Paediatrics Flashcards
Components of the Paediatric Examination (9)
1) General Observation
2) Initial measurements - height/weight/head circumference, vitals
3) Respiratory Exam
4) Cardiovascular exam
5) Abdominal Exam
6) Neurological Screen - general function
7) Skin Exam
8) Head and Neck - fontanelle closure, teeth, lymph nodes
9) ENT Screen - vision, hearing, throat
Paediatric Age Categories
Neonate = first 4 weeks of life Infant = up to first year of life Preschool Child = from 2-5 School Child = from 6-18 Teenager/Adolescent = 13-18
Normal Vitals - Neonate
RR - 30-60
HR - 100-160
Systolic - 50-85
Normal Vitals - Infant
RR - 20-40
HR - 90-140
Systolic - 60-100
Normal Vitals - Child
RR - 20-40
HR - 80-120
Systolic - 70-110
Normal Vitals - Adolescent
RR - 15-20
HR - 60-100
Systolic 80-120
4 Major domains of child development
> Gross motor
> Fine Motor/Vision
> Hearing/Language/Speech
> Social, emotional and behavioral
Developmental Correction
Correction needs to be made if the baby was born premature - should be staged from the expected date of birth. Correction no longer needed after 2 years of age.
The Primitive Reflexes (5)
Reflexes present in neonates, should disappear by 2-4 months of age.
> MORO - sudden head extension causes symmetrical arm extension then slow flexion
> GRASP - fingers grasp what is in palm
> ROOTING - head turns to stimulus when touched near mouth
> STEPPING RESPONSE - stepping movements when held vertically with feet touching floor
> ASYMMETRICAL TONIC NECK REFLEX - when lying down, limbs coordinate to head rotation
The Postural Reflexes (4)
Develop from the primitive reflexes, must be present for sitting and walking to occur
> LABRYNTHE RIGHTING - head moves in opposite direction of body tilting
> POSTURAL SUPPORT - when held upright, legs take weight and push up (bounce)
> LATERAL PROPPING - When sitting, arm extends to side when falling
> PARACHUTE - when face down, arms extend out
NEWBORN - development
- ## Head support when pulled up-Startled by noise
-
6-8 WEEKS - development
- Head elevated when lying on belly
- Follows objects with head
- Smiles responsively
6 MONTHS - development
- Sits without support
- Palmar grasp
- Vocalize
- Stranger Anxiety/Puts food in mouth
9 MONTHS - development
- Crawling
- Three finger grip
- “Mama”/”Dada”
- Waves bye/peek-a-boo
12 MONTHS - development
- Unsteady walking/with assistance
- 2 finger pincer grip
- 2-3 words apart from “Mama”/”Dada”
- Drinks from cup
18 MONTHS - development
- Walks well
- 3 block stack
- 6-10 words
- Eats w/spoon
2 YEARS - development
- 2 stairs
- 6 block stack/can draw line
- simple sentences
- Symbolic play
3 YEARS
- Tricycle
- Can draw circle
- 3-4 word speech
- Brush teeth
4 YEARS
- Hops
- Can draw square/triangle
- -
Vision - development
Babies born with immature fovea and unmyelinated optic nerve, so very poor vision. Reaches adult levels at around 3-4 years.
Causes of abnormal delay
> Genetic - e.g. down's, fragile X
> Teratogens
> TORCH infection
> Extreme prematurity
> Birth complications - asphyxia
> Trauma
> Infection
> UnknownCerebral Palsy - Definition and Causes
Defined as abnormal movement/posture, due to non-progressive disturbance of foetal brain - often with cognitive and communicative delay.
It is the most common cause of motor impairment in children, with 80% of cases caused by vascular occlusion, cortical migration disorders, or structural maldevelopment. 10% from postnatal causes.
Cerebral Palsy - Presentation and Subtypes (3)
Can present in the Neonatal period with abnormal posture, delayed motor milestones, feeding difficulty, and persistence of primordial reflexes.
There are 3 main clinical subtypes:
> SPASTIC CP - 90%. Damage to the pyramidal/corticospinal UMN tracts, with spasticity, brisk reflexes, and positive babinski. May be further divided into hemiplegic (one-sided, flexed and tiptoe walk), quadriplegic (severe) and diplegic (legs>arms)
> DYSKINETIC CP - 6%. Arises from damage to the basal ganglia/extrapyramidal systems, resulting in tremor, chorea and athetosis.
> ATAXIC CP - 4%. Arises from genetic abnormalities of cerebellum, results in hypotonia, poor balance, and uncoordinated movements.
Autism Spectrum Disorders - Presentation
Presents between 2-4 years of age, with the triad of:
> Impaired social interaction
> Speech/Language problems
> Imposition of routines with ritualistic behaviour
Other features include general learning/attention problems, seizures, and poverty of imagination.
Management involves support and applied behavioural analysis (ABA).
Hearing Impairment - Types (2), Causes and Management
Divided into 2 main causes
SENSORINEURAL - Uncommon
Present at birth, usually caused by:
> Genetic factors
> Congenital infection (e.g. rubella)
> Meningitis
> Head Trauma
Does not improve, requires hearing aids/cochlear
CONDUCTIVE HEARING LOSS
From middle ear disease caused by:
> Chronic otitis media/glue ear
> Eustachian tube dysfunction (e.g. down's, cleft palate)
Often mild and transient.
Neonatal Blood Gas Targets in Resuscitation
2 min - 65-70% 3 min - 70-75% 4 min - 75-80% 5 min - 80-85% 10 min - 85-95%
Neonatal Resuscitation - Adrenaline Dosing
Adrenaline given is 0.1mg/mL (catastrophic adrenaline)
Dosage is based on gestational age:
<26 = 0.1mL
27-34 = 0.25mL
>34 = 0.5mL
Can also be based on 10-30 micrograms/kg
Neonatal Resuscitation - Algorithm
Term Gestation? Breathing/Crying? Good tone?
NO
Warm baby, position and clear airway, and stimulate
If after a few seconds, still apnoea/gasping, or HR<100
START VENTILATION 30-60/min Pulse oximeter on right hand continue stimulating Continue for 60 seconds before re-assessing
Re-assess
Is HR<100?
Is airway blocked?
IF NO
Continue ventilating for another 60 seconds
IF YES - Start CPR (3:1) - Give 100% oxygen - Consider intubation Check HR and breathing every 30-60 seconds, give adrenaline every 3 minutes.
Complications of Suction in Neonates
- Vagal stimulation = bradycardia
- Laryngospasm
Paediatric Amiodarone Dosage
5mg/kg
Common Causes of Cardiac Arrest in Children (4H’s and 4T’s)
> Hypoxia
> Hyper/Hypokalaemia
> Hypovolaemia
> Hypothermia
> Tamponade
> Tension Pneumothorax
> Thromboembolism
> Toxins/PoisonsWETFLAG Mneumonic
WEIGHT ESTIMATION
1-12 months = (0.5age in months) +4
1-5 years = (2age in years) +8
6-12 years = (3*age in years) +7
ELECTRICITY DOSE (DEFIB) 4 J/kg biphasic
TUBE Internal diameter (age/4+4 = mm) and length (age/2+12=cm) estimation
FLUIDS
20mL/kg
LORAZEPAM DOSE
0.1mg/kg
ADRENALINE DOSE
0.1 mg/kg of 1:10000
GLUCOSE
2mL/kg of 10% dextrose
Fluid Calculation in Paediatrics - per hour and per 24 hours.
FOR HOURLY AMOUNT, 4:2:1 RULE
4mL/kg/hr ==> for first 10 kg
2mL/kg/hr ==> for next 10 kg
1mL/kg/hr ==> every kg over 20kg
FOR 24 HOUR AMOUNT, 100:50:20 RULE
100mL/kg ==> for first 10kg
50mL/kg ==> for next 10kg
20mL/kg==> for every kg over 20kg
Sepsis - Causes (4 pathogens) and Management Priorities (5)
Pathogenic causes include:
> Neisseria Meningococcus - MOST COMMON
> S. Pneumoniae
> Haemophilus Influenza B (Not in Norway)
> Group B Streptococcus (neonates)
Management priorities include:
> RESUSCITATION
> Antibiotics - depends on pathogen
> Fluids
> ICU admission if required
> Watch for pulmonary oedema and DIC
Important causes of Coma in children (5)
Disturbance of cerebral function/RAS, most important causes include:
> Hypoglycaemia/Diabetes
> Poisoning
> Sepsis/Meningitis
> HSV Encephalitis
> Raised ICPStatus Epilepticus - Definition and Management (with Dose)
Seizures lasting >30 minutes
Primary and Secondary Survey
CHECK BLOOD GLUCOSE
Administer Lorazopam (0.1mg/kg)(if IV access) or Diazepam (0.5mg/kg)
If no response, administer Lorazepam again, call seniors
Anaphylaxis Management (and Dose)
Adrenaline IM 1:1000 (Dose - <5 = 0.15mL, 5-12=0.3mL, >12 = 0.5mL)
Fluids
Chlorpheniramine
Hydrocortisone
SIDS - Definition and Risk Factors (6)
Defined as sudden death in infants >1 month, most common cause of death in infants from 1 month-1 year old, most common between 2-4 months old.
Risk factors include
> Low birthweight/Preterm
> Male
> Low socioeconomic family status
> Maternal age and parity
> Smoking
> Sleeping prone in high temperature
Down Syndrome - Pathophysiology
The extra chromosome on 21 may occur in 1 of 3 ways:
> MEIOTIC NON-DISJUNCTION (94%) - from failure of chromosomal split in Meiosis II, related to maternal age.
> TRANSLOCATION (5%) - from Robertsonian translocation, occurs when the extra 21 is attached to another chromosome (usually 14).
> MOSAICISM (1%) - from mitotic non-disjunction in fertilized embryo
Down Syndrome - Clinical Features (12, 9 on face) and Survival
> Round, flat face
> Third fontanelle
> Wide nasal bridge
> Epicanthal folds
> Almond-shaped, slanted eyes
> Brushfield Iris spots
> Short nose
> Low set years
> Protruding (hypotonic) tongue
> Single palmar crease > Neck folds > Intellectual disability
85% survive past 1 year (most die from AV canal defect in heart), 50% live past 50 years.
Down Syndrome - Clinical Diagnosis and Management
Usually screened for during pregnancy, using US and amniocentesis. FISH can be performed on blood sample once born to confirm diagnosis.
Once born, requires urgent physical examination, CXR, EKG and Echo (screen for cardiac defects)
Management involves multidisciplinary team for medical and developmental problems, parental support, and medical management of complications.
Down Syndrome - Complications
CONGENITAL HEART DISEASE
Seen in 40-50%, AV defects most common, however PDA, ASD and VSD common.
ORTHOPAEDIC PROBLEMS
Atlanto-axial instability is a worry, may lead to spinal cord injury later in life
AUTOIMMUNE DISEASE
Hypothyroidism, Diabetes type I and Coeliac disease
BOWEL PROBLEMS
Duodenal atresia
LEUKEMIA
LOW FERTILITY
PRESENILE DEMENTIA/ALZHEIMER’S
Other Trisomies
EDWARD’S SYNDROME (Tri-18)
Characterised by low birthweight, overlapping fingers, cardiac and renal malformation
PATAU SYNDROME (Tri-13) Structural brain defects, polydactyly, cardiac and renal malformation
Turner’s Syndrome (5 features)
Caused by missing sex chromosome - 45, XO, 95% of cases miscarry. US screen will show foetal oedema.
Characterised by:
> SHORT STATURE
> Neck webbing
> Delayed puberty and ovarian dysgenesis (infertility)
> Shield-shaped chest, wide spaced nipples
> Wide carrying angle
Managed with growth hormone therapy and ovarian replacement for puberty
Kleinfelter Syndrome (4 features)
Caused by extra sex chromosome - 47, XXY. Results in:
> Infertility
> Hypogonadism
> Gynaecomastia
> Tall statureDiGeorge Syndrome - Cause, Face (6), and Complications (6)
Relatively common deletion syndrome, from deletion of 22q11.2.
Present with:
> Long face
> Small Jaw
> Short philtrum/fish mouth
> High, broad nasal bridge
> Epicanthal fods
> Low-set, malformed ears
Complications:
> Cardiac Malformation (80%) - usually involves vessels
> Cleft Palate (70%)
> Hypocalcaemia (from hypoparathyroidism)
> Immune deficiency
> Developmental Delay/Learning difficulty
> Behavioural abnormality
Stillbirth - Definition
Foetus born at or before 24 weeks with no signs of life
Perinatal Mortality Rate
Stillbirths + Deaths in first week, given per 1000 stillbirths + live births
Neonatal Mortality Rate
Deaths of live neonates (within 28 days) per 1000 live births
Low Birthweight
Birthweight <2500g
Very Low Birthweight
Birthweight <1500g
Foetal Alcohol Syndrome - Diagnosis (3) and Associated conditions (3)
Diagnosed by 3 characteristic features:
> CHARACTERISTIC FACIAL ANOMALIES - small head, small eyes, small mouth, thin upper lip, indistinct philtrum, epicanthal folds
> GROWTH RETARDATION - IUGR, failure to catch up
> CNS INVOLVEMENT - Cognitive impairment and learning difficulties
Can be present with brain underdevelopment, VSD, bone and kidney problems.
Routine Newborn Examination (13)
> General observation - gross abnormalities?3)
> Head/chest circumference
> Weight
> Auscultation and Pulses - detect CHD
> Hip displasia check
> Check eyes and mouth
> Tone of baby, abnormal movements
> Fontanelle palpation
> Check for jaundice
> External genitalia and anus
> Abdominal palpation
> Back and spine palpation
> Reflexes - moro, gripRoutine Neonatal Biochemical Screening (4 diseases)
> Phenylketonuria
> Hb-opathy
> CF (via serum trypsin)
> MCAD)
Hypoxic Ischaemic Encephalopathy
From hypoxia and metabolic acidosis damage to the brain - presents up to 48h after birht, 3 grades:
> MILD - irritable infant, hyperventilation, poor feeding
> MODERATE - marked abnormality of tone and movement
> SEVERE - no normal spontaneous movement or responses, severe seizures
Management involves skilled respiratory support, EEG, anticonvulsants, and hypothermic treatment
Subgaleal Haemorrhage
Occurs between the periosteum and the galeal aponeurosis of the scalp, dangerous as can hide severe blood loss.
Prematurity Co-morbidities
> Respiratory Distress Syndrome (74%)
> Pneumothorax
> Apnoea Episodes
> Hypothermia
> PDA
> Infection risk
> Intraventricular Haemorrhage
> Paraventricular leukomalacia
> Necrotising Enterocolitis
> Retinopathy of prematurity
> Bronchopulmonary Dysplasia
> Issues following discharge - anaemia, poor growth, bronchiolitisRespiratory Distress Syndrome
Arises from lack of surfactant, leading to alveolar collapse and formation of hyaline membranes. Can be prevented with antenatal glucocorticoids.
Presents within 4 hours of birth with:
> Tachypnoea >60
> Laboured breathing with nasal flaring
> Cyanosis (if severe)
CXR will show diffuse granular “ground glass” appearance, management involves CPAP and surfactant therapy.
Paraventricular Leukomalacia
The most common ischaemic brain injury in premature infants - occurs in the white matter beside the lateral ventricles, leading to cyst formation. May lead to spastic CP, intelligence deficit, and visual disturbance.
Needs urgent cranial US and EEG, no management available.
Necrotising Enterocolitis
A serious illness affecting premature infants in the first few weeks of life - occurs as a result of bacterial invasion of ischaemic bowel. Most commonly seen in the terminal ileum.
Presents with pain, abdominal distension, and vomiting - can perforate, leading to pneumoperitoneum and shock.
Managed by stopping oral feeding and giving antibiotics (ampicillin+gentamicin+clindamycin) - may require surgical resection if perforate.
