Common Paediatric ProblemsCommon Paediatric Problems

General approach to Management

The common problemsThe common problems

(1). URTI symptoms: URTI, chest infection

asthmatic attack

(2). Abdominal pain: GE, gastritis

(3). Fever: UTI, febrile convulsion

Febrile ConvulsionFebrile 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

Febrile Convulsion--Febrile Convulsion--presentationpresentation

At peak of Fever/ sudden rise of temp.Occurs early in viral illnessGeneralized tonic-clonicUsu. Brief (1-2 mins, <10mins)No post-ictal drowsinessNo neurological signsOccur once within 24hr period

PrognosisPrognosis

“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

Risk Factors of subsequent Risk Factors of subsequent epilepsyepilepsy

(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 e

pilepsy/ >5 febrile convulsions(5). Prior abnormal developmental status 3x

ManagementManagement

--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

Childhood FeverChildhood Fever

Def. :>37.4 C (oral or armpit); >37.8 (rectal)Rectal temp not always desirableHigh fever: caution in

– neonates: “Sepsis until proven otherwise”– <2yrs: beware of bacteremia/septicemia/mening

itis

*Margin of safety lower the younger the child

Evaluate fever < 2y.oEvaluate fever < 2y.o

Immediate purpose: identify <sepsis??>DDx: URTI 60-70% of casesGE/ UTI next commonOther rare causes:Osteomyelitis/ arthritis/ meningitisConnective tissue disease/malignancy

History & P/EHistory & P/E

Most accurate (?sepsis) : from observationPlayfulnessAlertness: drowsy/ irritableConsolability + nature of crying: high pitch?Motor activityFeeding: vomiting/nauseated

P/EP/E

Hydration status

Periphery: cold/clammy?

Respiration: distress in pneumonia, metabolic acidosis, sepsis

Ix Ix

In all patient with fever < 6 months:Extensive investigation needed for focusMinimally:WCC + diff.Blood C/STUrinalysis for C/ST, R/M (SPA /cath)Consider LP in most cases (if no CI)

Urinary tract InfectionUrinary 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 epis

ode as:– >1/2 have structural abnormality– UTIscarHTCRF if scar bilateral

Clinical featuresClinical features

Infancy –non-specific Fever; Lethargy/irritability Vomiting/diarrhea Poor feeding/failure to thrive Prolonged neonatal jaundice Septicemia Febrile convulsion (>6 months)

Reminders…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

Urine sample collectionUrine 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

?Reliance on microscopy or ?Reliance on microscopy or dipsticks?dipsticks?

If both +ve => treatBoth-ve but clinical s/s highly suggestive=>

treatIf microscopy shows equivocal result + dips

tick +ve for WCC/esterase/nitrite + clinical condition likely UTI => treat

If microscopy shows organism in addition to white cells => treat

Simple measures to prevent Simple measures to prevent recurrencerecurrence

High fluid intake->high urine outputRegular voidingComplete bladder emptying (double micturi

tion) to empty residual urineMx of constipationGood perineal hygiene

Follow-up in recurrent UTIs + rFollow-up in recurrent UTIs + renal scarringenal scarring

Routine Urine culture every 3-4 monthsBlood pressureLong term low dose antibiotic prophylaxis:

Trimethoprim (2mg/kg nocte) +/- nitrofurantoin +/- nalidixic acid

Regular assessment of renal function

Typical Ix protocol for 1Typical Ix protocol for 1stst episode UTIepisode UTI

US +/- AXRGive prophylactic antibiotics until ALL Ix

completedAge: <1y.o: DMSA+MCUG 1-5 y.o: DMSA >5y.o: only if abnormal USGDMSA

Subsequent need for cystograSubsequent need for cystogramm

Abnormal DMSAAbnormal USGAcute pyelonephritisFamily Hx of refluxUnexplained Recurrent UTI