Paediatrics

363 Pages·2008·9.5 MB·English

by  Shyam Bhakthavalsala

First and second edition authors:
Christine Budd
Mark Gardiner
David Pang
Tim Newson
Contents
Third Edition
Paediatrics
Series editor
Daniel Horton-Szar
BSc (Hons), MBBS (Hons), MRCGP
Northgate Medical Practice
Canterbury
Kent, UK
Faculty advisor
Tim Newson
B Med Sci, BMBS, MRCP (UK), MRCPCH
Consultant Paediatrician
Kent & Canterbury Hospital
Kent, UK
Shyam Bhakthavalsala
MBBS, MRCPCH
Specialist Registrar, William Harvey Hospital, Ashford, Kent, UK
Edinburgh • London • New York • Oxford • Philadelphia • St Louis • Sydney • Toronto 2008
Commissioning Editor Alison Taylor
Development Editor Kim Benson
Project Manager Nancy Arnott
Page design Sarah Russell
Icon illustrations Geo Parkin
Cover design Stewart Larking
Illustration management Merlyn Harvey
© 1999, Mosby International Limited.
© 2004, Elsevier Limited.
© 2008, Elsevier Limited. All rights reserved.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in
any form or by any means, electronic, mechanical, photocopying, recording or otherwise,
without the prior permission of the Publishers. Permissions may be sought directly from
Elsevier’s Health Sciences Rights Department, 1600 John F. Kennedy Boulevard, Suite 1800,
Philadelphia, PA 19103-2899, USA: phone: [phone]; fax: [phone]; or,
e-mail: [email protected]. You may also complete your request on-line via the
Elsevier homepage (http://www.elsevier.com), by selecting ‘Support and contact’ and then
‘Copyright and Permission’.
First edition 1999
Second edition 2004
Third edition 2008
ISBN: 978-0-7234-3462-7
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress
Note
Knowledge and best practice in this fi eld are constantly changing. As new research and
experience broaden our knowledge, changes in practice, treatment and drug therapy may
become necessary or appropriate. Readers are advised to check the most current information
provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of the practitioner, relying on their
own experience and knowledge of the patient, to make diagnoses, to determine dosages and
the best treatment for each individual patient, and to take all appropriate safety precautions. To
the fullest extent of the law, neither the Publisher nor the Authors assumes any liability for any
injury and/or damage to persons or property arising out or related to any use of the material
contained in this book.
The Publisher
Working together to grow
libraries in developing countries
www.elsevier.com | www.bookaid.org | www.sabre.org The
publisher’s
policy is to use
paper manufactured
from sustainable forests
Printed in China
Contents
Preface

This new edition of Crash Course in Paediatrics has kept the same successful
format of previous editions. We have updated chapters with important
developments in paediatrics since the last edition. There is an extended self
assessment section. There has been an adaptation of the hints and tips boxes
which highlight points that can assume great importance in clinical practice, to
hopefully enhance their relevance. This remains a text that emphasizes the
practical aspects of paediatrics and will be invaluable to aid students on paediatric
attachments to clinical areas.
This book has been written for the undergraduate but its format and practical
emphasis means it will be of use for doctors on a paediatric attachment in their
foundation years or at the beginning of their careers in paediatrics either in
hospital or community.
Tim Newson
Shyam Bhakthavalsala
More than a decade has now passed since work began on the fi rst editions of the
Crash Course series, and over four years since the publication of the second
editions. Medicine never stands still, and the work of keeping this series relevant
for today’s students is an ongoing process. These third editions build upon the
success of the preceding books and incorporate a great deal of new and revised
material, keeping the series up to date with the latest medical research and
developments in pharmacology and current best practice.
As always, we listen to feedback from the thousands of students who use Crash
Course and have made further improvements to the layout and structure of the
books. Each chapter now starts with a set of learning objectives, and the self-
assessment sections have been enhanced and brought up to date with modern
exam formats. We have also worked to integrate material on communication
skills and gems of clinical wisdom from practising doctors. This will not only add
to the interest of the text but will reinforce the principles being described.
Despite fully revising the books, we hold fast to the principles on which we fi rst
developed the series: Crash Course will always bring you all the information you
need to revise in compact, manageable volumes that integrate pathology and
therapeutics with best clinical practice. The books still maintain the balance
between clarity and conciseness, and provide suffi cient depth for those aiming at
distinction. The authors are junior doctors who have recent experience of the
exams you are now facing, and the accuracy of the material is checked by senior
clinicians and faculty members from across the UK.
I wish you all the best for your future careers!
Dr Dan Horton-Szar
Series Editor
v
Glossary
Acute epiglottitis life threatening emergency, Chronic lung disease of prematurity Preterm
caused by infection with H. infl uenzae leading infant needing oxygen beyond 36 weeks
to infl ammation of the epiglottis and upper corrected gestation or beyond 28 days of age.
airway obstruction. Congenital adrenal hyperplasia a group of
Acute glomerulonephritis acute infl ammation of disorders caused by a defect in the pathway
the glomeruli leading to fl uid retention, that synthesizes cortisol from cholesterol,
hypertension, haematuria and proteinuria. often presenting with female virilization, salt
wasting and cortisol defi ciency.
Acute otitis media an acute infl ammation of the
middle ear due to a viral or bacterial Craniosynostosis premature fusion of the cranial
infection. sutures.
Croup acute infl ammation of the upper airways
Apnoea of prematurity episodes of apnoea seen
(larynx, trachea and bronchi) most
in preterm infants due to immaturity of the
commonly caused by parainfl uenza virus.
respiratory centre.
Cushing syndrome syndrome caused by
Attention defi cit hyperactivity disorder a
glucocorticoid excess either due to exogenous
condition characterized by lack of attention
replacement or endogenous overproduction,
beyond normal for the child’s age,
characterized by short stature, truncal
hyperactivity and impulsiveness.
obesity, skin striae and hypertension.
Autistic spectrum disorder a range of conditions
Developmental dysplasia of the hip progressive
usually with onset earlier than 3 years,
malformation of the hip joint leading to
characterized by impaired social interaction,
varying degrees of actebular dysplasia and
impaired communication and a restricted
dislocation of the femoral head; previously
pattern of behaviour.
known as congenital dislocation of the hip.
Breath holding attacks episodes characterized
Exomphalos abdominal contents herniate
by a screaming infant or toddler holding
through the umbilical ring, covered in a sac
his/her breath in expiration, goes blue and
formed by the peritoneum and amniotic
limp for a few seconds followed by rapid
membrane.
recovery.
Febrile fi t seizure episode associated with fever in
Bronchiolitis acute infl ammation leading to
a child between 6 months and 6 years of age
narrowing of the bronchioles and lower
in the absence of intracranial infection or
airways, most commonly caused by
any other neurological disorder.
respiratory syncytial virus.
Gastroschisis a developmental defect of the
Caput succedaneum diffuse swelling of the scalp abdomen where whole or part of the bowel
in a neonate that crosses the suture lines, and viscera, without a covering sac, protrude
caused by oedema. through a defect in the abdomen adjacent to
Cephalhaematoma subperiosteal haemorrhage the umbilicus.
into the scalp bones in a neonate, usually Gillick principle a child under 16 years of age can
associated with birth trauma. give consent for a treatment if he or she is of
Cerebral palsy a disorder of motor function due suffi cient understanding to make an
to a non-progressive lesion of the developing informed decision and does not wish the
brain; the manifestations may evolve as the parent to be asked.
child grows, although the lesion itself Global developmental delay a signifi cant delay in
remains the same. two or more developmental domains.
xi
Glossary
Guillain–Barré syndrome acute demyelinating Low birth weight weight less than 2500 g.
polyneuropathy, often following a viral or Muscular dystrophies group of disorders
bacterial infection, typically characterized by characterized by progressive degeneration of
hyporefl exia and an ascending paralysis. muscle in the absence of any storage material.
Haemolytic uraemic syndrome clinical syndrome Necrotizing enterocolitis infl ammation and
caused by verocytotoxin producing E. coli necrosis of the intestine, commonly seen in
O157:H7, resulting in microangiopathic preterm infants and often predisposed by
haemolytic anaemia, thrombocytopenia and early and rapid introduction of formula feeds.
renal failure.
Neonatal encephalopathy a combination of
Haemophilia A X-linked recessive coagulation abnormal consciousness, tone and refl exes,
disorder due to reduced or absent factor respirations, feeding and seizures in the early
VIII. neonatal period due to various reasons, not
Haemophilia B X-linked recessive disorder of necessarily from intrapartum asphyxia.
coagulation caused by defi ciency of factor IX. Neonatal screening this is done by the neonatal
Henoch–Schönlein purpura a multisystem spot blood test, screening for
vasculitis of small blood vessels, affecting phenylketonuria, hypothyroidism, cystic
skin, kidneys, joints and the gastrointestinal fi brosis, MCADD defi ciency and certain
tract. haemolytic anaemias.
Idiopathic thrombocytopenic purpura immune Nephrotic syndrome clinical condition
mediated destruction of platelets leading to characterized by proteinuria,
thrombocytopenia, for which no other cause hypoalbuminaemia and oedema.
is evident. Neural tube defect range of conditions caused by
Inborn errors of metabolism any inherited a failure of fusion of the neural plate,
disorder that results from a defect in the resulting in defects of the vertebra and/or the
normal biochemical pathways. spinal cord.
Infantile colic recurrent episodes of inconsolable Neurodegenerative disease disorders of the
crying of unknown aetiology, often central nervous system characterized by
accompanied by drawing up of the legs, seen delayed development and a loss of acquired
in the fi rst few months of life. skills (developmental regression).
Infantile spasms (West syndrome) a rare kind of Nocturnal enuresis involuntary voiding of urine
epilepsy which has its onset in late infancy during sleep beyond 5 years of age.
and is characterized by myoclonic spasms Otitis media with effusion (OME) persistent fl uid
and a typical EEG (hypsarrhythmia).
in the middle ear due to recurrent middle ear
Irritable hip transient infl ammation of the lining infections or poor Eustachian tube ventilation.
of the hip joint (transient synovitis), usually
Patent ductus arteriosus a vessel connecting the
following a viral infection.
aorta to the left pulmonary vein, that usually
Juvenile idiopathic arthritis arthritis involving closes a few hours after birth.
one or more joints in a child, persisting for
Persistent fetal circulation high pulmonary
more than 6 weeks after excluding other
vascular resistance leading to right to left
causes; previously known as juvenile chronic
shunt across the duct and at the atrial level,
arthritis/juvenile rheumatoid arthritis.
in the absence of any other congenital heart
Kawasaki disease a systemic vasculitis causing defect.
fever, redness of eyes, lymphadenopathy,
Physiological jaundice of the newborn jaundice
mucosal involvement and rash with a
occurring between 2 and 14 days of life, in a
potential for late coronary aneurysms.
term infant characterized by predominantly
Legg–Calve–Perthes disease idiopathic avascular unconjugated hyperbilirubinaemia and a
osteonecrosis of the femoral head seen in total bilirubin less that 350 μmol/L, in the
children between 3 and 12 years of age. absence of other causes.
xii
Glossary
Preterm less than 37 completed weeks’ gestation. Small for gestational age Birth weight less than
10th centile for gestational age.
Pyelonephritis infection of the upper urinary
tract involving the renal pelvis. Still’s disease a systemic variant of
Pyrexia of unknown origin documented juvenile rheumatoid arthritis
protracted fever for more than 7 days without characterized by high fever, typical rash,
a diagnosis despite initial investigations. lymphadenopathy, hepatosplenomegaly and
serositis.
Refl ex anoxic seizures episodes, usually provoked
by pain, where an infant or toddler turns Stridor predominantly inspiratory noise due to
pale and loses consciousness, sometimes narrowing of the extrathoracic airways.
associated with a few jerky movements Tetralogy of Fallot cyanotic congenital heart
followed by rapid recovery. disease characterized by a large VSD,
Respiratory distress syndrome respiratory distress, pulmonary stenosis, overriding of the aorta
usually in a preterm infant, due to surfactant and right ventricular hypertrophy.
defi ciency. Thalassaemia a group of haemolytic anaemias
Retinopathy of prematurity abnormal vascular characterized by defective globin chain
proliferation of the retina occurring in synthesis.
preterm infants in response to various Transient tachypnoea of the newborn a transient
injuries, especially hyperoxia. condition characterized by tachypnoea and
School refusal an unwillingness to attend school, respiratory distress due to delayed
usually due to separation anxiety, stressors reabsorption of lung fl uid.
like bullying or adverse life events; these Transposition of great arteries cyanotic
children usually tend to be good congenital heart disease where the aorta
academically, but oppositional at home. arises from the right ventricle and the
Short stature a height below 0.4th centile for age. pulmonary artery arises from the left
ventricle, usually associated with an ASD,
Slipped upper femoral epiphysis uncommon
VSD or a PDA.
condition characterized by progressive
slippage of the femoral head from the neck at Wheeze predominantly expiratory noise
the epiphysis, most commonly seen in obese due to obstruction of the intrathoracic
teenagers. airways.
xiii
1
Fever or rash
Objectives
At the end of this chapter, you should be able to
• Assess a child with fever.
• Understand the common types of rash in children.
• Identify the warning signs in a child with fever and rash.
• Learn a systematic approach to a child with petechial rash.
• Headache, photophobia and neck pain: suggest
THE FEBRILE CHILD
meningism.
Fever is a common presenting symptom in children Younger children (<2 years of age) might not
and can be a major challenge to paediatricians. Most localize symptoms and fever might be the only
of the causes are due to benign, self-limiting, viral symptom.
infections but skill is needed to distinguish these
Has there been recent foreign travel?
from serious infection (Fig. 1.1). The latter has the
potential to deteriorate rapidly so it is essential that Malaria or typhoid can be overlooked if recent travel
it is identifi ed as early as possible. abroad is not disclosed in the history.
Fever is defi ned as a central temperature of
greater than 38°C. Electronic tympanic membrane Examination
thermometers correlate moderately well with rectal
Is the child systemically unwell?
temperature and are adequate for most practical
purposes. The active, playing and communicative child is
unlikely to have sepsis. However, any ill child must
History
have an assessment of the airway, breathing and
circulation, and of the vital signs. Clues to serious
How long has the child been febrile?
sepsis include (see Fig. 1.7):
A duration of more than a week or two suggests
• Poor peripheral perfusion.
diseases such as tuberculosis (TB), malaria, typhoid
• Persistent tachycardia.
and autoimmune non-infectious disorders.
• Lethargy or irritability.
Are there any localizing symptoms?
An infection in certain systems will advertise itself:
• Cough or coryza: suggest respiratory tract
infection. Assume sepsis in all febrile infants aged
• Vomiting and diarrhoea: suggest gastrointestinal <3 months until proved otherwise.
tract infection, although vomiting alone is
non-specifi c.
• A painful limb: suggests infection of the bones
Are there local signs of infection?
or joints.
• Lower abdominal pain: suggests urine infection Tonsillitis, otitis media, pneumonia, meningitis and
but lobar pneumonia can also present this way. septic arthritis can all be revealed on examination
3
Fever or rash
child, however, they cannot rule out serious
Common causes of a fever
infection.
Minor illnesses Major illnesses
Upper respiratory infection Meningitis
Non-specific viral infections Pneumonia
A seriously ill child might initially have
and rashes
normal blood infl ammatory markers.
Gastroenteritis without Urinary tract infection
dehydration Septicaemia
Fig. 1.1 Common causes of a fever. • Samples for microbiological examination:
blood cultures, urine for microscopy and
culture, throat swab and cerebrospinal fl uid.
Polymerase chain reaction (PCR) is becoming
increasingly useful as it provides high sensitivity
Meningitis and specifi city.
Otitis media • Imaging: a chest X-ray (CXR) should be
Acute tonsillitis considered if there is any suspicion of lower
respiratory tract infection.
Pneumonia • A ‘septic screen’; infants suspected of severe
infection without localizing signs on
examination are investigated with a standard
Urinary tract
battery of investigations before starting
infection
antibiotic therapy. These include: blood culture,
full blood count (FBC), CRP, lumbar puncture,
urine sampling and CXR.
Septic arthritis
Aide-mémoire to identify serious sepsis
ILLNESS—Irritability, Lethargy, Low capillary refi ll,
Neutropenia or neutrophilia, Elevated or low tem-
perature suggests Serious Sepsis.
Management
Fig. 1.2 Fever: important sites of local bacterial infection.
If a benign viral infection is suspected then only
symptomatic therapy is needed. In the very young,
or those who look ill, antibiotics are started before
(Fig. 1.2); a rash might be diagnostic. Look for a
the results of diagnostic testing because quickly
bulging fontanelle in meningitis.
ruling out serious infection is often impossible;
Investigations treatment can be tailored when the results are back.
Treating the fever with antipyretics might reduce
In a well child in whom a confi dent clinical diagno- febrile convulsions.
sis has been possible, no investigation is required.
However, certain investigations are appropriate in Pyrexia of unknown origin (PUO)
any ill febrile child. These include:
The designation PUO should be reserved for a child
• Markers of infl ammation: white cell count with a documented protracted fever (more than 7
(raised or low in overwhelming sepsis), days) and no diagnosis despite initial investigation
differential (neutrophil predominance in (Fig. 1.3). It is frequently misapplied to any child
bacterial infection) and C-reactive protein. presenting with a fever of which the cause is
These are useful if there is uncertainty in not immediately obvious. Most are infectious and
diagnosis or for serial measurement of a septic 40–60% will resolve without diagnosis. Particular
4