Common Paediatric Problems General approach to Management

The common problems (1). URTI symptoms: URTI, chest infection asthmatic attack (2). Abdominal pain: GE, gastritis (3). Fever: UTI, febrile convulsion

Febrile Convulsion Def.: Seizure associated with fever in the absence of another cause, & not due to intracranial infection 3-4% of children (genetic predisposition) ; 6 months – 3 years Rare after 6 years of age

Febrile Convulsion-- presentation At peak of Fever/ sudden rise of temp. Occurs early in viral illness Generalized tonic-clonic Usu. Brief (1-2 mins, <10mins) No post-ictal drowsiness No neurological signs Occur once within 24hr period

Prognosis “Benign” (1). Development of epilepsy % develop epilepsy by 7 y.o --7% develop epilepsy up to 25 y.o. (2). Recurrence --30% after 1 st episode % after 2 nd 80% after 3rd

Risk Factors of subsequent epilepsy (1) Prolonged seizure in 1st episode (>30m) (2). Seizure is focal (3). Seizure recurs in same illness (4). Family Hx. of 1 st degree relative with epilepsy/ >5 febrile convulsions (5). Prior abnormal developmental status 3x

Management --To rule out other causes of seizure (infection screen) --To keep temperature low: remove warm clothing + tepid sponging --Antipyretics e.g paracetamol --Diazepam suppositories for any seizure > 5mins --Reassurance to parents + education for 1 st aid management

Childhood Fever Def. :>37.4 C (oral or armpit); >37.8 (rectal) Rectal temp not always desirable High fever: caution in – neonates: “Sepsis until proven otherwise” – <2yrs: beware of bacteremia/septicemia/meningitis *Margin of safety lower the younger the child

Evaluate fever < 2y.o Immediate purpose: identify DDx: URTI 60-70% of cases GE/ UTI next common Other rare causes: Osteomyelitis/ arthritis/ meningitis Connective tissue disease/malignancy

History & P/E Most accurate (?sepsis) : from observation Playfulness Alertness: drowsy/ irritable Consolability + nature of crying: high pitch? Motor activity Feeding: vomiting/nauseated

P/E Hydration status Periphery: cold/clammy? Respiration: distress in pneumonia, metabolic acidosis, sepsis

Ix In all patient with fever < 6 months:  Extensive investigation needed for focus  Minimally:  WCC + diff.  Blood C/ST  Urinalysis for C/ST, R/M (SPA /cath)  Consider LP in most cases (if no CI)

Urinary tract Infection <11 y.o: 1% boys/ 3% girls (symptomatic) 2 main principals of Mx: (1). Halt the complications (2). Thorough assessment & Ix after 1 st episode as: – >1/2 have structural abnormality – UTI  scar  HT  CRF if scar bilateral

Clinical features Infancy –non-specific Fever; Lethargy/irritability Vomiting/diarrhea Poor feeding/failure to thrive Prolonged neonatal jaundice Septicemia Febrile convulsion (>6 months)

Reminders … (1). As age increases, symptoms become more specific (2). Dysuria without fever  vulvitis in girls or balanitis in boys (3). Social Hx. To be explored for ?sexual abuse

Urine sample collection Child in nappies: (1). Clean catch (2). Adhesive plastic bag applied to perineum (3). SPA (preferred in severely ill infant <1y.o. OR contaminated previous sample) (4). Bag urine in low index of suspicion

?Reliance on microscopy or dipsticks? If both +ve => treat Both-ve but clinical s/s highly suggestive=> treat If microscopy shows equivocal result + dipstick +ve for WCC/esterase/nitrite + clinical condition likely UTI => treat If microscopy shows organism in addition to white cells => treat

Simple measures to prevent recurrence High fluid intake->high urine output Regular voiding Complete bladder emptying (double micturition) to empty residual urine Mx of constipation Good perineal hygiene

Follow-up in recurrent UTIs + renal scarring Routine Urine culture every 3-4 months Blood pressure Long term low dose antibiotic prophylaxis: Trimethoprim (2mg/kg nocte) +/- nitrofurantoin +/- nalidixic acid Regular assessment of renal function

Typical Ix protocol for 1 st episode UTI US +/- AXR Give prophylactic antibiotics until ALL Ix completed Age: <1y.o: DMSA+MCUG 1-5 y.o: DMSA >5y.o: only if abnormal USG  DMSA

Subsequent need for cystogram Abnormal DMSA Abnormal USG Acute pyelonephritis Family Hx of reflux Unexplained Recurrent UTI