Paediatrics

1. 2008 Paediatrics

2. Hip Pain • CDH age < 5yrs • Septic arthritis – febrile or unwell child • Perthe’s disease age 3-10yrs M:F = 4:1 bilateral in 10% • Slipped upper femoral epiphyses age >10yrs M:F 3:1 commoner in obese and afro- Caribbean • Transient synovitis age 2-10yrs acute onset often preceded by viral illness

3. Investigations • Fbc esr • Xrays of both hips to compare AP + Lat of whole pelvis • Ultrasound – shows effusions but no the cause i.e. Transient synovitis or septic arthritis • MRI if diagnosis still unclear

4. CDH • Predisposition • Familial 20-30x increase with family history • Breech presentation 10-15x increase • Females • First born • Oligohydramnios • Left hip

5. CDH • Clinical features • Asymmetry of hip folds • Limitation of abduction when applying nappy • Dislocated leg shorter and externally rotated • More difficult if dislocation bilateral • Trendelenberg gait and shoulder sway

6. CDH • Management • In new born – splinting 6-8 weeks needs follow up • 6months – 6 years gradual traction over 3/52 to reduce dislocation then splinting or operation • Operative reduction • Age > 11 operation performed only if painful

7. Perthes Disease • Clinical features • Limp • Ache • Groin pain • Knee pain • Often slight and intermittent

8. Perthes Disease • Examination • Muscle wasting • Hip movements limited by pain

9. Perthes disease • Management • Mild disease • Rest and analgesia with movement when not painful regular radiology • More severe disease • Hip abduction and bracing • Osteotomy to improve hip/acetabulum congruity • Children often manage well with problem therefore treatment can seem worse than disease

10. Slipped femoral epiphyses • Clinical features • Rest pain can be in groin • Limp • Pain on movement • Restricted range of movements • Affected leg externally rotated and shortened • External rotation becomes gross on flexion

11. Slipped femoral epiphyses • Management • Only option is surgery • Slips of < 50% • Pinning in situ • Slips of > 50% • Osteotomy and pinning

12. Transient synovitis of hip • Clinical features • Acute onset • Pain • Limp • Followed by knee pain and inability to weight bear

13. Transient synovitis of hip • Examination • Leg held in position of greatest ease • Flexion, abduction and slight external rotation • Movement is restricted especially adduction and extension • Child is well • Symptoms persist for 2-3 weeks then resolve spontaneously

14. Acute bronchilolitis • Causes • Respiratory syncitial virus in 80% • Rhinovirus • Adenovirus • Influenza • enteroviruses

15. Epidemiology • Disease of first year of life • Season is November to March • By age 3yrs virtually all children have serological evidence of RSV • Infection does not produce immunity so re infection common

16. Clinical presentation • 2-3 day coryzal illness • Worsening respiratory distress • Tachypnoeic with rib recession • Fine crackles all over lungs • May have wheeze • May have temperature

17. Treatment • Indications for admission • Cyanosis • Severe resp distress resp rate > 70, nasal flaring, grunting, severe chest wall recession • Marked lethargy • Resp distress preventing feeding < 50% normal intake in 24hrs • Apnoeic episodes • Diagnostic uncertainty – toxic infant temp >40

18. Treatment • Relative indications for admission • Congenital heart disease • Any survivor of prematurity • Any pre existing lung disease or immunodefiency • Down’s syndrome have pulmonary hypoplasia • Social factors – isolated family anxious family etc

19. Treatment • Management is supportive only • Humidified oxygen if sats < 94 • Paracetamol for fever • Antibiotics only if secondary bacterial infection • Ventilation if sats < 92 persistently • Steroids and bronchodilators don’t help

20. Treatment • After acute illness • Cough and wheeze often goes on for several weeks • Intermittent symptoms present for several years • Does not cause asthma.

21. Febrile Seizures • Summary • Most common seizure disorder • Benign and have normal cognitive outcome • Occur in 1/3 of children, Low risk of epilepsy • Are prolonged in 9% of cases • Epilepsy risk includes • Complex febrile seizures • Neurological abnormality • Family history of epilepsy

22. Risk Factors • 24% have family history of febrile seizures • 4% have family history of epilepsy • Polygenic inheritance usual • Rare autosomal dominant • Occur between 6/12 and 6 yrs of age • Median age of onset 18 months

23. Febrile seizures • Temp normally > 38’c • May occur before fever is apparent • Seizures are brief generalised tonic clonic • 4-16% have focal features • In 87% seizure duration is < 10 mins • 9% seizures last > 15 mins • 5% status epilepticus seizures lasting > 30 mins

24. Recurrent seizures • 30% have recurrent seizures • Risk factors for recurrence are • Onset before 18/12 • Lower temperature • Shorter duration of fever < 1 hr before seizure • Family history of febrile seizures • If all 4 risk factors present risk = 76% • No risk factors risk = 4%

25. Risk of epilepsy • Complex seizures associated with > risk of epilepsy • Complex seizures are • Duration > 15mins risk of epilepsy = 21% • Multiple seizures within 24 hrs • Focal features • All 3 features risk = 49% • No risk factors risk of epilepsy = 2.4% normal population = 1.4%

26. Management • If seizure persists > 5 mins call ambulance • Administer rectal diazepam 0.5mg/kg or intranasal midazolam if > 5 mins • No evidence that decreasing fever decreases recurrence of febrile seizure • Prophylactic treatment is not indicated as does not reduce risk of epilepsy

27. Management • Admit to hosp if • Meningitis cannot be excluded • Recovery is prolonged • No apparent cause for fever • Complex seizure occurred • Poor psychosocial setting • When on fever is present – this is not a febrile seizure

28. Chronic abdominal pain • Summary • Not usually caused by organic disease • Triage focuses on alarm symptoms • No further evaluation needed if no alarm symptoms • Family characteristic rather than patient characteristics influence chronicity of pain

29. Prevalence • Prevalence ranges from 0.5% - 19% • 2 age peaks • 4-6 years • 7-12 years • Girls more than boys

30. Diagnosis • No diagnostic tools distinguish functional abdominal pain from organic abdominal pain • Presence of alarm symptoms increases probability of organic disease • Children with alarm signs or symptoms need further investigation

31. Alarm symptoms • Involuntary weight loss • Decelerating linear growth • Gastrointestinal blood loss • Significant vomiting • Chronic severe diarrhoea • Unexplained fever • Persistent right upper quadrant pain • Family history of inflammatory boweldisease

32. Diagnosis • Value of history and examination • If no alarm symptoms found there is no evidence that pain characteristics distinguish between functional or organic pain • Other symptoms such as headache, arthralgia, anorexia, nausea, constipation occur just as often in children with organic as those with functional pain • Recent stressful life events no help in differentiating organic form functional

33. Investigations • Positive investigation results such as helico bacter antibodies TTg antibodies for coeliac disease occur with the same frequency in children with and without abdominal pain. There relation to the abdominal pain is questionable

34. Prognosis • In Netherlands < 2% of children with abdominal pain referred to secondary care • 29% persists with pain • Parental factors more predictive of prolonged pain than child factors • Acceptance of parents of psychological factors in role of pain is strongly associated with recovery

35. Management • Diagnostic triage of children age 4-18yrs • Triage should include assessment of alarm symptoms and physical examination • Additional diagnostic assessment is not required in children without alarm symptoms • Testing may be carried out to reassure parents and children

36. Treatment • Deal with psychological factors • Educate family • Focus on return to normal functioning rather than complete disappearance of pain • Use drugs sparingly

37. Fever in children • See nice guidelines

38. Uti in children • See nice guidelines

39. Acute gastroenteritis • Epidemiology • In the USA in children < 5 yrs • 10% of acute hospital admissions (220,000) • 1.5 million outpatient visits • 300 deaths • Costs $ 1 bn • In the UK • 204/1000 consultations in children < 5 • Admission rate is 7/1000 children

40. Acute gastroenteritis • Summary • Rotavirus = commonest agent • Vaccination against rotavirus will decrease disease rates • Most children are not dehydrated and can be managed at home • Drugs are usually unnecessary and may do harm • Mild/moderate dehydration can be treated with parenteral or enteral rehydration using low osmolality rehydration solutions

41. Acute gastroenteritis • Causes • Viruses • Rotavirus • Norovirus • Enteric adenoviruses • Calicivirus • Astrovirus • enteroviruses

42. Acute gastroenteritis • Causes • Protozoa • Cryptosporidium • Giardia lamblia • Entamoeba histolytic

43. Acute gastroenteritis • Causes • Bacteria • Campylobacter • Non-typhoid salmonella • E coli • Shigella • Yersinia enterocolitica • Salmonella typhi and S. Paratyphi • Vibrio cholera

44. Acute gastroenteritis • Diagnosis • Clinical on history • Beware spurious diarrhoea • Be careful with high temperature prolonged history and signs suggestive of a surgical cause such as severe abdominal pain, bilious vomiting, abdominal mass. • Diabetes may present with vomiting as may inborn errors of metabolism

45. Acute gastroenteritis • Stool culture should be done • When there are outbreaks in schools, residential settings etc • If diarrhoea persisting > 5-7 days

46. Acute gastroenteritis • Assessing dehydration • This determines management • No clinical signs till 5% of body weight lost • Best indicators are • Prolonged capillary refill time • Abnormal skin turgor • Absent tears

47. Acute gastroenteritis • Management • No or mild dehydration • Stop all food • Stop all fluids except water or dilute squash • For 24-48 hrs the longer the better • Restart feeding with jelly, toast or soup • Gradually increase other foods • In babies < 9/12 re feed with ½ strength milk for 24 hrs then full strength milk for 24 hrs then add in solids

48. Acute gastroenteritis • Management • Admit to hospital • All high risk children • Those with mild/moderate dehydration who do not tolerate fluids • All children with severe dehydration • Diagnosis in doubt • Severe abdominal pain • Parent or carer unable to cope • Young infants < 6 months

49. Acute gastroenteritis • Complications • Dehydration • Metabolic acidosis • Lactose intolerance • Susceptibility to re infection • Haemolytic uraemic syndrome • Death

50. Acute gastroenteritis • Differential diagnosis • Other infections • Uti, otitis media, pneumonia, septicaemia • Surgical causes • Intussusception, appendicitis, small intestinal obstruction • Taking antibiotics or drugs • Spurious diarrhoea • Diabetic ketoacidosis, inborn errors of metabolism