Paediatric Case 1 Flashcards
what is An Approach to general paediatrics?
•Holistic multi-system approach essential:
- More than one problem may exist
- More than one system may be involved
•Start with the age
- Guides approach to history taking and examination
- Common pathologies differ
- Conditions manifest differently at different ages
•Consider common differential for the presenting problem
what are the Principles of management?
- What is in the child’s best interests?
- Will investigations change your management?
- What do the parents expect?
- Blood tests often not necessary (but sometimes are essential)
- IV Fluids are never “routine” (consider NGT)
- Oral treatments can be effective
- Avoid rectal routes unless essential
- Be guided by the weight and use the BNFc
•Seek help and senior guidance
Case 1:
- Baby 1 (3m, Vomiting and unsettled): “He weighs 11lbs, he usually takes a 7oz feed 6 times per day, he always seems hungry and unsettled after his feed. What should we do?”
- What does he weigh?
- What are his feed volumes? (per feed)
- What are his feed volumes? (per kilo per day)
- What advice should you give the parents?
- Baby 1 (3m, Vomiting and unsettled):
- He weighs ~5kg
- He usually takes ~210ml feed 6 times per day
- 1260ml/day =~250ml/kg/day
- Advise reducing to 120-140ml (4-5oz) per feed (~155ml/kg/day)
Avoid term overfeeding as often not well received
Case 2:
- Baby 2 (6m Bronchiolitis and feeding concerns): “She weighs 151/2lbs, she usually takes a 10oz feed 5 times per day, she has just been taking 4oz every 3 hours. What should we do?”
- What does she weigh?
- What are her usual feed volumes? (per feed)
- What are her usual feed volumes? (kg/day)
- What are her current feed volumes? (per feed)
- What are her current feed volumes? (kg/day)
- What advice should you give the parents?
- She weighs ~7kg
- She usually takes 300ml 5 times per day
- =~1500ml/ day = ~215 ml/kg
- Currently taking 120ml every 3 hours
- =~960ml/day ~130ml/kg/day
- Reassure this is okay over the next few days
- Seek review if feed volume dropping further
- Could consider reducing usual feed to 600-700ml/day once recovered (~5-6oz x4- she is likely to be weaning)
Know your units….. (Weight) - what are they?
- What units do we measure a child’s weight in? - Kilograms (kg) and grams (g)
- What units do parents want the weight in? - Pounds (lb.) and ounces (oz.)
- What is a pound? - ~0.4536kg/ 453.6g
- What is an ounce? - 1/16th of a pound (i.e. 28.35g)
Know your units….. (Feeding) - what are they?
- What do we measure feed volumes in? - Millilitres (ml)
- What do parents measure feed volumes in? - Ounces (fl. oz)
- What is an ounce? - 28.4 ml (29.6ml in US), 1/20th of a pint (568 ml)
Case 3:
- A 10 week old boy presents with 4 weeks of frequent post feed effortless vomits and distress (back arching and pulling up knees)
- Examination showed a soft abdomen with no palpable masses
- Diagnosis and differential?
- Other questions to ask?
- Management and investigations?
•Diagnosis and differential:
Gastro-oesophageal reflux (GORD) +/- Milk intolerance
Consider pyloric stenosis (if more forceful)
Consider surgical causes if bilious
•Other questions
Vomits: Bilious or not/Volume/Amount/Blood
Feeding: Type/Volume/Frequency/Position
General: Weight gain+ centiles/Development/Cough
how do you manage GORD?
Case 4:
- 3m old boy, bottle fed, weight gain ~100-120g/w. Has loose stools (4-5/day) and several vomits a day. Older brother had asthma and mum had eczema. HV asking about changing the milk
- Diagnosis?
- Other important questions to ask?
- Investigations?
- Management?
- Which milk would you advise?
(Assuming history/examination normal)
Persistent loose stools and family history of atopy
- Diagnosis - Probable cow’s milk protein allergy/intolerance with reflux
- Other important questions - Bile? Blood in stool? Breathless? Cough? Urine? N Exam?…..
- Investigations - Probably none unless bilious vomits, FTT despite change of milk, markers of other pathology
- Management - Trial of hydrolysed feed (not comfort, lactose free, soya or…), Milk free advice for weaning via Health visitor, May need thickeners/acid suppression
How babies show that they are well?
How babies show that they are ill?
History taking at this age is focused towards what the parents/carers will have observed
Some concerns may be markers of pathology in any system, so enquiring around all potentially relevant areas may be required
Case 5:
- 4 weeks old otherwise healthy baby. Good weight gain (150g/w), breast fed, presents with streaks of fresh blood in stool for last 7 days. No fever or vomits
- Dad has asthma. Mum has “irritable bowel.”
- General/abdominal examination normal
- Diagnosis and differential?
- Other important questions to ask?
- Management and advice?
what is the difference in presentation of a baby with CMPA and pyloric stenosis – pyloric shorter history, more forceful vomit, vomit right after feed. CMPA is more reflux presentation, unsettled after feed, may bring something up
do you outgrow CMPI?
yes
how does IgE mediated food allergy present?
Allergy can happen to CMP but not all that common
Some do have a more serious IgE mediated reaction
how does non-IgE mediated food allergy present?
Majority of milk protein intolerance is non IgE mediated
This is what most have
what is required for a milk free diet?
- Avoid all milk and foods made from milk - eg yoghurt, cheese, custard
- Teach label reading (whey and casein mean milk)
- On-line info from baby food companies
- Milk free diet sheets from dietetics
- Dietetic referral if diet on going - By 12 months