Approach To Common Child Health Problems Flashcards
Integrated Child Health and Development Programme
- 0-5 years old
Take care of 3 aspects:
1. Physical
2. Cognitive
3. Psychosocial
3 Sub-programmes:
1. Parenting programme
- Positive Parenting Programme (Triple P)
2. Immunisation programme
3. Health and Developmental Surveillance programme
- Newborn consultation
- Growth monitoring + nutrition assessment
- Developmental surveillance scheme
- Hearing screening
- Vision screening
Comprehensive Child Development Service (CCDS)
- A Multidisciplinary and intersectoral service to provide a comprehensive service to 0-5 years old children using MCHC as the platform
- Aims to provide early engagement and timely intervention
- To improve health and developmental outcomes of the 3 main at-risk groups of children:
1. Mother suffering from active mental illness
2. Mother has history of heroin abuse / other illicit drug use within 1 year of her Expected Date of Delivery
3. Mother are teenagers with poor social support
(4. Domestic violence)
Antenatal period:
- At risk expectant mothers are screened and seen by CCDS midwives
- CCDS midwife has close liaison with CCDS Psychiatric nurses and Psychiatrist to monitor and treat the requiring expectant mothers
- CCDS Paediatrician regularly communicates with midwife and Psychiatrist for case monitoring, also collaborate with community partners (NGOs) for maternal and family support
Postnatal period:
- CCDS Paediatrician also works closely with hospital paediatric colleagues and IFSC/FCPSU workers for handling child welfare issues, play an significant role in child protection, participation in multidisciplinary case conference
- CCDS Paediatrician provides on site consultation (match with child’s immunisation schedule) and appropriate management for the child and family in MCHC aiming to provide a child focus, family centre and community based service
Other scopes:
1. Families with psychosocial needs
2. Mothers with postnatal depression
3. Pre-school children with developmental problems
Common child health problems
- Failure to thrive
- Feeding problems
- Constipation
- Eczema
- Developmental delay
- Injury prevention
- Dentition and common dental problems
Assessment of growth and nutrition
Background information:
1. Antenatal history
2. Birth and neonatal history
3. Past medical history and previous hospitalisations
4. Maternal and paternal medical history
5. Family and psychosocial history
6. Explore parental concerns regarding infants or children’s nutrition and growth
7. Observe maternal-infant interaction and attachment
8. Social and community supports available to the family
Nutritional assessment:
1. Assess nutritional intake (age-appropriate quality / quantity)
2. WHO and UNICEF recommend:
- Early initiation of breastfeeding within 1 hour
- Exclusive breastfeeding for the first 6 months of life
- Introduction of nutritionally-adequate and safe complementary (solid) food at 6 months together with continued breastfeeding up to 2 years of age / beyond
3. Assess the number of times of breast-feeding, duration of each breast feeding, signs of satiety in infants after feeding, assess the number of wet nappies per day
4. Assess safe use if supplemental infant formula: preparation and cleaning of infant feeding equipment
5. Weaning: a process of gradually introducing infants to adult solid food
- To meet with the increase in energy and nutritional requirement for growth, motor and mental development (e.g. Iron and other micronutrients)
- Infant at 6 months old with their oral motor coordination developing which is necessary to accept different food textures
- Delay in introduction of weaning diet much beyond 6 months old may put infant at risk for iron deficiency anaemia and other micronutrient deficiencies, as well as other feeding problems e.g. pricky eaters
- Principles for weaning diet:
—> Start with small amount of food and increase gradually
—> Suitable food choices to start: iron rich food with smooth in textures e.g. iron-fortified rice cereal, vegetable and fruit puree, dry beans puree and meat puree etc.
—> Observe for any allergic reactions, try the food 2-4 days before introducing another new food
—> Gradually increase food consistency and variety
—> Practise responsive feeding and avoid forced feeding
6. Assess / review children’s and family’s eating practices and feeding-related behaviour
- Feeding position
- Mealtime duration
- Behavioural / Parental concerns
Growth assessment:
1. Normal physical growth is an important indicator of an infant / child’s overall health and nutritional status
2. Following birth infants can lose up to 10% of their birth weight. By day 6 they should start to regain this weight and should have regained their birth weight by 2 weeks
3. There should be regular weight gain throughout the first year of life, approximately:
- birth to 3 months a gain of 150g – 200g per week
- 3-6months a gain of 100g–150g per week
- 6-12months a gain of 70g–90g per week
- Weight gain between 1-5 years of age approximately 2-3kg per year
4. Anthropometric measurement: body weight, height and head circumference: plot on standardised growth curve
5. Bone Mass Index (BMI) can be calculated and plotted from weight and height from 2 years
6. Interpret growth charts
Failure to thrive (FTT)
- Suboptimal weight gain or growth in children
- Decrease in velocity of weight gain results in falling off from the expected weight curve on growth curves
- A description of abnormal growth pattern, but not a diagnosis!
Different definitions on FTT:
1. BW <5th centile for sex and corrected age
2. Weight for height <5th centile
3. BMI for age <5th centile
4. Sustained decrease in growth velocity with weight for age or weight for height falls by 2 major percentiles
Causes:
Organic
1. Genetic / Chromosomal abnormalities (e.g. Russell-Silver syndrome)
(Genetic causes (SpC Revision):
Prenatal onset of growth retardation
- Russell-Silver syndrome
- Fetal alcohol syndrome
Postnatal failure + Developmental delay
- Williams syndrome
- Prader-Willi syndrome
- Costello syndrome)
- Inadequate caloric intake
- Gastroesophageal reflux
- Mechanical feeding difficulties (e.g. cleft lip / palate)
- Poor oral neuromotor coordination (e.g. cerebral palsy)
- Acute illness (e.g. Infection like UTI)
- Chronic illness (e.g. Congenital heart disease, cow’s milk protein allergy etc.) - Inadequate nutrient absorption
- Celiac disease
- Malabsorption
- Crohn’s disease - Abnormal metabolism
- IEM (e.g. Amino acid and organic acid disorders)
- Congenital hypothyroidism - Increase in energy consumption
- Chronic illness
- Malignancy
- Cystic fibrosis
Non-organic:
1. Feeding problems
2. Inadequate breast milk supply or ineffective latching
3. Incorrect formula preparation
4. Child neglect
5. Munchausen’s syndrome by proxy
Assessment of Failure to thrive
History:
1. Background history
- Antenatal and perinatal birth history
- Past medical history and hospitalisations
- Early feeding history
- Associated symptoms e.g. dysphagia, choking, aspiration, odynophagia, excessive crying and pain on feeding, frequent vomiting, profuse diarrhea, chronic cardiac or respiratory symptoms, associated skin problems or rash related to feeding
- Developmental milestones
- Other regulations: sleeping, toileting, soothing (for feeding problems)
- Family history: body size of family members, any chronic illness or metabolic / endocrine disorders
- Dietary history
- Detailed information on the type and timing of food intake
- Energy and nutrient intake - Feeding-related behaviour
- Feeding position
- Meal duration
- Behavioural and parental factors
Physical exam:
1. Anthropometric measurement: body weight, height and head circumference: plot on standardised growth curve
2. Dysmorphic features
3. Skin rash: cow’s milk protein allergy / food allergy
4. Signs of malnutrition: muscle wasting
5. Systemic exam: chronic illnesses
Investigations:
- No standard set of laboratory tests is recommended for FTT
- Considered for diagnostic purpose / evaluate the consequence of FTT
1. Blood tests
- CBC: Anaemia, infection, inflammation, immune deficiency
- RFT + Electrolyte: renal failure, renal tubular acidosis, metabolic disorders
- LFT: liver disease, metabolic disorders, malabsorption
- TFT: hypothyroidism
- Acute phase proteins (e.g. ESR, CRP): inflammation e.g. Crohn’s disease
- Iron profile: iron deficiency anaemia
- Immunoglobulins: immune deficiency
- Anti-endomysial and anti-gliadin antibodies: Coeliac disease
- Others:
—> Urinalysis, Urine microscopy and culture: UTI, renal disease
—> Stool microscopy and culture: Intestinal infection, parasites
—> Genetic tests or chromosomal analysis: Genetic or chromosomal abnormalities
—> Chest X Ray, sweat test: Cystic fibrosis
Management of Failure to thrive
Goal:
- Establish optimal growth velocity
- Manage and treat the organic problem or cause
- For non-organic problems or cause
- Multidisciplinary approach
—> lactation consultants
—> dietitians
—> speech or occupational therapists for oromotor stimulation
—> social worker for family psychosocial problem etc.
Indication of hospitalisation:
1. Need for precise documentation of nutritional intake
2. Failure of outpatient treatment
3. Serious underlying illness or medical problems
4. Severe malnutrition or dehydration
5. Extreme parental impairment or anxiety
6. Extremely poor parent-child interaction
7. Psychosocial factors that put a child’s safety at risks
Feeding problems
Definition:
- a disturbance in eating or feeding, as evidenced by one or more of substantial weight loss or absence of expected weight gain, nutritional deficiency, dependence on a feeding tube or dietary supplements, and significant psychosocial interference
- the disturbance is not due to limitations in food availability
- the disturbance is not due to anorexia nervosa or bulimia nervosa; and
- the disturbance is not explained by other medical conditions or mental disorders, or is not occurring concurrently with another condition
Causes:
Organic:
1. Dysphagia
2. Uncoordinated swallowing: choking, recurrent aspiration pneumonia
3. Regurgitation / GERD
4. Intestinal colic
5. Food allergy
6. Failure to thrive
7. Chronic illness e.g. congenital heart disease with heart failure
Non-organic:
1. Developmental-behavioural disorders
- Developmental delays
- ASD
- ADHD
- Behavioural
- Problematic behavioural feeding problems
- Parenting problems
- Signs of neglect - Psychological
- Somatoform disorder
Manifestations:
- Prolonged mealtime
- Food refusal
- Disruptive and stressful mealtimes
- Lack of appropriate independent feeding
- Prosecutory feeding (frequent consecutive attempts to offer food to override food refusal)
- Nocturnal feeding
- Mechanistic feeding (feeding a child precisely at regularly scheduled time with a given exact amount of food or formula at every meal, irrespective of child’s hunger cues)
- Conditional distraction (e.g. use of iPads)
- Failure to introduce advanced textures
Management of Feeding problems
- Management of underlying medical conditions
- Advice on age-appropriate amount, variety and textures of food intake, according to child’s requirement and oromotor skills
- Cut down between meal snacks and drinks
- Promote a pleasant and positive feeding environment, including feeding utensils and food presentations
- Position of body during feeding (e.g. High chair)
- Education to parents to recognise the signs of hunger and satiety cues of children
- Avoid force feeding or punishing children for not eating
- Avoid distraction
- Allow more self independent feeding in toddlers and older children, even if making a mess
- Limit mealtime duration no longer than 20-30 min and maintain appropriate boundary
- Consistent environment and atmosphere on feeding for the whole family
- Consider oromotor training by occupational or speech therapist in those with uncoordinated chewing or swallowing problems or some sensory integration problems
- Consider cognitive behavioural therapy by clinical psychologist for severe behavioural feeding problems
- Family therapy for management of family dynamic problems
Constipation
Normal bowel habits:
- Changes with age
—> First week of life: Average 3-4 times
—> later in infancy and toddler years: Average 2 times per day
—> Breastfed infants: Can be every several days or longer
—> Pre-school years: Average once per day to every 2 days
Diagnosis:
- Rome 3 diagnostic criteria
—> Frequency of bowel opening
—> Stool caliber and consistency
—> Associated symptoms
Causes:
1. Functional (no evidence of organic condition) (Most common)
- Caused by painful bowel movements that prompt a child to voluntarily withhold the stool
- Can also commonly associated with toilet training, changes in routine or diet, stressful events or psychological stress, illness, lack of accessible toilets, and busy child who defers defecation
- Withholding the stool can lead to prolonged fecal stasis in colon with reabsorption of fluid, causing the stool to become harder, larger and more painful to pass
- Over time, as rectum stretches to accommodate the retained fecal mass, rectal sensation decreases and fecal incontinence may develop
- Organic causes (Uncommon)
- Congenital anorectal abnormalities (e.g. Imperforate anus, colonic stenosis)
- Neuropathic GI disorders (e.g. Hirschsprung’s disease)
- Spinal cord abnormalities (e.g. meningomyelocele)
- Metabolic conditions (e.g. Hypothyroidism, hypercalcemia, hyperkalemia, urine concentrating disorder (e.g. Diabetes insipidus))
- Drug use (e.g. Anticholinergic agents)
- Others (e.g. Celiac disease, Cystic fibrosis, Psychiatric disorders)
Assessment of Constipation
History:
1. Age of onset of constipation is important
- The likelihood of an organic etiology for constipation is relatively greater in infants younger than 3 months old
- Timing of the first meconium passing
- Delayed passage of meconium (>48 hrs after birth), congenital anorectal abnormalities or Hirschsprung’s disease must be considered - Frequency, consistency, size of stools
- Diet history
- Breastfed infants: the frequency of bowel opening can be variable from several times per day to every several days
- Recent change in diet (e.g. Weaning period, recent sickness)
- Adequate amount of fiber and fluid intake - Associated symptoms
- Pain / bleeding when passing stools
- Recent fever or sickness
- Abdominal pain
- Faecal incontinence (suggest faecal impaction)
- Withholding behaviours - Social history
- Toilet training
- Recent stress events or trauma - Drug history
Physical exam:
1. Growth
2. Abdominal examination
3. Perineum and perianal area
4. Digital examination of anorectum
- assess for perianal sensation, anal tone, rectum size, anal wink and the amount and consistency of stool in the rectum
5. Spine and LL neurology exam
Management of Constipation
- Education and behavoural modification
- Positive reinforcement with regular toileting after meals
- Parents are encouraged to maintain a positive and supportive attitude and expect gradual improvement with occasional relapses - Dietary modification
- Increased intake of fluid
- Increased intake of absorbable and nonabsorbable carbohydrates (fibre)
- Probiotic may be helpful in some children with functional constipation although studies are preliminary - Disimpaction
- If fecal impaction is present
- Oral or rectal medication - Maintenance therapy (e.g. Lactulose)
- To avoid reaccumulation of stool by maintaining soft bowel movements
Eczema
- Common, chronic, itchy skin condition which usually develops in early childhood
- ~20% of children
- More severe in the first year of life, resolving in 50% by 12 years of age and 75% by 16 years
Manifestations:
1. Itchy rashes
2. Excoriated areas
- Erythematous, weeping, crusted
- Atopic skin
- Dry and persistent scratching may lead to lichenification (thickening of skin with accentuation of skin creases) - Distributions of rashes
- Changes with age
- Infants: face, scalp, trunk
- Older children: skin flexures (e.g. cubital fossa, popliteal fossa), frictional areas (e.g. neck, wrists and ankles) - Exacerbations
- Bacterial infection (e.g. Staphylococcus, streptococcus)
- Viral infection (e.g. HSV)
- Contact of triggering allergens / irritants
- Environment: heat, humidity
- Change / reduction in medication
- Psychological stress
Factors that influence Learning
- Child factors
- Maturation of the brain
- Temperament / personality
- Cognitive abilities
- Intelligence
- Motivation
- Experience
- Emotion
- Motor ability
- Physical health - Environment
- Physical
- Social - Opportunity
Developmental problems + disorders
- Neuropsychiatric
- ADD / ADHD
- Atypical behaviours (including PDD, tics etc.)
- Negative / Antisocial behaviour
- Emotion / Mood difficulties
- Eating / Elimination / Sleep problems
- Somatic symptoms
- Substance abuse
- Sexuality problems - Developmental disabilities
- GDD
- Persistent motor delays (e.g. cerebral palsy, developmental coordination disorder)
- Speech + language abnormalities (e.g. language disorders, stuttering)
- Learning difficulties (e.g. SLD)
- Blindness + severe VI
- Deafness + HI - Environmentally related developmental + behavioural problems
- Influences from family crisis, diversity in family constellations, culture and community
- Child abuse and neglect - Illness-related developmental + behavioural problems
- Influences from acute illnesses, hospitalisation, chronic / terminal illness
