Children’s Health – Respiratory, Cardiology and introduction to Neonatology

What is laryngomalacia

occurs where the supraglottic larynx (the part of the larynx above the vocal cords) is structured in a way that causes partial airway obstruction

What age does laryngomalacia present

• 6 months of age symptoms peak

Presentation of laryngomalacia

• Intermittent inspiratory stridor

• more prominent when feeding, upset, lying on the back, or during upper respiratory tract infections.

• It is not associated with respiratory distress.

 

Management of laryngomalacia

• Laryngomalacia resolves as the larynx matures and grows and can better support itself

• Usually, no interventions are required

• Rarely tracheostomy may be necessary

  • Surgery is also an option to alter the tissue in the larynx

What is epiglottitis

• involves inflammation and swelling of the epiglottis, usually due to infection.

• The epiglottitis can completely occlude the airway within hours.

• Epiglottitis is a life-threatening emergency.

 

The key causes of epiglottis are:

• Haemophilus influenzae type B (the leading cause but now rare due to vaccination)

• Streptococcus pneumoniae

 

Common age for epiglottitis

• Epiglottitis can occur at any age, including adulthood. The typical age is 2-7 years.

 

Typical symptoms of epiglottitis include:

• Sore throat

• Difficulty swallowing (dysphagia)

• Painful swallowing (odynophagia)

• High fever

• Stridor

• Drooling

  • Muffled “hot potato” voice

On general inspection, the child with epiglottitis may be:

• Scared and quiet

• Toxic appearance

• Sat in the tripod position (sat forward with a hand on each knee)

• Extending their neck and chin

 

Investigations for epiglottitis

• Investigations should not be routinely performed in suspected epiglottitis

• Lateral x-ray of the neck characteristically shows the “thumb sign” or “thumbprint sign”

 

Management of epiglottitis

• Avoid upsetting the child

• Alert the most senior paediatrician and anaesthetist available.

• Oxygen may be administered by holding the mask close to the child but not putting it on them.

  • Once the airway is secure, IV antibiotics (e.g., ceftriaxone) are initiated. Systemic steroids may also be used.

What is pneumonia

involves infection of the lung tissue, causing inflammation in the alveoli

What is acute bronchitis

• infection and inflammation in the bronchial tubes.

  • Both pneumonia and acute bronchitis are lower respiratory tract infections.

The top causes of bacterial pneumonia are:

• Streptococcus pneumoniae (most common)

  • Haemophilus influenzae

Viral causes of pneumonia:

• Respiratory syncytial virus (RSV) is the most common viral cause

• Parainfluenza virus

  • Influenza virus

In a neonate pneumonia, the causative organism may originate from the birth canal:

• Group B streptococcus (GBS)

• Escherichia coli (E. coli)

• Listeria

  • Klebsiella

In children with cystic fibrosis, the key causes of pneumonia are:

• Staphylococcus aureus

  • Pseudomonas aeruginosa

In immunocompromised patients, such as those with end-stage HIV, consider these causes of pneumonia:

• Pneumocystis jirovecii

  • Cytomegalovirus

Presenting symptoms of pneumonia include:

• Productive cough

• High fever

• Shortness of breath

• Lethargy

  • Drowsiness or confusion

Signs on examination of pneumonia include:

• Fever (above 38.5ºC)

• Tachypnoea (raised respiratory rate)

• Tachycardia (raised heart rate)

• Signs of respiratory distress (e.g., recessions, nasal flaring and tracheal tug)

• Low oxygen saturation

• Hypotension (low blood pressure)

  • Cyanosis (blue discolouration of the skin)

Auscultations findings in pneumonia

• Bronchial breath sounds

• Focal coarse crackles

• Dullness to percussion

 

Investigations in pneumonia

• CXR

• Bloods: WBC, CRP

• Blood culture

• Sputum culture/PCR

  • Capillary blood glucose (lactate, pH)

The choice of oral antibiotic in pneumonia will depend on the local guidelines. Typical choices include:

• Amoxicillin (usually first-line)

• Co-amoxiclav (particularly with concurrent influenza or in cystic fibrosis, to cover Staph aureus)

• Clarithromycin (penicillin allergy)

 

Further investigations may be required in children with recurrent hospital admissions for chest infections. Conditions to consider include:

• Cystic fibrosis

• Primary ciliary dyskinesia

• Bronchiectasis

• Immunodeficiency (e.g., HIV or selective IgA deficiency)

• Neurological disease (e.g., cerebral palsy)

  • Congenital heart disease

Why test IgG in a child

• Testing for IgG to previous vaccines can detect immunoglobulin class-switch recombination deficiencies.

• Patients with these conditions are unable to convert IgM to IgG and, therefore, do not form long-term immunity to that pathogen.

 

What is croup

• upper respiratory tract infection that causes oedema and inflammation of the larynx and airways

 

Epidemiology of croup

• It typically affects young children aged 6 months to 3 years.

  • It usually resolves within two days and responds well to treatment with dexamethasone.

Causes of croup

• Parainfluenza virus is the leading cause

• Influenza

• Respiratory syncytial virus (RSV)

• Rhinovirus

 

Symptoms / signs of croup

• rapid-onset “seal-like” barking cough

• Increased work of breathing

• Hoarse voice

• Stridor (high-pitched inspiratory noise)

• Low-grade fever

• A few days of coryzal symptoms (e.g., runny nose, dry cough and sore throat) may precede the onset of croup.

 

Management of croup

• Dexamethasone (0.15mg/kg) once only

• If needed:

• Oxygen

• Nebulised budesonide

• Nebulised adrenalin

• Intubation and ventilation

  •  

What is an allergy

immune-system hypersensitivity to allergens

What is an allergen

• proteins that the immune system recognises as foreign and potentially harmful, leading to an allergic immune response

 

What is atopy

• a genetic tendency to develop IgE-mediated allergic diseases, such as eczema, hayfever, allergic rhinitis, food allergies and allergic asthma.

 

Presentation of IgE-mediated food allergy

• typically develop within minutes to 2 hours after ingestion

• Skin symptoms (e.g., itching, urticaria and angioedema)

• Respiratory symptoms (e.g., cough, wheeze and breathlessness)

• Gastrointestinal symptoms (e.g., nausea, vomiting and diarrhoea)

• Systemic symptoms (e.g., tachycardia, hypotension and confusion)

 

Important areas to cover in an allergy history include:

• Timing after exposure to the allergen

• Previous and subsequent exposure and reaction to the allergen

• Symptoms of rash, swelling, breathing difficulty, wheeze and cough

• Previous personal and family history of atopic conditions and allergies

 

There are three key ways to test for allergy:

• Skin prick testing

• Serum allergen-specific IgE testing

• Food challenge testing

 

What is the skin prick test

• making a small break in the skin with a sample of a suspected allergen

• A drop of each allergen solution is placed at the marked points on the patch of skin, along with a saline control and a histamine control

• After 15 minutes, the size of the wheals to each allergen is assessed and compared to the controls.

 

 

What is serum allergen IgE testing

• measures the amount of IgE to specific allergens (e.g., peanuts) in a blood sample

• In patients with atopic conditions, the results are often positive when they do not have a clinical allergy.

 

What is the food challenge test

• given gradually increasing quantities of the suspected food allergen and closely monitored after each exposure

• This can be helpful for excluding allergies and providing reassurance.

 

What is patch testing

• used to test whether a specific allergen is causing allergic contact dermatitis

• The patient could be tested for reactions to metals, perfumes, or chemicals

• After 2-3 days, the skin reaction to the patch is assessed.

 

Management of food allergy involves:

• Carefully establishing the correct allergen

• Avoiding the allergen

• A written allergy management plan

• Adrenaline auto-injector (e.g., EpiPen), depending on the risk of anaphylaxis

 

Treatment of accidental allergen exposure with mild to moderate symptoms involves:

Non-sedating antihistamines (e.g., cetirizine or loratadine)

Management of severe, systemic reactions (e.g., anaphylaxis) involves:

Intramuscular adrenaline

Emergency admission

What is anaphylaxis

a severe, systemic hypersensitivity reaction involving rapid-onset symptoms, with airway, breathing and/or circulation compromise

Pathophysiology of anaphylaxis

• Immunoglobulin E (IgE) stimulates mast cells to rapidly release histamine and other pro-inflammatory cytokines, called mast cell degranulation.

 

Presentation of anaphylaxis

• Skin symptoms (e.g., itching, urticaria and angioedema)

• Respiratory symptoms (e.g., cough, wheeze, breathlessness, hoarse voice and stridor)

• Gastrointestinal symptoms (e.g., nausea, vomiting and diarrhoea)

• Systemic symptoms (e.g., tachycardia, hypotension, collapse and confusion)

 

Initial assessment of an acutely unwell child is with an ABCDE approach, assessing and treating:

• A – Airway: Assess for signs of airway compromise (with early senior/anaesthetic support if suspected)

• B – Breathing: Give oxygen if required and consider salbutamol for wheezing

• C – Circulation: Get IV access and give an IV fluid bolus if hypotensive

• D – Disability: Assess for confusion, agitation or impaired consciousness

• E – Exposure: Assess for flushing, urticaria and angioedema

 

What should be measured after anaphylaxis

• Tryptase

  • peaks at around 1-2 hours and gradually declines thereafter, often returning to baseline by 6-8 hours

How to use an EpiPen

1. Prepare the device by removing the safety cap on the non-needle end.

2. Grip the device in a fist with the needle end pointing downwards

3. Avoid placing a thumb over the other end

4. Administer the injection by firmly jabbing the device into the outer portion of the mid thigh until the device clicks

5. It is held in place for several seconds before removal

6. Remove the device and gently massage the area for 10 seconds.

7. Call emergency services when administering adrenaline for suspected anaphylaxis.

8. A second dose may be given (with a second device) after 5 minutes if required.

 

 

What is whooping cough

• a respiratory tract infection caused by Bordetella pertussis, a gram-negative bacteria

• It causes coughing fits so severe that the child cannot inhale between coughs, resulting in a distinctive whooping sound as they forcefully draw in the air afterwards.

 

Who is vaccinated against whooping cough

• Children and pregnant women are vaccinated against pertussis.

The approximate timeline for whooping cough (with significant variation):

• The incubation period lasts around 1 week

• Coryzal symptoms lasting around 1 week (e.g., blocked and runny nose, sore throat and mild dry cough)

• Severe paroxysmal cough lasting 1-10 weeks

  • Recovery over 2-3 weeks

In some cases of whooping cough, the coughing is so forceful that it may cause:

• Fainting

• Vomiting

• Subconjunctival haemorrhage

• Facial petechiae

• Pneumothorax

• Rib fractures

• Hernias

  • Intervertebral disc herniation

Diagnosis of whooping cough

• A nasopharyngeal or nasal swab with PCR testing or bacterial culture

• within 3 weeks of the onset of symptoms

• Where the cough has been present for more than 2 weeks, and they have not been vaccinated in the past year, patients can be tested for the anti-pertussis toxin immunoglobulin G.

 

Management of whooping cough

• Pertussis is a notifiable disease, and the UK Health Security Agency (UKHSA)

• Preventing the spread is important.

• Taking 48 hours of antibiotics

• 14 days from the onset of the cough (or 21 days for higher-risk work, such as caring for infants or pregnant women)

 

Antibiotics are started when the whooping cough onset is within 14 days (or 21 days if they have contact with vulnerable infants). The options are:

• Macrolides first-line (e.g., azithromycin, erythromycin and clarithromycin)

• Co-trimoxazole

 

Prophylactic antibiotics are recommended for close contacts in priority groups for whooping cough, for example:

• Unvaccinated infants

• Pregnant women over 32 weeks gestation

  • People who have close contact with infants or pregnant women

What prophylactic Abx is used for whooping cough

Macrolide

Prognosis of whooping cough

• typically resolve within 8 weeks

• also known as the “100-day cough” due to the potentially long duration of the cough.

  • A long-term complication of whooping cough is bronchiectasis

What is bronchiolitis

• involves infection and inflammation in the bronchioles, the small airways of the lungs

  • most commonly in the winter months

Causative pathogen for bronchiolitis

• Respiratory syncytial virus (RSV)

  • rhinovirus and adenovirus

Epidemiology of bronchiolitis

• Infants under 1 year old

  • Most common under 6 months

Basic pathophysiology of bronchiolitis

• Inflammation, oedema, and increased mucus production in the bronchioles cause the airway to narrow

• Infants’ airways are very small, so even minimal narrowing can cause significant symptoms

• Airflow obstruction causes increased work of breathing and reduced oxygen saturation

 

Around half of infants with RSV infection go on to develop bronchiolitis. A typical course of illness involves:

• Chest symptoms 1-2 days after the onset of coryzal symptoms

• Peak of symptoms on days 3-5

• Symptoms lasting 7-10 days total

• Full recovery within 3 weeks

 

Presenting symptoms of bronchiolitis include:

• Coryzal symptoms (runny nose, sneezing, watery eyes)

• Dyspnoea (heavy laboured breathing)

• Tachypnoea (fast breathing)

• Reduced feeding

• Mild fever (under 39ºC)

• Apnoeas (episodes where the child stops breathing)

• Cyanosis (due to low oxygen saturation)

 

Auscultation findings for bronchiolitis

• widespread harsh breath sounds

• wheezes and crackles

 

Signs of respiratory distress include:

• Raised respiratory rate

• Accessory muscle use (e.g., sternocleidomastoid, abdominal and intercostal muscle use)

• Intercostal and subcostal recessions

• Nasal flaring

• Head bobbing

• Tracheal tug

• Grunting

 

Causes of stridor include:

• Foreign body aspiration

• Croup

• Epiglottitis

• Laryngomalacia

 

Causes of grunting

• Exhaling with the glottis partially closed to create PEEP

• Stops airways collapsing during exhalation

• Sign of resp distress

 

Causes of wide spread wheeze

• Bronchiolitis

• Asthma

  • Viral-induced wheeze

Causes of a focal wheeze

• Foreign body

  • Obstructing tumour

Reasons for admission with bronchiolitis include:

• Aged under 3 months

• Pre-existing condition (e.g., prematurity, congenital heart disease, cystic fibrosis or Down’s syndrome)

• Less than 50-75% of their normal fluid intake

• Signs of dehydration (e.g., reduced urine output, dry mucus membranes or reduced skin turgor)

• Respiratory rate above 70

• Oxygen saturation below 92%

• Persistent severe signs of respiratory distress (e.g., deep recessions or grunting)

• Apnoeas

• Cyanosis

• Difficulty managing or seeking medical help from home

 

Management of bronchiolitis involves:

• Ensuring adequate intake (oral, NG feeds or IV fluids depending on the severity)

• Saline nasal drops and nasal suctioning may help clear nasal secretions, particularly before feeding

• Supplementary oxygen if the oxygen saturations remain below 90% (or 92% if under 6 weeks or high risk)

• Ventilatory support, if required

 

Feeding recommendations for bronchiolitis

• Full stomach restricts breathing so smaller more frequent feeds

 

Respiratory support may be required in severe bronchiolitis. These can be stepped up as required:

• Low-flow oxygen (e.g., 2 litres via nasal cannula)

• High-flow humidified oxygen via a tight nasal cannula (e.g., “Airvo” or “Optiflow”)

• Continuous positive airway pressure (CPAP)

• Intubation and ventilation

 

Signs of inadequate ventilation on ABG include:

• Rising pCO2 (severe airway obstruction reduces the clearance of carbon dioxide)

• Falling pH (rising carbon dioxide causes respiratory acidosis)

 

What is the relation of RSV vaccine and bronchiolitis

• The RSV vaccine is recommended for all pregnant women from 28 weeks of gestation.

  • It creates an immune response in the mother, generating antibodies that pass through the placenta to the fetus.

• These antibodies offer the baby protection for the first 6 months of life.

 

What is palivizumab

• monoclonal antibody that targets the respiratory syncytial virus

• involves monthly injections and is given to high-risk babies, such as ex-premature and those with congenital heart disease

• provides passive protection against RSV.

 

What is stridor

• Externally audible, high-pitched sound caused by turbulent airflow due to obstruction of upper respiratory tract

Typical symptoms of stridor include

• Sore throat

• Difficulty breathing

• Noisy breathing

• Drooling or inability to swallow saliva

• Dysphagia

• Voice change

  • Fever

The character of the stridor gives an indication as to the location of the obstruction:

• Inspiratory: obstruction above or at the level of the vocal cords (glottis or supraglottic)

• Biphasic: obstruction below the vocal cords (subglottic)

  • Expiratory: obstruction of the trachea or larger bronchi

Types of vaccines

• Inactivated vaccine

• Subunit and conjugate vaccines

• MRNA vaccines

• Live attenuated vaccines

  • Toxoid vaccines

Examples of inactivated vaccines

• Inactivated polio vaccine

• Injected influenza vaccine

• Hepatitis A

  • Rabies

What are inactivated vaccines

• giving an inactive version of the pathogen.

  • They cannot cause an infection and are safe for immunocompromised patients

What are Subunit and conjugate vaccines

• contain parts of the pathogen required to stimulate an immune response.

• They cannot cause infection and are safe for immunocompromised patients

 

Examples of subunit and conjugate vaccines

• Pneumococcus

• Meningococcus

• Hepatitis B

• Pertussis (whooping cough)

• Haemophilus influenza type B

• Human papillomavirus (HPV)

• Shingles (Shingrix)

 

What are MRNA vaccines

• deliver mRNA that codes for specific viral proteins into the body’s cells

•  The cells translate that mRNA into antigen proteins,

 

What are live attenuated vaccines

• contain a weakened version of the pathogen.

• They can rarely cause disease, particularly in immunocompromised patients.

 

Examples of live attenuated vaccines

• Measles, mumps and rubella vaccine: contains all three weakened viruses

• BCG (contains live attenuated Mycobacterium bovis)

• Chickenpox (contains weakened varicella-zoster virus)

• Nasal influenza (not the injected flu vaccine)

• Rotavirus vaccine

 

What are toxoid vaccines

• contain an inactivated toxin that is normally produced by a pathogen

• They cause immunity to the toxin, not the pathogen itself.

 

Examples of toxoid vaccines

• Diphtheria

• Tetanus

 

How is HPV spread

Sexual activity

What does the HPV vaccine prevent

• HPV infections

• cancer affecting the cervix, mouth, anus, penis, vulva and vagina

• genital warts

 

Which vaccine is given for HPV under NHS

• Gardasil 9,

• which protects against strains 6, 11, 16, 18, 31, 33, 45, 52 and 58

 

When is the BCG vaccine given

• offered at around 28 days old to newborns who are at higher risk of tuberculosis

•  It may also be given to children arriving from areas of high TB prevalence or in close contact with people who have TB.

 

What is post vaccination fever

• Fever can appear with vaccines.

• Most common with the MenB vaccine given at 8 weeks, 12 weeks and 12 months.

• Fever tends to peak around 6 hours post vaccine but can appear up to 48 hours after the vaccine.

 

What fluids given to children in septic shock

• For children under 16, the NICE guidelines recommend an initial 10 mL/kg bolus of a glucose-free crystalloid containing sodium of between 130-154 mmol/L (e.g., 0.9% sodium chloride), up to a maximum of 250 mL

  • Vasopressors

Their physical observations can be used to calculate the Paediatric Early Warning Score (PEWS) using age-specific ranges:

• Temperature

• Respiratory rate

• Heart rate

• Oxygen saturation

• Capillary refill time and blood pressure

  • Consciousness level

Key factors to consider when assessing a child for suspected sepsis include:

• History of fever

• Recent presentations (e.g., to their GP or A&E)

• Poor oral intake

• Reduced urine output

• Reduced consciousness

• Reduced body tone (floppy)

• Weak cry or inconsolable

• Skin colour changes (cyanosis, mottled, pale or ashen)

• Non-blanching rashes (meningococcal disease)

  • Skin breaks that could lead to infection (e.g., cuts)

Immediate management of paediatric sepsis

• Giving oxygen if the patient has evidence of shock or oxygen saturations are below 94%

• Obtaining IV access (cannulation)

• Blood tests, including a FBC, U&E, LFT, CRP and clotting screen

• Blood gas for lactate and glucose

• Blood cultures, ideally before giving antibiotics, provided it does not cause a delay

• Urine sample for dipstick testing and sent to the lab for microscopy, culture and sensitivities

• IV antibiotics within 1 hour for suspected sepsis with high-risk features, according to local guidelines

• IV fluids for shock or signs of poor perfusion