1

PAEDIATRICS
HISTORY TAKING FORMAT
Chief complaints
History of presenting illness(ODPARA)
Rule out the differential diagnosis
Essential Questions in Paediatrics
Past history
Personal history
Family history
Allergy history

History of presenting illness(ODPARA)

Onset
Duration
Progression
Aggravating factors
Relieving factors
Associated symptoms

Differential Diagnosis
More than one diagnosis
Prioritize the Diagnosis
Consider life threatening conditions followed by common conditions
Rare diseases are rare

For Paediatric History

B Birth How was the Birth?

I Immunisations
R Red Book (Personal Child
Health Record (PCHR))
D Development
Any Problem during or after birth?
+/-breastfeeding
Is the child up -to-date with vaccines or
jabs?
Any concerns about red book recording?
Is his/her development okay in comparison
to other same age children?

History Taking Stations

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1 Unconscious child

2 Delayed walking
3 Vaginal discharge in child
4 Red coloured stools in child
5 Vomiting in child
6 Chronic diarrohea / weight loss in child
7 Child with bruises (Idiopathic Thrombocytopenic Purpura)

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1.UNCONSCIOUS CHILD

TASK

A 12 year old girl or 6 year old boy has been brought to the hospital by
mother. Child lost consciousness in school assembly. Take History from
mother and give D/Ds to examiner.

What brings you to the hospital?

O Could you tell me more about it?

Elaborating the event

Before What was your child doing? Who was there? Any trauma? Any
headache? Turning pale? Fever? Aura? Palpitation? Sweating?
During How long? Did your child remember anything? Wet pant?
Shaking? Bite tongue? Got hurt?
After How did your child feel when he got conscious? Any memory
loss? Vomiting? Nausea? Coughing? Weakness? Fever?
Difficulty in speaking? Any pain anywhere?
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Other Is that first time? Ask cardinal symptom of nervous system?

Differential Diagnosis

V Vasovagal syncope Turning pale before incident? Sweaty?

Short duration, other causes excluded (Dx
Of Exclusion)
I Injury Got hurt on head?

M Meningitis Fever? Headache? Rash? Shy away from

light?

S Substances[Accidental Did your child eat/ drinkanything

Poisoning] accidently wgich might have caused this?
H Hypoglycaemia / DKA DM? When did you have your food?/Any
tummy pain, fruity smell, vomiting.

E Epilepsy Was your child shaking? Wetting pant or

biting tongue?
A Arrhythmia Palpitation/pounding/racing of heart?

T Trauma (Same as injury) Was there any trauma?

H Heart Problems Any heart problem?

P2-P7

Family History- Any family history of DM, Heart Problems or Epilepsy?

Other- Are you the biological father/mother?
Findings in the exam
1) Child was standing during the assembly
2) Was pale and sweaty before she/he fell unconscious
3) LOC for less than 2 min
4) No jerky movements
5) No head or any other injury
6) No fever or rash
7) No known heart problems/DM/Epilepsy
8) No family Hx of any of those diseases

Diagnosis: Vasovagal syncope

Head injury in children

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Indications for referral to hospital A&E department after

head injury for children
A high-energy head injury - eg, diving accident, high-speed
motor vehicle collision.
GCS <15 at any time since injury.
Any loss of consciousness as a result of the injury.
Any focal neurological deficit since the injury.
Amnesia for events before or after the injury.
Persistent headache since the injury.
Any vomiting episodes since the injury (clinical judgement
should be used in those aged 12 years).
Any seizure since the injury.
Irritability or altered behaviour, particularly in infants and young
children.
Any suspicion of a skull fracture or penetrating head injury since
the injury (eg, clear fluid from the ears or nose, black eye with
no associated damage around the eyes, bleeding from one or
more ears, new deafness in one or more ears, bruising behind
one or more ears).
Visible trauma to the head not covered above but still of concern
to the professional.

The following children meet the criteria for admission to

hospital following a head injury
History of loss of consciousness.
Neurological abnormality, persisting headache or vomiting.
Clinical or radiological evidence of skull fracture or penetrating
injury.
Difficulty in making a full assessment.
Suspicion of non-accidental injury.
Other significant medical problems.
Not accompanied by a responsible adult or social circumstances
considered unsatisfactory.

Selection of children (under 16 years) for CT scan

CT scan of the brain within one hour (with a written radiology report within
one hour of the scan being undertaken):
Suspected open or depressed skull fracture or tense fontanelle
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Signs of base of skull fracture*

Focal neurological deficit
Age <1 - bruise, swelling or laceration >5 cm on the head

If none of the above are present then CT brain scan is required within one hour if
more than one of the following are present (with a written radiology report within
one hour of the scan being undertaken):
Witnessed loss of consciousness >5 minutes
Amnesia (antegrade or retrograde) >5 minutes
Abnormal drowsiness
3 Discrete episodes of vomiting
Dangerous mechanism of injury (high-speed RTA, fall from >3 m, high-
speed projectile)
If only one of the afore mentioned risk factors is present then observe for a
minimum of four hours - CT scan of the brain within one hour if any of the following
occur (with a written radiology report within one hour of the scan being
undertaken):
GCS <15
Further vomiting
Abnormal drowsiness
 TASK

6
Q. 9 months old, Tommy, was brought to the hospital by her mother
for head injury. Talk to the mother and Discuss management with
the mother.

How did Tommy get head injury?

Tommy fell down from sofa and hit his head on the floor when I was changing
the nappy of the other child. ( Falling from suggests not high velocity trauma
a sofa is usually less than 2 feet height)

What happened to him after injury? Did he lose

consciousness?
He went floppy ( or limp) (floppy or limp = LOC for the PLAB exam )
for 2 min (sometimes she may say only for about 20 sec)

What did he do after that ?

He was OK after that

Was he drowsy or playful?

He was active and playful

Did he vomit?
He vomited twice.

Was there any bleeding from head, ears, nose or mouth ?

There was no bleeding but I noticed some swelling and redness around
forehead.

Did he have any jerky movements

No

Was there any change in behaviour after the injury?

No

Was he not moving any of his limbs? ( focal neurological

deficit?)
R/o NAI Are you the biological mother? Is his father the
biological father ? Is he is living with them? Who else is at home ?
Anyone else looks after the child ?
Any past history of injuries?
No

Management
Mrs Since your child had injury to his head we need to keep him in the
hospital and do CT scan of his head to check any serious injuries. If at all
there is any bleeding or any other injury we will treat him appropriately. If
the CT scan is normal and he is fine then we will discharge him. Is that OK?
Mother: I cant leave the the child in the hospital
Dr : Why
Mother: I have other children at home
Dr: It is important to keep your child in the hospital. If you take him home
and if there is bleeding inside the head it can be too late to bring him back to
the hospital. Is there anyone else who can look after your other children?
Mother: OK. I will arrange.

[If there is swelling on head or if there is history of floppiness or limp Admit

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2. DELAYED WALKING

Most children are able to walk alone by 11 to 15 months but the rate of
development is very variable. Some children will fall outside the expected range
TASK

Q. Mother has brought her 2 year old ( 24 months) child to the

paediatric department. She is concerned about child as he is not able
to walk. Take history and give D/Ds to examiner.

and yet still walk normally in the end. Walking is considered to be delayed if it has
not been achieved by 18 months.

Introduce yourself.
What brings you to the hospital?

Could you tell me more about it?

Ask about other milestone to verify from global developmental delay
or gross motor developmental delay.
1) Smiling 3 months
2) Neck holding 4 months
3) Sitting 6 months
4) Crawling 9 months
5) Standing alone 12 months
Ask about comparisons to other same age group child/ children.
Compare with other child or any other family members.
Never walked?
Is he/she trying? Did you try to make him or her walk?
Do you see any improvement?
Any other problem?
Weight? Height?Any problem with the weight or height in
comparison to similar age children? BIRD, milestones.

Differential Diagnosis

TIMM
PC2
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T Trauma-head injury At any point did she/he have any

I Infection - septic arthritis,
Meningitis, encephalitis, CMV
child
M Muscular dystrophy
Duchene muscular dystrophy
M Malnutrition
head injury?
did she/he have any infection of
in lower limb joints
Any infection of the brain or
meningitis?
Had any maternal infection during
pregnancy?
Gowers signthe child tries to
support his/her legs with his hands
while standing.
( standing up with the support of
furniture is not Gowers sign]
How is the diet of the child?

P Poliomyelitis Vaccines up to date? Travel to

endemic countries-take travel
history
C Cerebral palsy How was the birth? Hypoxic
labour? Muscle weakness or
stiffness? Involuntary movements?
Coordination problem?
C Constitutional delay/familial Family history (Take history from
mothers side and fathers side
anyone from your family or childs
fathers family had similar
problems?)
This is diagnosis of exclusion
All other milestones normal except
walking ?

P2-P7MAFTOSA
It is worth noting that obesity and developmental dysplasia of the hip are
not causes of delayed walking
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Govers sign in Duchene

Muscular Dystrophy

Milestones
3 months: can hold head at 90. Start smiling.
6 months: no head lag when pulled to sit. Can sit with support.
When lying face down, can lift up on forearms.
9 months: gets into sitting position. Sits unsupported and can
pivot. Crawls. (Age of crawling varies widely, and some infants
never crawl.)
10 months : pulls to standing and stands holding on.
12 months : stands and walks with one hand held. May stand
alone briefly. May walk alone.
18 months: walks well. Climbs stairs holding rail. Runs. Seats self
in chair.
2 Years : goes up and down stairs alone. Two feet per step. Kicks a
ball.

Diagnosis: Constitutional delay (all history negative)

[some time fathers side history not available because father has gone outside the
country for long time even then the diagnosis is Constitutional delay]

3. Vaginal Bleed or discharge in child

Task : 6 years old child has been brought to the hospital by her mother for
vaginal bleeding/ discharge. Take history and give D/Ds to examiner.

Introduce yourself. What brings you to the hospital?

Could you tell me more about it?

Colour? Amount? Smell? Clots? Bleeding? Itching?

Did you have a look at her private part? [any swelling/redness/foreign body]
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How did it start?

Since when?
How much?

Is it getting worse?
Anything makes it worse? Soap/irritants

Anything makes it better? Creams/washing

Any other problem?
Is it first time?
Ask all the cardinal symptoms of GU system[pain on passing
urine/fever/lump/ulcer]BIRD

B- Differential Diagnosis
VAGINA
B Bleeding D/Ds Bleeding disorder? Bleeding from anywhere else? FH
of bleeding disorder?
V Vulvo-vaginitis Fever? Itchy? Fish smell? Redness?

A Alien Did you have a look at her private part? By any

[Foreign chance small toy/tissue or any other small objects
body] got stuck?
G Genital Thrush Ask about DM, steroids, Any antibiotics? (all of these
can reduce body immunity) hygiene-toilet trained?
I Irritants Soap, shampoo or any other cosmetics
N NAI/ sexual Who looks after? Any change in behaviour?
abuse
A Accidental Sports, horse riding
injury/ Trauma

P2-P7MAFTOSA
Findings Child has white discharge and it is itchy associated with
bleeding
Diagnosis Vaginal Thrush

4. PR BLEED IN A CHILD
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TASK : Mother brought her 11 month old child to the hospital.

Mother has noticed some PR bleeding. Take history and give
D/D to the examiner and give reasons.

Introduce yourself.
What brings you to the hospital?

Could you tell me anything more about it?

What is the colour of blood? Loose Stool? Mucous? Smell? Cry? Cry when
you touch/press tummy? Any change in the tummy?
How did it start?

Since when?
How much blood? How often?

Is it getting worse?

Anything make it worse? Food

Any other problem? Cries a lot?
Is it first time?
Ask signs of anaemia
Ask about dehydration signs : Dry mouth,
Dry eyes ( no tears while crying, Passing less urine, Less active ( lethargic).

Differential Diagnosis
FAGOT-BINJ

P2-P7MAFTOSA

F Food allergy/milk protein Any change in milk?

allergy
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A Anal fissure Lumpy stool, cry while defecating,

G Gastroenteritis
O Obstruction/volvulus
T Trauma
B Bleeding dds
I Intussusceptions
N NAI
J Juvenile polyposis
did you have a look at the back
passage opening? Crack in anus?
Fever? Other siblings? Dehydration?
Drinking enough fluid?
Vomiting?
Constipation, vomiting fecal matter?
Got hurt by any chance?
Bleeding disorder?
Blood thinner?
Instrumentation /procedure
Red currant jelly stool? Pulling leg to
tummy? Lump in tummy?
Who looks after? Are you the
biological mother?
Family History?

If findings as below:
Child had bleeding from the back passage since yesterday mixed with loose
stool.
Diarrhoea was for 2 to 3 days.
Red currant jelly like stool
Mom felt tummy bloated
He is crying a lot and pulls up his legs towards the chest while crying

Diagnosis : - Intussusception
If findings as below:
Child has no vomiting but has mild temperature
His other brother has similar symptoms ( has diarrhoea)
Child is not as playful as before.

Diagnosis : Gastroenteritis
(because other siblings also has diarrhoea )
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5. VOMITING CHILD

Signs of dehydration
Dry or sticky mouth
Few or no tears when crying
Eyes that look sunken into the head
Soft spot (fontanelle) on top of babys head that looks sunken
Lack of urine or wet diapers for 6 to 8 hours in an infant ( or only a very
small amount of dark yellow urine)
Lack of urine for 12 hours is an older child (or only a very small amount
of dark yellow urine)
Dry, cool skin
Lethargy or irritability
Fatigue or dizziness in an older child

TASK: A 2 months old child has been brought with vomiting.

Take history and discuss
differential diagnosis with the
examiner
Introduce yourself.
What brings you to the hospital?
O Could you tell me more about it?
S About the vomit contents? Colour? Blood?
Character: projectile?
Timing: immediately or after 1-2 hours of food?
O How is it started?
D Since when?
I How many times in a day
P Is it getting worse?
A Anything makes it worse? Milk type
R Anything makes it better?
A Any other problems?
F Is it the first time?
c Ask signs of dehydration
Ask all the cardinal symptoms of GI system
Growth or weight gain? Activity?
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(Lethargy), playful?

Differential Diagnosis
PYLORIC STENOSIS
DUODENAL ATRESIA

PIG-OUD
P Pyloric After 1-2 hours of feeding, is vomiting projectile?
stenosis
I Intussusceptio Pulling leg, abdominal mass, blood in stool
ns
G Gastroenteriti Fever? Contacts? Food?
s
O Overfeeding Immediately after feeding, how much do you feed?
U UTI Fever, cry while passing urine, change in urine
colour or smell?
D Duodenal Since birth
atresia

Findings: child has fever and cries while passing urine.

Diagnosis: - UTI
IN OLDER CHILDREN:
TASK: A 4 year old Tommy has come vomiting. Take history from
mom discuss d/ds to examiner.
Head injury
Meningitis
URTI
Gastroenteritis
Intestinal obstruction
Diabetic ketoacidosis
Accidental poisoning
What else to consider in vomiting?

Assess level of dehydration

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Activity
Passing urine

6. CHRONIC
DIARRHEA/WEIGHT LOSS

TASK: A 3 year old child has come with a history of chronic diarrhea,
take history from mother and discuss D/Ds with examiner.
Differential diagnosis:
C Coeliac disease Diarrohea on consumption of bakery
products
C Cystic fibrosis Recurrent respiratory infection + Diarrohea
C Chronic infections Protozoa infections
L Long term medication Excessive laxatives
M Malabsorption Food and vegetable materials in stools

GRIPS
Could you tell me please that since how long has your child been having
loose poo?
How many times in a day he passes the loose poo?
Is there any blood in it?
Does he have fever? Or vomiting?
Did the loose poo start after your child was put on weaning diet?
Is the child on any medication?
Does the child have any breathing difficulty?
Did he have loose poo in the past?
Was everything fine at the time of birth and after birth?
Are you happy with childs development?
Has your child been feeding well? Is he playful or lethargic?
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Is there any person in the family who has loose poo?

7. Bruises in child

TASK: A 3 year old child, john has come with bruises since 48 hours,
take history from Mrs Smith and discuss the DDs with the examiner.
Differential Diagnosis
B Bleeding D/Ds Bleeding disorder, Blood thinner?
H Henoch-schonlein Rash on buttocks? Pain in joints? Tummy pain?
purpura
I Idiopathic Generally no symptoms, Rash, Bleeding from
Thrombocytopen nose, Past history of infection.
ic Purpura
T Trauma Did your child hurt himself?
L Leukaemia Lumps and bumps in body? Weight loss?
M Meningitis Fever? Severe headache? Shy away from light?
N NAI Biological parents? Who looks after?

Dr: hello I am doctor...., today I am here to talk to you regarding your childs
health/condition, and may I know what actually happened?
Mrs Smith: john has developed bruises (rushes) from the past 2 days.
Dr: I am sorry to hear that, may I know how it started?
Mrs Smith: I dont know how it started. Suddenly I noticed the
bruises.
Dr: Which part of the body?
Mrs Smith: All over his body
Dr: Did john hurt himself?
Mrs Smith: No.
Mrs Smith: Yes, john had a nose bleed one week back.
Dr: What did you do about that, how long did it go on?
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Mrs Smith: Took john to the GP, and he asked me to apply ice
packs on the nose.
Dr: Did john hurt himself at the time?
Mrs Smith: No.
Dr: Has this happened before?
Mrs Smith: No.
Dr: Did john have any fever?
Mrs Smith: Yes, that was about a month ago, My GP told that
was a viral infection.
Dr: How is the activity of john, do you find him active and playful?
Mrs Smith: He is active and playful.
Dr: Does he show any unusual behavior, does he seem to be
confused or scared?
Mrs Smith: No.
Dr: Are you the biological mother?
Mrs smith: Yes
Dr: Do you notice any lumps or bumps in his body?
Mrs Smith: No.
Dr: Did he bleed from anywhere else, like wee or poo?
Mrs Smith: No.
Dr: Thank you.

Diagnosis: Idiopathic Thrombocytopenic Purpura.

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PAEDIATRICS COUNSELLING

COUNSELLING STATIONS
1. BBN- Fracture of femur and rupture of spleen
2. BBN Meningococcal septicaemia
3. Coeliac disease
4. Parent- demanding antibiotics
5. Irritable hip
6. Downs syndrome
7. Diabetes in child
8. MMR Vaccination
9. Peanut allergy
10. Asthma
11. Febrile convulsion

1. FRACTURE OF FEMUR (THIGH BONE) AND RUPTURE OF

SPLEEN
TASK: A 9 year old child Alan Jackson has been brought to the
hospital after having RTA. X-ray showed fracture of femur, and US
showed rupture of spleen. (Sometimes task says there was some
bruising on tummy). Child has received enough analgesia and he is
on I.V fluids. His BP IS 90/60, Pulse 140 and O2 saturation is 88%.
Talk to the childs dad.

Dr: hello, Mr, I am Dr. , one of the doctors in this department.

Mr Jackson: How is my child? (Dad may be standing near the door)
Dr: Are you Alan Jacksons dad?
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Mr Jackson: Yes.
Dr: Mr Jackson, I have come to talk to you about your son Alan. Can we sit
and have a chat (If the dad is standing).
Mr Jackson: Doctor, how is he?
Dr: How much do you know about your childs condition?
Dad: My child had road traffic accident. Please, tell me what is happening?
Dr: I am sorry to hear that. As you know, your child unfortunately had an
accident, but we have good team of doctors who are taking care of him.
We have done some investigations such as X-rays and US, and
unfortunately, X-ray showed that your child has fracture of his thigh bone
which is called femur bone.
Dad: Okay, so it is not that serious.
Dr: I am really sorry to say that it is not only fracture. For the fracture, we
have already given him pain killers and he is not in pain. We have also
called orthopedics team. But apart from this, we also did US, and it
showed rupture of spleen. (If task says bruising on tummy, we will do US
scan and it might show rupture of one of the internal organs, most likely
spleen) But, we have an expert team of surgeon, they will look inside his
tummy and if needed they might remove his spleen.
Dad: What is spleen?
Dr: The spleen is a fist sized organ under your left rib cage near your
stomach.
Dad: Is it important?
Dr: It is important because it filters the blood, creates new blood cells and
stores platelets. It is also a key part of the bodys immune system
Dad: How is he going to survive without spleen?
Dr: While the spleen performs a number of important functions, it is not
essential to life. But after removing spleen, he will be more likely to get
infection. So we will give him some vaccines and antibiotics. If you travel
abroad to topical countries; he must be given medication to protect him
against malaria. Do you have any other concerns?
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IMPORTANT QUESTIONS
How is my son? Is he okay? Is he in pain?
He is in critical condition. He is not in pain, we have given him
adequate pain killers.
Is he going to die?
It is difficult question to answer, as I told you his condition is critical
but we are giving him the best possible treatment.
Can I see him?
You can see him.

2. MENINGOCOCCEMIA
Meningococcemia is defined as dissemination of meningococci
(Neisseria meningitides) into the bloodstream.

TRANSMISSION
The bacteria that cause meningococcal disease are common and live
naturally at the back of the nose and throat. Human beings are the
only place where meningococcal bacteria can live.
At any one time, one in ten of us carries the bacteria for weeks or
months without ever knowing that they are there, and for most of us
this is harmless because, fortunately, most of us have natural
resistance.
They are passed from person to person through prolonged
close contact: coughing, sneezing, breathing each others
breath or by kissing someone who is carrying the germ.
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The bacteria are so fragile that they cannot survive for more than a
few moments outside the human body. For this reason, they are not
very contagious; they cannot be carried on things like cups, toys,
furniture or clothing.
TASK: 5 year old boy, Andrew, has got meningococcal septicemia.
Talk to his mother (Mrs Hamilton) and address her concerns?

GRIPS
Hello, Mr. ., I am Dr. ., one of the doctors in the pediatric department.
Dr: How much do you know about Andrews condition? I am here to
talk to you about his condition. I am afraid that I dont have good news.
Do you want anyone else of your family members to be with you?
We have done some tests and we have found out that your child has a
condition called meningococcal septicemia
Do you know anything about it?
In this condition certain bugs called meningococcus bugs have been spread
in blood. We have started certain medications called antibiotics.
Mrs Hamilton: will my child be fine?
Dr: unfortunately he is in a very critical condition. We are giving him the best
possible management.
Mrs Hamilton: can I see Andrew? And can I hold him in my arms?
Dr: I am afraid it is not possible because we have kept him in room called
isolation room. But you can see your child from the glass window of the
room.
Mrs Hamilton: but doctor, I want to touch my baby?
Dr: I understand your feeling, but it is not possible at the moment because
this infection can spread.
I need to ask you something, Mrs Hamilton. Are they any other people,
living in the same house?
We need to give some medication to prevent the same condition.
Mrs Hamilton: Will my child have any long term complication because of
this illness?
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Dr: After recovery Andrew may develop difficulty in hearing. But we will
follow up your child, and if required, we can arrange hearing test as well.
Mrs Hamilton: Will Andrew die doctor?
Dr: It is very difficult to say anything at the moment. We have a very good
team of doctors looking after him. We are giving the best possible
management.
IMPORTANT QUESTIONS
How did he get it?
Will my child be fine?
Can I see him now?
I want to hug him?
Is he going to die?
Is there long term complications?
Will he become deaf?
What can you do?
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3. COELIAC DISEASE

Coeliac disease is a common digestive condition where a person has an

adverse reaction to gluten.
Definition and Causes:
Coeliac disease is an autoimmune condition. This is where the
immune system the body's defence against infection mistakenly
attacks healthy tissue.
Coeliac disease isn't an allergy or an intolerance to gluten.
In cases of coeliac disease, the immune system mistakes substances
found inside gluten as a threat to the body and attacks them.
This damages the surface of the small bowel (intestines), disrupting
the body's ability to absorb nutrients from food.
Exactly what causes the immune system to act in this way is still not
entirely clear, although a combination of a person's genetic make-up and
the environment appear to play a part.

GLUTEN
Gluten is a protein found in three types of cereal:
Wheat
Barley
Rye
Gluten is found in any food that contains the above cereals, including:
Pasta
Cakes
Breakfast cereals
Most types of bread
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On the gluten-free diet you can eat any naturally gluten-free foods, such
as:
Meat
Fish
Fruit and vegetables
Rice
Potatoes
Lentils

SYMPTOMS
Eating foods containing gluten can trigger a range of symptoms, such as:
Diarrhea, which may smell particularly unpleasant
Bloating and flatulence (passing wind)
Abdominal pain
Weight loss
Feeling tired all the time as a result of malnutrition (not getting enough
nutrients from food)
Children not growing at the expected rate
Symptoms can range from mild to severe.

DIAGNOSIS
Stages in diagnosis
1. If you have symptoms of coeliac disease, you should first discuss your
concerns with your GP. Do not remove gluten from your diet at this
stage.

2. Your GP will take a simple blood test to check for antibodies. These
can indicate coeliac
 25

Disease. However, its possible to have a negative test and yet still
have coeliac disease. Do not remove gluten from your diet at this
stage.

3. Your GP will then refer you, if the blood test is positive or there is
clinical suspicion of
Coeliac disease, to a gut specialist a gastroenterologist for a gut
biopsy. Do not remove gluten from your diet until the biopsy has been
done.
(Guidelines published by the British Society of Pediatric Gastroenterology,
Herpetology and Nutrition (BSPGHAN) and Coeliac UK recommend that
children who have symptoms of coeliac disease and a blood test that
shows high levels of antibodies may not need to have a biopsy to be
diagnosed with the disease. Instead, a second antibody blood test
followed by a genetic test can be used to confirm the diagnosis.)

TREATMENT:
Coeliac disease is usually treated by simply excluding foods that contain
gluten from your diet.

This prevents damage to the lining of your intestines (gut) and the associated
symptoms, such as diarrhoea and stomach pain.
If you have coeliac disease, you must give up all sources of gluten for life
because eating foods that contain it will cause your symptoms to return, as
well as long-term damage to your health.
This may sound daunting, but your GP can give you help and advice about
ways to manage your diet.
Even if you only consume a small amount of gluten, such as a
spoonful of pasta, you may have very unpleasant intestinal
symptoms. If you keep consuming gluten regularly, you will also be
at greater risk of osteoporosis and cancer in later life.
Your symptoms should improve considerably within weeks of starting a
gluten-free diet.
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However, it may take up two years for your digestive system to heal
completely. You will also need to return to your GP for regular check-ups.

Other treatment
As well as eliminating foods that contain gluten from your diet, a number of other
treatments are available for coeliac disease. These are described below.

Vaccinations
In some people, coeliac disease can cause the spleen to work less effectively,
making you more vulnerable to infection.
You may therefore need to have extra vaccinations, including:

flu (influenza) jab

Haemophilus influenza type b (Hib) and meningitis C. Which protects against
sepsis (blood poisoning), pneumonia and meningitis (an infection of the lining
of the brain)
Pneumococcal vaccine, which protects against infections caused by the
Streptococcus pneumonia bacterium

However, if your spleen is unaffected by coeliac disease, these vaccinations are not
usually necessary.

Supplements
As well as cutting gluten out of your diet, your GP or dietician may also recommend
you take vitamin and minerals supplements, at least for the first six months after
your diagnosis.
This will ensure you get all the nutrients you need while your digestive system
repairs itself. Taking supplements can also help correct any deficiencies, such as
anaemia (a lack of iron in the blood).

Complications
Malabsorption (where your body does not fully absorb nutrients)
1. Iron deficiency anaemia
2. Vitamin B12 and folate deficiency anaemia
3. Osteoporosis- this causes your bones become brittle and week
Malnutrition can cause stunted growth and delayed development.
Lactose intolerance (Coeliac disease damages the part of the gut where
lactase is produced)
Cancer. (Some research has suggested having coeliac disease can increase
your risk of developing certain types of cancer, including bowel cancer and
lymphoma (cancer of the lymphatic system, which is part of the immune
system).
 27

TASK: 5 year David diagnosed with Coeliac disease and Mr. White,
father of the child, has some concerns, please talk to him?

COELIAC DISEASE
GRIPS
Hello, Mr. White, I am Dr. ., one of the Doctors in this department.
Dr: What do you know about your childs condition?
Mr. White: David has been unwell recently. He is having diarrohea and pain in
tummy. His stools are pale, bulky with unpleasant smell. So I brought David to the
hospital. Your consultant did some investigations.
Dr: You are right. The results of investigations are with me. And it shows that David
has Coeliac Disease. Do you know anything about it?
Mr. White: No.
Dr: Coeliac disease is a lifelong autoimmune disease. It is caused by the immune
system (the bodys defense against infection) reacting to gluten. (A protein found in
wheat, barley and rye) When someone with coeliac disease eats gluten, their
immune system reacts by damaging the lining of the small intestine.
Mr. White: What are you going to do for David?
Dr: Once diagnosed, the only treatment for coeliac disease is a gluten-free diet for
life long. About gluten free diet. I will refer you to the dietician who can help you on
this. And it is freely available in the market. As well as cutting gluten out of your
diet, your GP or dietician may also recommend you take vitamin and mineral
supplements. In some people, coeliac disease can cause the spleen to work less
effectively, making you more vulnerable to infection. Your child may therefore need
to have extra vaccinations.
Mr. White: I am poor, I cannot afford these kind of food.
Dr: I can understand your concern. But we will give you prescription. And they are
free.
Mr. White: How about my other kid?
Dr: We have screening programme. And it is recommended for first-degree relatives
(parents, brothers, sisters and children) of the people with coeliac disease. We can
do this test for your other kid.
Mr. White: I have got Ulcerative Colitis, Is it responsible for my childs disease?
Dr: Though there is some family link between these 2 two conditions, it is does not
mean that your condition has passed on from you to your child.
 28

Mr. White: Is there any complications?

Dr: Yes. But if your child follows only gluten free diet, your child should not have any
complications. The possible complications are malabsorption which can lead to
anaemia and osteoporosis (thinning of bones) and malnutritions which can cause
stunned growth and delayed development. Very rarely it can cause bowel cancer
and lymphoma (cancer of lymphatic system which is part of immune system).
Mr. White: Is it dangerous, If David eats a small amount of gluten?
Dr: If David eats a small amount though there is no severe reaction like allergic
reaction which can be life threatening, your child may have very unpleasant
intestinal symptoms.

4. PATIENT- DEMANDING ANTIBIOTICS

Antibiotics are a group of medicines that are used to treat infections caused
by bacteria and certain parasites. They are sometimes called antibacterial.

SYMPTOMS OF AN EAR INFECTION

Earache is common
Dulled hearing
High temperature
Nausea or vomit
Young babies [hot. Irritable, crying baby]
Sometimes the eardrum bursts (perforates).

Q.

WHY NO AB
Side Effects- They can kill normal flora and cause diarrhoea [AB has
side effects so no need to take unnecessarily[
 29

No need [ it is not bacterial infection ]

Drug resistance [ if your child get bacterial infection in future, this AB
may not work as bugs get used to this and we call it drug resistance
which can be very dangerous sometimes ]
Viral infection [ as I listened to you it seem like a viral infection so AB
doesnt work ]

TASK: A 5 years old Micheal has been brought to the hospital by father,
Mr. Black, with fever. He thinks that it is an ear infection, because in
the past child had Antibiotics for ear infection. Talk to him and address
his concerns.
Sometimes in the task, it is mentioned that child does not need AB, do
not take history of Ear infection.

Take history- take presenting complain, ask why he thinks it is ear

infection and say ear infection may have these symptoms [ different ]
Reassure- [ it is not bacterial, we can see him again if it worse, AB will
not help ]
Give warning signs- if generally unwell or not eating or ear discharge
please come
Give non AB medication [paracetamol] and advice on rest

GRIPS
Hello, Mr. Black, I am Dr. ., one of the Doctors in this department.
Dr: May I know what your concerns are?
Mr. Black: Micheal has fever since past 4 days and I think that he has ear infection,
so please give antibiotics to my son, so that he can be well soon.
Dr: What makes you think that this is an ear infection?
Mr. Black: He had fever about 4 months back and he was diagnosed to have ear
infection, so I have feeling that it is again an ear infection.
Dr: Could you please answer my few questions?
Mr. Black: Yes, sure.
Dr: Have you checked temperature of your child?
Mr. Black: Yes it is not high grade fever.
Dr: Does he complain of any discharge from the ear?
Mr. Black: No,
Dr: Does he have cough and is he sneezing
Mr. Black: Yes
Dr: from what you have told me, my assessment is that your child has an upper
respiratory tract infection (common cold), not an ear infection. And common cold is
 30

caused by a bug called virus so no antibiotic is required for this. AB are used to treat
only bacterial infections. And even if we give antibiotics without any reason now,
this AB might not work in future because of drug resistance.
Mr. Black: Will you prescribe any medication?
Dr: This condition subsides on its own after few days. There is no specific treatment
required. However, we will give him paracetamolfor fever. Give him plenty of water
to drink. Do not worry; your child will be well soon. If generally unwell or not eating
or ear discharge, please bring him back to us. Do you have any other concern?

5. IRRITABLE HIP

This is inflammation (swelling) of the hip joint. It is also known as acute transient
synovitis. It is the most common identifiable cause of hip pain in young children.

Cause
The exact cause is unknown, although the problem often follows a viral infection or
an episode of trauma.

Symptoms
Your child will be complain of pain in their hip or knee. They will find moving and
putting weight on the hip uncomfortable. They may also limp.

Management and follow up

No investigations are required in the first instance (if unsure seek senior
review)
No imaging on initial presentation
Bring back to Emergency Department Review Clinic in 7-10 days.
Advise regular analgesia and rest while symptomatic.
Tell parents to return sooner if child becomes febrile, unwell or develops
worsening hip pain.

Treatment
Irritable hip is a short-lived condition that often gets better without any
serious intervention.
Sometimes a child may need a short stay in hospital to rest the hip joint.
This could be by bed rest alone or simple skin traction. Bed rest is sometimes
needed for a few days.
 31

Simple pain relief such as paracetamol and ibuprofen helps recovery.

Allow your child to gradually return to their usual activities Swimming is an
excellent way to reintroduce mobility in the hip joint. Your child will be seen
for an outpatient appointment within six weeks.

A small number of children have a further episode of hip pain. If this

happens your GP will need to see your child and they may need to come
back into hospital.
Irritable hip can affect boys and girls of any age. However, the condition
affects twice as many boys than girls. Its most often seen in boys
between the ages of four and 10
Most cases dont require specific treatment because the pain usually passes within
two weeks. A small number of children with irritable hip go on to have further
episodes. However, these episodes usually become less frequent and eventually
stop when the child is older.

Painkillers
The non-steroidal anti-inflammatory drug (NSAID) ibuprofen is the painkiller usually
recommended to treat hip pain.

Bed Rest
Bed rest is recommended until the symptoms of pain resolve, which usually takes
between seven and 10 days.

Recovery
It usually takes a couple of weeks to recover from irritable hip, although GP may
recommend that your child does not play sport or take part in any strenuous
activities for at least another two weeks following treatment. This is to reduce the
chances irritable hip returning.
Swimming is a good way to strengthen the joint and get it moving again.

Example approach
TASK: A 4 year old George has come with difficulty in walking and pain in
hip joint, you did all the necessary investigations, nothing abnormal was
found; please talk to the mother (Mrs Johnson) of the child.
Greet, introduce, check the identity, explain the purpose of your visit. Assess
knowledge. Disclose the diagnosis; you know your son had all these
symptoms like pain and we did necessary investigations, fortunately, nothing
abnormal. The symptoms he has could be due to a condition called irritable Hip.
Mrs Johnson: What is this?
Dr: Irritable hip is a self-limiting condition in which there is an inflammation of the
inner lining (the synovium) of the capsule of the hip joint. Irritable hip is a short-
lived condition that often gets better without any serious intervention. We will give
your child some pain killer. And he should take rest at least for two weeks.
 32

Mrs. Johnson: Is it serious?

Dr: Its is not a condition which will be there for a long time, neither will it cause any
permanent disability.
Mrs. Johnson: What if he has to go to Loo?
Dr: Yes, he can go to Loo with someone assisting him.
Mrs. Johnson: when can he go back to school?
Dr: He can go back to school after 2 weeks.
Mrs. Johnson: When can he start playing football? He is fond of it.
Dr: Yes, he can play football after a month. Swimming is a good way to strengthen
the joint and get it moving joint.
Mrs. Johnson: it will be very difficult to make him rest for two weeks.
Dr: I know but you can buy him some DVDs and you can also buy him some video
games.
Mrs. Johnson: Would you like to call him after some time?
Dr: Yes, Your child will be seen for an outpatient appointment within six weeks.
Mrs. Johnson: Can this happen again?
Dr: A small number of children can have further episodes. However, these episodes
usually become less frequent and eventually stop when the child is older.

Also, give warning sign like when to come to hospital [fever], unwell or
worsening hip pain.
Ask mother if she can manage at home? If not, ask for reason, try to address
by giving solution. If mother is not happy, tell that I will talk to my senior
about your concerns [admission]
 33

6. DOWN SYNDROME COUNSELING

Downs syndrome, also known as Down syndrome, is a genetic condition that

typically causes some level of learning disability and a characteristic range of
physical features. Down syndrome, itself, does not have a cure. But treatment is
available for many of the other symptoms conditions that can accompany the
diagnosis.
Downs syndrome is a genetic condition that occurs as a result of an extra
chromosome (chromosome 21).
Most babies born with Downs syndrome are diagnosed after birth and are likely to
have:

Reduced muscle tone leading to floppiness (hypotonia)

Eyes that slant upwards and outwards
Their palm may have only one crease across it (palmer crease)
A below average weight and length at birth
A big space between the first and second toe (sandal gap)

All children with Downs syndrome have some degree of learning disability and
delayed development, but this varies widely between individual children.
Since theres no cure for Down syndrome, treatments are based on a childs unique
behavioral, educational, and medical therapies for your child.
Surgery may be used to treat: congenital heart problems or upper neck
abnormalities
Downs syndrome is the most common and best known chromosome problem in
humans. About 1 in 1,000 babies born in the UK have Downs syndrome. It is
thought that around 60,000 people with Downs syndrome are living in the UK.

TASK: Child has been diagnosed to have Downs syndrome. Talk to mother.
 34

Hello, Mrs. /Miss. ., I am Dr. ., one of the Doctors in this department.

Dr: We did some test for your child and we came to know that your child has
Downs syndrome. Mother: What is that?
Dr: Downs syndrome is a genetic condition that occurs as a result of an extra
chromosome (chromosome 21). Chromosomes are found in the centre (nucleus) of a
cell. They carry genetic information in the form of genes.
Mother: What will happen to my baby?
Dr: Your child will have some level of learning disability and some physical features
specific to this condition. While some children with Downs syndrome may need to
go to a school that caters for their special needs, many are able to go to a
mainstream school. Likewise, as they get older, many people with Downs syndrome
are able to cope with some kind of job. People with Downs syndrome are also able
to make friends and have relationships.
Mother: What do you mean by learning disability?
Dr: It means that they can have difficulty in

Understanding new or complex information

Learning new skills
Coping independently

We will also provide the phone Numbers and address of Downs syndrome society
which gives help and support to the parents of the babies with Down syndrome.
Mother: Will my child have any problem other than learning disability?
Dr: Your child might have some other heart problem but his heart will be carefully
assessed to detect and treat any problems as soon as possible. He might have some
hearing vision problems but we will refer him to specialist doctors if it happens. We
will follow him up regularly.
Mother: How long will my child live?
Dr: The life span of these children is not predicted. Life expectancy is improving
due to advancements in medical treatments.
Mother: What other care my baby needs?
Dr: Some home adaptation may be needed in the house to protect the child from
house hold accidents and especially for those who are overactive, like arranging
locks, provision of safe space in home, toughened glass in the bed room. This can
be done be special services.

Important Questions.
 35

What will happen to my baby?

How long will child live?
What you can do for our child?
Is there any cure?
Do we have to any special arrangement for baby?
How is going to be like?
What annual checkup you do? [heart problem/ENT/EYE/DM/thyroid]

7. DIABETES MELLITUS

Q: 5 year old child is diagnosed to have IDDM, talk to mum and

address her concerns.
 36

Dr: Hello. Are you Mrs. /Miss . I am doctor.One of the doctors in this department
(Paeds). Can you please tell me, what do you know about your child condition?
Mother: My child has been drinking a lot water recently. His appetite is also
increased. And he is going to loo frequently. Sometimes he feels drowsy.
Dr: Yes, You are right. And we did some investigations and result that your child has
a condition called Diabetes Mellitus. In this condition, a protein called insulin (Insulin
is a hormone. It works as chemical messenger that helps your body use the glucose
in your blood to give you energy) is not formed by the body cells, so the level of
blood sugar rises, due to which child goes to loo and passes water very frequently.
Also he feels very thirsty and hungry most of the time. We will put him on a
medication called as insulin.

Make sure that whenever you take you little boy outside, you always keep
something to eat or sugary drink with you.
Make sure that is school nurse and GP are also informed about the condition
of your child, you should always address the concerns of patient.

Q. 5 year old Tommy has come with lethargy.

Take history from mother and discuss the diagnosis with the
examiner.
( diagnosis is Diabetes Mellitus in children/ DKA)

Hello, Mrs. / Miss. ., I am Dr. ., one of the Doctors in this department.

I have come to talk to you about your child condition.
Dr: Can you please tell me, what brought you to the hospital?
Mother: Tommy has been feeling Lethargic for last few days. He has flu like
symptoms and runny nose in the past few days. Apart from this, he is thirsty most
of the time, and going to the loo frequently and eating most of the time.
Dr: Is there any vomiting? Is there any tummy pain?
Mother: Yes/No
Dr: Does he have a fruity smell in his breath?
Mother: Yes/No
Dr: Did he become unconscious at any time?
Mother: Yes/No
Dr: Was he fine previously?
Mother: Yes/No
Dr: Do you have any one in the family with diabetes?
Mother: His father has DM
 37

Dr: Is there anything that you want to tell me about?

Ask BIRD questions.
Mom, thank you. You have been very cooperative.
I need to talk to my examiner, may I do so?

MMR

The MMR vaccine is an injection that prevents you from catching measles, mumps
and rubella.
Its usually given during childhood as part of the routine vaccination schedule.
However, you can have the MMR vaccine at any age.

MEASLES is a very contagious infection and may cause complications such as

diarrahea, ear infections, pneumonia.

MUMPS is also a contagious infection. It may cause complications such as

meningitis and deafness. In boys, it may damage the testicles and in girls, it may
cause swelling of the ovaries.

RUBELLA (German measles) is usually a mid-infection; however, it can be harmful

to pregnant women. It may cause deafness, brain and heart damage, and eye
defect in unborn babies.

OTHER FACTS
The MMR vaccine consists of a combination of three individual vaccine
against measles, mumps and rubella in a single shot. The three vaccine
combined in MMR are not available as single vaccine on the NHS.
This is because the NHS does not recommend single measles, mumps or
rubella vaccines as there is no evidence to support their use or to suggest
that they are safer than MMR.
World Health organization support the uase MMR, and none support the use
of single vaccines.
 38

Be aware, though, that MMR is a live single vaccine, they will have to wait at
least four weeks until they can have the MMR vaccines.
Child may develops a mild symptoms of measles [post-vaccination
symptoms] after receiving their MMR vaccine, post-vaccination symptoms are
not infectious, so your child will not pass anything on to non-vaccinated with
MMR vaccine at the scheduled times-between 12 and 13 months of age and
again at 3 years 4 months.

WHY MMR GIVEN AFTER 1 YEAR OLD?

Newborn babies are already protected against several diseases such as
measles, mumps and rubella, because antibodies have passed into them
from their mothers via the placenta. This is called passive immunity.
Passive immunity only lasts for a few weeks or months, which is why the
MMR jab is given to childrens just after their first birthday.

TASK: A child is 5 months old, father has come to you after reading an
article which was published few years ago about MMR causes autism. He
is worried about his child. Talk to him and address his concerns.

Greet, introduce yourself, check identity of patient, ask patient about purpose of
visit.

Mother: I have read an article which was published 5 year back according to this
article, MMR vaccination causes autism.
Dr: Yes, there was an article which related autism to MMR vaccine but

The article published was proven to be wrong and publishers withdrawn

The person who originally stated about autism found to have misconducts.
There are many study done after that and all shows it is safe.
The million peoples taking this vaccine around the world.

MMR is given around 15 months of age and this is the same age around which
autism is diagnosed so there was a fake impression that autism is caused by MMR.
MMR vaccine can cause mild reaction like indurations and pain at the site of
injection and fever some time.

(Screening
Take a short history for contraindication:
 39

Is your child currently unwell?

Do they have any long term illnesses?
Have they ever had any immunizations before?
Were there any problems afterwards?
Are they on any regular medications?
Any allergies?

Explanation; by giving your child a vaccination it helps to lower the chances of

them contracting a serious illness. It also helps to prevent other children
from contracting the disease as less people will have the disease to pass on.

What to expect during the vaccination

The vaccination will be given as an injection into the muscles of thigh or
upper arm.
EMLA cream is a local anesthetic cream that can be applied to the skin to
suppress the pain of injections.
After, may be Redness and Swelling around the site of the injection or fever.
Reassure: this is very common [calpol]
Contact a doctor if: very high temperature, fits, high pitched cry, huge
swelling anywhere on the body but especially around the site of injection or
lips and mouth)

WHY MMR IS SAFE?

Appreciate concerns and knowledge

Measles, rubella of mumps infection does not cause this autism and colitis so
its weaker part impossible to cause [Offer latest articles].
 40

9. PEANUT ALLERGY

It is an allergy to peanut protein (not oil) that causes the reaction after eating or
touching the nut. Peanut allergy is common, affecting 1/100 people, or about a
million people in the UK.

SYMPTOMS:
Mild- moderate symptoms
Swelling of face
Skin rash (hives, urticarial)
Tingling mouth
Runny /itchy nose, sneezing
Stomach cramps, vomiting

Severe symptoms (Anaphylaxis)

Swelling of tongue and/or throat
Difficulty in swallowing or speaking
Vocal changes (hoarse voice)
Wheeze or persistent cough
Difficult or noisy breathing
Dizziness / loss of consciousness

Peanuts
 41

Peanuts is a member of the legume (bean) family. Other members of this family
includes soya beans, lentils and garden peas. It is also referred to as ground nuts.

Tree nuts
Tree nuts are actually a type of seed from plants, such as almonds, cashews or
Brazil nuts. Many people allergic to sesame are also allergic to peanuts and tree
nuts.

Peanut oil
The allergic component of the peanut is protein, which the body identifies as an
alien substance and thus overreacts to. On the other hand, oils contain fats rather
than proteins.
Researchers have concluded that refined peanut oil will not cause allergic reaction
for the majority of peanuts allergic individuals.
Boiling the nuts will not remove the allergen, so do not try boiled nut.
Other siblings also, may have the allergy to same allergen, so it is better
to have an appointment with allergy clinic before trying on siblings. It is
not inherited condition, but there may be some genetical predisposition.

Diagnose
In any case where an allergic reaction to a nut is suspected, the patient should be
referred by their general practitioner to an NHS allergy clinic for testing to confirm
the diagnosis.
Testing can be done by skin prick tests or blood tests.

Skin prick test for allergens

A skin prick test is usually the first test to be done when looking for an allergen. Its
quick, painless and safe, and you get the results within about 20 minutes. Your skin
is pricked with a tiny amount of the suspected allergen to see if theres a reaction. If
there us, the skin around the prick will very quickly become itchy and red wheal
(swollen mark) will appear.

Blood test for allergens

The blood test used to test for allergens is called a specific IgE test (formally known
as the RAST test). Its used to measure the number of IgE antibodies in your blood
that have been produced by your immune system in response to a suspected
allergen.
 42

Food challenge for food allergies

A food challenge, also called an oral challenge, is the most accurate way to
diagnose a food allergy. During the test, youre given the food to which you think
you are allergic in gradually increasing amounts to see how you react. Only one
food can be tested at each appointment.

MANAGEMENT
Many people with an allergy to peanut or tree nut will be prescribed an Adrenaline
Auto-Injector Device (Epipen)

How to use EpiPen*

Pull off the blue safety release cap at the end.
Hold the pen firmly and swing your arm from about 10 cm (4 inches) away,
pushing the orange tip against your outer thigh.
The adrenaline will be released automatically into your thigh muscle.
Hold the pen in place for 10 seconds.
As soon as you release pressure, a protective cover will extend over the
needle tip.
Massage the area for 10 seconds.
Make sure you tell paramedics that you have used an adrenaline pen.

This medication any cause some side effects which are not very serious to worry
about. (Vomiting, sweating dizziness, pale skin, headache, shaking hands)

ANAPHYLAXIS AND SEVERE ALLERGIC REACTIONS

Anaphylaxis is a severe allergic reaction. Anaphylaxis is a medical emergency, and
requires immediate treatment. Once adrenaline has been given, antihistamines can
be given as well, but the adrenaline should be given first.
All patients receiving emergency adrenaline should immediately be transported to
hospital. Do not wait to see if the symptoms up-call ambulance immediately and
state that you are having anaphylaxis.
Current recommendations from UK Resuscitation Council are for patients to be
observed in hospital for at least 6 hours after anaphylaxis.
 43

TASK: A 5 year old child brought to A and E with rash all over
body, itching and breathlessness immediately after eating nuts
in restaurant. Child is being treated. Nurse had already explained
about how to use the epi pen. Talk to the mother old child and
address her concerns.
Dr: I am doctor one of the doctors in the paeds department. Are you the mother
of child?
Mother: yes, but how is my child now?
Dr: Do not worry, my colleagues are taking care of him, could you please tell me,
what recently happened?
Mother: yes, we went to eat in restaurant, my child was having food containing
some nuts. Suddenly, he started to complain of itching and rash all over his body
and he also developed shortness of breath. We rushed to A and E.
Dr: well, whatever history you have given me so far indicates that most probably
your child has developed allergy to some proteins in the peanuts. Peanuts allergy is
the result of your bodys immune system overreacting to a harmless substances,
such as food.
Mother: what are you going to do now?
Dr: please make sure that he doesnt eat peanuts or any other nuts (anything that
contains peanuts such as cake and bakery products). You may be referred to a
dietician to help with this.
Advice may include:

Always check food labels, even for products you know, as ingredients can
change.
When eating out, ask staff which foods contain nuts.
If your child has a nut allergy then make sure that anyone else who looks
after your child knows about it and knows what to do if a reaction starts. For
example, nursey staff, babysitters, teachers and other parents.
Your child should wear a medical emergency identification bracelet or
equivalent that tells other people about your allergy.
Mother: but, what if my child accidently eats peanuts and starts having similar
symptoms, what shall I do?
Dr: it is vitally important that if an allergic reaction starts you get treatment as
quickly as possible. The sooner your reaction is treated, the better.
Management depends on severity of symptoms.

You can give antihistamine tablets to your child if symptoms are mild (like
rash, swelling of face, tummy pain).
But, if symptoms are severe like breathlessness, you can use Epipen injection
straightaway and call an ambulance.
 44

Mother: what about my other kid?

Dr: The chances of your other kid getting this condition is higher as compared to
other kids.
Mother: what can you do for him?
Dr: we can refer you to the Allergy Clinic. They can offer him some tests depending
on his symptoms. These tests includes Skin Prick Test, Blood Test (specific IgE test)
and food challenge test.
Mother: I wash the pea nuts or boil it and then give it?
Dr: Unfortunately this may remain for the rest of this life.
 45

10. ASTHMA

Asthma is a disease affecting the airways that carry air to and from your
lungs. People who suffer from this chronic condition (long-lasting or
recurrent) are said to be asthmatic.
The inside walls of an asthmatics airways are swollen or inflamed. As inflammation
causes the airways to become narrow, less air can pass through them, both to and
from lungs. Symptoms of the narrowing includes wheezing, chest tightness,
breathing problems, and coughing.
Asthmatics usually experience these symptoms most frequently during the night
and the early morning.

RISK FACTORS FOR ASTHMA

Family history of atopic disease (asthma, eczema, allergic rhinitis, or allergic
conjunctions).
Co-existence of atopic disease.
Parental smoking, including perinatal exposure to tobacco smoke.
Low birth weight (associated with intrauterine growth retardation).

COMPLICATIONS
Respiratory complications: pneumonia, respiratory failure, and status
asthmaticus
 46

Growth and pubertal delay in children may be a direct result of chronic

disease.
Underperformance and time off school.

TRIGGER FACTORS

Allergence
Airborne irritants
Cold air
Exercise
Emotional factors, such as stress
Allergic rhinitis/sinusitis

DIAGNOSIS
Features that increase the probability of asthma in children include:

More than one of the following symptoms: wheeze, cough, difficulty

breathing, chest tightness.
Such symptoms particularly indicate asthma if they:

Are frequent and recurrent.

Are worse at night and in the early morning.
Occurs in response to, or are worse after, exercise or other triggers
Family history of asthma and/atopic disorder.
Widespread wheeze (bilateral, predominantly expiratory).

TREATMENT
There are two main types of asthma medicine which are equally important
but do different things.

Reliever inhalers are usually blue and you take them when you have
symptoms (like wheeze or caught). They work quickly by relaxing the
muscles surrounding the narrowed airways making it easier to breath.
Reliever inhalers are essential in treating asthma attacks.
Some relievers can temporarily increase your childs heartbeat, give
them mild muscles shakes or make your child a bit hyperactive but this
is usually when relievers are given in high doses or as a syrups. These
side effects generally wear off within a few minutes or hours at most.
Preventer inhalers usually come in brown, red or white. They work by
controlling the swelling and inflammation in the airways, stopping
them from being so sensitive and reducing the risk of severe attacks.
 47

They need to be taken every day, usually morning and evening, even
when you are feeling well. Preventers contain steroid medicine.
If your child uses preventer medicine there is a small risk of them
having a sore tongue or throat, hoarseness of the voice and a mouth
infection called thrush. To help prevent these side effects, ensure your
child rinses their mouth out and brushes their teeth after using their
preventer inhaler. Using a spacer will also help to reduce the possibility
of thrush.

STARTING ASTHMA TREATMENT

Explain that lifestyle changes and medication are meant to control
asthma symptoms and prevent an exacerbation.
Explain the difference between reliever and preventive therapy.
Provide education about asthma, such as how to monitor symptoms
and recognize an exacerbation.
A large volume spacer is recommended for the administration of
inhaled corticosteroids in all children younger than 16 years.

SELF-MANAGEMENT INFORMATION
Give all people with asthma self-management education and a
written plan.
At each review, repeat education and advice on: Taking medication
and avoiding known trigger factors.
Recognizing poor asthma control (worsening symptoms or peak
flow readings) and early signs of an exacerbation (sudden
persistent worsening symptoms).
Presenting for follow up annually or more frequently if symptoms
are not controlled.
Tailor self-management education and written action plans to the needs of
the individual.

ASTHMA IN CHILD

TASK: 5 years old child has been diagnosed with asthma,

talk to the mother.

Dr: as you know that little tommy came to us with difficulty in breathing.
After doing some tests, we have found out that he has a condition called
asthma.
Do you know about it?
 48

Mother: no, doctor. Can you please explain me?

Dr: Asthma is caused by inflammation of the small tubes, called bronchi,
which carry air in and out of the lungs.
Mother: what are you going to do for my child?

Dr: do not worry; we will give him certain medication to relive his
condition. There are two types of medication:

Reliever inhalers usually blue are taken to relieve asthma

symptoms quickly.
Some reliever can temporarily increase your childs heartbeat,
these side effects generally wear off within a few minutes or hours
at most.
Preventer inhalers usually brown, red or orange work over time
to reduce the amount of inflammation and sensitivity of the
airways, and reduce the chances of asthma attacks occurring. They
must be used regularly (typically twice or occasionally once daily).
If your child uses preventer medicine there is a small risk of them
having a sore tongue or throat, hoarseness of the voice and mouth
infection called thrush. To help prevent these side effects, ensure
your child rinses their mouth out and brushes their teeth after using
their preventer inhaler.
Our nurse will teach you how your child should take these inhalers. But there are
certain measures which need to be done.
Mother: yes, doctor.
Dr: if you have pets, please it is advisable that your child should not come in contact
with pets. Restrict pets to outdoor or to limited areas in the house certainly not in
the bedroom.

Wash cats and dogs regularly.

Keep your pets healthy and well-groomed (where appropriate)

Dr: do you smoke?

Mother: yes.
Dr: it is advised that you do not smoke in front of him or near him also, please make
sure that he is well protected with warm clothes, when he goes out.
You must carry his medications whenever you are travelling please inform the
school nurse and your GP about his conditions also we will provide a bracelet, which
your child should wear all the time.
We will keep him in follow up.
 49

In spite of these medications, if you feel that little tommy has difficulty in breathing,
please bring him back to us immediately.

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------------------------------------------------------------------------

11. FEBRILE CONVULSIONS

A febrile seizure is a convulsion that occurs in some children (aged 6 month to 5

years) with a high temperature (fever). The vast majority of febrile seizures are not
serious. Most occur with common illnesses such as ear infections and colds. Full
recovery with no permanent damage is usual. The main treatment is aimed at the
illness that caused the fever.
Symptoms of febrile seizures

The main symptom of a febrile seizure is a fit that occurs while a

child has a fever.

Febrile seizures often occurs during the first day of fever, which is defined as
a high temperature of 38C (100.4F) or above.
However, there appears to be no connection between the extent of your
childs fever and the start of a seizure. Seizures can occur even if your child
has mild fever.

Seeking medical advice

You should take your child to hospital or dial 999 for an ambulance if:

Your child is having a fit for the first time.

The seizure lasts longer than five minutes and shows no signs of stopping.
 50

You suspect the seizure is being caused by another serious illness, for
example meningitis.
Your child is having breathing difficulties.

If your child has previously had febrile seizures, its recommended that you
telephone your GP or call NHS 111 for advice.
You should also contact your GP or NHS 111 if your child shows signs and symptoms
of dehydration (a lack of fluid in the body). This includes:

A dry mouth
Sunken eyes
A lack of tears when crying
A sunken fontanelle the soft spot usually found at the top of a young childs
head.

MANAGING A FEVER
The reason to do this is not to treat the infection but to make the child more
comfortable. [to reduce the temperature]
It is important for your child to drink, small amounts of fluid little and often to
prevent them from getting dehydrated.
Give paracetamol and ibuprofen if your child is distressed or in pain, following
the instructions on the packet. Do not give paracetamol and ibuprofen at the
same time.
Do not tepid sponge your child if they have a fever. This causes them to
shiver which can make the temperature rise.
Do not use a fan directly on the child, use to cool the room and to circulate
the air around the room.

COMPLICATIONS
There is a slightly increased risk of epilepsy.

DIFFERENTIAL DIAGNOSIS
Meningitis
Epilepsy
Hypoglycemia
Febrile convulsion lesion
Head injury
Poisoning of any type
 51

ABOUT DIAZEPAM
Prophylaxis of febrile seizures may be considered for situations such as
prolonged recurrent seizures or for children who have a low threshold for
seizures, especially if the family lives far from medical help. [2 hours away
from hospital]
Rectal diazepam repeated once after 5 minutes if the seizure has not
stopped, or one dose of buccal midazolam.

TASK: 2 year old Ben, was brought to the hospital because he had
fit, The child had
URTI recently. Ben was admitted was 24 hours ago and he is
diagnosis to have
Febrile convulsion. Talk ro mother, confirm the diagnosis and
address the mothers
Concerns.

Dr: Can you please tell me how much do you know about your childs condition?
Mother: I bought Ben to the hospital yesterday because he fell doen from the chair,
his eyes were rolled up at breakfast time. I called to 999 immediately. After that,
Ben slept following fit and I took him to the hospital.
Dr: Did Ben have any other problem recently?
Mother: He had some flu like symptoms like cough and running nose. I gave him
Paracetamol because he was not feeling well.
Dr: Is it the first time?
Mother: No
Dr: Can you please confirm the duration of fits?
Mother: 2 min
Dr: Did Ben have any rash? High grade fever? Was he crying while moving his
neck? Mother: No
Dr: Is Ben diagnosed with any medical condition like Diabetes, Epilepsy?
Mother: No
Dr: Does Ben feel sick in morning? Does he have any weakness in limbs?
Mother: No
Dr: Is there any family history?
Mother: No, Dr, Can you please tell me, what is happening to child?
Dr: Your child had febrile convulsion and it seems that it happened after flu.
Mother: Is it dangerous?
Dr: Do not worry about it. The vast of majority of febrile seizures are not serious.
Full recovery with no permanent damage is usual. (Most illness which cause fever
 52

and febrile convulsions are the common coughs, colds and viral infections which are
not usually serious. However, the illness that causes the fever is sometimes
serious- for example, pneumonia or meningitis.)
Mother: What will happen in the future?
Dr: Febrile Convulsion is common in children aged between 6 months and 5 years,
Generally, most of the children grow out of this condition.
Mother: Will it happen again?
Dr: Yes. I m afraid it can happen again if he has high fever. But dont worry if you
keep the temperature under control then it is less likely to-happen again> To control
the temperature, you can give him Paracetamol/Ibuprofen and keep the child very
lightly dressed. You can also give him plenty of fluids to prevent dehydration.
Mother: Okay, I will do it. But, what should I do if my child gets fit even after
following your advice?
Lay them on their side with their face turned to on the side. (This will stop
them swallowing any vomit, and will keep their airway open and help
prevent injury)
Dont put anything , including medication, in your childs mouth while
theyre having a seizure.
Stay with your child and Note the time.
1. If the seizure lasts for less than five minutes, in your childs mouth while
theyre having a seizure.
2. If it lasts longer than five minutes,(or if its your childs first seizure) take
your child to the nearest hospital as soon as possible./ call the
ambulance.

Mother: Is febrile convulsion a type of epilepsy?

Dr: No, the cause of a febrile convulsion is related to the feverish illness and
epilepsy is because of abnormal electrical activity in brain.
Mother: Will it lead into epilepsy. Dr: Very rare possibility
Mother: Will it cause learnuing disability?
Dr: There is no research that suggests simple febrile convulsions cause long-term
problems, for example brain damage or learning difficulties
Mother: Will you give me some medication?
Dr: Its not recommended that your child is given a prescription of regular medicines
to prevent further febrile seizures. But, we might consider giving him diazepam, I
will talk to my seniors.

TASK: 18 months child had fit, brought to hospitals by mom. Take History
and address
mothers concerns.
 53

Dr: What brought you to the hospital?

Mother: Dr, My child had fits when we were in shopping plaza.
Dr: Could you please tell me in detail, what happened before that?(Rule out of all
DDs)
Mother: He was sweating before fits and he was pale as well.
Dr: Did he have fever before?
Mother: Yes, He had flu and his nose was running. I gave him Paracetamol. But still
he was hot before fits.
Dr: How long did the fit lasts?
Mother: 2 min
Dr: What happened during the fit?
Mother: He had jerky movements. But he did not bite himself/wet himself.
Dr: Is there any family history of epilepsy, DM?
Mother: No

Dr: It seems that your child had febrile convulsion.

Mother: What will you do now?
Dr: We will admit your child, we will do some tests (Blood tests and EEG). We will
keep him for observation for some time. If all investigations are normal, then it is
Febrile convulsion.
Important Points
Sometimes, Mother might say that my child did not have any fever before fits, or
she is not sure about fever. Assume all findings are before fits.
Sometimes, Mother might give family history of epilepsy, tongue biting and wetting
himself during fits. All this indicates to Diagnosis of Epilepsy.
 54

HISTORY AND COUNSELLING

1. Foreign body ingestion
2. Uncontrolled epilepsy.
3. Diarrohea Viral
4. Hypoglycemic fit
5. UTI
6. Murmur in child
7. URTI/Meningitis
 55

1. FOREIGN BODY INGESTION

The ingestion of foreign bodies is most commonly a problem in younger

children aged 6 months to 5 years, but can affect children of all ages.

Items commonly ingested by children include coins, small toys,

pencils, pens and their tops, batteries, safety pins, needles and
hairpins-they are mainly radio-opaque.

The majority of ingested foreign bodies will pass safely through the gut and
be passed with faeces, but some will cause damage to the
gastrointestinal(GI) tractand/or become lodged.

Patients swallowing foreign bodies are usually asymptomatic but symptoms

can result. It may even lead to life-threatening obstruction of the upper GI
and respiratory tracts.

INVESTIGATION
If there is a suspicion of swallowing a button battery, then X-
rays and further treatment should be performed urgently.
In adults, a PA and lateral chest radiogragh and/or plain
abdominal X-ray
Coins in the trachea are more usually seen in a saggital
orientation on frontal radiograghs.

MANAGEMENT
Urgent endoscopy is mandatory in cases where there is airway
obstruction or evidence of other severe complications.
Where the history of ingestion of such objects is not so clear-cut,
consider CT first to detect the object.
Definite indications for endoscopy are objects that are sharp, non-radio-
opaque, elongated, or where there are multiple swallowed objects or a
high risk of oesophageal injury.
Act quickly to locate and remove any object that may be causing acute
upper airway obstruction.
Where airway obstruction is life-threatening and an object cannot be
removed then obtain urgent senior A&E/anaesthetic/ENT advice and/or
consider cricothyroidotomy as a life-saving procedure.
 56

Stable patients who have swallowed small, smooth objects, who have no
evidence of oesophageal entrapment, otherwise negative imaging, and
with no evidence of damage, can often be managed conservatively with
follow-up at 24 hours or so to check that they remain well; passage of
objects in stool may take days to weeks and parents should observe for
their presence.
Metal detectors have been used to detect metal foreign bodies in several studies.
They have been proven to be both sensitive ad specific in confirming presence of
coins in particular, and localizing them to above or below the diaphragm.
In children who have a history of swallowing a radiolucent FB and are
asymptomatic with normal examination reassure and discharge with advice
to return if significant symptoms appear.
Several case studies have highlighted the danger of swallowing multiple mini
magnets(used on notice boards etc).
Children who have swallowed button batteries are at high risk of oesophageal
necrosis and should be referred urgently for removal of the object.
Pitfall: Falling to consider neglect or chaotic home circumstances in children
who
Present repeatedly with ingested foreign bodies.

TASK : 2 year old child, was found coughing and choking by mother and
brought to A & E.
Talk to mother and address her concerns.

Dr: Can you please tell me, what brought you to the hospital?
Mother: My child was playing in the front room about 2-4 hours ago. I was in the
kitchen/on the phone. Suddenly, I noticed that he started coughing and chocking.
(He was turning into blue). I found my wallet open around him. I think that my child
had something from wallet.
Dr: I am really sorry to hear that. Do you have any idea what was there in the
wallet?
Mother: I think it is a coin.
Dr: Is there any chance that button battery was in the wallet?
Mother: Iam sure, there was no button battery. What are you going to do for my
child?
Dr: We will do an X Ray and see whether your child has swallowed anything?

(Examiner will show you X ray, and shows coin in stomach) Show the X ray to
the mother.
 57

Fortunately, The coin has passed the food pipe(narrowest part of the gut is
the lower of the food pipe),and now is in the tummy. You should check your
childs stool for next 48 hours, (Keep checking the nappy for 2 days)
hopefully, coin will come out in this time.
But you can bring back to the hospital if he does not pass coin with in next 2
days. You should also bring your child back if he has distended tummy, any
vomiting, not opening bowl, tummy pain or he is crying.

Mother: Is it dangerous to wait for next 2 days?

Dr: It is not dangerous as Coin is not sharp or poisonous. And coin is already in
tummy, hopefully it should come out with the stool.
Mother: What if he vomits or choks?
Dr: It is very unlikely that it happens. But if it happens. Hold the child upside down,
and tap the back
Mother: What should I do in the future?
Dr: If possible , try to keep small objects away from the child, you can keep them in
small boxes. Make sure your child can not reach to those boxes. If possible, do not
leave your child unattended even for shorter time.

If it is in wind pipe, we will remove it by a flexible tube with camera

attached to it (Bronchoscopy).
If the coin is stuck in food pipe, and not in the tummy, we will remove
the coin with flexible tube.

2. UNCONTROLLED EPILEPSY

TASK: 3 years old John, was brought to the hospital by her mother, Mrs.
Smith. John had
Fits. John has been diagnosed with Epilepsy. Talk to Mrs. Smith, and
address her concerns.

Dr: What brought you to the hospital?

Mrs. Smith: John has been diagnosed with Epilepsy. He had some fits in previous
months. So, I brought John to the hospital.
 58

Dr: Since when John has epilepsy?

Mrs. Smith: About a year.
Dr: Have you noticed any changes in type of fit?
Mrs: No
Dr: Who supervised his medication?
Mrs. Smith: I supervise his medication.
Dr: Is John getting his medications as prescribed?
Mrs. Smith: Yes
Dr: Did John miss any dose?
Mrs. Smith: No
Dr: Has John put on weight recently, because if little Tommy has gained weight,
then the dose of medication needs to be increased?
Mrs. Smith: No
Dr: Have you given him any OTC medication?
Mrs. Smith: No
Dr: Did John had diarrohea or vomiting recently?
Mrs. Smith : No
Dr: Does John spend more time on watching TV/playing video games?
Mrs. Smith: Yes/No
Dr: Does he get adequate sleep?
Mrs. Smith: Yes.
Dr: Is he more playful nowadays?
Mrs. Smith: No
Dr: does he eat and drink well?
Mrs. Smith: Yes
Dr: From the history, we could not find any cause for fits. So We need to admit
your child so that we can do some investigations to find out the cause of fits in
child.
Advice to Mrs. Smith
Check if your child is receiving correct dose of medication.
If your child has gained weight, then the dose needs to be adjusted
accordingly.
 59

If he is throwing up or passing loose stools, we would like to do some

investigation to find out the cause, in the meantime we will try to make
sure that he is receiving proper dose of medication.
If he has started with some other medication, please contact your GP,
because that medication may be affecting the working of this medication.
Make sure that he gets adequate sleep.
He should not watch Tv for long hours.
He should not use computer for long hours.
Make Sure that he wears his epilepsy bracelet all the time.

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--------
3.DIARROHEA
TASK : 18 month old Henry had diarrohea in last 24 hours, talk to mother
and give advice over the telephone.

Mrs. Brown: Hello, Doctor, I want to talk to you about my child.

Dr: can you please confirm your name, address and contact
number..Thanks.
Dr: Can you please tell me the name and age of the child?

Dr. What is happening to child?

Mrs. Brown: Henry has been passing loose stools for the last 24 hours.
Dr: Was there any blood?/ did he vomit? Tummy pain?/ Any fever?/ is he playful?/
Any weight loss?/Does anyone in the family have diarrohea?/ Did he have any
problem in the past?
Findings. 1)loose watery stools(2-3times) in last 24 hours 2) No blood in stool 3) No
vomiting, tummy pain 4) No fever 5) Henry is playful, passing urine normally. He is
not lethargic 6) No weight loss 7) PMH-child was admitted to hospital for
Gastroenteritis 8)Mrs also has diarrohea
Dr: What you have told me, it seems that Henry has Viral Diarrohea. And it is self
limitng condition. You can give Henry plenty of clear drinks (such as water or clear
broth) to replace the fluid thats been lost. But avoid fruit juice o squash ,as these
drinks can cause diarrhea. Mrs. Brown, Can you manage Henry at home? Mrs.
Brown: Yes
Dr: If you find Henry has Drowsiness, Pale or mottled skin, Cold hands or feet, Very
few wet nappies or fast (but often shallow) breathing. Bring him to the Hospital
immediately.
(In the history, try to ask all the differentials responsible for diarrohea)
Symptoms of lack of fluid in the body(dehydration)
 60

Mild dehydration is common and is usually easily and quickly reversed by drinking
lots of fluids. Severe dehydration can be fatal unless quickly treated because the
organs of the body need a certain amount of fluid to function normally.
Symptoms of dehydration in children include:
Passing little urine.
A dry mouth
A dry tongue and lips.
Fewer tears when crying.
Sunken eyes.
Weakness.
Being irritable or lacking in energy(lethargic).

Symptoms of severe dehydration in children include:

Drowsiness.
Pale or mottled skin.
Cold hands or feet.
Very few wet nappies.
Fast (but often shallow) breathing.

This is a medical emergency and immediate medical attention is needed.

Dont forget to ask cardinal symptoms of Glsystem(fever, PR bleed tummy
pain,vomiting)

Make sure mother has good supportat home to look after the child.
COMMON DDs
Viralgastroenteritis
UTI, Medication
Foodallergy

GENERALADVICE
Give more fluid[may take oral rehydration from pharmacy]
If it is viral cause, explain that this is a self limiting condition and no need for
admission.
Bacterial or protozoal infection.

Viral Bacterial Protozoal

 61

Stool Loose Watery Loose

Blood/mucous - +/- +
Vomiting - + -
Fever - + -
Abdominal pain - + Relievedbydefeca
tion
Prognosis Self limiting Needintervention Needintervention

(UTI-Fever, vomiting, cries while passing urine, Medication-Is your child on any
medication?

4.HPOGLYCEMIC FIT

TASK: Mrs. Sharma has brought her 2 years old child, Rahul to the
hospital because Rahul had fit. Rahul has been diagnosed with Diabetes
Mellitus recently and he has been on insulin. On Investigation, Blood
Sugar level was 1.4. From the history and investigation, Hypoglycemic fit
has been diagnosed. Rahul was not well for the last few days. Talk to
Mrs. Sharma and address her concerns.

If task mentioned that hypo is diagnosed or you found out that it is a hypo, it is very
important that you found the cause of the hypo.

[DAW-VIM]
D Drug [insulin] What medication you
give?
When do you give
normally?
Is that usual dose?
Usual site of Infection?
Who gives? Only you?
Chances of double
dose?
Do you check glucose at
home? Is glucometer
working? How often?
What was last reading?
Any other medication
[drug interaction]
 62

A Activity Do you think, he might be

more active than
usual? [Today or
yesterday] Like playing a
lot?
W Weight loss Do you think he might
have loss some weight
recently?
V Vomiting Did he vomit recently?
When? How much time
after eating? Did you give
him meal after that?
I Illness Was he having any
feverish illness?
M Meal Did you give him the
usual meal at usual time?
Could you able to make
sure he finished eating?
Or he threw into bin?
If you ask the above question, you would less likely miss the cause of hypo.
Dr. Can you please tell me, what happened?
1) Mrs. Sharma: My 2 years old child, Rahul, has not been feeling will recently.
He is not able to eat properly, nowadays. Today, in the morning, Rahul was
not able to eat his breakfast/or he threw up before I gave him Insulin. As
advised by diabetic nurse, I generally check his blood sugar before hiving
insulin. But I was busy in the morning, so I could not remember to check his
blood sugar. I gave him insulin and he had fit after 10-15 minutes.
OR

2) Mrs. Sharma: Rahul was not well recently. In the morning. He threw up after
having his breakfast. I checked blood sugar, as advised by Diabetic nurse,
and blood sugar level was normal. I gave him insulin and I noticed that Rahul
had fit within 10-15 min.
OR
3) Mrs. Sharma: Rahul has not been well in last few days. He was not able to eat
yesterday night. He was busy playing with his cousin. I gave him insulin
before he went to bed. It was long acting insulin as prescribed by doctor. In
the next morning, I saw my child having fit before he had breakfast or Insulin.
(Try to finish DAW-VIM, but do not repeat the question)
Dr: I am really sorry to hear that. As you know, we did some investigations for your
child. And your history and results of Investigations have confirmed that your child
had Hypoglycemic fit. This fit occurs when blood sugar falls below the certain level.
Rahul had this fit because
1) Your child did not eat food or vomited after having food- he did not have
enough sugar in his body and you gave him insulin which further dropped
 63

his sugar level which causes the fit. (low blood sugar can cause fit). Please do
not give insulin at all if the child did not eat or vomits even if the blood sugar
level is normal.
2) Because your child did not eat food or vomited after having food- he did not
have enough sugar in his body and you gave him insulin which further
dropped his sugar level which causes the fit. (low blood sugar can cause fit).
Please do not give insulin at all if the child did not eat or vomits even if the
blood sugar level is normal.
It is good that you checked the BS level but it takes some time for the blood
sugar to fall after vomiting.
3) Because your child did not eat food or vomited after having food - he did not
have enough sugar in his body and you gave him insulin which further
dropped his sugar level which causes the fit. (low blood sugar can cause fit).
Please do not give insulin at all if the child did not eat or vomits even if the
blood sugar level is normal.
Moreover, he played a lot with his friends. BS level can be dropped by over
activity.
Mrs. Sharma: what can I do to prevent it?
Dr: Make sure child eats properly, try to feed your child even if he refuses.

If the child does not eat at all/ vomits/excessively playful, skip the dose of
insulin even if the blood sugar is normal.
It is better to have increased blood sugar rather than decreased blood
sugar.
Increased blood sugar is not life threatening immediately, but it takes 3-4
days to be fatal.
Decreased blood sugar can be life threatening/very dangerous
immediately.
If the child vomits, give some drinks. If the child keeps it down and does
not vomit check the blood sugar. And then give insulin.
Mrs. Sharma: What can I do if Rahul has fit again in the future?
Dr: Unfortunately, if it happens again, lay him on his side with his face turned to one
side. (This will stop them swallowing any vomit, and will keep their airway open and
help prevent injury)

If they lie flat, then tongue may obstruct their airways which is life
threatening. Dont put anything, including medication, in your childs mouth
while theyre having a seizure.
Dr: Make sure Rahul carry/wear some form of identification specifying he has
diabetes, like bracelet.
You should also inform to nursery teachers and GP
Whenever you find, Rahul is shaking, sweating or feeling sleepy. You should give
him any sugar containing food/ drink immediately.
 64

We will be regularly following up Rahul.

Hypoglycemia or hypo is when your blood glucose levels are too low (below
4mmols/l). This is potentially dangerous side-effect of some diabetes tablets and
insulin.
Causes of hypoglycemia

Too little or no carbohydrate at you last meal. (on bread, pasta, rice, potato)
Missed or late meal
Too much insulin or tablets (double dose)
More exercise than usual for example playing for long time.
Weight loss (whether intentional or not) or a change in your lifestyle. Your
medication may require to be reduced to prevent hypoglycemia
Some illness like flu or fever may influence
Vomiting after meal

General Advice for Hypoglycemia

Always carry some form of glucose for example dextrose tablets or glucoside
Always carry/wear some form of identification specifying you have diabetes
and your treatment
Tell your friends, relatives and colleagues that your diabetes and let them
know how to help if you have a hypo
You may have a high blood glucose for a few hours after a hypo. This may be
caused by the treatment of the hypo and your bodys natural response to
hypo.
Night sweats, morning headache and /or weakening during night may be
symptoms of hypoglycemia during the night.

5. UTI

Urinary tract infections (UTIs) are fairly common, but not usually serious,
and can be effectively treated with antibiotics.
The urinary tract is where our bodies make and get rid of urine. It comprises the
kidneys, and stretches out to the ureters (the tubes connecting the kidneys to the
bladder), down to the bladder, and finally the urethra (the tube that carries urine
from the bladder to out of the body).
Signs and Symptoms
It can be difficult to tell whether a child has a UTI, because the symptoms can be
vague and young children cannot easily communicate how they feel.
Signs that your child may have a UTI can include:
 65

High temperature (fever)

Vomiting
Tiredness
Irritability
Pain or a burning sensation when urinating
Needing to urinate frequently
Wetting themselves or their bed, having previously been dry
Pain in their tummy (abdomen) side or lower back
Unpleasant smelling urine
Blood in their urine

Causes of UTIs in children

Most urinary tract infections (UTIs) in children are caused by bacteria that
normally live in the digestive system getting into the urethra (the tube
that carries urine out of the body).

In young children, bacteria can enter the urethra when they wipe their
bottom after going to the toilet.
This is more of a problem for girls than boys, because girls bottoms are
much nearer the urethra.

Increased risk
There is usually no obvious reason why some children develop UTIs and others do
not. However, some children may be more vulnerable to UTIs due to a problem with
bladder emptying. Normally, we empty our bladder completely when going to the
toilet. If urine is left in the bladder, it can allow bacteria to grow and an infection to
develop.
Problems that can affect bladder emptying include:

Constipation This can sometimes cause part of the large intestine to

swell, which can put pressure on the bladder and prevent it from emptying
normally
Dysfunctional elimination syndrome a relatively common childhood
condition which a child holds on to their urine, even though they have the
urge to urinate
Vesicoureteral reflux an uncommon condition where urine leaks back up
from the bladder into the ureters (the tubes connecting the kidneys and
bladder) and kidneys. This occurs due to a problem with the valves in the
ureters, they enter the bladder.
Diagnosing UTIs in children

If your child has symptoms of a urinary tract infection (UTI) a

sample of their urine will be tested.
Further tests
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In many cases, treatment will start soon after a urine sample has been taken, and
your child will not need to have any further tests.
However, there are some circumstances where further tests may be carried out.
Including if:

Your child is less than six months old

There is no improvement in your childs symptoms within 24 to 48
hours of treatment
Your child has any unusual symptoms, such as reduced urine flow, high
blood pressure (hypertension), or a noticeable lump or mass in their tummy
(abdomen) or bladder
Your child has repeated UTIs

In these cases, doctors may recommend carrying out some scans to look for any
abnormalities.
Scans
There are many different scans that may be carried out to check for problems in
your childs urinary tract, including:

An ultrasound scan where sound waves emitted by a special probe move

over your childs skin and are used to build up a picture of the inside of their
body
A micturating cyst urethrogram (MCUG) where a catheter is used to
pass a special type of liquid (contrast agent) that shows clearly on X-rays
into your childs bladder, while a series of X-rays are taken, the contrast
agent will pass harmlessly out of your childs body, in their urine
The type of scans used and when they are carried out will depend on your childs
specific circumstances. In some cases, these scans may be carried out a few weeks
or months after your child originally developed the infection.

Ultrasound:
Can accurately assess rental size and outline and identify most
congenital abnormalities, renal calculi and hydro nephrosis or hydro
ureter, indicating the presence of obstruction or severe reflux
It is less effective in detecting mild or moderate vesico-ureteric reflux in
children with UTIs

Micturating cystography:
Is the gold standard investigation for reflux and is the only imaging
technique that provides information about the urethra?
Should be performed by a skilled radiologist with experience in acquiring
and interpreting the images.
The disadvantage of micturating cystography is its invasiveness, as it
requires catheterization.

DMSA scintigraphy:
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Is the gold standard for detecting renal parenchymal defects?

Study renal function using radio-pharmaceutical such as technetium 99m.
The Isotope is concentrated in the proximal renal tubules, and its
distribution correlates with functioning renal tissue.
Treating UTIs is children
Most urinary tract infections (UTIs) in children can be effectively treated
with antibiotic medication. This medication can be often given at home,
although there are some situations where it may be necessary for your child to stay
in hospital for a few days.
Treatment at home
If your child is over three months old and are not thought to be at risk of
serious illness, they can usually be treated at home with antibiotic
medication.

For lower UTIs, a three-day course of antibiotics is usually recommended. For

upper UTIs, a 7 to 10-day course of antibiotics is usually recommended.
Your child may experience some side effects while taking antibiotics, but
these are usually mild and should pass once they stop taking the medication.
Common side effects of antibiotics include feeling sick, vomiting, an upset
stomach, diarrhea and loss of appetite.
If necessary, paracetamol can also be used to treat any fever or discomfort
your child has. However, non-steroidal anti-inflammatory drugs (NSAIDs)
such as ibuprofen should not be used if your child has a UTI, as they can
harm the kidneys. Aspirin should never be given to children under the age of
16.
If your child is unable to swallow tablets or capsules, they can be given
antibiotics and paracetamol in liquid form.
Your childs condition will usually improve within 24 to 48 hours of treatment.
However, it is very important they finish the whole prescribed course of
antibiotics to prevent the infection recurring.
Treatment in hospital
If your child is less than three months old, or it is thought that their
condition could get worse, they will be referred to hospital for treatment.
Doctors may feel your child is at risk of becoming more seriously ill without hospital
treatment if:

They appear to be very unwell, dehydrated or unable to keep down

oral medication because they keep vomiting
They display unusual symptoms, such as reduced urine flow, high blood
pressure (hypertension), or a noticeable lump or mass in their tummy
(abdomen) or bladder
They have been previously diagnosed with a condition that affects their
urinary system.
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In these cases, your child will usually need to stay in hospital for a few days to
receive antibiotics directly into a vein (intravenous antibiotics). As with cases
treated at home, your child should improve within 24 to 48 hours.
Follow-up
Most UTIs in children will clear up within a day or two and wont causes any long-
term problems. Go back to your GP if your child is not showing any signs of
improvement by this point.

Preventing UTIs in children

It isnt possible to prevent all childhood urinary tract infections (UTIs), but
there are some things you can do to reduce the risk of your child getting
one.
The following advice may help:

Encourage girls to wipe their bottom from front to back this will help
to minimize the chances of bacteria entering the urethra (the tube through
which urine passes).
Make sure your child is well hydrated and goes to the toilet
regularly, as not urinating regularly and holding in urine can make it easier
for bacteria to infect the urinary tract.
Avoid nylon and other types of synthetic underwear, as these can help
promote the growth of bacteria loose-fitting cotton underwear should be
worn instead.
Avoid using scented soaps or bubble baths, as these can increase your
childs risk of developing a UTI.
Take steps to reduce your childs risk of constipation make sure they
drink enough to keep their urine pale and clear during the day, and speak to
your GP about medications that can help if constipation is a persistent
problem.

TASK: Mrs. Brown has brought her 3 years old child, Ronaldo, for fever
and vomiting. Talk to Mrs. Brown and discuss management with the
mother.

(in the history ask all the differentials which can cause fever and vomiting, like
meningitis, GE.)
Dr: What brought you to the hospital?
Mrs. Brown: My 3-year-old child, Ronaldo, has fever from yesterday. Today in the
morning, he vomited also. Thats why I brought him to the hospital.
Dr: Does he cry when he passes urine? /Do you have to change his nappies
frequently?
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Mrs. Brown: Yes

Dr. Has it happened before?
Mrs. Brown: It has happened 2 times before.
Dr: Does he pass urine frequently?
Mrs. Brown: Yes/No
Dr: Do you use scented soaps or give bubble bath to Ronaldo?
Mrs. Brown: Yes/No
Dr: Is Ronaldo toilet trained?
Mrs. Brown: Yes/No
Dr: Does Ronaldo wear tight underwear?
Mrs. Brown: Yes/No
Dr: From the history, it seems that your child has UTI, do you know anything about
it?
Mother: No
Dr: The urinary tract is where our bodies make and get rid of urine. The UTI is
infection of this tract.

We will do Urine test to confirm the diagnosis. If the UTI is confirmed, we will
give him antibiotics, (3 days for lower UTI (infection of bladder and urethra),
and 7 days for upper UTI (infection of kidney and ureter)).
We will also give Paracetamol for his discomfort and fever.
As your child had UTI twice before, we will also do some scan like an
ultrasound scan and a micturating cyst urethrogram (MCUG) to
look for any abnormality in the Urinary tract.
Take about follow up and give advice about how to reduce the risk to getting UTI.

TASK: 5-year-old Tom was brought to the hospital by his mother. She
complains that Tom has been crying whenever he passes urine. Urine
Test has confirmed that Tom has UTI. Talk to mom and address her
concerns.

Similar to the above station

6. Murmur in Child
TASK: Mrs. Brown took his 18 months old child, Jacob, to the GP surgery
for routine checkup. On auscultation, GP could hear some murmurs. Mrs.
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Brown is worried about this. She has come to the hospital, Address her
concerns.
Does this child have heart disease? (To check if the murmur is innocent or
pathological due to heart disease?)

Are there any symptoms and signs of heart disease?

Are there any predisposing medical conditions?
What are the characteristics of the murmur?
Common symptoms of heart disease in younger children

B Blue episode Sometimes the child

turns into blue?
O Oedema-pedal Any swelling around
ankle or feet?
B Breathlessness Fast breathing?
Shortness of breath?
P Poor feeding Difficulty in feeding?
P Poor growth How is the growth of
child? He/she gaining
weight?
P Perspiration [excessive wetting] Usually sweating?
P Positive Family Hx Any of your family
member have heart
problem?
Older child also may get exercise intolerance, chest pain, syncope
Also you may ask-any illness, medication, abnormal blood vessels around
chest?
BIRD, siblings? PH, FH, DH
Explain that all are not problematic but we have to investigate to say it is
normal.

Common medical conditions which cause murmur

Down syndrome
Noonans Syndrome
Turners Syndrome
Marfan Syndrome
Fetal alcohol syndrome
Fetal rubella infection

Investigations
ECG and CXR have limited use in the diagnosis of underlying pathology
associated with pathological heart murmurs, with low sensitivity and
specificity for identifying cardiac defects or anatomical abnormalities.
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Echocardiography is the gold standard to diagnose congenital

cardiac malformations definitively in pediatric patients. It is indicated
in any child with an asymptomatic heart murmur which has attributes of
pathological murmur or when the examiner is not comfortable in making a
clinical diagnosis of an innocent heart murmur.

Dr: Mrs. Brown, can you please tell me, what brought you to the hospital?
Mrs. Brown: I am here because my GP found a murmur in Jacob, my 18
months child, on routine checkup. I am worried because of this.

Dr: I need to ask you few questions to check if your child has any heart
condition.
How is the general health of your child?
Mrs. Brown: He is fine Doctor.
Dr: Any Fever/cough/running nose?
Mrs. Brown: Yes/No

Was there any incident when your child turned into blue?
Mrs. Brown: No

Dr: Have you noticed any swelling around the face or feet of Jacob?
Mrs. Brown: No

Dr: Does Jacob have any shortness of breath?

Mrs. Brown: No

Dr: Is there any difficulty in feeding Jacob?

Mrs. Brown: No

Dr: How is the growth of Jacob? Is he gaining weight?

Mrs. Brown: There is no problem with growth. He is gaining weight.

Dr: Does Jacob sweat a lot?

Mrs. Brown: No

Dr: Did you have any health problem during pregnancy?

Mrs. Brown: No

Dr: Was there any complication during or after delivery?

Mrs. Brown: No

Dr: Mrs. Brown, form the history, it seems that your child does not have any
heart condition and murmur of your child is innocent. Many murmurs in
children are innocent and result from normal patterns of blood flow through
heart and blood vessels. Heart murmurs are common in asymptomatic and
otherwise well children. But, some murmurs can be due to some heart
condition.

Mrs. Brown: What are you going to do for Jacob?

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Dr: We will to do Echocardiography t check any heart defect in your child.

(size and shape of heart, any valve defect). Most likely, there will be no
defect in heart which can cause murmur. We will also check his pulse and
Oxygen saturation in blood.

7. SUSPECTED MENINGITIS

RAT-PHONE

SIGNS OF MENINGITIS

R Rashes Any rash or discoloration of skin:

A Activity How the child is active? Lethargic?
T Temperature Feel fever?
P Photophobia Shy away from light? Hesitancy to
bright light?
H Headache Showing any signs of headache?
O Other contacts Any other people you know have same
symptoms?
N Neck Stiffness Difficulty in moving neck?
E Emesis Vomiting? Is the child sick?

If you think, it is definitely not meningitis (not even single sign of a meningitis
except fever). Then you may reassure but please give all the warning signs
and tell her what to do when they get these symptoms (call 999).

Tell her that if you are not happy you can bring the child, you can always call
back and even go to your GP. If equivocal or meningitis, tell her, that child
has to be seen by doctor immediately so take her to nearest A&E or call
ambulance (or we will send one).

You may also want to rule out some other condition

UTI- Pain or cry on passing urine
GE- Diarrhea, tummy pain, vomiting

What is the treatment for an upper respiratory tract infection?

A main aim of treatment is to ease symptoms whilst your immune system clears the
infection. The most useful treatments are:

Taking paracetamol, ibuprofen, or aspirin to reduce a high temperature

(fever), and to ease any aches, pains and headaches. (Children aged under
16 should not take aspirin.
Having plenty to drink if you have a fever, to prevent mild lack of fluid in the
body (dehydration).
URTI IN CHILD MOTHER WORRY OF MENINGITIS
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Tommy, a 5 years old child, has fever with rash. Mrs. Brown, his mom, is
worried and she thinks that Tommy has meningitis. She has called you,
talk to her.
Mrs. Brown: Hello, Doctor, I want to talk to you about my child.
Dr: Can you please confirm your name, address and contact number
Thanks.
Dr: Can you please tell me the name and age of the child?
Mrs. Brown: His name is Tommy and he is 5 years old.
Dr: What is happening to Tommy?
Mrs. Brown: Tommy has fever and rash, and I think it is meningitis. So I am really
worried.
Dr: Since how long does he have fever?
Mrs. Brown: he has fever for the last 2 days.
Dr: Did you check the temperature? Is it too high?
Mrs. Brown: It is mild fever
Dr: Since how long he has the rash?
Mrs. Brown: I noticed the rash just today.
Dr: Do you know anything about The Glass Test?
Mrs. Brown: No
Dr: Press a glass gently on the rash. If the rash blanches, then the chances are that
it is not meningitis. How is the activity of Tommy, is he playful? / is he lethargic?
Dr: Does Tommy have headache? Does he shy away from light? Difficulty in moving
neck? Vomiting?
Mrs. Brown: No
Dr: Does Tommy have cough, runny nose?
Mrs. Brown: Yes
Dr: From the history, it seems that Tommy has an Upper Respiratory Tract Infection
and not meningitis. Please take your child to the GP for medication. If you feel that
at any point the child is getting worse (or if you notice any sign of meningitis)
contact us immediately. We will send the Ambulance.

Upper Respiratory Infection Meningitis

Moderate temperature Very high temperature
Active Drowsy or lethargic
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Comfortable in bright Shying away from bright light

Vomiting always preceded by cough Vomiting not preceded by cough
Rash not present/if present is Non blanching rash.
Blanching Educate on the glass test
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