Paeds basics Flashcards

Question 1

Q

At 8 weeks old:

Which diseases are protected against?
Which vaccine(s) are given + what is its trade name?
What is the site of the vaccination?

Answer

A

Infarix hexa

CNS: polio, tetanus

Resp: diphtheria, haemophilius influenza B, pertussis

Liver: Hep B

Question 2

Q

At what ages are vaccines given?

Answer

A

8 weeks
12 weeks
16 weeks
1 year
3yrs 4 months
12-13 years
14 years
65 years
65 years +
70 years

Question 3

Q

At 12 weeks old:

Which diseases are protected against?
Which vaccine(s) are given + what is its trade name?
What is the site of the vaccination?

Question 4

Q

At 16 weeks old:

Which diseases are protected against?
Which vaccine(s) are given + what is its trade name?
What is the site of the vaccination?

Question 5

Q

At 1 year old:

Which diseases are protected against?
Which vaccine(s) are given + what is its trade name?
What is the site of the vaccination?

Question 6

Q

At 3 years and 4 months old:

Which diseases are protected against?
Which vaccine(s) are given + what is its trade name?
What is the site of the vaccination?

Question 7

Q

At 12-13 years old:

Which diseases are protected against?
Which vaccine(s) are given + what is its trade name?
What is the site of the vaccination?

Question 8

Q

At 14 years old:

Which diseases are protected against?
Which vaccine(s) are given + what is its trade name?
What is the site of the vaccination?

Question 9

Q

At 65 years old:

Which diseases are protected against?
Which vaccine(s) are given + what is its trade name?
What is the site of the vaccination?

Question 10

Q

At 65 years + old:

Which diseases are protected against?
Which vaccine(s) are given + what is its trade name?
What is the site of the vaccination?

Question 11

Q

At 75 years old:

Which diseases are protected against?
Which vaccine(s) are given + what is its trade name?
What is the site of the vaccination?

Question 12

Q

Which are the optional vaccines?

Question 13

Q

Which vaccine can cause a temperature/fever? How many hours post-immunisation is this fever expected to present?

Answer

A

Meningococcal

24-36 hours post vaccination

Question 14

Q

What are the 4 main areas of child developmental milestones?

Answer

A

Gross motor
Vision and fine motor
Hearing, speech and language
Social, emotional and behavioural

Question 15

Q

In terms of vision and fine motor development, what should a 6 week old be able to do?

What is the limit age for this?

Answer

A

Follows moving object or face by turning the head (fixing and following)

Limit age: 3 months

Question 16

Q

In terms of vision and fine motor development, what should a 4 month old be able to do?

What is the limit age for this?

Answer

A

Reaches out for toys + palmar grasp

Limit age: 6 months

Question 17

Q

In terms of vision and fine motor development, what should a 7 month old be able to do?

What is the limit age for this?

Answer

A

Transfers toys from one hand to another

Limit age: 9 months

Question 18

Q

In terms of vision and fine motor development, what should a 10 month old be able to do?

What is the limit age for this?

Answer

A

Mature pincer grip

Limit age: 12 months

Question 19

Q

In terms of vision and fine motor development, what should a 16-18 month old be able to do?

Answer

A

Makes marks with crayons

Question 20

Q

In terms of vision and fine motor development, what should a 14 month-4 year old be able to do?

Answer

A

Brick building

Question 21

Q

By when should a child be able to build a tower of three?

Answer

A

18 months

Question 22

Q

By when should a child be able to build a tower of 6?

Question 23

Q

By when should a child be able to build a tower of 8 or a train with 4 bricks?

Answer

A

2.5 years

Question 24

Q

By when should a child be able to build a tower of bridge from a model?

Question 25

Q

By when should a child be able to build steps (after a demonstration)?

Question 26

Q

In terms of vision and fine motor development, what should a 2-5 year old be able to do?

Answer

A

Pencil skills

should be able to draw without a demonstration, can copy 6 months before this

Question 27

Q

By what age should a child be able to draw a:

line
circle
cross
square
triangle

Answer

A

Line – 2 years
Circle – 3 years
Cross – 3.5 years
Square – 4 years
Triangle – 5 years

Question 28

Q

By what age should a child be able to build with bricks:

tower of 3
tower of 6
Tower of 8 or a train with 4 bricks
Bridge (from a model)
Steps (after demonstration)

Answer

A

tower of 3 - 18 months
tower of 6 - 2 years
Tower of 8 or a train with 4 bricks - 2.5 years
Bridge (from a model) - 3 years
Steps (after demonstration) - 4 years

Question 29

Q

In terms of hearing, speech and language development, what should a newborn be able to do?

Answer

A

Startles to loud noises

Question 30

Q

In terms of hearing, speech and language development, what should a child of 3-4 months be able to do?

Answer

A

Vocalises alone or when spoken to, coos and laughs “aa, aa”

Question 31

Q

In terms of hearing, speech and language development, what should a child of 7 months be able to do?

Answer

A

Turns to soft sounds out of sight

Polysyllabic babble (“babababa, lalalalala”)

Question 32

Q

In terms of hearing, speech and language development, what should a child of 7-10 months be able to do?

Answer

A

Sounds used indiscriminately at 7 months

Sounds used discriminately to parents at 10 months “Dada, Mama”

Question 33

Q

In terms of hearing, speech and language development, what should a child of 12 months be able to do?

Answer

A

Two to three words other than ‘Dada’ or ‘Mama’

Understands name “Drink”

Question 34

Q

In terms of hearing, speech and language development, what should a child of 18 months be able to do?

Answer

A

6-10 words

Is able to show two parts of the body “Where is your nose?” – Baby will point

Question 35

Q

In terms of hearing, speech and language development, what should a child of 20-24 months be able to do?

Answer

A

Joins two or more words to make simple phrases “Give me teddy”

Question 36

Q

In terms of hearing, speech and language development, what should a child of 2.5-3 years be able to do?

Answer

A

Talks constantly in 3 – 4-word sentences

Understands 2 joined commands “Push me fast Daddy”

Question 37

Q

In terms of gross motor development, what should a newborn be able to do?

Answer

A

Limbs flexed, symmetrical pattern

Marked head lag on pulling up

Question 38

Q

In terms of gross motor development, what should a child aged 6-8 weeks be able to do?

Answer

A

Raises head to 45 degrees in prone (tummy-time)

Question 39

Q

In terms of gross motor development, what should a child aged 6-8 months be able to do?

What is the limit age for this?

Answer

A

Sits without support (initially with a round back, then eventually with a straight back by 8 months)

Limit age: 9 months

Question 40

Q

In terms of gross motor development, what should a child aged 8-9 months be able to do?

Question 41

Q

In terms of gross motor development, what should a child aged 10 months be able to do?

Answer

A

Stands independently

Cruises around furniture

Question 42

Q

In terms of gross motor development, what should a child aged 12 months be able to do?

What is the limit age for this?

Answer

A

Walks unsteadily – a broad gait, with hands apart

Limit age: 18 months

Question 43

Q

In terms of gross motor development, what should a child aged 15 months be able to do?

Answer

A

Walks steadily

Question 44

Q

In terms of gross motor development, what should a child aged 2.5 years be able to do?

Answer

A

Runs and jumps

Question 45

Q

In terms of social, emotional and behavioural development, what should a child aged 6 weeks be able to do?

What is the limit age for this?

Answer

A

Smiles responsively

Limit age: 8 weeks

Question 46

Q

In terms of social, emotional and behavioural development, what should a child aged 6-8 months be able to do?

Answer

A

Puts food in their mouth

Question 47

Q

In terms of social, emotional and behavioural development, what should a child aged 10-12 months be able to do?

Answer

A

Waves bye-bye, plays peek-a-boo

Question 48

Q

In terms of social, emotional and behavioural development, what should a child aged 12 months be able to do?

Answer

A

Drinks from a cup with two hands

Question 49

Q

In terms of social, emotional and behavioural development, what should a child aged 18 months be able to do?

Answer

A

Holds spoon and gets food safely to mouth

Question 50

Q

In terms of social, emotional and behavioural development, what should a child aged 18-24 months be able to do?

what is the limit age for this?

Answer

A

Symbolic play

Limit age: 2 – 2.5 years

Question 51

Q

In terms of social, emotional and behavioural development, what should a child aged 2 years be able to do?

Answer

A

Toilet training: dry by day

Pulls off some clothing

Question 52

Q

In terms of social, emotional and behavioural development, what should a child aged 2.5-3 years be able to do?

Answer

A

Parallel play

Interactive play evolving

Takes turns

Question 53

Q

What is the normal RR, HR and systolic BP for children < 1 year?

Answer

A

RR: 30-40
HR: 110-160 bpm
systolic BP: 80-90

Question 54

Q

What is the normal RR, HR and systolic BP for children 1-2 years old?

Answer

A

RR: 25-35
HR: 100-150 bpm
systolic BP: 85-95

Question 55

Q

What is the normal RR, HR and systolic BP for children 2-5 years old?

Answer

A

RR: 25-30
HR: 95-140 bpm
systolic BP: 85-100

Question 56

Q

What is the normal RR, HR and systolic BP for children 5-12 years old?

Answer

A

RR: 20-25
HR: 80-120 bpm
systolic BP: 90-110

Question 57

Q

What is the normal RR, HR and systolic BP for children >12 years old?

Answer

A

RR: 15-20
HR: 60-100 bpm
systolic BP: 100-120

Question 58

Q

Summarise how normal ranged for RR, HR and systolic BP vary with age

Answer

A

RR and HR drops

BP increases

Question 59

Q

When is a newborn examination conducted, and what is its purpose?

Answer

A

Within 72hrs every baby should have a thorough examination to:

Detect congenital abnormalities not already identified at birth (e.g. eye abnormalities, congenital heart disease, undescended testes, DDH)
Check for potential problems arising from maternal disease or familial disorders
Provide an opportunity for parents to discuss qs about their baby

Question 60

Q

Are there any more newborn checks?

Answer

A

Newborn check is repeated at 6-8 weeks, usually by GP

Question 61

Q

Run through the newborn examination

Answer

A

General:
- Undress baby
- Measurements: weight, length, head circumference recorded on centile chart
- General observation of baby’s appearance, posture and movements
  - Colour, e.g. jaundice, pallor, plethora
  - Observe face for dysmorphic features
  - General neurological state and movements (tone, limitation of movement)
- Lift trunk to observe tone
- Primitive reflexes (Moro, grasp)
Skin:
- Look for birthmarks, petechiae
- Inspect and palpate back and spine (for defects, e.g. in spina bifida)
Hands:
- Look for polydactyly, lymphoedema (Turner syndrome), palmar creases (single in Down’s)
Limbs:
- Assess movements, check length looks normal
- Hips are checked for developmental dysplasia of the hip
  - Barlow manoeuvre: hip is flexed and femoral head is adducted and pushed downwards  if hip is dislocatable the femoral head is pushed posteriorly out of the acetabulum
  - Ortolani manoeuvre: adduct hip with upward leverage → a dislocated hip returns to the acetabulum with a ‘clunk’
- Also check feet → for abnormal position (e.g. positional talipes), number of toes
Head:
- Look for microcephalus and macrocephalus (head circumference measurement)
- Fontanelle and sutures are palpated
  - Tense fontanelle may be due to raised ICP (hydrocephalus, meningitis)
- Eyes are checked for red reflex with an opthalmoscope
  - If absent, may be from cataracts, retinoblastoma or corneal opacity
- Palate is visually inspected and palpated
  - To detect cleft palate or submucous cleft
Chest:
- Observe for signs of respiratory distress
- Auscultate for murmurs
Abdomen:
- Palpate liver (1-2cm below costal margin) and spleen
- Palpate for intra-abdominal masses
- Check for signs of umbilical cord infection (redness should not extend to skin)
Groin:
- Palpate femoral pulses
- Inspect and palpate hernial orifices
- Check for imperforate anus
- Girls: inspect genitalia for virilisation
- Boys: inspect genitalia for abnormalities (e.g. hypospadias), palpate for undescended testes

Question 62

Q

What is the acronym for an adolescent Hx? What does this stand for?

Answer

A

HEAADSSS

Home life, including relationship with parents
Education or employment, including financial issues
Activities, including friendships/hobbies/sports
Affect and mood
Drugs, including cigarettes, alcohol, recreational
Sex (relationships and sexual risk behaviours)
Suicide, depression, self-harm
Sleep

Question 63

Q

From what age can peak flow be measured in children?

Answer

A

Can be performed in most children from 5yo; reliable in most 7yo

Question 64

Q

Describe the technique for a peak flow measurement

Answer

A

Technique:

Take some big breaths; take a big breath in
Wrap mouth tightly around tube
Make sure peak flow meter is horizontal; don’t touch dial
Breathe out as fast as you can – “like you’re blowing out candles on a birthday cake”
Read and record in peak flow diary/chart

Answer 51

A

Normal range varies according to height and gender

Answer 52

A

For any age;
- 0-2yo: use spacer and face mask;
- >3yo: use spacer alone
Spacer is recommended for all children, as it increases drug deposition in lungs and reduces oropharyngeal deposition → reduced steroid SEs
Useful for acute asthma attacks when poor inspiratory effort may impair use of inhalers

Answer 53

A

For 6yo and older
Drug is released when a certain threshold of inspiration flow rate is reached
Less co-ordination needed than pressurised metered dose inhaler without a spacer → useful for delivering salbutamol when ‘out and about’ in older children

Answer 54

A

For 4yo and older
Easy to use when ‘out and about’ in older children
Needs good inspiratory flow, so less good in severe asthma & during an asthma attack

Answer 55

A

For any age
Used in acute asthma where oxygen is needed in addition to inhaled drugs

Answer 56

A

Clean catch method (recommended):
- Skin surrounding urethra is cleaned
- Sample caught into a waiting clean pot when the nappy is removed
- Midstream sample is the goal
Adhesive plastic bag applied to the perineum after washing
- May be contamination from skin
Urethral catheter
- If there is urgency in obtaining a sample and no urine has been passed
Suprapubic aspiration
- In severely ill infants requiring urgent diagnosis and treatment

Answer 57

A

Absorption:
- In neonates and infants, oral formulations are given as liquids → absorption is unpredictable (influenced by gastric emptying, gut motility, effects of milk in stomach)
  - In acutely ill neonates and infants, drugs are given IV → ensures reliable concentrations
- Avoid IM injections in infants if possible → little muscle bulk, absorption is variable, painful
- Rectal administration can be used → absorption more reliable than oral, but unpopular
- Significant systemic absorption can occur across the skin, esp in preterm infants → toxicity
Clearance:
- In neonates, drug metabolism is reduced (enzymes in the liver are immature) → prolonged half-life of drugs metabolised in the liver (e.g. theophylline, valproate)
- Renal excretion is reduced in infants (low GFR) → prolonged half-life of some drugs, e.g. gentamycin
Distribution:
- Water comprises a larger percentage of the body in the neonate (80%) than older children and adults (55%) → drugs that distribute in ECF need larger dose relative to body weight in infants
- In infants, plasma protein concentration is low and some drugs may be partially unbound and remain active
  - In jaundiced babies, bilirubin may compete with some drugs, e.g. sulphonamides, for albumin binding sites (making them unsuitable for use)

Answer 58

A

Many doses have to be calculated using either weight, age or surface area

This means that children are at high risk of prescribing errors
- Errors also occur because some drugs need to be diluted
- All dosages and dilutions must be checked independently by 2 members of staff

Answer 59

A

Body surface area is used to determine dose when an accurate dose is required, e.g. cytotoxic agents
- Because ECF correlates with body surface area
- Calculated using height & weight (formula)

Answer 60

A

For drugs with a high margin of safety, drug doses are given as per kg body weight or based on age, with the assumption that the child is of average size
- Weight-based doses should not simply be extrapolated to older children, as the dosage will be excessively large

Remember to check the maximum dose (don’t exceed max dose even when calculating based on weight)

Answer 61

A

In sepsis/shock, bolus is given
20ml/kg 0.9% saline (or blood if trauma)
- x2 if necessary
- Then fluid deficit may need to be replaced, and maintenance fluids may be needed

Answer 62

A

This is the amount of IV fluids children need each day (if not drinking)
Usually 0.9% saline + 5% dextrose
To calculate:
- 1^st 10kg: 100ml/kg
- 2^nd 10kg: 50ml/kg
- Subsequent kg: 20ml/kg
- This gives fluid requirements over 24hrs  divide by 24 to give amount per hr
- Max 2L in females; 2.5L in males

Answer 63

A

This is what needs to be replaced when a child is dehydrated (corrected over 24-48hrs)

Answer 64

A

The amount depends on how dehydrated the child is → need to calculate the % dehydration

If you have a recent weight (when child was well):
- (well weight – current weight) / well weight x100
If you don’t have a recent weight,
- must estimate based on clinical signs
Total fluid deficit = % dehydration x weight x 10
- E.g. a 32kg child is 5% dehydrated. How much fluid does she need over 24hrs?
  - Fluid deficit: 5 x 32 x 10 = 1600ml
  - Maintenance fluids: 1740ml
  - Total: 3340ml/24hrs → 139ml/hr
Remember to add ongoing losses (if necessary)

Answer 65

A

Clinical signs are only detectable when patient is 2.5-5% dehydrated
A child with clinical dehydration but no shock = assumed to be 5% dehydrated
If signs of shock, = child is 8-10% dehydrated (sometimes 8% used as max to avoid overhydration)
- E.g. tachycardia, low BP, pale/mottled skin, decreased GCS, prolonged cap refill

Answer 66

A

Requirements depend on gestation, age (day of life) and weight
Usually 10% dextrose
- May need additional additives, e.g. Na, K
On 1^st day of life, 60-90ml/kg is usually required;
- increases by 20-30ml/kg/d daily
- 150-180ml/kg/d by day 5 of life

Answer 67

A

Babies need 150ml milk/kg/day
Divide by 8 to give the amount in 3hrly feeds

Answer 68

A

Foetal
Infantile phase
Childhood phase
Pubertal growth spurt

Answer 69

A

Fastest period of growth
Size at birth is determined by genetics and placental nutrient supply → modulates foetal growth factors (IGF-2, human placental lactogen, insulin)
- Dependent on maternal factors; largely independent of growth factor
- Severe IUGR and extreme prematurity when accompanied by poor postnatal growth can cause permanent short stature

Answer 70

A

Growth to 18mo is largely dependent on adequate nutrition (also health and thyroid function)
There is rapid but decelerating growth rate
An inadequate rate of weight gain during this period is called ‘faltering growth’

Answer 71

A

Slow, steady, prolonged growth
Mainly dependent on pituitary GF secretion → acts to produce IGF-1 at epiphyses
- Also needs adequate nutrition and good health
- Thyroid hormone, vit D and steroids also affect cartilage cell division and bone formation

Answer 72

A

Slow, steady, prolonged growth
Mainly dependent on pituitary GF secretion → acts to produce IGF-1 at epiphyses
- Also needs adequate nutrition and good health
- Thyroid hormone, vit D and steroids also affect cartilage cell division and bone formation

Answer 73

A

Adds 15% to final height
Testosterone & oestradiol cause the back to lengthen and boost GH secretion
- They also cause fusion of the epiphyseal growth plates and cessation of growth (so if puberty is early final height is reduced due to early fusion of epiphyses)

Answer 74

A

In children >2yo → standing height (stand tall with feet flat, look horizontally)
In children <2yo → length is measured (by lying horizontally – using Harpenden neonatometer)
- Can be difficult to be accurate → legs need to be held straight, child doesn’t like it
- Not routinely performed → only if doubt about growth

Answer 75

A

Occipitofrontal circumference

Answer 76

A

Child’s growth should be assessed in the context of family size → heights from both biological parents should be used to calculate midparental height and the child’s target range (expected height)

Expected height:
- Mid-parental height is calculated, then -7cm if female and +7cm if male → range is +/-10cm

Answer 77

A

weight
height
head circumference
BMI

Answer 78

A

Breast bud is fist sign → 8.5-12.5yrs
Pubic hair growth and growth spurt occur almost immediately after
Menarche → 1.5-3yrs after onset of puberty (typically 12-13yo)
- Signals that growth is coming to an end, with only 5cm of height gain remaining

Answer 79

A

Testicular enlargement (>4ml – measured with orchidometer) is first sign
Pubic hair growth follows (10-14yo)
Growth spurt when testicular volume is 12-15ml (usually 18 months from onset)
- Later and greater magnitude than females → greater final average height

Answer 80

A

Children need 80-120kcal/kg/day → this decreases by 10% every 3yrs

Answer 81

A

Low nutritional scores
- Newborns, esp if IUGR or premature, have poor stores of fat and protein
- The smaller the child, the less the calorie reserve → shorter period able to withstand starvation
High nutritional demands for growth
- Rapid growth during infancy means nutritional requirements are high
Rapid brain growth and development
- Sensitive to malnutrition → modest energy deprivation leads to risk of adverse neurodevelopment
Effects of acute illness or surgery
- Recurrent illnesses are common in children → decreased dietary intake
- Illnesses and surgery cause increased nutritional demands

Answer 82

A

WHO recommend exclusive breast feeding for 6 months (continuing up to 2yrs)

Answer 83

A

Provides ideal nutrition for infants, ready-made and correct temperature
In low-income countries it dramatically improves infant mortality (mainly by reducing GI infection)
Also reduces time-interval between infants
In developed countries, it reduces GI infections, resp infections and otitis media, and protects against NEC in premature infants
Associated with reduced incidence of DM, obesity and HTN later in life
May help to establish bonding
Reduces risk of ovarian cancer and T2DM in mother

Answer 84

A

Transmission of infection (e.g. HIV), some medications and other contaminants (e.g. nicotine)
Difficult to know if the baby is getting enough milk (except by demonstrating weight gain)
Breast milk jaundice
Vitamin K deficiency (insufficient vit K in breast milk to prevent haemorrhagic disease of the newborn → supplementation needed)
Rarely possible to breast feed triplets or more
Restrictive to the mother → can’t leave baby for prolonged time
- Facilities for breastfeeding in public are limited
- Failure to establish breastfeeding can cause emotional upset in mother

Answer 85

A

Colostrum (rather than milk) is produced for the first few days → higher content of protein and Ig
First feed should take place ASAP after birth

Answer 86

A

~ preterm infants (higher energy and mineral content)
~ infants with cows milk protein allergy, lactose intolerance, cystic fibrosis, etc.
Derived from hydrolysed cow’s milk protein, amino acids or soya
- Soya formula should not be used if <6 months old as high aluminium content and contains phytoestrogens

Answer 87

A

After 6 months breast milk is not adequate → doesn’t provide sufficient energy, vitamins or iron
Solid food should be introduced around 6 months (not before 17wks, not after 26wks)
Gradual → small amounts of pureed fruit, root vegetables or rice
Avoid high salt/sugar foods; avoid honey until 1yr (risk of infantile botulism)

Answer 88

A

Height below the 2nd centile (i.e. 2SDs below the mean)

Growth failure can be identified from growth charts and growth velocity charts
- Growth velocity charts allow growth failure to be identified before height is below 2^nd centile
- Crossing centiles on growth charts is worrying
- Being short/tall is not necessarily pathological, but growing at an abnormal rate is
Height centile must be compared with the weight centile and their estimated height (from parental height)

Answer 89

A

Height below the 2nd centile (i.e. 2SDs below the mean)

Growth failure can be identified from growth charts and growth velocity charts
- Growth velocity charts allow growth failure to be identified before height is below 2^nd centile
- Crossing centiles on growth charts is worrying
- Being short/tall is not necessarily pathological, but growing at an abnormal rate is
Height centile must be compared with the weight centile and their estimated height (from parental height)

Answer 90

A

Familial (most common)
- Most children have short parents and fall within the centile target range for their estimated height
Constitutional delay in growth and puberty
- Variation of normal  short stature in teenage years due to delay in onset of growth and puberty
- Usually FHx of delayed growth and puberty, but normal adult height
- Growth during childhood is usually within the lower limits of normal, bone age is delayed, onset of secondary sexual development is delayed, but final height is normal
- Earlier pubertal growth spurts are more intense  so you don’t end up shorter if early puberty (unless pathological precocious puberty)
Small for gestational age and extreme prematurity
- 10% children who were born small for gestational age or extremely premature remain short
Chromosomal disorders/syndromes
- Many chromosomal syndromes are associated with short stature, e.g. Down’s Turner’s, Noonan’s
Nutritional/chronic illness
- Short and underweight (i.e. weight is on the same/lower centile than height)
- Inadequate nutrition may be due to insufficient food, restricted diets or poor appetite associated with long-term illness
- Chronic illnesses causing short stature include coeliac, Crohn’s, CF, congenital heart disease
Psychosocial deprivation
- Children subjected to physical and emotional deprivation can be short, underweight and have delayed puberty (due to decreased GH secretion)
- Affected children show catch-up growth if placed in a nurturing environment
Endocrine:
- Relatively uncommon causes; associated with child being relatively overweight
  - By contrast, children with nutritional obesity tend to be relatively tall
- Hypothyroidism
  - Growth failure, usually with excess weight gain
  - Catch-up growth occurs with treatment but rapid entry to puberty may limit final height
- GH deficiency
  - May be isolated or secondary to wider pituitary dysfunction (e.g. tumour, radiation)
  - Laron syndrome: defective GH receptors  GH insensitivity
- Corticosteroid excess, Cushing’s syndrome
  - Usually iatrogenic  effect is reduced by alternate-day therapy, low doses
Skeletal dysplasias:
- Rare
- E.g. achondroplasia, osteogenesis imperfecta
- Cause disproportionate short stature (abnormal body proportions)

Answer 91

A

History and examination (incl stage of puberty)
Growth charts
- Plot serial measurements of height and weight; ask to see red book → look for crossing centiles
- Calculate estimated height (from parental height)
- Usually no other Ix are needed
X-ray of L hand and wrist for bone age
- Some delay in constitutional delay of growth and puberty; marked delay in some endocrine disorders (GH deficiency, hypothyroidism)
Ix to look for underlying cause:
- Bloods:
  - FBC (anaemia in coeliac/Crohn’s), anti-TTG, CRP/ESR
  - Calcium, phosphate, ALP (renal and bone disorders)
  - TFTs
- Karyotype
- Growth hormone provocation tests (using insulin, glucagon, arginine) → GH deficiency
- 9am cortisol and dexamethasone suppression test → Cushing’s
- Skeletal survey → skeletal dysplasia

Answer 92

A

Depends on the cause
Reassurance
- If familial/constitutional
Correct underlying cause
- E.g. coeliac, hypothyroid
GH therapy
- For GH deficiency (doesn’t help children who are not deficient)
- Daily SC injection
- Expensive
- May also be used for Turner syndrome, Prader-Willi, CKD, small for gestational age

Answer 93

A

Familial (most common)
Obesity
- Puberty is advanced, so final height centile is less than in childhood
Secondary endocrine causes (rare)
- Hyperthyroidism
- Excess sex steroids (precocious puberty from whatever cause)
- Excess adrenal androgens (CAH)
  - In CAH and precocious puberty there is early epiphysial fusion → eventual height is reduced after an early excessive growth rate
- True gigantism (excess GH secretion)
Syndromes
- Marfan’s, Klinefelter’s, homocysteinuria, Sotos syndrome

Answer 94

A

Development of secondary sexual characteristics before:

8yo in females and
9yo in males

Answer 95

A

Precocious puberty
Premature breast development (thelarche)
Premature pubic hair development (pubarche or adrenarche)
Isolated premature menarche

Answer 96

A

Precocious puberty
Premature breast development (thelarche)
Premature pubic hair development (pubarche or adrenarche)
Isolated premature menarche

Answer 97

A

Gonadotrophin-dependent (central, true): from premature activation of the HPG axis
- Sequence of pubertal development is normal (consonant)
Gonadotrophin-independent (pseudo, false): from excess sex steroids outside the pituitary gland
- Sequence of pubertal development is abnormal (dissonant)

Answer 98

A

Ovaries are very sensitive to gonadotrophins → gonadotrophin-dependent precocious puberty is reasonably common in girls
Usually idiopathic or familial
Pathological causes of precocious puberty in girls are rare → can be secondary to:
- Gonadotrophin-independent causes, e.g. excess androgens from CAH/adrenal tumours → presents with pubic and axillary hair, adult body odour, acne and virilisation before breast development
- Gonadotrophin-dependent causes, e.g. pituitary adenoma →> pubertal development is consonant, but may be rapid
USS of ovaries and uterus can assess progress of puberty
- Uterus changes from an infantile ‘tubular’ shape to ‘pear’ shape with progression of puberty; endometrial lining can be identified close to menarche

Answer 99

A

Testes are relatively insensitive to secretion of gonadotrophins from the pituitary → gonadotrophin-dependent precocious puberty is uncommon in boys
It is important to exclude pathological cause (more important than females, when it is usually premature onset of normal puberty)

Answer 100

A

Examination of the testes may be helpful:
- Bilateral enlargement with volumes >4ml suggests gonadotrophin-dependent (e.g. intracranial tumour – do MRI, secretion of beta-hCG from liver tumour)
- Prepubertal testes suggests gonadotrophin-independent cause, e.g. CAH/adrenal tumour
- Unilateral enlarged testis suggests gonadal tumour

Answer 101

A

Directed towards:

Detection and treatment of underlying pathology, e.g. MRI for intracranial tumour (esp males)
Reducing rate of skeletal maturation (assessed by bone age)
- Early growth spurt may result in early cessation of growth and reduction in adult height
- Addressing psychological/behavioural difficulties associated with early puberty
Deciding whether to treat a girl who is simply going through puberty early needs further consideration
- If treatment is needed to delay onset of menarche, gonadotrophin-releasing hormone analogues are the treatment of choice
In gonadotrophin-independent cases, source of excess sex steroids needs to be treated
Inhibitors of androgens or oestrogens (e.g. methyprogesterone acetate) may be used

Answer 102

A

Usually affects females between 6mo-2yrs
Breast enlargement may be asymmetrical and fluctuate in size; rarely progresses beyond stage 3 of puberty
Differentiated from gonadotrophin-dependent precocious puberty because there is no axillary/pubic hair or growth spurt
It is non-progressive and self-limiting → no further Ix or Rx

Answer 103

A

Pubarche is the appearance of sexual hair;
Adrenarche is the onset of androgen-dependent body changes (e.g. sexual hair, body odour, acne)

Answer 104

A

Absence of pubertal development before:

14yo in females or
15yo in males

Answer 105

A

Constitutional delay of growth and puberty (most common)
Low gonadotrophin secretion (hypogonadotrophic hypogonadism)
- Systemic disease: CF, severe asthma, Crohn’s, organ failure, starvation/anorexia, excess exercise
- Hypothalamo-pituitary disorders: pituitary dysfunction, isolated gonadotrophin or GH deficiency, intracranial tumours, Kallmann syndrome (LHRH deficiency and inability to smell)
- Acquired hypothyroidism
High gonadotrophin secretion (hypergonadotrophic hypogonadism)
- Chromosomal abnormalities: Klinefelter, Turner
- Steroid hormone enzyme deficiencies
- Acquired gonadal damage: surgery, chemo, radio, trauma, testicular torsion, autoimmune disorder

Answer 106

A

More common in males than females (due to relative insensitivity of testes to gonadotrophin secretion)

In males, it is most commonly caused by constitutional delay → often FHx
In females, it is more likely to be pathological

Answer 107

A

Assessment includes:
- Pubertal staging, esp testicular volume
- Identification of long-term systemic disorders
Management:
- Reassurance that puberty will occur (if constitutional delay)
- If treatment is wanted, oral oxandrolone may be given  weakly androgenic anabolic steroid which induces some catch-up growth but not secondary sexual characteristics development
- In older boys, low-dose IM testosterone can be given to accelerate growth and secondary sexual characteristics

Answer 108

A

Exclude an organic cause
- Karyotyping for Turner’s
- TFTs and sex steroids
- Consider eating disorder and pituitary pathology
Aims of management:
- Identify/treat underlying cause
- Ensure normal psychological adaptation to puberty and adulthood
- Accelerate growth and induce puberty if necessary (oestradiol for several months can induce puberty)

Answer 109

A

Suboptimal weight gain in infants and young children

Aka failure to thrive (term not often used in UK anymore)

Answer 110

A

Inadequate intake of food (most common)
- Environmental:
  - Inadequate availability of food: feeding problems (e.g. poor breastfeeding technique, incorrect formula preparation), insufficient/unsuitable food offered, lack of regular feeding times, infant difficult to feed, conflict over feeding, low socioeconomic status
  - Psychosocial deprivation: poor maternal-infant interaction, maternal depression, poor maternal education
  - Neglect or child abuse
- Underlying pathology:
  - Impaired suck/swallow: oro-motor dysfunction, neurological disorder (e.g. CP), cleft palate
  - Chronic illness leading to anorexia: Crohn’s, CKD, CF, liver disease
Inadequate retention: vomiting, severe GORD
Malabsorption: coeliac, CF, cow’s milk protein allergy, short gut syndrome, post-NEC
Failure to utilise nutrients: syndromes, chromosomal disorders (e.g. Down’s), IUGR, metabolic disorders
Increased requirements: hyperthyroid, CF, malignancy, chronic infection, congenital heart disease, CKD

Answer 111

A

growth charts
Dietary history
Examination
Further info from GP, health visitors, social workers etc.

Answer 112

A

Healthy children’s weight fluctuates, but usually progresses within 1 centile space
- However, infants who are large at birth often cross down centiles and small babies move up centiles (catch up growth) to find their genetic centile lines
- Infants who become ill often lose weight, but regain their weight centile in 2-3wks
- Weight faltering is a sustained drop down 2 centile spaces
- Any child whose weight crosses 2 centile lines or is below 0.4^th centile or BMI <2^nd centile should be evaluated
- NB 5-10% weight loss is normal after birth → regained in first 10-14d

Answer 113

A

history of milk feeding,
age at weaning,
range and type of foods eaten,
mealtime routine,
eating and feeding behaviours,
3d food diary,
observe a meal if possible

Answer 114

A

Look for signs suggesting cause
dysmorphic features
signs suggesting malabsorption etc.

Answer 115

A

Bloods: FBC and iron studies (infection, IDA), U&Es (renal failure), LFTs (liver disease, metabolic disorders), TFTs, CRP/ESR, anti-TTG
Urine dip and MC&S (infection)
Karyotype in girls (Turner syndrome)
Sweat test (CF)

Answer 116

A

Mealtime observations, food diaries  health visitors can assess and support families
Paediatric dietician can assess quantity of food intake, recommend strategies for increasing food
SALT for feeding disorders
May need clinical psychologist and social services
Nursery placement can reduce stress at home and assist with feeding
Key outcome measure is rise up centiles  usually 4-8wks after intervention
If severe:
- Hospital admission may be necessary for active refeeding
- Treat underlying cause

Answer 117

A

Has a long-term effect on growth, with children remaining on low centile (but intervention helps)
May have a small adverse effect on cognition

Answer 118

A

Need to adjust for prematurity:

If a child has been born pre-term, need to calculate developmental age from the expected date of delivery
E.g. the developmental skills of a 9mo born 3 months early are more like those of a 6mo (corrected age)
Correction is not needed after about 2yo

Answer 119

A

They are evident from birth, and gradually disappear (around 6 months)

Moro: sudden extension of the head causes symmetrical extension then flexion of the arms
Grasp: flexion of the fingers when an object is placed in the palm
Rooting: head turns to the stimulus when touched near the mouth
Stepping response: stepping movements when held vertically and dorsum of feet touch a surface
Asymmetrical tonic neck reflex: when supine and head is turned, arm on opposite side to turn stretches out
Sucking reflex: child sucks when nipple/teat is placed in their mouth (automatic feeding action)

Answer 120

A

As the primitive reflexes disappear, postural reflexes emerge (essential for sitting and walking):
- Labyrinthine righting: head moves in opposite direction to which the body is tilted
- Postural support: when held upright, legs take weight and baby may push up (bounce)
- Lateral propping: in sitting, arm extends on the side to which child falls (saving mechanism)
- Parachute: when suspended face down, the baby’s arms extend as though to save himself

Answer 121

A

The short-cut approach:

Detailed developmental assessment is unnecessary in normal clinical practice → so use short-cut approach
Concentrates on the most actively-changing skills for the child’s age
Different developmental fields develop more rapidly at different ages
- Gross motor development → most rapid in 1^st year of life
- Vision and fine motor development → most rapid from 1 year onwards
- Hearing, speech and language → most rapid from 18 months
- Social, emotional and behavioural development → most rapid from 2.5 years
Therefore, questions about development should begin with the area most actively changing at that time
- E.g. if <18 months: begin questions about gross motor abilities
Developmental questioning needs to cover all areas, but this more focussed way of questioning is useful to direct assessment to current abilities rather than trying to remember past milestones
Child should also be observed → guide for where to begin questioning, gives overview of child’s abilities

Answer 122

A

Developmental assessment:

Detailed analysis of particular areas of development  follows concern after screening
Observe child for at least 30s
Gross motor:
- Ask parent to put child on play may on floor
- Lie on back  see if child can roll
- Lift shoulders to sitting position  look for head control (3 months)
- See if child can sit aided/unaided; look at curvature of spine (6/9months)
- Pull to stand  see how much support is needed (9 months)
- Get child to walk if able (15 months) or run (2 years)
- Place prone  see if lifts head, chest or crawls (10 months)
Fine motor and vision:
- Wave toy (vision)
  - Fixes and follows (3 months)
- Give child a toy and observe
  - Transfers (6 months)
  - Palmar grasp (6 months); pincer grip (10 months)
- Offer bricks
  - 3 cube tower (18 months); builds bridge (3 years)
- Give paper and pen if old enough
  - Scribbles (18 months); circular lines (2 years); copies circle (3 years); copies cross (4 years)
Hearing and language:
- Click fingers or use rattles (to see if they turn to sounds)
  - Startles to noise (newborn)
  - Turns to sounds (7 months)
  - Turns to name (12 months)
- Talk to child; ask parents what the child can say/what noises they can make
  - Babble (6 months)
  - Single non-specific word (9 months)
  - Mummy and daddy (10 months)
  - 2 word sentences (2 years)
- Commands, e.g. “put the brick in the cup” (2 years)
Social:
- Observe interaction with people/environment
  - Smile (6 weeks)
  - Laughs (3 months)
  - Stranger anxiety (9 months)
  - Plays peek-a-boo, waves bye-bye (10-12 months)
- Ask parents about diet
  - Solids (6 months)
  - Cup with both hands (12 months)
  - Fork and spoon (2 years)

Answer 123

A

Delay: slow acquisition in all fields (global delay) or one particular field (specific delay), usually in <5yo
Learning difficulty: used in relation to school age children; may be cognitive, physical, or both
Disorder: maldevelopment of a skill

Answer 124

A

Slow but steady
Plateau
Regression → acute regression following acute brain injury with slow recovery but not to normal levels (partial recovery) or slow regression as with neurodegenerative disorders

The gap between normal and abnormal development becomes greater with age → more apparent over time

Answer 125

A

Normal variation
Lack of training/opportunity
Physical/functional impairment
Learning difficulties

Answer 126

A

Prenatal:
- Genetic causes and syndromes, e.g. Down’s
- Maternal alcohol/drug abuse
- Congenital infection: rubella, CMV, toxoplasmosis, HIV
Perinatal:
- Extreme prematurity  IVH, PVL
- Hypoxic-ischaemic encephalopathy, cerebral palsy
- Hypoglycaemia, kernicterus
Postnatal:
- Infection: meningitis, encephalitis
- Anoxia: suffocation, near drowning, seizures
- Head injury
- Hypoglycaemia, inborn errors of metabolism
- Nutritional deficiencies, malabsorption disorders
Physical abuse, emotional neglect

Answer 127

A

Global developmental delay:
Abnormal motor development:
Speech and language delay:
Abnormal development of social/communication skills  see ASD
Slow acquisition of cognitive skills, general learning difficulty or specific learning difficulty, problems with concentration and attention  see learning disability, ADHD

Answer 128

A

Global developmental delay:
- Usually becomes apparent in first 2yrs
- Often associated with cognitive difficulties  these may only become apparent several years later ]

Answer 129

A

Abnormal motor development:
- May present as a delay in acquisition of motor skills, or as problems with balance/gait, asymmetry of hand use, involuntary movements or loss of motor skills
  - Hand dominance is not acquired until 1-2yo  asymmetry in first year is always abnormal
- Usually presents from 3 months – 2yrs
- Causes include:
  - CP (see separate topic)
  - Congenital myopathy/primary muscle disease
  - Spinal cord lesion, e.g. spina bifida
  - Global developmental delay

Answer 130

A

Speech and language delay:
- Causes of speech and language delay:
  - Hearing loss: sensorineural (usually present at birth) or conductive (usually from otitis media with effusion)
  - Anatomical deficit, e.g. cleft palate
  - Global developmental delay
  - Environmental deprivation/lack of opportunity for social interaction
  - Normal variant/familial pattern

Answer 131

A

Prenatal: FHx, neural tube defects, suspected genetic disorders
Perinatal: birth asphyxia, preterm infants with IVH/PVL, dysmorphic features, abnormal neurological behaviour (tone, feeding, movement, seizures, etc.), low Apgar scores
Infancy: delayed/asymmetric motor movement, dysmorphic features, vision/hearing concerns, persistence of primitive reflexes
Preschool: speech and language delay, abnormal gait, clumsy motor skills, poor social communication skills
School age: problems with balance and coordination, learning difficulties, attention control, hyperactivity, specific learning difficulties (e.g. dyslexia), social communication difficulties
Any age: acquired brain injury (e.g. meningitis, head injury), loss of skills

Answer 132

A

Developmental assessment
Specialised screening tests for ASD, ADHD; IQ testing
Hearing and vision tests
Nursery and school reports
Ix depending on likely cause: karyotype, metabolic screen, infection screen, brain imaging, EEG

Answer 133

A

Primary health care team:

GP, practice nurses, midwives, health visitors, school nurses, district nurses

Local authority:

Responsibilities for administration and delivery of education and social care
Central government is responsible for establishing national policies and guidance, but local need determines what services are available

Education:

Overseen by local authority
Mainstream schools or special schools
Allocated funds to support children with special needs; given extra resources if necessary

Specialist paediatric services:

Paediatricians in hospital and community
Specialist nurses, e.g. DM, epilepsy, asthma
Community paediatric nursing teams: nursing care at home for children with complex needs

Other members of the MDT:

Doctors from all specialities
Occupational therapists, physiotherapists, speech and language therapists, dieticians
Social workers
Play specialists
CAMHS

Voluntary/charitable organisations:

Many different services are available, esp. for children with disabilities
E.g. Homestart (support at home for children <5yo), Mencap (learning disability), Scope (CP)

Answer 134

A

Airway and breathing:

Look, listen and feel for:
- Airway obstruction
  - Airway obstruction is more common in children than adults (as airway is shorter/narrower, tongue is proportionally bigger, babies have big floppy heads)
- Work of breathing/respiratory distress
- RR
- Stridor, wheeze, auscultation for air entry
- Cyanosis (blue at 65-70% O2), O2 sats
- Level of consciousness  decreases ability to maintain airway if impaired

Circulation:

Feel and assess:
- HR and pulse volume
- Capillary refill time (sternum or a digit; prolonged if >2s)
- Skin temperature
- BP

Disability:

Level of consciousness
- Rapid assessment  AVPU (alert, responds to voice, responds to pain, unresponsive)
- More detailed assessment  GCS
  - Eyes (4), verbal (5), motor (6)
Pupil size and reactivity

Exposure

Rashes, injuries

Don’t ever forget glucose

Resuscitation is given immediately as you work through ABCDE (if necessary), followed by secondary assessment and other emergency interventions

Answer 135

A

SSS: Before starting → safety, shout for help, stimuli (shout, squeeze trapezius)

Open airway:

Airway must be patent for ventilation to take place
Head tilt: neutral in newborns; slightly extended in older children
Chin lift: using 1/2 fingers apply forward pressure to just under chin to pull tongue forwards
Jaw thrust: if head tilt/chin lift doesn’t work; apply forward pressure behind angles of jaw
Guedel oro-pharyngeal airway: slide over tongue and into throat
- To size: hold along line of jaw with the end in the middle of lips; end should be at angle of jaw
Endotracheal intubation
Suction: if above methods not successful (to get rid of obstruction)
Trachotomy: last resort; bypasses upper airway obstruction when oro-nasal endotracheal intubation fails

Check breathing (10s):

Look, listen and feel

Breathe:

Give 5 initial rescue breaths
Ideally with bag and mask
- Ensure patent airway (above)
- Use appropriately sized mask  should cover mouth and nose (but not eyes or extend over chin)
- Connect face mask to self-inflating bag or tubing with a T-piece and then to oxygen supply
  - Ensure adequate flow rate, e.g. 5-8L/min in newborn
  - In newborns, a pressure-limiting valve should be used (set at 25-30cm H2O)
- Apply mask over face; apply enough pressure to create a seal
- Give inflation breaths by compressing self-inflating bag or occluding open part of T-piece
Observe for adequate inflation
If inflation is poor or child is deteriorating  readjust airway, check airway is not obstructed

Assess for signs of life; pulse does not need to be checked

Chest compressions (x15)

It is rare for a child to have a shockable rhythm (unless cardiac patient)  defibrillators less important

15 compressions → 2 rescue breaths → repeat for 2 mins →reassess → repeat

Answer 136

A

Management depending on cause:

Resp failure:
- O2 if sats <92% via facemask
- Invasive ventilatory support (endotracheal intubation and mechanical ventilation) if severe
Shock:
- Fluid resuscitation: 0.9% saline bolus, 20ml/kg (or blood if trauma), x2 if necessary
- May need endotracheal intubation and mechanical ventilation, invasive BP monitoring, inotropic support etc.

Answer 137

A

Preterm birth is delivery before 37 completed weeks gestation

Extreme preterm: <28wks
Very preterm: 28-32wks
Moderate to late preterm: 32-37wks

Answer 138

A

Causes of preterm delivery:

25% are planned due to foetal or maternal conditions (pre-eclampsia, severe IUGR, etc.)
25% are due to an emergency event, e.g. placental abruption, eclampsia, severe infection
30-40% are due to premature labour or PPROM

Answer 139

A

Modifiable: short inter-pregnancy interval (<6 months), BMI <19 or >35, psychological stress, smoking/drugs, bacterial vaginosis
Non-modifiable: black women, previous preterm delivery, chronic medical conditions (DM, HTN etc.), problems with uterus/cervix/placenta (incl. infection, antepartum haemorrhage, cervical insufficiency)

Answer 140

A

If gestation is unknown:

Dubowitz/Ballard examination for gestational age → gives estimate of 2wk window of gestation

Answer 141

A

Stabilisation of preterm infants and newborn infants who become seriously ill:
- Airway and breathing:
  - Clear the airway, give oxygen, give CPAP or mechanical ventilation as necessary
    - Low concentration (21-30%) oxygen given (excessive oxygenation can cause tissue damage due to free-radicals)
Monitoring: O2 sats (maintain at 91-95% if preterm), HR, RR, T, BP, glucose, blood gases, weight
Temperature control:
- Pre-term infants are liable to hypothermia  must keep warm
- If <30wks place in plastic bag or wrapped in clear plastic sheeting (except face)
- Radiant heat source warms baby in bag (acts like another layer of skin to avoid evaporative heat loss)
Venous and arterial lines:
- Peripheral IV line: for IV fluids, antibiotics and other drugs
- Umbilical venous catheter: may be used for IV access at resuscitation, in extremely preterm infants for the first few days or to give high-osmolality fluids (e.g. high-conc dextrose) or medication needing central delivery (e.g. inotropes)
- Arterial line: if frequent blood gases, continuous BP monitoring and blood tests are required
- PIC line: for parenteral nutrition, if needed
Broad-spectrum antibiotics if any possibility of infection
- E.g. benzylpenicillin and gentamycin
Minimal handling → done as gently, rapidly and efficiently as possible

Answer 142

A

Begins antenatally if there is threat of pre-term delivery
- Tocolytics and transfer to appropriate centre (e.g. level 3 NICU if extremely preterm)
- Antenatal steroids (reduce risk of death, IVH and RDS in infants)
- Magnesium sulphate (neuroprotective to baby)

Answer 143

A

Investigations:
- Hb, neutrophil count, platelet count (high risk of infection, thrombocytopenia, anaemia)
- Blood urea, creatinine, electrolytes, lactate (risk of renal impairment), glucose, CRP
  - NB electrolytes may be more reflective of mother’s for first 24hrs
- Cultures: blood +/- CSF +/- urine (infection)
- Blood group and direct coombs test/direct antiglobulin test: many infants require a blood transfusion and almost 80% develop jaundice in first week of life

Answer 144

A

Need for resuscitation and stabilisation at birth
Hypothermia
Respiratory distress syndrome
Bronchopulmonary dysplasia
Patent ductus arteriosus
Necrotising enterocolitis
Intraventricular haemorrhage/periventricular leukomalacia
Retinopathy of prematurity, blindness
Inguinal hernias
Jaundice
Anaemia of prematurity
Infection, sepsis
Metabolic: hypoglycaemia, electrolyte imbalance, osteopenia of prematurity
Failure to thrive/nutritional deficiencies
Cerebral palsy and neurodevelopmental impairment
Hearing impairment

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