Pedratrics

Question 1

acronym for Infant development milestones?

Answer 1

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)

Question 2

When do you check a child weight from birth to 11 years ?

Healthy child schedule

Answer 2

1. Birth

Up to 2 weeks after birth

2. 6 -12 months
3. 21/2 years
4. 4 - 5 years - primary school entry
5. 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.

Question 3

When can BMI be used in children ?

Answer 3

From the second year .

Question 4

How and why do we measure circumference of head (OFC - Occciptal frontal circumference) ?

Answer 4

Prompt diagnosis of hydrocephalus , mirco/macrocephaly

Possible causes of microcephaly- intrauterine infections, congenital abnormality and developmental concerns.
(small head can be normal )

1. 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.

Question 5

How and why do we measure the weight of a child ?

Answer 5

to check for normal growth and check for no obesity of faltering growth.

Question 6

What it is the most you would measure a child’s weight if you were concerned (consider the different age groups ) ?

Answer 6

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)

Question 7

Babies’s weight - physiology

Answer 7

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 ?

Question 8

Measurement of height ?

Answer 8

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 )

Question 9

Hydrocephalus ?

Pathway of CSF production & flow ?

Answer 9

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)

Question 10

What is normal pressure hydrocephalus ?

Answer 10

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

1. 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

Question 11

Aqueductal stenosis ?

Answer 11

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.

Question 12

Neural tube defects?

Answer 12

Spina bifida

Question 13

Embryology - what structures does the ectoderm derive into ?

Answer 13

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 .

Question 14

Gastroenteritis ( Stomach bug) - CHILDREN

Answer 14

Types :

1. Viral (most commonly - Rota virus- vomiting really common)-
2. 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)

Question 15

Stages / categories of dehydration ?

Answer 15

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.

Question 16

Investigation of gastroenteritis ?

Answer 16

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.

Question 17

What drugs should you be careful off or aware of reduce efficacy in severe diarrhoea & vomiting ?

Answer 17

Warfarin , anticonvulsants , oral contraceptive pill.

Question 18

When would you consider Culture , M & S in acute gastronetritis ?

Answer 18

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

Question 19

Who is at increased risk of being dehydrated ? - CHILD

Answer 19

> 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

Question 20

Fluid volume requirements for a child ?

Answer 20

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

Question 21

Treatment of gastroenteritis in primary care ?

• note - children should stay of school until 48hrs after last diarrhea or vomiting.

Answer 21

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

Question 22

What is bronchiolitis ?

Answer 22

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)

Question 23

Diagnosis &

Management of Bronchiolitis ?

Answer 23

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%)