re in babies <2500g) and preterm babies (70% of deaths oc- cur in the 5% who are preterm). See p50 & p128. Regional variation in the UK is quite marked. There is a social class varia tion with rates being less for so- cial classes 1 and 2 than for classes 4 and 5. Teenage m others have higher rates than mothers aged 20 \200\22329. From 35yrs rates rise until they are 1.5-fold higher than the low-risk group (25 \200\22335yrs) by age >40. Second babies ha ve the lowest mortality rates. Mortality rates are doubled for fourth and \201 fth childr en, trebled by sixth and seventh (this eff ect is not independent of social class as more l ower social class women have many children). Rates are low- er for singleton births than fo r multiple ( \200\200 \211\21010 for triplets vs singletons). 195 Time to conception also h as an in \202 uence with mortality rates being 3 times more if it has taken a long time to conceive compared with short time (in Denmark). 196 Perinatal mortality in UK* (* \201 gu res exclude Scotland) is twice as high in off spring of mothers of black ethnicity; 1.5 tim es commoner if of Asian ethnicity. 197 s c i r t e t s b O Perinatal mortality rates in the UK have fallen over the years from 62.5 : 1000 in 1930 \200\2235 to 7.6 : 1000 in 2009 for UK*. Declining mortality re \202 ects improvement in s tandards of living, improved maternal health, and declining parity, as well as improvements in medical care. The main causes of stillbirth were congeni- tal abnormalities (9%), antep artum/intrapartum hemorrhage (11%), placen- tal conditions (12%) in 2009. The cause in 28% of stillbirths was unexplained. The main causes of neonatal death were prematurity (48%) an d malformation (22%). Examples of how changed medical care may reduce mortality \200 Worl dwide, treatment of syphilis, antitetanus vaccination (of mother during pregnancy), and cle an delivery (especially cord techniques) have the greatest in \202 uence in reducing perin atal mortality. Antenatal detection and termination of malformed fetuses. \200 Reduction of mid-cavity pr ocedures and vaginal breech delivery. \200 Detection of placenta praevia antenatally. \200 Prevention of rhesus incompatibility. \200 Preventing progression of preterm labor. \200 Better control of diabetes mellitus in aff ected mothers. \200 Antenatal monitori ng of \200\230at risk \200\231 pregnancies. \201\201While we must try to reduce morbidity and mortality still further, this must not blind us to other problems that remain, such as the \200\230over-medi- calization \200\231 of birth; the problem of reconciling maternal wishes to be in charge of her own d elivery with the immediate needs of the baby; and the problem of explaining risks and bene \201 ts in terms that both parents understand, so that they can join in the decision-makin g process. who are you, little i (5 or 6 years old) peering from some high window 98 2 Pediatrics e e cummings Cardiovascular: History & examination 100 \200\2232 \200 Is this child seriously ill? 103 Common infant sy mptoms 104 \200 The ill and feverish child 106 Infective endocarditis 166 Rheumatic fever 166 Gastrointestinal: Diarrhea 168 Malnutrition 168 Abdominal pain & distension 170 Coeliac disease 171 Some acute surgical pr oblems 172 Neonatology \200 Resus. and ITU 107 \200\2238 Ventilatory support for neonates 110 \200 T he ill neonate 112 Examining the neonate 114 Jaundice 115 Rhesus haemolytic disease 116 Res piratory distress syndrome 118 BPD; pulmonary hypoplasia 119 Necrotizing enterocolitis 120 Meconium aspiration 120 The bleeding neonate 120 Minor neonatal problems 121 Enteral & pare nteral feeding 122 Breastfeeding & bottle feeding 124 \200\2237 Preterm and light babies 12 8 Genitourinary: Urinary tract infection 174 Renal disease 176 \200\2239 Growth, Endocrine & Metabolic: Growth and failure to thrive 180 Short stature 180 Ethnospec i \201 c growth charts 181 Endocrine & metabolic disease 182 Phenylketonuria 183 Precociou s puberty 184 Diabetes and \200 ketoacidosis 186 \200\2239 Poisoning: general points 190 S alicylate and \200 paracetamol 192 Malformations GI 130 Genitourinary (incl. Wilms \200\231 and am- Hematology & Immunology: biguous genitalia) 132 \200\2235 Congenital heart disease 136 Murmurs and heart sounds 137 Head & neck and cleft palate 138 \200\2239 Neural tube defects 140 Acute lymphoblastic leukemia 194 Anemia 196 Purpura 197 Primary antibody de \201 ciency 19 8 Neurological: Some viral infections \200 Rising intracranial pressure 200 Migraine 201 \200 Encephalitis 202 \200 Meningitis 202 \200\2235 Epilepsy & febrile convulsions 206 \200\2239 Behavioral problems 210 \200 \22313 Delay in walking and talking 214 Handicap 216 Measles, rubella, mumps 142 Erythrovirus infection 142 Hand, foot and mouth 143 Roseola and other rashes 143 Chickenpox (varicella) 144 Childhood hiv infection 145 Injury & disease p revention Non-accidental injury 146 Sudden infant death 148 Screening & development 150 Imm unization 151 Genetic disease & prevention 152 Genetic counseling 154 Preventing heart dise ase, diabetes Reference intervals/ \202 uids/nutrition Developmental tests 218 \200\22319 Hematology and chemistry 220 Dentition 221; and growth 2 22 \200\2235 Dubowitz system 228 \200\22332 Body surface area 233 Nutrition tables for prem s 234 Fluid regimens 234 etc, starting in childhood 156 Diseases by system \200\224Respiratory: APLS advanced pediatric life support \200 Intraosseus transfusion 236 \200 Adrenaline in anaphylaxis 237 \200 Cardiorespirato ry arrest 239 Respiratory infections; upper lower (including pertussis) 158 \200\22360 Cystic \201 brosis 162 \200 Asthma 164 Other relevant pages: Orthopedics (Chapter 11); Infectious disease (OHCM p372 \200\223447); perinatal infection p36; child psychiatry p389; play therapy p377; squint p422; retinoblas toma p421; pain p718; syndromes: p638 \200\22355. We thank Professor Robert Tasker, our Spe cialist Reader, and Dr Shahzad Arain, our Junior Reader, for their contribution to this cha pter. rowing up can seem like joining the points on a growth chart, with the chief desiderata bei ng that we should not cross the dotted cen- tiles of our pre-determined course, set out in utero, and ending in adulthood or death (these states being synonymous in the mind of the a v- erage alienated 15-yr-old). Examples of points on growth chart might our metaphysical we are individu- be realizing that we lead sepa- als, next that our parents lives to rate Nex t may and carers. that there come a view s h a p i n g is a divinity give way our lives; th is may that this to a more subtle view care much divinity has ceased to a n o t h e r , abo ut us, one way or with each and that we are alone other minds other, those tantalizing we m ust learn that, in order to survive, to read. At last, standing on our own two feet, suppor ted and constrained by the dotted lines of our allowed variability, we realize that our har d-won independence may be an illusion (interdependence not independence is the human rule). Even our own unitary ego may come to look fragile compared with the system of interacting, con \202 icting processes which perpetually dissolve and reform in strange or familiar pa tterns of personal identity. 99 A d o l e s cent pregnancy Street crime e a nd solvent D r u g abuse r a c y Adolescent e r u g a n d solvent Adolescent t i o n a b u s e Prostitution Prostitution s e u T r u ancy s c e n t pregnanc S t reet crime Truancy c y Illit nan c y A ce d n Vio o itution l e P Ad olescent scent pregna s rostitutio c e Viole nt Drug and solvent olescent pre preg n n solv ent ancy n Street n cy Truanc abuse Truanc Viole Prostitution Prostitutio Drug and Adolesce nt pregnancy Illitera itution Vio Drug and y c V i o l e y n a c n u r T S y t i r a l u s n i tr e r Illitera c y Prostitutio n Adolescent T e t u c n a I lli t pre g n Prostitutio n Truancy Prostit u Drug an d s o l v solvent titution and g u r D c a n r i c T r y pr e m u D a e I l l i t ab n g c u n y s e a e t n n b p e l a m s y b a r c r V a e y a i c g o V V y o n i il S l e a o Illit y t A d o l e Violence lliteracy Tru a n Violence n e c l T r e n r n e e e im r c u e c r e t a c n y a n c c e c S t r e e t y e rim y e T e c n e l o i V s c i r t a i d e a P r c r i s o r P P u d r u g T r u a n c y r a o d n a D r u g n s e m e c y c r t P A d o l e s c e n t p olv e A d o le a i r t u t i o n c I l l i t e a r n a d c y o s t y t e e r t S t e e r g e e l I y r y c a r c n e m p e a n d s e c r im e c , e c i d u j e r p s n t i u y c r b S c a Violence reganacy nt abuse e n Ad e e a t t m s e i u ri c e l l tr g u r S T I b a e a c e n y e l Vio solv e m i t s y r c n y c u a e r t e b Illit e n a e c r e t y r a t i d e r e h S t n r o st lence y c n e solv P , l i a m k c a l b l a n o i t o m e Where is the child in front of you on his or her own unique journey through this landscape? You \200\231d better \201 nd out if you want to cure some diffi cult problems \200\224or perhaps you had better ignore this question. After all, the ward-round has just moved on, and you don \200\231t want to be left behind with a perplexed child on the point of confoun ding you. Sometimes it is enough to look after the body, thereby allowing the soul to look after itself. We cannot hope to enable children to realize their full potential \200\224for , un- surprisingly, potential is only ever lost. The egg has more potential than the embryo (its sex, for example, is yet to be determined). The child has more potential than the med ical student who is forever closing off lines of en- quiry to concentrate on one thing. So if potential can only be lost we must aim for potential to be lost in the least harmful way . e r a s r o n r e v o g e s o h w n o s i r p d e m r o f e r n u The essence of pediatrics is aligning embryology, growth and devel- opment, family interact ions, and preventive and therapeutic measures to achieve a person who is capable of making choices. Happy or free? Creative or reasonable? Self-destructive and isolated, or participa tory and social? We cannot hand down the answers \200\224we just peddle our wares down this one-way street. Ask children what childhood is for, and they will tell you \200\234Prepar ation. Learning. A time to become yourself \200 \200\235.1 This is why paedi- atrics must be holistic \200\224otherwise it will not contribute to these aims. It is against this back ground of enabling children to become themselves that pediatricians practice their art and their science. n a e k i l e r o M ! s l l a B ? t i n u d e r c a s We note with great interest that most patients between the ages of 15 and 20 who have acute leukemia treated by pediatricians are cured \200\224up to 63%, whereas <50% of this group survive if treated in adult units.2 This chapter aims to explain how this diff erence might arise \200\224and to encour- age the reader to extend the skills learned in pediatrics to all branches of medical practice. s a y l i m a f e h T Eliciting the history There are 3 aims. 1 To establish a good relationship with the child a nd par- ents, so that if diffi cult treatment is required (or there is nothing wrong) the p arents trust you and are able to accept this. 2 Reaching a diagnosis or diff er- ential dia gnosis. 3 Placing the diagnosis in the context of the child and family. There is no one tre atment for pneumonia, or diabetes, or anything else (same disease, but diff erent contexts require diff erent treatments).Try to avoid any hurry or distractions. Introduce yourself; explain your role in the ward or consulting room. Take a history from as many sources as po ssible \200\224the child, mother, father, and any signi \201 cant other \200\224but beware allowing the child to feel marginalized, so address yourself to the child \201 rst, and last. Presenting complaints Record the child \200\231s and parents \200\231 own words. The present illness When and how did it start? Was he/she well before? How did it develop? What aggravates or alleviates it? Has there been contact with infections? Has the child been ov erseas recently? 100 \200 \200 Especially in infants, enquire about feeding, excretion, alertness, and weight gain. After ascertaining the presenting complaint, further questioning is to test the various hypothese s of diff erential diagnosis. Past In utero: Any problems (eg PET, rubella, Rh disease); dr ug exposure? At birth: Gestation, duration of labor, mode of delivery, birthweight, resusci - tation required, birth injury, malformations. As a neonate: Jaundice, \201 ts, fevers, bleeding, feeding problems. s c i r t a d e a P i Ask about later illnesses, operations, accidents, screening tests, drugs, aller- gies, immunization, travel, and drug or solvent abuse. Development (p220) Does the mother r emember milestones reliably? Drugs Prescribed, recreational, in utero, and over-the-counter . Drug intoler- ances, adverse drug reactions, and true allergies (ie rashes; anaphylaxis). Family history Stillbirths, TB, diabetes mellitus, renal disease, seizures, jaun- dice, ma lformations, others. Are siblings and parents alive and well? Find out about late-onset dis eases with a genetic component.1 Consanguinity is com- mon in some cultures and may be rele vant to disease. Social history It may be vital to know who the father is, but damaging to ask directly. Asking about the \200\230family unit \200\231, or drawing a family tree (OHC M p21) is a way forward. Allow information to surface slowly, eg after chats with friendly nurses. Ask about play, eating, sleeping (excessively wrapped or liable to cold?), schoolin g and pets. Who looks after the child if the parents work? What work do they do? Is paterni ty leave available? Is it taken?2 Ask about their hopes, fears, and expectations about the child \200\231s illness and hospital stay. \201\201Child-centered care Taking into account the preferences of the child can be diffi cult, but it is our duty to discover these prefe rences, and this process starts with taking the history. It will often be the case that the child does not appear to want the treatment on off er (eg an IVI for dehydration). Explana tion sometimes leads to co-operation, but if this is not the case talk to colleagues to see what the alternatives are \200\224and whether bene \201 cence trumps ignoring au- tonomy. Beware overruling the child \200\224but sometimes it is your duty to do so. Privacy, digni ty, and con \201 dentiality are easy to pay lip-service to, but hard to ensure in busy war ds, where space is at a premium. During an average stay in hospital most patients and their relatives overhear con \201 dential exchanges, and only a few recall being off ered a scr een to preserve privacy during ex- aminations. 3 \200\207If the family does not speak your language, \201 nd an interpreter. 1 For example, if a parent has had a myocardial infarction before 40yrs old, do serum lipid s (>40% of these children will turn out to have hyperlipidaemia: the sooner it is treated, the better, p156). 2 Emotional/behavior problems are commoner at 3yrs old if no paternity l eave was taken.4 n=19,000 In the UK, 81% of fathers in professions get paternity leave vs 4 6% of those in less skilled work. 101 Systems review \200\224questions coming to the fore depend on age: \200 Neonate Tachypnoea, grunts wheeze, cyanosis, cold sweats (heart failure) Appetite, D&V, fee ding problems, stool frequency Jaundice Toddler Cough, exertional dyspnoea Older child Cough, wheeze sputum, chest pain Cardio- respiratory Gut Appetite, D&V, stool frequency Appetite, D&V, abdominal pain, stool frequency . e m i t Genitourinary Wet nappies (how Wet nappies (how often?) Haematuria, dysuria, sexual development Headaches, \201 ts, odd sensations, drowsy, schoo ling, vision hearing, co-ordination Earache, discharge, sore throat s c i r t a i d e a P e t s a w o t often?) Seizures; attacks; jitters Seizures, drowsy hyperactive hearing \200\201 vision \200\201 gait Neuromuscular n r a e l ; s n e p p a h Noisy breathing Ear discharge ENT; teeth t a h w e e s General weight, appetite, fevers, fatigue, lumps, everything else OK? d n a d n u o r a \200\234He went white, then red, then blue \200\235 If it \200\231s hard to ask the right ques- interpret the answers. tions, it can be harder still ( \201 rst to the grandmother, Each time a story is told to the junior doctor and then to the GP, then of meaning, color, or consultant) a new layer like ambiguity is disclosed, spirals swirling collective gobstop per. of color on a to get at the truth: Don \200\231t be impatient the \202 avour may be suck it and see: the \200\230facts \200\231. Often there as important as all just 5 diverg ing stories. are no unbiased facts, As Virginia Woolf once in cases such as said, these, tr uth is only to be had by laying together many varieties of error.5 Shakespeare \200\231s Si ster Girton & Newnham 1928 Wait on events; learn who you can trust, and accept that all \200\230conclusions \200\231 are, provisional \200\224as is the case with any professional historian who juggles his tinted and tainted sources. to g n a h t s u j : t i g n i k a t p o t s , l l e w g n i o g t o n s i y r o t s i h Pediatric encounters are among the best places to start the process of becoming an expert i n this generic skill of balancing diff erent sources. In adult medicine we typically pay 10 0% attention to what the patient says about his or her symptoms, and 0% to what anyone else says. With pre- verbal infants, the reverse is true \200\224underlying the point that we s hould not assume that patients have the most privileged access to their symptoms. I e h t g n i k a t f Physical examination: a method A single routine will not work for all children. If the chil d is very ill, examination is limited (p103). Also, points in the examination assume varyin g importance depending on age (for neonates, see p114). But it is helpful to have some sort of standard: here we look at a boy of 3 years who is being seen because of vomit- ing. Not everything on even this slimmed-down page will need to be done. The more experienced you a re, the better you will be able to judge when and how to take short cuts. Don \200\231t mis take taking short cuts for being lazy. Use the time saved to be available to answer questio ns, and to address the fears and hopes of the parents and child. NB: there is no correct or der: be opportunistic, eg with younger children on a lap listen to heart when there are gap s in crying. 102 \200 \200 1 Wash and warm your hands. Encourage both parents to be present. 2 Regard the child (eg wh ile feeding). Is he ill or well?1 Restless, still, or play- ing? If crying, is it high pitc hed or normal? Is he behaving normally? Any jaundice, cyanosis, rashes, anemia, or dehydrat ion (p235)? Is he moving normally? Does anything hurt, eg neck, abdomen, limbs? 3 Talk to the child. Explain what you are doing. This helps you both relax, and enjoy the o ccasion (not a trivial point: a happy doctor is an engaged doc- tor; an engaged doctor is m ore open to subtle signs). If he seems anxious, examine his teddy in a playful way, to allo w him to build up trust. Asking about pets or siblings often helps. s c i r t a d e a P 4 If quiet or asleep, now is the time to get any listening done, so examine his heart, lung s, and abdomen. Use a warm stethoscope. Undress in stages. 5 Examine \201 nger nails, the n the hands, radial pulse, BP, axillary and neck i nodes, neck lumps. Is there neck stiff ness? (a \200\230useless \200\231 sign in infants) 6 Size and shape of head (p224). Facial symmetry. In a baby, does the ante- rior fontanelle (between the parietal and frontal bones) feel tense (intrac- ranial pressure \200\200) or sunken (dehydration)? 7 Is there mucus in the nose? Leave ears and throat alone at this stage. 8 Count the respir ations. Is there intercostal recession (inspiratory indraw- ing of the lower costal area, signifying \200\200work of breathing)? 9 Percuss the chest if >2yrs old (not very reliable even then), and palpate the abdomen. Is it distended, eg by spleen, liver, \202 uid, \202 atus, feces? 10 Undo the nappy, if worn. Have an MSU pot to hand. If urine is passed, make a clean catch (p174). Inspect the nappy \200\231s contents. Examine the genitalia/ anus. Find the testes . Rectal examination is very rarely needed. 11 Note large inguinal nodes. Feel femoral pulses. Neurological examination After completin g the above, much will have been learned about the nervous system; if in doubt, check: Tone : Passively \202 ex and extend the limbs (provided this will not hurt). Power and co-ordi nation: Watch him walk, run, and pick up a small toy and play with it, with each hand in tu rn. Re \202 exes: Look for symmetry. Sensation: Light touch and pain testing are rarely re warding. Fundi. Ears/throat Leave to the end, as there may be a struggle. Mother holds the child on her lap laterally, one hand on the forehead, holding his head against her chest, a nd the other round his arms. Examine ear drums (p536) \201 rst (less invasive). Then, hol d the child facing outwards, one arm around his arms, one on his forehead. You can then int roduce a spatula and get one good look at mouth and tonsils. Inspect the teeth. Growth Char t height, weight, and head circumference (p224). TPR charts Pulse and respiratory rate; T (rectal T : normally <37.8 C). Finally ask child and parents if there is anything else y ou should look at. 1 In the mood of la belle poque, get the whole picture as a gestalt \202 ash, and mirro r that genius of pho- tography, Jaques Lartigue: \200\234I open my eyes, then I close them , then open them again, wide, and hey pres- to! I capture the image with everything \200 an d what I hold onto is something living, that moves and feels \200\235. 103 Is this child seriously ill?APLS Recognizing the need of prompt help is a central skill of pediatrics. It can be uncanny to watch the moment of transformation that this recognition b rings to a normally laid-back, easy-going doctor who is now galvanized into an effi cient, relentless device for delivering urgent care \200\224 \200\230omitting noth- ing necessary and adding nothing super \202 uous \200\231, a frame of mind recommended by Graham Greene for murder, but equally well suited to curing dis- ease. If you are new to pediatrics, take every opportunity to observe such events, and, later, closely question the doctor about wh at made her act in the way she did, using this page to prepare your mind to receive and ret ain her answers. Airway, breathing, circulation: then dynamic inverse \200\230traffi c lig ht \200\231 assessment Taking most feeds OK; normal color (lips, tongue, skin); responds to social cues, alert or wakens quickly, lusty cry, or playing. Breathing calmly. \200 67 Ta king \200\20550% of feeds; pale; not responding to social cues; hard to wake; \200\201act ivity; no smiling; >50 breaths/min if \200\2231yr old; SAO2 <95%; crepitations; nasal \202 aring if <1yr; capillary re \201 ll time >3sec. To elicit this, press on a digit for 5sec: capillary re \201 ll normally takes <2sec. Don \200\231t rely on BP & pulse. 8 Pale; mottled; ashen; blue. Doesn \200\231t stay awake when roused. 1 Consciousness \200\201 (no t engaging; apathy; coma); skin turgor \200\201. Any GRUNTING signs? (NICE 2007) \200 Typical causes \200 Sepsis, meningitiset al \200 D&V/gastroenteritis \200 Obstruction , eg volvulus \200 Arrhythmias \200 Hypoglycaemia \200 U&E imbalance \200 Metabolic errors \200 Myocarditis \200 Congenital heart dis. \200 Cardiomyopathies \200 Intu ssusception (p172) \200 DIC (p120 & OHCM p346) \200 Haemolytic uraemic syn. \200 Reye \200\231s syndrome (p652) s c i r t a i d e a P \200 Grunting; weak or continuous high-pitched cry; tachypnoea >60 breaths/min. \200 Rib recession; retraction of sternomastoid, use of alae nasae; wheeze; stridor. \200 Unequal o r unresponding pupils; focal CNS signs, \201 ts, marked hypotonia. 9 \200 Not using limb s/lying still; odd or rigid posture decorticate ( \202 exed arms, ex- tended legs); or decerebrate (arms + legs extended). \200 T \200\20638 C if <6 months or \200\20639 especially if cold or shutdown perip heries. \200 I \200\231m having a bad feeling about this baby. \200\207Learn to trust you r judgment.1 \200 Neck rigidity, non-blanching rash, meningism, bulging fontanelle, etc. \200 Green bile in vomit 10( \211\210 GI obstruction, 11 eg atresia, volvulus, intussuscept ion). 12 When assessing response level, use the Glasgow coma scale (if <4yrs, p201) or AVPU . A=alert; v=responds to voice; p=responds to pain; u=unresponsive. Systolic BP Breathing r ate Age \200\224Reference interval for: 30 \200\22340/min <1yr 70 \200\22390mmHg 20 \200 \22330/min 2 \200\2235yr 80 \200\223100mmHg 15 \200\22320/min 5 \200\22312yr 90 \200\223110 mmHg >12yr 2 \200\22316/ min 100 \200\223120mmHg Action \200\224if very ill \200 100% O2 b y tight- \201 tting mask with reservoir, then: \200 Immediate IV access. Go intraosseous if access cannot be found (p236). \200 Colloid: 20mL/kg bolus IV; repeat if no better. \211 40mL/kg; call PICU. \200 Do blood glucose (lab and ward test); U&E (ask speci \201 cally for HCO \200\223 vomiting, Cl \200\223); FBC; thick \201 lm if tropical travel poss ible or unknown. Pulse 110 \200\223160/min 95 \200\223140/min 80 \200\223120/min 60 \200\223100/min 3, and, if Crossmatch blood if trauma is possible, or patient looks anemic. \200 Consider the need f or CXR, MSU, and lumbar puncture. \200 Do swabs, blood culture (+suprapubic urine aspirat e if <1yr, before starting blind treatment with IV antibiotics, eg ceftriaxone or cefotaxime, p202). \200 If worseni ng, insert CVP. Get expert help; do blood gasses clotting screen. \200 Ventilation may be needed if very sick, to offl oad the heart. \200 If perfusion \200\201 despite 60mL/k g colloid or CVP >10cmH2O, consider inotropes, p203. 1 DoHUK free DVD Spotting the Sick Child (cat no 40630): tel 08701 555455 dh@prolog.uk.com + NICE 2006 2 This is a reason to spend hours and hours on the wards: to gain the experienc e that validates \200\230bad feels \200\231. We once asked an obstetrician how he had reco gnized placenta praevia during a vaginal exam in labor: \200\234It was easy \200\235 he sa id; \200\234I felt sick and started to sweat as soon as my \201 nger entered the os \200 \235. Common symptoms in infancy Sleep problems: see p392. Crying Up to 20% report problems with crying in the 1st 3 months of life; usu- ally no cause is found. Crying peaks at 6 \200\223 8 weeks old ( 3h/day, worse in the evenings) and subsides by 4 months. 13 Cries of hunger a nd thirst are indistin- guishable. The demand feeding vs routine feeding debate rages among st par- ents, with each group convinced that they have the happier babies. No doubt there a re good survival reasons for Nature making babies cry, 14 but in the 21st century this prov ision is counterproductive in 5%, who report crying-induced smothering, slapping or shaking . 15 Crying worsens \200\230postnatal blues \200\231 and may be the last straw for a paren t with few reserves. Aim to off er help before this stage (CRY \200\223SISuk, 08451 228 669 ). 16 It is OK to leave a baby crying if it is in the child \200\231s best interests. A bab y who is abused due to excessive crying would rather have been left alone. \200 Don \200 \231t make parents feel inadequate; foster a spirit of practical optimism with parents taki ng it in turns to sleep. Explain normal crying and sleeping. \200 Baby-centered approach to help parents help the baby deal with discomfort. \200 Help parents recognize when thei r baby is tired and hungry ( \200\230read-your-baby \200\231 lessons may be needed), 17 and to apply a consistent approach to care. \200 Vocal (singing), vestibular (rocking, going for a drive) or tactile stimulation (hugs) may help. 18 Encourage help from friends/family . Simplify daily living. \200 If not coping, admit to a parenting center or hospital; 19 don \200\231t over-medicalize! 3-month colic (Paroxysmal crying with pulling up of the legs , for >3h on \211 3days/wk). Cows \200\231 milk protein allergy, transitory lactose intole rance, 20 and parental discord are implicated1. There is an association with feeding diffi cul- ties. 21 Also, blunted rhythm in cortisol production is reported, suggesting delay in establishing circadian activity of the hypothalamic \200\223pituitary \200\223adrenocortica l axis and associated sleep \200\223wake cycles. 22 \201\227: Movement (carry-cot on wheel s) is often tried and may help. 23 Let the baby \201 nish the \201 rst breast \201 rs tFisher \200\231s (hindmilk is easier to digest). 24 Pre-incubation of feeds with lactase ( eg 2 drops of Colief Infant Drops per formula feed, left in the fridge for 4 \200\22312h 25 before heating) helps. 26 If breastfeeding: express 15mL of milk into a sterilized con- tainer; add 4 drops of Colief ; feed to the baby on a sterilized plastic spoon, then star t breastfeeding at once. Alternative: dimeticone (simeticone) drops (40mg/mL; 2.5mL PO with feeds). Few other drugs are licensed at this age. Consider 1mL of 30% glucose PO 27 or fen nel seed oil emulsion. 28 There is some evidence probiotics (Lactobacillus reuteri) may be bene \201 cial. 29 If breastfeed- ing, a \200\230low-allergen \200\231 diet may help. 30 Soya milk used to be tried, but is not rec- ommended ( \200\223 high levels of oestrogens). Reassure strongly; reduce stress; 31 encourage grandparent involvement. Remember: a crying baby may be a sign of major relationship problems. Nappy rash/diaper dermatitis 4 types (m ay co-exist). 32 1 The common \200\230ammonia dermatitis \200\231 \200\224red desquamating rash, sparing skin folds, is due to moisture retention, not ammonia. 33 It responds to fre quent nappy changes (cloth nappies retain more moisture than disposables), or nappy-free pe riods, careful drying, and emollient creams. Best treatment: leave nappy off . Use barrier cream: eg Sudocrem (zinc oxide cream). 104 \200 s c i r t a d e a P i rule 2 Candida/thrush is isolatable from of all nappy rashes. Its hallmark is sat- ellite sp ots beyond the main rash. Mycology: see p598. Treatment: as above, + clotrimazole ( 1% hy drocortisone cream, no stronger, eg as Canesten HC ). One trial favors thrice-daily mupiro cin ointment. 34 N=20 Avoid oral anti- fungals (hepatotoxic) and gentian violet (staining i s disliked). 3 Seborrhoeic dermatitis: a diff use, red, shiny rash extends into skin folds, of- ten occu rs with other seborrhoeic areas, eg occiput (cradle cap). \200\224: as for 1. 35 4 Isolated, psoriasis-like scaly plaques (p594), which can be hard to treat. 1 Consider this: are stressed parents simply more likely to report colic? 105 Vomiting Eff ortless regurgitation of milk is common during feeds ( \200\230posseting \200 \231). Vomit- ing between feeds is also common. Ask about carpets: signi \201 cant vomitin g in a baby will have caused lots of damage to the parent \200\231s carpets. No dam- age: u nlikely to be pathological. Causes: gastro-oesophageal re \202 ux, over- feeding (150mL/kg /day is normal), pyloric stenosis (projectile, at 8 weeks old), or UTI. Rarer causes: phar yngeal pouch, metabolic conditions, almost any other illness. Gastroenteritis is uncommon i n babies as their feed is usu- ally sterile. Observing feeding is helpful in deciding if vo miting is projectile (eg over the end of the cot), suggesting pyloric stenosis. Bilious (gr een) vomiting: Get urgent help, p130; consider duodenal obstruction or volvulus. \201\201Chronic childhood illness, and family support Diseases such as severe asthma, CNS disease, and neoplasia may cause disintegration of even the most apparently secure families : \200\207consequent strife and marital breakdown may be more severe and have more far- re aching consequences than the illness itself. s c i r t a i d e a P 6 3 \200\235 . e t o n Remember that illness makes families poor, and movement down the so- cial scale leads to un predictable consequences in housing and (un)employ- ment. Families experiencing housing ins tability and food insecurity (without homelessness or hunger) are known to miss out on heal th care. 37 n=12,746 e d i c i u s s \200\231 d n a b s u h Marital disharmony may seem to be beyond the scope of pediatrics, but any holistic view of child health must put the family at the center of all at- tempts to foster child health and wellbeing. y m d a e r We see many families coping well with severe, prolonged illness in a child. But don \200 \231t presume that because things are OK in clinic today, you can aff ord to neglect the fo stering of family life. Given a certain amount of stress al- most all families will show ps ychopathology, in time. Your job is to prevent this if possible. Counseling skills are freq uently needed (p380) \200\224but do they work? Various tools are helpful in answering this: 38 \200 Communication is vital in any family, and this can be measured by scales I n e h t \200 e m o h y m n e h t such as the Communication Skills Test (CST).1 The Dyadic Adjustment Scale (DAS) looks at the emotional interaction within a marriage or a ny other pairing. 39 \200 The Miller Social Intimacy Scale (MSIS) looks at intimacy in re lationships, and intimacy is, beyond doubt, a source of strength within a family expe- rien cing illness in a child. d n a b o j y m t s o l Speci \201 c therapies validated in randomized trials in families coping with severe chron ic illness in a child include Emotionally Focused Marital Therapy (EMT), with these bene \201 ts: 40 \200 Higher overall levels of marital adjustment (on the DAS scale). None of t he couples receiving the active therapy deteriorated by >7 points, whereas one-third of cou ples in the control group had such a deteriora- tion (which shows the stress these families were under, and supports the notion that family psychopathology in the face of chronic chi ldhood illness is an evolving phenomenon \200\224the stress is reversible if you take certa in steps). \200 Better levels of intimacy as measured on MSIS scale, with eff ects per- si sting for at least 5 months. \200 Lower rates of negative communication (on the CST score) . \200 NNT=2 (2 couples need treating for one to improve). I \200 k c i s t o g n o s y m n e h w g n i h t y r e v e t s o l I \200\234 1 Full instruments available in: K Corcoran Measures for clinical practice: A sourcebook. N ew York. \200 The ill and feverish child Temperature Rectal is most reliable. 41 \200\22343 In the axilla: use an electronic or chem- ical dot thermometer. In the ear: use an infra-red tympa nic thermometer. \200 2007 3 questions to ask: How severe are the symptoms? and How approp riate is the child \200\231s response to the illness? The symptom may be severe (eg \200 \234terrible diarrhea all over the cot \200\235) without being biologically serious (if the baby is alert, drinking, wetting many nappies, and behaving as usual), but ANY appar- entl y mild symptom should set your internal alarm bell ringing if: 44,45 \200 Less than half the usual amount of feed has been taken in the last day. \200 There is breathing diffi cu lty, or high-pitched continuous moans or cries. \200 There is a history of being pale, mo ttled, cyanosed, and hot. \200 Dull expression; apathetic; uninterested in you; drowsy; d ehydrated. \200 A signi \201 cant reduction in the number of wet nappies in the last 24h . \200 Blood in diarrhea, or seizures, or tachycardia not explained by pain or fever. The 3rd question is: Is neutropenia possible (eg on chemotherapy)? Assess the \200\230traffi c light \200\231 way, p103, paying especial attention to red signs (pale, mottled, ashen bl ue, not staying awake when roused, etc). Always listen to your sixth sense: act if you have a bad feeling about this. Then observe the limbs: pain causes pseudoparalysis, eg with leg s in a frog position (hips & knees semi \202 exed, feet rotated outward), eg in osteomyeli tis, or septic arthri- tis. 46 \200\22348 The above signs carry extra weight if immunocompr omised (eg neo- nates; post measles; AIDS; cystic \201 brosis; leukemia; chemotherapy/mal ignancy; absent spleen; B/T cell dysfunction); congenital anomaly or foreign body, eg an in dwelling IVI line (bacteria may be unusual and of low virulence). 49 Fever (meningitis, p20 2; pneumonia, p160; UTI, p174.) Fever is the major acute presentation in pediatrics, eg fro m viruses, otitis media, or pharyngitis (p564), and prognosis is good. Here, fever may help (aids neutrophil migration; \200\200bio- activity of cytokines, \200\200interferon and \200\200 T-cell proliferation). 49 The challenge is to treat serious bacterial infections p romptly, without medicalizing normal child- hood ills. Do MSU within 24h of fever onset. Is LP needed? see above & p206. Bacteraemia occurs in 4% of febrile children and, in most, a source of in- fection is found by a good history and examination, blood & urine cultures, FBC/ \201 lm, CXR LP (see above), etc. Rapid virology is becoming available \200\224eg PCR and direct \202 uorescent assay (for adenoviruses). 50 ESR >30mm/h and \200\200C- r eactive protein also indicate bacterial infection \200\224eg Strep pneumoniae, N. meningiti dis. Sometimes the child (esp. between 3 and 24 months of age) has T \200\20639 C and W CC >15 \211\210109/L, but despite being feverish, he does not look ill, and no obvious focu s of infection can be found. This can be due to occult bac- teraemia, which is usually tran sient and self-limiting (although a small but signi \201 cant number of these children may develop a serious bacterial infec- tion). Management: Management of the febrile child is v ery resistant to writ- ten guidelines. NICE guidance (2007) gives a framework for the under 5s, but a large amount of clinical acumen is still needed. If in doubt, ask for senior hel p. If they look toxic, do bloods and a blood culture. If you have not identi \201 ed a sou rce for the infection, then do a full septic screen. With a sick patient, however, there sh ould be no delay: give cefotaxime 50mg/kg/6h or ceftriax- one1 50mg/kg/24h (for weights <50 kg). Most patients <3 months with a fever should be admitted, those under 1 month will inva riably need at least 48h of IV antibiotics. There is some leeway if aged 1 \200\2233 months : those that look unwell, or have a WCC >15 or <5 will need an LP and antibiotics, but if i nvestigations are normal and they look well some infants may be suitable for observation on ly/ outpatient management \200\224this will depend on the experience of the practitioner, o bservational skills of the parent and ease of follow-up. 51,52 106 \200 \200 s c i r t a d e a P i 1 Concomitant \200\224 with calcium contraindicates ceftriaxone use in neonates (?older ch ildren too): it causes precipitation in the lungs. Other CI: neonatal jaundice, albumin \200\201, acidosis, \200\201bilirubin binding.