Paediatrics and child health 3rd Edition by Mary Rudolf, Tim Lee, Malcolm I Levene ISBN 140519474X 9781405194747

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ISBN 10: 140519474X 
ISBN 13: 9781405194747
Author: Mary Rudolf, Tim Lee, Malcolm I Levene

Paediatrics and child health 3rd Table of contents:

Part 1 About children
CHAPTER 1 Nature and nurture
Physical growth
Growth vs. development
Factors that affect growth (see Box 1.1)
Box 1.1 Factors necessary for normal growth
Growth in infancy
Growth in the preschool and school years
Growth in adolescence
Catch-up growth
Organ growth
Psychomotor development and social interaction
Babyhood and the preschool years
Figure 1.1 Dental development, showing the age at which teeth generally erupt.
Figure 1.2 X-ray of the left wrist taken for bone age. The development of the various bones is assessed, to give an estimate of the child’s skeletal maturity.
School age children
Adolescence
Parenting and parenting skills
Figure 1.3 Styles of parenting: the four styles relate to how responsive parents are to the child and how much they are in charge within the family.
Nutrition
Nutritional requirements in infancy
Water
Energy
Minerals
Figure 1.4 Mother breast-feeding her 6-week-old baby.
Vitamins
Trace elements
Breast-feeding (see Figure 1.4)
Table 1.1 Factors associated with successful breast – feeding
Physiology of lactation
Figure 1.5 Physiology of lactation. PIF, prolactin-inhibiting factor; PRF, prolactin-releasing factor.
Colostrum.
Technique of breast-feeding
Advantages of breast-feeding
Table 1.2 Advantages of breast – feeding
Box 1.2 Ways to encourage successful breast-feeding
Table 1.3 Role of anti-infective agents in breast milk
Contraindications to breast-feeding
Drugs in breast milk
Formula feeds
Table 1.4 Comparisons between breast and formula milk
Additives
Preparation of feeds
Weaning (see Boxes 1.3 and 1.4)
Figure 1.6 Preparation of formula feed.
Box 1.3 Principles of infant nutrition
Box 1.4 The weaning process
Figure 1.7 Mother feeding her 6-month-old baby. She is seated so she can interact with him and pick up on his hunger and fullness cues, ensuring that she does not under-or over-feed him.
Nutrition in the preschool years (see Box 1.5)
Box 1.5 Principles of good nutrition in young children
Nutrition in the school years
Figure 1.8 The Eatwell Plate, showing how a balanced diet is made up of foods from each of the five food groups. © Crown copyright.
Figure 1.9 A family mealtime. Eating regularly together as a family is associated with a broad range of benefits in such areas as social behaviour, language development and academic achievement.
Child care and education
Inequality and social disadvantage
Poverty
Housing
Table 1.5 Morbidity associated with poverty
Homelessness
Family structure
Ethnic minorities and immigrants
CHAPTER 2 Health care and child health promotion
The Healthy Child programme
Table 2.1 The Healthy Child Programme
Professionals involved in child health promotion in the UK
Health visitors
School nurses
Community paediatricians
General practitioners
Parents
Child health records
Parent-held child health records
Other records
Special registers
Detection of medical and developmental problems
Health education and promotion
Baby care
Nutrition (see Chapter 1)
Behavioural problems
Dental care
Passive smoking
Unintentional injury
Health promotion in school
Table 2.2 Strategies for the reduction of injuries in childhood
Screening (see Table 2.1)
Congenital hypothyroidism
Guthrie test for phenylketonuria
Figure 2.1 Neonatal screening blood test for phenylketonuria (Guthrie test) and hypothyroidism.
Other newborn screening tests
Cystic fibrosis.
Haemoglobinopathies (sickle cell disease and thalassaemia).
Medium-chain acyl-coA dehydrogenase deficiency (MCADD).
Eliciting the red reflex using an ophthalmoscope (see also p. 81)
Figure 2.2 Eliciting the red reflex using an ophthalmoscope.
Examination for congenital dislocation of the hips (see also pp. 430–1)
Palpation for testicular descent
Hearing test (oto-acoustic emissions)
Figure 2.3 Palpation for testicular descent.
Later hearing screening
Visual acuity using a Snellen chart
Figure 2.4 Testing visual acuity using a Snellen chart.
Growth and development
Normal growth
Growth monitoring
Common growth problems
Table 2.3 Problems seen in growth monitoring
Developmental evaluation
Immunization
General immunization guidelines
Routine immunizations
Diphtheria
The vaccine.
Tetanus
Table 2.4 Routine childhood immunization programme in the UK
The vaccine.
Pertussis (whooping cough)
The vaccine.
Polio
The vaccine.
Haemophilus influenzae B
The vaccine.
Meningococcus C
The vaccine.
Pneumococcal infection
The vaccine.
Measles
The vaccine.
Mumps
The vaccine.
Rubella (German measles)
The vaccine.
Tuberculosis
Figure 2.5 The Heaf test. In tuberculin-positive individuals six raised papules surrounded by a wheal are seen at 3–10 days.
BCG vaccination.
Cervical cancer
The vaccine.
Safeguarding children
The role of the child health service in safeguarding children
Ethical issues in paediatrics
Sanctity of life
Box 2.1 Principles of medical ethics
Omission vs. commission
Quality of life
Withdrawal of intensive care
Guidelines from the Royal College of Paediatrics and Child Health
Consent and parental rights
Ethical conflicts
CHAPTER 3 Children with long-term medical conditions
Chronic illness
The effect of chronic illness on the child
Table 3.1 Prevalence of chronic conditions in childhood
Table 3.2 Factors affecting a child’s adjustment to a chronic illness
The child and school
The effect of chronic illness on the family
The parents
Siblings
Paediatric care of children with chronic illness
Box 3.1 Key points to address when seeing a child with a chronic condition
Box 3.2 Principles in managing chronic illness
Principles of management (see Box 3.2)
Counselling
Education
Coordination
Genetic issues
Support
School
The child with cancer
Prevalence
Aetiology and pathophysiology
Initial presentation of the child with cancer
Table 3.3 Childhood cancers
Staging
Histology
Goals of management (see Box 3.3)
Box 3.3 Goals in managing cancer
Treatment
Surgery
Radiotherapy
Chemotherapy
Bone marrow transplantation
Management of acute problems and supportive treatment
Management of the effects of cancer and therapy
Metabolic consequences.
Bone marrow suppression.
Immunosuppression.
Nutrition
Symptom management
Emotional support
Monitoring and the management of relapses
Prognosis
Figure 3.1 Late consequences of cancer treatment.
Issues for the family
Issues at school
The child with a disability
How disability presents
Assessment of disability
Table 3.4 Commoner causes of disability among school children
The child development team
Principles of management (see Box 3.4)
Breaking the news
Medical management
Genetic counselling
Figure 3.2 Example of multidisciplinary team, consisting of specialist nurses, dietitian, physiotherapist, psychologist and clerical staff as well as medical staff.
Provision of services
Education
Mainstream and special schools
Table 3.5 The child development team
Box 3.4 Managing a child with a disability
Support
Issues for the family
Issues for the school
Part 2 A paediatric tool kit
CHAPTER 4 History taking and clinical examination
The consultation
How to take a history
Presenting complaint(s).
Previous medical history.
Perinatal history.
Box 4.1 What to ask about when taking a history
Family history.
Figure 4.1 Example of a family tree to illustrate family history.
Social history.
Review of systems.
Box 4.2 Review of systems
Examining the child
Notes, problem lists and plans of action
Hospital notes
An approach to examination
Growth
Weight
Height and length
Figure 4.2 Measurement of length using a frame.
Head (occipitofrontal) circumference (OFC)
Growth standards
Figure 4.3 Measurement of standing height.
Figure 4.4 Measurement of head circumference.
Figure 4.5 UK-WHO growth chart showing a baby’s growth at 28 weeks’ gestation until 1 year, corrected for prematurity. © Child Growth Foundation. New charts for children aged 0–4 years were introduced in the UK in 2009. They are now based on the growth of healthy breast-fed babies.
Figure 4.6 UK-WHO growth chart for children aged 1–4 years.
Figure 4.7 UK 1990 growth chart for children aged up to 20 years.
Plotting a child’s growth (see Box 4.3)
Box 4.3 Principles of plotting a child’s growth
Figure 4.8 UK BMI and waist circumference charts, used for the assessment of obesity. A child whose BMI is above the 98th centile is considered obese, and one with a BMI between the 91st and 98th centile is overweight.
Interpretation of growth charts
General observation
Figure 4.9 Nail bed angle: (a) normal and (b) clubbing.
Table 4.1 Commoner causes of finger clubbing
Cardiovascular examination
Observation
Box 4.4 How to examine the cardiovascular system
Palpation
Pulse
Table 4.2 Range of heart rates in normal children
Praecordium
Figure 4.10 Position to place hand to assess for a parasternal heave.
Figure 4.11 Valve areas: (a) pulmonary, (b) aortic, (c) mitral, (d) tricuspid.
Liver
Figure 4.12 Palpation of the apex beat by the index finger.
Ankle oedema
Capillary refill
Auscultation
Heart sounds
Murmurs (see also p. 192)
Table 4.3 Grading of cardiac murmurs. Grades 1 and 2 are usually innocent, grades 5 and 6 are always significant and grades 3 and 4 are suspect
Figure 4.13 Shape of cardiac murmurs: (a) ejection systolic murmur and (b) pansystolic murmur. 1, 2 denote the first and second heart sounds.
Respiratory system
Table 4.4 Upper limit of normal (above 2 standard deviations from the norm) for systolic blood pressure through childhood
Blood pressure
Key points: The cardiovascular system
Respiratory system
Box 4.5 How to examine the respiratory system
Observation
Respiratory distress
Figure 4.14 Sites of chest recession in a young child with respiratory distress.
Table 4.5 Normal respiratory rate at different ages
Signs of chronic disease
Figure 4.15 Commoner types of chest wall deformity: (a) barrel chest, (b) Harrison’s sulcus, (c) pectus excavatum, and (d) pectus carinatum.
Figure 4.16 Examining the position of the trachea.
Chest asymmetry
Palpation
Mediastinal deviation
Chest expansion
Percussion
Figure 4.17 Assessing chest expansion.
Auscultation
Breath sounds
Added sounds
Absent breath sounds
Tactile vocal fremitus and vocal resonance
Location in the chest
Figure 4.18 How to describe the location of physical signs in the chest.
Key points: The respiratory system
The abdomen
Box 4.6 How to examine the abdomen
Observation
Palpation
Figure 4.19 Palpation for an enlarged liver.
Liver
Spleen
Kidneys
Figure 4.20 Palpation for an enlarged spleen.
Figure 4.21 Bimanual examination for a moderately enlarged spleen.
Other masses
Hernias
Percussion
Ascites
Auscultation
Rectal examination
Location in the abdomen
Key points: The abdomen
Figure 4.22 How to describe the location of physical signs in the abdomen.
Reticuloendothelial system
Box 4.7 How to examine the reticuloendothelial system
General
Neck (see also swellings in the neck, p. 114)
Axillae
Groin
Figure 4.23 The cervical lymph nodes.
Hepatosplenomegaly
Key points: Lymph node enlargement
Genitalia
Observation
Palpation
Transillumination
Neurological examination of children
Box 4.8 How to examine the nervous system in an older child
Observation
Dysmorphic signs
Box 4.9 Interpretation of neurological signs
Abnormal movements
Gait
Gower’s sign
Figure 4.24 A child with hemiplegia. The gait can be exaggerated by asking the child to run.
Figure 4.25 A child with spastic diplegia. The gait is waddling.
Muscle bulk
Posture
Motor examination
Tone
Figure 4.26 Assessment of tone in the lower limbs: (a) assessment of adductor tone and (b) tone assessed at ankle by dorsiflexion/plantarflexion.
Power
Coordination
Reflexes
Sensation
Figure 4.27 Eliciting the ankle jerk in young children. The hammer percusses the examiner’s thumb.
Cerebellar signs and coordination
Tremor
Nystagmus
Nose – finger test
Heel–shin test (see Figure 4.28)
Figure 4.28 Heel – shin test.
Dysdiadochokinesis
Gait
Romberg’s sign
Figure 4.29 Romberg’s test: (a) child standing with feet together and eyes open; (b) same child unbalanced with eyes closed (positive for Romberg’s sign).
Speech
Cranial nerves
Neurological examination in babies
Box 4.10 How to examine the nervous system in a baby
Observation
Palpation
Tone
Figure 4.30 A hypotonic child lying in the frog position.
Figure 4.31 Scissoring of the lower limbs.
Figure 4.32 The popliteal angle.
Reflexes
Deep tendon reflexes
Primitive reflexes
Vision
Figure 4.33 Elicitation of primitive reflexes: (a) Moro reflex, (b) palmar grasp reflex, and (c) asymmetrical tonic neck reflex.
Table 4.6 Age at which primitive reflexes appear and the latest age by which they should have disappeared. Persistence after this time is definitely abnormal
Figure 4.34 The parachute reflex.
Hearing
The musculoskeletal system
Examination of a large joint
Observation
Palpation
Range of movements
Figure 4.35 Detection of scoliosis by asking the child to bend forward.
Scoliosis
The ear, nose and throat
Examination of the ear
Figure 4.36 Position to hold a baby for otoscopic examination.
Examination of the nose
Figure 4.37 Tympanic membrane appearances: (a) normal, (b) otitis media with a bulging drum, and (c) glue ear with a retracted drum.
Figure 4.38 Position for holding a child to examine the throat.
Examination of the throat
The visual system
Box 4.11 How to examine the eye
Visual acuity
Figure 4.39 The eight positions of gaze.
Figure 4.40 ‘Wiggly finger’ test.
Eye movements
Visual fields
Figure 4.41 Cover test to assess a squint.
Reflexes
Fundoscopy
Cover test
Box 4.12 Examination for a squint
CHAPTER 5 Developmental assessment
Figure 5.1 Carrying out a developmental assessment. The most useful tools are small wooden bricks, a ball, a formboard and crayons and paper.
Table 5.1 Milestones that are essential to memorize
Figure 5.2 Key components of a developmental assessment.
Gross motor development
Figure 5.3 Stages in gross motor development.
Figure 5.4 Stages in fine motor development.
Figure 5.5 Stages in speech and language development.
Fine motor development
Speech and language development
Figure 5.6 Stages in social development.
Social skills
Table 5.2 Developmental warning signs
Essential milestones and when to worry
CHAPTER 6 Investigations and their interpretation
Introduction
Full blood count (FBC)
Haemoglobin
Table 6.1 Normal range for the major haematological indices for children of 6 months and older
Mean cell volume
Mean cell haemoglobin
Examples of pathology
Microcytic hypochromic anaemia
Figure 6.1 Flow diagram to show investigation of anaemia.
Table 6.2 Distinction between microcytic anaemia and anaemia resulting from haemolysis or blood loss (normal range)
Figure 6.2 A peripheral blood film in severe iron deficiency anemia. The red blood cells are microcytic and hypochromic with occasional target cells.
Figure 6.3 Peripheral blood film of a child with acute lymphoblastic leukaemia.
Anaemia with reticulocytosis
Increased white cell count (leucocytosis)
Blood chemistry
Table 6.3 Normal ranges for basic clinical chemistry variables
Blood urea and serum creatinine
Sodium
Table 6.4 Causes of hyper- and hyponatraemia
Potassium
Alkaline phosphatase
Blood gases and acid–base balance
Blood pH
PO2
Table 6.5 Normal ranges for acid–base and blood gas measurements
PCO2
Bicarbonate
Table 6.6 Causes of acidosis and alkalosis
Table 6.7 Changes in acid–base and blood gas values according to type of alkalosis or acidosis
Figure 6.4 Flow diagram to guide the interpretation of blood gas results.
A simple approach to interpreting blood gases
Examples of pathology
Dehydration
Diabetic ketoacidosis (p. 278)
Pyloric stenosis (p. 176)
Cerebrospinal fluid
Urinalysis
Observation
Table 6.8 Interpretation of CSF analysis
Figure 6.5 Testing urine using dipsticks.
Dipstick testing
Urinalysis and culture
Examples of pathology
Haematuria
Proteinuria
Table 6.9 Timing and interpretation of dipstick urinalysis
Urinary tract infection
Reading a chest X-ray
Figure 6.6 (a) A normal PA chest X-ray. The thymus gland is seen as a ‘sail-shaped’ shadow (indicated by the arrow); (b) anatomical landmarks of a PA chest X-ray; (c) anatomical landmarks of a lateral chest X-ray.
Figure 6.7 Chest X-ray. (a) PA film showing collapse of right middle lobe with loss of definition of the right heart border; (b) the collapsed right middle lobe is seen as a wedge-shaped shadow on the lateral film.
Box 6.1 Approach to reading a chest X-ray
Examples of pathology (see Figures 6.7 and 6.8)
Collapse and consolidation
Pleural effusion
Figure 6.8 Some commonly seen abnormal features of a chest X-ray film. The arrow represents possible deviation of the heart shadow which occurs with collapse rather than consolidation. (a) Right upper lobe collapse; (b) right middle lobe collapse with loss of the right cardiac outline; (c) left lower lobe collapse; (d) right lower lobe collapse with loss of right diaphragm shadow.
Ultrasound
Figure 6.9 (a) Ultrasound of normal right kidney. (b) Ultrasound of hydronephrotic left kidney, with dilated renal pelvis showing up as echo-poor area: contrast with normal right kidney seen in (a). (c) Contrast study via nephrostomy, showing massive dilation of hydronephrotic renal pelvis and obstructed ureter (same patient as a and b). Images courtesy of Dr Rosemary Arthur.
Figure 6.10 Cranial ultrasound of a preterm neonate, showing a coronal view of dilated lateral ventricles. Intraventricular haemorrhage is visible on the right, with some surrounding venous infarction.
Figure 6.11 Head CT scan showing a severe extradural haematoma on the left with compression of the left lateral ventricle and midline shift towards the right.
CT scan
Figure 6.12 High-resolution CT scan of the lungs, showing bronchiectasis affecting both upper lobes. This child has cystic fibrosis.
MRI scan
Sweat test
Figure 6.13 MRI scan of a normal 6-year-old. On this T2-weighted image, cerebrospinal fluid in the lateral ventricles appears white. The dark grey areas show areas rich in myelin.
Collection of sweat
Figure 6.14 Sagittal T1-weighted MRI scan of a normal 6-year-old. Note the midline structures, including corpus callosum, brainstem and cerebellum. Note that cerebrospinal fluid appears black on T1-weighted images.
Figure 6.15 Sagittal T1-weighted MRI scan showing large white optic glioma, with some darker cystic change within it.
The sweat analysis
Figure 6.16 A sweat test being performed. Pilocarpine is carried into the skin by low-voltage electric current. The sweat is collected by filter paper and analysed for sodium and chloride concentration.
Diagnostic criteria for cystic fibrosis
Genetic testing
Part 3 An approach to problem-based paediatrics
CHAPTER 7 The febrile child
Fever as symptom and sign
Finding your way around. ..
Acute fever
History – must ask!
Box 7.1 Taking the temperature
Physical examination – must check!
Investigations
Table 7.1 Investigations that may be indicated in a child with fever (these are always required in an infant < 8 weeks old)
Managing fever as a symptom
Key points: The child presenting with fever
Clues to the differential diagnosis of acute fever in children
Fever with a rash
Common causes of fever and a rash
History – must ask!
Physical examination – must check!
The rash
General examination
Investigations
Management
Table 7.2 The course of childhood infectious diseases
Clues to diagnosing a febrile illness with a rash
Key points: Fever with a rash
Fever with a swelling in the neck
Causes of fever and a swelling in the neck
History and physical examination – must ask and check!
Investigations (see Table 7.3)
Table 7.3 Investigations which may be indicated for a swelling in the neck
Key points: Fever and swelling in the neck
Pyrexia of unknown origin
Causes of pyrexia of unknown origin
History – must ask!
Physical examination – must check!
Investigations (Table 7.4)
Table 7.4 Investigations and their relevance in pyrexia of unknown origin
Managing the child with a PUO
Key points: Pyrexia of unknown origin
Recurrent infections
Causes of recurrent serious infections
Febrile illnesses
Figure 7.1 Acute tonsillitis in an 8-year-old child presenting with fever and a sore throat.
Upper respiratory tract infection
Tonsillitis
Otitis media
Figure 7.2 Bulging tympanic membrane seen on otoscopy of a child with otitis media. Note the inflammation and loss of landmarks.
Secretory otitis media and glue ear
Non-specific viral infections
Cervical adenitis
Infectious mononucleosis (glandular fever)
Mumps
Figure 7.3 An 11-year-old child with mumps. Note the swelling of the parotid gland obscuring the angle of the jaw. CDC/Patricia Smith; Barbara Rice.
Mastoiditis
Measles
Figure 7.4 (a) A 2-year-old child with measles, demonstrating the typical maculopapular rash, conjunctivitis and miserable appearance. (b) Koplik spots.
Rubella (German measles)
Figure 7.5 Rubella. A 10-year-old girl with rubella – small pink macules shown on the back.
Roseola
Scarlet fever
Figure 7.6 Scarlet fever. Note the fine punctate maculopapular rash and perioral pallor.
Fifth disease (erythema infectiosum)
Chicken pox (varicella)
Figure 7.7 Fifth disease. Note the ‘slapped cheek’ rash in a well looking child.
Figure 7.8 Chicken pox. Note the characteristic vesicular rash at various stages of development, although few have reached the pustular or crusted stage.
Hand, foot and mouth disease
Meningococcal septicaemia
Figure 7.9 A temperature chart showing swings suggestive of septicaemia.
Box 7.2 Managing the child with meningococcal septicaemia
Figure 7.10 Meningococcaemia. Note the typical purpuric lesions that do not blanch under pressure.
HIV infection and AIDS
CHAPTER 8 Respiratory disorders
Respiratory symptoms and signs
Finding your way around. ..
Cough
Causes of cough by age
Evidence of serious chronic lower respiratory tract disease in children
History – must ask!
Table 8.1 Characteristics of coughs
Physical examination – must check!
Investigations (see Table 8.2)
Table 8.2 Investigations and their relevance in a coughing child
Managing cough as a symptom
Key points: A coughing child
Clues to the differential diagnosis of the coughing child
Wheezing
Commoner causes of wheezing
Figure 8.1 Intrinsic and extrinsic factors causing wheeze in childhood.
History – must ask!
Physical examination – must check!
Investigations
Managing wheezing
Key points: The wheezing child
Clues to the differential diagnosis of wheezing in children
Stridor
Causes of stridor
History – must ask!
Physical examination – must check!
Investigations
Managing stridor
Key points: The child with stridor
Clues to the differential diagnosis of stridor
Chest pain
Causes of chest pain
History – must ask!
Physical examination – must check!
Investigations
Managing chest pain
Respiratory disorders
Asthma
Definition and pathophysiology
Prevalence
Initial presentation of asthma
Diagnosis in infancy
Diagnosis in childhood
Allergy testing
Management of asthma
Box 8.1 Goals in managing asthma
Medication
Box 8.2 Management of asthma
Spacer device
Table 8.3 The medical management of asthma in children *
Table 8.4 Delivery of medication for asthma at different ages
Figure 8.2 Child using a spacer device.
Dry powder systems (Figure 8.3)
Figure 8.3 Metered dose inhaler, a dry powder Accuhaler, and dry powder Turbohaler.
Breath-activated metered dose inhaler
Nebulizer
Management of an acute attack
Figure 8.4 (a) Child using a nebulizer. (b) A nebulizer device.
Environmental control
Monitoring the condition
Figure 8.5 Child using a simple meter to measure peak flow rate.
Peak flow monitoring (Figure 8.5)
Figure 8.6 Peak flow chart: how exercise can affect peak flow. (a) The peak flow rate must be related to the child’s height to interpret whether it is low. (b) Fall in peak flow rate with exercise in an asthmatic child. Peak flow rate recovers on administration of salbutamol.
The diary
Routine follow-up of the child with asthma
Checklist for review of a child with asthma
Figure 8.7 Diary kept by a 9-year-old boy showing good control of his asthma until day 6 and 7.
Issues for the family
Education
Psychosocial
Issues at school
Prognosis
Cystic fibrosis
Prevalence and pathophysiology
Initial presentation of the child with cystic fibrosis
Clinical features of cystic fibrosis
Respiratory tract
Figure 8.8 A boy severely affected by Cystic fibrosis, with barrel chest and reduced muscle mass.
Intestinal tract
Management of the child with cystic fibrosis
Figure 8.9 Chest X-ray of a boy with Cystic fibrosis. There is gross overinflation of the lungs with hilar enlargement and ring shadows caused by bronchial wall thickening and bronchiectatic change.
Respiratory tract
Malabsorption and diet
Figure 8.10 High-resolution chest CT scan image of a child with severe bronchiectasis caused by cystic fibrosis.
Prognosis
Pneumonia
Table 8.5 The commoner organisms causing pneumonia
Figure 8.11 (a,i) Chest X-ray of a boy presenting with fever and cough. Consolidation of the right upper and middle lobes are seen. (a,ii) The lateral film shows the consolidation clearly delineated posteriorly by the oblique fissure. (b) X-ray of a child with viral pneumonia. Diffuse shadowing is seen throughout the lung fields.
Bronchiolitis
Figure 8.12 Chest X-ray of an 8-week-old baby with bronchiolitis. The X-ray shows gross overinflation of the lungs, clearly seen by the level of the diaphragm and the intercostal spaces. There is also some bronchial wall thickening.
Aspirated foreign body (see also p. 377)
Figure 8.13 X-ray of a child admitted with fever and cough which failed to respond to treatment. At bronchoscopy a Dinky car steering wheel was found in the right intermediate bronchus. The chest X-ray shows collapse of the right middle and lower lobe with loss of definition of the right hemidiaphragm and right heart border.
Croup (acute laryngotracheobronchitis)
Acute epiglottitis
CHAPTER 9 Gastrointestinal disorders
Gastrointestinal symptoms and signs
Finding your way around. ..
Vomiting
Common causes of vomiting
Worrying features in a vomiting child
History – must ask!
Physical examination – must check!
Figure 9.1 Palpation of the abdomen for pyloric stenosis.
Investigations
Management of the vomiting
Key points: The vomiting child
Acute diarrhoea
Causes of acute diarrhoea
History – must ask!
Physical examination – must check!
Investigations
Managing acute diarrhoea
Fluids
Use of antiemetics and antidiarrhoeal agents
Key points: Acute diarrhoea
Table 9.1 Investigations to be considered in acute diarrhoea
Clues to the differential diagnosis of acute diarrhoea
Chronic diarrhoea
Common causes of chronic or recurrent diarrhoea
Table 9.2 Normal stool patterns
History – must ask!
Physical examination – must check!
Laboratory investigations (Table 9.3)
Malabsorption
Inflammation
Infection
Managing diarrhoea as a symptom
Table 9.3 Laboratory investigations in the assessment of chronic diarrhoea
Key points: Chronic diarrhoea
Clues to the differential diagnosis of chronic diarrhoea
Recurrent abdominal pain
The more common causes of recurrent abdominal pain
History – must ask!
Table 9.4 Features differentiating organic and non-organic causes of abdominal pain
Physical examination – must check!
Investigations (Table 9.5)
Table 9.5 Useful investigations in assessing the child with recurrent abdominal pain
Managing abdominal pain
Key points: Recurrent abdominal pain
Box 9.1 Managing the child with non-organic recurrent pain
Clues to the diagnosis of recurrent abdominal pain
Acute abdominal pain
Commoner causes of acute abdominal pain in children
History – must ask!
Physical examination – must check!
Investigations
Managing acute abdominal pain
Table 9.6 Basic investigations in children with acute abdominal pain and their significance
Key points: Abdominal pain
Clues to the diagnosis of acute abdominal pain
Constipation
Causes of constipation
History – must ask!
Physical examination – must check!
Investigations
Key points: Constipation
Figure 9.2 X-ray of the abdomen of a 12-year-old boy with chronic constipation. The rectum and sigmoid colon are grossly distended by faeces, as indicated by the arrows.
Blood in the stool
Causes of blood in the stool
History – must ask!
Physical examination – must check!
Investigations
The commoner causes of jaundice in childhood
Figure 9.3 Bilirubin metabolism.
Jaundice
History – must ask!
Physical examination – must check!
Investigations
Key points: Jaundice
Table 9.7 Basic investigations indicated for the child with jaundice
Clues to the differential diagnosis of jaundice
Gastrointestinal disorders
Dental caries
Figure 9.4 Severe dental caries in a 2-year-old child who was given milk and juice by propping the bottle in the cot during night feeds.
Gastro-oesophageal reflux
Pyloric stenosis
Figure 9.5 Ultrasound of a baby with pyloric stenosis. Arrows indicate the elongated pyloric canal (thick arrow) and thickened pyloric muscle (thinner arrow).
Colic
Viral gastroenteritis
Bacterial gastroenteritis
Toddler diarrhoea
Lactose intolerance
Coeliac disease (Figure 9.6)
Figure 9.6 A 2-year-old child with coeliac disease, showing marked abdominal distension and wasted buttocks.
Figure 9.7 Histology of a jejunal biopsy taken from a child with coeliac disease, showing atrophy of the villi.
Cow’s milk protein intolerance
Crohn’s disease
Ulcerative colitis
Idiopathic recurrent abdominal pain
Irritable bowel syndrome
Peptic ulcer
Acute appendicitis
Mesenteric adenitis
Intussusception
Figure 9.8 Air enema of a child with intussusception. (a) The intussusception is clearly demarcated, indenting the colonic lumen (see arrows). (b) Following reduction, air is now seen in the small bowel.
Constipation
Table 9.8 Management of constipation
Box 9.2 Foods that can promote good bowel habits
Figure 9.9 An anal sfisure (at 6 o’ clock) in a child suffering from constipation with rectal bleeding.
Anal fissure
Encopresis and soiling
Viral hepatitis
Hepatic cirrhosis
Parasites
Threadworms (enterobiasis)
Figure 9.10 The sticky-tape test for threadworms.
CHAPTER 10 Cardiac disorders
Cardiac symptoms and signs
Finding your way around …
Heart murmurs
Box 10.1 Common cardiac murmurs
History – must ask!
Physical examination – must check!
Table 10.1 Characteristics of innocent and pathological murmurs
Key points: Cardiac murmurs
Clues to the clinical diagnosis of pathological cardiac murmurs
Investigations
Management of the child with a murmur
Cyanosis
Fainting / syncope
Clues to the differential diagnosis of syncope
Cardiac conditions
Innocent (functional) murmurs
Systolic ejection murmur
Pulmonary flow murmur
Venous hum
Defects causing a left to right shunt
Figure 10.1 Sites of innocent cardiac murmurs.
Atrial septal defect (Figure 10.2)
Figure 10.2 Atrial septal defect: high flow through the pulmonary valve causes a systolic murmur.
Ventricular septal defect (Figure 10.3)
Figure 10.3 Ventricular septal defect: blood flows through the defect to the right side of the heart leading to pulmonary hypertension, cardiomegaly and prominent pulmonary arteries. © British Heart Foundation 2008.
Obstructive lesions
Aortic stenosis (Figure 10.4)
Figure 10.4 Aortic stenosis. The stenosis causes enlargement of the left ventricle and prominence of the ascending aorta. © British Heart Foundation 2008.
Figure 10.5 Coarctation of the aorta. Blood flow to the lower limbs is maintained through a patent ductus arteriosus. © British Heart Foundation 2008.
Coarctation of the aorta (Figure 10.5)
Figure 10.6 Pulmonary stenosis. The right ventricle hypertrophies to overcome the obstruction presented by stenosis of the pulmonary valve. © British Heart Foundation 2008.
Pulmonary stenosis (Figure 10.6)
Figure 10.7 Transposition of the great vessels. The pulmonary artery arises from the left ventricle and the aorta from the right. The open ductus allows mixing of the blood. © British Heart Foundation 2008.
Congenital cyanotic heart disease
Transposition of the great vessels (Figure 10.7)
Fallot’s tetralogy (Figure 10.8)
Figure 10.8 Fallot’s tetralogy. (a) Pulmonary stenosis; (b) ventricular septal defect with shunt; (c) overriding aorta; (d) right ventricular hypertrophy. © British Heart Foundation 2008.
Infective endocarditis
Syncope
CHAPTER 11 Neurological disorders
Neurological symptoms and signs
Finding your way around. ..
Fits, faints and funny turns
Box 11.1 Types of fits, faints and funny turns at different ages
History – must ask!
Physical examination – must check!
Investigations
Key points: Diagnosing fits, faints and funny turns
Clues to the differential diagnosis of fits, faints and funny turns in infants and preschool children
Clues to the differential diagnosis of fits, faints and funny turns in the school-age child
Headaches
Causes of headache
Features of concern in a child with headache
History – must ask!
Physical examination – must check!
Investigations
Managing headaches as a symptom
Key points: Headaches
Clues to diagnosing headaches
Squint (strabismus)
Causes of squint
Physical examination – must check!
Management
Neurological disorders
Meningitis
Table 11.1 Causes of meningitis outside of the neonatal period
Box 11.2 Managing meningitis
Epilepsy
Table 11.2 International League Against Epilepsy (ILAE) classification of seizures
Generalized seizures
Generalized tonic–clonic seizures (GTCS)
Absence seizures
Figure 11.1 EEG of an 8-year-old boy presenting with absence seizures. The EEG during hyperventilation shows 3-Hz spike and wave activity bilaterally.
Myoclonic seizures
Infantile spasms (West syndrome)
Focal seizures
Temporal lobe seizures
Prevalence
Diagnosing epilepsy
Electroencephalography
Radiological investigations
Figure 11.2 EEG of a 10-year-old boy with generalized tonic–clonic seizures.
Box 11.3 Goals in managing epilepsy
Box 11.4 Medical management of epilepsy
Management of epilepsy
Medication
Table 11.3 Seizure type and drug therapy
Other management issues
Table 11.4 Side effects of anticonvulsants
Acute fits
Status epilepticus
Box 11.5 Instructions for the use of rectal diazepam or buccal midazolam
Monitoring the condition
Routine follow-up of a child with epilepsy (see Checklist)
Issues for the family
Education
Checklist for review of a child with epilepsy
Psychosocial
Issues at school
Prognosis
Migraine
Tension headaches
Raised intracranial pressure
Hydrocephalus
Subdural effusions and haematomas
Breath-holding spells
Cyanotic spells
Pallid spells (reflex anoxic seizures)
Night terrors
Benign paroxysmal vertigo
Syncope
Hysterical seizures
Hyperventilation
Tics
Refractive errors and disorders of vision
Myopia
Hypermetropia
Astigmatism
Strabismus (squints)
Paralytic strabismus
Figure 11.3 Disorders of refraction: (a) normal focusing on the retina; (b) the hypermetropic eye focuses the object beyond the retina; and (c) the myopic eye focuses the object too short – the eye is too long.
Non-paralytic strabismus
Figure 11.4 A 6-month-old baby with a convergent squint. Note the asymmetrical corneal light reflex which confirms that the visual axes are not parallel and that this child has a squint rather than simply a wide bridge to the nose.
‘False’ strabismus
Figure 11.5 Pseudosquint or false strabismus. A wide nasal bridge and epicanthic folds give the appearance of a squint, but the corneal light reflex test is normal.
Management
Amblyopia
CHAPTER 12 Development and neurodisability
Developmental concerns
Finding your way around…
Developmental warning signs
Table 12.1 Skills required in developmental paediatrics
Table 12.2 Aetiological factors underlying developmental problems
History – must ask!
Physical examination – must check

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