INTRODUCTION AND OVERVIEW

Infancy and childhood are characterised by a range of issues that broadly fall into three categories (Box 55.1):

Clearly, some cross these boundaries. However, problems in childhood need not extend into adult life even though they may have had major life effects in the short term. A sensitive approach to intervention that includes a holistic or integrative approach may have significant health benefits later. At the same time, a preventative strategy can alter family behaviour to abort important behavioural problems that are likely to lead to a lifetime of social disability.

It is difficult to separate the health of the child from the health of the family and the wider community. The health of the child is based not only upon his or her genetic background but also upon the prenatal environment, which is influenced by the lifestyle and mental and emotional health of the mother. Some of the most important investments in a child’s later health can be made by investing in the mental and physical health of the mother during and after pregnancy.

While not an extensive overview of paediatric ill health, this chapter addresses a range of common problems presenting in a primary care setting, to illustrate the role of an integrative approach to children and their families that will support family cohesion and rally mutual physical, psychological and social supports underpinning a healthy approach to living.

SCREENING

General practitioners are well placed to screen opportunistically for potential health issues when children present for routine immunisations or minor illnesses. Growth monitoring is appropriate at routine visits.

Developmental assessments should include hearing, vision (including strabismus), language acquisition, fine motor skills, social skills and family dynamics. Enquiries need to be made about physical activity, nutrition, time spent watching television, accident prevention and sun protection.¹ Given their high incidence, screen for iron deficiency and vitamin D deficiency in at-risk groups.

Parents should be encouraged to maintain a child’s personal health record with entries made by healthcare professionals, and to keep copies of relevant test results.

Children have tended to be the objects of healthcare; their opinions have frequently been ‘downgraded’ by healthcare professionals. Yet children also ‘acquire health-related knowledge through informal learning at home … they use their knowledge to promote their own well-being, in the context of and in interaction with social and physical features of their environment’.² Children actively participate in the maintenance of healthy lifestyles (their own and others’). A child-to-child approach to health education (albeit with reference to older children) is in operation worldwide, and acknowledges children as active participants in health promotion and maintenance of healthy lifestyles.³

GROWTH MONITORING

It is considered good clinical practice to monitor height and weight through childhood, and head circumference for the first 3 years. Most general practice record programs have embedded growth and development charts to assist in identifying deviations from normal that should invoke a second look.

Growth monitoring in children already identified as having a problem is mandatory, but when and how often do you monitor the typically normal child? Importantly, overweight is now considered as important as underweight. In a growth monitoring context it is easier to address developing overweight than to deal with established obesity.

Recording the measured growth parameters in the child’s personal health record is important, as this is the only record that moves with the child from one healthcare professional to the next.

Most parents are interested in their children’s growth and are keen to record progress over time. Maintaining growth records in the child’s personal health record beyond infancy can be very informative, particularly if the numbers have been plotted appropriately on the percentile charts. Lack of growth information even after frequent visits to any healthcare professional is a source of considerable frustration for the paediatrician.

Growth monitoring is important as a vehicle for providing health and nutrition advice, together with an opportunity for discussing lifestyle or childcare issues. It may also provide early identification of a range of diseases, including growth hormone deficiency, thyroid insufficiency, emotional or social deprivation and abuse, occult gastrointestinal disease, renal disease and a variety of syndromes including Russell-Silver syndrome, Turner syndrome and atypical mosaicism.

ATOPY

The prevalence of asthma and eczema among children (Fig 55.1) is increasing around the world.⁴ The notion of an ‘atopic march’ from eczema through to rhinitis has been coined,⁵ implying that early intervention may reduce the prevalence of disease in later life.

FIGURE 55.1 Incidence of different types of atopy

In our striving for cleanliness there is increasing evidence that skin sensitisation to known environmental allergens provokes immune responses that lead to eczema and, later, asthma. Immune provocation in susceptible individuals appears to trigger a cascade of events aggravated by early antibiotic exposure that may lead to medium- and long-term atopy.⁶

ALLERGIC RHINITIS

A diagnosis of allergic rhinitis should be considered in children who seem to have a ‘perpetual cold’, have frequent sore throats, mouth breathing, snoring, headaches, halitosis or poor concentration. Allergic rhinitis commonly occurs intercurrently with asthma, and control of allergic rhinitis may improve asthma control.

There is often a history of allergy in the child (infantile eczema) or the family.

A seasonal pattern of symptoms suggests that pollens or grasses are the allergen. Perennial rhinitis is most likely due to house dust mite or pet dander, mould or cockroaches. Food intolerance may be involved.

ASTHMA

(See also Ch 41, Respiratory medicine.)

Asthma is regarded as an inflammatory disorder of the airways, with oedema, hypertrophy of mucus glands, increased mucus secretion and smooth muscle constriction, resulting in recurrent episodes of cough, wheeze, chest tightness and breathlessness.

Symptoms tend to be worse at night or in the early morning, and may be triggered by exposure to allergens or changes in environmental temperature, emotional stressors or exertion. There is an inherited predisposition.

Between 100 and 150 million people around the globe suffer from asthma, and this number is rising. Worldwide, deaths from this condition have reached over 180,000 annually.²²

Asthma is not just a public health problem for developed countries. In developing countries, however, the incidence of the disease varies greatly.

It is important to distinguish between asthma and other causes of recurrent cough, particularly recurrent infective bronchitis. Misdiagnosis of childhood asthma leads to inappropriate treatment or overtreatment.

DIAGNOSIS

In children aged under 6 years, respiratory function tests are not practical or reliable. Diagnosis depends on careful history taking. A currently asymptomatic child is unlikely to have significant clinical signs.

In a child under the age of 12 months, wheeze is more likely to be due to respiratory syncytial virus (RSV) bronchiolitis or anatomically small airways, and a diagnosis of asthma is best withheld. Bronchodilators tend to be ineffective in this age group.

Once children are over the age of 2 years, persistent or recurrent wheeze or chronic nocturnal cough is more likely to be due to asthma.

Children aged over 6 years can have spirometry testing.

Allergy testing should be organised.

All children diagnosed with asthma will need an asthma management plan carefully developed with the child and their parents or carers, and conveyed to all carers and schools. The asthma action plan (Fig 55.2) chosen should be appropriate for the person’s age, educational status, language and culture.

FIGURE 55.2 Asthma management plan²³

*Not recommended for children under 12 years of age

My Asthma Management Plan © Commonwealth of Australia, reproduced with permission.

Metered dose inhalers are difficult to administer to a child, so a volume spacer with a face mask is a preferable option (cannot be used in children under the age of 7 years, as coordination is inadequate). Proper use of spacers, preferably large volume, is important, although carrying one of these around is tiresome. A small-volume spacer should be used when out, and a large-volume spacer used when at home.

Management involves a strategy for preventing and relieving attacks, and for recognising deterioration in control and intervening with pre-formulated strategies.

IRON DEFICIENCY

Iron deficiency is the most common nutrient deficiency in preschoolers, despite dietary advice from a wide range of sources. The prevalence varies between 16% and 22%, and it is more common in underprivileged and ethnic minorities. It is also a useful marker for general nutrition, as other nutritional deficiencies often may coexist with iron deficiency.

It is recognised that iron deficiency is associated with a range of developmental and behavioural problems in infancy and childhood that are reversible with iron supplementation and correction of the iron deficiency. Intellectual deficits arising from iron deficiency in infancy do persist into later years, if treatment is delayed. A high degree of suspicion is useful in infancy, as anaemia is a late manifestation of iron deficiency. Risk factors include prolonged breastfeeding without supplementation, more than six breastfeeds per day after 6 months, high cow’s milk intake after 12 months and poor solid intake because of high milk intake. Primary prevention of iron deficiency in infants and toddlers can be addressed by a range of measures (Box 55.2), and screening after 12 months is reasonable, particularly in high-risk groups. While prolonged breast feeding is beneficial, without an appropriate solid intake after 6–12 months iron deficiency is much more likely, and so care is required in advising about nutritional supplementation. Some infants become more iron deficient than others, probably because of feeding practices after birth but also because of the degree of intrauterine iron accumulation in the last trimester before birth. Preterm birth and intrauterine growth restriction interrupt normal iron stores and therefore are likely to lead to frank deficiency later if not addressed earlier.