ITM 1 The Paediatric Patient Flashcards
(117 cards)
1
Q
What does a full blood count involve
A
Haemoglobin Haematocrit Mean corpuscular volume Differential white cell count Reticulocyte count ESR
2
Q
What does Us and Es involve
A
EGFR Creatinine (and clearance) Na+ K+ Urea
3
Q
What does an ECG show
A
Cardiac problems of conduction, pathological changes of heart (LVH), ischaemia and abnormalities of rhythm
4
Q
What can a chest xray show
A
Information regarding respiratory system and heart
Lungs - pneumonia, infections (TB), carcinoma
Heart failure- enlarged heart, signs of pulmonary oedema
5
Q
Define safeguard
A
Protect from harm or damage with an appropriate measure
6
Q
What is the unicef definition of a child protection system
A
The set of laws, policies, regulations and services needed across all social sectors especially welfare, education, health, security and justice to support prevention and response to protection related risks
7
Q
Define harm
A
Ill treatment or the impairment of health or development eg depriving a child of the tools needed to develop eg sitting in a push chair all day means they wont learn to walk
8
Q
What are the 4 categories of abuse
A
Physical
Emotional
Sexual
Neglect
9
Q
Define neglect
A
The persistent failure to meet a childs basic physical and / or psychological needs, likely to result in the serious impairment of the childs health or development
10
Q
Define emotional abuse
A
Persistent emotional ill treatment of a child such as to cause severe and persistent adverse effects on the childs emotional development
It may include:
Conveying to the child that they are worthless or unloved
Developmentally inappropriate expectations being imposed on a child
Seeing or hearing the ill treatment of others
11
Q
What is sexual abuse
A
Forcing or enticing a child or young person to take part in sexual activities, including prostitution whether or not the child is aware that this is happening - often children from vulnerable backgrounds
12
Q
What can sexual abuse include
A
Penetrative and non penetrative acts, non contact acts such as involving children in looking at or being involved in the production of pornographic material or watching sexual activities or encouraging children to behave in sexually inappropriate ways
13
Q
What categories of children are at increased risk of abuse
A
Disabled children and non verbal
Asylum seeking / refugee children, private fostered
Children in care and children in secure accommodation
Children <1 year
14
Q
Why are children <1 year statistically most at risk
A
Injuries can be hidden
Non mobile children should not have bruises
Harder to recognise
15
Q
What are other risk factors that need to be considered
A
Domestic abuse
Are the family already known to social care
Is there a history of mental health problems
Is there a history of substance misuse
Are there other children in the house, they may need immediate protection
16
Q
What should you do if a disclosure is made
A
Tell the child or parent they have done the right thing by telling you
Avoid making comments or judgements about what is shared
Tell the child or parent what will happen next and be honest, dont break a childs trust
Document clearly
Tell a senior colleague
17
Q
What should you look for when examining a child
A
Look for injuries and document any
Document birth marks, demeanour
Document any rashes
18
Q
What should you do if you have a safeguarding concern
A
Ensure everything is documented
Share that worry with a seniour colleague
Refer to childrens social care
Arrange an appropriate child protection medical
CSC will ensure the child is safe
19
Q
What does ‘safe’ mean
A
Doesnt necessarily mean that the children are removed from their family, simple things like more support, supervision, behaviour management, housing support or education is often sufficient
20
Q
What does a paediatric history taking involve
A
Antenatal and birth details Early development Hearing and vision Family and social history School Nutrition
21
Q
What are the phases of growth and development and life
A
Prenatal Neonatal Infancy Pre school Primary school Secondary school
22
Q
What factors are measured in a growth assessment
A
Weight
Height / length
Head circumference (widest possible measurement)
BMI - limited value in a child as many toddlers are chubby but lose it after age 5
Pubertal stage
Bone age
23
Q
What is given if growth is not in conjuction with bone age
A
Growth hormone
24
Q
What happens when growth plates are fused
A
You stop growing
No gap between bones as they have been ossified (cartilage in between has gone- looks like a gap on xray as cartilage cant be seen on xray)
25
What is turner syndrome
Missing x chromosome
Short stature
Failure of ovaries to develop
Heart defects
26
What are the 4 domains of development
Gross motor
Fine motor
Language
Social
27
What are the stages of gross motor development
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3 months- head control when sitting
4-5 months - roll
9 months - sit unaided
8-10 months - crawling
1 yr - standing up
13-18 months - walking unaided
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28
Stages of fine motor and vision development
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6 weeks - palmar grasp
3 months - hand play
5 months - reaching
6 months - transfer
9 months - pincer grip
15 months - scribble
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29
Stages of language and hearing development
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Birth - cry and responds to sounds
8 weeks - vocalising
4 months - laughing
7 months - responds to names
12 months - single words
24 months - join 2 words together
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30
Stages of social and behavioural development
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6 weeks - smiles reponsively
6 months - finger feeds solids
9 months - wave bye
15 months - drink from a cup
22 months - knows body parts
3 years - feed with knife and fork
3 years - referential play
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31
How should you calculate age of a preterm child
Up to age 2 subtract how many week premature they were from their age
32
What should be a concern if a childs development is not sequential
Eg they were walking and then reverted to crawling - sign of a brain tumour
33
What are red flags in abnormal development that require thought
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Not similing at 8 weeks - a sign of lack of hearing
Not sitting at 9 months
Not walking unsupported at 18 months
Fewer than 6 words by 18 months
Apparent loss of skills
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34
What are the different forms of eczema
Atopic eczema (infantile)
Contact dermatitis
Pompholyx - vesicles on hands or feet, related to fungal infection, heat and stress
35
What is hyperkeratotic palmar eczema
Common in the middle aged
| Fissured eczema on hands
36
What is seborrhoeic eczema
Cradle cap
Common in babies
Treated with anti fungal shampoo
37
What is asteatotic eczema
Reduced lipids in the skin
Drying and cracking
Common in the older patient
38
What is atopic eczema
Inherited tendency for asthma, hayfever and eczema
Sensitivity to allergens
Dry and inflammed skin aggravated by cold, hear, hard water, infections, clothes
Often develops at 3 months - most grow out of it
Pruritis is prominent
Itchy papules on cheeks
Felxurs affected, elbows and knees; skin dry and lichenified
Infection risk through scratching
39
How to manage eczema with cleansing
Regular but not excessive washing, using emulsifying ointment - avoid soap
Bathe in emollient (hydrating agent)
Regulat emollient cream
40
How to manage eczema with the environment
Keep the house cool
| Limit allergens in the house- dust house mite increases severity
41
How to manage the scratching element of eczema
Cut nails
| Sedative oral antihistamine at night
42
When are steroids used in eczema
When emollients are not sufficient
| Topical 1% hydrocortisone (infants under 1) very effective
43
How to counsel a parent for a child being prescribed steroids for eczema
```
Apply thinly and evenly spread
Avoid face (telangiectasia- thinning of skin and prominent blood vessels) and anogenital region (scrotal skin absorbs 80x better than other skin)
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44
What are some of the side effects of more potent steroids
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2 degree infection
Thinning of skin
Telangiectasia
Acne
Mild depigmentation
Pituitary-adrenal axia suppression
Cushings
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45
Treatment options for infected eczema
Topical antiseptic - povidone
Topical fusidic acid or mupirocin
If widespread, oral flucoxacillin or erythromycin
Dermatophytes - topical antifungal
Eczema herpeticum (when eczema has been infected with herpes) - emergency IV antivirals in hospital
46
What is contact dermatitis
Irritant reaction to chemicals eg detergents, nickel, cosmetics
Atopy is a predisposing factor
Dryness and chapping
Remove contact
Emollients, barrier creams, topical steroids, oral antihistamines
47
What is napkin dermatits
Contact dermatitis +/- infection
Irritation to ammonia - skin folds not affected
Improve hygeine, barrier creams, emollients
Infection- skin folds affected. Often fungal
48
Treatment for psoriasis
Emollients
Topical steroids - anti inflammatory
Topical dithranol- antiproliferative; inhibits DNA synthesis often 1st line
UV- with psoralen. Bathe in psoralen prior to UVA, photosensitizing agent
49
When are oral retinoids used to treat psoriasis
After methotrexate and ciclosporin
They bind to nuclear retinoic acid receptor and affect gene transcription - antiproliferative
50
Risks of oral retinoids
Teratogenic
Avoid pregnancy for 3 years after stopping as accumulates in the fat
Negative pregnancy tests and 2 forms of contraception needed
51
What is ringworm
Fungal infection
Discoid, scaly regions
Culture of skin scrapings is best practice
52
What is acne vulgaris
Excessive sebum production
Comedones (blackheads)
Pustules (white heads)
53
How does co-cyprindiol ethinylestradiol contraceptive treat acne
It balances the imbalance of oestrogen and androgens
| Androgens drive the excessive sebum production
54
What is rosacea
An inflammatory condition
Acneform lesions, telangiectasia but not comedones
Commoner in women, during / after menopause
55
Treatment of rosacea
```
Topical metronidazole (antibacterial)
Then oral erythromycin or tetracycline
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56
What is a basal cell carcinoma
Small blackish area (often on the edge of the ear / temple)
Small colourless lump with pearly edges
Very slow growing - takes years
It is a malignant tumour but with limited local invasion
Cured by surgical removal - 97% cure rate
Extensive lesions may require radiotherapy or cryotherapy
57
What is a malignant melanoma
Evolution and possible malignant transformation in a large mole to produce malignant melanoma
More likley in large than small moles, in sun exposed skin
Itch
58
What is the ABCDE signs of a malignant melanoma
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Asymmetry
Border irregular
Colour irregular
Diameter >0.5cm
Elevation irregular
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59
Treatment of a malignant melanoma
Surgical excision outlook good. If the thickness of the lesion is <1.5mm the 5 year survival is 92% but only 37% for a more neglected lesion of >3mm thickness
Chemotherapy is palliative in disease which has spread
60
What is a pre term neonate
23-37 weeks gestation
| Rapid growth, fully formed, most systems not fully developed
61
What is a neonate
Birth - 1 month
| Normal initial period of human development and growth
62
What is an infant
One month - one year
| High growth rates and rapid changes
63
What is a child
One - 12 years
| Slower growth and development
64
What is an adolescent
12-18 years
| Final period of growth and puberty, stretching into adulthood
65
How are children different to adults
Organ systems develop throughout infancy, childhood and adolesence
Often poorer reserve in overdose
Inability / reluctance to swallow tablets, have injections etc
66
What are the 4 pharmacokinetic processes
Absorption
Distribution
Metabolism
Excretion
67
What is the primary organ for drug
Kidney
68
What organ is primarily responsible for drug metabolism
Liver
69
Define absoprtion
The extent to which the administered dose is transported to the blood stream and the speed with which this happens
70
Describe oral absorption in children
Neonatal / early absorption very unpredictable - use IV if patient is acutely unwell and / or the medicine is critical
Similar to adults from 4-6 months of age
71
Describe IM absorption in children
Unpredictable due to variable blood flow, reduced muscle mass and fewer muscle contractions in neonates and sedated / paralysed children
Painful - avoid if at all possible - ok for single doses
72
Describe percutaneous absorption in children
Enhanced in neonates and infants- higher risk of toxicity from drugs and excipients
73
Describe rectal absorption in children
Slow and unpredictable, especially in neonates
74
Describe the process of distribution of drugs in a child
Higher total body water in neonates affects water soluble drugs eg gentamicin
Continues to change right through adolescence but greatest changes occur during the first year of life
Reduced plasma protein concentration (drugs carried around the body attached to plasma proteins) binding capacity and affinity in neonates
75
What are hepatic phase I liver enzymes
Mature over the first few months of life. Adults levels reached at 6 months
Oxidation, reduction and hydrolysis reactions
76
What are hepatic phase II liver enzymes
Increase significantly over first 2-3 months of life. Adult levels reached at about 3 years of age (acetylation and glucuronidation reactions)
Present at birth at similar levels to those found in adults (sulphate conjunction, glycine conjugation)
77
Describe GFR in babies
Is bad at birth even in healthy babies
Around 20
90 is the lower end of adult volume
78
Describe excretion in neonates
GFR is low initially but improves rapidly in babies born >1.5kg over the first 14 days of life
Tubular secretion increases more slowly and is close to adult values by age 8-12 months of age
Impact is on renally excreted drugs (eg gentamicin, cefuroxime)- some drugs are dosed on post menstrual age, others on post natal age
79
What are the different ways of calculating dosage in a child
By age:
Ok for drugs with low toxicity / wide therapeutic window
By weight:
Most common, need to check weight seems sensible. Do not exceed the adult dose
By surface area: most accurate
80
Problems with oral liquid medicines
Not available for all drugs
| Multiple strenghts of liquid for the same drug (potential for confusion and under / over dose
81
Why are children more likely to be given overdoses than adults
Due to dosing being done universally for adults and scaling down for children
82
What is off label prescribing
Licensed drugs that have only been tested in adults so there is a greater degree of responsibility placed on the prescriber.
Means safety and efficacy cannot be assured
83
What is a prescribing error
The result of a prescribing decision or prescription writing process that results in an unintentional but significant reduction in the probability of the treatmetn given being timely anf effectively or an increased risk of harm compared with generally accepted practice
2-3 times more common in children
84
Why are children at greater risk of medication errors
Drug doses calculated individually, based on a patients age, weight or body surface area - often complex
Changing weight and pharmacokinetics throughout childhood
Lack of suitable dosage forms - need for dilution, measurement of small volumes
85
How are child medication errors avoided
Review doses frequently
Information in BNFC often complex - find right section for the patient
86
What are examples of common sources of error when prescribing for children
Miscalculations (10 fold and 100 fold overdoses)
Confusion between mg/ kg / dose versus mg/ kg / day
Confusion between doses in mg and ml
Confusion between units
87
Things to remember in order to prescribe safely to children
Use the BNFC checking that you have the right dose for the patients age, weight and condition
Watch out for maximum doses: should not exceed the adult dose
Check weight is appropriate for age
Check if patient has allergies
88
What are the different stages of childhood
Neonates- newborn (anything from preterm to 1 month)
Infants - up to 1 year
Child - 1-12 years
Adolescent - 13-16
89
Describe the upper respiratory system of a neonate / infant
Large head, short neck, prominent occiput (lots of mouth breathing, promotes rapid feeding)
Tongue is large
Larynx higher and anterior and more pliable (soft)
Epiglottis is long and stiff
Trachea relatively short
Mainstream bronchi have less of an angle than in adults
Smaller airway
90
Describe the lower respiratory system of the neonate / infant
Horizontal ribs (prevent bucket handle breathing action)
Not completely calcified
Diaphragmatic breathing
From birth - adolescence the rib cage increases in size, a decrease in thoracic kyphosis, ribs rotate inferiorly
They have 10% of the total number of alveoli found in adults so exhaust more quickly and have fewer type 1 fibres in respiratory muscles
91
What kind of airway obstruction occurs in the external to lumen
Masses
92
What kind of airway obstruction occurs in the intraluminal
Oedema
Anaphylaxis
Croup
Epiglottis tracheitis
93
What kind of airway obstruction occurs in the internal to lumen
Secretions
94
What is increased resistance in the airway caused by
Spasm (asthma)
| Infection
95
Describe respiratory rate in infants
Increased metabolic rate compared to adults so higher oxygen requirement
Rate varies with age and is irregular
Younger you are the few fatigue resistant fibres
96
Why does a difficulty to increase depth and strength of respirations lead to a greater dependence on respiratory rate
Horizontal ribs provide little leverage for increasing the AP diameter of the chest
Heart occupies a grater space in the thorax comparatively, less ability to increase lung volume
Diaphragm main muscle but restricted by small abdominal cavity
Less developed accessory muscle, more difficult to increase the strength and depth of ventilation
97
What are the signs of respiratory distress in an infant
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Flared nostrils
Frightened look
Pale skin
Blue nail beds
Rapid breathing
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98
What are some of the major CVS changes that occur after birth
Circulation (foramen ovale and ductus arteriosus begin to close)
Heart is large in the thoracic cavity, right V is stronger than the left (reverses in infancy) as heart pumps against a collapsed lung in utero
Size and weight of heart doubles in the first year of life
99
Average blood volume at different stages of childhood
Neonates 85-90 ml/kg
Infants 75-80 ml/kg
Children 70-75 ml / kg
Adults 65-70ml/kg
100
Why are musculoskeletal symptoms in children and adolescents common
Because the ossification sites are usually still cartilaginous in infants and young children and it is not until around 16 that nearly all the cartilage has been ossified
101
What are some musculoskeletal differences in children and how are they significant
More bony mass per unit area - quicker healing time
Greater vascularity - significantly reduced rates of non union
Thicker periosteum - higher degree of energy needed to fracture the bone
102
Why are physeal injuries (a growth plate weak portion of bone)
Unique to children
| Can be difficult to detect on xray as physis radiolucent and epiphysis may be incompletely ossified
103
What is a toddler fracture
Unidisplaced spiral fracture of the tibial shaft only
Usually <3 years
Low energy trauma with a rotational force (falling awkwardly)
104
Describe the oral cavity in an infant
Infants oral cavity is relatively small
| This combined with a large tongue promotes rapid feeding
105
Describe the salivary gland of an infant
Insufficient saliva in the first few months
| Salivation increases with teething
106
Describe the stomach of an infant
Limited capacity - increases quickly in the first month after birth due to frequent feeding
Immature lower oesophageal sphincter
In horizontally lying of baby the gastric fundus is lower as the antral part of the stomach- causes gastroeosophageal reflux
107
What is the impact of an infant having an underdeveloped liver
Decreased glycogen stores
108
Describe the small intestines of an infant
The small bowel increases in length with age from 150-200cm in the neonate to almost 6m in the adult
109
Describe the large intestine of the GI tract
Peyer’s patches appear at 2-3 years so local protection is weak
Haustra appear after 6 months
Muscle tissue is poorly developed so the propulsion capacity is insufficient
- major cause of constipation
110
Describe the urinary system at birth
Is immature
Kidneys are immature until 6 months
Renal blood flow and GFR are low in first 2 years of life due to high renal vascular resistance
Tubular function is immature until 8 months so infants are unable to excrete a large sodium load
111
Describe the skull of an infant
Sutures do not fuse until the head has reached adult size
Presence of fontanelle:
Anterior: palpated up to the age of 12-18 months
Posterior: may be palpated up to the age of 2 months
Thinner cranial bones
Growth of paranasal air sinuses
112
Describe the structure of the brain in the infant
Neonate - already has about all of the neurons it will ever have
Doubles in size in the 1st year
2/3 years - has up to twice as many synapses as it will have in adulthood
3/4 years - it has reached 8-% of its adult volume
113
Where does the spinal cord terminate
Neonates / infants - L2/L3
| Adolescent - L1/2
114
Why are infants at an increased risk of brain injury
Thinner bones
Head larger, higher centre of gracity - theoretical risk of increased head trauma
Increased risk of hypoglycaemia
Less mature blood brain barrier - increased risk of infection
115
What are protective measures for brain injury
Open sutures: volume can expand decreasing the risk of RICP (restricted intra cranial pressure)
116
Developmental factors to monitor in children
Visual, hearing, toilet trained
School performance
Behavioural issues
Puberty
117
What is the HEEADSSS acronym
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Home and relationships
Education and employment
Eating
Activities and hobbies
Drugs, alcohol, smoking
Sex and relationships
Self harm, depression and self image
Safety and abuse
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