Gastro-oesophageal reflux in infants DTB 2009, Vol 47 (12)

niddk.nih.gov gord infants

childrenshospital.org aug 07/reflux in infants

reflux medscape

 

Weaning

NHS Choices weaning

Weaning DOH Leaflet 2008

babyledweaning.com/

 

Lactose intolerance / cows milk allergy

Cows milk allergy BMJ 2009

Lactose Intolerance BMJ 2007

Lactose Intolerance emedicine

Lactose Intolerance NHS choices

cows milk intolerance expert babycentre.co.uk

Primary: due to a physiological decline in lactase concentrations at the time of weaning
Secondary: commonly due to temporary injury to the intestinal mucosa due to infection
Reduced intestinal lactase results in malabsorption of lactose, which is then metabolised by colonic bacteria to produce gas and fatty acids, abdo cramps, bloating, diarrhoea and flatulence

 

Failure to thrive

Inadequate wt gain and linear growth in infancy

Failure to thrive Medscape

youtu.be/-w3cexmZM_s

youtu.be/dAQPuc48GNU

youtu.be/P3oc2va1xwU

 

Short stature and growth disorders

• RETARD HEIGHT
  Rickets
  Endocrine (cretinism, hypopituitarism, Cushing’s)
  Turner syndrome
  Achondroplasia
  Respiratory (suppurative lung disease)
  Down syndrome
  Hereditary
  Environmental (post-radiation, postinfectious)
  IUGR
  GI (malabsorption)
  Heart (congenital heart disease)
  Tilted back (scoliosis)

Growth Rural Health West au

Growth disorders Health Direct au

 

Crying baby

A babies only way of communicating and usually an expression of unmet need – hunger thirst discomfort or need for more physical contact.
If feeding weight gain and overall health OK parents can be reassured wil settle at 3-4 months.

Hunger
Prem babies may need larger volumes at 2-3 hours
Demand feeding generally preferable to 4 hourly
Sleeping through the night occurs roughly when bay eaches 5kg

Thirst
Increased in pyrexia or hot weather. Offer fluids between feeds if baby remains unsettled.

Colic
Evenings 5-10pm till 3-4m. Baby cries and draws up legs

Wind
Excessive air swallowing may be due to blocked teat or excesive milk secretion in first few minutes.
Try expressing some milk before starting feeding and nursing upright after feeding.

Underfeeding
Overfeeding
Colics

 

Sleep problems in babies

youtu.be/SDnyHj7zk7w

Sleep problems in childhood
Incidence
about 10% of pre-school children are considered to be poor sleepers by their parents
Aetiology:
Possible causes of childhood sleep disturbance include:
a child may have become “trained to stay awake”
separation anxiety
depression
nightmares
child wakes terrified; remembers the dream
age 8-10 years
night terrrors
child half-wakes terrified; still dreaming; cannot remember the dream when he wakes in the morning
sleep walking
very rare condition
occurs generally between 11-14 years of age
child wakes half-awake and calm; child had no memory of the event on waking the following morning
childhood illness
Management:
A common cause of sleep disturbance in a child is that the child has been “trained to stay awake”. A child may have been ‘rewarded’ for waking or crying at night e.g. with a cuddle, drink or being taken into his parents’ bed.
Methods that might help with “training to sleep” include:
attending to the crying child but limiting the attention to excluding physical problems such as a wet, sodden nappy
not attending to a child as soon as he wakes but instead waiting until he cries. Children will often wake transiently at night
gradually increasing the time a child is left to cry before attending
not providing ‘rewards’ for waking e.g. cuddles, drinks
use of sedative medication (e.g. a sedative antihistamine such as Vallergan (R)) is a last resort used on a short-term basis. Parents should be encouraged to modify their own pattern behaviour so as to encourage good sleeping habits when the sedative medication is withdrawn. Specialist review may be required if the problem persists melatonin may be indicated in the management of childhood sleep disorders

Advice from the book Toddler Taming by Dr Christopher Green

Children with poor sleep patterns have an immense impact on the whole family as well as the child themselves and up to 1/3 of children between the ages of 1-4 wake at least once every night.
Sedatives can be used as a short-term measure, but they don’t solve the problem in the long run and often they can have the side-effects of making the child drowsy the following day or have the paradoxical effect of making them hyperactive. Possible advice that you could give to a parent with a child who has sleep problem to try to train and modify their sleep patters are:-
Follow a regular routine leading up to bedtime and put the child to bed at a consistent time.
Calm them down before bedtime. i.e. don’t wind them up and get them excited such as fighting, chasing, running, playing wild games with them. Instead ease them down by giving them bath, talking to them quietly and gently, tucking them in bed, giving them a cuddle, reading a bed time story.
Once it is time to leave do it decisively, say goodnight and mean it. Don’t rise to any request that have no purpose except to procrastinate e.g. needing a drink, wanting to go to the toilet, for you to lie down with them etc.
If the child gets out of bed, you must return them at once. Be firm, take charge, do it without any questions or fuss. Keep repeating this process each time the child reappears and make sure both parents do the same to show a united front.
Alternatively you can choose to sit quietly at the bedside of the child until they start to fall asleep. Your there to offer your presence, not act as bedtime entertainment. If they lie quietly then you stay, but once they start to climb out of bed or question then leave decisively.

Children who get up in the middle of the night and cry, often do it for attention. It has been shown that in children who wake in the middle of the night where comfort is not readily available, generally decide it is easier to settle themselves back to sleep without making much of a fuss. Dr Green in his book suggests the controlled crying technique as follows:
Decide on a length of time to leave the child crying for before you attend to them and the length of time depends on how tolerant the parent is and how genuinely upset the child becomes. The aim is to not let them get too hysterical or afraid. (on average 5mins, 10mins if tough and 2mins if they’re feeling weak).
After the allotted time has passed then go to the toddler room, lift, cuddle and comfort until the loud upset crying turns to sobs and eventually sniffles. This is the sign to then put them down and walk away. The child may be quite taken aback that the parents has dared to leave and likely will immediately start to cry again in protest. This time leave the child to cry 2mins longer than the last time and repeat the same procedure and continue adding on 2mins and increasing the time you take attend to the child. Follow the same routine each night and after a couple of days to weeks , they should soon notice a different. However, you have to encourage the parents to persevere and be strong in their resolve.
In this method the child knows that the comfort is always there and they are not left to cry for hours in fear alone, but they soon learn that it is not readily available and you won’t rush to their every whimper and demand and that it isn’t worth all the effort.

 

Abdo pain kids

aafp Abdo pain kids

http://www.patient.co.uk/doctor/Recurrent-Abdominal-Pain-in-Children.htm

 

Constipation

NICE CG99 2010 Constipation in children and young people

Constipation Medscape

Normal frequency varies 3x day -1 every 3 days

Quantity and frequency of defaecation depend first of all on the
quality and quantity of food and fluid consumed. Food with little
plant-based fibre provides only minimal undigested matter in the
colon, which means the capacity of the intestinal contents to absorb
water is very small. This results in faeces consisting primarily of dead
bacteria, so that, even if enough water is consumed, a small, dry mass
is produced. Because this mass does not expand in the colon, there
are minimal propulsive contractions, and transit is slow.
Normally, the faecal material is retained in the rectum and colon until
sufficient stimuli are present to relax the upper anal sphincter. As
the faeces enter the anal canal, there is an urge to defaecate. In
addition, the external anal sphincter contracts to prevent undesired
evacuation. Defaecation is only possible after this sphincter has been
relaxed consciously.
This normal process can become disrupted due to anatomical,
functional and psychological factors. In childhood, 90% of
constipation is functional. Organic causes are usually discovered
before the child’s third year. The various aetiologies of constipation
vary according to the child’s age.

In infants up to 5 months old, constipation is usually related to the composition of the milk. Breast-feeding can result in relatively
infrequent, hard faeces. Incorrectly prepared bottle formula (too
much milk powder per unit of water) can also lead to constipation,
and small anal fissures may aggravate the situation.

Rare causes – Hirschsprung’s disease and meconium ileus.

Between 2 and 5 months of age a baby may simply have difficulty
evacuating the faeces (its face turns red). The faeces are visible at the
anal opening, but are not easily passed. Incomplete coordination of
the various motor reflexes seems to be the cause. This ‘problem’
disappears spontaneously.
In children of pre-school age, constipation is usually caused by
emotional or behavioural factors, although changes in diet and
potty training may be relevant. Chronic constipation in children
under 2 years of age, a constantly bloated abdomen and an empty
rectum during a digital rectal examination, strongly suggest the
diagnosis of Hirschsprung’s disease. Early diabetes, lead intoxication,
hypercalcaemia and various renal and metabolic disorders can also
be the cause.
In school-age children, constipation usually presents as stomach
ache. Only on inquiry is slow, infrequent defaecation reported.
Peculiar dietary patterns, sometimes involving the entire family,
are often found. Acute painful constipation may also be related to
irritable bowel syndrome (lBS). Extreme cases of faecal soiling and
encopresis, both usually the result of long-term overfilling of the
colon and rectum, require a great deal of attention. The assistance
of a paediatrician and/or a child psychologist may be valuable.
In puberty, most constipation results from an imbalanced diet.
Anorexia nervosa can also playa role at this age: the resistance to
food and the desire to lose weight can lead to minimal food intake,
constipation and laxative use.
Some children may experience pain during defaecation, and the fear of this can cause them to suppress the mge to defaecate, thereby
aggravating the problem. In severe chronic constipation, symptoms may include a lack of
appetite and general malaise. Recurring stomach aches, urinary tract infections or ‘paradoxical’
diarrhoea can also be symptoms of constipation.

TREATMENT
For infants, provide dietary advice: if bottle-feeding, add more water, possibly with a few teaspoons of orange juice or juice from
soaked prunes an alternative is a lactose-rich milk formula; in those on solids, vegetables, h’uit (not too finely chopped) and
brown bread should be encouraged. Children who consume a lot of milk and juice often have less appetite for solid foods with the
necessary fibre.

Bristol stool chart

Stool form scale as a useful guide to intestinal transit time Lewis and Heaton 1997

 

Encoporesis and soiling

Encoporesis and Soiling PubMed 2009

Encoporesis.com Commercial Site

 

Gastroenteritis in infants

Management of feeding during rehydration and maintenance phases
Breast Fed	Continue breast-feeding throughout rehydration and maintenance phase
Formula fed	Restart feeding at full strength as soon as rehydration is complete (ideally after 4 hours)
Weaned children	Give the child normal fluids and solids after rehydration. Avoid fatty foods or foods high in simple sugar

Toddlers Diarrhoea PUK
Lactose intolerance PUK
E Coli 157 Common and potentially serious cause of admission with diarrhoea
Rotavirus causes one third of all hospital admissions for diarrhoea and leads to about 600 000
deaths per year / 6% ofdeaths in the under fives. In the UK, 1 in 40 children are admitted to hospital
for rotavirus infection in their first 5 years.

Rotavirus vaccination

 

Diarrhoea and Vomitting (babies/children)

 

Gastroenteritis in kids

NICE CG84 Diarrhoea and vomiting in children under 5 Apr 2009

1. Assessment of the state of hydration examine the child to exclude other diagnoses and to provide some indication of the state of hydration.
Remember that a baby who is seriously dehydrated may continue to feed well, so feeding itself should not be used as an indication of well being. Signs of dehydration are not usually present until there is a weight loss of about 3%.

Minimal
(Less than 3%)
MildModerate (3-8%)
Severe
(9% or more)

Decreased skin turgo

Tachycardia

Decreased urine outpu

Mouth dryness

Eye signs (sunkenness)

Level of consciousness

Clinical features
r +/ +++
– +/ + + +
t + + + + + +
+/(moist) + (dry) +++ (very dry)
(normal) + +(sunken) + + + (very sunken & dry)
(well, alert) +/(restless, irritable) + + +(lethargic, unconscious,floppy)

2. Rehydration For those with 3% or more dehydration give oral rehydration solution (eg dioralyte or electrolade) over 4 hours.
Mild to moderate dehydration (3-8% weight loss) 30-80mL/kg in 4 hours
Severe dehydration (weight loss of 9% or more) Refer to hospital immediately (????)
Give fluid little and often. If the child is vomiting, reduce the volume and give the fluid more frequently.

3. Maintenance Once rehydration has been achieved ensure that the child receives their normal fluid requirements. These can be calculated according
to the summative table below. Remember to compensate for ongoing fluid losses, such as watery stools or vomiting, by giving an additional 10mL/kg per vomit or stool.

Fluid requirement per day
First 10kg 100mL/kg
Second 10kg 50mL/kg
Subsequent kg 20mL/kg
For example: A 25kg child would require 1000 + 500 +100 = 1600mL/day

Management of feeding during rehydration and maintenance phases
Breast Fed
Continue breast-feeding throughout rehydration and maintenance phase
Formula fed
Restart feeding at full strength as soon as rehydration is complete(ideally after 4 hours)
Weaned children
Give the child normal fluids and solids after rehydration. Avoid fatty foods or foods high in simple sugar

Remember to advise the parent(s) or carer about what they should do to prevent spread of gastroenteritis (meticulous hand washing and hygiene). In
general, children can go back to school/nursery as soon as they are symptom-free, and have maintained a satisfactory fluid intake, for around 24 hrs.

Stool microscopy/culture – this is necessary when the child
has frank blood in the stool
has recently returned from abroad
has a history suggestive of food poisoning
appears systemically unwell or has severe or prolonged diarrhoea
is taking, or has recently taken, a broad spectrum antibiotic (request Clostridium difficile toxin detection).

Referral advice
Any child who is 9% or more dehydrated, or showing signs of shock, should be transferred to hospital immediately (????).
Children should be transferred to hospital urgently (???) if:
they will not take, or tolerate, sufficient fluids orally to maintain adequate hydration/urine output
they appear systemically unwell
there is a suspicion that the symptoms might be due to a cause other than acute gastroenteritis.

Most children can be managed at home but will need to be re-assessed regularly. Frequency of assessment will depend on the age of the child and
whether losses continue. Warn parents that stools may take several days (sometimes up to two weeks) to return to normal. If diarrhoea recurs once the child has returned to a normal, or near-normal, diet consider lactose or other intolerance, particularly if there is failure to thrive
Diarrhoea and Vomitting Under 5 NICE
Causes include:
1. Tonsillitis and otitis media
2. Intussusception
3. Meningitismay be atypical in infants
4. Pneumonia
5. Urinary tract infection
6. Gastroenteritis
Parents’ history may not be exact and vomiting may be a nonspecific symptom of an ill baby. Hence vital to examine fully every infant with diarrhoea and/or vomiting’

Management
If serious disease suspected, refer
1. If a simple gastroenteritis, assess dehydration from the length of the history, the frequency of the diarrhoea and vomiting, and the signs
2. Signs of dehydration (occur when baby is> 5% dehydrated)
(i) Loss of skin elasticity doughy skin
(ii) Weight loss
(iii) Oliguria, Le. fewer wet nappies
(iv) Tachycardia and tachypnoea
(v) Sunken eyes with no tears
(vi) Sunken fontanelle
(vii) Dry mouth
(viii) Irritability or lethargy

IF THERE ARE SIGNS OF DEHYDRATION, ADMIT
Management of simple gastroenteritis in infants is:
(i) Advice-no milk or solid food for 24-48 h
(ii) Clear fluids to be given-the ideal is a glucose electrolyte solution, e.g. Dioralyte sachets. Advise small sips often-intake should be about one to one-and-a-half times the usual feed volume
(iii) Review the next day, within 24 h. Tell the parents to contact you earlier if the infant refuses all fluid, the vomiting increases, the infant’s condition deteriorates or other complications develop
(iv) On review, if infant still vomiting or signs of dehydration evident, admit. If child improving, continue Dioralyte and then begin, as symptoms settle, to regrade through % strength to Y2 strength and finally to full strength feeds in 1224-h steps according to progress
(v) Recurrence of diarrhoea occasionally due to lactose intolerance-if so try a soya milk, e.g. Wysoy, for a month
(vi) Social circumstances and parental attitudes obviously important in determining management
(vii) A written advice sheet is helpful
(viii) If breast-fed the baby can continue-giving little and often, supplemented with Dioralyte

DIARRHOEA AND VOMITING IN OLDER CHILDREN
Much more likely to be just a simple gastroenteritis rather than a manifestation of other illness, but remember appendicitis

Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and management in children younger than 5 years NICE C

Perform stool microbiological investigations if:
you suspect septicaemia or there is blood and/or mucus in the stool or the child is immunocompromised

Assessing dehydration and shock
Use table below to detect clinical dehydration and shock

Fluid management
In children with gastroenteritis but without clinical dehydration:
continue breastfeeding and other milk feeds
encourage fluid intake
discourage the drinking of fruit juices and carbonated drinks, especially in those at increased risk of dehydration (see below)
offer oral rehydration salt (ORS) solution as supplemental fluid to those at increased risk of dehydration (see below)

In children with clinical dehydration, including hypernatraemic dehydration:
use low-osmolarity ORS solution (240–250 mOsm/l)* for oral rehydration therapy
give 50 ml/kg for fluid deficit replacement over 4 hours as well as maintenance fluid
give the ORS solution frequently and in small amounts
consider supplementation with their usual fluids (including milk feeds or water, but not fruit juices or carbonated drinks) if they refuse to take sufficient quantities of ORS solution and do not have red flag symptoms or signs (see below)
consider giving the ORS solution via a nasogastric tube if they are unable to drink it or if they vomit persistently
monitor the response to oral rehydration therapy by regular clinical assessment

Use intravenous fluid therapy for clinical dehydration if:
shock is suspected or confirmed
a child with red flag symptoms or signs (see table below) shows clinical evidence of deterioration despite oral rehydration therapy
a child persistently vomits the ORS solution, given orally or via a nasogastric tube

If intravenous fluid therapy is required for rehydration (and the child is not hypernatraemic at presentation):
use an isotonic solution, such as 0.9% sodium chloride, or 0.9% sodium chloride with 5% glucose, for both fluid deficit replacement and maintenance
for those who required initial rapid intravenous fluid boluses for suspected or confirmed shock, add 100 ml/kg for fluid deficit replacement to maintenance fluid requirements, and monitor the clinical response
for those who were not shocked at presentation, add 50 ml/kg for fluid deficit replacement to maintenance fluid requirements, and monitor the clinical response
measure plasma Na, K urea, creatinine and glucose at the outset, monitor regularly, and alter the fluid composition or rate of administration if necessary
consider providing intravenous potassium supplementation once the plasma potassium level is known

Nutritional management

After rehydration:
give full-strength milk straight away
reintroduce the child’s usual solid food
avoid giving fruit juices and carbonated drinks until the diarrhoea has stopped

Information and advice for parents and carers
Advise parents, carers and children that:†
washing hands with soap (liquid if possible) in warm running water and careful drying are the most important factors in preventing the spread of gastroenteritis
hands should be washed after going to the toilet (children) or changing nappies (parents/carers) and before preparing, serving or eating food
towels used by infected children should not be shared
children should not attend any school or other childcare facility while they have diarrhoea or vomiting caused by gastroenteritis
children should not go back to their school or other childcare facility until at least 48 hours after the last episode of diarrhoea or vomiting
children should not swim in swimming pools for 2 weeks after the last episode of diarrhoea

Assessing dehydration

These children are at increased risk of dehydration:
children younger than 1 year, especially those younger than 6 months
infants who were of low birth weight
children who have passed six or more diarrhoeal stools in the past 24 hours
children who have vomited three times or more in the past 24 hours
children who have not been offered or have not been able to tolerate supplementary fluids before presentation
infants who have stopped breastfeeding during the illness
children with signs of malnutrition

Symptoms and signs of clinical dehydration and shock
—————————————————————————————————————————————————————-›
No clinically detectable dehydration Clinical dehydration Clinical shock
Symptoms (remote and FTF assessments)
Appears well Appears to be unwell or deteriorating
Alert and responsive irritable, lethargic Decreased LOC
Normal urine output Decreased urine output
Skin colour unchanged Skin colour unchanged Pale or mottled skin
Warm extremities Warm extremities Cold extremities
Signs (remote and FTF assessments)
Alert and responsive irritable, lethargic Decreased level of consciousness
Skin colour unchanged Skin colour unchanged Pale or mottled skin
Warm extremities Warm extremities Cold extremities
Eyes not sunken Sunken eyes
Moist mucous membranes (except after a drink) Dry mucous membranes (except for ‘mouth breather’)
Normal heart rate Tachycardia Tachycardia
Normal breathing pattern Tachypnoea Tachypnoea
Normal peripheral pulses Normal peripheral pulses Weak peripheral pulses
Normal capillary refill time Normal capillary refill time Prolonged capillary refill time
Normal skin turgor Reduced skin turgor
Normal blood pressure Normal blood pressure Hypotension

 

Umbilical problems

umbilical problems medscape

 

Umbilical hernia

youtu.be/LRsZjWzka5c

youtu.be/Esxr1LKXqCY

Umbilical hernia medscape

Will usually resolve within first year – 2 years. surgical intervention is not advised before the third year, unless the neck of the hernia is larger than 2 cm at the time of the child’s first birthday, in which case spontaneous closure is very unlikely.
Paraumbilical hernia rarely resolve and will need surgical correction after the age of 2-3 years

 

Undescended testes

youtu.be/mhDqZWVRcPU

Undescended Testes @ Patient UK

 

Breast buds

baby-breast-lumps WebMD

 

Neonatal vaginal discharge and bleeding

Maternal oestrogens and progestogens from the placenta cross over into the foetal blood system causing development of the foetal endometrium.
Abrupt withdrawal of these hormones after birth causes atrophy and shedding of the mucosa causing a mucus / bloodstained discharge
source GPCSG

Hormonal Effects in Newborns medicine online.com

 

Pyloric stenosis

youtu.be/CNZ6MpWL634

<a href=”http://emedicine.medscape.com/article/803489-overview>Pyloric stenosis Medscape

Pyloric Stenosis information for parents GOSH

 

Intussusception

Intussusception Medscape

 

Circumcision

MPS Factsheet Circumcision

youtu.be/J2zBaKLYeqQ

youtu.be/QaFtcIrtbm0

 

Enuresis

Failure to voluntarily control micturition. Can be diurnal or nocturnal.

http://guidance.nice.org.uk/CG111

Dry & Mighty

ERIC

Lets Get Dry

Most children are dry at night by 4 years.
Age   % wetting
5         11
10       5
15       2

Ten per cent of 5-year-olds wet their beds.
Treatment is justified after the age of 4 years

History
1. Primary or secondary? Secondary may be emotional or organic
2. Other symptoms, e.g. dysuria, abdominal pain
3. Family history
4. Is the child developing normally, both mentally and physically
5. Family stress
6. Parental expectations

Examination
1. Examine the back and lower limbs for anatomical anomalies or lesions of the lower spinal cord
2. Palpate the abdomen for kidneys and bladder and examine the external genitalia of boys

Tests
MSU and dipstick urine if appropriate

Management
With no anomalies, neuropathic bladder or UTI, the management is:
1. Advice, e.g. lifting the child before going to sleep
2. Star charts, rewarding the child for engaging in pocess not for success! dry nights and reviewing the chart to encourage success
3. Enuresis alarms cure 80% in 6 months and are the treatment of choice. Relapse responds to restarting the alarm. Best for the 6+
age group, as a little frightening at 5 years old.
Health visitors ideally suited to educating parents and following up children with enuresis.

4. Drugs eg desmomelts

 

UTI in children

NICE CG54 Urinary tract infection in children Aug 2007

Pre and Post-treatment samples essential.
Refer if < 3 months or after first proven urinary tract infection.

UTI Children
Acute Cystitis	E. coli	Trimethoprim	Then treat as per culture.
Recurrent cystitis	E. coli		recurring UTI requires prophylaxis as does first attack for children < 1 yr
Pyelonephritis	E. coli	Ceftriaxone	Then oral therapy as per culture.

Urinary tract infections (UTIs) occur in at least 3% of boys and 5% of girls and account for 5% of fevers in infants and toddlers. In early infancy it is more common in boys but from six months is more common in girls. Re-infection is particularly likely in girls; in boys re-infection is uncommon unless there are severe underlying urinary tract anomalies. If not treated promptly, UTIs can lead to renal scarring which in some patients can result in hypertension, renal failure and complications of pregnancy. A UTI may mimic many of the common childhood illnesses and should be considered in any child with a fever.

Clinical features
In children under 2 years, a UTI may present with non-specific symptoms such as fever, feeding problems, malaise, vomiting, diarrhoea, abdominal
distension, febrile convulsions and failure to thrive.
In a child aged 2-3 years, more specific urinary features may be detected but this is unlikely if the child is still wearing nappies.
Older children may have signs of cystitis or acute pyelonephritis ) but often present with non-specific symptoms as described above.

Assessment
Assess the level of hydration
Look for evidence of sepsis (eg fever, tachycardia and malaise)
Inspect the external genitalia to look for alternative causes of urinary symptoms such as phimosis or perineal soreness
Examine the abdomen to check for suprapubic or loin tenderness and for an enlarged bladder or abdominal mass
Inspect the spine for evidence of dysraphism.

Management
1. Ensure that the parent/carer understands the need to establish whether or not the child has a UTI and the importance of treating it.

2. Collect urine to test for evidence of infection. The best urine samples are clean catch samples’where fresh urine is collected directly into a sterile
container. However, this is sometimes difficult or impossible in a sick infant or toddler. For them, urine can be collected into an adhesive plastic
bag ‘bag sample’ or into a specially designed ‘pad’ which can be placed inside the nappy. Samples from potty-trained toddlers can be collected
successfully from plastic potties thoroughly washed with hot water and washing-up liquid.
3. Use a dipstick to test for the presence of nitrite, leucocyte esterase, blood and/or protein. If any of these are positive send a urine sample for culture.
The sample should be transferred to the lab as soon as possible but can be stored overnight in the fridge at home, or in the surgery, if necessary.
4. If the dipstick test is positive for nitrites and/or leucocytes, or you strongly suspect a UTI, then start an antibiotic such as trimethoprim (4mg/kg twice a day for 5 days). The choice of antibiotic should reflect local sensitivity patterns. Reassess the child in around 48 hours and review the choice on antibiotic depending on the lab results.

5. Any child with a first UTI should undergo further investigation by ultrasound. Those under 5 years old should be given prophylaxis with
trimethoprim (1-2mg/kg) or nitrofurantoin (1mg/kg) at night, until the results of investigation are available and a long-term plan agreed.

Referral advice
Children should be transferred to hospital immediately (????) if they are more than 9% dehydrated (see page 73).
Children should be transferred to hospital urgently (???) if they:
are ‘septic’
have severe vomiting
have evidence of a UTI and are under 6 months old.

Children with recurrent episodes of acute pyelonephritis should be referred to be seen within a month (??).
Children should be referred to a paediatrician (?) if they:
need further investigation that cannot be undertaken in primary care.
This may include ultrasound, dimercaptosuccinic acid (DMSA) scan for children under 5 years, or micturating cystourethrogram (MCUG) in
children under 1 year
have frequently recurring UTIs and/or breakthrough infection while taking prophylaxis
have evidence of underlying renal disease such as an abnormal ultrasound, proteinuria, raised creatinine (adjusted for age) or hypertension.

Obtaining a Urine specimen in young children

InfoPOEMS Posterior Urethral Valves and CKD in Boys

1.   Introduction
A urinary tract infection (UTI) occurs when there is infection in any part of the urinary system (kidneys, ureters, bladder or urethra)

Key Issues

Red Flag Warnings

Where an unexplained fever of 38° C is present in an infant or young child consider UTI
Diagnosed renal abnormality
Dysfunctional voiding
History of recurring UTI
Family history of vesicoureteric reflux (VUX) or other renal pathology
Constipation
Poor growth
High blood pressure
Spinal lesion
Enlarged bladder
Abdominal mass

Presenting symptoms may include

Fever
Vomiting
Lethargy
Irritability
Poor feeding history
Failure to thrive
Abdominal pain
Jaundice
Haematuria
Offensive urine odor
Loin tenderness
Frequency
Dysuria
Changes to continence
Loin tenderness

Immediate Care Considerations

Assess airway, breathing and circulation (ABC’s)
Record temperature, heart rate, respiratory rate and capillary refill
Urinalysis
<3 months – 3 years request urgent paediatric evaluation/admission
Paracetamol or ibuprofen for comfort measures (do not administer together but consider use of the alternative medicine if no response to the first)

2.   Background Information
A urinary tract infection (UTI) occurs when micro-organisms enter the urinary system.

Urinary tract infections are categorised into two types, upper UTI and lower UTI.

Lower UTI is classified into cystitis where there is inflammation of the bladder or urethritis where there is inflammation of the urethra.

Upper UTI is classified as pyelitis where there is inflammation of the pelvis of the kidney, or pyelonephritis where there is inflammation of both the pelvis of the kidney and the actual kidney itself.

A UTI is considered undifferentiated when it is not possible to determine whether it is upper or lower in origin.

The most common organisms that cause a UTI are;
Escherichia coli
Klebsiella
Proteus mirabilis
Staphylococus saprophyticus

Less common organisms include;
Proteus vulgaris
Enterobacter species
Citrobacter species
Serritica species
Staphylococcus aureus

Rare organisms include;
Candida albicans

Urinary tract infections can occur on more than one occasion and are defined as recurrent when there have been 2 or more episodes of upper UTI; 1 episode of upper UTI plus one or more lower UTI; or 3 or more occurrences of a lower UTI.

UTIs can be a contributing factor in the development of Vesicoururetetic reflux (VUR) or can be diagnosed following a UTI in infants and young children where urine remains static in the bladder creating an ideal medium for bacteria to grow. Primary VUR occurs when;

A infant is born with an impaired valve where the bladder meets the urethra
The ureter has not grown long enough during fetal development
The valve fails to close causing urine to reflux from the bladder to the ureters and eventually to the kidneys

In instances of primary VUR as the child grows and the ureters lengthen the outcomes usually improve with greater valve efficiency.

Secondary VUR occurs when there is a blockage anywhere in the urinary system. In UTI the resulting inflammation causes a blockage and in turn causes reflux of urine to the kidneys.

Symptoms of VUR include
Urinary tract infection
Bedwetting (enuresis)
High blood pressure
Proteinuria
Kidney failure

Clinical features of obstruction to the urinary tract include poor urine flow, fever of uncertain origin, enlarged bladder, abdominal mass, poor growth and high blood pressure. Key features to be noted in the patient medical history and examination are ante-natal diagnosis of any renal abnormality, any spinal, ano-rectal or genitor-urinary abnormality.

Treatment of urinary tract infection is through the administration of antibiotics via a route that can be suitability tolerated by the infant/child.

For most infants and children the prognosis for recovery after antibiotic treatment is excellent. However UTI can reoccur and long term complications include renal scarring, hypertension, renal insufficiency and failure.

If the infant is <3 months old and has a possible UTI a referral to a paediatrician should be made immediately.

3.   Investigations
Where an infant or child has possible symptoms of a UTI:

Test urine using clean catch methods (consider urine collection pads/catheter sample if unable to collect via clean catch). If supra pubic aspiration is required an ultra sound must be used to check for presence of urine in the bladder before using this urine collection method.
Dipstick test

i.     Leucocyte esterase and nitrates positive: regard as UTI
ii.     Leucocyte esterase negative and nitrates positive: commence antibiotics and send for culture
iii.     Leucocyte esterase positive and nitrates negative: send urine for cultue, do not commence antibiotics unless good clinical evidence of UTI
iv.      Leucocyte esterase and nitrates negative: Not a UTI, explore other potential causes of illness

Send urine for urgent microscopy and culture
If atypical UTI an ultrasound should be performed during the acute stages of the infection to identify whether there are any structural abnormalities
Infants under 3/12 treatment managed by a paediatrician
Children >3 months and older

Upper Urinary tract infection –

Treat with oral antibiotic therapy (Cephalosporin or co-amoxuclave)
If oral antibiotics not tolerated consider intravenous or intramuscular injection if this is not possible.

Lower Urinary tract infection
Use local trust guidelines (consider Trimethoprim, Nitrofurantoin, Cephalosporin) for 3 days
Encourage adequate oral fluid intake in all age groups
To address any dysfunctional elimination syndromes, encourage the child not to delay voiding of urine, for example if delaying due to be involved in play
Management of constipation
Advice re access to clean toilets, personal hygiene after defecation in girls.
Only if the child has had recurrent UTI consider prophylaxis
Ultrasound within first 6 weeks if <6 months old or if there have been recurrent UTI in any age group

Trimethoprim Doses UTI Kids
Age	Trimethoprim dose
2-5 months	25mg twice daily for seven days
6m – 5 years	Trimethoprim 50mg twice daily for seven days
6-12 years	Trimethoprim 100mg twice daily for seven days

 

RTIs children

NICE CG69 RTIs> NICE CG69 July 08

 

Sore throat children

hacking-medschool/sore-throat-ent

Organisms
•Viruses: most common
–Adenovirus, influenza, entero-, rhinoviruses, coxsackie, herpes simplex, EBV
•Bacteria
–Group B a-haemolytic Streptococcus
–S. pneumoniae
–Haemophilus influenza
–Moraxella catarrhalis
–Other: N. gonorrhoea, Syphilis, diphtheria, Vincent’s angina

Bacterial tonsillitis
•Group B a-haemolytic streptococcus
–M surface proteins (serotyping), streptolysin O
–Positive cultures + negative ASO= carrier state
•N. gonorrhoea: common in male homosexuals
•Vincent’s angina (trench mouth): Pharyngitis and ulcerative gingivitis: synergistic infection of the anaerobic Fusobacterium fusiformisand the spirochaete Borrelia vincentii

Complications of acute tonsillitis
•Local
–Upper airway obstruction
–Abscess (peritonsillar, parapharyngeal, retropharyngeal)
•General
–Septicaemia
–Meningitis
–Acute rheumatic fever
–Acute glomerulonephritis

Treatment of Acute Bacterial Tonsillitis
•Analgesia
•Penicillin 500 mg qds 1/52
•?steroids: Prednisolone 40mg od 4-5 days
•Local anaesthetic spray/gargles
•If dysphagia to fluids refer to hospital for IV treatment and fluids

 

Centor score

www.mdcalc.com/ centorscore

 

Tonsils and adenoids

hacking-medschool/tonsillectomy-2

 

Grommets

hacking-medschool/grommets

 

Cough in children

aaaai.org cough in children

 

Bronchiolitis and viral croup

hacking-medschool/croup-score

Viral croup is a disorder of young children that involves shortness of breath, inspiratory stridor and a barking cough resulting from an infection of the mucosa of the larynx and trachea.

The disorder is viralusually the parainfluenza virus, but other causes include influenza A virus, influenza B virus, adenovirus and respiratory syncytial virus.
The interior wall of the larynx swells up, particularly in the mucosal folds just under the vocal cords. Because of the cartilage rings, the swelling can only expand in the lumen of the larynx, and not to the periphery. This narrowing high up in the airway causes the shortness of breath, cough and the often very audible inhalation. Mucus accumulation may also be present, in addition to the inflammation of the mucous membrane. The child’s agitation only serves to make the shortness of breath worse. Viral
croup is usually a harmless disordel: However, rarely, the lumen can become entirely occluded in a relatively short time.

PRESENTATION
There is a typical pattern to the presentation. The GP is often calledin the evening. The parent reports that the child played normally during the day, but had a bit of a cold. The child then went to bed atthe normal time, but after sleeping an hour or more, woke up with shortness of breath and a cough like a seal’s bark. Anyone who has
ever heard this will recognize it easily, even over the phone. Parents who have never heard it before are often very worried.

EPIDEMIOLOGY
Viral croup is a disorder that usually occurs in young children aged 3 months to 3 years. It occurs very occasionally in children of schoolage. The incidence is 0.7-3.5 per 1000 children under 6 years old per year. It is more common in boys than girls. As for the typical seasonal peaks of virus infections, viral croup occurs more often when there is an ‘R’ in the month especially in the autumn.

HISTORY
The GP asks:
when the child began experiencing shortness of breath
if there were symptoms earlier (during the day)
whether the child makes noises when breathing
whether fever is present (there may or may not be fever with viral croup, but it would be unlikely to produce a temperature above 40°C)
whether the child has (previously) had asthmatic symptoms
if there is any possibility of a foreign body.

EXAMINATION
Auscultation usually reveals nothing apart from the conduction of the inspiratory stridor. Rhonchi can be heard if tracheobronchitis is present, in which case the child’s temperature is usually higher. An important differential is epiglottitis. In such a case, the onset is sudden, and the child is older, sicker, paler and calmer than a child
with pseudo-croup. Usually, the child is unable to lie down and (characteristically) drools because he cannot swallow. If epiglottitis is suspected, the throat should not be examined.

TREATMENT
In the first (telephone) contact, the GP recommends that the parents sit with the child in a steamy bathroom or shower. It is important that the child sees the parents are calm agitation will aggravate the problem. The parents usually accept that this will help settle the situation. It is unclear what part of this treatment is the most
effective: the steam or the ‘calm’. If the parents are satisfied with this reassuring advice, the GP asks them to call back to inform him about the child’s progress.
However, if the parents remain anxious, or there is any diagnostic doubt, the GP should arrange to see the child to assess further. In rare cases, viral croup can cause significant airways obstruction, for which hospitalization and even intubation may sometimesbe necessary.

Treatment with steam has not been scientifically evaluated, although it is not harmfuland in daily practice, steaming has often already been started by the parents before they call the GP It is not known if it is in spite of, or thanks to, steaming that less than 5% of children with croup have to be referred to hospital. The effect of treatment with (inhaled) steroids has only been evaluated in selected populations.

The guideline Acute Coughing from the Dutch College of General Practitioners advises, for more severe croup with stridor and tachypnoea, a once-only dose of steroid (e.g. 5 to 10 puffs with fluticasone via a spacer). UPDATE THIS

PREVENTION AND ADDITIONAL INFORMATION
When giving information to the parents, emphasize the good prognosis of viral croup and the value of the most frequently recommended remedies steam and rest.
Key points
Viral croup is a disorder of young children that involves shortness of breath, inspiratory stridor and a barking cough resulting from an infection of the mucosa of the larynx and trachea.
The barking cough is instantly recognizable, even over the phone, but it may worry parents if they have never heard it before.
An important differential diagnosis is epiglottitis.
In rare cases, viral croup can cause significant airways obstruction.
Human metapneumovirus (hMPV), first isolated in 2001, is an important new virus in young children. Over a 25 year period, 20% of children, mean age 12 months, with a lower
respiratory infection tested positive for hMPV It usually presented as bronchiolitis, but also as croup and exacerbations of asthma.

 

Stridor

hacking-medschool/stridor

(A) Stridor
? inspiratory stridor only (partial airway obstruction at the larynx or above), both inspiratory and
expiratory stridor (partial tracheal obstruction), or expiratory stridor only (partial airway obstruction below
the carina).
? croup?, epiglottitis?, F.B.?, bacterial tracheitis?, peritonsillar abscess?/tonsillitis/pre-existing tonsillar
hypertrophy?, retropharyngeal abscess?, allergic reaction/angioedema? ? all seven may result in upper
airway obstruction. Do not agitate the child, leave them in a position of respiratory comfort.
? Bag and mask with 100% O2 prn.
? Intubation? Use an ET tube 1-2mm smaller than usual prn (with adequate lubricant, e.g. xylocaine jelly).
A small ET tube will suffice, at least temporarily. Consult anesthesia if time permits.
? Epiglottitis?, direct the ET tube through the “eye of the cherry.”
Aspiration of F.B. into tracheal-bronchial system?, esophagus?, unilateral wheezing? ? do bilateral decubitus
expiration views prn, or an upright expiratory film if the patient can cooperate (the side with the F.B. may
demonstrate ar trapping).
(B) Croup
? viral?, bacterial?, spasmodic?
The Gist of Emergency Medicine?

(C) Epiglottitis
? the child is sitting in the “sniffing position” ? toxic, fever, muffled voice, dysphagia/drooling, ± cyanosis.
? L ABC’s, position of respiratory comfort, humidified 100% O2, racemic epinephrine aerosol prn (0.5cc
2.25% with 4.5cc saline/100% O2), portable x-ray?, bag and mask with 100% O2 prn, intubate in the OR
prn, and claforan® 100mg/kg/I.V./day. The patient may require immediate intubation in the ER. The
presence of pharyngitis does not rule out epiglottitis. Bacterial tracheitis presents and is managed similarly
to epiglottitis.
Epiglottitis prophylaxis: L rifampin
? adults 600mg of rifampin bid X 4 days
? 1 month to 12 years of age, 10mg/kg bid X 4 days
? less than 1 month, 5mg/kg bid X 4 days
(D) Retropharyngeal or peritonsillar abscess
? tonsillitis/pre-existing tonsillar hypertrophy?
L ABC’s, position of respiratory comfort, humidified 100% O2 prn, intubate prn, penicillin G 100,000
units/kg/day/I.V., incision and drainage in the OR prn.
gist

 

ABs in LRTIs in children

1. Pneumonia
Lobar pneumonia Strep. pneumoniae
Haemophilus influenzae
Staph. aureus (< 1 yr) Amoxicillin > 1 year
or co-amoxiclav
< 1 year
Atypical pneumonia Mycoplasma pneumoniae and others Erythromycin (iv) or clarithromycin (oral)

Post-operative aspiration/hospital acquired pneumonia
Strep. pneumoniae
Haemophilus influenzae
Staph, aureus
Anaerobes

Co-amoxiclav
Post-viral pneumonia Staph. aureus
Haemophilus influenzae Co-amoxiclav

2. Bronchitis/Bronchiolitis
Children < 1 year RSV Ribavirin If NPA positive and clinical criteria apply, only on Consultants’ instructions (see Bronchiolitis Protocol 1994)

Exacerbation of cystic fibrosis (bronchiectasis)
Pseudomonas aeruginosa
Staph. aureus

Ceftazidime plus gentamicin Then treat as per culture

Upper Respiratory Tract Infections
Clinical conditions Pathogen(s) Antibiotic(s) Comments
Tonsillitis Virus (75%)
Strep. pyogenes

Nil
Penicillin V Clarithromycin if allergic to penicillin. Avoid amoxicillin or ampicillin. 10 days therapy required to prevent sequelae.

Epiglottitis/acute bacterial tracheitis ALTB Haemophilus influenzae
Staph. aureus Ceftriaxone (for epiglottitis) add flucloxacillin iv for other patients
Acute otitis media Strep. pneumoniae H influenzae Amoxicillin
Mastoiditis As above but wider spectrum of causes Co-amoxiclav
Pertussis B. pertussis Clarithromycin (oral) or erythromycin (iv)

 

Cough mixtures

MHRA advice

NEJM 2009 357;23

 

Wheezy child – preschool viral wheeze

Prescchool Wheeze ERJ 2008

asthma
viral or bacterial infection
anatomical anomalies (including laryngeal problems),
inhaled foreign body
cystic fibrosis
bronchiolitis

Various entities labelled, e.g. ‘wheezy bronchitic’, but they are largely academic as below the age of 2, where attacks of wheeze
can be brought on by infection, bronchodilators are generally ineffective. A proportion of ‘wheezy bronchitics’ will develop asthma

Consider asthma in the child with recurrent cough, especially nocturnal cough, and in those with dyspnoea on exertion

Preschool Viral Wheeze
THE CHILD WITH A COUGH
Commonly due to simple respiratory tract infections but if persistent think of:
1. Pertussis see chapter on Infectious diseases
2. Asthma
3. Inhaled foreign body
4. Chronic respiratory infection secondary to a postnasal drip from infected sinuses or adenoids
5. Anatomical anomalies
6. Immune disorders
7. Hiatus hernia with gastro-oesophageal reflux
8. Cystic fibrosis-associated with failure to thrive ~ malabsorption
9. Psychogenic cough-a well-recognized entity
Children with a persistent cough or a recurrent cough need therefore a good assessment including a history, chest and ENT examination and, as appropriate, CXR, RAST test, FBC and peak flows. Asthma is very common and a trial of bronchodilator is worthwhile, especially for those with recurrent coughs

 

Asthma in children

hacking-medschool/acute-asthma-children-under-2

hacking-medschool/acute-asthma-children-over-5

BTS Guidelines

NICE TA 131 Nov 2007 Steroids

NICE TA10 2000 Inhalers Spacers and Masks in under 5s

Childhood Asthma PUK

asthma.org.uk advice for parents

 

Cystic fibrosis

hacking-medschool/cf-genetics

 

Bronchiectasis in children

hacking-medschool/bronchiectasis

Bronchiectasis in Childrenmedscape

 

Allergies in childhood

NICE CG 116 Feb 11 Food allergies in children

Fighting food allergies among schoolchildren NICE Sep 2011

eGuidelines presentation June 2011 (Phadia)

 

Pyrexia in Kids – Nice traffic lights

hacking-medschool/child-with-fever-nice-traffic-lights-cg47-2007

Antipyretics in Children

Thermofocus Non-Touch Thermometer

 

Paracetamol ibuprofen in Kids

hacking-medschool/ibuprofen-paracetamol

Updated advice on paracetamol dosing in children NPC/MeReC Rapid Review Jun 2011

Paracetamol prescribing in primary care: Too little and too much?

http://www.nelm.nhs.uk//en/NeLM-Area/News/2011—November/15/MHRA-Public-Assessment-Report-on-revised-UK-dosing-recommendations-for-liquid-paracetamol-for-children-

Paracetamol post vaccination

Infant paracetamol suspension (120 mg/5ml)
3 – 6 months 2.5 ml Four times
6 – 24 months 5 ml Four times
2 – 4 years 7.5 ml Four times
4 – 6 years 10 ml Four times

Paracetamol six plus suspension (240/250 mg/5ml)
Age Dose How often (in 24 hours)
6 – 8 years 5 ml Four times
8 – 10 years 7.5 ml Four times
10 – 12 years 10 ml Four times

Paracetamol and asthma BMJ 2010;341:c4616

 

Febrile convulsions

newcastle-hospitals.org.uk febrile-convulsions

Febrile Sezures @ CKS

 

Paeds antibiotic doses (emergencies)

hacking-medschool/paeds-ab-doses-infections
hacking-medschool/abs-children

 

Neonatal conjunctivitis

Neonatal Conjunctivitis Medscape/emedicine

 

Epilepsy in children

NICE CG20 CG20 Epilepsy in children and young people Mar 2010

Epilepsy.org.uk Parents guide

Epilepsy Society Epilepsy and you

SIGN Guideline 81

 

Headaches and migraine in children

rcgp gps help with school headaches

 

Faints funny turns in Kids

stars.org.uk

Breatholding Attacks Sidney Childrens Hospital

Reflex Anoxic Seizures PUK

 

Henoch schoenlein purpura HSP

? acute vasculitis of small vessels with frequent multisystem involvement.
? etiology unknown, but believed to result from immune complex reactions to various antigenic stimuli.
? pathognomonic skin lesions ? erythematous progressing to purpuric, predominately on the buttocks and
lower extremities (feet and ankles in adults).
? GI, renal, pulmonary, CNS, and arthritic manifestations.
L ABC’s, supportive care, corticosteroids prn, consult pediatrics.

 

Haemolytic uraemic syndrome HUS

? usually follows an episode of gastroenteritis or respiratory infection.
? may result from eating undercooked hamburger meat contaminated with E. Coli.
? nephropathy, hemolytic anemia, and thrombocytopenia.
? seizures, hypertension, petechiae, acute renal failure.
L ABC’s and supportive care (e.g. L seizures, hypertension, hyperkalemia/renal failure, anemia,
thrombocytopenia), consult pediatrics, admit ICU prn.
HUS VS TPP

 

Petechiae in well children

Arch Disease Children 2010;95:518-20
Less than 4 isolaed lesions in a well afebrile child no need to investigate further.

 

Kawasaki disease (paeds)

250textbooks/kawasaki-disease-2

Kawasaki disease BMJ 2008

 

Childhood murmurs

Congenital heart disease in children

Cyanotic

Acyanotic

VSD

PS

ASD

PDA

Coartation of the aorta

Six S’s of an innocent murmur
Symptom free
Systolic
Split 2nd heart sound
Sternal edge (left) side
Small part of pulmonary area only
Signs otherwise normal

Murmers bhf factfile Oct 2001 pdf

Childhood Murmers
Flow Murmers
ASD
Small VSD
Bicuspid aortic Valve
Venous Hum

VSD
Pulmonary Stenosis
Aortic Stenosis

Mitral Regurgitation

 

Behavioural problems in toddlers

Is a long way from being a helpless baby to becoming a relatively independent 3 or 4 year old ready to go to play group or nursery. It can be an exciting journey of discovery but it can also seem a very bumpy ride for both you and your child.
As your child moves through his second year he will be wanting to take part in what is going on around him through exploring and playing, watching and imitating others and using his first words. He now feels he is a person in an interesting world of people and he wants to join in.
But he also has to discover all sorts of things he can’t yet do or mustn’t do and feelings that he can’t yet manage by himself without tears or tantrums.
Young children react very differently to the triumphs and set backs of their second and third year and need different kinds of support from their parents.
Some children can’t bear to feel little and helpless. They refuse to accept that there are things they can’t yet manage. Being bossy can be a way of covering this up and trying to make others feel small.
This can be so convincing that sometimes as parents we may come to believe they don’t need us or feel so irritated we want to cut them down to size. But bossy 2 year olds really need someone to offer them love and care even when they don’t seem to want it.
BEING FUSSY…
Many children of 2 or 3 develop all sorts of fads and rituals which they will absolutely insist on.
From a parent’s point of view it can seem silly and tyrannical but how does it look to a small child?
Everyone is expecting her to give up being a baby and become more independent. But she may feel as if the grown-ups are always interfering and bossing her around. When she insists on wearing something strange or doing things in a particular order she may be trying to get others to recognise her choices and preferences. It’s probably helpful to give in gracefully sometimes over things which don’t really matter. That way she will get the chance to learn what it is to back down.
And, of course, there are going to be plenty of times when she wants something impossible or dangerous. So there will still be opportunities for her to learn about “no” and for you to learn to cope with her tears.
‘I’D RATHER BE SMALL’
A child who is clingy and fearful can be very trying in a different way.
As parents we need the reassurance of seeing things move in the right general direction. So babyish’ behaviour is hard to bear because it makes us worry that things are going backwards.

NEW SITUATIONS CAN BE FRIGHTENING
Children of 2 or 3 sometimes feel quite scared about new situations, especially if they think it means being left with other people.
It is worth being truthful about new situations or child minding arrangements so that they don’t feel taken by surprise or tricked.
Allow plenty of time for settling in and a certain amount of fussing. And be prepared to take it seriously if your child really feels he isn’t ready for a new step forward.
BUT SOME OF THE FRIGHTENING THINGS ARE INSIDE HIM
A 2 or 3 year old is having to wage a constant battle with his own passionate wants, hopes and fears. He is still struggling to sort out who he is and what he feels about those who care for him why he loves them one moment and hates then the next.
Far a parent it’s very exhausting not knowing of you’ve got a baby or a big boy on your hands. When you feel you can’t get it right the chances are your child is feeling in a tremendous muddle too.
HAVING WORRIES….
Sometimes fussiness is to do with worries which your child can’t name or tell you about.
Then, his determination to avoid certain objects or situations may be his way of controlling his fears.
What’s worrying him may not have any obvious connection with the things he’s making a fuss about but it’s easier to control what you let your mum put on your plate than to control anxieties you don’t understand.
These sorts of fears tend to come and go but if his behaviour becomes especially difficult it is worth wondering if he’s under some particular stress.
NIGHTMARES
It is at this age that children first complain of bad dreams.
Sometimes the dreams seem to be connected with worrying events which happened during the day but quite often they seem to grow from feelings within the child.
You may never really know what’s troubling him, but it’s very comforting for a child who can’t yet understand himself if he feels that a grown up is trying to do the understanding for him.

TEMPER TANTRUMS
Your child is coping with strong feelings all day long. If he’s managing to keep on a reasonably even keel he’s doing wall but there are bound to be times when he can’t cope.

DOES IT REALLY MATTER IF I SCREAM BACK?”
In the heat of the moment it is easy to become as angry as your child.
As parents we feel helpless, embarrassed or exposed if our children have tantrums if public.
Even at home there are going to be times when they drive us too far.
But children learn by example so if they never see us struggling to cope with our frustration or worry how can they ever learn that is possible to be distressed or angry without throwing a tantrum?
‘SO WHY DOES SHE HAVE TANTRUMS?”
Isn’t she just wanting attention?
When your child throws a temper tantrum what she is doing is showing you what it feels like inside her when she can no longer cope.
She can’t tell you in words. She screams and throws herself around because she feels her big girl self has exploded.
She doesn’t just ask for your help but messes you around with contradictory demands because that’s how helpless and confused she feels.
She is probably scared as well as angry because her rage seems so powerful and dangerous and she has lost her picture of Mum and Dad as helpful or friendly.
She doesn’t need you to come up with a solution or to buy her off with treats (though everyone has done that at times).
She needs to see that you can feel upset and helpless and still take care of both you and go on loving her.
BUT WHAT ABOUT DISCIPLINE?
Firmness is important but so are understanding and tolerance. Simply telling a child to behave better doesn’t give them the strength to control their feelings. They can only learn slowly how to share, wit and accept “no”. And they learn this by example.
This doesn’t mean being perfect parents but it does mean parents who are trying expect more of themselves than their child.

SOME HELPFUL PRACTICAL TIPS
Unless she’s doing something dangerous count to 10 before taking any action at all.
Try not to get drawn into an argument about exactly what started it. She really is beyond reasoning with.
Don’t ask more of her than she can manage.
Coping with her temper doesn’t mean trying to stop her being angry, it means coping with how angry she makes you feel.
Try to avoid saying things just to hurt her backespecially threats of leaving home or having her put away. You may not mean it but she doesn’t know that.
Don’t worry that she’s growing up to be a monster. The temper tantrums of a 2 and 3 year old will start to tail off but only slowly. It will take 2 or 3 years.
Try to remember that through her tempers she’s learning important lessons about herself and both of you are practising for when she’s a teenager!
‘I’M AT THE END OF MY TETHER.’
Sometimes parents feel they are no longer able to keep going. They may become frightened that they will injure their child physically or emotionally.
If you feel this is happening to you for the sake of your child and yourself, you should seek help to sort out what’s wrong.
You may feel you don’t have enough help and support. You may have too many worries on your plate. You may feel depressed or unwell.
Your Health Visitor or GP are probably the best people to talk to first.
They will help you decide whether to seek help from a Social Services Department or Child Guidance Clinic or Hospital Department.
‘BUT MY CHILD’S TEMPERS ARE NOT JUST ORDINARY TANTRUMS.’
Sometimes parents feel that their child’s temper tantrums are not just the sort they will grow out of. Perhaps they feel that their child has never really got going with talking or doesn’t enjoy playing or being with other people. He may be restless and destructive as if he can’t take pleasure in anything. And most painful of all, parents in this situation feel there is a barrier between themselves and their child.
If you have concerns of this sort it is important to seek specialist advice. It is not a good idea to just leave things in the hope that they will sort themselves out.
If you feel you need help, please contact your GP or Health Visitor .

Published by The Child Psychotherapy Trust, 21 Maresfield Gardens, London, NW3 5SH.

 

Night terrors

http://youtu.be/EbCh-NrGHMs

Night terrors and nightmares are nightly sleep disturbances that usually occur in childhood. In a night terrolrs the child is incompletely
aroused from deep, slow-wave sleep. The child is not completely awake, and seems confused. He may make random movements with
his arms and legs, does not respond when spoken to, and does not remember anything about the episode the next day. These attacks
rarely last longer than 15 minutes.
Nightmares are frightening dreams that wake the child from sleep, and which are not accompanied by motor agitation. The child is
woken by the dream and can still remember it.

AETIOLOGY/PATHOGENESIS
Night terrors occur due to a sudden arousal from deep (non-REM sleep), generally at the beginning of the night. An episode usually
begins with a loud, penetrating scream, followed immediately by random movements of the arms and legs, and sometimes the entire
body, with the tendency to sit bolt upright in bed. Characteristically, the child will have an intensely frightened facial expression (with
bulging, wide-open eyes), and sometimes heavy perspiration with rapid heartbeat and breathing. After a few minutes, the severity
of the symptoms decreases, but the child remains confused for several minutes before falling asleep again. There is a familial predisposition, possibly in combination with sleepwalking and nocturnal enuresis. Upper respiratory disorders that disrupt sleep can aggravate the problem.
Nightmares are very frightening dreams that wake the patient from REM sleep, usually in the second half of the night. These are
GMC Guidance for dealing with children & Young People
Paediatrics is concerned with patients from 0 to 18 years. Guidance for all doctors can be found at www.gmc-uk.org/.
This is the first publication from the GMC issuing guidance on children. It outlines roles and expectations and may
help in making decisions that are in the best interest of the child/young person, assess capacity and consider consent issues.
Child Protection & Safeguarding Children
Child protection
In 2007 there were 27900 children under a Child Protection Plan (CPP). These
children are on a child protection register because they are at risk of ongoing
abuse. Such abuse could be physical, sexual (this includes contact and noncontact),
neglect and emotional illtreatment.
Following the Victoria Climbie trial there has been renewed effort to keep us
all informed on child protection issues and Working to Safeguard Children was
published. As GPs we are not expected to be trained in forensics, but we should
remain vigilant, keep good records, be prepared to set investigations in motion
through the child protection agency and maintain close contact with other health
professionals and the family. This is often tricky in that, although the welfare of
the child must be placed above all other considerations, usually all members of
the family are under our care and often at the start ofan investigative process you
may be reporting only suspicions.
….Sections missing