ITM 1 The Paediatric Patient Flashcards
What does a full blood count involve
Haemoglobin Haematocrit Mean corpuscular volume Differential white cell count Reticulocyte count ESR
What does Us and Es involve
EGFR Creatinine (and clearance) Na+ K+ Urea
What does an ECG show
Cardiac problems of conduction, pathological changes of heart (LVH), ischaemia and abnormalities of rhythm
What can a chest xray show
Information regarding respiratory system and heart
Lungs - pneumonia, infections (TB), carcinoma
Heart failure- enlarged heart, signs of pulmonary oedema
Define safeguard
Protect from harm or damage with an appropriate measure
What is the unicef definition of a child protection system
The set of laws, policies, regulations and services needed across all social sectors especially welfare, education, health, security and justice to support prevention and response to protection related risks
Define harm
Ill treatment or the impairment of health or development eg depriving a child of the tools needed to develop eg sitting in a push chair all day means they wont learn to walk
What are the 4 categories of abuse
Physical
Emotional
Sexual
Neglect
Define neglect
The persistent failure to meet a childs basic physical and / or psychological needs, likely to result in the serious impairment of the childs health or development
Define emotional abuse
Persistent emotional ill treatment of a child such as to cause severe and persistent adverse effects on the childs emotional development
It may include:
Conveying to the child that they are worthless or unloved
Developmentally inappropriate expectations being imposed on a child
Seeing or hearing the ill treatment of others
What is sexual abuse
Forcing or enticing a child or young person to take part in sexual activities, including prostitution whether or not the child is aware that this is happening - often children from vulnerable backgrounds
What can sexual abuse include
Penetrative and non penetrative acts, non contact acts such as involving children in looking at or being involved in the production of pornographic material or watching sexual activities or encouraging children to behave in sexually inappropriate ways
What categories of children are at increased risk of abuse
Disabled children and non verbal
Asylum seeking / refugee children, private fostered
Children in care and children in secure accommodation
Children <1 year
Why are children <1 year statistically most at risk
Injuries can be hidden
Non mobile children should not have bruises
Harder to recognise
What are other risk factors that need to be considered
Domestic abuse
Are the family already known to social care
Is there a history of mental health problems
Is there a history of substance misuse
Are there other children in the house, they may need immediate protection
What should you do if a disclosure is made
Tell the child or parent they have done the right thing by telling you
Avoid making comments or judgements about what is shared
Tell the child or parent what will happen next and be honest, dont break a childs trust
Document clearly
Tell a senior colleague
What should you look for when examining a child
Look for injuries and document any
Document birth marks, demeanour
Document any rashes
What should you do if you have a safeguarding concern
Ensure everything is documented
Share that worry with a seniour colleague
Refer to childrens social care
Arrange an appropriate child protection medical
CSC will ensure the child is safe
What does ‘safe’ mean
Doesnt necessarily mean that the children are removed from their family, simple things like more support, supervision, behaviour management, housing support or education is often sufficient
What does a paediatric history taking involve
Antenatal and birth details Early development Hearing and vision Family and social history School Nutrition
What are the phases of growth and development and life
Prenatal Neonatal Infancy Pre school Primary school Secondary school
What factors are measured in a growth assessment
Weight
Height / length
Head circumference (widest possible measurement)
BMI - limited value in a child as many toddlers are chubby but lose it after age 5
Pubertal stage
Bone age
What is given if growth is not in conjuction with bone age
Growth hormone
What happens when growth plates are fused
You stop growing
No gap between bones as they have been ossified (cartilage in between has gone- looks like a gap on xray as cartilage cant be seen on xray)
What is turner syndrome
Missing x chromosome
Short stature
Failure of ovaries to develop
Heart defects
What are the 4 domains of development
Gross motor
Fine motor
Language
Social
What are the stages of gross motor development
3 months- head control when sitting 4-5 months - roll 9 months - sit unaided 8-10 months - crawling 1 yr - standing up 13-18 months - walking unaided
Stages of fine motor and vision development
6 weeks - palmar grasp 3 months - hand play 5 months - reaching 6 months - transfer 9 months - pincer grip 15 months - scribble
Stages of language and hearing development
Birth - cry and responds to sounds 8 weeks - vocalising 4 months - laughing 7 months - responds to names 12 months - single words 24 months - join 2 words together
Stages of social and behavioural development
6 weeks - smiles reponsively 6 months - finger feeds solids 9 months - wave bye 15 months - drink from a cup 22 months - knows body parts 3 years - feed with knife and fork 3 years - referential play
How should you calculate age of a preterm child
Up to age 2 subtract how many week premature they were from their age
What should be a concern if a childs development is not sequential
Eg they were walking and then reverted to crawling - sign of a brain tumour
What are red flags in abnormal development that require thought
Not similing at 8 weeks - a sign of lack of hearing Not sitting at 9 months Not walking unsupported at 18 months Fewer than 6 words by 18 months Apparent loss of skills
What are the different forms of eczema
Atopic eczema (infantile)
Contact dermatitis
Pompholyx - vesicles on hands or feet, related to fungal infection, heat and stress
What is hyperkeratotic palmar eczema
Common in the middle aged
Fissured eczema on hands
What is seborrhoeic eczema
Cradle cap
Common in babies
Treated with anti fungal shampoo
What is asteatotic eczema
Reduced lipids in the skin
Drying and cracking
Common in the older patient
What is atopic eczema
Inherited tendency for asthma, hayfever and eczema
Sensitivity to allergens
Dry and inflammed skin aggravated by cold, hear, hard water, infections, clothes
Often develops at 3 months - most grow out of it
Pruritis is prominent
Itchy papules on cheeks
Felxurs affected, elbows and knees; skin dry and lichenified
Infection risk through scratching
How to manage eczema with cleansing
Regular but not excessive washing, using emulsifying ointment - avoid soap
Bathe in emollient (hydrating agent)
Regulat emollient cream
How to manage eczema with the environment
Keep the house cool
Limit allergens in the house- dust house mite increases severity
How to manage the scratching element of eczema
Cut nails
Sedative oral antihistamine at night
When are steroids used in eczema
When emollients are not sufficient
Topical 1% hydrocortisone (infants under 1) very effective
How to counsel a parent for a child being prescribed steroids for eczema
Apply thinly and evenly spread Avoid face (telangiectasia- thinning of skin and prominent blood vessels) and anogenital region (scrotal skin absorbs 80x better than other skin)
What are some of the side effects of more potent steroids
2 degree infection Thinning of skin Telangiectasia Acne Mild depigmentation Pituitary-adrenal axia suppression Cushings
Treatment options for infected eczema
Topical antiseptic - povidone
Topical fusidic acid or mupirocin
If widespread, oral flucoxacillin or erythromycin
Dermatophytes - topical antifungal
Eczema herpeticum (when eczema has been infected with herpes) - emergency IV antivirals in hospital
What is contact dermatitis
Irritant reaction to chemicals eg detergents, nickel, cosmetics
Atopy is a predisposing factor
Dryness and chapping
Remove contact
Emollients, barrier creams, topical steroids, oral antihistamines
What is napkin dermatits
Contact dermatitis +/- infection
Irritation to ammonia - skin folds not affected
Improve hygeine, barrier creams, emollients
Infection- skin folds affected. Often fungal
Treatment for psoriasis
Emollients
Topical steroids - anti inflammatory
Topical dithranol- antiproliferative; inhibits DNA synthesis often 1st line
UV- with psoralen. Bathe in psoralen prior to UVA, photosensitizing agent
When are oral retinoids used to treat psoriasis
After methotrexate and ciclosporin
They bind to nuclear retinoic acid receptor and affect gene transcription - antiproliferative
Risks of oral retinoids
Teratogenic
Avoid pregnancy for 3 years after stopping as accumulates in the fat
Negative pregnancy tests and 2 forms of contraception needed
What is ringworm
Fungal infection
Discoid, scaly regions
Culture of skin scrapings is best practice
What is acne vulgaris
Excessive sebum production
Comedones (blackheads)
Pustules (white heads)
How does co-cyprindiol ethinylestradiol contraceptive treat acne
It balances the imbalance of oestrogen and androgens
Androgens drive the excessive sebum production
What is rosacea
An inflammatory condition
Acneform lesions, telangiectasia but not comedones
Commoner in women, during / after menopause
Treatment of rosacea
Topical metronidazole (antibacterial) Then oral erythromycin or tetracycline
What is a basal cell carcinoma
Small blackish area (often on the edge of the ear / temple)
Small colourless lump with pearly edges
Very slow growing - takes years
It is a malignant tumour but with limited local invasion
Cured by surgical removal - 97% cure rate
Extensive lesions may require radiotherapy or cryotherapy
What is a malignant melanoma
Evolution and possible malignant transformation in a large mole to produce malignant melanoma
More likley in large than small moles, in sun exposed skin
Itch
What is the ABCDE signs of a malignant melanoma
Asymmetry Border irregular Colour irregular Diameter >0.5cm Elevation irregular
Treatment of a malignant melanoma
Surgical excision outlook good. If the thickness of the lesion is <1.5mm the 5 year survival is 92% but only 37% for a more neglected lesion of >3mm thickness
Chemotherapy is palliative in disease which has spread
What is a pre term neonate
23-37 weeks gestation
Rapid growth, fully formed, most systems not fully developed
What is a neonate
Birth - 1 month
Normal initial period of human development and growth
What is an infant
One month - one year
High growth rates and rapid changes
What is a child
One - 12 years
Slower growth and development
What is an adolescent
12-18 years
Final period of growth and puberty, stretching into adulthood
How are children different to adults
Organ systems develop throughout infancy, childhood and adolesence
Often poorer reserve in overdose
Inability / reluctance to swallow tablets, have injections etc
What are the 4 pharmacokinetic processes
Absorption
Distribution
Metabolism
Excretion
What is the primary organ for drug
Kidney
What organ is primarily responsible for drug metabolism
Liver
Define absoprtion
The extent to which the administered dose is transported to the blood stream and the speed with which this happens
Describe oral absorption in children
Neonatal / early absorption very unpredictable - use IV if patient is acutely unwell and / or the medicine is critical
Similar to adults from 4-6 months of age
Describe IM absorption in children
Unpredictable due to variable blood flow, reduced muscle mass and fewer muscle contractions in neonates and sedated / paralysed children
Painful - avoid if at all possible - ok for single doses
Describe percutaneous absorption in children
Enhanced in neonates and infants- higher risk of toxicity from drugs and excipients
Describe rectal absorption in children
Slow and unpredictable, especially in neonates
Describe the process of distribution of drugs in a child
Higher total body water in neonates affects water soluble drugs eg gentamicin
Continues to change right through adolescence but greatest changes occur during the first year of life
Reduced plasma protein concentration (drugs carried around the body attached to plasma proteins) binding capacity and affinity in neonates
What are hepatic phase I liver enzymes
Mature over the first few months of life. Adults levels reached at 6 months
Oxidation, reduction and hydrolysis reactions
What are hepatic phase II liver enzymes
Increase significantly over first 2-3 months of life. Adult levels reached at about 3 years of age (acetylation and glucuronidation reactions)
Present at birth at similar levels to those found in adults (sulphate conjunction, glycine conjugation)
Describe GFR in babies
Is bad at birth even in healthy babies
Around 20
90 is the lower end of adult volume
Describe excretion in neonates
GFR is low initially but improves rapidly in babies born >1.5kg over the first 14 days of life
Tubular secretion increases more slowly and is close to adult values by age 8-12 months of age
Impact is on renally excreted drugs (eg gentamicin, cefuroxime)- some drugs are dosed on post menstrual age, others on post natal age
What are the different ways of calculating dosage in a child
By age:
Ok for drugs with low toxicity / wide therapeutic window
By weight:
Most common, need to check weight seems sensible. Do not exceed the adult dose
By surface area: most accurate
Problems with oral liquid medicines
Not available for all drugs
Multiple strenghts of liquid for the same drug (potential for confusion and under / over dose
Why are children more likely to be given overdoses than adults
Due to dosing being done universally for adults and scaling down for children
What is off label prescribing
Licensed drugs that have only been tested in adults so there is a greater degree of responsibility placed on the prescriber.
Means safety and efficacy cannot be assured
What is a prescribing error
The result of a prescribing decision or prescription writing process that results in an unintentional but significant reduction in the probability of the treatmetn given being timely anf effectively or an increased risk of harm compared with generally accepted practice
2-3 times more common in children
Why are children at greater risk of medication errors
Drug doses calculated individually, based on a patients age, weight or body surface area - often complex
Changing weight and pharmacokinetics throughout childhood
Lack of suitable dosage forms - need for dilution, measurement of small volumes
How are child medication errors avoided
Review doses frequently
Information in BNFC often complex - find right section for the patient
What are examples of common sources of error when prescribing for children
Miscalculations (10 fold and 100 fold overdoses)
Confusion between mg/ kg / dose versus mg/ kg / day
Confusion between doses in mg and ml
Confusion between units
Things to remember in order to prescribe safely to children
Use the BNFC checking that you have the right dose for the patients age, weight and condition
Watch out for maximum doses: should not exceed the adult dose
Check weight is appropriate for age
Check if patient has allergies
What are the different stages of childhood
Neonates- newborn (anything from preterm to 1 month)
Infants - up to 1 year
Child - 1-12 years
Adolescent - 13-16
Describe the upper respiratory system of a neonate / infant
Large head, short neck, prominent occiput (lots of mouth breathing, promotes rapid feeding)
Tongue is large
Larynx higher and anterior and more pliable (soft)
Epiglottis is long and stiff
Trachea relatively short
Mainstream bronchi have less of an angle than in adults
Smaller airway
Describe the lower respiratory system of the neonate / infant
Horizontal ribs (prevent bucket handle breathing action)
Not completely calcified
Diaphragmatic breathing
From birth - adolescence the rib cage increases in size, a decrease in thoracic kyphosis, ribs rotate inferiorly
They have 10% of the total number of alveoli found in adults so exhaust more quickly and have fewer type 1 fibres in respiratory muscles
What kind of airway obstruction occurs in the external to lumen
Masses
What kind of airway obstruction occurs in the intraluminal
Oedema
Anaphylaxis
Croup
Epiglottis tracheitis
What kind of airway obstruction occurs in the internal to lumen
Secretions
What is increased resistance in the airway caused by
Spasm (asthma)
Infection
Describe respiratory rate in infants
Increased metabolic rate compared to adults so higher oxygen requirement
Rate varies with age and is irregular
Younger you are the few fatigue resistant fibres
Why does a difficulty to increase depth and strength of respirations lead to a greater dependence on respiratory rate
Horizontal ribs provide little leverage for increasing the AP diameter of the chest
Heart occupies a grater space in the thorax comparatively, less ability to increase lung volume
Diaphragm main muscle but restricted by small abdominal cavity
Less developed accessory muscle, more difficult to increase the strength and depth of ventilation
What are the signs of respiratory distress in an infant
Flared nostrils Frightened look Pale skin Blue nail beds Rapid breathing
What are some of the major CVS changes that occur after birth
Circulation (foramen ovale and ductus arteriosus begin to close)
Heart is large in the thoracic cavity, right V is stronger than the left (reverses in infancy) as heart pumps against a collapsed lung in utero
Size and weight of heart doubles in the first year of life
Average blood volume at different stages of childhood
Neonates 85-90 ml/kg
Infants 75-80 ml/kg
Children 70-75 ml / kg
Adults 65-70ml/kg
Why are musculoskeletal symptoms in children and adolescents common
Because the ossification sites are usually still cartilaginous in infants and young children and it is not until around 16 that nearly all the cartilage has been ossified
What are some musculoskeletal differences in children and how are they significant
More bony mass per unit area - quicker healing time
Greater vascularity - significantly reduced rates of non union
Thicker periosteum - higher degree of energy needed to fracture the bone
Why are physeal injuries (a growth plate weak portion of bone)
Unique to children
Can be difficult to detect on xray as physis radiolucent and epiphysis may be incompletely ossified
What is a toddler fracture
Unidisplaced spiral fracture of the tibial shaft only
Usually <3 years
Low energy trauma with a rotational force (falling awkwardly)
Describe the oral cavity in an infant
Infants oral cavity is relatively small
This combined with a large tongue promotes rapid feeding
Describe the salivary gland of an infant
Insufficient saliva in the first few months
Salivation increases with teething
Describe the stomach of an infant
Limited capacity - increases quickly in the first month after birth due to frequent feeding
Immature lower oesophageal sphincter
In horizontally lying of baby the gastric fundus is lower as the antral part of the stomach- causes gastroeosophageal reflux
What is the impact of an infant having an underdeveloped liver
Decreased glycogen stores
Describe the small intestines of an infant
The small bowel increases in length with age from 150-200cm in the neonate to almost 6m in the adult
Describe the large intestine of the GI tract
Peyer’s patches appear at 2-3 years so local protection is weak
Haustra appear after 6 months
Muscle tissue is poorly developed so the propulsion capacity is insufficient
- major cause of constipation
Describe the urinary system at birth
Is immature
Kidneys are immature until 6 months
Renal blood flow and GFR are low in first 2 years of life due to high renal vascular resistance
Tubular function is immature until 8 months so infants are unable to excrete a large sodium load
Describe the skull of an infant
Sutures do not fuse until the head has reached adult size
Presence of fontanelle:
Anterior: palpated up to the age of 12-18 months
Posterior: may be palpated up to the age of 2 months
Thinner cranial bones
Growth of paranasal air sinuses
Describe the structure of the brain in the infant
Neonate - already has about all of the neurons it will ever have
Doubles in size in the 1st year
2/3 years - has up to twice as many synapses as it will have in adulthood
3/4 years - it has reached 8-% of its adult volume
Where does the spinal cord terminate
Neonates / infants - L2/L3
Adolescent - L1/2
Why are infants at an increased risk of brain injury
Thinner bones
Head larger, higher centre of gracity - theoretical risk of increased head trauma
Increased risk of hypoglycaemia
Less mature blood brain barrier - increased risk of infection
What are protective measures for brain injury
Open sutures: volume can expand decreasing the risk of RICP (restricted intra cranial pressure)
Developmental factors to monitor in children
Visual, hearing, toilet trained
School performance
Behavioural issues
Puberty
What is the HEEADSSS acronym
Home and relationships Education and employment Eating Activities and hobbies Drugs, alcohol, smoking Sex and relationships Self harm, depression and self image Safety and abuse
