Dr Joseph Mizzi

Eczema is a common chronic skin condition that causes inflammation, redness, dryness and intense itching. Children with eczema are often uncomfortable and irritable, particularly at night, because their skin becomes very dry and itchy. Although the exact cause of eczema is unknown, we know that it is more common in children with a family history of allergic conditions such as eczema, hay fever or asthma. Eczema may begin during the first few months of life and affects approximately one in five children under the age of three. In most cases, the diagnosis is made simply by examining the child. Special tests are usually unnecessary unless there is a suspicion of a food allergy. Eczema can affect the face, the folds behind the knees, the front of the elbows, the hands, and many other parts of the body. The condition typically follows a fluctuating course. There are periods when the skin becomes inflamed and itchy (flare-up), followed by periods when it settles down (remission). These flar...

The paediatric viva consists of five 4-minute interviews with different examiners. The stations may include the following: communication, history, a practical, data interpretation, ECG, growth chart, case management, and a video. I trust you will find the following articles helpful as you prepare for the paediatric viva. The most effective way to revise is not only to study the topics but also to practise them actively, ideally with fellow students, taking turns as examiner and candidate, or even with a friend or family member. Speak your answers out loud, listen to yourself, and make sure to time your responses. This will build both your confidence and fluency. Stations History Charts Communication ECG - read ECG in SVT, VT, AV block , and hyperkalaemia; discuss causes and management. Topics Blood gases Rickets Croup Acute Asthma Pulse oximeter Peak flow meter Inhaler and spacer Acute gastroenteritis Breastfeeding Breastfeeding - advantages Formula milk Febrile child ...

What is coeliac disease? Coeliac disease is a lifelong condition of the small bowel caused by a reaction to gluten. It is an "auto-immune" disorder because the immune system damages its own body. Gluten is the name of a protein found in wheat, barley and rye. How does gluten affect the bowel? Gluten triggers the immune system to produce antibodies that attack the delicate lining of the bowel, which is responsible for absorbing nutrients from food. The damaged bowel is unable to absorb the nutrients, resulting in malnutrition. Who is at risk? Coeliac disease can be diagnosed at any age. It may first be diagnosed in babies after weaning, when cereals are first introduced into the diet, or later on in childhood and adulthood. The condition affects up to 1 in 300 people in Europe. Coeliac disease runs in families. An individual has a 10% risk of developing the condition if a parent or sibling suffers from coeliac. What are the symptoms? Symptoms do not appear unti...

Pulse oximetry is a simple, non-invasive method used to monitor oxygenation by estimating the percentage of oxygen-saturated haemoglobin (SpO₂) in arterial blood. Principles and Physiology Oximeters operate using the principles of spectrophotometry. They measure the differential absorption of red (660 nm) and infrared (940 nm) light by oxygenated and deoxygenated haemoglobin. During systole, pulsatile blood flow causes changes in light absorption that are detected by photodetectors on the opposite side of the emitter. The probe is typically placed on fingertips, toes, or earlobes, using either wrap-around or clip-style designs. Interpreting Oxygen Saturation A normal SpO₂ is ≥95% in healthy individuals. The oxyhaemoglobin dissociation curve is relatively flat at high saturations, but drops steeply below 90%, indicating a sharp fall in PaO₂ and thus a greater risk of tissue hypoxia. Clinical action is usually recommended when SpO₂ falls below 92% in room air, particularly in acute respi...

Definition Diabetic ketoacidosis (DKA) is a life-threatening metabolic state characterized by hyperglycaemia, ketosis, and metabolic acidosis, resulting from insulin deficiency and excess counter-regulatory hormones, particularly glucagon. This hormonal imbalance promotes gluconeogenesis, glycogenolysis, and lipolysis, leading to the formation of ketone bodies. Pathophysiology Hyperglycaemia induces osmotic diuresis, leading to significant loss of free water and electrolytes (including sodium, potassium, and phosphate). Resulting hypovolaemia contributes to tissue hypoperfusion and can precipitate lactic acidosis. Mortality is most commonly associated with cerebral oedema, severe hypokalaemia, and aspiration pneumonia. Causes New diagnosis of type 1 diabetes mellitus (IDDM) Infection (most common precipitant) Poor adherence to insulin therapy or missed doses Clinical Presentation Symptoms (often insidious, especially in young children): Polydipsia Polyuria Weight loss Nausea and vomit...

  Definition of Acute Gastroenteritis (AGE) in Children Acute gastroenteritis is defined as a decrease in stool consistency (loose or liquid) and/or an increase in the frequency of evacuations (typically more than three in 24 hours), with or without associated fever and vomiting. Diarrhoea usually lasts less than 7 days and not more than 14 days. Epidemiology Viral agents are the most common cause of AGE in children, especially rotavirus, for which an oral vaccine is available and given in two doses during the first 6 months of life. Other viral causes include adenovirus, norovirus, and astrovirus. Viral infections often present with vomiting and upper respiratory symptoms. Bacterial agents such as Campylobacter and Salmonella are less common but more likely to cause severe symptoms. Indicators of bacterial gastroenteritis include high fever, bloody stools, abdominal pain, and signs of systemic involvement (e.g. irritability, lethargy, seizures). Incidence: 0.5–2 episodes per child...

The Peak Flow Metre is a handheld device used to measure peak expiratory flow (PEF) – the maximum speed of expiration. Reflects the degree of airway obstruction. The reading reflects the degree of airway obstruction. Infants and young children (till 6 years) are not able to use the peak flow meter. Uses Diagnosis – diurnal variability > 20%, improvement of PEFR after bronchodilator or stereoids. Also useful as an assessment of response to treatment. Monitoring – as part of an individual management plan that includes education and symptom recognition (asthma symptoms during the day, interference with sleep, activities e.g. sports). There should be little variation in the reading from day to day, or morning/evening when asthma is well-controlled. Acute exacerbation – less than 50% best/predicted in severe attack; less than 33% in life-threatening attack or unable to perform measurement.  Method Attach mouthpiece. Set the meter to zero. Stands up or sit upright. Hold the meter...

In the History Station, you are not role-playing as the doctor speaking directly to the parent. Instead, you should describe your approach by saying something like, “I would ask the parents…” rather than speaking as if you are in the clinical interaction. The examiner will present a brief clinical scenario, such as: “A 6-month-old infant is brought to the pediatric casualty with fever. What questions would you ask his parents?” Avoid launching into a random list of questions. Instead, begin by outlining your approach in a structured manner. "I would begin by introducing myself to the parents and confirming the child’s name and age. I would then start by asking them to describe their concerns – in this case a 6 month old child with fever – followed by focused questions about the fever and associated symptoms, and continue to take full history" Once you have outlined your overall plan, proceed to take the history of the presenting complaint: “When did you first notice that the ...

Paediatrics Revision Questions © 2012-2025 Dr. Joseph Mizzi Case 1: Acute Ear Pain A 6-year-old girl presents to the Emergency Department with severe right ear pain and a fever of 39°C. Otoscopic examination reveals an inflamed right tympanic membrane.  a) What is the most likely diagnosis? b) Which pathogens are commonly implicated in this condition? c) Outline the appropriate management for this patient. d) What are potential complications if left untreated? e) When should a referral to an otolaryngologist be considered?  Case 2: Headaches A child presents to the outpatient clinic with a 4-week history of morning headaches and coughing. Fundoscopic examination reveals bilateral papilloedema.  a) What is the differential diagnosis? b) Which investigations are necessary to determine the underlying cause? c) What are the immediate management steps? d) Discuss the potential long-term sequelae of untreated raised intracranial pressure. Case 3: Pallor and Bruising An 8-year...

As you prepare for your exams, it's important to care not just for your academic performance, but also for your mental and physical wellbeing. The thoughts that follow are offered from personal experience and professional insight, with the hope that they will support you in managing stress and performing at your best. A certain level of anxiety before and during examinations is both natural and beneficial. In fact, it can enhance your focus, improve your ability to study, and optimise your performance. It is a signal that you care about doing well and that you are engaged with the task at hand. However, when anxiety becomes excessive, it can have the opposite effect. It may lead to overwhelming fear, memory blocks, reduced comprehension, difficulty concentrating, and distressing physical symptoms such as a rapid heartbeat, shortness of breath, and sweating. To help manage and reduce anxiety, I offer the following advice: Strategies to Support Your Wellbeing and Performance Pace you...

Children should always use a spacer with their inhaler: Easier to use (no synchronisation is needed). Increase delivery of the medication to the lungs. Reduce the risk of side effects from ICS (oral thrush and hoarseness). There are two ways to take the inhaler - the 'single-breath and hold' and the 'tidal breathing' techniques (the latter is preferred for children). Prime the inhaler if it is new or has not been used for more than a week. The one-way valve in the spacer device regulates inspiratory flow and prevents exhalation into the device.  How to use a pMDI with a spacer device: Remove the cap, and attach the inhaler to the spacer. Shake the inhaler well. Grip the mouthpiece gently between teeth, and close lips around it. If the child is using a spacer with a mask (usually less than 6 years) place the mask over the child’s mouth and nose, making sure there is a good seal. Press the inhaler once to release one puff in the chamber. Have the child breathe in and out ...

Colds are common. Children can catch as many as ten colds every year. The symptoms of a cold include throat irritation, sneezing and a runny or stuffy nose. Nasal discharge is watery at first, but may become thick yellow or green later on. The child may also have a cough, headache, mild fever, loss of appetite and fatigue. Cold symptoms clear up within a few days, though it is not uncommon for cough to persist for about two weeks. Helping your child Colds and most respiratory infections are caused by viruses. Antibiotics are not helpful since these medicines are only effective against bacteria. Antibiotics do not help children with colds to heal faster, and indeed they may cause unnecessary side-effects and increase the problem of antibiotic-resistant bacteria. Paracetamol or ibuprofen may be used to alleviate pain and to control fever. The best way to take the child’s temperature is by using a digital thermometer held in the armpit. Do not use a ‘forehead’ thermometer as ...

Assessment History – 1 to 6-year-old (usually a toddler) coryza and low-grade fever, followed by an acute barking cough, hoarseness, and stridor (harsh inspiratory sound caused by narrowing of the airways, esp. the sub-glottis), often presenting at night. Ask about difficulty with talking and feeding. Listen to stridor here .  Clinical examination – the child sits on mum’s lap (to calm the child). Do not examine the throat. Observe general condition (agitation), barking cough, stridor, recessions, tachypnoea. Cyanosis and drowsiness indicate severe hypoxaemia. Take temperature and pulse oximetry and heart rate. Differential diagnosis includes (1) bacterial tracheitis (high fever); (2) epiglottitis (Hib vaccination) (high fever, drooling, absent cough); (3) FB inhalation; (4) anaphylaxis. Management Home if no significant distress or stridor at rest and parents are informed and confident. Humidification is of unproven benefit. Antibiotics are not indicated (parainfluenza, a...

Assessment History Too breathless to eat or talk? Response to reliever? Previous admission? Clinical General condition and consciousness Cyanosis HR, RR, BP Recessions and accessory muscles Auscultation - air entry, diffuse wheeze Measurements PEFR Pulse oximetry Venous gases (if iv cannula for hydrocortisone) Classification Acute Severe SpO2 less than 92% PEF 33-50% best/predicted Can’t complete sentences in one breath or too breathless to talk or feed Tachycardia: above 125 (more than 5 years) or above 140 (2 to 5 years) Tachypnoea: above 30 breaths/min (more than 5 years) or above 40 (2 to 5 years) Life Threatening SpO2 less than 92% PEF less 33% best/predicted Confusion Exhaustion Poor respiratory effort Silent chest Cyanosis Hypotension Coma Initial Treatment Oxygen  Nebulized salbutamol, ipratropium  Steroids  Re-assessment and repeat nebulized salbutamol every 20 minutes as needed. Consult with senior clinician.

With a reverent attitude and deep humility. Keep in mind that the Bible is the Word of your Creator, your Master, your God. When you open the book, open your heart to listen attentively to God speaking to you. Read prayerfully and diligently, striving to understand its meaning. Do not attempt to make it fit your own preconceptions and beliefs, but rather let the Word shape your thinking, your faith and your life. It is worthless if you read the Bible just to gain intellectual knowledge; you will profit only if you are obedient to its message. You will profit, most of all, because through the Scriptures we come to know God intimately. A couple of practical hints: Have a reading plan. Four chapters a day will cover the entire Bible in a year. Some books deserve special emphasis, and these should be read over and over again, especially the four gospels and the epistles. Use the Psalms as model prayers. Plan beforehand the time and place, because if you don’t, you will probably not...

1. Increase monounsaturated lipids (add fresh olive oil to salads and food, avocado, seeds and a small handful of unsalted nuts like almonds and walnuts). 2. Strictly limit saturated fats (red meat, whole milk/products, palm oil, coconut oil, chocolates, etc) and trans-fats (partially hydrogenated oils – check ‘ingredients’). In practice, use skimmed milk, and low-fat yogurt, cottage cheese, chicken (remove skin), turkey, fish and rabbit. Use red-meat infrequently and trim off fat. Eat grilled, boiled, stew, baked food, not fried. 3. Increase Omega 3 (Fish - salmon, tuna, and mackerel. Include fish at least twice weekly.). 4. Increase soluble fiber (oatibix, oats porridge, all bran, cruchy bran and other high-fiber cereals, fruits, vegetables and legumes – peas, beans, chickpeas, barley and lentils). 5. Red wine in moderation (one or two glasses per week). 6. Subsititute refined grains with wholegrains (wholemeal bread, wholemeal pasta, brown rice, barley, quinoa). 7. ...

The most common charts used in paediatrics are: Weight-and-age Height-and-age OFC-and-age BMI-and-age It is not unusual for the babies to cross one centile band, up or down, in the first year of life. Babies with low birth weight tend to show ‘catch-up growth’ in the first months. Bottle fed infants tend to be heavier than breast-fed babies. Serial measurements give information on the growth pattern. The trend or direction of the curve is more important than actual centiles. Abnormal growth is indicated by values well beyond the upper and lower centiles on a single occasion or more commonly by crossing centiles. Compare height and weight centiles. For example, a baby is not necessarily overweight if his weight is on the 97th centile. If his height is also on the 97th centile (or close), his weight is appropriate. On the other hand, the baby may be overweight if his weight is on the 50th centile while his height is on the 3rd centile. BMI BMI = weight (kg)/height2 (m2)...

1. Should I feed the baby every 3 hours? For most babies, feeding should be ‘on-demand’ and not according to a fixed schedule. The baby can drink whenever and as long as he likes. In practice there will be some sort of pattern, but then again, it will change from time to time. 2. Should breastfeeding be interrupted if the mother has a cold or pharyngitis, or if she is prescribed an antibiotic or paracetamol? Breastfeeding should continue! Unfortunately many mothers stop breastfeeding on the basis of incorrect medical advice. (There are a few drugs and antibiotics that are absolutely contraindicated in breastfeeding). 3. Should breastfeeding continue if the baby has an enteritis or is it better to switch to low-lactose formula? Breastfeeding should continue uninterrupted. Low-lactose milk is not recommended in most cases of acute gastro-enteritis even for formula-fed infants. 4. How can you assess if a breast-fed infant is feeding sufficiently? Wet nappies and stools; B...

Measuring Temperature Use an electronic thermometer in the axilla (all ages) or infra-red tympanic thermometer (from 4 weeks) or temporal artery thermometers Forehead chemical thermometers are unreliable (surface temperature may not correspond with core temperature) Measure temperature in the axilla. Do not routinely measure temperature by the oral or rectal routes. Fever:  >37.5C (>99.5F) axillary temperature.   Caring for the Febrile Child Do not under-dress a child with fever. Tepid sponging and bathing are not recommended. Give paracetamol or ibuprofen if the child is uncomfortable, not drinking enough, or miserable (irrespective of temperature). No need for antipyretics if the child is happy or to prevent fever after immunization. Antipyretics do not reduce risk of febrile fits. Encourage drinking (as a child can become dehydrated - water loss by evaporation and sweating). Further Advice to Parents Identify a non-blanching rash using a clear glass. ...

Insertion Perform hand hygiene using alcohol rub Wear necessary PPE including disposable gloves Wipe skin at insertion site with chlorhexidine in 70% isopropyl alcohol and allow to dry Insert appropriately sized cannula Apply a sterile transparent dressing after insertion to allow for easy inspection Flush with normal saline Document insertion details (date and site) Complications Thrombo/Phlebitis - redness, inflammation and discomfort at iv site. Later pain along path of cannula, erythema, induration, palpable venous cord and pyrexia. Cannula should be re-sited at the first signs of inflammation or discomfort or at least every 72 hours. Infection – local and septicaemia. Extravasation – the inadvertent administration of a solution or drug into the tissues. Tissue necrosis may follow. Occlusion – occurs when infusion containers ‘run dry’ or the cannula is not flushed after insertion or use. Dislodgement - poorly fixation. IV Injections/Infusions Perform h...