Paediatrics and elder patients

Developmental Skills

• Developmental skills include posture and movement, vision and manipulation, hearing and speech, and social behavior.
• There is great variation in developmental skills; it is better to use 'usual' rather than 'normal' when discussing these skills.

Posture and Movement

• Body control develops from top down.
• Newborn babies typically exhibit 'head lag'.
• Walking usually occurs by 12-15 months of age.

Vision and Manipulation

• At 8 weeks, babies can observe a dangling toy or bright object about 30 cm from their face with a convergent gaze.
• From 2 months onward, babies tend to prefer watching faces.
• The ability to grasp objects usually develops by 12 months.

Hearing and Speech

• Babies can localize sound, turning to hear it, optimally by 7 months.
• From one year, children use single word labels.
• By two years, children join words to convey ideas through speech.
• By three years, children use sentences.

Social Behavior

• At 4-8 weeks, babies smile in response to a parent's face.
• By 9 months, babies start chewing lumpy food.
• By 3 years, children use a spoon and fork.
• Toilet training is a key aspect of social development.

Main Causes for Developmental Concern

• Delay in all 'milestones'
• Delay in walking
• Delay in speech
• Social/behavior problems

Immunisations

• It is important to ask if a child's immunizations are up-to-date.

Respiratory Infections in Childhood

• Upper respiratory tract infections (URTIs) account for almost half of children's visits to general practitioners (GPs).
• Up to 15% of the UK population has Asthma, and the cases are increasing.

Upper Respiratory Tract Infections

• Most upper respiratory tract infections (URTIs) are viral, but telling whether they are can be hard.

Otitis Media (OM)

• Otitis media is an acute infection of middle ear.

Acute Suppurative Otitis Media Symptoms

• Irritability
• Pain
• Pyrexia
• Hearing Loss
• Discharge
• Systemic Illness

Chronic Otitis Media with Effusion ("Glue Ear") Factors

• Multifactorial
• Eustachian insufficiency
• Environment
• Immunity
• Social class
• Allergy

Chronic Otitis Media with Effusion ("Glue Ear") Indicators

• Childhood screening
• Pure tone audiometry
• Endemic in under 5's
• Conductive hearing loss
• Language delay
• Behavioural issues
• Recurrent infections
• Poor school performance

Tonsillitis

• White exudate on the tonsil does not distinguish between viral and bacterial infection.
• Viral tonsillitis, often caused by adenovirus is more common in pre-school children.
• Streptococcal tonsillitis is more common in school age children.
• NICE guidelines relate to tonsillitis.

Acute Lower Respiratory Tract Infections

• It is the most common cause of death in children under 5 years of age worldwide.
• Mortality is low in the UK.
• It may be confined to children with pre-existing cardio-respiratory disease.

Bronchiolitis

• Acute viral infection of airways < 1 mm in diameter
• Mostly children under 1
• Respiratory Syncytial Virus (RSV) most common
• Mostly occurs in winter epidemics and often mild and self-limiting

Cystic Fibrosis

• It is responsible for majority of deaths in 'developed' countries from lung disease in childhood.
• Incidence is 1 in 2500 live births.
• It is Autosomal recessive
• Most deaths from respiratory failure

Cystic Fibrosis

• A multi-system disorder that affects the lung, sweat glands, GIT, pancreas reproductive system
• Failure of chloride transport into the lumen of affected exocrine organs
• Water is drawn from lumen into cells, dehydrating mucus and impairing action of cilia promoting bacterial colonization

Cystic Fibrosis diagnosis

• Dried blood spot sample collected on the 'Guthrie card' at 5 days.
• The dried blood test is taken at the same time as tests for phenylketonuria and hypothyroidism.
• A later test is the 'Sweat Test' used to measure chloride.

Cystic Fibrosis management

• Physiotherapy, daily
• Pancreatic enzyme supplements
• Vitamin, dietary supplements dietary supplementation and, in some cases,
• Nasogastric or gastrostomy feeding

Cystic Fibrosis – Later developments

• Complications in the biliary system may lead to biliary cirrhosis, portal hypertension & oesophageal varices.
• Older CF patients who do not gain weight may have diabetes mellitus & need regular insulin.

Causes of Learning Disability:

• Prenatal
• Peri-natal
• Post- natal

Prenatal causes of learning disability

• In-utero infections
• Foetal Alcohol Syndrome
• Chromosomal disorders e.g Down Syndrome, Turner's Syndrome
• Single gene defects e.g. Neurofibromatosis, Metabolic disorders

Peri-natal factors contributing to learning disability

• Complications of extreme prematurity
• Birth trauma and Severe asphyxia
• Bilirubin induced neurological damage such as Kernicterus
• Hypoglycaemia
• Meningitis
• Hydrocephalus

Post-natal factors contributing to learning disability

• NAI/Accidental trauma
• Prolonged convulsion
• Infection of CNS
• Environmental factors such as malnutrition

Paediatric Medical Emergencies

• Rare in dentistry
• Deteriorate rapidly
• ABCDE approach is taken
  • Airway
  • Breathing
  • Circulation
  • Disability
  • Exposure
• Children get well early.

Cardio-Pulmonary Arrest

• More likely to be due to airway/breathing problems
• Initial oxygenation/ventilation is important.

Paediatric Age Definitions:

• Infants are less than 1 year old
• A Child is from 1 year to puberty

Breathing Rates

• Expect higher respiratory rates in children
• Under 1 year up to 40 breaths/minute

Circulation

• Expect higher 'normal' pulse rates at rest
• 3 months – 2 years 100-180 bpm
• 2-10 years – 60-140 bpm

Disability

• Note if child is 'Floppy'
• Parents opinion is important

Exposure

• Minimise heat loss
• Note any rashes
• Check axillary temperature

CPR procedures

• Call CPR 999 if child not breathing normally
• Give 5 initial ventilations before chest compressions
• If alone, do CPR for 1 minute before 999

Chest Compressions

• Compress chest to one third of depth
• Use 2 fingers in infant
• Use one or two hands in a child

Use of AED

• Rare
• Usually airway/ventilation problems
• Most supply paediatric pads
• 50-75 J (2-4 J/Kg)
• Adult has been used under 8 years (ideally attenuated)

Inhaled Foreign Body

• Blind 'finger sweeps' not recommended
• Adult guidelines suitable for children over 1 year of age
• Chest thrusts instead of abdominal thrusts for infants

Infant with Airway Obstruction with Foreign Body

• Put infant across lap with head under lower than chest
• Heal
• kher even less celd ease don
• vod lder tes
• less

Infant with FBAO

• Put infant across lap with head under lower than chest
• 5 sharp inter-scapular blows
• If fails try 5 chest thrusts with patient supine (but head lower than chest), one every 3 seconds
• Repeat procedure
• Call 999 early
• If unconscious, start CPR

Doses of Adrenaline (Epinephrine 1 in 1000 solution)

• Over 12 years = 500 micrograms
• 6 – 12 years - 300 micrograms
• 6 months – 6 years 150 micrograms
• Less than 6 months – 100 micrograms

Epilepsy

• Buccal administration
• 1-2 months - 300 μg/kg
• 3 -11 months - 2.5 mg
• 1 - 4 Years – 5 mg
• 5 - 9 years – 7.5 mg

• 10 years – 10 mg

Presence of Relatives during a medical emergency

• Beneficial
• May Need to be 'looked after'

Paediatric Medical Emergencys Summary

• Same principles
• Even more rare!
• Have modified drug doses to hand

ADHD

• Affects behavior but some cases are more noticeable than others
• Cause isn't really known, it May have a familial element
• 'Micro-focusing'
• May be restless and have trouble concentrating

ADHD diagnosis

• Many cases diagnosed under 12 years of age
• The number of those diagnosed in in adults are increasing
• Sometimes symptoms can improve with age
• Can be associated with other disorders, such as anxiety and depression

Potential ADHD Signs – Children

• Potential Signs – Children:
  • Getting your child to sleep at night
  • Getting ready for school on time
  • Listening to and carrying out instructions
  • Note if they are Being (dis)organised
  • Social occasions
  • Shopping

Potential ADHD Signs - Adult

• Organisation and time management
• Following instructions
• Focusing and completing tasks
• Coping with stress
• Feeling restless or impatient
• Impulsiveness and risk taking
• Some adults may also have issues with relationships or social interaction

Management of ADHD - Children

• Educational support
• Support for parents (families)
• Sometimes medication

Management of ADHD - Adults

• Often medication
• Counselling
• CBT, DBT

ADHD Medication

• First line is often stimulant based e.g. methylphenidate (trade name 'Ritalin') and amphetamine
• Work faster than non-stimulant medications
• Non - stimulants include an Atomoxetine (norepinephrine modulator)
• Other non - stimulants include alpha agonists

Older Patients Demographics

• Life expectancy is increasing
• Proportionately more older people

Ageing

• Gradual development of changes in structure and function that are not due to preventable disease or trauma, and are associated with decreased functional capacity and an increased probability of death.
• Incidence of many diseases increases with age

Dementia - Different Types

• Ensure that treatable factors have been dealt with
• A syndrome of global cognitive impairment without impaired consciousness
• Affects memory and cognition
• There will have often been signs several months (or years) before

Dementia

• Sometimes associated with personality change
• Slow, repetitive speech
• Unusual < 55 years

Dementia - Assessment

• Mini-Mental State Examination with 30 questions
• Several questions with a maximum score of 30
• < 25 score suggests dementia

Dementia

• Alzheimer's Dementia
• Onset may be from 40 years
• Risk factors include gene defects
• Deposition of amyloid in cerebral cortex
• Specific treatments slow their progression rather than cure.

Dementia - Alzheimer's

• Failing memory
• Spatial disorientation
• Changed behaviour
• Hallucinations, delusions of persecution
• Eventually lose interest
• Parkinsonism may be seen

Dementia - Vascular Dementia

• Around 25% of dementia cases
• Multiple small strokes
• Sometime sudden onset

Lewy Body Dementia

• Associated with Lewy Bodies in neo-cortex and brainstem
• Associated with Cognitive impairment, hallucinations, Parkinsonism

Fronto-temporal Dementia

• Atrophy of frontal and temporal Lobes and not the pathological findings seen in Alzheimer's Disease
• Linked to Personality changes and disinhibition
• Does not affect spatial orientation

Dementia - Other Causes

• Alcohol abuse
• Huntingdon's
• Parkinson's Disease

Frailty

• Related to ageing
• A minor insult can lead to the risk of severe a deterioration in health
• Loss of in-built reserves
• Affects multiple systems

The Effects of Decreased Functional Capacity

• Decreased Muscle strength
• Decreased Cardio-respiratory reserve reduced
• Decreased Cognitive capacity
• Impaired Bladder capacity/sphincter strength

Impact on Reduced Homeostatic Reserve on Body Function

• Reduced Postural stability
• Reduced Thermo-regulation – increased risk of hypothermia
• Reduced Cognitive reserve – delirium
• Reduced Metabolic homeostasis – hypercapnia, hyponatraemia, hyperglycaemia
• Reduced Blood pressure control – risk of postural hypotension
• Increased risk of infection
• Reduced Renal reserve – AKI/CKI

Characteristics of Disease in Older People

• Non-specific or occult presentation
• Multiple pathology and interactions
• Affects function and independence
• Impaired homeostasis, resistance and recovery

The Giants of Geriatrics'- Multidisciplinary Approach Needed

• Instability
• Immobility
• Incontinence
• Intellectual impairment
• Isolation
• Iatrogenesis
• Multiple causes
• Coexist and interact
• Embarrassing, limiting, isolating

Dental Relevance for Geriatrics

• Increased bleeding risk or tissue fragility
• Possible difficulty lying flat
• Difficulty tolerating long procedures
• Difficulty complying with medication or other instructions
• Increased risk with sedatives and anaesthetics

National Service Framework 2001 for Geriatrics

• Respect for the individual by rooting out discrimination and person-centred care
• Offers Intermediate care between primary and hospital care services
• Provision of evidence-based specialist care
• Promotion of an active and healthy lifestyle for older people

Elder Abuse indicators:

• Neglect
• Physical abuse
• Emotional
• Financial
• Sexual

Safeguarding elderly patients

• Safeguarding is everyone's business
• Less often publicised than child abuse
• Report concerns to Social Services or GP

Problems with Medication in Geriatrics

• Compliance may be affected
• Presents possibility for different pharmacokinetics/drug action/interactions
• Presence of Adverse effects

Pharmacokinetics/Drug action in geriatrics

• Consider lower doses - often more sensitive
• Gl tract has Reduced absorption
• Kidneys, liver have Reduced excretion
• Altered protein binding – albumin e.g. LA, warfarin

Possible Poor Compliance with Medication vs Possible Solutions

• Poor explanation: use Careful explanation
• Side effects: Write things down-beware of impaired vision
• Run out: Use of dosing boxes
• No noticeable benefit Speak to relative/carer/GP
• Scared by package leaflet: Keep an eye on the patient
• Impaired mental, physical function: Aids

Drug Prescriptions and Interactions

• Do not prescribe unless sure of current medications and the possible effect known disorders
• Between drugs/adverse effect on another disease – multiple prescriptions

Increased Risk of Adverse effects

• Increased sensitivity to side effects
• Multiple drugs
• Antibiotics: causes diarrhoea, dehydration
• Sedatives- causes confusion, fall risk
• NSAIDs causes peptic ulceration, fluid retention, renal impairment
• Opioids: causes constipation and confusion
• Anticholinergic effects: causes confusion, constipation, urine retention, dry mouth

Geriatrics Summary

• Disability is common in old age
• Can lead to isolation and difficulty in accessing care
• Oral health is important for good nutrition
• Multiple pathologies/medications is common in older people
• Care when prescribing
• Safeguarding is key
• Problem solving may need the involvement of other stakeholders