The irritable child

A common presentation that can be difficult to address is a baby who is reported to cry excessively. A truly irritable baby dislikes handling and must be assumed to have serious illness and be admitted urgently to hospital. More common is the baby who will not settle or settles only briefly, or the misery of the febrile toddler: these children can cause considerable concern to new parents and healthcare professionals alike but are not necessarily very ill. The cause may be due to a multitude of reasons from significant pathology to poor parenting skills. Even when the practitioner can confidently determine there is no significant clinical problem (difficult at the best of times) admission to hospital or referral for further support should be considered if parents remain anxious.

Abdominal pain

Abdominal pain can also cause diagnostic conundrums. If a child is seriously ill (primary survey positive) he or she should be managed with immediate transfer to hospital and appropriate resuscitative measures. If the child is not seriously ill, the diagnosis can be divided into acute and chronic presentations.

Acute abdominal pain is common. Potential surgical pathology must be excluded and if this is not possible, the child referred for more detailed assessment. Appendicitis may be very difficult to diagnose in small children and must be actively considered. Other serious causes such as intussusception or volvulus may occasionally underlie the acute abdomen. Urinary tract infection must be sought as it often presents non-specifically with abdominal pain with or without urinary symptoms. One of the commoner causes of acute abdominal pain is mesenteric adenitis (acute lymphadenopathy in the abdominal lymph nodes) and a concurrent upper respiratory infection is characteristic. Infective gastroenteritis, Henoch–Schonlein purpura (HSP) and many other disorders all have their own spectrum of associated features and symptoms. If in doubt, refer.

Chronic abdominal pain is also common but more likely to present as a non-urgent complaint, unless the problem is an acute exacerbation of an ongoing problem. Causes are diverse and beyond the scope of this chapter – some of the commoner sources of abdominal pain include urinary tract infection, constipation, abdominal migraine and idiopathic causes (the aptly named ‘recurrent abdominal pain of childhood’).

The febrile child

Reducing the temperature of febrile children does not have any significant benefit in reducing the length or severity of the associated illness. However simple anti-pyretics, such as paracetamol (known as acetaminophen in the USA) or ibuprofen (which can be used concurrently), can reduce the misery in both child and carer alike (see below).

ENT problems

These are common in children. Infants are obligate nasal breathers up to about 6 months of age. Consequently a blocked nose may result in a significant increase in the work of breathing and may produce difficulty feeding. Otitis media, presenting with a red and sometimes bulging or perforated eardrum, is a common finding in a child with earache (see Chapter 11). Antibiotics have not been shown to alter the outcome of the disease in the majority of patients, but are still often given. The SIGN guidelines for management of otitis media recommend that antibiotics should not be immediately prescribed, but suggest a 5-day course of amoxicillin should be made available for collection from the GP if the child’s condition has not improved after 72 hours. Paracetamol (acetaminophen) and ibuprofen (alone or in combination) usually provide effective symptomatic relief.¹ Otitis externa is less common and usually also presents as earache (which may be severe), with or without a discharge. Antibiotic/steroid ear drops are appropriate.

Foreign bodies may be pushed into the ear by small children or, more commonly, into the nose, and should be sought in the presence of a snuffly child without symptoms of illness. The throat should be carefully examined in all sick children unless epiglottitis or croup is suspected. Streptococcal infections and glandular fever can cause petechial rashes on the palate, ulcers may indicate a Coxsackie virus infection, and Koplik’s spots are indicative of measles (which is rare nowadays). Swollen red tonsils, with or without exudates, and accompanied by flu-like symptoms suggest tonsillitis or possibly glandular fever. Unilateral enlargement may suggest a peri-tonsillar abscess.

Respiratory problems

Respiratory problems account for approximately 40% of children admitted to hospital, with the majority being for asthma (see Chapter 4). Croup is usually viral and presents with a seal-like bark with or without systemic illness or associated stridor. There may be other symptoms of upper respiratory tract infection including fever but the child is not generally very unwell. Sudden onset, short history, drooling due to pain and a very toxic child support the diagnosis of the now rare epiglottitis, which should be considered to be immediately life threatening.

Wheezing in babies may be due to a variety of causes, two of the commoner ones being asthma or bronchiolitis, the latter resulting in the hospitalisation of 2–3% of infants each year. Bronchiolitis is seasonal, occurring in the winter months and classically fine inspiratory crepitations may be heard on auscultation. Sudden or recurrent apnoea may occur in small babies with bronchiolitis, and infants with compromised immune systems, congenital heart disease or chronic lung disease. In older children asthma is the most likely cause of wheezing. Anaphylaxis should be considered as an unlikely possibility in a child with a first presentation of wheezing, as should the possibility of inhalation of a foreign body.

Significant respiratory tract infections, such as pneumonia, also occur in children and can result in hypoxia, respiratory failure, septicaemia, hypoglycaemia, or dehydration due to the inability to feed.

Tracheostomy tubes

In the event that a tracheostomy tube becomes obstructed, the following approach should be adopted:

Ventilated children

In the event of failure of a ventilator, confirm the problem is not due to airway obstruction. In the event of genuine failure of the device, assist breathing with a self-inflating bag with supplementary oxygen and transport to hospital. If an adjustable automatic ventilator is available on the ambulance, set this to deliver a tidal volume of 7–10 ml/kg to replace the work of the child’s normal ventilator and limit maximum airway pressure to 20 cmH₂O initially, increasing carefully until the chest moves.

Central venous catheters

Central venous catheters may be used for feeding, dialysis or administration of medication. If a catheter becomes dislodged, the wound should be dressed, and direct pressure applied as necessary to control bleeding. If bleeding occurs through a break in the catheter, the tube should be clamped proximally. The child’s hospital team should be contacted to arrange a review.

Infection at the insertion site will present as local reddening, tenderness, or a purulent discharge, which may also be associated with systemic signs of infection. Infection of the catheter itself will often present with signs of a non-specific serious infection and septicaemia. The catheter should not be used and the child referred to their medical team. Seriously damaged catheters are likely to require replacement whereas every effort is usually made to preserve the catheter in infection, if possible. Children with signs of septicaemia will require urgent antibiotic and supportive therapy.

In the event that a tube is obstructed, the child should be referred to hospital. The tube may be subsequently thrombolysed or, as a last resort, replaced. Fluid should not be forced down the tube. Hypoglycaemia and dehydration should be considered and managed in children dependent on the tube for nutrition.

Air embolism may occur as a result of incorrect flushing procedures or a mishap (usually during haemodialysis), and will present as coughing, dyspnoea and chest pain. The tube must be clamped and the child transferred urgently to hospital in a head-down, left-lateral position, with high concentration oxygen therapy. CPR may be necessary. The A&E department must be alerted.

Ventriculoperitoneal shunts

Ventriculoperitoneal (VP) shunts are surgically implanted in children with hydrocephalus to allow drainage of cerebrospinal fluid. Obstruction of the shunt will result in raised intra-cranial pressure, the signs of which will include altered affect, high pitched cry, fitting, and falling level of consciousness, similar to the presentation of meningitis. Children with evidence of an obstructed shunt require urgent hospital admission. The presence of Cushing’s triad (bradycardia, hypertension and Cheyne–Stokes ventilation) indicates the ICP is so high that brainstem impairment is occurring and is a critical situation. Supportive care should be provided during transfer to the hospital. If the child is very ill this will include airway care and high concentration oxygen therapy. Controlled hyperventilation (at a rate of 5 inflations per minute above the child’s normal respiratory rate) should be used only in children with signs of Cushing’s triad. Most children present sooner than this because parents have been trained to look for warning signs (and sometimes to check the shunt) and less rapid transfer will be more suitable.

Infection around the shunt may also occur, resulting in altered affect, headache, fever, and refusal to take feeds. Septicaemia can also result from shunt infections resulting in a lowered level of consciousness and shock. Urgent transfer to hospital with supportive and antibiotic therapy is indicated.

Feeding tubes

Feeding tubes may be positioned through the nose or rarely, the mouth, or be implanted through the abdominal wall. Most parents or carers (and indeed some children themselves!) in the UK are trained to replace nasogastric tubes, or local arrangements will have been made for a healthcare professional (for example at the community hospital or a community nurse) to do this. Hospital admission is therefore not usually necessary. Percutaneous tubes will usually require reinsertion in hospital as a matter of some urgency and the relevant unit should be contacted to arrange this.

Infected catheter sites should be cleaned and the hospital contacted to discuss review and to decide on appropriate antibiotic treatment. It is not necessary to discontinue use.

If correct placement of an enteral feeding tube cannot be confirmed, discontinue any infusion until the situation can be resolved by testing with litmus paper, which will show the presence of acid if the tube is in the stomach.

Table 6.2 provides a quick reference guide to managing a number of common problems.

Table 6.2 Management of common problems in technologically assisted children