30 COMMON CHILDHOOD COMPLAINTS 1. The small child Fahad (received) 2. The obese child Fahad (received) 3. Child who is failing to thrive Peter 4. The child with cough/wheeze Muneera (received) 5. The child with stridor Dema (received) 6. The child with URI Muneera Ali 7. Child with recurrent headaches Muneera Ali (received) 8. The drowsy child Selverus 9. The child who has had a funny turn (Fits, faints and funny turns) Hassan (received) 10. The child who is slow to walk Omar M 11. The child who is slow to talk Hassan (received) 12. The child with a limp Selverus (received) 13. Child with an unsteady gait Imran 14. Child with a waddling gait Dorra (received) 15. The child with a swollen/painful joint Dema (received) 16. The child with chronic diarrhea Omar S received) 17. The child with chronic constipation Aysha (received) 18. The child with recurrent abdominal pain Sara (received) 19. The child with acute abdominal pain with/without vomiting Sara (received) 20. The child who is vomiting Mohammed (received) 21. Child with a heart murmur Dorra (received) 22. The cyanosed/dusky child Aysha 23. The child with an itchy rash Reem AW (received) 24. The child with a non-itchy rash Ahmed 25. The child who bruises easily Nusiebeh (received) 26. The pale child Mohammed (received) 27. The child who is bed-wetting Reem AW (received) 28. The child with an emotional/ behavior disorder (Irrelevant) 29. The child with neck swelling Nusiebeh (received) 30. The child with a squint Muneera (received)
1. THE SMALL CHILD Short stature ! less than the 0.4th centile. Important to measure the rate of growth as well. Causes of Short Stature: - Familial o To measure the mid parental height in males: (Height of father + 12.5 + Height of mother)/2 o To measure the mid parental height in females: (Height of father – 12.5 + Height of mother)/2 - Intrauterine Growth Restriction and Extreme Prematurity o Ask about birth (Size and weight) - Constitutional Delay o Usually occurs in the parent of the same sex o Has anyone else had a problem with height in the family? Were they short for a long time and then suddenly grew? - Endocrine o The child is usually short and fat • Ask about /assess the weight! o Hypothyroidism • Signs and symptoms: • Cardiac o Bradycardia • Neurological o Learning difficulties o Slow relaxing reflexes • Metabolic o Cold intolerance o Constipation o Weight gain despite decreased appetite • Thin, dry, hair o Cushing’s • Are they taking any medication? (Corticosteroids) o Growth Hormone deficiency • Either isolated or secondary to panhypopituitarism • Panhypopituitarism • Can be caused by carniopharyngioma o Problems with vision (Bitemporal hemianopia) • Laron Syndrome ! growth hormone resistance - Nutritional/Chronic renal disease o What are their eating habits? o Any chronic illnesses? • Crohn’s, Coeliac, chronic renal disease o Assess nutrition on examination - Psychosocial Deprivation - Chromosomal Disorders o Downs o Turner’s o Russel silver o Prader Willi - Idiopathic short stature - Disproportionate Short Stature: Ex. storage disorder, scoliosis or achondroplasia. Focused Questions: - Compared to his siblings, have you noticed that he is significantly shorter? (Familial or not) - Is this problem common in the family? And does it tend to resolve? (Constitutional delay. You might have a father who says that all the men in the family tend to be short for the first few years then they suddenly grow) - Was he small from birth - How is his eating habits? Is he able to put on weight normally? (Nutritional) - Is he obese? (Obese and short tends to be metabolic) - Ask about hypothyroidism symptoms - Any known medical illnesses? Is he on any medication? o Nephrotic syndrome, asthma or anything that requires corticosteroids) o Crohn’s and Coeliac - Developmental milestones o Chromosomal abnormality - Consanguinity ! Chromosome Important to plot the child and see if there is any fall in the centile lines. If the child has a steady growth but is just short, this is probably normal. If he has is falling in the centile lines, you would be worried. Quick recap: History • Familial • General Health • Constitutional delay • Positive history if same condition is present in the same sex parent • Can be normal and all you need to do is reassure the parents. • Signs of hypothyroidism • Iatrogenic steroids • Psychological • IUGR • Chromosomal syndromes • Prader Willi o Hypotonic o Obesity o Learning difficulty • Russel Silver o Triangular face o Very short o Asymmetry of limbs • Laron syndrome o GH resistance o Midfacial hypoplasia o Increased growth hormone and low IGF-1 o Does not respond to GH • Turner’s Syndrome o 45 X, O o Wide spaced nipples in adults o Short stature o Congenital cardiovascular defects (Especially coarctation of the oarta) o Webbed neck o Infertility o Lymphodemia of the hands and feet o Wide carrying angle o Investigations • FBC ! Anemia • Coeliac, crohn’s, hypothyroidism o Coeliac and crohn’s can also cause short stature • Thyroid function test • X ray to check bone age • You ask for an X ray of the left hand • Creatinine + Electrolytes (rule out chronic renal failure) • Karyotyping (For females to check for turner’s) • Hormones • IGF1, GH o If IGF-1 is low and there is delayed bone age, you go for growth hormone stimulation test. • Using either glucagon, insulin, clonidine or arginine • If GH is more than 20 units/L this is normal • If it is below that, you do an MRI to check the pituitary gland • To check for panhypopituitirism: TSH, LH, FH, ACTH (By checking cortisol), Prolactin, ADH, Oxytocin o Treatment of GH deficiency ! Once daily subcutaneous GH o Other indications for subcutaneous growth hormone: • GH deficiency • Turner’s • Chronic renal failure • Idiopathic short stature
2. THE OBESE CHILD Obesity ! 98th centile and above on BMI chart in young children. Children who are 12 years and older, a BMI that is equal to or greater than 30 is considered obese. If a child is obese and short, you would consider an endocrine or chromosomal cause. The biggest problem that is brought to the clinic is obesity If they’re tall and fat ! Too many calories If they’re short and fat ! consider another problem, such as endocrine. DDx: - Diet and reduced exercise (Most common and increasing in prevalence) - Endocrine (Rare) o Hypothyroidism o Cushing’s - Chromosomal o Prader Willi Focused questions: - How is his eating habits? - Does he get the chance to move around and exercise? - Signs and symptoms of Hypothyroidism o Constipation o Decreased appetite and increased weight o Excessive tiredness o Cold intolerance o Dry skin and brittle hair - Any known medical illnesses? - Does he take any medication? o Corticosteroids - Developmental assessment o Prader Willi ! Delayed development Management depends on the cause.
4. THE CHILD WITH COUGH/ WHEEZE Nature of the cough Wet cough typically results from excessive mucus production, mostly due to infection or inflammation (eg, bronchiectasis, cystic fibrosis, primary ciliary dyskinesia, asthma, and chronic aspiration). In contrast, pure bronchoconstriction or structural causes for airway narrowing (eg, asthma, airway malacia or compression, foreign body, vascular ring) are usually associated with a dry cough.
Asthma History Features:
●Intermittent episodes of wheezing that usually are the result of a common trigger (ie, upper respiratory infections, weather changes, exercise, or allergens) ●Seasonal variation ●Family history of asthma and/ or atopy ●Good response to asthma medications
Features that suggest a diagnosis other than asthma include the following
●Poor response to asthma medications ●A history of neonatal or perinatal respiratory problems and wheezing since birth suggests a congenital abnormality. ●Wheezing associated with feeding or vomiting can result from gastroesophageal reflux or impaired swallowing complicated by aspiration. ●A history of choking, especially with associated coughing or shortness of breath, suggests foreign body aspiration, even if it does not immediately precede onset of wheezing symptoms. ●Poor weight gain and recurrent ear or sinus infections suggest cystic fibrosis, immunodeficiency, or ciliary dysfunction. ●History of progressive dyspnea, tachypnea, exercise intolerance, and failure to thrive suggest interstitial lung disease. Differential: Asthma( see table!) Transient Early Wheezing Non-topic Wheezing(Following RSV LRTI) Atopic Asthma Broncholitis: 1-9months. Pneumonia Cardiac Failure Inhaled Foreign Body Aspiration Feeds(NM disorder) Focused History Questions: Age Is important to reach the appropriate diagnosis. Describe the sound that you hear when your child is breathing? (whistling sound) WHEN did you start hearing it? determine if acute or chronic. DURATION constantly heard? Is it associated with Cough? Nature of cough? (wet versus dry). Frequency What brings the cough/ makes it worse? What relieves it? Is it constant throughout the day or increased in the morning or night? Associated Symptoms: Laboured breathing? Fever? Lethargy? PMH Is this the first time he/she have these symptoms? PMH Any known medical illness PMH Previous admissions PMH drugs(if uses inhaler, establish severity) + allergies BIRTH HISTORY Complications/stay in NICU NUTRITION Poor feeding? Vomiting? FMH of Asthma FMH of Eczema or allergy SOCIAL Missing school if it’s a young child! establish impact of life. SOCIAL Recent sick contact Physical Examination: 1. Plot weight on Growth chart, vital signs including oxygen saturation. 2. General Inspection 3. Respiratory distress (calculate RR)+ listen for Audible sounds upon breathing, color, hydration, nutrition, dysmorphic fx, paraphernalia. 4. Hands: a. presence of cyanosis or clubbing. b. Pulse
5. Face: Central cyanosis, nasal flaring, 6. Inspect Chest: a. Skin: Scars, eczema( atopic patients) b. Bone: deformities c. Muscle Recession d. Lung: symmetrical breathing, pattern of breathing( abdomino-thoracic in young/ thoracico-abdominal in older. e. Shape of the lung(barrel shaped) 7. Palpate: a. Trachea b. chest expansion. c. Liver: displaced in bronchiolitis. 8. Percussion: Any differences in resonance among lung regions? 9. Auscultation: a. characteristics and location of wheezing, as well as variations in air entry among different lung regions b. Crackles can be present in conjunction with wheezing in asthma, pneumonia, bronchiolitis, cystic fibrosis c. Heart Sounds: Heart Murmur-> cardiac failure. Response to treatment : For patients with diffuse wheezing, a trial of inhaled bronchodilators can be used to confirm the presence of reversible airway disease. Decreased wheezing after bronchodilator therapy is suggestive of asthma. Laboratory investigations: In most cases, the probable diagnosis is suspected on the basis of the clinical history and physical examination. The role of laboratory tests, when indicated, is either to confirm the diagnosis or to rule out other less likely diagnoses [Complete blood counts are important in patients with chronic or systemic symptoms and may reveal anemia, leukocytosis, or leukopenia. Eosinophilia in this setting supports an underlying allergic process or possible parasitic infection. Sputum stain and cultures may be useful in a setting suggestive of bacterial infections, Sweat chloride test — The sweat chloride test allows clinicians to assess physiologic changes associated with cystic fibrosis and is indicated in children with chronic lung problems, including wheezing. Immunoglobulin levels can be used to screen for immunodeficiency. Elevated IgE can be indicative of an allergic process.
Treatment: 1. Bronchiolitis: a. Humidified oxygen via nasal cannula
b. Nebulised bronchodilators (salbutamol and ipratropium bromide)
c. Mechanical ventilation in extremely severe cases (2%) 2. Pneumonia: Amoxicillin with Co-amoxiclav in those unresponsive.
3. Asthma: