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Common Paediatric Problems

Common Paediatric Problems. General approach to Management. The common problems. (1). URTI symptoms: URTI, chest infection asthmatic attack (2). Abdominal pain: GE, gastritis (3). Fever: UTI, febrile convulsion. Febrile Convulsion.

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Common Paediatric Problems

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  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, <10mins) • 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 (>30m) • (2). Seizure is focal • (3). Seizure recurs in same illness • (4). Family Hx. of 1st degree relative with epilepsy/ >5 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 > 5mins --Reassurance to parents + education for 1st aid management

  8. Childhood Fever • Def. :>37.4 C (oral or armpit); >37.8 (rectal) • Rectal temp not always desirable • High fever: caution in • neonates: “Sepsis until proven otherwise” • <2yrs: beware of bacteremia/septicemia/meningitis *Margin of safety lower the younger the child

  9. Evaluate fever < 2y.o • Immediate purpose: identify <sepsis??> • 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 < 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 • <11 y.o: 1% boys/ 3% girls (symptomatic) • 2 main principals of Mx: • (1). Halt the complications • (2). Thorough assessment & Ix after 1st episode as: • >1/2 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 (>6 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 <1y.o. OR contaminated previous sample) • (4). Bag urine in low index of suspicion

  17. ?Reliance on microscopy or dipsticks? • If both +ve => treat • Both-ve but clinical s/s highly suggestive=> treat • If microscopy shows equivocal result + dipstick +ve for WCC/esterase/nitrite + clinical condition likely UTI => treat • If microscopy shows organism in addition to white cells => treat

  18. Simple measures to prevent recurrence • High fluid intake->high 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: <1y.o: DMSA+MCUG • 1-5 y.o: DMSA • >5y.o: only if abnormal USGDMSA

  21. Subsequent need for cystogram • Abnormal DMSA • Abnormal USG • Acute pyelonephritis • Family Hx of reflux • Unexplained Recurrent UTI

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