Module 2 Flashcards
Gday
What’s up
Failure to thrive
Term given to child under 5 yrs and is defined as?
-Weight less than 2nd percentile on 2 seperate occasions
-Weight loss, then slow increase of height and in sever cases head circumference
Permanent damage to CNS function can result from poor nutrition
Failure to thrive signs (5)
-Disinterested in surroundings
-Avoid eye contact
-Become irritable
-regular night waking
-not reach developmental milestone like crawling, walking and talking
Cause of Failure to thrive
There is a problem with: Intake, absorption, Utilisation
1. Subluxation- can affect feeding coordination, or cause excessive vomiting/ reflux, pain increases metabolic rate
2. Social - parents too busy/ distracted/ stressed, are the parents missing hunger signs - ie is the child simply being underfed
3. Gut problems- GERD, chronic diarrhoea, cystic fibrosis, chronic liver disease.
4. Other medical conditions- cleft palate, heart, lung conditions
5. Cows milk protein allergy - very common cause, along with soy milk allergy
6. Urinary tract infections, parasites
7. Metabolic disorders- lactose intolerance, fatty acid malabsorption (ask fam history)
Diagnosis of FTT (history)
Taking a history?
What questions would you ask?
When did weight gain issue start? Post immunisation?
1. Allergies?
-Known/ Diagnoses/ suspected
-Risk factors (any siblings or parents on rice, oat, soy, goat milk due to allergy)
-Ask specifically about breastfeeding maternal intake of cows milk, cheese, yoghurt, wheat, soy, nuts, eggs, seafood.
-Mediterranean communities- increased risk of cows milk allergies
-Vomiting? Eczema? Recurrent nasal congestion?
- Prematurity
- Remember to correct for age till 24 months, Also increased risk of low iron - Feeding
-Breast/ formula, duration, frequency, strength - Overall mood
- Maternal Vit D levels during pregnancy
-reduces feeding vigour if child also low in vit D - Jaundice - makes children lethargic
- Any medications
-losec may increase risk of allergies - Any fever, illness, cough, smelly urine, nasal discharge
Maternal Milk Factors
Supply 4 major factors
1. Stress
2. Sleep
3. Nutrient density (ask about breakfast, lunch dinner, snacks)
4. Water intake
Also ask about
Exercise levels- don’t sweat, is mum trying to lose weight?
-Supplements (fenugreek and motilium)
Formula and solids:
- Which formula, when?
- Any past reactions/ changes?
-IF baby finished is quickly do you offer more?
Solids:
- what, how often, and who determines it is finished
- TIP if baby finishes bowl, give more till rejects
Bowel Motions:
-frequency (newborn- every nappy dirty, reduces to 1/day between 1-3 months)
-Size (small and infrequent if poor uptake)
- Consistency (watery if poor absorption, constipation of CMPA (cows milk protein allergy?), explosive if lactose intolerance)
-TIP colour is generally overemphasised, and variability is the norm
Examination of Failure to Thrive
Guidelines for the Chiropractor
-Visualise the overall wellbeing of the child
-observe parental responsiveness
-hold the child if irritated
-Weight naked on calibrated scales
-measure weight, length and HC
-Plot measurements on WHO chart
-Observe feeding if suitable
-Work with lactation consultant
- Subluxation assessment
- Assess conjunctiva and oral mucosa for pallor
- Palpate cervical auxiliary, supraclavicular lymph nodes
- Palpate kidneys for tenderness of UTI
- perform dipstick test * - Measure liver and spleen margin for allergy *
- Palpate the bowel for constipation caused by allergy *
- Cardiac and respiratory assessment*
How to we manage an infant who is failing to thrive?
For breast fed infant
For breast fed infant: manage as crisis!
1. Adjust subluxations as indicated
2. tell the family you will ‘step by step’ them through this process, and co- manage if required
3. Advise mother on milk supply (increase sleep, reduce stress, 2-4L water, huge meals, and snacks, modify exercise, supplement if required, Vit D, breast feeding cookies* )
4. Allergen elimination should be balanced against potential for impact on maternal supply
5. Look for decreased irritability, better feeding, decreased number of feeds as a result of treatment (re-weigh within 7 days)
- Caution to waking baby to feed- can be fussy if tired, and mother not rested enough
- Increase sun exposure if jaundiced.
- Offer ‘rollover/ dream’ feed
- Refer to:
-Lactation consultant
-Naturopath
-Paediatrician if persistent
-paediatric chiropractor
Management of failure to thrive for for formula fed infant
TIP: if not finishing bottle, may be:
-low iron- consider giving supplement
-flavour issues- trial another formula (ie HA, GMF)
- Too slow teat- consider faster teat
If high risk allergy (ie family history, or evidence on physical examination- enlarged liver/ spleen, constipation, respiratory wet sounds, eczema, constipation), move to cows milk- free formula trial for 2 weeks, and closely monitor
-Weight
-vomiting
-Subluxation recurrence
If allergy evidence, which formula is best?
1. Goat’s (Holle) formula first
2. 100% whey formula (HA)
3. Extensively hydrolysed
Eg Pepti- junior, Alfare
-purchase small tin from chemist, if helpful, get script from paediatrician
4. Amino- acid formula
Eg Neocate, elecare
Through paediatrician
How much weight is normal to lose after birth for baby?
Breast fed neonate may lose <10% of birth weight in first 1-2 weeks before mums milk is established
This is not considered full failure to thrive, but transient period before the feeding is established
-In Australia in 2004, the average birth weight was 3370g. So loss of 10% is 330 g
Most babies recover rapidly and achieve birth weight <2 weeks
Practice charting these details on growth chart.
Exam Q
Maddison presents at 4.5 months of age regarding poor weight gain and feeding difficulties
Born at 40 weeks gestation
Copy and past it from page 23
Serious Illness in Children
What is the red flags that warrant the referral criteria. IMPORTANT.
-Cyanosis
-Rapid breathing
-Poor peripheral circulation
-Petechial rash *
-Temperature >40deg C
Petechial rash in a well child
When is it normal ?
What are the causes if Petechial rash?
1 or 2 petechia are common and their presence should not be taken as pathological without other clinical signs
Causes:
1. Infection
-serious bacteria illnesses eg meningococcemia, or streptococcus, H - influenza, effective endocarditis.
2. Mechanical
-coughing or vomiting (limited to head and neck regions) local pressure or strangulation?
3. Haematological
-thrombocytopenia, leukaemia and hypersplenism, platelet dysfunction eg congenital drugs, + renal failure
- Vascular
-Vasculitis
Referral criteria (RED FLAGS)
Other worrying signs in children include
-unconsciousness
-meningeal irritation
-Shortness of breath (dyspnoea)
Other findings that indicated strong likelihood of serious illness.
-parental concern
-clinical instinct
-Altered crying pattern
So listen to parents, to your gut and to your baby
Referral Criteria - Traffic lights
Red- immediate referral to emergency by ambulance
Amber- refer if uncertain, or offer safety net
• Red: immediate referral to emergency by ambulance
• Amber: refer if uncertain, or offer ‘safety net’.
• Green: watch and wait, with ‘safety net’.
RED HIGH RISK
Unable to rouse or if roused doesn’t stay awake
Weak high pitched or continuous cry
Pale/ mottled/ blue/ ashen (cyanosis)
reduced skin turgor
Bile stained vomiting
Moderate to severe chest drawing (dyspnoea)
RR> 60
Grunting
Bulging fontanelle
Appearing all to healthcare professional
AMBER- Intermediate risk;
Wakes only with prolonged stimulation
Decreased Activity
Poor feeding in infants
Not responding normal to social cues/ no smile
Dry mucous membranes
reduced urine output
Pallor reported by parent or carer
nasal flaring
Green- Low risk:
Strong cry
Content/ Smiles
Stays awake
normal colour of skin, lips and tongue
Moist mucous membranes
normal response to social cues
Antibiotics and serious illnesses
“The fever is not the problem. It is the cause of the fever that we are concerned about”
In absence of red flags, medical guidance is clear regarding oral antibiotics for child with fever without apparent source.
“oral antibiotics are not to be prescribed to child with fever without an apparent source”
Reasons to refer a neonate to hospital for a suspected serious illness
• Acute body weight loss of 5% or greater
• Acute onset of signs/symptoms
• Subluxation-free infant
• Serious Illness Observational item score more than 10
• Poor arousal, circulation or dyspnea, floppy baby
• Decreased fluid intake or excretion
• Lethargy
• Jaundice
• Sustained posturing
• Persistent bile-stained vomiting
• A first convulsion
• Periods of apnoea
• Respiratory grunting or central cyanosis
• Lump >2cm diameter – excepting hydrocele and umbilical hernia
• Petechial rash
• Blood evidence in faeces
• Fever of >3 days duration in a child who is on antibiotics
• Any other clinical/examination finding that raises suspicions – respiratory, gastrointestinal, genitourinary or neurological
• Clinical intuition, as well as maternal intuition
Referral criteria (RED FLAGS)
5
• Cyanosis
• Rapidbreathing
• Poorperipheralcirculation
• Petechialrash*
• Temperature>40oC
Other:
• Unconsciousness
• Meningeal irritation
• Shortness of breath (dyspnoea)
• Parental concern
• Clinician instinct
• Altered crying pattern
List 13 causes of a fever
1 infection,
2 vaccines,
3 biologic agents (granulocyte-macrophage colony-
stimulating factor, interferons, interleukins),
4. tissue injury (infarction, pulmonary emboli, trauma, intramuscular injections, burns),
5. malignancy (leukemia, lymphoma, hepatoma, metastatic disease),
6. drugs (drug fever, cocaine, amphotericin B), possibility of drug fever should be considered if a patient is receiving any drugs
7. immunologic-rheumatologic disorders (systemic lupus erythematosus, rheumatoid arthritis),
8. inflammatory diseases (inflammatory bowel disease),
9. granulomatous diseases (sarcoidosis),
10. endocrine disorders (thyrotoxicosis, pheochromocytoma),
11 metabolic disorders (gout, uremia, Fabry disease, type 1 hyperlipidemia),
12 genetic disorders (familial Mediterranean fever), and
13 unknown or poorly understood entities
Retinoblastoma – mostly <2yrs
Signs and symptoms
In a child with a white pupillary reflex (leukocoria), an urgent referral should be made.
The chiropractor should pay careful attention to the report by a parent of noticing an odd appearance in their child’s eye.
A child with a new squint or change in visual acuity should be referred.
Whats going on here?
Normal moulding for breech position –
head against the uterine fundus. Long AP
and flat top. Like all moulding, resolves in days.
What is wrong with this infant?
Not sure look in book
But I imagine its Bells palsy
What is wrong with this infant?
What criteria is used to differentiate when dimples above anus need to be referred for further evaluation?
• The following criteria have been found to differentiate best between dimples that require further evaluation and those that require only routine follow-up evaluation:
multiple dimples
dimple diameter larger than 5 mm
location greater than 2.5 cm above the anal verge
association of the dimple with other cutaneous markers.
What is this and what does it mean?
Spinal Raphism
Spinal dysraphism (also called spina bifida) is a condition in which a baby’s spine and spinal cord do not form properly during pregnancy. The spine and spinal cords are then exposed to the surrounding environment inside or outside the body.
