Page 1044 - TNFlipTest

P10 Pediatrics
Common Complaints Toronto Notes 2019
• management
■ complete clean-out of bowel: PEG 3350 given orally is most effective, enemas and suppositories may
be second line therapies, but these are invasive and often less effective
■ maintenanceofregularbowelmovements(seeConstipation,P38)
■ assessment and guidance regarding psychosocial stressors ■ behavioural modification
• complications:recurrence,toxicmegacolon(requires>3-12mototreat),bowelperforation Toilet Training
• 90%ofchildrenattainbladdercontrolbeforebowelcontrol
• generally,femalestrainearlierthanmales
• 25%by2yr(inNorthAmerica),98%by3yrhavedaytimebladdercontrol • signsoftoiletreadiness
■ ambulatingindependently,stableonpotty,desiretobeindependentortopleasecaregivers(i.e. motivation), sufficient expressive and receptive language skills (2-step command level), can stay dry for several h (large enough bladder), can recognize need to go, able to remove clothing
Failure to Thrive
• clinicalpresentation
■ weight<3rdpercentile,fallsacrosstwomajorpercentilecurves,or<80%ofexpectedweightforheightandage ■ inadequatecaloricintakemostcommonfactorinpoorweightgain
■ mayhaveothernutritionaldeficiencies(e.g.protein,iron,vitaminD)
■ factorsaffectingphysicalgrowth:genetics,intrauterinefactors,nutrition,endocrinehormones,
chronic infections/diseases, psychosocial factors • clinicalpresentation
■ history
◆ nutritional intake
◆ current symptoms
◆ past illnesses
◆ family history: growth, puberty, parental height and weight including mid-parental height ◆ psychosocial history
■ physical exam
◆ growth parameters, plotted: height, weight, head circumference, arm span ◆ vital signs
◆ complete head to toe exam
◆ dysmorphic features or evidence of chronic disease
◆ upper to lower segment ratio
◆ sexual maturity staging
◆ signs of maltreatment or neglect
• investigations(asindicatedbyclinicalpresentation) ◆ CBC, blood smear, electrolytes, T4, TSH
◆ bone age x-ray
◆ chromosomes/karyotype
◆ chronic illness: chest (CXR, sweat Cl–), cardiac (CXR, ECG, Echo), GI (celiac screen, inflammatory markers, malabsorption), renal (urinalysis), liver (enzymes, albumin)
Mid-Parental Height
• Boys target height = (father ht + mother ht+13)/2
• Girls target height = (father ht + mother ht–13)/2
Note: height should be taken in cm
Clinical Signs of FTT
SMALL KID Subcutaneous fat loss Muscle atrophy Alopecia
Lethargy
Lagging behind normal Kwashiorkor
Infection (recurrent) Dermatitis
Upper to Lower Segment Ratio
• Increased in achondroplasia, short limb
syndromes, hypothyroid, storage diseases
• Decreased in Marfan’s, Klinefelter’s,
Kallman’s syndromes, and testosterone
deficiency
• Calculation: upper segment/lower segment
• Upper segment: top of head to pubic symphysis
• Lower segment: pubic symphysis to floor
Table 8. Failure to Thrive Patterns
Growth Parameters
Decreased Wt Decreased Wt Decreased Wt
Normal Ht Decreased Ht Decreased Ht
Normal HC Normal HC Decreased HC
Suggestive Abnormality
Caloric insufficiency Decreased intake
Structural dystrophies Endocrine disorder
Intrauterine insult
Hypermetabolic state Increased losses
Constitutional growth delay (BA < CA) Familial short stature (BA = CA)
Genetic abnormality
BA = bone age; CA = chronological age; HC = head circumference; Ht = height; Wt = weight
Etiology
• aninterplaybetweenpathophysiologyandpsychosocialinfluences.Investigationsshouldassess: ■ complex factors in the parent-child relationship
◆ dietary intake, knowledge about feeding, improper mixing of formula ◆ feeding environment
◆ parent-child interaction, attachment
◆ child behaviours, hunger/satiety cues
◆ postpartum depression
◆ social factors: stress, poverty, neglect, child/domestic abuse, parental substance abuse, restricted
diets