PEADS PPQ Flashcards
Briefly discuss how participation in sport may positively affect a child’s development. (4)
- Participation in sports is linked to positive attributes towards child development as it allows for
- Better grades
- Improved/better general behaviour
- Lower absenteeism
- Better development of executive fucntion
What are the risk factors for childhood sports injuries? (6)
- Training errors
- Muscullo-tendinous imbalance of strength, flexibility or bulk
- Anatomical malalignment of the lower extremities
- Improper footwear
- Faulty playing surfaces
- Associated pathology of the lower extremities either an old injury or specified pathology or re-injury
- Growth factors
- Nutritional status in a South Africa context-current and during development
Describe the signs of respiratory distress in a young child. (12)
- Tachypnoea- is the first sign of respiratory distress. Infants and young children increase rate of breathing rather than depth of breathing. This must be identified early as rapidly breathing children will eventually tire leading to respiratory arrest.
- Nasal/alar flaring –an attempt to decrease resistance to airflow.
- Grunting- is a sound heard during expiration as an r passes through a partially closed glottis. This is an automatic reaction to respiratory insufficiency, providing the lungs with increased expiratory pressures in order optimise gaseous exchange by splinting airways open.
- Recessions- or retractions are indrawing of the thoracic soft tissues during inspiration due to the very compliant chest wall. They may be subcostal, intercostal, supracostal, suprasternal or substernal.
- Head bobbing may occur in infants, indcaiting use of accessory muscles of respiration.
- Abnormal positioning- includes a refusal to lie down and the child assuming the tripod or sniffing position to instinctively open the airways and use the accessory muscles of ventilation most effectively. Respiratory opisthotonus (extensor posturing of the neck) should not be corrected.
- Expiratory wheeze/prolonged expiration may indicate an inhaled foreign body.
- Stridor- audible sound on inspiration indicating of upper airway obstruction which is a medical emergency.
Dangers of suctioning a non-intubated infant
Infection – use a clean (not sterile) procedure.
Mucosal damage – use an appropriate size catheter, be gentle
Laryngospasm – measure correctly and don’t insert the catheter too far
Aspiration – wait one hour after feeds. NEVER suction the child in supine
Hypoxia – don’t carry on for too long, monitor for signs of respiratory distress increase the oxygen if necessary
Make sure you have everything you need and that the suction unit works before you start suctioning.
Suction pressure should be as low as possible but high enough to clear secretions Suction pressure should be 60-80mmHg for a neonate and 80-100mmHg for a paediatric patient.
Always reassess the child when you have finished suctioning. Re-assess:
✓ Replace O2 mask (if applied)
✓ Reassess outcome measures: vital signs; auscultation and patient comfort
Discuss how you could introduce activity through play into a paediatric orthopaedic ward. (6)
- After completion of objective and subjective assessments to help determine the child’s favourite subject if enrolled to school and favourite sport to play or hobbies. Assuming they have chest problems such in ability to clear secretions effectively, using blow bubbles for PEP or suctioning bread tags from one cup into another using a foldable straw to imitate an incentive spirometer. Then using toys on an elevated bed-side adjustable table to level of clavicle to encourage above head activities with upper extremities if child is on traction. Throwing activities to hit bowling pins to enhance dynamic sitting balance and rhythmic stabilisation with play. Then using my phone to play military trench sounds, educate and facilitate buttocks shuffling or scooting in bed using upper extremities within precaution to promote bed mobility, sense of independence and prevention of pressure sores. If off traction then on the floor i would create an obstacle course with differently shaped bloxks and cylinders thst requires the child to climb, crawl, manoeuvre with bum shuffling to promote creativity, balance training using different heightened blocks, improving proprioceptive input using different terrains for tactile input and sensory stimulation training .
Related precautions of suctioning a non-intubated infant
Infection – use a clean (not sterile) procedure.
Mucosal damage – use an appropriate size catheter, be gentle
Laryngospasm – measure correctly and don’t insert the catheter too far
Aspiration – wait one hour after feeds. NEVER suction the child in supine
Hypoxia – don’t carry on for too long, monitor for signs of respiratory distress increase the oxygen if necessary
Make sure you have everything you need and that the suction unit works before you start suctioning.
Suction pressure should be as low as possible but high enough to clear secretions Suction pressure should be 60-80mmHg for a neonate and 80-100mmHg for a paediatric patient.
Always reassess the child when you have finished suctioning. Re-assess:
✓ Replace O2 mask (if applied)
✓ Reassess outcome measures: vital signs; auscultation and patient comfort
What advice would you give to parents on what they can do to increase their children’s levels of physical activity? (4)
Basic principles
* Sleep : 0-3 months old=14-17 hours; 12-16 months old=12-16 hours; 1-2 y/o=11-14 hours of sleep; 3-5 y/o=10-13 hours of sleep
* Limit screen time, 0-18 months no screentime; 18-24 months <1 hour; 2-5 y/o 0-3 hours; 6-17 y/o is 2 hours; >18 y/o 2-4 hours of screen time.
* Encourage physical activity by following the 24-hour movement guidelines Woza Mntwana
* Participation in competitive sports and organised community sports
* Play a game of basketball
* Walk a dog
* Dance to their favourite song
* Jump rope
* Ride a bicycle
* Remove TV sets from child’s bedroom
What factors would you consider when choosing a developmental screening tool? (10)
- Age Range and Developmental Domains: Choose a screening tool that is appropriate for the child’s age and covers the relevant developmental domains. These domains typically include areas like communication, gross motor skills, fine motor skills, problem-solving, and social-emotional development.
- Validity and Reliability: The screening tool should have demonstrated validity (measuring what it’s intended to measure) and reliability (consistency of results) through research and testing. Look for tools that have been validated and standardized on diverse populations.
- Cultural Sensitivity: Ensure that the tool is culturally sensitive and applicable to the population being assessed. Consider the child’s cultural background, language, and family dynamics to choose a tool that respects diversity.
- Ease of Administration: The tool should be easy for professionals to administer and score. It should also be user-friendly for parents or caregivers who might be involved in the assessment process.
- Accessibility: Choose a tool that is readily available and accessible. This includes availability of materials, training resources, and support for using the tool effectively.
- Sensitivity and Specificity: A good screening tool should strike a balance between sensitivity (ability to correctly identify children with developmental concerns) and specificity (ability to correctly identify children without developmental concerns). High sensitivity and specificity contribute to accurate identification of children who may need further evaluation.
- Ease of Interpretation: The results of the screening tool should be easy to interpret. Clear guidelines should be provided for determining whether a child’s developmental skills are within the expected range or if further assessment is needed.
- Standardization: The screening tool should have established normative data to compare a child’s performance against the average developmental milestones for their age group.
- Administrative Time: Consider the time required to administer the tool. While some tools can be completed quickly, others may take longer, which can affect the feasibility of using the tool in different settings.
Write short notes on three of the following common neonatal conditions. (9)
- Meconium aspiration- this occurs in gestation when the foetus breaths in faeces and amniotic fluid which leads to aspiration. This occurs before delivery. The results of this include alveoli collapse, difficulty breathing leading to respiratory distress. PT management of this includes chest clearance techniques, positioning and suctioning to clear the foreign material in the lung tissue.
- Pulmonary air leak- escape of air from the lungs to the extrapulmonary space where air is not normally found. Common in conditions such as pneumothorax or pulmonary interstitial emphysema, usually begins with a rupture of over-distended alveolar due to air trapping. Common in infants. Symptoms include sudden chest pain and SOB. PT management includes positioning and mobilising.
- Congenital diaphragmatic hernia- occurs when a gap forms in the sheet of muscle (diaphragm) causing the bowel, stomach and liver to move into the chest cavity. It is likely to be accompanied by under-developed lungs leading to reduced lung capacity and volume leading to breathing difficulties/problems. Child likely to have pulmonary hypoplasia and pulmonary hypertension. PT management aims to improve lung volumes, FRC, mucociliary escalator function and increase gaseous exchange.
- Oesophageal atresia- a birth defect characterised by underdeveloped oesophagus, it forms as a pouch instead of a connecting tube to the stomach. It can lead to coughing or choking, difficulty breathing, reflux and pneumonia. PT management includes positioning and chest clearance and lung squeeze.
- Gastoschisis and omphalocoele- Defects of the abdominal wall resulting in herniation of intestines from abdominal cavity and this can be detected prenatally. They will experience feeding difficulties, failure to thrive and reflux and respiratory distress.PT management includes positioning, facilitating milestones, chest clearance.
Explain why adolescent girls are at higher risk of ACL and lateral ankle ligament injuries than adolescent boys. (6)
Postulated to be due to:
* Anatomical variances- increased Q-angle, dropped navicular bone and excessive pronation.
* Hormonal status- testosterone is converted into oestrogen in fat cells increasing susceptibility to osteopenia thus resulting in stress fractures.
* Neuromuscular control differences
* Biomechanical variances- i.e. landing mechanics and muscle strength
* Guessing: girls mature faster than boys as they usually have their growth spurts at 11-17 years. The growing cartilage (elbow (osteochondritis), knee, ankle) has low resistance to repetitive trauma or shear and impact forces- micro trauma to cartilage or underlying growth plate. The shear or fracture can lead to epiphyseal displacement (the apophysis becomes weaker during the growth phase, long bones elongate/grows quicker than soft tissue which results in relative stretching of the musculotendinous structures). There is a relative loss of flexibility and a tightening of these structures. Thesse structures are loaded in a lengthened position. Thus therapy would focus in improving techniques and training.
List the benefits of Kangaroo Mother Care. (10)
Kangaroo mother care (KMC) is a method of caring for preterm or low birth weight infants by providing skin-to-skin contact between the baby and the parent, typically the mother. This approach offers numerous benefits for both the baby and the parents. Some of the key benefits of Kangaroo Mother Care include:
1. Thermoregulation encourages less hypothermia
2. Regulates and stabilises heart rate and respiratory rate (Cristóbal Cañadas et al., 2022)
3. Decreased risk of nosocomial infections
4. Improved sleep
5. Decreased mortality
6. Improved breastfeeding: improved lactation of the infant and increased milk production in the mother (Cristóbal Cañadas et al., 2022)
7. Decreased hospital length of stay
8. Enhances growth with positive effects on neurological, cognitive, emotional, behavioural and social development in the short and long term (Cristóbal Cañadas et al., 2022)
9. Improved oxygen saturation and respiratory rate with Higher SaO2, fewer desaturations (Cristóbal Cañadas et al., 2022)
10. Procedural pain is less in premature infants
- Temperature Regulation: Skin-to-skin contact helps regulate the baby’s body temperature, reducing the risk of hypothermia that is common among premature infants.
- Stabilised Heart Rate and Breathing: KMC has been shown to help stabilise the baby’s heart rate and breathing patterns, leading to better overall cardiorespiratory stability.
- Improved weight gain: Babies receiving KMC tend to gain weight more rapidly due to improved breastfeeding success and nutrient absorption.
- Enhanced Bonding: The close physical contact fosters a strong emotional bond between the parent and the baby, promoting a sense of security and comfort.
- Breastfeeding Promotion: KMC encourages early and exclusive breastfeeding, as the baby is in close proximity to the mother’s breast, making it easier to initiate and maintain breastfeeding.
- Increased milk supply: Regular breastfeeding and close contact with the baby can stimulate te mother’s milk production, leading to an increased supply of breast milk.
- Reduced infections: the skin-to-skin contact has been associated with decrease in hospital-acquired infections in premature babies.
- Improved Brain Development: The calming effects of KMC and the parent’s heartbeat may contribute to improved brain development and neurological outcomes for premature infants.
- Reduced Stress: The soothing touch and presence of the parent can help reduce stress levels for both the baby and parent, leading to improved overall well-being.
- Shorter Hospital Stays: Babies receiving KMC often have shorter hospital stays compared to those who do not, as they tend to show better weight gain and overall health.
Based on pathophysiology and clinical presentation of respiratory distress syndrome (RDS), justify why chest physiotherapy is not indicated for infants with RDS.(10)
Respiratory Distress Syndrome (RDS), also known as hyaline membrane disease, primarily affects premature infants due to their underdeveloped lungs and insufficient production of surfactant—a substance that helps keep the alveoli (tiny air sacs in the lungs) open. RDS leads to significant respiratory compromise, with symptoms including tachypnea (rapid breathing), grunting, nasal flaring, retractions (visible sinking of the skin between the ribs), and cyanosis (bluish discoloration of the skin).
Chest physiotherapy involves techniques such as percussion, vibration, postural drainage, and breathing exercises to assist in clearing excess mucus and promoting better lung function. However, in the case of infants with RDS, chest physiotherapy is generally not indicated for several reasons:
* Fragile Lung Tissue: Premature infants with RDS have extremely delicate and fragile lung tissue. The alveoli are prone to collapse and damage due to their lack of surfactant. The application of forceful techniques like percussion and vibration could potentially cause harm by further damaging these fragile structures.
* Risk of Barotrauma: Infants with RDS often require mechanical ventilation or oxygen therapy to support their breathing. Their lungs are susceptible to barotrauma, which refers to lung injury caused by excessive airway pressure. Chest physiotherapy, especially if performed inappropriately or excessively, could increase the risk of barotrauma and worsen the existing respiratory compromise.
* Potential Discomfort: Newborns and premature infants are highly sensitive to external stimuli. The physical manipulation involved in chest physiotherapy could cause discomfort, stress, and even pain for the already distressed infants, potentially leading to an increase in oxygen consumption and worsening of their respiratory status.
* Lack of Evidence: The effectiveness of chest physiotherapy in infants with RDS is not well established. Studies have shown mixed results, and the potential benefits of these techniques may not outweigh the risks and uncertainties, especially given the vulnerable state of the premature lungs.
* Alternative Treatment Focus: The primary focus in managing RDS is to provide respiratory support, stabilize oxygen levels, and administer exogenous surfactant if necessary. The mainstay of treatment includes providing mechanical ventilation, maintaining a stable oxygen environment, and addressing any underlying issues contributing to the respiratory distress.
Explain why children are at risk for apophyseal avulsion factures. (4)
- The growing cartilage (elbow (osteochondritis), knee, ankle) has low resistance to repetitive trauma or shear and impact forces- micro trauma to cartilage or underlying growth plate.
- The shear or fracture can lead to epiphyseal displacement.
- The apophysis becomes weaker during the growth phase, long bones elongate/grows quicker than soft tissue which results in relative stretching of the musculotendinous structures.
- There is a relative loss of flexibility and a tightening of these structures. These structures are loaded in a lengthened position. Thus, therapy would focus in improving techniques and training.
Discuss how you could introduce activity through play into a paediatric burn unit. (6)
- After completion of objective and subjective assessments to help determine the child’s favourite subject if enrolled to school and favourite sport to play or hobbies.
- Assuming they have chest problems such in ability to clear secretions effectively, using blow bubbles for PEP or suctioning bread tags from one cup into another using a foldable straw to imitate an incentive spirometer.
- Then using toys on an elevated bed-side adjustable table to level of clavicle to encourage above head activities with upper extremities if child is on traction.
- Throwing activities to hit bowling pins to enhance dynamic sitting balance and rhythmic stabilisation with play.
- Then using my phone to play military trench sounds, educate and facilitate buttocks shuffling or scooting in bed using upper extremities within precaution to promote bed mobility, sense of independence and prevention of pressure sores.
- then on the floor i would create an obstacle course with differently shaped bloxks and cylinders thst requires the child to climb, crawl, manoeuvre with bum shuffling to promote creativity, balance training using different heightened blocks, improving proprioceptive input using different terrains for tactile input and sensory stimulation training.
- 4-point puppy prone if hands are clear and assuming lower extremities can bend to 90 degrees. For UL the child would use horizontal flexion and trunk rotation to take objects from contralateral side of body to the ipsilateral side this would improve core strength, balance, WS & WB, for the lower extremities fire hydrant kick backs and hip abduction would allow for improved hip extension and abduction AROM required for improving cadence, stride length, gait pattern for pelvic-trunk dissociation when walking to bathroom or to the car on DC.
- Gait retraining starting off with a walking frame to enhance BoS and improve confidence with walking with support.
- From chosen sports or hobbies we would play games such as soccer for static and dynamic balance training with rhythmic stabilisation by kicking the ball forward, side-ways, backwards.
- for standing UL above head play we would do basketball/netball or soccer throw ins to hit bowling pins. Also wall creeps/spider-man climbs to improve shoulder flexion and abduction AROM and strength with activity.
- All these activities need be done in moderation and within precaution respecting pain.
Explain why babies in respiratory distress often have intercostal recessions. (5)
Babies in respiratory distress often exhibit intercostal (ribcage) retractions or recessions due to the increased effort required for breathing. Intercostal recessions occur when the muscles between the ribs, known as the intercostal muscles, are forced to contract more forcefully than usual to assist in expanding the chest during inhalation. This phenomenon is a sign that the baby is struggling to move air in and out of their lungs effectively. Here’s why intercostal recessions occur in babies with respiratory distress:
* Underdeveloped Muscles: Premature babies or infants with certain respiratory conditions may have underdeveloped or weaker muscles, including the diaphragm and intercostal muscles. This weakness makes it harder for them to generate the necessary negative pressure in the chest to draw air into the lungs during inhalation.
* Obstruction or Resistance: In respiratory distress, there might be obstructions or increased resistance within the airways, making it difficult for air to flow freely into the lungs. This can happen due to conditions like bronchiolitis, pneumonia, or other respiratory infections. The intercostal muscles are recruited to assist in overcoming this resistance and pulling the ribs upward to create more space for the lungs to expand.
* Increased Effort: Babies with respiratory distress need to exert extra effort to move air in and out of their lungs due to compromised lung function. This can result from conditions like respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), or meconium aspiration syndrome, where the lungs are not able to inflate fully or have difficulty maintaining proper oxygen and carbon dioxide exchange. The intercostal muscles work harder to lift the chest wall and create a larger volume in the chest cavity, attempting to enhance air entry into the lungs.
* Negative Pressure Breathing: Normally, during inhalation, the diaphragm contracts and the intercostal muscles relax. This increases the volume of the chest cavity, creating a negative pressure that draws air into the lungs . In cases of respiratory distress, the intercostal muscles might be utilized more intensively to support the weakened diaphragm, causing visible retractions between the ribs during inhalation.
* Sign of Struggle: Intercostal recessions are a visible indicator that a baby is having difficulty breathing. Healthcare professionals can recognize these retractions as a clear sign of respiratory distress and the need for intervention. It helps them assess the severity of the baby’s condition and decide on appropriate treatments or interventions.
List three indications and three contraindications for chest physiotherapy in neonates. (6)
Describe some of the complications that are seen post fracture in children which are preventable with optimal management. (10)
- Malunion or Growth Disturbance: If a fracture is not aligned properly during the healing process, it can lead to malunion, where the bone heals in a deformed position. This can also disrupt the growth plate, leading to growth disturbance in the affected bone. Optimal management involves accurate reduction of the fracture (realignment) and appropriate immobilization, which can prevent malunion and minimize growth disturbance risks
- Delayed Union or Nonunion: Fractures typically heal within a certain timeframe. However, if the healing process is delayed or the bone fails to heal completely, it’s known as delayed union or nonunion. Optimal management involves assessing the stability of the fracture, providing proper immobilization, and monitoring the healing progress through regular follow-up visits. In some cases, surgical intervention might be necessary to stimulate bone healing.
- Infection: Inadequate wound care or improper pin or wire placement (in cases of surgical intervention) can lead to infection at the fracture site. Optimal management includes maintaining proper hygiene, careful wound care, and using sterile techniques during surgical procedures to reduce the risk of infection.
- Compartment Syndrome: This occurs when swelling within the muscles and tissues becomes excessive after a fracture, leading to increased pressure within a confined space (compartment). It can result in reduced blood flow and damage to nerves and muscles. Optimal management involves careful monitoring of swelling, timely elevation of the affected limb, and, in severe cases, surgical intervention to relieve pressure.
- Nerve or Blood Vessel Injury: Fractures, especially those involving displaced bone fragments, can potentially injure nearby nerves or blood vessels. Optimal management requires careful examination to assess for any signs of nerve or vascular compromise and adjusting the treatment plan accordingly. Surgical intervention may be necessary to repair damaged structures.
- Joint Stiffness: Immobilization during fracture healing can lead to joint stiffness if not managed properly. Physical therapy and controlled range-of-motion exercises, guided by a healthcare professional, can help prevent joint stiffness during the healing process.
- Psychological Impact: Fractures can have a psychological impact on children, affecting their confidence and emotional well-being. Optimal management includes providing proper emotional support, explaining the treatment process in a child-friendly manner, and involving them in their own care.
- Osteomyelitis: This is a bone infection that can occur as a complication of an open fracture or a fracture-related surgery. Proper wound care, appropriate antibiotic treatment, and vigilant monitoring can help prevent osteomyelitis.
- Overuse Injuries: After the fracture has healed, returning to regular activities too quickly or engaging in high-impact activities before proper strength and bone density is regained can lead to overuse injuries. Optimal management involves guiding children through a gradual return to physical activities and ensuring they understand their limitations during the recovery period.
- Allergic Reactions or Irritations: Materials like casts, splints, or dressings can cause skin irritation or allergic reactions in some children. Optimal management involves choosing hypoallergenic materials and ensuring proper padding and protection to prevent skin issues.
Non-preventable: - Avascular necrosis
- physeal injuries
Write short notes on skeletal system development from prenatal to adolescence and comment on the injuries which are common at each stage. (12)
Components of the skeletal system include cartilage, bone, and joints
Skeletal system development:
Prenatal period
* Ossification is seen from the 5th week post conception and starts in the upper extremity.
Infancy and childhood
* Time of bone growth modelling and remodelling
* Secondary ossification centres in the epiphyses continue throughout childhood and adolescence.
* Genetics, nutrition, health status and hormonal levels affect growth rate
Adolescence
* Bone continues to grow and remodel in response to loading stresses.
* Growth spurt in girls begins at 12-13 years of age, boys at 14-15.
* Bone growth may exceed muscle growth resulting in decreased flexibility.
* Deformities eg scoliosis may become more apparent.
Age related skeletal concerns related to physical activity
* Prenatal: Intrauterine moulding late in gestation
* Newborn: Epiphyseal infection
* Childhood:
o Epiphyseal injury
o Apophyseal avulsion
o Greenstick fractures
* Adolescence:
o Scoliosis
o Epiphyseal injury
o Apophyseal avulsion
o Stress fractures
Skeletal maturity
* Attained when the epiphyseal plates close
* Usually complete by 25 years of age.
* Occurs earlier in girls than boys.
Discuss three of the myths that have plagued paediatric pain management. (9)
Explain why premature infants are at high risk of having neurological sequelae. (10)
Explain why a decrease in respiratory rate may be a red flag in an infant with a respiratory tract infection. (3)
- Falling respiratory rate or gasping are considered alarm bells because one of the first signs of respiratory distress is tachypnoea. Infants and young children first increase the rate rather than the depth of breathing. This must be recognised early as rapidly breathing children will eventually tire leading to respiratory arrest.
Explain why manual chest physiotherapy must be done with extreme care in premature infants. (10)
in addition to multiple sequelae of their underdeveloped bodies and being in the hospital setting, Chest physiotherapy can result in a number of complications,depending on the type application
Chest Techniques like Percussions may predispose child to shaken baby syndrome
They have very compliant chest chest wall might lead collaple
The ribs are fragile and may result in rib fracture
There can also be development of other complications like, apnea, hypoxia, intracranial haemorrhages and pneumothoraces
Explain why children with meningitis are at high risk of neurological complications. (5)
Differentiate between periventricular leukomalacia, intraventricular haemorrhage and periventricular haemorrhagic infarction. (15)
· 1. Periventricular leukomalacia
·
· Necrosis of white matter around the ventricals
· Caused by poor blood flow to the area
· Presents days to weeks after birth
· Associated with prematurity, cardiovascular disturbance, infection, ventilation
· May result in CP- especially spastic diplegia
- Intraventricular haemorrhage
· Appears in the 1st week of life
· Strongly associated with prematurity
· Bleeding from the fragile germinal matrix into the lateral ventricals
· Mild bleeds (gr1 and 2) usually resolve but more extensive bleeds (gr3 and 4) extend into the surrounding tissue and cause damage- may result in CP (spastic diplegia) - Periventricular haemorrhagic infarction
· Haemorrhagic necrosis in the white matter around the ventricals
· Often associated with IVH and a problem with venous circulation
· Onset within 72 hrs
· Is a strong predictor of disability
