Transcript Common Paediatric Problems - Luton & Dunstable Hospital

COMMON PAEDIATRIC
PROBLEMS
Dr Anne Ingram
Aims
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Brief overview of the following:
 Croup
 Pneumonia
 DKA
 Bronchiolitis
 Febrile
Convulsions
 Dehydration
 Meningitis/Sepsis
 Constipation
Croup
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Viral laryngo tracheobronchitis
Commonest cause of acute stridor in children
6 months – 3 years
Boys > girls
Preceeding coryza/cough
Clinical features
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Mild fever < 38.5 °C
Resp:
 Stridor
 Hoarse
voice
 Barking cough
DDx
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FB: localised wheeze, history, sudden onset
Smoke inhalation: history
Epiglottitis: RARE, toxic, drooling
Bacterial tracheitis: toxic, no drooling
EBV: enlarged lymph nodes
Retropharyngeal abscess: painful swallow
Diphtheria: unvaccinated
Westley Croup Score
Stridor:
Retractions:
None
Audible with stethoscope
Audible without stethoscope
None
Mild
Moderate
Severe
0
1
2
0
1
2
3
Air Entry:
Normal
Decreased
Severely decreased
0
1
2
Cyanosis:
None
With agitation
At rest
0
4
5
Level of consciousness: Normal
Altered
< 5 mild
5-9 moderate
0
5
> 9 severe
MILD
MODERATE
SEVERE
Respiratory Rate
Normal
Normal/
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Recessions
No
Mild
Significant
Air entry
Normal
Slightly 
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Heart rate
Normal
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Saturations
> 95 %
93 – 95 %
< 93 %
Consciousness
Normal
Normal
Altered
Management
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Keep comfortable and unstressed
MILD
Dexamethasone 0.15 mg/kg PO or 0.6 mg/kg OD
(or budesonide 2 mg neb)
Home, advice re recurrence
2 nd lower dose dexamethasone for 12 hours later
Humidified air – no evidence that helps, risk of
scalding
Management contd.
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MODERATE & SEVERE
Dexamethasone 0.15 mg/kg or Budesonide 2 mg
neb
Adrenaline neb 5 ml 1: 1000
Refer
LRTI/Pneumonia
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1
Severe disease more likely < 5 yrs and ex 24-28
weeks gestation
Mixed viral-bacterial 23-33%
 RSV,
paraflu, influenza
 Strep pneumoniae, mycoplasma, chlamydia
Clinical Features
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Fever
Tacypnoea
SOB/DIB
Cough
Wheeze
Chest pain
Abdo pain, vomiting, headache
Management
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CXR – not indicated
Bacterial studies – not indicated
PO Antibiotics
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All children with a clear clinical diagnosis of pneumonia should receive
antibiotics
Children <2 years with mild symptoms of lower respiratory tract infection
do not usually have pneumonia and do not need antibiotics but should be
reviewed if symptoms persist. A history of conjugate pneumococcal
vaccination gives greater confidence to this decision.
Amoxicillin / co-amoxiclav (if associated with flu), cefaclor,
erythromycin, azithromycin and clarithromycin.
Macrolide - add at any age if no response to first-line or if
suspect mycoplasma/chlamydia or if severe
Other management
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Management of fever
Preventing dehydration
Watch for signs of deterioration/ other serious illness
Providing a ‘safety net’
When to refer?
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Oxygen saturation <92%, cyanosis
RR >70 breaths/min (infant) >50 breaths/min
(older child)
Significant tachycardia for level of fever
Prolonged central capillary refill time >2 s
Difficulty in breathing
Intermittent apnoea, grunting
Not feeding/signs of dehydration
Chronic conditions
DKA
Incidence
Approximately 30-40% of childhood diabetes
present with DKA. Main cause of mortality in
children with diabetes
Diagnosis
 Hyperglycaemia (>15mmol/L)
 Metabolic acidosis (pH <7.3 & HC03 <18)
 Elevated blood ketones
Clinical Features of DKA
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Dehydration – often severe
Kussmaul breathing (secondary to acidosis)
Vomiting
Abdominal pain
Confusion
Coma
Infection – causative or secondary
h/o polyuria, polydipsia and weight loss
Bronchiolitis
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2
Associated with viral infection (RSV 75 %)
Seasonal November – March
Re-infection during season is possible
70% children infected with RSV during 1st year
22% of those develop symptomatic disease
1/3 all infants will develop bronchiolitis in first year
3% infants < 1 year admitted with bronchiolitis
90% hospitalised are <1 year
Peak incidence 3-6 months
Generally self-limiting and managed at home
Lasts 3-7 days
Clinical features
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2-3 day preceeding coryzal phase with Rhinorrhoea
Fever: Generally < 39°C
Dry wheezy cough
Incr RR and work of breathing
On auscultation fine inspiratory crackles and/or high
pitched expiratory wheeze
Apnoeas
Poor feeding
Deteriorate before improvement – Day 3/4
Risk factors for severe disease
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Age: < 2 months
Gestation: < 32/40 RR of hospital admission 3.6,
33-35/40 RR 1.9
CLD of prematurity
Congenital Heart disease
Parental smoking
Older siblings
Management
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Supportive only
Antibiotics – not recommended
Bronchodilators do not reduce the need for
hospitalisation, do not shorten the length of stay in
hospital or shorten illness duration at home (cochrane
summaries)
Nebulised 3% saline may reduce LOS in moderate
bronchiolitis (cochrane summaries)
Febrile Convulsions
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3
= seizure associated with fever caused by infection or
inflammation outside the central nervous system in a
young child who is otherwise neurologically normal
- isolated, generalised, tonic-clonic seizures
- less than 15 minutes,
- do not recur within 24 hours/same febrile illness
- in the absence of previous neurologic problems.
 Complex - partial (focal) onset or during the seizure
- more than 15 minutes
- incomplete recovery within 1 hour
- recurrence within 24 hours/same febrile illness
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Simple
Characteristic Features
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Age 6 months to 5 years
Duration of seizure 3–6 minutes
Generalised tonic-clonic (body stiffening; twitching
of the face, arms and legs; eye rolling; jerking of
the arms and legs; staring; loss of consciousness)
Complete recovery of consciousness within 1 hour
Fever around the time of the seizure
History of previous febrile seizure
When to refer?
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No obvious focus
More than 5 minutes
Focal features during the seizure
Seizure recurred in the same febrile illness, or within 24
hours
Incomplete recovery after one hour
Less than 18 months of age
Where the child has no serious clinical findings but is
currently taking antibiotics or has recently been taking them
When the parents are anxious and feel that they cannot
cope.
When the child has a suspected serious cause for the fever
If send home
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Seizures of short duration are not harmful to the
child
About 1 in 3 children will have another febrile
seizure in the future.
What to do if further seizures occur, including how
to protect them from injury during the seizure and
when to call for medical help.
Advise parents about managing fever, but explain
that reducing fever does not prevent recurrence.
Dehydration
Green – Low Risk
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Responds normally, smiles, stays awake, normal cry
Normal Skin turgor and colour
Normal HR, RR, BP, CRT < 2 sec
Moist mucous membrane
Normal Urine output
Normal Eyes
Amber – Intermediate Risk
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Decreased activity, altered response to social cues,
no smile
Normal Skin turgor, warm extremities
Mild tachycardia, normal peripheral pulses
CRT 2 – 3 sec, Normal BP
Dry mucous membrane
Reduced Urine output
Sunken Eyes
Red – High Risk
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Not responding to or no response to social cues, difficult
to rouse, weak high pitched cry
Pale/ Mottled/ Ashen blue, Cold extremities
Abnormal breathing/ Tachypnoea,
Severe tachycardia, weak peripheral pulses
CRT > 3 sec
Hypotensive
Meningococcal Sepsis
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N.meningitidis – 13 serotypes (A,B,C,W)- type B 85% since
Men C vaccine
Normal nasopharyngeal flora in 10 % adults
Spread via airborne droplets : cough, kissing, toys
Bacteria dies within 2 minutes outside body
Incubation 2-10 days (average 4)
Meningoccocal disease
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4
combination of meningitis and septicaemia in 60% of cases
septicaemia in 25% of cases
meningitis in 15% of cases
Risk groups: < 5 yrs & 15-19 yrs
Mortality 10 %, up to 20% permanent sequelae in survivors
www.meningitis.org
Petechiae (<2mm)
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“Benign” in 90 %
Viral infections
SVC distribution –
cough, vomiting
But if child unwell with
fever treat as sepsis
initially
If well: check FBC,
clotting + check for
hepatosplenomegaly
and LN (ITP vs
leukaemia)
Purpura (>2 mm)
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If unwell (fever) =
sepsis
If well:
 HSP
 Other
vasculitis
 Injuries
Pre-hospital management of suspected meningoccocal sepsis
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Im (Iv, IO) benzylpenicillin:
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Supportive management
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300 mg (< 1yr)
600 mg (1-9 yrs)
1200 mg (>9 yrs)
Airway stabilisation (if unconscious)
O2 (tachypnoea, sat < 92%)
Iv fluids if hypoperfusion
Urgent transfer in ambulance
Notification of CDC (chemoprophylaxis of contacts) usually
by hospital
Constipation
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5
5-30 % child population – chronic > 1/3 pts
Passage of hard and infrequent stool/soiling and
overflow
Straining
Streaks of blood
Poor appetite, nausea
General malaise
Behavioural changes
Excessive, foul smelling wind
Examination
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Palpable faeces in left iliac fossa
Management
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Disimpaction
 Increasing
doses of movicol
 + stimulant if not disimpacted in 2/52
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Maintenance
 Movicol
adjust according to symptoms
 Add stimulant if needed
 Continue medication at maintenance dose for several
weeks after regular bowel habit is established – this
may take several months
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Diet and Lifestyle
Any Questions
Aims
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Brief overview of the following:
 Croup
 Pneumonia
 DKA
 Bronchiolitis
 Febrile
Convulsions
 Dehydration
 Meningitis/Sepsis
 Constipation
Thank you
References
1. BTS guidelines paediatric pneumonia
2. SIGN guidelines bronchioloitis
3. NICE Clinical Summaries Febrile Convulsions
October 2013
4. www.meningitis.org
5. NICE guidance on paediatric constipation