Paediatrics Flashcards
DM at 6-8 weeks
GM: supports head
FM: tracks with eyes past midline
LH: orients eyes to sounds, coos
S: smiles
DM at 6 months
GM: sit with support, rolling
FM: transfers, hand to mouth, grasping
LH: head to sound, responds to name, different sounds on need
S: interested in people, recognises familiar faces
DM at 9 months
GM: crawls, stands with support, pulls to stand
FM: pincer grip
LH: understands no, babbling
S: stranger anxiety, favourite toy, peek a boo
DM at 12 months
GM: walks with support, cruises
FM: points, bangs objects together, should not prefer one hand
LH: mumma, dadda
S: waves, preference for caregiver, using objects
DM at 18 months
GM: runs, throws
FM: scribbles vertically, handedness
LH: six words, can point to some body parts
S: uses spoon and cup, points to items
DM at 2 years
GM: stairs, kicks ball
FM: scribbles horizontally
LH: two word sentence, follow simple command
S: helps in dressing, parallel play, interest in children
DM at 3 years
GM: jumps, catches ball
FM: draws circle, use scissors
LH: 3 word sentences, name, age and sex, some colours
S: dresses with supervision, interactive play, makes friends
DM at 4 years
GM: hopping
FM: draws square
LH: 4 word sentences, asks why and how
S: imaginative play, toilet trained, dresses self
DM at 5
GM: skips
FM: draws triangle
LH: 5 word sentence, fluent speech, tells stories
S: understands rules, sense of humour
Autism spectrum disorder criteria
A) deficits in social communication and interaction with deficits in all of:
RNR
-reciprocity
-non-verbal communication
-relationship development and maintenance
B) restrictive, repetitive movements, interests or activities with 2 of:
SOAR
-sensory input hypo/hyper reactivity
-obsessive, restricted interests
-adherence to rules and routines
-repetitive movements, speech, use of objects
C)
- not better explained by ID
- appears during development
- causes functional impairment
Background ASD
Prevalence
- 1% population
- 3 to 4 x male predominance
Risk factors
- male sex
- sibling with ASD
- poor perinatal or maternal health
- maternal medications (valproate)
- advanced parental age
- genetic disorders (tuberous sclerosis)
Pathogenesis
- heritability 30-90%
- epigenetic theory
- mostly polygenic
- > no gene accounts for >1% of cases
- predominately due to abnormal neural connectivity
Non pharm treatment ASD
Intensive behavioural interventions
- reinforce desirable/decrease undesirable
- uses reward based system
Developmental and relationship models
- aim to teach critical skills that have not been learnt
- many different models (eg. Denver) with different focuses
Parent mediated interventions
- training parents in specific behavioural intervention
- improves efficacy and parents sense of wellbeing
Effective programs
- start early
- intensive
- parental involvement
- high staff:student
- school teacher with expertise
Pharm interventions ASD
Inattention and hyperactivity
- stimulants
- > methylphenidate
- > dextroamphetamine
- atypical antipsychotics
- > risperidone
Behavioral disturbance
- atypical antipsychotics
- > risperidone
- > aripiprazole
Repetitive behaviors and rigidity
- SSRIs help with anxiety component
- > fluoxetine
Anxiety and depression
->SSRIs as usual
Mood lability
-atypical antipsychotics, SSRIs and mood stabilizers have not been in ASD
normal newborn vitals
Transitional period
- first 4-6 hours
- assess vitals every 30-60 minutes
Temp
- normal
- > 36.5-37.5
- abnormal
- > sepsis
- > maternal fever
RR
- normal
- > 40-60
- abnormal
- > tachy = cardiac or resp disease
- > apnea = CNS depression or NMD
HR
- normal
- > 120-160
- > can be lower in sleep
- abnormal
- > cardiac or respiratory disease
- > sepsis
- > metabolic disease
Colour
- normal
- > pink or acrocyanosis
- abnormal
- > cyanosis = resp or cardiac disease
Tone/posture/movement
benign skin findings in newborn
- Acrocyanosis
- blue hands and feet - Erythema toxicum
- small white papules on erythematous base
- usually on trunk
- never soles or palms - Transient pustular melanosis
- generalised pustules
- no base
- pustules leave temporary hyperpigmented macules
- occurs transiently in some african newborns - Miliae
- white papules on nose and cheeks
- retention of keratin and sebaceous fluid in pilosebaceous gland - Salmon patches (naevus simplex)
- pink/red patches
- eyelid, upper lip, forehead, nape of neck
- capillary malformation - Mongolian spots
- blue/green/brown macules
- delayed disappearance of dermal melanocytes - Infantile haemangiomas
- differentiate from congenital
- can occlude airway/be part of syndrome
- proliferate then involute - Jaundice
Pathological skin findings in newborn
Ritters disease of the newborn (staph infection)
- > staphylococcal scalded skin syndrome
- > disseminated staph aureus infection
- > toxins cause flaccid bullae to erupt days after birth
- > generalised erythematous rash
- > nikolskys sign (exfoliation of skin with gentle rubbing)
Staph and step infection
- Bullous impetigo
- > small vesicles become flaccid bullae and crust
- > staph aureus
- Non bullous impetigo
- > erythematous macule becomes vesicle or pustule and crusts
- > can be caused by s. aureus or s. pyogenes
Neonatal herpes
- Primary herpes
- > erythematous papules/vesicles/crusts
- > face/scalp
- > after vaginal delivery
Port wine stains
- > blanchable erythematous patches
- > low flow through capillaries
- > grow with child, become thicker and darker
- > associated with genetic conditions
Café au lait spots
- hyperpigmented skin lesion
- associated with neurofibromatosis
Normal posture in newborn
- Head in midline
- Limbs:
<28 weeks = extension of limbs
>32 weeks = flexion at knees
>38 weeks = all limbs flexed
Movement in newborn
Symmetrical, spontaneous movement
- normal
- absence
- > birth injury
- > neurological abnormality
- > genetic syndrome
Jerking
- normal
- > during sleep
- > benign for first few months
- pathological (seizures)
- > nystagmus
- > stereotypes (lip smacking, grunting etc)
Fasciculations
- normal
- > sensitive to stimulation
- > interrupted by flexion
- pathological
- > persistant or exaggerated
- > hypoglycaemia/hypocalcaemia/sepsis/asphyxia
Lower cranial nerve palsies
- difficulty swallowing
- abnormal cry
- inspiratory stridor
Apnoea
- brainstem dysfunction
- seizure
- phrenic nerve palsy
Primitive reflexes
Moro
- present at 32 weeks
- disappears by 6 months
Stepping
- present at 32 weeks
- disappears by 2 months
Palmar/plantar grasp
- present at 32 weeks
- palmar disappears by 3 months
- plantar disappears by 6 months
Asymmetrical tonic neck reflex
- never normal when present unprovoked
- present by 1 month post natal
- disappears by 4 months
rules of thumb for speech screening
1yrs
-1 word
2yrs
- 2 word phrases
- 1/2 understood by strangers
3yrs
- 3 word sentences
- 3/4 understood by strangers
4yrs
- 4 words, conversational
- almost all understood
5 years
- 5 word sentences
- complex sentences
- fluent and comprehensible
rules of thumb for weight
Average weight
- 3.5kg at birth
- 10kg at 1 year
- 20kg at 5 years
- 30kg at 10 years
Weight change
- weight loss in first few days = up to 10%
- return to birth weight = by 10 days
- double birth weight = by 6 months
- triple birth weight = by 1 year
- quadruple birth weight = by 2 years
Weight gain
- > 30g/day until 3 months
- > 20g/day until 6 months
- > 10g/day until 12 months
- > 2kg/year from 2 years to puberty
Finger rule
- left hand = 1,3,5,7,9
- right hand = 10,15,20,25,30
rules of thumb for height/length
Average length/height
- at birth = 50cm
- at 1 year = 75cm
- at 3 years = 3ft (90cm)
- at 4 years = 100cm
- > double birth length
Rate of growth
- 1 inch/month until 6 months
- 0.5 inch/month until 12 months
- slows considerably between 1 and 4 years
- there after 2 inches per year between 4 and puberty
measuring growth
Length -until approx 2 years Height Weight Head circumference -until 2 years old Growth velocity Proportionality -height for weight ->until 2 years old -BMI ->after two years old -US:LS ->distinguishes aetiology of tall/short stature ->approx 1.7 at birth ->approx 1 by age 10 ->less than 1 thereafter
aetiology and risk factors poor weight gain
Risk factors
- medical
- > premature
- > intrauterine growth restriction
- > intrauterine exposures
- > genetic disorder
- > ANY disease process
- psychosocial
- > poverty
- > poor parenting skills
- > disordered feeding techniques
- > violence or abuse
Aetiology
- nutrition going in
- > inadequate intake
- > inadequate absorption
- > inadequate metabolism
- nutrition going out
- > increase urinary or faecal losses
- > increased caloric needs
Evaluation of poor weight gain
Hx
- age of onset
- medical hx
- diet and feeding
- > vomiting/diarrhoea/rumination
- > picky eating, anorexia
- > food preferences/avoidance
- > dietary restrictions or beliefs
- > anatomical abnormalities
- psychosocial
- > stressors (poverty)
- > access to resources
- > feeding skills and knowledge
- > maternal health
Exam
- measurements
- > consider velocity and proportionality
- appearance
- > lethargic
- > wasted
- > dehydration
- caregiver-child interaction
- behaviour and development
Breast feeding, compliment feeding/supplementation
Breastfeeding
- recommended as exclusive source for 6 months
- by 1 year most infants predominately on solids
- benefits
- > antimicrobial effects (IgA, HMO)
- > promotes GI growth and function
- > reduces risk of acute illnesses
- > protects against chronic disease (T1DM, IBD)
- > reduces morbidity and mortality
Compliment feeding
- introduce compliment foods at 6 months
- by then breast milk deficient in
- > energy
- > protein
- > iron (plus vitamin C for absorption)
- > zinc
- > fat soluble vitamins (vitamin D)
- cereals recommended first
- > high in iron
