Paediatrics Flashcards
What are some of the physiological differences seen in children?
Surface area:volume % water content Metabolic reserves Faster pulse, resp rate Lower blood pressure - maintained until very shocked.
- They more easily get cold, dehydrated, hypoglycaemic.
Describe Physiological differences in terms of Ketotic hypoglycaemia
6-7am hypoglycaemic episode. 1-2 year old. Skinny Intercurrent illness. Most common form of hypoglycaemia between 18 months to 5 years.
What is different in children’s immune system?
Trust nature.
Immune system remarkably robust.
MMR, unconjugated pneumococcal vaccine.
Need to have infection before become immune.
What are some of the chronic conditions with childhood onset?
Asthma Autism Cerebral palsy Cystic fibrosis Gastroschisis Hirschusprungs disease Spina bifida
What are the reasons for reduced mortality of children?
Obstetric care
Better housing
Better Nutrition
Immunisations
What are some of the immunisations?
Measles
diphtheria
Polio
Rotavirus
What happens usually when children are admitted?
Acute admissions typically <2 years. Typically respiratory Increasing referrals Mostly watchful waiting No evidence of increasing severity.
Whats the important thing to remember in child care?
Understanding range of normal allows you to understand what is abnormal.
If in doubt review.
What are the 4 points to reflect on in child medicine?
- Children are not naturally healthy and need the right environment to develop and thrive.
- What outcome? All child health outcomes are linked.
- Child health and wellbeing is influenced by non-NHS policies e.g. housing, education, environmental.
- Children and young people (CYP) are the future… adults, parents, workforce, carers, leaders.
What can determine health and well being of the child?
Health and wellbeing of the adult.
Intervene early!
- Lifestyle
- Resilience
What are the key development fields?
Gross Motor Fine Motor Social and Self help. Speech and language. Hearing and vision.
Why is development important?
Learning functional skills for later life.
Hone skills in a safe environment.
Allow our brain’s genetic potential to be fully realised.
Equip us with tools needed to function as older children and adults.
Many are completely automatic.
What are some of the influencing factors for development?
Genetics
Environment
Positive early childhood experience.
Developing brain vulnerable to insults - antenatal, post natal, abuse and neglect.
What are some of the adverse environmental factors?
Antenatal - infections (CMV, Rubella, Toxoplasmosis, VZV)
Toxins (alcohol, smoking, anti-epileptics)
Postnatal - Infection (Meningitis, encephalitis) Toxins (Solvents mercury, lead) Trauma (Head injuries) Malnutrition (iron, folate, VitD) Metabolic (Hypo/hyperglycaemia) Maltreatment Maternal mental health issues.
Good (sensitive) histories are therefore important.
What are the red flags to notice in development?
No social smile by 2 months. Not sitting unsupported by 9 months. Not walking unsupported by 18 months. No words by 2 years. Hearing loss. Persistent low muscle tone/floppiness.
What are the stages of childhood and at what age does it occur?
Neonate <4w Infant <12m/1yr Toddler about 1-2y Pre-school 2-5y School age Teenager / Adolescent
For milestones in children when would you think about a referral?
If not achieved by limit age (2 SDs from mean)
Correct for prematurity until 2 years.
What are the reference values for Weight, lenght and OFC at 1. Birth 2. 4 months 3. 12 months 4. 3 years.
- W - 3.3 L- 50 OFC - 35
- W - 6.6 L-60
- 12months W- 10 L-75 OFC-45
- 3years W-15 L-95
What does failure to thrive indicate?
Supply of energy and nutrients is less than the demand for energy and nutrients.
What are the causes of failure to thrive in early life?
Deficient intake:
Maternal:
Poor lactation, incorrectly prepared food, unusual milk or other feeds, inadequate care.
Infant:
Prematurity, small for dates, oro palatal abnormalities (cleft palate), neuromuscular disease (cerebral palsy), genetic disorders.
Increased Metabolic demands: Congenital lung disease Heart disease Liver disease Renal disease Infection Anaemia Inborn errors of metabolism Cystic fibrosis Thyroid disease Crohn's / IBD Malignancy
Excessive nutrient loss: Gastro oesophageal reflux Pylroic stenosis Gastroenteritis Malabsorption - food allergy, persistant diarrhoea, coeliac disease, pancreatic insuffiency, short bowel syndrome.
Non-medical causes of failure to thrive?
Poverty / socio-economic status. Dysfunctional family interactions. Difficult parent-child interactions. Lack of parental support. Lack of preparation for parenting/education. Child neglect. Emotional deprivation. Poor feeding or feeding skills disorder.
3 months - Gross motor
Lifts head and chest when lying on stomach.
Turns around when lying on front.
3 months - fine motor
Looks at and reaches for faces and toys.
Picks up toy with one hand.
3 months - Language
Cries in a special way when hungry.
Makes sounds - ah,eh.
Laughs out loud.
3 months - Social
Social smile (6-8weeks) Distinguishes mother from others.
3 months self-help
Reacts to seeing bottle/breast.
Comforts self with thumb/dummy.
6 months gross motor
Rolls over from back to front.
Sits steadily without support (8-9months)
6 months fine motor
Transfers toy from one hand to the other.
Uses 2 hands to pick up large objects.
6 months language
Babbles
Responds to name.
Makes sounds like “da-da” - 2 syllable babble.
6 months social
Reaches for familiar people.
Pushes things away they don’t want.
6 months self-help
Feeds self biscuits / similar foods.
9 months gross motor
Crawls on hands and knees.
Pulls to stand.
Walks around furniture while holding on.
9 months fine motor
Picks up small objects with thumb and finger princer grip.
9 months language
Understands phrases like no no and all gone.
9 months social
Looks for objects that fall out of sight - object permanence. (9-12months)
Stranger awareness.
Plays social games.
Waves bye bye.
9 months self help
Picks up spoon by the handle.
12 months gross motor
Stands without support
Walks without help (by 18months)
Runs (some falls)
12 month fine motor
Stacks 2 or more blocks.
Picks up 2 small toys in one hand.
12 months language
Has 1 or 2 words with meaning.
Uses “mama” specifically for parents, or similar.
12 months social
Gives kisses or hugs.
Shows shared attention / pointing to things of interest.
12 months self help
Lifts cup to mouth and drinks.
Insists on doing things by self such as feeding.
Feeds self with spoon.
18 months gross motor
Kicks a ball forward.
Runs well - few falls
Walks up and down stairs without support.
18 months fine motor
Builds towers of 4 or more blocks.
Scribbles with crayon
Turns pages of picture books, one at a time.
18 months language
Uses at least 10 words
Asks for a drink or food using words or sounds.
Names a few familiar objects in picture books.
Follows 2 part instructions.
Starts to join words into sentences (21-24 months)
18 months social
Sometimes say “no” when interfered with.
Shows sympathy to other children, tries to comfort them.
Early pretend play.
Usually responds to correction by stopping.
18 months self-help
Eats with fork
Eats with spoon
Takes off open coat or shirt without help.
2years gross motor
Climbs on play equipment
2 years fine motor
Scribbles with circular motion.
2 years language
Has a vocabulary of around 30-50 words.
2 years social
“helps” with simple household tasks.
2 years self help
Opens door by turning knob.
2.5 years gross motor
Stands on one foot without support.
Walks up and down stairs one foot per step.
2.5 years fine motor
Draws or copies vertical lines.
Cuts with small scissors.
2.5 years language
Speaks clearly, understandable most of the time.
Knows what to do with objects.
2.5 years Social
Plays with other children.
Plays a role in games.
Plays games - tig, hide and seek.
2.5 years self-help
Washes and dries hands.
Dresses self with help.
3 years gross motor
Rides on a tricycle, using pedals.
3 years fine motor
Draws or copies complete circle.
3 years language
Asks questions beginning with “why”, “When”
Identifies >4 colours by name correctly.
3 year social
Gives directions to other children
3 year self help
Toilet trained - may need help wiping.
3.5 years gross motor
Hops on one foot without support.
3.5 years fine motor
Cuts across paper with small scissors
3.5 years language
Answers questions like “what do you do with your eyes”
Talks in long, complex sentences (10+)
Follows a series of 3 simple instructions in order.
3.5 years social
Plays co-operatively with minimum conflict and supervision.
Protective towards younger children.
3.5 years self help
Washes face without help.
Dresses and undress without help, except shoelaces.
4 years fine motor
Draws a recognisable picture
4 years language
Counts ten or more objects.
Prints a few letters or numbers.
4 years social
Follows simple rules in board/card games.
4 years self help
Fastens one or more buttons
4.5 years gross motor
Skips or makes running jumps.
4.5 years fine motor
Draws a person with 3 parts
4.5 years language
Reads a few letters (>5)
4.5 years self-help
Usually looks both ways before crossing the road.
5 years gross motor
Self propels on swing
5 years fine motor
Prints first name
5 years language
When asked what is an orange answers a fruit.
5 years self help
Goes to toilet without help.
What are the 4 red flag milestones
- No social smile by 2 months
- Not sitting unsupported by 9 months
- Not walking unsupported by 18 months
- No words by 2 years.
What are concerning respiratory symptoms?
Grunting
Chest drawing
Consistent fever and rigors
Neck stiffness
What are the indications for referral when thinking about dysmorphic syndrome features?
Extreme short / tall stature Height below target height Abnormal height velocity History of chronic disease Obvious dysmorphic syndrome Early / late puberty.
What are the common causes of short stature?
Familial SGA/IUGR Undernutrition Chronic illness (JCA, coeliac) Psychological and social Hormonal (hypothyroidism) Turner P-W syndromes.
What is characteristic of thyroid deficiency in children?
Loss of height and gain of weight.
What is the triad for HUS?
Microangiopathic haemolytic anaemia
Thrombocytopenia
AKI/ARF
What is the tanner method?
What is it based on?
Staging in puberty. Breast Genital Pubic hair Axillary hair Testes
What is early puberty and late in female?
Before 8 early After 13 (RARE)
What is early puberty and late in male?
Before 9 early After 14 ( common especially in CDGP)
What is the most common GM in children?
Minimal change disease:
What is the typical presentation of GM in children?
Gastroenteritis 10 days ago.
Swollen face, 1 eye closed, pale, inflated weight, peri-orbital oedema, ascites, pitting oedema.
FROTHY URINE.
What is the most common cause of CKD in children?
Congenital (birth defects)
UTI features in a child
Irritability
Dysuria
Failure to thrive
Pain on micturation
If more systemic could be pyelonephritis.
Treatment for children with a UTI?
BP - doppler used for young kids.
Trimethoprim 1st and then amoxicillin 2nd line. for 3-5 days orally.
What are the 3 types of diabetes that can be seen in a child?
Type 1 - most common
Type 2 - more common now due to obesity
Maturity onset diabetes of the young.
What are the 3 Ts in diabetes?
THINK - diabetes
TEST - blood glucose levels
TELEPHONE - referral nearest diabetes team.
What are the main signs seen in Type 1 in children?
Thirst, increased toilet use, decreased weight, more tired.
What are the red flag symptoms seen in diabetes in children?
Bed wetting / day-wetting after previously being fine.
What is the best test to do for children with suspected diabetes?
Random bed side capillary blood glucose.
What is needed for a diagnosis of diabetes?
Symptoms and 1 diagnostic test.
What is best treatment for type 1 in children?
Basal bolus insulin 4-5 times a day.
What are the signs of hypoglycaemia in children?
Headache Poor concentration Confusion Coma Weakness Lethargy Tremor Sweating Palpitations Seizures.
If child is awake and aware how do you treat hypo?
10-15g immediate acting carbohydrate by mouth.
Check blood glucose within 15mins
Follow up with additional complex carb to maintain.
If child is uncoperative how do you treat hypo?
Glucogel into buccal cavity.
If child has altered consciousness and fitting how do you treat hypo?
IM glucagon
IV 10% glucose if in hospital.
What do children with diabetes need to do when they are ill?
Increase blood glucose monitoring
Maintain carbs
High fluid intake
Ketones / urine check.
What headaches need more investigations?
Isolated acute
Chronic progressive
Acute severe.
What is most common cause of headache in children? Features of this are:
Migraine:
Non-specific abdominal pain, nausea, vomiting, focal symptoms, photophobia.
Features of tension headache?
Band-like distribution
Present most of time
Constant ache
Symmetrical, diffuse.
Features of increased ICP?
Bend, lift and cough make it worse.
Woken from sleep with headache / vomiting.
Generally well but headache when lying down.
What are red flags on imaging and features?
Cerebellar dysfunction Raised ICP Neurological deficit Seizures Personality changes
Treatment for migraine
Triptans - amytriptalyine.
Prevention is propanalol.
What is epilepsy?
Tendency of recurrent, unprovoked epileptic seizures.
EEG only for supportive evidence.
Usually a chemical trigger.
Treatment for epilepsy
Sodium valporate and levetivarcetam.
Carbamezepine - 1st line focal.
What is the most common dermatology problem in children?
Eczema atopic.
In neonates - face, neck and cheeks.
In older children - flexural areas.
Impetigo - presentation and treatment?
Most common - staph aureus.
Pustules and honey comb clusters.
Topical antibacterial. Oral antibiotics (flucloxacilin)
Presentation of molluscum contagiosum and treatment
Common, peraly papules, 24 months to clear - molluscipox virus. (can use potassium hydroxide)
Presentation of chicken pox and treatment
Varicella zoster.
Highly contagious - red papules progress to vesicles - start on trunk. Itchy. 10-21 days.
What is parvovirus and how does is present?
Slapped cheek - risk to pregnant women. Hand foot and mouth blisters.
Enterovirus - self-limiting.
What is most common fracture?
Clavicle.
Toddlers fracture of the tibia
Crack - very tender.
What is a green stick fracture?
Periosteal hinge on opposite side - 2 shape deformity.
What is SSSS?
Staph scalded skin syndrome - staph aureus - LEss than 5 years. Fever, widespread redness, fluid filled blisters, rupture easily.
What is TSS?
Toxic shock syndrome - S pyogenes and S.aureus - systemically unwell, widespread rash, multi-organ failure - rapidly fatal.
What is the criteria for Kawasaki disease?
Fever for 5 days or more bilateral conjuctival infection Cracked lips / strawberry tongue Cervical lymphadenopathy Polymorphous rash Changes in extremities
What is the criteria for Kawasaki disease?
Fever for 5 days or more bilateral conjuctival infection Cracked lips / strawberry tongue Cervical lymphadenopathy Polymorphous rash Changes in extremities
Treatment for Kawasaki disease
Immunoglobulins
Aspirin
Steroid
- leading cause of aquired heart disease in developed world.
Biggest complication in kawasaki disease?
Coronory artery anerysm
What is a bacterial infection of eczema treated with?
Flucloxacillin.
What is the recommended daily feed of 6 month old per kg?
130-160ml
What is the treatment for GORD in children?
Decrease feed volume
Feed thickners
Positional advice when feeding
Gaviscon
8 year old boy with purpuric rash over his buttocks and legs - red urine and palpable rash on examination - what is the most likely diagnosis?
Henoch Schonlein Purpura
Colicky abdominal pain and joint pain
What tests should be done in Henoch Schonlein purpura?
Blood pressure Dipstick U & Es Urine culture Urine protein : creatinine ratio
What can trigger Steven Jonson’s syndrome in children?
Viral infection (EBV)
Vaccinations
Medications i.e. anticonvulsants, NSAIDs
Erythema multiform (target like) rash.
Immune thrombocytopenic purpura - presentation and treatment.
Spontaneous bruising and isolated thrombocytopenia.
IVIg.
If severe bleeding in ITP what would be the treatment?
Trauma IV Immunoglobulin + steroids +/- platelet transfusion
Tranexamic acid may also be used for mucosal bleeding
