Paediatrics Flashcards
Is paediatric assessment the same as adult assessment
NO - Children are not miniature adults - All body systems still in development throughout childhood. Skeletal system not fully developed until 25.
Paediatrics covers a wide range from:
Age: 0 – 19 years old
Who are involved in treatment in paediatrics
Children are not alone in treatment - Parents/family come too!
Aims of paediatric assessment are:
To provide a baseline picture of the child
To evaluate the child’s abilities and inabilities
To compare their function to their chronological age
To place the child’s abilities within the context of their environment
The neurological system in children is driven by:
Lower centres of the brain
Motor development mirrors:
Development of the higher centres of the brain and the increased synapsing within the motor cortex
Initially nervous system operates by:
reflex activity
Neurological conditions may be:
congenital (spina bifida), developmental (cerebral palsy) or acquired (non-accidental head injury or traumatic brain damage)
Distribution of tone will interrupt:
normal motor development - Increased or decreased tone interrupts the child’s motor development, but also affects MSK development
In subjective assessment who we talk to depends on:
age of the child:
• Infants & toddlers – Parents
• Young children (4-5) – start to involve them in the questions but still ask parents to ensure reliable, accurate answers
• 12/13 should be directing most of the questions to the teenager
In PC problem may be referred to as:
“ developmental delay” from paediatricians +/-Presenting MSK problem, Associated with Cardio respiratory problem
Often HPC shows:
Problems present since birth
Parents may be the only ones who have noticed a problem
In young children these may cause developmental delay
PMH will look at:
Other associated conditions
• Epilepsy?
• Hydrocephalus?
• Cardiorespiratory condition - CF, Asthma
Surgery
• Shunt
• Corrective surgery - CP
DH is often:
extensive
What special questions would you ask in a subjective paeds assessment?
- Birth History
- Motor History
- Social History
- Cognitive history
- Family history
- (Parent and child perception)
BH often includes:
Any problems with birthing process - including pre, peri and post-natal
History of a particularly traumatic birthing process, i.e. emergency C-section or prior problems leading to elective C-section
Very important for many paediatric neurological conditions:
○ Cerebral palsy - premature, other MSK and C/R co-morbidities
○ Developmental Coordination Disorder - premature, CP children
MH looks at:
• When did your child achieve: Head control - 3/12, Rolling - 4-6/12, Sitting - 6-9/12, Crawling - 9-12/12, Walking - 12-18/12
Influence of motor skills: Affects experience, Affects self-concept, Affects social interaction, Delay affects other development
Social & Cognitive History asks:
- How well does your child sleep?
- How well does your child eat, any problems swallowing or particular foods?
- How well is he/she getting on at school? Has he/she got lots of friends? Interaction with teachers? Do they keep eye contact? How is their hearing? When they speak to you how do they speak? What do friend’s parents say about your child?
Autistic children have difficulty with:
some textures of food in their mouth and swallowing issues.
Social interaction is important in:
development and development delay.
Children whose muscle tone is altered have difficulty:
Resisting gravity, which can affect sleep patterns. Altered tone may affect swallowing and also using cutlery.
children with developmental coordination disorder may also have:
AD/HD, which may affect their sleep pattern
Co-ordination will affect use of:
Cutlery
School issues are often linked to:
Difficulties with social skills, which can affect children with developmental coordination disorder, or those on the autistic spectrum.
With older children you need to get:
(Parent and child perception)
The parent’s version – preferably not in front of the child and the child’s version – again preferably without the adults present.
Sometimes parents & children have:
(parent and child perception)
a different perspective – especially teenagers – remember your duty of care is to the child
What environments can physios complete assessment and treatment of children?
- Home
- Child development centre
- School
- Clinic / hospital
When visiting at home you see:
the child with their own context. Often where they are most comfortable so often easier and may help with goal setting
When visiting at a child development centre/social clubs (baby groups) you get:
A Formal MDT assessment process
When visiting at school (special/mainstream) you must work:
In liaison with special key worker teacher, child and parents. Help assessment in seating, standing, attention, PE
Child may visit you at a clinic/hospital depending on:
parents and child’s preference and age, if needing special equipment.
FH looks at:
Both parents present? Is one ill and child been left with grandparents causing lack of social interaction and being the reason behind developmental delay
Siblings? Ill and parents spending more time with them
Support networks? Grandparents
Work commitments?
Access to a vehicle? Widens opportunity for rehab in clinic as well as home
What is the most important part of an objective paeds assessment:
Observation
In observation we look at:
Observation of general movement patterns against age norms GMS & FMS
Observe with parents, yourself and whoever else is in the room
Observe at play - sharing toys, communicating with other children
Can & how do they get there?
Can they maintain the posture?
Is the posture symmetrical?
Can they move within/ without the postural set? Independently w/out support
Do they demonstrate associated reactions or reflex activity
In handling we assess for:
ROM: Contractures (Fixed?), Hypermobility
Passive movements -Stimulating tone? Quick and slow movements
Muscle Tone - Hypertonicity / spasticity, Hypotonicity
Muscle strength - Oxford scale
In objective assessment we need to think about:
- GMS & FMS Age appropriate?
- ROM
- Muscle tone
- Associated reactions & primitive reflexes
- Muscle strength
- Volitional & involuntary movements
- Co-ordination - games, i.e tap teddy then nose (FTN)
Fine motor skills (FMS) are:
small movements — such as picking up small objects and holding a spoon — that use the small muscles of the fingers, toes, wrists, lips, and tongue.
FMS is the way in which:
a baby explores it’s environment & therefore stimulates cognitive development
FMS is dependant on:
gross motor & visual development
Delay in FMS has an affect on:
cognitive development
Gross Motor Skills (GMS) are:
bigger movements — such as rolling over and sitting — that use the large muscles in the arms, legs, torso, and feet.
Name standardised assessment tools for measuring development (you should be able to explain and describe at least one of them):
- Normal motor milestones
- Chailey levels of ability
- Gross Motor Function Measure (GMFM)
- Movement ABC test (MABC)
Explain and describe Chaileys levels of ability
Designed for the assessment of postural ability in children and young adults with moderate to severe impairment.
Aim to create a naturalistic assessment in which the child is encouraged to move through play while the therapist observes.
Doesn’t require any specialist equipment. The Chailey Levels of Ability describe a progression of ability based on the components of loadbearing, movement and symmetry.
Explain and describe GMFM
Standardised observational instrument to measure change in gross motor function from birth - 16 years old.
Suitable for children with CP, Down’s Syndrome and developmental delay. Assesses motor function – quantity not quality. High intra & inter-rater reliability.
GMFM categorises children into:
5 levels of motor ability
Evidence-based practice shows that children rarely move between categories
Therefore can be used to predict a child’s motor prognosis, especially their expected mobility levels
Name the 5 levels of the GMFCS:
- Walks without restrictions: Limitations in more advanced gross motor skills
- Walks without assistive devices: limitations walking outdoors and in the community
- Walks with assistive devices; limitations walking outdoors and in the community
- Self-mobility with limitations; children are transported or use power mobility outdoors and in the community
- Self-mobility is severely limited even with the use of assistive technology
Name types of GMFM
88 - more descriptive, uses aids and orthotics,
66 - requires less time, more meaningful change, items ordered by difficulty
Explain and describe movement ABC test
Standardised assessment of coordination for children aged 3-12. Checklist and assessment package for children with coordination difficulties
Assesses quantity and quality. High intra & inter-rater reliability (not common)
Some treatment ideas:
Use imagination and PLAY:
Hydrotherapy
Sensory rooms
Toys incorporating GMS or FMS
Soft play
Hopscotch
Development delay is not always caused by
a brain injury or neurological condition.
Development delay can occur when a child initially has:
both parents, one parent becomes ill, i.e. Ca. That parent is being hospitalised and looked after by the other parent and the child is left with the grandparents. Leads to lack of social interaction for child, i.e. not speaking as much or playing, and the lack of exposure of socialising leads to a development delay
Prolonged sitting in car seat may lead to:
lack of use of core resulting in development delay and weaker in core muscles than they should be for their age.
Torticollis is:
tightening of SCM due to keeping child in one position for prolonged period of time. Leads to child only looking one side and therefore using one side of their body more
Adult CP can present with:
Pain, Fatigue, Falls 80% fallen
NICE guidelines for Adult CP recommends:
- Annual review
- Encourage independent living
- Encourage work
- Communication difficulties – refer to SALT
Adult CP are more likely to have:
Musculoskeletal problems esp hips leading to THR but orthopaedic consultants reluctant to operate
Selective Dorsal Rhizotomy is usually carried out:
to improve walking ability in children and young people (3-12 years) with spastic diplegia (commonly) at GMFCS level II or III
Name the 4 most important types of intervention for paediatrics
- Encourage symmetry
- Prevent & treat deformities
- Facilitate movement & mobility
- Encourage functional independence
We can encourage symmetry in:
sleeping, sitting at school, standing, walking, in physio
Prevent and treat deformities by:
- Standing early & in correct alignment. From ~ 1yr old. Can use standing frames for those that are unable to walk. Other standing benefits
- Passive stretches - lack of evidence. Casting, splints, positioning, ROM exercises to prolong stretch for plastic changes
- Positioning - school, home, seated, in bed.
- Botox injections - CP regularly
Facilitate movement and mobility by:
Strengthening exercises to be able to do this in the most symmetrical way.
Encourage functional independence by:
goal setting, taking into consideration that children are constantly growing and as such need to constantly be thinking about 24 postural movement and symmetry
Orthoses can be provided based on:
individual needs & aimed at specific goals. The Pros & Cons discussed with child. Correctly fitted with education of child, parents/ carers on checks and timetable for wearing. Monitored by team
Oral drugs commonly used are:
- Diazepam – rapid relief for spasm & pain
- Botulinum toxin A – focal spasticity
- Intrathecal Baclofen – more widespread spasticity with postural, functional or care difficulties
Spasticity in hip ADD and flexors increases risk of:
Hip subluxation/dislocation
