paeds3 Flashcards

Question

Red Flags for PAED constipation

Answer 1

Infants presenting \<6 weeks of age — should be discussed with a senior doctor Delayed passage of meconium — most infants pass meconium in the first 24 hours of life (consider Hirschsprung disease or anorectal malformation) Ribbon like stools — consider anorectal malformation Weight loss/poor growth Persistent vomiting Abdominal mass (not consistent with large faecal mass)

Answer 2

**Principles - soften stool, empty bowel, encourage toileting** **Behaviour Modifications** **Position** — footstool to ensure _knees are higher than hips_. Lean forward and put elbows on knees. A toilet ring should be placed over the toilet seat if needed **Toilet sits** — _up to 5 minutes, three times a day, preferably after meals._ A timer in the bathroom can help. Encourage child to bulge out their abdomen. **Praise child for sitting on toilet.** Ensure toileting remains a positive experience **Chart or diary** — to reinforce positive behaviour and record frequency of bowel actions Encourage children to **exercise** more **Review toilet access** eg investigate barriers to using school toilets Delay toilet training attempts until child is *painlessly passing soft stool* **Dietary modification** Increasing dietary **fibre** is not an adequate treatment for constipation **Excessive cow milk intake** may exacerbate constipation in some children. More information can be found here (Nutrition – babies & toddlers) There is no need to increase fluid intake beyond daily maintenance fluid requirements as shown here **Medications** **Osmotic and lubricant laxatives** are usually required on a long term basis (months to years). Reassure parents that this is safe and doesn’t produce a ‘lazy bowel’ **Titrate medication aiming for one soft, easy to pass bowel action per day** A common cause of recurrence is stopping laxatives too early **First line treatment options (oral laxatives)** **Infants \<1 month**: _Coloxyl drops_ I**nfants 1–12 months**: _Iso-osmotic laxative (Movicol™ or Osmolax™) or Lactulose_ **Children**: _Iso-osmotic laxative or lubricant (paraffin oil)_ Children with stool with-holding behaviours, pain while defecating or rectal bleeding or fissures may benefit from inpatient disimpaction management Kids **over 18months** - 1) Hydration (lots of water) 2. Encourage regular exercise eg running 3. High fibre diet. Can try Prune Juice. 4. Toilet Sits 5. May need psych intervention if fear of toileting exists

Answer 3

USE **MOVICOL HALF -6.56g** Less than 1 year - 1/2 sachet in 60mls water 1-6 years - Full sachet in 60mls Water Over 6 years - 2 Sachets in 120 mls water Each sachet is 6.56grams Not 666 (656)

Answer 4

Monosymptomatic enuresis (MSE) is defined as enuresis without any other lower urinary tract symptoms or history of bladder dysfunction. **MSE** is usually divided into primary and secondary enuresis

Answer 5

For most children, enuresis is only seen as a problem when it interferes with their ability to socialise with friends (for example overnight stays or school camps). If the enuresis is infrequent and/or not distressing to the child or parents, treatment is not indicated

Answer 6

Most children who wet the bed have no significant underlying physical or emotional problems. However, many will feel embarrassed or ashamed and suffer from decreased self-esteem, particularly as the child gets older

Answer 7

**Daytime bladder control** and coordination usually occurs by **4** years of age, however **night-time bladder** control typically takes longer and is not expected until a child is **5–7** years old. At 4 years of age, nearly 1 in 3 children wets the bed, but this falls to about 1 in 10 by age 6

Answer 8

Much of the history should focus on **voiding habits** Onset of bedwetting (if **acute** — last few days to weeks — consider whether this is a presentation of **systemic illness**) Has the child previously been dry at night without assistance for 6 months? (If so, consider possible medical, emotional, or physical triggers). The presence of **unexplained persistent secondary enuresis** despite adequate management should prompt specialist referral Presence of day-time symptoms (**frequency, urgency, polyuria, dysuria/recurrent UTI, poor urinary stream/straining, leakage**). If daytime symptoms predominate, consider treating before bedwetting Bedwetting pattern and trend (nights per week/month, amount, time of night, arousal from sleep) Fluid intake (restrictions in fluid intake, caffeine containing drinks, **polydipsia)** Bowel habit (constipation/soiling) Sleeping arrangements and routine (including own bed/bedroom, snoring and disturbed sleep) Medical History: consider other co-morbid factors which may exacerbate or prolong nocturnal enuresis; developmental or behavioural problems, diabetes mellitus or sleep apnoea Family history of bedwetting or **renal problems** Social history; family capacity and motivation to engage in treatment, social difficulties (vulnerable child/family)

Answer 9

Height, weight, BP — **poor growth / loss of weight / hypertension** Abdomen — **distended bladder,** faecal mass Inspection of external genitalia (and perianal area if constipation also present) Lower Back/Spine – exclude occult **spinal dysraphism** or t**ethered cord (**asymmetric/deviation of gluteal cleft) Assessment of lower limb neurology

Answer 10

**Dipstick urinalysis** is not required in primary enuresis. Consider if red flags apparent. Further imaging or blood tests are not routinely recommended in enuresis

Answer 11

**General Advice** _1. Treat Constipation,_ if present, should be adequately managed before addressing enuresis 2. Advise on _normal bladder function and the pathogenesis of enuresis_, including the genetic tendency. Also, that this is a **common problem** effecting their peer group and they should not be embarrassed 3. Encourage **regular fluids and toileting throughout the day** (e.g. during school break times) and just before bedtime **Advise against fluid restriction**, but eliminate caffeinated beverages in the evening Both **parent and child must be motivated** before starting behavioural interventions **4. Bedwetting (Pad and Bell) Alarms** Considered the **most useful and successful initial** way to treat bedwetting - good long-term success and fewer relapses than medication Require a supportive and helpful family and it is important to communicate to families that it **may take 6–8 weeks** to work Generally recommended in **children from 6–7 years of age,** depending on their physical ability, maturity and motivation Mild to moderate intellectual impairment does not preclude treatment and **in hearing impaired children consider using a vibrating alarm** **Not suitable if the carer is experiencing emotional difficulty**, expressing anger or blame toward the child, or is unlikely to cope with the additional burden of a bedwetting alarm and sleep disruption in the household **Practical considerations and duration of therapy** Bedwetting **alarms are available for hire from selected pharmacies, community continence services, tertiary centres, and private practitioners. The Continence Foundation** of Australia has a list of service providers **Children should be ‘in charge’ of their alarm and may need to be woken initially to turn the alarm off themselves.** It is critical for success of alarm therapy that the _child is fully awake during the process of going to the bathroom_ *_Reward systems can be useful during alarm therapy to reward behaviours such as waking or going to the toilet when the alarm goes off (Not for dry nights per se)_* If a child is showing **early signs of response after 4 weeks, continue treatment until 2 weeks of uninterrupted dry nights** are achieved **Discontinue** treatment **if no early signs of response within 4 weeks** If there is **incomplete dryness after 3 months, reconsider if ongoing treatment is appropriate** or a further trial of the alarm in 3–6 months **5. Overlearning** **Once dryness is achieved for 2 weeks or more, consider introducing “overlearning”** — to over condition the bladder. _Encourage the child to drink extra fluids in the hour before bedtime, providing a greater challenge to remaining dry, which may reduce the rate of relapse_ **6. Pharmacological Therapy** Note: *_Tricyclic medications are no longer recommended._* They are less effective than other therapies and have a higher risk of adverse events **Desmopressin: MinirinTM melt/tablet** Indicated when: **alarm therapy has failed or is not suitable** **if rapid onset/short-term improvement is a priority of treatment** _Relapse rates are high when withdrawn, (60–70 percent)_ *Evaluate maturational appropriateness of use for children \<7 years of age* **Sublingual** **\>6 years, sublingual, initially 120 micrograms at bedtime; if needed, after 1–2 weeks increase to a maximum of 240 micrograms at bedtime** **Oral** _**\>6 years, oral,** initially_ **_200 micrograms at bedtime;_** if needed, increase to 400 micrograms at bedtime Intranasal route is _not recommended_ due to higher risk of _hyponatraemia_

Answer 12

Behavioural Therapy: Lifting, Walking & Waking Neither lifting (carrying a child to the toilet with an effort not to wake them) nor waking and walking the child to the toilet will promote long-term dryness Waking a child by parents or carers, either regularly or randomly, is only a short-term method of managing bedwetting. A young person who self-instigates waking (using a mobile phone alarm or an alarm clock) may be a useful strategy

Answer 13

Red flags are present Persistent enuresis with failure of an enuresis alarm Day-time enuresis or combined day/night enuresis after exclusion or treatment of a UTI and constipation History of recurrent urinary tract infections Comorbidities such as type 1 diabetes, physical or neurological problems Substantial psychological or behavioural problems (consider mental health referral, paediatrician and/or child protection services if significant concern exists)

Answer 14

Febrile neonates ≤28 days of corrected age require investigations (FBE; CRP; blood, urine and CSF cultures; ± CXR) and empiric iv antibiotic therapy

Answer 15

Remember that in babies under 3 months of age, hypothermia or temperature instability can be signs of serious bacterial infection (or other serious illness).

Answer 16

*Activity Breathing Circulation/Colour Dehydration Neuro Other* **Colour** Pallor\* (including parent/carer report) Mottled Blue/Cyanosed **Activity** Lethargy or decreased activity\* Not responding normally to social cues Does not wake or only with prolonged stimulation, or if roused, does not stay awake Weak, high-pitched or continuous cry **Respiratory** Grunting Tachypnoea Increased work of breathing Hypoxia **Circulation and Hydration** Poor feeding\* Dry mucous membranes Persistent tachycardia Central CRT ≥3 seconds Reduced skin turgor Reduced urine output **Neurological** Bulging fontanelle Neck stiffness Focal neurological signs Focal, complex or prolonged seizures Other Non-blanching rash Fever for ≥5 days Swelling of a limb or joint Non-weight bearing/not using an extremity

Answer 17

**Axillary temperature: recommended for patients \<3 months of age** For a more accurate reading, the thermometer should be placed over the axillary artery for 3 minutes. **Tympanic temperature: recommended for patients \>3 months of age**. For an accurate measurement, the pinna must be retracted to straighten the external auditory meatus and the instrument should be directed at the tympanic membrane. Skin temperature: unreliable Rectal temperature: in neonates, screen first with axillary temperature, then consider performing a rectal temperature if a fever is still suspected.

Answer 18

LP should not be performed in a child with impaired conscious state, focal neurological signs impaired coagulation or haemodynamic instability (see Lumbar puncture). In this circumstance, treatment for meningitis/encephalitis can be commenced and an LP can be performed when the patient is stable and there are no other contraindications present.

Answer 19

**Simple Febrile Seizure** Fever and all of the following: generalised tonic-clonic seizure duration of less than 15 minutes complete recovery within 1 hour do not recur within the same febrile illness **Complex Febrile Seizure** Fever and any of the following: focal features at onset or during the seizure duration greater than 15 minutes incomplete recovery within 1 hour recurrence within the same febrile illness **Afebrile Febrile Seizure** Seizures in an acute infectious illness (particularly gastroenteritis) without documented fever Features consistent with simple febrile seizure

Answer 20

Risk factors for developing subsequent epilepsy include: family history of epilepsy any neurodevelopmental problem prolonged or focal febrile seizures febrile status epilepticus No risk factors: 1% risk of developing epilepsy (similar to population risk) Risk increases with more risk factors, up to 10%

Answer 21

Seizure in child without previous afebrile seizures, without significant prior neurological abnormality and without signs of CNS infection or metabolic disturbance Usually occur between 6 months and 6 years of age Benign Occur in 3% of healthy children Normally associated with simple viral infections Occur without previous afebrile seizures no significant prior neurological abnormality and no signs of CNS infection Recurrence rate depends on the age of the child; the younger the child at the time of the initial seizure, the greater the risk of a further febrile seizure (1 year old 50%; 2 years old 30%)

Answer 22

\<6 months of age (consider CNS infection) \>6 years of age any features of a complex febrile seizure signs of CNS infection previous afebrile seizures progressive neurological conditions developmental delay or regression **REFERALL WHEN:** Seizures unable to be controlled Complex febrile seizure Child does not return to normal mental state within 1 hour Child clinically unwell Ongoing concern regarding the nature of the febrile illness Frequent seizures (for consideration of anticonvulsants if indicated)

paeds3 Flashcards

(47 cards)