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YEAR 4 PAEDS > Community Paeds > Flashcards

Community Paeds Flashcards

1
Q

How is cerebral palsy defined?

A

a disorder of movement and posture due to a non-progressive lesion of the motor pathways in the developing brain

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2
Q

What are the causes of cerebral palsy? (Group them into antenatal, perinatal and postnatal)

A

Antenatal:
* Trauma during pregnancy
* Maternal congenital infections - rubella, toxoplasmosis, CMV
* Cerebral malformation

Intrapartum/Perinatal
* Birth asphyxia or birth trauma
* Preterm birth

Postnatal
* Meningitis
* Head injury - intraventricular haemorrhage
* Severe neonatal jaundice

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3
Q

List the types/classifications of cerebral palsy

A

Spastic
Dyskinetic
Ataxic
Mixed

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4
Q

Describe spastic cerebral palsy

A

Have hypertonia and reduced function resulting from damage to UMN
Subtypes include monoplegia, hemiplegia, diplegia and quadriplegia

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5
Q

Describe dyskinetic cerebral palsy

A

Have problems controlling muscle tone, with hypertonia and hypotonia.
Causes athetoid movements and oro-motor problems
Resulting from damage to basal ganglia and substantia nigra.

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6
Q

Describe ataxic cerebral palsy

A

Have problems with co-ordinated movement
Resulting from damage to cerebellum - so have typical cerebellar signs

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7
Q

Describe mixed cerebral palsy

A

A mix of spastic, dyskinetic and/or ataxic features.

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8
Q

Describe the following terminology for cerebral palsy:
1. Monoplegia
2. Hemiplegia
3. Diplegia
4. Quadriplegia

A
  1. Monoplegia: one limb affected
  2. Hemiplegia: one side of the body affected
  3. Diplegia: four limbs are affects, but mostly the legs
  4. Quadriplegia: four limbs are affected more severely, often with seizures, speech disturbance and other impairments
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9
Q

During child development, what signs and symptoms of cerebral palsy may present?

A

Failure to meet milestones
Increased or decreased tone, generally or in specific limbs
Hand preference before 18 months (Dr Tom says this is a key sign to remember for exams!)
Problems with coordination, walking or speech
Feeding or swallowing problems
Learning difficulties

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10
Q

You are carrying out a neurological examination on a child. Describe what these signs mean (relate signs to pathophysiology, e.g. are they UMN lesions etc):
1. Hemiplegic or a diplegic gait?
2. Broad based or ataxic gait?
3. High stepping gait?
4. Waddling gait?
5. Antalgic gait (limp)?

A
  1. Hemiplegic or a diplegic gait = UMN lesion
  2. Broad based or ataxic gait = cerebellar lesion
  3. High stepping gait = foot drop or LMN lesion
  4. Waddling gait = pelvic muscle weakness due to myopathy
  5. Antalgic gait (limp) = localised pain
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11
Q

You are carrying out a neurological examination for a child. Their signs indicate a UMN lesion. Based on this information, describe what would be found:
1. On inspection (how does muscle bulk look)?
2. Tone ?
3. Power ?
4. Reflexes?

A
  1. On inspection (how does muscle bulk look) = muscle bulk preserved
  2. Tone = hypertonia
  3. Power = slightly reduced power
  4. Reflexes = brisk reflexes
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12
Q

You are carrying out a neurological examination for a child. Their signs indicate a LMN lesion. Based on this information, describe what would be found:
1. on inspection (how does muscle bulk look)?
2. tone?
3. power?
4. reflexes?

A
  1. on inspection (how does muscle bulk look) = reduced muscle bulk with fasciculations
  2. tone = hypotonia
  3. power = significantly reduced power
  4. reflexes = reduced reflexes
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13
Q

Describe presentation of patient with cerebral palsy

A
  • Hemiplegic or diplegic gait - due to increased muscle tone and spasticity in the legs
  • Leg will be extended with plantar flexion of feet and toes, so will swing leg in large semicircle when walking
  • Will have signs of UMN lesion with good muscle bulk, increased tone, brisk reflexes and slightly reduced power.
  • May have athethoid movements that indicate basal ganglia involvement
  • May have cerebellar signs that indicate cerebellar involvement
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14
Q

What are the complications and associated conditions of cerebral palsy?

A

Learning disability
Epilepsy
Kyphoscoliosis
Muscle contractures
Hearing and visual impairment
Gastro-oesophageal reflux

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15
Q

How would you manage a pt with cerebral palsy?

A
  • Requires an MDT approach
  • Physio - strengthen muscles, maximise function and prevent muscle contractures
  • OT - to manage everyday activities
  • Speech and language therapy - help with speech and swallowing.
  • Dieticians - help meet nutritional needs (may require NG tube or PEG feeding)
  • Orthopaedic surgeons - surgery to release contractures or lengthen tendons (tenotomy)
  • Paediatricians optimise medications → muscle relaxants (baclofen) for spasticity and contractures. Antiepileptics for seizures. Glycopyrronium bromide for excessive drooling. Analgesia as required.
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16
Q

What are treatment options for spasticity? (pass med)

A

Oral diazepam
Oral and intrathecal baclofen
Botulinum toxin
Orthopaedic surgery
Selective dorsal rhizotomy

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17
Q

What are four main domains that child development is separated into?

A

Gross motor
Fine motor
Language
Personal and social

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18
Q

When thinking of child development, what is gross motor referring to?

A

Gross motor refers to the child’s development of large movements, such as sitting, standing, walking and posture. Development in this area happens from the head downwards

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19
Q

Describe normal gross motor development at:
4 months
6 months
9 months
12months
15months
18months
2 years
3 years
4 years

A

**4 months: **This starts with being able to support their head and keep it in line with the body
**6 months: **They can keep their trunk supported on their pelvis (i.e. maintain a sitting position) by 6 months, however they often don’t have the balance to sit unsupported at this stage.
**9 months: **They should sit unsupported by 9 months. They can start crawling at this stage. They can also keep their trunk and pelvis supported on their legs (i.e. maintain a standing position) and bounce on their legs when supported.
**12 months: **They should stand and begin cruising (walking whilst holding onto furniture).
**15 months: **Walk unaided.
**18 months: **Squat and pick things up from the floor.
**2 years: **Run. Kick a ball.
**3 years: **Climb stairs one foot at a time. Stand on one leg for a few seconds. Ride a tricycle.
4 years: Hop. Climb and descend stairs like an adult.

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20
Q

When thinking of child development, what is fine motor referring to?

A

Refers to a child’s development of precise and skilled movements. Also encompasses their visual development and hand-eye coordination.

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21
Q

Is hand preference before 12 months abnormal or normal? What could it indicate?

A

Abnormal - may indicate cerebral palsy.

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22
Q

When thinking of a child’s development, what is langage development referring to?

A

The development of understanding and using speech and language to communicate. There are two components:
Expressive language
Receptive language
Both of these have their own milestones.

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23
Q

What are the red flags for developmental milestones that would suggest there is a problem?

A
  • Lost developmental milestones
  • Not able to hold an object at 5months
  • Not sitting unsupported at 12 months
  • Not standing independently at 18 months
  • Not walking independently by 2 years
  • Not running at 2.5yrs
  • No words at 18 months
  • No interest in others at 18month
24
Q

What are early milestones of the fine motor domain?

A

**8 weeks **= fixes eyes on an object 30c in front of them and makes an attempt to follow it. Show preference for a face rather than an inanimate object
**6m **= palmar grasp of object (wrap thumb and finger around object)
**9m **= scissor grasp of object (squashes it between thumb and forefinger)
**12m **= pincer grasp (tip of thumb and forefinger)
**14-18m **= can clumsily use spoon to bring food from bowl to mouth

25
Q

What are expressive language milestones for 3m, 6m, 9m, 12m, 18m, 2yrs, 2.5yrs, 3yrs and 4yrs?

A

**3 months: **Cooing noises
6 months: Makes noises with consonants (starting with g, b and p)
**9 months: **Babbles, sounding more like talking but not saying any recognisable words
12 months: Says single words in context, e.g. “Dad-da” or “Hi”
**18 months: **Has around 5 – 10 words
**2 years: **Combines 2 words. Around 50+ words total.
**2.5 years: **Combines 3 – 4 words
**3 years: **Using basic sentences
4 years: Tells stories

26
Q

What are receptive language milestones for 3m, 6m, 9m, 12m, 18m, 2yrs, 2.5yrs, 3yrs and 4yrs?

A
  • 3 months: Recognises parents and familiar voices and gets comfort from these
  • 6 months: Responds to tone of voice
  • 9 months: Listens to speech
  • 12 months: Follows very simple instructions
  • 18 months: Understands nouns, for example “show me the spoon”
  • 2 years: Understands verbs, for example “show me what you eatwith”
  • 2.5 years: Understands propositions (plan of action), for example “put the spoon on / under the step”
  • 3 years: Understands adjectives, for example “show me the redbrick” and “which one of these is bigger?”
  • 4 years: Follows complex instructions, for example “pick the spoon up, put it under the carpet and go to mummy”
27
Q

Global developmental delay could indicate an underlying diagnosis such as…?

A

Down’s syndrome
Fragile X syndrome
Fetal alcohol syndrome
Rett syndrome
Metabolic disorders

28
Q

A delay that is specific to the gross motor domain may indicate an underlying diagnosis such as…?

A

Cerebral palsy
Ataxia
Myopathy
Spina bifida
Visual impairment

29
Q

A delay that is specific to the fine motor domain may indicate an underlying diagnosis such as…?

A

Dyspraxia
Cerebral palsy
Muscular dystrophy
Visual impairment
Congenital ataxia (v rare)

30
Q

A delay that is specific to the speech and language domain may indicate an underlying diagnosis such as…?

A

Specific social circumstances - e.g. exposure to multiple languages or having siblings that do all the talking
Hearing impairment
Learning disability
Neglect
Autism
Cerebral palsy

31
Q

delay that is specific to the personal and social domain may indicate an underlying diagnosis such as…?

A

Emotional and social neglect
Parenting issues
Autism

32
Q

What are personal and social milestones for 6wks, 3m, 6m, 9m, 12m, 18m, 2yrs, 3yrs and 4yrs?

A
  • 6 weeks: Smiles
  • 3 months: Communicates pleasure
  • 6 months: Curious and engaged with people
  • 9 months: They become cautious and apprehensive with strangers
  • 12 months: Engages with others by pointing and handing objects. Waves bye bye. Claps hands.
  • 18 months: Imitates activities such as using a phone
  • 2 years: Extends interest to others beyond parents, such as waving to strangers. Plays next to but not necessarily with other children (parallel play). Usually dry by day.
  • 3 years: They will seek out other children and plays with them. Bowel control.
  • 4 years: Has best friend. Dry by night. Dresses self. Imaginative play.
33
Q

What are the main referral points for a child with a developmental problem?

A

Doesn’t smile at 10 weeks
Cannot sit unsupported at 12m
Cannot walk at 18m

34
Q

Cause of Down’s syndrome?

A

Three copies of chromosome 21 = trisomy 21

35
Q

What are clinical features of Down’s syndrome?

A

Face:
* upslanting palpebral fissures (the gaps between the lower and upper eyelid)
* epicanthic folds (folds of skin covering medial portion of the eye and eyelid)
* Brushfield spots in iris
* protruding tongue
* small low set ears
* round/flat face

Flat occiput - small head with a flat back (called Brachycephaly)
Single palmar crease
Hypotonia
Congenital heart defects
Duodenal atresia
Hirschsprung’s disease
Short neck
Short stature

36
Q

What are complications associated to having Down’s syndrome?

A
  • Learning disability
  • Recurrent otitis media
  • Deafness. Eustachian tube abnormalities lead to glue ear and conductive hearing loss.
  • Visual problems such myopia, strabismus and cataracts
  • Hypothyroidism occurs in 10 – 20%
  • Cardiac defects affect 1 in 3, particularly ASD, VSD, patent ductus arteriosus and tetralogy of Fallot
  • Atlantoaxial instability
  • Leukaemia is more common in children with Down’s
  • Dementia is more common in adults with Down’s
37
Q

What are the cardiac complications of Down’s syndrome?

passmed

A

endocardial cushion defect (most common, 40%, also known as atrioventricular septal canal defects)
ventricular septal defect (c. 30%)
secundum atrial septal defect (c. 10%)
tetralogy of Fallot (c. 5%)
isolated patent ductus arteriosus (c. 5%)

38
Q
  1. What antenatal screening is initially done for Down’s syndrome?
  2. How many weeks along in the pregnancy is this done?
  3. What is involved?
A
  1. Combined test
  2. Done 11-14 weeks
  3. USS - measures NT. Maternal blood test for beta-HCG and Pregnancy associated plasma protien-A (PAPP-A)
39
Q

For antenatal screening of Down’s syndrome

  1. What is the triple test?
  2. How many weeks into the pregnancy is it performed?
  3. What results would indicate greater risk of Down’s?
A
  1. Only involves maternal blood test - Beta-HCG, AFP, serum oestriol
  2. 14-20 weeks
  3. greater risk with high B-HCG, lower AFP and low serum oestriol
40
Q

antenatal screening for Down’s

How does the quadruple test differ to the triple test for antenatal screening of Down’s syndrome?

A

It is identical to the triple test
* so is done between 14-20 weeks
* involves b-HCG, AFP and serum oestriol

BUT
also includes maternal blood for inhibin-A.
A higher inhibin-A indicates a greater risk.

41
Q

From antenatal screening, when a risk of Down’s is greater than 1 in 150, what antenatal tests is the woman offered?

A

Chorionic villus sampling = USS guded biopsy of placental tissue. Done before 15weeks
Amniocentesis = US aspiration of amniotic fluid using needle and syringe.

42
Q

What does non-invasive prenatal testing (NIPT) involve?

A
  • take sample of blood from mother.
  • blood will contain fragments of DNA - some of which are from the placental tissue so represent fetal DNA
  • Fragments are analysed for conditions such as Downs
43
Q

What are later complications of down’s syndrome?

(is part of another card too!)

A
  • subfertility
  • learning difficulties
  • short stature
  • repeated resp infections
  • hearing impairments from glue ear
  • acute lymphoblastic leukaemia
  • hypothyroidism
  • alzheimer’s
  • atlantoxial instability
44
Q

What MDT members are needing in managing Down’s syndrome patients?

A

LOADS !!

  • Occupational therapy
  • Speech and language therapy
  • Physiotherapy
  • Dietician
  • Paediatrician
  • GP
  • Health visitors
  • Cardiologist for congenital heart disease
  • ENT specialist for ear problems
  • Audiologist for hearing aids
  • Optician for glasses
  • Social services for social care and benefits
  • Additional support with educational needs
    • Charities such as the Down’s Syndrome Association
45
Q

What routine follow up investiagtions are important for children with Down’s syndrome?

A
  • Regular thyroid checks (2 yearly)
  • Echocardiogram to diagnose cardiac defects
  • Regular audiometry for hearing impairment
  • Regular eye checks
46
Q

What is prognosis of Down’s?

A

Varies based on severity of the complications.
Average life expectancy is 60 years.

47
Q

What are the types of abuse that a child may be a victim of?

A

Physical
Emotional
Sexual
Neglect
Identity
Financial

48
Q

What are RF for child abuse?

A
  • Domestic violence
  • Previously abused parent
  • Mental health problems
  • Emotional volatility in the household
  • Social, psychological or emotional stress
  • Disability in the child / developmental problems
  • Learning disability in the parents
  • Alcohol misuse
  • Substance misuse
  • Non-engagement with services
  • Excessive crying - shown to be a trigger for shaking infants
  • Unintended pregnancy
49
Q

Describe possible signs of child abuse

A
  • Change in behaviour or extreme emotional states
  • dissociative disorders
  • Bullying, self harm, suicidal behaviours
  • unusually sexualised behaviours
  • unusual behaviour during examination
  • poor hygiene
  • poor physical or emotional development
  • missing appointments or not complying with treatments
  • physical signs - in another BS card
50
Q

What physical signs of child abuse may a child present with?/ might you notice?

A

Bruises:
* shaped like hands, linear bruises, identifiable implement shape
* on soft tissue / non-bony
* multiple or clustered
* in a child that can not mobilise

Bites:
* appears to be human
* note: animal bites may be a sign of a poorly supervised child

Lacerations/abrasions:
* in non mobile children
* present symmetrically
* around the face
* around ankles or wrists - where ligatures could be applied

Thermal injuries:
* in areas where you wouldn’t expect body to come into contact with a hot object
* soles of feet, back, buttocks, back of hands
* shape of burn or scald - cigarette, certain shape/ borders

Fractures:
* occult rib fractures
* spiral fractures
* fractures in children without condition predisposing them to fragile bones
* fractures of different ages - e.g. can see many but not all recent ones, so can see some that are healing
* metaphyseal corner fractures

Intracranial injuries:
* in child under 3
* without an adequate explaination
* retinal haemorrhages
* rib or long bone fractures
* with other injuries
* with multiple subdural haemorrhages

Eye trauma:
* retinal haemorrhages with no medical explaination

51
Q

Differential for bruising (other than non accidental injury)?

A

Coagulopathy

52
Q

Differential for childhood fractures (other than non-accidental injury)?

A

Osteogenesis imperfecta

53
Q

What imaging would you do when non-accidental injury is suspected?

A

Skeletal survey:
* Head/chest - inclduing AP and lateral skull
* spine/pelvis
* upper limbs
* lower limbs

Follow up imaging:
* skeletal survey should be repeated at 11-14 days

Neurological imaging:
* CT head on day of presenation
* MRI within a week of presentation

54
Q

After confirming a child has been abused, what must you do for siblings?

A

If children = they may also be at risk.
Need to offer these children a skeletal survey too.
Involve child services, child protection, social services and police.

55
Q

What can be put in place to help support families of children with safeguarding concerns?

A
  • Home visit programmes to support parents
  • Parenting programmes to help parents develop parenting skills and manage their child’s behaviour
  • Attachment-based interventions to help parents bond and nurture their child
  • Child–parent psychotherapy
  • Parent–child interaction therapy
  • Multi-systemic therapy for child abuse and neglect (MST-CAN)
  • Cognitive behavioural therapy for children that have suffered trauma or sexual abuse

YEAR 4 PAEDS (19 decks)

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