Learning Points: Science & Scholarship

• Describe the pathophysiological basis of vomiting

  • Vomiting, or emesis, is a complex protective reflex designed to expel harmful substances from the stomach and upper intestine.

  • This reflex involves multiple components and pathways, integrating signals from the central nervous system, gastrointestinal tract, and other areas. Here’s a detailed explanation of the pathophysiology of vomiting:

  1. Central Nervous System Components

     • Vomiting Center:

       • Location: Medulla oblongata

       • Function: The primary control center that initiates the vomiting reflex

       • Receptors: Muscarinic receptors

       • Input: Receives signals from various sources, including the chemoreceptor trigger zone, labyrinth of the inner ear, higher brain centers, and the gastrointestinal tract.

     • Chemoreceptor Trigger Zone (CTZ):

       

       • Location: Area postrema, outside the blood-brain barrier, in the floor of the fourth ventricle.

       • Receptors: Dopamine and serotonin receptors

       • Function: Detects blood-borne toxins and chemicals (e.g., chemotherapy agents) and activates the vomiting center through muscarinic receptors

     • Labyrinth of the Inner Ear:

       • Function: Involved in motion sickness.

       • Pathway: Movements activate the vestibulocochlear nerve, which sends signals to the vestibular nuclei in the pons. This activates histamine and muscarinic receptors, relays to the CTZ, and finally to the vomiting center.

     • Higher Brain Centers:

       • Function: Emotional and sensory inputs (e.g., pain, repulsive sights or smells) can trigger vomiting.

       • Pathway: These inputs directly stimulate the vomiting center.

  2. Gastrointestinal Tract

     • Mechanoreceptors and Chemoreceptors:

     • Location: Throughout the gastrointestinal tract.

     • Function: Detect irritation, distension, and chemical stimuli.

     • Pathway: Signals from the vagal afferent nerves synapse in the nucleus tractus solitarius (NTS) in the medulla. Some neurons extend to the area postrema and other brain regions, contributing to the sensation of nausea.

     

     

  3. Vomiting Reflex Mechanism

     

     • Initiation:

       • The vomiting center sends efferent signals via cranial nerves V, VII, IX, X, and XII.

     • Physiological Responses:

       • Tachycardia: Increased heart rate.

       • Increased Saliva Production: Protects the teeth and mucosa from stomach acid.

       • Closure of Epiglottis: Prevents aspiration of vomitus.

       • Diaphragm Contraction: Creates negative thoracic pressure aiding in the expulsion of gastric contents

       • Relaxation of Lower Esophageal Sphincter: Allows contents to move from the stomach into the esophagus.

       • Contraction of Abdominal Muscles: Increases intra-abdominal pressure.

       • Anti-peristalsis: Reversal of normal peristaltic movement to push contents upwards.

     • Ejection Phase:

       • Gastric and Lower Esophageal Sphincter Relaxation: Facilitates the movement of stomach contents.

       • Retching: Preceding phase where the glottis closes, and respiratory muscles counteract abdominal contraction, preventing expulsion.

       • Final Expulsion: Chyme is forced upwards and expelled through the mouth.

     • Neurotransmitters Involved

       • Muscarinic M1 Receptors: Involved in the activation of the vomiting reflex

       • Dopamine D2 Receptors: Triggered by toxins and drugs in the CTZ

       • Histamine H1 Receptors: Play a role in motion sickness

       • 5-Hydroxytryptamine (5-HT)3 Receptors: Activated by serotonin in the gastrointestinal tract

       • Neurokinin 1 (NK1) Receptors: Substance P acts on these receptors in the vomiting center

• List the common causes of vomiting in infants and children including surgical and other causes

  • Infancy

    1. Gastroenteritis

       • Symptoms: Diarrhea (fluid stools), vomiting.

       • Cause: Viral or bacterial infection.

    2. Acute Infections

       • Examples:

         • Tonsillitis

         • Otitis media

         • Pneumonia

         • Meningitis

         • Urinary Tract Infection (UTI)

    3. Lesions of the GI Tract

       • Examples:

         • Duodenal obstruction from volvulus complicating malrotation

         • Strangulated inguinal hernia

         • Intussusception

    4. Gastroesophageal Reflux Disease (GORD)

       • Symptoms: Recurrent fussiness during or after feedings, poor weight gain, recurrent respiratory symptoms (e.g., cough, stridor, wheezing).

    5. Pyloric Stenosis

       • Symptoms: Recurrent projectile vomiting immediately after feeding in neonates aged 2–12 weeks, infrequent stools.

       • Infants may be emaciated (extremely thin or dehydrated) and dehydrated. Sometimes a palpable "olive" in the right upper quadrant.

       • Significance: Sudden onset of forceful, projectile vomiting, infants remain hungry/keen to feed, may contain blood, thickened pylorus felt.

    6. Malabsorption

       • Examples: Coeliac disease (not common).

    7. Intestinal Obstruction

       • Examples:

         • Meconium ileum

           • Meconium ileus is a condition in newborns where the meconium, which is the first stool passed by an infant, is abnormally thick and sticky, causing a blockage in the ileum, the final part of the small intestine

         • Volvulus

         • Intestinal malrotation

           • Intestinal malrotation refers to an abnormal rotation of the intestine during fetal development. This condition can lead to improper positioning of the intestines within the abdomen

         • Intestinal atresia

           • Intestinal atresia is a congenital condition where a portion of the intestine is absent, leading to a complete obstruction.

    8. Increased Intracranial Pressure (ICP)

       • Examples: Space-occupying lesion (e.g., trauma, tumor).

    9. Cyclical Vomiting Syndrome

       • Characteristics: Severe, discrete attacks of vomiting or nausea at varying intervals, with normal health between episodes and no demonstrable structural abnormalities.

  • Children

    1. Infections

       • Examples:

         • Respiratory tract infections

         • Gastrointestinal tract infections

    2. Acute Appendicitis and Peritonitis

       • Symptoms: Guarding, sometimes diarrhea.

    3. Poisoning

       • Examples: Ingestion of toxic substances.

    4. Migraine

       • Symptoms: Severe paroxysmal frontal headache with pallor, positive family history common.

    5. Intracranial Neoplasm

       • Symptoms: Signs of increased ICP, vomiting in the morning before breakfast.

    6. Psychological/Psychogenic Causes

       • Examples: Stress or anxiety-related vomiting.

    7. Cyclical Vomiting Syndrome

       • Characteristics: Exclusion diagnosis, periodic severe vomiting.

  • Surgical and Other Causes

    1. Intussusception

       • Symptoms: Colicky abdominal pain, inconsolable crying, lethargy, drawing of legs up to chest, later bloody ("currant jelly") stool. Typically ages 3–36 months but can be outside this range.

    2. Malrotation with Volvulus

       • Symptoms: In neonates, bilious emesis, abdominal distention, and pain, bloody stool.

    3. Sepsis

       • Symptoms: Fever, lethargy, tachycardia, tachypnea, widened pulse pressure, hypotension.

    4. Food Intolerance

       • Symptoms: Abdominal pain, diarrhea, possibly eczematous rash or urticaria.

    5. Other Medical Causes

       • Examples:

         • Urinary tract infection (UTI)

         • Meningitis

         • Raised intracranial pressure (ICP)

         • Metabolic disorders

    6. Surgical Causes

       • Examples:

         • Appendicitis

         • Surgical obstruction (e.g., adhesions)

         • Meckel’s diverticulum

  • Vomiting Clinical Scenarios

    • Acute Vomiting

      • Description: Discrete episode of moderate to high intensity, most common, usually associated with an acute illness.

      • Investigations:

        • Full Blood Count (FBC)

        • Urea & Electrolytes (U&E)

        • Creatinine

        • Stool for culture and virology

        • Abdominal X-ray (AXR)

        • Surgical opinion if obstruction or acute abdomen possible

        • Exclude systemic disease

      • Causes: GI infection, non-GI infection (e.g., UTI), GI obstruction (congenital or acquired), adverse food reaction, poisoning, raised intracranial pressure, endocrine/metabolic disease (e.g., diabetic ketoacidosis).

    • Chronic Vomiting

      • Description: Low-grade daily pattern, frequently with mild illness.

      • Investigations:

        • FBC

        • Erythrocyte Sedimentation Rate (ESR)/C-Reactive Protein (CRP)

        • U&E

        • Liver Function Tests (LFT)

        • Helicobacter pylori serology

        • Urinalysis

        • Abdominal ultrasound

        • Small bowel enema

        • Sinus X-rays

        • Test feed or abdominal ultrasound for pyloric stenosis

        • Brain imaging (CNS tumor)

        • Consider urine pregnancy testing in teenage girls

        • Upper GI endoscopy

      • Causes: Peptic ulcer disease, gastroesophageal reflux, chronic infection, gastritis, gastroparesis, food allergy, psychogenic, bulimia, pregnancy.

    • Cyclic Vomiting

      • Description: Severe, discrete episodes associated with pallor, lethargy, +/- abdominal pain. The child is well between episodes. Often a family history of migraine or vomiting.

      • Investigations:

        • As for chronic vomiting, plus:

          • Serum amylase

          • Serum lipase

          • Blood glucose

          • Serum ammonia

      • Causes: Usually non-GI cause, idiopathic, CNS disease, abdominal migraine, endocrine (e.g., Addison’s disease), metabolic (e.g., acute intermittent porphyria), intermittent GI obstruction, fabricated illness.

• More information

  • Distinguishing Features and Important Points for Vomiting in Infants and Children

    • Nature of Vomiting

      1. Bilious Vomiting

         • Indicates: Gastrointestinal (GIT) obstruction until proven otherwise.

         • Action: Requires urgent surgical referral.

      2. Blood in Vomit

         • Swallowed Blood:

           • Causes: Epistaxis (nosebleed), maternal blood due to delivery, or nipple trauma.

           • Action: Investigate source of blood.

         • Upper GI Hemorrhage:

           • Causes: Potential source if blood is present.

           • Action: Requires endoscopic evaluation.

      3. Projectile Vomiting

         • Indicates: Pyloric stenosis.

         • Action: Requires investigation and often surgical management.

      4. Early Morning Vomiting

         • Indicates: Raised intracranial pressure (ICP).

         • Action: Requires urgent evaluation for possible space-occupying lesion

    • Associated Signs and Symptoms

      1. Evidence of Diarrhea

         • Indicates: Gastroenteritis

      2. Fever or Systemic Illness

         • Indicates: Infection or sepsis

         • Action: Requires full sepsis workup and treatment

      3. Abdominal Distension and Tenderness

         • Indicates: GIT obstruction

         • Additional Clues: “Tinkling” or absent bowel sounds

      4. Headache

         • Indicates: Possible migraine, raised ICP, or infection

         • Action: Requires neurological evaluation

      5. Rectal Bleeding

         • Indicates: Gastroenteritis, colitis, intussusception, Meckel’s diverticulum.

      6. Bulging Fontanelle in Infants

         • Indicates: Raised ICP.

         • Action: Requires immediate investigation.

    • Specific Conditions

      • Meconium Ileus

        • Definition: Failure to pass the first stool in neonates (usually within the first 24-48 hours).

        • Cause: Cystic fibrosis (90% of cases)

        • Clinical Features: Signs of small bowel obstruction (bilious vomiting, abdominal distention, no passing of meconium)

        • Investigations: Abdominal X-ray (dilated small bowel loops, microcolon, Neuhauser signs - soap bubble appearance).

        • Management: Enema with a contrast agent, surgery in complicated cases.

      • Intestinal Malrotation

        • Definition: Abnormal or incomplete rotation of the gastrointestinal tract during fetal development.

        • Pathophysiology: Arrest in normal gut rotation leading to abnormal orientation of the bowel and mesentery.

        • Clinical Features: Mostly asymptomatic unless complicated by volvulus.

        • Associated Congenital Anomalies: Congenital diaphragmatic hernia, congenital heart defects, omphalocele (a birth defect in which the infant's intestine or other abdominal organs protrude through a hole in the belly button area and are covered with a membrane), Meckel’s diverticulum, esophageal atresia, biliary atresia.

        • Investigations: Upper GI series, barium enema, abdominal ultrasound, abdominal X-ray.

        • Management: Elective surgery (Ladd procedure).

      • Volvulus

        • Definition: Twisting of a loop of bowel on its mesentery.

        • Pathophysiology: Torsion of a malrotated gut leading to mechanical bowel obstruction.

        • Clinical Features:

          • Midgut Volvulus: Bilious vomiting, abdominal distention, signs of bowel ischemia (hematochezia, hematemesis, hypotension, tachycardia).

          • Gastric Volvulus: Severe abdominal pain, retching, inability to pass an NG tube.

          • Duodenal Obstruction: Bilious vomiting without abdominal distention.

        • Investigations: Upper GI series (duodenal obstruction, corkscrew duodenum), barium enema (Bird’s peak sign at the site of the twist), abdominal ultrasound (whirlpool sign), abdominal X-ray.

        • Management:

          • Initial: NPO, NGT insertion, IV fluids, broad-spectrum antibiotics.

          • Emergency Surgery (Ladd Procedure): Reduce/untwist the volvulus and remove Ladd bands.

      • Duodenal Atresia

        • Definition: Complete occlusion or absence of the duodenal lumen.

          

        • Epidemiology: Associated with chromosomal abnormalities, especially Down syndrome.

        • Pathophysiology: Failed or partial reuniting of the duodenum during the embryonic period.

        • Clinical Features:

          • Intrauterine: Polyhydramnios (excessive accumulation of amniotic fluid — the protective liquid contained within the amniotic sac of a pregnant woman)

          • Postpartum: Vomiting (bilious if stenosis is distal to the major duodenal papilla), distended upper abdomen, scaphoid lower abdomen, delayed meconium passage.

            

        • Investigations:

          • Prenatal: Ultrasound (double bubble sign).

          • Postnatal: Abdominal X-ray (gasless distal bowel).

        • Management:

          • Initial Management: IV fluids, NGT for gastric decompression.

          • Surgical Management: Bypass of the atresia or stenosis.

• List the common causes of abdominal pain in infants and children; Including surgical causes

  • Infants and Children

    • Gastrointestinal Causes

      1. Gastroenteritis

      2. Appendicitis

      3. Mesenteric Lymphadenitis

      4. Constipation

      5. Abdominal Trauma

      6. Intestinal Obstruction

      7. Peritonitis

      8. Food Poisoning

      9. Peptic Ulcer

      10. Meckel's Diverticulum

      11. Inflammatory Bowel Disease (IBD)

      12. Lactose Intolerance

      13. Hepatitis

      14. Cholecystitis

      15. Cholelithiasis

      16. Choledocholithiasis

      17. Splenic Infarction

      18. Splenic Rupture

      19. Pancreatitis

    • Genitourinary Causes

      1. Urinary Tract Infection (UTI)

      2. Urinary Calculi

      3. Dysmenorrhea

      4. Mittelschmerz

      5. Pelvic Inflammatory Disease (PID)

      6. Threatened Abortion

      7. Ectopic Pregnancy

      8. Ovarian/Testicular Torsion

      9. Endometriosis

    • Metabolic Disorders

      1. Diabetic Ketoacidosis (DKA)

      2. Hypoglycemia

      3. Porphyria

      4. Acute Adrenal Insufficiency

      5. Hematologic Disorders

      6. Sickle Cell Anemia

      7. Henoch-Schonlein Purpura

      8. Hemolytic Uremic Syndrome

    • Miscellaneous Causes

      1. Drugs and Toxins

         • Erythromycin

         • Salicylates

         • Lead Poisoning

         • Venoms

      2. Pulmonary Causes

         • Pneumonia

         • Diaphragmatic Hernia

         • Pleurisy

  • Time-Critical Causes of Abdominal Pain by Age

    • Neonates

      1. Hirschsprung Enterocolitis

         • Hirschsprung enterocolitis is an inflammatory condition of the bowel that occurs in patients with Hirschsprung disease. It involves inflammation of the colon and can lead to severe complications such as sepsis and bowel perforation.

         • Etiology (Causes)

           1. Hirschsprung Disease:

              • The primary underlying cause is Hirschsprung disease, where a segment of the colon lacks nerve cells (ganglion cells), leading to chronic obstruction and stasis of intestinal contents.

           2. Bacterial Overgrowth:

              • Stasis of intestinal contents can promote bacterial overgrowth and translocation, contributing to the development of enterocolitis.

           3. Mucosal Barrier Dysfunction:

              • The absence of ganglion cells can impair mucosal barrier function, making the bowel more susceptible to inflammation and infection.

      2. Incarcerated Hernia

      3. Intussusception

      4. Necrotizing Enterocolitis

      5. Volvulus

    • Infants and Children

      1. Abdominal Trauma

      2. Appendicitis

      3. Constipation

      4. Gastroenteritis

      5. Incarcerated Hernia

      6. Intussusception

      7. Meckel's Diverticulum

      8. Mesenteric Adenitis

      9. Ovarian Torsion

      10. Pyloric Stenosis

      11. Testicular Torsion

      12. Volvulus

    • Adolescents

      1. Appendicitis

      2. Abdominal Trauma

      3. Cholecystitis/Cholelithiasis

      4. Constipation

      5. Ectopic Pregnancy

      6. Gastroenteritis

      7. Inflammatory Bowel Disease (IBD)

      8. Ovarian Cyst – Torsion/Rupture

      9. Pancreatitis

      10. Pelvic Inflammatory Disease (PID)

      11. Renal Calculi

      12. Testicular Torsion

    • Important Non-Abdominal Causes of Abdominal Pain

      1. Diabetic Ketoacidosis (DKA)

      2. Headache (Migraine)

      3. Henoch-Schonlein Purpura

      4. Hip Pathology

      5. Pneumonia

      6. Psychological Factors

      7. Sepsis

      8. Sexually Transmitted Infection

      9. Sickle Cell Disease (Vaso-occlusive Crisis)

      10. Toxin Exposure or Overdose

      11. UTI/Pyelonephritis

    • Detailed Information on Specific Conditions

      • Hirschsprung Enterocolitis

        • Characterized by: An aganglionic colon segment (usually rectosigmoid) that fails to relax.

        • Epidemiology: Affects 1 in 5000 newborns, more common in males (4:1).

        • Cause: RET gene mutations associated with MEN2 and familial Hirschsprung disease.

        • Pathophysiology: Genetic mutation → defective migration of parasympathetic neuroblasts → absence of Meissner and Auerbach plexuses → aganglionic colon segment → inability to control intestinal wall muscles → uncoordinated peristalsis + slow motility → stenosis and functional obstruction → megacolon.

        • Clinical Features:

          • Early: Delayed passage of meconium, distal intestinal obstruction, tight anal sphincter, explosive stool on DRE.

          • Late: Chronic constipation, poor feeding, failure to thrive.

        • Investigations: Abdominal X-ray, barium enema.

        • Complications: Toxic megacolon, fecal incontinence, urinary dysfunction, erectile dysfunction, bowel perforation.

        • Management: Initial medical management (fluids, NGT, IV antibiotics), surgical correction.

      • Intussusception

        

        • Characterized by: Invagination of a proximal bowel segment into a distal lumen, most often occurs at the ileocecal valve.

        • Epidemiology: Most common between 2 months and 2 years, more common in males.

        • Cause: Idiopathic (90%) or pathological lead points (e.g., Meckel's diverticulum, polyps).

        • Pathophysiology: Imbalance in bowel wall → invagination (Invagination, in a medical context, refers to the process where a part of the intestine folds into an adjacent section) → venous impairment → ischemia → sloughed bowel wall → necrosis and perforation.

        • Clinical Features: Cyclic colicky abdominal pain, palpable sausage-shaped mass, red currant jelly stools, vomiting, high pitched bowel sounds, lethargy, pallor.

        • Investigations: Enema, ultrasound, abdominal X-ray.

        • Management: IV fluid resuscitation, NPO, analgesia, NGT, IV antibiotics, enema, surgical reduction if necessary.

      • Necrotizing Enterocolitis

        • Characterized by: Hemorrhagic necrotizing inflammation of the intestinal wall.

        • Epidemiology: Most common cause of acute abdomen in premature infants, typically between 2-4 weeks of life.

        • Cause: Unknown; factors include intestinal wall perfusion and motility disorders, microbial overgrowth, formula feeding, rapid increase in enteral nutrition.

        • Clinical Features: Lethargy, distended abdomen, gastric retention, vomiting, diarrhea, rectal bleeding, abdominal tenderness.

        • Investigations: FBC, ESR/CRP, coagulation studies, ABG, blood cultures, abdominal X-ray, portal vein gas.

        • Management: Supportive care, stop enteral feeding, decompression via NGT, IV antibiotics, radiographic monitoring, surgical intervention if needed.

      • Meckel's Diverticulum

        • Characterized by: A true diverticulum located approximately 2 feet proximal to the ileocecal valve.

        • Epidemiology: Most common congenital GIT abnormality, present in 2% of the population.

        • Pathophysiology: Persistence of the omphalomesenteric duct.

        • Clinical Features: Lower GI bleeding, bowel obstruction symptoms, diverticulitis symptoms.

        • Investigations: Meckel scintigraphy scan, CT angiography.

        • Management: Surgical resection if symptomatic.

      • Mesenteric Lymphadenitis

        • Characterized by: Enlargement and inflammation of mesenteric lymph nodes.

        • Epidemiology: Common in children under 15.

        • Cause: Yersinia species, beta-hemolytic streptococcus, E. coli, Strep viridans.

        • Clinical Features: Abdominal pain, fever, diarrhea, malaise, anorexia, nausea, vomiting.

        • Investigations: CT abdomen and pelvis.

        • Management: Supportive care, empirical antibiotics.

      • Pyloric Stenosis

        • Characterized by: Hypertrophy and hyperplasia of the pyloric sphincter.

        • Epidemiology: Most common cause of gastric outlet obstruction in infants, more common in males and firstborn children.

        • Causes: Environmental factors, genetic factors, macrolide antibiotics.

        • Clinical Features: Projectile non-bilious vomiting, palpable olive-shaped pylorus, peristaltic wave, "hungry vomiter."

        • Investigations: Abdominal ultrasound, UEC.

        • Management: Pyloromyotomy.

          • Pyloromyotomy involves making an incision in the outer layer of the hypertrophied pyloric muscle to relieve the obstruction.

• Describe the main causes and mechanisms for abnormal growth patterns

  • Abnormal Growth Patterns

    • Abnormal growth patterns can be divided into:

      1. Failure to thrive

      2. Short stature

      3. Tall stature

  • Failure to Thrive

    • Causes

      Mechanism	Specific Causes
      Inadequate Calorie Intake/Retention	- Inadequate nutrition (breastmilk, formula, and/or food)
      	- Breastfeeding difficulties
      	- Error in infant formula preparation
      	- Restricted diet (e.g., restricting food groups, vegan, sensory aversions)
      	- Structural (e.g., cleft palate)
      	- Persistent vomiting
      	- Appetite loss due to chronic disease
      	- Early (<4 months) or delayed (>6 months) introduction of solids
      Inadequate Absorption	- Cow milk protein allergy
      	- Coeliac disease (if having gluten-containing diet)
      	- Pancreatic insufficiency (e.g., cystic fibrosis)
      	- Chronic diarrhea
      	- Chronic liver disease
      Excessive Caloric Utilization	- Urinary tract infection
      	- Chronic illness/inflammation
      	- Chronic respiratory disease (e.g., cystic fibrosis)
      	- Congenital heart disease
      	- Diabetes mellitus
      	- Hyperthyroidism
      Psychosocial Factors	- Parental mental illness, disability, or chronic illness
      	- Poor carer understanding (e.g., language barrier, limited literacy)
      	- Non-secure attachment patterns
      	- Behavioral disorders
      	- Difficulties at meal times
      	- Coercive feeding (including feeding child while asleep)
      	- Food insecurity
      	- Social isolation
      	- Failure to attend appointments
      	- Parental substance abuse
      	- Family violence
      	- Trauma or neglect
      	- Current or past child protection involvement
      Other Medical Conditions	- Genetic syndromes
      	- Inborn errors of metabolism

    • Investigations

      • Bedside: Urinalysis, urine MCS, stool MCS, fat globules, fatty acid crystals, fecal calprotectin.

      • Bloods: FBC, UEC, LFT, ESR, iron studies, TSH, glucose, coeliac serology and total IgA (if on solid or feeds containing gluten), vitamin B12.

  • Short Stature

    • Causes

      Mechanism	Specific Causes
      Normal Variants of Growth	- Familial short stature
      	- Constitutional delay of growth and puberty
      	- SGA (small gestational age) infant with catch-up growth
      Systemic	- Undernutrition
      	- Glucocorticoid therapy
      	- GI disease (especially IBD)
      	- Rheumatological disease (e.g., systemic-onset juvenile idiopathic arthritis)
      	- Renal disease (e.g., CKD, renal tubular acidosis)
      	- Cancer
      	- Pulmonary disease (e.g., cystic fibrosis, severe asthma)
      	- Immunodeficiency
      Endocrine Diseases	- Hypothyroidism
      	- GH deficiency
      	- Precocious puberty
      	- Cushing syndrome
      	- Pseudohypoparathyroidism type 1
      Genetic Diseases	- Turner syndrome
      	- SHOX mutations
      Skeletal Dysplasias	- Osteogenesis imperfecta
      	- Achondroplasia
      	- Hypochondroplasia

      • Investigations

        • Bedside: Urinalysis

        • Bloods: FBC, UEC, CMP, CRP/ESR, TSH, cortisol studies, coeliac serology, ANA screening, GH, IGF-1, FSH, LH

        • Imaging: Bone age (X-ray of the wrist)

        • Other: GH stimulation test, karyotype analysis

  • Tall Stature

    • Causes

      • In Infancy

        Mechanism	Specific Causes
        Causes in Infancy	- Infant of a diabetic mother
        	- Cerebral gigantism
        	- Beckwith-Wiedemann syndrome

      • In Childhood or Adolescence

        Mechanism	Specific Causes
        Endocrine Disorders	- Familial/constitutional tall stature
        	- Precocious puberty
        	- Growth hormone excess
        	- Hyperthyroidism
        	- Sex hormone deficiency or insensitivity
        	- Familial glucocorticoid deficiency/resistance
        Non-Endocrine Disorders	- Exogenous obesity
        	- MC4R mutation
        	- Klinefelter syndrome (47XXY)
        	- 47, XYY
        	- Marfan syndrome

      • Investigations

        • Bloods: TSH, GH, IGF-1, LH, FSH, testosterone levels, serum cortisol, serum prolactin

        • Imaging: Bone age (X-ray of the wrist)

        • Other: Karyotype analysis

  • Detailed Information on Specific Conditions

    1. Cow Milk Protein Allergy

       • Epidemiology: One of the most common food allergies in children, affects 1-2% of preschool children.

         • Pathophysiology: IgE antibodies against milk proteins.

         • Risk Factors: Family history, atopic disease, allergic disease.

         • Clinical Features:

           • Mild to Moderate Reactions: Hives, swelling of the lips/face/eyes, tingling of the mouth, abdominal pain, vomiting.

           • Severe Reactions (Anaphylaxis): Difficulty/noisy breathing, swelling of the tongue, persistent cough, dizziness, collapse.

         • Investigations: Allergy skin prick test, RAST test.

         • Management: Diet free of cow’s milk and cow’s milk products.

         • Prognosis: 90% of children with delayed reactions and 50% with immediate reactions will outgrow their allergy by 3-5 years of age.

       1. Short Stature

          • Physiological Causes:

            • Familial short stature

            • Constitutional delay of growth and puberty

            • Small for gestational age infant with catch-up growth

            • Idiopathic short stature

          • Pathological Causes:

            • Defects of nutrition, digestion, or absorption

            • Social and emotional deprivation

            • Chronic disease (e.g., rheumatologic, CKD, cancer)

            • Genetic syndromes (e.g., Turner syndrome in girls)

            • Endocrine (e.g., deficiency of thyroid or growth hormone)

            • Iatrogenic (e.g., long-term steroid therapy)

            • Disorders of bone growth (e.g., skeletal dysplasia)

          • Investigations: Urinalysis, blood tests (FBC, UEC, CMP, etc.), imaging (bone age X-ray), GH stimulation test, karyotype analysis.

       2. Tall Stature

          • Causes of Overgrowth in Infancy:

            • Infant of a diabetic mother

            • Cerebral gigantism

            • Beckwith-Wiedemann syndrome

          • Causes of Overgrowth in Childhood or Adolescence:

            • Familial/constitutional tall stature

            • Endocrine disorders (e.g., precocious puberty, growth hormone excess, hyperthyroidism)

            • Non-endocrine disorders (e.g., exogenous obesity, Klinefelter syndrome, Marfan syndrome)

          • Investigations: TSH, GH, IGF-1, LH, FSH, testosterone levels, serum cortisol, serum prolactin, bone age X-ray, karyotype analysis.

• Describe the pathophysiology for the common causes of chronic abdominal pain and or diarrhoea in children (Coeliac disease, IBD)

  • Coeliac Disease

    • Coeliac disease is an autoimmune disorder characterized by an abnormal immune response to gluten, a protein found in wheat, rye, and barley.

      • Genetic Predisposition:

        • Majority of patients carry one of two major histocompatibility complex class-II molecules: HLA-DQ2 (95%) and HLA-DQ8 (5%).

      • Immune Response:

        • Loss of immune tolerance to gluten-derived peptides (gliadin) leads to the activation of an antigen-specific T-cell response.

        • Gluten peptides are resistant to human proteases and persist intact in the small intestinal lumen.

        • These peptides access the lamina propria through:

          • Faulty tight junctions.

          • Endothelial cell transcytosis.

          • Dendritic cell sampling of the intestinal lumen.

          • Passage during the resorption of apoptotic villous enterocytes.

      • Innate and Adaptive Immune Activation:

        • In the intestinal submucosa, gluten peptides trigger both innate and adaptive immune activation:

          • Innate Response:

            • Gluten peptides stimulate IL-15 production by dendritic cells, macrophages, and intestinal epithelial cells, leading to epithelial damage via intra-epithelial lymphocytes.

          • Adaptive Response:

            • In the submucosa, gluten peptides are deamidated by tissue transglutaminase (tTG), allowing high-affinity binding to HLA-DQ2 or DQ8.

            • This triggers activation of helper T (Th) cells, leading to:

              • Cell death and tissue remodeling with villous atrophy and crypt hyperplasia.

              • Th2-mediated plasma cell maturation and production of anti-gliadin and anti-tTG antibodies.

      • Associated Conditions:

        • Positive family history, Type 1 diabetes, Down syndrome, and IgA deficiency.

      • Presentation:

        • Initial Features:

          • Pallor, diarrhea, pale bulky floating stools, anorexia, failure to thrive (FTT), irritability.

        • Later Features:

          • Apathy, gross motor developmental delay, ascites, peripheral edema, anemia, delayed puberty, arthralgia, hypotonia, muscle wasting, specific nutritional disorders.

      • Investigations:

        • Bedside: Urinalysis, stool MCS.

        • Bloods: IgA tissue transglutaminase antibody (tTG IgA), total IgA, deamidated gliadin peptide, FBC (iron, folate, B12 deficiency anemia), endomysial antibody (EMA), HLA testing.

        • Other: Upper endoscopy and biopsy (villous atrophy, crypt hyperplasia, intraepithelial lymphocyte infiltration), skin biopsy (if dermatitis herpetiformis).

      • Management:

        • Consultation with a dietician.

        • Education about the disease.

        • Lifelong adherence to a strict gluten-free diet.

        • Identification and treatment of nutritional deficiencies (iron, vitamin D, B12, folate).

        • Continuous long-term follow-up by a multidisciplinary team (serology, FBC, TSH, vitamin D).

    

  • Inflammatory Bowel Disease (IBD)

    • IBD encompasses Crohn's disease and ulcerative colitis, both of which involve chronic relapsing inflammation of the gastrointestinal tract.

    • Crohn's Disease

      • Pathology:

        • Chronic relapsing inflammation with "skip lesions" affecting any part of the GIT.

        • Involves transmural inflammation (including the serosa), fissured ulceration, "cobblestone" appearance, and granuloma formation.

        • Commonly involves the ileum (80% of cases) and rectum (25% of cases).

      • Aetiology:

        • Genetic: Mutations in CARD15 (NOD2).

        • Environmental: Cigarette smoking, oral contraceptives, high refined sugar diet, nutritional deficiencies, infectious agents, NSAIDs.

      • Main Clinical Features:

        • Persistent or grumbling pain with severe acute attacks.

        • Diarrhea less prominent (without blood), rectal bleeding less common.

        • Abdominal mass relatively common, abdominal pain/tenderness.

        • Extra-intestinal manifestations include arthritis, uveitis, erythema nodosum, pyoderma gangrenosum, primary sclerosing cholangitis, vitamin B12 deficiency.

      • Complications:

        • Strictures, fistulae, anal and perianal lesions, massive hemorrhage, incomplete obstruction, toxic megacolon.

    • Ulcerative Colitis

      • Pathology:

        • Recurrent acute inflammation with intervening quiescent phases, continuous involvement of the affected colon.

        • Confined to the mucosa and submucosa, with widespread superficial ulceration, pseudopolyps.

      • Aetiology:

        • Genetic: 10% have a 1st-degree relative affected, higher incidence in Ashkenazi Jews.

        • Environmental: Higher incidence in developed countries, smoking protective, previous enteric infections increase risk.

        • Immunologic: Impaired epithelial barrier, reduced dendritic cell numbers, exaggerated Th2 cell response.

      • Main Clinical Features:

        • Severe diarrhea with blood, tenesmus, rectal bleeding very common.

        • Abdominal pain and tenderness.

        • Extra-intestinal manifestations include arthropathy, eye, skin, and biliary tract disorders, anemia.

      • Complications:

        • Strictures rare, fistulae rare, massive hemorrhage, toxic megacolon, high risk of malignant change with severe or longstanding disease.

  • Pathophysiology Overview

    Condition	Pathophysiology
    Coeliac Disease	Autoimmune response to gluten, leading to villous atrophy, crypt hyperplasia, and malabsorption due to an immune response triggered by gliadin peptides.
    Crohn's Disease	Immune dysregulation and chronic relapsing inflammation with transmural involvement, skip lesions, granuloma formation, leading to fibrosis, strictures, and fistulae.
    Ulcerative Colitis	Chronic inflammation confined to the mucosa and submucosa with continuous colonic involvement, leading to widespread ulceration, pseudopolyps, and increased risk of colorectal cancer.

    

  • Detailed Descriptions:

    1. Coeliac Disease:

       • Epidemiology: Females > males, bimodal peak incidence (8-12 months, 30-40s), more common in individuals of northern European descent.

       • Cause: Genetic predisposition (HLA-DQ2, HLA-DQ8), associated with autoimmune diseases.

       • Pathophysiology: Consumption of gluten triggers chronic intestinal inflammation due to an autoimmune response, leading to epithelial damage, villous atrophy, crypt hyperplasia, and malabsorption.

       • Clinical Features:

         • Gastrointestinal: Chronic or recurring diarrhea (steatorrhea), flatulence, abdominal bloating and pain, nausea, vomiting, lack of appetite.

         • Extraintestinal: Vitamin deficiency, iron deficiency anemia, fatigue, weight loss, osteoporosis, hypocalcemia, failure to thrive, growth failure, delayed puberty, dermatitis herpetiformis, neuropsychiatric symptoms, reduced fertility or infertility, autoimmune thyroid disease, type 1 diabetes mellitus, Turner syndrome, Down syndrome, rheumatoid arthritis, sarcoidosis, selective IgA deficiency.

       • Investigations: IgA tissue transglutaminase antibody (tTG IgA), total IgA, deamidated gliadin peptide, FBC, endomysial antibody (EMA), HLA testing, upper endoscopy and biopsy, skin biopsy (if dermatitis herpetiformis).

       • Management:

         • Consultation with dietician

         • Education about disease

         • Lifelong adherence to strict gluten-free diet - abdominal discomfort lessens within days and diarrhoea within weeks.

         • Identification and treatment of nutritional deficiencies - iron, vitamin D, B12, folate.

         • Access to an advocacy group

         • Continuous long term follow up by a multidisciplinary team

           • Serology at 6 month intervals until levels normalise, then annually.

           • Measure FBC, TSH, vitamin D.

           • Monitor growth of child

    2. IBD (Crohn's Disease and Ulcerative Colitis):

       • Epidemiology: More common in whites, particularly individuals of Ashkenazi Jewish descent, with 10-20% of IBD cases diagnosed during childhood. Peak age of onset at 15-29 years.

       • Risk Factors: Genetic predisposition (HLA-B27), smoking, oral contraceptive use, NSAIDs, high refined sugar diet, previous intestinal infection.

       • Pathophysiology:

         • Crohn's Disease: Dysregulation of Th17 signaling, immune dysregulation, NOD2 mutations leading to unregulated inflammation, transmural involvement, "skip lesions," granuloma formation.

         • Ulcerative Colitis: Abnormal host immune response to commensal bacteria, Th2-mediated response, continuous inflammation from the rectum proximally, confined to mucosa and submucosa.

       • Pattern of involvement

         • Ulcerative colitis

           • Inflammation is limited to the mucosa and submucosa.

           • Ascending inflammation beginning in the rectum and moves retrograde the colon.

           • In children, the disease is often pancolonic at diagnosis.

         • Crohn’s disease

           • Inflammation is transmural (i.e. affects the full thickness of the GI wall)

           • Most commonly infects the terminal ileum and colon.

           • Any part of the GIT can be involved, but the rectum is generally spared.

           • Inflammation is irregular and does not occur continuously throughout the GIT.

           • In children, upper GI involvement is more common than in adults.

       • Clinical Features:

         • Crohn's Disease: Chronic watery diarrhea, perianal fistulas and abscesses, malabsorption, abdominal pain, palpable abdominal mass.

         • Ulcerative Colitis: Bloody diarrhea with mucus, fecal urgency, abdominal pain and cramps, tenesmus.

       • Investigations:

         • Laboratory studies and stool tests

           • FBC: anaemia

           • LFT

           • UEC: electrolyte abnormalities from diarrhoea and dehydration.

           • ↑ ESR + CRP

           • Stool:

           • MCS: Microscopy, culture, sensitivities

           • OCP: Ova, cysts, parasites

         • Confirm diagnosis: colonoscopy & biopsy

           • Colonoscopy findings:

           • Ulcerative colitis: Circumferential inflammation or ulceration that is continuous throughout a section of rectum/ colon. Friable mucosa with bleeding on contact with endoscope.

           • Crohn’s disease: “Skip lesions” with cobblestone appearance - linear patches of damaged tissue with normal patches of mucosa in between. Usually does not involve the rectum.

         • Biopsy findings:

           • Ulcerative colitis: Neutrophil infiltration limited to the mucosa and submucosa. Crypt abscesses (due to aggression of lymphocytes) => crypt atrophy.

           • Crohn’s disease: Transmural inflammation. Inflammatory cells and non-caseous sarcoid granulomas.

         • Radiological studies

           • Plain x ray

           • Barium enema radiography

       • Management

         • Non-pharmacological therapy

           • Multidisciplinary team involvement - paediatrician, gastroenterologist, GP.

           • Education

           • Dietetic assessment

           • Consider social work, psychological or other allied health services.

           • Group support

           • Vaccination - ensure vaccinations are up to date and commence live vaccinations prior to starting immunosuppressive therapy. After therapy begins, NO LIVE vaccinations.

         • Pharmacological therapy

           • Ulcerative colitis

             • Acute flare

               • Mild to moderate:

               • Oral 5-aminosalicylate (induction)

               • If unresponsive, add oral prednisone

               • Moderate to severe:

               • IV hydrocortisone or methylprednisolone

               • If unresponsive, add IV infliximab or ciclosporin

             • Chronic (i.e. maintenance therapy)

               • Rectal and/or Oral 5-aminosalicylate

               • If unresponsive, add oral azathioprine, mercaptopurine or methotrexate

               • If unresponsive, add IV infliximab

• Gastroenteritis in children

  • Briefly describe common causes, investigations and treatment; antibiotics, fluid management, electrolyte management, antiemetics / antidiarrhoeal agents

    • Gastroenteritis in Children:

      • Common Causes

        • Viral Gastroenteritis:

          • Transmission: Faecal-oral route, often through contaminated water. Common during winter. Breastfeeding provides some protection. More severe in malnourished children.

          • Causes:

            • Rotavirus (most common before vaccination)

            • Norovirus

            • Enteric adenovirus

            • Astrovirus

            • Cytomegalovirus (CMV in immunocompromised patients)

        • Bacterial Gastroenteritis:

          • Sources of Infection: Contaminated water, poor food hygiene (meat, fresh produce, chicken, eggs, previously cooked rice). Most common in children under 2 years old.

          • Causes:

            • Salmonella spp.

            • Campylobacter jejuni

            • Shigella spp.

            • Yersinia enterocolitica

            • Escherichia coli

            • Clostridium difficile

            • Bacillus cereus

            • Vibrio cholerae

      • Presentation

        • Viral Gastroenteritis:

          • Watery diarrhea (rarely bloody)

          • Vomiting

          • Cramping abdominal pain

          • Fever

          • Dehydration

          • Electrolyte disturbances

          • Upper respiratory tract signs common with rotavirus

          • Vomiting predominates with norovirus

        • Bacterial Gastroenteritis:

          • Secretory and inflammatory diarrhea

          • Symptoms similar to viral gastroenteritis plus:

            • Malaise

            • Dysentery (bloody and mucous diarrhea)

            • Abdominal pain mimicking appendicitis or IBD

            • Tenesmus

      • Complications

        • Viral:

          • Prominent UGI symptoms (N/V)

          • Acute, resolves within 24-48h

          • Possible secondary cases due to person-to-person transmission

        • Bacterial:

          • Bacteraemia

          • Secondary infections (pneumonia, osteomyelitis, meningitis)

          • Reiter’s syndrome (Shigella, Campylobacter)

          • Haemolytic-uraemic syndrome (E. coli O157, Shigella)

          • Guillain-Barré syndrome (Campylobacter)

          • Reactive arthropathy (Yersinia)

          • Haemorrhagic colitis

        • Toxin-mediated:

          • N/V and abdominal pain prominent

          • Diarrhoea occurs later

          • Short incubation period (several hours)

          • Closely clustered cases

          • Infections arise from a single point source

      • Investigations

        • Assess degree of dehydration: Use weight change, signs, vital signs, pallor (blood loss), abdominal tenderness, signs of associated illness (e.g., petechial rash in HSP).

        • Calculate fluid deficit

        • Faecal samples for bacterial culture if significant abdominal pain or blood in faeces.

        • C. difficile infection: Based on clinical features (diarrhoea, ileus, toxic megacolon) and microbiological evidence or colonoscopy findings.

        • Stool microbiological investigations: If diarrhea persists beyond 7 days, suspicion of septicaemia, blood/mucus in stool, or immunocompromised child.

        • Blood tests: For severe dehydration, renal disease, altered conscious state, 'doughy' skin (hypernatraemia), home therapy with hypertonic/hypotonic fluids, profuse losses, ileostomy.

      • Treatment

        • Antibiotics:

          • Most acute diarrhoea is viral and does not require antibiotic therapy

          • Empirical antibiotics are usually not indicated for community-acquired infectious diarrhoea

          • In children with bloody diarrhoea without fever or sepsis, empirical antibiotic therapy is not recommended due to the risk of precipitating haemolytic uraemic syndrome (HUS) if the infection is caused by enterohaemorrhagic Escherichia coli

          • Empirical therapy is indicated or should be considered in some groups.

            • Empirical antibiotics are indicated for patients with manifestations of severe disease

            • Consider empirical antibiotics in immunocompromised patients, even if they do not have clinical features suggesting severe disease, as they are at greater risk of rapid deterioration and poor outcomes

            • There is evidence that empirical antibiotic therapy shortens the duration of illness by 1-3 days in returned travellers with acute diarrhoea

          • If empirical antibiotic therapy for acute infectious diarrhoea is indicated, obtain samples for faecal testing before starting therapy → use:

            • Ciprofloxacin 500mg (child: 12.5mg/kg up to 500mg) orally, 12-hourly for 3 days

            • Norfloxacin 400mg (child: 10mg/kg up to 400mg) orally, 12-hourly for 3 days

          • If the infection is likely to have been acquired in an area where quinolone resistance is common (e.g. South and East Asia), or an oral suspension is required (e.g. for young children), consider: azithromycin 500mg (child: 10mg/kg up to 500mg) orally, daily for 3 days

          • If oral therapy is not tolerated or absorption is likely to be impaired, consider: ceftriaxone 2g (child ≥1mth: 50mg/kg up to 2g) IV, daily for 3 days

          • C. difficile infection:

            • First episode:

              • Metronidazole 400mg (child: 10mg/kg up to 400mg) orally or enterally, 8-hourly for 10 days

              • OR vancomycin 125mg (child: 10mg/kg up to 125mg) orally or enterally, 6-hourly for 10 days

              • There is evidence that vancomycin has similar efficacy to metronidazole in this setting; however, for antimicrobial stewardship reasons, it is not the preferred drug

            • First recurrence or refractory disease

              • Vancomycin 125mg (child: 10mg/kg up to 125mg) orally or enterally, 6-hourly for 10 days

              • OR fidaxomicin 200mg orally, 12-hourly for 10 days

            • Second and subsequent recurrences or ongoing refractory disease

              • Vancomycin 10mg/kg up to 125mg orally or enterally, 6-hourly for 14 days

              • OR nitazoxanide 100mg (for children 1-3y/o) or 200mg (for children ≥4y/o) orally, 12-hourly for 10 days

            • Severe infection

              • Vancomycin 125mg (child: 10mg/kg up to 125mg) orally or enterally, 6-hourly for 10 days

              • IV vancomycin is not effective against C. difficile infection due to inadequate penetration of the drug into the lumen of the colon

              • In complicated cases (e.g. hypotension or shock, ileus, megacolon), in addition to oral or enteral vancomycin à use: metronidazole 500mg (child: 12.5mg/kg up to 500 mg) IV, 8-hourly for 10 days

              • Consider adding intracolonic vancomycin, particularly in the presence of ileus → use: vancomycin 500mg in 100mL sodium chloride 0.9% rectally (via rectal tube), administered as a retention enema, 6-hourly

              • Early surgical referral is indicated for patients with severe disease, because outcomes are poor after organ dysfunction is established

              • Patients with severe disease may require a colectomy to survive, particularly if toxic megacolon develops

              • Faecal microbiota transplantation (FMT) can also be considered

        • Fluid Management:

          • Children with minimal or no dehydration should be encouraged to continue eating and drinking as tolerated

          • Oral rehydration solutions are strongly recommended for patients at risk of dehydration (e.g. infants and toddlers, children having frequent episodes of vomiting or diarrhoea)

          • Children with mild to moderate dehydration can be adequately rehydrated with an oral rehydration solution

            • Contain a balanced quantity of sodium and glucose and other electrolytes e.g. potassium and chloride

            • Sodium concentrations of 45-60mmol/L, glucose concentrations of 80-120mmol/L and total osmolarity of about 240mOsm/L

          • Nasogastric rehydration (NGTR)

            • Most children stop vomiting after NGT fluids are started

            • If vomiting continues, consider ondansetron and slow NG fluids temporarily

            • Rapid nasogastric rehydration: 25mL/kg/h for 4h

          • Treatment is divided into the rehydration phase and the maintenance phase

            • Rehydration phase: replace the fluid deficit à give 50-100mL/kg of fluids (depending on the degree of dehydration) over 4h, then reassess hydration status

            • Maintenance phase: provide the usual maintenance fluid requirement and replace ongoing losses from diarrhoea or vomiting (10mL/kg body weight for each loose or watery stool, and 2mL/kg for each episode of vomiting)

            • Maintenance fluid requirements (24h)

              • 100mL/kg: for the first 10kg of weight (4mL/h)

              • +50mL/kg: for the second 10kg of weight (2mL/h)

              • +20mL/kg: for the remaining weight above 20kg (1mL/h)

              

          • Severe dehydration

            • Severely dehydrated children should be admitted to hospital for rehydration and close monitoring → IV rehydration is usually necessary

            • A fluid bolus of sodium chloride 0.9% (20mL/kg) is given, and may be repeated until the child’s mental state and perfusion improves

            • The child’s hydration status should be reassessed after each fluid bolus to determine ongoing fluid therapy, and serum electrolyte (especially sodium, potassium and bicarbonate) and glucose concentrations should be measured

            • Lack of response to intravenous rehydration may indicate an underlying condition such as infection, septic shock, or a cardiac or metabolic disorder

        • Electrolyte Management:

          • Use Plasma-Lyte 148 and 5% Glucose OR 0.9% sodium chloride (normal saline) and 5% Glucose for rehydration after any required boluses

          • If serum K <3mmol/L, add KCl 20mmol/L, or give oral supplements

          • Measure Na, K and glucose at the outset and at least 24-hourly from then on (more frequent testing is indicated for patients with comorbidities or if more unwell)

          • 24-hr electrolyte requirements

            

            

        • Antiemetics/Antidiarrhoeal Agents:

          • Antiemetics

            • Ondansetron reduces vomiting, improves intake of oral rehydration solutions, and reduces the need for intravenous fluids and hospitalisation

            • Well tolerated, non-sedating and does not cause extrapyramidal adverse effects (like dopamine receptor antagonists e.g. metoclopramide)

            • Ondansetron can worsen diarrhoea (possibly due to retention of fluids and toxins normally eliminated by vomiting)

            • If ondansetron is considered appropriate, use: ondansetron 0.15mg/kg up to 8mg orally or IV; repeat dose after 8-12h if necessary

          • Antidiarrhoeals: not recommended for acute diarrhoea in infants and children

• Urinary Tract Infection in children

  • Briefly describe common causes, investigations and treatment; Diagnosis, Investigations, Treatment, Follow up

    • Common Causes

      • Bacterial Infections:

        • Escherichia coli (E. coli): Causes 85-90% of pediatric UTIs.

        • Proteus mirabilis: Found in 30% of boys with uncomplicated cystitis.

        • Staphylococcus saprophyticus: Found in adolescents of both sexes with acute UTI.

        • Staphylococcus aureus: Common cause of renal abscess.

        • Pseudomonas species, Serratia marcescens, Citrobacter species, Staphylococcus epidermidis: Cause low-virulence infections in patients with urinary tract malformation or dysfunction.

        • Other Bacteria: Klebsiella aerogenes, Enterococcus species.

    • Risk Factors:

      • Younger Children:

        • Malformations and obstruction of the urinary tract.

        • Prematurity.

        • Indwelling urinary catheters.

        • Lack of circumcision (in males).

        • High-grade vesicoureteral reflux (VUR).

      • Older Children:

        • Diabetes.

        • Trauma.

        • Sexual intercourse (in females).

    • Epidemiology

      • Bimodal Peak Age Incidence: Infancy, 2-4 years.

      • Gender Ratio:

        • First 2 months: males > females.

        • 2 months to 2 years: females > males.

        • 4 years: females > males.

    • Clinical Presentation

      • Young Children (Infants and Pre-verbal):

        • Fever

        • Vomiting

        • Poor feeding

        • Lethargy

        • Irritability

      • Older Children:

        • Dysuria

        • Urinary frequency

        • Lower abdominal and loin pain

    • Diagnosis

      • Clinical Symptoms: Dysuria, frequency, loin pain.

      • Positive Urine Culture:

        • Urine bag: Not recommended due to high contamination rates.

        • Clean catch: >10^5 organisms/mL with pyuria/bacteriuria.

        • Catheterisation: 10% contamination rate.

        • Suprapubic aspiration: Gold standard with 1% contamination rate.

    • Urine Collection Methods:

      • Urine Bag: Adhesive plastic bag applied to perineum; used if all else fails.

      • Clean Catch (CCU or MSU): Stream of urine caught in a specimen jar; used if child can void on request.

      • Catheterisation (CSU): Mid-stream sample collected using an in/out catheter; used if unable to obtain CCU/MSU.

      • Suprapubic Aspiration (SPA): Needle inserted into the bladder under US guidance; used if child is unable to void.

    • Contamination Rates and Suitability:

      • Urine Bag: 50% contamination, not recommended (false positive rate 88-99%).

      • Clean Catch: 25% potential contamination.

      • Catheterisation: 10% potential contamination.

      • Suprapubic Aspiration: 1% contamination, gold standard.

    • Investigations

      • Initial Testing:

        • Infants and children presenting with unexplained fever of 38°C or higher should have a urine sample tested within 24h

        • Dipstick test in the urine: ‘leucocytes’ and ‘nitrites’ strongly suggests UTI

          

      • Urine should be sent for microscopy, culture, and sensitivity

        • In infants and children who are suspected to have acute pyelonephritis/upper UTI

        • In infants and children with a high to intermediate risk of serious illness

        • In infants <3mths

        • In infants and children with a positive result for leukocyte esterase or nitrite

        • In infants and children with recurrent UTI

        • In infants and children with an infection that does not respond to treatment within 24-48h, if no sample has already been sent

        • When clinical symptoms and dipstick tests do not correlate

        

      • Laboratory tests for localising UTI: CRP alone should not be used to differentiate acute pyelonephritis/upper urinary tract infection from cystitis/lower urinary tract infection

      • Imaging tests for localising UTI: routine use of imaging is not recommended

        • In the rare instances when it is clinically important to confirm or exclude acute pyelonephritis/upper urinary tract infection, power Doppler ultrasound is recommended

        • When this is not available or the diagnosis still cannot be confirmed, a dimercaptosuccinic acid (DMSA) scintigraphy scan is recommended

    • Treatment

      • Conservative:

        • For asymptomatic bacteriuria, improve hygiene, hydration, and bowel habits.

      • Medical:

        • Oral Antibiotics:

          • First Line: Trimethoprim or Trimethoprim-sulfamethoxazole.

          • Second Line: Cephalexin.

          • For non-severe UTI in infants >3 months.

        • IV Antibiotics:

          • Indicated for severe UTI, sepsis, or infants <3 months.

          • Antibiotics: Gentamicin with amoxicillin (or ampicillin), switch to oral when improving.

    • Specific Treatment for UTI:

      • Non-severe UTI in Infants >3 months:

        • Trimethoprim or Trimethoprim-sulfamethoxazole.

        • Cephalexin.

      • Severe UTI (e.g., sepsis, shock) or Infants <3 months:

        • Gentamicin with amoxicillin (or ampicillin).

        • Switch to oral when improving.

    • Special Considerations:

      • Circumcision: May lower the risk of UTIs; not routinely recommended but considered if recurrent UTIs.

      • Assess for Hypospadias: If indicated.

    • Follow-Up

      • Repeat Urine Culture: On completion of antibiotics.

      • Imaging: If <6 months, atypical UTI, or recurrent UTIs.

      • Specialist Follow-Up: For pyelonephritis, recurrent pyrexial UTIs, or known renal anomalies.

    • NICE Guidelines on Imaging Tests:

      

      • <6 Months:

        • Uncomplicated: USS as outpatient.

        • Atypical: Acute USS.

        • Recurrent: Acute USS, DMSA at 3 to 6 months after infection.

      • 6 Months to 3 Years:

        • Uncomplicated: No imaging for the first episode.

        • Atypical: Acute USS.

        • Recurrent: Routine USS, DMSA at 3 to 6 months after infection.

      • 3 Years:

        • Uncomplicated: No imaging for the first episode.

        • Atypical: Acute USS, nothing else if normal.

        • Recurrent: Routine USS.

    • CRP Testing:

      • Not recommended to differentiate acute pyelonephritis/upper UTI from cystitis/lower UTI.

    • Detailed Treatment Guidelines

      • Antibiotic Choices for Children

        • Trimethoprim 4mg/kg BD

        • Cefradine 25mg/kg BD

        • Cefalexin 25mg/kg BD

        • Co-amoxiclav 125/31 (1-6y/o), 5mL TDS

        • Co-amoxiclav 250/62 (7-12y/o), 5mL TDS

        • IV cefuroxime 25mg/kg 8-hourly

        • IV gentamicin 2.5mg/kg/dose 8-hourly

    • Antibiotic Treatment Duration

      • Cystitis: Oral antibiotics for 3-7 days.

      • Pyelonephritis: Oral antibiotics for 7-10 days or IV antibiotics for 2-4 days followed by oral antibiotics for a total duration of 10 days.

    • Follow-Up Imaging

      • <6 Months:

        • USS During Acute Infection: Yes for atypical and recurrent UTI.

        • USS Within 6 Weeks: Yes for uncomplicated.

        • DMSA 4-6 Months After Acute Infection: Yes for atypical and recurrent UTI.

        • Micturating Cystourethrography (MCUG): Yes for atypical and recurrent UTI.

      • 6 Months to 3 Years:

        • USS During Acute Infection: Yes for atypical and recurrent UTI.

        • USS Within 6 Weeks: No.

        • DMSA 4-6 Months After Acute Infection: Yes for atypical and recurrent UTI.

        • MCUG: Yes for recurrent UTI.

      • 3 Years:

        • USS During Acute Infection: Yes for atypical UTI.

        • USS Within 6 Weeks: No.

        • DMSA 4-6 Months After Acute Infection: No.

        • MCUG: Yes for recurrent UTI.

    • Prophylaxis

      • Oral Antibiotic Prophylaxis: May be needed and continued until investigations are complete.

        • Trimethoprim: 2mg/kg at night.

        • Nitrofurantoin: 1mg/kg.

        • Indications: Vesicoureteric reflux (VUR), recurrent UTIs (more than 2-3 episodes).

    • Additional Considerations from Uploaded Images

      • Diagnosis and Investigations:

        • Diagnosis is based on clinical symptoms and positive urine culture.

        • Clinical Symptoms: Dysuria, frequency, loin pain.

        • Positive Urine Culture: Varies depending on the method of collection:

          • Urine Bag: Adhesive plastic bag applied to perineum; if all else fails.

          • Clean Catch (CCU or MSU): Stream of urine caught in a specimen jar; child capable of voiding on request.

          • Catheterisation (CSU): Mid-stream sample collected using an in/out catheter; unable to obtain CCU/MSU sample.

          • Suprapubic Aspiration (SPA): Needle inserted into the bladder under US guidance; child unable to void on request.

    • Contamination Rates:

      • Urine Bag: 50% contamination, not recommended.

      • Clean Catch: 25% potential contamination from foreskin or reflux of urine into the vagina.

      • Catheterisation: 10% potential contamination.

      • Suprapubic Aspiration: 1% contamination, gold standard.

    • Positive Urine Culture:

      • Urine Bag: Not suitable due to high contamination rates.

      • Clean Catch: >10^5 organisms/mL clinically relevant organisms + pyuria/bacteriuria.

      • Catheterisation: >10^5 organisms/mL clinically relevant organisms + pyuria/bacteriuria.

      • Suprapubic Aspiration: Any growth of clinically relevant organisms + pyuria/bacteriuria.

    • DMSA = Technetium-99m-labeled dimercaptosuccinic acid scan of kidneys (for renal scarring from pyelonephritis)

Learning Points: Clinical Practice

• Professional skills in growth and GI problems

  • Demonstrate the accurate measurement and charting of growth

    • Weighing Children Less Than 2 Years

      • Equipment:

        • Use a levelled pan scale, either high-quality electronic digital or beam balance.

        • Scale should weigh up to 20kg, in 5g (0.005kg) increments.

        • The tray needs to be large enough to support children up to 2 years of age.

        • Scales should be located on a stable, non-carpeted surface.

        • Clean the scales after every use.

        • Service the scale (including calibration) according to manufacturers’ guidelines.

      • Preparation:

        • Place a sheet/paper towel on the scale.

        • Child is undressed with the nappy removed.

      • Procedure:

        • Turn on scale and ‘tare’ to zero.

        • Place the baby in the center of the scale and ensure that weight is evenly distributed.

        • Weigh with parent/carer on a platform scale if unable to weigh alone. This can be done either using a scale which can be ‘zeroed’ after the parent/carer stands on them (a ‘taring’ scale) or by subtraction as follows:

      • Example:

        • Weigh the parent/carer and record weight = 60kg

        • Weigh the parent carer with child = 66.5kg

        • Difference is the weight of the child. e.g. 66.5-60 = 6.5kg

      • Recording:

        • Wait until the scales settle at a reading.

        • Record weight to the nearest 5g (0.005kg).

        • Make a note if the child is in plaster, harness, or any other item unable to be removed.

        • Plot the World Health Organization (WHO) weight-for-age growth chart.

        • Children less than 2 who can stand without assistance may be weighed on either infant or platform scales.

        • Include measurements and weight status description on relevant clinical documents such as discharge summaries and in the Child Personal Health Record where appropriate.

    • Weighing Children 2 Years and Over

      • Equipment:

        • Scales for weighing children can be either high-quality beam balance with movable weights, or high-quality electronic.

        • The scale should weigh in 100g (0.1kg) increments and can be ‘locked’ in.

        • The scale can be easily ‘zeroed’.

        • Scales should have a stable weighing platform, which is large enough to support the child.

      • Preparation:

        • Place the scale on a firm surface (not carpet).

        • Explain to the child that you are measuring their weight.

        • Make sure that any outer heavy clothing such as a coat, jacket, or jumper is removed. Light clothing can be worn.

        • Remove shoes and socks and ensure pockets are empty.

      • Procedure:

        • Turn the scales on and wait until they zero.

        • Ask the child to stand on the middle of the scales, look straight ahead, and stand still.

        • You may need to move them into the right position.

        • Check the child is not holding onto a wall or table; and arms are at their side.

        • Wait until the scales settle at a reading.

        • Bend down if necessary to read the scale at eye level.

        • Record weight to the nearest 100g (0.1kg).

        • Plot weight on the appropriate weight-for-age growth chart.

        • Include measurements and weight status description on relevant clinical documents such as discharge summaries, and in the Child Personal Health Record where appropriate.

    • Length Measurement for Children Less Than 2 Years

      • Equipment:

        • Length is measured in the recumbent position using an infantometer (infant length board or mat) designed for the purpose.

        • The measuring board or mat should have a firm, flat, horizontal surface with a fixed measure in 1mm (0.1cm) increments.

        • The device has a fixed head-board at right angles to the measuring board or mat, and a smoothly-moving foot-board perpendicular to the measuring board or mat.

      • Preparation:

        • Ask the child to remove their shoes and socks.

      • Procedure:

        • Ask the parent/carer to place the child on the length-board.

        • The child should be facing vertically upwards with the crown of the head firmly on the headboard.

        • Ensure the child’s body and pelvis are straight along the measuring device.

        • Parent holds the child’s head against the immovable headboard.

        • A second person straightens both of the child’s legs, holds the feet with toes pointing directly up, and moves the foot-board into position against the child’s feet.

      • Recording:

        • Record length to the nearest 1mm (0.1cm).

        • Plot length on the WHO length-for-age chart.

        • Record whether length or height/stature has been measured because length is greater than height/stature. If measuring length of a child over 2 years, subtract 0.7 centimeters from the length to convert it to height because length measurements are usually larger than height measurements by this amount.

        • Include measurements and weight status description on relevant clinical documents such as discharge summaries, and in the Child Personal Health Record where appropriate.

    • Height/Stature Measurement for Children 2 Years and Older

      • Equipment:

        • Height is measured in the standing position using a stadiometer (height measurer).

        • A stadiometer consists of a vertical board with an attached metric ruler with an easily moveable horizontal headboard that can be brought into contact with the most superior part of the head.

        • The equipment has a wide and stable platform, or firm uncarpeted floor as the base.

        • Equipment should be accurately and firmly mounted on a wall.

        • Ensure that fixed position devices have been installed correctly, and re-check after moving or re-location.

        • Should have an easy-to-read, stable metric ruler or digital readout in 1mm (0.1cm) increments.

      • Preparation:

        • Show the child the stadiometer and explain you are going to see how tall they are.

        • It can be helpful to measure the parent first if the child is hesitant.

        • Take the child over to the stadiometer and make sure they face away from the equipment.

        • Remove the child’s shoes and socks.

      • Procedure:

        • Position the child facing away from the stadiometer or wall with bare feet close together, legs straight, arms at side, and shoulders relaxed.

        • Ask the child to look straight ahead and take a big breath in and out to relax.

        • Double-check their position, making sure their knees are straight, heels on the floor, and head, shoulder blades, bottom, and heels are in contact with the stadiometer (height measurer) or the wall. Check that their arms are by their sides, and shoulders relaxed. Check that a horizontal line can be drawn from the lower border of the eye to the tragus, located over the ear canal.

        • Bring the measuring device down to rest on the child’s head.

      • Recording:

        • Record height to the nearest 1mm (0.1cm).

        • Plot height on the appropriate height-for-age growth chart.

        • Record whether height/stature has been measured because length is greater than height/stature.

        • Include measurements and weight status description on relevant clinical documents such as discharge summaries, and in the Child Personal Health Record where appropriate.

    • Determining Weight Status in Children

      • For Children Aged Up to 2 Years Old:

        • Appropriate interpretation of serial measurements on the weight-for-age and length-for-age growth charts will allow determination of the child’s weight status. For example:

          • If the percentile recorded on the weight-for-age chart is roughly the same as the

  • Demonstrate the key steps for evidence-based assessment of hydration status in children

    • Degree of Dehydration and Corresponding Clinical Features:

      Clinical Feature	Mild Dehydration (<5%)	Moderate Dehydration (5-9%)	Shock (≥10%)
      Conscious State	Alert and responsive	Lethargic, irritable	Reduced conscious state
      Heart Rate	Normal	Normal/mild tachycardia	Tachycardia
      Breathing	Normal	Increased respiratory rate	Increased respiratory rate, deep acidotic breathing
      Blood Pressure	Normal	Normal	Hypotension
      Skin Color	Normal	Normal	Pale or mottled
      Extremities	Warm	Warm	Cold
      Peripheral Pulses	Normal	Normal	Weak
      Eyes and Fontanelle	Not sunken	Sunken	Deeply sunken
      Mucous Membranes	Moist	Dry	Dry
      Skin Turgor	Instant recoil	Mildly decreased	Decreased
      Central Capillary Refill Time	Normal	Prolonged	Markedly prolonged

    • Additional Clinical Features:

      Clinical Feature	Minimal (<3%)	Mild to Moderate (3-9%)	Severe (>9%)
      Mental State	Alert, well	Normal to irritable	Apathetic, lethargic
      Thirst	Normal, may refuse liquids	Thirsty	Drinks poorly
      Pulse	Normal and strong	Tachycardia	Tachycardia, weak
      Respiration	Normal	Tachypnoea	Tachypnoea and deep
      Capillary Refill	Normal (<2s)	Prolonged	Prolonged
      Skin Turgor	Normal	Recoil <2s	Recoil >2s
      Extremities	Warm peripheries	Cool peripheries	Cold, mottled, acrocyanosis
      Eyes and Fontanelle	Normal	Mildly sunken	Deeply sunken
      Oral Mucous Membranes	Moist	Dry	Parched
      Urine Output	Normal to reduced	Reduced	Minimal to anuric

    • Measured Weight Loss or Percentage Dehydration:

      • 5% dehydration = loss of 5mL of fluid per 100g body weight, or 50mL/kg or 10 x percent dehydrated/kg.

    • Deficit Calculation:

      • Calculated following an estimation of the degree of dehydration expressed as % of body weight.

      • Example: A 10kg child who is 5% dehydrated has a water deficit of 500mL.

      • The deficit is replaced over a time period that varies according to the child's condition. The rate of rehydration should be adjusted with ongoing assessment of the child.

    • Assessment Steps:

      • History:

        • Intake: Foods and fluids intake compared to normal.

        • Output: Urine and stool output compared to normal.

        • Excessive Loss: Vomiting, polyuria, diarrhea.

        • Recent Consumption: Intake of hypertonic or hypotonic fluids (e.g., diluted formula, lots of water, fortified feeds).

        • Risk Factors for Severe Dehydration and Electrolyte Disturbances:

          • Infants <6 months old.

          • GI issues (e.g., Hirschsprung, short gut syndrome, ileostomy, colostomy).

          • Cystic Fibrosis (CF).

          • Renal impairment.

          • Diuretic use.

          • Metabolic disorders.

        • Dehydration is especially dangerous in children with:

          • Congenital heart disease (especially if they have cardiac shunts).

          • Slow weight gain.

          • Immunocompromised.

          • Previous organ transplant.

          • Use of nephrotoxic medications.

      • Examination:

        • Vitals: Check vital signs.

        • Weight: Compare current weight with previous readings from the last two weeks.

        • Mucous Membranes: Assess for moisture.

        • Capillary Refill: Check time taken for capillary refill.

        • Skin Appearance and Turgor: Evaluate skin turgor and general appearance.

      • Investigations:

        • UEC: Check urea, electrolytes, and creatinine levels.

        • Blood Glucose Level: Assess blood glucose levels.

    • Additional Considerations:

      • Calculation of hydration status using clinical signs is typically inaccurate. However, a combination of examination findings is often utilized to assess hydration status.

      • "No single symptom or clinical sign reliably predicts the degree of dehydration" – NSW Health.

      • Weighing a child bare and comparing with previous readings from within the last two weeks is the most reliable measure, although this is not often available.

      • The most useful clinical signs are abnormal capillary refill time, abnormal skin turgor, and abnormal respiratory pattern. These can be used to guide a rough percentage loss:

        • Mild Dehydration (<4%): No clinical signs. May have increased thirst.

        • Moderate Dehydration (4-6%): Delayed CRT (>2 seconds), increased respiratory rate, and mild decreased tissue turgor.

        • Severe Dehydration (≥7%): Very delayed CRT (>3 seconds), mottled skin, other signs of shock (tachycardia, irritable or reduced conscious level, hypotension), deep, acidotic breathing, and decreased tissue turgor.

    • Other 'Signs of Dehydration':

      • Sunken eyes, lethargy, and dry mucous membranes may be considered in the assessment of dehydration. Although their significance has not been validated in studies, they are less reliable than the signs listed above.

  • Describe an evidence-based approach to the standards for paediatric IV fluid management (Clinical Practice Guidelines)

    • IV Fluid Content for Children (Excluding Neonates)

      • For Resuscitation/Bolus:

        • Fluid: 0.9% Sodium Chloride

        • Alternative (only under specialist direction): Other crystalloids (e.g., balanced salt solutions) or colloids may be used.

      • For Replacement Fluids (Dehydration or Ongoing Losses):

        • Fluid: 0.9% Sodium Chloride + 5% Glucose +/- Potassium Chloride 20mmol/L

        • Alternative (only under specialist direction): Plasma-Lyte148 + 5% Glucose

      • For Maintenance Fluids:

        • Fluid: 0.9% Sodium Chloride + 5% Glucose +/- Potassium Chloride 20mmol/L

        • Alternative (only under specialist direction):

          • 0.45% Sodium Chloride + 5% Glucose +/- Potassium Chloride 20mmol/L

          • Plasma-Lyte148 + 5% Glucose

      • Note: If electrolytes are outside the normal range, discussion with a specialist is necessary.

    • IV Fluid Content for Neonates (<1 Month)

      • For Resuscitation/Bolus:

        • Fluid: 0.9% Sodium Chloride

    • For Replacement (Dehydration or Ongoing Losses) or Maintenance:

      • Special Care Nurseries:

        • Day 1: 10% Glucose

        • Day 2 Onwards:

          • 0.225% Sodium Chloride + 10% Glucose +/- Potassium Chloride 10mmol/500mL (Special Care Nurseries)

          • 0.45% Sodium Chloride + 10% Glucose (No Potassium Chloride) (Emergency Departments)

          • 0.45% Sodium Chloride + 10% Glucose +/- Potassium Chloride 10mmol/500mL (Paediatric Wards)

      • Note: If electrolytes are outside the normal range, discussion with a specialist is necessary.

    • Detailed Guidelines for Paediatric IV Fluid Management

      • Resuscitation:

        • Indication: Shock

        • Fluid: 0.9% Sodium Chloride (NB: must write this in full)

        • Amount:

          • For infants and children (>28 days old): 20mL/kg bolus

          • For neonates (<28 days old): 10mL/kg bolus

        • Speed: Over 15-60 minutes

      • Maintenance:

        • Indication: Fasting or unable to tolerate oral fluids.

        • Fluid:

          • For infants and children (>28 days old): 0.9% Sodium Chloride + 5% Dextrose (+/- 20mmol/L Potassium Chloride).

          • For neonates (<28 days old):

            • Day 1: 10% Dextrose

            • Day 2 Onwards: 0.225% Sodium Chloride + 10% Dextrose (+/- 10mmol/500mL Potassium Chloride).

        • Amount:

          • For 1st 10kg: 100mL/kg/day (4mL/kg/hr)

          • For 2nd 10kg: 50mL/kg/day (2mL/kg/hr)

          • For every kg above 20kg: 20mL/kg/day (1mL/kg/hr)

        • Example Calculation:

          • 33kg child:

            • Total fluid per day = 1000mL + 500mL + 20 * 13mL = 1760mL/day

            • Hourly rate = 40mL + 20mL + 13mL = 73mL/hour

      • Rehydration:

        • Indication: Dehydration

        • Fluid:

          • For infants and children (>28 days old): 0.9% Sodium Chloride + 5% Dextrose (+/- 20mmol/L Potassium Chloride).

          • For neonates (<28 days old):

            • Day 1: 10% Dextrose

            • Day 2 Onwards: 0.225% Sodium Chloride + 10% Dextrose (+/- 10mmol/500mL Potassium Chloride).

        • Amount:

          • Volume deficit = weight (kg) x deficit (%) x 10

          • Only replace a max of 5% per 24 hours due to the risk of cerebral or pulmonary edema.

          • Example: If 10% dehydrated, give 5% replacement per 24 hours over 48 hours.

        • Example Calculation:

          • 22kg child with estimated 5% dehydration:

            • Maintenance = 1000mL + 500mL + 40mL = 1540mL/day

            • Replacement (5%) = 22kg x 5% x 10 = 1100mL/day

            • Total fluids = 1540 + 1100 = 2640mL/day

            • Hourly rate = 110mL/hour

      • Ongoing Losses:

        • Indication: Additional fluids may be required (i.e., beyond rehydration) if very high stoma/gut or renal losses.

        • Fluid: 0.9% Sodium Chloride

        • Amount:

          • Measure losses over 4-6 hours. Divide by the number of hours to find the hourly losses. Give this amount over the same timeframe in addition to other IV fluids.

          • Example: Child has stoma losses of 200mL over 4 hours. Give 50mL/hr of additional fluids for the next 4 hours.

      

      

      

  • Demonstrate communication of appropriate oral rehydration management

    • Criteria for Oral Rehydration Management:

      • Suitable for Intervention:

        • The patient has been assessed and triaged as category 4 or 5, and allocated to the waiting room.

        • The patient has vomiting, with or without diarrhea.

        • The child shows signs of dehydration consistent with mild dehydration.

      • Exclusion Criteria:

        • Abdominal distension

        • Bile-stained vomiting

        • Blood in vomitus or stool

        • Severe abdominal pain

        • Moderate to severe headache

        • Age less than 6 months

        • Respiratory distress

        • Moderate tachycardia or hypotension

    • Oral Rehydration Guidelines:

      • Appropriate Fluids for Rehydration:

        • Inappropriate Fluids: Lemonade, homemade oral rehydration solutions (ORS), and sports drinks.

        • Recommended ORS: Gastrolyte™, HYDRAlyte™, Pedialyte™.

      • Feeding and Hydration:

        • Stop any feed fortifications (e.g., extra scoops of formula, Polyjoule).

        • Encourage parents to use methods to help children drink (e.g., cup, icy pole, syringe), aiming for small amounts of fluid often.

        • Continue breastfeeding.

        • Early feeding (as soon as rehydrated) reduces stool output and aids gastrointestinal tract recovery.

        • Recommend returning to the usual diet once rehydrated.

        • If diarrhea worsens with formula feeding, consider temporary (2 weeks) use of lactose-free formula.

      • Trial of Oral Fluids in the Emergency Department:

        • Most children with mild/no dehydration can be discharged without a trial of fluids after appropriate advice and follow-up.

        • Aim for 10-20mL/kg fluid over 1 hour of ORS; give frequent small amounts.

        • Significant ongoing GI losses (frequent vomiting or profuse diarrhea) reduce the chance of successful rehydration at home.

    • Additional Causes of Vomiting to Consider:

      • Gastroenteritis: Common cause, but other causes should be ruled out.

      • Obstruction: Intussusception, volvulus.

      • Infection: Pneumonia, appendicitis, meningitis, urinary tract infection.

      • Raised Intracranial Pressure: Brain tumor.

      • Metabolic Disease: Diabetes.

      

  • Demonstrate charting oral rehydration and IV fluids for children

    

    

    

    

    • IV Fluids

      • Total fluid requirement = Maintenance + Replacement of deficit + Replacement of ongoing losses

      • Calculating fluid deficit

        • Deficit (mL) = Weight (kg) change (premorbid weight minus current weight) x 1000

          • g. a 10 kg child who now weighs 9.5 kg has a 500 mL water deficit and is 5% dehydrated

        • You need to replace the deficit over 24-48 hours

          • For children with ≤5% dehydration, replace deficit in the first 24 hours

          • For children with >5% dehydration, replace deficit more slowly. Give 5% in the first 24 hours and the remainder over the following 24 hours

        • Ongoing losses

          • Measure any ongoing loss and replace at the same rate it is lost

            • g. if there is a 200mL loss over 4 hours replace this by delivering 50mL/hr of fluids over the next 4 hours

          • GI losses are usually replaced with NaCl 0.9% + KCl 20mmol/L

        • Maintenance fluid rates

        

      • The preferred fluid type for IV maintenance is sodium chloride 0.9% with glucose 5%

  • Demonstrate appropriate history and examination in assessment of pain in children, including acute abdominal pain

    • History Taking:

      1. General Information:

         • Age: of the child

         • SOCRATES: (Site, Onset, Character, Radiation, Associated symptoms, Timing, Exacerbating/relieving factors, Severity) for pain assessment

         • Recent Trauma: Assess for any recent trauma or injury

         • Past Medical History: Including immunizations, allergies, previous illnesses, surgeries

         • Prenatal and Birth History: Complications, Apgar score, NICU admission, term or preterm

         • Developmental History: Milestones, delays

         • Growth and Nutrition Status: Weight, height, dietary habits

         • Sleep Patterns: Normal sleep habits and changes

         • Gynecological History: (if applicable)

         • Family History and Social History: Conditions, family dynamics

      2. GI-Specific History:

         • Stool Color and Character: Diarrhea, constipation, blood in stool

         • Vomiting: Frequency, color, presence of blood

         • Hematemesis: Presence of blood in vomit

         • Jaundice: Yellowing of skin/eyes

         • Abdominal Pain: Location, intensity, duration, radiation

         • Colic: Patterns of crying and discomfort

         • Appetite: Changes in eating habits

      3. GU-Specific History:

         • Urinary Symptoms: Frequency, dysuria, hematuria, discharge

         • Abdominal Pain: Related to urination

         • Quality of Urinary Stream: Changes or difficulties

         • Polyuria: Increased frequency of urination

         • Previous Infections: History of UTIs or other infections

         • Facial Edema: Swelling around the face

    • Physical Examination:

      1. General Inspection:

         • Alertness and Activity Level: How alert and active is the child?

         • Skin Color: Pallor, jaundice, cyanosis

         • Rash: Presence of any obvious rash

         • Healthy Weight: Does the child appear to be of a healthy weight?

         • Signs of Pain: Does the child look in pain?

         • Overall Appearance: Does the child look well or sick?

         • Genetic Condition Indicators: Stature, syndromic facial features

      2. Position During Exam:

         • Parent’s Lap vs. Exam Table: Depending on the child's comfort

      3. Order of Examination:

         • Least Distressing to Most Distressing: Use distraction as a valuable tool

      4. Pediatric Assessment Triangle (PAT):

         • Appearance:

           • Tone, interactiveness, consolability, look/gaze, speech/cry

         • Work of Breathing:

           • Abnormal airway sounds, positioning, retractions, flaring

         • Circulation to Skin:

           • Pallor, mottling, cyanosis

      5. Hands:

         • Finger Clubbing: Cystic fibrosis, liver disease, inflammatory bowel disease

         • Leukonychia: (whitened nail bed) – hypoalbuminaemia

         • Palmar Erythema: Liver disease, polycythaemia, Kawasaki disease, thyrotoxicosis

         • Peripheral Edema: Nephrotic syndrome, liver disease

         • Pulse Assessment: Radial pulse, femoral pulse in babies, assess rate and rhythm

      6. Face:

         • Oedema: Nephrotic syndrome, liver disease

         • Pallor: Anemia

         • Conjunctival Pallor: Anemia

         • Scleral Icterus: Jaundice (hepatic pathology, hemolysis)

         • Aniridia: Wilm’s tumor, WAGR syndrome

         • Kayser-Fleischer Rings: Wilson’s disease

         • Neuroblastoma: Loss of the eye’s red reflex

         • Xanthelasma and Corneal Arcus: Hyperlipidaemia

         • Angular Stomatitis: Inflammation of mouth corners (iron or vitamin B12 deficiency)

         • Glossitis: Smooth tongue swelling with erythema (iron/B12/folate deficiency)

         • Aphthous Ulcers: Benign, Crohn’s disease, Bechet’s disease

         • Dental Caries: Neglect, gastroesophageal reflux disease

         • Macroglossia: Down’s syndrome, hypothyroidism, mucopolysaccharidoses, Beckwith-Wiedemann syndrome

         • Pigmentation/Polyps: Peutz-Jeghers syndrome

         • Lymph Nodes: Palpate cervical and supraclavicular lymph nodes – may indicate infection or malignancy

      7. Abdomen:

         • Inspection:

           • Distension, caput medusae, spider naevi, hernia, drains/tubes/access

         • Palpation:

           • Tenderness (focal vs. generalized), rebound tenderness, guarding, rigidity, abdominal masses, distension, palpable feces

         • Percussion and Auscultation:

           • Assess for bowel sounds and other abnormalities

      8. Special Techniques for Abdominal Exam:

         • Play Techniques: To elicit subtle guarding

           • "Can you jump up and down?"

           • "Blow out your tummy as big as you can, then suck it in as far as you can"

      9. Specific Organ Examination:

         • Liver Palpation: Right upper quadrant for hepatomegaly or masses

         • Splenic Palpation: Left upper quadrant for splenomegaly

         • Kidneys: Bilateral palpation for masses

         • Ascites: Fluid wave test or shifting dullness

         • Auscultation: Bowel sounds, bruits

      10. Genital Examination:

          • Penile and Scrotal Development: Hypospadias, chordee, descended testicles, scrotal swelling

          • Female Genital Examination: Confirm external genitalia normalcy

      11. Rectal Examination:

          • Indicated Situations: Confirm anus looks normal and patent, assess for tags, prolapse, staining of underwear

      12. Lower Limbs:

          • Inspection: Ankle edema (nephrotic syndrome/liver disease)

    • History of Presenting Complaint:

      1. Site:

         • RLQ pain suggests appendicitis

         • Epigastric pain suggests peptic ulcer disease

         • Diffuse pain may indicate perforation or peritonitis

      2. Onset:

         • Gastroenteritis lasting >10 days suggests parasitic or non-infectious cause

         • Recurrent, self-resolving episodes of pain characteristic of biliary colic

         • Sudden-onset flank pain may indicate nephrolithiasis or pyelonephritis

      3. Character:

         • Peptic ulcer disease pain is dull, appendicitis is sharp/stabbing

      4. Radiation:

         • Abdominal pain radiating to the back suggests cholecystitis or pancreatitis

      5. Associated Symptoms:

         • Fever, nausea, vomiting, diarrhea (gastroenteritis)

         • Jaundice (viral hepatitis)

         • Blood in stool (ulcerative colitis)

         • Blood or bile in vomitus (small bowel obstruction)

         • Genitourinary symptoms: dysuria, frequency, hematuria (UTI)

      6. Timing:

         • History of trauma: blunt or penetrating, accidental or non-accidental

      7. Exacerbating or Relieving Factors:

         • Movement, food, medication

      8. Severity:

         • Assess using pain scales appropriate for the child's age

    • Past Medical History:

      • Previous Conditions:

        • Operations, medication use, immunizations, allergies, and current comorbidities

        • Conditions like sickle cell disease, cystic fibrosis, spina bifida, developmental delay, cerebral palsy, splenic infarction, recent or current URTI

    • Potential Complications Causing Abdominal Pain:

      1. Hirschsprung Disease:

         • Enterocolitis

      2. Cystic Fibrosis:

         • Abdominal distension, bloody diarrhea, electrolyte disturbances

      3. Liver Disease/Ascites:

         • Primary bacterial peritonitis

      4. Nephrotic Syndrome:

         • Pancreatitis

      5. VP Shunt:

         • Pancreatitis

      6. Chemotherapy:

         • Pancreatitis

      7. Immunocompromised:

         • Toxic megacolon

      8. Sickle Cell Disease:

         • Vaso-occlusive crisis

    • Family and Social History:

      1. Family History:

         • Risk factors for inflammatory bowel disease, nephrolithiasis

      2. Social History:

         • Travel history to developing countries, dietary habits, family dynamics, social and psychiatric history, sexual history in reproductive-age females

    • Examination Techniques:

      1. Comprehensive Physical Examination:

         • Including vital signs, abdominal examination, checking for non-abdominal causes

      2. Observation:

         • Child's movements, gait, position, level of comfort

      3. Pelvic Examination:

         • Reserved for sexually active adolescents

      4. Abdominal Examination:

         • Thorough inspection, palpation, percussion, and auscultation.

  • Describe the evidence-based approach to managing abdominal pain in children (Clinical Practice Guidelines)

    • General Management of Abdominal Pain

      1. Fluid Resuscitation: May be required in cases of dehydration or shock.

      2. Analgesia: Provide pain relief based on the severity of the pain (see detailed table below).

      3. NPO (Nil Per Os): Keep the child fasting, especially if surgical intervention is being considered.

      4. Consider NG Tube: If bowel obstruction is suspected.

      5. Early Referral: If surgical or gynecological management may be required.

    • Analgesic Options Based on Pain Severity

      Pain Severity	Analgesic	Route
      Mild to Moderate Pain	Sucrose	Oral
      	Paracetamol	Oral, PR (per rectum), IV
      	Ibuprofen	Oral
      Moderate to Severe Pain (in addition to the above)	Oxycodone	Oral
      	Morphine	IV, subcutaneous
      	Fentanyl	Intranasal
      	Tramadol	Oral, IV

    • Assessment and Monitoring

      • Repeated Examination: To look for persistence or evolution of signs and to evaluate the response to treatment.

      • Pain Assessment Tools:

        • Wong-Baker FACES Pain Rating Scale: For children 3 years and older.

        • FLACC Scale: Face, Legs, Activity, Cry, Consolability for behavioral observation.

        • Neonatal Infant Pain Scale (NIPS): For infants.

    • Common and Time-Critical Causes of Abdominal Pain by Age

      Age Group	Causes
      Neonates	Hirschsprung enterocolitis, Incarcerated hernia, Intussusception, Necrotizing enterocolitis, Volvulus
      Infants/Children	Abdominal trauma, Appendicitis, Constipation, Gastroenteritis, Incarcerated hernia, Intussusception, Meckel diverticulum, Mesenteric adenitis, Ovarian torsion, Pyloric stenosis, Testicular torsion, Volvulus
      Adolescents	Appendicitis, Abdominal trauma, Cholecystitis, Cholelithiasis, Constipation, Ectopic pregnancy, Gastroenteritis, Inflammatory bowel disease, Ovarian cyst - torsion/rupture, Pancreatitis, Pelvic Inflammatory Disease, Renal calculi, Testicular torsion

    • Important Non-Abdominal Causes to Consider

      • Diabetic ketoacidosis (DKA)

      • Headache (Migraine)

      • Henoch-Schonlein Purpura

      • Hip pathology

      • Pneumonia

      • Psychological factors

      • Sepsis

      • Sexually transmitted infections

      • Sickle Cell Disease (vaso-occlusive crisis)

      • Toxin exposure or overdose

      • Urinary Tract Infection (UTI)/Pyelonephritis

    • Investigations

      • Most children need no investigations.

      • Investigations may include:

        • Urine analysis: (+/- culture, +/- pregnancy test if indicated)

        • Electrolytes +/- Liver Function Tests (LFTs)

        • Lipase: For pancreatitis

        • Venous blood gas

        • Blood sugar: For DKA

        • Imaging:

          • Abdominal X-Ray (AXR): If obstruction is suspected.

          • Chest X-Ray (CXR): If pneumonia is suspected.

          • Ultrasound: After discussion with senior staff, appropriate for suspected ovarian torsion or intussusception.

    • Treatment

      • Fluid Resuscitation: May be required.

      • Analgesia:

        • Mild Pain (Pain Score 1-3, NIPS Score 1-2): Oral paracetamol and/or ibuprofen.

        • Moderate Pain (Pain Score 4-6, NIPS Score 3-4): Oral paracetamol or ibuprofen and oral oxycodone.

        • Severe Pain (Pain Score 7-10, NIPS Score 5-7): Oral paracetamol or ibuprofen and intranasal fentanyl or oral oxycodone or IV morphine.

      • Opioid and Non-Opioid Analgesia

        • Non-Opioid Analgesia:

          • AnGel/EMLA

          • Paracetamol

          • NSAIDs (e.g., ibuprofen, ketorolac)

          • Tramadol

          • Local anesthesia blocks

        • Opioid Analgesia:

          • Oral: Morphine/MS Contin, Oxycodone IR/oxycontin SR

          • IV: Morphine, Fentanyl, Hydromorphone

      • Additional Management Considerations

        • Keep children fasting: Consider enteral or intravenous fluids if assessment or diagnosis is delayed (consult local fasting guidelines).

        • Early referral: For possible diagnoses requiring surgical or gynecological management.

        • Consider a nasogastric tube: If bowel obstruction is suspected.

  • Describe the key features for recognising a presentation of Diabetic Ketoacidosis in children

    • Overview

      • Diabetic ketoacidosis (DKA) in children is a critical medical emergency requiring immediate hospital admission.

      • It primarily occurs in children with type 1 diabetes but can also be seen in type 2 diabetes under stress conditions.

    • Pathophysiology

      • Decrease in Effective Circulating Insulin: This is associated with elevations in counter-regulatory hormones (glucagon, catecholamines, cortisol, growth hormone).

        • Hyperglycemia: Increased glucose production by the liver and kidney and impaired peripheral glucose utilization.

        • Hyperosmolality: Due to high blood sugar levels.

        • Lipolysis: Increased fat breakdown leading to the production of ketone bodies (beta-hydroxybutyrate, acetoacetate).

        • Acidosis: Metabolic acidosis from ketone bodies.

        • Osmotic Diuresis: Leads to dehydration and electrolyte imbalances.

        • Ketoacid Accumulation: Causes nausea, vomiting, and exacerbation of dehydration.

      • Major Complications:

        

    • Clinical Features

      • History: Weight loss, abdominal pain, vomiting, polyuria, and polydipsia.

      • Examination:

        • Dehydration

        • Kussmaul breathing (deep and laboured), chest pain

        • Altered level of consciousness (due to cerebral oedema - occurs in severe DKA)

        • Abdominal pain and vomiting

        • Hx of polyuria and polydipsia

        • Hx of nocturnal enuresis (bed wetting)

        • Hx of weight loss

    • Precipitants

      • Inadequate Insulin: In known diabetics (e.g., missed doses, pump failure).

      • First Presentation of Type 1 Diabetes Mellitus.

      • Illness: Such as infections (e.g., pneumonia, UTI), surgery, or trauma.

    • Diagnostic Criteria

      • Serum Glucose > 11 mmol/L

      • Venous pH < 7.3 or Bicarbonate < 15 mmol/L

      • Presence of Ketonaemia/Ketonuria

    • Severity Assessment

      • Mild: Venous pH < 7.3, Bicarbonate < 15 mmol/L

      • Moderate: Venous pH < 7.2, Bicarbonate < 10 mmol/L

      • Severe: Venous pH < 7.1, Bicarbonate < 5 mmol/L

    • Investigations

      • Urine Analysis: To check for ketonuria and glucose.

      • Blood Tests: Serum glucose, electrolytes (UEC), liver function tests (CMP), venous blood gas (VBG), blood ketones, full blood count (FBC), HbA1c, and septic workup if infection is suspected.

      • Imaging: May include chest X-ray if pneumonia is suspected, abdominal X-ray if bowel obstruction is suspected, and ultrasound if indicated for other conditions.

    • Management

      • Goals:

        1. Correct Dehydration

        2. Reverse Ketosis, Correct Acidosis, and Glucose Levels

        3. Monitor for Complications: Cerebral edema, hypoglycemia, hypo/hyperkalemia.

        4. Identify and Treat Precipitating Causes

      • Supportive Measures and Monitoring:

        • Nurse Head Up: To prevent aspiration.

        • Airway Monitoring: Especially in children with reduced consciousness.

        • NPO (Nil Per Os): Until the child is alert and acidosis resolves.

        • IV Access: For fluid and insulin administration.

        • Neurological Observations: To monitor for cerebral edema.

        • Cardiac Monitoring: For electrolyte disturbances (e.g., hyperkalemia, hypokalemia).

        • Antibiotics: If febrile, after obtaining cultures.

        • Urinary Catheterization: For strict fluid balance in unconscious children.

      • Fluid Resuscitation:

        • Initial Bolus: 10 mL/kg 0.9% sodium chloride for children with tachycardia and delayed capillary refill.

        • Potassium Management: Add potassium to fluids if serum potassium < 5.5 mmol/L and child is passing urine.

        • Glucose Addition: Once blood glucose levels drop to 15 mmol/L, switch to 0.9% sodium chloride with 5% glucose and potassium chloride.

      • Insulin Therapy:

        • Infusion: Start with 0.1 units/kg/hour (0.05 units/kg/hour in specific cases).

        • Transition to Subcutaneous Insulin: Once the child is alert and stable.

      • Monitoring for Complications:

        • Cerebral Edema: Symptoms include headache, vomiting, altered consciousness, and rising blood pressure. Managed with mannitol infusion or hypertonic saline.

        • Hypoglycemia: Managed with glucose infusion.

        • Electrolyte Imbalances: Managed based on regular monitoring and adjustments.

      • Timeline of Monitoring and Management:

        

  • Demonstrate patient assessment leading to the recognition of serious illness using A-G assessment

    • A - Airway

      • Is the airway patent?

      • Signs of Airway Obstruction: Look for chest and abdomen rising and falling alternately and vigorously.

      • Skin Color: Is it blue or mottled?

      • Noises of Obstruction: Listen for snoring, expiratory wheezing, or gurgling.

      • Additional points for detailed airway assessment:

        • Facial Fractures: Look for signs.

        • Contaminants: Check for blood, vomit, or teeth in the mouth/airway.

        • Epistaxis: Note any nosebleeds.

        • Examine the Anterior Neck:

          • Tracheal deviation

          • Wounds

          • Subcutaneous emphysema

          • Laryngeal tenderness/crepitus

          • Venous distension

          • Esophageal injury (unlikely if the child can swallow easily)

          • Carotid hematoma/bruits/swelling

      • Management of Airway Obstruction:

        • Positioning: Age-appropriate positioning of the head into a neutral position (use a thoracic elevation device if <8 years old or a towel under the shoulder blades).

        • Suction: Gentle suction to remove blood/vomit/secretions.

        • Oxygen: Apply high-flow oxygen.

        • Jaw Thrust: Avoid head-tilt or chin lift.

        • Airway Devices: Use an oropharyngeal airway if tolerated, or a nasopharyngeal airway (if head injury is excluded/unlikely).

        • Intubation: To be performed by an experienced operator.

        • Cervical Spine Protection: Manual in-line stabilization, followed by the application of a properly fitted hard collar, sandbags, and strap.

    • B - Breathing

      • Observation: Look, listen, and feel.

      • Oxygen Saturation: Measure.

      • High-Flow Oxygen: Apply to all spontaneously breathing patients (10-15L O2 via a non-rebreather mask).

      • Work of Breathing: Check for recession, respiratory rate, and accessory muscle use.

      • Effectiveness of Breathing: Assess oxygen saturation, symmetry and degree of chest expansion, and breath sounds.

      • Effects of Inadequate Respiration: Check heart rate and mental state.

      • Signs of Injury: Look for seat belt marks, bruising, and wounds.

      • Thoracic Cage Assessment: Feel for emphysema/crepitus and clavicle/chest wall tenderness.

      • CXR: Request if needed.

    • C - Circulation

      • Pulse Rate: Check.

      • Skin Color and Temperature: Assess.

      • Capillary Refill Time: Measure.

      • Blood Pressure: Sometimes check.

      • Peripheral Skin Temperature: Measure.

      • Body Temperature: Measure.

      • Effects of Inadequate Circulation: Increased respiratory rate and decreased mental state.

      • IV Access: Establish with two large cannulae.

      • Intra-Osseous Needle: Consider if IV access is not quickly established.

      • Blood Tests: Take blood for BSL, FBC, crossmatch.

      • Fluid Bolus: Give 20mL/kg of normal saline if circulation is inadequate.

      • Tamponade: For any continuing external hemorrhage.

      • Repeat Fluid Bolus: If circulation remains unstable, using normal saline or colloid solution.

      • Packed Cells: Consider if a third bolus is necessary, and arrange early surgical intervention.

    • D - Disability

      • Level of Consciousness: Initial assessment using AVPU (Awake, Voice, Pain, Unresponsive).

      • Formal GCS Assessment: If AVPU shows impairment.

      • Pupil Response: Check reaction to light.

      • Movement in Limbs: Assess and check reflexes where possible.

      • BSL: Measure on arrival and periodically.

    • E - Exposure/Environment

      • Remove Clothing: To check for any obvious life-threatening injury.

      • Avoid Hypothermia: Limit exposure of the body and warm all ongoing fluids.

    • F - Fluids

      • Fluid Charts: Monitor fluid input and output.

      • Patient’s Urine: Check if available.

      • Skin Turgor: Assess for hydration status.

    • G - Glucose

      • Rapid Finger Prick: To check for hypoglycemia.

    • Further Information and Family and Friends

      • Gather Additional Information: From drug charts, medical notes, investigation results, friends, and relatives.

      • Social Assessment: Determine the patient’s next of kin or close relatives, living situation, and access to the building.

    • Goals

      • Patient Goals: Establish both short-term and long-term goals for the patient.

      • Monitoring Plan: Develop a plan for continuous monitoring.

      

  • Describe the patient monitoring and process of the Between the Flags model, and the Paediatric CERS and Escalation Matrix

    

    • Between the flags model

      • The standard observation charts have 3 colour-coded zones:

        • Blue zone = criteria for which increasing the frequency of observations and/or increased vigilance is required.

        • Yellow zone = clinical review required.

        • Red zone = rapid response call is required.

      • In paediatrics, observations are taken 6 times per day at 4 hourly intervals.

      • A newborn’s vitals must be taken before leaving the birthing environment.

      • Frequency of assessment is to be increased above the minimum requirements when:

        • The patient’s vital sign observations fall within a coloured zone on a standard observation chart

        • Assessment identifies other signs and symptoms of deterioration

        • A CERS call has been made.

      • Paediatric CERS

        • CERS = Clinical Emergency Response Systems

        • CERS refers to a health service/facility’s response to a deteriorating patient within its care.

        • The main components include:

          • Clinical review - respond within 30 minutes to a breach in clinical review criteria.

          • Rapid response - immediately in response to breach in the rapid response criteria.

    • Escalation Matrix

      • The Escalation Matrix determines local criteria that are a best fit for the organisation’s context and services.

      • It allows for a unified approach to levels of escalation across the facilities and LHD.

      

  • Demonstrate appropriate charting patient observations in children (use of BTF in SPOC charts)

Learning Points: Health society and environment

• List the public Health notifiable infectious illness in children and describe the rationale and process for reporting

  • List of Public Health Notifiable Infectious Illnesses in Children

    • All notifiable diseases can be found in the Public Health Act 2010 No 127. Below are some of the most relevant preventable diseases which are mandatory for reporting in schools and daycare centers:

      • Diphtheria

      • Mumps

      • Poliomyelitis

      • Haemophilus influenzae Type b (Hib)

      • Meningococcal disease

      • Rubella ("German measles")

      • Measles

      • Pertussis ("whooping cough")

      • Tetanus

      • Gastroenteritis (among people of any age in an institution, foodborne illness in two or more related cases)

  • Rationale for Reporting

    • Prevent Spread of Infectious Diseases: Enables public health units to take immediate action to control and prevent the spread of infectious diseases.

    • Protect Community Health: Reporting helps in safeguarding the community by ensuring that outbreaks are contained.

    • Identify Disease Patterns: Assists in identifying patterns of disease spread and potential patient zero, which is crucial for effective outbreak management.

    • Improve Healthcare Policy: Provides data that helps in the formulation and improvement of healthcare policies and standards.

    • Uphold Healthcare Standards: Ensures compliance with public health standards and protocols.

  • Process for Reporting

    1. Complete the NSW Health Communicable Diseases Notification Form:

       • Fill out the form with all relevant information about the case.

    2. Submission:

       • Send the completed form to the local Public Health Unit (for example, Hunter New England LHD - Wallsend).

    3. Immediate Phone Notification:

       • Some diseases require immediate phone notification, which is indicated by a phone icon on the form. This ensures prompt action is taken for highly contagious or severe diseases.

  • Detailed Steps in Disease Reporting

    1. Identification of a Notifiable Disease:

       • Once a notifiable disease is identified, healthcare providers must report it to the public health authorities.

    2. Form Completion:

       • Complete the NSW Health Communicable Diseases Notification form accurately with details such as patient information, disease specifics, and any relevant clinical information.

    3. Sending the Form:

       • The completed form must be sent to the appropriate local Public Health Unit. This can be done through various means, including electronic submission, fax, or mail.

    4. Phone Notification:

       • For certain diseases, an immediate phone call to the public health unit is required. This is to ensure that the authorities can take swift action to manage and control the spread of the disease.

    5. Follow-Up:

       • The public health unit may follow up with the reporting entity for additional information or to provide further instructions on managing the case and preventing further spread.

• Describe the societal and environmental influences on growth and nutrition

  • Societal Influences

    • Cost:

      • The cost of food and the ability to purchase it are primary determinants of food choice.

      • Low-income groups are reported to consume more unbalanced diets and have a lower intake of fresh fruits and vegetables due to financial constraints.

    • Social Class:

      • Higher social classes are associated with higher intakes of fruits, lean meats, oily fish, and wholemeal foods compared to lower social classes.

      • Economic disparities influence the quality and variety of food available to different social classes.

    • Social Context:

      • Peer Influences: Individuals, especially children and adolescents, are influenced by their peers' eating habits and preferences.

      • Parental Influences: Parents play a critical role in shaping their children's dietary habits through the foods they provide and their own eating behaviors.

      • Family Eating Practices: Regular family meals and shared eating practices can promote healthier eating habits.

      • Social Norms: Societal norms and cultural expectations can impact food choices and dietary practices.

    • Cultural Factors:

      • Cultural background influences food preferences, methods of preparation, and religious practices related to food.

      • Different cultures have unique dietary practices that can affect nutritional status and health outcomes.

  • Environmental Determinants

    • Access and Availability:

      • The availability of food and access to transportation can significantly influence dietary choices.

      • "Food deserts" are areas with little to no access to shopping facilities that provide fresh, healthy food, leading to reliance on processed and unhealthy food options.

    • Education, Knowledge, and Skills:

      • A lack of cooking skills can inhibit families from preparing fresh, healthy meals.

      • Education level is linked to better eating habits, as higher education often correlates with greater nutritional knowledge and healthier food choices.

      • Parents' ability to pass on cooking skills and nutrition education to their children is crucial for promoting long-term healthy eating habits.

    • Time Constraints:

      • Increasing numbers of dual-income families and longer working hours make it challenging to find time for preparing healthy meals.

      • Time constraints often lead to reliance on convenience foods, which are typically less nutritionally dense and can contribute to poor dietary choices.

    • Parental Monitoring and Motivation:

      • Parents' ability to monitor their children's growth and diet is essential for ensuring proper nutrition and preventing malnutrition or obesity.

      • Parental motivation and behavioral capability to encourage and provide healthy diets for their children play a significant role in shaping their children's eating habits and overall health.

• Describe the population health strategies employed for weight management in Children

  • Policies Influencing Food Environments

    • Marketing Restrictions:

      • Unhealthy Foods and Beverages: Strong links exist between TV advertising and children's food knowledge, preferences, purchase requests, and consumption patterns. Policies aim to limit the marketing of unhealthy foods to children.

    • Food Taxes and Subsidies:

      • Economic Measures: Implementing taxes on unhealthy foods and providing subsidies for healthier options like fruits and vegetables. Evidence shows that price has a significant effect on consumption choices.

    • Initiatives Promoting Healthy Foods:

      • Fruit and Vegetable Initiatives: Programs aimed at increasing the consumption of fruits and vegetables among children.

      • Other Food Policies: Includes restrictions on trans-fatty acids and policies ensuring healthy food service options in government institutions.

  • Policies Influencing Physical Activity Environments and Social Marketing

    • Physical Activity Recommendations:

      • WHO Guidelines: Children aged 5-17 should accumulate at least 60 minutes of moderate to vigorous intensity physical activity daily.

    • Social Marketing Campaigns:

      • Media Campaigns: Use of both paid and non-paid forms of media to increase knowledge and change attitudes towards diet and physical activity. Campaigns typically target both nutrition and physical activity behaviors.

  • National and Regional Initiatives

    • Australian Dietary Guidelines:

      • Dietary Advice: Provides up-to-date advice on the types and amounts of foods that should be consumed for health and wellbeing. Recommendations are based on scientific evidence.

    • Health Star Rating System:

      • Nutritional Labelling: A front-of-pack labelling system that rates the overall nutritional profile of packaged food from ½ a star to 5 stars, helping consumers make healthier choices.

    • Healthy Food Partnership:

      • Collaborative Efforts: A mechanism for the government, public health sector, and food industry to tackle obesity, encourage healthy eating, and empower food manufacturers to make positive changes.

    • Australia’s Physical Activity & Sedentary Behaviour Guidelines:

      • Guidance on Exercise: Provides guidelines on the duration and intensity of physical activity and sedentary behavior for different age groups to benefit overall health and wellbeing.

    • Clinical Practice Guidelines Portal:

      • Access to Guidelines: Provides access to clinical practice guidelines that have been adapted to the Australian context, ensuring relevance and applicability to local practice.

    • Healthy Weight Guide:

      • Information Resource: A comprehensive source of information developed by the Australian Government on how to achieve and maintain a healthy weight, based on recent Australian and international research.

    • Girls Make Your Move Campaign:

      • Inspiration for Physical Activity: Aims to inspire, energize, and empower young women to be more active through physical activities and sports.

  These comprehensive strategies aim to create supportive environments for children, promoting healthy eating habits and physical activity to manage weight and prevent obesity.

• Aboriginal & Torres Strait Islander Health:

  • What are some factors that contribute to higher prevalence of growth restriction and lower nutrition status of Aboriginal and Torres Strait Islander children?

    • Socio-Economic Factors

      1. Income:

         • Indigenous Australians are significantly more likely to experience food insecurity due to financial constraints. They are seven times more likely to go without food in the previous 12 months compared to non-Indigenous Australians.

         • Poverty often leads to maximizing calories per dollar spent, which typically results in lower nutritional quality as nutritious plant-based diets can be expensive.

      2. Socio-Economic Disadvantage:

         • Lower socioeconomic status impacts the ability to afford and access nutritious food.

         • Socio-economic disadvantage also affects other areas of life, including housing, education, and employment, which in turn impact nutritional status and growth.

    • Health and Lifestyle Factors

      1. Smoking During Pregnancy:

         • There is a strong relationship between smoking during pregnancy and low birthweight, which is a factor for growth restriction.

         • Smoking and other harmful behaviors during pregnancy, such as excessive alcohol consumption, contribute to poor prenatal health and low birthweight.

      2. Maternal Health:

         • Factors such as maternal age, illness during pregnancy, low socioeconomic status, multiple pregnancies, and poor antenatal care can contribute to low birthweight and growth restriction.

    • Geographical and Environmental Factors

      1. Food Security and Access:

         • Food security is a significant issue, particularly in rural and remote areas where access to fresh and nutritious food is limited.

         • Issues of supply and availability of food in remote communities lead to reliance on less nutritious, processed foods.

      2. Geographical Isolation:

         • Remote and rural locations often have limited access to healthcare and support services, which can impact prenatal and postnatal care and subsequently children's growth and nutrition.

      3. Housing and Infrastructure:

         • Overcrowding in housing and lack of appropriately designed and maintained homes can hinder safe storage, preparation, and consumption of food.

         • Poor housing conditions and infrastructure contribute to an unhealthy living environment that affects overall health and nutrition.

    • Cultural and Social Factors

      1. Cultural Food Values:

         • Traditional dietary practices and cultural food preferences may not always align with modern nutritional guidelines, leading to potential gaps in nutritional intake.

         • Cultural practices around food preparation and consumption are significant in understanding the nutritional status of Indigenous children.

      2. Education and Literacy:

         • Low levels of education, particularly in nutrition and food literacy, contribute to poor dietary choices.

         • Lack of knowledge and skills in preparing nutritious meals impacts food choices and overall nutrition.

      3. Social Factors:

         • Social norms and family practices around food and eating can influence children's nutritional status.

         • Peer influences and family eating practices play a role in shaping dietary habits.

    • Health Disparities

      1. High Rates of Low Birthweight (LBW):

         • Aboriginal and Torres Strait Islander babies are 2.5 times more likely to be born with low birthweight compared to non-Indigenous babies. This is often due to preterm birth or intrauterine growth restriction.

         • Contributing factors include poor maternal nutrition, inadequate prenatal care, and higher rates of maternal smoking and alcohol use.

      2. Chronic Diseases:

         • Poor nutrition contributes to higher rates of chronic diseases such as obesity, cardiovascular disease, type 2 diabetes, and tooth decay.

         • These conditions are exacerbated by the high prevalence of over-nutrition and under-nutrition among Indigenous populations.

      3. Health Inequities:

         • Five out of the seven leading factors contributing to the health gap between Indigenous and non-Indigenous Australians (obesity, high blood cholesterol, alcohol, high blood pressure, and low fruit and vegetable intake) are related to poor diet.

  • What are some of the strategies currently used by the Australian government to address factors affecting growth and nutritional status of Aboriginal and Torres Strait Islander children?

    • National and Community-Based Programs

      1. General Australian Government Department of Health Programs:

         • Various programs contribute to the prevention and management of diet-related disorders among Aboriginal and Torres Strait Islanders at a national level.

         • Since the expiration of the National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan (NATSINSAP) 2002-2010, there has been no national coordination of nutrition efforts.

      2. Community-Based Nutrition Programs:

         • Effective programs adopt a multi-strategy approach, addressing both food supply (availability, accessibility, and affordability) and demand for healthy foods.

         • Community involvement is crucial in all stages of program initiation, development, implementation, and evaluation to ensure cultural appropriateness and tailored interventions.

      3. Food Supply Improvement Programs:

         • Focus on food retail outlets, local food production (e.g., school or community gardens), food provided by community organizations, and food aid.

         • Community store nutrition policies play a significant role in influencing food supply and dietary intake in remote areas.

      4. Nutrition Education:

         • While alone it may not improve food security or dietary intake, it is effective when combined with strategies such as cooking programs, peer education, budgeting advice, and group-based lifestyle modification programs.

      5. Support for Nutrition Workforce:

         • A well-supported, resourced, and educated Aboriginal and Torres Strait Islander nutrition workforce is essential for successful nutrition interventions.

    • Specific Government Initiatives and Funding

      1. Better Start to Life Approach:

         • $94 million over three years from July 2015, aimed at expanding efforts in child and maternal health.

         • Includes $54 million for increasing sites providing New Directions: Mothers and Babies Services, offering antenatal care, parenting advice, and health checks for children.

         • $40 million to expand the Australian Nurse–Family Partnership Programme (ANFPP), improving pregnancy outcomes and supporting child health and development.

      2. National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan (NATSINSAP):

         • Key achievements in food supply in remote and rural communities, disseminating good practice, and developing a nutrition workforce.

         • Examples include Remote Indigenous stores and takeaways resources, nationally accredited nutrition training materials for Indigenous health workers, and the revival of the National Nutrition Networks conference.

      3. Aboriginal and Torres Strait Islander Guide to Healthy Eating:

         • Educational resources to support healthy dietary choices.

      4. Health Star Rating System:

         • Launched in December 2014 to help consumers make more nutritious choices when purchasing packaged foods.

         • Campaigns include specific media targeting Indigenous communities.

      5. Healthy Bodies Need Healthy Drinks Resource Package:

         • Launched in 2014, culturally appropriate materials encouraging school-aged children and their families to choose water over high-sugar drinks to prevent obesity, chronic disease, and dental caries.

      6. Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan 2013–2023:

         • Recognizes the importance of addressing social and cultural determinants of health contributing to poor dietary choices and health outcomes through coordinated whole-of-government action.

    • State and Territory Initiatives

      • Move Well Eat Well Program in Tasmania:

        • Operates in primary schools and early childhood settings to improve policies and practices supporting nutrition and physical activity.

• Resources

  • Aboriginal and Torres Strait Islander Health performance framework 2017 report

  • https://www.pmc.gov.au/sites/default/files/publications/indigenous/hpf-2017/tier2/219.html#important

Learning Points: Professional Development

• Demonstrate discharge summary documentation and communication to parents of sick child via examples of dehydration or abdominal pain

• Demonstrate communication and escalation using the ISBAR model