Child health Flashcards
Aspects of child health
Immunisation, identification of congenital abnormalities (6-8 week check), management of acute problems (infection, skin rash, GI symptoms, resp symptoms, allergy, behavioural and mental health issues), chronic disease (e.f. asthma, epilepsy, diabetes, mental health, ADHD, autism)
How long does an average baby cry for the first months of life
2 hours a day
How long does an average newborn baby sleep in 24 hours
16-18 hours in first 4 months, 12-16 hours in first year
Why do babies cry
Hunger, dirty/wet nappy, tiredness, wanting a cuddle, wind, being too hot or cold, boredom, overstimulation
Urgent hospital admission for baby if:
Has a fit (first epileptic vs febrile convulsion)
Has blue, mottled, ashen (grey) or very pale skin (peripheral circulation shutting down e.g. septic shock)
Is unresponsive, floppy or not waking up as easily (changed conscious level- infection, brain injury, electrolyte imbalance, poisoning)
Breathing rapidly/difficult to breathe
Projectile vomiting
High temperature but hands and feet cold
Spotty purple-red rash anywhere on body (sign of meningitis)
When baby brought to see a dr about crying need to think about
Features of crying episodes, birth history (and weight gain/loss), red flag symptoms (vomiting, pain, fever, rash etc), feeding and sleeping patterns, parental responses to crying (coping and support- any insomnia, stress, anxiety, depression, maternal diet if breastfeeding), parental interaction and handling of the infant
What is colic
A self-limiting condition- repeated episodes of excessive and inconsolable crying in an infant that otherwise appears to be healthy and thriving
Episodes of irritability, fussing or crying that begin and end for no apparent reason and last at least 3 hours a day, at least three days a week for at least one week, in an infant up to 4 months of age with no evidence of faltering growth
Presentation of colic
Excessive, inconsolable crying which starts in the first weeks of life and resolves by around 3-4 months
Crying which often occurs in the late afternoon or evening
Drawing its knees up to its abdomen or arching its back when crying
Cause of colic
Exact cause unknown but may reflect part of the normal distribution of infant crying
Other possible causes include abnormal GI motility, changes in intestinal microflora or psychological factors
What can parents do for baby with colic
Hold baby through the crying episode, gentle motion (pushing the pram/ rocking the crib), white noise, bathing infant in a warm bath, ensure an optimal winding technique is used during and after feeds, if needed
Possetting
Regurgitation of small amounts of undigested milk after a feed
GORD symptoms in baby
Distressed behaviour (excessive crying, crying while feeding and adopting unusual neck postures)
Hoarseness and/or chronic cough
Single episode of pneumonia
Unexplained feeding difficulties (refusing to feed, gagging or choking)
Faltering growth
GORD
Regurgitation and GORD usually begin before age of 8 weeks and 90% resolve before 1 year. Onset of regurg and/or vomiting after 6 months or persisting after 1 year old may indicate alternative diagnosis (e.g. UTI)
Why does GORD usually improve as baby grows
Increase in length of oesophagus, increase in tone of lower oesophageal sphincter, a more upright posture, a more solid diet
Managing GORD
Try not to overmedicalise normal.
For breast-fed babies: 1-2 week trial of alginate therapy (infant gaviscon)
Formula fed babies: check feeding volume
Total feed volume of 150ml/kg over 24 hours (6-8 feeds a day)
1-2 week trial of thickener then alginate
If these fail then 4 week trial of PPI
Sandifers syndrome
Eponymous disorder associated with GORD
Under 1% children with GORD will be affected
Peak incidence between 18-36 months
Children get spasmodic torticollis and dystonia
Can be misdiagnosed as seizures
Tongue tie anatomy
Due to abnormal lingual frenulum
What is lactose intolerance
Lactose is the most abundant carb in breast milk, digested by lactase in small intestine
Congenital absence of lactase is extremely rare
Lactose intolerance post gastroenteritis
Typical symptoms include loose, watery stools, abdo bloating and pain, increased flatus, nappy rash
Most commonly occurs after an episode of infectious gastroenteritis (secondary lactose intolerance) when damage to bowel mucosa causes deficiency in lactase
Deficiency causes temporary lactose intolerance, usually lasts 6-8 weeks.
Should be suspected in all children with acute gastroenteritis who uncommonly have loose stools persisting for more than 2 weeks
Diagnosis can be made if diarrhoea resolves within 2 weeks of exclusion of lactose from diet
Lactose intolerance secondary to gut enteropathy
If other symptoms are present e.g. rashes, eczema, rhinitis, vomiting, reflux and constipation or child not growing well, the child is more likely to have cow’s milk protein allergy
Cow’s milk protein allergy
About 2% prevalence, most prevalent in formula-fed infants but can affect breast-fed infants
Diagnosis on average made at 10 weeks of age
Majority of infants and children with it have over 2 symptoms (from over 2 organ systems)
Skin/ resp/ digestive/ general symptoms
CMPA management
Get onset and exacerbation of symptoms
Non-medical solutions include change detergent/nappy brand, switch to comfort formula
Initial treatment: anti-histamine, PPI
Mother can remove diary from her diet
Causes of CMPA
Abnormal immune response to protein cow’s milk
Most infants develop before 6 months of age, rare to develop after 12 months
If IgE mediated then immediate symptoms, if non-IgE mediated then delayed symptoms
Symptoms of CMPA
Immediate (mins-hours): immune reaction of mast cells, allergy testing usually positive, can develop anaphylaxis
Delayed (hours-days), about 70% this type, non-immune reaction, eosinophils and T cells, symptoms often dose related, allergy investigations negative
Statutory services
Health visitors is a universal service
Sure start centres give help and support to disadvantaged families on child and family health, parenting, money, training and employment
Social services: have statutory powers needed to investigate and protect children
Cow’s milk allergy
Commonest presentation of food allergy in childhood
Much more common than lactose intolerance (tends to present later)
Diagnosis is often delayed and unnecessary treatments may be prescribed
Exclusively breastfed babies can react to cows’ milk protein from the maternal diet, but this is rarer with a more common presentation being at introduction of formula or solid foods
When suspect CMPA in breast-fed baby, actively support continued breastfeeding with adaptation of maternal diet if needed
CMPA in history
Personal or family history of atopic disease (asthma, eczema, allergic rhinitis)
Presenting symptoms include speed of onset of symptoms following food contact (and how much food was eaten), severity of reaction, duration of symptoms, frequency of occurrence and reproducibility of symptoms on repeated exposure
Dietary history: any foods avoided and reasons why, how they were fed from borth, including at what age they were weaned and (if breast-feeding) maternal diet. If mixed-fed then need to know what type of feed the baby reacts to
CMPA examination features
Weigh and measure child and plot of centile chart to assess growth, look for signs of malnutrition, signs of allergy-related comorbidities (atopic eczema, asthma, allergic rhinitis)
Symptoms and speed of onset cruicial in determining whether this is CMPA and the type (immediate/ delayed, mild/moderate/severe etc)
GI symptoms of IgE mediated CMPA
Angioedema of oropharynx
Oral pruitis
Nausea
Vomiting
Diarrhoea
Colicky abdo pain
GI symptoms of non-IgE mediated CMPA
Reflux
Loose/frequent stools or constipation
Blood and/or mucus in stools
Perianal redness
Abdo pain/ colic
Food refusal/ aversion
Pallor and tiredness
Skin symptoms (IgE and non-IgE) of CMPA
IgE: pruritus, erythema, urticaria/ angioedema
Non-IgE: pruritus, erythema, atopic eczema
Resp symptoms of CMPA
Upper or lower resp tract symptoms
Upper: nasal itching, sneezing, rhinorrhoea or congestion
Lower: cough, chest tightness, wheezing or SOB
Management of mild to moderate IgE mediated CMPA
Mild to mod: refer to paediatrician with allergy interest, need IgE testing, dietician referral, if diagnosis confirmed then need follow-up, serial IgE testing and supervised challenge to test for acquired tolerance
If formula feeding then need to use extensively hydrolysed formula, if symptoms persist then swap to amino acid formula
If exclusively breast-feeding: advise mother to exclude all cows’ milk protein from their diet, take 1000mg calcium and 10mcg vit D daily
Management of severe IgE mediated CMPA
Treat anaphylaxis: emergency admission (urgent referral to paediatrician with interest in allergy and urgent dietetics referral)
If formula feeding the use amino acid formula (NOT extensively hydrolysed formula)
If exclusively breastfeeding: mother to exclude all cows’ milk protein from diet and take 1000mg Ca and 10mcg vit D daily)
