6: PAEDIATRICS

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CHAPTER 6 PAEDIATRICS

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.

ROUTINE CHILDHOOD IMMUNISATIONS

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

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).

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.

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.

Management

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

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.

• Lifting the child to the lavatory when the parent goes to bed may be helpful.

• A star chart with stars given for dry beds encourages the child.

• A child who is <7 years of age might wear nappies or trainer pants at night if the above methods are unsuccessful.

Treatment

An enuresis alarm can be used if the above methods fail (obtainable via health visitors, school nurses or the local enuresis clinic). This is placed in the child’s bed so that the alarm rings when the child wets. Most children become dry within 2–3 months. Stop using the alarm after about 28 consecutive dry nights. Relapse responds well to re-treatment.

Drug treatment is usually helpful in children who do not respond to conservative measures. Use e.g. desmopressin nasal spray (synthetic analogue of ADH) 20–40 μg at bedtime. Withdraw treatment for at least 1 week for reassessment after 3 months. Desmopressin can be used intermittently, e.g. when staying away from home.

Refer to a urologist if history, examination or investigations suggest an organic cause, or if response to treatment is poor.

A child with a neuropathic bladder has daytime as well as night-time wetting. Examine for absent ankle jerks and a sacral dimple or hairy naevus. Refer to a urologist.

URINARY TRACT INFECTION IN CHILDREN

See also UTI, p. 64.

Eight per cent of girls and 2% of boys will have a UTI in childhood. From 25 to 50% of children with UTIs have associated urinary tract abnormalities (mainly vesicoureteric reflux). Appropriate and prompt antibiotic treatment reduces the risk of renal damage, which can occur in children as a result of recurrent UTIs.

Older children tend to present, like adults, with urinary frequency, dysuria, haematuria and/or abdominal pain.

Consider a UTI in any child who is failing to thrive or who has symptoms of fever, vomiting, diarrhoea, irritability and/or enuresis.

Investigation.

Dipstick urine to test for protein, nitrite and leucocytes.

Send MSU for MC&S before treatment with antibiotics. In younger children special collecting bags or pads can be used to obtain a urine specimen.

Management

Initial treatment of a suspected UTI is with antibiotics, e.g. trimethoprim or nitrofurantoin (see BNF for dose according to age) for 7 days, without waiting for the MSU result. Advise analgesia, if appropriate, and copious fluids.

All children under 5 years of age with a first confirmed UTI should be referred to a paediatric urologist for further investigation (e.g. renal tract ultrasound, micturating cystourethrogram, DMSA scan, IVP). Arrange an ultrasound while awaiting specialist assessment.

Follow local guidelines if available:

• Children over 5 years of age should have a renal tract ultrasound, including postvoiding residual urine volume, and should be referred to a paediatric urologist if this is abnormal.

• Antibiotic prophylaxis should be given to under 3-year-olds, and to older children where there is likely to be delay before investigation, e.g. trimethoprim 1–2 mg/kg at night or nitrofurantoin 1 mg/kg at night. Longer term antibiotic prophylaxis may be necessary in children in whom an underlying renal tract abnormality is confirmed, in order to prevent further renal scarring, and should be considered for children with recurrent UTIs in whom investigations have been normal.

• Arrange a repeat MSU for MC&S 1 month after the UTI, to ensure resolution.

SLEEP PROBLEMS

Sleep problems are very common and are nearly always simply habitual. Parents may be concerned that the child will not go to sleep, wakes during the night, or wakes very early. They are likely to be exhausted, and will need reassurance. Try to involve both parents in consistent management. Always consider involving the health visitor.

Exclude specific problems, e.g. unhappiness, fear, bed-wetting, environmental noise or illness.

Management

Advice

• An initial sleep diary, recording details of the sleep disturbance, is extremely useful. It should include waking time in the morning, times and lengths of naps during the day, time that the child went to bed, time of settling in bed, and times and lengths of waking during the evening and night, as well as parent management.

• Instil a disciplined bedtime routine.

• If the child gets out of bed, put them straight back with a firm reminder that it is time to sleep. Unless this plan is adhered to every time without fail, the child will continue to wake in the knowledge that the parent will eventually give way.

• Avoid rewards for night-waking, e.g. drinks, taking the child to the parents’ bed.

• Ensure a satisfactory environment, e.g. night light, adequate warmth.

• As far as possible, reward success and avoid chastisement.

• Consider the short-term use of hypnotics, in addition to the above, especially if parents are experiencing difficulty coping, e.g. promethazine 15–20 mg (2–5 years), 20–25 mg (5–10 years), at bedtime.

PRESCHOOL CHECK

This check is carried out by the GP when the child is 3.5 years old. The aim is to detect any potential special educational needs, as well as physical and emotional problems, and arrange for referral and assessment where necessary.

• Discuss parental concerns, asking specifically about vision, hearing, language and behaviour.

• Growth: plot height and weight on a centile chart.

• Examine heart and testes.

• Further examination is only necessary if indicated by parental concerns.

• Immunisations (see p. 334).

GROWTH PROBLEMS

Growth reflects general health and also the nutritional and emotional environment of a child. (For standard growth charts for girls and boys see appendices, pp. 349–352.)

Regular weight and head circumference measurements are useful to detect abnormalities and to reassure the parents that the baby is thriving.

FAILURE TO THRIVE

If the infant’s growth pattern is causing concern:

• Measure and plot the infant’s weight and head circumference at 2-weekly intervals and plot all previous measurements.

• Discuss milk intake, diet, nature and frequency of stools, and parental attitude and concerns.

• Perform a full examination.

• Check urine for protein, nitrite and leucocytes and send for culture.

• Discuss with the health visitor and other members of the primary healthcare team who may be involved.

• Refer if concern persists.

The most common reason for poor weight gain in breast-fed babies is insufficient milk intake. After attention to feeding technique, a trial of complementary bottle-feeding should be considered.

Serious abnormalities affecting growth, in addition to poor weight gain, are usually accompanied by other symptoms and signs. Most babies who gradually cross centiles downwards are normal and are simply adopting their true growth trajectory.

FAT BABIES

Babies whose weight lies above the 97th centile should only be a cause for concern in extreme cases. Infant obesity is not a good predictor of adult obesity.

HEAD GROWTH

Large head

The most common cause of head enlargement is a familial large head, where the head circumference may cross centiles upwards, but additional symptoms are absent. Hydrocephalus usually presents as a head measurement that is crossing centile lines upwards, together with signs of raised intracranial pressure (e.g. tense fontanelle, suture separation, irritability).

• Measure the parents’ head circumferences.

• Examine the baby for signs of raised intracranial pressure.

• Refer if there is concern.

Small head

Refer if the head circumference is below the 3rd centile.

SHORT/TALL STATURE

Short stature is considered to be a height below the 3rd centile, tall stature is above the 97th centile (see pp. 349–352). Both are usually normal variants. If there is concern about a child’s height:

• Plot the child’s height and weight together with previous recordings.

• To assess the expected final adult height of the child, plot the mean parental centile at age 19 (adult) on the growth chart:

– for a boy this is [father’s height + (mother’s height + 12.5 cm)]/2

– for a girl this is [father’s height + (mother’s height − 12.5 cm)]/2.

A height 8.5 cm above the mean centile is the 97th centile; 8.5 cm below it is the 3rd centile.

If the child’s predicted final adult height is reasonably consistent with the mean parental centile, monitor the height. Refer if this is not the case, if centile lines are crossed or if the final height is extreme and the parents/child are unduly concerned.

RESPIRATORY PROBLEMS

CORYZA

There is rarely any need for antibiotic treatment. Consider paracetamol syrup to reduce irritability, and nasal decongestants if feeding is difficult, e.g. xylometazoline paediatric nasal drops, 2 drops per nostril tds (maximum duration of use 7 days).

COUGH

Bronchiolitis

Bronchiolitis usually presents as an irritable cough with tachypnoea after coryzal symptoms in infants and toddlers, mainly in winter months. There may be feeding difficulty and a low-grade fever. The most common cause is respiratory syncitial virus. Examination confirms widespread crepitations, especially on expiration. Advise paracetamol, fluids and provision of warm moist air, if appropriate. Confident supportive care of the child is important. Refer if there is significant feeding difficulty or if the child is ill or distressed. Antibiotics do not help.

Croup

Croup involves fever, rhinorrhoea and sore throat, together with the diagnostic features of inspiratory stridor and a barking cough. Calm, confident management is important. Ask the parents to place the child in a steamy room (e.g. boil the kettle without a lid), and the symptoms will often improve after 10–20 minutes. Nebulised steroids, e.g. budesonide 2 mg, can be helpful. Antibiotics do not help. Refer if there is intercostal recession or if the child is ill.

Whooping cough (pertussis)

CHRONIC ASTHMA IN CHILDREN UP TO AGE 12

See also p. 170.

There is no evidence that early diagnosis or treatment affects the long-term prognosis of asthma in children under age 5.

Acute viral wheezy episodes in very young children are probably clinically distinct from atopic asthma.

The diagnosis of asthma in young children relies almost entirely on history.

History.

• a persistent nocturnal cough (a very common presentation in young children)

• recurrent wheezing (most commonly induced by exercise, upper respiratory tract infections and allergens).

Investigations.

Consider a chest X-ray if e.g. the child has recurrent chest infections or there is poor response to treatment.

Drug therapy.

Start the patient at the appropriate step according to symptoms (see pp. 96, 97):

• inhaled short-acting β₂ agonist, e.g. salbutamol 2 puffs tds

• inhaled steroid, e.g. beclometasone 100 μg bd.

Consider inhaled steroids if:

– using inhaled β₂ agonists more than three times per week

– symptomatic in the day more than three times per week or at night more than once per week

– there has been an exacerbation of asthma in the last 2 years.

Consider stepping down dose of inhaled steroids by 25–50% each time at intervals of 3 months or more. Maintain on the lowest dose of inhaled steroid which controls symptoms:

• leukotriene receptor antagonist, e.g. montelukast 4 mg in the evening

• long-acting β₂ antagonist (LABA), e.g. salmeterol 50 μg bd

• SR theophylline, e.g. Slo-Phyllin 60 mg bd.

A 5-day course of soluble prednisolone (<1 year, 1–2 mg/kg/day; 1–5 years, 20 mg/day; older children, 30–40 mg/day) should be considered at any time to gain rapid control.

Management of acute asthma.

Administration

Quality and Outcomes Framework for Asthma (see p. 175).

Summary of stepwise management of asthma in children aged <5 years, 2004. Reproduced with permission from the British Thoracic Society/Scottish Intercollegiate Guidelines Network Executive Committee.

Summary of stepwise management of asthma in children aged 5–12 years, 2004. Reproduced with permission from the British Thoracic Society/Scottish Intercollegiate Guidelines Network Executive Committee.

CONVULSIONS AND SEIZURES

ABSENCE SEIZURES (PETIT MAL EPILEPSY)

During these episodes, the child suddenly ceases activity, and may stare blankly for a period of seconds. The child may seem to be day-dreaming, and the episodes may occur many times per day. Diagnosis relies on witness reports usually from family or school teachers.

Refer to a paediatric neurologist for investigation and management.

NON-FEBRILE CONVULSIONS

Diagnosis

History.

• loss of consciousness

• shaking or jerking

• incontinence

• postictal state

• period of amnesia

• family history.

General management

• Admit all infants with a convulsion under the age of 6 months.

• Refer older children who have had a convulsion to a paediatric neurologist.

• Children with epilepsy should not cycle in traffic. They may swim in the presence of a responsible adult.

• The tendency to have seizures resolves during childhood in >60% of children. Anticonvulsant therapy can be stopped, on specialist advice, if the child has been free from seizures for 2 or 3 years.

Management of status epilepticus

• Ensure that the airway is patent.

• Give diazepam 0.3 mg/kg iv slowly, or rectally 2.5 mg (age <1), 5 mg (age 1–3), 10 mg (age >3).

• Admit the child if fitting continues.

FEBRILE CONVULSIONS

Febrile convulsions are very common, affecting about 4% of all children, usually in the second year of life.

CHILD PROTECTION

Child abuse is often divided into four categories. Few cases in practice fall neatly into one category.

2. SEXUAL ABUSE

This includes direct and indirect (e.g. pornography and indecent exposure) sexual acts perpetrated on a child who is either too young to give consent, or is old enough to give consent but is in an exploitative relationship.

Examination is usually unhelpful, but there may be genital or anal injury, emotional disturbance or sexually inappropriate behaviour. The most common presentation is with a statement by the child or by another member of the family.

3. NEGLECT

This involves persistent neglect and failure to protect the child from exposure to danger or threats to health. It may involve persistent absence from school without reason or failure to seek appropriate medical care. It may present as failure to thrive, severe nappy rash, unkempt condition, developmental delay or behavioural and emotional disturbance.

4. EMOTIONAL ABUSE

This involves severe psychological mistreatment. The child is denied comfort, nurture, control and love. There may be persistent verbal denigration and humiliation in the absence of positive interest.

CHILD PROTECTION PROCEDURES

The child’s welfare is paramount. The duty of confidentiality is overridden by the duty to protect the child from abuse.

Children’s best interests are served by being cared for within their own families wherever this is possible.

• Take a full history, and carefully record observations.

• Fully examine the child, except in cases of possible sexual abuse when examination should be carried out only by doctors with appropriate training.

• Expert anonymous consultative advice is always available in doubtful cases from e.g. child protection coordinators at Social Services.

• Discuss with other appropriate members of the primary healthcare team, particularly the health visitor.

If abuse is suspected:

• Refer as soon as possible to the Child Protection Investigation Team at Social Services. They will consider the need to remove the child to a place of safety.

• Refer immediately (see below) to the paediatric registrar/consultant for further medical examination.

• In the case of sexual abuse refer to an approved doctor.

The degree of urgency depends on the severity and type of abuse, the age of the child (younger children are more vulnerable) and continued exposure to risk.

• Involve the parents as far as is possible.

• Attend the case conference, or provide a written report. The child may be placed on the Child Protection Register for regular monitoring.

• The case may be taken to court where a supervision order or a care order may be issued.

SUDDEN INFANT DEATH

Sudden infant death syndrome (SIDS) is defined as the sudden, unexpected death of an infant or young child, for which post-mortem fails to show a cause. It occurs in 1 in 500 live births and there is a peak incidence between 2 and 3 months of age. It is rare after 6 months.

Management

The management of families suffering a sudden infant death has similarities with other cases of bereavement (see p. 327).

A phone call from parents whose baby has stopped breathing

• Call an ambulance if the parents have not done so.

• Tell the parents you will come immediately.

• Has resuscitation been attempted? Tell the parents how to attempt mouth-to-mouth resuscitation.

• Continue resuscitation until the ambulance arrives, unless the child is clearly dead (see below).

The ‘near miss’ (i.e. the apnoeic child has been resuscitated).

Admit the child to hospital. The risk of further episodes or of sequelae, whether real or perceived, is lessened by hospital admission.

The dead baby.

Immediate action

• Confirm death (see p. 325).

• Comfort parents and siblings. Be prepared for severe grief reactions, including anger.

• Try to answer parents’ questions, which often reflect their feelings of guilt.

• Inform the coroner/police, who will arrange for the baby to be taken to A&E or a mortuary. The police will usually take a statement from the parents.

• Encourage the parents to hold their dead baby.

• Suggest the parents call a close friend or family member to help. This also allows the GP to leave.

Parents’ anxieties over the next pregnancy and baby following a sudden infant death.

• Common feelings are doubt, loss of confidence, and fear of loving the new baby too much.

• Reassure the parents that the risk of further SIDS is very low and involve others in supporting the family, e.g. health visitor and midwife, paediatrician and CONI (Care of Next Infant) (see p. 356).

• Apnoea monitors, room thermometers, weighing scales and charts are available from the Foundation for the Study of Infant Deaths (see p. 357).

• Offer same-day appointments for minor illnesses.

Primary prevention of sudden infant death

Advise all pregnant women and mothers of babies, to avoid:

• overwrapping the baby in the cot

• placing the baby face down to sleep

Related

Churchills Pocketbook of General Practice