Common Paediatric Problems Dr Martin Hewitt Consultant in Paediatric Medicine and Paediatric Oncology

Introduction Common presentations – GP Letters Identify concerns How I would approach Informal Referral to Service – Nottingham Structure

Nottingham Structure Adult approach refer to specialities Paediatrics: 3 paediatric neurologists for East Midlands north 3 paediatric oncologists for EMN 2 paediatric rheumatologists for EM   Referrals pooled and allocated Does it matter - only for what patients are told

Nottingham Structure Acute admissions / Advice Line Week 09:00 to 18:00 Paediatric Consultant – GP phone – admissions AND advice Consultant and registrar in Hospital until 22:00 Weekends Consultant on wards until 18:00  

Topics Paediatrics Lymph nodes Screaming baby Abdominal pain Diarrhoea Headache Heart murmur

Paediatric Services… Up until their 18th birthday. GMC NUH By 16 years make decisions about own care,  

Parental Responsibility… Up to 18 years Mothers and married fathers have parental responsibility Unmarried fathers of children registered since 1 December 2003 in England have responsibility as long as the father is named on the child’s birth certificate.  Parents do not lose parental responsibility if they divorce.

Lymph nodes Urgent referral 6 years old Attended as neck pain following RTA. Multiple lymph nodes in the cervical and submandibular region all about 1.5cm. No liver or spleen enlargement. Child otherwise well. Reviewed and LN still present 4 weeks later.  

Lymph nodes What are we missing? Malignancy (lymphoma or leukaemia) Infection Different teams have differing approaches (medical v surgical)

Lymph nodes Adult approach Paediatric approach 2WW 2WW history history bloods image (USS) biopsy (FNA/excision) Paediatric approach 2WW history size location progression investigations

Lymph nodes Red Flag Features Supraclavicular Nodes Size greater than 2 cm Fixed to the underlying structures Weight loss of more than 10% Drenching Night sweats (although this is rare) Progressive enlargement Persistent fever.

Lymph nodes Message Size matters Progressive enlargement matters Duration doesn’t matter (in main) Refer - medical v surgical (gen / ENT)

Screaming baby 3 month old child who has colic. His mother is now anxious of a serious illness as the child cries every day and is difficult to settle. Worse in evening but can occur at any time of day. The child’s weight is 4.2kg. There are no abnormal findings on examination.  

Screaming baby “Colic” – what is it What are we missing? like labelling leukaemia as ‘white blood’.   What are we missing? Volvulus / GI obstruction Headache (Intracranial pressure – unlikely) check fontanelle & OFC Not much

“Colic” Causation Research Ethics Unknown – but can have massive impact Associations Speculation  Research Ethics

“Colic” Management gripe water Infacol/Dentinox GO reflux Sodium Hydroxide Carbonate & herbs Infacol/Dentinox simeticone = “anti-foaming agent” GO reflux Gaviscon Paediatric Omeprazole MUPS (1-2mg/kg OD) Lansoprazole Pink

Abdominal pain 4 year old boy central abdominal pain for 6 months. most days and often interrupts meal times. otherwise well and is not constipated. well grown no abnormalities on examination of the abdomen.  

Abdominal pain What are we missing? Hirschsprungs Disease (younger) Inflammatory Bowel Disease (older) Malignancy Gastro-oesophageal reflux

Abdominal pain who tells the story Timing – night – meal times History who tells the story Timing – night – meal times Child’s story – question

Abdominal pain Treatment Lactulose – young child Macrogols – older Paediatric preparation (sodium 50% adult prep) Dose Duration

Diarrhoea 3 year old girl progressively worse and now 6x per day developing an excoriated perianal area. stool is loose – contains food particles - no blood tried a diary-free diet with some improvement occasional abdominal pain father has Crohn’s disease good growth and no abnormalities in the abdomen.

Diarrhoea What are we missing? Food intolerance / allergy Coeliac disease Inflammatory bowel disease

Diarrhoea History Age Food particles No blood Examination Follows centile lines  

Diarrhoea Impression Toddler diarrhoea – rapid transit Treatment Increase fat in the diet ?? Food allergies

Headache 12 year old boy persistent headaches over the last 12 months most days Frontal progressively more intense over the day no problems at home or school Examination is normal including fundoscopic review.

Headache What are we missing? CNS malignancy Hypertension Migraine Musculo-skeletal Visual problems Vascular abnormalities Psycho-social issues Lots more

Headache History Pain that wakes in the night School performance Examination Invariably normal   HeadSmart Project  

Pics

Heart murmurs 3 year old girl systolic murmur on recent review for a persistent cough. follow up review confirms its persistence.

Heart murmurs  What are we missing? Structural defects  

Heart murmurs History Examination Heart scan? Poor feeding Central cyanosis (v circumoral pallor) Collapse (in older child)  Examination Peripheral pulses (femoral) Thrill Murmur location, radiation, grade, position Heart scan?  

Growth Weight problems BMI in children – different ranges Overweight: BMI - 85 – 95% Obese: BMI > 95%  

Growth 2014-2015 UK Obese Overweight Total Reception (4-5) 9.1 12.8 21.9 Year 6 (10-11) 19.1 14.2 33.3

Guidelines www.nuh.nhs.uk