6 - Community Paediatrics 1 Flashcards
Who does Jpal look like?
Perry the Platypus
What are some red flags for development?
What are some reasons for developmental variation?
- 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
What are some correctable causes of slow development?
- Undernutrition (failure to thrive)
- Iron deficiency anaemia
- Social isolation of the family or maternal depression
- Hypothyroidism
What are some examples of behavioural problems?
- Poor sleeping
- Poor eating
- Soiling
- Over-activity and poor concentration
- Unusual, repetitive behaviours
- Disobedience, argumentative, labile mood
- Worries and fears
What factors affect the behaviour of children?
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
What are some sleep problems in children?
- Refusal to go to bed
- Frequent night waking
- Parasomnias
- Chronic illness e.g asthma
How can sleep problems in children be managed?
What are some non-epileptic behaviours that can mimic epilepsy?
- Simple faint
- Breath holding spells
- Temper tantrums
- Hyperventilation
- Infantile colic
- Self stimulatory behaviours
What investigations need to be done for children with food refusal?
- 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)
How can food refusal be managed in children?
- 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
What are some causes of soiling in children?
– Consider malabsorption, excessive fruit juice
– Faulty toilet training
– Neglect
– Other stressors
– Constipation with overflow diarrhoea
What is encopresis?
- Repeated passage of solid faeces in the wrong place in those >4yrs old
- It may be voluntary or non-voluntary
- Usually due to overflow in constipation, behavioural response to sexual abuse, learning disability
What investigations should you do if a child is soiling?
How can soiling in children be treated?
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
What is the definition of enuresis and some causes of this?
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
How can enuresis be managed?
- 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
What are some key points on managing childhood behaviour?
Positive reinforcement
What is the difference between conduct and oppositional defiant disorder?
SEE PSYCHIATRY NOTES
ODD is less severe and has emotion/mood disorders
Conduct disorder have limited pro-social emotions
What is the definition of a learning disability, including the classification?
- Lower intellectual ability (IQ<70)
- Impairment of social or adaptive functioning
- Started in childhood
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
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
What are some genetic conditions associated with learning disability?
- Tuberous sclerosis
- Downs syndrome
- Fragile X
How are learning disabilities managed?
- Exclude treatable cause is missed
- Other members of the family may need special support
- MDT
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
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
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
What is the prevalence of self-harm in teenagers?
10%
How can you decide whether a child who is self-harming is low-risk or high-risk?
What interventions are available when a child is self-harming?
Always develop a safety plan
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
If a child is having issues with speech what is the first issue you need to rule out?
Hearing impairment
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
What might regression of speech indicate?
Autistic Spectrum Disorder
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
How should you manage a child with speech delay?
- Check for hearing impairment
- Refer early before school starts for Speech and Language Therapy
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
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
What are some neurodevelopmental disorders?
- ADHD
- Autism
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
What is the epidemiology of ADHD?
3-5% prevalence UK, 7% worldwide
More common in boys than girls
Genetic component
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
What are some differential diagnoses for ADHD?
- Auditory processing disorder
- Oppositional defiant or conduct disorder
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
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
What medications are used in ADHD?
Aim is to improve their attention and concentration to maximise educational potential
- Methylphenidate (Ritalin): 1st line (stimulant) 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
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
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
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
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
- 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”.
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
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
What are the hallmarks of autistic spectrum disorder?
Pervasive (more than 1 setting)
- Limited in social interaction
- Limited in social communication
- Restricted repetitive interests
When do the symptoms of ASD first occur?
Before 3 years
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
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
What needs to be present for a diagnosis of autism?
What are some co-morbidities associated with autism?
- ADHD
- LD
- Sleep issues
- Anxiety
- Epilepsy
- Tuberous Sclerosis (check for skin markings)
What are some differential diagnoses for autism?
- Learning difficulties
- Attachment disorder
- Rett’s Syndrome
- Schizophrenia
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
What questionnaire is given to home and school for investigating a suspected ASD diagnosis?
GARS
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)
What is the prognosis with autism?
- Lifelong
- Spectrum so some will live independent lives but others may need supported living
What is cerebral palsy?
Permanent neurological problems, leading to disorderly movement and posture, due to damage to the brain around the time of birth
Not a progressive condition
Huge variation in the severity and type of symptoms,
What is the epidemiology of cerebral palsy?
Every 1 in 400 births
What are the causes of cerebral palsy?
Antenatal: (most common 80%)
- 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
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
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
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
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
What are some co-morbidities associated with cerebral palsy?
- Learning disability
- Epilepsy
- Kyphoscoliosis
- Hip dislocation
- Muscle contractures
- Hearing and visual impairment
- GORD
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
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
What questionnaire is used to screen the motor ability of children with cerebral palsy?
Gross Motor Function Classification System (GMFCS)
What is the biggest cause of death in CP?
Aspiration Pneumonia
Control their drooling
How can you tell the difference between CP and SMA?
SMA has reversal of developmental milestones but CP does not
What can be given for muscle contractures in CP?
- Baclofen
- Botulin injections
