Children: Special Observations

INTRODUCTION

The diagnostic approach to the child is based on the ability to achieve good lines of communication with both the child and the parent.

ESTABLISHING RAPPORT

Showing a genuine interest in the child with strategies such as:

• asking them what they like to be called

• passing a compliment about the child, such as a clothing item or a toy or book they are carrying

• taking time to converse with them

• asking them if they would like to be a doctor when they grow up

• asking about their teacher or friends

To facilitate the examination:

• play games, such as a flashing light, tickling or peekaboo, and use any type of noise, particularly animal noises

Distract attention with strategies such as:

• small animal images (e.g. koalas on stethoscopes)

• a small toy duck with rattle inside to palpate abdomen

• a clockwork revolving musical toy over examination couch

• a mechanical toy (e.g. rabbit playing a drum on the desk)

Recognition of serious illness in infancy

It is vital to diagnose serious life-threatening disease in children, esp. in early infancy. The signs of a very sick child include:

• inactive, lying quietly, uninterested

• reduced mental state

• increased respiratory rate

• increased work of breathing

• noisy breathing

  • – chest wall retraction

  • – wheezes, grunting, stridor

• tachycardia

• sunken eyes

• mottled, cold, pale skin

• drowsiness

  (Red flag pointers, 128)

Serious illnesses to consider include:

• meningococcal infection

  • – septicaemia

  • – meningitis

Note: Meningococcaemia can present with a maculopapular rash before becoming purpuric.

• H. influenzae type B (Hib) infection (now uncommon since Hib immunisation)

  • – acute epiglottitis

  • – meningitis

• other forms of meningitis

• acute myocarditis

• asthma/bronchitis/bronchiolitis

• pneumonia

• intussusception/bowel obstruction/appendicitis

• severe gastroenteritis

• urinary tract infection

THE CHILD AS A BAROMETER OF THE FAMILY

A disturbed child is a very common indicator of family disharmony. There is a saying that ‘love is to a child what sunlight is to a flower’.

The child’s reaction to the family disharmony may manifest in three ways (with significant overlap):

• behavioural problems

• psychosomatic symptoms

• school difficulties

FAILURE TO THRIVE (FTT)

FTT is failure to gain expected weight, being below the 3rd percentile up to 2 yrs on ≥2 occasions. It is an indicator of an underlying disorder, either non-organic (psychosocial) or organic. The main reasons for FTT (up to 90%) are nutritional deprivation and normal variants.

Non-organic FTT can be caused by emotional deprivation or by poor nutrition from inadequate intake. A home visit to evaluate the home environment, including adequacy of parenting, is invaluable. This includes liaison with a community nurse.

Organic FTT includes ...