Paediatric core condition- 4 Flashcards
Intestinal obstruction
Intestinal obstruction is where a physical obstruction prevents the flow of faeces through the intestines. This blockage will lead to a back-pressure through the gastrointestinal system, causing vomiting. It also causes absolute constipation, where the patient is unable to pass stools or wind.
Causes and diagnosis of intestinal obstruction
Causes= Meconium ileus, Hirschsprungs disease, Oesophageal atresia, Duodenal atresia, Intussusception, Imperforate anus, Malrotation of the intestines with a volvulus, strangulated hernia
Diagnosis= Abdominal xray. This may show dilated loops of bowel proximal to the obstruction and collapsed loops of bowel distal to the obstruction. There will also be absence of air in the rectum.
Presentation of intestinal obstruction
- Persistent vomiting. This may be bilious, containing bright green bile.
- Abdominal pain and distention
- Failure to pass stools or wind
- Abnormal bowel sounds. These can be high pitched and “tinkling” early in the obstruction and absent later.
Management of intestinal obstruction
Needs to be referred to a paediatric surgical unit as an emergency. Initial management involves making them nil by mouth and inserting a nasogastric tube to help drain the stomach and stop the vomiting. They will also require IV fluids to correct any dehydration and electrolyte imbalances, and keep them hydrated while waiting for definitive management of the underlying cause.
Anxious personality disorder category
- Avoidant personality disorder features severe anxiety about rejection or disapproval and avoidance of social situations or relationships.
- Dependent personality disorder features heavy reliance on others to make decisions and take responsibility for their lives, taking a very passive approach.
- Obsessive compulsive personality disorder features unrealistic expectations of how things should be done by themselves and others, and catastrophising about what will happen if these expectations are not met.
Suspicious personality disorder
- Paranoid personality disorder features difficulty in trusting or revealing personal information to others.
- Schizoid personality disorder features a lack of interest or desire to form relationships with others and feelings that this is of no benefit to them.
- Schizotypal personality disorder features unusual beliefs, thoughts and behaviours, as well as social anxiety that makes forming relationships difficult.
Emotional/impulsive personality disorder
- Borderline personality disorder features fluctuating strong emotions and difficulties with identity and maintaining healthy relationships.
- Histrionic personality disorder features the need to be at the centre of attention and having to perform for others to maintain that attention.
- Narcissistic personality disorder features feelings that they are special and need others to recognise this or else they get upset. They put themselves first.
Management= CBT and psychotherapy, no medical treatment available
Attachment disorder- principles of diagnosis
- difficult
- no specific validated tools for screening/assessing attachment disorders
- many available tools e.g. Attachment Q-sort, Manchester Child Attachment Story Task…
- can only diagnose based on interviews, history, and behavioral observation
2 types of attachment disorder and main cause
- reactive attachment disorder: inability to attach to preferred caregiver
- disinhibited social engagement disorder: indiscriminate sociability and disinhibited attachment behaviour
Most common cause of attachment disorder: early pathogenic care
Disinhibited social engagement disorder criteria
- > 2 of:
-Reduced/no reticence in approaching and interacting with unfamiliar adults
-Overly familiar verbal or physical behavior
-Reduced/no checking back with caregiver after venturing away, even in unfamiliar settings
-Willingness to go off with an unfamiliar adult with little/no hesitation - Sx NOT characterized by impulsivity (i.e. ADHD)
- Pathogenic care – e.g. social neglect/deprivation, repeated change in caregivers, growing up in unusual settings
- developmental age >9m
Reactive attachment disorder criteria
- chronic pattern of being emotionally withdrawn/inhibited – rarely seeks comfort when distressed
- chronic social/emotional perturbation-may incl. social withdrawal, negative affect, unfounded episodes of irritability or sadness or fear, disproportionate reactions to stress
- hx of extremely insufficient care i.e. deprivation or social neglect of basic emotional needs, constant flux of caregivers/homes, growing up in unusual settings
- can’t meet ASD criteria
- behavioral perturbation must begin <5y
- must be developmentally >9m
Attachment disorder- management
- Enhanced caregiving: e.g. safe, responsive, and consistent caregiver; safe and stable living situation; positive, stimulating, environment; address medical, safety, and housing needs; develop positive interactions and strengthen attachment with carers
- May need adjunct treatment for aggression and oppositional behavior
- Also consider individual and family counseling, education of carers about condition, parenting skills classes
Neonatal sepsis: common organisms, risk factors and clinical features
Common organisms: Group B strep (GBS), E.coli, Listeria, Klebsiella
Risk factors= vaginal GBS colonisation, GBS sepsis in previous baby, maternal sepsis, chorioamnionitis, prematurity, PPROM
Clinical features= fever, poor feeding, reducing tone, respiratory distress, vomiting, tachycardia, hypoxia, jaundice within 24 hours, seizures, hypoglycaemia
Treatment for presumed sepsis
- If there is one risk factor or clinical feature, monitor the observations and clinical condition for at least 12 hours
- If there are two or more risk factors or clinical feature of neonatal sepsis start antibiotics
- Antibiotics should be started if there is a single red flag
- Antibiotics should be given within 1 hour of making the decision to start them
- Blood cultures should be taken before antibiotics are given
- Check a baseline FBC and CRP
- Perform a lumbar puncture if infection is suspect meningitis (e.g. seizures)
Antibiotics for presumed neonatal sepsis
Antibiotic choice= Benzylpenicillin and gentamycin are first line. Cefotaxime can be given in lower risk babies
Neonatal sepsis: ongoing management
- Check the CRP again at 24 hours and check the blood culture results at 36 hours:
- Consider stopping the antibiotics if the baby is clinically well, the blood cultures are negative 36 hours after taking them and both CRP results are less than 10.
- Check the CRP again at 5 days if they are still on treatment:
- Consider stopping antibiotics if the baby is clinically well, the lumbar puncture and blood cultures are negative and the CRP has returned to normal at 5 days.
- Consider performing a lumbar puncture if any of the CRP results are more than 10.
Irritable hip i.e. transient synovitis pathophysiology
Temporary irritation and inflammation in the synovial membrane of the joint. Most common cause of hip pain in children aged 3-10 years, often associated with viral upper respiratory tract infections. Children with transient synovitis typically do not have a fever. Children with joint pain and a fever need urgent management for septic arthritis.
Transient synovitis features
- limp/refusal to weight bear
- groin or hip pain
- a low-grade fever is present in a minority of patients
- Usually self limiting, requiring only rest and analgesia
Transient synovitis: NICE guidelines
Children aged 3 – 9 years with symptoms suggestive of transient synovitis may be managed in primary care if the limp is present for less than 48 hours and they are otherwise well, however they need clear safety net advice to attend A&E immediately if the symptoms worsen or they develop a fever. They should also be followed up at 48 hours and 1 week to ensure symptoms are improving and then fully resolve.
Acute lymphoblastic leukaemia (ALL)
The most common malignancy affecting children and accounts for 80% of childhood leukaemias. The peak incidence is at 2-5 years of age and boys are affected slightly more commonly than girls. Associated with Downs syndrome and the Philadelphia chromosome (t(g:22) translocation.
Symptoms of Acute lymphoblastic leukaemia (ALL)
Features may be divided into those predictable by bone marrow failure:
* anaemia: lethargy and pallor
* neutropaenia: frequent or severe infections
* thrombocytopenia: easy bruising, petechiae
* Other symptoms: bone pain (secondary to bone marrow infiltration), splenomegaly, hepatomegaly, testicular swelling
* fever is present in up to 50% of new cases (representing infection or constitutional symptom)
Types of ALL
- common ALL (75%), CD10 present, pre-B phenotype
- T-cell ALL (20%)
- B-cell ALL (5%)
ALL: poor prognostic factors
- age < 2 years or > 10 years
- WBC > 20 * 109/l at diagnosis
- T or B cell surface markers
- non-Caucasian
- male sex
ALL: diagnosis and treatment
- FBC- within 48 hours, children with ptechae or hepatosplenomegaly should be immediately
- Blood film- blast cells and leukocytosis
- Lactate dehydrogenase (LDH)- will be raised
- Bone marrow biopsy- definitive diagnosis
- Lymph node biopsy
ALL is commonly treated with chemotherapy
Acute myeloid leukaemia
- Most common acute leukaemia in adults
- Bone marrow failure: anaemia, bleeding, infection. Hepatomegaly, Splenomegaly and gum hypertrophy
- Blood tests show leukocytosis, white cells can be normal or low. Bone marrow biopsy shows Auer rods
- Management: chemotherapy and bone marrow transplant
- Poor prognosis: death within 2 months without treatment
Chronic myeloid leukaemia
- Commonly affects middle aged men
- Strongly associated with the Philadelphia chromosomes
- Symptoms: weight loss, tiredness, fever, sweating. Common signs include massive splenomegaly, bleeding (due to thrombocytopenia) and gount
- Diagnosis: Blood tests commonly show leukocytosis, in particular raised myeloid cells
- Treated with chemotherapy, with treatment survival is 5-6 years
Chronic lymphoblastic leukaemia
- Most common in males over 60 due to the proliferation of functionally incompetent malignant B cells
- Normally asymptomatic but can present with non-tender lymphadenopathy, hepatosmegaly, weight loss, night sweats and fever
- Diagnosis= The most common initial blood result is an incidental lymphocytosis. Subsequent blood film shows smudge cells, which are cells damaged as they lack a cytoskeletal protein. Also use flow cytometry and bone marrow biopsy
- Treatment: chemotherapy
Risk factors for leukaemia= syndromes
Downs syndrome, Kleinfelters syndrome, Noonan syndrome, Fanconi’s anaemia
Pyloric stenosis
Pyloric stenosis typically presents in the second to fourth weeks of life with vomiting, although rarely may present later up to four months. It is caused by hypertrophy of the circular muscles of the pylorus. More common in males, first borns and with family history
Pyloric stenosis: features
- ‘projectile’ vomiting, typically 30 minutes after a feed
- constipation and dehydration may also be present
- a palpable mass may be present in the upper abdomen
- hypochloraemic, hypokalaemic alkalosis due to persistent vomiting
- Failure to thrive, if examined after feeding you can see peristalsis in the abdomen
Pyloric stenosis: diagnosis and management
Diagnosis is most commonly made by ultrasound.
Management involves laparoscopic pyloromyotomy (known as Ramstedt’s operation). Until the procedure should be nil by mouth and kept on IV fluids. Severely dehydrated babaies may require acute fluid resuscitation.
Non accidental history
Any bodily injury on a child that has been deliberately inflicted upon them, or any injury which the caregiver has failed to prevent
Non accidental injury: History
- Most often occurs in children <2 years old
- Often delayed presentation with injury
- Caregiver history may be inconsistent in terms of: Changing narratives, Narrative not matching up with the severity/type of injury shown
- Injury is unwitnessed
- Evidence of drug or alcohol use in the household
Non- accidental injury: Examination
Findings will vary based on type of injury inflicted
* Injuries of varying ages
* Presence of burns or scalds
* Multiple or clustered bruising
* Bruises on arms, legs or face consistent with gripping
* Subconjunctival haemorrhage
* Retinal haemorrhage
* Human bite marks
Non-accidental injury: Radiology
A full skeletal survey may be required:
* Rib fractures
* Skull fractures / cranial bleeds
* Metaphyseal corner fractures (occur due to a twisting/pulling motion on a limb)
* Finger fractures
* Clavicle fractures
* Bloods to exclude organic causes such as clotting disorders or haematological malignancy
Non-accidental injury: management
- Always inform a senior if you suspect non-accidental injury. Every workplace will additionally have a named safeguarding lead you can contact
- Admit the child for safeguarding while investigations continue. Ensure other children at home are also safe.
- Management of injuries
- Clear and thorough documentation is vitally important
- Contact social care to see if the child/caregiver is known to them already
Non-accidental injury: risk factors
- Substance abuse or mental health condition
- Excessive crying- can trigger shaking of baby
- Unintended pregnancy
- Developmental problems
Prematurity: risk factors
Social deprivation, smoking, Alcohol, Drugs, Overweight or underweight mother, maternal co-morbidities, twins, family history
Medication for delaying labour
- Prophylactic vaginal prostaglnadins
- Prophylactic cervical cerclage
Medications to improve outcomes antenatally
- Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour
- Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality
- IV Magnesium sulphate: can be offered before 34 weeks gestation and helps protect the baby’s brain
- Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby
Prematurity: issues in early life
- Respiratory distress syndrome, Hypothermia
- Hypoglycaemia, Poor feeding
- Apnoea and bradycardia
- Neonatal jaundice
- Intraventricular haemorrhage
- Retinopathy of prematurity
- Necrotising enterocolitis
- Immature immune system and infection
Prematurity: long term effects
- Chronic lung disease of prematurity
- Learning and behavioural difficulties
- Susceptibility to infections, particularly respiratory tract
- Hearing and visual impairment
- Cerebral palsy
Small for gestational age: complications
- Iatrogenic prematurity
- Antenatal or intrapartum asphyxia
- Operative delivery
- Perinatal death including stillbirth
- Neonatal hypoglycaemia and hypocalcaemia
- Necrotising enterocolitis
Small for gestational age: Delivery
- <37 with absent/reverse end diastolic flow measured on a umbilical artery doppler= recommend Caesarean section
- <37 weeks with abnormal end diastolic flow measured on a umbilical artery doppler= offer induction of labour
- At 37 weeks with normal umbilical artery doppler= offer induction of labour
Diagnosing and classifying SGA
SGA = EFW (estimated fetal weight) OR AC (abdominal circumference) is less than the 10th centile on a customised growth chart
Severe SGA =EFW OR AC less than the 3rd centile on a customised growth chart
Serial ultrasound scans are used for diagnosis of SGA performed from 26-28 weeks gestation. US measurement of size and assessment of wellbeing with umbilical artery doppler is performed every 3-4 weeks until delivery
SGA: screening
Any woman with one major risk factor will be referred for serial growth scans, which are essential to monitor and diagnose SGA. If a woman has three or more minor risk factors, she should be referred for uterine artery Doppler at 20-24 weeks gestation. Women with abnormal uterine artery Doppler should also be referred for serial growth scans.
SGA: risk factors
- Major: previous stillbirth, previous SCG fetus, cocaine use, >40, maternal disease, threatened miscarriage, low PAPP-A, pre-eclampsia, cigarette somking
- Minor: nulliparity, IVF, maternal BMI <20 or >25, previous pre-eclampsia
Causes of SGA
- Constitutionally small
- Non-placental mediated growth restriction: chromosomal or structural abnormalities, fetal infection, inborn errors of metabolism
- Placental mediated growth restriction: pre-eclampsia, autoimmune disease, thrombophilia, renal disease and essential hypertension
Obesity: NICE recommendations
- consider tailored clinical intervention if BMI at 91st centile or above.
- consider assessing for comorbidities if BMI at 98th centile or above
Obesity: risk factors
- Asian children: four times more likely to be obese than white children
- female children
- taller children: children with obesity are often above the 50th percentile in height
Cause of obesity in children
- growth hormone deficiency
- hypothyroidism
- Down’s syndrome
- Cushing’s syndrome
- Prader-Willi syndrome
Consequences of obesity in children
- orthopaedic problems: slipped upper femoral epiphyses, Blount’s disease (a development abnormality of the tibia resulting in bowing of the legs), musculoskeletal pains
- psychological consequences: poor self-esteem, bullying
- sleep apnoea
- benign intracranial hypertension
- long-term consequences: increased incidence of type 2 diabetes mellitus, hypertension and ischaemic heart disease
