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Paediatricsat a Glance

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Dedication

To our children: Charlie, Mollie and Rosie, Aaron and Becca,Edward and Daniel and our spouses: Domini, Michael andKathy and all the patients who have taught us so much over

the years.

This title is also available as an e-book.For more details, please seewww.wiley.com/buy/9781118947838or scan this QR code

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Paediatricsat a GlanceFourth EditionLawrence MiallMBBS, BSc, MMedSc, MRCP, FRCPCHConsultant in Neonatal Medicine andHonorary Senior LecturerLeeds Teaching Hospitals NHS Trust andUniversity of LeedsLeeds

Mary RudolfMBBS, BSc, DCH, FRCPCH, FAAPProfessor of Population HealthBar Ilan University Faculty of Medicinein the Galilee, IsraelVisiting Professor of Child HealthUniversity of Leeds, UK

Dominic SmithMBBS, MMedSc, MRCP, MRCPCHConsultant PaediatricianDepartment of Child HealthYork Teaching Hospital and Hull York MedicalSchoolYork

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This edition first published 2016 © 2016 by John Wiley & Sons, Ltd.

Registered office:John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

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Library of Congress Cataloging-in-Publication Data

Names: Miall, Lawrence, author. | Rudolf, Mary, author. | Smith, Dominic,1970- , author.

Title: Paediatrics at a glance / Lawrence Miall, Mary Rudolf, Dominic Smith.Other titles: At a glance series (Oxford, England)Description: Fourth edition. | Chicester, West Sussex ; Ames, Iowa : John

Wiley & Sons, Inc., 2016. | Series: At a glance series | Includesbibliographical references and index.

Identifiers: LCCN 2015047744 (print) | LCCN 2015048187 (ebook) | ISBN9781118947838 (pbk.) | ISBN 9781118947821 (pdf) | ISBN 9781118947807 (epub)

Subjects: | MESH: Pediatrics–methods | HandbooksClassification: LCC RJ61 (print) | LCC RJ61 (ebook) | NLM WS 39 | DDC

618.92—dc23LC record available at http://lccn.loc.gov/2015047744

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may notbe available in electronic books.

Cover image: © TrevOC/gettyimages

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1 2016

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Contents

Preface viiiAcknowledgements ixAbbreviations xHow to use your textbook xiiAbout the companion website xiv

Part 1 Evaluation of the child 11 Paediatrics and child health 22 The paediatric consultation 43 Systems examination 64 Development and developmental assessment 125 Growth and puberty 166 Understanding investigations 20

Part 2 Moving through childhood 277 Screening 288 Genetics and inherited disorders 319 The newborn baby 3410 Congenital abnormalities 3611 Common neonatal problems 3812 The premature baby 4013 Nutrition in childhood 4214 Common behaviour concerns 4415 Child care and school 4616 Child health promotion 4817 The immunization schedule 50

Part 3 Growth, endocrine and metabolic 5318 Weight faltering and failure to thrive 5419 Short stature and poor growth 5620 Obesity 5821 Diabetes 60

Part 4 Cardiovascular disorders 6322 Congenital heart disease 6423 Heart problems in older children 66

Part 5 Fever 6924 Acute fever 7025 Persistent fever and serious recurrent infections 72

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Part 6 Respiratory disorders 7526 Cough and wheeze 7627 Stridor 7828 Swellings in the neck 7929 Asthma 8030 Cystic fibrosis 82

Part 7 Abdominal disorders 8531 Acute abdominal pain 8632 Vomiting 8833 Acute diarrhoea and dehydration 9034 Chronic diarrhoea 9235 Recurrent abdominal pain 9436 Constipation 96

Part 8 Urogenital disorders 9937 Urinary tract infections 10038 Haematuria and proteinuria 10239 Bedwetting and daytime wetting 10440 Swellings in the groin and scrotum 105

Part 9 Neurological disorders 10741 Developmental delay 10842 Headache 11043 Fits, faints and funny turns 11244 Epilepsy 11445 Cerebral palsy 116

Part 10 Musculoskeletal disorders 11946 Swollen joints 12047 Juvenile idiopathic arthritis 12148 Leg pain and limp 12249 Common childhood skeletal problems 123

Part 11 Blood disorders 12550 Anaemia and thrombocytopenia 12651 Jaundice 12852 Leukaemia and childhood cancer 130

Part 12 Skin disorders 13353 Rashes—types of skin lesions 13454 Rashes—infancy and congenital 13655 Rashes—infections and infestations 13856 Rashes—common inflammatory disorders 14057 Allergy 142

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Part 13 Emergency paediatrics 14558 Assessing the acutely ill child 14659 The collapsed child 15060 The unconscious child 15461 The fitting child 15662 Injuries and burns 15863 Poisoning 159

Part 14 Child health in the community 16164 Living with a chronic illness 16265 Living with a disability 16466 Learning disability and autism 16667 Visual and hearing impairment 16868 Neglect and abuse 17069 Adolescent issues 17470 Sudden infant death 17671 Ethics, research and consent 17872 Palliative and end-of-life care 180

Index, 182

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Preface

“ ‘What is the use of a book,’ thought Alice, ‘without pictures or conversations?’ ” Lewis Carroll, Alice in Wonderland.

Paediatric medicine requires an understanding of develop-ing anatomy, physiology and psychology as well as a holisticfamily-orientated approach. There are a wide range of professionalchallenges: from the technical aspects of intensive care to theethical and sociological questions relating to issues of autonomy,independence and children’s rights. The paediatric environmentis very different to the world of adult medicine. This can all bedaunting to those who are new to the specialty, but developing theskills and confidence in successfully managing these challengescan enable professionals to make significant differences to the livesof children and families. This makes paediatric medicine amongstthe most rewarding of all the medical specialties.

In preparing the fourth edition, we have updated the text toreflect changes in understanding of childhood illness over the last 5years. The new edition includes advances in genetics, screening andtherapy of childhood illness. Multiple choice questions to test andexpand on knowledge from the text are included on the compan-ion website. Video clips highlighting clinical signs and examinationtechniques are available on the companion website.

Children have complex needs that require medical staff towork together with other professionals in child health, psychology,

education and social care. There is increasing recognition of theneed for all health professionals to have a good understanding oftheir role in safeguarding vulnerable people. New chapters havebeen added to expand on psychological issues and ethics in childhealth. There is a new chapter on Palliative Care, which is anemerging area in the specialty.

We hope that this edition will continue to educate and inspirestudents and trainees in taking the first steps towards an under-standing of children, their illnesses, their resilience in the face ofadversity and amazing capacity for recovery. It is a book with manypictures to aid the introduction and revision of the key topics. Wehope this will help as students begin their all-important conversa-tions with young patients.

Lawrence MiallMary Rudolf

Dominic SmithLeeds, United Kingdom

February 2016

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Acknowledgements

We would like to acknowledge Dr Tim Lee, Dr Adam Glaser,Dr Michael Harari, Dr Claire Wensley and Dr JemmaCleminson for their contributions to chapters.

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Abbreviations

AABR automated auditory brainstem responseACTH adrenocorticotropic hormoneADD attention deficit disorderADH anti-diuretic hormoneADPKD autosomal dominant polycystic kidney diseaseAFP alpha-fetoproteinAIDS acquired immunodeficiency syndromeALL acute lymphoblastic leukaemiaALT alanine transaminaseALTE acute life-threatening eventAML acute myeloid leukaemiaANA antinuclear antibodyAPTT activated partial thromboplastin timeARPKD autosomal recessive polycystic kidney diseaseASD atrial septal defectASOT antistreptolysin O titreAVPU alert, voice, pain, unresponsiveAVSD atrioventricular septal defectAXR abdominal radiographAZT zidovudine (azidothymidine)BCG bacille Calmette–GuérinBMI body mass indexBP blood pressureBSER brainstem evoked responsesCDH congenital dislocation of the hipCF cystic fibrosisCFTR cystic fibrosis transmembrane regulatorCFU colony-forming unitCHARGE coloboma, heart defects, choanal atresia,

retarded growth and development, genitalhypoplasia, ear anomalies

CHD congenital heart diseaseCMV cytomegalovirusCNS central nervous systemCONI care of the next infantCPAP continuous positive airway pressureCPR cardiopulmonary resuscitationCRP C-reactive proteinCRT capillary refill timeCSF cerebrospinal fluidCSII continuous subcutaneous insulin infusionCT computed tomographyCXR chest radiographDDH developmental dysplasia of the hipDIC disseminated intravascular coagulationDIDMOAD diabetes insipidus, diabetes mellitus, optic

atrophy and deafness

DKA diabetic ketoacidosisDM diabetes mellitusDMD Duchenne muscular dystrophyDMSA dimercaptosuccinic acidDTPA diethylenetriamine penta-acetateEBV Epstein–Barr virusECG electrocardiogramEDD expected due dateEEG electroencephalogramENT ear, nose and throatESR erythrocyte sedimentation rateFBC full blood countFDP fibrin degradation productFSGS focal segment glomerulosclerosisFTT failure to thriveG6PD glucose 6-phosphate dehydrogenaseGCS Glasgow Coma ScaleGH growth hormoneGI gastrointestinalGOR gastro-oesophageal refluxGP general practitionerGTT glucose tolerance testHAART highly active antiretroviral therapyHb haemoglobinHbF fetal haemoglobinHbS sickle-cell haemoglobinHIE hypoxic-ischaemic encephalopathyHIV human immunodeficiency virusHPLC high-performance liquid chromatographyHSP Henoch–Schönlein purpuraHSV herpes simplex virusHUS haemolytic uraemic syndromeICP intracranial pressureIg immunoglobulinIM intramuscularINR international normalized ratioIO intraosseousIRT immunoreactive trypsinITP idiopathic thrombocytopenic purpuraIUGR intrauterine growth retardationIV intravenousIVC inferior vena cavaIVF in vitro fertilizationIVH intraventricular haemorrhageIVU intravenous urogramJCA juvenile chronic arthritisLFT liver function test

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LIP lymphocytic interstitial pneumonitisLMN lower motor neuronLP lumbar punctureMag-3 radioisotope technetium 99mTc mertiatideMCAD medium-chain acyl-carnitine deficiencyMCGN minimal change glomerulonephritisMCH mean cell haemoglobinMCUG micturating cystourethrogramMCV mean cell volumeMDI metered dose inhalerMLD mild learning difficultyMMR measles, mumps, rubellaMRI magnetic resonance imagingMUAC mid-upper arm circumferenceNEC necrotizing enterocolitisNF neurofibromatosisNHL non-Hodgkin’s lymphomaNICU neonatal intensive care unitNPA nasopharyngeal aspirateNSAID non-steroidal anti-inflammatory drugOAE otoacoustic emissionsOFC occipitofrontal circumferenceORS oral rehydration solutionPCO𝟐

partial pressure of carbon dioxidePCP pneumocystis pneumoniaPCR polymerase chain reactionPCV packed cell volumePDA patent ductus arteriosusPEFR peak expiratory flow ratePKU phenylketonuriaPNET primitive neuroectodermal tumourPR per rectumPT prothrombin timePTT partial thromboplastin timePUJ pelviureteric junctionPUO pyrexia of unknown originPVL periventricular leucomalaciaRAST radio-allergosorbent test

RBC red blood cellRDS respiratory distress syndromeRNIB Royal National Institute for the BlindROP retinopathy of prematurityRSV respiratory syncytial virusSCBU special care baby unitSCID severe combined immunodeficiencySGA small for gestational ageSIADH syndrome of inappropriate antidiuretic hormone

secretionSIDS sudden infant death syndromeSLD severe learning difficultySSPE subacute sclerosing encephalitisSTD sexually transmitted diseaseSUDI sudden unexpected death in infancyT4 thyroxineTAPVD total anomalous pulmonary venous drainageTB tuberculosisTGA transposition of the great arteriesTNF tumour necrosis factorTORCH toxoplasmosis, other (syphilis), rubella,

cytomegalovirus, hepatitis, HIVTS tuberous sclerosisTSH thyroid stimulating hormonetTG tissue transglutaminaseU&E urea and electrolytesUMN upper motor neuronURTI upper respiratory tract infectionUTI urinary tract infectionUV ultravioletVACTERL vertebral anomalies, anal atresia, cardiac

anomalies, tracheo-oesophageal fistula, renalanomalies, limb defects

VER visual evoked responseVKDB vitamin K deficiency bleedingVSD ventricular septal defectVUR vesicoureteric refluxWCC white cell count

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How to use yourtextbook

Features contained within your textbook

Each topic is presented in adouble-page spread with clear,

easy-to-follow diagramssupported by succinct

explanatory text.

Key point boxes give a summaryof the topics covered in a topic.

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Your textbook is full ofphotographs, illustrations and

tables.

The ‘play icon’ indicates relatedvideos which can be found on thecompanion website. The visual system

Observation of eyes• Look at the iris, sclera and pupil• Check pupils are equal and react to light, both directly and indirectly• Look for red reflex to exclude cataract, especially in the newborn• Look at reflection of light on the cornea— is it symmetrical or is one eye squinting? (see box opposite)• Look at the inner epicanthic folds—if very prominent they may cause a pseudosquint

Normal symmetrical light reflex

Pseudosquint due to prominent innerepicanthic folds

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About the companionwebsite

Don’t forget to visit the companion website for this book:

www.ataglanceseries.com/paediatrics

• Interactive self-assessment case studies• Multiple-choice questions• Videos on various procedures and concepts covered in the book• Links to online resources

Scan this QR code to visit the companion website.

There you will find valuable materialdesigned to enhance your learning, including:

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Evaluation of the child Part 1

Chapters1 Paediatrics and child health 2

2 The paediatric consultation 4

3 Systems examination 6

4 Development and developmental assessment 12

5 Growth and puberty 16

6 Understanding investigations 20

1

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1 Paediatrics and child health

Childhood morbidity in the 21st centuryPaediatric morbidity until this century wasdominated by infections. Followingthe introduction of immunisations andantibiotics new morbidities have emerged:

• Emotional and behavioural problems

• Childhood obesity

• Accidents and injuries

• Child abuse and neglect

• Sexually transmitted disease & teenage pregnancy

• Increase in disabilities and chronic illness

• Substance misuse, suicide and self harm

• Poor vaccine uptake

Causes of death in childhoodInfancy Prematurity Congenital anomalies SIDS (see Chapter 70) Infection Respiratory problems

Preschool children Accidents Congenital anomalies Infections

School aged children Cancer Accidents Infections

The social determinants of healthHealth is determined as much by psychosocial

circumstances as by genetics. Poverty andsocioeconomic status are particularly significantdeterminants. The Dahlgren and Whitehead model

provides a way to help you consider the variousinfluences impacting on the health of an individual

According to the United Nations Convention on the Rights of the Child, every child has the right to enjoy the highest attainable standard of health and to be able to access facilities for the treatment of illness and the rehabilitation of health.

General socio economic, cultural and environmental conditions

Living and workingconditions

Workenvironment

Education

Agricultureand food

production

3 2 1

4

Unemployment

Water &Sanitation

Health careservices

Housing

Social and community networks

Individual lifestyle factors

Age, sex andconstitutional factors

Paediatrics and child health

Hospitalinpatient

departments

Primary care services staffed byfamily doctors or pediatricians

Maternal child clinics staffedby health visitors/public health nurses

providing guidance and child health promotion

Hospital outpatientsdepartments/day

case observation andemergency rooms

The pyramid of careWho’s who in services for children?• Parents have the central role

• Child care providers and minders

• Teachers

• Social workers and care workers Nurses• Health visitors/public health nurses

• School nurses

• Practice/community nurses

• Specialist nurses Therapists• Speech therapists

• Physiotherapists

• Occupational therapists Doctors• General practitioners (Family doctors)• Paediatricians

The early years are a particularly vulnerable period Factor Long term outcomes

Depression, anxiety, drug abuse, suicidal behaviour, STIs, health issues, trust problems

Sustained poverty Unemployment, low income, low working hours

Abuse and neglect

Early mental health problems Emotional problems, leaving school early, criminal justice system contact, poor physical health

Conduct problems Anti-social and criminal behaviour

Poor health and nutrition More health problems; poor academic achievement, not graduating on time

Encouragingly the evidence shows that intervention in the early years can bring long term improvements in outcomes

Paediatrics at a Glance, Fourth Edition. Lawrence Miall, Mary Rudolf and Dominic Smith. © 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd.Companion website: www.ataglanceseries.com/paediatrics

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Paediatrics is not just about the recognition and treatment ofchildren’s illness. It also encompasses child health, covering allaspects of growth and development, promotion of children’s

health and the prevention of disease. It includes every aspect of lifefrom birth through adulthood. In many countries, such as the UK,paediatric care extends up to the age of 18 and covers all childrenfrom the very premature infant to teenagers in the workforce.

All aspects of paediatrics are coloured by the fact that thechild is growing and developing both physically and emotionally.Anyone involved in the medical care of children needs to have anunderstanding of children’s normal development and a realizationthat children must not be considered as mini adults. In paediatrics,more than in any other branch of medicine, the needs of the familyand carers must also be taken into consideration. At the end ofchildhood, a smooth transition of care to adult services is needed,especially for those with chronic conditions.

The changing face of paediatrics and childhealthOne hundred years ago, infection was the major cause of morbidityand mortality in childhood. Improvements in the environment,sanitation and housing began the trend for advancement in pop-ulation health, and this was accelerated by the introduction ofimmunizations and antibiotics. Changes have occurred in societytoo, many of which are beneficial to children and their health andwell-being. Children are better and more widely protected thanwas the case a century ago. Educational standards, social support,medical care and knowledge about child development have allimproved, and child abuse has become unacceptable.

However, inequalities in both wealth and health are increasing,and the ‘gap’ between the richest and poorest has a profound impacton children’s lives. Referrals for emotional and behavioural prob-lems are rising dramatically, and childhood obesity is seen as themajor public health problem of our time. A relatively new aspect ofpaediatrics is the understanding that many determinants of adulthealth have their origins antenatally, in infancy and in the earlyyears of childhood.

Health care has also changed in paediatrics. Over the last 40years, we have seen more children admitted to hospital, but theexperience of hospitalization has changed. Once visiting hours forparents were limited to 30 minutes per day, but now the normalexpectation is that parents will stay with their child. Where possi-ble every effort is made to keep children out of hospital, and manyaspects of specialized complex care have become available in thecommunity. Even for the acutely ill child, short-stay observationwards now allow serious causes of illness to be excluded and chil-dren to be discharged to recover at home. A significant proportionof admissions are for social reasons, for example, if there are con-cerns that the family is unable to cope or they live too far away tosafely send the child home.

The determinants of healthThe way health is considered has also changed over the decades.In the early part of the 20th century, health was considered to bethe absence of disease. However, in 1948, the World Health Orga-nization changed the way we look at health when it declared that‘health is a state of complete physical, mental, and social well-being,

and not merely the absence of disease and infirmity’. In paediatrics,this has been accompanied by a more holistic approach to children,with greater emphasis on well-being especially for those copingwith chronic conditions and disabilities.

Two major factors have changed priorities in the care of chil-dren and their services. The first is the understanding that socioe-conomic status has a powerful influence over many aspects of chil-dren’s health. Poverty is now known to be a significant predictor ofa number of major measures of health, including:• Birth weight• Perinatal morbidity• Sudden infant death syndrome (SIDS)• Admission to hospital• Obesity.

The other factor that has changed the way we view disease arisesfrom the ‘Barker hypothesis’. Barker and his colleagues brought tolight how events in pregnancy and infancy can have a long-termeffect on health. Exploring infant growth records from the last cen-tury, they showed that babies born small for gestational age wereat significantly increased risk for hypertension, cardiovascular dis-ease, diabetes and obesity in adult life, particularly if they showedrapid catch-up growth in the first year of life. Their findings demon-strated how critical the early years are in programming later healthoutcomes.

Rather reassuringly, economists have shown that although thepreschool years are a vulnerable period, they are also a criticalperiod amenable to intervention. The evidence clearly shows thatwhen society invests in the early childhood years and providesupport, community programmes, guidance for parents and edu-cation, there are profound benefits on many later outcomes such asphysical health, academic achievement, mental health, antisocialbehaviour and substance abuse.

Types of paediatric problemsWith the changing face of childhood disease, health professionalsneed to be competent at managing a broad variety of conditions.These conditions include the following broad categories:• Acute illnesses such as bronchiolitis, respiratory infections andanaphylaxis• Chronic illnesses such as asthma, epilepsy, diabetes and cancer• Disabilities—both physical and intellectual• Injury: accidental and non-accidental• Disorders of eating and nutrition, including weight faltering,obesity and anorexia• Mental health disorders such as attention deficit disorder, chal-lenging behaviour, depression and anxiety.

Some of the particular challenges we need to face are emotionaland behavioural problems, childhood obesity, child abuse andneglect, accidents and injuries, sexually transmitted disease andteenage pregnancy, increase in disabilities and chronic illness,substance misuse, suicide and self-harm and poor vaccine uptake.

By directly treating childhood conditions, by ensuring effectivescreening and prevention programmes and by advocating for betterpublic health interventions, paediatricians and all those working inchild health have a fantastic opportunity to influence the long-termoutcome of their patients. Paediatrics is a challenging specialty buta very rewarding one.