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Question 1
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You assess a 6-year-old boy who has been experiencing a persistent cough for the past 2 weeks after a recent upper respiratory tract infection. Upon examination, there are no notable findings. The child's mother is interested in trying a cough syrup to alleviate his symptoms, as it is causing him to have difficulty sleeping at night. Which of the following options could be considered?
Your Answer: Simple linctus (paediatric)
Explanation:Changes in Regulation of Over-the-Counter Cough and Cold Remedies for Children
In 2009, the Medicines and Healthcare products Regulatory Agency (MHRA) and Commission on Human Medicines (CHM) made a significant change in the regulation of over-the-counter (OTC) cough and cold remedies for children. The change affected medicines containing various ingredients, including cough suppressants, expectorants, nasal decongestants, and antihistamines. These ingredients, such as dextromethorphan, guaifenesin, ephedrine, and chlorphenamine, were found to be potentially harmful to children under the age of 6 years. As a result, products with these ingredients should be avoided in young children. For children aged 6-12 years, products containing these ingredients will only be available after consultation with a pharmacist. This change in regulation aims to ensure the safety of children when using OTC cough and cold remedies.
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This question is part of the following fields:
- Children And Young People
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Question 2
Incorrect
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You receive a call from the mother of a 2-year-old boy who has been suffering from a suspected viral upper respiratory tract infection for the past few days. The mother reports that the child has just had a seizure, and three months ago, he had a confirmed febrile convulsion after a similar illness. You schedule an appointment to see the child that morning. What factor should indicate the need for referral to paediatrics?
Your Answer: A family history of epilepsy
Correct Answer: The child still being drowsy 2 hours after the seizure
Explanation:If a child remains drowsy for more than an hour, it is unlikely that they are experiencing a ‘simple’ febrile convulsion. A tonic-clonic seizure is a common occurrence and should not cause concern. Additionally, the presence of a confirmed infection focus, such as otitis media, should provide reassurance rather than necessitating hospitalization.
Febrile convulsions are seizures that occur in otherwise healthy children when they have a fever. They are most common in children between the ages of 6 months and 5 years, affecting around 3% of children. Febrile convulsions usually occur at the onset of a viral infection when the child’s temperature rises rapidly. The seizures are typically brief, lasting less than 5 minutes, and are usually tonic-clonic in nature.
There are three types of febrile convulsions: simple, complex, and febrile status epilepticus. Simple febrile convulsions last less than 15 minutes and are generalised seizures. Complex febrile convulsions last between 15 and 30 minutes and may be focal seizures. Febrile status epilepticus lasts for more than 30 minutes. Children who have had their first seizure or any features of a complex seizure should be admitted to paediatrics.
Following a seizure, parents should be advised to call an ambulance if the seizure lasts longer than 5 minutes. Regular antipyretics have not been shown to reduce the chance of a febrile seizure occurring. If recurrent febrile convulsions occur, benzodiazepine rescue medication may be considered, but this should only be started on the advice of a specialist, such as a paediatrician. Rectal diazepam or buccal midazolam may be used.
The overall risk of further febrile convulsions is 1 in 3, but this varies depending on risk factors for further seizure. These risk factors include age of onset under 18 months, fever below 39ºC, shorter duration of fever before the seizure, and a family history of febrile convulsions. Children with no risk factors have a 2.5% risk of developing epilepsy, while those with all three risk factors have a much higher risk of developing epilepsy, up to 50%.
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This question is part of the following fields:
- Children And Young People
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Question 3
Incorrect
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A 12-month-old girl comes in with a unilateral purulent nasal discharge and worsening bad breath over the past few days. However, she doesn't exhibit any systemic symptoms. What is the probable diagnosis?
Your Answer: Nasal foreign body
Correct Answer: Allergic rhinitis
Explanation:Unilateral Discharge in Children: A Possible Sign of Foreign Body
The occurrence of unilateral discharge in an otherwise healthy child may indicate the presence of a foreign body, especially in this age group. It is important to consider the child’s history to determine the possible cause of the discharge. If a foreign body is suspected, prompt removal is necessary to prevent further complications. Fortunately, removal of the foreign body is usually curative and can alleviate the symptoms.
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This question is part of the following fields:
- Children And Young People
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Question 4
Incorrect
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Which one of the following is an example of a primary accident prevention strategy?
Your Answer: Cycling helmets
Correct Answer: Stair guards
Explanation:Accidents and Preventive Healthcare
Accidents are a common cause of childhood deaths, with road traffic accidents being the most common cause of fatal accidents. Boys and children from lower social classes are more likely to have an accident. Around 15-20% of children attend Emergency Departments in the course of a year due to an accident. Preventive healthcare can be divided into primary, secondary, and tertiary prevention strategies. Primary prevention aims to prevent accidents or diseases from happening, while secondary prevention aims to prevent injury from the accident or disease. Tertiary prevention aims to limit the impact of the injury. Examples of preventive healthcare strategies include teaching road safety, wearing seat belts, and teaching parents first aid. Some strategies, such as reducing driving speed, may have a role in both primary and secondary accident prevention. By implementing these strategies, we can reduce the number of accidents and improve the overall health and safety of children.
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This question is part of the following fields:
- Children And Young People
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Question 5
Incorrect
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You are seeing a 4-year-old child who has been brought back to the clinic one afternoon having been seen by a colleague in the morning.
You review the notes from this morning's consultation which show that the child presented with a fever and malaise and that a suspected viral infection was diagnosed and advice given accordingly. The mother reports that the child has become increasingly drowsy and hasn't really drunk anything since being seen earlier. Despite regular paracetamol a fever has persisted.
You examine the child who is clearly lethargic. Tympanic temperature is 38.1°C. The child is undressed and you find several non-blanching spots on the lower legs.
The clinical record states that the child is allergic to penicillin; you ask the mother who says that when he was given it in the past for a sore throat he came out in a rash on his trunk which resolved when the antibiotics were stopped.
What is the most appropriate initial treatment to institute acutely in the community?Your Answer: No antibiotic treatment, rapid hospital transfer only
Correct Answer: Gentamicin
Explanation:Management of Suspected Meningococcal Septicaemia in Children
When a child presents with suspected meningococcal septicaemia, it is crucial to note the presence of a non-blanching rash. Immediate administration of parenteral antibiotics is necessary, and it will not delay hospital transfer. In such cases, calling a 999 ambulance and administering antibiotics in the interim is recommended.
Benzylpenicillin can be given intramuscularly or intravenously, except in children with a clear history of anaphylaxis after a previous dose. A history of rash following penicillin use is not a contraindication.
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This question is part of the following fields:
- Children And Young People
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Question 6
Incorrect
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A 7-year-old girl presents to your clinic with a blanching rash that started on her abdomen and chest before spreading to her neck, legs, and arms. The rash is rough and has a sandpaper-like texture. She reports feeling feverish with a temperature of 38.5 ºC, a sore throat, and nausea two days before the rash appeared. On examination, you note her tongue has a beefy, red appearance and prominent cervical lymphadenopathy. You suspect scarlet fever. The patient has no significant medical history and no allergies. Hospital admission is not necessary. What is the most appropriate management option in primary care?
Your Answer: Notify public health england (PHE) and commence 10 days of oral azithromycin
Correct Answer: Notify public health england (PHE) and commence 10 days of oral phenoxymethylpenicillin (penicillin V)
Explanation:Scarlet fever is a condition caused by erythrogenic toxins produced by Group A haemolytic streptococci, usually Streptococcus pyogenes. It is more common in children aged 2-6 years, with the highest incidence at 4 years. The disease is spread through respiratory droplets or direct contact with nose and throat discharges. The incubation period is 2-4 days, and symptoms include fever, malaise, headache, sore throat, ‘strawberry’ tongue, and a rash that appears first on the torso and spares the palms and soles. Scarlet fever is usually a mild illness, but it may be complicated by otitis media, rheumatic fever, acute glomerulonephritis, or rare invasive complications.
To diagnose scarlet fever, a throat swab is usually taken, but antibiotic treatment should be started immediately, rather than waiting for the results. Management involves oral penicillin V for ten days, while patients with a penicillin allergy should be given azithromycin. Children can return to school 24 hours after starting antibiotics, and scarlet fever is a notifiable disease. Desquamation occurs later in the course of the illness, particularly around the fingers and toes. The rash is often described as having a rough ‘sandpaper’ texture, and children often have a flushed appearance with circumoral pallor. Invasive complications such as bacteraemia, meningitis, and necrotizing fasciitis are rare but may present acutely with life-threatening illness.
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This question is part of the following fields:
- Children And Young People
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Question 7
Incorrect
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As part of the UK immunisation schedule, which immunisation is administered to a 65-year-old who is in good health?
Your Answer: Haemophilus influenza
Correct Answer: Pneumococcal
Explanation:Pneumococcal Vaccines
There are two types of pneumococcal vaccines available – the pneumococcal conjugate vaccine (PCV) and the pneumococcal polysaccharide vaccine (PPV). The PCV vaccine is given to children under the age of 2, with a booster at 1 year old. On the other hand, the PPV vaccine is given to individuals over the age of 2, particularly those who are 65 years old and above.
Moreover, individuals with certain medical conditions are also eligible for the pneumococcal vaccine. These include those with asplenia or splenic dysfunction, cochlear implants, chronic respiratory or heart disease, chronic neurological conditions, diabetes, chronic kidney disease stage 4/5, chronic liver disease, immunosuppression due to disease or treatment, and complement disorders (including those receiving complement inhibitor treatment).
Getting vaccinated against pneumococcal disease is important in preventing serious illnesses such as pneumonia, meningitis, and blood infections. It is recommended to consult with a healthcare provider to determine the appropriate vaccine and schedule for each individual.
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This question is part of the following fields:
- Children And Young People
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Question 8
Incorrect
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A 10-month old baby is brought in for a developmental review by his parents. He is able to sit without support, crawl, and pull himself up to stand. He shows a preference for using his left hand for most activities. He has a weak pincer grip and can point at objects.
However, he is unable to walk without support, even with one hand. He has not yet said mama or dada but does understand the word no. He also doesn't respond to his own name.
Which of these findings is the most concerning?Your Answer: Inability to say 'mama' or 'dada'
Correct Answer: Left-handedness
Explanation:Having a hand preference before the age of 12 months is not normal and could be a sign of cerebral palsy. The child’s left-handedness is not a concern, but their early hand preference is. By 12 months, children should be able to walk with support from one parent and respond to their name. They should only be able to walk independently between 13-15 months. While 9-month old babies can typically say mama and dada, it is too early to worry about this in the child’s case.
Common Developmental Problems and Their Causes
Developmental problems can manifest in various ways, including referral points, fine motor skill problems, gross motor problems, and speech and language problems. Referral points may include a lack of smiling at 10 weeks, inability to sit unsupported at 12 months, and inability to walk at 18 months. Fine motor skill problems may be indicated by abnormal hand preference before 12 months, which could be a sign of cerebral palsy. Gross motor problems are often caused by a variant of normal, cerebral palsy, or neuromuscular disorders like Duchenne muscular dystrophy. Speech and language problems should always be checked for hearing issues, but other causes may include environmental deprivation and general developmental delay. It is important to identify and address these developmental problems early on to ensure the best possible outcomes for the child’s future.
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This question is part of the following fields:
- Children And Young People
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Question 9
Incorrect
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A 6-year-old girl has been suffering from constipation and soiling for many months and her mother feels that something needs to be done now that she is starting school. She was born after a normal delivery and had no problems until the age of three. On physical examination, the only obvious abnormality is a loaded colon.
What is the most appropriate next step?Your Answer: Treat the child for Hirschsprung’s disease
Correct Answer: Check for related symptoms of systemic disease
Explanation:Approach to Constipation in Children: Consider Systemic Disease and Avoid Stimulant Laxatives and Enemas
Constipation in children can have various organic causes, such as anorectal malformations, but when a systemic disease is the underlying issue, other symptoms of that disease are likely to be present. Therefore, it is important to check for related symptoms of systemic disease. For instance, hypothyroidism may cause constipation along with a goitre, slow growth, weight gain, and intolerance to cold. Diabetes mellitus or diabetes insipidus may cause constipation due to associated polyuria.
Stimulant laxatives may be necessary in some cases, but macrogols should be the first-line treatment for constipation in children. Hirschsprung’s disease is a possible cause of chronic constipation, but it usually presents early in life, and functional constipation is more common. Reassuring parents that their child will grow out of constipation is not advisable, as prompt treatment can help resolve symptoms sooner.
Enemas should be avoided if possible, as they can cause emotional and physical trauma. If necessary, the child should be admitted to the hospital for this procedure. Overall, a thorough evaluation of the child’s symptoms and medical history is necessary to determine the best approach to managing constipation.
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This question is part of the following fields:
- Children And Young People
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Question 10
Incorrect
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Which one of the following statements regarding developmental dysplasia of the hip is true?
Your Answer: The Ortolani test attempts to dislocate an articulated femoral head
Correct Answer: 20% of cases are bilateral
Explanation:Developmental dysplasia of the hip (DDH) is a condition that affects 1-3% of newborns and is more common in females, firstborn children, and those with a positive family history or breech presentation. It used to be called congenital dislocation of the hip (CDH). DDH is more often found in the left hip and can be screened for using ultrasound in infants with certain risk factors or through clinical examination using the Barlow and Ortolani tests. Other factors to consider include leg length symmetry, knee level when hips and knees are flexed, and restricted hip abduction in flexion. Ultrasound is typically used to confirm the diagnosis, but x-rays may be necessary for infants over 4.5 months old. Management options include the Pavlik harness for younger children and surgery for older ones. Most unstable hips will stabilize on their own within 3-6 weeks.
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This question is part of the following fields:
- Children And Young People
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Question 11
Incorrect
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A 12-year-old boy with cystic fibrosis comes to the clinic with abrupt onset of intense pleuritic chest pain. There is no record of hemoptysis. During the examination, he has a normal body temperature but an elevated respiratory rate and reports sharp chest pain with every inhalation. The pain is localized to the right side of his chest. Auscultation reveals breath sounds on both sides. What is the most probable diagnosis?
Your Answer:
Correct Answer: Spontaneous pneumothorax
Explanation:Pneumothorax in Children with Cystic Fibrosis
Pneumothorax is a known complication of cystic fibrosis, and sudden onset of severe pleuritic chest pain is a common symptom. However, only large pneumothoraces give the classic reduced breath sounds and hyperresonant percussion note. Children with congenital lung disease like cystic fibrosis may develop small pneumothoraces, which can be difficult to diagnose due to airflow limitation.
If a child with cystic fibrosis presents with sudden onset of severe pleuritic chest pain, they should be referred to the hospital for a chest X-ray to confirm the diagnosis and assess the need for drainage. Pneumothoraces can also occur due to chest trauma or pneumonia infection.
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This question is part of the following fields:
- Children And Young People
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Question 12
Incorrect
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The practice pediatrician has seen several adolescents with orthopaedic abnormalities and is uncertain about their management. You have been tasked with creating a tutorial on the subject. Which of these adolescent orthopaedic abnormalities is MOST LIKELY to require active intervention? Choose only ONE option.
Your Answer:
Correct Answer: Scoliosis in an 8-year-old girl
Explanation:Common Pediatric Orthopedic Conditions and Their Management
Scoliosis is a lateral curvature of the spine that can occur in children at different ages. Infantile scoliosis is more common in boys and may resolve spontaneously or progress to severe deformity. Juvenile and adolescent scoliosis are more common in girls and often require surgical intervention.
In toeing is a condition where the feet point inward when a child walks. It is most commonly due to internal tibial torsion in children under 2 years old, which usually resolves on its own. Over 2 years old, internal femoral torsion is the most common cause and can be treated by correcting abnormal sitting positions.
Bow legs, or genu varum, occur when the legs curve outward at the knee. This is usually caused by a tight posterior hip capsule and typically resolves by age 2. In severe cases, night splints or an osteotomy may be necessary. Rickets should be ruled out as a possible cause.
Flexible flat feet, or hypermobile pes planus, are common in young children and usually resolve by age 6. If the child experiences pain, difficulty walking, or trouble with shoes, ankle-stretch exercises and foot orthoses may be necessary.
Knock knees, or genu valgum, occur when the legs curve inward so that the knees touch but the feet are apart. This condition is usually benign and resolves by age 5-8. Surgery may be necessary if it persists beyond age 10.
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This question is part of the following fields:
- Children And Young People
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Question 13
Incorrect
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A 30-year-old woman brings her 4-year-old daughter to the surgery. According to both the family and the nursery she attends for day care, her left eye has become increasingly amblyopic, and she has developed a divergent squint. It appears also that she has become increasingly clumsy and has difficulty using stereoscopic vision to play with her lego.
She was born two months premature but has achieved normal milestones since and has had all of her planned vaccinations.
Which of the following is the most appropriate next step?Your Answer:
Correct Answer: Check for red reflex
Explanation:Importance of Red Reflex Assessment in Diagnosing Retinoblastoma
In cases where a patient presents with loss of the red reflex, it is crucial to rule out the development of a retinoblastoma. This is because retinoblastoma is the most common intraocular malignancy of childhood, and delay in diagnosis can have negative prognostic implications. Therefore, urgent referral to an ophthalmologist is necessary.
Diagnosis of retinoblastoma is typically confirmed through indirect dilated ophthalmoscopy under anaesthetic. Referral to a community optician or non-urgent referral to an ophthalmologist can result in significant delays in diagnosis, making both options inappropriate. While referral to an optician may seem like a viable option, testing the red reflex is a quick and easy procedure that a GP can perform themselves.
Re-examining the patient in six weeks is not a suitable course of action as it will only delay diagnosis. In situations where loss of the red reflex is present, reassurance is not appropriate, and urgent referral for further assessment is necessary. Therefore, it is essential to prioritize red reflex assessment in diagnosing retinoblastoma.
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This question is part of the following fields:
- Children And Young People
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Question 14
Incorrect
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A worried father brings his 14 month old child into the clinic, concerned that he is not walking. He says that many other children his age in his playgroup are already walking but his child is still crawling.
At what age would you consider referring a child who is not yet walking?Your Answer:
Correct Answer: 18 months
Explanation:Further assessment should be sought if a child is unable to walk without support by the age of 18 months.
Gross Motor Developmental Milestones
Gross motor developmental milestones refer to the physical abilities that a child acquires as they grow and develop. These milestones are important indicators of a child’s overall development and can help parents and healthcare professionals identify any potential delays or concerns. The table below summarizes the major gross motor developmental milestones from 3 months to 4 years of age.
At 3 months, a baby should have little or no head lag when pulled to sit and should have good head control when lying on their abdomen. By 6 months, they should be able to pull themselves to a sitting position and roll from front to back. At 9 months, they should be able to crawl and pull themselves to a standing position. By 12 months, they should be able to cruise and walk with one hand held. At 18 months, they should be able to walk unsupported and squat to pick up a toy. By 2 years, they should be able to run and walk up and down stairs holding onto a rail. At 3 years, they should be able to ride a tricycle using pedals and walk up stairs without holding onto a rail. Finally, at 4 years, they should be able to hop on one leg.
It is important to note that while the majority of children crawl on all fours before walking, some children may bottom-shuffle, which is a normal variant that runs in families. By monitoring a child’s gross motor developmental milestones, parents and healthcare professionals can ensure that they are meeting their developmental goals and identify any potential concerns early on.
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This question is part of the following fields:
- Children And Young People
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Question 15
Incorrect
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Who is recommended to receive the Human Papillomavirus (HPV) immunisation according to the January 2020 UK immunisation update?
Your Answer:
Correct Answer: Boys aged 10 to 12
Explanation:Changes to UK Immunisation Schedule in 2020
In January 2020, the UK immunisation schedule was updated with a few minor changes. It is important to stay up-to-date with these changes as they may be tested in exams. One change to note is that both boys and girls should receive the HPV immunisation at the age of 12 to 13. This is an important step in protecting against certain types of cancer caused by the human papillomavirus. It is recommended that parents and healthcare providers ensure that children receive this immunisation at the appropriate age.
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This question is part of the following fields:
- Children And Young People
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Question 16
Incorrect
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Sophie is a 2-year-old girl who is brought in by her father. She has had a fever overnight, along with a sore throat and cough. Her father is worried that she seems more tired than usual today. During the examination, you note the following:
Temperature 38.5 degrees
Heart rate 160 bpm
Respiratory rate 40 / min
Oxygen saturation 95%
The lungs are clear, but there is inflammation and redness in the throat, and there are swollen lymph nodes in the neck.
According to the NICE traffic light system for assessing fever in children, which of the following is considered 'amber'?Your Answer:
Correct Answer: Heart rate 155 bpm
Explanation:The NICE Feverish illness in children guidelines were introduced in 2007 and updated in 2013 to provide a ‘traffic light’ system for assessing the risk of febrile illness in children under 5 years old. The guidelines recommend recording the child’s temperature, heart rate, respiratory rate, and capillary refill time, as well as looking for signs of dehydration. Measuring temperature should be done with an electronic thermometer in the axilla for children under 4 weeks or with an electronic/chemical dot thermometer in the axilla or an infra-red tympanic thermometer. The risk stratification table categorizes children as green (low risk), amber (intermediate risk), or red (high risk) based on their symptoms. Management recommendations vary depending on the risk level, with green children managed at home, amber children provided with a safety net or referred to a specialist, and red children urgently referred to a specialist. The guidelines also advise against prescribing oral antibiotics without an apparent source of fever and note that a chest x-ray is not necessary if a child with suspected pneumonia is not being referred to the hospital.
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This question is part of the following fields:
- Children And Young People
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Question 17
Incorrect
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A mother brings in her 7-year-old girl and is worried about her daughter's swollen, painful fingers. The mother describes the fingers as looking like sausages when they are swollen. You observe that the patient has had previous consultations for joint pains in her knees and hands. During the examination, you notice some nail pitting.
What is the MOST LIKELY diagnosis?Your Answer:
Correct Answer: Septic arthritis
Explanation:Types of Juvenile Arthritis and Their Symptoms
Juvenile arthritis is a condition that affects children and adolescents, causing joint pain, swelling, and stiffness. There are different types of juvenile arthritis, each with its own set of symptoms. It is important to identify the type of arthritis a child has in order to provide appropriate treatment.
Juvenile psoriatic arthritis is a type of arthritis that should be considered if a child has arthritic symptoms along with dactylitis, nail pitting, or nail onycholysis, even if there is no personal or family history of psoriasis. This is because arthritis can occur before psoriasis develops.
Enthesis-related JIA should be considered if the arthritis is associated with inflammation at the site of a tendon or ligament insertion, such as heel pain.
Oligoarticular JIA should be considered if the arthritis is affecting up to four joints for over six months, often presenting with joint swelling and stiffness but with no or mild pain.
Septic arthritis and Systemic JIA are usually associated with fever and do not explain the nail pitting or dactylitis.
In summary, identifying the type of juvenile arthritis a child has is crucial for proper treatment. Symptoms such as dactylitis, nail pitting, and inflammation at the site of a tendon or ligament insertion can help differentiate between different types of juvenile arthritis.
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This question is part of the following fields:
- Children And Young People
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Question 18
Incorrect
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A young woman who is ten weeks pregnant comes to you with an erythematous rash, mild fever and enlarged glands in her neck. You suggest taking a blood test to check if she is immune to rubella since there is no record of her being immunised. She asks about the potential risk to her baby if she does have rubella. What is the percentage of infants that may develop congenital rubella syndrome and potential birth defects if a woman contracts rubella at ten weeks gestation?
Your Answer:
Correct Answer: Up to 90%
Explanation:Maternal Rubella Infection in Pregnancy
Maternal rubella infection during pregnancy can lead to fetal loss or congenital rubella syndrome (CRS). CRS is characterized by various abnormalities such as cataracts, deafness, cardiac defects, microcephaly, retardation of intrauterine growth, and inflammatory lesions in the brain, liver, lungs, and bone marrow.
If the infection occurs within the first eight to ten weeks of pregnancy, up to 90% of surviving infants may experience damage, often with multiple defects. However, the risk of damage decreases to about 10-20% if the infection occurs between 11 and 16 weeks of gestation. Infections after 16 weeks of pregnancy are rare and typically only result in deafness, with no other fetal damage reported up to 20 weeks of pregnancy.
Overall, maternal rubella infection during pregnancy can have severe consequences for the developing fetus, highlighting the importance of vaccination and prevention measures.
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This question is part of the following fields:
- Children And Young People
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Question 19
Incorrect
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A 5-year-old boy comes to your morning clinic with his father. His father reports that he has been feeling unwell for the past 24 hours with a fever, sore throat and eating less than usual. This morning he developed a rash. His father has been encouraging fluids and has given paracetamol. He has no significant medical history and is up to date with his immunisations.
On examination, he is alert and talkative but looks slightly flushed. His temperature is 37.5 ºC, heart rate 95 bpm, respiratory rate 22/min, capillary refill time 1 second. He has moist mucous membranes, his tonsils are not inflamed, he has a strawberry tongue. There is a rough, pinpoint, erythematous blanching rash on his torso.
You prescribe a 10-day course of penicillin V and give adequate safety netting. His father asks if he can return to school as he feels he is well enough.
When can he go back to school?Your Answer:
Correct Answer: 24 hours after starting antibiotics
Explanation:After beginning a course of antibiotics, a child with scarlet fever is able to return to school after 24 hours. This particular girl displayed the typical symptoms and signs of scarlet fever, which is a notifiable disease that is treated with 10 days of penicillin V (or azithromycin for those with a genuine penicillin allergy, taken once a day for 5 days). Based on the clinical and immunisation history, it was less probable that the child had measles or rubella, both of which allow for a return to school 4 days after the rash appears. Children with whooping cough can also return to school under certain circumstances.
Scarlet fever is a condition caused by erythrogenic toxins produced by Group A haemolytic streptococci, usually Streptococcus pyogenes. It is more common in children aged 2-6 years, with the highest incidence at 4 years. The disease is spread through respiratory droplets or direct contact with nose and throat discharges. The incubation period is 2-4 days, and symptoms include fever, malaise, headache, sore throat, ‘strawberry’ tongue, and a rash that appears first on the torso and spares the palms and soles. Scarlet fever is usually a mild illness, but it may be complicated by otitis media, rheumatic fever, acute glomerulonephritis, or rare invasive complications.
To diagnose scarlet fever, a throat swab is usually taken, but antibiotic treatment should be started immediately, rather than waiting for the results. Management involves oral penicillin V for ten days, while patients with a penicillin allergy should be given azithromycin. Children can return to school 24 hours after starting antibiotics, and scarlet fever is a notifiable disease. Desquamation occurs later in the course of the illness, particularly around the fingers and toes. The rash is often described as having a rough ‘sandpaper’ texture, and children often have a flushed appearance with circumoral pallor. Invasive complications such as bacteraemia, meningitis, and necrotizing fasciitis are rare but may present acutely with life-threatening illness.
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This question is part of the following fields:
- Children And Young People
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Question 20
Incorrect
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A 5-year-old girl, who has been wetting the bed at night attends surgery today with her father, as her mother is at work. Her father is worried because it was also an issue for her older sister, who is 10-years-old and she is prescribed desmopressin. The girl in front of you is otherwise well and her bowels open regularly. An examination is unremarkable and she has a soft non-tender abdomen.
What recommendations would you make?Your Answer:
Correct Answer: Reassurance and general advice
Explanation:Reassurance and advice can be provided to manage nocturnal enuresis in children under the age of 5 years.
Managing Nocturnal Enuresis in Children
Nocturnal enuresis, also known as bedwetting, is a common condition in children. It is defined as the involuntary discharge of urine during sleep in children aged 5 years or older who have not yet achieved continence. There are two types of nocturnal enuresis: primary and secondary. Primary enuresis occurs when a child has never achieved continence, while secondary enuresis occurs when a child has been dry for at least 6 months before.
When managing nocturnal enuresis, it is important to look for possible underlying causes or triggers such as constipation, diabetes mellitus, or recent onset urinary tract infections. General advice includes monitoring fluid intake and encouraging regular toileting patterns, such as emptying the bladder before sleep. Lifting and waking techniques and reward systems, such as star charts, can also be effective.
The first-line treatment for nocturnal enuresis is an enuresis alarm, which has a high success rate. These alarms have sensor pads that detect wetness and wake the child up when they start to wet the bed. If an enuresis alarm is not effective or not acceptable to the family, desmopressin can be used for short-term control, such as for sleepovers. It is important to note that reward systems should be given for agreed behavior rather than dry nights, such as using the toilet to pass urine before sleep. By following these management strategies, children with nocturnal enuresis can achieve continence and improve their quality of life.
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This question is part of the following fields:
- Children And Young People
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Question 21
Incorrect
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A 7-month-old infant comes in with a one day history of fever (39°C), and a generalised rash, which started on the legs and is now present on limbs and trunk virtually equally. The rash is purplish, non-palpable, and non-blanching. What is the most probable diagnosis?
Your Answer:
Correct Answer: Meningococcal septicaemia
Explanation:Meningococcal Septicaemia and Other Skin Conditions
Meningococcal septicaemia is a serious condition that can cause a non-blanching purpuric eruption all over the body. This symptom is a key indicator of the disease and should be taken seriously. Other skin conditions, such as giant urticaria, measles rash, and haemophilia, do not typically present with this type of rash.
Giant urticaria is characterised by recurrent attacks of oedema that appear suddenly in various areas of the body. The measles rash, on the other hand, appears as a macular eruption on the face and neck that spreads over three days. Haemophilia is not associated with any generalised rash.
HSP, another skin condition, may present in a subacute manner and is not typically associated with a high fever in an acutely unwell child. It may occur following an upper respiratory tract infection.
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- Children And Young People
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Question 22
Incorrect
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A 6-year-old girl presents to the clinic with complaints of dysuria. Upon examination, her temperature is 37.2ºC, her abdomen appears normal, and a urine dipstick test reveals the presence of leukocytes and nitrites. The patient has no significant medical history. Besides urine microscopy, what is the most suitable course of action for management?
Your Answer:
Correct Answer: Oral antibiotics for 3 days + follow-up if not settled
Explanation:Urinary Tract Infection in Children: Symptoms, Diagnosis, and Treatment
Urinary tract infections (UTIs) are more common in boys until 3 months of age, after which the incidence is substantially higher in girls. At least 8% of girls and 2% of boys will have a UTI in childhood. The presentation of UTIs in childhood depends on age. Infants may experience poor feeding, vomiting, and irritability, while younger children may have abdominal pain, fever, and dysuria. Older children may experience dysuria, frequency, and haematuria. Features that may suggest an upper UTI include a temperature of over 38ºC and loin pain or tenderness.
According to NICE guidelines, a urine sample should be checked in a child if there are any symptoms or signs suggestive of a UTI, with unexplained fever of 38°C or higher (test urine after 24 hours at the latest), or with an alternative site of infection but who remain unwell (consider urine test after 24 hours at the latest). A clean catch is the preferable method for urine collection. If not possible, urine collection pads should be used. Invasive methods such as suprapubic aspiration should only be used if non-invasive methods are not possible.
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 the 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.
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This question is part of the following fields:
- Children And Young People
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Question 23
Incorrect
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At what ages is the immunisation given as part of the routine UK schedule, specifically at 8 and 12 weeks?
Your Answer:
Correct Answer: Rotavirus
Explanation:Routine Childhood Immunisation Schedule
The routine childhood immunisation schedule is a crucial aspect of healthcare for young children. It protects them from a range of diseases that can cause serious harm or even death. The schedule includes vaccinations for diphtheria, tetanus, pertussis, polio, Hib, hepatitis B, pneumococcal disease, meningococcal group B, and rotavirus.
At 8 weeks, infants receive vaccinations for diphtheria, tetanus, pertussis, polio, Hib, hepatitis B, pneumococcal disease, meningococcal group B, and oral rotavirus. At 12 weeks, they receive vaccinations for diphtheria, tetanus, pertussis, polio, Hib, and oral rotavirus. At 16 weeks, they receive vaccinations for diphtheria, tetanus, pertussis, polio, Hib, hepatitis B, pneumococcal disease, and meningococcal group B.
It is important to note that the hepatitis B immunisation was added to the routine schedule in 2017, but not hepatitis A. Additionally, pneumococcal immunisation is given at 8 and 16 weeks, but not at 12 weeks, while meningococcal B immunisation is given at 8 and 16 weeks, but not at 12 weeks. Understanding the routine childhood immunisation schedule is crucial for healthcare professionals and parents alike to ensure the health and safety of young children.
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- Children And Young People
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Question 24
Incorrect
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A 4-year-old boy presents with croup to the out-of-hours centre. He has a temperature of 38.2°C, a respiratory rate of 24 breaths/min and a croupy cough. There is no intercostal recession.
What is the most appropriate treatment for him? Select ONE answer only.Your Answer:
Correct Answer: Oral dexamethasone
Explanation:Treatment Options for Croup: Choosing the Right Approach
Croup is a common respiratory illness in children that can cause coughing, difficulty breathing, and other symptoms. When it comes to treating croup, there are several options available, but not all of them are appropriate for every child. Here’s a breakdown of some common treatment options and when they might be used:
Oral Dexamethasone: For mild-to-moderate croup, a single oral dose of dexamethasone is often the best choice. This medication can help reduce inflammation in the airways and alleviate symptoms. If the child is too unwell to take oral medication, inhaled budesonide may be used instead.
Nebulised Epinephrine: For children with moderate-to-severe distress, nebulised epinephrine can be effective in reducing swelling in the trachea. However, this treatment only lasts for a few hours, so close monitoring is necessary.
Inhaling Humidified Air: While inhaling humidified air may help reduce a child’s anxiety, there is little evidence to suggest that it provides any significant symptomatic relief.
IM Hydrocortisone: IM hydrocortisone is not typically used to treat croup. However, IM dexamethasone may be used as an alternative to oral dexamethasone.
Nebulised Salbutamol: Salbutamol is not an appropriate treatment for croup, as it is typically used to treat asthma.
In summary, the best treatment for croup will depend on the severity of the child’s symptoms and their overall health. If you suspect that your child has croup, it’s important to seek medical attention promptly to ensure that they receive the appropriate care.
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This question is part of the following fields:
- Children And Young People
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Question 25
Incorrect
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Assuming the patient has no significant medical history, what is the recommended age for administering the Meningitis ACWY vaccine according to the UK immunisation schedule?
Your Answer:
Correct Answer: 8 weeks
Explanation:Understanding the Timing of Men ACWY Immunisation
When reading the introduction, it is important to pay attention to the specific type of immunisation being discussed. This question pertains to Men ACWY, not Men B. Misreading the question could lead to confusion about the correct timing of the immunisation. For Men ACWY in an otherwise healthy individual, the vaccine is administered at 14 years of age.
It is important to note that patients with certain medical conditions should also receive the Men ACWY vaccine. These conditions include asplenia or splenic dysfunction (including Coeliac disease and sickle cell disease) and complement disorders (including those receiving complement inhibitor therapy). By understanding the timing and circumstances in which Men ACWY immunisation is necessary, we can ensure the best possible protection against meningococcal disease.
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This question is part of the following fields:
- Children And Young People
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Question 26
Incorrect
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For which children is it necessary to defer their polio vaccination and refer them to a child specialist for additional guidance?
Your Answer:
Correct Answer: A child with uncontrolled epilepsy
Explanation:Polio Vaccination and Neurological Conditions
The Department of Health’s ‘Green Book’ provides guidelines for polio vaccination and neurological conditions. According to the book, stable pre-existing neurological conditions such as spina bifida and congenital brain abnormalities do not prevent polio vaccination. However, if a child has an unstable or deteriorating neurological condition, vaccination should be deferred, and the child should be referred to a specialist for further assessment and advice. This includes children with uncontrolled epilepsy.
It is important to note that a family history of seizures or epilepsy doesn’t prevent immunization. However, if there is a personal or family history of febrile seizures, there is an increased risk of these occurring after any fever, including post-immunization. In such cases, immunization should proceed as recommended, with advice on the prevention and management of fever beforehand.
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This question is part of the following fields:
- Children And Young People
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Question 27
Incorrect
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As a GP in a busy clinic, you are conducting a 2-month check on an infant. During the examination of the genital area and buttocks, you observe a rash. The rash doesn't affect the gluteal cleft and is made up of well-defined, merging red patches that have a beefy red appearance. Additionally, there are some isolated papules. The mother has been using Sudocrem daily for almost two weeks, but the issue has not been resolved.
What would be the most appropriate course of action for managing this patient?Your Answer:
Correct Answer: Prescribe topical antifungal
Explanation:The presence of well-defined, confluent patches that are beefy red and spare the gluteal cleft and inguinal regions suggest a candidal cause of nappy rash. The appearance of satellite papules also supports this diagnosis. Therefore, the best course of action would be to use a topical antifungal such as clotrimazole.
Calcipotriol, a vitamin D derivative used to treat psoriasis, would not be appropriate for a nappy rash caused by psoriasis, which is much less common than candidiasis. Psoriasis plaques typically display scaling, and the rash would likely be more widespread rather than confined to the buttocks and genitalia.
Referral to dermatology is not necessary in this case, as primary care can manage the problem effectively.
Continuing to use a barrier cream like Sudocrem can actually worsen fungal infections, so it is advisable to discontinue this treatment.
While hydrocortisone cream can help reduce inflammation, it will not treat the underlying candidal infection. Therefore, a topical antifungal is the best option for managing the condition.
Understanding Napkin Rashes and How to Manage Them
Napkin rashes, also known as nappy rashes, are common skin irritations that affect babies and young children. The most common cause of napkin rash is irritant dermatitis, which is caused by the irritant effect of urinary ammonia and faeces. This type of rash typically spares the creases. Other causes of napkin rash include candida dermatitis, seborrhoeic dermatitis, psoriasis, and atopic eczema.
To manage napkin rash, it is recommended to use disposable nappies instead of towel nappies and to expose the napkin area to air when possible. Applying a barrier cream, such as Zinc and castor oil, can also help. In severe cases, a mild steroid cream like 1% hydrocortisone may be necessary. If the rash is suspected to be candidal nappy rash, a topical imidazole should be used instead of a barrier cream until the candida has settled.
It is important to note that napkin rash can be uncomfortable for babies and young children, so it is essential to manage it promptly. By following these general management points, parents and caregivers can help prevent and manage napkin rashes effectively.
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This question is part of the following fields:
- Children And Young People
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Question 28
Incorrect
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Sophie is a 4-year-old girl who has been brought in by her father with a 2 day history of cough and fever. Her father describes the cough sounds like a bark and today Sophie has appeared more breathless.
On examination, Sophie appears alert with moist mucous membranes. You observe nasal flaring and moderate intercostal recession. You check Sophie's temperature which is 38.2°C and oxygen saturation is 97% in air. Her respiratory rate is 52 breaths per minute and heart rate is 138 beats per minute.
What red flag symptoms have you observed in Sophie?Your Answer:
Correct Answer: Moderate intercostal recession
Explanation:When a child has a fever, moderate or severe intercostal recession is a concerning symptom. This is considered a red flag according to NICE guidelines, which indicate a high risk of serious illness. Other red flag symptoms include those in the amber risk category, such as nasal flaring and a respiratory rate over 40 breaths per minute for children over 12 months old. A heart rate of 138 beats per minute is not a red flag symptom, but a heart rate over 140 beats per minute for children aged 2-5 years is considered an amber symptom. A temperature of 38°C or higher is only a red flag symptom for infants aged 0-3 months.
The NICE Feverish illness in children guidelines were introduced in 2007 and updated in 2013 to provide a ‘traffic light’ system for assessing the risk of febrile illness in children under 5 years old. The guidelines recommend recording the child’s temperature, heart rate, respiratory rate, and capillary refill time, as well as looking for signs of dehydration. Measuring temperature should be done with an electronic thermometer in the axilla for children under 4 weeks or with an electronic/chemical dot thermometer in the axilla or an infra-red tympanic thermometer. The risk stratification table categorizes children as green (low risk), amber (intermediate risk), or red (high risk) based on their symptoms. Management recommendations vary depending on the risk level, with green children managed at home, amber children provided with a safety net or referred to a specialist, and red children urgently referred to a specialist. The guidelines also advise against prescribing oral antibiotics without an apparent source of fever and note that a chest x-ray is not necessary if a child with suspected pneumonia is not being referred to the hospital.
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This question is part of the following fields:
- Children And Young People
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Question 29
Incorrect
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A toddler is brought in for a development review. The child has a vocabulary of approximately 50 single words, some two-word phrases and many of the words can be easily understood by strangers.
Which of the following is the most likely age range for this child if development is normal?Your Answer:
Correct Answer: 18-24 months
Explanation:Speech Development Milestones in Children: From 12-42 Months
Speech development in children is a gradual process that varies from child to child. It starts with responding to sounds and progresses to babbling and saying simple words like mama and dada. By 18-24 months, children have a vocabulary of 50 or more words and can use some two-word phrases. By 24-30 months, their vocabulary expands to about 300 words, including names. Between two and three years, children can form sentences of three to five words and use pronouns, plurals, and past tense. By three to four years, they can use three to six words per sentence, ask and answer questions, and tell stories. It’s important to note that speech delay affects between 6% and 19% of children, and early detection and intervention can prevent educational, emotional, and social problems. Serious causes of delayed speech include deafness, learning disability, and autism.
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This question is part of the following fields:
- Children And Young People
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Question 30
Incorrect
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During a localised outbreak of measles your practice is inundated with requests for MMR vaccine from worried parents of young children.
In which of the following age groups is MMR vaccine contraindicated?Your Answer:
Correct Answer: Pregnant women
Explanation:Who Should Not Receive the MMR Vaccine?
There are only a few circumstances where the MMR vaccine cannot be given. Firstly, pregnant women should not receive the vaccine. Secondly, those with a confirmed anaphylactic reaction to gelatin or neomycin should not receive the vaccine. Thirdly, those who are immunocompromised should not receive the vaccine. Lastly, those who have had a confirmed anaphylactic reaction to a previous dose of measles, mumps or rubella-containing vaccine should not receive the vaccine.
Breastfeeding is not a contraindication to MMR immunisation, and MMR can be given to breastfeeding mothers without any risk to the baby. While two MMR vaccinations are needed for 99% protection, there is no limit to the number of MMR vaccinations an individual can receive. The risk of adverse reactions becomes less with increasing doses of MMR. Additionally, there is no upper age limit to receiving the MMR vaccine, and a 1-year-old child could theoretically receive the vaccine.
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- Children And Young People
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