Child Health Presentation PDF

Child Health in Clinical Practice DR RATHNA B. VEERNI Learning objectives  Be able to identify and manage commonly encountered respiratory conditions in the paediatric population  Be able to identify and manage commonly encountered infectious diseases in the paediatric population  Be able to iden...

Child Health in Clinical Practice DR RATHNA B. VEERNI Learning objectives  Be able to identify and manage commonly encountered respiratory conditions in the paediatric population  Be able to identify and manage commonly encountered infectious diseases in the paediatric population  Be able to identify conditions that require school exclusion and public health notification  Be able to identify and manage commonly encountered surgical presentations  Be able to identify and manage commonly encountered orthopaedic presentations MLA roadmap HTTPS://WWW.GMCUK.ORG/EDUCATION/MEDICAL-LICENSINGASSESSMENT/MLA-CONTENT-MAP Common Respiratory conditions: Bronchiolitis  Viral infection of the bronchioles common caused by RSV  Affects children under 2 years old  Male to female ratio is 1:1  Mainly in the Winter and Spring months  Risk Factors:  Being breast fed for less than 2 months  Smoke exposure (eg. parents’ smoke)  Having siblings who attend nursery or school (increased risk of exposure to viruses)  Chronic lung disease due to prematurity Bronchiolitis  Presentation:  Coryzal Symptoms – runny or snotty nose, sneezing, mucus in throat and watery eyes  Signs of respiratory distress: raised RR, use of accessory muscle of breathing, Intercostal and subcostal recessions, nasal flaring, head bobbing, tracheal tugging, cyanosis, abnormal airway noises (wheezing, grunting and stridor)  Dyspnoea, tachypnoea  Poor feeding  Mild fever  Wheeze and crackles on auscultation  Apnoeas NICE referral guidelines:   NICE recommend immediate referral (usually by 999 ambulance) if they have any of the following: apnoea (observed or reported)  child looks seriously unwell to a healthcare professional  severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute  central cyanosis  persistent oxygen saturation of less than 92% when breathing air. NICE recommend that clinicians 'consider' referring to hospital if any of the following apply:  a respiratory rate of over 60 breaths/minute  difficulty with breastfeeding or inadequate oral fluid intake (50-75% of usual volume 'taking account of risk factors and using clinical judgement')  clinical dehydration. Management:  Upper airway suctioning  Oxygen administration – if consistently less than 92%  Hydration – nasogastric/orogastric/intravenous  Ventilator support if required Viral URTIs  Upper respiratory tract infections involve the mucosa of the nasal cavity, sinuses, nasopharynx, oropharynx and larynx.  Peak incidence is between the ages of 1 – 5  Male to female ratio is 1:1  Commonly caused by Rhinovirus and Corona viruses, but can also be caused adenovirus, influenza, parainfluenza, RSV and enteroviruses  Presentation: Coryzal symptoms, sore throat, headache, cough, tiredness and general malaise. Other symptoms include facial pain, earache, hoarseness and nausea. Viral URTIs Clinical signs: Erythema or injection of the back of the throat, Nasal discharge, tender cervical lymphadenopathy, Mild fever Management: supportive, assess hydration status and for signs of respiratory distress Croup  Croup is also known as acute laryngotracheitis or acute laryngotracheobronchitis  Is a viral upper respiratory tract infection which results in oedema and mucosal inflammation anywhere between the nose and trachea caused by parainfluenza virus  Commonly affect children aged 6 months to 3 years – peak incidence is 2 years  Male to female ratio 1.43/1.73:1  More common in Autumn and Spring seasons Croup  Presentation: 1-to-4-day history of cough, progressing to “barking” cough, symptoms typically worse at night and agitation, Increased work of breathing, hoarse voice, stridor, low grade fever  On examination: stridor, respiratory distress, exclude red flags of respiratory distress Management:  Give controlled supplementary oxygen to all children with symptoms of severe illness or impending respiratory failure.  Administer a dose of oral dexamethasone (0.15 mg/kg)/inhaled budesonide (2 mg nebulised as a single dose)/intramuscular dexamethasone (0.6 mg/kg as a single dose) are possible alternatives.  Emergency: Nebulised adrenaline, high-flow oxygen, contact anaesthetist if airway concerns Croup  CKS guidelines: Mild — seal-like barking cough but no stridor or sternal/intercostal recession at rest. Moderate — seal-like barking cough with stridor and sternal recession at rest; no (or little) agitation or lethargy. Severe — seal-like barking cough with stridor and sternal/intercostal recession associated with agitation or lethargy. Impending respiratory failure — minimal barking cough, stridor may become harder to hear. Increasing upper airway obstruction, sternal/intercostal recession, asynchronous chest wall and abdominal movement, fatigue, pallor or cyanosis, decreased level of consciousness or tachycardia. The degree of chest wall recession may diminish with the onset of respiratory failure as the child tires. A respiratory rate of over 70 breaths/minute is also indicative of severe respiratory distress. Whooping cough:  Upper respiratory tract infection caused by Bordetella Pertussis (gram negative bacteria)  Vaccines against pertussis are given at 2, 3 and 4 months of age, with a booster at 3 years and 4 months  Clinical features: the catarrhal phase, lasts 1 to 2 weeks and produces symptoms including:  Rhinitis  Conjunctivitis  Irritability  Sore throat  Low-grade fever  Dry cough Whooping cough:   The paroxysmal phase usually lasts 1–6 weeks but can last up to 10 weeks:  rapid, violent, and uncontrolled coughing fits (paroxysms) due to difficulty expelling thick mucus from the tracheobronchial tree producing the “whoop” sound  Frequent at night  triggered by external stimuli, such as cold or noise.  associated with post-tussive vomiting and may be severe enough to cause cyanosis in children.  Apnoea  Neurological complications  Fever absent or minimal The convalescent phase usually lasts 2–3 weeks, during which there is a gradual improvement in cough frequency and severity. Whooping cough  Management: Arrange hospital admission for people with significant breathing difficulties or significant complications  If admission is not necessary and the onset of the cough is within the previous 21 days, prescribe antibiotic treatment. Prescribe a macrolide first line, or co-trimoxazole.  Even with treatment may take several weeks to completely resolve  That exclusion from nursery, school, or work is required for suspected and confirmed cases of whooping cough until completed 48 hours of appropriate antibiotic treatment, or for 21 days from the onset of symptoms if not treated. Extra resources: https://cks.nice.org.uk/topics/feverish-children-riskassessment-management/ Hand, foot and mouth disease  Acute viral illness characterized by vesicular eruptions in the mouth and papulovesicular lesions of the distal limbs with low-grade fever  Caused mainly by Coxsackie A16 and Enterovirus 71  Most common in children under the ages of 10  Conservative management: analgesia , antipyretics, adequate nutrition and hydration  Does not require school exclusion Image courtesy: DermNetNZ https://dermnetnz.org/images/hand-foot-and-mouthdisease-images Impetigo  Impetigo is a superficial bacterial skin infection  Caused by either Staphylcoccus aureus or Streptococcus pyogenes  Bullous or Non-bullous:  Non-bullous - 'golden', crusted skin lesions  Bullous - fluid filled vesicles to form on the skin, which burst to form the golden crust (staph, aureus) Impetigo  Severe infections: staphylococcus scalded skin syndrome. very contagious and therefore school exclusion is required until lesions are crusted and healed or 48 hours after commencing antibiotic treatment Management:  limited, localised disease – NICE Clinical Knowledge Summaries now recommend hydrogen peroxide 1% cream for 'people who are not systemically unwell or at a high risk of complications’  Extensive disease: oral flucloxacillin or erythromycin  Bullous Impetigo – oral antibiotics first-line Impetigo Image courtesy: BMJ Best Practice https://bestpractice.bmj.com/topics/en-gb/476 Image courtesy: DermNetNZ https://dermnetnz.org/topics/impetigo Viral Xanthemas  Measles  Scarlet Fever  Rubella  Dukes’ Disease  Parvovirus B19  Roseola Infantum Measles  Caused by measles virus  Symptoms start 10 – 12 days after exposure  Fever greater than 38.3 associated with at least one of coryza and conjunctivitis or cough  Koplik spots – greyish/blue-white spots on buccal mucosa ( pathognomic)  Rash starts on face, noted behind the ears. Then spreads to the rest of the body.  Macular rash with flat lesions  Self-resolving after 7 – 10 days  Notifiable disease  Children should be isolated until 4 days after their symptoms resolve Measles Image courtesy: DermNetNZ https://dermnetnz.org/topics/measles-images Image courtesy: BMJ Best Practice https://bestpractice.bmj.com/topics/en-gb/217/history-exam Scarlet Fever  Is an exotoxin-mediated disease arising Group A Streptococcus, Streptococcus pyogenes  Aerosal or droplet spread  Incubation period 2 – 5 days  Starts with a sore throat, headache, fever, tender cervical lymphadenopathy and malaise, sometimes abdominal pain (children)  This followed by a red-pink, blotchy, macular rash with rough “sandpaper” skin. Starts on the Trunk and spreads outwards. Patients can have red, flushed cheeks  Other features: strawberry tongue, pharyngitis, circumoral pallor, desquamation of hands, feet and groin  Treatment is with Phenoxymethylpenicillin (Penicillin V) for 10 days  Notifiable disease  Children should be kept off school until 24 hours after starting antibiotics Scarlet Fever Image Courtesy: BMJ Best Practice https://bestpractice.bmj.com/topics/en-gb/3000301 Rubella  Caused by Rubella virus  Highly contagious and spread by respiratory droplets  Incubation period 2 weeks, starts with associated with mild fever, joint pain, and sore throat, often enlarged lymph nodes behind ears and back of the neck. Followed by milder erythematous macular rash, which starts on the face and spreads to the rest of the body, lasting 3 days.  Forschheimer spots are sometimes seen - these are pin-point red macules and petechiae, which may be seen on the soft palate and uvula during the rash phase.  Supportive management  Notifiable disease  Children should stay off school for at least 5 days after the rash appears and should avoid pregnant women Rubella Image courtesy: BMJ Best Practice https://bestpractice.bmj. com/topics/en-gb/1167 Duke’s disease  Most forgotten  Is defined as a non-specific viral rash Parvovirus B19  Also known as fifth disease, slapped cheek syndrome and erythema infectiousum  Caused by Parvovirus B19  Incubation 4 – 14 days, can be as long as 21 days  Characterised by mild fever, coryza and non-specific viral symptoms. After 2 – 5 days they develop diffuse bright red rash on both cheeks (“slapped cheeks”). A few days later reticular (net-like) mildly erythematous rash affecting the trunk and limbs which can be raised and itchy.  Self-limiting, usually fades over 1 – 2 weeks Parvovirus B19 Image courtesy: BMJ Best Practice https://bestpractice.bmj.com/topics/en-gb/684 Roseola Infantum  Known as roseola or sixth disease  Caused by HHV-6 and less frequently HHV-7  Incubation period 5 – 1 5 days  Characterised by 3 – 5 days of fever that comes on suddenly and then disappears suddenly, associated with coryzal symptoms, sore throat and swollen lymph nodes. Once the fever settles appears for 1 – 2 days, mild erythematous macular rash across the arms, legs, trunks and face and is not itchy.  Main complication is febrile convulsions Roseola Infantum Image Courtesy: DermNetNZ https://dermnetnz.org/topics/roseola Kawasaki disease  Mucocutaneous lymph node syndrome. It is a systemic, medium-sized vessel vasculitis.  It affects young children, typically under 5 years.  More common in Asian children, particularly Japanese and Korean children.  Key complication is coronary artery aneurysm Characterised by fever that has lasted 5 days or longer usually resistant to antipyretics. Additional features of Kawasaki disease may include Bilateral conjunctival injection without exudate. Other symptoms:   Erythema and cracking of lips, strawberry tongue, or erythema of oral and pharyngeal mucosa.  Oedema and erythema in the hands and feet.  Polymorphous rash.  Cervical lymphadenopathy. Management: High dose aspirin, IV immunoglobulin, echocardiogram to look for coronary artery aneurysms. Surgical Presentations Hirschsprung’s disease  A congenital condition characterised by partial or complete colonic functional obstruction associated with the absence of ganglion cells  Presents in the neonatal period  Signs of abdominal distension, bilious vomiting and failure to pass meconium  Male to female ratio is 4:1  Strongest association with Receptor tyrosine kinase (RET) gene – 10 to 15% associated with Down’s syndrome  Strong family history  Failure to pass faeces leads to dilation of the proximal bowel. The faecal mass can be palpated in the left lower abdomen.  Empty rectal vault noted on PR examination Hirschsprung’s disease  Investigations: plain abdominal radiograph, gold standard is rectal suction biopsy however according to the NICE guidelines should only be carried out if the following are present:  Delayed passage of meconium (more than 48 hours after birth in term babies)  Constipation since first few weeks of life  Chronic abdominal distension plus vomiting  Family history of Hirschsprung’s disease  Faltering growth in addition to any of the previous features.  Initial management: IV antibiotics, NG tube insertion and bowel decompression  Definitive management: resecting the aganglionic section of bowel and connecting the unaffected bowel to the dentate line (or just above the dentate line in the pull-through)  Complications: Hirschsprung associated enterocolitis (HAEC) is the main cause of mortality of patients with Hirschsprung’s disease. Biliary Atresia  Biliary atresia is a rare, congenital condition that affects the biliary tree. It is characterised by progressive inflammation and fibrosis of the extrahepatic ducts leading to cholestasis, liver damage and failure.  Presents shortly after birth with significant jaundice due to high conjugated bilirubin levels, pale stools, or hepatomegaly.  The initial investigation for possible biliary atresia is conjugated and unconjugated bilirubin which should reveal a high proportion of conjugated bilirubin  Management – surgical Intussusception  Intussusception is the movement or ‘telescoping’ of one part of the bowel into another, most commonly around the ileo-caecal region  Affects infants between 6-18 months old  Male to female – 2:1  Risk factors: Meckel diverticulum (most common) Polyps Henoch-Schönlein purpura Lymphoma and other tumors Post-operative Intussusception  Features:  intermittent, severe, crampy, progressive abdominal pain  inconsolable crying during paroxysm the infant will characteristically draw their knees up and turn pale  Vomiting  bloodstained stool - 'red-currant jelly' - is a late sign  sausage-shaped mass in the right upper quadrant Intussusception  Investigations:   Abdominal USS Doughnut/target sign on a transverse plane Management:  reduction by air insufflation under radiological control  If this fails, or there are signs of peritonism – surgery Necrotising Enterocolitis  Common neonatal surgical emergency and has significant mortality and morbidity  It is characterised by variable injury to the intestines, ranging from mucosal damage to necrosis and perforation.  Risk factors: Prematurity or very low birth weight (VLBW) Formula feeding Intrauterine growth restriction (IUGR) Polycythaemia Exchange transfusion Hypoxia Necrotising Enterocolitis  Features:  feeding intolerance,  vomiting (may be bile or blood-stained)  abdominal distention  haematochezia.  As symptoms progress abdominal tenderness, abdominal oedema, erythema and palpable bowel loops (due to loop dilation)  Systemic features: apnoea, lethargy, bradycardia and decreased peripheral perfusion Necrotising Enterocolitis  Prophylaxis – antenatal steroids, breast feeding is a protective factors.  Medical management - Withhold oral feeds for 10-14 days and replace with parenteral nutrition, IV antibiotics for 10-14 days based on local protocols and systemic support.  Surgical management Pyloric Stenosis  Pyloric stenosis is characterised by progressive hypertrophy of the pyloric muscle, causing gastric outlet obstruction.  Presented typically in the 2nd to 4th weeks of life  Male to female ratio – 4:1  Risk factors: Male gender, positive family history  Features: 'projectile' vomiting, typically 30 minutes after a feed constipation and dehydration may also be present a palpable mass may be present in the upper abdomen hypochloraemic, hypokalaemic alkalosis due to persistent vomiting Pyloric Stenosis  Investigations: Ultrasound is the imaging modality of choice. An ultrasound of the abdomen will demonstrate hypertrop hy of the pyloric muscle  Management: Ramstedt’s pyloromyotomy Image courtesy: BMJ Best Practice https://bestpractice.bmj.com/topics/en-gb/680 Developmental dysplasia of the Hip  Structural abnormality in the hips caused by abnormal development of the fetal bones during pregnancy. This leads to instability in the hips and a tendency or potential for subluxation or dislocation.  Female to male ratio – 6:1  Risk factors: female sex breech presentation positive family history firstborn children oligohydramnios birth weight > 5 kg congenital calcaneovalgus foot deformity Developmental Dysplasia of the Hip  Screening for DDH: The following infants require a routine ultrasound examination first-degree family history of hip problems in early life breech presentation at or after 36 weeks gestation, irrespective of presentation at birth or mode of delivery multiple pregnancy all infants are screened at both the newborn check and also the six-week baby check using the Barlow and Ortolani tests Physical examination reveals - A physical exam may reveal asymmetric skin folds, extremity shortening, and limited hip abduction. Barlow test: attempts to dislocate an articulated femoral head. Ortolani test: attempts to relocate a dislocated femoral head Developmental Dysplasia of the Hip  Investigations: ultrasound is generally used to confirm the diagnosis if clinically suspected  Management:  Most unstable hips will spontaneously stabilise by 3-6 weeks of age.  Pavlik harness (dynamic flexion-abduction orthosis) in children younger than 4-5 months.  Older children may require surgery Perthes disease  Involves disruption of blood flow to the femoral head, causing avascular necrosis of the bone, affecting the epiphysis distal to the physis  Affects the ages 4 – 8 years  Male to Female Ratio – 5: 1  Features:  Slow onset, pain in the groin or hip  Limp  Stiffness and reduced range of movement  Referred pain to the knee Perthes disease  Investigations:  x-ray: AP lateral and frog lateral views.  early changes include widening of joint space, later changes include decreased femoral head size/flattening  Technetium bone scan  MRI scan Both Images: BMJ Best Practice https://bestpractice.bmj.com/topics/en-gb/751/investigations#7515_default Catterall Classification  The Catterall classification for Legg-Calvé-Perthes disease is based on radiographic appearances and is as follows: Group I: involvement of the anterior epiphysis only Group II: involvement of the anterior epiphysis with a clear sequestrum Group III: only a small part of the epiphysis is not involved Group IV: total head involvement Image courtesy: Radiopedia https://radiopaedia.org/cases/43848 Perthes Disease  Severity varies between patients  Management:  Conservative management in patients with less severe symptoms and younger children < 6 years (crutches, braces, bed rest, analgesia)  Surgical management in patients with severe symptoms and severe deformities as well as children > 6 years Slipped upper femoral epiphysis  Displacement of the femoral head epiphysis postero-inferiorly  Affects ages 8 – 15 years  More common in boys and obese children  Bilateral slip in 20% of cases  Presentation:  Minor trauma that triggers symptoms  Hip, groin, distal thigh or knee pain  Restricted range of hip movement  Painful limp  Restricted movement in the hip  loss of internal rotation of the leg in flexion  Obligatory external rotation on hip flexion is a key examination finding Slipped upper femoral epiphysis   Investigations:  X-ray initial choice of investigation  Technetium bone scan  CT scan  MRI scan Management: Surgery is required to return the femoral head to the correct position and fix it in place to prevent it slipping further. Image courtesty BMJ Best Practice; https://bestpractice.bmj.com/topics/en-gb/757/images-and-videos Extra resources: HTTPS://CKS.NICE.ORG.UK/TOPICS/ACU TE-CHILDHOOD-LIMP/ HTTPS://PHESCREENING.BLOG.GOV.UK/ 2020/01/23/REDUCING-RISK-OF-HIPPROBLEMS-IN-BABIES/ Any Questions? CONTACT: [email protected] References:  https://www.nice.org.uk/guidance/ng9/cha pter/1-Recommendations  https://teachmepaediatrics.com/respiratory/l ower-respiratory-tract/bronchiolitis/  https://bestpractice.bmj.com/topics/e n-gb/682  https://bestpractice.bmj.com/topics/e n-gb/217  https://cks.nice.org.uk/topics/cough/#!scena rio:1  https://cks.nice.org.uk/topics/commoncold/management/management/  https://bestpractice.bmj.com/topics/e n-gb/1167  https://cks.nice.org.uk/topics/croup/#!mana gement   https://teachmepaediatrics.com/respiratory/ upper-respiratory-tract/croup/ https://bestpractice.bmj.com/topics/e n-gb/3000301  https://zerotofinals.com/paediatrics/d ermatology/viralexanthemas/  https://bestpractice.bmj.com/topics/e n-gb/68  https://cks.nice.org.uk/topics/whoopingcough/  https://teachmepaediatrics.com/respiratory/ upper-respiratory-tract/whooping-cough/ References:  https://teachmepaediatrics.com/surgery/ abdominal/intussusception/  https://bestpractice.bmj.com/topics/engb/751  https://bestpractice.bmj.com/topics/engb/679  https://zerotofinals.com/paediatrics/ortho/pert hes/  https://teachmepaediatrics.com/surgery/ abdominal/necrotising-enterocolitis/  https://radiopaedia.org/cases/43848  https://bestpractice.bmj.com/topics/engb/757  https://bestpractice.bmj.com/topics/engb/3000241   https://teachmepaediatrics.com/surgery/ abdominal/pyloric-stenosis/ https://bestpractice.bmj.com/topics/engb/756  https://teachmepaediatrics.com/surgery/abdo minal/hirschsprungs-disease/  https://bestpractice.bmj.com/topics/engb/742  https://bestpractice.bmj.com/topics/engb/739\