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

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

3. 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

4. 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

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

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

7. 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.

8. 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.

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

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

11. 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.

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

13. 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.

14. 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

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

16. “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

17. 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.

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

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

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

21. 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.

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

23. Diarrhoea History Age Food particles No blood Examination
Follows centile lines

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

25. 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.

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

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

28. Pics

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

30. Heart murmurs
 What are we missing?
Structural defects

31. 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?

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

33. 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

35. Guidelines