Table of Contents
Failure to thrive
Exploring symptom
- Ask to see growth chart and determine age of onset
- Input: detailed dietary history, feeding history (including time of weaning), hunger
- Use: energy, activity level, exercise, anorexic?
- Output: wet nappies, stools and GI symptoms
- Others: behaviour, general health, happiness, parents’ health
Relevant system reviews
- General
- Fever, behaviour, activity/apathy/alertness, cough
- Gastrointestinal
- Work down body: dysphagia, reflux/vomiting, abdominal pain/colic, diarrhoea/constipation, stools (blood/mucus/pale)
Differential diagnoses and clues
Gastrointestinal
- Coeliac disease
- Dietary protein intolerance
- Carbohydrate intolerance
- Pyloric stenosis
- GORD
- Cystic fibrosis
- Inflammatory bowel disease
- Presents any age after weaning
- Diarrhoea (pale stools)
- Bloating
For example cow’s milk protein allergy
- Cow’s milk protein allergy usually presents in first few months
- Diarrhoea after being fed with formula milk for a few months
- Reflux
For example lactose intolerance
- Flatulence, diarrhoea, bloating and cramps within a few hours of consuming lactose
- May be congenital (rare) or develop after gastroenteritis (transient)
- Projectile non-bilious vomiting after feeding
- Starts around 3-6 weeks of age
- Effortless regurgitation
- Crying during feeding
- Cough/hoarseness
- Recurrent chest infections
- Pale stools that float
- Older child (e.g. teenager)
- Abdominal pain
- Diarrhoea with blood/mucus
Non-gastrointestinal
- Not enough food offered/taken
- Nutritional neglect
- Emotional neglect
- Eating disorder
- Other non-gastrointestinal differentials
- Commonest cause
- Not offered enough food
- Hungry, food seeking/hoarding
- Poor interaction between child and parent
- Withdrawn, fearful, anxious
- Adolescent girls
- Fear of weight gain
- Feel fat when thin
- Efforts to lose weight: diuretics/laxatives, vomiting, excessive exercise
- Consequential symptoms: amenorrhoea, developmental delay, myopathy, poor sleep, GI symptoms, poor dental hygiene
- Prenatal
- Prematurity
- Intrauterine growth restriction
- Chromosomal abnormalities
- Toxins (alcohol, smoking, drugs)
- Others
- Poor feeding
- Inborn errors of metabolism (e.g. abetalipoproteinaemia)
- Chronic infections (including HIV)
- Chronic illness
- Malignancy
Weight increase
Exploring symptom
- Ask to see growth chart and determine age of onset
- Input: detailed dietary history, feeding history (including time of weaning), hunger
- Use: energy, activity level, exercise
- Others: behaviour, general health, happiness, parents’ health and BMI
Relevant system reviews
- General
- Fever, behaviour, activity/apathy/alertness, cold intolerance
- Top to toe
- Stature (short/normal)
- Changes in appearance (skin/hair/acne)
- Hirsutism
- Fat distribution
- Bowel habit
- Pubertal changes (including menses)
Differential diagnoses and clues
Endocrine
- Delayed growth/puberty
- Fatigue, cold intolerance
- Dry skin, coarse hair
- Delayed growth/puberty
- Central obesity
- Easy bruising
- Cushingoid facial features
- Intrascapular and supraclavicular fat pads
- Adolescent female
- Oligo/amenorrhoea
- Hirsutism, acne
Non-endocrine
- Snacking
- Lack of exercise
- Parents with high BMI
- Oedema (cardiac or renal)
- Steroid use
- Genetic syndromes (e.g. Turner’s syndrome, Prader-Willi syndrome)
- Hepatosplenomegaly (e.g. in leukaemia)
Developmental delay
Exploring symptom
- Development
- Current developmental stage in each category (see notes on paediatric history)
- Gross motor
- Fine motor and vision
- Hearing and language
- Social
- Ages of key milestones in each
- Current developmental stage in each category (see notes on paediatric history)
- If motor problem
- How mobile?
- Hand dominance
- Balance problems
- Behavioural problem
- If language/social problem
- Senses: hearing, vision
- Vocalisation/articulation
- Comprehension: follows commands, responds to voice
- Non-verbal communication: pointing, gestures, facies
- Social responsiveness: reaction to new situations, tantrums, playing, gestures
- As part of history
- Prenatal problems (e.g. alcohol/drugs in pregnancy, maternal infections)
- Perinatal problems (e.g. prolonged/difficulties in labour)
- Postnatal problems (e.g. meningitis/encephalitis)
Relevant system reviews
- General
- Fever, behaviour, activity/apathy/alertness
- Neurological
- General: fits/LOC, headache, dizziness, vision/hearing
- Motor: weakness/ wasting
Differential diagnoses and clues
Generalised delay
- Chromosomal/genetic disorders (e.g. Downs = Dysmorphic features)
- Alcohol/drugs in pregnancy (history of mother taking alcohol or drugs in pregnancy)
- TORCH infections in pregnancy (history of toxoplasmosis/rubella/CMV/herpes)
- Extreme prematurity (born very premature)
- Hypoxic brain injury (perinatal hypoxic insult, e.g. prolonged/difficult labour)
- Hypoglycaemia (period of neonatal hypoglycaemia)
- Intracerebral haemorrhage (risks = abnormal labour, prematurity) – usually diagnosed within first few days
Onset after episode of…
- Meningitis/encephalitis
- Head injury
- Hypoglycaemic or hypoxic episode
Motor delay
- Muscle stiffness/weakness/floppiness
- Spasm or dyskinetic or ataxic
- Caused by prenatal/perinatal/postnatal insult (<3 years)
For example Duchenne muscular dystrophy
- Progressive muscle weakness (beginning proximally)
- Onset 2-3 years
- Usually identified at birth but may present later with a limp
Language delay
- Reduced hearing
- Birth defects (e.g. cleft palate)
- Similar history in family
- Poor interaction with parents
- May show signs of neglect
Precocious puberty
(BOYS <9 YEARS, GIRLS <8 YEARS)
Exploring symptom
- Puberty staging and order
- Order for boys:
- Testicular enlargement
- Pubic hair
- Penis enlargement
- Height spurt
- Order for girls:
- Breast development
- Pubic/axillary hair
- Height spurt
- Menarche
- Order for boys:
- Other development
- Previous growth and development
- Height
- Weight and nutrition
- Behavioural changes
- Family history
- Parents’ pubertal ages, heights and maternal menarche
Relevant system reviews
- General
- Fever, behaviour, activity/apathy/alertness, general health
- Neurological
- General: fits/LOC, headache, dizziness, vision/hearing
- Motor: weakness/ wasting
Differential diagnoses and clues
Gonadotrophin dependent (central)
- Majority of girls
For example: hydrocephalus, hypoxic brain injury
- Relevant history
- Associated neurological symptoms
Gonadotrophin independent (peripheral)
i.e. sex hormones not under pituitary control
- Excessive pubic hair, penis/clitoris enlargement
- Weight gain
- Ovarian: bloating, menorrhagia, pelvic pain
- Testicular: painless lump
Note: it is also important to know the terms premature thelarche (breasts only) and premature pubarche (pubic hair only)
Delayed puberty
(BOYS >15 YEARS, GIRLS >14 YEARS)
Exploring symptom
- Puberty staging and order
- Order for boys:
- Testicular enlargement
- Penis enlargement
- Pubic hair
- Height spurt
- Order for girls:
- Breast development
- Pubic/axillary hair
- Height spurt
- Menarche
- Order for boys:
- Other development
- Previous growth and development
- Height
- Weight and nutrition
- Behavioural changes
- Family history
- Parents’ pubertal ages, heights and maternal menarche
Relevant system reviews
- General
- Fever, behaviour, activity/apathy/alertness, general health
- Symptoms of other systemic diseases (CF, thyroid disorder, anorexia, Crohn’s)
- Neurological
- General: fits/LOC, headache, dizziness, vision/hearing
- Motor: weakness/ wasting
Differential diagnoses and clues
The majority of cases are constitutional/familial, but other differentials include:
Hypogonadotropic hypogonadism
For example: IBD, CF, anorexia
- Symptoms of underlying disease
- Delayed growth
- Fatigue, cold intolerance
- Dry skin, coarse hair
- Kallmann syndrome
- Intracranial tumour
- Panhypopituitarism
- Syndromal
Hypergonadotropic hypogonadism
- Turner (female): short stature, amenorrhoea
- Klinefelter (male): small testes, gynaecomastia, tall and thin
- Oligo/amenorrhoea
- Hirsutism, acne
- Steroid hormone enzyme deficiency
- Acquired gonadal damage
Behavioural problems
Exploring symptom
- Expand on nature of problems
- Ask about specific symptoms of each described disorders
Get history from school and at home
Differential diagnoses and clues
Psychiatric
- ADHD
- Conduct disorder
- Oppositional defiant disorder
- Obsessive compulsive disorder
- Autism
- Other psychiatric differentials
- Hyperactivity
- Inattentiveness
- Bullies/threatens/intimidates
- Aggressive
- Cruel to people/animals
- Loses temper
- Argues with adults and defies requests
- Deliberately annoys others
- Intrusive thoughts (obsessions)
- Repetitive behaviours (compulsions)
- Excessive washing/cleaning/checking
- Speech/language delay
- Imposition of routines
- Doesn’t seek friendships, prefers own company
- Limited gestures and expressions
- Anxiety disorders
- Attachment disorder
- Schizophrenia
- Depression
- Bipolar disorder
Childhood bruising
Exploring symptom
- Bruising
- Onset and progression
- Pattern
- Mechanism of injury
- Associated symptoms
Have a low threshold for raising safeguarding concerns
Relevant system reviews
- General
- Fever, behaviour, activity/apathy/alertness
Differential diagnoses and clues
Injury related
- Bruises on soft tissues (ears/neck/ chest/abdomen/buttocks/ calves/thighs)
- Story inconsistent with injury
- Bruising overlying bony prominences (forehead, shins, hips etc.)
- Story consistent with injury
Non-injury related
- Henoch-Schönlein purpura
- Idiopathic Thrombocytopenic Purpura
- Meningococcal septicaemia
- Other non-injury differentials
- Symmetrical rash on back of legs and buttocks; purpuric and slightly raised
- May have abdominal/joint pain
- May have evidence of nephritis
- Spontaneous purpura and petechiae
- Usually post-infection
- Non-blanching rash
- Neck pain/stiffness
- Photophobia
- Fever
- Acute lymphoblastic leukaemia
- Coagulation disorders (e.g. haemophilia)
- Traumatic petechiae (e.g. due to forceful coughing)
Faint / fit / funny turn
Exploring symptom
- Attack
- Before: warning, circumstance
- During: duration, LOC, movements (floppy/stiff/jerking), incontinence/tongue biting, complexion
- After: amnesia, muscle pain, confusion/sleepiness, injuries from fall
- Background to attacks
- e.g. Previous attacks, frequency, impact on life
Relevant system reviews
- General
- Fever, behaviour, activity/apathy/alertness
- Neurological
- General: fits/falls/LOC, headache, dizziness, vision/hearing, memory loss, neck stiffness/ photophobia
- Motor: weakness/ wasting, incontinence
- Sensory: pain, numbness, tingling
- Cardiorespiratory
- Dyspnoea, cyanosis, chest pain/palpitations
Differential diagnoses and clues
Neurological
- Short, self-limiting generalised seizure
- Early in infection when fever is rising
- Types include:
- Absence seizure
- Focal seizure
- Generalised tonic-clonic seizure (suggested by loss of bladder/bowel control, tongue biting)
- Characteristic features of epileptic syndromes, e.g. trunk spasms, trunk flexion, myoclonus, eye deviation, language impairment etc.
- Often precipitated by a bump on head, emotion (e.g. fear, surprise), crying or fever
- Stops breathing, loses consciousness and falls to floor
- Very pale
Non-neurological
- Faint after prolonged standing/emotion/pain
- Atypical seizures
- Child holds breath and goes blue
- Usually when upset
- Simple faint
- Narcolepsy
- Arrhythmia
- Hypertrophic cardiomyopathy
Some questions to test your knowledge
What are the TORCH congenital infections and what are their potential sequalae?
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What are the normal developmental milestones of a child?
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How do you define short stature? Please list some causes.
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What are the potential causes of childhood obesity?
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