Paediatric Case 1

Question 1

what is An Approach to general paediatrics?

Answer 1

•Holistic multi-system approach essential:

• More than one problem may exist
• More than one system may be involved

•Start with the age

• Guides approach to history taking and examination
• Common pathologies differ
• Conditions manifest differently at different ages

•Consider common differential for the presenting problem

Question 2

what are the Principles of management?

Answer 2

• What is in the child’s best interests?
• Will investigations change your management?
• What do the parents expect?
• Blood tests often not necessary (but sometimes are essential)
• IV Fluids are never “routine” (consider NGT)
• Oral treatments can be effective
• Avoid rectal routes unless essential
• Be guided by the weight and use the BNFc

•Seek help and senior guidance

Question 3

Case 1:

• Baby 1 (3m, Vomiting and unsettled): “He weighs 11lbs, he usually takes a 7oz feed 6 times per day, he always seems hungry and unsettled after his feed. What should we do?”
• What does he weigh?
• What are his feed volumes? (per feed)
• What are his feed volumes? (per kilo per day)
• What advice should you give the parents?

Answer 3

• Baby 1 (3m, Vomiting and unsettled):
• He weighs ~5kg
• He usually takes ~210ml feed 6 times per day
• 1260ml/day =~250ml/kg/day
• Advise reducing to 120-140ml (4-5oz) per feed (~155ml/kg/day)

Avoid term overfeeding as often not well received

Question 4

Case 2:

• Baby 2 (6m Bronchiolitis and feeding concerns): “She weighs 151/2lbs, she usually takes a 10oz feed 5 times per day, she has just been taking 4oz every 3 hours. What should we do?”
• What does she weigh?
• What are her usual feed volumes? (per feed)
• What are her usual feed volumes? (kg/day)
• What are her current feed volumes? (per feed)
• What are her current feed volumes? (kg/day)
• What advice should you give the parents?

Answer 4

• She weighs ~7kg
• She usually takes 300ml 5 times per day
• =~1500ml/ day = ~215 ml/kg
• Currently taking 120ml every 3 hours
• =~960ml/day ~130ml/kg/day
• Reassure this is okay over the next few days
• Seek review if feed volume dropping further
• Could consider reducing usual feed to 600-700ml/day once recovered (~5-6oz x4- she is likely to be weaning)

Question 5

Know your units….. (Weight) - what are they?

Answer 5

• What units do we measure a child’s weight in? - Kilograms (kg) and grams (g)
• What units do parents want the weight in? - Pounds (lb.) and ounces (oz.)
• What is a pound? - ~0.4536kg/ 453.6g
• What is an ounce? - 1/16th of a pound (i.e. 28.35g)

Question 6

Know your units….. (Feeding) - what are they?

Answer 6

• What do we measure feed volumes in? - Millilitres (ml)
• What do parents measure feed volumes in? - Ounces (fl. oz)
• What is an ounce? - 28.4 ml (29.6ml in US), 1/20th of a pint (568 ml)

Question 7

Case 3:

• A 10 week old boy presents with 4 weeks of frequent post feed effortless vomits and distress (back arching and pulling up knees)
• Examination showed a soft abdomen with no palpable masses
• Diagnosis and differential?
• Other questions to ask?
• Management and investigations?

Answer 7

•Diagnosis and differential:

Gastro-oesophageal reflux (GORD) +/- Milk intolerance

Consider pyloric stenosis (if more forceful)

Consider surgical causes if bilious

•Other questions

Vomits: Bilious or not/Volume/Amount/Blood

Feeding: Type/Volume/Frequency/Position

General: Weight gain+ centiles/Development/Cough

Question 8

how do you manage GORD?

Answer 8

Question 9

Case 4:

• 3m old boy, bottle fed, weight gain ~100-120g/w. Has loose stools (4-5/day) and several vomits a day. Older brother had asthma and mum had eczema. HV asking about changing the milk
• Diagnosis?
• Other important questions to ask?
• Investigations?
• Management?
• Which milk would you advise?

(Assuming history/examination normal)

Persistent loose stools and family history of atopy

Answer 9

• Diagnosis - Probable cow’s milk protein allergy/intolerance with reflux
• Other important questions - Bile? Blood in stool? Breathless? Cough? Urine? N Exam?…..
• Investigations - Probably none unless bilious vomits, FTT despite change of milk, markers of other pathology
• Management - Trial of hydrolysed feed (not comfort, lactose free, soya or…), Milk free advice for weaning via Health visitor, May need thickeners/acid suppression

Question 10

How babies show that they are well?

How babies show that they are ill?

Answer 10

History taking at this age is focused towards what the parents/carers will have observed

Some concerns may be markers of pathology in any system, so enquiring around all potentially relevant areas may be required

Question 11

Case 5:

• 4 weeks old otherwise healthy baby. Good weight gain (150g/w), breast fed, presents with streaks of fresh blood in stool for last 7 days. No fever or vomits
• Dad has asthma. Mum has “irritable bowel.”
• General/abdominal examination normal
• Diagnosis and differential?
• Other important questions to ask?
• Management and advice?

Answer 11

what is the difference in presentation of a baby with CMPA and pyloric stenosis – pyloric shorter history, more forceful vomit, vomit right after feed. CMPA is more reflux presentation, unsettled after feed, may bring something up

Question 12

do you outgrow CMPI?

Answer 12

yes

Question 13

how does IgE mediated food allergy present?

Answer 13

Allergy can happen to CMP but not all that common

Some do have a more serious IgE mediated reaction

Question 14

how does non-IgE mediated food allergy present?

Answer 14

Majority of milk protein intolerance is non IgE mediated

This is what most have

Question 15

what is required for a milk free diet?

Answer 15

• Avoid all milk and foods made from milk - eg yoghurt, cheese, custard
• Teach label reading (whey and casein mean milk)
• On-line info from baby food companies
• Milk free diet sheets from dietetics
• Dietetic referral if diet on going - By 12 months

Question 16

what is the milk challenge at home?

Answer 16

• Where initial symptoms were of eczema, poor weight gain, diarrhoea
• Consider around 1 year/or 6 months off milk - 50% achieve tolerance by 1 year,75% by 3 years

–Start with baked milk in biscuit/pancake, then cooked milk in custard, build up over a week, then yogurt, then relax all solids. Finally stop milk substitute

• Give guidance on adequate calcium intake
• Look up iMAP Milk Ladder for further illustration

Question 17

Reflux and milk allergy - what is the relationship between them?

Answer 17

• 16-40% of children with reflux may be milk allergic
• Think about it if:
• No or poor response to anti-reflux medications
• Aversive feeding
• Personal or family history of atopy

•These babies merit trial of milk free diet/hydrolysed feed

Question 18

whats hte process of dealing with CMPI?

Answer 18

Question 19

Case 6:

• A 2 week old baby present with a 2 day history of vomiting all feeds. The parents bring in one of his baby grows. Weight is down 30g
• He is unsettled on examination
• Differential diagnosis?
• Investigations?
• Management?

Answer 19

Bile is green Not yellow! So ask what colour the vomit is!!

Green vomits is a very important question to ask about, when they do vomit bile its usually a marker that something is not right at all

Common for families to say they have a bit of bile in vomit and turns out that is was yellow so wasn’t actually bile

Question 20

Case 6- Bilious Vomiting:

• Should always ring alarm bells
• But remember to check if it is bile!
• Due to intestinal obstruction until proved otherwise
• What are the Causes? (age of child is v important to understand)

Answer 20

Malrotation (few weeks old)

Intussusception (Usually older infants + toddlers)

Ileus (?sepsis) (any age)

Crohn’s disease (unusual in infants) (older child)

Intestinal atresia (in newborn babies only!)

Bile is an emergency

Biliary atresia has nothing to do with bilious vomits, it is to do with jaundice

Pyloric stenosis = non-bilious vomiting

If bile then it cannot be pyloric stenosis as obstruction at end of the stomach so if there is bile then the obstruction is further down the GI tree

Question 21

In bilious vomiting – ___ is critical in knowing what the cause is

Answer 21

age

Question 22

what is the management and investigations for bilious vomiting?

Answer 22

•Management

• Urgent surgical opinion
• IV Access
• IV Fluids
• Nil by mouth
• NG tube

•Investigations

• Abdominal x-ray
• Contrast meal likely to be needed

Question 23

Case 7:

• A 6y old boy presents with 12m of abdominal pain. He passes stools 1/week with occasional blood. He is on the 98th weight centile and 50th height centile.
• Examination shows small soft masses in the LLQ (left lower quadrant)
• Diagnosis?
• Additional features of the history/ examination?
• Management?

Answer 23

• Diagnosis - Constipation +/- impaction (Constipation is a very common topic)
• History
• Stool frequency/consistency/size/pain/blood
• Toilet training and use/Soiling/Withholding
• Diet/appetite/fluids/activity (If significant difference between weight and height then may be an issue in terms of balance of levels of activity)/school routine

•Examination

• Inspect lower spine and anus
• Check lower limb neurology (often can tell by observation)
• Measurements and centile
• No rectal examination

Question 24

what is the Constipation Cycle?

Answer 24

Aim of therapy is to break this

Usually around age of 2 or 3

Important to get a good idea in your head of what is coming out – Bristol stool chart

Question 25

what is the result of constipation?

Answer 25

If treated and emptied rectum, then still likely to have an over stretched rectum and more likely to refill so need to give treatment for longer periods rather than treating an episode then stopping

Question 26

how do you manage constipation?

Answer 26

**•Treat early and effectively!** * Stool softeners/stimulants - Senna, lactulose, movicol - As long and as much as needed (Don’t be aversive around starting laxitvie therapies so get it started and give as much as it is needed) * Increase fluid intake * Fruit, veg and fibre * Reduce milk/sweets * Toilet routine and comfort (positioning important) * Praise and star charts * Watch for “diarrhoea”

Question 27

Case 8: * 2y old boy referred for poor weight gain and loose, pale stools (1 year, 3-4 times/day)+ flatus, miserable. Picky eater, all normal diet, formula fed, tried milk free diet- no benefit * No significant past illness or family history * Examination; Pale, less sub cutaneous fat, muscle wasting, distended abdomen * Diagnosis? * Investigations? * Management?

Answer 27

•Diagnosis - Coeliac disease ## Footnote Tend to present with less obvious symptoms - Affect growth, constipation, fussy about diet •Investigations: - Stool screen (faecal elastase, electrolytes, reducing substances, culture) - FBC, iron status, CRP, Renal, liver, bone profile, Vitamin D status - Coeliac serology - IgA (needs separate biochem sample) - Small bowel biopsy (If screen positive) •Treatment - Gluten free diet with dietitian input

Question 28

what is the process of dealing with someone with FTT?

Answer 28