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Paediatrics > Child with chronic condition > Flashcards

Child with chronic condition Flashcards

1
Q

What is chronic fatigue syndrome?

A
  • CFS/ ME affects around 20,000 young people in the UK
  • Unexplained fatigue >3months
  • Significant impairment of functioning not relieved by rest
  • Post exertional malaise
  • No other cause found after investigation
  • Associated cognitive difficulties, chronic pain, non refreshing sleep
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2
Q

What is avoidant/ restrictive food intake disorder (ARFID)?

A
  • Most common type of eating disorder - previously known as eating disorder not otherwise specified
  • Can be a mix of signs and symptoms associated with anorexia and bulimia
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3
Q

Implications of a chronic illness/ diagnosis

A
  • Time off school and difficulty completing work
  • Feeling different to friends
  • Needing to plan meals and medications
  • Increased dependence on parents when independence is normally developing
  • Impact on employment
  • Future fertility
  • Life expectancy
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4
Q

First sign of puberty in girls?

A
  • First sign of puberty in girls is breast development (Tanner stage 2)
  • Menarche follows within 2 yrs
  • Early growth spurt
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5
Q

First sign of puberty in boys

A
  • First sign of puberty in boys is testicular enlargement (Tanner stage 2)
  • Later growth spurt
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6
Q

What is Fraser / Gilick competence?

A
  • A young person under 16 can consent to treatment provided he or she is competent to understand the nature, purpose and possible consequences of the treatment proposed

Competent if:

  • Understands the doctor’s advice
  • Doctor cannot persuade the young person to inform his or her parents
  • Young person is very likely to begin or continue having sexual intercourse with or without contraception
  • The young persons physical or mental health or both are likely to deteriorate if he or she does not receive contraceptive treatment
  • The young persons best interest require the doctor to give contraceptive advice or treatment or both without parental consent
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7
Q

HEEADSSS framework

A

Framework to ask children about personal life

  • Home
  • Education
  • Eating
  • Activities
  • Drugs
  • Sexuality
  • Suicide
  • Safety
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8
Q

Why might a young person miss their medications?

A
  • Poorly developed abstract thinking and planning
  • They forget
  • Difficulty in managing future self
  • Feels bulletproof and long term implications are not a priority right now
  • Rejection of medical professionals as part of normal peer identification and separation from parents
  • Side effects unacceptable e.g. weight gain with insulin or feeling spaced out with anticonvulsants
  • Not a rebellion against their condition
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9
Q

When does palliative care begin?

A

At time of diagnosis

*Palliative care does not mean end of life care

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10
Q

Palliative car: symptom control

A
  • Pain: one of the most common symptoms to manage. Treatment tailored to cause of pain e.g. bone vs nerve pain. In children with communication difficulties always consider pain in hips (time in wheelchair), teeth (decay) and abdomen
  • Nausea and vomiting: review medication to see if it’s the cause of the symptoms, consider whether the cause is central when prescribing anti-emetics, jejunal feeding can help
  • Seizures: anticonvulsants, check medications are not interfering with the metabolism of others
  • Agitation: sedatives, address underlying cause/ pain
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11
Q

Psychological and spiritual aspects of palliative care

A

Available from:

  • Specialist psychological support
  • Community nursing teams
  • Specialist nurses
  • GP
  • Hospice teams: often build a relationship with the child and their parents

Spiritual support

  • Faith leaders
  • Often people do not describe themselves as religious but have a sense of spirituality
  • Can be difficult in times of crisis and can challenge beliefs
  • Professionals working in palliative care or closely with families can help support during this time
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12
Q

What is the doctrine of double effect?

A

Risk of hastening death is accepted if the intention of using the drugs is solely to control symptoms when death is inevitable

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13
Q

Care of a child after death

A
  • Most hospices have refrigerated bed rooms - families often report a very positive experience after being allowed time to spend time with their loved one after they have passed
  • Allows families to grieve at own pace
  • Practical support to arrange funerals
  • Bereavement support likely needed for months and years
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14
Q

Outline the needs of a child following diagnosis of DM

A

Depends on the age of the child

  • Child aged 4 wont have much awareness of what’s going on but will be scared, information for parents
  • Aged 9: more aware, may be able to check blood glucose, still need support from school staff to check glucose levels and give injections etc
  • Aged 13: moving around in school, moving classrooms etc, will be doing almost all diabetes related tasks, school staff need to be aware of emergencies
  • Aged 18: from children’s clinic to adult clinic, transition should be gradual
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15
Q

Signs that patients are struggling with DM control

A
  • Testing: several tests in a day but then none for a number of days
  • Insulin: missing doses, no carb counting or correcting high levels
  • Hypoglycaemia: seems sporadic, can be severe with patient needing help to manage, not correcting with recommended dextrose tablets
  • Some signs of early complications
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16
Q

Impact of living with a chronic condition

A
  • Distress at diagnosis - major chance added difficulty and stress
  • Chronic burden - never a break
  • Multiple tasks a day related to condition
  • Impairs spontaneity
  • Dealing with distress of parents as well as self
17
Q

What is motivational interviewing?

A
  • Seeks to find strengths in each patient and build on their aims for positive change
  • Avoid critical language/ challenge/ directing
  • Ask open questions
  • Affirm and praise positivity
  • Normalise negative thoughts
  • Patient decides what is important to them
  • Doctor reflects back what the patient has been saying
  • If the patient cannot manage chance at the moment then that is their choice
18
Q

Epidemiology of diabetes in children

A
  • 97% of cases of diabetes diagnosed in children is type one, the annual UK incidence is 24 cases per 100,000 children
  • The incidence of both type one and type two diabetes has been increasing in Europe in recent years
19
Q

Aetiology of diabetes in children

A
  • Type one diabetes is an autoimmune condition in which beta cells of the pancreatic eyelets are destroyed. The major risk factors for Type II diabetes are obesity and a sedentary lifestyle, South Asian and African children are at a higher risk than white children
  • Diabetes may also occur as a consequence of other conditions that affect the pancreas for example cystic fibrosis
20
Q

Clinical feature of diabetes in children

A
  • Higher levels of glucose in the blood increase its osmolarity which is a measure of solute concentration - this leads to the following symptoms
    • Threshold for renal glucose reabsorption is increased which leads to glycosuria
    • High levels of glucose in the urine leads to an osmotic diuresis which causes polyuria i.e. voiding large volumes of urine
    • Polyuria leads to polydipsia and may result in nocturnal bedwetting
    • Inability of cells to use glucose leads to general lethargy and eventually weight loss can occur despite good appetite
21
Q

Diagnosis of diabetes in children

A
  • Blood glucose conc.
    • Random blood glucose of 11.1mmol/L+
    • Fasting blood glucose of >7mmol/L
  • 25% of children are in ketoacidosis on presentation
22
Q

Management of diabetes

A
  • Type 1 is controlled by control of diet and exogenous insulin delivery guided by regular blood glucose testing
  • Type 2 management centres around lifestyle change
  • Education is essential: advice regarding diet and exercise and education on the symptoms and management of hypoglycaemia
  • Medication: type one diabetes mellitus requires multiple daily doses of subcutaneous insulin and different regimes are use depending on the Childs age and lifestyle
  • Careful monitoring of blood glucose is essential when it’s done by finger prick blood testing before meals and maintenance of a diary record
  • Measurement of glycosylated haemoglobin – HbA1c provides a measure of glycaemic control over a longer period of time
    • The target is an HbA1c concentration of less than 7.5%
23
Q

Types of insulin regimens

A

1. Basal bolus regimen: short acting insulin at meal times, long acting at bed time

Most common regimen

2. Twice daily injections: biphasic insulin (mixture of short and intermediate acting insulin)

3. Continuous subcut infusion via pump: continuous background dose of rapid acting insulin + additional boluses with food

24
Q

What are the sick day rules regarding diabetes?

A

A child’s insulin requirement is increased during illness even if they are not eating, this is because stress hormones induce gluconeogenesis

Therefore sick day rules with diabetes advise the insulin injections should be continued and the glucose carefully monitored

25
Q

Why are thryoid disorders a particular concern in children?

A

Effect on growth and development

26
Q

Discuss congenital hypothyroidism

A

A reduced amount of thyroxine or none at all is produced from birth

  • Affects 1 in 3500 live births
    • Most common cause is agenesis or dysgenesis of thyroid gland
    • Other causes are disorder of thyroxine synthesis or function and disorders of the hypothalamus or pituitary
  • Clinical features
    • Most are diagnosed at asymptomatic stage during newborn screening
    • Babies described as god or quiet because they sleep for longer and are less active
    • Poor feeding, constipation, hypotonia, large fontanelle, prolonged jaundice
  • Diagnosis
    • Identified through newborn screening when blood spot cards shows increased TSH.
      • Serum TSH and thyroxine are then measured and raised TSH combined with low thyroxine is diagnostic
    • Blood spot test will not pick up central congenital hypothyroidism because TSH levels will not be raised - high index of suspicion if baby shows symptoms but blood spot test negative
  • Management
    • Lifelong thyroxine, if picked up when asymptomatic prognosis is good
    • Untreated babies develop severe developmental disabilities which are irreversible
27
Q

Discuss acquired hypothyroidism in children

A
  • Can develop at any age
  • Most common cause is hashimotos - autoimmune
    • Antibodies produced against thyroid peroxidase, thyroglobulin and TSH receptors
    • Acquired hypothyroidism is rarely secondary to hypothalamic pituitary problems
  • Prevalence is highest in adolescents girls - affects 1/1000 overall
  • Clinical features
    • Symptoms similar to those in adults but children have slow growth or short stature and delayed puberty and declining school performance
  • Diagnosis
    • Confirmed with TFTs showing high serum TSH - unless cause is central in which case TSH will be low - and low T4
    • Presence of thyroid autoantibodies confirms autoimmune cause
  • Management
    • Oral thyroxine replacement with levothyroxine
    • Hypothyroidism associated with other autoimmune conditions such as DM and coeliac
    • Children with autoimmune conditions need regular screening for hypothyroidism
28
Q

Signs and symptoms of hypothyroidism in children

A

Slow growth, short stature

Delayed puberty

Goitre

Lethargy

Constipation

Cold, dry skin

Facial puffiness

Bradycardia

29
Q

Signs and symptoms of hyperthyroidism in children

A
30
Q

Normal or accelerated growth/ tall stature

Advanced bone age

Goitre

Hyperactivity/ decreased attention span

Loose stools/ diarrhoea

Warm, sweaty skin

Exopthalmos

Tachycardia/ palpitations

A
31
Q

Most common cause of hyperthyroidism in children

A

Graves

  • Affects 1 in 100,000
  • Adolescent girls most affected
  • TSH antibodies stimulate TSH receptor and cause excessive thyroxine production
  • Babies of mothers with graves may have transient neonatal hyperthyroidism because high levels of TSH receptor antibodies can cross the placenta
32
Q

Diagnosis of hyperthyroidism

A
  • TFTs show excess T4 and low TSH
  • Presence of TSH receptor antibodies confirms Graves as cause
33
Q

Management of hyperthyroidism

A

Aim to reach euthyroid levels – often have to totally block gland and then replaced with thyroxine

  • First line is carbimazole which block thyroid hormone production – most are euthyroid within 8-12 weeks
  • B-blocker can be used to control symptoms until carbimazole kicks in
  • Radioactive iodine therapy
    • Considered if medical management doesn’t work
      • Radioactive iodine is absorbed by gland and this causes damage to cells meaning they are no longer able to produce thyroxine
        • Secondary hypothyroidism often develops which then requires treatment with levothyroxine
  • Surgery
    • When other management has failed the gland is removed – esp. In children under 5 in whom radioactive treatment is contra-indicated
34
Q

Prognosis of hyperthyroidism

A
  • Carbimazole is usually stopped after a few years once patient is in remission but many relapse
  • Lifelong monitoring is needed – many develop hypothyroidism in later life either due to treatment or due to autoimmune destruction of gland
35
Q
A

Paediatrics (19 decks)

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