Paediatrics Flashcards
When is the NIPE (neonatal and infant physical examination) done and why?
Multisystem examination done in first 24 hours of life then repeated at about 6-8 weeks. Performed to:
- Identify congenital abnormalities
- Make referrals if necessary
- Opporrunity for health education & parental reassuracne
Describe how to complete a newborn examination/NIPE (neonatal and infant physical examination)
Multisystem examination done in first 24 hours of life then repeated at about 6-8 weeks. Also an opporutunity for parental reassurance and health education:
- History: find out about pregnancy, birth, any issues/concerns, if baby has pased meconium and urine in first 24hrs, feeding
- Prepare for examination: ask for baby clothes to be removed except for nappy
- General inspection: movements, colour, obvious abnormalities
- Head inspection: shape, feel fontanelles & suture lines, measure occipito-frontal circumference, look in eyes and try and elicit red reflex bilaterally, feel in mouth for cleft palate, check suckling reflex, check ears (mobile pina & patent meatus)
- Chest inspection: check neck for lumps or webbing, feel clavicles, look at shape and movements of chest, ausculate lungs and heart, HR, RR, saturations
- Abdomen inspection: distension, movement with breathing, umbilicus, palpate for masses, ausculatate bowel sounds, feel for femoral pulses, external genitalia inspection (cryptorchidism & hypospadias), anal inspection (position & patency)
- Limb inspection: movement, symmetrical, count digits, palm inspection for palmar crease (single associated with Down’s syndrome), grasp reflex, hips (Barlow’s and Ortoleni’s tests)
- Spine inspection: curvature, palpate spinal processes, assess tone. Moro’s reflex, stepping reflex
- Final documentation: weight, length, occipital-frontal circumference, oxygen saturations and all other findings.
State some of the conditions the NIPE screens for
- Congenital vascular malformations e.g. coarctation or aorta
- Congential heart murmurs
- Spina bifida
- Hypospadias
- Cryptorchidism
- Congenital cataracts
- Retinoblastoma
- Cleft palate
- Developmental dysplasia of hips
… list not exhaustive
What is the red reflex, in eyes, and what does it test for in the NIPE?
Asseses for congential cataracts, retinal detachment, vitreous heamorrhage and retinoblastoma.
- Look through opthalmoscope- shine light towards patients eye at distance of approximately one arms length
- Observe for reddish/orange reflection in each pupil caused by light reflecting back from vascularised retina
Absence of a red reflex or a white reflex suggests presence of one of above pathologies and requires immediate opthalmology referral
Why do we perform Barlow’s and Ortolani’s tests in the NIPE?
What order should they be done in?
Detect any hip joint instability and dislocation. Each hip should be examined individually with all clothing- including nappy- removed.
- Barlow’s
- Ortolani’s
Describe Barlow’s test
Barlow’s test
- Adduct hip whilst applying light pressure on knee with your thumb directing force posteriorly.
- If hip is unstable, femoral head will slip over posterior rim of acetabulum producing palpable sensation of subluxation or dislocation.
Barlow’s test is used to confirm that the hip is actually dislocated.
Describe Ortolani’s test
Ortolani’s test
Used to confirm posterior dislocation of hip.
- Flex hips and knees to supine infact at 90 degrees
- With your index fingers placing anterior pressure on greater trochanters gently abduct the infants legs using your thumbs
A positive sign is a distinctive clunk which is heard and felt as the femoral head relocates anteriorly into the acetabulum
List members of the interprofessional team involved in the care of pre-school children
State some reflexes you should assess for in the NIPE
- Palmar grasp
- Sucking
- Rooting (newborn will turn its head to anything that strokes it’s cheek or mouth to aid breastfeeding. Disappear 4 months)
- Stepping reflex
- Moro reflex (support infacnts upper back with one hand then drop back once or twice into other hand. Normal refelx is extension of legs and head whilst arms jerk upwards with fingers extended. Arms are then brought together and hands clenched into fists)
State some developmental milestones for infants- include the usual age range
- 2 months: smile, can hold head up, begins to push up if lie on front
- 4 months: roll over, push up to elbows when led on front, hold and shake a toy
- 6 months: rolls over, begins to sit without supoort, babbles
- 9 months: crawls, stands holding on, makes lots of different sounds
- 12 months: may stand alone, may take a few steps, simple gestures like wave, responds to simple commands, simple words ‘mama’
- 18 months: walk, help undress, hold spoon, says several words, build tower of 3 blocks
- 2 years: sentences with few words, knows names of familiar people
- 3 years: runs easily, climbs, walks up and down steps, copies drawing a circle
- 4 years: plays make-believe, names some colours, sings songs/nursery rhymes
- 5 years: toilet on own, count to 10
Discuss community perinatal care (up to the 6 week baby check)
- Day 3-4: midwife visits to check health of mum and baby
- Day 5-8: offered newborn hearing screening test & heel prick test
- Day 10: health visitor should visit within 10 days of birth. Check how both mother and baby are doing. Offer advice, safety netting, contraception advice etc..
- 6-8 weeks: GP appointment for them to perform NIPE examination again and check health of mum and baby
After this have numerous health checks by health visitors up to age of 5
What’s the cut off for weight loss in first 7 days?
10%
Dicuss what vaccinations are offered to children in the first 4 months- include at what age they are offered each
- 6 in 1: dipheria, polio, hepatitis B, HiB, tetanus, whooping cough
Discuss what vaccinations are offered to children aged 1-15 years
- 4 in 1 preschool booster: dipheria, polio, tetanus, whooping cough
- 3 in 1: dipheria, tetanus, polio
How is the flu vaccination given to children aged 2 and 3?
Nasally
Discuss some differences between consulting with adults and consulting with children; include any differences aswell as helpful tips
When consulting with children need to:
- Use simple language rather than medical terms or acronyms to explain things in an easier way (should avoid jargon in consultations anyway- but be even more aware e.g. say we need to get a picture of inside your tummy rather than we need to do an x-ray
- Talk directly to child, even if parent or guardian present. If child 4 or more your first question/words should be directed towards them
- Make age appropriate
- Be more relaxed and informal
- Extra reassurance as you would with all vulnerable/anxious patients
- If child is anxious, talk to parent or sibling first to gain child’s trust
- Ask young people if they’d like to speak to you on their own
State some skin conditions that are commonly seen in the first few months of life
- Mongolian spots
- Erythema toxicum
- Milia
- Newborn dry skin
- Cradle cap
- Baby acne
- Heat rash
- Eczema
- Nappy rash
What are mongolian spots?
Explain why they occur
What is the management?
- A Mongolian spot is a blue-grey marking of the skin that usually affects the lower back and buttock region of newborn babies. Poorly defined edges and can vary in size. Look like bruises.
- Due to functional melanocytes in the dermis (melanocytes failed to reach epidermis)
- They are benign and so reassurance is normally all that is required as most will fade in early childhood, although larger and extra-sacral spots can persist for much longer
What is erythema toxicum?
- Combination of erythematous macules (flat red patches) and papules (small bumps- can be filled with fluid or puss). Often begins on face and spreads to trunk and limbs. Rash comes and goes, lesions don’t usually last for more than 24hrs. Infant is otherwise well. Generally occurs in first 3-14 days of life.
- No treatment- disappear on it’s own. Reassurance is all that’s needed
What are milia?
- Small white bumps which are commonly found on nose, cheeks and chin. May find them on the roof of the mouth (Epstein Pearls) and/or on dental ridge (Bohn’s nodules)
- Due to occlusion of developing sweat ducts/accumulation of sweat in blocked pores
- Most resolve in first few weeks of life.
Dry skin in newborns is common as they adjust from being in a fluid environment; state some advice you can give to parents if their baby has dry skin
- Reduce bath times (only need to bath them ~2/3 times a week. Each bath should be 5-10 mins)
- Apply baby friendly moisturiser
- Protect baby from cold air
- If doesn’t improve within a few weeks- see doctor
Describe the appearance of cradle cap
What is it’s ‘proper name’?
What causes cradle cap?
What is the management?
- Looks like patches of greasy and yellow crust; crusts can flake an dmake skin look red. Mainly occurs on scalp but can occur in other areas like eyebrows, nose and nappy area. Not itchy or painful. Typically occurs in first few weeks; usually disappears on it’s own. If it doesn’t disappear,
- Infantile seborrheic dermatitis
- Unclear what causes it. Not contagious.
What does this image show?
Infantile seborrhoheic dermatitis
What is baby acne?
What is it’s ‘proper name’?
What is the management?
- Raised rash characterised by red and white bumps or pimples and some small pus-filled spots. Can look similar to erythema toxicum but isn’t as transient as erythema toxicum
- Erythema toxicum neonatorum
- Disappear on it’s own. Do not pick. Treat baby’s skin as norma;l
Describe the appearance of heat rash in a baby
Discuss the management of heat rash
- Small red spots. Can be itchy so may notice baby scratching.Often found on neck, armpits and nappy area
- Disappears on own; keep baby at comfortable temperature
Describe the appearance of eczema in a baby
Discuss the management of eczema in a baby
- Itchy rash that can leave skin looked red, dry, flaky and/or weepy. In first few months of life most prominent on cheeks, forehead and scalp. As baby crawls then may spread to elbows and knees (extensor surfaces) then as they get older become more prominent on flexor surfaces
Breastfeeding mothers can get sore and/or cracked nipples; it’s important they adress and treat the issue otherwiseit may get worse and there is infection risk. Midwifes and health visitors will be able to offer help. State some advice you could give to breastfeeding mothers to help with sore and/or cracked nipples
Most common cause is that baby is not positioned properly, advise:
- Baby’s head and body should be in straight line
- Support neck and shoulders but allow them to tilt head back so they can swallow easily
- Bring baby’s nose to nipple- will encourage them to open mouth wide to get a good latch
Other advice:
- Change breast pads at each feed
- Wear cotton bra
- Feed baby for as long as they want as oppose to doing frequent short feeds because you think this will help the nipple
- Try dabbing a bit of expressed milk on cracked nipples after feeds
- Avoid nipple shields
- Warn signs of infection
State some signs that indicate a baby is getting enough milk
- Starts with few rapid sucks then longer sucks
- Cheeks stay rounded during feeds
- Appear content after most feeds
- Gaining weight
- At least 6 wet nappies per day
- At least 2 soft or runny yellow poos per day
Breast engorgement occurs when the breasts get too full of milk; they may feel hard, tight and painful. Discuss:
- When it commonly occurs
- What mums can do to help/soothe
- Commonly occurs in first few days as mother is getting used to matching milk supply to baby’s needs and also when you start weening a baby
- What can do to help:
- Make sure you alternate feeding between breasts
- Wear a good breastfeedng bra
- Warm flannels on breast just before expressing if they are leaking
- Paracetamol and ibuprofen
Breastfeeding mums can get blocked ducts (which will feel like a lump in breast) and/or mastitis (inflammation of breast tissue). Discuss what you should advise a woman who has blocked duct or mastitis
- Continue to breast feed
- Start feeds with sore breast first
- Massage breasts (blocked duct)
- Tips to ease pain: warm flannel or bath, paracetamol & ibruprofen
- See GP if symptoms no better after 24hrs even though you’ve continued to breastfeed
For headlice, discuss:
- Difference between the lice and eggs
- Symptoms
- Contagiousness
- Management
- Can you prevent head lice
- Lice are the insects that move and the eggs (also known as nits) are brown or white empty shells attached to hair
- Symptoms:
- Itching
- Feel like something is moving
- Visible eggs or lice
- Contagious therefore must check other members of household and treat them if lice or nits are seen. Keep checking regularly. Don’t need to keep kids off school or wash laundry on hot wash.
- Management:
- Wet combing
- If lice still present after 17 days, pharmacist may prescribe lotion or spray
- Can’t prevent headlice but can stop spread by catching and treating early
Describe ‘wet combing’ as treatment for head lice
What is colic (in children)?
- Colic is when baby cries a lot for no obvious cause (>3hrs a day- mostly in afternoon & evening)
- Other signs include:
- Hard to soothe
- Clenched fists
- Red in face
- Knees up to tummy or arched back
- Very windy
- Can start when few weeks old but usually resolves by 6 months
- If worried, nothing seems to work to soothe baby or it has persisted past 6 months contact GP
It is recommended that all babies and children, aged 6 months to 5 years, are given vitamins ______ every day
A, C and D
Why must you not give honey to a child under 1 years old?
Honey has been known to contain Clostridium botulinum spores which can cause infantile botulism
Children have a different gait to adults; discuss some normal variations in a child’s gait. For each variation, state by age they should resolve
- Toe walking- 3 years
- Bow legs- ealry toddler
- Knock knees- 7 years
- Flat feet- 6 years
- In-toeing- common between 3-8 years
If normal variations persist past expected age, are progressive or asymmetric, there is pain and/or functional limitation then referral is needed. Consider hypophosphataemic rickets in children with bow legs or knock knees especially if child is also short
Remind yourself of some abnormal gaits
- Antalgic
- Circumduction
- Spastic (foot dragging with foot inversion)
- Ataxic
- Trendelenburg (seen in Perthes’ disease, SCFE, developmental dysplasia of hip)
- Stepping gait
- Clumsy gait
State some questions you should ask if a child presents with an abnormal gait
- Other symptoms e.g. poor coordiination
- Sitting habits
- Any pain
- Aggrevating factors
- Any unwitnessed trauma
- Variation in symptoms
- Detailed pregnancy and birth history
- Family history
- Any other conditions
What is an xanthem?
What are the 5/6 childhood xanthems?
Exanthem is the medical name given to a widespread rash that is usually accompanied by systemic symptoms such as fever, malaise and headache
Describe the appearance and progresion of the measles rash
- Small red-brown flat, or slighly raised, spots that may join together to form larger blotchy patches
- Usually fist appears on head or neck then spreads to rest of body
- Resolution of fever after rash appears
What sign is pathognomonic of measles?
Koplik’s spots (red spots often with a blue-ish white central dot found on erythematous mucosa in mouth)
Describe the appearance and progression of the scarlet fever rash
- Erythematous, rough like sandpaper rash
- Usually starts on trunk then spreads
- May be accenuated in folds of skin e.g. neck, axilla, groin
Describe the appearance of strawberry tongue in scarlet fever
- Initially a white coating appears
- Then this peels off leaving tongue red and swollen
Scarlet fever rash primarily affects the face; true or false
FALSE- rash doesn’t affect face however cheeks may be flushed
For rubella, discuss:
- Pathophysiology
- Signs & symptoms
- Investigations
- Management
- Complications
- Rubella (also known as German measles) is a viral infection spread by direct contact with an infected person or droplet spread from respiratory secretions. Generally a mild infection but can cause serious complications in pregnancy
- Signs & symptoms:
- Maculopapular rash
- Lymphadenopathy
- Fever
- Headache
- Sore throat
- Athralgia
- Investigations:
- Rubella specific IgM serology
- FBC
- Management= supportive e.g. paracetamol & NSAIDs. If pregnant refer immediately to specialist
- Complications:
- Encephalitis
- Congenital rubella syndrome
Describe the appearance and progression of rubella rash
- Erythematous
- Maculopapular
- May be accenuated by heat
- May be mildy pruritic
- Usually begins on face and spreads to feet
Describe the appearance and progression of fifth’s disease rash
Erythematous rash that starts on cheeks and spreads
Describe the appearance and progression of the roseloa infantum rash
- Pinkes-red spots, patches or lumps
- Starts on chest, tummy and back before spreading elsewhere
For varicella (chickenpox), state:
- Signs & symptoms
- Management
- Signs & symptoms
- Rash: red spots that fill with fluid (become blisters) then blisters burst and form scab. VERY itchy
- High temperatues
- Achiness
- Loss of appetite
- Usually resolves itself in 1-2 weeks:
- Paracetamol
- Plenty of fluids
- Antihistamines to stop itching e.g. chlorphenamine
- Wear socks/mittens to bed to stop scratching
- Use cooling creams/gels from pharamcy
- Bathe in cool water
- Wear loose clothes
For croup, discuss:
- What it is
- Signs and symptoms
- Viral infection of the larynx and trachea; numerous viruses are associated with it but one of the most common ones is parainfluenza virus
- Prodromal symptoms (such as fever, rhinitis, non-barking cough) may have been present for 12-48hrs followed by:
- Sudden onset of barking cough
- Stridor
- Hoarseness of voice
- Drooling
- Signs of respiratory distress e.g. subcostal and intercostal recessions, tracheal tug
- Agitation
- Lethargy
Croup can be classifed as mild, moderate and severe; discus each
For eczema, discuss the typical presentation:
- Signs and symptoms
- Risk factors/triggers
- Management
- Signs & symptoms:
- Dry skin
- Itching
- Redness
- Excoriation
- Flares & remission
- Risk factors/triggers:
- Atopy
- Family history
- Triggers: animal dander, house dust mites, pollen
- Management:
- Education: regarding triggers, washing etc
- Emollients (advise to use liberally!)
- Topical corticosteroids:
- Hydrocortisone 1%
- Eumovate
- Betnovate
- Dermovate
- Non-sedating antihistamines (to help itching)
- Oral corticosteroids (at this point they’d be reffered to a dermatologist)
State some examples of emollients used in eczema
What is eczema herpeticum?
What investigations are required?
/
Management
- Disseminated herpes simplex virus infection characterised by fever, clusters of itchy and painful blisters, punched out erosions and symptoms such as fever and malaise. It can then occasionally be complicated by a secondary staphylococcal infection. Occurs in children with atopic eczema who are infected with herpes simplex virus. Medical emergency as it can cause have eye or meningeal involvement and cause scarring.
- Investigations: swabs of blister to confirm HSV as cause and check for secondary bacterial infection
- Management:
- Oral aciclivor
- Flucloxacillin if secondary staphyloccoal infection
What is Perthe’s disease?
How does it present?
What investigations are required?
Discuss the management
Prognosis
- Rare condition in which part or all of the femoral head loses its blood supply and may become mishapen leading to arthritis later in life.
- Symptoms:
- Pain in groin, thigh or knee
- Pain worse after physical activity
- Limp
- Stiffness/reduced ROM in affected hip
- Symptoms are transient (on and off. Disease lasts a few years)
- Investigations:
- Examinations every few months
- X-rays every few months
- Arthrogram
- Management:
- Limit physical activity during flare
- Analgesia
- Physiotherapy
- Crutches
- Operation to reshape bone
- 60% recover without any treatment. Some pts end up with arhritis as an adult
For SUFE, dicusss:
- What it is
- Who common in
- Symptoms & signs
- Investigations
- Management
- Displacement of femoral epiphysis from the metaphysis of the femur
- Common in boys aged 11-17yrs
- Symptoms:
- Pain in knee, hip or groin
- Difficulty walking/limp
- Affected leg may appear shorter and externally rotated
- Limited movement
- Investigations: x-ray of hip
- Management:
- Operation: surgical screw inserted across growth plate. Followed by few days best rest & no weight-bearing for 6 weeks- physio involvement
