Flashcards in Paeds 3 Deck (59)
How is nocturnal enuresis defined?
involuntary wetting during sleep, without any inherent suggestion of frequency or pathophysiology.
generally considered to be normal in children younger than 5 years of age
Describe the different types of enuresis
primary without daytime symptoms - the child has never achieved sustained continence at night and does not have daytime symptoms.
primary with daytime symptoms - the child has never achieved sustained continence at night and has daytime symptoms such as urgency, frequency, daytime wetting, abdominal straining, or poor urinary stream, or pain passing urine.
secondary - bedwetting occurs after the child has been dry at night for more than 6 months
What are the causes of primary enuresis without daytime symptoms
Sleep arousal difficulties — inability to wake to noise, the sensation of a full bladder, or bladder contractions.
Polyuria — a larger than normal production of urine at night which is greater than bladder capacity.
Bladder dysfunction — a small bladder capacity or overactive bladder.
What are the causes of primary enuresis with daytime symptoms
An overactive bladder.
Structural abnormalities (for example ectopic ureter).
Neurological disorders (for example neurogenic bladder secondary to spinal dysraphism).
Urinary tract infection.
What are the causes of secondary enuresis
urinary tract infection,
psychological problems (for example behavioural or emotional problems),
family problems (vulnerable child or family)
What are the risk factors for enuresis
delay in development
psych or behavioral problems - ADHD, ASD, anxiety, depression, conduct disorder
What questions are important to ask in a history of enuresis
primary or secondary
any day time symptoms
medical or physical tigger
social, emotional or enviromental problems
What would be red flags for child maltreatment in an enuresis history
parents blaming the child - think the child is wetting onpurpose
punishments for bedwetting
bedwetting persists after adequate managment
What investigaitons could be done in enuresis
urinalysis if started recently, daytime symptoms, child seems unwell or history suggesting UTI/diabetes
ask parents to keep diary with fluid intake, toilet use and wetting recorded
What is the management for enuresis
<7y - usually resolves over time. ensure fluid intake not excessive, encourage to empty bladder before bed
>7y - first line is enuresis alarm
if daytime symptoms, need referral
if secondary, exclude cause before referral
Describe the enuresis alarm and its usefulness
most effective long term treatment
useful in those >7y
An enuresis alarm has a sensor pad which senses wetness. The sensor is linked to an alarm which wakes the child if it becomes wet. There are two main types of enuresis alarms:
Beside alarms — where a noise box is placed next the child's bed and a sensor pad is positioned under a draw sheet beneath the child in the bed.
Body-worn alarms — where a tiny sensor is attached to the child's pants for example between two pairs of tightly fitting underpants and the alarm is worn on the pyjama top.
contunue to use until 14 dry nights in a row
Who might an enuresis alarm not be suitable for?
The child or parents and carers do not want to use one.
The child wets the bed (infrequently) less than once or twice a week.
Parents or carers have emotional difficulty coping with the burden of bedwetting.
Parents or carers express anger, negativity, or blame towards the child.
The child is younger than 7 years of age and is not able to use an alarm.
What are the signs of response to enuresis alarm treatment
Smaller wet patches.
Waking to the alarm.
The alarm going off later and fewer times per night.
Fewer wet nights.
Describe the mechanism of action of desmopressin and its usefulness in managing enuresis
ADH analogue so reduces quantity of urine produced
used in short term management if:
A rapid onset in improvement or a short-term improvement is required (for example for sleepovers or school trips).
The child or parents or carers are unable to use an alarm or do not want to use a alarm as first-line treatment.
The child or parents and carers are currently using an alarm and want to stop.
How should desmopressin be taken?
take at bedtime
sips only from one hour before taking until 8 hours after taking - reduces risk of hyponatraemia and fluid overload
When can desmopressin not be prescribed
What is necrotising enterocolitis
vascular, mucosal, toxic and other insults to the immature gut leads to serious intestinal injury
damage to the mucosa leads to the spread of commensal organisms
What are the features of necrotising enterocolitis
occurs in preterm or very low birth weight neonates
in first two weeks of life
bloody mucoid stool
abdominal distension and erythema
intestinal loops visible
abdominal mass present/ascites
reduced bowel sounds
bradycardia, lethargy, shock, apnoea, resp distress
What investigations should be done in suspected necrotising enterocolitis
FBC CRP VBG U+E
What can be seen on AXR in necrotising enterocolitis
gas filled loops of bowel
pneumatosis intestinalis = intramural gas
portal venous gas
What is the management of necrotising enterocolitis
NBM - bowel rest
NG tube to decompress bowel with intermittent suction
IV abx - cefotaxime + metronidazole
intubation or ventilation if apnoea
surgery if perforation/necrotic bowel
What are the potential complications of necrotising enterocolitis
Acquired short bowel syndrome (following surgery).
Sepsis and shock.
Intestinal strictures (~30%).
Iatrogenic complications - eg, central venous catheter-related thrombotic events and nosocomial infections, metabolic complications secondary to prolonged hyperalimentation (a nutrient mixture given to premature babies before giving milk).
How can necrotising enterocolitis be prevented?
small feeds - increase volume slowly
What is coeliac disease?
autoimmune condition in which glutens activate an abnormal mucosal response leading to chronic inflammation and damage (mucosal atrophy) to the lining of the small intestine
What are the risk factors for coeliac disease
FH - first degree relatives
genetic - HLA DQ2 and HLA DQ8
other automimmune - T1DM, automimmune thyroid
down's, turner's william's syndromes
What are the symptoms of coeliac disease
failure to thrive
prolonged and unexplained diarrhoea, bloating, constipation, indigestion
mouth ulcers - severe or persistent
What skin condition is associated with coeliac disease
Describe dermatitis herpetiformis
on extensor surfaces, scalp and natal cleft
vesciles or papules on erythematous patch of skin
How is dermatitis herpetiformis treated