1.2

Question 1

As an obstetric SHO, you are presented with a primigravida who is 41 weeks + 2 days pregnant. She has had an uneventful pregnancy but has been admitted to hospital for induction of labour. She is unsure how to prepare a feed of formula milk. She asks you for advice. List four pieces of practical advice you would give her on how to prepare a feed.

Any four of the following;

  • •Hands must be washed and absolutely clean before handling the bottles and teats
  • • Suitable bottles and teats must be thoroughly washed and sterilised before use
  • •Water should be boiled before it is used to make a feed
  • •Information on how much water and the number of scoops of formula powder needed for a feed for a baby of various ages can be found on the back of the manufacture’s formula milk container.
  • •Water should be put into the bottle FIRST and accurately measured in the bottle by using the fluid ounces/mls guide at the side of bottle.
  • •The correct number of scoops of formula powder should be put into the bottle AFTER the water has been added
  • •A clean knife should be used to scrape off any excess powder in each scoop to ensure the correct amount of formula powder is in each scoop
  • •The bottle filled with water and formula powder should be GENTLY shaken to ensure adequate mixing
  • •The milk should be allowed to cool and tested on the back of the hand before giving it to the baby
  • •The milk, once prepared can be stored in the fridge for up to 24 hours.
  • •The best way to warm a refrigerated bottle is by placing it in a jug of warm water. Take great care if you heat the feed in a microwave oven because of the risk of hot spot burning.

Question 2

A mother presents to the GP clinic and is concerned about when and how to wean her 20 week old baby.

a. What is the current recommended age for weaning a baby?

  • 6 months (recommended by department of health)

b. List three signs are suggestive that a child is ready for weaning?

  • The baby is hungrier and cries more for food
  • The baby wakes up for a feed more time during the night than previously
  • The baby shows more interest in food
  • The baby starts to make chewing motions with their mouth

c. What types of foods can be initially introduced to the baby? List two.

l  Baby Rice cereal mixed in with breast or formula milk (recommended by the department of health as a starter)

  • Pureed fruit (e.g. Banana)
  • Pureed cooked vegetables ( e.g potatoes, carrots broccoli, peas, parsnips)

d. List two types of food you would advice the mother to avoid in the first stages of weaning

  • Gluten containing products (if weaned before 6 months)

l  Don't add sugar or salt to any foods

  • Don't feed hot spices in the first 12 months
  • Avoid (until 12 months) raw or soft eggs, patè, soft cheeses such as brie, honey( in rare cases it can lead to infant botulism
  • Avoid peanut butter until 12 months or 3 years if allergies run in the family,
  • Avoid whole nuts until 6 years (due to the dangers of choking).

e. The mother asks you ‘What about milk, do I have to discontinue that now?’ What will you reply? Give a reason for your answer.

  • You should reply ‘No’
  • The reason for this is that babies still rely on milk for most of their energy (calorie) intake.

1.2 Feeding

By the end of the course students should be able to:

• make and give a feed

• give advice to parents about infant feeding and weaning

1.5

Question 1

A two-day-old term infant on a postnatal ward has had bilious vomits after every feed since birth. The baby is hungry and feeds well but is yet to pass meconium. Clinical examination reveals a dysmorphic child with a flat occiput, large tongue, low set ears and single palmar crease. A plain abdominal film was taken and showed a double bubble appearance in the stomach.

a.  What is the ‘double bubble appearance’ indicative of?

l  Duodenal atresia

b.  What genetic condition does this child have that accounts for his dysmorphic features?

l  Down’s Syndrome

c. List three further investigations you would perform and give a reason for each investigation stated

  • Karyotype: To confirm the diagnosis of chromosomal abnormality
  • Upper gastrointestinal (GI) contrast study: There has been no passage of meconium for 48 hours
  • Echocardiogram: Congenital heart disease should be actively looked for in babies with Down’s syndrome

d.  Give three possible short term or long term complications of this condition that may necessitate intervention.

Any three of the following:

  • Congenital heart disease
  • Duodenal atresia
  • Severe learning disability
  • Small stature
  • Recurrent respiratory infections
  • Hearing impairment from acute otitis media
  • Visual impairment from cataracts, squints
  • Increased risk of leukaemia
  • Atlanto-axial subluxation (rare)
  • Hypothyroidsm
  • Alzheimer’s disease

e.  What information, support or advice can be given to the parents at the time of diagnosis and thereafter?

Any one of the following:

  • Written explanation of condition and its cause
  • Information about the short term and long term implications of diagnosis
  • Information about national charities and self help groups e.g Down Syndrome Association
  • Professional counselling to help deal with feelings of guilt, disappointment or anger
  • Antenatal diagnosis for future pregnancies

Question 2

Ben aged two months is admitted with tachypnoea following an upper respiratory tract infection. On examination there is a thrill, a loud (grade4/6) pansystolic murmur at the left sternal edge and the liver is palpable 4 cm below the costal margin.

a.  What is the most likely cause of his clinical condition?

  • Heart failure, probably precipitated by an upper respiratory tract infection

b.  What is the most likely underlying diagnosis?

  • Ventricular septal defect (VSD)

c. A chest x-ray was performed. Name 3 signs on the x-ray that may be indicative of your chosen diagnosis

  • Cardiomegaly,
  • Enlarged pulmonary arteries,
  • Increased pulmonary vascular markings
  • Pulmonary oedema

d. What single diagnostic investigation would you perform now?

  • Echocardiography

e. Outline 2 important aspects of management that may be considered in this condition and give a reason for performing each intervention

  • 1) Drug therapy – furosemide, thiazide, spironolactone, ACE inhibitors
  • Reason – To treat symptomatic heart failure
  • 2) Surgery
  • Reason: Severe symptoms with failure to thrive OR

Reason: Pulmonary hypertension with possible progression to pulmonary vascular disease and subsequent Eisenmenger’s syndrome.

  • 3.) Monitoring and observation (symptoms, signs, CXR, echocardiography)
  • Reason: This is acceptable in asymptomatic patients. By the age of 2 years at least 50% of small and moderate sized VSDs undergo sufficient partial or complete spontaneous closure to make intervention unnecessary.

1.5 Congenital Abnormalities

By the end of Phase II , students should be able to:

• recognise and explain to parents the principles of management of the commoner congenital abnormalities

1.6

1. Nick and Judith have been blessed with a bouncing baby boy, Gavin.

What three measurements are plotted on his centile growth chart?

  • Head circumference
  • Weight
  • Height

Being distinctly average, he follows the 50th centiles. What would be noted on his chart to constitute mild failure to thrive?

  • Mild failure to thrive is a fall across two centile lines.
  • (Severe failure to thrive is a fall over three centile lines)

Name two Organic and two Non-Organic causes of failure to thrive.

Organic:

  • Inability to feed
  • Poor retention of food
  • Illness-induced anorexia
  • Impaired nutrient absorption
  • Increased energy requirements
  • Metabolic causes
  • Chromosomal disorders/syndromes
  • Congenital infection

Non-Organic:

  • Feeding problems
  • Maternal stress
  • Lack of stimulation and undernutrition
  • Munchausen’s syndrome by proxy

Three years later, Gavin’s parents tell you he has reached all his developmental milestones at the correct age.

Name three of the five developmental areas that are measured.

  • Gross motor
  • Fine motor
  • Vision
  • Hearing and Speech
  • Social behaviour

At what median age are the following milestones achieved?

Crawls –

  • 8-9 months

Has a mature pincer grip –

  • 10 months

Smiles responsively -

  • 6 weeks

What screening tool is used for testing hearing in infants?

  • The Distraction test

At what age would this tool be used?

  • 6-9 months

2. Child X has cerebral palsy. Name two ways in which cerebral palsy might present.

  • Abnormal tone and posturing
  • Feeding difficulties
  • Delayed motor milestones
  • Abnormal gait when walking is achieved
  • Language and social developmental delay

The management of Child X’s cerebral palsy will involve a multidisciplinary team approach.

Name four members who might be involved.

  • Paediatrician
  • General Practitioner
  • Eric’s Family
  • Physiotherapist
  • Occupational therapist
  • Speech and language therapist
  • Social worker
  • Health visitor
  • Surgeon (e.g. fundoplicaiton for recurrent oesophageal reflux)

1.6 Developmental child health

By the end of Phase II , students should be able to:

• recognise failure to thrive, its common causes and initiate management

• make a developmental assessment of the infant and toddler

• recognise delay in speech and in walking

• examine a child for hearing loss, including distraction testing

• examine a child for reduced visual acuity and squint

• outline to parents the facilities available for children with learning difficulties

• outline to parents the facilities available for children with mobility difficulties

• recognise short stature and refer appropriately

• recognise delayed puberty and discuss the causes and investigation with patients and parents


1.7

JB is a child who has been diagnosed with cystic fibrosis. This requires daily medication, frequent visits to hospital and several hospital admissions for respiratory illness. When he is 3 he is admitted to hospital for 2 weeks. During this time his parents are unable to visit.

1) What are the stages of the acute separation response in young children?

  • Protest
  • Despair
  • Detachment

2) What factors in family life can have a negative impact on the psychological wellbeing of a child? Give 6 examples.

  • Parental mental illness
  • Inconsistent, unpredictable discipline
  • Divorce
  • Inappropriate expectations/responsibilities for age.
  • Abuse
  • Intrusive overprotection.
  • Bullying.

3) What are the common disorders of psychological development that could present in any child at age <5 yrs, 5-10 years old and as an adolescent? Give 3 examples for each.

-  Age <5 yrs

  • Meal refusal
  • Sleeeping problems (night terrors, nightmares, waking at night)
  • Breath-holding attacks
  • (Aggressive behaviour, Autism, Tantrums).

-  5-10 years old

  • Nocturnal enuresis
  • Hyperactivity
  • School refusal
  • (Anxiety, antisocial behaviour, Tics, Faecal soiling)

-  Adolescence

  • Anorexia nervosa
  • Chronic fatigue syndrome
  • Deliberate self-harm
  • (Drug misuse, depression)

JB starts at nursery, and the nursery nurse expresses concerns that he may have features of an autistic spectrum disorder.

4) What are the three main features of autism?

  • Poor social interaction
  • Lack of imagination
  • Poor communication skills.

5) What other behaviour patterns can be seen in autism? Give 2 examples.

  • Obsessive behaviours
  • Repetitive behaviours

When JB is 9 he starts refusing to go to school.

6) What are the two main causes of school refusal?

  • Separation anxiety persisting beyond the toddler years.
  • School phobia – anxiety provoked by an aspect of school.

7) Name 3 professional groups who could be involved when an older child refuses to go to school.

  • Teachers
  • Educational psychologist
  • Educational welfare officer

8) Name 6 behavioural features that might suggest attention deficit disorder.

  • Fidgeting
  • Continually interrupts
  • Instructions never obeyed
  • Blurts out answers
  • Behind with schoolwork
  • Short attention span.

9) What are the social and emotional issues that JB might face when he becomes a teenager?

  • Low self esteem
  • Problems gaining independence from parents
  • Rebelling against medication regime.
  • Problems conforming with peer group because of limitations of illness.
  • Depression
  • Anxiety
  • Alcohol and drug misuse

1.7 Child Psychiatry

By the end of Phase II , students should be able to:

•recognise the common presentations of psychiatric disorder in children and distinguish the common causes

•recognise the interaction between child and family upon the psychological disorders of childhood

•discuss attachment theory

•recognise the common disorders of childhood psychological development

•recognise the impact on children of physical/mental illnesses in a parent

•recognise the psychological aspects of chronic physical illness in children

•discuss school refusal with a child and its parents

•recognise the social and emotional issues in adolescents with chronic illness


1.10

1) You are a house officer in A+E and you see an 8 month old child who has had vomiting and diarrhoea for 2 days.

What signs would you look for to assess hydration? (6 marks)

Any 6 of:

  • Sunken fontanelle
  • Prolonged capillary refill time
  • Dry mucous membranes
  • Reduced skin turgor
  • Sunken eyes/tearless
  • Oliguria
  • Tachypnoea
  • Tachycardia
  • Reduced level of consciousness
  • Hypotension

How would you clinically assess severity of dehydration in terms of body weight loss? (3 marks)

  • Mild dehydration < 5%
  • Moderate dehydration 5-10%
  • Severe dehydration >10%

Name some routes through which rehydration therapy be administered? (2 marks)

Oral

  • NG tube
  • Intravenous
  • Intra-osseous

Name a micro-organism that commonly causes gastroenteritis in children in developed countries? (1 mark)

Any of:

  • Viruses –Rotavirus, Adenovirus, Coronavirus
  • Bacteria – Campylobactor, Shigella, E.Coli, Staphylococcus, Salmonella

2)  A 2 year old boy is given the diagnosis of coeliac disease in outpatient clinic.

What symptoms and signs would suggest this diagnosis? (6 marks)

Any of:

  • Failure to thrive
  • Abnormal stools/diarrhoea – foul smelling, pale, frequent and bulky
  • Vomiting
  • Weight loss
  • Constipation
  • Short stature
  • Abdominal distension
  • Buttock wasting
  • Irritability
  • Delayed motor milestones
  • Glossitis, angular stomatitis
  • Dermatitis Herpetiformis

What serological investigations would you consider? (2 marks)

Any of:

  • Anti-gliadin antibodies
  • Anti-endomysial antibodies
  • Anti-tissue transglutaminase antibodies
  • Anti-reticulin antibodies

What advice would you give to parents about the long term management and implications of coeliac disease? (2 marks)