Introduction to Hospital Paediatrics

1
Introduction to Hospital Paediatrics

• Dr Elma Stephen
• Consultant Paediatrician

2
An Overview

• Paediatric history and examination
• Common paediatric problems
• Prescribing for children

3
HELP, but whats different ?

• Paediatrics is a speciality governed by age
• H - the History
• E - the Examination
• L - Logical deduction of facts
• P Plan of Action
• Holistic view of child and family

4
Reasons for paediatric medical admisssions (2160
consecutive admissions to a DGH)

• Respiratory 31 (asthma 11, URTI 6, Croup 4,
  Bronchiolitis 4, Pneumonia 3, Tonsillitis 2.5)
• Environment 22 (HI 12, Poisoning 8, Child
  protection 1.5)
• Gastroenterology 15 (Gastroenteritis 7,
  Constipation 2, Abdo pain/vomiting 2, FTT 1)
• Infection 10 (Viral infection 6,
  Sepsis/meningitis 1.5)
• Neurology 8 (Feb fits 3, Epilepsy 3, Apnoea/
  cyanotic attacks 2
• Kidney and urinary tract 3 (UTI 2.5)
• Other 11

(Courtesy Dr Macfaul, Wakefield)
5
Common paediatric problems

• Respiratory distress
• Rashes
• Gastroenteritis
• Growth problems

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Scenario 1 The child with breathing difficulties

• Structured approach to assessment
• Is it respiratory upper or lower respiratory
  tract?
• Is it cardiac?
• Accidental Choking or poisoning?
• Degrees of respiratory distress and cough are not
  useful diagnostic discriminators

7
Physiological differences

• Susceptibility to infection
• Smaller upper and lower airways
• Compliant chest wall
• Respiratory muscles relatively more inefficient

8
Key features of assessment of respiratory distress

• Stridor upper airway obstruction
• Wheeze lower airway obstruction
• Fever infection, dehydration
• Signs of heart failure congenital or acquired
  heart disease
• Suspicion of ingestion and abscence of
  cardiorespiratory pathology poisoning

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Asthma

• Commonest reason for hospital admission in
  paediatrics
• 10-20 of acute medical admissions
• Major cause of childhood morbidity over years
• Often underdiagnosed and under treated
• 3-4 of asthmatic children admitted to hospital
  per year
• Mortality 1/ 100000 children per year

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Asthma
Patterns of asthma in children Physical
examination Diagnosis symptoms, peak flows
bronchodilator responsiveness Tests CXR, tests
for atopy Emergency management of asthma
11
BTS/ SIGN guidelines for asthma management
12
Case History 1

• 7 mo infant admitted with 3 day h/o coryzal
  symptoms followed by increasing breathlessness
  and poor feeding.
• Diagnosis ?
• Management ?
• Prognosis ?
• Complications ?
• Which infants are at higher risk?

13
Bronchiolitis

• Commonest serious respiratory infection of
  childhood
• 10 of all infants affected
• Rare after one year of age
• RSV pathogen in 75-80 cases

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What is your diagnosis?
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Upper Airway Obstruction

• Croup
• Viral LTB (very common)
• Spasmodic croup (common)
• Bacterial tracheitis (rare)

• Rare Causes
• Epiglottitis
• Smoke inhalation
• Trauma
• Retropharyngeal abscess
• Foreign body
• Angioedema
• IMN
• Measles
• Diphtheria

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Age distribution of acute respiratory infections
in children
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Scenario 2 The child with a rash
The Good. Chicken Pox
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The Bad.
And the Ugly..
Impetigo
Epidermolysis bullosa
19
Spot the Rash
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Scenario 3 Gastroenteritis

• Second most common cause of paediatric admission

• Problems
• Dehydration
• Metabolic disturbance
• Oliguria/ ARF
• HUS
• Septicemia
• Protracted diarrhoea
• Malnutrition

21
Gastroenteritis pathogens
E Coli 0157
Rotavirus
Adenovirus
22
Assessment of Dehydration

• Features of dehydration
• Accurate weighing
• Oral and intravenous dehydration
• Promotion of nutrition
• Avoidance of metabolic disturbance
• Appropriate use of antibiotics

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Fluid requirements Baseline

• lt10 kg 100ml/kg/d
• 10-20 kg 1000ml/d 50ml/kg for every kg gt 10kg
• gt20kg 1500ml/d 20ml/kg for every kg gt 20kg
• Dehydration correction dehydration x 10ml/kg

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Case History 2

• A 7- year old child is admitted with a
  4 day h/o loose watery stool and vomiting.
  Examination shows sunken eyes, reduced skin
  turgor and oliguria.
• What is the estimated weight of this child?
  2(age) 8
• What is the degree of dehydration?
• Calculate the amount of fluids needed for
  rehydration.
• What is the best route of delivery of rehydration
  fluids?
• What investigations would you recommend?
• What is the approximate composition of Dioralyte?
  How is this different from WHO ORS and why?
• What is the role of antibiotics in diarrhoea?

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Major constituents of ORS in mmol/l
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Scenario 4 Assessment of Growth
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Normal growth

• Antenatal
• Birth size
• First year of life
• Early and mid childhood
• Puberty

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Growth charts
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Growth monitoring

• Routine part of child health surveillance
• Indications for paediatric referral
• Short stature and investigation
• Failure to thrive
• Obesity

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Drug Treatment and Prescribing in children

• Differ from adults in their response to drugs
• Calculate doses with care
• Prescribing by weight and body surface area
  (nomograms)
• BNF for children
• Identification and reporting of adverse drug
  reactions in children

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The Rewards of Paediatrics

• Stimulating and challenging!
• Seeing children get better
• Relatively fewer long term health problems
• Sharing in team working
• Learning patience and enjoying hard work
• Learning to be unpompous.because sitting on the
  floor, accepting that the social worker or nurse
  may have a better perspective and occasionally
  being pee-ed on are all part of the job!