Gen paeds mgmt issues Flashcards
Mx of behavioural escalation/behavioural difficulties
- Behavioural escalation
- Why?
- What is leading to these meltdowns, is there a particular trigger?
- What is the parents/caregivers response?
- Sleep disturbance? OSA?
- Assess for developmental delays?
- Evolving underlying diagnosis - ASD? ADHD? ODD?
- Consider further ix if NEW, out of character
- Provide framework for family in management
- Identify triggers
- Remain calm
- Consistency
- Ignore bad behaviours and praise good behaviours
- Environmental modifications - remove harm
- Emergency safety plan if escalating to violence (take away things he could hurt you with, call police)
- PRN medication (risperidone or clonidine)
- Consider referral to behaviour management clinic under NDIS plan (if eligible)
- Respite for family
- Close follow up
- Why?
Mx of obesity
- Information gathering
- Need height and weight -> BMI
- Current diet and exercise levels
- Medications with obesity as SE?
- Barriers to weight loss
- Sleep: sx of OSA- Ix
- Consider organic cause
- Steroid excess
- TFTs (hypothyroid)
- Urinary cortisol (Cushings)
- Consider genetics (microarray and/or methylations tudies) if low IQ/ASD (prayer will or chromosomal microdeletions)
- Cx of obesity
- Blood pressure
- LFT
- Fasting BGL
- Fasting lipids
- ECG
- Vitamin levels if restrictive (but high calorie)
- Consider liver USS if liver derangement
- Sleep oximetry
- Consider organic cause
- Ix
- Management
- Non-pharmacological
- Diet - education (selection and serving sizes) and dietician if needed
- Whole family needs to be on board - meal prep healthy options
- Replace unhealthy treats with healthy ones (acknowledge this may be more expensive)
- If eating for boredom, brainstorm a distraction activity
- If eating for hunger, brainstorm more satiating meal options
- Exercise - education and physiotherapy if needed
- Referral to weight mgmt clinic
Management of sleep disturbance
History
- Onset, sleep maintenance (restless, heavy or light sleeper), waking overnight
- Time of going to bed vs falling asleep, time of waking (refreshed or groggy?)
- Where do they sleep, what is the sleep environment like, current sleep hygiene
- Ask about OSA signs/sx (pauses/gasps/apnoeas, snoring, mouth breather, daytime somnolence/naps)
- Need to assess child’s development - is poor sleep affecting their development and/or behaviour?
- Need to assess child (anxiety/depression or stress as underlying cause) and parents’ mental health/impact on them
Ix
- Sleep diary
- Examine tonsils (or ?hypotonia) -> Oximetry -> sleep study
- Video EEG (if history suggestive of seizures)
Mx
- OSA: Weight loss, IN steroids, T&As -> CPAP if severe
- Sleep hygiene (consistent routine, bed is for sleep only, no screen time before bed, no drinking before bed, exercise during day, avoid caffeine)
- Pharmacological
- Melatonin trial or clonidine if sleep onset is a problem
- Benzos, chloral, periactin may be used in children with disability
- Sleep school (private clinic - day or overnight)
General health management points
- Immunisation of patient and whole family (herd immunity) according to schedule
- Consider additional immunisations: fluvax, DTP booster, RSV-Ig (palivizumab), pneumococcal, meningococcal - Regular screening of vision and hearing
- Bowels and continence
- Sleep
- Sleep hygiene and – where appropriate – consideration of pharmacotherapy - Medication vigilance
- regular review of medication doses and responses, aiming for lowest effective dose
- rationalise meds when appropriate
- review dose for weight
- monitor compliance and address barriers - Growth and nutrition
- Development
- eyes and ears checked - Emergency planning
- Crisis plans - written
- CPR training
- Medicalert bracelet - Health literacy
- Mental health surveillance
Coordination of treating team - mgmt strategies
- Multi disciplinary meetings every 12-18months
- Information gathering nad collation from multiple sources
- Liaison with GP
- Liaison with school and early intervention service
- Thinking ahead - puberty, transition
Health literacy management
Written emergency plan
Assessment of parental competence with XX - education
Involve all caregivers
Written health record/passport
First aid training
Refer to support organisation
Management strategies for behavioural issues with ADHD kids
Hyperactivity/motor overactivity
Conservative
#Inattention
- Sit at front of class
- Break things into small parts
- Give written, spoken instructions, visual demonstration
- Allow to run errands and stand during schoolwork
- Ensure breaks between classes
- Help child get organised with notebooks, dividers, folders, planners
- Check child’s diary to ensure homework is finished and assignments completed
- Encourage supervised activities - sport, scouts
- Cooperative learning tasks w other kids
- Teaching aid or tutor for problem areas
- Give more time for tests
- Praise contributions to class
- Help child get organised with notebooks, dividers, folders, planners
- Check child’s diary to ensure homework is finished and assignments completed
Pharmacological
- Stimulant (methylphenidate or dexamphetamine, starting dose 1mg/kg)
–> SE - HTN, appetite loss, LOW, afternoon crash
Seizure management
- Seizure plan in verbal and written form (copies for all carers)
- Ensure all family members and carers there
- Additional information for school
- Emergency action plan
- Consider midazolam if not already prescribed (esp if previous hospital admissions for prolonged seizures or compromising seizures or lives far from hospital)
- Know when to call an AV
- Additionally skills training
- First aid or CPR course
- Midazolam administration (demonstrate how to give) - Medicalert bracelet
- No swimming unattended - supervision around water, roads, biking, heights at all time
- Consult with neurology team if already involved or new seizure semiology
Constipation mgmt
Hx:
- Toileting habits
- Are they toilet trained?
- Bristol stool chart
- Anxiety or pain around stooling, withholding
- Diet and fibre
- Fluid intake
- Medications contributing?
- Organic
- When did they pass mec? (Hirschsprungs, CF)
- Blood or mucus in stool, eczema (CMPI)
Ix
- Bowel and bladder diary
- Screen for organic causes
- TFTs
- Coeliac serology done at some stage
- Ca
- Non-pharmacological mx
- Diet - fibre and fluids
- Exercise
- Toileting habits: toilet insert, foot stool with knees above hips, toileting three times a day 30min after meals, staying on toilet for 10-15min at a time
- Star chart/positive reinforcement
- Psyllium husk mixed into food
- Pharmacological mx for at least 3-4months (until Review)
- Movicol/osmolax
- Parachoc
- Lactulose
- Emergency plan - Disimpaction plan if worsening and safety netting
- Education - Clear goal!! Compliance!!
- Follow up - ensure compliance
Anxiety, depression mgmt
- Info gathering: identify triggers/exacerbating factors
- Assess impact on daily functioning
- Risk assessment - safety plan
- Mx
- Non-pharmacological
- Diet, exercise
- Psychology/CBT - mental health care plan, CAHMS or origin referral
- Peer support groups
- School supports - counselled, friends
- Pharmacological
- SSRI
- Crisis plan
- Non-pharmacological
Siallorrhoea mgmt
- Mx
- Speech path motor movements
- Optimise head position
- Meds - anticholinergics
- Glycopyrollate, Artane (benzhexol), hyoscine (SE - constiation, urinary retention, dry eyes)
- Surgical
- Botox (lasts ~6mo)
- Salivary gland excision
Optimisation of resp health
- Assess for aspiration (clinical swallow review with speech path)
—> manage risk factors for aspiration (dysphagia, epilepsy, reflux, siallorrhoea) - Optimise airway clearance
—> optomise positioning and tone mgmt
—> PT if needed - Optimise asthma management
- Assess/manage OSA
- Physical exercise
- Dental hygiene
- Immunisation (yearly flu)
- Ensure no smoking exposure
Risk of and Mgmt of scoliosis
- Surveillance Xrays, especially approaching/through puberty as this is when it tends to worsen
- Cobb angle > 40 = refer to orthopaedics
- Risk - pain, chest infections, restrictive lung disease, mobility and function limitations
- Surgical mx - bipilar surgery
Mgmt of hip subluxation and risk factors
- RF: CP, hypo and hypertonia (Risk is directly related to GMFCS level)
- Surveillance: Annual pelvic X-ray
- Surgical mx (b/l hip derogation and osteotomies)
Mgmt - poor compliance
- Info gathering: find out what meds, doses and frequency; what are the barriers
- Education - reason for taking meds, consequences of not taking meds
- Management
- Need to build rapport
- Restrict frequency of medications as much as possible, simplify timetable
- Set reminders (phone)
- If taste or form is a problem: explore other forms
- Embarassment - dosing schedule not around peers
- Side-effects - explore alternatives
- Low motivation/affect - HEADDSS screen, consider psychologist
- Involve parents more
Mgmt of chronic pain
- Triad of Pain, Sleep and Mood
- Pain:
- Address underlying cause
- Mx
- Non-pharmacological: heat packs, distraction, CBT, physiotherapy
- Pharmacological: analgesic ladder (paracetamol, neurofen then clonidine, endone …), consideration of neuropathic agents (gabapentin, TCA), referral to pain specialist
- Sleep
- Hygiene optimisation
- Explore impacting factors (OSA etc)
- Pharmacological (melatonin)
- Mood
- Psychology
- Meds: SSRI
- Pain:
Management of enuresis (urinary incontinence)
Hx:
- Bladder and bowel diary
- Hx of voiding sx
- Daytime and/or nighttime wetting?
- Urgency
- Frequency
- Hx of constipation?
- Hx of fluid intake
- Hx of polydipsia/polyuria
Ix
- Urine MCS
- Renal USS (pre and post void residual volumes)
Mx
- Sx: pads, convene catheters
- Manage constipation or untreated UTI
- Behavioural modifications
- Timed voiding
- Avoid fluids at night
- Pad and bell alarm for at least 2-3 month trial period
- IF pad and bell fails, desmopressin (Minirin) is first line
- IF suspected overactive bladder (urgency), rial oxybutynin
- REFER continence service
- If underlying disability: ask if NDIS funding covers continence products/services?
Steroid dependence - management
- Hx
- Ask about signs, sx of steroid excess
- Need for stress dosing/emergency plan for adrenal crisis- Mx
- Minimise dose
- Working with specialist, consideration of steroid sparing agents, biologics etc
- Monitor for side effects
- Serial growth monitoring (Weight, height)(
- Blood pressure (HTN)
- Mood, affect
- Opthal review (cataracts/ICP)
- DEXA scan
- Fasting BSL and HBA1C
- Functional muscle assessment (prox myopathy)
- Treat complications
- Vitamin D and Ca supps; bisphosphanates
- SSRI
- PPI (gastritis)
- Health prevention
- Extra vaccines incl yearly flu (caution with live vaccines as immunosuppressed)
- Diet and exercise (obesity and mood and BP)
- Stress dosing plan for when unwell/surgeries etc
- Education about pregnancy (teratogenic)
- Med alert bracelet if teenager
- Minimise dose
- Mx
Management of bone health
- Review contributing factors: diet (Ca), physical activity, sun exposure, medications (steroids and anticonvulsants can impact metabolism of Vitamin D), puberty
- Review ix performed: Via D, Ca, Ph, PTH, PO4 and vertebral xray (?fractures), dexa scans
- Mx
- Vitamin D supplementation
- Pubertal induction
- Bisphosphate therapy (zoledronic acid) - if has had pathologic #s
- General bone health
- Sunlight, diet, weight baring exercise
- Allied health input and NDIS - PT, OT and dietician
- Consider ortho referral if any genu valgum (knock knees)
- Supplements - vit D and Ca
- Ensure puberty occurs
- Manage falls risk - home mods, equipment, transfers/hoist etc
