1-

A 4-month-old boy turns up at the clinic after his mother has discovered a
lump in the scrotum.
On examination, the child is well, the lump is smooth and non-tender, and
the testis is part of the swelling.
Which of the following statements is/are true regarding this baby?

True / False
He is at risk of epididymo-orchitis Correct

It may resolve spontaneously Correct

Surgery is indicated soon Correct

The child has a testicular tumour Correct

The lump is likely to be transilluminable Correct

This scenario describes a hydrocoele in a well 4-month-old child.

This is an accumulation of fluid around the testicle within the tunica vaginalis. Most
hydrocoeles resolve spontaneously and therefore do not require surgery.

Patients are usually asymptomatic. The swelling is uniformly smooth and fluctuant.

The testis cannot be felt separately and transillumination confirms the diagnosis.

2-Do the following vaccines contain live virus?

True / False
Hepatitis B Correct

Influenza Correct

Mumps Correct

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 Rabies Correct

Rubella Correct
Rubella and mumps vaccines contain live virus.

Influenza is inactivated, either split virion or surface antigen.

The rabies virus contains killed virus and the hepatitis B vaccine contains purified viral
proteins.

3-A 7-year-old girl complains of a sore throat. She has experienced this
symptom on two previous occasions over the past three years.
Her tonsils are large and congested. Also found is a benign heart murmur.
Are the following true or false?
True / False
An ENT opinion should be sought to advise whether to recommend tonsillectomy Correct

Further sore throats should be treated aggressively with antibiotics to lessen the risks of sub-ac
endocarditis Correct

If antibiotics are given, tetracycline is the drug of choice Correct

Petechiae on the palate suggest infectious mononucleosis Correct

White exudates on the tonsils indicate a bacterial infection Correct

This question describes a child with an upper respiratory tract infection. This is
extremely common and in most cases the cause is viral and treatment is conservative
only.

Tonsillectomy is considered in children with a history of recurrent tonsillitis causing them

to miss significant time at school.

If antibiotics are required to treat a bacterial infection penicillin is the drug of choice.
Tetracycline is contraindicated in children due to the side effects affecting bones and
teeth.

Palatal petechiae are often seen in patients with glandular fever.

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4-Which of the following statements are true regarding breath-holding
attacks?
True / False
Are a type of epileptic seizure Correct

Are associated with cyanosis and stiffness Correct

Occur most frequently in the first year of life

Remit spontaneously with increasing age Correct

Usually follow a noxious stimulus Correct

Breath holding attacks are common.

They typically affect children between the ages of approximately 2 years and 5 years.
They are rare before the age of 6 months.The peak age is 2 years.

They are frightening for the parents because the child appears limp and
unresponsiveness.

They usually follow a noxious stimulus such as the child being hurt or upset. The
episode is heralded by a shrill cry, following which there is forced expiration and
apnoea.There is often associated cyanosis and this may result in repeated clonic jerks,
opisthotonus and bradycardia.

The parents need reassurance regarding the diagnosis and no specific treatment is
indicated as there is spontaneous resolution.

Most abate by the age of 5 years.

5-Groin swelling in a 5-year-old child may be due to which of the following?

True / False
Acute leukaemia

Factor VIII deficiency

Osgood-Schlatter’s disease

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 Rheumatoid arthritis

Transient synovitis of the hip

Acute leukaemia often presents with lymphadenopathy.

Transient synovitis often occurs secondary to an upper respiratory tract infection (URTI)
and lymphadenopathy.

Rheumatoid arthritis is a condition characterised by inflammation of the joints as well as

rheumatoid nodules.

Osgood-Schlatter's is an apophysitis of the tibial tubercle and often presents with pain,
tenderness and a swelling at the insertion of the patellar tendon.

Factor 8 deficiency is also known as haemophilia. The hallmark of this condition is

haemarthroses or spontaneous bleeding into the joints resulting in swelling.

6-A child separated from his parents for hospital admission is more likely to
have difficulties on return home if:
True / False
Aged between 7 months and 4 years

Previous recent traumatic separation Correct

An unhappy home Correct

Regressive behaviour is punished Correct

Frequent visits from parents Correct

A child admitted to hospital should be adequately prepared for the procedure to be
carried out. If possible the child should attend prior to the appointment to see the lay out
of the ward and to meet the staff. Plenty of opportunity should be given for the child to
ask any questions he or she may have. In most cases, parents are allowed to stay with
the child on the ward and this is of considerable benefit to the child's emotional well
being. In cases where it is not possible for either parent to stay the child will benefit from
frequent visits. Most children wards have open visiting (although the nature of the
condition/procedure/operation) will need to be taken into account. Children are more
likely to have problems following admission to hospital if there are other adverse social
factors. These may include previous traumatic separation or an unhappy home (E.g.
Marital disharmony). The pre-school child is more likely to experience separation

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anxiety than a child of school age and therefore needs careful preparation with stories,
visits to the hospital play room etc. Regressive behaviour should never be punished,
instead the focus needs to be on positive praise and a reward system for the good
behaviours.

7-Which of the following would make the diagnosis of non-accidental injury

in a child is more likely?
True / False
He/she is six months old and has a torn labial frenulum Correct

The child is three years old and has bruising to the shin Correct

The history of injury given by the father is consistent with that given by the mother Correct

The presentation of a child with significant injuries to a health professional is delayed Correct

There is extensive bruising and thrombocytopaenia Correct

Abused children may present in many different ways and recognition is very rarely
straightforward.

As always, it is very important to document the injuries clearly and accurately. It is also
essential to take a detailed history of how the injuries were sustained, preferably from
more than one person.

Social background and family circumstances are important factors to ask about in the
history. Other relevant details which may point to a diagnosis of non-accidental injury
include the following:

1. A delay in seeking advice from health professionals.

2. An inadequate, inconsistent or unrealistic explanation.
3. Indifferent, or inappropriate concern of the carer.
4. Parent unwilling for the child to be examined.
5. Child or siblings on the child protection register.

A child of three years is very likely to have bruising to the shins as a result of accidental
minor injury. If a child with extensive bruising is found to have a thrombocytopaenia, the
child will need further haematological investigations.

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It is, however, important to emphasise that children with other medical conditions may
also be the victims of child abuse and therefore it is important to take all factors into
account.

The first stem relates to a 6-month-old baby presenting with a torn frenulum. This
scenario should raise serious suspicion of the baby either being force fed or having
other objects thrust into his/her mouth. A mobile child can tear the labial frenulum as a
result of an accidental fall, however this is not the case in non-ambulatory children.

8-Which of the following would strengthen your suspicion that a child of two
years is a victim of non-accidental injury (child abuse)?
True / False
Bruising behind the ear Correct

Bruising on the anterior surface of the tibia Correct

Bruising on the forehead Correct

Bruising on the sacrum Correct

Glove and stocking type scalds Correct

When assessing a child with suspected non-accidental injury it is important to examine
the child thoroughly.

Important features of the examination include the distribution and nature of soft tissue
injuries.

Nearly every mobile child will have bruising to the shins but this would be a worrying
feature in a baby of six weeks. Similarly an active toddler may have bruising to the
forehead but an immobile baby will not without a very clear and concise explanation.

Skin overlying bony prominences is prone to bruising, however it is extremely difficult to

bruise around the neck and behind the ear as these areas are well protected.

Bruising of different ages is also significant although it is extremely difficult to age

bruises accurately with any degree of certainty.

Scalds with a "glove and stocking" distribution are a worrying discovery and are
consistent with a child being immersed into hot water. An accidental scald is more likely
to have an irregular margin with splash marks evident.

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9-Child battering (non-accidental injury) is to be considered in a child
presenting with which of the following?
True / False
Bilateral orbital haematomata (black eyes) Correct

Blue sclerae Correct

Frequent visits to the local casualty department Correct

Unexplained limb fracture Correct

Pica
Child physical abuse is to be considered in any child repeatedly presenting to the local
casualty department with injuries. A history of a child or siblings presenting to various
surgeries and specialists with a variety of symptoms should also raise alarm bells.

This may be an indicator of factitious illness with stories of illness being invented by the
perpetrator.

Any unexplained injury such as a fracture should raise the possibility of non-accidental
injury (NAI). Relevant details of history pointing towards a diagnosis of NAI include an
inadequate, unrealistic or inconsistent explanation of the injury. For example a 2-month-
old sustaining a spiral fracture of the tibia from 'rolling' in his cot.

A child presenting with bilateral periorbital haematomata needs to be carefully

assessed, as this may be the result of physical abuse. A careful history and examination
needs to be carried out.

Pica is the term used to describe the ingestion of non-food substances, such as mud
and soil. This may be present in children with emotional and behavioural difficulties as
well as in children with developmental delay and learning difficulties.

Clearly many of these problems co-exist and it is important to consider all factors
present.

Blue sclerae are seen in children with connective tissue problems such as osteogenesis
imperfecta and Ehlers-Danlos syndrome. It is therefore an important physical sign to
look for in a child presenting with repeated fractures.

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10-Would the following would strengthen your suspicion that a 6-month-old
infant with multiple bruises is a case of "child abuse" (non-accidental
injury)?
True / False
A. Subperiosteal haemorrhages of the thighs and poorly calcified lower femoral epiphys

B. Prolongation of the thromboplastin generation test Correct

C. Emotional deprivation of the parents when they were children Correct

D. Knowledge that the infant was premature

E. Prolonged bleeding time Correct

Any baby of 6 months presenting with multiple bruises should raise serious concern.
Generally speaking "babies that don't cruise rarely bruise".

It is always vital to take a detailed history as well as performing a thorough examination

as there may be a plausible reason for a non- ambulatory baby sustaining bruising.

A baby presenting with such bruising needs careful evaluation, and as well as careful
examination including fundoscopy, the child should also undergo blood tests. These
include a full blood count to exclude a thrombocytopenia, and a coagulation profile to
exclude a clotting disorders (suggested in B and E).

Scurvy is suggested by subperiosteal haemorrhage and poor long-bone calcification.

This patient will also need a full skeletal survey and a CT head scan to exclude the
possibility of occult bony or cerebral injury.

A suspicion of child physical abuse would be strengthened with other factors such as
previous social concerns in the family (C), a parental history of mental health disorders
including a history of drug and alcohol misuse, teenage parents, as well as knowledge
that the child was born prematurely (D).

Other factors which would raise suspicion include a delay in seeking appropriate
medical advice, an inadequate or inconsistent explanation for the injuries as well as the
accompanying adult being someone other than the parent with no reason why the
parent is not present.

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11-According to the 1989 Children Act, are the following principles and provisions
applicable if child abuse is suspected?

True / False

A child assessment order allows a child to be taken into local authority care

A child assessment order can be granted by a local authority

An emergency protection order lasts for one month Correct

The length of an emergency protection order cannot be extended

The welfare of the child is paramount Correct

The 1989 Children Act states that the welfare of the child is paramount.

An emergency protection order allows a child to be taken into care and lasts for eight
days. It may be extended at the discretion of the court for a further seven days. After
three days the parent or the child may challenge the order.

A child assessment order allows medical or psychiatric examination to be carried out. A

full court order is necessary. If the parents or carers do not co-operate, the assessment
order may be converted to an emergency protection order.

12-Regarding the Haemophilus influenzae type B vaccine (Hib) vaccine,

which of the following is/are true?
True / False
Is a live attenuated vaccine Correct

Is contraindicated if there is a history of egg allergy in the family Correct

Is recommended for children aged between 2 months and 10 years

Is very effective Correct

Needs to be given as three doses in all children

Hib is a capsular conjugated polysaccharide vaccine.

It is generally given in a course of three doses at monthly intervals at 2, 3 and 4 months

with the other routine vaccinations.

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Over 13 months of age a single dose is effective.

As the risk of invasive Haemophilus falls rapidly after 10 years, it is only given after this
age to those children considered to be at increased risk of
invasive Haemophilus disease (sickle cell disease, antineoplastic therapy, an absent
spleen).

It is known to be highly effective but vaccination failures have been reported.

Hypersensitivity to egg contraindicates influenza vaccines.

Evidence of previous anaphylactic reaction contraindicates the use of the measles,

mumps and rubella (MMR) and yellow fever vaccines.

13-Do the following provide clear evidence of child sexual abuse (CSA)?
True / False
A sudden deterioration in school performance

Enuresis in a child who has previously been continent at night

Inappropriate sexual knowledge

Laboratory evidence of Chlamydia trachomatis in a vaginal swab

Reflex anal dilatation

Reflex anal dilatation is not exclusively found in child sex abuse. It is also commonly
seen in children with constipation and is no longer regarded as prima facie evidence of
CSA.

Although enuresis, deterioration of school performance and sexual knowledge may be

relevant they are not diagnostic.

Finding of a sexually transmitted disease is good evidence for CS

14-Are the following contraindications to breast feeding?

True / False
Galactosaemia Correct

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 Maternal mastitis

Maternal metronidazole therapy

Maternal tetracycline therapy Correct

Prematurity Correct
Breast feeding should be encouraged, except in some rare inborn errors of metabolism
where breast milk must be excluded from the diet.

These include

 Galactosaemia
 Phenylketonuria and
 Alactasia.

Tetracycline will stain teeth and should not be prescribed to lactating mothers.

Maternal metronidazole therapy alters the taste of breast milk, but this is not a
contraindication.

Regular expression, either by continued feeding or pumping, should be recommended

for maternal mastitis, along with analgesia and antibiotic treatment.

15-Regarding otitis media with effusion, which of the following statements

is/are true?
True / False
Breast feeding may be protective.

It is associated with Turner's Syndrome. Correct

It occurs at some time in about 3% of pre-school children. Correct

It usually has significant effects on hearing and language development.

The incidence is increased in households where the parents smoke. Correct

Otitis media with effusion used to be called secretory otitis media.

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In poorer communities it may be associated with chronic perforation of the ear drum and
suppuration.

About 31% of children will be affected at some time, but only in 7% of cases will this be
persistent.

The risk is increased by

 Smoking
 Down's syndrome
 Cleft palate
 Turner's syndrome
 Facial malformation syndromes.

It is reduced by breast feeding.

The disability associated with it depends on whether it is transient or persistent.

If transient (the majority of cases) there is minimal influence on speech. If it is persistent

or severe, there may be significant delay in language development, behavioural
disturbances, and even alterations in balance.

In unilateral or asymmetric cases there may be decreased ability to locate sound, and a
difficulty in distinguishing speech from background noise.

16-The following are among the five most common causes of death under
five years in the United Kingdom:
True / False
Cot death Correct

Non-accidental injury

Congenital heart disease Correct

Malignant disease Correct

Meningitis Correct
Accidents are the main cause of death between the ages of 1 and 14 years and account
for approximately 800 deaths per year.

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In the under 5 age group the causes of deaths can be subdivided into the following.

4 weeks-1 year:
 Conditions arising in the perinatal period(46%)
 Congenital anomalies(16%)
1-4 years:
 Accidents(21%)
 Congenital anomalies(20%)

In the 5-14 year age group the two most leading causes of death include Accidents
(35%) and cancer (20%) respectively.

17-Regarding breaking bad news to parents, which of the following

statements is/are true/false?
True / False
Disbelief is a normal reaction. Correct

Information may not be taken in because of super-added emotional factors. Correct

Information should be withheld if the family do not seem ready for it. Correct

Other relatives should be kept out of the room so the parents can be spoken to alone.

Psychological adaptation can be expected within 700 days. Correct

Initial reactions are usually grief accompanied by anger, guilt, despair or denial.

Realisation and acceptance often follow, though this may take several weeks. Family
members may react differently. During the interview, it is important that sensitivity is
used so that the relationship between parents, doctors and other professionals remains
constructive. This requires honesty and trust.

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Both parents should be seen together and the facts presented simply, honestly and
early. Great resentment arises if information is withheld on the grounds that the family
were "not ready to receive it".

Many meetings may be required for the information to sink in, and it is helpful for health
visitors, social workers or other relatives to be present to assist is formulating further
questions.

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