Master Child Health (Paediatrics)
for AMC Cat 1
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Core Concepts
Paediatrics focuses on comprehensive child health from birth through adolescence. Key concepts include understanding normal growth and development milestones (physical, cognitive, social, emotional), recognising deviations, and addressing common childhood illnesses. Immunisation schedules are critical for preventative health. Nutrition, including breastfeeding and healthy weaning practices, forms a cornerstone. Child protection (recognition and reporting of abuse/neglect) is paramount. A structured approach to fever, respiratory distress, and abdominal pain in children is essential. Paediatric emergencies require rapid assessment and management due to physiological differences from adults (e.g., smaller airways, higher metabolic rate, rapid decompensation).
Clinical Presentation
- Fever: Common, but always consider serious bacterial infection in infants <3 months; non-blanching rash (meningococcaemia).
- Respiratory Distress: Tachypnoea, grunting, retractions, nasal flaring, cyanosis (bronchiolitis, asthma, croup, foreign body aspiration).
- Croup (Laryngotracheobronchitis): Barking cough, inspiratory stridor, hoarseness, often viral.
- Bronchiolitis: Viral (RSV), infants <2 years, wheeze, crackles, tachypnoea, nasal congestion.
- Asthma: Recurrent wheeze, cough, dyspnoea, chest tightness, triggers.
- Meningitis: Fever, irritability, poor feeding, bulging fontanelle (infants); headache, neck stiffness, photophobia (older children).
- Febrile Seizures: Generalised seizure, age 6 months - 5 years, associated with fever, no CNS infection.
- Gastroenteritis: Vomiting, diarrhoea, dehydration (lethargy, dry mucous membranes, reduced urine output).
- Pyloric Stenosis: Non-bilious projectile vomiting, olive-like mass in RUQ, visible peristalsis, typically 2-8 weeks old.
- Intussusception: Sudden onset severe colicky abdominal pain, drawing up knees, 'redcurrant jelly' stool, palpable sausage-shaped mass (RUQ).
- Hirschsprung's Disease: Neonatal failure to pass meconium, chronic constipation, abdominal distension, bilious vomiting.
- Urinary Tract Infection (UTI): Fever, irritability, poor feeding (infants); dysuria, frequency, urgency, enuresis (older children).
- Developmental Dysplasia of Hip (DDH): Hip click/clunk (Ortolani/Barlow), limited abduction, leg length discrepancy, asymmetrical skin folds.
- Type 1 Diabetes Mellitus (T1DM): Polyuria, polydipsia, polyphagia, weight loss, fatigue.
- Child Abuse/Neglect: Unexplained injuries, inconsistent history, developmental delay, poor hygiene, fearful demeanour.
Diagnosis (Gold Standard)
Bronchiolitis: Clinical diagnosis. Croup: Clinical diagnosis. Asthma: Clinical, response to bronchodilators, PFTs (older children). Meningitis: Lumbar puncture (CSF analysis for cell count, protein, glucose, culture, PCR). Pyloric Stenosis: Abdominal ultrasound (target sign, thickened pyloric muscle). Intussusception: Abdominal ultrasound (target sign). Hirschsprung's Disease: Rectal biopsy demonstrating absence of ganglion cells. Urinary Tract Infection: Urine culture (from MSU, catheter, or suprapubic aspirate). Developmental Dysplasia of Hip: Ultrasound (infants <6 months), X-ray (older infants/children). Type 1 Diabetes Mellitus: Elevated random/fasting plasma glucose, HbA1c, autoantibodies (GADA, ICA, IAA).
Management (First Line)
Fever: Paracetamol or Ibuprofen (for comfort), adequate hydration. Bronchiolitis: Supportive care (nasal suction, oxygen if SpO2 <92%). Croup: Oral dexamethasone (single dose), nebulised adrenaline if severe stridor at rest. Asthma Exacerbation: Salbutamol (via spacer), oral corticosteroids (prednisolone). Meningitis: IV empiric antibiotics (e.g., ceftriaxone, vancomycin) immediately after LP or blood cultures, then targeted. Gastroenteritis: Oral Rehydration Therapy (ORT). Pyloric Stenosis: Pyloromyotomy. Intussusception: Air enema (therapeutic and diagnostic). Urinary Tract Infection: Appropriate oral or IV antibiotics (e.g., trimethoprim, cephalexin). Anaphylaxis: Intramuscular adrenaline (0.01mg/kg of 1:1000 soln, max 0.5mg). Child Abuse: Immediate safety assessment, documentation, reporting to child protection services. Dehydration: ORT for mild-moderate, IV fluids for severe.
Exam Red Flags
- Non-blanching rash: Suspicion for meningococcal disease (medical emergency).
- Lethargy, poor feeding, reduced urine output: Signs of severe dehydration, sepsis, or other critical illness.
- Bulging fontanelle, persistent vomiting, focal neurological signs: Possible raised intracranial pressure, CNS infection, or mass.
- Severe respiratory distress (grunting, severe retractions, cyanosis): Indicates impending respiratory failure.
- Bilious vomiting in a neonate: Surgical emergency (e.g., malrotation with volvulus) until proven otherwise.
- Sudden onset severe abdominal pain with redcurrant jelly stool: Classic for intussusception.
- High fever in an infant <3 months: Sepsis until proven otherwise, requires hospital admission and full septic workup.
- Absent femoral pulses or significant differential blood pressure upper vs. lower limbs: Consider coarctation of the aorta.
- Inconsistent or vague history of injury, particularly with multiple or unexplained bruises/fractures: High suspicion for child abuse.
- Rapidly deteriorating conscious state or unresponsiveness: Neurological emergency (e.g., meningitis, severe head injury, metabolic crisis).
Sample Practice Questions
A 9-month-old infant presents with sudden onset, severe, colicky abdominal pain. He cries inconsolably and draws his knees to his chest. These episodes last for a few minutes and then resolve, only to recur. The parents also report he has passed a 'red currant jelly' stool. On examination, a sausage-shaped mass is palpable in the right upper quadrant, and his abdomen is soft but slightly tender.
A mother expresses concern about her 2.5-year-old son's development. She reports he rarely makes eye contact, does not respond consistently to his name, has very limited speech (only a few single words), and often engages in repetitive play such as lining up his toy cars for extended periods. He also becomes very distressed by minor changes in his daily routine.
A previously healthy 15-month-old boy presents to the emergency department with a 12-hour history of fever (39.5°C), irritability, and poor feeding. His mother reports he has been unusually drowsy. On examination, he is lethargic, has a purpuric rash on his trunk, and a stiff neck. His fontanelle is closed, and there are no focal neurological signs. What is the most urgent diagnostic investigation required in this patient?
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