Paediatric Pearls

I’ve given a talk on Paediatric Pearls in the past. I recently revived the talk for my residents, so thought I’d put it up here. 15 paediatric pearls. Now some of you may not agree with them, some may think they are too conservative, some may think they are not conservative enough.

I make no apology for the fact that they are reactive, to some of the patients I’ve seen that may have slipped through the cracks if I didn’t have these. I hope they are of help to you.

Here we go….

15 Paediatric Pearls

1. Most of the kids we see are well……. DON’T BECOME COMPLACENT

2. Not everything that occurs in the emergency department is an emergency

3. Listen to the parent(s). If they say their child’s not right, then pay attention to that.

-If they say the child complains of abdominal pain and won’t eat, listen

-If they say the child’s temperature at home was 40 Celcius, listen, even if it’s normal the whole time in the ED

4. Any child with corrected age <30 days or who is brought in more than twice, gets seen by an Emergency Specialist and/or paediatrics.

5. Don’t Walk…..Don’t Go home.

The limping child can be difficult to diagnose. The well child with localised limb pain, but no fever, no injury, no recent viral illness and normal xrays, that doesn’t improve with analgesia…..that’s a challenge. I don’t send them home if I’m unsure. I might go fishing….. The last child I saw with a limp, that didn’t make sense and I did bloods on, had the following pancytopaenic picture

-WCC 1.1, Hb 6.3, Plt 25, Neut 0.2, Lymph 0.67: = Leukaemia

6. Right Iliac Fossa Pain and the ultrasound cannot visualise the appendix, then trust your clinical findings.

Although we know that appendicitis is a clinical diagnosis, we are ordering more and more abdominal ultrasounds looking for the appendix. I many cases, the report comes back as appendix not visualised. There may be no secondary signs of inflammation such as free fluid, fat changes or enlarged lymph nodes, How many times has this happened to you? My rule is to trust my clinical exam and how well the child looks. Of those children that were sent home less than 0.3% had an appendix.

7. Give them analgesia. 

No child should be in distress in the emergency department. Analgesia does not mask the clinical findings.

8. Never send a patient home without seeing the vitals.

-A  case presented to me a few years ago, was……… “well 7 month old has been to the GP 4 days ago with some shortness of breath, on the background of a viral illness and was commenced on antibiotics for a chest infection. It sounds like bronchiolitis, the sats are 100%. I’m happy for the baby to go home.” When asked for the vitals “Couldn’t quite measure the pulse as it was a little fast, probably around 150 beats per minute.”

-When attached to the monitor the pulse was a little higher as shown below. This child had an SVT, that was promptly reverted with some ice in a plastic bag over the eyes. The wheeze was heart failure as the child had probably been in an SVT for the last 4 days. The cause, probably myocarditis.

9. Don’t be afraid to order an ECG on a child.

A case presented was “…2 year old with a recent history of viral illness, presents lethargic, short of breath and diaphoretic. She is afebrile, with a heart rate of 80bpm, sats of 97% on room air and BP of 102/67″

-Again this is all about the Vitals— the heart rate of 80 is too slow. ECG was done that showed a complete heart block, probably secondary to myocarditis from the recent viral illness.

10. Up to 50% of myocarditis cases are misdiagnosed as asthma or pneumonia.

11. Beware the child that turns blue or gets short of breath or diaphretic when feeding.

Think cardiac cause until proven otherwise.

12. If a child looks sick then investigate. 

It might just be a viral illness but it’s not necessarily benign. If a child looks unwell work them up. A past case I had was of a child that was febrile and pale and lethargic, but with a fairly normal examination. The shild looked unwell.

-A set of bloods demonstrated: Hb 44, WCC 14.9, Plt 411. A Coombs test was done that was strongly positive. There was bilirubin in the urine. This haemolysis secondary to the viral illness.

13. Kids can have strokes.

Paediatric ischaemia occurs at a rate of about 4-6/100000 per year. Remember the risk factors: congenital heart disease, sickle cell disease, CNS inflammation, Trauma, vascular abnormalities and coagulation abnormalities.

14. Don’t just order bloods.

15. Always think of Non-Accidental Injury