paeds 3rd year (not trauma) Flashcards
child protetction
activity undertaken to protect specific children who are suffering or are at risk of suffering significant harm
‘children in need’
require additional support/services to achieve their full potential
safeguarding
measures taken to minimise the risks of harm to children
- protection from maltreatment
- preventing impairment of health or development
- ensure growing up in safe and caring env
neglect
failure to meet child’s needs
child abuse definition - 3 elements
1 - significant harm to child
2 - carer has some responsibility for that harm
3 - significant connection between carer’s responsibility for child and harm to child
child protection legislation and guidance
National Guidance for Child Protection in Scotland 2014 - Scottish Gov
Children and Young People’s Act 2014
GIRFEC
parenting capacity - 3 big concerns
domestic violence
drug and alcohol misuse
mental health problems
cumulative problems increase likelihood of a negative outcome
aetiology of child abuse - contributing factors
adult
- drugs, alcohol, poverty, unemployment, marital stress, mental illness, disabled, domestic violence, step-parents, isolation, abused as a child, unrealistic expectations
child
- crying, soiling, disability, unwanted pregnancy, failed expectations, wrong gender, product of forced/coercive/commercial sex
community/env
- housing conditions, neighbourhood
family violence and dysfunctional family
- intergenerational cycle, violence towards pets, social isolation, poverty
categories of child abuse
physical
emotional
neglect
sexual
vulnerable children
U5s
irregular attenders
- repeatedly DNA, return in pain, exposed to GA risks
medical problems and disabilities
- more at risk
- serious impairment of health/development is more likely as a result of untreated dental disease
- ‘looked after’ children
child’s needs
nutrition warmth clothing shelter hygiene health care stimulation education affection
effects of neglect
failure to thrive/short stature
inappropriate clothing, cold injury, sunburn
ingrained dirt (finger nails), headlice, caries
developmental delay
withdrawn/attention-seeking behaviour
short-term damage caused by neglect
physical health
emotional health
social development
cognitive development
long-term damage caused by neglect
adults neglected as children have higher incidence of:
- arrest
- suicide attempts
- major depression
- diabetes
- heart disease
definition of dental neglect
persistent failure to meet a child’s basic oral health needs, likely to result in the serious impairment of a child’s oral or general health or development
- broader definition than USA - doesn’t have to be wilful just persistent
neglect of neglect
less incident focused
less understanding
dental-general neglect
severe dental disease can cause: - toothache - disturbed sleep - eating problems - school absence may put child at risk of: - teasing - repeated ABs - repeated GAs - severe infections
current child protection guidance
Child Protection and the Dental Team
is dental neglect wilful neglect?
after problems pointed out:
- irregular attendance
- repeated failed appts
- failure to complete tx
- returning in pain at repeated intervals
- repeated GA for exts
why shouldn’t you make dental neglect assumptions?
caries multifactorial
varied individual susceptibility
inequalities in dental health
inequalities in access to dental tx
indicators of dental neglect
obvious dental disease
impact on the child
practical care has been offered, yet child has not returned for tx
managing dental neglect stages
preventive dental team management
preventive multi-agency management
child protection referral
managing dental neglect - preventive dental team management
raise concerns with parent
offer support
set targets
keep records and monitor progress
managing dental neglect - preventive multi-agency management
liase e.g. HV, school nurse, GP, social worker to see if concerns are shared
may be subject of CAF at this level
check if child subject to child protection plan
agree joint plan, review agreed intervals
letter to HV of <5s who fail appointments and have failed to respond to letter from practice “if this family is known to you, we would welcome working together to promote their oral health”
managing dental neglect - child protection referral
complex/deteriorating situations
follow local guidelines
to SS
- usually telephone followed up in writing
assessment framework for safeguarding
child’s developmental needs
family and env factors
parenting capacity
physical abuse - differentiating
overchastisement (cultural) acute/compassionate (shaking) - spontaneous uncalculated reaction - remorse, takes app action - child's needs priority chronic/pathological (way of life) - help sought but not actively - no remorse - child's needs not priority
what % of injuries in abuse cases are H and N?
60%
95% serious head injuries in 1st year of life are abuse
typical accidental injuries
bony prominences one side match history in keeping with development of child head: parietal bone, occipuit of forehead nose chin palm hand elbows knees shins
non-accidental injuries concerns
both sides STs patterns doesnt fit explanation delays in presentation untreated injuries
non-acccidental injuries regions
black eyes (esp bilateral) ears (esp pinch marks) STs of cheeks IO injuries "triangle of safety" - ears, side of face and neck, top of shoulders forearms (raised to protect self) chest and abdomen inner arms back and side of trunk (except over bony spine) groin/genital inner thighs soles of feet
orofacial signs of abuse: EO
bruising: punch, slap, pinch bruising of ears: pinch, pull abrasions and lacerations burns and bites neck - choke/cord marks eye injuries hair pulling fractures
IO signs of abuse
contusions bruises - can bruise HP themselves but would always want to ask about this injury - force feeding etc abrasions and lacerations burns tooth trauma frenal injuries
about a third prevalence
major clinical features of abuse
skin lesions - bruises, burns, bites, lacerations bone lesions - fractures intracranial lesions - from shaking visceral lesions (intra-abdominal) - blunt trauma bruising of different vintages tattoo bruising grip marks slap marks
child abuse - what could look similar to cigarette burns?
impetigo
child abuse - what could look similar to bruises?
birthmarks
child abuse - what could look similar to trauma?
facial infection
child abuse - what could look similar to lots of bruising?
coagulation problems
index of suspicion
delay in seeking help story vague, lacks detail, varies account not compatible with injury parents mood abnormal e.g. preoccupied parents behaviour concerning child's appearance and interaction with parents is abnormal child may say something contradictory history of prev injury history of violence in family
role of dental team in abuse
observe record communicate refer - not expected to diagnose
physical abuse - final checklist
could injury have been caused accidentally? how?
does explanation fit age and clinical findings?
if explanation is consistent with injury, is this itself within normally acceptable limits of behaviour?
if delay in seeking advice, are there good reasons why?
child’s general demeanour
parent child relationship
child’s reaction to other people
reaction of child to medical/dental exam
any comments by child/guardian that give concern about child’s upbringing or lifestyle
Shared Referral form
your details (designated contact person) referral to subject of referral - language - any disability family details - other adults/siblings summary of concerns reason for referral agreed actions (from phone referral) agency involvement
disguised non- compliance
appts booked but always cancel at last min so you never see them
CYPA and info sharing
duty to share any concern about a risk to a child’s wellbeing with NP
also share info in relation to a child’s plan
not restricted to instances where there is a significant risk of harm
specific provision that info can be shared even where this breaches confidentiality
if making the referral - what to tell parent
should discuss with parent, unless for safety
if dental neglect good to tell them as they will realise it is you
infections
PHG herpangina HFM disease HPV candida
PHG cause
HSV
- primary infection can be subclinical - often U2s
PHG symptoms
widely varying severity
- pyrexic, malaise, loss of appetite
- can cause severe systemic upset
- vesicles on mucosa, rupture - ulcers 1-3mm
- fiery red gingivae
- v painful
- refuse to eat/toothbrushing
- halitosis
PHG tx
supportive only: fluids, analgesics, bed rest
reassurance - self-limiting, resolves 7-10 days
?acciclovir? - only in v early stages or if pt immunocompromised
herpangina
highest incidence in young children 2-9 day incubation fever, malaise, muscle pain pinhead vesicles on tonsils, uvula, SP vesicles rupture to form large ulcers heal 5-7 days no gingivitis less unwell lesions all at the back
HFM
1 week incubation coxsackie A16 vesicular rash on limbs, fingers and toes oral lesions on tongue/buccal mucosa ulcers shallow, painful, self-limiting
minor aphthae location
recurrent ulcers on non-keratinised mucosa
- labial, buccal, FOM
minor aphthae - prevalence
> 2%
minor aphthae - aetiology
? stress FH HLA type immunological (altered T cell ratio)
some go on to develop crohns disease
many have relative Fe deficiency due to increased demands of growing or menstrual blood loss
ulceration
minor aphthae
major aphthae
trauma
minor aphthae - management
Fe replacement
tx symptoms e.g. difflam MW
prevent secondary infection
minor aphthae - features
well-demarcated variable size red halo 1-10 heal 1-3 weeks no scarring more common second decade
cause of HPV
verruca vulgaris
papillomas
focal epithelial hyperplasia (Heck’s disease)
HPV presentation
warts on lips and tongue papillomas on gingivae and palate - "cauliflower" appearance - localised - increased incidence in immunocompromised
eruption cyst location
superficial to crown of an erupting tooth
11% of infants develop over incisors, 30% over canines/molars
more prevalent in maxilla
features of eruption cyst
dilation of follicular space around crown
compressible
can become infected
resolve when tooth erupts
like a blood filled blister ahead of tooth
causes of trauma
accidents - physical/chemical/electrical assault/NAI self-inflicted - Lesch Nyhan syndrome radiation
traumatic ulcer
history
non-recurrent
less well-defined
irregular outline
causes of self-inflicted trauma
self-harm/accidental
mucoceles v common
ranula
OFG associated disease
Crohns
OFG features
2nd-3rd decade presentation lip swelling biopsy shows non-caseating granulomas Langhans type giant cells lymphocytic infiltrate swelling due to oedema cobblestone mucosa deep penetrating ulcers mucosal tags gingivitis pyostomatitis
tx of OFG
patch testing (allergies - cinnamaldehyde, E numbers) dietary avoidance systemic steroids
proliferative conditions - benign
fibroepithelial polyp
pyogenic granuloma
giant cell granuloma
proliferative condiitons - malignant
most common cause of death in childhood
leukaemia
lymphoma
rhabdomyosarcoma
fibroepithelial polyp
exaggerated response to “trauma”
usually excised
- probably wouldn’t if need a GA for it
squamous epithelium overlying fibrous CT, minimal inflammation
pyogenic granuloma
fibro-endothelial growth gingival margin common in children red/purple, v vascular mimic haemangioma ulcerate and can bleed profusely complete excision? - cryo - shrink it
leukaemia
peak age 2-5yrs M>F 80% ALL best prognosis F 4yrs gingival bleeding, fatigue etc (like primary herpes)
congenital/hereditary condiitons
geographic tongue
hereditary gingival fibromatosis
haemangiomas
geographic tongue
2-10% prevalence <4yrs most common red zones of depapillation, move around - snake like appearance white margins due to heavy infiltration no successful tx - benign, doesnt bother child much, can struggle with spicy and minty toothpastes
hereditary gingival fibromatosis
non-specific progressive enlargement may be localised e.g. palatal aspect of the tuberosities, or generalised may be isolated or part of a syndrome teeth don't look fully erupted may do gingivectomy with electrocautery need vvv good OH tends to regrow, may need redone
drug induced gingival hyperplasia
phenytoin - epilepsy
cyclosporin - transplant patients
haemangioma
present at birth or soon after grow rapidly malformations of blood vessels benign tumour, endothelial proliferation capillary/cavernous can occur within bone most will involute spontaneously problems with extracting teeth - need a scan first
endo in primary molars - consequences of inadequate tx
pain
infection (overall growth)
damage to permanent successor - hypoplasia
loss of space (drifting)
endo in primary molars - considerations
rapid caries progression small teeth, large pulp chambers broad contact areas irreversible pathological changes before pulp exposure early radicular pulp involvement
endo in primary molars - at what point is there likely to be pulpal inflammation?
> 2/3 marginal ridge breakdown, likely to be at least pulp horn inflammation, may extend
endo in primary molars - indications
good cooperation avoid GA MH precludes ext - bleeding disorder etc lack of permanent successor - hypodontia pt age ortho considerations - space preservation
endo in primary molars - why would you never do under GA?
not guaranteed success so would just extract
endo in primary molars - contraindications
poor cooperation MH precludes pulp tx - immunocompromised/cardiac pt age ortho - space closure desired severe/recurrent pain space management advanced RR cellulitis pus in pulp chamber gross bone loss
