General Flashcards
What are the systems that we check in newborn exams?
General exam:
-asleep/awake, difficulty breathing, jaundice, dysmorphic features
Head
Face
Neck
Chest
Abdomen
Groin
Limbs
Back
Neuro
plot basic measurements on WHO growth chart
what do you check for on an infants :
Head
Face
Neck
Head
- Head circumference: occipital-frontal circumference
(plot n compare by length, weight, gestation )
- feel sutures + fontanelles
- Swellings, haematomas, haemorrhage
Face
- Ear: mobile pinna? patent external meatus?
- positioning & formation; abnormalities could be associtaed with inherited disorders
- Eyes; slant/palpebral fissures; normal variants or congenital disorders eg downs syndrome
- Eyes; Red reflex - +ve = normal retinal vessels
- > white = retinoblastoma or cataract
- Nose; patency of nares
- Mouth; reflex suck, soft & hard palate
- > cleft palate or lip? tongue tie (usaully normal)
Neck
- Webbing - Turners
- Clacivle; fracture - shoulder dystocia
what do you check for on an infants :
Chest
Abdomen
Groin
Chest:
- Sternum
- Pectus excavatum - concave
- Pectus carinatum - convex- > Abnormal in marfans
2. Auscultate A. Heart - 120-160bpm HR normal - Machine like murmur - normal and benign resolves within 1 week * patent ductus arteriosus B. Lungs - RR (30-60 bpm)
- Peripheral saturations
- put probe on baby foot
Abdomen;
- Distensions? movement with respiration
- Palpate for masses;
->intraabdominal neoplasms - Wilms tumour,
Neuroblastoma
- Palpate liver; should just be plapable in a newborn
Groin
- Femoral pulse palpation
- > cant feel: aorctic coarctation - Inguinal hernias
- External genitals - palpate scrotum
- (testicle descent), hypospadias
- > Anal patency
- (testicle descent), hypospadias
- Hip dysplsia
- Barlow before Ortolani manuvre (test of dislocation)
- if clunk / dislocation refer to orthopaedics
what are the risk factors for hip dysplasia?
FH, Female, Breech presentation
what do you check for on an infants :
Limbs
Back
Neuro
Limbs:
polydactyly
bracydactyly - short digits. or long ones
single trnasverse palmar crease - downs syndrome or normal variant in 1%
Back
- Mongolian blue spots - normal
- Erythema toxic - pustules - normal
- Spinal cord anomalies
odd patch of hair
assymetric gluteal cleft
Sacral dimple: can suggest spina bifida occulta
Neuro
- Awake/asleep, Irritable/Calm, Consolable/Inconsolable
- Sensation - do they respond to your touch
- Movement; moving limbs?
-Pull up by hands:
hypertonic/hypotonic
- Moro reflex ; want a symmetrical response
- Palmar grasp reflex
when would the newborn exam be done?
1st week of life ideally <24hrs old
at 6-8 weeks by GP
why do we avoid ceftriaxone in empirical therapy in young infants?
risk of kernicterus
far as i know dont use in under 3 months old
Define neglect
Neglect is the persistent failure to meet a child’s basic
physical and/or psychological needs, likely to result in
the serious impairment of the child’s health or develop-
ment. It may involve a parent or carer failing to provide:
• adequate food and clothing
• shelter, including exclusion from home or
abandonment
• protection from physical and emotional harm or
danger
• adequate supervision, including the use of
inadequate caregivers
• access to appropriate medical care or treatment.
It may also include neglect or unresponsiveness to a
child’s basic emotional needs.
what are the risk factors of child abuse?
In the child:
• failure to meet parental expectations and
aspirations, e.g. disabled, ‘wrong’ gender, ‘difficult’ child
• born after forced, coercive, or commercial sex.
Parent/carer:
• mental health problems
• parental indifference, intolerance, or over-anxiousness
• alcohol, drug abuse.
In the family: • step-parents • domestic violence • multiple/closely spaced births • social isolation or lack of social support • young parental age.
Environment:
• poverty, poor housing.
what are the different ways child abuse can present?
Child abuse may present with one or more of:
• physical symptoms and signs
• psychological symptoms and signs
• a concerning interaction observed between the
child and the parent or carer
• the child may tell someone about the abuse
• the abuse may be observed.
Identification of child abuse in children with disabilities
may be more difficult
what are the key principles of safeguarding?
• safeguarding is everyone’s responsibility: for
services to be effective each professional and
organization should play their full part
• child-centred approach: for services to be effective
they should be based on a clear understanding of
the needs and views of children.
what are the factors to consider in a presentation of a physical injury?
• the child’s age and stage of development
• the history given by the child (if they can
communicate)
• the plausibility and/or reasonableness of the
explanation for the injury (Case History 8.1)
• any background, e.g. previous child protection
concerns, multiple attendances to AnE department or GP
• delay in reporting the injury • inconsistent histories from caregivers • inappropriate reaction of parents or caregivers who are vague, evasive, unconcerned, or excessively distressed or aggressive.
- Seek input from paediatric radiologists and paediatric or orthopaedic surgeons, senior members of the team.
what are the factors to consider in a presentation of a physical injury?
• the child’s age and stage of development
• the history given by the child (if they can
communicate)
• the plausibility and/or reasonableness of the
explanation for the injury (Case History 8.1)
• any background, e.g. previous child protection
concerns, multiple attendances to AnE department or GP
• delay in reporting the injury • inconsistent histories from caregivers • inappropriate reaction of parents or caregivers who are vague, evasive, unconcerned, or excessively distressed or aggressive.
- Seek input from paediatric radiologists and paediatric or orthopaedic surgeons, senior members of the team.
How does child abuse present?
• babies:
– apathetic, delayed development, non-demanding
– described by the mother as ‘spoiled, attention
seeking, in control, not loving her’
• toddlers and preschool children:
– violent, apathetic, fearful
• school children:
– wetting, soiling, relationship difficulties, non-attendance, antisocial behaviour
Unexpected awareness or acting out of sexualized
behaviour beyond what would be expected
for age.
• adolescents:
– self-harm, depression, oppositional, aggressive,
and delinquent behaviour.
which typese of physical injuries are likely to be inflicted and non-accidental? NAI
Fractures:
- Any fracture in a non-mobile child (excluding fragile bones)
- Rib fractures
Burns:
- A ‘glove or stocking’ burn consistent
with forced immersion.
- burns in non-mobile child
Bruising:
Bruising in the shape of a hand
Bruises on the neck that look like
attempted strangulation
Inflicted or accidental injuries are more likely:
Skull fracture in young child.
Long bone fractures in a young but mobile child
Trunk, neck, ear bruising + inconsistent/vague history
when is intercourse with a girl considered sexual abuse?
if she is under 13
list some differentials for common physical injuries?
bruising – coagulation disorders
Mongolian blue spots on the back or thighs
• fractures – osteogenesis imperfecta
The type commonly involved with unexplained fractures is type I, which is an autosomal dominant disorder,
so there may be a family history.
Blue sclerae are a key clinical finding and there may be generalized osteoporosis and Wormian bones in the skull (extra bones within skull sutures) on skeletal
survey
• scalds and cigarette burns – may be misinterpreted in children with bullous impetigo or scalded skin syndrome.
What investigations do we do in event of suspecting non-accidental injury (Where brain injury is suspected)?
NAI
• an immediate CT head scan followed later by a
MRI head scan if abnormalities found
• a skeletal survey to exclude fractures
• an expert ophthalmological examination to
identify retinal haemorrhages
• a coagulation screen.
forensic assessment?
what is the management and full workup of suspected abuse?
OR
what are the procedures pertaining to raising safeguarding concerns about child maltreatment?
- Histories
History from parent
Child’s history
Child’s Behaviour and interaction with parent - Physical symptoms + Physical examinations
- Follow local child safeguarding protocols
If strong case for NAI:
- Admit child to hospital
- try to obtain consent from them/parent to alert SS
- if not CA 1989 S1.1
- consider other siblings. then:
- Social work assessment:
- they ultimately decide what happens with parent and child
- calling them doesnt mean they take child away straight away - Child protection conference may be called
includes social workers, health visitors, police, GP, Paeds, teachers, lawyers and Parents.- share infomration about the case
- decide in child protection plan is needed
- if application to court for above is needed
Sexual abuse:
Police inquiry - if very serious / sexual abuse / FGM
Forensic assessment - sexual abuse
Define the legal framework and explain the principles of managing child maltreatment using case scenarios
Children act 1989
S1.1 - the childs welfare is paramount
- takes precedence to parental wishes
Safeguarding laws:
Section 11 - allows us to break confidentiality if in best interest of child
Once a Dr reports concerns -> a social worker has 1 day to decide what kind of investgiation is needed:
A. Section 17 investigation - a child in need
B. Section 47 investigation - a child at risk of significant harm.
Sexual offences act 2003
Cannot consent if under 13 but 13-16 lawful if both between that age.
what are the events following a social worker initiating an investigation?
The ivx must start within 1.5 months and involves:
- Social workers meeting with the parents, child’s teacher or doctor.
- They will look at the child’s records.
Following this:
In cases of serious abuse, and in all cases of sexual abuse, the local authority will tell the police.
Occasionally they will take urgent action to have the child removed from the family home immediately.
Sometimes, a child protection conference is called.
Often, they may decide no further action is needed.
Parental rights If they take child away - can seek legal advice. more advice on citizens advice.org.uk
what is the difference between Gillick competence and Fraser guidelines?
Gillick competence is concerned with determining a child’s capacity to consent.
Fraser guidelines, on the other hand, are used specifically to decide if a child can consent to contraceptive or sexual health advice and treatment.
- including STIs
- including terminations
what are the Fraser guidelines?
in which cases can confidentiality be broken?
- He/she has sufficient maturity and intelligence to UNDERSTAND the nature and implications of the proposed treatment
- He/she CANNOT be PERSUADED to tell her parents or to allow the doctor to tell them
- He/she is very likely to begin or CONTINUE having sexual intercourse with or without contraceptive treatment
- His/her physical or mental HEALTH is likely to suffer unless he/she received the advice or treatment
- The advice or treatment is in the young person’s BEST INTEREST
Must; offer to tell the parents. try to convince them to tell parents
Can break confidentiality or refuse if:
- All conditions not met
- Suspect coercion / exploitation
What is the law about 16-17 year olds?
Young people aged 16 or 17 are presumed in law, like adults, to have the capacity to consent to medical treatment.
However, unlike adults, their refusal of treatment can in some circumstances be overridden by a parent, someone with parental responsibility or a court, if refusal can cause harm to them
