6: PAEDIATRICS

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CHAPTER 6 PAEDIATRICS

Examination of the neonate
6–8-week check
Routine childhood immunisations
Neonatal jaundice
Infant feeding
Weaning
Babies with colic
Constipation
Nocturnal enuresis
Urinary tract infection in children
Sleep problems
Nappy rash
Preschool check
Growth problems
Respiratory problems
Convulsions and seizures
Child protection
Sudden infant death

EXAMINATION OF THE NEONATE

Examination of the neonate should be completed and recorded at all deliveries within 5 days of the birth. One in 40 newborns will be found to have a congenital malformation. The aim is to assess the baby’s general condition and respiratory function, and to identify any special management requirements in the first few days.

Routine examination should include:

• Measurements: check weight and head circumference.
• General appearance: look for dysmorphic features. Assess general muscle tone. Jaundice appearing within 24 hours requires urgent attention.
• Head: look for abnormalities in the cranial shape, allowing for moulding. An unusually full anterior fontanelle suggests hydrocephalus and an ultrasound should be arranged.
• Eyes: look for eye-size asymmetry. (Discrepancy suggests an infection, a developmental defect, or congenital glaucoma, which is an emergency.) Look for the red reflex to exclude a cataract.
• Nose: look for signs of obstruction.
• Mouth: check the palate for clefts.
• Chest: observe respiratory movements. Auscultate, if appropriate.
• Heart: heart murmurs are common at birth. Checking for murmurs at 8 weeks is more selective.
• Abdomen: look for distension or organomegaly. Exclude a single umbilical artery.
• Groins: check femoral pulses which may be absent in aortic coarctation. Look for hernias.
• Genitalia: check that the testes are in the scrotum. Exclude hypospadias and epispadias, and sexual ambiguity.
• Anus: exclude imperforate anus. The passing of meconium excludes this.
• Spine: exclude a scoliosis. Exclude any possible spinal cord abnormalities by looking for naevi, lumps, pits or hairy patches over the spine.
• Hips: exclude congenital dislocation.

6–8-WEEK CHECK

This check is completed by the GP and is combined with the first immunisations. It should include:

• Discussion of parental concerns: ask about vision, hearing and general development. Ask how the parents and siblings are adjusting to the birth of the baby.
• General observation: look for alertness, response to handling, dysmorphic features, etc.
• Skin: ask about and look for blemishes and abnormalities.
• Growth: plot weight, head circumference and, where necessary, length on a centile chart.
• Eyes: look for abnormal movements, squint or failure of fixation.
• Heart: check for murmurs.
• Genitalia: check that the testes are in the scrotum. Exclude hypospadias and epispadias, and sexual ambiguity.
• Hips: exclude congenital dislocation.

ROUTINE CHILDHOOD IMMUNISATIONS

See p. 334.

All newborn babies should receive vitamin K to prevent vitamin K deficiency bleeding (haemorrhagic disease of the newborn). Some areas recommend a single intramuscular vitamin K injection at birth. Other areas recommend oral vitamin K, two doses to be given in the first week of life (usually by the midwife). Babies who are being >50% breast-fed should receive a third oral dose at age 4 weeks (usually given by the health visitor).

NEONATAL JAUNDICE

• Jaundice within 24 hours of birth is always pathological.
• Serum bilirubin should be checked in babies with significant jaundice. Refer if the level lies above the limit for the baby’s age. (Discuss with laboratory.)
• ‘Physiological’ jaundice appears after 48 hours and usually disappears by day 7–10 of life.
• Jaundice persisting or presenting after 10 days of age (14 days in immature babies) is abnormal and the baby should be referred for assessment. If the prolonged jaundice is associated with breast-feeding it should fade by 6 weeks of age.

INFANT FEEDING

BREAST-FEEDING

See p. 35.

Breast-feeding is the preferred method from birth until weaning and beyond.

BOTTLE-FEEDING

Bottle-fed babies, like breast-fed babies, should be fed on demand and allowed to find their own pattern. Bottles and teats should be sterilised until the baby is >6 months old. Formula milk, as opposed to cow’s milk (which has relatively low iron and vitamin A, C, D and E content), should ideally be given until the baby is 1 year old. The baby requires about 150 ml per kg body weight per day. This is usually given as about six feeds/bottles per day. In the first week or so, the baby takes about 50–70 ml 7–8 times per day.

Changing milks because the baby has colic or seems unsettled is of little value. Soya milks are often misused. They have no advantage over other formulae but should be reserved for proven cow’s milk intolerance.

Milk feeds after 6 months

• Formula milk should ideally be continued for the first year.
• Cow’s milk can be introduced after 6 months.
• Low-fat milk should not be introduced before the age of 2.

WEANING

Weaning is the transition from an all-milk diet to a varied diet using solid foods. Advice should be sought from the health visitor.

• Solid foods are usually introduced by 6 months, but not before 3 months.
• Food should be offered by spoon in small quantities. If a food is rejected, it should be tried again after a while.
• Early foods should be low in salt and sugar.
• Plain rice cereals mixed with milk are usually given first, followed by stewed and puréed fruit or vegetables.
• As the baby starts to cut down milk consumption, small quantities of protein foods, e.g. meat or fish, can be added.
• By 9–12 months infants should be encouraged to have three regular meals per day, eating normal chopped family food. They will need about 0.5 litre (1 pint) of milk (breast, formula or cow’s) per day, as well as additional fluids. Only give drinks after meals, to avoid reducing appetite. Water should be encouraged, and fruit juices should be diluted with water.
• Avoid an excessively high fibre intake, as high-fibre foods are bulky and have a relatively low nutrient and energy content.
• Supplementary vitamins (A, D and C), 5 drops daily from 6 months to 5 years, may be given to children with an inadequate diet.
• If, from the age of 6 months, a child uses fluoride toothpaste, fluoride supplements (even in areas where there is no added fluoride in the water supply) are now considered unnecessary.

BABIES WITH COLIC

When called to see a crying baby, important physical causes must be excluded. Consider volvulus, intussusception or acute infection (e.g. otitis media or UTI).

Colic tends to start after 2 weeks of age, and usually settles by 4 months of age. The infant is often well in the morning, but by the evening may be distraught, pale and drawing up its legs. The parents are often quite unable to comfort the baby. They need reassurance that the problem is self-limiting and that they are not at fault since there is no clear cause. Involve the health visitor and encourage the parents to get as much rest as possible. Changing milk formulae is rarely helpful. Breast-feeding technique may need attention. A consistent feeding and sleeping routine may help, as may increased carrying and treatment with e.g. dimethicone (Infacol) 0.5–1 ml before feeds. Be alert for a child at risk (see child protection, p. 99).

Tip

Crying for long periods of time, especially in the evening, is usually due to ‘colic’.

CONSTIPATION

CONSTIPATION IN INFANTS

Constipation is more common in formula-fed than in breast-fed babies. It is only considered to be a problem if hard stools cause straining and discomfort. The passage of a normal soft stool once a week, for example, is not a problem. The cause is not always clear, but it may be due to inadequate fluid intake or to inadequately diluted formula feeds.

Management

• Consider the possibility of Hirschsprung’s disease if there is delay in first passing meconium and subsequent constipation.
• Exclude an anal fissure.
• Encourage the parent to give abundant fluids. (Unsweetened fruit juice can be given to babies in addition to milk.)
• Abdominal massage can be helpful.
• Laxatives are very rarely required.

CONSTIPATION AND SOILING IN OLDER CHILDREN

Hard stools may cause faecal retention and chronic constipation. This can lead to soiling due to a distended rectum, which leads to relaxation of the internal sphincter. The external sphincter is then put under considerable strain and is unable to prevent leakage of faeces. Most children are clean by 2.5 years of age and soiling may be viewed as abnormal after 4 years of age.

Acute constipation often follows febrile illnesses.

Diagnosis

History.

Ask about:

• the child’s diet and fluid intake
• previous bowel habit
• present management and how the parents are coping.

Examination.

Check:

• the abdomen for a loaded colon
• the anus for an anal fissure
• the rectum for the presence of faeces.

Management

The aim of treatment is to regain the child’s confidence in being able to defaecate painlessly.

• An enema may be required to dislodge a faecal mass. However, this can be distressing for a child, and a course of an oral stimulant laxative, e.g. senna syrup (age >6 years, 5–10 ml in the morning), and a faecal softener, e.g. lactulose solution (age 5–10 years, 10 ml bd), may be prescribed.
• Encourage copious fluids and a high-fibre diet.
• Refractory cases may require a prolonged course of senna and/or lactulose in gradually reducing dosage in order to amplify the gastrocolic reflex. Consider referral to a paediatric gastroenterology clinic.
• The child should be encouraged to go to the toilet, in unhurried time, after each meal, in order to encourage the gastrocolic reflex.
• The child with intentional defaecation in unacceptable places (encopresis) should, if appropriate, be referred to a child psychiatrist.

NOCTURNAL ENURESIS

Bed-wetting in children is a common problem. Most children are dry at night by the age of 3, 90% are dry by the age of 5 and >95% by the age of 10. The cause of bed-wetting is usually unclear, but the problem nearly always resolves with time. About 1% of children will have an organic problem, e.g. a congenital abnormality of the urinary tract, a urinary tract infection or a neuropathic bladder.

Diagnosis

History.

Ask about:

• Whether the child has ever been dry. (A period of dryness suggests that the problem is not organic unless the child has an acute UTI.)
• Whether the child wets during the day. (After the age of 4 this suggests a neuropathic bladder and the child should be referred.)
• Family history: children often follow a familial pattern.
• Any behavioural or emotional problems.
• Heavy sleeping.

Investigations

• Dipstick urine for glucose, nitrite, leucocytes and protein
• send an MSU for MC&S.

Management

Involve both the parent and the child, as well as the health visitor. Some areas have specific enuresis clinics.

Tip

Specific treatment is unnecessary under the age of 7 years. Ten per cent of 5-year-olds still wet the bed.

Advice

• Drinks should be avoided in the evening.
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