Acute Paediatrics

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

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

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

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

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

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

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

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

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

Acute Paediatrics UK Medical PG Question 4: A 8-year-old child presents with fever, irritability, and a widespread petechial rash that doesn't blanch with pressure. The child appears unwell and has neck stiffness. What is the most appropriate immediate management?

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

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

Acute Paediatrics UK Medical PG Question 5: A 4-year-old child presents with fever, irritability, and neck stiffness. Lumbar puncture shows: opening pressure 25 cmH₂O, WCC 800/μL (90% neutrophils), protein 2.8 g/L, glucose 1.2 mmol/L (serum glucose 6.0 mmol/L). What is the most likely diagnosis?

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

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

Acute Paediatrics Flashcard 1 of 5

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

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

Acute Paediatrics Flashcard 2 of 5

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

Answer: Seek paediatric opinion and assessment

Acute Paediatrics Flashcard 3 of 5

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

Answer: Febrile convulsions

Acute Paediatrics Flashcard 4 of 5

Question: Features of Threadworm infestation includes: _____ vulval symptoms

Answer: perianal itching (particularly at night)

Acute Paediatrics Flashcard 5 of 5

Question: What is the taxanomical name for Threadworms? _____

Answer: Enterobius vermicularis