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Probability diagnosis

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Normal/hunger

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Infantile ‘colic’

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Teething

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Viral URTI/illness

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Otitis media

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Constipation

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Serious disorders not to be missed

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Vascular:

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  • Cardiac failure

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Infection:

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  • Meningitis/encephalitis

  • Gastroenteritis

  • Other systemic infection

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Other:

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  • Gastro-oesophageal reflux/oesophagitis

  • Injury esp. non-accidental, birthing

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Pitfalls (often missed)

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Severe nappy rash

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Constipation

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Cow’s milk intolerance

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Lactose intolerance

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Balanitis (males)

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Rarities:

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  • Bowel obstruction/pyloric stenosis

  • Intussusception

  • Other congenital e.g. oesophageal atresia

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Masquerades checklist

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Urinary tract infection

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Is the patient trying to tell me something?

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?hunger ?soiled napkin ?tiredness ?family dysfunction ?inattention

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Key history

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Obtain detailed account from parents of the crying pattern and duration, as well as the circumstances of discomfort incl. feeding, time relationship to feeds and associations, particularly vomiting or possetting, presumed abdominal discomfort, constipation, bowel actions and fever. Establish if breastfeeding or providing other milk and food. Ask about recent immunisation.

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Key examination

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  • General features: appearance of the child, growth parameters and vital signs

  • Abdominal examination esp. inspection, palpation and auscultation

  • Examine skin looking for evidence of eczema and napkin rash

  • Examine the ears, fontanelles

  • Also assess the child’s temperament and coping abilities

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Key investigations

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Nil for most cases

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Consider:

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  • urinalysis

  • MCU

  • FBE

  • ESR/CRP

  • stool analysis

  • referral for upper GIT investigation

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Diagnostic tips

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The normal pattern is for crying to start increasing around 2 weeks of age, to peak around 2 months and then settle down 3–4 months of age.

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