Child Health Flashcards
Haemorrhagic disease of the newborn
Bleeding problem that occurs in a baby during the first few days of life.
Babies are normally born with low levels of vitamin K, an essential factor in blood clotting.
A deficiency in vitamin K is the main cause of hemorrhagic disease in newborn babies.
Haemorrhagic disease of the newborn Mx
Vitamin K: IM or oral
hypoxic ischaemic encephalopathy
Brain injury caused by oxygen deprivation to the brain, also commonly known as intrapartum asphyxia.
Hypoxia (lack of oxygen), ischaemia (restriction of blood flow to brain) and encephalopathy (malfunctioning of the brain)
The newborn’s body can compensate for brief periods of depleted oxygen, but if the asphyxia lasts too long, brain tissue is destroyed. Leads to cerebral palsy and multisystem organ damage
hypoxic ischaemic encephalopathy signs/symptoms
events that could lead to hypoxia during the perinatal or intrapartum period
acidosis (pH < 7) on the umbilical artery blood gas
features of mild, moderate or severe HIE (see below) or evidence of multi organ failure.
Poor Apgar scores – active resuscitation required
Neurodevelopmental sequalae
hypoxic ischaemic encephalopathy causes
- Maternal shock
- Intrapartum haemorrhage
- Prolapsed cord, causing compression of the cord during birth
- Nuchal cord, where the cord is wrapped around the neck of the baby
hypoxic ischaemic encephalopathy Mx
active resuscitation required: ongoing optimal ventilation, circulatory support, nutrition, acid base balance
• monitoring and treatment of seizures
• therapeutic hypothermia: protect brain from hypoxic injury (reduce inflammation and neurone loss)
Neonatal Jaundice: physiological jaundice
exaggerated with prematurity and immature liver – increased risk of kernicterus
- Fetal red blood cells break down more rapidly than normal red blood cells, releasing lots of bilirubin.
- Normally this bilirubin is excreted via the placenta, however at birth the foetus no longer has access to a placenta to excrete bilirubin. Additionally liver systems have not fully matured
- This leads to a normal rise in bilirubin shortly after birth, causing a mild yellowing of skin and sclera from 2 – 7 days of age.
- This usually resolves completely by 10 days.
Neonatal Jaundice: Increased production of bilirubin
- Haemolytic disease of the newborn
- ABO incompatibility
- Haemorrhage including Intraventricular haemorrhage
- Cephalo-haematoma (scalp and the skull)
- Polycythaemia
- Sepsis and (DIC)
- G6PD deficiency
Neonatal Jaundice: Decreased clearance of bilirubin:
- Prematurity
- Breast milk jaundice
- Neonatal cholestasis
- Extrahepatic biliary atresia
- Endocrine disorders (hypothyroid and hypopituitary)
- Gilbert syndrome
Jaundice in first 24 hours?
first 24 hours of life is pathological. This needs urgent investigations and management. Neonatal sepsis is a common cause. Babies with jaundice within 24 hours of birth need treatment for sepsis if they have any other clinical features or risk factors.
Breast milk Jaundice why?
Components of breast milk inhibit the ability of the liver to process the bilirubin. Breastfed babies are more likely to become dehydrated if not feeding adequately.
Inadequate breastfeeding may lead to slow passage of stools, increasing absorption of bilirubin in the intestines.
Keep on breastfeeding – just extra support
Prolonged Jaundice
- More than 14 days in full term babies
- More than 21 days in premature babies
- biliary atresia, hypothyrodisim and G6PD deficiency common causes
Neonatal Jaundice Ix
FBC & blood film for polycythaemia or anaemia
- Conjugated bilirubin: elevated levels indicate a hepatobiliary cause
- mother and baby for ABO or rhesus incompatibility
• Direct Coombs Test (direct antiglobulin test) for haemolysis
• Thyroid function, particularly for hypothyroid
• Blood and urine cultures if infection is suspected.
• Glucose-6-phosphate-dehydrogenase (G6PD) levels for G6PD deficiency
Neonatal Jaundice Mx
Phototherapy
Exchange transfusion
Hypothermia - which babies at risk?
Small for dates / Preterm
o Low stores of brown fat
o Little subcutaneous fat
o Larger surface area: vol
Hypothermia Mx
Dry Hat Skin to skin blanket Heated mattress incubator
Intraventricular Hemorrhage
bleeding into the brain’s ventricular system, where the cerebrospinal fluid is produced and circulates through towards the subarachnoid space.
Intraventricular Hemorrhage classification grades
Grade 1 and 2 : Neurodevelopmental delay up to 20% and Mortality 10%
Grade 3 and 4: Neurodevelopmental delay up to 80% and Mortality 50%
Necrotizing enterocolitis (NEC)
Disorder affecting premature neonates, where part of the bowel becomes necrotic. Usually affects babies in the first week of life. It is a life-threatening emergency.
• Death of the bowel tissue can lead to bowel perforation.
• Bowel perforation leads to peritonitis and shock.
Risk factors for NEC
- Very low birth weight or very premature
- Formula feeds (it is less common in babies fed by breast milk feeds)
- Respiratory distress and assisted ventilation
- Sepsis
- Patient ductus arteriosus and other congenital heart disease
NEC signs/symptoms
Intolerance to feeds/poor feeding
Vomiting, particularly with green bile • Generally unwell – decreased activity • Distended, tender abdomen • Absent bowel sounds • Blood in stools • Perforation leading to peritonitis and shock
NEC Ix
FBC - thrombocytopenia, neutropenia, CRP and blood cultures - Cap blood gas: metabolic acidosis - stool cultures - AXR: Pneumatosis intestinalis & Pneumoperitoneum
NEC Mx
- stop feeding orally
- PN with IV fluids and broad spectrum antibiotics
NG tube - drain fluid and gas
Surgery - remove dead tissue and temp stoma
Tetralogy of Fallot
Four defects include a ventricular septal defect (VSD), pulmonary valve stenosis, a misplaced aorta and a thickened right ventricular wall (right ventricular hypertrophy)
Tetralogy of Fallot
- VSD: blood flow between ventricles.
- “overriding aorta” refers to the fact that the entrance to the aorta (the aortic valve) is placed further to the right than normal
- right ventricle contracts and sends blood upwards, the aorta is in the direction of travel of that blood, therefore a greater proportion of deoxygenated blood enters the aorta from the right side of the heart.
- Pulmonary stenosis promotes blood through VSD and into aorta - cyanosis
Tetralogy of Fallot signs/symptoms
- Cyanosis (blue discolouration of the skin due to low oxygen saturations)
- Clubbing
- Poor feeding & weight gain
- Ejection systolic murmur heard loudest in the pulmonary area (second intercostal space, left sternal boarder) – pulmonary stenosis
- “Tet spells”: intermittent symptomatic periods where the right to left shunt becomes temporarily worsened, precipitating a cyanotic episode (SVR decreases or PVR increases): irritable, cyanotic and short of breath
- Severe cases will present with heart failure before one year of age.
- In milder cases, they can present as older children once they start to develop signs and symptoms of heart failure.
Tetralogy of Fallot Mx
Tet spell: squat when a tet spell occurs (increases SVR) - supplementary oxygen - beta blockers (relax RV) - IV fluids - increase preload - morphine -sodium bicarbonate - phenylephrine infusion - increase SVR • Neonates: Prostaglandin infusion – ductus arteriosus is opened (blood flow from aorta back to pulmonary arteries)
Corrective surgery by 6 months
Transposition of great arteries
aorta and pulmonary artery swap
life threatening - no connection - cyanosed
Transposition of great arteries signs/symptoms
A patent ductus arteriosus or ventricular septal defect can initially compensate by allowing blood to mix between the systemic circulation and the lungs
However: within few weeks of life:
o Respiratory distress, tachycardia, poor feeding, poor weight gain and sweating.
Transposition of great arteries Mx
Prostaglandin infusion: maintain ductus arteriosus (blood from aorta to pulmonary arteries)
surgery
- balloon septostomy: create atrial septal defect
- open heart surgery is definitive management
Coarctation of the aorta
aortic narrowing, is a congenital condition whereby the aorta is narrow, usually in the area where the ductus arteriosus (ligamentum arteriosum after regression) inserts.
- Narrowing of the aorta reduces the pressure of blood flowing to the arteries that are distal to the narrowing.
- It increases the pressure in areas proximal to the narrowing, such as the heart and the first three branches of the aorta.
Coarctation of the aorta signs/symptoms
- weak femoral pulse
- radiofemoral pulse
- hypertension and ejection systolic murmur
- CXR: Rib notching 3-5
- ECG: LVH
Coarctation of the aorta Mx
- In mild cases patients can live symptom free until adulthood without requiring surgical input, and in severe cases patients will require emergency surgery shortly after birth.
- In cases of critical coarctation where there is a risk of heart failure and death: Prostaglandin E is used keep the ductus arteriosus open while waiting for surgery
- Surgery or stent by the age of 5 to avoid pulmonary hypertension or end organ damage
Hypoplastic heart
left side of the heart is severely underdeveloped. It may affect the left ventricle, aorta, aortic valve, or mitral valve
TAPVD
Pulmonary veins connect straight into systemic circulation
Patent Ductus Arteriosus
The ductus arteriosus (shunt: trunk of the pulmonary artery to the proximal descending aorta) normally stops functioning within 1-3 days of birth and closes completely within the first 2-3 weeks of life.
PDA pathology
aorta is higher than that in the pulmonary vessels, so blood flows from the aorta to the pulmonary artery.
• This creates a left to right shunt where blood from the left side of the heart crosses to the circulation to the right side.
• increases the pressure in the pulmonary vessels causing pulmonary hypertension, leading to right sided heart strain as the right ventricle struggles to contract against the increased resistance.
•lead to right ventricular hypertrophy.
increased blood flowing through the pulmonary vessels and returning to the left side of the heart leads to left ventricular hypertrophy.
PDA signs/symptoms
- Shortness of breath
- Difficulty feeding
- Poor weight gain
- Lower respiratory tract infections
- Continuous machine murmur below left clavicle
- Thrill, collapsing pulse, failure to thrive and loud S2
PDA management
oral or IV ibuprofen
• After 1 year of age it is highly unlikely that the PDA will close spontaneously and trans-catheter or surgical closure can be performed.
• Symptomatic patient or those with evidence of heart failure as a result of PDA are treated earlier.
Persistent Pulmonary Hypertension of the Newborn (PPHN)
defined as the failure of the normal circulatory transition that occurs after birth
marked pulmonary hypertension that causes hypoxemia secondary to right-to-left shunting of blood at the foramen ovale and ductus arteriosus..
BP in lungs does not drop, blood does not go to lungs, blood does not get oxygenated. Persistent pulmonary hypertension
Persistent Pulmonary Hypertension of the Newborn (PPHN) Ix
• Pre and post O2 sats (more than 3% difference)
o Pre: right hand
o Post: left foot
• Echo: right to left shunt
• Persisting desaturation despite intensive oxygen use
PPHN Mx
Ventilation O2 NO Sedation Inotropes ECMO
Transient tachypnoea of the newborn (TTN)
benign, self-limited condition that can present in infants of any gestational age, shortly after birth.
It is caused due to delay in clearance of fetal excess lung fluid after birth
Transient tachypnoea of the newborn (TTN) Signs/symptoms
ineffective gas exchange, respiratory distress, and tachypnea
Respiratory distress syndrome
occurs <32 weeks gestation
Surfactant deficiency
o Inadequate surfactant leads to high surface tension within alveoli.
o This leads to atelectasis (lung collapse), as it is more difficult for the alveoli and the lungs to expand.
o This leads to inadequate gaseous exchange, resulting in hypoxia, hypercapnia (high CO2) and respiratory distress.
• Structural immaturity
secondary causes of respiratory distress syndrome
intubation and ventilating
respiratory distress syndrome signs/symptoms
Respiratory distress •Tachypnoea o Grunting o Intercostal recessions o Nasal flaring o Cyanosis • Worsen over minutes to hours
respiratory distress syndrome Ix
CXR: Ground glass appearance
respiratory distress syndrome Mx
antenatal Dexamethasone -increase surfactant
Intubation and ventialtion
endotracheal intubation
CPAP
Microcephaly
condition where the head (circumference) is smaller than normal. Microcephaly may be caused by genetic abnormalities or by drugs, alcohol, certain viruses, and toxins that are exposed to the fetus during pregnancy and damage the developing brain tissue.
Neonatal sepsis risk factors
- Vaginal GBS colonisation
- GBS sepsis in a previous baby
- Maternal sepsis, chorioamnionitis or fever > 38ºC
- Prematurity (less than 37 weeks)
- Early (premature) rupture of membrane
- Prolonged rupture of membranes (PROM)
Neonatal sepsis organisms
Early Onset
o Gp B Streptococcus
o Gram negatives
Late Onset
o Coagulase negative staphylococci
o Gram negatives
o Staph Aureus
Neonatal sepsis signs/symptoms
- Fever
- Reduced tone and activity
- Poor feeding
- Respiratory distress or apnoea
- Vomiting
- Tachycardia or bradycardia
- Hypoxia
- Jaundice within 24 hours
- Seizures
- Hypoglycaemia
Red flags
o Confirmed or suspected sepsis in the mother
o Signs of shock
o Seizures
o Term baby needing mechanical ventilation
o Respiratory distress starting more than 4 hours after birth
o Presumed sepsis in another baby in a multiple pregnancy
Autism features
1) Communication
2) social interaction
3) Imagination
4) repetitive
5) sensory issues
ADHD Triad
consistent across all settings
- Hyperactivity
- inattention
- impulsivity
ADHD medication
Methylphenidate (“Ritalin“)
Dexamfetamine
Atomoxetine
Attachment disorders
Secure, ambivalent and avoidant attachment
Insecure - Avoidant attached adolescents –Type A
- Hard to engage
- View relationships as unimportant
- Don’t feel a huge need for other people
- Seen as cold – reported (often falsely) as lacking empathy and remorse
Insecure – ambivalent attached adolescents – Type C
- Disruptive, ‘attention seeking’ and difficult to manage
- Insecure and coercive
- Can alternate between friendly charm and hostile aggression
- Display antisocial behaviour, impulsivity, poor concentration
- Feel a growing sense of unfairness and injustice –lots of complaining
Reactive attachment disorder
Markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before the age of five and is associated with grossly pathological care.
Reactive attachment disorder subtypes
Inhibited
• Refers to children who continually fail to initiate and respond to social interactions in a developmentally appropriate way
- Example: A child or infant that does not seek comfort from a parent or caregiver during times of threat, alarm or distress
Disinhibited
• Refers to a child who has an inability to display appropriate selective attachments
- Example: A child who displays excessive familiarity with strangers. indiscriminate sociability or lack of selectivity in their choices of attachment figure
RAD Mx
Family Tx Individual Tx Play Tx Medication Special education
Conduct disorder
repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate norms or rules are violated
CD features
• The presence of three or more of the following criteria in the past 12 months with at least one criterion present in the past 6 months o Aggression to people or animals o Destruction of properly o Deceitfulness or theft o Serious violation of rules
CD types
Mild to Moderate
o Restricted to family environment
Severe
o Unsocialised – predominantly violent behavior and more likely to be dealt within the criminal justice system
o Socialised - more covert antisocial acts or better ability to avoid getting involved with criminal justice system
Constipation - underlying serious organic disease to exclude
Hirschsprung’s, thyroid
coeliac, anorectal abnormalities, neuromuscular
consider if onset is from early infancy or refractory to treatment
Constipation Mx
High fibre diet & good hydration
laxatives e.g. movicol
Red flags of constipation
- Delay in passage of meconium > 24 hours after birth
- Neurological signs or symptoms, particularly in the lower limbs (cerebral palsy or spinal cord lesion)
- Vomiting (intestinal obstruction or Hirschsprung’s disease)
- Ribbon stool (anal stenosis)
- Abnormal anus (anal stenosis, inflammatory bowel disease or sexual abuse)
- Abnormal lower back or buttocks (spina bifida, spinal cord lesion or sacral agenesis)
- Failure to thrive (coeliac disease, hypothyroidism or safeguarding)
- Acute severe abdominal pain and bloating (obstruction or intussusception)
Headaches
o Headache on waking o Worse with coughing or bending o Associated vomiting - especially in the morning o visual disturbance o Gait disturbance o Cranial nerve palsy
Obstruction: Neonates causes
- Meconium ileus
- Hirschsprung’s disease
- Oesophageal atresia
- Duodenal atresia
- Intussusception
- Imperforate anus
- Malrotation of the intestines with a volvulus
- Strangulated hernia
Meconium Ileus
bowel obstruction that occurs when the meconium in your child’s intestine is even thicker and stickier than normal meconium, creating a blockage in a part of the small intestine called the ileum
associated with CF
Meconium Ileus signs/symptoms
- Presents with failure to pass stool or vomiting in the first 2 days of life
- Distended loops of bowel are seen through abdominal wall
- A plug may show one firm mass of meconium in one such loop
- Tiny bubbles may be seen in the meconium (inspissated)
Meconium Ileus Mx
Milk feed stropped NG tube - drain Antibiotics Enema: dissolve meconium Temp stoma Blood test: CF
Jejunal atresia
characterized by partial or complete absence of the membrane connecting the small intestines to the abdominal wall (the mesentery).
small intestines (the jejunum) to twist around an artery that supplies blood to the colon (the marginal artery).
Jejunal atresia Mx
Surgery and PN
Duodenal atresia
2nd part of duodenum
Duodenal atresia signs/symptoms and Ix
presents with bilious of non-bile-stained vomiting
AXR: Double bubble and no gas within bowel distally
Duodenal atresia Mx
NG tube
IV fluids
Surgery
Malrotation with volvulus
- Malrotation happens when the intestine doesn’t turn like it should.
- A volvulus happens when the intestine becomes twisted.
- This causes an intestinal blockage.
- Most will present in the first month of life
- When the bowel twists around the superior mesenteric artery
- If DEJ flexure is low – twist very easily around the
Malrotation with volvulus signs/symptoms
vomiting bile, stomach pain, diarrhoea or constipation, and bloody stools.
Non-symmetrical creases
Laddering – sign of bowel obstruction
Green vomiting is a sign that this could be going on
Malrotation with volvulus Mx
NG tube - fluid and gas
IV fluids
Surgery: Ladd procedure
Pyloric stenosis
Hypertrophy (thickening) and therefore narrowing of the pylorus prevents food traveling from the stomach to the duodenum as normal
Pyloric stenosis signs/symptoms
Presents at 3-8 weeks, vomiting after feeds and is projectile: within few minutes of feed
Does not contain bile: obstruction is high
No diarrhoea: Constipation is likely
Alert, hungry: malnourished and dehydrated: generally failing to thrive
Observe left to right LUQ peralistalis during feed
Olive sized pyloric mass: RUQ
Severe water and NaCl deficit: urine and plasma Cl- vital tests: guide resuscitation and surgery. Cl- > 90mmol-1
If hypochloraemia, hypokalaemia and metabolic alkalosis (baby is vomiting HCl acid from stomach) – don’t rush to surgery
Pyloric stenosis Mx
Electrolytes - correct
NG tube
Laparoscopic pyloromyotomy
Intussusception (Telescoping of the bowel)
one segment of intestine “telescopes” inside of another, causing an intestinal obstruction (blockage). Although intussusception can occur anywhere in the gastrointestinal tract, it usually occurs at the junction of the small and large intestines
Thickens overall bowel and narrows lumen
6 months to 2 years and more common in boys
Intussusception signs/symptoms
Severe, colicky abdominal pain
Pale, lethargic and unwell child
Right upper quadrant mass on palpation. This is described as “sausage shaped”
Vomiting
Intestinal obstruction
Episodic intermittent inconsolable crying with drawing of legs up (colic) +/- vomiting +/- blood PR (Redcurrent jelly stool)
Intussusception Ix and Mx
Ix: USS (target lesion) and contrast enema
Mx: therapeutic enemas. If this fails, laproscopy or laparotomy
Appendicitis signs/symptoms
Typically starts as central abdominal pain, that moves down to the right iliac fossa (RIF) over time and eventually becomes localised in the RIF.
On palpation of the abdomen there is tenderness in McBurney’s point (1/3rd distance from ASIS to the umbilicus)
Loss of appetite: Anorexia
• Slight vomiting
• Slight fever and tachycardia
• Rovsing’s sign (palpation of the left iliac fossa causes pain in the RIF)
• Guarding
• Rebound tenderness is increased pain when quickly releasing pressure on the right iliac fossa – suggests peritonitis
• Percussion tenderness - suggests peritonitis
Appendicitis Ix and Mx
Raised inflammatory markers
USS
CT
Mx: diagnostic laparoscopy followed by appendectomy
Hydatid of Morgagni
The appendix testis (or hydatid of Morgagni) is a vestigial remnant of the Müllerian duct (paranephric duct – female), present on the upper pole of the testis and attached to the tunica vaginalis. It is present about 90% of the time.
Balanitis Xerotica Obliterans
Chronic, often progressive disease, which can lead to phimosis (tight foreskin) and urethral stenosis, affecting both urinary and sexual function.
Hypospadias
urethral meatus (the opening of the urethra) is abnormally displaced posteriorly on the penis.
Hypospadias Mx
- Mild cases may not require any treatment
- Surgery is usually performed after 3 – 4 months of age
- Surgery aims to correct the position of the meatus and straighten the penis
Hydrocele
collection of fluid within the tunica vaginalis that surrounds the testes.
simple vs communicating hydrocele
Simple:
• Simple hydroceles are common in newborn males. They occurs where fluid is trapped in the tunica vaginalis.
• Usually this fluid gets reabsorbed over time and the hydrocele disappears
Communicating
- tunica vaginalis around the testicle is connected with the peritoneal cavity via a pathway called the processus vaginalis. This allows fluid to travel from the peritoneal cavity into the hydrocele, allowing the hydrocele to fluctuate in size.
Hydrocele main s/s and Mx
Transilluminate with light
Mx:
simple - resolve within 2 years
communicating - surgical operation to remove or ligate the connection between the peritoneal cavity and the hydrocele (the processus vaginalis).
cryptorchidism signs/symptoms
might be palpable in the inguinal canal (in the inguinal region)
Undescended testes in older children or after puberty hold a higher risk of testicular torsion, infertility and testicular cancer.
cryptorchidism Mx
watchful waiting - most descend in first 3-6 month
Orchidopexy (surgical correct) - 6 and 12 months
Bronchiolitis
Acute inflammatory injury of the bronchioles
• Viral – RSV (most common), adenovirus, coronavirus, rhinovirus
Most common in 6 month olds, gen < 1 year
Bronchiolitis signs/symptoms
Coryzal symptoms
Signs of respiratory distress
o Raised respiratory rate
o Use of accessory muscles of breathing, such as the sternocleidomastoid, abdominal and intercostal muscles
o Intercostal and subcostal recessions – skin sucks in
o Nasal flaring
o Head bobbing
o Tracheal tugging – see trachea sucking in with each breath
o Cyanosis
dyspnoea tachypnoea poor feeding mild fever apnoeas harsh breath sounds, wheeze and crackles
Bronchiolitis Mx
- Oxygen if below 92%
- adequate intake e.g. NG tube
- CPAP
- Ventilatory support
- Palivizumab
Croup
• Larygnotracheobronchitis
Caused by: Parainfluenza (most common), influenza, adenovirus and RSV
children 6 months-2 years
croup signs/symptoms
- Increased work of breathing
- “Barking” cough, occurring in clusters of coughing episodes
- Hoarse voice
- Stridor
- Low grade fever
- Chest wall is coming in on breathing
Croup Mx
Most managed at home
Oral dexamethasone Oxygen Nebulised budesonide Nebulised adrenalin Intubation and ventilation
Asthma vs viral induced wheeze
- Presenting before 3 years of age
- No atopic history e.g. hayfever, eczema or food allergies
- Only occurs during viral infections
Asthma in children diagnosis
not diagnosed until 2-3 years old
intermediate vs high probs of asthma - trial
• Spirometry with reversibility testing (in children aged over 5 years)
• Direct bronchial challenge test with histamine or methacholine
• Fractional exhaled nitric oxide (FeNO)
• Peak flow variability measured by keeping a diary of peak flow measurements several times a day for 2 to 4 weeks
Asthma Mx (under 5)
- Start a short-acting beta-2 agonist inhaler (e.g. salbutamol) as required
- Add a low dose corticosteroid inhaler or a leukotriene antagonist (i.e. oral montelukast)
- Add the other option from step 2.
- Refer to a specialist
Pneumonia signs/symptoms
- Cough (typically wet and productive)
- High fever (> 38.5ºC)
- Tachypnoea
- Tachycardia
- Increased work of breathing
- Lethargy
- Delirium (acute confusion associated with infection)
Meningitis signs/symptoms
• Fever, neck stiffness, vomiting, headache, photophobia, altered consciousness and seizures
Neonatal Meningitis signs/symptoms
hypotonia, poor feeding, lethargy, hypothermia and a bulging fontanelle.
Encephalitis Mx
o Aciclovir treats herpes simplex virus (HSV) and varicella zoster virus (VZV)
o Ganciclovir treat cytomegalovirus (CMV)
o Treat with antibiotics before lumbar puncture as sepsis is deadly
o Start acyclovir empirically in suspected
UTI
Fever may be the only symptom of a urinary tract infection, especially in young children.
Always consider (and exclude) a urinary tract infection in a child with a temperature, unless there is a clear alternative source of infection.
UTI Mx
All children under 3 years with a fever – IV antibiotics (e.g. ceftrianxone) and septic screen including blood cultures, bloods and lactate
> 3 years – oral antibiotics if well enough
UTI Ix
<6 months: Abd USS within 6 weeks
DMSA scan 4-6 months after illness - scarring
Vesico-ureteric reflux (VUR)
MCUG
Fits, faints and funny turns
febrile seizures vasovagal episode Reflex anoxic seizures Breath holding attacks Behavioural episodes Epilepsy Arrhythmias
Nipple trauma Mx
- Observe feed and review positioning and attachment/Check pump use
- May need to rest and express if Mum can’t stand to have baby on but revisit where nipple will be with effective attachment
- Lanolin, barrier cream to aid moist wound healing
- Leave a few drops of breast left to dry on nipple may be soothing and protective
- Pain relief
Engorgement Causes
o Delay in first feed o Ineffective positioning and attachment o Restricted feeding o Ineffective emptying o Supplementation
Engorgement signs/symptoms
- The breasts look shiny because of the oedema and can be painful.
- The milk does not flow well due to increased pressure in the breast.
- The breast(s) maybe red
- The mother may be feverish.
- They will feel lumpy and be painful for the mother.
Engorgement Mx
continue to express and ensure good attachment
• Mild analgesia, e.g. Paracetamol or Ibruprofen will help discomfort and reduce the temperature.
• Cold compresses, cold gel packs or cold, uncooked cabbage leaves can soothe and reduce oedema after or between feeds
Mastitis Mx
Flucloxacillin 1g
Clindamycin 450mg TDS
formula-fed infants and vitamins?
formula-fed infants should not be given vitamin supplements if they consume more than 500ml infant formula per day. If under, they should take A, C and D vitamins
Vit D and formula
• By 2 weeks of age breastfed babies should be given a supplement of 8.5 to 10mg of vitamin D per day up to one year of age (infant formula has added vitamin D so babies consuming ≥500ml formula a day do not require vitamin D supplements) (51% SMINS, SG 2017)
Weaning period for breastfeeding
4 months min
6 months
Cows milk
Can be gradually introduced as a drink from 12 months
Semi-skimmed milk should not be given before 2 years
Skimmed milk should not be given before 5 years
Live virus vaccine
attenuated organism, replicates in host
e.g. OPV, measles, mumps, rubella, varicella, rotavirus, flu
Inactivated vaccines
Suspensions of killed organisms
e.g. whole cell pertussis (whooping cough), whole cell typhoid
Subunit vaccines
- Toxoids e.g. diphtheria toxoid, tetanus toxoid, pertussis toxoid
- Polysaccharides e.g. pneumococcal, typhoid (Vi
Conjugate vaccines
- polysaccharide attached to immunogenic proteins
* e.g. Hib, MenC
Contraindications to vaccines
• Confirmed anaphylaxis reaction to previous dose of same antigen or vaccine component
• Live vaccines:
Immunosuppression (primary, radiotherapy, high-dose steroids/other drugs, HIV)
o Pregnancy
• Egg allergy (yellow fever, flu)
• Severe latex allergy
• Acute or evolving illness – defer till resolved/ stabilised
Gross Motor development
Head control: 3 months Sitting balance: 6 months Crawling: 9 months Standing: 12 months Walks alone:14 months Runs/pick toy without falling: 18 months Stairs2 feet/tread: 24 months Stairs – alternate feet 36 months Hops: 48 months
Fine Motor and vision
Hand regard in midline: 3 months
Grasps toy: Palmar 6 months
Scissor grasp: 9 months
Pincer grasp: 12 months
Tower of 3-4 bricks: 18 months
Tower of 6-7/scribble 24 months
Tower of 9 bricks/copies circle 36 months
Draws simple man 48 months
Hearing and language
Vocalises 3 months
• Babbles 6 months
• Imitates sounds 9 months
• Knows name 12 months
• 2 body parts/5-20 words 18 months
• Simple instructions/50+ words 24 months
• Complex instructions/asks questions 36 months
• Can tell stories of experiences 48 months
Social behaviour and play
• Social smile 6 weeks
o if not there by 8 weeks – concerned – parent baby bond
• Pleasure on friendly handling 3 months
• Plays with feet/friendly with strangers 6 months
• Plays peek-a-boo/stranger awareness 9 months
• Drinks from cup/waves bye-bye 12 months
• Feeds with spoon 18 months
• Symbolic play/puts on some clothes 2 years
• Pretend interactive play/toilet-trained 3 years
• Understands turn-taking/dresses fully 4 years
Red flags for development
Asymmetry of movement – child is not using one hand at all
Not reaching for objects by 6 months
Unable to sit unsupported by 12 months
Unable to walk by 18 months → check CK
No speech by 18 months
Concerns re vision or hearing
Loss of skills
APGAR Score
Objective measure of perinatal adaptation Score out of 10 0, 1 or 2 per component o Heart rate o Respiratory rate o Responsiveness o Tone o Colour “Normal” > 8
