Table of Contents Failure to thrive GastrointestinalNon-gastrointestinalWeight increaseEndocrineNon-endocrineDevelopmental delay Generalised delayMotor delayLanguage delayPrecocious puberty Gonadotrophin dependent (central)Gonadotrophin independent (peripheral)Delayed puberty Hypogonadotropic hypogonadismHypergonadotropic hypogonadismBehavioural problems PsychiatricChildhood bruising Injury relatedNon-injury relatedFaint / fit / funny turn NeurologicalNon-neurologicalSome questions to test your knowledgeNow try some OSCE stations 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 intoleranceCarbohydrate intolerancePyloric stenosisGORDCystic fibrosisInflammatory 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 neglectEmotional neglectEating disorderOther 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Commonest cause Not offered enough food Hungry, food seeking/hoarding Poor interaction between child and parent Withdrawn, fearful, anxious Adolescent girls Fear of weight gain Feel fat when thin Efforts to lose weight: diuretics/laxatives, vomiting, excessive exercise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 Hypothyroidism Cushing’s syndromePCOS 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 Simple obesity FamilialOther non-endocrine differentials 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 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 causesPerinatal causesPostnatal causes 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 Cerebral palsy Muscular dystrophyHip dysplasia 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 Deafness Articulation problemFamilialLack of stimulus 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 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 CNS abnormalitiesIntracranial tumour 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 Adrenal tumour/hyperplasia Ovarian/testicular tumour 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 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 Systemic disease HypothyroidismOthers 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 Klinefelter/Turner syndrome PCOSOthers 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 disorderOppositional defiant disorderObsessive compulsive disorderAutismOther 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 Non-accidental injury Accidental injury 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 PurpuraMeningococcal septicaemiaOther 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 Febrile convulsion SeizurePaediatric epileptic syndromesReflex anoxic seizure 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 Vasovagal syncope PseudoseizureBreath holding spellOther non-neurological differentials 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? Oops! This section is restricted to members. What are the normal developmental milestones of a child? Oops! This section is restricted to members. How do you define short stature? Please list some causes. Oops! This section is restricted to members. What are the potential causes of childhood obesity? Oops! This section is restricted to members. Now try some OSCE stations An unwell child Vomiting Failure to thrive Behavioural problems More here!