6 - Community Paediatrics 1 Flashcards
1
Q
0t. / DO PAEDIATRICS DECK OF GP
A
2
Q
What are some red flags for development?
A
3
Q
What are some reasons for developmental variation?
A
- Late talking or walking (including bottom shuffling) may be familial
- Language development may seem delayed at first in children of bilingual families, but counting total words in both languages typically compensates for perceived delay
4
Q
What are some correctable causes of slow development?
A
- Undernutrition (failure to thrive)
- Iron deficiency anaemia
- Social isolation of the family or maternal depression
- Hypothyroidism
5
Q
What are some examples of behavioural problems?
A
- Poor sleeping
- Poor eating
- Soiling
- Over-activity and poor concentration
- Unusual, repetitive behaviours
- Disobedience, argumentative, labile mood
- Worries and fears
6
Q
What factors affect the behaviour of children?
A
Individual
- Genetics
- Gender
Family
- Early attachment
- Family structure
- Parental style
- Domestic violence
- Parental mental illness
- Parental substance misuse
Environment
- Social class
- Abuse physical / emotional /sexual, Neglect
- Schools
7
Q
What are some sleep problems in children?
A
- Refusal to go to bed
- Frequent night waking
- Parasomnias
- Chronic illness e.g asthma
8
Q
How can sleep problems in children be managed?
A
9
Q
What are some non-epileptic behaviours that can mimic epilepsy?
A
- Simple faint
- Breath holding spells
- Temper tantrums
- Hyperventilation
- Infantile colic
- Self stimulatory behaviours
10
Q
What investigations need to be done for children with food refusal?
A
- History (feeding pattern, weaning, family eating etc.)
- Dental examination
- Abdominal examination for constipation
- Monitor growth against projected range
- Investigate for organic causes (check ferritin and FBC)
11
Q
How can food refusal be managed in children?
A
- Social reinforcement (‘praise’) crucial
- Avoid coaxing & forcing
- Avoid using preferred foods as reward
“if mummy has to bribe me to eat this then it can’t be very nice” - Family mealtimes
- Encourage communal eating with peers
- Rejection of new foods can be overcome by repeated exposure to small quantities
12
Q
What are some causes of soiling in children?
A
– Consider malabsorption, excessive fruit juice
– Faulty toilet training
– Neglect
– Other stressors
– Constipation with overflow diarrhoea
13
Q
What is encopresis?
A
- the repeated passing of stool (usually involuntarily) into clothing. Typically it happens when impacted stool collects in the colon and rectum: The colon becomes too full and liquid stool leaks around the retained stool, staining underwear.
- It may be voluntary or non-voluntary
- Usually due to overflow in constipation, behavioural response to sexual abuse, learning disability
14
Q
what are some risk factors for developing encopresis
A
Encopresis is more common in boys than in girls. These risk factors may increase the chances of having encopresis:
- Using medications that may cause constipation, such as cough suppressants
- Attention-deficit/hyperactivity disorder (ADHD)
- Autism spectrum disorder
- Anxiety or depression
15
Q
What investigations should you do if a child is soiling?
A
16
Q
what is hirschsprungs disease?
A
congenital condition that affects the large bowel, there are missing nerve cells too the bowel. without these nerve cells the bowel cannot move contense through it and hence causes a block in the bowels
17
Q
what are some signs and symptoms of hirschsprungs disease
A
- Swollen belly
- Vomiting, including vomiting a green or brown substance
- Constipation or gas, which might make a newborn fussy
- Diarrhea
- Delayed passage of meconium — a newborn’s first bowel movement
18
Q
how to treat hirschsprungs disease
A
surgery to remove the affected bowel or to bypass it
19
Q
How can soiling in children be treated?
A
Constipation
- Escalating macrogol dose for impaction then maintenance dose
- Increase fluid, vegetable and fibre intake
- Regular toileting e.g after meals and before bed
- Rewarding e.g star charts
- Treat any perianal cellulitis with amoxicillin
May need some psychological input and investigation into social issues
20
Q
What is the definition of enuresis and some causes of this?
A
Bedwetting at night after the age of 5 in girls and the age of 6 in boys
Secondary when been dry for 6 months but returns to bed-wetting
21
Q
How can enuresis be managed?
A
- first line is lifestyle, then enuresis alarm and positive encouragment then medication
- Urine dipstick and culture for UTI
- Treat any underlying constipation
- Check for diabetes
- Cut down fluids before bed
- Reward system for dry nights
- Do not punish
- Alarm
- Desmopressin sublingual dose (if >5yrs) at bedtime useful for sleepovers and school trips but relapse is common
22
Q
What are some key points on managing childhood behaviour?
A
Positive reinforcement
23
Q
What is the difference between conduct and oppositional defiant disorder?
A
SEE PSYCHIATRY NOTES
ODD is less severe and has emotion/mood disorders
Conduct disorder have limited pro-social emotions
24
Q
conduct disorder
A
characterised by persistent behaviour in patients under 18 that repeatedly violates the rights of others and demonstrates a disregard for societal norms. Key signs include demonstration of physical aggression, destructive behaviour, and stealing.
- Persistent and serious violation of rules, societal norms, and the rights of others
- Physical aggression directed towards people and animals
- Destructive behaviour, such as arson or vandalism
- Deceitfulness or theft
Serious violation of rules, such as truancy or running away from home
25
Oppositional defiant disorder
defiant, disobedient, and hostile behaviour directed towards authoritative figures, such as parents or teachers. This disruptive behaviour, however, does not meet the severity threshold for conduct disorder, which significantly impairs social functioning.
26
What is the definition of a learning disability, including the classification?
1. Lower intellectual ability (IQ\<70)
2. Impairment of social or adaptive functioning
3. Started in childhood
27
What is the definition of the following types of learning disability:
* Dyslexia
* Dysgraphia
* Dyspraxia
* Auditory processing disorder
* Non-verbal learning disability
* Profound and multiple learning disability
28
What are some risk factors for learning disability?
* Family history
* Abuse and Neglect
* Genetic disorders such as Downs syndrome
* Antenatal problems, such as fetal alcohol syndrome and maternal infections
* Problems at birth, such as prematurity and HIE
* Problems in early childhood, such as meningitis
* Metabolic disorders e.g PKU, Homocystinuria
* Autism
* Epilepsy
* Lead exposure
29
What are some genetic conditions associated with learning disability?
* Tuberous sclerosis
* Downs syndrome
* Fragile X
* Tuberous Sclerosus
30
How are learning disabilities managed?
* Exclude treatable cause is missed
* Other members of the family may need special support
* MDT
31
How do you communicate with a patient that has learning disabilities in the OSCE?
* Speak to patient first not their carer
* Involve patient in discussions
* Simplify information and give in small chunks
* Check understanding
* Always assume has capacity until proven otherwise
32
What are some causes of self-harm in children?
• expressing or coping with emotional distress
* trying to feel in control
* a way of punishing themselves
* relieving unbearable tension
* a cry for help
* a response to intrusive thoughts
33
What are some coping strategies that can be taught to children who self harm?
* adults can help build their self-esteem
* paint, draw or scribble in red ink
* hold an ice cube in hand until it melts
* write down negative feelings then rip the paper up
* wear an elastic band on your wrist and snap it every time feel the urge to self-harm
* listen to music
* punching or screaming into a pillow
* talk to friends or family
* take a bath or shower
* exercise
34
What is the prevalence of self-harm in teenagers?
10%
35
How can you decide whether a child who is self-harming is low-risk or high-risk?
36
What interventions are available when a child is self-harming?
Always develop a safety plan
37
Where can we refer children with substance misuse issues to?
**Turning Point**
Need to involve social services, this is safeguarding
Give skills training and also information about the harmful effects of the specific drug use
38
If a child is having issues with speech what is the first issue you need to rule out?
Hearing impairment
39
What are some causes of delayed talking in children?
Look at other developmental milestones for cues and get speech and language therapist involved
* Familial delay
* Hearing impairment
* Global developmental delay
* Autism
* Abuse
* Poor social interaction
40
What might regression of speech indicate?
Autistic Spectrum Disorder
41
Parents should be able to understand most speech by 2 and a half years of age. What are some causes of poor speech clarity in children?
* **Articulatory dyspraxia**
* **Tongue tie:** may need frenulum surgery
* **Audio-premotor syndrome (APM):** The child cannot reflect sounds correctly heard into motor control of larynx and respiration
* **Respirolaryngeal (RL) dysfunction:** incorrect vocal fold vibration
42
How should you manage a child with speech delay?
* Check for hearing impairment
* Refer early before school starts for Speech and Language Therapy
43
What is global neurodevelopment delay?
Delay in all skill areas; it may be more pronounced in fine motor, speech, and social skills
There are many causes although in some instances it remains unknown
44
What are some causes of global developmental delay?
**•** **Genetic:** Down's, Fragile X, Duchenne muscular dystrophy, metabolic eg PKU
**•** **Congenital brain abnormalities:** Hydrocephalus, microcephaly
**•** **Prenatal cause:** Teratogens such as alcohol and drugs, congenital infections (particularly rubella, CMV, or toxoplasmosis), hypothyroidism
**•** **Perinatal cause:** Extreme prematurity leading to intraventricular haemorrhage or periventricular leukomalacia, birth asphyxia
**•** **Postnatal cause:** Brain injury from suffocation, drowning, head injury, CNS infection, particularly meningitis or encephalitis
45
What are some neurodevelopmental disorders?
* ADHD
* Autism
46
What are the hallmarks of ADHD? (ICD10)
Have to be present before the age of 6 and occur in more than one setting (e.g cannot just be behaviour at school)
* Hyperactivity
* Inability to concentrate
* Impulsivity
47
What is the epidemiology of ADHD?
**3-5% prevalence UK, 7% worldwide**
More common in boys than girls
Genetic component
48
How may a child with ADHD appear?
* Very short attention span
* Quickly moving from one activity to another
* Quickly losing interest in a task
* Constantly moving or fidgeting
* Impulsive behaviour
* Disruptive or rule breaking
49
What are some differential diagnoses for ADHD?
* Auditory processing disorder
* Oppositional defiant or conduct disorder
50
What investigations should you do if you suspect a child to have ADHD?
* Take BP and ECG as baseline before treatment
* Plot heigh and weight on growth chart
* **Conner's Questionnaire** (from school, home, relatives to show in more than one environment)
* School observation
51
What is the management for diagnosed ADHD?
Depends on severity and age as to treatment given first line (see image)
* **Behavioural techniques**
* **Medication**
* Healthy diet eliminating triggers
* Exercise
52
What medications are used in ADHD?
Aim is to improve their attention and concentration to maximise educational potential
* **Methylphenidate (Ritalin):** 1st line either short or long term release. Do not give at weekends or school holidays as reduces appetite
* **Dexamfetamine**
* **Atomoxetine:** takes 6 weeks to reach full efficacy but effects on withdrawal. Given 2nd line or if risk of diversion
53
What are the side effects of ADHD medication?
* Raised blood pressure
* Palpitations (representing potentially dangerous arrhythmias)
* Disturbed sleep
* Impaired growth and appetite suppression
* Child becoming more aggressive emotional, anxious or depressed
54
What is the prognosis with ADHD?
* **Symptoms improve over time and ⅔ will lead to normal adulthood**
* Increased risk of substance abuse
* Increased risk of poor educational attainment
* Increased risk of criminality
55
What screening tools are useful in the assessment of ADHD?
* **Conners Questionnaire**
* **Dundee Difficult Times of the Day Scale (D- DTODS)**
* **SNAP–IV**
* **Strengths and Difficulties questionnaire**
QB test - computerised
56
What is the DSM-5 diagnostic criteria for ADHD?
At least **6 of the criteria**, present in **more than one setting**, for **more than 6 months**, **before the age of 12**
these symptoms should be present everywhere so in school and at home - pervasive!!
* **_Inattention criteria:_** “easily distracted by extraneous stimuli”, “forgetful in daily activities” and “often has difficulty sustaining attention in tasks or play activities”.
* **_Hyperactivity criteria_**“often fidgets with hands or feet or squirms in seat”, “often talks excessively” and “is often on the go or often acts as if driven by a motor”.
* **_Impulsivity criteria_** “often has difficulty waiting turn” and “often bursts out answers before questions have been completed”.
57
If a child is being put on ADHD medication and they have a family history of cardiac disease, what investigations need to be done?
Refer to paediatric cardiologist for:
* Blood pressure
* Echocardiogram
* ECG for QTc interval
58
What needs to be monitored if a child is put on ADHD medication?
* Blood pressure
* Height
* Weight
* Pulse
Rare potential side effects of cardiac arrest, angina pectoris, NMS and sudden cardiac death
59
What are the hallmarks of autistic spectrum disorder?
Pervasive (more than 1 setting)
* Limited in social interaction
* Limited in social communication
* Restricted repetitive interests
60
When do the symptoms of ASD first occur?
Before 3 years
61
What is the epidemiology of ASD?
* 1% of children
* More common in boys
* Advancing maternal/paternal age and perinatal hypoxia are risks
* Common in Fragile X, Angelmann and Tuberous sclerosis
62
What are some clinical features of ASD?
**_Social Interaction_**
* ***Lack of eye contact***
* Delay in smiling
* Avoids physical contact
* Unable to read non-verbal cues
* Difficulty establishing friendships
* Not displaying a desire to share attention (i.e. not playing with others)
**_Communication_**
* ***Delay, absence or regression in language development***
* Lack of appropriate non-verbal communication such as smiling, eye contact, responding to others and sharing interest
* Difficulty with imaginative or imitative behaviour
* Repetitive use of words or phrases
**_Behaviour_**
* Greater interest in objects, numbers or patterns than people
* Stereotypical repetitive movements used to comfort themselves, such as hand-flapping or rocking
* Repetitive behaviour and fixed routines
* Anxiety and distress with experiences outside their normal routine
* Extremely restricted food preferences
63
What needs to be present for a diagnosis of autism?
64
What are some co-morbidities associated with autism?
* ADHD
* LD
* Sleep issues
* Anxiety
* Epilepsy
* Tuberous Sclerosis (check for skin markings)
65
What are some differential diagnoses for autism?
* Learning difficulties
* Attachment disorder
* Rett's Syndrome
* Schizophrenia
66
What investigations should you do for a diagnosis of autism?
* Educational psychology assessment
* Family history of autism
* Parental views about diagnosis
* School report and observation
* Speech and language assessment
67
What questionnaire is given to home and school for investigating a suspected ASD diagnosis?
GARS
68
How is autism managed?
**MDT Approach**
* **Behavioural management strategies** – visual timetables, preparation and explanation for changes in routine
* **Educational measures** – Schools can access ‘Higher Needs Funding’ based on the needs of the individual child, but a diagnosis is needed for an **‘Education, Health and Care Plan’**
* **Adequate treatment of co-morbid conditions e.g** ADHD, sleep disorders, learning disabilities, anxiety)
69
What is the prognosis with autism?
* Lifelong
* Spectrum so some will live independent lives but others may need supported living
70
What is cerebral palsy?
***Permanent neurological*** problems resulting from damage to the brain around the time of birth
***N******ot*** a progressive condition
Huge variation in the severity and type of symptoms,
71
What is the epidemiology of cerebral palsy?
Every 1 in 400 births
72
What are the causes of cerebral palsy?
**Antenatal:**
* Maternal infections e.g toxoplasmosis
* Trauma during pregnancy
**Perinatal:**
* Birth asphyxia (HIE)
* Pre-term birth
* Intraventricular haemorraghe
**Postnatal: (Insults up to 3 months of age)**
* Meningitis
* Severe neonatal jaundice
* Head injury e.g NAI shaken baby
* Neonatal hypoglycaemia \<2
73
What are the different types of cerebral palsy?
* ***_Spastic/Pyramidal_***_:_ hypertonia resulting from damage to upper motor neurones, EXTREME PREMATURITY
* ***_Dyskinetic/Athetoid/Extrapyramidal_***_:_ problems controlling muscle tone, with hypertonia and hypotonia, causing athetoid movements and oro-motor problems. Due to damage of basal ganglia
* ***_Ataxic_***_:_ problems with coordinated movement resulting from damage to the cerebellum
* ***_Mixed_***_:_ a mix of spastic, dyskinetic and/or ataxic features
74
What are the different patterns of cerebral palsy?
* ***Monoplegia***: one limb
* ***Hemiplegia***: one side of the body
* ***Diplegia***: four limbs are affected, but mostly the legs
* ***Quadriplegia***: four limbs are affected more severely, often with seizures, speech disturbance and other impairments
75
How may cerebral palsy present?
Difficult to tell the extent it occurs to until the child begins to develop more. If have HIE need to closely monitor child:
* Failure to meet milestones
* Head circumference not increasing
* Increased or decreased tone
* **Hand preference below 18 months**
* **Persisting reflexes**
* Problems with coordination, speech or walking
* Feeding or swallowing problems
* Learning difficulties
* Hypotonic baby
76
What might you see on neurological examination of a child with cerebral palsy?
* **Hemiplegic or Diplegic Gait:** if spastic CP. Will have extended legs with plantar flexed toes
* **UMN signs:** good muscle bulk, hypertonia, brisk reflexes
* **Look for athetoid movements** for extrapyramidal involvement
* **Test co-ordination** for cerebellar involvement
77
What are some co-morbidities associated with cerebral palsy?
* Learning disability
* **Epilepsy**
* Kyphoscoliosis
* Muscle contractures
* Hearing and visual impairment
* **GORD**
78
How is cerebral palsy managed?
**“Management will involve a multi-disciplinary approach”**
* ***Physiotherapy:*** stretch and strengthen muscles, prevent muscle contractures
* ***Occupational therapy:*** help patients manage their everyday activities, such as getting dressed and using the bathroom. Make adaptations and supply equipment, such as rails for assistance
* ***Speech and language therapy*** can help with speech and swallowing
* ***Dieticians*** can help ensure they meet nutritional requirements. May need PEG
* ***Orthopaedic surgeons*** : release contractures or lengthen tendons (***tenotomy***)
* ***Paediatricians*** will regularly see the child to optimise their medications
* ***Social workers*** to help with benefits and support
* ***Charities*** and ***support groups***
79
What medications are commonly prescribed for cerebral palsy?
* ***Muscle relaxants*** (e.g. baclofen) for muscle spasticity and contractures
* ***Anti-epileptic drugs*** for seizures
* ***Glycopyrronium bromide*** for excessive drooling
80
What questionnaire is used to screen the motor ability of children with cerebral palsy?
Gross Motor Function Classification System (GMFCS)
81
What is the biggest cause of death in CP?
Aspiration Pneumonia
Control their drooling
82
How can you tell the difference between Cerebral P and Spinal Muscular Atrophy?
SMA has reversal of developmental milestones but CP does not
While both SMA (Spinal Muscular Atrophy) and Cerebral Palsy affect muscle function, the key difference lies in their origin: SMA is a genetic disorder causing progressive muscle weakness due to damage to motor neurons in the spinal cord, while Cerebral Palsy results from brain damage during or shortly after birth, leading to impaired muscle control and coordination, often with varying muscle tone issues depending on the affected brain area.
83
What can be given for muscle contractures in CP?
* Baclofen
* Botulin injections
84
where do young boys get their source of oestrogen
from a breakdown of testosterone
85
which hormone is essential for stopping growing
oestrogen causes fusion of the epiphyseal growth plates
86
what age can you diagnose ADHD
post 6
87
if the child is a picky eater what do you need to rule out
coeliacs
88
when screening for the neurodevelopmental condition what is also important to screen for
genetic screen to understand why they have this
89
what is global delay
a condition where a child is significantly delayed in meeting developmental milestones.
What are developmental milestones?
Learning to walk
Learning to talk
Interacting with others
Learning new things
Processing information
Remembering things
major delay in 2 areas - delay by almost half their age
90
when boys are not walking what differential can be considered
Duchenne muscular dystrophy
when the muscle fibres break down and there is more of a build up of fat is struggle to walk
91
what are some differentials for not being able to walk
- hip dysplasia
- downs
- cerebral palsy
- di georges
- hypothyroidism
-neglect
-teretogenic meds
92
what is a big red flag with development and some causes
DEVELOPMENTAL REGRESSION
- when a child starts to lose their develomental milestones eg they used to be able to talk now they dont
- tumour
-metabolic conditions
-autosomal recessive conditions
93
what form is useful in children with neurodevelopment conditions
EHCP forms - Education, Health and Care (EHC) plan form is a legal document that outlines a child's special educational needs and the support they need.
A brief description of what tasks or activities your child can do well, and what they struggle with
What an adult can do to help your child
What strategies are helpful to enable your child to express what they need or want, make choices, and express when they are unhappy or something is wrong
94
what are some questionairres for ADHD
conners
strength and difficulty
SNAP iv
95
what do you need to measure before starting ADHD meds
- height
- weight
- pulse
- BP
