Paeds - Safeguarding Flashcards
What steps should you take if you have any suspicion of NAI in a child?
- Seek an explanation - from both the carer and the child for any injury / presentation
- Record - what was said, by whom and when and note any concern of NAI and why that is your impression
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Discuss - your concerns with one of the following:
- More experienced colleague
- Peadiatrician
- Designated proffesional for child safeguarding
- Child & adolescent mental health service colleague
- Refer - if there are continuing cues that child maltreatment is occuring then under advisment refer the child/young person to children’s social care
Which organisms are most likley to cause Meningitis for the age range, neonate - 3 months?
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Group B Streptococcus
- Usually acquired from the mother at birth
- More common if; 1) low birth weight babies or 2) following prolonged rupture of the membranes
- E. coli & other Gram -ve organisms
- Listeria monocytogenes
Which organisms are most likley to cause Meningitis for the age range, 1 month to 6 years old?
- Neisseria meningitidis (meningococcus)
- Streptococcus pneumoniae (pneumococcus)
- Haemophilus influenzae
Which organisms are most likley to cause Meningitis for the age range, older than 6 years up to 60 years?
- Neisseria meningitidis (meningococcus)
- Streptococcus pneumoniae (pneumococcus)
What organism can cause meningitis in immunosuppressed patients?
Listeria monocytogenes
What are 5 signs of raised ICP are contraindications to doing a LP to test for meningitis in a child?
Signs of raised ICP:
- Focal neurological signs
- Papilloedema
- Significant bulging of the fontanelle
- Disseminated Intravascular Coagulation (DIC)
- Signs of cerebral herniation
How is meningitis managed in a child?
-
Abx
- < 3 months –> IV amoxicillin + IV cefotaxime
- > 3 months –> IV cefotaxime
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Steroids
- < 3 months –> NO steroids (NICE guidelines)
-
IV Dexamethasone if LP shows any of the following:
- Frank purulent CSF
- CSF WBC count > 1000/μL
- Raised CSF WBC count + protein concentration > 1 g/L
- Bacteria on Gram stain
- Fluids - any shock –> treat with colloid
Why is IV Dexamethasone given in meningitis?
To ↓ risk of neurological sequalae via
anti-inflammatory action
A patient is suspected of having meningitis but is also diagnosed with meningococcal septicaemia - LP or no?
Pt has meningococcal speticaemia = NO LP
do blood cultures + PCR for meningococcus
What subsequent (sequalae) can meningitis cause?
- Sensorineural hearing loss (most common)
- Epilepsy
- Paralysis
- Infective –> sepsis, intracerebral abscess
- Pressure –> brain herniation, hydrocephalus
What are some common features of meningitis?
- headache
- papilloedema
- drowsiness
- decreased / change in conciousness
- neck stiffness
- fever
- purpuric non-blanching rash (particularly with meningococcal disease)
- nausea & vomiting
- photophobia
- seizures
- Kernig’s sign - pt supine, thigh flexed to 90, straightening leg at knee is met with resistance
- Infants: poor feeding, irritability, hypothermia, bulging fontanelle
- Rare: focal neurological deficit, facial palsy, balance problems (CN VIII)
What is ‘Shaken Baby Syndrome’?
Caused by intentional shaking of a child (0-5 years old)
Triad of:
- Retinal haemorrhages
- Subdural haematoma (see pic)
- Encephalopathy
What is meningitis?
An infection of the subarachnoid space which subsequently causes meningeal inflammation
What investigations might you suggest for a pt with suspected meningitis?
- FBC
- CRP
- coagulation screen
- blood culture
- whole-blood PCR
- blood glucose
- ABG or VBG
- Lumbar puncture (if no signs of raised ICP)
If you suspect shaken baby syndrome what agencies need to be contacted?
- Child safeguarding
- Social services (they will contact police if needed)
Which rare metabolic disorder predisposes patients to subdural haematoma (thus needs to be checked for in shaken baby syndrome)?
Glutaric aciduria type 1 (GA1)
- Metabolic disorder causing glutaryl-CoA-dehydrogenase enzyme deficiency
- Predisposed to subdural haematoma
- proposed to be due to stretching of cortical veins secondary to cerebral atrophy & expansion of CSF spaces
What is aplastic anaemia?
Characterised by:
- Pancytopenia (reduced RBC, WBC and platelets)
- Hypoplastic bone marrow (few blood cells vs aplastic which is no cells)
Peak incidence = 30 years old
What are the features of aplastic aneamia?
Features:
- Normochromic, normocytic anaemia
- Leukopenia (lymphocytes relatively spared)
- Thrombocytopenia
- Can be the presenting features of acute lymphoblastic or myeloid leukaemia
What can cause aplastic anaemia?
- Idiopathic
- Infections: parvovirus, hepatitis
- Congenital: Fanconi anaemia, dyskeratosis congenita (DKC)
- Drugs: cytotoxics, chloramphenicol, sulphonamides, phenytoin, gold
- Toxins: benzene
- Radiation
What are the different types of child maltreatment?
- Physical
- Emotional
- Neglect
- Sexual
- Factitious or Induced Injury
What risk factors can increase the likelihood of child abuse?
Split into 1) child risk factors and 2) parental risk factors
Child risk factors:
- Younger child
- Disabled
- Low birth weight
- Multiple siblings
Parental risk factors:
- Younger parental age
- Mental illness
- Drug/ alcohol abuse
- Domestic Violence
- Lower Socio-economic group
- Parents were themselves abused
- Parental criminal history
- Vulnerable and unsupported parent
- Previous child maltreatment in members of the family
- Known maltreatment of animals
What features of a history make an injury more likely to be due to NAI?
- Recurrent injuries
- Injuries inconsistent with child’s age, development and mobility e.g. bruising in non-mobile babies
- No mechanism of injury offered / not consistent with story given
- Delay in seeking medical attention
- Inconsistent histories between carers
- Inappropriate reaction of parents e.g. unconcerned, excessively distressed, aggressive, elusive
What features of fractures might indicate NAI?
- Metaphyseal fractures
- Posterior rib fractures
- Complex skull fractures
- Fractures of different ages
- Long bone shaft fractures in non-mobile child
What features of brusies might indicate NAI?
- Bruises on ; Face, Back, Buttock
- Bruise outlines of particular object e.g. hand, belt
- Pattern of bruising e.g. fingertips
What features of burns might indicate NAI?
- Uniform shape e.g. cigarette burn or lighter top burn
- Glove-stocking distribution
What does this picture show?
Retinal haemorrhages on fundoscopy
from shaken baby syndrome (NAI)
Social services may decide a Child Protection Medical Assessment is required in suspected NAI - what does this involve?
- Carried out by at least registrar level paediatrician (with named consultant)
- Consists of: full history and examination, Growth Chart, Observations, Body Map, Photography, Investigations as appropriate
- Peadiatrician reports on likelihood of injuries being accidental / non-accidental
- CHILD MUST BE QUESTIONED AWAY FROM CARERS!
- VOICE OF CHILD IS CRUCIAL!
What differential diagnoses might there be to NAI for a child with bruising?
Point is - there are LOTS!!
- Accidental injury
- ITP
- Meningococcal Septicaemia
- Henoch Schonlein Purpura
- Mongolian Blue Spot
- Leukaemia
- Haemophilia A
- Christmas disease
- Von Willebrands disease
- Children with hypermobility syndromes eg Ehlers Danlos syndrome (DNA test now available) may bruise more easily
What does this picture show?
Mongolian blue spot
- Also called ‘slate-grey naevi’ or congenital dermal melanocytosis
- Are a pigmented birthmark
What could you include in the differential diagnoses to NAI for a child with fractures?
- Accidental Injury
- Osteogenesis Imperfecta
- Copper Deficiency
- Vit D defiency
- Vit C deficiency
- Ehlers Danlos and other hypermobility syndromes
When is an infant normally weened?
~ 4-6 months of age
From breast fed –> bottle / some solid food
