Management Plans Flashcards
Acne
Assess severity and extent that it is an issue.
Simple measures:
- Eat plenty of fresh fruit and vegetables.
- Avoid comodegenic beauty products.
- Regular cleansing - OTC preparations
- Stop smoking.
- May take weeks to months to help.
Topical antibiotics:
- Clindamycin/erythromycin - best used with benzoyl peroxidase/azelic acid to decrease resistance.
Oral antibiotics:
- Oral doxycycline (minocycline partially funded).
- Use for at least 3 months.
- Sensitivity to sun, oesophageal irritation.
Hormonal:
- OCP with cyproterone (Ginette)
- May help with premenstrual flares.
Iso-retinoin:
- Topical - often combined with antibiotic.
- 10-20% local skin irritation.
Isotretinoin:
- For severe cystic acne.
- Require 2x contraception - teratogen.
- Depression.
- Dry skin and sun sensitivity.
- Monitor for pregnancy, LFT’s and lipids.
Adherence
Medication, chest physiotherapy, appointments.
Important for long term care but need short term goals and reinforcement.
Consider as an issue in adolescence and any child moving out of home.
Approach:
- Explain poor adherence with medications is normal.
- Identify barriers:
- Lack of understanding of long term complications.
- Short term seen as more important than long term.
- Educate.
- Side effects.
- Doesn’t fit in to lifestyle - many medications/complicated regime:
- Simplify regime as much as possible.
- Negotiate regime with patient.
- Forgetful.
- Teasing at school:
- Avoid school time medications.
- Work with school on taking meds privately.
- Depression:
- Seek appropriate treatment.
- Start increasing autonomy over illness:
- Start seeing alone and discuss confidentiality.
- Re-educate - often miss out on undertanding of issues in illnesses that start as a child.
- Explore and correct misunderstandings around illness.
- Educate about medications.
- Simplify regime:
- Decrease number of medications.
- Decrease frequency of dosing.
- Tailor to daily routine (avoid school time).
- Involve adolescent in decision making process.
- Manage side-effects.
- Increase access to medications:
- Oral and written instructions.
- Keep by items of daily use.
- Make part of routine.
- Negotiate role of parents that is acceptable to adolescent.
- Set alarms on phone.
- Ensure they have community services card.
- Focus on short term goals and follow-up:
- Encourage and praise.
- Negotiate short term goals.
- Medication free periods.
- “Tom is now 13 years old and it would be appropriate for him to start taking over the administration of his medications. I would like to enhance compliance by increasing Tom’s ownership of the illness. I would do this by spending more appointments alone with Tom and exploring his understanding of his condition. I would ensure that he has a complete understanding of both his condition and the purpose of each medication.*
- I would review his current regime and ensure that it is as simple as possible. In Tom this would include trying to decrease his frusemide to twice daily dosing so that he doesn’t need to take medications at school.*
- I wouldalso make sure he wasn’t experiencing any unwanted effects that might prevent him from being compliant such as frequent toileting or teasing for this at school.*
- I would provide written instuctions in addition to oral instructions.*
- I would provide Tom with a short term goal such as trying his current regime for at least 1 month and assessing the impact that has on his breathlessness during sports. Regular review would be important”.*
Aspiration
Contributes to recurrent pneumonia in neurologically impaired children.
From above - swallow dysfunction, or below - GOR
Investigations:
- Plain CXR or CT - changes in dependent areas.
- Aspiration:
- Video fluoroscopy - only investigation correlated with decreased aspiration.
- Milk study.
- Saliva study.
- GOR:
- pH probe.
- Endoscopy if does not respond to conservative therapy.
- Barium - only useful in structural cause.
- Trial of therapy.
Management:
- Aspiration:
- Feed position
- Thickening
- Reduce volumes
- Percutaneous feeds to bypass upper GIT.
- GOR:
- Feed thickening
- Proton pump inhibitor ( more efficacious than H2 blockers)
- Fundoplification (60-90%) improve.
- Post-pyloric feeds
Augmentative communication
Basics:
- Formal hearing and vision assessment initially.
- Regular reassessments.
- Provision of hearing aides and glasses.
- Environmental modification - provide contrast, increase light, turn off radia/television when speaking.
- Involve speech therapist.
- Depends on fine motor abilities and memory/ability to learn.
- Access via - direct touch, fist or head pointer, light pointer.
Non-aided system:
- Gestures - informal vs. formal
- Key word signs (Makaton vocabulary)
Aided system:
- Non-technical
- Printed words, pictures, tactile feeling boards, real objects.
- Low tech
- Communication boards/books, switches.
- Hi tech
- Sound picture books, computer.
Resources - Talk Link
Behavioural problems
Prioritise problem behaviours:
- List all that parents would like to change.
- Select 2 most troubling (consider dangerousness).
- Tackle sleep first.
- Ignore others and reassure they will be addressed in time.
Educate parents:
- Slow process.
- May get worse before improving.
- Stabilise routines.
- Have specific time for the child each day.
- 3 C’s - clear boundaries, consistency, consequences.
4 pronged approach:
- Environmental modulation.
- Time out for prioritised behaviour:
- Clear boundaries.
- Safe but boring.
- Min/year of age up to 5min.
- Takes 1-2 months to work.
- >5y removal of priviledges more effective.
- Ignore other behaviours:
- Difficult.
- Avoid eye contact.
- Walk away.
- Praise for good behaviour:
- Specific.
- Immediate.
- Sticker charts.
Early review.
For tantrums:
- Ensure safe.
- Completely ignore.
- +ve reinforcement the moment they stop.
- “Firstly I would get the parents to prioritise the problem behaviours by listing all the things they would like to change and choosing 2 they would like to target first. This should take in to account the dangerousness of the behaviours.*
- I would warn the parents that behavioural change is a slow process and that the problem behaviour may get worse before it gets better. I would emphasise that the most important aspect in implementing a behavioural change programme is consistency.*
- My usual approach is a 4 pronged approach including environmental modification, time out for proritised behaviours, ignoring other behaviours and praise for good pehaviour.*
- For this child, his biggest problem was running away. I would modify the environment by ensuring the property is safe and an appropriate fence erected. Time out should be used for any attempts to run away. This should be an age-appropriate amount of time (1min/year) in a safe but boring environment such as a hallway or corner. Othe behaviours that have not been prioritised such as the childs tv watching should be ignored. Parents often find this difficult and I would advise the parents to distract themselves and remove themselves from the room if they find they are getting irritated by the behaviour.*
- I would also like to emphasise the importance of praise for good behaviours. I would encourage the parents to find 2-3 opportunities to praise their child every day. Praise should be immediate. A sticker chart could also be implemented. This needs to have a short time frame with an appropriate reward which can be negotiated with the child”.*
Bone Health
Osteopenia
Osteoporosis
Osteopenia = poor bone density (-1SD or 2x # on DEXA).
Risk factors:
- Immobility, reduced weight bearing.
- Diet - PEG feeds good! Dieting is bad.
- Decreased sun exposure/dark skin.
- Delayed puberty and amenorrhoea.
- Antiepileptics (valproate and phenytoin)/steroids/warfarin.
- Liver failure/fat malabsorption.
- Renal failure.
Investigations:
- Ca/PO/ALP/Vit D (+/- PTH)
- X-ray
- Bone mineral density (DEXA) - usually hip and lumbar spine (beware crush fractures falsely elevating score).
- Use patient as own control.
- Expect 10%/year increase in puberty.
Treatment:
- Supplements: calcium carbonate
- Vitamin D: cholecalciferol, calcitriol
- Hormone replacement if hypogonadal.
- Exercise programme.
- Bisphosphonates - Low BMD with 2+ long bone fractures (low trauma), and/or vertebral crush fracture irrespective of BMD, or skeletal fragility syndrome.
- SE: initial low calcium, myalgia, bone pain, fevers, AVN of TMJ.
- Unknown longterm effects - refer to endocrinology.
- Weekly.
- Monitor with ALP.
Osteoporosis = poor bone density and quality (-2SD or 4x# on DEXA).
Risk factors:
- Low Ca diet.
- Decreased Ca absorption - ETOH, caffeine, tannins, PO4.
- Increased Ca excretion - high salt diet, excess protein.
- Lack of sunlight/dark skin.
- Immobility.
- Prematurity.
- Malabsorption (CF).
- Chronic lung disease.
- Chronic renal failure.
- Drugs - AED (valproate and phenytoin)/steroid/warfarin
- Caffeine/ETOH
Investigation:
- Ca/PO4/ALP/Vit D/PTH
- Bone density for bone age.
- DEXA
Treatment:
- Ca
- Sun exposure.
- HRT if hypogonadal.
- Calcium - take between meals. If renal failure take with meals also to bind PO4.
- Vitamin D - cholecalciferol needs liver and kidney action to become calcitriol.
- Bisphosphanates - with endocrine consult.
Bullying
Explore underlying causes and fix if able.
Increase protective factors:
- Highlight strengths and improve self esteem.
- Gain assertiveness/confidence skills through counselling.
- Ensure positive family environment - support at home.
- Liase with school - ?senior “buddy”
- Trusted adult to report to.
Decrease bullying behaviour:
- School policy.
- Avoid situations that exacerbate (walking to school).
- If really bad ?change schools.
Constipation
Rule out organic causes:
- Dairy protein intoleranc can manifest as constipation in first 3 years of life.
- Hirschsprungs disease.
- Coeliac disease, hypothyroidism, hypercalcaemia and spinal cord problems.
Assess problem:
- Stool chart - Bristol stages.
- Toileting regime.
- Anxiety with toileting.
- Soiling.
- Activity.
- Examine for faecal loading.
- Rectal exam and AXR not routine - assess tone if neuro problem.
Educate:
- Common problem (1/4)
- No blame approach.
- Likely to take a long time to improve.
- Continue treatment 3-4 months after regular BM achieved.
- Risk of relapse on stopping treatment.
- Avoid enemas - unpleasant, exacerbates fissures.
- Behavioural:
- Regular toileting - 3x daily for 3-5min after meals.
- Star charts with timely and appropriate rewards.
- Lifestyle:
- High fibre diet (uncertain evidence).
- Increased fluids.
- Excercise.
- Inappropriate emphasis on fluid/diet places blame.
- Position - feet up on stool so that knees are higher than hips, lean forward and place elbows on knees.
- Acute disimpaction:
- Movicol: 1 sachet –> 4 sachets BD.
- Picosulphate drops if cannot tolerate movicol volumes.
- Daily treatment
- Infants <1m: coloxyl drops.
- Infants 1-12m: Molaxol or lactulose.
- Children: Molaxol or paraffin oil.
Education
Missed School
School Refusal
Missed School
- Extra exam time.
- Psychometric testing.
- WPPSI - <6y
- WISC - 6-16y
- WAIS - >16y
- In hospital:
- Central Regional Health School.
- Online learning and Zoom.
- School visits if able.
- Visits from friends/teachers.
School Refusal
1-5% of all school children.
Peaks at 5-7y, 11y and 14y.
Differs from truancy - do not attempt to conceal. Overt anxiety around going to school.
Outcomes:
- Poor academic performance.
- Family difficulties.
- Worsening peer relationships.
Long term consequences:
- Employment difficulty.
- Increased risk of psychiatric illness.
Poor prognostic features:
- Longer periods of refusal >3y.
- Adolescence.
- Depression.
- Low IQ.
Assessment:
- Determine extent of problem - number of days.
- Consideration of predisposing, precipitating and perpetuating factors.
- Stressors:
- Bullying/teasing.
- Poor self image/esteem.
- Poor grades.
- Seperation anxiety.
- Chronic fatigue.
- Truancy (different to school refusal – stays home to enjoy pleasurable activities).
- Unwell parent.
- Pattern - after holidays, start of week.
- Parental responses and parent child relationship.
- Stressors:
- Discuss with school.
- Behaviour and functioning.
- Academic performance.
- Attendance record.
- If somatic complaints.
- Throrough examination and judicious investigations.
- Reassure likely due to emotional upset.
Management:
- Ensure parental support - agree a time schedule.
- Immediate return if refusal period has been brief.
- Graded exposure if longer.
- Acknowledge reality of feelings.
- Parent involvement - calm morning routines and escort to school.
- School involvement - try hard to keep at the same school, special supports (modified curriculum, less homework), active tasks (need to be there).
- Child - relaxation training/breathing retraining, social skills training, praise and graded reward system (star chart).
- Adolescents - consider alternative education.
- Monitor for mental health symptoms.
- Referral to multidisciplinary mental health team for longer term school refusal.
- If no improvement after 2 weeks or suspect more severe mental health.
- Regular monitoring of progress and signs of relapse.
Encoporesis
Diagnose and treat constipation.
Regular toileting.
Nappies/continence pads - continence nurse/public health nurse.
High health needs application for teacher aide to assist with toileting/changing.
Psychology input in severe cases.
Enuresis
Diagnose and treat constipation.
Rule out UTI.
Consider renal tract abnormalities:
- Constant dribbling.
- Recurrent infections.
- Dysuria.
- Poor urinary stream.
- Neurology - leg weakness.
High fluid intake.
Avoid caffeinated drinks/
Regular toileting/timed toileting.
Double voiding (PU count to 20 and then try again).
Spare underwear/change of clothes at school or panty liners.
Pelvic floor exercises.
Nappies/incontinence pads or pants ??funding.
Public health nurse input.
Investigations - MSU, USS further as indicated.
Can use oxybutynin in overactive bladder.
Fussy Eating
Normal.
Differentiate between fussy and malnourished, and fussy and thriving.
Fussy and thriving:
Dietary advice:
- Exessive fluid intake reduces solid intake, offer food before fluid.
- If weight ok offer water, if FTT offer milk or formula.
- Variety is not important.
- Offer foods that are easy to handle.
Feeding times:
- Eat often not constantly.
- Offer a snack every 2-3h, allow 3 meals and 2 snacks/day.
- Avoid snacks directly after unfinished meal.
- Children work well with schedules, keep meals/snack times the same each day.
- Allow 1h without food/water before a meal to stimulat appetite.
- Do not make meal time too long (15min for toddler).
Feeding behaviour:
- Relax, mealtimes should be pleasant.
- Recognise hunger cues, satiety and food preferences.
- Parents decide what is offered child decides how much to eat.
- Avoid battles, encourage but avoid forcing, threatening, bribing or punitive approaches. Use reinforcement instead.
- Do not withold food as punishment.
- Allow child to feed themselves, small amounts first, seconds later. Expect messiness and be prepared for easy clean-ups.
Future directions
Prognosis:
- Check understanding, education, information, contact with other families.
- Families expectations of what child can achieve.
- ?expectation that siblings will become future carers.
End of life plans:
- Slowly introduce idea.
- Need both parents.
- Involve palliative care.
- Optimal timig of discussion (around severe illness).
Transplant:
- Immunisation.
- Bloods.
- Donor selection (family v. non-family).
Genetic Counselling:
- Discussion with geneticist.
- Understand implications for future children/patients children.
- For family if wanting more children.
- For young person if wants family.
- Timing of testing for patient and siblings.
- Options for future children - prenatal testing, antenatal testing (what would they do if positive).
GOR in CP
2/3 with CP have GIT motility disorders.
Symptoms include:
- Constipation (delayed transit, poor muscle tone, inadequate feeding, prolonged imobility).
- Swallowing disorders (dysfunction of oral/pharyngeal phase of swallowing from corticobulbar dysfunction).
- Vomiting/regurgtation (delay in gastric emptying, abnormal oesophageal motility, GORD).
- Abdominal pain (oesophagitis, constipation).
- Respiratory symptoms (2º chronic pulmonary aspiration 2º GORD).
Often FTT due to GORD/impairment of swallowing.
Work-up for GORD:
- Endoscopy + biopsy.
- 40-50% will show oesophagitis, 40-50% will be normal and the remainder will have H. pylori, eosinophlic oeophagitis or Barretts oesophagus.
- pH studies.
- Barium studies.
- Nuclear medicine milk/saliva scan.
Management:
- Acid suppression
- Anti-reflux surgery
- Uncomplicated in 70%.
- Complications included gagging, wretching, dumping, bloating and cyclic vomiting.
- Re do needed about 3%.
- No evidence to support efficacy of prokinetics or thickened feeds.
Patients with funoplification have similar rate of aspiration as those with gastrojejunal feeding.
Dietician - assess diet and increase calories
SLT - altering food consistency
PT - postitioning during feeding
Post-gastrostomy there is usually improvement in weight, height and skin fold thickness and a decrease in chest infections but no change in hospitalisation rates.
Health Promotion
Dental referral - encourage tooth brushing.
Smoking cessation.
Immunisation - advice, education.
Flu vaccination - child and family.
Exercise and diet - Active families/green prescription.