Common Paediatric Problems

1
Common Paediatric Problems

• General approach to Management

2
The common problems

• (1). URTI symptoms URTI, chest infection
• asthmatic
  attack
• (2). Abdominal pain GE, gastritis
• (3). Fever UTI, febrile convulsion

3
Febrile Convulsion

• Def. Seizure associated with fever in the
  absence of another cause, not due to
  intracranial infection
• 3-4 of children (genetic predisposition)
• 6 months 3 years
• Rare after 6 years of age

4
Febrile Convulsion--presentation

• At peak of Fever/ sudden rise of temp.
• Occurs early in viral illness
• Generalized tonic-clonic
• Usu. Brief (1-2 mins, lt10mins)
• No post-ictal drowsiness
• No neurological signs
• Occur once within 24hr period

5
Prognosis

• Benign
• (1). Development of epilepsy
• -- 2-4 develop epilepsy by 7 y.o
• --7 develop epilepsy up to 25 y.o.
• (2). Recurrence
• --30 after 1st episode
• --50-70 after 2nd
• 80 after 3rd

6
Risk Factors of subsequent epilepsy

• (1) Prolonged seizure in 1st episode (gt30m)
• (2). Seizure is focal
• (3). Seizure recurs in same illness
• (4). Family Hx. of 1st degree relative with
  epilepsy/ gt5 febrile convulsions
• (5). Prior abnormal developmental status 3x

7
Management

• --To rule out other causes of seizure
• (infection screen)
• --To keep temperature low remove warm
  clothing tepid sponging
• --Antipyretics e.g paracetamol
• --Diazepam suppositories for any
• seizure gt 5mins
• --Reassurance to parents education for 1st aid
  management

8
Childhood Fever

• Def. gt37.4 C (oral or armpit) gt37.8 (rectal)
• Rectal temp not always desirable
• High fever caution in
• neonates Sepsis until proven otherwise
• lt2yrs beware of bacteremia/septicemia/meningitis
• Margin of safety lower the younger the child

9
Evaluate fever lt 2y.o

• Immediate purpose identify ltsepsis??gt
• DDx URTI 60-70 of cases
• GE/ UTI next common
• Other rare causes
• Osteomyelitis/ arthritis/ meningitis
• Connective tissue disease/malignancy

10
History P/E

• Most accurate (?sepsis) from observation
• Playfulness
• Alertness drowsy/ irritable
• Consolability nature of crying high pitch?
• Motor activity
• Feeding vomiting/nauseated

11
P/E

• Hydration status
• Periphery cold/clammy?
• Respiration distress in pneumonia, metabolic
  acidosis, sepsis

12
Ix

• In all patient with fever lt 6 months
• Extensive investigation needed for focus
• Minimally
• WCC diff.
• Blood C/ST
• Urinalysis for C/ST, R/M (SPA /cath)
• Consider LP in most cases (if no CI)

13
Urinary tract Infection

• lt11 y.o 1 boys/ 3 girls (symptomatic)
• 2 main principals of Mx
• (1). Halt the complications
• (2). Thorough assessment Ix after 1st episode
  as
• gt1/2 have structural abnormality
• UTI?scar?HT?CRF if scar bilateral

14
Clinical features

• Infancy non-specific
• Fever
• Lethargy/irritability
• Vomiting/diarrhea
• Poor feeding/failure to thrive
• Prolonged neonatal jaundice
• Septicemia
• Febrile convulsion (gt6 months)

15
Reminders

• (1). As age increases, symptoms become more
  specific
• (2). Dysuria without fever? vulvitis in girls or
  balanitis in boys
• (3). Social Hx. To be explored for ?sexual abuse

16
Urine sample collection

• Child in nappies
• (1). Clean catch
• (2). Adhesive plastic bag applied to perineum
• (3). SPA (preferred in severely ill infant lt1y.o.
  OR contaminated previous sample)
• (4). Bag urine in low index of suspicion

17
?Reliance on microscopy or dipsticks?

• If both ve gt treat
• Both-ve but clinical s/s highly suggestivegt
  treat
• If microscopy shows equivocal result dipstick
  ve for WCC/esterase/nitrite clinical condition
  likely UTI gt treat
• If microscopy shows organism in addition to white
  cells gt treat

18
Simple measures to prevent recurrence

• High fluid intake-gthigh urine output
• Regular voiding
• Complete bladder emptying (double micturition) to
  empty residual urine
• Mx of constipation
• Good perineal hygiene

19
Follow-up in recurrent UTIs renal scarring

• Routine Urine culture every 3-4 months
• Blood pressure
• Long term low dose antibiotic prophylaxis
  Trimethoprim (2mg/kg nocte) /- nitrofurantoin
  /- nalidixic acid
• Regular assessment of renal function

20
Typical Ix protocol for 1st episode UTI

• US /- AXR
• Give prophylactic antibiotics until ALL Ix
  completed
• Age lt1y.o DMSAMCUG
• 1-5 y.o DMSA
• gt5y.o only if abnormal USG?DMSA

21
Subsequent need for cystogram

• Abnormal DMSA
• Abnormal USG
• Acute pyelonephritis
• Family Hx of reflux
• Unexplained Recurrent UTI