• X-ray changes in fractures:
• Peaks:
• Resolution of soft tissue changes: 4-10 days
• Sub-periosteal new bone formation (SPBNF): 10-14 days
• Soft callus formation: 14-21 days
• Causes loss of fracture line definition
• Hard callus formation
• 21-42 days
• These processes are very variable and all overlap
• Extremely hard to reliably date fractures
• No-one has any idea what vitamin D deficiency does to fracture risk + healing time
• LOADS of kids are vit D deficient
• 50% of acute rib fractures are not visible on CXR
• Much easier to see after callus formation
• Brain haematomas
• Extradural are convex
• Lens-shaped
• Because they're bounded by the dura
• Subdural are concave
• Spread out easily
• Timing
• CT or X ray is good for acute changes
• Blood is bright
• MRI is better for later changes
  

Asthma teaching

• Upper airway obstruction can be very difficult to distinguish from lower airway obstruction
• Because it's transmitted - especially in children
  
• Listen all over the lungs - if the sound doesn't change, it's probably from the upper airways
• Atopy tetrad
• Asthma
• Eczema
• Allergies
• Hay fever
• Triad of airway narrowing in asthma
• Muscle spasm
• Oedema
• Mucous
• Pressure-Volume curves
• Volume on the X-axis!
• Work done is area under the line / Area enclosed by a closed cycle
• At high lung volumes (i.e. with air trapping)...
• Compliance is less
• So dV/dP is lower
• So the area enclosed by the breathing cycle is bigger
• => Raised WOB in a hyperinflated lung
• Biologics used in asthma
• Omalizumab
  
• IgE MAb
  
• Binds free IgE
• Useful in severe persistent allergic asthma patient who have a positive skin test or in vitro reactivity to a perennial aeroallergen
• Mepolizumab
• Anti-IL5
• Doesn't work
• Golimumab
• Anti-TNF alpha
• Poor side-effect profile - discontinued
• Etanercept
• Anti-TNF
• Very modest improvement

Nutrition

• Domains:
• What you eat (nutrient balance)
• What you are (body composition)
• What you do (functional)
• Birth weight definitions
• LBW < 2500 g
  
• VLBW < 1500 g
• ELBW < 1000 g
• Neonatal calorie requirements
• 40 kcal/kg/day just to lie still
• Additional 40-80 kcal/kg/day to grow, cry, etc
• Calorie density in foods
• Fats: 9 kcal/g
• Glucose: 4 kcal/g
• Breast milk: 70 kcal/100 ml
• Weight triples between 29-40 weeks gestation
• Much of this is fat
• Due to increasing fetal insulin production
• Babies can breast feed at around 33-34 weeks gestation
• Reflexes not developed before then
• Can't give hypertonic fluids (e.g. TPN) through a peripheral line
• => Oedema => Leakage into tissues => Tissue damage (e.g. calcium)
• Breast feeding => 5-fold reduction in NEC
• Even with bank milk (pasteurised)
• Breast feeding effect on IQ
• Normally 2-6 point increase
• Even more effect for pre-term babies
• Due to lipids needed for brain development
  

Histories

• DRILL DOWN
• Home nebs
• Why?
• Where from?
  
• Do you know how to use them?
• Food allergy
• What happens?
• Have you consulted anyone?
• Who were they?
• Were they medically trained or just a "nutritionist"
• NB Dieticians are registered and licensed but most other "nutritionists" aren't
• What medication do you have?

Notes

• Eczema first presenting in the first year of life tends not to persist
• Croup really just refers to the noise (from any cause)
• What we mean is laryngotracheobronchitis (LTB)
  
• Anion gap is predominantly due to proteins
• RDS => Chronic lung disease of prematurity
  
• WOB in RDS rips lungs apart within 15 mins
• => Usefulness of HFOV
• Base excess is measured in mmol/L
• => Direct measure of how much bicarb you need to use to correct acidosis
• Normally only "half-correct" to avoid giving too much sodium
• Fluid from a ruptured Baker's cyst tracks down between soleus + gastrocnemius and gives calf/Achilles pain
• The most dangerous thing about home nebs is being falsely reassured by decreased WOB, when it's actually due to exhaustion
• Crucial to monitor sats
• Spacers must be held at 45 degrees when used with a face mask, to keep the valve open
  
• Term is 37 - 42 weeks