Paediatrics and Child Health, 2nd edition

433 Pages·2006·8 MB·English

by  Mary Rudolf

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Paediatrics and Child Health
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To our children: Aaron and Rebecca Krom;
Alysa, Katie, Ilana, Hannah and David Levene.
To our spouses: Michael and Sue.
To those individuals who over the course of years have influenced our
approach to children in health and disease:
Ben Berliner, Victor Dubowitz, Ze’ev Hochberg, Hugh Jolly, Esther
Rudolf, Hedva Steiner, Myron Winick
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Paediatrics and
Child Health
Mary Rudolf
MB BS BSc DCH FRCPCH FAAP
Professor of Child Health
East Leeds PCT and University of Leeds
Leeds, UK
Malcolm Levene
MD FRCP FRCPCH FMedSc
Professor of Paediatrics and Child Health
School of Medicine
Leeds General Infirmary
Leeds, UK
SECOND EDITION
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© 2006 Mary Rudolf and Malcolm Levene
Published by Blackwell Publishing Ltd
Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148–5020, USA
Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK
Blackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia
The right of the Authors to be identified as the Authors of this Work has been asserted in accordance with the Copyright, Designs and
Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any
means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents
Act 1988, without the prior permission of the publisher.
First published 1999
Reprinted 2000
Second edition 2006
Library of Congress Cataloging-in-Publication Data
Rudolf, Mary.
Paediatrics and child health / Mary Rudolf, Malcolm Levene. –
2nd ed.
p. ; cm.
Includes index.
ISBN-13: 978-1-4051-2661-8 (alk. paper)
ISBN-10: 1-4051-2661-2 (alk. paper)
1. Pediatrics. 2. Children–Health and hygiene. I. Levene,
Malcolm I. II. Title.
[DNLM: 1. Pediatrics. 2. Child Welfare. WS 200 L657p 2006]
RJ45.R86 2006
618.92–dc22 2005013048
ISBN-13: 978-1-4051-2661-8
ISBN-10: 1-4051-2661-2
A catalogue record for this title is available from the British Library
Set in 9.5/11.5pt Minion by Graphicraft Limited, Hong Kong
Printed and bound in India by Replika Press PVT Ltd
Commissioning Editor: Vicki Noyes
Editorial Assistant: Caroline Aders
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Contents
Preface, vi Part 4 Emergency paediatrics
20 Emergency paediatrics, 252
Part 1 Introduction to paediatrics
1 How to use this book, 1 Part 5 The child with long-term medical
2 About children, 3 and educational needs
21 Chronic medical conditions, 283
Part 2 A paediatric toolkit 22 The child with a disability, 322
3 History taking and clinical examination, 17
4 Developmental assessment, 46 Part 6 Before and beyond childhood
5 Investigations and their interpretation, 52
23 The newborn, 338
6 Taking an evidence-based approach, 63
24 The adolescent, 367
Part 3 Common paediatric symptoms and
Part 7 Health care and child health
complaints
surveillance
7 Introduction to common symptoms and
25 Health care and child health promotion, 379
complaints, 70
8 The febrile child, 72
9 Respiratory symptoms, 91 Part 8 Test your knowledge
10 Gastrointestinal symptoms, 104
Questions, 391
11 Pain, 124
Answers, 407
12 Urinary symptoms, 140
13 Rashes and skin lesions, 149
Index, 411
14 Genitalia, 174
15 Lumps, bumps and swelling, 179
CDVideo: Clinical Examination of the Child (inside
16 Growth problems, 189
back cover)
17 Developmental concerns, 208
18 Emotional and behavioural problems, 222
19 Other problems, 230
v
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Preface to the Second Edition
Paediatrics and Child Healthis a textbook that aims to pro- We hope that the book provides students with the com-
vide medical students with the tools to become competent panion they need to accompany and complement their
diagnosticians, along with the knowledge and sensitivity clinical experience, so setting them on the path to becom-
to take good care of young patients and their parents. ing doctors who understand the special nature of child-
As before, the focus is on developing a working approach hood, appreciate children and are competent in their
to paediatric problems and child health, written from work with young patients and their families.
the angle of symptoms and problems as they present in
primary care. Acute problems take the front stage, but
Acknowledgements
emphasisis also given to children with chronic conditions
and long-term medical or educational needs, who are We are grateful to the following who have contributed
seen in the context of their families and the issues they illustrations: Dr Rosemary Arthur, Mr P.D. Bull, Dr Tony
encounter at school. Growth and development, both unique Burns, Professor Martin Curzon, Dr Mark Goodfield, Dr
to paediatrics, also receive particular attention, along with Phillip Holland, Mr Tim Milward, Dr P.R. Patel, Dr John
nutrition, education, parenting, disadvantage and ethics. Puntis, Mr Mark Stringer, Ms Clare Widdows, Dr Susan
The new edition has been written so that it is easier to Wyatt and Mr Jane Wynne. We would like to thank the
navigate. In restructuring the book, we were influenced by Child Growth Foundation for permission to reproduce
popular tourist guides that identify attractions and also their growth charts.
highlight those sites that should not be missed. Each chap- We would like to thank the following: Extract of ‘Henry
ter of the book starts with a ‘mind map’ that allows the King who chewed string and was cut off in dreadful
reader to visually grasp the differential diagnosis for any Agonies’ from Cautionary Verses by Hilaire Belloc
symptom, and highlights the common and important (Copyright © The Estate of Hilaire Belloc 1930) is repro-
conditions that must be learned. duced by permission of PFD (www.pfd.co.uk) on behalf
of the Estate of Hilaire Belloc. Extract of ‘Rebecca who
slammed doors for fun, and perished miserably’ from
CD
Cautionary Verses by Hilaire Belloc (Copyright © The
An innovative feature of the book is the accompanying Estate of Hilaire Belloc) is reproduced by permission of
CD on the clinical examination of the child. Skill in exam- PFD (www.pfd.co.uk) on behalf of the Estate of Hilaire
ining children is hard to acquire during the few weeks of a Belloc. Extract from ‘Now We Are Six’ © A.A. Milne.
paediatric rotation. The CD guides the student through Published by Egmont UK Limited, London and used with
the physical examination in a systematic way, demonstrat- permission. Published by Dutton’s Children’s Books,
ing correct technique and explaining the significance of a division of Penguin Young Readers Group, a member
findings. E-help: Media Services, University of Leeds, of Penguin Group (USA) Inc, 345 Hudson Street, New
Leeds, LS2 9JT. Tel: [phone]. Fax: [phone]. York, NY 10014, and used with permission. All rights
Other new features include a focus on competences reserved. Extract from When We Were Very Young © A.A.
that medical students should acquire – the knowledge Milne. Published by Egmont UK Limited, London and
(Must know), skills (Must be able to) and attitudes (Must used with permission. Published by Dutton’s Children’s
appreciate). The section on testing your knowledge offers Books, a division of Penguin Young Readers Group, a
multiple-choice questions that cover the syllabus and member of Penguin Group (USA) Inc, 345 Hudson Street,
relate to each chapter in the book. There is a new chapter New York, NY 10014, and used with permission. All rights
on evidence-based paediatrics. reserved.
vi
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1
How to use this book
1
Experience is the child of Thought, and Thought is the child of Action. We cannot learn men from books.
Benjamin Disraeli
Was Disraeli right? Are books a very limited resource? your way around...overview, with the possible diagnoses
Certainly, the only way to become competent as a doctor outlined in some order of likelihood (see Fig. 1.1 overleaf).
for children is to encounter children and their medical The key conditions that you need to visit in more detail
problems on the wards, in clinics and in their homes. It is (i.e. worth a detour and should not be missed!) are high-
only through these Experiences that Thought and under- lighted in bold.
standing are generated to lead you to the Action required A competent diagnosis can only be reached if your his-
to meet children’s medical needs. tory and examination are focused. Each topic opens with
But reading must accompany experience and fill out an approach you should take, giving questions you ‘must
those gaps that experience does not provide. In fact, it ask’ and signs you ‘must check’. Helpful investigations
simply is not possible to develop a sound approach with- follow with a table providing you with the significance of
out the aid of a good companion to experience. Paediatrics any results. The topic ends with a ‘Clues to diagnosis’ box,
and Child Health aims to be this companion and to pro- giving you the key conditions to be considered in your
vide you with a guide to becoming a competent doctor for differential diagnosis, and features that will help you
children. arrive at the correct diagnosis. The conditions are then
This book differs in the way it approaches the art and covered individually under the headings of aetiology, clin-
science of paediatrics. It aims first and foremost to provide ical features, useful investigations and management, with
you with the necessary tools to arrive at a diagnosis and to the most important summarized in an ‘At a glance’ box.
care for children in the context of their family and school. Lastly, to ensure that you are clear about the com-
We believe that learning to practise medicine is like petences we hope you will acquire, we list the knowledge
learning a language. You cannot learn to speak a foreign (Must know), skills (Must be able to) and attitudes (Must
language from studying a dictionary; instead, you need a appreciate) at the opening of each chapter.
language guide to take you through the steps to fluency. The book opens with background information that
The building blocks to most medical textbooks are diseases you need to know about children. Growth and develop-
– rather like an encyclopaedia, they work through the ment are two aspects that are unique to paediatrics, and so
various medical conditions systematically. But if you rely receive particular attention. Nutrition, education, parent-
on the encyclopaedic approach, it may be hard, when ing, disadvantage and ethics are also covered.
faced with a patient, to work out whether their symptoms Part 2 provides you with a toolkit to practise paediatrics.
are likely to be due to a cold, cancer or TB. This book takes The cornerstone to practicing paediatrics is a competent
the child’s symptom or presenting problem as its starting clinical examination and the only way to learn this is to see
point, and works from there to lead you through the steps it being done. We have prepared a teaching CD that is
to the most reasonable diagnosis. included with the book.* Each organ system is covered in
In developing the structure of the book we have been detail and we recommend that you take each system in
influenced by popular and successful tourist guides that turn working through the book and CD together, so
are based on identifying the attractions available, but which ensuring that you acquire good technique and appreciate
also highlight those that should not be missed. Around this the significance of any findings. Wise use of investigations
framework, they provide you with background informa- needs to follow and the next chapter is given to guiding
tion and the tools you need to get around the city. you through the commonly requested investigations on
In a similar way, Paediatrics and Child Healthprovides children and how to interpret the results. The last compo-
you with an overview of the common and important nent of the toolkit is the chapter on evidence-based health
medical problems children encounter, along with a clear care, which gives you the grounding for an evidence-based
guide as to those conditions that you must not miss, either approach, focusing on an understanding of guidelines.
because they are serious or because they are common. While acute problems take the front stage, special
Each chapter tackles a cluster of presenting symptoms, emphasis is also given to children who have chronic
which are initially presented schematically as a Finding conditions and long-term medical or educational needs.
1
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2 Part 1 Introduction to paediatrics
1 Finding your way around . . .
DIAGNOSTIC POSSIBILITIES –
IN SOME ORDER OF
LIKELIHOOD AND KEY
CONDITIONS HIGHLIGHTED
SYMPTOMS
IN BOLD
COVERED IN
THIS CHAPTER Gastroenteritis
Gastro-oesophageal
reflux
Soiling and Pyloric stenosis
encopresis Systemic infection
Viral hepatitis
Jaundice Vomiting
Hepatic cirrhosis
Gastrointestinal
Viral gastroenteritis
Blood in Acute Bacterial
symptoms
the stool diarrhoea gastroenteritis
Non GI infections
Chronic
diarrhoea
Constipation
Toddler diarrhoea
Anal fissure
Lactose intolerance
Dysentery & salmonella
Cow’s milk protein allergy
Milk allergy Functional constipation
Cystic fibrosis
Intussusception Hirschsprung’s
Coeliac disease
Inflammatory bowel disease Fluid depletion
Ulcerative colitis
Henoch–Schönlein purpura Bowel obstruction
Crohn’s disease
Overflow in constipation
Parasites
Fig. 1.1 The ‘Finding your way around’ box.
These children, with their complex needs, are increasingly pass examinations but rather to help you identify what
encountered on the wards, in clinics and in surgeries. you have yet to learn.
Their medical problems are presented within the broad We hope that this book provides you with the compan-
context of the issues faced by their families and the issues ion that you need to work competently with children. Dip
they encounter at school. into it or read it from cover to cover, but above all enjoy
The last chapter moves away from the starting point of the opportunities you have on your rotation to get to
the individual child to look at health care provision, the know children and understand their medical concerns.
professionals involved and the role of child health surveil-
lance. Finally, in recognition that learning is best acquired *Further copies of the CD and an accompanying booklet are
interactively, we provide you with the opportunity to test available from University of Leeds, Media Services, see CD for
your knowledge by working through multiple-choice details.
questions to ensure that you have truly focused on the To test your knowledge on this part of the book, please go
principal issues. This section is not intended to help you to p. 391.
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About children Chapter 2 3
2
About children
1
And one man in his time plays many parts,
His acts being seven ages. At first the infant,
Mewling and puking in the nurse’s arms.
And then the whining schoolboy, with his satchel,
And shining morning face, creeping like a snail
Unwillingly to school.
William Shakespeare
Finding your way around . . .
Physical growth
Ethical issues
About
Psychomotor
Inequality and social
development and
disadvantage children
social interaction
Parenting, childcare Nutrition
and education Breast-feeding
Formula feeds
Weaning
Children
You must . . .
Know about Be able to Appreciate
n The factors that affect growth n Make up a formula feed n The difference between growth and
n The advantages of breast-feeding development
n The components of a balanced n How development progresses from
healthy diet babyhood to childhood
n The effects of poverty on health n The challenge of parenting
n The ethical issues that arise when
working with children
n When a young person is able to
consent to treatment
3