Paediatrics seminar: child in the family

Question 1

What are live attenuated vaccines?

Answer 1

• Viral e.g. MMR, varicella, rotavirus
• Bacterial e.g. BCG

Question 2

What are inactivated vaccines?

Answer 2

• Whole viral/bacterial e.g. polio, hep A
• Fractional e.g. hep B, influenza, acellular pertussis, HPV
• Polysaccharide based: pure polysaccharide e.g. PPSV23, conjugated vaccines: PCV13, Hib

Question 3

What is the timeline for childhood vaccination in public sector?

Answer 3

Question 4

What is the timeline for childhood vaccination in private sector?

Answer 4

Question 5

Why is measles vaccine given at 12 months?

Answer 5

MMR and varicella vaccines are live vaccines
Circulating maternal antibodies in babies <12 months old could neutralize the vaccine

Question 6

Why is MMR and varicella vaccines not given in combination at 1 years old?

Answer 6

The risk of febrile convulsion is slightly higher with the measles, mumps, rubella, varicella (MMRV) combination vaccine is given than MMR and varicella vaccines are given separately.

Question 7

What is the definition of obesity in children?

Answer 7

• Sex- and age-specific BMI percentile
• Overweight: BMI 85th to 95th cenrile
• Obesity: BMI >95th cenrile
• severe obesity is defined as BMI ≥120% of the 95th percentile or a BMI ≥35kg/m2 (whichever lower)

Question 8

What is the definition of overweight used in SHS?

Answer 8

Question 9

What is the history for obesity in child?

Answer 9

Pathological vs simple obesity: onset of obesity, stunted growth (hypothyroidism or cushing syndrome), features of monogenic obesity
History on diet, excercise, screen time and sleeping habits
Comorbidities: joints pain, OSA symptoms, polyuria/polydipsia (rare in early T2D)

Question 10

What is the age of onset of monogenic obesity?
What features?

Answer 10

Onset usually <5y

Other features:
* Extreme hyperphagia, developmental delay, unique dysmorphism (e.g., characteristic faces in Prader Willi syndrome; syndactyly, brachydactyly or polydactyly in Bardet-Biedl syndrome),
* Visual problem (e.g., retinal dystrophy in Bardet-Biedl syndrome, Alstrom syndrome and TUB deficiency)
* Hearing impairment (e.g., TUB deficiency)

Question 11

What to do in child obesity physical exam?

Answer 11

Question 12

What are the comorbidities of obesity?

Answer 12

• Pre-diabetes/type 2 diabetes
• Prehypertension/hypertension
• Obstructive sleep apnoea
• Dyslipidaemia
• Fatty liver
• Polycystic ovarian syndrome
• Evidence that obesity tracks from childhood to adulthood
• Persistent excess in adiposity would increase the risk of type 2 diabetes, hypertension, dyslipidemia, and carotid- artery atherosclerosis in adulthood
• Psychologicaleffects
• Depression, low self-esteem, emotional and behavioral problems..

Question 13

What is the management of childhood obesity?

Answer 13

• To adjust the chronically positive energy balance
• A BMI reduction of > 0.25 SDS (~BMI reduction of 1 kg/m2)
• Associated with a reduction in cardiovascular risk
• Developmentally appropriate and agreeable by the child and adolescent
• Incremental goal in each clinic visit
• Initial goal: not aiming at weight reduction, but merely change in weight gain trajectory or modification in lifestyles
• Growing child: a static body weight would indeed translate to improvement in BMI
• Mainly focus only lifestyle modification: exercise and diet control
• Pharmacological agents/bariatric surgery: reserved for severe obesity refractory to lifestyle modifications/those with obesity related complications

Question 14

What are common developmental problems?

Answer 14

* Global developmental delay/intellectual disability(ID) * Physical impairment
* Autism spectrum disorder(ASD)
* Attention deficit hyperactivity disorder
* Anxiety disorder
* Acquired brain injury with cognitive impairment * Specific learning disorder (SLD)
* Developmental coordination disorder (DLD)
* Hearing Impairment
* Visual impairment

Question 15

What is global developmental delay?

Answer 15

Significant delay in at least 2 developmental domains from the following
* Gross or fine motor
* Speech language
* Cognition
* Social/personal
* Activities of daily living

Question 16

What is intellectual disability

Answer 16

Question 17

What are developmental red flags?

Answer 17

• No head control by 6m
• Noreachoutby6m
• Cannot stand with support by 12 m
• Not walking by 18 m
• No single words by 2 years
• No sentence by 3 years
• School age children with learning and self-care problems

Question 18

Child with intellectual disability, what can be done?

Answer 18

Question 19

What is the most common motor disability in childhood?

Answer 19

Cerebral palsy: a group of permanent disorders of the development of movement and posture, causing activity limitations that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain
Often accompanied by disturbances of sensation, perception, cognition, communication and behaviour; by epilepsy

Question 20

What are possible early motor features in the presentation of cerebral palsy?
What are common delayed motor milestones in children with cerebral palsy?

Answer 20

 unusual fidgety movements or other abnormalities of movement, including asymmetry or paucity of movement
 abnormalities of tone, including hypotonia (floppiness), spasticity (stiffness) or dystonia (fluctuating tone)
 abnormal motor development, including late head control, rolling and crawling
 feeding difficulties.

Delayed motor milstones
 not sitting by 8 months (corrected for gestational age)
 not walking by 18 months (corrected for gestational age)
 early asymmetry of hand function (hand preference) before 1 year (corrected for gestational age).

Refer children who have persistent toe walking to a child development service for further assessment.

Question 21

What are the types of cerebral palsy?

Answer 21

• Hemiplegia
• Spastic diplegia: common in premature baby, benefits from neuromotor rehabilitation intervention
• Dystonic, dyskinetic CP
• Spastic dystonic quadriplegia

Question 22

What is the management of cerebral palsy?

Answer 22

Question 23

What is the ddx for cerebral palsy?

Answer 23

Question 24

What is autism spectrum disorder characterized by?

Answer 24

• characterized by severe pervasive impairment in several areas of development:
  1. Abnormalities in communication and reciprocal social interaction
  2. Restricted, repetitive and stereotyped patterns of behaviour, interests and activities (RRB)

Question 25

What are the red flags of ASD?

Answer 25

* Poor social interaction – Poor eye contact, poor response to name calling, poor joint attention, seldom shares enjoyment or things of interest with others * Poor language development – No words by two, echoes what others say, poor communication skills; poor symbolic, imaginative or interactive play * Restricted, stereotyped, repetitive behavior that are abnormal in content and focus; inflexible adherence to specific, non-functional routines and rituals

Question 26

What can be done for children with ASD?

Answer 26

* Interimsupportinchildassessmentcentre–Parentinformationday/ training by HA therapists * ReferraltoChildPsychiatry * Mildsymptomswithgoodgeneralfunction:NKG +/- OPRS, EETC or ICCC * More severe symptoms:SCCC * School age children:EDBSENsupport * School age children with ID:Specialschool

Question 27

What are the types of common anxiety disorders and treatment?

Answer 27

Treatment: cognitive behavioural therapy choice for children medical treatment: for severe case or ineffective CBT, SSRI as 1st line

Question 28

What is the maternal and child health centers (MCHC) under? What is integrated program for?

Answer 28

Under the family health service An integrated child health and development program Core components of the integrated program: * Parenting * Immunization * Health surveillance * Developmental surveillance

Question 29

What is the student health service (SHS) under? What is it comprised of?

Answer 29

Under department of health Safeguard both the physical and psychological health of school children through health promotion and disease prevention services Consists of * 12 student health service centers (SHSC) * 3 special assessment centers * 4 regional offices of adolescent health program (equip adolescents, their parents and teachers with knowledge, attitudes and skills)

Question 30

* Which of the following scenarios fulfils the definition of anaphylaxis? a) A 5y.o. girl, 5-min after ingestion of peanut, develops generalized urticaria and swelling of the eyes and lips b) A 5y.o. girl, 5-min after ingestion of peanut, developed hoarseness of voice c) A 5y.o. girl, 5-min after ingestion of peanut, repeatedly vomits but no other symptoms d) A 17y.o. girl, 6 hours after a dental extraction surgery, developed painful swelling of the eyes and lips without urticaria. Her mother had similar recurrent and unprovoked episodes previously.

Answer 30

b) A 5y.o. girl, 5-min after ingestion of peanut, developed hoarseness of voice

Question 31

* A 5y.o. girl, 5-min after ingestion of peanut, developed generalized urticaria, lip swelling and repeated vomiting. What is the first treatment that you should give a) IV hydrocortisone b) IV chlorpheniramine (or piriton) c) IM adrenaline d) Oral prednisolone

Answer 31

c) IM adrenaline

Question 32

* Which of the following scenarios should be referred to an allergist to receive vaccine? a) MMR vaccine for a 12-month-old boy with mild egg allergy (urticaria only) b) 18-year-old with peanut and egg anaphylaxis hoping to receive COVID-19 mRNA vaccine c) 27-year-old man with egg anaphylaxis planning to visit Kenya required to receive Yellow Fever vaccine d) History of large local reactions at the injection site after inactivated influenza vaccines

Answer 32

c) 27-year-old man with egg anaphylaxis planning to visit Kenya required to receive Yellow Fever vaccine

Question 33

What is the definition of anaphylaxis?

Answer 33

One of the following 2 criteria * Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (e.g. generalized hives, pruritus or flushing, swollen lips/tongue/uvula) AND AT LEAST ONE OF THE FOLLOWING: * Respiratory compromise (e.g.dyspnea,wheeze-bronchospasm,stridor,reducedPEF, hypoxemia) * ReducedBPorassociatedsymptomsofend-organdysfunction(e.g.hypotonia [collapse], syncope, incontinence) *Severe gastrointestinal symptoms (e.g.severe crampy abdominal pain, repetitive vomiting), especially after exposure to non-food allergens * Acute onset of hypotension OR bronchospasm or laryngeal involvement after exposure to a known or highly probable allergen for that patient (minutes to several hours), even in the absence of typical skin involvement.

Question 34

What is basic principles of anaphylaxis management?

Answer 34

* Remove the allergen * Assess vitals (airway, breathing, circulation) * Give IM adrenaline 1:1000 * Reassess eficacy, may need second dose in 5-15 mins * Consider other drugs (long acting non sedating antihistamines, corticosteroids, bronchodilators)

Question 35

What is vaccine allergy?

Answer 35

* IgE mediated/immediate type allergic reactions to any component of a vaccine * Anaphylactic reactions to vaccines are estimated to occur at a rate of approx 1 per million doses. Other types of immune mediated reactions to vaccines * Type 4 delayed hypersensitivity reactions, usually mild * Arthus type reactions (type 3): rare, local vasculitis phenemenon complex deposition (when vaccinating a hyperimmunizaed patients by previous injections of a vaccine (tetanus) * ITP or GBS after influenza vaccines

Question 36

What are the non allergic reactions after vaccination?

Answer 36

Immunological/non immunological delayed vaccine reactions * Fever * Local reactions e.g. redness, swelling * Serum thickness/serum sickness like reactions: rash, fever, malaise, polyarthralgias, polyarthritis Reactions that mimic anaphylaxis * Vasovagal syncope (usually associated with bradycardia), whereas tachycardia is more common in anaphylaxis * Anxiety related symptoms: panic attacks: globus sensation, hypertension, tachycardia, dyspnoea

Question 37

What vaccines are relatively contraindicated in egg allergic patients? What proposed workflow for vaccinating patients with suspected egg allergy?

Answer 37

* MMR/MMRV vacines * Influenza vaccine * Yellow fever vaccine

Question 38

What is gelatin used as in vaccines? What food may have allergies previously? What investigations?

Answer 38

* Gelatin is added to vaccines as stabilizers * Gelatin allergic individuals may have previous reactions after ingestion of marshmallows or gummy candies Investigations * SPT and sIgE to gelatin * Skin testing to the gelatin-containing vaccines * Or use gelatin free version of the vaccine

Question 39

What is the overview of vaccine allergies investigations?

Answer 39

Question 40

What was the role of PEGs in COV19 vaccine?

Answer 40

PEG2000 bound to liposomal matrix that coats the viral mRNA of the covid19 vacine * Stabilizer to prevent premature degradation of the nanoparticles by the mononuclear phagocytosis system * A solublizer during the transition of the particles into the intracellular cytosol due to its hygroscopic properties * An adjuvant due to its immunogenic potential Hypersensitivity to PEG is VERY RARE Tends to react to higher molecular weights PEGs and at higher concentrations

Question 41

What is the investigations for PEG allergy?

Answer 41

Question 42

What is the DSM-V diagnostic criteria for ADHD?

Answer 42

Six (or more) symptoms of inattention >6m that is maladaptive and inconsistent with developmental level Six (or more) symptoms of hyperactivity-impulsivitiy >6m that is maladaptive and inconsistent with developmental level

Question 43

What is care for BCG scar?

Answer 43

Injection site reaction in almost all kids at 2-4 weeks: red, tender and indurated papule, progressing to become ulcerating healing No treatment is needed regardless the presence of lymphadinitis