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
