Common Problems in Paediatric Outpatients

Question 1

What should be considered when a child is being allocated to a clinic?

Answer 1

Age of child (0-14), where they live, principal issues, degree of urgency, presence of red flags

Question 2

What details should be included in a referral letter?

Answer 2

General health = growth/height/weight, all with centiles and development
Relevant social information (i.e on CP register)
Parental concern and impact on schooling

Question 3

What is the role of secondary care in the management of paediatric outpatients?

Answer 3

Help make diagnosis/confirm GP diagnosis
Advice on ongoing management
Useful when there is concern in missing serious disease
Reassurance

Question 4

What are the top ten reasons for paediatric outpatient referral?

Answer 4

Concerns about growth, UTI, constipation, abdominal pain, headaches, funny turns, heart murmurs, food allergy/intolerance, minor abnormalities, asthma

Question 5

Why might a child display short stature?

Answer 5

Familial implication (i.e small parents) or constitutional delay

Question 6

What should be considered in an obese child who also has short stature?

Answer 6

Endocrine causes

Question 7

What is the most common pathogen implicated in UTIs in children?

Answer 7

E.coli

Question 8

What determines whether a UTI should get further investigation?

Answer 8

The age of the child, nature of infection, family history of UTI/renal disease, other concerns about general health

Question 9

Do all children with UTIs need to be seen in secondary care?

Answer 9

No = some can be managed at home

Question 10

What are some more complicated renal problems that may present with a UTI?

Answer 10

Vesicouretric reflux, renal scarring, renal tract abnormalities

Question 11

What are some concerning features of a child with a UTI?

Answer 11

Younger age, frequent infections, non-E.coli pathogens, family history of renal disease, poor growth/general health, poor urinary flow in infant, voiding problems/constipation, spinal abnormalities, raised BP, abdominal mass, renal tract abnormalities on antenatal scan

Question 12

What is constipation defined as?

Answer 12

Pain, difficulty or delay in defaecation

Question 13

What is the definition of soiling?

Answer 13

Escape of stool into underclothing = affects 2% of school age children

Question 14

What is encopresis?

Answer 14

Passage of normal stool in abnormal places

Question 15

How is constipation treated?

Answer 15

Laxatives, attention to food and drink, toileting behaviour advice

Question 16

When should an underlying disease be considered in constipation?

Answer 16

Onset from early infancy or refractory to treatment

Question 17

What is a red flag for constipation in paediatrics?

Answer 17

Delay in passage of meconium more than 24hrs after birth

Question 18

What aspect of a child’s life can abdominal pain interfere with?

Answer 18

Very disruptive to school attendance

Question 19

What should particular attention be paid to when taking a history in a child with abdominal pain?

Answer 19

The growth of the child

Question 20

What are important diagnoses not to miss that present with abdominal pain?

Answer 20

Coeliac disease, IBD, malrotation, intermittent volvulus

Question 21

What is a red flag in a child with abdominal pain?

Answer 21

Vomiting bile

Question 22

What are some concerning features in a child with abdominal pain?

Answer 22

Involuntary weight loss, deceleration of linear growth, GI blood loss, significant vomiting, chronic severe diarrhoea, family history of IBD, recurrent oral ulceration, perianal disease

Question 23

What are some specific sites of abdominal pain that may indicate a certain diagnosis?

Answer 23

Epigastric = if chronic, may indicate heartburn

Acute RIF pain = appendicitis

Question 24

How are headaches usually diagnosed?

Answer 24

By history and examination alone

Question 25

What are some red flags in a child with headaches?

Answer 25

Headache on walking, worse when coughing/bending, associated vomiting (especially in morning), visual disturbance, gait disturbance, cranial nerve palsy

Question 26

What is vital in diagnosing funny turns?

Answer 26

Clear history from a first hand witness

Question 27

What does the aetiology of a funny turn depend on?

Answer 27

The age of the child

Question 28

What are some causes of funny turns in children?

Answer 28

Seizures, breath-holding, reflex anoxic seizures, benign neonatal sleep myoclonus, night terrors, faints, gratification disorder, cardiac, ALTE, toxins

Question 29

What are red flags for children with cardiac syncope?

Answer 29

Syncope in child with known congenital heart disease Syncope during exercise/when supine Syncope preceded by palpitations Heart murmur or other CV abnormalities on examination

Question 30

What are some features of the family history that would raise a red flag in children with cardiac syncope?

Answer 30

Family history of sudden death, prolonged QT syndrome or hypertrophic cardiomyopathy

Question 31

What are some red flag symptoms in children with heart murmurs?

Answer 31

Breathlessness, pallor, sweaty, poor feeding, dysmorphism, cyanosed

Question 32

Are most paediatric murmurs benign or malignant?

Answer 32

Most are benign murmurs that may resolve over time

Question 33

What are some features that would indicate an innocent heart murmur?

Answer 33

Systolic, low intensity, second left interspace, medial to the apex, beneath clavicle (may be continuous venous hum that disappears when supine)

Question 34

What are some red flag features of heart murmurs?

Answer 34

Any diastolic murmur, loud >= grade 3, harsh, associated thrill, radiates widely, symptomatic

Question 35

What are some features of food allergies?

Answer 35

Type 1 IgE mediated response, acute allergic reaction, may cause anaphylaxis

Question 36

What are some features of food intolerances?

Answer 36

Delayed reaction, more varied symptomatology, mechanism unclear

Question 37

What are some minor abnormalities that may occur in infants?

Answer 37

Head shape or size, skin lesions, feeding concerns, crying excessively

Question 38

What are some concerning features in children with minor abnormalities?

Answer 38

Abnormal growth (weight and OFC), concerns about development

Question 39

How do symptoms of minor abnormalities present in infants?

Answer 39

Non-specific = low index of suspicion

Question 40

How is asthma usually diagnosed in children?

Answer 40

Tests are less helpful = diagnosis often based on probability

Question 41

What are some features that increase the probability of a child having asthma?

Answer 41

Personal history or atopic disease, family history of atopic disease/asthma, widespread wheeze on auscultation, more than one of cough/wheeze/difficulty breathing/chest tightness

Question 42

In what scenarios would a child having symptoms indicate a diagnosis of asthma?

Answer 42

Frequent and recurrent onsets, worse at night or early morning, occur or are worse during exercise or with other triggers, occur apart from colds