Community

Question 1

Cerebral palsy
- Definition
- Causes - Antenatal, perinatal, postnatal
- Symptoms (6)
- Types (4)
- Signs (5)
- DD (2)
- Risk factors
- Complications (6)
- Management (6)

Answer 1

Cerebral palsy

• Definition: permanent neurological problems resulting from damage to the brain around time of birth
• Causes
  Antenatal - maternal infections, trauma
  Perinatal - birth asphyxia, premature
  Postnatal - meningitis, severe jaundice, head injury
• Symptoms: variates, failure to meet milestones, inc/dec tone, hand preference when <18 months, problems with coordination/speech/walking, feeding/swallowing problems, learning difficulties
• Types: zero2 finals
• Signs: hemi/diplegic gait due to inc muscle tone/spasticity in legs (leg extended with feet plantar flexion so can’t extend leg in straight line when moving leg infront), umn signs (zero2finals)
• DD: brain injury, tumour causing umn lesion
• Complications: learning disability, epilepsy, kyphoscoliosis, muscle contractures, hearing/visual impairment, GORD
• Management: physio to strengthen/stretch muscles + prevent contractures, SALT, dieticians (peg feeding), OT, paeds for meds - muscle relaxants (baclofen for spasticity), antiepileptics, glycopyrronium bromide for excessive drooling, ortho surgeons to release contractures, social workers

Question 2

Down’s syndrome:
- Definition
- Risk factors (1)
- Symptoms (16)
- DD (2)
- Investigations: antenatal screening, once born
- Management
- Complications

Answer 2

Down’s syndrome:

• Definition: aneuploidy trisomy 21 (47 chromosomes) which disrupts development producing the dysmorphic features and mild to severe cognitive impairment. Affects 1:1000 births in UK
• Risk factors: maternal maturity
• Symptoms: small dysplastic ears, flat nasal bridge, small mouth with relative macroglossia, prominent epicanthic folds (folds of skin covering eyelid), upward sloping palpebral fissures (gaps between lower + upper eyelid), brushfield spots, brachycephaly, single palmar crease, poor growth + development (short neck/stature), brachycephaly
  visual problems: cataracts, infantile glaucoma, strabismus + nyastagmus
  hearing loss: conductive
  ENT: small upper airway spaces inc risk of infection such as glue ear, sleep apnoea (which can cause obesity, htn, cor pulmonale)
  Resp infections: impaired immune function
  MSK: hypotonia in neonatal presenting by problems in feeding / atlanto axial dislocation
  Cardiac: ASD, VSD, PDA, TOF
  GI: oesophageal atresia, trachea-oesophageal fistula, slight increase in hirschprungs
  Endocrine: inc risk hypothyroid
  Haematological: transient myeloproliferative disorder which corrects in 3 months but inc risk AML
• DD: trisomies 13 (patau), 18 (edwards)
• Investigations:
  Antenatal screening: combination test at 11 + 14 weeks, maternal blood (measures cell free foetal DNA) and nuchal translucency (thickness of back of neck) on uss. If T2 then quadruple test offered (beta HCG (high = inc risk), AFP (low = inc risk), serum oestriol (low = inc risk), inhibin A (high = inc risk). If risk >1:150 then chorionic villi sampling (<13 weeks) or amniocentesis (>15 weeks). If identified then G banding analysis confirms
  Once born: bloods (QF PCR then G banding analysis, fbc, blood film), newborn eye assessment, hearing screen, guthrie test (blood spot test on day 5 for hypothyroid), echo, ecg
• Management: personal child health record additional insert for red book to treat associated conditions and promote development. Further genetic counselling if want more children. Recommended surveillance list on teachmepaeds - regular thyroid checks, echos, audiometry, eye checks
  OT, SALT, physio, dietician, paed, GP, cardio, ENT etc
• Complications (most listed above): inc risk Alzheimer’s, life expectancy 60yrs

Question 3

Developmental delay:
- Definition
- Causes (8)
- Causes of global delay
- Symptoms (3)
- Red flags (4)
- Investigations
- Management
- Extra facts

Answer 3

Developmental delay:

• Definition: delay in either gross motor, fine motor, speech + language, social + emotional. Global developmental delay is delay in either 2 or more
• Causes: neurological (congenital spina bifida, antenatal vascular event, hypoxic ischaemic encephalopathy, intraventricular haemorrhage), infection (rubella, CMV, meningitis, encephalitis), neuromusc disorders (spinal muscular atrophy), hypothyroidism, genetic disorders (downs), pervasive developmental disorders (autism), premature, idiopathic
• Causes of global: down’s, fragile x syndrome, fetal alc syndrome
• Symptoms: parent notices not hitting milestones, health visitor, school concerns
• Red flags:
  Social: not smiling by 10 weeks (neglect, autism)
  Gross motor: not sitting unsupported by 12 months, not walking by 18 (cerebral pal, ataxia, spina bif, visual impairment)
  Fine: showing hand preference before 12 months (cerebral pal, musc dystrophy, visual impair)
  Speech: not knowing 2-6 words by 18 months (hearing impair, learning disab, neglect, autism)
• Investigations: bloods: fbc (iron/b12/folate def), u+es (renal failure/hyponat causes poor growth), creatinine kinase (duchenne), TFTs (congen hypo), lfts (metabolic disorders), vit d (can cause motor delay), hearing test (maybe just hearing impairment), karyotyping, MRI, EEG
• Management: refer to community paed who will do detailed developmental assessment such as Griffiths scales of child development. Then SALT, OT, orthoptists
• Extra facts - remember to keep it simple - if there’s delay maybe something wrong with senses - how is hearing, vision etc?

Question 4

Attention Deficient Hyperactivity Disorder:
- Definition
- Pathophysiology
- Causes (2)
- Symptoms (5) + criteria
- DD (3)
- Investigations
- Management
- Complications
- Extra facts

Answer 4

Attention Deficient Hyperactivity Disorder:

• Definition: neurobehavioral disorder characterised hyperactivity, inattention, impulsivity IN ALL SETTINGS. More common in boys
• Pathophysiology: structural and functional changes in brains and changes in levels of neurotransmitters such as dopamine
• Causes: genetic, environmental
• Symptoms: short attention span, moves onto another activity quickly, looses interest quickly, fidgeting, impulse behaviour (no sense of danger), disruptive
  ICD10 criteria: early onset (before 6 years) of hyperactivity, inattention, impulsivity. Impaired attention and overactivity needed for diagnosis, recklessness or DSMV criteria which includes 3 subtypes of ADHD and diagnosis made when at least 6 criteria are met before age 12 for at least 6 months in more than 1 setting (more on teachmepaeds)
• DD: general developmental delay, side effects of meds like antihistamines, ill disciplined, overtired, emotional abuse / neglect
• Investigations: Conner’s questionaire, Qb test, school observation, general physical exam including HR/BP in prep for starting meds, height + weight on growth chart
• Management: no meds if preschool. Food diary if trigger with certain foods. If school age and moderate then behavioural strategies such as CBT or parent/teacher education sessions. If severe then meds to improve attention/concentration: methyphenidate (stimulant med), atomoxetine (can damage liver), lisdexamfetamine. Do not use antipsychotics.
• Complications: SE of meds: inc bp, palpits, disturbs sleep, impairs growth, suppresses appetite. Increased substance use, more criminal convictions, unemployment
• Extra facts:
  Assoc with Autism, learning difficulties, tics, anxiety

Question 5

Autism spectrum disorder:
- Definition
- Pathophysiology
- Symptoms (5)
- Diagnosis
- Signs (3)
- DD (4)
- Investigations
- Management
- Comorbidities

Answer 5

Autism spectrum disorder:

• Definition: neurodevelopmental disorder where there is an impairment of social interaction, communication and behaviour
• Pathophysiology: genetics, environmental factors cause structural changes in brain
• Symptoms: poor eye contact/ failure to use facial expression/body language/ play alone (abnormal social interaction), delay in language/ abnormal pitch/rate speech / echolalia / failure to continue conversations (impaired social communication), (restrictive/ repetitive activities) preoccupied and obsessions with unusual subjects / need for routine, motor mannerisms, sensory issues (only eat certain foods or can’t have hair cut or don’t like loud noises)
  The spectrum ranges where some function in everyday life with milder cases known as Aspergers syndrome
• Diagnosis: at least 1 of these before age 3: lack of social attachments, abnormal receptive or expressive speech development, abnormal symbolic play
• Signs: skin stigmata of neurofibromatosis or tuberous sclerosis using woods light, self harm, congen anomalies and dysmorphic features such as macro/microcephaly
• DD: CNS developemental abnormalities, fragile x, tuberous sclerosis, rett syndrome
• Investigations: clinical diagnosis (symptoms present in different environments)
• Management: parent support groups, community based services, behavioural management strategies (timetables for routine), education, health and care plan for school, CAMHS child psychology and child and adolescent psychiatry, SALT, dietician, meds for comorbidities
• Comorbidities: ADHD, sleep disorders, learning disabilities, depression, anxiety

Question 6

Eating Disorder:
- Definition
- Anorexia nervosa
- Bulimia nervosa
- Binge eating
- Management
- Complications

Answer 6

Eating Disorder:

• Definition: stems from an unhealthy and distorted obsession with body image and food. There is strong correlation with personality disorders, OCD, anxiety
• Anorexia nervosa: obsessive restricting of calorie intake with intention of loosing weight. Excessive weight loss (diet pills, laxatives, excessive exercise), amenorrhoea, lanugo hair, hypokal, hypotension, hypothermia, changes in mood, BMI <17.5. Bloods (low U+Es, leukopenia, low sex hormones, hyperchol). Can cause arrhythmia, cardiac atrophy, sudden cardiac death
• Bulimia Nervosa: binge eating followed by inducing vomiting / taking laxatives. Normal body weight, alkalosis due to vomiting, hypokal, erosion teeth, swollen salivary glands, mouth ulcers, GORD, Russell’s sign (calluses on knuckles where have been scraped across the teeth)
• Binge Eating Disorder: episodes of excessive eating so usually overweight. Planned binge, eating v quickly, may not even be hungry, becoming uncomfortably full
• Management: self help, counselling, cbt, admission if severe cases, SSRI meds
• Complications: refeeding syndrome where severe nutritional deficit for extended period (bmi <20 + bad eating for 5 days) where metabolism in cells slows down so as cells start to suddenly eat again cells start to process glucose, protein, fats and use up mg (hypomagnesaemia), k (hypokal), phosphorus (hypophosphataemia) which can lead to cardiac arrythmias, HF, fluid overload
  Manage: slowly reintroduce, mg/k/pi/glucose monitor, fluid balance, ecg monitor, supplements esp b Vitamins + thiamine

Question 7

Non accidental injury:
- Definition
- Consequences
- Types injuries
- Risk factors
- Types abuse (4)
- DD (2)
- Investigations
- Management (2)

Answer 7

Non accidental injury:

• Definition: NAI includes injuries that result from deliberate actions against a child or failure to prevent injury. Most common in 1-2yrs.
• Consequences: death, mental/physical/cognitive disability, scars, PTSD, behviour
• Types:
  Head injuries: EDH, skull fractures, SDH, retinal haemorrhage esp if <3 yrs
  Skeletal fractures: rib, clavicle, scapular, vertebral, fingers, multiple of different ages, metaphyseal corner fractures
  Thermal injuries: burns, scalds, acids (soles feet/buttocks/back)
  Soft tissues: bites, lacerations (symmetrical), bruises (esp hands/object shapes on non bony parts (red flag if child can’t mobilise)), intraoral
  Visceral injuries: thorax, abdomen, kidneys, liver, spleen
  Ingestions: bleach, methadone, drugs
• Risk factors: excessive crying, unintended preg, development problems, <4. For adults: mental illness, drug/alc misuse, financial difficulties, own abuse
• Types abuse:
  Physical: suspect if history of injury not compatible with injury, developmental stage not compatible with injury, little explanaion from child, delay in presenting, inconsistent history, recurrent
  Emotional: poor sleep, development delay, eating disorders, difficult behaviour
  Sexual: STI, ano-genital injury, unexplained bleeding
  Neglect: unimmunised, not complying to meds, not attending appointments/school, growth faltering, hygiene poor, freq accidents/a+e
• DD: coagulopathy, osteogenesis imperfecta
• Investigations: bloods (fbc, crp, U+es, lfts, clotting), toxicology screen, full skeletal survey, medical photography, metabolic tests, ophthalmology review
• Management: admit to paed ward whilst social worker makes plan (document everything, don’t make promises, don’t ask leading questions) child protection review