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Paediatrics > Paediatrics Development > Flashcards

Paediatrics Development Flashcards

1
Q

How long is breast feeding recommended for?

A

First 6 months (from WHO)

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2
Q

What are the benefits of breast feeding?

A

Free

Overfeeding is less common (than in bottle fed)

Breast milk contains antibodies which protect neonate from infection

Linked to reduced infections in neonatal period, better cognitive development, reduced risk of SIDS, less obesity in later life

Evidence that breastfeeding reduces breast cancer and ovarian cancer risk in mother

Some benefits may be linked to confounding factors

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3
Q

What are the disadvantages of breastfeeding?

A

Poor milk supply

Difficulty latching

Discomfort or pain for the mother

= inadequate nutrition for the baby

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4
Q

How much should a baby be fed?

A

150ml of milk per kg of body weight (preterm/underweight may require larger) evenually they transition to feeding on demand (when they are hungry)

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5
Q

How are feeding volumes in increased in the first week of life?

A

60mls/kg/day on day 1

90mls/kg/day on day 2

120mls/kg/day on day 3

150mls/kg/day on day 4 and onwards

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6
Q

How much weight can a baby lose by day 5 of life?

A

Breast fed = 10%

Formula = 5%

Back at birth weight by day 10

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7
Q

What if a baby loses more weight than expected?

A

Admission to hospital and assessment

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8
Q

What is the most common cause of excessive weight loss?

A

Dehydration due to underfeeding even when don’t look clinically dehydrated

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9
Q

When does weaning usually start?

A

Around 6 months - starts with pureed foods which are easy to palate, swallow and digest e.g. pureed fruit and “baby rice” over the next 6 months

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10
Q

What are growth charts?

A

Used to plot a childs weight, height and head circumference for age and gender

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11
Q

What are the 3 phases of growth?

A

First 2 years = rapid growth driven by nutrition

From 2 years to puberty = steady slow growth

During puberty = rapid growth spurt driven by sex hormones

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12
Q

Why is there an increase in obesity in children?

A

Readily available, affordarble, hyper-palatable, high calorie food = overconsumption

Physical activites replaced by sedentary activities

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13
Q

What is overweight and obese?

A

Overweight = BMI above 85th percentile

Obese = above 95th percentile

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14
Q

What are the features of obese patients?

A

Tall for their age and come from overweight families

If short and obese then consider endocrine investigations (e.g. for hypothyroidism)

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15
Q

What is the effect of obesity in childhood?

A

Bullying

Impaired glucose tolerance

Type 2 diabetes

CVD

Arthritis

Cancer

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16
Q

What is the definition of faltering growth?

A

Fall in weight across:

One or more centile spaces

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17
Q

What are the causes of failure to thrive?

A

Inadequate nutritional intake

Difficulty feeding

Malabsorption

Increased energy requirements

Inability to process nutrition

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18
Q

What are some causes of inadequate nutritional intake?

A

Maternal malabsorption if breastfeeding

Iron deficiency anaemia

Family or parental problems

Neglect

Availability of food (i.e. poverty)

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19
Q

What are some causes of difficulty feeding?

A

Poor suck e.g. cerebral palsy

Cleft lip or palate

Genetic conditions with abnormal facial structure

Pyloric stenosis

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20
Q

What are some causes of malabsorption?

A

Cystic fibrosis

Coeliacs disease

Cows milk intolerance

Chronic diarrhoea

IBD

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21
Q

What are some causes of increased energy requirements?

A

Hyperthyroidism

Chronic disease e.g. congenital heart disease and cystic fibrosis

Malignancy

Chronic infections e.g. HIV or immunodeficiency

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22
Q

What may cause an inability to process nutrients properly?

A

Inborn errors of metabolism

Type 1 diabetes

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23
Q

What are the aspects to the assessment for failure to thrive?

A

Pregnancy, birth, developmental and social history

Feeding history (breast / bottle fed, times, volume, frequency)

Eating history (food choices, aversions, meal time routines, appetitie in children)

Ask for food diary

Observe feeding

Mums physical and mental health

Parent-child interactions

Height, weight and BMI (if older than 2 years) and plotting these on a growth chart

Calculate the mid-parental height centile

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24
Q

What outcome from assessment would suggest growth disorder?

A

Height more than 2 centile spaces below the mid-parental height centile

BMI below the 2nd centile

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25
Q

What are the initial investigations for faltering growth?

A

Urine dip for UTI

Coeliac screen (anti-TTG or anti-EMA)

Further investigations where additional signs/symptoms suggest diagnosis e.g. CF or pyloric stenosis

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26
Q

What is the management of faltering growth due to breast feeding problems?

A

Multidisciplinary team with regular reviews

Breast feeding problems = help from midwives, health visitors, peer groups and “lactation consultants)

Supplement with formula milk to improve growth (often results with breastfeeding stopping)

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27
Q

What is the management of faltering growth when inadequate nutrition is the cause?

A
  • Encourage regular structured mealtimes and snacks
  • Reduce milk consumption to improve appetite for other foods
  • Review by dietician
  • Additional energy dense foods to boost calories
  • Nutritional supplement drinks
  • Consider enteral tube feeding: has to have defined end point
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28
Q

What is a childs predicted height?

A

Boys = (M+D + 14)/2

Girls = (M+D-14cm)/2

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29
Q

What are the causes of short stature?

A

Familial short stature

Constitutional delay in growth and development

Malnutrition

Chronic diseases e.g. coeliac disease, IBD or congenital heart disease

Endocrine disorders e.g. hypothyroidism

Genetic conditions e.g. Down syndrome

Skeletal dysplasias e.g. achondroplasia

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30
Q

What is constitutional delay in growth and puberty?

A

Variation on normal development - causes short stature in childhood when compared to peers but normal height in adulthood

Puberty is delayed and growth spurt is then longer

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31
Q

What is a key feature of CDGP?

A

Delayed bones age - age of child estimated with x-ray images of wrist and hand ans assessing the size and shapre of bones and growth plates - these children have a delayed bones age

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32
Q

How is the diagnosis of CDGP made?

A

Suggestive history and examination

X-ray of hand and wrist to assess bone age

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33
Q

What is the management of CDGP?

A

Exclude other causes

Reassure parents

Monitor growth over time

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34
Q

What are the 4 domains of child development?

A

Gross motor

Fine motor

Language

Personal and social

35
Q

What are the gross motor milestones?

A

Head downwards:

4 months: Support their head and keep it in line with the body

6 months: Maintain sitting position by 6 months, however they often don’t have the balance to sit

9 months: They should sit unsupported by 9 months. They can start crawling at this stage. Maintain a standing position

12 months: They should stand and begin cruising (walking whilst holding onto furniture).

15 months: Walk unaided.

18 months: Squat and pick things up from the floor.

2 years: Run. Kick a ball.

3 years: Climb stairs one foot at a time. Stand on one leg for a few seconds. Ride a tricycle.

4 years: Hop. Climb and descend stairs like an adult.

36
Q

What are the early milestones for fine motor skills?

A

8 weeks: Fix their eyes on an object 30 centimetres in front of them attempt to follow it. Preference for a face rather than an inanimate object.

6 months: Palmar grasp of objects (wraps thumb and fingers around the object).

9 months: Scissor grasp of objects (squashes it between thumb and forefinger).

12 months: Pincer grasp (with the tip of the thumb and forefinger).

14-18 months: They can clumsily use a spoon to bring food from a bowl to their mouth.

37
Q

How do drawing skills in an child develop?

A

12 months: Holds crayon and scribbles randomly

2 years: Copies vertical line

2.5 years: Copies horizontal line

3 years: Copies circle

4 years: Copies cross and square

5 years: Copies triangle

38
Q

How do tower of bricks skills develop in a child?

A

14 months: Tower of 2 bricks

18 months: Tower of 4 bricks

2 years: Tower of 8 bricks

2.5 years: Tower of 12 bricks

3 years: Can build a 3 block bridge or train

4 years: Can build steps

39
Q

How do pencil grasps develop over time?

A

Under 2 years: Palmar supinate grasp (fist grip)

2-3 years: Digital pronate grasp

3-4 years: Quadrupod grasp or static tripod grasp

5 years: Mature tripod grasp

40
Q

What other fine motor skills develop over time?

A

3 years - thread large beads onto string

4 years - cut paper in half

41
Q

What are the expressive language milestones?

A

3 months: Cooing noises

6 months: Makes noises with consonants (starting with g, b and p)

9 months: Babbles, sounding more like talking but not saying any recognisable words

12 months: Says single words in context, e.g. “Dad-da” or “Hi”

18 months: Has around 5 – 10 words

2 years: Combines 2 words. Around 50+ words total.

2.5 years: Combines 3 – 4 words

3 years: Using basic sentences

4 years: Tells stories

42
Q

What are the receptive language milestones?

A

3 months: Recognises parents and familiar voices

6 months: Responds to tone of voice

9 months: Listens to speech

12 months: Follows very simple instructions

18 months: Understands nouns, for example “show me the spoon”

2 years: Understands verbs, for example “show me what you eat with”

2.5 years: Understands plan of action, for example “put the spoon on / under the step”

3 years: Understands adjectives, for example “show me the red brick” and “which one of these is bigger?”

4 years: Follows complex instructions, for example “pick the spoon up, put it under the carpet and go to mummy”

43
Q

What are the social developmental milestones?

A

6 weeks: Smiles

3 months: Communicates pleasure

6 months: Curious and engaged with people

9 months: They become cautious and apprehensive with strangers

12 months: Engages with others by pointing and handing objects. Waves bye bye. Claps hands.

18 months: Imitates activities such as using a phone

2 years: Extends interest to others beyond parents, such as waving to strangers. Plays next to but not necessarily with other children (parallel play). Usually dry by day.

3 years: They will seek out other children and plays with them. Bowel control.

4 years: Has best friend. Dry by night. Dresses self. Imaginative play.

44
Q

What red flags suggest that there is a problem?

A

Not able to hold an object at 5 months

Not sitting unsupported at 12 months

Not standing independently at 18 months

Not walking independently at 2 years

Not running at 2.5 years

No words at 18 months

No interest in others at 18 months

45
Q

How to perform a developmental assessment?

A

Use their name

Use parents to encourage

Visually estimate how old

Test milestones and work up

Say things to let examiner know“really good pincer grip” “you build a tower of 6 bricks” “thats really good walking”

46
Q

What is:

Dyslexia

Dysgraphia

Dyspraxia

Auditory processing disorder

Non-verbal learning disability

Profound and multiple learning difficulty

A

Dyslexia - difficulty in reading, writing and spelling

Dysgraphia - difficulty in writing

Dyspraxia (aka developmental co-ordination disorder) - specific type of difficulty in physical co-ordination - delayed gross and fine motor skills

Auditory processing disorderb - difficulty processing auditory information

Non-verbal learning disability - difficulty in processing non-verbal information e.g. body language and facial expressions

Profound and multiple learning disability - difficulties across multiple areas - often requiring help with all aspects of daily life

47
Q

How is the severity of learning disability measured?

A

55-70 = mild

40-55 = moderate

25-40 = severe

Under 25 = profound

48
Q

What are the causes of learning difficulties?

A

Often no clear cause

FH increases risk

Environmental factors e.g. abuse, neglect, phychological trauma and toxins all increase risk

49
Q

Which genetic conditions are associated with learning difficulty?

A

Down’s syndrome

Antenatal problems e.g. Fetal alcohol syndrome and maternal chickenpox

Problems at birth e.g. prematurity and hypoxic ischaemic encephalopathy

Meningitis

Autism

Epilepsy

50
Q

Who is in the multidisciplinary team for learning difficulties?

A

Health visitors

Social workers

Schools

Educational psychologists

Paediatricians, GPs and nurses

Occupational therapists

Speech and language therapists

51
Q

How does capacity vary with learning difficulties?

A

Decision specific - may take several attempts on different days to make a decision

52
Q

How is capacity demonstrated?

A

Understand decision to be made

Retain information long enough to make decision

Weight up options

Communicate decision

53
Q

When does puberty happen in girls and boys respectively?

A

Girls = 8-14

Boys = 9-15

Taking 4 years from start to finish

54
Q

How does puberty progress in girls?

A

Breast buds

Pubic hair

Menstrual periods about 2 years from start of puberty

55
Q

How does puberty progress in boys?

A

Enlargement of testicles

Enlargement of penis

Darkening of scrotum

Development of pubic hair

Deeping of voice

56
Q

What scale is used for puberty?

A

Tanner scale

57
Q

What is hypogonadism?

A

Lack of the sex hormones, oestrogen and testosterone which normally rise prior to and during puberty

58
Q

What are the 2 causes of hypogonadism?

A

Hypogonadotrophic hypogonadism: deficiency of LH and FSH

Hypergonadotrophic hypogonadism: lack of response to LH and FSH by the gonads (testes and ovaries)

59
Q

What could cause hypogonadotropic hypogonadism?

A

Abnormal functioning of the hypothalamus or pituitary gland

  • Previous damage to the hypothalamus or pituitary e.g. by radiotherapy or surgery for previouc cancer
  • Growth hormone deficiency
  • Hypothyroidism
  • Hyperprolactinaemia (high prolactin)
  • Serious chronic conditions e.g. CF or IBD
  • Excessive exercise or dieting can delay onset of menstuation
  • Constituational delay in growth or development - temp delay in grwoth and puberty without underlying physical pathology
  • Kallman syndrome
60
Q

What are the causes of hypergonadotrophic hypogonadism?

A

Abnormal functioning of the gonads, due to:

Previous damage to gonads (e.g. testicular torsion, cancer, infections e.g. mumps

Congenital absence of testes

Kleinfelter’s syndrome (XXY)

Turner’s syndrome (XO)

61
Q

What is Kallman syndrome?

A

Genetic condition causing hypogonadotrophic hypogonadism resulting in failure to start puberty associated with anosmia

62
Q

When to start investigating for delayed puberty?

A

No evidence of pubertal changes in girl aged 13 or a boy aged 14

63
Q

How to assess a patient with delayed puberty?

A

Take detailed history of general health, development, FH, diet and lifestyle

Examination to assess height, weight, stage of pubertal development and features of underlying conditions

64
Q

What are the inital investigations for pubertal delay?

A

FBC and ferritin for anaemia

U&Es for chronic kidney disease

Anti-TTG or anti-EMA antibodies for coeliac disease

65
Q

What hormonal blood tests for delayed puberty?

A

Early morning serum FSH and LH

TFTs

Growth hormone testing (insulin-like growth factor I is used as a screening test for GH deficiency)

Serum prolactin

66
Q

What genetic testing is there for pubertal delay?

A

Genetic testing with a microassay

  • Kleinfelter’s syndrome (XXY)
  • Turner’s syndrome (XO)
67
Q

What imaging can be used for pubertal delay?

A

X-ray of the wrist for bone age and to inform a diagnosis of constitutional delay

Pelvic ultrasound in girls to assess ovaries and other pelvic organs

MRI of the brain to look for pituitary pathology and assess the olfactory bulbs in possible Kallman syndrome

68
Q

What is the management of pubertal delay?

A

Treat underlying condition

Constitutional delay = reassurance and observation

Oestrogen in girls and testosterone in boys (replacement sex hormones) can be used to induce puberty under expert guidance

69
Q

What is safeguarding and child protection?

A

Safeguarding = all aspects of ensuring welfare of child

Child protection = process of protecting a child that is at risk of / suffering harm

70
Q

What is the legal framework for child safeguarding?

A

Children Act 1989

71
Q

What are the different types of abuse?

A

Physical

Emotional

Sexual

Neglect

Financial

Identity

72
Q

What are the risk factors for abuse?

A

Domestic violence

Previously abused parents

Mental health problems

Emotional volatility in the household

Social, psychological or economic stress

Disability in the child

Learning disability in the parents

Alcohol misuse

Substance misuse

Non-engagement with services

73
Q

What are some possible signs of abuse?

A
74
Q

Who to raise safeguarding concerns to?

A

Safeguarding team - person who identifies concern should escalate it to someone who can action it

75
Q

Who does the safeguarding team refer cases to?

A

Children’s services (social services)

76
Q

What the the management of safeguarding concerns?

A
77
Q

What health decisions can 16 and 17 year olds make?

A
78
Q

Can children under 16 make decisions about treatment?

A

Yes but only if they are

79
Q

What is Gilick competence?

A
80
Q

What are Frazer guidelines?

A
81
Q

At what age can a child give consent to sexual activity?

A

Over 13 years old

82
Q

How is child palliative care different from adult?

A
  • Number of children who die is small
  • Many of the conditions are rare and diverse / genetic
  • Needed for few days, weeks or months
83
Q

What are the four fundamental principles?

A

Autonomy - right to self-determination

Non-maleficence - need to avoid harm

Beneficence - ability to do good

Justice

Paediatrics (18 decks)

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