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 | -Presents any age after weaning -Diarrhoea (pale stools) -Bloating |
| Dietary protein intolerance (e.g. 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 |
| Carbohydrate intolerance (e.g. lactose intolerance) | -Flatulence, diarrhoea, bloating and cramps within a few hours of consuming lactose -May be congenital (rare) or develop after gastroenteritis (transient) |
| Pyloric stenosis | -Projectile non-bilious vomiting after feeding -Starts around 3-6 weeks of age |
| GORD/oesophagitis | -Effortless regurgitation -Crying during feeding -Cough/hoarseness |
| Cystic fibrosis | -Recurrent chest infections -Pale stools that float |
| Inflammatory bowel disease | -Older child (e.g. teenager) -Abdominal pain -Diarrhoea with blood/mucus |
Non-gastrointestinal
| Not enough food being offered or taken | -Commonest cause |
| Nutritional neglect | -Not offered enough food -Hungry, food seeking/hoarding |
| Emotional neglect | -Poor interaction between child and parent -Withdrawn, fearful, anxious |
| Eating disorder | -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 |
Others
| Prenatal | Prematurity, Intrauterine growth restriction, Chromosomal abnormalities, Toxins (alcohol, smoking, drugs) |
| Other differentials | 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
| Hypothyroidism | -Delayed growth/puberty -Fatigue, cold intolerance -Dry skin, coarse hair |
| Cushing’s syndrome | -Delayed growth/puberty -Central obesity -Easy bruising -Cushingoid facial features -Intrascapular and supraclavicular fat pads |
| PCOS | -Adolescent female -Oligo/amenorrhoea -Hirsutism, acne |
Non-endocrine
| Simple obesity | -Snacking -Lack of exercise |
| Familial | -Parents with high BMI |
Others
| Other differentials | 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
| Prenatal | 1) Chromosomal/genetic disorders, e.g. Downs = Dysmorphic features 2) Alcohol/drugs in pregnancy = History of mother taking alcohol or drugs in pregnancy 3) TORCH infections in pregnancy = History of Toxoplasmosis/rubella/CMV/Herpes |
| Perinatal | 1) Extreme prematurity = Born very premature 2) Hypoxic brain injury = Perinatal hypoxic insult, e.g. prolonged/difficult labour 3) Hypoglycaemia = Period of neonatal hypoglycaemia 4) Intracerebral haemorrhage = Risks abnormal labour, prematurity + Usually diagnosed within first few days |
| Postnatal | 1) Meningitis/encephalitis = Onset after episode of meningitis/encephalitis 2) Head injury or hypoxic/hypoglycaemic episode = Delay subsequent to episode |
Motor delay
| Cerebral palsy | -Muscle stiffness/weakness/floppiness -Spasm or dyskinetic or ataxic -Caused by prenatal/perinatal/postnatal insult (<3 years) |
| Duchenne muscular dystrophy (or other muscular disorders) | -Progressive muscle weakness (beginning proximally) -Onset 2-3 years |
| Hip dysplasia | -Usually identified at birth but may present later with a limp |
Language delay
| Deafness | -e.g. due to chronic otitis media |
| Articulation problem | -Birth defects (e.g. cleft palate) |
| Familial | -Similar history in family |
| Lack of stimulus | -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)
| Familial/idiopathic | -Majority of girls |
| Central nervous system abnormalities, e.g. hydrocephalus, hypoxic brain injury | -Relevant history |
| Intracranial tumour | -Associated neurological symptoms |
Gonadotrophin independent (peripheral), i.e. sex hormones not under pituitary control
| Adrenal tumour/hyperplasia | -Excessive pubic hair, penis/clitoris enlargement -Weight gain |
| Ovarian/testicular tumour | -Ovarian: bloating, menorrhagia, pelvic pain -Testicular: painless lump |
Others
| Other differentials | Premature thelarche (breasts only), Premature pubarche (pubic hair only), External sex hormones |
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
Familial
| Constitutional | -Majority of cases |
Hypogonadotropic hypogonadism
| Systemic disease (e.g. IBD, CF, anorexia) | -Symptoms of underlying disease |
| Hypothyroidism | -Delayed growth -Fatigue, cold intolerance -Dry skin, coarse hair |
Hypergonadotropic hypogonadism
| Klinefelter/Turner syndrome | -Turner (female): short stature, amenorrhoea -Klinefelter (male): small testes, gynaecomastia, tall and thin |
| PCOS | -Oligo/amenorrhoea -Hirsutism, acne |
Others
| Hypogonadotropic | Kallmann syndrome, Intracranial tumour, Panhypopituitarism, Syndromal |
| Hypergonadotropic | 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
| Attention deficit hyperactivity disorder | -Hyperactivity -Inattentiveness |
| Conduct disorder | -Bullies/threatens/intimidates -Aggressive -Cruel to people/animals |
| Oppositional defiant disorder | -Loses temper -Argues with adults and defies requests -Deliberately annoys others |
| Obsessive compulsive disorder | -Intrusive thoughts (obsessions) -Repetitive behaviours (compulsions) -Excessive washing/cleaning/checking |
| Autism | -Speech/language delay -Imposition of routines -Doesn’t seek friendships, prefers own company -Limited gestures and expressions |
Others
| Other differentials | 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
| Non-accidental injury | -Bruises on soft tissues (ears/neck/ chest/abdomen/buttocks/ calves/thighs) -Story inconsistent with injury |
| Accidental injury | -Bruising overlying bony prominences (forehead, shins, hips etc.) -Story consistent with injury |
Non-injury related
| Henoch-Schönlein purpura | -Symmetrical rash on back of legs and buttocks; purpuric and slightly raised -May have abdominal/joint pain -May have evidence of nephritis |
| Idiopathic Thrombocytopenic Purpura | -Spontaneous purpura and petechiae -Usually post-infection |
| Meningococcal septicaemia | -Non-blanching rash -Neck pain/stiffness -Photophobia -Fever |
Others
| Other differentials | Acute lymphoblastic leukaemia, Traumatic petechiae (e.g. due to forceful coughing), Coagulation disorders (e.g. haemophilia) |
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
| Febrile convulsion | -Short, self -limiting generalised seizure -Early in infection when fever is rising |
| Seizure | Types include: -Absence seizure -Focal seizure -Generalised tonic-clonic seizure (suggested by loss of bladder/bowel control, tongue biting) |
| Paediatric epileptic syndromes | -Characteristic features of epileptic syndromes, e.g. trunk spasms, trunk flexion, myoclonus, eye deviation, language impairment etc. |
| Reflex anoxic seizure | -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
| Vasovagal syncope | -Faint after prolonged standing/emotion/pain |
| Pseudoseizure | -Atypical seizures |
| Breath holding spell | -Child holds breath and goes blue -Usually when upset |
Others
| Other differentials | 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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