2021 Flashcards
Define Developmental Coordination Disorder?
DCD = common neurodevelopmental disorder
- Difficulties with learning gross or fine motor skills
- Low scores on standardized motor testing and a history of motor problems from the early developmental period
- Leading to functional impairment in academic achievement or ADLs
- RULE OUT = motor difficulties cannot be result of a medical condition like CP or visual impairment
What is the DSM5 criteria for Developmental Coordination Disorder (DCD) and how do you test for it?
DSM5 Criteria and how to test:
- Acquisition and execution of coordinated motor skills substantially below expectation for child’s age and opportunities of motor skill learning (ie. clumsy, slow, inaccurate motor skills ex. with catching ball, using scissors, handwriting, bike riding, sports)
- OT or PT assessment of standard motor assessment (MABC-2 = Movement Assessment Battery for Children-2)
- Motor skills deficit significant and constantly interferes with ADLs for age and impacts school/leisure and play
- Hx and parent questionnaires like DCDQ (5-15yo) or Little DCDQ (3-4yo) to determine functional impact.
- scores are ‘indicative of DCD’, ‘suspect’ or ‘probably not’
- Onset of Sx in early developmental period
- developmental history focusing on difficulties in LEARNING motor skills, b/c usually meet motor milestones
- Motor skills deficit not better explained by ID, visual impairment, neuro conditions like CP, DMD, etc)
- ensure vision assessed
- neuro exam
- standardized IQ testing might be needed
What are ‘soft’ neurological signs for DCD?
What are other clinical features to look for on exam?
Soft signs:
- non-specific markers of performance difference in age approp motor task (usually fade by age 6 but may persist in DCD)
- overflow movements (hands posturing when heel/toe walking)
- mirror movements (one hand copying other when imitating finger pattern)
- finger agnosia (visual monitoring to copy finger pattern when proprioceptive feedback not enough)
- coordination struggles (ie. trouble with finger-nose or rapid alt mvmt but normal Romberg)
- low-normal tone
- should NOT have ‘hard’ signs = hypertonia, true hypotonia, abnormal DTR, ataxia, spasticity, asymmetry)
What are risk factors for DCD and co-occurring conditions?
Risk factors:
- male > female (2:1 to 7:1)
- preterm
Co-occurring conditions
- ADHD
- Autism
- specific LD
- language delays
- anxiety
- depression
What are other things to test on exam when evaluating for DCD?
- neurocutaneous exam for NF1 or TS
- dysmorphism and growth concerns
- joint hypermobility (have be hypermobile esp hands/feet but no other EDS Sx)
- joint swelling (r/o JIA)
- joint pain
- posture
- spine exam
- Investigations (based on Hx/PE):
- Hearing/vision test
- CK
- metabolic panel
- TSH
- nerve conduction studies
- neuroimaging
- microarray, fragile X, karyotype
- Evaluate for co-occurring:
- ADHD, LD, ASD, anxiety/depression
What are management aspects for DCD?
- Monitor for secondary sequelae (ie. obesity, sedentary, poor self-esteem, MH)
- Refer to OT/PT
- Task-specific interventions preferred (ex. Cognitive Orientation to Occupational Performance CO-OP)
- Encourage participation in individual, non-competitive sports
- CanChild website for resources
Age of onset of FPIES
2-7 months
Which has more severe presentation, FPIES or FPIAP?
FPIES
How long after ingesting a trigger food do FPIES symptoms begin?
1-4 hrs
How long after ingestion of trigger food does diarrhea begin in FPIES?
5-10 hours
Hypothermia, hypotension, hypotonia, acidemia and methemoglobinemia are severe complications of FPIES
True or False?
True
FPIES reactions include cutaneous and respiratory symptoms.
True or False?
False
Age of onset of FPIAP
0-6 months
Vomiting and diarrhea are part of FPIAP
True or False?
False
Failure to thrive occurs with FPIAP
True or False?
False
Physical exam of FPIAP
Normal
Bloodwork findings in FPIES
leukocytosis, neutrophilia, thrombocytosis, methemoglobinemia, metabolic acidosis
Top acute management priorities in FPIES
hydration - IV fluids
Ondansetron 0.15mg/kg
Dose of ondansetron for
- < 15kg
- 15-30kg
- > 30kg
- 2mg
- 4m
- 8mg
Kids with FPIES should avoid all foods that “may contain” their trigger food
True or False?
False
Kids who have FPIES to milk should NOT avoid soy products once they’re > 6 months old
True or False
True
Which other grain protein has a high level of cross-reactivity with rice?
oat
What are the top 4 trigger foods for FPIAP?
cows milk, soy, egg, corn
What are the top 4 trigger foods for FPIES?
Milk, soy, grains, egg
What are the top 2 meat triggers of FPIES?
Chicken, Turkey
What are the top 2 fruit triggers of FPIES?
banana, apple
What are the top 2 vegetable triggers of FPIES?
sweet potato, pea
What is the prognosis of FPIAP?
spontaneous resolution by age 1 year
What is the prognosis of FPIES?
Resolution:
35% spontaneous resolution by 2y/o, 70% by 3 y/o, 85% by 5 y/o
When can you trial re-introduction of a trigger food?
12-18 months after the most recent reaction
When do you refer to an allergist for FPIES?
for oral food challenge if trigger unclear, atypical symptom time course or lack of symptom resolution with trigger elimination
for oral food challenge when ready to reintroduce trigger foods
What are rescue meds used in procedural sedation?
Rescue medDose range and routeCommentsAtropine0.02mg/kg IV (max 0.5mg)May repeat once (max 1mg/child; 3mg teen)Epinephrine (0.1 mg/mL)0.01mg/kg IV (max 1mg)May repeat q3-5minFlumazenil (benzo reversal)0.01mg/kg IV (max 0.2mg)
May repeat q1min to max cumulative 0.05mg/kg or 1mg total, whichever is less
Contraindicated in pt with seizure d/o
Naloxone (opioid reversal)0.1mg/kg IV (max 2mg)
Dilute + titrate to effect; may repeat q2-3min
Contraindicated in chronic opioid use
Succinylcholine
1-2mg/kg IV (max 150mg)
2-4mg/kg IM
Essential rescue med for severe laryngospasm and RSI
Repeat doses increase bradycardia risk
What are the ASA levels for anesthesia risk?
- Healthy
- Mild systemic disease
- Severe systemic disease
- Severe with life threat
- Won’t live 24h with/without the procedure
What are the ASA fasting guidelines pre-procedure?
1h clear liquids, 4h human milk, 6hr formula/other milk/light meals
What are the recommendations prior to providing procedural sedation?
- Recommendations:
- Only do sedation if there is HCP present for airway and resus, extra HCP to do just sedation (and not also procedure), continuous monitoring, immediate emerg equipment, place to monitor post, including admission if needed
- Need to check ASA class 1 or 2, fasting status, informed consent, and refer to anesthesia if more complex
- Clinicians need approp skills and credentials, know indications/contrind and risk of meds, can manage pt at any depth of sedation and competent in resus and stabilization
- Develop institutional policies/procedures at hospital (with documentation, checklist and review process)
What are possible congenital complications associated with SSRI/SNRIs in pregnancy?
- Congenital malformations risk is controversial
- Some possible associations but absolute risk increase is small and some studies showed no risks
- Overall = CHD (TOF and Ebsteins), anorectal defects, gastroschisis, renal dysplasia, clubfoot if used in first trimester
- Sertraline = no association
- Citalopram = no association
- Paroxetine = anencephaly, ASD, RVOTO, gastroschisis, omphalocele;
- Fluoxetine = RVOTO, craniosynostosis
- Some possible associations but absolute risk increase is small and some studies showed no risks
- Also some association with preterm birth and low birth weight (<2500g)
What are common post-natal complications of SSRI/SNRI use in pregnancy?
- Most common is Poor Neonatal Adaptation Syndrome (PNAS) or NAS/serotonin discontinuation syndrome (in 30% of babies)
- Can have symptoms hours to 2 weeks post birth (usually mild/self-limiting)
- Poor tone, tremors, jitteriness, irritability, sz, poor feed/sleep, hypoglycemia, resp distress
- Modified Finnegan not validated for this
- Consider observing infants 24-48h post birth + eat/sleep/console, encourage BF, don’t need to taper/stop SSRI pre-birth
- Monitor for hypoglycemia, and if severe, may need antiepileptic, fluids or resp support
- Can have symptoms hours to 2 weeks post birth (usually mild/self-limiting)
What is the causative triad for early childhood caries (ECC)? What are complications of ECC? What is the definition of severe ECC?
Triad of childhood caries:
- Cariogenic bacteria (usually Strep mutans)
- Fermentable carbs
- Host susceptibility (enamel integrity)
Complications: tooth loss, malocclusion, more caries into adolescence, low oral health
Severe-ECC = aggressive form of ECC classified by location, # of teeth and age; usually needs surgery under GA
What are medications used to assist with sleep in children?
Melatonin:
- Only medication shown to be safe and effective in children > 2years
- Useful for delayed sleep phase and sleep onset assoc disorders
- positive effects for ADHD and autism
- 2.5 - 10mg
- Can have side effects = nightmares
What are factors that make Indigenous children higher risk for caries?
- Acquire S. mutans early (ie. less than 12 months vs usually acquire at 19-31 months)
- Earlier teeth eruption (new teeth more prone to caries)
- Teeth microbiome more likely to have S. mutans (due to poverty, overcrowding, family size, nutrition and other health behaviours)
- Parents with caries
- Prolonged bottle feed (if BF, then would be protective unless BF >12 months)
- Sugary drinks/snacks
- Tobacco smoke
- GDM, obesity
What are prevention strategies for early childhood caries?
- Prenatal ECC prevention: maternal dental care, oral hygiene education, prenatal nutrition, fluoride toothpaste
- Fluoride: fluoride toothpaste BID (<3yo brushed by adult w/ grain sized toothpaste; 3-6yo w/ pea-sized amount)
- Community water fluoridation only received by 2% of FN
- Topical fluoride w/ first tooth eruption helps prevent (doesn’t work once already cavity)
- Oral health education: more benefit if oral health education at first tooth eruption
- Community based strategies: promotion of traditional foods first and BF can be helpful
What are possible therapies for treatment of early childhood caries (ECC)?
- Therapies:
- Sealants – for pits and fissures, apply on primary molars at eruption (74% remain caries free), fluoride varnish q3-6m
- Minimally invasive restoration (glass ionomer etc) prevent caries progression (can be done by hygienists etc)
- Silver diamine fluoride – stops caries progression (turns it black/hard) biannually if high risk for progression
- GA repair – prevention etc way more cost effective, and less risk of GA/pain etc
What are recommendations for improving early childhood caries in Indigenous children?
- Promote changes to diet (less sugary foods), exclusive BF until 12 months
- Prenatal and early oral health education
- Discuss oral health at well child visits with caries risk assessment once first tooth eruption
- Community water fluoridation
- Fluoridated toothpaste BID (grain sized for <3yo, pea sized for >3yo)
- Fluoride varnish with first tooth and q3-6 months
- Silver diamine fluoride to prevent spread of caries and consider interim therapeutic restoration and sealants on primary molars
- Consider expanding dental therapists, dental hygienist and PCP roles in remote places (and train in culturally approp manner)
- Advocate for adequate dental workforce and increased representation of Indigenous people
- Support ECC research in Indigenous communities
What are signs and symptoms of adrenal suppression?
- Poor linear growth*** (in ~50%)
- Poor weight gain
- Anorexia
- Nausea/vomiting
- Malaise
- Weakness/fatigue
- Headache
- Abdominal pain
- Myalgias/arthralgias
- Psych symptoms
- Cushingoid features
- Adrenal crisis = hypotension, hypoglycemia, seizures, coma
What are the recommendations to reduce risk of adrenal suppression with steroid use?
- Use lowest effective dose of steroid possible
- Reassess dosing regularly
- Give steroids in the morning if possible
- Use once-daily dosing if possible
When should you consider screening for adrenal suppression in children with steroid use?
- Screen if symptomatic
- Screen in asymptomatic children if:
- > 2 week use of systemic glucocorticoids
- > 3 month use of high dose inhaled corticosteroids (>500mcg Flovent daily)
- > 1 month oral swallowed glucocorticoids (ie. budesonide for EoE)
- > 3 months of inhaled corticoids of any dose if used with CYP3A4 inhibitors (ie clarithromycin, ketoconazole)
What are recommendations regarding glucocorticoid tapers?
Glucocorticoid tapers:
- Don’t prevent adrenal suppression so no need for long tapers (outside of course of treatment)
- < 1 month use = no taper
- 1 - 3 month use = 1 - 2 week taper
- 3 - 6 month use = 2 - 3 week taper
- 6+ month use = 3 - 4 week taper
- Watch for steroid withdrawal symptoms (can mimic adrenal suppression)
- If suspected, check AM cortisol level (to make sure not adrenal suppression) and if normal, taper more slowly
How do you confirm/screen for adrenal suppression (AS) post glucocorticoid use?
- In asymptomatic individuals:
- Screen with AM cortisol level (7-9am) before tapering below physiologic dosing (8mg/m2/day)
- Must be off steroids for 24-48hr before test, and must have normal sleep-wake cycles
- If cortisol <100 nmol/L = diagnostic for AS
- If 100 - 275 nmol/L = possible AS
- Should do ACTH stim test for these patients or empiric GC treatment (ie stress dosing or daily physiologic dosing)
- > 275 = normal
- Must be off steroids for 24-48hr before test, and must have normal sleep-wake cycles
- Screen with AM cortisol level (7-9am) before tapering below physiologic dosing (8mg/m2/day)
- If symptomatic, treat and consult endo
When do you give stress dosing in adrenal suppression?
- Adrenal crisis, severe illness/injury
- IV STAT dose, then divided q6h doses or infusion
- Major surgery
- Pre-op IV dose, then divided q6h doses or infusion
- Minor/ moderate surgery or GA procedure
- 3 days of steroids until Sx resolve
- Moderate illness (can’t tolerate oral)
- IV/IM doses x 24 h then reassess to oral dosing, or consult endo if still can’t tolerate oral
- Moderate/ severe illness and can’t tolerate oral (PRE-ED)
- Teach parents IM administration
- Also for travel/camping
Daily physiologic dosing = Hydrocortisone at 8mg/m2/day and divide into BID/TID if pt symptomatic)
What are the vaping terms ‘ghosting’, ‘dripping’, ‘dosing’ and ‘dabbing’?
- ‘Ghosting’ = keep aerosol in lungs to make it disappear
- ‘Dripping’ = leak liquid onto coil directly for stronger effects but higher risk of injury
- ‘Dabbing’ = heat high cannabis concentrated products to make aerosol
- ‘Dosing’ = consuming high amounts of nicotine when vaping