Paediatrics
Michael Grant
Notes based on QUB online Med Portal lectures, QUB student manual, NICE Guidelines,
Oxford Clinical handbook and various external online resources
A) Four Basic Paediatric Skills:
How to pick up and hold a baby
Taking a paediatric history (different emphasis to adults)
Introduce yourself – name / role
Confirm patient details – name / DOB
Explain the need to take a history
Gain consent to take a history
Ensure the patient is comfortable
Presenting complaint
Give the patient time to explain the problem/symptoms they‘ve been experiencing.
In a paediatric history this may well be a collateral history from a parent.
It‘s important to use open questioning to elicit the patient‘s or parent‘s presenting complaint.
“So what’s brought your child in today?” or “What’s brought you in today?”
This can sometimes be difficult when talking to children and you may need to adopt an approach involving more direct
questioning. So instead of saying “Tell me about the pain” you may need to ask a series of questions requiring only yes or no answers.
“Is the pain in your tummy?” “Is the pain in your back?”
Allow the patient time to answer and do not interrupt.
History of presenting complaint
Onset – when did the symptom start? / was the onset acute or gradual?
Duration – minutes / hours / days / weeks / months / years
Severity – e.g. if symptom is shortness of breath – are they able to talk in full sentences?
Course – is the symptom worsening, improving, or continuing to fluctuate?
Intermittent or continuous? – is the symptom always present or does it come and go?
Precipitating factors – are there any obvious triggers for the symptom?
Relieving factors – does anything appear to improve the symptoms e.g. an inhaler
Associated features – are there other symptoms that appear associated e.g. fever / malaise
Previous episodes – has the patient experienced this symptoms previously?
Key paediatric questions
Feeding – volume of intake / frequency of feeding
Vomiting – frequency / volume / timing – projectile? / bilious? / blood?
Fever – confirmed using thermometer vs subjectively feeling hot?
Wet nappies / urine output – number of wet nappies a day – ↓ in dehydration
Stools – consistency / steatorrhoea? (biliary obstruction) / red currant jelly (intussusception)
Rash – any obvious trigger? / distribution? / blanching?
Behaviour – irritability / less responsive
Cough – productive? / associated increased work of breathing?
Rhinorrhoea – often associated with viral upper respiratory disease
Weight gain or loss – check baby book if the parent has it with them
Sleeping pattern – more sleepy than usual?
Unwell contacts – often children become infected from unwell siblings
Localising symptoms – tugging at an ear/ holding tummy
Pain – if pain is a symptom, clarify the details of the pain using SOCRATES
◦ Site – where exactly is the pain / where is the pain worst
◦ Onset – when did it start? / did it come on suddenly or gradually?
◦ Character – what does it feel like? (sharp stabbing / dull ache / burning?)
◦ Radiation – does the pain move anywhere else? (e.g. chest pain with left arm radiation)
◦ Associations – any other symptoms associated with the pain (e.g. chest pain with SOB)
, ◦ Time course – does the pain have a pattern (e.g. worse in the mornings)
◦ Exacerbating / relieving factors – anything make it particularly worse or better?
◦ Severity – on a scale of 0-10, with 0 being no pain & 10 being the worst pain you’ve ever felt
Ideas, Concerns & Expectations – often addressed to parents
Ideas – what are the patient’s / parent’s thoughts regarding their symptoms?
Concerns – explore any worries the patient / parent may have regarding the symptoms
Expectations – gain an understanding of what the patient / parent is hoping to achieve from the consultation
Summarising
Summarise what the patient / parent has told you about the presenting complaint.
This allows you to check your understanding regarding everything the patient/parent has told you.
It also allows the patient/parent to correct any inaccurate information & expand further on certain aspects.
Once you have summarised, ask the patient/parent if there‘s anything else that you‘ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Paediatrics: Page 3 of 78
Signposting
Signposting involves explaining to the patient/parent:
◦ What you have covered – “Ok, so we’ve talked about the symptoms””
◦ What you plan to cover next – “Now I’d like to discuss any previous medical history”
Past medical history
Antenatal period – illnesses or complications during gestation – e.g. rubella
Birth – delivery complications / prematurity / birth weight
Neonatal period – illness /admission to special care baby unit (SCBU)?
Medical conditions
Previous hospitalisation – when and why?
Previous surgery
Accidents & injuries – remain vigilant for signs of non accidental injury
Developmental history
Current weight and height – weight is required to calculate drug doses
Developmental milestones (are they on track for their given age?):
◦ e.g. sitting up, crawling, walking, talking, toilet training, reading
Family history
Family history of disease – e.g. coeliac / T1DM
Genetic conditions – e.g. cystic fibrosis
Family tree – useful to draw out if considering genetic disease
Drug history
Regular medication – e.g. inhalers for asthma
Over the counter medication
ALLERGIES
Immunisations - Is the child up to date with their immunisations?
Social history
Living situation + Social services – accommodation / main carer / who lives with child?
Second hand smoke exposure – risk factor for otitis media / asthma / SIDS
Dietary history
Type of food? – formula / breast milk / solids
Intake – e.g. how many ounces of milk?
Frequency of feeding – reduced or increased?
Special dietary requirements? – cow’s milk intolerance / coeliac disease
Parents occupation
Pets – important when considering allergies / asthma triggers
Schooling – stage of learning / any issues?
Foreign travel – may be important when considering certain diagnoses e.g. TB
Top to bottom:
CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion
GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
Cardiovascular – Chest pain / Palpitations / Dyspnoea / Syncope / Orthopnoea / Peripheral oedema
Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain
Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence
Musculoskeletal – Bone and joint pain / Muscular pain
Dermatology – Rashes / Skin breaks / Ulcers
Clinical examination - gaining maximum information with minimum upset (including normal
neonate, infant, dysmorphic child, developmental assessment, ENT, eyes for squint). How to
modify systematic examination of CVS, RS, GIT, CNS, PNS in light of child‘s age, ability to
, understand and co-operate, and the relevance of signs at different ages.
Learn to:
o Understand the anxieties and worries parents have about their ill children.
o develop the ability to show parents that you understand and grasp what they perceive
to be the problem.
o develop communication skills that will allay fears or convey information in a way that is
understood by parents and by children.
, Paediatrics: Page 4 of 78
Child Abuse and Neglect
Physical abuse:
Physical abuse may involve hitting, shaking, throwing, poisoning,
burning or scalding, drowning, suffocating, or otherwise causing
physical harm to a child.
Factors to consider in the presentation of a physical injury are:
• The history given by the child (if they can communicate)
• The child‘s age and stage of development
• The plausibility and/or reasonableness of the explanation for
the injury
• Any background, e.g. previous child protection concerns,
multiple attendances to A&E or general practitioner
• Delay in reporting the injury
• Inconsistent histories or reactions from caregiver (e.g. vague,
evasive, aggression)
Investigations:
• X-rays
o If under 30 months, full radiographic skeletal
survey with oblique views – esp. posterior ribs
o Repeat x-ray at 1-2 weeks later
• Bruising:
o Rule out coagulation disorders
o Be aware of Mongolian blue spots on back or
thighs
o The age of a bruise cannot be accurately estimated
o Can be hard to detect on dark skinned children
• Fractures:
o Exclude osteogenesis imperfecta – type 1 causes #, autosomal dominant,
blue sclerae, wormian bones in skull sutures
• Scalds and cigarette burns
o Exclude bullous impretigo (Staph aureus scalded skin syndrome)
• Head and neck trauma:
o Extra dural (direct trauma) Subdural (shearing, shaking trauma +/- retinal
haemorrage) or subarachnoid (retinal bleeds, aneurysm) bleeds
o Retinal haemorrhages or injury to the eye in a child if there is no major
confirmed accidental trauma
• RECORDING:
o Make sure to clearly document any injuries, the histories and – if consenting –
photographic evidence
o Discuss with senior paediatrician
Sexual abuse:
Involves forcing or enticing a child or young person to take part in sexual activities, including prostitution, whether or not the child is aware
of what is happening. The activities may involve physical contact, or non-contact activities, such as involving children in l ooking at or
producing pornographic material.
• Recognition can occur when: child informs someone, becomes pregnant (automatically sexual absuse if girl >13 years), STI with no clear
reason (although they can be contracted from mother during birth)
• Physical symptoms: vaginal/rectal bleeding
• Behaviour symptoms: soiling, secondary enuresis, self harm, sexualised behaviours, poor school
performance
• Signs:
o Can be difficult to find as gential area heals very quickly in young children
o STI screening
o Forensic swabs of body, clothing, bedding for semen
Emotional abuse:
Is the persistent emotional maltreatment of a child resulting in severe and persistent adverse
effects on the child‘s emotional development. It may involve conveying to children that they are
worthless or unloved, inadequate, or valued only insofar as they meet the needs of another
person. This may arise form the fact the child is seen as the ―wrong‖ gender, born at a time of parental
separation or violence, r is seen as unduly difficult.
• Clues come from child‘s behaviour:
o Babies:
Apathetic, delayed development, non-demanding
Michael Grant
Michael Grant
Notes based on QUB online Med Portal lectures, QUB student manual, NICE Guidelines,
Oxford Clinical handbook and various external online resources
A) Four Basic Paediatric Skills:
How to pick up and hold a baby
Taking a paediatric history (different emphasis to adults)
Introduce yourself – name / role
Confirm patient details – name / DOB
Explain the need to take a history
Gain consent to take a history
Ensure the patient is comfortable
Presenting complaint
Give the patient time to explain the problem/symptoms they‘ve been experiencing.
In a paediatric history this may well be a collateral history from a parent.
It‘s important to use open questioning to elicit the patient‘s or parent‘s presenting complaint.
“So what’s brought your child in today?” or “What’s brought you in today?”
This can sometimes be difficult when talking to children and you may need to adopt an approach involving more direct
questioning. So instead of saying “Tell me about the pain” you may need to ask a series of questions requiring only yes or no answers.
“Is the pain in your tummy?” “Is the pain in your back?”
Allow the patient time to answer and do not interrupt.
History of presenting complaint
Onset – when did the symptom start? / was the onset acute or gradual?
Duration – minutes / hours / days / weeks / months / years
Severity – e.g. if symptom is shortness of breath – are they able to talk in full sentences?
Course – is the symptom worsening, improving, or continuing to fluctuate?
Intermittent or continuous? – is the symptom always present or does it come and go?
Precipitating factors – are there any obvious triggers for the symptom?
Relieving factors – does anything appear to improve the symptoms e.g. an inhaler
Associated features – are there other symptoms that appear associated e.g. fever / malaise
Previous episodes – has the patient experienced this symptoms previously?
Key paediatric questions
Feeding – volume of intake / frequency of feeding
Vomiting – frequency / volume / timing – projectile? / bilious? / blood?
Fever – confirmed using thermometer vs subjectively feeling hot?
Wet nappies / urine output – number of wet nappies a day – ↓ in dehydration
Stools – consistency / steatorrhoea? (biliary obstruction) / red currant jelly (intussusception)
Rash – any obvious trigger? / distribution? / blanching?
Behaviour – irritability / less responsive
Cough – productive? / associated increased work of breathing?
Rhinorrhoea – often associated with viral upper respiratory disease
Weight gain or loss – check baby book if the parent has it with them
Sleeping pattern – more sleepy than usual?
Unwell contacts – often children become infected from unwell siblings
Localising symptoms – tugging at an ear/ holding tummy
Pain – if pain is a symptom, clarify the details of the pain using SOCRATES
◦ Site – where exactly is the pain / where is the pain worst
◦ Onset – when did it start? / did it come on suddenly or gradually?
◦ Character – what does it feel like? (sharp stabbing / dull ache / burning?)
◦ Radiation – does the pain move anywhere else? (e.g. chest pain with left arm radiation)
◦ Associations – any other symptoms associated with the pain (e.g. chest pain with SOB)
, ◦ Time course – does the pain have a pattern (e.g. worse in the mornings)
◦ Exacerbating / relieving factors – anything make it particularly worse or better?
◦ Severity – on a scale of 0-10, with 0 being no pain & 10 being the worst pain you’ve ever felt
Ideas, Concerns & Expectations – often addressed to parents
Ideas – what are the patient’s / parent’s thoughts regarding their symptoms?
Concerns – explore any worries the patient / parent may have regarding the symptoms
Expectations – gain an understanding of what the patient / parent is hoping to achieve from the consultation
Summarising
Summarise what the patient / parent has told you about the presenting complaint.
This allows you to check your understanding regarding everything the patient/parent has told you.
It also allows the patient/parent to correct any inaccurate information & expand further on certain aspects.
Once you have summarised, ask the patient/parent if there‘s anything else that you‘ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Paediatrics: Page 3 of 78
Signposting
Signposting involves explaining to the patient/parent:
◦ What you have covered – “Ok, so we’ve talked about the symptoms””
◦ What you plan to cover next – “Now I’d like to discuss any previous medical history”
Past medical history
Antenatal period – illnesses or complications during gestation – e.g. rubella
Birth – delivery complications / prematurity / birth weight
Neonatal period – illness /admission to special care baby unit (SCBU)?
Medical conditions
Previous hospitalisation – when and why?
Previous surgery
Accidents & injuries – remain vigilant for signs of non accidental injury
Developmental history
Current weight and height – weight is required to calculate drug doses
Developmental milestones (are they on track for their given age?):
◦ e.g. sitting up, crawling, walking, talking, toilet training, reading
Family history
Family history of disease – e.g. coeliac / T1DM
Genetic conditions – e.g. cystic fibrosis
Family tree – useful to draw out if considering genetic disease
Drug history
Regular medication – e.g. inhalers for asthma
Over the counter medication
ALLERGIES
Immunisations - Is the child up to date with their immunisations?
Social history
Living situation + Social services – accommodation / main carer / who lives with child?
Second hand smoke exposure – risk factor for otitis media / asthma / SIDS
Dietary history
Type of food? – formula / breast milk / solids
Intake – e.g. how many ounces of milk?
Frequency of feeding – reduced or increased?
Special dietary requirements? – cow’s milk intolerance / coeliac disease
Parents occupation
Pets – important when considering allergies / asthma triggers
Schooling – stage of learning / any issues?
Foreign travel – may be important when considering certain diagnoses e.g. TB
Top to bottom:
CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion
GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
Cardiovascular – Chest pain / Palpitations / Dyspnoea / Syncope / Orthopnoea / Peripheral oedema
Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain
Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence
Musculoskeletal – Bone and joint pain / Muscular pain
Dermatology – Rashes / Skin breaks / Ulcers
Clinical examination - gaining maximum information with minimum upset (including normal
neonate, infant, dysmorphic child, developmental assessment, ENT, eyes for squint). How to
modify systematic examination of CVS, RS, GIT, CNS, PNS in light of child‘s age, ability to
, understand and co-operate, and the relevance of signs at different ages.
Learn to:
o Understand the anxieties and worries parents have about their ill children.
o develop the ability to show parents that you understand and grasp what they perceive
to be the problem.
o develop communication skills that will allay fears or convey information in a way that is
understood by parents and by children.
, Paediatrics: Page 4 of 78
Child Abuse and Neglect
Physical abuse:
Physical abuse may involve hitting, shaking, throwing, poisoning,
burning or scalding, drowning, suffocating, or otherwise causing
physical harm to a child.
Factors to consider in the presentation of a physical injury are:
• The history given by the child (if they can communicate)
• The child‘s age and stage of development
• The plausibility and/or reasonableness of the explanation for
the injury
• Any background, e.g. previous child protection concerns,
multiple attendances to A&E or general practitioner
• Delay in reporting the injury
• Inconsistent histories or reactions from caregiver (e.g. vague,
evasive, aggression)
Investigations:
• X-rays
o If under 30 months, full radiographic skeletal
survey with oblique views – esp. posterior ribs
o Repeat x-ray at 1-2 weeks later
• Bruising:
o Rule out coagulation disorders
o Be aware of Mongolian blue spots on back or
thighs
o The age of a bruise cannot be accurately estimated
o Can be hard to detect on dark skinned children
• Fractures:
o Exclude osteogenesis imperfecta – type 1 causes #, autosomal dominant,
blue sclerae, wormian bones in skull sutures
• Scalds and cigarette burns
o Exclude bullous impretigo (Staph aureus scalded skin syndrome)
• Head and neck trauma:
o Extra dural (direct trauma) Subdural (shearing, shaking trauma +/- retinal
haemorrage) or subarachnoid (retinal bleeds, aneurysm) bleeds
o Retinal haemorrhages or injury to the eye in a child if there is no major
confirmed accidental trauma
• RECORDING:
o Make sure to clearly document any injuries, the histories and – if consenting –
photographic evidence
o Discuss with senior paediatrician
Sexual abuse:
Involves forcing or enticing a child or young person to take part in sexual activities, including prostitution, whether or not the child is aware
of what is happening. The activities may involve physical contact, or non-contact activities, such as involving children in l ooking at or
producing pornographic material.
• Recognition can occur when: child informs someone, becomes pregnant (automatically sexual absuse if girl >13 years), STI with no clear
reason (although they can be contracted from mother during birth)
• Physical symptoms: vaginal/rectal bleeding
• Behaviour symptoms: soiling, secondary enuresis, self harm, sexualised behaviours, poor school
performance
• Signs:
o Can be difficult to find as gential area heals very quickly in young children
o STI screening
o Forensic swabs of body, clothing, bedding for semen
Emotional abuse:
Is the persistent emotional maltreatment of a child resulting in severe and persistent adverse
effects on the child‘s emotional development. It may involve conveying to children that they are
worthless or unloved, inadequate, or valued only insofar as they meet the needs of another
person. This may arise form the fact the child is seen as the ―wrong‖ gender, born at a time of parental
separation or violence, r is seen as unduly difficult.
• Clues come from child‘s behaviour:
o Babies:
Apathetic, delayed development, non-demanding
Michael Grant
