Paediatric Notes

Paediatric History

  • Presenting Complaint
  • History of Presenting Complaint
  • Systems Review
  • General: fever, rash, weight loss
  • CVS: sweating, cyanosis, pallor, SOB,faints
  • Resp: runny nose, sore throat, earache,cough, SOB, snoring, exercisecapacity
  • GI: appetite, feeding, vomiting, stools,abdominal pain/distension
  • GU: urine output, smell, colour
  • Neuro: headaches, fits, hearing, vision,developmental milestones
  • Musc: joint pain or swelling
  • Past Medical History
  • Chronic conditions
  • Hospital admission
  • Operations
  • Medications & Allergies
  • Immunisations
  • Pregnancy & Birth
  • Born at: ? wks in which country
  • Mother’s health during pregnancy
  • Delivery: normal, instrumental, elective C-section,emergency C-section
  • Neonatal & Infant Development
  • Admission to SCBU, oxygen required
  • Breast-feeding
  • Do they have red book?
  • Has anyone been worried about thechild’s development?
  • Age when: smiled, sat unsupported,crawled, used 3-4 words, ate solids,talked, walked
  • Family History
  • Siblings
  • Mother & Father age & occupation
  • Parents blood related?
  • Diseases that run in the family
  • Social History
  • Lives with: parents? siblings? adopted?
  • Lived in the UK since? / Ethnic origin
  • First language
  • Accommodation: house/flat
  • Pets / Travel
  • Alcohol / Smoking / Drugs
  • Schooling
  • Which year
  • Any problems/concerns
  • Happy at school

Developmental Milestones

Gross Motor / Fine Motor & Vision / Hearing, Speech & Language / Social
Newborn / Limbs Flexed
Head Lag
Primitive reflexes / Startles to noise
6 weeks / Raise Head (4mths)
Primitive reflexes / Fixes & follows moving object (3mths) / Smiles Responsively
6 months / Sits without support (9mths) / Reaches for toys
Palmar grasp
Transfers (8mths) / Vocalises
Turns to sounds out of sight / Puts food in mouth
Stranger awareness
10 months / Crawls
Cruises / Pincer Grasp / Parents can discriminate sounds / Waves bye-bye
Peek-a-boo
12 months / Unsteady braod based gait / 2-3 words / Drinks from cup
18 months / Steady walking / 3 block tower / 6-10 words / Uses a spoon to eat
2 years / 6 block tower
Draws a straight line / 2-3 word sentences / Symbolic play and potty trained

Primitive Reflexes

Reflex / Eliciting / Description
Moro / Sudden head extension / Symmetrical extension then flexion of all 4 limbs
Grasp / Place object in palm of hand / Flexion of the fingers of the hand around object
Rooting / Stimulus near mouth / Turning of head towards stimulus
Placing / Hold infant vertically and place the dorsum of feet on a hard surface / Child steps with one foot then the other
Positive Supporting reflex / Infant held vertically, feet on a surface / Legs support body weight, may push up against gravity
Atonic Neck reflex / Head turned to one side whilst supine / Fencing posture with arm outstretch in the direction of the head

N/B - these reflexes should be gone by 6 months

Immunisation Schedule

Age / Vaccnations
Birth / BCG & Hep B (to high risk Groups)
2 Months / Diptheria, Tetanus, Pertusis, Polio, Hib, Pneumococcal
3 Months / Diptheria, Tetanus, Pertusis, Polio, Hib, Men C
4 Months / Diptheria, Tetanus, Pertusis, Polio, Hib, Pneumococcal, Men C
12 Months / Hib, Men C
13 Months / MMR, Pneumococcal
4 Years / Diptheria, Tetanus, Pertusis, Polio, MMR
12 – 13 Years / HPV
13 – 18 Years / Diptheria, Tetanus, Polio

NEONATES

  • 28days old
  • Full term preg is 37-42 weeks
  • Pre-term preg is <37wks.
  • Post term >42 wks.
  • Low BW <2.5kg, V .low BW <1.5kg, extremely low BW <1kg

Infectionsof the newborn

  • ↑ risk if PROM (>24h), chorioamnionitis, preterm
  • Organisms: Group B Strep, Listeria Monocytogenes, Candida Albinans, HSV

Neonatal sepsis

  • Temp instability - fever, hypothermia
  • Poor feeding
  • Abdo distension
  • Vomiting
  • Apnoea
  • BC
  • Resp distress
  • Pallor/mottled skin
  • Jaundice
  • Neutropenia
  • Hypo-perglycaemia
  • Shock
  • Irritability
  • Seizures

Ix/Rx:

  • septic screen: FBC, blood culture, CRP, urine/CSF M,C,S + CXR
  • IVABs:
  • Penicillin/amoxicillin for group B strep, listeria
  • Ceph for gram -ve bacteria.

Rubella

  • Routine antenatal screening for rubella IgM.
  • Live Vacine before birth if neg.
  • Complications:
  • <8/40: sensorineural deafness, congenital HD, cataracts/glaucoma, hepatosplenomegaly, dev delay/IUGR.
  • 13-16/40: impaired hearing (30%)
  • >18/40: minimal risk

CMV

  • Most common
  • 40% of infants infected in maternal infection
  • 90%: normal at birth and development
  • 5%: clinical features of infection at birth:

  • IUGR
  • Petechiae
  • Jaundice
  • HSmegaly
  • Pneumonitis
  • Deafness
  • Encephalitis/microencephaly/IC calcification IQ

Malformations of the Neonate

Down’s syndrome (trisomy 21)

  • 1 in 1000 LBs
  • Sx:
  • Newborn: ++nuchal skin, hypotonia, sleepy
  • Facial appearance: round face, epicanthic folds, protruding tongue, upslanting palpebral fissures, small low set ears
  • Other anomalies: flat occipital, single palmar creases, incurving 5th digit, saddle gap
  • Complications:

  • Learning diff
  • Congenital HD
  • Duodenal atresia
  • Recurrent resp inf
  • Vision/hearing impairment
  • Hypthyroid
  • Leukaemia
  • Alzeheimers

Patau’s Syndrome (trisomy 13)

  • 1 in 14000 LBs
  • Sx:

  • Small head and eyes
  • Absent corpus calloscum with single ventricle
  • Heart lesion
  • Polycystic kidneys
  • Cleft lip/palate
  • Hands show flexion contractures +/- polydactyl

Edward’s syndrome (trisomy 18)

  • 2nd commonest trisomy
  • Female 2:1 male
  • Sx:

  • Rigid baby + limb flexion
  • Odd low set ears
  • Receding chin
  • Proptosis (forward displacement of eyes)
  • Rocker bottom feet
  • Cleft lip/palate
  • Umbilical/inguinal hernia
  • Short sternum (therefore widely spaced nipples)
  • Mean survival 10/12

Turner’s syndrome (45X)

  • >95% result in early miscarriage
  • 1 in 2500 LBs
  • Females only
  • Sx:

  • Lymphoedema of hands and feet (neonate)
  • Short stature; webbed neck
  • Wide carrying angle (cubitus valgus)
  • Widely spaced nipples
  • Congenital HD (esp coarctation of the aorta)
  • Ovarian dygenesis (infertility)
  • Normal interlectual development

  • Dx:
  • Detect on USS - cystic hygroma and oedema
  • Rx:
  • GH and oestrogens

Klinefelter’s syndrome (47, XXY)

  • 1-2 in 1000 LBs
  • Males only
  • Sx:

  • Infertility (commonest presentation)
  • Hypogonadism and small testes
  • Gynaecomastia in adolescence
  • Tall stature
  • N intelligence but psychological probs

Microdeletion syndromes

  • Cri du chat syndrome: High-pitch mewing cry in infancy, CVS abnorms, Microencephaly, Widely spaced eyes, ‘moon’ face
  • Di George:Congenital HD, cleft palate, thymus
  • William’s: Usually sporadic, face - epicanthic folds, small ears, stellate eyes
  • Angelman’s:Maternal deletion. ataxia, seizures, microencephaly
  • Prader-willi: Hypotonia, obesity, hypogonad, dev delay

Preterm infants

Respiratory distress syndrome (RDS)

  • Due to surfactant def
  • Most babies <28/40 effected
  • Rare at term
  • Rx:
  • Antenatal corticosteroids (need 24h to act)
  • Exogenous surfactant: via ET tube, decreasing mortality by 40%
  • CPAP: increases end exp press. Intubation + ventilation

Pneumothorax

  • In RDS air from overdistended alveoliinterstitium
  • Present in 20% of ventilated infants
  • Sx:

  • O2 requirement
  • TV
  • breath sounds/exp

  • Rx:

  • Chest drain
  • Preventable by ventilating with low press

Apnoea and bradycardia

Temp control

  • Large SA:vol ratio
  • Little subcut fat

PDA

  • May need inotrphic support.
  • Rx with fluid restriction + indomethacin (prostaglandin synthase-I)

Hypotension

Nutrition

  • high nutritional requirement for rapid growth (Suckling reflex develops at 34/40)
  • NG tube, Pref breast milk
  • Consider parentral nutrition
  • Supplement with phosphate, Ca and Vit D (bone mineralization)

Anaemia of prems

  • Fe transferred in last trimester
  • Blood loss from blood samples + inadequate erythropoietin

Infection

  • Increased risk (esp group B strep and coliforms)

Intracranial lesions

  • Interventricular hemorrhage
  • High risk if: asphyxia, RDS, pneumothorax
  • Post-haemorrhage hydroencephalus
  • Sutures separate, incraesed HC, bulging fontanelle
  • Rx: LP/ventricular tap, shunt
  • Periventricular leucomalacia
  • Due to ischaemia
  • High risk if: inf, hypoT, MZ twins sharing placenta

Renal

  • Low renal flow in fetus.
  • At 28/40 GFR=25% of term. Doubles in 1st 2/52 of life

Necrotizing enterocolitis (NEC)

  • Bowel wall ischaemia (gut microorganisms to colonise bowel wall)
  • Sx:

  • No feeding
  • Milk aspirations
  • Vomiting (bile stained)
  • Distended abdo
  • Blood in stool

  • Can cause shock if haemorrhagic colitis

  • AXR: shows distended bowel + air in bowel wall/portal tract
  • Rx: stop feeding, IVABs, ventilate/circ support, surgery (if perforated)
  • Complications: strictures, short bowel syndrome (malabs)

Retinopathy of prematurity (ROP)

  • Common (50%)
  • Can cause retinal detachment, fibrosis, blindness (in 1%)
  • Screen all v.low BW at 6-7/52 with opthalmoscopy
  • Rx: Cryotherapy/laser Rx

GOR

Inguinal hernias

Metabolic

  • Hypoglycaemia: maintain BM (>2.6mmol/L) to prevent neurodamage
  • Hypocalcaemia
  • Electrolyte imbalance: due to poor renal function and por resorption
  • Osteopenia of prems: therefore give ca, phosphate, Vit D

Bronchopulmonary dysplasia/chronic lung disease

  • If infant has prolonged O2 requirements (beyond 36/40)
  • Lung damage is from: press/vol trauma from ventilation, O2 toxicity, inf, ++lung secretion
  • CXR shows: areas of opacification + cystic change
  • Wean infants onto CPAP
  • Complications: inf, cor pulmonale

The consequences of traumatic delivery

  • Injury occurs if baby:

  • Malpositioned
  • Too large for pelvic outlet
  • Manual manoeuvres
  • Forceps
  • Ventouse

Soft tissue injuries

  • Caput succedaneum - presents immediately, oedema of scalp, superficial to periosteum, resolves spontaneously
  • Cephalhaematoma - bleed below periosteum within skull sutures, fluctuant + slower to develop, resolves over wks, may cause/contribute to jaundice
  • Chignon - large caput from ventouse
  • Bruising – face, genitalia/buttocks if breech, Prems bruise easily
  • Abrasions - from scalp electrodes
  • Subaponeurotic heamatoma – rare, ++blood loss between aponeurosis + periosteum

Nerve palsies

  • Erb’s palsy - upper N root injury (C5 + C6). Straight arm, limp pronated hand.
  • Lower roots injury - less often. Weak wrsit extensor and intrinsic muscles of hand.

Fractures

  • Clavicles - from shoulder dystocia, may hear snap or see lump/callus
  • Humerus/femur - usually mid shaft occurring in breech. Heal quickly if immobilised

Neonatal jaundice

  • Yellow pigmentation of skin/whites of eyes, due to a high bilirubin in plasma
  • Clinically jaundiced = >80-120mol/L

Jaundice <24h

  • Rhesus haemolytic disease
  • ABO incompatibility
  • G6PD deficiency

Jaundice 24h - 2wks of age

  • Physiological - UNCONJUGATED
  • Breast milk jaundice - UNCONJUGATED
  • Infection - UNCONJUGATED
  • Other causes

Persistent jaundice (>2weeks)

UNCONJUGATED:

  • Breast milk jaundice - 15%, disappears by 3-4/52
  • Infection - UTI
  • Congenital hypothyroidism

CONJUGATED (dark urine, pale stools):

  • Neonatal hepititis syndrome
  • Biliary atresia:

Management:

  • Hydration
  • Phototherapy
  • Exchange transfusion

Respiratory distress

  • Signs:

  • Tachypnoea
  • Laboured breathing
  • Expiratory grunting
  • TC
  • Cyanosis

  • Admit to SCBU
  • Monitor: HR,RR,sats,circ
  • CXR
  • Causes

  • Transient tachypnoea of the newborn
  • Meconium aspiration
  • Pneumonia
  • Pneumothorax
  • Milk aspiration
  • Persistent pulmonary HT of the newborn
  • Diaphragmatic hernia

The childhood exanthems

Measles

Cause:RNA paramyoxovirus

Spread:Droplets

Incubation:7-21 days

Sx:Prodrome (catarrh, wretchedness, conjunctivitis, fever)

Conjunctiuvae look glassy, then semilunar fold swells (Meyer’s sign).

Koplik spots are pathognomonic, often fade as the rash appears (starts behind ears on day 3-5, then spreads down body becoming confluent).

Complications: Febrile fits, otitis media, meningitis, D&V, keratoconjunctivitis, immunosuppression, subacute sclerosing panencephalitis. Worst complication is encephalitis (headache, lassitiude, fits coma), 15% may die.

Treatment:Isolate in hospital. Ensure adequate nutrition. Treat 2º bacterial inf e.g. Amoxicillin

Immunisation:MMR

Chickenpox (Varicella Zoster virus)

Presentation:Crops of vesicles of diff ages on the skin, typically starting on back.

Incubation:11-21 days

Infectivity:4 days before the rash until all lesions have scabbed (1 wk)

Spread:Droplet. Immunity is life-long.

Tests:Fluorescent Ab tests and Tzanck smears rarely needed.

Course:Fever, rash (2 days later). Macule, papule, vesicle

Treatment:Keep cool, daily antiseptic for spots, trim nails, Flucloxacillin if bacterial inf. Anti-VZV Igs + acyclovir if immunosuppressed or on steroids.

Complications: If spots blackish (purpura fulminans) or coalescing and bluish (necrotising fasciitis)

Immunisation:With live-attenuated vaccine if pre-cytotoxics/steroids.

Rubella (german measles)

Cause:RNA virus

Incubation:14-21 days

Infectivity:5 days before and 5 days after rash starts

Signs:Usually mild, macular rash, suboccipital lymphadenopathy

Treatment:Symptomatic

Immunization:Live virus

Complications:small joint arthritis. Malformations in utero.

RESPIRATORY SYSTEM

Asthma

  • Reversible airway obstruction with wheeze, dyspnoea or cough.
  • RF:

  • Male
  • BW
  • Family Hx
  • Bottle fed
  • Atopy
  • Past bronchopulmonary dysplasia
  • Passive smoking

  • Presentation:

  • Recurrent wheeze
  • Cough and breathlessness
  • Nocturnal cough
  • Eosiniophilia and  serum IgE

  • Diagnosis:
  • Hyperinflation of chest (pectus carinatum and Harrison’s sulcus)
  • Generalised exp wheeze with prolonged exp phase
  • Signs of atopy
  • Ix:

  • Skin tests
  • CXR (hyperinflatio)
  • PEFR (in over 5yrs)

  • Management:
  • High-dose inhaled B2 bronchodialtor (Salbuatmol or Terbutaline)
  • Ipratropium nebulised
  • O2 if low sats
  • IV aminophylline or salbutamol
  • IV hydrocortisone

Cystic fibrosis

  • Autosomal recessive disorder.
  • Mutations in the CF transmenbrane conductance regulator gene (CFTR)
  • Abnorm ion transport across epithelial cells of exocrine glands of resp tract and pancreas
  • Clinical features:
  • Malabs + FTT from birth + recurrent/persistent chest inf.
  • Meconium ileusinspissated meconium causes intestinal obst + vomiting + abdo distension + failure to pass meconium
  • Malabs and steatorrheoa due to insufficiency of pancreatic
  • Management:

  • Genetic counselling
  • Abs
  • Good nutrition
  • Pertussis, MMR and pneumococcal vaccination
  • Physio 3xday
  • Inhaled salbutamol for reversible airway obst
  • Lung transplant?
  • Synthetic Es (pancrex)
  • Cimetidine (H2-R antagonist)
  • Vit supplements
  • High calorie/protein diet

Pertussis

  • Specific and highly infectious form of bronchitis, caused by Bordetella pertussis.
  • Signs:
  • Bouts of coughing ending with vomiting (+/- cyanosis),
  • Worse at night and after feeding
  • Whoop (not always present) is caused by inspiration against a closed glottis.
  • Peak age: 3yrs
  • Incubation: 10-14days
  • Complications:

  • Prolonged illness
  • Petechiae
  • Microhaem
  • Hernias
  • Bronchiecttasis

  • Rx:

  • Erythromycin to exposed infants
  • Admit if <6/12 old
  • Live vaccine at 2 months

Bronchiolitis

  • Typical cause: winter epidemics of RSV
  • Signs:

  • Coryza (coldlike Sx)
  • Sharp, dry cough
  • Low fever
  • Tachypnoea
  • Wheeze (high pitched exp>insp)
  • Apnoea
  • Intercostal recession +/- cyanosis
  • Hyperinflation of chest
  • Fine end-insp crackles

  • Diagnosis:
  • Immunoflourescence of nasopharyngeal aspirates
  • CXR shows hyperinflation of the lungs
  • Management:

  • Admit if feeding diff
  • Supportive care

  • Should recover in 2 weeks
  • Prevention:
  • Monoclonal AB to RSV given to at risk

Pneumonia

  • Signs:

  • Fever
  • Malaise
  • Feeding diff
  • Tachypnoea
  • Cyanosis
  • Grunting on exp.
  • Consolidation
  • CXR changes

  • Management:
  • Abs (oral or IV penicillin and erythromycin)
  • May need O2

TB

  • Signs:

  • Anorexia
  • Prolonged low fever
  • Failure to thrive
  • Malaise
  • Cough

  • Diagnosis:

  • Screen with heaf test
  • Diagnose with Mantoux test
  • CXR: consolidation, cavities, miliary spread

  • Treatment:
  • 6/12 of triple therapy (Rifampicin, isoniazid and pyrazinamide)
  • Dropped to Rifampicin & isoniazid after 2/12.
  • BCG given to at risks at birth

Croup (laryngotracheobronchitis)

  • >95% of laryngotracheal infections
  • Parainfluenza viruses commonest cause, also RSV
  • Peak age 2yrs
  • Sx: start and worse at night.
  • If severe can treat with oral dex, nebulised steroids and adrenaline

Acute Epiglottitis

  • Med Emergency
  • Caused by H. influenzae type B (incidence  due to Hib vaccine)
  • Secure airway, take bloods for culture, start IV Abs (2nd or 3rd generation cephalosporins)

Common cold (coryza)

  • Classsical features: clear or mucopurulent nasal discharge + nasal blackage
  • Commonest pathogens = viruses: rhinoviruses, coronaviruses and RSV.

Sore throat (pharyngitis)

  • Usually due to viral inf with respiratory viruses (adenovirus, enterovirus, rhinovirus)
  • Pharynx and soft palate are inflammed + local lymph nodes are enlarged + tender

Tonsillitis

  • Form of pharyngitis with intense inflammation and purulent exudate
  • Common pathogens: group A -H. Strep and the EBV
  • Marked constitutional disturbances e.g. headache, apathy, abdo pain
  • ABs (penicillin or erythromycin)
  • Avoid amoxicillin

Red Ear

  • Otitis externa (swimmers ear): pain, discharge due to inflammation of the skin of the meatus. Pseudomonas common organism. Aural toilet is the key to treatment.
  • Otitis media: inflammation of the middle ear and classified on timing: acute, subacute and chronic.
  • Rx: paracetamol and ABs (amoxycillin/augmentin)
  • Complications: COM, mastoiditis, meningitis, cerebral abscess
  • Foreign bodies.

CARDIOVASCULAR SYSTEM

Innocent murmur

Heard in up to 30% of all children

Ejection murmur

  • Generated in ventricles, outflow tracts or great vessels on either side of heart by turbulent blood flow
  • No structural abnormalities
  • Soft blowing syst murmur, localised to L-sternal edge, no diastolic component, no radiation

Venous hum

  • Turbulent blood flow in head and neck veins
  • Disappears when lying flat or compressing ipsilateral jug V

Acyanotic congenital heart lesions

  • VSD:
  • Sx: asymptomatic, heart failure, recurrent chest inf, cyanosis, endocarditis
  • Signs: parasternal thrill, harsh loud pansystolic ‘blowing murmur’, tachyop, tachycardia, enlarged liver
  • Ix: CXR=heart, pul A, pul vascular markings. ECG=ventricular hypertrophy, upright T wave=pul HT.
  • Course: 20% close in 9/12. Diuretics and ACE-Is. Surgery if pul HT as can cause pul vascular disease. ABs to prevent bacterial endocarditis.
  • PDA:
  • Common in prem
  • Left to right shunt (aortapul A)
  • Signs: FTT, pneumonias, heart failure, collapsing pulse, thrill, S2, continuous murmur beneath L-clavicle
  • Ix: CXR: vasc markings, enlarged aorta. ECG: usually N, LVH
  • Rx: most close over time. Dex in preterm labour. If symptomatic, Rx with fluid restriction, diuretics, indomethacin (a prostaglandin synthetase inhibitor). Surgical ligation or transvenous occlusion with coil device.
  • ASD:
  • Special form of VSD, often seen in kids with Down’s syn.
  • Signs: widely split, fixed S2 and midsystolic murmur (2nd IC space of L sternal edge)
  • Ix: CXR: cardiomegaly, globular heart (primum defects). ECG: RVH +/- incomplete RBBB
  • Coarctation
  • Associated with other lesions e.g. bicuspid aortic valve and VSDs.
  • Neonates present with duct-dependent circ
  • Sx: circulatory collapse when duct closes, heart failure, murmur between shoulder blades.
  • Signs: diff in feeling femoral pulses, BP in arms, BP in legs, no foot pulses
  • Ix: CXR: rib notching (late), due to large collateral IC As running under ribs posteriorly to bypass obstruction. ECG: RVH in neonate, LVH in older child
  • Rx: surgical: resection and end to end anastomosis or balloon dilatation.

Cyanotic congenital heart lesions

  • Tetralogy of Fallot
  • 4 cardinal anatomical features:

Large outlet VSD

Overriding of the aorta with respect to the ventricular septum

RV outflow tract obstruction (pul stenosis)

RVH

  • Signs: cyanosis as ductus closes, hypercyanotic spells, dyspnoea, faints, squatting at play, clubbing, thrills, absent pulmonary part of S2, long, loud ejection systolic murmur at L sternal base.
  • Ix: FBC: Hb CXR: small heart, uptitling apex (RVH), pulmonary artery ‘bay’. ECG: RVH and RAD (R axis deviation)
  • Transposition of the great arteries
  • When there are 2 parallel circulations: no mixing is incompatible with life (ass. Anormalities)
  • Sx: usually present day 1 or 2 of life with cyanosis
  • Signs: cyanosis, clubbing, CCF +/- systolic murmur.
  • Ix: CXR: narrow pedicle, ‘egg on side’, pul vasc markings. ECG: RVH. Echo: diagnostic
  • Rx: prostaglandin infusion to keep ductus arteriosus open. Life-saving balloon atrial septostomy

NEUROLOGY