Diagnoses to consider: (not mutually exclusive)
Diaries of input/output, wetting/waking and measuring overnight urine output may be helpful. The expected bladder capacity is (Age + 1)x 30, max 390ml. If night time urine output is substantially greater than this eg 130% of expected, then suggests nocturnal polyuria. Similarly, day time voiding of consistently less than 65% of expected capacity suggests a small bladder. Going 8x a day or more (with a normal fluid intake) is another clue. Quantify daytime wetting - pants only, patch on clothes, or puddle.
Incomplete bladder emptying can be defined as post void residual urine volume of greater than 20 ml, on more than one ultrasound, without excessive bladder distension before hand. See Practical.
So consider instigating:
See ERIC (Childhood continence) website for parent information. Hjalmas, J Urol 2004 International evidence based strategy for nocturnal enuresis. International Children's Continence Society.
International Headache Society 2004 Migraine without aura def:
American Academy of Neurology recommendations are that neuroimaging should be considered in:
Other points:
CurrOpPeds Dec 2004
Paracetamol, ibuprofen, and nasal-spray sumatriptan are all effective symptomatic treatments for episodes of migraine (peds sys rv 2005). Migraleve is paracetamol, codeine (8mg), buclizine - for 10yr plus. Paramax, with metoclopramide, for 12 yr plus.
For prophylaxis, Pizotifen does not work (grade I evidence), flunarizine (CCB) is the most effective but not available in UK, also amitriptyline, propanolol. Encouraging data (grade IV) for topiramate, valproate, levetiracetam, cyproheptadine.
V rare - unilateral, orbital, conjunctival injection, nasal congestion, forehead sweating, agitation. Peak incidence in 20s, Males predominate. Treat with high flow O2! Sumatriptan SC better than nasal, Zolmitriptan is oral. Safe, licensed for kids.
An outdated term, suggesting poor growth as well as poor social and neurological development. Weight faltering is a less judgemental, more specific term but definition? Various criteria possible, all with their own merits and drawbacks:
Measures that do not rely on velocities are useful where you cannot rely on follow up. Measures that do not rely on age are useful in developing countries where children may not be accompanied. But in developed countries, BMI tends to detect children who are tall and slim, and whose parents are tall. Measures depending on low weight miss larger children with abnormal growth velocity. Equally, falling through centiles can just reflect children born relatively big who are regressing to the mean.
Because centile charts are constructed using cross sectional data, they fail to demonstrate the range of normal growth rates. Children who are born small tend to catch up, those who are born large tend to drop down (so called regression to the mean). Those dropping down will be flagged up as falling through centiles. Charlotte Wright's failure to thrive charts try to get round this by building in different centiles that allow for bigger drops at the higher end, so that only the slowest growing 5% drop through 2 centiles (commercially available)(Arch Dis Child 1998;78:40).
Slowest growers (on thrive index) had more feeding probs (slow feeding, weak suck, small quantities/breast refusal but not with mode of feeding) and more developmental delay at 9 months. Not associated with maternal age, education, economic circumstances. Other studies confirm that slow wt gain, esp in first few months of life, affect IQ at school age. Durham cohort, Wright Arch Dis Child 2009:94:549)
Danish infant cohort (14 to 37 weeks of age) - roughly 20% of the population could be considered faltering on one or more criteria. Waterlow detected 1%, crossing major centiles 22%. Nor did they tend to detect the same subgroup: for measures depending on low weight, signficant assocation with low gestational age; for BMI and waterlow, children significantly taller; for crossing centiles, children larger at birth, greater gestational age, and signficantly heavier than babies identified by other criteria. Crossing centiles seems "invalid", as, like low length for age, it has poor sensitivity and PPV (Olsen, Arch Dis Child 2007;92:109-114). Raynor and Rudolf found similarly that different criteria gave very different prevalences, none particularly predicted developmental delay (Arch Dis Child2000;82:364-5).
Just because a child in one setting may become undernourished because he or she is ill or neglected it does not mean all undernourished infants are ill or neglected or that all small infants are undernourished. Equally, just because a small child is not neglected or ill does not mean he or she is necessarily sufficiently nourished or growing normally. Consider underlying medical problems eg Endocrine (esp hypothyroidism), IUGR (often impaired growth later in life), Chromosomal, any chronic disease, coeliac, immunodeficiency.
The perception is still that the majority of children failing to thrive are associated with social deprivation, but population studies show most cases come from "average" homes, even if rates are slightly higher in most (and least) deprived areas. No gradient with parental educational level. Short term only (4/12) effect of maternal depression in Gateshead cohort, other studies conflicting. Most (95%) have no evidence of abuse/neglect. Review of case notes suggests that "constitutionally small" used more often when social class higher; but actually no difference in outcome (Batchelor clinic notes study). Perhaps welfare and cheapness of foods prevents deprivation being a more significant factor. Vulnerability comes from high energy requirements (3x that of adult on per kg basis), low energy density food (milk), dependence on others for food.
So why does it happen in "normal" homes? Probably intrinsically low appetite drive is the main issue (just as other children seem to have intrisically high appetite drive, putting them at risk of obesity), plus minor illnesses, subtle neurodev delay, distracted parents, overpersuading (ie where food is forced on child). Need to destigmatise. HV led care effective. (Arch Dis Child 2007;92:95-96; PMID 17264277)
Need a new term for weight velocity that is below average but not below normal - weight adjustment?
Parents strongly link quality of parenting and sufficiency of nutrition to growth, and experience great anxiety and a sense of diminished worth when their child's growth is below average. But below average is not necessarily abnormal, in that it may not represent undernutrition. Problems are generally due to mismatch of parental/professional concern:
Those who don't ever catch up probably have intrinsically low appetite (cf intrinsically excessive appetite that leads to obesity).
Liquid paraffin used first line in US - contraindicated under 3 yrs in BNF (lipoid pneumonia associated with reflux). No cramps, but can seep (orange) and cause irritation. Use 1 ml/kg at night in addition to bisacodyl, increase every 3 to 5 days up to 30 ml until habit established. Mix with yogurt if taste a problem. Keep in fridge to reduce viscosity.
Radiology scoring for constipation on AXR - poor interobserver correlation but good intraobserver correlation. Useful for intractable?
(Leech, Ped Rad 1999)
Nurse led clinics for constipation - probably better than consultant, certainly not worse. Use bowel diaries...
Hands on Scotland - resources for mental wellbeing issues in children.
youthinmind.co.uk - Strengths and Difficulties Questionnaire online.
Parental mental disorder is associated with mental disorder in the child; quality of parenting and family interaction are the key mediators, rather than genes or environment.
Even stroppy teenagers see relationships with their parents as central to how they feel about themselves. Resilience comes from sense of self-worth and problem solving / dispute resolution skills. Wants vs needs - children who believe their feelings control the world will come a cropper. Ability to identify and express emotions. Being listened to equates with fairness. Clear ground rules, educative discipline.
Children attending OPD have 20% risk of psych disorder esp emotional (double normal). Presumably somatizing and/or lack of resilience. Plus parents more likely to see them as unwell - unable to reassure their kids? Parents of kids with unexplained symptoms are likely to be psycho-averse ie reluctant to accept interrelation of physical and mental problems.
Children who report frequent somatic complaints or who have a functional diagnosis are easily differentiated on emotional-type scores from those who don't, but it's difficult to tell them apart - parental factors?.
Social Science & Medicine Volume 63, Issue 10 , November 2006, Pages 2640-2648
Post Traumatic Stress Disorder occurs in 20-50% of mothers after PICU admission or cancer diagnosis.
Defined as:
Commonly associated with oppositional defiant disorder, obsessiveness, learning difficulties, speech and language disorders.
There is high concordance for monozygotic twins, which supports a genetic cause. There are also MRI/PET lesions, which support a physical cause (cortical abnormalities in the frontal, temporal, and parietal lobes, Lancet 2003). It is 3 times more common in boys. It may be related to traumatic experience in infancy.
There are rating scales eg Conner's ADHD index, which is 94% sensitive.
Examples of inattention:
Examples of hyperactivity/impulsivity:
There should be impairments in at least 2 settings eg school and home.
Methylphenidate, a dopamine agonist, is effective, esp for concentration, hyperkinesis and impulsiveness. Clonidine has been suggested.
Behaviour modification (NOT cognitive behavioural) is effective only when combined with medication.
Hyperactivity tends to improve over time, but there are associated antisocial behaviours and learning difficulties long term.
Associated with ADHD and lower IQ. Toddler egotism clashes with real life, plus communication frustration, modelling, love paradox (parents care but also make rules and punish).
Management:
Managing the tantrum:
Associated with recidivist juvenile delinquency - of whom 90% have history of conduct disorder at 7 yrs. US Perry/High Scope project supported families with 3 yr olds, showed significant benefit at 27 yrs of age in employment, education and income.
Even stroppy teenagers see relationships with their parents as central to how they feel about themselves. Resilience comes from sense of self-worth and problem solving / dispute resolution skills. Wants vs needs - children who believe their feelings control the world will come a cropper. Ability to identify and express emotions. Being listened to equates with fairness. Clear ground rules, educative discipline.
2yr preventive programme targeting disruptive and aggressive behaviour in boys at age 7 found that age 24 there was significantly better high school completion rates (46 vs 32%) and lower criminal record rates (22 vs 33%)
A disorder of social interaction, communication and imagination. Now affects 1 in 225 people: cases have levelled out after peaking in 1992, probably reflects increased awareness, changes in diagnostic criteria.
Autism is one of a range of related conditions, sometimes referred to as autism spectrum disorders of which the most obvious other member is Asperger syndrome.
Can be associated with other neurological disorder eg fragile X, congenital rubella, tuberosclerosis, but these are only 10% or so of all cases.
Epilepsy is associated with autism, which would suggest a neurological cause. Siblings have a 2-6% risk, suggesting a polygenic cause. However, brain scans have not demonstrated any consistent abnormality.
Men, scientists, mathematicians in particular tend to systemize eg maps, calendars, timetables. Asperger himself suggested that the syndrome he described in some ways represented the extreme end of natural male behaviour. Systemizing is a way of trying to understand the world. One way of doing this is repetitive experimentation, until a pattern is discerned. In lower level autism, children never move beyond the experimentation, so that the repeated action seems to offer a level of security, that the world is predictable, and does not change all the time. The disadvantage of trying to systemize the world is that you struggle with things that are unpredictable, especially language, emotion and behaviour. These are entities that are better understood by empathizing, ie recognizing that another being is involved, with their own internal world. Parents of children with autism tend to be high level systemizers. Archives of disease in childhood 2006;91(1):2-5.
Usually around 18 months. In a minority there will be regression, typically from 10 word stage accompanied by social withdrawal, but even here in retrospect development was usually abnormal.
Communication:
Social:
Behaviour:
In most autistic children, most special skills eg manipulation of mechanical objects, music, drawing are delayed, or else one is relatively preserved. In the least affected, who tend to be diagnosed later, one skill may be manifest at an unusually advanced level eg idiot savant, Rain Man.
For screening, Childhood Autism Rating Scale (CARS) is 15 item examination (commercial). CHAT (Checklist for autism in toddlers) is a 5 item examination plus parental rating test, but poor sensitivity; has been modified into 23 item M-CHAT which is much better - freely available and online.
ICD 10 diagnosis has long list of criteria, must show each of social/communication/behaviour impairments, plus abnormal development in at least one from before the age of 3. Cognitive ability (IQ) must be normal, and first 3 years must have been normal for self-help skills, curiosity in environment, and adaptive behaviour.
Plus early onset epilepsy, Rett syndrome, Neurodegenerative disorders, lead poisoning, iron deficiency, hypothyroidism, PKU, Fragile X.
Needs to be individualized. Early and intensive behavioral intervention achieved normal intellectual functioning after 2-3 yrs in half but 30+ hrs per week.
Risperidone for Autism was given conditional approval, on basis of severe aggression only, and establishment of a new registry. The company then withdrew its application. Beware masking inadequate care by indiscriminate mood altering drugs.
What doesn't work:
Other associated problems:
Primary Care: Clinics in Office Practice - Volume 34, Issue 2 (June 2007)
Some parent experiences at:
Common presenting complaint, with wide range of possible causes. But frequently no cause found - probably gut related, but transient motility problem? Same way as some people get headaches, some children seem to get tummy pains. Stress (emotional) may or may not be a factor, but undoubtedly stress can cause physiological effects eg increased cortisol levels, sympathetic tone, and tachycardia, and can affect individual perception of pain.
Family dynamics and individual coping styles influence the way in which children express or even acknowledge pain. In some families, chronic pain is a fact of daily life for one or more members. The way that parents respond to a child's symptoms is likely to influence the ways in which that child understands the experience of pain, and may provide positive attention that may otherwise be lacking.
Non-specific pain is typically periumbilical, unrelated to meals or activities, and does not wake the child from sleep (although symptoms may be reported when lying in bed, which is not the same thing). Bowel habit is normal or else tends towards constipation, weight velocity is normal or excessive, physical examination is normal. Whether or not the pain interferes with normal activities (esp school attendance) is rarely related to the frequency and severity of the episodes, but of course this is a good indicator of the significance of the pain.
Typically:
Consider use of antispasmodics eg hyoscine, mebeverine.
Crohns in particular may be insidious and nonspecific. Abdominal pain may be intermittent, there may not be diarrhoea or bloody stools. Beware lethargy, poor growth and pubertal delay, and extraintestinal manifestations such as mouth ulcers, joint/skin problems, and perianal involvement (often asymptomatic).
Some racial/ethnic groups are predisposed to lactase deficiency, and symptoms may be relate to the amount of lactose consumed. As with other forms of food intolerance, symptoms may include nausea, bloating, loose stools, and cramping abdominal pain. Stool pH and reducing substances are the classic tests, but have poor sensitivity and specificity so may be more sensible to just try dairy-free diet empirically for a few weeks, with or without diary.
A meta-analysis of more than 40 published reports shows weak or no evidence for an association between H pylori infection and RAP. H pylori-associated peptic ulcer disease should be suspected when abdominal pain is primarily epigastric; when it awakens the child from sleep; and when it is associated with anorexia, nausea, recurrent vomiting, anemia, or gastrointestinal bleeding.
Real diagnosis? Usually recognized when episodes of paroxysmal abdominal pain occur in association with nausea and vomiting, with complete recovery between episodes and sometimes with associated headache. A strong family history of migraine lends credibility to the diagnosis.
Yersinia enterocolitica and Giardia can cause enteritis that mimics IBD, albeit usually associated with diarrhea.
In postpubertal females, consider early menarche, endometriosis, pelvic inflammatory disease, and ovarian cyst.
Always consider.
Interference with the child's activities and school absence. Family function, school performance, and manifestations of anxiety, depression, or social maladjustment. Beware:
The perianal area should be examined carefully for fissures, skin tags, or signs of sexual abuse. Although a rectal examination may be appropriate, it is highly upsetting to many children and should not be performed routinely.
An AXR can be valuable in defining the presence of significant constipation, especially when suspicion is high but the history is sketchy and results of the physical examination are inconclusive. USS abdo is an appropriate investigation when the pain is lateralized, when there are abnormalities on urinalysis, or when the pain localizes to the lower quadrants in a female of any age.
FBC, LFTs, ESR
Breath test for H pylori, not serology.
Many parents will assume that "nonphysical" pain implies that the child is "faking it." Compare the abdominal pain with headache in adults: rarely any abnormal physical findings or investigations, the pain is undoubtedly real and not imagined. Concept of visceral hypersensitivity is useful. The parents need to maintain a sympathetic attitude that acknowledges the pain but encourages continued activities and school attendance to the greatest degree possible. It is important to point out that young children are highly suggestible, and parents should refrain from questioning the child about the pain if the child is not complaining. Consider increasing dietary fibre (one RCT).
Consider mental health professionals if clear markers of a psychogenic origin, with repeated interference with school attendance and other activities. Pain team may be helpful.
In Apley's classic follow-up study (1973), more than one third of former RAP patients continued to complain of abdominal pain 1 to 2 decades later. Fewer than 5% of the follow-up sample were identified as having an organic cause for their pain. Walker et al (1995 and 1998) found patients 5 to 6 years after initial evaluation reported significantly higher levels of abdominal pain and other somatic symptoms, averaged twice as many absences from work or school, and made significantly more mental health visits during the intervening years than the well patients.
Prolonged illness characterised by disabling fatigue, musculoskeletal pain, neurocognitive difficulties, and mood disturbance - in an adult sample (n=253) with EBV, Q fever or Ross River virus (Australia) 11% met the diagnostic criteria for chronic fatigue syndrome at 6 months, stereotyped and developing at a similar incidence after each infection; predicted largely by the severity of the acute illness rather than by demographic, psychological, or microbiological factors. Suggests a genuine clinical entity. BMJ. 2006 Sep 16;333(7568):575. Epub 2006 Sep 1.
RCPCH guidelines 2004 - little evidence, but at least consensus statements.
McArdle's disease: autosomal recessive, abnormal accumulation of glycogen in muscles due to phosphorylase B deficiency. Symptoms are muscular pain, fatigability, and muscle cramping following exercise. May develop myoglobinuria after severe cramps. Lactate does not rise.
Differential - anorexia, drugs, abuse, sleep obstruction. McArdle's disease?
NICE guideline CG53 similarly, but no viral serology without history. In child, diagnosis made after 3/12 of symptoms. CBT and graded exercise therapy recommended for mild- mod disease. No evidence in severe. In a survey, half of patients found such therapy harmful, though a later survey attributed this to inappropriate advice or lack of therapeutic support. Recognises that little research exists on CFS generally, specifically on causes and diagnosis.
GOS out patient programme for chronic fatigue syndrome led to 43% having complete resolution of CFS/ME (by 24 months) compared to only 4.5% of those having supportive care alone. The presence of depressed mood and family beliefs about the aetiology of CFS/ME were not significantly associated with outcomes. (ArchDisChild 2004;89)
DCD is a debated diagnosis. Co-exists often with ADHS, speech/language impairment. Four criteria for DCD in DSM IV for analysis of the appropriateness of referrals. These are:
Specific growth charts available. Surveillance advice from DSMIG.
Psychological debriefing is a technique used to try to mitigate long term consequences of exposure to critical incident stress such as the death of a child. The value of psychological debriefing has been questioned in a recent Cochrane review and is currently not recommended for healthcare professionals, as it may increase the risk of post-traumatic stress disorder.
Squint is associated with maternal smoking in 3rd trim! It also goes with late crawling but which comes first?! Or are both just manifestations of delayed development?
Myopia increases with age - inversely associated with TV watching, positively associated with computer use! Presumably staring from a fixed distance is the worst thing you can do. But not all environmental - very heritable in twin studies.
Issues to do with moving from paediatric to adult clinic:
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