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Abdominal Masses

An abdominal mass or abdominal fullness in a child usually becomes apparent when it enlarges enough to be visualized during bathing or palpable on physical examination. Masses may arise from intraperitoneal, retroperitoneal, or abdominal wall locations and emanate from both solid and hollow viscera ( Figs. 20.1 and 20.2 ). An abdominal mass may prove life threatening (e.g., malignant neoplasm, splenic sequestration crisis in sickle cell…

Constipation

Constipation is defined symptomatically as the infrequent passage of hard stools, straining while passing a stool, or pain associated with the passage of a hard stool. The range of normal defecation patterns in children is widely variable, though in general, formula-fed infants may have four to five stools per day in the first weeks of life, while breast-fed infants usually pass softer and more frequent stools.…

Jaundice

Jaundice, the yellow discoloration of skin and sclerae, results when the serum level of bilirubin, a pigmented compound, is elevated. Jaundice is not evident until the total serum bilirubin is at least 2–2.5 mg/dL in children out of the neonatal period. Bilirubin is formed from the degradation of heme-containing compounds, particularly hemoglobin ( Fig. 18.1 ). Microsomal heme oxygenase, located principally in the reticuloendothelial system, catabolizes…

Hepatomegaly

Hepatomegaly can occur as a feature of primary liver disease or as a result of systemic disorders such as congenital anomalies, inborn errors of metabolism, and perinatal or postnatal infections ( Tables 17.1 and 17.2 ). Common symptoms of hepatic dysfunction, such as fatigue, fever of unknown origin, pruritus, failure to thrive, confusion, change in mental status, and/or diarrhea, are nonspecific. Hepatomegaly and jaundice are frequently the…

Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding in children can range from small amounts of blood in the stool, associated with milk protein allergy or anal fissure, to life-threatening hemorrhage, associated with portal hypertension or peptic ulcer disease. Severe bleeding is a true medical emergency and necessitates prompt diagnostic attention and appropriate management since overall mortality of children hospitalized in the United States with GI bleeding is approximately 2%. Hemodynamic…

Vomiting and Regurgitation

Definitions Vomiting/emesis is a protective reflex in response to a variety of stimuli that results in forceful ejection of stomach contents. The emetic reflex is complex and composed of three sequential events. Initially there is a prodromal phase characterized by nausea and autonomic changes, followed by retching and finally vomiting or forceful expulsion of gastric contents through the oral cavity. These events may occur independent of…

Diarrhea

Diarrhea is the passage of unusually loose or watery stools, typically at least three times in a 24-hour period, and should be considered in a child who is passing stools more frequently than usual with a consistency looser than what is considered normal for that individual. Diarrhea is classified broadly by the duration of symptoms. Acute diarrhea is usually a self-limited illness that lasts for 2…

Abdominal Pain

Acute abdominal pain is usually a self-limiting, benign condition that is commonly caused by gastroenteritis, constipation, or a viral illness. The challenge is to identify children who require immediate evaluation for potentially life-threatening conditions. Chronic abdominal pain is also a common complaint in pediatric practices, as it makes up 2–4% of pediatric visits. At least 20% of children seek attention for chronic abdominal pain by the…

Failure to Thrive

Calories from food provide energy for the body’s maintenance functions of repair, regulation, metabolism, replacement of losses, and daily activity. Children have additional caloric requirements because they are growing. Children under the age of 3 years whose caloric needs are not met do not grow according to published norms and are said to have failure to thrive (FTT) or growth faltering. FTT raises serious concerns. It…

Hypertension

The first step in the evaluation of a child for hypertension is to define whether the child is in fact hypertensive. For children under 13 years of age, the normative data for blood pressure are interpreted based on gender, age, and height because all these are variables that influence blood pressure norms. The current hypertension definition and staging lead to seamless interfacing with the 2017 American…

Shock

What Is Shock: Pathophysiology Shock is a condition in which inadequate tissue perfusion results in an insufficient delivery of oxygen to meet the body’s metabolic needs. Tissue perfusion is dependent on cardiac output. Cardiac output (CO) is determined by the heart rate (HR) and the stroke volume (SV): CO = HR × SV. If either the heart rate or the stroke volume does not allow for…

Murmurs

A heart murmur is a sign, the audible turbulence of blood flow through the heart or the major vessels; symptoms associated with heart murmurs vary by the underlying cause, as well as the nature and severity of any cardiac lesion producing the murmur. While the majority of heart murmurs are normal or innocent, they must be distinguished from the pathologic murmurs of congenital or acquired cardiac…

Chest Pain

Chest pain in children is a common complaint; however, it is rarely due to underlying cardiac illness. This underscores the importance of avoiding a false sense of safety in low-risk causes and maintaining vigilance for potential life-threatening etiologies. Chest pain can be the presenting complaint for a child describing chest tightness, burning, pressure, stabbing sensations, palpitations, and/or heartburn. It can be encountered in outpatient, emergency, and…

Syncope and Dizziness

Dizziness is a common but very nonspecific chief complaint about which some elaboration by the patient is generally required for the physician to understand exactly what the patient is experiencing. The description of the sensation is critical in distinguishing whether it is caused by vertigo, disequilibrium, lightheadedness, presyncope, or ataxia ( Table 7.1 ). Although the differential diagnoses of these entities may overlap, there are conditions…

Apparent Life-Threatening Event/Brief Resolved Unexplained Event

A brief resolved unexplained event (BRUE) is a term used to describe events occurring in infants younger than 1 year of age that are characterized by the observer as “brief” (lasting <1 minute but typically <20–30 seconds) and “resolved” (meaning the patient returned to baseline state of health after the event) and with a reassuring history, physical examination, and vital signs at the time of clinical…

Earache

Earache (otalgia) is pain that arises from a pathologic process in the external, middle, or inner ear or that is referred to the ear from another structure. Acute otitis media (AOM) is the most common cause of otalgia in children ( Table 5.1 ). At least 80% of children will experience one or more episodes of AOM in the first 3 years of life. The second…

Respiratory Distress

The main function of the respiratory system is to supply oxygen to meet the body’s demands and remove excess carbon dioxide. Many processes are involved in ensuring that this occurs, including ventilation (gas delivery to and from the lungs), perfusion (blood supply to the lungs), and diffusion (the exchange of gases along the alveoli). Respiratory distress arises when there is impaired air exchange that leads to…

Cough

Introduction Cough is an important defense mechanism of the lungs and is a common symptom, particularly during winter months. In most patients, it is self-limited. However, cough can be ominous, indicating serious underlying disease, because of accompanying problems (hemoptysis) or because of serious consequences of the cough itself (e.g., syncope and hemorrhage), or cough may present as an uncommon disorder that mimics a common disease. Pathophysiology…

Sore Throat

Most causes of sore throat are nonbacterial and neither require nor are alleviated by antibacterial therapy ( Tables 2.1, 2.2, and 2.3 ). Accurate diagnosis is essential. Acute streptococcal pharyngitis warrants proper diagnosis and prompt therapy to prevent serious suppurative and nonsuppurative sequelae. Life-threatening complications of oropharyngeal infections, whether caused by streptococci or other pathogens, may manifest initially with poorly differentiated symptoms of mouth pain and…

Pearls for Practitioners

Chapter 197 Orthopedics Assessment Orthopedic rough guide to developmental milestones Sit independently at 6 months Pull to stand at 10 months Cruising at 12 months Walk at 18 months Lower extremity angular profile Genu varum (bowlegs) at birth and begin to straighten out by 18 months Genu valgum (knock knees)—maximum at 4 years old and resolves by 5–8 years of age Pathologic genu verum: Blount disease…