Clinical Paediatrics

Dr. Masoud Mustafa

Paediatrician
 Question 1
A 2-week-old boy is brought to the clinic for persistent vomiting.
The neonate is exclusively fed a standard cow milk– based formula.
He takes 4 oz every 2 hours and vomits after every feeding, despite burping.
The emesis is not bloody, bilious, or projectile.
He has 4 yellow, seedy, soft stools per day without blood.
He is otherwise healthy.
The neonate was born at term via an uncomplicated delivery and had an
unremarkable newborn nursery course.
His weight today is greater than his birth weight.
His vital signs and physical examination findings are unremarkable.
The MOST likely cause of this neonate’s symptoms is
• A. gastroesophageal reflux disease
• B. milk protein allergy
• C. overfeeding
• D. pyloric stenosis
 Question 2
• At 1 year of age, a boy was at the 50th percentile for
height and weight. At 2 years of age, he is at the 25th
and 10th percentiles respectively. Review of systems
reveals fussiness, loose stools, and possibly stomach
aches all beginning after the mother stopped breast-
feeding the boy and introduced table foods. Mother has
consumed milk products lifelong, but her son does not
drink cow milk.
• Which is the most likely cause of these symptoms?
• (A) toddler ’s diarrhea
• (B) lactose intolerance
• (C) celiac disease
• (D) cow milk protein allergy
• (E) chronic giardiasis
 Constipation
• Constipation can be defined as a difficult passage of
hard, dry stools, commonly associated with a
reduction in the frequency of motions to less than 2
stools per week.
• Stool-withholding behavior with poor dietary and hydration
habits is suggestive of functional constipation, especially in the
absence of alarming symptoms, such as fever, anorexia, weight
loss, delayed growth, diarrhea, vomiting, history of delayed
passage of meconium, blood in the stool (when an anal fissure
is absent), urinary incontinence, or other extraintestinal
symptoms.
• Severe constipation that starts before 3 years of age should
raise the concern of an organic cause.
• Delayed passage of meconium during the first 24 h of life may
suggest Hirschsprung disease, cystic fibrosis, hypothyroidism,
intestinal obstruc-tion, or maternal drug use (e.g., opiates).
• Hirschsprung disease should be considered in any child with a
history of delayed passage of meconium, enterocolitis in early
infancy, constipation before 3 months of age, symptoms of
intestinal obstruction (vomiting, abdominal distension), failure
to thrive, and trisomy 21 (Down syndrome) with constipation.
 Abdominal pain
• Abdominal pain can originate from intra-abdominal
structures (gastrointestinal or non-gastrointestinal causes)
or refer from extra-abdominal sites, such as lower-lobe
pneumonia, which is also commonly seen in children.
It can be acute (lasts <2 weeks) or chronic (lasts ≥2 weeks).
• Acute gastroenteritis is the most common cause of acute
abdominal pain in children, while functional abdominal
pain (FAP) is the most common cause of chronic
abdominal pain.
• Acute appendicitis is the most common surgical cause of
the acute abdomen in the paediatric population.
• Radiation of the pain may provide a clue to the diagnosis.
For example, the pain of pancreatitis radiates to the back, while the pain of
renal stones or a ureteropelvic junction obstruction is radiated to the groin.
• Abdominal pain that is aggravated by defecation suggests chronic IBD, while
pain that is relieved by defecation suggests a diagnosis of IBS.
• The pain of gastroesophageal reflux disease (GERD), gastritis, cholecystitis,
or pancreatitis may get worse by eating.
• Abdominal pain occurring at nighttime and relieved by a meal may suggest
peptic ulcer disease.
• Suprapubic or loin pain associated with dysuria, frequency, fever, anorexia,
nausea, and vomiting suggests a urinary tract infection, a common cause of
abdominal pain in children.
• Abdominal pain in adolescent females requires special inquiry regarding
menstrual history and sexual activity.
• Abdominal pain with fresh bleeding per rectum may suggest colonic
bleeding or massive upper-gastrointestinal bleeding.
• A periumbilical pain that travels to the right lower-quadrant and associates
with anorexia, nausea, and vomiting is suggestive of acute appendicitis.
• Abdominal pain and vomiting in a child with diabetes mellitus should raise
the suspicion of diabetic ketoacidosis (DKA).
Different between organic & non organic
causes of abdominal pain.
 Haematuria
• Haematuria is the presence of red blood cells
(RBCs) in the urine.
It is either gross or microscopic (>5 RBCs per high-
power field seen on microscopy of centrifuged
urine).
It can result from glomerular causes or non-
glomerular causes, the latter being more common.
• Passage of bright-red- or pink-colored urine or visible blood clots suggests urinary tract bleeding,
while passage of brown-, tea-, or cola-colored urine suggests renal or glomerular bleeding.
• The combination of gross hematuria, facial or body edema, hypertension, and decreased urine
output may suggest glomerulonephritis, e.g., acute post-streptococcal glomerulonephritis (APSGN)
or IgA nephropathy.
• Passage of bloody urine only at initiation of micturition suggests urethral bleeding, whereas
terminal hematuria suggests trigonitis or hemorrhagic cystitis, and a constant bloody stream
indicates a renal source.
• Hematuria that is preceded by an upper-respiratory infection or, in some cases, gastroenteritis,
or an episode of impetigo may suggest acute post- streptococcal glomerulonephritis, hemolytic-
uremic syndrome (HUS), or Henoch–Schönlein purpura nephritis.
• IgA nephropathy (Berger disease) commonly presents with recurrent episodes of microscopic or
frank hematuria, which is often preceded by a viral prodrome 1–3 days before the onset of
hematuria.
• Hematuria associated with dysuria, fever, frequency, or urgency suggests a urinary tract
infection.
• Gross hematuria with renal colic that may radiate to the groin is suggestive of renal stone
disease.
• Painless hematuria may point to a glomerular origin.
• Rashes and joint pain may suggest Henoch–Schönlein purpura nephritis or SLE nephritis.
• An abdominal mass, with or without abdominal pain, should raise the concern for Wilms tumor,
which may be associated with microscopic hematuria in 50% of cases, whereas gross hematuria is
uncommon.
• The occurrence of hematuria in conjunction with a change in mental status, headache, visual
changes (diplopia), epistaxis, or heart failure is suggestive of significant hypertension.