Many children and infants will be found to have systolic murmurs on routine examination, especially in the presence of a fever, anxiety or fear. The majority, which will be innocent or physiological, are found in asymptomatic children and due to normal turbulence of flow within the heart and great vessels.
An innocent murmur can be diagnosed in children over 12 months of age if the following 4 criteria are met:
there are no other abnormal physical findings
the child is asymptomatic (e.g. no dyspnoea, palpitations, fatigue, nausea/vomiting, ongoing cough)
no history of risk factors for structural heart disease (e.g. family history, maternal gestational DM/alcohol abuse, previous Kawasaki disease/rheumatic fever, genetic disorders, prematurity)
auscultatory features typical of an innocent murmur (see 7 Ss below)
In murmurs heard in infants under 12 months of age, the risk of asymptomatic structural heart disease is higher, and further assessment is warranted.
The 7 Ss of innocent murmurs:
Sensitive (changes with child’s position or with respiration)
Short duration (not holosystolic)
Single (no associated clicks or gallops)
Small (murmur limited to a small area and non-radiating)
Soft (low amplitude)
Sweet (not harsh sounding)
Systolic (occurs during and is limited to systole)
Chest X-rays and ECGs rarely assist in the diagnosis, and can give false reassurance. When a murmur cannot be definitively diagnosed as innocent, the child should be referred for echocardiography, paediatric cardiologist review or both.
Nocturnal enuresis (NE), or bedwetting, is urinary incontinence occurring during sleep in a child with a developmental age of 5 or older. An absence of other urinary symptoms (e.g. frequency, urgency, straining or daytime wetting) is referred to as monosymptomatic NE, but if present then the term non-monosymptomatic NE is used. Primary enuresis (80% of cases) occurs in a child who has never had urinary continence for 6 months, and secondary enuresis (20%) occurs after 6 months or more of day and night dryness, and is more commonly associated with organic or psychological causes.
15–20% of 5 year olds
5% of 10 year olds
1–2% of 15 year olds
The spontaneous resolution of NE is 15% per year. Boys are affected 3 times as much as girls, and there is a strong familial tendency (75% have an affected first degree relative, with maternal enuresis a greater risk factor than paternal enuresis). Twenty per cent of children with NE will also have daytime symptoms.
The causes of NE are not fully understood, but are thought to be multifactorial, including:
disturbance in arousal—children with NE often do not wake adequately in response to a full bladder
overactive bladder—which leads to a reduced bladder capacity. Children in this situation will often have daytime symptoms or other urinary symptoms (e.g. urgency, frequency)
nocturnal polyuria—this is caused by reduced nocturnal vasopressin (which normally reduces nocturnal urine production)
Other common contributing factors include constipation (more than a third of patients) and obstructive sleep apnoea. Both of these should be carefully enquired about in the history. UTIs, diabetes and psychopathology (e.g. behavioural problems, ADHD, stress or trauma, depression, anxiety) can also contribute to and/or are associated with NE.
As well as assessing for the above contributing factors, a detailed history of the urinary symptoms and pattern should be taken. This is greatly assisted by getting the parents (and child if old enough) to complete a 48-hour time and volume chart of fluids and urine (including urine symptoms).
Physical examination should include ENT examination (looking for large tonsils or nasal obstruction causing OSA), abdominal examination (large bladder, faecal loading) and a focused neurological examination.
Urinalysis and culture can help detect infection. Blood tests, imaging and urodynamics are not usually required for uncomplicated primary NE. If there are daytime symptoms, significant other urinary symptoms, history or diagnosis of UTIs, structural abnormalities of the urinary system or genitals, secondary enuresis or refractory problems, then further investigations and/or specialist review is warranted.
Advice for parents/child: ‘they/you will very likely grow out of it’
Both the parents and child should be reassured that primary NE is common, unlikely to be a medical concern, not the child’s fault and will nearly always resolve by itself with time. If the issue is not bothering the child then treatment is not needed. If conducted, treatment should be delayed until the child is able and willing to comply, which is generally around age 7 years.
Tips to help the family deal with the situation
Do not scold or punish the child.
Praise the child if achieving dryness.
Use a night light to help the child who wakes.
Use absorbent ‘pyjama pants’ or mattress protectors (absorbent underlays), which can help reduce distress for parents and child, and will not contribute to the enuresis.
Make sure the child has a shower or bath before going to kindergarten or school (to avoid teasing).
The treatment of primary monosymptomatic NE requires educated and motivated child and parents. Guilt, shame and punishment need to be avoided. The child should be involved in the treatment (even though the child didn’t cause the problem, he or she has a role in treating it).
Urotherapy, or improving urination habits, includes increasing daytime fluid intake (to increase bladder capacity and awareness of bladder fullness). Six to eight reasonable-sized drinks spaced throughout the day (not just after school) are recommended (50 ml/kg/day). Regular voiding every 2–3 hours will help the child become more cognitively aware of the bladder sensations.
Promptly and aggressively treating constipation will help bladder capacity and control.
Alarms can be obtained through enuresis clinics, pharmacies and community health clinics. They can be body-worn, or bed alarms, and work on operant conditioning. The buzzer goes off and wakes the child when urine is passed.
Alarms take effort and commitment. It takes around 3 weeks for the child to recognise the sensation of a full bladder, and around 12 weeks to achieve dryness (success is measured as 14 consecutive dry nights). If dryness is achieved it is either through the child waking to urinate (a third of children) or sleeping through dry (two-thirds).
The success rate is around two-thirds of children, and half of these remain dry. ‘Overlearning’ (giving additional fluids at bedtime to those who achieve dryness) can improve the child’s response to a full bladder signal and reduce the risk of relapse, especially in those who are sleeping through dry. If bedwetting restarts after stopping treatment, alarm training can be retried.
Desmopressin acetate: while this vasopressin analogue is very effective, it has a high relapse rate. It comes in tablets, melts and nasal spray, with the tablets and melts preferable as they have a lower risk of hyponatraemia. Fluids need to be restricted from 1 hour before taking to 8 hours after the dose. It is very useful for children in school camps or having sleepovers.
Other treatment options include using anticholinergics, tricyclic antidepressants, combinations of alarms and medications, or combinations of medications. These options should be undertaken by a specialist or through an enuresis clinic.
Constipation in children16,17,18
Constipation is quite common in children, although no cause has been discovered in 90–95% of cases. Constipation usually appears between 2 and 4 years of age, and up to a third of primary school-aged children will report constipation over a 12-month period. In toddlers, the gender distribution is equal, but by age 5, boys are more likely to get constipation than girls, with the frequency of faecal incontinence three times higher in boys. The most common factor is diet. Organic causes of chronic constipation are rare.
Refer to CHAPTER 41 for detailed information.
COMMON SKIN PROBLEMS19,20,21
Many of the common problems (e.g. acne, psoriasis, atopic dermatitis, seborrhoeic dermatitis) are covered in more detail in CHAPTER 121. The following are specifically (or usually) disorders of the neonatal period and early infancy.
Toxic erythema of newborn
This benign condition occurs in around half of babies, usually 1–2 days after birth (but may appear up to 2 weeks later) with 2–3 mm erythematous macules and papules developing into pustules, with a surrounding blotchy area of erythema, described as a ‘flea-bitten’ appearance. The rash starts on the face and spreads to the torso and proximal limbs, and spares the palms and soles. The rash usually fades over a week, but may recur for a few weeks. No treatment is required.
Salmon patch (naevus flammeus nuchae)
These are flat patches of pink or red skin with poorly defined borders. They occur in 40% of all newborns, and are seen at the nape of the neck (‘stork bite’) or between the eyebrows/on the eyelids (‘angel’s kiss’) (see FIG. 91.6). They are more prominent when the child is crying. They fade over 6–12 months but neck patches may persist into adult life. No treatment is required.
Salmon patch on the upper eyelid: called an ‘angel’s kiss’
Infantile haemangiomas can be superficial (‘strawberry haemangioma’, flat or lumpy, resembling strawberry jam splashed on the skin, see FIG. 91.7) or deep (‘cavernous haemangioma’, a bluish swelling). They usually appear after birth, and occur in 10% of infants.
Strawberry haemangioma on the face of a child
Some 80% occur on the head and neck and 80% of their growth occurs in the first 3 months (most stop by 5 months, though some continue until 18 months). They usually involute and disappear (50% by 5 years, 70% by 7, 90% by 10), though regression of bulky ones tends to be incomplete, and they often leave an atrophic ‘dented’ scar. Large, deep or multiple haemangiomas can be associated with malformations of organs, and referral of these, those causing cosmetic issues (such as being prominent on the face), those that impair vision/hearing/breathing or feeding, or that are in other important locations (e.g. perineum or sacrum) is recommended. Active non-treatment is the rule, but beta blockers have proven effectiveness. Propanolol is useful, especially if used early in the growth phase, and is now usually preferred over oral steroids. Preparations include oral propanolol (with caution) and topical timolol drops or gel.22
Capillary vascular malformation (‘port wine stain’)
These dark red to purple lesions (a type of naevus flammeus) are present from birth and affect 3 in 1000 neonates. They are usually flat at birth, though they can become lumpy. There is an association with vascular syndromes, including Sturge–Weber syndrome, where a port wine stain on the skin supplied by the ophthalmic division of the trigeminal nerve is accompanied by glaucoma and seizures, and patients are at increased risk of developmental delay and hemiplegia. Port wine stains will often respond well to pulse dye laser (the treatment of choice). Cosmetic camouflage is useful.
Lymphatic malformation (lymphangioma)
These are present at birth but can subsequently grow. They can vary from large fluid-filled spaces (cystic hygromas) down to clusters of small firm blisters resembling frogspawn. They can be skin-coloured, red or purple (if associated vascular involvement) or brown or black. Surgical excision may be required.
Dermal melanocytosis (‘Mongolian spot’)
This condition presents as blue-grey discolouration of the skin over the lower back and sacrum in babies of east Asian and other dark-skinned ethnic backgrounds. These are of no clinical significance but may be mistaken for bruising or non-accidental injury. They usually disappear by 4 years of age.
Hyperplastic sebaceous glands appear as tiny yellow–white papules on the nose or forehead. They disappear in several weeks.
Blocked sebaceous glands, leading to pearly-white lumps under the skin, especially on the face, are present in 50% of neonates. The firm, white papules are about 1–2 mm in diameter and differ from the yellowish papules of sebaceous hyperplasia. These also disappear after several weeks, and usually no treatment is required (see FIG. 91.8).
Milia on the face of a 2-week-old infant
This is related to overheating and occurs in skin folds such as around the neck and armpits, but also on the face. It appears as two types:
It is a benign condition that disappears after a few weeks.
keep skin dry and cool (e.g. fan, air-conditioner)
dress in loose-fitting cotton clothing
avoid frequent bathing and overuse of soap
mild topical steroids (e.g. hydrocortisone) can help if inflamed
These are a hyperplastic response to suckling, and are common on the upper lip. Reassure that these will settle.
When the umbilical stump first separates, some granulation and mild exudate can be present until healing occurs. If the umbilicus is discharging pus and there is surrounding erythema in the neonate, infection should be considered, and a bacterial swab taken and appropriate antibiotics given. Be watchful for urine or faecal discharge.
Small amounts of bleeding may occur as the cord is separating and requires no treatment unless it is more profuse (if so, consider infection or a bleeding disorder).
These common fleshy pink-red growths can cause a persisting seropurulent discharge after the separation of the umbilical stump. The granuloma is often seen only by carefully examining the base of an ‘innie’ umbilicus. Drying out of the granulomatous tissue and healing can be achieved by the parent airing regularly, applying salt twice a day at home for a week or two (followed by irrigation), or the GP using a silver nitrate stick or copper sulphate crystals every few days until healing occurs. Protect the surrounding skin with Vaseline. Large pedunculated and persistant granulomas may be helped by applying a double ligature to the neck of the granuloma.
These are round or oval pale skin patches usually on the face of children and adolescents, and are more visible in tanned or dark-skinned patients.
They can occur on the neck and upper limbs, occasionally on the trunk.
Full repigmentation occurs after a couple of years
They may start out pale pink then fade to white, and can leave slight depigmentation.
Atopic dermatitis (eczema)
Atopic dermatitis (eczema) in a 3-year-old child with widespread distribution and severe pruritus
This common condition may appear typically in infants on the cheeks of the face, the folds of the neck and scalp and extensor surface of the limbs. For further information on its manifestation in children and management refer to CHAPTER 121.
Seborrhoeic dermatitis in a 10-week-old child, showing a red, scaly rash affecting the scalp, forehead, face, axillae and nappy area. Both cradle cap and nappy rash are present.
This is quite different from adult seborrhoeic dermatitis and appears in the first 2 to 3 months.
Nappy rash occurs under the nappy in response to wetness. The most common cause is contact dermatitis from urine and faeces, which will inevitably cause a rash if left on the skin for long enough. This will lead to the dull red rash being most prominent where the nappy contacts the skin, and sparing the folds. Sometimes ammonia is formed, resulting in a chemical burn (hence the alternative term ammoniacal dermatitis).
Nappy rash in the folds is more commonly found in infants with cradle cap and seborrhoeic dermatitis. Thrush can also coexist, with the rash appearing more bright red, and often having satellite lesions or pustules around the main rash. Bacterial superinfection (impetigo, see later in this chapter) can occur, with crusting, pustules and irregular blisters. Swabs should be taken for this if suspected. Other conditions such as psoriasis and atopic dermatitis also need to be considered, especially for resistant or recurrent nappy rash.
Keep the area dry. Air dry when possible (e.g. lying on towel without a nappy).
Do not use powder, which can irritate the skin.
Change wet or soiled napkins promptly—disposable ones with their absorbent hydrocellulose gel are very effective.
If using cloth nappies, nappy liners can help keep the skin dry. Do not use plastic pants around them.
Give evening fluids early to reduce night-time wetting, and change the nappy before parents go to bed.
Wash gently with warm water and pat dry (do not rub).
Avoid excessive bathing and soap.
Use moisturisers to keep skin lubricated (e.g. zinc oxide and castor oil cream). Silicone barrier creams can also help.
Hydrocortisone and/or antifungal cream while rash is present.
Antifungal can be continued for a few more days if thrush suspected.
Do not use strong steroid creams on baby’s bottom.
Cradle cap is infantile seborrhoeic dermatitis confined to the scalp. The seborrhoeic dermatitis may also involve other areas (see CHAPTER 121). Cradle cap is very common, usually occurring in the first 6 weeks of life and settling over the next few weeks to months, but it sometimes takes much longer.
Greasy yellow scales are formed in response to sebum combining with old skin cells as they try to dry and fall off. The yeast Malassezia furfur may be involved. It is not usually itchy or distressing to the child.
Reassurance and watchful waiting (if not too bad, given the natural history is to improve with time)
Use vegetable oil overnight to soften scales and then gently brush off (not olive oil; this encourages Malassezia)
Baby shampoos and then gentle brushing off of scales
2% ketoconazole shampoo (Nizoral) twice weekly
Apply hydrocortisone cream to red and inflamed areas
Molluscum contagiosum in children23
Molluscum is usually diagnosed by its distinct pink pearly appearance and central punctum (see CHAPTER 124). It is very common in children (up to 10% of the paediatric population have it at any given time), and is usually spread by direct contact, sharing towels and bath toys, or through water (e.g. sharing baths or swimming).
The rash lasts weeks to months, or occasionally a couple of years. Molluscum rarely leaves tiny pit-like scars. It can have a reactive dermatitis surrounding the lesions (especially in children prone to atopic dermatitis) and hydrocortisone cream can be used to help this.
Give the child a shower instead of a bath (the bath can spread the virus to other parts of the body).
Don’t share baths.
Wash and dry bath toys after use.
After showers/baths/swimming, dry areas with molluscum last and don’t share/re-use towels.
Wash hands after touching molluscum.
Don’t exclude children from school or playing together.
If swimming, reasonable precautions include covering the lesions with waterproof tape and having personal kick-boards.
The most common approach in children is to leave the rash alone and wait for it to clear. Treatments designed to irritate the lesion can make the rash clear more quickly (see CHAPTER 124) but can be distressing to the child and so are not normally done.
Warts affect about 10% of children. Even without treatment, 50% of them will go in 6 months, and 90% in 2 years. It is therefore best to avoid painful treatments unless the parent and child are motivated (e.g. for cosmetic reasons, or uncomfortable plantar warts). A reasonable option that can help the wart disappear faster is to cover with occlusive tape (e.g. duct tape) 24 hours a day.
Refer to CHAPTER 68 (plantar warts) or CHAPTER 124 (general warts) for more active treatment options.
Hair problems in children
Young children are susceptible to lead poisoning. They are more likely than adults to be exposed to lead because of their exploratory and mouthing behaviour and because they absorb more of any ingested dose. The most common source seen in general practice is home renovation, involving paint removal in houses built before the 1980s.
All Australians should have a blood lead level below 10 mcg/dL (though there is no known safe level of lead).
Some communities are more susceptible to lead exposure due to industrial or mining activity, and some occupations and hobbies can also increase risk to household members. These include home and furniture restoration, soldering, burning of plastics and paints and cigarette smoking. Other potential sources include imported toys containing lead or coated with lead-based paints, some ‘traditional’ medicines and improperly fired ceramic cookware (e.g. imported tagines).
Levels of lead have increased in the biosphere 1000-fold in the past 300 years, especially during the second half of the twentieth century, but the elimination of lead in petrol has helped reduce the exposure risk.
Levels above 10 mcg/dL are associated with adverse neurocognitive effects including decreased IQ levels and behavioural issues, and it is uncertain whether levels below this also cause problems.
When symptoms appear, they are usually non-specific and may include lethargy, intermittent abdominal pain, irritability, headache, abnormal behaviour and, in acute high-level exposure (rare), encephalopathy.
High blood lead levels should be considered in the presence of unexplained iron-deficiency anaemia.
Advise parents or parents-to-be to reduce exposure to lead by testing paint (particularly old or peeling paint) in houses (testing kits are readily available in paint shops), painting over old paint, being careful with old furniture and imported toys, and avoiding exposure to smoking or other sources.