Paediatric Challenges

Neurology
Acute headache
● 3 yo child
● Holding head as if in pain - this is worrying! Children unlikely to malinger
● Child with headache is unusual
● Irritable - can’t be settled
● Photophobia
● Fever = 39 C

History
We’re looking for systemic symptoms - want to differentiate between an acutely unwell and
well
● Fever?
● Photophobia?
● Neck stiffness?
● Irritability and pain?
● History of trauma?
● eating/ drinking normally?
● Urinating normally?
● Vaccination history

Exam
● Papilloedema (difficult to see)
● Petechial rash
○ Press between two thumbs
Bulging fontanelle
● Check for dehydration
● Obvious source of infection (e.g. sore throat)

Ddx
● Meningitis
● Encephalitis
● Mastoiditis
● Migraine
● Tension headache
● Sinusitis
● Hypoglycaemia
● Haemorrhage
● Trauma
Investigations
screening, Diagnostic, and prognostic indications
● FBC
● CRP
● ESR
● Blood culture (prognostic)
● U&E
● Blood gas if unwell
● Glucose
● Throat swab
● LP - contraindicated if there is papilloedema (diagnostic)
○ If bacterial…
○ Raised WCC
○ Low glucose
○ High protein
● Neuroimaging (depends on suspicion - looking for a space occupying lesion

Unresponsive child
● 15 yr old boy
● Found near pub

Next steps
● Exam
● Judicious investigation
● Family and friends

Exam
● Check GCS (or AVPU)
● Look for head trauma
● Focal neurology
● 4 cm laceration on posterior aspect of skull

Collateral history
● Fight with parents

Investigation
● CT - good for bones and will tell you if there’s a haemorrhage (also quick, so you
don’t need the patient to be very compliant)
● Blood alcohol and tox screen
● Baseline bloods
○ Blood gas and glucose
○ FBC
○ U and E
 ○ LFT
○ CRP
CT comes back normal. Repeat neurological exam is normal. Awake several hours later,
doesn’t remember the injury.

Cerebral Palsy
“A disorder of movement and posture caused by a non-progressive insult to the developing
brain”
Classified as...
● Hemiplegia
● Paraplegia
● Diplegia
● Quadriplegia
Or…
● Prenatal (e.g. stroke - most common form)
● Perinatal (HIE/ birth asphyxia)
● Postnatal (e.g. meningitis)
Cause of CP often unknown

● Sverity varies
● Treatment depends on aetiology

Case
● 1 yo girl
● Delayed motor development
● Can’t sit unsupported (should be able to at 6 months)
● Preference for one side
● 1 seizure as a neonate
● Injury at time of delivery

History
● Social interaction
● Speech
● Other areas of development

Exam
● Check for hypertonia
● Poor central tone
● Weak on right side
● Right sided hemiplegia

Investigation
● MRI
● Muscle biopsy if if male and suspect MD
● Genetic testing
MDT care
● Assessment of need - patient will be assessed within 6 months
● Early intervention team if diagnosed
● Neurology
● Psychologist
● Social work
● OT
● Orthopaedics (If very spastic - tendon release)

Development
Autism

Clinical features
● Poor eye contact (feeds into poor social interaction and non-verbal interaction)
● Obsessive interest in one thing
● Repetitive behaviours
● Delayed speech
● Sensory issues (don’t like being touched)
● May be associated with other disorders
● Usually presents in early childhood

Case
● Doesn’t use verbal language
● Suspicious of a developmental disorder

History
● How are they compared to their siblings?
● Is there any obsessive interest they have?
● Do they have a restricted diet?
● Are they averse to being touched (e.g. bath time)

Exam
● Do they reciprocally interact with their parents?
● How do they show their parents something? (bring it over and talk, or bring them to it
and show them)

Diagnosis
● Psychologist needed
● Parent interview
● Play-based session
MDT
● Educational psychology
● SLT
● Phsyio
● OT
● Social work

Management
● School input and support
● Parental education and support
● Address any additional medical concerns
● MDT approach

Delayed Walking
● 18 mo
● Can’t walk
● Otherwise well
● Shuffles on his bum to mobilise

History
● Check other milestones

Exam
● Tone
● Hip dysplasia (difficult to do this at this stage)
● Atrophy
● Check for Gower’s sign in older child (DMD)
● Calf hypertrophy in older child (DMD)

Management
● Hip xray (may be DDH)
● Reassure
● OPD in 3 months
Aetiology
● Neurological (CP)
● Muscular (DMD)
● Skeletal (DDH)
● Neglect
● Normal variant
● Metabolic/ genetic
● congenital infection
Gastrointestinal
Diarrhoea

Case 1
● 4 yo
● 48 hr hx of watery diarrhoea
● Other siblings sick
● gastroenteritis

Case 2
● 2 yo
● 5 loose stools a day
● Undigested food
● Normal growth and exam
● Toddler’s diarrhoea

Case 3
● 15 yo girl
● 3 mth hx
● Abdo pain
● Blood stained diarrhoea
● Minor weight loss
● Lethargy
● Travel history

Investigations
● CRP/ESR - if normal, not IBD
● Stool culture
● LFT
● FBC
● U and E
● Calprotectin test of stool (avoid scope if low)
Ddx
● infectious/travel
● Inflammatory
● IBD
Case 4
● Eczema
● Abdo pain and constipation
● Allergy testing-
○ Wheat IgE high
○ Egg normal
○ Cows milk IgE high
● Eats these foods daily
 ● Sensitisation - positive for Ig
● Allergic - reactive physically
● This isn’t an allergic history

Neonatal Jaundice
● Early <24hrs after birth (more likely to be pathological)
● Late > 24 hrs
● Many normal neonates get jaundice in first week
● Conjugated - post liver
○ metabolic disease
○ Hepatitis
○ Sepsis
● Unconjugated - pre liver
○ Sickle cell - won’t present until after 6 months

Rules of thumb
● Conjugated hyperbilirubinaemia is always abnormal
● Unconjugated bilirubin crosses the BBB, causes kernicterus
● Early jaundice needs investigation
● Jaundice beyond 2-3 weeks is abnormal (e.g. biliary atresia presents a bit late)
● Physiological and breast-feeding jaundice are the most common causes

Early Late

● Rhesus disease ● Endocrine

● ABO incompatibility ● Did not catch the rest
● Other blood group incompatibility
● Neonatal sepsis
● Metabolic disease

Diagnosis - Serum bilirubin, or transcutaneous bilimeter

● Bilimeter not as accurate with different ethnicities
● If the child has had phototherapy, also inaccurate

Case
● 27 hr old baby
● Appears yellow

History
● Sepsis risk factors
● Blood group of mother

Investigation
● Serum bilirubin and bilimeter
○ Unconjugated high
 ○ Conjugated normal
● Blood group - A RH +
● Direct coombs test - positive
Rhesus disease
How do you decide if they need phototherapy? Plot it

Management
● Phototherapy - not useful in conjugated bilirubinaemia

Neonatal vomiting
History
● effortful/ effortless - i.e. are they positing?
● Reflux - only need to treat if FTT
○ PPI
○ Feed thickener - won’t be refluxed back up
○ Keep them sitting up after feed
○ Wind them after feeds
● Frequency?
● Colour
○ Bilious is very abnormal

FTT
● Intake too low
● Losing calories
● Not absorbing calories

Describing a line
● Number of lumens
● How they are placed
● Where are they placed

DKA
*give fluids for an hour if abcd clear and well (before insulin)

JIA
● Swelling and joint deformity
● FBC/ CRP/ ESR
● Autoimmune screen
● Bone imaging - MRI
Limping Child
https://www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/paediatrics-
the-limping-child.pdf

● Many causes
● Always admit
● Osteomyelitis
● SA
● Transient synovitis
● Fracture
● MS injury
● Acute leukaemia
● Perthes disease (