Dr. Rodney Martinez

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The way in which the environment impacts on a

child is exemplified by the contrast between the major child health problems in developed and developing countries.

In developed countries they are a range of complex, often previously fatal, chronic disorders and behavioural, emotional or developmental problems.

By contrast, in developing countries the predominant problems are infection and malnutrition

Enviroment and paediatrics

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Developing countries

Infection - respiratory tract, diarrhoea, malaria, tuberculosis, HIV

Malnutrition - marasmus, kwashiorkor, severe iron deficiency anaemia

Developmental and learning problems of organic pathology - Down's syndrome, congenital anomalies

Sanitation, water supply, food hygiene, housing and education

Poverty and unemployment

Health care - not available or poor quality

High birth rate - children constitute high proportion of population

Health problems in peadiatrics

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Developed countries Severe, often previously fatal chronic disorders -

malignant disease, cystic fibrosis Provision of paediatric and neonatal intensive care, organ

transplantation and other specialist services Behavioural and emotional disorders - attention deficit

disorder, anorexia nervosa Neurodevelopmental disorders - language delay, reading

difficulties, clumsiness, cerebral palsy Road traffic and other accidents Lack of family cohesion Socioeconomic disadvantage among the 'have-nots' - lack

of money, unemployment, inadequate housing and education

Inequality of access to health services Excessive consumption - obesity Drug and alcohol abuse, smoking, teenage pregnancies

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low-birthweight infants

injuries

hospital admissions

asthma

behavioural problems

special educational needs

child abuse

Healthcare problems in which the UK prevalence rates are increased by poverty and

deprivation include:

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Clinical History in Paediatrics

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In approaching clinical history and examination of

children, it is helpful to visualise some common clinical scenarios in which children are seen by doctors an acute illness, e.g. respiratory tract infection, meningitis,

appendicitis a chronic problem, e.g. failure to thrive, chronic cough a newborn infant with a congenital malformation or

abnormality, e.g. developmental dysplasia of the hip, Down's syndrome

suspected delay in development, e.g. slow to walk, talk or acquire skills

behaviour problems, e.g. temper tantrums, hyperactivity, eating disorders.

Introduction

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to establish the relevant facts of the history; this is

always the most fruitful source of diagnostic information

to elicit all relevant clinical findings

to collate the findings from the history and examination

to formulate a working diagnosis or differential diagnosis on the basis of logical deduction

to assemble a problem list and management plan.

The aims and objectives are:

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H = history

E = examination

L = logical deduction

P = plan of management.

HELP

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The Paediatric Assessment

Outline of paediatric history Presenting complaint and history of presenting complaint. Birth history: Place of birth. Gestation and pregnancy. Birth weight. Delivery. Perinatal events and SCBU admission.

Feeding methods If bottle fed, note how the bottle feed is mixed

PMH including hospital admissions, infections, injuries. Developmental history.

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The Paediatric Assessment

School progress. Immunizations. Drugs. Allergies. Family tree with sibling's ages, including deaths, miscarriages Parental age and occupation. Family illnesses and allergies. Housing. This should include a discussion about the child's bedroom as

they may spend 12 hours of each day there. Travel. Systems review.

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the child's age is always a key feature in the history

and examination as it determines:

the nature and presentation of illnesses, developmental or behaviour problems

the way in which the history-taking and examination are conducted

the way in which any subsequent management is organised.

parents are astute observers of their children. Never ignore or dismiss what they say.

Key points in paediatric history and examination

are:

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Full details are required of the presenting symptoms.

Let the parents and child recount the presenting complaints in their own words and at their own pace.

Make sure you know: what prompted referral to a doctor

what the parents think or fear is the matter.

Presenting symptoms

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general health - how active and lively?

normal growth

pubertal development (if appropriate)

feeding/drinking/appetite

any recent change in behaviour or personality.

General enquiry

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general rashes, fever (if measured) respiratory - cough, wheeze, breathing problems ENT - throat infections, snoring, noisy breathing (stridor) cardiovascular - heart murmur, cyanosis, exercise tolerance gastrointestinal - vomiting, diarrhoea/constipation, abdominal

pain genitourinary - dysuria, frequency, wetting, toilet-trained neurological - seizures, headaches, abnormal movements musculoskeletal - disturbance of gait, limb pain or swelling,

other functional abnormalities.

Make sure that you and the parent or child mean the same thing when describing a problem.

Systems review

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maternal obstetric problems, delivery

birthweight and gestation

perinatal problems, whether admitted to special care baby unit

immunisations (ideally from the personal child health record)

past illnesses, hospital admissions and operations, accidents and injuries.

Past medical history

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past and present medications

known allergies.

Medication

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Family history

Families share houses, genes and diseases!

Have any members of the

family or friends had similar problems or any serious disorder?

Draw a family tree. If there is a positive family history, extend family pedigree over several generations.

Is there consanguinity?

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Check: Relevant information about the family and its

community - parental occupation, economic status, housing, relationships, parental smoking, marital stresses.

Is the child happy at home? What are the child's preferred play or leisure activities?

Is the child happy at nursery/school?

Social history

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This 'social snapshot' is crucial

alcohol and drug abuse

long-term unemployment/poverty

poor, damp, cramped housing

parental psychiatric disorders

unstable partnership.

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•Check: parental worries about vision, hearing, development •key developmental milestones •previous child health surveillance developmental checks •bladder and bowel control •child's temperament, behaviour •sleeping problems •concerns and progress at nursery/school.

Look through the personal child health record.

Development

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Make friends with the child. Be confident but gentle. Avoid dominating the child. Short mock examinations, e.g. auscultating a teddy or the mother's

hand, may allay a young child's fears. When first examining a young child, start at a non-threatening area,

such as a hand or knee. Explain what you are about to do and what you want the child to do,

in language he can understand. As the examination is essential, not optional, it is best not to ask his permission, as it may well be refused!

A smiling, talking doctor appears less threatening, but this should not be overdone as it can interfere with one's relationship with the parents.

Leave unpleasant procedures until last

Obtain child’s cooperation

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Babies in the first few months are best examined on an

examination couch with a parent next to them. A toddler is best initially examined on his mother's lap or

occasionally over a parent's shoulder. Parents are reassuring for the child and helpful in facilitating the examination if guided as to what to do.

Preschool children may initially be examined whilst they are playing.

Older children and teenagers are often concerned about privacy. Teenage girls should normally be examined in the presence of their mother, or a nurse or suitable chaperone. Be aware of cultural sensitivities in different ethnic groups.

Adapt to the child’s age

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Examination

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Careful observation is usually the key to success in

examining children. Look before touching the child. Inspection will provide information on: severity of illness

growth and nutrition

behaviour and social responsiveness

level of hygiene and care.

Initial observations

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Severity of the illness

Is the child sick or well? If sick, how sick? For the acutely ill infant or child, perform the '60-second rapid assessment': Airway and Breathing - respiration rate and effort, presence of stridor or wheeze, cyanosis

Circulation - heart rate, pulse volume, peripheral temperature, capillary refill time

Disability - level of consciousness.

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Measurements

As abnormal growth may be the first manifestation of illness in children, always measure and plot growth on centile charts for: weight, noting previous

measurements from personal child health record

length (in infants, if indicated) or height in older children

head circumference in infants.

As appropriate: temperature blood pressure peak expiratory flow rate

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Physical examination: term newborn

Average weights: 3.4 kg

Average length: 50cm

Head circumference: 35 cm

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General appearence

The face, head and neck, and hands are examined. The general morphological appearance may suggest a chromosomal or dysmorphic syndrome. In infants, palpate the fontanelle and sutures.

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Respiratory Rate

Age Normal Tachypnoea

Neonate 30-50 Over 60

Infants 20-30 Over 50

Young children 20-30 Over 40

Older children 10-20 Over 30

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Age Beats per minute

Less than 1 110-160

2-5 95-140

5-12 80-120

Over 12 60-100

Pulse

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Show the child that there is a balloon in the cuff and

demonstrate how it is blown up.

Use largest cuff which fits comfortably, covering at least two-thirds of the upper arm. (Too small a cuff often causes an abnormally high reading.)

The child must be relaxed and not crying.

Systolic pressure is the easiest to determine in young children and clinically the most useful.

Diastolic pressure is when the sounds disappear. May not be possible to discern in young children

Blood pressure

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Summarise the key problems (in physical, emotional, social and

family terms, if relevant). List the diagnoses or differential diagnoses. Draw up a management plan to address the problems, both short-

and long-term. This could be reassurance, a period of observation, performing investigations or therapeutic intervention.

Provide explanation to the parents and to the child, if old enough. Consider providing further information, either written or on the internet.

If relevant, discuss what to tell other members of the family. Consider which other professionals should be informed. Write a brief summary in the child's personal child health record. Ensure your notes are dated and signed

Summary and management

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Paediatric emergencies

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INFANT MORTALITY

- 35.58 per 1000 live births die before their 1st birthday

10x more in the1st wk of life than in the 2nd wk

Born< 34th wk with Wt 1-1500 g : 50%M

90%m

Born > 34th wk with Wt of 1-1500 g: 13%M

86%m

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According to UNICEF, most child deaths (and 70%

in developing countries) result from one the following five causes or a combination thereof:

acute respiratory infections

diarrhea

measles

malaria

malnutrition

Causes

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CAUSES OF DEATHS

1ST 12 MONTHS:

Immaturity

Birth trauma, Birth asphyxia

Congenital anomalies

Complications of Pregnancy

Bacterial sepsis, Pneumonia,

Meningitis

CNS disease

Accidents

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1st - 4th & 5th -14th y/o

Accidents – leading

cause of death

Natural Diseases:

Congenital anomalies

Malignant neoplasm

Pneumonia

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Two-thirds of deaths are preventable.

Malnutrition and the lack of safe water and sanitation contribute to half of all these children’s deaths.

Research and experience show that most of the children who die each year could be saved by low-tech, evidence-based, cost-effective measures such as vaccines, antibiotics, micronutrient supplementation, insecticide-treated bed nets, improved family care andbreastfeeding practices, and oral rehydration therapy

Prevention

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APGAR SCORE

METHOD: evaluating physiologic condition & responsiveness of the Newborn at birth and the chances of survival

Evaluation at 1 min or at

5 min

10 – best condition 44

…APGAR SCORE

0-1 = 50% Mm in 1st mo.

4 = 20% M in 1st mo.

7 or > = 0% M in 1st mo.

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SIGN 0 1 2

HR Absent < 100 > 100

Resp effort Absent Slow, Irregular Good, Crying

Muscle Tone

Limp

Some flexion of extremities

Active motion

Response to catheter in nostril (tested after oropharynx is clear)

No response

Grimace

Cough or sneeze

Color Blue, pale Body pink, extremities blue

Completely pink

APGAR SCORING

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The rapid clinical assessment of the seriously ill child will identify if there is potential respiratory, circulatory or neurological failure. This should take less than 1 minute. Resuscitation is given immediately if necessary, followed by secondary assessment and other emergency treatment.

The seriously ill child may present with shock, respiratory distress, as a drowsy/unconscious or fitting child or with a surgical emergency. In children, the key to successful outcome is the early recognition and active management of conditions that are life-threatening and potentially reversible.

Seriously ill child

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RAPID CLINICAL ASSESMENT ABCDE

Febrile child

Most febrile children have a brief, self-limiting viral infection.

Mild localised infections, e.g. otitis media or tonsillitis, may be diagnosed clinically.

The clinical problem lies in identifying the relatively few children with a serious invasive bacterial infection which needs prompt treatment.

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past medical history

illness of other family members

if a specific illness is prevalent in the community

immunisation status

recent travel abroad, e.g. malaria, typhoid

contact with animals, e.g. brucellosis

predisposition to infection, e.g. nephrotic syndrome, sickle cell disease, HIV infection, chemotherapy for malignant disease or, rarely, a primary immunodeficiency.

Factors which need to be considered are:

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Full blood count including differential white cell

count

Blood culture

Acute-phase reactant, e.g. C-reactive protein

Urine for microscopy, culture and sensitivity

CSF (unless contraindicated) for microscopy, culture and sensitivity

Chest X-ray

Septic screening after physical examination

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upper respiratory tract infection (URTI) is an

extremely common cause

check for otitis media

serious bacterial infection must be considered

if fever in an infant is unexplained, exclude a urinary tract infection

the younger the child the lower the threshold for performing a septic screen and starting antibiotics

Remember

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Status epilepticus

This is a seizure lasting 30 minutes or longer, or when successive seizures occur so frequently that the patient does not recover consciousness between them.

After immediate primary assessment and resuscitation, the priority is to stop the seizure as quickly as possible

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In children, the most common causes are ingestion or

contact with nuts, egg, milk or drugs.

Urticaria and angioedema causing facial swelling are treated with an oral antihistamine (e.g. chlorphenamine) and observed over 2 hours for possible complications.

Anaphylaxis is life-threatening, from laryngeal oedema, brochoconstriction and shock.

Children who have had a serious allergic reaction should carry an epinephrine (adrenaline) auto-injector (e.g. Epipen) with them so that treatment can be initiated immediately

Anaphylaxis

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These occur in infants and are a combination of

apnoea, colour change, alteration in muscle tone, choking or gagging, which are frightening to the observer.

They may occur on more than one occasion.

ALTEs may be the presentation of a potentially serious disorder, although often no cause is identified.

Apparent life-threatening events

(ALTE)

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In most, the episode is brief, with rapid recovery, and the

baby is well clinically.

Baseline investigations and overnight monitoring of oxygen saturation, respiration and ECG are found to be normal.

The parents should be taught resuscitation and will find it helpful to receive follow-up from a specialist paediatric nurse and paediatrician

Detailed specialist investigation and assessment will be required if clinical, biochemical or physiological abnormalities are identified.

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