‘Site of tumour and clinical | atures spect | snatomia postition Supratentril -cortex | +setzures + Hemiplega | Feat nerogca sons | | mtn | sn altos - ‘Typleal case history ‘V4year-old. Aggressive behaviour at school, headaches, selzure (MA sean ~ (Fig. 22.8b) Diagnosis - astrocytoma — glioblastoma multiforme ‘Management -surgery, radiotherapy +/- chemotherapy, but [rognosts poor (<308% survival) Astrocytomas ~ commonly found in the cerebral hemispheres, ‘thalamus and hypothalamus. For posterior fossa tumours, see below. 10-year-old complaining of headaches, vomiting, poor growth, struggling to see the board at school. MRI scan ~ (Fig. 22.8¢) Diagnosls ~craniopharyngioma Management - surgical exclson +/—radiotherapy ‘Prognosis - good surdval but risk oflong- term visual Impairment and lfelona, complex pitultary insufficleney bitemporat hemianopla = Pituitary fallure- growth fallur, dlabetes insipidus, wight galn ‘Cerebellar and ivth ventricle Truncal ataxia Coordination aficulties Abnormal eye movements, 3-year old vomiting n the mornings, unsteady on his feet, ‘new-onset convergent squint Ml scan — (Fig. 22.84) Diagnosis - medulloblastoma Management ~ surgery, chemotherapy, radlotherapy. Prognosis survival ates re Improving with 5-year survival about Som ‘Other posterior fossa tumours: Astacytoma = st, sow growing. Good prognoss folowing suger. ‘Scanned with CamScannerVartation in vitamin © production with time of year and cay When the sun's ays enter the atmosphere at an acute ane, the atmosphere ‘blocks the UVB part of the rays so the skin does not convert ‘7dehydrocholesterol to vitamin D), Tiss the situation during the early and, oO {ate parts ofthe day in spring and auturnn and for the entre day n inter located avay from the equator. Asa rule of thumb, if your shadow ls longer than you are tall, you are unlikely to produce much vitamin Dy. Tea tao ff tn | sets “etyocesel cau sor toon tydrogytamin einen iver ‘cakidil) Vitamin D, and Oy (ergocalcferol + cholecaetferol Uitaviolet 8 (uve) att { Oletay towio20%| sources ‘Scanned with CamScannerBO] Bsns enon ct oa ° z e eb nee cone 9 - Cresege (Dagevie | Andsnes tate BB | Table 10.1 Maternal medication that may adversely affect the fetus Medication Adverse effect on fetus ‘Amtiepleptic Fetal valproate/ drugs: valproate, 40; fever >38.5°C; and white blood cell count >12,000. Figure 28.14 MRI scan (post contrast coronal T1 fat saturated) that demonstrates the enhancing synovium in the left hip (arrow) suggesting synovitis. Synovitis can be seen in both transient synovitis and early septic arthritis; they need to be differentiated by clinical examination ‘Scanned with CamScannerAnxiety Pathological anxiety exists in two forms: specific and general. In phobias there is fear of a specific object or situ- ation that is excessive and handicapping and cannot be dealt with by reassurance. Most children have a number of irrational fears (e.g. fear of the dark, ghosts, kidnappers, dogs, spiders, bats, snakes) which are common and do not usually handicap the child's ordinary life. Some of these persist into adulthood. If they are so severe that the child’s ability to lead an ordinary life is affected, then treatment by cognitive behavioural therapy with graded exposure to the feared event may be indicated and is usually successful. More diffuse general anxiety presents indirectly in childhood and it is uncommon for a child to complain directly about anxiety. Often, it is first manifest as physi- cal complaints: nausea, headache or pain. It may take the form of health worries. and the child repeatedly asks for Box 24.9 Treatment of school re + Advise and support parents ; condition + Treat any underlying emotio + Plan and facilitate an early ar school at a pace tolerable for involved (child, family, teach: psychologist and educationa + Help the parents make it mo child to return to school thar + Address bullying or educatio present relatives or friends), while arran school. Some adolescents with depressive disorder, but more u action between an anxiety diso ‘Scanned with CamScannerYY 2 nerves ewoce ott x o @ eat r er) os Scone we | Miata Ltstee BBB | s " @ erfecta type showing Faure 2825 Osteogenesss imperfect type! showing = A 4 8 fusculoskeletal disorders Figute 28.26 Osteogenesis impr ‘Scanned with CamScanneratte dt % S$ mae woe EE o @ [om > a PF Crt mm Dhan | A Retaens Laci B BO | A een | ew 2 . ° This is caused by a poxvirus. The lesions are small, skin-col- Psychosocial support red, pearly papules with central umbilication (Fig. 25.14). Eczema can be sufficiently severe to be disrupting both to the child and to the whole family. The parents and the ‘Rithneed considerable edvice, help, and support from Tutt prteslonas other acted families, o fellow suf fees In the UK the Notional Eczema Society provides pport and education about the disorder Infections and infestations tao 2 patio has been consid elt i ths chapter, and acute bacterial and viral infections of the Figure 25.14 Molluscum contagiosum. Some of the Shin ae considered In chapter 15 pently lesions show characteristic umbilication, Deng x ammount nian Kode Bek om hyo Eon Ang Se esis Ns Strat Wibout persion Copyright C2021 Ekevier Ie. All is teseved. Mewes a euagce oe | ‘Scanned with CamScanner— + D F Cretropie Drgeven | AVRadaos frm B El rarely suffer neuralgic pain. Shingles in childhood is more common in those who had primary varicella zoster infec- tion in the first year of life. Recurrent or multidermatomal shingles is strongly associated with underlying immuno- compromise, eg. HIV infection. In immunocompromised individuals, reactivated infection can also disseminate to cause severe disease. Recurrent or multidermatomal shingles suggests a primary of secondary T-cell immune detect. Chickenpox + Clinical features - fever and itchy, vesicular rash, which crops for up to 7 days. + Complications ~ secondary bacterial infection, encephalitis; disseminated disease in the. immunocompromised, Figure 15.16 Herpes zoster (shingles) in a child. + Human varicella zoster immunoglobulin - if Distribution is along the $1 dermatome. (Courtesy of immunocompromised and in contact with Dr Sam Walters.) chickenpox or if there is maternal chickenpox shortly before or after delivery. ‘Scanned with CamScannermp Qo Diep nt (e.g. ur from muscle fibrosis) Ision (e.g. thyroglossal soitre) r ubbery? le? Figure 2.14a Asymmetry identified on inspection: the left ; ear is pushed forward by mastoiditis. lump with a Dm omenmoa ella a 4 oe EM ‘Scanned with CamScannerFigure 25.17 Head lice. Profuse nits (egg capsules) are Figure 25.18 Guttate psoriasis over the backin a visible on scalp hairs. Live lice were visible on the scalp. S-year-old. ‘Scanned with CamScannerFigure 19.5 Horseshoe kidney. = + DA Citwee Drom | Alintine L tsi & BB) & vy} \ parenchyma. The kidneys Reflux Ureterocele Figure 196 Duplex kidney showing ureterocele of ‘upper moiety and reflux into ower pole moiety. are enlarged. Figure 19.7 Prune-belly syndrome (absent ‘musculature syndrome). The name arises from the wrinkled appearance of the abdomen. itis associated with a large bladder, dilated ureters, and yplorchicism. Courtesy of Jane Deal) ‘Scanned with CamScanner Leoe Denititaeonre re uced growth rate/short stature and trunk obesity ertension hological/behavioural cheeks utism e sing lin resistance cle wasting and weakness ‘openia ors and prolonged use in high dosage will lead to adult height and osteopenia, This unwanted side- systemic corticosteroids is reduced by taking cor- id medication in the morning on altemate days, atrogenic Cushing syndrome is extremely rare jood and may be caused by pituitary or adrenal © Wpereetosearch onenmae A © 6 06 oe metered * # oon Fs ~ = + DF Cairne CD mgeven | A tetas f Astros Diabetes r® - | ee Figure 26.16 Facial obesity following prolonged course of high-dose corticosteroids in a preterm infant. Additional ‘oxygen therapy is being given via nasal cannulae. ‘Scanned with CamScanneren bo @ wu set = eo keene 2 — + FF Creme omen | AlRatind Lidinm BB BZ ture — long narrow skull jture ~ asymmetrical skull suture — flattening of skull od : > utures resulting in microcephaly and 2 ental delay o indromes, e.g. with syndactyly in Apert 2 s, with exophthalmos in Crouzon a a Ts < Figure 12.13 Long flat head of a preterm infant. This can © be avoided by lying preterm infants on a soft surface “5 and regularly changing their head position. = _Sorenal > WP Hoeteretseoeh onen mae An 4 at oe 2M ‘Scanned with CamScanner= comms 2 — +.B 2 creme Mrave | A tesios Lame & BB | 2 weaning foods were started at 7-8 months of age, but he _ vitamin Ddeficlency/calclopenic rickets, Liver and renal func- preferred feeding at the breast. He had only recently begun _ tion tests were normal, and coellac serology was negative. to sit without support. His wrist X-ray showed characteristic features (Fig. 13.18). . Figure 13.18 X-ray of the child's wrist showing rickets, ‘The ends of the radius and ulna are expanded, rarefied, and cup-shaped, and the bones are poorly mineralized (Courtesy of Paul Arundel) Figure 13.17 Wrist expansion from rickets. (Courtesy of Nick Shaw.) ‘Scanned with CamScanner2 we REL ne ~ +9 4 Creme Dg | Anat Liam & BB | s o Figure 14.10 (a) Visible gastric peristalsis in an infant with pyloric stenosis (b) Diagram showing a test feed being performed to diagnose pyloric stenosis. The pyloric mass feels like an ‘olive’ on gentle, deep palpation halfway between the midpoint of the anterior margin ofthe right ribcage and the umbilicus (© Ultrasound examination showing elongated (between crosses) and hypertrophied (between targets) pylorus. (Courtesy of David Hughes (d)Pyloric stenosis at operation showing pale, thick pyloric muscle, and pyloromyotomy incision. (Courtesy of Anthony Lander.) ‘Scanned with CamScannerBs] Beers canes x © @ 0 Mmyucanae eo cis | Seow = + DA arene Mngeion | ARacaad f sainons x ‘A.4-month-old infant, formula fed since birth, has loose stools and faltering growth. " ‘Skin-prick test to cow's milk is negative (0 mm weal). Elimination of cow’s milk results in roy resolution of symptoms, which return on trial re-introduction. MED Toehere to search ont @ nm a @ apawoa” a ‘Scanned with CamScanner4s | Sms + DA Ciittopnge Biceview | AM Rendsoud BL Add note of 298mosmol/kg (normal <295). His urine osmolality of gland showed a small lesion in his pituitary stalk consistent 125mosmol/kg demonstrated an inability to concentrate with histiocytosis (Fig. 26.12). Figure 26.12 MR scan demonstrates a homogenously enhancing infundibular (pituitary stalk) mass after contrast. (Courtesy of Or Jonathan Crookdal fospitals of Derby and Burton. ‘Scanned with CamScannerFigure 20.10 (a) Penile shaft in coronal hypospadias showing the urethral meatus (arrow). (b) Dorsal hooded prepuce and ventral curvature of the penis (chordee) in hypospadias. (Courtesy of Nic Alexander) Scanned with CamScannerSS een tt = + 2 2 Dmome Figure 15.25 Lyme disease. Site of tick bite and red, expanding rash, erythema migrans. Further examples of the rash in Lyme disease can be seen in support of NICE Guideline on Lyme disease at https://www.nice.org.uk/ guidance/ng95/resources/lyme-disease-rash-images-pdf- 4792273597. according to how contagious an in ductive ratio of an infection [Ro], the infected by one individual). A high such as measles (12-18 individuals i vidual) requires 95% vaccine coverag 80%. Differences exist in the compo 1g of immunization programmes it and schedules change as new vac able. Developing new vaccines and into national programmes is a long process, involving not only devel vaccine, but large efficacy trials, licer their implementation, consistent sup toring. Finance is often another maj usually takes 3-10 years, though wa the development and introduction The majority of vaccines are: ‘Scanned with CamScanner‘Any part of the lower motor neurone pathway can be affected in a neuromuscular disorder, including anterior hhom cell disorders, peripheral neuropathies, disorders (of neuromuscular tfansmission, and primary muscle dis- ‘eases. The causes of neuromuscular disorders are shown in Fig, 295, The key clinical feature of a neuromuscular disorder ‘Alfected children may present with: History and examination may provide useful cues. Chileeen ity myopathy often show 3 wadding galt ‘or postive Gowers sign suggestive of proximal muscle Gowers’ sign Is the need to tum prone to rise weakness, urological disorders ‘Scanned with CamScannerBS] meas mcs . a) lagnosed. Periorbital oedema is often the initial sign phrotic syndrome but diagnosis is often delayed until complications develop. Investigations performed are 19.3. Investigations performed at presentation of otic syndrome rine protein - on test strips (dipstick) to confirm. eavy proteinuria (23+ protein) ull blood count to assess whether there is an nfection. Also a high haemoglobin suggests ntravascular fluid depletion rea, electrolytes, creatinine, albumin lyponatraemia is common in presentation of ephrotic syndrome. Intravascular fluid depletion ; indicated by high urea and/or creatinine ‘omplement levels - C3, C4 to differentiate from ther causes of proteinuria such as postinfectious Jomerulonephritis, when C3 will be low, or SLE, vhen both C3 and C4 are low intistreptolysin O or anti-DNAse B titres and throat Figure 19.17 Facial oedema in nephrotic syndrome which improves during the day and is often misdiagnosed as an allergy. Steroid-sensitive nephrotic syndrome Scanned with CamScannerhumeral metaphysis; (b) MRI shows a large destructive soft tissue mass arising from the proximal metadiaphysis of the left humerus; (¢) bone scan shows prominent abnormal tracer uptake in the proximal left humerus; and (d) post-surgery, most of the humerus has been resected and replaced by a metallic prosthesis. Figure 22.19 Lytic bone lesions on a skull X-ray in Figure 22.18 White pupillary reflex in retinoblastoma Langerhans cell histiocytosis. Jinuatine a rrm. Invaluable in-confirming.the.diagngs's AnsLinsRARIAAABas ‘Scanned with CamScannero @ ens esp A en with CF are now identified -reening. In a handful of cases infections, faltering growth, or CF lung disease is character- fection, inflammation and lung hogens include Staphylococcus influenzae. Subsequent patho- 4s aeruginosa and Burkholderia nfections can be eradicated if nfection can become chronic, ng damage and bronchiectasis 1g disease causes a persistent, f purulent sputum. It can also neumothorax. On examination on due to air trapping, coarse nd/or expiratory wheeze and Iv. 95% of individuals with CF rectosittoRttedatchstetSei S85 pt ke eL Le + 2 2 imme (Deg | AM aatead Lie SB BL Figure 17.23 A chest X-ray in cystic fibrosis showing hyperinflation, marked peribronchial shadowing, bronchial wall thickening and ring shadows. ‘Scanned with CamScanner(a) (b) (©) @ Figure 22.17 Ewing sarcoma of the humerus. (a) Plain X-ray shows a destructive bone lesion within the proximal humeral metaphysis; (b) MRI shows a large destructive soft tissue mass arising from the proximal metadiaphysis of the left humerus; () bone scan shows prominent abnormal tracer uptake in the proximal left humerus; and (d) post-surgery, most of the humerus has been resected and replaced by a metallic prosthesis Scanned with CamScannerSingapore.) true phimosis. (Courtesy of Alun V ‘Complications following circur but include bleeding, ulceration o and subsequent meatal stenosis. A non-retractile foreskin preschool children, Hypospadias Genital disc This has an incidence of up to 1 ir to arise from failure of developme tissues of the penis. ‘Typically there are three featur Figure 20.7 Normal foreskin in an infant. (Courtesy of rence is variable: Anette Jacobsen, Singapore.) '* abnormal site of ventral urethr: The commonest condition that gives rise to a true phi- meatus is variable in position (/ HP Wpeheetoseach on enmeaee ana we OO ‘Scanned with CamScannerBS] B secrsns maces x oe , eed he 7 — + 9 2 CMe Breve | Mtetied Liste & BB | z eres ee yg 2 ° 3 3.3 Severity of haemophilia e VII Severity Bleeding tendency Ey Severe Spontaneous joint/ i muscle bleeds Moderate Bleed after minor trauma O% Mild Bleed after surgery I features Figure 23.15 Severe arthropathy from recurrent joint bleeds in haemophilia. The aim of modern management rider is graded as severe, moderate, or mild, js to prevent this from occurring, ng on the FVIII (or IX in haemophilia 8) level (Table ‘Scanned with CamScannerGonadotrophin dependent (TLH>TFSH) _) ( Pituitary Gonadotrophin independent ( JFSH, | LH) ) & Geceeee estrogen from ovary ++ Testosterone from: testis ++ adrenal + ‘Scanned with CamScannerFigure 3.11 Visual reinforced audiometry. While an assistant plays with the child, sounds of a specific frequency are emitted from a speaker. When the child turns to it, the tester lights up a toy by the speaker to reinforce the sound with a visual reward. This test is particularly useful at 10-18 months of age. ‘Scanned with CamScanner— $ D P Caktopege Deagevin | AD Retains AL adits fxcreton inble | stercobiinogen inogen Figure 1115 The breakdown product of haemoglobin is unconjugated bilirubin (Indirect bilirubin), which is insoluble in ‘water but soluble In lipids. scaled in the blood bound to albumin. When the albumin binding is saturated, free Unconjugated bilirubin can cross the blood-brain barrier, as itis lipid soluble. Unconjugated bilirubin bound to albumin Is taken up by the liver and conjugated by glucuronyl transferase to conjugated bilirubin (direct bilirubin), which is ‘water soluble and excreted in bile into the gut and then as stercoblinogen and urobilinogen. Some bilirubin in the gut 182 is converted to unconjugated bilirubin and reabsorbed via the enterohepatic circulation and metabolized inthe liver. Dowate or Anyone (a) Even Kacaledae Buk fom Chay com by Eerie on August 8, "UN Fox prea non No er woes witout peomsn Coprgh C2031 lene ac. Alig reared ‘Scanned with CamScannerBS] ies reraekot 2 come 8 n may develop persistent pulmonary hyper- of the newborn, which may make it difficult to adequate oxygenation despite high-pressure an (see the following section for management). \econium aspiration is associated with significant y and mortality. There is no evidence that aspira- neconium from an infant's oropharynx immedi + delivery of the head or removal of meconium by mn and tracheal suctioning of the infant after birth ihe incidence or severity of meconium aspiration nonia d rupture of the membranes, chorioamnionitis birthweight are risk factors for pneumonia nothorax jothorax may occur spontaneously in up to 2% of «It ie still aevmotomatic but may cause res~ Q 2 Creme 1 pata D pew Figure 1118 Chest X-ray of diaphragmatic hernia showing loops of bowel in the left chest and placement of the mediastinum. toe fst Le ea els natal medicine ‘Scanned with CamScannereo kL ee + DF Creme Diwan | Mtatios Lasinm & BB | F + Bacterial infection, e.g. Staphylococcus, Streptococcus spp. + Viral infection, e.g. herpes simplex virus + Ingestion of an allergen, e.g. egg + Contact with an irritant or allergen + Environment: heat, humidity + Change or reduction in medication + Psychological stress Unexplained BP Typeheetosearch A 6 o6 Sm ‘Scanned with CamScanneraEEG monitor * Start cooling within isuseful to confirm 6 hours of birth encephalopathy Avoid hyperthermia (37.5°C). and identify seizures Infant wrapped in cooling jacket to ‘maintain rectal temperature of 33-34°C for 72 hours Figure 11.22 Therapeutic hypothermia for moderate of severe hypoxic-ischaemic encephalopathy. Relative risk 95%C) Caen cistern ate este ne ‘Scanned with CamScannerrere ore @ HUIWEL YI miveauyasuD ¥ included as part of a paediatric consultation and which are described here. Other more specific investigations are described throughout the book. In general, investi gations are kept to a minimum and are only performed if their results would change management. If possible, non-invasive investigations such as ultrasound are used, and invasive tests such as blood tests or ionizing radiation from X-rays and CT scans kept to a minimum. sway ve Blood pressure Blood pressure must be measured in acutely unwell chil- dren as part of assessing ‘Circulation’. It should also form part of the assessment whenever the blood pressure may be abnormal, for example when assessing a child who is overweight or obese or has with renal or cardiac disease, diabetes mellitus, receiving drug therapy that may cause hypertension, e.g, corticosteroids, and some neurological presentations or disorders, e.g. headaches. Hypertension is considered in more detail in Chapter 19 (Kidney and + PF cariwmme (Bigeven | AP Radi f atirom —— Figure 2.16 Measurement of peak flow rate with a peak Scanned with CamScannerBS] teraacreont tt x ethttectock th i = ke RL Le oo 2 = $2 F Camo iD rgenee | Arasaas Lawes BB Figure 22.12 Burkitt lymphoma involving facial bones. (Courtesy of Liz Molyneux) Figure 22.10 Venous distension over the chest wall Investigations secondary to superior vena cava obstruction from T lymphobiastic lymphoma, Biopsy, radiological assessment of all nodal sites (CT or MB), and examination of the bone marrow and CSF. Mananamant ‘Scanned with CamScannerBS] B eras meee EY Theimps [Dean | A hedains Lats & AB | 2 pallor Bossing of the skull Maxillary overgrowth Spl jomegaly and hepatomegaly Need for repeated blood transfusions ‘Complications shown in Box 22.3, Figure 23.13 Facies in {-thalassaemia showing maxillary Type hereto sear ormenmae Box 23.3 Complications of long-term blood transfusion in children Iron deposition - the most important (all patients) + Heart - cardiomyopathy + Liver - cirrhosis * Pancreas - diabetes + Pituitary gland — impaired growth and sexual maturation + Skin - hyperpigmentation Antibody formation (10%) + Allo-antibodies to transfused red cells in the patient make finding compatible blood very difficult + Infection ~ now uncommon Infection - now uncommon + Hepatitis A, B.C A © @ 0 oe SEM Scanned with CamScannerFigure 13.21 Kwashiorkor, a particular manifestation of severe protein-energy malnutrition in some lowincome countries, where infants are weaned late from the breast and the young child’ diet is high in starch. A key feature Is ‘oedema around the eyes, legs and feet (a). This is demonstrated in (b). There Is also redness of the hair (see Figure 21.12 In Ch. 31), hyperkeratosis and depigmentation ofthe skin, Scanned with CamScanner Nutritionboth the upper and lower face, emene022 9 eo #2 + DS Grmece Mepi | AV eassons ftsinae & Figure 29.9 Myasthenia gravis showing ptosis from ocular muscle fatigue which improved with edrophonium. ‘Scanned with CamScanneroa P owe P Down syndrome Figure 9.2a Characteristic facies seen in Down syndrome. The Girl's posture is due to hypotonia, Figure 9.2b Single palmar crease. ew oF Ai rena A8s te Figure 9.2c Pronounced ‘sandal’ gap with wide space and often a deep fissure between the big toe and second toe. ‘Scanned with CamScannerBS] Beers seats x oO @ f e eine 28 PS nen ee OX 29.8 Causes OF nyarocepnalus bstructive hydrocephalus (obstruction in ie ventricular system) ongenital anomaly: + Aqueduct stenosis + Chiari malformation (cerebellar tonsils herniation through foramen magnum) »sterior fossa neoplasm or vascular malformation traventricular haemorrhage in preterm infant ommunicating hydrocephalus (failure to 2absorb CSF) sbarachnold haemorrhage Figure 29.18 Grossly enlarged head and downward deviation of the eyes (setting-sun sign) from untreated eningitis, e.g. pneumococcal, tuberculous twarooephalis, ombined hydrocephalus Burr hole. ™ ‘Scanned with CamScannerPotter facies: — Low-set ears Beaked nose Prominent epicanthic folds and downward slant to eyes Reduced fetal urine excretion resulting in oligohydramnios Pulmonary hypoplasia and fetal compression Stillbirth or death from respiratory failure Figure 19.1a Features of Potter sequence. Intrauterine compression of the fetus from oligohydramnios caused by lack of fetal urine causes a charactarietir fariac Inna hunnnlacda and nnctural dafrrmitiac Pulmonary hypoplasia ‘causing respiratory failure S timb deformities Figure 19.tb Facies in < Potter sequence. ‘Scanned with CamScannerAc Figure 78 tide of injury t the ivr and spleen ‘choking child from a fareian body aiqway obstuction (FBAQ, ‘Scanned with CamScannerSS] Bact tte [BH ba | of observation, Tom is dis- return if he: headache y side of his body but the following morning becomes lethargic. He is icy department where a CT ural haematoma (Fig. 7.6) red by the neurosurgeons, ecovery. Figure 7.6 CT scan of head showing a left extradural haemorthage (arrow). \ccidents and poisonin Scanned with CamScannerme), posterior ears and a previously Figure 2.14g Posterior palate petechiae in Epstein-Barr virus (EBV) infection. ‘Scanned with CamScannerune ction Uru older subdural bleed Normal CSF or active bleeding density \ . \ Acute bloodin subdural space Figure 8.5 Subdural haemorrhage. CSF, cerebrospinal fluid. QP aiteae UB geven | A ea Figure 87 Retinal haemorrhages from trauma to the head, (Courtesy of Clare Roberts) Figure 88 Metaphyseal fracture of distal humerus. Scanned with CamScanner2 cts | tones 2 = + Fo Gnome (Drone | Matin Las BEB | d ase; In general, ase. One of the verity of sickle ‘ Most patients of 1%, genetic urally produce globin may be rity. As a result, into drugs that Figure 23.9 Dactylitis in sickle cell disease. 23.9 and 23.10.) ‘Scanned with CamScannerDirect spread of osteomyelitis uphyseal ns in aninfant plate Intra-articuar Infection causing septic arth ew Capsular attachment below metaphysis as Inthe hip, shoulder, metaphysis and elbow J Soft weve Metaphyss Infection Subpertosteal abscess Infection ofthe metaphysis Figure 28.11 Possible spread of osteomyelitis. In children, the epiphyseal growth plate limits the spread of ‘metaphyseal Infection. In Infants, before there has been maturation of the growth plate, Infection can spread directly to cause Joint destruction and arrested growth. ‘Scanned with CamScannerSEY art et oa = . ion e eLLe . Zcom 9) = + 9 2 Grae Dio | A tetind Latime & BB Edwards syndrome and Patau syndrome Box 9.3 Clinical features of Patau Box 9.2 Clinical features of syndrome (trisomy 13) Edwards syndrome (trisomy 18) + Structural defect of brain + Low birthweight + Scalp defects + Prominent occiput + Small mouth and chin + Small eyes ee croster ai (microphthalmia) and other eye defects + Flexed, overlapping fingers (Fig. 95) + ‘Rocker-bottom’ feet + Cardiac and renal malformations Figure 9.5 Overlapping of the fingers in Edwards syndrome. + Cleft lip and palate + Polydactyly * Cardiac and renal malformations ‘Scanned with CamScanner© 2 Oho Figure 17.2. Marked sternal recession in an infant, indicating increased work of breathing. e Increased work (effort) of breathing — An increase Disewen | Atatsas f sscroe BB E Summary The clinical features of respira infants and young children are * Cough. + Respiratory noises ~ wheeze Increased rate of breathing + Increased work of breathing recession, + Reduced oxygen saturation supplemental oxygen and r necessary. Upper respiratory tr Scanned with CamScannerDP pee DB rgesen eee rate) Cobre ce et yoee Pata corer ro Downloaded for Anonymous User (8) a lan Knowledge Bank from ClinialKey com by Else For personal use only. No other uses without permission. Copyright ©2021, Elsevier In. All * Ai rensont FL satnoee Scanned with CamScannerliver disease Nutrition Effective nutrition is esse patients with liver disea include: * fat malabsorption = {c . absorbed without bil a triglyceride containin aan sd required if children ai Figure 216 Kayser-Fleischer rings from copper in the it does not require bi cornea in a child with Wilson disease. to 40% of fat needs t Scanned with CamScanneroa * ot Bows 9 —+ y requiring bone marrow transplantation, and in ore intensive solid tumour protocols. ieee gre | AV end’ f Mino rointestinal damage, nausea and ing, and nutritional compromise ) ulcers are common, painful and, when severe, event a child eating adequately. Many chemother- yents are nauseating and induce vomiting, which e only partially prevented by the routine use of retic drugs. These two complications can result in cant nutritional compromise and supplementary astric or parenteral feeding regimes may be needed. atherapy-induced gut mucosal damage also causes 2ea and may predispose to Gram-negative infection. |-specific side-effects ndividual druas have specific side-effects: e.a. cardio- HD Tipe nee tosearch on @h mae Scanned with CamScannero--~~ hild with toxic shock syndrome receiving acluding mechanical ventilation via a de. The lips are red and the eyelids are m capillary leak. (Courtesy of Professor Scanned with CamScannermild corebral pay, tightness of the Achilles tendons, or Inflammatory arthitis In the foot or ankle. In older boys, Duchenne muscular dystrophy should be excluded. Abnormal posture Talipes equinovarus (clubfoot) Postional_talipes from Intrauterine compressions ‘common. The foot Is of normal stze, the deformity 1s mi, {nd itcan be corected tothe neutral postion with passive ‘manipulation (sce Fig. 10.15) Often the baby's intrauter tne posture can be recreated. I the positional deformity 's marked, parents can be shown passive exerts by the physiotherapist. Talipes equnovans sa complex abnormally (Fo.28.5, fg, 286). The entire foot Is Inverted and supinated, the forefoot Is adducted, and the hee! rotated inwards and In plantar flexion. The affected foots shorter and the calf muscles thinner than normal, The postion ofthe foot is fixed, cannot be corrected completely and ts often biat- ‘eral. The bit prevalence i 1 per 1000 ve births, affects predominantly males Q:1), can be fami butts usually Idiopathic. However, it may also be secondary to oliga- hydramnios during pregnancy, a feature of a malforma tion syndrome ot of 2 neuromuscular dsorder such as spina bifida, There's an association with developmental dysplasia of the hip (ODM). Treatment is started promptly with plaster casting and bracing (Ponsett! method, which may be required for ‘many months and esultsn successful outcome for most Infants, with a minty requiring corrective surgery ithe Musculoskelet, Figure 285 Abnormalitios In talipes equinovarus es Figure 286 Talipes equinovarus wa wa < y—Fvession : osexion ‘Scanned with CamScanner° ene - Figure 9.19 Sean’s facial appearance showing the short philtrum (vertical groove in the upper lip), thin upper lip, and prominent ears. +9 2 Diep = eo el ee S88 Drevin | A tases f Aste obsessional tendencies); input from speech therapist and plastic surgeon (indistinct speech due to velopharyngeal incompetence); and audiology review (conductive hearing loss due to recurrent otitis media). The impact of the diagnosis and its implications was con- siderable for the family, and the parents needed support from a variety of professionals while coming to terms with the various problems as they became apparent. Written informa- tion and details of the 22q11 support group were given to the parents, Medical care was coordinated by the paediatrician. There was the additional worry for the family about a sub- sequent pregnancy. Fetal echocardiography showed no evi- dence of congenital heart disease, and the offer of invasive tests for cytogenetic analysis was declined because of the low chance of recurrence and the risk of miscarriage from the test. The baby was born unaffected, with chromosome studies per- formed on a cord blood sample revealing no abnorm: ‘Scanned with CamScanner’ @ ; : * Le : com $2 2 Kniwme bie | Mtalied Lathes BBB |S 12"18a,b). He was noted to have multiple caféau-lai Consistent with a diagnosis of neurofibromatosis 1. An MRI scan showed a mass in the hypothalamus, | proved to be an optic glioma. He was treated with therapy, although full remission was not possible to ve. The site of injection of gonadotrophin releasing one analogue treatment to suppress his sexual devel- tis covered by the plaster. @ ©) Figure 12.18 (a) Multiple café-au-tat spots. Neurofibromatosis type 1 was diagnosed. (b) Genitalia showing stage 3 genitalia and pubic haie with 12-ml testicles bilaterally. He also had adult body odour. (From Wales JKH, Rogol AD, Wit JM: Pediatric endocrinology and growth, London, 2003, Saunders, with permission) 2 perweroren on @n mae an 2 eo oe Ty ‘Scanned with CamScanneroe " o Some 2 shes 2s are common. Some causes are listed in ermatitis, the most common nappy rash, is quently nowadays with the use of modern appies (diapers) but still occurs if nappies are { frequently enough or if the infant has diar- ver, irritant dermatitis can occur even when ea is cleaned regularly. The rash is due to the t of urine on the skin of susceptible infants. g organisms in faeces increase the alkalinity 1d of a rash. at eruption affects the convex surfaces of the rineal region, lower abdomen, and top of the acteristically, the flexures are spared, which sit from other causes of nappy rash. The rash tous and may have a scalded appearance. forms are associated with erosions and ulcer ‘Scanned with CamScannerresult in a red tongue with prominent papillae. (Courtesy of: Don't Forget the Bubbles) Figure 15.10 Impetigo showing characteristic confluent honey-coloured crusted lesions. (Courtesy of Dr Paul Figure 15.11 Periorbital cellulitis. It should be treated Hutchins) promptly with intravenous antibiotics to prevent spread into the orbit. Boils ‘Scanned with CamScannerFigure 28.22 Growth failure and marked genu valgum (knock-knees) in an 8-year-old girl with juvenile Idinnathie arthritic Ear enmnarican har cictar an the laft The management of JIA has radically changed in the last decade and improvement in outcome is evident as long as children access appropriate care. Although JIA cannot be cured, early, aggressive control of joint inflammation Improves long-term outcome, Deformity and disability are much less common with current treatment approaches and early diagnosis, Medical management includes: + NSAIDs and analgesics - do not modify disease but help relieve symptoms during flares. * Joint injections ~ effective, first-line treatment for oligoarticular JIA; in polyarticular disease multiple joint injections are used as a bridging agent when starting methotrexate. Often requires sedation or Inhaled anaesthesia (Entonox). Depending on the Joint, guidance with ultrasound or X-rays may be needed. '* Methotrexate - early use reduces joint damage. Effective in approximately 70% with polyarthritis, less effective in systemic features of JIA. It is given as weekly dose (tablet, liquid, or injection) and regular blood monitoring is required (for abnormal liver function and bone-marrow suppression). Nausea Is Scanned with CamScannerWW Md hypothermia tor moderate and severe HIE reduces death and severe disability and increases the likelihood of survival with normal neurological function. (a) (b) Figure 11.24 Magnetic resonance image (T1 in axial view) of the brain at 14 days in a term infant. (a) Normal scan for comparison, showing high signal in the posterior limb of the internal capsule (PLIC) (arrow). (b) Following severe HIE, showing loss of the normal high signal from myelin in the internal capsule (PLIC) (white arrow) and abnormal hiah sianal in the adiacent basal aanalia and thalami (vellow arrow). These findinas would be associated Scanned with CamScannerFigure 2.84 Cyanosis is a blueish discolouration best Figure 2.8 Scars to look out for include media seen under the tongue. It is caused by desaturated left lateral (2) thoracotomy scars as well as sites haemoglobin. (Courtesy of Don't forget the Bubbles.) (e.g. 3). ‘Scanned with CamScannerTurner syndrome This girl (Fig. 12.11) presented when 10 years old with short stature. She had a history of recurrent ear infections, but was otherwise well. She had always been very short, and her height of 126.4cm was well below the 0.4th centile on the standard growth chart. Her chromosomes confirmed Turner syndrome 45,XO. She was started on growth hormone injections followed by ethinyl oestradiol (oestrogens) for pubertal induction at 14 years of age. At 15 years of age her height was 150cm (2nd centile. Figure 12.11 At 15 years, this girl has few clinical features of Turner syndrome, demonstrating the need Scanned with CamScannerStew 9 Exomphalos and gastroschisis These lesions are often diagnosed antenatally (ee Ch. 10 Perinatal medicine). In exomphalos (also called ompha- locele), the abdominal contents protrude through the umbilical ring, covered with a transparent sac formed by the amniotic membrane and peritoneum (Fig. 11.34), Itis often associated with other major congenital abnormal: ties and genetic testing should be undertaken. In gas- troschisis, the bowel protrudes through a defect in the anterior abdominal wall adjacent to the umbilicus, and there Is no covering sac (see Fig. 10.2). It is not associated with other congenital abnormalities. Gastroschisis carrles a much greater risk of dehydra- tion and protein loss, so the abdomen of affected infants should be covered with a clear occlusive wrap to min- imize fluid and heat loss. A nasogastric tube is passed and aspirated frequently and intravenous fluids given, Replacement of fluid loss is often required early on to prevent hypovolaemia. Many lesions can be repaired by primary closure of the abdomen. With large lesions, the intestine is enclosed in a silastic sac sutured to the edges of the abdominal wall and the contents gradually returned WF Chrtwsine Drevin | AY eseaous Adare: +9 described and documented, eg. dermal melanocyto- sis (Mongolian blue spots) as they may be mistaken for bruising, and subconjunctival haemorrhages following delivery, which may be mistaken for non-accidental injury. Acknowledgements We would like to acknowledge contributors to this chapter in previous editions, whose work we have drawn on: Tom Lissauer (Ist, 2nd, 3rd, 4th, Sth Editions), Karen Simmer (ist Edition), Michael Weindling (2nd Edition), ‘Andrew Whitelaw (3rd Edition), Andrew Wilkinson (4th Edition), Don Sharkey (Sth Edition). We thank Dr Phillipa Lewis for her helpful suggestions. We would like to thank John Rasquinha and Matthew McGovern for reviewing the chapter. Further reading Lissauer T, Fanaroff AA, Miall |, et ak Neonatology at a glance, ed 4, Oxford, 2020, Wiley Blackwell. Short, ‘Scanned with CamScanner© @ | 0 Neryeasernne presented oTnboottetatbaeda Rtv ASA: pot we orb ee cis | comme 9 = +2 2 Crm Degen | antes Lisi & BB (d) Nutrition and + gustointestinal robin clsease Bone age ‘Scanned with CamScanner= + 9 A Coren Chrmeven | A macaae fates BBB | 2 ‘© loyal College of Paediatrics and Child Health) ing villous bluntina. ervot hunernlasia and intra-enitholia ‘Scanned with CamScannerFigure 10.2 Gastroschisis on antenatal ultrasound showing free loops of small bowel outside the fetal abdomen, in the amniotic fluid (a) and following delivery (b). Antenatal diagnosis allowed the baby to be delivered at a paediatric surgical unit and the parents to be counselled antenatally by a paediatric surgeon, Satisfactory surgical repair was achieved. (Courtesy of Karl Murphy.) ‘Scanned with CamScannerFigure 162 Allergic faces. (a) There is a habitually open mouth due to mouth breathing. (b) An allergic salute, from rubbing an itchy nose. (Courtesy of Professor George Du Tort) ‘Scanned with CamScannerbecome tense. A ventriculoperitoneal or subgaleal shunt may be required, but initially symptomatic relief may be provided by removal of CSF by lumbar puncture. About half of infants with progressive post-haemorrhagic ven- tricular dilatation have cerebral palsy, a higher proportion if parenchymal infarction is also present. Preterm infants are susceptible to white matter injury and abnormal cerebral development following ischaemia and inflammation even in the absence of haemorrhage. It may result in cystic white matter lesions visible on cranial ultrasound. Bilateral multiple cysts, called periventricular leukomalacia (PVL), have an 80%-90% risk of spastic diple- gia, often with cognitive impairment, if posteriorly sited (Fig. 11.114). This has become uncommon, More common, is damage to neural pathways, which increases the risk of neurocognitive impairment. Both IVH and periventricular leukomalacia may occur in the absence of abnormal clinical signs. Retinopathy of prematurity Figure 1112 Chest X-ray of bronchopulmonary dysplasia (BPD) showing fibrosis and lung collapse, cystic changes and over-distension of the lungs. Scanned with CamScanner vu ¢ 1atal medBS] B ersestcnecett o ms es toe Lo © as | moun f $2 F Cee Dru | Atm Lesnar & BB 2 2 = ° me Ts Collodion baby. 7 = e membrane (Fig. 25.7). Theres a risk of dehy- 3 llients are applied to moisturize and soften 4 : membrane becomes fissured and separates 2 weeks, usually leaving either ichthyotic or, far aly, normal skin. € Figure 25.8 Napkin rash due to Candida infection. The e skin flexures are involved and there are satellite pustules a of infancy visible. shes =a ‘Scanned with CamScannerBS] Beers sects x Oo @ o8 sp jenoch-Schénlein purpura or, rarely, ic lupus erythematosus], microscopic , polyarteritis nodosa) pathy and mesangiocapillary ephritis ular basement membrane disease re syndrome) - very rare cal and postinfectious 2phritis streptococcal sore throat or skin infection d by evidence of a recent streptococcal e of the organism, raised ASO/anti-DNAse w complement C3 levels that return to | weeks. Long-term prognosis is good. Gnlein nuroura pede DSHS AIEIEp ew ei ae = + 9 2 Deep Lime & BB) sf Buttocks (a) Extensor surfaces of legs and arms ‘Ankles (b) Joint pain and swelling Knees and ankles (b) ‘Abdominal pain Haematemesis and melaena Intussusception y tract disorders 8D Wpeheretosearch of eu mae ae ww OO ‘Scanned with CamScannercongenital cataracts (presumed idiopathic, but many are _(Fig. 10.18a) and coloboma (Fig. 10.18b). — y (a) (o) Figure 10.17 Checking for Figure 10.18 Eye abnormalities on newborn examination. (a) Congenital glaucoma of ted reflex. Done by right eye. And (b) iris coloboma. Keyhole-shaped pupil due to defect of the iris examining the eyes inferiorly. (a, Courtesy of Alistair Fielder; b, Courtesy of Louise Allen.) through a direct ophthalmoscope 15-20¢m from the eyes. ‘Scanned with CamScannerlarge (giant) congenital pigmented hairy smaller naevi are also visible. osure to sunlight should be avoided and arations with a sun protection factor of 30 Id be applied liberally to exposed skin in and reapplied every few hours. yelanoma is rare before puberty, except in wever, in adults, the incidence of malig- 1 has been increasing for many years. Risk 2 Wpereeto search o e 4 2 Give rae x oe Le Miaiiad idiom & BB 2 Figure 25.5 A child with oculocutaneous albinism, with her parents. The hair is silvery white. Aw a woe OM my, ‘Scanned with CamScanneren oe 2 Somme 2 Figure 8:10 A thorough medical assessment is required in all children when non-accidental injury is suspected. This girl's large bruise followed what was said to be a minor bump. Non-accidental injury was suspected, but examination showed multiple bruises and petechiae. She +29 2 Dieee had immune thrombocytopenic purpura. Po DBreven | AP Ravens f titre LB |g When dealing with any child : been abused, the safety of any oth at home must be considered. The pc vices should be alerted to any conc In addition to a detailed medica tion by social workers and other he: be required. A strategy meeting an tion conference may be convened local procedures. Members may in health visitors, police, general practi teachers, lawyers and other profess child and family. Parents attend al conference. Details of the incident to the conference and the family ba cussed. Good communication anda tionship between the professionals extremely difficult to evaluate the li were inflicted deliberately and the legal proceedings. The conference v 2 Hpereretosearen ot e@nhmhae Aw 4 ane BM ‘Scanned with CamScanner° bf Bien (Dreever | Aeaiae Laci BP BB Management In both tumours, treatment involves the use of combina tion chemotherapy given before surgery. Whenever pos- sible, amputation s avoided by using en bloc resection of tumours with endoprosthetic resection (Fig. 22176) In Ewing sarcoma, radiotherapy is also used in the man: agement of local disease, especially when surgical resec tion is impossible or incomplete, eg. in the pelvis or axial skeleton, Retinoblastoma Retinoblastoma is a malignant tumour of retinal cells and, although rare, accounts for about 5% of severe visual impairment in children. it may affect one or both eyes. Ail bilateral tumours are hereditary, as are about 20% of Unilateral cases, The retinoblastoma susceptibility gene A Is on chromosome 13, and the pattem of inheritance is dominant, but with incomplete penetrance. Most chil- dren present within the first 3 vears of life. Children from lalignant disease Scanned with CamScanner= ee stoon220 ke eLLe os ots 2 — + DL ewe Magen | Anatase Lamm & BB caer ‘unUntat eAteHBIUH \UELEIEDIaLe pute s None No response 1 oO 6 A score of <8 out of 15 means that the child's airway is at isk and will need to be maintained. a Pinpoint, fixed Fixed, dilated Unilateral dilated pupil Opiates/barbiturates Severe hypoxia Expanding ipsilateral lesion Pontine lesion During/post-seizures Tentorial herniation Anticholinergic drugs ‘Third nerve lesion Hypothermia Seizures Figure 6.9 Pupillary signs in coma Fluid management level of consciousness - done rapidly with the AVPU Following fluid resuscitation, children in shock will require Scale (see Box 6.1 above) or the Glasgow Coma Scale, #2 Iyse neve cench of e@n mae apaae Ho ‘Scanned with CamScannerBS] B msezestccncets x ft ew eLae Mrassos Ladin GBB | 2 (Courtesy of Alun \ Complications following circur but include bleeding, ulceration c and subsequent meatal stenosis. A non-retractile foreskin preschool children, Hypospadias This has an incidence of up to 1 i to arise from failure of developm tissues of the penis. Typically there are three featur rence is variable: © abnormal site of ventral urethr jives rise to a true phi- meatus is variable in position ( - 30 @ ot mats sactapectonkSsbtoP sete SAMAATESCAAICIED Go 7579 | cms — + DF Creep TD reve infant. (Courtesy of | © fypenererosearen or e@nmee aw 6 os MO ‘Scanned with CamScannerfe) Endocrine + hypothyroidism * growth hormone deficiency + steroid excess Iatrogenic = Cushing syndrome Figure 12.9 Continued Falling across] hhelght centiles. ‘Weight centile height centile, i.e. short and bone age $99 2 CiRwee (Dpeever Boys 0-20 yrs en sushessgavessse ‘Scanned with CamScanner‘Assessment of diabetes: + Any episodes of hypoglycaemia, diabetic ketoacidosis, hospital admission? {s there still awareness of hypoglycaemia? ‘Absence from school? School supportive of diabetes care? Interference with normal life? HbAIc results ~ less than 48 mmol/mol (6.5%)? Review the diary of blood glucose results or glucose meter uploads- are appropriate actions to results being taken? + Insulin regimen - appropriate? + Lipohypertrophy or lipoatrophy (Fig. 26.8b,c) at injection sites? + Diet —healthy diet, manipulating food intake and insulin to ‘maintain good control? General overview (period: Normal growth and pubertal development, avoiding obesity ~ measure height, weight and BMI and plot on growth chart at each clinic visit + Blood pressure check for hypertension annully from 12 years of age (age-specific centiles) + Renal disease ~ screen for microalbuminuria, an early sign of nephropathy, annually from 12 years ‘Scanned with CamScanneres | Semen 2 — +. FF Bremen Brecon | Amaia frais GE Sng saves seaunes Wr Vises seyUeIRe Hiouieinre Conipreaatan on the fetus from oligohyaramnios caused by lack of fetal urine causes a characteristic faces, lung hypoplasia, and postural deformities including severe talipes. The infant may be stillborn or dle soon after birth from respiratory failure. Figure 19.4 Autosomal Figure 193 Autosomal dominant polycystic recessive polycystic kidney kidney disease (ADPKD). disease (ARPKO). There is There are bilateral separate diffuse bilateral enlargement of cysts of varying size both kidneys. between normal renal parenchyma. The kidneys are enlarged ‘Scanned with CamScanner Figure 19.2 (a) Normal left kidney and multicystic dysplastic kidney (MCDK) on. right. The kidney is replaced by cysts of vatlable size, with atresia of the ureter; and (b) renal ultrasound showing ‘multiple discrete cysts of variable size.‘the neck become covered with hair. Figure 10.150 frythema toxlcum poo Wines Winn oobreay oeegemant ie aebcn often has a raed pale centre, Roaey Rivers) wa (Courtesy of Nim Subhedar,) Figure 015d Chgenital dermal melonocytoss x (Mongolian blue SQ } ) spots) > . ef OM 2 (e) o Figure 10.15 (e) Positional tallpes. Appearance at birt, (P) The foot can be fully dorsifiexed to touch the front of the lower leg. in true talipes equinovarus this is not possible. ‘Scanned with CamScanneren o@ ; hoe ERS 8 os | Smee 2 = + DF Aaetepme (Dameron | APs Latins BBB | x Box 11.4 Causes of neonatal seizures + Hypoxic~ischaemic encephalopathy + Intracranial haemorrhage + Cerebral anomalies + Infection: septicaemia, meningitis, encephalitis, ‘congenital infection + Metabolic: + hypoglycaemia + hyponatraemia/hypernatraemia + hypocalcaemia + inborn errors of metabolism + Drugs: neonatal abstinence syndrome + Kernicterus + Other: pyridoxine dependency, genetic epilepsy syndrome Figure 11.31 Micrognathia in Pierre Robin sequence. natal medicine ‘Scanned with CamScannerFigure 21.2 Pale stool secondary to biliary atresia, Kiriwpoe [Daseven | AY Radaind stirs BB Figure 213 Several months after successful bile drainage by hepatoportoenterostomy (Kasai procedure) for biliary atresia. The scar is from her surgery. Scanned with CamScanneroa cin AternevCestpmsnsecnteoisoe saosin n2022 pot eo eee » | Scone 9 = + QF Diop Dosen | Atresaind Lssioe BEB | Z ale a HeLUNrpapUla! HERD), BE MMeYuIA HI Ste ain . ceengegns 0 ‘outline, and may have a necrotic centre (Fig. 15.7). They are Shiels.) Figure 15.7 The glass test for meningococcal purpura. Parents are advised to suspect meningococcal disease \f their chid is febrile and has a rash that does not blanch when pressed under a glass. (Courtesy of Parviz Habibi.) 266 Dowrloaded or Ancaymens er) x EgntinKnsiledge Bank om Chay com hy Eaveom Auge 9, "OD Perper tc oy No or anes wt poms Copy C0 lena es Allure SP pehereto search onen mee apa doe NO ‘Scanned with CamScannerLe Lisi BAB | 2 2 WaFtepge ( ageven | AD dae arm and leg. The arm is usually affected more than the leg, with the face unaffected. Affected children often present at 4-12 months of age with fisting of the affected hand, thumb adduction, a flexed arm, a pronated forearm, asymmetric reaching, hand function or toe pointing when lifting the child, Subsequently, Table 4.5 Gross Motor Function Classification System (GMFCS) for children 6-12 years old Level| Walks without limitations Level Il ‘Walks with limitations Level Ill ‘Walks using a handheld mobility device LevellV_Self-mobility with imitations; may use powered mobility Level V Transported in a manual wheelchair Figure 4.4 An infant with spastic bilateral (quadriplegia) cerebral palsy showing scissoring of the legs from Note: See w id es -25/4)-qmics-e-t for furth excessive adduction of the hips, and pronated forearms HD Hpereieros on en mee A 6 os EM Scanned with CamScannerBI] Betas raeket x & > O @ © tnysCArenyunoesnprisrtedredhoARatot:thedabrsAZISKMOOtoHALN22 pt wo ori he es oie | Somes 0 = + 2 2 Grom iDrgn | Aner Laven & BB | x Normal urethral meatus Most common types Glanular | ‘Coronal —midshatt | types of } hypospadias &\ Penoscrotal Figure 20.9 Varieties of hypospadias. ‘Scanned with CamScannerB52 mars © @ Non-communicable diseases (NCDs) Non-communicable diseases, predominantly cancer, cardiovascular disease, chronic respiratory disease and, diabetes, have markedly increased in low- and middle. income countries, such that they now constitute 80% of the global burden. Five key risk factors are an unhealthy diet predisposing to obesity, tobacco use, alcohol abuse, physical inactivity and air pollution, which accompany increasing affluence in low- and middle- income countries and often have their origins in child- hood. Undernutrition in early childhood followed by overnutrition appears to be a particular risk for subse quent cardiovascular disease and diabetes. Household air pollution from smoke in homes using solid fuels, such as wood or charcoal for cooking and heating, pre- disposes children to lower respiratory infections and Figure 3111 Facial burns in a rural Nigerian girl acthma and-the-swaman-ta-chenmie an dB ripen nosexen on e@n mae re | ‘Scanned with CamScannerBIS] B masestenootets x @ m we eL ae 20 cise | Somme 2 = + DF emp Boece | AP asad A, satnow Eb Figure 29.10 Pink-purple rash in dermatomyositis Dermatomyositis This is a systemic illness, probably due to an angiopathy. Onset is usually between 5-10 years of age. This can be acute, but more typically is insidious with fever, misery, Figure 29.41 Myotonic dystrophy in an 8-year-old who and eventually symmetrical muscle weakness, which is fas marked facial weakness and moderately severe mainly proximal. Sometimes pharyngeal muscle involve- earning difficulties ment affects swallowing. Muscle pain is common and arthritis may occur. There is aso a characteristic violaceous (oink-ourple) rash on the evelids, and periorbital oedema sun HD treme rosea on en meee aw oo um ‘Scanned with CamScanner(a) Figure 2.11 Examples of neurological abnormalities identified on observation. (a) Microcephaly. (b) Asymmetry of the face in Bell palsy. (c) Play being used to test muscles of facial expression. Limb power © First test proximal, then distal, muscle power and From 6 months, observe the pattern of mobility. When compare sides. ‘old enough, observe gait and standing up from lying and ‘© Ask the child to hold their arms out straight with ‘Scanned with CamScannerBa en mS Oo @ om sree a foe ihe or ois | Stews 2 Se en en ee Sues abd SERGI tent joint swelling (of >6 weeks duration) presenti 16 years of age in the absence of infection or defined cause. Most children have a disease that i and immunogenetically distinct from theumatoi in adults It has a prevalence of approximately children (ie. similar to epilepsy), with over 12,00 children in the UK and estimated over 2 milion ¥ There are seven different subtypes of subtype and its clinical features are shown in f Classification is clinical and based on the numbe affected in the fist 6 months: © oligoarthritis - up to and including four join © polyarthritis ~ more than four joints (Fig. 28. systemic - with fever and rash (see Case hist + externally rotated No spontaneous movement (pseudoparalysis) Psoriatic arthritis and enthesitis (localized inflam insertion of tendons or ligaments into bone, oft are further subtypes. Subtyping is further according to the presence of rheumatoid facto 827 tissue type. Figure 28.17 Septic arthritis of the hip in infants, showing the characteristic posture to reduce intracapsular pressure. Any leg movement is painful and is resisted. iloskeletal disorders ‘Scanned with CamScannerSee 9 <2 2 Greene Memever | Atatsoed Latina BB @ | % a1 82 83 4 85 Prepubertal, Breast bud with elevation —_Juvenile smooth Areola and papilla Adult with projection of breast and papilla plus contour ‘project above breast of papilla only as. enlargement ofthe areola. ateoahas recessed Akey stage of female puberty 2 ittgnfies the onset of puberty ‘Scanned with CamScanner1 therefore helpful to cons The role of paediatric a avoid and to manage ch disease, The manageme conditions is described | Age of onset of Figure 16.3 Skin-prick testing for IgE-mediated allergy. A drop of the allergen is placed on the skin, the site is marked, and pricked with a needle, and any weals measured. Weals of 4mm or greater are considered positive. Multiple positive results are present. (Courtesy of Dr Pete Smith.) Allergic children develo different ages: Eczema and food alle Allergic thinitis, conju often in preschool an BO Rlnenie cltenerdnee aft ‘Scanned with CamScannerRY en -~sb@ Aver ennanestcraangat woe Benes 2 = + DL Gimme Messen | Madde L tate & The plasma cortisol is low and the plasma ACTH ation high (except in pituitary dysfunction). ynosis is confirmed with an ACTH (Synacthen) ere plasma cortisol concentrations remain low 10 Features of adrenal insufficiency ing ay natraemia kalaemia slycaemia ration ension Figure 26.13 Buccal pigmentation in adrenal insufficiency entation (gums, scars, skin creases) (Addison disease). This 9-year-old boy presented with salt irubincan cross eae verona + ences ‘Scanned with CamScannerFigure 25.12 Lichenification. ‘Scanned with CamScannerFigure 117 Chest X-ray in respiratory distress syndrome showing a diffuse granular or ‘ground glass’ appearance of the lungs and an air bronchogram, where the larger airways are outlined. The heart border is indistinct. A tracheal tube is present. (From: Lissauer T, Fanaroff AA, Miall L, et al: Neonatology at a Glance, ed 3. Oxford, 2015, Figure 118 Chest X-ray showing bilateral Pneumothoraces in a preterm infant with respiratory distress syndrome. ‘Scanned with CamScanner al medicinea A ee <2 04 [ ii ntieaee eed Le © <2 Omen Dae Meni Latin G2 BA Meckel diverticulum + Occurs in 2% of individuals. + Generally asymptomatic, but may present with bleeding (which may be life-threatening) of Intussusception of volvulus. + Treatment is by surgical resection. 4A Technetium scan showing uptake by ectopic gastric mucosa na oe ea recente it ha os row, The can has a outing 35rc Mecet ivr stomach and excretion into the blades. a we ea ‘Scanned with CamScannerBS] mersarrecont a = 304 Atarax Dette ap TtonkctcPolatnN SCOR eB we Lk 2 ine | eae 2 $F A Citone [Dbgiee | AlRndind Lido & BB | Downloaded for Anonymous User (ta) at Egyptian Knowledge Bank from ClinicalKey-com by Elsevier en August 09, 2021. For personal we only. No oer uses without permission. Copyright ©2021, Efsevier Ine. All nights reserved. a ee Figure 13.20 Marasmus in a 3-month-old baby who was unable to establish breastfeeding because of a cleft palate. Figure 13.19 Mid-upper-arm circumference (MUAC) measurement to identify malnutrition. It is colour-coded; amber is moderate malnutrition, red is severe (<115mm). ‘Scanned with CamScannerBarlow manoeuvre Femoral head dislocated posteriorly out of acetabulum Ortolani manoeuvre Dislocated femoral head relocated back into acetabulum ‘Scanned with CamScannerRS en oe « —— vei « et e ee nhe 2 + DL Cimeme rgeven | Means Ladi BBB | Z 2s Figure 8.6 Multiple rib fractures of different ages. ild abuse resulting in death gains 1 from the media but is rare, esti- id per week in the UK. Many more snent injury after serious physical n seen previously by health profes- on and response to child protection it severe injury. Maltreatment of ¢ Mixed density blood, either older subdural bleed SF oractive bleeding \ Figure 8,7 Retinal haemorthages from trauma to the head, (Courtesy of Clare Roberts.) MD ype nereto sear om e@nma@ Apa oe INO ‘Scanned with CamScannero@ in 10 cis | omen 2 ous injection. The family were taught y2 Day3 Day4 DayS Day6 perature chart showing spikes, often. normal in between times. — + PF Coimmome CBngevee | ANd f tbe Figure 28.23b Salmon-pink rash. Ca Bln Fs ye Musculoskeletal di: ID ypeneerosearch ° Py enaane Ne at he, ‘Scanned with CamScannerSi Cel @ CL SH SH $4 we ws on Atresia with fistula, Atresia without Hetype fistula between distal fistula without atresia ‘oesophagus and trachea Figure 1.32 Oesophageal atresia and tracheo-oesophageal fistula, ‘Scanned with CamScannerFigure 18.22 Kawasaki disease. Angiogram showing coronary artery aneurysm. Scanned with CamScannersp cise | mere B the UK, the most common causes nteroviruses, respiratory viruses herpesviruses (e.g. HSV, varicella Shuman herpesvirus 6 [HHV-6)). isms causing encephalitis include srferi (Lyme disease), Bartonella isease), rickettsial infections (e.g- 4 fever), and arboviruses. f childhood encephalitis but it can term consequences. All children | therefore be treated initially with ciclovir (acyclovir) until this diagno- ecause this is a very safe treatment. o not have outward signs of herpes sores, gingivostomatitis, or skin stect HSV in CSF. As HSV encephali- on, the electroencephalogram and >cal changes, particularly within the nilaterally or bilaterally (Fig. 15.5). Figure 15.6 A child with toxic shock syndrome receiving intensive care, including mechanical ventilation via a nasotracheal tube. The lips are red and the eyelids are oedematous from capillary leak. (Courtesy of Professor ‘Scanned with CamScannersmaller area Figure 12.7 Schematic drawings of male and female stages of puberty. Pubertal changes are shown according to the Tanner stages of puberty. Figure 12.8 Orchidometer to assess testicular volume (in mi). (From: Wales JKH, Rogol AD, Wit JM: Pediatric Endocrinology and Growth. London, 2003, Saunders, with permission.) Downloaded for Anonymous User (n/a) at Egyptian Knowledge Bank from ClinicalKey.com by Elsevier on August 09, 12021. For personal use only. No other uses wilhout permission. Copyright C2021, Elsevier Inc. All rights reserve. ‘Scanned with CamScannerBS] Berenson st Boy red Cre Sacred oe atin erp TREE Soe we el ee QP Crem Brwein | Added Laden BB Figure 12.10 X-rays of the left hand and wrist to determine bone age. This technique allows assessment of skeletal maturation from the time of appearance of the epiphyseal centres, using a standardized rating system. The child's height can be compared with skeletal maturation and an adult height prediction made. The ages shown are the bone age of each Xray. Scanned with CamScanner© @ | 0 | emfaniDeigtn oo 1s | Semen 2 been increasing for many years. Risk 1a include a positive family history, ber of melanocytic naevi, fair skin, f sunburn, and living in a hot climate aosure to the sun, id prevent their children nburnt. netic defect in biosynthesis and di . The albinism may be oculocutane- al, depending on the distribution of ne skin and eye (Fig. 25.5). The lack of retina, eyelids, and eyebrows results ) a fixation reflex. There is pendular otophobia, which causes constant nf rafractive arrnre and tinted lanene HDF Creep Baie ke tine AMtedind Eason & BB | 2 ‘Scanned with CamScannerFigure 29.14 Telangiectasia of the conjunctiva are present from about 4 years of age in ataxia telangiectasia Box 29.3. Causes of cerebellar ataxla Toxins, e.g. ethanol Drugs, eg. carbamazepine, lamotrigine Post-infectious cerebellitis - varicella bbe with anaemia and shock. The diagnosis Is confirmed with a CT scan. Management is to correct hypovolaemia, Urgent evacuation of the haematoma and arrest of the bleeding, Subdural haematoma This results from tearing of the bridging veins as they toss the subdural space. Itis acharacteristic lesion in non- accidental injury caused by shaking and/or direct trauma In Infants and toddlers. Retinal haemorthages are typical of shaking injury. Subdural haematomas are occasionally seen following afall froma considerable height, and rarely, In association with brain shrinkage through atrophy or ‘overdrainage of hydrocephalus. Subarachnoid haemorrhage This Is much more common in adults. Presentation Is usually with a severe headache with rapid onset (thun- daccian hearlarhe\ vewritinn eenfircon ar a rlarreater ‘Scanned with CamScanner jical disordersgay ef mime ements a ED A Ciitepme ragesen | AP fea toes ‘inept ernou ‘Rwsrans cst dw ena, God roars bung {pemiymoma mon argos uu «4 yerold tas oat unable to cnb as st “ental dfets falrmny anon ara ons acon” 22.88) Ceol age atae Piaoras besten alma. Bt ot for psy as toohazado. Toten orate aca peerage we ebee Losi BBB | 2 Figure 228 (a Location of brain tumours. Clinical features of bran tumours. Ml scans showing (b) ronto-paretal mass large midline suprasllar mas; cerebellar mass; and (@) brainstem mas. we ss ay SS Ga ea prs ed a Ehcteta A + Gnloohanmngloma 4 - 9 developmental tumour Seng rom the squamous remnsatof Rtke pouch ittsnet tly alignart buts focally invasve and 2 tener tosenc on e@umae oe | Scanned with CamScannero@ averse 2 osm | mmm 2 atory signs or a chronic cough with a persistent jogical abnormality. It occurs most commonly in en aged 6 months to 3 years. The aspirated mate- most often food, but can be bits off toys, or coins. fory of choking is present in >80%, but only when. ically asked about. Radio-opaque foreign bodies can adily identified on plain chest X-ray (Fig. 17.19). A lucent foreign body such as a peanut is more difficult 1gnose (see Case history 17.2). Removal is using a pronchoscope. any child with a severe, persistent cough, tuberculosis d be considered (see Ch. 15). tasis is irreversible dilatation of the bronchial which can be confirmed on a CT scan. In practice, it ynosed by the presence of clinical features of chronic irative lung disease, namely recurrent episodes of je wet cough, coarse crackles on auscultation and ons ctsAcOtoMk22 pt we rite e S$ DF Die me Rgesien Aehassed £ Adina ; Figure 17.19 Chest X-ray showing a pin (arrow) in the right main bronchus. ‘Scanned with CamScannered Took ott " sent ot took00pszoPediaticsn20stnzoedon.020 we £Lee cone — $+ DF Giiemeage UB omeven | Aansnins Lassie & BB | AZ Tigh upperio upper lobe Left upper lobe ‘Scanned with CamScannerBs] B ter octets EI > @ r + 2 etm -+a¢ Doever | A tetsost f tate & BB | nal mass and an MRI scan characterized a very large upper Figure 22:14 The MI8G scan ‘maps’ metastatic tumour. Upper poof et kidney Thls image shows the lower haf of the abdomen, pelvis, and legs. The dark areas are evidence of high ‘Nrta and coeliac vessels 'sotope uptake and the pattern is consistent with, Figure 22.13 Transverse MRI image showing a large left-sided widespread metastatic disease. (Normal uptake from primary neuroblastoma arising from the adrenal region and excretion of isotope into urine in the bladder has been distorting coeliac and mesenteric blood vessels. blocked in this exposure.) Scanned with CamScannerP 7 Figure 25.18 Ringworm of the scalp showing hair loss and kerion They may be single but are usually multiple. Lesions are often widespread but tend to disappear spontaneously wo oRLe DP Ditepe angen | AlRetsond fasinne BB Figure 25.16 Scabies, Sole of foot in this 2 month old infant showing burrows (arrows). ‘Scanned with CamScanner- +00 ef Aare CesophstecnTacodk Rote GPO? pet we ihe. 25 ois | i coneme — +O 2 Diener | Alediod Laine BBB | omy in Figure 17.27 Long-term ventilation via a tracheostomy. ‘Scanned with CamScanneroa mee srt we eine 7 » — +2 2 Bene Devin | Aten Lien BBB | J SIHait Stee Parapheusnoric EHusIOHs UCLUL I Up WO lig Severe spasiiis UF OUI UF Ly. one-third of children with pneumonia and usually resolve admitted to hospital and isolate: once the pneumonia is treated. Persistent fever despite The organism can be identifi 48hours of antibiotics in a child with an effusion sug- from culture of a pernasal swa gests it has become infected. This is a pleural empyema; merase chain reaction) is more. diagnosed serologically. Chara marked lymphocytosis (>15 x 1 Although macrolide antibiotics ism, they decrease symptoms or catarrhal phase. Siblings, paren are at risk and close contacts sh prophylaxis. Unimmunized infa vaccinated. Immunization reduc ing pertussis and the severity of does not guarantee protection. declines steadily during childho a oe POM Prognosis and follow- “up BD wos heretazearn on em ‘Scanned with CamScanner€ Oo @ (venta oektoprt . a e eine fs) | mee — + DF Cmeme Dover | A tatoos fidinin BB Bs is positive if the palpable induration is § mm or ‘more in diameter irespective of whether or not y "F hhad BCG immunization (NICE guidelines, 2016, for the UK). Only the induration should be y ‘measured (not the surrounding erythema). g Ib) Chest X-ray of pulmonary TB. ‘There is marked left hilarlymphadenopathy Dormancy and dissemination Both asymptomatic and symptomatic infections may become dormant but subsequently reactivate and spread by lymphohaematological routes. ‘Scanned with CamScannerSIS B thr tenbock ott x o @ user Desktop ilusraed Cert 24 of 579 | | disease showing multiple cerebral infarcts -ment xis ~ Because spleen function is severely impaired patients, they are particularly susceptible to infec- h encapsulated organisms, e.g. Streptococcus niae and Haemophilus influenzae type B, and all affected children should be fully immunized, J against pneumococcal, Haemophilus influenzae 1d meningococcus infection. To ensure full cover- I| pneumococcal subgroups, daily oral penicillin but childhood should be given. Vaso-occlusive ould be minimized by avoiding exposure to cold, ion, excessive exercise, undue stress, or hypoxia, uires practical measures such as dressing chil- mly, giving drinks especially before exercise, and ctra care to keep children warm after swimming playing outside in the winter. nent of acute painful episodes, also known as Padi woot “ * = + D 2 Cito Preview | Ab Readalad Adin continuous positive airways pressure (CPAP). An exchange transfusion was performed. Broad-spectrum antibiotics were commenced. She responded well to treatment, Figure 23.11 Chest X-ray in acute sickle chest syndrome showing bilateral lower zone consolidation. (Courtesy of Parviz Habibi.) SSS es ‘Scanned with CamScanner© @ & eyicavervoektpuenedaoreocknatchctedticcth 2 ti 2202 9 +e ee ne — + DF Biene Dome | Mantis Lisinn BBB |Z © the recognition and staged treatment of hypoglycaemia © where to get advice 24hours a day © the help available from voluntary groups, e.g. local groups or Diabetes UK * the psychological impact of a lifelong condition with potentially serious short-term and long-term complications. A diagnosis of diabetes is life-changing and many fe lies grieve for the loss of their previous life. The speci nurse should liaise with the school (teachers, those \ prepare school meals, physical education supervisors). the primary care team, so that the child is well suppor in all environments. Figure 26.2 Acanthosis nigricans in axilla. A sign of Insulin insulin resistance, The insulin regimen aims to mimic normal physiol _ -al_secretion-of insuli sb all amounts of ins 2 toeteeionve on en mae we oe a ‘Scanned with CamScanner