Accidents and Poisonings (the child in Accident & Emergency)

• Basic Knowledge
  • Common childhood injuries, burns, accidents, poisonings
  • Patterns of poisonings: accidental, iatrogenic, intentional, drug abuse, Munchausen syndrome by proxy
  • Epidemiology and preventive measures
  • Pathophysiology of common poisonings elimination and reduction of absorption
  • Pathophysiology of shock complicating trauma
• Clinical Skills
  • Recognition of the seriously ill child
  • Potential respiratory failure
  • Impending/established shock
  • Initial management of coma
• Assessment/management of the seriously injured child
  • History to establish mechanism of injury
  • Handling of the traumatised child
  • Structural approach to trauma: primary survey, resuscitation, and secondary survey
• Assessment/management of head injury
  • Use of Glasgow coma scales
  • Assessment of percentage of skin burnt at different ages
  • How to use national poison centres
  • Initiation of urgent treatment for certain common poisons, e.g. iron, paracetamol, tricyclic antidepressants, opiates
• Technical Skills
  • Cardiopulmonary resuscitation
  • Cervical spine immobilisation, log rolling etc
  • Emergency vascular access
  • Thoracocentesis
  • Pericardiocentesis
  • Surgical airway - needle cricothyroidotomy
  • Administration of emetics
• Attitudes
  • Recognise opportunity for education in dealing with accidents and poisonings
  • Appreciation of and sensitivity towards parents of the acutelyunwell child
  • Awareness of the needs of children and parents in the A&E department: dangers of a medical environment
• Particular Problems
  • Ability to recognise, initiate diagnostic tests and outline the management of:
    
  • Anaphylaxis
  • The child with burns
  • Child abuse
  • Drowning/near drowning
  • Drug abuse
  • Head injury
  • Hypothermia
  • Sudden infant death syndrome and acute life threatening episode
  • - The child who dies in the emergency department
    
    

Genetics and Congenital Defects (errors of morphogenesis)

• Basic Knowledge
  • An understanding of DNA as the basis of inheritance
  • Modes of inheritance of common and important genetic diseases: mutation, consanguinity
  • Prenatal diagnosis: indications, practical issues and ethics
  • Screening for genetic disorders: prenatal, newborn, carrier. hereditary cancers
  • Basic principles of genetic counselling
  • Common chromosome aneuploidies (e.g. chromosome 21, 18, 13): non-disjunction, translocation, mosaicism
  • Clinical pointers towards genetic disorders
  • Environmental influences:
  • in multifactorial inheritance - interaction with genes
  • in foetal development (e.g. alcohol, drugs).
  • Recombinant DNA technology: principles and application
  • Embryological basis of errors of morphogenesis and their classification into malformations, deformations, disruptions, sequences, and syndromes
  • Common dysmorphology syndromes
  • Application of DNA analysis including family analyses to the diagnosis of common genetic conditions (e.g. Duchenne's, Becker's, cystic fibrosis)
    
    
• Clinical Skills
  • History taking, pedigree construction, and interpretation
  • Recognition of physical features of common genetic and dysmorphic disorders
  • Provide simple genetic counselling
  • Understand when to refer to appropriate specialist
    
• Attitudes
  • Awareness that genetic counselling is non-directive in nature and follows the gathering and interpretation of information rather than firm recommendations for action
  • Understanding the ethical difficulties involved in pre-symptomatic or carrier testing in children (e.g. Huntington's chorea, adult polycystic kidney disease, cystic fibrosis carriers)
    
• Particular Problems
  • The following are examples of common and/or serious problems in genetics. Each emphasises particular aspects of screening, inheritance, diagnosis, management, or prevention:
  • Cystic fibrosis
  • Sickle-cell disease
  • Beta thalassaemia
  • Phenylketonuria
  • Werdnig-Hoffman disease
  • Duchenne muscular dystrophy
  • Haemophilia
  • Neurofibromatosis
  • Down's syndrome
  • Cleft lip and palate
  • Fragile X
  • Myotonic dystrophy

Growth

• • Basic Knowledge
  • Normal growth and physical development through infancy, childhood, and adolescence: normal variation
  • Knowledge of the basic endocrinology of growth and puberty
  • The effects of deprivation and social class on growth: differences between races.
  • Influence of genetic, prenatal, and postnatal environmental factors
  • Understanding principles of growth charts: normal distribution
  • Normal sequence of puberty: the variation in its timing in the different sexes
  • Bone age as a measure of physical maturity
  • Principles of growth monitoring
  • Common and important causes of growth failure: chronic disease: long-term steroid therapy
  • - Disproportionate growth
    
    
  • Clinical Skills
    • - Use of growth charts: distance and velocity
    • - Assessment of stages of puberty (Tanner) - including measurement of testicular size using an orchidometer
      
      
    • - Technical Skills
      • - Accurate measurement of height, length, weight, head circumference: knowledge of suitable measuring equipment
        
        
      • Attitudes
        • - Acceptance that concerns about growth and puberty can have long term effects on psychological development and social relationships
        • - Understanding that most concerns about growth and puberty do not have a basis in organic disease
          
          
        • Particular Problems
          • Ability to recognise early, initiate diagnostic tests and outline the management of concerns about growth including the following:
          • "Failure to grow"
          • Emotional deprivation
          • Short and tall stature
          • Abnormalities of puberty
          • - Obesity
            
            

Development

• Basic Knowledge
  • - Normal development including gross motor, fine motor, speech and language, emotional, cognitive: normal variation and deviation
  • Tests of vision and hearing at different ages
  • Influence of genetic and environmental factors
  • Principles of child health promotion and surveillance
  • Understanding of different methods of developmental assessment
  • - Common and important causes of developmental delay
    
    
  • Skills
    • - Perform developmental screening.
    • Learn to undertake and manage a child health promotion programme
    • - Carry out developmental assessment
      
      
    • • Attitudes
      • - Understand that normal biological variation in growth and development may cause concern to children, parents, and health staff alike
        
        
      • Particular Problems
        • - Variation in acquisition of speech
        • Boys who walk late
        • - Late development of control of bladder and bowel
          
          

Adolescent Health

• Basic Knowledge
  • - Erikson's goals for adolescence: sexual identity, work role, independence, and ideals
  • Understanding adolescent sexuality: contraception and sex education
  • Risk-taking behaviour: alcohol, drugs, sexual behaviour
  • Influence of adolescence on health and disease: diabetes, cystic fibrosis
  • Recognition of eating disorders
  • - Deliberate self-harm
    
    
  • - Clinical Skills
    • - Communicate with adolescents, both with and without their parents
      
      
    • Attitudes
      • Awareness that adolescents have particular health needs which are distinct from children and adults
      • Understanding that young people should be allowed to take a lead in decisions surrounding their own treatment and health
      • - Understanding the importance of planning the transition to adult-based care
        
        
      • Particular Problems
        • - Anaemia
        • Adolescent pregnancy
        • - Sexually-transmitted diseases
          
          

Neurological and Muscular Disorders

• - Basic Knowledge

• Structure and function of clinically relevant neurological pathways
  • - Early symptoms and signs of neuromuscular problems, e.g. cerebral palsy, muscular dystrophies
  • Common epileptic syndromes: presentation at different ages
  • Differentiation of fits, faints, and "funny turns"
  • Diagnosis and management of headache: when to investigate
  • Principles of use of anti-epileptic drugs (AEDs)
  • Basic principles of rehabilitation: multidisciplinary approach: liaison with community staff
  • When and when not to perform investigations, e.g. LP, CT scan, EEG
  • - The place for special investigations, e.g. nerve conduction, electromyogram, MRI muscle biopsy
    
    
  • Clinical Skills
    • - Perform neurological assessment: learn to recognise patterns of movement
    • Recognise neurological complications of systemic disease
    • Learn how to give news on diagnosis (initially by example)
    • Interpret the results of investigations, e.g. EEG
    • - How to draw up a management plan taking into account continuing medical problems and attendant social, educational and psychological factors
      
      
    • Technical Skills
      • - Perform LP, transillumination of the skull
      • - Perform a subdural tap, ventricular tap
        
        
      • - Attitudes
        • - Effect of seizures on individual and family
          
          
        • Particular Problems
          • Ability to recognise, initiate diagnostic tests and outline the management of:
          • Febrile convulsions
          • Meningitis
          • Head injury
          • Cerebral palsy
          • Sensory deficits - hearing and visual impairment
          • Spinal bifida, hydrocephalus, microcephaly, craniosynostosis
          • Muscular dystrophies
          • Neuropathies and myopathies (the more common)
          • Degenerative disorders (in outline) prolonged seizures
          • The unconscious child
          • Increased intracranial pressure
          • Space-occupying lesion
          • The floppy infant
          • - Scoliosis
            
            

Learning Difficulties

• - Basic Knowledge
  - Definition of learning disabilities in respect of understanding or use of spoken or written language
  - Classification: specific, global; prevalence
  - Causes of learning difficulties
  - Range of presenting symptoms at different ages
  - Associated medical problems, e.g. epilepsy, physical disability, movement disorders
  - Approach to investigation: basic knowledge of psychological and educational evaluation tests
  - Role of educational specialists: educational psychologist: specialist teacher: special needs coordinator: when to refer
  - Principles of management: multidisciplinary approach, range of resources, statutory regulations, statement of special educational needs
  - Consequences of learning difficulties: social, behavioural, medical, educational
  
  
• Clinical Skills
  • - Take an appropriate history including behaviour, language, thinking, and memory
  • Developmental screening: be familiar with tests of vision and hearing at different ages
  • Developmental assessment
  • Recognition of common associated syndromes, e.g. Down syndrome, tuberous sclerosis, fragile X
  • - When and how to share unexpected news of a child with learning difficulties (initially by example)
    
    
  • Attitudes
    • - An appreciation of the impact the child with learning difficulties has on the family and society
    • - Recognition of the help needed for people to live with their difficulties and achieve social integration
      
      
    • Particular Problems
      • Ability to recognise, diagnose and manage, in association with others, problems of learning including:
      • Specific learning difficulties
      • Children with multiple disabilities
      • Learning difficulties compounded by hearing and/or visual impairments
      • The deaf and blind child
      • -
        
        

Behavioural and Psychological Problems

• Basic Knowledge
  • - Normal emotional and behavioural development
  • Influences on the development of personality: parenting
  • Effects of stress on children at different ages
  • Common behavioural problems at different ages and their management, e.g. the crying baby, poor sleep patterns, enuresis, and encopresis.
  • Psychological aspects of physical illness
  • Psychological problems including:
  • Conduct disorders - attention deficit hyperactivity disorder
  • Emotional disorders/depression
  • Psychosomatic problems: somatization
  • - Roles in diagnosis and management: GP, paediatrician, child, and adolescent psychiatrist, psychologist, psychotherapist
    
    
  • Clinical Skills
    • - Take a basic psychiatric history
    • Interview children at all ages regarding psychiatric symptoms
    • Assess the impact of psychosocial factors on common paediatric conditions
    • Assess the impact of family factors, including mental illness, on treatment and cause of psychopathology in children
    • Involve the family in the interview and management
      
    • Attitudes
      • Appreciation of behavioural difficulties in the child with chronic, terminal, disfiguring and disabling diseases
    • Particular Problems
      • To recognise and be involved in the diagnosis and management of psychological problems including:
      • Major disturbances of mood, perception and communication associated with:
      • Schizophrenia
      • Autism, Asperger syndrome
      • Antisocial behaviour
      • Threatened suicide and deliberate self-harm
      • Non-medical use of drugs including alcohol
      • Promiscuity
      • Anorexia nervosa
      • Hysteria
      • Truancy and school phobia
      • Adolescent problems
      • - The child "who seems strange" or "doesn't fit in"
        
        

Nutrition

• Basic Knowledge_
  • - Clinical importance of absorption and intermediary metabolism of nutrients
  • Maternal nutrition before and during pregnancy: effect on the foetus
  • Growth and nutrient accretion: reference foetus and infant
  • Nutritional requirements during infancy, childhood and adolescence: recommendations
  • Nutritional requirements of the preterm and light for dates infant
  • Health of the Nation, dietary targets
  • Breast feeding: including physiological, psychological and social aspects: importance for infant health and development
  • Composition, cost, relative benefits of commonly-available milk formulae: special milk formulae.
  • Weaning: vitamin supplementation: minority practices
  • Common feeding problems mi infancy, e.g. posseting, vomiting, 'colic'
  • Interaction between diet and disease; immediate (e.g. deficiency of iron, vitamin D), medium term (e.g. dental caries), long-term (e.g. obesity, coronary artery disease)
  • Principles of dietary modification in the management of systemic diseases, e.g. diabetes, Crohn's disease, PKU, cystic fibrosis
  • Definition of malnutrition, acute and chronic: prevalence
  • Nutritional disorders in ethnic minorities in the UK
  • Nutritional disorders in economically poor countries
  • - Principles of nutritional support in disease: enteral and parenteral nutrition: indications and complications
    
    
  • • Clinical Skills
    • Take a dietary history to estimate intake of major nutrients: use of the dietetic service including home/school nutritional assessment
    • Assess the state of nutrition and hydration
    • Advise on healthy eating for normal children
    • - Outline the appropriate diet for children with specific diseases, e.g. PKU, coeliac disease, CF, diabetes mellitus, cystic fibrosis
      
      
    • - Technical Skills
      • - Prescribe parenteral nutrition
        
        
      • - Attitudes
        • - Understanding the importance of good nutrition in childhood in reducing disease in adult life
          
          
        • Particular Problems
          • Ability to recognise, initiate diagnostic tests and outline the management of:
          • Failure to thrive
          • Obesity
          • Deficiencies of specific nutrients, e.g. tickets, iron deficiency, protein/ energy
          • - Food allergy, food intolerance, food aversion
            
            

Fetal and neonatal medicine

 

• - Basic Knowledge
  - Demographic, medical and psychosocial factors which influence perinatal mortality and morbidity
  - Measurement and assessment of foetal well-being
  - The high-risk pregnancy and its outcome
  - Effects of antenatal illness, and its therapy, on foetal well-being
  - Management of labour and delivery, and their effects on the neonate
  - Relationship of perinatal events to perinatal, neonatal and infant mortality and morbidity
  - Drug therapy and its significance for the foetus, infant and for breast feeding
  - General principles of care of the newborn:
  - Nursing care
  - Infant feeding
  - Temperature regulation
  - Fluid balance
  - Acid-base balance
  - Drug therapy and the importance of pain relief
  - Care for parents, assessment of home care and support
  - Early pointers towards significant illness
  - Prevention, diagnosis, and initial management of infection, hypoglycaemia, and jaundice
  - Biochemical screening programmes
  - Foetal physiology, growth, and development (including placenta)
  - Mechanisms of neonatal adaptations
  - Principles of total homeostatic support in the very immature or sick newborn
  - Foetal and neonatal nutrition in well and sick infants
  - Common and important neonatal problems including extreme immaturity and related disorders
  - The growth-retarded baby, complications, and outcome
  - Aftercare of high-risk infants and long-term outcome

• - Clinical Skills
  - History:
  - Use relevant sources (and in particular liaison with the obstetric service) to elicit history of present pregnancy, social and environmental information, and details of labour and delivery in order to understand problems of the newborn
  - Physical examination - as appropriate:
  - Screening examination, including the Apgar score to determine immediately the need for appropriate care
  - Detailed examination including an assessment of foetal growth, gestational age, and behavioural and neurological state
  - An understanding of normal variation
  - Interpretation of data
  - Advise and guide mother in feeding and general care of her infant
  - Use of ventilatory support
  - Sharing unexpected news, bereavement, and follow-up counselling (initially by example)

 

• - Technical Skills
  - Basic life support
  - Neonatal resuscitation: skills of early observation to await spontaneous breathing: bag and mask ventilation and intubation
  - Venepuncture and cannulation
  - Emergency vascular access: umbilical, intraosseous.
  - Lumbar puncture
  - Suprapubic bladder aspiration
  - Thoracocentesis
  - Use and application of non-invasive and invasive monitoring
  - Arterial access: umbilical, peripheral, puncture
  - Surfactant therapy
  - Passing nasogastric tube and orogastric tube to exclude choanal atresia and tracheo-oesophageal fistula (TOF)
  - Exchange transfusion

 

• - Attitudes
  - Awareness of the attachment process of parents and child, and the long-term sequelae that might result from interference with this process
  - Understanding the importance of breast-feeding and knowledge of the economic pressures opposing its use
  - The recognition that infants feel pain and that adequate pain relief is important.
  - An understanding that especially in the care of the newborn, interventions have a potential for harm as well as for benefit
  - Awareness of the ethical, social and legal issues related to the care of the critically-ill newborn who are malformed or extremely immature

 

• - Particular Problems
  Ability to recognise, initiate diagnostic tests and outline the management of:
  - Multiple births
  - Perinatal asphyxia
  - Respiratory distress including surfactant deficiency lung disease
  - Chronic lung disease
  - Meconium aspiration syndrome. intraventricular haemorrhage
  - Infant of the diabetic mother or mothers with other medical problems
  - Common congenital anomalies
  - Common orthopaedic problems
  - Common surgical emergencies
  - Bleeding disorders
  - Drug withdrawal syndromes
  - Ambiguous genitalia. hydrops fetalis
  - Iatrogenic injuries
  - Apnoea
  - Vomiting
  - Seizures

Cardiovascular System

 

• - Basic Knowledge
  - Anatomy and physiology of the foetal circulation. Circulatory changes at birth in health and disease
  - Anatomy and functional consequences associated with common congenital heart defects
  - The association of cardiac disorders with other abnormalities
  - Pathophysiology and management of cardiac failure - shock
  - Pathophysiology and management of acute cardiopulmonary arrest
  - Awareness of genetic and environmental factors in aetiology of congenital heart diseases (CHD), e.g. alcohol, prenatal infections, maternal PKU
  - Indications for bacterial endocarditis prophylaxis and knowledge of an appropriate regime
  - Complications of common types of CHD
  - Indications, limitations and complications of cardiac investigations

 

• - Clinical Skills
  - Recognise common congenital heart problems
  - When the neonate with CHD requires immediate cardiological referral
  - Recognise innocent cardiac murmurs
  - Recognise the signs of heart failure in the infant and child
  - Cardiopulmonary resuscitation in the infant and child
  - Measure and interpret blood pressure at different ages
  - Interpretation of chest X-rays including pulmonary vascularity and chamber size
  - Interpretation of ECGs, rhythm, rate, axis and evidence of chamber hypertrophy
  - Differentiate cardiac and pulmonary causes of respiratory distress and cyanosis in the newborn
• - Technical Skills
  - Insertion of arterial lines

 

• - Attitudes
  - Awareness of when to refer for specialist cardiological assessment and treatment

 

• - Particular Problems
  Ability to recognise, initiate diagnostic tests and outline the management of:
  - The child with a heart murmur
  - Medical treatment of persistent ductus arteriosus
  - Balloon surgery
  - Coarctation of the aorta in infancy and childhood
  - Arrhythmias including SVT
  - Hypertension
  - Infective endocarditis
  - Coronary complications of Kawasaki disease
  - Myocarditis, pericarditis
  - Rheumatic fever and rheumatic heart disease

Endocrinology

• - Basic Knowledge
  - The synthesis, transport, biochemical actions, and control of hormones
  - Screening for endocrine disorders, e.g. hypothyroidism
  - Presentation and management of diabetes mellitus in infancy, childhood, and adolescence
  - An understanding of when children with short or tall stature, precocious or delayed sexual development require endocrinological investigation

 

• - Skills
  - Administer and interpret investigations of common endocrine disorders

 

• - Attitudes
  - Understanding the importance of teamwork in diabetic care

 

• - Particular Problems
  Ability to recognise, initiate diagnostic tests and outline the management of
  - Short stature
  - Growth delay
  - Excessive growth
  - Early and late sexual development
  - Hypo and hyperthyroidism
  - Goitre
  - Ambiguous genitalia
  - Adrenal hyper and hypo secretory states
  - Hypoglycaemia
  - Polyuria / polydipsia
  - Turner syndrome
  - Klinefelter's syndrome
  - Hypo and hypercalcaemia
  - Consequences of treatment for malignancies on growth and endocrine functions

Gastroenterology, Hepatic and Biliary System

 

• - Basic Knowledge
  - The relationship of abnormal embryogenesis to clinical disorders, e.g. diaphragmatic hernia, malrotation, biliary atresia, etc
  - Physiology of the GI tract including liver and pancreas: causes of malabsorption, steatorrhoea, and protein-losing enteropathy
  - Fluid balance causes and treatment of dehydration
  - Presentation, investigation, and treatment of important gastrointestinal disorders including malabsorption states, e.g. coeliac disease, inflammatory bowel diseases
  - Recognition and interpretation of common symptoms including failure to thrive in infancy, chronic diarrhoea, recurrent abdominal pain
  - Causes and management of acute gastroenteritis: which children need admission?
  - Tests of liver dysfunction, malabsorption, and inflammatory bowel diseases, e.g. H-breath tests; oesophageal pH monitoring
  - Indications and usefulness of relevant imaging and endoscopic techniques

 

• - Clinical Skills

 

• - Assessment of nutritional state of infants and children
  - Assessment of dehydration: planning fluid therapy.
  - Interpretation of plain X-ray films and barium studies

 

• - Technical Skills
  - Jejunal biopsy

 

• - Attitudes
  - Understanding that investigations may be unpleasant, painful, or frightening and that child and parents must be counselled in advance.

 

• - Particular Problems
  Ability to recognise, initiate diagnostic tests and outline the management of
  - Pyloric stenosis
  - Intussusception
  - Hirschsprung disease
  - Peptic ulceration and helicobacter pylori infection
  - Vomiting and reflux
  - Constipation
  - Recurrent or protracted diarrhoea
  - Acute and recurrent abdominal pain
  - Persistent jaundice in the young infant
  - Intestinal bleeding
  - Intestinal obstruction
  - Differentiation of abdominal masses
  - Liver failure
  - Short gut syndrome