management topics Flashcards
Aspiration
Feed position, thickening, reduce volumes
Can give only the consistency that is shown not to reflux on video fluoroscopy
Percutaneous feeds (PEG or PEJ) to bypass upper gastrointestinal tract
Behaviour problems
Prioritise problem behaviours
● List all behaviours that parents would like to change
● Select the two that are most troubling (take into account dangerousness)
● Always tackle sleep problems first as this exacerbates bad behaviour
Educate parents
● Slow process
● May get worse before better (escalation of behaviour)
● Most important aspects are the three Cs: clear boundaries, consistency, and consequences
● Triple P (positive parenting program)
Four-pronged approach ● Environmental modulation o Remove TV from room ● prioritised behaviour o Clear boundaries (if appropriate give a warning first) o consistent consequence ● Ignore other behaviours ● Praise for good behaviours o Be specific o Immediate o Sticker charts – short term goals/can’t take stickers away o Involve child in choosing a reward
Disabled child
- exploring triggers/causes
- lessen triggers
- safe environment (padding, no hard edges) and sensory spaces
Medication
risperidone and olanzepine
doperidol
Bone health
Non-pharmocological
o increase wt bearing exercise
o diet
o R/V absorption and exclude medical cause for poor bone health eg. coeliac, renal failure
● Pharmacological:
o Supplements
▪ Calcium – caltrate 600mg OD
▪ Between meals for absorption
In chronic renal failure, may give with meals also to bind phopshate and reduce
absorption of phosphate
▪ Vitamin D - ergocalciferol/cholecalciferol
▪ Calcitriol
▪ Hormonal therapy
o Prolia (SC q6m)
o Bisphosphonates (BMD)
▪ Used for osteogenesis imperfecta initially
▪ Only if have had at least one fracture (controversial)
▪ Side effects: initial low calcium, myalgia, bone pain, fevers, avascular necrosis of the TMJ
▪ Unknown long term effects (therefore refer to endocrinology)
▪ Usually given weekly – IV palmidronate/zoledronic acid (yearly),
Tonizimab (6mnthly s/c)
▪ Monitor treatment - alkaline phosphatase
● Reduce fracture risk – optimise vision (improve lighting/contrast, eliminate glare)
o Review medication (especially sedatives/altering gait/hypotension)
o Home modification
o Exercise program
Improving communication
Formal hearing and vision assessment initially
● Regular re-assessments
● Provision of hearing aids/glasses
● Environmental modification – provide contrast/increase light
● Turn off radio/television when speaking
Involve a 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 (facial expression/gestures) v formal
● Key word signs – usually taken from Makaton vocabulary (varies from indicating
wants to 2-3 word sentences)
Aided system ● Non-technological o Printed words o Pictures o Tactile feeling boards o Real objects ● Low technology o Communication boards/books o Switches ● High technology o Sound picture boards - simple message systems o Computer – allow producing long messages with a few selections
Constipation
● Rule out organic causes
● Dairy protein intolerance can manifest as constipation in first three years of life
● Hirschsprungs disease
● Coeliac disease, hypothyroidism, hypercalcemia & spinal cord problems
Assess problem ● Stool chart – Bristol stages ● Toileting regime ● Anxiety associated with toileting ● Soiling ● Exam – faecal loading/FTT/neuro o Rectal exam and AXR not routine (assess tone if there is a neurological problem)
Educate
● Common problem (1 in 4 children)
o “No blame” approach
● Likely to take a long time – not a quick fix
● Continue treatment 3-4 months after regular bowel movements are achieved
o Risk of relapse once stop treatment
● Emphasises bowel/worsens behavioural aspects
Behavioural:
o Regular toileting – three times per day for 3-5 mins after meals (gastro-colic reflex)
o Star charts for positive behaviour with appropriate and timely rewards
Acute disimpaction:
Movicol 1 sachet - building up to four sachets BD (<12 years = movicol 1/2)
Daily treatment:
● Softener
Parachoc = sweet, contains soluble fibre
o 1-6 years old 10-15ml, 7-12 years old 15-20ml, adults up to 40ml/day
o >6 months: lubricant/stool softener - paraffin oil
o Colourless/ odourless, so easily disguised
o Avoid in GOR/neurological impairment (aspiration risk)
o Risk of fat soluble vitamin malabsorption with chronic use
Coloxyl
o <6 months -10 drops TDS, 6-18 months – 15 drops tds, 18-36 months – 25 drops
TDS
● Bulking –> Metamucil
●Osmotic
Lactulose
o Flatulence, abdo discomfort
o Electrolyte disturbance very uncommon
o Can use >1 month
o <1 year old - 5ml daily, 1-6 years old - 10ml daily, >6 years old - 15ml daily
movicol - Osmotic stool softener
o Nausea and vomiting, diarrhoea, cramps
o Electrolyte disturbance very uncommon
o Must be dissolved in correct amount of water (62.5ml/sachet)
● Picoprep
o Caution re electrolyte shifts
Rectal
o Glycerine suppository
o Microlax
o Usually start with parachoc/lactulose +/- sennacot
Drooling/secretions
● Conservative
o Positioning and seating (physiotherapy input)
o Speech therapy input - sucking (straw)
o Child’s oral awareness (recognise feeling of wetness)
o Tell them that they are drooling
o Swallow more frequently
o Waterproof bibs/scarves/specially designed clothes
o Orthodontic devices (poor success rate)
● Medical – anti-cholernergics
o Hyoscine butylbromide patch (SAS script)
o Benzhexol (artane) – cheaper and easier to obtain from chemist;
o Side effects: anti-cholinergic (sedation/urinary retention/constipation), thickened
saliva ( increasing risk of aspiration)
o Glycopyrulate – fewer side effects but more expensive
o Botox injections – ultrasound guided into parotid gland (under GA)
o Risk of facial nerve palsy/thickened saliva
● Surgical
o For severe drooling or failure of conservative therapy
o Preferred option = relocation of submandibular ducts with excision of sublingual
glands
o Side effects: dry mouth and dental problems (need careful follow up with dentists)
o 80% success rate
Enuresis
● Reassurance
● Stop blame – inherited
● Exclude encopresis, constipation, detrusor instability (try an anticholinergic)
● Don’t treat under 7 years old
Non-pharm
● Pad and bell for 8 weeks (70% cure, 30% relapse, better next time)
● Toilet before bed, undies only, alarm on, wake with alarm, child to turn off, go to toilet, clean and repeat
● When dry for 1/52, give a large glass of water to stress bladder and test
Desmopressin – ADH analogue
● Short term stop gap (school camp, sleep overs)
● Medium term solution if alarm has failed – use 3-6/12 then try again
● May have synergistic role with alarm
● Withdraw when vomiting, diarrhoeal illness – hyponatraemic seizures
Detrusor instability
● Girls 2-8
● Urgency and squatting
● High fluids before 5pm, frequent voiding through day, fibre, anticholinergic (probanthine or oxybutynin)
Hearing impairment
Management
● Multidisciplinary – monitor linguistic and social development
● Treat underlying cause
● Otitis media – decrease smoking, daycare and dummies
● Antibiotics – one month course
Non-pharm
Decrease background noise
● Use louder than normal voice
● Protect hearing – ear plugs with loud noise
Early intervention programs - speech therapy
safety - cross roads with child
Medication
● Early treatment of otitis media
Surgery
Grommets
short term symptomatic benefit – no convincing long term benefit
● May help in children with other disabilities – decreased IQ, neuro/cleft
● Perform if bilateral >30db conductive hearing loss with recurrent otitis media/ externa
50dB = amplification
● Hearing aids for conductive and sensorineural hearing loss
● If not compliant – may be ok if school performance ok
● Cochlear implants – stimulate auditory nerve – aim for <2 years
80dB = alternative form of communiciation
● Lip reading/signing
Reflux
Non-pharm
● Feed thickening - meta-analysis shows that this has some efficacy in reducing reflux episodes and also increases the caloric density of feeds
● Positioning
● Optimise volume of feeds/ method (bolus vs continuous, gastric vs jej)
● Post-pyloric feeds
● All reflux tends to improve with age
Meds
● PPIs are more effective than H 2 blockers – decrease acidity and gastric volumes
Surgery
● Fundoplication is reasonably efficacious with 60-90% of children improving after surgery - however there is a reasonably high complication and reoperation rate.
● Post-pyloric feeds
scoliosis
Monitoring
● Yearly x-rays (Cobb angle) +/- pulmonary function tests
● Cobbs measure – take angle of top and bottom of deformity
● Severity - 25-40 moderate, >40 significant
Treatment based on…
● Location – thoracic more likely to worsen than thoracolumbar or lumbar
● Maturity – brace if still young
● Potential to progress (neuromuscular, before growth spurt)
Treatments
● Observe (small curves, low risk of progression)
o Annual x-ray as a child, 5-yearly as an adult
● Idiopathic <30 watch, consider brace, >40consider surgery
● Conservative - physiotherapy – stretching and strengthening exercises
● Bracing – 25-40with growth still happening
o Prevents further but doesn’t correct
o Succeeds in 80% of cases
o Risk - pressure sores/respiratory compromise
o Requires chair that fits the curve (to minimise progression)
● Surgery if >40 /progression/affecting QOL/non-brace respondent
o Posterior spinal fusion
▪ Using bone graft from hip, several hours
▪ Most don’t need bracing after, out of hospital in one week, back to school in 2-4
weeks, back to total function in 4-6 months
o Anterior spinal fusion
▪ Deflate lung, remove rib, anterior approach
▪ Shorter recovery, better cosmetic, less segments, but need brace for several months
o Risks – death, respiratory failure, infection, protrusion of metalware
spasticity
Conservative(more effective for localised)
● Physiotherapy – stretching exercises
● Orthoses/serial casting – AFO (initially at night)
● Equipment: patient specific modifications for home/ sleep/ wheelchair. padding between legs to prevent sweeping
● Must be well-fitting or risk of pressure sores
Medical therapy
● Aims are to:
o Reduce spasticity to reduce pain and make care easier (possible)
o Prevent contractures and to improve function (unknown if current drugs do this)
● Better evidence for botox than oral drugs and has significantly fewer complications
● Botox, baclofen (oral/intrathecal), benzodiazepines, dantrolene (NB potentiates sedative effect benzos, interacts with Ca channel blockers)
o Botox 4-6 monthly
o Baclofen IT- programmable pump (continuous)
● Dystonia – baclofen/benzhexol/L-dopa
● Pain management: AS above, gabapentin
Surgical intervention
● Selective dorsal rhizotomy is the sectioning of the sensory nerve root which interrupts
the afferent arc causing spasticity, thus spasticity is reduced without affecting motor
function. Has good long term effects but which patients benefit most is unknown (i.e.
whether to operate only on severely affected patients)
● Monitoring for hip subluxation 6-monthly from 18 months, and early corrective surgery
on tight adductors and iliopsoas
● Muscle and tendon lengthening and transfer usually done once mature (8+ years) to
improve gait may include surgery on hamstrings, calves. Planning involves gait
analysis.
Acne
Simple measures
● Avoid precipitants (non-comodegenic beauty products)
● Don’t pick (causes scars)
● Regular cleansing - OTC cleansers (benzylperoxidase)
Topical antibiotics
● Clindamycin/erythromycin
Oral antibiotics
● Minocycline (avoid pregnancy/dry skin/sun sensitivity)
● Use for at least 3 months
Hormonal
● OCP - may help if premenstrual flares
Iso-retinoin
● Topical – often combined with antibiotic
● 10-20% have local irritation
Roaccutane
● Oral – for severe cystic acne
● Has to be prescribed by dermatologist for severe (cystic) acne
● Side effects: dry skin, sun sensitivity; teratogenicity (must be on at least two forms of contraception); depression
Bullying
Explore the underlying causes and fix if able
● Smelly PEG/drooling
Increase protective factors
● Increase self esteem
● Highlight the child’s strengths e.g. music, sports, art
● Assertiveness/confidence skills through counseling
● Increase socialisation and supports e.g. peer groups
● Ensure a positive family environment to provide support at home
● Liaise with the school – consider a ‘buddy’
● Find a trustworthy adult to report to
Reduce the bullying behaviour
● School policy - discuss with school
● Avoid situations that exacerbate it
● If really bad – may need to change schools
Compliance
When discussing medications explain that poor adherence is normal
Identify barriers
● Lack of understanding of long term complications
● Short term seen as more important than long term
● Educate
● Side effects or dislike taste
o Consider changing medication
● Doesn’t fit into their lifestyle – many medications/complicated regime
o Make regime as simple as possible and lifestyle friendly
o Negotiate regime with adolescent
● Forgetful
o Suggest reminders
o Enlist the support of others with adolescent’s approval
● Teasing at school
o Try to avoid school time medications or work with teacher to allow taking of medications privately
● Depression
o Seek appropriate treatment
Start increasing adolescents autonomy over illness
● Start seeing them alone and discuss confidentiality
● Re-educate (often they miss out on understanding as the problems begin as child or neonate) - explore their understanding of illness and correct any misunderstandings
● Educate about medications
Simplify the regime
● Reduce the number of medications (cease any that aren’t providing benefit)
● Reduce the frequency of dosing
● Tailor to their daily routine (avoid school-time medications)
● Involve the adolescent in the decision-making process (be flexible)
● Manage side effects
Increase their access to medications
● Oral and written instructions (avoid jargon)
● Keep medications by items of daily use (clock/toothbrush)
● Make it part of their routine (during ad break of favourite programme)
● Negotiate the role of parents that is acceptable to the adolescent
● Set alarms on phone (every adolescent now has a mobile phone that stays with them, turned on, 24/7)
Ensure they have health care card
● Focus on short term goals and follow up
● Encourage and praise
● Negotiate short term goals
● Medication free periods – ADHD on school holidays
School refusal
●Ensure parental support – agree on a time schedule
o Immediate if refusal period has been brief
o Graded exposure if longer (parent in class - tearoom - phone contact)
● Acknowledge reality of feelings
● Parent involvement - calm morning routines and escort to school
● School involvement:
o Try hard to keep child at same school
o Special supports (modified curriculum, reduced homework)
o Give child active tasks (i.e. lunch orders) therefore need to be there
● Child:
o Relaxation training/breathing retraining
o Social skills training
o Praise +/- graded reward system (star chart)
● Adolescents – consider alternative education options, e.g. TAFE, apprenticeship
● Monitor for mental health symptoms – anxiety, depression
● Referral to multidisciplinary mental health team for longer term school refusal
o If no improvement after two weeks or you suspect a more severe mental health
● Regular monitoring of progress and signs of relapse
Fussy eating
Dietary advice
● Consumption of excessive fluid reduces the intake of solid foods, so offer solids
before liquids
● Limit intake of juice, and carbonated drinks
● If weight is ok, offer water, if failure to thrive offer milk or formula instead
● Variety is not important
● Offer foods that are easy to handle (e.g, Cheerios, French fries, slices of banana, or peas)
Feeding times
● Children need to eat often, not constantly
● Offer something every two to three hours, to allow three meals and two to three snacks per day
● Avoid snacks right after an unfinished meal
● Children work well with schedules - try to keep mealtimes and snack times about the same each day.
● Allow one hour without food or drink (except water) before a meal to stimulate the appetite.
● Do not make mealtime too long - 15 minutes is probably long enough for a toddler
Feeding behavior
● Try to relax; feeding/eating and mealtimes should be pleasant for everyone
● Recognise the childs cues indicating hunger, satiety, and food preferences
● Parents are responsible for deciding what food the child is offered (with consideration for the childs preferences); the child decides how much to eat
● Avoid battles over eating - encourage, but avoid forced feeding, threatening, bribing, or punitive approaches; instead, use positive reinforcement (e.g. praise for eating
well)
● Do not withhold food as a form of punishment
● Allow the child to feed himself or herself - try very small amounts at first, offer seconds later.
● Expect messiness and be prepared for easy clean-up (bibs, newspaper under high chair, etc)
growth
Management:
● Ensure intake is adequate
● Manage chronic disease
● Ensure losses are reasonable (not malabsorping)
Growth hormone principles
● Short term catch up, long term linear growth
● Achieve familial potential
Indications (given daily >6 days/wk)
● <1st centile and growth velocity <25th over 1 year
● Usually need three heights over a year, bone age
● Radiotherapy/pituitary surgery
o Male >15 years old and bone age >13 years
o Female >12.5 years old and bone age >10.5 years
o And velocity <25th centile over 6 months
● Renal
o GFR <30ml/min/m2
o And velocity <25th and height <25th
● Turner syndrome
o <95th centile on Turner syndrome charts
Side effects
● Slipped upper femoral epiphysis, benign intracranial hypertension, gynaecomastia,
reversible hypothyroid
● IGF1 – increased risk of prostate, breast, colon cancer
Stop treatment if:
● Bone age >13.5 in girls, >15.5 in boys
● >10th centile for adult height
● No response (<4cm/yr)
Immunosuppressants.
Monitor for specific adverse effects
● Mycophenolate - GI upset, leucopenia
● Tacrolimus - renal impairment, hyperglycemia, hypomagnesemia, neuro (seizures,
tremors) does not increase cholesterol, is CYP450 substrate
● Cyclosporin - renal impairment, “hyper” - tension, trichosis, kalemia, plasia of gingiva -
and hypomagnesemia
● Methotrexate - mucositis or ulcers, bone marrow suppression, heptatotoxicity
● Not:
o Lipids with CSA despite previous teaching
o Infertility unless cyclophosphamide
In practice:
● Clinical and laboratory monitoring is baseline BP and bloods (FBE, UEC, LFT), two- weekly for the first few months and then two-monthly after that
● If adverse effects - reduction in dose, changing of drug or management of known adverse effects
Monitoring for leading causes of death (proportional to degree of immunosuppression)
● Infection - especially EBV, CMV, PCP (less on prophylaxis)
● Post-transplant lymphoproliferative disorder
● Cardiovascular risk factor reduction (major cause of death in adult transplant patients)
● Sunscreen and skin cancer monitoring
● Immunisations (not varicella if immunosuppressed per previously mentioned criteria) including for family
Irritability
Differential diagnosis:
● GORD, constipation, dental, fractures, pressure sores, otitis media
Treatments:
● Behaviour - sleep hygiene, routine
● Environment - light, music
● Alternatives – melatonin, massage, acupuncture
● Treatment – diazepam, paracetamol, baclofen
Menstruation
Treatment:
● Sanitary pads, nappies (suppression is an option)
● Heavy bleeding - NSAIDs (by 30%) or tranexamic acid (by 50%)
● Contraception - reduces frequency of periods
● Reduce dysmenorrhea
● Control timing
● OCP (daily) – compliance may be an issue
o Beneficial for bones
o Risk of thromboembolism
o May require dose adjustment if on anticonvulsants
● Transdermal patch (weekly) or Depo Provera (IM 3 monthly)
o Side effects - mood, pain, weight gain, spotting
● Implants (3-5 years)
● Mirena (progesterone only device) – amenorrhea ~5 yrs
o May have spotting
● Intrauterine devices – not recommended if cognitive impairment
o Can’t report pain
o Side effects - menorrhagia/dysmenorrhea
Remember -need for a concurrent barrier protection against STDs
Menorrhagia
● Change super pads every two hours
● Education is dependent on the response to blood/toileting/intellectual capabilities
● FBC, iron, TFT, APTT, PTT, von Willebrand factor, platelet function
● Treatment – NSAIDs (reduction in 30%), tranexamic acid (reduction in 50%), OCP, Depo, implanon)
Needle phobia
Address fears
Trauma of procedure
● Use different room
● Anaesthetic cream/nitrous/midazolam/sucrose and swaddle
● Experienced personnel with equipment prepared earlier
● Consider a long line if repeated access is required
Coping strategies
Child
● Prepare: demonstrate on a doll first
● During - play therapist for distraction techniques
● Blow away the pain
Adolescent
● Prepare - plan including who will be in the room/techniques
● During - breathing exercises/hypnotherapy
● Distraction - rub on the site to close pain gate
Parents role
● Educate parents about what not to say (no bargaining/apologies/threats)
● Encourage to keep calm and their main role is as distraction
● Not to be involved in restraining the patient
Note: consider long line/port/CVC if repeated access is required.
obesity
Attitudes and motivation (both patient and family), especially where there is parental obesity
Overall goals
● Establishment of permanent healthy lifestyle habits
● Improvement in medical and psychological complications of obesity
BMI as primary measure – aim for static weight gain (grow into height)
Parental participation vital as role models/authority figures and purchasers of food (create environment)
Age appropriate portions in toddlers and stroller in pre-schoolers
General measures:
● Limit sugary beverages
● Energy dense food
● Avoid dining out (especially fast food)
● Encourage breakfast every day
● Fruit and veggies (aim for 5 times per day)
● Family meals/eating together (associated with higher quality diet)
● Self-regulation of portions (parents decide what, child decides how much)
● Limit TV and other screen time (<2 hrs/day)
● Exercise (60 mins/day)
If overweight, aim is weight maintenance (decrease in BMI as gets older, height increases)
● Ensure monthly follow-up
● If no improvement in BMI or weight in 3-6 months, seek dietician involvement
● Ask what they think they could do
● Exercise, dog walks, stairs, decrease screen time
● Nutrition and drinks – healthy snacks
● Follow up
oral aversion
● Eliminate the underlying cause if possible (NG tube/O 2 tubes/nausea/GORD)
● Better to avoid food if there is an active issue (can cause long-term aversion)
● Involve a speech pathologist and dietician
Educate parents
● May take a long time to improve
Start introducing food at an early age
● Make it fun - play therapy to introduce foods of different tastes, textures and smells
(lay it on a mat on the ground and they can play with it)
● Have this done during family meals – also improve bonding of the child with family, understands the concept of meal time, and that eating is fun
Monitor growth and nutritional status
Monitor dental health
