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Child Health - Paediatrics > Child Health 2 > Flashcards

Child Health 2 Flashcards

1
Q

What is the most common cause of motor impairment in children?

A

Cerebral Palsy

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2
Q

Define Cerebral Palsy

A

A permanent disorder of movement and/or posture and of motor function due to a non-progressive abnormality in the developing brain.

“An umbrella term referring to a non-progressive disease of the brain originating during the antenatal, neonatal, or early postnatal period when brain neuronal connections are still evolving.”

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3
Q

How do the features of cerebral palsy appear?

A

The clinical manifestations emerge over time, reflecting the balance between normal and abnormal cerebral function.

80% present with spasticity.

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4
Q

At what age does brain injury become acquired?

A

Brain injury after the age of 2 is an acquire brain injury.

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5
Q

How many live births are affected by Cerebral Palsy?

A

2 (2.5) per 1000

1 per 500

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6
Q

What percentage of Cerebral Palsy is antenatal?

Of these what are the common causes?

A

80%

  1. Haemorrhage or ischaemia (Cerebrovascular) (10%)
  2. Cortical migration disorder
  3. structural maldevelopment

They may have a genetic link.

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7
Q

Which babies are most at risk of of brain damage

A

Preterm infants are most at risk due to periventricular leukomalacia due to ischaemia or intraventricular haemorrhage and venous infarction.

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8
Q

What are the postnatal causes of cerebral palsy? (7)

A

Meningitis

Encephalitis

Encephalopathy

Head trauma

Hypoglycaemia (Symptomatic)

Hydrocephalus

Hyperbilirubinaemia

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9
Q

What are early features of cerebral palsy?

A
  1. Abnormal limb and/ or trunk posture and tone in infancy with delayed motor milestones (there may be slow head growth)
  2. feeding difficulties, with oromotor incoordination, slow feeding, gagging and vomiting.
  3. abnormal gait
  4. asymmetric hand function <12 mo
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10
Q

At what age range are babies expected to push up on their arms and hold their head up?

What abnormality could their be?

A

1.5 to 3 months

Babies should be pushing up on their forearms and holding their head up.

There could be stiff extended legs, constantly fisted hand and stiff leg on one side and difficulty moving out from this position.

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11
Q

What would constitute normal motor development between 3 to 6 months?

A

Sitting with support

holding the head up

rounded back

At 3 - 6 months

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12
Q

If a baby can sit without support, having it’s arms free to reach and grasp what age range could it be?

A

6 to 9 months.

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13
Q

If a baby is 9 to 13 months what can be expected of is motor development?

What might signal an abnormality?

A

At 9 - 13 months you could expect a baby to pull itself to stand

A lack of interest in weight bearing, difficulty pulling to standing and stiff legs with pointed toes.

Also poor head control and an arched back.

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14
Q

When can a baby be expected to have independent standing and walking?

A

between 12 to 18 months. (1 - 1.5 year)

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15
Q

What are the common classifications of cerebral palsy?

A
  1. spastic - bilateral, unilateral, other (90%)
  2. dyskinetic (6%)
  3. ataxic (4%)
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16
Q

What is GMFCS?

A

Gross Motor Function Classification System

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17
Q

Summaries the different orders of GMFCS

A

5.

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18
Q

What are the 3 common patterns of wheeze?

A
  1. Viral episodic wheeze - wheeze only in response to viral infections?
  2. Multiple trigger wheeze - multiple triggers -> develops to asthma
  3. Asthma
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19
Q

What dose viral episodic wheeze result from?

When does it resolve?

A

Thought to be the result of small airways being more likely to narrow and obstruct due to inflammation and aberrant immune responses to viral infection.

Which gives it the episodic nature.

Usually it resolves by age 5 - presumably from increase in airway size.

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20
Q

What can trigger multi-trigger wheeze?

A
  1. viruses
  2. cold air
  3. dust
  4. animal dander
  5. exercise
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21
Q

If a patient has recurrent wheezing, associated with symptoms between viral infections and they have demonstrable allergies what is this called?

A

They have interval symptoms, and allergy to house dust mite, pollen or pets leading to
Atopic Asthma

22
Q

Describe wheeze to a parent

A

A whistling in the chest when the child breaths out

23
Q

What symptoms give a high probability of asthma?

What age is it normally diagnosed?

A
  1. Worse night time and early morning symptoms (diurnal)
  2. Non-viral triggers (exercise, cold air, allergens)
  3. Interval symptoms (symptoms between viral infections)
  4. Positive response to asthma therapy (i.e. bronchodilator reversibility) [improved PEF] - an improvement of 12% confirms bronchodilator reversibility.
  5. personal or family history of atopy.

diagnosed over 5 (difficult to differentiate from other illnesses younger than this)

24
Q

What questions should be used to assess asthma control in children?

A
  1. Closed questions - “do you use your reliever (blue) every day?”
"time off school/nursery"
"inhaler techinque"
"adherence"
"asthma plan"
"exposure to smoke"
  1. Growth (height and weight centile)
  2. The best predictor of future attacks is current control.
25
Q

What is a risk factor for recurrent wheezing?

A
  1. Prematurity and low birth weight.
26
Q

What do you need to know from a patient with a current asthma attack?

A

Hx:
Past hx of asthma, previous hospital attendances, duration of current attack.

Trigger factors for current attack
Frequency of attacks
School days misses
Usual medication and route of administration
Repeat courses of roids
history of atopy
Family history
Previous PICU admission
27
Q

What should be documented in a child with an acute asthma attack?

A 
Pulse rate
Oxygen Saturations
Respiratory rate and degree of breathlessness
Use of accessory muscles
Amount of wheezing
Degree of conscious level
PEFR in children >5 years
28
Q

What would you give a child with acute exacerbation of asthma?

A

Consider admission if mild-moderate and not improving

1a. Nebulised or inhaled salbutamol with oxygen
1b. give oral prednisolone
2. include ipratropium in nebuliser
3. bolus IV magnesium. IV hydrocortisone
4. bolus IV salbutamol and consider PICU

29
Q

What are the 5 steps of the SIGN/RTS gudeliens for the management of asthma in children?

A
  1. monitored initiation of treatment of very low ICS with PRN Beta agonist. [Always consider moving up if using more than 3 doses a week or more]
  2. Regular preventer of very low dose ICS or Leukotriene Receptor Anatognists in the under 5s
  3. ICS + children over 5 LABA or children under 5 LTRA
  4. stop LABA if no use and increase ICS
    or keep LABA and increase ICS
    trial of LTRA
  5. Increase ICS - refer
    add SR theophylline
  6. Daily roids - refer
30
Q

What are the classic symptoms of a upper respiratory tract infection?

A
  1. Coryza (nasal discharge and blockage)
  2. Sore throat
  3. Earache
  4. Sinusitis
  5. Stridor
31
Q

What are the classic symptoms of lower respiratory tract infection?

A
  1. Cough
  2. Wheeze
  3. Respiratory distress
32
Q

What are the signs of moderate respiratory distress?

A
  1. Tachypnoea
  2. Tachycardia
  3. Nasal Flaring
  4. Use of accessory respiratory muscles
  5. Intercostal and Subcostal recession
  6. head retraction (head bobbing)
  7. Inability to feed
33
Q

What are the signs of severe respiratory distress?

A
  1. cyanosis
  2. tiring
  3. reduced consciousness
  4. oxygen saturation < 92% despite oxygen therapy
34
Q

Explain when extra thoracic or intrathoracic obstructions are worse.

A

Extrathoracic obstructions are worse during inspiration as this when the airway naturally bulges inwards. (because negative pressure in the airway vs atmospheric)

intrathoracic obstructions are worse during expiration.

35
Q

how should stridor be assessed?

A
  1. Is it only on crying?
  2. At rest
  3. Biphasic
36
Q

What is Croup? - Affecting what ages?

What causes it?

What are the typical features?

A

Laryngotracheobronchitis - 6 months to 6 years (2nd year peak - in the autumn

Viral croup is 95% - parainfluenza, rhinovirus, RSV, influenza

  1. Coryza - 2+ days
  2. Fever
  3. Hoarseness because of vocal cord inflammation
  4. barking cough - trachea oedema and collapse
  5. harsh stridor
  6. varying breathing difficulty
  7. worse at night
37
Q

What factors decide admission in a child with croup?

A
  1. Severity [SpO2 >93% in air]
  2. time of day (closer to night more likely for admission)
  3. ease of access to hospital
  4. age - <12 months more likely due to smaller airways
  5. parental understanding and confidence
  6. Children with T21 have more severe croup
38
Q

What is the management of croup?

A
  1. Provide a calm, reassuring atmosphere - keep with parents if possible.

For mild - moderate
2. Oral Dexamethasone (0.6 mg/kg) or nebulised budesonide (2 mg) or IM dexamethasone

  1. Assess hourly. Reassess at 4 hours, if improving consider discharge.

For moderate to severe:
4. Oxygen for saturation >93%

  1. Steroid as above
  2. Assess hourly, admit to ward
  3. If poor response to steroid, senior review, review diagnosis. Consider nebulised epinephrine.
39
Q

What are the main differentials are upper airway obstruction?

A
  1. Croup
  2. Epiglottitis
  3. Bacterial Tracheitis (high fever, without response to steroids)
  4. Inhaled foreign body
  5. Anaphylaxis/ Angioedema
40
Q

What is epiglottitis?

What is the cause?

How can you differentiate from croup?

A

Intense swelling of the epiglottis and surrounding tissues associated with septicaemia.

Caused by Haemophilius influenza b (HiB)

Uncommon due to vaccination but occurs between 1-6 normally.

in contrast to croup:

  1. very acute onset - over hours
  2. No preceding coryza
  3. high fever >38.5, very ill
  4. intensely painful throat, saliva drools out of mouth due to the inability to swallow
  5. soft inspiration stridor and rapidly increasing respiratory difficulty.
  6. child is sitting upright, immobile with a wide open mouth.
  7. mild cough or non.
41
Q

When is AOM (acute otitis media) most common?

What causes it?

A

6- 12 months

Its common because their auditory tubes (Eustachian) are short, horizontal and function poorly.

Tympanic membranes are red and lack a light reflection.

Viruses: RSV and rhinovirus
S. pneumoniae, S. pyogenes. S. aureus, H influenza, Moraxella catarrhalis

42
Q

What is the management of otitis media?

A
  1. Analgesia (paracetamol or ibuprofen - NICE says not together but alternate if bad) - regular over intermittent
    - decongestants or antihistamines don’t help.
  2. Many are viral causes:
    - in 80% of people it is normally resolved by day 4
    - ABX don’t reduce pain in the first 24 hours, subsequent infection or deafness
    - Amoxicillin 500 mg TDS 5 days or clarithromycin 500 mg BD 5 days
43
Q

What are features of bacterial tracheitis?

A

Pseudomembranous croup

  • similar to epiglottitis
  • high fever
  • appears very ill
  • rapidly progressive airway obstruction with copious secretions

Typically caused by S.aureus

44
Q

What are examples of URTI?

What are some complications?

A
  1. common cold (coryza)
  2. Sore throat (pharyngitis - tonsillitis)
  3. acute otitis media
  4. sinusitis (uncommon)
  5. difficulty feeding
  6. febrile seizures
  7. acute exacerbation of asthma
45
Q

What is the common cause (aetiology) of bronchiolitis?

What is the most common age?

What is the pathophysiology?

A
  1. Respiratory Syncytial Virus
    - causes 60-75% (80%) of cases.

Other causes are

  • human metapneumovirus
  • influenza
  • rhinovirus
  • adenovirus
  • parainfluenza
  • bocavirus

There can be co-infection with two viruses

Peak incidence between November and March.

  1. 90% are aged 1 - 9 months
  2. Obstruction of the small airways, caused by acute inflammation, oedema, necrosis of the epithelial cells, with increased mucus production that can cause mucus plugging.
  3. Most will recovery without problem, though up to 40% may have subsequent wheezing episodes through five years of age.
46
Q

What is the natural history of bronchiolitis?

A

3 day history of coryzal symptoms preceding a dry cough, fever and increasing respiratory distress. Young infants <6 weeks can present just with apnoea.

  1. Rhinorrhoea and dry cough (coryzal)
  2. Exposure to an individual with an URTI
  3. difficulty breathing - increasing = admission
  4. tachypnoea
  5. cyanosis
  6. apnoeas - admission
  7. poor feeding - admision
47
Q

What are the examination findings in a child with bronchiolitis?

Which of these form the characteristic diagnostic triad?

A
  1. Observations:
    - tachypnoea
    - low SpO2
    - fever
    - dry cough
    - cyanosis, colour change or apnoea
    - signs of respiratory distress
    - - tachypnoea
    - - intercostal/subcostal/sternal recession
    - - tracheal tug
    - - accessory muscle use (nasal flaring and head bobbing)
    - - hyperinflated chest
  2. On auscultation:
    - widespread fine inspiratory crackles +/- wheeze (which is expiratory > inspiratory)
  3. Liver may be displaced downwards due to hyperinflation of lungs

CHARACTERISTIC TRIAD:

  1. EXPIRATORY WHEEZE
  2. INSPIRATORY CREPITATIONS
  3. HYPERINFLATED CHEST
48
Q

List some cause of acute respiratory distress in an infant

A
  1. Bronchiolitis
  2. Viral episode wheeze
  3. Pneumonia
  4. Heart Failure
  5. Foreign body
  6. Anaphylaxis
  7. Pneumothorax or pleural effusion
  8. metabolic acidosis
  9. severe anaemia
49
Q

What features would make you want to admit a baby with bronchiolitis?

What additional risk factors increase the likelihood of admission?

A

FACTORS FOR ADMISSION

  1. Persistent SpO2 <92%
  2. Persistent respiratory distress RR >70, marked inspiratory recession/ grunting
  3. History of apnoeas (reported or observed)
  4. Less than 50% of usual feeds/ oral fluid intake/ concerning hydration status
  5. Lethargic or appearing unwell.
  6. Family unable to cope: social circumstances, skill and confidence in spotting red flags, distance to health care if deteriorating.

RISK FACTORS

  1. infants <6 weeks
  2. Ex-preterm
  3. Chronic lung disease
  4. Congenital heart disease
  5. Immunodeficiency
  6. Trisomy 21 or syndromic association
  7. Neuromuscular disorders
  8. Congenital abnormalities
  9. Smoke exposure
50
Q

Baby Jimmy has bronchiolitis. Parents say he’s been struggling for about 2 days.

He’s boarderline as to whether he can go home. Parents are not too far away but unsure about managing him. He has no other risk factors and his observations are boarderline.

What other factor affects his admission?

A

Bronchiolitis symptoms peak typically day 3 - 5 so given Jimmy’s moderate symptoms he may get worse, so should be considered for admission

51
Q

What investigations and management would you arrange for a infant with bronchiolitis?

When might an infant be expected to recover?

Is RSV infectious or not?

A

INVESTIGATIONS:

  1. Nasopharyngeal aspirate (NPA)
  2. Observations

U&Es if IVI as risk of hyponatraemia
FBC/culture if sepsis
Blood gas if advanced respiratory support

MANAGEMENT
- Management is supportive

  1. Oxygen if SpO2 <90% Nasal cannulae, face mask or head box
  2. Hydration if feeding <50% [NG feeds or frequent breastfeeding/small feeds) [though reconsider if RR >60]

No real evidence for other interventions

RECOVERY

  1. Normally within 2 weeks.

RSV

  1. RSV is highly infections, gloves and gown + usual hand hygiene.
52
Q

What advice should be given to parents caring for a child with bronchiolitis?

A

PARENT AND FAMILY EDUCATION.

  1. Nature of illness and suspected clinical course: A viral infection of the upper airways causing a cough which may persist for 2 - 4 weeks and there may be wheezy episodes in future.
  2. Call the GP or return to ED if the following RED FLAGS are present:
    - Increasing RR/work of breathing
    - Apnoea/ Cyanosis
    - Inability to maintain hydration 50% of feeding
    - no wet nappies in more than 8 hours
    - worsening general appearance
    - exhaustion/ not responding to social cues
  3. importance of hand washing before and after contact
  4. avoid exposure to environmental smoking
  5. avoid exposure to sick contacts
  6. provide PIL
  7. Check understanding, especially with language and competent and confidence for caring for them at home.

Child Health - Paediatrics (5 decks)

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