Pediatrics
Obstructive sleep apnea syndrome in children
➢ It’s mainly due to enlarged tonsils and adenoids
Presentation
• Snoring - usually parents seek attention; many will just get better as they grow older
• Mouth breathing
• Witnessed apneic episodes → episodes of cessation of breathing
• Daytime sleepiness and somnolence are less important in children
• Sleep-deprived children tend to become hyperactive, with reduced attention and be labelled as difficult or
disruptive, or even ADHD. They may not be doing well at school due to poor concentration
• In adults → increased daytime somnolence + DM and HTN
Investigations
• Simple studies: pulse oximetry and overnight study of breathing patterns → initial investigation
• Overnight in-laboratory polysomnography (PSG) → the gold standard
Epworth sleepiness scale → a questionnaire to predict the likelihood the patient will fall asleep in certain conditions
Treatment
• Conservative → weight loss and reducing alcohol consumption
• Continuous positive airway pressure (CPAP)
• Rare cases require surgery to relieve pharyngeal obstruction (e.g. tonsillectomy, adenoidectomy or
tracheostomy)
Acute epiglottitis
• Caused by Hemophilus influenza type B
Features
Croup
• Rapid onset
• Barking cough, stridor, HOV and fever
• Fever • Cause by Para-influenza virus
• Stridor • X-ray → steeple sign
• Managed by oral dexamethasone
• Drooling of saliva • Emergency TTT → high flow O2 + nebulized adrenaline
• Difficulty speaking
• Muffling or changes in the voice
• X-ray → thumb sign “indicating an edematous and enlarged epiglottis and it suggests acute infectious
epiglottitis”
Management
- In acute attack → summon an anesthetist → intubation is required to avoid obstruction
PLABverse - 1
, Pediatrics
Childhood viral rashes
➢ Most children rashes present with similar flu-like symptoms such as a runny nose, cough, a high temperature
(38℃ or above), a sore throat, loss pf appetite and swollen neck glands
Roseola
• Sudden high temperature followed by non-itchy pink/red spots or patches after resolution of fever by 12-
24h on chest or legs and spreads to the rest of the body + Nagayama soft palate spots
• The most common rash of its kind under 2 years old
Parvovirus B19
• Bright red rash on both cheeks (slapped cheek syndrome) which may spread to the rest of the body
• Also called → Erythema infectiosum
• The rash can be itchy, especially on the soles of the feet
Measles
• Red-brown blotchy maculopapular rash on the head or neck (starts
behind the ear) and spreads to the rest of the body
• Tiny grey-white spots in the mouth (Koplik spots – not always but
diagnostic sign if occurs)
• Unwell child, usually fever >40℃
Hard K sound
- Koplik spots (before rash), white spot “grain of salts” on buccal mucosa
- Cough
- Conjunctivitis
- Coryza, inflammation of URT
Rubella
• Red/pink spotty rash which starts behind the ears and spreads to
the rest of the body
• Swollen LN
• Spots on the soft palate (Forchheimer spots)
• Very unlikely if had both doses of MMR vaccine
Hand, foot and mouth disease (HFMD)
• Commonly caused by Coxsackievirus A16 (CA16) and enterovirus 71 (EV71), very contagious among children
• Painful ulcers on the tongue or buccal mucosa and grey blisters in hands and feet
Management for all
- Paracetamol or ibuprofen
- Ensure adequate dehydration
- Fever and rashes will usually subside within a week
When to worry → Meningitis
• Non-blanching red pinpricks rashes which quickly spread turning into red or purple blotches
• Stiff neck, photosensitivity and uncontrollable fever
PLABverse - 2
, Pediatrics
Chickenpox
• Caused by VZV
• If the rash appears within a week of delivery or within 2 days after delivery, there’s a risk of neonatal
chickenpox. There’s transplacental transmission of virus but not antibody, as there is no time for IgG to
develop and the baby is at 30% risk of death from severe pneumonia or fulminant hepatitis → managed by
VZIG and Acyclovir
• If the mother’s onset of rash is >7 days before delivery or >7 days post-delivery → varicella zoster
immunoglobulin (VZIG) and isolation is not necessary for the neonate; just observation
Scarlet fever
Key points
• Commonest age → 2-8 years
• Caused by → group A streptococcus pyogenes
• Diagnosis is clinical
• Presents with sore throat, fever (usually >38.3℃) and a rash
• Rash → starts at torso 12-48h after fever and spreads to extremities, has a coarse texture like sandpaper
• Other features
- Strawberry tongue
- Cervical lymphadenopathy
- Tonsils covered with pal exudates with red macules on palate (Forchheimer spots)
• Treatment is with penicillin V for 10 days
Scarlet fever is the game os “S”
- Strept pyogenes
- Sore throat
- Strawberry tongue, tonsils could be coated with white exudates
- Sandpaper rash
- Spot le Forchheimer
- Servical lymphadenopathy
Kawasaki disease [RED + adenopathy]
➢ A febrile systemic vasculitis primarily affects children <5 years
➢ Coronary aneurysm is a potentially devastating complication
➢ Often misdiagnosed as a viral rash (exanthem) and sent home
Diagnosis [CRASH BURN]
• Fever >39℃ for more than 5 days + at least 4 of the following:
- Conjunctivitis
- Polymorphous rash
- Extremity changes: Erythema of palms and soles that later leads to desquamation
- Mucous membrane changes: Red, fissured lips, strawberry tongue
- Cervical lymphadenopathy
Management
• High dose aspirin → reduces risk of thrombosis
- Once fever subsides and inflammatory markers fall, low dose aspirin is given until ECHO is performed at
6 weeks to exclude aneurysm
• IVIG → if given within first 10 days, reduces the risk of coronary artery aneurysm
PLABverse - 3
Obstructive sleep apnea syndrome in children
➢ It’s mainly due to enlarged tonsils and adenoids
Presentation
• Snoring - usually parents seek attention; many will just get better as they grow older
• Mouth breathing
• Witnessed apneic episodes → episodes of cessation of breathing
• Daytime sleepiness and somnolence are less important in children
• Sleep-deprived children tend to become hyperactive, with reduced attention and be labelled as difficult or
disruptive, or even ADHD. They may not be doing well at school due to poor concentration
• In adults → increased daytime somnolence + DM and HTN
Investigations
• Simple studies: pulse oximetry and overnight study of breathing patterns → initial investigation
• Overnight in-laboratory polysomnography (PSG) → the gold standard
Epworth sleepiness scale → a questionnaire to predict the likelihood the patient will fall asleep in certain conditions
Treatment
• Conservative → weight loss and reducing alcohol consumption
• Continuous positive airway pressure (CPAP)
• Rare cases require surgery to relieve pharyngeal obstruction (e.g. tonsillectomy, adenoidectomy or
tracheostomy)
Acute epiglottitis
• Caused by Hemophilus influenza type B
Features
Croup
• Rapid onset
• Barking cough, stridor, HOV and fever
• Fever • Cause by Para-influenza virus
• Stridor • X-ray → steeple sign
• Managed by oral dexamethasone
• Drooling of saliva • Emergency TTT → high flow O2 + nebulized adrenaline
• Difficulty speaking
• Muffling or changes in the voice
• X-ray → thumb sign “indicating an edematous and enlarged epiglottis and it suggests acute infectious
epiglottitis”
Management
- In acute attack → summon an anesthetist → intubation is required to avoid obstruction
PLABverse - 1
, Pediatrics
Childhood viral rashes
➢ Most children rashes present with similar flu-like symptoms such as a runny nose, cough, a high temperature
(38℃ or above), a sore throat, loss pf appetite and swollen neck glands
Roseola
• Sudden high temperature followed by non-itchy pink/red spots or patches after resolution of fever by 12-
24h on chest or legs and spreads to the rest of the body + Nagayama soft palate spots
• The most common rash of its kind under 2 years old
Parvovirus B19
• Bright red rash on both cheeks (slapped cheek syndrome) which may spread to the rest of the body
• Also called → Erythema infectiosum
• The rash can be itchy, especially on the soles of the feet
Measles
• Red-brown blotchy maculopapular rash on the head or neck (starts
behind the ear) and spreads to the rest of the body
• Tiny grey-white spots in the mouth (Koplik spots – not always but
diagnostic sign if occurs)
• Unwell child, usually fever >40℃
Hard K sound
- Koplik spots (before rash), white spot “grain of salts” on buccal mucosa
- Cough
- Conjunctivitis
- Coryza, inflammation of URT
Rubella
• Red/pink spotty rash which starts behind the ears and spreads to
the rest of the body
• Swollen LN
• Spots on the soft palate (Forchheimer spots)
• Very unlikely if had both doses of MMR vaccine
Hand, foot and mouth disease (HFMD)
• Commonly caused by Coxsackievirus A16 (CA16) and enterovirus 71 (EV71), very contagious among children
• Painful ulcers on the tongue or buccal mucosa and grey blisters in hands and feet
Management for all
- Paracetamol or ibuprofen
- Ensure adequate dehydration
- Fever and rashes will usually subside within a week
When to worry → Meningitis
• Non-blanching red pinpricks rashes which quickly spread turning into red or purple blotches
• Stiff neck, photosensitivity and uncontrollable fever
PLABverse - 2
, Pediatrics
Chickenpox
• Caused by VZV
• If the rash appears within a week of delivery or within 2 days after delivery, there’s a risk of neonatal
chickenpox. There’s transplacental transmission of virus but not antibody, as there is no time for IgG to
develop and the baby is at 30% risk of death from severe pneumonia or fulminant hepatitis → managed by
VZIG and Acyclovir
• If the mother’s onset of rash is >7 days before delivery or >7 days post-delivery → varicella zoster
immunoglobulin (VZIG) and isolation is not necessary for the neonate; just observation
Scarlet fever
Key points
• Commonest age → 2-8 years
• Caused by → group A streptococcus pyogenes
• Diagnosis is clinical
• Presents with sore throat, fever (usually >38.3℃) and a rash
• Rash → starts at torso 12-48h after fever and spreads to extremities, has a coarse texture like sandpaper
• Other features
- Strawberry tongue
- Cervical lymphadenopathy
- Tonsils covered with pal exudates with red macules on palate (Forchheimer spots)
• Treatment is with penicillin V for 10 days
Scarlet fever is the game os “S”
- Strept pyogenes
- Sore throat
- Strawberry tongue, tonsils could be coated with white exudates
- Sandpaper rash
- Spot le Forchheimer
- Servical lymphadenopathy
Kawasaki disease [RED + adenopathy]
➢ A febrile systemic vasculitis primarily affects children <5 years
➢ Coronary aneurysm is a potentially devastating complication
➢ Often misdiagnosed as a viral rash (exanthem) and sent home
Diagnosis [CRASH BURN]
• Fever >39℃ for more than 5 days + at least 4 of the following:
- Conjunctivitis
- Polymorphous rash
- Extremity changes: Erythema of palms and soles that later leads to desquamation
- Mucous membrane changes: Red, fissured lips, strawberry tongue
- Cervical lymphadenopathy
Management
• High dose aspirin → reduces risk of thrombosis
- Once fever subsides and inflammatory markers fall, low dose aspirin is given until ECHO is performed at
6 weeks to exclude aneurysm
• IVIG → if given within first 10 days, reduces the risk of coronary artery aneurysm
PLABverse - 3
