Paediatric core condition- 4 Flashcards
Intestinal obstruction
Intestinal obstruction is where a physical obstruction prevents the flow of faeces through the intestines. This blockage will lead to a back-pressure through the gastrointestinal system, causing vomiting. It also causes absolute constipation, where the patient is unable to pass stools or wind.
Causes and diagnosis of intestinal obstruction
Causes= Meconium ileus, Hirschsprungs disease, Oesophageal atresia, Duodenal atresia, Intussusception, Imperforate anus, Malrotation of the intestines with a volvulus, strangulated hernia
Diagnosis= Abdominal xray. This may show dilated loops of bowel proximal to the obstruction and collapsed loops of bowel distal to the obstruction. There will also be absence of air in the rectum.
Presentation of intestinal obstruction
- Persistent vomiting. This may be bilious, containing bright green bile.
- Abdominal pain and distention
- Failure to pass stools or wind
- Abnormal bowel sounds. These can be high pitched and “tinkling” early in the obstruction and absent later.
Management of intestinal obstruction
Needs to be referred to a paediatric surgical unit as an emergency. Initial management involves making them nil by mouth and inserting a nasogastric tube to help drain the stomach and stop the vomiting. They will also require IV fluids to correct any dehydration and electrolyte imbalances, and keep them hydrated while waiting for definitive management of the underlying cause.
Anxious personality disorder category
- Avoidant personality disorder features severe anxiety about rejection or disapproval and avoidance of social situations or relationships.
- Dependent personality disorder features heavy reliance on others to make decisions and take responsibility for their lives, taking a very passive approach.
- Obsessive compulsive personality disorder features unrealistic expectations of how things should be done by themselves and others, and catastrophising about what will happen if these expectations are not met.
Suspicious personality disorder
- Paranoid personality disorder features difficulty in trusting or revealing personal information to others.
- Schizoid personality disorder features a lack of interest or desire to form relationships with others and feelings that this is of no benefit to them.
- Schizotypal personality disorder features unusual beliefs, thoughts and behaviours, as well as social anxiety that makes forming relationships difficult.
Emotional/impulsive personality disorder
- Borderline personality disorder features fluctuating strong emotions and difficulties with identity and maintaining healthy relationships.
- Histrionic personality disorder features the need to be at the centre of attention and having to perform for others to maintain that attention.
- Narcissistic personality disorder features feelings that they are special and need others to recognise this or else they get upset. They put themselves first.
Management= CBT and psychotherapy, no medical treatment available
Attachment disorder- principles of diagnosis
- difficult
- no specific validated tools for screening/assessing attachment disorders
- many available tools e.g. Attachment Q-sort, Manchester Child Attachment Story Task…
- can only diagnose based on interviews, history, and behavioral observation
2 types of attachment disorder and main cause
- reactive attachment disorder: inability to attach to preferred caregiver
- disinhibited social engagement disorder: indiscriminate sociability and disinhibited attachment behaviour
Most common cause of attachment disorder: early pathogenic care
Disinhibited social engagement disorder criteria
- > 2 of:
-Reduced/no reticence in approaching and interacting with unfamiliar adults
-Overly familiar verbal or physical behavior
-Reduced/no checking back with caregiver after venturing away, even in unfamiliar settings
-Willingness to go off with an unfamiliar adult with little/no hesitation - Sx NOT characterized by impulsivity (i.e. ADHD)
- Pathogenic care – e.g. social neglect/deprivation, repeated change in caregivers, growing up in unusual settings
- developmental age >9m
Reactive attachment disorder criteria
- chronic pattern of being emotionally withdrawn/inhibited – rarely seeks comfort when distressed
- chronic social/emotional perturbation-may incl. social withdrawal, negative affect, unfounded episodes of irritability or sadness or fear, disproportionate reactions to stress
- hx of extremely insufficient care i.e. deprivation or social neglect of basic emotional needs, constant flux of caregivers/homes, growing up in unusual settings
- can’t meet ASD criteria
- behavioral perturbation must begin <5y
- must be developmentally >9m
Attachment disorder- management
- Enhanced caregiving: e.g. safe, responsive, and consistent caregiver; safe and stable living situation; positive, stimulating, environment; address medical, safety, and housing needs; develop positive interactions and strengthen attachment with carers
- May need adjunct treatment for aggression and oppositional behavior
- Also consider individual and family counseling, education of carers about condition, parenting skills classes
Neonatal sepsis: common organisms, risk factors and clinical features
Common organisms: Group B strep (GBS), E.coli, Listeria, Klebsiella
Risk factors= vaginal GBS colonisation, GBS sepsis in previous baby, maternal sepsis, chorioamnionitis, prematurity, PPROM
Clinical features= fever, poor feeding, reducing tone, respiratory distress, vomiting, tachycardia, hypoxia, jaundice within 24 hours, seizures, hypoglycaemia
Treatment for presumed sepsis
- If there is one risk factor or clinical feature, monitor the observations and clinical condition for at least 12 hours
- If there are two or more risk factors or clinical feature of neonatal sepsis start antibiotics
- Antibiotics should be started if there is a single red flag
- Antibiotics should be given within 1 hour of making the decision to start them
- Blood cultures should be taken before antibiotics are given
- Check a baseline FBC and CRP
- Perform a lumbar puncture if infection is suspect meningitis (e.g. seizures)
Antibiotics for presumed neonatal sepsis
Antibiotic choice= Benzylpenicillin and gentamycin are first line. Cefotaxime can be given in lower risk babies
Neonatal sepsis: ongoing management
- Check the CRP again at 24 hours and check the blood culture results at 36 hours:
- Consider stopping the antibiotics if the baby is clinically well, the blood cultures are negative 36 hours after taking them and both CRP results are less than 10.
- Check the CRP again at 5 days if they are still on treatment:
- Consider stopping antibiotics if the baby is clinically well, the lumbar puncture and blood cultures are negative and the CRP has returned to normal at 5 days.
- Consider performing a lumbar puncture if any of the CRP results are more than 10.
Irritable hip i.e. transient synovitis pathophysiology
Temporary irritation and inflammation in the synovial membrane of the joint. Most common cause of hip pain in children aged 3-10 years, often associated with viral upper respiratory tract infections. Children with transient synovitis typically do not have a fever. Children with joint pain and a fever need urgent management for septic arthritis.
Transient synovitis features
- limp/refusal to weight bear
- groin or hip pain
- a low-grade fever is present in a minority of patients
- Usually self limiting, requiring only rest and analgesia
Transient synovitis: NICE guidelines
Children aged 3 – 9 years with symptoms suggestive of transient synovitis may be managed in primary care if the limp is present for less than 48 hours and they are otherwise well, however they need clear safety net advice to attend A&E immediately if the symptoms worsen or they develop a fever. They should also be followed up at 48 hours and 1 week to ensure symptoms are improving and then fully resolve.
Acute lymphoblastic leukaemia (ALL)
The most common malignancy affecting children and accounts for 80% of childhood leukaemias. The peak incidence is at 2-5 years of age and boys are affected slightly more commonly than girls. Associated with Downs syndrome and the Philadelphia chromosome (t(g:22) translocation.
