Community paediatrics Flashcards
Feeding volumes
60 mls/kg/day - Day 1
90 mls/kg/day - Day 2
120 mls/kg/day - Day 3
150 mls/kg/day - Day 4 and onwards
Every 2 - 3 hours, extended to 4 hourly or longer then to on demand
Initial weight loss in babies
Normal - 10% for breast fed and 5% for formula fed by day 5
Back at birth weight by day 10
Weaning
Occurs at 6 months
Introduce normal foods
Start with puree
Obesity in children
Overweight - BMI above 85th centile
Obese - BMI above 95th centile
When to suspect endocrine conditions in children
If short and obese
Failure to thrive
If dropped 1 + centile spaces if their birthweight was below the 9th centile
If dropped 2 + centile spaces if their birthweight was between the 9th - 91st centile
If dropped 3 + centile spaces if their birthweight was above the 91st centile
Causes of failure to thrive
Inadequate nutritional intake - neglect or iron deficiency
Difficulty feeding - cleft lip, pyloric stenosis
Malabsorption - cystic fibrosis, CMPA, Coeliacs, IBD
Increased energy requirement - hyperthyroidism, malignancy
Inability to process nutrition - T1DM
Investigations for failure to thrive
- observe feeding
- growth chart - mid parental height centile
- BMI
Presentation dependent:
- urine dipstick - UTI
- Bloods - TTG (coeliacs), FBC
- faecal calprotectin
- sweat test
- abdominal USS - pyloric stenosis
Mid parental height
Mum’s height + dad’s height / 2
Management of breastfeeding difficulty
Support by midwives and health vistiors
Supplement feeds with high nutritional formulas
NGT
Short stature definition
Height more than 2 standard deviations below the average expected
Below 2nd centile
Predicted height
Boys = mother’s height + farther’s + 14 / 2
Girls = mother’s height + farther’s - 14 / 2
Causes for short stature
Inherited
Malnutrition
Chronic disease - IBD, coeliacs, congenital heart disease
Endocrine disease - hypothyroidism
Genetic conditions - down syndrome, achondroplasia
Investigation for constitutional delay in growth and puberty
Taking a xray from hands and wrists to estimate the bone age - +ve result is delayed bone age
Refusal of treatment in children
Under 18s cannot refuse treatment and can be overruled
Decisions about treatment in children
Children under 16 can make decisions about treatment, but only if they are deemed to have Gillick competence
Gillick Competence
Assessed on a decision by decision basis
Consent needs to be given voluntarily
- Weigh up options
- Understand
- Retain information
- Communicate
Frazer Guidelines
Guidelines for providing contraception to patients under 16 years without having parental input
- Intelligent enough to understand the treatment
- Can’t be persuaded to discuss it with their parents
- Likely to have intercourse regardless of treatment
- Their physical or mental health is likely to suffer without treatment
- Treatment is in their best interest
Sexual activity in under 13s
Children < 13 yo cannot give consent for sexual activity
All intercourse in children under 13 years should be escalated as a safeguarding concern
Questions to ask in children with deppresion
Potential triggers (e.g. loss of a family member)
Home environment and Family relationships
Relationship with friends
Sexual relationships
School situations and pressures -Bullying
Drugs and alcohol
History of self harm and suicide
Family history - Parental depression
Parental drug and alcohol use
History of abuse or neglect
Management of mild depression
Managed with watchful waiting and advice about healthy habits
Follow up within 2 weeks is advised.
Management of moderate to severe depression
Referral to CAMHS:
- Full assessment to establish a diagnosis
- 1st line - CBT, non-directive supportive therapy, interpersonal therapy and family therapy
- 2nd line - Fluoxetine 10mg - first line antidepressant) - can increas to a max of 20mg
3rd line- Sertraline and citalopram
How long should antidepressants be taken for
Continue 6 months after remission is achieved
Assessment of generalised anxiety disorder
- GAD-7 - establish the severity of the diagnosis
- Assess for co-morbid mental health problems, such as depression and OCD
- Assess for environmental triggers such as family relationships, friendships, bullies and school pressures
Management of mild anxiety
Watchful waiting and advice about self-help strategies
Management of moderate to severe anxiety
Referral to CAMHS services to initiate:
- Counselling
- Cognitive behavioural therapy
- Medical management - SSRI such as sertraline
How is mild OCD treated
Education and self help resources
Managment of moderate to severe OCD
Referral to CAMHS
Patient and carer education
CBT - behaviour response prevention
SSRI
Autism triad
Impaired social interactions
Inpaired communicatoon
Rigid, repetitive routines
Features of autism
Social interaction:
- lack of eye contact
- delay in smiling ( > 10 weeks)
- avoids physical contact
- unable to read non verbal cues
- difficulty establishing friendships
- doesnt play with others ( > 2 years)
Communication:
- delay
- difficulty with imaginiative behaviour
- repetitive use of words
Behaviour:
- greater interest in objects than people
- hand flapping or rocking
- deep interests
- repetitived behaviours and fixed routines - anxiety
- restricted food choices
Management of autism
MDT
- child psychology
- Speech and language specialists
- dietician
- social worker
- specially trained educator - SENCo
- charities - national autism society
ADHD triad
Inattention
Hyperactivity
Impulsivity
Features of ADHD
Short attention span - inattention Easily distracted Constantly moving or fidgeting Impulsive behaviour Lack of fear Disruptive Often have sleep disturbance
How to diagnose ASD
GARS questionnaire - not diagnostic
School observation
Thorough history taking
How to diagnose ADHD
Conner’s 3 questionnaire
QB test
Thorough history
Managment of ADHD
Medication:
- methylphenidate- stimulant
- atomexatine
- dexamfetamine
- melatonin for sleep if there is a disturbance
Behavioural support
Educational support
Conditions associated with eating disorders
Personality disorders
Anxiety
ADHD
Side effects of methylphenidate
Lack of appetite - measure weight and height
High blood pressure - measure BP
Features of anorexia nervosa
- Excessive weight loss
- Amenorrhoea
- Lanugo hair
- Hypokalaemia
- Hypotension
- Hypothermia
- Changes in mood, anxiety and depression
- Solitude
Features of bulimia
Normal body weight Metabolic alkalosis - due to vomiting Hypokalaemia Erosion of teeth Swollen salivary glands Mouth ulcers GORD Calluses on the knuckles - Russel’s sign
Management of eating disorders
Self help resources
Counselling
CBT
SSRI - CAMHS
Complications of refeeding syndrome
Hypomagnesaemia
Hypokalaemia
Hypophosphataemia
Cardiac arrythmias
Heart failure - fluid overload
Management of refeeding syndrome
Slowly reintroduce food Monitor magnesium, phosphate and pottasium ECG - heart monitoring Fouids Supplements- vitamins like B12
Conditions associated with Tourette’s
OCD and ADHD
Tourettes features
Tics - head jerking, sniffing, grunting, eye rolling, blinking or clearing throat
Premonitory sensations - the more they try to suppress it, the greater the urge
Copropraxia
Urge to make obscene gestures
Coprolalia
Urge to say obscene words
Echolalia
Urge to repeat other people’s words
When do tics often present
Around the age of 5 years old
Managment of tics
- Reduce stress, anxiety and triggers
Severe tics:
- habit reversal training
- exposure response prevention
- antipsychotics
