common paediatric problems general approach to management
TRANSCRIPT
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