6 - Community Paediatrics 1 Flashcards

1
Q

Who does Jpal look like?

A

Perry the Platypus

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2
Q

What are some red flags for development?

A
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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
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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
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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
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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
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7
Q

What are some sleep problems in children?

A
  • Refusal to go to bed
  • Frequent night waking
  • Parasomnias
  • Chronic illness e.g asthma
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8
Q

How can sleep problems in children be managed?

A
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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
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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)
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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
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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

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13
Q

What is encopresis?

A
  • 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
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14
Q

What investigations should you do if a child is soiling?

A
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15
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

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16
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

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17
Q

How can enuresis be managed?

A
  • 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
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18
Q

What are some key points on managing childhood behaviour?

A

Positive reinforcement

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19
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

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20
Q

What is the definition of a learning disability, including the classification?

A
  1. Lower intellectual ability (IQ<70)
  2. Impairment of social or adaptive functioning
  3. Started in childhood
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21
Q

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
A
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22
Q

What are some risk factors for learning disability?

A
  • 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
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23
Q

What are some genetic conditions associated with learning disability?

A
  • Tuberous sclerosis
  • Downs syndrome
  • Fragile X
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24
Q

How are learning disabilities managed?

A
  • Exclude treatable cause is missed
  • Other members of the family may need special support
  • MDT
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25
Q

How do you communicate with a patient that has learning disabilities in the OSCE?

A
  • 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
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26
Q

What are some causes of self-harm in children?

A

• 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
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27
Q

What are some coping strategies that can be taught to children who self harm?

A
  • 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
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28
Q

What is the prevalence of self-harm in teenagers?

A

10%

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29
Q

How can you decide whether a child who is self-harming is low-risk or high-risk?

A
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30
Q

What interventions are available when a child is self-harming?

A

Always develop a safety plan

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31
Q

Where can we refer children with substance misuse issues to?

A

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

32
Q

If a child is having issues with speech what is the first issue you need to rule out?

A

Hearing impairment

33
Q

What are some causes of delayed talking in children?

A

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
34
Q

What might regression of speech indicate?

A

Autistic Spectrum Disorder

35
Q

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?

A
  • 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
36
Q

How should you manage a child with speech delay?

A
  • Check for hearing impairment
  • Refer early before school starts for Speech and Language Therapy
37
Q

What is global neurodevelopment delay?

A

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

38
Q

What are some causes of global developmental delay?

A

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

39
Q

What are some neurodevelopmental disorders?

A
  • ADHD
  • Autism
40
Q

What are the hallmarks of ADHD? (ICD10)

A

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
41
Q

What is the epidemiology of ADHD?

A

3-5% prevalence UK, 7% worldwide

More common in boys than girls

Genetic component

42
Q

How may a child with ADHD appear?

A
  • 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
43
Q

What are some differential diagnoses for ADHD?

A
  • Auditory processing disorder
  • Oppositional defiant or conduct disorder
44
Q

What investigations should you do if you suspect a child to have ADHD?

A
  • 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
45
Q

What is the management for diagnosed ADHD?

A

Depends on severity and age as to treatment given first line (see image)

  • Behavioural techniques
  • Medication
  • Healthy diet eliminating triggers
  • Exercise
46
Q

What medications are used in ADHD?

A

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
47
Q

What are the side effects of ADHD medication?

A
  • Raised blood pressure
  • Palpitations (representing potentially dangerous arrhythmias)
  • Disturbed sleep
  • Impaired growth and appetite suppression
  • Child becoming more aggressive emotional, anxious or depressed
48
Q

What is the prognosis with ADHD?

A
  • 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
49
Q

What screening tools are useful in the assessment of ADHD?

A
  • Conners Questionnaire
  • Dundee Difficult Times of the Day Scale (D- DTODS)
  • SNAP–IV
  • Strengths and Difficulties questionnaire
50
Q

What is the DSM-5 diagnostic criteria for ADHD?

A

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”.
51
Q

If a child is being put on ADHD medication and they have a family history of cardiac disease, what investigations need to be done?

A

Refer to paediatric cardiologist for:

  • Blood pressure
  • Echocardiogram
  • ECG for QTc interval
52
Q

What needs to be monitored if a child is put on ADHD medication?

A
  • Blood pressure
  • Height
  • Weight
  • Pulse

Rare potential side effects of cardiac arrest, angina pectoris, NMS and sudden cardiac death

53
Q

What are the hallmarks of autistic spectrum disorder?

A

Pervasive (more than 1 setting)

  • Limited in social interaction
  • Limited in social communication
  • Restricted repetitive interests
54
Q

When do the symptoms of ASD first occur?

A

Before 3 years

55
Q

What is the epidemiology of ASD?

A
  • 1% of children
  • More common in boys
  • Advancing maternal/paternal age and perinatal hypoxia are risks
  • Common in Fragile X, Angelmann and Tuberous sclerosis
56
Q

What are some clinical features of ASD?

A

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
57
Q

What needs to be present for a diagnosis of autism?

A
58
Q

What are some co-morbidities associated with autism?

A
  • ADHD
  • LD
  • Sleep issues
  • Anxiety
  • Epilepsy
  • Tuberous Sclerosis (check for skin markings)
59
Q

What are some differential diagnoses for autism?

A
  • Learning difficulties
  • Attachment disorder
  • Rett’s Syndrome
  • Schizophrenia
60
Q

What investigations should you do for a diagnosis of autism?

A
  • Educational psychology assessment
  • Family history of autism
  • Parental views about diagnosis
  • School report and observation
  • Speech and language assessment
61
Q

What questionnaire is given to home and school for investigating a suspected ASD diagnosis?

A

GARS

62
Q

How is autism managed?

A

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)
63
Q

What is the prognosis with autism?

A
  • Lifelong
  • Spectrum so some will live independent lives but others may need supported living
64
Q

What is cerebral palsy?

A

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,

65
Q

What is the epidemiology of cerebral palsy?

A

Every 1 in 400 births

66
Q

What are the causes of cerebral palsy?

A

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
67
Q

What are the different types of cerebral palsy?

A
  • 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
68
Q

What are the different patterns of cerebral palsy?

A
  • 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
69
Q

How may cerebral palsy present?

A

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
70
Q

What might you see on neurological examination of a child with cerebral palsy?

A
  • 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
71
Q

What are some co-morbidities associated with cerebral palsy?

A
  • Learning disability
  • Epilepsy
  • Kyphoscoliosis
  • Hip dislocation
  • Muscle contractures
  • Hearing and visual impairment
  • GORD
72
Q

How is cerebral palsy managed?

A

“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
73
Q

What medications are commonly prescribed for cerebral palsy?

A
  • Muscle relaxants (e.g. baclofen) for muscle spasticity and contractures
  • Anti-epileptic drugs for seizures
  • Glycopyrronium bromide for excessive drooling
74
Q

What questionnaire is used to screen the motor ability of children with cerebral palsy?

A

Gross Motor Function Classification System (GMFCS)

75
Q

What is the biggest cause of death in CP?

A

Aspiration Pneumonia

Control their drooling

76
Q

How can you tell the difference between CP and SMA?

A

SMA has reversal of developmental milestones but CP does not

77
Q

What can be given for muscle contractures in CP?

A
  • Baclofen
  • Botulin injections