1
Q
WHO recommends which form of feeding for the first 6 months of life?
A
Exclusive breast milk (EBM)
2
Q
What are the benefits of breastfeeding?
A
- reduced infections in neonatal period
- better cognitive development
- reduced risk of SIDS
- reduced risk of obesity
- reduce breast cancer and ovarian cancer risk in the mother
3
Q
What are the feeding volumes in babies?
A
Titrated up across the first week of life as tolerated, to target of 150ml/kg/day.
This is initially split between feeds every 2-3 hours, then to 4 hours and longer.
Eventually babies transition to feeding on demand.
4
Q
What is the acceptable rate of initial weight loss in babies?
A
Lose up to 10% of body weight in the first 5 days.
However, they should regain their birth weight by day 10.
5
Q
What is the most common cause of excessive initial weight loss in babies?
A
Dehydration due to under feeding.
The most reliable sign of dehydration in babies is weight loss - even when they do not clinically look dehydrated.
6
Q
When does weaning begin?
A
At around 6 months of age, babies are gradually transitioned from milk to normal food.
It starts with pureed foods that are easy to palate, and gradually progresses towards a healthy diet resembling an older child.
Until the age of 1 year, this can be supplemented with milk and snacks.
7
Q
What is plotted on growth charts?
A
- weight
- height
- head circumference
against normal distribution for their age and gender.
8
Q
What are the phases of growth?
1) First 2 years
2) 2 years to puberty
3) During puberty
A
a) rapid growth driven by nutritional factors
b) steady slow growth
c) rapid growth spurt driven by sex hormones
9
Q
What factors have contributed towards an increase in childhood obesity?
A
Increased access to readily available, affordable, high calorie foods. This leads to the overconsumption of calories.
There has also been a shift from physical activities and outdoor play, to sedentary activities such as video games and screens.
10
Q
Define
a) overweight
b) obesity
in children.
A
a) above the 85th percentile for BMI
b) above the 95th percentile for BMI
11
Q
What are the effects of childhood obesity?
A
- bullying and psychosocial consequences
- impaired glucose tolerance
- T2DM
- cardiovascular disease
- arthritis
- cancer
12
Q
What is failure to thrive?
A
The poor physical growth and development in a child.
13
Q
NICE (2017) definitions of failure to thrive.
A
Fall in weight across:
- one or more centile spaces if birthweight was below the 9th centile
- two or more centile spaces if their birthweight was between the 9th and 91st centile
- three or more centile spaces if their birthweight was above the 91st centile
14
Q
What is a centile space?
A
The distance between two centile lines.
For example, if the initial weight of a child is plotted halfway between the 9th and 25th centile lines, and several months later is plotted halfway between the 2nd and 9th centile lines, they have dropped a full centile space.
15
Q
What are the broad categories of failure to thrive?
A
- inadequate nutritional intake
- difficulty feeding
- malabsorption
- increased energy requirements
- inability to process nutrition
16
Q
Causes of inadequate nutritional intake.
A
- maternal malabsorption if breastfeeding
- iron deficiency anaemia
- family or parental problems
- neglect
- availability of food (i.e. poverty)
17
Q
Causes of difficulty feeding.
A
- poor suck
- cleft lip or palate
- abnormal facial structure
- pyloric stenosis
18
Q
Causes of malabsorption.
A
- cystic fibrosis
- coeliac disease
- cows milk intolerance
- chronic diarrhoea
- inflammatory bowel disease
19
Q
Causes of increased energy requirements.
A
- hyperthyroidism
- congenital heart disease
- cystic fibrosis
- malignancy
- immunodeficiency
20
Q
Causes of inability to process nutrients properly.
A
- inborn errors of metabolism
- T1DM
21
Q
How is a child failing to thrive assessed?
A
- pregnancy, birth, developmental and social history
- feeding or eating history
- observe feeding
- mum’s physical and mental health
- parent-child interactions
- height, weight and BMI
- calculate mid-parental height centile
22
Q
Define mid parental height.
A
(height of mum + height of dad) / 2
23
Q
Outcomes from assessment that suggest inadequate nutrition or a growth disorder are?
A
- height more than 2 centile spaces below the mid-parental height centile
- BMI below the 2nd centile
24
Q
NICE (2017) recommend which investigations for failure to thrive?
A
- urine dipstick (?UTI)
- coeliac screen (anti-TTG / anti-EMA antibodies)
Focused investigations should be considered where additional signs or symptoms suggest an underlying diagnosis.
25
How can difficulty breastfeeding be managed?
Support from midwives, health visitors, peer groups and lactation consultants.
Supplementation with formula milk.
26
Where inadequate nutrition is the cause of failure to thrive, what is the management?
- encourage regular structured mealtimes and snacks
- reduce milk consumption to improve appetite for other foods
- review by dietician
- additional energy dense foods to boost calories
- nutritional supplement drinks
Where other measures fail and there are serious concerns, NG feeding may be considered.
27
Define short stature.
Height below the 2nd centile average for their age and sex.
28
How can a child's predicted height be calculated? (M)
(mother height + father height + 14cm) / 2
29
How can a child's predicted height be calculated? (F)
(mother height + father height - 14cm) / 2
30
Causes of short stature.
- familial short stature
- constitutional growth delay
- malnutrition
- coeliac disease
- IBD
- hypothyroidism
- Down syndrome
31
What is constitutional delay in growth and puberty?
A normal variation in development, leading to short stature in childhood compared to peers, but normal height in adulthood.
Puberty is delayed and the growth spurt during puberty lasts longer.
32
How is constitutional growth delay diagnosed?
History and examination, supported by an x-ray of the hand and wrist to assess bone age.
33
What are the four major domains of child development?
- gross motor
- fine motor
- language
- personal and social
34
Gross motor development in children.
4 months
Able to support head and keep it in line with the body.
35
Gross motor development in children.
6 months
Maintain a sitting position, however may be unbalanced.
36
Gross motor development in children.
9 months
Maintain a sitting position unsupported.
Start crawling.
Bounce on legs when supported.
37
Gross motor development in children.
12 months
Stand and begin cruising.
38
Gross motor development in children.
15 months
Walk unaided.
39
Gross motor development in children.
18 months
Squat and pick things up from the floor.
40
Gross motor development in children.
2 years.
Run & kick a ball.
41
What are the red flags in developmental milestones?
- lost developmental milestones
- unable to hold an object at 5 months
- unable to sit unsupported at 12 months
- unable to stand unsupported at 18 months
- unable to walk unsupported at 2 years
- unable to run at 2.5 years
- no words at 18 months
- no interest in others at 18 months
42
What is global developmental delay?
Slow development in all developmental domains:
- gross motor delay
- fine motor delay
- language delay
- personal and social delay
43
Causes of gross developmental delay.
- Down's syndrome
- Fragile X syndrome
- fetal alcohol syndrome
- metabolic disorders
44
Causes of gross motor delay.
- cerebral palsy
- ataxia
- myopathy
- spinal bifida
- visual impairment
45
Causes of fine motor delay.
- dyspraxia
- cerebral palsy
- muscular dystrophy
- visual impairment
- congenital ataxia (rare)
46
Causes of language delay.
- exposure to multiple languages
- hearing impairment
- learning disability
- neglect
- autism
- cerebral palsy
47
How is language delay managed?
Referral to speech and language, audiology and a health visitor.
Referral to safeguarding is required if neglect is a concern.
48
Causes of personal and social delay.
- emotional and social neglect
- parenting issues
- autism
49
What is dyslexia?
A specific learning difficulty in reading, writing and spelling.
50
What is dysgraphia?
A specific learning difficulty in writing.
51
What is dyspraxia?
A specific learning difficulty in physical co-ordination, presenting with delayed gross and fine motor skills.
The child may appear clumsy.
52
What is auditory processing disorder?
A specific learning difficulty in processing auditory information.
53
What is non-verbal learning difficulty?
A specific learning difficulty in processing non-verbal information, such as body language and facial expressions.
54
What is the difference between a learning disability and a learning difficulty?
Learning difficulty is defined as reduced intellectual ability for a specific form of learning (e.g. dyslexia, dyspraxia, ADHD).
A person with a learning disability may also have one or more learning difficulties.
54
What is learning disability?
- lower intellectual ability
- significant impairment of social or adaptive functioning
- onset in childhood
55
Severity of learning disability.
IQ 55-70: mild
IQ 40-55: moderate
IQ 25-40: severe
IQ <25: profound
56
Causes of learning disability.
Often no clear cause.
Risk factors:
- family history
- abuse
- neglect
- psychological trauma
- Downs syndrome
- fetal alcohol syndrome
- maternal chickenpox
- prematurity
- hypoxic-ischaemic encephalopathy
57
Management of learning disability.
Multidisciplinary team to support the parents and child:
- health visitors
- social workers
- schools
- educational psychologist
- paediatricians
- GPs
- occupational therapy
- speech and language therapist
58
How is capacity demonstrated?
Time and decision specific ability to:
- understand the decision that needs to be made
- retain the information long enough to make the decision
- weigh up the options and implications of choosing each option
- communicate their decision
59
Normal age for puberty to start in:
a) boys
b) girls
a) 9-15 years
b) 8-14 years
60
How long does puberty usually last?
4 years from start to finish.
61
What is the first sign of puberty in:
a) girls
b) boys
a) development of breast buds
b) enlargement of the testicles
62
How is puberty staged?
Tanner scale
63
What is hypogonadism?
A lack of the sex hormones, oestrogen and testosterone.
64
What is the consequence of hypogonadism?
Delayed puberty.
65
What are the causes of hypogonadism?
Hypogonadotrophic hypogonadism: a deficiency in LH and FSH.
Hypergonadotrophic hypogonadism: a lack of response to LH and FSH by the gonads.
66
What is hypogonadotrophic hypogonadism?
A deficiency in LH and FSH, leading to a deficiency of testosterone and oestrogen.
This is the result of an abnormal functioning of the hypothalamus or pituitary gland.
67
Causes of hypogonadotrophic hypogonadism.
A deficiency of LH and FSH as a result of abnormal functioning of the hypothalamus or pituitary gland:
- damage to the hypothalamus or pituitary
- growth hormone deficiency
- hypothyroidism
- hyperprolactinaemia
- cystic fibrosis
- excessive exercise or dieting
- constitutional delay in growth
- Kallman syndrome
68
What is hypergonadotrophic hypogonadism.
The gonads fail to respond to stimulation from LH and FSH.
Therefore, there is no negative feedback from testosterone and oestrogen, so the anterior pituitary produces increasing amounts of LH and FSH.
69
Causes of hypergonadotrophic hypogonadism.
Abnormal functioning of the gonads:
- damage to the gonads (e.g. testicular torsion, cancer, mumps)
- congenital absence of gonads
- Kleinfelter's syndrome (XXY)
- Turner's syndrome (XO)
70
What is Kallman syndrome?
A genetic condition causing hypogonadotrophic hypogonadism.
Results in a failure to start puberty, and a reduced or absent sense of smell.
71
What is the threshold for initiating investigations for delayed puberty?
No evidence of pubertal changes in a girl aged 13, or a boy aged 14.
72
Initial investigations for delayed puberty.
- FBC and ferritin (?anaemia)
- U&Es (?CKD)
- anti-TTG / anti-EMA (?coeliac)
73
Hormonal blood tests for delayed puberty.
- early morning serum FSH and LH
- TFTs (?hypothyroidism)
- growth hormone testing
- serum prolactin (?hyperprolactinaemia)
74
What genetic conditions are often screened for in delayed puberty?
- Kleinfelter's sydrome (XXY)
- Turner's syndrome (XO)
75
What imaging is requested for delayed puberty?
- xray of wrist to assess bone age (?constitutional delay)
- pelvic ultrasound in girls to assess the ovaries
- MRI brain (?pituitary pathology; ?Kallman syndrome)
76
Management of delayed puberty.
Identifying and treating the underlying condition where there is one.
Patients with constitutional delay may only require reassurance and observation.
Under expert guidance, replacement sex hormones can be used to induce puberty.
77
What are the types of abuse?
- physical
- emotional
- sexual
- neglect
- financial
- idenity
78
Risk factors for abuse.
- domestic violence
- previously abused parent
- mental health problems
- disability in the child
- learning disability in parents
- substance misuse
- non-engagement with services
79
Possible signs of abuse in children.
- change in behaviour
- extreme emotional states
- dissociative disorders
- bullying
- DSH / suicidal ideation
- sexualised behaviour
- poor hygiene
- developmental delay
- medical non-compliance
80
How should a safeguarding concern be managed?
Refer to safeguarding team or safeguarding lead, to discuss referral to social services.
Most safeguarding cases don't involve children being removed from their parents, and instead focus on providing extra support and services.
81
What measures can be arranged by social services to support families of children with safeguarding concerns?
- home visit programmes to support parents
- parenting programmes
- attachment-based interventions to help parents bond
- child-parent psychotherapy
- cognitive behavioural therapy for children that have suffered trauma or sexual abuse
NB: if the child is in immediate danger the police may need to be involved; if they are acutely unwell or need a place of safety they should be admitted to hospital.
82
When is a person recognised as an adult with full autonomy to make decisions about their health?
Aged 18.
16 or 17 year olds can make independent decisions about their health, but if they refuse treatment this can be overruled by people with parental responsibility (or the court) in certain situations.
83
How are children aged under 16 assessed to have capacity to make a decision?
Gillick competence - refers to a judgement about whether the understanding and intelligence of a child is sufficient to consent to treatment.
Consent must be given voluntarily, and it's important to assess for coercion or pressure.
84
What are the Frazer guidelines used for?
Providing contraception to patients under 16 years without having parental input and consent.
85
What are the criteria of the Frazer guidelines?
- mature and intelligent enough to understand the treatment
- can't be persuaded to discuss it with their parents, or let the health professional discuss it
- likely to have intercourse regardless of treatment
- physical or mental health likely to suffer without treatment
- treatment is in best interest
Children should be encouraged to inform their parents, but if they decline and meet the criteria for Gillick competence and the Frazer guidelines confidentiality can be kept.
86
At what age should sexual activity raise a safeguarding concern?
Children under 13 cannot give consent for sexual activity, so should be escalated as a safeguarding concern.
87
What is the age of sexual consent in England and Wales?
16 years - however children under the age of 13 are seen as being less capable of consenting than those aged 13 and over.
Year 4 - Paediatrics
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