Community Paediatrics Flashcards
Developmental delay
- 7 Neuro causes
- Vascular
- Anatomical
- Accidental
Developmental Delay:
- Neuro causes
1 CVA
2 HIE
3 IVH
4 Spina bifida
5 Epilepsy
6 Hypoglycaemia
7 Brain trauma
Developmental delay
- 3 Infectious causes
Developmental delay
- Infectious cause
- ToRCH
- Toxoplasmosis, Rubella, CMV, Herpes, HSV - Meningitis
- Encephalitis
Developmental delay
- 2 Neuromuscular causes
Muscular developmental delay
- SMA (Spinal muscular atrophy)
- DMD (Duchenne’s muscular dystrophy)
Developmental delay
- A genetic cause
- Endocrine cause
- A pervasive disorder
Developmental delay
- Trisomy 21
- Genetic cause - Hypothyroidism
- Endocrine cause - Autism
- Pervasive disorder
Early Autism Signs
- GM
- Speech
- Social
Autism signs
- GM
1. Spinning objects - Speech
2. 16 mo only one word
3. Echolalia
4. Not babbling - Social
5. No eye contact
6. No smile reflex
7. No touching
8. No mixing with others
9. Inappropriate laughing/giggling
Developmental red flags
- GM
- FM
- Speech
- Social
Developmental red flags
- GM
- 12 months no sitting
- 18 months no walking - FM
- 12 months hand preference - Speech
- 18 mo 2-6 words - Social
- 10 weeks smiling
Global development delay
- 6 Investigations
Global delay - Ix:
- FBC
- Iron/B12/folate - U&E
- CKD/Hyponatraemia - CK
- DMD - TFTs and LFTs
- Vit D
- Hearing test
Developmental delay
- Mx
Developmental delay - Mx
1 Detailed dev. assessment
2. MDT
ADHD
- Definition
ADHD Definition
- Neuro-behavioural disorder
- Hyperactivity, inattention, impulsivity
- Inability to focus
ADHD
- Epidemiology
ADHD
- Prevalence
- 7% - Boys 2x Girls
- 50% co-morbid
- ASD
- LD
- Communication/defiance
- Depression/anxiety
- Tics/Tourettes
ADHD
- Pathophysiology
ADHD
- Brain changes
- Structural
- Functional - Genetic
- 88% twin hereitability
ADHD
- ICD-10 Criteria
ADHD ICD10
- Early onset
- <6yo - Context
- Two or more settings
- Child’s age and IQ - Triad
- Inattention
- Hyperactivity/Impulsivity
ADHD
- Three subtypes
ADHD subtypes
- Predominantly inattentive
- Predominantly hyperactive/impulsive
- Combined
ADHD DDx
- Conduct disorder
- Oppositional-defiant disorder
ADHD DDx
- Conduct disorder
- Marked aggression - Oppositional-defiant disorder
- Anger/vindictiveness
- Argumentative
ADHD
- Ix
ADHD Ix
- Conner’s questionnaire
- School observation
ADHD Mx
- Pre-school
- Mild-moderate
- Severe
ADHD Mx
- Pre-school
1. Parental training
2. Care plan
3. SEN
4. No medication - Mild-moderate
1. Behavioural strategy - Parental education
- Teacher education
2. CBT - Social skills training
3. Medication if necessary - Severe impairment
1. Medication
ADHD
- Five medications
ADHD Medications
- Methylphenidate
- Ritalin/Concerta/Medikinet
- Stimulant - Atomoxetine (Strattera)
- ADR: Liver
- Non-stimulant
- Used in Tic/anxiety (Ritalin abuse) - Lisdexamfetamine (Elvanse)
- Stimulant
- When methylphenidate not effective - Guanfacine (Intuniv)
- Non stimulant - Antipsychotics
- Adults
ADHD Medication
- ADRs
ADHD Meds
- BP and palpitations
- ECG if heart condition - Disturbed sleep
- Impaired growth and appetite
- Aggression/emotional
- Anxiety/depression
ADHD Prognosis
- Natural history
- ADRs
ADHD
- 2/3 no evidence in adulthood
- Associations
- Substance abuse
- Criminal convictions
- Lower education attainment
- Unemployment
ASD
- Definition
ASD Definition
- Neurodevelopmental disorder
- Social interaction, communication, behaviour
- Diagnosed in childhood
- Key symptoms present before 3
ASD Epidemiology
- UK Prevalence
- RFs
- Associations
ASD
- 1% in UK
- B>G - RFs
- Prematurity
- Maternal/paternal age
- Perinatal hypoxia - Associations
- Fragile X
- Tuberous sclerosis
- Angelmann
ASD Features
- Interaction
- Communication
- Activities
- Sensory
ASD Features
- Interaction
1. Eye contact
2. Little facial/body language
3. Difficulty reading signals - Communication
1. Delayed spoken/sign language
2. Abnormal language - Echolalia (repetition)
- Abnormal intonation, pitch, rate, rhythm
- Activities
1. Unusual preoccupations
2. Need for routine
3. Motor mannerisms - Hand-flapping
- Sensory
1. Restricted diet
2. Haircuts/teeth brushing
3. Loud noises
4. Self-harm
ASD
- Examination
ASD Examination
- NF or TS
- Wood’s light
- Skin stigmata - Injury
- DSH
- NAI - Congenital
- Macrocephaly
- Microcephaly
ASD
- DDx
ASD DDx
- LD
- Separate/co-morbid - Attachment disorders
- No stranger anxiety - Rett’s syndrome
- Largely girls
- >18mo regression
- Speech delay
- Repetitive hand-movements - Schizophrenia
- Disordered language/behaviour - Specific language disorders
- SALT diagnosis
ASD
- Mx
ASD Mx
- Diagnosis
- Co-morbid mx
- ADHD
- Sleep disorder
- LD
- MH - Behavioral strategies
- Visual timetables
- Preparation for changes - Education
- EHCP (formerly SEN)
- Education, health, care plan
Behaviour disorder
- Eight common underlying disorders
Behaviour involving disorders
- ADHD
- ODD (oppositional defiant)
- ASD
- Anxiety
- Depression
- Bipolar
- LDs
- Conduct disorder
Conduct disorder
- Behaviour patterns
- Mx
Conduct disorder
- Behaviour pattern
1. Repeated violation of rights/rules
2. 4 main groups of behaviour - Hurtful aggression (people/animals)
- Property destruction
- Lying/stealing
- Serious rule violations
- Management
1. Consider psychiatric referral
ODD
- Pattern of behaviour
- Investigations
- Management
Oppositional defiant disorder
- Pattern
1. Hostile, angry, defiant, rebellious
2. Directed at an authority figure - Ix
1. Conners rating scale
2. Child behaviour checklist - Mx
1. Consider psychiatric referral
Short stature
- Definition
- Centile
Short stature
- Definition
- 2sigma + - Centiles
- below 2.5th centile
Growth deceleration
- Definition
- Centile change
Growth deceleration
- Definition
- Growth velocity below fifth percentile - Centile change
- Height drop of two centiles
Normal growth
- Antenatal
- Post-natal
- Pubertal
Normal growth
- Antenatal
1. Uterine size
2. Placental/maternal funciton
3. IGF, IGF-binding proteins (IGFBPs) - Post-natal
1. Rapid
2. Plateau at 3yo (5-7cm/year)
3. Large or small babies ‘channel’ to correct centil by 2yo - Pubertal
1. Pre-pubertal dip
2. Growth spurt - Sex hormones, GH, TFTs
3. Girls first, then boys, for longer (13m difference)
Short stature
- Four common differentials
Four common Short Statures
- Familial
1. Born adequate for GA
2. Steady growth below 5th centile
3. Puberty not delayed
4. Normal exam, proportionate stature - Constitutional delay
1. First 2 years growth deceleration
2. Bone age delayed by 1-2 years
3. Final height close to target
4. Thin and sexually immature for age - Idiopathic short stature
1. Short but healthy
2. Normal puberty and exams
3. Normal bone age, IGF, IGFBP - SGA without catch-up (2yo)
1. IUGR and SGA at birth
2. Normal exams
3. Proportionate short stature
Short stature DDx
- Hormonal causes
- Genetic causes
- Chronic causes
- Dysplasias
- Psychosocial causes
Eight uncommon Short-Stature
- Hormonal
1. GH Deficiency
2. Hypothyroid
3. Cushing
4. GH Insensitivity (Laron)
5. Craniopharyngioma - Genetic
1. Trisomy 21
2. 45 X
3. Nonan
4. Russell-Silver
5. Prader-Willi
6. DiGeorge - Chronic disease
1. Celiac/IBD
2. CF
3. CHD
4. DM
5. CKD - Malignancy
- Skeletal dysplasia
1. Juvenile idiopathic arthritis
2. Achondroplasia
3. Hypochondroplasia
4. Osteogenesis imperfecta - Psychosocial
1. AN/BN
2. FAS
3. Abuse/institutionalisation
JIA
- Subtypes
Juvenile idiopathic arthritis
- Subtypes
1. Oligoarticular - 4 or fewer joints ever involved
2. Polyarticular - 5 or more joints involved
3. Systemic onset
JIA Presentation
- RFs
- S&S
- Ix
JIA Presentation
- RFs
1. Female sex
2. Under 6yo
3. Autoimmune FHx - S&S (6 weeks duration)
1. Pain, swelling, morning stiffness
2. Diurnal variation
3. Fever
4. Macular rashes, psoriatic scales, dactylitis
5. Purpura, bruising - Ix
1. ESR and CRP - Sub-type dependent
2. FBC - Systemic onset
3. Serology - ANA 30-60%
- Predictive of uveitis
- RF/Anti-CCP
4. Chlamydia screen in monoarticular teens
Poly articular JIA
- Management
Polyarticular JIA - Mx
- DMARD
- Methotrexate
- Leflunomide/sulfasalazine - Supportive
- Biological
- Adalimumab/etanercept etc - NSAID
- IArt CST
- PO CST
Oligoarticular JIA
- Mx
Oligoarticular JIA Mx
- IArt CST
- Triamcinolone acetonide
- Methylprednisolone acetate
+ Supportive care
+ NSAID
+ Methotrexate
- TNF-alpha inhibitor
- adalimumab/etanercept
- infliximab
+ Supportive
+ IArt CST
+ NSAID
JIA - Systemic onset
- Mx
Systemic onset JIA
- Mx
- PO/IV CST
- Methylprednisolone sodium succinate
- Prednisolone
+ Supportive care
+ NSAIDs
- Tocilzumab/canakinumab/anakinra
+ supportive care
+ PO CST
+ NSAID
DiGeorge Syndrome
- Pathology
- Triad
DiGeorge Syndrome (22qDS)
- Velo-cardio-facial syndrome
- CATCH22/Shprintzen’s
- Pathology
1. Chromosome 22q deletion syndrome
2. Pharyngeal arch transcription factor deficiency - Triad
1. Cardiac anomalies
2. Hypoplastic thymus
3. Hypocalcaemia (hypoplastic PT)
DiGeorge Syndrome
- Two phenotypic components
DiGeorge Syndrome Components
- Pharyngeal phenotypes
1. CHD
2. PT hypoplasia
3. Thymic hypoplasia
4. Cleft lip/palate
5. Mild dysmorphic facial features - Neurological phenotypes
1. Mild cognitive dysfunction - LD
- Speech impairment
- Increased incidence of schizophrenia
RTA
- Syndrome Characterisation
- Definition
Renal tubular acidosis
- Characterisation
1. Hyperchloremic metabolic acidosis
2. Normal serum anion gap - Definition
1. Group of disorders
2. Acid-base homeostasis
3. Impairment - Excretion of fixed acid
- Reabsorption of bicarb
RTA
- Paeds presentation
1 S&S
2 Ix
Paeds Renal tubular acidosis
- S&S
1. Small for age
2. Frailty
3. Bowing of knees
4. History of UTI, DM, PBC, kidney stones - Ix
1. low pH - Metabolic
- Amino aciduria
- Hyperuricosuria
- Hyperphosphatemia
- Hypophosphaturia
RTA
- Four types
RTA
Type I - Classical
Type II - Proximal
(Type III - Proximal and Distal
- Carbonic anhydrase II deficiency)
Type IV - Distal
RTA
- Type 1 Management
- Type 2 Management
RTA Mx
I Classical
- Alkali solution
- Sodium alkali
- Potassium-containing alkali - Potassium supplementation
II Proximal
- Alkali solution
- Potassium supplementation
- Hydrochlorothiazide
- Volume contraction
- Proximal reabsorption
RTA Management
Type III
Type IV
RTA Management
Type III (Rare, mixed)
1. Alkali solution
- Sodium or potassium based
2. Potassium supplementation
Type IV (Distal)
T.iv WITH Mineralocorticoid deficiency
1. Fludrocortisone + low K diet
2. Sodium alkali
T.iv WITHOUT Mineralocorticoid deficiency
1. Loop diuretic +low K + high Na
2. Sodium alkali
DBT
- Definition
Dialectical behaviour therapy
- Intensive psychological treatment
- Skills in emotion/behaviour regulation
- Balance/resolve difference
- 1 year
- weekly 1-2-1
- weekly group meetings
Therapeutic risk taking
- Definition
Therapeutic risk taking
- Empowering decision making
- Risk not just harm
- Opportunity
- Achievement
Opioid overdose
- Presentation
Opioid overdose
- Respiratory depression
- Apnoea
- CNS depression
- Miosis
Cocaine use disorder
- Gradation
- Chronic use sequelae
- State
Cocaine use disorder
- Gradation
- (Occasional use)
- Mild/moderate/severe - Chronic use
- Myocardial remodelling
- Myocardial hypertrophy
- Lethal arrhythmias - Hyperadrenergic state
- Nausea
- Jitteriness
- Anxiety and paranoia
- Trouble concentrating
- Euphoria
Cocaine toxicity
- S&S
Cocaine toxicity
- Minutes or hours of use
- Hyperthermia
- Rhabdomyolysis
- Dysrhythmia
- Ischaemia
- Intracranial haemorrhage
- Agitation
- Psychosis
- Seizures
MDMA toxicity
- S&S
MDMA toxicity
- S&S
- Agitation
- Confusion/headache
- Seizure
- Hypertension
- Hyperthermia
- Rhabdo
- Dysrhythmias/Hypotension
- ACS
MDMA Toxicity
- Mx
MDMA Toxicity Mx
- Supportive
1. Hypotension
2. Hyperthermia - Aggressive cooling
- Benzodiazepines
3. Hypoxia
4. Metabolic abnormalities
MDMA Toxicity
- Mx
MDMA Toxicity Mx
- Supportive
- Hyperthermia
- Aggressive cooling
- Benzodiazepines - Hyponatremia
- Fluid restriction
- Normal saline
- Benzos and hypertonic saline - Seizures
- Benzos/phenobarbitone
- GA
- Head CT - Hypotension
- Fluids - Hypertension
- BEnzos
- Nitroglycerin, nitroprusside, phentolamine - Rhabdomyolysis
- Fluid resuscitation - Hypoxia
- Metabolic abnormalities
Cannabis use
- Chronic health effects
Cannabis use
- Chronic health effects
- Cognitive impairment
- Impaired cognitive development - Dependence
- Increased risk
- Schizophrenia
- Anxiety disorder - Worsened
- Bipolar
- Respiratory symptoms
- Chronic bronchitis
Benzodiazepine overdose
- S&S
Benzodiazepine overdose S&S
- Excessive sedation
- Coma
- Respiratory depression
Acute alcohol misuse
- Two drugs
Acute alcohol misuse
1. Chlordiazepoxide
2. Pabrinex
Development
- Speech vs language
Development
- Speech
- Sounds
- Tongue, lips, jaw, vocal - Language
- Verbal and non-verbal - Speech and language
- Intact hearing
- Muscle control
- Exposure
Speech and language
- Development
1 d
6-8 wks
3 mo
6 mo
9 mo
12 mo
18mo
24mo
30mo
36mo
Speech and language
- Development
1 d - Cry
6-8wk - Coo
3 mo - Laugh/vocalise
6 mo - mama, dada, byebye, babble
9 mo - Understands no
12 mo - Own name, 2-6 words
18mo - 6-40 words, sing, parts of body
24mo - 200 words, joins words
30mo - continual questions
36mo - 2/3 colours, 1-10, songs, simple conversation
Specific language disorder
- S&S
- Mx
Specific language disorder
- S&S
1. Delayed/disordered language
2. Normal social communication - MDT
1. Pediatrician
2. Psychologist
3. SALT
4. OT
CAPD
1. S&S
2. Ix
3. Mx
Central auditory processing disorder
- S&S
1. Verbal instructions - Difficulty understanding
- Difficulty responding
2. No attention deficit
3. May have dyslexia - Ix
1. Hearing test
2. Screening questionnaire
3. APD listening test
Osteogenesis imperfecta
- Epidemiology
- Pathology
- Mx
Osteogenesis imperfecta
- Epidemiology
1/20,000 - Pathology
1. Collagen defect
2. Minimal impact fractures
3. Blue sclera
4. Hypermobility - Mx
1. PT
2. Bisphosphonates - Pamidronate/zoledronic acid
3. Vitamin D
