Community Paediatrics Flashcards
What is a skeletal survey?
Series of x-rays to include whole skeleton or at least axial skeleton
What is a key sign of a shaken baby?
Retinal haemorrhages
Therefore need assessment from opthalmology
Bleed in brain due to tearing of bridging vessels, and back of the eyes
Why must x-rays be repeated following suspected abuse?
Look for bone healing e.g. periosteal reaction
Do not assume initial imaging is normal, might not often be able to see initial fracture
What are the clinical features of autism?
Social communication impairments and repetitive behaviours present during early children 2-3
Abnormality of social interaction, communication, stereotyped behaviours
Impaired social communication and interaction
Play alone, uninterested in other children
Poor eye contact
Failure to use facial expression or body language
Failure to pick up emption
Restrictive or repetitive behaviours, interests, activities Preoccupations with unusual subject Need for routine Licking objects Motor mannerisms - hand flapping
Sensory issues
Severely restricted diet
Teeth brushing or hair cut hard
Intolerance to loud noises
High pain threshold - self harm
What general examination is recommended for autism?
Skin stigmata of neurofibromatosis or tuberous sclerosis
Signs of injury, self harm, maltreatment
Congenital anomalies, dysmorphic features
What are the differentials for autism?
Learning difficulties Attachment disorders Rett's syndrome - regression of skills Schizophrenia Specific language disorders
What is the management of autism?
Behavioural management strategies
Education, Health and Care Plan for higher needs funding
Treatment of co-morbidities
SSRIs, antipsychotics, methylphenidate for ADHD
Parental education
What are the clinical features of ADHD?
Symptoms must be early onset - before 6 years old
Hyperactivity - fidgets, talks excessively, on the go
Inattention - early distracted, forgetful, not concentrated
Impulsivity - difficulty waiting turn, blurts out answers
Present before age of 12 for at least 6 months
What are some differentials for ADHD?
Auditory processing disorder
Opposition defiant disorder or conduct disorder
What are some investigations?
Conner’s questionnaire
Qb test
What is the management of ADHD?
Preschool - no meds
Mild-mod - behavioural strategies and CBT first line
Severe - medication
- methylphenidate - stimulant
- lisdexamfetamine
- atomoxetine if associated tic or anxiety disorder
- Guanfacine - non stimulant, if not suited or tolerated
Side effects include raised BP, palpitations, disturbed sleep
Impaired growth and appetite, aggression
What is cerebral palsy?
Disorder of movement and posture due to non-progressive lesion in motor pathways of the brain
What are causes of cerebral palsy?
Antenatal - infections, trauma
Perinatal - birth asphyxia, pre-term birth
Postnatal - meningitis, severe neonatal jaundice, head injury
What are the types of cerebral palsy?
Spastic - hypertonia, reduced function due to UMN damage
Dyskinetic - (jaundice)
Problems controlling muscle tone, hypertonia, hypotonia
Damage to basal ganglia
Ataxia - problems with coordinated movement
Damage to cerebellum
Mixed
What are the types of spastic cerebral palsy?
Monoplegia - one limb
Hemiplegia - one side
Diplegia - four limbs, mostly legs
Quadriplegia - four limbs affected more severely, seizures, speech disturbance, other impairments
What is the presentation of cerebral palsy?
Becomes more evident during development Failure to meet milestones Increased/decreased tone Hand preference below 18 months Problems with coordination Speech problems Walking problems Issues with feeding/swallowing Learning difficulties
What does gait analysis indicate in cerebral palsy?
Hemiplegic - UMN Broad based/ataxic - cerebellar High stoppage - foot drop/LMN Waddling gait - pelvic muscle weakness due to myopathy Antalgic gait - localised pain
What are UMN signs?
Muscle bulk preserved
Hypertonia
Power slightly reduced
Brisk reflexes
What are the LMN signs?
Reduced muscle bulk Fasciculations Hypotonia Power dramatically reduced Reflexes reduced
What are the lesion signs in cerebral palsy?
Increased muscle tone and spasticity leads to hemiplegic gait
Extended leg
Plantar flexion of foot
Means have to swing extended leg round
UMN signs
Athetoid movements - indicate extrapyramidal basal ganglia involvement - constant writhing movements, spastic hands etc
What are the complications and associated conditions with cerebral palsy?
Learning disability Epilepsy Kyphoscoliosis Muscle contractures Hearing and visual impairment Gastro-oesophageal reflux
What is the management of cerebral palsy?
Physiotherapy
Occupational therapy
Speech and language
NG/PEG fitted, dieticians
Orthopaedic surgeons - tendon release, lengthen
Paediatricians for -
muscle relaxants, anti-epileptics for seizures, glyopyrronium bromide for excessive drooling
Social workers, support
What is global developmental delay?
Delay in all domains
Down's Fragile X Fetal alcohol syndrome Rett syndrome Metabolic disorders
What is gross motor delay?
In the gross motor domain
Cerebral palsy Ataxia Myopathy Spina bifida Visual impairment
What is fine motor delay?
Specific to fine motor domain Dyspraxia Cerebral palsy Muscular dystrophy Visual impairment Congenital ataxia (rare)
What can occur in language delay?
Specific social circumstances e.g. multiple languages, family members do all the talking Hearing impairment Learning disability Neglect Autism Cerebral palsy
What may a personal and social delay indicate?
Emotion/social neglect
Parenting issues
Autism
What perinatal problems may indicate a neurodevelopment problem?
Birth asphyxia, encephalopathy
Leukomalacia, haemorrhage
Dysmorphic features
Abnormal behaviour e.g. tone, feeding, movement, seizures, inattention
What problems in infancy may indicate a neurodevelopment concern?
Global developmental delay
Delayed or asymmetric motor development
Vision, hearing concerns
Neurocutaneous/dysmorphic features
What. are causes of abnormal motor development?
Central motor deficit e.g. cerebral palsy
Congenital myopathy/primary muscle disease
Spinal cord lesions e.g. spina bifida
Global developmental delay
What are some investigations for developmental delay?
Chromosome karyotype, FISH analysis
TFTs, bloods, blood gases
Congenital infections screen
Cranial ultrasound in newborn, CT, MRI
Skeletal survey, bone age
EEGs for seizures
Nerve conduction studies
Hearing, vision Cognitive assessment Child psychiatry Dietician Nursery/school reports
What can occur in dyskinetic cerebral palsy?
Chorea - irregular sudden brief non repetitive movements
Athetosis - slow writhing movements, e.g. fanning fingers
Dystonia - simultaneous contraction of agonist and antagonist muscles of trunk and proximal muscles gives twisting appearance
What are types of learning difficulties?
General - typically measured by IQ, borderline is 70-80, moderate 50-70
Severe 35-50 tends to have organic cause
Specific -
Dyspraxia - disorder of motor planning or execution with no significant findings on neurological exam - poor handwriting, messy eating, dribbling
Dyslexia - reading skills disproportionate to IQ, 2 years behind
Dyscalculia, dysgraphia - calculation or writing skills
Disorder of executive functions - consequence of brain injury, poor concentration, forgetfulness, volatile mood, overeating, poor social skills
What are the causes of hearing impairment?
Sensorineural Majority genetic Congenital infection Postnatal infection, injury Neurodegenerative Management with amplification or cochlear
Conductive
Otitis media with effusion
Eustachian tube dysfunction - Down’s, cleft palate, Pierre Robin sequence
Wax
How many loss of vision in infancy present?
Loss of red reflex - cataract White reflex - retinoblastoma, cataract, ROP Not smiling by 6 weeks Lack of eye contact Visual inattention Random eye movements Nystagmus Squint Photophobia
What are the types of squints?
Misalignment of visual aex
Concomitant - due to refractive error, glasses - light reflex, reflection should be in same position in both eyes
Paralytic - SOL
What are causes of visual impairment?
Genetic
Cataract, albinism
Retinal dystrophy
Retinoblastoma
Antenatal and perinatal
Infection, ROP, HIE
Cerebral abnormality
Optic nerve hypoplasia
Postnatal
Trauma
Infection
Juvenile idiopathic arthritis
What is trisomy and examples?
Extra chromosome, three copies of particular one
Patau’s - trisomy 13
Edwards - trisomy 18
Down’s - trisomy 21
What are examples of translocation disorders?
Portion of one chromosome swapped with portion of another
Predisposes to conditions such as cancer and infertility e.g. Philadelphia in acute myeloid leukaemia
What is an example of a duplication chromosomal disorder?
Charcot Marie Tooth
Chromosome 17 duplication of short arm
Sensory and motor neuropathy, pes caves high arching foot
What are the dysmorphic features of Down’s?
Hypotonia Brachycephaly - small head, flat back Short neck, short stature Flattened face and nose Prominent epicanthic folds Upward sloping palpable fissures Single palmar crease Sandal gap
What are some of the complications for Down’s syndrome?
Learning disability Recurrent otitis media Deafness Visual problems Hypothyroidism Cardiac defects Atlantoaxial instability Leukaemia Dementia
What screening is available for Down’s?
Combined test:
USS - nuchal translucency, thickness is over 6mm
Blood tests - beta HCG higher, PAPPA lower
Triple test
Beta HCG
Alpha fetoprotein
Serum oestriol
Chorionic villous sampling
Amniocentesis
if high risk
Who is involved in the management of Down’s?
MDT OT, SALT, physio, dietician Paediatrician, GP Cardiologist ENT Audiologist Optician Social services, support
Routine check ups: Thyroid 2 yearly ECHO Audiometry Regular eye checks
What is Klinefelter’s and its features?
Male has additional X - XXY
Taller height, wider hips Gynaecomastia Weaker muscles Small testicles Reduced libido Shyness, infertility Subtle learning difficulties
What is the management of Klinefelter’s?
Testosterone injections
IVF, breast reduction
MDT, OT, physio, SALT
What are the features of Turner’s?
45 XO - single x in females
Short stature Webbed neck High arching palate Downward sloping eyes, ptosis Broad chest, wide nipples Cubitus valgus Underdeveloped ovaries Late/incomplete puberty Most women infertile
What are the associated conditions with Turner’s?
Recurrent otitis media Recurrent urinary tract infections Coarctation of the aorta Hypothyroidism Hypertension Obesity Diabetes Osteoporosis Various specific learning disabilities
What is the management of Turner’s?
GH therapy
Oestrogen and progesterone
Fertility treatment
Management of e.g. HTN hypothyroidism
What is Noonan syndrome and its features?
Autosomal dominant condition Short stature, broad forehead Downward sloping eyes Hypertelorism - wide space between eyes Low set ears, webbed neck Wide spaced nipples
Associated with heart disease, ASD Cryptochordism - infertility Learning disabilities Bleeding disorders Lymphoedema
What is Fragile X and its features?
FMR1 mutation, x linked
Intellectual disability Long narrow face Large ears Large testicles Hypermobile joints ADHD, autism, seizures
What is Prader-Willi syndrome and its features?
Deletion, loss of genes on chromosome 15 from father
Constat insatiable hunger Obesity Hypotonia as an infant Learning disability Hypogonadism Fair, soft skin - bruising Mental health problems Dysmorphic features, narrow forehead, downturned mouth
What is the management of Prader Willi?
GH aimed at improving muscle development and body composition
Weight control
MDT input
What are some features of Angelman syndrome?
Unusual fascination with water Happy demeanour Widely spaced teeth Inappropriate laughter ADHD, epilepsy Speech delay Fair skin, light hair, blue eyes
What are some of the features of William syndrome?
Broad forehead Starburst eyes - star like pattern on iris Flattened nasal bridge Trusting personality Wide mouth, big smile
Associated with supravalvular aortic stenosis
ADHD, hypercalcaemia
What are the features of anorexia nervosa?
Excessive weight loss Amenorrhoea Lanugo hair Hypokalaemia Hypotension Hypothermia
Cardiac complications - arrhythmia, cardiac atrophy
What are the features of bulimia nervosa?
Body weight fluctuates, normal body weight
Binging, purging
Alkalosis due to vomiting Hypokalaemia Erosion of teeth Swollen salivary glands Mouth ulcers, GORD Russell's sign - calluses on knuckles
What is referring syndrome?
Starved cells start to process glucose protein and fats
Leads to hypomanesaemia, hypokalaemia and hypophosphataemia
What is the management of referring syndrome?
Slowly reintroducing
Magnesium, potassium, phosphate, glucose monitoring
Fluid balance monitoring
ECG monitoring
Supplementation with electrolytes and vitamins
What are the categories of abuse seen in children?
Physical - physical harm to child
Emotional - emotional ill-treatment resulting in harm to emotional development
Neglect - persistent failure to meet needs of child
Sexual - forcing or enticing child into sexual activity
Almost all cases have crossover
What things would make you worry a child may be being abused? (V long list)
Inconsistent stories Genital injury Pregnancy or STI <13yo Sexualised behaviour Unresponsive or negative towards child Inappropriate threats Reported change in behaviour Extreme emotional response Female genital mutilation Fractures of different ages Retinal haemorrhage Suspicious burns, scalds, bites, bruising Injuries to non-mobile baby Poor hygiene/dirty clothes Fail to get medical help Fail to thrive
When might you suspect a non accidental injury with a fracture?
Delayed presentation
Delay in attaining milestones
Lack of concordance between proposed and actual mechanism of injury
Multiple injuries
Injuries at sites not commonly exposed to trauma
Children on the at risk register
How can physical abuse manifest?
Fractures - tend to occur less than 18 months
Head injury - shaking, leads to small vessel rupture and subdural haemorrhage
Burns and scalds - symmetrical, bilateral, glove and stocking areas or buttocks, shape of burn
Abdominal injury
Bruises in non mobile child usually uncommon, back, face and buttocks
What are findings in a shaken baby?
Subconjunctival haemorrhage Apnoea Poor feeding Convulsions Reduced consciousness Signs of raised ICP No signs of bruising Retinal haemorrhages
What are important investigations for physical abuse?
Bruising - coag screen, FBC check for bleeding disorder, check birth markers, infection markers
Fractures - full skeletal survey, CT scan, bone biochemistry
Ophthalmological exam
What is the presentation of neglect?
Medical:
Unimmunied, DNA, poor compliance with treatment
Failure to seek advice
Nutritional
Faltering growth or obesity
Emotional abuse
Poor school attendance
Physical
Inadequate hygiene, severe or persistent infection, inappropriate clothing
Failure to supervise
Frequent A&E, preventable injuries, ingestion of harmful substances
What are the symptoms of emotional abuse?
Developmental delay
Poor sleep, persistent crying
Irritable, feeding difficulties
Difficult violent behaviour, academic failure
Delayed social/language skills
Depression, self-harm, substance abuse, criminal activity, eating disorders, relationship difficulties
What can be the presentation of sexual abuse?
Allegation - disclose abuse Pregnancy, STIs Ano-genital injury Unexplained vaginal or rectal bleeding Recurrent vaginal discharge Soiling, bowel problems, enuresis Behavioural difficulties
What is sexual abuse?
Physical contact, including penetrative or non-penetrative acts, exposure to sexually explicit material, child sexual exploitation
How do you respond to disclosure of abuse?
Try not to look shocked Let the child know you believe them Tell them they are not in trouble Listen to what they have to say, don’t make an excuse to leave Don’t ask leading questions – this may affect the case if it goes to court Don’t make promises you cant keep Be honest at all times Inform your senior
What is achondroplasia?
Cause of disproportionate short stature, type of skeletal dysplasia
Autosomal dominant
What are the features of achondroplasia?
Avg height of 4 feet
Limbs most affected, proximal limbs more than forearm and lower leg
Normal trunk length
Short digits
Bow legs - genu varum
Disproportionate skull - different areas grow by different methods
Foramen magnum stenosis
Endochondrial ossification affected leads to flattened mid-face and nasal bridge
What are the associations with achondroplasia?
Recurrent otitis media due to cranial abnormalities
Kyphoscoliosis
Spinal stenosis
Obstructive sleep apnoea
Obesity
Foramen magnum stenosis - cervical compression, hydrocephalus
What are the 2 main types of deliberate self-harm?
Self-poisoning
Self-injury
Name 3 risk factors for repeated self-harm
Previous self harm
Psychiatric Hx
Unemployment, low SE Hx trauma or abuse Forensic Hx or violence Single, divorced, separated Family Hx - 4x risk
List motives for acts of deliberate self-harm
Wish to die
Cry for help
Communication
Unbearable symptoms
What are the stages involved in management of self harm?
1 Acute management - suture wound, antidotes
2 Assess risk - consider MHA section 2
3 Treat psychiatric issue
4 Resolve social issues
5 Future planning
What are the gross motor milestones at 3 months?
Little or not head lag on being pulled to sit
Good head control
When can a baby sit without support?
7-8 months
What are the red flags for gross motor development?
Cannot sit without support at 12 months
Cannot walk unsupported at 18 months
When should a baby crawl by?
9 months
When should a baby being walking unsupported?
Cruises at 12 months
13-15 months
When can a child run?
2 years
What can a child do at 3 years?
Ride a tricycle
Walk up stairs without holding on to a rail
What can a child do at 4 years?
Hop on one leg
At what age can a child do the pincer grip?
9 months
Good grip at 12 months
When does a child point with finger?
9 months
When does a child use palmar grasp?
6 months
At what age can a child build towers of bricks?
2 - 15 months
3 - 18 months
6 - 2 years
At what age can a child do a circular scribble?
18 months
At what age can a child copy a circle?
3 years
At what age can a child draw a triangle?
Copies square and triangle age 5
What does a hand preference before 12 months indicate?
Abnormal
Cerebral palsy
When will a child turn book pages one at a time?
2 years
When does a baby turn their head towards sound?
3 months
When does a baby start to babble?
Double syllables at 6 months
When does a baby start saying words?
Mama and dada at 9 months
When can a child know and respond to own name?
12 months
When can a child combine two words?
2 years
Can also point to parts of the body
When can a child talk in short sentences?
3 years
When does a child start to smile?
6 weeks
What is a red flag for social behaviour milestones?
Refer at 10 weeks if not smiling
When does a child start to put everything in their mouth?
Becomes shy
At 9 months
How does feeding develop up until 1 year?
6 months - may put hand on bottle when being fed
12-15 months - drinks from cup, uses spoon, develops over 3 month period
When can a child become competent with spoon, or not spill drinks?
2 years
When can a child use their knife and fork?
5 years
At what age can a child be helped getting dressed/undressed?
12-15 months
At what age can a child dress independently except for laces/buttons?
4 years
At what age can a child wave bye bye?
12 months
When will a child play with other children?
By 4 years of age
What is a child born with difficult temperament prone to?
Predominantly negative moods, whinging, crying
Intense emotional reactions
Irregular biological functions - lack of rhythm in sleeping, hunger, toileting
Negative initial response to new situations
Protracted adjustment to new situations
What are reasons a child may not settle at night?
Too much sleep in afternoon Displaced sleep cycle Separation anxiety Overstimulated in evening Kept awake by siblings etc Erratic parental practices Use of bedroom as punishment Dislike of darkness and silence Chronic physical conditions
What can be some causes of antisocial behaviour e.g. stealing, lying, disobedience, picking fights?
Failure to learn when to exercise social restraint
Lack of social skills
Responding to challengers of peers
Chronically angry, resentful
Find own notions of good behaviour overwhelmed by sadness or temptation
What are some causes of underachievement at school?
Visual or hearing problems Dyslexia Generalised learning probs Hyperactivity Anti-education family background, chaotic fam
Recent onset problems e.g. pre-occupation with divorce, bullying etc Fatigue Depression Rebellion Sexual abuse, drugs Prodromal period of illness Degenerative brain condition
What is CSF?
Persisting high levels of subjective fatigue
High levels of exhaustion on minimal physical or mental exertion
Myalgia, migratory arthralgia, headache, difficulty getting off to sleep, poor concentration
Depressive symptoms
Exercise therapy
CBT
What can be asked to assess suicide risk after adolescent overdose?
P - problems longer than a month A - alone at the time T - plan overdose for more than three hours ago HO - feeling hopeless S - were you sad before
What may be some features indicating substance misuse?
Intoxication
Unexplained absences from home or school
Mixing with known users
High rates of spending or stealing money
Possession of equipment required for drug use
Medical complications associated with use
