PAEDS - MISCELLANEOUS Flashcards
CHILD ABUSE
What are some risk factors for child abuse?
- Child = failure to meet expectations (disabled, wrong sex), born after forced or commercial sex work
- Parent = MH issues, substance abuse, LD, young
- Family = stepparents, domestic abuse, multiple or closely spaced births
- Environment = low socioeconomic status
CHILD ABUSE
Give 3 examples of abuse
- Emotional = persistent emotional mistreatment of a child resulting in adverse effects of a child’s emotional development
- Sexual = forcing a child to take part in sexual activities
- Neglect = persistent failure to meet a child’s basic physical + psychological needs
CHILD ABUSE
How might childhood sexual abuse present?
- PV/PR bleed or itching
- PV discharge
- STIs
- Bruising
- Oversexualised child
- Dilated anus
CHILD ABUSE
Give some examples of neglect
How might neglect present?
- Inadequate food, drink, emotional support, clothing, shelter
- Inadequate supervision or access to medical care = severe + persistent infections (scabies, lice), failure to engage with child health promotion, failure to attend follow-ups
CHILD ABUSE
What features in the history are suspicious for child abuse?
- Too many injuries, wrong site, unusual shape or pattern
- Delay in presenting (old injuries), multiple A&E visits
- No Hx, Hx inconsistent with injuries or that changes
CHILD ABUSE
Where are normal and abnormal places for a child to bruise?
- Shins, knees, elbows, toddlers can bump their heads
- Abdo, genitalia, insides of arms/legs, behind neck or other soft bits, young babies that cannot roll
CHILD ABUSE
What other features may raise alarms for child abuse?
- # = metaphyseal, multiple # at different healing stages, posterior rib # in babies v. specific, radial, humeral, femoral
- Bruising, burns, scalds, failure to thrive
- Torn frenulum (forcing bottle into mouth)
CHILD ABUSE
What is the management for suspected child abuse?
- FBC, clotting screen, bone profile, radiology
- Developmental + social services assessment
- If suspected > hospital admission + can break confidentiality
- Fundoscopy for retinal haemorrhages
CHILD ABUSE
Why do you perform fundoscopy?
Other features?
- Shaken baby syndrome = retinal haemorrhages, subdural haematoma + encephalopathy
CHILD ABUSE
What law is relevant to child abuse?
- Child act 2004 allows to speak to child without parents’ consent, safeguards children
FAS
How much alcohol is safe in pregnancy?
What are some features of foetal alcohol syndrome?
- None
- Microcephaly
- Short palpebral fissures, hypoplastic upper lip, small eyes, smooth philtrum
- LDs, poor growth + cardiac malformations
- Can have alcohol withdrawal Sx a birth = irritable, hypotonic, tremors
SWELLINGS + CYSTS
What is mastoiditis?
How does it present?
Management?
- Med emergency as can cause meningitis, sinus thrombosis
- External ear may protrude forwards, severe otalgia (classically behind), fever
- Swelling, erythema + tenderness over mastoid process
- Abx ±mastoidectomy
SWELLINGS + CYSTS
What is a thyroglossal cyst?
How does it present?
Management?
- Persistence of thyroglossal duct
- Midline, smooth + moves when they stick their tongue out
- USS shows thin walled + anechoic (echoic suggests cyst infection)
SWELLINGS + CYSTS
Where would you find a branchial cyst?
How does it present?
- Not in midline, tend to appear along border of sternocleidomastoid
- 75% originate from second branchial cleft, often unilateral + smooth
SWELLINGS + CYSTS
What is a cystic hygroma?
- Soft lesion in posterior triangle that transilluminates (seen in Turner’s)
SWELLINGS + CYSTS
What is a dermoid cyst?
Caution?
Investigation?
- Found on lateral aspect of eye + produces sebaceous material
- Can communicate intracranially causing meningitis
- USS shows heterogeneous + have variable amounts of calcium + fat
PAEDS FLUIDS
What are 3 essential components to a safe fluid prescription?
- Fluid constituents + bag size = NaCl 0.9% + dextrose 5% + KCl 10mmol (500ml)
- Rate of administration in ml/hour
- Signature
PAEDS FLUIDS
What are important things to consider prior to prescribing fluids?
- Weight ([Age + 4] x 2), including weight change
- Fluid input/output in past 24h
- Fluid status (dehydrated)
- Recent bloods (electrolytes)
PAEDS FLUIDS
What is used for maintenance fluids?
How are they calculated?
- 0.9% NaCl + 5% dextrose + KCl 10mmol
- 100ml/kg/day for first 10kg
- 50ml/kg/day for next 10kg
- 20ml/kg/day for every kg after 20kg
- Divide by 24 = ml/hour
PAEDS FLUIDS
What are some clinical signs of dehydration?
- <5% = slight thirst, dry lips
- 5-10% = sunken eyes, reduced skin turgor, decreased urine output, dry lips + mucous membranes (no shock)
>10% = reduced GCS, cold, mottled peripheries, anuria, sunken fontanelle, CRT >2s, hypotension (late)
PAEDS FLUIDS
How can you calculate % dehydration?
How do you calculate fluids to correct dehydration?
- (Well weight [kg] – current weight [kg]) ÷ well weight
- % dehydration x 10 x weight (kg)
PAEDS FLUIDS
What is the general rule for fluid boluses?
- Given in shock
- 0.9% NaCl at 20ml/kg over <10m
- After >3 boluses call for paeds intensive care support as risk > pulmonary oedema
PAEDS FLUIDS
What are exceptions to the fluid bolus in shock rule?
What is advised?
- Trauma, primary cardiac pathology (heart failure), DKA (after first 20ml/kg)
- 10ml/kg boluses to prevent pulmonary oedema
PAEDS FLUIDS
What fluids do neonates require?
What are their intake requirements?
- Day 1 = just 10% dextrose
- From day 2 = Na (3mmol/kg/day) + K (2mmol/kg/day)
- Day 1 = 60ml/kg/day
- Day 2 = 90ml/kg/day
- Day 3 = 120ml/kg/day
- Day 4 + beyond = 150ml/kg/day
CHILD ABUSE
What is the most common form of abuse?
Neglect
DEVELOPMENTAL STAGES
What is meant by…
i) median age?
ii) limit age?
i) When half a standard population of children reach that level of development
ii) Age a child is expected to have reached a milestone (often 2 standard deviations from the mean)
DEVELOPMENTAL STAGES
How do the developmental milestones correspond with prematurity?
- Age correct up to 2 years
- 9m born 2 months early should only be expected to be at developmental stage of 7m
DEVELOPMENTAL STAGES
What is developmental surveillance?
- Ongoing process of following child over time
- Can be incorporated into well-child checks, general physical exam or routine vaccine visits
DEVELOPMENTAL STAGES
What are the 4 domains of development?
- Gross motor
- Fine motor + vision
- Speech, hearing + language
- Social, emotional + behavioural
DEVELOPMENTAL STAGES
In terms of gross motor development, what would you expect for a new born?
New born = Limbs flexed, symmetrical posture, head lag on pulling up
DEVELOPMENTAL STAGES
In terms of gross motor development, what would you expect for a 8 month old baby?
8 months = Crawl (some may bottom shuffle or commando crawl)
DEVELOPMENTAL STAGES
In terms of gross motor development, what would you expect for a 2 year old child?
2 years = Runs, kick ball (2.5y)
DEVELOPMENTAL STAGES
In terms of fine motor + vision development, what would you expect for a 6 week old baby?
Turns head to follow object (fix + follow)
Limit age = 3 months
DEVELOPMENTAL STAGES
In terms of fine motor + vision development, what would you expect for a 7 month old baby?
transfers toys from one hand to the other
- limit age = 9 months
DEVELOPMENTAL STAGES
In terms of fine motor + vision development, what would you expect for an 18 month old child?
- Crayon scribbles
- 3 brick tower
DEVELOPMENTAL STAGES
In terms of fine motor + vision development, what would you expect for a 3.5 year old child?
draws a cross
DEVELOPMENTAL STAGES
In terms of fine speech, hearing + language development, what would you expect for a new born baby?
Startles at loud sounds, quietens to parent’s voice
DEVELOPMENTAL STAGES
In terms of fine speech, hearing + language development, what would you expect for a 9 month old baby?
Responds to own name, imitates adult sounds “dada, mama”
DEVELOPMENTAL STAGES
In terms of fine speech, hearing + language development, what would you expect for a 20-24 month old child?
joins two or more words together to make simple phrases, “Give me teddy”
DEVELOPMENTAL STAGES
In terms of social, emotional + behavioural development, what would you expect for a 6 week old baby?
Smiles responsively
– Limit age 8w
DEVELOPMENTAL STAGES
In terms of social, emotional + behavioural development, what would you expect for a 12 month old child?
Drinks from cup with 2 hands
DEVELOPMENTAL STAGES
In terms of social, emotional + behavioural development, what would you expect for a…
i) 3y?
ii) 4y?
iii) 5y?
i) Seek out other children + play with them, turn-taking, follows simple rules, bowel control, fork + spoon
ii) Has best friend, bladder control, dresses self, imaginative play
iii) Knife + fork
DEVELOPMENTAL STAGES
What are the primitive reflexes?
- Moro (startle)
- Grasp (palmar/plantar)
- Sucking/rooting
- Stepping
- Asymmetrical tonic neck reflex
DEVELOPMENTAL STAGES
Explain the following primitive reflexes…
i) moro?
ii) grasp?
iii) sucking/rooting?
i) Sudden extension of head causes symmetrical extension then flexion of limbs. Stops 3–4m
ii) Touch palm (palmar) or sole (plantar) + baby will grasp or curl toes. Stops 4–5m
iii) Head turns to stimulus when touched near mouth, assists in breastfeeding. Stops at 4m
DEVELOPMENTAL STAGES
Explain the following primitive reflexes…
i) stepping?
ii) asymmetrical tonic neck reflex?
i) Stepping movements when held vertically + dorsum of feet touch surface. Stops at 2m
ii) Baby supine + head turned to one side > arm on that side stretches out + opposite flexes at elbow
DEVELOPMENTAL STAGES
What are the postural reflexes?
- Parachute
- Postural support
- Labyrinthine righting
- Lateral propping
DEVELOPMENTAL STAGES
Explain the following postural reflexes…
i) parachute?
ii) postural support?
i) Suspend baby prone + slowly lower head towards a surface > arms + leg extend in protective fashion
i) When held upright if feet touch a surface legs take weight + may push up like a bounce
DEVELOPMENTAL STAGES
Explain the following postural reflexes…
i) labyrinthine righting?
ii) lateral propping?
i) Head moves in opposite direction to which body is tilted
ii) When sitting, arms extends on the side to which child falls as saving mechanism
DEVELOPMENTAL STAGES
What is the relevance of the primitive and postural reflexes?
- Persistence of primitive reflexes + lack of development of postural reflexes is the hallmark of UMN abnormality in the infant (cerebral palsy)
DEVELOPMENTAL DELAY
In terms of developmental delay, define…
i) delay?
ii) learning difficulty?
iii) disorder?
i) Implies slow acquisition of all skills or of one particular field
ii) Cognitive, physical, both or relate to specific functional skills
iii) Maldevelopment of a skill
DEVELOPMENTAL DELAY
In terms of developmental delay, define…
i) impairment?
ii) disability?
iii) disadvantage?
i) Loss/abnormality of physiological function or anatomical structure
ii) Any restriction or lack of ability due to the impairment
iii) Results from disability + limits fulfilment of a normal role
DEVELOPMENTAL DELAY
In terms of developmental delay, what are the 3 broad aetiological categories?
- Prenatal
- Perinatal
- Postnatal
DEVELOPMENTAL DELAY
What are some prenatal causes of developmental delay?
- Genetics (Down’s, fragile X)
- Congenital hypothyroidism
- Teratogens (alcohol + drug abuse)
- Congenital infection (TORCH)
- Neurocutaneous syndromes (tuberous sclerosis, neurofibromatosis)
DEVELOPMENTAL DELAY
What are some perinatal causes of developmental delay?
- Extreme prematurity (intraventricular haemorrhage)
- Birth asphyxia (HIE)
- Hyperbilirubinaemia
- Hypoglycaemia
DEVELOPMENTAL DELAY
What are some postnatal causes of developmental delay?
- Infection (meningitis, encephalitis)
- Anoxia (suffocation, near-drowning, seizures)
- Head trauma (accidental or NAI)
- Hypoglycaemia
DEVELOPMENTAL DELAY
What are some risk factors for developmental delay?
- Bio = prems, LBW, birth asphyxia, hearing/vision impairment
- Environment = poverty, poor parental education, maternal substance abuse
DEVELOPMENTAL DELAY
What is global developmental delay?
How does it present?
What are some causes?
- Slow development in all developmental domains
- Presents in first 2y of life
- Down’s, fragile X, foetal alcohol syndrome, Rett syndrome + metabolic disorders
DEVELOPMENTAL DELAY
What is abnormal gross motor development?
What are some causes?
- Slow development in gross motor domain
- Cerebral palsy, ataxia, myopathy, spina bifida + visual impairment
DEVELOPMENTAL DELAY
What is abnormal fine motor development?
What are some causes?
- Slow development in fine motor domain
- Dyspraxia, cerebral palsy, muscular dystrophy, visual impairment, congenital ataxia (rare)
DEVELOPMENTAL DELAY
What is abnormal speech or language development?
What are some causes?
- Slow development in speech + language domain
- Specific social circumstances, hearing impairment, LD, neglect, autism + cerebral palsy, cleft lip/palate
DEVELOPMENTAL DELAY
What are some specific social circumstances that can lead to abnormal speech or language development?
What is the management?
- Exposure to multiple languages, sibling that do all the talking
- Referral to SALT, audiology + health visitor with safeguarding if ?neglect
DEVELOPMENTAL DELAY
What is personal + social delay?
What are some causes?
- Slow development in personal + social domain
- Emotional + social neglect, parenting issues + autism
DEVELOPMENTAL DELAY
What is the management of developmental delay?
- Thorough Hx + exam (hearing + vision)
- Cytogenic (chromosome karyotype)
- Metabolic (TFTs, LFTs, U+Es, CK, lactate)
- Infection (congenital infection screen)
- Focal neuro (CT/MRI head, EEGs)
MEASUREMENT
What are some determinants of growth?
- Parental phenotype + genotype
- Nutrition
- Pregnancy factors
- Psychosocial deprivation
- Endocrine function
MEASUREMENT
What are 3 important components to measurements?
- Weight = naked infant or child only in underclothing
- Height = >2y standing height, <2y horizontal
- Head circumference = occipitofrontal circumference is a measure of head + accurate representation of brain size + development
MEASUREMENT
What are some concerns with various head circumferences?
- Microcephaly = ?brain not formed properly, ?LDs
- Macrocephaly = ?hydrocephalus
- Note = small babies likely to have small heads, compare ALL values
MEASUREMENT
How might the accuracy of measurements be compromised?
A part of measurement is working out the mid-parent height.
How is this done for boys and girls?
- Faulty technique (inexperienced staff), faulty equipment (wrongly calibrated), uncooperative child
- Boys = [(Dad + mum height in cm) ÷ 2] + 7
- Girls = [(Dad + mum height in cm) ÷ 2] – 7
MEASUREMENT
What is the role/management of measurements in paediatrics?
- Assess if a child’s overall height is abnormal (<2nd or >98th centile)
– GP review if <2nd, Paeds review if <0.4th - Assess if a child is failing to follow their growth potential (drop centile line)
– More concerning than consistently 9th centile - Assess if a child is losing or gaining weight quickly
– ?Pathology
MEASUREMENT
What are the phases of growth in children?
When does growth end?
- First 2y = growth velocity fastest in utero + infancy, driven by nutritional factors
- 2y-puberty = steady slow growth (genes, thyroid + growth hormones, health)
- Puberty = rapid growth spurt driven by sex hormones
- When the epiphyses fuse
DEVELOPMENTAL STAGES
In terms of speech, hearing + language development, what would you expect for a…
i) 3.5y?
ii) 4y?
i) Understands comparatives “which one is BIGGER”
ii) “Why”, “when”, “how” questions, understands complex instructions “before you put x in y give z to mummy”
NIPE EXAMINATION
What is the process of the NIPE exam?
What are the components?
- First within 72h of birth + second by GP at 6–8w
- General observation, eyes, heart, hips + genitalia
NIPE EXAMINATION
What is looked for in the general observation?
- Weight, height, head circumference (HC = measure of brain size)
- Palpate sutures + fontanelle
- Dysmorphic features
- Reflexes (grasp, sucking, rooting, moro)
NIPE EXAMINATION
What is looked for in the eyes examination?
- Red reflex (congenital cataracts, retinoblastoma)
- Movement (visual loss)
NIPE EXAMINATION
What is looked for in the cardiac examination?
- HR 110–160bpm
- Murmur (CHD)
- Femoral pulse (coarctation)
- Central cyanosis (cyanotic CHD)
NIPE EXAMINATION
What is looked for in the hip examination?
- Barlow + Ortolani test (DDH)
NIPE EXAMINATION
What is looked for in the genitalia examination?
- Testes (cryptorchidism)
- Ambiguous genitalia (CAH)
- Genitalia (hypospadias)
- Imperforate anus (bladder/vaginal fistula)
NIPE EXAMINATION
What is the purpose of the NIPE examination?
- Detect congenital abnormalities that were not identified at birth
- Check for potential problems that could arise due to FHx
- Provide opportunity for parents to ask questions about baby
DEVELOPMENTAL STAGES
In terms of gross motor development, what is the age limit for sitting without support
9 months old
DEVELOPMENTAL STAGES
In terms of gross motor development, what is the age limit for walking?
18 months
DEVELOPMENTAL STAGES
In terms of gross motor development, what would you expect for a 6 week old baby?
6 weeks = Lifts head when lying prone + moves it side-side
DEVELOPMENTAL STAGES
In terms of gross motor development, what would you expect for a 3 month old baby?
3 months = Holds head upright when held sitting
DEVELOPMENTAL STAGES
In terms of gross motor development, what would you expect for 6 month old baby?
6 months = Rolls, sits without support (6m = rounded back, 8m = straight back)
Limit age = 9 months old
DEVELOPMENTAL STAGES
In terms of gross motor development, what would you expect for a 10 month old baby?
10 months = Stand independently, cruise around furniture
DEVELOPMENTAL STAGES
In terms of gross motor development, what would you expect for a 12 month old baby?
12 months = Walk unsteadily, broad gait hands apart
DEVELOPMENTAL STAGES
In terms of gross motor development, what would you expect for a 15 month old baby?
15 months = Walks steadily
– Limit age 18m: ?Duchenne’s, ?hip issues, ?cerebral palsy
DEVELOPMENTAL STAGES
In terms of gross motor development, what would you expect for a 3 year old child?
3 years = Jump, stand on 1 leg briefly, pedal tricycle, stairs (1 foot up 2 down)
DEVELOPMENTAL STAGES
In terms of gross motor development, what would you expect for a 4 year old child?
4 years = Hops, balance on one leg for few seconds, stairs like adult
DEVELOPMENTAL STAGES
In terms of gross motor development, what would you expect for a 5 year old child?
5 years = Rides bike, skip on both feet
DEVELOPMENTAL STAGES
In terms of fine motor + vision development, what would you expect for a 4 month old baby?
Reaches for toys
– Limit age = 6 months
DEVELOPMENTAL STAGES
In terms of fine motor + vision development, what would you expect for a 6 month old baby?
Palmar grasp of objects, transfers toys
– Limit age (toys) 9m
DEVELOPMENTAL STAGES
In terms of fine motor + vision development, what would you expect for a 10 month old baby?
mature pincer grip
- limit age = 12 months
DEVELOPMENTAL STAGES
In terms of fine motor + vision development, what would you expect for a 12 month old baby?
Index finger to point, casting bricks (disappear by 18m) + builds 2 brick tower
DEVELOPMENTAL STAGES
In terms of fine motor + vision development, what would you expect for a 2 year old child?
- Vertical line
- 6 brick tower
DEVELOPMENTAL STAGES
In terms of fine motor + vision development, what would you expect for a 2.5 year old child?
Copies circle
8 brick tower or train with 4 carriages
DEVELOPMENTAL STAGES
In terms of fine motor + vision development, what would you expect for a 3 year old child?
draw a circle
copies or makes bridge
DEVELOPMENTAL STAGES
In terms of fine motor + vision development, what would you expect for a 4 year old child?
draws square
makes steps (after demonstration)
DEVELOPMENTAL STAGES
In terms of fine motor + vision development, what would you expect for a 5 year old child?
draw a triangle
DEVELOPMENTAL STAGES
In terms of fine speech, hearing + language development, what would you expect for a 3 month old baby?
Cooing noises, vocalises alone or when spoken to “aa, aa”
DEVELOPMENTAL STAGES
In terms of fine speech, hearing + language development, what would you expect for a 6 month old baby?
Turns head to sounds, understands “bye bye” + “no” (7m), monosyllabic babbles (consonants) “bababa”
DEVELOPMENTAL STAGES
In terms of fine speech, hearing + language development, what would you expect for a 12 month old baby?
Understands names “drink”,
3 words other than “mama” and “dada”
DEVELOPMENTAL STAGES
In terms of fine speech, hearing + language development, what would you expect for an 18 month old child?
6-10 words,
understands nouns “show me the SPOON”
is able to show two body parts, “where is your nose?” - baby will point
DEVELOPMENTAL STAGES
In terms of fine speech, hearing + language development, what would you expect for a 2.5-3 year old child?
- talks constantly in 3-4 word sentences
- understands 2 joined commands “push me fast Daddy”
DEVELOPMENTAL STAGES
In terms of social, emotional + behavioural development, what would you expect for a 6-8 month old baby?
Puts food in mouth,
shakes rattle
DEVELOPMENTAL STAGES
In terms of social, emotional + behavioural development, what would you expect for a 9 month old baby?
Separation anxiety from parent,
stranger fear (until 2y)
DEVELOPMENTAL STAGES
In terms of social, emotional + behavioural development, what would you expect for a 10-12 month old baby?
Waves bye-bye, plays peek-a-boo, claps
DEVELOPMENTAL STAGES
In terms of social, emotional + behavioural development, what would you expect for an 18 month old child?
Uses spoon to feed self
DEVELOPMENTAL STAGES
In terms of social, emotional + behavioural development, what would you expect for an 18-24 month old child?
Extends interest beyond parents (waves at strangers),
parallel play (next to but not with children),
symbolic play (copies actions like feeding a doll),
dry by day,
removes some clothes
CHILD ABUSE
what are the features of shaken baby syndrome
Retinal haemorrhages
Encephalopathy
Subdural haemotoma
