PAEDS ILA 5&6

Question 1

what are the four fields of development?

Answer 1

groos motor
fine motor
coral
speech and language

Question 2

what developmental milestones would you expect to see a child achieve by six months?

Answer 2

gross motor - head control, able to lift head and chest and support onto extended arms, can sit with support, can roll from tummy to back

Fine motor - palmer grasp, transfer objects

speech and language - starts to babble, turns head to loud sounds, understands bye bye

social - puts objects to mouth, shakes rattle, reaches bottle

Question 3

List the developmental milestones that you expect a child to have achieved by twelve months?

Answer 3

gross motor - independently rises from lying to sitting, walks alone 9-18 months

fine motor - refined pincer grip

Speech and language - shows understanding of nouns (where is mummy) 2-3 words, can point to body parts

social - waves bye bye, hand clapping, drinks from cup with lid with two hands, finger feed

Question 4

what is the moro reflex?

what is the significance of abnormal persistence of primitive reflexes?

Answer 4

moro reflex is a primitive reflex which presents in all infants/newborns up to 3 or 4 months of age - it is a response to a sudden loss of support, when the infant feels as if it is falling. It involves three distinct components - spreading the arms (abductuion) then unspreading the arms (adduction) and often crying

if there is persistent primitive reflexes usually it means there is an upper motor neurone deficit - commonly cerebral palsy

Question 5

what are the primitive reflexes?

Answer 5

• Palmar – from birth to 2-3 months
• Rooting – from birth to 3-4 months
• Moro – from birth to 2-4 months
• Asymmetric Tonic neck reflex-from birth to 4-6 months

Question 6

what is cerebral palsy?

Answer 6

an umbrella term for a permanent disorder of movement and/or posture and of motor function due to a non-progressive abnormality in the developing brain

Question 7

what can cause cerebral palsy ?

Answer 7

80% are antenatal origin due to cerebrovascular haemorrhage or ischaemia, cortical migration disorders or structural maldevelopment of the brain during gestation. can also be due to an antenatal infection

perinatal - infection, hypoxia or trauma

post natal - trauma, infection, haemorrhage

Question 8

why do a child symptoms with cerebral palsy change over time?

Answer 8

because as the child grown, what they cannot do become more evident and as you do the signs become more obvious.

Question 9

what are the different types of cerebral palsy ?

Answer 9

spastic - increased tone (presents early, initial hypotonia) can be hemiplegia, diplegia or quadriplegia
ataxic
dyskinetic
mixed

Question 10

what investigations would you perform for suspected cerebral palsy?

Answer 10

MRI - may show periventricular leukomalacia, congenital malformation, stroke or haemorrhage, cystic lesions

metabolic screen
genetic testing

Question 11

who would be involved in the care of a child with cerebral palsy?

Answer 11

MDT approach to care 
Physio
OT
dietician 
paediatrician 
GP 
pharmacy 
neurologist
orthopaedic surgeon 
psychologist 
social services

Question 12

when would you prescribe botox for cerebral palsy?

Answer 12

botox reduces spasticity
consider in focal spasticity of libs where it is impeding fine motor function/gross motor function
consider in focal dystonia with postural/functional difficulties

Question 13

A 6 year old girl is referred to the outpatient clinic because she is having repeated episodes of daydreaming at school. These have been occurring over at least the last year. Since they were highlighted by school, her parents have noticed them occurring at home. There are no concerns about her development, although the school have noticed that her work has deteriorated since these episodes started. Examination is unremarkable; in particular neurological examination is normal.

What possible explanations are there for her symptoms?

Answer 13

absence seizures
learning difficulties
hearing and sight problems

Question 14

how would you investigate someone presenting with suspected absence seizures?

Answer 14

EEG - WITH AN ABSENCE SEIZURE YOU WOULD FIND 3Hz SPIKE AND WAVE COMPLEX ALL 4 QUADRANTS

hyperventilation - can cause absence seizure

Question 15

what is the first line treatment for absence seizures?

AND SIDE EFFECTS

Answer 15

1st line: ethosuximid - aggression, agranulocytosis, decreased appetite, bone marrow disorders, depression, dizziness, drowsieness

2nd options = sodium valproate or lamotrigine
sodium valproate side effects: abdominal pain, alopecia, anaemia, abnormal behaviour
lamotrigine side effects: aggression, agitation, diarrhoea , dizziness, drowsiness

Question 16

what are the different types of squint ?

Answer 16

paralytic vs non-paralytic
paralytic - nerve palsy you can only move your eye in certain. directions
non-paralytic - you can move your eyes in all directions just there is a misalignment

manifesto (all the time) vs talent (just some of the time)
conversion vs diversion

Question 17

why might children develop a squint?

Answer 17

visual problems - refract error, cataract, retinoblastoma

hereditary

Question 18

how can you treat squint? what happens if it is not corrected?

Answer 18

Non- Paralytic normally due to refractory error, corrected with glasses or rarely patch
If not corrected, leads to amblyopia

Question 19

what squint may require imaging of the head and orbitis?

Answer 19

paralytic squints need investigation

Question 20

how do you manage a preterm baby?

Answer 20

intubation, incubation, put them in a warm plastic bag, keep them warm, monitor sats, if you are intubating then they will need surfactant

IV access for antibiotics
you can put a line in the vein in the umbilical cord and a line in the artery in the umbilical cord (for blood sampling, invasive BP monitoring)
fluids give 10% glucose
CXR to check everything is in the right position

Question 21

a preterm baby (27 weeks) presents with hard work to breathe and is dependant on oxygen to maintain the saturations. What are the likely causes of his problems?

Answer 21

respiratory distress syndrome
congenital pneumonia/sepsis
pneumothorax

Question 22

what antibiotics should you give to pre-term babies?

Answer 22

benzypenicillin and gentamycin

Question 23

who might you feed and extremely premature baby?

Answer 23

total parental nutrition through a PICC line
NG tube
immature gut so may not be able to tolerate milk
can be bottle fed at 32-35 weeks

Question 24

if a premature infant deteriorates suddenly and looks pale and has low BP, what could have happened?

Answer 24

sepsis 
cardiac failure 
shock - hypovolemia, blood volume loss 
pneumothorax 
displaced tube
obstructed tube
equipment failure

Question 25

You are asked to see an infant who is twelve hours old, having been born to a couple from Saudi Arabia. He is their second child and there are concerns that he is jaundiced. Mother is well although she now has a temperature of 37.9°C.

how would you assess jaundice? what are the possible causes?

Answer 25

serum bilirubin

• this baby has early onset jaundice - which is never normal
• start the baby on antibiotic
  causes
  sepsis - TORCH
  rhesus disease - can cause haemolysis
  haemolytic anaemia can cause it
  G6PD

consider septic screen

Question 26

how do you know if you need to treat jaundice in neonates?

Answer 26

plot their serum bilirubin on a bilirubin chart

Question 27

how do you treat jaundice?

Answer 27

phototherapy

Question 28

can jaundice be dangerous?

Answer 28

yes it can cause kernicterus

Question 29

what is kernicterus ?

Answer 29

bilirubin encephalopathy
develops due to excessive neurological-toxic uncojugated bilirubin levels
lead to selective damage of the cerebellum , basal ganglia and brainstem auditory pathways

Question 30

what factors mean the infant/neonate is at more risk of developing kernicterus as lower levels of bilirubin?

Answer 30

if they are less than 24 hours
if they are pre-term
if they are severely ill
if they are acidotic
caused by iso-immunisation haemolytic disease
reduced albumin binding caused by drugs or hypoalbuminanaemia

Question 31

if jaundice persists for longer than two weeks what should you do?

Answer 31

look at the conjugated fraction - see what percentage of the bilirubin is conjugated. If higher conjugated they will need further investigation
look for biliary atresia

Question 32

what are some causes of prolonged jaundice?

Answer 32

breastfeeding, enclosed bleeding, prematurity, haemolysis, sepsis, hypothyroid, conjugated jaundice, hepatic enzyme disorders

Question 33

what is prolonged jaundiced classified for term and pre-term infants?

Answer 33

term = 14 days 
preterm = 21 days

Question 34

what are some causes of conjugated jaundice?

Answer 34

SEPSIS 
TPN 
biliary tract atresia 
viral hepitiis 
TORCH infections 
alpha antitrypsin deficiency 
CF

Question 35

if a child presents with a fracture and no explanation what do you need to do?
what are you differential diagnosis?

Answer 35

full history - including detailed social history - ensure there is no child abuse
non-accidental injury
vitamin D deficiency
Osteogenesis imperfecta

Question 36

what clinical features would you look for when infants brought in with fracture?

what investigations?

Answer 36

X-ray 
skeletal survey 
bone profile 
PTH 
VD levees 
Bone mineral density 

look for blue/grey/white sclera - osteogenesis imperfect 
look at teeth 
look for hyperextensibilty 
MSK exam 
look for bruises