Paediatrics
Seán Keenan
2022
,The Seriously Ill Child
Description
Recognizing the need for prompt help is a central skill of paediatrics. Use ABC + traffic light assessment to determine.
Note that BP is not always a reliable vital to evaluate.
Green Light Red Light
- Feeding: Most feeds are accepted - Colour: Pale; Mottled; Ashen; Hypoxic
- Colour: Normal colour on lips, tongue + mouth - Social: Does not wake; Apathy; Coma
- Social: Alert or wakens quickly; Normal crying - Vitals: ↓ Skin turgor
- Vitals: ↔ RR (see below) - GRUNTING: See below for signs
Amber Light
- Feeding: Taking ≤50 % of feeds
- Colour: Pale
- Social: Hard to wake; No smiling; ↓ Activity
- Vitals: ↑ RR; Creps; Nasal flaring <1 YO
Vitals by Age
Age (years) Respiration Rate (BPM) Pulse (BPM) Systolic BP (mmHg)
<1 30-40 110-160 70-90
1-2 25-35 100-150 75-95
2-5 25-30 95-140 80-100
5-12 20-25 80-120 90-110
>12 12-20 60-100 100-120
Chest compressions are indicated if Neonates (<4 wks) HR <60 BPM
GRUNTING Signs
- Grunting: Weak or continuous high-pitched cry; Tachypnoea
- Respiration: Rib Recession; Retraction of sternocleidomastoid; Nasal flaring; Wheeze; Stridor
- Unresponsive: Unequal/Unresponsive Pupils: Focal CNS signs; Seizures; Marked hypotonia
- Neurology: Odd or rigid posture; Decorticate; Decerebrate
- Temperature: ≥38oC if <6 months; Cold peripheries
- Intuition: Judgement of need for investigations with child
- Neisseria: Neck Rigidity: Non-blanching rash; Meningism; Bulging fontanelle
- Gastroenterology: Green bile in vomit (Atresia; Volvulus; Intussusception)
,Common Complaints in Infancy
Crying
Description Management
- Prevalence: 20 % report problems in first 3 months - Sleep: Encourage parents to take turns sleeping
- Peaks: Crying peaks at 6-8 weeks old (~3 hrs/d) - Sooth: Tactile; Vocal; Vestibular (rocking)
- NB: Usually subsides by 4 months - Recognise: Recognise feeding vs sleeping needs
Colic
Description Management
- Prevalence: Occurs in 20 % of infants - Movement: May help with soothing
- Sx: Paroxysmal crying with pulling up of legs - Breastfeeding: Allow to finish first breast first
- Duration: Lasts >3 hrs on ≥3d/wk; Worse in evenings - NB: Fisher’s rule; Hind milk easier to digest
- NB: There is no association with feeding difficulties - Signs: May be sign of relationship issues
Cows’ Milk Protein Allergy/Intolerance
Description Management
- Key: Separate from colic - Breastfeeding: Maternal excludes cow milk in diet
- Path: Either IgE or Non-IgE mediated - Formula: Hypoallergenic formula (eHF milk)
Presentation - eHF Milk: Extensively hydrolysed milk formula
- General: Colic-Sx; GORD; Blood/mucus in stool - NB: Continue with eHF milk after breastfeeding
- Allergy: Urticaria; Wheeze; Coughing Prognosis
- NB: May lead to failure to thrive - IgE: 55 % will be intolerant by 5 YO
- Anaphylaxis: Uncommon - Non-IgE: Most children intolerant by 3 YO
Investigations
- Basic: Skin prick or patch testing
- RAST: Initial IgE and specific IgE for Cow milk protein
- Challenge: Usually in hospital (anaphylaxis risk)
Diaper Dermatitis (Nappy Rash)
Presentation Management
- Ammonia: Red, desquamating rash; Spares skin folds - Ammonia: Frequent changes; Sudocrem
- NB: Due to moisture retention - Thrush: As above + Clotrimazole ± Hydrocortisone
- Thrush: Satellite (beefy red) spots beyond main rash - NB: Avoid barrier creams until thrush eradicated
- NB: Candida is isolated from 50 % of diapers - Seborrhoeic: Same as in ammonia dermatitis
- Seborrheic: Diffuse, red, shiny rash; Enters skin folds - Psoriasis-like: Can be hard to treat
- NB: Associated with cradle cap - NB: Types often coexist with one another
- Psoriasis-like: Psoriasis like symptoms
Vomiting
Description Causes
- Posseting: Effortless regurgitation during feed - Common: GORD; Gastritis; Feeding >150 mL/kg/d
- NB: Vomit between meals is also common - Other: Pyloric stenosis (projectile vomiting)
- Emergency: Bilious (green) vomiting (obstruction) - Rare: Pharyngeal pouch; Poison; ↑ ICP; DKA
, Pre-School Wheeze in Children
Description Management
- Prevalence: 25 % experience an episode by 18 MO - Episodic Viral Wheeze
- Path: Viral-induced wheeze is commonest diagnosis o 1L: SABA inhaler + spacer
Classification o 2L: Add intermittent LRTA and/or ICS
- Episodic Viral: Only wheeze during URTI; Episodic - Multiple Trigger Wheeze
- Multiple Trigger: Multi-factors; Exercise; Pollutants o 1L: Trial of ICS or LRTA for 4-8 wks
Seborrhoeic Dermatitis
Presentation Management
- Sx: Coarse, yellow scales - Mild-Mod: Baby shampoo; Baby oils
- Location: Scalp (cradle cap); Nappy area; Face; Flexors - Severe: Mild topical steroids (1 % hydrocortisone)
Tongue-Tie (Ankyloglossia)
Description Types
- Path: Congenital deformity causing ↓ tongue mobility - Anterior: Frenulum anterior to floor of mouth
- Incidence: 10 % of live births - Posterior: Frenulum not visible due to being
- NB: Can cause trouble feeding and speech deeper in the mouth with ↓ tongue lift
Seán Keenan
2022
,The Seriously Ill Child
Description
Recognizing the need for prompt help is a central skill of paediatrics. Use ABC + traffic light assessment to determine.
Note that BP is not always a reliable vital to evaluate.
Green Light Red Light
- Feeding: Most feeds are accepted - Colour: Pale; Mottled; Ashen; Hypoxic
- Colour: Normal colour on lips, tongue + mouth - Social: Does not wake; Apathy; Coma
- Social: Alert or wakens quickly; Normal crying - Vitals: ↓ Skin turgor
- Vitals: ↔ RR (see below) - GRUNTING: See below for signs
Amber Light
- Feeding: Taking ≤50 % of feeds
- Colour: Pale
- Social: Hard to wake; No smiling; ↓ Activity
- Vitals: ↑ RR; Creps; Nasal flaring <1 YO
Vitals by Age
Age (years) Respiration Rate (BPM) Pulse (BPM) Systolic BP (mmHg)
<1 30-40 110-160 70-90
1-2 25-35 100-150 75-95
2-5 25-30 95-140 80-100
5-12 20-25 80-120 90-110
>12 12-20 60-100 100-120
Chest compressions are indicated if Neonates (<4 wks) HR <60 BPM
GRUNTING Signs
- Grunting: Weak or continuous high-pitched cry; Tachypnoea
- Respiration: Rib Recession; Retraction of sternocleidomastoid; Nasal flaring; Wheeze; Stridor
- Unresponsive: Unequal/Unresponsive Pupils: Focal CNS signs; Seizures; Marked hypotonia
- Neurology: Odd or rigid posture; Decorticate; Decerebrate
- Temperature: ≥38oC if <6 months; Cold peripheries
- Intuition: Judgement of need for investigations with child
- Neisseria: Neck Rigidity: Non-blanching rash; Meningism; Bulging fontanelle
- Gastroenterology: Green bile in vomit (Atresia; Volvulus; Intussusception)
,Common Complaints in Infancy
Crying
Description Management
- Prevalence: 20 % report problems in first 3 months - Sleep: Encourage parents to take turns sleeping
- Peaks: Crying peaks at 6-8 weeks old (~3 hrs/d) - Sooth: Tactile; Vocal; Vestibular (rocking)
- NB: Usually subsides by 4 months - Recognise: Recognise feeding vs sleeping needs
Colic
Description Management
- Prevalence: Occurs in 20 % of infants - Movement: May help with soothing
- Sx: Paroxysmal crying with pulling up of legs - Breastfeeding: Allow to finish first breast first
- Duration: Lasts >3 hrs on ≥3d/wk; Worse in evenings - NB: Fisher’s rule; Hind milk easier to digest
- NB: There is no association with feeding difficulties - Signs: May be sign of relationship issues
Cows’ Milk Protein Allergy/Intolerance
Description Management
- Key: Separate from colic - Breastfeeding: Maternal excludes cow milk in diet
- Path: Either IgE or Non-IgE mediated - Formula: Hypoallergenic formula (eHF milk)
Presentation - eHF Milk: Extensively hydrolysed milk formula
- General: Colic-Sx; GORD; Blood/mucus in stool - NB: Continue with eHF milk after breastfeeding
- Allergy: Urticaria; Wheeze; Coughing Prognosis
- NB: May lead to failure to thrive - IgE: 55 % will be intolerant by 5 YO
- Anaphylaxis: Uncommon - Non-IgE: Most children intolerant by 3 YO
Investigations
- Basic: Skin prick or patch testing
- RAST: Initial IgE and specific IgE for Cow milk protein
- Challenge: Usually in hospital (anaphylaxis risk)
Diaper Dermatitis (Nappy Rash)
Presentation Management
- Ammonia: Red, desquamating rash; Spares skin folds - Ammonia: Frequent changes; Sudocrem
- NB: Due to moisture retention - Thrush: As above + Clotrimazole ± Hydrocortisone
- Thrush: Satellite (beefy red) spots beyond main rash - NB: Avoid barrier creams until thrush eradicated
- NB: Candida is isolated from 50 % of diapers - Seborrhoeic: Same as in ammonia dermatitis
- Seborrheic: Diffuse, red, shiny rash; Enters skin folds - Psoriasis-like: Can be hard to treat
- NB: Associated with cradle cap - NB: Types often coexist with one another
- Psoriasis-like: Psoriasis like symptoms
Vomiting
Description Causes
- Posseting: Effortless regurgitation during feed - Common: GORD; Gastritis; Feeding >150 mL/kg/d
- NB: Vomit between meals is also common - Other: Pyloric stenosis (projectile vomiting)
- Emergency: Bilious (green) vomiting (obstruction) - Rare: Pharyngeal pouch; Poison; ↑ ICP; DKA
, Pre-School Wheeze in Children
Description Management
- Prevalence: 25 % experience an episode by 18 MO - Episodic Viral Wheeze
- Path: Viral-induced wheeze is commonest diagnosis o 1L: SABA inhaler + spacer
Classification o 2L: Add intermittent LRTA and/or ICS
- Episodic Viral: Only wheeze during URTI; Episodic - Multiple Trigger Wheeze
- Multiple Trigger: Multi-factors; Exercise; Pollutants o 1L: Trial of ICS or LRTA for 4-8 wks
Seborrhoeic Dermatitis
Presentation Management
- Sx: Coarse, yellow scales - Mild-Mod: Baby shampoo; Baby oils
- Location: Scalp (cradle cap); Nappy area; Face; Flexors - Severe: Mild topical steroids (1 % hydrocortisone)
Tongue-Tie (Ankyloglossia)
Description Types
- Path: Congenital deformity causing ↓ tongue mobility - Anterior: Frenulum anterior to floor of mouth
- Incidence: 10 % of live births - Posterior: Frenulum not visible due to being
- NB: Can cause trouble feeding and speech deeper in the mouth with ↓ tongue lift
