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Emotional neglect	-Poor interaction between child and parent -Withdrawn, fearful, anxious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 p8)
    • Gross motor
    • Fine motor and vision
    • Hearing and language
    • Social
  • Ages of key milestones in each
• 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
• 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
• 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

Now try some OSCE stations

1. An unwell child
2. Vomiting
3. Failure to thrive
4. Behavioural problems
5. More here!