The focus of the book is similar to the parent Pediatrics and Child Health book. In pediatrics, the focus of the consultation changes depending on the age and understanding of the child.
The doctor–patient relationship
The pediatric consultation Assessing the child 11 language appropriate for their age—'I'm going to feel you. Try to get an exact chronology from when the child was last completely healthy.
Respiratory system
Cardiovascular system
Abdominal system and nutritional status
Neurological assessment
The visual system
Neurological examination in infants
Musculoskeletal system
Gross motor development
Fine motor development
Speech and language development
Social development
It is important to understand the normal course of development in the early years and to develop skills in screening to assess the development of infants and children of different ages. It is difficult to remember all the main points, so learn the essentials given in the table.
Growth
IUGR probably started early in pregnancy because head circumference and length are also affected.
Puberty
Haematology
Interpretation of blood gases
Electrolytes and clinical chemistry
Check that alignment is central by looking at the head of the clavicles and the shape of the ribs on each side. At its widest it should be less than half the width of the ribcage (cardiothoracic ratio <0.5), although in infants it may be wider due to the antero-posterior way the radiograph is taken.
Features to look for on a chest radiograph
The manner in which the blood sample is taken is crucial—the skin must be thoroughly cleaned with antiseptic and an aseptic technique must be used. A healthy baby can be put straight to the breast and will nurse shortly after birth (see Chapter 10).
The newborn examination
The cranial part of the neural tube does not exist and the cerebral cortex does not develop. There is severe lower limb weakness with bladder and anal denervation and associated hydrocephalus.
Complications of prematurity
Premature babies are at risk of brain damage, and this is the most important factor affecting their long-term prognosis. Premature babies are at higher risk of cerebral palsy due to intracranial bleeding and white matter damage.
Breast-feeding
Colic tends to occur in the evening; tantrums may be more common if the child is tired. Little help that the child can complete works best, and other help can be given if desired.
Who is involved?
In the UK, health promotion is carried out by outreach teams as part of the Healthy Child programme. An important aspect of child health promotion is recognizing when it is a problem and directing parents to appropriate help.
Immunization and the diseases it protects against
Tetanus is caused by the anaerobic organism Clostridium tetani, which is found everywhere in the earth and enters the body through open wounds. Polio is caused by the polio virus, which causes a mild fever that progresses to meningitis in some children.
Weight faltering
Short stature is usually physiological and results from reduced genetic potential or delayed maturation (slow physical development). Turner syndrome or gonadal dysgenesis is an important cause of short stature and delayed puberty in girls.
Causes of obesity
Despite its prevalence, obesity remains a stigma and obese children have a high incidence of emotional and behavioral difficulties. Obese children are often victims of peer bullying and psychological distress is common.
Insulin-dependent diabetes mellitus (type 1 diabetes)
Type 1 diabetes mellitus
Diabetes in children is usually insulin-dependent diabetes (type 1) due to autoimmune destruction of beta cells in the islets of Langerhans in the pancreas, resulting in insulin deficiency. High blood glucose spills into the urine, causing osmotic diuresis with polyuria and dehydration.
Type 2 diabetes mellitus
Because cells cannot use glucose, they switch to fat metabolism, leading to the production of ketones, resulting in acidosis.
Presentation of congenital heart defects
Others manifest at birth, with cyanosis (for example, transposition of the great arteries or pulmonary atresia) or shock (hypoplastic left heart syndrome). Some duct-dependent lesions are present when the arterial duct closes within the first few days (e.g. coarctation of the aorta, severe pulmonary stenosis).
Causes of heart murmurs in older children
The chamber of the heart proximal to the lesion hypertrophies and heart failure may develop. The size of the shorthand. This can be demonstrated with echocardiography and cardiac catheters. If severe, balloon valvuloplasty is performed.
Causes of acute fever
Complications include conductive hearing loss, mastoiditis, and secretory otitis media (glue ear) - a thick, gluey exudate in the middle ear. The child often looks flushed because the blood vessels in the skin vasodilate in an attempt to lose heat.
Causes of persistent fever
Blood cultures should be obtained at the time of fever peaks when yields are higher. Care must be taken to avoid contact with chicken pox, herpes simplex and other common infections.
Causes of ‘chestiness’
23 Coughing and wheezing. Coughing and Wheezing Respiratory Disorders 65 zumab) against RSV can be given prophylactically to high-risk children throughout the winter months to provide passive immunity against infection. When the airways are protected, blood cultures can be taken and intravenous antibiotics (cefotaxime) given.
Acute stridorChronic stridor
Causes of swellings in the neck
Mild intermittent asthma Inhaled short-acting
These can be two copies of the same mutation (homozygous) or two different CF-causing mutations (compound heterozygous). Children with CF can be diagnosed by screening shortly after birth or prenatally in affected families.
Causes of acute abdominal pain
Colicky abdominal pain is a very common feature of gastroenteritis (Chapter 30) and may precede vomiting and diarrhea by several hours. HSP causes abdominal pain due to disseminated vasculitis (Chapter 53), and these children are at risk of intussusception.
Causes of vomiting
It may be due to congenital duodenal or ileal atresia or malrotation of the small intestine. Vomiting is one of the most common symptoms in childhood and is often caused by gastroenteritis.
Causes of dehydration
When Na+ > 150 mmol/L, the child is very thirsty and the skin may feel pasty. If the child is doing well and there are no other symptoms or signs, examinations are rarely necessary.
Causes of chronic or recurrent diarrhoea
Diarrhea may be bloody and urticaria, stridor, wheezing and very rarely anaphylaxis may occur. Where is the worst? (non-organic pain is classically peri-umbilical) What time of day does it occur. it may be helpful to ask them to keep a journal).
Causes of recurrent abdominal pain
Inspection of the stool for the presence of cysts or parasites (three separate specimens are required) is warranted in all children with recurrent abdominal pain. Ask about hard stools, painful stools, abdominal cramps and blood on the stool or toilet paper.
Causes of constipation
- Stage 1
- Stage 2: Disimpaction (for 1–2 weeks or until symptoms resolve)
- Stage 3: Maintenance
- Stage 4: Vigilance
Hirschprung's disease (congenital aganglionosis) is the absence of ganglion cells in the nerve plexus of the intestinal wall. It usually manifests in the newborn period with delayed passage of meconium (for >48 hours after birth) and abdominal distension, but if only a short portion of the gut is affected, it may later manifest with constipation and stunted growth.
Urinary tract infection
Shows functional clearance and can identify stasis of urine in the renal pelvis due to obstruction. Obstructive uropathy can be caused by an obstruction at the level of the renal pelvis, the connection between the ureter and the bladder or at the bladder outlet.
Haematuria and proteinuria
Most children have mild oliguria (reduced urine output), but a minority may develop acute renal failure and hypertension. Acute renal failure is managed by careful monitoring of fluid balance and kidney function.
Bedwetting and daytime wetting
Swellings in the groin and scrotum and impalpable testes
Causes of developmental delay
At presentation, the child may be apathetic, appear physically neglected with dirty clothing, messy hair, and diaper rash, and may have signs of nonaccidental injury. When developmental difficulties are complex, the child should be seen by a child development team (Chapter 42) for assessment and therapy.
Causes of headache
In younger children, the headache may be bilateral without prior aura and without vomiting. Always consider whether headaches may be a manifestation of anxiety about school - whether the child is being bullied or parents have unreasonable expectations.
Types of fits, faints and funny turns
Parents should be reassured and taught to place the child in the recovery position and wait for recovery. In a tonic-clonic seizure, the child should be placed in the recovery position after the pace is over.
Joint inflammation
ESR Raised in systemic form, may be elevated in polyarticular but normal in pauciarticular arthritis FBC Microcytic anemia of chronic disease. Rheumatoid factor Rarely positive – marker for persistence of polyarticular arthritis into adulthood Radiology Radiography and MRI of affected joints.
Causes of leg pain and limp in childhood
Common childhood skeletal problems
Causes of anaemia and pallor
Beta-thalassemia trait (heterozygous form) causes a mild hypochromic, microcytic anemia, which can be confused with iron deficiency. Iron deficiency is common in children as it is difficult to maintain iron stores in the face of rapid growth and a child's low consumption of iron-rich foods.
Causes of jaundice in the neonatal period
Jaundice in the neonatal period is very common and is usually due to an immature liver. Almost all preterm infants develop jaundice in the first days of life because the immature hepatocytes are unable to adequately conjugate bilirubin.
Types of childhood cancer
Bone marrow suppression and febrile neutropenia Bone marrow suppression may be due to invasion by tumor cells or the effect of chemotherapy. Short stature or asymmetric growth may be caused by radiotherapy to the spine or hypothalamo-pituitary axis.
Vascular birthmarks
May be a sign of Sturge-Weber syndrome with an underlying meningeal hemangioma, intracranial calcification and seizures.
Pigmentation disorders
Common transient neonatal rashes
Nappy rash
Treated by regularly combing out the eggs with an extra fine comb or using anti-pediculosis shampoo.
The allergic child
Very rarely, there can be cross-reactivity between airborne allergens and food allergens (eg birch pollen and apples), leading to seasonal mucositis in response to certain foods (oral allergy syndrome). Testing for allergy is controversial, as skin prick tests and IgE assays can be ambiguous.
Presentation of the acutely ill child
Circulatory failure (shock)
Causes of respiratory failure
Since 20-30% of the population may be nasopharyngeal carriers of Neisseria meningitides, close contacts should be given rifampicin prophylaxis. The original site of infection may be trivial, such as a pasture, or in girls it may be associated with menstruation.
Common causes of cardiorespiratory arrest
Abdominal thrusts (the Heimlich maneuver) should not be used in infants because of the risk of trauma to the liver and spleen; instead, perform five alternating backstrokes and chest thrusts with the child in a head-down position. If the child is unresponsive and not breathing, continue with basic life support.
Causes of coma
Reye's syndrome can be preceded by a viral illness such as the flu or chicken pox and is more common in winter. A CT scan of the brain and skeletal survey may show evidence of trauma and retinal hemorrhages may be present.
Causes of convulsions
Febrile convulsions should be treated by identifying and treating the source of the fever, and cooling the child down by undressing and sponging with lukewarm water. Any convulsion lasting longer than 10 minutes should be terminated with buccal midazolam or rectal diazepam.
Accidents
Burns
KILLER WEED
Accidental ingestion in young children
Intentional overdose in older children and adolescents
Living with a chronic condition
The assessment includes reports from an educational psychologist, a pediatrician and other professionals such as therapists and the child's nursery school or school. Attending a specialized pre-school can be enjoyable and promote social learning for a child.
Types of abuse and neglect
Abuse can be suspected from a pattern of soft tissue trauma (mouth, anus or genitalia) or infection. Screening for sexually transmitted infection, pregnancy and forensic tests can be performed after sexual abuse.
Sudden infant death and acute life-threatening events
- A vomiting baby
- Developmental delay
- A wheezy child
- Headaches
- Joint swelling
- Failure to thrive
- Heart murmur
- Obesity
- Abdominal pain
- A short girl
- Constipation
- Cough and fever
- Fits, faints and funny spells
- A jaundiced baby
- A baby with suspected cyanosis
- A swelling in the groin
- A 3-month-old baby with bruises
- A 14-year-old girl with cystic fibrosis
- A 12-year-old girl with progressive tiredness
- A collapsed child
- A child with vomiting and altered conscious level
- Case 1: A short girl
- Case 2: Constipation
- Case 3: Cough and fever
- Case 4: Fits, faints and funny spells
- Case 7: A swelling in the groin
- Case 8: A collapsed child
- Case 5: A jaundiced baby
- Case 6: A baby with suspected cyanosis
- Case 10: A 3-month-old baby with bruises
- Case 11: A 14-year-old girl with cystic fibrosis
- Case 12: A 12-year-old girl with progressive tiredness
- Case 9: A child with vomiting and altered conscious level
Human rights – the right to life: There are different views on whether life should always be preserved in all circumstances, but there is a common view that life should be respected and not harmed. Other investigations may be indicated if there are specific characteristics in the history or examination.
