Crash Course Paediatrics [5 ed.] 0702073709, 9780702073700

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Crash Course Paediatrics [5 ed.]
 0702073709, 9780702073700

Table of contents :
Front Cover
Inside Front Cover
Crash Course: Paediatrics
Copyright
Series Editors’ foreword
Preface
Acknowledgements
Series Editors’ acknowledgements
Contents
1 History and examination
Paediatric history taking
Presenting complaint
Medical history
Drug history
Birth history
Developmental history
Family history
Social history
Adolescent history
Neonatal history
Antenatal events
Birth
Postnatal events
Paediatric examination
General examination
Respiratory system
Inspection
Palpation
Percussion
Auscultation
Cardiovascular system
Inspection
Palpation
Auscultation
Gastrointestinal system
Inspection
Palpation
Percussion
Auscultation
Nervous system
Ear, nose and throat
The neonatal examination
General inspection
Skin
Head and neck
Face
Chest
Abdomen
Genitalia and anus
Limbs and spine
Neurology
Medical sample clerking
Further reading
2 Investigations
Urine tests
Blood tests
Haematology
Full blood count
Haemoglobin electrophoresis
Coagulation studies
Biochemical analysis
Urea and electrolytes
Sodium (Na +)
Potassium (K +)
Chloride (Cl –)
Urea
Creatinine
Liver function tests
Bilirubin
Enzymes
Transaminases (aminotransferases)
Alkaline phosphatase
γ -Glutamyltranspeptidase
Albumin
Glucose
Calcium and phosphate
Blood gases and acid–base metabolism
Immunology
Tests for immunodeficiency
Immunoglobulins
Differential white cell count
Lymphocyte subsets
Autoantibodies
Antinuclear antibodies
Rheumatoid factors
Thyroid antibodies
Diagnostic serology
Viral antibody tests
Epstein–Barr virus
Mycoplasma pneumoniae
Antistreptolysin O titre
Acute-phase reactants
Microbiology
Urine culture
Blood culture
Upper respiratory culture
Cerebrospinal fluid
Appearance
Microbiology
Microscopy
Culture and sensitivity
Biochemistry
Protein
Glucose
Rapid diagnostic techniques
Polymerase chain reaction and DNA hybridization
Imaging
X-rays
Chest X-ray
Indications for doing a CXR
Abdominal X-ray
Indications for doing an AXR
Skull X-ray
Computed tomography
Ultrasound
Antenatal ultrasound
Neonatal cranial ultrasound
Abdominal and renal ultrasound
Hip ultrasound
Magnetic resonance imaging
Micturating cystourethrograms
Dimercaptosuccinic acid scans
Further reading
3 Cardiovascular system
Congenital heart disease
History
Examination
Cyanosis
Murmurs
Innocent murmurs
Significant murmurs
Cardiac failure
Clinical features
Causes
Investigation
Classification
Acyanotic congenital heart disease
Left-to-right shunts (L to R)
Ventricular septal defect
Small VSD
Medium VSD
Large VSD
Atrial septal defect
Clinical features
Diagnosis
Patent ductus arteriosus
Clinical features
Diagnosis
Obstructive lesions
Coarctation of the aorta
Preductal coarctation
Postductal coarctation
Aortic stenosis
Pulmonary stenosis
Cyanotic congenital heart disease
Tetralogy of Fallot
Clinical features
Diagnosis
Management
Transposition of the great arteries
Clinical features
Management
Rheumatic fever
Clinical features
Diagnosis
Management
Complications
Cardiac infections
Infective endocarditis
Clinical features
Diagnosis
Management
Myocarditis
Kawasaki disease
Cardiac arrhythmias
Supraventricular tachycardia
Clinical features
Diagnosis
Management
Further reading
4 Respiratory system
Presentation of paediatric respiratory disease
Cough
History
Stridor
Wheeze
Respiratory distress
Apnoea
Upper respiratory tract infections
Sore throat: pharyngitis and tonsillitis
Clinical features
Management
Croup
Clinical features
Management
Acute epiglottitis
Clinical features
Management
Bacterial tracheitis
Diphtheria
Whooping cough
Clinical features
Investigations
Management
Complications
Lower respiratory tract infections
Bronchiolitis
Clinical features
Investigations
Management
Complications
Pneumonia
Clinical features
Investigations
Management
Complications
Asthma
Epidemiology
Aetiology
Pathophysiology
Clinical presentation
Investigations
Management
Nonpharmacological management
Medication
Steroid therapy in asthma
Long-acting β 2 agonists
Leukotriene receptor antagonists
Theophylline
Antiimmunoglobulin E monoclonal antibody
Acute severe asthma
Prognosis of asthma
Cystic fibrosis
Incidence and aetiology
Clinical features
Investigations
Management
Respiratory management
Nutritional management
Prognosis
Ears, nose and throat
Ears
Ear pain or discharge
Acute otitis media
Clinical features
Management
Hearing impairment
Otitis media with effusion
Assessment of hearing
Clinical features
Management
Nose
Nasal discharge and bleeding
Throat
Snoring and obstructive sleep apnoea
Further Reading
5 Gastrointestinal and hepatobiliary systems
Presentation of gastrointestinal disease
Acute abdominal pain
History
Examination
Investigations
Recurrent abdominal pain
Investigations
Treatment
Vomiting
History
Examination
Haematemesis
Acute diarrhoea
Chronic diarrhoea
History
Examination
Investigations
Constipation
History
Examination
Management
Faltering growth
Important gastrointestinal conditions
Infantile colic
Gastro-oesophageal reflux
Clinical features
Investigations
Management
Pyloric stenosis
Clinical features
Investigations
Management
Acute appendicitis
Clinical features
Investigations
Management
Mesenteric adenitis
Intussusception
Clinical features
Investigations
Management
Meckel diverticulum
Hirschsprung disease (congenital aganglionic megacolon)
Clinical features
Investigations
Management
Bowel obstruction
Gastroenteritis
Causes
Clinical features
Investigations
Management
Inflammatory bowel disease
Aetiology
Pathophysiology
Clinical features
Investigations
Management
Coeliac disease
Clinical features
Investigations
Management
Food intolerance
Lactose intolerance
Liver disease
Jaundice
Causes of jaundice after infancy
Hepatomegaly
Further Reading
6 Renal and genitourinary conditions
Haematuria
Causes
History
Examination
Investigations
Proteinuria
Definition of proteinuria
Causes
Examination
Investigations
Urinary tract anomalies
Renal anomalies
Obstructive lesions of the urinary tract
Pelviureteric junction obstruction
Vesicoureteric junction obstruction
Posterior urethral valves
Vesicoureteric reflux
Clinical features
Investigation
Management
Urinary tract infection
Causes
Clinical features
Diagnosis
Treatment of the acute infection
Further investigation
Acute nephritis
Causes
Clinical presentation
Investigation
Management
Nephrotic syndrome
Causes
Clinical features
Investigation
Management
Acute kidney injury
Haemolytic–uraemic syndrome
Chronic kidney disease
Genital conditions
Inguinoscrotal disorders
Undescended testis
Examination
Investigation
Management
Inguinal hernias and hydroceles
Hydroceles
Inguinal hernias
The acute scrotum
Penile conditions
Hypospadias
Phimosis and paraphimosis
Circumcision
Ambiguous genitalia
Further Reading
7 Endocrine system and growth
Hypothalamus and the pituitary gland
Anterior pituitary disorders
Posterior pituitary disorders
Diabetes insipidus
Syndrome of inappropriate secretion of ADH
Growth
Short stature
Causes
History
Examination
Management
Puberty
Variations of sex differentiation
Puberty
Precocious puberty
Delayed puberty
Adrenal disorders
Cushing syndrome
Clinical presentation
Management
Adrenocortical insufficiency
Clinical presentation
Management
Congenital adrenal hyperplasia
Clinical features
Investigations
Treatment
Thyroid disorders
Hypothyroidism
Congenital hypothyroidism
Clinical features
Management
Acquired hypothyroidism
Clinical presentation
Management
Hyperthyroidism
Neonatal hyperthyroidism
Causes
Clinical presentation
Management
Acquired hyperthyroidism
Clinical presentation
Management
Diabetes mellitus
Causes
Pathophysiology
Clinical presentation
Investigations
Management
Education and psychological support
Insulin replacement
Diet and exercise
Monitoring
Management of complications
Hypoglycaemia
Diabetic ketoacidosis
Late complications of diabetes
Inborn errors of metabolism
Clinical features
Investigations
Treatment
Phenylketonuria
Clinical presentation
Management
Galactosaemia
Glycogen storage diseases
Mucopolysaccharidoses
Polyendocrinopathies
Multiple endocrine neoplasia
Autoimmune polyendocrine syndromes
Further Reading
8 Haematology
Haematopoiesis
Normal developmental changes in haemoglobin
Anaemia
History
Examination
Investigations
Iron-deficiency anaemia
Iron requirements
Causes of iron deficiency
Clinical features
Diagnosis
Management
Thalassaemias
β -Thalassaemia
β -Thalassaemia major
Clinical features
Diagnosis
Treatment
β -Thalassaemia trait
α -Thalassaemia
Haemolytic anaemia
Hereditary spherocytosis
Clinical features
Diagnosis
Management
Sickle cell disease
Clinical features
Vasoocclusive crises
Management
Sickle cell trait
Red cell enzyme deficiencies
G6PD deficiency
Clinical features
Management
Pyruvate kinase deficiency
Splenomegaly
History
Examination
Investigations
Bleeding disorders
Disorders of blood vessels
Henoch–Schönlein purpura
Clinical features
Diagnosis and management
Disorders of platelets
Thrombocytopaenia
Idiopathic thrombocytopaenic purpura
Clinical features
Diagnosis
Treatment
Coagulation disorders
Haemophilia A (factor VIII deficiency)
Clinical features
Diagnosis
Management
Haemophilia B (factor IX deficiency, Christmas disease)
von Willebrand disease
Disseminated intravascular coagulation
Clinical features
Diagnosis and management
Thrombotic disorders in childhood
Further reading
9 Oncology
Childhood cancer
Aetiology
Genetic causes of childhood cancer
Infections
Environmental
Clinical features
Investigations
Management
Supportive care
The leukaemias
Investigations
Acute lymphocytic leukaemia
Clinical features
Prognosis
Management
Acute myeloid leukaemia
Lymphomas
Non-Hodgkin lymphoma
Clinical features
Management
Hodgkin lymphoma
Clinical features
Diagnosis
Management
Brain tumours
Diagnosis
Astrocytomas (40%)
Clinical features
Diagnosis and management
Medulloblastoma (20%)
Craniopharyngioma (4%)
Neuroblastoma
Clinical features
Diagnosis
Treatment
Wilms tumour (nephroblastoma)
Clinical features
Genetics and aetiology
Diagnosis
Treatment
Soft-tissue sarcomas
Bone tumours
Osteosarcoma
Clinical features
Diagnosis
Treatment
Ewing sarcoma
Clinical features and diagnosis
Treatment
Retinoblastoma
Langerhans cell histiocytosis
Further reading
10 Fever, infectious diseases and immunodeficiency
Fever
History
Examination
Investigations
Management
The child with fever and a petechial rash
Meningococcal sepsis
Pyrexia of unknown origin
Kawasaki disease
Incidence
Clinical features
Investigations
Management
Viral infections
Viral exanthems
Measles
Clinical features
Complications
Management
Rubella
Clinical features
Complications
Management
Congenital rubella
Erythema infectiosum or slapped cheek disease (fifth disease)
Clinical features
Complications
Management
Roseola infantum (sixth disease)
Clinical features
Complications
Management
Herpes infections
Herpes simplex virus 1 (HSV1, HHV-1)
Management
Herpes simplex virus 2 (HSV2, HHV-2)
Varicella zoster virus (HHV-3)
Clinical features
Complications
Management
Congenital varicella
Herpes zoster (shingles)
Epstein–Barr virus (HHV-4, EBV)
Clinical features
Management
Cytomegalovirus (HHV-5, CMV)
Clinical features
Management
Congenital CMV
Other viruses
Mumps
Clinical features
Complications
Management
Enteroviruses
Hand, foot and mouth disease
Polio
Viral hepatitis
Hepatitis A virus
Clinical features
Investigations
Treatment
Hepatitis B virus
Clinical features
Investigations
Management
Perinatal exposure
Bacterial infections
Streptococcal infections
Alpha-haemolytic streptococci
Beta-haemolytic streptococci
Scarlet fever
Erysipelas
Staphylococcal infections
Impetigo
Boils and abscesses
Staphylococcal scalded skin syndrome
Gram-negative infections
Typhoid and paratyphoid fever
Clinical features
Diagnosis
Management
Tuberculosis
Pathophysiology
Clinical features
Tuberculous infection: asymptomatic infection
Tuberculous disease: symptomatic infection
Haematogenous dissemination
Diagnosis
Tuberculin testing
Interferon-gamma testing
Culture and histology
Polymerase chain reaction
Radiology
Treatment and prevention
Parasitic infections
Malaria
Pathophysiology
Clinical features
Diagnosis
Management
Toxocariasis
Clinical features
Management
Worms (nematodes)
Threadworm
Clinical features
Diagnosis
Management
Immunodeficiency
Primary immunodeficiencies
X-linked agammaglobulinaemia (Bruton disease)
Common variable immunodeficiency
IgA deficiency
Severe combined immunodeficiency
Chronic granulomatous disease
Management
Secondary immunodeficiency
Immunosuppressive therapy
Human immunodeficiency virus
Transmission
Clinical features
Diagnosis
Management
Prevention
Further reading
11 Allergy and anaphylaxis
Epidemiology
Pathophysiology
IgE-mediated allergy
Non-IgE-mediated allergy
Cross-reactivity
Aetiology
Clinical aspects of allergy
History
Examination
Investigations
Skin-prick testing
Serum-specific IgE
Food challenge
Management
Anaphylaxis
Pathophysiology
Causes
Clinical presentation
Management
Prevention
Further reading
12 Dermatology
The child with a rash
Causes
History
Examination
Site and distribution
Morphology
Investigations
Specific rashes
Eczema
Atopic eczema
Clinical features
Investigations
Management
Complications
Infantile seborrhoeic eczema
Napkin dermatitis
Nappy rash
Candidiasis
Acne vulgaris
Clinical features
Management
Pityriasis rosea
Erythema multiforme
Erythema nodosum
Skin infections
Bacterial skin infections
Viral skin infection
Viral warts
Molluscum contagiosum
Fungal skin infections
Dermatophytoses (tinea capitis, corporis, pedis and unguium)
Candidiasis (thrush)
Infestations
Scabies
Clinical features
Management
Head lice ( Pediculosis capitis)
Clinical features
Management
Further reading
13 Nervous system
Fits, faints and funny turns
History
Provoking events
Description of the episodes
Other important features
Examination
The well child
Acute presentations
Seizures
Faints (vasovagal syncope)
Funny turns
Breath-holding attacks
Reflex anoxic seizures
Rigors
The unconscious child
Examination
Systemic examination
Neurological examination
Epilepsy
Classification of seizures
General onset seizures
Tonic–clonic seizures
Absence seizures
Focal onset seizures
Classification of epilepsies and epilepsy syndromes
Childhood absence epilepsy
Infantile spasms (West syndrome)
Aetiology
Diagnosis
Investigations
EEG
Neuroimaging
Other investigations
Management of epilepsy
Antiepilepsy drugs
Febrile convulsions
Clinical features
Management
Prognosis
Headache
History
Examination
Tension headaches
Migraine
Management
Raised intracranial pressure
Management
Infections of the central nervous system
Meningitis
Bacterial meningitis
Clinical features
Diagnosis
Treatment
Prevention
Complications
Encephalitis
Clinical features
Diagnosis
Management
Postinfectious syndromes
Guillain–Barré syndrome
Clinical features
Management
Malformations of the central nervous system
Hydrocephalus
Clinical features
Diagnosis
Treatment
Neural tube defects
Cerebral palsy
Clinical features
Diagnosis
Classification
Spastic cerebral palsy (70%)
Ataxic cerebral palsy (10%)
Dyskinetic cerebral palsy (10%)
Management
Neurocutaneous syndromes
Neurofibromatosis type 1 (von Recklinghausen disease)
Neurofibromatosis type 2
Tuberous sclerosis
Sturge–Weber syndrome
Neurodegenerative disorders of childhood
Clinical features
Neuromuscular disorders
Clinical features
Diagnosis
Muscular dystrophies
Duchenne muscular dystrophy
Clinical features
Diagnosis
Management
Becker muscular dystrophy
Myotonic dystrophy
Clinical features
Spinal muscular atrophies
Further reading
14 Musculoskeletal system
Limp
Differential diagnosis
History
Examination
Investigations
Blood tests
Imaging
Disorders of the hip and knee
Developmental dysplasia of the hip
Cause
Diagnosis
Management
Transient synovitis (irritable hip)
Diagnosis
Management
Perthes disease
Clinical features
Diagnosis
Management
Slipped upper femoral epiphysis
Disorders of the spine
Back pain
Scoliosis
Idiopathic scoliosis
Torticollis
Disorders of the upper limbs
Pulled elbow
Disorders of the skull
Craniosynostosis
Fractures
Bone and joint infections
Osteomyelitis
Clinical features
Diagnosis
Treatment
Septic arthritis
Clinical features
Investigation
Management
Rheumatic disorders
Juvenile idiopathic arthritis
Systemic (previously Still disease)
Polyarticular
Rheumatoid factor-negative polyarticular JIA
Rheumatoid factor-positive polyarticular JIA
Oligoarticular
Diagnosis
Management
Juvenile dermatomyositis
Systemic lupus erythematous
Diagnosis
Management
Genetic skeletal dysplasias
Achondroplasia
Osteogenesis imperfecta (brittle bone disease)
Further reading
15 The newborn
Definitions
Maternal and fetal health
Fetal assessment and antenatal diagnosis
Maternal conditions affecting the fetus
Maternal diseases
Diabetes mellitus
Hypertension
Maternal thyroid disease
Maternal drugs affecting the fetus
Maternal infections and the fetus
Cytomegalovirus
Rubella
Varicella zoster virus
Human immunodeficiency virus
Toxoplasmosis
Normal neonatal anatomy and physiology
Size and growth
Skin
Head
Respiratory system
Cardiovascular system
Gastrointestinal system
Genitourinary system
Haematopoietic and immune system
Central nervous system
Birth
Assessment and care at a normal birth
Perinatal asphyxia
Hypoxic–ischaemic encephalopathy
Birth injury
The newborn
Size and gestational age
Small for gestational age
Large for gestational age infants
Feeding difficulties
Breastfeeding
Bottle feeding
Weight gain in infants
Vomiting
Neonatal jaundice
Jaundice in the first 24 hours
Rhesus (Rh) haemolytic disease of the newborn
ABO incompatibility
Jaundice at 2 days to 2 weeks
Prolonged jaundice ( > 2 weeks)
Management of neonatal jaundice
Phototherapy
Exchange transfusion
Biliary atresia
Clinical features
Investigations
Management
Disorders of the term infant
Respiratory disorders
Transient tachypnoea of the newborn
Pneumonia
Management
Laryngomalacia
Pneumothorax
Chylothorax
Meconium aspiration
Persistent pulmonary hypertension of the newborn
Management
Aspiration
Gastrointestinal and hepatic disorders
Cleft lip and palate
Oesophageal atresia
Bowel obstruction
Small bowel obstruction
Duodenal atresia
Midgut volvulus and malrotation
Meconium ileus
Large bowel obstruction
Hirschsprung disease
Anorectal atresia
Cardiovascular disorders
Haematological disorders
Haemorrhagic disease of the newborn
Neurological disorders
Neonatal seizures
Initial investigations
Neonatal abstinence syndrome
Clinical features
Diagnosis
Management
Infections
Minor infections
Skin pustules and paronychia
Acute mastitis
Conjunctivitis
Thrush (moniliasis)
Major infections
Septicaemia
Diagnosis
Group B streptococcal infection
Treatment
Meningitis
Diagnosis
Treatment and outcome
Pneumonia
Urinary tract infection
The preterm infant
General care of the preterm infant
Predelivery care
Stabilization at birth
Body temperature
Avoiding infection
Nutrition and fluids
Which milk for preterm infants?
Supplements
Disorders of the preterm infant
Respiratory disorders
Surfactant deficiency (hyaline membrane disease, RDS)
Clinical features
Management
Apnoeic attacks
Cardiovascular problems
Patent ductus arteriosus
Management
Neurological problems
Intracranial haemorrhage
Periventricular leukomalacia
Gastrointestinal problems
Jaundice
Necrotizing enterocolitis
Management
Long-term prognosis
Retinopathy of prematurity
Chronic lung disease
Management
Neurodevelopmental problems
Congenital malformations
Craniofacial
Craniosynostosis
Cleft lip and palate
Respiratory
Cystic adenomatoid malformation of the lung
Congenital diaphragmatic hernia
Gastrointestinal
Gastroschisis (1:5000)
Exomphalos (1:2500)
Central nervous system
Neural tube defects
Spina bifida occulta
Meningocele
Myelomeningocele
Urogenital
Musculoskeletal
Congenital talipes equinovarus (club foot)
Developmental dysplasia of the hip
Further reading
16 Genetics
Basic genetics
Single-gene disorders
Autosomal dominant disorders
Achondroplasia
Marfan syndrome
Autosomal recessive disorders
X-linked disorders
Fragile X syndrome
Ornithine transcarbamylase deficiency
Multifactorial disorders
Chromosomal disorders
Chromosomal abnormalities
Down syndrome (Trisomy 21)
Nondisjunction
Translocation
Mosaicism
Clinical features
Management and prognosis
Edwards syndrome (trisomy 18)
Patau syndrome (trisomy 13)
Sex chromosome disorders
Turner syndrome
Clinical features and diagnosis
Management
Klinefelter syndrome
Structural chromosomal abnormalities
Mitochondrial inheritance
Genetic counselling
17 Developmental assessment and developmental day
History
Examination
Key gross motor milestones
Key fine motor and visual milestones
Key speech and hearing milestones
Key social and cognitive milestones
Signs of abnormal development
Global developmental delay
Investigation and management
Specific developmental delay
Delayed walking
Examination
Investigations
Speech and language delay
Further reading
18 Child and adolescent mental health
Attachment
Problems of early childhood
Babies
Toddlers
Sleep-related problems
Difficulty in getting to sleep at night
Nightmares and night terrors
Food refusal
Tantrums
Breath-holding spells
Autism spectrum disorders
Clinical presentation
Assessment and diagnosis
Management
Attention deficit hyperactivity disorder
Incidence and aetiology
Clinical features
Investigations
Management
Behavioural therapy
Drug therapy
Alternative therapies
Prognosis
Behavioural problems
Conduct disorder
Oppositional defiant disorder
Continence problems
Enuresis
History
Examination
Investigations
Management
Encopresis (faecal soiling)
History
Examination
Management
Affective disorders
Depression
Clinical features
Management
Self-harm and suicide
Anxiety
School refusal
Selective mutism
Psychosis
Eating disorders
Aetiology
Anorexia nervosa
Clinical features
Investigations
Management
Prognosis
Bulimia nervosa
Medically unexplained physical symptoms
Chronic fatigue syndrome
Management
Recurrent pain syndromes
Management
Further reading
19 Community paediatrics, public health and child protection
Prevention in child health
Screening
Child health promotion
Neonatal examination
1–2-Week check
6–8-Week check
9–12-Month review
2–2.5-Year review
School entry
Immunization
Active immunization
Passive immunization
Routes of administration
Immunization schedule
Indications and contraindications to immunization
False’ contraindications
Sudden infant death syndrome
Brief resolved unexplained events
Children with disabilities
Causes of childhood disability
Assessment and diagnosis
Management: the multidisciplinary team
Education, health and care plan
Child protection
Types of abuse
Physical abuse or nonaccidental injury
Sexual abuse
Emotional abuse
Neglect
Diagnosis
Management
Children and the law
The Children Act
Parental responsibility
Foster care
Adoption
Consent to medical care
Confidentiality
Further reading
20 Accidents and emergencies
Emergencies
The seriously ill child
Assessment
Airway
Breathing
Circulation
Disability
Cardiorespiratory arrest
Basic paediatric life support
Airway manoeuvres
Rescue breaths
Assessing for signs of life
Chest compressions
Advanced paediatric life support
Neurological emergencies
Reduced level of consciousness
Assessment
Diagnosis
Management
Seizures
History
Examination
Management
Cardiac emergencies
Respiratory emergencies
Upper airways obstruction
Croup
Acute epiglottitis
Foreign body inhalation
Management
Lower airways obstruction
Acute asthma
Bronchiolitis
Shock (circulatory failure)
Clinical features
Management
Specific shock syndromes
Anaphylactic shock
Septic shock
Clinical features
Management
Diabetic ketoacidosis
Clinical features
Diagnosis
Management
Fluids
Insulin
Complications
Accidents
Trauma
Major trauma
Management
Immediate
Focused
Detailed review
Head injury
Clinical features
Diagnosis
Management
Burns and scalds
Assessment
Management
Nonaccidental injury consideration in burns and scalds
Near drowning
Management
Prognostic indicators of near drowning
Poisoning
Clinical features
Diagnosis
Management
Deliberate self-poisoning in older children
Further reading
21 Nutrition, fluids and prescribing
Nutrition
Normal nutritional requirements
Infant feeding
Breastfeeding
Weaning
Special milks
Malnutrition
Assessment of nutritional status
Dietary history
Anthropometry
Laboratory investigations
Management
Vitamin deficiencies
Vitamin D deficiency: rickets
Diagnosis
Treatment
Vitamin A (retinol) deficiency
Obesity
Management
Fluids and electrolytes
Basic physiology
Fluid compartments
Normal requirements
Intravenous fluids
Important features of intravenous solutions
Specific fluid and electrolyte problems
Sodium
Potassium
Paediatric pharmacology and prescribing
Absorption and administration
Metabolism and excretion
Further reading
Part: Self-Assessment
Single best answer (SBA) questions
Extended matching questions (EMQs)
SBA answers
EMQ answers
Glossary
Index
Inside Back Cover

Citation preview

Paediatrics

First and second edition authors: Christine Budd Mark Gardiner David Pang Tim Newson

Third edition author: Shyam Bhakthavalsala

Fourth edition authors: Rajat Kapoor Katy Barnes

5

th Edition

CRASH COURSE SERIES EDITORS

Philip Xiu

MA, MB BChir, MRCP GP Registrar Yorkshire Deanery Leeds, UK

Shreelata Datta MD, MRCOG, LLM, BSc (Hons), MBBS Honorary Senior Lecturer Imperial College London Consultant Obstetrician and Gynaecologist King's College Hospital London, UK

FACULTY ADVISOR

Cassandra Gyamtso MBBS, MRCPCH Consultant Paediatrician and Neonatologist North Middlesex University Hospital London, UK

Paediatrics Anna Rodgers

MBBS, MRCPCH, ST5 North Middlesex University Hospital London, UK

Jessica Salkind

MBBS Academic Clinical Fellow in Paediatrics Imperial College London London, UK

Content Strategist: Jeremy Bowes Content Development Specialist: Alexandra Mortimer Project Manager: Andrew Riley Design: Christian Bilbow Illustration Manager: Karen Giacomucci Illustrator: MPS North America LLC Marketing Manager: Deborah Watkins © 2020 Elsevier Limited. All rights reserved. First edition 1998 The right of Anna Rodgers and Jessica Salkind to be identified as authors of this work has been asserted by them in accordance with the Copyright, Designs and Patents Act 1988. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. ISBN: 978-0-7020-7369-4



Printed in Poland Last digit is the print number: 9 8 7 6 5 4 3 2 1

Series Editors’ foreword The Crash Course series was conceived by Dr Dan Horton-Szar who as series editor presided over it for more than 15 years - from publication of the first edition in 1997, until publication of the fourth edition in 2011. His inspiration, knowledge and wisdom lives on in the pages of this book. As the new series editors, we are delighted to be able to continue developing each book for the twenty-first century undergraduate curriculum. The flame of medicine never stands still, and keeping this all-new fifth series relevant for today's students is an ongoing process. Each title within this new fifth edition has been re-written to integrate basic medical science and clinical practice, after extensive deliberation and debate. We aim to build on the success of the previous titles by keeping the series up-to-date with current guidelines for best practice, and recent developments in medical research and pharmacology. We always listen to feedback from our readers, through focus groups and student reviews of the Crash Course titles. For the fifth editions we have reviewed and re-­written our self-assessment material to reflect today's ‘singlebest answer’ and ‘extended matching question’ formats. The artwork and layout of the titles has also been largely re-worked and are now in colour, to make it easier on the eye during long sessions of revision. The new on-line materials supplement the learning process. Despite fully revising the books with each edition, we hold fast to the principles on which we first developed the series. Crash Course will always bring you all the information you need to revise in compact, manageable volumes that still maintain the balance between clarity and conciseness, and provide sufficient depth for those aiming at distinction. The authors are junior doctors who have recent experience of the exams you are now facing, and the accuracy of the material is checked by a team of faculty editors from across the UK. We wish you all the best for your future careers!

Philip Xiu and Shreelata Datta

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Preface The new edition of Crash Course: Paediatrics has been reformatted compared to previous editions to combine the chapters which previously dealt with individual body systems with their relevant clinical aspects, including history, examination and disease process. This edition continues to provide a practical approach to paediatrics through the use of hints and tips boxes. New boxes such as red flags, communication and ethics boxes have been added in the hope that these will prove useful in both clinical practice and exam settings. The self-assessment section has been updated and now includes OSCEs and clinical cases. The book is aimed at undergraduates but would be a great resource for foundation trainees or specialty doctors embarking on a career in paediatrics.

Anna Rodgers Jessica Salkind Cassandra Gyamtso

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Acknowledgements With thanks to our family and friends for their encouragement and the editors for their patience in the creation of this new edition.

Anna Rodgers Jessica Salkind Cassandra Gyamtso

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Series Editors’ acknowledgements We would like to thank the support of our colleagues who have helped in the preparation of this edition, namely the junior doctor contributors who helped write the manuscript as well as the faculty editors who check the veracity of the information. We are extremely grateful for the support of our publisher, Elsevier, whose staffs’ insight and persistence has maintained the quality that Dr Horton-Szar has set-out since the first edition. Jeremy Bowes, our commissioning editor, has been a constant support. Alex Mortimer and Barbara Simmons our development editors have managed the day-to-day work on this edition with extreme patience and unflaggable determination to meet the ever looming deadlines, and we are ever grateful for Kim Benson’s contribution to the online editions and additional online supplementary materials.

Philip Xiu and Shreelata Datta

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Contents Series Editors’ foreword . . . . . . . . . . . . . . . . . . . . . . . . v Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . vii Series Editors’ acknowledgements. . . . . . . . . . . . . . . viii 1 History and examination. . . . . . . . . . . . . . . . . . . . . . . 1 Paediatric history taking................................................1 Adolescent history.........................................................2 Neonatal history.............................................................3 Paediatric examination..................................................4 The neonatal examination..............................................6 Medical sample clerking................................................8 Further reading.............................................................11 2 Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Urine tests....................................................................13 Blood tests...................................................................13 Cerebrospinal fluid.......................................................20 Imaging........................................................................21 Further reading.............................................................24 3 Cardiovascular system. . . . . . . . . . . . . . . . . . . . . . . 25 Congenital heart disease.............................................25 Rheumatic fever...........................................................31 Cardiac infections........................................................32 Cardiac arrhythmias.....................................................33 Further reading.............................................................34 4 Respiratory system. . . . . . . . . . . . . . . . . . . . . . . . . . 35 Presentation of paediatric respiratory disease............35 Upper respiratory tract infections................................37 Lower respiratory tract infections................................39 Asthma.........................................................................40 Cystic fibrosis..............................................................44 Ears, nose and throat...................................................46 Further reading.............................................................49 5 Gastrointestinal and hepatobiliary systems. . . . . . 51 Presentation of gastrointestinal disease......................51 Important gastrointestinal conditions..........................56 Liver disease................................................................61 Further reading.............................................................63 6 Renal and genitourinary conditions . . . . . . . . . . . . 65 Haematuria...................................................................65 Proteinuria....................................................................66 Urinary tract anomalies................................................67 Urinary tract infection...................................................69 Acute nephritis.............................................................71 Nephrotic syndrome....................................................71 Acute kidney injury.......................................................72

Chronic kidney disease................................................72 Genital conditions........................................................72 Further reading.............................................................75 7 Endocrine system and growth. . . . . . . . . . . . . . . . . 77 Hypothalamus and the pituitary gland.........................77 Growth.........................................................................78 Puberty.........................................................................80 Adrenal disorders.........................................................83 Thyroid disorders.........................................................84 Diabetes mellitus..........................................................85 Inborn errors of metabolism.........................................89 Polyendocrinopathies..................................................91 Further reading.............................................................91 8 Haematology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Haematopoiesis...........................................................93 Anaemia.......................................................................93 Haemolytic anaemia....................................................97 Splenomegaly..............................................................99 Bleeding disorders.....................................................100 Coagulation disorders................................................102 Thrombotic disorders in childhood............................103 Further reading...........................................................104 9 Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Childhood cancer.......................................................105 The leukaemias..........................................................107 Lymphomas...............................................................108 Brain tumours............................................................109 Neuroblastoma...........................................................110 Wilms tumour (nephroblastoma)................................111 Soft-tissue sarcomas.................................................111 Bone tumours............................................................111 Retinoblastoma..........................................................112 Langerhans cell histiocytosis.....................................112 Further reading...........................................................113 10 Fever, infectious diseases and immunodeficiency. . . . . . . . . . . . . . . . . . . . . . . . . . 115 Fever..........................................................................115 Viral infections............................................................118 Bacterial infections....................................................124 Parasitic infections.....................................................127 Immunodeficiency......................................................129 Further reading...........................................................131 11 Allergy and anaphylaxis . . . . . . . . . . . . . . . . . . . . . 133 Epidemiology.............................................................133 Pathophysiology........................................................133 Aetiology....................................................................134

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Contents Clinical aspects of allergy..........................................134 Anaphylaxis................................................................136 Further reading...........................................................138 12 Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 The child with a rash..................................................139 Specific rashes...........................................................140 Skin infections............................................................143 Infestations.................................................................144 Further reading...........................................................144 13 Nervous system. . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Fits, faints and funny turns........................................145 The unconscious child...............................................146 Epilepsy......................................................................147 Febrile convulsions....................................................150 Headache...................................................................150 Infections of the central nervous system...................152 Malformations of the central nervous system............154 Cerebral palsy............................................................155 Neurocutaneous syndromes......................................156 Neurodegenerative disorders of childhood................157 Neuromuscular disorders...........................................158 Further reading...........................................................159 14 Musculoskeletal system. . . . . . . . . . . . . . . . . . . . . 161 Limp...........................................................................161 Disorders of the hip and knee....................................162 Disorders of the spine................................................164 Disorders of the upper limbs......................................165 Disorders of the skull.................................................165 Fractures....................................................................166 Bone and joint infections...........................................166 Rheumatic disorders..................................................167 Genetic skeletal dysplasias........................................169 Further reading...........................................................170 15 The newborn. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 Maternal and fetal health...........................................171 Fetal assessment and antenatal diagnosis................171 Maternal conditions affecting the fetus.....................171 Normal neonatal anatomy and physiology................174 Birth............................................................................176 Birth injury..................................................................178 The newborn..............................................................178 Disorders of the term infant.......................................182 The preterm infant......................................................186 Disorders of the preterm infant..................................188 Congenital malformations..........................................190 Further reading...........................................................192 16 Genetics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 Basic genetics............................................................193 Single-gene disorders................................................193 Autosomal dominant disorders..................................193

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Autosomal recessive disorders..................................195 X-linked disorders......................................................195 Multifactorial disorders..............................................196 Chromosomal disorders.............................................196 Mitochondrial inheritance..........................................199 Genetic counselling...................................................199 17 Developmental assessment and developmental day . . . . . . . . . . . . . . . . . . . . . . . . . 201 History........................................................................201 Examination...............................................................201 Signs of abnormal development................................203 Further reading...........................................................205 18 Child and adolescent mental health . . . . . . . . . . . 207 Attachment.................................................................207 Problems of early childhood......................................207 Autism spectrum disorders........................................208 Attention deficit hyperactivity disorder......................209 Behavioural problems................................................210 Continence problems.................................................210 Affective disorders.....................................................212 Anxiety.......................................................................212 Psychosis...................................................................212 Eating disorders.........................................................213 Medically unexplained physical symptoms...............214 Further reading...........................................................215 19 Community paediatrics, public health and child protection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .217 Prevention in child health...........................................217 Children with disabilities............................................220 Child protection.........................................................221 Children and the law..................................................223 Further reading...........................................................224 20 Accidents and emergencies . . . . . . . . . . . . . . . . . 225 Emergencies..............................................................225 Accidents...................................................................236 Further reading...........................................................241 21 Nutrition, fluids and prescribing . . . . . . . . . . . . . . 243 Nutrition.....................................................................243 Fluids and electrolytes...............................................247 Paediatric pharmacology and prescribing.................249 Further reading...........................................................250 Self-Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Single best answer (SBA) questions . . . . . . . . . . . . . . Extended-matching questions (EMQs). . . . . . . . . . . . SBA answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . EMQ answers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

251 253 275 283 295 301 305

History and examination While the majority of adult patients will be compliant with history and examination, it often takes skilled communication to perform these key aspects of assessment in paediatrics. Building rapport with the child or young person, as well as their caregivers, is vital. Your approach should be age appropriate and flexible. The only way to gain these skills is by clinical experience, so make the most of your paediatric placements, taking opportunities to interact directly with babies, children and adolescents wherever possible. When summarizing the clinical history and examination, begin to think about how you would investigate and manage the case. It is good to practise this skill as a student, as it will be expected of you once you become a foundation doctor.

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Presenting complaint As with any history, begin with open questions to establish the reason for presentation. Explore the nature of any symptoms, the onset, duration and any precipitating factors. In addition, explore associated symptoms. If the child has a possible infection, find out if anyone is currently unwell at home, whether they have travelled abroad or eaten anything unusual. It is useful to establish which symptoms are most worrying to the child and/or their parents. Do not dismiss parental anxiety: a parent who tells you ‘my child is not himself/herself ’ may have picked up on something that you have missed.

Medical history PAEDIATRIC HISTORY TAKING Introduce yourself and establish who is in the room, taking time to establish rapport. Whilst it can be tempting to take a history directly from the parent/carer, especially where a child is shy or anxious, it is much better to take your history at least partly from a child who can speak, wherever possible. This is particularly important where child protection concerns have been raised. COMMUNICATION It is key to establish who everybody is and not make assumptions about how people are related (it is highly embarrassing to incorrectly assume an older mother as a grandmother or a two-dad family as a father and uncle!) A helpful approach can be to ask a verbal child, ‘who have you brought with you today?’ and confirm precise relationships with the adult(s).

Explore any previous diagnoses, hospital admissions and previous treatment. Many children will have no previous conditions, but some children, for example, those who were born very prematurely or with congenital syndromes, may have a list of medical history as long as many adult patients you have seen. It can be useful to read previous discharge letters or clinic correspondence, especially if the child is under the care of a specialist centre. Inquire as to whether the child is up to date with their immunizations and if not, explore the reasoning behind this. It may be that they are open to having catch-up immunizations which can be arranged via their general practitioner.

Drug history Take a full history of current and previous medications, including doses, frequencies, route of administration and indication, if known. It is very important to explore compliance with treatment – lack of a compliance may be a safeguarding concern. Document carefully any drug allergies including whether the child has taken that drug and the nature of the allergic reaction.

Birth history ETHICS The initial clerking is the appropriate time to establish parental responsibility, which is absolutely vital if consent for investigations or treatment is going to be needed or where there are any child protection concerns. See Chapter 19 for more information on parental responsibility.

In an older child, you only need to briefly establish any key events around birth (e.g., prematurity or congenital conditions). For neonates and infants, the birth history is key (see the ‘Neonatal history’ section).

Developmental history Ask about the age at which key developmental milestones were reached including any concerns about vision or hearing. See Chapter 17 for more details.

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History and examination Example (autosomal dominant inheritance)

RED FLAG

deceased grandmother divorced

Taking a thorough social history will allow you to identify children who are at risk of abuse. The ‘toxic trio’ are three factors identified together as high risk for child abuse:

married

7 years

5 years

unaffected male

unaffected female

affected male

affected female

line through = deceased

arrow = your patient (the “proband”)

Fig. 1.1 How to draw a family tree.

Family history Ask about medical and mental health problems within the family. In paediatrics, drawing a family tree can be very useful, both in diagnosing heritable conditions and in establishing the social history (see Fig. 1.1). Ask specifically about parental consanguinity, which can increase the likelihood of autosomal recessive conditions (e.g., metabolic conditions).

Social history You must establish who the child lives with and any contact with parents/other caregivers who they do not live with, as well as any involvement with social care.

• domestic violence • parental mental health problems • substance misuse

ADOLESCENT HISTORY The key consideration when taking a history from an adolescent is to always offer to speak to the young person alone. This is important for two reasons. First, young people should be supported to take responsibility for their own health, which includes interacting with the doctor or healthcare professional themselves. Second, and very importantly, there are many important things that a young person may not be comfortable in saying in front of their parents.

COMMUNICATION A good way to speak to the adolescent alone is simply to say ‘we routinely speak to all young people of your age on their own, and also with their parents/carers, are you happy for us to do that now?’ and ensure you find a place somewhere for their parents to sit which is well out of earshot.

COMMUNICATION Always ask about other services that are involved, in particular whether the family has any current or historic involvement with social care. You can preface the question by explaining, ‘this is a routine question that we ask all paediatric patients’.

Other important things to ask about include: • parental occupations • any difficulty at home (e.g., divorce, recent bereavements and domestic violence) • pets at home and exposure to other possible allergens • parent/carer smoking, alcohol or drug use. These questions should also be asked of an adolescent patient (see the ‘Adolescent history’ section)

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ETHICS Confidentiality can be complex when working with adolescents, especially if they disclose a potential safeguarding risk. It is important to be up front with the young person by explaining that there may be situations where you would have to share what they have told you with another healthcare professional, and potentially their parents, but this is not common and you would always discuss it with them before doing so.

Adolescents generally appreciate honesty so be up front and acknowledge that some topics might be difficult to talk about. If you seem embarrassed, they likely will be too.

Neonatal history The Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicidal ideation and Safety (HEEADSSS) framework has been developed to give a structured way of exploring different aspects of a young person’s life. • Home: find out where they live, who they live with and whether there are any difficulties at home. • Education/Employment: find out about school/college and explore their plans/ambitions. Discuss friendship groups and any problems such as bullying. • Eating: it is useful to explore eating habits to detect any eating disorders which commonly start in adolescence. See Chapter 18 for more information. • Activities: find out what they do in their free time, exploring hobbies and interests. This is an opportunity to discuss social media use, including potential risks like cyberbullying, ‘sexting’ and meeting up with people they have spoken to online. • Drugs: explore smoking, alcohol and drug use, and whether they have felt any peer pressure to use substances. You may want to explore how they are paying for any substances used. • Sexuality: you may need to preface this by acknowledging that some young people find these issues embarrassing to talk about. Explore any relationships, and if they are having sex, whether they are using any forms of protection, and whether there are any issues around consent. Explore their feelings and whether they have felt pressured or unsafe during sexual activities. • Suicide/low mood: ask about sources of stress and whether they feel down or anxious. If they do, you should specifically ask about self-harm and thoughts or plans of ending their own life. Evidence shows that asking about suicide does not make it more likely to happen. • Safety: you may have covered this already but make sure you have established potential sources of danger at home, at school, online or in other arenas. Specific safeguarding risks include joining gangs, radicalization, child trafficking and grooming. You will need to use your judgement: often many of these areas need to only be briefly covered. If you feel unsure or that things warrant further discussion, seek senior paediatric advice and/or help from your local child protection team.

COMMUNICATION According to the Office for National Statistics, in 2017, 4.1% of young people identified as ‘lesbian, gay or bisexual’ – ask about relationships in an open way, making no assumptions about the gender of any partners.

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HINTS AND TIPS Society’s understanding of gender is evolving rapidly. You should respect the identity of a transgender young person, using the name and pronouns that they are comfortable with. Many people are coming out as nonbinary: this is any gender that is not exclusively ‘man’ or ‘woman’ – explore what this means to the young person in front of you and mirror the language they use.

NEONATAL HISTORY When taking a neonatal history, more emphasis should be on the details of the birth. Many maternal conditions affect the newborn infant and the details of delivery and resuscitation are essential.

Antenatal events • Establish the results of antenatal ultrasound scans as well as any invasive testing (amniocentesis or chorionic villus biopsy). • Ask about antenatal blood tests for infection. • Ask about any maternal illness during pregnancy such as diabetes and hypertension. • Ask about maternal smoking, alcohol and drug use during pregnancy.

Birth Key facts about the birth: • gestational age at delivery • mode of delivery • duration of rupture of membranes • birthweight

RED FLAG In a neonatal history, you should ask about and clearly document any risk factors for sepsis in the newborn: • known maternal group B Streptococcus (GBS) colonization or a previous baby with GBS • prelabour rupture of membranes • prolonged rupture of membranes (>18 hours in preterm birth)

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History and examination • prematurity (gestation 38°C during labour or maternal treatment with intravenous antibiotics for suspected/confirmed bacterial infection in 24 hours before/after birth • suspected/confirmed infection in another baby if multiple birth

Postnatal events • Whether the baby needed any resuscitation. • Any problems encountered after birth, for instance, admission to the neonatal unit, issues with feeding or jaundice. • Whether the baby is breastfed or bottle-fed, establishing how often they are feeding and what volume. • Whether they passed meconium within 48 hours (if not, could be suggestive of Hirschsprung disease) and urine within 12 hours (if not, could suggest a genitourinary problem, e.g., posterior urethral valves in a baby boy).

General examination • Ideally you would measure the weight and height, and plot on a growth chart. While not feasible in objective structured clinical examinations (OSCEs), you should mention this. • Look at the observation chart, and compare their values with the age-appropriate normal limits (Table 1.1). • Does the child look generally unwell to you? If the child is happily playing, this tells you that they are unlikely to be seriously unwell. A child who does not interact or react much on you examining them is a worrying sign. • Look generally at the colour of the skin, any rashes or injuries, and at the face for any unusual (dysmorphic) features indicating an underlying condition.

Respiratory system • Count the respiratory rate. Note the different normal values with age (Table 1.1). Measure oxygen saturations.

Inspection HINTS AND TIPS It is useful to review the personal child health record (or ‘Red Book’) for all infants and young children with respect to immunizations, growth development.

PAEDIATRIC EXAMINATION The key to successful paediatric examination is being flexible and opportunistic. If the child is sitting quietly on their parents lap, that is probably a good time to auscultate their heart. If they are already crying or screaming, you might be able to examine their throat. Watching a child playing on the floor in front of you will give a lot of information about their neurology. The parent/carer is often the best person to help you to examine their child.

COMMUNICATION Play is an excellent way to help young children understand and overcome their anxiety. Asking the child to help you examine their teddy bear first is one way of doing this.

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• Are there any clues around the bedside (e.g., inhalers or sputum pots)? • Note any cyanosis or finger clubbing (Table 1.2). • Inspect the chest for any chest wall deformities (pectus excavatum, pectus carinatum) or scars suggesting previous surgery. • Look for signs of respiratory distress: – Nasal flaring. – Use of accessory muscles to breathe or head bobbing in an infant. – Intercostal, subcostal or sternal recession. • During your initial inspection, listen for audible stridor (inspiratory), wheeze (expiratory) and any cough (a barking cough is suggestive of croup).

Table 1.1 Acute paediatric life support: normal values for heart rate, respiratory rate and systolic blood pressure Systolic blood pressure (mmHg)

Age (years)

Heart rate (beats/min)

Respiratory rate (breaths/min)

12

60–100

15–20

100–120

70–90

Paediatric examination Table 1.2 Causes of paediatric clubbing Respiratory

Cardiovascular

• Pulmonary abscess or empyema • Tuberculosis • Cystic fibrosis/other cause of bronchiectasis

• Cyanotic congenital heart disease • Infective endocarditis • Infected graft

Gastrointestinal • Inflammatory bowel disease (especially Crohn disease) • Coeliac disease • Chronic liver disease

Palpation

• Feel for chest expansion and whether it is symmetrical. • Assess for a central trachea and the apex beat.

Percussion

• Percussion is more useful in children aged over 5 years and can give additional information to auscultation alone – are there any areas of dullness or hyperresonance?

Auscultation

• Auscultate the chest over the front and back for: – Understanding whether air entry is equal. – Ratio of inspiration to expiration. – Any additional sounds: bronchial breathing, wheeze or crepitations (in a coryzal child, you may hear transmitted upper airway noises).

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Auscultation

• Auscultate for heart sounds and added sounds and murmurs. • See Chapter 3 for the murmurs heard in specific conditions. • Innocent murmurs are common in children and should be distinguished from pathological murmurs (Box 1.1).

Gastrointestinal system Inspection

• Are there any clues around the bedside (e.g., vomit bowls or nasogastric feeds)? • Note any clubbing, nail changes [leukonychia (low albumin) or koilonychia (iron deficiency)] or jaundice. • Inspect the abdomen for distension and scarring.

Palpation

• Watch the child’s face for any sign of tenderness. • Feel for masses and organomegaly: the liver is usually palpable until puberty. In a constipated child, you may feel hard stool. • Peristalsis: this might represent obstruction or pyloric stenosis. • Assess for hernias.

HINTS AND TIPS While palpating the abdomen, ask the child questions to distract them. True tenderness (e.g., from an inflamed appendix) will not be distractible.

Cardiovascular system • Measure the heart rate and blood pressure, and compare them with the normal values for age.

Inspection

• Are there any clues around the bedside (e.g., supplementary oxygen or medications)? • Note any cyanosis, clubbing or peripheral signs of infective endocarditis (splinter haemorrhages, Osler nodes or Janeway lesions). • Inspect the chest for scarring.

Palpation

• Feel whether the peripheries are warm and well perfused. • The brachial pulses are used rather than the radial pulses. Palpating the femoral pulses is important as they can be absent in coarctation of the aorta. • Palpate the apex beat: in dextrocardia it is on the right. • Hepatomegaly is one of the signs of cardiac failure. In contrast to adults, children with cardiac failure usually do not show crepitations or sacral/peripheral oedema.

Percussion

• Percuss for organomegaly or a distended bladder.

Auscultation

• Auscultate for bowel sounds. Absence suggests obstruction.

BOX 1.1  FEATURES OF INNOCENT HEART MURMURS • Changes with posture • Localized • Asymptomatic • Normal cardiac examination • Systolic only • No thrill

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History and examination

Nervous system Most children will give you a lot of information in their play and the examiner must observe how the child interacts with his or her surroundings. Observe: • the gait as the child walks in • posture at rest • level of alertness or conscious level Assess tone, reflexes, power, coordination and sensation, cranial nerves and cerebellar function as for an adult, adapting your examination to the age of the child. HINTS AND TIPS The plantar reflexes are predominantly extensor (down-going) in infants aged