Child Health

Question 1

Define neonatal mortality

Answer 1

Deaths occurring within first 28 days following a live birth.

Question 2

Define perinatal mortality

Answer 2

Deaths up to 7 days of life and stillbirths.

Question 3

Define infant mortality

Answer 3

Deaths of children under the age of one year.

Question 4

What are the most common congenital anomalies in babies?

Answer 4

• Congenital heart (most common).
• Chromosomal (2nd most common).

Question 5

What is the most common cause globally of neonatal death?

Answer 5

Prematurity (most common).
Also, congenital anomalies.

Question 6

Describe the epidemiology of stillbirth in UK and globally

Answer 6

• UK: ~ 1 in every 250 pregnancies. 3.54 stillbirths per 1,000 live births. 8 babies per day.
• Globally: 13.9 per 1,000 live births.

Question 7

Describe the epidemiology of neonatal death in UK and globally

Answer 7

• UK: 1.65 deaths per 1,000 live births.
• Globally: 18 deaths per 1,000 live births.

Question 8

Identify risk factors for perinatal mortality and outline strategies to reduce it

Answer 8

RISK FACTORS:
- Parity.
- Age of mother.
- Maternal education.
- Engagement with maternal services.
- Previous history of perinatal mortality.
- Low income/deprivation.
- Birth interval.
- Smoking.
- Drugs and alcohol.
- Preterm delivery.
- Congenital anomalies.
- Low birth weight.
- Maternal obesity
- Multiple pregnancy

REDUCE RISK:
- Midwife led care.
- Screening for UTIs and genital infections.
- Vit D supplements.
- Cervical stitching.
- Smoking cessation.
- Avoidance of drugs and alcohol use during pregnancy.

Question 9

Describe the availability and provision of services for patients with visual impairment and deafness

Answer 9

VISUAL IMPAIRMENT:

• Guide dogs
• Braille
• Vision aids
• Low-vision clinics
• Support groups and charities e.g. Royal National Institute of Blind People
• Ophthalmologist certify as sight impaired or severely sight impaired with a certificate of vision impairment
• Disability benefits
• Reduced TV licence fee
• Reduced fees on public transport
• Home alterations e.g. big-button telephone, community alarm
• E-readers
• Long cane
• Gov access to work scheme

HEARING LOSS:

• British sign language (BSL)
• Interpreters
• Hearing aids and cochlear implants
• Lipreading
• Support groups and charities
• The National Deaf Service provides mental health services for deaf people
• Disability benefits

Question 10

Outline evidence-based strategies for the prediction and prevention of preterm birth and low birth weight

Answer 10

PREDICTION:

• Cervical length.
• Biomarkers: foetal fibronectin, insulin-like growth factor binding protein-1, placental alpha-macroglobulin-1.
• US growth scans (low birth weight).

PREVENTION:

• Prophylactic vaginal progesterone.
• Prophylactic cervical cerclage.

Question 11

Identify major complications, management, and both short and long-term outcomes for preterm birth and low birth weight

Answer 11

Early issues:

• RDS.
• Hypothermia.
• Hypoglycaemia.
• Poor feeding.
• IVH.
• Retinopathy of prematurity.
• Necrotising enterocolitis.
• Neonatal sepsis.

Long-term effects:

• Chronic lung disease of prematurity.
• Learning and behavioural difficulties.
• Susceptible to infections.
• Hearing and visual impairment.
• Cerebral palsy.
• Developmental delay.

Question 12

List the common and important congenital anomalies; describe how these are identified and managed in the neonatal period?

Answer 12

• Common: abdominal wall, nervous system, trisomy chromosomal, congenital heart, genetic, limb, kidney & urinary tract, GI tract, genital, oro-facial clefts, respiratory.
• Identified: detected on antenatal screening tests or scans (most common), postnatal.
• Managed: surgical correction.

Question 13

Demonstrate knowledge of the newborn screening programme of physical examination and metabolic testing

Answer 13

• NIPE: first 72 hours of birth and repeated at 6-8 weeks. Screens for testicular, hip, eye and heart problems.
• Metabolic testing via newborn blood spot on day 5, screens for 9 congenital conditions: sickle cell disease, cystic fibrosis, congenital hypothyroidism, PKU, MCADD, MSUD, IVA, GAI, homocystin.

Question 14

Describe the epidemiology of Sudden unexpected death in infancy

Answer 14

• Highest incidence rates at 2-4 months.
• 90% deaths occur within 6 months of age.
• ~200 deaths per year in UK.

Question 15

Outline protective and risk factors for SIDS and demonstrate how to give relevant guidance to parents

Answer 15

Protective factors:

• Baby on back when sleeping.
• Head uncovered in cot.
• Foot at end of bed to prevent sliding down under blanket.
• Cot clear of toys and blankets.
• Comfortable room temperature.
• Avoid smoking and handling baby after smoking.
• Avoid co-sleeping with baby.
• Breastfeeding.

Risk factors:

• Prematurity.
• Low birth weight.
• Smoking during pregnancy.
• Male baby.

Question 16

Outline the epidemiology and scale of childhood asthma in the UK and its impact on primary care

Answer 16

• Asthma is the most common long-term medical condition in children in the UK.
• 1 in 11 children and adolescents living with asthma.
• The UK has one of the highest prevalence, emergency admission and death rates for childhood asthma in Europe.
• 1 million children in UK receiving treatment for asthma.
• Less than 25% of children with asthma have a personalised asthma action plan (PAAP).
• Nearly half have had an asthma attack in the previous year.
• Emergency admissions for asthma are strongly associated with deprivation.
• Increased risk of developing asthma if living in disadvantaged circumstances e.g. deprivation, poor quality housing, overcrowding, addiction households.

Impact on primary care: increases number of appointments, increased medication and prescription charges, overdiagnosis of childhood asthma in primary care leading to unnecessary treatment, struggling to manage demand for services.

Question 17

What is The National bundle of care for children and young people with asthma?

Answer 17

Phase one of a plan to support integrated care systems to deliver high quality asthma care. In order to improve asthma outcomes for children and young people.

Question 18

Discuss the role of screening for congenital dysplasia of the hip

Answer 18

• Identifies subgroup of population who need further testing e.g. hip US.
• Early identification of cases leads to earlier treatment and therefore better outcomes for patients.
• Reduces risk of long-term hip (e.g. dislocation, degeneration) and mobility/gait problems.
• Treatment with Pavlik harness or surgery.

Question 19

Demonstrate understanding of how multidisciplinary teams care for children with cerebral palsy (or other neurological conditions)

Answer 19

• Physiotherapy: stretch and strengthen muscles, improve function and prevent contractures.
• Occupational therapy: manage ADLs, improve techniques and make adaptations/supply equipment.
• Speech and language therapy: speech and swallowing.
• Dietician: NG tube or PEG tube.
• Orthopaedic surgeons: release contractures and tenotomy.
• Paediatricians: optimise medications e.g. muscle relaxants, anti-epileptics, laxatives, anti-cholinergics (drooling), analgesia.
• Social worker: benefits and support.
• Charities and support groups.

Question 20

Outline how doctors along with other health professionals act to prevent spread of childhood infection including referral, use of chemoprophylaxis and control of ward infection

Answer 20

• Separate cubicles/bays for notifiable diseases to reduce transmission and spread (barrier nursing).
• Referral to infectious disease and microbiology.
• School exclusion criteria.
• Childhood immunisation schedule.
• PPE, sterilise equipment and surfaces, hand hygiene.
• Prophylactic antibiotics to close contacts and immunocompromised e.g. for exposure to meningococcal disease.

Question 21

Understand the principle of disease prevention through immunisation, the calendar of routine UK childhood immunisations and additional immunisations in special circumstances

Answer 21

NHS VACCINATION SCHEDULE

• 8 weeks: 6-in-1 (diphtheria, hep B, Hib, polio, tetanus, whooping cough), rotavirus, MenB.
• 12 weeks: 6-in-1 (2nd dose), pneumococcal, rotavirus (2nd dose).
• 16 weeks: 6-in-1 (3rd dose), MenB (2nd dose).
• 1 year: Hib/MenC, MMR, pneumococcal (2nd dose), MenB (3rd dose).
• 2 to 15 years: children’s flu vaccine (annual).
• 3 years and 4 months: MMR (2nd dose), 4-in-1 pre-school booster (diphtheria, polio, tetanus, whooping cough).
• 12 to 13 years: HPV.
• 14 years: 3-in-1 teenage booster (diphtheria, polio, tetanus), MenACWY.
• 65 years: flu vaccine (annual), pneumococcal, shingles.
• 70 to 79 years: shingles.
• Pregnant women: flu vaccine and whooping cough.
• At risk babies: BCG vaccine at 28 days old (born in area with high prevalence of TB or parents/grandparents born in country with many cases of TB). Hep B at birth, 4 weeks and 12 months (babies born to mothers with hep B). Flu vaccine from 6 months to 17 years (long-term health conditions).

UK childhood immunisation rates are in decline. No vaccinations meg the 95% target set by WHO. Regional uptake of routine vaccinations was at its lowest in London.

Question 22

Understand common concerns about vaccination, follow up management of vaccine reaction and failed immunisation

Answer 22

• No individual freedom or choice.
• Public mistrust due to Andrew Wakefield falsely linking MMR vaccine to autism.
• Question safety and effectiveness.
• Scared of side effects and can be harmful.
• Vaccines haven’t been properly trialled and tested for safety and effectiveness e.g. COVID-19 vaccines.

Question 23

Give some examples of live-attenuated vaccines

Answer 23

• MMR
• Rotavirus
• Smallpox
• Chickenpox
• Yellow fever

Question 24

Outline the effects of altered life expectancy at a time when a young person is becoming independent of parental control

Answer 24

IMPACTS OF CHRONIC CONDITION ON THE CHILD:

• Visible v Non-visible: non-visible harder to adjust to.
• Time off school/difficulty completing school work/exams → worse academic performance.
• Rebelliance = not taking medications.
• Feeling different to friends + self image.
• Needing to plan day around meals/medications etc.
• Increased dependence on parents at a time of when independence is normally developing.
• Impact on employment.
• Future fertility.
• Life expectancy: feelings of depression and anxiety, why me?, unfair, alone.
• Emotional response can be similar to bereavement/grief reaction.

Reaction dependent on: nature of illness + symptoms, stage of illness, age of the child, temperament, family factors, intellectual capacity.

Question 25

Outline the epidemiology of childhood injury/accidents and methods of prevention

Answer 25

• Accidents are the main cause of death among children aged 1-5 years. About 100,000 children are admitted to hospital annually in the UK and 2 million attend emergency departments.
• More common in male children.
• Babies = burns, scalds, being dropped.
• Toddlers = burns, poisoning (looks like candy), falls, scalds.
• Older children = falls.

Falls:

• Constantly changing center of gravity.
• As meeting milestones.
• Age where explore a lot but not a lot of cognitive ability = not knowing it is dangerous.

Prevention:

• Stairs with gates until 2 years old.
• Do not leave babies unattended.
• Don’t change nappies on raised surface.
• Vehicle safety e.g. car seats and seatbelts.
• Avoid toys with small parts (choking hazard).
• Keep plastic bags away from children (suffocation risk).
• Keep knives and kettles out of reach.
• Do not leave a young child unsupervised in a bath or near any water.

Most common causes of accidental deaths: transport, asphyxia, drowning, smoke/fire/flames, poisoning, falls.

Question 26

Describe the purpose of the multidisciplinary approach and information gathering in child protection

Answer 26

• GP
• Health visitor
• Community midwife
• Social worker

Collateral history - home and school.

Question 27

Understand the duties and responsibilities of health care professionals in the safeguarding of babies, children and young people

Answer 27

• Health workers are witnesses to the injustice.
• Health workers have high public trust.
• Health workers can interfere with some elements of the system e.g. supporting cases.
• Health workers mostly have some level of privilege that enables us to engage with these issues.

Question 28

Develop an understanding of the concept of advocacy for a healthy lifestyle in children and young people and for the protection of their rights

Answer 28

Housing is a child public health emergency (mould).

The aim of child advocacy is to encourage empowerment of children and uphold their human rights.

A child advocate can offer advice and support to a child or young person.

• Bearing witness to their conditions and listening to their testimony - write letters and attend meeting.
• Uplifting their voices to hold truth to power by building community power.
• Collaborating with legal experts to mount a class action lawsuit.
• Participating in a protest.
• Undertaking research.

Question 29

Understand the importance of effective team work with colleagues in multi-disciplinary teams to ensure consistency and continuity and a holistic approach to the treatment and care of children and young people

Question 30

Outline the ‘Healthy Child Programme’ of screening and surveillance

Answer 30

• The ‘Healthy Child Programme’ gives comprehensive advice on health and social care throughout a child’s life.

AIMS:

• Help parents develop a strong bond with children.
• Encourage care that keeps children healthy and safe.
• Protect children from serious diseases, through screening and immunisation.
• Reduce childhood obesity by promoting healthy eating and physical activity.
• Encourage mothers to breastfeed.
• Identify problems in children’s health and development (for example, learning difficulties) and safety (for example, parental neglect), so that they can get help with their problems as early as possible.
• Make sure children are prepared for school.
• Identify and help children with problems that might affect their chances later in life.

It consists of:

• Health and development reviews: by the 12th week of pregnancy, neonatal examination, new baby review (2 weeks old), 6 to 8 week check, 1 year old and 2-2.5 years old.
• Screening: antenatal and newborn screening (NIPE, newborn hearing, newborn blood spot).
• Immunisations.
• Health promotion: smoking, alcohol, drugs, nutrition, dental health, hazards, attitudes.

Question 31

Describe the role of health promotion programmes in childhood including prevention of: dental decay, smoking, accidents, obesity, sudden infant death

Answer 31

• Dental decay: parents brush teeth twice daily as soon as teeth erupt, low sugar diet, encourage drinking from a cup from 6 months, fluoride toothpaste.
• Smoking: stop smoking in pregnancy, don’t smoke around children, smoke-free home,
• Accidents: see earlier card on accident prevention.
• Obesity: healthy free school meals, PE lessons, healthy diet at home, encourage breastfeeding, encourage an active lifestyle.
• SIDS: see earlier card on SIDS prevention.

Question 32

Outline protective and risk factors and demonstrate how to give relevant guidance to parents

Answer 32

Risks:

• Food scarcity (FTT, poor growth and development).
• Forced migration (mental health and well-being).
• Pollution/sites of natural resource extraction (insults to lung development).
• Economic and political instability (poverty and destitution).

Protective:

• Food (availability, affordability and acceptability).
• Adaptation and mitigation to reduce forced migration whilst enabling climate refugees safe and dignified possibilities for safety and well-being.
• Reducing and ending use of harmful extractive processes and products.
• Economic justice (economic stability, communities, resources to thrive).
• Immunisations protect against infectious disease.
• Free education.

Advice to parents:

• Direct them to NHS inform.
• In touch with community midwife.
• Community group meetings.
• Letter to council to address concerns.
• Reach out to other health workers.

Question 33

Outline some parent-based disadvantages that can lead to adverse outcomes for children

Answer 33

• Both parents are unemployed.
• The family lives in poor-quality or overcrowded housing.
• Neither parent has any educational qualifications.
• Either parent has mental health problems.
• At least one parent has a long-standing limiting illness, disability or infirmity.
• The family has a low income.
• The family cannot afford a number of food and clothing items.

Question 34

Outline the risk factors for child abuse

Answer 34

• ⅓ children in UK are vulnerable.
• Toxic trio, coexistence of these factors: parental substance misuse, parental MH condition, domestic violence.
• Family: MH problems, instability, young parental age, step-parents, multiple or closely spaced births.
• Child: failure to meet parent’s expectations, born to forced gender, previous child abuse of other family members, young children and adolescence, LD.

Question 35

Describe the risk factors for non-accidental injury

Answer 35

Poverty, social isolation, disability, chronic disease.

Question 36

Red flags for non-accidental injury

Answer 36

• Excessive multiple bruises at different stages of healing.
• Bruise patterns that indicate slapping, griped tightly, belts.
• Bruises to face, neck, ears, buttocks, trunks, proximal parts of lower limbs.
• Well demarcated burn injuries.
• Spiral or metaphyseal fractures.
• Explanation for injury absent or unsuitable.
• Child is not independently mobile.
• Injury on an area that wouldn’t come into contact with hot surface e.g. soles of feet, back, buttocks.
• Injury in the shape of an object e.g. iron, belt etc.
• Delayed presentation.
• Evasive or changing history.
• Inconsistency between age of injury and examination findings.
• Signs of restraint on limbs.

Question 37

Describe the features of child protection and safe guarding

Answer 37

It’s everyone’s responsibility:

• If a child tells HCP → statutory obligation to tell appropriate agency.
• Discuss with senior.
• Social worker → MDT → child protection plan.

Action to promote welfare of children and protect them from harm:

• Protect from maltreatment.
• Prevent impairment of health and development.
• Ensure child can grow up in circumstances consistent with provision of safe and effective care.

Children’s act 2004:

• Child protection outweighs confidentiality.

Working together to safeguard children 2015:

• For everyone working with children.
• How organisations and individuals work together and how to conduct assessment for children.

Question 38

Outline the requirements for adoption

Answer 38

Requirement of child:

• Under the age of 18 (when adoption application is made).
• Not have to be married or civil partnership.

Requirement of birth parents to agree unless:

• Can’t be allocated/found.
• Cannot give consent - i.e. LD.
• Child would be put at risk if not adopted.

Application to local authority:

• Social work assessment.
• Full medical assessment.
• DBS check.

Question 39

Paediatric palliative care

Answer 39

Doctrine of Double Effect - all about intent:

• Giving medications i.e. benzos for pain relief is justified even though it may shorten life.
• As intent was to relieve suffering.

Big MDT:

• Include parents = they are expert carers, expert on condition and on the child.

Parallel planning = hoping for the best but planning for the worst:

• Conditions categorised by chances of reversibility.

Role of hospices:

• Symptom control and respite care.
• Specialist in music, play, art.
• Support family and siblings.

Levels of paediatric palliative care:

• Level 1: life-threatening condition for which curative treatment may be feasible but can fail e.g. malignancy.
• Level 2: conditions where premature death is inevitable, long intensive treatment e.g. CF.
• Level 3: progressive conditions without curative options where treatment is palliative and may go over many years e.g. Batten disease.
• Level 4: irreversible but non-progressive conditions causing severe disability leading to susceptibility to health complications and likelihood of premature death e.g. severe brain injury.

Question 40

Describe the support to the newborn infant

Answer 40

Hospital at birth:

• Kept in 4-5 days if C-section.
• Can be as fast as 6 hours for an uncomplicated birth provided baby has opened bladder/bowels.

GP – new babies can be registered with a practice as soon as possible – pink card given at hospital.

Health visitor – usually 1st visit or seen at clinic within 10 days:

• Nurse with specialist neonatal training.
• Holistic family assessment, check that everyone is managing (not just baby).
• Can offer extra support, put you in touch with groups/other mothers etc.

Child health clinics – regular GP clinics for vaccinations and development reviews. Also screen maternal health.

Sure Start Children’s Centres (local authority) – focus on increasing outcomes for young children and families, focus on the most disadvantaged families, aim to reduce inequalities in child development and school readiness:

• Can offer educational support and full/part time child care.

Question 41

WHO 10 steps to successful breastfeeding

Answer 41

• Have a written breastfeeding policy that is routinely communicated to all healthcare staff = visibly posted in all areas serving mothers/children and for staff to refer to.
• Train all healthcare staff in skills necessary to implement policy = all staff in contact with mothers should know how to implement the policy.
• Inform all pregnant women about the benefits and management of breastfeeding.
• Help mothers initiate breastfeeding within 30mins of birth = normal vaginal deliveries should have skin-skin contact for 30 mins and help with starting feeding - Earlier start makes it more likely to be successful.
• Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants = teach positioning and attachment techniques e.g. if separated for medical reason.
• Give newborn infants no food or drink other than breastmilk unless medically indicated.
• Practice rooming-in – allow mothers and infants to remain together 24hrs a day = no nurseries! Allows mother to learn feeding cues and helps establish bond/feeding relationship.
• Encourage breastfeeding on demand = no restrictions on number or length of feeds e.g. ‘greedy baby’.
• No artificial teats or pacifiers to breastfeeding infants = interferes with suckling and baby’s learning of how to suckle/feed.
• Establishment of breastfeeding support groups and refer mothers to them on discharge from hospital.

Question 42

What are the signs of successful breastfeeding?

Answer 42

• Wide mouth and mouthful of breast.
• Baby’s chin is on breast: lower lip rolled down and nose isn’t squashed.
• No pain when baby is feeding.
• Areola visible on top lip compared to bottom.
• Rounded cheeks.
• Rhythmic sucking and swallowing.
• Breast feels softer after feeds.
• Mother sleepy and relaxed after feeds.

Question 43

Describe the community management of diabetic eye disease

Answer 43

• Control of blood glucose, cholesterol and BP.
• Diabetic eye screening every 1-2 years.
• Stop smoking.
• Healthy lifestyle.
• Treatment for advanced diabetic retinopathy: laser treatment, eye injections, steroid eye implants, eye surgery.

Question 44

Outline global health patterns of visual loss

Answer 44

Prevalence changes around the world:

• Depends on nutrition, economic factors.
• More common in LEDs compared to UK - 90% of blind live in developing countries and 80% blind people could’ve been prevented.

Commonest causes (worldwide) - based on most common: cataract, glaucoma, ARMD, corneal opacity, trachoma, childhood (vit A deficiency).

Commonest in developed country: congenital causes, cataracts, ARMD, glaucoma, DM.

Comment cause in UK: age-related macular degeneration (ARMD).

Question 45

Assess the possibility of neo-natal and childhood deafness and outline the process of screening for hearing loss

Answer 45

Newborn hearing screening within a few weeks of birth:

• Automated otoacoustic emission (AOAE) test: gentle clicking sounds into ear.
• Automated auditory brainstem response (AABR) test: 2nd test if 1st fails, 3 small sensors on baby’s head and neck, soft headphones are placed over baby’s ears and gentle clicking sounds are played.

From 9 months to 2.5 years of age – you may be asked whether you have any concerns about your child’s hearing as part of your baby’s health and development reviews, and hearing tests can be arranged if necessary.

At around 4 or 5 years old – some children will have a hearing test when they start school, this may be conducted at school or an audiology department depending upon where you live. Pure tone audiometry.

Question 46

Outline effective approaches to the prevention of deafness

Answer 46

• Neonatal screening.
• Vaccination: MMR, Meningitis.
• Avoidance of ototoxic drugs.
• Treatment of jaundice babies.
• Better industrial noise exposure limits & use of PPE. Limiting exposure to excessive noise and providing suitable ear protection.
• Early detection of otitis media with effusion (OME) in children.

Question 47

Describe the role of the optometrist

Answer 47

• Primary HCP trained to examine eyes + identify any defects in vision.
• Makes assessment + refer to specialist + prescribe glasses.

Question 48

Outline the benefits of blindness registration

Answer 48

• Local authority keeps record → registration via consultant ophthalmologist.
• Allows access to specialist + benefits easier.
• Blue badge parking permit.
• Leisure centre concessions.
• Bus and rail ticket concessions.
• TV licence concessions.
• Career and employment advice.
• Disability living allowance.
• Benefits, income support, etc.

Question 49

Outline the referral pathway for paediatric squints

Answer 49

• Refer any suspected or confirmed squint to paediatric eye services by routine referral, or urgent if serious underlying condition suspected.
• Refer to squint clinic in older children/adults.
• Secondary care: corrective glasses, eye exercises, surgery.