.- Relying solely on nebulizers at this stage delays the necessary **parenteral management** and critical care involvement required for a failing patient.*Commence aminophylline infusion after loading dose*- **Aminophylline** is generally considered a third-line agent and has a narrow therapeutic index with significant **side effects** like arrhythmias.- It should only be initiated in a high-dependency setting after **senior clinicians** have assessed the patient and potentially tried IV magnesium first.
