1
Q
MILESTONES: Gross motor
A
- 3 months: Hold head up independently
- 6 months: Sit unsupported, roll over, pull to crawling position and rock
- 9 months: Get into sitting position unsupported, wriggle, crawl, put things in mouth
- 10 months: Pull self up to a standing position on furniture
- 1 year: Crawl upstairs, walk short steps and collapse
- 18 months: Walk independently, stoop and pick objects up
2
Q
MILESTONES: Fine motor
A
4 months: Play with rattle
5 months: Reach for objects using whole hand grasp
6 months: Basic manipulation between hands
7 months: Eat finger foods
9 months: Beginning to use pincer grip
12 months: Mature pincer grip (fingers and thumbs)
15months: Build a tower of 2 blocks
18 months: Scribble with a pencil, build a tower of 4 blocks
3
Q
Milestone- social developments
A
4-6wks: Fixes eyes to faces
6wks: Smile in response
3mths: Simple babbles
4mths: Laughing out loud
7mths: Stranger anxiety
8mths: Double babbles
9mths: Peakaboo, waving bye
12mths: 2/3 words
18mths: 10 words
24mths: 2 word sentences
3 years: Chatterboxes!!
4
Q
Milestone red flags:
A
- Parental concerns
- If they’re losing skills
- if they’re not smiling by 10wks
6mths:
- If they have a persistent squint, referral to ophthalmology
- Hand preference- too early to determine at this age
- Little interest in people, toys, noise- ?neurodivergent
10-12 mths:
- no sitting
- no double syllable babble
- not chewing
18mths:
- not walking independently
- Less than 6 words
- Persistent mouth drool
2 1/2 yrs:
- no 2-3 word sentences
- not responding to one word commands
- no symbolic play- acting like role models
4 yrs:
- unintelligeble speech
5
Q
Head injuries
A
- Very common in toddlers
- Breath holding in under 3, look very cyanotic, usually stops by 5.
- When they respond to the trauma, instead of crying, they go cyanotic as they change their breathing pattern.
6
Q
Reflex anoxic sezures
A
- Tantrum after head injury is abnormal behaviour
- Common in 6mths-2yrs
- Lasts 30-60secs, not life threatening, may be mistaken for a tantrum
- In very rare cases, a pacemaker may be required
- Breath holding
7
Q
Head injury assessment:
A
- More difficult to assess in paeds
- Children are more likely to vomit and fit after banging their head, not necessarily a sign of raised ICP
- Worsening care advice- give very clearly to an adult
- Teenagers may experience headaches 2-3 weeks post head injury, it should respond to OTC analgesia and should self resolve
8
Q
Skull
A
- Base of skull fractures
- Very subtle
- Battle sign is a late sign in paeds!
9
Q
Facial injuries
A
- Very unlikely to fracture nose in paeds under 7 as their nose hasn’t ossified yet!
- Still, look inside the nose for haematoma around the septum
- Nose bleeds- prior? Is it quick to stop
- If frequent and hard to stop, think childhood leukaemia/haemolytic disorders
- Lip tissue heals faster than facial tissue
10
Q
Oral injuries
A
- Torn frenulum: Contains an artery so it will bleed a lot.
- Think abuse, are they being force fed, how are parents coping?
- Intraoral injuries- what happened, paeds soft palpate is more vulnerable, any post nasal drip/bleeding?
- Inspection tounge
11
Q
Teeth
A
- Baby teeth that’s come out should not be reinserted due to choking hazard
- Permanent tooth can be put in within 2 hours, store in cheek or milk
- Only successful if blood supply is reestablished
12
Q
Critic
A
- Ossification of the elbow
- elbow ossifies later in life
- With a FOOSH, the transferred force has gone up the arm resulting in a fractured clavicle/scapula, due to lack of lower ossification
- everything ossifies at approx 20
13
Q
Fractures
A
- Children have bendy bones due to 20% more water than adults
- worried about growth of bone if physis or Epiphysis is injured.
14
Q
Non accidental injuries
A
- Rule of 4: Any bruising on a child less than 4 months is suspicious as they don’t have the mobility.
- Look at trunks, underneath the clothes
- Ears: Pinch marks for pulling, grabbing
- Neck injuries are a red flag
Trunk
Ears
Neck
4 years or younger
Frenulum- inside of mouth around lips
Auricular area
Cheek
Eyes
Sclera- blood, shaken baby
Patterned bruising- handprints? - Does hx match injury?
- Burns: immersion?
- Bruising in a child who is not independently mobile, neck is a red flag, always consider hx
- One or more fractures with no hx of fragile bone conditions, absent or unsuitable explanations
15
Q
Common childhood illnesses:
A
16
Q
PAED assessment triangle
A
Appearance:
- Abnormal tone?, interactivity, consolability, abnormal look/gaze, speech, cry?
Circulation:
- Pallor, mottling, cyanosis
Work of breathing
- Abnormal sounds, position, retraction, flaring?, apnea/gasping
17
Q
TICLS
A
- TONE- Good muscle tone?, limp?, resisting examination?
- INTERACTIVITY- Alert?, playing with toys/caregiver?, following pen torch, equipment?
- CONSOLABILITY- Can they be consoled by the caregiver?, responding well to reassurance?
- LOOK- Are they watching you?, giving eye contact to the caregiver, non focused gaze?
- SPEECH- are they crying?, is their cry strong or weak?, is voice normal/abnormal
18
Q
Appearance
A
- Baby’s should be able to hold their head up
- Floppy baby’s have bad tone, make a u shape hang upside down, making little to no movement.
19
Q
Circulation
A
- Cynaosis
- Pallor
- Mottling
20
Q
Child VS adult breathing
A
- Infants up to 6months are nose breathers, due to narrow nasal passages which increase the risk of obstruction.
- Upper & Lower airways are relatively small, more prone to obstruction
- Infants rely mainly on diaphragmatic breathing, greater risk of tiring (abdominal breathing)
- Pre term infants are at a higher risk of respiratory failure as they have fewer type 1 fibres.
- Ribs lie more horizontal in infants, so less chest expansion
ASSESS FOR:
- Nasal flaring, head bopping, intercostal recession , tracheal tug (late sign), grunting, IWOB
21
Q
Child vs Adult neuro
A
- Primitive reflex present in infants:
- Palmar grasp- trying to grab finger when placed in palm of their hand, disappears by 3 months
- Plantar grasp- putting finger on bottom of foot, their foot moves towards your finger.
- Moro reflex- startle reflex, disappears by 6 mths
- Stepping
- Fencing, disappears by 6mths
22
Q
IMMUNITY
A
- PAEDS have less Immunoglobulin stores
- Pre term babies are more prone to infections because they received less passive immunity from mum in the 3rd trimester as they came out too early :/
23
Q
GI
A
- Paeds stomachs can only hold 10-20ml volume at birth, and it empties very very fast.
- Initially they can use ketones, it may be normal for child’s BM to be less than adults.
- How many wet nappies are they having?
24
Q
Thermoregulation
A
- Neonates & infants are at a greater risk of hypothermia due to large surface area to body mass
- Paeds can’t thermoregulate
- Effect of cold stress: Hypoxia, acidosis, hypoglycaemia
25
Fontanelles
- Look out for sunken and bulging fonatanelle
Sunken fonatnelle:
- Dehydration
Bulging fontanelle:
- Raised ICP
26
Dehydration
- sunken eyes
- lack of tears when crying
- excessive thirst
- no water in first 6mths
27
Gastroenteritis
- It’s common for babies to vomit in the early weeks of life:
1. Posseting- Bringing up small amounts of milk after a feed
2. Reflux- bringing up lots of vomit after a feed
- If accompanied by diarrhoea and look unwell, it may be gastroenteritis (stomach bug)
* Babies have a greater risk of dehydration
*ADVICE: drioralyte, ice lolly, small sips, small sips
- seek help if not resolving after a few days
28
Pertussis/whopping cough
- Not always accompanied with a fever
- Paroxysmal coughing
- Bacterial infection
- Incubation period is one week, stay awayyy!
- May result in hypoxia, seizures, pneumonia
29
Croup
- Dexamethasone, fast acting steroid
- Common viral respiratory illness in paeds
- Seal bark cough
- Keep child as calm as possible, sit child up, increase humidity by getting a cool shower going.
30
Bronchiolitis
- May be mild or severe
- Diagnosis: Coryzal prodrome lasting 1-3 days, followed by:
. Persistent cough
. Tachypnoea and/or chest recession
. Wheeze or crackles on auscultation
<6weeks may just present with apnoea
31
Epiglottis
- Stridor
- Upper airway is occluded
- Not necessary to look as it may distress them or occlude them more
32
Asthma
- Official diagnosis is for >5
- Have they tried to use their inhalers?, inhaler techniques
- What causes attacks?
- Peak flow>5, best of 3
33
Varicella zoster virus
- AKA chicken pox
- Fever, malaise, rash
- Children are infectious 48hrs before spots appear and 5 days to a week after spots dry out.
- No ibuprofen as we want their inflammatory defences to help manage it.
- Calamine lotion can soothe it
- Antihistamines may help
* Stay away from: Elderly, immunocompromised people- pregnant
- Check their eyes for pustules as they will need to be seen by ophthalmology!
34
Chicken pox in pregnancy
- Up to 28wks, risk of foetal varicella, which can affect the baby’s skin, eyes, limbs, brain, bladder and bowel
- 28-36 wks- virus remains in baby’s body but not symptomatic, however may become active in 1st year of life causing shingles!
-> or equal to 36 wks, baby may be born with chicken pox or may contract it as a neonate. Both mum and baby need to be assessed and treated!
35
Shingles
- Varicella zoster within one nerve
- Usually one one side
- Shingles on the tip of the nose means the optic nerve is affected and pt needs an ophthalmology review
- Sensory nerve is affected, always unilateral!
- Acyclovir an antiviral can be used as treatment
36
Impetigo
- Very contagious
- Very itchy and sore and vesicles and pustules erupt and crust over
- Treatmnet is usually topical, bacterial
- Child should not be going school
37
Scarlet fever
- Antibiotics are needed to prevent rheumatic fever
- Rash is really rough, tounge has a white coating and after 5 days, it looks like strawberry seeds
- They get a 10 day course of pen B, very contagious
38
Hand, foot and mouth
- Limiting viral infection
- Small vesicles on hand and feet, sore throat and feeling unwell
- Avoid acidic food and drinks, as it’s a virus, it’ll go away on its own!
39
Henoch -scholein purpura
- Non blanching rash, follows a primary infection
- Occurs in <10
*Caused by vasculitis by abnormal immune response. Takes 4 weeks to recover, usually without complications
* Mistaken for meningitis!
40
Slapped cheek
- Mistaken for abuse
- Fever, drippy nose, bright red cheek
- Common in 2-12
- Starts as a bright red rash on cheek which spreads to trunks, joint pains, pyrexia, runny nose and diarrhoea
- Achy nose, high temp, runny nose, diarrhoea, pt feels rubbish
- Paracetamol & ibuprofen
- Paeds with known blood disorders like sickle cell disease are at a greater risk of anaemia, speak to a rapid response team!
* Pregnant pts to be referred to GP to rule out rubella
41
Rubella
- MMR is the vaccine
- Incubation period is 10-15 days
- Initially presents with a cold (pt is now contagious) - Pt develops a macula rash, 2 days later on the face and body
- Rash disappears after 3 days but are still contagious
- Pt will have lymphoedema
- High risk of premature birth/birth defects and stillbirth if pt is pregnant!
42
Measles
- Symptoms develop 7-10 days post infection
- Infectious 4 days before and 4 days after the rash
- Rash develops after 3 days, rash is not itchy, rash usually starts behind the ears, spreads to the face, neck and body!
- Really bad cold, watery sore eyes, feverish
- Usually ill for about a week
- More serious than chicken pox!
- Serious complication: pneumonia, death, encephalitis
43
Mumps
- Swelling of the face- Pain and swelling in front of the ears, under the chin
- Swelling usually starts on one side of the face then the other
- Symptoms 14-25 post infection, infectious for a week before facial swelling
- Malaise, pyrexia
- Complication: Swelling of testes in grown males
PMMH
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