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.
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
Acetaminophen, 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.
20% of normal 2yr olds perceived by their parents as problem eaters esp fussy, poor appetite! Consider:
If growth normal, then they must be a secret eater! Red book useful for seeing trends.
Key is engagement with the family, with everyone presenting a united front. Examine personality & parental response. Reduce parental anxiety! Reassurance, identify trigger, explain difficulty. Frequent introduction of new foods, crumb size! Repeat at least 15-20x before giving up! Smaller portions!! Mealtimes should be limited to 20-30 min, minimal fuss. Use behavioural management (rules, rewards, encourage autonomy). Involve child in planning/preparation. BDA do useful leaflets.
Food supplement= appetite killer! Similarly for NG feeding: good for can't eat, bad for won't eat. Don't get your forumlas confused - eg nutrini (blue) vs nutrini energy (yellow).
Defined as BMI >95th centile for age on special BMI chart. Overweight defined as >85th centile. Cut off for overweight/obesity starts at 18/20 age 2, nadir of 17/19 at age 5, rising to 20/24 at 10 then usual 25/30 at age 18. Girls same as boys, slightly fatter after 10 yrs. Chart is in the SIGN guideline 69. International data, BMJ 320:1242)
SIGN suggests referral to secondary care for:
Does not specify what investigations. Suggests weight loss rather than weight maintenance as a reasonable goal where:
Proposes limit of 0.5kg per month as a weight loss target. No recommendation on residential weight loss camps or drugs due to lack of evidence/licences respectively.
For more severe cases, consider:
Before puberty, aim for weight maintenance, not weight loss. Self esteem important, so have realistic goals. Family attitudes crucial, behavioural therapy is useful, exercise esp lifestyle eg cycling good but encourage choice. Avoid sedentary activities. Traffic light diet (Red is bad, Yellow is careful etc) and count number of each. Avoid take aways, snack foods, juice. Decrease portion size.
WATCH IT: a community based programme for obese children, family focused, motivated families only, combined diet and lifestyle. Seems to be effective, certainly increases self confidence and friendships. But feasible to roll it out to the whole community? Arch Dis Child 2006; 91: 736-739
Waist circumference is arguably better measure of obesity (distribution has metabolic implications). Rising even faster than BMI. Centile charts are available.
Variations between rates of early childhood obesity in different parts of the UK appear to be largely independent of individual risk factors! Suggests that environmental differences (obesogenic environment) may be important. This provides support for policies that promote opportunities for families with young children to be physically active and access healthy foods. pmid 18089633
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:
Appears to be visceral in origin, but no pattern of consistent motility disturbance has been identified. Saying that emotional stress leads to RAP is too simplistic. However, stress can cause recognized physiologic effects, such as increased cortisol levels, sympathetic tone, and tachycardia, so it is entirely plausible that it could exert physiologic effects on the gut through altered motility or some other as yet unidentified mechanism.
Are they anxious children? Studies are conflicting. There are no objective methods of measuring stress. For some children, anxiety and emotional stress seem to manifest in a range of pain complaints, of which abdominal pain and headache are the two most common. Family dynamics and individual coping styles influence the way in which children express or even acknowledge their pain. Some families encourage their children to express pain in ways that unwittingly may reinforce the complaint.
Most typically, the pain occurs in episodes that are periumbilical, self-limited, unrelated to meals or activities, and rarely if ever sufficient to awaken the child from sleep. The growth pattern and findings on the physical examination are normal. The degree of interference with normal activities and school attendance may seem out of proportion to the frequency and severity of the episodes as described.
The criteria for making this diagnosis are:
There may be a long latency between onset of symptoms and a confirmed diagnosis of inflammatory bowel disease (IBD), in particular, early Crohn's may be insidious and nonspecific. Abdominal pain and diarrhea may be intermittent, and the clinician must be alert to the presence of lethargy, growth and pubertal delay, and extraintestinal manifestations such as mouth ulcers, joint, and perirectal involvement.
A wide range of racial/ethnic groups (Asian, Jewish, Mediterranean, and African-Americans) are predisposed to lactase deficiency, with incidences reported as high as 60% to 80%. Lactose ingestion will cause symptoms of bloating, loose stools, and cramping abdominal pain in those who are affected. It appears to be an uncommon cause of RAP in the absence of other gastrointestinal symptoms.
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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