Common Childhood Presenting Chronic Symptoms - Paediatrics

Common Childhood Presenting Chronic Symptoms

My Child Won’t Eat

·        Key issue: do they have normal growth:

o   Normal growth:

§  1^st year: go from 3.5 ® 9 or 10 Kg

§  2^nd year: from 9 or 10 kg to 12.5 or 13 kg.  Ie Growth slows markedly

o   Normal intake for first year:

§  100 cal/kg/day

§  150 mls fluid/kg/day 

§  Breast milk has 67 cal/100 mls ® 100 mls breast milk at 150 mls/kg gives 100 cal/kg 

o   If normal growth – what are parent‟s perceptions of amount the child does and should eat. If perceptions not right then ® stress, unhelpful dynamics around food (especially for strong willed child) ® parents give them lots of milk so they at least get something ® iron deficient 

o   If not normal growth consider disease, congenital syndromes, are they being offered enough (eg maternal depression/anorexia).

Reflux

·        Symptoms: poor growth, vomiting, cry (especially after food), cough

·        But:

·        All babies have some reflux

o  All babies cry – parents may not realise how much is normal! Average baby peaks at 4 hours per day at 6 weeks, then declines. Is an association between crying and maternal depression 

·        Can measure pH via NG tube over 24 hours, or scope them (only in Auckland). But most babies with presentation of reflux don‟t have oesophagitis. 

·        If neuromuscular problems (eg Cerebral Palsy) then more likely to have problems with severe reflux oesophagitis 

·        Treatment:

o  Antacids, ranitidine, omeprazole

o  Crying decreases from 6 weeks – is this a treatment effect or normal development

o  Ensure good support: wider family, Plunket, etc

·        See Topic: The Crying Baby

Abdominal Pain

·        „Functional‟ pain (no organic cause) is „benign‟:

o  Parents didn‟t know until child said

o  Distractible from it

o  Central pain (point to umbilicus)

o  No sleep disturbance

o  No associated symptoms

o  Intermittent

·        Organic causes mimicking functional pain:

o  Constipation (parents may not be aware that child has problem with constipation) 

o  Abdominal migraine: migraine in 3 – 8 year old often presents as abdominal pain. Intermittent, goes pale, last an hour or two, not distractible. As they get older may develop into normal migraine. Check family history 

o  Always examine genitalia in a boy with acute abdominal pain 

·        Other causes: appendicitis, intussusception, UTI, testicular torsion, volvulus secondary to malrotation, Meckel‟s diverticulitis, renal colic, pyelonephritis, acute glomerulonephritis, drug ingestion, reflux oesophagitis 

·        Other causes are rare without associated symptoms (eg coeliac, Crohn‟s)

Diarrhoea

·        Is growth normal 

o  Yes Þ no significant malabsorption:

§  Low grade infection, eg Giardia, Cryptosporidium 

§  Diet, eg too much juice ® overload sucrose absorption ® osmotic diarrhoea 

§  „Toddlers diarrhoea‟: 18 – 24 months, sloppy poos 3 – 4 times a day. ?Variation of normal. Gets less messy/tiresome when toilet trained

o  No:

§  Chronic infection: giardia, Cryptosporidium, parasites/worms

§  Immunosuppressed: any infection (eg Rotavirus, campylobacter etc) may become chronic

§  Coeliac: bloating, miserable, diarrhoea, signs of malabsorption

§  IBD: uncommon < 10 years.  Abdominal pain, diarrhoea, blood in stool

§  Constipation ® ?overflow diarrhoea

Encopresis/Constipation

·        Definitions vary: mainly long term constipation/soiling pants, but may also include inappropriate toileting behaviour (eg going on the lounge floor!)

·        Constipation is common

·        The main issue is that hardness of the stool, not the frequency

·        History: 

o  Need information from both parent and child. Parent is unlikely to know about an older child‟s toileting habits. Perhaps ask child while you‟re doing the exam – that way parents are off to one side. “I‟m going to ask you some really silly questions about your poos…” 

o  Soiling (HPC): duration, frequency, severity, ever been continent 

o  Associated constipation, withholding, absence of warning (likely), pain (eg fissure), associated wetting

o  Toileting behaviour: avoidance, motions in toilet rare

o   Associated behaviours: hiding soiled underpants (common), scared of toilets at school, more serious conduct disorder (rare)

o   Parent‟s management style: what‟s been tried, punitive (unhelpful but common), supportive

o   (ignore soiled pants, praise for toileting, not common but more helpful)

o   General developmental milestones

·        Exam:

o   Inspection of perineum: situation of anus, dilated anus

o   Inspection of lumbo-sacral area

o   Neurological exam of the legs: (spina bifida), test ankle jerk (S1-2, anal reflex is S2-5)

o   Abdominal palpation: for palpable faeces

o   PR usually not necessary

·        Differentials: 

o   Fissure: usually secondary to constipation ® vicious cycle

o   Drugs: morphine, codeine, leukaemia drugs

o   Hypothyroidism (NB: associated with Downs) 

o   Rare causes: Spina bifida occulta, Hirschsprung‟s (ask about delayed passage of meconium), anal stenosis (often anal opening is more anterior)

·        Pathogenesis: 

o   Vicious cycle: chronic dilation of rectum, sigmoid and descending colon ® ¯sensation of fullness ® go less often ® faeces dry out more ® hard ® don‟t completely evacuate ®­distension ® ¯strength ® overflow diarrhoea (with no awareness) 

o   Constipation is common post-gastroenteritis or after surgery

o   Can more rarely be due to food allergy

·        Management:

o   Explain normal anatomy and function of the rectum.  Use a diaphragm. 

o   Explain process: withholding stool ® dilated rectum ® loss of normal sensation ® no warning its coming ® he‟s not being naughty and will take a while to come right (ie stick with treatment) 

o   Test transit time by eating a pile of whole kernel corn and seeing how long it takes to come out the other end. The ideal is < 24 hours 

o   Structured toileting programme: diary and reward system for sitting (take a book if they‟re bored) not for clean pants. Toilet for 10 minutes after each meal. Use timer 

o   Fibre and adequate fluids to keep stools soft

o   Treatment of severe constipation: 

·        Use enemas to completely empty bowel – get visiting paediatric nurse to do it – easier on Mum and Dad 

·        Laxatives every day to empty bowel (eg lactulose, magnesium sulphate) + regular toileting. Coloxyl drops (a stimulant) may ® colic in kids. Lubricants (eg paraffin oil) are good but not very palatable

·        Continue for weeks/months until rectum normal size again

o   Frequent visits for support of parents and encouragement of child