Paediatric lectures Flashcards
Paediatric history differences
Antenatal/ postnatal
Immunisations
Development
Antenatal and postnatal questions
Gestation Growth scans Special care Mode of delivery Weight
Immunisations questions
Shows how theyre interacting with healthcare
Measles?
Development history
Ask parents what they can do
Paediatric social history
Smoking
School
Pets
Examination differences
Observation is important
Opportunistic
Which pulse do you do in babies
Femoral
Heart failure in children
Scrotal and labial oedema (gravity)
Perioorbital oedema
How is oedema different in children
No pitting
How to assess hydration in children
Fontanelle
Respiratory examination differences
They get recessions as rib cage isnt calcified
- tracheal tug
- head nod
Abdominal examination differences
Do SHRUG
Neurological examination differences
chair?
4 domains of development
Gross motor
Fine motor and vision
Speech and hearing
Social and emotional
When should you smile by
6 weeks
Who developed pGALS
Versus arthritis
Theres an app
What to use for development
MRCPSYCH A4 sheet
ADHD age
kids act a 3rd younger than they are
3 core symptoms of ADHD
Inattention
Impulsivity
Hyperactivity
ADHD Diagnosis
Inattentive
Hyperactive/impulsive symptoms
Criteria for hyperactive/ impulsive symptoms
Present before 12 years
Developmentally inappropriate
Several symptoms in 2 or mroe symptoms
Clear evidence symptoms effect on function
Inatttentive symptoms
Easily distracted
Hyperactive symptoms
Talks excessively, cannot perform quietly
Impulsive symptoms
Blurts out answers, difficulty awaiting turn
What are ADHD at risk of
Risky behaviour
What birth age is likely to lead to ADHD
Preterm birth
New accurate test for ADHD
QB test
Causes of ADHD
Polygenetic
CNS insults
Environmental factors
CNS insults which can cause ADHD
Prematurity
Fetal alcohol syndrome
NF
Treatment of ADHD
Education Parenting programme School support Medications Examinations Healthy lifestyle
Which disease is high risk in ADHD
Cardiac disease
Treatments for ADHD
Stimulants or non stimulants
Stimulant for ADHD
Methylphenidate
Autism key areas
Social communication
Social interaction
Social imagination
Sensory issues
Communication difficulties in autism
Lack of desire to communicate
Communicating needs onlyu
Disordered or delayed language
Language pause at 20 months is suggestive of
Autism
What is echolalia
repeating back, happens in autism
Social interaction in autism
No desire to interact with others Being interested in others to have needs met Lack of motivation please others Affectionate on own terms ONE SIDED IN PLAY
Play interaction in autism
Using toys as objects Inability to play or write imaginatively Poor problem solving Resist change Obsessions and rituals
What are the differences in obsessions between OCD and ADHD
OCD= anxiety and upsetting ADHD= enjoyable and relaxing
What commonly coexists with Autism
ADHD
Management for autism
Education and information
Parenting workshop
School support
Manage comorbidity
What aids are useful in ADHD
Visual aids
What should you consider in paediatric haemotology
Different referrence ranges, also depends on gestation
Where are blood cells made in childhood
At birth all bone marrow cavities, with age it is central bones
Which central bones produce stem cells in later childhood
Vertebrae
Sternum
Ribs
Pelvis
Describe pluripotent stem cells
Develop into precursor cells that give rise to mature erythrocytes, monocytes, megacaryoctes or lymphocytes.
Regulated by cytokines
3 mechanisms of anaemia
Decreased production
Increased consumption
Increased loss
What does low reticulocyte count suggest
Lack of production
What does high reticulocyte production suggest
Haemloysis or blood loss
Hypochromic microcytic anaemia
Iron deficiency
Thalassaemia
Normochromic normocytic anaemia
Chronic
Blood loss
Malignancy
Macrocytic anaemia
Vit B12
Folate
Hypothyroid
High reticulocyte anaemia
Haemolytic
Causes of hameolysis
Haemoglobinopathy
Enzymopathy
Membranopathy
Immune haemolytic anaemia
Causes of severe anemia at birth
Haemolytic disease of the newborn
Bleeding
Cause of haemolytic disease of the newborn
Rhesus negative mother, rhesus positive baby
Signs and symptoms of haemolytic disease of the newborn
Severe anemia
Compensatory enlargement of spleen and liver
Treatment of haemolytic disease of the newborn
Prevention of sensitisation with Rh.
Intrauterine transfusion of affected fetuses
Physiological anemia of the newborn
Fall in Hb from birth
Anaemia of prematuirty
Low birth weight infants have poor erythropoietin response
Iron deficiency anaemia
Poor intake and increased requirement
Breast feeding and infection
Much more dependent on dietary sources
Why do cows milk toddlers get anaemia
Reduces absorption of iron
Presentation of anaemia
Pallor Irritability Anorexia Tachycardia Murmur
Treatment of iron deficiency
Oral iron dose for 3-6 months (non compliance common)
What is haemolysis
Breakdown of red cells more rapidly than the body normal does
What is a consequence of haemolysis
Heart, liver and endocrine failure due to increased free iron
Intracorpuscular causes of haemolysis
Haemoglobin
Enzyme
Membrane
Extracorpuscular causes of haemoluysis
Autoimmune
Fragmentation
Hyper splenism
Plasma factors
Iron overload treatment
Chelation
Haemolytic anaemia presentations
High bilirubin
Hydrops
Failure to thrive
Stools
Haemoglobinopathies
Sickle cell and thalassemias
Sickle cell disease
Point mutation causes HbS to be produced
Thalassaemia
Imblance of the hemoglobin chains which means the tetramers dont form
What cells might be seen with anaemia on microscopy
Target cells
How is sickle cell found
Screened antenatally
Treatment for sickle cells
Prophylactic penicillin, immunisations
Sickle cell presentation
Always anaemia Infarction Infection Acute chest Iron overload
Sickle cell crisis
Bone pain due to sickling of cells in bones causing infarcts
Treatment for sickle cell crisis
Oxygen, antibiotics, opiates
Exchange transfusion
What is happening in thalassaemia
Reduced globin chain synthesis
Presentation of B thalassaemia minor
Asymptomatic
Mild anaemia, low MCV, riased Hb A2
Why dont you see thalassaemia at birth
Lots of HbF still
When does thalassaemia occur
6 months
B thalassaemia major presentation
Progressive severe anaemia Jaundice Splenomegaly Failure to thrive Skeletal deformity Delayed puberty Death
B thalassaemia major management
Genetic counselling
Transfusions
Iron chelation
Bone marrow transplant
G6PD presentations
Neonatal jaundice
Chronic anaemia
Intermittent intravascular haemolysis
What food can cause G6PD
Fava beans
Hereditary spherocytosis
AD
Mild to needing transfusion
Pure red cell aplasia
RBC failure of bone marrow (parvovirus)
Clinical sign of parvovirus
Slapped cheeks
Bone marrow failure syndromes
All cell lines affected
fanconi’s anaemia
Causes of bone marrow infiltration
Leuakaemia
Lymphoma
Neuroblastoma
Osteoporosis
Requirements for haemostasis
Platelets
Coagulation factors
Vascular integrity
ITP
Bruises
Petichiae
Very low platelets
Name two bleeding disorders
Haemophilia
Von willebrand disease
Name three clotting disorders
Antithrombin, protein C, protein S
Von willebrand disease
Reduction in vwf for factor 8.
VW disease bleeds
Bleeding from nose and injuries etc
Haemophilia bleeds
Joint and muscle bleeds
Treatment for VWF
For bleeds/ surgery
Tranexamic acid
Haemophilia A and B
X linked recessive. factors 8 and 9.
Which factor is haemophilia A
8
Which factor is haemophilia B
9
Presentation of haemophilia
FHx
Bruising
Mouth bleeds
Following trauma
Symptoms of leukaemia
Anaemia Infection Bleeding Systemic symptoms Organ infiltration
What is pathognomic of AML
Auer rod
What organisms cause tonsilitis
Gp A strep, adenovirus, EBV
What organisms cause epiglotitis
Haemophilius influenze B
What organism causes whooping cough
Pertussis
What organism causes otitis media
Pneumococcus
GpA strep
What organism causes Croup
Parainfluenza
What organism causes tracheitis
S. Aureus, strep A, haemophilius
What organism causes pneumonia
Strep A, pneumo, staph, haemophilus, TB
What organism causes bronchiolitis
RSV, rhino, flu, adeno paraflu
Varicella zoster virus presentation
Self limiting but deadly if secodnary staph or strep
Herpes simplex virus presentation
Stomatitis
Simple cold sore
Encephalitis
Excema
Kawasaki disease presentation
Fever Rash Stomatitis Periphery change Adenopathy
Under 3 months fever investigations
FBC
Blood culture
CRP
Urine culture
Child over 3 months fever investigations
FBC
Blood culture
CRP
Urine culture
CSF bacterial findings
Raised cell count
Raised protein
Low glucose
Bacteria identified or PCR
CSF viral findings
Raised cell count
Normal protein
Normal glucose
Virus identified in CSF, stool, throat or blood
Baby looks sick and WCC under 10
Antibiotics
Antibiotic for under 3 months meningitis
Cefotaxime and amoxicillin
Treatment for herpes simplex virus
Aciclovir
Over 3 months mengitis treatment
Cefotaxime
Meningitis under 3 months organism
GpB strep
Meningitis over 3 months organism
Meningococcus, pneumococcus, haemophilus influenza
Meningitis symptoms
Neck stiffness Sensitive to light Drowsy Irritable Vomit Headache Full fontanelle
Septicaemia symptoms
Red non blanching rash
Cold hands and feet
Tachypnoea
Flu like symptoms
Bronchiolitis findings
Bilateral crackles and wheeze
Which antibody moves across the placenta
IgG
10 warning signs of primary immunodeficiency
4+ ear infections 2+ sinus infections 2+ months on antibiotics 2+ pneumonia Failure to grow Recurrent abscesses Thrush IV antibiotics Sepsis FHx
Treatment of primary immunodeficiency
Antibiotic prophylaxis
Prompt treatment of infections
Replacement Ig
Bone marrow transplant
TB screening test
Mantoux test
In very young how do stats compare to adult
HR high
RR high
BP low
Temp same
Where does croup affect
Below the larynx
Respiratory distress symptoms
Recessions
Head nod
Tracheal tug
Cyanosis
3 things happening in asthma
Increase mucous production
Inflammation and oedema
Bronchoconstriction
Anaphylaxis affect on the lungs
Bronchospasm
Laryngospasm
How do you assess circulation
Capillary refill
Blood pressure
Heart rate
Colour
What is a very good surrogate sign to monitor for shock
Urine output
Why does lactate rise in shock
Increased anabolic metabolism
Causes of increased intercranial pressure
Space occupying lesion
Hydrocephalus
Trauma
Why does 6th nerve palsy occur
Longest intercranial route
How does heart rate and metabolism differ with temperature
Every degree increased is heart rate +10
What things are higher in children (relating to fluid balance)
Surface/ mass
Metabolism
Respiratory rate
What things are lower in children (relating to fluid balance)
Response to thirst
Independence
Glomerular filtration
% loses in children of water
Urine 60%
Skin and lungs 35%
Stool 5%
Reasons for reduced fluid intake
Dysphagia Neurodisability Vomiting Behavioural Psychiatric Social
Reasons for increased fluid losses
Gut
Kidneys
Skin
Lungs
Gut causes of increased fluid loss
Gastroenteritis
IBD
Stoma
Kidney causes of increased fluid losses
Renal tubular disease
Renal dysplasia
Skin causes of increased fluid losses
Burns
Sepsis
Signs of mild dehydration
Thirst
Dry lips
Reslessness
Irritbaility
Signs of moderate dehydration
Sunken eyes
Reduced skin turgor
Decreased urine output
Signs of severe dehydration
Reduced consciousness
Cold
Mottled peripheries
Anuria
Chronic dehydration consequences
Failure to thrive Malnutrition Developmental delay Constipation UTIs
How much fluid to a child
Maintenance + 50ml/kg
Which fluid do you give to neonates
10% glucose
How do you estimate weight in kilo
(Age + 4)x 2
Which fluid do you give children for maintenance
0.9% sodium chloride + 5% glucose
Less than 10kg how much fluid
100ml/kg/day
10-20kg how much fluid
50ml/kg/day
20+ kg how much fluid
20ml/kg/day
How much fluid to give to a shocked child
100ml/kg extra
Side effects of too much fluid
Oedema
Renal problems
Hyponatraemia
Cerebreal oedema
What is fluid bolus (exam question)
20mls/kg of 0.9% sodium chloride
Treatment of DKA in children
10mls/kg 0.9% sodium chloride
How much is too much fluid
More than 100ml in an hour
Procedural issues with paediatric radiology
Are they starved
Anatomy differences between adults and children
Flexible skeleton
Growth plates
Plastic bones
Why do children loose more heat
Greater surface area to volume ratio
Disease of newborns but not adults
Congenital
Disease of adults but not newborns
Coronary artery disease
Strokes
Lung cancer
Parent worries about radiology
Radiation
Invasive procedures
Why are children susceptible to mutations
Rapidly turning over cells
High radiation scans
CT
Nuclear medicine
PET
Low radiation scns
MRI
US
Name of end of bone
Epiphysis
Name of bit near the end of bone
Metaphysis
Where does the bone grow from
Metaphysis
What is the shaft of a bone called
Diaphysis
Where is the lamboid suture
At the back
Name of heart on wrong side
Dextrocardia
What is inverted whole system
Situs invertus
Fragile bones name
Oesteogensis imperfecta
What are the key radiological differences between childrens and adults
Size
Normal anatomy
Congenital problems
Lines and tubes
A normal chest xray should be
A good quality film No trachea No mediastinal deviation Lungs should be clear Heart borders and diaphragm
Why measure growth
Sensitive pointer to health problems in children. Growth is narrowly defined in healthy children with adequate nutrition and an emotionally supportive environment
Determinants of growth
Parental phenotype and genotype Quality and duration of pregnancy Nutrition Specific system and organ integrity Psycho social Growth hormones and factors
What is chondrogenesis
Growth
What regulates growth at a cellular level
Endocrine signals
Nutrition
Extracellular fluid
Inflammatory cytokines
What needs to be considered when assessing growth
Parental heights
Social inequalities
Ethnic background
Body proportions of newborn
Larger head, smaller mandible, short neck, rounded chest, prominent abdomen, short limbs
Hormone growth problem classic patient
Short and fat
Body proportions of adults
Relative growth of limbs compared to trunk
What does short limbs suggest
Hypochondroplasia
What does short back and long legs suggest
Delayed puberty
What measurements are used for growth
Standing height
Lying height
Sitting height
Factors that affect head circumference
Centile position
Relation to body size
Sutures and fontanelles
Familial factors
Reasons for unreliable growth measurements
Inaccuracy
Uncooperative child
Differenct observers
Different times of the day
Key problem with the normal growth charts in UK
White UK children
3 phases of growth
Infant
Mid childhood
Puberty
What is infant growth phase dependent on
Nutrition
What is midchildhood growth phase dependent on
Brain
What is pubertal growth phase dependent on
Hormones and pregnancy
Two common causes of low height
Familial short stature
Constituional delay in growth and puberty
Which hormone is needed for fusion of the growth plates
Oestrogen
What is an indicator of true male puberty
Testes over 3ml (tanner 2)
Klinefelter symptoms
Pubertal problems (small testes, less hair)
Azoospermia, gynaecomastia
Tall stature
Osteoporosis
Primary hypogonadism or hypergonadism, where is the problem
Primary
Secondary hypogonadism or hypergonadism, where is the problem
Pituitary
Tertiary hypogonadism or hypergonadism, where is the problem
Hypothalamus
Name of the pubertal growth stages
Tanner stages
What is the indicator of true female pubery
Breast bud palpable (tanner 2)
Klinefelter (boys) chromosomes
47, XXY
Turner (girls) syndrome chromosomes
45, X0
Turner presentation
Oedema at birth Upper airway infections High arch palate Cardiovacular and renal malformations Short stature
Hypergonadotrophic hypogonadism
Turners
Primary hypogonadism
Klinefelters
Normal range of puberty for girls
8-13
Normal range of puberty for boys
9-14
Which race goes into puberty early
Black
Why arent some hand bones seen in children
Theyre sitll cartilage
Factors that affect birth weight
Maternal size and weight Parity Gestational diabetes Smoking Paternal size
Common associations of poor growth of children
Vomiting Dysmorphic features Diarrhoea Poor social circumstances Actual weight loss
Common causes of short stature
Constitutional Idiopathic Environmental Nutrition Physical disease Skeletal disease Turners Endocrine
Chronic diseases that cause short stature
Coeliac disease IBD Congenital heart disease Chronic anaemia Cystic fibrosis Chronic infection
Overgrowth with impaired final height causes
Precocious puberty
Congenital adrenal hyperplasia
McAlbright syndrome
Hyperthyroid
Overgrowth with increased final height
Androgen or oestrogen deificency
GH excess
Klinefelter
Marfan
What social factors can cause growth restriction
Emotional rejection
Abuse
Consequence of obesity in children
Non alcoholic fatty liver disease
What is a guide for communicating with teenagers (HEADDSSS)
Home Education Activities Drugs and alcohol Depression Sexual health Spirituality Sleep
What is a limp
Assymetric lower limb movement when walking
Causes of limp
Pain
Weakness
Irritability
Shortening
History points for limping child
Age Pain Trauma Acute or chronic Red flags
Age under 4 limping child
Toddlers fracture
Age 4-10 limping child
Transient synovitis
Legg Calve Perthes disease
Age 10+ limping child
Osgood schlatter disease
SCFE
SCFE (SUFE)
Slipped capital femur epithysis
Two problems which can affect any age causing limping
Oesteomyelitis
Septic arthritis
Questions for osteogenesis imperfecta
Blue sclera
Family history
Deficient
Social history
Toddlers fracture
Undisplaced spiral fracture
What prevents toddlers bones displacing
Periosteum (much thicker in children)
Greenstick fracture
Bending fracture with intact periosteum
Acute limping child
Trauma
Chronic limping child
Infection
SUFE
Red flags limping child
Night pain Sweats Weight loss Unexplained rash or bruising Stiffness
What does stiffness suggest
Pathology inside joint capsule
Henlock shlong purpuria
Can cause joint pain
Severe pain, anxiety and agitation after a traumatic injury.
Compartment syndrome
How does compartment syndrome work
Increased pressure leads to stop of blood flow and necrosis
Examination of limping child
Temperature
Rotational profile
Joint movements
Spine and neurological
Criteria for septic arthritis
Kocher criteria
Kocher criteria
Non weight bearing
Pyrexia
WCC high
ESR high
Perthes disease
Idiopathic avascular necrosis of proximal femoral epiphysis
What is the name of the growth plate
Physis
Perthe disease associations
Low birth weight
Family history
Fat adolescent boy limping
SUFE/ SCFE
What is SUFE
Slippage of the metaphysis relative to the epiphysis
SUFE associations
Obesity
Family history
Hypothyroidism
What line is used for diagnosis of SUFE
Frog legs view xray with Klein lines
Klein lines
If line from femoral head doesnt intersect epiphysis then its SUFE
Define child development
Biological, pscyhological and emotional changes that occur between birth and adolescence as the individual progresses from dependency to increasing autonomy
What affects healthy development
Education Genetics Maternal nutrition Pregnancy Domestic violence Attachment Substances Parenting style Prematurity Nutrition Medical conditions Hearing and vision Stimulating environment Abuse Mental health Peer relationships
4 Domains of development
Gross motor
Fine motor and vision
Speech, language and hearing
Social interaction and self care
When is median for walking
12 months
When is worrying for walking
18 months
When should baby reflexes diasappear
6 months
Name 5 baby reflexes
Moro Grasp Rooting Placing Atonic neck reflex
Moro reflex
Sudden head extension causes symmetrical extension followed by flexion of all limbs. Goes at 4 months (4 letters)
Gross motor progression (to 1 year walking)
Flexed arms and legs equal movmeents,
Lifts head
Rolls, sits unsupported
Pulls to stand
What do you do at 6 months
Sit
Gross motor progression (from 1 year walking)
Walking Walk up stairs Jumps Hops Rides bike
Fine motor and vision development
4m- grasp, use both hands 8m- takes cube in each hand 12m- scribble with crayon 18m- 2 cube tower 3 years- 8 cube tower
What are you aiming for within a year
1 word with meaning
Speech and language and hearing progression (to 1 year)
Laughs and squeels
Dada, mama
1 word
How many words at 2
2 word sentences
How many words at 3
3 word understandably
What speech at 4
Knows colours, can count to 5
What should you be able to understand at 2
2 part instructions
What should you be able to understand at 3
3 part instructions
When should you be smiling
6 weeks
Social self care, 1 year goal
Uses spoon/fork
Development of social self care (to 1 year)
Smiles spontaneously
Finger feeds
Waves bye bye
Uses spoon/fork
Can children dress themselves when they go to school
yes
Red flags gross motor
Not sitting by a year
Not walking at 18
Fine motor red flags
Hand preference before 18 months
Speech and language red flags
Not smiling at 3 months
No clear words by 18months
Social development red flags
No response to carers by 8 weeks
Not playing with peers by 3 years
Tools for developmental assessment
Screening tool
Schedule of growing skills, Griffiths and baileys
5 categories of causes of childhood developmental delay
Genetics Factors in pregnancy Factors around birth Factors in childhood Environmental factors
Good easy test for developmental delay
Microarray (and bloods)
Definition of disability
Someone who has a physical or mental impairment that results in marked, pervasive limitation of activity
Impairment definition
An abnormality of loss of function
Physical impairment examples
Cerebral palsy, brain injury, neuromuscular disorders, musculoskeletal conditions
Sensory impairments example
Hearing and visual impairments
Neurodevelopmental impairments
ADHD, autism
Emotional/ behavioural impairments
Depression conduct disorder, attachment disorder
Disability determinates
Biopsychosocial model
WHO disability assessment schedule has 6 domains of functioning
Cognition Mobility Self care Social Life activities Participation
Steps in supporting children with impairments
Holistic assessments
Address medical, social, environmental and psychological factors for best outcomes
Child focused
Involves work with a multi disciplinary team
Aspects of health education social care
Physiotherapy SALT Dietician Doctors GP Early years inclusion Housing support Social worker Team around child meetings
Name paediatric cancers
Wilms Neuroblastoma Rhabdomyosarcoma Leukaemia Bone tumours Lymphoma
Presentation of paediatric malignancy
Localised mass
Problems from disseminated disease
Problems from localised mass
What does not finishing a feed suggest
Anaemia
Bone marrow infiltration symptoms
Pain
Easy bruising
Infections
Anaemia
Recent URTI, pale and tired
Post viral or leukaemia
Lump in neck otherwise well
Atypical mycobacteria or hodgkins
Early morning headache
Sinusitis or brain tumour
Recurrent fever and bone pain
Arthritis
Leukaemia
Ewings
Neuroblastoma
Abnormal red reflex in eye
Retinoblastoma
Proptosis
Infection, neuroblastoma, rhabdomyosarcoma
Recurrent discharging ear
Infection
Rhabdomyosarcoma
LCH
Acute leukaemia presentation
Fever Fatigue Frequent infections Lymphadenopathy Hepatomegaly and splenomegaly Anaemia Bruising, petechiae Bone or joint pain
Acute leukaemia investigations
Blood film Serum chemistry CXR Bone marrow and aspirate Lumbar puncture
5 phases of chemotherapy
Induction Consolidation Interim maintenance Delayed intesification Maintenance
When do you give stem cell transplant in leukaemia
High risk patients in first remission
Relapsed patients
CNS tumours
Headache Vomiting Papilloedema Squint Nystagmus Ataxia Personality of behaviour change
Not doing something they used to be doing
Very bad sign
Worrying signs with headache
Pappiloedema Decreased acuity, visual loss Neuro signs Recurrent or early morning Vomiting Reduced growth DI Under 3 years old
CNS tumours treatment
Surgery
Chemotherapy
Radiotherapy (not brain)
Lymphadenopathy causes
HIV infection
AI conditions
Storage disorders
Malignancy
Bad signs with lymphadenopathy
Enlarging Persistent Unusual site Fever, weight loss, enlarged liver/ spleen Abnormal CXR
Lymphoma therapy
Chemotherapy
Radiotherapy
Surgery
What is wilms tumour
Renal mass
Abdominal mass symptoms
Pain Haematuria Constipation Hypertension Weight loss
Investigations for abdominal mass
Ultrasound
CT scans
Biopsy
Neuroblastoma treatment
Surgery
Chemotherapy
Radiotherapy
Wilms tumour treatment
Chemotherapy
Surgery
Radiotherapy
Symptoms of retinoblastoma
Loss of red reflex and squint
Late effects of cancer treatment
Endocrine Intellectual Cardiac toxicity Renal toxicity Fertility Psychological
When do you break most bones
Peak growth velocity
Factors affecting fracture rates
Growth
Activity
Trauma
Fragility
Define osteoporosis
Disease characterised by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility
Two categories of osteoporosis causes
Inherited (osteogenesis imperfecta)
Acquired
(steroids)
Acquired causes of osteoporosis
Drug induced Endocrinopathies Malabsorption Immobilisation Inflammation
Osteogensis imprefecta observations
Fragility, fractures, deformity. Bone pain. Impairs mobility and growth
Common treatment for osteoporosis in children
Bisphosphonates
Key roles of vitamin D
Makes calcium available
Maternal VitD influences bone size and mass
Role in immune function and tolerance
Presentation of Vit D deficiency
Bowed legs Hypocalcaemic convulsions Gross motor delay X-Ray finding Swollen ankle Carpopedal spasm
Causes of vitamin D deficiency
Maternal vit D insufficiency
Lack of exposure to sunlight
Lack of vit D in diet
Pathologically what is rickets
Failure to mineralise new bone
Presnetation of rickets
Metaphyseal swellings Bowing deformity Slowed linear growth Motor delay Hypotonia Fractures Respiratory distress
Biochemical changes in rickets
Low phosphate
Raised AlkPhos
Vit D defiency chemical changes
Raised PTH
Low 25 OH-D
Vitamin D deficiency treatment
Vitamin D (+- calcium)
Vit D facts
Steroid like substance
Fat soluble
Specific DNA response elements
Define self harm
Act with intent to hurt self
Define suicide attempt
Act with intent to kill self
Do more boys or girls self harm
Girls
Do more boys or girls commit suicide
Boys
Reasons for self harm
Release tension, make self feel, search for help
Best treatment for bullying
Interpersonal therapy
CAHMS self harm assessment
STAR team assessment Psychological intervention CBT therapy Family therapy Pharmacological intervention
Is self harm present in nature
Obsessive behaviour
Desire to cope better with internal conflicts
What factors can predispose to self harm in young children
Communication difficulties
How does depression differ from low mood
Depression is low mood + anhedonia + reduced energy leading to increased fatiguability and diminished activity
What is terminal insomnia
Early morning waking. REM sleep comes earlier
Criteria for depression affects
Pervasive, persistent, affects other domains of life, persists through different environments
Why is depression diagnosis hard in children
They are bad communicators
Child symptom of depression
Regression
- clinging
- bed wetting/ thumb sucking
- 3 wish test
How to find distressors in children
3 wish test
Things that can cause progression from depression to suicide
No support Better to be dead Death wishes Plan Attempt Suicide
Biological basis of depression
Low trypotophan
Low serotonin
HPA dysregulation
Low 5HIAA
Risk factors in self harm behaviour
Intent Lethality Comorbid mental illness Depression Psychosis PHx FHx Substance abuse
Which hallucinations are worrying for self harm
Commanding voices
Thought echo
Discussing auditory hallucinations
Where does ductus arteriosus join
Pulmonary artery and descending aorta
Where does the formane ovale join
right and left atria
Describe ASD clinical signs
Fixed and widely split S2
Ejection systolic in pulmonary area
What symptoms do you get with ASD
Asymptomatic when younger and can get palpitations when older
Name three types of ASD
Ostium secundum
Ostium primum
Sinus venosus ASD
PDA clinical presentation
Preterm
Poor feeding, failure to thrive, tachypnoea
Clinical signs of PDA
Active precordium, thrill, gallop rhythm
Continuous machinery murmur pulmonary area
Hepatomegaly
Oedema
VSD clinical presentation
poor feeding
failure to thrive
tachypnoea
Clinical signs of VSD
Active precordium, thrill, gallop rhythm
Pansystolic murmur
Hepatomegaly
Oed
Where does VSD murmur radiate
USE and axillae
What is a common defect in trisomy 21
Atrioventricular septal defect
What can AVSD lead to
Pulmonary vascular disease
AVSD clinical presentation
Poor feeding, failure to thrive, tachypnoea
Clinical signs in coarctation of the aorta
Weak femoral pulse
4 Limb BP
Murmur over back in older children
If duct has closed in coarctation of aorta how will a baby present
Collapsed and acidotic
Clinical findings of pulmonary stenosis
Ejection systolic murmur LUSE
Radiates to back
Right ventricular heave
Cyanotic heart conditions
Tetralogy of fallot
Transposition of the great arteries
Presentation of cyanotic congenital heart disease (ToF, TpOGA)
Cyanosis
Acidosis
Collapse/ death
What mutation should you check for in tetralogy of fallot
22q deletion
Normal range for fasting plasma glucose
3.5-5.6
Normal range for post prandial plasma glucose
<7.8
What fasting glucose is diabetes diagnostic
> 7
What fasting glucose is prediabetes
<7
What fasting glucose is normal
3.5-5.6
What post Oral Glucose Tolerance test is diabetes
> 11.1
What HbA1C is diabetes
> 6.5
How do you treat type 1 diabetes
Insulin
How do you treat type 2 diabetes
Insulin and or diet and exercise
Does type 1 or type 2 diabetes have more genetic transmission
Type 2
Actions of insulin
Stimulates formation of glycogen
Stimulates glucose uptake from food
What happens when there is insufficient insulin in the body
Increased glucagon,
Glycogenolysis
Gluconeogenesis
Ketogenesis
Insulin deficiency and glucagon excess causes what changes in the blood
Increased blood ketones and glucose
What causes vomiting in diabetes
Increased blood ketones
What causes acidosis in diabetes
Increased blood ketones
What causes osmotic diuresis in diabetes
Increased blood ketones and glucose
What causes fluid and electrolyte depletion in diabetes
Vomitting and osmotic diuresis
What causes acidosis in diabetes
Increased blood ketones
What can cause shock in diabetes
Fluid and electrolyte depletion
What can cause cerebral oedema in diabetes
Acidossi and fluid and electrolyte depletion
How do you manage DKA
Fluid Insulin Monitor glucose hourly Monitor electrolytes 2 hourly Strict fluid balance Hourly neuro obs
Autonomic hypo symptoms
Irritable Hungry Nauseous Shakey Anxious Sweaty Palpitations Pallor
Neuro hypo symptoms
Dizzy Headache Confused Drowsy Visual problems Hearing loss Problem concentrating Hearing loss Slurred Odd behaviour LOC Convulsions
Mild hypo management
Check blood glucose to confirm
- 5 glucose tablets
- 200ml fizzy drink
- 100ml lucozade
Vomiting definition
Physical act that results in the gastric contents forcefully brought up to and out of the mouth.
- contraction of abdo muscles and diaphragm
- cardia of stomach is raised
- pylorus is contracted
Regurgitation definition
Effortless expulsion of gastric contents
Rumination definition
Frequent regurgitation of ingested food (largely behavioural)
Possetting definition
Small volume vomits during or between feeds in otherwise well child
What are the 2 areas of the CNS involved in the vomiting reflex
Vomiting centre
Chemoreceptor trigger zone
Receptors involved in vomiting reflex
Muscarinic Dopaminergic Histaminergic Serotonin Substance P
Triggers for vomitting
Toxic material in lumen of GI tract Visceral pathology Vestibular disturbance CNS stimulation Toxins in blood or CSF
Vomiting history
Billious? Bloody? Projectile? Age? Febrile? Other symptoms Hydration?
Red flags vomiting symptoms
Meningism
Costovertebral tenderness
Abdominal pain
ICP raised
Vomiting examination
General Abdomen Neurological Plot growth Hydration Infection Genetic problems?
Causes of GI obstruction in children
Pyloric stenosis Malrotation and volvulus Intestinal duplication Hirschprungs Foreign body Incarcerated hernia
GI problems that can cause vomiting
Achalasia Gastoparesis Gastroenteritis Peptic ulcer Food allergy IBD Pancreatitis Appendicitis
Which other systems can cause vomiting
Neuro (increased ICP) Infections Metabolic (toxins) Renal (obstruction or renal insufficiency) Toxic Cardiac (Congestive HF) Psychiatric
Vomiting in neonates
Duodenal or other intestinal atresia
TEF
Vomiting in newborn
Gastroenteritis Pyloric stenosis Malroatation TEF NEC Milk protein intolerance
Vomiting in infant
Gastroenteritis UTI GORD Ingestion Intusseseption Milk protein intolerance
Vomiting in child
Gastroenteritis UTI DKA Increased ICP Appendicitis
Vomiting in adolescent
Gastroenteritis Appendicitis DKA increased ICP Eosinophilic oesophagitis Bulimia Pregnancy
Describe malroation/ volvulus presentation
Bilious vomitnig, abdominal distension
Describe malrotation/ volvulus management
Contrast study for diagnosis
Urgent surgical referral
Describe presentation of hischprungs, meconium ileus and intestinal atresias
Delayed passage of meconium, abdominal distension, bilious vomiting
Managmeent of hischprungs meconium ileus and intestinal atresias
Surgical referral
Presentation of NEC
Usually pre term, abdominal distension, bilious vomiting
Treatement of NEC
Antibiotics
Gut rest
Surgical referral
First line investiagtions in vomiting
U&E, stool virology, abdominal X ray, surgical opinion, exclude systemic disease
Consequences of vomiting
Metabolic Nutritional Mechanical Dental Anaemia, stricture, aspiration
Metabolic consequcnes of vomiting
Potassium deficiency
Alkalosis
Sodium depletion
Mechanical consequences of vomiting
Mallory Weiss
Boerhaaves syndrome
Tears of short gastric arteries
GORD symptoms
Bilious vomiting GI bleed New onset vomiting Failure to thrive Bulging fonatenelle, spleen and liver
Define GOR
Passage of gatric contents into the oesophagus with or without regurgitation or vomiting
Define GORD
Presence of troublesome symptoms and or complications of persistent GOR
What is used to diagnose GORD
pH studies
Investigations for GORD
pH studies
Barium swallow
Endoscopy
PPI test
Management of GORD
Position Thicken feeds Change feeds Antacid H2 blocker PPI Surgery
What is cows milk protein allergy associated with
Atopy IgA deficiency IgA subclass anomaly
Is cows milk protein allergy a multi system disease
Yes
- GI
- Respiratory
- Skin
Magement of cows milk protein allerg
Hydrolysed or amino acid feeds( AA if severe)
How to diagnose cows milk protein allergy
Elimination diet
Lactose intolerance symptoms
Explosive watery stools, abdo distension, flatulence, audible bowel sounds
Lactose intolerance diagnosis
Stool chromatography, lactose hydrogen breath test, small bowel biopsy and elimination diet
Lactose intolerance treatment
Lactose free formula, milk free diet, calcium and vitamin D supplements
Define contipation
Infrequent passage of stool associated with pain and difficulty or delay in defecation
Define encopresis
Involuntary faecal soiling or incontinence secondary to chronic constipation
Cycle of functional constipation
Painful fecation
Voluntary witholding
Prolonged fecal stasis and reabsorption of fluids
More pain
Consitpation red flags
Delayed passage of meconium Fever, vomiting, bloody diarrhea Failure to thrive Tight, empty rectum with presence of palpable abdominal faecal mass Abnormal neuro mass
Long term consequences of constipation
Acquired megacolon, anal fissures, overflow incontinence, behavioural problems
Which investigations might you do in constipation
T4/ TSH Serum calcium Coeliac panel Sweat test AXR Anal manometry Rectal biopsy Spinal imaging
Management of constipation
Explanation of normal bowel function Diet fluids and exercise Behavioural advice Toilet training advice Simple reward schemes
Name a bowel softener
Lactulose, liquid parrafin
Name a bowel bulking agent
Fybogel
Name a bowel laxative
Movicol
name a bowel stimulant
Senna
Dulcolax
Treatment of anal fissure
Anaesthetic cream
Vasodilator
Define diarrhoea
Change in the consistency of stools and increase in the ferquency of evacuations with or without fever or vomiting which lasts less than 7 days and not longer than 14 days
Viral causes of diarrhoea
Rotavirus
Calcivirus
Astrovirus
Bacterial causes of diarrhoea
C. jejuni
Salmonella
E coli
Shigella
Causes of acute diarrhoea
infections Hypersensitivity Drugs Haemolytic uraemic syndrome Obstruction
Presntation of acute diarrhoea
Diarrhoea Bloody stools Fever Vomiting Dehydration Redueced conciousness
Diarrheoa examination
Dehydration
- cap refill
- skin turgor
- absent tears
Investigations for diarrhoea
Stool microbiology
Glucose
U and E
Consequences of chronic diarrhoea
Constipation
Food intolerance
Malabsorption
Crohns features
Mouth to anus Transmural inflammation Discontinous Granuloma Rectal sparing Fissures Fistula Abscesses and strictures Perianal disease
Ulcerative colitis features
Colon only affected Mucosal inflammation Continous No granuloma No rectal sparing Abscesses and strictures rare Primary sclerosing cholangitis
How is IBD different in kids
More crohns
IBD consequences
Growth -delayed puberty Reduced final adult height Catch up growth poor growth
Treatment for crohns
Steroids Aminosalicylates Antibiotics Methotrexate Infliximab Surgery
UC treatment
Corticosteroids then azathioprine in remission
Acute causes of abdominal pain
Appendicitis Intussusception Pancreatitis Cholecystitis Pneumonia
Define chronic abdominal pain
Long lasting, intermittent or constant pain that is functional or organic
Define abdominal pain
Abdominal pain without evidence of disease/ pathologic process
Organic causes of abdo pain
GORD PUD H pylori infection Food intolerance Coeliac disease IBD Constipation UTI Dysmenorrhoea Pancreatitis
Functional abdo pain causes
Functional dyspepsia
IBS
Functional abdo pain
Abdominal migraine
Functional pain pathology
Physiologic stimuli
Noxoius stressful stimuli
Pyschological stressful stimuli
Abdo pain red flags
Involuntary weight loss Reduced growth Blood loss Vomiting Diarrhoea RU lower quadrant Fever IBD family history
Strabismus/ squint definition
Misallignment of one eye
Define esotropia
Convergent manifest
Define exotropia
Divergent manifest
Define hypertropia
Upwards manifest
Define hypotropia
Downwards manifest
Manifest strabismus
You can see the difference
Latent strabismus
No evidence when both eyes open. Cover one eye reveals misallignment
Define esophoria
Latent convergent
Define exophoria
Latent divergent
Define hyperphoria
Latent upwards
Define hypophoria
Latent donwards
Symptoms of latent squints
Headaches
Eye symptoms
Intermittent diplopia
Causes of strabismus
Often hereditary
Refractive error
Neurological problems
What is hypermetropia
The image is focussed behind the retina
What is secondary strabismus
Due to loss of vision in one eye
Investigation of strabismus
History
Corneal reflections
Cover test
What are you looking for in corneal reflections
Symmetry
Causes of pseduostrabismus
Narrow or wide eyes Epicathic folds of skin Facial assymetry Ptosis unilateral Deepset or prominent eyes
Define amblyopia
Defective visual acuity which persists after correction of the refractive error and removal of any pathology
How can you treat amblyopia
Glasses or occlusion of better eye
Strabismus treatment
Glasses
Orthoptic exercises
Surgery
Botox
Risk of strabismus
Development of amblyopia (lazy eye)
Childrens act 1989
Parental responsibility
Safeguarding
Who has parental responsibility
Whoever gives birth
Dad only if married
How long can babies go unregistered
6 weeks
Do dads have rights
Only if married or on birth certificate
Childrens act 2004
CCG
Child protection
GP
Health
Mental health act 1983
Applies to children
When does the child get the right to refuse
- Can accept from 16
Does mental capacity act apply to paediatrics
No
What is deontology
What people do, not the consequence
What is justice
Fair treatment
Capacity
Understand
Retain
Weigh up
Communicate
What age gestation do you resuscitate if the parents want
23 weeks
At what gestation do you always resuscitate
24 weeks
Gillick competence
Capacity
Fraser guidlines
Hypo management moderate
As for mild but if needed, glucogel. Bread or biscuit. Check BG in 15 minutes
Severe hypo managmenet
Dont give anything by mouth
Give glucagon
Give sugar when conscious
Education for newly diagnosed diabetics
Injections Choice of devices BG monitroing Inuslin Hypos Sick day rules Dietary glucose Carb counting Exercise advice
Diabetes MDT
Education School PDSNs Diabetes UK Local groups
Aims of diabetes managmentt
Normal growth and development
Normal childhood
Avoidance of SE or hypos
Common side effects of diabetes
Retinopathy
Nephropathy
Neuropathy
Microalbuminuria
Where to examine in a diabetic
Eyes Urine Feet Blood pressure Injection sites
Do you give fat in a hypo
NO
Do you give fluid or insulin first in DKA
Fluid
Define oedema
Increase in interstitial fluid
Describe oedema clinically
Swelling, pitting oedema, fluid moves under influence of gravity, ascites, pleural effusions, pulmonary oedema
Causes of increased interstitial fluid
Lymphoedema
Venous obstruction
Low oncotic pressure
Salt and water retention
Causes of. lyphoedema
Congenital blockage
Causes of low oncotic pressure
Malnutrition
Decreased production by liver
Increased loss from gut or nephrotic syndrome
Causes of salt and water retention
Kidney- impaired GFR
Heart failure
3 symptoms of nephrotic syndrome
Heavy proteinuria
Hypoalbuminaemia
Oedema
Hypoalbuminaemia consequences
Fluid retention
Oedema
What is a 4th consequence of nephrotic syndrome
Hyperlipidaemia
3 types of nephrotic syndrome
Congenital
Steroid sensitive
Steroid resistant
Bile stained vomit is a sign of
Intestinal obstruction
Haematemesis is a sign of
Oesophagitis, peptic ulceration, oral/nasal bleeding
Projectile vomiting in the first few weeks of life is a sign of
Pyloric stenosis
Vomiting at the end of paroxysmal coughing is a sign of
Whooping cough
Abdominal distension and vomitting is a sign of
Intestinal obstruciton, including strangulated hernia
Hepatosplenomegaly is a sign of
Chronic liver disease
Blood in the stool is a sign of
Intussusception, gastroenteritis- salmonella or campylobacter
Severe dehydration, shock is a sign of… in a vomiting child
Severe gastroenteritis, systemic infection (UTI, meningitis)
Bulging fontanelle, vomitting and seizures in a child
Raised intracranial pressure
Fialure to thrive causes (with vomiting)
GORD, coeliac, chronic GI conditions
