Paediatrics seminar: child in the family Flashcards
What are live attenuated vaccines?
- Viral e.g. MMR, varicella, rotavirus
- Bacterial e.g. BCG
What are inactivated vaccines?
- Whole viral/bacterial e.g. polio, hep A
- Fractional e.g. hep B, influenza, acellular pertussis, HPV
- Polysaccharide based: pure polysaccharide e.g. PPSV23, conjugated vaccines: PCV13, Hib
What is the timeline for childhood vaccination in public sector?
What is the timeline for childhood vaccination in private sector?
Why is measles vaccine given at 12 months?
MMR and varicella vaccines are live vaccines
Circulating maternal antibodies in babies <12 months old could neutralize the vaccine
Why is MMR and varicella vaccines not given in combination at 1 years old?
The risk of febrile convulsion is slightly higher with the measles, mumps, rubella, varicella (MMRV) combination vaccine is given than MMR and varicella vaccines are given separately.
What is the definition of obesity in children?
- Sex- and age-specific BMI percentile
- Overweight: BMI 85th to 95th cenrile
- Obesity: BMI >95th cenrile
- severe obesity is defined as BMI ≥120% of the 95th percentile or a BMI ≥35kg/m2 (whichever lower)
What is the definition of overweight used in SHS?
What is the history for obesity in child?
Pathological vs simple obesity: onset of obesity, stunted growth (hypothyroidism or cushing syndrome), features of monogenic obesity
History on diet, excercise, screen time and sleeping habits
Comorbidities: joints pain, OSA symptoms, polyuria/polydipsia (rare in early T2D)
What is the age of onset of monogenic obesity?
What features?
Onset usually <5y
Other features:
* Extreme hyperphagia, developmental delay, unique dysmorphism (e.g., characteristic faces in Prader Willi syndrome; syndactyly, brachydactyly or polydactyly in Bardet-Biedl syndrome),
* Visual problem (e.g., retinal dystrophy in Bardet-Biedl syndrome, Alstrom syndrome and TUB deficiency)
* Hearing impairment (e.g., TUB deficiency)
What to do in child obesity physical exam?
What are the comorbidities of obesity?
- Pre-diabetes/type 2 diabetes
- Prehypertension/hypertension
- Obstructive sleep apnoea
- Dyslipidaemia
- Fatty liver
- Polycystic ovarian syndrome
- Evidence that obesity tracks from childhood to adulthood
- Persistent excess in adiposity would increase the risk of type 2 diabetes, hypertension, dyslipidemia, and carotid- artery atherosclerosis in adulthood
- Psychologicaleffects
- Depression, low self-esteem, emotional and behavioral problems..
What is the management of childhood obesity?
- To adjust the chronically positive energy balance
- A BMI reduction of > 0.25 SDS (~BMI reduction of 1 kg/m2)
- Associated with a reduction in cardiovascular risk
- Developmentally appropriate and agreeable by the child and adolescent
- Incremental goal in each clinic visit
- Initial goal: not aiming at weight reduction, but merely change in weight gain trajectory or modification in lifestyles
- Growing child: a static body weight would indeed translate to improvement in BMI
- Mainly focus only lifestyle modification: exercise and diet control
- Pharmacological agents/bariatric surgery: reserved for severe obesity refractory to lifestyle modifications/those with obesity related complications
What are common developmental problems?
* Global developmental delay/intellectual disability(ID) * Physical impairment
* Autism spectrum disorder(ASD)
* Attention deficit hyperactivity disorder
* Anxiety disorder
* Acquired brain injury with cognitive impairment * Specific learning disorder (SLD)
* Developmental coordination disorder (DLD)
* Hearing Impairment
* Visual impairment
What is global developmental delay?
Significant delay in at least 2 developmental domains from the following
* Gross or fine motor
* Speech language
* Cognition
* Social/personal
* Activities of daily living
What is intellectual disability
What are developmental red flags?
- No head control by 6m
- Noreachoutby6m
- Cannot stand with support by 12 m
- Not walking by 18 m
- No single words by 2 years
- No sentence by 3 years
- School age children with learning and self-care problems
Child with intellectual disability, what can be done?
What is the most common motor disability in childhood?
Cerebral palsy: a group of permanent disorders of the development of movement and posture, causing activity limitations that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain
Often accompanied by disturbances of sensation, perception, cognition, communication and behaviour; by epilepsy
What are possible early motor features in the presentation of cerebral palsy?
What are common delayed motor milestones in children with cerebral palsy?
unusual fidgety movements or other abnormalities of movement, including asymmetry or paucity of movement
abnormalities of tone, including hypotonia (floppiness), spasticity (stiffness) or dystonia (fluctuating tone)
abnormal motor development, including late head control, rolling and crawling
feeding difficulties.
Delayed motor milstones
not sitting by 8 months (corrected for gestational age)
not walking by 18 months (corrected for gestational age)
early asymmetry of hand function (hand preference) before 1 year (corrected for gestational age).
Refer children who have persistent toe walking to a child development service for further assessment.
What are the types of cerebral palsy?
- Hemiplegia
- Spastic diplegia: common in premature baby, benefits from neuromotor rehabilitation intervention
- Dystonic, dyskinetic CP
- Spastic dystonic quadriplegia
What is the management of cerebral palsy?
What is the ddx for cerebral palsy?
What is autism spectrum disorder characterized by?
- characterized by severe pervasive impairment in several areas of development:
1. Abnormalities in communication and reciprocal social interaction
2. Restricted, repetitive and stereotyped patterns of behaviour, interests and activities (RRB)
What are the red flags of ASD?
- Poor social interaction
– Poor eye contact, poor response to name calling, poor joint attention, seldom
shares enjoyment or things of interest with others - Poor language development
– No words by two, echoes what others say, poor communication skills; poor symbolic, imaginative or interactive play - Restricted, stereotyped, repetitive behavior that are abnormal in content and focus; inflexible adherence to specific, non-functional routines and rituals
What can be done for children with ASD?
- Interimsupportinchildassessmentcentre–Parentinformationday/ training by HA therapists
- ReferraltoChildPsychiatry
- Mildsymptomswithgoodgeneralfunction:NKG
+/- OPRS, EETC or ICCC - More severe symptoms:SCCC
- School age children:EDBSENsupport
- School age children with ID:Specialschool
What are the types of common anxiety disorders and treatment?
Treatment: cognitive behavioural therapy choice for children
medical treatment: for severe case or ineffective CBT, SSRI as 1st line
What is the maternal and child health centers (MCHC) under?
What is integrated program for?
Under the family health service
An integrated child health and development program
Core components of the integrated program:
* Parenting
* Immunization
* Health surveillance
* Developmental surveillance
What is the student health service (SHS) under?
What is it comprised of?
Under department of health
Safeguard both the physical and psychological health of school children through health promotion and disease prevention services
Consists of
* 12 student health service centers (SHSC)
* 3 special assessment centers
* 4 regional offices of adolescent health program (equip adolescents, their parents and teachers with knowledge, attitudes and skills)
- Which of the following scenarios fulfils the definition of anaphylaxis?
a) A 5y.o. girl, 5-min after ingestion of peanut, develops generalized urticaria
and swelling of the eyes and lips
b) A 5y.o. girl, 5-min after ingestion of peanut, developed hoarseness of voice
c) A 5y.o. girl, 5-min after ingestion of peanut, repeatedly vomits but no other symptoms
d) A 17y.o. girl, 6 hours after a dental extraction surgery, developed painful swelling of the eyes and lips without urticaria. Her mother had similar recurrent and unprovoked episodes previously.
b) A 5y.o. girl, 5-min after ingestion of peanut, developed hoarseness of voice
- A 5y.o. girl, 5-min after ingestion of peanut, developed generalized urticaria, lip swelling and repeated vomiting. What is the first treatment that you should give
a) IV hydrocortisone
b) IV chlorpheniramine (or piriton)
c) IM adrenaline
d) Oral prednisolone
c) IM adrenaline
- Which of the following scenarios should be referred to an allergist to receive vaccine?
a) MMR vaccine for a 12-month-old boy with mild egg allergy (urticaria only)
b) 18-year-old with peanut and egg anaphylaxis hoping to receive COVID-19 mRNA vaccine
c) 27-year-old man with egg anaphylaxis planning to visit Kenya required to receive Yellow Fever vaccine
d) History of large local reactions at the injection site after inactivated influenza vaccines
c) 27-year-old man with egg anaphylaxis planning to visit Kenya required to receive Yellow Fever vaccine
What is the definition of anaphylaxis?
One of the following 2 criteria
* Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (e.g. generalized hives, pruritus or flushing, swollen lips/tongue/uvula) AND AT LEAST ONE OF THE FOLLOWING:
* Respiratory compromise (e.g.dyspnea,wheeze-bronchospasm,stridor,reducedPEF, hypoxemia)
* ReducedBPorassociatedsymptomsofend-organdysfunction(e.g.hypotonia [collapse], syncope, incontinence)
*Severe gastrointestinal symptoms (e.g.severe crampy abdominal pain, repetitive vomiting), especially after exposure to non-food allergens
* Acute onset of hypotension OR bronchospasm or laryngeal involvement after exposure to a known or highly probable allergen for that patient (minutes to several hours), even in the absence of typical skin involvement.
What is basic principles of anaphylaxis management?
- Remove the allergen
- Assess vitals (airway, breathing, circulation)
- Give IM adrenaline 1:1000
- Reassess eficacy, may need second dose in 5-15 mins
- Consider other drugs (long acting non sedating antihistamines, corticosteroids, bronchodilators)
What is vaccine allergy?
- IgE mediated/immediate type allergic reactions to any component of a vaccine
- Anaphylactic reactions to vaccines are estimated to occur at a rate of approx 1 per million doses.
Other types of immune mediated reactions to vaccines - Type 4 delayed hypersensitivity reactions, usually mild
- Arthus type reactions (type 3): rare, local vasculitis phenemenon complex deposition (when vaccinating a hyperimmunizaed patients by previous injections of a vaccine (tetanus)
- ITP or GBS after influenza vaccines
What are the non allergic reactions after vaccination?
Immunological/non immunological delayed vaccine reactions
* Fever
* Local reactions e.g. redness, swelling
* Serum thickness/serum sickness like reactions: rash, fever, malaise, polyarthralgias, polyarthritis
Reactions that mimic anaphylaxis
* Vasovagal syncope (usually associated with bradycardia), whereas tachycardia is more common in anaphylaxis
* Anxiety related symptoms: panic attacks: globus sensation, hypertension, tachycardia, dyspnoea
What vaccines are relatively contraindicated in egg allergic patients?
What proposed workflow for vaccinating patients with suspected egg allergy?
- MMR/MMRV vacines
- Influenza vaccine
- Yellow fever vaccine
What is gelatin used as in vaccines?
What food may have allergies previously?
What investigations?
- Gelatin is added to vaccines as stabilizers
- Gelatin allergic individuals may have previous reactions after ingestion of marshmallows or gummy candies
Investigations - SPT and sIgE to gelatin
- Skin testing to the gelatin-containing vaccines
- Or use gelatin free version of the vaccine
What is the overview of vaccine allergies investigations?
What was the role of PEGs in COV19 vaccine?
PEG2000 bound to liposomal matrix that coats the viral mRNA of the covid19 vacine
* Stabilizer to prevent premature degradation of the nanoparticles by the mononuclear phagocytosis system
* A solublizer during the transition of the particles into the intracellular cytosol due to its hygroscopic properties
* An adjuvant due to its immunogenic potential
Hypersensitivity to PEG is VERY RARE
Tends to react to higher molecular weights PEGs and at higher concentrations
What is the investigations for PEG allergy?
What is the DSM-V diagnostic criteria for ADHD?
Six (or more) symptoms of inattention >6m that is maladaptive and inconsistent with developmental level
Six (or more) symptoms of hyperactivity-impulsivitiy >6m that is maladaptive and inconsistent with developmental level
What is care for BCG scar?
Injection site reaction in almost all kids at 2-4 weeks: red, tender and indurated papule, progressing to become ulcerating healing
No treatment is needed regardless the presence of lymphadinitis
