Paediatrics APEX

Fever/PUO

Infective:

• Neuro: Meningitis

• Resp: pneumonia, viral URTI, croup, bronchiolitis

• GIT: Gastro, IBD

• Urinary: UTI, Pyelonephitis

• MSK: Osteomyelitis, Septic Arthritis

• Sepsis

Inflammatory:

• Rheumatic Fever

  • GAS, requires long-term abx >10yrs or until age 21 (whichever is longer)

• Kawasaki

• Cancer

• JIA (systemic)

• Post-Covid Fever

• Post-Immunisation

Malignancy:

• ALL

Ix: Blood cultures, VBG, FBE, CRP/ESR

Consider: Urine, UEC, LP, Stool Sample, Throat Swab, Sputum MCS

Cough/Breathing Difficulties/Noisy Breathing

Resp:

• Pneumonia

• Viral URTI

• Croup

• Bronchiolitis

• Asthma

• OSA

• Tonsillitis/Tonsillar Hypertrophy

• CF

Systemic:

• Anaphylaxis/Allergy

• Lymphoma

• Sepsis

Cardio:

• HF/congenital defects

GIT:

• GORD

• Pyloric Stenosis: Ix = US

• Tracheo-Oesophageal Fistula: Ix = barium swallow

• Diaphragmatic Hernia

Urinary:

• Renal Failure causing fluid overload

Endocrine:

• DKA

• Obesity

Neonatal:

• TTN

• RDS

• Downs Syndrome

Hx: sick contacts, PMHx/FHx atopy, snoring, reflux/vomiting, Neonatal (infant of diabetic mother)

Mx: ensure O2 + fluids

Diarrhoea ± Vomiting

Neonatal:

• GORD

• GER

• Surgical: Pyloric stenosis, Volvulus/Malrotation, Duodenal Atresia

• Intussuception

• Hirschsprung’s Disease (constipation → D/V)

Systemic: do top-to-toe as V is non-specific!

• Sepsis/Any Infection

• Eating Disorder

GIT:

• Gastroenteritis

• Cow’s Milk Protein Allergy

• Coeliac

• IBD

• Appendicitis

ENT:

• Otitis Media

Neuro:

• Brain Tumour

Endocrine:

• Diabetes/DKA

• Thyroid Disorders (diarrhoea)

Haematological:

• Iron Deficiency Anaemia

Exam: Weight/BMI,

Ix: BGL, UEC

Mx: Fluid Resus, ?Surgery

Abdominal Pain ± Constipation

Neonates:

• Surgical: Pyloric stenosis, Volvulus/Malrotation, Duodenal Atresia

• Intussuception (red current jelly stools)

• Hirschsprung’s Disease

GIT:

• Gastroenteritis

• Appendicitis

• Functional Constipation (not due to a pathalogical/organic cause → mx w high fibre diet + laxatives)

• IBD

• Coeliac

• Infantile Colic

• Bowel Obstruction

Respiratory:

• LL Pneumonia

Urinary:

• Pyelonephritis

• UTI

Endocrine:

• DKA

Gynae:

• Ovarian/Testicular Torsion

• Pregnancy/Ectopic

Psych:

• Eating Disorder

• Anxiety

Generalised or Local Swelling

Systemic:

• Anaphylaxis

• Turner’s Syndrome (swelling in legs at birth)

• LN Swelling → Infection/Malignancy

• Neglect → Low Protein → Low Albumin → Malnutrition (risk of refeeding syndrome)

Neonatal:

• Caput Molding

• Cephalohaematoma

• Subgalial Haematoma

  • Measure head circumferance, mx hypovoleamia

Urinary:

• Nephrotic Syndrome (most common = minimal change disease!): Ix = Urine Protein:Creatinine ratio, Urine Albumin:Creatinine ratio, Serum Albumin, dipstick, UEC

  • Mx: prednisalone + diuretics

  • Monitoring: daily morning urine dipstick for 2-3yrs

• Nephritic Syndrome

• AKI

Cardio:

• HF/Congenital Defects

Dermatology:

• Cellulitis

Endocrine:

• Hypothyroidism

  • Myxedema, Edema, Goitre

• Protein-Energy Malnutrition (↓ protein → hypoalbuminaemia)

MSK:

• Fracture

• Non-Accidental Injury

• Septic Arthritis

• JIA

• Osteomyelitis

ENT:

• Peri/Orbital Cellulitis

• Mumps (Parotid Swelling)

• Diptheria (Bull Neck LNs)

Neuro:

• Neuroblastoma (‘raccoon eyes’)

The Pale Child

Haematological: Causes of Anaemia

• Coeliac: Ix = TTG-Ab + Scope

• Hamolysis: Ix = Blood Film (+ Coombs ± Hb Electrophoresis)

• B12 Deficiency

• High Milk Intake (low iron-rich foods + calcium inhibits iron absorption)

• Heavy Menstrual Bleeding

• ALL

• IBD

• Hypothyroidism (macrocytic anaemia)

Systemic:

• Hypotension

• Anaphylaxis

Cardio:

• CF

• Heart defects - cyanotic

• Infective endocarditis

sepsis/meningitis

pyloric stenosis

intasusseption

retinoblastoma

neuroblastoma

nephroblastoma

Neonatal:

• Prematurity

Ix: FBE, Iron Studies, TFT, Blood Film (+ Coombs if haemolytic)

Bruising or Abnormal Bleeding

Haematological:

• ITP

  • Preceeding viral illness

  • Painless oral ulcer = outpatient mx; Painful = inpatient mx

  • Mx = FBE/Review in a week, Corticosteroids → IVIG if moderate, Life-threatening = Platelets

• HSP: Ix = clinical dx ± BP monitoring

• Non-Accidental Injury

• Haemophilia: Ix = blood film, APTT/Clotting Times

  • Mx = replacement factor

• Von-Willebrand’s Disease (clotting disorder)

  • Mx = desmopressin

• Kawasaki

  • Warm CREAM: Warm = 4-5d fever, Conjunctivitis, Rash, Erythema of extremities, Adenopathy, Mucosal Changes

• ALL (thrombocytopaenia): Ix = blood film + bone marrow biopsy

  • FBE = low cells (blasts take over)

  • Blood Film = blasts (>20%)

  • Bone Marrow Biopsy = blasts

Infective Endocarditis

Meningitis - Meningococcal Disease

Sepsis

Chickenpox

Failure to thrive/weight loss

Infection → Poor Oral Intake

• Otitis media

Cancer

Inadequate Caloric Intake/Retention:

• Breastfeeding Difficulties/Inadequate Nutrition

• Restricted Diet (Beige Diet, Veganism etc)

• Persistent Vomiting (GER, GORD etc)

• Appetite Loss due to Chronic Disease (Cancer)

Inadequate Absorption:

• Cows Milk Protein Allergy

• Coeliac Disease

• Pancreatic Insufficiency (CF)

• Chronic Diarrhoea

• Chronic Liver Disease

Excessive Caloric Utilisation:

• UTI!!!

• Chronic Illness/Inflammation

• Chronic Respiratory Disease (CF)

• CHD

• DM

• Hyperthyroidism

Other Medical Causes:

• Genetic syndromes

• Metabolism errors

Psychosocial Factors:

• Food insecurity

• Parental mental illness

• Family Violence, Trauma, Neglect

Fits/Faints and Funny Turns

DKA/Hypoglycaemia, Infection, Brain Tumour, Epilepsy, Febrile Convulsion, HIE

>5min = call ambulance, may recur

Infection (Febrile Convulsions):

Most likely if 6m-6yrs with no other features = febrile convulsion (do LP if <6m)

Outside age range = more likely Meningitis, Epilepsy etc

• Meningitis

  • 0-2m = Benpen + Cefotaxime/Ceftriaxone

  • >2m = Cefotaxime/Ceftriaxone

• Sepsis = IV Cef

  • Early Onset Sepsis = Benpen + Gent

  • Late Onset Sepsis = Gent + Cefazolin

• PUO

• Otitis Media (if infant - picking at ears)

• Encephalitis

  • Different from meningitis due to unusual behaviour, seizures, confusion, focal neuro sx, maternal HSV

  • Give Cefotaxime/Ceftriaxone + Aciclovir

Neuro:

• Brain Tumour (balance, neuro/eye sx → do MRI)

• Epilepsy (>2 seizures in over 24hrs)

  • Mx = Levitoracetam (Non-Absence), Ethosuxamide (Abesence) if diagnosed

  • Record events/time (call 000 if >5min), advise for driving, educate carers

  • Biggest risk of recurrence after first seizure is the following 3m

• Cerebral Palsy

• Status Epilepticus

Endocrine:

• T1DM

• DKA

• Hypoglycaemia → nutritional deficiency

• Hyperthyroidism

Cardiac:

• Arrhythmia

• Valvular Issues

• Congenital Defects

Neonatal:

• Birth Asphyxia/HIE/Meconium Aspirate

  • RF = prolonged birth

• Foetal Alcohol Spectrum Disorder

Systemic:

• Hypotension/Anaphylaxis

• Asthma

Headache

Headache/Neuro:

• Migraine

  • Mx: Acute = NSAIDs/Analgesia, Avoid Triggers, Triptans; Prophylactic = Propranolol, Amytriptyline

• Cluster Headache

• Tension Headache

• Brain Tumour

• Medication Overuse Headache (if using migraine meds/analgesia for >50% of the month)

Infective:

• Meningitis

• URTI/Tonsillitis/Sinusitis

Pressure:

• HTN

• Raised ICP

Eye:

• Retinoblastoma

• Myopia (eye strain): Ix = Vision assessment/optometry

Respiratory:

• OSA

Ix = MRIB, Optometry review, Propranolol

Limp or Joint Pain

Infective:

• Osteomyelitis: Ix = MRI; Mx = Abx = IV Abx 3-6wks

• Septic Arthritis: Ix = Joint Aspirate; Mx = IV Abx 2-3wks (Cefazolin)

• Rheumatic Fever:

  • Sx = JONES, past sore throat

  • Ix: Throat Swab, Antistreptolysin O (ASO), Echocardiogram

  • Mx = Analgesia (avoids NSAIDs), Steroids, Benpen → IM abx for 10yrs or until age 21

Inflammatory/Haematological:

• JIA

• Kawasaki’s

• Cancer/ALL: Ix = Bone Marrow Biopsy

• HSP

  • Mx: supportive (analgesia ± steroids)

  • Follow-up = weekly BP + urine dipstick for 1m then fortnightly for 8wks

• Haemophilia (Haemarthrosis)/Bleeding Disorder

Traumatic/Structural:

• Orthopoedic: Osgood-Schlatter, Perthe’s, Transient Synovitis

• Fracture

• Non-Accidental Injury

Unwell Infant

Infection:

• UTI

Surgical:

• Intussusseption

• Pyloric Stenosis

• Duodenal Atresia

• Hirschsprung’s Disease

• Hernia

Jaundice

FTT

Eczema: Mx = Eczema Mx Plan

Benpen/Gent <48hrs, Fluclox/Cef >48hrs

Respiratory Distress of the Newborn

Respiratory/Airway:

• RDD (preterm):

  • Mx = surfactant, thermal stability/temperature control! mx, O2 (nasal CPAP), ?prophylactic abx, avoid PO (IV feeding)

• TTN (term, C-section):

  • Mx = (respiratory support as needed) PEEP/PEAK → Nasal Cannula → CPAP + Time (<72hrs)

• Meconium Aspiration (Mec-stained liquor):

  • Mx = clear mouth/nose (NOT trachea) + airway/breathing mx

Infective:

• Sepsis

Cardiac:

• Acyanotic = VSD, ASD, PDA (give NSAIDs if under 5kg)

• Cyanotic = Transposition of the Great Arteries (prostaglandins), TOF (surgery), Tricuspid Atresia

Endocrine/Systemic:

• Infant of Diabetic Mother (Hypoglycaemia: BGL <2.6): Mx = glucose gel + monitoring

Surgical/Structural:

• Diaphragmatic Hernia: Mx = Surgery

• Tracheo-Eosophageal Fistula

Jaundice of the Newborn

Physiological: natural bilirubin breakdown

Pathological: other cause

<24hrs: early onset

SBR, Coombs/DAAT, FBE

• Haemolysis: Rhesus, ABO

• Sepsis

24hrs-14d: prolonged

SBR, Coombs/DAAT, FBE, Blood Group, TFTs, ?LFTs

• Physiological

• Haemolysis

• Sepsis

• Dehydration

• Cephalohaematoma/Bruising/Birth Trauma

• Breastmilk jaundice (breastmilk stops breakdown of bilirubin)

• Breastfeeding jaundice (starvation jaundice → not enough intake)

• Congenital Hypothyroidism

• Biliary Atresia

>14d: long-term

SBR, Coombs/DAAT, FBE, Blood Group, TFTs, ?LFTs

• Congenital Hyperthyroidism (Sx = Poor Feeding, ↓ Tone, Large Tongue, Brady, Hernia, Cold Temp, FHx)

• Biliary Atresia

Conjugated Hyperbilirubinaemia:

SBR, Imaging (Abdo US), Coags

• Biliary Atresia/Extrahepatic Obstruction (choledocal cysts, Antitrypsin 1 def)

  • Consider pale stools, can be otherwise well

• Neonatal Hepatitis

Hx: Assess intake, stools, birth, FHx, general activity/lethargy

Mx: Phototherapy, Fluid Mx, Transfusion if severe ± abx, surgery, thyroxine

Paediatric History Elements

Best Friends Have Very Good Sex

• Birth (+ screening, heel prick etc)

• Feeding (breastfeeding, solids, variety)

• Hydration (fluids)

• Vaccinations (up to date, previous illnesses, hospitalisations)

• Growth/Development (progression, greenbook, academics/school, HEEADSSS)

• Sick Contacts/Sleep