Pedratrics Flashcards
acronym for Infant development milestones?
B.A.B.I,E.S
Infant - birth - 1 year
B - body changes
0 Anterior
fontanelle (
18 months
closure)
0 Posterior ( 2 months of age )
Weight -
A - achieved milestones ( motor & cognitive) B - Baby safety I - interventions E -eating plan S - social stimulation (play)
When do you check a child weight from birth to 11 years ?
Healthy child schedule
- Birth
Up to 2 weeks after birth
- 6 -12 months
- 21/2 years
- 4 - 5 years - primary school entry
- 10 - 11 years - end of primary school.
* babies should be measured more often if there is concern about poor or excessive weight
* excessive frequent weighing is generally unhelpful.
When can BMI be used in children ?
From the second year .
How and why do we measure circumference of head (OFC - Occciptal frontal circumference) ?
Prompt diagnosis of hydrocephalus , mirco/macrocephaly
Possible causes of microcephaly- intrauterine infections, congenital abnormality and developmental concerns.
(small head can be normal )
- Measured at Birth or as soon as head is moulded at delivery.
( measure 3 times - largest reading taken)
GP check - 6 - 8 weeks after birth.
How and why do we measure the weight of a child ?
to check for normal growth and check for no obesity of faltering growth.
What it is the most you would measure a child’s weight if you were concerned (consider the different age groups ) ?
0 Daily if less than (1 month old
Weekly (Between 1–6 months old)
0 Fortnightly (between 6–12 months)
0 Monthly from (1 year of age)
Babies’s weight - physiology
Baby lose weight after being born by 80 % gain it within 2 weeks , some within 3
- assess if more than 10 % is lost- check for :
- signs of illness
- parents know when baby is hungry ?
- Breast fed - do full feeding assessment ( attachment to breast etc)
- Is supplementation required ?
Measurement of height ?
Up to 2 years - supine length - measured on their
back.
Aged over 2 years - height on feet . (unless able to stand - due to disablilty - length should be used. )
Faltering growth - can be endocrine , skeletal, genetic disorders
(e.g Turner’s syndrome , growth hormone deficiency
Rapid growth - precocious (early puberty )
Hydrocephalus ?
Pathway of CSF production & flow ?
Choroid plexus contains ependymal cells —> produce CSF —> Lateral ventricle ——> 3rd ventricles ———> cerebral aqeduct —————-> 4th ventricle —————-> subarachnoid space (but arachnoid and pia matter ) ——————————> Dural sinus - in dura matter
(* arachnoid matter has finger like projection into dura mater so CSF flow from high pressure to low pressure)
What is normal pressure hydrocephalus ?
Primary - idiopathic
Secondary - damage to arachnoid villi ( CSF cannot get out of ventricles into dural sinus - ventricles enlarge/dilate , CSF not reabsorbed & compress nearby structures)
NOTE - pressure normal because ventricles dilate to normalize pressure
- Lateral ventricle - can compress corona radiata - nerve fibers - sensory and motor btw body & cerebral cortex.
e. g. especially those for leg & bladder
- URINARY INCONTINENCE
- GAIT DISTURBANCE
- compress - PERIVENTRICULAR LIMBIC SYSTEM ( limbic system around ventricles - responsible fr emotions, behaviour responses , memory e.g fornix , corpus callosum , pineal gland etc) - DAMAGE - DEMENTIA
- Commonly affect the elderly .
CAUSES - Secondary ( damaged villi )
0 Subarachnoid haemorrhage
0 Meningitis / infection
0 Tumour
0 complications of surgery
Symptoms 3 W *Wet - urinary incontinence *Wobbly - Gait disturbance ( wide based - set far apart and slow) *Wacky - dementia
CT / MRI - enlarged ventricles
Spinal tap / lumbur puncture
Treatment
Short term - lumbar puncture
Long term - Shunt
Aqueductal stenosis ?
Blockage of cerebral aqueduct - e.g pineal tumor
Congenital - malformed aqueduct (Forking )
——————————-> Obstructive hydrocephalus —> ventricles dilate , compresses brain tissue
Headaches Seizures Vomiting Balance disturbance Visual disturbances
Children
- Enlarged head
Developmental delays
Intellectual disability
Investgation - MRI - visualise entire lenght of aqueduct
Treatment - SHUNT - venticuloperitoneal shunt.
Physiotherapy - help develop motor skills.
Neural tube defects?
Spina bifida
Embryology - what structures does the ectoderm derive into ?
Neural tube - forms CNS ( neurons , Gial cells (astrocytes , oligodendrites ) , Posterior pituary , Pineal gland , Retina )
Neural crest cells
C - chromaffin cells ( in adrenal medulla)
R - rostral tissues ( tissues towards head e.g bone , muscles , connective tissue )
E - enteric nervous system
S - satilile cells , schwann cells (glial cells of peripheral nervous system)
T - the PNS (Spinal nerves & ganglion)
C - Carotid bodies (measure conc of o2 and co2)
E - endocardial cushions (helps form spetum & valves)
L - Light skin and dark skin - melanocytes
L - Leptomeningeses - PIA & Arachnoid mater.
Olfactory placode - form roof of nasal cavity - olfactory epithelium
Lens placode - Cillary msucle e.g. far & near vision
OTIC placode - inner ear - cochlea , vestibule , semicircular canals.
Surface ectoderm - epithelial tissue (epidermis nails , hair, sweat glands, lines cavities e.g. nasal (except roof) , oral , external ear canal , inferior anus below pectinate line )
E - epithelial tissue C - CNS The lens pLacode Otic & olfactory placode Dang crest cells E - eyes (retina- part of CNS) RATHKE'S POUCH - becomes anterior pituary gland after budding of epithelial tissue in nasal cavity
M - Melatonin (pineal gland) - CNS .
Gastroenteritis ( Stomach bug) - CHILDREN
Types :
- Viral (most commonly - Rota virus- vomiting really common)-
- Bacterial
* if bloody diarrhea - most likely bacterial rather than viral.
Symptoms
0 diarrhoea -------------------------------> dehydration ( can be severe - signs - reduced skin turgor , prolonged capillary refill , thirst , dry mucous membranes , decreased urine output etc - signs depend on severity) 0 vomiting 0 fever - low grade (viral) - High grade (> 39 - bacterial)
0 Crampy abdominal pain
0 abdominal tenderness
- Mild - viral
- Severe - more likely bacterial.
( abdomen is usually soft , non -distended - if distended suggest underlying malnutrition)
0 hyperactive bowel sounds.
0 decreased body weight - linked to dehydration
- may have mucous in stool.
RF
- under 5
- poor hygiene
- Winter months
- immunodeficiency
- lack of rota virus vaccine.
(given between 8 week and 12 weeks - 2 doses , 4 weeks apart) - lack of breastfeeding / feeding ( lack of fluid intake)
Ask about symptoms (blood , pus , mucus in stool , diarrhoea - how many times , urine output , fluid intake ? , occupation e.g food handler , nursey worker( common in children) , risk factors (inclu . foreign travel , anyone else you have been contact with have the same symptoms. , recent hospital - C.diff)
Stages / categories of dehydration ?
assess skin , capillary refill , state of mucous membranes & eyes , fontanelles.
Signs of mild dehydration include: alert state; slightly decreased urine output; slightly increased thirst; slightly dry mucous membrane; slightly elevated heart rate; normal capillary refill; normal skin turgor; normal eyes; and normal anterior fontanelle.
Signs of moderate dehydration include: alert state, fatigued, or irritable; decreased urine output; moderately increased thirst; dry mucous membranes; elevated heart rate; prolonged capillary refill; decreased skin turgor; sunken eyes; and sunken anterior fontanelle.
Signs of severe dehydration include: apathetic or lethargic state; markedly decreased or absent urine output; greatly increased thirst; very dry mucous membranes; greatly elevated heart rate; prolonged or minimal capillary refill; decreased skin turgor; very sunken eyes; very sunken anterior fontanelle; cold extremities; hypotension; and coma.
Investigation of gastroenteritis ?
Viral - clinical
Bacterial - stool cultures considered , FBC etc.
Serum electrolytes , urea and creatine (ABNORMAL IN SEVERE DEHYDRATION )only really done if severe dehydration and IV therapy needed
ADMIT - if systemically unwell , clinical feature od severe dehydration , shock.
Intractable vomiting (difficult to control) , bilious vomiting (yellow tinge or green - suggests bile present indicating intestinal obstruction).
- acute onset of painful diarrhoea.
- Sepsis ,
- heamolytic uraemic syndrome ( small BV in kidenys become damaged and inflamed) - block kidney filtering can cause kidney failure.
What drugs should you be careful off or aware of reduce efficacy in severe diarrhoea & vomiting ?
Warfarin , anticonvulsants , oral contraceptive pill.
When would you consider Culture , M & S in acute gastronetritis ?
Systemically unwell
- immuncomprimised
- blood , mucus or pus in stool ( suggest desentery - infection of intestines causing diarrhoea containg blood or mucus -maybe E.COLI)
- diarrhoea present afte 7 days
- suspected food poisoning
- travel abroad outside western world ( need to exclude parasite infection - send addition 3 specimens for ova , cyst , parasites)
- age up to 5 and going to school , nursey , child minding etc - risk of E,COLI
Who is at increased risk of being dehydrated ? - CHILD
> 6 or more stools passed in 24 hours > 3 or more vomiting in 24 hours < 1 year , particularly under 6 months - infant - low birthweight - stopped breastfeeding due to illness - signs of malnutrition
Fluid volume requirements for a child ?
0 Weight 0–10 kg: child needs 100 mL/kg fluids per day
( e.g - 5kg -500 ml)
0 Weight 10–20 kg: child needs 1000 mL plus 50 mL/kg for each kg over 10 kg per day.
(15kg - 1000 x 10 = 1000ml + ( 50 x 5 = 250) = 1250ml
0 Weight more than 20 kg: child needs 1500 mL plus 20 mL/kg for each kg over 20 kg per day
(25kg - 1500 + (20 x 5) - 1600 ML /DAY
Treatment of gastroenteritis in primary care ?
- note - children should stay of school until 48hrs after last diarrhea or vomiting.
usual; feeds - including breastfeeding
- regular fluid intake
- offer ORS solution - low osmolality oral dehydration salt if at risk of dehydration.
(not fruit juices , carbonated drinks )
if signs of dehydration but can be safely managed at home :
- Give low-osmolarity ORS solution frequently ,in small amounts, to rehydrate the child.
- Consider supplementation with usual fluids if the child refuses to take sufficient quantities of ORS solution, o red flag symptoms and signs suggesting increased risk of progression to shock).
(AVOID SOLID FOODS UNTIL REHYDRATION)
- ANTIBIOTIC NOT USUALLY GIVEN , IF BACTERICAL SUSPECTED - STOOL CM & S
What is bronchiolitis ?
Inflammation of bronchioles.
MOST COMMON RESPIRATORY TRACT INFECTION IN NEONATES - (mostly affects under 2 years) - commonly confused with symptoms of asthma (mostly over 2 years).
Caused by RSV - respiratory syncytical virus - MOST COMMON
OTHERS - rhinovirus , parainfluenza.
SYMPTOMS
0 Taxhypnoea
0 increased work of breathing e.g. nasal flaring ,
0 abdominal breathing
0 intercostal recessions ( when blockage in airways - pressure in area after blockage decreases so intercostal muscles pull inwards)
0 fever
0 tracheal tug (abnormal downward movement of trachea with in- drawing towards thoracic cavity during inspiration.
0 Wheeze
0 Inspiratory crepitations
SEVERE - infant distress warning signs
- Look unwell (systemically ?)
High or low respiratory rate - can have episodes of apnoea (no breathing - 15 - 20 secs) - oxygen sat below 90 % consitently or below 92 % undr 6 weeks of age or underlying health conditions.
- RR of 77 or over
- Cyanosis or paleness
- difficulty feeding (less than 50 %)
- Grunting - nosy breathing sound to keep air in the lungs
narrowing of airways due to : - excessive mucus secretion - Cell thickening - Smooth muscle contraction (similar to asthma , so bronciolitis can be mistaken for asthma in children around 2 years.
- Air trapping - DIFFICULTY BREATHING inflammation means air can be inhaled but gets trapped in the lower respiratory tract when being exhaled.
NOTE *Bronchitis ( inflammation of the bronchi - normally affects adult smokers)
Pathophysiology - droplets of virus enter through the nasal cavity etc - then travel to bronchioles in the lower respiratory tract an invade the epithelial cells ——————-> cause inflammation ———————> oedema , mucus production by goblet cells , and necrosis of epithelial cells ( to destroy infected cells & regenerate new layer) — cause increased resistance & small airway obstruction.
DIFFERENTIALS
- Acute asthma -
- Viral induced wheeze
(for first two - persistent wheeze without crackles or recurrent episodic wheeze or personal/family HX of atopy) - Pneumonia ( high grade fever > 39 and /or presistently focal crackles ( do not rountinely use CXR - mimics pneumonina )
- Congestive HF
- Pertussis ( whooping cough)
Diagnosis &
Management of Bronchiolitis ?
Coryzal prodome lasting 1-3 days followed by
Presistent cough & tachpnoea or chest recession & wheeze or crackles on ausculation.
SYMPTOMS USALLY PEAK AROUND 3 - 5 days.
If hospital admission not required :
- Advise it is self limiting
( give para or inbu if child has fever and looks distressed) - regular fluid intake
- advise no smoking at home - increases risk of serious illnes sin child.
ANTIBIOTICS , SABA . LABA , CORTICOSTERIODS , ADRENALINE - ARE NOT USED HERE. FOR CHILDREN
SEVERE - under 2
- blood gas testing
- Airway suctioning
(if evidence of airway secretions or apnoea) - Chest physiotherapy ( when relevant comorbidities present e.g musclar dystopy , tracheomalcia)
- Oxyge supplementation ( below 90% , 6 weeks below 92%)
