Chapter 91: Specific problems of children

The family doctor usually treats children for common minor complaints such as non-serious viral respiratory infections and minor skin problems, offering parental advice and reassurance. Many of these everyday problems are discussed in this chapter, while immunisations (CHAPTER 9) and more complicated problems such as anaemia, diarrhoea and chronic cough are covered elsewhere (see PART 3, Problem solving in general practice).

Crying and fussing in infants

Crying and fussing is a very common concern in the infant in the first few months. The term ‘colic’ (which is still widely used) needs to be used with caution, as it infers something is wrong with the gut of the infant, when most of the time this is not the case.¹

The normal pattern is for crying to start increasing around two weeks of age, to peak around two months, and then settle down around three to four months of age, perhaps five. On average, a baby cries or fusses for 3 hours a day. The amount of crying varies from baby to baby, but all babies cry—and not just human babies; in the early months babies of other mammal species cry as well. This is a survival instinct, to get the full attention of the carer and to establish attachment. It can also cause a great deal of distress for a mother or other carer, so active listening, careful assessment to exclude other causes and advice and reassurance are important.

Management

• History—crying pattern and duration, assessment of the child’s temperament and parents’ coping abilities.

• Perform careful physical examination, including growth parameters, feeding and settling pattern, and development.

• Reassure parents that extra attention will not affect the baby but overstimulation should be avoided.

• Give parental reassurance and education (including advice on soothing techniques and coping strategies).

Causes (to exclude)

• Cow’s milk intolerance

• Lactose intolerance

• Gastro-oesophageal reflux

• Pain from UTIs and other infections, bowel obstruction/hernias, other causes

Soothing techniques

• Gentle stroking and cuddling

• Providing close contact or skin-to-skin contact

• Talking to them, singing to them, smiling at them and rocking them

• Repetitive rocking movements help calm an overstimulated baby’s brain

Coping strategies¹

• Increase carry, comfort, walk and talk responses—the baby may still continue to cry, but there is a reasonable chance the parents may be able to soothe him or her.

• It’s okay to walk away—it’s important for parents to calm themselves before trying to calm their baby.

• Never shake or hurt a baby—advise that shaking a baby is a critically dangerous thing to do.

It is also useful to advise a parent to try and learn their baby’s signals and body language, which are unique for every infant. Some typical body language patterns include:

• tired—stiff, jerky movements, being quiet or still, blank faced, rubbing eyes, moodiness, droopy eyelids or slow blinking and crying

• hungry—open mouth, eager expression and crying

• ready for action—wide open eyes, alert expression and kicking legs

• upset—jerky movements, turning away and crying

Teething

Baby teeth (milk or deciduous teeth)

• Babies usually cut their teeth from age 6 months until 2–3 years.

• The first teeth to appear (which seldom cause discomfort) are usually the lower incisors (during the first year).

• The first and second molars (ages 1–3) tend to cause problems.

• Usually the first set (20 teeth) is complete soon after the second birthday (see FIG. 91.1).

Symptoms

• The gum is slightly swollen and red

• This may cause little or no discomfort but may be quite tender

• The child may be more clingy and fretful, and dribbling more than usual

• Chews and mouths (though mouthing fingers, hands and other objects is a normal infant behaviour, especially from 4 months onwards)

• Irritability and crying (on and off for no more than a few days)

Treatment

Parents are often misinformed about the importance and consequences of teething pain. Reassure parents that teething rarely results in anything more than minor distress, that it does not cause fever, rashes or diarrhoea, and that it will usually settle quickly.

Soothing methods

• Gentle massaging of the gum with the parent’s forefinger wrapped in a soft cloth or gauze pad is comforting.

  or

• Allow the baby to chew on a clean, cold, lightly moistened facewasher (a piece of apple can be placed inside the facewasher).

  or

• Give the baby a teething ring (kept cold in the refrigerator) or a teething biscuit.

Medication

Medicine is usually not necessary for teething. Paracetamol should be used only for significant discomfort. Teething gels are salicylate-based and are not recommended.

Pitted dark teeth and bruised teeth

Some children who are breastfed for long periods (e.g. 3 years) may develop unsightly pitting of the front surface of their teeth. This will not go away but parents should be reassured that the adult teeth will be normal when they appear.

Bruised teeth can result from minor trauma, with the tooth appearing a grey-brown colour. While a cosmetic issue for some parents, these too are not a concern and the adult tooth will appear and develop normally.

Thumb sucking

Thumb sucking involves placing the thumb or finger on the roof of the mouth behind the teeth (hard palate) and sucking with the mouth closed. Sucking is a normal and soothing behaviour for the infant, but it can become an entrenched habit. It occurs in children up to the age of 12 years but is most common under the age of 4 years. It usually settles by the early primary school years, and will sometimes stop if the child becomes self-conscious because other children notice. It can cause problems with the child’s bite, especially as the adult teeth appear, at about age 7. One effect is that the pressure on the front teeth may cause protrusion of the front teeth (i.e. buck teeth); another is a narrowing of the bite with a gap between the top and bottom incisors, referred to as an open anterior bite. This can also happen with pacifiers. The best approach is for parents to notice when the child is doing it less, and to comment on how grown up the child is becoming, rather than scolding or overly drawing attention to the behaviour.

Advice to parents

• No special diet or medication is necessary. Unpleasant-tasting topical applications to the pacifier or thumb are counter-productive.

• For a child over 6 years, carefully observe trigger factors and find ways of avoiding them. Provide distractions.

• Help the child explore other solutions to sooth themselves.

• Give praise and rewards for efforts to stop.

Snuffling infants

Snuffling frequently occurs in normal babies in the few weeks after birth and is not a problem unless it affects feeding. Infants and small children have particularly small noses, which block easily.

Snuffling in older infants is usually caused by rhinitis due to an intercurrent viral infection. The presence of yellow or green mucus should not be a cause for concern and is not an indication for antibiotics. Give reassurance, and advise that using a saline nasal solution to clear congestion is reasonable.

Blocked nasolacrimal duct

About 20% of infants develop watery eyes, but most resolve by 12 months. Excessive eye watering in infants is the key sign that there is inherited narrowing of the nasolacrimal ducts (see FIG. 91.2). It usually becomes obvious in infants between 3 and 12 weeks and affects one or both eyes. Mucus and mucopus may appear in the tears. The discharge is worse on waking. In some infants, watering and discharge soon after birth indicate that the ducts have failed to open. Infection may intervene (refer to CHAPTER 51) and conjunctivitis can be problematic.

Outcome

In most cases the problem improves spontaneously. Self-correction usually occurs from 6 months of age onwards or even earlier. It remains a matter of controversy whether massage helps or not.

Minor infection can be treated with warm cotton-wool soaks. For more severe blockage, recurrent conjunctivitis or when eye watering has not settled by 12 months, referral to an ophthalmologist for consideration of whether probing is warranted.

Failure to thrive (FTT)^2,3

It is essential to monitor growth of children, particularly infants (see CHAPTER 90). The sequential plotting of the weight, length and head circumference (anthropometric criteria) on growth charts (see Appendices I–IV) in the personal health record (PHR) and/or the doctor’s medical file on the child enables appropriate monitoring of this growth. The growth charts mean little without considering the context of the baby’s growth (e.g. premature babies, children of small parents). Correcting for prematurity (under 37 weeks) should be done until the age of 24 months.

Also, growth charts themselves have reliability issues. They are based on Caucasian children and are not fully representative for some other groups (e.g. Asian children tend to be smaller). Growth charts can also vary depending on whether they use data based on populations of exclusively breastfed infants or include formula-fed infants (who tend to grow faster).

Classically, failure to thrive (FTT) has been defined as children whose weight <3rd percentile on ≥2 occasions, or whose weight crosses two centile lines over time. These criteria, however, are met by 5% of infants at some stage, many of whom do not have concerning growth progression; they will also fail to pick up all children who may not be growing adequately. It is therefore important to consider the contextual issues of measurement mentioned above, as well as taking into account the overall clinical picture of the growth over time (e.g. how quickly is the percentile change happening) and the general health and development of the child. While FTT is a useful term to help identify and describe infants and children that may have growth issues, it is not a diagnosis in itself.

Average weight gain/week:

Weight gain slows further after 12 months of age.

Causes

Traditionally, FTT was divided into organic and non-organic causes. It is becoming increasingly recognised that in many cases the cause is multifactorial, including biological, psychosocial and environmental contributors. A practical way of considering potential causes is looking at caloric intake, absorption and expenditure. In many cases (>80%) no cause is found.

History

• Antenatal/birth/postnatal history—including growth parameters

• Feeding history (most important aspect)

  • – Infants—BF/attachment, formula feeding, timing, volumes (e.g. weigh infant before and after, mother expressing and measuring breast milk), vomiting?, solids introduction (see CHAPTER 90)

  • – Toddlers—types and amounts of foods/liquids (see CHAPTER 90), especially iron-containing foods, food intake inside and outside home, mealtime battles, distractions, food refusal, milk volume, parental food attitudes

• Medical history

• Developmental history (e.g. regression, specific known syndromes)

• Family history (e.g. mid-parental height, parents’ or siblings’ childhood weight gain)

• Social history (e.g. finance, supports)

Examination

• Growth charts (refer to FIG. 91.3)

• General appearance (does the child look sick/irritable/lethargic? dehydration? loss of subcutaneous fat? pallor? inappropriate bruising or affect)

• Observation of infant feeding and child–parent interaction (a home visit, or assessment by a lactation consultant/early childhood nurse may be useful here)

• Dysmorphic features

• Developmental assessment

• Jaundice/bruising/scratches

• Skin, hair and nails

• ENT

• Cardiac/respiratory

• Abdomen (e.g. distention, organomegaly)

• Endocrine (e.g. goitre, urinalysis, finger prick glucose)

• Lymphadenopathy

Investigations

In a healthy infant with no concerns found on history and examination, no investigations are required, and reassuring the family and further monitoring is appropriate. If concerns are found, targeted investigation for these should be done. Simple first-line investigations may include:

• FBC, CRP

• iron studies

• UEC/LFTs

• urine MC&S

• coeliac screen

• stool fat globules/fatty acid crystals

Other issues to consider

Frequent weighing of children may exacerbate parental anxiety. Babies under 3 months of age should not be weighed more than weekly, and not more than fortnightly after that. A paediatric review may be required in more significant FTT situations, and occasionally admission to hospital to further assess feeding, psychosocial aspects and other medical causes. In difficult cases, a team-based approach potentially using paediatricians, lactation consultants, dietitians, early childhood nurses, speech pathologists or psychologists as well as the family doctor can be utilised.

Short stature^4,5,6

Short stature is considered to be below the 3rd percentile. In general, it is important to differentiate between normal physiological variants of growth and pathological causes.

Causes

1. Familial short stature—this follows the family trend of a genetically small family.

2. Constitutional delay in maturation—a common and normal variant in which the growth spurt is later than average. Bone age is delayed.

3. Pathological causes—of the many causes, some are rare but serious conditions, such as coeliac disease, Crohn disease and chronic kidney failure. These may present with slow growth as the only abnormal sign.

Recombinant human growth hormone treatment for those children with idiopathic short stature (ISS, a diagnosis of exclusion) increases height in some children, with the range of benefit usually between 3 cm and 7 cm. It is expensive, and while considered safe in the short term, long-term safety is lacking. Specialist advice is recommended.

Tall stature

Tall stature is considered to be above the 97th percentile. It is not a common presenting childhood problem in general practice. The estimated mature height is:

• females: 182.9 cm

• males: 193.1 cm

Causes

• familial (predicted final height should roughly match mid-parental height)

• precocious puberty

• growth hormone excess (pituitary gigantism)

• hyperthyroidism

• syndromic: Marfan, Klinefelter, homocystinuria

Management

As tall stature is generally socially acceptable, reassurance, counselling and education may alleviate the family’s concerns. If treatment is considered appropriate, high-dose oestrogen is used in very tall girls (accelerates epiphyseal maturation and reduces final height) while high-dose testosterone is used for boys. The management should be undertaken by endocrinologists. The ideal time to commence hormone therapy is just after the appearance of the first pubertal changes.

Approximately a quarter of Australian children are overweight or obese.⁷ A recent national nutrition survey showed that children eat too much saturated fat and sugar and regularly exceed the recommended maximum times spent watching screens.⁸ Obesity in childhood increases the risk of adult obesity. Nutritional obesity is associated with growth acceleration and advancement of bone age, while endocrine obesity has the opposite effect. Refer to CHAPTER 78.

Delayed puberty⁹

This is the absence of pubertal development (testicular enlargement in boys or breast development in girls) in:

• girls >13 years

• boys >14 years

Significant causes include:

• constitutional delay of growth and puberty (CDGP) is usually familial and the commonest cause. It is associated with delayed growth and bone age

• chronic illness (e.g. severe asthma, cystic fibrosis, kidney failure)

• poor nutrition and exercise

• anorexia nervosa

Other less common causes include chromosomal abnormalities (e.g. Turner syndrome) and gonadal hormone deficiency (e.g. Kallmann syndrome, post-chemotherapy). Consider referral to a paediatric endocrinologist for investigation and management, which can include testosterone for boys and oestrogen for girls.

Precocious puberty¹⁰

Puberty is trending earlier than in previous generations, known as the ‘secular trend’, and is presumed to be due to improved nutrition and absence of chronic disease. True precocious puberty is considered to be:

• girls <8 years

• boys <9 years

Growth spurts will be earlier and bone growth will be advanced, though final adult height may be reduced from what would otherwise be expected due to premature fusion of the long bones (height issues may determine the need for treatment). True precocious puberty is 20 times more common in girls than boys. It is usually idiopathic, though pituitary adenomas are a rare cause and more common as a cause in boys (boys always require brain imaging). Treatments are often not required, but may include gonadotrophin releasing hormone (GnRH) analogues and cyproterone.

Premature thelarche¹⁰

This is breast development in girls under 8 years old without other pubertal signs. It usually occurs in girls under 3 years and spontaneous regression can be expected. It may present at birth. Observation with reassurance for this benign condition is appropriate.

Premature adrenarche¹⁰

This is the isolated appearance of pubic hair in boys or girls aged 6–9 years old. There are no other features of virilisation or oestrogenisation, and the hair remains until other signs of puberty appear at the normal time. It is usually a normal variant (no specific treatment necessary) but may rarely signify atypical congenital adrenal hyperplasia. Referral is indicated if any concerns.

Pubertal gynaecomastia¹⁰

This is a normal variant of male puberty, with a prevalence of about 40–50% and is usually a transient phenomenon, subsiding in 2–3 years.

There is a palpable and/or visible disc of breast tissue, which in boys may feel quite firm and needs to be distinguished from adipose tissue in overweight boys. There is no hormonal or medical treatment and surgical removal is rarely necessary. Advice regarding clothes (e.g. loose T-shirts for social activities or swimming) or explanatory letters to school can be helpful.

Asymmetrical breast development¹⁰

This may occur in both sexes—in males being a variant of pubertal gynaecomastia and in females part of a normal development process—and reassurance that the breast sizes will usually normalise in time is all that is required. If the discrepancy persists and is causing psychological problems, further strategies, such as prostheses or reconstructive surgery, may be advised by specialists.

Infant breast hyperplasia

A breast ‘bud’ is common in most term babies and may enlarge with breastfeeding (see FIG. 91.4). Milk may discharge from some (‘witches’ milk) but reassurance is all that is required (see CHAPTER 101).

Growing pains^11,12

Growing pains (benign nocturnal limb pains) are real and common (around 1 in 5 children).

Features

• Typical age 3–12 years

• Positive family history

• Usually bilateral and non-articular

• Poorly localised in leg—typical sites include shins, calves, thighs, popliteal fossa (see FIG. 91.5)

• Episodic, with pain-free intervals from weeks to months

• Last minutes to hours, regardless of treatments, and usually gone by the morning

• Usually occur late in the day or during the night

• Normal examination

• No associated symptoms

• No pain or disability next morning (runs okay)

• Very active days or being moody may lead to a ‘bad’ night

Management

• Problem resolves spontaneously in time

• Reassurance

• Consider analgesic and heat packs (usually unsuccessful)

• Massage is a reasonable option—appears to help

• Check ESR if in doubt

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.

Innocent murmurs¹³

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:

1. Sensitive (changes with child’s position or with respiration)

2. Short duration (not holosystolic)

3. Single (no associated clicks or gallops)

4. Small (murmur limited to a small area and non-radiating)

5. Soft (low amplitude)

6. Sweet (not harsh sounding)

7. Systolic (occurs during and is limited to systole)

Investigation

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^14,15

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.

What is normal?

Prevalence:

• 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.

Aetiology

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.

Assessment

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).

Treatment

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

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.

Alarm therapy

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.

Medications

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 children^16,17,18

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.

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.

Infantile haemangioma

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.

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.

Sebaceous hyperplasia

Hyperplastic sebaceous glands appear as tiny yellow–white papules on the nose or forehead. They disappear in several weeks.

Milia

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).

Miliaria (‘sweat rash’)

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:

• ‘crystallina’—beads of sweat trapped under the epidermis with surrounding erythema

• ‘rubia’—itchy red papules

It is a benign condition that disappears after a few weeks.

If problematic:

• 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

Suckling ‘blisters’

These are a hyperplastic response to suckling, and are common on the upper lip. Reassure that these will settle.

Umbilical discharge

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.

Bleeding umbilical cord

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).

Umbilical granuloma

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.

Pityriasis alba

• 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.

Treatment

• Reassurance

• Simple emollients

• Restrict use of soap and washing

• Mild steroids if scaly and itchy (rarely necessary)

Atopic dermatitis (eczema)

See FIGURE 91.9.

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

See FIGURE 91.10.

This is quite different from adult seborrhoeic dermatitis and appears in the first 2 to 3 months.

Refer to CHAPTER 121.

Nappy rash

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.

Advice to parents

• 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.

Treatment

• 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

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.

Treatment

• 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.

Advice to parents

• 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.

Treatment

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 in children²⁴

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

Refer to CHAPTER 126.

Lead poisoning²⁵

• 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.

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Bed-wetting (enuresis)

• Crying and unsettled baby

• Dyslexia and other SLDs

• Faecal incontinence in children (encopresis)

• Growing pains

• Infant colic

• Nappy rash

• Seborrhoea in infants

• Snuffling infant

• Tear duct blockage

• Teething

• Thumb sucking