Child health Flashcards
Measuring growth
Centile charts
- dots for height and weight, x for bone health
- MPH plotted at 20 years (mid +7 for boys -7 for girls)
- TPR ±10cms for males, ±8.5cms for females
Height velocity on chart
Monitor secondary sex characteristics with Tanner staging (absent=0): B1-5 (breast stage) P1-5 (pubic hair stage) G1-5 (penis and testicle development) A0-1 (axillary hair)
Key ages in growth
- age 0-2 – driven by nutrition mainly
- 2-puberty – driven by GH mainly
- Puberty-adulthood – driven by sex steroids and increased GH
- Menarche ~13
- Sexual precocity (if any signs of puberty developing before these ages, then urgent investigation needed)
In girls before 8
In boys before 9 - Peak height velocity
In girls, when breast stage 2-3 (early)
In boys, when 12-15mls testes (late)
Factors affecting height
Normal
- familial short stature
- intrauterine growth retardation
- constitutional delay in growth and puberty – not a disease – but many find it problematic (depends on parental ages of puberty)
Pathological
- hypothyroidism (congential hypothyroidism should be detected on screening at day 4 – but if central (low TSH) then won’t be detected)
- chronic disease – coeliac, crohn’s, cystic fibrosis
- excess corticosteroids (Cushings syndrome common, Cushings disease rare)
- parental neglect
- growth hormone deficiency
- diabetes mellitus (usually T1, so need short acting insulin in day + long acting at night, ~30% on insulin pumps, aim to maintain 2-4.0mmol, can use continuous blood sugar monitoring)
- coeliac disease
Investigating short stature
= height <3rd centile - record birth weight - record both parental final heights \+ calculate MPH and TPR - check feeding technique!
- measure height velocity, if poor…
- check bone age
- check FBC, U+Es, TFTs, coeliac screen
- karyotype in girls (Turner’s XO)
- MSU
- coeliac serology, U+E, glucose, LFT, calcium levels, proteins, CRP, TSH (hypothyroid common!), FBC
- sweat test
- stools (MC+S and sugar)
- CXR, renal or CNS USS
- skeletal study for dwarfism and abuse
- ECG/echo
1st – assume constitutional delay (likely parents were the same), so offer testosterone. If testosterone not improving height velocity…
- hypogonadothropic hypogonadism (small gonads due to pituitary problem – lack of gonadotrophs, test FSH / LH levels)
- Kleinfelter’s syndrome – XXY, test karyotype
Turner’s syndrome
XO
- can present with hand/foot lymphoedema, webbed neck, shield chest (nipples point out), cardiac/renal abnormalities, intellectual delay
- but often just detect in growth clinic as short stature (if mosaic, not complete)
- need oestrogen replacement therapy for life, and also give GH eg somatotrophin
Increased height
- thyrotoxicosis
- precocious puberty
- Marfan’s syndrome
- homocystinuria
Precocious puberty
If onset before 8 in girls, before 9 in boys (10x more common in girls)
Central PP - with genital changes
- due to abnormality in pituitary gland -> LH + FSH -> testes/ovaries
- can be idiopathic in females
- in males, is often due to tumours (craniopharyngioma), so always brain scan
Pseudo PP - only other SSCs, not gonadal enlargement
- due to sex steroids from adrenal glands - CAH or tumours
- congenital adrenal hyperplasia, autosomal recessive (usually 21-hydroxylase (on cholesterol)) affecting aldoesterone/cortisol pathways)
- GIRLS – most present with ambiguous genitalia as neonate, clitoromegaly (and can be so extreme that labia fuse and appears male. But can be partial CAH and present later (eg age 3) – further clitoral growth, and more ossification in bones, increased bone age – will end up being very short as androgens drive fusion of growth plates.
- BOYS – present around 4-6 weeks usually, with salt loss crisis – low Na, high K, acidosis, low glucose, shock. Needs emergency aldosterone or will die. Or can be partial CAH, and just get precocious puberty.
Advantages of breastfeeding
- mutual gaze, emotional input from mother, oxytocin surge
- sucking promotes uterine contractions, so avoiding some PPHs
- less insulin resistance, high BP, & obesity
- breast milk is free and clean!
- colostrum has endorphins: good for birth-associated stress
- IgA, macrophages, lymphocytes (with interferon), and lysozyme protect from infection, acids in breast milk promote growth of friendly lactobacilli in the baby’s bowel (less gastroenteritis)
- lower infant mortality, otitis media, pneumonia, & diarrhoea
- breast milk contains less Na+, K+, and Cl– than other milk, so aiding homeostasis - less risk dehydration and hyponatraemia
- future disease protection eg T1DM, RA, IBD, allergies etc
- natural contraceptive and weight loss for mother
- protection in premenopausal years against maternal breast cancer
Mastitis
Common reason to give up breastfeeding but easily treatable
- tender red hot area of breast ± fever
- treat with flucloxacillin 7-10days, ibuprofen, continue breastfeeding/expressing, check technique
Ages for feeding
- recommend exclusive breastfeeding until 6mo
- if bottle feeding, essential to sterilise
- start weaning around 6mo when showing signs of ready, starting with soft food then finger food, continuing with milk also until toddler!
Causes of undernutrition (growth faltering)
Reduced intake of food
- social/parental factors (insufficient diet, formula dilution / excessive juice, errors in food preparation, child/parent interaction problems, maternal depression/mental health problems, child abuse, neglect or emotional deprivation)
- feeding difficulties (breastfeeding difficulties, oromotor dysfunction – cerebral palsy, cleft palate, developmental delay, behavioural)
- medical problems eg recurrent vomiting (GI problems – reflux, intestinal obstruction, malrotation), neurological problems)
Malabsorption
- cystic fibrosis
- coeliac disease
- hepatobiliary disease
- food protein allergy/intolerance
- infection
- short gut syndrome
Increased metabolic demand
- chronic disease
- congenital infection – HIV, TORCHES
- syndromes
- malignancy
- metabolic disorders
- immunodeficiency/autoinflammatory
- endocrine – diabetes mellitus, diabetes insipidus, hyperthyroid
- complications of prematurity and IUGR
Childhood obesity
= BMI >98th centile (91st is overweight)
- due to diet, exercise, sleep deprivation, SES, genetics, medication, + hypothyroid, Cushing’s, GH deficiency, Prader-Willi syndrome
Medium and long term consequences… (insulin resistance, T2DM, sleep apnoea, orthopaedic problems, NAFLD, psychosocial, PCOS, Vit D deficiency) + (atherosclerosis, CVS disease, cancers, subfertility, hypertension)
Bronchiolitis
- <2 years, but most seen in <6 months
- bilateral wheeze and creps (is always the diagnosis if <1) – URTI, then cough, then development of respiratory distress over 3-4 day
- viral, due to RSV usually (diagnose with naso-pharyngeal aspirate)
- winter peaks
- self-limiting illness, supportive treatment – rare mortality, so look for signs of exhaustion (but salbutamol doesn’t work)
- breathing support (nothing -> oxygen (nasal) -> CPAP ->I + V)
- feeding support (little and often -> NG tube -> IV fluids)
- higher risk if bronchopulmonary dysplasia (preterm, BPD), congenital heart disease, or severe combined immunodeficiency (SCID) so given monthly passive antibody vaccination over winter season
Community acquired pneumonia
- creps/decreased air entry in just one area – lobar pneumonia
- birth-3 weeks
Bacterial – E. coli, GBS, monocytogenes - 3 weeks-3 months
Bacterial – Chlamydia trachomatis (with sticky eye), Pneumococcus
Viral – adeno, influenza, parainfluenza, human metapneumovirus, RSV - 4 months-5 years
Bacterial – Pneumococcus, Chlamydia pneumoniae, Mycoplasma pneumoniae, H influenza
Viral – adeno, influenza, parainfluenza, rhinovirus, RSV - 5 years-adolescence
Bacterial – Pneumococcus, C pneumoniae, M pneumoniae, H influenza
Stridor
- high-pitched inspiratory noise, from partial obstruction at the larynx or large airways
Causes
- congenital: laryngomalacia, web/stenosis, vascular rings
- inflammation: epiglottitis, croup, anaphylaxis, laryngitis
- tumours: haemangiomas or papillomas (usually disappear without treatment)
- trauma: thermal/chemical, or from intubation
- foreign body
Croup
- barking cough ± respiratory distress due to upper airway obstruction
- often worse at night (low cortisol)
- usually viral, eg parainfluenza
- give all children a single dose of dexamethasone, or inhaled adrenaline if emergency
- advise usually self-limiting and resolves within 48hrs (well-seeming, just lots of coughing)
Epiglottitis
- rapidly progressive inflammation of the epiglottis
- emergency! as respiratory arrest can occur abruptly due to airway obstruction
- 2–4 years old, present with a short history of fever, irritability, sore throat, pooling and drooling of saliva, and a muffled voice or cry, NO cough
- prefer to lean forward
- rare in children in the UK (Haemophilus influenzae type b vaccination)
- needs rapid intubation
DO NOT EXAMINE THROAT
Laryngomalacia
- congenital anomaly of the larynx, noticeable from birth (noisy breathing)
- excessive collapse and indrawing of the supraglottic airways during inspiration leading to stridor, breathing and feeding difficulties
- noise varies with alertness and with positioning
- usually not a problem, investigate if severe obstruction or failure to gain weight
Asthma vs viral associated wheeze
Viral associated wheeze
- common in first 2-3 years
- initially indistinguishable from early onset asthma
- majority lose symptoms by school age
- no evidence for need to use bronchodilators or steroids
Atopic asthma
- associated with eczema and rhinitis
- asymptomatic intervals, but wheeze on most days and night waking
Asthma drug therapy
- occasional B-agonists with spacer. If needed >3≈ per week, add step 2 (also if >5 yrs and many exacerbations, or asthma wakes from sleep >once/wk)
- inhaled steroid, eg beclometasone
- Review diagnosis; check inhaler use/concordance; eliminate triggers; monitor height
- if <5yrs: Add montelukast
- if >5yrs: LABA or montelukast - Refer to specialist (±CXR), increase steroid dose and consider theophylline
Acute asthma treatment
Severe asthma
- unable to complete sentences
- using accessory muscles of respiration
- O2 sats on air <92%
- peak expiratory flow <50% predicted
Life threatening asthma
- able to only say few words or unable to speak
- signs of exhaustion
- cyanosis
- silent chest
- PEF <33% predicted
A-E and giving oxygen throughout!
1st – 3,2,1 burst step – if this is working at 1 hour, maintain with hourly salbutamol (if needed) until they can have no treatment for 4 hours before discharge
- 3x salbutamol
- 2x Atrovent (ipratropium)
- 1x prednisolone
If needing more before an hour, IV bolus step
- MgSO4
- Salbutamol – look out for toxicity – vomiting and tremors
- Aminophylline
IV infusion step
- Aminophylline
- Salbutamol
Panic step
- Intubate and ventilate
Cystic fibrosis
- multiple episodes of bacterial infection, + pale bulky stools, + poor weight gain (= classical, but now really unusual presentation – newborn screening!)
- commonest autosomal recessive condition from CFTR mutations (usually dF508), affecting transmembrane chloride channels in lung, gut, sweat glands
- diagnose with genetics (+ sweat test)
- treatment - physiotherapy, antibiotics, mucolytics, nutritional support, small molecule therapy
Bacterial tracheitis
- barking cough
- bacterial cause
- toxic, NO drooling (unlike epiglottitis)
- croupy cough
- long onset history
- 80% need intubation
- treat with ceftriaxone and flucloxacillin
Causes of wheeze
If <1 year = bronchiolitis – salbutamol and other asthma meds don’t work!
1-5 years acute = viral induced wheeze (common)
1-5 years multiple episodes = multi-trigger wheeze
Over 5 years = asthma
Can also be caused by:
- respiratory infection (acute – bronchiolitis (common complication -> bacterial infection) or chronic – post-bronchiolitic wheezing, CF)
- aspiration pneumonitis (gastroesophageal reflux, abnormal airways (TOF))
Causes of cardiovascular disease by age
First few hours
- pulmonary/aortic critical stenosis
- hypoplastic heart syndrome
First few days
- transposition, tetralogy, large PDA in prematures
- co-arctation of the aorta
First few weeks
- aortic stenosis
- co-arctation of the aorta
First few months
- any left to right shunt as pulmonary resistance falls, eg VSD
(but most serious problems should present antenatally at 20 week scan!)
Cardiology presentations at birth
Murmur
- normal in most, don’t refer if Soft, Systolic, aSymptomatic, left Sternal edge (likely due to physiological tricuspid regurgitation or pulmonary artery flow), should disappear by day 2
Blue baby
Collapse
Left to right shunt
- breathless and pink from 2-3 weeks (signs of heart failure - breathless, sweaty, hepatomegaly, cold peripheries, failure to thrive)
- atrial septal defect (may present with chest infection from wet lungs)
- ventricular septal defect (most common ‘hole in the heart’, usually presents with asymptomatic murmur at 8 weeks, most close spontaneously)
- persistent arterial duct (allowed until gestational age reached, machinery murmur)
Right to left shunt
- present blue baby, cyanosed with sats <94% in first few days
- tetralogy of Fallot’s - subpulmonary stenosis, VSD, subaortic area overriding aorta, right ventricle hypertrophy (loud murmur, clubbed and cyanosed by 8 weeks, surgical repair at 6 months)
- transposition of the great arteries (collapse at days 2-5, severe cyanosis with death if duct closes this way - give prostaglandins until surgery)
Mixed shunt
- presents breathless and blue
- AVSD (usually due to Down’s syndrome, so automatic screening both ways), maybe + complex lesions. Give early surgery 3-4 months
Well + obstruction
- aortic stenosis (asymptomatic, carotid thrill and ejection systolic murmur louder on expiration, treat only when severe narrowing with balloon dilatation and then replace aortic valve as adult)
- pulmonary stenosis (asymptomatic, as above, louder on inspiration)
Sick + obstruction
- coarctation of the aorta (presents at 2 days as duct closes, no femoral pulses and severe acidosis, resuscitate with prostaglandins and ICU support, surgery ASAP)
- hypoplastic left heart syndrome (LV too small to maintain life, need multiple operations through life)
Signs of the seriously ill child
GRUNTING
Grunting, weak or continuous high-pitched cry, tachypnoea
Rib recession, retraction of sternomastoid, nasal flaring, wheeze, stridor
Unequal or unresponsive pupils, focal CNS signs, fits, marked hypotonia
Not using limbs/lying still, odd or rigid posture, decorticate (flexed arms, extended legs), de-cerebrate (arms + legs extended)
T° >38°c if <6 months or >39° especially if cold or shutdown peripheries
I have a bad feeling about this baby!
Neck rigidity, non-blanching rash, meningism, bulging fontanelle, etc
Green bile in vomit (≈GI obstruction, eg atresia, volvulus, intussusception).
