AKT Questions

1. In accordance with recent NICE guidelines on urinary tract infection in children, which one of the following patients would not require a urine sample to be obtained?

A. 4-year-old with a 5 day history of urinary frequency
B. 2-year-old who has a persistent pyrexia after 48 hours of antibiotic treatment for otitis media
C. 16-month-old complaining of abdominal pain
D. 2-month-old who is feeding poorly and vomiting
E. 3-year-old with a temperature of 37.7ºC who is well and has no obvious focus of infection

Answer: E

Urinary tract infection in children: features, diagnosis and management
Urinary tract infections (UTI) are more common in boys until 3 months of age (due to more congenital abnormalities) after which the incidence is substantially higher in girls. At least 8% of girls and 2% of boys will have a UTI in childhood

Presentation in childhood depends on age:

infants: poor feeding, vomiting, irritability
younger children: abdominal pain, fever, dysuria
older children: dysuria, frequency, haematuria
features which may suggest an upper UTI include: temperature > 38ºC, loin pain/tenderness

NICE guidelines for checking urine sample in a child
if there are any symptoms or signs suggestive or a UTI with unexplained fever of 38°C or higher (test urine after 24 hours at the latest)
with an alternative site of infection but who remain unwell (consider urine test after 24 hours at the latest)

Urine collection method

clean catch is preferable
if not possible then urine collection pads should be used
cotton wool balls, gauze and sanitary towels are not suitable
invasive methods such as suprapubic aspiration should only be used if non-invasive methods are not possible

Management
infants less than 3 months old should be referred immediately to a paediatrician
children aged more than 3 months old with an upper UTI should be considered for admission to hospital. If not admitted oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days
children aged more than 3 months old with a lower UTI should be treated with oral antibiotics for 3 days according to local guidelines, usually trimethoprim, nitrofurantoin, cephalosporin or amoxicillin. Parents should be asked to bring the children back if they remain unwell after 24-48 hours
antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs

2. An 8-year-old boy is reviewed in clinic due to nocturnal enuresis. Of the following options, what is the most appropriate initial management strategy?
A. Enuresis alarm
B. Trial of oral desmopressin
C. Trial of imipramine
D. Trial of intranasal desmopressin
E. Discourage fluids at night

Answer: A

A reward based system may also be used as a first line treatment in enuresis. Restricting fluids is not recommended advice - Clinical Knowledge Summaries suggest: 'Do not restrict fluids. The child should have about eight drinks a day, spaced out throughout the day, the last one about 1 hour before bed.'
Nocturnal enuresis
The majority of children achieve day and night time continence by 3 or 4 years of age. Enuresis may be defined as the 'involuntary discharge of urine by day or night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract'Nocturnal enuresis can be defined as either primary (the child has never achieved continence) or secondary (the child has been dry for at least 6 months before)Management
dip urine for protein and sugar, send for culture (helps exclude diabetes mellitus and UTI)
explanation, reassurance and education (e.g. avoid punitive measures)
star charts are useful (the child earns a star for a dry night)
if star charts fail then alarms which awake the child following a wetting episode may be tried

3. At what age would the average child acquire the ability to crawl?

A. 6 months
B. 9 months
C. 12 months
D. 18 months
E. 2 years

Answer: B

The table below summarises the major gross motor developmental milestones


Age - Milestone
3 months
Little or no head lag on being pulled to sitLying on abdomen, good head controlHeld sitting, lumbar curve
6 months
Lying on abdomen, arms extendedLying on back, lifts and grasps feetPulls self to sittingHeld sitting, back straightRolls front to back
9 months
Sits without support (Refer at 12 months)Pulls to standingCrawls
12 months
CruisesWalks with one hand held
15 months
Walks unsupported (Refer at 18 months)
18 months
Squats to pick up a toy
2 years
RunsWalks upstairs and downstairs holding on to rail
3 years
Rides a tricycle using pedalsWalks up stairs without holding on to rail
4 years
Hops on one leg

Notes
the majority of children crawl on all fours before walking but some children 'bottom-shuffle'. This is a normal variant and runs in families

4. A 9-year-old boy is brought to surgery as his asthma has been getting worse over the past 2 days. His mother is concerned that his breathing is getting worse and not responding to inhaled salbutamol as normal. Which one of the following is consistent with a life-threatening asthma attack?
A. Quiet breath sounds on auscultation
B. SpO2 of 94%
C. Heart rate of 120 bpm
D. Respiratory rate of 30 / minute
E. Peak flow 40% of predicted

Answer: A

Quiet breath sounds in a child with asthma is a worrying feature. Children with asthma normally have an obvious bilateral wheeze - the absence of this may suggest a life-threatening asthma attack

Asthma in children: assessment of acute attacks
The table below summarises the grading of asthma attacks in children between 2 and 5 years of age
Moderate attack
SpO2 > 92%No clinical features of severe asthma
Severe attack
SpO2 <> 130/minRespiratory rate > 50/minUse of accessory neck muscles
Life-threatening attack
SpO2 <92%Silent chestPoor respiratory effortAgitationAltered consciousnessCyanosis

The table below summarises the grading of asthma attacks in children greater than 5 years of age
Moderate attack
SpO2 > 92%PEF > 50% best or predictedNo clinical features ofsevere asthma
Severe attack
SpO2 <> 120/minRespiratory rate > 30/minUse of accessory neck muscles
Life-threatening attack
SpO2 < 92%PEF < 33% best or predictedSilent chestPoor respiratory effortAltered consciousnessCyanosis