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Year 3- placement > Paediatrics: Feeding and Development > Flashcards

Paediatrics: Feeding and Development Flashcards

1
Q

Maintenance fluid for neonates

A

0.9% saline + 5% dextrose

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2
Q

Preterm infant: categories

A
  • Preterm birth <37 week gestation
  • Very preterm <32 weeks
  • Extremely preterm <28 weeks
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3
Q

Preterm infant: causes

A

Most common is no known cause with spontaneous onset, though you get risk factors such as smoking and deprivation. Multiple pregnancies and prelabour rupture of membranes are the next most common reasons

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4
Q

Preterm infant: outcomes

A
  • Improves with gestational age
  • > 32 weeks – similar to those >37 weeks
  • Poor for those born <26 weeeks
  • 40% survival at 23 weeks approaching 90% survival for those at 27 weeks.
    *At 26 weeks, one quarter of survivors have a severe disability and another quarter have a moderate disability
  • If 10 children born at 24 weeks gestation- 5-6 will die before discharge home. Of the 4-5 that will survive – 1 will have a severe disability, 1 moderate and 2 out of the 10 will have a mild or no disability
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5
Q

Preterm babies: delivery room management

A
  • Senior staff presence
  • Temperature Control: roasting bags can be used to maintain the temperature of babies born <32 weeks gestation. There are manufactured thermal bags for preterm infants on the market but a lot more expensive. Also hats
  • Respiratory support
  • Surfactant
  • Usually in presence of parents
  • Once stabilised – transfer to NICU, usually at 10-15 minutes of age
  • Usually stabilisation rather than rescusitation
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6
Q

Preterm babies: Temperature control and fluid balance

A
  • Preterm babies susceptible to heat and fluid loss
  • At birth placed in plastic bag with direct heat
  • Nursed in humidified incubators to prevent fluid loss
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7
Q

Preterm babies: neonatal care

A
  • Temperature/Fluid loss
    *Skin Care- preterm babies have very friable skin which is prone to breaking which can lead to infection.
  • Pain
  • Optimal Environment/ Minimal Handling
  • Respiratory Support- most preterm infants have respiratory failure due to weak respiratory muscles, immature respiratory centre and surfactant deficiency
  • Cardiovascular Support
  • Prevention of Infection
  • Feeding
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8
Q

Respiratory distress syndrome: preterm babies

A
  • Deficiency of pulmonary surfactant
  • Surfactant: reduces surface tension, maintains alveolar stability. Mainly produced at 30-32 weeks onwards. Antenatal steroids increase cortisol levels which stimulate surfactant production
  • CXR: ground glass appearance, limited expansion, air bronchogram
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9
Q

Preterm babies: cardiovascular problems

A
  • Patent ductus arteriosus
  • Cardiac failure
    *Careful fluid management and ionotropic (support cardiac muscle contractility) support
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10
Q

Preterm babies: feeding/nutrition

A
  • Fewer nutrient reserves- fat and glycogen are only deposited in the third trimester
  • Increased physiological and metabolic stresses
  • <34 weeks oral feeding may not be safe/possible
  • Feeds slowly established over a few days, preterm babies have a lack of suckling reflex
  • Babies fed with breast milk/ EBM/ Preterm formula. May need formula for adequate growth
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11
Q

Preterm babies: providing nutrition

A
  • Fine feeding tube passed via nose/mouth into stomach (orogastric/nasogastric feeding tube). If unable to tolerate sucking/swallowing/breathing
  • Very preterm infants: slow to tolerate feeds (takes 7-10 days), fed by Total Parenteral nutrition (TPN), expressed breast milk
  • Prevention of Necrotising Enterocolitis
  • Feeding slowly introduced at <32 weeks gestation and takes several days to build up
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12
Q

Preterm babies: Necrotising enterocolitis

A
  • Inflammation and necrosis of the bowel wall
  • Increased risk with lower gestational age
  • High morbidity and mortality
  • Breast milk protective
  • AXR: intestinal pneumatosis and perforation
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13
Q

Preterm babies: Neurological problems

A
  • Premature brain- highly vascular
  • Intraventricular haemorrhage- prone to bleeding in the first 7-10 days of life, can be mild in ventricles or severe in brain tissue. Graded 1-4, with 4 being severe. Diagnosed by cranial US
  • Prognosis related to severity: motor problems, developmental delay
  • Promote normal development in NICU: environment i.e. reducing noise and light
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14
Q

Preterm babies: Long term issues

A
  • Preparation for discharge
  • Chronic lung disease/ home oxygen
  • Risk of different development- Neurodisability input
  • Allied health professionals-Physio, SAKT, Dietician
  • Opthalmology follow up- if significant retinopathy of prematurity
  • Audiology follow up- risk of hearing loss
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15
Q

Chronic lung disease of prematurity

A
  • Need for ventilatory support/oxygen at 36 weeks after gestation
  • Majority of babies born <28 weeks gestation will go home on oxygen
  • More at risk of respiratory conditions i.e. bronchiolitis
  • Home oxygen: have small portable cylinder which carer wears as a backpack for short visits out which is discreet and can fit in the bottom of the pram
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16
Q

The experience of carers for preterm babies

A

Very intense environment, very noisy, often able to only hold their baby for short periods until more stable; preterm babies anticipated in patient stay will be until maternal due date (3-4 months in extremely premature infant); in patient stay not usually straightforward and infant will have 1-2 complications; if parents have other children it is very difficult to visit for prolonged periods and many live 2 bus rides away.

Can experience grief for non-complicated pregnancy and delivery which had been anticipated by parents; difficulties with bonding; increased anxiety

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17
Q

Reasons for admission to NICU

A
  • Respiratory distress
  • Neurological: Hypoxic-ischaemic Encephalopathy, seizures
  • Infection
  • Feeding intolerance: congenital anomaly
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18
Q

Intensive care: respiratory care- clinical signs

A
  • Worsening respiratory distress at/soon after birth
  • Tachypnoea (>60/minute)
  • Recession – intercostal, subcostal, sternal)
  • Tracheal tug
  • Expiratory grunting
  • Cyanosis
  • Decreased breath sounds

Differentials: RDS, Transient Tachypnoea of Newborn, Infection, Meconium Aspiration Syndrome, Congenital anomaly (Congenital Diaphragmatic Hernia, Abnormalities of airway/lungs)

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19
Q

Intensive care: Respiratory distress- CXR findings

A
  • TTN: Fluid level in right lung in horizontal fissure
  • Meconium aspiration – bilateral patchy changes
  • Congenital diaphragmatic hernia – bowel in left side of chest
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20
Q

Intensive care: cause of hypotonic infant at birth

A
  • Antenatal/perinatal insult: Hypoxic ischaemic encephalopathy
  • Genetic/syndromes: Trisomy 21, prader Willi, muscular dystrophy
  • Infection, metabolic, congenital brain abnormalities
21
Q

Intensive care: Hypoxic ischaemic encephalopathy

A
  • Oxygen shortage around the time of and during birth
  • Can lead to brain injury resulting in disability or death
  • Some babies can benefit from therapeutic hypothermia, where the baby’s temperature is lowered to 33.5 degrees for 72 hours by cooling mat. Slows down/prevents inflammatory cascade that can cause brain injury. Not all babies are suitable. Only done on term, near-term babies, has to be after 6-8 hours after birth
22
Q

Intensive care: infection in term infants

A
  • Usually onset within 48 hours of birth
  • Risk factors- prelabour rupture of membranes, maternal infection
  • Common organisms: Group B streptococcus, E.coli
23
Q

Intensive care: congenital abnormalities- GIT

A
  • Feeding intolerance: upper GI atresia, malrotation. Duodenal atresia has a classic bubble sign
  • Abdominal distension: Hirschsprung, volvulus/malrotation, meconium plug (associated with CF), lower GI atresia
24
Q

Primitive reflexes 1-3

A

1) Palmar grasp – stimulation of the lateral edge of the palm initiates a flexion of the fingers around the object; replaced by pincer at 6months.
2) Moro/startle – legs quickly abduct then adduct when ‘startled’; symmetrical
3) Suckling/rooting – head and mouth will turn towards stimulation of the cheek and suckling is initiated by stimulation of the roof of the mouth; integrates by 4 months

25
Q

Primitive reflexes: 4-6

A

1) Stepping – will attempt to walk when feet placed near the ground, gone by 6 weeks
2) Asymmetric tonic neck reflex – when head turned to one side, opposite arm bends and the same side straightens out, integrates by 6mo
3) Galant reflex – flexion of the spine when stroked in the prone position toward the stimulat-ed side; integrates by 6-9 months

26
Q

Global delay

A

Global delay is defined as significant delay in two or more domains (two or more standard deviations from ‘normal’). Causes are variable; applying a ‘sur-gical sieve’ can be useful to order these.

27
Q

Causes of global delay: 1-3

A

1) Genetic – Trisomy 21, Fragile X, Duchenne Muscular dystropy, inborn errors of metabolism, e.g. PKU, Rett’s, mucopolysaccharidoses
2) Antenatal infection – TORCH, CMV, VZV, malaria, HIV
3) Antenatal toxin exposure – smoking, alcohol, illicit drugs, radiation, maternal medication

28
Q

Cause of global delay:4-6

A

1) Perinatal events – hypoxia/HIE, birth trauma, complications of prematurity inc. IVH/periventricular leukomalacia, hypoglycaemia, hypothyroidism, hyperbili-rubinaemia
2) Post-natal events – meningitis, encephalitis, CMV, hypothyroidism, hypogly-caemia, hypo/hypernatraemia, head injury, toxin exposure, abuse, iron/folate/vitamin D deficiency
3) Correctable causes include: neglect, under-nutrition, iron deficiency anaemia and hypothyroidism. Consider assessing hearing and vision if there are concerns.

29
Q

Positive indicators of developmental delay

A

‘Positive indicators’ of developmental delay which would warrant referral to a community paediatrician include:
* Loss of skills at any age
* Parental or professional concern about vision, fixing or following an object
* Hearing loss
* Persistently low muscle tone or ‘floppiness’
* No speech by 18 months
* Asymmetrical movements
* Persistent toe walking
* Other complex disabilities
* Head circumference >99.6th centile or <0.4th centile or a change in circumference of 2 centiles or more.

30
Q

Negative indicators of developmental delay

A

‘Negative indicators’ or ‘limit ages’ include inability to:
* Sit unsupported by 12 months
* Walk by 18 months (boys) or 2 years (girls)
*Walk without tiptoes
* Run by 2.5 years
*Hold object placed in hand by 5 months
* Reach for objects by 6 months
* Point at 2 years

31
Q

Investigations and imaging for developmental delay

A

1) Investigations: if there are motor concerns, check a CK (e.g. muscular dystro-phy)
2) Bloods – FBC, U&Es, CK, TFTs, vitamin D, B12, iron studies; consider metabolic screen (not included in Guthrie spot)
Imaging: MRI, EEG
3) Clinical: audiometry screening, visual assessment, community paediatrician evaluation

32
Q

Fine motor and vision milestones

A
  • 3 months= reaches for object, holds rattle briefly if given to hand, visually alert particularly to human faces, fixes and follows to 180 degrees
  • 6 months= holds in palmar grasp, pass object from one hand to another
  • 9 months= points with finger, early pincer
  • 12 months= good pincer grip, bangs toys together
33
Q

Gross motor developmental milestones

A
  • 3 months= little or no head lag, lying on abdomen, good head control
  • 6 months= pulls self to sitting, rolls front to back
  • 7-8 months= sits without support (refer at 12 months)
  • 9 months= pulls to standing, crawls
  • 12 months= cruises, walks with one hand held
  • 13-15 months= walks unsupported (refer at 18 months)
  • 18 months= squats to pick up toy
  • 2 years= runs
  • 3 years= walks upstairs not holding rail
  • 4 years= hops on one leg
34
Q

Social milestones

A
  • 6 weeks= Smiles (refer at 10 weeks)
  • 3 months= laughs, enjoys friendly handling
  • 6 months= not shy
  • 9 months= shy, takes everything to mouth
  • 12-15 months= helps getting undressed
  • 18 months= plays alone
  • 2 years= doesn’t spill from cup
  • 4 years= plays with other kids
  • 5 years= can use knife and fork
35
Q

Speech and hearing milestones

A
  • 3 months= quietens to parents voice, turns towards sound
  • 6 months= double syllables ‘adah’
  • 9 months= says ‘mama’ and ‘dada’, understands no
  • 12 months= knows and responds to own name
  • 12-15 months= knows 2-6 words (refer at 18 months), follows simple commands
  • 2 years= combine two words, points to body part
  • 3 years= talks in short sentences (3-5 words), count to 10, idientifies colours, asks ‘what’ and ‘who’ questions
  • 4 years= asks ‘why,’ ‘when’ and ‘how questions’
36
Q

Types of formula milk

A
  • First infant formula- this is what can be given to newborns and continued for the first year
  • ‘Hungry baby milks’ or second milks- these contain more of a protein called casein and is thought to make the baby feel more full, however there is no evidence that it makes babies settle for longer
    *Follow on formula- there is no need to switch to these milks as babies can have first formula until 1 year and they should never be given to babies less than 6 months
  • Other types of milk to avoid under 1 year of age: goat’s milk, sheep’s milk, soya milk (unless advised by the GP), rice/oats/almond ‘milks’, evaporated or condensed milk
37
Q

Feeding: cows milk

A

Cows milk can be introduced as a main drink from 1 year of age and can be introduced from 6 months into cooking. The risk of giving babies over 12 months more than 500mls of cow milk a day is that they will get iron deficient anaemia.

38
Q

Formula: amount to give

A

Overfeeding is more commonly associated with bottle fed babies

Amount to give= On formula feed, babies should receive around 150ml of milk per kg of body weight. Preterm and underweight babies may require larger volumes. This is split between feeds every 2-3 hours initially, then to 4 hours and longer between feeds. Eventually babies and infants transition to feeding on demand (when they are hungry).

39
Q

Formula: weaning

A

Weaning usually starts around 6 months of age. It starts with pureed foods that are easy to palate, swallow and digest, for example pureed fruit and “baby rice”. Over 6 months this will progress towards a healthy diet resembling an older child, supplemented with milk and snacks to 1 year of age.

40
Q

Formula: initial weight loss

A

It is acceptable for breast fed babies to loose up to 10% and formula fed babies to loose up to 5% of their body weight by day 5 of life. They should be back at their birth weight by day 10. The most common cause of excessive weight loss is dehydration due to under feeding.

41
Q

Cows milk allergy

A
  • IgE mediated- this is immediate onset and symptoms can include wheezing, urticaria, blood in stools and colicky abdominal pain
  • Non IgE mediated- this is delayed and symptoms can include atopic eczema, constipation, loose stool and GORD. There is a wide variety of symptoms.
  • Affects up to 5-7% of infants, most grow out of it by 5 years old
42
Q

Cows milk allergy: management

A
  • Avoid the allergen - refer to paediatric dietitians for advice, especially around dairy-free weaning.
  • You could trial extensively hydrolysed formula such as nutramigen LGG,
  • To confirm the diagnosis, they should try reintroducing cow’s milk again after a 2-4 week trial to see if symptoms return
  • If the symptoms persist then the next step would be an amino acid based formula such as neocate LCP
  • Ensure calcium and vitamin D supplements if still breast fed
  • Children with CMPA can have a ‘challenge test’ every 6- 12 months. 50% of children will no longer have the allergy at 1 year of age. Can be done in stages via the milk ladder
43
Q

How much milk do babies take

A
  • Day 1: 20-60ml/kg/day
  • Week 1 – 3m/o: 150ml/kg/day
  • 3-6m/o: 120ml/kg/day
  • > 6m/o: 100ml/kg/day
  • Feed every 2-3 hours (ie: 8-12x a day)
  • These figures apply to term babies only; pre-term babies often have higher nutritional requirement (sometimes up to 180 – 200 ml/kg/day)
44
Q

Challenges of breastfeeding

A
  • Painful, tiring- breastfed babies feed more frequently, no one else can feed the baby, leaking
  • Mastitis, milk supply, anxiety
  • HIV- not recommended
  • Baby- hungry baby, colic, constipation, reflux, thrush, tongue tie, prematurity
  • Will need vitamin D supplements
45
Q

Women are more likely to breastfeed if

A
  • Are from a minority ethnic group
  • Are in managerial and professional occupations
  • Live in England (compared to other parts of the UK)
  • Are aged over 30
  • Are first-time mothers
  • Left full-time education when they were over 18
  • More likely to stop within 2 weeks if they haven’t been breastfed themselves and none of their friends breast feed
46
Q

Bottle feeding

A
  • Still aiming for volumes as per breastfeeding
  • Infant formula is the only alternative to breast milk
  • Cow’s milk is not suitable until a baby is 1 year old
  • Need to sterilize bottles and make up formula
47
Q

Corrected age

A
  • Corrected age = Chronological/Actual Age – (Term– Gestational age)
  • Term is considered 40 weeks
  • Eg: An 8-week old (chronological/actual age) baby born at 35 weeks has a corrected age of 3 weeks
48
Q

Brushing children teeth

A
  • Start brushing as soon as first tooth appears- last thing at night and another occasion
  • Parents should supervise until at least 7 years old
  • Don’t rinse out your mouth after brushing
49
Q

Oral health advice

A
  • Bottle feeding should be discouraged from 12 months
  • Only breast/formula milk or cooled boiled water should be given in bottles
  • For babies only water or milk should be drunk between meals
  • All children should have a maximum of 150mls per juice a day and should be with meals to reduce tooth decay
  • Only give sweet food including dry fruit at mealtimes
  • All children over 3 years should have fluoride varnish applied
  • Dental treatment is free for children under 19

Year 3- placement (34 decks)

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