WEEK 5 - DEVELOPMENTAL & ENT Flashcards
7 Key Points?
- What is the most common cause of a neonate to fail their newborn hearing screen?
- What is the most common neonatal eye condition?
- What is the the most common eye problem affecting children?
- What is the single most common isolated developmental disorder?
- 5 Domains of Development?
- 4 Differentials for Hearing impairment?
- 5 Differentials for Floppy Infant?
- 2 Differentials for Isolated Developmental Delay?
- 4 Differentials for Global Developmental Delay?
CAHS Guidelines - General Movement Assessment
- What is the Role of General Movement Assessments?
- 2 Stages?
- Sensitivity of GM assessments?
- Early identification of babies at increased risk of movement problems enables closer monitoring and earlier intervention. Having normal general movements in the face of an abnormal USS/MRI can also give some reassurance regarding normal motor
outcomes. - Risk: Failure to identify babies at increased risk may lead to delayed interventions.
- Observation of the quality of spontaneous movements (also known as general movements, GM) of preterm and term infants can provide information on likely future motor function, in particular cerebral palsy. The results of brain MRI in ex-preterm
infants at term age and GM assessment have been shown to have complementary roles.
CAHS Guidelines - General Movement Assessment
- 8 Potential Infants for GM Assessment?
- How are General Movements Assessed?
- What does an Abnormal Assessment at 3 Months Mean?
- Outcome of Abnormal Assessment at 3 Months Corrected Age (Absent Fidgety Movement)?
Potential Infants for GM Assessment
1. Grade 3 or 4 IVH.
2. Significant post haemorrhagic hydrocephalus.
3. Cystic PVL.
4. Significantly abnormal MRI (mod severe WMA or mod-severe cerebellar abnormality).
5. Significant neurological concern from
6. Neonatal Team (e.g. meningitis with abnormal MRI).
7. HIE stage 2 or 3.
8. Other neonatal encephalopathy
CAHS Guidelines - Newborn Hearing Screening
- What is the Process for Screening Infants within Neonatology?
- When does it occur?
- What happens if they do not pass?
CAHS Guidelines - Newborn Hearing Screening
- 9 Risk Factors for Neonatal Screening Abnormalities?
PCH ED Guidelines - Acute Agitation & Behavioural problems
- What should ED staff do?
- De-escalation techniques?
PCH ED Guidelines - Acute Agitation & Behavioural problems
- Initial management of Acute Agitation?
- Physical restraint?
PCH ED Guidelines - Acute Agitation & Behavioural problems
- Oral Sedation?
- Intramuscular sedation?
PCH ED Guidelines - Acute Agitation & Behavioural problems
- IV Sedation?
- Medication Side effects? Antidotes?
Intravenous sedation
- Midazolam: Dosing as per IM administration (see above).
- This medication works rapidly and can be titrated to achieve the desired clinical response.
- Dosages can be repeated after 5 minutes.
- Droperidol: Dosing as per IM administration (see above)
RCH Guidelines - Cerebral Palsy
- What is Cerebral Palsy?
- Presentation?
- 5 Associated Disorders?
Cerebral palsy is a persistent but not unchanging disorder of movement and posture due to a defect or lesion of the developing brain. It is accepted that children up to five years, who acquire permanent motor impairment due to non-progressive neurological insults, have cerebral palsy. There are many causes, a wide range of manifestations of the motor disorder and various associated problems.
*Cerebral palsy is not a single disorder but a group of disorders with diverse implications for children and their families.
RCH Guidelines - Cerebral Palsy
- Management Step 1 - Accurate diagnosis and genetic counselling?
RCH Guidelines - Cerebral Palsy
- Management Step 2 - Associated disabilities?
- Health problem?
- Consequences of the motor disorder?
- 5 Options for Spasticity management aims to improve function?
Spasticity management aims to improve function, comfort and care and requires a team approach. Options include:
1. Oral medications, for example, diazepam, dantrolene sodium and baclofen.
2. Inhibitory casts, for example, below knee casts increase joint range and facilitate improved quality of movement.
3. Botulinum toxin A reduces localised spasticity.
4. Intrathecal baclofen is suitable for a small number of children with severe spasticity and may enhance quality of life.
5. Selective dorsal rhizotomy is a neurosurgical procedure whereby anterior spinal roots are sectioned to reduce spasticity.
RCH Guidelines - Cerebral Palsy
- 3 Common presentations to the emergency department?
Common presentations to the Emergency Department
1. Respiratory problems particularly pneumonia
2. Uncontrolled seizures / status epilepticus
3. Unexplained irritability - consider acute infections, oesophagitis, dental disease, hip subluxation, pathological fracture. Review medications
RCH Guidelines - Autism and developmental disability: Management of distress/agitation
- 4 Key Points?
- 3 Behavoiurs autistic children may exhibit?
Key points
1. The parents, carers and/or child should be able to advise on what techniques have previously worked well to minimise distress.
2. Maintain a low stimulus environment wherever possible.
3. Assume the child with acute distress may have an underlying medical issue, until proven otherwise. Repeated examinations may be required.
4. Avoid unnecessary distress through repeated interventions (eg venepuncture) and plan thoroughly ensuring all investigations are performed together.
RCH Guidelines - Autism and developmental disability: Management of distress/agitation
- Algorithm for the management of a Child with Autism presenting with distress/agitation?
PCH ED Guidelines - Otitis Externa
- What is Otitis Externa?
- History?
- Examination?
Otitis externa is an infection of the external ear canal. It is also referred to as ‘swimmer’s ear’.
Assessment
- Key features include ear pain and discharge.
- No investigations are generally required. However, consider ear swabs if recurrent episodes or no response to treatment.
History - Common symptoms of otitis externa are:
1. Ear pain
2. Conductive hearing loss
3. Feeling of fullness (blockage) or pressure
4. Itchiness
5. +/- discharge.
PCH ED Guidelines - Otitis Externa
- Investigations?
- 1 Differential Diagnoses?
- Management?
- Prophylaxis?
- Complications?
Investigations - Ear swabs are not required for simple otitis externa, they are unhelpful as the organisms grown on culture may or may not be true pathogens. Ear swabs should be performed for patients with recurrent otitis externa, who are immunocompromised or did not respond to treatment.
Differential diagnoses - Otitis media with rupture of the tympanic membrane.
Management - Analgesia is the most important aspect of management. Topical treatment should be used instead of oral antibiotics (topical antibacterial/corticosteroid combinations are usually first line).
PCH ED Guidelines - Otitis Media
- What is Otitis Media?
- 3 Separate Clinical Entities?
Otitis media is an infection of the middle ear cavity. Otitis media can be divided into 3 separate clinical entities that are managed differently.
1 - Acute Otitis Media (AOM)
- This is a common cause of children presenting to a GP or an emergency department.
- Peak age is 6-18 months and almost all children have at least one episode.
- The underlying cause can be viral, bacterial or both in combination.
- Bacterial causes can include Streptococcus pneumoniae, Haemophilus influenza and Moraxella catarrhalis.
- The diagnosis of AOM is not always clear, particularly in the infant.
PCH ED Guidelines - Otitis Media
- 5 Risk factors/ At-risk groups?
- Assessment?
- History?
- Examination?
- Investigations?
Risk factors and At-Risk Groups
1. Low socio-economic status
2. Aboriginal and Torres Strait Islander
3. Immunocompromised
4. Down syndrome
5. Other risk factors may include cigarette smoking and attending day care
Assessment - Otoscopy must be performed in all children. No investigations are required.
PCH ED Guidelines - Otitis Media
- Management?
Guidelines for Otitis Media in Aboriginal & Torres Strait Islander Children
Guidelines for Otitis Media in Aboriginal & Torres Strait Islander Children
- Diagnosis & Management of Persistent bilateral or unilateral OME?
Guidelines for Otitis Media in Aboriginal & Torres Strait Islander Children
- Diagnosis & Management of AOM without perforation (AOMwoP)?
Guidelines for Otitis Media in Aboriginal & Torres Strait Islander Children
- Diagnosis & Management of Recurrent AOM (rAOM)?
Guidelines for Otitis Media in Aboriginal & Torres Strait Islander Children
- Diagnosis & Management of AOM with perforation (AOMwiP)?
Guidelines for Otitis Media in Aboriginal & Torres Strait Islander Children
- Diagnosis & Management of Chronic
Suppurative OM (CSOM)?
Guidelines for Otitis Media in Aboriginal & Torres Strait Islander Children
- Diagnosis & Management of Dry
Perforation (DP)?
Guidelines for Otitis Media in Aboriginal & Torres Strait Islander Children
- Diagnosis & Management of Tympanostomy Tube Otorrhoea (TTO)?
Developmental follow-up of children and young people born preterm: summary of NICE guidance?
Developmental Red Flags Early Identification Guide
Developmental Red Flags Early Identification Guide
DEVELOPMENTAL MILESTONES - Gotta Find Strong Coffee Soon?
PURPLE crying acronym?
Clinical Practice Points on the diagnosis, assessment and management OF ADHD in children and adolescents
- What are the core symptoms?
- Diagnostic criteria?
Clinical Practice Points on the diagnosis, assessment and management OF ADHD in children and adolescents
- What causes ADHD?
- Does the presentation vary with age and over time?
Clinical Practice Points on the diagnosis, assessment and management OF ADHD in children and adolescents
- How common is ADHD?
- Prognosis?
Clinical Practice Points on the diagnosis, assessment and management OF ADHD in children and adolescents
- Subtypes of ADHD?
- Can young children (under 7 years) be diagnosed with ADHD?
Clinical Practice Points on the diagnosis, assessment and management OF ADHD in children and adolescents
- What is involved in the Initial assessment?
- General Principles of Management?
Clinical Practice Points on the diagnosis, assessment and management OF ADHD in children and adolescents
- What is the GP’s role in management?
- Psychological management?
Clinical Practice Points on the diagnosis, assessment and management OF ADHD in children and adolescents
- How does the Psychological management differ for Young (under 7 years) and school aged (6-12 years) children? Adolescents? Aboriginal and Torres Strait Islander children and adolescents?
Aboriginal and Torres Strait Islander children and adolescents
There is scant evidence for psychosocial interventions in Aboriginal and Torres Strait Islander communities. The evidence that is available suggests that parent-training programs that have been culturally tailored to Aboriginal and Torres Strait Islander communities (e.g. a variation of the Group Triple P) are culturally acceptable and can have positive outcomes in terms of reducing children’s challenging behaviours and
parent’s reliance on some dysfunctional parenting practices.
Clinical Practice Points on the diagnosis, assessment and management OF ADHD in children and adolescents
- Pharmacological Management?
Clinical Practice Points on the diagnosis, assessment and management OF ADHD in children and adolescents
- What factors should be considered before a child/adolescent starts taking stimulant medication?
- What are the adverse effects of stimulant medications?
Clinical Practice Points on the diagnosis, assessment and management OF ADHD in children and adolescents
- Outline the monitoring and review of children with ADHD on stimulant treatment?
Clinical Practice Points on the diagnosis, assessment and management OF ADHD in children and adolescents
- Combination treatment?
- Educational management?
- 10 Other therapies for which there is currently no evidence to support?
Other therapies - Current evidence does not support the use of the following treatments:
1. elimination or restriction diets
2. diet supplementation with essential fatty acids (e.g. fish oils)
3. chiropractic treatment
4. behavioural optometry
5. biofeedback (including neurofeedback)
6. homeopathy
7. acupuncture
8. physical activity
9. massage
10. sensory integration therapies.
RCH Guidelines - Autism spectrum disorder
- What is Autism Spectrum Disorder?
- Signs and symptoms – How does ASD present?
- What other problems can arise for children with ASD? (9)
There are a range of conditions that may occur alongside ASD. They include:
1. Attention Deficit Hyperactivity Disorder (ADHD)
2. Global Developmental Delay
3. Intellectual Disability
4. Anxiety and mood disorders
5. Challenging behaviour
6. Learning difficulties
7. Motor co-ordination difficulties
8. Eating and sleeping difficulties.
9. Medical and genetic disorders such as Fragile X Syndrome
RCH Guidelines - Autism spectrum disorder
- What Support should be offered to children with ASD?
- When to see a doctor?
- 4 Key points?
Key Points
1. A child with ASD usually has difficulties in two main areas: social communication and repetitive behaviour.
2. If you are concerned about your child, see your GP and ask for a referral to a specialist psychologist or pediatrician. Do not try to make a diagnosis yourself.
3. No two children with ASD show exactly the same signs and symptoms. Because the symptoms can vary so much, there is no single test for ASD.
4. Treatment varies for each child and family and usually changes over time.
NDIS Eligibility Checklist? (6 points)
Outline an approach to diagnosis in a child with school and social difficulty?
List some checklists for assessing paediatric developemental concerns?
What is the prevalence and consequences of Otitis Media in the Indigenous population?
- Living conditions remote communities provide an environment conducive to early onset bacterial colonisation of upper airways
- Primary aim of management to control disease , so that hearing maintained and prevent perforations of TM
- Vaccination doesn’t substantially reduced complicated OM but may reduce rate of tympanic perforation
- Long term AB’s (6 month)deceased prevalence of tympanic perforation but not OME
- Hearing aids/amplification poorly accepted
- Little difference in ear disease between desert and tropical communities
What are the 3 types of OM?
What is Acute OM? Types? Most reliable indicators of Acute OM?
What is Otitis Media with Effusion?
- Most reliable indicators of OME?
What is Chronic Suppurative Otitis Media (CSOM)?
What is this?
Mastoiditis = Infection of the mastoid air cells of the mastoid bone (behind the middle ear).
What is this?
= Cholesteatoma
- destructive and expanding growth
- consisting of keratinizing squamous epithelium in the middle ear and/or mastoid process.
- Not strictly speaking tumours or cancers but cause significant problems
- erosive and expansile properties resulting in the destruction of the ossicles (hearing loss) as well as their possible spread through the base of the skull into the brain.(meningitis/brain abscess)
What are the principles of management of Otitis Media?
- Education? (9)
Education
- Anticipatory Guidance- educate expectant mothers
- Encourage Early Interventions- educate re symptoms, hearing loss, early attendance at clinics
- Breast feeding at least 6 months
- Personal hygiene frequent hand washing/nasal secretions
- Vaccination pneumococcal conjugate vaccine
- Pacifier after 6 months increases OM
- Swimming should not be discouraged
- Smoking
- Bottle feeding in an upright position
What is the medical management of:
- Episodic OME?
- Persistent OME?
What is the medical management of:
- AOM woP (without perforation)?
- AOM wiP (with perforation)?
What is the medical management of:
- Recurrent AOM?
- CSOM?
What are the surgical options for Otitis Media? (5)
- Chronic OME?
Surgical Management
- Myringotomy- very small incision into TM to drain fluid
- Grommet- ventilation tube (VT) = pressure equalisation tube(PET)
- Myringotomy and grommets
- Adenoidectomy - removal of lymphoid tissue in post nasal space close to Eustachian tube. Adenoiditis with nasopharyngeal flora →Eustachian tube (ET)→ OM. Replaced the theory that large adenoids obstruct the ET
- Myringoplasty- repair of chronic perforation of TM
- Mastoidectomy - removal of diseased mucosa/cholesteatoma in mastoid and middle ear
What are Grommets?
- 4 Advantages?
- 4 Disadvantages?
Grommets
Advantages
1. Removes fluid
2. Restores hearing almost immediately
3. Restores normal press to middle ear
4. Can decrease recurrent infections
Disadvantages
1. Needs general anaesthesia
2. Can extrude prematurely
3. Chronic otorrhea – hearing loss (Urti/swimming)
4. Can cause chronic perforation and CSOM
What are 4 significant points made in the American OM/Tympanostomy guidelines?
- Many children with a fluid build-up (otitis media with effusion, or OME) in the middle ear (behind the eardrum) get better on their own, especially when the fluid is present for less than three months.
- Children with persistent OME for three months or longer should get an age-appropriate hearing test.
- Tympanostomy tubes should be offered to children with hearing difficulties and OME in both ears for at least three months, because the fluid usually persists and inserting tubes will improve hearing and quality of life.
- Tympanostomy tubes may be offered to children with OME, lasting at least three months in one or both ears, and symptoms that are likely attributable to OME–including: balance (vestibular) problems, poor school performance, behavioural problems, ear discomfort, or reduced quality of life.
Tonsils Grading?
Create a table outlining major developmental milestones across the five domains of child development in 3 month intervals for the first two years of life (i.e. a 5x9 table, starting at birth).
a. Consider as part of this, thresholds of concern for non-typical development
Describe an approach to the management of a young infant (e.g. 2 month old) who presents with concerning crying behaviour.
Investigations may be indicated when a presumptive diagnosis is not clear from the history and the physical examination. A urine culture is the minimum investigation. Unfortunately there are no immediately useful investigations for conditions such as cow milk protein allergy or gastro-oesophageal reflux disease.
Treatment is directed to the presumptive diagnosis. Parents should have their concerns validated and it can be useful to explore other supports available to them. In some instances it may even be useful to observe the infant in hospital, both to refine the diagnosis, but also to provide parent-crafting advice to the carers/parents. Parents/caregivers should be given permission to continue seeking help, wherever that may come from, including extended family. It takes a village.
A 3 year old presents with language achievement of a single word vocabulary of three words: “Mum”, “No”, “Milk”. How would you approach diagnosis and management?
Clinicians may should appraise the five developmental domains, and may use a questionnaire (e.g. the ASQ) to determine the pattern of development. Clinicians do need to perform a careful physical examination, with a focus on ENT health. Investigations such as audiometry may be required. Referral to an ENT specialist may also be indicated in chronic ear and nose (upper airway) conditions. Ultimately, referral to speech pathology to perform a more rigorous assessment of communication development and formulate a therapy plan may be indicated.
Regarding chronic middle ear disease:
a) What are the risk factors for developing chronic middle ear disease? (7)
b) What are the range of conditions of chronic middle ear disease? (4)
c) What are the range of treatment options?
The range of conditions of chronic middle ear disease include:
1. Chronic Otitis Media with Effusion (COME, a.k.a. “Glue Ear”)
2. Chronic Suppurative Otitis Media (CSOM)
3. Chronic tympanic perforation (a.k.a “Dry Perforation” with or without Cholesteatoma)
4. Tympanostomy Tube Otorrhoea
Describe an approach to the management of a 4 year old who presents with schooling and socialisation problems.
- A four year old can still be assessed with the ASQ (up until 60 months old), but the MCHAT questionnaire is only validated for up to 30 months of age. Some developmental paediatricians will use the “Strengths and Difficulties Questionnaire” (SDQ) because it is relatively quick, free, and valid between age 2y-17y.
- Referral is often required unless the problem is a very simple biological one (e.g. chronic otitis media with brief period of hearing loss). Neurodevelopmental and psychological contributors usually require multidisciplinary management.
What might Cramped Synchronized General Movements in Preterm Infants be indicative of?
- Aetiology, Risk factors & Clinical features of this condition?
= Cerebral Palsy
Aetiology - Idiopathic (most cases)
Risk factors:
1. Preterm birth and low birth weight (most important risk factors)
2. TORCH infection
3. Perinatal asphyxia
4. Intracranial hemorrhage
Clinical features
All types
- Patients do not reach certain milestones
- Intellectual disability
- Joint contractures
Spastic type:
- ↑ Muscle tone in one or more limbs
