2. Common Complaints Flashcards
Describe clinical features: Breath holding spells (2)
Types
- cyanotic (more common), usually associated with anger/frustration
- pallid, usually associated with pain/surprise
Describe etiology: Breath holding spells (1)
- child is provoked (usually by anger, injury, or fear) → holds breath and becomes silent→ spontaneously resolves or loses consciousness
Describe management: Breath holding spells (3)
- usually resolves spontaneously and rarely progresses to seizure
- help child control response to frustration and avoid drawing attention to spell
- may be associated with iron deficiency anemia, improves with supplemental iron
Name common etiologies: Crying/Fussing Child (4)
- functional (e.g.hungry,irritable)
- colic
- trauma
- illness
Describe history: Crying/Fussing Child (7)
- description of baseline feeding, sleeping, crying patterns
- infectious symptoms: fever, tachypnea, rhinorrhea, ill contacts
- feeding intolerance: gastroesophageal reflux with esophagitis, N/V, diarrhea, constipation
- trauma
- recent immunizations (vaccine reaction) or medications (drug reactions), including maternal drugs taken during pregnancy (neonatal withdrawal syndrome) and drugs that may be transferred via breast milk
- inconsistent history, pattern of numerous emergency department visits, high-risk social situations all raise concern of maltreatment
- consider broad array of possible underlying causes such as meningitis, sepsis, respiratory distress, constipation, etc.
Describe clinical features: Infantile Colic (2)
- unexplained paroxysms of irritability and crying for > 3h/d,
- >3d/wk for >3wk in an otherwise healthy, well-fed baby (rule of 3s)
Describe epidemiology: Infantile Colic (2)
- 10% of infants;
- usual onset 10d to 3 mo of age with peak at 6-8wk
Describe etiology: Infantile Colic (2)
- unknown.
- Theories: alterations in fecal microflora, cow’s milk intolerance, GI immaturity or inflammation, poor feeding, maternal smoking
Is infantile colic a diagnosis of exclusion? (1)
diagnosis of exclusion after thorough history and physical exam to rule out identifiable causes such as otits media, cow’s milk intolerance, GI problem, fracture
Describe management: Infantile Colic (6)
- parental relief, rest, and reassurance
- hold baby, soother, car ride, music, vacuum, check diaper
- some evidence for probiotics
- maintain breastfeeding but eliminate allergens (cow’s milk protein, eggs, wheat, and nuts) from mother’s diet
- time-limited (2 wk) trial of protein hydrolysate formula (e.g. Nutramigen®)
- time – all resolve, most in the first 3-6 mo of life, no long-term adverse effects
Describe: primary dentition (4)
- (20 teeth)
- first tooth at 5-9 mo (lower incisor), then 1/mo
- 6-8 central teeth by 1 yr
- assessment by dentist 6 mo after eruption of first tooth and certainly by 1 yr of age (Grade B recommendation)
Describe: Secondary dentition (1)
- first adult tooth is 1st molar at 6 yr, then lower incisors
Describe: Early childhood caries (1)
- presence of one or more decayed, missing (due to caries), or filled tooth surfaces in any primary tooth in a preschool-aged child
Describe etiology: Caries (2)
- multifactorial with biomedical factors (e.g.diet, bacteria, host) and social determinants of health
- inappropriate feeding practices are important factors (e.g.
- frequent, prolonged bottle feeding,
- putting to bed with bottle,
- prolonged breast feeding,
- and excessive juice consumption)
Name prevention techniques: Caries (5)
- no bottle at bedtime, clean teeth after last feed
- minimize juice and sweetened pacifier
- clean teeth with soft damp cloth or toothbrush and water
- water fluoridation
- ensure every child has a dentist by 1 year of age
Define: Enuresis (1)
involuntary urinary incontinence by day and/or night in child >5yr
Describe general approach: Enuresis (5)
should be evaluated if:
- dysuria
- change in colour, odour, or stream
- secondary or diurnal
- change in gait
- or stool incontinence are present
Treatment for primary nocturnal enuresis should not be considered until when? (1)
until 7 yr of age due to high rate of spontaneous cure
Describe clinical feature: Primary Nocturnal Enuresis (2)
- involuntary loss of urine at night
- bladder control has never been attained
Describe epidemiology: Primary Nocturnal Enuresis (4)
- boys>girls
- 10% of 6yr olds
- 3% of 12 yr olds
- 1% of 18yr olds
Describe etiology: Primary Nocturnal Enuresis (1)
developmental disorder or maturational lag in bladder control while asleep
Describe management: Primary Nocturnal Enuresis (5)
- time, reassurance (~20% resolve spontaneously each yr), and avoidance of punishment or humiliation to maintain self-esteem
- behaviour modification (limiting fluids and avoid caffeine-containing food before bedtime, void prior to sleep, ensure access to toilet, take out of diapers)
- conditioning: “wet” alarm wakes child upon voiding (70% success rate)
- medications (for children >7 yr, considered second line therapy, may be used for sleepovers/camp):
- DDAVP oral tablets (similar success rate as “wet” alarm therapy but higher relapse rate), imipramine (Tofranil®) (rarely used, lethal if overdose, SE: cardiac toxicity, anticholinergic effects)
Describe clinical features: Secondary Enuresis (2)
- involuntary loss of urine at night
- develops after child has sustained period of bladder control (>6 mo)
Describe etiology: Secondary Enuresis (2)
- inorganic regression due to stress or anxiety (e.g. birth of sibling, significant loss, family discord, sexual abuse)
- secondary to organic disease (UTI, DM, DI, sleep apnea, neurogenic bladder, CP, seizures, pinworms)
Describe management: Secondary Enuresis (1)
treatunderlyingcause
Describe clinical feature: Diurnal Enuresis (1)
daytime wetting (60-80% also wet at night)
Describe etiology: Diurnal Enuresis (6)
micturition deferral (holding urine until last minute) due to
- psychosocial stress (e.g.shy),
- structural anomalies (e.g. ectopic ureteral site, neurogenic bladder)
- UTI
- constipation
- CNS disorders
- DM
Describe management: Diurnal Enuresis (3)
- treat underlying cause, behavioural (scheduled toileting,double voiding,good bowel program, sitting backwards on toilet, charting/incentive system, relaxation/biofeedback)
- good constipation management
- pharmacotherapy
Describe clinical feature: Encopresis (1)
fecal incontinence in a child > 4yr old, at least once per mo for 3 mo
Describe prevelance: Encopresis (2)
- 1-1.5% of school-aged children (rare in adolescence)
- M:F=6:1 in school-aged children
Name causes: Encopresis (7)
- chronic constipation (retentive encopresis)
- Hirschsprung disease
- hypothyroidism,
- hypercalcemia
- spinal cord lesions
- anorectal malformations
- bowel obstruction
Define: Retentive Encopresis (1)
child holds bowel movement, develops constipation, leading to fecal impaction and seepage of soft or liquid stool (overflow incontinence)
Describe etiology: Retentive Encopresis (2)
- physical: painful stooling often secondary to constipation
- emotional: disturbed parent-child relationship, coercive toilet training, social stressors
Describe history: Retentive Encopresis (5)
- crosses legs or stands on toes to resist urge to defecate
- distressed by symptoms, soiling of clothes
- toilet training coercive or lacking in motivation
- may show oppositional behaviour
- abdominal pain
Describe physical exam: Retentive Encopresis (3)
- digital rectal exam or abdo x-ray: large fecal mass in rectal vault
- anal fissures (result from passage of hard stools)
- palpable stool in LLQ
Describe management: Retentive Encopresis (3)
- complete clean-out of bowel: PEG 3350 given orally is most effective, enemas and suppositories may be second line therapies, but these are invasive and often less effective maintenance of regular bowel movements (see Constipation, P39)
- assessment and guidance regarding psychosocial stressors
- behavioural modification
