Paediatrics Flashcards
Gross Motor Development - 6w, 6m, 9m, 12m and 18m milestones
6 weeks -
- Good head control (raises head to 45 degrees when prone on tummy)
- Head stabilised when raised to sitting position
6 months -
- Unsupported sitting w/ rounded back
- Rolls prone to back (vice versa later)
9 months -
- Stands holding on
- Straight back sitting (7 1/2 months)
12 months - Walks alone (9-18months); 18m is threshold for worry eg Duchenne’s MD, Hip problems, CP etc
18 months -
- Runs (16m)
- Jumps (18m)
Gross Motor Development - 2y, 2.5y, 3y and 4y
2 years -
- Tiptoe running
- Ball throw at shoulders
- Upstairs walking with both feet on each step
2.5 years - Kicks ball
3 years -
- Hops on 1 foot x3 (each)
- Upstairs walking 1 foot per step
- Downstairs 2 feet per step
4 years - Stair walking both ways in adult manner
Fine Motor/Vision Development - 6w, 6m, 9m, 12m and 18m milestones
6 weeks - Tracks object/face
6 months -
- Palmar grasp (5m)
- Transfers objects hand to hand
9 months -
- Inferior pincer grip (pads of fingers in pincer)
- Object permanence (understanding that objects continue to exist when they cannot be seen, heard, or touched - eg peek-a-boo)
12 months -
- 2 brick tower
- Neat pincer grip (10m)
- Casting bricks like fishing (should disappear by 18m otherwise abnormal)
18 months -
- Drawing to and fro
- 4 brick tower (should be smooth wooden blocks to force balance)
Fine Motor/Vision Development - 2y, 2.5y, 3y, 3.5y and 4y
2 years -
- Draw; vertical line
- Bricks; 8 block tower
- Turns several pages of book at a time
- Puzzles; shape matching >2y
2.5 years - Draw; horizontal line
3 years -
- Draw; Circle
- Bricks; Bridge or train
- Cuts; Single
- Griffiths Beads
3.5 years - Cuts pieces
4 years -
- Draw; Cross, Sqaure (4.5y), Triangle (5y)
- Bricks; 12 block tower, 6 brick steps, 10 brick steps (5y)
- Cuts; paper in half
- Beads; small beads
Speech/Language Development - 6w, 6m, 9m, 12m and 18m milestones
6 weeks - Stills/startles at loud noises
6 months -
- Turns head to loud sounds
- Understands bye-bye/no (7m)
- Monosyllabic babbles
9 months -
- Responds to own name
- Imitates adult sounds (polysyllabic)
12 months -
- Shows understanding of nouns eg where’s mummy
- 3 words (50% 13m)
- Points to own body parts (15m), points to body parts on doll (18m)
18 months -
- Shows understanding of nouns eg show me the x
- 1-6 different words
Speech/Language Development - 2y, 2.5y, 3y, 3.5y and 4y milestones
2 years -
- Shows understanding of verbs; eg what do you draw with, what do you eat with
- 2 words joined together (50+ word vocabulary)
2.5 years -
- Shows understanding of prepositions in/on (eg put the cat on the bowl)
- 3-4 words joined together
3 years -
- Understands negatives; which of these is NOT an animal?
- Understands adjectives; which of these is red?
3.5 years - Understands comparitives; which boy is bigger than this one (point to middle sized)?
4 years -
- Understands complex instructions; before you put x in y, give z to mummy
- Uses complex narrative/sequences to describe events
Social Development - 6w, 6m, 9m, 12m and 18m milestones
6 weeks - Social smile (visual problem if not)
6 months -
- Puts object to mouth (stops at 1y)
- Shakes rattle
- Reaches for bottle/breast
9 months -
- Stranger fear (6-9m to 2y)
- Holds and bites food; eg digestive on table
12 months -
- Waves bye-bye
- Hand clapping
- Plays alone if familiar person nearby
- Drinks from beaker with lid
18 months - Imitates every day activities
Social Development - 2.5y, 3y and 4y milestones
2.5 years - Eats skillfully with a spoon (no/little spillage)
3 years -
- Begins to share toys with friends
- Plays alone without parents
- Eats with fork + spoon
- Bowel control
4 years -
- Concern/sympathy for others if hurt
- Has best friend
- Bladder control (4.5y)
- Engages in imaginative play/observing rules; eg pretending to be an animal (4.5-5y)
- Eats skillfully with little help
- Handles knife (5y)
- Dressing and undressing
Paediatric Respiratory Conditions - Causative agents (Croup, Acute Epiglottitis, Bronchiolitis, Whooping Cough)
Croup - Parainfluenza virus
Acute Epiglottitis - Haemophilus influenzae type B
Bronchiolitis - RSV
Whooping Cough - Bordetella pertussis
Downs Syndrome - aetiology and percentage of cases with each (3)
Meiotic Chromosomal Non-Disjunction (Maternal Chromosome 21) - 95%
Robertsonian Translocation of Unbalanced Chromosomal Material (often t(14,21) translocation) - 4%
Mosaicism - 1%
Downs Syndrome - strongest risk factor
Increased maternal age at time of delivery
- 20 y/o = 1/1,530
- 45 y/o = 1/37
Downs Syndrome - dysmorphic features (General, head, neck, hands, feet)
General -
- Hypotonia
- Hyperflexibility
Head -
- Oblique palpabral fissures (edge of eyes)
- Epicanthic folds (upper eyelid skin fold covers the inner corner of the eye)
- Flat nasal bridge
- Brachycephaly (flat occiput)
- Dysplastic, low set ears
- Open mouth with protruding or furrowed tongue
- High arched palate
- Brushfield spots in eyes (small, often white spots arranged in a ring)
Neck - Short neck with excessive skin at nape
Hands -
- Transverse palmar crease (Simian)
- Short and incurved little finger
Feet - Sandal toe deformity
Downs syndrome - congenital heart defects; 3 most common
~ 40-50% of neonates with T21 will have congenital heart disease
- AVSD; 37%
- VSD; 31%
- ASD; 15%
Downs Syndrome - neurological complications
Developmental delay + intellectual disability (varies significantly)
Autism, ADHD, aggressive behaviour more prevalent
Alzheimer’s - 75% develop by 6th decade of life
Downs Syndrome - cause of deafness
Eustachian tube abnormalities lead to glue ear -> conductive hearing loss (so need for regular audiometry)
Downs Syndrome - respiratory complications
Asthma and OSA
Downs Syndrome - GI tract abnormalities
12% require surgery
Most characteristic is duodenal atresia (failure of intestine to recanalize during development)
Others include:
- Imperforate anus
- Tracheo-oesophageal fistula
- Increased risk of Hirschsprung’s disease
Down’s Syndrome - endocrine complications
Hypothyroidism - 10-20%
T1DM
Down’s Syndrome - haematological complications
ALL
Immunodeficiency
Transient myeloproliferative disorder
Polycythaemia
Acute megakaryoblastic leukaemia (AMKL)
Down’s Syndrome - ophthalmological complications
Myopia, strabismus, cataracts
Down’s Syndrome - Screening; Combined Test (timing, components, results)
10-14 weeks
Serum Screening
- Beta-hCG; increased in T21
- PAPPA-A; decreased in T21
Nuchal Translucency Screening - increased nuchal translucency (thickness >6mm)
- Less reliable later in pregnancy
Down’s Syndrome Screening - comparison between triple and quadruple test
Less reliable than the combined test
Both performed at 14-20 weeks
Both maternal blood tests only
Triple - beta-hCG (raised) + AFP (low) + Serum uE3 (low)
Quadruple - beta-hCG (raised) + AFP (low) + Serum uE3 (low) + Inhibin A (raised)
Down’s Syndrome - what is a positive screening result (ratio score)
Risk >1/150 - then offered diagnostic testing
Down’s Syndrome - comparison of antenatal testing methods
Methods collect foetal cells to karyotype them for definitive answer
Chorionic Villus Sampling (9-12 weeks)
- US Guided biopsy of placental tissue
- Done when testing is done earlier in pregnancy
- A higher risk of pregnancy loss with chorionic villus
Amniocentesis (15-19 weeks)
- US Guided fluid aspiration of amniotic fluid using needle and syringe
- Later in pregnancy once enough amniotic fluid to make it safer to sample
Down’s Syndrome - what does NIPT test?
Cell-free DNA shed from placenta into maternal blood stream
Down’s Syndrome - post-natal investigations
Echocardiogram - congenital heart defects
Red reflex testing - congenital cataracts
TFTs - congenital thyroid disease
FBC - myeloproliferative disorders/polycythaemia
Hearing assessment - congenital hearing issues
Radiographic swallowing assessment - performed if feeding difficulties present to screen for GI abnormalities eg duodenal atresia
Down’s Syndrome - prognosis
60 y/o
- Varies depedning on severity of associated complications
Kawasaki Disease - definition
An acute, self-limiting, systemic, medium-vessel vasculitis of unknown cause that mainly affects children <5 y/o and commonly presents with a high fever (above 39ºC) lasting 5 or more days
Kawasaki Disease - risk factors
Asian ethnicity - especially Japanese
Aged <5 y/o - 80% of cases
Male - 1.5:1 (M:F)
Kawasaki Disease - clinical features
Consider in any child with persistent high fever (above 39ºC) lasting 5 or more days
CREAM:
- Conjunctivitis; bilateral, non-exudative
- Rash; any non-bullous rash, often maculopapular and desquamation of hands and feet occurs in sub-acute phase
- Edema/Erythema; of hands of feet
- Adenopathy; cervical, commonly unilateral and non-tender
- Mucosal involvement; strawberry tongue, oral fissures etc
AHA Diagnostic criteria is similar
Kawasaki Disease - complications
Most Common - Coronary Artery Aneurysms - 15-25% untreated children develop aneurysms but risk much lower with early treatment (giant aneurysms can rupture -> cardiac tamponade)
Coronary Artery Thrombosis/MI
Myocarditis/Pericarditis
Valvular Disease - eg MR
Kawasaki Disease - management
Hospital admission - early treatment to prevent coronary artery aneurysms
Oral aspirin (reduce thrombosis risk) -
- High dose until fever resolves for 48 hours
- Low dose for ~6 weeks after
IVIG (reduce CA aneurysm risk)- infusions within first 10 days can reduce incidence of coronary artery aneurysms (clinical improvement within 36 hours or 2nd dose may be given)
- Corticosteroids or infliximab (anti-TNF) if ineffective/resistant
Kawasaki Disease - natural history
Acute Phase (1-2 weeks from fever onset) -
* High fever
* Irritability
* Rash
* Lymphadenopathy
* Mucositis
* Peripheral erythema and oedema
Subacute Phase (2-4 weeks from fever onset)
* Afebrile
* Most clinical features begin to resolve, desquamation of the hands and feet
* Arthralgia
- The highest risk period for developing cardiac complications
Convalescent Phase (4-8 weeks from fever onset)
* Asymptomatic period
* Clinical features have resolved
- Coronary artery aneurysms often improve but may get worse
Kawasaki Disease - investigations
Bedside -
- ECG; may show arrhythmias or ST-T changes if myocarditis/MI occurs
- Urinalysis; may show sterile pyuria (raised WCC w/o infection)
Lab:
Baseline Bloods -
- FBC - may be anaemia, raised WCC, thrombocytosis
- U&Es
- LFTs - may be deranged if hepatitis occurs, hypoalbuminaemia can occur
ESR + CRP; Often significantly raised
Anti-streptolysin O Titre (ASOT); Exclude GAS infection
Consider PIMS-TS blood tests if suspected as DDx - Troponin
- D-dimer
- Coagulation w/ fibrinogen
- Ferritin
Imaging:
- Echocardiography essential
* Findings include:
○ Coronary artery aneurysms
○ Valvular disease (e.g. mitral regurgitation)
○ Coronary artery thrombosis
○ Poor ventricular function/evidence of myocarditis
- Pericardial effusion/evidence of pericarditis
Kawasaki Disease - complication of treatment
Aspirin use in <16 y/o associated w/ Reye’s Syndrome; rare acute encephalopathy associated with liver failure
Difference between CMPA, CMPI and Lactose Intolerance
CMPA - hypersensitivity to cow’s milk protein; allergic process (IgE mediated or non-IgE mediated)
CMPI - non-allergic process (no immune system response) to cow’s milk protein, just GI symptoms and no systemic allergic symtpoms like wheeze/sneezing etc
Lactose Intolerance - lactose is a sugar not a protein and no allergic response
CMPA - types and differences between
IgE Mediated/Immediate - Rapid reaction to cow’s milk, occurring within 2 hours of ingestion
Non-IgE Mediated/Delayed - reactions occur slowly over several days
CMPA - epidemiology
- Typically affects infants and young children <3 y/o
- Typically presents within first 3 months of life in formula-fed infants
- Rarely seen in exclusively breastfed infants
- 3-6% of all children
- More common in:
- Formula fed babies and those with a personal or family history of atopic conditions
CMPA - presentation (onset and symptoms)
Presents before 1 y/o typically <3 months; often apparent when weaning from breast milk to formula milk/food containing milk
* Breastfed babies when mother is consuming milk products
* In severe cases - failure to thrive (needs paediatric referral)
GI Symptoms
- Bloating and wind
- Colic symptoms/Abdominal pain - irritability and crying
- Diarrhoea
- Vomiting
Systemic Allergic Symptoms
- Urticarial rash (hives)
- (Rare) Angio-oedema (facial swelling)
- Cough or wheeze
- Sneezing
- Watery eyes
- Atopic eczema
*Rarely, in severe cases, anaphylaxis
CMPA - diagnosis/investigations
Often clinical diagnosis and trial of eliminating cow’s milk (with symptom resolution) should support diagnosis
Others:
- Skin prick/patch testing
- Total IgE and specific IgE (RAST) for cow’s milk protein
