Paediatrics Flashcards
Paediatric assessment important measurements
- Weight
- Length/height
- OFC
Progressive growth chart important
Weight
- 6 - 3.8kg to term
- Gain 100-200g/week in first 6 months (double weight by 5/6 months)
- 10 kg at 1y
Length/height (>2y)
50cm at birth
75cm at 1y
OFC
35cm at birth
45cm at 1y
Feeding
140-180 ml/kg/day
- 100 if ill
Weight faltering causes
Deficient intake (maternal/infant)
- Poor lactation
- Incorrect feeds
- Premature
- Oro-palatal abnormalities
- Neuromuscular disease
Increased metabolic demand
- Congenital disease
- Infection
- Anaemia
Excessive loss
- Vomiting: GOR, pyloric stenosis
- Diarrhoea: malabsorption, gastroenteritis
Non-medical
- Poverty
- Dysfunctional family (depression, drug use)
Development influences
Genetic, environmental, positive early childhood experience, pathological (antenatal, post-natal)
Assessment of child development
- History and examination (including observation)
- Pre/peri/postnatal events
- Milestones (Child Health Programme Scotland)
- Red book
- Parental videos
- Healthy Child Programme (UK)
- Primary care tools: ASQ, PEDS, M-CHAT (autism), SOGS-2
- Secondary care tools: Griffiths, Bayley, Wechsler
Child Health Programme
New-born exam (including hearing) Blood spot screen Health visitor 6-8w review 27-20m review Orthoptist screen
Developmental domains
Gross motor Fine motor Speech and language Hearing and vision Social and self help
Milestones
- Social smile by 2 months
- Sit unsupported by 9 months
- Walk unsupported and speech by 18 months
- First words by 2 years
Vaccinations (2-4 months)
- Diphtheria
- Tetanus
- Pertussis
- Polio
- Haemophilus influenzae type B
- Hepatitis B
^Repeat at 3 and 4 months - Pneumococcal disease
- Meningococcal group B
^Repeat at 4 months - Rotavirus
^Repeat at 3 months
Vaccinations (12 months)
- Haemophilus influenzae type B
- Meningococcal group B and C
- Measles, mumps and rubella
- Pneumococcal disease
Vaccinations (3 years 4 months)
- Diphtheria
- Tetanus
- Pertussis
- Polio
- MMR
Vaccinations (12-14 years)
- HPV (cervical cancer types 16/18)
- Diphtheria
- Tetanus
- Polio
- Meningococcal groups A/C/W/Y
Selective vaccinations
- BCG (TB)
- Hepatitis B
- Meningococcal group A
Developmental progress red flags
Positive
- Regression
- Visual/hearing concerns
- Floppiness, asymmetry
- No speech by 18-24 months
- Persistent toe walking
- OFC out-with centiles
Negative
- Sit unsupported by 12 months
- Walk by 18m-2y
- Hold objects by 5 months
- Reach objects by 6 months
- Points to share interest by 2 years
Developmental delay
Delay in domains
- Global
- Isolated
Disorder
- Abnormal progression and presentation
Regression
Assessment of developmental delay
History and examination
Investigations (guided): 1st line - Genetic testing (chromosomes) - U&E - CK - Thyroid screen
2nd line
- Metabolic testing
- Ophthalmology
- Audiology
- Neuroimaging
Common causes for delayed development
Motor: cerebral palsy, coordination disorder
Sensory: deafness, visual impairment
Language/cognitive: impairment, disability
Social/Communication: autism, asperger
Syndromes
- Down’s
- Fragile X
- William’s
Additional Support Needs
- Personalised learning plan
- Individualised educational plan
- Co-ordinated support plan (CSP): legal
- Child’s plan (GIRFEC)
Causes of vomiting (infants)
- GOR
- Cow’s milk protein allergy
- Infection
- Intestinal obstruction
- Overfeeding
Causes of vomiting (children)
- Gastroenteritis
- Infection
- Appendicitis
- Intestinal obstruction
- Raised ICP
- Coeliac disease
Causes of vomiting (adolescent)
- Gastroenteritis
- Infection (H. pylori)
- Appendicitis
- Raised ICP
- DKA
- Cyclical vomiting syndrome
- Eating disorders
Pyloric stenosis
4-12 weeks (male) with high volume projectile non-bilious vomiting
- Weight loss
- Dehydration +/- shock
Test feed: olive tumour, visible gastric peristalsis
Blood gas: hypochloraemic, hypokalaemic metabolic alkalosis
US
Management: feed stop, NG tube inserted, fluid resuscitation and refer to surgery (Ramstedt’s pyloromyotomy)
Gastro-oesophageal reflux (GOR)
- Clinical features
Very common: LOS lax, supine and liquid feeds
- Effortless vomiting (haematemesis - rare)
- Irritable, crying
- Feeding problems, failure to thrive
- Resp: apnoea, cough, wheeze, chest infection
Red flags:
- Weight loss, poor weight gain
- Recurrent/bilious vomiting
- GI bleeding
- Persisting diarrhoea
- Dysphagia, stridor, hoarseness
Sandifer’s syndrome
GORD, spastic torticollis and dystonia
Gastro-oesophageal reflux (GOR)
- Investigation and management
History and examination
Investigate if >1 year
- Growth monitor
- Oesophageal pH study
- Impedance monitor
- Endoscopy
- Video fluoroscopy
- Barium swallow
Management:
- Reassure as self-limiting
- Feeding advice: fluid thickeners, position, volumes
- Nutritional support
- Medical treatment: Prokinetics, acid-suppressing (H2 receptor blockers, PPIs)
- Surgery: Nissen fundoplication
Intestinal obstruction
Bilious vomiting (red flag!)
Causes
- Intestinal atresia
- Malrotation +/- volvulus
- Intussusception (telescope)
- Ileus
- CD with strictures
Investigation: AXR, contrast meal, exploratory laparotomy
Chronic diarrhoea
4 or > stools/day for >4 weeks
- Osmotic: movement of water into bowel to equilibrate osmotic gradient (enzyme, transport defect)
- Secretory: associated with infection (Vibrio cholerae toxin and enterotoxigenic E. Coli)
Chronic diarrhoea aetiology
Motility disturbance;
- Toddlers diarrhoea, IBS
Active secretion:
- Acute infective diarrhoea, IBD
Nutrient malabsorption:
- Allergy (CMPI), coeliac disease, CF
Fat malabsorption:
- Pancreatic/hepatobiliary disease
Coeliac disease
- Aetiology and clinical features
Gluten-sensitive enteropathy
- Autoimmune: HLA DQ2/DQ8
- Abdominal bloatedness
- Diarrhoea
- Constipation
- Fatigue
- Pallor
- Failure to thrive
- Poor weight gain
- Short stature
- Dermatitis herpatiformis
Coeliac disease
- Investigation and Management
Endoscopy and duodenal biopsy
- Partial/total villous atrophy
- Epithelial lymphocytic infiltration
- Crypt hyperplasia
Serological screens
- Anti-tissue transglutaminase (anti-TTG)
- Anti-endomysial
- Serum IgA
Genetic testing
Refer to dieticians - life-long gluten-free diet
Chronic constipation
- Aetiology
Infrequent passage of stool with difficulty and pain (no movement for 3+ days)
- Poor diet: insufficient fluids
- Social: school
- Intercurrent illness (dehydration)
- Medication: Gaviscon, opiates
- Psychological
Chronic constipation
- Clinical features
Bristol Stool Chart
- Poor appetite
- Irritable
- Fatigue
- Abdominal pain or distension
- Withholding
- Diarrhoea
Complications
- Megarectum
- Urinary retention, UTI
- Soiling
Chronic constipation
- Management
- Education
- Dietary modification
- Psychological: reduce aversive factors, reward behaviour
- Increase fluids
- Isotonic laxatives (Movicol, Laxido)
- Also osmotic laxatives
- Stimulant laxatives
- Manual evacuation
Crohn’s disease
More severe, extensive disease in children.
Symptoms more general
- Weight loss
- Growth failure
- Abdominal pain
- Delayed sexual development
Ulcerative colitis
More severe, extensive disease in children (pancolitis)
- Diarrhoea
- Rectal bleeding
- Abdominal bleeding
Inflammatory bowel disease undetermined
Can’t distinguish between CD and UC
IBD Investigations
History
- Nocturnal, bloody diarrhoea, >6/8 stools/day
Examination
- Ulcers/oral change (CD)
- Rash: erythema nodosum (CD)
- Perianal tags, fissures
- Arthritis
Nutrition: height/weight
Biochemistry: stool calprotectin, CRP raised, low albumin
Bloods: FBC, ESR, thrombocytopenia
Microbiology: no stool pathogens
Radiology: MRI, USS, barium meal and follow through
Endoscopy/colonoscopy and biopsy
- Enteroscopy
IBD Management
Medical
- Anti-inflammatory
- Immunosuppressive
- Biologics (Inflixumab)
Nutritional
Surgical:
- Colectomy
- Limited in CD (not curative)
Jaundice
Yellow discolouration of skin and tissues due to accumulation of bilirubin - sclera involvement (distinguish from carotenemia)
Early jaundice (<24 hours)
Always pathological
Haemolysis
- ABO or rhesus incompatibility
- Bruising, cephalhaematoma
- Red cell membrane/enzyme defects
Sepsis
Intermediate jaundice (24 hours - 2 weeks)
Physiological
- Shorter RBC lifespan (80-90 days)
- Relative polycythaemia
- Relative immaturity of liver function
Breast milk (can persist -> 12 weeks)
Haemolysis
Sepsis
Abnormal conjugation
- Gilbert’s disease
- Crigler-Najjar syndrome
Prolonged (>2 weeks, >3 weeks preterm)
Conjugated jaundice (‘split’, pale stools) always abnormal
- Extrahepatic obstruction
- Neonatal hepatitis
Unconjugated: hypothyroidism, breast milk
Extrahepatic obstruction
Biliary atresia
- Congenital fibro-inflammatory disease of bile ducts (-> destruction)
- Prolonged, conjugated jaundice, pale stools, dark urine
- US, liver biopsy
- Complication: LF
- Kasai portoenterostomy, liver transplantation
Choledochal cyst
Alagille syndrome: dysmorphism, intra-hepatic cholestasis, congenital heart disease
Neonatal hepatitis
- Alpha-1-antitrypsin deficiency
- Galactosaemia
- Tyrosinaemia
- Urea cycle defects
- Haemochromatosis
- Glycogen storage disorder
- Hypothyroidism
- Viral hepatitis
- Parenteral nutrition
Kernictus
Unconjugated bilirubin is neurotoxic (can cross blood brain barrier) and can deposit in brain.
- Encephalopathy
- Poor feeding
- Lethargy
- Seizures
- Complications: severe choreoathetoid cerebral palsy, learning difficulties, sensorineural deafness
Management: phototherapy
Breastfeeding
Exclusively for 6 months
- > complementary
- Complete, well tolerated nutrition
- Passive immunity
- Inc. active immunity and development of gut mucosa
- Dec. infection
- Minimal antigen load
- Dec. breast cancer, endometriosis
- Inc. postpartum weight loss
Formula
Standard: cow-milk based
Indications:
- Pre-term
- CMPI
- Lactose intolerance
- Nutrient dense
- Disease-specific
- Prevent transmission of BBVs, drugs
Benefits: accurate food volumes, don’t need mum, Vit K, dec. jaundice
Drawbacks: no immunological benefit, high antigen load, contamination, expensive
Colic
- Inconsolable crying
- <3 months
- > 3 hours/day
- > 3 days/week
- For at least a week
