UNIT 1: LESSON 1

Learning Outcomes:

• Define Paediatrics and child health terminologies.
• Explain concepts and principles in Paediatrics and Child health.
• Take a comprehensive paediatric history.

Meaning of Paediatrics:

• It is a medical specialty that is concerned with the health of infants, children, and adolescents.
• It focuses on their growth and development.
• And aims for children to achieve their full potential as adults.
• Medical specialty focusing on the care of newborn babies, sick babies, and premature babies.
• Neonatology comes from:
• Neo: new
• Natal: birth
• ology: science of

Preterm Birth:

• Baby born before 37 weeks gestation.
• Types of preterm babies:
• AGA (Appropriate for Gestational Age)
• SGA (Small for Gestational Age)
• LGA (Large for Gestational Age)

Birth Weight Categories:

• Very Low Birth Weight (VLBW): Baby weighing 1.5 kg or less.
• Extremely Low Birth Weight: Baby weighing 1 kg or less.
• Incredibly Low Birth Weight: Baby weighing 750 g or less.
• LGA: Birth weight > 90th centile for gestational age.
• SGA: Birth weight < 10th centile for gestational age.

Mortality Rates:

• Infant Mortality Rate: Number of deaths in the first 12 months per 1000 live births.
• Neonatal Mortality Rate: Number of deaths in the first 28 days per 1000 live births.
• Perinatal Mortality Rate: Stillbirths and neonatal deaths up to 7 days per 1000 total births.

Perinatal Mortality:

• Includes all stillbirths & neonatal deaths in the first week of life.
• Any death or abortion > 500 g or death at 24 weeks and more.
• Stillbirth: A baby born after 24 weeks gestation without any signs of life (cardiopulmonary activity).

Normal Newborn:

• Born between 37—41 weeks.
• Weighs 2.5 kg—4 kg.
• Head circumference: 33—37 cm.
• APGAR score: 7—10.
• Length: 50 cm.
• No abnormalities & does not require resuscitation at birth.

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UNIT 1: TOPIC 2: PAEDIATRIC HISTORY

Introduction:

• History-taking is the cornerstone of clinical practice.
• Importance of distilling important information from history.
• Builds clinical skills, attitude towards patients, and knowledge about diseases and disorders.

Starting the Interview:

• Read referral letters and notes before starting the interview.
• Welcome child and parents, address them by name.
• Introduce yourself.
• Determine the relationship of adult to child.
• Establish eye contact and rapport with the family.
• Ensure a welcoming and unthreatening interview room.
• Have toys available for children.

History Taking:

• Start with patient identification data.
• Complain and duration (reason for hospital visit).
• History of presenting illness.

Past Medical and Surgical History:

• Previous illnesses, hospitalizations, operations.
• Allergies, bleeding tendencies, accidents, injuries.
• Past and present medications.

Antenatal History:

• Mother’s health during pregnancy.
• Relevant genetic history, infections during pregnancy.
• Abnormalities detected in antenatal ultrasounds.
• Antenatal profile and results, immunizations.

Natal History:

• Type of labor and delivery.
• Birth weight, duration of labor, APGAR score.
• Neonatal details: respiratory distress, meconium passage, etc.

Nutrition History:

• Breastfeeding, eating patterns, vomiting after feeds.

Developmental Milestones:

• Key developmental milestones.
• Control of neck, sitting, standing, walking, speaking, schooling.

Immunization History:

• KEPI schedule, immunization status.

Personal Social Economic History:

• Family and community details.
• Parental occupation, economic status, housing, etc.

Family History:

• Family illnesses, cause of death of close relatives.

Systemic Review:

• Respiratory, cardiovascular, gastrointestinal, genitourinary, and central nervous system.

Examination:

Approach:

• Obtain child’s cooperation.
• Make friends with the child, be confident but gentle.
• Explain procedures in language children understand.
• Leave unpleasant procedures till last.

Undressing Children:

• Be sensitive to children’s modesty.
• It’s kinder to let parents do the undressing.
• Inspect the area to be examined in stages.

General Examination:

• Initial survey or observations.
• Inspection, palpation, percussion, and auscultation.

Respiratory System Examination:

• Inspection, palpation, percussion, and auscultation.

Cardiovascular System Examination:

• Inspection, palpation, and auscultation.

Per Abdominal Examination:

• Routine examination, acute abdomen, abdominal distension or mass.
• Associated signs in abdominal examinations.

Inspection:

• Abdomen is protuberant in normal toddlers.
• Causes of abdominal distension.
• Fat
• Fluid (ascites – uncommon in children, commonly nephrotic syndrome)
• Faeces (constipation)
• Flatus (malabsorption, intestinal obstruction)
• Fetus (remember this when female child is in puberty)

Occasionally abdominal distension is caused by:

• Grossly enlarged liver and/or spleen.
• Muscle hypotonia.

Causes of Localized Abdominal Distension:

• Upper abdomen: gastric dilatation from pyloric stenosis, hepatosplenomegaly.
• Lower abdomen: distended bladder or masses.

Other signs to be inspected are:

• Dilated veins and abdominal striae.

Abdominal Examination

Inspection

• Inspect for operative scars
• Inspect for peristalsis – from pyloric stenosis, intestinal obstruction
• Inspect buttocks if well rounded or wasted as in malabsorption as in coeliac disease or malnutrition

Palpation

• Use warm hands, explain, relax the child and keep the parent close at hand. Ask if it hurts
• Palpate in systematic fashion – liver, spleen, kidneys, bladder through the four abdominal quadrants
• Ask about any tenderness. Watch the child’s face for any grimacing as you palpate
• NB: a young child may be cooperative if you first start palpating with his hand or putting your hand on top of his

Tenderness

• Is localized in appendicitis, hepatitis, pyelonephritis, generalized mesenteric adenitis, peritonitis
• Guarding: often not impressive on direct palpation in children. However pain on coughing, on moving about, on walking, bumps during a car journey suggests peritoneal irritation.
• Back bent on walking maybe be from psoas inflammation in appendicitis

Hepatomegaly

• Palpate from right iliac fossa
• Locate edge with tips or side of finger
• Edge maybe soft or firm
• One is unable to get above it

Spleenomegaly

• Palpate from left iliac fossa
• Edge is usually soft
• Unable to get above it
• Moves with respiration
• Measure size below costal margin (in cm) in mid clavicular line
• If uncertain whether it palpable or not, use bimanual approach
• A palpable spleen is at least twice its normal size

Causes of Spleenomegaly

• Congenital Infections, Infectious mononucleosis
• Hepatitis, Malaria, Parasitic infections, Haematological, -Sickle cell anemia, Thalassemia

Causes of Hepatomegaly

• Liver disease, Chronic active hepatitis, Portal hypertension, Polycystic disease, Malignancy- Leukemia Lymphoma, Neuroblastoma, Wilms tumor, Hepatocellular carcinoma
• Metabolic – Glycogen and lipid storage disorders, Mucopolysaccharidosis
• Cardiovascular- Heart failure

Kidneys

• Not usually palpable beyond neonatal period unless enlarged or the abdominal muscles are hypotonic
• Palpate by balloting bimanually
• They move on respiration
• One can get above them
• Tenderness implies inflammation

Abdominal masses

• Wilms tumor – these are renal masses, sometimes are visible and does not cross the midline
• Neuroblastoma – these are irregular firm masses, may cross the midline, the child is usually very unwell
• Fecal mass – these are mobile, non-tender, indentable
• Intussusception – child becomes acutely unwell, mass may be palpable and most often in the right quadrant.

Percussion

• Liver – dullness delineate upper and lower border, record the span
• Spleen – dullness delineate the lower border
• Ascites – shifting dullness. Percuss from most resonant spot to most dull point

Auscultation

• Not very useful in routine examination, but important in acute abdomen
• Increased bowel sounds – intestinal obstruction, acute diarrhea
• Reduced or absent bowel sounds – paralytic ileus, peritonitis

Genital Examination

• Check for inguinal hernia or perineal rash
• In males check for:
• The size of the manhood.
• Development of scrotum
• Are the testes palpable? Place one hand on the inguinal area, palpate with the other hand. Record if the testes is descended, retractile or impalpable
• Is there any scrotal swelling (it could either be hernia or hydrocele)
• In females:
• Examine the external genitalia, comment whether it looks normal. Does it look normal? Any evidence of fissure?

Rectal Examination

• This is not part of routine exam
• It is unpleasant and disliked by children
• Its usefulness in acute abdomen (e.g. appendicitis) is debatable in children as they have a thin abdominal wall and so tenderness and masses can be identified on palpation of the abdomen
• If intussusception is suspected, the mass maybe palpable and stools looking like redcurrant jam maybe revealed on rectal exam

CNS – Neurological screen

• Conduct a quick neurological and development overview
• Avoid unnecessary examination
• Adapt it to the child’s age
• Take into account the parent’s account of the developmental milestones
• Watch child draw or write, assess manipulative skills, language, speech, social interactions as appropriate, vision and hearing (are they normal)

In infants

• Assess first by observation…what does one assess?
• Posture and movement of limbs
• When picking child note the muscle tone. The body or limbs may feel normal or floppy or stiff. Head control maybe poor, with abnormal head lag on pulling to sitting
• NB: Most children are neurologically intact and do not require formal neurological examination of reflexes, tone etc.
• Detailed neurological exam is performed only if indicated

Detailed Neurological Exam

Patterns of movement

• Observe walking or running
• Normal walking heel – toe: a toe – heel walking suggests pyramidal tracts (cortico-spinal) dysfunction particularly hemiplegia or diplegia
• A foot drop – suggests superficial peroneal nerve lesion
• A tight tendo achilles as in muscular disorder
• A broad-based gait – immature gait or secondary to cerebellar disorder
• Standing from lying down supine – observe children from 36 months of age will turn prone in order to stand because of poor pelvic muscle fixation. But if beyond this age it suggests neuromuscular weakness (duchennes muscular dystrophy)

Coordination

• Assess this by
• Asking child to build one brick upon another
• Ask child to stretch his arms out straight, close their eyes and observe for tremors or drift
• Finger nose testing (use teddy’s nose to reach out and touch if necessary)
• Rapid alternating movements of hands and fingers
• Touching tip of each finger in turn with thumb
• Ask the child to walk heel-toe, jump and hop

Inspection of Limbs

• Muscle bulk
• Wasting maybe secondary to cerebral palsy, meningomyelocele, or a muscle disorder or from previous poliomyelitis
• Increased bulk of calf muscles may indicate duchennes muscular dystrophy

Muscle Tone

• Best assessed by taking the weight of a whole limb and then bending and extending it around a single joint
• Testing is easiest at the knee and ankle joints. Assess for the range of movement as well as the general feel of it
• Increased tone at adductors and internal rotators of the hips, clonus at the ankles or increased tone on pronation of forearms at rest is due to pyramidal dysfunction
• Scissors of legs in posture of limbs with pronated forearms result from increased tone

Truncal Tone

• In pyramidal tract disorders, the trunk and head tend to arch backwards (extensor posturing)
• In muscle disease and some central brain disorders, trunk maybe hypotonic. Child feels floppy to handle and cannot support the trunk
• Head lag: best tested by pulling the child up by the arms from a supine position

Power

• Difficult to test in babies
• Watch for anti-gravity movements and note motor function
• From 6 months onwards; watch pattern of mobility and gait
• From age 4 years, power can be tested formally

Reflexes

• Test with the child in a relaxed position
• Brisk reflexes may reflect anxiety in the child or due to pyramidal disorder
• Absent reflexes may be due to neuromuscular lesion or within spinal cord or may be due to poor technique
• Plantar responses: equivocal. With overreaction. It’s unpopular in children as it is unpleasant

Sensation

• You test the ability to tickle
• Loss of sensation is likely in meningomyelocele. In this instance do a more detailed sensory testing

Cranial Nerves

• CN 1-These can usually be tested formally from 4 years of age
• No need to test during routine practice. Can be done by recognizing the smell of a hidden mint sweet
• CN 2- Visual acuity: determined according to age. It refers to the clarity of vision, determine the smallest letter they can read. Direct and consensual pupillary response tested to light and accommodation
• CN 3,4,5 – full eye movement through horizontal and vertical planes.
• Check the presence of squint
• Check presence of nystagmus – avoid extreme lateral gaze as it can induce nystagmus in normal children
• CN 6 – clench teeth and waggle jaw from side to side against resistance
• CN 7 – close eyes tight, smile and show teeth
• CN 8 – hearing: ask parents, although unilateral deafness may be missed this way
• CN 9 – levator palate…let them say aagh
• CN 10 – Recurrent laryngeal nerve – listen for hoarseness or stridor
• CN 11 – Trapezius and sternomastoid muscles are responsible for power – shrug shoulders and turn head against resistance
• CN 12 – let them put out tongue and waggle it from side to side

Bones and Joints

• Presentation of bone and joint disorders include
• Limb pain, Unwillingness to use limb, Limb, joint or muscle pain
• Joint swelling, Muscle wasting

Inspection

• Swelling could be due to joint effusion (there will be loss of joint outline)
• Swelling may also be due to synovial thickening (there will be redness, pain on movement)

Palpation

• Palpate for heat, comparing both joints, tenderness, fluctuation or effusion
• Movements – passive before active in order not to hurt the child. Explain movements in child-friendly words. If necessary show with your own limbs the movements you want to test. Record joint movement in degrees
• Scoliosis – inspect spine especially in older children/adolescents. Ask them to stand straight as a soldier and note the shape of the spine

Neck Examination

• Thyroid
• Inspect for swelling, it is uncommon in childhood, occasionally at puberty
• Palpate behind and front for swelling, nodule or thrill
• Auscultate if enlarged
• Look for sign of hypo/hyperthyroidism

Examination of Lymph node

• Examine symmetrically – check the occiput, cervical, inguinal, axillary. Note the size, number and consistency of the nodes felt
• Nodes can be small, discrete, pea-sized, mobile in the neck, groin, and axilla. This is common in normal children especially if thin
• Nodes can be small, multiple nodes in the neck. This is common in URTI which is either viral/bacterial
• Multiple lymph nodes of variable size in child with extensive eczema
• Lymph nodes can be large, hot, tender sometimes fluctuant usually on the neck. This can be due to infection or abscess
• Nodes can be of variable size and shape
• Nodes can be caused by
• Infections e.g. viral (infectious mononucleosis), or bacterial (TB)
• Rare causes e.g. malignancy (usually non-tender), Kawasaki disease, cat scratch

Indications for taking a pressure

• Critically ill child, Child with renal or cardiac disease, Diabetes mellitus, If receiving drugs such as corticosteroids causing hypertension

Technique

• Measured by use of sphygmomanometer
• Show child the balloon in the cuff and demonstrate how it is blown up
• Use a cuff that fits comfortably, covering at least 2/3rds of the upper arm
• The child must be calm, relaxed and not crying
• Systolic pressure is easiest to determine in young children and clinically the most useful
• Diastolic pressure is when the sounds become muffled
• Normal: use the available charts related to age. An abnormally high reading must be repeated, with the child relaxed

Examination of the eye

• Inspect eyes, pupil, iris, and sclera
• Are eye movements full and symmetrical? Is nystagmus detectable? If present, may have cerebellar or ocular cause
• Are pupils equal and central? Is there a squint?

Ophthalmoscopy

• In infants, the red reflex is seen from a distance of 20-30cm, absence of red reflex occurs in corneal clouding, cataract or retinoblastoma

Fundoscopy

• Is difficult to conduct, it requires experience and cooperation from the child. Mydriatics are needed in young children
• Check for the condition of fundi of the eye
• Retinopathy of prematurity
• Retinopathy of congenital infections
• Choroido-retinal haemorrhages
• Retinal haemorrhages maybe seen in the shaken baby syndrome (non-accidental injury)
• Exam usually left till last, as it can be unpleasant

Explain the procedure

• Show the parent how to hold and gently restrain a younger child to ensure success and avoid possible injury

Throat

• Look at the uvula, tonsils, pharynx, and posterior palate
• Older children, 5 years plus will open their mouths wide open as possible to avoid spatula
• Look for redness, swelling pus or palatal petechiae, teeth, dental caries and gross abnormality

Ear

• Examine the ear canals and drums gently, trying not to hurt the child
• Look for anatomical landmarks on the ear drum and for swelling, redness, perforation

, dullness, and fluid.

Topic summary

By the end of this topic you should be able to take a comprehensive pediatric history and perform general and systemic examination. A good history helps establish relevant facts, it is a source of diagnostic information

• It helps elicit all relevant clinical findings,
• It helps collate the findings from the history and examination. It helps formulate a working diagnosis or differential diagnosis on the basis of logical deduction
• It helps to assemble a problem list and management
• At the end of history and examination: Summarize the key problems (in physical, emotional, social and family terms if relevant).
• List the diagnosis and differential diagnoses
• Draw up a management plan to address the problem, both short and long term. This could be reassurance, a period of observation, performing investigations or therapeutic interventions
• Provide an explanation to the parent and child, if old enough provide further written information
• Ensure your notes are well written, dated and signed.