Paeds basics Flashcards

Question

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

Answer 1

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

Answer 2

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

Answer 3

* 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

Answer 4

Startles to loud noises

Answer 5

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

Answer 6

Turns to soft sounds out of sight Polysyllabic babble (*“babababa, lalalalala”*)

Answer 7

Sounds used indiscriminately at 7 months Sounds used discriminately to parents at 10 months *“Dada, Mama”*

Answer 8

Two to three words other than ‘Dada’ or ‘Mama’ Understands name *“Drink”*

Answer 9

6-10 words Is able to show two parts of the body *“Where is your nose?” – Baby will point*

Answer 10

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

Answer 11

Talks constantly in 3 – 4-word sentences Understands 2 joined commands *“Push me fast Daddy”*

Answer 12

Limbs flexed, symmetrical pattern Marked head lag on pulling up

Answer 13

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

Answer 14

Sits without support (initially with a round back, then eventually with a straight back by 8 months) *Limit age: 9 months*

Answer 15

Stands independently Cruises around furniture

Answer 16

Walks unsteadily – a broad gait, with hands apart *Limit age: 18 months*

Answer 17

Walks steadily

Answer 18

Runs and jumps

Answer 19

Smiles responsively *Limit age: 8 weeks*

Answer 20

Puts food in their mouth

Answer 21

Waves bye-bye, plays peek-a-boo

Answer 22

Drinks from a cup with two hands

Answer 23

Holds spoon and gets food safely to mouth

Answer 24

Symbolic play *Limit age: 2 – 2.5 years*

Answer 25

Toilet training: dry by day Pulls off some clothing

Answer 26

Parallel play Interactive play evolving Takes turns

Answer 27

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

Answer 28

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

Answer 29

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

Answer 30

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

Answer 31

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

Answer 32

RR and HR drops BP increases

Answer 33

**_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

Answer 34

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

Answer 35

* **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

Answer 36

HEAADSSS * **H**ome life, including relationship with parents * **E**ducation or employment, including financial issues * **A**ctivities, including friendships/hobbies/sports * **A**ffect and mood * **D**rugs, including cigarettes, alcohol, recreational * **S**ex (relationships and sexual risk behaviours) * **S**uicide, depression, self-harm * **S**leep

Answer 37

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

Answer 38

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 39

Normal range varies according to height and gender

Answer 40

* **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 41

* 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 42

* 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 43

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

Answer 44

* **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 45

* _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 46

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 47

* 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 48

* 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 49

* 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 50

* 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 51

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

Answer 52

**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 53

* 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 54

* 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 55

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

Answer 56

* Foetal * Infantile phase * Childhood phase * Pubertal growth spurt

Answer 57

* 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 58

* **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 59

* **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 60

* **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 61

* **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 62

* **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 63

* Occipitofrontal circumference

Answer 64

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 65

* weight * height * head circumference * BMI

Answer 66

* 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 67

* 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 68

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

Answer 69

* **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 70

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

Answer 71

* 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 72

* **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 73

* **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 74

* ~ **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 75

* 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 76

**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 77

**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 78

* **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 79

* **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 80

* **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 81

* **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 82

Development of secondary sexual characteristics before: * 8yo in females and * 9yo in males

Answer 83

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

Answer 84

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

Answer 85

* **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 86

* 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. exce**ss 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 87

* 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 88

* 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 89

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 90

* 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 91

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

Answer 92

Absence of pubertal development before: * 14yo in females or * 15yo in males

Answer 93

* **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 94

**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 95

* 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 96

* **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 97

Suboptimal weight gain in infants and young children * Aka failure to thrive (term not often used in UK anymore)

Answer 98

* **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 99

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

Answer 100

* 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 101

* 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 102

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

Answer 103

* **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 104

* 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 105

* 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 106

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 107

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 108

* 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 109

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 110

_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 111

* 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 112

* **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 113

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

Answer 114

* **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 115

* 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 116

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

Answer 117

* 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 118

* 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 119

* **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 120

* 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 121

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 122

**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 123

**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 124

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 125

Preterm birth is **delivery before 37 completed weeks gestation** * Extreme preterm: \<28wks * Very preterm: 28-32wks * Moderate to late preterm: 32-37wks

Answer 126

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 127

* 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 128

If gestation is unknown: * **Dubowitz/Ballard examination for gestational age** → gives estimate of 2wk window of gestation

Answer 129

* **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 130

* 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 131

* 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 132

* 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