Paediatric: SDL and mental health Flashcards
National child measurement programme
In reception (4-5y)
In year 6 (10-11y)
Trained staff weight and measure the height of the child. If outside a healthy weight, support will be offered. Participation is not mandatory
What are the two components of the new-born hearing screening programme
0-5w (done either in hospital or in community)
- 1-2 in 1000 babies in the UK are born with a permanent HL or deafness in one or both ears.
- 90% of babies with HL are born to families with no history of deafness.
- There are separate protocols for screening babies who have been in NICU or SCBU.
2 tests are carried out as part of the newborn hearing screening:
1) Automated otoacoustic emissions test (all)
2) Automated auditory brainstem response test (some)
Referrals are given a full audiological assessment
Preschool hearing and vision screening
Vision screen: between ages 4-5- Visual acuity in both eyes
Hearing screen: usually in y1 or y2 at school- Behavioral test
Paediatric sepsis 6
Complete within 1 hour:
- Give high flow oxygen
- Obtain IV/IO access and take blood tests: cultures, BM (treat if low), gas (+ FBC, lactate/CRP as available)
- Give IV or IO antibiotics (broad spectrum per local policy)
- Consider fluid resus (titrate 10 ml/kg bolus, then re-evaluate and repeat as needed)- Careful of fluid overload – examine for crepitations and hepatomegaly
- Involve senior clinicians/specialists early
- Consider inotropic support early
What to do after the paediatric sepsis 6
If normal physiological parameters arent restored after 40ml/kg fluids or more. NB adrenaline or dopamine may be given via peripheral IV or IO access
Newborn resus algorithm
- Following birth, dry the baby (maintain temp) and start the clock.
- Following this you assess tone breathing and heart rate.
- If gasping or not breathing, open the airway to give 5 inflation breaths.
- Then reassess for an increase in HR.
- If there no increase HR, ensure the inflation breaths are adequate by checking chest movement.
- If chest is not moving, assume the inflation breaths are inadequate and recheck head position, consider 2-person airway control and other maneuvers, and repeat inflation breaths then look for a response.
- If the chest is moving but the HR is still undetectable or <60, you start chest compressions at a ratio of 3:1 inflation breath.
- Reassess HR every 30s, and if still undetectable or very slow, consider IV access and drugs.
What are the red flag features in the NICE traffic light system for evaluating unwell children
Pale/mottled/ashen/blue
No response to social cues
Appears ill to a healthcare professional
Does not wake or if roused does not stay awake
Weak, high-pitched or continuous cry
Grunting
RR >60
Moderate or severe chest indrawing
Reduced skin turgor
Age <3 months, temperature >=38°C
Non-blanching rash
Bulging fontanelle
Neck stiffness
Status epilepticus
Focal neurological signs
Focal seizures
Developmental dysplasia of the hip risk factors
The Department of Health advises that:
- all babies that were breech at any point from 36 weeks (even if not breech by time of delivery)
- babies born before 36 weeks who had breech presentation
- all babies with a 1st degree relative with a hip problem in early life
should be referred for ultrasound of the hips (at 6w).
If one of a pair of twins is breech, both should be screened. Some trusts refer babies for other reasons
APGAR score- 2
Pulse >100
Respiratory effort- strong/crying
Colour- Pink
Muscle tone- active movement
Reflex irritability- cries on stimulation/sneezes, coughs
Apgar score 1
Pulse <100
Respiratory effort- weak, irregular
Colour- body pink, extremities blue
Muscle tone- limb flexion
Reflex irritability- Grimace
Apgar score- 0
Pulse- absent
Colour- blue all over
Muscle tone- Flaccid
Reflex irritability- Nil
Apgar score- meaning
A score of 0-3 is very low score, between 4-6 is moderate low and between 7 - 10 means the baby is in a good state
Newborn Baby Assessment (NIPE) 1/2
- Performed within 72 hours of birth by a qualified practitioner
- Record weight and check on a weight chart: if baby is small, plot head circumference and length to check if its symmetrical/asymmetrical growth restriction’
- General inspection: jaundice
- Tone: move the limbs passively
- Head: record head circumference, inspect cranial sutures and fontanelles
- Skin: colour, bruising
- Auscultate lung and heart
- Pulse oximetry
- Lower limbs: tone, movement and palpate both femoral pulses
- Hips: Barlow and Ortolani tests
NIPE 2/2
- Face: appearance, symmetry, trauma, nose
- Eyes: appearance, fundal reflex (preferred over red reflex)
- Ears
- Mouth and palate: look for cleft lip or palate and tongue tie
- Neck and clavicle: look for webbing, neck lumps, clavicle fracture
- Upper limbs: symmetry, inspect fingers and palms. Palpate brachial pulse in both arms
- Observe the chest especially for respiratory rate and work of breathing
- Abdomen: palpate
- Genitalia: inspect and palpate scrotum to ensure both testes are present
- Back, spine, reflexes
Basic life support: positioning the childs heag
- Infant: in the neutral position (avoid over extending), cover the mouth and nose and blow steadily for one second
- Child: in the sniffing position, cover mouth and pinch nose and blow for one second
Infants: reflexes
1) Rooting reflex
2) Sucking reflex
3) Moro reflex: when a baby is dropped, they open their arms wide
4) Grasping or palmar reflex
5)Babinski or plantar: stroking the foot it curls in
6) Walking or stepping reflex: when a baby is held upright an their feet brush a surface they take a step
7) Tonic neck: when a baby is on their back and turn to one side they make the fencing posture
8) Galant: stroke one side of the spine and the pelvis swings towards the stimulated side
Psychosocial poor growth
Growth disorder caused by extreme emotional deprivation or stress, despite adequate nutrition
- Pathophysiology: decreased growth hormone
- Presents: short stature, low weight for height, immature skeletal age
- Management: removal of source of stress foster/care home if appropriate
If under 0.4th centile for height review by paediatrician
Classifying learning disability
Mild: IQ less than 70
Moderate: IQ less than 50
Severe: IQ less than 35
Learning disability
Definition: IQ two standard deviations below the mean
Common causes: Autism, downs
Genetic: Downs, Prader willi, Fragile X, DiGeorge
Cause of global development delay
genetic syndromes (Down’s, Prader Willi, fragile X, DiGeorge)
autism
cerebral palsy
congenital infection or injury (rubella, alcohol, hypoxic brain injury)
Cause of gross motor and fine motor delay
Gross motor= cerebral palsy, dyslpasia of the hip, spina bifida, neuromuscular disorder
Fine motor= Cerebral palsy, visual loss, neuromuscular disorder
What red flag features in a child with fever warrant immediate paediatric referral
- pale, blue or mottled skin
- no response to social cues or does not wake if roused
- high pitched or continuous cry
- appears ill to HPC
- grunting, chest undrawing or RR > 60
- reduced skin turgor
- non blanching rash
- bulging fontanelle
- neck stiffness
- status epilepticus
- focal neurological signs
- focal seizures
Two types of innocent murmurs
Venous hum= continuous blowing noise just below clavicle
Still’s murmur= low pitched sound at lower left sternal edge
Cause of small head circumference
- normal variation or familial
- congenital infection or foetal alcohol syndrome
- genetic syndrome e.g. Patau
Risk factors for AKI in children
- kidney or liver disease
- malignancy or bone marrow transplant
- dependent on others for fluid
- exposed to nephrotoxins (ACEi, ARBs, NSAIDs, diuretics)
First signs of puberty
Males: testicular growth at 12
Females: breast development at 11.5
Causes of hypertension in children
- pain
- anxiety
- obesity
- renal scarring or nephritis
- coarctation of aorta
- adrenal tumours
Kallmans disorder
Features= usually boys, delayed puberty, anosmia
Hormones= Low gonadotrophins(LH/FSH)
How does gonadal tumour and Klinefelter’s present
Klinefelter’s= small testes, infertility, low testosterone
Gonadal tumour= precocious puberty in males with unilateral enlarged testes
Benzodiazepines and Gabapentinoid cautions
- Contraindications: Acute pulmonary insufficiency; marked neuromuscular respiratory weakness; sleep apnoea syndrome; unstable myasthenia gravis
- Cautions: Debilitated or elderly, history of EtOH or drug abuse, personality disorders, respiratory disease
Gabapentinoids Cautions: Encephalopathy, substance abuse, severe congestive cardiac failure
First line treatment for anxiety disorder
Often psychological e.g.
- CBT or relaxation for GAD
- Psychoeducation for panic
- Graded exposure for phobias
Decisions to use medication in anxiety and depression
- Before using medication for depression ensure over the DSM threshold for a syndrome (and consider function)
- For anxiety disorders, mostly determined by the degree of distress and functional impairment
Pharmacological management of GAD
- First line: SSRIs – follow same doses/duration of treatment trials as per depression
- Second line= SNRIs (venlafaxine and duloxetine), buspirone, pregabalin
- Alternative/additional options= ?gabapentin, Benzodiazepines, Quetiapine (for more difficult to treat anxiety)
When to use Benzodiazepines
- Benzodiazepines are indicated for the short-term relief (two to four weeks only) of anxiety that is severe, disabling or causing the patient unacceptable distress
- The use of benzodiazepines to treat short-term ‘mild’ anxiety is inappropriate.
- Benzodiazepines should be used to treat insomnia only when it is severe, disabling or causing the patient extreme distress.
- Can be used in GAD, panic and social anxiety. Can cause sedation, cognitive impairment, tolerance and dependence
- Reserved for patients who haven’t responded to three previous treatments
Pharmacological management of panic disorder
- SSRIs first-line treatment; some evidence for SNRIs
- Initially treatment can increase panic attacks
- Minimise by starting with a low dose and slowly increasing (or adding a BZ for a few weeks)
- Response takes longer to assess than depression or GAD - up to 12 weeks to assess efficacy
- BZs “in the pocket/bag” can have a positive psychological benefit
Pharmacological management of OCD
- Antidepressants: SRI’s (especially SSRI’s and clomipramine), higher doses required, longer treatment (8-12 weeks)
- Difficult to treat OCD: higher doses of SSRI’s or clomipramine, augment with a second generation antipsychotic
First generation antipsychotics
- E.g. chlorpromazine, haloperidol
- Block D2 receptors
- Also antagonise histamine, NA and acetylcholine receptors. Haloperidol less so
- Multiple effects: Sedative, Tranquiliser, Antipsychotic
- Hyperprolactinaemia: gnaecomastia, galactorrhoea
- Extra pyramidal: dystonia, akathisia, parkinsonisn, tardive dyskinesia
Second generation antipsychotics
- Attempt to replicate clozapines efficacy: risperidone, olanzapine, quetiapine, lurasidone
- Aim to balance dopamine function: aripiprazole, cariprazine
- Low affinity for D2 receptors, potent 5-HT2A antagonists
- Metabolic side effects: weight gain, metabolic syndrome and diabetes
Antipsychotics: contraindications and cautions
FGAs (chlorpromazine)= Contraindications: CNS depression; comatose states; hypothyroidism; phaeochromocytoma
All antipsychotics= Cautions: CVD, epilepsy, depression, diabetes, Hx of jaundice, Parkinson’s, photosensitivity, prostatism, respiratory disease, glaucoma
Before starting antipsychotics assess
- Weight & waist
- Pulse & BP
- Fasting glucose & HbA1C
- Lipids
- Prolactin
- Assess for movement disorders
- Diet & physical activity
- ECG if indicated
Clinical use of antipsychotics
- All antipsychotics: Schizophrenia (+ve symptoms), psychosis of any aetiology, acute mania, for tranquiliser effect
- Specific antipsychotics: bipolar depression, prophylaxis in bipolar, augmentation of antidepressants for unipolar depression.
Treating acute mania in bipolar disorder
- (Consider) stopping any antidepressant the patient is on
- Haloperidol, olanzapine, quetiapine or risperidone (NB – all antipsychotics tested have efficacy for acute mania)
- If ineffective consider adding: Li, valproate (NB NOT in women of child bearing potential)
Treating acute depression in bipolar disorder
- Evidence suggests SSRIs don’t work (on average). Little/no information re other antidepressants
- Use Olanzapine plus fluoxetine (? Olazapine alone), Quetiapine, Lamotrigine
- Don’t prescribe antidepressants without an anti-manic treatment
Long term treatment for bipolar disorder
- Li – prevents both mania and depression
- Valproate – primarily prevents mania (??) but less good than Li
- Carbamazepine – ditto, ditto
- Olanzapine – prevents mania and to less extent depression
- Aripiprazole – just prevents mania
- Quetiapine – Prevents both depression and mania equally?
- Lamotrigine – prevents depression more than mania
- Do not routinely use antidepressants
Prescribing in the elderly
- Adverse drug reactions are more harmful
- Delirium and cognitive decline with anticholingeric medications, causes a decline in MMSE over time
- Anticholingeric drugs: warfarin, prednisolone, benzos, ampicillin, ISMI, ranitidine, opioids
- Falls and fractures with postural hypotension due to adrenergic block
- Lithium tremor disabling
What is the lasting power of attorney and what are the two types?
A legal doc allowing a “donor” to appoint an “attorney” to make decisions on their behalf. The donor must have capacity at the time the LPA is put in place
1. health and welfare
2. property and financial affairs
The three criteria for detaining and treating patients with psychiatric illness
Per the Mental Health Act 1983:
1. mental disorder of a nature or degree which makes it appropriate for them to receive treatment in hospital
2. risk to self or others
3. appropriate treatment is available
4. note dependence on drugs/alcohol and learning disability are 2 notable exclusion criteria
What sections of the mental health act can be used by the police to hold people with a mental illness who need care
Section 136 - public place: used to take someone to a place of safety. 24h, can be extended for 12h
Section 135 - private address: allows access to a private address without permission. Used to take someone to a place of safety, up to 36h
Place of safety may be home, a friend/relative’s home, a hospital, a police station
Section 5 of the mental health act
- Used to stop patients from leaving hospital if so far they have been in hospital voluntarily. Only if 2, 3, 4 not possible
- Section 5 (4): nurses holding power, can hold a patient for up to 6h. Only trained mental health or learning disability nurse if no doctor available
- Section 5 (2): doctors holding power, only FY2 and above, up to 72h
Section 2 of the mental health act
- 1st assessment (or 1st in a while) under the MHA
- allows for time for doctors to determine= type of mental disorder, whether treatment is needed, what treatment this will be and impact on overall health
- 28 days
- 2 doctors + AMHP
- treatment can be given against their will on this section
Section 3 of the mental health act
- Used to treat the patient
- 2 doctors (>FY2) and an AMHP
- May be kept in hospital for 6 months – may be renewed
- May be treated without their consent for 3 months (after this requires a 2nd opinion approved doctor (SOAD))
