1047

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Third edition 2012
Second edition 2006
First published 2002
ISBN 978 1905635 764
eISBN 978 1909491 045
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The information contained within this book was obtained by the author from reliable sources. However, while every effort has been made
to ensure its accuracy, no responsibility for loss, damage or injury occasioned to any person acting or refraining from action as a result of
information contained herein can be accepted by the publishers or author.
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Contents
Contributors
Preface to the Third edition
CHAPTERS
1. Cardiology
Robert Tulloh
2. Child Development, Child Mental Health and Community Paediatrics
Joanne Philpot and Ruth Charlton
3. Child Protection and Safeguarding
4. Clinical Governance
Robert Wheeler
5. Clinical Pharmacology and Toxicology
Steven Tomlin
6. Dermatology
Helen M Goodyear
7. Emergency Paediatrics
Serena Cottrell
8. Endocrinology and Diabetes
Heather Mitchell and Vasanta Nanduri
9. Ethics and Law
Vic Larcher and Robert Wheeler
10. Gastroenterology and Nutrition
Mark Beattie and Hemant Bhavsar
11. Genetics
Natalie Canham
12. Haematology and Oncology
Michael Capra
13. Hepatology
Nancy Tan and Anil Dhawan

14. Immunology
Pamela Lee and Bobby Gaspar
15. Infectious Diseases
Nigel Klein and Karyn Moshal
16. Metabolic Medicine
Mike Champion
17. Neonatology
Grenville F Fox
18. Nephrology
Christopher J D Reid
19. Neurology
Neil H Thomas
20. Ophthalmology
Ken K Nischal
21. Orthopaedics
Vel K Sakthivel
22. Respiratory
Rebecca Thursfield and Jane C Davies
23. Rheumatology
Nathan Hasson
24. Statistics
Angie Wade
25. Surgery
Merrill McHoney
Picture Permissions
Index
Contributors to the Third Edition
Dr R M Beattie BSc MBBS MRCP FRCPCH

Consultant Paediatric Gastroenterologist, Southampton General Hospital, Southampton
Hemant S Bhavsar MBBS DCH MRCPCH MD

Specialist Registrar in Paediatric Gastroenterology, Birmingham Childrens Hospital, Birmingham
Natalie L E Canham MBChB BA (Hons) MRCP (Paeds)

Consultant in Clinical Genetics, North West Thames Regional Genetics Service, Northwick Park
Hospital, Harrow, Middlesex
Michael L Capra MBBCH DCH Dip. Obst FRPCH MMedSci (Clinical

Education)
Consultant Paediatric Oncologist, Department of Haematology/Oncology, Our Ladys Childrens
Hospital, Crumlin, Dublin 12
Michael P Champion BSc MBBS MRCP FRCPCH

Consultant in Paediatric Inherited Metabolic Disease, Evelina Childrens Hospital, Guys and St.
Thomas NHS Foundation Trust, London
Ruth Charlton MBBS MRCP MRCPCH

Consultant Paediatrician, Epsom and St. Helier University Hospitals NHS Trust, Epsom, Surrey
Serena Cottrell BSc (Hons) MBBS MRCPI MMed Sci FRCPCH

Lead Consultant in Paediatric Emergency Medicine, Queen Alexandra Hospital, Portsmouth
Jane C Davies MBChB MRCP MRCPCH MD

Honorary Consultant, Paediatric Respiratory Department, Royal Brompton Hospital, London
Professor Anil Dhawan MD FRCPCH

Paediatric Liver Centre, Kings College Hospital NHS Foundation Trust, London
Grenville F Fox MBChB MRCP FRCPCH

Consultant Neonatologist, Evelina Childrens Hospital Neonatal Unit, Guys and St Thomas Hospital
Foundation Trust, London
Professor Bobby Gaspar BSc MBBS MRCP (UK) PhD MRCPCH

Professor of Paediatrics and Immunology, Centre for Immunodeficiency, Molecular Immunology Unit,
UCL Institute of Child Health, University College London, London
Helen M Goodyear MBChB MRCP FRCPCH MD MMed

Consultant Paediatrician and Associate Postgraduate Dean, Birmingham Heartlands and Solihull NHS
Trust, Department of Child Health, Birmingham
Nathan Hasson MBChB FRCPCH

Consultant Paediatric Rheumatologist, The Portland Hospital, London
Professor Nigel Klein BSc MBBS MRCP FRCPCH PhD

Professor of Infection and Immunology, University College London, Consultant in Infectious Diseases,
Great Ormond Street Hospital, London
Vic Larcher BA MA MB BChir MRCP FRCPCH

Consultant in Adolescent Medicine (Chronic Fatigue) and in Clinical Ethics, Adolescent Medicine
Department, Level 10 Southwood Building, Great Ormond Street Hospital, London
Pamela Lee MBBS MRCPCH

Honorary Clinical Fellow, Great Ormond Street Hospital NHS Trust, London
Merrill McHoney FRCS(Paed Surg) PhD

Consultant Paediatric Surgeon, Royal Hospital for Sick Children Edinburgh, Edinburgh
Heather Mitchell BM.BCh MD MA FRCPCH MRCP(Paeds) MRCGP DCH

DRCOG
Consultant Paediatrician, West Hertfordshire Hospitals Trusts
Karyn Moshal MBChB MRCP (UK) MRCPCH DTM+H

Consultant in Paediatric Infectious Diseases, Great Ormond Street Hospital for Children, London
Vasanta R Nanduri MBBS DCH MRCP MD FRCPCH

Consultant Paediatrician, Watford General Hospital, Watford
Ken K Nischal FRCOphth

Director and Professor, UPMC Childrens Hospital of Pittsburgh, USA
Honorary Consultant, Great Ormond Street Hospital for Children, London
Joanne Philpot BA MBBS MD DCH MRCPCH

Consultant Paediatrician, Wexham Park Hospital, Slough
Christopher J D Reid MB ChB MRCP (UK) FRCPCH

Consultant Paediatric Nephrologist, Evelina Childrens Hospital, London
Vel K Sakthivel FRCS(Ed), FRCS (Orth)

Consultant in Trauma and Orthopaedics, University Hospitals Southampton, Southampton
Nancy Tan MBBS MMED (Paeds) MRCPCH (Edin) Dip (FP) Derm (Spore)
Consultant, Department of Paediatrics Medicine, KK Womens and Childrens Hospital, Singapore
Neil H Thomas MA MB MChir FRCP FRCPCH DCH

Consultant Paediatric Neurologist, Southampton General Hospital, Southampton
Rebecca Thursfield MBChB MRCPCH

Clinical Research Fellow, Dept Paediatric Respiratory Medicine, Royal Brompton Hospital, London
Stephen R Tomlin FRPharmS ACPP

Consultant Pharmacist Childrens Services, Evelina Childrens Hospital, London
Honorary Senior Lecturer, Centre for Paediatric Pharmacy Research, University College School of
Pharmacy
Robert M R Tulloh MA DM FRCP FRCPCH

Consultant in Paediatric Cardiology with an interest in Pulmonary Hypertension, Bristol Congenital
Heart Centre, Hon reader in Clinical Sciences, University of Bristol
Director of Medical Education, University Hospitals Bristol NHS Foundation Trust, Bristol
Angie M Wade MSc PhD CSTAT ILTM

Senior Lecturer in Medical statistics, Centre for Paediatric Epidemiology and Biostatistics, Institute
of Child Health, London
Robert Wheeler FRCS MS LLB(Hons) LLM

Consultant Neonatal and Paediatric Surgeon, Senior Lecturer in Clinical Law, Wessex Regional
Paediatric Surgical Centre, Southampton General Hospital, Southampton
Preface to the Third Edition
The first edition of Essential Revision Notes for the MRCPCH was in response to the candidates
often expressed desire for a single text covering essential information required for the examination in
a clear and concise way. The format of the examination has changed considerably over the 10 years
since, although the need for a sound knowledge base of the principles and practice of paediatrics
remains crucial for success. We have been delighted with the response to the first and second edition
of this text and the consistent positive feedback from trainees. The third edition has been completely
revised and extensively updated and we hope will continue to be considered as relevant to the
examination and future paediatric practice.
We are indebted to the many contributing authors, experts in their fields and expert clinical teachers.
We are indebted to PASTEST for their continued enthusiastic support.
We are also indebted to the candidates for their enthusiasm and commitment to the speciality and hope
very much that this new edition of Essential Revision Notes for the MRCPCH will continue to help
trainees to get through their paediatric membership and be useful to them subsequently as an up to
date and relevant paediatric textbook.
Mark Beattie
Mike Champion
Chapter 1
Cardiology
Robert Tulloh
CONTENTS
1. Diagnosis of congenital heart disease
1.1 Fetal cardiology
1.2 Epidemiology
1.3 Cardiac anatomy
1.4 Nomenclature for sequential segmental arrangement
1.5 Examination technique
1.6 Innocent murmurs
2. Basic cardiac physiology

2.1 Physiology of adaptation to extrauterine life
2.2 Physiology of congenital heart disease
2.3 Physiology of heart muscle and heart rate
3. Left-to-right shunt
3.1 Atrial septal defect (ASD)
3.2 Ventricular septal defect (VSD)
3.3 Persistent ductus arteriosus (PDA)
3.4 Aortopulmonary window
3.5 Others
4. Right-to-left shunt
4.1 Tetralogy of Fallot
4.2 Transposition of the great arteries
4.3 Pulmonary atresia
4.4 Ebstein anomaly
4.5 Eisenmenger syndrome
5. Mixed shunt
5.1 Complete atrioventricular septal defects
5.2 Tricuspid atresia
5.3 Others
6. Obstruction in the well child

6.1 Aortic stenosis
6.2 Pulmonary stenosis
6.3 Adult-type coarctation of the aorta
6.4 Vascular rings and slings
7. Obstruction in the sick newborn

7.1 Coarctation of the aorta
7.2 Hypoplastic left heart syndrome
7.3 Critical aortic stenosis
7.4 Interruption of the aortic arch
7.5 Total anomalous pulmonary venous connection
8. Non-bypass surgery for congenital heart disease

8.1 Shunt operation
8.2 Coarctation of the aorta repair
8.3 Pulmonary artery band
8.4 Arterial duct ligation
9. Bypass surgery for congenital heart disease

9.1 Switch operation
9.2 Fontan
9.3 Norwood
9.4 Rastelli
9.5 Other operations
10. Syndromes in congenital heart disease

10.1 Isomerism
10.2 Trisomy
10.3 Williams syndrome
10.4 Noonan syndrome
10.5 DiGeorge syndrome
10.6 Alagille syndrome
10.7 Turner syndrome
10.8 Marfan syndrome
10.9 VACTERL
10.10 HoltOram/Thrombocytopenia and absent radius (TAR)/Fanconi syndromes
10.11 CHARGE
10.12 Pentalogy of Cantrell
10.13 Dextrocardia
10.14 Other syndromes
11. Syncope in childhood

12. Pulmonary hypertension
12.1 Persistent pulmonary hypertension of the newborn
12.2 Increased pulmonary blood flow
12.3 Chronic hypoxia
12.4 Pulmonary venous hypertension
13. Drug therapy for congenital heart disease

13.1 Heart failure
13.2 Anticoagulation
13.3 Pulmonary hypertension
13.4 Antiarrhythmia
14. Acquired heart disease

14.1 Kawasaki disease
14.2 Dilated cardiomyopathy
14.3 Hypertrophic cardiomyopathy
14.4 Suspected bacterial endocarditis
14.5 Rheumatic fever
14.6 Pericarditis
15. ECG
15.1 The ECG and how to read it
15.2 Tachycardias
15.3 Bradycardias
16. Chest X-rays

16.1 Cardiac outlines
17. Cardiac catheterization

17.1 Diagnostic cardiac catheterization
17.2 Interventional cardiac catheterization
18. Imaging
18.1 Echocardiography
18.2 Magnetic resonance imaging
18.3 Positron emission tomography
18.4 Radionuclear angiography
19. Further reading
Cardiology
1. DIAGNOSIS OF CONGENITAL HEART DISEASE

1.1 Fetal cardiology
Diagnosis
In the UK, most children (>70%) who require infant surgery for congenital heart disease (CHD) are
diagnosed during pregnancy at 1620 weeks gestation. This gives a significant advantage to the
parents who are counselled by specialists who can give a realistic guide to the prognosis and
treatment options. A few undergo termination of pregnancy (depending on the diagnosis). Most
continue with the pregnancy and can be offered delivery within the cardiac centre if there could be
neonatal complications or if treatment is likely to be needed within the first 2 days of life. Surgical
intervention during fetal life is not yet routinely available.
Screening (by a fetal cardiologist) is offered to those with:
Abnormal four-chamber view on routine-booking, antenatal-anomaly ultrasound scan
Increased nuchal translucency (thickness at back of the neck), which also increases the risk of
Down syndrome
Previous child with or other family history of CHD
Maternal risk factors, such as phenylketonuria or diabetes
Suspected Down, or other, syndrome
Important normal findings on fetal echocardiography include echodensities:
Used to be called golf balls

Found on anterior mitral valve papillary muscle
Thought to be calcification during development
No importance for CHD
Positive association with Down syndrome
Do not need echocardiogram after delivery
Arrhythmias
Diagnosed at any time during pregnancy: an echocardiogram is required to confirm normal anatomy
and to confirm type of arrhythmia. Fetal electrocardiogram (ECG) is not yet a routine investigation
Multiple atrial ectopics are usually not treated
Supraventricular tachycardia is usually treated with maternal digoxin or flecainide
Heart block may be treated with maternal isoprenaline or salbutamol
Presence of hydrops is a poor prognostic sign
1.2 Epidemiology of congenital heart disease

Eight per 1000 live births have CHD, of which the most common are:
Ventricular septal defect
Persistent arterial duct
Atrial septal defect
Pulmonary stenosis
Aortic stenosis
Coarctation of the aorta
Tetralogy of Fallot
Transposition of the great arteries
Atrioventricular septal defect
30%
12%
7%
7%
5%
5%
5%
5%
2%
Incidence is increased by a positive family history, so the proportion of live births with CHD will be:
Previous sibling with CHD
Two siblings with CHD
Father with CHD
Mother with CHD
2%
4%
3%
6%
Incidence also increased by:
Presence of other anomaly or syndrome

Parents with an abnormal genotype
Maternal ingestion of lithium (Ebstein anomaly)
Third-trimester enterovirus or Coxsackievirus infection (myocarditis, dilated cardiomyopathy)
Maternal systemic lupus erythematosus (anti-ro, anti-la antibodies leading to congenital heart
block)
1.3 Cardiac anatomy
Normal heart
1.4 Nomenclature for sequential segmental arrangement

The European (as opposed to American) system for complete heart diagnosis is referred to as
sequential segmental arrangement. The advantage is that it is no longer necessary to remember the
pattern of an eponymous syndrome. The disadvantage is that it is quite long-winded. The idea is that
each component is described in turn:
Atrial arrangement (atrial situs)
Usual (solitus)
Mirror image (inversus)
Right isomerism (asplenia syndrome)
Left isomerism (polysplenia syndrome)
Atrioventricular (AV) connection

Type of atrioventricular connection
Biventricular:
Concordant
Discordant
Ambiguous (with atrial isomerism)

Univentricular:
Absent left AV connection
Absent right AV connection
Double inlet AV connection
Mode of atrioventricular connection
Two AV valves
Common AV valve
Straddling right or left AV valve
Imperforate right or left AV valve
Overriding right or left AV valve
Ventricular topology
Right-hand (normal) or left-hand topology
Ventriculoarterial connection
Type of ventriculoarterial connection
Concordant
Discordant
Double outlet
Single outlet:
Common arterial trunk
Solitary arterial trunk
With pulmonary atresia
With aortic atresia
Mode of ventriculoarterial connection

Two perforate valves
Left or right imperforate valve
Infundibular morphology
Arterial relationships
Associated malformations
Position of heart in the chest left, right or middle
Systemic and pulmonary veins
Atrial septum
Atrioventricular valves
Ventricular septum
Semilunar valves
Anomalies of great arteries (e.g. double aortic arch)
Surgical or interventional procedures

Acquired or iatrogenic lesions
1.5 Examination technique
To many candidates the diagnosis of congenital heart disease is daunting. Certainly, if the candidate
examines the child, listens to the heart and then tries to make a diagnosis, this will prove difficult.
The following system should be used instead.
History
The history taking is short and to the point. The candidate needs to know:
Was the child born preterm?
Are there any cardiac symptoms of:
heart failure (breathlessness, poor feeding, faltering growth, cold hands and feet)?
cyanosis?
neonatal collapse?
Is it an asymptomatic heart murmur found on routine examination?
Is there a syndrome such as Down syndrome?
Is there any family history of congenital heart disease?
Did the mother have any illnesses or take any medication during pregnancy?
Examination
Introduce yourself to mother and patient. Ask if you can examine the child.
Position child according to age:
For a 6 year old at an angle of 45
For a toddler upright on mothers knee
For a baby flat on the bed
Remove clothes from chest
Stand back and look for:
Dysmorphism
Intravenous infusion cannula
Obvious cyanosis or scars.
The following examinations should be performed.
Heart failure
The delivery of oxygen to the peripheral vascular bed is insufficient to meet the metabolic demands of
the child. Usually because of left-to-right shunt with good heart pump function.
A thin, malnourished child (faltering growth)

Excessive sweating around the forehead
Tachycardia
Breathlessness subcostal or intercostal recession
Poor peripheral perfusion with cold hands and feet
A large liver
Never found with ventricular septal defect (VSD) or other left-to-right shunt in first week of life
An emergency if found up to 7 days of age. Implies a duct-dependent lesion, e.g. hypoplastic left
heart syndrome or coarctation
Cyanosis
Mild cyanosis is not visible use the pulse oximeter
Clubbing
Visible after 6 months old
First apparent in the thumbs or toes
Best demonstrated by holding thumbs together, back to back to demonstrate loss of normal nail-bed
curvature
Disappears a few years after corrective surgery
Pulse
Rate (count for 6 seconds 10)
Rhythm (only regular or irregular, need ECG for sinus rhythm)
Character at the antecubital fossa with the elbows straight, using the thumbs on both arms together
Head and neck

Anaemia for older children only ask the patient to look up and examine the conjunctivae (not
appropriate in a baby).
Cyanosis the tongue should be examined for central cyanosis. If in doubt ask the child to stick out
their tongue and ask the mother to do the same. This will detect oxygen saturations of <85%.
Jugular venous pressure the head is turned towards the candidate so that the other side of the neck
(the left side) can be seen with the jugular venous pressure visible, outlined against the pillows. In
a child who is under 4 years, the jugular venous pressure should not be assessed.
Carotid thrill essential part of the examination, midway up the left side of the neck, felt with the
thumb, proof of the presence of aortic stenosis
Precordium
Inspection
Respiratory rate
Median sternotomy scar (= open heart surgery see Section 9)
Lateral thoracotomy scar (BlalockTaussig [BT] shunt, patent ductus arteriosus [PDA] ligation,
pulmonary artery [PA] band, coarctation repair)
Additional scars, e.g. on the abdomen
Palpation
Apex beat the most inferior and lateral position where the index finger is lifted by the impulse of
the heart. Place fingers along the fifth intercostal space of both sides of chest (for dextrocardia)
and count down apex position only if patient is lying at 45
Left ventricular heave
Right ventricular heave at the left parasternal border
Thrills at upper or lower left sternal edge
Auscultation
Heart sounds and their character
Additional sounds
Murmurs, their character, intensity and where they are best heard
Heart sounds
First heart sound is created by closure of the mitral and then tricuspid valves. It is not important for
the candidate to comment on the nature of the first heart sound.
Second heart sound, however, is more important, created by closure of first the aortic and then the
pulmonary valves.
Loud pulmonary sound pulmonary hypertension
Fixed splitting of second sound (usually with inspiration the sounds separate and then come
together during expiration). Listen when patient is sitting up, at the mid-left sternal edge in
expiration:
Right bundle-branch block
Single second sound in transposition of great arteries (TGA), pulmonary atresia or hypoplastic left
heart syndrome
Quiet second sound may occur in pulmonary valve stenosis or pulmonary artery band
Additional sounds
Added sounds present may be a normal third or fourth heart sound heard in the neonate or these
sounds can be pathological, for example in a 4 year old with a dilated cardiomyopathy and heart
failure. An ejection click is heard at aortic valve opening, after the first heart sound, and is caused by
a bicuspid aortic valve in most cases.
Murmurs
Before listening for any murmurs, the candidate should have a good idea of the type of congenital
heart disease, which is being dealt with. The candidate should know whether the child is blue (and
therefore likely to have tetralogy of Fallot) or is breathless (likely to have a left-to-right shunt) or has
no positive physical findings before auscultation of the murmurs (and therefore more likely to either
be normal, have a small left-to-right shunt or mild obstruction). By the time the murmurs are
auscultated, there should only be two or three diseases to choose between, with the stethoscope being
used to perform the fine tuning. It is best to start at the apex with the bell, and move to the lower left
sternal edge with the diaphragm. Then on to the upper left sternal edge and upper right sternal edge
both with the diaphragm. Additional areas can be auscultated, but provide little additional
information. Murmurs are graded out of six for systolic: 1 = very soft, 2 = soft, 3 = moderate, 4 =
loud with a thrill, 5 = heard with a stethoscope off the chest, 6 = heard as you enter the room.
Murmurs are out of four for diastolic: 14 as above, no grades 5, 6.
Ejection systolic murmur
Upper sternal edge implies outflow tract obstruction. Right or left ventricular outflow tract
obstruction can occur at valvar (+ ejection click), subvalvar or supravalvar level:
Upper right sternal edge (carotid thrill) = aortic stenosis

Upper left sternal edge (no carotid thrill) = pulmonary stenosis or atrial septal defect (ASD)
Mid/lower left sternal edge = innocent murmur (see below)
Long harsh systolic murmur + cyanosis = tetralogy of Fallot
Pansystolic murmur
Left lower sternal edge ( thrill) = VSD
Apex (much less common) = mitral regurgitation
Rare at left lower sternal edge ( cyanosis) = tricuspid regurgitation (Ebstein anomaly)
Continuous murmur
Left infraclavicular ( collapsing pulse) = persistent arterial duct
Infraclavicular (+ cyanosis + lateral thoracotomy) = BT shunt
Any site (lungs, shoulder, head, hind-quarter) = arteriovenous fistula
Diastolic murmurs
Unusual in childhood
Left sternal edge/apex ( carotid thrill or VSD) = aortic regurgitation
Median sternotomy ( PS (pulmonary stenosis) murmur) = tetralogy of Fallot, repaired
Apical ( VSD) = mitral flow/(rarely stenosis)
Note that listening to the back gives little diagnostic information, but is useful thinking time.
Presentation of findings
Few candidates pay enough attention to the case presentation. This should be done after the
examination is complete. The candidate should stand, look the examiner in the eye, and put hands
behind his or her back and present. The important positives and negatives should be stated quickly
and succinctly with no umms or errrs. It is important to judge the mood of the examiner, if he or
she is looking bored, then go faster. Practise with a tape recorder or video recording.
To complete the examination you would:
Measure the blood pressure

Measure the oxygen saturation
Feel the femoral pulses
Feel the liver edge
The presentation should be rounded off with the phrase the findings are consistent with the diagnosis
of . . ..
Algorithm for clinical examination.

The patient with surgical scars
Left lateral thoracotomy:
PA band
Thrill + ejection systolic murmur at upper left sternal edge
Coarctation left brachial pulse
Shunt
Blue + continuous murmur
PDA
No signs
Right lateral thoracotomy:
Shunt Blue + continuous murmur
Median sternotomy:
Any intracardiac operation
1.6 Innocent murmurs

The most common murmur heard in children is the functional, innocent or physiological heart murmur
(40% of all children). They are often discovered in children with an intercurrent infection or with
anaemia. These all relate to a structurally normal heart but can cause great concern within the family.
There are several different types depending on the possible site of their origin. It is clearly important
to make a positive diagnosis of a normal heart. The murmur should be:
Soft (no thrill)

Systolic
Short, never pansystolic
ASymptomatic
Left Sternal edge
It may change with posture.
Diastolic murmurs are not innocent.
An innocent murmur is not associated with abnormal or added heart sounds.
Types of innocent murmur include:
Increased flow across branch pulmonary artery this is frequently seen in preterm neonates, is a
physiological finding and resolves as the pulmonary arteries grow. The murmur disappears after a
few weeks of age, and never causes symptoms
A Still murmur this is vibratory in nature and is found at the mid-left sternal edge. It may be
caused by turbulence around a muscle band in the left ventricle
Venous hum it may be easy to hear the venous blood flow returning to the heart, especially at the
upper sternal edge. This characteristically occurs in both systole and diastole and disappears on
lying the child flat
2. BASIC CARDIAC PHYSIOLOGY

2.1 Physiology of adaptation to extrauterine life
During the adaptation from fetal life there are a number of changes in the normal child:
A fall in the pulmonary vascular resistance, rapidly in the first few breaths, but this continues until
3 months of age
A resultant fall in the pulmonary arterial pressure
Loss of the placenta from the circulation
Closure of the ductus venosus
Closure of the ductus arteriosus
Closure of the foramen ovale
The arterial duct is kept patent with prostaglandins E1 or E2 infusion in children with duct-dependent
circulation such as transposition of the great arteries, or pulmonary atresia.
2.2 Physiology of congenital heart disease

The main principles of congenital heart disease are:
The pressure on the left side of the heart is usually higher than that on the right
Any communication between atria, ventricles or great arteries leads to a left-to-right shunt
Pulmonary vascular resistance falls over the first 12 weeks of life, increasing the shunt
There will only be cyanosis if the desaturated blood shunts from the right to left side
Common mixing leads to cyanosis and breathlessness
Duct-dependent conditions usually present at 2 days of life
Prostaglandin E2 or E1 can be used to reopen the duct up to about 2 weeks of life
2.3 Physiology of heart muscle and heart rate

Arterial pulse volume depends on stroke volume and arterial compliance.
Small pulse volume in:
Cardiac failure
Hypovolaemia
Vasoconstriction
Large pulse volume in:
Vasodilatation
Pyrexia
Anaemia
Aortic regurgitation
Hyperthyroid
CO2 retention
Pulsus paradoxus:
Exaggeration of normal rise and fall of blood pressure with respiration, seen in airways
obstruction, such as asthma
Sinus arrhythmia:
Variation of the normal heart rate with respiration. Faster in inspiration and slower in expiration.
Can be very marked in children
Cardiac output is increased by:
Adrenergic stimulus
Increased stretch (Starling curve)
Increased preload
Reduced afterload
3. LEFT-TO-RIGHT SHUNT
(Pink breathless)
General principles
No signs or symptoms on first day of life because of the high pulmonary vascular resistance. Later, at
1 week, infant can develop symptoms and signs of heart failure.
Symptoms of heart failure:
Tachypnoea
Poor feeding, Faltering growth
Cold hands and feet
Sweating
Vomiting
Signs of heart failure:
Thin
Tachypnoea
Displaced apex
Dynamic precordium
Apical diastolic murmur
Hepatomegaly
3.1 Atrial septal defect (ASD)

Types of defect
Secundum ASD
Primum ASD (partial atrioventricular septal defect)
Sinus venosus ASD
Other
Secundum ASD
A defect in the centre of the atrial septum involving the fossa ovalis.
Clinical features
Asymptomatic
80% of ASDs
Soft systolic murmur at upper left sternal edge
Fixed split S2 (difficult to hear)
ECG
Partial right bundle-branch block (90%)
Right ventricle hypertrophy
Chest X-ray
Increased pulmonary vascular markings

Management
Closure at 35 years (ideally)
90% undergo device closure in catheter laboratory
10% undergo surgical closure (too large or personal preference)
Partial atrioventricular septal defect (primum ASD)

A defect in the lower atrial septum, involving the left atrioventricular valve which has three leaflets
and tends to leak.
Clinical features
Asymptomatic
10% of ASDs
Apical pansystolic murmur (atrioventricular valve regurgitation)
Fixed split S2 (difficult to hear)
ECG
Partial right bundle-branch block (90%)
Superior axis
Chest X-ray
Management
Closure at 35 years
All require surgical closure (because of the need to repair valve)
Sinus venosus ASD

A defect at the upper end of the atrial septum, such that the superior vena cava (SVC) overrides the
atrial septum. The right pulmonary veins are usually anomalous and drain directly into the SVC or
right atrium adding to the left-to-right shunt.
Clinical features
Asymptomatic or heart failure

5% of ASDs
Fixed split S2 (easily heard)
ECG
Partial right bundle-branch block
Chest X-ray
Cardiomegaly
Management
Closure at 15 years
All require surgical closure and repair to the anomalous pulmonary veins
There are other rare types of ASD, which are similarly treated.
3.2 Ventricular septal defect (VSD)

Small defect
A defect anywhere in the ventricular septum (peri-membranous or muscular, can be inlet or outlet).
Restrictive defects are smaller than the aortic valve. There is no pulmonary hypertension.
Clinical features
Asymptomatic (8090%)
May have a thrill at left lower sternal edge
Loud pansystolic murmur at lower left sternal edge (the louder the murmur, the smaller the hole)
Quiet P2
ECG
Normal
Chest X-ray
Normal
Management
Review with echocardiography
Spontaneous closure, but may persist to adult life
Large defect
Defects anywhere in the septum. Large defects tend to be the same size or larger than the aortic valve.
There is always pulmonary hypertension.
Clinical features
Symptomatic with heart failure after age 1 week

1020% of VSDs
Right ventricular heave
Soft or no systolic murmur
Apical mid-diastolic heart murmur
Loud P2
ECG
Biventricular hypertrophy by 2 months (see Section 15)
Chest X-ray
Cardiomegaly
Management
Initial medical therapy, diuretics captopril + added calories
Surgical closure at 35 months
3.3 Persistent ductus arteriosus (PDA)

There is persistence of the duct beyond 1 month after the date the baby should have been born.
Clinical features
Asymptomatic usually, rarely have heart failure
Continuous or systolic murmur at left infraclavicular area
ECG
Usually normal
If large, have left ventricle volume loading (see Section 15)
Chest X-ray
Usually normal
If large, have increased pulmonary vascular markings
Management
Closure in cardiac catheter laboratory with coil or device at 1 year
If large, surgical ligation age 13 months
Note the presence of an arterial duct in a preterm baby is not congenital heart disease. If there is a
clinical problem, with difficulty getting off the ventilator, or signs of heart failure with bounding
pulses, the problem is usually treated with indometacin or ibuprofen (<34 weeks). If medical
management fails, surgical ligation is undertaken.
3.4 Aortopulmonary window

A defect in the wall between the aorta and pulmonary artery.
Clinical features
Rare
Usually develop heart failure
Continuous murmur as for PDA
ECG
If large, have left ventricle volume loading (see Section 15)
Chest X-ray
If large, have increased pulmonary vascular markings
Management
If large, surgical ligation age 13 months
3.5 Others
There are other rare causes of significant left-to-right shunt, such as arteriovenous malformation.
These are all individually rare. Medical and surgical treatment is similar to that for large ducts or
VSDs.
Summary of left to right shunts
4. RIGHT-TO-LEFT SHUNT
(Cyanosed)
General principles
Cyanosis in a newborn can be caused by:
Cardiac problems (cyanotic heart disease)

Respiratory problems (diaphragmatic hernia, etc.)
Metabolic problems (lactic acidosis, etc.)
Infections (pneumonia, etc.)
Cardiac cases that present on days 13 are usually duct dependent:
Transposition of great arteries (common)

Tetralogy of Fallot with pulmonary atresia (less common)
Pulmonary atresia with intact ventricular septum (PA/IVS) (rare)
Tricuspid atresia or other complex hearts (rare)
Ebstein anomaly (rare)
Investigations
Chest X-ray (to exclude lung pathology and large wall-to-wall heart in Ebstein anomaly)
Blood culture (to exclude infection)
ECG (superior axis in tricuspid atresia)
Hyperoxia test, 10 min in 100% O2 + blood gas from right radial arterial line. If PO2 > 20 kPa then
it is not cyanotic heart disease you must not use a saturation monitor, because this is
notoriously inaccurate in the presence of acidosis
Echocardiogram is not first line but should be considered early on
Management
Resuscitate first
Ventilate early
Prostaglandin E1 or E2 infusion (520 ng/kg per min) (may cause apnoeas)
Transfer to cardiac centre
Treat as for specific condition
4.1 Tetralogy of Fallot

Ventricular septal defect + subpulmonary stenosis + overriding aorta + right ventricular
hypertrophy (RVH)
Clinical features
Asymptomatic usually, rarely have severe cyanosis at birth, worsens as they get older
Loud, harsh murmur at upper sternal edge day 1
Do not usually develop heart failure
ECG
Normal at birth
RVH when older
Chest X-ray
Usually normal
If older have upturned apex (boot shaped) + reduced vascular markings
Management
10% require BT shunt in newborn if severely cyanosed
Most have elective repair at 69 months
4.2 Transposition of the great arteries
Aorta is connected to the right ventricle, and pulmonary artery is connected to the left ventricle. The
blue blood is therefore returned to the body and the pink blood is returned to the lungs. These children
have high pulmonary blood flow and are severely cyanosed, unless there is an ASD, PDA or VSD to
allow mixing.
Clinical features
Cyanosed when duct closes

No murmur usually
Can be very sick, unless diagnosed antenatally
May be associated with VSD, coarctation or pulmonary stenosis (PS)
ECG
Normal
Chest X-ray
Normal (unusual to detect egg-on-side appearance)
May have increased pulmonary vascular markings
Management
Resuscitate as above
20% require balloon atrial septostomy at a cardiac centre (usually via umbilical vein see Section
17)
Arterial switch operation usually before 2 weeks
4.3 Pulmonary atresia

Duct-dependent pulmonary atresia
Clinical features
Cyanosed when duct closes

No murmur usually
Can be very sick, unless diagnosed antenatally
May have IVS or VSD
ECG
Normal
Chest X-ray
Normal at birth (unusual to diagnose boot-shaped heart, until much older)
Decreased pulmonary vascular markings
Management
BT shunt inserted surgically
Radiofrequency perforation of atretic valve if appropriate
Pulmonary atresia with VSD and collaterals

Collaterals are abnormal arterial connections direct from the aorta to the lung substance.
Clinical features
Not usually duct dependent
No murmur usually
Usually present with heart failure at 1 month but may present with cyanosis at any age if collaterals
are small
ECG
Biventricular hypertrophy
Chest X-ray
Boot-shaped heart
Cardiomegaly
Increased pulmonary vascular markings if in heart failure, or reduced vascular marking if severely
cyanosed
Management
Diuretics, if in failure
Further imaging with cardiac catheter or magnetic resonance imaging (MRI)
Staged surgical repair
4.4 Ebstein anomaly

The tricuspid valve is malformed such that it leaks, and is set further into the right ventricle than
normal.
Clinical features
Cyanosed at birth
Loud murmur of tricuspid regurgitation
Can be very sick
May be associated with maternal lithium ingestion
ECG
May have a superior axis
Chest X-ray
Massive cardiomegaly (wall-to-wall heart)
Reduced pulmonary vascular markings
Management
Pulmonary vasodilator therapy (ventilation, oxygen, etc., see Section 12)
Try to avoid surgical shunt insertion, in which case prognosis is poor
4.5 Eisenmenger syndrome

This is secondary to a large left-to-right shunt (usually VSD or AVSD (atrioventricular septal defect))
where the pulmonary hypertension leads to pulmonary vascular disease (increased resistance) over
many years. Eventually the flow through the defect is reversed (right to left) so the child becomes
blue, typically at 1520 years of age.
Clinical features
Cyanosed in teenage life

Uncommon
Usually secondary to untreated VSD or AVSD
No murmur usually
Develop right heart failure eventually
ECG
Severe RVH + strain
Chest X-ray
Decreased pulmonary vascular markings
Management
Supportive
May need diuretic and anticoagulant therapy
Oxygen at night, consider other therapy (see Pulmonary hypertension, Section 12)
Consider heart/lung transplantation
Summary of right-to-left shunts
5. MIXED SHUNT
(Blue and breathless)
General principles
Tend to present either antenatally (most often) or at 23 weeks. Symptoms are that of mild cyanosis
and heart failure
Includes most of the complex congenital heart diseases
5.1 Complete atrioventricular septal defects

There is an atrial and ventricular component to the defect, so there is pulmonary hypertension as with
a large VSD. There is a common atrioventricular valve with five leaflets, not a separate mitral and
tricuspid valve.
Clinical features
May be cyanosed at birth
No murmur usually at birth, may develop in first few weeks

Often present on routine echo screening (neonatal Down syndrome)
May present with heart failure at 12 months
ECG
Superior axis
Biventricular hypertrophy at 2 months of age
Right atrial hypertrophy (tall P wave)
Chest X-ray
Normal at birth
Increased pulmonary vascular markings and cardiomegaly after 1 month
Management
Treat increased pulmonary vascular resistance at birth if blue
Treat as for large VSD if in failure (diuretics, captopril, added calories)
Surgical repair at 35 months
5.2 Tricuspid atresia

There is no tricuspid valve and usually the right ventricle is very small.
Clinical features
Cyanosed when duct closes if duct dependent
No murmur usually
Can be very well at birth
ECG
Superior axis
Absent right ventricular voltages
Large P wave
Chest X-ray
May have decreased or increased pulmonary vascular markings
Management
BT shunt inserted surgically if very blue

PA band if in heart failure
Hemi-Fontan after 6 months of age (see Section 9.2)
Fontan at 35 years of age
5.3 Others
There are many other types of complex congenital heart disease.

Double inlet left ventricle
Total or partial anomalous pulmonary venous connection (unobstructed)
Right or left atrial isomerism dextrocardia
Individually, these are quite rare and their management is variable, depending on the pulmonary blood
flow, the sizes of the two ventricles, etc. For further information a larger textbook of congenital heart
disease should be consulted.
6. OBSTRUCTION IN THE WELL CHILD

(Neither blue nor breathless)
General principles
Often present to general practitioner with murmur
Asymptomatic
6.1 Aortic stenosis

The aortic valve leaflets are fused together, giving a restrictive exit from the left ventricle. There may
be two or three aortic leaflets.
Clinical features
Asymptomatic
Always have a carotid thrill
Ejection systolic murmur at upper sternal edge
May be supravalvar, valvar (and ejection click) or subvalvar
Quiet A2 (second heart sound aortic component)
ECG
Left ventricular hypertrophy
Chest X-ray
Normal
Management
Balloon dilate when gradient reaches 64 mmHg across the valve
6.2 Pulmonary stenosis

The pulmonary valve leaflets are fused together, giving a restrictive exit from the right ventricle.
Clinical features
Asymptomatic (not cyanosed)
May have a thrill at upper left sternal edge

Ejection systolic murmur at upper sternal edge from day 1
May be supravalvar, valvar (ejection click) or subvalvar
Quiet P2
ECG
Right ventricular hypertrophy
Chest X-ray
Normal
Management
Balloon-dilate when gradient reaches 64 mmHg across the valve
6.3 Adult-type coarctation of the aorta

Not duct-dependent, this gradually becomes more severe over many years.
Clinical features
Rare
Asymptomatic
Always have systemic hypertension in the right arm
Ejection systolic murmur at upper sternal edge
Collaterals at the back
Radiofemoral delay
ECG
Chest X-ray
Rib-notching
3 sign, with a visible notch on the chest X-ray in the descending aorta, where the coarctation is
Management
Stent insertion at cardiac catheter when gradient reaches 64 mmHg, or surgery via a lateral
thoracotomy
6.4 Vascular rings and slings

Embryological remnant of aortic arch and pulmonary artery development.
Clinical features
Often present with stridor
May have no cardiac signs or symptoms
ECG
Normal
Chest X-ray
May have lobar emphysema as a result of bronchial compression
Management
Diagnose with barium/Gastrografin swallow

Additional imaging often required (computed tomography, magnetic resonance imaging,
angiography)
Surgical treatment
7. OBSTRUCTION IN THE SICK NEWBORN

General principles
Present when duct closes or antenatally
Often have normal ECG and chest X-ray when first present
Must feel pulses!!
7.1 Coarctation of the aorta

Duct-dependent narrowing, the ductal tissue encircles the aorta and causes an obstruction when the
duct closes.
Clinical features
Very common diagnosis

Often diagnosed antenatally
Absent femoral pulses
Should be born in a cardiac centre
If not detected antenatally, presents as sick infant with absent femoral pulses
No murmur, usually
Signs of right heart failure (large liver, low cardiac output)
May be breathless and severely acidotic
Associated with VSD and bicuspid aortic valve
ECG
Normal
Chest X-ray
Normal, or cardiomegaly with heart failure
Management
Resuscitate
Commence prostaglandin E1 or E2 (520 ng/kg per min)
Ventilate early (before transfer to cardiac centre)
Surgery 24 hours later, usually through a left lateral thoracotomy, to resect the narrow segment,
unless the whole aortic arch is small, in which case the surgery is performed via a median
sternotomy on bypass.
7.2 Hypoplastic left heart syndrome

A spectrum of disorders where the mitral valve, left ventricle and/or the aortic valve are too small to
sustain the systemic output.
Clinical features
Common diagnosis (200400 born annually in UK)

Usually diagnosed antenatally
If sick, presents with absent femoral + brachial pulses
No murmur
Anatomy varies from mitral stenosis to mitral and aortic atresia
ECG
Absent left ventricular forces
Chest X-ray
Management
Resuscitate
Commence prostaglandin E1 or E2 (520 ng/kg/per min)
Surgery (see Section 9.3) 35 days later
7.3 Critical aortic stenosis

Critical means duct-dependent, i.e. there is not enough flow across the stenotic valve to sustain the
cardiac output.
Clinical features
Rare diagnosis
Usually diagnosed antenatally
If sick, presents with absent femoral + brachial pulses
No murmur
Poor prognosis
ECG
Chest X-ray
Management
Resuscitate
Balloon dilatation 24 hours later, may require cardiac surgery
7.4 Interruption of the aortic arch

A gap in the aortic arch, which may occur at any site from the innominate artery around to the left
subclavian artery. It is always duct-dependent.
Clinical features
Rare diagnosis
Presents with absent left brachial + femoral pulses
No murmur
Heart failure (large liver, low cardiac output)
Breathless and severely acidotic
Associated with VSD and bicuspid aortic valve
Associated with 22q11.2 deletion and DiGeorge syndrome (see Section 10.5)
ECG
Normal
Chest X-ray
Management
Resuscitate
Surgery 24 hours later
7.5 Total anomalous pulmonary venous connection

The pulmonary veins have not made the normal connection to the left atrium. Instead they can drain up
to the innominate vein (supracardiac), to the liver (infracardiac) or to the coronary sinus
(intracardiac).
Clinical features
Uncommon diagnosis
Not a duct-dependent lesion
If obstructed, presents day 17 with cyanosis and collapse
No murmur
May, however, present later up to 6 months of age if unobstructed, with murmur or heart failure
ECG
Normal in neonate
RVH in older child
Chest X-ray
Normal, or small heart
Snowman in a snowstorm or cottage loaf because of visible ascending vein and pulmonary
venous congestion. Appearance usually develops over a few months
Management
Resuscitate (ABC)
Prostaglandin not effective if obstructed pulmonary veins
Emergency surgery if obstructed
Summary of obstructed hearts
Overview
There are other causes in each column, but these are less common and are unlikely to appear in
examinations.
VSD, pansystolic murmur at LLSE
ASD, ejection systolic murmur at ULSE + fixed split S2
Partial AVSD, ASD + apical pansystolic murmur of mitral regurgitation
PDA, continuous murmur under left clavicle collapsing pulses
Tetralogy of Fallot, blue + harsh long systolic murmur at ULSE
TGA, no murmur. Two-thirds have no other abnormality, never in examinations
Eisenmenger syndrome, 10 years old Down syndrome, often no murmurs, loud P2
Complete AVSD, never in examinations
AS, ejection systolic murmur at URSE + carotid thrill
PS, ejection systolic murmur at ULSE thrill at ULSE
TAPVC/HLHS/AS/CoA/Interrupted aortic arch, never in clinical exam, but common in vivas, grey
cases, data; present in first few days of life. May see postoperative cases
Key: AS, aortic stenosis; ASD, atrial septal defect; AVSD, atrioventricular septal defect; CoA,
coarctation; HLHS, hypoplastic left heart syndrome; Int Ao Arch, interrupted aortic arch; LL/LRSE,
lower left/right sternal edge; PDA, persistent ductus arteriosus; PS, pulmonary stenosis; TAPVC, total
anomalous pulmonary venous connection; TGA, transposition of great arteries; UL/RSE, upper
left/right sternal edge; VSD, ventricular septal defect
8. NON-BYPASS SURGERY FOR CONGENITAL HEART DISEASE

Non-bypass surgery is performed by means of a lateral thoracotomy, right or left. The scar is found
underneath the right or left arm, the anterior border of the scar tends to end under the axilla and may
not be seen from the front of the chest. It is imperative that the arms are lifted and the back inspected
as a routine during clinical examination otherwise the scars will be missed.
8.1 Shunt operation
Right or left modified BT shunt

Modified shunts will mean an intact brachial pulse on that side
Most likely to be for tetralogy of Fallot with pulmonary atresia
If there is no median sternotomy, the infant will still be cyanosed
Definitive repair will be performed usually by age 18 months
8.2 Coarctation of the aorta repair

May have absent left brachial pulse (subclavian flap technique) or a normal left brachial pulse
May have no murmur and normal femoral pulses
8.3 Pulmonary artery band
Uncommon operation these days

Usually for complex anatomy which may be palliated in the neonatal period
There may be a thrill at the upper left sternal edge
When present, the child is cyanosed
The band is usually removed at 12 years old as part of the next procedure
8.4 Arterial duct ligation

Rare except for the ex-preterm neonate
No murmurs and no abnormal pulses
Usually not associated with other defects
9. BYPASS SURGERY FOR CONGENITAL HEART DISEASE

Any child who undergoes open cardiac surgery, cardiopulmonary bypass, placement of a central shunt
or repair of the proximal aortic arch will need a median sternotomy. Therefore any repair of
intracardiac pathology will need to be performed via a midline incision.
9.1 Switch operation
Performed for transposition of the great arteries

Undertaken before 2 weeks of age (if no VSD present)
Involves cutting aorta and pulmonary artery and changing them round
Have to relocate coronary arteries as well
Mortality rate is low now, around 1%
Outcome is affected by presence of associated defects, such as VSD, coarctation, abnormal
coronary artery patterns
9.2 Fontan
Any child with a complex heart arrangement that is not suitable for a repair with two separate
ventricles will end up with a Fontan operation. If the pulmonary blood flow is too low at birth
(cyanosis), they will have a BT shunt. If the pulmonary blood is too high (heart failure) they will
have a PA band. If physiology is balanced, then conservative treatment will be undertaken until the
hemi-Fontan is performed
At about 68 months, the venous return from the head and neck is routed directly to the lungs. A
connection is therefore made between the superior vena cava and the right pulmonary artery. The
hemi-Fontan (or a Glenn or cavopulmonary shunt) is performed on bypass, via a median
sternotomy. Following the operation, the oxygen saturations will typically be 8085%
At 35 years, there will be insufficient blood returning from the head to keep the child well. Hence
a Fontan operation will be performed, where a channel is inserted to drain blood from the inferior
vena cava up to the right pulmonary artery. This means that the child will be almost pink,
saturations around 9095%
When completely palliated, the ventricle pumps pink oxygenated blood to the body, whereas the
blue deoxygenated blood flows direct to the lungs
9.3 Norwood
Used to palliate hypoplastic left heart syndrome
Stage I at 35 days of age:
Pulmonary artery sewn to aorta so that right ventricle pumps blood to body, branch pulmonary
arteries are isolated.
Atrial septectomy so that pulmonary venous blood returns to right ventricle
BT shunt from innominate artery or a conduit from right ventricle to pulmonary arteries
Stage II (hemi-Fontan) at 56 months old
Stage III (Fontan) at 35 years old
Results of survival to 5 years are approximately 7080%
Unknown long-term results
9.4 Rastelli
Used for TGA/VSD/PS

Left ventricle is channelled through VSD to aorta
VSD is closed with a patch of Gortex material
Right ventricle is connected to pulmonary artery with a homograft (donor artery)
Homograft is replaced every 20 years
9.5 Other operations

A child with median sternotomy scar and lateral thoracotomy scar with a systolic and diastolic
murmur at the left sternal edge:
This is typical of a child who has undergone insertion of a BT shunt, and then had complete repair
for tetralogy of Fallot
The child with Down syndrome who has a murmur at the left lower sternal edge and a median
sternotomy scar:
Atrioventricular septal defect or ventricular septal defect, who has undergone repair and who has
a residual ventricular septal defect the child may also have residual left atrioventricular valve
(i.e. mitral) regurgitation with systolic murmur at the apex
Bikini incision in girls, for cosmetic reasons who have undergone closure of atrial septal defect
Groin puncture site it may be worth inspecting the area of the right and left femoral vein to look
for the small puncture scar of previous cardiac catheterization, for example for balloon dilatation
of pulmonary stenosis
For further information, consult a larger textbook (see Section 19).
10. SYNDROMES IN CONGENITAL HEART DISEASE

General principles
Septal defects are the most common
Anomalies of kidneys, vertebra or limbs are often connected with cardiac disorders
Genetic causes of many syndromes now known
10.1 Isomerism
Genetic defect multifactorial, several candidates isolated
Right atrial isomerism

Heart defects
Both atria are morphological right atria

May have apex to right (dextrocardia)
Must have anomalous pulmonary venous connection (no left atrium to connect to)
May have complex anatomy, with AVSD, pulmonary atresia, etc.
Associated defects
Asplenia (penicillin prophylaxis)

Midline liver
Malrotation of small bowel
Two functional right lungs
Left atrial isomerism

Heart defects
Both atria are morphological left atria
May have anomalous pulmonary venous connection
May have complex with AVSD, etc.
Associated defects
Polysplenia (usually functional)
Malrotation (less often than in right isomerism)
Two functional left lungs
10.2 Trisomy
Down syndrome
Genetic defect trisomy 21
Heart defects
30% have CHD
Usually VSD and AVSD
All offered surgery with low risk
Associated defects
Diagnosed antenatally increased nuchal translucency
Edward syndrome
Genetic defect trisomy 18

Heart defects
VSD
Double outlet right ventricle
Associated defects
Rocker-bottom feet
Crossed index finger
Developmental delay
Patau syndrome
Genetic defect trisomy 15 or 13
Heart defects
VSD
Double-outlet right ventricle
Associated defects
Holoprosencephaly
Midline facial cleft
Renal anomalies
10.3 Williams syndrome

Genetic defect 7q11.23 deletion including elastin gene ELN
Heart defects
Supravalve aortic stenosis
Peripheral pulmonary artery stenosis
Associated defects
Gene abnormality on long arm of chromosome 7
Hypercalcaemia
Serrated teeth
Carp-shaped mouth
Hypertelorism
Cocktail party chatter
10.4 Noonan syndrome

Genetic defect PTPN11 mutation (or a small number of others)
Heart defects
Hypertrophic cardiomyopathy
Pulmonary valve stenosis
ASD
Associated defects
Almond-shaped eyes and shallow orbits

Shield-shaped chest, widely spaced nipples
Short
Not male Turner, can be girls

Genetic defect 22q11.2 deletion
It is increasingly recognized that DiGeorge syndrome may not always occur with the classic form of
hypocalcaemia, absent thymus, lymphopenia, cardiac defect and characteristic facies (CATCH 22).
Chromosomal abnormalities have been recognized in partial cases, or even in those with familial
VSD or tetralogy of Fallot (22q11.2 deletion). Deletions of the chromosome are detected using
fluorescent in situ hybridization (FISH) probes.
Heart defects
Conotruncal anomalies
Interrupted aortic arch
Tetralogy of Fallot
Familial VSD
Associated defects
22q11.2 deletion
Only have full DiGeorge syndrome if there is deletion + heart + two out of three of:
Cleft palate
Absent thymus (T cells low)
Absent parathyroids, hypocalcaemia
Small jaw, small head, pinched nose, hypertelorism
Small baby, slow development
Renal anomalies (20%)
Physical examination
Features to describe or exclude in this syndrome are as follows:
Dysmorphic features of face, skull or pelvis

Exclude cleft palate
Check spine for scoliosis
Check males for hypospadias
Investigations
Full blood count and film (ask for haematologists report)

Calcium and magnesium levels
Thyroid function tests
Check total CD4 count
Measure total immunoglobulin E levels
Chest X-ray
Thymic ultrasound
If abnormal: T-cell precursors and response to tetanus, Haemophilus influenzae type b (Hib) and
pneumococcus vaccination
Medical treatment (if T-cell deficient)
Maintenance co-trimoxazole (if lymphocyte count <1.5 109/l)

Regular immunoglobulin
Cytomegalovirus-negative, irradiated blood until immunological status is known
No live vaccines, but with component or fixed vaccines

Genetic defect jagged 1 gene (JAG1) mutations in 70%
Heart defects
Associated defects
Prominent forehead; wide-apart, deep-set eyes

Small, pointed chin
Butterfly vertebra
Intrahepatic biliary hypoplasia jaundice
Embryotoxon (slit lamp for cornea)
Kidney, growth, abnormalities of development, high-pitched voice
10.7 Turner syndrome

Genetic defect XO
Heart defects
Coarctation of the aorta
Associated defects
Webbed neck
Short stature
Shield-shaped chest, wide-spaced nipples
Infertility
10.8 Marfan syndrome

Heart defects
Aortic root dilatation (may rupture in later teenage life)

Aortic regurgitation
Mitral valve prolapsed
Mitral regurgitation
Associated defects
FBN1 gene mutation on chromosome 16, or TGFBR2 mutation

Dural ectasia
High arched palate
Arm-span greater than height
Hypermobility
Lens dislocation
Pectus excavatum
Patients have to be managed with regular echocardiography to detect if cardiac surgery is required.
The operations can be delayed by the use of -blocker medication or angiotensin receptor-2 blockers,
to keep the blood pressure as low as reasonable. Neonatal Marfan syndrome is particularly severe.
10.9 VACTERL
Heart defects
VSD
Tetralogy of Fallot
Coarctation
PDA
Associated defects
Vertebral
Anorectal
Cardiac
Tracheo-oEsophageal fistula
Renal/Retardation
Limb
10.10 HoltOram/TAR (thrombocytopenia and absent radius) (TAR)/Fanconi

syndromes
Genetic defect for HoltOram syndrome 12q2 mutations
Heart defects
ASD
Associated defects
Radial aplasia
Limb abnormalities
10.11 CHARGE
Heart defects
VSD
Tetralogy of Fallot
Associated defects
Coloboma
Heart
Atresia choanae
Renal/retardation
Genital/growth
Ear
10.12 Pentalogy of Cantrell

Heart defects
Tetralogy of Fallot
Associated defects
Absent sternum
Absent pericardium
Absent diaphragm
Absent heart (ectopic, on the front of the chest)
Absence of normal heart (tetralogy of Fallot)
10.13 Dextrocardia
A clinical diagnosis with the apex beat in the right chest. It is dangerous to use in cardiology because
it gives no information about the connections or orientation of the heart. For example, if the right lung
was collapsed and there was a tension pneumothorax on the left, it would be possible to find the apex
beat in the right chest. However, the child would not suddenly have developed a cardiac anomaly. We
use the term apex to right to imply the orientation of the heart and then talk about the connections
such as situs inversus (right atrium is on the left and left atrium is on the right) or some other situs.
In practice, most children with dextrocardia have a normal heart. This is most often the case when the
liver is on the left. It may be part of Kartagener syndrome (primary ciliary dyskinesia) where the
organs failed to rotate properly during embryological development. It is easily diagnosed by
performing nasal brushings to look at the dynein arms of the cilia on electron microscopy. Associated
with bronchiectasis, sinus occlusion and infertility.
If the child is blue with dextrocardia, there is almost always complex heart disease with right atrial
isomerism (see above).
10.14 Other syndromes

Cri-du-chat syndrome
Genetic defect 5p
Heart defects VSD, ASD
Tuberous sclerosis
Genetic defect TSC1 and TSC2 genes
Heart defects cardiac rhabdomyoma which reduce in size with age
Hypertrophic obstructive cardiomyopathy
Genetic defect multiple genes, e.g. MYH7
Heart defects obstruction in left ventricle may be associated with Noonan syndrome and many
more. In general, cardiac defects may be associated with other defects. The most common cardiac
defect is a septal defect (ASD or VSD).
11. SYNCOPE IN CHILDHOOD

Syncope in childhood is very common. Most episodes are benign, not dangerous and are the result of
neurocardiogenic syncope. Most of the investigations are of limited use and most often, it is
reassurance that is needed. A suggested protocol follows for the paediatrician.
Careful history is syncope associated with a drop in blood pressure on standing
Known groups of causes are:
Neurally mediated syncope, including postural hypotension, is most common. Tend to have
prodrome with dizziness on standing, or sitting upright. Nausea, vomiting and pallor before loss of
tone and consciousness
Cardiovascular causes, including arrhythmia, structural and vascular
Non-cardiovascular pseudo-syncope, including psychogenic
Investigations:
ECG, 12-lead. Exclude long QT interval, pre-excitation or heart block
If there is a good history of neurally mediated syncope, then no further tests are required, but if very
frequent or severe attacks, then refer to a cardiologist for Tilt testing
If there are some warning bells, such as exercise-related symptoms, then:
Exercise ECG if the symptoms relate to exercise
Cardiac event monitoring (longer than 24-hour) or reveal implantation

Electroencephalogram is rarely helpful
Management, in increasing complexity:
Reassurance, advice to stand slowly and sit down if dizzy
Encourage to drink more water and take more salt
Fludrocortisone 50100 g/day
Blocker
12. PULMONARY HYPERTENSION

For children, pulmonary hypertension is when the systolic pulmonary artery pressure is higher than
50% systemic systolic pressure. Needless to say this is normal in the 1-day-old baby, but is abnormal
after that time.
Classification of pulmonary hypertension

1 Pulmonary arterial hypertension (PAH)
1.1 Idiopathic
1.2 Heritable
1.2.1 BMPR2
1.2.2 ALK1, endoglin (with or without hereditary haemorrhagic telangiectasia)
1.2.3 Unknown
1.3 Drugs and toxins induced
1.4 Associated with (APAH)
1.4.1 Connective tissue diseases
1.4.2 HIV infection
1.4.3 Portal hypertension
1.4.4 Congenital heart disease
1.4.5 Schistosomiasis
1.4.6 Chronic haemolytic anaemia
1 Pulmonary veno-occlusive disease and/or pulmonary capillary haemangiomatosis
2 Pulmonary hypertension due to left heart disease
2.1 Systolic dysfunction
2.2 Diastolic dysfunction
2.3 Valvular disease
3 Pulmonary hypertension due to lung diseases and/or hypoxia
3.1 Chronic obstructive pulmonary disease
3.2 Interstitial lung disease

3.3 Other pulmonary diseases with mixed restrictive and obstructive pattern
3.4 Sleep-disordered breathing
3.5 Alveolar hypoventilation disorders
3.6 Chronic exposure to high altitude
3.7 Developmental abnormalities
4 Chronic thromboembolic pulmonary hypertension
5 PH with unclear and/or multifactorial mechanisms
5.1 Haematological disorders: myeloproliferative disorders, splenectomy.
5.2 Systemic disorders: sarcoidosis, pulmonary Langerhans cell histiocytosis,
lymphangioleiomyomatosis, neurofibromatosis, vasculitis
5.3 Metabolic disorders: glycogen storage disease, Gaucher disease, thyroid disorders
5.4 Others: tumoural obstruction, fibrosing mediastinitis, chronic renal failure on dialysis
ALK-1 = activin receptor-like kinase 1 gene; APAH = associated pulmonary arterial hypertension;
BMPR2 = bone morphogenetic protein receptor, type 2; HIV = human immunodeficiency virus;
PAHV = pulmonary arterial hypertension.

Aetiology
A relatively uncommon scenario, there are numerous causes, most commonly:
Structural lung disease (e.g. congenital diaphragmatic hernia)

Respiratory distress syndrome (hyaline membrane disease)
Group B streptococcal infection
Idiopathic
Diagnosis
Persistent hypoxia
Low cardiac output
Loud P2 on examination
Oligaemic lung fields
Hepatomegaly
Episodic desaturation, preceding a fall in blood pressure
Echocardiographic appearance of pulmonary hypertension:
High-velocity tricuspid regurgitation jet
Dilated right ventricle
Right-to-left shunt via atrial septum

Long right ventricle ejection time
High-velocity pulmonary regurgitation jet
Right-to-left shunt via arterial duct
Treatment
Good ventilation (high O2, low CO2)

Use oscillation ventilation if necessary
Sedation with morphine or fentanyl
Paralysis
Good chest physiotherapy
Restricted fluids
Pharmacology:
Nitric oxide (520 ppm, inhaled)
Prostacyclin (50 ng/kg, nebulized each 15 minutes)
Magnesium sulphate (200 mg/kg intravenous)
Extracorporeal membrane oxygenation (ECMO) as last resort
12.2 Increased pulmonary blood flow

Post-tricuspid shunts:
Ventricular septal defect

Arterial duct
Aortopulmonary window
Treatment
Repair defect by 3 months of age to avoid irreversible pulmonary vascular disease
12.3 Chronic hypoxia

Aetiology
Bronchopulmonary dysplasia
High altitude
Cystic fibrosis
Upper airway obstruction
Chronic bronchiectasis
Investigation
Sleep studies
ECG (right ventricular hypertrophy)
Ear/nose/throat opinion (upper airway obstruction)
Chest X-ray
Echocardiogram
Cardiac catheterization with pulmonary vascular resistance study
Treatment
Ensure good airway mechanics

Treat underlying cardiac condition if appropriate
Added O2 to keep O2 saturations >94%
Maintain low CO2 (consider night-time ventilation)
If responsive to vasodilators:
Nifedipine (0.1 mg/kg three times a day)
Dipyridamole (2.5 mg/kg 12 hourly)
Nebulized or intravenous prostacyclin
Consider heart/lung transplantation if appropriate
12.4 Pulmonary venous hypertension

Aetiology
Uncommon
Mitral valve stenosis (rare in children)
Total anomalous pulmonary venous connection
Pulmonary vein stenosis
Hypoplastic left heart syndrome
Investigation and treatment are determined by aetiology.
13. DRUG THERAPY FOR CONGENITAL HEART DISEASE

13.1 Heart failure
Diuretics (furosemide (frusemide) and spironolactone or amiloride)

Captopril
Added calories
Note that digoxin not routinely used now in left-to-right shunt
13.2 Anticoagulation
Aspirin for arterial platelet aggregation prevention orally (5 mg/kg per day)
Heparin for arterial anticoagulation, intravenous
Warfarin for venous or arterial thrombus prevention
Streptokinase for thrombolysis
Tissue plasminogen activator for thrombolysis
13.3 Pulmonary hypertension
Oxygen therapeutic vasodilatation

Low CO2 good ventilation
Alkalosis bicarbonate if needed
Dipyridamole increases cyclic guanosine monophosphate (cGMP) levels
Amlodipine only if proven to tolerate it
Nitric oxide 220 ppm
Prostacyclin nebulized (Iloprost) or intravenous
Bosentan endothelin receptor (ETA and ETB) antagonist
Sildenafil increases cGMP levels
13.4 Antiarrhythmia
Supraventricular tachycardia (SVT)
Vagal manoeuvres first
Adenosine intravenous 50250 g/kg
DC synchronized cardioversion 0.52 J/kg
Ventricular tachycardia (VT)

Cardioversion if pulse present synchronized 0.52 J/kg
Defibrillation if no pulse 24 J/kg
Prophylaxis for arrhythmias

This tends to be very variable from unit to unit. Suggestions are:
SVT flecainide, sotalol, digoxin or propranolol
VT flecainide, sotalol, amiodarone (toxic side effects on thyroid, skin and lungs)
14. ACQUIRED HEART DISEASE

Clinical features
Fever >5 days
Plus at least four of:
Rash
Lymphadenopathy
Mucositis (sore mouth, strawberry tongue)
Conjunctivitis
Extremity involvement (red fingers/toes)
coronary artery aneurysms (25% of untreated cases, 4.6% of treated cases)
abdominal pain, diarrhoea, vomiting, irritable, mood change, hydrops of gallbladder, peeling
extremities, thrombocytosis
Pathology
Marked similarity to toxic shock syndrome
Perhaps immune response to disease or toxin
Investigation
Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), white blood count (WBC), blood
culture, antistreptolysin O test (ASOT), viral, throat swab, ECG
Heart
Pericardial effusion
Myocardial disease (poor contractility)
Endocardial disease (valve regurgitation)
Coronary disease:
Ectasia, dilatation
Small, 35 mm, aneurysms resolve
Medium, 58 mm, aneurysms usually resolve
Giant, >8 mm, aneurysms ischaemia later
Greatest risk if male, <1 year, fever >16 days, ESR >100, WBC >30 000
Echocardiogram at 1014 days, 6 weeks, 6 months or longer if abnormal.
Treatment
Immunoglobulin 2 g/kg over 12 hours

Aspirin 30 mg/kg per day (four times per day dosage) reduce to 5 mg/kg per day when fever
resolves
Continue aspirin until 6 weeks or longer if abnormal echocardiogram
14.2 Dilated cardiomyopathy

History
Multiple transfusions, recent viral illness, family history of myopathy or autoimmune diseases.
Consider nutritional deficiencies (e.g. selenium, thiamine)
Examination
Full cardiovascular examination
Exclude myopathy
ECG
Evidence of ischaemia
Arrhythmias unrecognized tachycardia
Echocardiogram
Exclude anomalous coronary artery
X-ray
Look for arterial calcification
Blood
Metabolic:
Carnitine (and acylcarnitine) profile
Amino acids, organic acids, lactate
Creatinine and electrolytes (including phosphate)
Liver function tests and lactate dehydrogenase, membrane-bound creatine kinase
Selenium and thiamine
Autoimmune:
Antinuclear, anti-DNA antibodies; immune complexes
Virology:
Full blood count, ESR, CRP,
Polymerase chain reaction for EpsteinBarr virus, Coxsackievirus, adenoviruses, echoviruses
Stools for viral culture
Other investigations include abdominal ultrasound for arterial calcification, electromyography and
muscle biopsy if there is myopathy. Rare causes include endomyocardial fibrosis, tropical diseases,
amyloid.
14.3 Hypertrophic cardiomyopathy

History
Family history of sudden unexplained death, cardiomyopathy or myopathy. If a neonate, check if an
infant of diabetic mother, or if mother was given ritodrine. Hypertrophy is more suggestive of
metabolic cause compared to dilated cardiomyopathy. Consider inherited causes.
Examination
Exclude syndromes, Noonan syndrome, Leopard syndrome, Friedreich ataxia, neurofibromatosis,
lipodystrophy
Exclude endocrine disease, thyroid (hyper- and hypo-), acromegaly
Exclude hypertension; check for gross hepatomegaly
Check for cataracts, ophthalmoplegia, ataxia, deafness, myopathy
Look for signs of mucopolysaccharidoses
Echocardiogram
Exclude tumours, amyloid, endocardial infiltration
ECG
Look for short PR + giant complexes (Pompe syndrome)
Look for QRST axis dissociation (Friedreich ataxia)
Blood tests
Carnitine (decreased) + acylcarnitine profile
Creatine phosphokinase (increased = glycogen storage disease type III)
Blood film for vacuolated lymphocytes, if positive check white cell enzymes (suggesting storage
disorders)
Calcium (hyperparathyroidism)
Thyroid function tests, fasting blood sugar
Lactate, amino acids
Urine
Glycosaminoglycans (for mucopolysaccharidosis)

Organic acids
Vanillylmandelic acid
If no cause is found, screen family for hypertrophic obstructive cardiomyopathy (HOCM) and
consider a gene probe for HOCM
14.4 Suspected bacterial endocarditis

All children and adults with congenital, and many with acquired, heart disease are no longer given
antibiotic prophylaxis before dental extraction and potentially septic procedures in the UK.
History
If a child is admitted with an unexplained fever, has or might have congenital heart disease, has
murmurs (? changing), suspect bacterial endocarditis
Ask for history of recent boils, sepsis, dental extraction, etc.
Suspected bacterial endocarditis may be found postoperatively following insertion of prosthetic
material such as homograft or prosthetic valve
Examination
Full cardiovascular examination
Hepatosplenomegaly, fever, heart sounds and signs of infected emboli: Osler nodes, Roth spots,
septic arthritis, splinter haemorrhages, haematuria, nephrosis
Investigations
Six blood cultures from different sites at different times over 2 days, using the most sterile
technique possible, but do not clean blood culture bottles with alcohol (or else the organisms will
be killed off)
Full blood count, ESR, CRP, ASOT throat swab
Echocardiogram and ECG
Consider ventilationperfusion scan, white cell differential
Urine test for blood
Dental opinion
Treatment
If proven, treatment is for 6 weeks, predominantly intravenous
Blood antibiotic levels may be taken for back titration after stabilization on antibiotic regimen
this will be used to assess that there is sufficient antibiotic present to have a bactericidal effect
Antibiotics chosen should be those with a good record of deep-tissue penetration, e.g. fusidic acid,
gentamicin
14.5 Rheumatic fever
Uncommon in UK
Increasing incidence with reduced use of antibiotics to treat sore throats
Diagnosed by modified DuckettJones criteria (two major or one major + two minor criteria):
Major criteria:
Carditis
Polyarthritis
Chorea
Erythema marginatum
Subcutaneous nodules
Minor criteria:
Fever
Arthralgia
Previous rheumatic fever or carditis
Positive acute-phase reactants (ESR, CRP)
Leukocytosis
Prolonged PR interval
Investigations
ASOT
Throat swab for group A streptococci
ECG
Echocardiogram (mitral regurgitation, myocarditis, pericarditis)
Treatment
Penicillin or cefuroxime (if sensitive)
Prophylactic phenoxymethylpenicillin orally for 25 years
14.6 Pericarditis
Aetiology
Coxsackieviruses
Enteroviruses
Staphylococci
Tuberculosis
Oncological
Rheumatic fever
Presentation
Chest pain (inspiratory)
Acute collapse (effusion)
Soft, muffled heart sounds
Examination
Pericardial friction rub
Fever
ECG
ST elevation, convex upwards
T-wave inversion
Treatment
Anti-inflammatory drugs (ibuprofen)
Drain large pericardial effusion
15. ECG
15.1 The ECG and how to read it
Before interpreting a paediatric ECG it is essential to know the following:
How old is the child?
Is the ECG recorded at a normal rate (25 mm/s) and voltage (10 mm/mV)?
Rate
When measuring the heart rate on the ECG, the number of large squares is counted between the R
waves. The rate is calculated as 300/number of squares.
Rhythm
Sinus rhythm can only be inferred if there is one P wave before each QRS and if the P-wave axis is
between 0 and 90.
Axis
QRS axis
This is calculated by adding the total positive deflection (R wave) and subtracting the negative
deflection (Q + S wave). The resulting vector is plotted for lead I and AVF:
The P-wave and T-wave axes should be plotted similarly. This is important. For example, if there is
left atrial isomerism, there is no sinoatrial node (a right atrial structure). This means that the P-wave
axis is abnormal (superior) and can lead to the diagnosis. Similarly, in cardiomyopathies, such as
Friedreich ataxia, there is a difference in the axis between QRS and T of more than 75. This can help
to make the diagnosis (see below).
Normal QRS axis for
newborn 90180
25 years 45135
>5 years 10100
Causes of a superior axis (>180)

Tricuspid atresia
Ebstein anomaly
Noonan syndrome
WolffParkinsonWhite syndrome
<1% of normal individuals
Note that AVSD will have right ventricular hypertrophy, whereas tricuspid atresia usually has no right
ventricular forces. Either can have large P waves.
P wave
The axis should be from 0 to 90. The normal size is 2 2 little squares (0.08 s, 0.2 mV). If there
are not regular P waves before each QRS consider the following:
Complete heart block there is complete dissociation between the QRS and P waves, i.e. with no
fixed relationship; see below for list of causes
Atrial flutter usually with 2:1 block, there is a typical saw-tooth baseline
Inverted P waves these are typically seen with:
Left atrial isomerism (no RA no sinus node)

Postoperatively
Occasionally in normal individuals (coronary sinus rhythm).
Peaked P waves seen in right atrial hypertrophy:
Tricuspid regurgitation (e.g. Ebstein anomaly)
Pulmonary hypertension
Cardiomyopathy
PR interval
Normal in children is two to four little squares (0.080.16 s).
Causes of a long PR interval
Atrioventricular septal defects

Myocarditis
Digoxin toxicity
Hyperkalaemia
Duchenne muscular dystrophy
Hypothermia
Diphtheria
Causes of a short PR interval

WolffParkinsonWhite syndrome
Pompe disease (wide QRS)
LownGanongLevine syndrome (normal QRS)
Q wave
Not often seen in paediatrics. Rare to see signs of infarct. Normal Q waves are seen in V1, V2 in
young children and are allowed in other leads if small <0.2 mV.
Causes of Q waves
Dextrocardia
Left ventricular volume overload V5, V6 (e.g. large PDA or VSD)
Congenitally corrected transposition
Ischaemia (Kawasaki disease, anomalous left coronary artery from pulmonary artery)
Ischaemia postoperatively
QRS wave
Normal duration is 0.08 seconds. Prolonged in right bundle-branch block, e.g. after repair of tetralogy
of Fallot.
Delta () wave seen in WolffParkinsonWhite syndrome, the slurred upstroke to R wave,
represents depolarization via the accessory pathway, with a short PR interval. There will be a
wide QRS and the QRS axis will be unusual, even superior. Likely to have supraventricular
tachycardias (re-entry).
RS progression the best way to assess ventricular hypertrophy. The following pattern should be
seen:
Therefore, if there is persistence of the newborn pattern in an infant then right ventricular hypertrophy
is suggested. Other features of hypertrophy are:
Right ventricular hypertrophy
Upright T waves V1 (from 1 week to 16 years is abnormal)
Q wave in V1
R waves >20 mm in V1
Inverted T waves in V6
Q waves in V6
Left axis deviation for age
R waves >20 mm in V6
Biventricular hypertrophy
Total voltage (R+S) in V3 or V4 of >60 mm only sign of large VSD
QT interval
Measured from the start of the Q wave to the end of the T wave (U wave if present). This represents
the total time taken for depolarization and repolarization. Normal is <0.44 seconds for a heart rate of
60/min. To correct for the heart rate use the Bazett formula:
i.e. QT (corrected) = QT measured/(square root of time from R to R).

For example: if QT measured = 0.30 s at a rate of 120, then QTc = 0.3/(0.5) = 0.4 (normal).
If QT interval is long then abnormal T waves and a slow heart rate may result. The cause of long Q
T is thought to be differential sympathetic drive to the two sides of the ventricle, allowing one side to
repolarize before the other, hence prolonging the total time of repolarization. This also explains why
the T waves are abnormal.
Causes of long QT interval
Genetic causes of long QT syndrome (LQT1, LQT2, LQT3, LQT4, formerly RomanoWard
syndrome and JervellLangeNielsen syndrome and may be associated with sensorineural
deafness)
Hypocalcaemia
Hypokalaemia
Hypomagnesaemia
Head injury
Hypothermia
Drug administration such as domperidone or erythromycin
ST segment
Unusual to get marked changes in ST segments. May represent ischaemia in Kawasaki disease,
anomalous left coronary artery from pulmonary artery and postoperative cardiac surgery.
T waves
Normally T waves are downward in V1 from 1 week to 16 years of age.
T-wave axis should be within 75 of QRS. If not think of:
Friedreich ataxia
Dilated cardiomyopathy
Noonan syndrome
Long QT syndrome
Peaked T waves seen in hypokalaemia and digoxin toxicity.
15.2 Tachycardias
Supraventricular tachycardia (SVT)
Likely if the heart rate is >240/min

Tend to be faster rates approximately 300/min
Tend to be narrow complex (<0.08 s, unless aberrant conduction)
Often caused by WolffParkinsonWhite syndrome
Respond to adenosine (intravenous rapid bolus) or vagal manoeuvres such as immersion in icecold water, carotid sinus massage or Valsalva manoeuvre in older children
Can use flecainide, propranolol, sotalol, esmolol, amiodarone for treatment/prophylaxis.

Do NOT use eyeball pressure, or intravenous verapamil.
For atrial flutter, adenosine challenge brings out flutter waves. Standard treatment is then to use
synchronized DC cardioversion (1 J/kg)
Ventricular tachycardia (VT)
Tend to be slower rates approximately 200/min

Tend to be wide complex (>0.08 s)
There is P-wave dissociation
Can have torsade de points, which can degenerate to ventricular fibrillation
Treatment is usually amiodarone (can use flecainide, etc.)
15.3 Bradycardias
Complete heart block
Often present at birth but may be diagnosed antenatally. Baby is born (sometimes following
emergency caesarean section) with heart rate of about 70/min but is perfectly well. Usually needs no
treatment for several years. Intervene if faltering growth, collapses, heart failure, StokesAdams
attacks or resting heart rate <40/min. These would be indications for pacemaker insertion.
Causes
Maternal systemic lupus erythematosus

Congenitally corrected transposition of the great arteries
Postoperative
Myocarditis
Rheumatic fever
Sick sinus syndrome
Tachy/brady syndrome
May be seen after heart surgery
Caused by scar formation over sinus node
To be differentiated from sinus arrhythmia which is normal variation in heart rate caused by the
effects of respiration
If symptomatic needs pacemaker insertion.
16. CHEST X-RAYS

16.1 Cardiac outlines
Neonatal
Egg-on-side:
Transposition of great arteries
Narrow vascular pedicle (aorta in front of pulmonary artery)
Boot-shaped:
Tetralogy of Fallot with pulmonary atresia
Pulmonary artery bay because of absent pulmonary artery
Snowman in a snowstorm:
Obstructed total anomalous pulmonary venous connection
Small heart with pulmonary venous congestion
Wall-to-wall heart:
Ebstein anomaly
Massive cardiomegaly with right atrial dilatation
Infantile
Cottage loaf:
Total anomalous pulmonary venous connection
Visible ascending vein on upper left border
The older child

Cardiomegaly with increased pulmonary vascular markings:
Small heart with pulmonary oligaemia:
Eisenmenger syndrome
Probably secondary to VSD or AVSD
Globular heart
Usually associated with pericardial effusions, perhaps secondary to pericarditis or dilated
cardiomyopathy.
Situs
Check the heart is on the left along with the stomach bubble, and that the liver is on the right. This may
be helpful in diagnosing right atrial isomerism, etc., as above.
Oligaemic lung fields

Reduced pulmonary blood flow such as tetralogy of Fallot, Ebstein anomaly, persistent pulmonary
hypertension.
Plethoric lung fields

Left-to-right shunts, especially VSD and AVSD. Useful in transposition of the great arteries.
Normal lung fields

Those lesions with no shunt, such as pulmonary stenosis and aortic stenosis.
17. CARDIAC CATHETERIZATION

17.1 Diagnostic cardiac catheterization
Normal
Right atrium
SaO2 = 65%
Left atrium
SaO2 = 99%
Press = 4 mmHg
Right ventricle
SaO2 = 65%
Press = 6 mmHg
Left ventricle
SaO2 = 98%
Press = 25/4
Pulmonary artery
SaO2 = 65%
Press = 75/6 (age dependent)

Aorta
SaO2 = 97%
Press = 25/15
Press = 75/50 (age dependent)
To analyse cardiac catheter data, it is important to start with the aortic saturations. Follow the
algorithm below.
Algorithm for cardiac catheter data

If pink (aortic SaO2 94%) check pulmonary artery SaO2. If this is greater than systemic venous
SaO2, then there is a left-to-right shunt. If it is the same as venous SaO2 then look for a pressure
drop (AS/CoA).
If blue (aortic SaO2 < 94%) check pulmonary artery SaO2. If this is greater than aortic SaO2, then
the diagnosis is transposition of the great arteries. If it is less than aortic SaO2 then the problem is
not TGA. Check pulmonary artery pressure. If less than right ventricular pressure then there is right
ventricular outflow obstruction, probably tetralogy of Fallot.
True diagnostic catheterization is rarely performed, use echocardiography instead
Usually for assessment between staged surgical operations
Pulmonary vascular resistance assessments for left-to-right shunts to determine operability:
Measure pulmonary artery pressure and resistance (PVR) at baseline
Measure oxygen consumption for accurate determination
Repeat measurement in nitric oxide at two different doses
Repeat measurement in oxygen or prostacyclin
If PVR > 7 Wood units m2, then inoperable
If PVR falls by more than 20% then is partly reversible
17.2 Interventional cardiac catheterization

Interventional cardiac catheters
Eighty per cent of cardiac catheters are used for interventional treatment:
ASD septal occlusion device in 90% of secundum ASD after 3 years of age
VSD not usually used, but may be appropriate in apical muscular VSDs
PDA coil or device occlusion at 1 year of age
AS balloon dilatation is standard treatment at any age (see above)
PS balloon dilatation is standard treatment at any age
Coarctation stent insertion in teenagers or adults
Pulmonary atresia radiofrequency perforation as newborn or shunt insertion surgically
Branch PS stent insertion in older children

Arrhythmias radiofrequency or cryoablation
Balloon atrial septostomy

Usually performed under echocardiographic control at the bedside in the paediatric intensive care
unit
Mostly performed in babies less than 2 days old with transposition of the great arteries (see
above), who are severely cyanosed where there is insufficient mixing or where it is not possible to
perform a neonatal switch operation
May be required in other conditions, such as pulmonary atresia with intact ventricular septum
Most are performed via the umbilical vein and the procedure only takes a few minutes
If the child is older than 3 days, the femoral vein approach is usually required
A catheter is passed via the vein into the right atrium and hence into the left atrium across the
foramen ovale. The balloon on the end of the catheter is inflated and the balloon is withdrawn
rapidly into the right atrium. This tears a hole in the atrial septum allowing blood to pass freely
from right to left and vice versa.
18. IMAGING
18.1 Echocardiography
Mainstay of diagnostic tools

Doppler to assess velocity (and hence pressure gradient) across valves or VSD
Colour flow to highlight small defects or turbulent blood flow
Transoesophageal echo for posterior heart structures or during interventional cardiac
catheterization, especially in adults with congenital heart disease
Future uses for intravascular ultrasound, three-dimensional ultrasound and contrast
echocardiography
18.2 Magnetic resonance imaging
Standard diagnostic imaging for complex diseases where echocardiogram is insufficient

Spin-echo for routine imaging
Contract-enhanced for blood flow
Three-dimensional magnetic resonance imaging for reconstruction
18.3 Positron emission tomography

Uses ammonium ion to give blood-pool images
Best for myocardial perfusion imaging
18.4 Radionuclear angiography

For quantifying left-to-right shunt (e.g. ASD)
For determining right or left ventricle function and ejection fraction
19. FURTHER READING

Anderson RH, Baker EJ, Macartney FJ, Rigby ML, Shinbourne EA, Tynan M, eds (2009). Paediatric
Cardiology, 3rd edn. London: Churchill Livingstone.
Andrews RE, Tulloh RMR (2002). Hypoplastic left heart syndrome: diagnosis and management.
Hospital Medicine 63:247.
Brogan PA, Bose A, Burgner D, et al. (2002). Kawasaki disease: an evidence-based approach to
diagnosis, treatment, and proposals for future research. Archives of Diseases in Childhood 86:286
90.
Park MK, Guntheroth WG (1987). How to Read Pediatric ECGs. Chicago, IL: Year Book Medical
Publishers (still the best ECG book).
Tulloh RMR (2005). Congenital heart disease in relation to pulmonary hypertension in paediatric
practice. Paediatric Respiratory Reviews 63:17480.
Website
www.childrens-heart-fed.org.uk
Chapter 2
Child Development, Child Mental Health and Community
Paediatrics
CONTENTS
Child Development
1. Developmental assessment
1.1 Milestones
1.2 Developmental assessment
1.3 Management of the child with global developmental delay
2. Vision
2.1 Assessment of visual acuity
2.2 Squints
3. Hearing
3.1 Assessment of auditory function
4. Speech and language

4.1 Communication
4.2 Differential diagnosis of speech and language problem
4.3 Specific speech and language delay
4.4 Clinical assessment
5. Autistic spectrum disorder

5.1 Assessment of children on the autistic spectrum
6. Developmental coordination disorder
7. Attention deficit hyperactivity disorder

8. Special educational needs and the educational statement
Child Mental Health
9. Chronic fatigue syndrome/Myalgic encephalopathy
10. Eating disorders in childhood and adolescence
11. Depression in childhood and adolescence
12. Self-harm and suicide
13. Schizophrenia with childhood onset
14. Conduct disorders
15. Common behavioural problems in pre-school children
15.1 Sleep disorders
15.2 Feeding problems in infancy and childhood
15.3 Temper tantrums
15.4 Breath-holding attacks
16. Common problems in the school-aged child

16.1 School refusal
16.2 Non-organic abdominal pain/headache/limb pains
16.3 Sleep problems in the school-aged child
16.4 Tics
17. Enuresis/Encopresis and soiling

17.1 Enuresis
17.2 Encopresis
Community Paediatrics
18. Child health surveillance
18.1 Summary of newborn screening
18.2 School-aged children
19. Immunization in childhood

19.1 Immunization schedule
19.2 Contraindications to immunization

19.3 Immunization reactions
19.4 Additional information on vaccines
20. Adoption and fostering

20.1 Adoption
20.2 Fostering
21. The Children Act 1989 and Human Rights Act 1998
21.1 Aims of the Children Act
21.2 Human Rights Act 1998
22. Sudden infant death syndrome and Child Death Review

23. Accident prevention
24. Further reading
Child Development
1. DEVELOPMENTAL ASSESSMENT
This is a key part of the assessment of any child. It is important to learn the common milestones.
1.1 Milestones
It is important to consider the following four areas:
1. Gross motor
2. Fine motor and vision
3. Speech and hearing (language)
4. Social
Milestones in child development
1.2 Developmental assessment

It is important when assessing development to determine the skills achieved in the four areas
Use a structured approach. Complete one area of development before moving on to the next
If the child is already sitting use the opportunity to assess language, social and fine motor
development. Do not disrupt the child to do gross motor tests you may well have difficulty
settling them again and in older children gross motor gives you the least additional information.
Leave it to the end
If the child is playing, WATCH. He or she will often demonstrate skills
Start with tasks that you expect the child to be able do. Once you have demonstrated that the child
can do one level, push up to the next level until he or she is not able to perform the task, e.g. if you
have demonstrated that the child can copy a square do not ask him or her to draw a circle because
you have already demonstrated that the child is past this level; instead see if he or she can copy a
triangle
Work through the parents if the child is shy or apprehensive, e.g. ask the parents to draw a circle for
the child to copy or test the child about colours, numbers, stories, etc
If child does not cooperate do not panic. You can still get clues from observing. Remember stranger
awareness and non-compliance are developmental milestones in themselves
There are a number of standardized assessments that can be used to more accurately determine the
childs development age:
The Griffiths Mental Development Scales
The Bayley Scales of Infant Development
The Schedule of Growing Skills
1.3 Management of the child with global developmental delay

Developmental delay can result from many causes:
40% have chromosomal abnormalities
510% have developmental malformations
4% have metabolic disorders
Causes of developmental delay

Static causes
Prenatal
Chromosomal abnormalities
Intrauterine infections
Teratogens
Congenital brain malformations, e.g. neuronal migration defects
Specific syndromes
Perinatal
Prematurity
Ischaemichypoxic encephalopathy
Birth trauma
Meningitis
Postnatal
Trauma
Intracranial infections
Progressive causes
Endocrine
Hypothyroidism
Metabolic
Aminoacidurias
Galactosaemia
Mucopolysaccharidoses
LeschNyhan syndrome
Degeneration of the cerebral grey matter
TaySachs disease
Gaucher disease
NiemannPick disease
Batten disease
Leigh disease
Menkes disease
Degeneration of the cerebral white matter

Krabbe disease
Metachromatic leucodystrophy
Canavan disease
Peroxisomal disorders
Zellweger syndrome
Infection
Subacute sclerosing panencephalitis (SSPE)
History
A good history is essential to help determine the cause and appropriate investigations. Information is
required on prenatal history, perinatal history and postnatal development. Are there any associated
symptoms such as seizures? General health is important when considering metabolic disorders.
Family history may give the strongest clue to a chromosomal disorder. Enquire about previous
pregnancy losses.
Examination
A thorough examination is essential.
Neurodegenerative conditions affecting the grey matter tend to present with dementia and seizures.
Conditions affecting the white matter tend to present with spasticity, cortical deafness and blindness.
Inspect for:
Sex of child X-linked conditions such as fragile X, Menkes, Hunter and LeschNyhan syndromes
Age of the child:
First 6 months: TaySachs disease, Leighs disease, infantile spasms, tuberose sclerosis
Toddlers: infantile metachromatic leucodystrophy, mucopolysaccharidoses, infantile Gaucher
disease, Krabbes disease
Older children: juvenile Batten disease, SSPE, Wilsons disease, Huntington disease
Dysmorphic features: Down syndrome, mucopolysaccharidoses
Neurocutaneous signs: ataxia telangiectasia, SturgeWeber syndrome, incontinentia pigmenti,
tuberose sclerosis
Extrapyramidal movements: cerebral palsy, Wilsons disease, Huntington disease
Tremor: Wilsons disease, Friedreichs ataxia, metachromatic leucodystrophy
Note growth of child
Large head: Alexander, Canavan and TaySachs syndromes, mucopolysaccharidoses
Small head : cerebral palsy, autosomal recessive microcephaly, RubinsteinTaybi, SmithLemli
Opitz and Cornelia de Lange syndromes
Growth pattern (e.g. faltering growth with metabolic disease, gigantism with Soto syndrome)
Systematic examination
Eyes: corneal clouding, cataract, cherry-red spot, optic atrophy
Neurological examination including gait, scoliosis, tremor, extrapyramidal movements, tone, power
and reflexes of limbs
Associated system involvement (e.g. cardiac abnormalities, organomegaly in metabolic disease)
Genitalia
Hearing and vision should be checked
Further assessment often involves input from other professionals of the child development team, e.g.
speech and language therapists and physiotherapists.
Investigations
A thorough history and examination may lead to targeted investigations, e.g. a specific genetic test or
metabolic test. For approximately 40% of cases no cause is found. The two most useful investigations
are genetic studies and brain imaging.
If no specific diagnosis is suggested then consider the following.
Blood tests
Chromosomal analysis
TORCH serology in infants (TORCH, toxoplasmosis, other [congenital syphilis and viruses],
rubella, cytomegalovirus and herpes simplex virus)
Plasma amino acids
Ammonia
Lactate
White cell enzymes
Urine tests
Urinary organic acids
Urinary amino acids
Urinary mucopolysaccharidoses
Brain imaging
This will identify congenital brain abnormalities and diagnose degenerative conditions such as the
leucodystrophies and grey matter abnormalities.
EEG
This will identify SSPE and Batten disease
Management
This is multidisciplinary. A child in whom a disability has been identified will be referred to a child
development team. The precise make-up of the team depends on the local resources but can include
the following:
Community paediatrician
Speech and language therapist
Physiotherapist
Occupational therapist
Child psychologist/psychiatrist
Play therapist
Pre-school therapist, e.g. portage
Nursery teachers
Health visitors
Social workers
The role of the multidisciplinary team is to:
identify the disability and try to determine the cause

support the family
liaise with education and social services as appropriate
refer to other appropriate professionals, e.g. for genetic counselling
provide ongoing therapy to support needs, e.g. physiotherapy, speech and language therapy
2. VISION
Each year around 500 children are registered blind or partially sighted. Early diagnosis is important
because:
appropriate treatment may reduce the severity of the disability or stop progression
other medical conditions associated with visual problems can be diagnosed
genetic counselling can be offered
pre-school learning support can be started
Causes of visual impairment in childhood

Cataract
Glaucoma
Optic nerve:
Leber optic atrophy
Septo-optic dysplasia
Raised intracranial pressure, e.g. hydrocephalus
Retinal abnormalities:
Retinopathy of prematurity
Hereditary Leber amaurosis
Retinoblastoma
Amblyopia as a result of squint, refractive error or ptosis
2.1 Assessment of visual acuity

There is no national policy on visual screening or who should do it (primary care or orthoptists) in
the UK. At present there are different screening policies in different health authorities. Visual
screening is under review together with the results from trials on treatment of amblyopia.
Current recommendations
Newborn screening inspecting the eyes for anomalies
Repeat eye examination at the 6-week check

Orthoptists assessment of all children in the 4- to 5-year age group. This is to assess acuity and to
detect squints. The advantage of screening at this age is easier testing of visual acuity compared
with younger children. Parents will usually recognize a squint but amblyopia as a result of
refractive error will be detected only when the childs vision is assessed monocularly
Screening very-low-birthweight babies to detect retinopathy of prematurity
Visual screening in children with other major disabilities
Between the ages of 6 weeks and 4 years identification of visual defects will rely on concern being
raised by the parents or other professionals.
Methods of testing visual acuity

Newborn: inspection of the eye for cataract and other abnormalities including red reflex
6 weeks: inspection of the eye. The child should also be able to fix and follow an object held at
arms length through 90 in the horizontal plane
12 weeks: the child should be able to fix and follow an object 180 in the horizontal and vertical
planes
10 months: an infant can pick up a raisin. By one year they can pick up individual 100 and 1000s
sweets. If possible try to test the acuity of both eyes
23 years: test each eye individually. Various tests for visual acuity are available:
Preferential looking test this can be used in a child too young to identify objects. Large cards
with pictures on in different positions, i.e. top right-hand corner, bottom left-hand corner, are
shown to the child and the eye movements are observed as the child focuses on the picture as it
moves around the card
Picture cards children asked to identify picture cards at a set distance. Picture size varies to
determine the acuity
3 years: visual acuity should be assessed in each eye. By this age the SheridanGardner test can
usually be used. The child has a card with five letters on, the Key card. The examiner stands 6 m
away and holds up a letter that the child has to identify on his card
4 years and upwards: by this age the child can usually verbally identify letters and therefore a
Snellen chart can be used
Refer for specialist examination

Abnormality detected in routine examination
Child at high risk of visual disorders:
Child with other major disabilities

Family history of inheritable visual disorders
Parental concerns
2.2 Squints
Squints are common, occurring in approximately 4% of children. There is a strong familial incidence.
A squint is usually noticed by the parents first and parental report of squint should be taken seriously.
A squint is a misalignment of the visual axis of one eye. To prevent seeing double, the image from the
squinting eye is suppressed by the brain. Without treatment, this can lead to amblyopia.
A squint is either:
latent, i.e. only there at certain times (such as fatigue, illness, stress) or
manifest, i.e. present all the time
It is either:
alternating the patient uses either eye for fixation while the other eye deviates. As each eye is
being used in turn, vision develops more or less equally in both or
monocular only one eye is used for fixation and the other eye consistently deviates. The child is
more prone to develop amblyopia as the deviated eye is consistently not being used
It is either:
convergent, i.e. turns in, or
divergent, i.e. turns out
It is either:
non-paralytic or
paralytic
Non-paralytic squint
This is the more common type of squint and includes the following:
Most of the congenital and infantile convergent squints
The accommodative convergent squint. This is the most common type of squint. The child is usually
long-sighted. The degree of accommodation used to attempt to focus results in convergence of the
eyes. It commonly occurs around 18 months to 2 years. In the most cases the squint can be
controlled by spectacles that correct for the long-sightedness
In a few cases a non-paralytic squint is the result of an underlying ocular or visual defect, e.g.
cataract, high refractive errors, retinopathy of prematurity, retinoblastoma
Paralytic squints
These are the result of weakness or paralysis of one or more of the extraocular muscles. They are less
common.
The deviation worsens on gaze into the direction of action of the affected muscle
Congenital paralytic squints are more commonly the result of developmental defects of the cranial
nerves, muscle disease or congenital infection
Acquired paralytic squints usually signify a serious pathological process, e.g. brain tumour, central
nervous system infection, neurodegenerative disease
Assessment of squint
Ocular movements assessed to exclude paralytic squint
Corneal reflex examined, looking for symmetry of the light reflex
Cover/uncover test: the child sits comfortably on a parents lap. Their attention is attracted and,
while looking at an object, one of the eyes is covered. If the uncovered eye moves to fix on the
object there is a squint present, a manifest squint. This may be one of the following:
Unilateral squint the squinting eye takes up fixation of the object when the other eye is
covered. When the cover is removed the squinting eye returns to its original squinting position
Alternating squint the squinting eye takes up fixation of the object when the other eye is
covered. When the cover is removed the squinting eye maintains fixation and the previously
fixing eye remains in a deviated position, i.e. the squint alternates from one eye to the other
Rapid cover/uncover test: sometimes a squint is not present all the time but only when tired or
stressed. In the rapid cover test the occluder is moved quickly between the eyes. If the eye that
has been uncovered moves to take up fixation there is a latent squint
Principles of treatment for a squint

Develop best possible vision for each eye:
Correct any underlying defect, e.g. cataract
Correct refractive errors with spectacles
Treat any amblyopia with occlusion therapy to encourage use of the amblyopic eye
Achieve best ocular alignment:
In accommodative squints correction of long-sightedness by spectacles usually controls the
excessive convergence
For other types of squints surgery is required. This is particularly important for congenital
squints. The longer the defect persists untreated the less chance there is for development of good
visual function
3. HEARING
Between 1 and 2 children per 1000 population have permanent childhood deafness, 84% congenital
and 16% acquired. Early detection of hearing problems and treatment has permanent beneficial
effects.
Hearing loss can be:
conductive: external or middle-ear problems
sensorineural: inner ear (cochlea) or nerve VIII problems
mixed
Possible interventions
Hearing aids
Cochlear implant will allow more deaf children to develop spoken language
Involvement of Speech and Language therapy services
Pre-school/in-school learning support, e.g. signing
Routine hearing screening programme

There is universal neonatal screening to identify deafness. The neonatal screening tests used are the
otoacoustic emissions test and auditory brain-stem response testing.
Well baby
Otoacoustic emissions test
Special care baby
Auditory brain-stem response test
If these tests are not passed then refer for audiology assessment.
At pre-school entry
A pre-school hearing test is currently performed in some areas of the UK. The screening test used is
the sweep audiogram.
If the screening test is failed the child is referred to an audiologist for further assessment. Referrals to
audiology can also be made at any time if concerns are raised about hearing or speech and language
development, e.g. by the parents.
High-risk infants who should be referred on for audiology assessment

Babies who do not pass screening tests
Babies with craniofacial abnormalities
Babies with chromosomal abnormalities

Babies diagnosed with a syndrome
Family history of sensorineural deafness
Babies ventilated as neonates for 5 days
Babies with hyperbilirubinaemia to exchange level
Babies with a congenital infection
Babies who have received ototoxic drugs with levels outside the therapeutic range
Babies with neonatal meningitis
3.1 Assessment of auditory function

Babies:
Diagnostic auditory brain-stem response testing
2 years:
Visual reinforcement audiometry
Performance games
Speech discrimination test
Free-field audiometry
3 years and over:
Pure-tone audiometry
It is important to consider both the developmental and the chronological age when deciding which test
to use.
Automated otoacoustic emissions test

Measures function of inner ear
In healthy cochlea, vibration of the hair cells in response to noise generates acoustic energy
called otoacoustic emissions
Probe placed in ear canal and generates clicks. The energy produced is detected by a microphone
within the probe
Screen displays pass or refer no interpretation needed
Quick to perform:
Needs quiet baby
No debris in canal or middle ear
Only assesses function of ear no assessment of neural pathway
Automated auditory brain-stem response

Measures integrity of inner ear and the auditory pathway
Stimulus is presented using earphones or ear canal probe. Electrophysiological response from the
brain stem is detected by scalp electrodes
Screening can be performed by non-specialist pass/fail

Takes 15 minutes:
Needs quiet baby
Debris in canal or middle ear can affect test
Visual reinforced audiometry

Sounds are presented to the child via a loudspeaker arrangement which enables the sound to be
presented precisely at different decibels (dB) for each frequency tested. If the head turns to the sound
the child is rewarded by a visual stimulus, e.g. a toy lighting up in a box. Headphones can be used in
a compliant child so allowing individual ears to be tested.
Performance test or Go games

These tests are useful for children with an actual or developmental level of 24 years. They require
some understanding and cooperation. The child is asked to perform a task when he or she hears a
noise, i.e. put man in boat. It can be performed by health visitors.
Speech discrimination test

This test is useful for children with a 2.5 years plus actual or developmental level. An example is the
McCormick Toy Test. Toys are laid out in front of the child on the table and the examiner asks the
child to identify the toy called. The examiner must test voice level against a sound meter. The mouth
is covered to prevent lip reading and the tester has to be careful not to give visual clues. The toys are
in pairs to test for consonants, e.g. duck/cup.
Free-field testing
Suitable for children aged 2 years and over. It does not require understanding or cooperation so it is
useful for children with developmental delay or behavioural problems. Sounds are produced within a
free field at different frequencies. The childs reaction to sound is observed and assessed if
satisfactory.
Pure-tone audiometry
By 4 years of age a child should be able to cooperate with this test. Both ears can be tested
separately. The audiometer delivers sounds at different frequencies and intensities. It is possible to
determine the childs threshold at each sound frequency. It takes at least 10 minutes to perform.
The audiogram
Key to symbols used:
x-axis = frequency (Hz)
y-axis = hearing level (dBHL)

= air conduction right ear
X = air conduction left ear
= bone conduction unmasked vibrator vibrates whole skull no matter on which mastoid it is
placed. Assesses both cochleas unless one ear is masked
Air conduction assesses the whole auditory system
Bone conduction assesses the auditory pathway from the cochlea and beyond
If bone conduction is normal but air conduction thresholds are raised a conductive hearing loss is
present
If both bone and air conduction thresholds are raised a sensorineural hearing loss is present
An impairment greater in air than bone conduction suggests a mixed loss
Normal range
10 to +20 dBHL
Moderate hearing loss 2040 dBHL
Profound hearing loss 90120 dBHL
High-frequency hearing loss in a child with speech delay.
Sweep audiometry
Same principle as above but quicker to perform because various sound frequencies are tested at only
one intensity (around 25 dB). It is used as a screening test at the pre-school entry. If the child fails at
any frequency then full audiometry is performed.
Tympanometry
The compliance of the tympanic membrane and ear ossicles is assessed by a probe that fits snugly in
the external auditory canal, which is able to generate positive and negative pressures while recording
the sound reflected back from a small microphone within the probe. It is suitable for any age child,
but primarily used to check for glue ear. In the normal ear, the peak is at 0 pressure, reflecting the
equal pressures on either side of the drum. The trace is flattened if a middle-ear effusion is present.
Normal trace
Flattened trace with no clear peak

middle-ear effusion
Peak at negative pressure (shift to left)
eustachian tube dysfunction (retracted drum)
4. SPEECH AND LANGUAGE

4.1 Communication
Acquisition of communication involves the following.
Speech
Expressive production of speech
Comprehension understanding what is being said
Comprehension development is ahead of expressive development
Non-verbal communication
Eye contact, pointing, body gestures
Social communication
Reciprocity and sharing of communication, insight into what is socially acceptable, sharing
communication, listening skills
Problems in speech and language development are very common in pre-school children (510%) and
more common in boys.
4.2 Differential diagnosis of speech and language problem

Problem with language input
Hearing deficit
Reduced exposure to spoken language, e.g. social circumstances, twins, poor parenting skills
Problems with language processing

Specific speech and language delay
Associated with general developmental delay
Associated with reduced communicative intent and poor social skills, i.e. autistic spectrum
disorder
Associated with brain abnormalities, e.g. epilepsy, LlandauKleffner syndrome
Problems with language output

Neurological or muscular problems, e.g. cerebral palsy
4.3 Specific speech and language delay

Most children with specific language disorders have no cause identified for their disorder. There is
often a positive family history of language disorders. Many children have a mixture of problems but
they can be divided as follows.
Problems in auditory/linguistic processing leading to difficulties with expressions

Phonology articulation and making the speech sounds
Grammar understanding the forms and structure of language
Problems in understanding the appropriate meaning and use of language

Semantics the meaning of words and sentences
Pragmatics the appropriate social use of language
4.4 Clinical assessment

The role of the doctor is to determine:
the nature of the speech and language problem
if there are other problems such as general delay, autistic spectrum
any underlying cause, e.g. deafness, cleft palate, neuromuscular disorder
Investigations
It is important to confirm that the hearing is normal (see earlier)

EEG if there is a clear history of loss of language skills to exclude epilepsy syndromes
Chromosomal studies if there are other associated difficulties
Management of speech and language problem

If speech and language delay is the only problem, it is usually managed by speech and language
therapists alone without continuing paediatric input
If there are other additional problems, multidisciplinary assessment is usually necessary, involving
some or all of the multidisciplinary team
It is also important that advice is given to education team about the childs difficulties to enable
them to access the national curriculum. Children with severe difficulties are sometimes placed in
language units with access to on-site speech and language therapists. The majority, however, are
managed in mainstream school with a speech and language programme incorporated into their
individual education plans. Speech and language therapists then review the programme
intermittently
5. AUTISTIC SPECTRUM DISORDER

There is a wide variation in the clinical presentation of autism (autistic spectrum disorder). It is a
communication disorder. The spectrum includes classic autism through to Asperger syndrome. The
prevalence of autistic spectrum disorder is around 4/1000. Boys tend to outnumber girls by 3:1.
Three areas of development are affected.
Social skills
Non-verbal behaviours, e.g. eye contact, body posture
Failure to develop peer relationships
Lack of social and emotional sharing
Verbal and non-verbal communication
Delay in development of spoken language

No attempt to communicate by other means
Inability to initiate conversation
Stereotyped and repetitive language, lack of imaginative play
Repetitive and stereotype patterns of behaviour
Adherence to routines
Lack of imaginative play and behaviour
Restrictive patterns of interest
Preoccupation with parts of objects
Repetitive motor mannerisms, e.g. hand flapping, door closing
Other features in classic autism

The abnormal functioning is observed in one of these areas of development before the age of 3
years
The behaviour is not accounted for by another diagnosis. A large number of children with
syndromes and chromosomal abnormalities have autistic features
Over 50% also have associated intellectual impairment that can affect the behaviours observed
By middle age 30% have developed epilepsy
Hearing and visual problems are common
Dyspraxia is common
Asperger syndrome
Presentation is usually after 3 years of age
Early language appears normal
Presentation is often via school with behavioural and social difficulties and speech and language
problems
Children are often aware that he or she is different which can lead to anxiety, psychiatric
morbidity and social exclusion
5.1 Assessment of children on the autistic spectrum

This is by multidisciplinary assessment. The format varies depending on local services but should
include: a developmental paediatrician, a psychiatrist/psychologist and a speech and language
therapy assessment:
History: it is important to obtain a thorough history, including developmental milestones and family
history. Information from other sources, e.g. nursery, is important. There are now formal scored
tools to help assessment
Examination: it is important to exclude other diagnoses that can present with autistic features, e.g.
fragile X, tuberose sclerosis
Investigation: children on the autistic spectrum often do not tolerate investigations. Chromosomes
and brain imaging are more likely to yield a positive result in children with associated severe
cognitive impairment. An EEG should be considered in children showing development regression
Management
Each child needs to be assessed as an individual to determine the degree of difficulty in social and
communication skills, and an individual management plan must be decided upon.
Health
Communication with parents about their concerns and difficulties with management of the child is
essential. Access to more information should be provided, e.g. the National Autistic Society. Access
to psychiatric/psychology services for the individual and the family is essential.
Education
Liaison with education is essential. Pre-school intervention within the home and nursery is possible
with early diagnosis. Local outreach services may be available to go into the home to give
management advice. Formal pre-school notification by health to education allows the childs needs to
be assessed before school placement. School placement can vary from mainstream with support
through to a special unit depending on the individual child. Children on the autistic spectrum often
require a high teacher to pupil ratio in a highly structured environment to minimize disruptions.
Speech and language input to help communication skills is also important.
Social services
Living with a child on the autistic spectrum affects all members of the family. Families often need
respite care and support in the home.
6. DEVELOPMENTAL COORDINATION DISORDER

Developmental coordination disorder (DCD) is a common type of sensory-processing problem that
causes difficulty in performing coordinated actions. The child is often described as clumsy. There
may be associated problems of language, perception and thought processing. Concern about motor
coordination is one of the most common reasons for a referral to a paediatrician from education.
Children present with both fine- and gross-motor difficulties.
In the younger child symptoms include:
Slow gross-motor development

Poor motor skills, e.g. running, jumping, not able to catch a ball
Difficulty dressing
Poor pencil grip
Difficulty with jigsaws
Anxiety
In the older child symptoms include the following:
Avoidance of physical education

Slow school progress
Reduced attention span
Difficulty with maths, reading
Trouble copying from the blackboard

Poor writing skills
Inability to follow instructions
Poor organizational skills
Differential diagnosis
Learning disability
Neuromuscular problem
Attention-deficit hyperactivity disorder
Specific speech and language delay
Visual problem
Cerebral palsy
Brain tumour
Assessment
In the pre-school child initial assessment is usually by a paediatrician to exclude other pathologies,
including general developmental delay. The school-age child is usually assessed by a paediatrician,
but information should also be obtained from the school about the childs difficulties and overall
progress. In addition, often a speech and language assessment and occupational therapy assessment
are required.
The occupational therapist examines:
fine- and gross-motor developmental levels

visual motor integration (e.g. doing puzzles or copying shapes)
visual perception
balance and posture
responses to sensory stimulation
bilateral coordination
motor planning
Management
DCD is not curable but the child often improves in some areas with maturity. Liaison of education,
health professionals and the child and parents is crucial to help the child within the classroom and the
home environment. The schools special educational needs coordinator (SENCO) and school nurse
can play an important role in the communication between health and education. Speech and language
therapists and occupational therapists give advice to the school to help with difficulties in the
classroom. Sometimes group and individual therapy can help, e.g. a phonology course for articulation
difficulties. Advice for parents to help with home activities is also important.
7. ATTENTION DEFICIT HYPERACTIVITY DISORDER

It is estimated that up to 3% of school-age children meet the diagnostic criteria for attention deficit
hyperactivity disorder (ADHD). It is more common in boys.
Diagnosis
Problems occur in three areas:
Inattention
Hyperactivity
Impulsiveness
It is possible to have one of these features without the others, e.g. marked inattention without the
hyperactivity or hyperactivity without inattention.
In addition:
The behaviour should have persisted for at least 6 months

The behaviour should be inconsistent with the childs developmental age
There must be clinically significant impairment in social or academic development
The symptoms should occur in two or more settings including social, familial, educational and/or
occupational settings
There should be no other explanation for the symptoms, e.g. psychiatric illness
Diagnosis requires detailed history and information gathering from parents, school and other
professionals. Structured questionnaires, e.g. Conner Scales, are used to screen and diagnosis
ADHD.
Examination to exclude other differential diagnoses is important.
Children with ADHD develop emotional and social problems, poor school performance and
problems within the home because of the difficult behaviour. It is associated with unemployment,
substance abuse and crime in adulthood.
Inappropriate expectations
Language/communication disorder
Social problem
Specific learning difficulty
Chronic illness, e.g. asthma
Epilepsy
DCD
Drugs
Management
Management involves a comprehensive treatment programme. There needs to be multiprofessional
collaboration of the parents, the child, the school and other professionals. In some areas children with
ADHD are managed by child psychiatrists and in others community paediatricians take on this role.
Assessment
This should include assessment of:
an individuals needs
coexisting conditions
physical health
social, familial and educational/occupational circumstances
Treatment
Psychological/behavioural interventions; range of interventions from support groups through to
psychotherapy can help including parent training/education programme (first line in pre-school
age)
Educational support: close communication with school is vital with the development of an
individual education plan if necessary. Simple changes such as working in smaller groups, reward
systems and moving the child nearer the teacher can help
Social services support if necessary
Drug treatment; for older children and young people with severe ADHD, drug treatment should be
offered as a first-line treatment but should always form part of a comprehensive treatment plan
Stimulant medications, e.g. methylphenidate (Ritalin), are used for the treatment of ADHD. They are
usually given twice a day, morning and lunchtime. An evening dose is usually avoided because of
difficulties with sleep. A drug holiday is recommended once a year. Side effects include weight and
growth retardation and hypertension. Treatment should be started and monitored by child psychiatrists
or paediatricians with expertise in ADHD. Height, weight, pulse and blood pressure should be
monitored at least 6-monthly. Drug treatment does not cure ADHD. It improves the symptoms to allow
the other interventions an opportunity to take effect.
Methylphenidate can be used as part of a comprehensive treatment programme for children with
severe ADHD as can atomoxetine and dexamfetamine
Not licensed for those under 6 years
Diagnosis should be made by a psychiatrist or paediatrician with expertise in ADHD
The clinical expert should supervise the medication GPs may agree to share care
Treatment should be stopped if there is no benefit
Treatment should also include advice and support to parents and teachers
Children should be regularly monitored

Transition to adult care requires careful planning
A balanced diet, good nutrition and regular exercise are recommended
8. SPECIAL EDUCATIONAL NEEDS AND THE EDUCATIONAL

STATEMENT
Many children have special educational needs, but only a small percentage (approximately 2%) need
statements because their difficulties are such that they require provision additional to or different
from that normally available to children.
With the pre-school child it is often health that first becomes aware of the special educational
needs, e.g. global developmental delay, Down syndrome, cerebral palsy
Some medical conditions may have significant impact on the childs academic attainment and the
ability to participate fully in the curriculum. Some of the most common medical conditions are
congenital heart disease, epilepsy, cystic fibrosis, haemophilia and childhood cancers
Pre-school children
Health authorities are required by law to notify the local education authority (LEA) of children
over the age of 2 years who may have special educational needs
The parents, nursery and social services are also able to notify education
The LEA then collects information about the child, which is passed on to the educational
psychologist who decides if a formal assessment for statementing is appropriate
If formal assessment is requested the health authority is asked to write a report on the childs needs
the E medical. This report will give information about health, e.g. hearing, vision, epilepsy,
physical problems, and a summary of the developmental problems. It also informs education of
other therapists involved such as physiotherapy, and speech and language. In addition it describes
the practical needs of the child, e.g. toileting, feeding, dressing, what to do if the child has a fit.
Other professionals also submit reports including the parents
Once the formal assessment is completed the LEA decides whether to statement the child or not.
(Most children are issued a statement after formal assessment.)
Schoolchildren
When school or the family identify that a child has special educational needs, the schools SENCO
should be informed. This is a teacher with expertise in managing children with educational needs.
The school, with the help of the SENCO, will decide what support the child needs.
School Action
A child is on School Action if the school feels that they can support the childs needs with no
additional support.
School Action Plus

A child is on School Action Plus if the school feels that help from other services is required, e.g.
speech and language.
Educational Statement
If the school feels that they can no longer support the childs educational needs sufficiently on School
Action Plus, an assessment of educational needs is initiated. This formal assessment clarifies the
childs needs, determines how these needs will be met within the educational setting, and decides
whether a formal statement should be issued.
A statement is a legal contract and allows extra funding for the individual. When possible the child
will continue in mainstream school with extra help, e.g. one-to-one full-time help.
Sometimes if it is felt more appropriate for the child to attend a special school with staff with
expertise in special needs. These schools may be specific for one need, e.g. visual impairment,
deafness or able to support children with multiple special needs.
Child Mental Health
9. CHRONIC FATIGUE SYNDROME/MYALGIC ENCEPHALOPATHY

This remains an ill-understood condition that may present to either paediatricians or psychiatrists and
which requires a coordinated multiprofessional approach. The cardinal symptoms are severe and
disabling physical and mental fatigue lasting for more than 3 months. Symptoms are usually
continuous, their effects on the individual manifest to a pathological degree and are rarely objectively
confirmed. The diagnosis excludes known causes of chronic fatigue such as chronic illness and also
excludes known psychological disease.
Aetiology
Although viruses such as EpsteinBarr virus and the enteroviruses are often implicated in the disease
process, direct evidence of this is often hard to find. Case clustering does occur and, although
anecdotal cases have suggested that immunization may be a trigger, there is no direct evidence to
support this theory. The aetiology is likely to be a combination of physical, psychological and
behavioural factors. Often a trigger for the childs symptoms can be found.
Depression may be an associated feature, and the chronic course the disease takes makes
psychological support and evaluation essential.
Epidemiology
The UK prevalence of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) in children
and young people is 50100 per 100 000 with the highest prevalence in adolescents. Where studies
have reported a difference in gender, girls outnumber boys 3:1, but overall evidence of a gender
difference is inconclusive.
Clinical features
The onset may be gradual or sudden. In addition to fatigue the following are other frequently reported
symptoms:
Headaches
Sleep disturbance
Concentration difficulties
Memory impairment
Myalgia/muscle pain
Nausea
Sore throat
Tender lymph nodes
Abdominal pain
Arthralgia/joint pain
Feeling too hot or too cold
Dizziness
Cough
Eye pain
Vision or hearing disturbance
Weight gain or loss
Muscle weakness
Diarrhoea
There are no agreed diagnostic criteria for children/young people.

Some children and young people also have psychological symptoms, including
depression/anxiety/social phobia/somatization/social withdrawal and typical personality features.
Initial assessment
All patients referred for consideration of the diagnosis require a full and thorough assessment with an
appreciation of the reality of the childs symptoms and acknowledgement of their validity. A thorough
history and examination should be taken, exploring precise symptomatology. Organic and
psychological disease should be looked for. Of particular importance is determining the effect of the
childs symptoms on their normal daily routine including activities at home and attendance at school.
Investigation
Routine tests on all patients should include a blood test and a urine test for the following
investigations:
Full blood count and film

Erythrocyte sedimentation rate and C-reactive protein
Blood glucose
Blood biochemistry (to exclude renal insufficiency and Addison disease)
Creatine kinase
Thyroid function
Liver function
Urine for protein/glucose and infection screen
Viral titres: EpsteinBarr virus IgM, IgG and EBNA (EpsteinBarr nuclear antigen)
Other investigations may be required if there are specific disease pointers.
Investigations should be performed early on and, if possible, on one occasion only to prevent reliance
on test results. The differential diagnosis is wide and requires careful and comprehensive clinical
assessment.
Management
Management is complex and requires the input of many professionals. It needs to be tailor-made to the
individual child in the form of a management plan with a single coordinator.
Key points are as follows:
Facilitate the child and family to acknowledge the diagnosis, understand its implications and
embark on a period of rehabilitation
Assess current level of functioning by completing a daily programme to establish periods of eating,
rest and activity
Liaise closely with school/education authority
Set goals:
Attendance at school is a key aim but gradual reintegration is usually required, with rest periods
within school. Part days in school are preferable to exclusive home tuition
Aim to increase activity levels by around 5% each week
Encourage child to keep a diary
Advice re healthy balanced diet
Help/support with sleeping difficulties
Recognize early any predominant psychological symptoms, including school phobia or depression,
and seek appropriate psychological or psychiatric help
Appropriate pain management (may include psychological intervention and/or low-dose
amitriptyline or nortriptyline)
Pharmacological interventions such as corticosteroids, antidepressants (particularly selective
serotonin re-uptake inhibitors SSRIs) and immunoglobulin have been used, but in a recent metaanalysis of treatments only physiotherapy (with a graded exercise programme) was shown to have
a clearly beneficial effect
There is no evidence to support the use of magnesium injections, essential fatty acids, high-dose
vitamin B12 supplements, anticholinergic drugs, staphylococcal toxoid or antiviral therapies
Cognitive techniques are used to assist patients to re-evaluate their understanding of the illness,
combat depression and anxiety, and look for underlying thoughts and assumptions that may
contribute to disability
Inpatient admission is rarely needed in the context of children with severe/very severe CFS/ME
It is critical to work closely with the child/young person and the family and to review progress
regularly
See here for flow chart on the Management of Chronic Fatigue Syndrome
Prognosis
Outcome data vary; studies with extended follow-up show 6080% partial or complete. Younger
people tend to have a better outcome.
Good prognostic factors in chronic fatigue syndrome are:
Clearly defined trigger to illness

Short duration of symptoms
Supportive family with good interpersonal relationships
Young age (adolescents overall do better than young or older adults)
10. EATING DISORDERS IN CHILDHOOD AND ADOLESCENCE

The eating disorders anorexia nervosa and bulimia nervosa have become increasingly recognized in
paediatric practice over the last two decades. Both are rare in pre-pubertal children. Anorexia
nervosa increases in incidence through mid- and late adolescence and is thought to affect at least 1%
of females aged between 15 and 25 years. Bulimia nervosa most commonly presents in the late teens
or early 20s. Over 90% of those affected by eating disorders are female.
Many clinical features are common to both anorexia and bulimia nervosa and patients may satisfy
criteria for anorexia or bulimia at different stages of their illness.
Diagnostic criteria for anorexia nervosa

Self-induced weight loss of >15% body weight (avoidance of fattening foods aggravated by selfinduced vomiting, purging or exercise)
Intense fear of gaining weight or becoming fat, even though underweight
Abnormal perception of body image
Amenorrhoea in postmenarchal female (absence of at least three menstrual cycles)
Diagnostic criteria for bulimia nervosa

Recurrent episodes of binge eating, characterized by consuming an excessive amount of food within
a short, defined time span, with lack of control of eating during the episode
Recurrent inappropriate compensatory behaviour to prevent weight gain, e.g. laxative abuse or selfinduced vomiting
Binges and compensatory behaviour occur at least twice per week for 3 months
Self-evaluation unduly influenced by body shape and weight
Disturbance does not occur exclusively during periods of anorexia nervosa
Aetiology
Familial factors: concordance rate for anorexia nervosa in monozygotic twins is 50%, compared
with 10% for dizygotic twins. Other risk factors include family history of depression, alcoholism,
obesity or eating disorder. Children with anorexia nervosa often come from overprotective and
rigid families where there is a lack of conflict resolution
Individual factors, e.g. previous obesity, fear of losing control, self-esteem dependent on the
opinion of others and previous or ongoing abuse
Sociocultural factors: there is a higher prevalence in high social classes and certain occupations,
e.g. ballet dancers
Neurohumoral factors: controversy remains over the exact role of substances such as serotonin in
the pathogenesis of eating disorders
Clinical features
Anorexia nervosa
Usually this begins as a typical adolescent diet to reduce stigmatization from obesity. Once weight
begins to reduce, weight goals are constantly reset and compulsive weighing becomes a feature. Often
physical activity is increased and social contacts diminish. Disordered thinking and poor
concentration develop as the disease process progresses.
Bulimia nervosa
Bulimia is even more common than anorexia in those with a past history of obesity. Self-loathing and
disgust with the body are also greater than in anorexia. Patients are more likely to seek medical help
for their symptoms. Coexisting substance abuse is not uncommon. Both bulimia and anorexia are
frequently associated with major depressive and anxiety disorders.
Medical complications of anorexia nervosa and bulimia

Central nervous system
Reversible cortical atrophy
Non-specific EEG abnormalities
Dental
Caries
Periodontitis
Pulmonary
Aspiration pneumonia (rare)
Cardiovascular
Bradycardia
Hypotension
Arrhythmias
Cardiomyopathy (rare)
Gastrointestinal
Parotitis
Delayed gastric emptying
Gastric dilatation
Constipation
Raised amylase (bulimia)
Renal/electrolyte
Hypokalaemia
Hypochloraemic metabolic alkalosis
Oedema
Renal calculi (rare)
Neuroendocrine
Amenorrhoea
Oligomenorrhoea (bulimia)
Musculoskeletal
Myopathy
Osteoporosis and pathological fractures
Haematological
Anaemia
Thrombocytopenia
Hypercholesterolaemia
Hypercarotenaemia
Dermatological
Dry, cracking skin

Lanugo
Callous on dorsum of hand (from vomiting)
Perioral dermatitis
Treatment
Most patients with anorexia can be treated as outpatients, with hospital admission only if adequate
weight gain at home is not possible or there are complications such as depression.
A combined multidisciplinary approach with monitoring of eating and weight, biochemical
monitoring and ongoing psychotherapy is required. At present the psychotherapy usually involves
behavioural, cognitive and psychodynamic components. Rarely, medication such as antipsychotics or
antidepressants may be required. Appetite stimulants are used even less often. Adequate provision for
education is essential. Feeding against the will of the patient can be done only in the context of the
Mental Health Act 1983 or the Children Act 1989.
Young people with bulimia may be treated with cognitivebehavioural therapy, adapted to suit their
age and development. A trial of selective SSRIs may be considered but no other drugs are
recommended for the treatment of bulimia nervosa.
Course and prognosis

Five to ten years after the diagnosis of anorexia nervosa around 50% will have recovered, 25% will
have improved but still have some features of an eating disorder and the remainder will either not
have improved or be dead. Mortality rates are between 5% and 20%, with the most frequent causes
of death being starvation, electrolyte imbalance, cardiac failure and suicide.
Good prognostic factors
Younger age at onset
Less denial
Improved self-esteem
Poor prognostic factors
Parental conflict
Bulimia nervosa
Coexisting behavioural disorders
The long-term outcome of bulimia nervosa is less clear.
11. DEPRESSION IN CHILDHOOD AND ADOLESCENCE

Depression affects around 1 in every 200 children under the age of 12 years and 23 in every 100
teenagers. The cause is usually multifactorial but recognized risk factors include the following:
Adverse personal experiences/life events such as family breakdown, death of friend/family
member, neglect, abuse, bullying
Physical illness including infectious mononucleosis (acute trigger) or chronic disease
Stress especially if unable to share concerns and/or lack of practical support
Positive family history
Female sex
History of drug/alcohol problems
Symptoms
These include the following:
Moodiness/irritability
Withdrawal from friends, family, regular activities
Self-critical/self-blaming
Poor concentration
Lack of care for personal appearance
Changes in sleep pattern may sleep too little or too much
Tiredness
Changes in appetite
Frequent minor health problems particularly headaches/abdominal pain
Treatment
General advice should be given to all children and young people with mild, moderate or severe
depression on:
self-help materials
the benefits of regular exercise
sleep, hygiene and anxiety management
the benefits of a balanced diet
Mild depression: if this persists for 4 weeks or more with no significant comorbid problems or
suicidal ideation, offer one of the following psychological therapies for a limited period of 23
months:
Individual non-directive supportive therapy

Group cognitivebehavioural therapy
Guided self-help
Antidepressant medication should not be used for the initial treatment of mild depression
Moderate/severe depression:
First-line treatment is psychological therapy such as individual cognitivebehavioural therapy or
interpersonal therapy or family therapy
If depression is unresponsive consider additional psychological therapies or medication (after
multidisciplinary review)
Fluoxetine is the most commonly prescribed but it is not licensed for under-18s and should be used
extremely cautiously, especially in under-11s
Second-line drug treatments include sertraline and citalopram
High-risk of suicide, serious harm and self-neglect:
Consider inpatient treatment
Use electroconvulsive therapy very rarely in 1218 year olds
Do not use:
Paroxetine, venlafaxine, tricyclic antidepressants, St Johns wort

Consideration should be paid to the parents mental health particularly the possibility of depression
and substance abuse.
12. SELF-HARM AND SUICIDE

Suicide is rare before puberty, yet it is the third leading cause of death for adolescents with rates in
young men continuing to rise. Methods include drug overdose, hanging, inhalation of car exhaust
fumes and shooting. It is by far the minority of adolescents making suicide attempts who have either
an underlying psychiatric disorder or serious suicidal intent. All individuals who attempt suicide
must undergo psychiatric assessment. The use of violent methods, attempts that take place in isolated
places and the writing of a suicide note should ring particular alarm bells.
Risk factors for suicide in adolescents
Male sex
Broken home, disturbed relationships with parents
Living alone
Immigrant status
Family history of affective disorder, suicide or alcohol abuse
Recent loss or stress
Previous suicide attempt
Drug or alcohol addiction
Characteristics of deliberate self-harm in adolescents

Self-poisoning
Much more common in girls
Accounts for >90% of cases of deliberate self-harm
Overdose often taken in environment where patient is likely to be found
Drugs most commonly taken include paracetamol, aspirin, benzodiazepines and antidepressants
Multiple drug ingestion common (often with alcohol)
Under 20% need intensive medical management but all should be admitted until assessed by child
psychiatrist/social services as appropriate
Mortality rate well below 1%
Blood and urine toxicology screens are useful because there is often a poor correlation between the
quantity of drugs taken and their clinical effect
Paracetamol and aspirin levels should be taken routinely
Self-mutilation
Includes scratching, cutting, cigarette burns, tattooing, bruising, biting and inserting needles
Typically seen in teenage girls with personality problems, e.g. aggressive/impulsive behaviour,
eating disorders, poor self-esteem
Also occurs in those with schizophrenia/learning disability
Difficult to treat need to address underlying personality/emotional problems.
Over 10% of adolescents who attempt suicide will repeat within 1 year.
13. SCHIZOPHRENIA WITH CHILDHOOD ONSET

Schizophrenia is rare in childhood and adolescence with an incidence of less than 3 in 10 000. A
genetic component can be implicated in at least 10% of cases, but other factors, including perinatal
difficulties, psychosocial factors and difficulties with premorbid personality, are also important.
Boys outnumber girls by approximately 2:1.
Presentation
May be acute or insidious (gradual withdrawal and failing schoolwork).
Major symptoms include:
Delusions
Hallucinations
Distortions of thinking (thought insertion and withdrawal)
Movement disorders, commonly catatonia
It may be difficult to distinguish from major mood disturbance, e.g. manicdepressive psychosis, or
organic causes of psychosis, e.g. neurodegenerative or drug-induced episode, systemic lupus
erythematosus, epilepsy, Wilson disease, thyrotoxicosis and vasculitis. Any child presenting with
psychotic symptoms should have an EEG and brain MRI.
Treatment
Drugs: antipsychotics, e.g. clozapine (few extrapyramidal side effects but risk of agranulocytosis),
chlorpromazine, haloperidol
Individual and family therapy
Adequate educational provision essential
Prognosis
Chronic or relapsing course is common
Good prognostic factors include high intelligence, acute onset, precipitating factors, older age at
onset and normal premorbid personality
14. CONDUCT DISORDERS

Persistent antisocial or socially disapproved of behaviour often involving damage to property and
unresponsive to normal sanctions.
Prevalence
Approximately 4%
Strong male predominance
Clinical features
Temper tantrums
Oppositional behaviour (defiance of authority, fighting)
Overactivity
Irritability
Aggression
Stealing
Lying
Truancy
Bullying
Delinquency, e.g. stealing, vandalism, arson in older children/teenagers
Oppositional defiant disorder is a type of conduct disorder characteristically seen in children under
10 years. It is characterized by markedly defiant, disobedient, provocative behaviour and by the
absence of more severe dissocial or aggressive acts that violate the law or the rights of others.
Aetiology
Family factors: lack of affection, marital disharmony, poor discipline, parental violence/aggression
Constitutional factors: low IQ, learning difficulties, adverse temperamental features
Oppositional peer group values
Urban deprivation/poor schooling
Depression
Bullying
Abuse
Young people with conduct disorders have an increased incidence of neurological signs and
symptoms, psychomotor seizures, psychotic symptoms, mood disorders, ADHD and learning
difficulties.
Treatment
Family/behavioural therapy
Practical social support, e.g. rehousing
Prognosis
Half have problems into adult life
15. COMMON BEHAVIOURAL PROBLEMS IN PRE-SCHOOL CHILDREN

15.1 Sleep disorders
Reluctance to settle at night and persistent waking during the night are common problems in young
children, with one in five 2 year olds waking at least five times per week.
Factors contributing to sleep difficulties
Adverse temperamental characteristics in child

Perinatal problems
Maternal anxiety
Poor accommodation
Physical illness
Medication, e.g. theophyllines
Timing of feeds
Co-sleeping with parents
Medication, such as sedating antihistamines, is usually unhelpful in this situation. A behavioural

strategy is usually successful but often needs to be combined with some respite for the parents.
Unlicensed melatonin is, however, sometimes used to reduce both the time to sleep onset and the
number of episodes of night wakening. Its use in children with coexisting neurodevelopmental
pathology has been well described.
Nightmares are most common between the ages of 3 and 5 years with an incidence of between 25%
and 50%. The child who awakens during them is usually alert and can recall the dream and
frightening images. They are usually self-limiting and may be related to obvious frightening or
stressful events. In severe cases the involvement of a psychologist or psychiatrist may be needed.
15.2 Feeding problems in infancy and childhood
Most children at some point will be picky eaters a phase that will usually pass spontaneously.
Infants and children may also, however, refuse to feed if they find the experience painful or
frightening. Reasons contributing to this may include the following:
Unpleasant physical experiences associated with eating, e.g. gastro-oesophageal reflux, oral
candidiasis, stricture postoesophageal atresia repair
Oral motor dysfunction
Children who have required early nasogastric tube feeds
Maternal depression
Being forced to eat by caregiver
Developmental conflict with caregiver
Emotional and social deprivation
Non-organic faltering growth is a diagnosis of exclusion.
Evaluation of feeding disorders

Complete history including detailed social history
Complete physical examination need to exclude physiological, anatomical and neurological
abnormalities
Assess emotional state and developmental level
Observe feeding interaction
Help parents to understand that infants and children may have different styles of eating and food
preferences
Management of feeding disorders
Eliminate and/or treat physical cause
Multidisciplinary approach including paediatrician, GP, health visitor, speech and language
therapist, dietician and/or psychologist
Childs behaviour may need modification
If there is also faltering growth, exclude medical disorders and maltreatment
Pica (the ingestion of inedible material such as dirt and rubbish) may be normal in toddlers but
persistent ingestion is found in children with learning difficulties and in psychotic and socially
deprived children. Lead poisoning is a theoretical risk from pica.
15.3 Temper tantrums

These are common in the pre-school child and generally occur when the child is angry or has hurt
him- or herself. Usually they are typified by screaming and/or crying, often in association with
collapsing to the floor. It is rare for children to injure themselves during such episodes. If necessary
the child should be restrained from behind by folding ones arms around the childs body. It is
important to minimize any additional attention to the child and to respond and praise only when
behaviour is back to normal.
15.4 Breath-holding attacks

These episodes typically occur after a frustrating or painful experience. The child cries inconsolably,
holds his or her breath and then becomes pale or cyanosed. In the most serious cases loss of
consciousness may ensue and there may be stiffening of the limbs or brief clonic movements. Clearly
it may be difficult to distinguish from a generalized seizure; however, the fact that after a breathholding attack the child will take a deep breath and immediately regain consciousness may facilitate
differentiation. Typical onset is between 6 and 18 months. No specific treatment is needed and the
episodes diminish with age.
16. COMMON PROBLEMS IN THE SCHOOL-AGED CHILD

16.1 School refusal
This problem refers to the childs irrational fear about school attendance and is seen most commonly
at the beginning of schooling or in association with a change of school or move to secondary school.
Typically the child is reluctant to leave home in the morning and may develop a headache or
abdominal pain.
Factors contributing to school refusal

Separation anxiety
Specific phobia about an aspect of school attendance, e.g. travelling to school, mixing with other
children, games lessons
A more generalized psychiatric disturbance such as depression or low self-esteem
Bullying
Characteristics of school refusers

Good academic achievements
Conformist at school
Oppositional at home
Treatment
Avoid unnecessary investigation of minor somatic symptoms

Early, if necessary graded, return to school
Support for parents and child
Close liaison with school
In chronic cases a gradual reintegration back into school is required, possibly with a concurrent
specific behavioural programme and targeted family therapy.
Overall two-thirds of children will return to school regularly. Those who do badly are often
adolescents from disturbed family backgrounds.
Truancy
In contrast to the above, truancy always reflects a lack of desire to go to school rather than anxiety re
school attendance and as such may be part of a conduct disorder.
Bullying
Bullying may be defined as the intentional unprovoked abuse of power by one or more children to
inflict pain or cause distress to another child on repeated occasions. Estimates on the prevalence of
bullying vary widely, but many studies report that between 20% and 50% of school-aged children
have either participated in or been victims of bullying. Verbal harassment is the most common form of
bullying and is often not recognized as such. Cyber bullying is increasing in prevalence, particularly
among older children.
Although it is important not to stereotype, certain characteristics are commonly exhibited by bullies:
Poor psychosocial functioning

Unhappiness in school
Concurrent conduct disorders
Emotional problems
Social problems
Alcohol and nicotine abuse
Children who suffer at the hands of bullies may consequently suffer from:
anxiety
insecurity
low self-esteem and self-worth
mental health problems
sleep difficulties
bed wetting
headaches
abdominal pain
Carefully planned programmes may reduce the incidence of bullying by 50% or more. Such strategies
rely on teaching appropriate social skills to children who bully, developing clear rules that they are
expected to adhere to, providing an increased level of supervision, particularly within the school
environment, and facilitating access to other services that they may require, e.g. child mental health,
social services.
16.2 Non-organic abdominal pain/headache/limb pains

Over 10% of children experience such symptoms. It is important to exclude organic pathology
promptly and to search for any underlying stresses. Most run a short course but if symptoms are
persistent and involve several systems the term somatization disorder is used.
16.3 Sleep problems in the school-aged child

To understand sleep disorders a basic knowledge of the sleep cycle is necessary.
Sleep stages
Sleep consists of several stages that cycle throughout the night. One complete cycle lasts 90100
minutes.
Stages of Sleep
Sleep stage
1 Slow wave sleep (SWS) or non-rapid eye

movement (NREM)
2 SWS or NREM
3 SWS or NREM
4 SWS or NREM
5 REM
Features
Transition state between sleep and wakefulness
Eyes begin to roll slightly
Mostly high-amplitude, low-frequency theta
waves
Brief periods of alpha waves similar to those
when awake
Lasts only a few minutes
Peak of brain waves higher and higher sleep
spindles
Lasts only few minutes
Also called delta sleep or deep sleep
Very slow delta waves account for 2050% of
brain waves
Also called delta sleep or deep sleep
Over 50% of brain waves are delta waves
Last and deepest of sleep stages before REM
sleep
Frequent bursts of rapid eye movement and
occasional muscular twitches
Heart rate increases
Rapid shallow respirations

Most vivid dreaming during this phase
Night terrors
These are most commonly seen in children between the ages of 4 and 7 years. Typically the child
wakes from deep or stage 4 sleep apparently terrified, hallucinating and unresponsive to those around
him or her. Usually such episodes last less than 15 minutes and the child goes back to sleep, with no
recollection of the events in the morning. It is unusual to find any underlying reason or stresses
contributing to the problem.
Nightmares
These occur during rapid eye movement (REM) sleep and the child remembers the dream either
immediately or in the morning. Underlying anxieties should be sought.
Sleepwalking
This occurs during stages 3 or 4 of sleep and is most often seen in those between 8 and 14 years.
16.4 Tics
These occur transiently in 10% of children and are much more commonly seen in boys. Onset is
usually around the age of 7 years, although simple tics are seen most commonly. Gilles de la Tourette
syndrome may occur in childhood. This phenomenon is characterized by complex tics occurring in
association with coprolalia (obscene words and swearing) and echolalia (repetition of sounds or
words).
Factors predisposing to tics

Positive family history
Stress (including parental)
Neurodevelopmental delay
Treatment
Most resolve spontaneously

Reassure accordingly
Behavioural or family therapy if appropriate
Medication: haloperidol, pimozide, clonidine (in very severe cases only)
Outcome
Simple tics complete remission

Gilles de la Tourette syndrome 50% have symptoms into adult life
17. ENURESIS/ENCOPRESIS
17.1 Enuresis
This is defined as the involuntary passage of urine in the absence of physical abnormality after the age
of 5 years. Nocturnal enuresis is much more common than diurnal enuresis, affecting at least 10% of 5
year olds. Although most children with nocturnal enuresis are not psychiatrically ill, up to 25% may
have signs of psychiatric disturbance. Diurnal enuresis is much more common among girls and those
who are psychiatrically disturbed. Secondary enuresis is more commonly associated with underlying
problems.
Aetiology
Positive family history in 70%

Developmental delay
Psychiatric disturbance
Small bladder capacity
Recent stressful life events
Large family size
Social disadvantage
Treatment
Exclude physical basis (history, examination, urine culture imaging)

Look for underlying stresses
Reassure child and parents of benign course
Star chart
Enuresis alarm (7 years and older)
Drugs (short-term control only): desmopressin, tricyclic antidepressants
It must be remembered that child sexual abuse may present with enuresis and/or encopresis.
17.2 Encopresis
This is defined as the inappropriate passage of formed faeces, usually on to the underwear, after the
age of 4 years. It is uncommon, with a prevalence of 1.8% among 8-year-old boys and 0.7% for girls.
Psychiatric disturbance is common and enuresis often coexists. Broadly speaking, children with
encopresis may be divided into those who retain faeces and develop subsequent overflow
incontinence (retentive encopresis) and those who deposit faeces inappropriately on a regular basis
(non-retentive).
Type of encopresis and common family characteristics

Retentive obsessional toilet-training practices
Non-retentive continuous, disorganized, chaotic families
Other risk factors for encopresis

Poor parentchild relationship
Emotional stresses (including sexual abuse)
Past history of constipation/anal fissure
Treatment
Exclude physical problems, e.g. Hirschsprung disease/hypothyroidism/hypercalcaemia

Laxatives to clear bowel
Education for parents and child
Star chart
Individual psychotherapy
Family therapy
It is unusual for this problem to persist into adolescence.
Community Paediatrics
18. CHILD HEALTH SURVEILLANCE

This begins in the antenatal period with a major focus on antenatal care, support for both parents and
early identification of at-risk families. Health promotion and advice on feeding are shared.
Although all children are assigned a health visitor, increasingly their input is targeted and varied. All
infants have a parent-held child health record red book and in this all contacts with health
professionals should be documented. The most appropriate opportunities for screening tests and
developmental surveillance, as well as for discussing social and emotional development with parents
and children and linking children to early years services, are as follows:
Week 12 of pregnancy
Neonatal examination: performed by nurse practitioner, hospital doctor or GP. Full physical
examination including weight, head circumference, heart, eyes, hips, genitalia.
New baby review at 14 days when health visitor takes over from community midwife
6- to 8-week check usually done by GP and often combined with first immunisations.
1-year checks performed variably in different geographical areas
2 1/2-year checks performed variably in different geographical areas
18.1 Summary of newborn screening

1. Newborn hearing screening offered to all babies in the UK by 45 weeks of age uses combination
of automated otoacoustic emissions (AOAEs) and automated brain-stem response (AABR) should
be done by 44 weeks gestational age
2. Phenylketonuria screening (PKU)
3. Congenial hypothyroidism
4. Sickle cell disease and thalassaemia
5. Cystic fibrosis
6. Medium chain acyl-CoA dehydrogenase deficiency (MCADD)
The last five tests are all performed on a heel-prick sample taken from all neonates by a midwife or
health visitor at age 58 days.
18.2 School-aged children

Programmes differ significantly between local authorities. A health questionnaire is completed on
school entry and reviewed by the school nurse. Screening of hearing and vision may also be
undertaken. In most areas medical examination is carried out only on a selective basis.
Informal drop-in centres run by the school nurse provide valuable support to the child and their
family. A full medical may be requested if parents, teachers or school nurse have concerns.
19. IMMUNIZATION IN CHILDHOOD

19.1 Immunization schedule
The current immunization schedule for infants and children in the UK (active
from November 2010)
Notes on immunization schedule
Bacille CalmetteGurin (BCG) vaccine

High-risk categories include:
Infants born to immigrants from countries with high prevalence of tuberculosis
Infants who are to travel abroad to high-prevalence areas
Infants born in the UK where high prevalence of tuberculosis
Rubella vaccine
Any girl who missed the MMR should be immunized between the ages of 10 and 14 years.
Hepatitis B vaccine
At present the vaccine is recommended only for:
babies born to mothers who are chronic carriers of hepatitis B virus or to mothers who have had
acute hepatitis B during pregnancy
families adopting children from countries such as south-east Asia, in whom hepatitis status is
unknown
19.2 Contraindications to immunization

General considerations
Acute illness: immunization should be deferred if the individual is acutely unwell but not if he or
she has a minor infection without fever or systemic upset
Previous severe local or general reaction: if there is a definite history of severe local or general
reaction to a preceding dose, then subsequent immunization with that particular vaccine should not
be performed
Local reactions: extensive redness and swelling which becomes indurated and involves most of
the anterolateral surface of the thigh or a major part of the circumference of the upper arm
General reactions: this is defined as: fever >39.5C within 48 hours of immunization; anaphylaxis;
bronchospasm; laryngeal oedema; generalized collapse. In addition, prolonged unresponsiveness;
prolonged inconsolable or high-pitched screaming for more than 4 hours; convulsions or
encephalopathy within 72 hours
Live vaccines (e.g. BCG, MMR)

Contraindications to live vaccine administration include the following:
Prednisolone (orally or rectally) at a daily dose of 2 mg/kg per day for at least a week or 1 mg/kg
per day for a month; corticosteroid use via other routes (e.g. intra-articular or inhaled) does not
contraindicate live vaccine administration
Children on lower doses of steroid also on cytotoxic drugs or with immunosuppression secondary
to an underlying disease process
Those with impaired cell-mediated immunity, e.g. DiGeorge syndrome

Children being treated for malignant disease with chemotherapy and/or radiotherapy, or those who
have completed such treatment within the last 6 months
Children who have received a bone marrow transplant within 6 months
Immunoglobulin administration within previous 3 months
Specific contraindications
Egg allergy individuals with confirmed anaphylactic reaction to egg should not receive influenza
or yellow fever vaccines. MMR can be safely given to most children who have had allergic
reactions to egg. For those with confirmed anaphylactic reaction many can be immunized under
controlled conditions
Severe latex allergy vaccines should be given from latex-free syringes/vials
Pregnancy delay live vaccines until after delivery
Myths surrounding contraindications

The following are NOT contraindications to immunization:
Family history of adverse immunization reaction
Stable neurological condition, e.g. Down syndrome or cerebral palsy
Egg allergy hypersensitivity to egg contraindicates influenza vaccine and yellow fever vaccine,
but there is good evidence that MMR can be safely given to children who have had previous
anaphylaxis after egg
Personal or family history of inflammatory bowel disease does not contraindicate MMR
immunization
Family history of convulsions
Mother is pregnant
In addition, it should be noted that the Council of the Faculty of Homeopathy strongly supports the
immunization programme.
19.3 Immunization reactions

These can be localized or generalized. Predictable adverse reactions (side effects) are generally mild
and resolve quickly. They are known as adverse events following immunization (AEFIs). AEFIs may
be due to inappropriate practices in the provision of immunization, e.g. wrong dose/prepared
incorrectly. These are known as programme-related AEFIs.
In contrast vaccine-induced AEFIs are reactions in individuals specifically caused by a particular
vaccine or its component parts. These may be induced, direct effects of the vaccine or one of its
components and/or due to an underlying medical condition or an idiosyncratic response in the
recipient.
Examples of vaccine-induced AEFIs

Direct effects:
Local reactions and fever within 48 hours of DTaP/IPV/HiB
Rash and fever 710 days after MMR
Parotitis after MMR
AEFIs due to underlying medical condition vaccine-associated paralysis after use of live
attenuated oral polio vaccine in child with previously unrecognized severe combined immune
deficiency
Idiosyncratic responses idiopathic thrombocytopenic purpura (ITP) within 30 days of MMR and
anaphylaxis after immunization
Coincidental AEFIs
These are not true adverse reactions to immunizations or vaccines but linked only because of the
timing of their occurrence, e.g. development of a cold after a flu immunization.
Common vaccine-induced AEFIs

Pain, swelling or redness at site of injection
Local adverse reactions that start within a few hours and are usually mild or self-limiting. Although
often referred to as hypersensitivity reactions, they are not allergic in nature but may be due to high
titres of antibody or a direct effect of the vaccine product. These do not contraindicate further
doses
Systemic side effects: these include fever, myalgia, malaise, irritability and loss of appetite.
19.4 Additional information on vaccines
23
20. ADOPTION AND FOSTERING

20.1 Adoption
Adoption is about meeting the needs of a child and not those of the prospective parents. When a child
is adopted full parental rights are taken on by the adopting parents and the child has all the rights of a
natural child of those parents. Up to 4000 children per year are adopted in the UK, most of these
being children over 4 years of age. Over half involve children being adopted by step-parents.
Adoption of newborn babies is increasingly uncommon. Although infants and children from overseas
are brought into the UK for adoption, it must be recognized that the legal complexities surrounding
this area are immense.
In England and Wales social services and voluntary organizations act as adoption agencies. Before
any child is adopted the following steps must occur:
Freeing of child for adoption baby/childs natural parents must give consent for adoption. Cannot
be done until at least 6 weeks after birth for newborn infants. May not be required if parents are
deemed incapable of decision-making (e.g. severe mental illness)
Meticulous assessment of prospective adoptive parents carried out by social services. There are
very few absolute contraindications to adoption (certain criminal offences will exclude). Detailed
medical history of prospective parents is important to ensure that they are physically able to look
after child. Disabled adults are encouraged to adopt. Choice of family will ideally reflect birth
heritage of child (i.e. ethnic origin)
Application for adoption order can be applied for as soon as the child starts living with
prospective adoptive parents but it will not be heard for at least 3 months (for newborn infants the
3-month period begins at the age of 6 weeks)
Adoption hearing an Adoption Panel, including social workers and medical advisers, consider
the needs of both the child and the prospective parents. May be contested. Decision on day as to
whether Adoption Order to be granted
Medical services are involved at two levels:
In an advisory capacity to the adoption agency, e.g. scrutinizing reports, collecting further medical
information if needed
Carrying out pre-adoption medicals it is essential that prospective parents have all available
information on, for example, the health of both natural parents, pregnancy, delivery, neonatal
problems, development, etc. so that they can make a fully informed decision about adopting the
child. Any special needs of the child should be identified at such an examination and additional
reports by psychiatrists/psychologists may be needed. Children with special needs usually thrive in
secure family environments, but full medical information must be made available to prospective
adopters.
There are no medical conditions in the child that absolutely contraindicate adoption.
20.2 Fostering
Foster care offers a child care in a family setting but does not provide legal permanency because
parental rights remain with the natural parents, local authority or courts, depending on the legal
circumstances. Different types of foster care include the following:
Care of babies awaiting adoption

Young children in whom return to parents is anticipated
Short break fostering
Remand fostering
For some children with strong natural family ties long-term fostering is appropriate.
Foster parents are selected by a foster panel and, as with adoption, their health and that of the
children awaiting fostering is considered.
Foster carers receive a financial allowance.
21. THE CHILDREN ACT 1989 AND HUMAN RIGHTS ACT 1998
21.1 Aims of the Children Act
This Act introduced extensive changes to legislation affecting the welfare of children. Its main aims
included:
restructuring custody and access in divorce

moving towards a family court handling all public and private proceedings about children
creating a single statutory code for the protection of children through the courts
promoting interagency cooperation in the prevention, detection and treatment of child abuse and
neglect
making legal remedies more accessible while also encouraging negotiation, partnership and agreed
solutions that avoid the need to resort to court
In all of the above, the Act stresses that the childs welfare is the paramount consideration. It
provides a checklist of welfare parameters aimed at ensuring that, in planning for the childs
protection and upbringing, full account is taken of his or her needs, wishes and characteristics.
Child protection issues contained in the Act

Social services have a duty to investigate if they have reasonable cause to suspect that a child has
suffered, is suffering or is likely to suffer significant harm. If investigation confirms the suspicion
then the child may need to be accommodated by social services while matters are taken further.
Parents of an accommodated child retain full parental responsibility, including the right to remove the
child at any time. An Emergency Protection Order may be available, enabling the child to be detained
in hospital, if parents do not agree to voluntary admission.
Emergency Protection Order

This replaced the Place of Safety Order and may be needed if, for example, non-accidental injury is
suspected. The order lasts a maximum of 8 days with a possibility of extension for a further 7 days. It
may be granted by the court if one of the following is satisfied:
There is reasonable cause to believe that the child is likely to suffer appreciable harm if not
removed from his or her current accommodation
Enquiries by local authority or an authorized person are being frustrated by lack of access
In addition, a child likely to suffer significant harm may also be taken into police protection for 72
hours. This involves a decision internal to the police force, and in cases of extreme emergency is
likely to be quicker than applying for an Emergency Protection Order.
A Care Order
This order confers parental responsibility on the social services (in addition to that of the parents)
and usually involves removal from home, at least temporarily. It may be applied for in cases of nonaccidental injury, where enquiries will take some time and where the child is not regarded as being
safe at home.
A Supervision Order
This gives social services the power and duty to visit the family and also to impose conditions, such
as attendance at clinic, nursery, school or outpatient visits.
Both care and supervision orders may be taken out by a court if that court is convinced that thresholds
for appreciable harm to the child have been met. The court, however, is under duties to consider the
full range of its power and not to make any order unless doing so would be better for the child than
making no order. While proceedings for either of these orders are pending, the court may make 8- and
then 4-weekly cycles to allow time for the childs needs to be comprehensively assessed, and for
parties to prepare their proposals for court.
Child Assessment Order (CAO)

This order may be used if there is a situation of persistent but non-urgent suspicion of risk. It is
available if:
significant harm is suspected
a necessary medical or other assessment would be unlikely or unsatisfactory without a court order
It therefore overrides the objections of a parent to whatever examination or assessment is needed to
see whether the significant harm test is satisfied. In addition it may override the objection of a child
who is of sufficient understanding to make an informed decision. This order lasts up to 7 days.
Wardship
If insufficient powers are available via the Children Act then wardship via the High Court may be
applied for. This gives the court almost limitless powers and is used in exceptional circumstances,
such as when a family objects to surgery or medical treatment for religious reasons.
Despite all the above, the implementation of the Children Act has been associated with a significant
reduction in the number of compulsory child protection interventions through the courts, in part
because of greater social services reliance on voluntary help and increased partnership with parents.
21.2 Human Rights Act 1998

This Act requires that all UK law be interpreted in accordance with the European Convention of
Human Rights so as to give effect to the requirements of the convention rights. The Act enables
individuals to take action for breach of these rights which include:
Article 2 Right to life

Article 3 Prohibition of torture
Article 6 Right to a fair trial
Article 8 Right to respect for private and family life
During child protection investigations there is potential conflict between the right of the childs family
(Article 8) and the duties of the child protection team as they relate to Articles 2 and 3. Legal advice
will need to be sought in situations of doubt.
22. SUDDEN INFANT DEATH SYNDROME AND CHILD DEATH REVIEW

Definition
The definition of sudden infant death syndrome (SIDS) is the sudden death of an infant under 1 year
of age which remains unexplained after the performance of a complete postmortem examination and
examination of the scene of death.
Incidence
Over 300 babies die of cot death or SIDS in the UK each year 0.4/1000 live births.
Many hypotheses have developed about the causes of SIDS. The search for an individual cause has
shifted towards a more complex model. It seems likely that SIDS is the result of an interaction of risk
factors developmental stage, congenital and acquired risks and a final triggering event.
Established risk factors for SIDS
Age 416 weeks

Prone sleeping position and side sleeping position4
Overheating/overwrapping
Soft sleeping surfaces
Fever/minor infection
Bed sharing with parents (contraindicated if parent has had alcohol, smokes, has taken sedative
medication or feels very tired)
Maternal smoking (ante- and postnatal)5
Low maternal age
High birth order
Low birthweight
Preterm delivery
Medical complications in the neonatal period
Social deprivation
Male sex
Protective factors for SIDS
Supine sleeping position

Separate cot
Appropriate environmental temperature
? pacifier (dummy) use (may prevent baby sleeping deeply)
Stop smoking
The death of any child should be managed in accordance with the Child Death Review process. Each
hospital should have its own protocol for dealing with SIDS, which should be adhered to.
Multiagency working is essential. The following are general guidelines:
Contact consultant paediatrician immediately
Ensure that parents have a member of staff allocated to them and an appropriate room in which to
wait
Baby should be taken to appropriate area within A&E and not to the mortuary
Initiate resuscitation unless it is evident that baby has been dead for some time (e.g. rigor mortis or
blood pooling)
Parents should have option of being present during resuscitation with nurse supporting them
throughout
Take brief history of events preceding admission, including babys past illnesses, recent health and
any resuscitation already attempted; identify any predisposing factors for SIDS
Consultant should decide, in consultation with parents, how long resuscitation should be continued
for (it is usual to discontinue if there is no detectable cardiac output after 30 minutes)
Once baby has been certified dead, consultant paediatrician should break news to parents, with
support nurse present
Explain to parents the need to inform the coroner and initiate the Child Death Review process
Physical examination
Carried out by most senior paediatrician present as soon as resuscitation has been
completed/abandoned. Need to record the following:
Babys general appearance, state of nutrition and cleanliness

Weight, and position on centile chart
Rectal temperature
Marks from invasive or vigorous procedures such as venepuncture, cardiac massage
Any other marks on skin
Appearance of retinas
Lesions inside mouth
Any signs of injury to genitalia/anus
Further action within A&E

Inform child death coordinator who will initiate child death review process
Keep all clothing removed from baby in labelled specimen bags because it may assist the
pathologist and may be needed for forensic examination
Inform coroners office and discuss collection of further laboratory specimens, take photographs
and mementoes such as lock of hair or hand- and footprints
Arrange for skeletal survey
Contact Coroners Office and request them to instruct a specialist paediatric pathologist for the
postmortem examination
If there are any concerns re suspicious death contact the police urgently
Taking of samples
In some centres all samples are taken post mortem; however, in others some or all of the following
should be taken within A&E:
Blood for urea and electrolytes, full blood count, blood culture, toxicology (clotted sample)
Metabolic screen including amino and organic acids, oligosaccharides, blood spot on Guthrie card
(for MCAD)
Chromosomes (if dysmorphic)
Lumbar puncture
Nasopharyngeal aspirate, swabs (as appropriate) for bacteriology, suprapubic aspirate for urine
microscopy, culture and sensitivity
Consider skin and muscle biopsy
Support for family

The Child Death Review doctor and/or nurse will arrange an urgent home visit
Ensure that the family have Foundation for Study of Infant Death leaflet and helpline number and
Department of Health leaflet on postmortem examinations
Offer to put in touch with local support organizations
If mother was breast-feeding discuss suppression of lactation
If baby was a twin recommend admission/investigation of surviving twin
Ensure that family have telephone numbers of appropriate members of hospital team
Offer to organize psychological support for older siblings
Give details of counselling services
Arrange transport home
Communication checklist
The following should be informed as soon as possible about the babys death:
Child death coordinator
Coroner
Coroners officer
Police
Family doctor
Health visitor
Social worker
Medical records
Other paediatric colleagues previously involved in care
Immunization office
Follow-up arrangements
For all unexpected child deaths a home visit with the child death nurse and/or doctor is organized.
The police may also join the same visit. Subsequent follow-up arrangements differ but parents must
be supported and given the opportunity to discuss management and postmortem results. A post death
planning meeting will be held as part of the Child Death Review process and a report prepared for
their overview panel. A debrief should be held for members of clinical staff.
23. ACCIDENT PREVENTION

Around 400 children per year die as a result of accidents in England and Wales and several thousand
others suffer serious injuries.
Examples of how mortality and morbidity rates may be reduced include:
Use of cycle helmets and car restraints (reduce severity of injury in road traffic accidents)
Urban safety measures (e.g. crossing patrols, traffic redistribution schemes, improving safety on
individual roads)
Use of home safety devices (e.g. smoke detectors, stairgates, thermostat control of hot water)
Studies have established that educational programmes alone are not successful in preventing
accidents and that to reduce accidents the educational material must be accompanied by:
targeting the families most at risk of accidents
home visits
free distribution of devices such as smoke alarms
24. FURTHER READING

Baroness Kennedy QC (2004). Sudden unexpected death in infancy. A report from the working
group of the Royal College of Paediatrics and Child Health and the Royal College of Pathologists.
Department of Health (1996). Immunisation Against Infant Disease. London; HMSO.
Department of Health and Home Office (2003). The Victoria Climbi Inquiry, Report of an Inquiry
by Lord Laming, Cm. 5730. London; HMSO.
Foundation for the Study of Infant Deaths. Responding when a baby dies campaign.
FSID. Sudden Unexpected Deaths in Infancy; suggested guidelines for accident and emergency
departments. London; Foundation for the Study of Infant Deaths. Available at; www.sids.org.uk/fsid.
National Institute for Health and Clinical Excellence (2004). Eating Disorders; Core interventions
in the treatment and management of anorexia nervosa, bulimia nervosa and related eating
disorders. London; NICE.
National Institute for Health and Clinical Excellence (2005). Depression in Children and Young
People. Identification and management in primary, community and secondary care. London; NICE.
Royal College of Paediatrics and Child Health (2005). Evidence Based Guideline for the
Management of CFS/ME in Children and Young People. London; RCPCH.
Rutter M (2002). Child and Adolescent Psychiatry Modern approaches. Oxford; Blackwell
Science.
Websites
Foundation for Study of Infant Deaths (FSID): www.fsid.org.uk
Hearing screening: http://hearing.screening.nhs.uk
Vision testing and screening in young children: www.patient.co.uk
Autism: www.cdc.gov/ncbddd/autism
Child development: www.cdc.gov/ncbddd/childdevelopment/index.html
Chapter 3
Child Protection and Safeguarding
CONTENTS
1. Definition
2. Physical abuse
2.1 History taking
2.2 Predisposing factors
2.3 Examination
2.4 Types of injury seen in physical abuse
2.5 Investigation
2.6 Management of abuse/suspected non-accidental injuries
2.7 Specific presentations of abuse/non-accidental injury
3. Sexual abuse
3.1 Presentation
3.2 Examination and physical signs
3.3 Investigation
3.4 Management
3.5 Long-term complications
4. Emotional abuse
5. Neglect
6. Fabricated or induced illness
Child Protection and Safeguarding
1. DEFINITION
The term safeguarding is preferred to child protection because it is broader and encompasses
preventive strategies and approaches. It is defined as:
The process of protecting children from abuse or neglect, preventing impairment of their health
and development, and ensuring they are growing up in circumstances consistent with the
provision of safe and effective care that enables children to have optimum life chances and enter
adulthood successfully.
This definition applies to all children and young people who have not yet reached their eighteenth
birthday, including unborn children. All doctors who see children and young people have a
responsibility to protect children and young people as outlined in Good Medical Practice. New
guidance (Protecting children and young people: the responsibilities of all doctors) is currently
under development by the General Medical Council (GMC) and gives more detailed guidance on how
doctors can fulfil their duty to protect infants, children and young people who are living with their
families or away from home.
The term child protection can be used to refer to the activity that is undertaken to protect specific
children who are or at risk of suffering serious harm. Sadly, in the UK up to 100 children per year die
as a result of non-accidental injuries.
Other useful definitions are as follows:
Child in need
This term is applied to children defined as being in need under section 17 of the Children Act 1989,
whose vulnerability is such that they are unlikely to reach or maintain a satisfactory level of health or
development, or their health or development will be significantly impaired without the provision of
services. This can also apply to disabled children.
Significant harm
Some children are in need because they are suffering or likely to suffer significant harm. This is the
threshold that justifies compulsory intervention in family life in the best interest of children.
Types of abuse
Physical injury may be inflicted deliberately or by failure to provide a safe environment.
Neglect is the persistent failure to meet a childs basic physical and/or psychological needs to an
extent that is likely to result in serious impairment of the childs health or development, e.g.
inadequate provision of food, shelter or clothing, failure to protect from physical harm or danger. It
also includes failure to ensure adequate care takers and failure to ensure appropriate access to
medical care or treatment, as well as unresponsiveness to a childs basic emotional needs.
Emotional abuse
This is the persistent emotional ill treatment of a child such as to cause severe and persistent adverse
effects on the childs emotional development. Although some degree of emotional abuse is involved
in all types of ill treatment of a child it may occur alone.
Sexual abuse
This involves forcing or enticing a child or young person to take part in sexual activities, including
prostitution, whether or not the child is aware of what is happening. This may involve physical
contact (e.g. rape or oral sex) or non-contact such as watching pornographic material.
The potential for abuse should also be recognized (e.g. another sibling previously harmed).
2. PHYSICAL ABUSE
There are features that can be elicited during history taking and examination which may increase the
risk there has been harm to a child; however, the absence of these should not falsely reassure
clinicians.
2.1 History taking

A full and comprehensive medical history should be taken whenever a child or young person is seen
by clinical staff.
Key points when taking a history and abuse/non-accidental injury is suspected

Consider taking the history directly from the child even without the consent of the carer
Ask detailed questions re any mechanism of injury, e.g. how did child fall, how far, on to which
surface, who witnessed, etc.

Record any difference of medical opinion
Ensure that all notes are comprehensive/contemporaneous (include content of all telephone calls,
handovers, etc.)
Ask about previous admissions/attendances to other hospitals and obtain/validate information
Within a given location work from one set of medical notes
Where relevant/possible gain information from multiple sources, e.g. school, GP, health visitor
Concerns are particularly raised by the following:
Injuries in an infant
Vague, unwitnessed, inconsistent, discrepant history
Time delay in presentation
Unconcerned/aggressive carers
Inappropriate response in chid (e.g. didnt cry, felt no pain)
Presence of other injuries
Child/family known to social services, child protection plan in place
Previous history of unusual injury
Repeated attendance/presentation
2.2 Predisposing factors

Social and family factors predisposing to abuse:
Young, immature, lonely and isolated parents

Poor interparental relationship
Substance abuse in parent
Parents who had rejection, deprivation or abuse in their childhoods
Parents with learning difficulties
History of difficult pregnancy
Early illness in child
Difficult behaviour in child
2.3 Examination
All children in whom any form of abuse is suspected should have a full and comprehensive
examination, which should include assessment of growth and development as well as looking for
physical injuries. The child should be fully undressed and examined in a warm, secure environment
by an appropriately experienced doctor. Careful charting of injuries is imperative using body maps as
needed. Certain injuries are typical in abuse, as follows.
2.4 Types of injury seen in physical abuse

Bruises
Bruises are uncommon in children under 1 year especially if not mobile; bruises of different ages or
finger-shaped bruises, bruises on head, face and lumbar region, bruising around wrists and ankles
(swinging), bruising inside and behind pinna (blow with hand) and ring of bruises (bite mark) should
all raise concerns. Two black eyes may indicate blood tracking down after a significant injury to the
forehead. Accidental bruises are uncommon in all ages on the buttocks, neck, hands, trunk and lower
jaw. In contrast bruises to the front of the body and over bony prominences are more likely to be
accidental. Differential diagnosis of bruising includes bleeding disorder, meningococcal sepsis
HenochSchnlein purpura and mongolian blue spots (most common on buttocks/lower back in those
of Asian origin).
Fractured ribs
Unless major trauma or underlying bone disease very suspicious (particularly in younger children) of
abuse. May be caused by shaking.
Skull fractures
Whether accidental or non-accidental, these require significant force. Linear parietal fractures are the
most common accidental or non-accidental fracture. Features of particular concern include: occipital
fractures, depressed fracture, growing fracture, wide fracture, fracture crossing suture line, history of
fall less than 3 feet.
Femoral fractures
In children who are not independently walking these are suspicious of abuse.
Fractures of humerus
Spiral fractures are uncommon and commonly linked with abuse.
Epiphyses torn off

This may indicate swinging.
Metaphyseal fractures
These are rare and may indicate abuse particularly in those under 2 years.
Important differentials to consider in diagnosis of non-accidental fractures
Accidental injury
Osteopenia including prematurity, chronic illness, e.g. renal disease, severe growth faltering
Osteogenesis imperfecta
Iatrogenic, e.g. post-interosseous insertion, also described after holding neonates for blood
sampling
Malignancy
Infection
Vitamin D deficiency (rickets) more common than other vitamin deficiencies and highlights
importance of careful dietary history
Vitamin A and vitamin C deficiency (uncommon)
Copper deficiency
Burns
Burns and scalds are common in children and most are accidental; however, they may involve cases
of inadequate supervision/neglect. Hot drinks cause most accidental injuries, with heaters, fires,
cookers, fireworks, candles and sunburn also being implicated. Concerns that burns are nonaccidental should be raised by presence of small circular burns which may be caused by cigarettes,
burns or scalds to both feet or buttocks; these raise the possibility of immersion injury and clearly
demarcated burns where a hot object has been applied to skin.
Torn frenulum
This may indicate direct blow to mouth or forced feeding.
Perforated eardrum
This can be caused by slap or blow to side of head.
Strap or lash marks

Nail injuries
Marks from strangulation
Subdural haematoma
This may be caused by shaking (see below under Management of abuse/suspected non-accidental
head injuries).
Retinal haemorrhages
This may be caused by shaking (see below under Management of abuse/suspected non-accidental
head injuries).
Multiple injuries and injuries at different ages

Estimating ages of bruises and fractures
This cannot be accurately done and should not be relied on as part of the assessment.
2.5 Investigation
These will be dictated by clinical presentation but may include the following:
Full blood count, clotting, bleeding time
Radiograph/skeletal survey: must be performed and reported by specialist paediatric radiologist.
Should be considered particularly in child under 2 years. May need to be repeated if first survey
negative, bone scan not available and bony injury suspected
Bone scan: consider particularly if bony injury suspected but not confirmed on initial skeletal
survey
Cranial imaging: ultrasonography, computed tomography (CT) or magnetic resonance imaging
(MRI) as clinically indicated. Ultrasonography not always able to pick up subdurals. CT of the
brain often included with all skeletal survey requests in under 2 year olds
Others: calcium, phosphate, alkaline phosphatase, vitamin D, copper, DXA (dual energy X-ray
absorptiometry) scan, acylcarnitines + urinary organic acids (if subdural haemorrhage)
When to consider a skeletal survey
Suspected physical abuse

Unexplained neurological symptoms including apnoeas, seizures, reduced consciousness
Intracranial injury (when no history of significant accidental trauma)
As part of investigation of siblings where abuse has been identified in other child in family unit
Child dying in unusual/unexplained circumstances
2.6 Management of abuse/suspected non-accidental injuries

Put the interests of the child first
Adhere to local protocols
If suspicion of non-accidental injury, early senior decision-making with involvement (as needed) of
named/designated nurse/doctor
Additional information form school, GP other professionals
Check with social care if child is subject of child protection plan
Consider investigations as appropriate to clinical presentation
Piece together jigsaw of information from multiple sources
Early liaison/referral to social services if suspected abuse (in most cases parents/carers should be
told that referral is taking place)

Telephone referrals should be followed by written referral within 48 hours and written referral
should be acknowledged within 1 working day. Social care will then initiate and lead on
assessment as needed
Secure place of safety for child consider hospital admission if injury/illness require or it
temporary safe place needed
Immediate referral to childrens social care and/or police

Suspected abuse or neglect where concern that child and/or siblings unprotected
Serious abuse witnessed
Immediate referral to police if

Allegations of recent rape or sexual assault
Dead or severely injured children where abuse is thought likely (preservation of crime scene)
Threatened removal from hospital where child is thought to be in danger
Strategy meeting
This is a formal gathering of individuals with a legitimate interest in the child and family and usually
includes social services, police and other relevant agencies including health. Where needed this is
convened urgently. The meeting allows exchange of relevant information and decision-making about
further management which will include decisions about immediate safeguarding actions needed, e.g.
where and by whom the child should be looked after, whether any criminal investigations should be
initiated and what information should be shared with family.
After the strategy meeting decisions will be taken as to whether any further involvement is needed by
childrens social care and/or the police. Further meetings and information may result in a child
protection plan being put in place. This will then be subject to further and ongoing review.
Although publications such as What to Do if Youre Worried a Child is Being Abused (Department of
Health 2003) describe in detail processes that should be followed this should not be seen as a
substitute for discussing all such cases and concerns with senior clinicians.
2.7 Specific presentations of abuse/non-accidental injury

Head injury
The presentation is variable and ranges from sudden death, or seizures, to feeding difficulties. The
varied potential presentation highlights that non-accidental head injury (NAHI) should be considered
in any child who suddenly collapses. Although most common in infants under 6 months, NAHI can be
seen in older children too. The mortality rate and rate of long-term sequelae in survivors are high.
Controversy surrounds the mechanisms of injury in NAHI; however, the conventional view is that the
injuries are caused by either impact to the head or severe repetitive rotational injury. This can result
in the development of:
Brain injury of the brain substance directly by trauma or hypoxic or ischaemic change
Intracranial bleed note that, although subdural, subarachnoid and intraventricular/parenchymal
bleeds are typical, an extradural bleed is rare
Skull fracture
Retinal haemorrhage
Other bruising/lacerations to body/limbs/scalp/face
Rib or long bone fractures
Spinal cord injury
A full history and examination should be taken as above and, of particular note, a fontanelle, head
circumference and retinal examination should be done. Guidance suggests that the first line in
neuroimaging is CT followed up with MRI where needed and skeletal survey. It is recommended that,
in all children under 2 years in whom a skeletal survey is requested, a CT of the brain should also be
performed.
Potential differential diagnosis of NAHI that must be considered/excluded

Severe accidental injury highlights the importance of careful history taking and information
gathering
After birth retinal haemorrhage and subdural haemorrhage occur but resolve within the neonatal
period
Bleeding disorders ensure that these are excluded
Other causes of subdural haemorrhage glutaric aciduria type 1, postoperative, hypernatraemic
dehydration, rare congenital malformations
Management is as described above; however, such infants are usually managed in tertiary units and
early strategy discussions will determine whether criminal investigation should be pursued.
Poisoning
This is rare but consider if signs and symptoms are difficult to explain. Blood and urine will need to
be screened.
Intentional upper airway obstruction

This is a difficult and controversial area because it may be impossible to distinguish intentional
airway obstruction from other causes of sudden and unexplained death in infancy (SUDI). In many
cases there are no clinical signs evident externally and for those who survive the sequelae may be
significant. Presentation can be with the following:
Sudden death
Acute life-threatening event (ALTE)
Apnoea/transient respiratory difficulty
Cyanotic spells
Recurrent seizures
Other unexplained collapse/illness
Bleeding from nose or mouth
The presence of blood around the mouth in an infant who has survived ALTE should raise particular
concerns, as should petechiae on the neck and conjunctival haemorrhage. At-risk factors from the past
or family history should also be considered
3. SEXUAL ABUSE
3.1 Presentation
Sexual abuse may present in many ways:
Allegations by a child or adult

Injury to genitalia or anus (including bleeding or sexually transmitted infection)
Unexplained recurrent urinary tract infection
Sexual explicitness in play, drawing, language, behaviour (including excessive masturbation)
Sudden or unexplained changes in behaviour, e.g. sleep disturbance, loss of trust in individuals
close to them, overdose, running away from home
Psychosomatic indicators including recurrent headache, abdominal pain, enuresis, encopresis,
eating disorder
Pregnancy
Sexually transmitted infection
3.2 Examination and physical signs

The examination should take place in a quiet, child-centred room with appropriate facilities.
Examination for suspected abuse requires a doctor with specific expertise and training, and facilities
for colposcope and photo documentation. Older children may prefer a doctor of the same sex.
Consent is required before the examination and a forensic pack will be needed if the last assault was
within 72 hours.
The signs elicited must be taken in the context of the complete examination. Careful documentation
should be made in the form of sketches and photographs. A full general examination should also be
performed because there is a significant chance of coexisting physical abuse. Remember that up to
50% of children subject to sexual abuse have no abnormal physical signs.
Specific features to look for in girls

Reddening, bruising, lacerations and swelling of labia, perineum and vulva
Vaginal discharge (comment on quantity and colour on its own not strongly suggestive of abuse)
Hymenal opening comment on size, margins, tears (>0.5 cm suspicious of sexual abuse, >1 cm
greater likelihood)
Posterior fourchette laceration/scars
Vaginal examination only in older girls if clinically indicated
In boys
Penis bruising, laceration, scars, burns

Perineum reddening, bruising
Scrotum bruising, reddening, burns
Anal examination
Examine young children on carers knee and older children in left lateral position.
Rectal examination rarely necessary; instead inspection should determine the presence or absence of
acute signs such as:
Swelling, reddening, bruising, haematoma, laceration or tears of anal margin
Spasm, laxity and dilatation of anal sphincter
Dilatation of perianal veins
3.3 Investigation
It may be appropriate to screen for sexually transmitted infections and to send forensic swabs for
analysis of semen/grouping. These should be handled in a forensic way.
3.4 Management
Clinical
Emergency contraception/antibiotics for sexually transmitted infections as needed
Consider possibility of HIV infection
Treat and deal with medical issues identified during assessment
Non-clinical
Follow guidelines as outlined in management of suspected non-accidental injury.
3.5 Long-term complications

This includes post-traumatic stress, suicidal behaviour, psychiatric illness, problems with
relationship and sexual adjustment.
Differential diagnosis of vaginal bleeding
Trauma sexual abuse or accident such as straddle injury

Precocious puberty
Skin disease, e.g. lichen sclerosis et atrophicus
Rare anatomical abnormalities
Differential diagnosis of rectal bleeding
Fissures (constipation or abuse)

Infective diarrhoea
Inflammatory bowel disease
Polyp
4. EMOTIONAL ABUSE
A wide variety of symptoms may result from emotional abuse, rendering recognition of this difficult
and emphasizing the importance of working closely with colleagues in the Child and Mental Health
Services (CAMHS) and psychology.
In babies this may include feeding difficulties and poor weight gain, crying excessively or conversely
being excessively quiet and non-demanding. Similarly, in toddlers, symptoms range from being quiet
and clingy to being overactive with a bad temper.
Older children may present to clinicians with difficulties in school performance, antisocial or
difficult behaviour, wetting, soiling or developmental delay, or regression. Growth delay may be seen
and, if investigated, suboptimal growth hormone production may be noted (as a consequence of
emotional neglect/abuse).
As indicated above, management involves close working between professionals in social care, health
and psychological medicine.
5. NEGLECT
Neglect can manifest in a multitude of different ways to different agencies. Presentation to health
services includes: multiple A&E attendances with injuries, non-concordance with treatment plans for
health conditions or failure to present for medical intervention with untreated medical conditions,
failure to take up routine immunisations, failure to thrive, behavioural changes ranging from craving
attention from adults to being shy and withdrawn, difficult/challenging behaviour and school failure.
As above, a multiprofessional/multiagency approach to assessment and management is required.
6. FABRICATED OR INDUCED ILLNESS

This used to be termed Munchausen syndrome by proxy and may coexist with other forms of child
abuse. The spectrum of presentation is wide and includes suffocation, non-accidental poisoning and
sudden infant death.
Typically the child presents multiply for medical assessment and may have multiple procedures and
investigations performed. Although uncommon it should be considered in any child with inconsistent
symptoms/signs, unexplained or prolonged illness and poor response to treatment. Features in the
history that may raise concerns about fabricated or induced illness (FII) include the following:
Family history of unexplained illness or death
History given of deaths/illnesses that are not substantiated
Actions of parents/care givers not appropriate for symptoms described
Accurate history taking and reconciliation from all professionals involved are pivotal in making a
diagnosis.
Management often requires hospital admission/investigation. Early multiprofessional referral to
police, social workers and mental health teams is required, in addition to medical and nursing input
and assessment. Referral to other agencies above should not wait until the diagnosis is proved and
early multiagency strategy planning is critical.
FURTHER READING
Department of Health (2003). What to Do if Youre Worried a Child is Being Abused. London: DH.
General Medical Council (2006). Good Medical Practice. London: GMC.
Chapter 4
Clinical Governance
Robert Wheeler
CONTENTS
1. A brief history
2. The influences bearing on an NHS trust
3. Patient safety
4. Patient experience
5. Clinical outcome and experience
6. Education, appraisal and revalidation
7. Conclusion
8. References
Clinical Governance
At the time of writing, the Government in England is pausing, to reflect on the national reaction to the
Health and Social Care Bill, regarded variously as an essential measure or a disastrous experiment
by equally vociferous factions. From the perspective of clinical governance, it is an interesting
historical moment, because it demonstrates how an incoming government can simply flush away
expensive institutions, if it wishes, in order that the governance of governance can better accord with
a political vision. In reality, the expected demise of the National Patient Safety Agency (NPSA) and
the National Information Governance Board will have little noticeable effect on those of us who look
after patients, because the functions of these bodies will be subsumed into the overarching Care
Quality Commission (itself a descendant of the Healthcare Commission), or its derivatives. But these
transitions are occurring all the time, unbeknownst to most of us. In this existence of two parallel
worlds, one group (usually comprising senior nurses who have moved away from clinical practice) is
entirely immersed in the machinations of governance, dedicating substantial efforts to activities
described by mysterious acronyms that are of utterly crucial importance to a trusts relationship with
the Department of Health. At the same time, and in the same hospital, the other group (clinicians) will
be treating patients, and providing data for the first group to use to assuage the scrutiny under which
they live their daily lives. This chapter tries to demonstrate the pressures on all servants of a trust,
whether managerial or clinical, in delivering clinical governance. One can then better sympathize
with ones colleagues in the parallel world that is the trusts governance department, and also
understand how both the patient and the health service can benefit from this method of quality control.
1. A BRIEF HISTORY
Since the inception of the NHS (National Health Service Act 1946) the practice of medicine was
governed by professional judgement. Clinical decisions were made on the basis of knowledge
accumulated during an apprenticeship, and this knowledge was validated by certification from The
Royal Colleges. Compulsory registration with the General Medical Council (GMC) was assumed to
provide an assurance of fitness to practise and propriety, together with sanctions for transgressions.
Clinical practice itself, based on written and oral precedent, was seen as an evolving body of
knowledge, against which new information could be evaluated.
These arrangements lasted, with varying degrees of satisfaction depending on the commentator, for
more than 40 years. However, because of inexorable rise of the cost of litigation,1 the drug budget and
institutional catastrophes,2,3 there was a profound shift from the internal standard of medical selfregulation to an externally imposed regulatory apparatus, conforming to standards derived from state
control.
With the advent of the hospital trusts, politicians took renewed interest in quality issues. The
Conservative administration had already coined the phrase clinical governance by 1996, and the
advent of the New Labour government in 1997 confirmed clinical governance as the byword for
quality assurance and enforcement. A White Paper followed,4 translating the concept into several
national developments, with a mission to set or enforce standards. By late 1998, when interested
parties had recovered from the onslaught of novel watchdogs, words and concepts, a steady stream of
contradictory literature had begun to flow at national and local level, all trying to make sense of what
clinical governance actually meant.
The concept of governance was adapted from industry,5 meaning to control and direct, with
authority.6 It was originally conceived as being based upon seven central pillars: risk management;
clinical effectiveness; education and training; patient and public involvement; using information;
research and development; management and manpower. Organized within these broad categories, any
aspect of clinical practice that could be regarded as pertaining to quality of care could be subjected
to intense scrutiny. Although the pursuit of quality now seems uncontroversial, the reaction by
doctors was not universally favourable,7 many feeling that governance added no further value to their
standard of care, which already exemplified many of the principles contained within the pillars. This
conflict of understanding may have arisen from the necessity for clinical governance to be delivered
by a team, rather than by an individual doctor. Consultants considered that they still retained
ownership, the basis of continuity of care, which remained their touchstone of quality. As time has
passed, the resistance to this change has all but melted away.
However, regrettably, the burden of implementation of clinical governance has now been taken on
largely by the nursing staff, arguably because of doctors reluctance to do so. There are notable and
honourable exceptions to this generalization, but review of the staffing of your local clinical
governance arrangements may reveal a level of medical engagement that is disproportionately low,
when considering the number of doctors in your trust.
2. THE INFLUENCES BEARING ON AN NHS TRUST

Currently, and even following the implementation of whatever creature is born from the Health and
Social Care Bill, NHS trusts and their derivative foundation trusts will be controlled by the Care
Quality Commission (CQC). Already the cornerstone of quality control in the NHS, its absorption of
the functions of other arms length bodies of the NHS, such as the NPSA, will make it the main
controller of safety and quality within the NHS. The CQC achieves this through inspections of
hospitals, and by demanding that an exhaustive series of standards are complied with, which range
throughout all clinical activities to which a patient may be exposed. Closely allied to the CQC is
Monitor, an organization created to ensure that the financial aspects of health care are equally well
governed. As NHS trusts are inexorably converted to foundation trusts, the role of Monitor (in
financial governance) will mirror that of the CQC in clinical governance.
Another separate influence is exerted by the NHS Litigation Authority (NHSLA). This organization
assesses the financial risk faced by the NHS as a whole, and defends clinical negligence cases where
deemed appropriate. Each trust that subscribes to the Clinical Negligence Scheme for Trusts (CNST)
pays an annual subscription for this service and the NHSLA acts as an insurer, settling successful
claims on behalf of the Schemes members. The NHSLA provides an incentive for the CNST
members. If a trust can pass one of three thresholds, it will secure a reduction of 10, 20 or 30% of
the insurance premium, depending on the threshold passed. This assessment of the trusts risk
management is performed during a visit by inspectors, but the trust will have been striving for months
or years to meet the numerous highly prescriptive standards set by the NHSLA. These standards are
imposed in order to reduce the risk that patients are harmed, that they will thus be less likely to
become claimants and that, of course, the trust will pass the inspection at the chosen threshold.
The burden of complying with the CQC, Monitor, the NHSLA and other agencies that will be
mentioned later falls initially upon the chief executive of the trust; he or she will then devolve this to
the medical director, the head of nursing and those in charge of finance. Furthermore, failure to
comply with the demands of these agencies will lead to attention from the Department of Health, and
ultimately a Health Minister, anxious to avoid a blemish on his or her political ascendancy. All of this
weight will rapidly descend on to the shoulders of the hapless clinical governance staff, whose jobs
depend upon compliance with the various standards.
And the standard setting is not monopolized by these key organizations. Primary care trusts (while
they still exist) have a contractual obligation (to those who fund them) to ensure competent
governance in clinical areas under their nominal control. As illustrated later, they, in turn, exercise
their contractual influence over the hospitals in their domain to fulfil this obligation. Others also bring
pressure to bear: coroners, fire authorities, environmental health, HFEA (Human Fertilisation and
Embryology Authority), HTA (Human Tissue Authority), counterterrorism, counterfraud, GMC, NMC
(Nursing and Midwifery Council), radiation protection, cellular pathology accreditation, MHRA
(Medicines and Healthcare products Regulatory Agency), and many more partners, shareholders,
stakeholders (choose your own jargon), will be pointing out that their particular standards need to
be adhered to immediately, if not earlier, and that this should be achieved under the broad control of
clinical governance.
This may give you some appreciation of what your clinical governance department has to put up with,
and why, on occasions, it is simply desperate for some somewhat obscure data that have no apparent
clinical value. In reality, the job of someone in your trust (at a very much lower pay scale than your
own) depends upon it.
The division of clinical governance now broadly divides into patient safety, patient experience, and
clinical outcomes and effectiveness. Information governance and education, although still of great
importance, are now sometimes seen as contributors, rather than ends in themselves. The principal
three disciplines went through a stage of being firmly centralized at the heart of the trust, from where
these activities were coordinated. More recently, certainly in the bigger organizations, a restructuring
into divisions has made it possible to devolve these functions to divisional level; thus a women and
childrens division is likely to deal with the daily business of governance, but will still send data to
a central coordinating governance department, who will liaise directly with the agencies mentioned
above.
3. PATIENT SAFETY
This web of communication can best be discerned within the governance discipline of patient
safety, formerly known as risk. Risk describes anything that may put the patient, clinician or parent
in harms way. This may be as specific as the risk of injecting the wrong chemotherapy into the spine,
or as banal as ensuring that the doors to the outpatients do not trap childrens fingers. Risks can thus
come from the spectrum of practice, and the principle of management is to identify them before they
cause damage. The reporting of risks is now commonplace, usually achieved with the use of the
ubiquitous adverse incident form. Those who have filled one in will be familiar with the details that
are required: of the incident in question; witnesses and participants; and of the inherent risk
assessment incorporated in the form. This combines, within a matrix, the consequences (ranging from
none to catastrophic, death) with the likelihood of recurrence (ranging from rare to certain).
The product of the matrix is a risk assessment encoded in colours, ranging from a very low green
risk to an extreme red/red risk. This categorization is important, because the trusts reaction to the
risk is directly proportionate to its severity.
All risks need to be reported, usually by the trusts governance apparatus, to the National Reporting
and Learning Service (NRLS). This organization, established in 2003, provides a unique national
database for incidents affecting patient safety, and is widely recognized8 as a world leader, giving an
opportunity to identify systemic errors that may be avoidable in the future. The NRLS is a division of
the NPSA, but it seems likely that the NRLS will be incorporated within an as yet ill-defined body,
the NHS Commissioning Board. The functions and remit of this Board should be determined as the
effects of the Health and Social Care Bill (and then Act) become clearer.
The incidents assessed by the trust as being at the higher levels of severity are subjected to added
scrutiny. This may take the form of root cause analysis (RCA), or review by an internal expert
serious event committee or by a coroner. If the incident meets the local strategic health authoritys
(SHA) threshold of seriousness, it will be reported as a Serious Incident Requiring Investigation
(SIRI). Worse, if included in the Department of Healths shortlist (see
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance) of 25
very serious, largely preventable patient safety incidents that should not occur if the relevant
preventative measures have been put in place, the incident will be reported as a Never Event, with
serious financial and reputational consequences for the trust (let alone the wretched patient on whom
it was inflicted). However, even the apparently prescriptive never events, which are imposed on
trusts as part of a contractual agreement, leave room for interpretation. Wrong site surgery was one
of the eight points in the core list originally produced in 2009 (see
www.nrls.npsa.nhs.uk/resources/collections/never-events). But what of a wrong level laminectomy?
It transpires that this would not qualify as wrong site surgery, because the intention was only to avoid
lateralized errors. This does not inspire reassurance that the system is sufficiently flexible to
discourage poor practice.

Perhaps it is not crucial, in approaching the MRCPCH, to be familiar with the jargon in the last
paragraph. But the story illustrates the significant subjectivity employed in dealing with risks to our
patients. The SHA threshold appears to vary across the country, and is ill defined. So trusts, when
considering whether their incident has met the SIRI threshold, are unsure of what that threshold is. In
the meantime, PCT assessors, anxious both to fulfil their own obligations and to enforce a trusts
obligations to the PCT scrutinize reports to the NRLS. They may identify cases that they believe have
met the SIRI threshold, and complain that the trust has failed so to do. Negotiations then commence.
Thus the appearance of certainty about what is reported; and how it is reported; and what effect the
reporting has, is somewhat illusory. There is, however, no doubt at all that this process has created a
reporting industry. As we have seen, there may be tangible patient benefit from its product in the
NRLS, but it can also be seen that there is some way to go before the system can be considered
watertight.
4. PATIENT EXPERIENCE
Emerging with the initial tranche of governance themes, what was originally described as patient and
public involvement has sometimes been elusive in definition. It is easy to identify what it represents,
which is a laudable aim for tailoring medical services to the requirements of the patients, rather than
making the patient fit in with what proves convenient for the doctor. It also lends itself admirably to
politicians, ever anxious to be seen to be listening to patients, of affording them choice. The
difficulty, of course, is to do either of these things in a meaningful way, leading to benefit.
Furthermore, there appears to be little or no evidence that these efforts at patient participation create
any measurable benefit to the patient.
Trusts have struggled to implement the political agenda of listening to patients. Patient Advocacy and
Liaison Services (PALS) have provided a valuable conduit for patients who are distressed or
disgruntled by their management in the hands of a trust, and continue to play a vital role clarifying the
mysteries of the health service to those who have contact with it. Considerable creativity has resulted
in patient forums, although the advent of foundation trusts has made patient and public involvement
mandatory. Surveys, focus groups and a variety of methods by which patients feed their comments
back to providers, ranging from the distribution of postcards to patients to providing contact numbers
for text messaging, have all been tried. One great difficulty is determining what to ask. Although the
political demand for patient involvement can be met by simply asking how was your stay?, the yield
of useful information is low, once the problems surrounding car parking, decent food, clean wards
and reliably communicative clinicians have been addressed. These are hardly revelations. However,
it has become increasingly clear that systematic surveys by experts in the field, such as the Picker
Institute (see www.pickereurope.org/policyprimers), have filled this gap and, over the last few years,
Government, trusts and patient groups have used the data collected to clarify what patients and their
relatives need (and want) from their contact with health services.
An interesting aspect of the choice element, now implemented nationally, is the rapid enforcement of
the patients ability to choose where and by whom they should be treated. It remains to be seen
whether this will result in improved patient satisfaction or clinical outcome.
5. CLINICAL OUTCOME AND EXPERIENCE

The much-publicised medical errors, together with a logarithmic rise in medical negligence litigation,
led to calls for measurement of clinical performance. At its most simplistic, it has afforded the
Government an opportunity to publish league tables for trusts in such areas as cardiac mortality.
Although recognized as a potential oversimplification, this has led the call for trusts to publish the
results of their clinical department. Such data are now available, via Dr Foster (see
www.drfosterhealth.co.uk). This organization produces data relating to hospital trusts, procedures,
consultants and maternity units. Their first consumer guide to health services was published in 2001.
This, Dr Foster notes, was the first time that comparative adjusted death rates for all NHS hospital
trusts had ever been published. Their recent hospital report covers deaths in hospital, stroke,
orthopaedic care, urological care and the recording of safety incidents, notably those involving
venous thromboembolism (see www.drfosterhealth.co.uk/docs/hospital-guide-2010.pdf). Independent
of external organizations, clinicians have for many years used audit to ensure that their local results
compare favourably with an established gold standard, thus measuring whether the local unit is at
variance with the standard, modifying practice to improve results and then remeasuring (re-auditing)
to ensure that the modification has achieved the desired result.
Any conceivable clinical intervention has potential for audit and this has been a highly satisfactory
tool as a measure of clinical performance, provided that it is used appropriately and correctly. Audit
programmes can be integrated with other aspects of clinical governance. If a clinical intervention is
identified as a risk as a result of either adverse incident reporting or a cluster of similar complaints,
then this gives an ideal opportunity for audit.
On a larger scale, the National Institute for Health and Clinical Excellence (NICE see
www.nice.org.uk) has employed similar techniques to provide clinicians with robust evidence that
therapies and interventions are efficacious and cost-effective. It should be acknowledged that the
latter criteria, of cost-effectiveness, has lead to ferocious opposition to some of NICEs judgements,
on behalf of patients who felt disadvantaged as a result of treatments that were not deemed to be costeffective. It could well be argued that, faced with spiralling costs for pharmaceuticals, the
Governments creation of organizations such as NICE was largely motivated by the wish to limit NHS
costs, a theme that feels contemporary in 2011. Notwithstanding this, the current remit of NICE
appears to have turned away from determining whether an intervention is cost-effective, but it seems
inevitable that a financial threshold for whether a drug (or treatment) can be paid for by the NHS will
continue to be of crucial importance. At the time of writing, PCTs are attempting to identify therapies
that they will not pay for. Attempts are being made to persuade the High Court that denial of bariatric
surgery is contrary to patients human rights, and this claim has failed (see
www.anhourago.co.uk/show.aspx?l=8362077); one way or another, there seems little doubt that the
Government will succeed in rationing some aspects of health care.
NICE has developed a series of national clinical guidelines with the intention of securing consistent,
high-quality, evidence-based care for NHS patients. Not all guidelines formulated by NICE have been
welcomed by practitioners. The opposition to the guidance on the management of urinary tract
infection in children (see www.nice.org.uk/CG54) is particularly memorable an example of where
a spirited opposing medical consensus (see www.bmj.com/content/335/7616/395.short/reply) can, at
times, effectively challenge a national edict. There remains a belief, by a substantial minority of
childrens doctors, that the gaps in the evidence supporting the guidelines can lead to unnecessary
investigations and a consensus is lacking. Nevertheless, these guidelines are generally of
considerable value. Together with a wealth of additional educational text and resources, they are
promulgated by NHS Evidence (see www.evidence.nhs.uk), acting as an information portal.
To maintain enthusiasm for audit within a department is quite a different matter, partly because some
doctors see this merely as a self-fulfilling process. The role of the divisional or trust clinical
effectiveness department is crucial in this, because, with its links to patient safety and education,
audits that are genuinely worthwhile can be identified and supported by an entire department. A
pragmatic approach is a rolling audit, where a topic is chosen that continually poses a clinical
challenge; the adherence to the unit protocol for the management of bronchiolitis would be a recurring
theme. The audit can be set up along the usual lines, but then the re-audit phases, together with
retrospective comparisons and prospective protocol adjustment, can be undertaken by successive
generations of junior staff. In this way, audit becomes an integrated part of the working routine, not
dependent on additional enthusiasm or drive by the medical team. Ideally, a combination of rolling
routine audit, with additional audits reacting to risks, should run simultaneously.
6. EDUCATION, APPRAISAL AND REVALIDATION

These elements of governance run in parallel with other activities. Continuing education for doctors
has been mandatory for many years. Although there was once optimism that this would be reflected in
fixed consultant education sessions, the financial state of the NHS makes this increasingly unlikely.
Nevertheless, education is, in many senses, the glue that holds governance together. Lessons learnt
from patient safety sources, such as adverse incidents, SIRIs and the like, can be disseminated, as
may those identified by patient experience surveys. Educational theory, harnessed to improve and
diversify the approach of clinical teachers, will enhance the communication of these important
messages.
Assessment (which is a mere observation a measurement of attendance, workload, waiting times,
educational target fulfilment) is a great deal easier to perform than appraisal (a process of valuation,
estimating the worth and quality of clinical activity).
This is because the individual can perform assessment themselves; it may involve tedious and timeconsuming data collection and form filling, but it is an objective exercise. Appraisal, however, can be
performed only by an outsider who shares enough of the appraisees training to allow pertinent
questions to be asked, and relevant feedback to be given. This is equally time-consuming, but
potentially threatening and more subjective than assessment. Local appraisal is now elevated to a
new level, of strengthened or enhanced medical appraisal. This will require more engagement from
both appraisee and appraisers, but is motivated by the desire to make appraisal more effective.
The need to have an effective form of regular scrutiny of qualified doctors was prominent on the
political agenda, prompted by the crimes of Dr Harold Shipman. This in part explains the anxiety of
the GMC to produce a workable formula in 2001 to facilitate revalidation of a doctors original
medical registration. It is a tribute to the difficulty of the task that, by 2011, a workable solution has
yet to be implemented, although this appears to be imminent. To an extent, this has been delayed by
the political rhetoric. Although apparently a convenient moment to incorporate a mechanism to
identify potential mass murderers through the revalidation process, it is becoming clear that this is
unworkable, and that cyclical revalidation of doctors will be largely based on local appraisal. The
local appraisal process remains a matter for individual medical directors, who now take on the
additional responsibility of being responsible officers, reflecting the devolution of some of the
responsibilities of revalidation away from the GMC. It seems that reforms to the laws concerning the
registration of death are more likely to reduce the risk of another similar tragedy than the revalidation
of doctors, but this remains to be seen.
7. CONCLUSION
There is little doubt that hospital patients and clinicians should equally welcome additional
supervision of clinical activities. Clinical freedom may seem insufficiently controllable to guarantee
adequate quality of care, and it is understandable that any government would wish to demonstrate an
augmented quality of care, rather than merely reiterate a financial commitment to health. External
regulation has become a cornerstone of the Governments third way in health care.9 This has been
achieved by asking doctors to comply with standards set by NICE, and deterring variance by the
employment of agencies such as the CQC and the NHSLA. The product of this alliance is
implemented by the clinical governance structure. Residual concerns that the evidence base is
unreliable and the individual patients best clinical interest may not be best achieved by following a
guideline produced from an averaged population must be addressed. Effectively enforced bulletpoint medicine is likely to interfere significantly with the therapeutic relationship between a patient
and doctor.10 The counter argument is that, from a utilitarian point of view, the rather broad brush
approach of clinical governance, controlling and directing (the clinicians) with authority, may
confer the least risk on the greatest number.
But it seems that a workable compromise between what is effective for the population, compared
with what will benefit the child in front of you, is emerging.
REFERENCES
1. Harpwood V. Negligence in Healthcare. London: Informa Publishing Group, 2001: Chaps 10, 11.
2. Department of Health. Report of the Public Inquiry into Childrens Heart Surgery at Bristol
Royal Infirmary 19841995: Learning from Bristol. Cm5207. London DH, 2001.
3. Department of Health. The Royal Liverpool Childrens Inquiry Report. London: The Stationery
Office, 2001.
4. Department of Health. The New NHS Modern, dependable. London: The Stationery Office, 1997.
5. Donaldson L. Clinical governance. (Originally Sir Adrian Cadbury, referred to by Clinical
Governance.) Medico-Legal Journal 2000;68: 89100.
6. Department of Health (1998). A First Class Service: Quality in the new NHS. London: Department
of Health, 1998.
7. Klein R. The New Politics of the NHS, 4th edn. Harlow: Prentice Hall, 2000.
8. Scarpello J. After the abolition of the National Patient Safety Agency. BMJ 2010;341:10056.
9. Walshe K. The rise of regulation in the NHS. BMJ 2002;324:967.
10. Teff H. Clinical guidelines, negligence and medical practice. In: Freeman M, Lewis A (eds), Law
Medicine: Current legal problems, vol 3. Oxford: Oxford University Press, 2000: 80.
Chapter 5
Clinical Pharmacology and Toxicology
Steven Tomlin
CONTENTS
1. Pharmacokinetics and dynamics
1.1 Absorption
1.2 Distribution
1.3 Half-life
1.4 Hepatic metabolism
1.5 Renal excretion
1.6 Other clinical considerations
2. Formulation
3. Paediatric dosing
4. Prescribing outside licence
5. Drug monitoring
6. Intravenous management
6.1 Maintenance fluids
6.2 Monitoring
7. Drugs in pregnancy
8. Drugs in breast milk
9. Toxicology
9.1 Paracetamol
9.2 Iron
9.3 Tricyclic antidepressants
9.4 Aspirin overdose
9.5 Lead poisoning
9.6 Carbon monoxide
9.7 Button batteries
10. Further reading
Clinical Pharmacology and Toxicology
The large intergroup variability within childhood has profound consequences on the way in which
they handle medicines. This is true in terms of pharmacokinetics and dynamics, but also requires the
prescriber to have an appreciation of the physical and psychological variances that may affect
medicine use safety and efficacy (e.g. can they swallow tablets, open bottles, read information?).
1. PHARMACOKINETICS AND DYNAMICS

Pharmacokinetics is what the body does to a drug
Pharmacodynamics is what the drug does to the body
1.1 Absorption
Liquid and intravenous forms of drugs (i.e. those already in solution) are readily absorbed into the
bodys systemic circulation
Solid dosage forms (tablets and capsules) and suspensions must first be dissolved in the
gastrointestinal tract (dissolution phase) before they can be absorbed, and so absorption is slower
The term bioavailability is applied to the rate and extent of drug absorption into the systemic
circulation
Oral
First-order kinetics
Oral absorption of drugs is often considered as demonstrating first-order kinetics. This is especially
true with oral solutions. First-order kinetics implies that the fractional rate of absorption is constant,
so absorption decreases the less there is left in the stomach. If a drug is absorbed at a constant rate
independent of the amount left to absorb, then it is referred to as having zero-order kinetics.
Ionization
Absorption of most medicines is dependent on how ionized they are (their pKa) and the acidity at the
site of absorption. Drugs with acidic pKa values (e.g. aspirin, phenoxymethylpenicillin [penicillin V])
will be mainly non-ionized in the acid stomach and so readily absorbed. Phenobarbital, being a
weaker acid, is better absorbed in the more alkaline intestine.
Neonates
Neonates (especially those who are premature) have reduced gastric acid secretion, so the extent of
drug absorption is altered and less predictable.
At birth, drugs with an acidic pKa will have decreased absorption. Twenty-four hours after birth, acid
is released into the stomach, so increasing the absorption of acidic drugs. Normal adult gastric acid
secretions are achieved by about 3 years of age.
Gastric motility is decreased during infancy, thus increasing the absorption of drugs that are absorbed
in the stomach. However, drugs absorbed from the intestine will have a decreased or possibly
delayed absorption.
Absorption and pKa of some drugs in adults and neonates

Drug
Neonatal oral absorption compared with adult
pKa
Ampicillin
Penicillin
Phenytoin
Paracetamol
Diazepam
Increased
Increased
Decreased
Decreased
Same
2.7
2.8
8.3
9.9
3.7
Rectal
If the enteral route is not available (e.g. vomiting) then the rectum offers an alternative good
absorption route. This route is not acceptable to all children and careful dialogue should take place
before use of this route. However, if medicines are intended for this route they will be well absorbed
provided that they are retained for an adequate length of time which requires them to be placed well
up the rectal vault.
Topical
Although most children will respond similarly to adults with percutaneous administration, extra care
and consideration should be taken during infancy and particularly in the first couple of weeks of life
and in preterm babies. The immature epidermal barrier, combined with well-hydrated skin and a
relatively high surface area:body mass ratio leads to enhanced absorption. Toxicity has been seen
with a number of products over the years. Care should be taken with products such as chlorhexidine
(especially if in alcohol), povidoneiodine and steroid creams.
Intramuscular
It may seem strange to say that intrasmuscular injections should be avoided in childhood when we
give intramuscular vitamin K to just about every baby admitted to the neonatal intensive care unit
(NICU). However, it is the fact that it acts so slowly from this site of injection (depot effect) that
allows it (in this one case) to be so effective giving several weeks of cover from just the one
injection. The lack of muscle and the fact that it is so poorly perfused means that most drugs will just
not achieve adequate plasma level concentrations for the route to be effective. The fact that the small
muscle mass means that these injections are very painful leads to this route being rarely used in
children.
1.2 Distribution
The concentration of a drug at various sites of action depends on the drugs characteristics and those
of the tissue. Most drugs are water soluble and will naturally go to organs such as the kidneys, liver,
heart and gastrointestinal tract.
At birth, the total body water and extracellular fluid volume are much increased, and thus larger
doses of water-soluble drugs are required on a milligram per kilogram (mg/kg) basis to achieve
equivalent concentrations to those seen in older children and adults. This has to be balanced against
the diminished hepatic and renal function when considering dosing.
Distribution is also affected by a decreased protein-binding capacity in newborns, and particularly in

preterm newborns, therefore leading to increased levels of the active free drug for highly proteinbound drugs.
For example, phenytoin is highly protein bound, but, as there is less protein binding in neonates
(lower plasma protein levels and lower binding capacity), there is more free phenytoin than in
older children and adults. Thus the therapeutic range for phenytoin in neonates is lower than in the
rest of the general population because it is the free phenytoin that has the therapeutic action and can
cause toxicity
Therapeutic range for neonates = 615 mg/l
Therapeutic range for children and adults = 1020 mg/l
The reduced protein binding is the result of:
Low levels of plasma protein, particularly albumin
Qualitative differences in binding capacity

Competition with endogenous substances, particularly increased bilirubin after birth
Volume of distribution
Distribution is measured by a theoretical volume in the body called the volume of distribution. It is
the volume that would be necessary to dilute the administered dose to obtain the actual plasma level
within the body. The volume will be affected by the following characteristics: body size, body water
composition, body fat composition, protein binding, haemodynamics and the drug characteristics. As
a rule of thumb drugs that are plasma protein bound will mainly stay in the plasma and thus have a
small volume of distribution; highly lipid-soluble drugs (especially in people with a high fat content)
will have high volumes of distribution. Water-soluble drugs have increased volumes of distribution in
neonates because of the increased total body water content of neonates.
The parameter can change significantly throughout childhood. Plasma albumin levels reach adult
levels at approximately 1 year of age.
Bloodbrain barrier
The bloodbrain barrier in the newborn is functionally incomplete and hence there is an increased
penetration of some drugs into the brain.
Transfer across the barrier is determined by the following:
Lipid solubility
Degree of ionization
Drugs that are predominantly unionized are more lipid soluble and achieve higher concentrations in
the cerebrospinal fluid. It is as a result of this increased uptake that neonates are generally more
sensitive to the respiratory depressant effects of opiates than infants and older children.
Some drugs will displace bilirubin from albumin (e.g. sulfonamides), so increasing the risk of
kernicterus (encephalopathy due to increased bilirubin in the central nervous system in at-risk
neonates).
1.3 Half-life
Half-life is the time taken for the plasma concentration of a drug to decrease to half of its original
value. Thus it follows that less drug will be eliminated in each successive half-life:
For example, theophylline:
if there is initially 250 mg in the body, after one half-life (4 h) 125 mg will remain; after two halflives (8 h) there will be 62.5 mg left; and so on
When a medicine is first given in a single dose, all the drug is at the absorption site and none is in the
plasma. At this point, absorption is maximal and the rate of elimination is zero. As time goes on the
rate of absorption decreases (first-order kinetics) and the rate of elimination increases. All the time
that the absorption rate is higher than the elimination rate, the plasma level will increase. When the
two rates are equal, the concentration in the plasma will be at a maximum. After this point, the
elimination rate will be higher and the levels will drop. A drug is said to be at steady state after
about four to five half-lives. So if multiple dosing is occurring, the plasma levels at any particular
point after a dose will always be the same.
1.4 Hepatic metabolism

Hepatic metabolism is generally slower at birth compared with adults. However, it increases rapidly
during the first few weeks of life, so that in late infancy hepatic metabolism may be more effective
than in adults.
The age at which the enzyme processes approach adult values varies with the drug and the metabolic
pathway. For drugs such as diazepam, which are extensively metabolized by the liver, the decrease in
half-life with age demonstrates this process.
The hepatic metabolism process occurs by sulphation, methylation, oxidation, hydroxylation or

glucuronidation. Most hepatically metabolized drugs will undergo one or two of these processes.
Processes involving sulphation and methylation are not greatly impaired at birth, whereas those
involving oxidation and glucuronidation are. It might be assumed that neonates would be at an
increased risk of paracetamol toxicity; however, neonates use the sulphation pathway instead of
glucuronidation and are able to deal with paracetamol adequately.
Hydroxylation of drugs is deficient in newborns, particularly in preterm babies, and this is the
process that accounts for the huge variation in diazepam half-life as shown in the table above.
Grey-baby syndrome is a rare, but potentially fatal, toxic effect of chloramphenicol in neonates. It is
the result of the inability of the liver to glucuronidate the drug effectively in the first couple of weeks
of life if correct doses are not given.
It is impossible to predict with any accuracy the possible toxic dose for a neonate and young infant
even by applying all the above rules, e.g. neonates unlike adults convert most theophylline to caffeine
in the liver. Thus, without dedicated studies we really are only guessing as to what toxic or nontoxic
metabolites are being formed in this age group.
First-pass metabolism
Medication that is absorbed from the gastrointestinal tract goes straight to the liver before entering the
systemic circulation. This is useful for some types of medication, which have to go to the liver to be
activated (pro-drugs), e.g. enalapril. It is, however, limiting for medications that have to achieve
good levels when given orally. Propranolol has a high first-pass metabolism, so quite large doses
need to be given to achieve adequate systemic levels. Inhaled budesonide is often said to be
relatively free of systemic side effects because the steroid that is deposited in the throat and
swallowed is almost entirely eliminated by first-pass metabolism.
1.5 Renal excretion

Drug excretion by the kidneys is mainly dependent on glomerular filtration and active renal tubule
secretion. Preterm infants have approximately 15% (or less) of the renal capacity of an adult, term
babies have about 30% at birth, but this matures rapidly to about 50% of the adult capacity by the
time they are 45 weeks old. At 912 months of age, the infants renal capacity is equal to that of an
adult.
1.6 Other clinical considerations

Many other factors influence drug handling and may alter an individuals response to a given dose.
Pharmacodynamics
Although pharmacokinetics is significantly different in children (especially infants and neonates) than
in adults, the same is not true for the dynamics of most drugs. Generally children respond to
medicines in a similar way, but this cannot be assumed and thus any extrapolation of use must be done
with great care.
Examples
Salbutamol is less effective in infancy as the 2 receptors are relatively unresponsive to agonists
Caffeine (a xanthine, similar to theophylline) is more effective in neonates than adults due to an
enhanced responsiveness of receptors for treating apnoea. Combined with its long half-life and
wider therapeutic range it has become the drug of choice for neonatal apnoea against theophylline
Genetic variations
Genetic considerations can lead to altered drug metabolism or altered responses, e.g. glucose 6phosphate dehydrogenase (G6PD) deficiency, suxamethonium sensitivity, acetylation status.
G6PD deficiency
This is a commonly inherited enzyme abnormality. It is an X-linked recessive disorder. Male
homozygotes show significant drug-related haemolysis, but females only have minor symptoms.
Anaemia is the most common presentation.
The following are the main drugs to avoid:
Dapsone, nitrofurantoin, quinolones (ciprofloxacin, nalidixic acid, ofloxacin, norfloxacin),
sulfonamides (co-trimoxazole), quinine, quinidine, chloroquine
Suxamethonium sensitivity
Some people are extremely sensitive to the muscle relaxant suxamethonium. Serum
pseudocholinesterase activity is reduced and the duration of action of the muscle relaxant (usually a
few minutes) may be greatly increased, thus leading to apnoea (deaths have been reported). The
incidence is about 1 in 2500 of the population.
Acetylation status
Differences in the metabolism of isoniazid are seen in certain people and inherited as an autosomal
recessive trait. People who are slow inactivators have reduced activity of acetyltransferase, which
is the hepatic enzyme responsible for the metabolism of isoniazid and sulfadimidine (and thus affects
phenelzine and hydralazine metabolism). Toxic effects of such drugs may be seen in people who are
slow acetylators.
Slow acetylators are also predisposed to spontaneous and drug-induced systemic lupus erythematosus
(SLE).
Examples of drugs that may induce SLE

Phenytoin
Penicillin
Hydralazine
Sulfonamides
Isoniazid
Chlorpromazine
Blockers
Clonidine
Procainamide
Tetracyclines
Lithium
Methyldopa
Liver disease
Toxic substances normally cleared by the liver may accumulate in patients with liver impairment.
Opioids and benzodiazepines may accumulate and cause central nervous system depression,
thereby causing respiratory depression

Diuretics (loop and thiazide) may cause hypokalaemia
Rifampicin, which is excreted via the bile, will accumulate in patients with obstructive jaundice
Cirrhosis may cause hypoproteinaemia and thus reduce the number of binding sites for highly
protein-bound drugs (e.g. phenytoin)
Clotting factors are reduced in liver impairment, thus increasing the chances of bleeding in patients
on warfarin
Renal disease
Nephrotoxic drugs will make any renal impairment worse by exacerbating the damage. Drugs that
are renally excreted (most water-soluble drugs) will accumulate in renal impairment and the
dosing intervals will need to be increased to avoid toxicity
Drugs that cause toxicity in severe renal impairment include:
Digoxin cardiac arrhythmias, heart block
Penicillins/cephalosporins (high-dose) encephalopathy
Erythromycin encephalopathy
Nephrotoxic drugs include:
Aminoglycosides (gentamicin, amikacin)
Amphotericin B
Non-steroidal anti-inflammatory drugs (e.g. diclofenac, indometacin)
2. FORMULATION
Medicinal preparations often contain ingredients (i.e. excipients) other than the medicine that is being
prescribed. These adjuvants can have a pharmacological effect that needs to be taken into account
when looking at medication consumption and assessing possible toxicity.
Benzyl alcohol and methylparaben can displace bilirubin from albumin-binding sites, leading to
exacerbation of jaundice. Benzyl alcohol may also cause a potentially fatal gasping syndrome
Propylene glycol is a common solubilizing agent. In excess, it may cause severe toxicity including
hyperosmolarity, lactic acidosis, dysrhythmias and hypotension
Polysorbate 20 and Polysorbate 80, which are used as emulsifying agents, have been associated
with renal and hepatic dysfunction as well as hypotension (secondary to hypovolaemia),
thrombocytopenia and metabolic acidosis
Lactose is a common additive, but rarely associated with severe toxicity. It may, however, be
important if a child has lactose intolerance
Sugar and sorbitol are frequently added to liquid preparations for sweetness and occasionally
cause problems. Sugar can cause dental caries and sorbitol may cause diarrhoea
Alcohol is another common ingredient of many liquid pharmaceutical products and the quantity is
often fairly significant. Products such as Phenobarbital BP contain as much as 38% alcohol per 15
mg/5 ml. Equating this to a mg/kg quota, it would not be that unusual to subject a neonate to the
equivalent of an adult swallowing one or two glasses of wine
Formulation issues are a fundamental problem in paediatric medicine management. Palatability
causes many problems with compliance and it is well demonstrated that taste preferences change with
age. Few medicines are made specifically for children and thus products needed in clinical use may
not be available in a formulation that is appropriate for young children. This often leads to tablets
being crushed and aliquots being given. If this is necessary, the properties of the preparation may
change significantly or the dose may be inaccurate, depending on whether the tablet dissolves or
disperses and on the release mechanisms built into the tablet originally (e.g. coating or matrix). To put
this into some context, a 1-ml aliquot taken from a 50 mg tablet dispersed in 5 ml would be expected
to deliver 10 mg. In a study looking at diclofenac dispersible tablets showed that the 1-ml solutions
had anywhere between 2 mg and 8 mg (never 10 mg) and that was a dispersible tablet! A pharmacist
should be consulted if there is any doubt.
Formulations of the same medicine may differ and give varying effects. This is generally not the case
for licensed medicines where a generic medicine will have had to prove that it has a very similar
therapeutic effect to the brand leader, although this must still be borne in mind for changes of effect
with medicines with narrow therapeutic windows such as anticonvulsants. Even with licensed
preparations, different formulations may officially need different dosing, such as the liquid may be
more effective than the tablet, e.g. 50 mcg of digoxin liquid is equivalent to 62.5 mcg of the tablet. If
medicines are completely unlicensed (specials or extemporaneously prepared) the situation is
very different because there is no licensed standard. Thus not only may a liquid have a completely
different bioequivalence to a tablet, but a liquid produced by one manufacturer may contain different
excipients and have a different bioequivalence to that produced by another manufacturer. If possible,
try to ensure that a child stays on the same product (prescribe, putting the manufacturer, strength and
form on the prescription!) to ensure quality continuity of care this is particularly important when
there is transition of care between health-care settings and prescribers.
3. PAEDIATRIC DOSING
Pharmacokinetic and pharmacodynamic data are seldom available for children; this is because many
medicines are licensed only for adult use and have not undergone specific pre-marketing clinical
studies in children. Data on therapeutic dosing for children are often anecdotal and based on case
reports or very small population studies. New drugs are usually studied only in adult populations.
Some of the reasons for the lack of medicines licensed in children were the stringent regulations put
in place in 1962 after the thalidomide tragedy; these had the effect of discouraging research.
However, in recent years European Legislation has changed to encourage more drug companies to
seek paediatric licences. This Paediatric Regulation came into force in 2007 and ensures that all new
medicines are looked at for their paediatric use potential and if applicable industry has to conduct the
paediatric studies. Note that it is not unethical to study medicines in children; it is unethical to use
medicines that have not been studied.
The surface area and weight are the only common methods currently available to predict paediatric
therapeutic doses from those used for adults.
Surface area
The surface-area or percentage method for estimating doses is calculated as follows:
where 1.76 m2 is the average adult surface area.

Children are often said to tolerate or require larger doses of drugs than adults based on a weight
basis, and the percentage method helps to explain this phenomenon. Body water (total and
extracellular) is known to equate better with surface area than body weight. It thus seems appropriate
to prescribe drugs by surface area if they are distributed through the extracellular fluid volume in
particular.
Weight
where 70 kg is the average adult weight.

This method will give lower doses than the surface area method. It is far less accurate in clinical
terms and is usually inappropriate for accurate therapeutic dosing. However, as it gives lower and
thus safer estimates of what the toxic dose may be, it is a more practical and reasonably cautious
method for extrapolating toxic doses.
Most paediatric doses given in textbooks are described in small age or weight groups on a milligram
per kilogram basis. However, these will often have been originally obtained from surface area data
and thus are larger than the adult dose divided by 70.
To estimate the weight of a child (1 year to puberty):
Weight (kg) = 3(age) + 7
There are many algorithms, but this one has reasonable recent data. Always check that the child is
normal for age before just accepting the calculated weight.
There are, however, many medications that can be used in children and accuracy of prescribing is
essential because of the vast physical size differences in children (i.e. from 0.5 kg to 120 kg) let alone
their changes in kinetics. Children should be regularly weighed so that up-to-date weights can be used
for prescribing. However, remember the practicalities of what is to be given to the child. If a child
weighs 6.5 kg and requires 2 mg/kg of ranitidine, it would seem wiser to prescribe 15 mg, which is 1
ml of the oral liquid, rather than 13 mg, which equates to 0.867 ml. Some knowledge of the
therapeutic range of the drug is required to know when and by how much it is suitable to round doses,
and sometimes awkward quantities are required.
These small volumes also create risks in practice for intravenous therapy. A couple of studies have
shown that about a quarter of all doses prescribed on an NICU require only a tenth of the content of
the preparation kept as stock on the ward with 5% requiring only one-hundredth. Although it is hard
to give a 100 times overdose to an adult, it is easy to see how this can happen easily in neonatal
practice.
4. PRESCRIBING OUTSIDE LICENCE

The unlicensed and off-label (licensed drugs being used outside their licence) use of medicines in
children is widespread. It has been accepted by the Royal College of Paediatrics and Child Health
(RCPCH) and the Neonatal and Paediatric Pharmacists Group (NPPG) that informed use of such
medicines is necessary in paediatric practice when there is no suitable licensed alternative. Those
who prescribe for a child should choose the medicine that offers the best prospect for that child, with
due regard to cost. Legally, the prescriber is required to take full responsibility for such prescribing,
which must be justifiable in accordance with a respectable, responsible body of professional opinion.
The choice of a medicine is not therefore necessarily determined by its licence status, although it
should take into account information made available as a consequence of licensing and contained in
the summary of product characteristics. This can be of only limited help when the medicine chosen is
unlicensed or off-label, and the necessary information to support safe and effective prescribing must
be sought elsewhere.
In September 2005 the first British National Formulary for Children (BNF-C) was produced and
distributed to all doctors and pharmacists by the Department of Health. This was a fundamental move
forward in accepting that medicines need to be used outside their licence for children and to try to
rationalize and standardize some paediatric medicine management using evidence-based data and
expert peer review.
If prescribing outside the licence, remember that the medication supplied has to legally be given with
the manufacturers patient information sheet. This will probably not mention the use for which you are
prescribing and may even suggest that it should be avoided in such a condition or age group. This has
fundamental implications with compliance and concordance. Leaflets are available on the RCPCH
website explaining to children and their carers why this situation may arise, and decreasing the fears
that this situation may cause. There are also medicine information leaflets for individual medicines
used for specific indications written specifically for parents and carers. These have been developed
by the RCPCH, NPPG and the Wellchild charity, and are available at
www.medicinesforchildren.org.uk.
5. DRUG MONITORING
Most drugs have wide therapeutic windows and thus toxicity is unlikely at normal doses. It is
usually easy to see a medication effect, e.g. analgesics take away pain. There are, however, certain
circumstances when it is important to measure drug levels to ensure that there are adequate levels for
effect and/or that the levels are unlikely to cause toxicity.
A drug with a narrow therapeutic window has a narrow range between the drug concentration
exhibiting maximum efficacy and that producing minimum toxicity.
Medications that have narrow therapeutic windows are often monitored, because it is hard to predict
whether a dose for an individual patient will be clinically effective or will cause toxicity.
Common drugs for therapeutic monitoring

Phenytoin
Warfarin
Carbamazepine
Gentamicin
Phenobarbital
Vancomycin
Digoxin
Theophylline
Indications for monitoring:
To confirm that levels are not toxic and are at a level that is normally effective (usually checked
once steady state has been reached), e.g. gentamicin, vancomycin
If toxicity is expected
If external factors may have changed a level (change in renal/hepatic function, change in interacting
concomitant medication)
To check compliance
It is important to know that a drug was at a steady state when a level was measured and whether
trough levels or peak levels are important.
Adverse drug reactions

Whether a drug has a wide or narrow therapeutic index they can all cause adverse drug reactions that
can be broken down into different categories:
Side effects
Allergic reactions
Toxic effects (see later)
Probably the greatest worry in children is unexpected adverse drug reactions (ADRs), which are of
particular concern in children when using unlicensed and off-label medicines. The variances in
kinetics and dynamics means that a side effect may occur that has not been seen in adults. The
excipients of the formulation may also give rise to these unexpected ADRs as discussed earlier.
Although many side effects are well documented and may even be expected to happen (e.g. increase
in heart rate with an infusion of salbutamol), it is suggested that all adverse drug reaction that happen
in children are reported using the Yellowcard scheme of the Commission on Human Medicines or
Medicines and Healthcare products Regulatory Agency (MHRA) as it is now known, including those
using unlicensed and off-label medicines.
Drug interactions
Many situations arise where interactions between different medications are important. Some drugs
may just cause the same affects, such as two sedative drugs or medicines with sedation as a side
effect will of course lead to an additive effect of sedation. Other drugs may actually interact with
each other either in the childs body or before the medicines actually enter the body.
Liver interactions
One drug may alter the metabolism of the other medicine via the effects on liver enzymes. Drugs may
either inhibit or induce the liver enzyme systems as follows.
Liver induction
Will lead to treatment failure of: warfarin, phenytoin, theophylline, oral contraceptive pill
Caused by: phenytoin, carbamazepine, barbiturates, rifampicin, chronic alcohol consumption,
sulfonylureas
Liver inhibition
Will lead to potentiation of: warfarin, phenytoin, carbamazepine, theophylline, ciclosporin
Caused by: omeprazole, erythromycin, valproate, isoniazid, cimetidine, sulfonamides, acute
alcohol consumption
Absorption interactions
Medication that changes the pH of the stomach or the motility of the stomach may vastly change the
absorption of another medication (see Section 1.1).
Drugs that make the stomach more alkaline include H2-receptor antagonists (e.g. ranitidine) and
proton pump inhibitors (e.g. omeprazole).

Drugs that may increase gut transit time include any drugs that may cause diarrhoea, such as many
antibiotics but particularly erythromycin.
Compatibility interactions
When medications are given, always be aware of their interactions before they enter the body. This is
particularly important with parenteral medication. Many medications interact to produce noneffective products, toxic products or precipitates.
Examples of incompatible injections
Amiodarone: precipitates in the presence of sodium ions

Fat (in total parenteral nutrition): emulsifies when mixed with heparin
Erythromycin: is unstable in acidic medium (glucose), so must be made up in sodium chloride
Gentamicin: is partly inactivated by penicillin, so lines must be flushed between administrations
6. INTRAVENOUS MANAGEMENT
The intravenous route offers many advantages to drug administration. By avoiding all the issues of
absorption and delivering straight into the blood circulation, you can be fairly sure what dose is
circulating and that it is acting quickly. However, unlike most other routes it is finite once the drug
has gone in, there is no way of getting it out if an error has been made.
In children, and especially neonates, medicines often account for a large proportion of their total
daily fluid (and electrolyte!) allowance. Although a 1 ml/h infusion in an adult would not be
accounted for in their fluid management, the same infusion to a 0.5 kg pre-term infant would equate to
almost half their entire circulating fluid volume.
Fluids should be as isotonic with plasma as possible, but children also require more energy than
adults and thus the fluids used in children and neonates vary.
Always review the fluid regimen in light of plasma electrolytes and fluid input/output charts and
clinical progress.
6.1 Maintenance fluids

This is the volume required in a 24-h period to maintain normal hydration when there is no significant
prior fluid deficit from dehydration and no significant ongoing fluid loss.
Type of fluid
Most children should use 0.9% sodium chloride with 5% glucose

Note: use of Hartmanns solution or 0.9% sodium chloride may be considered as an alternative.
Occasionally 0.45% sodium chloride with glucose may be used if sodium levels are dangerously
high.
Add potassium chloride 10 mmol/500 ml (20 mmol/l) once U&Es known and urine output
established. Children with hypokalaemia may need more (40 mmol/l).
Neonates will require 10% glucose due to their high glucose requirement (usually electrolyte free for
the first 48 h of life).
Weight (kg)
Fluid requirement (ml/kg per 24 h)
Day 1 of life
Day 2 of life
Day 3 of life
Day 4 of life and after
>4 weeks of age 10 kg or less
Additionally for each kg up to 20 kg (i.e. 1000 ml+)
Additionally for each kg thereafter (i.e. 1500 ml+)
60
90
120
120 to 150
100
50
20
Usual maximum of 2500 ml/day in boys and 2000 ml/day in girls.
Volume of maintenance fluid

Fluid balance must be monitored and fluids adjusted as needed depending on clinical state (including
weight), urine output, environmental factors, plasma and U&E measurements.
6.2 Monitoring
Monitor fluid replacement both clinically and biochemically.
Avoid hyponatraemia:
Hyponatraemia may pre-exist or develop during therapy
Symptomatic hyponatraemia is a medical emergency
Other electrolyte disturbances may occur and need fluid regimen tailoring based on results:
Check plasma electrolytes before starting the infusion, except before most cases of elective surgery.
Consider monitoring plasma glucose if glucose-free solutions are used. If postoperative fluids are
needed for more than 68 h, must send U&Es
Check plasma electrolytes every 24 h while intravenous fluids are being given. If plasma
electrolytes are abnormal, consider rechecking every 46 h, but definitely if plasma sodium
concentration <130 mmol/l
Check plasma electrolytes if clinical features suggestive of hyponatraemia develop, including
nausea, vomiting, headache, irritability, altered level of consciousness, seizure and apnoea
Where possible, all children on intravenous fluids should be weighed before the start of therapy
and be weighed again each day
Document accurate fluid balance daily. Assess urine output oliguria may be due to inadequate
fluid, renal failure, obstruction or the effect of antidiuretic hormone
Rule of 6
Most medicines in adults are infused at a rate of 1 ml/h for the standard dose and then titrated, e.g.
morphine 50 mg in 50 ml will normally be started at 1 ml/h, regardless of the size of the adult
because adults usually vary in weight only by a magnitude of about twofold (i.e. 50 kg up to 100
kg). Children start at about 0.5 kg for a pre-term baby and also go up to 100 kg a weight variance
of 200-fold, so a standard concentration will not work for all children.
Many continuous infusion medicines are therefore usually worked out using a factor of the weight
from an algorithm known as the Rule of 6.
It is worked out with the same principle that 1ml/h of infusion should deliver the usual dose:
(6 weight of child in kg) mg of drug in 100 ml will deliver 1 mcg/kg per min if run at 1 ml/h
Examples:
(1 kg) mg of morphine in 50 ml
1 ml/h = 20 mcg/kg per h
(3 kg) mg of midazolam in 50 ml
1 ml/h = 1 mcg/kg per min
7. DRUGS IN PREGNANCY
Summary of product characteristics that come with medicines usually indicate whether the medicine
can be used (or not) in pregnancy, although most will state that the risk is unknown. This requirement
stems from the thalidomide tragedy of the 1960s. It must be remembered that many women are already
taking medicines before they know that they are pregnant and others must continue to take medicines
for chronic conditions. The specialty of fetal medicine is also growing where high doses of medicines
are given to the mother, specifically to treat the unborn child. This is not an area where false
reassurance is appropriate because future litigation is high in this area.

Generally, any effects of medicines will be seen immediately after birth, but some data suggest that
this may not be the whole story and long-term effects may also occur, particularly in
neurodevelopment.
For medicines that have known teratogenic properties, it is essential that adequate counselling occurs
to establish all the risk issues (preferably before they become pregnant).
Neural tube defects are probably the most common teratogenic effect with antiepileptic medication,
but warfarin can cause nervous system defects and of course alcohol can cause a multitude of
problems under the term fetal alcohol syndrome. However, many factors will affect the fetal
response to the teratogen: period of exposure during the pregnancy (first and third trimesters generally
being the worst for exposure), dose and genetic factors. Most drugs do cross the placenta and thus
will enter the fetus. Some such as insulin are physically too large to cross the barrier, but of course
the effects on sugar will still be felt by the unborn baby.
8. DRUGS IN BREAST MILK

There is now a great deal of evidence establishing the benefits of breastfeeding for both the mother
and the baby. The ability of a drug to pass into the breast milk will depend on its partition coefficient,
pKa, its plasma and milk protein binding, and selective transport mechanisms. With milk being
slightly acidic and fatty, medicines that are acid or protein bound or lipid insoluble are likely to pass
into breast milk in low concentrations. Unfortunately, lack of knowledge about drug safety in
breastfeeding often causes women to stop breastfeeding or never start in the first place because of
their own anxiety or that of the health-care professionals involved in their care.
The BNF for Children takes a more pragmatic approach to drugs that are safe in breastfeeding than
the licensing manufacturers information. A majority of medications do pass into breast milk, but most
will have little or no effect on an infant at normal therapeutic doses because the dose being delivered
to them is subclinical.
It must always be remembered that, even if drugs do enter breast milk, they must still go through the
infants gut to be absorbed and this offers another barrier to many drugs such as omeprazole. The
infants short gastric emptying time also reduces exposure to some drugs.
The frequency and volume of the feeding must also be considered because there will be less exposure
to the drug if the infant is receiving supplementary feeds and/or other liquids. Further reassurance can
be given to a parent if the medication that is being given has a long-term history of safety in children
at therapeutic levels.
Taking all this into consideration, there are very few drugs that are contraindicated in breastfeeding
women. The table opposite lists the medicines that are usually seen as a contraindication to
breastfeeding. The benefits of breastfeeding usually outweigh the small theoretical risk of harm to the
neonate. This said, we should never become complacent and should look for the evidence and
approach newer drugs with more caution.
Drugs that are contraindicated in breastfeeding

Amiodarone
Androgens
Antithyroid drugs
Cancer chemotherapy
Chloramphenicol
Dapsone
Doxepin
Ergot alkaloids
Indometacin
Iodine, Iodides
Lithium
Nalidixic acid
Nitrofurantoin (in G6PD-deficient infants)
Oestrogens (high dose)
Radiopharmaceuticals
Reserpine
Sulfonamide (in jaundiced or G6PD-deficient infants)
Tetracyclines
Vitamins A and D (high dose)
G6PD, glucose-6-phosphate dehydrogenase.
9. TOXICOLOGY
Each year 40 000 children attend accident and emergency departments (A&Es) with suspected
poisonings/accidental ingestion. These incidents fall into three categories:
Accidental typically boys in the 1- to 4-year age group
Intentional usually teenage girls
Deliberate suspected if the signs cannot be explained in any other way
Principles of management include the following:
Resuscitation if necessary
Contact a national poisons unit for advice
Induction of emesis (with ipecacuanha, for example) is no longer indicated
Consider limiting absorption of poison by:
Activated charcoal if ingestion is within 1 hour

Gastric lavage if a life-threatening quantity of poison is ingested
Acid, alkali or corrosive substances should be treated with caution do not intervene with the
above before seeking advice from the poisons unit
9.1 Paracetamol
Levels >250 mg/kg are likely to lead to severe liver damage.
Clinical features
Nausea and vomiting are the only early symptoms although most patients are asymptomatic
Right subcostal pain may indicate hepatic necrosis
Management
Activated charcoal if ingestion <1 h earlier of 150 mg/kg (75 mg/kg if high risk)
Measure plasma paracetamol level at 4 hours or as soon as possible thereafter
Acetylcysteine, a glutathione donor, is almost 100% effective if administered up to 24 hours
(ideally 8 hours) post-ingestion in preventing hepatotoxicity and nephrotoxicity
Be aware of high-risk factors that may require a lower threshold (total paracetamol ingestion as
low as 75 mg/kg) for active management. These include conditions that decrease hepatic
glutathione stores (e.g. anorexia nervosa, cystic fibrosis, malnourishment) and drugs that induce
cytochrome P450 microenzymes (e.g. phenytoin, carbamazepine, rifampicin, phenobarbital)
9.2 Iron
Severity of poisoning is related to the amount of elemental iron ingested:
A 200 mg tablet of ferrous sulphate contains 65 mg elemental iron
A 300 mg tablet of ferrous gluconate contains 35 mg elemental iron
<20 mg/kg toxicity unlikely
>20 mg/kg toxicity may occur
>60 mg/kg significant iron poisoning
Clinical features
First stage
Within a few hours:
Nausea and vomiting
Abdominal pain
Haematemesis
Second stage
816 hours:
Apparent recovery
Third stage
1624 hours:
Hypoglycaemia
Metabolic acidosis (due to lactic acid)
Late stage
Hepatic failure 24 days:
Management
Initial treatment depends on the likelihood of toxicity, i.e. was >20 mg/kg ingested?
Plasma iron level
Abdominal X-ray:
No iron visible but >20 mg/kg ingested: give desferrioxamine orally
Iron in stomach: gastric lavage with desferrioxamine in the lavage fluid
Iron in intestine: desferrioxamine orally, Picolax orally a bowel stimulant
If >60 mg/kg ingested: administer parenteral desferrioxamine
9.3 Tricyclic antidepressants

Ingestion of >10 mg/kg of a tricyclic antidepressant is likely to produce significant toxicity, with 20
30 mg/kg potentially being fatal, as a result of sodium channel block leading to cardiac conduction
abnormalities.
Clinical features
Depressed level of consciousness

Respiratory depression
Convulsion
Arrhythmia
Hypotension
Anticholinergic effects:
Pupillary dilatation
Urinary retention
Dry mouth
Management
Resuscitation
Activated charcoal within 1 h of ingestion
ECG monitoring
Sodium bicarbonate and systemic alkalinization:
Monitor potassium because sodium bicarbonate can cause hypokalaemia
All anti-arrhythmics should be avoided especially class Ia agents. Treat convulsions aggressively
with benzodiazepines and sodium bicarbonate and, if refractory, with general anaesthesia and
supportive care
9.4 Aspirin overdose

Mild toxicity follows ingestion of >150 mg/kg with severe toxicity associated with doses >500
mg/kg.
Clinical features
In young children, dehydration and tachypnoea

In older children and adults, tachypnoea and vomiting with progressive lethargy
Tinnitus and deafness
Hypoglycaemia or hyperglycaemia can occur
Three phases
Phase 1
May last up to 12 h
Salicylates directly stimulate the respiratory centre, resulting in a respiratory alkalosis with a
compensatory alkaline urine with bicarbonate sodium and potassium loss
Phase 2
May begin straight away, particularly in a young child, and lasts 1224 h
Hypokalaemia with, as a consequence, a paradoxical aciduria despite the alkalosis
Phase 3
After 624 h
Dehydration, hypokalaemia and progressive lactic acidosis, the acidosis now predominating
Can progress to pulmonary oedema with respiratory failure, disorientation and coma
Management
Gastric lavage up to 4 h. Activated charcoal for sustained release preparations. Salicylate level at
6 h plotted on a normogram and repeat every 34 h until level has peaked. Levels between 200 and
450 mg/l can be treated by activated charcoal and oral or intravenous rehydration whereas levels
>450 mg/l require alkalinization
Alkalinization of the urine to aid drug excretion, adequate fluids including bicarbonate, sodium and
potassium, with close monitoring of acidbase and electrolytes
Discuss care with national poisons centre
9.5 Lead poisoning

Lead poisoning is uncommon but potentially very serious. It often results from pica (persistent eating
of non-nutritive substances, e.g. soil) and is therefore more common in pre-school-age children. Other
causes include sucking/ingesting lead paint, lead pipes, discharge from lead batteries and substance
abuse of leaded petrol.
Lead intoxication can be divided into acute and chronic effects, and results from its combination with
and disruption of vital physiological enzymes.
Acute intoxication
Reversible renal Fanconi-like syndrome
Chronic intoxication
Failure to thrive
Abdominal upset: pain/anorexia/vomiting/constipation
Lead encephalopathy: behavioural and cognitive disturbance, drowsiness, seizures, neuropathies,
coma
Glomerulonephritis and renal failure
Anaemia microcytic/hypochromic, basophilic stippling of red cells
A coexisting iron deficiency is common which, first, further exacerbates the anaemia and, second,
actually contributes to increased lead absorption. Basophilic stippling is the result of inhibition of
pyrimidine 59-nucleotidase and results in accumulation of denatured RNA.
Treatment involves:
Removing source
Chelation:
Mild oral D-penicillamine
Severe intravenous sodium calcium edetate (EDTA)

Very severe intramuscular injections of dimercaprol to increase effect of EDTA
Some US states implement universal screening for elevated lead levels in children.
9.6 Carbon monoxide

Carbon monoxide is a tasteless, odourless, colourless and non-irritant gas
Carbon monoxide binds to haemoglobin to form carboxyhaemoglobin, which reduces the oxygencarrying capacity of the blood and shifts the oxygen dissociation curve to the left. The affinity of
haemoglobin for carbon monoxide is 250 times greater than that for oxygen
Endogenous production occurs and maintains a resting carboxyhaemoglobin level of 13%
Smoking increases carboxyhaemoglobin levels. Other sources of raised levels include car exhaust
fumes, poorly maintained heating systems and smoke from fires
Clinical features of carbon monoxide poisoning occur as a result of tissue hypoxia. PaO2 is normal
but the oxygen content of the blood is reduced. Toxicity relates loosely to the maximum
carboxyhaemoglobin concentration. Other factors include duration of exposure and age of the
patient
Maximum carboxyhaemoglobin concentration

10%
1030%
60%
Not normally associated with symptoms

Headache and dyspnoea
Coma, convulsions and death
Neuropsychiatric problems can occur with chronic exposure.

Treatment of carbon monoxide poisoning is with 100% oxygen, which will reduce the
carboxyhaemoglobin concentration. Hyperbaric oxygen is said to reduce the carboxyhaemoglobin
level quicker
9.7 Button batteries

Commonly ingested by children
Systemic toxicity is rare although localized mucosal ulceration is common, possibly leading to
gastrointestinal haemorrhage or perforation
Batteries identified on plain film to be within the oesophagus are to be removed endoscopically
Patients with batteries within the stomach are to be admitted and re-imaged within 2448 h. If
battery is still in the stomach after 48 h then it must be removed endoscopically
Batteries distal to the pylorus should not cause problems as long as there is no delay in transit time.
It is recommended to monitor progress of the battery with plain films every 48 h to ensure that it
remains intact and has been passed
10. FURTHER READING

Briggs GG, Freeman RK, Yaffe SJ (2002). Drugs in Pregnancy and Lactation, 6th edn. Philadelphia,
PA; Lippincott Williams & Wilkins.
British National Formulary for Children (2011). London; BMJ Publishing Group, Royal
Pharmaceutical Society and RCPCH Publications.
Conroy S, Nunn T, Tomlin S (2006). Compliance or concordance in children? In; Jacqz-Aigrain E,
Choonara I (eds), Paediatric Clinical Pharmacology. Lausanne, New York; FontisMedia and Taylor
& Francis, 265273.
Department of Health (2004). The National Service Framework for Children and Younger People.
London; Department of Health.
Greene SL, Dargan PI, Jones AL (2005). Acute poisoning; understanding 90% of cases in a nutshell.
Postgrad Med J 81;204216.
Jacqz-Aigrain E, Choonara I, eds (2006). Paediatric Clinical Pharmacology. Lausanne, York;
FontisMedia, and Taylor & Francis.
McIntyre J, Conroy S, Avery A, et al. (2000). Unlicensed and Off-label prescribing of drugs in
general practice. Arch Dis Child 83;498501
Maxwell GW (1989). Paediatric drug dosing. Drugs 37:113115.
Royal College of Child Health/Neonatal & Paediatric Pharmacists Group (1999). Medicines for
Children. London: RCCH.
Rylance GM (1988). Prescribing for infants and children. BMJ 296:984986.
Tomlin S, Cokerill H, Costello I, et al. (2009). Making Medicines Safer For Children guidance
for the use of unlicensed medicines in paediatric patients. Guidelines. Connect Medical.
Watson D, Getschman S, Koren G, et al. (1993). Principles of drug prescribing in infants and
children: a practical guide. Drugs 46:281288.
Young YL, Koda Kimble MA (2001). Applied Therapeutics: The clinical use of drugs, 6th edn.
Philadelphia, PA: Lippincott Williams & Wilkins.
Chapter 6
Dermatology
Helen M Goodyear
CONTENTS
1. Structure and function of the skin
1.1 Structure of the skin
1.2 Function of the skin
1.3 Skin biopsy
1.4 Description of skin rashes
2. Neonatal skin disorders

2.1 Embryology
2.2 Physiological lesions
2.3 Differential diagnosis of vesiculopustular lesions
2.4 Neonatal erythroderma
2.6 Neonatal lupus erythematosus
3. Birthmarks
3.1 Strawberry naevi (capillary haemangioma)
3.2 Salmon patch (stork bite)
3.3 Port wine stain (naevus flammeus)
3.4 Sebaceous naevi
3.5 Melanocytic naevi
4. Differential diagnosis of an itchy, red rash

4.1 Atopic eczema
4.2 Urticaria
4.3 Infections and infestations
4.4 Psoriasis
5. Blistering disorders
5.1 Epidermolysis bullosa
5.2 Drug eruptions
5.3 Autoimmune blistering disorders
6. Erythemas
6.1 Erythema multiforme
6.2 Erythema nodosum
6.3 Erythema marginatum
6.4 Erythema migrans
7. Photosensitive disorders
7.1 Genetic causes of photosensitivity
8. Ichthyoses
8.1 Inherited ichthyoses
8.2 Collodion baby
8.3 Harlequin ichthyosis
9. Hair, nails and teeth

9.1 Hair
9.2 Nails
9.3 Teeth
10. Disorders of pigmentation

10.1 Causes of hypopigmentation
10.2 Causes of hyperpigmentation
10.3 Disorders associated with multiple caf-au-lait macules
10.4 Skin changes associated with tuberous sclerosis
11. Miscellaneous disorders

11.1 Granuloma annulare
11.2 Dermatitis artefacta
11.3 Nappy rash
11.4 Acne
11.5 Spitz naevus
11.6 Keloids
11.7 Acanthosis nigricans
11.8 Stings and snake bites
12. Further reading
Dermatology
1. STRUCTURE AND FUNCTION OF THE SKIN

1.1 Structure of the skin
Epidermis
Four layers
Stratum corneum keratinization
Stratum granulosum
Stratum spinosum
Stratum basale
Marked regional variation in thickness of epidermis
Cells
Keratinocytes (95%)
Merkel cells
Melanocytes
Langerhans cells
Dermoepidermal junction
A barrier and a filter.
Dermis
1520% of body weight

Variable thickness 5 mm back, 1 mm eyelids
Two protein fibres collagen and elastin
Supporting matrix/ground substance (proteoglycan (polysaccharide and protein))
Rich blood supply
Cells
Fibroblasts
Mast cells
Macrophages
Subcutaneous fat
Epidermal transit time: 5275 days. Greatly decreased in hyperproliferative conditions, e.g.
psoriasis
Palmoplantar skin: extra layer, stratum lucidum, present between stratum granulosum and stratum
corneum
Two types of skin: glabrous skin on palms and soles and hair-bearing skin
1.2 Function of the skin
Barrier: to the inward/outward passage of water and electrolytes

Mechanical: depends on collagen and elastin fibres
Immunological: cytokines, macrophages, lymphocytes and antigen presentation by Langerhans cells
UV irradiation protection: melanin is a barrier in the epidermis, protein barrier in the stratum
corneum
Temperature regulation: involves sweat glands and blood vessels in the dermis; heat loss by
radiation, convection, conduction and evaporation
Sensory: touch, pain, warmth, cold, itch
Respiration: skin absorbs O2 and excretes CO2, accounting for 12% of respiration
Endocrine: vitamin D3 synthesized in stratum spinosum and stratum basale from pre-vitamin D3 due
to UVB radiation
1.3 Skin biopsy

For uncertain diagnosis, serious skin disorders, histological confirmation of diagnosis before
treatment
Usually a 3- to 4-mm punch biopsy under local anaesthetic. Stitch often not necessary
Epidermolysis bullosa needs special shave technique of unaffected rubbed skin
1.4 Description of skin rashes

Some dermatological terms:
Macule: a circumscribed area of discoloration
Papule: a small raised area
Nodule: a palpable mass >1 cm in diameter
Plaque: a large disc-shaped lesion

Vesicle: a small blister <0.5 cm in diameter
Bulla: a blister >0.5 cm in diameter
Pustule: a visible accumulation of free pus
2. NEONATAL SKIN DISORDERS

2.1 Embryology
Nails: form from 8 weeks to 9 weeks onwards

Hair: synthesis from 17 weeks to 19 weeks
Keratinization: of epidermis from 22 weeks to 24 weeks
Epidermis: all layers present from 24 weeks
Preterm: (2434 weeks) have poor epidermal barrier with thin stratum corneum directly
correlating to degree of prematurity; increased skin losses and absorption; within 2 weeks skin is
the same as that of term infant
Dermis: is less thick in neonate compared with adult; collagen fibre bundles are smaller, elastin
fibres are immature, vascular and neural elements are less well organized
2.2 Physiological lesions
Cutis marmorata
Physiological scaling
Vernix caseosa
Sebaceous gland hyperplasia
Acrocyanosis (peripheral cyanosis)
Harlequin colour change
Sucking blisters
Milia (large ones = pearls)
Lanugo hairs in preterm baby
2.3 Differential diagnosis of vesiculopustular lesions

Transient rashes
Miliaria: blockage of sweat ducts; vesicles (miliaria crystallina) or itchy red papules (miliaria
rubra); first 2 weeks
Erythema toxicum neonatorum: in first 48 hours; may recur beyond first month
Transient neonatal pustulosis melanosis: superficial fragile pustules at birth, rupture easily
leaving pigmented macule which lasts for up to 3 months
Infantile acropustulosis: presents in first 3 months; recurrent crops of 1- to 4-mm vesicopustules

usually on hands and feet; resolves by second to third year
Eosinophilic pustular folliculitis: recurrent crops of papules on scalp, hands and feet; rare, usually
in males
Neonatal acne: relatively common, resolves by 3 months
Infections and infestations

Always take a swab to exclude Staphylococcus aureus/streptococcal infection and others in preterm
infants or the immunocompromised. Scabies can occur in the first month of life.
Genetic and naevoid disorders

Epidermolysis bullosa
Incontinentia pigmenti: X-linked dominant, usually lethal in males; vesicular lesions in first 48
hours, verrucous lesions, streaky pigmentation and then atrophic pale lesions; associated with other
abnormalities: skeletal, eye, CNS and dentition (SEND)
Urticaria pigmentosa: lesions in first year of life which urticate when rubbed; can be present at
birth; systemic involvement is more common if presents >5 years
2.4 Neonatal erythroderma

Causes of neonatal erythroderma
Skin disorders
Seborrhoeic dermatitis
Atopic eczema
Psoriasis
Ichthyosis
Netherton syndrome
Immunological disorders
Omenn syndrome
DiGeorge syndrome
T-cell lymphoma
Hypogammaglobulinaemia
Graft-versus-host disease
Metabolic/nutritional deficiencies
Zinc deficiency
Cystic fibrosis
Protein malnutrition
Multiple carboxylase deficiencies
Amino acid disorders

Amniotic bands
Aplasia cutis congenita: isolated defect commonly on posterior scalp; associations include
epidermolysis bullosa, limb defects, spinal dysraphism, trisomy 13, Goltz syndrome and Adams
Oliver syndrome
2.6 Neonatal lupus erythematosus

Presents in first few weeks of life. Erythematous scaly rash, typically around the eyes. May be
associated with congenital heart block.
3. BIRTHMARKS
3.1 Strawberry naevi (capillary haemangioma)
Usually appear in first few weeks of life

More common in preterm infants
Precursor is an erythematous/telangiectatic patch pale halo
Three phases:
Proliferative (610 months)
Stabilization
Spontaneous resolution pale centre initially
Complications ulceration, infection, bleeding, cardiac failure
Treat if obstructs vital structures (propranolol 2 mg/kg; prednisolone 24 mg/kg)
Often deep component: cavernous haemangioma
Multiple small diffuse haemangiomas in infants <3 months of age may be associated with visceral
involvement, particularly liver; high mortality if untreated.
KasabachMerritt syndrome: thrombocytopenia, rapidly enlarging haemangioma, microangiopathic
haemolytic anaemia, localized consumption coagulopathy,
PHACES syndrome: posterior fossa defects, haemangiomas (usually large facial ones), arterial
anomalies, cardiac defects and coarctation of the aorta, eye anomalies, sternal clefting and/or
supraumbilical raphe.
3.2 Salmon patch (stork bite)

Nape of neck, upper eyelids, glabella; 1020% in occipital region persist whereas others resolve
spontaneously.
3.3 Port wine stain (naevus flammeus)
Present at birth
Capillary malformation
Associations:
SturgeWeber syndrome
KlippelTrenaunayWeber syndrome
Persists throughout life
Can treat with pulse dye laser
3.4 Sebaceous naevi

Present at birth; scalp/face; flat/slightly raised and hairless; can undergo neoplastic change after
puberty
3.5 Melanocytic naevi

Present in 12% at birth. Congenital usually >5 mm, acquired <5 mm. Giant melanocytic naevi
(bathing trunk naevi) have increased melanoma risk (414%). May be associated with
neurocutaneous melanosis (EEG abnormalities, raised intracranial pressure, hydrocephalus and
space-occupying lesion).
4. DIFFERENTIAL DIAGNOSIS OF AN ITCHY, RED RASH

4.1 Atopic eczema
Affects 1020% of children.
Multifactorial disease including:
Genetic factors: 70% of children have positive family history of atopy
Immunological abnormalities: immunoglobulin E (IgE) dysregulation, skin immune abnormalities
altered cytokine secretion
Altered pharmacological mechanisms
Exacerbating factors of atopic eczema (URTIs, upper respiratory tract infections; AD, autosomal
dominant).
Features of atopic eczema
Age of onset: usually in first 6 months, around 3 months most common

Site: face/scalp initially, then flexures; extensor aspects may be involved
Erythematous macules/papules/plaques/oozing/crust formation
Tendency to secondary infection: Staphylococcus aureus, group A -haemolytic streptococci,
herpes simplex virus (HSV) (eczema herpeticum), warts, molluscum contagiosum
Skin colonization with S. aureus in 90%
Lichenification: chronic eczema
Resolves: 50% by 6 years, 90% by 14 years
Associated conditions
Ichthyosis vulgaris
Keratosis pilaris
Food intolerance and allergy
Pityriasis alba
Juvenile plantar dermatosis
Asthma
Cataract
Differential diagnoses
Lichen simplex chronicus: asymmetrical lesion, chronic rubbing and scratching
Infantile seborrhoeic dermatitis: usually in first 3 months, yellow greasy scales on scalp,
forehead, napkin area and skin folds, lack of pruritus. Treat with emollients and 1% hydrocortisone
if needed (see eczema treatments)
Contact dermatitis
Hyper-IgE syndrome (Job syndrome): IgE >2000 IU/ml, recurrent cutaneous and sinopulmonary
infections
WiskottAldrich syndrome: X-linked recessive, thrombocytopenia and recurrent pyogenic
infections. Risk of malignancies, non-Hodgkin lymphoma most common
Management of atopic eczema

General
Avoid exacerbating factors

Cut nails short, file edges
Wear cotton clothes
Education for parents and child, demonstrating treatments and giving information to help them selfmanage the condition
Topical treatments
Stepwise management see NICE guidelines on management of atopic eczema in children aged
12 years
Emollients bath oil once or twice daily, soap substitute, moisturizer four times daily. Any of the
moisturizers can be used as soap substitutes. Aqueous cream should not be used as a leave-on
emollient. Use antiseptic bath oils, e.g. Dermol 600, Oilatum Plus, and emollients, e.g. Dermol 500
lotion, Eczmol if recurrent infection
Steroid creams/ointments weakest strength possible applied twice daily using fingertip unit
(FTU) to control the eczema. In general: mild potency 1% hydrocortisone if <2 years; moderate
potency if needed, e.g. Eumovate, Betnovate 1 in 4, if >2 years. Never use potent, e.g. Betnovate,
or very potent, e.g. Dermovate, in children except in specialized centres. Some evidence that
moderate potency three times weekly is as good as mild potency twice daily. Risk of side effects
increases with potency and includes skin thinning, irreversible striae and telangiectasia, acne,
depigmentation and Cushing syndrome
Bandages zinc impregnated, e.g. ichthopaste, worn with elasticated bandage such as Coban over
the top. Change every 2448 hours. Useful for chronic limb eczema
Wet wraps use ready-made vest and leggings with liberal emollient. Make first layer wet with
either water or emollient and place second dry layer over the top. Cotton gloves and socks are also
available. If itching is a problem then silk suits can be helpful
Tacrolimus (Protopic) 0.03% ointment and pimecrolimus (Elidel) works on skin immune system;
affecting cytokine release is second-line treatment for atopic eczema that is not improving on
conventional treatment. Use twice daily for 3 weeks then once daily. Caution about long-term
continuous use due to concerns of cancer risk
Antihistamines do not use routinely. Use with caution in children < 1 year. One month trial of
non-sedating antihistamine for severe atopic eczema or severe itching. Give sedating antihistamine
for 714 days in acute exacerbations with sleep disturbance
Antibiotics consider a 10-day course if eczema flares up. Flucloxacillin
phenoxymethylpenicillin or erythromycin. Beware of MRSA (meticillin-resistant S. aureus) and

resistance to erythromycin in some hospital-acquired S. aureus infections
Aciclovir 1.5 g/m2 per day intravenously for 5 days if eczema herpeticum (generalized HSV
infection of atopic eczema). Oral aciclovir for HSV recurrences. Suspect eczema herpeticum if
eczema deteriorates and vesicopustules or punched-out lesions are present
Diet avoid obvious trigger foods. Give 6- to 8-week trial of hydrolysed protein or amino acid
formula to bottle-fed infants with severe eczema aged <6 months. Do not use sheep or goats milk.
Soya protein can be used if >6 months. Involve paediatric dietitian
Systemic therapy severe eczema unresponsive to above therapies. Therapies include
prednisolone (starting around 2 mg/kg to control eczema, then weaning down to lowest alternateday dose that controls eczema), short-course ciclosporin (up to 5 mg/kg per day) for 36 months,
monitoring renal and liver function carefully, and azathioprine
Alternative remedies many patients will use these, e.g. homoeopathy, Chinese herbal medicine.
Beware of potent steroid creams in Chinese herbal creams and monitor liver and renal function 3monthly if taking herbs. Avoid in children <2 years
4.2 Urticaria
Transient erythematous/oedematous itchy swellings of the dermis. Lasts from a few minutes to 24
hours. Clears leaving normal skin. Fifty per cent have angio-oedema (swelling of subcutaneous
tissues). Histamine is the principal mediator released from mast cells.
Causes of urticaria
Infection
Viral
Streptococcus sp.
Toxocara canis
Drugs
Penicillin/cephalosporins
Non-steroidal anti-inflammatory drugs (NSAIDs)
Food
Cows milk
Eggs
Nuts
Fish
Exotic fruits
Physical agents
Cholinergic urticaria
Cold urticaria
Dermatographis
Idiopathic (50% cases)
Associated with systemic disease
4.3 Infections and infestations

Scabies
As a result of the mite Sarcoptes scabiei humanis. The mite can survive for 2436 hours off the
human host.
Variable intensely itchy skin eruption, about 1 month after infestation, is an immune response to the
mite and includes:
Burrows
Excoriations
Eczematization
Papules
Vesiculopustular lesions
Bullae
Secondary bacterial infection
Nodules
Burrows common on palms, soles and sides of digits. Examine all family members if scabies is
suspected. Treat all family at same time.
Management of scabies
Use aqueous-based preparation (alcohol-based preparation will sting), e.g. malathion (Derbac M)
and permethrin 5%
Treat all family members at the same time
Two applications from the neck downwards at 7-day interval. Get under nails and in skin creases.
Reapply after hand washing. Caution if <1 year old, applying for less time depending on age of
child
Apply to lesions on face if present (more common if <1 year)
Treat any secondary infection with systemic antibiotics
Treat residual dry skin with emollients
Wash all clothing, bedlinen and towels at the end of treatment
Pediculosis
Usually Pediculus humanus capitis (head louse). May get lice on eyelashes and pubic hair
Occurs in from <10% to 40% of children
Spread by head-to-head contact
Pruritus, scratching and excoriation may lead to secondary bacterial infection and cervical lymph
nodes
Look for nits on hairs. Lice visible if recently had a blood meal
Treat with two applications 7 days apart of malathion-based aqueous lotion or permethrin 5%
cream (off-licence use)
Bug busting with wet combing evidence varies of effectiveness
Viral infections
Tend to be maculopapular erythematous rashes which may be pruritic. Last from <24 hours to a few
weeks. Associated features include cough, runny nose, diarrhoea, vomiting and pyrexia.
Tinea
Erythematous, circular, scaly lesions with clearly defined margin. Microsporum canis fluoresces
with UV light, Trichophyton tonsurans (of human origin, common in inner cities) does not. Take skin
scrapings.
Impetigo
Superficially spreading skin infection characterized by yellowish-brown crust. May be bullous. Peaks
in late summer and is most common in children <5 years. Causative agent S. aureus or group A haemolytic streptococci. Treat with oral antibiotics.
Staphylococcal scalded skin syndrome

Caused by exotoxin-producing staphylococci. Localized infection becomes widespread after 2448
hours. Characteristic signs are fever, skin tenderness, marked erythema, bullae and peeling of the
skin. Treat with systemic antibiotics (flucloxacillin) and watch fluid balance.
Warts
Caused by human papillomavirus. Most common on hands and feet (plantar warts/verrucas) but occur
at any site. Most resolve spontaneously but can last for several years.
Treat with salicylic acid-based wart paint, e.g. Salactol, applying each night and rubbing wart down
with an emery board until wart is flat. May need to treat for 3 months or longer. Freezing with liquid
nitrogen is effective but often requires multiple treatments at monthly intervals. Poorly tolerated in
children <5 years.
Perianal warts
Usually innocently acquired but consider sexual abuse. Only treat if multiple and spreading. Use
imiquimod 5% cream three times a week or supervised use of podophyllin 15%. May need surgery.
Molluscum contagiosum
Water warts. Caused by poxvirus. Dome-shaped papules with an umbilicated centre. Spread by
autoinoculation. Resolve spontaneously but can last for several years. Treatments tend to be
associated with scarring.
Note that both warts and molluscum contagiosum are more common in children who are
immunosuppressed and in those with underlying skin disorders such as atopic eczema.
4.4 Psoriasis
Onset: <2 years in 2% and at <10 years in 10% of cases of psoriasis. In childhood onset tends to
be between 5 and 9 years in girls and 15 and 19 years in boys
Increased epidermal turnover time
Relapsing and remitting: scaly rash, typically affects extensor surfaces and scalp (Pityriasis
amiantacea)
Genetic predisposition: risk of psoriasis is 10% if a first-degree relative is affected, risk is 50%
if both parents are psoriatic; 73% monozygotic and 20% dizygotic twins have concordant disease;
HLA-Cw6 (-B13 and -B17) linked to 915 times the risk; HLA-B27 associated with psoriatic
arthropathy
Nail involvement: pits, onycholysis, subungual hyperkeratosis; may precede onset of skin lesions
Arthropathy: may be severe; higher incidence in patients with nail changes
Recognized types of psoriasis
Common plaque: chronic psoriasis, psoriasis vulgaris

Guttate psoriasis: (raindrop psoriasis) multiple small lesions on trunk
Flexural sites: intertriginous areas
Erythrodermic psoriasis
Pustular psoriasis: acute generalized form or chronic localized to hands and feet
Provoking factors
Trauma (Koebner phenomenon)
Infection: streptococcal disease especially in throat in guttate psoriasis; may also play a role in
chronic plaque psoriasis
Endocrine: peaks at puberty (and menopause); gets worse in postpartum period
Sunlight: usually beneficial but makes a small number worse
Metabolic: hypocalcaemia, dialysis
Drugs: withdrawal of systemic steroids, blockers, antimalarials and lithium
Psychogenic factors: stress
Human immunodeficiency virus: psoriasis may appear for the first time or get dramatically worse
Hyperkeratotic eczema
Lichen planus: flat-topped, purple polygonal papules with white reticulate surface (Wickham
striae); oral and nail changes may be present; rare in children; 90% resolve in 12 months
Pityriasis rosea: larger herald patch, smaller lesions in Christmas tree distribution; clears in 6
weeks; linked to human herpesvirus 7
Pityriasis lichenoides chronica: excoriated papules on trunk and limbs in crops; lasts up to a few
years
Management of psoriasis
Avoid triggering factors
Treat streptococcal infection
Topical treatment
Emollients
Tar-based bath emollients, e.g. Polytar
Tar and salicylic acid ointments
Vitamin D-derivative creams calcipotriol (Dovonex) for mild-to-moderate psoriasis (up to 40%
of skin area affected)
Mild-potency topical steroid creams with tar, e.g. Alphosyl HC for delicate areas, such as the
face, flexures, ears, genitals
Carefully supervised dithranol preparations, e.g. dithrocream
Topical retinoids used but unlicensed
Phototherapy: UVB phototherapy if child is old enough to comply. PUVA is contraindicated in
young children
Systemic therapy: severe psoriasis, acute pustular psoriasis, e.g. methotrexate, ciclosporin,
acitretin
5. BLISTERING DISORDERS
Causes of blistering disorders
Inherited
Incontinentia pigmenti
Bullous ichthyosiform erythroderma
Drugs
Fixed drug eruptions
Photosensitivity reactions
Sulfonamides
Barbiturates
Autoimmune
Chronic bullous disease of childhood

Pemphigoid
Epidermolysis bullosa acquisita
Dermatitis herpetiformis
Pemphigus
Mechanobullous
Trauma/friction
Burns
Insect bites/papular urticaria
Contact dermatitis
Infection
Bullous impetigo
Herpes simplex virus
Varicella-zoster
Hand, foot and mouth disease
Scabies
Neonatal disorders
Infantile acropustulosis
Miliaria
Others
Erythema multiforme
StevensJohnson syndrome
HenochSchnlein purpura
Porphyria
Toxic epidermal necrolysis
Hartnup disease
Pachyonychia congenita
Dermatoses
Eczema
Lichen planus
5.1 Epidermolysis bullosa (EB)

Heterogeneous condition. Need skin biopsy for definitive diagnosis. First-trimester prenatal
diagnosis is possible. Severe types at risk of nutritional deficiencies and anaemia.
There are three broad categories:
EB simplex: mainly autosomal dominant (AD) defect in basal layer of epidermis affecting
keratins 5 and 14. Usually appears when child begins to crawl or walk, with blisters at friction
sites, e.g. knees, hands and feet. Hair, teeth and nails not affected
Junctional EB: autosomal recessive (AR) lethal and non-lethal variants. Mucous membranes can
be severely affected and teeth are often abnormal. Laminin-5 defect. Raw denuded areas show
little tendency to heal. Hoarseness as a result of laryngeal involvement

Dystrophic EB: AD and AR subepidermal blister. Defect in collagen VII production. Lesions
heal with scarring. Hair and teeth are normal in dominant form, whereas involvement of mucous
membranes, nails, hair and teeth may all be abnormal in recessive form. Web formation between
digits leads to a useless fist. May develop squamous carcinoma
5.2 Drug eruptions

Fixed drug eruptions: localized brownpurple plaques, may be bullous. Recur at fixed sites when
drug is ingested. Hyperpigmentation may persist
Hypersensitivity syndrome reactions: usually 728 days after first exposure to drug. Fever,
maculopapular/pustular skin lesions, erythema, swelling. Can get nephritis, hepatitis and
pneumonitis
Severe cutaneous adverse reaction: erythema multiforme, StevensJohnson syndrome and toxic
epidermal necrolysis
Toxic epidermal necrolysis: bullae, extensive areas of skin necrosis, denuded areas, systemically
toxic. May be 1- to 3-day prodome of high fever, sore throat, conjunctivitis and tender skin.
Causative drugs similar to those for StevensJohnson syndrome. In toxic epidermal necrolysis
there is full-thickness necrosis of epidermis whereas in staphylococcal scalded skin syndrome
there is no necrosis and epidermal separation is just beneath the stratum corneum
5.3 Autoimmune blistering disorders

All rare. Listed in order of decreasing frequency.
Chronic bullous dermatosis of childhood

Usually >3 years, mean age 5 years. Tense blisters like a string of pearls usually on abdomen and
buttocks. May present as genital blisters/erosions. 40% have mucous membrane involvement. Clears
after 3 years. Linear basement membrane IgA.
Bullous pemphigoid
Can be <12 months. Palm and sole involvement common. Seventy-five per cent have mucous
membrane changes. Lasts 24 years. Linear basement membrane IgG.
Mean age 7 years. Affects buttocks, elbows, back of neck and scalp. Itchy. Fifteen per cent resolve
spontaneously. Skin changes can persist up to 18 months after gluten-free diet. IgA in papillary
dermis.
Epidermolysis bullosa acquisita

Mechanobullous picture with blisters localized to areas of trauma. Remits in 24 years. Linear
basement membrane IgG.
Pemphigus
Very rare. Flaccid blisters. Nikolsky sign positive (i.e. a blister is induced by rubbing normalappearing skin). Mucous membrane involvement in vulgaris type, with stomatitis the presenting sign
in 50% of cases. Intercellular IgG.
6. ERYTHEMAS
Acute self-limiting onset of symmetrical fixed red papules, some of which form target lesions. May
blister. Can show Koebner phenomenon. May involve lips, buccal mucosa and tongue.
Cause of erythema multiforme

Infections
Mycoplasma spp.
EpsteinBarr virus
Chlamydiae
Orf
Deep fungal infections (histoplasmosis)
Drugs
Sulfonamides
Penicillin
Collagen diseases
Systemic lupus erythematosus
Polyarteritis nodosa
Underlying malignancy
StevensJohnson syndrome
Causes as for erythema multiforme but child much more unwell with malaise and a prodromal
respiratory illness:
Severe erosions of at least two mucosal surfaces including eyes, genitalia and internal mucosa (GI
and respiratory), with associated swallowing difficulties. Oral mucosa is always involved with
haemorrhagic crusting
Extensive necrosis of lips often with blistering around mouth

Purulent conjunctivitis
Variable skin involvement red macules, bullae, skin necrosis and denudation; Nikolsky sign
positive

Nodular, erythematous eruption on extensor aspects of legs, less commonly on thighs and forearms.
Regresses to bruises. Lasts 36 weeks.
Causes of erythema nodosum
Infections
Streptococcus spp.
Salmonella spp.
Yersinia spp.
Campylobacter spp.
Tuberculosis
Acnes
Chlamydia spp.
Cat-scratch fever
Hepatitis B
EpsteinBarr virus
Mycoses
Gut disorders
Ulcerative colitis
Crohn disease
Malignancy
Leukaemia
Lymphoma
Drugs
Sulfonamides
Oral contraceptive pill
6.3 Erythema marginatum

Annular migratory erythema found in 10% of cases of rheumatic fever. Recurrent crops of lesions
weekly. Active cardiac disease. Frequently precedes onset of migratory arthritis.
6.4 Erythema migrans
Lyme disease due to Borrelia burgdorferi. Red papule which develops with annular red ring around
it.
7. PHOTOSENSITIVE DISORDERS
Causes of photosensitive disorders
Idiopathic
Polymorphic light eruption
Actinic prurigo
Contact dermatitis due to plants
Photosensitivity rash in 1530%
Drugs
Sulfonamides
Thiazides
Tetracycline
Genetic
7.1 Genetic causes of photosensitivity

Phenylketonuria
AD. In addition to photosensitivity, skin changes include:
Decreased pigmentation
Eczema
Fair hair
Lightly pigmented eyes
Xeroderma pigmentosum
AR group of disorders caused by a DNA-repair defect:
Extreme photosensitivity
Severe ophthalmological abnormalities
Skin malignancies in childhood
Neurological complications in 20%
Freckling
Cockayne syndrome
AR. Cells have increased sensitivity to UV light. Onset of symptoms is in the second year of life:
Progressive neurological degeneration and growth failure

Sensorineural hearing loss
Skeletal abnormalities
Dental caries
Pigmentary retinopathy
Cataracts
Trichothiodystrophy
AR. Hair has low sulphur content. Includes following defects PIBIDS:
Photosensitivity
Ichthyosis
Brittle hair
Intellectual impairment
Decreased fertility
Short stature
RothmundThomson syndrome
AR. Characterized by poikiloderma (atrophic pigmented telangiectasia) by end of first year.
Sparse hair
Skeletal dysplasia
Short stature
Cataracts
Hypogonadism
Hypotrophic nails
Increased risk of osteosarcoma and skin malignancy
Bloom syndrome
AR.
Growth retardation
Immunodeficiency (IgA and IgM)
Telangiectasia
Pigmentary abnormalities
Malignancies in third decade leukaemia, lymphomas
Hartnup disease
AR. Impaired amino acid transport in kidneys and small intestine. Most children asymptomatic:
Photosensitivity with pellagra-like appearance is first sign

Can form blisters
Intermittent cerebellar ataxia
Psychotic behaviour
Mild learning disability
Porphyrias
Group of diseases leading to accumulation of haem precursors. 5-Aminolaevulinic acid (ALA) and
porphobilinogen (PBG) have no cutaneous manifestations. Elevated porphyrins are associated with
either acute photosensitivity or skin fragility with vesiculobullous and erosive lesions.
Erythropoietic protoporphyria (EPP)

Usually AD. Most common porphyria in children:
Small pitted scars on nose and cheeks

Burning/stinging sensation on exposed skin
Photosensitivity less severe in adult life
Gallstones in childhood
Excess protoporphyrins in red cells and faeces (urine normal)
Congenital erythropoietic porphyria

AR. Presents at or shortly after birth. Acute episodes become less severe with time, leaving residual
scarring, ulceration and marked deformity with sclerodactyly and loss of terminal phalanges.
Severe photosensitivity
Red staining of nappy
Haemolytic anaemia
Splenomegaly
Hypertrichosis
Teeth and bones may be red (fluoresce with UV light)
Porphyria cutanea tarda (PCT)

Familial or provoked by drugs, alcohol or infection.
Skin fragility leading to vesicles/blisters and erosions

Hypertrichosis
Yellow/blue nails and onycholysis
Systemic manifestations anorexia, constipation, diarrhoea
Urine dark brown
8. ICHTHYOSES
Disorders of keratinization, characterized by excessively dry and visibly scaly skin. Hereditary or
associated with systemic disease.
8.1 Inherited ichthyoses

Ichthyosis vulgaris
AD. Variable range of expression; may affect in winter months only, affects 1:250. Fine, light scaling.
Associated with keratosis pilaris and atopic eczema.
X-linked recessive ichthyosis (XRI, steroid sulphatase deficiency)

Occurs in 1:2000 boys. Dark-brown scaling affecting limbs and trunk. Gene in Xp22.3 region.
Cryptorchidism
Corneal opacities
Prolonged labour (placental sulphatase deficiency)
Lamellar ichthyoses
AD and AR. Large, dark, plate-like scales, reptilian appearance.
Bullous ichthyosiform erythroderma

AD. Erythroderma and severe blistering at birth. Mutations in keratin 1 or 10.
Non-bullous ichthyosiform erythroderma

AR. Generalized fine scaling and erythroderma.
Associated congenital ichthyoses

SjgrenLarsson syndrome
AR. Fatty alcohol oxidation defect in fibroblasts. Spastic diplegia or tetraplegia, learning disability.
Onset of neurological signs at 413 months of age.
Refsum disease
AR. Phytanic acid oxidase defect.
Retinitis pigmentosa
Peripheral neuropathy
Anosmia
Sensory deafness
Variable ichthyosis ichthyosis vulgaris-type appearance
Associated steroid sulphatase deficiency

X-linked recessive ichthyosis can be associated with:
Kallmann syndrome
Pyloric stenosis
Chondroplasia punctata
Hypogonadism
Learning disability
Multiple sulphatase deficiency

AR. Lack of arylsulphatase A, B and steroid sulphatase.
Neurodegenerative disease
Coarse facies
Hepatosplenomegaly
Lumbar kyphosis
Trichothiodystrophy syndromes Tay syndrome and PIBIDS

AR. Those with Tay syndrome do not have photosensitivity. Hair has decreased sulphur content.
Netherton syndrome
AR.
Neonatal erythroderma
Ichthyosis linearis circumflexa
Atopy
Faltering growth
Recurrent infections
Trichorrhosis invaginata hair shaft abnormality
Happle syndrome
X-linked dominant. ConradiHunermann syndrome is AD and is now thought not to have cutaneous
manifestations.
Cicatricial alopecia
Cataracts
Short stature
Follicular atrophoderma
KID syndrome
Mode of inheritance uncertain ? AD or AR.
Keratitis
Ichthyosis
Deafness
Neutral-lipid storage disease (ChanarinDorfman syndrome)
AR. Fatty changes of the liver, variable neurological and ocular involvement. Multiple lipid vacuoles
in monocytes and granulocytes.
CHILD syndrome
Congenital hemidysplasia, ichthyosiform erythroderma and limb defects.
8.2 Collodion baby

Yellow, shiny, tight film covering skin at birth. Ten per cent have normal skin. Film shed at 14 weeks
of life. Can persist for 3 months. Biopsy after day 14 is helpful.
Disorders presenting as collodion baby include:
Gaucher disease
Lamellar ichthyosis
Trichothiodystrophy
SjgrenLarsson syndrome
Non-bullous ichthyosiform erythroderma
Neutral-lipid storage disease
Ichthyosis vulgaris
Netherton syndrome
Neonatal problems of collodion baby and harlequin ichthyosis (see below)
Hypothermia
Dehydration
Hypernatraemia
Cutaneous infection
Poor sucking
May need up to 250 ml/kg per day fluids. Nurse in high-humidity incubator with up to 1-hourly
application of white soft paraffin and liquid paraffin 50:50.
8.3 Harlequin ichthyosis

AR. Problems are the same as for collodion babies. Most of the survivors have non-bullous
ichthyosiform erythroderma. Need continued high-intensity skin care and high-calorie feeds,
otherwise fail to thrive. Use of retinoids (acitretin) is thought to account for increasing survival of
these children. Genetic mutation (ABCA12) recently identified. ABCA12 is thought to play a critical
role in formation of lamellar granules in the epidermis and the discharge of lipids into the
intercellular spaces. This is defective in harlequin ichthyosis and leads to the epidermal barrier
defect.
Features of harlequin ichthyosis at birth:
Usually preterm
Erythroderma
Thick plate-like scales at birth coat of armour
Deep-red fissures
Ectropion and eclabium (mouth pulled open with eversion of lips)
Hands and feet have tightly bound digits; tips may be necrotic
Nose and ears bound down
Respiratory distress depending upon prematurity and the degree of restriction of chest movement
9. HAIR, NAILS AND TEETH

9.1 Hair
The hair has cyclical periods of growth throughout life. The three phases are:
Anagen: growth phase
Catagen: intermediate phase
Telogen: resting, usually 3 months before hair being shed
These phases occur randomly so that no one area is depleted of hair. Anagen lasts for variable lengths
of time depending on site. Usually >3 years on the scalp.
Genetic causes of hair loss (diffuse)

Ectodermal dysplasias AD/AR. Group of disorders with two or more abnormalities including
teeth, nails, sweat glands and other ectodermal structures
Acrodermatitis enteropathica
Netherton syndrome
Cockayne syndrome
Hair-shaft abnormalities monilethrix, pili torti, Menkes kinky hair syndrome (X-linked
recessive copper transport defect)

Hartnup disease
Homocystinuria
Causes of non-scarring alopecia (hair loss)
Telogen effluvium
Trichotillomania
Trauma from rubbing or traction from pony tails
Endocrine causes: hypothyroidism, hypopituitarism
Drugs: oral contraceptive pill
Loose anagen syndrome: young girls; hair increases in density and thickness as child gets older
Nutritional: malnutrition, iron deficiency, zinc deficiency
Alopecia areata
2% prevalence; usually > 5 years.
Family history in 525%
Associated with autoimmune disorders (thyroiditis, vitiligo) and Down syndrome
Scalp is normal in appearance; exclamation-mark hairs are characteristic
Outcome unpredictable; most children have small patchy hair loss and outlook is good; the more
extensive the disease the worse the prognosis
Causes of scarring alopecia
Aplasia cutis congenita

Fungal infection tinea capitis, kerion
Incontinenti pigmenti
Pachyonychia congenita
Ichthyoses CHILD syndrome, KID syndrome, syndromes with chondroplasia punctata
Causes of scalp scaling
Atopic eczema
Fungal infection
Psoriasis
Pityriasis amiantacea
Histiocytosis
Excessive hair growth

This is either androgen-independent hypertrichosis or androgen-dependent hirsutism.
Causes of hypertrichosis
Congenital
Hypertrichosis lanuginosa
Cornelia de Lange syndrome
RubinsteinTaybi syndrome
Hurler syndrome
Porphyria EPP, PCT
Endocrine
Hyper-/hypothyroidism
Acrodynia (mercury poisoning)
Drugs
Ciclosporin
Minoxidil
Phenytoin
Diazoxide
Streptomycin
Acetazolamide
Head trauma
Dermatomyositis
Focal lesions Becker naevus
Causes of hirsutism
Adrenal
Congenital adrenal hyperplasia
Cushing syndrome
Virilizing adrenal tumours
Turner syndrome
Ovarian
Polycystic ovary syndrome
Ovarian tumours
Gonadal dysgenesis
9.2 Nails
Development begins at week 9 of gestation and is complete after week 22. Toenail development lags
behind that of fingernails.
Nail changes normal variants
Koilonychia: normal variant in early childhood due to thin nail-plate; commonly toenails; also
associated with iron deficiency anaemia
Superficial longitudinal ridges: normal variant
Beau lines: transverse depressions; can appear at 12 months of age and with any severe illness
that affects nail growth
Longitudinal pigmented bands: pigmented bands in dark-skinned children
Conditions affecting the nails
Acute paronychia
Congenital malalignment of the big toe (triangular shape to nail)
Atopic eczema: pitting, Beau lines, onycholysis
Parakeratosis pustulosa: hyperkeratosis, onycholysis, pitting
Psoriasis: nail pitting, onycholysis, salmon patches of nail-bed
Leukonychia: liver disease, hypoalbuminaemia, hereditary and if punctate found following
repetitive minor trauma
Twenty nail dystrophy: many nails affected; spectrum of nail-plate surface abnormalities; may be
associated with alopecia areata; regresses spontaneously
Lichen planus: longitudinal ridging, pterygium
Nailpatella syndrome: AD; nail hypoplasia, patella hypoplastic or absent, radial head
abnormalities, iliac crest exostosis and nephropathy
Epidermolysis bullosa: may be permanent nail loss
Pachyonychia congenita: AD; severe nail-bed thickening as a result of hyperkeratosis; other
features depend on type; include palmar plantar hyperkeratosis, cataracts, alopecia and bullae of
palms and soles
Ectodermal dysplasias: variable dystrophic nails depending on type
Alopecia areata: nail pitting
Chronic mucocutaneous candidiasis: nails are yellowbrown and are thickened; recurrence is
common because of underlying immune defects
Fungal infection
Dystrophy: CHILD syndrome, congenital erythropoietic porphyria
Hypothyroidism: decreased nail growth, ridging and brittleness
RothmundThomson syndrome: hypotrophic nails
Pityriasis rubra pilaris: half-and-half nail; thickened curved and terminal hyperaemia
Incontinentia pigmenti: nail dystrophy in 40%
9.3 Teeth
Always look at the teeth as part of a dermatological examination.
Conditions affecting the teeth
Ectodermal dysplasia: hypodontia; small, conical, discoloured teeth and caries
Epidermolysis bullosa: dental caries
Cockayne syndrome: dental caries, malocclusion, small mandible so teeth appear large
Dyskeratosis congenita: poorly formed teeth, thin enamel. Degenerative disorder with reticulate
skin pigmentation, atrophic nails, leukoplakia and bone marrow failure
Congenital syphilis: Hutchinson teeth (developmental abnormality of upper lower incisors where
teeth are notched/small); mulberry molars (first molars have maldevelopment of cusps and look
like mulberries)
Congenital erythropoietic porphyria: teeth may be pink/red and fluoresce with UV light
Incontinentia pigmenti: 80% have dental abnormalities hypodontia, delayed eruption,
malformed crowns
Langerhans cell histiocytosis: premature eruption of teeth
Trichothiodystrophy: enamel hypoplasia, caries
10. DISORDERS OF PIGMENTATION

Colour of the skin is the result of melanin produced by melanocytes in the basal layer of the
epidermis.
10.1 Causes of hypopigmentation

Causes of hypopigmentation
Nutritional deficiency
Copper
Selenium
Kwashiorkor
Genetic
Oculocutaneous albinism
Phenylketonuria
Homocystinuria
Apert syndrome
Piebaldism
Waardenburg syndrome
Tuberous sclerosis
Menkes kinky hair syndrome
Epidermolysis bullosa (at sites of bullae)
Hypomelanosis of Ito (incontinentia pigmenti achromians of Ito)
Autoimmune
Vitiligo
Infection
Pityriasis versicolor
Vaccination sites
Trauma sites
Post-inflammatory
Eczema
Psoriasis
ChdiakHigashi syndrome
AR. Incomplete oculocutaneous albinism, photophobia and severe recurrent infections.
Vitiligo
Total loss of pigment. Often symmetrical. Spontaneous repigmentation uncommon. Associated with
autoimmune disorders.
10.2 Causes of hyperpigmentation

Causes of hyperpigmentation
Genetic
Goltz syndrome (focal dermal hyperplasia)
PeutzJeghers syndrome
Albright syndrome
Metabolic
Liver disease
Haemochromatosis
Wilson disease
Porphyria
Congenital erythropoietic porphyria
Hepatic cutaneous porphyria
Infection
Pityriasis versicolor
Drugs
Minocycline
Tetracycline
AZT (zidovudine)
Rifabutin
Clofazimine
Endocrine
Addison disease
Hyperthyroidism
Nelson syndrome
Cushing syndrome (ectopic ACTH production)
Nutritional
Malabsorption
Pellagra (sun-exposed sites)
Kwashiorkor
Post-inflammatory
nsect bites
Acne
Atopic eczema
Lichen simplex chronicus
Other pigmentary changes

NiemannPick type A
Greybrown/yellowbrown discoloration of sun-exposed areas
Metals
Silver, bismuth and arsenic
Slate-grey pigmentation
Mongolian blue spot
Blue skin
Typical site is lower back
Common in AfricanCaribbean and Asian babies
Increased numbers of melanocytes deep in dermis
Tends to disappear by 4 years of age
10.3 Disorders associated with multiple caf-au-lait macules
Neurofibromatosis type I (NFI)

NFII (minority of patients)
Piebaldism
Ataxia telangiectasia
Multiple endocrine neoplasia
RussellSilver syndrome
McCuneAlbright syndrome
Tuberous sclerosis
Noonan syndrome
Bloom syndrome
Tay syndrome
10.4 Skin changes associated with tuberous sclerosis

Earliest changes are forehead plaques, shagreen patch and hypomelanotic macules. Shagreen patch
occurs typically in lumbar region but can be at top of leg
Facial angiofibromas (adenoma sebaceum): rare <2 years. Present in 85% >5 years
Periungual fibromas: uncommon in first decade of life
11. MISCELLANEOUS DISORDERS

11.1 Granuloma annulare
Ring of firm skin-coloured papules. Usually asymptomatic. May follow non-specific trauma in 25%;
50% clear in 2 years; 40% have recurrent eruptions. Link to diabetes mellitus controversial. Always
test urine for glucose.
11.2 Dermatitis artefacta

Self-inflicted lesions on sites readily accessible to patients hands. Take a variety of forms including
blisters.
11.3 Nappy rash

Irritant contact dermatitis
Common
Due to urine and faeces
Intertriginous areas characteristically spared
May be infected with Candida albicans (satellite lesions and skinfold involvement)
Other causes
Atopic eczema
Psoriasis
Scabies
Langerhans cell histiocytosis
Kawasaki disease
Child abuse
Blistering disorders
11.4 Acne
Affects face and upper trunk. Lesions include comedones, papules, pustules, nodules and cysts.
Usually 1016 years. May get neonatal acne and infantile acne. Investigate for underlying cause if
acne appears for the first time between 1 and 7 years.
Treatment
Topical benzoyl peroxide 2.510%, topical retinoids, topical antibiotics

Oral antibiotics erythromycin, oxytetracycline (not if <12 years) taken twice daily
Dianette (cyproterone acetate with ethinylestradiol) for females
Isotretinoin (Roaccutane): vitamin A derivative for severe acne. Causes dry mucous membranes
and may cause depression. Council and assess for depression before therapy, which is started by a
dermatologist only. Teratogenic if taken in pregnancy. Lipid levels and liver function tests should
be monitored before treatment and at 1 month
11.5 Spitz naevus

Pink/red, sometimes brown in colour. Benign lesion that can be difficult to distinguish from malignant
melanoma. Excise if suspicious features, e.g. unusual pigmentation, rapid growth and size >1 cm.
11.6 Keloids
Hypertrophic scar extending beyond boundary of original wound. More common in pigmented skin.
Intralesional injections of steroid (triamcinolone) may help. Tend to recur if surgically excised.
11.7 Acanthosis nigricans

Hyperpigmentation is the earliest feature (dirty skin), preferentially in the flexures. May become
hyperkeratotic and warty lesions occur elsewhere on the body. Occurs in families and is associated
with obesity, syndromes of insulin resistance, hyper-androgenaemia and hypothyroidism.
11.8 Stings and snake bites

Bee/wasp stings
Local effects: burning, pain, erythema, oedema. Subsides in a few hours
Systemic: usually due to multiple stings. Hypertension, generalized vasodilatation, severe
headache, diarrhoea, vomiting, shock

Late-onset reaction: urticaria, serum sickness-like reaction
Snake bites
Depends on type of snake

Local swelling/necrosis
Haematological abnormalities including coagulation disturbance and complement depletion
Treat with compression bandage and immobilization by splinting
Important to identify venom (in urine, swab and kill snake) so that antivenom can be administered
12. FURTHER READING

Ashcroft DM et al. (2005). Efficacy and tolerability of topical pimecrolimus and tacrolimus in the
treatment of atopic dermatitis: meta-analysis of randomized controlled trials. BMJ 330: 51622.
Burden AD (1999). Management of psoriasis in childhood. Clin Exp Dermatol 24: 3415.
Flohr C, Williams HC (2004). Evidence based management of atopic eczema. Arch Dis Child Educ
Pract Ed 89: ep359.
Higgins E, Du Vivier A (1996). Skin Disease in Childhood and Adolescence. Oxford: Blackwell
Science.
Irvine AD, Hoeger OH, Yan AC, eds (2011). Harpers Textbook of Pediatric Dermatology, 3rd edn.
Oxford: Wiley-Blackwell.
Lewis-Jones S, ed (2010). Paediatric Dermatology. Oxford: Oxford University Press.
National Institute for Health and Clinical Excellence Atopic eczema in children: Management of
atopic eczema in children from birth up to the age of 12 years. Available at:
http://guidance.nice.org.uk/CG57
Pediatric Clinics of North America (2000). Pediatr Dermatol 47(4).
Chapter 7
Emergency Paediatrics
Serena Cottrell
CONTENTS
1. Introduction
2. Out-of-hospital cardiac arrest
2.1 Airway opening procedures
2.2 Look, listen and feel
2.3 Rescue breaths
2.4 Checking the circulation
2.5 Chest compressions
3. In-hospital cardiac arrest

3.1 Airway adjuncts
3.2 Oxygen
3.3 Assessment of rhythm
3.4 Treatment of non-shockable rhythms
3.5 Treatment of shockable rhythms
3.6 Post-resuscitation management
3.7 When to stop resuscitation
3.8 Resuscitation care plans
4. Electrocution injury
4.1 Lightning injury
4.2 Treatment of electrocution
4.3 Myoglobinuria
5. Airway
5.1 Airway obstruction
5.2 Choking
5.3 Inadequate airway protection
6. Respiratory failure
6.1 Apnoea
6.2 Trauma and breathing difficulties
6.3 Management of acute severe asthma
6.4 Ventilating children with bronchiolitis
6.5 Children with pertussis needing admission to the PICU
6.6 Cardiac causes of respiratory failure
6.7 Treatment of respiratory failure
7. Cardiovascular system
7.1 The child with tachycardia
7.2 Supraventricular tachycardia
7.3 Causes of tachyarrhythmia
7.4 Ventricular tachycardia
7.5 Causes of bradyarrhythmia
7.6 Emergency management of severe heart failure
7.7 Recognizing low cardiac output state
7.8 Inotropes
7.9 The child in shock
8. Anaphylaxis
9. Managing the child with severe burns
9.1 Epidemiology
9.2 Pathophysiology
9.3 Assessment
9.4 Indications of an inhalational injury
9.5 Assessment of the burn
9.6 Treatment
9.7 When to transfer to a burns centre
9.8 Chemical burns
10. Injuries due to severe cold

10.1 Frostbite
10.2 Systemic hypothermia
11. Severe head injury

11.1 Maintaining an adequate cerebral perfusion pressure
11.2 Reducing raised ICP
11.3 Complications in intensive care
11.4 Imaging
12. The convulsing child and the PICU

12.1 Pathophysiology
12.2 Treatment
13. Non-traumatic coma

14. Trauma
14.1 Life-threatening extremity injuries
14.2 Gunshot wounds and stabbing
15. Drowning
15.2 Treatment
15.3 Re-warming
15.4 Prognostic signs
16. Further reading
1. INTRODUCTION
It is vital to have a structured approach when managing a critically ill child. A structured approach
enables you to prioritize and stabilize most sick children even when the diagnosis is unknown.
Preparation is useful, although not always possible, and good communication is essential both
between members of the multidisciplinary team and with families. The structured approach
concentrates on identifying and managing the immediate threats to life first: ABCDE, where A for
airway, B for breathing, C for circulation, D for disability and E for exposure/environment.
2. OUT-OF-HOSPITAL CARDIAC ARREST

Cardiac arrest should be suspected when a patient is found unconscious and not breathing normally
and when there are no signs of circulation or palpable pulses.
Traditionally the three Ss approach is taught:
S safety
S stimulate
S shout for assistance
Stimulation may be either verbal or physical, e.g. are you alright? to establish responsiveness.
If there is any risk of cervical spine injury the neck should not be moved while establishing
responsiveness
Then the ABCDE approach with basic life support is established.
2.1 Airway opening procedures

An obstructed airway results in hypoxia and then cardiac arrest. The airway can be opened by either
of two manoeuvres:
Head tilt with a chin lift (providing that there is no risk of a cervical spine injury)
Jaw thrust
2.2 Look, listen and feel

Look for chest movement
Listen for breath sounds
Feel for the warmth of the breath
2.3 Rescue breaths

Agonal/gasping breaths may be present in cardiac arrest so if the child is not breathing normally five
rescue breaths should be attempted. The chest should be seen to rise. This can be done with a bag and
mask if available.
2.4 Checking the circulation

Take no more than 10 seconds to look for signs of circulation. The pulse may also be checked but
should not be used as the sole determinant of the need for chest compressions.
Signs of circulation include:
Any movement
Coughing
Normal breathing
Response to stimulation
The brachial pulse is felt in an infant and the carotid pulse can be felt in a child.
If there are no signs of circulation, no pulse or a slow pulse; in an infant of less than 60 beats/min
with poor perfusion or, if you are unsure, start compressions.
2.5 Chest compressions

Compressions should be done at a rate of 100120/min in all ages and should be sufficient to depress
the sternum by at least one-third of the depth of the chest.
The ratio is 15 compressions to 2 breaths in both the infant and the child when performed by health
professionals. After puberty and in layperson-performed resuscitation, the ratio becomes 30
compressions to 2 breaths. For all children compress over the lower half of the sternum.
Infant <1 year

Two fingers for the single rescuer
Hands encircling the chest, two-thumb technique for two rescuers
Algorithm for basic life support (healthcare professionals with a duty to respond). Reproduced with
kind permission of the Resuscitation Council (UK) (www.resus.org.uk/pages/pbls.pdf)
Child 1 year to puberty

The heel of one or two hands may be used, depending on the size of the rescuer and the child
3. IN-HOSPITAL CARDIAC ARREST

Safety, stimulate, shout for help
Initiate basic life support (BLS)
Call cardiac arrest team
3.1 Airway adjuncts

Oral and nasopharyngeal airways are often underused
They are particularly useful to aid bagging while awaiting the arrival of a doctor with advanced
airway skills or in the pre-arrest child
Oral airway: to find the right size hold the flange of the airway at centre of incisors and the tip
should reach to the angle of the mandible
Nasal airway: can be sized by measuring the distance from the tip of the nose to the tragus of the
ear
3.2 Oxygen
This should be:
Administered immediately in all arrest scenarios
Given by facemask or bag and mask with a flow of 15 l/min
With a reservoir or non-re-breathe bag attached
Make sure that the arrest team and appropriate senior help are called.
3.3 Assessment of rhythm

Once effective ventilation is achieved with a patent airway and movement of the chest, assess the
circulation, including use of monitoring and assessing the rhythm.
Asystole
This is the most common arrest rhythm in neonates and children and is usually secondary to hypoxia
and acidosis from respiratory failure. It is often preceded by a bradycardia.
Check the leads are attached correctly
Increase the gain on the monitor (on some makes of defibrillator this is done automatically)
Check for signs of life and a pulse (no longer than 10 seconds)
Pulseless electrical activity (PEA)

There are recognizable complexes on the ECG but no pulse.
Algorithm for advanced management of cardiac arrest. Reproduced with the kind permission of the
Resuscitation Council (UK) (www.resus.org.uk/pages/pals.pdf)
Ventricular fibrillation/pulseless ventricular tachycardia

This is an uncommon rhythm in children but can occur in:
Hypothermia
Electrocution injury
Cardiac disease
Poisoning with tricyclic antidepressants
Hyperkalaemia
3.4 Treatment of non-shockable rhythms

Interruptions in compressions should be minimized
Adrenaline 0.1 ml/kg of 1 in 10 000 is given as soon as intravenous access is obtained and then
every alternate cycle
3.5 Treatment of shockable rhythms
Interruptions in compressions should be minimized

Following defibrillation do 2 min of CPR before checking the rhythm
If the rhythm has altered, do a pulse check
The shock is asynchronous
Adrenaline is given after the third shock and then during every alternate cycle (i.e. every 35 min)
Amiodarone (5 mg/kg) is given intravenously after the third shock and then repeated after the fifth
shock
3.6. Post-resuscitation management
This usually involves transfer to a paediatric intensive care unit (PICU)

Regular reassessment should be performed
Capnography should be used to monitor the carbon dioxide levels
Pulse oximetry should be used to titrate delivered oxygen once spontaneous circulation has been
restored to avoid hyperoxia
ECG, blood pressure monitoring invasive or non-invasive, temperature, urine output and blood
gases should be measured regularly
Central venous pressure monitoring may also be needed
Induced hypothermia should be considered
3.7. When to stop resuscitation

The outcome for out-of-hospital cardiac arrest is poor, especially if the rhythm is asystole
If there is no return of spontaneous circulation after 30 minutes, resuscitation is unlikely to be
successful
In hypothermia, resuscitation should be continued until the child has been warmed
The decision to stop resuscitation is made by the most senior member of the team
3.8. Resuscitation care plans

Children or young people with life-limiting or life-threatening diseases are increasingly being
provided with personal resuscitation care plans. Care plans have a number of different titles: advance
care plans, emergency care plans, emergency health care plans. These are usually written by the
clinician who knows the child best, in partnership with the child, the family and the multidisciplinary
team. They usually include a care plan in event of cardiac arrest, a care plan for the event of acute
clinical deterioration and a wishes document. The traditional concept of do not attempt
cardiopulmonary resuscitation (DNACPR/DNAR) is less useful in children and young people, and
so a spectrum of options is considered ranging from full resuscitation through to full palliative care.
The emphasis is on what to do rather than what not to do, as is traditionally found in DNACPR
orders, and gives families options such as considering non-invasive ventilation but not intubation and
full intensive care.
4. ELECTROCUTION INJURY
Severe electrocution injury in children is uncommon
It can occur with faulty electrical appliances such as living room fires
If the injury has been obtained out of the domestic environment it is often associated with other
injuries such as falls or with the child being thrown into the air
Being struck by lightning is another cause
The risk of cardiac arrest is associated with the size of the current, duration of exposure and
whether the current is AC (alternating current) or DC (direct current)
Tetany can occur in the muscles which may make the child cling on to the electrical source, e.g. the
bar of an electric fire
If tetany occurs in the diaphragm and other respiratory muscles, it can lead to a respiratory arrest
which continues until the child is disconnected
May present as a ventricular fibrillation arrest
Dysrhythmias may occur late
The child should be examined for entry and exit burns and other injuries should be considered
The path of the current can be estimated from the site of the entry and exit burns and by assuming
that the current will take the path of least resistance from the point of contact to the earth
Fluid and blood have the least resistance whereas skin and bone have a high resistance
The damage is caused by heat. Nerves, blood vessels, skin and muscle are damaged the most
Swelling of tissues, especially muscles, can lead to compartment syndrome and myoglobinuria
Myoglobinuria occur as a result of massive internal thermal injuries with a relatively small external
burn and can lead to renal failure if unrecognized and untreated
4.1 Lightning injury

Large direct current of short duration
Can depolarize the myocardium and cause immediate asytole
4.2 Treatment of electrocution
Disconnect from source of electrocution

Immobilize cervical spine
ABCDE: airway, breathing, circulation, disability and exposure
A greater fluid requirement is needed because of internal heat injury despite a relatively small
external burn
4.3 Myoglobinuria
Occurs after muscle injury such as a crush injury or electrocution

Myoglobin can be detected in the urine
Treatment involves maintaining a urine output of more than 2 ml/kg per h by fluid loading and
diuretics, using mannitol if required
Alkalinize the urine by using intravenous sodium bicarbonate to improve the excretion of
myoglobin
Alkalinization of the urine is used to keep a toxin in its ionized form, to reduce the amount of
absorption in the renal tubule
This is called forced alkaline diuresis and is also used for aspirin and phenobarbitone overdose
5. AIRWAY
The main aspects of airway that need to be addressed are:
Obstruction
Choking
Failure to protect the airway from aspiration of gastric contents
5.1 Airway obstruction

Obstruction of the airway can occur at all anatomical levels of the respiratory tract from the nose to
the small airways. Obstruction of the upper airway is characterized by stridor, which is a highpitched sound, heard on inspiration, whereas a lower airway obstruction produces an expiratory
wheeze
The upper and lower airways in children are smaller than in adults. Airway resistance is inversely
proportional to the radius raised to the power of four. Therefore, halving the radius results in a 16fold increase in resistance. This means that airway resistance is higher in small children
Mucosal swelling and secretions are also more likely to obstruct the airway in infants, as the
airways are small
A bubbling or gurgling noise suggests pharyngeal secretions and is common in children with poor
pharyngeal tone, as in cerebral palsy
Poor pharyngeal tone also causes partial obstruction and snoring especially when the child is
asleep or post-ictal
Grunting is more likely to be heard in neonates and is the noise caused by expiration against a
partially closed glottis. The lung volume at the end of expiration is almost equal to the closing
volume in infants, making atelectasis and areas of collapse common
Causes of airway obstruction

Croup/laryngotracheobronchitis (stridor). There may be thick secretions, as in bronchitis, that may,
rarely, obstruct the airway
Epiglottitis (drooling, toxic, quiet stridor)

Bacterial tracheitis
Inhaled foreign body
Asthma (wheeze or silent chest) or bronchiolitis
Tracheobronchomalacia (prolonged expiratory phase)
Extrinsic compression: vascular ring, mediastinal tumour
Facial trauma and burns
Anaphylaxis
Angioneurotic oedema
Retropharyngeal abscess, large tonsils and adenoids
Diphtheria
Treatment of airway obstruction

If there is a concern about airway obstruction it is essential to get help from a senior doctor
experienced in the management of the airway. It may be necessary to move the child to theatre. Before
the arrival of senior help the child should be kept calm, and be left in the position that they find most
comfortable, often on the parents knee. They should be given high-flow oxygen and a saturation
monitor should be attached. The saturations in air and high-flow oxygen should be recorded at regular
intervals. It is important not to distress the child. Nebulized adrenaline (5 ml of 1:1000) with oxygen
through a facemask can be used while awaiting the arrival of experienced help. When experienced
help arrives they will intubate using a gas induction anaesthetic of sevoflurane or halothane via an
anaesthetic machine. This is usually done in theatre with the ENT surgeon present.
Once the childs airway is secured, oral prednisolone and antibiotics, if a bacterial infection is
suspected, can be commenced.
If the obstruction is the result of poor pharyngeal tone a soft nasal airway is useful for both opening
the airway and suctioning of secretions.
Airway obstruction can occur with an endotracheal tube in position and is the result of either
obstruction distal to the tube or secretions within the lumen of the tube. This presents as desaturation.
5.2 Choking
Paediatric choking treatment algorithm. Reproduced with the kind permission of the Resuscitation
Council (UK) (www.resus.org.uk/pages/pchkalgo.pdf)
A blind finger sweep should not be performed
The baby is placed along one of the rescuers arms in the head-down position with the rescuers
hand supporting the babys jaw, keeping it open in the neutral position
The rescuer then rests his or her arm along the thigh and delivers five back blows with the heel of
the hand
If the obstruction is not relieved, the baby is turned over and with head down given five chest
thrusts using the same landmarks as for cardiac compression
The back blows and chest thrusts are at a rate of 1/second
If the infant is too large, place across the rescuers lap and perform the same technique
Child choking protocol

For the choking child, use abdominal thrusts instead of chest thrusts. The rest of the protocol
remains the same including the back blows
The Heimlich manoeuvre can be performed in a child but never in an infant because of the risk of
trauma to internal structures. The patient can be standing, sitting, kneeling or lying for the Heimlich
manoeuvre
5.3 Inadequate airway protection

This is usually the result of decreased consciousness level and has several causes:
Head injury associated with P on the AVPU scale, only responding to pain or a Glasgow Coma
Scale score of 8 and below (A = alert, V = responds to voice, P = responds to pain, U =
unconscious)
Fits
Metabolic encephalopathy
Hepatic encephalopathy
Encephalitis
Meningitis
Poisoning and overdoses

Alcohol intoxication
Severe sepsis
Inadequate cardiac output
Blocked/infected ventriculoperitoneal (VP) shunt
Diabetic ketoacidosis resulting in cerebral oedema
Treatment of inadequately protected airway

The most immediate treatment is to provide a definitive patent airway. This involves an endotracheal
tube placed in the trachea, adequately fixed and attached to a source of ventilatory support.
Adequate preparation and training are essential. Unless the child has arrested it is important to both
anaesthetize and give paralysis before attempting intubation. Anaesthetic induction should be
performed by an experienced anaesthetist/intensivist or a person trained in airway skills.
If the child is not starved, a rapid sequence induction should be used with cricoid pressure to prevent
aspiration of gastric contents.
If there is airway obstruction, it is preferable to use a gas induction using sevoflurane or halothane.
It is important for the paediatrician to recognize airway compromise and to call for appropriate
senior help. While awaiting help it is useful to draw up emergency drugs adrenaline, atropine and
suxamethonium to get out appropriately sized endotracheal tubes, and to know when and how to use
basic airway adjuncts such as oral and nasopharyngeal airways.
An endotracheal tube in the right main bronchus, even for a short period of time, can cause right upper
lobe collapse. It is therefore important to confirm the position of the endotracheal tube on a chest Xray soon after placement. It is good practice to write in the notes the size of endotracheal tube used,
the length at which it is taped or fixed at the nose or mouth, as well as a comment on the view of the
vocal cords at intubation (a grade 1 intubation is where the whole of the cords are viewed) and the
degree of space round the tube at the vocal cords.
6. RESPIRATORY FAILURE
Respiratory failure is defined as an inability of physiological compensatory mechanisms to ensure
adequate oxygenation and carbon dioxide clearance resulting in either arterial hypoxia or
hypercapnia, or both.
The most common causes of respiratory failure are an upper or lower respiratory tract illness;
however, disorders of other systems can present with breathing difficulties and should be considered
in the differential diagnosis.
Other causes of respiratory failure

Neuromuscular disease
Muscle weakness
Respiratory failure
Gut disease, e.g. peritonitis Abdominal distension Pain Respiratory failure

Cardiac failure
Pulmonary oedema
Tachypnoea
Head injury and fits
Central causes
Reduced respiratory drive
Diabetic ketoacidosis
Metabolic acidosis
Deep sighing respirations
Poisoning
or respiratory drive
In children with respiratory infections the reduced lung compliance is reflected in recession, which is
an indrawing of the ribs and is a useful clinical sign. Recession, however, reduces the efficiency of
breathing and makes it harder to retain lung volume.
6.1 Apnoea
This is a common sign in neonates and small infants and has a wide differential diagnosis.
Prematurity
Bronchiolitis
Pertussis
Pneumonia
Sepsis
Severe gastro-oesophageal reflux
Fits
NAI (non-accidental injury)
Vascular ring
6.2 Trauma and breathing difficulties

Chest injury after trauma can be difficult to differentiate from other causes of respiratory distress.
Childrens rib cages are much more compliant than those of adults and so rib fractures are far less
common. If rib fractures are present it suggests severe chest injury and underlying lung contusion is
almost inevitable. If they occur in the absence of a good story of trauma, non-accidental injury should
always be considered, although it is important to exclude osteogenesis imperfecta or metabolic bone
disease.
If there is a history of trauma, then inhalational injuries and, rarely, a fractured larynx should be
considered as well as pneumothorax, tension pneumothorax, massive haemothorax and cardiac
tamponade.
Abdominal pain and distension can present with breathing difficulties.
6.3 Management of acute severe asthma

The initial treatment of asthma is described in Chapter 22 and is summarized as:
Oxygen aiming to keep saturations 9498%

Nebulized bronchodilators continuously (salbutamol)
Add in nebulized atrovent
Hydrocortisone i.v.
Salbutamol i.v. loading dose for 218 year olds 15 g/kg over 10 min; maximum dose 250 g
Salbutamol i.v. up to a maximum of 5 g/kg per min after an initial loading dose
Consider magnesium sulphate i.v.
In a child with asthma, ventilation should be avoided if possible but is necessary if the child is either
hypoxic or exhausted.
If child is intubated
Ketamine is the induction agent of choice as it is a bronchodilator

Ketamine infusion can be added in
Manual decompression of the chest on expiration gives an indicator of the severity
Permissive hypercapnia is a ventilation strategy where the carbon dioxide levels are allowed to
rise as long as the pH remains above 7.2
Finding the ideal level of positive end-expiratory pressure (PEEP) is difficult in a ventilated
patient with asthma and is often done by trial and error. Measuring the auto-PEEP can help
A slow respiratory rate is usually necessary, i.e. <20
It is important to remember that there is still mortality from asthma and so a respiratory
paediatrician should be consulted in any child with asthma severe enough to need admission to the
paediatric intensive care unit (PICU)
6.4 Ventilating children with bronchiolitis

There are three reasons to ventilate a child with bronchiolitis:
Apnoea
Worsening blood gases, usually hypoxia despite maximum oxygen
Exhaustion
Once a baby is ventilated they:

need enteral nutrition
usually need to remain ventilated for at least 4 days or until the basal crepitations have disappeared
Severe bronchiolitis can be confused with pertussis (history, raised lymphocyte count). Prophylactic
immunization can be used in children at high risk of respiratory syncytial virus (RSV) bronchiolitis.
6.5 Children with pertussis needing admission to the PICU
Indications as for bronchiolitis

Usually babies <2 months of age
Is associated with a high white cell count
May have a prolonged stay on the PICU
Occasionally needs extracorporeal membrane oxygenation (ECMO)
6.6 Cardiac causes of respiratory failure

The pulmonary vascular bed is more muscular in infants and can lead to pulmonary hypertension or
pulmonary vasoconstriction. This can lead to right-to-left shunting across a patent foramen ovale,
open up the ductus arteriosus or cause shunting across any pre-existing cardiac defects such as an
atrial or ventricular septal defect. This results in cyanosis.
Children with cardiac disease with high pulmonary blood flow are more susceptible to pulmonary
hypertension. Oxygen is a potent pulmonary vasodilator. It is also important to normalize the carbon
dioxide levels and to avoid acidosis. Specific treatments such as inhaled nitric oxide or sildenafil can
also be used. Pulmonary hypertension that does not respond to these treatments is called unreactive
pulmonary hypertension and is a poor prognostic sign.
6.7 Treatment of respiratory failure

Some form of respiratory support is often needed. This includes:
Supplementary oxygen with or without an airway

Non-invasive ventilation
Conventional ventilation
Oscillation
ECMO
Airways
The oropharyngeal or Guedel airway is poorly tolerated in the conscious patient and may cause
vomiting
The nasopharyngeal airway is better tolerated but may cause haemorrhage from the vascular nasal
mucosa
Non-invasive ventilation
Nasal prong or short-tube continuous positive airway pressure (CPAP) may be an intermediate
intervention as is nasal or facemask biphasic positive airway pressure (BIPAP)
Non-invasive ventilation is particularly useful in children with neuromuscular disorders as an
alternative to ventilation, or as part of the weaning process post-extubation
If there are areas of atelectasis or collapse, recruitment of the lung can be achieved with CPAP or
BIPAP, so avoiding the need for intubation
Oscillation
Oscillation is used as a lung protective strategy to prevent damage to the lungs caused by high
pressures and excessive shearing forces
Oscillation uses a high mean airway pressure to recruit the lung and prevent alveolar collapse
ECMO
ECMO is a treatment used for reversible conditions where ventilation has become extremely
difficult and the pressures required to adequately oxygenate are damaging to the lungs
For respiratory disorders veinvein ECMO is used, where both cannulas are inserted into veins
It can also be used to support the heart either as a bridge to transplantation or if there is a
reversible cardiac failure; this requires veinartery ECMO where both a vein and an artery are
cannulated
ECMO is a very specialist therapy and is performed only in ECMO centres
A cardiac surgeon inserts the cannulas for ECMO
7. CARDIOVASCULAR SYSTEM
7.1 The child with tachycardia
Tachycardia is one of the most useful clinical signs. There are multiple causes, so having a structured
system is helpful. The following system is one of exclusion and is a useful bedside exercise.
There are seven main groups of causes for tachycardia:
Arrhythmia
Inadequate cardiac output:
Preload
Inotropic
Afterload
Tamponade
Ventilation:
Hypoxia
Hypercapnia
Anaemia
Blocked tube
Pneumothorax (usually tension)
Central:
Pain
Fits
Fever
Anxiety
Drugs
Poor ventricular function
Most of these causes can be excluded on clinical signs or by simple measures such as giving some
pain relief. It is then possible to decide whether it is necessary to get a cardiac opinion.
7.2 Supraventricular tachycardia

Supraventricular tachycardia (SVT) is the most common tachyarrhythmia dealt with by paediatricians.
It can often be difficult to differentiate from a sinus tachycardia. This is because the QRS complex is
narrow and regular. The younger the child the more likely SVT will cause cardiovascular instability.
Symptoms include palpitations, heart failure and shock. However, with SVT:
The onset is sudden as opposed to a gradual increase in rate

There is no beat-to-beat variation
The rate does not become slower with a bolus of fluid.
Rate is usually >220 beats/min in an infant or >180 beats/min in a child
P waves, if visualized, are negative in leads II, III and AVF
Treatment of SVT
ABCDE
Vagal stimulation
Diving reflex; iced water on the face or immerse the face in iced water for 5 seconds
Carotid body massage on one side only
Valsalva manoeuvre in the older child
Drug management
Intravenous adenosine must be given quickly and into a large vein followed by a large saline flush
the child must be ECG monitored:
Start with a bolus of 100 g/kg

If unsuccessful after 2 minutes increase the dose to 200 Hg/kg
If unsuccessful after a further 2 minutes increase to 300 g/kg
The maximum total dose is:
300 g/kg if child is <1 month of age
500 g/kg if child is >1 month to a maximum of 12 mg single dose
Side effects are short lived though unpleasant (flushing, nausea, chest tightness, shortness of
breath). Some older children describe a feeling of impending doom
It is important to involve a paediatric cardiologist
They will consider cardioversion, especially if the child is shocked, or further drug treatment with
flecainide, amiodarone, digoxin or blockers
Cardioversion
This should be performed under anaesthesia using a synchronized DC shock

Initially use 1 J/kg
Follow with 2 J/kg if unsuccessful
Hands-free defibrillation is a safe alternative to using the paddles
A 12-lead ECG is essential to adequately diagnose any change in rhythm.
7.3 Causes of tachyarrhythmia
Re-entrant tachycardia
Cardiomyopathy
Post-cardiac surgery
Drug induced
Long QT syndrome
Metabolic disturbances
Poisoning
7.4 Ventricular tachycardia

If the child is haemodynamically stable it is vital to consult a paediatric cardiologist:
Treat electrolyte disturbances of potassium, calcium and magnesium
Cardiologists may use amiodarone, often with a loading dose. However, this drug is negatively
inotropic and can depress cardiac function
Use anaesthesia for DC synchronized cardioversion

Use 1 J/kg, then 2 J/kg
If the child is pulseless follow the ventricular fibrillation protocol.
7.5 Causes of bradyarrhythmia

The rate is slow and usually irregular. It is usually a pre-terminal sign.
If there has been a vagal stimulant to the bradycardia use atropine 20 g/kg i.v. or via interosseous
access:
Pre-terminal event in hypoxia and shock

Raised intracranial pressure
Conduction damage post-cardiac surgery
Congenital heart block
Myocarditis
7.6 Emergency management of severe heart failure
Assess ABCDE
Give high-flow oxygen
Ventilation
Diuresis
Offload the heart
Maximize oxygen-carrying capacity exclude anaemia
Inotropes
A child with a severe cardiomyopathy may need a dobutamine infusion. This can be given
peripherally through an intravenous cannula. Non-invasive ventilation may also be useful.
The management of heart failure within the context of structural heart defects is discussed in Chapter
1.
7.7 Recognizing low cardiac output state
Tachycardia
Low urine output or anuria
Poor capillary refill
Confusion
Late signs include:
Hypotension
Bradycardia
Confusion can be a late sign
ST depression on ECG
7.8 Inotropes
An inotrope is used to improve the cardiac output:
Cardiac output = Heart rate Stroke volume
In the healthy adult the heart has the ability to change its stroke volume dramatically; this occurs
during exercise and improves with training
Neonates, however, have a more fixed stroke volume so need to increase their heart rate to improve
the cardiac output
Once a neonate or child becomes too tachycardic, the heart no longer has time to fill and the
cardiac output will reduce
When a child is in sinus rhythm the atrial kick can provide between 10 and 25% of the cardiac
output; if a child goes into atrioventricular block the blood pressure drops
There is no perfect inotrope as all inotropes have unwanted effects such as increasing the metabolic
demands of the heart
The best way to understand which inotrope to use and when is to understand which adrenoreceptor of
the sympathetic nervous system each inotrope works on:
Stimulating 1-receptors increases both the heart rate and the contractility of the heart
Stimulating 2-receptors causes muscle relaxation in the smooth musculature of the airways,
causing bronchodilatation, and also relaxes the peripheral vessels, causing a peripheral
vasodilatation
Stimulating -receptors causes a peripheral vasoconstriction, increasing the peripheral vascular
resistance
Most inotropes stimulate increased production of the enzyme adenylyl cyclase to promote an increase
in intracellular calcium, which results in increased contractility of the cardiac muscle.
Adrenaline
Works on all the above receptors but its 1-receptor and -receptor effects predominate
Increases heart rate
Increases cardiac contractility
Increases blood pressure by increasing the peripheral vascular resistance
However:
It makes the heart stiff, i.e. the ventricle is unable to fully relax in diastole
It greatly increases the metabolic demands of the heart
These effects are also seen with other inotropes.
Dopamine
Stimulates mainly 1-receptors at lower doses but at higher doses it has increasing -receptor
effects
Increases contractility
There is probably a low-dose renal effect
However, dopamine is more arrhythmogenic than other inotropes.
Dobutamine
Stimulates mainly 1- and 2-receptors at lower doses but at higher doses it has increasing receptor effects
Increases contractility of the heart
Vasodilates at low doses and vasoconstricts at high doses
Can bronchodilate
Can be given peripherally
However, like dopamine, it is very arrhythmogenic.
Noradrenaline
Stimulates mainly -receptors, although in large doses it has some -receptor effects
Increases blood pressure by increasing the peripheral vascular resistance
Milrinone
It is a phosphodiesterase inhibitor that works by preventing breakdown of adenylyl cyclase. It is an
inotrope that is used mainly with cardiac conditions
It can be given peripherally
It has a long half-life (2.5 hours in adults)
It causes peripheral vasodilatation
It relaxes the ventricle in diastole (lusiotrophic action)
It has an inotropic effect
It is often termed an inodilator rather than an inotrope
When they are used for more than a few days in large amounts, inotropes become less effective as the
receptors down-regulate. When this happens, either the inotrope is changed or steroids are given.
Decreasing the metabolic demands can have an inotrope-like effect. This is seen when a child is
ventilated, pain is controlled and pyrexia is treated.
7.9 The child in shock

Shock is defined as inadequate perfusion and oxygenation of the tissues.
Causes of shock:
Cardiogenic, e.g. cardiomyopathy, arrhythmias, myocarditis

Hypovolaemic, e.g. haemorrhage, burns, gastroenteritis
Distributive, e.g. anaphylaxis, sepsis
Dissociative, e.g. severe anaemia, carbon monoxide poisoning
Obstructive, e.g. tension pneumothorax, cardiac tamponade
Shock is further subdivided into:

Compensated
Uncompensated
Irreversible
The most common causes of shock in children are bleeding, septicaemia and gastroenteritis.
Septic shock
One of the most common causes of shock in children is meningococcal disease
Systemic inflammatory response syndrome is seen, characterized by:
Vasodilatation
Pyrexia
Cascade of inflammatory markers
Coagulation disorder
Depressed myocardial function
Spinal shock
Bradycardia
Hypotension
8. ANAPHYLAXIS
Anaphylaxis can present as respiratory distress with either stridor or wheeze, or as cardiovascular
collapse.
Treatment
Remove allergen
Assess ABCDE
Give high-flow oxygen
Adrenaline 1:1000 i.m.; <6 years 150 g (0.15 ml) ; 612 years 300 g (0.3 ml); >12 years 500 g
(0.5 ml) or alternatively 10 g/kg
If complete obstruction, obtain a definitive airway
If partial obstruction:
Give nebulized adrenaline 5 ml of 1:1000
Give hydrocortisone (<6 months 25 mg; 6 months to 6 years 50 mg; 612 years 100 mg; >12 years
200 mg)
If wheeze present, give nebulized salbutamol
Consider intravenous salbutamol 15 g/kg per min
If shock present, give 20 ml/kg fluid bolus, consider adrenaline infusion
Chlorpheniramine i.v. (250 g/kg if <6 months; 6 months to 6 years 2.5 mg; 612 years 5 mg; >12
years 10 mg)
9. MANAGING THE CHILD WITH SEVERE BURNS

The main issues to consider are:
Early first-aid measures are important, minimizing the duration of exposure to the heat; tepid water
is used
The airway can deteriorate rapidly and swelling of the airway can make intubation difficult, so
early intervention and experienced airway help are necessary
Shock in the first few hours is unlikely to be the result of the burn injury and other causes of fluid
loss, e.g. bleeding, must be considered
Fluid requirements are high and should be calculated from the time of injury and not from the time
of arrival in the accident and emergency department
Circumferential burns of the chest may restrict breathing so a burns surgeon should be consulted
Burns are associated with other injuries, e.g. jumping out of windows in house fires or explosions,
so consider that the cervical spine, for example, may be injured
9.1 Epidemiology
Burn injuries are very common but the majority are minor
70% occur in children <5 years
Infants and children with learning difficulties are at increased risk

House fires account for most fatal burn injuries and the cause of death is usually smoke inhalation
In England and Wales 23 children died in 2001 from burns; in 2007 his had reduced to 18 deaths
There is a strong link between burns and poverty
Late infection is a significant cause of morbidity in children with burns injuries
9.2 Pathophysiology
The severity of the burn depends on both the temperature and the time of contact with the burn
Six hours of contact at 44C would be needed to cause cellular destruction, whereas at 54C only
30 seconds of contact is needed to cause cellular destruction
9.3 Assessment
Signs of inadequate breathing include abnormal respiratory rate, abnormal chest movement and
cyanosis, which is a late sign
Reduced consciousness may be the result of other injuries causing hypovolaemia or of a head
injury, or it may be secondary to hypoxia
Child protection issues should be considered
9.4 Indications of an inhalational injury

History of exposure to smoke in a confined space
Carbonaceous sputum (black sputum)
Soot deposits around nose or mouth or on clothes
9.5 Assessment of the burn

The severity of the burn is described by the percentage of the total body surface area affected and
by the depth of the burn
The patients palm and adducted fingers cover a surface area of approximately 1% of the total
surface area
The rule of nines for calculating the percentage burn is not applicable to children and a paediatric
chart should be used
Burns are classified as superficial, partial thickness and full thickness:
Superficial burns cause injury only to the epidermis and are red and painful with no blisters
Partial-thickness burns are also painful and blistered, and the skin is pink or mottled
Full-thickness burns are painless and both the dermis and epidermis are involved and sometimes
deeper tissues. The skin is white or charred and feels leathery
Special areas include the face, hands and feet, perineal burns and circumferential burns, i.e. a burn
that extends round the whole circumference of a limb or trunk, which can act as a tourniquet round
the limb or trunk as the burned skin contracts
9.6 Treatment
High-flow oxygen
Early airway assessment
Ideally two intravenous cannulas should be placed avoiding burnt areas
Early and adequate analgesia is important
Burns of >10% will need extra fluid in addition to their maintenance requirements. The estimated
fluid = percentage burn weight (kg) 4 given over 24 hours. Half of this is given in the first 8
hours from the burn injury. Urinary catheters are essential in severe burns to assess adequate fluid
resuscitation and urine output should be kept at 2 ml/kg per h
There is a high risk of rapid heat loss following a burn injury so after initial exposure the child
should be re-covered and kept warm
Circumferential burns may need surgical intervention (escharotomies):
Escharotomies are needed when the burn injury affects the whole of the dermis and the skin loses
its ability to expand as oedema progresses. The burned wound is excised surgically down to the
subcutaneous fat
Carbon monoxide poisoning is discussed in Chapter 5
Inhalation of carbon monoxide may occur when a child has been in a house fire
Inhalation of carbon monoxide induces the production of carboxyhaemoglobin which has a much
higher affinity for oxygen than normal haemoglobin. Oxygen is therefore not given up to the cells
and cellular hypoxia occurs
The pulse oximeter may show a normal saturation
The treatment is 100% oxygen or hyperbaric oxygen if very high levels are found
9.7 When to transfer to a burns centre
10% partial- and/or full-thickness burns

5% full-thickness burns
Burns to special areas: face, hands, feet or perineum
Any circumferential burn
Significant inhalational burn (excludes pure carbon monoxide poisoning)
Chemical, radiation or high-voltage burns
9.8 Chemical burns

Alkali burns are more serious than acid burns because alkalis penetrate more deeply
If dry powder is present, brush it off before irrigation
Irrigate with water for 2030 minutes
10. INJURIES DUE TO SEVERE COLD

10.1 Frostbite
Treatment for frostbite should be immediate to reduce the duration of injury unless there is a risk of
re-freezing
Provide warm blankets and a warm drink
Place the injured part in circulating water at 40C until pink in colour (periods of 20 minutes are
recommended)
Avoid dry heat
Give analgesia because re-warming can be very painful
Cardiac monitoring is required during re-warming
10.2 Systemic hypothermia

(See also Section 15.3)
Core body temperature is below 35C

Use special low-registering thermometer
Decreased level of consciousness is a common sign
Arrhythmias are common
Clotting abnormalities occur
Re-warming can lead to shock, especially if rapid, and should be carried out over the same time
period as the initial cooling process
Cardiac drugs and defibrillation are not usually effective if hypothermia is present, so perform
defibrillation only once until the temperature is above 30C
The dose interval for adrenaline is doubled between 30C and 35C
Patients should not be pronounced dead until they have been re-warmed to at least 32C and ideally
to above 35C
11. SEVERE HEAD INJURY

The aim of intensive care management in severe head injury is to prevent further brain injury.
Therefore, it is important to:
Maintain good oxygenation

Avoid hypotension
Avoid pyrexia
Avoid hyper- or hypoglycaemia
The head is a closed box once the fontanelle has closed. If there is an expanding lesion within this
closed box, such as a bleed or swelling of the brain, the pressure inside the box increases. This is
called the MonroKellie doctrine.
The compartments in the closed box are:
Brain
Cerebrospinal fluid (CSF)
Arterial blood
Venous blood
As the brain swells or a bleed increases in size, there is initial compensation. Venous blood and CSF
are drained out of the head. Once this has occurred there is a decompensation where a small increase
in volume causes a rapid increase in pressure.
The clinical signs of herniation include bradycardia, hypertension and enlarging pupils.
It is important to maintain the blood supply to the brain. This is measured by cerebral perfusion
pressure (CPP)
CPP = MAP ICP
where MAP = mean arterial blood pressure in mmHg and ICP = intracranial pressure in mmHg.
11.1 Maintaining an adequate cerebral perfusion pressure

This requires the blood pressure to be significantly higher than the ICP. The CPP levels for different
age groups are a minimum of 40 mmHg in infants and young children and a minimum of 60 mmHg in a
teenager or adult.
Often the child needs to be hypertensive to maintain adequate blood supply to the head. A higher than
normal blood pressure may be needed to maintain adequate blood supply to the head. This is
achieved using noradrenaline as the inotropic support.
This means that a child with a severe head injury will need ventilating, central and arterial access,
and a means of measuring the ICP:
Intracranial bolt
Ventricular drain
A device to detect fits, e.g. a cerebral function analysis monitor
11.2 Reducing raised ICP
Keep head central

Keep head raised 2030
Maintain low to normal CO2, aiming for 4.5 kPa
Maintain high serum sodium levels >140 mmol/l
Maintain high serum osmolality; give mannitol or hypertonic saline
Drain CSF from a ventricular drain
Minimize stimulation to the brain by pain relief and sedation
Give a paralysing drug
Provide extra sedation for procedures such as suction
Avoid seizures
The benefits of either cooling (3234C) and/or craniectomy are controversial. It is important to
avoid pyrexia.
The outcome following severe head injury is better in children than adults. The initial Glasgow Coma
Scale (GCS) at the scene is a useful guide. If it is 8 or less, it is essential to intubate. It is essential to
evacuate any expanding bleed as soon as possible; however, speed should not exclude adequate
resuscitation.
11.3 Complications in intensive care

Neurogenic diabetes insipidus can occur and, if the urine output is excessive, paired serum and
urine osmolalities must be performed and vasopressin given
Constipation
Pneumonia
Pressure sores
Risk of infection in ventricular drains
11.4 Imaging
Cervical spine injuries cannot be excluded by a normal radiograph or computed tomography (CT),
but must be cleared clinically as well
Regular CT scans of the head are used to monitor progress
Thoracolumbar spinal radiographs exclude a fracture (if the spine is fractured in one place, there is
an increased risk of a second spinal fracture)
Secondary survey must be documented in the notes. This is a top-to-toe examination for other
injuries and is important because smaller non-life-threatening injuries can cause significant
morbidity
12. THE CONVULSING CHILD AND THE PICU
Generalized convulsive status epilepticus is defined as a generalized convulsion lasting 30 min or

longer or when successive convulsions occur so frequently over a 30-min period that the child
does not recover consciousness in between them
The protocol for the management of status epilepticus is described in Chapter 19
Mortality still occurs and the rate is 4%. Death may be caused by airway obstruction, aspiration
from vomiting, hypoxia, an overdose of medication, cardiac arrhythmias or the underlying disease
process
Complications of prolonged fitting include hyperthermia, arrhythmias, brain damage, hypertension,
pulmonary oedema, diffuse intravascular coagulation and myoglobinuria
Convulsions increase the cerebral metabolic rate
Blood pressure and heart rate increase as a result of a surge in sympathetic activity
Cerebral arterial regulation is impaired and, as the blood pressure increases, there is increased
cerebral blood flow; this is followed by a drop in blood pressure if fits are prolonged and
therefore a reduction in cerebral blood flow
There is an increase in lactate and subsequent cell death and oedema
The ICP rises
Calcium and sodium cellular metabolism is impaired
12.2 Treatment
ABCDE and treat hypoglycaemia
High-flow oxygen
Follow flow chart in Chapter 19, p. 581)
Rapid sequence induction

This is an anaesthetic procedure undertaken in which there is a risk of aspiration of gastric contents. It
involves the following sequence:
Preoxygenation with 100% oxygen
Give induction agent (e.g. thiopentone 4 mg/kg or less if the child is hypovolaemic) and muscle
relaxant (suxamethonium 2 mg/kg)
Cricoid pressure is applied by an assistant to occlude the oesophagus
The child is not bagged during this process
Intubation
Assess chest movement to confirm tube position, and listen with a stethoscope in both axillae and
over the stomach
Release cricoid pressure
The child is then taken for a CT scan or to the PICU with full monitoring including saturation
monitoring, capnograph, and ECG and blood pressure monitoring
Most children with status epilepticus will stop fitting with these measures. A minority do not and then
a thiopental coma is considered.
Thiopentone coma
This usually involves a thiopentone infusion sufficient to achieve burst suppression on the EEG. The
coma is continued for 13 days. Continuous cerebral function analysis monitoring is needed:
ICP monitoring may be useful
Standard neuroprotective measures may be needed if raised ICP is suspected
Complications include:
Status epilepticus may persist or fits may restart

Chest infection
Hypotension secondary to thiopentone
Renal impairment secondary to thiopentone infusion
Alternatives include high-dose midazolam or high-dose phenobarbitone. A paediatric neurologist

must be consulted.
Consider the differential diagnoses:
Meningoencephalitis
Pneumococcal meningitis
Poisoning
Metabolic disorder
Electrolyte imbalance
Trauma
Pyrexia and infection
Hypertension
Non-accidental injury
Pertussis in a neonate
Apnoea in a neonate leading to hypoxia
However, a cause is often not found.
13. NON-TRAUMATIC COMA

PICUs are often asked to see these children because there is a concern that they will either
hypoventilate or not adequately protect their airway.
In children coma is caused by a diffuse metabolic insult in 95% of cases and by structural lesions in
the remaining 5%.
There are many investigations that need to be considered but the following gives the basic essential
investigations when the cause of coma is unknown:
History
Examination including temperature and pupils
Haematology
Full blood count and film
Erythrocyte sedimentation rate
Coagulation
Biochemistry:
Blood gas
Glucose
Urea and electrolytes and creatinine
Liver function tests (aspartate aminotransferase [AST], alkaline phosphatase [ALP], bilirubin,
albumin)
Calcium, phosphate
C-reactive protein
Serum lactate
Ammonia
Amino acids (especially raised leucine in maple-syrup urine disease)
Creatine kinase
Drug levels, e.g. salicylate levels, anticonvulsant levels including thiopental
Septic screen:
Culture and sensitivity; blood, urine, stool, bronchoalveolar lavage (BAL), nasopharyngeal
aspirate (NPA)
Antibodies mycoplasma IgG
Viral titre EpsteinBarr virus, herpes virus and common respiratory viruses
Virus isolation from NPA and BAL, common respiratory viruses
Polymerase chain reaction for meningococci, herpes simplex virus, pneumococci
Urine:
Dipstick
Microscopy, culture and sensitivity (MC&S)
Toxicology
Myoglobin
Urine electrolytes
Organic acids
Ketones
Chest X-ray
ECG
Cranial ultrasound
EEG
CT scan
14. TRAUMA
14.1 Life-threatening extremity injuries
Crush injuries of the abdomen and pelvis
Traumatic amputation of an extremity; partial amputation is often more life threatening than
complete amputation
Massive open long-bone fractures
Crush injuries
Splinting of the pelvis required
Embolization of bleeding vessels may be useful
Trauma to the internal organs is more likely in children than adults after crush injuries
Complete or partial amputation

Compression over femoral or brachial artery may help. Use of a tourniquet is now being
encouraged in the pre-hospital environment if death from uncontrollable bleeding is likely
Elevation of the limb
Advice from a specialist centre
Long-bone fracture
Splinting
Consider vascular injury and compartment syndrome
Consider tetanus immunization status
14.2 Gunshot wounds and stabbing

These are both rare in children but the following tips are useful aide memoires:
Bullets usually follow the path of least resistance, so do not assume that the trajectory of the bullet
is in a direct line from the entrance to the exit wound
The entrance wound is often round or oval with a blackened area of burn
The exit wound is often ragged because of tearing of tissues
In both stabbing and gunshot wounds it is important to define which structures are likely to have
been penetrated
15. DROWNING
450 000 people die per year worldwide as a result of drowning

Drowning can occur in even small amounts of water, e.g. a few inches of rainwater in a bucket
Worldwide, for children <15 years of age, drowning is the most common cause of accidental death
Most drownings are preventable
Bradycardia and dsyrhythmias are common as a result of the severe hypoxia
Hypoxia is usually the cause of death
Pathophysiology of drowning
15.2 Treatment
ABCDE
Consider:
Hypothermia
Hypovolaemia
Spinal injury
Other injuries
Child protection issues
Contaminated water can lead to infection with unusual organisms
Hypothermia can lead to disorders of coagulation and dysrhythmias and increased risk of infection.
Remove from the water in a horizontal position to prevent venous pooling and distributive
hypovolaemia
Immobilize the spine
Early and effective basic life support has been shown to improve outcome
Secure an airway early and decompress the stomach with a nasogastric tube
If core temperature <30C prevent further cooling and re-warm
Continue resuscitation until core temperature is at least 32C and cannot be raised despite active
re-warming
Below 30C ventricular fibrillation may be refractory. Repeated shocks and inotropes should be
delayed until the temperature is above this level, even in circulatory failure
15.3 Re-warming
(See also Section 10.2)
External re-warming
Remove cold or wet clothes

Supply warm blankets
Use a heating blanket
Use warm air
Use an infrared radiant heat lamp
Core re-warming
Only use warm fluids (warm to 39C)

Warm ventilator gases (42C)
Warm peritoneal dialysis fluids at 42C
Gastric or bladder lavage with 0.9% saline at 42C
Pleural or pericardial lavage
Extracorporeal blood warming

External re-warming is appropriate for temperatures >30C
During re-warming vasodilatation occurs, producing a relative hypovolaemia, often requiring fluid
boluses
Re-warming also increases the metabolic demands on the heart so myocardial dysfunction may
become apparent on re-warming. Inotropes may be needed once the temperature is above 30C
15.4 Prognostic signs

Signs associated with a poor prognosis:
Immersion for >10 min
If no respiratory effort has occurred after 40 min of full CPR, the chances of survival are small;
however, caveats to this are immersion in very cold water, a history of medication or alcohol
intake
It is unlikely for water in the UK to ever be cold enough to be neuroprotective
Persisting coma
pH <7.1 despite treatment
PO2 <8 kPa despite treatment
Signs associated with a good prognosis:
If respiratory effort occurs within 3 min of starting CPR, the prognosis is good
Provision of basic life support at the scene
Respiratory compromise may occur several hours after the drowning episode.
16. FURTHER READING

Advanced Life Support Group (2011). Advanced Paediatric Life Support, 5th edn. London: BMJ
Books, Wiley-Blackwell.
Pearson G (2002). Handbook of Paediatric Intensive Care. London: Saunders.
Resuscitation Council (2010). Resuscitation Guidelines. London: Resuscitation Council.
Resuscitation Council (2011). Emergency Paediatric Life Support, 3rd edn. London: Resuscitation
Council.
Shann F, Henning H (2005). Paediatric Intensive Care Guidelines, 12th edn. Collective Pty Ltd.
South Central Strategic Health Authority (2010). Advance Care Planning (ACP): ACP, Policy and
Staff Guide. Available at: www.southcentral.nhs.uk/what-we-are-doing/end-of-life-care/childrensadvance-care-plan (accessed November 2011).
Chapter 8
Endocrinology and Diabetes
Heather Mitchell and Vasanta Nanduri
CONTENTS
1. Hormones
1.1 Introduction
1.2 Hormone physiology
1.3 Hormonereceptor interactions
1.4 Second messengers
1.5 Endocrine disorders
1.6 Investigation of hormonal problems
2. Growth
2.1 Physiology of normal growth
2.2 Assessment and investigation of growth disorders
2.3 Short stature
2.4 Tall stature
3. Hypothalamus and pituitary glands

3.1 Anatomy
3.2 Physiology of the hypothalamus
3.3 Hormone physiology of the anterior pituitary
3.4 The neurohypophysis posterior pituitary
3.5 Pituitary disorders
3.6 Investigation of hypothalamic and pituitary hormone disorders
3.7 Principles of management of hypothalamicpituitary disorders
4. Puberty
4.1 Physiology of normal puberty
4.2 Clinical features of normal puberty
4.3 Abnormal puberty
5. Adrenal gland
5.1 Anatomy
5.2 Physiology
5.3 Disorders of the adrenal gland
6. Thyroid gland
6.1 Anatomy
6.2 Physiology
6.3 Regulation
6.4 Functions of thyroid hormone
6.5 Investigation of thyroid disorders
6.6 Disorders of thyroid function
7. Diabetes and hypoglycaemia

7.1 Physiology of glucose homeostasis
7.2 Diabetes mellitus
7.3 Hypoglycaemia
8. Bone metabolism
8.1 Physiology of calcium and phosphate homeostasis
8.2 Disorders of calcium and phosphate metabolism
8.3 Investigation of bone abnormalities
9. Miscellaneous endocrine disorders

9.1 Obesity
9.2 Multiple endocrine neoplasia syndromes
9.3 Autoimmune polyglandular syndromes
9.4 Endocrine complications of other disorders
9.5 Disorders of sexual development
9.6 Amenorrhoea
10. Further reading
Endocrinology and Diabetes
1. HORMONES
1.1 Introduction
The endocrine system consists of a series of ductless glands that secrete the hormones that they
produce into the bloodstream. The human fetus is dependent on endocrine development for hormones,
which support normal development. Peripheral endocrine glands (thyroid, pancreas, adrenals and
gonads) form early in the second month from epithelial/mesenchyme interactions. The fetus also has a
unique hormonal system that combines not only its own developing endocrine system, but also that of
the placenta and maternal hormones. In addition to the main endocrine glands, other important sources
of hormones are the gastrointestinal tract, kidney, heart and adipose tissue.
1.2 Hormone physiology

Hormones
Hormones are chemical messengers produced by a variety of specialized secretory cells. They have
effects on a wide range of biological processes. Hormones are classified according to their chemical
nature:
Amine: catecholamines, serotonin (5-hydroxytryptamine, 5HT)
Peptide: growth hormone (GH), insulin, thyroxine
Steroid: cortisol, aldosterone, androgens, oestrogen, progesterone
Mode of transmission
Hormone effects may be:
Paracrine: a direct effect on nearby cells
Autocrine: act on the tissue that secretes them
Endocrine: carried by the circulation to a distant site of action
Transport and metabolism

Most endocrine hormones are secreted into the systemic circulation, but those secreted from the
hypothalamus are released into the pituitary portal system.
Many hormones are bound to proteins when in the circulation but only free hormones can exert their
biological action on tissues. These binding proteins buffer against very rapid changes and act as a
reservoir for the hormones.
Hormone
Hormone-binding proteins
Thyroxin
Testosterone/oestrogen
Insulin-like growth factor-1
Cortisol
Thyroid-binding globulin, albumin

Sex hormone-binding globulin
Insulin-like growth factor-binding proteins
Cortisol-binding protein
Regulation
The effect and measured amount of a particular hormone in the circulation at any one time is the result
of a complex series of interactions.
Control and feedback
The rate of biosynthesis and secretion is controlled by negative feedback systems involving:
Stimulating or releasing hormones

Environmental effects
Plasma concentrations of binding hormones
Nutrient levels
Most hormones are controlled by some form of feedback. Insulin and glucose work on a feedback
loop. Elevated glucose concentrations lead to insulin release, whereas insulin secretion is switched
off when the glucose level decreases.
Receptor up- or downregulation also occurs. Downregulation leads to reduced sensitivity to a
hormone and a reduced number of receptors after prolonged exposure to high hormone concentrations.
A good example of this is the administration of intermittent gonadotrophin-releasing hormone
(GnRH), which induces priming and facilitates a large output of gonadotrophins, whereas continuous
GnRH leads to a downregulation of receptors and hence has a protective effect. However, this is not
true of all pituitary hormones (e.g. ectopic adrenocorticotrophic hormone or ACTH secretion leads to
receptor upregulation, which is the reverse process).
Hormones are usually metabolized in the liver or kidney but some are degraded peripherally (e.g.
thyroid hormone) or in the plasma (e.g. catecholamines).
Patterns of secretion
Individual hormones have different patterns of secretion which include:
Continuous, e.g. thyroxine

Pulsatile, e.g. follicle-stimulating hormone (FSH), luteinizing hormone (LH), growth hormone (GH)
Circadian, e.g. cortisol
Stress related, e.g. ACTH
Sleep related, e.g. GH, prolactin
1.3 Hormonereceptor interactions

Amine and peptide hormones have short half-lives (minutes) and act on cell-surface receptors. They
often act via an intracellular second messenger (e.g. adenosine cyclic monophosphate or cAMP,
calcium). Steroid hormones have longer half-lives (hours) and act on intracellular receptors. They act
on DNA to alter gene transcription and protein synthesis. Thyroxine is the exception to this rule
because it acts as a steroid hormone and binds to intracellular receptors.
Hormone receptors
Hormones act by combining with a specific receptor protein which the starts the intracellular signal
transduction pathway. There are two main types of receptor
1. Cell surface membrane receptors:
G-protein-coupled receptors (GPCRs)
Tyosine kinase receptors (TKRs)
2. Intracellular receptors (for fat-soluble hormones)
G-protein receptors
G-protein receptors are a large family of receptors that are integral to the cell-surface membrane and
have seven transmembrane domains. The G-proteins may be inhibitory Gi (e.g. somatostatin) or
stimulatory Gs (e.g. all other hormones). When activated they cause dissociation of an intracellular
trimeric G-protein which then acts via a second messenger. The intracellular messenger can be:
Adenosine cyclic monophosphate: used by glucagon, ACTH, LH, FSH, PTH, calcitonin,
adrenaline and noradrenaline
Guanine cyclic monophosphate (cGMP): used by peptide hormones such as nitric oxide and
atrial natriuretic hormone. The action of cGMP is opposed by phosphodiesterases
Inositol triphosphate system: used by adrenaline and acetylcholine. The cytoplasmic enzyme
phospholipase C (PLC) is activated and then releases inositol triphosphate from membrane
phospholipids. These in turn release calcium from stores in the endoplasmic reticulum
Tyrosine kinase receptors
The binding of the hormone results in dimerization and hence activation of the receptor. This may be
by phosphorylation of the receptor itself or by activation of cytoplasmic tyrosine kinase. Hormones

activating this type of receptor include GH and insulin.
Intracellular receptors
Receptors for the lipophilic hormones, e.g. steroids and thyroxine, are located within the cell
cytoplasm or the nucleus. In nuclear receptors, the hormone receptor complex acts as a transcription
factor binding to the promoter region of genes, hence modulating its expression. The nuclear receptor
has a characteristic three-domain structure and is divided into three classes.
Class I: steroid receptor family
These receptors can be found in the cytoplasm bound to heat shock proteins (HSPs). The binding of
the hormone leads to release of the HSP and the formation of a homodimer. This binds to hormone
response elements at promoter sites.
Class II: thyroid/retinoid family
These are typically located in the nucleus. They function as heterodimers and are bound to response
elements. Ligand binding leads to displacement of a co-repressor removing the suppression of gene
activation.
Class III: orphan receptor family
No ligands have yet been identified.
1.4 Second messengers

Some hormonal actions are carried out via second messengers.
Insulin-like growth factor-1 (IGF-1) and IGF-2 are GH-dependent peptide factors. They are believed
to modulate many of the anabolic and mitogenic actions of GH. IGF-1 is important as a postnatal
growth factor, whereas IGF-2 is thought to be essential for fetal growth.
1.5 Endocrine disorders due to receptor abnormalities

Syndromes of G-protein abnormalities, e.g. McCuneAlbright syndrome
Syndromes of receptor resistance: these mutations in nuclear receptors result in end-organ
unresponsiveness, e.g. vitamin D-resistant rickets. The hormone levels are raised but the clinical
picture is one of hormone insufficiency
Mutations of nuclear receptors, e.g. pseudohypoparathyroidism
1.6 Investigation of hormonal problems

In view of the complexities of control on the concentration of a particular hormone and the various
factors that influence its distribution and elimination, the use of a single random measurement of a
hormone can be difficult to interpret. The plasma levels vary throughout the day because of pulsatile
secretion, environmental stress or circadian rhythms. They are also influenced by the values of the
substrates that they control. It is therefore often hard to define a normal range and dynamic testing may
be required.
Blood hormone concentration measurements

Basal levels: those hormones in a steady state, e.g. thyroid function
Timed levels: those hormones with levels that need to be interpreted with a normal range for the
time of day, e.g. cortisol measured at 00:00 h and 08:00 h
Stimulated: in suspected hormone deficiency, e.g. GH-stimulation tests
Suppression: in conditions of hormone excess because hormone-producing tumours usually fail to
show normal negative feedback, e.g. dexamethasone suppression test for suspected Cushing
disease
Urine concentrations
Useful for identifying abnormalities in ratios of metabolites, e.g. diagnosis of the specific enzyme
defect in congenital adrenal hyperplasia
2. GROWTH
2.1 Physiology of normal growth
Prenatal
Factors influencing intrauterine growth
Nutrition
Genetic
Maternal factors (smoking, blood pressure)
Placental function
Intrauterine infections
Endocrine factors, e.g. IGF-2
Postnatal
Phases of postnatal growth
Nutrition
Infancy: nutrition
Childhood: GH (thyroxine)
Puberty: sex hormones (GH)

Average growth during the pubertal phase is 30 cm (12 inches).
The genetics of growth is poorly understood but shows many characteristics of a polygenic model
involving many genes. There are, however, some single gene growth defects including defects of
human GH and the human GH receptor.
2.2 Assessment and investigation of growth disorders

The following parameters are important in the assessment of growth:
Standing height
Sitting height
Head circumference
Weight
Skin-fold thicknesses
Mid-arm circumference
Pubertal status
Auxology
When measuring height, the optimal method is for the child to be measured by the same trained
measurer, on the same equipment and at the same time of day on each occasion in order to minimize
measurement error. A stadiometer should be used and supine height measured at <2 years of age and
standing height at >2 years.
A childs height may be compared with the population using centile charts, and also considered in
terms of his or her genetic potential by comparison with the mid-parental height.
Mid-parental height
Add 13 cm to mothers height to plot on a boys chart
Subtract 13 cm if plotting a fathers height on a girls chart
Mid-parental height is half-way between the plotted corrected parental heights
The measurement of skin-fold thicknesses (e.g. triceps, subscapular) gives important information
about body fat distribution, which changes at different ages. For example, in puberty there is an
increase in truncal fat but a reduction in limb fat. Mean arm circumference can be used to assess
muscle bulk.
To estimate the rate at which a child is growing it is necessary to measure the height on two separate
occasions (at least 46 months apart) and divide the change in height by the period of time elapsed.
This is the height velocity and is expressed in centimetre per year. The height velocity can be plotted
on standard reference charts.
2.3 Short stature

Causes of short stature
Familial
Constitutional short stature, constitutional delay of growth and puberty
Chronic illness:
Congenital heart disease
Respiratory disorders, e.g. cystic fibrosis
Renal failure
Gastrointestinal (GI) disorders: malabsorption, e.g. coeliac disease, Crohn disease
Neurological, e.g. intracranial tumours
Endocrine:
GH insufficiency
Hypothyroidism
Cushing syndrome
Dysmorphic syndromes:
Turner syndrome
Down syndrome
Low birthweight, e.g. RussellSilver syndrome
PraderWilli syndrome
Skeletal dysplasia:
Achondroplasia
Hypochondroplasia
Spondyloepiphyseal dysplasia
Psychosocial/emotional deprivation
As a general rule, if a child has a normal growth rate then the cause of the short stature is in the past
history, whereas a child with a low growth rate requires thought as to what current process(es) is
causing the growth failure.
Familial short stature

This remains one of the most common causes of short stature, whereby the child takes after the
parents heights and grows along a centile that is appropriate for their genetic potential.
Constitutional short stature

This is a condition commonly seen in teenage boys who have a combination of delay in growth and
delay in puberty. There is often a history of a similar pattern of growth in male members of the family.
Bone-age assessment (see below) is often the only investigation initially required and usually shows
a delay. Children do reach their genetic potential, but later than their peers. Management consists
primarily of reassurance and, in certain circumstances, the use of a short (<6-month) course of
androgens to kick start puberty.
Note that constitutional delay of growth and puberty should not be diagnosed in girls without thorough
investigation.
Common syndromes associated with short stature

Achondroplasia
Genetics:
Caused by mutations in the FGFR3, gene which provides the instructions for making a protein
involved in the maintenance and development of brain and bone tissue. The inheritance is
autosomal dominant but there are new mutations in 80%
Clinical features:
Megalocephaly
Short limbs
Prominent forehead
Thoracolumbar kyphosis
Midfacial hypoplasia
Disproportionate short stature
Radiology:
Diminishing interpeduncular distances between L1 and L5
Complications:
Short stature
Dental malocclusion
Hydrocephalus
Repeated otitis media
Hypochondroplasia
Definition:
Rhizomelic short stature distinct from achondroplasia
Inheritance:
About 70% affected individuals have mutations in the FGFR3 gene
Clinical features:
Affected individuals appear stocky or muscular
Usually recognized from age 23 years
Wide variability in severity
Radiology:
No change in interpeduncular distances between L1 and L5
Complications:
Short stature
Inheritance:
This can be autosomal recessive or X-linked recessive. Mucopolysaccharidoses (MPS) result
from enzyme deficiencies that break down the complex carbohydrates called glycosaminoglycans
Clinical features depend on type of MPS:
Short spine and limbs
Coarse facial features
Reduced intelligence and abnormal behaviour in some forms
Hurler syndrome shortened lifespan
Marked skeletal abnormalities and severe short stature in Morquio syndrome
RussellSilver syndrome
Inheritance:
Sporadic: the genetic causes are complex but research has focused on genes located in particular
regions of chromosomes 7 and 11. Parent-specific gene expression is also thought to play a role
Definition:
Syndrome of short stature of prenatal onset
Occurrence is sporadic and aetiology is unknown
Clinical features:
Short stature of prenatal onset
Limb asymmetry
Short incurved fifth finger
Small triangular face
Caf-au-lait spots
Normal intelligence
Bluish sclerae in early infancy
Turner syndrome
Definition: a syndrome with a 45XO (or XO/XX or rarely XO/XY) karyotype associated with short
stature, ovarian dysgenesis and dysmorphic features
Inheritance: sporadic
Clinical features:
Neonatal lymphoedema of hands and feet
Skeletal: short stature (mean adult height is 142 cm); widely spaced nipples, shield-shaped chest;
wide carrying angle; short fourth metacarpal; hyperconvex nails
Facial: prominent, backward-rotated ears; squint, ptosis; high arched palate; low posterior
hairline, webbed neck
Neurological: specific spaceform perception defect
Endocrine: autoimmune diseases (hypothyroidism); type 2 diabetes; infertility and pubertal failure
Associations: horse-shoe kidneys; coarctation of the aorta; excessive pigmented naevi
Turner syndrome needs to be excluded in all girls whose height is below that expected for the midparental centile because not all girls with Turner syndrome show the classic phenotype.
Assessment of a child with short stature

Measure and plot the childs and parents height and see if child is growing along the predicted
centile for genetic potential. Assess pubertal status according to Tanner stages (see Section 4.2). In
teenage boys who are not yet in puberty, constitutional delay is the most likely.
History and clinical examination should identify an obvious chronic illness, which should then be
specifically investigated. Features of recognized dysmorphic syndromes should be looked for. A child
who is disproportionate should undergo skeletal survey to rule out a skeletal dysplasia.
Investigation of short stature
Full blood count

Urea and electrolytes, C-reactive protein (CRP)
Coeliac antibodies screen
Karyotyping in females
IGF-1 and IGF-BP3 levels
Bone age
GH provocation tests
Bone age
This is a measure of the maturation of the epiphyseal ossification centres in the skeleton. Bone age
proceeds in an orderly fashion and therefore defines how much growth has taken place and the amount
of growth left. A delayed bone age may be caused by constitutional delay of growth and puberty, GH
deficiency or hypothyroidism. An advanced bone age is caused by precocious puberty, androgen
excess (e.g. congenital adrenal hypoplasia, CAH) and GH excess.
2.4 Tall stature

Causes of tall stature in childhood
Familial tall stature

Constitutional obesity
Precocious puberty
Androgen excess:
GH excess
Thyrotoxicosis
Syndromes:
Cerebral gigantism (Sotos syndrome)
Marfan syndrome
Klinefelter syndrome
Familial tall stature
This is a child of tall parents whose height follows a centile line above, yet parallel to, the 97th
centile, which is appropriate for the predicted mid-parental centile.
Constitutional obesity
Remember: if a child is tall and fat it is most probably due to constitutional obesity. These children
often have a slightly advanced bone age and go into puberty relatively early (not precocious) and thus
end up appropriate (or slightly tall) for parents heights.
Syndromes of tall stature

Marfan syndrome
Inheritance:
Autosomal dominant. Caused by mutations in the FBN1 gene which codes for fibrillin 1. 25% of
affected individuals have a new mutation
Clinical features:
Skeletal:
Arachnodactyly
Tall stature
Scoliosis
High arched palate
Pectus excavatum/carinatum
Joint hypermobility
Central nervous system (CNS):
Learning disabilities
Ocular:
Lens dislocation
Cardiovascular system:
Aortic dissection
Mitral valve prolapse
Respiratory:
Pneumothorax
Definition:
Karyotype 47XXY
Inheritance:
Sporadic
Clinical features:
Tall and slim
Cryptorchidism
Gynaecomastia
Learning disability
Azoospermia and infertility
Immature behaviour
Sotos syndrome (cerebral gigantism)
Inheritance:
Sporadic caused by mutations in the NSD1 gene
Clinical features:
Birthweight and length >90th centile
Excessive linear growth during the first few years (which characteristically falls back)
Head circumference is proportional to length
Large hands and feet
Large ears and nose
Intellectual retardation
Clumsiness
Assessment of a child with tall stature

Measure child and parents heights and compare with weight. Assess pubertal status. History and
clinical examination should identify an obvious cause or syndrome that can then be investigated.
Investigation of tall stature
Thyroid function
Bone age
Skeletal survey
Karyotype
3. HYPOTHALAMUS AND PITUITARY GLANDS

The hypothalamicpituitary axis is of vital importance because it regulates many of the other
endocrine glands in the body.
3.1 Anatomy
Hypothalamus
The hypothalamus lies between the preoptic area and the mamillary bodies. It interacts with the
frontal cortex, thalamus limbic system and brain stem. The axonal processes extend down into the
median eminence where regulatory hormones are secreted into the portal circulation.
Pituitary gland
The pituitary gland is a midline structure situated inferior to the hypothalamus within the pituitary
fossa. It consists of three lobes: the anterior and posterior lobes with a small intervening intermediate
lobe. The anterior and intermediate lobes are derived from the buccal mucosa whereas the posterior
lobe is derived from neural ectoderm. The anterior pituitary has five neuroendocrine cell types each
defined by the hormone they produce: corticotrophs (ACTH), somatotrophs (GH), gonadotrophs (LH,
FSH), thyrotrophs (thyroid-stimulating hormone or TSH) and lactotrophs (prolactin or PRL). The
posterior pituitary secretes oxytocin and antidiuretic hormone.
The development of the normal pituitary gland relies on a number of transcription factors called
homeobox genes and Prop-1 (prophet of Pit-1) is a homeobox gene necessary for the development of
GH-, PRL- and thyrotrophin-producing cells. HESX1 is a homeobox gene implicated in some forms
of septo-optic dysplasia.
3.2 Physiology of the hypothalamus

The hypothalamus plays important roles in appetite suppression and temperature control. Leptin is a
hormone encoded by the ob gene which is expressed primarily by adipocytes. Leptin provides the
body with information about nutritional status. The hypothalamus contains large numbers of leptin
receptors and plays an important role in controlling feeding behaviour and hunger. Leptin also plays a
significant role in the regulation of reproduction. Ghrelin is a gastric peptide that stimulates GH
secretion and increases adiposity. It acts at the GH secretagogue receptors located in the
hypothalamus and pituitary gland. Data also suggest a role for neuropeptide Y in the regulation of
body fat and its regulation by leptin.
3.3 Hormone physiology of the anterior pituitary

Growth hormone
Structure
GH is a 191-amino acid peptide (22 kDa) secreted by somatotrophs. It circulates in the unbound form
and also bound to binding proteins, which are portions of the extracellular receptor domain.
Function
GH has direct effects on carbohydrate and lipid metabolism. The growth-promoting effects of GH are
mediated by somatomedin C (otherwise known as IGF-1), which is produced in the liver cells after
GH binding to cell-surface receptors and results in gene transcription. IGF-1 and IGF-2 are 70-amino
acid peptides, structurally related to insulin. IGF-1 increases the synthesis of protein, RNA and DNA,
increases the incorporation of protein into muscle and promotes lipogenesis. The IGFs are bound to a
family of binding proteins (IGFBP-1 to -6), of which IGFBP-3 predominates. These binding proteins
not only act as transporters for the IGFs, but also increase their half-life and modulate their actions on
peripheral tissues.
Regulation
GH secretion is pulsatile, consisting of peaks and troughs. Nocturnal release occurs during nondreaming or slow-wave sleep, shortly after the onset of deep sleep. There is a gradual increase in GH
production during childhood, a further increase (with increased amplitude of peaks) during puberty
secondary to the effect of sex steroid, followed by a postpubertal fall.
Three peptides are critical to the control of GH secretion:
Growth hormone-releasing hormone (GHRH)
Growth hormone-releasing peptide (GHRP) ghrelin
Somatostatin
These peptides mediate stimulation, inhibition and feedback suppression of GH secretion, and form
the final common pathway for a network of factors that influence the secretion of GH, which include
sex steroids, environmental inputs and genetic determinants.
GHRH and somatostatin act via the activation of G-protein receptors on the somatotrophs, increasing
or reducing cAMP and intracellular Ca2+. GHRH stimulates GH release, whereas somatostatin
inhibits both GH synthesis and its release. GH and IGF-1 exert a tight feedback control on
somatostatin, and probably also on GHRH. GHRP ghrelin is an oligopeptide derivative of
enkephalin and is a 28-peptide residue predominantly produced by the stomach. It requires fatty
acylation of the N-terminal serine for biological activity. Ghrelin is released in response to acute and
chronic changes in nutritional state. The concentrations of ghrelin fall postprandially and in obesity,
and rise during fasting, after weight loss or gastrectomy, and in anorexia nervosa. GHRP and GHRH
act synergistically in the presence of a functioning hypothalamicpituitary axis.
Gonadotrophins
LH and FSH
Structure
LH and FSH are glycoproteins composed of an and a subunit. The subunits are identical to other
glycoproteins within the same species, whereas the subunits confer specificity.
Function
In the male, Leydig cells respond to LH, which stimulates the first step in testosterone production. In
the female, LH binds to ovarian cells and stimulates steroidogenesis.
FSH binds to Sertoli cells in the male, increases the mass of the seminiferous tubules and supports the
development of sperm. In the female, FSH binds to the glomerulosa cells and stimulates the
conversion of testosterone to oestrogen.
Regulation
Gonadotrophin-releasing hormone (GnRH) is released in a pulsatile fashion, which stimulates the
synthesis and secretion of LH and FSH. Expression and excretion of FSH are inhibited by inhibin, a
gonadal glycoprotein. This has no effect on LH. In the neonate there are high levels of gonadotrophins
and gonadal steroids. These decline progressively until a nocturnal increase occurs, leading up to the
onset of puberty (amplification of low-amplitude pulses).
Thyroid-stimulating hormone
Structure
TSH is a glycoprotein containing the same subunit as LH and FSH but a specific subunit.
Function
TSH is a trophic hormone and hence its removal reduces thyroid function to basal levels. It binds to
surface receptors on the thyroid follicular cell and works via activation of adenylyl cyclase to cause
the production and release of thyroid hormone.
Regulation
TSH synthesis and release are modulated by thyrotrophin-releasing hormone (TRH), which is
produced in the hypothalamus and secreted into the hypophyseal portal veins, from where it is
transported to the anterior pituitary gland. TRH secretion is influenced by environmental temperature,
somatostatin and dopamine. Glucocorticoids inhibit TSH release at a hypothalamic level.
Adrenocorticotrophic hormone
Structure
ACTH is a 39-amino acid peptide cleaved from a large glycosylated precursor (proopiomelanocortin or POMC) which also gives rise to melanocyte-stimulating hormone (MSH) and endorphin.
Function
ACTH is responsible for stimulation of the adrenal cortex, in particular the production of cortisol.
Hypothalamic control of its function is evident in the late-gestation fetus. ACTH plays a role in fetal
adrenal growth.
Regulation
Corticotrophin-releasing hormone (CRH) stimulates ACTH release via increasing cAMP levels.
Arginine vasopressin (AVP) also stimulates ACTH release and potentiates the response to CRH.
Prolactin
Structure
Prolactin has a similar amino acid sequence to GH, and acts via the lactogenic receptor, which is
from the same superfamily of transmembrane receptors as the GH receptor.
Function
Prolactin is responsible for the induction of lactation and cessation of menses during the puerperium.
During the neonatal period, prolactin levels are high secondary to fetoplacental oestrogen. It then falls
and remains consistent during childhood but there is a slight rise at puberty.
Regulation
Dopamine inhibition from the hypothalamus.
3.4 The neurohypophysis posterior pituitary

Water regulation
The body maintains water balance by regulating fluid intake and output. There is a narrow range of
normal serum osmolality between 280 and 295 mosmol/l.
Output
Controlled by:
Hypothalamic osmoreceptors and neighbouring neurons that secrete AVP
Concentrating effect of the kidney
Input
Controlled by:
Hypothalamic thirst centre
Arginine vasopressin
Structure
AVP is a nonapeptide containing a hexapeptide ring. It is produced as a pro-hormone in the supraoptic and paraventricular nuclei. Action potentials from the hypothalamus cause its release from the
posterior pituitary gland into the circulation.
Regulation
This is largely by the osmolality of extracellular fluid and haemodynamic factors. The release of AVP
is modulated by stimulatory and inhibitory neural input. Noradrenaline inhibits AVP release and
cholinergic neurons facilitate it.
Physiology
The normal mature kidney is able to produce urine in a concentration range of 601100 mosmol/kg.
The ability to vary urine concentration depends on the spatial arrangements and permeability
characteristics of the segments of the renal tubules.
AVP regulates the permeability of the luminal membrane of the collecting ducts. Low permeability in
the presence of a low AVP concentration leads to dilute urine.
3.5 Pituitary disorders

Anterior pituitary
Congenital:
Agenesis of the corpus callosum
Structural abnormalities:
Septo-optic dysplasia
Pituitary hypoplasia
Idiopathic hormonal abnormalities:
Isolated GH deficiency
Idiopathic precocious puberty
Acquired:
Excess:
Intracranial tumours
Cushing disease pituitary adenoma
Deficiency, e.g. secondary to treatment with radiation or surgery:
Pituitary damage
Tumours
Surgery
Radiotherapy
Trauma
Septo-optic dysplasia (De Morsier syndrome)
A developmental anomaly of the midline structures of the brain. Classically characterized by:
Absence of septum pellucidum and/or corpus callosum
Optic nerve hypoplasia
Pituitary hypoplasia with variable pituitary hormone deficiencies (most commonly this is GH
deficiency which may either be isolated or progress to an evolving endocrinopathy)
Treatment is by hormone replacement and management of visual difficulties.
Craniopharyngioma
This is one of the most common supratentorial tumours in children. It commonly presents with
headaches and visual field defects. On imaging, the tumour is frequently large and cystic. Treatment is
by resection plus radiotherapy if initial resection is incomplete or recurrence occurs.
Postoperative hormonal deficiencies are common, involving both anterior and posterior pituitary
hormones. Treatment is by hormonal supplementation. There is also the risk of hypothalamic damage.
Remember: the hypothalamus is responsible for other effects that are not so easily treated by
replacement therapy, e.g. temperature, appetite and thirst control. The obesity associated with
hypothalamic damage (secondary to hyperphagia) is very difficult to manage and has a poor
prognosis. The maintenance of fluid homeostasis in children with the combination of diabetes
insipidus and adipsia (loss of thirst sensation) can be a challenge.
Acquired endocrine problems secondary to tumours and/or their treatment
Short stature
Pubertal delay or arrest
Precocious puberty
Thyroid tumours
Infertility
Hypopituitarism isolated or multiple
Gynaecomastia
Posterior pituitary
Diabetes insipidus
Defined as insufficient AVP causing a syndrome of polyuria and polydipsia. With an intact thirst
mechanism copious water drinking maintains normal osmolalities. However, problems with the thirst
mechanism or insufficient water intake lead to hypernatraemic dehydration.
It is important to remember that cortisol is required for water excretion. Therefore in children with
combined anterior and posterior pituitary dysfunction, there is a risk of dilutional hyponatraemia if
they are cortisol deficient and receiving DDAVP (1-deamino-8-D-arginine vasopressin) treatment.
Hence the emergency management of the unwell child is to increase the hydrocortisone treatment and
to stop the DDAVP.
Causes of diabetes insipidus

Central:
Craniopharyngioma
Germinoma
Langerhans cell histiocytosis (LCH)
Idiopathic
Trauma
Nephrogenic:
X-linked nephrogenic diabetes insipidus
Secondary to renal damage
Syndrome of inappropriate ADH (SIADH) secretion

Defined by the criteria of:
Water retention with hypo-osmolality

Normal or slightly raised blood volumes
Less than maximally dilute urine
Urinary sodium > sodium intake
Causes of SIADH
CNS disorders: meningitis, abscess; trauma; hypoxicischaemic insult

Respiratory tract disease: pneumonia; cavitation
Reduced left atrial filling: drugs
Malignancies: lymphoma; bronchogenic carcinoma; idiopathic
Management of SIADH
Management focuses on treatment of the underlying cause and management of the fluid and electrolyte
imbalance. Accurate input and output charts are required as are twice daily weights in the initial
period of assessment. Fluid restriction is the mainstay of management.
3.6 Investigation of hypothalamic and pituitary hormone disorders

Anterior pituitary stimulation tests
Many hormones (e.g. GH, LH and FSH) are secreted in a pulsatile fashion, and therefore a random
measurement of the concentration of the circulating hormone is often inadequate for diagnosing a
deficiency disorder.
Hormone measurement tests include:
GH release/ACTH (via cortisol response): insulin tolerance test/glucagon stimulation test
TSH/prolactin response: TRH test
FSH/LH response: LHRH test
GH tests
Provocation tests of GH are potentially hazardous. Insulin tolerance tests should be performed only in
specialist centres because of the risk of severe hypoglycaemia. Other GH provocation tests include
the use of glucagon, arginine and clonidine. Physiological tests of GH secretion include a 24-h GH
profile and measurement of GH after exercise or during sleep.
Combined pituitary function test

The standard test involves the intravenous injection of either insulin or glucagon in combination with
TRH and LHRH (in the pubertal child).
Blood samples are taken at 0 min (before stimulation), 20, 30, 60, 90 and 120 min.
After insulin administration, a profound hypoglycaemia results in 20 min which needs to be corrected
by the use of an oral glucose solution or the judicious use of intravenous 10% dextrose. (Remember:
the rapid correction of hypoglycaemia with a hypertonic glucose solution can result in cerebral
oedema.)
GH concentrations rise at 30 min after insulin, or 6090 min after glucagon injection. A rise to over 6
mg/l rules out GH deficiency.
A normal TSH response to TRH is a rise at 20 min post-dose and then a fall by 60 min. A continued
rise of TSH at 60 min implies hypothalamic damage. Secondary hypothyroidism is demonstrated by a
low baseline TSH level, whereas primary hypothyroidism is associated with a raised TSH.
A raised baseline prolactin level suggests a lack of hypothalamic inhibition of its release. Under
normal circumstances, after the administration of TRH, prolactin would be expected to rise at 20 min
and then to be falling by 60 min.
In the absence of precocious puberty, the LHRH test will demonstrate only a rise in FSH and LH at 20
and 60 min during the first 6 months of life and in the peripubertal period. Raised baseline
gonadotrophin levels reflect gonadal failure.
Posterior pituitary function tests

Paired urine and serum osmolalities
Water deprivation test
The child is weighed in the morning and is then deprived of water for a maximum of 7 h, during
which time the childs weight, pulse rate and blood pressure, and urine osmolality are measured
hourly.
Plasma sodium levels and osmolality are measured every 2 h.
The test is terminated if the patients weight falls by 5% from the starting weight, serum osmolality
rises (>295 mosmol/kg of water) in the face of an inappropriately dilute urine (<300 mosmol/kg) or if
the patient becomes significantly clinically dehydrated/clinically unwell.
A diagnosis of diabetes insipidus (DI) may be made in the presence of a plasma osmolality >290
mosmol/kg of water with an inappropriately low urine osmolality.
The child is then given a dose of DDAVP and the urine and plasma osmolality are then measured. A
rise in urine concentration confirms a diagnosis of central DI, whereas a child with nephrogenic DI
will fail to concentrate urine after DDAVP.
3.7 Principles of management of hypothalamicpituitary disorders

Treatment of anterior pituitary deficiencies
When specific hormones or their stimulating hormones are deficient the actual hormone may be
replaced, e.g.:
Lack of GH response: replace with GH
However, if the deficient hormone is a trophic or regulatory hormone then it is the target hormone that
is replaced, e.g.:
Lack of TFT: replace with thyroxine

Low gonadotrophins: replace with testosterone in males, oestrogen in females
ACTH: replace with hydrocortisone
Vasopressin: replace with DDAVP
Growth hormone treatment

The following are the licensed indications for treatment with GH.
These recommendations have been endorsed by the National Institute for Health and Clinical
Excellence (NICE):
Documented GH deficiency congenital or acquired

Turner syndrome
Chronic renal failure
Small for gestational age
GH deficiency should be treated by a specialist who has experience of managing children with
growth disorders. Most regimens involve daily injections with different doses of GH depending on
the indications. Close local community liaison is required for this.
Panhypopituitarism
Panhypopituitarism is much less common than isolated hormone deficiency and may develop as an
evolving endocrinopathy. Management includes replacement with GH, thyroxine, cortisol during
childhood with induction and maintenance of puberty with the appropriate sex hormone (testosterone
or estradiol). Parents of children who are cortisol or ACTH deficient should be given written
instructions and training in the management of an acute illness and must have emergency supplies of
intramuscular hydrocortisone available at all times.
Treatment of posterior pituitary deficiencies

Central diabetes insipidus
Treatment with DDAVP (desmopressin) as either a nasal spray or tablets
4. PUBERTY
4.1 Physiology of normal puberty
The clinical manifestations of normal pubertal development occur secondary to sequential changes in
endocrine activity.
Hormonal control of puberty
Hormonal control of puberty.

The pulsatile release of GnRH from the hypothalamus leads to the secretion of LH and FSH from the
gonadotrophin cells of the pituitary gland.
In the male, Leydig cells respond to LH, which stimulates the first step in testosterone production. In
the female, LH binds to ovarian cells and stimulates steroidogenesis. FSH binds to Sertoli cells in the
male where it increases the mass of the seminiferous tubules and supports the development of sperm.
In the female, FSH binds to the glomerulosa cells and stimulates the conversion of testosterone to
oestrogen.
Sex steroids
Testosterone is produced by the Leydig cells of the testes. It is present in the circulation bound to sex
hormone-binding globulin (SHBG). Free testosterone is the active moiety at the level of target cells.
Testosterone is then converted either to dihydrotestosterone (DHT) by 5-reductase or to oestrogen
by aromatase. Both DHT and testosterone attach to nuclear receptors, which then bind to steroidresponsive regions of genomic DNA to influence transcription and translation.
Oestrogen is produced by the follicle cells of the ovary. The main active form of oestrogen is
estradiol. This circulates bound to SHBG and causes growth of the breasts and uterus, and the female
distribution of adipose tissue, and increases bone mineralization.
Inhibin
Inhibin is a glycoprotein produced by Sertoli cells in males and granulosa cells in females.
SHBG
Androgens reduce SHBG formation, and oestrogens stimulate its formation. Therefore increased free
testosterone levels magnify androgen effects.
Hormonal regulation
In the presence of GnRH the gonadotrophins are controlled by the sex steroids and inhibin. LH and
FSH levels are under the influence of negative feedback mechanisms in both the hypothalamus and the
pituitary. Inhibin inhibits only FSH and acts at the level of the pituitary.
Positive feedback also occurs during mid-puberty in females. Increased oestrogen primes
gonadotrophins to produce LH until, at a critical stage at the middle of the menstrual cycle, a large
surge occurs causing ovulation.
4.2 Clinical features of normal puberty

The physical changes of pubertal development may be described by an objective method derived by
Tanner.
Tanner stages
Male genitalia development
Stage 1: pre-adolescent
Stage 2: enlargement of scrotum and testes and changes in scrotal skin
Stage 3: further growth of testes and scrotum; enlargement of penis
Stage 4: increase in breadth of penis and development of glans; further growth of scrotum and testes
Stage 5: adult genitalia in shape and size
Female breast development
Stage 2: breast-bud formation
Stage 3: further enlargement and elevation of breast and papilla with no separation of their contours
Stage 4: projection of areola and papilla to form a secondary mound above the level of the breast
Stage 5: mature stage with projection of papilla only
Pubic hair
Stage 2: sparse growth of long, slightly pigmented, downy hair
Stage 3: hair spread over junction of the pubes, darker and coarser
Stage 4: adult-type hair, but area covered is smaller
Stage 5: adult in quantity and type
Axillary hair
Stage 1: no axillary hair
Stage 2: scanty growth
Stage 3: adult in quantity and type
Puberty starts on average at age 12 years in boys and 10 years in girls. As nutrition and health
improve, the age of onset of puberty is becoming earlier with each generation.
In the male, acceleration in growth of the testes (from a prepubertal 2 ml volume) and scrotum is the
first sign of puberty. This is followed by reddening and rugosity of scrotal skin, and later by
development of pubic hair, penile growth and axillary hair growth.
A 4 ml testicular volume signifies the start of pubertal change.
Peak height velocity occurs with testicular volumes of 1012 ml.
In the female, the appearance of the breast bud and breast development are the first sign of puberty. It
is due to production of oestrogen from the ovaries. This is followed by the development of pubic and
axillary hair, which is controlled by the adrenal gland. Peak height velocity coincides with breast
stage 23. Menarche occurs late at breast stage 4, by which stage growth is slowing down. Most girls
have attained menarche by age 13 years.
Body composition
Prepubertal boys and girls have equal lean body mass, skeletal mass and body fat. The earliest
change in puberty is an increase in lean body mass.
Growth spurt
The pubertal growth spurt is the most rapid phase of growth after the neonatal period. This is an early
event in girls and occurs approximately 2 years earlier than in boys, i.e. at a mean age of 12 years.
The mean height difference between males and females of 12.5 cm is due to the taller male stature at
the time of pubertal growth spurt and increased height gained during the pubertal growth spurt.
Adrenarche
Adrenal androgens, dehydroepiandrosterone sulphate (DHEAS) and androstenedione, rise
approximately 2 years before gonadotrophins and sex steroids rise. Adrenarche begins at 68 years
of age and continues until late puberty. Control of this is unknown. Adrenarche does not influence
onset of puberty.
Gynaecomastia
Gynaecomastia is physiological and occurs in 75% of boys to some degree (usually during the first
stages of puberty), but most regress within 2 years. Management is by reassurance, support and
weight loss if obesity is a factor.
Causes of gynaecomastia
Normal puberty (common)

Obesity (common)
Partial androgen insensitivity
4.3 Abnormal puberty

Early (precocious):
<9 years in boys
<8 years in girls
Discordant (abnormal pattern)
Delayed:
>14 years in boys
>13 years in girls
Precocious puberty
Definition
Central precocious puberty is consonant with puberty (i.e. occurs in the usual physiological pattern of
development but at an earlier age). It is due to premature activation of the GnRH pulse generator. In
girls, often no underlying cause is found; however, it is almost always pathological in males.
Causes of true precocious puberty (gonadotrophin dependent)
Idiopathic
CNS tumour
Neurofibromatosis
Septo-optic dysplasia in this rare condition precocious puberty may occur in the presence of
deficiencies of other pituitary hormones (see Section 2.4)
Causes of gonadotrophin-independent precocious puberty

McCuneAlbright syndrome (usually due to ovarian hypersecretion)
Testicular/ovarian tumours
Liver or adrenal tumours may cause virilization
Useful tests for the investigation of precocious puberty
Estradiol/Testosterone
Adrenal androgens, including 17-hydroxyprogesterone
LHRH stimulation test
Bone age
Pelvic ultrasound scan
Brain magnetic resonance imaging (MRI)
Abdominal computed tomography (CT) if adrenal/liver tumour suspected
Management of precocious puberty

A GnRH analogue (GnRHa) may be used to halt the progression of puberty. Children who enter
puberty early are tall initially, but end up as short adults due to premature closure of epiphyses.
Although GH has been used in addition to GnRHa, there is no clear evidence that final height is
improved.
Discordant puberty (abnormal pattern)
Breast development only gonadotrophin-independent precocious puberty, e.g. McCuneAlbright
syndrome
Inadequate breast development, e.g. gonadal dysgenesis, Poland anomaly
Androgen excess pubic hair, acne, clitoral enlargement, e.g. CAH, Cushing disease, polycystic
ovarian syndrome (PCO), adrenal neoplasm
Inadequate pubic hair, e.g. androgen insensitivity, adrenal failure
No menarche, e.g. polycystic ovaries/rarely absent, abnormal uterus, imperfect hymen
No growth spurt, e.g. hypothalamicpituitary disorders, skeletal dysplasias
Premature thelarche
Usually in girls aged between 1 and 3 years

Isolated breast development (never more than stage 3)
No other signs of puberty
Normal growth velocity for age
Normal bone age
Prepubertal gonadotrophin levels
Progress to puberty at normal age
Delayed puberty
Definition
No signs of puberty at an age when pubertal change would have been expected.
Causes of delayed puberty

Constitutional delay of growth and puberty
Hypothalamic or pituitary disorders:
Hypogonadotrophic hypogonadism
Idiopathic
Pituitary tumours
Post-central irradiation
Post-intracranial surgery
Post-chemotherapy
Anorexia nervosa
Systemic disease
Kallman syndrome hypogonadotrophic hypogonadism with anosmia
Gonadal dysgenesis:
Turner syndrome
Hypothyroidism
At least 17 different single gene mutations are recognized to cause delayed puberty in humans.
Several of these genes are involved in the development of the olfactory system and are frequently
associated with the clinical features of Kallman syndrome. The KAL1 gene codes for a protein called
anosmin 1 which helps control the growth and migration of neurons that form the olfactory bulb and
those that produce GnRH.
Investigation of delayed puberty in boys
In otherwise well boys with short stature and delayed puberty the most likely cause is constitutional
delay. Initially this requires no investigations apart from a bone age. If after a trial of treatment there
is no progression of puberty, further investigations may be needed including the following:
In boys:
LH, FSH, testosterone

LHRH test
Karyotyping
In girls, delayed puberty must always be investigated:
Karyotyping
LH, FSH, oestrogen
LHRH test
Pelvic ultrasonography
Treatment
Constitutional delay
Reassurance
Androgens: oxandrolone orally daily or depot testosterone injection monthly
Reassess at 46 months
Other causes of delayed puberty
Treat underlying cause
Induce and maintain puberty with testosterone in boys, ethinylestradiol in girls
Pathways of adrenal hormone synthesis.
5. THE ADRENAL GLAND

5.1 Anatomy
The adrenals are triangular in shape and located at the superior pole of the kidneys. Each adrenal
gland is made up of cortex, arising from mesoderm at the cranial end of the mesonephros, and
medulla, which arises from neural crest cells.
The cortex consists of three zones:
Zona glomerulosa: produces aldosterone

Zona fasciculata: produces cortisol/androstenedione
Zona reticularis: produces DHEAS
5.2 Physiology
Cortex
The adrenal cortex has three principal functions:
Glucocorticoid production (cortisol)
Mineralocorticoid production (aldosterone)
Androgen production (testosterone, androstenedione)
Glucocorticoids
Cortisol is the principal glucocorticoid. It plays a vital role in the bodys stress response and is an
insulin counter-regulatory hormone increasing gluconeogenesis, hepatic glycogenolysis, ketogenesis
necessary for the action of other hormones, e.g. noradrenaline, adrenaline, glucagons.
It influences other organ physiology:
Normal blood vessel function

Cardiac and skeletal muscle
Nervous system
Inhibition of the inflammatory response of tissues to injury
Secretion of a water load
Cortisol secretion is under pituitary control by ACTH. ACTH has a circadian rhythm, being at its
lowest at midnight and rising in the early morning. There is also a negative feedback loop from
cortisol. ACTH acts via cAMP and causes a flux of cholesterol through the steroidogenic pathway.
Mineralocorticoids
Aldosterone has the main mineralocorticoid action:
It increases sodium reabsorption from urine, sweat, saliva and gastric juices in exchange for
potassium and hydrogen
The secretion of aldosterone is primarily regulated by the reninangiotensin system, which is
responsive to electrolyte balance and plasma volumes. Hyponatraemia and hyperkalaemia can also
have a direct aldosterone stimulatory effect. ACTH can produce a temporary rise in aldosterone but
this is not sustained.
Renin
Renin is a glycoprotein synthesized in the juxtaglomerular apparatus, and stored as an inactive proenzyme in cells of the macula densa of the distal convoluted tubule. Its release is stimulated by
reduced renal perfusion, hyperkalaemia and hyponatraemia.
Renin hydrolyses angiotensin to form angiotensin I (an 2-globulin synthesized in the liver). This is
converted to angiotensin II by angiotensin-converting enzyme (ACE). ACE is present in high
concentrations in the lung, but is also widely distributed in the vasculature for local angiotensin II
release.
Adrenal androgens
These include testosterone, androstenedione and DHEAS. Secretion varies with age and, although
responsive to ACTH, do not always parallel the cortisol response.
5.3 Disorders of the adrenal gland

Medulla
Phaeochromocytoma
Catecholamine-secreting tumour. Malignancy is uncommon, but 10% are bilateral. Catecholamine
excess leads to sustained hypertension. Phaeochromocytomas are associated with von Recklinghausen
disease, von HippelLandau disease and syndromes of multiple endocrine neoplasia (MEN).
Investigation
MIBG (meta-iodobenzylguanidine) isotope scans
Plasma and urine catecholamine measurement
Management
The management of phaeochromocytoma is by surgical excision. Preoperative management requires
both - and -adrenoceptor blockade in order to prevent an acute hypertensive crisis or cardiac
dysrhythmias.
Cortex
Adrenal insufficiency
Causes
Primary:
Idiopathic

Adrenal haemorrhage
Addison disease
TB
Autoimmune disease
Iatrogenic
Secondary:
Pituitary hypoplasia
Isolated ACTH deficiency
Panhypopituitarism
Tumour, e.g. craniopharyngioma
Addison disease
Definition:
Adrenal hypofunction
Aetiology:
Autoimmune
Secondary to TB
Associated with adrenal leukodystrophy
Presentation:
Often with non-specific symptoms of tiredness and abdominal pain
May present with collapse related to a salt-losing crisis
Investigation of adrenal cortical insufficiency
The Synacthen test, which assesses the ability of the stimulated adrenal glands to mount a hormone
response. A dose of synthetic ACTH is given and the cortisol level measured after 30 and 60 min.
A normal adrenal response would be a cortisol level >450550 nmol/l at 30 min
A 24-h blood cortisol profile assesses the natural secretion from the adrenal gland. This would be
expected to show the normal diurnal rhythm of cortisol secretion, with an increase in the morning
and a nadir at midnight
Treatment
Glucocorticoid and mineralocorticoid replacement using hydrocortisone and fludrocortisone,
respectively. At the time of illness, injury or acute stress, the body naturally increases the output of
corticosteroids from the adrenal glands. A person on replacement hydrocortisone needs to mimic this
process and to increase his or her hydrocortisone at these times. It is therefore important that a steroid
users card is carried at all times to alert medical professionals at the time of an emergency.
Adrenal steroid excess (Cushing syndrome)
Cushing syndrome is a syndrome of cortisol excess. Cushing disease is the term used when this is
secondary to a pituitary ACTH-producing tumour (adenoma).
Causes
Primary: adrenal tumour
Secondary: pituitary ACTH-secreting tumour; ectopic ACTH production

Iatrogenic: exogenous administration of steroids
Clinical features
Obesity central distribution of fat buffalo hump
Purple striae
Hypertension
Osteoporosis
Hypogonadism
Growth failure
Muscle wasting/hypotonia
Investigations
24-h urine cortisol
24-h profile (loss of circadian rhythm, no suppression of midnight cortisol level)
Dexamethasone suppression test
MRI of the brain/CT of the adrenals
CAH describes the deficiency of one of the enzymes in the biosynthetic pathway of the adrenal cortex.
The classic type is deficiency of the enzyme 21-hydroxylase.
Genetics
Two genes encoding 21-hydroxylase expression have been localized to the short arm of chromosome
6, namely CYP21B and CYP21A. Deletion of CYP21B is associated with severe salt wasting and
HLA-B47, -DR7 haplotype.
Pathophysiology
In classic CAH, there is a block in the production of cortisol and aldosterone with a build-up of 17hydroxyprogesterone, the precursor before the block. The continuing ACTH drive leads to the
precursors being directed along the androgen biosynthetic pathway, causing virilization.
Presentation
Ambiguous genitalia (in girls with 21-hydroxylase deficiency, and occasionally in boys with 3hydroxy-steroid dehydrogenase deficiency)
Salt-losing crisis and hypotension
Hypertension may occur in 11-hydroxylase deficiency
Precocious puberty (in boys)
Virilization
Investigation
Karyotype
17-Hydroxyprogesterone (17-OHP)
Urine steroid profile (metabolite pattern will help in diagnosing specific enzyme block)
Adrenal androgen levels
Bone age in older children

Treatment
Hydrocortisone and fludrocortisone replace the deficient steroids and also suppress the ACTH drive
to the adrenal androgens. Growth is a good method of monitoring replacement therapy. Children who
grow excessively fast with increased height velocity either are getting inadequate doses or may be
non-compliant. 17-OHP levels are also useful for monitoring treatment.
It is important to teach parents to recognize signs of illness and to be able to administer emergency
hydrocortisone
Additional sodium chloride replacement is also required during the first year of life and
electrolytes may need to be monitored over this period
Surgery may be required in girls with virilization
Side effects of glucocorticoid treatment
When glucocorticoids are used in non-physiological doses such as in asthma, chronic renal failure or
rheumatological and Immunological conditions, the following side effects may be seen:
Gastritis
Osteoporosis
Raised blood glucose/altered glucose tolerance
Increased appetite and weight gain
Increased susceptibility to infection
Poor healing
Menstrual irregularities
Unpredictable mood changes
Sleep disturbances
Increased risk of glaucoma and cataracts
6. THE THYROID GLAND

6.1 Anatomy
The thyroid gland is formed from a midline outpouching of ectoderm of the primitive buccal cavity,
which then migrates caudally. It consists of follicles made of colloid surrounded by follicular cells
and basement membrane. Thyroid hormone is synthesized at a cellular level and stored in
thyroglobulin, a glycoprotein that is the main constituent of the colloid. Between the follicular cells
are the parafollicular cells (C-cells), which are of neurogenic origin and secrete calcitonin.
6.2 Physiology
The function of the thyroid gland is to concentrate iodine from the blood and return it to peripheral
tissues in the form of thyroid hormones (thyroxine or tetraiodothyronine [T4] and triiodothyronine
[T3]). In blood, the hormones are linked with carrier proteins, e.g. thyroxine-binding globulin and
pre-albumin. T4 is metabolized in the periphery into T3 (more potent) and reverse T3 (less potent).
Hormonogenesis
Steps include:
1. Follicular cells actively uptake and tap iodine from the blood
2. Synthesis of thyroglobulin
3. Organification of trapped iodine as iodotyrosines (monoiodotyrosine [MIT] and diiodotyrosine
[DIT])
4. Coupling of iodotyrosines to form iodothyronines and storage in the follicular colloid
5. Endocytosis of colloid droplets and hydrolysis of thyroglobulin to release T3, T4 and MIT and DIT
6. Deiodination of MIT and DIT with intrathyroid recycling of the iodine
Thyroid hormone acts by penetrating binding to a specific nuclear receptor. It modulates gene
transcription and mRNA synthesis which leads to increased mitochondrial activity
6.3 Regulation
Thyroid hormone release is regulated by TSH and iodine levels. TSH has both immediate and
delayed actions on thyroid hormone secretion.
Immediate actions:
Stimulates binding of iodide to protein
Stimulates thyroid hormone release
Stimulates pathways of intermediate metabolism
Delayed action (several hours):
Stimulates trapping of iodide
Stimulates synthesis of thyroglobulin
Physiological variations in iodide modulate trapping by the thyroid membrane.
Iodide inhibits the stimulation of cAMP by TSH and pharmacological doses block organification.
6.4 Functions of thyroid hormone

Thyroid hormone has multiple physiological actions as follows:
Growth and development (required for somatic and neuronal growth)
Thermogenesis
Catabolism (increased glycogenolysis, lipolysis and fee fatty acid oxidation)

It also potentiates the actions of catecholamines
6.5 Investigation and management of thyroid disorders
Baseline blood tests: free T4/T3/TSH measurements

Stimulation tests: TRH test
Thyroid ultrasound scan
Radionuclide scans
In primary hypothyroidism, T4 will be low and associated with a raised TSH. In hyperthyroidism, T4
will be raised and TSH suppressed.
In secondary hypothyroidism, T4 will be low in association with a low TSH. Further investigation is
with a TRH test. This involves the injection of TRH followed by measurement of TSH at 30 and 60
min post-dose. In an individual with normal thyroid function, TSH would rise at 30 min but fall by 60
min. However, in patients with hypothalamic dysfunction, TSH would continue to rise at 60 min postinjection.
Sick thyroid syndrome refers to the scenario of a variety of abnormalities on thyroid function testing
in an unwell patient that spontaneously resolve as the illness improves. Usually there is a normal free
T4 level with raised TSH.
Thyroid ultrasound scans can identify nodules or cysts. Functional assessment can be made using the
technetium radionuclides. Uptake is increased in thyrotoxicosis and reduced in thyroiditis.
Furthermore, it may reveal a cold nodule which might be suggestive of malignancy.
6.6 Disorders of thyroid function

Hypothyroidism
Hypothyroidism may be primary (thyroid gland) or secondary (central). Furthermore it may be
congenital or acquired. However, the most common cause of thyroid dysfunction is iodine deficiency
disorder (IDD). Salt iodization has proven a cost-effective solution.
Primary hypothyroidism
Congenital:
Thyroid dysgenesis
Agenesis
Hypoplasia
Ectopic gland
Biosynthetic defects
Maternal thyroid disorder

Acquired:
Autoimmune
Post-surgery
Post-cervical irradiation
Systemic disorders
Iodine deficiency
Iodine overload
Secondary hypothyroidism
Congenital:
Congenital pituitary abnormalities
Receptor resistance
Acquired:
Post-cranial irradiation
Post-tumour
Post-surgery
Congenital hypothyroidism has an incidence of 1/4000 live births. Most cases of thyroid dysgenesis
are sporadic. The TSH receptor is critical for gland development and inactivating mutations may
cause a range of severity of hypothyroidism. An activation mutation in GNAS1 causes McCune
Albright syndrome. Thyroid dyshormonogenesis has an autosomal recessive inheritance and mutations
of SLC26A4 cause Pendred syndrome. Transient congenital hypothyroidism may be due to maternal
anti-TSH antibodies or heterozygous DUOX2 mutations.
The most common cause of acquired hypothyroidism is autoimmune.
Screening for congenital hypothyroidism
TSH is measured as part of the newborn screening programme performed between days 5 and 7 of
life. A blood spot from a heel prick is put on to a filter paper. Concentrations of TSH >10 mU/l are
picked up by this test and abnormal results are immediately notified by the test centre to the relevant
local hospital/specialist unit or the GP.
This screening programme detects >90% of cases of congenital hypothyroidism. Those due to
secondary (pituitary causes) are picked up as TSH levels are low.
It is essential that treatment with oral thyroxine is started as soon as the definitive measurements of
TSH and free T4 have been performed because delay may lead to a lower IQ and affect psychomotor
development.
Management of hypothyroidism
Treatment is with L-thyroxine and is monitored by regular measurements of free T4 and TSH.
Hyperthyroidism
Thyrotoxicosis is uncommon in childhood but rises to 3/100 000 in adolescence with a female:male
ratio of 8:1; 95% of young people with thyrotoxicosis have Graves disease which is caused by
stimulatory antibodies to the TSH receptor. This is a multisystem disorder affecting the skin, eyes and
thyroid gland. Very rarely a monogenic cause is found caused by activating mutations in the TSH
receptor gene or GNAS1.
Causes of thyrotoxicosis
Autoimmune thyroiditis, e.g. Graves disease

Diffuse toxic goitre
Nodular toxic goitre
TSH induced
Factitious
Neonatal thyrotoxicosis is a rare condition caused by the transplacental passage of thyroidstimulating antibodies from mothers with either Graves disease (active or inactive) or Hashimoto
thyroiditis. The neonate usually presents with a rapidly developing tachycardia, dysrhythmia,
hypertension and weight loss. A goitre may be present. There may also be associated jaundice and
thrombocytopenia. The condition is usually self-limiting in 412 weeks but severely affected
neonates will require treatment with propranolol, carbamazepine and Lugols iodine. A response is
usually seen within 2436 hours.
Thyroid neoplasia
This usually presents as solitary nodules, of which 50% are benign adenomas or cystic lesions. The
prevalence of malignancy in childhood is 3040% and the risk increases following radiation to the
neck during infancy or early childhood. Hyperfunctioning adenomas are rare and most (90%) are
well-differentiated follicular carcinomas.
Medullary carcinoma may occur as part of the MEN II (hyperparathyroidism and
phaeochromocytoma) syndrome.
Management of hyperthyroidism
Initial medical treatment:
Suppression of thyroid hormone secretion using specific antithyroid treatments, e.g. carbimazole,
propylthiouracil
Blunting the peripheral effects of the thyroid hormones using blockade, e.g. propranolol
Definitive treatment:
This is contemplated if there has been no remission in symptoms on medical treatment, and may
involve subtotal thyroidectomy or radioactive iodine, which is becoming an increasingly popular
choice for teenagers. The mortality rate is 1/1000 for thyroidectomies and morbidity includes
recurrent laryngeal nerve damage and hypoparathyroidism
7. DIABETES AND HYPOGLYCAEMIA

7.1 Physiology of glucose homeostasis
The concentration of glucose in the blood is maintained by a balance between food intake or glucose
mobilization from the liver and glucose utilization. Homeostatic mechanisms keep this within a
narrow range.
In the fed state, insulin release is stimulated by a raised glucose and amino acid concentration. It is
also stimulated by gut hormone release. In the fasting state, blood glucose concentrations fall and
insulin production is turned off under the influence of somatostatin. A low glucose concentration is
sensed by the hypothalamus, which regulates pancreatic secretion and stimulates the release of the
counter-regulatory hormones glucagon, ACTH, GH, prolactin and catecholamines.
Actions of insulin
Liver:
Conversion of glucose to glycogen
Inhibits gluconeogenesis
nhibits glycogenolysis
Peripheral:
Stimulates glucose and amino acid uptake by muscle
Stimulates glucose uptake by fat cells to form triglycerides
Actions of the counter-regulatory hormones
Inhibition of glucose uptake

Stimulation of amino acid release by muscle
Stimulation of lipolysis to release free fatty acids which can be oxidized to form ketones
Stimulation of gluconeogenesis and glycogenolysis
7.2 Diabetes mellitus

Definition
The World Health Organization (WHO), in its 2006 publication, defines diabetes as a fasting blood
>7 mmol/l or a blood glucose 2 h after a glucose load >11.1 mmol/. In 2011 an addendum to these
diagnostic criteria was added as a glycated haemoglobin (HbA1c) of >6.5%. A glucose tolerance test
is not routinely necessary for the diagnosis.
Epidemiology
The UK annual incidence is 20 per 100 000 children. Many countries report a rising incidence,
particularly in children <5 years of age. Peaks occur at age 46 years and 1014 years. There is no
clear pattern of inheritance but there is an increased risk if a family member is affected. A person has
a 10% risk of developing type 1 diabetes mellitus if they have an affected sibling.
Aetiology of diabetes in children

Type 1 diabetes mellitus (95%):
Autoimmune destruction of the pancreatic islet cells
Type 2 diabetes mellitus:
A combination of -cell failure and insulin resistance
Cystic fibrosis-related diabetes
Maturity-onset diabetes of the young (MODY)
Genetic syndromes (Down syndrome, Wolfram syndrome, DIDMOAD and neonatal diabetes)
The most common type of diabetes in childhood is type 1.
Risk factors for type 2 diabetes
Family history of type 2 diabetes

High-risk ethnic groups (African, Caribbean, Asian, Hispanic)
Obesity
Female sex
Clinical signs of insulin resistance (acanthosis nigricans, POS)
Biochemical signs of insulin resistance (high insulin or C-peptide)
Pubertal
Absence of islet cell antibodies
Physiology of diabetes in -cell failure in type 1 diabetes mellitus

Low insulin level ultimately leads to ketoacidosis through the following mechanisms:
Liver glycogen mobilization to form glucose
Muscle protein breakdown to form free amino acids
Adipose tissue breakdown of triglycerides to form free fatty acids which are oxidized to form
ketone bodies
As the blood glucose level increases, the glucose in the glomerular filtrate exceeds the ability of the
proximal tubules to reabsorb it. This leads to glycosuria. Polyuria then occurs, as the loop of Henle is
unable to concentrate the urine because the renal tubules are insufficiently hyperosmolar.
Extracellular volume depletion leads to thirst and polydipsia.
Differential diagnosis of polyuria and polydipsia
Diabetes mellitus
Diabetes insipidus:
Cranial arginine vasopressin deficiency
Nephrogenic AVP insensitivity
Habitual water drinking
Drug induced
Presentation of childhood diabetes

Children usually present acutely with polyuria (including nocturia and incontinence), thirst,
polydipsia. About 40% have diabetic ketoacidosis. Other symptoms are weight loss, fatigue,
infections (e.g. abscess formation, urinary tract infections), muscle cramps and abdominal pain.
Management of a child with newly diagnosed diabetes

In 2004 NICE published specific guidance on the management of type 1 diabetes in children and
young people. Diabetic ketoacidosis (DKA) is the most common presentation of type 1 diabetes and
the most common cause of diabetes-related death in children.
DKA is defined as:
hyperglycaemia (glucose >11 mmol/l)
pH <7.3
bicarbonate <15 mmol/l
and patients who are:
5% or more dehydrated
and/or vomiting
and/or drowsy
and/or clinically acidotic
National guidelines were published in 2009 by the British Society of Paediatric Endocrinology and
Diabetes for the management of DKA.
Principles of management of DKA
General resuscitation
If there is evidence of shock (tachycardia, poor peripheral pulses, poor capillary refill and /or
hypotension) then give 10 ml/kg of 0.9% saline and repeat as necessary to a maximum of 30 ml/kg.
Confirm the diagnosis

This is confirmed by clinical assessment, capillary blood glucose testing, blood gas and urine or
blood ketone measurement.
Full clinical assessment
This should include an assessment of dehydration and conscious level.
Fluid management
Requirement = Maintenance + Deficit
Fluid already given
Maintenance requirements:
Weight
Fluid requirement
012.9 kg
1319.9 kg
3559.9 kg
(>60 kg)
80 ml/kg per 24 h
55 ml/kg per 24 h
45 ml/kg per 24 h
35 ml/kg per 24 h
Deficit (litres) = Percentage dehydration Bodyweight (kg)

For most children, use 58% dehydration to calculate fluids.
Hourly rate = [48 h maintenance + Deficit Resuscitation fluid already given]/48
Initially use 0.9% saline with 20 mmol KCl in 500 ml, and continue this sodium concentration for at
least 12 hours. Once the blood glucose has fallen to 14 mmol/l add glucose to the fluid. After 12 h, if
the plasma sodium level is stable or increasing, change to 500 ml bags of 0.45% saline/5%
glucose/20 mmol KCl. If the plasma sodium is falling, continue with 0.9% saline
Insulin
DO NOT start insulin until intravenous fluids have been running for at least an hour. The insulin
solution should then run at 0.1 units/kg per hour. For children who are already on long-acting insulin
you may want this to continue at the usual dose and time throughout the DKA treatment, in addition to
the intravenous insulin infusion, in order to shorten length of stay after recovery from DKA.
Cerebral oedema
The signs and symptoms of cerebral oedema include:
Headache and slowing of heart rate
Change in neurological status (restlessness, irritability, increased drowsiness, incontinence)
Specific neurological signs (e.g. cranial nerve palsies)
Rising BP, decreased O2 saturation

Abnormal posturing
The following measures should be taken immediately while arranging transfer to the paediatric
intensive care unit (PICU):
Exclude hypoglycaemia as a possible cause of any behaviour change
Give hypertonic (2.7%) saline (5 ml/kg over 510 min) or mannitol 0.51.0 g/kg stat (= 2.55
ml/kg mannitol 20% over 20 min)
Restrict intravenous fluids to 1/2 maintenance and replace deficit over 72 rather than 48 h
The child will need to be moved to PICU (if not there already)
Discuss intubation with PICU consultant
Long-term management of diabetes
Children and young people with type 1 diabetes should be offered an ongoing integrated package of
care by a multidisciplinary paediatric diabetes care team.
The target for long-term glycaemic control is an HbA1c level <7.5% (to minimize the risk of longterm complications) without frequent disabling hypoglycaemia.
Children and young people with type 1 diabetes should be offered screening for the following:
Coeliac disease at diagnosis and at least every 3 years thereafter until transfer to adult services
Thyroid disease at diagnosis and annually thereafter until transfer to adult services
Retinopathy annually from the age of 12 years
Microalbuminuria annually from the age of 12 years
Blood pressure annually from the age of 12 years
Insulin regimens
One, two or three insulin injections per day
These are usually injections of short-acting insulin or rapid-acting insulin analogue mixed with
intermediate-acting insulin.
Multiple daily injection regimen
The person has injections of short-acting insulin or rapid-acting insulin analogue before meals,
together with one or more separate daily injections of intermediate-acting insulin or long-acting
insulin analogue.
Continuous subcutaneous insulin infusion
A programmable pump and insulin storage reservoir attached to a subcutaneous needle or cannula
give a continuous amount of rapid-acting insulin analogue as basal insulin and via which bolus insulin
may be given.
Diet
The aim is for a healthy balanced diet. The intensive insulin regimens allow for a more flexible eating
pattern because the rapid-acting insulin can be adjusted according to the carbohydrate content of
individual meals. However, the twice-daily insulin regimen requires a consistency of meal times with
regular snacks and consistent carbohydrate content of meals.
Exercise
Exercise is important to maintain cardiovascular fitness but also reduces blood glucose levels.
Blood glucose testing
Capillary blood glucose testing many times daily is essential to monitor glycaemic control and
enables insulin dose adjustment. In addition continuous glucose monitoring systems are available.
Hypoglycaemia in a child on insulin treatment
Hypoglycaemia in a person on glucose-lowering treatment is defined as a blood glucose <4 mmol/l.
The symptoms may be divided into neuroglycaemic and adrenergic, and include weakness, trembling,
dizziness, poor concentration, hunger, sweating, pallor, aggressiveness, irritability and confusion.
The initial management of hypoglycaemia is to have refined sugar, e.g. glucose tablets, followed by a
complex carbohydrate food, e.g. a biscuit or sandwich. If the hypoglycaemic child is unconscious or
unable to cooperate with glucose administration orally, then intramuscular glucagon may be
administered.
7.3 Hypoglycaemia
Causes of hypoglycaemia
Inadequate glucose production:
Counter-regulatory hormone deficiencies
Glycogen storage disease
Enzyme deficiency, e.g. galactosaemia
Excessive glucose consumption, i.e. hyperinsulinism:
Transient
Infant of a mother with diabetes
BeckwithWiedemann syndrome
Persistent:
Persistent hyperinsulinaemic hypoglycaemia of infancy
Insulinoma
Exogenous insulin
Investigation of hypoglycaemia
Blood taken for a diagnostic screen is useful only if taken when the patient is hypoglycaemic (glucose
<2.6 mmol/l) and should include the following:
Blood:
Glucose
Insulin (C-peptide)
Cortisol
GH
Lactate
Free fatty acids
Amino acids
Ketone bodies (-hydroxybutyrate and acetoacetate)
Acylcarnitines
Urine:
Organic acids
In hypoglycaemic states in the absence of ketones it is important to look at the free fatty acids (FFAs).
Normal FFAs suggest hyperinsulinism and raised FFAs a fatty-acid oxidation defect. Hypoglycaemia
in the presence of urinary ketones suggests either a counter-regulatory hormone deficiency or an
enzyme defect in the glycogenolysis or gluconeogenesis pathways.
(For further information please refer to Chapter 16.)
8. BONE METABOLISM
8.1 Physiology of calcium and phosphate homeostasis
Principal regulators of calcium concentration:
Vitamin D (and its active metabolites)
PTH
Calcitonin
Regulators of phosphate concentrations:
Main regulator is vitamin D
Less strictly controlled than calcium
Vitamin D
Vitamin D3 (cholecalciferol) is produced in the skin from a pro-vitamin as a result of exposure to
ultraviolet light. Excess sunlight converts pro-vitamin D to an inactive compound, thus preventing
vitamin D intoxication. Vitamin D is also ingested and is a fat-soluble vitamin. Vitamin D is
converted to its active form by hydroxylation initially to its 25-hydroxyl form in the liver and the
subsequent 1,25-dihydroxylation occurs in the kidney.
Vitamin D activation pathway

Actions of vitamin D
Increases intestinal absorption of calcium
Increases osteoclastic bone resorption
Inhibits PTH secretion and hence increases 1-hydroxylation
There is some evidence to suggest the existence of a signalling pathway connecting bone and glucose
metabolism, involving the hormones leptin, osteocalcin and adiponectin.
A position statement from the UK Scientific Advisory Committee on Nutrition 2007 concluded that a
significant proportion of the UK population have a low vitamin D status. At-risk groups include
infants, and people of south Asian and AfricanCaribbean ethnic origins.
Parathyroid hormone
The PTH gene is located on chromosome 11. Active PTH is cleaved from a pro-hormone and then
secreted by the parathyroid glands. Low calcium, cortisol, prolactin, phosphate and vitamin D all
affect PTH secretion, but maximal PTH secretion occurs at a calcium concentration of <2 mmol/l.
Immediate effects of PTH
Reduction in renal calcium excretion. It promotes calcium reabsorption in the distal tubule by
stimulating the 1-hydroxylation of vitamin D
Promotion of phosphaturia by inhibiting phosphate and bicarbonate reabsorption in the proximal
tubule
Mobilization of calcium from bone together with vitamin A, the osteoblasts are stimulated to
produce a factor that activates osteoclasts to mobilize calcium
Delayed effects of PTH
Promotion of calcium and phosphate absorption from gut
Calcitonin
This is produced by the C-cells of the thyroid gland and synthesized as a large precursor molecule. Its
primary functions:
It inhibits bone resorption
It is thought to interact with GI hormones to prevent postprandial hypercalcaemia
8.2 Disorders of calcium and phosphate metabolism

Hypocalcaemia
Causes of hypocalcaemia
Transient neonatal hypocalcaemia

Dietary
Malabsorption
Vitamin D deficiency
Hypoparathyroidism
Pseudohypoparathyroidism
Hypoparathyroidism
Causes of hypoparathyroidism
Parathyroid absence or aplasia

DiGeorge syndrome (thymic abnormalities/cardiac defects/facial appearances)
Autoimmune
Associated with multiple endocrinopathy
Iatrogenic post-thyroid surgery
Treatment
In primary hypoparathyroidism, the management of neonatal tetany consists of intravenous calcium
gluconate and oral 1,25-dihydroxycholecalciferol.
Subsequent management is with vitamin D and an adequate intake of calcium.
Clinical features
Learning disability
Short stature
Characteristic facies
Shortening of fourth and fifth metacarpal and metatarsal
Ectopic calcification
Aetiology
PHP types 1a and 1c result from heterozygous inactivating mutations of the subunit of the
stimulatory G-protein (Gs). Both are associated with Albright hereditary osteodystrophy and, when
the mutation is maternally derived, end-organ resistance to multiple hormones. Due to complex tissue
specific imprinting of Gs, paternally derived mutations do not usually lead to hormone resistance
resulting in the condition termed pseudo-pseudohypoparathyroidism. More than 100 mutations have
been characterized in PHP-1 with a mutational hotspot in exon 7.
Hypercalcaemia
Clinical features are non-specific, often with anorexia, constipation, polyuria, nausea and vomiting in
a child with failure to thrive.
Causes of hypercalcaemia
Low PTH:
Vitamin D intoxication
nfantile hypercalcaemia
Transient
Williams syndrome
Associated with tumours
High PTH:
Primary hyperparathyroidism
Familial hypocalciuric hypercalcaemia
Rickets
Causes of rickets
Hypocalcaemic:
Calcium deficiency:
Dietary
Malabsorption
Vitamin D deficiency:
Dietary
Malabsorption
Lack of sunlight
Liver disease
Anticonvulsants
Biosynthetic defect of vitamin D
1-Hydroxylase deficiency
Defective vitamin D action
Phosphopenic:
Renal tubular loss
Isolated, e.g. X-linked hyphosphataemia
Mixed tubular, e.g. Fanconi anaemia
Abnormal bones
Renal osteodystrophy
8.3 Investigation of bone abnormalities
Calcium, phosphate, alkaline phosphatase

Creatinine
1,25-Hydroxy-vitamin D, 25-hydroxy-vitamin D, vitamin D concentrations
PTH
Urinary calcium, phosphate, creatinine and cAMP
X-rays
DXA (dual-energy X-ray absorptiometry)
9. MISCELLANEOUS ENDOCRINE DISORDERS

9.1 Obesity
Obesity is an excessive accumulation of fat. This may be due to an increase in size or the number of
adipocytes. There is no threshold value at which fatness becomes pathological.
Causes of obesity
Nutritional:
Simple obesity/constitutional obesity
Monogenic
Associated with genetic syndromes:
Down syndrome
LaurenceMoonBiedl syndrome
Endocrine:
Hypothalamic damage
Hypopituitarism, GH deficiency
Hypogonadism
Hypothyroidism
Cushing syndrome
Hyperinsulinism
Iatrogenic
Glucocorticoids
Oestrogens
Inactivity
Psychological disturbances
In general, simple constitutional obesity is associated with tall stature in childhood, whereas
endocrine causes of obesity tend to be associated with short stature or a reduction in height velocity.
Monogenic causes of obesity syndromes are characterized by normal birthweights, followed by a
rapid weight gain in the first few months of life. The obesity is primarily truncal and limb in
distribution and is associated with intense food-seeking behaviour. This leads to hyperinsulinism and
a high risk in adulthood of type 2 diabetes. The main monogenic forms of obesity identified are
mutations in the leptin gene (or receptor gene), the POMC gene and MC4R (melanocortin receptor).
Consequences of obesity
Childhood
Insulin resistance and abnormal glucose tolerance

Type 2 diabetes
Non-alcoholic steatohepatitis
Psychological problems
Obstructive sleep apnoea
Increased cardiac diameter
Adulthood
Hyperlipidaemia
Hypertension
Diabetes
Increased risk of death from cardiovascular disease
Syndromes associated with obesity

Genetics: deletion from paternally derived long arm of chromosome 15q
Clinical features:
Neonatal hypotonia
Feeding difficulties in the newborn period
Obesity (food-seeking behaviour)
Hypogonadism
Tendency to diabetes mellitus
Strabismus
Facial features:
Narrow forehead
Olive-shaped eyes
Anti-mongoloid slant
Carp mouth
Abnormal ear lobes
Orthopaedic:
Small, tapering fingers
Congenital dislocation of the hips
Retarded bone age
IQ: reduced, usually 4070
Behavioural difficulties: food seeking
Endocrine: insulin resistance
BardetBiedl syndrome
Genetics
Mutations in at least 14 different genes have been identified. These genes often referred to as BBS
genes, are involved in the structure and function of cilia
Clinical features:
Learning disability
Obesity marked by 4 years of age
Retinitis pigmentosa/strabismus
Polydactyly/clinodactyly
Moderate short stature
Hypogonadism
Associations:
Renal abnormalities
Diabetes insipidus
Genetics:
Usually occurs where there is abnormal regulation of genes in a particular region of chromosome
11. Up to 20% cases are due to paternal uniparental disomy
Clinical features:
Large birthweight
Transient hyperinsulinism
Macrosomia
Linear fissures on ear lobes
Umbilical hernia/exomphalos
Hemihypertrophy
Associations:
Wilms tumour
Assessment of the obese child
Height, weight and pubertal assessment
Body mass index (BMI): BMI = weight (kg)/height (m)2; in children, the BMI should be compared
with BMI centile charts for age as BMI varies during different phases of childhood.
Identification of an underlying cause:

Cortisol measurements
Evidence of complications:
Respiratory function
Liver function tests
Orthopaedic problems
Blood pressure
Fasting lipids
Oral glucose tolerance test
Management of obesity
Identification and treatment of underlying cause

Dietary measures
Reduction in sedentary behaviour
Increased exercise
Psychological support
9.2 Multiple endocrine neoplasia syndromes

Autosomal dominant syndromes:
Type I (Wermer syndrome): pancreatic (gastrinoma, insulinoma)/pituitary/parathyroid. This is
caused by mutations in the MEN1 gene which provides instructions for producing a protein called
menin; this acts as a tumour suppressor
Type II (Sipple syndrome): medullary thyroid cancer/parathyroid/phaeochromocytoma. This is
caused by mutations in the RET gene which provides instructions for a protein involved with
signalling within cells
Patients with MEN IIb have additional phenotypic features marfanoid habitus, skeletal
abnormalities, abnormal dental enamel, multiple mucosal neuromas.
9.3 Autoimmune polyglandular syndromes

Type 1: Addison disease, chronic mucocutaneous candidiasis, hypoparathyroidism
Type 2: primary hypothyroidism, primary hypogonadism, type 1 diabetes, pernicious anaemia,
Addison disease, vitiligo
9.4 Endocrine complications of other disorders
The endocrine glands may be affected by other chronic illnesses or their management regimens:
Chronic pancreatitis
Cystic fibrosis-related diabetes
Exogenous steroids (adrenal suppression/diabetes)
Tumours local erosion, radiotherapy, chemotherapy, surgical excision
Thalassaemia (e.g. secondary iron overload due to multiple blood transfusions)
9.5 Disorders of sexual development

Classification
Virilized female
Inadequately virilized male
True hermaphrodite
Causes of a virilized female
Androgens of fetal origin
CAH
Androgens of maternal origin
Drugs/maternal CAH
Tumours of ovary or adrenal gland
Idiopathic
Causes of an inadequately virilized male
XY gonadal dysgenesis
LH deficiency: Leydig cell hypoplasia
Inborn errors of testosterone synthesis
5-Reductase deficiency
Androgen insensitivity
Useful investigations
Karyotype
Urine steroid profile
Pelvic ultrasonography
17-Hydroxyprogesterone (day 3)
LH/FSH or testosterone/dihydrotestosterone
Human chorionic gonadotrophin (hCG) test
Management of a child with a disorder of sexual development requires multidisciplinary assessment
and management involving endocrinology, paediatric urology, gynaecology and psychology input.
9.6 Amenorrhoea
Causes of amenorrhoea
Ovarian
Gonadal dysfunction
Secondary to irradiation/chemotherapy/surgery
Polycystic ovarian syndrome
Genital tract
Mllerian dysgenesis
Hypothalamopituitary
Hypogonadotrophic hypogonadism
Secondary to tumours/irradiation/chemotherapy/surgery
Functional
Weight loss
Exercise induced
Chronic illness
Psychogenic
Management of amenorrhoea
Management of amenorrhoea depends on the underlying cause. Structural abnormalities may need
surgical correction. Primary amenorrhoea may require pubertal induction with exogenous oestrogen.
In secondary amenorrhoea the underlying cause needs to be identified and addressed.
10. FURTHER READING

Brook CGD, Hindmarsh PC, eds (2001). Clinical Paediatric Endocrinology, 4th edn. Oxford:
Blackwell Science.
Diabetes Control and Complications Trial Research Group (1994). Effect of intensive diabetes
treatment on the development and progression of long-term complications in adolescents with insulindependent diabetes mellitus: Diabetes Control and Complications Trial. J Pediatr 125:177188.
Hindmarsh PC (2002). Optimization of thyroxine dose in congenital hypothyroidism. Arch Dis Childh
86:7375.
National Institute for Health and Clinical Excellence (2004). Type 1 Diabetes: Diagnosis and
management of Type 1 diabetes in children and young people. London: NICE.
Word Health Organization (2006). Definition and Diagnosis of Diabetes Mellitus and Intermediate
Hyperglycaemia. Geneva: WHO.
Word Health Organization (2011). Use of Glycated Haemoglobin (HbA1c) in the Diagnosis of
Diabetes Mellitus. Geneva: WHO.
Chapter 9
Ethics and Law
Vic Larcher and Robert Wheeler
CONTENTS
Ethics
1. Ethical issues, technology and law
2. Moral theories and principles
2.1 Consequentialism/Utilitarian moral theory
2.2 Deontology
2.3 Virtue ethics
2.4 Principles
3. Moral analysis of cases and issues

3.1 Moral duties of doctors
3.2 Moral conflicts for doctors
3.3 Best interests
4. Moral theory and moral status of children

4.1 Childrens autonomy
5. Parental responsibilities, rights, duties and powers

6. Childrens rights
6.1 Key principles of UN Convention
7. Withholding or withdrawing life-sustaining treatment

7.1 The legal framework for withholding or withdrawing life-sustaining treatment
7.2 Professional guidance
7.3 The process of decision-making

7.4 Managing disputes/dissent
7.5 The extremely preterm infant (<24 weeks gestation)
8. Consent (ethical basis)

9. Confidentiality
9.1 Confidentiality and children
9.2 Confidentiality and child protection
10. Contraception, consent and confidentiality in teenagers

11. Abortion
12. Research in children
13. Ethics and law
Child Law
14. An introduction
15. Children Act 1989
16. What is a child?
16.1 Full legal capacity
17. Status in courts

18. Who owns the child?
18.1 Children Act 1989
18.2 Parental responsibility
18.3 Wardship
18.4 Guardians
19. Consent
20. Childrens capacity
20.1 1617 years
20.2 Preschool
20.3 The intervening years: Gillick competence
20.4 Fraser Guidelines
21. Further reading
Ethics
1. ETHICAL ISSUES, TECHNOLOGY AND LAW

The purpose of this chapter is to provide an account of the ethical principles that underpin good
clinical paediatric practice and of the law as it relates to children in the UK. A knowledge of ethical
principles will help trainees in the analysis of ethical dilemmas that may arise in clinical practice and
hopefully improve their resolution. It is important that ethical principles are applied in a way that is
consistent with the law.
Ethical and legal dilemmas arise more frequently in paediatric practice than in adult medicine
because of the perceived vulnerable status of children and the unique ethical and legal status that their
parents have with respect to them. Parents have an ethical and legal duty to make decisions for
children who lack the capacity to do so, while protecting them from harm and acting in their best
interests. These duties may themselves conflict; parental perceptions of their duties and their childs
needs may also lead to disagreements with professionals.
Contemporary paediatric practice may demand the application of advanced technology, the
availability of which defines what can be done. It does not follow that what can be done should be
done. Ethical dilemmas arise when appeal to clinical or scientific facts cannot determine what should
be done, when ethical principles appear to conflict or when those involved, e.g. parents and
clinicians, do not appear to share the same values. Their resolution involves value judgements that
need to be reasonable, transparent, accountable and based on sound ethical principles or theory; there
may be more than one right answer. Such judgements must also conform to the law. Although the law
is based on ethical principles, it has a different and more prescriptive function in decreeing what
must or must not be done.
2. MORAL THEORIES AND PRINCIPLES

A moral philosophers approach to dilemmas involves the application of classical moral theories or
principles to deduce whether a proposed course of action is morally acceptable. In understanding this
process some basic awareness of relevant moral theories and principles together with their strengths
and weaknesses is helpful.
2.1 Consequentialism/Utilitarian moral theory

In consequentialism, the rightness or wrongness of an action is determined by its actual or foreseeable
consequences. Utilitarianism is a type of consequentialism in which the best consequences are those
in which happiness is maximized and harms are minimized for all relevant persons involved. An
action is therefore morally correct if it maximizes welfare or individual preferences the greatest
good for the greatest number. Application of utilitarian moral theory requires calculation of
risks/benefits and as such it underpins reflective, evidence-based, audited practice.
Strengths of utilitarianism
Consequences of actions do matter

Appears to provide a clear answer as to what an individual should do
Egalitarian, because everyone involved counts equally
Satisfies aspirations, in that it promotes a happy society
Weaknesses of utilitarianism
Difficult to predict consequences with precision
No universally agreed single measure of the components of the utilitarian calculus
Some actions are wrong, even if they lead to best consequences, e.g. use of torture to gain
information to prevent harm
Maximizing happiness of the majority may be unjust to the minority, especially those who are weak
and vulnerable and those who lack capacity
Which counts more intensity or length of happiness?
Application of the principle of utility requires a potentially difficult calculation of the effects of
uncertain consequences, but this is so for many other decisions that involve balancing values. Some
calculation of harms/benefits is routinely required in medicine, e.g. in distribution of health care to
populations, or in allocation of scarce resources.
2.2 Deontology
According to deontological theory to be moral is to do ones duty, or intend to do it, regardless of the
consequences. This involves obeying moral rules, which can be derived by rational consideration or
discovery, in the same way that natural laws, e.g. the laws of gravity or motion, can be deduced from
physical events. Moral rules are universal (apply to everyone), unconditional (no exceptions) and
imperative (obligatory or absolutely necessary). Some obligations are right regardless of
consequences, e.g. truth telling, avoidance of harm to others.
Moral individuals should be rational (capable of discerning rules), able to formulate and carry out
plans and govern their own conduct, and be free to do so (autonomous). Such individuals have their
own intrinsic value and should be respected. In particular they should not be used to further the ends
of others (however praiseworthy) without their express consent. Although it is not clear as to the
extent to which children and young people are to be considered as rational and autonomous, it is clear
that they are owed some respect.
Strengths of deontology
General belief that some actions are wrong irrespective of consequences

Upholds dignity and intrinsic value of individual
Rational and supports equality
Do as you would be done by
Weaknesses of deontology
Impossibility of truly free decisions Autonomy is a philosophers myth
Absolutist, austere, no place for duty of beneficence (obligation to benefit patients by acting in their
best interests)
Consequences do matter at times
What if duties conflict? For example, the duties to avoid harm and tell the truth
Deciding between competing moral duties is difficult without taking some account of the
consequences or likely consequences of actions.
2.3 Virtue ethics

In virtue ethics an action is right if it is what a virtuous person (clinician) would do in similar
circumstances. A virtuous person is one who exhibits the human character traits (virtues) that are
required for the best life overall (flourishing). It is associated with a deeper sense of happiness or
wellbeing than that described by utilitarianism. Although ostensibly concerned with personal
flourishing many of the virtues, e.g. kindness, generosity and tolerance, are not intrinsically selfish.
Strengths of virtue ethics
It seems intuitively right to consider character in assessing right and wrong

Explains why we might treat some people, e.g. family, differently
Provides a richer moral vocabulary than other theories
Pluralistic employing values that other theories ignore
Encourages clinicians to develop moral characters that make them good doctors
Weaknesses of virtue ethics

Virtue ethics is based on the concept of flourishing which is (1) hard to analyse and (2)
insufficiently independent of other moral theories
Fundamentally egocentric
May not provide a separate helpful analytical framework for addressing moral dilemmas
May be too conservative, tied to cultural norms
2.4 Principles
A more practical day-to-day approach is the application of moral principles that are compatible with
or endorsed by a wide range of moral theories. Use of such principles is intended to transcend
religious, cultural and philosophical differences.
When faced with an ethical dilemma it may be helpful to apply the following four moral principles
that set out prima facie moral duties. When there is conflict between obligations or duties the prima
facie obligation is the one that it seems morally more important to follow. The principles are:
Respect for autonomy this entails respecting the rights of patients to exercise as much selfdetermination as they are capable of. It involves giving sufficient information to permit informed
choice and a duty to respect decisions of autonomous patients even when they conflict with those of
professionals
Beneficence an obligation to benefit patients by acting in their best interests, e.g. by providing
treatments that are intended to produce net clinical benefits. We do not usually have an obligation
to benefit others, apart from those with whom we have special relationships, e.g. family and close
friends. In contrast doctors do have duties, which are often referred to as superogatory to benefit
their patients.
Non-maleficence an obligation not to cause net harm to patients even though some treatments may
produce initial harm, e.g. chemotherapy. Applies to all, not just patients
Justice the obligation to act fairly and without discrimination, e.g. the distribution of health-care
resources
Strengths of principles approach
Broad agreement that the four principles are valid and relevant
Provides a moral checklist
More flexible than moral theories
More easily understood easier to use
Weaknesses of principles approach
Questionable moral origin of the principles no overarching moral theory

No hierarchy of principles to resolve conflicts between them
Do not provide solutions but a means of analysis
Different cultures may place different emphasis on different principles non-uniform approach
Regarded by some as formulaic ethics by numbers
Scope to whom or to what are duties owed and how widely do they apply?
The application of the four principles helps to clarify what ethical problems exist, but may not
resolve dilemmas.
3. MORAL ANALYSIS OF CASES AND ISSUES

A moral philosophers approach to dilemmas is essentially deductive. Clinicians tend to approach
problems in a different fashion, working from the facts of a given case to the general medical/nursing
principles that might apply.
Ethical examination of cases can follow this approach by starting from the features of the particular
case and seeking to recall similar cases, which might help in resolving it. For example, in dealing
with a 15 year old who is refusing further chemotherapy that his or her doctors recommend, we might
examine how similar cases were resolved and what ethical principles were relevant to them.
An alternative four-quadrant approach is to consider specific aspects of the case. These are (1) the
clinical indicators or facts, e.g. prognosis, (2) the patients preferences, (3) the quality of life that he
or she has or will have and (4) contextual factors, e.g. parental views, and cultural and religious
factors.
Whatever technique is used, arguments used to justify positions adopted should be fair and based on
valid and sound reasoning. Emotional responses to dilemmas the yuk factor cannot be
discounted altogether because emotional responses may be morally important, moral intuitions have a
role in moral reasoning and emotional responses to others are an essential component of the doctor
patient relationship. Nevertheless, such emotional responses require rational analysis and
justification
3.1 Moral duties of doctors

Doctors have a number of moral duties derived from application of theory and principle, namely:
Preserve life, restore health and prevent disease

Offer treatments that are intended to provide overall benefit and minimise harm
Offer evidence-based treatment derived from ethically conducted research
Respect the autonomy of their patients by respecting their right to as much self-determination as
they are capable of
Respect the human dignity of all patients regardless of their abilities
Obtain appropriately informed voluntary consent
Carry out the above duties fairly and justly and with appropriate skill and care
Act within the framework provided by national and international law
3.2 Moral conflicts for doctors

From the above it follows that all medical interventions should be in the best interests of the patient
and have their valid, freely given consent. The obligations to protect health and respect autonomy can
and do conflict. In normal circumstances, the respect that is accorded to the principle of autonomy
means that great importance is placed upon respecting the wishes, beliefs and preferences of those
who are capable of expressing and acting upon them. Most adults are capable of making informed
choices to accept or refuse treatment but children may lack this capacity. An important moral issue
that arises in paediatric practice is what constitutes the best interests of a child and who should
determine what they are.
3.3 Best interests

From a purely clinical perspective a treatment is in a childs best interests if it confers more clinical
benefits than harms. This is a narrow view of best interests that may also be equated to welfare. Other
considerations are important in coming to a wider view of best interests, including:
The ascertainable wishes and feelings of the young person concerned, considered in the light of
their age and understanding
Physical, emotional, and educational needs
Likely effect of change of circumstances on a young persons life
Age, sex, cultural, religious and ethnic background
Harm or risk of harm (physical, psychological, emotional, social, etc.)
Capability of parents or others to meet the young persons needs
4. MORAL THEORY AND MORAL STATUS OF CHILDREN

As a result of the importance that we attach to respecting the worth of rational autonomous
individuals, the moral status that we accord to children is important because it will determine how
we should treat them. There are several views, namely:
All children regardless of age have the same moral worth as adults
All children are potential adults and should therefore be treated as such
Society should grant children moral status because the consequences of doing so are better than
treating them as though they have none
Childrens moral status depends on the extent to which they possess the qualities that we associate
with personhood, e.g. consciousness, self-awareness, rationality, capacity for social interaction
The last approach accords with concepts of differing rates of growth and development with which
paediatricians are familiar. It also seems an intuitive expression of respect for humanity to accord
children more status than an animal with similar amounts of personhood-satisfying characteristics.
4.1 Childrens autonomy

Children vary enormously as do adults in their possession of personhood-satisfying
characteristics
Autonomy may be affected by illness, its treatments or moods
Clinicians have a duty to enhance the development of as much autonomy as the child is capable of,
e.g. by giving information and encouraging participation in decision-making
Some children may not live long enough to develop autonomy, e.g. a child with aggressive
glioblastoma
Children may not achieve physical autonomy because of disability, e.g. muscular dystrophy
Children may lack cognitive ability for self-determination, e.g. severe microcephaly, spastic
quadriplegia
Experience of illness may enhance autonomy, e.g. cystic fibrosis, Duchenne muscular dystrophy
5. PARENTAL RESPONSIBILITIES, RIGHTS, DUTIES AND POWERS

When children lack the capacity to make their own decisions, others have ethical and legal authority
to act on their behalf. In most cultures, religions and legal systems parents have this responsibility
(see Child law section). Parents also have moral obligations for their childrens upbringing and for
promotion and enhancement of their autonomy.
Application of both moral theory and law supports the autonomy of parents to rear their children in
accordance with their own values provided that they act in the childs best interests and do not harm
them.
A familys concept of their childs best interests is likely to be determined by a number of factors
including:
Their own ethical and value system

Social, cultural and spiritual influences
Religious beliefs
Political and cultural attitudes
Peer pressure, e.g. religious groups, neighbours
Life experiences and outside influences, e.g. media reports
These may conflict with:

Values of professionals from different socioeconomic backgrounds
Childrens need to make decisions that do not coincide with professional or parental choices
Conflicts may be exacerbated by:
Power imbalances in professionalpatient (child)parent relationship
Communication difficulties, e.g. language, understanding
6. CHILDRENS RIGHTS
Rights are justifiable moral claims that confer obligations on others and may be derived from
fundamental moral principles or form part of a social contract. They provide status and protection for
individuals, especially those who lack capacity or rationality and enable others to seek redress on
their behalf if rights are infringed. Rights may be positive or negative and may be defined by special
relationships, e.g. parentchild.
Positive rights
Negative rights
Welfare, institutional and legal rights

Require action by others
Established by social contract
Change as our society changes
Examples
Rights to information and best available health
care
Natural or liberty rights

Entail an obligation not to infringe
Natural, Constant
Take precedence over positive rights
Examples
Freedom of movement, speech, religious
beliefs
The UN Convention of Rights of the Child applies to all aspects of a childs life. The World Medical
Association (WMA) has codified those rights pertaining to health. Both endorse the development of a
rights-based, child-centred, health-care system.
6.1 Key principles of the UN Convention

Any decision or action concerning children as individuals or a group must have their best interests
as a primary consideration
A child who is capable of forming his or her views has a right to express them freely
A childs view should be given due weight in accordance with that childs age and maturity
Applied to medical practice this confers an obligation to consult children about treatment decisions
and their implications, especially where cognitive ability is unimpaired, e.g. cystic fibrosis, cancer,
renal failure and muscular dystrophy.
Other UN Convention articles affirm the right to:
Freedom of expression (A13)

The highest attainable standards of health care and rehabilitation from illness (A24)
Privacy (A16)
Freedom from discrimination (A2) and the right to family life and to hold religious beliefs
In addition, there are obligations to provide families with the necessary support, advice and services
in caring for their children.
The WMA document emphasizes childrens rights to:
Child-centred health care
Encouragement to achieve their full potential
Choose how much they should be involved in decision-making and how much information they wish
to receive
Help and support in decision-making
Delegation of decision-making to others
Confidentiality
An explanation of reasons why their preferences cannot be met
In considering a childs capacity to exercise his or her own rights it is important not to underestimate
a childs capacity even though it clearly does not equate to an adults. Parents, professionals or
advocates may make decisions from an adult perspective and with a desire to protect children. These
interventions may result in potential for personal choice being restricted, e.g. a teenage child with
learning difficulties or muscular dystrophy who is prevented from mixing with the opposite sex. Some
children may be unable to make a big choice, e.g. as to whether they will have a particular treatment,
but they can decide where they will have it.
Individual rights may conflict, e.g. the right to life as opposed to freedom from inhuman and degrading
treatment, as may rights possessed by various parties, e.g. children, parents, clinicians. A childs right
not to be harmed takes precedence over the rights to family life when the latter cannot be maintained
without abuse or neglect. Resources may not allow rights to be exercised in full. It is not clear whose
rights take precedence and mere appeal to rights may be insufficient to protect childrens interests.
7. WITHHOLDING OR WITHDRAWING LIFE-SUSTAINING TREATMENT

In most circumstances preserving a childs life is clearly in their best interests because treatment will
be to their overall benefit. There may be circumstances in which this is not so, including:
Life-limiting or life-shortening conditions for which there is no reasonable hope of cure or from
which they will die
Life-threatening conditions for which curative treatment may be feasible but can fail
Children whose lives may be regarded as having limited value to the extent to which certain
qualities, e.g. the capacity for meaningful social interaction, may be lacking or lessened
Life-sustaining treatments (LSTs) are those that have the potential to prolong life. They may include
experimental therapies that are not validated by research as well as more conventional treatments
such as cardiopulmonary resuscitation, mechanical ventilation, intravenous inotropes, antibiotics,
renal dialysis, and clinically assisted nutrition and hydration. Evidence for burdens and benefits may
not always be available.

There are several different types of decision made about LST. Treatment that has not been commenced
may be withheld. Alternatively, decisions may be made to withdraw treatment that has already
started, or to impose limits on that treatment (e.g. to impose a maximum level of respiratory or
cardiovascular support that will be provided).
The moral and legal justification for considering withholding, withdrawing or limiting LST must be
that it is no longer in a childs best interests to continue to provide it.
There may be uncertainty about the likely prognosis for a small child with any given condition
compounded by uncertainties about their potential for growth and development. In consequence
children may receive more chances to revive from or survive their illnesses than comparable adults,
with the imposition of greater burdens.
There must be a frank but sensitive discussion of the childs condition and prognosis, and a conscious
decision to change the goals of treatment from cure to palliation. Palliative care for children and
young people with life-limiting conditions is an active and total approach to care, from the point of
diagnosis or recognition, throughout the childs life, death and beyond. It embraces physical,
emotional, social and spiritual elements, and focuses on the enhancement of quality of life for the
child/young person and support for the family. It includes the management of distressing symptoms,
provision of short breaks and care through death and bereavement.
7.1 The legal framework for withholding or withdrawing LST

Deliberate killing is currently illegal and clinicians who deliberately act to shorten a childs life or
take no action to save the life of patients whose death is foreseeable may face prosecution for murder
or manslaughter.
The following principles are derived from specific judgments in individual cases in the UK. They
clarify the circumstances in which withholding or withdrawing LST may be considered but do not
provide legal sanction for individual future cases. If there is doubt or dispute in individual cases
legal advice should always be sought
Courts have determined that the provision of LST is not in the best interests of patients in the
following circumstances:
Where an infant has such a demonstrably awful life that no reasonable person would want to live
Where death is imminent and irreversibly close, e.g. hydrocephalus and cerebral malformation
Where the baby, although not close to death, had such severe disabilities that he would never be
able to engage in any form of self-directed activity, e.g. severe spastic quadriplegia, with deafness,
blindness and extremely limited capacity for interaction
Where clinicians believe that LST is not in the best interests of the child, they cannot be forced to
administer it even when the parents insist on it, e.g. severe brain damage as a consequence of
microcephaly and cerebral palsy. However, they may need to seek an alternative unit that will do
so
Permanent vegetative state, dependent on tube feeding for survival. The Court ruled that tube
feeding was medical treatment and could be withdrawn because it was not in the best interests of
the patient
Further judgements have determined:
There is no legal distinction between withdrawing and withholding LST
Non-provision of cardiopulmonary resuscitation is acceptable in circumstances of very severe
brain damage
Adults who are competent to do so may request that LST be withdrawn, especially if they face
continuation of life that they regard as being worse than death
Requests for assisted suicide or active euthanasia continue to be rejected by English courts, despite
attempts to change the law. It is unlikely that any legal authorisation of assisted dying will apply to
children.
The legality of withdrawal of fluids from children who are not close to death or in a permanent
vegetative state remains unclear and many professionals have ethical concerns about it.
Even considering UK Human Rights legislation, the courts appear to accept that there are
circumstances in which the continued provision of LST no longer serves the broader concept of best
interests.
7.2 Professional guidance

The Royal College of Paediatrics and Child Health (RCPCH) has published an ethical and legal
framework within which decisions to withhold or withdraw LST might be made, and has provided
advice on the process of decision-making and the resolution of conflicts. This document is currently
under review but the RCPCH identified five situations in which withholding or withdrawing LST
might be discussed. These were:
Brain-stem death
Permanent vegetative state
The no chance situation when LST only marginally delayed death without alleviating suffering
The no purpose situation when survival is possible but only at the cost of physical or mental
impairment, which it would be unreasonable to expect the child to bear. It was envisaged that such
children would never be capable of sufficient self-directed activity to make decisions for
themselves (see legal criteria above)
The intolerable situation where survival was again possible but, in the face of progressive and
irreversible illness, the child and/or family believe that further treatment is more than the child
and/or family can endure with any acceptable degree of human fulfilment. This situation clearly
includes children with and without mental impairment
7.3 The process of decision-making
All remediable causes for the childs condition must be excluded

Absolute certainty over likely outcomes may not be possible and thus should be acknowledged
There should be general acceptance that value judgements have to be made
There should be openness and transparency in discussions within teams and with parents/children
Consider second opinions to clarify the clinical position
Formal ethics consultation may be helpful
7.4 Managing disputes/dissent

Disputes and dissent may arise within teams or with families as to what should be done. Where
possible the reasons for this should be analysed so as to provide a means of resolution. Attention to
or consideration of the following may be helpful:
Communication
Education/information sharing
Negotiation/mediation/conciliation
Trade offs, e.g. deferring to requests for benign treatment
Consensus building
Referral/second opinions
Ethical review, e.g. clinical ethics committee
Application to courts
7.5 The extremely preterm infant (<24 weeks gestation)

In some countries neonatal intensive care may not be routinely offered to extremely preterm infants. In
the UK there are guidelines for the management of babies according to gestational age and taking into
account parental preferences and evidence available from outcome studies; it would not be
recommended practice to resuscitate babies of under 22 weeks gestation. If practicable, treatment
options should be discussed with the family before the birth and decisions should be informed by the
disclosure of both national, e.g. EPICURE 1 and 2, and local survival figures and complication rates.
Decisions to withhold or withdraw LST are often viewed as psychologically and emotionally
distinct; withholding treatment may deprive a child of treatment from which they may potentially
benefit.
If there is doubt concerning parental wishes or lack of senior paediatric support, the infant should be
resuscitated and treated until a clearer picture of outcome emerges and parental views can be
clarified.
Where disputes over the provision of LST cannot be settled by the above mechanisms a legal ruling
on what is in the best interests of the child should be obtained before any action to withdraw LST.
Checklist for end of life decision-making

Individuals may find the following checklist helpful in formulating end-of-life care plans and
obtaining consent for them.
The childs clinical condition

Are sufficient and adequate medical facts available to make a diagnosis and give accurate
prognosis?
Has a potentially treatable condition been excluded?
Is a second medical opinion necessary/desirable?
Is there a need for a psychiatric or psychological assessment of the child?
What are the problems in providing nursing care in the current situation?
What are the views of nursing staff about changing goals for the child?
What are the views of other therapists/professionals involved with the child?
How has dissent in the team been handled?
Is the child able to form a view about what he or she wants?
Has he or she been consulted?
The family
Is the familys understanding of their childs condition adequate?

What are the familys relevant religious and cultural beliefs and values?
Has there been a psychosocial assessment of the family?
What are the familys likely or actual views on changing goals of treatment?
Do the family need the help of an advocate?
The decision-making process
How has uncertainty about the outcome been addressed?

Has there been an ethical review of the case?
Has there been a strategy meeting or psychosocial meeting?
Have human rights issues been properly considered?
Is there a proportionate justification for any infringement of human rights?
Is there a need for a legal opinion?
Is there a properly formulated care plan?
Has informed consent for this care plan been obtained?
Do the notes adequately reflect the process?
How is the process to be maintained/audited?
8. CONSENT (ETHICAL BASIS)

The need to obtain consent for medical treatment is morally justified because it respects the rights of
patients to make informed choices as to what will be done to them, respects their autonomy and
avoids treating them merely as a means. It is likely to have good consequences for those involved. To
be ethically valid, consent should be sufficiently informed, given by a person who has the capacity to
understand the issues involved and obtained freely.
Children may have the legal capacity to give consent but, even if they do not, they still have the right
to receive information given in a form and at a pace that they can comprehend.
Although it may be logical to suppose that a child who is competent to consent to treatment is also
competent to refuse it and should have that refusal honoured this is not necessarily the law in
England and Wales (see below). It may be that refusal to consent is not the same as a right to veto but
this is ethically questionable. If a childs views are to be overridden they should receive an
explanation as to why this will happen. It may be considered good practice to seek their assent, i.e.
agreement, and where a treatment or intervention is not immediately necessary to delay it until they
have had further opportunity to discuss it.
9. CONFIDENTIALITY
There is a general duty of confidentiality over the disclosure of personal information about patients
(including children) to third parties.
In general such information should not be disclosed without the consent of the patient or those with
parental responsibility in the case of children.
The ethical justifications for the above approach are:
The obligation to respect childrens autonomy and their right to exert control over their own
personal data
Confidentiality is a professional duty implied promise not to disclose
The duty of the virtuous doctor is to keep patient details confidential
Better consequences follow if patients know that they can trust their doctors not to reveal
information
General principles of confidentiality:
Wherever possible consent for disclosure should be sought

Data should be made anonymous if unidentifiable data will serve the purpose
Only information necessary for the purpose in question should be disclosed
Information can be shared within health-care teams, unless patients specifically object, because
sharing of clinical and other information is implicit in and necessary for the effective delivery of
health care
In general the laws approach to breaches of confidentiality is to consider whether there is a public
interest in favour of breaching confidentiality or not breaching it.
Disclosure of information is a legal duty in certain circumstances:
Notification of certain specified infectious diseases
Notification of births and deaths
If the court makes a specific request for it
Disclosure of information is discretionary in circumstances where:
There is risk of significant harm to a third party
It is necessary to do so for detection or prevention of serious crime including child abuse
9.1 Confidentiality and children

Children are owed the same duty of confidentiality as adults, irrespective of their legal status. The
disclosure of information usually depends on the consent of the child or a person with parental
responsibility.
Although children over 16 years are assumed to be competent to give consent, those under 16 may do
so if they are able to understand what is involved and its consequences for their family (see Child
law section). The principle that determines whether disclosure should take place is whether it is in
the childs best interests to do so. Doctors may therefore ethically disclose information to parents of
children younger than 18 years, even with the childs refusal, if they genuinely believe that it is in the
young persons best interests to do so. This needs to be justified and the reasons for disclosure
carefully explained.
9.2 Confidentiality and child protection

The paediatricians primary duty is to the child not the carers. If a doctor has reasonable grounds to
believe that a child is at risk of significant harm the facts should be reported to the appropriate
statutory authority. Doctors have ethical and legal duties to assist statutory authorities in making
relevant enquiries in such cases. They must satisfy themselves that disclosure of information is in the
childs best interests. Information about competent children can be disclosed without their consent if
to do so is justified on the above grounds. Information about non-competent children can be disclosed
without parental consent if it is necessary to protect the child. The child and/or parents should
normally be told about disclosure of information unless to do so would not be in the childs best
interests or would expose them to risk of serious harm. All decisions about disclosure must be
justifiable and reasonable.
10. CONTRACEPTION, CONSENT AND CONFIDENTIALITY IN

TEENAGERS
Concern about teenage pregnancy rates stems from the ethical duty to protect children from harm.
Ethical (and legal) dilemmas arise when children under the age of 16 years seek contraceptive advice
without the express consent or knowledge of their parents and are adamant that their parents should
not be informed.
Ethical justifications for respecting the young persons wishes are:
The duty to respect their autonomous wishes
The duty to confer more benefits than harms
The adverse consequences of failing to provide confidential advice, e.g. increased pregnancy rates,
sexually transmitted infections
The respect for childrens rights to health, information, identity
With respect to the legality of prescribing contraception to young people under the age of 16, it is
clear that such children are considered to have the capacity to consent to medical treatment provided
that they understand the nature and purpose of what is involved and its implications for themselves
and their family.
The legal (Frasers) criteria for the prescription of contraception (including emergency
contraception) to adolescents are:
Ability to understand implications for self and family
There is a sustained and consistent refusal to discuss with parents
The young person has made a decision to start or continue to have sexual intercourse, despite
attempts at persuasion
The adolescents health will suffer or is likely to suffer if contraception is not given
Prescribing contraception is in the young persons best interests
11. ABORTION
Children and young people may request abortion under the terms of the Abortion Act 1967 as
amended in 1990. This provides that abortion may be carried out in pregnancies that do not exceed 24
weeks if:
The continuation of the pregnancy would result in injury to the physical or mental health of the
woman or any existing children in her family
The termination is necessary to prevent that risk
The continuation of the pregnancy would involve risk to the life of the mother, greater than if it
were terminated
There is a substantial risk that, if the child were born, it would suffer from such physical or mental
abnormalities as to be seriously handicapped

Under the Act the young person needs to be assessed by two doctors who must be satisfied that the
abortion is justified.
The ethical justifications for abortion in young women are essentially similar to those in adults but a
more paternalistic approach with appeal to best interests is reasonable in those who cannot consent
because they lack the capacity to do so.
12. RESEARCH IN CHILDREN

There are sound ethical reasons to conduct ethical research in children, including:
Children have unique, physiological, psychosocial status and specific needs
Children have a right to receive treatments that are tested and evidence based
Children are not mini-adults or animals so results from adult and animal research (though ethically
preferable) may not be transferable to them
Non-therapeutic research is ethically important in children
Although children are vulnerable, this is not sufficient reason to exclude them from research from
which they could benefit
Criteria for worthwhile general research in children include:
Identifiable prospect of benefit to children with minimal risk

Well designed, well conducted
Subject to informed consent freely given with opportunity to withdraw
Primary motivation for conduct of research should not be financial or career
Sufficient statistical power
Intention to report
Appropriate ethical review
Research ethics committees have the responsibility for assessing whether research proposals are
ethical. They are particularly concerned with assessment of risk, which is the likelihood of harm and
the harm that may occur. Risk is often categorized according to level, namely:
Minimal, e.g. questioning, observation, urine samples, use of spare clinical blood samples
Low, e.g. venepuncture, injections
High, e.g. biopsy, cardiac catheterization
In addition research ethics committees need to satisfy themselves that there are proper arrangements
for obtaining informed consent, that they are particularly concerned with the information that is
presented to children and parents, and that those obtaining consent are themselves competent to do so.
13. ETHICS AND LAW

There may be tensions between ethical and legal obligations, e.g. in relation to end-of-life issues. It is
important that, whatever ethical views are held, practice conforms to the law.
Child Law
14. AN INTRODUCTION
It is not feasible, here, to state comprehensively the law pertaining to paediatric medicine, let alone
the body of law applicable to children. This section simply touches on some of the legal topics that
frequently vex doctors, and reviews child law in England and Wales. The stage is set by
consideration of the very wide remit of the Children Act 1989. Subsequently, the status of the child
and those with parental responsibility are considered, before discussing the most frequently exercised
issue of medical law in childhood, namely the provision of valid consent.
15. CHILDREN ACT 1989

The underlying themes of this Act are that:
The childs welfare is paramount
The courts should impose orders on children only if:
The imposition of an order would be better for the child than making no order at all
Any delays in decisions concerning the upbringing of a child are likely to prejudice the welfare
of the child
The Act provides for state intervention in family matters, such as adjudication in issues of contact,
residence, and in things that must and may not be done in relation to the child (i.e. Section 8 orders
Contact, residence, Specific issue and Prohibited steps). The Act ensures that local authorities
provide services and support to families, and to children who are looked after by a local authority.
Finally, provision is made for the protection, care and supervision of children, establishing a
threshold of harm (Section 31(9): harm means ill-treatment or the impairment of health or
development including for example, impairment suffered from seeing or hearing the ill-treatment of
another).
16. WHAT IS A CHILD?

16.1 Full legal capacity
Childhood ends on the 18th birthday. At this point, transition to Majority occurs and the new adult
assumes all decision-making powers (although applicants for adoption and holders of Public offices
cannot generally be under 21 years), including the ability to make their own decisions concerning
health care. The significance of the 21st birthday as a landmark occasion in our society derives in
part from this being the age of majority, until legislation in 1969 (the Family Law Reform Act 1969).
Under the same Act, 16 and 17 year olds were given the legal right to agree to treatment
independently of their parents, although the courts have not interpreted this statute as giving a right to
refuse.
17. STATUS IN COURTS

Children traditionally have no voice in courts (the word infant derives from the Latin infari; no
speech). This means that, in civil litigation, the childs interests can be represented only through a
litigation friend or a guardian ad litem; it is a parents right and duty to perform these roles, and it can
be seen how conflicts of interest may arise between adult and child in these circumstances.
This rule also applies in family proceedings, where childrens guardians now ensure that the
feelings and wishes of the child are represented. However, it has been modified by the Children Act
1989, permitting a child with sufficient understanding to have an independent voice under some
circumstances.
18. WHO OWNS THE CHILD?

18.1 Children Act 1989
Although it is clear that no-one owns a child, the title serves as a reminder that until 1989, the legal
emphasis was on parental rights and influence. This legacy derived from times when the father had
exclusive and total power over his child, while a mother was merely entitled only to reverence and
respect. Such power enabled unscrupulous fathers to earn money from the work of their children.
Stealing children and effectively enslaving them reflected their economic value, and was legal until
1814. Progressive legislation addressed this appalling situation, but the central theme, of parental
rights having overarching significance, was only finally reversed by the Act in 1989.
18.2 Parental responsibility

A key feature of the Act was to codify parental responsibility as the central role of the adult who
cares for the child. In most cases, it will obviously be the parents who have parental responsibility,
but others may also share it, such as the local authority.
Defined as all the rights, duties, powers, responsibilities and authority, which by law a parent of a
child has in relation to a child and his property, parental responsibility is automatically vested in the
childs biological mother (although it should be noted that any of these basic rules would be
invalidated by an adoption order). She, it is accepted in English law, is the person who gives birth to
the child (as opposed to the genetic mother, in the case of some surrogates).
There is a legal presumption that the man who is married to the mother is the biological and thus legal
father, whatever the truth of the situation. If married to the mother at the time of the birth, the father
will have parental responsibility. An unmarried father whose name appears on the birth certificate on
or after 1 December 2003 automatically has parental responsibility by marriage to the mother or it
can be acquired by other unmarried fathers by formal agreements with the mother, or the court.
Guardians, local authorities, adoption agencies and prospective adopters can share parental
responsibility with the parents but the parents only surrender their parental responsibility when the
child reaches majority, or is adopted away from them. Under a court order, the local authority has the
power to determine the extent to which a childs parent may meet his or her parental responsibility for
the child.
In terms of the residual rights of parenthood, the naming of the child, the determination of education
and religion, and the right to appoint a guardian remain. The other incidents of parenthood (i.e. to
provide a home, to protect and maintain, to provide for education, to discipline, etc.) would largely
be viewed as duties or responsibilities, placed by the state on the parent.
18.3 Wardship
In ancient times, wardship described a right to have custody over an infant who was the heir to land.
Combined with the sovereigns powers to act as the parent of any abandoned (or orphaned) child, it
can be seen that this was a potent mechanism for a land-hungry monarch (parens patriae: Latin:
parent of the fatherland or parent of the homeland; in law, it refers to the power of the state to act
as the parent of any child or the power to act on behalf of any individual who is in need of protection,
such as an incapacitated individual or a child whose parents are unable or unwilling to take care of
the child).
In the modern era, the High Court can use wardship as one means of exercising its parens patriae
powers, to ensure that no important or major steps in the life of a ward of court can be taken without
prior consent from the court. This certainly extends to medical treatments because for a ward of court,
the court has parental responsibility. In general terms, one of the aims of the Children Act 1989 was
to reduce the necessity for wardship proceedings, by incorporating its more worthwhile powers into
the statute.
18.4 Guardians
Guardianship is confusing (see Bainham 2005), because there are several separate roles that adults
play in relation to children which have acquired this label.
Natural or parental guardian

Over centuries, the legitimate father has been the natural or parental guardian of the child, not least
because of the property rights this conferred. English literature is peppered with references to fathers
exercising their rights of guardianship, rarely to the childrens advantage. A father could exercise all
parental rights, to the exclusion of the mother, until 1973, when mothers were given equal rights and
authority. Fathers retained some residual rights of this natural guardianship even after 1973. This
was reflected in their ability to prohibit the mothers unilateral wish for a change of a childs surname
following divorce, even if they had lost custody of the child. This natural or parental guardianship
has been abolished by the Children Act 1989, removing the final vestiges of parental legal inequality.
Guardians taking legal responsibility for a child after parental death

These guardians provide a vital, if under-utilized, function. They can be appointed (commonly) by
parents or (less commonly) by courts. When parents contemplate the sad reality that they may die
together, in an accident, leaving children, they may well wish to have influence over who brings up
their orphaned family. Appointing a guardian enables them to exercise this influence, because the
guardian will assume parental responsibility on the death of the second parent. Guardians may be
appointed with no more formality than a signed and dated letter, and this rather surprising theme of
informality applies to several aspects of guardianship. Nevertheless, it permits parents to avoid the
nightmare of having their children brought up by their least-favourite relative in the event of their
untimely and simultaneous death.
The family court may have to intervene if the second parent has died without appointing guardians,
particularly if there is a dispute within the family as to who should look after the children. Have you
got appropriate arrangements in place?
Childrens guardian
Childrens guardians represent children in court during proceedings involving state intervention in
the family; they are one of a number of individuals, collectively described as officers of the service,
falling within the remit of the Children and Family Court Advisory and Support Service (CAFCASS).
They are appointed on the basis of their expertise in social work and childcare law. Their role is to
inform the court of the childs wishes and feelings, while providing all the information that may be
relevant to the childs welfare. They are loosely equivalent to guardians ad litem, who represent
children in civil litigation.
Special guardian
This is a new legal concept (introduced by the Adoption and Children Act 2002), providing legal
security for permanent carers of children but falling short of adoption, for situations where adoption
has been thought inappropriate for the child.
19. CONSENT
Those with parental responsibility have a duty to provide consent for the childs medical treatment.
Consent is required before any intervention, because society opposes the uninvited touch.
At its simplest, the outstretched hand, by implication, invites touching. However, the patient who
consults their doctor does not assume that their very presence in the consulting room gives the doctor
licence to touch them. The uninvited touch is, historically, an act of common assault. However, it is
not the avoidance of this rather dramatic accusation that drives most contemporary doctors to obtain
consent, although very occasionally the charge is still made.
What is far more relevant is the concept of negligence, where the doctor causes some harm by failing
to deliver a reasonable standard of care to the patient, to whom there is undoubtedly a duty to provide
such care.
One aspect of this standard of care is obtaining valid consent. This entails the provision of all
necessary information for the patient to make an informed decision. Often, the only record of this
provision is the annotated and signed consent form. This document thus acts both as a shield against a
claim of assault, and objective evidence that some formal provision of information has occurred.
There are two excellent documents concerning consent which provide comprehensive guidelines (the
DH Reference Guide and the BMA report of the Consent working party). The main questions to be
considered when obtaining consent may be summarized as follows.
When is consent required?
Consent is required for any intervention
Who should obtain consent?
The person who will perform the proposed treatment
In what form should consent be taken?
There is no legal requirement for written consent, which can equally be verbal, or by
acquiescence, provided the patient is correctly informed. However, a written document, which is
signed by the patient, forms a piece of objective evidence that consent has been taken. Furthermore,
if the document also records the details of the information given, it increases the certainty that
relevant issues have been discussed. If the consent were verbal, it would be prudent to record the
circumstances, topics discussed and outcome in the clinical notes
From whom should consent be obtained?
Anyone with parental responsibility for a child may provide consent for his or her medical
treatment. To consent to treatment, an individual must have the capacity (i.e. intelligence and
understanding) fully to understand what treatment is being proposed (see below)
It is assumed that a young person of 16 years has such capacity, and because the law provides
that they can give valid consent, no additional consent from parents is required. In the period
between 16 and 18 years, if the young person is incapacitated, their parents may consent on their
behalf
A child of less than 16 years may give consent if capacity can be established, but the test is
relatively rigorous
In the absence of a parent, where a child is unable to consent because of lack of capacity, can
the doctor treat in the emergency situation?
If emergency treatment is necessary to save life or avoid a significant deterioration in health, the
doctor may treat on the basis of this necessity. However, the views of the parents and the child (if
known), the likelihood of improvement with treatment and the need to avoid restricting future
treatment options where possible must all be considered in this situation
What information should be provided to obtain informed consent?
Any information that a reasonable patient would require when considering whether to consent to
the proposed intervention should be discussed. This should include the certainties of diagnosis, the
options for treatment (including non-treatment), a balanced opinion of the likely outcome of these
options, and the purpose, risks, benefits and side effects of the intervention. The General Medical
Council would also recommend ensuring that the name of the senior clinician is reiterated, together
with a reminder that withdrawal from the treatment continues to be an option
20. CHILDRENS CAPACITY

20.1 1617 years
There is a legal presumption that these young people have the capacity to consent, so there is no
requirement for clinicians to test capacity in this age group. However, if there is doubt that an
individual is competent to provide consent, their competence should be assessed according to the
criteria used for any adult (according to Re C (Adult: Refusal of Medical Treatment) [1994] 1 All
ER 819), and reiterated by the Mental Capacity Act 2005 s3(1). According to Grubb (2004) the
patient must be able to:
Comprehend and retain the relevant information
Believe it
Weigh it in the balance so as to arrive at a choice
Refusal of therapy, particularly if the treatment is for life-threatening disease, gives more difficulty,
and legal advice should be sought. Despite wishing to uphold the autonomy of competent children,
English courts effectively prohibit children from refusing treatment that will save them from death or
serious permanent harm.
20.2 Preschool
It is self-evident that children in this age group are unable to provide valid consent but they still have
autonomy and their interests should be considered. It is good practice to involve them where possible
in the process of obtaining consent, particularly offering to answer their questions, and to remind them
of the obvious consequences of a procedure (e.g. the scar).
20.3 The intervening years: Gillick competence

The child who has yet to reach 16 years is presumed, by the law, to be incapable of providing
consent. However, some children who quite clearly possess a degree of capacity may be able to
demonstrate their competence. If they can, they may provide consent independently of their parents.
However, it is both good manners and good practice to involve their parents; and it will be rare for
such parental involvement to be inappropriate, unless confidentiality is an issue. In determining
whether a child might have capacity for consenting to a particular procedure, their age is probably the
least important consideration. The House of Lords have provided the means for the determination, in
their ruling on the Gillick case (Gillick v West Norfolk & Wisbech AHA [1985] 3 All ER 402, HL).
The child would need to:
Understand that a choice exists

Understand the purpose and nature of the proposed treatment
Understand the risks, benefits and alternatives
Understand the consequences of not undergoing the treatment
Furthermore, the child must:

Be able to remember the information for long enough to make a considered decision
Be free from undue pressure
It is clear that the ability of the child to pass this test is entirely dependent on both the proposed
procedure and the childs experience. It is not difficult to picture 14 year olds with newly diagnosed
leukaemia, bewildered and terrified, who would be entirely incapable of providing valid consent to a
diagnostic lumbar puncture. On the other hand, a younger child who has spent months on the oncology
ward, has already had numerous similar procedures, and witnessed the consequences in many of his
fellow patients, may well be competent.
It should be reiterated that the Gillick test, understandably, sets a high threshold for capacity that
would probably be unattainable by many adults.
As with the 16 to 17 year olds, the ability of Gillick-competent children to provide valid consent
does not extend to a right to refuse.
20.4 Fraser guidelines

Emerging from the House of Lords judgement, Lord Fraser also gave guidance on how the Gillick
principle could be applied to the provision of contraceptives to young people. These guidelines
emphasize the importance of parental support, acknowledging confidentiality and weighing the best
interests of the child (see BMA 2004). They also take account of the risk that the patient may have
unprotected sex if the contraception is denied, and the potential effects on their mental and physical
health.
21. FURTHER READING

Bainham A (2005). Children: The modern law. London: Jordan Publishing.
British Medical Association (2001). Report of the Consent Working Party. London: BMA Medical
Ethics Department.
British Medical Association (2004). Medical Ethics Today. London: BMA Medical Ethics
Department.
British Medical Association (2007). Withholding and Withdrawing Life-prolonging Medical
Treatment: Guidance for decision-making, 3rd edn. London: BMA Publications.
Department of Health (2001). Reference Guide to Consent for Examination or Treatment. London:
DH. Available at: www.doh.gov.uk/consent.
Diekema DS, Botkin JR (2009). Clinical report forgoing medically provided nutrition and hydration
in children. Pediatrics 124:81322.
General Medical Council (2010). Treatment and Care towards the End of Life. London: GMC.
Grubb A (2004). Principles of Medical Law. Oxford: Oxford University Press.
Hope T, Savulescu J, Hendrick J (2003). Medical Ethics and Law: The Core Curriculum. London:
Churchill Livingstone.
Kennedy I, Grubb A (2000). Medical Law Text and Materials, 3rd edn. London: Butterworths.
Montgomery J (2002). Health Care Law, 2nd edn. Oxford: Oxford University Press.
Nuffield Council on Bioethics (2009). Critical Care Decisions in Fetal and Neonatal Medicine:
Ethical issues. London: Nuffield Council on Bioethics.
Raphael DD (1994). Moral Philosophy, 2nd edn. Oxford: Oxford University Press.
Royal College of Paediatrics and Child Health (2004). Withholding or Withdrawing Life Sustaining
Treatment in Children: A framework for practice, 2nd edn. London: RCPCH. Available at:
www.rcpch.ac.uk.
Royal College of Paediatrics and Child Health: Ethics Advisory Committee (2000). Guidelines for
the ethical conduct of medical research involving children. Arch Dis Child 82:17782.
Sokol DK, Bergson G (2000). Medical Ethics and Law; Surviving the wards and passing exams.
London: Trauma Publishing.
Wheeler RA (2006). Gillick or Fraser? A plea for consistency over competence in children. BMJ
332;807.
Wheeler RA (2010). Presumed or implied; Its not consent. Clin Risk 16;12.
Website
UK Clinical Ethics Network: www.ethics-network.org.uk
Chapter 10
Gastroenterology and Nutrition
Mark Beattie and Hemant Bhavsar
CONTENTS
1. Basic anatomy and physiology
1.1 Anatomy
1.2 Digestion
2. Nutrition
2.1 Nutritional requirements
2.2 Nutritional assessment
2.3 Breast-feeding
2.4 Iron
2.5 Folate
2.6 Vitamin B12
2.7 Zinc
2.8 Fat-soluble vitamins
2.9 Nutritional impairment
2.10 Proteinenergy malnutrition
2.11 Faltering growth
2.12 Organic causes of faltering growth
2.13 Malabsorption
3. Nutritional management
3.1 Nutritional supplementation
3.2 Enteral nutrition
3.3 Parenteral nutrition
3.4 Re-feeding syndrome
3.5 Intestinal failure
3.6 Home parenteral nutrition
4. Food allergy and intolerance

4.1 Cows milk protein intolerance
4.2 Peanut allergy
4.3 Food-induced anaphylaxis
4.4 Carbohydrate intolerance
5. Gastro-oesophageal reflux
5.1 Differential diagnosis of reflux oesophagitis
5.2 Feeding problems in neurodisability
5.3 Eosinophilic oesophagitis
5.4 Achalasia
5.5 Dysphagia
6. Peptic ulcer disease

6.1 Helicobacter pylori infection
6.2 Other causes of antral gastritis and peptic ulceration
6.3 ZollingerEllison syndrome
7. Chronic diarrhoea
7.1 Congenital diarrhoea/intractable diarrhoea of infancy
7.2 Post-enteritis syndrome
7.3 Cows milk protein sensitive enteropathy
7.4 Giardiasis
7.5 Exocrine pancreatic insufficiency
7.6 Bacterial overgrowth (small bowel)
7.7 Intestinal lymphangiectasia
7.8 Protein-losing enteropathy
7.9 Chronic non-specific diarrhoea
8. Coeliac disease
9. Abdominal pain
9.1 Recurrent abdominal pain
9.2 Functional gastrointestinal disorders
10. Inflammatory bowel disease

10.1 Crohn disease
10.2 Ulcerative colitis
10.3 Differential diagnosis of colitis
10.4 Eosinophilic enterocolitis
10.5 Pseudomembranous colitis
11. Gastrointestinal bleeding

11.1 Common causes of gastrointestinal bleeding
11.2 Intussusception
11.3 Meckel diverticulum
11.4 Polyposis
12. Gastroenteritis
13. Constipation
13.1 Perianal streptococcal infection
13.2 Hirschsprung disease
14. Further reading
Gastroenterology and Nutrition
1. BASIC ANATOMY AND PHYSIOLOGY

1.1 Anatomy
Oesophagus
Outer longitudinal and inner circular muscle layers with myenteric plexus in between. Mucosa is
lined by stratified squamous epithelium. Adult length 25 cm.
Stomach
Lined by columnar epithelium. Chief cells produce pepsin. Parietal cells produce gastric acid and
intrinsic factor. Secretions in adults are 3 l/day. Gastric acid secretion is stimulated by vagal
stimulation, gastrin and histamine via H2-receptors on parietal cells. Secretion is inhibited by
sympathetic stimulation, nausea, gastric acidity and small intestinal peptides. Blood supply from
coeliac axis.
Small intestine
Main function is absorption, mostly in the duodenum and jejunum, apart from bile salts and vitamin
B12 which are absorbed in the terminal ileum. Blood supply from mid-duodenum onwards is the
superior mesenteric artery. Adult length 23 metres.
Colon
Functions primarily for salt and water reabsorption. Blood supply from superior mesenteric artery
until the distal transverse colon and then the inferior mesenteric artery after that. Approximately 1 m
long in adults.
Pancreas
Retroperitoneal. Endocrine function (2% of tissue mass) and exocrine function (98%). Blood supply
from coeliac axis.

Congenital anomalies of the gastrointestinal system are described separately in Chapter 17.
1.2 Digestion
Carbohydrate digestion
Carbohydrates are consumed as monosaccharides (glucose, fructose, galactose), disaccharides
(lactose, sucrose, maltose, isomaltose) and polysaccharides (starch, dextrins, glycogen)
Salivary and pancreatic amylase break down starch into oligosaccharides and disaccharides.
Pancreatic amylase aids carbohydrate digestion but carbohydrate digestion is not dependent upon it
Disaccharidases (maltase, sucrase, lactase) in the microvilli hydrolyse oligo- and disaccharides
into monosaccharides:
Maltose into glucose
somaltose into glucose
Sucrose into glucose and fructose
Lactose into glucose and galactose
Monosaccharides are then absorbed, glucose and galactose by an active transport mechanism and
fructose by facilitated diffusion
Protein digestion
In the stomach, gastric acid denatures protein and facilitates the conversion of pepsinogen into
pepsin
Trypsin, chymotrypsin and elastase, secreted as the inactive precursors, are produced by the
exocrine pancreas. Enterokinase (secreted in the proximal duodenum) activates trypsin and trypsin
further activates trypsin, chymotrypsin and elastase
These proteases convert proteins into oligopeptides and amino acids in the duodenum
The small intestine absorbs free amino acids and peptides by active transport and these substances
then enter the portal vein and are carried to the liver.
Fat digestion
Entry of fats into the duodenum causes release of pancreozymincholecystokinin which stimulates
the gallbladder to contract
Hydrolysis of triglycerides by pancreatic lipase takes place
Free fatty acids, glycerol and monoglycerides are emulsified by bile salts to form micelles which
are then absorbed along the brush border of mucosal cells
Short-chain fatty acids enter the portal circulation bound to albumin. Long-chain fats are reesterified within the mucosal cells into triglycerides which combine with lesser amounts of
protein, phospholipid and cholesterol to create chylomicrons
Chylomicrons enter the lymphatic system and are transported via the thoracic duct into the
bloodstream
Pancreatic function
The pancreas secretes more than a litre of pancreatic juice per day, which is bicarbonate rich and
contains enzymes for the absorption of carbohydrate, fat and protein. Faecal elastase is a commonly
used screen of pancreatic function.
Gut hormones
The main gut hormones are:
Gastrin stimulated by vagal stimulation, distension of the stomach. Stimulates gastric acid,
pepsin and intrinsic factor. Stimulates gastric emptying and pancreatic secretion
Secretin stimulated by intraluminal acid. Stimulates pancreatic bicarbonate secretion, inhibits
gastric acid and pepsin secretion, and delays gastric emptying
Cholecystokininpancreozymin stimulated by intraluminal food. Stimulates pancreatic
bicarbonate and enzyme secretion. Stimulates gallbladder contraction, inhibits gastric emptying and
gut motility
Other gut hormones include:
Gastric inhibitory peptide stimulated by glucose, fats and amino acids; inhibits gastric acid
secretion, stimulates insulin secretion and reduces motility
Motilin stimulated by acid in the small bowel; increases motility
Pancreatic polypeptide stimulated by a protein-rich meal; inhibits gastric and pancreatic
secretion
Vasoactive intestinal peptide (VIP) neural stimulation; inhibits gastric acid and pepsin
secretion; stimulates insulin secretion; reduces motility
Enterohepatic circulation
Bile is produced by the liver and stored in the gallbladder. It is secreted into the duodenum after
gallbladder contraction (stimulated by cholecystokininpancreozymin release). Bile acids aid fat
digestion and are formed from cholesterol. Primary bile acids are produced in the liver, and
secondary bile acids are formed from primary bile acids through conjugation with amino acids by the
action of intestinal bacteria. Primary and secondary bile acids are deconjugated in the intestine,
reabsorbed in the terminal ileum and transported back to the liver bound to albumin for recirculation.
2. NUTRITION
2.1 Nutritional requirements
This is age dependent and there are standard tables available (reference nutrient intake, RNI). The
energy needs per kilogram of the infant are higher than the older child.
Daily requirements
Infant 03 months
Fluid
Calories
Protein
Sodium
Potassium
150 ml/kg
100 kcal/kg
2.1 g/kg
2-3 mmol/kg
1.53.0 mmol/kg
12-year-old boy
Fluid
Calories
Protein
Sodium
Potassium
55 ml/kg
50 kcal/kg
1 g/kg
2 mmol/kg
2 mmol/kg
Energy requirements list calories but nutrient and micronutrient requirements are also important to
ensure that intake is balanced. It is essential, for example, to have an appropriate balance of fat,
carbohydrate and protein. Calcium is essential for bone growth. Iron is required to prevent anaemia.
Energy requirements include resting energy expenditure (basal metabolic rate, BMR), which
represents 6070% of requirements and the component that arises as a consequence of physical
activity (physical activity level).
Physical status (metabolic condition, bedridden, physical activity level) will impact on requirements.
2.2 Nutritional assessment

It is important to take a careful history, assess intake, consider requirements and perform basic
anthropometry including weight, height (length in children who are unable to stand) and head
circumference
Body mass index (BMI) is a useful marker of fatness measured as (weight)/(height2) in kg/m2. The
values need to be plotted against age on standard charts
Other methods of assessing nutritional state include skin-fold thickness as an estimate of fat mass
and mid-arm circumference as an estimate of lean body mass. Standard age-matched reference
values are available
Bioimpedance and indirect calorimetry as research tools are also used
Important factors in the history

Consider the following:
Conditions that interfere with intake

Conditions that interfere with absorption, e.g. intestinal resection
Conditions associated with increased losses, e.g. diarrhoea, vomiting
Condition associated with increased needs, e.g. fever, sepsis, tissue injury
Conditions that restrict intake, e.g. cardiac disease, renal disease, food intolerance
Gastrointestinal conditions, e.g. gastro-oesophageal reflux, constipation
Ensure that you understand relevant social and family factors that may impact on the childs nutrition.
2.3 Breast-feeding
Breast-feeding and infection
Ten per cent of the protein in mature breast milk is secretory immunoglobulin A (IgA). Lymphocytes,
macrophages, proteins with non-specific antibacterial activity and complement are also present.
There have been many studies in developing countries to show that infants fed formula milk have a
higher mortality and morbidity particularly from gastrointestinal infection. In the UK, studies have
shown:
Breast-feeding for more than 13 weeks reduces the incidence of gastrointestinal and respiratory
infections
The response to immunization with the Hib (Haemophilus influenzae type b) vaccine is higher in
breast-fed than in formula-fed infants
The risk of necrotizing enterocolitis in low-birthweight babies is lower in those who are breast-fed
Breast-feeding and allergy

The incidence of atopic eczema in infants born to atopic mothers is reduced by breast-feeding.
Overall, however, there is no definitive proven reduction in atopy apart from this specific
circumstance.
Breast-feeding and neurological development

Although there are confounding variables that make study of this subject difficult, there is work that
suggests that neurological development is enhanced in breast-fed infants.
Breast-feeding and diabetes
Infants who are breast-fed have a reduced risk of developing diabetes.
Breast-feeding and infantile colic

There is no good evidence to show that breast-feeding reduces the incidence of infantile colic.
Contraindications to breast-feeding
Maternal drugs and breast-feeding are discussed in Chapter 5, Section 6.2 and Chapter 17.
With regard to tuberculosis, infants can be immunized at birth with isoniazid-resistant BCG and
treated with a course of isoniazid
With regard to human immunodeficiency virus (HIV), the virus has been cultured from breast milk
and is transmitted in it. In the western world this means that breast-feeding is contraindicated in
HIV-positive mothers, because it will increase the perinatal transmission rate. The problem is not
so straightforward in the developing world where the risks of bottle-feeding are high because of
contaminated water supplies
Term and preterm formula

The principal differences are that preterm formula contains more electrolytes, calories and minerals.
All of the following are higher in preterm than in term formula: energy, protein, carbohydrate, fat,
osmolality, sodium, potassium, calcium, magnesium, phosphate and iron.
Human (breast) milk and cows milk

The energy content is the same. Human milk contains less protein than cows milk; cows milk having
a much higher casein content. The fat, although different qualitatively, is the same in amount. Human
milk contains more carbohydrate. Cows milk contains more of all the minerals except iron and
copper.
2.4 Iron
Dietary sources include cereals, red meat (particularly liver), fresh fruit and green vegetables
Absorbed from the proximal small bowel; vitamin C, gastric acid and protein improve absorption;
510% of dietary iron is absorbed
Deficiency causes hypochromic microcytic anaemia. Associated with poor appetite and reduced
intellectual function
Common causes of deficiency include poor diet (particularly prolonged or excess milk feeding),
chronic blood loss, malabsorption
Low serum iron/high transferrin suggests deficiency; low iron/low transferrin suggests chronic
disease. Ferritin is an indicator of total body stores but is also an acute-phase reactant
Treatment is directed against the underlying cause. Dietary advice and iron supplements, of which
numerous commercial preparations are available, are indicated in most patients. Side effects of
iron supplements include abdominal discomfort and constipation. Iron supplements can be fatal in
overdose
2.5 Folate
Dietary sources include liver, green vegetables, cereals, orange, milk, yeast and mushrooms.
Excessive cooking destroys folate
Absorbed from the proximal small bowel
Deficiency causes megaloblastic anaemia, irritability, poor weight gain and chronic diarrhoea.
Thrombocytopenia can occur
The serum folate reflects recent changes in folate status and the red-cell folate is an indicator of the
total body stores
Treatment of deficiency is with oral folic acid
Folate levels are not affected by the acute-phase response
Folate deficiency in mother around the time of conception causes neural tube defects in the baby
Causes of folate deficiency
Reduced intake
Malabsorption, e.g. coeliac disease
Congenital folate malabsorption (autosomal recessive)
Increased requirements (infancy, pregnancy, exfoliative skin disease)
Drugs, e.g. methotrexate, trimethoprim, anticonvulsants, oral contraceptive pill
2.6 Vitamin B12

Dietary sources include foods of animal origin, particularly meat
Absorbed from the terminal ileum, facilitated by gastric intrinsic factor
Deficiency causes megaloblastic anaemia, low vitamin B12 and increased methylmalonic acid in the
urine
Clinical features include anaemia, glossitis, peripheral neuropathy, subacute combined
degeneration of the cord and optic atrophy
Causes include pernicious anaemia (rare in childhood); gastric- and parietal-cell antibodies are
usually positive
Other causes of vitamin B12 deficiency include poor intake (vegan diet) and malabsorption, e.g.
blind-loop, post-resection
Treatment is with vitamin B12, usually given intramuscularly once or twice a week initially then 3monthly. Folic acid is also needed
2.7 Zinc
Dietary sources include beef, liver, eggs and nuts

Deficiency occurs secondary to poor absorption rather than poor intake
Clinical features include anaemia, growth retardation, periorofacial dermatitis, immune deficiency,
diarrhoea
Responds well to oral zinc
Autosomal recessive inheritance
Basic defect is impaired absorption of zinc in the gut
Presents with skin rash around the mouth and perianal area, chronic diarrhoea at the time of
weaning and recurrent infections. The hair has a reddish tint; alopecia is characteristic.
Superinfection with Candida sp. is common as are paronychia, dystrophic nails, poor wound
healing and ocular changes (photophobia, blepharitis, corneal dystrophy)
Diagnosis is by serum zinc levels and the constellation of clinical signs. Measurement is difficult
because the serum zinc is low as part of the acute-phase response. Measurement of white-cell zinc
levels is more accurate. The plasma metallothionein level can also be measured. Metallothionein
is a zinc-binding protein that is decreased in zinc deficiency but not in the acute-phase response
Zinc deficiency in the newborn can produce a similar clinical picture
The condition responds very well to treatment with oral zinc
2.8 Fat-soluble vitamins

Vitamin A
Deficiency causes night blindness, poor growth, xerophthalmia, follicular hyperplasia and impaired
resistance to infection
Excess causes carotenaemia, hyperostosis with bone pain, hepatomegaly, alopecia and
desquamation of the palms. Acute intoxication causes raised intracranial pressure
Dietary sources are milk, fat, fruit and vegetables, eggs and liver
Vitamin A has an important role in resistance to infection particularly at mucosal surfaces. In
developing countries where vitamin A deficiency is endemic, vitamin A reduces the morbidity and
mortality associated with severe measles
Vitamin E
Is an antioxidant
Found in green vegetables and vegetable oils
Deficiency causes ataxia, peripheral neuropathy and retinitis pigmentosa
Abetalipoproteinaemia

Pathogenesis is failure of chylomicron formation with impaired absorption of long-chain fats with
fat retention in the enterocyte
Presents in early infancy with faltering growth, abdominal distension and foul-smelling, bulky
stools
Symptoms of vitamin E deficiency (ataxia, peripheral neuropathy and retinitis pigmentosa) develop
later
Diagnosis is by low serum cholesterol, very low plasma triglyceride level, acanthocytes on
examination of the peripheral blood film and absence of betalipoprotein in the plasma
Treatment is by substituting medium-chain triglycerides for long-chain triglycerides in the diet
(absorbed via the portal vein rather than the thoracic duct). In addition, high doses of the fatsoluble vitamins (A, D, E and K) are required. Most of the neurological abnormalities are
reversible if high doses of vitamin E are given early
Vitamin D
Vitamin D is important for calcium homeostasis and optimal bone growth
Sources are fish oil, vegetable oil, skin synthesis by ultraviolet B light and egg yolks
Two main forms vitamin D2 and vitamin D3. Vitamin D3, also known as cholecalciferol, is either
made in the skin or obtained in the diet from fatty fish. Vitamin D2, also known as ergocalciferol, is
obtained from irradiated fungi, such as yeast. In order to become active, vitamin D requires two
sequential hydroxylations to form 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D, which
happens in the liver and kidney respectively.
Deficiency can occur because of dietary deficiency (e.g. prolonged breast-feeding, inadequate
diet), inadequate exposure to sunlight, malabsorption, medications
Vitamin D deficiency leads to decreased calcium absorption, low plasma calcium, high alkaline
phosphatase and raised parathyroid hormone
Deficiency results in rickets, impaired bone formation and growth. Older children can get bowing
of long bones, enamel hypoplasia, kyphoscoliosis and pelvic deformity
25-Hydroxyvitamin D is the most accurate way to measure how much vitamin D is in the body
Oral calciferol and cholecalciferol are used as treatment. The principal aim of therapy is to
replenish vitamin D stores; patients are then continued on a lower maintenance dose. Large bolus
doses are also equally effective
Vitamin D deficiency is very common in the UK and under-diagnosed. From a public health
perspective, primary prevention of vitamin D deficiency in the UK is socially as well as medically
justifiable. The key groups for health-care professionals to target are infants, children, adolescents
and pregnant women, particularly those with dark skin. Other high-risk groups are elderly and
institutionalized people
Vitamin K
Found in cows milk, green leafy vegetables and pork; very little in breast milk
Deficiency in the newborn presents as haemorrhagic disease of the newborn. This usually presents
on day 2 or 3 with bleeding from the umbilical stump, haematemesis and melaena, epistaxis or
excessive bleeding from puncture sites. Intracranial bleeding can occur. Diagnosis is by
prolongation of the prothrombin and partial thromboplastin times, with the thrombin time and
fibrinogen levels being normal. Treatment is with fresh frozen plasma and vitamin K
There is no proven association between intramuscular vitamin K and childhood cancer
2.9 Nutritional impairment

Energy balance
A positive energy balance implies that intake exceeds requirements and a negative energy balance
implies that intake is less than requirements. It is important to remember that requirements during
childhood include those needed for growth.
Pathogenesis of malnutrition
It is essential to think about the pathogenesis of malnutrition when assessing nutrition and looking at
nutritional supplementation. Malnutrition can only result from:
Inadequate intake or excessive losses
Increased metabolic demand without increased intake
Malabsorption
One or all of these may contribute to malnutrition in an individual.
A good example is cystic fibrosis in which:
Pancreatic malabsorption causes increased losses
Increased energy needs are caused by:
Chronic cough
Dyspnoea
Recurrent infection
Inflammation
Reduced intake is caused by:
Anorexia
Vomiting
Psychological problems
Together, all of these factors result in an energy deficit. They all need to be taken into account when
nutritional supplementation is considered.
2.10 Proteinenergy malnutrition
Marasmus is characterized by muscle wasting and depletion of the body fat stores. Kwashiorkor is
characterized by generalized oedema with flaky or peeling skin and skin rashes. Most children with
malnutrition rare in the western world exhibit a combination of the two. Micronutrient
deficiencies are common in these children.
2.11 Faltering growth

Faltering growth (previously called failure to thrive) refers to not only failure of growth but also
impairment of other aspects of a childs wellbeing. It is common in infancy. It occurs because of one
or a combination of the following:
Failure of carer to offer adequate calories
Failure of the child to take sufficient calories
Failure of the child to retain adequate calories
Clearly this can be organic or non-organic. Insufficient calories may be offered as a consequence of
parental neglect or because of a failure of the carer to appreciate the calorie requirements of the
child. Insufficient calories may be taken as a consequence of feeding difficulties (e.g. cerebral palsy)
or increased needs (e.g. cystic fibrosis), and calories may not be retained because of absorptive
defects or loss through vomiting or diarrhoea.
It is important to consider other causes that can influence growth such as familial short stature, genetic
abnormality, birth size (intrauterine growth retardation), psychological deprivation and environmental
factors (poverty).
The investigation of faltering growth is generally fruitful only when specific pointers to organic
problems are elucidated in the history or on physical examination.
The management of non-organic faltering growth requires health visitor input and often dietary
assessment. In difficult cases hospital admission is indicated for multidisciplinary evaluation and to
ensure an adequate weight gain can be obtained if sufficient calories are given.
2.12 Organic causes of faltering growth

This list provides examples only and is by no means exhaustive:
Gastrointestinal coeliac disease, cows milk-protein intolerance, gastro-oesophageal reflux

Renal urinary tract infection, renal tubular acidosis
Cardiopulmonary cardiac disease, cystic fibrosis, bronchopulmonary dysplasia
Endocrine hypothyroidism, growth hormone deficiency
Neurological cerebral palsy
Infection/immunodeficiency HIV, malignancy
Metabolic inborn errors of metabolism
Congenital chromosomal abnormalities

ENT adenotonsillar hypertrophy
2.13 Malabsorption
Malabsorption is difficulty absorbing nutrients from food. Several malabsorption syndromes have
been described. They can be genetically determined or acquired, and affect one or more of the
several mechanisms responsible for the absorption of food; they result in chronic diarrhoea,
abdominal distension and failure to thrive:
Genetically determined malabsorption syndromes coeliac disease and cystic fibrosis are two
very common causes
Common acquired causes include cows milk protein intolerance, acute enteritis, post-enteritis
syndrome
A detailed list of causes is described in Section 7 on chronic diarrhoea
3. NUTRITIONAL MANAGEMENT
3.1 Nutritional supplementation
Nutritional supplementation should be with the help of a dietician. It is essential, however, to have
some background information and to:
treat underlying pathology, which may be a factor
assess the childs requirements
give additional calories either by increasing the calorie density of feed or giving feed by a different
route, e.g. nasogastric tube, gastrostomy tube or parenterally
Enteral nutrition refers to that given either directly (by mouth) or indirectly (via nasogastric tube or
gastrostomy) into the gastrointestinal tract. Parenteral nutrition is given into either the peripheral or
the central veins, usually the latter.
It may be helpful to consider specific scenarios:
A 6-month-old infant with congenital heart disease is failing to thrive comment on his
nutritional status. What nutritional supplementation would you recommend?
In this infant the poor nutritional state will be as a consequence of increased metabolic demands and
poor intake secondary to breathlessness. Supplementation would be by increasing the calorie density
of feeds and consideration of other methods of administration such as via a nasogastric tube. It is
obviously also of importance to maximize medical therapy of the heart disease.
This 6-month-old infant has bronchopulmonary dysplasia and severe faltering growth.
Comment on possible causes.
In this infant the above applies. In addition, other factors may be relevant such as chronic respiratory
symptoms, gastro-oesophageal reflux and neurodevelopmental issues. Supplementation would be by
increasing calorie density of feeds and considering using a nasogastric tube or gastrostomy to give the
feed. In addition, investigation for problems such as gastro-oesophageal reflux may be considered.
This 3-month-old infant, born at 29 weeks gestation, had a massive resection for volvulus in
the neonatal period and has poor feed tolerance, parenteral nutrition (PN) dependence and
severe liver disease. What strategies are required in this childs subsequent management?
This child has intestinal failure with persistent PN dependency and liver disease. The priority is to
maximize enteral intake which will reduce the likelihood of progression of the liver disease. A
hydrolysed feed given by continuous infusion will probably be tolerated best. PN should be weaned
only when the feed is tolerated and absorbed. Loperamide may reduce transit. Bacterial overgrowth
is likely and should be managed with cyclical antibiotics. Macro- and micronutrients should be
checked to ensure that they are adequate. Attention should be given to promoting the childs oral
feeding skills.
This 13-year-old boy has cerebral palsy. Comment on his nutritional status. What strategies
could be used to improve his nutrition? Why do you think his nutritional status is so poor?
This childs principal problem is likely to be with intake, either because of reflux or secondary to
bulbar problems, or both. In addition to nutritional supplements, this child may benefit from help with
feeding practices including the involvement of a dietician, speech and language therapist,
occupational therapist and neurodevelopmental paediatrician. Other medical problems may be
relevant such as recurrent chest infections secondary to aspiration and intractable fits. Consideration
needs to be given to feeding via nasogastric tube or gastrostomy tube if appropriate. In some instances
a fundoplication will also be required.
This boy has cystic fibrosis. Comment on his nutritional status. What can be done to help?
The additional factor in this child is malabsorption for which pancreatic supplementation is required.
Children with cystic fibrosis often dislike food and need either a nasogastric tube or gastrostomy to
help with administration. The energy requirements are high and calorie supplementation with energydense supplements is required.
Nutritional supplements
Normal infant feeds or milk contain 0.7 kcal/ml

Feeds can be concentrated
Carbohydrate supplements can be used, usually as glucose polymer in powder form to add to feeds
Combined carbohydrate and fat supplements can be used
Feeds with a higher calorie density can be used, e.g. 1 kcal/ml, 1.5 kcal/ml
Special feeds can be used, e.g. hydrolysed protein formula feeds, soya-based feeds, lactose-free
feeds, medium-chain triglyceride-based feeds
Milk-based or juice-based supplements can be given
There are many commercially available products available
3.2 Enteral nutrition

Enteral feeding strictly refers to enteral feed given directly into the gastrointestinal tract. For the
purpose of this section, an enteral feed has been considered as a supplementary feed, i.e. not
including foods normally taken by mouth, and therefore refers principally to feeds given by
nasogastric or nasojejunal tube, gastrostomy, gastrojejunostomy or jejunostomy.
Indications for enteral tube feeding

Insufficient energy intake by mouth
Wasting
Stunting
Diseases for which enteral nutrition may be indicated

Gastrointestinal
Short-bowel syndrome
Pseudo-obstruction
Chronic liver disease
Gastro-oesophageal reflux
Glycogen storage disease types I and III
Fatty acid oxidation defects
Coma and severe facial and head injury
Severe learning disability and cerebral palsy
Dysphagia secondary to cranial nerve dysfunction, muscular dystrophy or myasthenia gravis
Malignant disease
Obstructing disease
Head and neck
Oesophagus
Stomach
Abnormality of deglutition after surgical intervention
Gastrointestinal side effects from chemotherapy and/or radiotherapy

Terminal supportive care
Pulmonary disease
Bronchopulmonary dysplasia
Cystic fibrosis
Chronic lung disease
Congenital abnormalities
Tracheo-oesophageal fistula
Oesophageal atresia
Cleft palate
Pierre Robin syndrome
Other
Anorexia nervosa
Cardiac cachexia
Chronic renal disease
Severe burns
Severe sepsis
Severe trauma
Choice of feed type

A wide range of feeds are available and the decision about which to use is based on the childs
needs. Factors that are of relevance include whether the enteral feed will be the sole source of
feeding, in which case the feed needs to be nutritionally complete, or whether the feed is going to be
given as a supplement. Feed tolerance and calorie requirements are relevant. A modified feed may be
required, e.g. lactose free in a child with carbohydrate intolerance. Factors such as fibre content and
calorie density are also important, particularly if supplementary feeding is going to be long term.
A hydrolysed protein is one that is broken down into oligopeptides and peptides. A hydrolysed
protein milk formula is therefore one that does not contain whole protein. An elemental formula is a
hydrolysed protein formula in which the protein is broken down into amino acids.
Hydrolysed protein formula feeds are used in children with cows milk allergy, enteropathies, e.g.
post-gastroenteritis, post-necrotizing enterocolitis, short-gut syndrome, severe eczema and Crohn
disease.
Choice of feed regimen
This will depend on a combination of requirements, tolerance and factors such as gastric emptying.
Options include bolus feeding and continuous feeding or a combination of the two.
In the severely malnourished child, the volume and calorie density of a new feed regimen may need to
be increased slowly, as tolerated, over a few days. This avoids metabolic upset (re-feeding
syndrome) in the vulnerable child, e.g. severe postoperative weight loss, anorexia nervosa.
Dysmotility
The motility of the gut is a key factor in feed tolerance. Preterm infants, and children with cerebral
palsy, may have delayed gastric emptying which can impact significantly on the ability to feed,
particularly if nutrition is dependent on nasogastric or gastrostomy feeding. Abdominal pain, bloating
and constipation are common features of gut dysmotility.
It may be necessary to give a prokinetic agent such as domperidone or erythromycin, laxatives and
occasionally, if there is a need for distal gut deflation, suppositories. It may be necessary to give
feeds by continuous infusion. Milk-free diets can be used and in difficult cases full gastrointestinal
investigation including upper and lower gastrointestinal endoscopy, barium radiology, pH studies and
scintigraphy may be indicated. A number of children, particularly those with cerebral palsy, respond
to milk exclusion using a hydrolysed protein formula feed as an alternative.
Methods of feed delivery

Nasogastric tube feeding
This is the most commonly used route for short-term (<6 weeks) enteral feeding given either by bolus
or continuously. There is a risk of reflux and aspiration pneumonia. Nasal irritation and inhibition of
oral feeding sometimes occur. Most infants will not tolerate nasogastric feeding long term.
Nasojejunal feeding
This is indicated when nasogastric feeding is not tolerated because of delayed gastric emptying or
gross gastro-oesophageal reflux. Feed usually needs to be given continuously to avoid dumping. If
nasojejunal feeding is required long term a gastrojejunal tube or jejunostomy can be fashioned.
Gastrostomy tube feeding
Gastrostomy is probably the best route for long-term (>6 weeks) feeding. Gastrostomy tubes are
commonly inserted endoscopically (percutaneous endoscopic gastrostomy). They can also be inserted
laparoscopically, surgically and under fluoroscopic control (by an interventional radiologist). The
complications are few including small risk of bleeding, infection, leaking, dislodgement of the tube,
over granulation and rarely worsening of reflux.
Indications for gastrostomy tube placement
Chronic disease with nutritional impairment, e.g. cystic fibrosis, bronchopulmonary dysplasia
For nutritional therapy, e.g. Crohn disease
Difficulties with feeding, e.g. cerebral palsy, particularly with an associated bulbar palsy. Some of
these children may also have severe gastro-oesophageal reflux and require fundoplication
Children long-term dependent upon nasogastric feeding for any other reason
Jejunal feeding long term
Long-term (>6 weeks) jejunal feeding can be considered in cases of severe reflux or delay in gastric
emptying where surgery is not possible. This can be done by following methods:
Jejunal tube insertion via PEG (percutaneous endoscopic gastrostomy)

Percutaneous endoscopic jejunostomy
Subcutaneous jejunostomy
Surgical jejunostomy (e.g. roux-en-Y)

There are differences between children and adults particularly in terms of nutritional reserve:
Adults can survive 90 days without food

Preterm infants of 1 kg can survive 4 days
Preterm infants of 2 kg can survive 12 days
Term infants of 3.5 kg can survive 32 days
One year olds can survive 44 days
General principles of parenteral nutrition

Parenteral nutrition (PN) is usually indicated when a sufficient nutrient supply cannot be provided
orally or enterally to prevent or correct malnutrition or to sustain appropriate growth
It is, however, important to use the gut where possible
The complete exclusion of luminal nutrients is associated with atrophic changes in the gut, reduced
pancreatic function, biliary stasis and bacterial overgrowth
It is not usually necessary to use PN for less than 5 days except in the extremely preterm infant
It is important to evaluate risk of re-feeding syndrome before considering PN
Benefits of minimal enteral nutrition in children who are PN fed
Stimulation of mucosal adaptation (trophic feeding)

Protection against sepsis (normalize flora)
Improved bile flow with decreased risk of cholestasis
Reduced time to establish enteral feeds
Indications for PN
Neonates
Absolute indications
Intestinal failure (short gut, functional immaturity, pseudo-obstruction)
Necrotizing enterocolitis
Relative indications
Hyaline membrane disease
Promotion of growth in preterm infants
Possible prevention of necrotizing enterocolitis
Older infants and children
Intestinal failure
Short bowel syndrome
Protracted diarrhoea
Chronic intestinal pseudo-obstruction
Postoperative abdominal or cardiothoracic surgery
Radiation/cytotoxic therapy
Exclusion of luminal nutrients
Crohn disease
Organ failure
Acute renal failure or acute liver failure
Hypercatabolism
Extensive burns
Severe trauma
Practical issues
PN prescribing
There are standard regimens for PN prescribing at different ages. This will include the starter
regimen which then increases in nutrient density over the first few days. Protein is supplied as amino
acid, carbohydrate as glucose and fat as a lipid emulsion. Electrolyte, calcium and phosphate contents
need to be carefully controlled. Calorie density is increased through an increase in carbohydrate
gradually over first few days. It is important to use standard regimens adjusted according to fluid
balance, electrolyte status and tolerance, e.g. of increases in glucose. It is important not to push
calorie density up too much without expert advice because this may result in poor tolerance and
toxicity with a net reduction in metabolized energy intake. The use of a PN pharmacist together with a
nutrition team is essential in difficult cases.
Monitoring during PN
The initial frequency of biochemical monitoring will depend on the degree of electrolyte impairment
and other factors, e.g. sepsis, liver disease. It is especially important in poorly nourished children
who are at risk of re-feeding syndrome. It is generally necessary in the acute situation to do at least
routine biochemistry (including blood glucose, phosphate, magnesium and urine dipstix) daily until
stable and then twice weekly. Urine electrolytes should be monitored twice weekly at least initially.
Liver function, calcium and phosphate should be done weekly. Trace metals (copper, zinc, selenium,
magnesium) should be checked monthly. In children on long-term PN 6-monthly iron status, vitamin
B12, red cell folate, fat-soluble vitamins, aluminium and chromium should be measured. Chest
radiograph, liver ultrasonography and echocardiography should be done 6- to 12-monthly.
Blood glucose should be monitored frequently during periods of increasing carbohydrate load.
Complications
Complications associated with use of PN
Phlebitis
Infection
Hypo- and hyperglycaemia, hypophosphataemia
Electrolyte disturbance
Fluid overload
Anaemia
Trace element deficiencies
Vitamin deficiencies
Essential fatty acid deficiency
Cholestasis and hepatic dysfunction
Metabolic acidosis
Hypertriglyceridaemia
Granulomatous pulmonary arteritis
Complications associated with central venous catheter insertion
Sepsis
Air embolism
Arterial puncture
Arrhythmias
Chylothorax
Haemothorax
Pneumothorax
Haemo-/hydropericardium
Malposition of catheter
Central venous thrombosis
Thromboembolism
Extravasation from fractured catheter

Tricuspid valve damage
Catheter tethering
Central venous catheter-related bloodstream infection
Central venous catheter (CVC) infections are the most common and potentially life-threatening
complication associated with PN. Coagulase-negative staphylococcal infection is the most common.
A child on PN should have cultures taken (both central and peripheral) and broad-spectrum
antibiotics started promptly if the temperature is more than 38.5C or there are other strong
indications of sepsis. It is important that appropriate procedures are in place to ensure that lines are
dealt with aseptically and only by trained personnel. Long-term feeding lines should not, for example,
be used for blood letting. Antibiotic locks can be used once the sensitivities are available and
treatment is continued for at least 1014 days. Removal of a CVC is considered in patients presenting
with overwhelming sepsis or shock, and those with persistent positive cultures (colonized lines)
despite appropriate antibiotic treatment.
Children with short gut/enteropathy are at highest risk because of bacterial translocation; they should
have regular gut decontamination, particularly if infections are frequent.
Occlusion of a CVC
This can be partial or complete occlusion. Partial occlusion can be resolved through prompt
intervention to unlock the line by checking for external occlusion (clamps or kinks in the tubing) or
flushing the CVC with saline/heparin sodium (10 U/ml) using strict aseptic technique. Smaller size
syringe (5 ml/2 ml) can be used to deliver greater pressure. If this fails, an unblocking agent such as
urokinase/alcohol/hydrochloric acid can be used. Rarely, a CVC is completely occluded and needs to
be removed.
PN-associated liver disease
PN-associated liver disease (PNALD) develops in 4060% of infants who require long-term PN for
intestinal failure. The clinical spectrum includes cholestasis, cholelithiasis, hepatic fibrosis with
progression to biliary cirrhosis, and the development of portal hypertension and liver failure. The
pathogenesis is multifactorial and is related to prematurity, low birthweight and duration of PN. The
degree and severity of the liver disease is related to recurrent sepsis, including catheter sepsis,
bacterial translocation and cholangitis. Lack of enteral feeding leading to reduced gut hormone
secretion, reduction of bile flow, and biliary stasis are important mechanisms in the development of
cholestasis, biliary sludge and cholelithiasis. The management strategies for the prevention of PNinduced liver disease include early enteral feeding, a multidisciplinary approach to the management
of parenteral nutrition, and aseptic catheter techniques to reduce CVC-related bloodstream infection
(CRBSI). Cyclical PN, use of reduced intravenous fat intake and empirical change to different lipid
emulsion (SMOF) can help reduce progression of PNALD. The administration of ursodeoxycholic
acid may improve bile flow and reduce gallbladder and intestinal stasis. Fat-soluble vitamin
replacement is essential by the intravenous route when child is parenterally fed, but may be given
orally with regular monitoring during the transition to oral/enteral feeding.
Consequences of trace element abnormalities described during parenteral

nutrition
3.4 Re-feeding syndrome

Re-feeding syndrome is a potential metabolic complication in any malnourished patient which can
happen with enteral or parenteral nutrition. This happens as a consequence of severe fluid and
electrolyte shifts, which can cause disturbances in body systems including cardiac arrhythmias.
Before feeding it is important to assess nutritional status and hydration, cardiac status, serum
electrolytes, magnesium and phosphate. The greatest vigilance is required especially in the first week
of feeding. Patients at risk of re-feeding syndrome usually have feeds introduced gradually over the
first 48 hours with careful monitoring of electrolytes, calcium, urea, creatinine, phosphate and
magnesium. Feeds are subsequent increased over the next 57 days with supplementation if
necessary.
Risk factors for re-feeding syndrome

One or more
BMI <16
Unintentional weight loss >15% in 36 months
10 days with little or no nutritional intake
Low magnesium, potassium or phosphate before feeding
Two or more
BMI <18.5
Unintentional weight loss >15% in 36 months
5 days with little or no nutritional intake
Alcohol misuse, chronic diuretic, antacid, insulin use or chemotherapy
3.5 Intestinal failure

Intestinal failure is defined as a reduction in the functioning intestinal mass below the amount
necessary for adequate absorption to allow for growth. Management of intestinal failure has been
revolutionized in last five decades by the availability of PN, advances in neonatal intensive care and
paediatric surgical techniques with increase in survival of children with intestinal failure.
Aetiology
Short bowel syndrome
See below.
Motility disorders
An example of this is chronic idiopathic intestinal pseudo-obstruction syndrome. This is a group of
rare disorders that present with signs and symptoms of intestinal obstruction in the absence of
identifiable mechanical obstruction. These disorders usually present in infancy and death or
dependence on PN is common.
Mucosal disorders
These disorders present in early life with intractable diarrhoea. They can be primary epithelial
abnormalities such as microvillus inclusion disease, tufting enteropathy and glycosylation disorder,
immune-mediated mucosal disorders such as underlying immune deficiencies (e.g. severe combined
immunodeficiency), autoimmune enteropathy and syndromic diarrhoea. Most of these children are
long-term PN dependent and ultimately need consideration of small bowel transplantation.
Short-bowel syndrome
This is defined as intestinal failure secondary to massive resection of the diseased gut or as a
consequence of congenital bowel abnormality. The consequence are inadequate absorption of fluids,
electrolytes and nutrients from the bowel.
Aetiologies
Neonatal necrotizing enterocolitis, intestinal atresia, volvulus, gastroschisis and total
aganglionosis
Older child trauma, Crohn disease requiring resection of bowel, vascular abnormalities, tumour,
radiation enteritis and mesenteric infarction.
Factors that determine outcome in short-bowel syndrome

Length of bowel resected and remaining bowel length preterm bowel is likely to undergo further
growth (bowel length increases by 100% in the third trimester)
Less than 40 cm of residual small bowel in infancy is usually associated with a need for long-term
nutritional support
Quality of bowel remaining ischaemic, distended, ileum greater potential to adapt than jejunum
Presence of ileocaecal valve loss of ileocaecal valve results in faster transit. Backflow (loss of
the one-way valve) makes bacterial overgrowth more likely
Improved outcome if colon still present
Coexistent disease, e.g. enteropathy is an adverse risk factor
Presence of intestinal failure-associated liver disease (IFALD) is an adverse risk factor
Failure to achieve full enteral feeding after 5 years of PN suggest lifelong dependency on PN
Management
1. Maintenance of normal growth through adequate calorie, nutrient and micronutrient intake given
through PN. Careful clinical and biochemical monitoring is essential. Home PN is considered as
soon as clinical stability is achieved
2. Use of enteral feeding when gut function allows to help intestinal adaptation. There are three
phases of intestinal adaptation: acute (PN-dependent, postoperative ileus), adaptive (increasing
enteral nutrition, can take months to years) and chronic. The early introduction of enteral feeds
promotes intestinal adaptation and will improve subsequent feed tolerance. Feeds are usually best
given as a continuous infusion in the first instance and should be increased only if tolerated, i.e. no
diarrhoea (or excess stoma output if present). PN should not be weaned until feed is tolerated and
absorbed. Weight needs careful monitoring during weaning of PN
3. Minimizing risk of complications of gut failure and nutritional support
4. Optimizing quality of life: multidisciplinary management is required, including attention to the
childs oral skills, social and psychological development and the needs of the family.
5. Non-transplantation surgery (bowel-lengthening procedures): aim is to provide maximum mucosal
contact without disturbing motility or reducing total absorptive mass. Entire length of the bowel
available is used. The Bianchi (bowel lengthening) procedure, intestinal tapering or plication and,
recently, the serial transverse enteroplasty procedure (STEP) have been tried with varying success
6. Isolated liver transplantation considered in those patients with short gut who have at least 30 cm
of residual small bowel, have previously tolerated 50% of their estimated enteral feeds and
demonstrated weight gain, but failed to achieve maximal adaptation because of end-stage liver
disease
7. Intestinal transplantation (ITx) has emerged as a life-saving option for patients with intestinal
failure who develop major complications. The indications for ITx are irreversible intestinal failure
and one of the following: impaired venous access (reduced to two suitable veins for placement of
feeding catheters); progressive liver disease with coagulopathy, ascites and encephalopathy; and
life-threatening episodes of catheter sepsis. This can be isolated small bowel transplantation or
combined liver and small bowel transplantation
3.6 Home parenteral nutrition

Home PN is considered when it is anticipated that full enteral feeding would take more than 4 months
to be established. Where possible PN is infused over 12 hours at night and a CVC is locked with
heparinized saline in the day time. Parental motivation, suitable housing and adequate training by the
multidisciplinary team looking after the child is extremely important. These patients need close
follow-up to monitor their growth, tolerance to enteral feeds and biochemistry.
4. FOOD ALLERGY AND INTOLERANCE

Food allergy is one of the most common allergic disorders in the UK and its prevalence has increased
dramatically in recent years. It is important to distinguish between allergy and intolerance. An allergy
implies an immune-mediated reaction to food antigen (protein). Classically this is by IgE-mediated,
type I hypersensitivity. The signs of this include anaphylaxis, urticaria and atopic dermatitis. Allergy
can be non-IgE mediated which is characterized by delayed or non-acute onset and implies
intolerance. Rarely it can present as a mixed reaction involving both IgE and non IgE responses.
Intolerance does not necessarily need to be to a protein and includes, for example, lactose
intolerance.
The National Institute for Health and Clinical Excellence (NICE) has recently produced clinical
guidelines for diagnosis and assessment of food allergy in children and young people in primary care
and community settings (February 2011).
4.1 Cows milk protein intolerance

Cows milk protein intolerance (CMPI) is the clinical syndrome resulting from sensitization to one or
more proteins in cows milk.
Clinical spectrum of cows milk protein intolerance
Acute type 1-mediated hypersensitivity

Delayed-onset hypersensitivity
Cows milk allergic oesophagitis (eosinophilic)
Cows milk-sensitive enteropathy
Cows milk allergic colitis (eosinophilic)
Non-specific symptoms possibly attributable to cows milk
Presentation is most commonly with gastrointestinal symptoms such as vomiting, diarrhoea, colic and
constipation. Other rare presentations can be respiratory (wheeze, rhinitis, asthma), dermatological
(atopic dermatitis, eczema, urticaria) and behavioural (irritability, crying and milk refusal).
Diagnosis is dependent on the clinical manifestations. A good history and, if possible, dietetic
assessment is essential. Skin-prick testing and IgE radioallergosorbent testing (RAST) are sometimes
used but lack sensitivity or specificity. A negative result does not exclude allergy and a positive result
can be seen in children who tolerate cows milk protein without a problem. If either an enteropathy or
colitis is suspected then it is useful to obtain histological confirmation.
Management
Milk exclusion with a milk substitute. Soya preparations are commonly used and are palatable.
Soya products should not be used in infants aged <6 months because of the presence of
phytoestrogens in soya milk. There is a cross-reactivity between cows milk and soya protein of up
to one-third and so extensively hydrolysed protein formula feeds are preferred. Minimum of 24
weeks trial should be given. Risk of failure with extensively hydrolysed formula is 10% when
amino acid-based feeds should be used. In exclusively breast-fed infants with suspected CMPI,
mothers may need to exclude cows milk from their diet
It is common in children with milk allergy to see reactions to other foods, the most common of
which are soya, egg, wheat and peanut. In the case of suspected multiple food allergy or severe
reaction to CMP, a strict exclusion diet with amino acid-based formula should be considered
The natural history of cows milk intolerance is one of resolution with 8090% back on a normal
diet by their third birthday. It is sensible to challenge regularly. It is usual to organize challenges in
hospital, particularly if the initial reaction was severe, because of the risk of anaphylaxis
4.2 Peanut allergy

Peanut and nut allergies are seen with increasing frequency. Between 60 and 80% of children with
peanut allergy (peanuts are a vegetable rather than a nut) are also allergic to other nuts. Reactions
vary from mild urticaria to life-threatening anaphylaxis. Skin-prick testing is useful with a high
sensitivity and specificity. Peanut avoidance is difficult and dietetic support is essential. Cross
contamination in food production is common. The natural history suggests that children with earlyonset allergy may grow out of it, although allergy in older children with symptomatic reactions is
more likely to persist. Active management involves challenging peanut skin-prick-negative children.
This is clearly not without risk and needs to be done in an inpatient setting with facilities for
resuscitation.
Common other nuts that cause allergic reactions include brazil nut, cashew nut, hazelnut, walnut,
almond and pistachio nut.
4.3 Food-induced anaphylaxis (IgE mediated)

Children who have had an anaphylactic reaction are at increased risk of a second reaction after
second exposure, for which there is a significant mortality. These children benefit from an adrenaline
pen. It is important that such children and their families are taught properly about the indications for
use of the pen and subsequent action that should be taken. The school and all the main carers need to
be involved. A MedicAlert bracelet is useful. Children should also have antihistamines kept in their
house. These are appropriate for minor reactions and some units advocate their use before potential
accidental exposure.
It is essential to be aware of the guidelines for the management of an anaphylactic reaction. Please
refer to the APLS anaphylaxis algorithm (November 2009) by the Advanced Life Support Group
(ALSG) (see www.doh.gov.za/docs/immunization/anaphylaxis.pdf).
4.4 Carbohydrate intolerance

Disorders of disaccharide absorption
Primary
Congenital alactasia
Congenital lactose intolerance
Sucroseisomaltase deficiency
Secondary (acquired)
Post-enteritis (rotavirus), neonatal surgery, malnutrition
Late-onset lactose intolerance
Disorders of monosaccharide absorption

Primary
Glucosegalactose malabsorption
Secondary (acquired)
Post-enteritis, neonatal surgery, malnutrition
Lactose intolerance
This is usually acquired, most commonly post-rotavirus infection. The deficient enzyme is the brushborder enzyme lactase, which hydrolyses lactose into glucose and galactose. The intolerance will
characteristically present with loose explosive stools. The diagnosis is made by looking for reducing
substances in the stool after carbohydrate ingestion. Formal confirmation of the specific offending
carbohydrate is through stool chromatography. Treatment is with a lactose-free formula in infancy and
a reduced lactose intake in later childhood.
Glucosegalactose malabsorption
This is a rare, autosomal recessively inherited condition, characterized by rapid-onset watery

diarrhoea from birth. It responds to withholding glucose (stopping feeds) and relapses on
reintroduction. The diagnosis is essentially a clinical one. Reducing substances in the stool will be
positive. Small-bowel biopsy and disaccharide estimation will be normal. Treatment is by using
fructose as the main carbohydrate source.
Sucraseisomaltase deficiency
This is a defect in carbohydrate digestion, with the enzyme required for hydrolysis of sucrose and
alpha-limit dextrins not present in the small intestine. Symptoms of watery diarrhoea and/or faltering
growth develop after the introduction of sucrose or complex carbohydrate into the diet.
Symptoms can be very mild
Reducing substances in the stool are negative (non-reducing sugar)
Diagnosis is by stool chromatography. Management is by removal of sucrose and complex
carbohydrate from the diet.
Hydrogen breath testing

The hydrogen breath test looks for carbohydrate malabsorption. Lactose is the usual substrate. The
principle is that malabsorbed carbohydrate will pass to the colon where it is metabolized by bacteria
and hydrogen gas is released. The gas is then absorbed and released in the breath. If there is a peak it
suggests carbohydrate malabsorption. Other carbohydrates can be given as the substrate.
5. GASTRO-OESOPHAGEAL REFLUX
Gastro-oesophageal reflux (GOR) is common and implies non-forceful regurgitation of milk and other
gastric contents into the oesophagus (regurgitation). It is a normal physiological phenomenon. It is
common in infancy and is also seen in older children and adults, particularly after meals.
Functional reflux is regurgitation without morbidity or clinical signs suggestive of gastro-oesophageal
reflux disease.
Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GORD) is defined as gastro-oesophageal reflux associated with
troublesome symptoms or complications. It refers to reflux with significant morbidity including
faltering growth, respiratory disease and oesophagitis, or complications of oesophagitis such as
stricture.
Differential diagnosis of GOR
Infection, e.g. urinary tract infection, gastroenteritis, peptic ulcer disease

Intestinal obstruction, e.g. pyloric stenosis, malrotation, intestinal atresia
Food allergy and intolerances, e.g. cows milk allergy, soy allergy, coeliac disease
Eosinophilic oesophagitis
Metabolic disorders, e.g. diabetes, inborn errors of metabolism
Psychological problems, e.g. anxiety, irritable bowel syndrome
Intestinal dysmotility, e.g. primary, achalasia, secondary to neurodisability
Drug-induced vomiting, e.g. cytotoxic agents
Primary respiratory disease, e.g. asthma, cystic fibrosis
Rumination
Symptoms and signs of GORD

Typical
Excessive regurgitation/vomiting
Nausea
Weight loss/faltering growth
Irritability with feeds, arching, colic/food refusal
Dysphagia
Chest/epigastric discomfort
Excessive hiccups
Anaemia iron deficiency
Haematemesis/melaena
Aspiration pneumonia
Oesophageal obstruction due to stricture
Atypical
Wheeze/intractable asthma
Cough/stridor
Apnoea/apparent life-threatening events/sudden infant death syndrome
Cyanotic episodes
Generalized irritability
Sleep disturbance
Neurobehavioural symptoms breath-holding, Sandifer syndrome, seizure-like events
Worsening of pre-existing respiratory disease
Secondary, e.g. post-surgery
Investigation of GOR
Physiological reflux is common and resolves with symptomatic treatment. Full clinical assessment
and consideration of differential diagnosis are essential. Parental reassurance is all that is needed in
most cases. Severe cases need investigations and may need further assessment by multidisciplinary
team involving a dietician, speech and language therapist, paediatric gastroenterologist and paediatric
surgeon.
Barium radiology
This assesses the patient over only a short period and therefore may either miss pathological reflux or
overdiagnose physiological reflux. It is a good test to pick up anatomical abnormalities associated
with recurrent vomiting, such as malrotation, duodenal web.
A pH study
This is considered the gold standard for acid reflux.
Specific indications for pH study
Diagnostic uncertainty
Poor response to medical treatment
If surgery is being considered
Children in whom doing the test will lead to a change in management
Symptoms suggestive of occult reflux
Unexplained or difficult-to-control respiratory disease
The most sensitive marker of acid reflux on pH study is the reflux index (percentage of time pH <4).
The North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN)
consensus recommendation is that a reflux index >7% is abnormal:
Mild reflux up to 10%
Moderate reflux 1020%
Severe 2030%
There are several limitations to a pH study such as it is unable to detect anatomical abnormalities or
aspiration and alkaline reflux. Reproducibility is poor. Severity of pathological acid reflux does not
correlate with symptom severity and complications such as degree of oesophagitis.
Nuclear medicine milk scan
This is used to assess acid or alkali reflux after a physiological meal, assess gastric emptying and it
is possible to make a 24-hour film to look for evidence of aspiration (technetium-99m
radioscintigraphy)
Oesophageal impedance
This measures the changes in the electrical impedance (resistance) between multiple electrodes
located along an oesophageal catheter. The impedance changes suggestive of retrograde bolus
movement indicate reflux. This test is superior to pH monitoring alone for evaluation of the temporal
relationship between symptoms and GOR.
Oesophageal manometry
This measures the pressure inside the lower part of the oesophagus. It may be abnormal in patients
with GORD but the findings are not sufficiently sensitive or specific to confirm the diagnosis, or to
predict response to medical or surgical therapy. It is useful to confirm a diagnosis of achalasia or
other motor disorders of the oesophagus that may mimic GORD.
Upper gastrointestinal endoscopy with biopsy
A useful investigation in children with severe symptomatic reflux with suspected oesophagitis. An
eosinophilic infiltrate in oesophageal biopsies is characteristic of reflux oesophagitis. However, an
excess of eosinophils suggests cows milk allergic oesophagitis/eosinophilic oesophagitis. Normal
oesophageal histology does not exclude GOR.
Management of GOR
Step-up approach to the treatment of GOR
Step 1 lifestyle changes

Step 2 antacids/thickeners/H2-receptor blockers/?prokinetics
Step 3 proton pump inhibitors
Step 4 add prokinetics if not already tried/consider change in diet/feed regimen
Step 5 surgery
Simple measures
Infants
Functional reflux does not require specific treatment
Explanation and reassurance
Review of feeding posture
Review of feeding practice, e.g. too frequent feeds, large-volume feeds
Use of feed thickeners or an anti-reflux milk
Cows milk allergy is a potential differential and infants with persistent reflux may benefit from a
24 weeks trial of extensively hydrolysed formula.
Older children
Lifestyle and diet
Avoid excess fat, chocolate, tea, coffee, gaseous drinks
Avoid tight-fitting clothes
Specific treatment
Indicated in children with severe symptomatic reflux suggestive of GORD. Acid suppression agents
are the mainstay of the treatment. It is important to balance benefit of treatment with potential adverse
effects of acid suppression, including increased risk of community-acquired pneumonia and
gastrointestinal infections.
Compound alginates (e.g. Gaviscon)

These react with gastric acid to form a viscous gel.
Acid suppression
H2-receptor blockers, e.g. ranitidine, are widely used and well tolerated. Oral ranitidine provides
symptomatic relief and endoscopic improvement of oesophagitis in children with GORD.
Proton pump inhibitors, e.g. omeprazole, lansoprazole, increase the pH of gastric content, decrease
the total volume of secretions and facilitate emptying. Superior to histamine-receptor blockers in
healing erosive oesophagitis. Also effective in children with GORD resistant to histamine-receptor
blockers.
Prokinetic drugs
These drugs increase lower oesophageal sphincter pressure, improve oesophageal clearance and
promote gastric emptying:
Metoclopramide
Domperidone
Erythromycin
Other agents
Buffering agents (magnesium hydroxide and aluminium hydroxide) are useful for occasional
heartburn but long-term use is associated with significant risk of toxicity
Sucralfate binds to inflamed mucosa and forms a protective layer that resists further damage from
gastric acid
Children with severe reflux resistant to medical management
They may benefit from:
Trial of hydrolysed protein formula feed
Period of continuous feeding
Trial of gastrostomy/gastrojejunal feeding
Surgery
It is required for reflux resistant to medical treatment. It is essential to rule out non-GORD causes of
symptoms before considering surgery.
Indications for surgery
Failure of optimal medical therapy
Dependence on long-term medical therapy
Extraoesophageal manifestation (asthma, cough, chest pain, recurrent pulmonary aspiration of
refluxate)
Complication of GORD (e.g. Barrett oesophagus, peptic stricture)

Surgery is usually fundoplication with consideration of a pyloroplasty if there is delayed gastric
emptying. A gastrostomy for feeding is often done at the same time, particularly if there are feeding
problems, e.g. neurodisability. Most fundoplications are done laparoscopically these days with
reduced postoperative complications, reduced hospital stay and good long-term outcome. Potential
complications of surgery are recurrence of reflux (10%), bloating, dumping and intestinal obstruction.
5.1 Differential diagnosis of reflux oesophagitis
Cows milk allergic oesophagitis

Eosinophilic oesophagitis
Candidal oesophagitis
Chemical oesophagitis from caustic ingestion
Achalasia
Crohn disease
5.2 Feeding problems in neurodisability

Feeding difficulties in children with neurodisability are common and there are many potential causes.
Children require careful multidisciplinary assessment by a feeding team including a dietician, speech
and language therapist, occupational therapist and neurodevelopmental paediatrician.
Relevant issues to consider
Bulbar weakness with oesophageal incoordination

Primary or secondary aspiration
Reflux oesophagitis
Widespread gut dysmotility
Mobility and posture, degree of spasticity
Nutritional state
Constipation
Attention to nutrition is of key importance and many children benefit from a feeding gastrostomy with
or without fundoplication.
Gastro-oesophageal reflux disease is common and should be treated aggressively.
Gut dysmotility may be an important factor in these patients often resulting in delayed gastric
emptying, which can significantly impact on the ability to feed. This can present as bloating,
constipation and abdominal pain, and must be carefully evaluated. Possible therapeutic interventions
include prokinetic agents, laxatives and rarely suppositories.
5.3 Eosinophilic oesophagitis

Eosinophilic oesophagitis (EO) is an important differential diagnosis of GOR that presents with
similar symptoms but fails to respond to conventional acid blockade therapy. In older children,
dysphagia and food impaction can occur. It is more commonly seen in patients with atopy or in those
with a family history of atopic disease. Diagnosis is based on endoscopic findings with characteristic
histology.
Standardised skin-prick testing and RAST are not generally informative.
Treatments include those for GOR, trial of dietary elimination, inhaled corticosteroids (swallowed),
anti-inflammatories and immunosuppressants. There is a natural history of relapse, remission and
chronicity.
5.4 Achalasia
This is a motility disorder where the lower oesophageal sphincter fails to relax in response to
swallowing. It presents typically in late childhood/adult life and clinical features include dysphagia,
regurgitation, cough and chest discomfort. It is an important differential of GORD presenting in older
children. It can develop as a complication of antireflux surgery. There is an increased risk of
oesophageal carcinoma in untreated achalasia.
Diagnosis is by barium radiology, which shows the fluid level and rat-tail appearance of narrow
distal oesophagus. Oesophagoscopy and biopsies can be done if oesophagitis is suspected.
Manometry can be useful.
Treatment options are balloon dilatation of the lower oesophageal sphincter and the Heller myotomy.
Botulinum toxin has been used.
5.5 Dysphagia
Dysphagia means difficulty in swallowing:
It can cause coughing or choking on swallowing, inability to swallow, pain or swallowing,
regurgitation of food or feeling of something stuck in the throat
Long-term effects could be faltering growth and repeated chest infections secondary to aspiration
events
Causes could be organic or functional:
Organic causes deformity in the oropharynx or infection of nerves or muscles responsible for
swallowing. Cerebral palsy is the most common cause of dysphagia due to neuromuscular
weakness. In achalasia and scleroderma, muscles of the oesophagus are affected and there is
difficulty pushing the food forward in stomach. Severe GORD can also present as dysphagia, as
can eosinophilic oesophagitis
Functional causes children with learning difficulties and developmental delay can present with
dysphagia. Oral aversion and lack of oral feeding experience due to prolonged nasogastric feeding
in early life can be a factor
Investigation and treatment depend on the underlying cause. Assessment by dietician and speech
and language therapist is extremely helpful
6. PEPTIC ULCER DISEASE

6.1 Helicobacter pylori infection
Helicobacter pylori is a Gram-negative bacterium. Infection is usually acquired in childhood.
Prevalence rates are, however, very variable. Persistent infection causes a chronic gastritis which
may be asymptomatic. There is a strong relationship between helicobacter infection and peptic
ulceration in both adults and children. There is no proven association between helicobacter infection
and recurrent abdominal pain. Transmission is faeco-oral and familial clustering is common.
Investigations are considered in children with symptoms suggestive of peptic ulcer disease and
depends on the clinical picture, local prevalence and tests available.
Diagnosis is by the following:
Stool antigen testing highly sensitive and specific. Need to stop antibiotics and antacids before
the test
Serology less specific, with high false-positive rates. Negative test excludes infection. Usually
reverts to negative within 612 months of treatment
Rapid urease tests 13C breath test, CLO (Campylobacter-like organism) test
Endoscopy allows detection of ulcer as well as gastritis/oesophagitis. Histology as well as the
CLO test on biopsy specimens can be diagnostic but culture has low yield.
There are various treatment regimens and the reader is referred to the British National Formulary for
children for the most up-to-date regimen. Acid inhibition with antibiotic treatment is used. There is
usually no need to continue antacid treatment further unless the ulcer is large or complicated by
haemorrhage or perforation. Reinfection can occur. Treatment failure usually indicates resistance,
reinfection within families or institutions, or poor compliance.
6.2 Other causes of antral gastritis and peptic ulceration

Anti-inflammatory drugs
Crohn disease
ZollingerEllison syndrome
Autoimmune gastritis (adults)
6.3 ZollingerEllison syndrome

Gastrin-producing tumour of the endocrine pancreas, presenting with gastric acid hypersecretion and
resulting in fulminant and intractable peptic ulcer disease.
7. CHRONIC DIARRHOEA
Chronic diarrhoea refers to diarrhoea that has persisted for more than 23 weeks. Children with
chronic diarrhoea and faltering growth need investigation, because the underlying cause may be a
malabsorption. Examination of stool is essential as a part of the clinical assessment.
Common causes
Infections including post-enteritis syndrome

Coeliac disease (see Section 8)
Food intolerance (see Section 4)
Bacterial overgrowth
Short-bowel syndrome (see Section 3.5)
Protein-losing enteropathy
Pancreatic insufficiency, e.g. cystic fibrosis, SchwachmanDiamond syndrome
Inflammatory bowel disease (see Section 10)
Drug induced, e.g. antibiotics, laxatives
Rare causes
Congenital diarrhoeas/intractable diarrhoea of infancy

Intestinal lymphangiectasia
Abetalipoproteinaemia (see Section 2.8)
Immunodeficiency
In children with chronic diarrhoea who are thriving the following alternative diagnoses should be
considered:
Constipation with overflow (see Section 13)

Toddlers diarrhoea (chronic non-specific diarrhoea of childhood)
Carbohydrate intolerance (see Section 4.4)
Irritable bowel syndrome
Red flags in the history and examination for further investigation
Poor weight gain/weight loss

Continuous diarrhoea
Night stools
Acid stools
Blood and mucus in the stools
Faltering growth
Associated symptoms suggestive of systemic disease fever, rash, arthritis
7.1 Congenital diarrhoea/intractable diarrhoea of infancy

This refers to persistent diarrhoea starting at birth with four or more stools per day and faltering
growth. The following are examples.
Congenital microvillous atrophy (microvillous inclusion disease)

Intractable diarrhoea with poor weight gain present from birth. Poor tolerance of even minimal
enteral intake. Pathology is ultrastructural abnormality at the microvillous surface. Patients have longterm PN dependence with poor survival rate. Intestinal transplantation offers a potential cure.
Tufting enteropathy
Presentation is similar to microvillous inclusion disease. There is a primary intestinal epithelial
dysplasia with the presence of tufts of extruding epithelial cells on biopsy. They are PN dependent
in early life; however, there is a potential to tolerate some enteral feeds as intestinal function
improves with age. They can have associated problems such as choanal atresia, oesophageal atresia,
imperforate anus, short stature, delayed bone age and non-specific punctate keratitis.
Glucosegalactose malabsorption (see Section 4.4)

Congenital chloride diarrhoea
Rare autosomal recessive condition. Severe watery diarrhoea starting at birth often with a past
history of polyhydramnios. There is a failure of chloride reabsorption (in exchange for bicarbonate)
in the ileum. Serum sodium and chloride are low with metabolic alkalosis. Stool pH and stool
chlorides are high (>90 mmol/l). Treatment is with sodium and potassium chloride supplements.
Prognosis is good if the diagnosis is made early.
Autoimmune enteropathy
Protracted diarrhoea presenting in infancy associated with the presence of circulating autoantibodies
against intestinal epithelial cells. There is partial villous atrophy with an inflammatory infiltrate on
small bowel biopsy. Associated with other autoimmune conditions (IPEX syndrome immune
dysregulation, polyendocrinopathy, enteropathy, X-linked). Treatment is with nutritional support and
immunosuppression.
7.2 Post-enteritis syndrome

This is diarrhoea post-gastroenteritis that continues for more than 3 weeks with poor weight gain or
weight loss. It is usually seen in infants. Potential causes can be continuing infection, further infection,
carbohydrate intolerance or enteropathy presenting as a severe malabsorptive syndrome (secondary
to either initial infection or unmasking underlying pathology, e.g. coeliac disease, CMPI, cystic
fibrosis). Treatment of associated condition usually suffices in most cases. Occasionally it can be
severe and need a period of bowel rest with parenteral nutrition.
7.3 Cows milk protein-sensitive enteropathy

This implies enteropathy secondary to cows milk protein and improves after withdrawal of cows
milk protein with a longer-term history of resolution in most cases (see Section 4.1).
7.4 Giardiasis
Giardia sp. is a protozoal parasite that is infective in the cyst form, and found in contaminated food
and water. Clinical manifestations vary; it can be asymptomatic, acute diarrhoeal disease or chronic
diarrhoea. Diagnosis is by stool examination for cysts or examination of the duodenal aspirate on
endoscopy. Treatment is with metronidazole and is often given blind in suspicious cases.
7.5 Exocrine pancreatic insufficiency

Presents as chronic diarrhoea secondary to fat malabsorption. Diagnosis is suggested by the presence
of fat in stool (steatorrhoea). Faecal elastase <150g/g is suggestive of exocrine pancreatic
insufficiency (false positive if stool is watery). Treatment is by pancreatic enzyme replacement.
Important causes are:
Inherited disorders cystic fibrosis, SchwachmanBodianDiamond syndrome, Pearson syndrome,
JohansonBlizzard syndrome, hereditary pancreatitis
Pancreatitis idiopathic, traumatic, viral, drug induced, nutritional and autoimmune
Post-pancreatic surgery
Crohn disease, coeliac disease, primary sclerosing cholangitis
Autoimmune conditions (systemic lupus erythematosus)
Anatomical abnormalities pancreatic agenesis/hypoplasia
Cystic fibrosis
This subject is well covered in the Respiratory Chapter 22. It is important to remember the
gastrointestinal manifestations.
Gastrointestinal manifestations of cystic fibrosis
Pancreatic
Insufficiency occurs in up to 90%
Pancreatitis
Abnormal glucose tolerance in up to 10% by the second decade
Diabetes mellitus
Intestinal
Meconium ileus
Atresias
Rectal prolapse
Distal obstruction syndrome
Strictures, perhaps secondary to high-dose pancreatic supplementation
Hepatobiliary
Cholestasis in infancy
Fatty liver
Focal biliary fibrosis
Multilobular cirrhosis
Abnormalities of the gallbladder
Cholelithiasis
Obstruction of the common bile duct
SchwachmanBodianDiamond syndrome
A rare autosomal recessive condition, the gene responsible is located on the long arm of chromosome
7 at position 7q11. Incidence of 1:20 to 1:200 000
Main features are pancreatic insufficiency, neutropenia and short stature. Other features include
metaphyseal dysostosis, hepatic dysfunction, increased frequency of infections, and haematological
abnormalities (including thrombocytopenia, increased risk of leukaemia)
7.6 Bacterial overgrowth (small bowel)

Malabsorption with steatorrhoea and fat-soluble vitamin malabsorption can occur as a consequence
of bacterial overgrowth. Risk factors include previous gastrointestinal surgery, strictures and shortbowel syndrome, particularly if there is loss of the ileocaecal valve. Repeated courses of antibiotics
also are a risk factor. Treatment involves management of the underlying cause. Metronidazole, which
is effective orally and intravenously, is the antibiotic of first choice. Probiotics have been used.
7.7 Intestinal lymphangiectasia

Functional obstruction of flow of lymph through the thoracic duct and into the inferior vena cava.
Leads to fat malabsorption and a protein-losing enteropathy. It can be primary (congenital disorder of
the lymphatic system) or secondary (pancreatitis, pericarditis, post-Fontan procedure or malignancy).
Small bowel biopsies show patchy areas of dilated lymphatics in the absence of other pathology.
Treatment is with medium-chain triglycerides absorbed directly into the portal vein.
7.8 Protein-losing enteropathy

Refers to excess loss of protein from the gut secondary to altered permeability or lymph stasis or a
combination of the two. It can happen as a feature of number of disease processes presenting as
chronic diarrhoea. Investigation is directed to the likely underlying cause, based on history and
examination. Serum albumin is low and stool 1-antitrypsin is generally raised
7.9 Chronic non-specific diarrhoea of childhood (toddlers diarrhoea)

Children tend to pass frequent, often explosive, loose stools with undigested food particles, which
leads to significant anxiety. There are no additional features such as weight loss, abdominal pain,
night stools or blood in the stools. Possible aetiology includes gut immaturity, dysmotility, emotional
stress, excess fructose-containing juices/sorbitol/fibre in the diet and incomplete rectal evacuation.
Management is by reassurance and avoidance of potential triggers.
8. COELIAC DISEASE
Coeliac disease is a reversible immune-mediated enteropathy of the small intestinal mucosa that
involves heightened immunological response to ingested gluten (from wheat, barley or rye) in
genetically susceptible people.
Prevalence is 1% when populations are screened. There are associations with HLA-DQ2 and -DQ8.
There is an increased incidence in first-degree relatives.
Clinical presentation: coeliac disease presents anytime after gluten is introduced in to the diet
(usually after 6 months).
Classic phenotype (minority) presents in early childhood with chronic diarrhoea, abdominal
distension, faltering growth, pallor and irritability after introduction of gluten-containing foods to
the diet
Children presenting with gastrointestinal symptoms presentation in late childhood with more
insidious symptoms related to the bowel such as abdominal pain, intermittent diarrhoea,
constipation, vomiting, flatulence, anorexia and abdominal distension
Children presenting with non-gastrointestinal symptoms
Non-gastrointestinal manifestations of coeliac disease
Osteoporosis/rickets/osteomalacia
Iron deficiency anaemia
Prolonged fatigue/lethargy
Unexplained alopecia
Delayed puberty/short stature
Infertility/recurrent abortions/amenorrhoea
Recurrent aphthous stomatitis
Faltering growth
Unexplained neurological symptoms, e.g. ataxia, irritability, neuropathies, migraine
Asymptomatic children diagnosed by target screening of the high-risk groups

Risk factors for the development of coeliac disease with estimated lifetime prevalence (if known)
NICE Guideline CG86 advises offering screening if present:
Autoimmune thyroiditis 715%

Type 1 diabetes mellitus 210%
Irritable bowel syndrome 711%
Dermatitis herpetiformis 6989%
First-degree relatives of patients with coeliac disease 10%
HLA-matched siblings 2030%
Monozygotic twins 70%
NICE Guideline CG86 advise to consider screening if present:
Addison disease 1.212.5%

Autoimmune liver disease 7%
Autoimmune myocarditis
Chronic thrombocytopenic purpura
Depression or bipolar disorder
Down syndrome 512%
Epilepsy
Lymphoma
Osteoporosis/osteomalacia 17%
Rickets
Persistent raised liver enzymes without a cause 9%
Polyneuropathy
Recurrent miscarriage
Sarcoidosis
Sjgren syndrome
Turner syndrome 68%
Unexplained subfertility
Other conditions identified as being associated with increased risk of developing

coeliac disease
IgA deficiency 7.7%

Juvenile chronic arthritis 2.5%
Williams syndrome 8.2-9.5%
Noonan syndrome
Diagnosis
Diagnosis is based on positive serology, small bowel biopsy with characteristic histology and
response to treatment within 24 weeks.
Serological testing
IgA TTG (tissue transglutaminase) is currently the first-line investigation of choice for guiding
diagnosis. It has very high accuracy with sensitivity between 95 and 97% and specificity between 98
and 100%.
IgA levels are routinely performed in all patients because those with low IgA levels can be falsely
negative (IgA deficiency is very common). This group should have IgG to TTG measured because
they have a higher incidence of coeliac disease.
Small bowel biopsy
All children with a positive serological test should have small bowel biopsies to confirm the
diagnosis before starting a gluten-free diet, although whether children with high TTG levels always
need biopsy is the subject of international discussion and debate. Children with high clinical
suspicion should be considered for small bowel biopsy even with negative serology because other
enteropathies may be found.
The characteristic features on biopsy are of subtotal villous atrophy, crypt hypertrophy, intraepithelial
lymphocytosis and a lamina propria plasma-cell infiltrate. These appearances may be patchy and so
multiple biopsies are necessary.
Differential diagnosis of partial villous atrophy

Coeliac disease
Cows milk protein sensitive enteropathy
Soy protein-sensitive enteropathy
Eosinophilic gastroenteritis
Gastroenteritis and post-enteritis syndrome
Giardiasis
Small bowel bacterial overgrowth
Immunodeficiency
Intractable diarrhoea syndromes, e.g. autoimmune enteropathy
Drugs, e.g. cytotoxics
Radiotherapy
Gluten challenge
There are two common indications for a formal gluten challenge:
1. Patients presenting having restricted or excluded gluten from their diet before the diagnosis being
confirmed
2. If the diagnosis of coeliac disease is made at age <2 years and there is any doubt about the full
diagnostic criteria being met, a formal gluten challenge should at least be considered.
Gluten challenge involves a period of adequate gluten reintroduction (1015 g gluten/day), usually at
6 weeks to 3 months, under the supervision of a dietician. Symptomatic relapse may occur rapidly or
after many months of gluten exposure and patients should be followed with serial serological testing
with biopsy once serology becomes positive.
Other investigations
HLA-DQ2 or -DQ8 can be considered in specific clinical situations where there is uncertainty in the
diagnosis. A negative result indicates that coeliac disease is unlikely.
Silent coeliac disease refers to seropositivity with histological evidence of villous atrophy in
keeping with a diagnosis of coeliac disease in an asymptomatic individual.
Latent coeliac disease refers to seropositivity in the absence of histological changes in the small
bowel mucosa to meet the diagnostic criteria for coeliac disease. A significant number of these
patients will go on to develop the mucosal changes associated with coeliac disease and its clinical
consequences.
Coeliac crisis is a rare complication of coeliac disease characterized by explosive diarrhoea,
abdominal distension, dehydration and electrolyte disturbance with hypoalbuminaemia, which may
necessitate treatment with steroids during the initial phase.
Management of coeliac disease

A gluten-free diet for life is the only effective treatment for coeliac disease. Children should be seen
regularly by a dietician to help with compliance and assess nutritional adequacy. Adherence to a
strict gluten-free diet improves growth, normalizes haematological and biochemical markers, and
reduces morbidity. A small proportion of children, who are markedly symptomatic with watery
diarrhoea at presentation and do not settle with a gluten-free diet, benefit from a period of lactose
exclusion. These patients need monitoring of growth, compliance with gluten-free diet, iron status and
other nutritional deficiencies. Iron, calcium and multivitamin supplements are often needed in patients
with inadequate intake.
Non-adherence to a gluten-free diet is associated with increased morbidity and mortality as follows:
Persistent gastrointestinal symptoms, impaired nutrition

Impaired growth and pubertal development
Reduced bone mineralization leading to osteoporosis
Infertility/low-birthweight infants
Increased risk of gastrointestinal malignancy
If there is problem with compliance, patients need to be seen more regularly by a dietician and a
gastroenterology team. It is sometimes necessary to provide support from psychology/mental health
team/counsellor/education and social services.
9. ABDOMINAL PAIN
Abdominal pain is a very common symptom in childhood. The differential diagnosis varies
considerably depending on the presentation. Children who present with acute abdominal pain need
urgent evaluation to rule out surgical causes that need intervention, the most common being
appendicitis. However, the differential diagnosis is wide and includes many other potential causes.
Approach through detailed history, careful physical examination, assessment of pain and associated
symptoms. Initial investigations include full blood count, biochemistry, inflammatory markers, serum
amylase and urinalysis. Other investigations considered are a chest radiograph if there are chest
signs, abdominal radiograph if bowel obstruction is suspected, and abdominal ultrasonography for
possible intussusception, pyelonephritis or inflammatory bowel disease.
Differential diagnosis of acute abdominal pain
Appendicitis/peritonitis
Intussusception
Urinary tract infection/pyelonephritis
Mesenteric adenitis
Constipation
Peptic ulceration
Meckel diverticulum
Pancreatitis
Gastroenteritis
HenochSchnlein purpura
Hernia/testicular torsion/trauma
Pelvic inflammatory disease/ovarian pathology

Cholecystitis
Sickle cell crisis
Renal colic
Metabolic, e.g. acute porphyria
Pneumonia
9.1 Recurrent abdominal pain

Recurrent abdominal pain is very common, affecting up to 10% of the school-age population. In most
cases the aetiology is non-organic. The condition is more common in girls than in boys and a family
history is common. The pain is usually periumbilical and rarely associated with other gastrointestinal
symptoms such as diarrhoea, blood per rectum or weight loss. Investigations are usually unhelpful but
are considered to rule out underlying organic pathology.
Abdominal pain accompanied by other symptoms suggests organic pathology. Night pain is suggestive
of oesophagitis or peptic ulceration. Diarrhoea with blood per rectum suggests a colitis and diarrhoea
associated with weight loss suggests a malabsorption syndrome.
Children with chronic abdominal pain lasting for longer than 3 months should have initial
investigations including a full blood count, inflammatory markers and coeliac serology, renal
function, liver function and urine microscopy with culture.
Factors that suggest an organic cause
Age <5 years

Constitutional symptoms fever, weight loss, poor growth, joint symptoms, skin rashes
Vomiting particularly if bile stained
Pain that awakens the child from sleep
Pain away from the umbilicus referred to back/shoulders
Urinary symptoms
Family history of inflammatory bowel disease, peptic ulcer disease
Perianal disease
Occult or gross blood in the stool
Abnormal screening blood tests
9.2 Functional gastrointestinal disorders

Functional gastrointestinal disorders (FGIDs) are defined as a variable combination of chronic or
recurrent gastrointestinal symptoms not explained by structural or biochemical abnormalities. There
is a range of disorders affecting children and adolescents. Classification is useful for clinical
assessment by subtypes; however, children can often have overlapping symptoms of more than one
subtype.
Cyclical vomiting
syndrome
Must include all of the following:

1. Two or more periods of intense nausea and unremitting vomiting or
retching lasting hours to days
2. Return to usual state of health lasting weeks to months
Functional dyspepsia
Criteria fulfilled at least once per week for at least 2 months before
diagnosis and must include all of the following:
1. Persistent or recurrent pain or discomfort centred in the upper abdomen
(above the umbilicus)
2. Not relieved by defecation or associated with the onset of a change in
stool frequency or stool form (i.e. not irritable bowel syndrome)
3. No evidence of an inflammatory, anatomical, metabolic or neoplastic
process that explains the childs symptoms
Irritable bowel
syndrome (IBS)
1. Abdominal discomfort (an uncomfortable sensation not described as
pain) or pain associated with two or more of the following at least 25% of
the time:
(a) improved with defecation
(b) onset associated with a change in frequency of stool
(c) onset associated with a change in form (appearance) of stool
Abdominal migraine
Criteria fulfilled two or more times in the preceding 12 months and must
include all of the following:
1. Paroxysmal episodes of intense, acute periumbilical pain that lasts for 1
hour or more
2. Intervening periods of usual health lasting weeks to months
3. The pain interferes with normal activities
4. The pain is associated with two or more of the following:
(a) anorexia
(b) nausea
(c) vomiting
(d) headache
(e) photophobia
(f) pallor
process considered that explains the childs symptoms
Childhood functional
abdominal pain
1. Episodic or continuous abdominal pain
2. Insufficient criteria for other FGIDs
Childhood functional
abdominal pain
syndrome
diagnosis:
Must include childhood functional abdominal pain at least 25% of the time
and one or more of the following:
1. Some loss of daily functioning
2. Additional somatic symptoms such as headache, limb pain and difficulty
sleeping
From Childhood Functional Gastrointestinal Disorders: Child/Adolescent. Gastroenterology

2006;130:1527 37.
Associations in children with FGIDs

Personality type
Timid, nervous anxious characters, perfectionists, over-achievers
Increased number of stresses and more likely to internalize problems than other children, but no
increase in the risk of depression or other psychiatric problems when compared with children with
organic pain
May be a degree of school refusal or issues in school environment
Family factors
Marital discord, separation, divorce, excessive arguing

Extreme parenting over-submissive or excessive punishment
History of alcoholism
Antisocial or conduct disorders, somatization disorders
High degree of medical complaints in the family members
Physical stresses in children
Recent physical illness postviral infection

Food intolerances poor diet, intolerance to wheat, carbohydrates
Multiple medications
Constipation, lack of exercise, chronic illness
Psychosocial stresses in children
Death of a family member

Separation of a family member divorce, child going to college
Illness in family member
Problem in school, altered peer relationship
Poverty
Geographical move
Clinical approach to recurrent abdominal pain (syndrome)

Positive diagnosis
Detailed history and examination with initial investigations to rule out organic cause. Rome III
criteria often help to classify symptoms into subtypes and guide further investigations. It is important
to avoid doing excessive tests, reassure families with normal results and look into possible family
factors and stresses.
Reassurance and lifestyle changes
It is important to acknowledge that the pain is real and not psychogenic. Explanation of non-organic
nature of the condition with normal initial investigation is useful to gain confidence of child and
families. Emphasis should be on rehabilitation. Lifestyle changes help, such as avoiding possible
dietary triggers, healthy eating, regular exercise and regular attendance at school; assessment by
dietician might be useful. It is important to address associated symptoms such as headaches and
constipation. Diary of symptoms useful in severe cases.
Pharmacological therapy
Pharmacological treatments are used, although the evidence base is limited. Avoid excessive use of
non-steroidal anti-inflammatory drugs (NSAIDs). H2-receptor blockers are useful in functional
dyspepsia. Peppermint oil is beneficial in irritable bowel syndrome (IBS). Pizotifen is useful in
abdominal migraine. Simple analgesics, antiemetics and antispasmodics are often prescribed although
are not generally helpful. Laxatives may be helpful if constipation is present.
Psychological intervention
The aim of psychological treatment is to modify thoughts and behavioural response to symptoms.
Acceptance of a biopsychosocial model of the condition by the patient and the family is crucial for
the response to treatment. The therapies include biofeedback, relaxation therapy, behavioural and
cognitive therapies, coping skills training, family therapy and hypnosis. Graded rehabilitation with a
goal-based approach is useful. Patients with severe symptoms need long-term psychological input and
follow-up until symptoms resolve.
10. INFLAMMATORY BOWEL DISEASE

Inflammatory bowel disease (IBD) encompasses two related but distinct disorders of as yet unknown
aetiology: Crohn disease and ulcerative colitis (UC). Indeterminate colitis is a term reserved for
cases of colitis in which findings are not sufficient to allow differentiation between the two and
accounts for 1015% cases. The only prospective national survey (2001) suggested that the incidence
of IBD in children under 16 years is 5.2 per 100 000, with Crohn disease being twice as common as
ulcerative colitis. Precise aetiology of IBD is unknown and reflects a complex interaction of genetic
predisposition, environmental triggers (viral infection, smoking, NSAIDs) and immune dysfunction.
IBD runs a chronic relapsing course and the mainstay of the treatment is to maintain growth and
nutrition by inducing and maintaining remission with minimal side effects.
10.1 Crohn disease

Crohn disease is a chronic idiopathic inflammatory disorder of the bowel involving any region from
the mouth to the anus.
The most common presenting symptoms are abdominal pain, diarrhoea and weight loss. Growth
failure with delayed bone maturation and delayed sexual development is common. The presentation
can be insidious with growth failure as the only presenting feature. Examination might reveal mouth
ulcers, pallor and presence of anal tags on perianal examination.
Investigation
Full blood count, inflammatory markers (more likely raised in Crohn disease than in UC), and basic
biochemistry including liver function tests
Infective colitis is ruled out by stool culture and checking for Cl. difficile toxin
Endoscopy with biopsies assesses extent of the disease and provides a tissue diagnosis, showing
focal lesion with transmural inflammation and granulomas in 4060% of the cases
Barium radiology/ultrasonography/MRI (magnetic resonance imaging) to look for small bowel
disease
MRI can be useful in assessment of difficult perianal disease
In cases with indeterminate histology, immunological markers can be helpful (perinuclear antineutrophil cytoplasmic antibody [pANCA] positive in 70% patients with UC and antiSaccharomyces cerevisiae antibody [ASCA] positive in 5060% patients with Crohn disease)
Management
The aim of management is to induce and maintain disease remission and thereby facilitate normal
growth and development. A multidisciplinary approach is essential including paediatric
gastroenterologist, general paediatrician, paediatric surgeon, radiologist, histopathologist, paediatric
dietician, nurse specialist and psychologist.
Exclusive enteral nutrition is the most widely used treatment as an exclusion diet for up to 68 weeks,
followed by a period of controlled food reintroduction. The type of enteral nutrition used varies and
can be either elemental (protein broken down into peptide chains or amino acids, e.g. EO28) or
polymeric (whole protein, e.g. Modulen IBD). This treatment induces remission in up to 7080% of
patients. The formula can be flavoured to improve compliance and given by nasogastric tube in cases
where it is not tolerated orally.
Corticosteroids are considered in children with severe disease, isolated colitis or failure of response
to enteral nutrition. Given as soluble prednisolone or intravenous hydrocortisone and weaned
gradually once remission is achieved.
Children often need antacids/proton pump inhibitor if gastritis is present.
Maintaining remission is a challenge as up to 90% of patients relapse in the first 12 months.
Maintenance is with 5-aminosalicylic acid (5-ASA) derivatives (poor evidence base), thiopurines,
methotrexate and monoclonal antibody therapy. Nutritional requirements are high and long-term
continued nutritional support is sometimes needed. Repeated courses of exclusive enteral nutrition or
corticosteroids are used for disease flare-ups.
Other supportive treatments: antibiotic courses such as metronidazole for up to 6 weeks can be used
in cases of severe perianal disease. Parenteral nutrition may be required in some cases. Oral disease
is treated with topical steroids or intralesional steroids.
Management of refractory disease

Refractory Crohn disease is disease unresponsive to first-line treatment including an adequate course
of steroid treatment. Second-line treatments for active disease include methotrexate and monocolonal
antibody therapy.
Immunosuppressive agents
The most commonly used additional immunosuppressive agents are thiopurines such as azathioprine
or 6-mercaptopurine, a metabolite of azathioprine. They reduce steroid requirements (steroid sparing)
and will induce a long-term remission in 6080%. Important toxicity includes the risk of
myelosuppression, pancreatitis, hepatitis, rash, flu-like symptoms and infections. Regular blood
counts are required for monitoring of bone marrow function. Toxicity is common in patients with low
levels of TPMT (thiopurine methyltransferase), an enzyme required for the metabolism of thiopurines.
Anti-tumour necrosis factor (TNF) antibodies
These are indicated for induction of remission in refractory Crohn disease in which surgery is not
possible, including cases with fistulating disease. Infliximab is the most widely used, given as an
initial course at 0, 2 and 6 weeks, with continued 8-weekly intervals if effective. There is significant
potential toxicity and a riskbenefit discussion needs to occur before treatment is started. Patients
who become refractory to infliximab can be considered for adalimumab, which is a newer humanized
monoclonal antibody effective in Crohn disease.
Surgery
This is considered in isolated ileocaecal disease, stricturing and fistulating disease, and in those with
failed medical management. At least 30% will require surgery in the first 10 years of the disease and
7080% will require surgery in their lifetime.
10.2 Ulcerative colitis

Ulcerative colitis is a diffuse (rather than patchy) mucosal inflammation limited to the colonic and
rectal mucosa. It is the more distal bowel that is most involved. A backwash ileitis into the terminal
ileum is often seen. Aetiology is unknown. Disease is more common in females than males.
Clinical presentation
The disease can present as distal (proctitis, proctosigmoiditis), left-sided colitis (up to splenic
flexure), extensive colitis (up to hepatic flexure) or pancolitis affecting the whole colon (mild,
moderate or severe). Pancolitis is the most common presentation in children. Rarely it can present as
acute toxic colitis.
The symptoms of colitis are diarrhoea, blood per rectum and abdominal pain. Night stools are
common. Systemic disturbance can accompany more severe disease: tachycardia, fever, weight loss,
anaemia, hypoalbuminaemia and leukocytosis, and raised inflammatory markers (less common than in
Crohn disease).
Although unusual, the disease can present with predominantly extraintestinal manifestations, including
growth failure, arthropathy (ankylosing spondylitis rare in children), erythema nodosum, iritis,
uveitis and liver disease (sclerosing cholangitis and autoimmune hepatitis).
Complications of UC include toxic megacolon, growth failure (secondary to prolonged
corticosteroids), osteoporosis, cholangitis, increased thrombotic tendency and colon cancer. The
cancer risk reflects the disease severity and duration of disease. Regular screening is carried out in
adult life. Proximal constipation is common in distal colitis. UC in remission is often associated with
development of irritable bowel-type syndrome.
Diagnosis
Careful history and examination considering wide differential diagnosis for colitis (see Section
9.3)
Bloods include full blood count, biochemistry and inflammatory markers (C-reactive protein or
CRP and erythrocyte sedimentation rate or ESR) can be normal in some cases
It is essential to exclude infective colitis by stool culture
Gastroscopy and colonoscopy give histological diagnosis (mucosal and submucosal inflammation
with goblet-cell depletion, cryptitis and crypt abscesses but no granulomas) and helps to assess the
severity of the disease. Endoscopy is deferred in severe cases (e.g. toxic megacolon) where
empirical treatment is considered
If liver function is abnormal, more detailed autoantibody screen, liver ultrasonography with
consideration of ERCP (endoscopic retrograde cholangiopancreatography)/liver biopsy is
indicated
Management
Treatment depends on disease activity and distribution. Severe disease needs urgent treatment with
intravenous steroids.
Induction of remission
Mild or left-sided UC
Topical mesalazine and steroid treatment is effective with oral 5-ASA derivatives such as mesalazine
and sulfasalazine. Oral steroids if 5-ASAs are not effective.
Moderate-to-severe UC
Treat with oral prednisolone for 24 weeks at full dose (12 mg/kg per day, maximum 40 mg) and
weaned gradually over 48 weeks.
Acute severe colitis/toxic megacolon
Patient should be admitted to hospital for close monitoring and intravenous steroids. Urgent surgical
opinion is needed if toxic megacolon is suspected. Patients not responding to steroids can be
considered for ciclosporin or infliximab treatment. Colectomy may be required
Maintenance of remission
Oral mesalazine or sulfasalazine is the first-line maintenance treatment (monitor liver and renal
function 6-monthly). Steroids have no role in maintenance of remission. Azathioprine or 6mercaptopurine is second line in cases with relapse within 6 months or steroid dependence, with
careful monitoring of liver and bone marrow function. 5-ASA derivatives are generally continued
long term for the cancer-protective effect.
Surgery
Can be curative for UC and is required in at least 15% within 5 years of diagnosis and 25% by 10
years. Indications for surgery include failure to respond to medical treatment with morbidity from
disease or complications of treatment. Subtotal colectomy and ileostomy are the commonly performed
operations with an interval join up (pouch) procedure.
Differences between Crohn disease and ulcerative colitis

Crohn disease
Panenteric
Skip lesions
Transmural
Granulomas
Perianal disease
Ulcerative colitis
Colon only
Diffuse
Mucosal
Crypt abscesses
Nutrition is the integral part of management of IBD and nutrition support should be considered where
appropriate. Growth needs to be carefully monitored especially in the pubertal years because both the
disease and corticosteroid treatment can affect it. Bone health may be poor in IBD and improves with
nutritional input, with consideration of vitamin D and calcium supplements when appropriate.
Immunosuppressive treatment needs careful monitoring for side effects and immunization advice (no
live vaccines while on treatment and varicella immunoglobulin post-exposure if not immune)
10.3 Differential diagnosis of colitis

Causes of infective colitis
Salmonella spp.
Shigella spp.
Campylobacter pylori
Escherichia coli O157 (and other E. coli)
Clostridium difficile (pseudomembranous colitis)
Yersinia spp.
Tuberculosis
Cytomegalovirus
Entamoeba histolytica
Causes of non-infective colitis
Ulcerative colitis
Crohn disease
Microscopic colitis
Behet disease
Eosinophilic enterocolitis
10.4 Eosinophilic enterocolitis

This refers to wide spectrum of involvement of small and large bowel with allergic (eosinophilic)
inflammation. Patients may have associated allergies, eczema, asthma or rhinitis. Diagnosis is by
presence of gut symptoms, eosinophilic infiltrate (>20 eosinophils per high power field) on biopsies
and absence of other causes of eosinophilia (parasitic infection, drugs). Peripheral eosinophilia is not
required for diagnosis but is often present.

Eosinophilic enterocolitis of infancy is usually dietary protein induced, commonly cows milk or
soya protein. It is a non-IgE-mediated disorder and presents with severe diarrhoea, dehydration,
lethargy and acidosis. Treatment is by avoiding the offending antigen and use of amino acid-based
formula. Most children outgrow the allergy. The challenge is usually in hospital after 23 years
with hypersensitivity persisting occasionally
Eosinophilic proctocolitis of infancy is a milder disorder presenting with blood in the stool in the
absence of significant systemic disturbance
Eosinophilic enterocolitis in older children can affect any part of the bowel and most children have
hypersensitivity to foods such as egg, milk, soya and wheat, and a trial of exclusion is attempted.
Those not responding to food exclusion may need immunosuppressive treatment including steroids
10.5 Pseudomembranous colitis

This occurs secondary to infection with Clostridium difficile, which is an increasingly significant
pathogen in hospitals. A risk factor is disruption of the normal intestinal flora by antibiotics. Clinical
features vary from asymptomatic carriage to life threatening.
Pathogenesis is through toxin production. Treatment is with vancomycin (oral) or metronidazole
(intravenous or oral); probiotics may have a role. Relapse rate is 1520%
11. GASTROINTESTINAL BLEEDING

Overt bleeding can happen as a part of an acute illness or as a feature of chronic disease. Obscure
bleeding over a long period may present as anaemia. It can be from an upper or lower gastrointestinal
source.
Upper gastrointestinal bleeding

Haematemesis vomiting frank blood or coffee grounds (soil particles). This needs to be
distinguished from haemoptysis.
Lower gastrointestinal bleeding

Melaena offensive black tarry stools
Haematochezia bright-red or dark-red blood per rectum
Obscure gastrointestinal bleeding

Bleeding from a presumed gastrointestinal source when initial investigations such as
oesophagogastro-duodenoscopy (OGD) and colonoscopy are normal.
11.1 Common causes of gastrointestinal bleeding
Trace or small amount of upper gastrointestinal (GI) bleeding is not worrying and usually settles
down. Children rarely need an extensive work-up and invasive tests and parents can be advised to
monitor children at home for a further bleed
Detailed history and examination with appropriate laboratory tests help with diagnosis. Blood
results should be interpreted with caution in cases of acute severe bleeding. Haemoglobin could be
falsely high because of haemoconcentration and urea could be high because of absorption of blood
from the gut. Bleeding from upper GI can be diagnosed by nasogastric tube lavage and further
confirmed by endoscopy. In cases with suspected bleeding from colon (haematochezia),
colonoscopy is the initial investigation of choice. If bleeding source is not identified on
gastroscopy and colonoscopy or when small bowel bleeding (obscure) is suspected, various
radiological investigations are considered such as ultrasonography with Doppler, barium
radiology, nuclear radionuclide scan, CT enterography, MR angiography/venography, Meckel
diverticulum scan and capsule endoscopy
Active upper or lower GI bleeding needs resuscitation with assessment of airway, breathing and
circulation. In case of circulatory compromise, needs prompt intravenous access followed by fluid
resuscitation with possible blood transfusion. These patients should be admitted to a paediatric
intensive care unit and need careful monitoring
Variceal bleeds may need endoscopic control of active haemorrhage with sclerotherapy, an elastic
ligature or (in rare cases) a transjugular intrahepatic portosystemic shunt (TIPS). Failure to control
bleeding may require the placement of a SengstakenBlakemore balloon for temporary tamponade
if endoscopic treatment fails or is not possible at the time due to the massive bleeding. Significant
GI bleeding that cannot be controlled may require laparoscopy/laparotomy with intraoperative
endoscopy
Peak incidence aged 69 months. Male:female ratio 4:1, usually ileocaecal. Presents with spasmodic
pain, pallor and irritability. Vomiting is an early feature and rapidly progresses to being bile stained.
Passage of blood-stained stools often occurs and a mass is frequently palpable.
Can be secondary to causes such as Meckel diverticulum, polyp, reduplication, lymphosarcoma and
HenochSchnlein purpura. Diagnosis is clinical and can be confirmed by plain abdominal
radiograph, ultrasonography or airenema examination. Treatment is either with airenema reduction
if the history is short or surgically at laparotomy. Contraindications to air enema include peritonitis
and signs of perforation.

Remnant of the vitellointestinal duct present in 2% of individuals; 50% contain ectopic gastric,
pancreatic or colonic tissue. Presents with intermittent, painless blood per rectum; bleeding can be
quite severe and may require a blood transfusion; other presentations include intussusception (more
common in older boys), perforation and peritonitis. The technetium scan is used to look for ectopic
gastric mucosa.
11.4 Polyposis
Polyps generally present with painless rectal bleeding or through genetic screening of affected
families with polyposis syndromes. Investigation requires upper and lower GI endoscopies with
small bowel imaging.
Classification of polyps
Hamartomas
Solitary juvenile polyps most common

Juvenile polyposis syndrome
Cowden syndrome
BannayanRileyRuvalcaba syndrome
Familial adenomatous polyposis
Adenomas
Hyperplastic
Inflammatory
Gardner syndrome
Turcot syndrome
Single, antrum/duodenum, benign
Can be multiple, associated with inflammatory bowel disease, postinfective,
ischaemic causes
No malignant potential
Juvenile polyps
Account for 85% of the polyps seen in childhood. Present at age 26 years with painless blood per
rectum. Most polyps are solitary and located within 30 cm of the anus. Not premalignant. Juvenile
polyposis syndrome refers to multiple juvenile polyps and can be premalignant.
Autosomal dominant inheritance. Diffuse GI hamartomatous polyps associated with
hyperpigmentation of the buccal mucosa and lips. Premalignant. Polyps generally found in jejunum
and can cause bleeding, anaemia, intussusception or obstruction. Endoscopic screening and small
bowel imaging start from age 8 years.
Gardener syndrome and familial adenomatous polyposis coli

Best considered together. Both conditions are inherited as autosomal dominant. Mutation in APC
(adenomatous polyposis coli) gene located on chromosome 5q21. Gardener syndrome is familial
adenomatous polyposis plus bony lesions, subcutaneous tumours and cysts. Both conditions carry a
very high risk of colonic carcinoma, and prophylactic colectomy at the end of the second decade is
advised. Individuals identified with family specific gene mutations need endoscopic surveillance
from their early teens.
Other polyposis syndromes

Grolin syndrome hamartomas, autosomal dominant
Turcot syndrome multiple colorectal adenomas with primary brain tumour
12. GASTROENTERITIS
Gastroenteritis is a common problem. Most cases can be managed at home. Oral rehydration therapy
is the mainstay of treatment, using rapid rehydration over 46 hours with reassessment and the early
reintroduction of normal feeds after that. Breast-feeding should not be stopped. Antimicrobials are
only of use in very specific circumstances. Antidiarrhoeal agents are of no use. Complications such as
carbohydrate intolerance and chronic diarrhoea and faltering growth are relatively rare.
The NICE has produced guidelines for diagnosis, assessment and management of acute gastroenteritis
in children younger than 5 years (April 2009).
Composition of oral rehydration solution

Oral rehydration therapy, which has probably saved more childrens lives worldwide than any other
medical intervention, remains the mainstay of treatment. The World Health Organizations (WHOs)
oral hydration solution (ORS) contains 90 mmol/l of sodium and is specifically designed for cholera
treatment. European ORS contains between 35 and 60 mmol/l of sodium with varying concentrations
of glucose and potassium. There remains controversy over the best combination but it would appear
that all of the available formulations are effective and safe. Homemade solutions, usually with an
excess of salt, put children at risk of hypernatraemic dehydration.
Causes of gastroenteritis
Unknown in both the developed and developing world, no pathogens are identified in up to 50%
of cases, even when the condition is fully investigated
Viral rotaviruses (most common), adenovirus, small-round viruses and astroviruses
Bacterial Campylobacter spp. (most common), Shigella spp., Salmonella spp., enteropathogenic
E. coli, enterotoxigenic E. coli O157:H7 (rare but associated with haemolyticuraemic syndrome),
Vibrio cholerae, Yersinia enterocolitica
Protozoa Cryptosporidium sp. (particularly in the immunocompromised host), Giardia sp.,
which has a varied presentation ranging from the asymptomatic carrier state to chronic diarrhoea
with growth failure, Entamoeba histolytica (amoebic dysentery)
This is potentially wide and includes many other potential conditions:
Other infections, e.g. otitis media, tonsillitis, pneumonia, septicaemia, urinary tract infection,
meningitis
Food intolerance
Haemolyticuraemic syndrome
Intussusception
Pyloric stenosis
Acute appendicitis
Drugs, e.g. laxatives, antibiotics
Assessment of dehydration
Remember
Less than 3% of dehydration is clinically not apparent
A normal capillary refill time (<2 s) makes severe dehydration very unlikely (measured by pressing
the skin and measuring the time taken for the skin to re-perfuse)
Useful signs include reduced skin turgor, dry oral mucosa, sunken eyes and altered consciousness
level
Hospital admission should be considered when:
Diagnosis is unclear/complications have arisen, e.g. carbohydrate intolerance (see Section 4.4)
Home management fails/unable to tolerate fluids/persistent vomiting
Severe dehydration
Significant other medical condition, e.g. diabetes, immunocompromised
Poor social circumstances
Hydration difficult to assess, e.g. obesity
Inability to reassess
Assessment of dehydration
Percentage
dehydration
3
35
5
10
1214
Severity
Clinical features
Undetectable
Mild
Slightly dry mucous membranes
Decreased skin turgor, slightly sunken eyes, depressed
Moderate
fontanelle, circulation preserved
All the above plus more marked drowsiness, rapid weak pulse,
Severe
cool extremities, capillary refill time >2 s
Moribund
Children with 10% dehydration usually require intravenous fluid resuscitation.
13. CONSTIPATION
Childhood constipation is very common (530%). Most children (about 95%) do not have an
underlying cause (functional constipation). Delay in treatment can affect physical growth and
development, as well as education and psychological wellbeing.
Constipation is delay in passage of stools leading to distress and may include other symptoms such
as pain, discomfort, anorexia, soiling, encopresis.
Soiling is leakage of stools with megarectum. The soiling occurs because the normal sensory process
of stool being in the rectum, resulting in distension and the urge to defecate, is lost when the rectum is
permanently distended. This should be distinguished from encopresis in which stool is passed into the
pants at inappropriate times and in inappropriate places with no underlying constipation the latter
being a primarily psychological problem:

The definition of chronic constipation (according to the Paris Consensus Group) is the occurrence of
two or more of the following characteristics, during the last 8 weeks:
Frequency of bowel movements <3/week

More than one episode of faecal incontinence per week
Large stool in the rectum or palpable on abdominal examination
Passing of stools so large that they may obstruct the toilet
Display of retentive posturing and withholding behaviours
Painful defecation
Many factors can trigger constipation including:

Intercurrent illness with poor fluid and food intake
Perianal pathology such as anal fissure or streptococcal infection resulting in stool-withholding
cycle
Difficult early toilet training resulting in stool withholding
Prolonged faecal impaction leads to megarectum with loss of normal rectal sensation further stool
impaction
Coexisting functional disorders such as irritable bowel syndrome
History and clinical examination should be aimed at looking for diagnostic clues that indicate
functional constipation.
Red flags in the history
Constipation reported from birth or first few weeks of life

Failure to pass meconium/delay (more than 48 hours) in a term baby
Infrequent/very large (ribbon) stools
Faltering growth
Previously known or undiagnosed weakness in legs/locomotor delay
Abdominal distension with vomiting
Red flags in the clinical examination

Perianal inspection abnormal appearance/patency/position of anus, anteriorly placed anus or
absent anal wink, fissures, fistulae, bruising, tight or patulous anus (think of sexual abuse)
Gross abdominal distension, palpable faecal mass (in at least half of these patients)
Spine and gluteal examination asymmetry of gluteal muscles, scoliosis, evidence of sacral
agenesis, overlying skin over sacral region with discoloration, naevi, sinus, hairy patch, lipoma or
central pit
Deformity in lower limbs such as talipes
Abnormal neuromuscular signs unexplained by any existing condition, such as cerebral palsy
Abnormal tendon reflexes
Investigations
In the absence of red flags on history and clinical examination, diagnosis is likely to be chronic
functional constipation and further investigations are not indicated. The following investigations are
sometimes considered:
Coeliac serology as constipation can be a presenting feature
Electrolytes (hypercalcemia), endocrine (hypothyroidism) and micronutrients (iron status looking
for iron deficiency anaemia) are checked if suggested by clinical examination
Abdominal radiograph selectively used to delineate faecal loading when abdominal examination
is difficult or inconclusive. It is also useful if neural tube defect is suspected (vertebral
abnormalities)
Bowel transit studies and anorectal manometry
Full-thickness rectal biopsy if Hirschsprung disease suspected
Management of constipation
NICE produced a guideline Constipation in children and young people in May 2010.
Most constipation is short term and is readily treated with bulk and/or stimulant laxatives. The
management of chronic functional constipation is more difficult and often requires a multidisciplinary
approach. It involves drug therapy together with several other principles as described below. Drug
therapy alone is rarely effective:
Explanation of normal bowel function helps understanding of the family and improves compliance.
Parents and children should be reassured that constipation is common and responds well to
treatment
High-fibre diet is recommended along with adequate fluid intake because it adds bulk to the stool.
Regular exercise promotes peristalsis and helps bowel transit
Regular toileting is a crucial part of the management. Child should be made to sit on the toilet (with
appropriate toilet seat and foot support) on waking, after all meals and before bed. This
encourages regular emptying of the rectum
Behavioural advice and reward schemes (star charts) are helpful to gain childs trust in the
management. Rewards can be given for compliance (sitting on the toilet) at first and then for
success (opening bowel in the toilet). Children should not be routinely referred to psychologist or
Child and Adolescent Mental Health Services
Drug treatment: there is very poor evidence base for the drug treatment and practice varies between
different units. There are various medications available with different mechanisms of action (see
table below) and they need close monitoring and support initially because they can increase soiling
and make stools loose, and also to monitor compliance
Disimpaction
All patients at diagnosis should be considered for disimpaction especially if there is a megarectum.
Senna or polyethylene glycol can be used as sole agents in high doses. In severe cases, sodium
picosulphate (liquid or sachets) may be required.
Rectal medications (suppositories, enemas) are not used for disimpaction unless all oral medications
have failed. Rarely, if oral and rectal treatments fail, manual evacuation of the bowel under
anaesthesia is considered.
Maintenance therapy
Laxatives are often needed for a long period. Treatment needs to be closely monitored along with
other supportive strategies, and weaned only after a sustained period of normal stooling with no
soiling. Polyethylene glycol (Movicol) is widely used. Senokot given in the evening, at reasonable
doses, is effective. Other agents can be used and the choice of agent depends on local preference as
well as individual patient circumstances. Children who are toilet training should remain on laxatives
until toilet training is well established.
13.1 Perianal streptococcal infection

This is a common cause of perianal redness that can present as constipation or perianal pain. Occurs
secondary to group A streptococcal infection. Treatment is with penicillin. There may be a need for
continuing laxatives.
Other causes of perianal soreness
Poor perineal hygiene

Soiling/encopresis
Threadworm infestation
Lactose intolerance (acidic stool)
Anal fissure
Sexual abuse (rare)
13.2 Hirschsprung disease

Absence of ganglion cells in the myenteric plexus of the most distal bowel. Males more than females;
1 in 5000. Gene on chromosome 10. Associated with Down syndrome; high frequency of other
congenital abnormalities. Usually presents in infancy, failure to pass meconium with presentation in
the older child being rare the diagnosis in this group usually being chronic functional constipation.
Most children with Hirschsprung disease will never have had a normal bowel habit
Enterocolitis can occur commonly before or after surgery

Definitive test is by rectal biopsy to confirm the absence of ganglion cells in the submucosal plexus
Surgery is excision, usually with temporary colostomy followed by pull-through at a later stage
Ultra-short-segment Hirschsprung disease is very rare and can present significant diagnostic
difficulty
14. FURTHER READING

Beattie RM, Dhawan A, Puntis JWL (2009). Oxford Specialist Handbook of Paediatric
Gastroenterology, Hepatology and Nutrition. Oxford: Oxford University Press.
Benninga M, Candy DC, Catto-Smith AG, et al. (2005). The Paris Consensus on Childhood
Constipation Terminology (PACCT) Group. J Paediatr Gastroenterol Nutr 40:2735.
European Society of Paediatric Gastroenterology, Hepatology and Nutrition and the European Society
for Clinical Nutrition and Metabolism (2005). Guidelines on Paediatric Parenteral Nutrition of the
ESPGHAN and the ESPEN. Supported by the European Society of Paediatric Research (ESPR). J
Pediatr Gastroenterol Nutr 41(suppl 2):S187.
Gupte GL, Beath SV, Kelly DA (2006). Current issues in the management of intestinal failure. Arch
Dis Child 91:25964.
Rasquin A, Di Lorenzo C, Forbes D, et al. (2007). Chronic abdominal pain in children. BMJ
334:9971002.
Rudolph CD, Vandenplas Y, Di Lorenzo C, et al. (2009). Paediatric gastro-oesophageal reflux
clinical practice guidelines: joint recommendation of NASPGHAN and ESPGHAN. J Pediatr
Gastroenterol Nutr 49:498547.
Sandhu BK, Fell JME, Beattie RM, Mitton SG (2010). Guidelines for the management of
inflammatory bowel disease in children in the United Kingdom. J Pediatr Gastroenterol Nutr 50:S1
13.
Vandenplas Y, Brueton M, Dupont C, et al. (2007). Guidelines for the diagnosis and management of
cows milk protein allergy in infants. Arch Dis Child 92:9028.
Wyllie R, Hyams JS, eds (2011). Paediatric Gastrointestinal and Liver Disease, 4th edn. London:
Elsevier.
NICE guidelines
Coeliac disease Recognition and assessment of coeliac disease. NICE, February 2010. Available
at: www.nice.org.uk/nicemedia/live/12166/44356/44356.pdf
Constipation in children and young people. NICE, May 2010. Available at:
www.nice.org.uk/nicemedia/live/12993/48741/48741.pdf
Crohns disease Infliximab and adalimumab TA187. NICE, May 2010. Available at:
http://guidance.nice.org.uk/TA187/QuickRefGuide/pdf/English
Diarrhoea and vomiting in children. NICE, October 2009. Available at:
Food allergy in children and young people. NICE, February 2011. Available at:
Chapter 11
Genetics
Natalie Canham
CONTENTS
1. Chromosomes
1.1 Common sex chromosome aneuploidies
1.2 Common autosomal chromosome aneuploidies
1.3 CGH microarray
1.4 MLPA
1.5 Qf-PCR
1.6 FISH testing
1.7 Microdeletion syndromes
1.8 Genetic counselling in chromosomal disorders
2. Mendelian inheritance
2.1 Autosomal dominant (AD) conditions
2.2 Autosomal recessive (AR) conditions
2.3 X-linked recessive (XLR) conditions
2.4 X-linked dominant (XLD) conditions
2.5 Constructing a pedigree diagram (family tree)
3. Molecular genetics
3.1 DNA (deoxyribonucleic acid)
3.2 RNA (ribonucleic acid)
3.3 Polymerase chain reaction (PCR)
3.4 Reverse transcription PCR (rt-PCR)
3.5 Next generation sequencing
3.6 Exome sequencing
4. Trinucleotide repeat disorders

4.1 Fragile X syndrome
5. Mitochondrial disorders
6. Genomic imprinting
7. Genetic testing
8. Important genetic topics
8.1 Ambiguous genitalia
8.2 Cystic fibrosis
8.3 Duchenne and Becker muscular dystrophies
8.4 Neurofibromatosis (NF)
8.5 Tuberous sclerosis
8.6 Marfan syndrome
8.7 Homocystinuria
8.8 Noonan syndrome
8.9 Achondroplasia
8.11 CHARGE syndrome
8.12 VATER (VACTERL) association
8.13 Goldenhar syndrome
8.14 Pierre Robin sequence
8.15 Potter sequence
9. Fetal teratogens
9.1 Maternal illness
9.2 Infectious agents
9.3 Other teratogens
10. Prenatal testing

11. Non-invasive prenatal testing
12. Preimplantation genetic diagnosis (PGD)
13. Genetic counselling
14. Further reading
Genetics
1. CHROMOSOMES
Background
Within the nucleus of somatic cells there are 22 pairs of autosomes and one pair of sex chromosomes.
Normal male and female karyotypes are 46,XY and 46,XX respectively. The normal chromosome
complement of 46 chromosomes is known as diploid. Genomes with only a single copy of every
chromosome or with three copies of each are known respectively as haploid and triploid. A
karyotype with too many or too few chromosomes, where the total is not a multiple of 23, is called
aneuploid. Three copies of a single chromosome in a cell are referred to as trisomy, whereas a
single copy is monosomy.
Chromosomes are divided by the centromere into a short p arm (petit) and a long q arm.
Acrocentric chromosomes (13, 14, 15, 21, 22) have the centromere at one end and only a q arm.
Lyonization is the process in which, in a cell containing more than one X chromosome, only one is
active. Selection of the active X chromosome is usually random and each inactivated X chromosome
can be seen as a Barr body on microscopy. Genes are expressed only from the active X chromosome.
Mitosis occurs in somatic cells and results in two diploid daughter cells with nuclear chromosomes
which are genetically identical both to each other and the original parent cell.
Mitosis
Meiosis occurs in the germ cells of the gonads and is also known as reduction division because it
results in four haploid daughter cells, each containing just one member (homologue) of each
chromosome pair, all genetically different. Meiosis involves two divisions (meiosis I and II). The
reduction in chromosome number occurs during meiosis I and is preceded by exchange of
chromosome segments between homologous chromosomes called crossing over. In males the onset of
meiosis and spermatogenesis is at puberty. In females, replication of the chromosomes and crossing
over begins during fetal life but the oocytes remain suspended before the first cell division until just
before ovulation.
Meiosis
Translocations
Reciprocal exchange of genetic material between non-homologous chromosomes

Robertsonian fusion of two acrocentric chromosomes at their centromeres, e.g. (14;21)
Unbalanced if chromosomal material has been lost or gained overall
Balanced if no chromosomal material has been lost or gained overall
Carriers of balanced translocations are usually phenotypically normal but are at increased risk for
having offspring with a chromosomal imbalance. There is also commonly an increased risk of
miscarriage and of reduced fertility.
Carriers of a robertsonian translocation involving chromosome 21 are at increased risk of having
offspring with translocation Down syndrome. For female and male (14;21) translocation carriers the
observed offspring risks for Down syndrome are approximately 15% and 5%, respectively. This may
be due to a selective disadvantage to spermatozoa carrying an extra chromosome. Remember,
translocation carriers can also have offspring with normal chromosomes or offspring who are
balanced translocation carriers like themselves.
1.1 Common sex chromosome aneuploidies
Turner syndrome (karyotype 45,X)

This affects 1 in 2500 live-born girls but it is a frequent finding among early miscarriages. Patients
are usually of normal intelligence. They have streak ovaries that result in failure of menstruation, low
oestrogen with high gonadotrophins and infertility. Normal secondary sexual characteristics may
develop spontaneously or can be induced with oestrogens. If puberty is achieved, the uterus is usually
normal and pregnancy is possible with the use of donated ova. Short stature throughout childhood
with failure of the pubertal growth spurt is typical. Final height can be increased by early treatment
with growth hormone. Other features may include:
Webbed or short neck

Low hairline
Shield chest with widely spaced nipples
Cubitus valgus (wide carrying angle)
Cardiovascular abnormalities (particularly aortic coarctation in 1015%)
Renal anomalies (e.g. horseshoe kidney, duplicated ureters, renal aplasia) in a third
Non-pitting lymphoedema in a third
Triple X syndrome (karyotype 47,XXX)

This affects 1 in 1000 live-born girls. These patients show little phenotypic abnormality but tend to
be of tall stature. Although intelligence is typically reduced compared with siblings it usually falls
within normal or lownormal limits. However, mild developmental and behavioural difficulties are
more common. Fertility is normal but the incidence of early menopause is increased.
Klinefelter syndrome (karyotype 47,XXY)

This affects 1 in 600 live-born boys. Phenotypic abnormalities are rare prepubertally other than a
tendency to tall stature. At puberty, spontaneous expression of secondary sexual characteristics is
variable but poor growth of facial and body hair is common. The testes are small and associated with
azoospermia, testosterone production is around 50% of normal and gonadotrophins are raised.
Gynaecomastia occurs in 30% and there is an increased risk of male breast cancer. Female
distribution of fat and hair and a high-pitched voice may occur but are not typical. Intelligence is
generally reduced compared with siblings but usually falls within normal or lownormal limits. Mild
developmental and behavioural problems are more common.
47,XYY males
This affects 1 in 1000 live-born boys. These males are phenotypically normal but tend to be tall.
Intelligence is usually within normal limits but there is an increased incidence of behavioural
abnormalities. Previous studies suggesting an increase in criminality have been disproved.
1.2 Common autosomal chromosome aneuploidies
Down syndrome (trisomy 21)

Down syndrome affects 1 in 700 live births overall and is usually secondary to meiotic nondisjunction during oogenesis, which is more common with increasing maternal age. Around 5% of
patients have an underlying robertsonian translocation, most commonly between chromosomes 14 and
21. Around 3% have detectable mosaicism (a mixture of trisomy 21 and karyotypically normal cells)
usually resulting in a milder phenotype.
Phenotypic features include:
Brachycephaly
Upslanting palpebral fissures, epicanthic folds, Brushfield spots on the iris
Protruding tongue
Single palmar crease, fifth finger clinodactyly, wide sandal gap between first and second toes
Hypotonia and moderate learning disability
The following are more common in patients with Down syndrome:

Cardiovascular malformations in 40%, particularly atrioventricular septal defects
Gastrointestinal abnormalities in 6%, particularly duodenal atresia and Hirschsprung disease
Haematological abnormalities, particularly acute lymphoblastic, acute myeloid and transient
leukaemias
Hypothyroidism
Cataracts in 3%
Alzheimer disease in the majority by 40 years of age
Edward syndrome (trisomy 18)

This typically causes intrauterine growth retardation, a characteristic facies, prominent occiput,
overlapping fingers (second and fifth overlap third and fourth), rockerbottom feet (vertical talus) and
short dorsiflexed great toes. Malformations, particularly congenital heart disease, diaphragmatic
hernias, renal abnormalities and dislocated hips, are more common. Survival beyond early infancy is
rare but associated with profound learning disability.
Patau syndrome (trisomy 13)

Affected infants usually have multiple malformations including holoprosencephaly and other central
nervous system abnormalities, scalp defects, microphthalmia, mid-line cleft lip and cleft palate, postaxial polydactyly, rockerbottom feet, renal anomalies and congenital heart disease. Survival beyond
early infancy is rare and associated with profound learning disability.
1.3 CGH microarray

CGH (comparative genomic hybridization) microarray is a method of more detailed chromosome
analysis than that provided by karyotyping. Patient genomic DNA and control genomic DNA are
differentially labelled with different fluorescent probes and then hybridized together. The ratio of
fluorescent intensity between patient and control DNA is then compared which detects areas of copy
number difference. This can detect microdeletions and microduplications as well as anomalies that
would have been visible on karyotype. The sensitivity of the test, and thus the size of the imbalances
detected, are determined by the distances between and number of the fluorescent probes. Highresolution arrays can detect imbalances as small as 200 base-pairs, but those in current diagnostic use
typically detect anomalies above 100 kilobases (kb). Arrays are not able to detect balanced
rearrangements, so the karyotype is still appropriate in cases such as recurrent miscarriage. Many
small anomalies detected are inherited from a normal parent, and thus are probably not significant in
the pathogenesis of developmental problems.
1.4 MLPA
MLPA (multiplex ligation-dependent probe amplification) is a multiplex PCR (polymerase chain
reaction) method able to detect abnormal copy numbers of multiple genomic DNA sequences. This
can be used at a gene level, detecting exon deletions or duplications, or at a chromosomal
microdeletion level. Typically kits are generated with a set of probes such as all the telomeres, or the
common microdeletion syndromes.
1.5 Qf-PCR
Qf-PCR (quantitative fluorescence polymerase chain reaction) is a technique allowing fast
assessment of copy numbers of whole chromosomes on small samples. Small sections of DNA from
the sample are amplified, labelled with fluorescent tags and the amounts measured by
electrophoresis. This is most commonly used for identification of aneuploidy on prenatal samples.
Typically only chromosomes 13, 18 and 21, and perhaps the sex chromosomes, are tested because no
other whole chromosome aneuploidy is survivable to term. Results are available in 2448 hours.
1.6 FISH testing

FISH (fluorescent in situ hybridization) is a technique used to assess the copy number of specific
DNA sequences in the genome. Fluorescently labelled probes are designed that are complementary to
the DNA sequences being assessed, and they are allowed to hybridize to the chromosome spread. The
number of copies can then be visualized as fluorescent spots using confocal microscopes. FISH can
be performed much more rapidly than formal karyotyping. However, the use of MLPA, Qf-PCR and
CGH microarray has largely superseded this process, except in testing other members of a family for
a known chromosomal anomaly.
1.7 Microdeletion syndromes
These are caused by chromosomal deletions that are too small to see on standard microscopy but
involve two or more adjacent (contiguous) genes. They can be detected using specific FISH testing,
MLPA or CGH microarray.
Examples of microdeletion syndromes:
22q11 microdeletion (parathyroid gland hypoplasia with hypocalcaemia, thymus hypoplasia with
T-lymphocyte deficiency, congenital cardiac malformations, particularly interrupted aortic arch and
truncus arteriosus, cleft palate, learning disability) also previously called by many names including
DiGeorge syndrome. There appears to be an increased incidence of psychiatric disorders,
particularly within the schizophrenic spectrum
Williams syndrome (supravalvular aortic stenosis, hypercalcaemia, stellate irides, characteristic
facial appearance, learning disability) due to microdeletions involving the elastin gene on
chromosome 7
16p11.2 microdeletion syndrome (autism, seizures, learning disability) no real diagnostic
phenotypic features meant that this was not previously identified, but with the widespread use of
CGH microarray it is now apparent that this is the most common microdeletion syndrome, found in
1 in every 100 on the autistic spectrum. Frequently also found in a normal parent, giving a high
recurrence risk.
1.8 Genetic counselling in chromosomal disorders

As a general rule the following apply.
For parents of a child with trisomy 21

Recurrence risks will be around 1% above the maternal age-related risks for which there are tables.
At age 36 years the background risk for Down syndrome is 0.5%. Parents with a robertsonian
translocation involving chromosome 21 have a much higher recurrence risk.
For parents of a child with any other trisomy

Recurrence risks in future pregnancies for that specific trisomy will be <1%. However, couples are
generally counselled that there is a 1% risk for any chromosome abnormality in future offspring,
which takes into account the small risks that one parent may be mosaic or may have an increased risk
of chromosome mis-segregation at meiosis.
For parents of a child with a microdeletion

Parental chromosomes should be checked. If they are normal, recurrence risks will be <1%. If one
parent carries the microdeletion then recurrence risks will be 50%.
For parents of a child with any other chromosome abnormality
Parental chromosomes should be checked. If they are normal then recurrence risks are usually small
(<1%). If one parent carries a predisposing translocation then recurrence risks will be higher,
depending on the nature of the translocation.
Prenatal karyotyping is available for any couple who have had a previous child with a chromosome
abnormality.
2. MENDELIAN INHERITANCE
2.1 Autosomal dominant (AD) conditions
These result from mutation of one copy of a pair of genes carried on an autosome. All offspring of an
affected person have a 50% chance of inheriting the mutation. Within a family the severity may vary
(variable expression) and known mutation carriers may appear clinically normal (reduced
penetrance). Some conditions, such as achondroplasia and neurofibromatosis type 1, frequently start
anew through new mutations arising in the egg or (more commonly) sperm.
Examples of autosomal dominant conditions

Achondroplasia
Alagille syndrome
EhlersDanlos syndrome (most)
Facioscapulohumeral muscular dystrophy
Familial adenomatous polyposis
Familial hypercholesterolaemia
Gilbert syndrome
Huntington disease
Marfan syndrome
Myotonic dystrophy
Neurofibromatosis types 1 and 2
Noonan syndrome
Porphyrias (except congenital erythropoietic which is AR)
Tuberous sclerosis
Von Willebrand disease
Conditions pre-fixed hereditary or familial are usually autosomal dominant.
2.2 Autosomal recessive [AR] conditions

These result from mutations in both copies of an autosomal gene. Where both parents are carriers
(with only one mutation and a normal copy), each of their offspring has a 1 in 4 (25%) risk of being
affected and a 2 in 4 (50%) chance of being a carrier. Carriers are usually indistinguishable from
normal other than by DNA analysis.
Examples of autosomal recessive conditions

Alkaptonuria
-Thalassaemia
Congenital adrenal hyperplasias
CriglerNajjar syndrome (severe form)
Cystic fibrosis
DubinJohnson syndrome
Fanconi anaemia
Galactosaemia
Glucose-6-phosphatase deficiency (von Gierke diseased)6
Glycogen storage diseases
Homocystinuria
Haemochromatosis
Mucopolysaccharidoses (all except Hunter syndrome)
Phenylketonuria
Rotor (usually)
Sickle cell anaemia
Spinal muscular atrophies
Wilson disease
Xeroderma pigmentosa
Risk calculations for AR disorders

Remember:
People who have no family history of an autosomal recessive disorder have the background
population carrier risk
The parents of a child with an autosomal recessive disorder are assumed to be carriers
Where both parents are known to be carriers for an autosomal recessive disorder, any of their
children who are known to be unaffected are left with a two-thirds carrier risk (because if the
possibility that they are affected is discounted, only three possibilities remain).
Autosomal recessive inheritance and consanguinity

It is believed that everybody carries a few deleterious autosomal recessive genes. First cousins share
on average one-eighth of their genes because they share one set of grandparents. As a result, they are
more likely to be carrying the same autosomal recessive disorders. For consanguineous couples in a
family with a known AR disorder, specific risks should be calculated and appropriate testing should
be arranged. For first-cousin parents who have no known family history of any autosomal recessive
disorder, their offspring have around a 3% increased risk above the general background risk of any
genetic abnormality of 2% (i.e. a 5% overall risk). Screening should be offered for any autosomal
recessive disorder that is available and known to be common in their ancestral ethnic group, e.g.:
White people cystic fibrosis

African/AfricanCaribbean people sickle cell anaemia
Mediterranean/Asian people thalassaemia
Jewish people TaySachs disease and multiple other recessive disorders
Although consanguinity is regarded as taboo in many societies, around 20% of all marriages are
consanguineous (second cousin or closer). There are sound financial and societal reasons for
consanguineous marriages in societies where these relationships are common, and the majority of
offspring are healthy. Geneticists would never advise against consanguineous marriage (or indicate
that a childs recessive disorder is the fault of the marriage), but families affected with recessive
disorders have been known to employ carrier testing to assist in marriage planning.
2.3 X-linked recessive (XLR) conditions

These result from a mutation in a gene carried on the X chromosome and affect males because they
have just one gene copy. Females are usually unaffected but may have mild manifestations as a result
of lyonization. New mutations are common in many XLR disorders which means that the mother of an
affected boy, with no preceding family history, is not necessarily a carrier. XLR inheritance is
characterized by the following:
No male-to-male transmission an affected father passes his Y chromosome to all his sons
All daughters of an affected male are carriers an affected father passes his X chromosome to all
his daughters
Sons of a female carrier have a 50% chance of being affected and daughters have a 50% chance of
being carriers
Examples of X-linked recessive conditions

Alport syndrome (usually XLR; some AR forms)
Becker muscular dystrophy
Fabry disease
Fragile X syndrome
Glucose-6-phosphate dehydrogenase deficiency (favism)
Haemophilias A and B (Christmas disease)
Hunter syndrome (MPS II)
LeschNyhan disease
Ocular albinism
Redgreen colour blindness
Testicular feminization syndrome
WiskottAldrich syndrome
2.4 X-linked dominant (XLD) conditions

These are caused by a mutation in one copy of a gene on the X chromosome but both male and female
mutation carriers are affected. As a result of lyonization, females are usually more mildly affected
and these disorders are frequently lethal in males. New mutations are common. For the reasons
outlined above:
There is no male-to-male transmission
All daughters of an affected male would be affected
All offspring of an affected female have a 50% chance of being affected
Examples of X-linked dominant conditions include:

Goltz syndrome
Rett syndrome
Hypophosphataemic (vitamin D-resistant) rickets
2.5 Constructing a pedigree diagram (family tree)

The basic symbols in common usage are shown in the figure below. Occasionally symbols may be
half shaded or quarter shaded. This generally means that the individual manifests a specified
phenotypic feature denoted in an accompanying explanatory key, e.g. lens dislocation in a family with
Marfan syndrome.
Basic symbols used in pedigree diagrams
3. MOLECULAR GENETICS
3.1 DNA (deoxyribonucleic acid)

DNA is a double-stranded molecule composed of purine (adenine + guanine) and pyrimidine
(cytosine and thymine) bases linked by a backbone of covalently bonded deoxyribose sugar
phosphate residues. The two anti-parallel strands are held together by hydrogen bonds which can be
disrupted by heating and reform on cooling:
Adenine (A) pairs with thymine (T) by two hydrogen bonds
Guanine (G) pairs with cytosine (C) by three hydrogen bonds
3.2 RNA (ribonucleic acid)

DNA is transcribed in the nucleus into messenger RNA (mRNA) which is translated by ribosomes
in the cytoplasm into a polypeptide chain. RNA differs from DNA in that:
It is single-stranded
Thymine is replaced by uracil (U)
The sugar backbone is ribose
3.3 Polymerase chain reaction (PCR)

This is a widely used method for generating large amounts of the DNA of interest from very small
samples. PCR can be adapted for use with RNA provided that the RNA is first converted to DNA.
PCR is a method by which a small amount of target DNA (the template) is selectively amplified to
produce enough to perform an analysis. This might be the detection of a particular DNA sequence
such as that belonging to a pathogenic microorganism or an oncogene, or the detection of differences
in genes such as mutations causing inherited disease. Therefore the template DNA might consist of
DNA derived from peripheral blood lymphocytes, a tumour biopsy or a biological fluid from a
patient with an infection.
In order to perform PCR, the sequence flanking the target DNA must usually be known so that specific
complementary oligonucleotide sequences, known as primers, can be designed. The two unique
primers are then mixed together with the DNA template, deoxyribonucleotides (dATP, dCTP, dGTP,
dTTP) and a thermostable DNA polymerase (Taq polymerase, derived from an organism that inhabits
thermal springs):
In the initial stage of the reaction the DNA template is heated (typically for about 30 seconds) to
make it single stranded. As the reaction cools the primers will anneal to the template if the
appropriate sequence is present.
The reaction is then heated to 72C (for about a minute) during which time the Taq DNA
polymerase synthesises new DNA between the two primer sequences, doubling the copy number of
the target sequence.
The reaction is heated again and the cycle is repeated. After 30 or so cycles (each typically lasting
a few minutes) the target sequence will have been amplified exponentially.
The crucial feature of PCR is that to detect a given sequence of DNA it only needs to be present in
one copy (i.e. one molecule of DNA): this makes it extremely powerful.
Clinical applications of PCR

Mutation detection
Single cell PCR of in vitro fertilized embryo to diagnose genetic disease before implantation
Detection of viral and bacterial sequences in tissue (herpes simplex virus in CSF, hepatitis C, HIV
in peripheral blood, meningococcal strains)
Polymerase chain reaction
3.4 Reverse transcription PCT (rt-PCR)

This is a modification of conventional PCR used to amplify messenger RNA (mRNA) sequence in
order to look at the expression of particular genes within a tissue. mRNA is single stranded, unstable
and not a substrate for Taq DNA polymerase. For that reason it must be converted to complementary
DNA (cDNA) using reverse transcriptase, a retroviral enzyme, which results in a double-stranded
DNA copy of the original RNA sequence. PCR can then be performed in the normal way.
3.5 Next generation sequencing
DNA sequencing is used to identify point mutations, or small deletions/duplications, in a specific

gene. Typically a small number of individuals DNA is tested for mutations in one gene. This is
expensive in terms of time and substrates. Next generation sequencing allows multiple parallel
analyses to be performed at the same time. This can be used to test a single individuals DNA for
mutations in multiple genes, or to test large numbers of individuals at the same time. Chips are being
developed for specific related conditions caused by multiple genes, such as aortic dissection, Noonan
syndrome, cardiomyopathies and cardiac arrhythmias. These will allow rapid genetic diagnosis of
individuals with a clinical diagnosis. Next generation technology is also the basis of exome
sequencing.
3.6 Exome sequencing

Whole genome sequencing is expensive and time-consuming. The exome consists of only the coding
sequences in the genome, i.e. the parts of the genome that are translated into protein. This only
represents around 5% of the total genome, but is estimated to contain 85% of all disease-causing
mutations. Exome sequencing is a method of analysing the entire exome for mutations. This is
primarily a research tool used to identify unknown genes responsible for mendelian disorders, but has
also been used to identify functional variation associated with more common conditions such as
Alzheimer disease.
4. TRINUCLEOTIDE REPEAT DISORDERS

These conditions are associated with genes containing stretches of repeating units of three nucleotides
and include:
Fragile X syndrome X-linked

Myotonic dystrophy AD
Huntington disease AD
Friedreich ataxia AR
Spinocerebellar ataxias AD
In normal individuals the number of repeats varies slightly but remains below a defined threshold.
Affected patients have an increased number of repeats, called an expansion, above the diseasecausing threshold. The expansions may be unstable and enlarge further in successive generations
causing increased disease severity (anticipation) and earlier onset, e.g. myotonic dystrophy,
particularly congenital myotonic dystrophy after transmission by an affected mother. Between the
normal range and the affected range, there are two other expansion sizes. Premutation sizes are
smaller than the lowest copy number to cause disease and are not associated with a risk of the
condition, but have a high risk of increasing into the disease range during gametogenesis, generating
an affected child. This risk can be gender dependent in some conditions. Intermediate alleles are
smaller than the premutation range, but larger than normal. They have a risk of increasing into the
premutation range during gametogenesis.
4.1 Fragile X syndrome

This causes learning disability, macro-orchidism, autism and seizures, and was historically
associated with a cytogenetically visible constriction (fragile site) on the X chromosome. The
inheritance is X linked but complex. Among controls there are between 6 and 45 stably inherited
trinucleotide repeats in the FMR1 gene. The intermediate allele size is 5058 repeats, and people
with between 58 and 230 repeats are premutation carriers but are unaffected. Only female
gametogenesis carries a risk of expansion into the disease-causing range (230 to >1000 repeats)
known as a full mutation which is methylated, effectively inactivating the gene. All males and around
50% of females with the full mutation are affected, though females are typically less severely
affected. The premutation does not expand to a full mutation when passed on by a male. Male
premutation carriers are known as normal transmitting males and will pass the premutation to all their
daughters (remember that they pass their Y chromosome to all their sons). Although premutation
carrier status is not associated with learning disability, female carriers have a high risk (around 50%)
of premature ovarian failure or early menopause. There is also a condition called fragile Xassociated tremor and ataxia syndrome (FXTAS), which predominantly affects male premutation
carriers over the age of 50. Parkinsonism and cognitive decline are also features. The lifetime male
risk of developing FXTAS is 3040% though 75% of men older than 80 show signs.
5. MITOCHONDRIAL DISORDERS
Mitochondria are exclusively maternally inherited, deriving from those present in the cytoplasm of
the ovum. They contain copies of their own circular 16.5-kilobase chromosome carrying genes for
several respiratory chain enzyme subunits and transfer RNAs. Mitochondrial genes differ from
nuclear genes in having no introns and using some different amino acid codons. Within a tissue or
even a cell there may be a mixed population of normal and abnormal mitochondria known as
heteroplasmy. Different proportions of abnormal mitochondria may be required to cause disease in
different tissues, known as a threshold effect. Disorders caused by mitochondrial gene mutations
include:
MELAS (mitochondrial encephalopathy, lactic acidosis, stroke-like episodes)
MERRF (myoclonic epilepsy, ragged red fibres)
Mitochondrialy inherited diabetes mellitus and deafness (typically caused by the same mutation as
seen in MELAS but at lower levels)
Leber hereditary optic neuropathy (note that other factors also contribute)
Prader-Willi syndrome
Clinical
Angelman syndrome
Neonatal hypotonia and poor feeding

Moderate learning disability
Hyperphagia + obesity in later
childhood
Small genitalia
Unprovoked laughter/clapping
Microcephaly, severe learning disability
Ataxia, broad-based gait
Seizures, characteristic EEG
Genetics
70% deletion on paternal
chromosome 15
30% maternal uniparental disomy 15
(i.e. no maternal contribution)
80% deletion on maternal chromosome 15

23% paternal uniparental disomy 15
(i.e. no paternal contribution) remainder due to subtle
mutations
6. GENOMIC IMPRINTING
For most genes both copies are expressed but for some genes, either the maternally or paternally
derived copy is preferentially used, a phenomenon known as genomic imprinting. The unused copy is
frequently methylated, which inactivates the gene. These genes tend to aggregate together in imprinted
regions on chromosomes. Abnormalities of inheritance or methylation of imprinted genes can
therefore cause disease even in the presence of two apparently normal copies. The best examples are
the PraderWilli and Angelman syndromes, both caused by cytogenetic deletions of the same region
of chromosome 15q, uniparental disomy of chromosome 15 (where both copies of chromosome 15
are derived from one parent with no copy of chromosome 15 from the other parent), or abnormalities
of methylation, which labels both chromosomes as deriving from one parent. The disease condition is
caused by the absence of one parents copy of genes in the region, rather than by excessive numbers of
copies of the other.
Other imprinting disorders

SilverRussell syndrome
Prenatal onset growth retardation, relative macrocephaly, triangular facies, asymmetry, fifth finger
clinodactyly and frequently normal IQ. Around 35% are caused by abnormal methylation of genes on
chromosome 11p15, whereas 10% are associated with maternal uniparental disomy of chromosome
7. The cause in the remainder is not yet known.
Prenatal-onset macrosomia, facial naevus flammeus, macroglossia, ear lobe creases, pits on the ear
helix, hemihypertrophy, nephromegaly, exomphalos (omphalocele) and neonatal hypoglycaemia.
There is an increased risk of Wilms tumour, adrenocortical and hepatic tumours in childhood. Similar
to SilverRussell syndrome, the condition results from abnormalities of inheritance or methylation of
chromosome 11p15 which contains several imprinted genes, including the IGF-2 (insulin-like growth
factor 2) gene. The results in BWS tend to be directly opposite to those in SilverRussell syndrome.
7. GENETIC TESTING
Genetic tests can be thought of as diagnostic, predictive or for carrier status. Informed verbal, and
increasingly written, consent (or assent) should be obtained before genetic testing.
Diagnostic tests
These are chromosomal investigations such as karyotype and CGH microarray, or mutation analysis
of specific genes. The latter is frequently used where the diagnosis is already suspected on clinical
grounds but genetic testing is useful for confirmation, or for counselling or predictive testing in the
wider family.
Predictive tests
When an individual is clinically normal but is at risk for developing a familial disorder, such as
Huntington disease, myotonic dystrophy or a familial cancer syndrome. Predictive testing is not
usually offered without a formal process of genetic counselling over more than one consultation with
time built in for reflection. Where there are intervening relatives whose genetic status may be
indirectly revealed, there are additional issues that must be taken into consideration. Written consent
for predictive testing is required by most laboratories. Nationally agreed guidance is that predictive
testing in children for disorders that have no implications in childhood should not be undertaken until
the child is old enough to make an informed choice.
Carrier tests
These are usually undertaken in autosomal recessive or X-linked recessive disorders where the result
has no direct implications for the health of the individual, but is helpful in determining the risks to
their offspring. Carrier status may be generated as a by-product of diagnostic or prenatal testing.
National guidance is that specific testing for carrier status should be avoided in children until they are
old enough to make an informed choice.
Genetics in children
Diagnostic tests are obviously necessary and useful, as are predictive tests for disorders that may
manifest in childhood, and have a screening programme or treatment, such as the multiple endocrine
neoplasias (MEN1, MEN2) and familial adenomatous polyposis. Predictive testing for adult onset
disorders such as BRCA-1/-2 or Huntington disease are not appropriate in children, because they are
unable to give informed consent, and a diagnosis can never be removed once it has been made. Many
adults opt not to have predictive tests for untreatable disorders such as Huntington disease, and an atrisk child should be allowed to make the same decision. Equally, carrier status for AR or X-linked
disorders will impact only on a childs reproductive decisions, not childhood health, and thus is only
tested when the child is able to participate in the process and give proper informed consent. Parents
do occasionally request such testing, and a clinical geneticist would meet them in clinic to discuss
their reasons for testing and the reasons for a reluctance to offer it.
8. IMPORTANT GENETIC TOPICS

This section includes short notes on conditions that form popular examination topics.

Normal development of the reproductive tract and external genitalia
A simplified outline is shown below.
Outline of the normal development of the reproductive tract and external genitalia
The 6-week embryo has undifferentiated gonads, mllerian ducts (capable of developing into the
uterus, fallopian tubes and upper vagina), wolffian ducts (capable of forming the epididymis, vas
deferens and seminal vesicles) and undifferentiated external genitalia.
In the presence of a Y chromosome the gonads become testes that produce testosterone and mllerian
inhibiting factor (MIF). Testosterone causes the wolffian ducts to persist and differentiate and, after
conversion to dihydrotestosterone (by 5-reductase), masculinization of the external genitalia. MIF
causes the mllerian ducts to regress.
In the absence of a Y chromosome the gonads become ovaries which secrete neither testosterone nor
MIF and, in the absence of testosterone, the wolffian ducts regress and the external genitalia feminize.
In the absence of MIF, the mllerian ducts persist and differentiate.
The causes of ambiguous genitalia divide broadly into those resulting in undermasculinization of a
male fetus, those causing masculinization of a female fetus, and those resulting from mosaicism for a
cell line containing a Y chromosome and another that does not. They are summarized in the diagram
opposite.
Ambiguous genitalia outline of causes
8.2 Cystic fibrosis

This results from mutations in the CFTR (cystic fibrosis transmembrane regulator) gene. The F508
mutation (deletion of three nucleotides coding for a phenylalanine residue at amino acid position 508)
accounts for 75% of mutations in white people. Most laboratories now screen for 32 common
mutations including F508. Such testing identifies 90% of cystic fibrosis mutations in white people,
but a much smaller proportion in many other ethnic groups. Therefore, negative molecular testing
cannot exclude a diagnosis of cystic fibrosis.
8.3 Duchenne and Becker muscular dystrophies

These result from different mutations within the dystrophin gene on chromosome Xp21.
Important distinguishing features of Duchenne and Becker muscular

dystrophies
Immunofluorescent
dystrophin on muscle
biopsy
Wheelchair
dependence
Learning disability
Duchenne muscular
dystrophy
Becker muscular
dystrophy
Undetectable
Reduced/abnormal
95% at <12 years
5% at <12 years
20%
Rare
In around a third of boys with Duchenne muscular dystrophy, the condition has arisen as a new
mutation, whereas a further third are the result of a new mutation in the mother. Mutation analysis in
the affected boy can often identify mothers who are carriers, but a normal result does not exclude
germline mosaicism, where mutated cells are present in the ovaries but not the blood. A woman
proven to be a carrier has a 25% (1 in 4) recurrence risk, but a woman without the mutation in her
blood still has up to a 20% recurrence risk, and prenatal diagnosis is offered in all circumstances.
Given the high new mutation rate, both in the affected child and in the mother, calculation of risks to
other family members can be challenging. The risk that the mother of an isolated case is a carrier is
two in three. The maternal grandmothers risk is one in three, due to the chance of a new mutation in
the mother. Thus, the sister of the isolated affected boy has a one in three risk of being a carrier, but
the maternal aunt has a one in six risk, and so on.
In practical terms, most families will have an identifiable mutation, and thus carrier identification
will be relatively easy. In the absence of a mutation, e.g. the affected individual has died with no
DNA stored, or no mutation is identified (a small proportion), then the above risks can be modified
using linkage to the X chromosome and Bayes theorem to take into account the number of unaffected
males in the family, and the creatine kinase (CK) levels in the at-risk females. Carrier females can
have elevated CK levels, although a normal result does not exclude carrier status because they follow
a normal distribution. A woman known to be at high risk, but with no identifiable mutation, may only
be able to opt to terminate male pregnancies if she wishes to avoid having an affected child.
8.4 Neurofibromatosis
There are two forms of neurofibromatosis (NF) that are clinically and genetically distinct:
NF1
Major features 6 Caf-au-lait patches
Axillary/inguinal freckling
Lisch nodules on the iris
Peripheral neurofibromas
Minor features Macrocephaly
Short stature
Complications
Plexiform neuromas
Optic glioma (2%)
Other cranial and spinal tumours
Pseudarthrosis (especially tibial)
Renal artery stenosis
Phaeochromocytoma
Learning difficulties
Scoliosis
Spinal cord and nerve compressions
Malignant change/sarcomas
NF2
Bilateral acoustic neuromas
(vestibular schwannomas)
Other cranial and spinal tumours
Caf-au-lait patches (usually <6)
Peripheral schwannomas
Peripheral neurofibromas
Deafness/tinnitus/vertigo
Lens opacities/cataracts
Spinal cord and nerve compressions
Malignant change/sarcomas
Gene
Protein
Chromosome 17
Neurofibromin
Chromosome 22
Schwannomin

There are at least two separate genes that cause tuberous sclerosis (TS), on chromosomes 9 (TSC1;
hamartin) and 16 (TSC2; tuberin).
Clinical features of tuberous sclerosis

Skin/nails
Ash-leaf macules
Shagreen patches (especially over the lumbosacral area)
Adenoma sebaceum (facial area)
Subungual/periungual fibromas
Eyes
Retinal hamartomas
Heart
Cardiac rhabdomyomas, detectable antenatally, usually regressing during childhood
Kidneys
Angiomyolipomas
Renal cysts
Neurological
Seizures
Learning disability
Neuroimaging
Intracranial calcification (periventricular)
Subependymal nodules
Neuronal migration defects
8.6 Marfan syndrome

This results from mutations in the fibrillin 1 (FBN1) gene on chromosome 15. Intelligence is usually
normal. New diagnostic criteria do not include joint laxity or hyperextensibility, and this alone in a
tall individual is not sufficient to suspect the diagnosis of Marfan.
Clinical features of Marfan syndrome

Musculoskeletal
Tall stature with disproportionately long limbs (dolichostenomelia)

Characteristic facial appearance
Arachnodactyly
Pectus carinatum or excavatum
Scoliosis
High, narrow arched palate with dental overcrowding
Pes planus
Heart
Aortic root dilatation and dissection
Mitral valve prolapse
Eyes
Lens dislocation (typically up)
Myopia
Skin
Striae
Lungs
Spontaneous pneumothorax
Apical bullae
8.7 Homocystinuria
(see also Chapter 16)
This is most commonly the result of cystathione--synthase deficiency and causes a Marfan
syndrome-like body habitus, lens dislocation (usually down), learning disability, thrombotic tendency
and osteoporosis. Treatment includes a low methionine diet pyridoxine.
8.8 Noonan syndrome

This is an autosomal dominant condition. Around 50% of individuals with Noonan syndrome have
mutations in the PTPN11 (protein-tyrosine phosphatase, non-receptor-type 11) gene on chromosome
12. A further 1015% are caused by SOS1 (son of seven-less homologue 1 (Drosophila), on
chromosome 2) and RAF1 (v-raf-1 murine leukaemia viral oncogene homologue 1 on chromosome 3)
causes another 510%. Multiple other genes on the RAS-MAPK pathway have also been implicated
in small proportions of cases. The karyotype is usually normal.
Clinical features of Noonan syndrome

Cardiac
Pulmonary valve stenosis

Septal defects (atrial and ventricular septal defects)
Branch pulmonary artery stenosis
Musculoskeletal
Webbed or short neck

Pectus excavatum or carinatum
Wide-spaced nipples
Wide carrying angle (cubitus valgus)
Short stature in 80%
Other features
Ptosis
Low-set and/or posteriorly rotated ears
Small genitalia and undescended testes in boys
Coagulation defects in 30% (partial factor XI:C, XIIC and VIIIC deficiencies, von Willebrand
disease, thrombocytopenia)
Mild learning disability in 30%
8.9 Achondroplasia
A short-limb skeletal dysplasia resulting from specific autosomal dominant mutations in the FGFR3
(fibroblast growth factor receptor 3) gene on chromosome 4. There is a high new mutation rate.
Important complications are hydrocephalus, brain-stem or cervical cord compression resulting from a
small foramen magnum, spinal canal stenosis, kyphosis and sleep apnoea. Intelligence is usually
normal.

A variable autosomal dominant disorder resulting from deletions of or mutations in the JAG1 (jagged)
gene on chromosome 20. Major features of the syndrome include:
Cardiac peripheral pulmonary artery stenosis complex malformations

Eye posterior embryotoxon, abnormalities of the anterior chamber
Vertebral butterfly vertebrae, hemivertebrae, rib anomalies
Hepatic cholestatic jaundice, paucity of intrahepatic bile ducts
8.11 CHARGE syndrome

A malformation syndrome including:
Colobomas
Heart malformations
Atresia of the choanae
Retardation of growth and development (learning disability)
Genital hypoplasia (in males)
Ear abnormalities (abnormalities of the ear pinna, deafness)
Cleft lip/palate and renal abnormalities are also common
The majority of patients with CHARGE syndrome have new mutations or deletions of the CHD7
(chromodomain helicase DNA-binding protein 7) gene on chromosome 8.
8.12 VATER (VACTERL) association

A sporadic malformation syndrome including:
Vertebral abnormalities
Anal atresia fistula
Cardiac malformations
Tracheo-oesophageal fistula
Renal anomalies, radial ray defects
Limb anomalies, especially radial ray defects
The cause is not yet known.
8.13 Goldenhar syndrome

Also known as oculo-auriculovertebral spectrum, or first and second and branchial arch syndrome. It
is mainly sporadic and the cause is unknown. Major features include:
Craniofacial asymmetry, hemifacial microsomia, micrognathia

Ears malformed pinnas, deafness, preauricular tags
Eyes epibulbar (scleral) dermoid cysts, microphthalmia
Oral macrostomia, cleft lip/palate
Vertebral hemivertebrae
Cardiac cardiac malformations
Renal renal malformations
8.14 Pierre Robin sequence

An association of micrognathia and cleft palate which may occur alone, but a proportion will have
22q11 deletions or Stickler syndrome.
8.15 Potter sequence

Oligohydramnios as a result of renal abnormalities, urinary tract obstruction or amniotic fluid leakage
may lead to secondary fetal compression with joint contractures (arthrogryposis), pulmonary
hypoplasia and squashed facies known as the Potter sequence.
9. FETAL TERATOGENS
9.1 Maternal illness
Maternal diabetes
Maternal diabetes is associated with fetal macrosomia, neonatal hypoglycaemia and increased risk of
a wide variety of malformations, particularly cardiac (transposition of the great arteries, aortic
coarctation, septal defects, cardiomyopathy), vertebral (sacral abnormalities, hemivertebrae), renal
(agenesis, duplex collecting systems), intestinal (imperforate anus, other atresias) and limb
abnormalities (short femurs, radial ray abnormalities).
Maternal myasthenia gravis

This is associated with fetal arthrogryposis.
Maternal phenylketonuria
Although the fetus is unlikely to be affected by phenylketonuria (PKU: which is autosomal recessive),
if an affected mother has relaxed her low phenylalanine diet, the fetus is at risk of microcephaly,
cardiac defects and learning disability secondary to exposure to the raised maternal phenylalanine
levels.
Maternal systemic lupus erythematosus

Maternal systemic lupus erythematosus (SLE) with anti-Ro and anti-La antibodies is associated with
an increased risk of fetal bradycardia and congenital heart block for which pacing may be required. A
self-limiting neonatal cutaneous lupus may also occur.
9.2 Infectious agents

The following agents are associated with increased fetal loss in the first trimester;
hepatosplenomegaly, jaundice and thrombocytopenia in the neonate; and abnormalities particularly
those affecting the central nervous system, vision and hearing.
Fetal cytomegalovirus
Infection may be associated with microcephaly, intracranial calcification, chorioretinopathy, deafness
and learning disability.
Fetal toxoplasmosis
Infection with Toxoplasma species, a protozoan, may be associated with microcephaly,
hydrocephalus, intracranial calcification, chorioretinopathy and learning disability.
Fetal rubella
Infection with rubella virus is most often associated with deafness particularly in the first and early
second trimesters, but cardiac abnormalities (persistent ductus arteriosus, peripheral pulmonary
stenosis, septal defects), microcephaly, chorioretinopathy, cataract and learning disability are also
associated.
Congenital syphilis, herpes and varicella

See Chapter 15, Section 11.1.
9.3 Other teratogens
Fetal alcohol syndrome

Pre- and postnatal growth retardation, neonatal irritability, microcephaly, learning disability,
hyperactivity in childhood, cardiac defects (particularly ventricular and atrial septal defects), small
nails on fifth fingers and toes, facial anomalies (short palpebral fissures, ptosis, smooth philtrum, thin
upper lip) and a variety of less common, often midline, malformations. It is likely that the effects on
any one fetus are determined by the degree, timing and duration of exposure as well as the
susceptibility of the fetus which is probably genetically determined.
Illicit drugs in pregnancy

Opiate drugs in pregnancy have a high risk of dependency in the newborn, intrauterine growth
retardation and still birth, but do not appear to be associated with significant risk of structural
anomalies. There are behavioural issues during childhood. Fetal cocaine has a higher risk of defects,
apparently associated with vascular disruption, such as limb reduction defects and porencephaly.
Survivors of this do not appear to have long-term intellectual deficit once their home circumstance
has been taken into account, though there is evidence of some attention and behavioural problems.
Fetal retinoic acid

Exposure to retinoic acid (which is used in the treatment of acne) is associated with structural brain
abnormalities, neuronal migration defects, microtia and complex cardiac malformations.
Fetal valproate syndrome

Fetuses exposed to valproate have an increased risk of cleft lip and palate, neural tube defects,
cardiac defects, radial ray defects, learning disability and facial anomalies (frontal narrowing
including metopic craniosynostosis, thin eyebrows, infraorbital skin grooves, long philtrum, thin
upper lip). These effects appear to be dose dependent.
Fetal warfarin syndrome

Fetuses exposed to warfarin typically have nasal hypoplasia, stippled epiphyses and are at risk of
learning disability and brain, eye, cardiac and skeletal malformations.
10. PRENATAL TESTING

Chorionic villous sampling or biopsy (CVS or CVB) a small piece of placenta is taken either
transabdominally or transvaginally. CVS testing can be safely performed from 11 weeks gestation
Amniocentesis amniotic fluid is taken, containing cells derived from the surfaces of the fetus and
amniotic membranes. Amniocentesis is usually performed from 15 weeks gestation
Cordocentesis a method of obtaining fetal blood that can be performed from 18 weeks gestation
Chromosome and DNA testing can be performed on any of the above types of sample, and
biochemical analyses can often also be performed if necessary. Each method carries a small risk of
miscarriage. As a result, most couples opt for prenatal testing only if they wish to terminate an
affected pregnancy. Although chromosome analysis can be performed on any pregnancy, DNA
analysis can be used only in families where known mutations have already been identified, and the
family is at significant risk.
It is possible to identify the sex of an unborn fetus by prenatal testing and, in the case of X-linked
conditions where no specific mutation has been identified, this is often the only available prenatal
test. However, it is illegal in the UK to terminate a pregnancy on the basis of gender alone unless the
child is at risk of a genetic condition due to its gender.
11. NON-INVASIVE PRENATAL TESTING

Cell-free fetal DNA can be detected in the mothers circulating blood from 4 weeks gestation. The
vast majority of the cell-free DNA is maternal, however, so testing is currently limited to the
identification or exclusion of genetic material not present in the mother, such as Y chromosome, or
rhesus D in RhD-negative women. In those at risk of an X-linked disorder in sons, this process will
remove the necessity for invasive testing in 50% of pregnancies. Currently it is not possible to test for
trisomy 21 or other chromosomal anomalies by this method.
12. PREIMPLANTATION GENETIC DIAGNOSIS

This technique is an in vitro fertilization (IVF)-based process. At the 8- to 16-cell stage a single cell
is removed from each embryo for testing. Only embryos predicted to be unaffected are reimplanted
into the mother. Preimplantation genetic testing (PGD) is technically difficult and has a similar viable
pregnancy rate to IVF (25%). It is available in the UK for a limited, although increasing, number of
conditions and virtually all inherited chromosome anomalies. For funding purposes it is frequently
regarded as fertility treatment, so families can find it hard to get NHS treatment. Overseas centres
have a wider range of conditions, but it is very expensive.
13. GENETIC COUNSELLING

This is the process of assisting families or individuals affected by genetic disease to understand the
cause of their condition, the risk of recurrence and the options available to them. It is entirely nondirective and the aim is to deliver all available information to allow the family to make the
appropriate decisions. Some families will opt for prenatal diagnosis and termination, although this
will not be acceptable for others. Equally, with predictive testing, not everyone at significant risk of a
condition chooses to have testing to clarify this risk further. Genetic counselling will be offered to all,
with no obligation to pursue testing.
14. FURTHER READING
Firth HV, Hurst JA. Oxford Desk Reference Clinical Genetics. Oxford University Press, 2005.
Harper PS. Practical Genetic Counselling, 7th edn. London: Hodder Education, 2010.
Jones KL. Smiths Recognizable Patterns of Human Malformation, 6th edn. Philadelphia: Elsevier
Saunders, 2005.
Kingston HM. ABC of Clinical Genetics, 3rd edn. Oxford: Wiley-Blackwell, 2002
Chapter 12
Haematology and Oncology
Michael Capra
CONTENTS
1. Haemoglobin
1.1 Haemoglobin synthesis
1.2 Red cell physiology
1.3 Oxygen-dissociation curve
2. Haemoglobin abnormalities
2.1 Thalassaemia
2.2 Sickle cell disease (SCD)
2.3 Other haemoglobinopathies
3. Blood group antibodies

3.1 ABO system
4. Blood product transfusion

4.1 Acute blood product transfusion reactions
4.2 Massive transfusion reactions
5. Anaemia
5.1 Iron deficiency anaemia
5.2 Aplastic anaemia
5.3 Hereditary haemolytic anaemias
5.4 Haemoglobin defects
5.5 Polycythaemia
6. The white cells: phagocytic cells

6.1 Neutrophils
6.2 Eosinophils
6.3 Basophils
6.4 Monocytes
7. The white cells: lymphocytes

8. Platelets
8.1 Thrombocytopenia
8.2 Immune thrombocytopenic purpura
8.3 Neonatal isoimmune thrombocytopenia
8.4 Functional abnormalities of platelets
9. Blood film
9.1 Approach to a blood film at MRCPCH level
10. Coagulation
10.1 Natural anticoagulants
10.2 Coagulation disorders
11. Bruising
11.1 An approach to bruising in children
12. Malignant pathology

12.1 Leukaemia
12.2 Lymphoma
12.3 Tumour-lysis syndrome
12.4 Tumours of the CNS
12.5 Retinoblastoma
12.6 Neuroblastoma
12.7 Wilms tumour (nephroblastoma)
12.8 Bone tumours
12.9 Soft-tissue sarcomas
12.10 Malignant germ-cell tumours
12.11 Hepatoblastoma
12.12 Langerhans cell histiocytosis
12.13 Haemophagocytic lymphohistiocytosis
12.14 Role of bone marrow transplantation
12.15 Principles of managing malignancy
12.16 Palliative care
12.17 Late effects of cancer treatment
13. Further reading
Haematology and Oncology
1. HAEMOGLOBIN
1.1 Haemoglobin (Hb) synthesis
Erythropoietic activity is regulated by erythropoietin, a hormone secreted by the peritubular complex
of the kidney (90%), the liver and elsewhere (10%). The stimulus to erythropoietin production is the
oxygen tension within the kidney. Mitochondria of the developing erythroblast are the main sites for
the synthesis of haem:
The cofactor vitamin B6 is stimulated by erythropoietin and inhibited by haem
The Fe2+ is supplied by circulating transferrin
Globin chains, comprising a sequence of polypeptides, are synthesized on ribosomes
A tetramer of four globin chains, each with its own haem group attached, is formed to make a
molecule of haemoglobin
Haem synthesis.
1.2 Red cell physiology

The 8-m diameter red cell has three challenges:
To pass through the microcirculation of capillaries (diameters of 3.5 m)
To maintain haemoglobin in the reduced state
To maintain an osmotic equilibrium despite a high concentration of protein (five times that of
plasma)
It achieves this by:
The protein, spectrin, which enables it to have a flexible biconcave disc shape
Generating reducing power in the form of nicotinamide adenine dinucleotide (NADH) from the
EmbdenMeyerhof pathway and NAD phosphate (NADPH or reduced NADP+) from the hexose
monophosphate shunt; this reducing power is vital in preventing oxidation injury to the red cell and
for reducing functionally dead methaemoglobin (oxidized haemoglobin) to functionally active,
reduced haemoglobin (see figure below)
Generating energy in the form of ATP from the EmbdenMeyerhof pathway; this energy is used to
drive the cell membrane Na+/K+ pump to exchange three ions of intracellular Na+ for two ions of
K+ thus maintaining an osmotic equilibrium
Generating 2,3-diphosphoglycerate (2,3-DPG) to reversibly bind with haemoglobin to maintain the
appropriate affinity for oxygen.
The EmbdenMeyerhof and associated pathways.
2,3-DPG, 2,3-diphosphoglycerate; F6-P, fructose 6-phosphate; F1,6-DP, fructose 1,6-diphosphate;

G6-P, glucose 6-phosphate; G6-PD, glucose-6-phosphate dehydrogenase; MetHb, methaemoglobin;
PK, protein kinase.
1.3 Oxygen-dissociation curve
When oxygen is unloaded from a molecule of oxygenated haemoglobin, the chains open up,
allowing 2,3-DPG to enter. This results in the deoxygenated haemoglobin having a low affinity for
oxygen, preventing haemoglobin from stealing the oxygen back from the tissues. This 2,3-DPG-related
affinity for oxygen gives the oxygen-dissociation curve its almost sinusoidal appearance rather than
that of a straight line.
Factors that cause this dissociation curve to shift are summarized in the figure below.
Factors shifting the oxygen-dissociation curve. HbF, fetal haemoglobin; HbS, sickle cell haemoglobin.
Shift of the curve by changes in the blood CO2 is important to enhance both oxygenation of the blood
in the lungs and = the release of oxygen from the blood to the tissues. This is the Bohr effect.
As CO2 diffuses from the capillaries into the alveoli within the lungs, PCO2 is reduced and the pH
increases. Both of these effects cause the curve to shift left and upwards. Therefore the quantity of
oxygen that binds with the haemoglobin becomes considerably increased, so allowing greater oxygen
transport to the tissues. When the blood reaches the capillaries the exact opposite occurs. The CO2
from the tissues diffuses into the blood, decreasing the pH and causing the curve to shift to the right
and downwards, i.e. the curve shifts to the right in the tissues and to the left in the lungs.
2. HAEMOGLOBIN ABNORMALITIES
These result from the synthesis of an abnormal haemoglobin (haemoglobinopathy) or from a
decreased rate of synthesis of normal or -globin chains (thalassaemia). The chain structure is
determined by a pair of autosomal genes. The genes for , and chains are carried on chromosome
16, whereas chromosome 11 carries the chain. Haemoglobinopathy and thalassaemia genes are
allelomorphic (different genes can occupy the same locus on a chromosome) which is the reason
why mixed haemoglobinopathies can occur in one patient, e.g. HbS and thalassaemia may occur in
one patient.
2.1 Thalassaemia
Thalassaemia results from a genetically determined imbalanced production of one of the globin
chains. -, -, - and -globin chains make up normal fetal and adult haemoglobin in the following
combinations:
Fetal Hb:
HbF (2 + 2
Hb Barts 4
Adult Hb:
HbA 2 + 2 (97%)
HbA2 2 + 2 (2.5%)
Haemoglobin types in the different haemoglobinopathies
Clinical management of thalassaemia

Safe blood transfusion programmes with effective iron-chelation therapy have transformed the
outlook for children with thalassaemia.
Red cell transfusions

The aim here is to eliminate the complications of anaemia and ineffective erythropoiesis, which will
allow the child to grow and develop normally. The decision to start on a transfusion programme can
be difficult but generally the recommendation is to start when the haemoglobin concentration is <6.0
g/dl over 3 consecutive months. The desired maintenance haemoglobin level is around 9.5 g/dl, with
care being taken not to increase the iron burden too much.
Chelation treatment
Iron overload is the most important challenge of life-saving transfusions in thalassaemia. Up until the
late 1990s parental deferoxamine (DFO) was the only available chelating agent of choice but, over
the last decade, particularly in the last 5 years, two oral agents, deferiprone (L1) and deferasirox
(DFRA), have been made available. L1 is approved for use in Europe but not in North America.
Unfortunately, due to imperfect comparative data, it remains unclear which agent is the most effective
with the least toxicity. The oral agents are now widely used, with DFO being used predominantly
only in combination.
When to initiate chelation therapy remains unclear but it is recommended that a liver biopsy be
performed after 1 year of a transfusion programme to establish the iron burden. Serum ferritin,
although helpful, is not entirely accurate especially at the high levels seen in such patients.
Curative treatment
Up until recently bone marrow transplantation has been the only curative option but this treatment
option must be carefully balanced against the morbidity (e.g. graft-versus-host disease) and
significant mortality associated with allogeneic transplantation. A recent publication from Italy (see
Section 13) reported a 89.2% 20-year overall survival rate for 115 patients with thalassaemia who
were treated with allogeneic transplantation. Currently there is some renewed optimism in the
possibility of replacement gene therapy for thalassaemia (see Section 13).
2.2 Sickle cell disease (SCD)

It primarily affects people of African, AfricanCaribbean, Middle Eastern, Indian and
Mediterranean descent
In parts of Africa, 30% of the population have sickle cell trait
It is caused by a single-base mutation of adenine to thiamine, resulting in a substitution of valine for
glutamic acid (at the sixth codon) on the -globin chain
HbS is insoluble and forms crystals when exposed to low oxygen tension
The symptoms of anaemia are mild relative to the severity of the anaemia, as HbS shifts the
oxygenhaemoglobin curve to the right (see figure on p. 303)
It presents after the age of 6 months the time at which the production of haemoglobin should have
switched from HbF to HbA
The two predominant major pathophysiological processes are vaso-occlusion with ischaemia
reperfusion injury (crises) and haemolytic anaemia.
Crises may be visceral, aplastic, haemolytic and painful (see below), and are precipitated by
infection, acidosis, dehydration and deoxygenation from whatever cause
Patients are susceptible to infections with pneumococci and Haemophilus and Salmonella spp. due
to possible multiple causes: impaired splenic function, defective complement activation, tissue
ischaemia and micronutrient deficiencies.
General management
Neonatal screening programmes are now available, including in USA and England, facilitating
early access to a comprehensive sickle cell programme including antibiotic (penicillin)
prophylaxis, parental education and early identification of complications.
Hydroxyurea, a well-tolerated oral cytotoxic agent, increases HbF concentrations which is
beneficial to patients with HbS and has proven efficacy in reducing complications of sickle cell
disease. Long-term toxicity is still to be determined.
Blood transfusion plays an important role by correcting anaemia, suppressing HbS synthesis,
decreasing HbS percentages and reducing haemolysis. If rapid decrease in HbS is required (e.g. in
acute neurological complications) an exchange transfusion may be indicated.
Bone marrow transplantation (BMT) is the only know curative treatment but not commonly
performed because the risk of BMT-related morbidity and mortality is high (mortality rate in the
region of 7%).
Gene therapy remains experimental although promising
Specific management
Acute pain secondary to vaso-occlusive crises is the most frequent complication of sickle cell
disease. Opiate analgesia is the mainstay of treatment
Infection risk penicillin prophylaxis and conjugate vaccines against Streptococcus pneumoniae
and Haemophilus influenzae minimize this risk substantially
Neurological complications sickle cell disease is the most common cause of stroke in childhood
due to the underlying vasculopathy. Transcranial Doppler ultrasonography can detect vasculopathy
at an early stage, facilitating preventive management with regular blood transfusions (see STOP
study, see Section 13). Progressive vasculopathy predisposes to moyamoya-like syndrome in young
children whereas acute intracranial haemorrhages are more common over the age of 20 years.
Cognitive deficits may be due to silent brain infarcts
Acute chest syndrome defined as a new pulmonary infiltrate involving at least one lung segment
caused by a combination of infection, fat embolism and vaso-occlusion of pulmonary vasculature.
It is potential fatal and requires acute intervention, including assisted ventilation, blood
transfusion, oxygen, antibiotics, bronchodilators, and possibly dexamethasone and/or
bronchodilators
Aplastic crisis coexisting red cell production reduction in the background of chronic haemolysis,
often associated with parvovirus infection. Treatment is by blood transfusion
2.3 Other haemoglobinopathies

Sickle cell trait
Individuals are usually asymptomatic as long as they are maintained with good oxygenation an
important point during anaesthesia.
HbC disease
Is the result of a substitution of lysine for glutamic acid in the -globin chain at the same point as
the substitution in HbS
Milder clinical course than HbS
Prevalent in West Africa
HbD and HbE disease

HbD is prevalent on the north-west coast of India, whereas HbE is in south-east Asia both
demonstrate mild anaemia only
Sickle cellHbC disease

Typically has a similar clinical picture to that of HbS, although fewer infections and fewer crises
are described
Associated with avascular necrosis of the femoral head and vascular retinal changes
Asplenia
Definition loss of splenic function can be partial (splenic hypofunction) or complete (asplenia)
Causes surgical resection of the spleen, autosplenectomy (due to infarction secondary to
haemoglobinopathy), congenital (e.g. Ivemark [asplenia] syndrome)
Management there are four important management areas:
Penicillin is the antibiotic of choice given twice a day. When to discontinue prophylactic
antibiotics remains controversial. Some centres discontinue at 5 years of age whereas others
continue for life
Appropriate immunization routine immunization should be followed. In addition,
pneumococcal and meningococcal immunization is recommended. For pneumococcal immunization
in children aged <2 years use conjugated heptavalent; in children aged >2 years use 23-valent
conjugated immunization. For meningococcal immunization use polysaccharide quadrivalent
immunization (note that this does not offer protection against Neisseria meningitidis serogroup B)
Aggressive management of suspected infection patients with suspected infection must be
evaluated promptly, appropriate specimens for bacterial culture must be obtained and empirical
intravenous broad-spectrum antibiotics should be commenced
Parent education parents must be educated to seek medical assistance immediately on
suspicion of an infection and must be informed of the potential life-threatening complications of
such infections
3. BLOOD GROUP ANTIBODIES

Approximately 400 red blood cell group antigens have been described, of which the ABO and rhesus
(Rh) groups are of major clinical significance. Kell, Duffy, Kidd and Lutheran groups occasionally
cause reactions, while the remaining groups rarely do.
3.1 ABO system

This consists of three allelic genes A, B and O. Each gene codes for a specific enzyme that will
result in the production of a carbohydrate residue. This residue will attach itself to one of the three
respective lipid and sugar chains H-antigen, A-antigen and B-antigen chains on the red cell
membrane. The O gene is an amorph and therefore does not transform the H antigen.
The A gene encodes for a carbohydrate residue that will attach itself to the end of the A-antigen chain,
thereby blocking the distal glycoprotein antigenic portion. Similarly, the B gene encodes for a
carbohydrate residue that will block the antigenic portion of the chain (see figure on p. 307).
ABO blood groups

A, B, AB and O blood groups
A, B, AB and O blood groups.
4. BLOOD PRODUCT TRANSFUSION

Paediatricians prescribing, and administering, blood product transfusions must be familiar with the
principles of blood product replacement therapy and how to manage adverse transfusion reactions.
Serious or life-threatening acute reactions are rare; however, new symptoms or signs that occur
during a transfusion must be taken seriously because they may be the first warning of a serious
reaction.
4.1 Acute blood product transfusion reactions
Haemolytic reaction (ABO incompatibility)

Antibodies in the recipients plasma are directed against antigens present on donor red cells
Usually most severe in group A blood transfused into a group O recipient
Results in haemolysis, disseminated intravascular coagulation, renal failure and possible
complement-mediated cardiovascular collapse
ABO incompatibility following an administrative or clerical error is the most likely cause
Bacterially contaminated infusion

Causes severe acute reaction with rapid onset of hypotension, rigors and circulatory collapse
Transfusion-related acute lung injury (TRALI)
Acute onset of breathlessness, non-productive cough

Chest X-ray demonstrates bilateral infiltrates
Clinical characteristics are in keeping with acute respiratory distress syndrome, so treat as such
Caused by donor antibodies reacting with recipients leukocytes
Non-haemolytic febrile reaction

Results from the production of cytokines by donor leukocytes in the transfused blood (preformed at
the time of the infusion) or from an interaction between leukocyte and anti-leukocyte antibodies in
the recipient
Usually seen after platelet transfusions but may occur with red cell transfusions
Symptom complex includes: fever, chills and rigors
Anaphylactic reaction
A rare but life-threatening complication
Increased risk with transfusion containing large volumes of plasma, e.g. fresh frozen plasma or
platelets
Clinical presentation hypotension, bronchospasm, periorbital and laryngeal oedema, vomiting,
erythema, urticaria, conjunctivitis, dyspnoea, chest/abdominal pain
Occurs in patients presensitized to allergen-producing immunoglobulin E (IgE) antibodies, less
commonly with IgG or IgA antibodies
4.2 Massive transfusion reactions

A massive transfusion, defined as replacement of more than half of the patients blood volume at one
time or the replacement of the entire blood volume within a 24-hour period, may be complicated by:
Coagulopathy (secondary to a relative thrombocytopenia and platelet dysfunction)
Volume overload
Hypothermia
Hypokalaemia (the potassium-depleted donors red cells have the ability to absorb serum
potassium)
Hypocalcaemia (secondary to citrate toxicity citrate is used as an anticoagulant to prevent
coagulation of stored blood)
Details of blood products for transfusion
RBC, red blood cells; U, unit; DIC, disseminated intravascular coagulopathy; vWD, von Willebrand
disease; F VIII, factor VIII; F XIII, factor XIII.
5. ANAEMIA
Anaemia results when the oxygen-carrying capacity of the blood is decreased. This is generally
caused by having fewer than the normal number of red blood cells (either decreased production or
increased destruction of red cells) or less than the normal quantity of haemoglobin in the blood. This
definition helps us to formulate the following simple working classification of anaemia, thereby
aiding the necessary work up of such patients:
decreased substrate
abnormal production of red cells
abnormal destruction of red cells
Working classification of anaemia.
5.1 Iron deficiency anaemia

The major part of body iron is in the form of haem essential for the delivery of oxygen to the tissues.
Iron can exist in both the reduced (electron-gain) and the oxidized (electron-loss) state, the vital
property for electron transfer reactions. A useful mnemonic is LEO loss of an electron is oxidation.
As iron is a major constituent of many important respiratory chain enzymes it is therefore directly
involved in the production of cellular energy in the form of ATP. Deficiency of iron results in
widespread non-haematological effects, e.g. reduced central nervous system (CNS) higher functions,
diminished T-cell function and cell-mediated immunity, as well as diminished muscle performance.
Iron deficiency anaemia (Hb <11 g/dl) occurs in 1030% of preschool children living in inner
cities in the UK
Causes of iron deficiency
Dietary insufficiency, e.g. unfortified milk

Increased physiological requirement infancy/adolescence
Blood loss gastrointestinal
Malabsorption coeliac disease
The most common reason in infancy is the early weaning to cows milk. Giving an infant ironsupplemented formula milk instead of cows milk not only prevents anaemia but reduces the decline
in developmental performance observed in those given only cows milk.
Causes of a microcytic anaemia

Definition: mean corpuscular (or cell) volume (MCV) <72 fl in children <2 years or <78 fl in older
children (where fl = femtolitres).
Causes include:
Iron deficiency
Anaemia of chronic disorders infection, malignancy
Disorders of globin synthesis thalassaemia trait, homozygous haemoglobinopathies
Lead poisoning
Sideroblastic anaemia
5.2 Aplastic anaemia

Classification of aplastic anaemia
Constitutional (30%):
Fanconi anaemia
Familial marrow aplasia in association with hand anomalies, deafness, ataxia, immune
deficiencies
Dyskeratosis congenita ectodermal dysplasia, X linked
ShwachmanDiamond syndrome pancreatic insufficiency
Amegakaryocytic thrombocytopenia
Reticular dysgenesis
Acquired:
Idiopathic majority of cases
Drugs, e.g. acetazolamide, chloramphenicol
Infections, e.g. EpsteinBarr virus (EBV), viral hepatitis, parvovirus
Toxins, e.g. glues, dichlorodiphenyltrichloroethane (DDT)
Paroxysmal nocturnal haemoglobinuria
Steroids and/or anti-thymocyte globulin has some beneficial effects in a few cases. The prognosis is
invariably poor in severe cases, with bone marrow transplantation the only viable treatment option
available.
5.3 Hereditary haemolytic anaemias

For an understanding of hereditary haemolytic anaemias, one has to consider the membrane, red cell
enzyme and haemoglobin defects involved.
Membrane defects
Hereditary spherocytosis
The most common hereditary haemolytic anaemia in north Europeans
Autosomal dominant
Complex defect but involves the spectrin structural protein
Diagnosis made on appearances of blood film the presence of spherocytes identified by

demonstrating that the cells are osmotically active using the osmotic fragility test
The serum bilirubin and lactate dehydrogenase (LDH) may be elevated
Treatment, by splenectomy, is reserved for severe cases
Hereditary elliptocytosis
Usually autosomal dominant
Most cases are asymptomatic
Red cell enzyme defects

Although a deficiency of any enzyme involved in the EmbdenMeyerhof pathway may cause
haemolysis, the two most commonly occurring deficiencies are as follows.
Glucose-6-phosphate dehydrogenase (G6PD) deficiency
G6PD helps to maintain glutathione in a reduced state, thus protecting the red cell from oxidative
injury
It is X linked
Different mutations of the gene are all found in different racial groups black Africans: 10%
incidence; Mediterranean races: up to 35% incidence
Neonatal jaundice may be the first sign
Precipitating causes include infections, acidosis, favism, drugs
Diagnose by assaying G6PD enzyme
Drugs to avoid in G6PD deficiency are:
Analgesics/antipyretics: aspirin, probenecid

Antimalarials: chloroquine
Sulphonamides: dapsone
Antibiotics: co-trimoxazole, nitrofurantoin, nalidixic acid, chloramphenicol
Cardiovascular drugs: procainamide
Miscellaneous: ascorbic acid, methyldopa, urate oxidase
Pyruvate kinase (PK) deficiency

Deficiency of PK blocks the EmbdenMeyerhof pathway see figure on p. 302)
PK deficiency causes a rise in 2,3-DPG, which causes a shift to the right on the oxygen-dissociation
curve and consequent improvement in oxygen availability (see figure on p. 303). Patients can
therefore tolerate very low Hb levels
It is autosomal recessive
Infections, especially parvovirus, can produce dramatic haemolysis
Splenectomy may be beneficial
5.4 Haemoglobin defects

See also Section 2 Haemoglobin abnormalities.
Autoimmune haemolytic anaemia (AIHA)

Coombs test (anti-human globulin) positive (see opposite)
Uncommon in childhood, but if present is usually the result of an intercurrent infection
predominantly viral but occasionally mycoplasmal in origin
In the older child, AIHA may be a manifestation of a multisystem disease, e.g. systemic lupus
erythematosus (SLE)
Causes include drugs (high-dose penicillin), infections (non-specific viral, measles, varicella,
EBV), multisystem disease (SLE, rheumatoid arthritis) and lymphoproliferative disease (Hodgkin
lymphoma)
Can be divided into warm and cold types depending on the temperature at which the causative cellbound antibody is best detected:
Warm (usually IgG) multisystem disease
Cold (usually IgM) infective causes
Microangiopathic haemolytic anaemia

A rapidly developing haemolytic anaemia with fragmented red cells and thrombocytopenia
Occurs in haemolyticuraemic syndrome and thrombotic thrombocytopenic purpura
Hypersplenism
The red cell lifespan is decreased by sequestration in an enlarged spleen for whatever cause
Infections
Malaria
Septicaemia
Miscellaneous
Burns
Poisoning
Hyperphosphataemia
The Coombs (antiglobulin) test

Anti-human globulin (AHG) is produced in many animal species after the injection of human globulin.
When AHG is added to human red cells that have been coated (sensitized) by immunoglobulin or
complement components, agglutination of the red cells will occur, indicating a positive test.
There are two anti-globulin tests.
Direct antiglobulin test
This is used to detect antibody or complement on the red cell surface where sensitization has
occurred in vivo.
A positive test occurs in:
Haemolytic disease of the newborn

Autoimmune haemolytic anaemia
Drug-induced immune haemolytic anaemia
Haemolytic transfusion reactions
Indirect antiglobulin test

This is used to detect antibodies that have coated the red cells in vitro. It is a two-stage procedure.
The first stage involves incubation of test red cells with serum. The second stage involves washing
these red cells with saline to remove free globulins. AHG is then added to the washed red cells.
Agglutination implies that the original serum contained antibody, which has coated the red cells in
vitro.
This indirect antiglobulin test is used in the following circumstances:
Routine cross-matching procedures to detect antibodies in the patients serum that will be
directed towards the donor red cells
Detecting atypical blood group antibodies in serum during screening procedures
Detecting blood group antibodies in a pregnant woman
Detecting antibodies in serum in autoimmune haemolytic anaemia
5.5 Polycythaemia
Defined as an increase in the absolute quantity of red cells or total RBC volume when haematocrit is
65%. It is classified into:
Primary (rare in childhood) due to factors intrinsic to the red cell precursor, predominantly
encompassing specific mutations in the erythrocyte receptor: primary familial and congenital
polycythaemia, polycythaemia vera (part of the myeloproliferative syndrome)
Secondary due to factors outside of the red cell
Response to tissue hypoxia with increased erythropoietin production:
Heart disease congenital cyanotic cardiac defects, e.g. tetralogy of Fallot
Lung disease
Increased altitude
High-oxygen affinity haemoglobinopathies, e.g. congenital methaemoglobinaemia

Neonatal period polycythaemia is common within the first 612 h after birth, usually
resolving by 24 h. It is more common in small- or large-for-gestational age infants or when there
has been delayed clamping of the cord
Ectopic production of erythropoietin
Renal disease, e.g. polycystic kidneys, Wilms tumour
Liver disease, e.g. hepatocellular carcinoma
Polycythaemia causes hyperviscosity which in turn may lead to diminished blood flow to organs with
CNS, cardiopulmonary, GI and renal systems most at risk. Metabolic disturbances, predominantly of
glucose and calcium, may be seen and coagulation may be affected. Treatment includes intravenous
fluids (in neonatal period, partial exchange transfusion may be of benefit) and monitoring of glucose
and calcium levels.
6. THE WHITE CELLS: PHAGOCYTIC CELLS
White cells or leukocytes can broadly be classified into groups.
The primary function of the white cells, together with immunoglobulins and complement, is to protect
the body against infection.
Granulocytes and monocytes comprise the phagocytic (myeloid) group of white cells. They
originate from a common precursor cell. It takes between 6 and 10 days for the precursor cell to
undergo mitosis and maturation within the bone marrow. The immature neutrophil remains in the
bone marrow as a reserve pool until required in peripheral blood. Bone marrow normally contains
more myeloid than erythroid precursors in a ratio of up to 12:1 and between 10 and 15 times more
the number of granulocytes than in peripheral blood. Granulocytes spend only a matter of hours within
the bloodstream before going into tissues. There are two pools of cells within the bloodstream the
circulating pool (what is included in the blood count) and the marginating pool (not included in the
blood count as these cells adhere to the endothelium).
Formation, proliferation, differentiation and function
Growth factors are produced in stromal cells (endothelial cells, fibroblasts and macrophages) and
from T lymphocytes. Under the influence of specific growth factors stem-cell factor, interleukin-1
(IL-1), IL-3 and IL-6 a haematopoietic stem cell is produced. Granulocytemonocyte colonystimulating factor (GM-CSF) increases the commitment of this stem cell to differentiate into a
phagocyte. Further differentiating and proliferating stimulus is required from G-CSF for neutrophil
production, from IL-5 for eosinophil production and from M-CSF for monocyte production.
In addition, growth factors affect the function of the mature myeloid cells:
Optimizing phagocytosis, superoxide generation and cytotoxicity in the neutrophil

Optimizing phagocytosis, cytotoxicity and production of other cytokines in the monocyte
Increasing membrane integrity and surface-adhesion properties of target cells
GM-CSF can immobilize phagocytes at local sites of inflammation thereby causing accumulation at
these sites
6.1 Neutrophils
Neutropenia
Neutropenia is defined as a reduction of the absolute neutrophil count below the normal for age.
Neutropenia can be divided according to the severity, indicating the likely clinical consequences:
Mild: 1.01.5 (109/l) usually no problem
Moderate: 0.51.0 (109/l) clinical problems more common
Severe: <0.5 (109/l) potentially severe and life threatening, especially if prolonged beyond a few
days
Bacterial infections such as cellulitis, superficial and deep abscess formation, pneumonia and
septicaemia are the most common problems associated with isolated neutropenia, whereas fungal,
viral and parasitic infections are relatively uncommon.
The typical inflammatory response may be greatly modified with poor localization of infection,
resulting in a greater tendency for infection to disseminate.
The normal range of white blood cell (WBC) and neutrophil counts for children at different ages
Although challenging in some cases, it is important to identify the cause of the neutropenia, see
following box, especially for the two following reasons:
The clinical significance of the neutropenia will depend upon whether or not there is underlying
marrow reserve
Identifying the cause can help in predicting the duration of the neutropenia and therefore effect
subsequent management
Marrow suppression (decreased production) will usually cause a severe neutropenia. The majority of
children treated with chemotherapy will be in this group. Increased consumption or sequestration will
cause mild to moderate neutropenia.
Causes of neutropenia
Decreased marrow production
Congenital
Acquired
Kostmann syndrome
Reticular dysgenesis
Aplastic anaemia
Fanconi anaemia
Drug suppression
Cyclical neutropenia
Vitamin B12, folate,
copper deficiency
Chronic benign
neutropenia
Myelofibrosis
Osteopetrosis
Export
Metabolic conditions:
Propionic, isovaleric and methylmalonic acidaemia
Hyperglycinaemia
Consumption
Autoimmune antibodies
Neonatal isoimmune haemolytic disease
Infection/endotoxaemia
Sequestration
Immune complexes
Viral
SLE
Felty syndrome
Sjgren syndrome
Hypersplenism
Associated with immune deficiency

X-linked hypogammaglobulinaemia
Selective immunoglobulin deficiency states
Associated with phenotypically abnormal syndromes

Shwachman syndrome
Cartilage hair hypoplasia
Dyskeratosis congenita
The risk of infection is directly proportional to the duration of neutropenia. If the duration of
neutropenia is predicted to be prolonged, preventive measures against possible future infective
episodes may be considered, e.g.:
Good mouth care and dental hygiene

Prophylaxis against Pneumocystis spp. (co-trimoxazole)
Prophylaxis against fungal infections (fluconazole)
Prophylaxis against recurrent herpes simplex virus infection (aciclovir)
Regular throat and rectal swabs looking for Gram-negative colonization
Dietary avoidance of unpasteurized milk and salads
Avoidance of inhaling building/construction dust because of the risk of acquiring aspergillus
infection
Neutrophilia
The neutrophil count can be increased in one of the following three ways:
Increased production of neutrophils as a result of increased progenitor cell proliferation or an
increased frequency of cell division of committed neutrophil precursors
Prolonged neutrophil survival within the plasma as a result of impaired transit into tissues
Increased mobilization of neutrophils from the marginating pools or bone marrow
Acute neutrophilia
Neutrophils can be mobilized very quickly, within 20 minutes of being triggered, from the marginating
pool. A stress response (acute bacterial infection, stress, exercise, seizures and some toxic agents)
releases adrenaline (epinephrine) from endothelial cells, which decreases neutrophil adhesion. This
results in the neutrophils adhering to the endothelial lining of the vasculature (the marginating pool)
being dragged into the circulation.
The bone marrow storage pool responds somewhat slower (a few hours) in delivering neutrophils in
response to endotoxins, released from microorganisms, or complement.
Corticosteroids may inhibit the passage of neutrophils into tissues, thereby increasing the circulating
number.
Chronic neutrophilia
The mechanism in chronic neutrophilia is usually an increased marrow myeloid progenitor-cell
proliferation. The majority of reactions last a few days or weeks. Infections and chronic inflammatory
conditions (e.g. juvenile chronic arthritis, Kawasaki disease) are the predominant stimulators of this
reaction. Less common causes include malignancy, haemolysis or chronic blood loss, burns, uraemia
and postoperative states.
Splenectomy or hyposplenism may result in a reduced removal of increased neutrophils from the
circulation.
6.2 Eosinophils
Eosinophils enter inflammatory exudates and have a special role in allergic responses, in defence
against parasites and in removal of fibrin formed during inflammation. Eosinophils are
proportionately reduced in number during the neonatal period. The causes of eosinophilia are
extensive but some of the major causes are:
Allergic diseases, e.g. asthma, hay fever, urticaria

Parasitic diseases, e.g. worm infestation
Recovery from infection
Certain skin diseases, e.g. psoriasis, dermatitis herpetiformis
Pulmonary eosinophilia
Drug sensitivity
Hodgkin disease
6.3 Basophils
Basophils, the least common of the granulocytes, are seldom seen in normal peripheral blood. In
tissues they become mast cells. They have attachment sites on their cell membrane for IgE which,
when attaching, will cause degranulation to occur resulting in the release of histamine.
6.4 Monocytes
Monocytes, the largest of the leukocytes, spend a short time in the bone marrow and an even shorter
time in the circulation (2040 hours) before entering tissues where the final maturation to a phagocyte
takes place. A mature phagocyte has a lifespan of months to years.
7. THE WHITE CELLS: LYMPHOCYTES

Lymphocytes, divided into T lymphocytes and B lymphocytes, are the immunologically active cells
which help the phagocytes to defend the body from an infective or other foreign invasion by aiding
specificity.
Formation
The bone marrow and thymus are the two primary sites in which lymphocytes are produced, not by
specific antigens but by non-specific cytokines. Thereafter they undergo specific transformation in
secondary or reactive lymphoid tissue the lymph nodes, spleen, the circulating lymphocytes and the
specialized lymphoid tissue found in the respiratory and gastrointestinal tracts.
Diagrammatic illustration of immunocyte production.
T cells are produced in the bone marrow and undergo transformation in the thymus, whereas the exact
location where the B lymphocytes are transformed remains unknown.
In peripheral blood 80% of the lymphocytes are T cells, whereas only 20% are B cells. T cells are
responsible for cell-mediated immunity (against intracellular organisms and transplanted organs). B
cells and plasma cells (differentiated B cells) are responsible for humoral immunity by producing
immunoglobulins.
8. PLATELETS
Megakaryocytes, produced in the bone marrow, develop into platelets by a unique process of
cytoplasm shedding. As the megakaryocyte matures the cytoplasm becomes more granular; these
granules develop into platelets and are released into the circulation as the cytoplasm is shed.
Platelet production is under the control of growth factors, particularly thrombopoietin and IL-6,
whereas GM-CSF and IL-3 have megakarocyte CSF (MG-CSF) properties.
The main function of platelets is the formation of mechanical plugs during the normal haemostatic
response to vascular injury.
8.1 Thrombocytopenia
A useful classification of thrombocytopenia is listed in the box.
Thrombocytopenia causes
Impaired production
Congenital
Thrombocytopenia and absent radius (TAR) syndrome
Fanconi anaemia
Acquired:
Aplastic anaemia
Bone marrow replacement, for example infiltration by malignant disease
Decreased platelet survival

Immune mediated:
Immune (idiopathic) thrombocytopenic purpura (ITP)
Neonatal isoimmune thrombocytopenia
Alloimmune neonatal thrombocytopenia
Neonatal ITP
Infections
Drug induced
Autoimmune disorders (e.g. SLE)
Malignancy
Non-immune mediated:
Disseminated intravascular coagulation
Thrombotic thrombocytopenic purpura (TTP)
KasabachMerritt syndrome
Cyanotic congenital heart disease
Liver disease
Drug-induced
Miscellaneous
8.2 Immune thrombocytopenic purpura

Immune thrombocytopenic purpura is a generic term used to describe an immune-mediated
thrombocytopenia that is not associated with drugs or other evidence of disease. It may follow a viral
infection or have no antecedent illness. It is caused by an inappropriate response of the immune
system, mediated by an IgG autoantibody, although the exact mechanism remains poorly understood.
ITP does not have a predictable course, although it usually follows a benign self-limiting course.
Approximately 20% of cases, in older girls predominantly, fail to remit over 6 months (chronic ITP).
Investigations
Bone marrow examination is not indicated in a typical case (blood counts are normal apart from the
platelet count, blood smear confirms no abnormal cells and no splenomegaly is present). However, if
corticosteroids are to be used for treatment it is recommended to perform a bone marrow to confirm
that there is no underlying acute leukaemia because corticosteroids are lympholytic and therefore may
delay or mask this important diagnosis.
Management
No data exist to suggest the treatment of acute ITP alters the course of the illness
Written information about ITP, sensible advice (avoidance of contact sports, what to do in the event
of an accident, etc.) and a contact person to call are usually sufficient
Treatment to raise the platelet count is not always required as the few remaining platelets, even if
profoundly low in number (<10 109/l), function more efficiently due to an increased platelet
volume (bigger platelets). The risk of serious bleeding from ITP, compared with that from
thrombocytopenia related to marrow failure syndromes, is low
Patients with ITP may bleed from any site particularly when the platelet counts is <10 109/l. The
risk of severe bleeding is very low 0.6% of patients with a platelet count <20 109/l, with the
risk of intracranial haemorrhage (ICH) in the region of 0.10.2%. Patients who have ITP and a
headache warrant a CT brain scan to exclude ICH. Patients with mucosal bleeding, overt petechiae
and ecchymoses should be considered at high risk of bleeding even if platelet counts are >20
109/l
Treatment includes the following modalities.
Intravenous immunoglobulin
Intravenous immunoglobulin (IVIG) is the treatment of choice in severe haemorrhage because it raises
the platelet count the fastest usually within 48 hours. The most practical and effective administration
of IVIG is a single dose of 0.8 g/kg, although side effects are common at this dose. Traditionally, 0.4
g/kg per day has been given over 5 days.
Side effects with IVIG are common and, as IVIG is a pooled blood product, a risk of viral
transmission does exist.
Steroids
Given at a dose of 12 mg/kg daily for up to 2 weeks. There is evidence that a higher dose of 4 mg/kg
for 4 days may raise the platelet count as quickly as IVIG.
Anti-D
This has been shown to be effective in children who are Rh positive. It is a rapid single injection,
although it may cause significant haemolysis.
Splenectomy
Rarely required and is only indicated in a patient with chronic ITP who has significant bleeding
unresponsive to medical treatment. The failure rate after splenectomy is at least 25%.
Transfusions
Platelet transfusions are generally not indicated in ITP because it is a consumptive disorder.
Cost of treatment
IVIG is the most expensive, approximately 5550 for a 40-kg child for a total dose of 2 g/kg
compared with 1900 for anti-D (75 g/kg) and 3/day for steroids.
Other agents
In addition to the above, -aminocaproic acid may be useful in the uncommon event of a patient with
recurrent epistaxis, menstrual or gastrointestinal bleeding. Vincristine, cyclophosphamide and
ciclosporin have all been used with varying degrees of success. The combination of
cyclophosphamide and rituximab (an anti-CD2O antibody) is currently demonstrating promising
results.
Neonatal isoimmune thrombocytopenia
Babies may be born thrombocytopenic as a result of the transplacental passage of maternal
antiplatelet antibodies. This can occur in two ways.
Alloimmune neonatal thrombocytopenia (ANT)
Maternal antibodies are produced as a result of direct sensitization to fetal platelets (analogous to
haemolytic disease of the newborn)
Nineteen human platelet alloantigen (HPA) systems have been documented, the most important one
being HPA-1a, causing 85% of ANT cases. Only 3% of the population do not express HPA-1a, so,
if a mother does not express HPA-1a, the chances of her partner expressing HPA-1a is high
resulting in an HPA-1a-positive fetus. Only 6% of such mothers will become sensitized, and then
not all sensitized mothers will produce a thrombocytopenic baby

Antibodies against HPA-1a are IgG and can therefore cross the placenta, bind to fetal platelets and
decrease their survival time
Not only is it possible but it is common for ANT to occur in the first born
The diagnosis of ANT is suspected when a low platelet count is demonstrated in an otherwise
healthy term neonate with a normal clotting screen
Treatment is in the form of an urgent platelet transfusion if severe (platelet count <20 109/l)
because the risk of an intracerebral bleed is high in the first few days of life. IVIG may play a role
in elevating platelet count too, although there is no convincing evidence for the use of
corticosteroids
Treatment of the fetus with periumbilical transfusions of immunologically compatible platelets
(maternal platelets can be used) or maternal infusions of IgG and/or corticosteroids is possible
but not without significant risks
Genetic counselling, identification of the paternal genotype (heterozygous for HPA-1 results in a
50% chance of a positive genotype fetus) and close liaison of the haematologist, obstetrician and
neonatologist are essential.
8.3 Neonatal isoimmune thrombocytopenia

Occurs in babies born to mothers with active or previous ITP
Clinically identical presentation to ANT but treatment is different, in that maternal platelets cannot
be used because they would be consumed
Maternal steroid therapy before delivery may improve the fetal platelet count
Drug-induced thrombocytopenia
An immune thrombocytopenia may occur with the following commonly prescribed drugs:
Sodium valproate
Phenytoin
Carbamazepine
Co-trimoxazole
Rifampicin
Heparin (non-immune mechanisms also possible)
8.4 Functional abnormalities of platelets

Before classifying these abnormalities it is important to understand the normal function of platelets.
To achieve haemostasis, platelets undergo the following reactions of adhesion, secretion or release
reaction, aggregation and procoagulation.
Adhesion
Adhesion of platelets to the subendothelial lining requires interactions between platelet membrane
glycoproteins, elements of the vessel wall (e.g. collagen) and adhesive proteins such as von
Willebrand factor (vWF) and fibronectin.
Release reaction
Collagen exposure results in the release or secretion of the contents of platelet granules: fibrinogen,
serotonin, ADP, lysosomal enzymes, heparin-neutralizing factor. The cell membrane releases an
arachidonate derivative that transforms into thromboxane A2 a stimulus for aggregation as well as
being a powerful vasoconstrictor.
Production of prostacyclin and thromboxane.
Aggregation
The contents of the platelet granules, specifically ADP and thromboxane A2, cause additional
platelets to aggregate at the site of the injury.
Function of prostacyclin and thromboxane.
Platelet procoagulation activity

After secretion and aggregation have taken place a phospholipid (platelet factor 3) becomes exposed
on the platelet membrane, thereby making itself available for its surface to be used as a template for
two important coagulation protein reactions the conversion of factor X to Xa and prothrombin to
thrombin. These reactions are Ca2+ dependent.
Procoagulant activity.
Functional platelet abnormalities classification
Congenital
Defects of platelet membrane
Glanzmann thrombasthenia: rare, autosomal recessive, failure to aggregate, normal platelet count
and morphology
BernardSoulier syndrome: rare, autosomal recessive, failure of adhesion, no receptor to bind to
vWF, giant platelets, moderate platelet count reduction
Deficiency of storage granules
Defects of thromboxane deficiency
For example, thromboxane synthetase deficiency cyclooxygenase deficiency
Acquired
Renal failure
Liver failure
Myeloproliferative disorders
Acute leukaemia, especially myeloid
Chronic hypoglycaemia
Drugs
Aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), penicillin, cephalosporin, sodium
valproate
Investigations
A prolonged bleeding time and normal or moderately reduced platelet count are the characteristic
hallmarks of a congenital/hereditary platelet disorder (or von Willebrand disease)
Platelet size followed by tests of aggregation and secretion in response to ADP, collagen,
arachidonate and ristocetin will be necessary
9. BLOOD FILM
9.1 Approach to a blood film at MRCPCH level
Is the pathology in the red or white blood cell?
This is the first and most vital question that you need to ask yourself when presented with a blood
film to interpret. Apart from the accompanying history being important in helping you to answer this
question, the other clue will be the number of white cells seen. If there is an abundance of white cells
the likelihood that the pathology will be in the white cells is very high, with acute lymphoblastic
leukaemia being top of your differential diagnosis. If only an occasional white cell is seen then red
cell pathology is likely. Platelet pathology will be unlikely at MRCPCH level the only real
possibility is one of giant platelets (same size as a red cell, or bigger) in BernardSoulier syndrome.
Red cell pathology?

Once you have decided on red cell pathology then look at the following parameters.
Shape
Sickle-shaped cells, as in sickle cell disease
Fragments of red cells (e.g. helmet cells, etc.) indicative of microangiopathic haemolysis such as in
the haemolyticuraemic syndrome
All different shapes, i.e. poikilocytosis as in thalassaemia, sickle cell disease, iron deficiency
anaemia
Size
Small cells or microcytosis in iron deficiency anaemia
Large cells or macrocytosis in vitamin B12 and/or folate-deficient anaemia
Different sizes: anisocytosis (haemoglobinopathies, anaemias)
Amount of central pallor in red cell
No central pallor: spherocytosis (e.g. hereditary spherocytosis, haemolytic conditions, burns)
Large central pallor: hypochromic anaemia
Halo central pallor: target cells (haemoglobinopathies, hyposplenism)
Red cell inclusions
Malaria: most commonly Plasmodium falciparum, seen as a signet-ring inclusion
HowellJolly bodies: remnants of nuclear fragments, seen in hyposplenism
Heinz bodies: denatured haemoglobin, resulting from oxidant stress (e.g. G6PD) or haemolysis; can
be seen only with a special stain, so if normal staining was used then it is most likely a Howell
Jolly body
Basophilic stippling: multiple small inclusions in a red cell, e.g. lead poisoning
White cell pathology?

The abundance of white cells is most likely to be leukaemia at the MRCPCH level. A lymphoblast
cell is recognized by its size (large), with a large nucleus taking up nearly the entire cell with only a
rim of cytoplasm remaining (in contrast, a mature neutrophil has a multilobed small nucleus). The
morphological differentiation between acute lymphoblastic leukaemia (ALL) and acute myeloid
leukaemia (AML) is not realistic at this level, but remember the relative incidence of each, 4:1,
respectively.
10. COAGULATION
A representation of the coagulation cascades is shown below. It consists of an extrinsic pathway
(tissue thromboplastin is the initiator) and the intrinsic pathway (what happens in the blood when it
clots away from the body). These two pathways share a common final pathway resulting in the
production of a fibrin clot.
Representation of the coagulation cascades.
The system can be divided into boxes, each box representing one of the following three basic
screening tests of coagulation:
Prothrombin time (PT) measures the extrinsic system and common pathway
Activated partial thromboplastin time (APTT) measures the intrinsic system and common
pathway
Thrombin time (TT) measures the final part of the common pathway, it is prolonged by the lack of
fibrinogen and by inhibitors of this conversion, e.g. heparin and fibrin degradation products
10.1 Natural anticoagulants

It is important that thrombin is limited to the site of injury. This is achieved by circulating inhibitors
of coagulation:
Antithrombin III the most potent inhibitor, heparin potentiates its effect markedly
Protein C inhibits factors Va and VIIIa and promotes fibrinolysis
The action of protein C is enhanced by protein S
10.2 Coagulation disorders

Haemophilia A (factor VIII deficiency or absence)
Levels of factor VIII in carriers are variable because of random inactivation of the X chromosome
(lyonization). As a result, DNA probes are now recommended to detect carrier status
Prolonged APTT and factor VIII clotting assay reduced
Bleeding time and prothrombin times are normal
Vasopressin (DDAVP) may be useful in releasing endogenous factor VIII from its stores in mild
haemophilia. Tranexamic acid, by inhibiting fibrinolysis, may be useful
Haemophilia B (factor IX deficiency or absence), Christmas disease

Exactly the same as above, except factor IX is involved rather than factor VIII
Incidence is one-fifth that of haemophilia A
Von Willebrand disease

Von Willebrand disease (vWD) is a more complicated entity compared with haemophilia A or B and
is generally poorly described hence it is often overlooked in clinical practice. It therefore deserves
an in-depth explanation.
Von Willebrand factor is an adhesive glycoprotein encoded by a gene on chromosome 12. It is
produced by endothelial cells and by platelets; vWF has two main functions:
To stabilize and protect circulating factor VIII from proteolytic enzymes
To mediate platelet adhesion
vWD will therefore result when the synthesis of vWF is reduced or when abnormal vWF is produced.
The clinical presentation of vWD will include the following:
Mucous membrane bleeding
Excess bleeding following surgical/dental procedures
Easy bruising
Three types (at least) have been described.
Type 1 vWD
Most common, accounts for at least 70% of vWD
Due to a partial deficiency of vWF
Autosomal dominant
Type 2 vWD
Due to abnormal function of vWF
Type 3 vWD
Due to the complete absence of vWF
Can often be mistaken for haemophilia A because factor VIII levels will be low as there is no vWF to
protect factor VIII from proteolysis. Laboratory results are important in distinguishing the types of
vWD and in the differentiation from haemophilia. In vWD type 1 the following results will be
expected:
Platelet count
Bleeding time
Factor VIII
vWF
Ristocetin cofactor activity
N
N/
Ristocetin, an antibiotic, is now confined to laboratory-only use after it was documented to cause
significant thrombocytopenia. Ristocetin, when added to a patients plasma, will bind vWF and
platelets together causing platelet aggregation (hence the clinical thrombocytopenia). In the absence
of vWF, no platelet aggregation will be seen (vWF type 3). In the presence of decreased vWF,
diminished aggregation will ensue (vWD type 1). Hence, when faced with the clinical picture of
haemophilia A (bruising, normal platelet count, slightly increased bleeding time and a decreased
factor VIII), the ristocetin cofactor test will be able to differentiate between vWD (decreased) and
haemophilia A (normal).
Vitamin K deficiency bleeding (VKDB) of early infancy

Previously termed haemorrhagic disease of the newborn.
Classified into three categories depending on time of presentation:
Early within first 24 h of delivery (usually associated with maternal drugs interfering with
vitamin K metabolism, e.g. warfarin, anticonvulsants
Classic between 1 and 7 days (mainly idiopathic or in breastfed babies)
Late day 8 onwards (usually peaks between 3 and 8 weeks), and can be idiopathic or
secondary (e.g. malabsorption, cholestasis, antibiotic therapy, diarrhoea, breastfeeding)
Bleeding can be from any site
Vitamin K-dependent factors (factor II, VII, IX, X) are low at birth and fall further in breastfed
infants in the first few days of life
Other factors associated with this deficiency include:
Liver cell immaturity
Lack of gut bacterial synthesis of the vitamin K
Low quantities in breast milk (standard formula feeds contain 50 times the concentration of
vitamin K compared with breast milk)

PT is prolonged, APTT may be prolonged whereas platelet count and fibrinogen levels are normal.
PT becomes prolonged only when prothrombin levels drop below about 50% of normal, so PT
will detect only overt and not subclinical cases of VKDB. When vitamin K supply is limited,
vitamin K-dependent coagulation factors produced will be defective (undercarboxylated). Such
undercarboxylated factors (also known as proteins induced by vitamin K absence or PIVKA) can
now be assayed, with the most readily available one being PIVKA-II. Now for the first time,
subclinical vitamin K deficiency can be detected
Treatment is with vitamin K1 (phylloquinone) single intravenous dose (250300 g/kg). If no
intravenous access is possible, an intramuscular route must not be used because of possible
bleeding complications; however, the subcutaneous route can be used
Vitamin K restores the production of coagulation factors rapidly, with clinical effect seen within 20
min
There is no international consensus on the best route of administration of prophylactic vitamin K to
newborn babies. Many countries still utilize the gold standard of intramuscular administration
whereas other countries give oral vitamin K
There is no convincing evidence associating vitamin K administration and the risk of subsequent
cancer, despite a UK-based possible association reported in the early 1990s. The American
Academy of Pediatrics claims that there is no such evidence
11. BRUISING
11.1 An approach to easy bruising in children
Easy bruising in childhood is a common sign but poses significant challenge to the paediatrician
regarding the level of investigation required, if any, and the responsibility of considering the
possibility of non-accidental injury. Here is a simple approach to easy bruising:
An approach to easy bruising. (Modified from Voray A, Makris M. Arch Dis Child 2001;84:488491 [see Section 13].)
12. MALIGNANT PATHOLOGY

There are 1200 new cases of malignancy diagnosed each year in the UK in children aged <15 years
(an incidence of 1 in 600 children aged <15 years)
The relative incidence rates for the different tumour types are illustrated below
Leukaemia, together with lymphoma, accounts for almost 50% of all cases
Brain and spinal cord tumours are the most commonly occurring solid tumours
Overall, childhood cancer is about a third more common in boys than in girls
Environmental factors predisposing to cancer

Ultraviolet radiation skin cancer, particularly malignant melanoma
Ionizing radiation:
Preconceptual paternal exposure remains controversial
In vitro exposure increased incidence of leukaemia
Postnatal exposure leukaemia
Electromagnetic fields remains controversial
Syndromes/conditions predisposing to cancer

Syndrome
Down
Cancer
Acute leukaemia
Neurofibromatosis type 1
LiFraumeni
Gorlin
Klinefelter
Tuberous sclerosis
von HippelLindau disease
Familial adenomatous polyposis (FAP)
WAGR
(Wilms tumour, aniridia, genitourinary abnormalities,
learning disability)
BeckwithWiedemann
(macroglossia, organomegaly, omphalos, hemihyertrophy)
DenysDrash
(pseudohermaphroditism, Wilms tumour, nephrotic
syndrome)
Perlman
(phenotypically similar to BeckwithWiedemann)
20 times more susceptible than

population
Brain tumours, including optic
glioma
Juvenile myelomonocytic
leukaemia
Phaeochromocytoma
Soft tissue sarcomas
Brain tumours
Medulloblastoma
Basal cell carcinoma
Germ-cell tumours, including
dysgerminoma
Benign tumours in organs
Cerebellar haemangioblastomas
multiple
Retinal angiomas
Renal-cell carcinoma
Phaeochromocytoma
Hepatoblastoma
Thyroid cancer
Medulloblastoma
Wilms tumour
Wilms tumour
Hepatoblastoma
Rhabdomyosarcoma
Neuroblastoma
Adrenocortical carcinoma
Wilms tumour
Wilms tumour
Basal- and squamous-cell skin
carcinoma
Leukaemia and B-cell lymphoma
12.1 Leukaemia
The leukaemias can be divided into acute and chronic leukaemia. Chronic leukaemia accounts for less
than 5% of all leukaemias in childhood all of these cases would be chronic myeloid leukaemia
(CML) because chronic lymphoblastic leukaemia does not exist in childhood.
In acute leukaemia, a differentiating white cell undergoes a structural and/or numerical change in its
genetic make-up, causing a failure of further differentiation, dysregulated proliferation and clonal
expansion
Aetiology remains unknown, although associations or risk factors have been identified
Chromosomal breakage or defective DNA repair mechanisms (e.g. Fanconi anaemia, ataxia
telangiectasia)
Chemotherapy second malignancy effect
Immunodeficiency syndrome, e.g. WiskottAldrich syndrome
Trisomy 21
Identical twin, especially if twin contracted leukaemia in infancy
Ionizing radiation
Clinical presentation is related to bone marrow failure and possibly to extramedullary involvement
Acute lymphoblastic leukaemia

Acute lymphoblastic leukaemia (ALL) is divided into B-cell or T-cell ALL depending on which cell
line (determined by immunophenotyping) is affected. The majority of cases (>80%) originate from the
B-cell line with pre-B, or common ALL (cALL), being the most common. About 15% are T-cell ALL
with 2% demonstrating mixed lineage; cALL has the most favourable prognosis out of all the immunophenotypes.
Poor prognostic signs in ALL include:
Presenting white cell count (WCC) >50 109/l
<2 and >9 years
Boys do less well than girls
Chromosomal abnormalities/translocations: rearrangement of the mixed lineage leukaemia (MLL)
gene (11q23), e.g. t(4:11) purports a poor prognosis, whereas t(9:22) involving the Philadelphia
chromosome carries a dismal prognosis
Hypodiploidy (ploidy = number of chromosomes in lymphoblast). Near haploploidy carries the
worst prognosis and generally, as the ploidy increases, so does the prognosis, with hyperdiploidy
the best
AfricanCaribbean ethnicity
CNS disease
The poor risk or prognostic factors above, together with the presence or absence of minima residual
disease (MRD) after induction treatment, are now used to tailor treatment, i.e. a child with a high
WCC will receive more intensive treatment than if the WCC had been normal, patients with MRDpositive disease at various time points (predominantly at end of induction) will receive more
intensive treatment. MRD detection (detection of lymphoblast clone by the use of polymerase chain
reaction [PCR] or reverse transcription PCR [rt-PCR]) and associated prognostic significance has
been one of the most important developments in the management of ALL over the last decade.
Treatment is divided into three broad stages: induction, consolidation (including CNS-directed
treatment) and maintenance, administered over a total period of 2.53 years. Cytotoxic/chemotherapy
agents used in the treatment of leukaemia include the following: corticosteroids (prednisone and/or
dexamethasone, vincristine, asparaginase, daunorubicin/doxorubicin, cytarabine, cyclophosphamide,
methotrexate, mercaptopurine. CNS-directed treatment is a vital component of treatment because
lymphoblasts can be protected from systemic chemotherapy by the bloodbrain barrier. In standardrisk children this will comprise intrathecal chemotherapy at regular intervals, but for higher-risk
children, high-dose intravenous methotrexate (at a sufficient dose to cross the bloodbrain barrier) or
cranial or cranio-spinal radiotherapy (very rarely used now) may be required. The long-term
consequences of cranio-spinal/cranial radiotherapy are significant, and hence not commonly utilized
now. Bone marrow transplantation is generally reserved for specific patients with relapsing ALL or
with extremely poor prognosis ALL. The 5-year survival rate for standard-risk ALL is now in excess
of 80%.
Acute myeloid leukaemia

AML is a heterogeneous group of haematological malignancies involving the precursors of the
myeloid, monocyte, erythroid and megakaryocyte cell lines, in contrast to ALL, which involves the
lymphoid cell line only
AML is divided into seven subtypes depending on morphology (FAB French, American, British
classification) and immunophenotyping characteristics M1M7
Chromosomal abnormalities occur in at least 80% of cases, with translocations the most common
Treatment is with a more intensive, but shorter (6-month) chemotherapy regimen than that used for
ALL
Bone marrow transplantation plays a much more prominent role in the treatment of AML although
its use remains controversial in some subsets of patients because the increased complete remission
rates with this modality need to be weighed up against the increased mortality of the transplantation
procedure
Five-year survival figures are now in excess of 50%
The immediate dangers, at presentation, of patients with acute leukaemia, include: life-threatening
infections, hyperleukocytosis/hyperviscosity syndrome, tumour lysis syndrome, bleeding and, in
patients with an associated mediastinal mass, airway obstruction and ventricular outflow tract
obstruction may ensue. Prompt and careful attention to these potential complications are required.
12.2 Lymphoma
Two types of lymphoma are recognized: non-Hodgkin lymphoma (NHL) and Hodgkin lymphoma
(HL). In NHL the originating cell is either a B or T lymphocyte, or an immature form thereof, whereas
in HL the originating cell is a B-lineage lymphoid cell. Histologically, the presence of the Reed
Sternberg cell remains pathognomonic of HL.
Non-Hodgkin lymphoma
NHL is the term adopted to describe a heterogeneous group of malignant proliferations of lymphoid
tissue
The classification of NHL is complicated, and controversial. A practical way of classifying NHL is
to divide the entities into immature forms (T- or B-cell acute lymphoblastic lymphoma), mature
form (e.g. Burkitt lymphoma a mature B-cell NHL) and large cell lymphomas (e.g. anaplastic
large cell lymphoma, diffuse B-cell large cell lymphoma, peripheral T-cell lymphoma)
The acute lymphoblastic lymphoma form of NHL is derived from the same T- and B-lineage
lymphoid cells as ALL, but an important difference exists between these two entities. In ALL, 80%
of cases are pre-B-cell derived, whereas 20% are T-cell derived. In NHL this is reversed, with Tcell tumours predominating
The following sites are commonly affected, in descending order of frequency:
Abdomen usually with B-cell disease
Mediastinum typically T cell in origin
Head and neck no specific cell
Chemotherapy is the mainstay of treatment because NHL is a systemic disease, despite the apparent
local sites of disease.
Hodgkins lymphoma
Painless cervical lymphadenopathy is the most frequent presenting symptom
The EBV-related causal hypothesis remains unproven
An excision biopsy of the entire lymph node, not just a biopsy of a portion of the node, is necessary
to examine lymph node architecture and stromal cellular elements
Presence of systemic symptoms (also known as B symptoms: loss of weight, fever, night sweats)
is negatively prognostic and therefore upstages patients to receive more intensive treatment
Combined modality treatment with chemotherapy and radiotherapy remains the treatment of choice
with attempts now being made to decrease treatment intensity (specifically radiotherapy) in an
attempt to minimize treatment-related side effects. Patients with HL have the highest incidence of
such complications compared with children with any other type of malignancy.
Positron emission tomography (PET) scan is currently the focus of an international collaborative
trial to prospectively study the role of such metabolic imaging to help the decision of whether or
not to safely withhold radiotherapy in patients depending on their PET scan response after two
cycles of chemotherapy
12.3 Tumour-lysis syndrome

High-count ALL (especially T-cell) and B-cell NHL (specifically Burkitt lymphoma) have the
potential for bulky disease a high cell mass, which will undergo lysis with treatment, resulting in
the intracellular contents of potassium, phosphate and nuclear debris being released into the
circulation
Lymphoblast cells have four times the amount of phosphate compared to normal white cells
Uric acid crystals and phosphate (precipitating out with calcium) crystals may cause acute renal
failure and the following:
Fluid overload
Phosphate
Potassium
Urea and creatinine
Calcium
Treatment involves:
Hyperhydration
Uric acid-lowering agents urate oxidase (drug of choice) or allopurinol
Treatment of hyperkalaemia
Consideration of fluid filtration or dialysis
12.4 Tumours of the CNS

The anatomical grouping together of brain tumours masks their diverse biological differences
Brain tumours in children tend to be located in the posterior fossa, in the midline, have greater
differentiation and have slightly better survival figures than their counterparts in adults
Brain tumours as a general rule do not metastasize out of the CNS
They are notoriously difficult to diagnose because of their varied and often non-specific
presentations. The mean time from onset of symptoms to diagnosis is 5 months.
Presenting symptoms of brain tumours

Presenting symptoms
Percentage of children
Vomiting
Headache
Changes in personality and mood
65
64
47
Squint
Out-of-character behaviour
Deterioration of school performance
Growth failure
Weight loss
Seizures
Developmental delay
Disturbance of speech
24
22
21
20
16
16
16
11
Astrocytoma
Most commonly occurring brain tumour
Range from low-grade (benign) tumours, usually in the cerebellum, to high-grade (malignant)
tumours, usually supratentorial and brain stem
The high grade glioblastoma multiforme tumour has a near-fatal prognosis
Medulloblastoma (primitive neuroectodermal tumour (PNET) occurring in the

cerebellum)
20% of brain tumours
The most commonly occurring high-grade tumour
Recently it has become possible to classify medulloblastoma relative to the histology/biology of the
tumour, with desmoplastic nodular subtype having the most favourable outcome and large cell
medulloblastoma the least favourable
Commonly metastasizes within the CNS, and it is the one tumour that may metastasize out of the
CNS (<5% of cases)
Prognosis is in the region of a 5070% 5-year survival rate for standard-risk medulloblastoma
Brain-stem glioma
20% of brain tumours
Can be either diffuse (e.g. diffuse pontine glioma) or local
Less than 10% survival
Craniopharyngioma
8% of all brain tumours
Situated in the suprasellar region predominantly
Presenting features may be in the form of raised intracranial pressure, visual disturbances, pituitary
dysfunction and psychological abnormalities
Treatment remains controversial but usually involves conservative surgery and/or radiotherapy
12.5 Retinoblastoma
Retinoblastoma usually presents with leukocoria (white eye reflex), strabismus or decreased vision.
Retinoblastoma can be hereditary or sporadic.
Hereditary
40% of retinoblastomas
Deletion of a tumour-suppressor gene at chromosome 13q14
Behaves in an autosomal dominant fashion (with a high degree of penetrance) but requires
inactivation of remaining allele at the cellular level
Usually presents with bilateral, and in some cases multifocal, disease
Early onset (mean 10 months)
Increased risk of developing a second primary tumour
Sporadic
60% of retinoblastomas
Unifocal
Late onset (mean 18 months)
Treatment involves chemotherapy, focal treatment (cryotherapy, laser), enucleation, radiotherapy or
combinations thereof, depending on the extent of tumour. It is a readily curable tumour if detected
early with overall survival rate for unilateral retinoblastoma treated with enucleation alone being in
excess of 95%.
12.6 Neuroblastoma
Aggressive embryonal tumour of the autonomic system, originating from neural crest-derived
sympathetic nerve cells (e.g. sympathetic chain, adrenal medulla)
Most common cancer diagnosed at age <1 year
Has the biological potential to involute and resolve spontaneously or behave aggressively with
widespread metastases/organ invasion
Presenting symptoms are extremely variable (asymptomatic to life-threatening invasive/metastatic
disease) and can mimic commonly occurring conditions; symptoms are the result of the numerous
possible tumour sites, metastases and the associated metabolic disturbances (caused by
catecholamine secretion: sweating, pallor, diarrhoea, hypertension)
Urinary and plasma catecholamine metabolites (vanillylmandelic acid [VMA]) and homovanillic
acid [HVA]) may be raised
Prognostic factors are:
Tumour stage: inversely proportional to outcome, with the exception of stage 4S a local primary
tumour with dissemination to liver, skin or bone marrow occurring in infancy in which spontaneous
regression occurs in approximately 85% of patients
Age: inversely proportional to outcome patients <18 months have superior survival rates
compared with older children.
Histopathological characteristics, specifically the characteristics of the stroma
Molecular biology: presence of the following confers a poor prognosis:
N-myc amplification
11q abnormality
DNA ploidy diploid worse than hypo-/hyperdiploid
Combining the above factors, four categories of neuroblastoma have been devised that will guide the
intensity of treatment relative to the associated prognosis: very-low-, low-, intermediate- and highrisk groups. Treatment options range from observation only to the most intensive incorporating highdose chemotherapy and stem cell rescue, surgery, radiotherapy, immune-mediated therapy, biological
agents and MIBG therapy. High-risk NBL continues to have a poor prognosis (<50% 5-year event
free survival rate).
12.7 Wilms tumour (nephroblastoma)

Embryonic tumour of the developing kidney
Presents in a well child with a painless (or minimal discomfort) abdominal mass, and/or
haematuria and/or hypertension (independently or collectively)
Patients with BeckwithWiedemann syndrome have an increased propensity for developing Wilms
tumours
Intensity of treatment is relative to the staging and histology of the tumour, incorporating surgery
(usually nephrectomy), chemotherapy and radiotherapy if required
Very good overall prognosis in excess of 90% 5-year survival rate
12.8 Bone tumours

Osteosarcoma
Twice as common as Ewing sarcoma
Predominantly in the metaphyses of long bones, 50% occurring the knee joint (distal femur,
proximal tibia)
Presentation, usually with pain and/or mass, peaks in teenage years, suggesting a relationship
between rapid bone growth and tumour formation
High proportion of patients develop lung metastases
Ewing sarcoma
Occurs more commonly in flat bones (e.g. pelvis, ribs, vertebra) than osteosarcoma, although long
bones can be affected
Can be extraosseous in rare cases
12.9 Soft-tissue sarcomas

These are a group of tumours derived from contractile, connective, adipose and vascular tissue.
Rhabdomyosarcoma is the most common of these, arising from cells destined to be striated muscle
cells. Rhabdomyosarcomas can occur anywhere in the body, with the common sites being
genitourinary (bladder, prostate), parameningeal and orbital. Presentation is relative to the site of
origin.
12.10 Malignant germ-cell tumours

Tumours derived from germ cells (cells giving rise to gonadal tissue) can be gonadal (30%) or
extragonadal (70%):
Extragonadal sites are the sacrococcygeal region, retroperitoneum, mediastinum, neck and the
pineal area of the brain
As gonadal tissue can give rise to any cell type, tumours derived from such cells may express any
cell line in any stage of differentiation. This gives rise to a range of tumours, from an
undifferentiated embryonal carcinoma to a benign and fully differentiated mature teratoma
Presenting features vary reflecting site of origin but typically when gonadal in nature may present
with testicular swelling in males, pelvic pain as a direct result of tumour extension or secondary to
ovarian torsion caused by the tumour. Occasionally endocrinology-related pathology with
abnormal or precocious puberty may be present
Serum markers -fetoprotein and -human chorionic gonadotrophin are useful in diagnosing and
monitoring disease state
12.11 Hepatoblastoma
Hepatoblastoma, an embryonal tumour of the liver, occurs in an otherwise normal liver (compared
with hepatocellular carcinoma) and generally presents in children under the age of 2 years
Patients with BeckwithWiedemann syndrome or familial adenomatous polyposis have an
increased incidence of hepatoblastoma
There is evidence to suggest that low-birthweight babies are predisposed to hepatoblastoma
Presentation is often with an asymptomatic abdominal mass/swelling detected by parents when
bathing or dressing their child
Treatment involves chemotherapy and surgery (partial liver resection or in some cases liver
transplantation)
Overall survival rate figures of 7080% have been reported
12.12 Langerhans cell histiocytosis

Langerhans cell histiocytosis (LCH) is a clonal accumulation and proliferation of abnormal bone
marrow-derived Langerhans cells. These cells, functioning as potent antigen-presenting cells,
together with lymphocytes, eosinophils and normal histiocytes form infiltrates, in various organs,
causing inflammatory tissue damage responsible for the morbidity, and in some cases mortality,
associated with this disease
Any age group may be affected
Patients can have localized disease (to skin, bone or lymph node) or multisystem disease (with
spleen, lung, liver and bone marrow involvement carrying a worse prognosis)
The disease course is unpredictable varying from spontaneous regression to rapid progression
and death or repeated recurrences
Treatment is with a combination of corticosteroids, vinblastine, methotrexate and 6-mercaptopurine
12.13 Haemophagocytic lymphohistiocytosis

Haemophagocytic lymphohistiocytosis (HLH) is a rare disease resulting from abnormal
proliferation of histiocytes (macrophages) in tissues and organs, causing an uncontrolled and
ineffective immune response, with an associated high fatality rate
Classified into familial or secondary HLH
Familial HLH is an autosomal recessive condition, with five genetic mutations identified to date,
resulting in a defect in the natural killer (NK) cell and T-cell cytotoxic function. It is thought that
this causes strong immunological activation of phagocytes and mediators of inflammation, resulting
in multisystem pathology that may, if untreated, be fatal. Active treatment with corticosteroids and
chemotherapy is required in the acute phase followed by definitive treatment with a bone marrow
transplantation
Secondary HLH, or its other commonly used term macrophage-activating syndrome, is not
inherited but has a similar pathophysiological process usually precipitated by infection,
rheumatological, immune deficiencies, malignant and metabolic disorders
Typical findings of HLH are fever, hepatosplenomegaly, cytopenia, hypertriglyceridaemia,
coagulopathy, hypofibrinogenaemia, elevated soluble CD25, liver dysfunction, elevated ferritin
and neurological symptoms.
12.14 Role of bone marrow (haematopoietic stem cell) transplantation

Haematopoietic stem cell transplantation can be:
Autologous the patient receives his or her own stem cells
Allogeneic patient receives donated stem cells from a donor; matched related or unrelated donor
Haematopoietic stem cell transplantation is indicated in the following conditions:
Malignancy:
to eradicate disease, e.g. high-risk leukaemia
to rescue bone marrow following high dose therapy, e.g. myeloablative therapy in many solid
tumours such as neuroblastoma, brain tumours
Metabolic: to replace a missing/defective enzyme, e.g. mucopolysaccharidosis
Immunodeficiency: to correct an underlying immune deficiency, for e.g. severe combined immune
deficiency
Bone marrow failure syndromes: to reconstitute normal bone marrow activity, e.g. acquired
aplastic anaemia, congenital Fanconi anaemia
Haemoglobinopathy: to correct abnormal globin chain, e.g. sickle cell disease, thalassaemia
Stem cells can be obtained from the donor via a bone marrow harvest or via peripheral blood stem
cell collection or from umbilical cord blood.
12.15 Principles of managing malignancy

The ultimate goal of oncological treatment is to cure the patient, i.e. to ensure that the patient is in
life-long remission, while at the same time keeping treatment-related side effects to the minimum.
The first step in achieving this goal in patients with haematological malignancies, such as leukaemia,
is to get the patient into remission. This is achieved with induction chemotherapy, usually over a 4week period. To ensure that this remission is durable, further treatment in the form of consolidation,
intensification and maintenance chemotherapy is required.
Patients with solid-tumour malignancies generally require sequential multimodal treatment. In some
isolated cases surgical resection may be sufficient for cure (e.g. gonadal stage 1 germ cell tumours).
Adjuvant treatment after surgery is usually with chemotherapy and/or radiotherapy. In some instances
where initial surgery is not indicated, i.e. tumour is anatomically irresectable, initial biopsy is
performed to confirm tumour type and then the patient starts neoadjuvant therapy, usually in the form
of chemotherapy but in some cases with radiotherapy. The aim here is to reduce tumour bulk in an
attempt to minimize treatment-related morbidity and to ensure complete tumour resection. Disease,
chemotherapy and/or radiotherapy is started to reduce tumour bulk, thereby enabling resection at a
later stage of treatment.
12.16 Palliative care

Despite the high rate of cure in childhood cancer patients, approaching 80% in developed countries,
palliative care is an integral component of the management of any paediatric haematology/oncology
unit. Paediatric palliative care is an emerging specialty, reflecting the specific needs of the child,
compared with adults, with a life-threatening condition: developmental factors influence the childs
understanding of illness and death; the ability to communicate and participate in decision-making;
parents play a very active caring role and decision-makers; different physiology and
pharmacokinetics; sibling needs; and the grief of parents tends to be severe, complicated and more
prolonged. It is believed that early introduction of the patient and the family to the palliative care
team is beneficial in order to facilitate a trusting and familiar relationship before the child enters a
terminal state. Such an early intervention may be facilitated by introducing the palliative team as the
symptom control team, to help manage challenging symptoms such as pain or seizures, for example.
This close multidisciplinary interaction of paediatric oncologist, palliative care team, the child and
the parents/family is fundamental in managing the symptoms of the child effectively, and shepherding
the child/parents/family through a very emotional journey.
12.17 Late effects of cancer treatment

Chemotherapy
Second malignancies
Leukaemia and lymphoma are the two most likely secondary malignancies to occur particularly
AML with topoisomerase II inhibitors (e.g. etoposide), whereas alkylators (e.g. nitrogen mustard,
cyclophosphamide) may cause either.
Cardiac
Cardiomyopathy, secondary to anthracycline chemotherapy (e.g. doxorubicin) in a cumulative dosedependent linear relationship, is the most likely complication. This toxicity may be exacerbated by
thoracic radiotherapy.
Reduced fertility or infertility
Diminished fertility/infertility potential with increasing cumulative doses of alkylating chemotherapy
(e.g. procarbazine, ifosfamide, cyclophosphamide) is possible.
Pulmonary
Pulmonary fibrosis may result from bleomycin-containing chemotherapy regimens, e.g. germ cell
tumour, Hodgkin lymphoma regimens.
Neurocognitive
The use of methotrexate is linked to potential and neurocognitive limitations.
Auditory
Ototoxicity may result from platinum-containing agents, e.g. cis-platinum and to a lesser extent
carboplatinum, used commonly in the treatment of CNS and other solid tumours.
Renal
Decreased renal function as measured by the glomerular filtration rate (GFR) and/or renal
tubulopathy may be caused by platinum-containing agents, methotrexate, ifosfamide.
Radiotherapy
The developing child is extremely susceptible to the damaging effects of radiotherapy, particularly in
the following areas:
Neurocognitive especially in the younger child

Endocrine abnormalities particularly growth and hypothyroidism
Second malignancies particularly sarcomas and lymphoma
Musculoskeletal atrophy
Organ damage, e.g. cardiac, lung, gastrointestinal
13. FURTHER READING

Adams RJ, McKie VC, Hsu L, et al. (1998). Prevention of a first stroke by transfusions in children
with sickle cell anemia and abnormal results on transcranial Doppler ultrasonography. N Engl J Med
339:511.
Blanchette V, Bolton-Maggs P (2010). Childhood immune thrombocytopenic purpura: diagnosis and
management. Hematol Oncol Clin North Am 24:24973.
Bussel J (2009). Diagnosis and management of the fetus and neonate with alloimmune
thrombocytopenia. J Thromb Haemost 7(suppl 1):2537.
Di Bartolomeo P, Santarone S, Di Bartolomeo E, et al. (2008). Long-term results of survival in
patients with thalassemia major treated with bone marrow transplantation. Am J Hematol 83:52830
Freeman HR, Ramanan AV (2011). Review of haemophagocytic lymphohistiocytosis. Arch Dis Child
96:68893.
Kontoghiorghes GJ (2011). The Proceedings of the 19th International Conference On Chelation,
London, UK: major changes in iron chelation therapy in the last 25 years using deferiprone (L1) has
resulted In the complete treatment of iron overload. Hemoglobin 35:1815.
Maris JM (2010). Recent advances in neuroblastoma. N Engl J Med 362:220211
Neufeld EJ (2010). Update on iron chelators in thalassemia. Hematol Am Soc Hematol Educ
Program 4515.
Pui CH, Evans WE (2006). Treatment of acute lymphoblastic leukemia. N Engl J Med 354:16678.
Pui CH, Relling MV, Downing JR (2004). Acute lymphoblastic leukemia. N Engl J Med 350:1535
48.
Rees DC, Williams TN, Gladwin MT (2010). Sickle cell disease. Lancet 376:201831.
Segel GB, Feig SA (2009). Controversies in the diagnosis and management of childhood acute
immune thrombocytopenic purpura. Pediatr Blood Cancer 53:31824.
Shearer MJ (2009). Vitamin K deficiency bleeding (VKDB) in early infancy. Blood Rev 23:4959.
Voray A, Makris M (2001). An approach to investigation of easy bruising. Arch Dis Child 84:488491
Walters MC (2010). Gene therapy and bone marrow transplantation for thalassemia: changing of the
guard? Mol Ther 18:1577.
Chapter 13
Hepatology
Nancy Tan and Anil Dhawan
CONTENTS
1. Jaundice in infancy
1.1 Bilirubin metabolism
1.2 Approach to a jaundiced infant
1.3 Unconjugated hyperbilirubinaemia
1.4 Conjugated hyperbilirubinaemia
2. Acute hepatitis
2.1 Acute infective hepatitis
2.2 Drug-induced liver disease
3. Acute liver failure

3.1 Paracetamol poisoning
3.2 Wilson disease
4. Chronic liver disease and end-stage liver failure

4.1 Autoimmune hepatitis
4.2 Chronic viral hepatitis
4.3 Non-alcoholic fatty liver disease
4.4 Liver transplantation
5. Portal hypertension
6. Liver function test
7. The pancreas
7.1 Acute pancreatitis
7.2 Chronic pancreatitis
8. Further reading
Hepatology
1. JAUNDICE IN INFANCY
See also Chapter 16 Neonatology, Section 10.
1.1 Bilirubin metabolism

Unconjugated bilirubin is a product of haem metabolism and is transported by albumin to the
hepatocytes
Hepatocyte uptake is via membrane receptor carriers or by simple passive diffusion
Conjugation with glucuronic acid by esterification to make it water soluble (enzyme bilirubin
uridine diphosphate glucuronosyltransferase UGT)
Secretion of conjugates against a concentration gradient through the canalicular membrane into the
bile
The two models of hepatic organization
1.2 Approach to a jaundiced infant

3050% of normal term neonates experience jaundice; few have significant underlying disease
Physiological and breast-milk jaundice (unconjugated hyperbilirubinaemia) account for the
majority of cases in the first weeks of life
Approximately 1 in every 2500 infants is affected with cholestatic jaundice (conjugated
hyperbilirubinaemia)
Infants with risk factors should be monitored closely in the first days to weeks of life
Factors that influence hyperbilirubinaemia

Identify babies as being more likely to develop significant hyperbilirubinaemia if they have any of the
following:
Gestational age <38 weeks

A previous sibling with neonatal jaundice requiring phototherapy
Mothers intention to breastfeed exclusively
Visible jaundice in the first 24 hours of life
Risk factors for kernicterus/or adverse sequelae

Identify babies with hyperbilirubinaemia as being at increased risk of developing kernicterus if they
have any of the following:
A serum bilirubin level >340 mol/l in babies with a gestational age 37 weeks
A rapidly rising bilirubin level >8.5 mol/l per h
Clinical features of acute bilirubin encephalopathy
Up to 15% of neonates can be jaundiced at 2 weeks of age and need to be investigated.
In babies with a gestational age 37 weeks with jaundice lasting more than 14 days, and in babies
with a gestational age <37 weeks with jaundice lasting more than 21 days:
Look for pale chalky stools and/or dark urine that stains the nappy
Measure the conjugated bilirubin
Carry out a full blood count
Carry out a blood group determination (mother and baby) and DAT (Coombs test). Interpret the
result taking account of the strength of reaction, and whether mother received prophylactic anti-D
immunoglobulin during pregnancy:
Carry out a urine culture
Ensure that routine metabolic screening (including screening for congenital hypothyroidism) has
been performed
1.3 Unconjugated hyperbilirubinaemia

The most common causes include:
Physiological jaundice
Breast-milk jaundice
Haemolysis
Congenital hyperbilirubinaemia
Unconjugated bilirubin is normally tightly bound to albumin
Kernicterus may result from high levels of unbound, lipid-soluble, unconjugated bilirubin
Albumin-bound bilirubin may also cross the bloodbrain barrier if damage has occurred because of
asphyxia, acidosis, hypoxia, hypoperfusion, hyperosmolality or sepsis in the newborn
Management strategy is with phototherapy, adequate hydration, and identification and treatment of
the underlying causes
Effects of bilirubin toxicity in the newborn baby
50% of term and 80% of preterm babies are jaundiced in the first week of life
Jaundice within the first 24 h of life is always pathological and cannot be attributed to
physiological jaundice
The aetiology of physiological jaundice is not precisely known but may be related to immaturity of
bilirubin UGT activity
Jaundice peaks on day 3 of life; declines over first week
Treatment is by phototherapy or by exchange transfusion for severe hyperbilirubinaemia
Occurs in 0.52% of neonates
Early onset: develops after day 4, relative caloric deprivation, decreased volume and frequency of
feeding with resultant mild dehydration and delayed passage of meconium
Late onset: develops around day 7, substances in maternal milk, such as -glucuronidases, and nonesterified fatty acids, may inhibit normal bilirubin metabolism
Jaundice peaks around the end of the second week
May overlap with physiological jaundice or be protracted for 12 months
Diagnosis is supported by a drop in serum bilirubin (50% in 13 days) if breastfeeding is
interrupted for 48 hours
Haemolysis
Commonly the result of isoimmune haemolysis (rhesus [Rh], ABO incompatibility), red cell
membrane defects (congenital spherocytosis, hereditary elliptocytosis), enzyme defects (glucose-6phosphate dehydrogenase or pyruvate kinase deficiency) or haemoglobinopathies (sickle cell
anaemia, thalassaemia)
Findings of jaundice in the presence of anaemia and a raised reticulocyte count would necessitate
further investigation for the cause of haemolysis
Inherited disorders of unconjugated hyperbilirubinaemia

This spectrum of disease depends on the degree of bilirubin UGT deficiency. Liver function tests and
histology are normal.
Gilbert syndrome
Mild deficiency (50% decrease of UGT activity) occurring in 7% of population
Polymorphism with TA repeats in the promoter region (TATA box) in white individuals compared
with exon mutations in Asian individuals on chromosome 2q37
Correlation between hepatic enzyme activity and serum bilirubin levels is unpredictable because
up to 40% of patients with Gilbert syndrome have a reduced red blood cell lifespan
Higher incidence of neonatal jaundice and breast-milk jaundice
Usually presents after puberty with an incidental finding of elevated bilirubin on blood tests or
jaundice after a period of fasting or intercurrent illness
More common in males
No treatment required, compatible with normal lifespan
CriglerNajjar type II
Moderate deficiency
May require phototherapy and phenobarbital
CriglerNajjar type I
Severe deficiency of UGT
High risk of kernicterus
Requires life-long phototherapy or even liver transplantation
Autosomal recessive inheritance. Both Gilbert syndrome and CriglerNajjar type II can also have
autosomal dominant transmission.
Causes of neonatal unconjugated hyperbilirubinaemia

Increased production of unconjugated bilirubin from haem
Haemolytic disease (hereditary or acquired)
Isoimmune haemolysis (neonatal; acute or delayed transfusion reaction; autoimmune):
Rh incompatibility
ABO incompatibility
Other blood group incompatibilities
Congenital spherocytosis
Hereditary elliptocytosis
Infantile pyknocytosis
Erythrocyte enzyme defects:
Glucose-6-phosphate dehydrogenase deficiency
Pyruvate kinase deficiency
Haemoglobinopathy:
Sickle cell anaemia
Thalassaemia
Others
Sepsis
Microangiopathy:
Haemangioma
Ineffective erythropoiesis
Drugs
Infection
Enclosed haematoma
Polycythaemia:
Diabetic mother
Fetal transfusion (recipient)
Delayed cord clamping
Decreased delivery of unconjugated bilirubin (in plasma) to hepatocyte

Right-sided congestive heart failure
Portacaval shunt
Decreased bilirubin uptake across hepatocyte membrane
Presumed enzyme transporter deficiency

Competitive inhibition:
LucyDriscoll syndrome
Drug inhibition (radiocontrast material)
Miscellaneous:
Hypothyroidism
Hypoxia
Acidosis
Decreased storage of unconjugated bilirubin in cytosol (decreased Y and Z

proteins)
Competitive inhibition
Fever
Decreased biotransformation (conjugation)

Inhibition (drugs)
Hereditary (CriglerNajjar):
Type I (complete enzyme deficiency)
Type II (partial deficiency)
Gilbert disease
Hepatocellular dysfunction
Enterohepatic recirculation
Intestinal obstruction:
Ileal atresia
Hirschsprung disease
Cystic fibrosis
Pyloric stenosis
Antibiotic administration
1.4 Conjugated hyperbilirubinaemia
Jaundice, dark urine, pale stools and hepatomegaly or hepatosplenomegaly

Baby may be acutely ill with hypoglycaemia, acidbase imbalance, electrolyte imbalance,
coagulopathy and liver failure
Biochemical definition is direct bilirubin >20% of total
Top causes are:
Idiopathic neonatal hepatitis (40%)
Extrahepatic biliary atresia (2530%)
Intrahepatic cholestasis syndromes (20%), e.g. Alagille syndrome, progressive familial
intrahepatic cholestasis (PFIC)
1-Antitrypsin deficiency (710%)
Work-up of conjugated hyperbilirubinaemia

Investigations
Pathology
General investigations
Liver function tests
Type and level of jaundice

Degree of liver failure
Normal GGT levels (PFIC1, PFIC2 and defects of bile
acid synthesis)
Full blood count and peripheral blood

film
Marrow suppression (familial haemophagocytic

lymphohistiocytosis, lysosomal storage diseases)
Anaemia/acanthocytosis/thrombocytosis (HFI)
Vacuolated lymphocytes (Wolman disease)
PT/PTT, INR
Coagulopathy (liver failure)

Vitamin K deficiency
Blood glucose
Hypoglycaemia (liver failure, metabolic disorders)
Renal function test
Impaired renal function (liver failure, Zellweger

syndrome)
Lipid profile
Hypercholesterolaemia and hypertriglyceridaemia

(Wolman syndrome, Alagille syndrome, PFIC)
Blood gas
Metabolic acidosis (metabolic disorders)
Infections
Urine cultures
Urinary tract infection
Herpes, toxoplasma, CMV, rubella,

syphilis, parvovirus B19 serology
Intrauterine infection
Hepatitis B and A serology

HIV
Hepatitis B and rarely hepatitis A
Enterovirus serology, CSF for PCR or

cultures
Neonatal systemic infection
Blood cultures, CSF cultures
Systemic bacterial infection
Endocrine
Thyroid function test
High TSH, low T4, free T4 and T3 (hypothyroidism,

hypopituitarism)
Cortisol
Low cortisol (hypopituitarism, septo-optic dysplasia)
Metabolic
Serum 1-antitrypsin levels and PI type
Low level and PI ZZ (1-antitrypsin deficiency)
Galactose-1-phosphate uridyl
transferase (Gal-1-PUT)
Deficiency (galactosaemia)
Lactate
Elevated (HFI, mitochondrial disorders)
Urine-reducing substances
Positive (galactosaemia, HFI)
Ferritin
Grossly elevated (neonatal haemochromatosis)
-Fetoprotein
Grossly elevated (tyrosinaemia)
Plasma amino acid, urine amino acid
3 plasma tyrosine, phenylalanine, methionine,

urinary succinylacetone (tyrosinaemia)
Urinary organic acid
Organic aciduria (tyrosinaemia, peroxisomal enzyme

deficiency, mitochondrial hepatopathies)
Urinary bile acid intermediates
Elevated (primary disorders of bile acid synthesis,

Zellweger syndrome)
Very long chain fatty acids (VLCFA)

Plasma transferrin isoforms
Sweat chloride
Elevated (peroxisomal enzyme deficiency)

Characteristic patterns in congenital disorders of
glycosylation
Abnormal chloride levels (cystic fibrosis, PFIC)
Genetic testing
Karyotyping
Trisomy (trisomies 21 and 18)

Duplication of chromosome 22 (cat eye syndrome)
Specific mutations
Immune
Autoantibodies
Anti-Ro and anti-La antibodies (neonatal lupus

erythematosus)
Biopsy
Liver
Biliary atresia
Giant cell hepatitis
Immunostaining for PFIC
Bile duct paucity (syndromic and non- syndromic
causes)
Gaucher cells (Gaucher syndrome)
Foamy histiocytes (NiemannPick, Wolman)
Lip
Extrahepatic siderosis (neonatal haematochromatosis)
Skin biopsy and fibroblast culture

studies
Sea blue histiocytes (Wolman disease)
Accumulation of intracytoplasmic unesterified

cholesterol (NiemannPick C)
Glucocerebrosidase deficiency (Gaucher)
Sphingomyelinase deficiency (NiemannPick A, B)
Acid lipase deficiency (Wolman)
1,4-glycan-6-glycosyltransferase deficiency (GSD IV)
Muscle biopsy
Bone marrow aspirate
Steatosis and ragged red fibres, respiratory chain

enzyme analysis (mitochondrial)
Gaucher cells (Gaucher)
Foam cells (NiemannPick, Wolman)
Erythrophagocytosis (familial phagocytic
lymphohistiocytosis)
Imaging
Hepatobiliary ultrasound
Adrenal calcification (Wolman)

Triangular cord sign and absent or small irregular gall
bladder (biliary atresia)
Structural abnormalities (e.g. choledochal cyst)
HIDA scan
Normal excretion excludes biliary atresia.

Delayed or no excretion usually seen in neonatal
hepatitis
Eye examination
Cherry red spot (NiemannPick)

Oil-drop cataracts, intraocular haemorrhage and
retinal detachment (galactosaemia)
Corneal clouding, cataracts, pigmentary retinopathy
(Zellweger syndrome)
Coloboma (cat-eye syndrome)
Posterior embryotoxon, optic disc drusen (Alagille
syndrome)
GGT, -glutamyl transferase; PT/PTT, prothrombin time/partial thromboplastin time; INR,

international normalized ratio; CMV, cytomegalovirus; HIV, human immunodeficiency virus; CSF,
cerebrospinal fluid; PCR, polymerase chain reaction; TSH, thyroid-stimulating hormone; T3, tri
iodothyronine; HFI, hereditary fructose intolerance; T4, thyroxine; PI, protease inhibitor.
Idiopathic neonatal hepatitis

Diagnosis of exclusion
Associated with low birthweight or prematurity
Histology
Hepatocellular swelling (ballooning), focal hepatic necrosis and multinucleated giant cells
Bile duct proliferation and bile duct plugging are usually absent
Factors predicting poor prognosis
Severe jaundice beyond 6 months
Acholic stools
Familial occurrence
Persistent hepatosplenomegaly
90% do well with no long-term liver disease
Biliary atresia (BA)
Incidence: 1 per 16 000 live births

Slight female preponderance
Exact pathogenesis is unknown
25% associated with other congenital malformations
Anatomical variants:
Type I obliteration of the common bile duct
Type II obliteration is extended to the common hepatic duct
Type III obliteration of the entire extrahepatic biliary tree (most common form)
Diagnosis is suggested by:
Hepatobiliary ultrasound (fasting) will show absent gallbladder or irregular outline and
triangular cord sign
Radionuclide imaging (phenobarbital priming) no excretion indicates possible biliary atresia;
excretion indicates that it is not biliary atresia
Liver biopsy expanded portal tracts with bile duct proliferation, bile plugs and fibrosis
Gold standard for diagnosis is exploratory and operative cholangiography
Portoenterostomy (Kasai operation) should be offered to all children unless there is decompensated
liver disease
Between 70 and 80% achieve partial bile flow with 50% becoming jaundice free after surgery
Ascending bacterial cholangitis follows the first year of surgery in 4550%
It is a progressive disease even with a successful Kasai operation, although prognosis may be
better if procedure is performed within 8 weeks of birth
Majority (80%) require liver transplantation by 20 years of age
Fat-soluble vitamin supplementation is essential
Role of choleretic agents such as phenobarbital and ursodeoxycholic acid and steroids is unproven
The three variants of biliary atresia
Alagille syndrome (arteriohepatic dysplasia)
Autosomal dominant
Incidence is 1 per 100 000 live births
Defect of the JAG1 gene on chromosome 20p12
Intrahepatic biliary hypoplasia
Characteristic facies (may not be prominent at birth):
Broad forehead
Deep-set eyes
Mild hypertelorism
Small chin
Skeletal abnormalities:
Thoracic hemivertebrae/butterfly vertebrae
Eye findings:
Posterior embryotoxon
Retinal changes
Cardiac disease:
Other congenital cardiac malformations
Intrauterine growth retardation and faltering growth with severe malnutrition occur in 50%
Others:
Renal disease
Delayed puberty or hypogonadism
Learning disability, learning difficulties or psychosocial dysfunction
Vascular abnormalities
Hypothyroidism and pancreatic insufficiency
Recurrent otitis media, chest infection
Variable phenotype; severe liver disease may require liver transplantation
Progressive familial intrahepatic cholestasis

Group of inherited diseases which present as neonatal hepatitis, faltering growth, pruritis and
progressive liver disease, requiring liver transplantation in the first few years of life.
Type 1
Byler disease
Mutation of the FIC1 gene on chromosome 18q21-22
Pancreatitis, persistent diarrhoea, short stature and sensorineural hearing loss
Normal -glutamyltransferase (GGT), serum cholesterol
Elevated serum bile salts, sweat chloride
Low chenodeoxycholic acid in bile
Type 2
Mutations on chromosome 2q24, bile salt export pump (BSEP) gene

Normal GGT
Type 3
Mutations in the P-glycoprotein MDR-3 gene (ABCB4)

Elevated GGT
Bile phospholipids 15% of normal
1-Antitrypsin deficiency
Most common inherited cause of conjugated jaundice

Autosomal recessive
Incidence is 1 in 16002000 live births
Mutation at the protease inhibitor (Pi) locus on chromosome 14
More than 75 variants are known but not all mutations result in disease
The most common disease phenotype is PiZZ, homozygous for a point mutation in which glutamic
acid is replaced by glycine at position 342. This causes abnormal folding of the 1-antitrypsin
molecule so that it becomes trapped in the endoplasmic reticulum, causing liver damage
Associated with intrauterine growth retardation
Hepatomegaly at presentation is common
Cholestasis may be severe enough to produce totally acholic stools
Approximately 2% of infants will present with vitamin K-responsive coagulopathy
Diagnosis is from:
Low 1-antitrypsin levels
Phenotype (Pi) by isoelectric focusing
Replacement with recombinant 1-antitrypsin is not helpful because abnormal protein continues to
accumulate in the endoplasmic reticulum
Prognosis 50% of children presenting with neonatal hepatitis develop chronic liver disease with
half of them requiring a liver transplantation in the first 10 years of life.
Causes of conjugated jaundice
Infections
Bacterial

Septicaemia7
Syphilis
Listeriosis
Tuberculosis
Parasitic
Toxoplasmosis
Malaria
Viral
Cytomegalovirus
Herpes simplex virus7
Human herpesvirus type 67
Herpes zoster virus
Adenovirus
Parvovirus7
Enterovirus
Reovirus type 3
Human immunodeficiency virus
Hepatitis B virus7
? Hepatitis A
? Rotavirus
Metabolic disorders
Carbohydrate metabolism
Galactosaemia7
Fructosaemia7
Glycogen storage type 4
Congenital disorders of glycosylation7
Protein metabolism (amino acid)

Tyrosinaemia7
Hypermethioninaemia
Urea cycle defects (arginase deficiency)
Lipid metabolism
NiemannPick disease (type C)
Wolman disease7
Cholesterol ester storage disease
Bile acid disorders7

Fatty acid oxidation defects7
Disorders of oxidative phosphorylation7
Zellweger syndrome
Other mitochondrial disorders7
Endocrine disorders
Hypothyroidism
Hypopituitarism (with or without septo-optic dysplasia)
Chromosomal disorders
Down syndrome
Trisomy E
Patau syndrome
Leprechaunism
Other geneticmetabolic defects
Cystic fibrosis
Familial cholestasis syndromes
Alagille syndrome
Byler syndrome (PFIC-1)
Bile salt export protein defect (BSEP defect, PFIC-2)
Multidrug-resistant 3 deficiency (MDR-3, PFIC-3)
Hereditary cholestasis with lymphoedema (Aagenaes syndrome)
Metals and toxins

Neonatal haemochromatosis7
Copper-related cholestasis7
Parenteral nutrition
Drugs
Haematological disorders
Haemophagocytic lymphohistiocytosis7
Langerhans cell histiocytosis
Inspissated bile syndrome
Biliary tree disorders

Biliary atresia
Mucus plug
Bile duct stenosis/stricture
Spontaneous perforation of common bile duct
Neonatal sclerosing cholangitis
Caroli disease
Compression of bile duct by a mass
Inflammatory pseudotumour at porta hepatis
Immunological disorders
Neonatal lupus erythematosus
Giant cell hepatitis with Coombs test-positive haemolytic anaemia7
Graft-versus-host disease
Adenosine deaminase deficiency
Vascular anomalies
Haemangoendothelioma
Congenital portacaval anomalies
Idiopathic
Familial
Non-familial (good prognosis)
Miscellaneous
Hypoperfusion of liver7
DubinJohnson syndrome
2. ACUTE HEPATITIS
Acute hepatitis is characterized by liver inflammation and necrosis. The underlying trigger varies,
including infective, autoimmune, toxic (e.g. drugs) and metabolic causes.
2.1 Acute infective hepatitis

Acute infection of the liver may result from many pathogens. Complete recovery from an infection is
dependent on the hosts ability to eliminate the infective agent, resolution of liver inflammation and
prevention of infection by effective antibody production.
Symptoms in hepatitis may include:
Prodrome of malaise
Anorexia
Nausea
Vomiting
Fever
Tender hepatomegaly
Splenomegaly
Lymphadenopathy
Rash
Jaundice
Viruses are the most common cause of acute infective hepatitis.
Causes of acute infective hepatitis

Viruses
Hepatotropic viruses
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E
Non-hepatotropic viruses
Paramyxovirus (measles)
Togavirus (rubella)
Enterovirus
Echovirus
Cosackievirus
Flavivirus
Marbug virus
Ebola virus
Arenavirus (Lassa fever)
Parvovirus B19
Adenovirus
Herpesvirus
Herpes simplex type 1
Herpes simplex type 2
Varicella-zoster virus
Cytomegalovirus
EpsteinBarr virus
Human herpesvirus 6
Bacterium
Bartonella hensele/Quintana spp.
Brucella melitensis
Legionella pneumophila
Leptospira ictohaemorrhagica
Listeria monocytogenes
Mycobacterium tuberculosis
Salmonella typhi
Protozoa
Toxoplasma gondii
Helminths
Cestodes (tapeworms)
Echinococcus multilocularis
Echinococcus granulosus
Nematodes (roundworms)
Ascaris lumbricoides
Toxocara canis
Toxocara catis
Trematodes (flukes)
Schistosoma mansoni
Schistosoma japonicum
Fasciola hepatica
Hepatitis A infection
The most common form of acute viral hepatitis, accounting for 2025% of all clinically apparent
hepatitis worldwide
Picornavirus family, RNA virus
Orofaecal route of spread
Incubation period 26 weeks
Infectivity from faecal shedding begins during the prodromal phase, peaks at the onset of symptoms
and then rapidly declines. Shedding may persist for up to 3 months
Usually asymptomatic; <5% of infected people have an identifiable illness
Symptomatic infection increases with age of acquisition
Mortality rate is 0.20.4% of symptomatic cases and is increased in individuals >50 or <5 years
Morbidity and mortality are associated with:
Fulminant hepatic failure
Prolonged cholestasis
Recurrent hepatitis
Extrahepatic complications
Neurological involvement GuillainBarr syndrome, transverse myelitis, postviral encephalitis,
mononeuritis multiplex
Renal disease Acute interstitial nephritis, mesangioproliferative glomerulonephritis, nephrotic
syndrome, acute renal failure
Acute pancreatitis
Haematological disorders autoimmune haemolytic anaemia, red cell aplasia, thrombocytopenic
purpura
Non-specific elevation of conjugated bilirubin and aminotransferase enzymes. Degree of elevation
does not correlate with severity of illness or likelihood of complications
Confirmation of diagnosis relies on detection of:
Anti-HAV IgM indicator of recent infection; peak levels occur during acute illness or early
convalescent phase; persists for 46 months after infection
Anti-HAV IgG appears early; peaks during convalescent phase; persists lifelong, conferring
protection
Supportive symptomatic treatment and adequate hydration. Complete recovery is usual within 36
months
Active immunization with a formaldehyde-inactivated vaccine is available
Passive immunization with human normal immunoglobulin offers up to 6 months of protection and is
effective if given within 23 weeks of exposure
2.2 Drug-induced liver disease

Most drugs are lipophilic and are detoxified and excreted in bile. This is achieved by oxidation or
demethylation by the cytochrome P450 enzyme system or conjugated by glucuronidation or sulphation
by specific transferases. Intermediate metabolites can be potentially harmful and may be detoxified by
the binding of gluthathione, catalysed by gluthathione-S-transferase.
Mechanism of drug-induced liver disease
Direct hepatotoxicity usually dose dependent

Adverse drug reaction unpredictable and idiosyncratic
Spectrum of drug-induced liver disease

Enzyme induction without disease
Acute hepatitis/hepatocellular necrosis (most common) paracetamol, methyldopa, isoniazid,
halothane, phenytoin
Cholestasis erythromycin, co-trimoxazole
Granulomatous hepatitis carbamazepine
Drug-induced chronic hepatitis methyldopa, nitrofurantion
Fatty liver microvesicular (aspirin, valproate, tetracycline) or macrovesicular (amiodarone)
Fibrosis methotrexate, vitamin A, actinomycin D
Vascular disorders sinusoidal dilatation (oestrogen) or veno-occlusive disease (6mercaptopurine)
Hepatic tumours oral contraceptives
Diagnosis of drug-induced liver disease is usually based on circumstantial evidence and exclusion of
other causes.
Withdrawal of the causative drug is the most effective treatment.
Specific therapy is available for paracetamol (N-acetylcysteine).
3. ACUTE LIVER FAILURE

Acute liver failure or fulminant hepatitis is rare in childhood. The mortality rate is 70% without
appropriate management or liver transplantation. It is the indication for liver transplantation in about
1020% of paediatric recipients in major transplant centres. The 1-year survival rate is in the range
6070%.
It is a multisystemic disorder, defined as:
Severe impairment of liver function (INR >2 and unresponsive to vitamin K)
encephalopathy (not essential to make diagnosis)
Associated hepatocellular necrosis
No previous underlying recognizable liver disease
The most common causes of acute liver failure are:
In the neonate:
Neonatal haemochromatosis
Disseminated herpes simplex infection
Haemophagocytic lymphohistiocytosis
Metabolic causes
In the older child:
Viral hepatitis
Metabolic causes
Paracetamol toxicity
Autoimmune hepatitis
Wilson disease
Idiopathic
Causes of acute liver failure

Infective
Viral
Viral hepatitis A, B, B + D, E
Non-AE hepatitis (seronegative hepatitis)
Adenovirus, EpsteinBarr virus, cytomegalovirus
Echovirus
Varicella, measles viruses
Yellow fever
Rarely Lassa, Ebola, Marburg viruses, dengue virus, Toga virus
Bacterial
Salmonellosis
Tuberculosis
Septicaemia
Others
Malaria
Bartonella spp.
Leptospirosis
Drugs
Paracetamol
Halothane
Idiosyncratic reaction
Isoniazid
Non-steroidal anti-inflammatory drugs
Phenytoin
Sodium valproate
Carbamazepine
Ecstasy
Troglitazone
Antibiotics (penicillin, erythromycin, tetracyclines, sulfonamides, quinolones)
Allopurinol
Propylthiouracil
Amiodarone
Ketoconazole
Antiretroviral drugs
Synergistic drug interactions
Isoniazid + rifampicin
Trimethoprim + sulfamethoxazole
Barbiturates + acetaminophen
Amoxicillin + clavulinic acid
Toxins
Amanita phalloides (mushroom poisoning)
Herbal medicines
Carbon tetrachloride
Yellow phosphorus
Industrial solvents
Chlorobenzenes
Metabolic
Galactosaemia
Tyrosinaemia
Hereditary fructose intolerance
NiemannPick disease type C
Wilson disease
Mitochondrial cytopathies
Congenital disorders of glycosylation
Acute fatty liver of pregnancy
Autoimmune
Type 1 autoimmune hepatitis
Type 2 autoimmune hepatitis
Giant cell hepatitis with Coombs test-positive haemolytic anaemia
Vascular/Ischaemic
BuddChiari syndrome
Acute circulatory failure
Heat stroke
Acute cardiac failure
Cardiomyopathies
Infiltrative
Leukaemia
Lymphoma
Causes of neonatal acute liver failure

Perinatal herpes simplex virus infection
Galactosaemia
Tyrosinaemia
Septicaemia
Mitochondrial cytopathies
Severe birth asphyxia
Biochemistry of acute liver failure
prothrombin time (does not improve with parenteral vitamin K)

direct and indirect bilirubin
aminotransferase activities (AST), then as patient deteriorates
serum ammonia
Complications of acute liver failure

Encephalopathy:
May be absent or difficult to recognize in children
Stage 1 mild confusion/anxiety, disturbed or reversal of sleep rhythm, shortened attention span,
slowing of ability to perform mental tasks (simple addition or subtraction). In young children,
irritability, altered sleep pattern, unexplained bursts of excessive crying
Stage 2 drowsiness, confusion, mood swings with personality changes, inappropriate behaviour,
intermittent disorientation of time and place, gross deficit in ability to perform mental tasks. In
young children, excessive sleepiness, inability to interact with or recognize parents, lack of interest
in favourite toys or activities
Stage 3 pronounced confusion, delirious but arousable, persistent disorientation of time and
place, hyperreflexia with a positive Babinski sign
Stage 4 comatose with or without decerebrate or decorticate posturing, response to pain present
(stage 4a) or no response to pain (stage 4b)
Renal insufficiency/failure:
1015% have renal failure, 75% have renal insufficiency as a result of hepatorenal syndrome,
direct kidney toxicity or acute tubular necrosis
50% require haemodialysis or haemofiltration support
Cardiovascular:
Early hyperdynamic circulation with decreased peripheral vascular resistance
Late haemodynamic circulatory failure as a result of falling cardiac output, depression of brainstem function or cardiac arrhythmias
Pulmonary:
Aspiration, intrapulmonary shunting, atelectasis, infection, intrapulmonary haemorrhage,
respiratory depression or pulmonary oedema
Metabolic:
Hypoglycaemia
Acidbase imbalance: respiratory alkalosis, metabolic alkalosis and metabolic acidosis
Coagulopathy:
Vitamin K deficiency: vitamin K functions as a cofactor for carboxylation of glutamic acid,
which allows the calcium binding that is required for the activation of factors II, VII, IX, X and
proteins C, S and Z of the coagulation cascade
synthesis of clotting factors
fibrinolysis and clearance of activated factors and fibrin degradation products
Thrombocytopenia (correlates with risk of haemorrhage)
Infections:
Poor host defences, poor respiratory effort, multiple invasive lines and tubes
Others:
Adrenal hyporesponsiveness, pancreatitis, aplastic anaemia
Management of acute liver failure involves management of complications, and elucidation and
treatment of the cause:
Discuss/refer to a liver centre
No sedation unless patient is on assisted ventilation
Ventilate for respiratory failure, agitation with grade I or II encephalopathy or severe
encephalopathy (grade III or IV)
No coagulation support unless bleeding or for invasive procedures
Monitoring should involve:
Continuous oxygen saturation monitoring
At least 6-hourly neurological observations/vital signs (may need invasive monitoring)/urine
output/blood glucose (maintain >4 mmol/l)
At least 12-hourly acidbase/electrolytes/prothrombin time (PT)/partial thromboplastin time
(PTT), INR (international normalized ratio)
Gastric pH (>5)
Daily or more often haemoglobin and platelet count
Fluid balance:
75% maintenance with 0.45% (or less) saline with dextrose
Maintain circulating volume with colloid, crystalloids or blood products as appropriate

Haemofiltration if there is renal failure
Coagulation:
Fresh frozen plasma when bleeding
Keep platelet count >50 109/dl
Drugs:
H2-receptor blockers or proton pump inhibitors (prevent gastrointestinal bleed)
Lactulose to achieve two or three stools per day
N-Acetylcysteine as experimental for non-paracetamol-induced acute liver failure
Intravenous broad-spectrum antibiotics and antifungals as prophylaxis
Nutrition:
Enteral feeding (12 g protein/kg per day)
Parenteral nutrition is rarely indicated
Specific therapy
Paracetamol toxicity N-acetylcysteine (100 mg/kg per day)
Hereditary tyrosinaemia NTBC
Neonatal haemochromatosis iron chelation and antioxidant cocktail/N-acetylcysteine (100
mg/kg per day intravenous infusion)/selenium (3 g/kg per day intravenous)/desferrioxamine (30
mg/kg per day intravenous)/prostaglandin E1 (0.40.6 g/kg per hour intravenous)/vitamin E (25
U/kg per day intravenous/oral)
Mushroom poisoning benzylpenicillin (1 000 000 U/kg per day) or thiotic acid (300 mg/kg per
day)
Hepatic support with liver assist devices such as molecular adsorbent recirculating system
(MARS) is still under investigation
Emergency liver transplantation
3.1 Paracetamol (acetaminophen) poisoning

Mainly one large dose in a suicidal attempt, occasionally accidental over-ingestion over several
days
Direct dose-dependent hepatotoxic effect
With overdosage, gluthathione is depleted and NAPQI (N-acetyl-p-benzoquinone imine) is not
detoxified
Acute ingestion of 150 mg/kg is likely to cause significant hepatotoxicity
Triphasic clinical course:
Stage 1 (024 h) nausea, vomiting, anorexia
Stage 2 (2448 h) liver enlarged and tender from hepatic necrosis
Stage 3 (4896 h) acute liver failure
If patient survives stage 3, resolution of liver dysfunction within 4 days to 2 weeks
Prognosis is bad if:
Arterial pH <7.3
PTT >100 s or INR >6.6, creatinine >300 mol/l, grade IIIIV encephalopathy (all three)
Management:
Discuss with a liver centre

N-Acetylcysteine infusion 100 mg/kg per day until INR <1.5
Metabolism of paracetamol
3.2 Wilson disease

An autosomal recessive disease with incidence of 1 in 50 000; caused by a mutation of the ATP7B
gene at 13q14.3 (most common H1069Q).
Clinical presentation is as follows:
Asymptomatic: family screening
Hepatic (512 years):
Insidious onset with vague symptoms followed by jaundice
Abnormal liver function tests
Acute hepatic failure
Acute hepatitis
Chronic liver disease
Cirrhosis and portal hypertension
Neurological (second decade):
Deteriorating school/work performance
Mood/behaviour changes
Incoordination (e.g. deterioration of handwriting)
Resting and intention tremors
Dysarthria, excessive salivation
Dysphagia
Mask-like facies
Others:
Sunflower cataracts
Acute haemolytic anaemia
Renal, cardiac, skeletal abnormalities
Diagnosis is suggested by:
total serum copper

plasma ceruloplasmin (<200 mg/l)
urinary copper (>5 mol/24 h [baseline], >25 mol/24 h [after penicillamine challenge])
Liver copper concentration (>250 g/g dry weight of liver)
Mutation analysis
KayserFleischer rings
Treatment
Penicillamine 20 mg/kg per day (gradually increased from 5 mg/kg per day)
Pyridoxine 10 mg/week
Other drugs include: triethylene tetramine dihydrochloride (trientine), zinc sulphate/acetate,
tetrathiomolybdate
Liver transplantation:
fulminant hepatic failure
chronic, progression of hepatic dysfunction despite treatment
4. CHRONIC LIVER DISEASE AND END-STAGE LIVER FAILURE

Chronic liver diseases of childhood lead to cirrhosis and/or cholestasis. The resulting fibrosis and
regenerative nodular formation distort the liver architecture and compress hepatic vascular and
biliary structures, resulting in portal hypertension and a vicious cycle of events that worsen the
hepatic injury.
Diagnostic considerations
Confirming the presence and type of liver disease
Compensated may be asymptomatic
Decompensated presence of liver synthetic failure and occurrence of complications
End-stage a persistent rise in bilirubin, prolongation of the INR >1.3, persistent fall in serum
albumin to <35 g/l, faltering growth despite intensive nutritional support, severe hepatic
complications such as chronic hepatic encephalopathy, refractory ascites, intractable pruritus or
recurrent variceal bleeding despite appropriate medical management
Determining aetiology
Assessing complications
Complications and management

Malnutrition and growth failure
Specialized formula ( Na+, MCT [medium-chain triglyceride])

Supplement vitamins A, D, K and E
caloric density of enteral feeds
Continuous nocturnal nasogastric or nasojejunal feeds
Parenteral nutritional support
Portal hypertension
Major cause of morbidity and mortality (3050%)
Portal vein pressure >5 mmHg or portal vein to hepatic vein gradient >10 mmHg:
Splenomegaly hypersplenism
Oesophageal, gastric and rectal varices
Ascites
Encephalopathy
Prevention and management of oesophageal variceal bleeding:
Sclerotherapy
Variceal ligation
Surgical portosystemic shunts
Transjugular intrahepatic portosystemic shunt (TIPS)
Oesophageal transection and devascularization
Pharmacotherapy, e.g. propranolol
Factors that predict bleeding
Portal veinhepatic vein gradient >12 mmHg
Large, tense varices
Red weal marks, red spots on varices
Severity of underlying liver disease
Ascites
50% of patients will die within 2 years of developing ascites
Treatment:
Step 1 sodium restriction (12 mmol/kg per day)
Step 2 spironolactone
Step 3 chlorthiazide/furosemide and fluid restriction
Spontaneous bacterial peritonitis can occur insidiously and causes high mortality
Coagulopathy
Vitamin K malabsorption/deficiency
Vitamin K-dependent coagulation protein deficiencies (factors II, VII, IX and X)
Hypofibrinogenaemia and dysfibrinogenaemia
Thrombocytopenia
Consumption coagulopathy
Parenteral vitamin K and transfusion of fresh frozen plasma (prothrombin time >40 s) or platelets
(<40 109/l)
Hepatopulmonary syndrome
Triad of:
Liver dysfunction
Intrapulmonary arteriovenous shunts
Arterial hypoxaemia arterial oxygen pressure <9.3 kPa (70 mmHg) in room air and an
alveolar/arterial gradient of >20 mmHg (2.7 kPa)
Type 1 functional shunt
Type 2 anatomical
Should be suspected if there is increasing history of breathlessness, cyanosis, clubbing and
platypnoea
Platypnoea and orthodeoxia occur because the intrapulmonary arteriovenous shunts occur
predominantly in the bases of the lung. Therefore, when sitting up or standing, blood pools at the
bases of the lung with resultant increased arteriovenous shunting
Site and extent of shunt is assessed by:
Arterial blood gas analysis
Technetium-99m-labelled macroaggregated albumin ([99mTc]MAA) study
Contrast echocardiogram
Definitive treatment is with liver transplantation
Portopulmonary hypertension
Mean pulmonary artery pressure >25 mmHg, pulmonary capillary wedge pressure <15 mmHg in the
absence of any secondary causes of pulmonary hypertension
Comparison of hepatopulmonary syndrome and portopulmonary hypertension

Hepatopulmonary syndrome
Intrapulmonary vasodilatation
Alveolar arterial gradient >2.7 kPa (20
mmHg)
Normal mean pulmonary artery pressure
Perform shunt fraction study
Trial of 100% O2
Often reversible with liver transplantation
Poor prognosis: PaO2 <9.3 kPa (300
mmHg) on 100%O2
Histology: pulmonary artery normal
Portopulmonary hypertension
Intrapulmonary vasoconstriction
Alveolar arterial gradient usually normal
Mean pulmonary artery pressure >25 mmHg
Perform right heart catheterization
Vasodilator therapy trial
May not reverse with liver transplant
Poor prognosis: pulmonary artery pressure >45
mmHg
Histology: pulmonary artery abnormal; concentric
medial hypertrophy
Hepatorenal syndrome
Diagnostic criteria:
Oliguria: urine output <1 ml/kg per day
Factorial excretion sodium <1%
Urine:plasma creatinine ratio <10
glomerular filtration rate, creatinine
Absence of hypovolaemia
Other kidney pathology excluded
Type 1 rapidly progressive with poor prognosis
Type 2 less precipitous loss of renal function
Mortality rate of >90% with severe liver disease
Reversed with liver transplantation
Causes of chronic liver disease in children

Onset in infancy
Structural
Extrahepatic biliary atresia
Alagille syndrome, biliary hypoplasia
Choledochal cyst, tumours, stones
Storage/metabolic diseases
Carbohydrate defects: galactosaemia, fructosaemia, glycogen storage III and IV
Amino acid defects: tyrosinaemia, urea cycle disorders
Metal storage defects
Lipid storage diseases: Gaucher disease, NiemannPick type C
Fatty acid oxidation defects
Zellweger syndrome
Mitochondrial disorders
Progressive familiar intrahepatic cholestasis syndrome
Total parenteral nutrition-associated cholestasis
Cystic fibrosis liver disease
Haematological: Langerhans cell histiocytosis
Infection/inflammation
Neonatal hepatitis
Hepatitis B and hepatitis C
Onset in childhood
All of the above and:

Autoimmune liver disease
Autoimmune hepatitis
Autoimmune sclerosing cholangitis
Sclerosing cholangitis
Drugs/toxins (e.g. chemotherapy-induced veno-occlusive disease)
Fibropolycystic disorders
Chronic hepatic venous outflow obstruction:
Hepatic vein thrombosis
BuddChiari syndrome
Veno-occlusive disease
Cardiac cirrhosis
4.1 Autoimmune hepatitis

Autoimmune hepatitis has a 75% female preponderance. Other autoimmune disorders are present in
20% and 40% of first-degree relatives may also have autoimmune disease.
Clinical presentation is variable:
Acute hepatitis
Insidious onset
Portal hypertension
Diagnostic criteria are based on:
Serum non-organ-specific autoantibodies
Type 1:
Anti-nuclear antibody (ANA)
Anti-smooth muscle antibody (SMA)
Type 2:
Anti-liverkidney microsomal (LKM-1)
Up to 20% may not have antibodies detectable at presentation
Serum biochemistry:
aminotransferases
Serum IgG:
>1.5 normal
Liver histology
Absence of:
Markers of viral infection and metabolic disease
Excessive alcohol consumption
Use of hepatotoxic drugs
Treatment involves:
Corticosteroids
Azathioprine for poor response or as steroid sparing
Liver transplantation for fulminant hepatic failure or failure of medical therapy
Response to therapy (International Autoimmune Hepatitis Group) is defined as follows:
Marked improvement of symptoms and return of serum aspartate/alanine aminotransferase
(AST/ALT), bilirubin and immunoglobulin levels to completely normal within 1 year and sustained
for at least a further 6 months on maintenance therapy,
Liver biopsy specimen during this period showing minimal activity, or
Marked improvement of symptoms together with at least 50% improvement of all liver test results
during the first month of treatment, with AST/ALT levels continuing to fall to less than twice the
upper limit of normal within 6 months during any reduction towards maintenance therapy,
Liver biopsy within 1 year showing minimal activity
Relapses are common (occurring in 40%).
IgG levels and autoantibody titres correlate with disease activity.
4.2 Chronic viral hepatitis

Hepatitis B and C viruses (HBV and HCV) are the top causative agents
Hepatitis B (a DNA hepadnavirus)

Worldwide prevalence of 5% (chronic carriers)
Transmission:
Perinatal hepatitis B e antigen (HBeAg)-positive mothers have a 7090% risk of transmission
to their offspring
Horizontal parenteral, sexual and environmental transmission
Symptomatic acute hepatitis:
Complete resolution occurs in 90%
Lifelong immunity
Asymptomatic chronic infection (hepatitis B surface antigen [HBsAg] positive for at least 6
months):
90% progress to chronic liver disease
Three stages immune tolerance, immune clearance and residual non-replicative infection
Chronic infection may lead to cirrhosis and hepatocellular carcinoma
Serological markers of HBV
Immunization
Treatment
Immunomodulation interferon-, pegylated interferon

Antivirals lamivudine, famciclovir, adefovir
Not much paediatric experience
50% of patients seroconvert with therapy (adult data)
Liver transplantation for fulminant HBV disease, chronic liver disease, hepatocellular carcinoma
Hepatitis C infection (an RNA flavivirus)

Worldwide prevalence is 3%
Transmission:
From blood transfusion or plasma-pooled products
Vertical transmission (rare)
Usually asymptomatic but leads to cirrhosis over years
One of the most common indications for liver transplantation in adults
Serology:
Anti-HCV antibody positive
HCV RNA positive in two consecutive samples
Treatment:
Interferon- monotherapy
Interferon-/ribavirin combination therapy
Paediatric experience is minimal
70% of patients seroconvert with therapy (adult data)
4.3 Non-alcoholic fatty liver disease (NAFLD)

Most common cause of paediatric liver disease; prevalence ranges from at least 3% in children
overall to about 50% in obese children
Occurs more in boys than in girls (2:1), with genetic and racial predisposition
Associated with obesity although it can occur in non-obese children
Spectrum of disease from simple steatosis to non-alcoholic steatohepatitis (NASH) to advanced
fibrosis and cirrhosis
Metabolic disease as a result of hyperinsulinaemia and insulin resistance
Asymptomatic or may present with abdominal pain, hepatomegaly and acanthosis nigricans. An
elevated ALT with an enlarged echogenic liver on ultrasonography, in the setting of being
overweight or obese and/or evidence of insulin resistance, is highly suggestive, but is not
conclusive, for NAFLD
Liver biopsy is the ultimate standard for the diagnosis and semiquantitative analysis of injury in
NASH
Type 1 NASH (adult pattern) steatosis with ballooning degeneration and/or perisinusoidal
fibrosis in the absence of portal features
Type 2 NASH steatosis along with portal inflammation and/or fibrosis in the absence of
ballooning degeneration and perisinusoidal fibrosis. Central vein is consistently spared, portal
inflammation was predominantly lymphocytic. Type 2 NASH is more common and associated with
younger age and obesity
No proven drug therapy. Management consists of (1) diagnosis and treatment of related metabolic
disturbances such as diabetes and hyperlipidaemia, (2) targeting IR by weight loss (healthy
lifestyle: diet and exercise) or pharmacotherapy and (3) control of the secondary processes
promoting to oxidative stress, inflammation, apoptosis and hepatic fibrosis by using
hepatoprotective agents such as antioxidants
4.4 Liver transplantation

Indications for transplantation
Acute liver failure

Decompensated chronic liver disease
Liver-based metabolic diseases
Liver tumours
Relative contraindications
Severe systemic sepsis
Malignant hepatic tumours with extrahepatic involvement
Severe, irreversible extrahepatic disease (e.g. structural brain damage, severe cardiopulmonary
disease not correctable with surgery)

Severe systemic oxalosis with cardiac involvement (haemodynamic instability)
Mitochondrial cytopathies with multisystem involvement
Giant cell hepatitis with Coombs test-positive haemolytic syndrome
Source of organ
Deceased donor
Living related donor
Type of graft
Whole liver
Segmental graft
Procedure
Orthotopic
Auxiliary
Lifelong immunosuppression is required with:
Calcineurin inhibitors:
Ciclosporin
Tacrolimus
Renal sparing drugs:
Mammalian target of rapamycin (mTOR) inhibitor
Sirolimus (mTOR inhibitor)
Mycophenolate mofetil
Azathiaprine
Interleukin-2 receptor antibodies basiliximab, daclizumab
Others anti-thymocyte globulin, OKT3
Steroids
Postoperative complications
Early:
Graft failure (primary non-function)
Surgical (intra-abdominal haemorrhage, hepatic artery thrombosis, portal vein thrombosis
Drug side effects (renal failure, hyperglycaemia, hypertension)
After first week:
Acute rejection
Biliary leaks and strictures
Persistent wound drainage
Sepsis
Late:
EpsteinBarr virus infection
Side effects of immunosuppression (renal failure, hyperglycaemia, hyperlipidaemia)
Post-transplantation lymphoproliferative disease
Graft rejection
Late biliary strictures, hepatic artery thrombosis or portal vein thrombosis
Recurrent disease (HBV infection, malignant hepatic tumours)
New autoimmune hepatitis
Patient survival
1 year 8090%
5 years 7080%
10years 7075%
5. PORTAL HYPERTENSION
The portal vein contributes to two-thirds of the livers blood supply. Portal venous pressure is a
product of blood flow from the splanchnic circulation and vascular resistance within the liver:
Portal hypertension is defined as a portal vein pressure >5 mmHg or portal vein to hepatic vein
gradient >10 mmHg
A rise in portal pressure leads to splenomegaly and development of portosystemic collaterals and
varices
A gradient of >12 mmHg is associated with the development of oesophageal varices. The junction
between the mucosal and submucosal varices in the lower 25 cm of the oesophagus is the usual
site of variceal bleeding
Not all portal hypertension is a result of intrinsic liver disease although chronic liver disease is the
most common overall cause. Portal vein occlusion is the most frequent extrahepatic cause of portal
hypertension
Presentation is typically with acute gastrointestinal haemorrhage, splenomegaly or as part of the
manifestation of chronic liver disease
In long-standing disease, varices around the common bile duct may cause portal hypertensive
biliopathy resulting in bile duct dilatation and obstructive jaundice
Rarely, pulmonary hypertension may coexist with portal hypertension, more often in children with
chronic liver disease
Anaemia, leukopenia and thrombocytopenia may result from hypersplenism
Management:
Portal hypertension associated with chronic liver disease:
variceal banding or sclerotherapy
liver transplantation if variceal bleeding is uncontrolled with therapy
Extrahepatic portal hypertension:
variceal banding or sclerotherapy
portacaval or mesoportal shunt

Pharmacotherapy is not proven in children
Causes of portal hypertension

Prehepatic (portal vein occlusion)
General factors
Developmental malformation
Septicaemia
Thrombophilia
Myeloproliferative disorders
Paroxysmal nocturnal haemoglobinuria
Protein C deficiency
Protein S deficiency
Antithrombin III deficiency
Factor V Lieden mutation
Anti-phospholipid antibodies
Factor II gene mutation (G20210A)
Homocysteinaemia
Local factors
Umbilical sepsis, catheterization, infusion of irritant solutions

Intra-abdominal sepsis and portal pyaemia
Abdominal trauma
Structural lesions
Cholangitis/choledochal cyst
Pancreatitis
Malignant disease/lymphadenopathy
Splenectomy
Intrahepatic
Presinusoidal
Hepatoportal sclerosis
Neoplasia
Hepatic cyst
Sinusoidal
Chronic liver disease and congenital hepatic fibrosis
Postsinusoidal
Veno-occlusive disease
Posthepatic
BuddChiari syndrome
Chronic constrictive pericarditis
Right ventricular failure
6. LIVER FUNCTION TESTS

This reflects the severity of liver dysfunction but rarely provides diagnostic information on individual
diseases.
Bilirubin
Conjugated (direct) hyperbilirubinaemia:
Specific to liver disease
Conjugated fraction >20% of total bilirubin is indicative of hepatic dysfunction
Unconjugated (indirect) hyperbilirubinaemia
Normal bilirubin levels does not exclude liver cirrhosis
Aminotransferases
AST and ALT

Most common tests of liver cell dysfunction
Intracellular enzymes
Indicate hepatic necrosis
AST is produced in the cytosol and mitochondria of the liver, heart, skeletal muscle, kidney,
pancreas and red cells
ALT is found in the cytosol of liver and muscle cells and so is more liver specific
In isolated AST or ALT elevations, a normal creatine kinase level is helpful in ruling out muscle
pathologies
ALT:AST ratio >1 is suggestive of fibrosis in some liver pathologies such as steatohepatitis and
chronic hepatitis C
There is no correlation between the enzyme levels and the severity of disease
Levels may be normal in compensated cirrhosis or end-stage liver disease
Alkaline phosphatase (ALP)

Found in liver, kidney, bone, placenta and intestine
Reflects biliary epithelial damage

Children have higher ALP levels than adults (bone isoenzyme)
Levels are low in zinc deficiency
-Glutamyltransferase
Present in biliary epithelia, hepatocytes, renal tubules, pancreas, brain, breast and small intestine
Reference range is age related. Normal levels in newborns are five to eight times higher than those
of adults but reach adult values by 9 months
Most sensitive test for hepatobiliary disease but cannot differentiate between extra- and
intrahepatic biliary disease
May be normal in familial intrahepatic cholestasis, bile acid synthesis disorders, ARC
(arthrogryposis, renal and cholestasis) syndrome and very advanced liver disease
Albumin concentration
Reflects the synthetic capacity of the liver

Produced in the liver
Long half-life (1520 days), so it is not decreased in acute liver injury
Levels <35 g/dl in chronic liver disease suggest decompensation
Prothrombin time (PT)

Prolongation of PT >3 s above normal or INR >1.3 may indicate vitamin K deficiency
Failure of INR to normalize after a parenteral dose of vitamin K (1 mg/year of age up to a maximum
of 5 mg) suggests liver failure
Reflects the decreased synthesis of factor VII and IX which have short half-lives
Useful in monitoring progress of acute liver failure
Causes of hepatosplenomegaly
Cirrhosis
(early)
Haematological
Infection
Immune
Metabolic
Proliferative
Storage diseases
biliary atresia, sclerosing cholangitis, congenital hepatic fibrosis

thalassaemia, spherocytosis, sickle cell anaemia
infectious mononucleosis, TORCH, malaria, septicaemia
juvenile rheumatoid arthritis, systemic lupus erythematosus,
immunodeficiency states
1-antitrypsin deficiency, tyrosinaemia, cystic fibrosis
leukaemia, lymphoma, Langerhans cell histiocytosis
Gaucher (long term), NiemannPick, mucopolysaccharidoses
Causes of hepatomegaly SHIRT
S structural
Extrahepatic biliary atresia, choledochal cyst, intrahepatic biliary hypoplasia, polycystic disease,
congenital hepatic fibrosis
Storage/metabolic
Defective lipid metabolism Gaucher disease, NiemannPick disease, hyperlipoproteinaemias,
cholesteryl ester storage disease, carnitine deficiency, mucolipidoses
Defective carbohydrate metabolism diabetes mellitus, glycosyltransferase deficiency (types 1, 3,
4 and 6), hereditary fructose intolerance, galactosaemia, Cushing syndrome,
mucopolysaccharidoses
Defective amino acid/protein metabolism tyrosinaemia (type 1), urea cycle enzyme disorders
Defective mineral metabolism Wilson disease, juvenile haemochromatosis
Defective electrolyte transport cystic fibrosis
Defective nutrition protein calorie malnutrition, total parenteral nutrition
Deficiency of protease 1-antitrypsin deficiency
Defective bile flow progressive familial intrahepatic cholestasis syndrome
H haematological
Thalassaemia, sickle cell disease (chronic haemolysis and transfusion haemosiderosis), acute
lymphoblastic, acute myeloid and chronic myelocytic leukaemias
Heart/vascular
Congestive cardiac failure, constrictive pericarditis, obstructed inferior vena cava, BuddChiari
syndrome
I infection
Viral infection congenital rubella, cytomegalovirus (CMV) infection, Coxsackievirus, echovirus,
hepatitis A, B, C, D and E viruses, infectious mononucleosis
Bacterial infections neonatal septicaemia, Escherichia coli urinary tract infection, tuberculosis,
syphilis
Parasitic infections hydatid disease, malaria, schistosomiasis, toxoplasmosis, visceral larva
migrans
Fungal infection coccidioidomycosis
Inflammatory
Autoimmune liver disease
Inflammatory bowel disease associated liver disease
R reticuloendothelial
Non-Hodgkin lymphoma, Hodgkin disease, Langerhans cell histiocytosis
Rheumatological
Systemic juvenile chronic arthritis, systemic lupus erythematosus
T tumour/hamartoma
Primary hepatic neoplasms hepatoblastomas, hepatocellular carcinoma (hepatoma)
Secondary deposits neuroblastoma, Wilms tumour, gonadal tumours
Vascular malformation/benign neoplasm infantile haemangioendothelioma, cavernous
haemangioma
Trauma
Hepatic haematoma
7. THE PANCREAS
7.1 Acute pancreatitis
Defined clinically as the sudden onset of abdominal pain associated with a rise in amylase or
lipase of at least three times the upper limit in the blood or urine
Rare in children
Involves premature activation of trypsinogen
Presents with epigastric or back pain. May have prominent nausea and vomiting. Less commonly
there may be fever, tachycardia, hypotension, jaundice, and abdominal signs such as guarding,
rebound tenderness and a decrease in bowel sounds
Recurrent acute pancreatitis is seen in 10% of children after a first episode of acute pancreatitis
and is commonly associated with structural abnormalities, idiopathic or familial pancreatitis
The most common cause of familial pancreatitis:
Mutations in cationic trypsinogen gene (e.g. PRSS1) enhance trypsin activation
Mutations in the SPINK1 (serine protease inhibitor Kazal type 1) gene result in an abnormal
pancreatic secretory trypsin inhibitor
Mutations of the CFTR (cystic fibrosis transmembrane conductance regulator) gene, which
reduces the pancreatic fluid secretion capacity, increase the risk of keeping activated trypsin in the
pancreas for a longer period of time
The mainstay of current treatment is analgesia, intravenous fluids, pancreatic rest and monitoring
for complications
Acute pancreatitis scoring system for children that predicts severity of disease and mortality
include the following parameters:

Age (<7 years)
Weight (<23 kg)
Admission white blood cell count (>18.5 109/l)
Admission lactate dehydrogenase (>2000 IU/l)
48-hour trough Ca2+ (<8.3 mg/dl)
48-h trough albumin (<2.6 g/dl)
48-hour fluid sequestration (>75 ml/kg per 48 h)
48-hour rise in urea (>5 mg/dl)
Each criterion is assigned a value of 1 point, cumulative score predicts the outcome of patients
02 points 8.6% severe, 1.4% death
24 points 38.5% severe, 5.8% death
57 points 80% severe, 10% death
Surgical management is limited to debridement of infected necrotic pancreas or cholecystectomy or
endoscopic sphincterotomy in the presence of gallstones
A Cochrane review conducted in 2010 suggested that enteral nutrition significantly reduced
mortality, multiple organ failure, systemic infections and the need for operative interventions
compared with total parenteral nutrition. In addition, there was a trend towards a reduction in
length of hospital stay
Antibiotics are usually not necessary unless in severe pancreatic necrosis
Octreotide infusions may reduce pancreatic secretions in those with pancreatic fluid sequestration
Causes of acute pancreatitis
Idiopathic
Pancreatitis associated with systemic illness
Trauma
Structural abnormalities of pancreas, pancreatic or common bile duct
Medications (valproate, L-asparaginase, prednisolone, azathioprine, 6-mercaptopurine,
furosemide, phenytoin)
Infections (mainly viral, e.g. mumps, enterovirus, EpsteinBarr virus, hepatitis A, CMV, rubella,
Cosackievirus, rubeola, measles, influenza)
Gallstones
Familial (PRSS1, SPINK1 or CFTR mutation)
Post-endoscopic retrograde cholangiopancreatography
Metabolic:
Hypercalcaemia
Hypertriglyceridaemia
Cystic fibrosis
Complications of pancreatitis
Local
Systemic
Oedema
Inflammation
Fat necrosis
Phlegmon
Pancreatic necrosis
Sterile
Infected
Abscess
Haemorrhage
Fluid collections
Pseudocysts
Duct rupture and strictures
Extension to nearby organs
Shock
Pulmonary oedema
Pleural effusions
Acute renal failure, coagulopathy
Haemoconcentration
Bacteraemia, sepsis
Distant fat necrosis
Vascular leak syndrome
Multiorgan system failure
Hypermetabolic state
Hypocalcaemia
Hyperglycaemia
7.2 Chronic pancreatitis

Defined as a complex process beginning with acute pancreatitis and progressing to end-stage
fibrosis as the result of recurrent and chronic inflammatory processes
It is the final common pathological pathway of a variety of pancreatic disorders
Usually associated with genetic conditions such as cystic fibrosis or hereditary pancreatitis or is
idiopathic
Cystic fibrosis is the most important cause of chronic pancreatitis in children. CFTR mutationassociated pancreatitis can be divided into four mechanistic subtypes, where CFTRsev is the severe
CFTR mutation phenotype and CFTRm-v is the mild or variable CFTR mutation phenotype:
Type 1 CFTRsev/CFTRsev genotype
Type 2 CFTRsev/CFTRm-v genotype
Type 3 CFTRsev or CFTRm-v plus a second pancreatitis modifier or susceptibility gene (e.g.
CFTRsev/SPINK1)
Type 4 CFTRsev or CFTRm-v plus a strong environmental risk factor such as alcohol
Pancreatic insufficiency is a sign of chronic pancreatitis but is not diagnostic. The pancreas has
marked functional reserve and has to be severely damaged before functional loss can be clinically
recognized
Faecal elastase <100 g/g is suggestive of severe exocrine pancreas insufficiency
Invasive pancreatic stimulation tests are the standard for assessment of pancreatic insufficiency but
are not usually indicated
Chronic pancreatitis with calcifications can be identified on abdominal radiography or by
transabdominal ultrasonography. When present, the diagnosis of chronic pancreatitis can be made
with 90% confidence
Other abdominal imaging methods used include computed tomography, endoscopic retrograde
cholangiopancreatography, endoscopic ultrasonography, and magnetic resonance imaging or MRCP
(magnetic resonance cholangiopancreatography)

Genetic testing for PRSS1, SPINK1, CFTR and other mutations can be performed if there is history
of recurrent acute pancreatitis, unexplained chronic pancreatitis or presence of a positive family
history of hereditary pancreatitis
8. FURTHER READING
Al-Omran M, AlBalawi ZH, Tashkandi MF, Al-Ansary LA (2010). Enteral versus Parenteral
Nutrition for Acute Pancreatitis. The Cochrane Library.
American Association for Study of Liver Disease (2008). Diagnosis and treatment of Wilson disease:
An update Hepatology 47:2089111.
American Academy of Pediatrics (2004). Management of hyperbilirubinemia in the newborn infant 35
or more weeks of gestation. American Academy of Pediatrics clinical practice guidelines. Pediatrics
114:297316.
Dhawan A, Cheeseman P, Mieli-Vergani G (2004). Approaches to acute liver failure in children.
Pediatric Transplantation 8:5848.
Kelly D, ed. (2008). Diseases of the Liver and Biliary System in Children, 3rd edn. Oxford: WileyBlackwell Publishing.
Kleinman RE, Sanderson IR, Goulet O, Sherman PM, MieliVerhani G (2008). Walkers Pediatric
Gastrointestinal Disease, 5th edn. PMPHUSA.
National Institute for Health and Clinical Excellence (2012). CG98 Neonatal Jaundice. NICE
Guideline. London: NICE.
North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (2004). Guideline
for the evaluation of cholestatic jaundice in infants: recommendations of the North American Society
for Pediatric Gastroenterology, Hepatology and Nutrition. J Paediatr Gastroenterol Nutr 39:11528.
Villatoro E, Mulla M, Larvin M (2010). Antibiotic therapy for Prophylaxis against Infection of
Pancreatic Necrosis in Acute Pancreatitis. The Cochrane Library, Patient Support Resource:
Childrens Liver Disease Foundation. Available at: www.childliverdisease.org.
Chapter 14
Immunology
Pamela Lee and Bobby Gaspar
CONTENTS
1. Key concepts
2. The immune system
2.1 The lymphoid organs
2.2 Cellular origin and components of the immune system
2.3 Generation of immune diversity
2.4 Induction of self-tolerance
2.5 Innate immunity
2.6 Adaptive immunity
3. Approach to a child with recurrent infections

3.1 When to consider a diagnosis of primary immunodeficiency
3.2 Categories of primary immunodeficiencies
3.3 Common patterns of infections in primary immunodeficiencies
3.4 Non-infective manifestations associated with primary immunodeficiencies
3.5 Taking a family history for suspected primary immunodeficiency
3.6 Examining a child with suspected primary immunodeficiency
3.7 Diagnostic approach to common clinical presentations
4. Antibody deficiencies
4.1 Causes of low immunoglobulins
4.2 Defects in early B-cell development
4.3 Class-switch recombination defects
4.4 Common variable immunodeficiency (CVID)
4.5 IgA deficiency
4.6 Transient hypogammaglobulinaemia of infancy
5. Combined immunodeficiencies
5.1 Severe combined immunodeficiency (SCID)
5.2 Combined immunodeficiency
6. Other immunodeficiency syndromes

6.1 WiskottAldrich syndrome
6.2 Ataxia telangiectasia
6.4 Hyper-IgE syndrome
6.5 Chronic mucocutaneous candidiasis
7. Phagocytic disorders
7.1 Congenital neutropenia
7.2 SchwachmanDiamond syndrome
7.3 Cyclical neutropenia
7.4 Leukocyte-adhesion deficiency
7.5 Chronic granulomatous disease
8. Defects of the interleukin-12/interferon- axis

9. Diseases of immune dysregulation
9.1 X-linked lymphoproliferative disease
9.2 Immunodysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX)
9.3 ChdiakHigashi syndrome
10. Complement deficiencies

11. Hypersensitivity reactions
12. Vaccinating the immunocompromised child
13. Immunosuppressants and immune-modulating agents
13.1 T-cell immunosuppressants
13.2 Clinically used monoclonal antibodies/fusion proteins
13.3 Interferons
14. Haematopoietic stem cell transplantation and gene therapy

14.1 Haematopoietic stem cell transplantation
14.2 Gene therapy
15. Further reading
Immunology
1. KEY CONCEPTS
Hostpathogen interaction
From early life humans come into contact with a wide variety of microorganisms, including
bacteria, fungi and virus, which vary in the degree of pathogenicity
Some microorganisms exist as commensals, some commonly cause infections in the neonatal and
childhood period, whereas some remain to be significant human pathogens throughout life
Immunity against specific infectious agents is brought about by a complicated set of interactions
between host and pathogen which, under normal circumstances, maintain an adequate balance
between the two
Increased susceptibility to infectious diseases occurs in individuals with a wide variety of
abnormalities including anatomical, metabolic, haematological, oncological and immunological
abnormalities
Functions of the immune system

Host defence against pathogens
Recognition of self and non-self
Sensing of oncogenic stress and elimination of malignant clones
A functional immune system requires:
Normal development and differentiation of immune cells

Prompt recognition of a diversity of pathogens and initiation of immune response
Generation of specific and effective immune response to pathogens
Immune memory to recall antigens
Sustenance of immune tolerance to self-antigens
Immune surveillance to DNA damage
Check and balance.
Deficient or dysregulated immunity may lead to the following consequences:
Susceptibility to infections
Autoimmunity and allergy
Haemophagocytosis
Malignancy
2. THE IMMUNE SYSTEM

2.1 The lymphoid organs
Central lymphoid organs: generation of lymphocytes bone marrow, thymus
Peripheral lymphoid organs: stations where nave lymphocytes meet antigens and initiate adaptive
immune response lymph nodes, spleen, mucosal-associated lymphoid tissues in the gut, airway,
etc.
2.2 Cellular origin and components of the immune system

Cells of the immune system are derived from bone marrow, pluripotent, haematopoietic stem cells
(HSCs), which are capable of cell renewal
HSCs and the more committed progenitor cells are characterized by the expression of CD34
surface antigen
Common lymphoid progenitor gives rise to T cells, B cells and natural killer (NK) cells
Common myeloid progenitor gives rise to megakaryocyte/erythrocyte progenitor, dendritic cells
and granulocyte/macrophage progenitor, which differentiate into neutrophils, monocytes,
eosinophils and basophils. Monocytes then differentiate into macrophages in the tissues.
Phagocytes
There are three types:
Monocytes/macrophages
Neutrophils
Dendritic cells (DCs)
Neutrophils and macrophages (Figure 14.1): phagocytosis and intracellular killing of pathogens by
various processes including acidification, production of toxic oxygen radicals and nitric oxide,
antimicrobial peptides and lysosomal digestion
Tissue DCs take up pathogens at the site of infection and become activated, after which they migrate
to peripheral lymphoid organs, where they present antigens to nave T cells
Macrophages and DCs are professional antigen-presenting cells (APCs) that activate T cells and
initiate adaptive immune response
Lymphocytes
B cells develop in the bone marrow where assembly of pre-B cell and B-cell receptors by V(D)J
(variable, diversity and joining) immunoglobulin (Ig) gene rearrangement occurs. Immature B
cells migrate to peripheral lymphoid organs, where activation by antigens leads to proliferation
and differentiation into antibody-producing plasma cells (Figure 14.2)
T-cell precursors migrate from the bone marrow to the thymus where V(D)J recombination of T-cell
receptors (TCRs) occurs, and T-cell precursors develop into nave CD4 and CD8 T cells (Figure
14.3)
Nave T-cells that emigrate from the thymus circulate in the bloodstream and enter peripheral
lymphoid organs, where activation, clonal expansion and further differentiation into effector T
cells occur upon antigen encounter (priming)
Some of the antigen-activated T cells and B cells differentiate into memory cells, which promptly
differentiate into effector cells upon re-exposure to the specific antigen
2.3 Generation of immune diversity

The variable region of Ig and TCR is encoded by V, D and J gene segments
The variable region is assembled by random gene rearrangement (somatic recombination) initiated
by the recombination activating genes (RAGs) in the bone marrow and thymus, where primary Ig
and TCR repertoires are generated respectively
Further diversity is generated after antigen stimulation of nave B cells in the germinal centre of
peripheral lymphoid organs:
Class-switch recombination: isotype switching from IgM to IgG/IgA/IgE
Somatic hypermutation: introducing point mutations to the variable region in antigen-activated B
cells to develop high-affinity Ig receptors
DNA breaks and repair are involved in all the three processes
Excision of the intervening gene segments during V(D)J recombination of TCR generates T-cell
receptor excision circles (TRECs), which is an indicator of intact normal T-cell development and
thymic function, and is used as a marker for newborn screening of severe combined
immunodeficiency (SCID)
2.4 Induction of self-tolerance (Figure 14.4)

Central tolerance: immature B cells and T cells that bind strongly to self cell-surface antigens
will be removed from the primary repertoire before they can become bone marrow and thymus,
respectively
Double-positive (CD4+CD8+) T cells expressing receptors with very low affinity for selfpeptideMHC complexes expressed on cortical thymic epithelial cells die by neglect
Immature T cells with receptors that bind self-peptideMHC complex with high affinity will
undergo apoptosis (negative selection or clonal deletion)
Only interactions with an intermediate affinity lead to CD4 or CD8 lineage commitment (positive
selection), followed by passage through the thymic medulla and exit to the periphery
Lymphocytes newly emigrated from central lymphoid organs will be eliminated if they encounter a
strongly cross-linking antigen in the periphery
2.5 Innate immunity

First line of host defence: barriers that prevent the establishment of infection, e.g. skin, tears,
saliva, mucus in the respiratory tract and gut, bile and digestive enzymes in the gastrointestinal
tract, acidity of urine and gastric secretions, normal skin and gut commensals that prevent
colonization of pathogens
Once the epithelial defence is breached, innate immune response is activated locally at the site of
infection
Three important functions of innate immunity:
Recognition: pathogens are recognized by their pathogen-associated molecular patterns (PAMPs)
through germline-encoded pattern recognition receptors (PRRs) on macrophages, neutrophils and
DCs, e.g. toll-like receptors, mannose receptors
Acute inflammatory response: pathogens are engulfed and killed intracellularly by activated
macrophages and neutrophils, which also secrete cytokines and chemokines and further augment the
inflammatory response by recruiting more effector cells and molecules to the site of infection
Induction of adaptive immune response: activated APCs, e.g. DCs, migrate to lymphoid organs
where antigens are presented to T cells and B cells
Complement (Figure 14.5):
Plasma proteins that are activated by pathogens or pathogen-bound antibody

Links innate and adaptive immunity
Classical pathway: C1q, C1r, C1s, C4, C2, C3
Lectin pathway: mannose-binding lectin (MBL), MBL-associated serine protease (MASP) 1 and
2
Alternative pathway: factor B, factor D, properdin (upregulating factor)
Membrane attack complex: C5b, 6, 7, 8, 9
Down-regulating factors: C1 inhibitor, C4-binding protein, factor H, factor I, S protein
Membrane control proteins: decay accelerating factor (DAF)
Cytokines and chemokines:
Produced in response to pathogen recognition
Cytokines: soluble factors that mediate signalling between immune cells, may act in an autocrine,
paracrine or endocrine manner (see table below)
Families of cytokines: interleukins, interferons, tumour necrosis factor (TNF) family
Chemokines: chemoattractants recruiting neutrophils, monocytes and other effector cells to the
site of infection
Families of chemokines: CXCL, CCL
Interferons and cytokines secreted by macrophages activate NK cells which control intracellular
infections, especially virus
Cytokines and chemokines are also secreted by lymphocytes of the adaptive immune system (see
Section 2.6)
Cellular origin and functions of cytokines
2.6 Adaptive immunity

Divided into humoral and cellular responses
Humoral immunity: production of specific antibody against an invading pathogen or vaccine antigen
Cellular immunity: T-cell dependent macrophage activation, cytotoxic T cells
Effectors of adaptive immunity: antigen recognition and effector functions

All T-cell effector functions involve cellcell interactions
Effector T cells recognize peptide antigens bound to the major histocompatibility (MHC) molecule
on the surface of APCs by the T-cell receptor, which delivers the signal for T-cell activation
(Figure 14.6)
CD8 T cells (cytotoxic T cells) recognize viral peptides associated with MHC class I molecules
on the surface of infected cells, and trigger apoptosis by releasing cytotoxic granules into the
cytosol of target cell, thus preventing further replication and spread.
Effector molecules: interferon-, TNF-, perforin, granzymes
Nave CD4 T cells recognize antigens presented by MHC class II molecules, and differentiate into
distinct functional types of effector cells:
T-helper 1 cells: activate macrophages to kill the engulfed intracellular pathogens, e.g.
mycobacteria, salmonellae
Effector molecules: interferon-, TNF-, granulocytemacrophage colony-stimulating factor
(GM-CSF), CD40 ligand, Fas ligand
T-helper 2 cells coordinate humoral immune response with T-helper 1 cells by inducing
differentiation of nave B cells into antibody-producing plasma cells
Effector molecules: IL-4, IL-5, IL-13, CD40 ligand

T-helper 17 cells: recruit neutrophils to the sites of infection
Effector molecules: IL-17A, IL-17F, IL-6
T-regulatory cells: suppress T-cell response and maintain immune homeostasis
Effector molecules: IL-10, transforming growth factor (TGF-)
B-cell receptors recognize extracellular protein antigens of pathogens and differentiate into plasma
cells which secrete antibodies, the functions of which include:
Binding and neutralization of bacterial toxins and viruses
Opsonization of bacteria to facilitate phagocytosis
Activation of complement
Antibody (Figure 14.7)
The soluble form of B-cell receptor

Each Ig molecule is composed of two heavy chains and two light chains ( and )
Each heavy or light chain is composed of constant and variable regions
The constant region of heavy chain defines the isotype and effector functions (see table below)
The variable region corresponds to the antigen-binding site
Digestion with papain releases Fab fragments which bind antigens in the extracellular space
Fc region has complement-activating domains
Effector cells recognize antibody-coated pathogens by their Fc receptors which bind to Fc region of
the antibody
Properties of the five isotypes of immunoglobulin
Generation of immunological memory

A distinctive feature of specific immunity mediated by humoral and cellular systems
Immunological memory is sustained by long-lived antigen-specific lymphocytes induced by
natural infection or immunization
This provides long-lasting protection upon subsequent challenges with the same pathogen by
rapidly mobilizing antigen-specific antibody and effector T cells
Memory is learnt during the development of the immune system, and explains the difference in
frequency of infections between adults and children
3. APPROACH TO A CHILD WITH RECURRENT INFECTIONS
3.1 When to consider a diagnosis of primary immunodeficiency

Infections are common in children school-age children may have 810 upper respiratory tract
infections per year
Infections in otherwise healthy children are usually self-limited and uncomplicated, and the child is
healthy in between episodes with normal growth and development
Primary immunodeficiencies (PIDs) are RARE. Extrinsic or secondary causes for recurrent
infections should be considered first:
Breach of physical barrier:
Sinopulmonary: allergic rhinitis, ciliary dysfunction, cystic fibrosis, aspiration pneumonia
caused by oromotor dysfunction or gastro-oesophageal reflux
Urinary: vesicoureteric reflux
Central nervous system: basal skull fracture
Skin: atopic eczema, burns
Foreign bodies, e.g. indwelling catheters
Secondary immunodeficiencies: immunosuppressive therapy, malignancy, malnutrition, proteinlosing states (nephrotic syndrome, enteropathy), diabetes mellitus, renal failure
Primary immunodeficiencies should be considered if a child has:
Recurrent/persistent infections of unusual severity, often affecting multiple sites
An infection that rapidly progresses and runs a fulminant, life-threatening course
Frequent use of antibiotics and suboptimal treatment response
Infections caused by opportunistic organisms
Failure to thrive
Family history of recurrent infections or early infant deaths
3.2 Categories of PIDs

PIDs occur as many as 1 in 5000 live births, and are categorized according to the defects of specific
immunity:
Humoral (antibody) deficiencies

Cellular deficiencies
Combined deficiencies that affect both humoral and cellular immunity
Phagocytic defects
Defects of the innate immunity
Complement deficiencies
Autoinflammatory disorders
Immune dysregulation
Other well-defined disorders
3.3 Common patterns of infections in PIDs
Recurrent sinopulmonary infections

Chronic diarrhoea
Invasive infections, e.g. meningitis, osteomyelitis, deep organ abscess, bacteraemia
Opportunistic pathogens, e.g. Pneumocystis jiroveci, Cryptosporidium sp.
Chronic/extensive candidiasis
Severe or long-lasting warts, generalized molluscum contagiosum
Recurrent cutaneous or soft tissue abscess/fistula
Complications of live vaccines, e.g. BCG, oral polio, rotavirus, varicella
3.4 Non-infective manifestations associated with PIDs

Autoimmunity, e.g. WiskottAldrich syndrome (WAS), hyper-IgM syndrome
Haemophagocytosis, e.g. familial haemophagocytic lymphohistiocytic (HLH) syndromes
Lymphoproliferation and malignancy, e.g. autoimmune lymphoproliferative syndrome (ALPS),
common variable immunodeficiency (CVID)
3.5 Taking a family history for suspected PID

Family history of recurrent infections, autoimmune and blood diseases, early infant deaths related
to infections or unknown cause
Pattern of inheritance: X-linked, autosomal recessive, autosomal dominant
Parental consanguinity
Ethnic origin: ancestral founder mutations in certain ethnic groups
Examples of X-linked disorders: X-linked agammaglobulinaemia (XLA), X-linked chronic
granulomatous disease (X-CGD), X-linked severe combined immunodeficiency (X-SCID, common
-chain defect), WAS, X-linked lymphoproliferative disease (XLP)
Examples of autosomal dominant disorders: autosomal dominant hyper-IgE syndrome (ADHIES,
caused by STAT3 deficiency), interferon- receptor 1 deficiency
3.6 Examining a child with suspected PID

The patient should be examined for:
1. Site(s) of infection and its severity
2. Evidence/sequelae of past infections
3. Organ damage, e.g. lung, liver
4. Other non-infective manifestations
A systematic approach to physical examination is shown in the table below.
Examining a child with suspected primary infection
General
Faltering growth and falling off centile charts, clinical evidence of wasting
Finger clubbing indicates chronic lung disease
Skin
Eczema: WiskottAldrich syndrome, hyper-IgE syndrome

Petechiae e.g. WiskottAldrich syndrome, autoimmune lymphoproliferative
disease
Scars e.g. perianal fistula: chronic granulomatous disease
Warts e.g. autosomal recessive hyper-IgE syndrome
Paper-thin scars or poor wound healing: leukocyte adhesion deficiency
Complex BCG scar with delayed healing: chronic granulomatous disease
Telangiectasia: ataxia telangiectasia
Hypopigmentation e.g. ChdiakHigashi syndrome
Dysmorphic
Facial dysmorphism e.g. DiGeorge syndrome

Some primary immunodeficiency syndromes are associated with skeletal
dysplasia
features
Eyes
Conjunctivitis: antibody deficiency

Telangiectasia
Ears
Perforated tympanic membrane, chronic draining of ears: antibody deficiency
Oral cavity
Oral candidiasis: T-cell or phagocytic deficiency, defective innate immunity

against fungi
Gingivitis/periodontitis: phagocytic deficiency
Absent tonsils: severe combined immunodeficiency, X-linked
agammaglobulinaemia
Chest
Signs of chronic chest infections/bronchiectasis: antibody deficiency

Scars of chest drain insertion for pneumothorax, pleural fluid drainage
Lymph nodes,
liver & spleen
Lymphadenopathy and hepatosplenomegaly may be caused by infections,

granulomas, lymphoproliferation or malignancy
Joints
Arthritis may be caused by infections or autoimmunity
Neurology
Microcephaly e.g. DNA repair defects

Sequelae of previous central nervous system infection
Ataxia
3.7 Diagnostic approach to common clinical presentations

Approach to an infant with recurrent infections and failure to thrive
Infants are protected by passive transfer of maternal antibodies, which wane after 6 months
T-cell and phagocytic deficiencies should be considered for young infants presenting with
recurrent infections and failure to thrive
Common presentations in a neonate or young infant with primary immunodeficiency:
An infant with recurrent bronchiolitic diseases, oral candidiasis, diarrhoea, poor weight gain,
skin rash and persistent lymphopenia should raise suspicion for SCID
Recurrent infections, bleeding tendency and eczema: WiskottAldrich syndrome
Delayed separation of umbilical cord (>3 weeks): leukocyte adhesion defect (LAD)
Recurrent perianal abscess, perianal fistula, skin abscess: phagocytic disorder
Prolonged discharge from BCG (bacillus CalmetteGurin) scar, disseminated BCG: chronic
granulomatous disease, defects of the IL-12IFN- axis, SCID
Basic investigations:
White cell differentials: note that an absolute lymphocyte count (ALC) <2.5 109 /l is abnormal
in infants
Lymphocyte subset (enumeration of T, B and NK cells) in infants who are lymphopenic
Ig pattern (IgG, IgA, IgM): note that serum IgG in infants under the age of 6 months reflects
passive maternal transfer, and local age-specific reference range should be used for interpretation
of serum immunoglobulin levels in all ages
HIV testing, if clinically appropriate
Further evaluations as guided by clinical features and initial investigations (refer to specific
disease entities below)
SCID is a medical emergency infants with suspected SCID should be urgently assessed and
managed by paediatric immunologists
Approach to a child with recurrent sinopulmonary infections

Sinopulmonary infections include otitis media, sinusitis and bronchopneumonia
Recurrent chest infections may lead to chronic parenchymal damage and bronchiectasis
Common causes for recurrent sinopulmonary infections:
Atopy: allergic rhinitis, asthma
Cystic fibrosis
Structural anomalies, e.g. congenital cystic adenomatoid malformation, lung sequestration,
primary ciliary dyskinesia
Aspiration pneumonia related to swallowing dysfunction or gastro-oesophageal reflux
Recurrent pneumonia caused by encapsulated bacteria, e.g. Streptococcus pneumoniae,
Haemophilus influenzae, Moraxella catarrhalis are common presentations of primary antibody
deficiencies
Patients with cellular immunodeficiencies may present with recurrent bacterial pneumonia, but
often have other opportunistic viral or fungal infections
Sputum culture
White cell differentials: lymphocyte count
Ig pattern (IgG, IgA, IgM)
Total haemolytic complement, C3, C4

Functional antibodies, e.g. anti-diphtheria, anti-tetanus and anti-pneumococcal antibodies; note
that response to polysaccharide antigens is poor until age >2 years
Lymphocyte subset: T- and B-cell count
Screening for cystic fibrosis
CT of the thorax if significant chronic symptoms or abnormalities are apparent on chest X-ray
Always check that patient has not received blood products or intravenous immunoglobulin (IVIG)
before interpreting immunoglobulin levels if the patient has received such products, it is
necessary to wait approximately 3 months before reassessment
Approach to recurrent skin abscess

Secondary causes are more common, e.g. atopic eczema and other chronic dermatoses,
staphylococcal colonization, diabetes mellitus, inflammatory bowel disease
PID associated with recurrent skin abscess:
Phagocytic disorders, e.g. congenital neutropenia, chronic granulomatous disease, leukocyte
adhesion deficiency
IL-12IFN- axis defects for Mycobacterium bovis BCG and atypical mycobacterial infections
Hyper-IgE syndrome
White cell differentials: neutrophil, lymphocyte and platelet count
Blood film: neutrophil and platelet morphology
Blood glucose: to rule out diabetes mellitus
Skin swab for culture
Ig pattern (IgG, IgA, IgM and IgE)
Specific investigations guided by clinical features and initial investigations (see relevant sections)
Approach to fungal infections

Oral or perineal candidiasis is common in neonates and young infants, but unusually severe,
treatment-refractory candidiasis warrants attention
Mucocutaneous candidiasis and invasive fungal infections are common in immunocompromised
hosts, e.g. recipients of chemotherapy or immunosuppressants
Opportunistic fungal infections commonly associated with PID:
Yeasts: Candida sp., cryptococci
Filamentous moulds: Aspergillus, Mucor spp.
Endemic mycoses, e.g. histoplasmosis
PID associated with fungal infections:
Phagocytic disorders
Cellular immunodeficiencies, e.g. SCID, DiGeorge syndrome, CD40 ligand deficiency (X-linked
hyper-IgM syndrome)
Hyper-IgE syndrome
Common variable immunodeficiency
Chronic mucocutaneous candidiasis syndromes (see Section 6.5)
White cell differentials: neutrophils, lymphocytes
Blood glucose: to rule out diabetes mellitus
Ig pattern (IgG, IgA, IgM and IgE)
HIV serology
Lymphocyte subset
Specific investigations guided by clinical features and initial investigations (see relevant sections)
Summary of clinical indications and stepwise approach of immunological investigations for
suspected primary immunodeficiencies (see table).
4. ANTIBODY DEFICIENCIES
4.1 Causes of low immunoglobulins
Primary antibody deficiencies:
Account for 65% of all primary immunodeficiencies
Three main groups:
1. Defects in early B-cell development
2.Class-switch recombination defects
3. Common variable immunodeficiencies
Other less severe forms of antibody deficiencies: selective IgA deficiency, IgG subclass
deficiency, transient hyopgammaglobulinaemia of infancy (see Sections 4.5 and 4.6)
Prematurity: transfer of maternal antibody to fetus is low before 36 weeks gestation
Excessive losses: nephrotic syndrome, protein-losing enteropathy, severe burns involving large
body surface area
Drug-induced: antimalarials, captopril, carbamazepine, phenytoin, gold salts, sulfasalazine
Infections: HIV, EpsteinBarr virus (EBV), congenital cytomegalovirus, congenital toxoplasmosis
Others: malignancy, systemic lupus erythematosus (SLE)
4.2 Defects in early B-cell development

X-linked agammaglobulinaemia (XLA) accounts for 85% of cases; the rest are autosomal
recessive forms
XLA is caused by defect in the Bruton tyrosine kinase (Btk) involved in the B-cell signal
transduction pathway, leading to arrest in B-cell differentiation at the pre-B-cell stage
Autosomal recessive agammaglobulinaemia is clinically indiscernible from XLA.
Defects include components of the pre-B-cell receptor ( heavy chain, 5 surrogate light chain),
signal transduction molecules (Ig and Ig, BLNK and CD19
Panhypogammaglobulinaemia with low B-cell numbers
Pattern of infections:
Onset: over 36 months of age when maternal antibodies fall below protective level; majority
present with recurrent infections before age 2 years
Some patients with atypical form may present beyond adolescence and have milder phenotype
with small number of circulating B cells and borderline Ig levels
Recurrent infections caused by encapsulated bacteria such as Streptococcus pneumoniae and
Haemophilus influenzae, e.g. otitis media, sinusitis, conjunctivitis, pneumonia and empyema,
septicaemia, meningitis
Giardiasis
Pyoderma gangrenosum and pseudomonas sepsis, especially in young infants
Enterovirus encephalomyelitis
Arthritis caused by Mycoplasma and Ureaplasma spp.
Absence of tonsils and lymph nodes is a characteristic physical finding

Investigations:
Low IgG (classically <0.2 g/l), IgA and IgM
Poor or absent antibody response to vaccines
CD19+ B cells <2% of total lymphocyte count
Btk expression in CD14+ monocytes by flow cytometry
BTK gene mutation analysis
Treatment:
Immunoglobulin replacement
Early antibiotic treatment for infections
Prophylactic antibiotics if frequent chest infections
Monitoring:
Trough IgG levels to guide the adjustment of immunoglobulin replacement dose
Chest X-ray/CT of the thorax to detect development of bronchiectasis
4.3 Class-switch recombination defects

Failure of class switch from IgM to IgA and IgG, resulting in elevated or normal IgM but low IgG,
IgA and IgE
Three groups of disorders:
1. Defective CD40LCD40 interaction: CD40 ligand (CD40L) and CD40 deficiencies
2. Defect in CD40-mediated NF-B activation: anhidrotic ectodermal dysplasia with
immunodeficiency (EDA-ID) caused by NEMO gene mutation
3. Defects initiating double-stranded DNA breaks in the process of class-switch recombination:
activation-induced cytidine deaminase (AID) and uracil-N-glycosylase (UNG) deficiencies
CD40L deficiency constitutes 70% of class-switch recombination defects and is transmitted by Xlinked inheritance; the remaining are autosomal recessive and very rare
CD40L deficiency (X-linked hyper-IgM syndrome)

Class-switch recombination is induced by the binding of CD40L on activated T cells and CD40 on
B cells
Defect of CD40L leads to both cellular and humoral immunodeficiency
Most patients present before the age of 2 years
Recurrent sinopulmonary infections caused by encapsulated bacteria
Pneumocystis jiroveci pneumonia (PCP formerly Pneumocystis carinii)
Cryptosporidium enteritis and sclerosing cholangitis
Viral infections, e.g. cytomegalovirus, herpes simplex virus, parvovirus B19
Mycobacterial infections
Patients with associated neutropenia may develop pyogenic or fungal infections
Other manifestations and long-term complications:
Anaemia and neutropenia
Autoimmunity: thrombocytopenia, seronegative arthritis, inflammatory bowel disease

Bronchiectasis
Hepatic complications (sclerosing cholangitis, liver cirrhosis, liver failure, hepatic and biliary
tract malignancy) constitute major cause of mortality in adult patients
Haematological malignancies
50% of patients die before the fourth decade despite optimal Ig replacement
Investigations:
Raised/normal IgM, low IgG and IgA
T- and B-cell numbers often normal
Absent CD40 ligand expression on activated T cells by flow cytometry
CD40L gene mutation
Treatment and monitoring:
PCP prophylaxis with co-trimoxazole
Ig replacement
Drinking water must be boiled
Screen stool for cryptosporidium infection; however, eradication is often unsuccessful
(paramomycin, azithromycin)
Monitor liver function and ultrasound, cholangiography and liver biopsy in selected cases
Chest imaging to monitor for bronchiectasis
Patients with severe neutropenia may require granulocyte colony-stimulating factor (GCSF)
Patients with severe disease despite adequate treatment are considered for haematopoietic stem
cell transplant (HSCT)
4.4 Common variable immunodeficiency (CVID)

Recurrent sinopulmonary infections with reduction in two or more Ig isotypes and impaired
vaccine responses usually in patients >2 years
The most common form of clinically significant PID; prevalence 1 in 10 00050 000
Clinically heterogeneous with wide range of presentations and varying severity
Typically presents in adolescence and early adulthood, less commonly in late childhood
Majority of cases are sporadic; 1025% of patients have familial inheritance, mostly in autosomal
dominant fashion
Single gene defects can be detected in only 1020% of patients
Four main groups of clinical manifestations:
Infections:
Sinopulmonary infections caused by encapsulated bacteria
Gastroenteritis: Giardia intestinalis (lamblia), Campylobacter jejuni
Severe varicella-zoster virus (VZV) infection, recurrent herpes zoster
Rarely PCP and atypical mycobacterial infections in those with abnormal T-cell function
Autoimmunity:
Occurs in over half of the patients
Haematological: cytopenia, e.g. autoimmune haemolytic anaemia (AIHA), immune
thrombocytopenia purpura (ITP)
Gastrointestinal: pernicious anaemia, Crohns disease
Skin: vitiligo
Endocrine, e.g. thyroiditis
Rheumatological: rheumatoid arthritis, SLE, dermatomyositis, Sjgren syndrome
Granulomatous disease:
Non-caseating granulomatous inflammation with sarcoidosis-like lesions involving the lungs,
liver, skin, spleen, gastrointestinal tract
Non-malignant lymphoproliferative disease:
Splenomegaly, lymphadenopathy, follicular nodular lymphoid hyperplasia of gastrointestinal
tract
Long-term complications:
Bronchiectasis
Chronic diarrhoea and malabsorption
Gastrointestinal obstruction caused by granuloma
Increased risk of malignancy: non-Hodgkin lymphoma, gastric cancers
Investigations:
Reduction in at least two of IgG, IgA and IgM
Impaired functional antibody response to vaccines
CD19+ B cells >1% of total lymphocyte count; may have CD4 lymphopenia
B-lymphocyte memory panel: reduction in class-switched memory B cells
20% of patients have impaired lymphocyte proliferation
Management:
Ig replacement if significant hypogammaglobulinaemia with poor functional antibody response
Prophylactic antibiotics if frequent infections
Regular monitoring of blood count, renal and liver function, thyroid function
Lung function test and CT of the thorax to monitor development of bronchiectasis
Surveillance for autoimmunity and malignancy, e.g. autoimmune markers, endoscopy
Immunosuppressive therapy, e.g. steroid for autoimmune diseases and granulomatous
manifestations
Severe cases may require haematopoietic stem cell transplantation
4.5 IgA deficiency
Estimated prevalence of 1:6001:300 in white people; the most common form of PID
Usually asymptomatic
Increased risk of atopy, and pulmonary and gastrointestinal infections
Association with IgG2 deficiency
Possible complications: autoimmunity, ulcerative colitis, Crohn disease, coeliac disease,
malignancy
Diagnosis:
Serum IgA <0.07 g/l in a male or female aged >4 years
Normal IgG and IgM
Normal IgG response to immunizations
Other causes of hypogammaglobulinaemia excluded
30-40% have antibodies to IgA; there is risk of anaphylactic reactions to blood products or Ig but
the incidence is extremely rare. Individuals who are IgA deficient with anti-IgA should be given an
IgA-deficient antibody card
Management: early use of antibiotics at the onset of infection, prophylactic antibiotics if frequent
infections
4.6 Transient hypogammaglobulinaemia of infancy (THI)

Normally serum IgM is detected by 1 week of age and reaches adult levels by 12 months, whereas
IgA is detectable by 2 weeks and reaches adult levels by 7 years; IgG reaches adult levels by 712
years
THI refers to delayed maturation of normal Ig production and antibody response
In THI, there are normal numbers of B cells, distinguishing this from congenital
agammaglobulinaemias such as XLA
Most infants with THI have repeated minor infections; major infections uncommon unless Ig levels
are very low and Ig replacement may be necessary during this period
Serum Ig and vaccine response eventually normalizes with age, and needs to be documented
5. COMBINED IMMUNODEFICIENCIES
5.1 Severe combined immunodeficiency
SCID arises from severe defects in both cellular and humoral immunity, typically characterized by
lymphopenia and hypogammaglobulinaemia
Abnormality in T-cell development and differentiation with variable defects in B-cell and NK-cell
development, arising from impairments in:
Cytokine signalling, e.g. common gamma chain (c), IL-7, JAK3, STAT5b
T-cell receptor signalling, e.g. CD3 subunits, ZAP70
Antigen presentation, e.g. MHC class I and II deficiencies
V(D)J recombination, e.g. RAG1, RAG2, Artemis, ligase IV
Basic cellular processes, e.g. disorder of purine metabolism (adenosine deaminase deficiency,
purine nucleoside phosphorylase deficiency) and mitochondrial energy metabolism (reticular
dysgenesis)
Estimated incidence of all forms of SCID is 1:50 0001:500 000 live births
Males affected more than females because X-linked SCID caused by c deficiency is the most
common form of SCID; all the remaining forms are autosomal recessive
Classical SCID
Infants with classical SCID present early with recurrent, often life-threatening infections at a mean
age of 67 months
Respiratory complications interstitial pneumonitis caused by PCP, respiratory syncytial virus,
cytomegalovirus (CMV), adenovirus, influenza and parainfluenza infections. Bacterial and fungal
pneumonias are also common.

Diarrhoea and faltering growth there may be a viral aetiology (rotavirus, adenovirus) but in
many cases no cause is defined. Faltering growth as a result of diarrhoea or recurrent infection is
seen in nearly all patients.
Persistent oral thrush and perineal candidiasis
BCG-related complications, e.g. abscess formation at the site of inoculation, ipsilateral axillary
lymphadenopathy, disseminated BCG
Disseminated viral infections, e.g. CMV hepatitis, encephalitis, viraemia
Skin rash may be the result of a viral infection but an erythrodermic macular rash is often
indicative of maternal T-cell engraftment or Omenn syndrome
Absent lymphoid tissues
Investigations:
Lymphopenia: absolute lymphocyte count <2.5 109 /l is abnormal in infants
Chest X-ray: absent thymic shadow, signs of interstitial pneumonitis and hyperinflation
Low IgG, IgA and IgM: note IgG level may reflect residual maternal IgG; IgM and IgA production
is impaired
HIV infection can also present as faltering growth with a similar spectrum of infectious
pathogens, and should first be excluded (see Section 7.1, Chapter 15)
Red cell adenosine deaminase (ADA) levels and metabolites
Lymphocyte subsets: T-, B- and NK-cell numbers and proportions can be indicative of an
underlying molecular defect and further investigations, including genetic diagnosis
The same immunological phenotype can arise from different molecular defects (genetic
heterogeneity Figure 14.8)
Exceptions to the above scheme (denoted as T+B+ or T+B SCID) include:

Omenn syndrome: characteristic immunological profile with activated non-functional CD8+ cells
and oligoclonality
Maternal engraftment: maternal T cells that are mostly non-functional CD8+ cells
Atypical variants: for many of the defined forms there have been reports of less severe phenotypes
where there may be small but abnormal numbers of T/B or NK cells
Omenn syndrome
Exaggerated inflammatory response caused by emergence of oligoclonal T-cell populations, often
autoreactive in nature
Clonally expanded T cells infiltrate various tissues:
Skin: generalized erythroderma with thickened and leathery skin, alopecia, loss of eyebrows and
eyelashes
Gut: chronic diarrhoea, protein loss leading to generalized oedema
Reticuloendothelial system: lymphadenopathy, hepatosplenomegaly
Often presents within first few weeks of life
May have lymphocytosis rather than lymphopenia because of clonal T-cell expansion. Therefore, a
normal ALC does not exclude SCID
Eosinophilia and raised IgE is characteristic
Omenn syndrome is most frequently described in RAG1 or RAG2 deficiency, in which B cells are
absent
Maternofetal engraftment
Patients with SCID lack functional T cells and cannot reject foreign lymphocytes
Maternal T lymphocytes that have crossed the placenta engraft in the infant, mediating a graftversus-host process
Commonly present as morbiliform erythroderma or papular dermatitis
A similar condition may occur with viable donor lymphocytes acquired from non-irradiated red
blood cell transfusion
Management
Specific treatment of infectious complications

Protective isolation, strict handwashing measures
Supportive nutrition, skin care, genetic counselling for family
Avoid breast-feeding if mother is CMV positive
CMV negative and irradiated blood products
Antimicrobial prophylaxis:
Co-trimoxazole for prevention of PCP
Aciclovir as antiviral prophylaxis
Itraconazole/fluconazole as antifungal prophylaxis
Ig replacement
Exogenous enzyme replacement using bovine ADA conjugated to polyethylene glycol (PEG-ADA)
provides detoxification and stabilizes the condition while awaiting haematopoietic stem cell
transplantation (HSCT)
Curative therapies:
For majority, HSCT is the only curative treatment option; best results if genotypically matched
donor, i.e. sibling, is available (>90% success)
Outcomes for unrelated donor transplantation are approaching those of matched siblings with
reduced intensity conditioning and advances in bone marrow transplant (BMT) supportive care
Gene therapy has been used to treat X-linked SCID and ADA deficiency
5.2 Combined immunodeficiency (CID)

CID refers to a genetically undefined group of immunodeficiencies in which there are variable
defects in T- and B-cell function
CID patients present at a later stage with less severe infections
Over time, immune function deteriorates leading to recurrent infections and resulting in chronic
damage, especially to the liver and lungs
Principles of management are the same as for SCID
HSCT is less successful in CID because of underlying chronic organ damage and increased age of
transplant
Purine nucleoside phosphorylase (PNP) deficiency

Lack of expression of PNP and defect in purine salvage pathway
Triad of immune deficiency, neurological manifestations and autoimmune phenomena
Infective complications are the most common presenting complaint, but generally at a later age than
most SCID types
Two-thirds have neurological problems, e.g. spasticity, global developmental delay
One-third develop autoimmune disease including autoimmune haemolytic anaemia and immune
thrombocytopenia
HSCT offers the only cure, but its effect on correcting or preventing further neurological
deterioration is controversial
6. OTHER IMMUNODEFICIENCY SYNDROMES

6.1 WiskottAldrich syndrome
X-linked inheritance pattern, approximately 110 per million live male births
Classic triad: thrombocytopenia, combined immunodeficiency and eczema; most present before
first year of life
Also susceptible to autoimmunity, lymphoproliferative disease and lymphoreticular
malignancies in later life
WiskottAldrich syndrome protein (WASP) plays a key role in actin cytoskeleton organization in
haematopoietic cells
WASP deficiency leads to global aberrations in innate and adaptive immunity impaired cellular
migration, phagocytosis, immune synapse formation, NK-cell function, T-cell proliferation,

antibody production and memory response, and T-regulatory functions
Considerable clinical heterogeneity; some patients have thrombocytopenia alone (X-linked
thrombocytopenia, XLT) caused by less severe WAS mutations
Bleeding diathesis varies from mucosal bleeding to life-threatening intracranial haemorrhage
Sinopulmonary infections caused by encapsulated bacteria
Skin infections
Viral infections, e.g. CMV disease
Autoimmune manifestations include haemolytic anaemia or neutropenia, nephropathy, arthritis,
enteropathy, peripheral and large-vessel vasculitis
Investigations:
Diagnosis is suggested by classic clinical phenotype and X-linked pedigree
Thrombocytopenia is the most consistent feature
Small-sized platelets (may appear as platelet dusts) on peripheral blood film with low mean
platelet volume (MPV, often <5 fl)
Ig levels are variable, but antibody responses to polysaccharide antigens are impaired
Progressive reduction in T-cell numbers and function
Diagnostic confirmation by abnormal WASP expression on immunoblotting or flow cytometry, and
WAS gene mutation
Management is oriented to the different clinical problems:
Topical treatment for eczema
Thrombocytopenia sometimes responds to high-dose Ig (2 g/kg) and steroids
Platelet transfusion is indicated in life-threatening bleeding episodes or major surgery
Blood product should be irradiated and CMV negative
Splenectomy is performed in selected patients to improve platelet count
Immune defect is treated by prophylactic antibiotics, Ig replacement and aggressive management
of active infections
Immunosuppressive drugs may be needed for autoimmune manifestations
HSCT is curative and survival is better when performed below the age of 5 years
6.2 Ataxia telangiectasia

DNA-repair defect
Clinical features:
Immunodeficiency characterized by lymphopenia and antibody deficiency, with increased
susceptibility to recurrent sinopulmonary infections
Early onset of progressive neurological impairment: cerebellar ataxia and choreoathetosis
Oculocutaneous telangiectasia in those aged 2 years and above
Growth retardation, diabetes and liver dysfunction
Increased risk of developing lymphoid malignancies
Investigations and diagnosis:
IgA levels are reduced and serum -fetoprotein is raised
Cultured cells exhibit increased radiation-induced chromosomal breakage
Clinical diagnosis is supported by genetic analysis (ATM gene mutation)

Management:
Joint management with pulmonologist, neurologist and immunologist
The need for antibiotic prophylaxis and Ig replacement depends on the severity of T-cell and Bcell deficiency
Lung damage is a major cause of morbidity, regular lung function monitoring and chest imaging
are warranted

Developmental defects of the fourth branchial arch, and the third and fourth pharyngeal pouches
caused by monosomic deletion of chromosome 22q11.2
Clinical features:
Dysmorphism: lateral displacement of the inner canthi, short philtrum, micrognathia, ear
abnormalities
Velopharyngeal insufficiency and cleft palate: feeding difficulties, speech problems
Parathyroid hypoplasia: hypocalcaemic tetany
Thymic hypoplasia: majority have partial T-cell defects (reduced T-cell numbers and TCR
repertoire diversity), 1% have thymic aplasia and SCID phenotype
Cardiac: aortic arch and conotruncal anomalies such as truncus arteriosus, tetralogy of Fallot,
interrupted aortic arch or aberrant right subclavian artery
Susceptibility to infections is multifactorial including underlying cellular and humoral defects,
velopharyngeal insufficiency, reflux, cardiac disease and poor nutrition
Increased incidence of autoimmunity in older children, e.g. immune cytopenia, arthritis,
endocrinopathies caused by impaired central tolerance and generation of regulatory T cells
The most common presentation leading to diagnosis is congenital cardiac malformation, and
screening for chromosome 22q11.2 microdeletion is performed as part of the investigations
Diagnosis is confirmed by the detection of 22q11.2 deletion by fluorescent in situ hybridization
(FISH); patients with opportunistic infections and lymphopenia should be investigated as for SCID
Management:
Infants with DiGeorge syndrome should undergo immune evaluations and receive irradiated blood
products if required for surgical procedures
Depending on the severity of immunodeficiency, prophylactic antibiotics and Ig replacement may
be indicated
Thymus transplantation shows promise in patients with complete DiGeorge anomaly
Multidisciplinary inputs from cardiac, respiratory, immunology, general paediatric, speech and
language, clinical and education psychology teams
6.4 Hyper-IgE syndrome (HIES)

A triad of (1) high IgE and eosinophilia, (2) eczema and (3) recurrent skin and pulmonary infections
Autosomal dominant HIES (Job syndrome) is caused by STAT3 mutation
Newborns may present with pustular rash, which evolve into eczematous eruption with chronic
Staphylococcus aureus colonization
Cutaneous cold abscesses (lacking sign of inflammation redness, warmth and pain)
Otitis media, sinusitis, pyogenic pneumonia caused by staphylococci, pneumococci, and
Haemophilus and Pseudomonas spp.
Susceptibility to fungal infections due to impaired Th17 function: chronic mucocutaneous
candidiasis, pulmonary aspergillosis
Non-immunological manifestations:
Typical facies: prominent forehead and chin, deepset eyes, bulbous nose, coarse facial features,
facial asymmetry, high palate
Retained primary teeth
Scoliosis, fractures with minor trauma, osteoporosis, hyperextensibility
Midline anomalies: cleft palate, hemivertebrae
Craniosynostosis, ArnoldChiari I malformation
Vascular abnormalities: arterial tortuosity, dilatation, aneurysm
Food allergy and allergic airway problems are rare
Complications: pneumatocele and spontaneous pneumothorax, pulmonary haemorrhage,
bronchiectasis, increased susceptibility to lymphoma
Investigations:
Eosinophilia, often >0.8 109/l
Raised serum IgE, usually >1000 IU/ml
Reduced Th17 cells
STAT3 gene mutation
Management:
Prophylactic antibiotics and antifungals
Antiseptic baths
Monitoring of lung function and development of bronchiectasis
Autosomal recessive HIES:
Much rarer than AD-HIES
Distinct propensity of developing severe cutaneous viral infections, e.g. molluscum contagiosum,
human papillomavirus (warts), herpes simplex virus and VZV
Other clinical features: autoimmunity, vasculitis
No skeletal or connective tissue abnormalities
6.5 Chronic mucocutaneous candidiasis (CMC)
Presents in childhood with extensive candida infections of the skin, nails and mucous membranes
Related to defects of dendritic cells or impaired Th1 and Th17 immune response
Genetic basis of most cases is unknown, but some monogenic syndromes are described
CMC may be associated with autoimmune endocrinopathies, e.g. hypoparathyroidism and Addison
disease in the entity called autoimmune polyendocrinopathy, candidiasis and ectodermal dysplasia
(APECED) caused by autoimmune regulator (AIRE) gene mutation
Innate immune defects, e.g. CARD9, dectin-1 deficiency
The mainstay of therapy is prophylactic, systemic antifungal therapy
7. PHAGOCYTIC DISORDERS
Neutrophil defects can be classified into:
Reduced numbers of circulating neutrophils
Defective chemotaxis
Defective intracellular killing
Infections are often caused by Staphylococcus aureus and Gram-negative bacteria, e.g.
Pseudomonas spp.
Also at risk of fungal infections
7.1 Congenital neutropenia

Failure of differentiation and maturation of the myeloid lineage
Commonly presents in the first year of life with pyogenic infections often caused by
Staphylococcus aureus
Pattern of infections: cellulitis, skin abscess, osteomyelitis, colitis, septicaemia, meningitis
Diagnosis:
Persistent neutropenia <0.5 109/l over a 3-month period
Extrinsic causes of neutropenia should be excluded, e.g. viral infection, drugs, alloimmune or
autoimmune phenomenon, hypersplenism and malignancy
Bone marrow examination: maturation arrest of myelopoiesis at the level of
promyelocyte/myelocyte stage
Genetic diagnosis for a number of congenital neutropenia syndromes
Treatment:
Aggressive treatment of infections
Most patients respond to G-CSF
Long-term risk of developing myelodysplastic syndromes and leukaemia
HSCT is considered for patients with G-CSF refractoriness, cytogenetic abnormality in bone
marrow or frank malignant transformation
7.2 SchwachmanDiamond syndrome

Combination of pancreatic exocrine insufficiency, skeletal abnormalities and recurrent infections of
lungs, bones and skin
Most patients have neutropenia and up to 25% may develop pancytopenia
The risks of myelodysplasia and leukaemia are increased
HSCT may be curative
7.3 Cyclical neutropenia
Patients recurrently become neutropenic for 36 days over a 21-day cycle (range from 14 days to
36 days)
Presentation: cyclical pattern of stomatitis, oral ulcers or bacterial infections
The condition is autosomal dominant and has been linked to elastase (ELA2) gene mutation
7.4 Leukocyte adhesion deficiency

Defective binding of circulatory neutrophils to vascular endothelium
Three forms of LAD with type I being the most common, which is an autosomal recessive defect of
2-integrin adhesion molecules (CD18) on neutrophils, resulting in defective aggregation and a
paradoxical leukocytosis
Classic presentation:
Delayed separation of umbilical cord (beyond 3 weeks)
Poor wound healing, often without pus
Periodontitis and recurrent orogenital infections
Leukocytosis and neutrophilia, may reach up to 100 109/l in acute infections
Pathogens include Staphylococcus aureus, Aspergillus, Candida spp. and Gram-negative enteric
bacteria
Additional features:
LAD type II: dysmorphism, growth and developmental retardation
LAD type III: thrombocytopenia
Investigation:
LAD type I: abnormal CD11/CD18 complex expression on neutrophils by flow cytometry, genetic
diagnosis (ITGB2 mutation)
Management:
Prophylactic antibiotics and early treatment of infections
HSCT should be considered for severe disease which otherwise results in early death
7.5 Chronic granulomatous disease

A disorder of impaired intracellular killing of pathogens and hyperinflammatory state
Impaired hydrogen peroxide generation and oxidative burst caused by genetic defects of phox
protein subunits constituting the phagocytic NADPH oxidase
X-linked form of CGD (gp91phox deficiency) accounts for two-thirds of cases and usually presents
earlier and with more severe disease than autosomal recessive forms (p47phox, p22phox, p67phox
and p40phox deficiencies)
Faltering growth, severe bacterial infections, abscesses (skin, perianal) or osteomyelitis caused
by Staphylococcus aureus and Pseudomonas spp. within the first year of life are common
Suppurative adenitis
Pneumonia caused by pyogenic bacteria, Nocardia, Aspergillus spp. and Burkholderia cepacia
Osteomyelitis, e.g. Staphylococcus aureus, Serratia marcescens

Non-typhoidal salmonellosis
BCG-osis and atypical mycobacterial infections
Hyperinflammatory state: inflammatory bowel disease, granulomatous lesions and
lymphadenopathy which may result in intrathoracic, gastrointestinal or urinary obstruction
Investigations:
Nitroblue tetrazolium (NBT)/dihydrorhodamine (DHR) tests
Immunoblot or flow cytometric analysis of phox proteins
Mutation analysis
Management:
Prophylactic antibiotics and antifungals
Steroids to treat granulomatous disease
Aggressive use of antifungal agents and granulocyte infusions along with interferon- may be
required to manage severe fungal infections
HSCT offers good chance of cure especially in patients with matched sibling donor
8. DEFECTS OF THE INTERLEUKIN-12-INTERFERON- AXIS

Intracellular pathogens taken up by macrophages or dendritic cells trigger production of IL-12,
which binds to IL-12 receptor on T cells and NK cells to induce IFN- secretion and, in turn,
activate phagocytic-mediated killing through release of TNFs
Defects of the IL-12IFN- axis lead to increased susceptibility to intracellular organisms such as
Mycobacterium and Salmonella spp.
Eight molecular defects have been discovered; the more commonly described forms are defects of
IL-12 receptor 1, IFN- receptor 1 and IL-12p40
Infants may present with disseminated BCG and typical mycobacterial infections, and they are
usually unable to form granulomas
Treatment includes antimicrobials and recombinant IFN-
Successful HSCT has been reported in patients with severe disease
9. DISEASES OF IMMUNE DYSREGULATION

9.1 X-linked lymphoproliferative disease (XLP)
Characterized by defective CD8+ and NK-cell cytotoxicity, T-cell cytokine production and
activation-induced cell death
XLP (Duncan disease) is caused by defect of signalling lymphocytic activation molecule (SLAM)associated protein (SAP) which is critical in the regulation of T-cell stimulation
Another form of XLP is caused by mutation of the X-linked inhibitor of apoptosis (XIAP) gene, with
similar clinical features to SAP deficiency
Unique susceptibility to EBV-driven lymphoproliferative disease, and affected boys are well until
they contract EBV infection usually at 23 years
Clinical features:
Fulminant infectious mononucleosis (60%) manifesting as high fever, generalized
lymphadenopathy, splenomegaly and cytopenia, often complicated by secondary haemophagocytic
lymphohistiocytosis (HLH) characterized by T- and B-cell lymphoproliferation
Lymphoma (30%)
Dysgammaglobulinaemia (30%)
Aplastic anaemia (3%)
Phenotypes can exist together or evolve from one to another
EBV is not always the trigger for these dysregulatory phenomena, and a significant number of
boys are EBV negative
Features of HLH: pancytopenia, serum ferritin and triglyceride, fibrinogen,
haemophagocytosis in bone marrow, spleen, lymph node or cerebrospinal fluid, soluble CD25 in
blood
Hypogammaglobulinaemia, some with dysregulated raised IgM production
Lymphocyte subset: reduced or absent NK T cells, reversed CD4:CD8 ratio
Impaired NK-cell cytotoxicity
Reduced or absent SAP expression by flow cytometry
Mutation of SH2D1A which encodes SAP
Management:
Treatment of HLH with immunosuppression and chemotherapy (etoposide, dexamethasone,
ciclosporin)
Anti-CD20 monoclonal antibody (rituximab) is used to treat EBV infection by eliminating B cells
Ig replacement
HSCT offers the only curative option but risk is high if remission of HLH is not achieved by
medical treatment
Fulminant infectious mononucleosis carries a high mortality rate >90%, and the major cause of
death is hepatic necrosis
In affected boys identified by family history, prophylactic antibiotics and Ig replacement do not
provide protection from severe EBV infection
9.2 Immunodysregulation, polyendocrinopathy, enteropathy, X-linked syndrome

(IPEX)
Onset: infancy
An immunodysregulatory syndrome with a clinical triad of:
Enteritis: commonly presents with intractable diarrhoea, failure to thrive; bowel histology shows
villous atrophy with lymphocytic infiltrate
Endocrinopathy: type 1 diabetes mellitus, hypothyroidism
Dermatitis: eczematous skin rash
Susceptibility to bacterial, viral and fungal infections secondary to enteropathy, dermatitis and
immunosuppression
Other autoimmune manifestations: cytopenia, glomerulonephritis, hepatitis
Investigations:
Eosinophilia is common
May have hypoalbuminaemia caused by protein-losing enteropathy
Hypergammaglobulinaemia
Autoantibodies, e.g. anti-islet cell antibodies
Lack of FOXP3 expression in CD4+CD25+T cells; mutation in FOXP3 gene
Management: imunosuppression, HSCT
High rate of mortality; most die before the age 2 years without HSCT
9.3 ChdiakHigashi syndrome

A lysosome-related organelle disorder with defective exocytosis of intracellular proteins
Affected cell types: NK cells, cytotoxic T cells, phagocytes, melanocytes, neural cells
Clinical features:
Immunodeficiency: recurrent pyogenic infections of the chest and skin
Neurological: weakness, ataxia, peripheral neuropathy, progressive neurodegeneration
Hypopigmentation: oculocutaneous albinism
Accelerated phase: haemophagocytosis, lymphocyte and monocyte infiltration of tissues, often
fatal
Peripheral blood film: giant intracytoplasmic lysosomal granules in neutrophils
Light microscopy of hair shaft: aggregates of pigment granules
Abnormal granule release assay
Mutation of the lysosomal trafficking regulator (LYST) gene
Management: HSCT is the definitive treatment, and should be undertaken before the onset of the
accelerated phase if a matched donor is available
10. COMPLEMENT DEFICIENCIES

Susceptibility to pyogenic infections caused by encapsulated bacteria, usually less severe in
deficiency of the early complement pathway components (C1, C4, C2) compared with deficiency
of properdin, C3 or terminal component
Deficiencies of early complement pathway components more commonly present with autoimmunity,
e.g. systemic lupus erythematosus, glomerulonephritis
Reduction in serum C3, C4 or both; more likely to be a consumptive process, e.g. autoimmune
disease, or infections than congenital complement deficiencies
Functional screening assays of the classic or alternative pathways can be performed in patients
with suspected complement deficiencies
Inherited complement deficiencies and clinical manifestations
AP, alternative pathway; CP, classic pathway; HUS, haemolyticuraemic syndrome. LP, lectin
pathway, MAC, membrane attack complex; SLE, systemic lupus erythematosus
Hereditary angio-oedema
Deficiency of C1 inhibitor leads to spontaneous activation of the classic complement pathway and
the kinin-releasing system
Recurrent acute attacks of facial, airway and periorbital oedema, limb swelling and abdominal pain
The swelling builds up over 12 hours and spontaneously subsides within 4872 hours; does not
respond to antihistamines, adrenaline or steroid
Laryngeal oedema can cause fatal upper airway obstruction
Attacks may be triggered by trauma, including surgery and dental procedures, cold exposure,
anxiety and emotional stress
Often manifests in older children or teenagers and tends to persist throughout lifetime
Autosomal dominant inheritance; positive family history is common
Diagnosis: characteristic clinical features, low C4, reduced C1 inhibitor level
Management: airway and fluid management, C1 inhibitor concentrate (or fresh frozen plasma if not
available); prophylactic drugs, e.g. danazol, if attacks frequent or severe
11. HYPERSENSITIVITY REACTIONS
12. VACCINATING THE IMMUNOCOMPROMISED CHILD

Live vaccines are contraindicated in patients with severe T-cell deficiency, e.g. SCID, Wiskott
Aldrich syndrome, CD40 ligand deficiency and other major immunodeficiencies, e.g. LAD, HIES
BCG should not be given to patients with CGD and IL-12IFN- axis defects
Live vaccines should not be given to patients receiving chemotherapy and systemic
immunosuppressive therapy
Vaccines are not likely to be beneficial while the patient is on Ig replacement, and should be
deferred until at least 3 months after stopping Ig
Patients with antibody deficiency will benefit from seasonal influenza immunization
Patients with sickle cell disease, nephritic syndrome, malnutrition and chronic disease should
receive pneumococcal (if not already given according to standard immunization schedule) and
seasonal influenza immunizations
Post-splenectomy patients should receive pneumococcal, Haemophilus influenzae type b (Hib) and
meningococcal C conjugate vaccines, if not already given according to standard immunization
schedule
Consider giving varicella-zoster vaccine to seronegative family members to provide indirect
protection
13. IMMUNOSUPPRESSANTS AND IMMUNE-MODULATING AGENTS

13.1 T-cell immunosuppressants
13.2 Clinically used monoclonal antibodies/fusion proteins
13.3 Interferons (IFNs)
14. HAEMATOPOIETIC STEM-CELL TRANSPLANTATION AND GENE

THERAPY
14.1 Haematopoietic stem cell transplantation
Offers a curative option for haematological malignancies, congenital immunodeficiencies,
haemoglobinopathies, inherited metabolic defects and autoimmune conditions
Source of haematopoietic stem cells (HSCs):
Bone marrow: in addition to HSCs, also contains mesenchymal stem cells
Peripheral blood stem cells harvested by leukapheresis after giving the donor a course of G-CSF
for stem cell mobilization, a high stem cell dose can be obtained but risk of graft-versus-host
disease (GVHD) is higher
Umbilical cord blood: advantage of less GVHD and faster immune reconstitution, but the number
of cells that are available in a cord blood unit may limit its use in older children and adults
Donor source:
Autologous: collected from the patient, usually before intensive chemotherapy or radiotherapy for
solid tumours, and reinfused to rescue the haematopoietic system; also used for some autoimmune
conditions, e.g. SLE, juvenile idiopathic arthritis
Allogeneic: matched sibling donor (offers best outcome among all donor sources), matched
family donor (often in consanguineous families), haploidentical parent, matched unrelated donor,
unrelated cord blood units
Indications: relapsed leukaemias, primary immune deficiencies, haematological disorders
(Fanconi syndrome, thalassaemia, sickle cell disease) or metabolic conditions
(adrenoleukodystrophy, Hurler syndrome, osteopetrosis)
Conditioning:
Chemotherapy and/or radiotherapy is used to eradicate disease (e.g. leukaemia), prevent rejection
of donor stem cells by existing host immune system and facilitate engraftment of donor cells in the
host bone marrow; in some cases, e.g. X-linked SCID, conditioning may not be necessary
depending on the level of residual immunity
Early post-transplantation complications:
Infections: bacterial, fungal and viral e.g. EBV, adenovirus, CMV
GVHD: mediated by T cells in the graft and graded IIV on the basis of skin rash, liver
impairment and gastrointestinal involvement. Note that donor T cells can mount a graft-versusleukaemia effect which helps to eradicate malignant cells in recipients with leukaemia
Engraftment syndrome
Graft rejection or failure
Organ complications related to toxicities of conditioning agents: mucositis, haemorrhagic cystitis
(cyclophosphamide), veno-occlusive disease (alkylating agents), thrombotic microangiopathy
Late post-transplantation complications: chronic GVHD (skin, gut, liver, sicca syndrome,
bronchiolitis obliterans, cytopenia), incomplete immune reconstitution, growth retardation and
endocrine problems, cognitive impairment in some patients
14.2 Gene therapy

Gene therapy has been used to treat X-linked SCID, ADA deficiency, WiskottAldrich syndrome
and chronic granulomatous disease
The patients own bone marrow stem is harvested for collection of stem cells, followed by ex vivo
gene transfer of the therapeutic gene into the patients stem cells, using a non-replicating viral
vector
The modified viral vector stably integrates into the genome of the recipients stem cells
The gene-modified stem cells are then infused back into the patient
Immune reconstitution follows over a period of several months
Although this approach has been shown to be potentially curative, there is a risk of insertional
mutagenesis whereby oncogenes are activated by the integrating viral vector, leading to the
development of leukaemia, which occurred in several gene therapy recipients
Continuous efforts are made in improving vector design, gene transfer efficiency and safety, and
currently gene therapy is offered to patients with no HLA-matched donors available for
transplantation
15. FURTHER READING

Arason GJ, Jorgensen GH, Ludviksson BR (2010). Primary immunodeficiency and autoimmunity:
lessons from human diseases. Scand J Immunol 71:31728.
Department of Health (2008). Clinical Guidelines for Immunoglobulin Use, 2nd edn. London:
Department of Health. Available at: www.dh.gov.uk/en/index.htm.
Gaspar, HB, Gilmour, KC (2001). Severe combined immunodeficiency molecular pathogenesis and
diagnosis. Arch Dis Child 84:16973.
Johnston SL (2008). Clinical immunology review series: an approach to the patient with recurrent
superficial abscesses. Clin Exp Immunol 152:397405.
National Blood Service, NHS Blood and Transplant (2007). Investigation and clinical management
of suspected reactions to IgA. Available at:
http://hospital.blood.co.uk/library/doc/SPN_DDR_RC_019_03_IgA.doc (accessed on 22 October
2011).
Notarangelo LD. Primary immunodeficiencies (PIDs) presenting with cytopenias. Hematol Am Soc
Hematol Educ Program 2009:13943.
Oliveira JB, Fleisher TA (2010). Laboratory evaluation of primary immunodeficiencies. J Allergy

Clin Immunol 125(suppl 2):S297305.
Steihm ER, ed. (2004). Immunologic Disorders in Children and Infants, 5th edn. WB Saunders.
Wood P, Stanworth S, Burton J et al., on behalf of the UK Primary Immunodeficiency Network
(2007). Recognition, clinical diagnosis and management of patients with primary antibody
deficiencies: a systematic review. Clin Exp Immunol 149:41023.
Chapter 15
Infection Diseases
Nigel Klein and Karyn Moshal
CONTENTS
1. Notification of infectious diseases
2. Pathogenesis of infection
3. Fever with focus
3.1 Central nervous system infections
3.2 Respiratory infections
3.3 Bone and joint infections
3.4 Gastrointestinal infections
3.5 Urogenital infections
4. Fever with no focus/prolonged fever

4.1 Bacteraemia/septicaemia
4.3 Infective endocarditis
4.4 Toxic shock syndrome
4.5 Brucellosis
4.6 Lyme disease
4.7 Listeriosis
4.8 Leptospirosis
4.9 Cat-scratch disease
5. Mycobacterial infections
5.1 Tuberculosis
5.2 Atypical mycobacteria
6. Fungal infections
6.1 Cutaneous fungal infections
6.2 Candidiasis (thrush, moniliasis)
6.3 Aspergillosis
7. Viral infections
7.1 Human immunodeficiency virus
7.2 Hepatitis
7.3 EpsteinBarr virus
7.4 Cytomegalovirus
7.5 Herpes simplex virus
7.6 Varicella-zoster virus
7.7 Parvovirus B19 (erythema infectiosum, slapped cheek or fifth disease)
7.8 Roseola infantum (exanthem subitum or HHV-6)
7.9 Measles
7.10 Mumps
7.11 Rubella (German measles)
7.12 Adenovirus
7.13 Enteroviruses
7.14 Molluscum
8. Parasitic infections
8.1 Toxoplasmosis
8.2 Head lice (pediculosis capitis)
9. Tropical and geographically circumscribed infections

9.1 Malaria
9.2 Enteric (typhoid/paratyphoid) fever
9.3 Dengue fever
9.4 Viral haemorrhagic fevers
9.5 Hantaviruses
9.6 Giardia
9.7 Amoebiasis
9.8 Hookworm
9.9 Leishmaniasis
9.10 Schistosomiasis
9.11 Travellers diarrhoea
10. New and emerging infections

10.1 Severe acute respiratory syndrome
10.2 West Nile virus
10.3 Avian influenza
10.4 H1N1 influenza virus: swine flu
11. Congenital infections

11.1 Diseases
12. Miscellaneous
12.1 Differential diagnosis of prolonged fever
12.2 Differential diagnosis of cervical lymphadenopathy
12.3 Infections commonly associated with atypical lymphocytosis
12.4 Diseases associated with eosinophilia
12.5 Causes of hydrops fetalis
12.6 Oxazolidinones: a new class of antibiotics
12.7 Echinocandins: a new class of antifungals
12.10 Anthrax
12.11 Botulism
12.12 Bovine spongiform encephalopathy and new variant CreutzfeldtJakob disease
13. Further reading
Infectious Diseases
1. NOTIFICATION OF INFECTIOUS DISEASES

Doctors in England and Wales have a statutory duty to notify the local authority, usually the CCDC
(Consultant in Communicable Disease Control), of cases of certain infections: this is done via the
notification book in each hospital.
Notifications of infectious diseases, some of which are microbiologically confirmed, prompt local
investigation and action to control the diseases.
Diseases notifiable (to Local Authority Proper Officers) under the Health Protection (Notification)
Regulations 2010:
Acute encephalitis
Acute meningitis
Acute poliomyelitis
Acute infectious hepatitis
Anthrax
Botulism
Brucellosis
Cholera
Diphtheria
Enteric fever (typhoid or paratyphoid fever)
Food poisoning
Haemolyticuraemic syndrome (HUS)
Infectious bloody diarrhoea
Invasive group A streptococcal disease and scarlet fever
Legionnaires disease
Leprosy
Malaria
Measles
Meningococcal septicaemia
Mumps
Plague
Rabies
Rubella
Severe acute respiratory syndrome (SARS)
Smallpox
Tetanus
Tuberculosis (TB
Typhus
Viral haemorrhagic fever (VHF)
Whooping cough
Yellow fever
As of April 2010, it is no longer a requirement to notify the following diseases: dysentery, ophthalmia
neonatorum, leptospirosis and relapsing fever.
2. PATHOGENESIS OF INFECTION
The course and outcome of any infectious disease is a function of the interaction between the pathogen
and host.
The pathogens
Human infections are caused by bacteria, viruses, fungi and parasites. However, despite the vast
array of potential pathogens, only a minority have the capacity to cause infection in a human host.
Many factors determine an individual organisms ability to initiate disease, but successful organisms
have three essential characteristics: the ability to invade a host; the ability to travel to an environment
within the host that is conducive to their propagation; and the ability to survive the hosts defence
mechanisms. Increasing understanding of the molecular mechanisms underlying these pathogenic
events should enable the development of new treatment strategies.
Bacterial properties important in the pathogenesis of infections

Bacterial characteristic
Function
Pili
Capsular polysaccharide
Enzyme production
Toxin production
Antigen variation
Aid adhesion to host targets

Inhibit phagocytosis
Inactivate antibody, degrade host tissue
Lyse circulating cells
Evade host defences
The host
The essential elements of all components of the immune system are present at birth. Initially, however,
the babys circulating immunoglobulin is derived predominantly from the mother. It is only after
encountering a wide range of potential pathogens that defences fully mature to provide adequate
protection in later life. Meanwhile, these children are particularly susceptible to infections.
The importance of acquiring a fully competent host defence system is illustrated clinically by the
problems encountered in immunodefective individuals, e.g. primary immunodeficiencies, acquired
immune deficiency syndrome (AIDS), and those receiving chemotherapy and radiotherapy. These
patients not only have severe and persistent infections caused by common organisms, but are also
vulnerable to a range of unusual or opportunistic pathogens. The role played by each component of
the host defence system can be deduced from the nature of infections associated with specific
immunological defects, many of which present in childhood.
Immune deficiency and susceptibility to infection

The molecular basis for many primary immunodeficiencies has been established (see Chapter 14).
The table below gives a broad indication of the type of infections experienced by patients with
defects affecting different components of the immune system.
3. FEVER WITH FOCUS

3.1 Central nervous system infections
Meningitis and encephalitis

Encephalitis is predominantly viral in origin.
Common viral causes include:
Enteroviruses
Herpes simplex virus (HSV)-1 and HSV-2
Measles
Mumps
Influenza
Rare causes include:

Adenoviruses, rubella virus, EpsteinBarr virus (EBV), arenaviruses (e.g. Japanese B
encephalitis), rabies virus and Mycoplasma spp., West Nile virus
Herpes simplex virus causes a predominantly encephalitic illness. Aciclovir dramatically reduces
mortality if given early in HSV disease.
The peak incidence of viral encephalitis is in the first 6 months of life with 1 or 2 cases per 1000
children. In about 50% of cases a mild lympho-cellular pleocytosis is seen.
The most common cause of viral meningitis is enterovirus and these infections peak in summer.
Bacterial meningitis
Neisseria meningitidis is the most common cause of community-acquired bacterial meningitis in
the UK, with most cases being N. meningitidis B since the introduction of the conjugate
meningococcal C vaccine.
Streptococcus pneumoniae is the second most common cause
The incidence of Haemophilus influenzae type b (Hib) meningitis has dropped from around 2500
cases per year to fewer than 50 per year since the introduction of the Hib vaccine
A rare, but serious, form of bacterial meningitis is caused by Mycobacterium tuberculosis. This
organism can affect patients of all ages and should be considered in any atypical presentation of
meningitis, particularly in patients presenting with an insidious illness
Neonatal meningitis
In the neonatal period, group B streptococci are the predominant meningeal pathogen, followed by
Gram-negative bacilli, Strep. pneumoniae and Listeria monocytogenes.
Diagnosis of bacterial meningitis
If meningitis is suspected, the diagnosis should be confirmed by lumbar puncture and examination of
the cerebrospinal fluid (CSF).
Specific contraindications to lumbar puncture include:

Signs of raised intracranial pressure with changing level of consciousness, focal neurological signs
or severe mental impairment
Cardiovascular compromise with impaired peripheral perfusion or hypotension
Respiratory compromise with tachypnoea, an abnormal breathing pattern or hypoxia
Thrombocytopenia or a coagulopathy
A lumbar puncture should also be avoided if it causes a significant delay in treatment.
Very high white cell counts of more than 1000/mm3 can be seen in bacterial meningitis. There is a
broad correlation between a predominance of polymor-phonuclear leukocytes in the CSF and
bacterial meningitis. However, lymphocytes may predominate in early or partially treated bacterial
meningitis, in tuberculous meningitis and in neonates.
In bacterial meningitis, the CSF glucose level is usually low with a CSF:blood ratio <0.5, and the
protein level is frequently raised to >0.4 g/l. Numerous studies have now shown that, even after the
administration of intravenous antibiotics, the diagnostic cellular and biochemical changes in the CSF
may persist for at least 48 hours.
Treatment antibiotics for bacterial meningitis
In infants up to 3 months of age a combination of ampicillin and cefotaxime is a logical choice:
cefotaxime provides cover for both neonatal and infant pathogens, and ampicillin is effective against
L. monocytogenes.
Penicillin-resistant meningococci are emerging worldwide, as are chloramphenicol-resistant strains,
but these have not yet resulted in treatment failures. Fortunately, almost all strains in the UK remain
sensitive to the third-generation cephalosporins. At the moment, the routine use of vancomycin for
community-acquired meningitis is not justified in the UK.
If the cause of meningoencephalitis is unclear it is usual to start empirical treatment with aciclovir,
erythromycin and cefotaxime/ceftriaxone to cover HSV, Mycoplasma spp. and bacteria,
respectively
Treatment the role of corticosteroids
Several studies of patients with Hib meningitis have demonstrated some improvement in morbidity
(deafness or neurological deficit) if corticosteroids were given either before antibiotic administration
or at the same time. Data supporting the use of steroids in pneumococcal and meningococcal
meningitis are lacking.
Complications
Convulsions occur in 2030% of children, usually within 72 h of presentation
Subdural collections of fluid are common, particularly during infancy. They are usually sterile and
rarely require aspiration

The most common long-term complication of meningitis is sensorineural deafness. The overall rate
of deafness after meningitis is less than 5%. Hearing impairment is higher in cases of
pneumococcal meningitis than in meningococcal infections
Prevention
Conjugate vaccines against Hib and group C N. meningitidis are routinely given in the UK as part of
the primary course of immunization at 2, 3 and 4 months of age. The conjugate pneumococcal vaccine
is now also part of the routine immunization schedule, and given at 2, 4 and 13 months.
3.2 Respiratory infections

See Chapter 22.
3.3 Bone and joint infections

Bacterial infections of bones (osteomyelitis) and joints (septic arthritis) should be suspected in
infants of children who present with:
Fever
Unexplained limp and/or abnormal posture/gait and/or reluctance to use the limb
Musculoskeletal pain, especially in the presence of local bone or joint tenderness, swelling,
erythema, and complete or partial limitation of movement
Osteomyelitis and septic arthritis may occur separately or together and may affect one or many
joints, often depending on the organism and host immunity
Osteomyelitis
This is either haematogenous (most common), resulting from bacterial seeding to the bone secondary
to a bacteraemia, or non-haematogenous, which is secondary to trauma resulting in compromised
bone tissue which then becomes infected. Long bones, followed by vertebrae, are the most common
sites of infection.
Most common in those aged >1 year or 310 years of age
More frequent in boys than in girls
Mild (often unnoticed) trauma causes bone compromise, allowing bacterial seeding during transient
bacteraemic events and subsequent osteomyelitis
Destruction of the growth plates can occur in neonates, but not in older children
Acute haematogenous osteomyelitis presents as an acute bacteraemic illness with fever and
localized bone symptoms within a week.
Subacute haematogenous osteomyelitis has an insidious onset, over 14 weeks, with fewer
systemic features and more pronounced localized bone signs.
Chronic osteomyelitis lasts for months, often as the result of an infection that has spread from a
contiguous site, e.g. a fracture, or infection with an unusual organism e.g. mycobacteria.
Organisms
Staphylococcus aureus is the most common organism causing osteomyelitis in the normal host,
followed by streptococci. Consider Mycobacterium tuberculosis in patients who present with
chronic or atypical osteomyelitis, as well as Kingella kingae, a more recently recognized pathogen.
Organisms involved in acute haematogenous osteomyelitis
Diagnosis
Increased white cell count (inconsistent) with neutrophilia, increased erythrocyte sedimentation
rate (ESR) and C-reactive protein (CRP) present in 9298% of cases, but is non-specific
Blood cultures positive in only 4060% of cases
Needle aspiration of periosteal space or bone or arthrocentesis if associated septic arthritis
Tuberculin skin test if tuberculosis is suspected
Characteristic radiological changes occur after 1014 days with periosteal elevation and
radiolucent metaphyseal lesions
Technetium bone scan is positive within 2448 h of infection
Magnetic resonance imaging detects changes early in the disease
Malignant and benign bone tumours, e.g. Ewing sarcoma, osteosarcomas, leukaemia with bony
infiltrates and bone infarcts, e.g. sickle cell disease.
Treatment
46 weeks of intravenous antibiotics depending on the organism. The most common cause is Staph.
aureus and should be treated with an anti-staphylococcal penicillin. Some authorities also add
fusidic acid. A definitive diagnosis from bone culture at debridement is optimal. Positive blood
cultures or joint fluid cultures provide useful information
Surgery is required if dead or necrotic bone is present
Associated septic arthritis (especially the hip) requires incision and drainage
Subacute or chronic infections, or disease caused by atypical organisms, e.g. mycobacteria, require
longer courses of antibiotics
Complications
Serious damage to the growth plate can cause differential limb length and a limp (if leg is involved).
Septic arthritis
Serious pyogenic infection of the joint space

Slightly more common than osteomyelitis
Secondary to bacteraemia caused by haematogenous spread
Most common in children aged <3 years and in sexually active young women
Usually monoarticular, except in neonates when it is often multifocal
Characterized by fever and a swollen, painful joint. Similar to haematogenous osteomyelitis.
Neonates often present with crying when changing their nappy because of the movement of the hip
joint.
Organism
Depends on age and immune status of the child
Infectious arthritis may be caused by viral, fungal (very rare in immunologically normal hosts, but
is well documented in the premature neonatal population) or bacterial agents
Septic arthritis implies pyogenic arthritis secondary to bacterial infections, including
Organisms are similar to those in osteomyelitis with Staph. aureus being the most common. Group
A streptococci are also often implicated. Neisseria spp. should be considered
N. meningitidis infection may present with acute or occasionally chronic arthritis
N. gonorrhoeae infection is not uncommon in sexually active teenagers who have polyarticular
septic arthritis
Brucella spp. may cause chronic septic arthritis
Viral infections such as rubella, mumps, parvovirus B19 and hepatitis B

Post-infectious, reactive and immune-complex arthritides
Intermittent polyarticular arthritis of Borrelia burgdorferi (Lyme disease)
Migrating arthritis of rheumatic fever
Connective tissue diseases

Irritable hip a transient synovitis of the hip in children aged <5 years after an upper respiratory
tract infection; there is mild fever and limp with minimal systemic features, a normal ESR and
white cell count, and an almost full range of movement of the affected limb
Diagnosis clinical
Ultrasound scan and aspiration of joint fluid for Gram staining and microbiological culture
Look for associated osteomyelitis
Technetium bone scan
Computed tomography (CT) and magnetic resonance imaging (MRI) can provide useful information
early in the disease
Blood cultures will be positive in 50% of cases
Treatment
Antibiotic treatment depending on the organism for at least 2 weeks
Open surgical drainage is indicated for recurrent joint effusions and for any case of septic arthritis
of the hip at the time of presentation
Needle aspiration of fluid in other joints washout of the joint
Septic arthritis of the hip in a child is an emergency. Immediate open drainage reduces the intraarticular pressure and avoids aseptic necrosis of the femoral head. The femoral metaphysis can be
drilled during this procedure if osteomyelitis is suspected.
3.4 Gastrointestinal infections

See Chapter 10, Section 11.
3.5 Urogenital infections

See Chapter 18, Section 12.
4. FEVER WITH NO FOCUS/PROLONGED FEVER

4.1 Bacteraemia/septicaemia
Definitions
SIRS (systemic inflammatory response syndrome) is defined by the presence of two or more
abnormalities in temperature, heart rate, respiratory rate and white blood count. SIRS can follow
any severe insult including infection, trauma, major surgery, burns or pancreatitis
Sepsis is used to describe SIRS in the context of bacterial infection
Severe sepsis is used to describe a state characterized by hypoperfusion, hypotension and organ
dysfunction
Septic shock is restricted to patients with persistent hypotension despite adequate fluid
resuscitation, and/or hypoperfusion even after adequate inotrope or pressor support
Microbial aetiology of sepsis

The most common organisms in childhood are:
Strep. pneumoniae (decreasing because of the introduction of the pneumococcal vaccine)
N. meningitidis
Hib (drastically reduced in countries with an immunization programme)
Rarer causes of sepsis in healthy children include:
Staph. aureus
Group A streptococci
Salmonella spp.
These may be associated with wound and skin infections, varicella or a history of diarrhoea,
respectively.
In neonates the usual causes of sepsis are:
Group B streptococci
E. coli and other Gram-negative bacteria
L. monocytogenes
In immunocompromised patients:
Gram-negative organisms, such as Pseudomonas aeruginosa
Fungi
In patients with indwelling catheters:
Coagulase-negative staphylococci
Enterococci
Some viruses, including herpesviruses, enteroviruses and adenoviruses, can produce diseases that
may be indistinguishable clinically from bacterial sepsis, particularly in neonates and infants.
Children with chronic diseases are more susceptible to infection with specific organisms, e.g. cystic
fibrosis and pseudomonal infections and sickle cell disease and salmonella infections.
Pathophysiology of sepsis
Lipopolysaccharides from Gram-negative bacteria and a variety of other microbial products have the
capacity to stimulate the production of mediators from many cells within the human host.
Tumour necrosis factor (TNF), interleukin-1 and interleukin-6 are just a few of the many
inflammatory mediators reported to be present at high levels in patients with sepsis. Recently, a
family of receptors has been identified capable of transducing cellular signals in response to bacteria.
These are known as human toll-like receptors.
It is the cytokines and inflammatory mediators that are produced in response to microbial stimuli
which stimulate neutrophils, endothelial cells and monocytes and influence the function of vital
organs, including the heart, liver, brain and kidneys.
The net effect of excessive inflammatory activity is to cause the constellation of pathophysiological
events seen in patients with sepsis and septic shock.
Treatment
Successful treatment involves the administration of appropriate antibiotics, and intensive care with
particular emphasis on volume replacement and inotropic and respiratory support. A number of
adjuvant therapies have been investigated, but, at present, none is used routinely.

In 1967, Tomisaku Kawasaki described 50 Japanese children with an illness characterized by
fever, rash, conjunctival injection, erythema and swelling of the hands and feet, and cervical
lymphadenopathy
Kawasaki disease is associated with the development of systemic vasculitis (multisystem disease
affecting medium-sized muscular arteries) complicated by coronary and peripheral arterial
aneurysms, and myocardial infarction in some patients
It is the most common cause of acquired heart disease in children in the UK and the USA
Kawasaki disease is most common in Japan, where more than 125 000 cases have been reported.
The disease is also more common in Japanese and other Oriental children living abroad.
Children aged between 6 months and 5 years are most susceptible, with peak incidence in children
aged 911 months. Seasonal variation in the disease incidence has been reported, with the peak
occurrence during the winter and spring months
Slight male predominance (1.6:1)
Diagnosis of Kawasaki disease

There is no diagnostic test for Kawasaki disease, so diagnosis is based on clinical criteria
The differential diagnosis includes toxic shock syndrome (streptococcal and staphylococcal),
staphylococcal scalded-skin syndrome, scarlet fever and infection with enterovirus, adenovirus,
measles virus, parvovirus, EpsteinBarr virus, CMV, Mycoplasma pneumoniae, rickettsiae and
Leptospira spp.
Diagnostic criteria
Fever of 5 days duration plus four of the five following criteria:
Conjunctival injection
Lymphadenopathy
Rash
Changes in lips or oral mucosa
Changes in extremities
Or the presence of fever and coronary artery aneurysms with three additional criteria is required
for the diagnosis of complete cases
Incomplete cases comprise those with fewer than the prerequisite number of criteria. Irritability is
an important sign which, although virtually universally present, is not included as one of the
diagnostic criteria
Other relatively common clinical findings in Kawasaki disease include arthritis, aseptic meningitis,
pneumonitis, uveitis, gastroenteritis, meatitis and dysuria, as well as otitis. Relatively uncommon
abnormalities include hydrops of the gallbladder, gastrointestinal ischaemia, jaundice, petechial
rash, febrile convulsions and encephalopathy or ataxia. Cardiac complications other than coronary
arterial abnormalities include cardiac tamponade, cardiac failure, myocarditis, endocardial
disease and pericarditis
Acute phase proteins, neutrophils and the ESR are usually elevated. Thrombocytosis occurs
towards the end of the second week of the illness and therefore may not be helpful diagnostically.
Liver function may be deranged. Sterile pyuria is occasionally observed, and also CSF pleocytosis
(predominantly lymphocytes) representing aseptic meningitis
Treatment of Kawasaki disease

Treatment of Kawasaki disease is aimed at reducing inflammation and preventing the occurrence of
coronary artery aneurysms and arterial thrombosis. Patients receive aspirin and intravenous
immunoglobulin (IVIG) 2 g/kg as a single dose infused intravenously. If no response a further dose of
IVIG can be given. Increasingly other interventions are being used including high dose steroids or
anti-TNF.
An echocardiogram is performed at 1014 days, 6 weeks, 6 months and then at further times if an
abnormality is detected.
Cardiac complications of Kawasaki disease

2040% of untreated Kawasaki disease patients develop coronary artery abnormalities
50% of these lesions regress within 5 years, and regression occurs within 2 years in most cases of
mild coronary artery aneurysms (34 mm)
The risk of these complications is markedly reduced with the use of IVIGs and other interventions
In 1993, a report from the British Paediatric Surveillance Unit (BPSU) indicated a mortality rate of
3.7% in the UK for Kawasaki disease. Current mortality rates reported from Japan are much lower at
0.14%.
4.3 Infective endocarditis

Usually occurs as a complication of congenital or rheumatic heart disease or of prosthetic valves,
but it can occur in children without cardiac malformations
There is an increased risk with central lines and intravenous drug use
Highest-risk lesions are those associated with high-velocity blood flow, e.g. ventricular septal
defects, left-sided valvular lesions and systemic pulmonary arterial communications
Uncommon with atrial septal defects
Vegetations occur at the site of endocardial erosion from turbulent flow
Organisms
Most common organisms
Native valve:
Streptococcus viridans group (Strep. mutans, Strep. sanguis, Strep. mitis)
Staph. aureus
Enterococci (e.g. Strep. faecalis, Strep. bovis)
Prosthetic valves:
Staph. epidermidis
Staph. aureus
Strep. viridans
Uncommon organisms
Strep. pneumoniae, H. influenzae, Coxiella burnetii (Q fever), Chlamydia psittaci, Chlamydia
trachomatis and Chlamydia pneumoniae, Legionella spp., fungi and the HACEK organisms
(Haemophilus spp. [H. parainfluenzae, H. aphrophilus, H. paraphrophilus], Actinobacillus
actinomycetem comitans, Cardiobacterium hominis, Eikenella corrodens and Kingella kingae)
Acute: fever and septicaemia
Non-acute: more common prolonged fever, non-specific symptoms, e.g. fatigue, myalgia,
arthralgia, weight loss, or no symptoms at all
New murmurs or changes in known murmurs, splenomegaly, neurological manifestations, e.g.
emboli, cerebral abscesses (usually Staph. aureus), mycotic aneurysms and haemorrhage
Cardiac failure from valve destruction
The classic skin lesions occur late in the disease and are now rarely seen, e.g. Osler nodes (tender
nodules in pads of the fingers and toes), Janeway lesions (painless haemorrhagic lesions on soles
and palms) and splinter haemorrhages (linear lesions below nails). These are caused by circulating
antigenantibody complexes
Investigations
At least three separate blood cultures are taken from different sites and at different times over 2
days, cultured on enriched media for >7 days. This increases the likelihood of a positive yield, as
does an increased volume of blood inoculum in each blood culture bottle
Look for raised white cell count, high ESR, microscopic haematuria
Echocardiography the presence of vegetations or valvular abnormalities
Treatment
Broad-spectrum intravenous antibiotics, e.g. penicillin and gentamicin or vancomycin and
gentamicin (depending on the most likely organism), at high bactericidal levels should be started as
soon as possible after the blood cultures have been taken, because delay causes progressive
endocardial damage
Treatment duration is usually 46 weeks, but may be shorter for fully sensitive organisms
Surgical intervention may be required
Prevention
Antibiotic prophylaxis is no longer recommended for dental procedures or for patients undergoing
non-dental procedures involving the upper and lower gastrointestinal (GI) tract, genitourinary tract,
and upper and lower respiratory tracts
4.4 Toxic shock syndrome

Syndrome of high fever, conjunctivitis, diarrhoea, vomiting, confusion, myalgia, pharyngitis and
rash with rapid progression to severe, intractable shock in some cases
Caused by exotoxins produced by Staph. aureus, e.g. staphylococcal enterotoxin B or C (SEB,
SEC) or toxic shock syndrome toxin-1 (TSST-1) or group A streptococci, e.g. streptococcal
pyrogenic exotoxin A (SPEA)
In staphylococcal toxic shock the focus of infection is often minor, e.g. skin abrasion
Classically occurred in the past in females using tampons
In streptococcal toxic shock the focus is usually severe and deep-seated, e.g. fasciitis and myositis
Superantigen mediated, i.e. causes massive, non-major histocompatibility complex-restricted, Tcell response
Diagnostic criteria
Fever >38.8C
Diffuse macular erythroderma

Desquamation 12 weeks after onset, especially on palms and soles
Hypotension
Involvement of three or more organs GI tract, renal, hepatic, muscle, central nervous system
(CNS); mucositis, disseminated intravascular coagulation
Diagnosis
Clinical
Identification of toxin or antibodies to toxin
Treatment
Supportive
Intravenous antibiotics: clindamycin or linezolid
4.5 Brucellosis
Brucella species (e.g. B. abortus, B. melitensis) are non-motile Gram-negative bacilli
Zoonotic disease, transmitted to humans by ingestion of unpasteurized milk or by direct inoculation
to abraded skin
Incubation period 14 weeks
Disease is often mild in children
Acute brucellosis
Fever, night-sweats, headaches, malaise, anorexia, weight loss, myalgia, abdominal pain, arthritis,
lymphadenopathy, hepatosplenomegaly
Complications include meningitis, endocarditis, osteomyelitis
Chronic brucellosis
Fevers, malaise, depression, splenomegaly
Diagnosis
Prolonged culture of blood, bone marrow or other tissue, paired serology
Treatment
Co-trimoxazole at high dose and rifampicin for 6 weeks
Alternative regimen in children over 8 years: doxycycline and rifampicin for 6 weeks
4.6 Lyme disease

Disease occurs on the east coast of the USA and in parts of Europe and the UK
Caused by spirochaete Borrelia burgdorferi, transmitted by ixodes ticks
Incubation from tick bite to erythema migrans is 331 days
Clinical manifestations
There are three stages:
Early localized distinctive rash (bulls eye lesion) erythema migrans red macule/papule at
site of tick bite, which expands over days/weeks to large annular erythematous lesion with partial
clearing, approximately 15 cm in diameter. Associated with fever, malaise, headache, neck
stiffness
Early disseminated 35 weeks after bite multiple erythema migrans, cranial nerve palsies
especially cranial nerve VII, meningitis, conjunctivitis, arthralgia, myalgia, headache, malaise,
rarely carditis
Late disease recurrent arthritis, pauciarticular, large joints, neuropathy, encephalopathy
Diagnosis
Clinical
Serology and immunoblotting to detect production of antibodies to B. burgdorferi can be
problematic because they are negative in early disease and, once present, persist beyond resolution
of disease
Polymerase chain reaction (PCR) amplification currently a research tool only
Treatment
Doxycycline for child >8 years (avoid sun exposure), or amoxicillin if <8 years for 1421 days if
early disease, 2128 days if disseminated or late disease
Intravenous ceftriaxone or intravenous penicillin if meningitis, encephalitis, carditis or recurrent
arthritis
4.7 Listeriosis
Caused by Listeria monocytogenes, a Gram-positive bacillus
Variable incubation of 370 days
Isolated from a range of raw foods, including vegetables and uncooked meats, as well as processed
foods and soft cheeses and meat-based pts
Most cases are believed to be food borne. Some cases are the result of direct contact with animals.
Mother-to-fetus transmission in utero or during birth or via person-to-person spread between

infants shortly after delivery
Unborn infants, neonates, immunocompromised individuals, pregnant women and elderly people
are at high risk
Influenza-like illness or meningoencephalitis/septicaemia; spontaneous abortion
Maternal infections can be asymptomatic
Treatment
Ampicillin
4.8 Leptospirosis
This is a spirochaetal disease caused by Leptospira spp.
Many wild and domestic animals, e.g. rats, dogs and livestock, harbour and excrete Leptospira
spp. in their urine
Transmission is by direct contact of mucosal surfaces or abraded skin with urine or carcasses of
infected animals; or by indirect contact, e.g. swimming in water contaminated by infected urine
Incubation period is 12 weeks
This is an acute febrile illness that can be biphasic. The initial phase is septicaemic in nature and
varies in severity from a mild self-limited illness to life-threatening disease. The initial illness
lasts 37 days. Clinically, there is abrupt onset with fevers, rigors, headaches, myalgia, malaise
and conjunctival injection
Recovery can then be followed, a few days later, by an immune-mediated disease. Clinical
presentation includes fever, aseptic meningitis, uveitis, myalgias, lymphadenopathy and vasculitis
rashes
90% will be anicteric; however, 10% will be severely unwell with jaundice, renal dysfunction,
respiratory, cardiac and CNS disease. There is a case fatality rate of 540% in this group
Diagnosis
Blood and CSF culture in the first 10 days of illness and urine after 1 week. Yield is low, the
incubation period is prolonged and special culture media are required
Serology, although retrospective, is the most reliable diagnostic tool
PCR is useful for early diagnosis but is available in a only few laboratories
Treatment
Intravenous penicillin for severe disease

Oral doxycycline (if child is >8 years old) or oral amoxicillin if child <8 years for mild disease
4.9 Cat-scratch disease

Caused by Bartonella henselae a fastidious Gram-negative bacterium
Organism transmitted between cats by the cat flea. Humans are incidental hosts. There is no personto-person spread
More than 90% of patients have a history of contact with cats (usually kittens)
Fever and mild systemic symptoms occur in 30% of patients

A skin papule is often found at the site of presumed bacterial inoculation
Predominant sign is regional lymphadenopathy, involving the nodes that drain the site of inoculation
In up to 30% of cases the lymph node will suppurate spontaneously
Complications
Encephalitis, aseptic meningitis, neuroretinitis, hepatosplenic microabscesses and chronic systemic
disease occur occasionally but are more common in the immunocompromised patient
Diagnosis
Immunofluorescence antibody assays are the most useful diagnostic tests
PCR is available in some laboratories but is not recommended
Histology of the lymph node and staining with WarthinStarry silver stain may show characteristic
necrotizing granulomas and/or the causative organism
Treatment
Most disease is self-limiting so treatment is symptomatic
For those who are severely unwell and for immunocompromised patients, antibiotics such as
ciprofloxacin, rifampicin, azithromycin and intravenous gentamicin are used
5. MYCOBACTERIAL INFECTIONS
5.1 Tuberculosis
Disease caused by infection with Mycobacterium tuberculosis, an acid-fast bacillus
Incubation period, i.e. infection to development of positive tuberculin skin test, is 212 weeks
(usually 34 weeks)
Incidence is increasing again in the UK (especially in immigrant patients and those with human
immunodeficiency virus [HIV])
Host (immune status, age, nutrition) and bacterial (load, virulence) factors determine whether
infection progresses to disease. Defects in interferon- and interleukin-12 pathways predispose to
infection
Children usually have primary TB, adults may have either new infections or reactivation disease
Children are rarely infectious
Children are usually infected by an adult with open, i.e. sputum-positive pulmonary TB, so
notification and contact tracing are essential
Approximately 30% of healthy people closely exposed to TB will become infected, of whom only
510% will go on to develop active disease. Young children exposed to TB are more likely to
develop disease than healthy adults
Risk of disease is highest in the first 6 months after infection
TB exposure:
Patient exposed to person with contagious pulmonary TB
Clinical examination, chest radiograph and Mantoux negative
Some will have early infection, not yet apparent
TB infection:
Positive Mantoux test

Asymptomatic with normal clinical examination
Chest radiograph normal
Treat with chemoprophylaxis
TB disease:
Positive Mantoux test

Clinical symptoms/signs of TB, and/or
Chest radiograph signs consistent with TB
Treat with chemotherapy
Pathogenesis
Majority of infections are acquired via the respiratory route, occasionally ingested
Organisms multiply in periphery of the lung and spread to regional lymph nodes, which may cause
hilar lymphadenopathy
Pulmonary macrophages ingest bacteria and mount a cellular immune response
In most children, this primary pulmonary infection is controlled by the immune system over 610
weeks. Healing of the pulmonary foci occurs, which later calcifies (Ghon focus). Any surviving
bacilli remain dormant but may reactivate later in life and cause tuberculous disease which can be
smear positive and contagious
Clinical symptoms/signs
TB infection usually asymptomatic, may develop fever, malaise, cough or hypersensitivity reactions
erythema nodosum or phlyctenular conjunctivitis.
Clinical signs=disease
Progressive primary pulmonary TB: foci of infection not controlled but enlarge to involve whole
middle and/or lower lobes, often with cavitation (look for immunodeficiency) fever, cough,
dyspnoea, malaise, weight loss
Dissemination to other organs (especially in children aged <4 years):
Miliary TB acutely unwell, fever, weight loss, hepatosplenomegaly, choroidal tubercles in
retina, miliary picture on chest radiograph
TB meningitis (see Section 3.1)
TB pericarditis fever, chest pain, signs of constrictive pericarditis
Bone and joint infection
Urogenital infection (very rare in childhood)
Gastrointestinal tract abdominal pain, malabsorption, obstruction, perforation, fistula,
haemorrhage, doughy abdomen (usually ingested rather than disseminated)
Congenital TB
See Section 11.
Neonatal contact for mother with TB

Infant is at high risk of acquiring TB. Evaluate mother and child (with clinical examination and chest
radiograph).
If mother is smear positive or has an abnormal chest radiograph, separate neonate and mother
until both are on adequate medication and mother is non-contagious
If congenital TB is excluded, give 3 months of prophylactic isoniazid
At 3 months, perform a Mantoux test:
If this is negative and a repeat chest radiograph is negative then give BCG (bacille Calmette
Gurin) and stop chemoprophylaxis
If it is positive reassess for TB disease if there is no disease continue isoniazid for another 3
months; if disease is present then treatment with triple or quadruple therapy is required
Diagnosis
Tuberculin tests
Tuberculin tests involve an intradermal test of delayed hypersensitivity to tuberculin purified-protein
derivative (PPD).
Mantoux test dose in UK is 0.1 ml of 1:1000, i.e. 10 tuberculin units (use 1:10 000 if risk of
hypersensitivity, e.g. erythema nodosum or phlyctenular conjunctivitis). Mantoux tests are more
accurate than Heaf tests and should be used for all patients where disease is suspected and for
contact tracing. Measure induration, not erythema, at 4872 h. Interpretation is difficult but test is
positive if:
>15 mm induration in anyone (equivalent to Heaf 34)
>514 mm induration (equivalent to Heaf 2) if not had BCG and at high risk, e.g. found at contact
or new immigrant screening, or in child aged <4 years
Note that a negative Mantoux test does not exclude a positive diagnosis the test may be
negative if it was incorrectly inserted; if anergy is present (in 10% of the normal population and
also occurs in very young children), if there is overwhelming disseminated TB and in some viral
infections, e.g. HIV, measles, influenza
Heaf test used for mass screening only. If positive refer to TB clinic. Positive is grade 24 if no
previous BCG, grade 3 or 4 if BCG received previously. This is not an appropriate test for contact
tracing, and not as accurate as a Mantoux test
IGRA (interferon- release assays) these are increasingly being used. They are tests in which
blood is incubated with TB antigens and the interferon- is then measured. They give a similar
level of detection to Mantoux tests. The combination of using both tests improves diagnosis by
around 15% over each test alone
Microbiological tests
ZiehlNeelsen stain for acid-fast bacilli, and culture for 48 weeks of sputum, gastric washings,
bronchoalveolar lavage fluid, CSF, biopsy specimens (culture is required because it will provide
details of type and sensitivities)
All have low yield in children because there are lower numbers of bacteria
Other
Histology caseating granuloma and acid-fast bacilli
PCR poor sensitivity and specificity at present but improving
Chest radiograph typical changes of hilar lymphadenopathy parenchymal changes
Treatment
Chemoprophylaxis
Chemoprophylaxis is required:
For those with TB infection (i.e. a positive Mantoux test, well child, normal chest radiograph) to
prevent progression to disease
For close contacts of smear-positive TB patients if they are HIV positive or immunosuppressed
patients because they may not develop a positive Mantoux response
Options for chemoprophylaxis are:
Isoniazid for 6 months (+ pyridoxine for breastfed infants and malnourished infants)
Or isoniazid and rifampicin for 3 months
A repeat chest radiograph at the end of treatment is not required if there has been good compliance
and the child is asymptomatic.
Chemotherapy
For those with signs of disease four drugs are used in the initial 2 months of treatment because of the
increase in isoniazid resistance (now over 7% in London, UK). The fourth drug (usually
ethambutol/streptomycin) can be omitted if there is a low risk of isoniazid resistance, i.e. previously
untreated, white, proven or suspected HIV-negative patients, or those who have had no contact with a
TB patient with drug resistance.
Pulmonary and non-pulmonary disease (except meningitis) isoniazid and rifampicin for 6 months
with pyrazinamide and a fourth drug for the first 2 months
Meningitis 12 months total therapy with isoniazid and rifampicin, with pyrazinamide and a fourth
drug for the first 2 months
Multidrug-resistant TB (1% of all cases) seek expert advice
Note that directly observed therapy is recommended if there is any chance of non-compliance
Corticosteroids should be used for 68 weeks if there is TB meningitis, pericarditis, miliary TB
and endobronchial disease with obstruction, but only with anti-TB therapy
Prevention
Improvement of social conditions and general health
BCG immunization (live attenuated strain of Mycobacterium bovis) gives approximately 50%
protection. It is effective in the prevention of extrapulmonary disease in the age group <4 years. In
the UK, BCG is given at birth to high-risk groups and at 1214 years of age to tuberculin testnegative children
Complications of BCG immunization

Include subcutaneous abscess, suppurative lymphadenitis and disseminated disease in severely
immunocompromised children.
5.2 Atypical mycobacteria

Infections caused by non-tuberculous mycobacteria, e.g. Mycobacterium avium complex,
M. scrofulaceum, M. kansasii
Ubiquitous organisms found in soil, food, water and animals
Found worldwide
Acquired via ingestion, inoculation or inhalation of organism
Many people exposed, but only a small number have infection or disease
May cause disseminated disease in immunodeficient patients, e.g. HIV positive
Clinical presentations
Lymphadenitis (usually cervical), pulmonary infections, cutaneous infections and occasionally,
osteomyelitis
Diagnosis
Isolation and identification by culture (PCR in some laboratories)
May have weakly positive Mantoux test (with no signs of TB)
Treatment
For non-tuberculous mycobacterial lymphadenitis surgical excision alone
If excision is incomplete, or other site is involved, medical treatment with at least two drugs for 3
6 months is required
Note that for differential diagnosis of persistent cervical lymphadenopathy, see Section 12.2.
6. FUNGAL INFECTIONS
Many fungi are ubiquitous, growing in soil, decaying vegetation and animals
Infection is acquired by inhalation, ingestion and inoculation from direct contact
Often produce spores
Superficial infections are common
Invasive disease occurs almost exclusively in immunocompromised people, mainly those with
neutrophil defects or neutropenia. Consider if a neutropenic patient is not responding to
antibacterial therapy after 48 h of illness
6.1 Cutaneous fungal infections

Tinea versicolor or pityriasis versicolor
Caused by Malassezia furfur (Pityrosporum orbiculare)

Oval, macular lesions on neck, upper chest, back, arms; may be hypo- or hyperpigmented
Diagnosis by microscopy of skin scrapings
Treatment with topical antifungals and salicylic acid preparations
Ringworm (dermatophytoses)
These are caused by filamentous fungi belonging to three main genera Trichophyton, Microsporum
and Epidermophyton diagnosed by skin scrapings.

Tinea capitis (ringworm of scalp)
Causes patchy dandruff-like scaling with hair loss, discrete pustules or kerion boggy,
inflammatory mass fever and local lymphadenopathy
Treat with oral antifungals, e.g. griseofulvin, terbinafine. Topical agents not effective
Tinea corporis (ringworm of body)
Usually dry, erythematous annular lesion with central clearing, on face, trunk and limbs
Treat with topical antifungals for 4 weeks; if no response use oral antifungals
Tinea cruris (jock itch!)
Infection of groin and upper thighs causing itchy erythematous, scaly skin
Treat as tinea corporis
Tinea pedis (athletes foot)
Infection in interdigital spaces, may involve the whole foot. Fungi are common in damp areas, e.g.
swimming pools. Treat as tinea corporis
6.2 Candidiasis (thrush, moniliasis)
Usually caused by Candida albicans

Present on skin, in the mouth, and in the GI tract and vagina of healthy individuals
Person-to-person transmission occurs
Use of antibiotics may promote overgrowth of yeasts
Mild mucocutaneous infection
Oral thrush and/or nappy-area dermatitis are common in infants
Vulvovaginal candidiasis occurs in adolescents
Intertriginous lesions, e.g. in neck, groin, axilla
Chronic mucocutaneous candidiasis
Associated with endocrine disease and progressive T-cell immunodeficiencies
Invasive disease
Disseminated disease to almost any organ, especially in very low-birthweight newborns and those
who are immunocompromised
Diagnosis
Microscopy showing pseudohyphae or germ-tube formation (C. albicans only)
Culture
Treatment
For minor mucocutaneous disease, use oral nystatin or topical nystatin/clotrimazole/miconazole
For severe or chronic mucocutaneous disease, use an oral azole, e.g. fluconazole
For invasive disease, treat as for aspergillus infection (see below)
6.3 Aspergillosis
Caused by Aspergillus fumigatus, A. niger, A. flavus and, rarely, others
No person-to-person transmission
Allergic bronchopulmonary aspergillosis episodic wheezing, low-grade fever, brown sputum,
eosinophilia, transient pulmonary infiltrates. Usually in children with cystic fibrosis or asthma.
Treat with steroids
Sinusitis and otomycosis of external ear canal usually benign in immunocompetent patients
Aspergilloma fungal balls that grow in pre-existing cavities or bronchogenic cysts non-invasive
Invasive aspergillosis extremely serious
May cause peripheral patchy bronchopneumonia with clinical manifestations of acute pneumonia
Often disseminates to brain, heart, liver, spleen, eye, bone and other organs in the
immunocompromised patient population
Diagnosis
High clinical index of suspicion

Microscopy shows branched and septate hyphae
Culture
Molecular testing is useful but availability is limited
Treatment
For invasive disease treatment with two agents is now often used: liposomal amphotericin in high
dose or voriconazole and a second antifungal, e.g. an echinocandin, an azole or flucytosine
depending on culture results
Surgical excision of localized lesion
7. VIRAL INFECTIONS
7.1 Human immunodeficiency virus
HIV is a retrovirus, i.e. it contains the enzyme reverse transcriptase, which allows its viral RNA to
be incorporated into host-cell DNA
Two main types are known: HIV-1 (widespread) and HIV-2 (West Africa)
Mainly infects CD4 helper T cells, causing reduction of these cells and acquired immunodeficiency
Transmission
Vertical (most common mode of transmission in children):
Prenatal
Intrapartum (most common)
Postnatally via breast milk
Blood or blood products, e.g.
People with haemophilia (of historical interest only in the UK now)
Non-sterile needle use
Via mucous membranes, e.g. sexual intercourse (note sexual abuse)
Diagnosis
Virus detection by PCR (rapid, sensitive, specific)
Detection of immunoglobulin G (IgG) antibody to viral envelope proteins (gp120 and subunits)
Diagnosis of HIV infection if:
HIV antibody-positive after 18 months old if born to an infected mother, or at any age if mother is
not infected on two occasions
PCR positive on two separate specimens taken at different times
Babies of HIV-positive mother:
Start zidovudine (AZT, azidothymidine) orally for baby within 12 h of birth. This is continued for 4
weeks:
2448 h HIV PCR (50% true positive by 1 week, 90% by 2 weeks)
6 weeks repeat HIV PCR, start Septrin prophylaxis
34 months repeat HIV PCR
If all three PCRs are negative then >95% chance baby is not infected
Stop Septrin
Follow up until HIV antibody (vertically acquired from mother) is negative
Note that still HIV affected, i.e. many issues re infection in family
Follow-up of HIV-positive babies/children:
Every 36 months depending on health

History and examination for signs of persistent or unusual infections and growth/puberty
Psychological and social support, issues re awareness of diagnosis
Full blood count, T-cell subsets/CD4 count, HIV viral load
Hepatitis B and C viruses, CMV, toxoplasma status if indicated
Immunization information
Septrin prophylaxis is continued for the first year of life in all HIV-positive children regardless of
CD4 count:
All infants under the age of 24 months require triple antiretroviral treatment
All children between 2 and 5 years with a CD4 count <25% or absolute count <750 cells/mm3
require antiretroviral treatment
All children >5 years with an absolute CD4 count <350 cells/mm3 require treatment
Children who fulfil the clinical criteria for treatment should be given antiretroviral treatment
regardless of their CD4 counts
WHO clinical staging

Clinical stage 1
Asymptomatic
Persistent generalized lymphadenopathy
Clinical stage 2
Unexplained persistent hepatosplenomegaly

Papular pruritic eruptions
Extensive wart virus infection
Extensive molluscum contagiosum
Recurrent oral ulcerations
Unexplained persistent parotid enlargement
Lineal gingival erythema
Herpes zoster
Recurrent or chronic upper respiratory tract infections (otitis media, otorrhoea, sinusitis,
tonsillitis)
Fungal nail infections
Clinical stage 3
Unexplained moderate malnutrition not adequately responding to standard therapy
Unexplained persistent diarrhoea (14 days or more)
Unexplained persistent fever (above 37.5C, intermittent or constant, for >1 month)
Persistent oral candidiasis (after first 6 weeks of life)
Oral hairy leukoplakia
Acute necrotizing ulcerative gingivitis/periodontitis
Lymph node TB
Pulmonary TB
Severe recurrent bacterial pneumonia
Symptomatic lymphoid interstitial pneumonitis
Chronic HIV-associated lung disease including bronchiectasis
Unexplained anaemia (<8.0 g/dl), neutropenia (<0.5 109/l) or chronic thrombocytopenia (<50
109/l
Clinical stage 4
Unexplained severe wasting, stunting or severe malnutrition not responding to standard therapy
Pneumocystis pneumonia
Recurrent severe bacterial infections (e.g. empyema, pyomyositis, bone or joint infection,
meningitis, but excluding pneumonia)
Chronic herpes simplex infection (orolabial or cutaneous of more than 1 months duration, or
visceral at any site)
Extrapulmonary TB
Kaposi sarcoma
Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs)
CNS toxoplasmosis (after the neonatal period)
HIV encephalopathy
CMV infection; retinitis or CMV infection affecting another organ, with onset at age >1 month
Extrapulmonary cryptococcosis including meningitis
Disseminated endemic mycosis (extrapulmonary histoplasmosis, coccidioidomycosis,
penicilliosis)
Chronic cryptosporidiosis (with diarrhoea)
Chronic isosporiasis
Disseminated non-tuberculous mycobacterial infection
Cerebral or B-cell non-Hodgkin lymphoma
Progressive multifocal leukoencephalopathy
HIV-associated cardiomyopathy or nephropathy
All children who fulfil stages 3 and 4 clinical criteria require triple antiretroviral therapy
regardless of their CD4 counts.
1997 20% of vertically infected children developed AIDS in infancy; most common AIDSdefining illness was Pneumocystis jiroveci pneumonia
2001 improved antenatal detection and prophylaxis, therefore fewer AIDS-defining illnesses in
infancy
Approximately 5% of children with HIV develop AIDS each year
Recurrent bacterial infections

B-cell dysregulation occurs, despite often high immunoglobulin levels, because of poor CD4 (Thelper cell) function
Recurrent serious bacterial infections, such as pneumonia, meningitis, septicaemia and
osteomyelitis, may occur. The most common organisms are those that are normally pathogenic,
Strep. pneumoniae, H. influenzae, coliforms and Salmonella spp.
Treatment depends on clinical condition and probable infective organism
Faltering growth
This is frequently multifactorial, e.g.:
Reduced nutrient and fluid intake psychosocial reasons or oral and oesophageal thrush
Increased nutrient and fluid requirement with chronic disease (3050%)
Increased fluid loss with diarrhoea look for gut pathogens, microsporidiosis, cryptosporidiosis,
Giardia spp., atypical mycobacteria and viruses
Treatment: improve immune function with highly active antiretroviral therapy (HAART); treat
specific infections; provide dietary supplements
Lymphocytic interstitial pneumonitis
Caused by diffuse infiltration of pulmonary interstitium with CD8 (cytotoxic) lymphocytes and
plasma cells
Often diagnosed from a chest radiograph in an otherwise asymptomatic child
May cause progressive cough, hypoxaemia and clubbing
Associated with parotitis
Superimposed bacterial infections and bronchiectasis may occur
May have element of reversible bronchoconstriction
Treatment: symptomatic; HAART; if severe use oral prednisolone
HIV encephalopathy
May present with regression of milestones, behavioural difficulties, acquired microcephaly, motor
signs, e.g. spastic diplegia, ataxia, pseudobulbar palsy
Exclude CNS infections and lymphoma
Treatment: HAART
Thrombocytopenia
Not associated with other indicators of disease progression
Treatment: only if symptomatic or platelet count persistently <20 000/mm3. Options include
intravenous immunoglobulin, steroids, HAART or last-resort splenectomy (not recommended
because it further increases the risk of sepsis)
Opportunistic infections
Protozoa
Pneumocystis jiroveci pneumonia CMV pneumonitis:
Most common at 36 months of age; presents with persistent non-productive cough, hypoxaemia,
dyspnoea, minimal chest signs on auscultation
Chest radiograph shows bilateral perihilar butterfly shadowing; diagnosis by bronchoalveolar
lavage; ensure no concurrent CMV infection
Treatment: supportive, may need to be treated in paediatric intensive care unit. High-dose cotrimoxazole (Septrin) for 21 days together with steroids. Intravenous aciclovir if there is
concurrent CMV disease. Once stable, commence HAART. Prophylactic low-dose Septrin after
treatment
Cerebral toxoplasmosis:
Rare in childhood HIV infection; may present with focal signs fits
CT shows multiple intraparenchymal ring-enhancing lesions. Positive toxoplasmosis serology
Treatment: 6 weeks of pyrimethamine and sulfadiazine with folinic acid and HAART
Cryptosporidosis:
Cryptosporidium parvum causes severe secretory diarrhoea, abdominal pain and sometimes
sclerosing cholangitis
Diagnosis by stool microscopy small-bowel biopsy
Treatment: supportive, paromomycin
Fungi
Candida albicans oropharyngeal, oesophageal, vulvovaginal, disseminated (rare):
Treatment: chronic antifungal therapy, e.g. fluconazole, voriconazole, intravenous liposomal
amphotericin B if severe
Cryptococcus neoformans meningitis (insidious onset), pneumonia:
Diagnosis by CSF examination (Indian ink stain, antigen, culture), serum culture, antigen
Treatment: fluconazole. In severe disease, two antifungal agents should be used
Viruses
CMV retinitis, colitis, pneumonitis, hepatitis, pancreatitis:
Diagnosis by serum PCR, immunofluorescence in relevant sample and characteristic retinal
changes if present; differentiate disease from carriage
Treatment: intravenous ganciclovir; HAART
Herpes simplex virus:
Types 1 and 2 extensive oral ulceration
Treatment: intravenous aciclovir, oral prophylaxis if recurrent and severe; HAART may help
Measles, varicella-zoster virus, respiratory syncytial virus, adenovirus all may cause severe
disease in HIV-infected children, especially pneumonitis
TB and atypical TB
Increased risk of TB and atypical TB, especially disseminated M. avium complex
See Section 5
Tumours
These are rare in children.
Kaposi sarcoma tumour of vascular endothelial cells, associated with human herpesvirus-8
(HHV8); involves skin, gut, lung and lymphatics:
Treatment: HAART, local radiotherapy, chemotherapy if disseminated
Lymphoma non-Hodgkin B-cell primary CNS lymphoma:
Focal neurological signs fits; CT shows single lesion
Definitive diagnosis by brain biopsy
Treatment: radio-/chemotherapy; poor prognosis
HIV treatment
Highly active antiretroviral therapy
When to start treatment in children differs in each country.
In the UK, start treatment if there is an AIDS-defining illness, or the child fulfils stage 3 or 4 WHO
clinical criteria or has a rapidly decreasing CD4 count.
All children aged <2 years should be started on treatment regardless of CD4 count (CHER Study);
children aged 25 years require treatment if CD4 count <25% or absolute count <750 cells/mm3 and
all children aged >5 years with CD4 count <350 cells/mm3 require treatment.
Three-drug therapy is the gold standard. This reduces resistance and suppresses viral load to
undetectable levels
The standard HAART regimen comprises a backbone of two nucleoside reverse transcriptase
inhibitors (NRTIs) and either a non-NRTI or a protease inhibitor. Tenofovir, a nucleotide reverse
transcriptase inhibitors, can be used interchangeably with the NRTIs in the backbone of the
regimen. Liaise with the tertiary centre for any treatment decisions
Monitor for efficacy (viral load and CD4 count) and side effects
P. jiroveci prophylaxis
For first 12 months of life if vertically infected
If CD4 count <15%
Reduction of vertical transmission
With breast-feeding and no intervention vertical transmission rate is 1530%.
Interventions:
No breast-feeding (where safe alternative is possible): transmission rate is 15%

+ antiretrovirals to mother and baby, e.g. ACTG O76 trial reduces rate to 5%
+ elective caesarean section reduces transmission to 2% (or less if very low maternal viral load)
To allow intervention, women need to be diagnosed before giving birth. National targets and
objectives were set in 1999 that involve the offer and recommendation of an HIV test to all pregnant
women throughout the UK. By 2001 80% of maternity units in the UK offered this service, with an
uptake of approximately 70%.
Some units now favour vaginal delivery for women who have had uncomplicated deliveries in the
past, and are well controlled on treatment with good CD4 counts and undetectable viral loads.
Note that, if vaginal delivery, avoid invasive fetal procedures, e.g. fetal blood sampling.
There are five classes of antiretroviral drugs:
Nucleoside (and nucleotide) reverse transcriptase inhibitors (NRTIs)

Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
Protease inhibitors
Intergrase inhibitors
CCR5 receptor blockers
The last two classes of drugs are not used as standard for children, and studies are still being run to
determine dosages, efficacy and side effects in children. They are being used for very drugexperienced adolescents where other treatment options have been exhausted.
Combined drug preparations are available for older children and adults. Fixed drug combination
tablets are available in the developing world setting, but not in the UK.
Major side effects of commonly used antiretroviral drugs used in children

Drug
Nucleoside reverse transcriptase
inhibitors
AZT zidovudine
DDI didanosine
3TC lamivudine
Abacavir
D4T stavudine (rarely used)
Non-nucleoside reverse
Side effect
Nausea, bone marrow suppression, myopathy

Peripheral neuropathy, pancreatitis function test
Rare peripheral neuropathy, pancreatitis
Life-threatening hypersensitivity reactions usually
present as rash and fever
Peripheral neuropathy, pancreatitis, elevation of liver
transcriptase inhibitors
Efavirenz
Nevirapine
Rash, sleep disturbances, hallucinations (rare in children)

Rash, hepatitis
Protease inhibitors
Gastrointestinal side effects common in first 4 weeks,
paraesthesia
Ritonavir
Kaletra (lopinavir boosted with
ritonavir)
Atazanavir
Raised transaminases
Jaundice, rarely psychosis
Note that protease inhibitors and D4T are associated with lipodystrophy.
7.2 Hepatitis
See Chapter 13.
7.3 EpsteinBarr virus

This causes infectious mononucleosis (glandular fever). EBV infects pharyngeal epithelial cells and
then B lymphocytes. These disseminate and proliferate until checked by activated T cells.
Transmission: saliva, aerosol
Incubation: 3050 days
Clinical presentation:
Fever, sore throat, lymphadenopathy, palatal petechiae and malaise
Splenomegaly (50%), hepatomegaly (30%), hepatitis (80%), clinical jaundice (5%),
thrombocytopenia, haemolytic anaemia
Maculopapular rash (515%), 90% if given ampicillin
Complications:
Meningitis, encephalitis, GuillainBarr, syndrome, myocarditis, splenic rupture, airway
obstruction from pharyngotonsillar swelling
Chronic fatigue-like syndrome
Disseminated disease with B-cell proliferation in those with T-cell immunodeficiencies
Diagnosis: atypical lymphocytosis, positive PaulBunnell (often negative in young children) or
Monospot test, serology, heterophile antibodies, PCR
Treatment: supportive, steroids for severe inflammatory processes
7.4 CYTOMEGALOVIRUS
Transmission: close contact, blood, organ transplantation

In normal hosts often asymptomatic or glandular fever-like picture
In immunocompromised patients severe disease may occur with pneumonitis, retinitis,
encephalitis, hepatitis and GI disturbance
CMV is the most common congenital infection
Diagnosis: immunofluorescence, intranuclear inclusions in biopsy specimens, culture, detection of
early antigen fluorescence foci (DEAFF) test, PCR
Treatment: symptomatic, intravenous ganciclovir and/or intravenous foscarnet if
immunosuppressed. An oral drug, valganciclovir, has been introduced and may be used instead of
intravenous therapy. Its use is still being evaluated.
7.5 Herpes simplex virus

Infection: two types recognized: HSV-1 (usually infects skin and mucous membranes) and HSV-2
(usually genital):
Primary infections 85% subclinical
Recurrent infections reactivation of latent infection
Transmission: direct contact. Congenital infections occur in approximately 1:10 000 live births in
the UK. They can present as localized infection, disseminated infection or neonatal encephalitis
Acute herpetic gingivostomatitis primary infection acute painful mouth ulcers and fever, most
common between 1 and 3 years of age, self-limiting, lasts 49 days (may be asymptomatic)
Recurrent stomatitis localized vesicular lesions in nasolabial folds, cold sores
Keratoconjunctivitis and corneal ulcers
Meningoencephalitis (peak incidence in the neonatal group and in adolescence)
Eczema herpeticum widespread infection of eczematous skin with HSV vesicles may be very
severe
Genital lesions usually in sexually active adolescents (note child abuse)
Neonatal HSV usually from vaginal secretions at delivery high morbidity and mortality
Diagnosis:
Clinical, electron microscopy of vesicular fluid (very fast), PCR, culture (this is a fast-growing
virus and cultures can be positive within 25 days)
Treatment:
Aciclovir intravenous if severe disease, immunocompromised, neonate or eczema herpeticum
Oral, topical, eye drops
7.6 Varicella-zoster virus

This produces chickenpox (varicella) as a primary infection. Shingles (herpes zoster) is caused by
reactivation of dormant varicella-zoster virus (VZV) from dorsal root or cranial ganglia. You can
catch chickenpox from contact with chickenpox or shingles. You cannot catch shingles.
Chickenpox
Incubation: chickenpox: 1124 days
Transmission: direct contact, droplet, airborne; infectious from 24 h before rash appears until all
spots have crusted over (approximately 78 days)
Clinical presentation: prodrome of fever and malaise for 24 h; rash appears in crops, papular then
vesicular and itchy, usually start on trunk and spread centripetally; crops continue to appear for 34
days and each crusts after 2448 h. Household contacts, who receive a higher viral inoculum, tend
to have more severe disease
Complications:
Secondary bacterial infection often with group A streptococci
Thrombocytopenia with haemorrhage into skin
Pneumonia
Purpura fulminans
Post-infectious encephalitis
Immunocompromised patients severe disseminated haemorrhagic disease
Diagnosis: clinical, viral culture, serology and immunofluorescence assay, PCR
Treatment: supportive; intravenous aciclovir for immunosuppressed or severely unwell patient
Prophylaxis: zoster immunoglobulin (ZIG) if high risk (e.g. immunodeficiency, immunosuppressive
treatment). Note that, if mother develops chickenpox within 5 days before to 2 days after delivery,
give the neonate ZIG. If baby develops chickenpox treat with intravenous aciclovir. Note that the
incubation period in children who have received ZIG is extended to 28 days
Herpes zoster
Increased incidence if immunosuppressed.
Prodrome of pain and tenderness in affected dermatome with fever and malaise; within a few
days the same rash as varicella appears in distribution of one (sometimes two or three) unilateral
dermatomes
If infection of cranial nerve V occurs, it may affect the cornea (ophthalmic branch)
If nerve VII is involved, may develop paralysis of facial nerve and vesicles in external ear
(Ramsay Hunt syndrome)
Complications: dissemination in immunocompromised; post-herpetic pain rare in children
Treatment: supportive; intravenous aciclovir if severe and patient is immunocompromised
Note that VZV vaccine now available routinely in the USA, and for at-risk patients in the UK.
7.7 Parvovirus B19 (erythema infectiosum, slapped cheek or fifth disease)
This virus affects red cell precursors and reticulocytes in the bone marrow.
Incubation: approximately 1 week
Transmission: respiratory secretions, blood; not infectious once rash has appeared
Very erythematous cheeks, then erythematous macular papular rash on trunk and extremities,
which fades with central clearing giving the characteristic lacy or reticular appearance
Rash lasts 230 days
Complications:
Aplastic crisis in chronic haemolytic diseases, e.g. sickle cell disease, thalassaemia
Aplastic anaemia
Arthritis, myalgia more common in older children/adults
Congenital infection with anaemia and hydrops (see Section 11)
Diagnosis: clinical, serology, PCR
Treatment: supportive
7.8 Roseola infantum (exanthem subitum or HHV-6)

Transmission: respiratory secretions
Clinical presentation: characteristic sudden onset of high fever (up to 41C) with absence of
clinical localizing signs; at days 34 fever abruptly stops and macular/papular rash appears which
lasts from <24 h to a few days:
This is one of the most common causes of febrile convulsions in the 6- to 18-month age group.
Febrile convulsions typically occur on the first day of illness
This virus is ubiquitous in the population and can occur either subclinically or as a non-specific
febrile illness without focus
Diagnosis: Diagnostic tests are not well established. PCR is available on a research basis and
serological tests are available but differentiating primary disease from reactivation is problematic
Treatment: antipyretics
7.9 Measles
Transmission: respiratory droplets; infectious from 7 days after exposure, i.e. from pre-rash to 5
days after rash starts
Prodrome: 35 days, low fever, brassy cough, coryza, conjunctivitis, Koplik spots
(pathognomonic white spots opposite lower molars)
Eruptive stage: abrupt rise in temperature to 40C associated with macular rash which starts
behind ears and along hairline, becomes maculopapular and spreads sequentially to face, upper
arms, chest, abdomen, back, legs; lasts approximately 4 days
Complications:
Otitis media, laryngitis, bronchitis

Interstitial pneumonitis, secondary bacterial bronchopneumonia, myocarditis
Encephalomyelitis: mainly post-infectious, demyelinating (1:1000 cases)
Subacute sclerosing panencephalitis (see Chapter 19)
Temporary immunosuppression for up to 6 weeks post-infection, causing increased susceptibility
to secondary bacterial infections
Diagnosis: clinical, viral culture, immunofluorescence, serology
Treatment: symptomatic; human pooled immunoglobulin <5 days of exposure to high-risk patients
only. Vitamin A in children who are malnourished or who have severe measles. Ribavirin has been
used in immunocompromised children, but no controlled studies demonstrating efficacy have been
performed
Prophylaxis: immunization measles, mumps, rubella (MMR)
7.10 Mumps
Transmission: respiratory droplets, infectious 24 h before to 3 days after parotid swelling
Clinical presentation: mild prodrome of fever, anorexia, headache; painful bilateral (may be
unilateral) salivary submandibular gland swelling
Complications: occur as a result of viraemia early in the infection:
Meningoencephalitis clinically 10% (subclinically 65%):
Infectious symptoms same time as parotitis
Post-infectious symptoms approximately 10 days post-parotitis
Orchitis/epididymitis:
Rare in childhood, 1435% in adolescents/adults
Occurs within 8 days of parotitis, abrupt onset of fever and tender, swollen testes
Approximately 3040% of affected testes atrophy; may cause subfertility
Pancreatitis, nephritis, myocarditis, arthritis, deafness, thyroiditis
Diagnosis: viral culture, serology
Prophylaxis: immunization (MMR) to ensure herd immunity
7.11 RUBELLA (GERMAN MEASLES)

Transmission: respiratory droplets; transplacental
Mild coryza, palatal petechiae
Characteristic tender, retroauricular, posterior cervical and suboccipital adenopathy 24 h before
rash appears, lasting 1 week
Rash is an erythematous maculopapular generalized rash which begins on face, spreading quickly
to trunk
Complications: arthritis, encephalitis, congenital rubella syndrome (see Section 11)

Diagnosis: clinical, serology
Prophylaxis: although a mild illness, immunization of all children prevents childbearing women
contracting rubella
7.12 Adenovirus
Transmission: respiratory droplets, contact, fomites, very contagious, strict infection control policy
Upper respiratory tract infection
Conjunctivitis pharyngitis
Gastroenteritis more common in those aged <4 years
Complications: severe pneumonia (more common in infants); disseminated disease in
immunocompromised patients
Diagnosis: viral culture, PCR
Treatment: supportive; ribavirin has been used with limited success in immunocompromised
patients. Cidofovir is also used, and can be used in combination with adenovirus for severely
immunocompromised children. Success is limited, and side effects, particularly renal toxicity, can
be significant.
7.13 Enteroviruses
These include polioviruses: types 13; Coxsackieviruses: A and B and echoviruses.
Transmission: faecal/oral and respiratory droplets, infections peak during summer and early
autumn
Non-specific febrile illness: abrupt onset of fever and malaise headache and myalgia, lasts 34
days
Respiratory manifestations: pharyngitis, tonsillitis, nasopharyngitis, lasts 36 days
GI manifestations: diarrhoea, vomiting, abdominal pain
Skin manifestations: hand, foot and mouth usually Coxsackievirus A16 and enterovirus 71;
intraoral ulcerative lesions, vesicular lesions on hands and feet 37 mm; rash clears within 1 week
Pericarditis and myocarditis: usually Coxsackie B viruses
Neurological manifestations: aseptic meningitis (especially Coxsackievirus B5), encephalitis
(especially echovirus 9), cerebellar ataxia and GuillainBarr, syndrome
Although some clinical entities are more closely associated with specific enterovirus species,
any of the enteroviruses can cause any of the clinical syndromes
Diagnosis: viral culture, PCR. There is no place for the use of serology in the diagnosis of
enteroviral infections
Prophylaxis: nil for Coxsackie- and echoviruses. Polio vaccine for prevention of polio. The WHO
are aiming for worldwide eradication
7.14 Molluscum
Incubation: 28 weeks
Transmission: direct contact with infected person or fomites or autoinoculation
Clinical presentation: discrete, pearly papules 15 mm, face, neck, axillae and thighs
Diagnosis: clinical, microscopy
Treatment:
Self-limiting but may last months to years
Need to treat in immunodeficient patients or it will become widespread, e.g. remove with liquid
nitrogen
8. PARASITIC INFECTIONS
8.1 Toxoplasmosis
Caused by Toxoplasma gondii
Worldwide distribution and infects most warm-blooded animals
Cat is the definitive host and excretes oocysts in stools
Intermediate hosts include sheep, pigs and cattle who have viable cysts in their tissues
Human infection is by eating undercooked meat containing cysts or by ingestion of oocysts from
soil; may also be acquired from blood transfusion or bone marrow transplantation
Congenital infection (see Section 11)
Often asymptomatic, or non-specific fever, malaise, myalgia, sore throat

May also have lymphadenopathy or mononucleosis-like illness
Complications rarely include myocarditis, pericarditis and pneumonitis, encephalitis
Isolated ocular toxoplasmosis is usually a result of reactivation of congenital infection, but may be
acquired
Immunodeficient patients may have more serious/disseminated disease
Diagnosis
By serology (PCR in special cases)
Isolation of T. gondii is difficult and is not performed routinely.
Atypical lymphocytosis, eosinophilia and inversion of CD4:CD8 ratio
Treatment
Supportive if mild
Pyrimethamine (and folinic acid) and sulfadiazine if symptomatic. If sulfadiazine is not tolerated,
clindamycin can be used instead. A prolonged course of treatment, up to 1 year, is usual but the
optimal length of treatment is not established
8.2 Head lice (pediculosis capitis)
Caused by lice Pediculus humanus capitis

Itching is the most common complaint
Adult lice or eggs (nits) may be seen in the hair
Very common in school-aged children
Transmission
Occurs by direct contact with hair of infested individuals
Diagnosis
Clinical; can confirm by microscopy
Treatment
Two applications, 1 week apart, of a parasiticidal lotion, left on overnight, e.g. permethrin and
malathion. Resistance is developing, so if the treatment fails try another insecticide for the next
course. Many people use mechanical means of louse control, e.g. nit comb. Remember to treat
the whole family ( school class) at the same time.
Malaria
See Section 9.1.
Leishmaniasis
See Section 9.9.
Schistosomiasis
See Section 9.10.
Pneumocystis
See Section 7.1.
9. TROPICAL AND GEOGRAPHICALLY CIRCUMSCRIBED INFECTIONS

Travel is increasing, with people travelling to ever more exotic regions of the world, and a mobile
population brings immigrants to our shores. This presents a challenge when confronted with unusual
patterns of illness. There are a number of infections that are endemic to very specific regions of the
world, and others that are endemic to large swathes of the globe.
Always obtain a travel history because imported infections in returning travellers, those from abroad
holidaying in the UK and recent immigrants are part of the differential diagnosis of fever.
In the last decade, 100 people of all ages have died in the UK from malaria contracted in malarious
areas. Only one of these people was taking full doses of what would currently be considered an
adequate antimalarial. Of these 100 cases, 94 were contracted in Africa and 6 in the countries of
south Asia. Four African countries accounted for 67% of all the fatal cases (Kenya 25%, Nigeria
17%, the Gambia 14% and Ghana 11%).
However, it is not just in the developing world and the tropics that diseases unknown in the UK occur.
There are a number of diseases, endemic to the Americas, that need to be considered in travellers
returning from those regions. Babesiosis and Lyme disease are found on the east coast of the USA,
Rocky Mountain Spotted Fever (a rickettsial infection) and ehrlichiosis occur in the south and southwest of the country, as does coccidioidomycosis, a fungal respiratory infection. Outbreaks of
Hantavirus infections have occurred in Texas and Arizona and also in eastern Europe, where
tularaemia can also be found. Leishmaniasis occurs in the Mediterranean as well as in Africa, and
should be considered in patients returning from European holidays with symptoms. The list continues.
However, a good travel and contact history can point to the possibility of an imported infection in a
timely fashion, even if the precise nature of the infection is initially elusive.
9.1 Malaria
Caused by Plasmodium spp. (P. vivax, P. malariae, P. ovale and P. falciparum) invading
erythrocytes
Endemic in the tropical world, especially sub-Saharan Africa and parts of south-east Asia
Transmitted by bite of the female anopheles mosquito
Congenital infection and blood transfusion-acquired infection may also occur
P. vivax and P. ovale have hepatic stages and may cause relapses of infection
Recrudescence of P. falciparum and P. malariae occurs from persistent low levels of parasitaemia
P. falciparum malaria is the most severe and potentially fatal disease. This is the predominant
species in Africa
Symptoms appear 815 days after infection, with high fevers, chills, rigors and sweats, which
classically occur in a cyclical pattern depending on the type of Plasmodium sp. involved. Patients
can present with malaria up to 3 months after returning from an endemic area and a high index of
suspicion is the key to making the diagnosis:
Headaches, abdominal pain, arthralgia, diarrhoea and vomiting are common

Pallor and jaundice occur secondary to haemolysis
Hepatosplenomegaly is more common in chronic infections
Nephrotic syndrome may occur with P. malariae, because of immune complex deposition in the
kidney
P. falciparum may present as a febrile or flu-like illness with no localizing signs, or as one of the
following clinical syndromes:
Cerebral malaria with confusion, fits, decreased level of consciousness, coma
Severe anaemia with signs of haemolysis
Hypoglycaemia from disease (metabolic requirements of parasites) and also quinine treatment
Pulmonary oedema (rare in children)
Renal failure with acute tubular necrosis, or blackwater fever, caused by haemoglobinuria
resulting from severe, acute intravascular haemolysis (rare in children)
Diagnosis
Thick blood films allow the detection of parasites; thin films allow species identification and
determination of parasitaemia (percentage of erythrocytes harbouring parasites)
Need at least three negative films at 12- to 24-h intervals to be confident of negative result if there
is a high index of clinical suspicion
New tests being evaluated include PCR and malarial ribosomal RNA (urine dipstix are in use in the
developing world)
Note that in hyperendemic areas, low-level parasitaemia, indicating a semi-immune state in
children aged >4 years, is common and malaria is not necessarily the cause of the symptoms.
However, people who move from these endemic areas do not retain their semi-immune status and
any parasitaemia does become significant
Treatment
Look for and treat hypoglycaemia
Chemotherapy is based on the infecting species, possible drug resistance and disease severity.
P. falciparum malaria
In the UK, we assume that all cases of P. falciparum malaria are chloroquine resistant and treat
with quinine, orally if possible, or intravenously if severely unwell for 37 days (monitor glucose
and ECG if intravenous regimen used). Clindamycin should be given to children who are severely
ill and/or have higher parasite counts because this increases the rate of parasite clearance.
One dose of pyrimethaminesulfadoxine (Fansidar) is given on the last day of quinine therapy or,
increasingly, a 3-day course of atovaquone/proguanil (Malarone) because Fansidar resistance is on

the increase in Africa. Artesunate is now being recommended as first-line therapy for severe
malaria in the UK
Exchange transfusion may be warranted if parasitaemia exceeds 10%
Monitor sequential blood smears until negative
P. malariae malaria
Treat with chloroquine (if no resistance)
P. vivax and P. ovale malaria
Treat with chloroquine then primaquine to eradicate the liver stage and prevent relapses. Quinine
can also be used, and is increasingly the drug of choice, because chloroquine resistance is
increasing on the Indian subcontinent. Check that the patient is not glucose-6-phosphate
dehydrogenase (G6PD) deficient before giving primaquine
Prophylaxis
From dusk to dawn (because Anopheles spp. are night-biters) use protective clothing, mosquito
repellents and bed nets impregnated with insecticide
Prescribe chemoprophylaxis from 1 week before departure until 4 weeks after return:
Chloroquine-sensitive area chloroquine once a week or proguanil daily
Chloroquine-resistant areas mefloquine once a week or Malarone or doxycycline (in children
>8 years) daily
9.2 Enteric (typhoid/paratyphoid) fever

Caused by Salmonella typhi, S. paratyphi Gram-negative bacilli in family Enterobacteriaceae
S. typhi found only in humans, transmitted by faecaloral route
Onset of illness is gradual with fever, headache, malaise, constipation (initially), diarrhoea (second
week), abdominal pain, hepato-/splenomegaly, rose spots. Infants may present with Gram-negative
septicaemia. Within a week, fever becomes unremitting, and delirium and disorientation may occur.
The paradoxical relationship between high fever and low pulse rate is uncommon in children
Complications
Intestinal perforation occurs in 0.53%, severe haemorrhage in 110% of children
Focal infections, e.g. meningitis, osteomyelitis, endocarditis, pyelonephritis, more common in the
immunocompromised host
Osteomyelitis and septic arthritis in children with haemoglobinopathies
Chronic carriage local multiplication in the wall of the gallbladder produces large numbers of
salmonellae, which are then discharged into the intestine and may cause chronic carriage and
shedding (in 5% of adults but much less in children)
Diagnosis
Perform bacterial cultures on blood, stool, bone marrow or rose spot aspirate
Microscopy of stool reveals many leukocytes, mainly mononuclear
Blood leukocyte count is at the low end of normal. Frank neutropenia can occur
Treatment
Drug choice and route of administration depend on susceptibility of organism, host response and site
of infection, including:
Ampicillin, ceftriaxone, cefotaxime, chloramphenicol; in view of resistance, a fluoroquinolone is
now frequently used as first-line therapy for 14 days, although resistance to this class is developing
as well
For osteomyelitis as above for 46 weeks
For meningitis ceftriaxone or cefotaxime for 4 weeks
To eradicate carriage high-dose ampicillin or amoxicillin or cholecystectomy
Prophylaxis
Personal hygiene and proper sanitation for food processing and sewage disposal
Vaccine is available, but only 1766% effective depending on type
9.3 Dengue fever

Caused by an arbovirus (i.e. arthropod borne); 570 arboviruses have been identified with more
than 30 human pathogens
Dengue fever is caused by the genus Flavivirus (which also causes Japanese encephalitis and
yellow fever)
Transmitted by the mosquito Aedes aegypti a day-biting mosquito
Dengue fever is now endemic in south-east Asia, Central and South America, and the Caribbean
Include fever for 17 days, frontal or retro-orbital headaches, back pain, myalgia and arthralgia
(breakbone fever), nausea and vomiting
12 days after defervescence a generalized morbilliform rash occurs lasting 15 days. As this rash
fades the fluctuating temperature reappears, producing the biphasic temperature curve
Complications
Dengue haemorrhagic fever (DHF) fever, haemorrhage, including epistaxis and bleeding of the
gums, and capillary fragility and fluid leakage. Complications include hepatitis, pneumonia,
encephalopathy and cardiomyopathy. DHF occurs with the second infection with the arbovirus and
there is an immunological component that causes augmentation of the disease and increased
severity of clinical presentation. Rare in childhood
Diagnosis
PCR, serology, isolation of virus (note prior yellow fever immunization will give positive dengue
IgG)
Treatment
None is specific; supportive only. Aggressive fluid resuscitation in DHF markedly decreases
mortality
9.4 Viral haemorrhagic fevers

Many different viruses are found in different parts of world, so an accurate travel history is
necessary
These diseases range from mild infections to severe acute febrile illnesses with cardiovascular
collapse. Fever, headaches, myalgia, conjunctival suffusion and abdominal pain are early
symptoms. Mucosal bleeding occurs with vascular damage and thrombocytopenia, and may cause
life-threatening haemorrhage. Shock develops 710 days after the onset of illness
Elevated alanine aminotransferase (ALT) is a poor prognostic factor in Lassa fever. Transmission
is by inhalation or by contact of broken skin with the urine or saliva of infected rodents
Diagnosis
Serology
Treatment
Intravenous ribavirin for Lassa fever, especially in the first week of illness, reduces mortality
Symptomatic management and supportive treatment for all other viral haemorrhagic fevers
Prevention
Strict isolation of patient and contacts. These infections are highly contagious
For suspected cases examine a malarial film only (labelled Very high risk for laboratory staff
awareness). If negative, i.e. diagnosis is NOT malaria, then contact local microbiologist/public
health laboratory service urgently for transfer of the patient to the designated unit
9.5 Hantaviruses
These are bunyaviruses and cause two different clinical syndromes. Rodents are the definitive hosts
and are asymptomatic carriers that shed virus in their saliva and excreta. Disease is contracted
through contact with infected rodents and their excreta
Old World hantaviruses cause haemorrhagic fever with renal syndrome. Found throughout Asia
and eastern and western Europe. Cause up to 100 000 cases a year
New World hantaviruses, which occur in the south-west states of the USA and in the Andes region
of South America, cause hantavirus pulmonary syndrome
Both have an incubation period of 16 weeks and present with a prodrome of a non-specific flulike illness
Haemorrhagic fever with renal syndrome (Old World)
Prodrome characterized by vascular instability, followed by renal failure presenting with oliguria,
followed by polyuria, hypotension, bleeding and shock
The European disease is milder and presents most commonly as non-specific flu-like symptoms and
proteinuria. Acute severe renal failure is rare
Pulmonary syndrome (New World)
Non-specific flu-like prodrome followed by the abrupt onset of progressive pulmonary oedema,
hypoxaemia and hypotension. This is the result of diffuse pulmonary leakage and is most likely to
be immune mediated
After 24 days, there is onset of diuresis with rapid improvement and resolution of pulmonary
disease
Diagnosis
Serology
Characteristic full blood count abnormalities in pulmonary syndrome which include:
haemoconcentration, thrombocytopenia and neutrophilia with the presence of immunoblasts on
blood film
Treatment
Supportive and symptomatic as required. Intubation and ventilation in pulmonary syndrome.
Dialysis is rarely required in haemorrhagic fever. Meticulous fluid management
Ribavirin has been used and thought anecdotally to be useful, but evidence for efficacy is lacking
9.6 Giardia
Caused by Giardia lamblia, a protozoan that produces infectious cysts

Faecaloral transmission
Infection limited to small intestine and/or biliary tract
Worldwide distribution, some animals and humans infected, may infect water supply
Very varied
Acute watery diarrhoea with abdominal pain, or foul-smelling stools and flatulence with abdominal
distension and anorexia
Diagnosis
Stool microscopy, rarely by duodenal biopsy
Treatment
Metronidazole or tinidazole
9.7 Amoebiasis
Caused by Entamoeba histolytica, a protozoan, excreted as cysts or trophozoites in stool of
infected patients
Faecaloral transmission of cysts
Worldwide distribution, with infection rates as high as 2050% in the tropics
Intestinal disease asymptomatic or mild symptoms, e.g. abdominal distension, flatulence,
constipation, loose stools
Acute amoebic colitis (dysentery) abdominal cramps, tenesmus, diarrhoea with blood and mucus
complications include toxic megacolon, fulminant colitis, ulceration and, rarely, perforation
Extraintestinal disease
Liver abscess acute fever, abdominal pain and liver tenderness, or subacute with weight loss and
vague abdominal symptoms; rupture of the abscess into the abdomen or chest may occur
Rarely, abscesses in the lung, pericardium, brain and genitourinary tract
Diagnosis
Microscopy of stool, biopsy specimens and aspirates, serology if extraintestinal disease
Treatment
To eliminate the tissue-invading trophozoites as well as cysts
Metronidazole followed by a luminal amoebicide, e.g. paromomycin
9.8 Hookworm
Caused by Ancylostoma duodenale and Necator americanus

Prominent in rural, tropical areas where soil may be contaminated with human faeces
Humans are the major reservoir
Infection is by infectious larvae penetrating the skin, usually the soles of feet
May be asymptomatic
May develop pruritus and papulovesicular rash for 12 weeks after initial infection
Pneumonitis associated with migrating larvae in this phase is uncommon and usually mild
Diagnosis
Stool microscopy
Treatment
Antihelmintic drug, e.g. mebendazole (note also treat any associated iron-deficiency anaemia)
9.9 Leishmaniasis
Leishmania spp. are obligate intracellular parasites of monocytes/macrophages

Variety of hosts including canines and rodents
Vector is the sandfly
Incubation period is usually days to months, but may even be years
Three major clinical syndromes:
Cutaneous leishmaniasis shallow ulcer at site of sandfly bite; lesions commonly on exposed
skin, i.e. face and extremities; may have satellite lesions and regional lymphadenopathy
Mucosal leishmaniasis initial cutaneous infection disseminates to midline facial structures, e.g.
oral and nasopharyngeal mucosa
Visceral leishmaniasis (kala-azar) parasites spread throughout the reticular endothelial system
and are concentrated in the liver, spleen and bone marrow. Presents with fevers, weight loss,
splenomegaly (may be massive), hepatomegaly, lymphadenopathy, anaemia, leukopenia,

thrombocytopenia and hypergammaglobulinaemia
Diagnosis
Microscopic identification of intracellular leishmanial organisms from skin or splenic biopsy, or
bone marrow
Serology may be helpful
Treatment
Sodium stibogluconate or amphotericin B. Liposomal amphotericin is particularly effective and is
the treatment of choice in the developed world
9.10 Schistosomiasis
Caused by the trematodes (flukes) Schistosoma mansoni, S. japonicum, S. haematobium and others
Humans are the principal host; snails are intermediate host
Eggs are excreted in urine or stool into fresh water, hatch and infect snails; after further
development, cercariae emerge and penetrate human skin
Usually infection is asymptomatic
May have initial transient pruritic, papular rash
May have acute infection Katayama fever: 48 weeks after infection an acute illness with fever,
malaise, cough, rash, abdominal pain, diarrhoea, arthralgia, lymphadenopathy and eosinophilia
Chronic infection with S. mansoni and S. japonicum may cause diarrhoea, tender hepatomegaly,
chronic fibrosis, hepatosplenomegaly and portal hypertension
Chronic infection with S. haematobium may cause dysuria, terminal microscopic haematuria, gross
haematuria, frequency and obstructive uropathy
Haematogenous spread to the lungs, liver and CNS may occur
Diagnosis
Identification of the eggs in stool/urine, respectively
Bladder biopsy
Serology
Treatment
Praziquantel
9.11 Travellers diarrhoea

Travellers diarrhoea is a syndrome characterized by a twofold or greater increase in the frequency
of unformed bowel movements
Food- and water-borne diseases are the number one cause of illness in travellers
Travellers diarrhoea can be caused by viruses, bacteria or parasites, which can contaminate food
or water
The most important determinant of risk is the destination of the traveller
Attack rates of 2050% are commonly reported
Diarrhoea, abdominal cramps, nausea, bloating, urgency and malaise; sometimes vomiting also
occurs
Nature of stool may indicate particular organism
Travellers diarrhoea usually lasts from 3 days to 7 days, but is rarely life threatening
Enteric bacterial pathogens

Enterotoxigenic Escherichia coli (ETEC) is among the most common causative agents; ETEC
produces a watery diarrhoea associated with cramps and low-grade or no fever
Salmonella gastroenteritis usually results from non-typhoidal Salmonella spp. that cause dysentery
characterized by small-volume stools containing bloody mucus
Shigella bacillary dysentery is seen in up to 20% of travellers to developing countries
Campylobacter jejuni causes a small percentage of the reported cases of travellers diarrhoea,
some with bloody diarrhoea
Vibrio parahaemolyticus is associated with the ingestion of raw or poorly cooked seafood
Less common bacterial pathogens include other diarrhoeagenic E. coli, Yersinia enterocolitica,
Vibrio cholerae O1 and O139, non-O1 V. cholerae, V. fluvialis, and possibly Aeromonas hydrophila
and Plesiomonas shigelloides.
Viral enteric pathogens

Rotaviruses and Norwalk-like virus may cause travellers diarrhoea
Parasitic enteric pathogens

These include Giardia intestinalis, Entamoeba histolytica, Cryptosporidium parvum and
Cyclospora cayetanensis. The likelihood of a parasitic aetiology is higher when diarrhoeal illness
is prolonged. Entamoeba histolytica should be considered when the patient has dysentery or
invasive diarrhoea (bloody stools)
Treatment
Antimotility agents should NOT be used in children. Occasionally in adolescents, similar to adults,
they may be used to provide prompt symptomatic but temporary relief of uncomplicated travellers
diarrhoea. However, they should not be used by people with high fever or with blood in their
stools
Oral rehydration solutions and plenty of fluids should be drunk to prevent dehydration
Antibiotics should be reserved for: those with severe diarrhoea that does not resolve within
several days; if there is blood or mucus, or both, in the stools; if fever occurs with shaking chills
Prevention
Treatment of water:
Boiling for at least 5 min is the most reliable method to make water safe to drink
Chemical disinfection can be achieved with either iodine or chlorine, with iodine providing
greater disinfection in a wider set of circumstances
Food:
Any raw food can be contaminated, particularly in areas of poor sanitation
Foods of particular concern include salads, uncooked vegetables and fruit, unpasteurized milk
and milk products, raw meat and shellfish
Some fish are not guaranteed to be safe even when cooked because of the presence of toxins in
their flesh. Tropical reef fish, red snapper, amber jack, grouper and sea bass can occasionally be
toxic at unpredictable times if they are caught on tropical reefs
10. NEW AND EMERGING INFECTIONS

10.1 Severe acute respiratory syndrome
New infectious disease. Restricted to China, Hong Kong and Vietnam and visitors to those regions
and their contacts, resulting in outbreaks in Toronto and Singapore. Probably originated in the
animal populations and crossed over into humans. Disease restricted to a single outbreak
Aetiology: novel coronavirus
Incubation period: 210 days. More severe cases present earlier
Clinical presentation: non-specific flu-like prodrome followed by fever, shortness of breath and
diffuse pneumonia, and acute respiratory distress syndrome. Associated diarrhoea in some patients.
Less severe in children and few cases <15 years; 10% mortality rate
Diagnosis: PCR of nasopharyngeal aspirate, stool and urine. Serology is useful for epidemiological
purposes only
Treatment: No effective treatment. Ribavirin has been used and also steroids in the more severe
affected patients, with limited success. Intensive care with mechanical ventilation required for a
large percentage of infected patients
10.2 West Nile virus

West Nile virus is a flavivirus. Widely distributed throughout Africa, the Middle East, Asia,
Australia and parts of Europe. First detected in the USA in 1999 and is now widespread throughout
the continent. Primary hosts are birds and the vectors are mosquitoes. Peak infection is late
summer, but sporadic cases occur
Clinical presentation: most patients present with a self-limiting febrile flu-like infection,
characterized by headaches, myalgias, malaise, back pain and loss of appetite. Vomiting, diarrhoea,
abdominal pain and pharyngitis are common, and the disease lasts 310 days
The mortality rate in this group is approximately 2%
Neurological complications occur in <1% of patients, and elderly and immunocompromised
individuals are more at risk. This presents typically as an encephalitis with muscle weakness, and
in some cases a flaccid paralysis. Parkinsonian-like features can also occur
Diagnosis: serology
10.3 Avian influenza virus

The H5N1 strain of avian influenza virus is endemic in the bird population in south-east Asia, with
sporadic human spread, and culling of domestic birds has been necessary to prevent further spread.
Pigs are an important reservoir that could facilitate mutation of the virus
Concern that close proximity of birds, swine and humans in south-east Asia will facilitate mutation
and, although no cases have been reported outside this region, there is widespread concern that
mutation and spread to the human population will cause a severe influenza pandemic worldwide
>90 cases in humans in 20042005. Mortality rate of 68%. Predominance in children and young
adults
Treatment: oseltamivir
10.4 H1N1 influenza virus: swine flu

The H1N1 strain of influenza emerged in Mexico during the summer of 2009 and quickly spread
around the world. Most cases were mild or asymptomatic, but, in a small proportion of cases, it
caused severe illness and death. This is a novel strain of influenza, sufficiently different to other
circulating strains that there is no cross-over immunity from previous influenza infections or the
previous seasons immunization. It was thought to be similar to the strain that caused a large outbreak
in the 1950s and this accounts for the relative immunity enjoyed by the over-60 age group, the group
usually most severely affected by influenza. The most severely affected in this pandemic were
children and young adults. In 2010 it was the predominant circulating influenza strain during the
influenza season.
Treatment: oseltamivir or zanamavir. Not susceptible to amantidine or ramantidine
11. CONGENITAL INFECTIONS

Congenital infections are acquired in utero, usually transplacentally, during maternal infection.
Manifestations are most severe if acquired in the first trimester.
Suspect if:

Microcephaly or hydrocephalus
Ocular defects
Hepatosplenomegaly
Thrombocytopenia
Developmental delay/fits
11.1 Diseases
CMV, congenital rubella syndrome, toxoplasmosis
Approximately two-thirds of pregnancies complicated by rubella during the first 8 weeks of
gestation will result in fetal death or severe abnormality
There is a 40% risk of toxoplasmosis transmission from mother to fetus
In CMV and toxoplasmosis, approximately 10% of infected infants are clinically affected at birth,
although symptoms will often become apparent during childhood
Characteristic features of CMV, rubella and toxoplasmosis infection
Parvovirus B19
Women who become infected with parvovirus B19 during the first 20 weeks of pregnancy have a
9% fetal loss
Hydrops fetalis occurs in approximately 3% if the mother is infected between 9 and 20 weeks
gestation
Congenital varicella
Infection during the first or second trimester may rarely cause congenital varicella syndrome (0.5
2%)
Skin scarring, limb malformation/shortening, cataracts, chorioretinitis, micro-ophthalmia,
microcephaly, hydrocephalus
Vast majority of infants are infected peripartum, only 5% transplacentally

Cutaneous scars or vesicles
Choreoretinitis, keratoconjunctivitis, micro-ophthalmia
Microcephaly, intracranial calcifications
Hepatosplenomegaly
Developmental delay
Syphilis
High transmission rate, 40% mortality rate if left untreated

Snuffles, congenital nephrotic syndrome, chorioretinitis, glaucoma
Osteochondritis, periostitis
Hepatosplenomegaly, lymphadenopathy
Rash maculopapular, desquamative, bullous, condylomas
Very rare, high mortality
Presents as disseminated disease with fevers and often respiratory distress
Needs Mantoux testing, chest radiograph, lumbar puncture, quadruple therapy + steroids if
meningitis is confirmed
Diagnosis
TORCH screen toxoplasmosis, other, rubella, CMV and herpes-specific IgM in neonates <4
weeks old implies congenital infection
Screen for specific infection based on clinical findings in neonate and mother, rather than
requesting a TORCH screen
Note: look at specific antibody responses in mothers booking-visit blood samples and postdelivery blood samples to see rise/fall in titres depending on time of infection acquisition
PCR can be useful in some infections

Ophthalmological examination characteristic retinal changes
Treatment
Prevention through immunization is the only way to reduce the risk of congenital rubella
Spiramycin may be used for toxoplasmosis in pregnancy to reduce transmission to the fetus.
Affected infants are treated with pyrimethamine and sulfadiazine after birth
Ganciclovir or valganciclovir may be used in cases of congenital CMV. At present 6 weeks of
treatment soon after birth is recommended to reduce hearing loss. There are ongoing studies to
assess the efficacy of longer courses of therapy and therapy later in childhood
Aciclovir is recommended for up to a year in patients with neonatal herpes simplex
Penicillin is used to treat syphilis
HAART used for HIV infection
Anti-TB treatment
12. MISCELLANEOUS
12.1 Differential diagnosis of prolonged fever
Systemic bacterial disease:
Viral disease:
Salmonellosis
Mycobacterial infection
Brucellosis
Leptospirosis
Spirochaete infections
CMV
Hepatitis viruses
EBV
Human herpesvirus-6
Focal bacterial infections:
Parasitic infections:
Other infections
Abscesses
Sinusitis
Osteomyelitis
Endocarditis
Urinary sepsis
Malaria
Toxoplasmosis
Leishmaniasis
Chlamydia
Rickettsia
Fungi
Non-infectious diseases:
Collagen vascular diseases: systemic lupus erythematosus (SLE), juvenile inflammatory arthritis
(JIA)
Familial Mediterranean fever
Kawasaki disease
Sarcoidosis
Malignancies
Drugs
Autonomic/CNS abnormalities
12.2 Differential diagnosis of cervical lymphadenopathy

Differential diagnosis of cervical lymphadenopathy
Cervical abscess
Tuberculosis (usually atypical)
Cat-scratch fever (caused by Bartonella henselae)
Gram-negative organism
Mumps
Malignancy
Infectious mononucleosis
Toxoplasmosis
Brucellosis
Salivary stones
12.3 Infections commonly associated with atypical lymphocytosis
EBV
CMV
Toxoplasmosis
Mumps
Tuberculosis
Malaria
12.4 Diseases associated with eosinophilia

An increase above 0.4 109/l is seen with:
Allergic disease, e.g. asthma, eczema
Parasitic disease, e.g. hookworm, amoebiasis, ascariasis, tapeworm infestation, filariasis,
schistosomiasis
Recovery from acute infection
Skin disease, e.g. psoriasis, pemphigus
Hodgkin disease
Drug sensitivity
Hypereosinophilia syndrome
Eosinophilic leukaemia (very rare)
12.5 Causes of hydrops fetalis

1015% immune aetiology:
Fetal anaemia caused by anti-D, anti-Kell and anti-C antibodies
8590% non-immune cause:
Human parvovirus B19 infection (most common), CMV, toxoplasmosis, syphilis, leptospirosis
Aneuploidy
Cardiac cause, e.g. supraventricular tachycardia and congenital complete heart block
Primary hydrothorax
Cystic hygroma
Twintwin transfusion syndrome
Massive transplacental haemorrhage
Fetal akinesia and muscular dystrophy
12.6 Oxazolidinones: a new class of antibiotics

Linezolid
Active against meticillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant
enterococci:
Bacteriostatic agent
Good CNS penetration
Does not have good activity against Gram-negative organisms
Reserve for those with infections resistant to other antibacterial agents
Side effects include myelosuppression monitor blood count weekly
12.7 Echinocandins: a new class of antifungals

Active against Aspergillus and Candida spp. Fungistatic in aspergillosis, but fungicidal in candidal
disease. Useful as adjunctive therapy together with either amphotericin B (AmBisome) or
voriconazole in severe fungal infections
Widely distributed in all tissues and has good CNS penetration when disease is present
Intravenous preparation only
Adverse effects: raised aminotransferases, headaches and gastrointestinal disturbances

Characteristic target lesions; also macules, papules, weals, vesicles and bullae
Systemic symptoms common fever, malaise, arthralgia
StevensJohnson syndrome severe erythema multiforme with mucosal bullae in mouth, anogenital
region and conjunctiva
Causes
Idiopathic (> 50%)

Herpes simplex
Mycoplasma spp.
Viruses enteroviruses
Drugs sulfonamides, penicillins, barbiturates
Treatment
Treat underlying cause; supportive; steroids in severe erythema multiforme (early)

Inflammatory disease of skin and subcutaneous tissues characterized by tender, red nodules
predominantly pretibial (also arms and other areas):
Streptococcal upper respiratory tract infection

Sarcoid
Primary tuberculosis
Ulcerative colitis
Drugs (sulfonamides, contraceptive pills, bromides)
Other leprosy, histoplasmosis, psittacosis, lymphogranuloma venereum, coccidioidomycosis
Treatment
Antimicrobials specific to the infection
Steroids: systemic most effective
12.10 Anthrax
Caused by the Gram-positive organism Bacillus anthracis
Wild and domestic animals in Asia, Africa and parts of Europe carry the bacterium
The bacterium can exist as a spore, which allows it to survive in the environment (e.g. in the soil)
Cutaneous anthrax (95% of cases)

Caught by direct contact with the skin or tissues of infected animals. A lesion appears on the skin,
often on the head, forearms or hands, and develops into a characteristic ulcer with a necrotic
centre. It is rarely painful. Untreated, the infection can spread to cause bacteraemia, which can be
fatal in 520% of cases
Inhalation anthrax
Much less common. Caused by breathing in anthrax spores. Symptoms begin with a flu-like illness,
followed by respiratory difficulties and shock after 26 days. High fatality rate
Intestinal anthrax
Very rare form of food poisoning, which results in severe gut disease, fever and septicaemia.
Mortality rate of up to 50%
Vaccine available for very-high-risk groups only
Post-exposure prophylaxis with antibiotics can be very effective in preventing disease, provided
that it is given early enough
Treatment
High-dose penicillin and doxycycline or ciprofloxacin
12.11 Botulism
Botulism is caused by a botulinum toxin, produced by the bacterium Clostridium botulinum
The bacterium is anaerobic and common in the soil in the form of spores
Food-borne botulism occurs when the spores of C. botulinum have germinated and the bacteria
have reproduced in an environment (usually food) outside the body and produced toxin. The toxin
is consumed when the food is eaten
The toxin is destroyed by normal cooking processes
Botulism is a neuroparalytic disorder that can be classified into three categories:
Food borne:
Onset of symptoms is usually abrupt, within 1236 h of exposure
Symmetrical, descending, flaccid paralysis occurs, typically involving the bulbar musculature
initially
Sometimes diarrhoea and vomiting occur
Most cases recover, but the recovery period can be many months; the disease can be fatal in 5
10% of cases
Infant botulism:
Extremely rare, but occurs when spores are ingested that germinate, multiply and release toxin in
the intestine; not related to food ingestion in this population; more common in breast-fed babies and
in certain regions of the world
Incubation period is much longer: 330 days
Presents with floppy infant with poor feeding, weak cry, generalized hypotonia, constipation
Wound botulism:
Same symptoms as other forms, but occurs when the organisms get into an open wound and are
able to reproduce in an anaerobic environment
Diagnosis
Enriched selective media are used to culture C. botulinum from stools and food
A toxin neutralization assay can identify botulinum toxin in serum, stool or food
Electromyography has characteristic appearances
Treatment
Supportive care, especially respiratory (e.g. ventilation) and nutritional
Antitoxin
Baby Big (botulism immune globulin): treatment for infant botulism effective if given early in the
disease process. Shortens course of the illness, decreases intensive care time
Concerns about the effectiveness and side effects of the vaccine against botulism; it is not widely
used
Immunity to botulism toxin does not develop, even with severe disease
Prevention
Education about food preparation.
Therapeutics
Botulinum A toxin, in small doses, is used therapeutically to prevent excessive muscular activity, e.g.
in torticollis, cerebral palsy and recently in cosmetics to reduce wrinkles.
12.12 Bovine spongiform encephalopathy and new variant CreutzfeldtJakob

disease
Transmissible spongiform encephalopathies (TSEs) are caused by proteinaceous infectious
particles or prions. These are abnormal isoforms of a cell-surface glycoprotein designated PrP
Disease is caused when a disease-specific isoform, PrPSc, interacts with PrP producing
conversion to PrPSc. This protein is not readily digested by proteases and therefore accumulates,
causing a rapidly progressive and fatal encephalopathy
PrPSc is very resistant to standard methods of sterilization and disinfection. The genotype of
polymorphic codon 129 of the human PrP gene appears to influence susceptibility to infection and
disease phenotype. Of white people 37% are methionine homozygous (MM), 12% are valine
homozygous (VV) and 51% are heterozygous (MV). Cases of new variant CreutzfeldtJakob
disease (nv-CJD) have been found in MM individuals
CreutzfeldtJakob disease
The principal human spongiform encephalopathy. Features include a progressive dementia, movement
disorder and death in a median of 4 months. The incidence is between 0.5 and 1 case per million.
Most cases present between 55 and 75 years of age and most have no known cause; 15% have a
hereditary predisposition to CJD, with recognized mutations of the human PrP gene on chromosome
20. A small number of iatrogenic cases have occurred following the use of contaminated growth
hormone.
Kuru
A disease of motor incoordination, this was endemic in Papua New Guinea in the 1950s and 1960s.
Kuru was a TSE spread by the ritual cannibalism of deceased relatives. Cannibalism ceased in the
late 1950s, but there are still a few cases in older adults indicating a long incubation period.
New variant CJD

This was first reported with 10 cases in 1996. The source appeared to be bovine spongiform
encephalopathy (BSE), acquired after the ingestion of infected cattle. The disease starts as a
psychiatric illness followed by ataxia, myoclonus, akinetic mutism and death after about 12 months.
There are now more than 100 cases. The incubation period may be very long and therefore the total
number of cases is difficult to predict. Only six cases in children have been identified since 1997, the
youngest being 12 at diagnosis.
13. FURTHER READING

American Academy of Paediatrics (2009). Report of the Committee on Infectious Diseases. Red
Book. Elk Grove Village, IL: American Academy of Paediatrics.
BMA and RPSGB (2011). British National Formulary for Children, March.
Feigin R, Cherry J (2009). Textbook of Paediatric Infectious Diseases, 6th edn. Philadelphia, PA:
WB Saunders.
Gardiner M, ed. (2009). Training in Paediatrics. Oxford: Oxford University Press.
Kliegman RM, ed. (2010). Nelson Textbook of Paediatrics, 19th edn. Philadelphia, PA: WB
Saunders.
Shingadia D, Davies EG, eds (2011). Manual of Childhood Infections. The Blue Book. Oxford:
Oxford University Press.
WEBSITES
Centers for Disease Control (CDC): www.cdc.gov
Health Protection Agency (HPA): www.hpa.org.uk
Chapter 16
Metabolic Medicine
Mike Champion
CONTENTS
1. Basic metabolism
1.1 Carbohydrate metabolism
1.2 Protein metabolism
1.3 Fat metabolism
2. Approach to the metabolic case

2.1 Inheritance
2.2 Presentation
2.3 Examination
2.4 Investigations
2.5 Acute management
2.6 Long-term management
3. Disorders of amino acid metabolism

3.1 Phenylketonuria
3.2 Tyrosinaemia (type 1)
3.3 Maple syrup urine disease
3.4 Homocystinuria
3.5 Non-ketotic hyperglycinaemia
4. Organic acidaemias
4.1 Propionic, methylmalonic and isovaleric acidaemias
4.2 Glutaric aciduria type 1
5. Urea cycle defects
6. Fat oxidation disorders

6.1 Medium-chain acyl-CoA dehydrogenase deficiency
6.2 Long-chain defects
7. Mitochondrial disorders
7.1 Mitochondrial genetics
7.2 Clinical features
8. Disorders of carbohydrate metabolism

8.1 Glycogen storage disease
8.2 Galactosaemia
8.3 Hereditary fructose intolerance
9. Lipid disorders
9.1 Hypertriglyceridaemias
9.2 Hypercholesterolaemias
9.3 Abetalipoproteinaemia
10. Peroxisomal disorders

10.1 Zellweger syndrome
10.2 X-linked adrenoleukodystrophy
11. Mucopolysaccharidoses
11.1 Classification
11.2 Hurler syndrome
12. Sphingolipidoses
12.1 TaySachs disease
12.2 Gaucher disease
12.3 NiemannPick disease
12.4 Fabry disease
13. Miscellaneous
13.1 Porphyria
13.2 SmithLemliOpitz syndrome
13.3 Congenital disorders of glycosylation
13.4 LeschNyhan syndrome
13.5 Menkes syndrome
13.6 Ketotic hypoglycaemia
14. Screening
14.1 Principles of screening
14.2 UK neonatal screening programme
15. Further reading
Metabolic Medicine
1. BASIC METABOLISM
1.1 Carbohydrate metabolism
Glucose has three metabolic fates in the body: oxidation for energy, storage as glycogen, and
conversion to amino acids and triglycerides.
A steady supply of adenosine triphosphate (ATP) is needed to power each cells essential processes.
This ATP is usually supplied from the oxidation of glucose provided in the diet and from glycogen
stores. In the fasted state, the hormone-mediated response is to draw on the bodys reserves, fat and
protein (catabolism), to make up the fuel shortfall to generate ATP.
The diet rarely contains glucose as the only carbohydrate source; other carbohydrates, e.g. fructose,
galactose, lactose, need to be converted to glucose first before they can be used for energy.
Glycolysis
Glycolysis takes place in the cytoplasm of all cells and describes the breakdown of one molecule of
glucose to produce two molecules of pyruvate. It can occur under aerobic (large energy production
via the tricarboxylic acid [TCA] cycle and oxidative phosphorylation) or under anaerobic conditions
(small energy production via lactate). Glycolysis provides an emergency mechanism for energy
production when oxygen is limited, i.e. in red cells (which have no mitochondria, so glycolysis is
their only means of energy production) or in skeletal muscle during exercise. Glycolysis also
provides intermediates for other metabolic pathways, e.g. pentoses for DNA synthesis. The three
enzyme steps are irreversible.
Pyruvate metabolism
Pyruvate, produced by glycolysis and other metabolic pathways, can be converted to oxaloacetate (by
pyruvate carboxylase) for entry into the TCA cycle, or acetyl-CoA (by pyruvate dehydrogenase),
which has a number of potential fates:
Oxidation in the TCA cycle
Fatty acid synthesis

Ketone body synthesis
Steroid synthesis
Tricarboxylic acid cycle

This cycle is present in all cells with mitochondria (not red cells) and provides the final common
pathway for glucose, fatty acids and amino acid oxidation via acetyl-CoA or other TCA cycle
intermediates. The cycles main function is the provision of reduced cofactors (reduced nicotinamide
adenine dinucleotide or NADH, reduced flavin adenine dinucleotide or FADH2) which donate
electrons to the respiratory chain for ATP production (see Section 7). The cycle also provides
metabolic intermediates for other synthetic pathways, e.g. amino acid synthesis and has a key
regulatory role in metabolism.
Glycogen metabolism
Glycogen is a branched glucose polymer stored in the liver, kidney and muscle for the rapid release
of glucose when needed. Liver glycogen is a store to release glucose to the rest of the body, whereas
muscle glycogen supports muscle glycolysis only.
Glycogen synthesis is promoted by insulin and involves:
Uridine diphosphate (UDP)-glucose synthesis (glucose donor) from glucose 1-phosphate
Elongation of glycogen (glucose linked to existent glycogen strand (-1,4-glycosidic bond)
Branch formation (-1,6-glycosidic bond)
Glycogenolysis is promoted by adrenaline and glucagon and involves:
shortening of chain to release glucose 1-phosphate
Sequential removal until the branch point is reached
Removal of the branch point
1.2 Protein metabolism

Proteins are assembled from amino acids, which are composed of an amino group metabolized to
urea via ammonia and a carbon skeleton which has a number of potential metabolic fates: acetylCoA, pyruvate and ketone bodies.
Amino acids may be used for protein synthesis or converted to other non-essential amino acids,
(transamination) or oxidized via the TCA cycle. Essential amino acids cannot be synthesized in the
body. There is a continual turnover of the bodys protein because amino acids in the bodys amino
acids pool are used for protein synthesis and then broken back down to amino acids. Protein cannot
be stored and therefore any amino acids not used are catabolized and hence, to remain in neutral
nitrogen balance, protein is an essential constituent of a healthy diet.
Gluconeogenesis is the new synthesis of glucose from non-carbohydrate sources such as amino
acids, lactate and glycerol. This usually occurs in the liver but also occurs in the kidney in prolonged
starvation. Gluconeogenesis is promoted by glucagon, cortisol and adrenocorticotrophic hormone
(ACTH).
1.3 Fat metabolism

Fat has the highest caloric value and therefore is an essential energy source. Triglycerides comprise
three fatty acid molecules and one glycerol molecule which are broken down by lipase (lipolysis).
The released glycerol is converted to glyceraldehyde 3-phosphate in the liver, a key intermediate of
both glycolysis and gluconeogenesis. The fatty acids undergo -oxidation (see Section 6) within
mitochondria, which shortens the fatty acid by two carbons per cycle, releasing acetyl-CoA for entry
to the TCA cycle or the production of ketone bodies.
Fatty acids can be synthesized from acetyl-CoA by adding two carbons sequentially to the elongating
fatty acid chain (lipogenesis). This occurs mainly in the liver, adipose tissue, lactating mammary
gland and, to a minor degree, the kidney. Essential fatty acids cannot be synthesized by the body
because the enzyme required to form double bonds beyond nine carbons in length is not present. The
principal essential fatty acids are linoleic (C18:2) and -linolenic (C18:3) acids. Walnut oil is used
as a rich source in children on very-low-fat diets.
2. APPROACH TO THE METABOLIC CASE

2.1 Inheritance
Inborn errors of metabolism are individually rare but collectively they have an incidence of about 1
per 800 births. Autosomal recessive inheritance is the most common. Exceptions include the
following:
X-linked recessive: LeschNyhan syndrome, Hunter syndrome, ornithine transcarbamylase (OTC)
deficiency, Fabry disease, adrenoleukodystrophy
Autosomal dominant: porphyrias (some recessive), familial hypercholesterolaemia
Matrilineal: mitochondrial DNA point mutations
2.2 Presentation
Presentation is notoriously non-specific, so clues should be sought in the history. The most common
misdiagnosis is sepsis.
Clues from the history
Consanguineous parents
Previous sudden infant death (especially late, i.e. >6 months)
Ethnicity (for certain conditions only)
Previous multiple miscarriages (suggesting previously affected fetuses)
Maternal illness during pregnancy, e.g.:
Acute fatty liver of pregnancy (AFLP) and haemolysis, elevated liver enzymes, low platelets
(HELLP) syndrome: association with carrying fetus with long-chain fat oxidation defect
Increased fetal movements (in utero seizures)
Faddy eating (avoidance of foods that provoke feeling unwell)
Previous encephalopathic or tachypnoeic episodes (latter implies acidosis)
Inborn errors of metabolism present at times of metabolic stress, e.g.:
Neonatal period
Weaning (increased oral intake, new challenges, e.g. fructose)
End of first year (slowing in growth rate, so more protein catabolized as less used for growth. May
exceed metabolic capacity of defective pathway)
Intercurrent infections
Puberty
Neonatal presentation can be divided into four groups for diagnostic purposes.
1. Failure to make or break complex molecules
2. Intoxication
3. Energy insufficiency
4. Neonatal seizures
Failure to make or break complex molecules
These are usually dysmorphic syndromes at birth because of the absence of structural molecules that
are important for embryogenesis (failure to make complex molecules), e.g.
SmithLemliOpitz syndrome (cholesterol synthesis defect)
Zellweger syndrome (peroxisomal disorder)
Congenital disorders of glycosylation (glycosylation defects)
Many storage disorders appear normal at birth and become progressively more obvious with time as
storage accumulates (failure to break down complex molecules).
Intoxication
Key feature is a symptom-free period before decompensation while the toxic metabolites build up,
i.e. once feeds are established and the neonate no longer relies on the placenta for clearance. Classic
presentation is collapse on day 3 of life. Differential diagnosis includes sepsis and duct-dependent
cardiac problems.
Aminoacidopathies: tyrosinaemia, maple syrup urine disease (MSUD)
Urea cycle defects (UCDs)

Organic acidaemias (OAs)
Sugar intolerances: galactosaemia
Energy insufficiency
Absence of symptom-free period with immediate onset of symptoms in congenital lactic acidosis.
There is a spectrum of severity and some may take longer to decompensate fully:
Respiratory chain defects
Pyruvate metabolism defects (pyruvate dehydrogenase, pyruvate carboxylase)
The group includes conditions that present only if there is a delay in fuel provision, e.g. fat oxidation
defects, and glycogenolysis and gluconeogenesis defects; these may not present for some months or
longer, e.g.
Fat oxidation defects medium-chain acyl-CoA dehydrogenase (MCAD), long-chain hydroxyacylCoA dehydrogenase (LCHAD), very-long-chain acyl-CoA dehydrogenase (VLCAD)
Glycogen storage disease (GSD) types I and III
Defects of gluconeogenesis fructose bisphosphatase deficiency
Neonatal seizures
Suspect if evidence for in utero seizures or early onset in the absence of birth asphyxia
Effective treatment
Pyridoxine-dependent seizures
Pyridoxal phosphate-dependent seizures
Biotinidase deficiency
GLUT1 (glucose transporter type 1) deficiency
Creatine disorders
No effective treatment
Molybdenum cofactor deficiency
Non-ketotic hyperglycinaemia (NKH)
2.3 Examination
Clinical examination may reveal few clues in many disorders of intermediary metabolism.
Dysmorphic features may suggest certain diagnoses. Odours are usually unhelpful and rarely
significant (exceptions include MSUD, in which the nappies smell sweet, and isovaleric acidaemia,
in which there is a pungent sweaty odour). Eyes should be carefully examined for corneal clouding
(mucopolysaccharidoses, cystinosis), cataracts (galactosaemia, peroxisomal, mitochondrial),

pigmentary retinopathy (fat oxidation, mitochondrial) and cherry-red spot (TaySachs disease,
NiemannPick disease, Sandhoff disease, gangliosidosis GM1). Organomegaly is a key revealing sign.
Hepatosplenomegaly is a feature of storage disorders. Massive hepatomegaly in the absence of
splenomegaly suggests glycogen storage disease because glycogen is not stored in the spleen. More
prominent splenomegaly is suggestive of Gaucher disease.
2.4 Investigations
Perform investigations at the time of decompensation when diagnostic metabolites are most likely to
be present and avoid the need for stress tests at a later date, e.g. diagnostic fast.
Key initial metabolic investigations
Blood gas (venous, capillary or arterial)

Glucose
Lactate
Ammonia
Amino acids (plasma)
Acylcarnitines
Organic acids (urine)
Ketones (urinary dipstick)
Perimortem investigations
There are occasions when a metabolic diagnosis is considered in a patient in extremis. It is essential
to take the samples that will help secure the diagnosis and hence inform future reproductive choices
before the opportunity is lost.
Perimortem investigations
Blood
Red cells
Plasma
Acylcarnitines
DNA
Urine
Skin biopsy
Refrigerate 4C
Freeze 20C
Four spots on a Guthrie card
EDTA sample
Freeze 20C
If culture medium is not available, sample will survive happily in 0.9% saline
in the fridge over a weekend at 4C before being sent to the lab. Do NOT freeze
Muscle or liver biopsy is taken only if specific diagnosis is considered that requires this for
confirmatory enzymology. Sample must be frozen <1 hour after death to ensure meaningful
interpretation before autolysis of the bodys enzymes.
Acidbase status
Anion gap = Na+ + K+ (Cl + HCO3)
A normal anion gap (1018 mmol/l) in the presence of metabolic acidosis signifies bicarbonate loss
rather than an excess of acid, e.g. renal or gut. Although the pH may be normal, a low PCO2 (<4.5
kPa) indicates significant acidbase disturbance. Marked ketosis is unusual in the neonate and is
therefore highly suggestive of an underlying metabolic disorder. Urea cycle defects may initially
present with a mild respiratory alkalosis. Ammonia acts directly on the brain stem as a respiratory
stimulant.
Characteristics of metabolic and respiratory acidosis and alkalosis

Metabolic acidosis (low pH, low CO2)
Increased acid load
Organic acids
lactate
hypotension, hypoxia
mitochondrial, OAs
ketosis
diabetic ketoacidosis, OAs
Drugs/poisoning
Reduced acid excretion
distal renal tubular acidosis
renal failure
Bicarbonate loss
gastrointestinal
severe diarrhoea
total villus atrophy
renal loss
proximal renal tubular acidosis
Metabolic alkalosis (high pH, high CO2)
Increased alkali load
Drugs/poisoning
Loss of unbuffered acid
gastrointestinal
gastric aspiration
pyloric stenosis
chloride-losing diarrhoea
renal
mineralocorticoid excess
(Cushing, Conn)
diuretics
correction of chronic raised CO2
OAs, organic acidaemias.
Respiratory acidosis (low pH, high CO2)
Hypoventilation
encephalopathy (includes metabolic, drugs, anoxia, trauma, raised intracranial pressure, etc.)
neural/neuromuscular
thoracic restriction
dysostosis multiplex
kyphoscoliosis
lung compression
pleural effusion
pneumothorax
lung disease
airway obstruction
pneumonia etc
Respiratory alkalosis (high pH, low CO2)
Hyperventilation
hyperammonaemia
drugs, e.g. salicylate
mechanical ventilation/overbagging pain/anxiety
Metabolic acidosis
Key investigations: ketones, glucose, lactate, ammonia
Metabolic acidosis with ketosis
Diabetes
Organic acidaemias
Ketolysis defects,
Mitochondrial disorders
Gluconeogenesis defects
Metabolic acidosis without ketosis
Fat oxidation defects

Pyruvate dehydrogenase deficiency
Ketone synthesis defects
Renal tubular acidosis
Hypoglycaemia
Hypoglycaemia is defined as a blood glucose concentration of 2.6 mmol/l, and should always be
confirmed in the laboratory
Hypoglycaemia screen:
Glucose
Insulin, C-peptide
Cortisol
Acylcarnitines
Lactate
Amino acids
Free fatty acids:ketones (NEFA:BOHB)
Growth hormone
Ketones (dipstick urine)
The key additional investigation is the presence or absence of ketosis. Hypoketotic hypoglycaemia
has a limited differential diagnosis that can usually be resolved on history and examination:
Hyperinsulinism (endogenous or exogenous)

Fat oxidation defects (e.g. MCADD)
Liver failure
Mitochondrial disorder
Hyperinsulinism is suggested by a persistently increased glucose demand >10 mg/kg/min

Glucose requirement (mg/kg/min) = (ml/h % dextrose)/(6 weight in kg)
Fasting tolerance may give additional clues:
<1 hour: hyperinsulinism

<46 hours: glycogen storage disorders
1020 hours: gluconeogenesis defects
1524 hours: fat oxidation defects, ketone synthesis and ketolysis defects
Lactate
Lactate is a weak acid that can be used directly as a fuel for the brain and is readily produced during
anaerobic respiration. Secondary causes of lactate level anomalies (e.g. hypoxia, sepsis, shock, liver
failure, poor sampling) are much more common than primary metabolic causes. Ketosis is usually
present in primary metabolic disease, unlike in secondary causes, with the exception of pyruvate
dehydrogenase deficiency, GSD type I and fat oxidation defects. The level of lactate is unhelpful in
distinguishing the cause, and the lactate:pyruvate ratio usually adds little. A low ratio (<10) may
indicate pyruvate dehydrogenase deficiency. Exacerbation when a patient is fasted is a feature of
gluconeogenesis defects, of GSD type I compared with GSD type III, and of respiratory chain
disorders in which lactate may increase postprandially. The markedly raised lactate in
decompensated fructose bisphosphatase deficiency characteristically resolves rapidly on treating the
hypoglycaemia.
Cerebrospinal fluid (CSF) lactate is raised in mitochondrial disorders, central nervous system (CNS)
sepsis and seizures.
Ammonia
Hyperammonaemia may result from poor sampling (squeezed sample) and/or delays in processing.
The level of ammonia may prove discriminatory as to the cause.
Diagnosis from ammonia concentration

Ammonia concentration (mol/l)
<40
40 to <150
150 to <250
250 to <450
450 to >2000
Normal
Sick patient, fat oxidation defect, OA, liver failure, UCD
Fat oxidation defect, OA, liver failure, UCD
OA, liver failure, UCD
Liver failure, UCD, (OA rarely)
OA, organic acidaemia; UCD, urea cycle defect.
Transient hyperammonaemia of the newborn

(THAN) is characterized by very early onset; usually in the first 36 hours before feeding is truly
established. It is associated with low glutamine. THAN is managed as other UCDs acutely, but has an
excellent prognosis if treated early because hyperammonaemia is secondary to blood bypassing the
liver (e.g. patent ductus venosus), rather than a block in the urea cycle.
Amino acids
Amino acids are measured in both blood and urine. The latter reflects renal threshold, e.g.
generalized aminoaciduria of a proximal renal tubulopathy or the specific transporter defect of
cystinuria (cystine, ornithine, arginine, lysine). An increase in the serum levels of a specific amino
acid may be missed if only a urine sample is analysed and the renal threshold has yet to be breached.
Plasma amino acids are useful in the work-up of a number of metabolic disorders, and are essential
for monitoring in some:
leucine, isoleucine and valine MSUD
glutamine, arginine ( citrulline) UCDs
alanine lactic acidosis
glycine NKH, OAs

phenylalanine phenylketonuria
tyrosine tyrosinaemia
Organic acids
These are measured in urine only and are diagnostic in many organic acidaemias, e.g. increased
propionate in propionic acidaemia, increased isovalerate in isovaleric acidaemia, but are also
essential in the diagnosis of other disorders.
orotic acid UCDs, mitochondrial, benign hereditary orotic aciduria

methylmalonate vitamin B12 deficiency and disorders methylmalonic aciduria
succinylacetone tyrosinaemia type I
dicarboxylic acids fat oxidation defects, medium-chain triglyceride feeds, mitochondrial
Acylcarnitines
Carnitine conjugates with acyl-CoA intermediates proximal to the block in fat oxidation defects. The
chain length of the acylcarnitines formed is diagnostic of where the block lies, e.g. medium-chain
(MCAD), very long-chain (VLCAD). Likewise, conjugation with organic acids allows diagnosis of
organic acidaemias, e.g. propionylcarnitine. Total and free carnitine levels can be measured at the
same time: very low in carnitine transporter defects, low in fat oxidation defects and organic
acidaemias, high in carnitine palmitoyltransferase deficiency 1 (CPT1).
Urate
Urate is the end-product of the breakdown of purines. Raised levels in plasma may indicate increased
production (e.g. LeschNyhan syndrome, GSD type I, rhabdomyolysis) or decreased excretion
(familial juvenile hyperuricaemic nephropathy or FJHN). It is essential to measure a concurrent
urinary urate because urate clearance in children is so efficient that plasma levels may be in the upper
normal range in LeschNyhan syndrome, whereas urinary levels are grossly elevated. In FJHN the
reverse is true with high plasma urate, but low urinary urate. Low plasma urate is seen in
molybdenum cofactor deficiency as a result of a block in the conversion of purine bases to urate.
Acute patient screening

Specific metabolites are used to screen acute patients for specific disorders or groups of disorders.
Specific metabolite screens

Metabolite
Disorder
Very-long-chain fatty acids
Peroxisomal disorders, e.g. Zellweger syndrome,

adrenoleukodystrophy
Transferrin isoelectric focusing

Urate
7-Dehydrocholesterol
Biotinidase
Cardiolipins
Creatine and guanidinoacetate (GAA)
Urinary glycosaminoglycans and
oligosaccharides
Urinary reducing substances
Urinary sulphites
Urinary AASA (L--aminoadipicsemialdehyde)
Urinary purine and pyrimidine
metabolites

Purine disorders
SmithLemliOpitz syndrome
Barth syndrome
Creatine disorders
Mucopolysaccharidoses and mucolipidoses
Galactosaemia
Sulphite oxidase deficiency, molybdenum cofactor
deficiency
Pyridoxine-dependent seizures
Purine and pyrimidine disorders
Secondary investigations include:

Neuroimaging: leukodystrophies, mitochondrial disorders, peroxisomal
Neurophysiology: mitochondrial, peroxisomal, sphingolipidoses
Echocardiogaraphy: especially hypertrophic cardiomyopathy, mitochondrial, fat oxidation, Pompe
disease (GSD type II), storage disorders
ECG: fat oxidation, mitochondrial, Pompe disease
EEG: metabolic encephalopathy, e.g. MSUD, hyperammonaemia
Enzymology
Definitive diagnosis is confirmed on enzymology. The sample requirement depends on which tissues
express the enzyme, e.g. galactosaemia (blood), OTC deficiency (liver), mitochondrial (muscle).
Genotype has superseded invasive biopsy in some conditions, e.g. GSD type I (glucose 6phosphatase deficiency).
White cell enzymes are often requested in patients with potential neurodegenerative or storage
disorders. Laboratories usually undertake different lysosomal assays for different presentations. The
neurodegeneration panel includes TaySachs disease, Sandhoff disease, Sly mucopolysaccharidosis
(MPS VII) and mannosidosis in plasma; GM1 gangliosidosis, arylsulphatase A deficiency, Krabbe
disease and fucosidosis in white cells. The organomegaly panel includes Sly syndrome (MPS VII)
and mannosidosis in plasma, GM1 gangliosidosis, Gaucher disease, NiemannPick disease A and B,
mannosidosis, fucosidosis and Wolman disease in white cells.
Developmental delay
A screen for metabolic causes of developmental delay has a low yield in unselected patients; 1-3%.
However, these are important diagnoses to exclude as there may be specific treatment and the
opportunity to prevent further decompensation. It is therefore important to look for clues to help target
investigation. Clues from history include the following:
Pregnancy: maternal health
Family history: consanguinity
Past medical: unexplained hypoglycaemia, encephalopathy, protein aversion, self-injurious
behaviour, seizure disorder
Type of delay:
Regression
Hypotonia
Speech delay
Metabolic screen for developmental delay
Ammonia
Urate
Lactate
Amino acids
Glycosaminoglycans (GAGs) and oligosaccharides (urine)
Specific clues may point to the need for specific investigations.
2.5 Acute management

Stop feeds
Promote anabolism give 10% dextrose with appropriate electrolyte additives (add insulin rather
than reduce percentage dextrose if hyperglycaemic). Note that high-concentration glucose can
exacerbate the lactic acidosis of pyruvate and respiratory chain defects, so 5% dextrose should be
used if primary lactic acidosis is suspected
Correct biochemical disturbance along standard guidelines, e.g. hypernatraemia, low phosphate etc.
Clear toxic metabolites:
Dialysis lactate, organic acids, ammonia, leucine
Drugs UCDs: sodium phenylbutyrate, sodium benzoate; OAs: carnitine, glycine
Supplement enzyme cofactors, e.g. biotin, thiamine, riboflavin
In defects of intermediary metabolism feeds are stopped during intercurrent infections to reduce the
metabolic load and glucose polymer drinks are substituted to avoid catabolism. Failure to tolerate the
emergency regimen requires admission for intravenous therapy.
Pitfalls in management
Prolonged cessation of feeds promotes catabolism. Protein should be withheld for a maximum of
4872 hours. Restart 0.5 g/kg per day if results still not available
Hypotonic fluids risk of hyponatraemic seizures. Ensure dextrose fluids include appropriate
sodium and potassium supplementation
Post-acidosis correction hypokalaemia ensure close monitoring and correction of potassium
during correction of acidosis
2.6 Long-term management
See text for abbreviations.
See text for abbreviations.
Genetic counselling
Risk of recurrence
Availability of prenatal testing and preimplantation genetic diagnosis (PGD)
Screen siblings if at risk
3. DISORDERS OF AMINO ACID METABOLISM

3.1 Phenylketonuria
The most common inborn error of metabolism in the UK; incidence of 1:10 000, carrier rate of 1:50.
Clinical features
Untreated classic PKU (phenylalanine >1000 mol/l)
Developmental delay in the first year

Learning disability
Behavioural problems
Decreased pigmentation
Dry skin
Treated classic PKU

Asymptomatic
IQ approximately 10 points below unaffected sibling
One to two per cent result from defects in biopterin, which is the essential cofactor for phenylalanine
hydroxylase and neurotransmitter synthesis.
Diagnosis
Raised phenylalanine level (usually newborn screen)
Check for biopterin defects
Management
Phenylalanine restriction (given as exchanges of natural protein titrated against phenylalanine
levels, monitored on home fingerprick blood tests)
Amino acid supplement (no phenylalanine)
Special PKU products (minimal or no phenylalanine)
Free foods (negligible phenylalanine)
Neurotransmitter replacement in biopterin defects ( folinic acid)
Phenylalanine is an essential amino acid and therefore cannot be totally excluded from the diet.
Patients with milder elevations of phenylalanine, hyperphenylalaninaemia (HPA), require monitoring
only. Biopterin is licensed but not currently funded in the UK for management of PKU, but is most
likely to be effective in HPA.
Phenylalanine is teratogenic and therefore affected girls need strict dietary control pre-conception
and during pregnancy to ensure the best outcomes.
3.2 Tyrosinaemia (type 1)

Tyrosinaemia type 1 results from a block in the catabolism of tyrosine, producing by-products that
damage the liver and kidney.
Clinical features
Early onset liver disease with coagulopathy and proximal renal tubulopathy
Late onset: faltering growth and rickets (secondary to renal Fanconi syndrome); developmental
delay
Development of hepatocellular carcinoma in late childhood/adolescence
Diagnosis
Raised tyrosine
Organic acids: succinylacetone is pathognomonic
Deranged clotting (prolonged international normalized ratio or INR)
Confirmation liver enzymology (fumarylacetoacetase)
Genotype
Management
Tyrosine restricted
Amino acid supplement (tyrosine free and phenylalanine free)
Nitisinone blocks catabolic pathway proximal to the production of the damaging metabolites.
Liver transplantation is reserved for patients failing to respond to nitisinone, or those who develop
tumours or progressive cirrhotic liver disease. Tumour surveillance includes interval hepatic MRI
and monitoring of -fetoprotein
3.3 Maple syrup urine disease

MSUD results from a block in the degradation of the branched-chain amino acids leucine, isoleucine
and valine. MSUD also belongs to the family of organic acidaemias.
Clinical features
Encephalopathy
Seizures
Sweet odour (especially nappy) hence the name
Biochemical disturbance, i.e. acidosis, ketosis, may be minimal, so the diagnosis is often delayed
with the illness frequently being attributed to sepsis. Intermittent forms may present at a later age,
patients appearing entirely symptom free between bouts. Cerebral oedema is a well-recognized
complication during acute episodes.
Diagnosis
Elevated branched-chain amino acids (leucine, isoleucine and valine) plus alloisoleucine
Elevated branched-chain oxo-acids on urinary organic acids
Enzymology on fibroblasts
Management
Low-protein diet
Branched-chain amino acid-free supplement
Valine and isoleucine may require additional supplementation because levels may fall too low
while controlling leucine
Trial of thiamine (enzyme cofactor)
3.4 Homocystinuria
Homocystinuria may result from a number of metabolic defects. Classic homocystinuria (cystathione-synthase deficiency) presents with a typical dysmorphology similar to Marfan syndrome.
Differences include lower IQ, stiff joints, direction of lens dislocation and malar flush in
homocystinuria.
Clinical features of homocystinuria

Marfanoid habitus (span greater than height), high arched palate, arachnodactyly
Restricted joint movements
Ectopia lentis (classically downward, but may be sideways!)
Developmental delay/retardation (variable severity)

Thrombosis (deep vein thrombosis and pulmonary embolus most common)
Osteoporosis
Diagnosis
Elevated homocysteine
Raised methionine
Enzymology in fibroblasts
Management
Treatment aims to reduce plasma total homocysteine to in turn reduce the risks of thrombosis and lens
dislocation.
Protein restriction for patients diagnosed on newborn screening

Pyridoxine (cofactor) 50% patients respond
Folate
Betaine: lowers homocysteine by remethylation and is particularly useful in the pyridoxine nonresponsive patient
3.5 Non-ketotic hyperglycinaemia

Defective glycine cleavage produces this early onset seizure disorder. Glycine is a neurotransmitter,
excitatory centrally and inhibitory peripherally.
Clinical features of NKH
Increased fetal movements (in utero seizures)

Hiccups, hypotonia
Progressive apnoeas/encephalopathy
Seizures
Marked developmental delay/psychomotor retardation
Diagnosis
Elevated glycine in urine or plasma
CSF:plasma glycine ratio (>0.09)
Enzymology in liver or lymphocytes
Management
Sodium benzoate: reduces plasma glycine, but little effect on neurological outcome
Dextromethorphan (partial N-methyl-D-aspartate or NMDA receptor antagonist): helps block the

central action of glycine to reduce fits
Prognosis remains poor for development. Prenatal testing is available.
4. ORGANIC ACIDAEMIAS
Defects in the catabolism of amino acids result in the accumulation of organic acids which are
detected in urine. Propionic acidaemia (PA) and methylmalonic aciduria (MMA) result from blocks
in branched-chain amino acid degradation, isovaleric acidaemia (IVA) is the result of a block in
leucine catabolism, and glutaric aciduria type 1 (GA-1) results from a block in lysine and tryptophan
metabolism.
4.1 Propionic, methylmalonic and isovaleric acidaemias

Clinical features of organic acidaemias
Acute neonatal encephalopathy (intoxication) or chronic intermittent forms

Dehydration
Marked acidosis ( anion gap), ketosis
Neutropenia thrombocytopenia (acute marrow suppression)
Progressive extrapyramidal syndrome (MMA, PA), basal ganglia necrosis
Renal insufficiency (MMA)
Pancreatitis
Acute-onset cardiomyopathy (PA, MMA)
Diagnosis
Marked metabolic acidosis

Ketosis
Raised lactate
Raised ammonia (secondary urea cycle inhibition)
Glucose may be low, normal or raised
Neutropenia
Urinary organic acids key metabolites
Enzymology
Propionate is partly produced by gut organisms, so decompensation in PA and MMA may be

precipitated by constipation. Enzyme deficiency is confirmed on enzymology.
Management
Dietary protein restriction

Carnitine: helps eliminate organic acids via conjugation and renal excretion. Glycine is used
similarly in IVA
Metronidazole (MMA and PA), to alter the gut flora, reduces propionate production and helps
avoid constipation
Some forms of MMA are vitamin B12 responsive
Liver transplantation (PA, MMA) does not completely eliminate the risk of neurological
deterioration
4.2 Glutaric aciduria type 1

Clinical features of glutaric aciduria type 1
Before decompensation:
Asymptomatic
Macrocephaly/frontal bossing
After decompensation (usually precipitated by an intercurrent infection), usually occurring towards
the end of the first year:
Encephalopathy
Dystonia/choreoathetosis
Feeding problems (oral dystonia)
Irritability
Diagnosis
Raised 3-hydroxyglutarate, glutarate in organic acids

Raised glutarylcarnitine
MRI of the brain: frontal atrophy, subdural haematomas, decreased signal for basal ganglia
Enzymology on fibroblasts
Genotyping
The diagnosis must be actively sought in children with large heads and no other explanation, in an
effort to prevent metabolic decompensation and subsequent severe neurology.
GA-1 may mimic non-accidental injury with encephalopathy and bilateral subdurals.
Management
Carnitine
Protein restriction (low lysine diet)

Hyperalimentation and use of the emergency regimen (glucose polymer) when unwell
5. UREA CYCLE DEFECTS

The urea cycle is the pathway by which waste nitrogen is converted to urea for disposal. UCDs are
inherited in an autosomal recessive manner except OTC deficiency, which is X-linked recessive.
Girls may present symptomatically if during lyonization sufficient good genes are switched off in the
liver.
Clinical features of UCDs
Vomiting (may be a cause of cyclical vomiting)

Encephalopathy (intoxication after symptom-free period in neonate)
Tachypnoea (ammonia is a respiratory stimulant acting centrally)
Progressive spastic diplegia and developmental delay (arginase deficiency)
Arginase deficiency rarely presents with classic hyperammonaemia
Diagnosis
UCDs are suggested by the presence of a respiratory alkalosis in the child with encephalopathy.
Indication of the exact level of the enzyme block depends on plasma amino acids and urinary organic
acids for the presence or absence of orotic acid. Orotic aciduria indicates a block at the level of OTC
or beyond. Final confirmation of the diagnosis requires enzymology.
Characteristics of urea cycle defects
Arg, arginine; Cit, citrulline; Glu, glutamine.
Management
Protein restriction
Sodium benzoate and sodium phenylbutyrate conjugate with glycine and glutamine, respectively, to
produce water-soluble products that can be excreted by the kidney, therefore bypassing the urea
cycle and reducing the nitrogen load on the liver
Arginine supplementation (an essential amino acid in UCDs except arginase deficiency)
Liver transplantation in patients with brittle control
6. FAT OXIDATION DISORDERS

The fat oxidation defects form a large group of conditions that commonly present with hepatic,
cardiac or muscle symptoms. Fatty acids are a major fuel source in the fasted state and are oxidized
by most tissues except the brain, which is reliant on hepatic fatty acid -oxidation for ketone
production. Fatty acids are the preferred substrate for cardiac muscle, and during prolonged exercise
they are a vital energy source for skeletal muscle.
6.1 Medium-chain acyl-CoA dehydrogenase deficiency

MCADD is the most common fat oxidation disorder in the UK with an incidence of 1 in 10 000 (as
common as PKU). Peak presentation in unscreened patients occurs in autumn and winter precipitated
by intercurrent infections. The mortality rate is 25% on first presentation in clinically presenting
(unscreened) patients, with 13% of survivors having neurological sequelae.
Clinical features of MCADD
Hypoketotic hypoglycaemia
Encephalopathy
Reye syndrome-like syndrome: hepatomegaly, deranged liver function
Mean age at presentation 15 months; most common precipitant is diarrhoea
Sudden infant death (consider in older infant >6 months)
Common G985 mutation
Diagnosis
Hypoglycaemia with absent or low ketones

Raised octanoylcarnitine (C8 carnitine) on acylcarnitines
Raised hexanoylglycine in urinary organic acids
Genotyping
Newborn screening for MCADD is undertaken in England, Scotland and Northern Ireland.
Management
Avoidance of fasting
If unwell, emergency regimen drinks (glucose polymer). If not tolerated intravenous 10% dextrose
with electrolyte additives (sodium and potassium)
In the at-risk neonate born to a family with a previously affected sibling, feeds should be frequent
with intervals no longer than 3 hours, and top-up feeds established if needed while acylcarnitine
results are awaited. Neonatal deaths have been reported.
6.2 Long-chain defects

The long-chain fat oxidation defects, VLCAD and LCHAD are more severe, presenting at an earlier
age and requiring meticulous dietary management to ensure normoglycaemia and to reduce long-term
complications. Liver dysfunction may occur in the carrier mother during pregnancy: AFLP or HELLP
syndrome.
Clinical features of long-chain defects
Myopathy
Pigmentary retinopathy (LCHAD)
Peripheral neuropathy (LCHAD)
Maternal hepatic symptoms in pregnancy
Diagnosis
Characteristic long-chain acylcarnitines
Characteristic dicarboxylic aciduria in urinary organic acids
Raised creatine kinase (risk of rhabdomyolysis)
Fat oxidation studies on fibroblasts
Genotyping (common LCHAD mutation)
Acylcarnitines should be checked in infants born to mothers with AFLP or HELLP syndrome.
Management
Long-chain fat restriction
Essential fatty acid supplementation (walnut oil)
Avoidance of fasting frequent bolus feeds during the day, and overnight nasogastric or
gastrostomy feeds in infancy
Uncooked cornstarch can be introduced from 2 years of age to smooth and prolong glycaemic
control
An emergency regimen is used during intercurrent infections with admission for intravenous therapy
if not tolerated
7. MITOCHONDRIAL DISORDERS
Mitochondria are the power stations of the cell, producing ATP to drive cellular functions. The
respiratory chain, the site of oxidative phosphorylation, is embedded in the inner mitochondrial
membrane and consists of five complexes (See figure opposite). Electrons are donated from reduced
cofactors (NADH, FADH2) and passed along the chain, ultimately reducing oxygen to water, while
the energy so produced pumps hydrogen ions from the mitochondrial matrix into the intermembrane
space. Discharge of this electrochemical gradient through complex V (ATP synthase) generates ATP.
7.1 Mitochondrial genetics

Mitochondria are unique in containing their own DNA (mtDNA), contained within a circular doublestranded molecule. The mtDNA is inherited solely from the maternal egg, the sperms mitochondria
being left outside within the tail at fertilization. Inheritance of mtDNA point mutations is therefore
matrilineal, only being handed on by females although males and females are affected. However, the
mitochondrion is not self-sufficient but relies on nuclear genes for many essential proteins, including
respiratory chain subunits. Approximately 10% of all nuclear genes are involved in the production
and maintenance of healthy mitochondria. All complex II subunits are encoded within the nucleus. If a
nuclear gene is at fault then normal mendelian inheritance applies. Autosomal recessive inheritance is
probably the most common mode of inheritance for paediatric practice.
Mitochondria also contain more than one copy of mtDNA, and each cell may contain many
mitochondria. It is possible to have mutant and wild-type mtDNA present in the same cell
(heteroplasmy). The accumulation of mutant mtDNA will result in symptoms when a threshold is
breached. As a result of heteroplasmy, symptoms may be patchy within and between organ systems. In
rapidly dividing cells, such as the bone marrow and gut, wild-type cells may have a reproduction
advantage and therefore symptoms in these organ systems may improve compared with the
progressive brain and muscle involvement. Unless a nuclear defect is identified, prenatal diagnosis is
not available. It is hoped that newer genetic techniques such as next generation sequencing and whole
exome sequencing will allow rapid genotyping in these patients.
Nuclear defects may result in reduction in qualitatively normal mtDNA the mitochondrial depletion
syndromes, e.g. POLG, DGUOK and TK2 genes.

As mitochondria are present in all cells except erythrocytes, any organ system can be involved at any
time with any inheritance. High-energy-demand tissues are more commonly involved, particularly
brain, muscle, heart, kidney and liver, but any system can be involved. Thirty-three per cent of
children present in the neonatal period, and 80% in the first 2 years. Many syndromes have been
described; however, these were initially reported in adults and are associated with mtDNA mutations
that are less common in children (e.g. mitochondrial encephalomyopathy with lactic acidosis and
stroke-like episodes [MELAS], myoclonic epilepsyragged red fibres [MERRF] and KearnsSayre
syndrome). Syndromes may also be incomplete.
CNS: Leigh syndrome, hypotonia, deafness, epilepsy, stroke-like episodes

Muscle: myopathy, fatigue
Heart: hypertrophic cardiomyopathy, heart block
Kidney: proximal tubulopathy
Liver: failure, cirrhosis
Gut: diarrhoea, malabsorption, pancreatic insufficiency, faltering growth
Eye: external ophthalmoplegia, pigmentary retinopathy
Bone marrow: refractory anaemia
Endocrine: short stature, diabetes, endocrinopathies
Investigation
Studies of mtDNA are preferred if a classic mitochondrial syndrome is identified. Preferred tissue is
either muscle or bladder cells (extracted from a urine specimen). Blood may be less reliable as the
mutant load may decrease with time. Usually mitochondrial disease is suspected when there is
multiorgan involvement in apparently unrelated organs so-called illegitimate associations.
Peripheral lactate may be persistently elevated. Further organ involvement may be sought before
muscle biopsy for histochemistry (staining for complex II and IV), and respiratory chain enzymology:
complexes IIV + V.
CNS: MRI, brain-stem auditory evoked potentials, CSF lactate

Heart: echocardiography, electrocardiogram (ECG)
Kidney: proximal tubular proteins, tubular resorption of phosphate
Liver: biopsy, enzymology
Gut: stool elastase
Eye: fundoscopy, electroretinogram (ERG), visual evoked responses
Marrow: full blood count (FBC), aspirate
Endocrine: electrolytes
Management
Management remains supportive. A variety of antioxidants and respiratory-chain pick me ups have
been described with success in only a handful of cases, e.g. ubiquinone, riboflavin. Dichloroacetate
resolves the raised lactate but does not appear to improve outcome. Graded exercise has been used in
some patients with myopathy.
8. DISORDERS OF CARBOHYDRATE METABOLISM

8.1 Glycogen storage disease
Glucose is stored in the liver, muscles and kidneys as glycogen. GSDs result from defects of glycogen
breakdown. Hepatic forms present with hepatomegaly and hypoglycaemia, the muscle forms present
with weakness and fatigue.
GSD Ia (glucose-6-phosphatase deficiency von Gierke disease)

The enzyme deficiency fails to remove the phosphate from glucose 6-phosphate, so export of glucose
from the liver through glycogenolysis and gluconeogenesis is blocked. Fasting tolerance is therefore
limited, usually 14 h. Infants usually present at around 3 months when feeds are spread further apart.
Clinical features
Massive hepatomegaly (in the absence of splenomegaly). Glycogen is not stored in the spleen,
unlike the material in lysosomal storage disorders
Abnormal fat distribution (doll-like faces and thin limbs)
Failure to thrive
Bruising (secondary to poor platelet function)
Nephromegaly common
Long-term complications include renal insufficiency, liver adenomas with potential for malignant
change, gout, osteopenia and polycystic ovaries.
Investigations
Hypoglycaemia
Raised plasma lactate. Lactate levels fall on glucose loading
Hyperuricaemia
Hyperlipidaemia
Genotyping has superseded liver enzymology for confirmation
Treatment
Frequent feeds during the day with continuous feed overnight. From age 2, uncooked cornstarch is
introduced as a slow-release form of glucose, prolonging the gap between feeds
Allopurinol to control the uric acid level in the blood
Liver transplantation is reserved for patients with malignant change in an adenoma or failure to
respond to dietary treatment
GSD Ib (glucose-6-phosphate translocase deficiency)

The translocase deficiency shares the above phenotype with the addition of neutrophil dysfunction,
with associated recurrent skin sepsis, large mouth ulcers and inflammatory bowel disease.
Management is as above with the addition of prophylactic Septrin (co-trimoxazole) for severe
recurrent mouth ulcers, or granulocyte colony-stimulating factor (GCSF) in resistant cases.
GSD II (Pompe disease)

GSD II, acid maltase deficiency, is really a lysosomal storage disorder with accumulation of
glycogen in lysosomes. The infantile form presents with severe hypotonia, weakness, hyporeflexia
and a large tongue. ECG reveals giant QRS complexes. Vacuolated lymphocytes are seen on the blood
film. Confirmatory enzymology is performed on fibroblasts. Death is usual within the first year;
however, enzyme replacement therapy trials have shown encouraging results. Milder forms with
mainly myopathy exist.
GSD III (debrancher enzyme)

Type IIIa affects liver and muscle, whereas type IIIb is purely hepatic. Type III may be clinically
indistinguishable from type I; however, fasting tolerance is longer because gluconeogenesis is not
blocked, and glycogen can be pruned to near the branch points. Nephromegaly is not a feature.
Myopathy is notable and may be progressive in type IIIa. Cardiomyopathy is a complication, but
usually clinically insignificant. Adenomas, liver fibrosis and cirrhosis are rare.
Lactate level rises, unlike in type I, on glucose loading. The diagnosis may be confirmed on white
cell enzymology. Dietary management is similar to but not as intensive as for type I. A high protein
diet has been suggested for the type IIIa.
GSD IV (branching enzyme)

This form is very rare and presents with hepatomegaly and progressive liver disease. The diagnosis
is usually made on liver histology and enzymology. Liver transplantation is the treatment for
progressive disease.
GSD VI (liver phosphorylase deficiency) and GSD IX (phosphorylase-b-kinase

deficiency)
Hypoglycaemia is rarely a problem. Hepatomegaly may be an incidental finding. GSD IX enzymology
is assayed in red cells but may be normal in the isolated liver form. Treatment consists of uncooked
cornstarch once or twice a day to aid growth. Inheritance is X-linked or recessive depending on
subgroup.
Muscle GSDs
GSD V (muscle phosphorylase deficiency), McArdle disease and GSD VII (phosphofructokinase
deficiency)
Weakness and fatigue with post-exercise stiffness are the presenting features. Serum creatine kinase is
usually elevated along with uric acid. On exercise, lactate fails to rise with excessive increases in
uric acid and ammonia. After a brief rest, exercise can be restarted (second-wind) as fatty acids
slowly become available as an alternative fuel. Protein in the diet may be beneficial. Glucose is of
benefit in McArdle disease because glycolysis is still intact. Extreme exercise should be avoided but
regular gentle exercise is probably of benefit.
8.2 Galactosaemia
Clinical features of galactosaemia
Neonatal onset jaundice, hepatomegaly, coagulopathy and oil-drop cataracts, usually at the end
of the first week
Later presentation with faltering growth, proximal tubulopathy and rickets at a few months
Association with Escherichia coli sepsis
Diagnosis
Reducing substances in the urine (rapidly disappear if feeds stopped)
Deranged liver function including prolonged INR
Gal-1-PUT (galactose-1-phosphate uridyltransferase) assay. If the child has already received a
transfusion, the parents should be screened for carrier-level activity instead
Management
Lactose-/galactose-free diet
Ensure adequate calcium intake. Milk is replaced with a soya-based formula
Long-term complications, in spite of good control, include developmental delay, particularly
involving speech, feeding problems and infertility in girls.
8.3 Hereditary fructose intolerance

The key to diagnosis is the linking of symptoms with the exposure to fructose, which usually occurs at
weaning.
Clinical features of hereditary fructose intolerance
Acute vomiting and symptomatic hypoglycaemia

Chronic exposure faltering growth, hepatomegaly, ascites, jaundice and proximal renal
tubulopathy
Milder cases learn to avoid sugary foods
Exacerbations may occur AFTER exposure to fructose contained in medicines
Diagnosis
History
Lactic acidosis
Hyperuricaemia
Deranged liver function
Aldolase B activity in liver
Genotyping is used when liver biopsy is contraindicated because of coagulopathy
Management
Lifelong avoidance of fructose.
9. LIPID DISORDERS
Cholesterol and triglycerides are transported in the circulation bound to lipoproteins.
The four major classes are:
Chylomicrons: carry dietary lipids, mainly triglycerides, from the gut to the liver. Lipoprotein
lipase releases free fatty acids from chylomicrons in the portal circulation
Very-low-density lipoprotein (VLDL): carries predominantly triglycerides and some cholesterol
synthesized in the liver to the peripheries. Lipoprotein lipase releases the free fatty acids leaving
IDL (intermediate-density lipoprotein)
Low-density lipoprotein (LDL): transports cholesterol and some triglyceride from the liver to the
peripheries. Direct uptake by cells via the LDL receptor
High-density lipoprotein (HDL): carries cholesterol from the peripheries to the liver. Inverse
association with ischaemic heart disease (good cholesterol)
9.1 Hypertriglyceridaemias
Defective chylomicron removal lipoprotein lipase deficiency, apolipoprotein C-II deficiency
Overproduction of VLDL familial hypertriglyceridaemia
Hypertriglyceridaemias are rare. Clinical features include colic, hepatosplenomegaly, eruptive
xanthomas and creamy plasma. Complications include abdominal pain and pancreatitis but rarely
develop in patients until the triglyceride level exceeds 20 mmol/l. Secondary causes of elevated
triglycerides include obesity, chronic renal failure, diabetes mellitus and liver disease. Treatment
comprises a very-low-fat diet supplemented with essential fatty acids. Drugs used to lower
triglycerides include fibric acid derivatives, niacin or statins. Fibrate drugs reduce hepatic
triglyceride synthesis and enhance peripheral triglyceride clearance; statins reduce triglycerides,
probably by reducing VLDL synthesis.
9.2 Hypercholesterolaemias
Defective LDL removal familial hypercholesterolaemia
Familial hypercholesterolaemia is a monogenic disorder with a heterozygote incidence of 1:500, and
homozygote 1:1000 000. It is the most common hyperlipidaemia, resulting from mutations in the LDL
receptor, Apo B or PCSK9 gene. Patients are picked up through premature ischaemic heart disease, or
through cascade screening for hypercholesterolaemia after diagnosis in a relative usually at least 5
years old. Family history is an important risk factor for ischaemic heart disease, particularly at a
young age and especially in girls. In homozygotes, xanthomas may appear in the first decade, and
angina before the age of 20.
In children, diet and exercise are the mainstay of treatment, see the NICE (National Institute for
Health and Clinical Excellence) guideline (www.nice.org.uk/CG71).
Dietary management
Total fat intake 30% total calories

Saturated fat intake 10% total calories (increased mono- and polyunsaturated fats)
Cholesterol intake <300 mg
Fruit and vegetables 5 a day
Fish twice a week
Smoking is strongly discouraged as is excessive alcohol intake. Statins are usually reserved for
children aged 10 years or above. The decision to treat should consider family history, comorbidities,
e.g. hypertension, age and LDL-cholesterol concentration. Their mechanism of action is the
competitive inhibition of 3-hydroxy-3-methylglutaryl-CoA (HMG-CoA) reductase, the rate-limiting
step of cholesterol synthesis. Statins are teratogenic and so effective contraception must be used in
young women using statins. Patients who are unable to tolerate statins should be offered other lipidmodifying treatment including bile acid sequestrants (statins), fibrates or ezetimibe. Liver function
and creatine kinase are regularly monitored for adverse effects. Lipid-modifying drugs are used
before plasma apheresis in patients who are homozygous.
Familial combined hyperlipidaemia

Patients present with hypercholesterolaemia or hypetriglyceridaemia or both. Diagnosis is confirmed
by the finding of a first degree relative who has a different biochemical phenotype. The genetics is
unknown. Management includes healthy lifestyle (diet and exercise) with usually a statin in
combination with fibrate or nicotinic acid.
9.3 ABETALIPOPROTEINAEMIA
Rare autosomal recessive disorder with undetectable apoenzyme B (Apo B) levels and resultant fat
malabsorption including fat-soluble vitamins.
Clinical features
Poor weight gain

Steatorrhoea
Ataxia, neuropathy and other CNS symptoms
Retinitis pigmentosa
Investigations
Hypocholesterolaemia
Acanthocytes (blood film)
Low vitamins A, D, E and K
Management
Reduced fat intake (520 g/day)
Essential fatty acid supplement (walnut oil)
Fat-soluble vitamin supplementation
10. PEROXISOMAL DISORDERS

Peroxisomes harbour many vital cellular functions, including the synthesis of plasmalogens, (essential
constituents of cell walls), cholesterol and bile acids, and the -oxidation of very-long-chain fatty
acids and breakdown of phytanic acid (vitamin A) and glyoxylate. Disorders are biochemically
characterized by the number of functions impaired:
Multiple enzymes affected (peroxisomal biogenesis defects): Zellweger syndrome (ZS), neonatal
adrenoleukodystrophy (NALD), infantile Refsum disease (IRD)
Several enzymes involved rhizomelic chondrodysplasia punctata (RCDP)
Single enzyme block X-linked adrenoleukodystrophy (X-ALD), Refsum disease, hyperoxaluria
Inheritance is autosomal recessive with the exception of X-ALD. The first-line investigation is verylong-chain fatty acids that are elevated in ZS and X-ALD but normal in RCDP. In this group,
plasmalogens are the first screen. Further investigation requires fibroblast studies.
10.1 Zellweger syndrome

ZS is the classic peroxisomal biogenesis disorder with distinctive dysmorphic features. There is
clinical overlap with NALD and IRD, which are milder with better prognosis.
Clinical features of Zellweger syndrome
Dysmorphic faces prominent forehead, hypertelorism, large fontanelle

Severe neurological involvement including hypotonia, seizures and psychomotor retardation
Sensorineural deafness
Ocular abnormalities retinopathy, cataracts
Hepatomegaly and liver dysfunction
Calcific stippling (especially knees and shoulders)
Faltering growth
Diagnosis
Loss of all peroxisomal functions raised very-long-chain fatty acids, phytanate and bile acid
intermediates and decreased plasmalogens. Confirmatory enzymology on fibroblasts.
Treatment
Management is supportive. Docosahexaenoic acid supplementation has been tried but no clear benefit
has been demonstrated. Death usually occurs within the first year.
10.2 X-linked adrenoleukodystrophy

The paediatric cerebral form presents with severe neurological degeneration, usually between age 5
and 10 years, progressing to a vegetative state and death within a few years. Brothers in the same
family may present at different ages.
Clinical features of X-ALD
School failure, behaviour problems

Visual impairment
Quadriplegia
Seizures (late sign)
Adrenal involvement may precede or follow neurological symptoms by years. Some develop only
neurological symptoms, and others just have adrenal insufficiency. All boys developing adrenal
failure should have very-long-chain fatty acid measurements taken to ensure that the diagnosis is not
missed. Neurological symptoms may occur for the first time in adults (adrenomyeloneuropathy),
resembling a cord syndrome with spastic gait and bladder involvement. Female carriers may develop
multiple sclerosis-like symptoms in adulthood.
Diagnosis
Elevated very-long-chain fatty acids, blunted Synacthen response or frank hypoglycaemia.
Neuroimaging shows bilateral, predominantly posterior, white-matter involvement. The differential
diagnosis for neurodegeneration in the school-age child includes:
subacute sclerosing panencephalitis

Batten disease
Wilson disease
NiemannPick C disease
Management
Lorenzo oil (oleic and erucic acid) normalizes the very-long-chain fatty acids but fails to prevent
progression. Bone marrow transplantation is the mainstay of therapy in patients before
neurodegeneration, i.e. prospectively diagnosed siblings, and those diagnosed after presentation with
adrenal insufficiency or other problems. Serial psychometry/neurophysiology and neuroimaging are
used to detect the first signs of neurological deterioration the stimulus for transplantation. Adrenal
function should be closely monitored, and steroid replacement therapy should be given once it is
indicated.
11. MUCOPOLYSACCHARIDOSES
Mucopolysaccharides (glycosaminoglycans) are structural molecules integral to connective tissues
such as cartilage. Degradation occurs within lysosomes, requiring specific enzymes. Patients with
MPSs appear normal at birth and usually present with developmental delay in the first year. The
features of storage become more obvious with time.
11.1 Classification
AR, autosomal recessive.
Hurler syndrome is the classic MPS with storage affecting the body and CNS. Sanfillipo syndrome
predominantly affects the CNS and Morquio and MaroteauxLamy syndromes affect the body.
Atlantoaxial instability is common in the latter two, often necessitating prophylactic cervical spinal
fusion in the first 23 years. Hunter syndrome is phenotypically similar to Hurler syndrome; however,
there is no corneal clouding and scapular nodules are seen.
11.2 Hurler syndrome

Hurler syndrome typifies the MPS group and their associated clinical problems. The enzyme
deficiency is -iduronidase, a deficiency shared with Scheie disease, the milder variant.
Clinical features of Hurler syndrome
Coarse faces, macroglossia, hirsutism, corneal clouding

Airway/ear, nose, throat problems, secretory otitis media
Dysostosis multiplex
Cardiomyopathy, valvular disease
Hepatosplenomegaly
Hernias umbilical, inguinal, femoral
Stiff joints
Developmental delay and retardation
Diagnosis
Urinary screen for glycosaminoglycans (raised dermatan and heparan sulphate). Enzymology
confirmed on white cells.
Management
Treatment depends on early recognition to allow early bone marrow transplantation, which
significantly modifies the phenotype. Enzyme replacement therapy (ERT) is available; however,
bloodbrain barrier penetration is limited, so the neurological features are less responsive.
Supportive care is the mainstay of untransplanted patients, with particular regard to the chest and
airway including regular sleep studies.
12. SPHINGOLIPIDOSES
Sphingolipids are complex membrane lipids. They are all derived from ceramide and can be divided
into three groups: cerebrosides, sphingomyelins and gangliosides. Lysosomal hydrolases break these
molecules down; deficiencies result in progressive storage and disease. Typical features include
psychomotor retardation, neurological degeneration including epilepsy, ataxia and spasticity, with or
without hepatosplenomegaly.
12.1 TaySachs disease

Clinical features of TaySachs disease
Developmental regression within first year

Macrocephaly
Hyperacusis
Cherry-red spot
Spastic quadriplegia
Death within 24 years
No hepatosplenomegaly compared with Sandhoff disease
Diagnosis
The presence of vacuolated lymphocytes on the blood film is a further clue. Hexosaminidase A
deficiency is confirmed on white cell enzymology.
Management
Currently, management is supportive. However, research into substrate-deprivation therapy,
chaperone therapy and other treatments is currently under investigation.
12.2 Gaucher disease

Glucocerebrosidase deficiency results in the accumulation of cerebroside in the visceral organs the
brain depending on the type.
Clinical features of Gaucher disease

Type 1
Non-neuropathic (most common 8090% cases)

Splenomegaly > hepatomegaly
Anaemia, bleeding tendency
Skeletal pain, deformities, osteopenia
Abdominal pain (splenic infarcts)
Type 2
Acute neuropathic
Severe CNS involvement (especially bulbar), rapidly progressive
Convergent squinting and horizontal gaze palsy

Hepatosplenomegaly
Type 3
Subacute neuropathic
Convergent squint and horizontal gaze palsy (early sign)
Splenomegaly > hepatomegaly
Slow neurological deterioration
Diagnosis
Elevated angiotensin-converting enzyme (ACE) and acid phosphatase are markers for the disease.
Bone marrow aspiration may reveal Gaucher cells (crumpled tissue-paper cytoplasm). White cell
enzymes for glucocerebrosidase give the definitive diagnosis. The enzyme chitotriosidase is markedly
elevated and may be used to follow disease activity.
Management
ERT is effective in visceral disease in types 1 and 3. Bone marrow transplantation has been used in
the past, and may have benefit for cerebral involvement in type 3. Splenectomy has been used to
correct thrombocytopenia and anaemia and relieve mechanical problems, but may accelerate disease
elsewhere. There is no effective treatment for type 2.
12.3 NiemannPick disease

NiemannPick disease is the eponymous name for the sphingomyelinoses; however, types A and B are
biochemically and genetically distinct from type C.
Sphingomyelinase deficiency
Clinical features of sphingomyelinase deficiency
Type A (infantile)
Feeding difficulties
Hepatomegaly > splenomegaly
Cherry-red spot
Lung infiltrates
Neurological decline, deaf, blind, spasticity
Death within 3 years
Type B (visceral involvement)
Milder course, no neurological involvement

Hepatosplenomegaly
Pulmonary infiltrates
Ataxia
Diagnosis
Bone marrow aspirate for NiemannPick disease cells. White cell enzymes. Genotyping may help
distinguish between the two types before the onset of neurological signs.
Management
Supportive. ERT for NiemannPick disease type B is undergoing clinical trials.
Lysosomal cholesterol-export defect (secondary sphingomyelin accumulation)

Clinical features of lysosomal cholesterol-export defect
Type C
Conjugated hyperbilirubinaemia (earliest sign)

Hepatosplenomegaly
Neurological deterioration (variable age of onset)
Dystonia
Cherry-red spot
Vertical ophthalmoplegia
Diagnosis
NiemannPick disease cells on bone marrow aspirate; however, white cell enzymes show normal or
mildly decreased sphingomyelinase deficiency. Definitive diagnosis requires cholesterol studies on
fibroblasts and genotyping.
Management
Supportive. Miglustat, substrate deprivation therapy, has been shown to delay the onset of
neurological symptoms. Prognosis is guided by age of onset.
12.4 Fabry disease

-Galactosidase deficiency results in the storage of glycolipids in blood vessel walls, heart, kidney
and autonomic spinal ganglia. It is X-linked recessive. Increasingly, female carriers with symptoms
are being recognized.
Clinical features of Fabry disease
Severe pain in extremities (acroparaesthesia)

Angiokeratoma (bathing-trunk area)
Corneal opacities
Cardiac disease
Cerebrovascular disease
Nephropathy
Normal intelligence
Diagnosis
Maltese crosses (birefringent lipid deposits) in urine under microscope. White cell enzymes.
Management
ERT now reduces pain and stabilizes renal function.
13. MISCELLANEOUS
13.1 Porphyria
Porphyrias are a group of disorders of haem biosynthesis that present with acute symptoms and/or
skin symptoms. Inheritance is autosomal dominant except in congenital -aminolaevulinic acid (ALA)
dehydratase deficiency, erythropoietic porphyria and hepatoerythropoietic porphyria. Symptoms in
children are extremely rare.
Classification
Hepatic:
Plumboporphyria
Acute intermittent porphyria (AIP)
Porphyrea cutanea tarda (PCT)
Hereditary coproporphyria (HCP)
Variegate porphyria (VP)
Erythropoietic:
Congenital erythropoietic porphyria (CEP)
Erythropoietic protoporphyria (EPP)
Clinical features of porphyria
Acute symptoms
Autosomal dominant with poor penetrance. Attacks more common in girls but rare before puberty.
Periods of remission. Attacks precipitated by environmental factors: drugs, alcohol, stress, infection,
smoking, reduced caloric intake. Severe pain is usually abdominal but may be back or legs. Attacks
lasts no more than 12 weeks.
Neurovisceral: AIP, plumboporphyria
Neurological: pain, muscle weakness, paralysis, fits, mental changes
Gastrointestinal: abdominal pain, vomiting, constipation, diarrhoea
Cardiovascular: tachycardia, hypertension
Neurovisceral + skin: HCP, VP
Above + skin
Treatment of acute attack

Remove precipitating factor
Supportive treatment with drugs known to be safe:
Pain opiates
Psychosis chlorpromazine
Tachycardia, hypertension blockers
Seizures gabapentin, vigabatrin
Carbohydrate (10% dextrose) switches of ALA synthase induction
Haem arginate (negative feedback on ALA synthase)
Skin symptoms: CEP, PCT:
Skin: blisters, scarring, pigmentation, fragility, hirsutism
Photosensitivity: EPP
Cutaneous forms are managed by avoidance of precipitants, especially sunlight, and good skin care.
Diagnosis
Acute attacks (neurovisceral):
Raised urinary porphobilinogen during attacks (fresh urine)
Faecal and urinary porphyrin analysis to distinguish type
Skin lesions:
Porphyrins urine, faeces, blood
Photosensitivity:
Protoporphyrin (blood)
13.2 SmithLemliOpitz syndrome

The SmithLemliOpitz (SLO) syndrome is the most common sterol biosynthesis defect a group of
disorders characterized by limb defects, major organ dysplasia and skin abnormalities.
Clinical features of SmithLemliOpitz syndrome
Dysmorphic faces microcephaly, narrow frontal area, upturned nose, ptosis

Syndactyly of second and third toes
Genital anomalies
Learning disability
Renal anomalies
Faltering growth
Sunlight sensitivity
Diagnosis
SLO syndrome is the result of a block in the penultimate step of cholesterol biosynthesis, so
cholesterol is low with a raised 7-dehydrocholesterol level, the immediate precursor.
Management
Management is supportive. Cholesterol supplementation may benefit behaviour and general health.
Trials are underway evaluating the use of statins to block the build-up of precursors.
13.3 Congenital disorders of glycosylation

Most extracellular proteins, membrane proteins and some intracellular proteins have glycans
(oligosaccharide antenna-like structures) attached to them. This group of disorders results from
defects in the synthesis of these carbohydrate moieties of glycoproteins. N-Glycans are linked to the
amide group of asparagines and O-glycans are linked to the hydroxyl group of serine or threonine.
N-Glycosylation defects
Group I defects in the assembly of oligosaccharide chain synthesis and transfer to the protein
Group II defects in the further processing of the protein-bound oligosaccharide chain.
The two most common disorders are congenital disorder of glycosylation (CDG) Ia
(phosphomannomutase deficiency) and CDG Ib (phosphomannose isomerase deficiency).
CDGs are multiorgan disorders affecting particularly the brain, except CDG Ib which is mainly a
hepatogastrointestinal disorder. CDG Ia has typical dysmorphology.
Clinical features of CDG Ia

Dysmorphic features inverted nipples, fat pads
Muscular hypotonia
Faltering growth
Cerebellar hypoplasia
Diagnosis
Transferrin isoelectric focusing is used to screen for CDGs, but does not detect all of them.
Enzymology is performed on white cells and fibroblasts.
Management
CDG Ib is effectively managed with mannose supplementation. The other types are treated
symptomatically.
13.4 LeschNyhan syndrome

This is an X-linked disorder of purine metabolism caused by hypoxanthineguanine phosphoribosyltransferase (HGPRT) deficiency.
Clinical features of LeschNyhan syndrome

Motor disorder:
Hypotonia initially, evolving dystonia or choreoathetosis + spasticity
Bulbar disorder speech and feeding difficulties
Growth faltering
Hyperuricaemia stones, nephropathy, gout
Compulsive self-injury
Cognitive impairment
Diagnosis
Elevated urate and hypoxanthine in urine. Plasma urate may be normal because of the excellent renal
clearance in childhood and so a urinary urate must also be measured. Enzymology of red cells or
fibroblast studies.
Management
Allopurinol and liberal fluids are used to reduce the risk of renal complications. Urinary xanthine and
urate should be assessed to ensure that the xanthine concentration remains below the limit of
solubility, and may require reduction in allopurinol dose because xanthine stones are much less
soluble than urate stones. Seating and positioning are essential to aid development and avoid selfinjury together with relaxation techniques and communication skills. A full multidisciplinary team is
essential. A low-purine diet is often undertaken but the evidence base for its use is limited.
13.5 Menkes syndrome

An X-linked membrane copper-transporter defect. Copper uptake by cells is normal; however, export
from the cell is blocked and the copper-requiring enzymes do not receive the necessary copper for
normal function.
Clinical features of Menkes syndrome
Hypothermia
Epilepsy
Hypotonia
Prominent cheeks
Pili torti
Retardation
Connective tissue problems
Early death
Diagnosis
Low serum copper and ceruloplasmin, although these may be normal in the neonatal period.
Confirmed on copper-flux studies in fibroblasts, and ultimately by genotyping.
Management
Daily copperhistidine injections have proven effective in altering the neurological outcome if the
diagnosis is made early and treatment is not delayed. The connective tissue complications
subsequently dominate the clinical picture in treated patients.
13.6 Ketotic hypoglycaemia

Ketotic hypoglycaemia (KH) is a common disorder presenting usually in late infancy, which usually
resolves by 710 years of age. The underlying defect is unknown and likely to represent more than
one metabolic defect. There is no specific diagnostic marker and it is usually a diagnosis of
exclusion. KH classically presents in the morning after a prolonged fast and usually together with an
intercurrent infection. At the time of hypoglycaemia, ketosis is marked. Alanine on amino acid
analysis may be low. Management is the avoidance of fasting and using an emergency regimen
(glucose polymer drinks) when unwell. If these drinks are not tolerated refused, vomiting or
diarrhoea admission for intravenous 10% dextrose with appropriate electrolyte additives is
required until fully feeding again.
14. SCREENING
14.1 Principles of screening

Screening for defined disorders aims to prevent avoidable morbidity and mortality. The sensitivity of
a screening test is the rate of true positives, and its specificity is the rate of true negatives. The aim is
not to miss any cases with the minimum of false positives. The necessary requirements for including a
condition in a screening programme are as follows:
Important health problem

Accepted treatment
Facilities available for diagnosis and treatment
Latent or asymptomatic disease
Suitable test
Natural history understood
Agreed case definition
Early treatment improves prognosis
Economic
Case finding may need to be continuous
The UK National Screening Committee added a further requirement: randomized controlled trial
evidence to support introduction of new screens.
14.2 UK neonatal screening programme

Neonatal blood spots are collected on day 6 with the aim of commencing treatment by day 21 for
hypothyroidism and PKU. Laboratories still using the Guthrie test for PKU, which relies on
phenylalanine-dependent bacterial growth, may give false negatives if the baby is receiving
antibiotics. This information is requested on the card in those regions. The feeding status is also
requested to ensure adequate protein intake, but newer techniques are able to detect PKU reliably on
day 1 (routine screening day in the USA).
Current UK programme
Universal:
Congenital hypothyroidism (thyroid-stimulating hormone)
Phenylketonuria (phenylalanine)
Haemoglobinopathies (sickle cell disease and thalassaemia)
MCADD
Cystic fibrosis
Some regions:
Galactosaemia
Homocystinuria
Duchenne muscular dystrophy is an example of a condition not fulfilling the criteria (being ultimately
incurable); however, the public and professional support for the programme has grown with time. An
important health problem has been interpreted on an individual rather than a population basis.
Potential benefits include avoidance of the diagnostic odyssey, with all its associated emotional and
financial expense before the correct diagnosis is made, influences on reproductive choice in the
parents (at a time before subsequent pregnancies), and the hope that earlier identification may lead to
positive interventions to influence outcome and better research.
Newer screening technologies, such as tandem mass spectrometry, further challenge the established
criteria because it is now much easier to diagnose a whole number of not only inborn errors of
metabolism, but also liver disease, haemoglobinopathies, etc. Although additional screening costs
may be minimal because the current system of blood-spot collection can be utilized, there is a large
burden placed on diagnostic and support services dealing with the new caseload. Rarity may no
longer preclude screening a whole population when there is an effective treatment available, e.g.
biotinidase deficiency cured with biotin supplementation.
The number of conditions screened for has massively increased in some countries. The USA screens
for some 30 conditions; however, for many of these disorders the natural history is poorly understood
and the diagnostic test does not always clearly decide who will develop symptoms. Concerns remain
that individuals will be given a diagnostic label on the basis of a raised marker or mutation, but will
never develop symptoms the so-called un-patient. Considering MCAD deficiency screening, many
new mutations have been detected since the introduction of screening, many of which have never
previously been found in clinically presenting cases.
15. FURTHER READING

Campbell NP, Smith AD, Peters TJ (2005). Biochemistry Illustrated, 5th edn. London: Churchill
Livingstone.
Hoffmann GF, Zschocke J, Nyhan WL, eds (2010). Inherited Metabolic Diseases: A clinical
approach. Heidelberg: Springer.
Lyon G, Kolodny E, Pastores G (2006). Neurology of Hereditary Metabolic Disease of Children,
3rd edn. New York: McGraw Hill
McIntosh N, Helms P, Smyth R, Logan S, eds (2008). Inborn errors of metabolism: biochemical
genetics. In: Forfar and Arneils Textbook of Pediatrics, 7th edn. London: Churchill Livingstone,
Chapter 26.
Saudubray J-M, van den Berghe G, Walter J, eds (2011). Inborn Metabolic Diseases: Diagnosis and
treatment, 5th edn. Berlin: Springer-Verlag.
Chapter 17
Neonatology
Grenville F Fox
CONTENTS
1. Embryology, obstetrics and fetal medicine
1.1 Embryology of the cardiovascular system
1.2 Embryology and post-natal development of the respiratory system
1.3 Embryology of the gastrointestinal system
1.4 Embryology of the central nervous system
1.5 Embryology of the genitourinary system
1.6 Maternal conditions affecting the fetus and newborn
1.7 Placental physiology, fetal growth and wellbeing
1.8 Amniotic fluid, oligohydramnios and polyhydramnios
1.9 Body composition at birth
1.10 Hydrops fetalis
1.11 Fetal circulation, adaptation at birth and persistent pulmonary hypertension of the newborn
2. Prematurity definitions and statistics

2.1 Mortality definitions
2.2 Incidence and causes/associations of pre-term birth
2.3 Outcome after pre-term birth
2.4 Small-for-gestational-age babies
3. Respiratory problems
3.1 Surfactant deficiency
3.2 Chronic lung disease (bronchopulmonary dysplasia)
3.3 Meconium aspiration syndrome
3.4 Pneumonia
3.5 Pulmonary air leak
3.6 Congenital lung problems
3.7 Chest wall abnormalities
3.8 Upper airway obstruction

3.9 Principles of mechanical ventilation in neonates
3.10 Extracorporeal membrane oxygenation
4. Cardiovascular problems
4.1 Patent ductus arteriosus
4.2 Hypotension
4.3 Hypertension
4.4 Cyanosis in the newborn
5. Gastroenterology and nutrition

5.1 Necrotizing enterocolitis
5.2 Composition of infant milks
5.3 Breast-feeding
5.4 Fluid and nutritional requirements in neonates
5.6 Congenital abnormalities of the gastrointestinal system
6. Neurological problems
6.1 Peri-intraventricular haemorrhage
6.2 Periventricular leukomalacia
6.3 Neonatal encephalopathy
6.4 Neonatal seizures
6.5 Causes of hypotonia in the newborn
6.6 Retinopathy of prematurity
7. Genitourinary problems
7.1 Congenital abnormalities of the kidneys and urinary tract
7.2 Haematuria in the newborn
7.3 Causes of acute renal failure in neonates
8. Infection
8.1 Bacterial infection
8.2 Congenital viral infection
8.3 Fungal and protozoal infections
9. Neonatal endocrine problems

9.1 Neonatal hypoglycaemia
9.2 Panhypopituitarism
9.3 Adrenal insufficiency
10. Neonatal jaundice

10.1 Physiological jaundice
10.2 Causes of non-physiological jaundice

10.3 Management of non-physiological unconjugated hyperbilirubinaemia
10.4 Prolonged jaundice
11. Neonatal haematology/coagulation problems

11.1 Polycythaemia
11.2 Haemorrhagic disease of the newborn and vitamin K
11.3 Disseminated intravascular coagulation
11.4 Haemophilia A
11.5 Von Willebrand disease
12. Neonatal orthopaedic problems

13. Further reading
Neonatology
1. EMBRYOLOGY, OBSTETRICS AND FETAL MEDICINE

1.1 Embryology of the cardiovascular system
The heart develops initially as a tube from yolk sac mesoderm. It begins to beat from about 3
weeks gestation
In the fourth week the primitive heart loops to form four chambers. Septation between the four
chambers and the aorta and pulmonary trunk occurs in the fifth week. The septum primum grows
down from the upper part of the primitive atrium and then fuses with the endocardial cushions
(septum intermedium) in the atrioventricular canal
Bulbotruncal septation divides the common arterial trunk into the aorta and pulmonary trunk as
spiral ridges develop in the caudal end of the heart. Completion of ventricular septation occurs as
these fuse with the septum intermedium
Blood is pumped caudally from the embryonic heart by six pairs of pharyngeal arch arteries to the
paired dorsal aortas. Some of this system regresses and the third arch arteries form the carotid
vessels. The right fourth arch artery forms the right subclavian artery with that of the left, forming
the aortic arch. The left sixth arch artery forms the ductus arteriosus with branch pulmonary arteries
forming from the right
1.2 Embryology and postnatal development of the respiratory system

Embryonic phase (35 weeks gestation) the lung bud begins as an endodermal outgrowth of
foregut. This branches into the surrounding mesoderm to form the main bronchi
Pseudoglandular phase (616 weeks) airways branch further to terminal bronchioles (preacinar
airways). Cartilage, lymphatics and cilia form. Main pulmonary artery forms from sixth left
branchial arch
Canalicular phase (1724 weeks) airways lengthen, epithelium becomes cuboidal, pulmonary
circulation develops. The acinar structures (gas-exchanging units) begin to develop and surfactant
production begins by 24 weeks gestation as type 1 and 2 pneumocytes become distinguishable.
Lungs fill with amniotic fluid, which facilitates further lung growth
Terminal sac phase (2440 weeks) further development of the acinar structures (respiratory
bronchioles, alveolar ducts and terminal sacs [alveoli]) occurs and an increasing amount of
surfactant is produced. Type 1 pneumocytes eventually cover approximately 95% of the alveolar
surface and facilitate gas exchange. The surfactant-producing type 2 cells cover only about 5%.
Development of the pulmonary circulation continues and results in a thicker intra-arteriolar smooth
muscle layer by term, which may respond to intrauterine hypoxia by vasoconstriction. This
regresses rapidly after birth
Postnatal lung development the number and size of alveoli increase rapidly during the first 2
years (approximately 150 million at term to 400 million by 4 years). The conducting airways also
increase in size
Diaphragm development arises as a sheet of mesodermal tissue, the septum transversum. It begins
close to the third, fourth and fifth cervical segments and therefore its nerve supply, the phrenic
nerve, is derived from this area. The primitive septum transversum migrates caudally to form the
pleural space and the two posterolateral canals in which the lung buds develop fuse. Failure to do
this results in a Bochdalek hernia. Failure of the retrosternal part of the septum transversum to form
causes a Morgagni-type diaphragmatic hernia. The diaphragm is completed as primitive muscle
cells migrate from the body wall. If this fails, eventration of the diaphragm results
1.3 Embryology of the gastrointestinal system

The endodermal lining of the yolk sac forms the primitive gut
The midgut lengthens and protrudes into the yolk sac via the vitelline duct. Meckels diverticulum is
the remnant of this
The extra-abdominal gut rotates 270 anticlockwise around the mesentery which contains the
superior mesenteric artery. Failure to complete this results in malrotation
The gut returns to the abdominal cavity by the end of week 12. Exomphalos is the result of this not
occurring
Gastroschisis is a failure of closure of the anterior abdominal wall
1.4 Embryology of the central nervous system

The neural plate develops from ectoderm and forms the neural tube by 3 weeks gestation. The
neural groove closes in a cranial-to-caudal direction by the end of the fourth week
Three swellings evolve from the caudal end of the neural tube the prosencephalon (forebrain)
forms the cerebral hemispheres, the mesencephalon forms the midbrain, and the rhombencephalon
(hind brain) forms the pons, medulla and cerebellum
Neuroblasts migrate from the centre of the brain to further develop the cerebral hemispheres
Myelination from Schwann cells occurs from 12 weeks gestation. Myelination accelerates from
about 24 weeks but is not complete until around 2 years of age. This has important implications for
the interpretation of brain MR (magnetic resonance) scans in neonates and early childhood
Neural crest cells form the meninges, peripheral nerves, chromaffin cells, melanocytes and adrenal
medulla
1.5 Embryology of the genitourinary system

The genitourinary systems develop from mesoderm on the posterior abdominal wall and drain into
the urogenital sinus of the cloaca
The pronephros is the primitive kidney resulting from this and is replaced initially by the
mesonephros. The ureteric bud appears at the start of week 5 of embryogenesis as a small branch
of the mesonephric duct. The mesonephric (wolffian) ducts drain urine from primitive tubules into
the urogenital sinus. Repeated branching from week 6 onwards gives rise to the calyces, papillary
ducts and collecting tubules by week 12
Differentiation of the metanephros into nephrons glomeruli, tubules and loop of Henle occurs
from 4 weeks. These structures then join with the lower wolffian ducts to form the collecting
systems. Branching and new nephron induction continues until week 36
The metanephros develops from the most caudal part of the mesodermal ridge, but the kidney
eventually becomes extrapelvic because of the growth of surrounding areas
The Y chromosome (SRY gene) influences development of primitive gonads to form testes after 6
weeks. Testes secrete mllerian inhibition factor (MIF) which results in regression of mllerian
structures (uterus, fallopian tubes and vagina)
Testosterone influences the development of wolffian structures (prostate, seminiferous tubules and
vas deferens) as well as later masculinization
1.6 Maternal conditions affecting the fetus and newborn

Diabetes:
Threefold increased risk of congenital malformations (congenital heart disease, sacral agenesis,
microcolon, neural tube defects)
Small for gestational age (SGA) three times the normal rate because of small-vessel disease
Macrosomia as a result of increased fetal insulin
Hypoglycaemia
Hypocalcaemia
Hypomagnesaemia
Surfactant deficiency
Transient hypertrophic cardiomyopathy (septal)
Polycythaemia and jaundice
Hypertension and pre-eclampsia SGA, polycythaemia, neutropenia, thrombocytopenia,
hypoglycaemia
Maternal thyroid disease
Neonatal thyrotoxicosis can be caused by transplacental thyroid-stimulating antibodies (i.e. longacting thyroid stimulator [LATS]) with maternal Graves disease
Rare only 1:70 mothers with thyrotoxicosis
May present with fetal tachycardia or within 12 days of birth, but sometimes delayed if mother is
taking antithyroid drugs
Usually causes goitre
Thyroid function tests (TFTs) should be assessed between 7 and 10 days in all babies of mothers
with Graves disease (or sooner if the baby is symptomatic)

Only severe cases require treatment with blockers and antithyroid drugs because it resolves
spontaneously as antibody levels fall over the first few months
Neonatal hypothyroidism may be caused by maternal antithyroid drugs taken during pregnancy, so
check TFTs between 4 and 7 days after birth.
Maternal systemic lupus erythematosus (SLE) is associated with:
Increased risk of miscarriage; recurrent miscarriage is associated with antiphospholipid antibody

Increased risk of SGA babies. Risk is higher with maternal hypertension and renal disease
Congenital complete heart block associated with presence of anti-Ro and anti-La antibodies
Butterfly rash transient because of transplacental passage of SLE antibodies
Thrombocytopenia
Transplacental passage of maternal antiplatelet antibodies causes neonatal thrombocytopenia. If the
mother is also thrombocytopenic, the cause is likely to be maternal idiopathic thrombocytopenia (also
associated with maternal SLE):
Platelet count proportional to that of mother
Rarely causes very low neonatal platelet counts or symptoms
Risk of intracranial haemorrhage if platelet count <50 109/l (may occur antenatally, so caesarean
section not always protective)
Treatment: intravenous immunoglobulin G (IgG) and platelet transfusion
Alloimmune thrombocytopenia occurs following maternal sensitization if mother is PLA1 antigen
negative:
Approximately 3% of white people are PLA1 antigen negative

First pregnancies may be affected; severity is usually greater in subsequent pregnancies
Antenatal intracranial haemorrhage is common (2050%)
Treatment washed irradiated maternal platelets or intravenous IgG and random donor platelets
Myasthenia gravis
Babies of mothers with myasthenia gravis have a 10% risk of a transient neonatal form of the disease:
Usually the result of transplacental passage of anti-acetylcholinesterase receptor antibodies but
baby may produce own antibodies
Risk is increased if a previous baby was affected
Maternal disease severity does not correlate with that of baby; a range of symptoms from mild
hypotonia to ventilator-dependent respiratory failure may occur
Diagnosis antibody assay, electromyography and edrophonium or neostigmine test (also used as
treatment)
Babies of mothers with myasthenia gravis should be monitored for several days after birth
Usually presents soon after birth and resolves by 2 months. Physiotherapy may be required to
prevent/relieve contractures
Congenital myasthenia gravis should be considered if antibodies are absent or if symptoms persist
or recur
Fetal alcohol syndrome
Although more than three or four alcohol units per day during pregnancy are thought to be necessary to
cause fetal alcohol syndrome, even moderate alcohol intake may reduce birthweight.
Features of fetal alcohol syndrome include:
Dysmorphic face with mid-face hypoplasia short palpebral fissures, epicanthic folds, flat nasal
bridge (resulting in small upturned nose), long philtrum, thin upper lip, micrognathia and ear
abnormalities
Microcephaly with subsequent intellectual impairment
Postnatal growth failure
Maternal smoking
Reduces birth weight by 10% on average
Increases risk of sudden infant death syndrome
Maternal drugs
Teratogenic drugs include:
Phenytoin (fetal hydantoin syndrome) dysmorphic face (broad nasal bridge, hypertelorism, ptosis,
ear abnormalities)
Valproate neural tube defects, fused metopic suture, mid-face hypoplasia, congenital heart
disease, hypospadias, talipes, global developmental delay
Retinoids (isotretinoin) and large doses of vitamin A dysmorphic face (including cleft palate),
hydrocephalus, congenital heart disease
Cocaine SGA, prune belly and renal tract abnormalities, gut, cardiac, skeletal and eye
malformations
Other teratogenic drugs include thalidomide (limb defects), lithium, carbamazepine,
chloramphenicol and warfarin
Maternal opiate abuse
Associated with intrauterine growth retardation (IUGR)

Results in withdrawal symptoms or neonatal abstinence syndrome onset usually within 12 days
of birth but may be delayed until 710 days and continue for several months; onset is later and
symptoms persist for longer with methadone
Symptoms are:
Wakefulness
Irritability
Tremors, temperature instability, tachypnoea
High-pitched cry, hyperactivity, hypertonia
Diarrhoea, disorganized suck
Respiratory distress, rhinorrhoea
Apnoea
Weight loss
Autonomic dysfunction
Lacrimation
Also seizures, myoclonic jerks, hiccups, sneezing, yawning

Surfactant deficiency is less common
Sudden infant death syndrome is more common
Management monitor using withdrawal score chart. Less than 50% require pharmacological
intervention. Indications for this are severe withdrawal symptoms or seizures. Oral morphine is the
usual treatment of choice. Methadone, phenobarbital, benzodiazepines and chlorpromazine have
also been used
1.7 Placental physiology, fetal growth and wellbeing

The fertilized ovum divides to form a blastocyst which attaches itself to the inside wall of the uterus.
The outer cells of the blastocyst, the trophoblasts, eat their way into the endometrium and these and
surrounding endometrial cells form the placenta and membranes. The trophoblasts are therefore the
source of nutrition for the early embryo in the first 12 weeks.
In the second and third trimesters, maternal blood flows into the placental sinuses which surround the
placental villi. Active transport of amino acids and other nutrients occurs across the chorionic
epithelium into the villi, early in pregnancy, but this becomes less after the first trimester. Oxygen and
nutrients diffuse into the fetal blood supply via the villi. Diffusion of oxygen occurs because maternal
PO2 is approximately 7 kPa, compared with 4 kPa in the fetus.
Oestrogen
Initially produced by the corpus luteum and then in increasing amounts by the placenta as pregnancy
progresses
Causes the uterine smooth muscle to proliferate
Enhances development of the uterine blood supply
Changes pelvic musculature and ligaments to facilitate birth
Causes breast development by increasing proliferation of glandular and fatty tissue
Progesterone
Limited amounts produced by the corpus luteum in the early part of pregnancy much larger
amounts produced by the placenta after the first trimester
Causes endometrial cells to store nutrients in first trimester
Relaxes uterine smooth muscle; decrease in secretion of progesterone in the final few weeks of
pregnancy coincides with onset of labour
Facilitates glandular development of breasts
Human chorionic gonadotrophin

Secreted by trophoblasts
Prevents degeneration of corpus luteum
Peak concentration at around 10 weeks; falls rapidly to low levels by 20 weeks gestation
Human placental lactogen

Secreted by placenta in increasing amounts throughout pregnancy
Has growth hormone-like effect on fetus
Has prolactin-like effect on breasts, facilitating milk production
Oxytocin
Produced by the hypothalamicposterior pituitary axis

Release is stimulated by irritation of the cervix
Oxytocin causes contraction of uterine smooth muscle
Causes milk secretion stimulation via the hypothalamus
Prolactin
Produced by the hypothalamicanterior pituitary axis
Production is inhibited during pregnancy by high levels of oestrogen and progesterone produced by
the placenta; the sudden decrease in these after delivery of the placenta increases prolactin release
Prolactin causes secretion of milk from the breasts
Hypothalamic production of a prolactin inhibitory factor increases if the breasts are engorged with
milk and decreases as the baby breast-feeds
Prolactin inhibits follicle-stimulating hormone immediately postpartum, thereby preventing
ovulation
Identifying fetal compromise
Kick charts
Symphysisfundus height to estimate fetal size/growth
Ultrasound scan measurement to estimate fetal size/growth
Amniotic fluid volume (see below)
Umbilical artery Doppler studies reflect placental blood flow
Fetal Doppler scans reflect hypoxia if abnormal
Biophysical profile fetal movement, posture and tone, breathing, amniotic fluid volume and
cardiotachograph assessed
1.8 Amniotic fluid, oligohydramnios and polyhydramnios

Amniotic fluid is produced by the amnion, fetal urine and fetal lung secretions
Oligo- or polyhydramnios is diagnosed on ultrasound scan if clinically suspected
Deepest pool of amniotic fluid normally 38 cm. The amniotic fluid index (AFI) is the sum of the
depth of the deepest pool in each quadrant
Oligohydramnios (decreased AFI) may be caused by:
Placental insufficiency (IUGR is usually also present)
Fetal urinary tract abnormalities
Prolonged rupture of membranes (PROM)
Polyhydramnios (increased AFI) may be the result of:
Maternal diabetes
Karyotype abnormalities
Twin-to-twin transfusion syndrome (sometimes called polyhydramniosoligohydramnios
sequence)
Neuromuscular disorders such as:
Congenital myotonic dystrophy
Spinal muscular atrophy (types 1 or 0 type 0 is antenatal presentation of the disease)
Congenital myopathies
Mbius syndrome
Oesophageal atresia
Congenital diaphragmatic hernia
Idiopathic/unexplained (a cause is more likely to be found in severe cases)
1.9 Body composition at birth

There is a gradual decrease in extracellular fluid with increasing gestation (approximately 65% of
weight at 26 weeks, 40% at 40 weeks)
Early postnatal diuresis occurs within 12 days because of further loss of extracellular (interstitial)
fluid and partly accounts for up to 10% of the weight loss this may be delayed in babies with
respiratory failure
Surface area to weight ratio is high in newborn babies (more so in preterm infant) so that the heat
loss to heat production ratio is also high
Newborn babies are able to generate heat as a response to cold stress using brown adipose tissue
(non-shivering thermogenesis). Peripheral vasoconstriction may also help maintain body
temperature. These mechanisms may be impaired in preterm or sick babies and are also limited
during the first few hours of postnatal life
1.10 Hydrops fetalis

Definition: subcutaneous oedema and fluid in at least two of: pleural effusions, ascites, pericardial
effusion.
Causes
Immune cause is usually rhesus disease.
Non-immune causes include:
Anaemia:
Twin-to-twin transfusion
Fetomaternal haemorrhage
Homozygous -thalassaemia
Heart failure:
Arrhythmias (supraventricular tachycardia, complete heart block)
Structural (cardiomyopathy, hypoplastic left and right heart, etc.)
High output (arteriovenous malformations, angiomas)
Chromosomal abnormalities (Turner syndrome, trisomy 21 and other trisomies)
Congenital malformations:
Congenital cystic adenomatoid malformation
Diaphragmatic hernia
Cystic hygroma
Chylothorax and pulmonary lymphangiectasia
Osteogenesis imperfecta
Asphyxiating thoracic dystrophy
Infection:
Parvovirus B19
Cytomegalovirus (CMV)
Toxoplasmosis
Syphilis
Chagas disease (a South American parasite infection)
Congenital nephrotic syndrome
Idiopathic 1520% cases
1.11 Fetal circulation, adaptation at birth and persistent pulmonary

hypertension of the newborn
Fetal haemoglobin (HbF)
Four globin chains are 22 (adult is predominantly 22)
The chains have reduced binding to 2,3-diphosphoglycerate (2,3-DPG)
The reduced 2,3-DPG in HbF causes the oxyhaemoglobin dissociation curve to be shifted to the
left, i.e. there is a higher saturation for a given PO2 or P50 decreases (the PO2) at which half the
haemoglobin is saturated. Fetal red blood cells therefore have a higher affinity for oxygen, making
it easier to unload from the maternal circulation. Delivery of oxygen to the fetal tissues is
facilitated by the steep oxyhaemoglobin dissociation curve of HbF, but the lower P50 leads to a
decreased rate of unloading to tissues. Levels of 2,3-DPG rise rapidly in the first few days to meet
the increased metabolic requirements that occur after birth. Preterm infants have lower 2,3-DPG
levels and therefore have a limited ability for oxygen to be unloaded from red blood cells
Approximately 80% of haemoglobin is HbF at term. This falls to <10% by 1 year
The following also shift the oxyhaemoglobin dissociation curve to the left:
Alkalosis
Hypocapnia
Hypothermia
Circulatory changes at birth

Functional closure of the ductus venosus occurs within hours of birth, with anatomical closure
completed within 3 weeks
Ductus arteriosus patency is maintained in fetal life by prostaglandin E2 and prostaglandin I2
(prostacyclin). Functional closure of the ductus arteriosus usually occurs within 15 hours of birth
and is facilitated by:
Reduced sensitivity of the ductus to prostaglandins and increased breakdown of prostaglandin E2
occurring in the lungs towards the end of pregnancy
Increased PO2 after the onset of breathing
Reduced pulmonary vascular resistance
Before birth only about 10% of cardiac output goes to the lungs because pulmonary vascular
resistance is higher than systemic vascular resistance
Chemosensitivity of the pulmonary arteriolar bed increases with advancing gestation
Increased PO2 and lung expansion immediately after birth, along with increased release of
vasodilator substances (prostaglandins, bradykinin and nitric oxide), lead to a fall in pulmonary
vascular resistance after birth
Pulmonary artery pressure falls to half the prebirth levels within 24 hours and pulmonary blood
flow doubles as a result
After birth, the left atrial pressure increases as a result of increased pulmonary blood flow and
right atrial pressure falls because of the absence of placental blood from the umbilical vein. This
causes a functional closure of the foramen ovale within a few minutes of birth. Anatomical closure
may take weeks
Persistent pulmonary hypertension of the newborn

Normal circulatory changes after birth are delayed either because of increased muscularization of
the pulmonary arterioles or as a response to hypoxia
Treatment includes ventilation with hyperoxia, induced metabolic alkalosis and the use of
pulmonary vasodilators such as nitric oxide
Nitric oxide
Free radical
Synthesized in endothelial cells from L-arginine by the enzyme nitric oxide synthase also known
as endothelium-derived relaxing factor
In vascular smooth muscle nitric oxide activates guanylyl cyclase to increase intracellular
guanosine cyclic 3':5'-monophosphate (cGMP). This leads to smooth muscle relaxation and
vasodilatation by stimulating cGMP-dependent protein kinase which reduces intracellular calcium
2. PREMATURITY DEFINITIONS AND STATISTICS

2.1 Mortality definitions
Stillbirth in utero death after 24 weeks gestation (28 weeks in most other European countries, 20
weeks in USA, 12 weeks in Japan). Stillbirth rate for England, Wales and Northern Ireland in 2009
= 4.7 per 1000 live- and stillbirths
Perinatal mortality rate stillbirths and deaths within 6 days of birth per 1000 live- and
stillbirths. Perinatal mortality rate for England, Wales and Northern Ireland in 2009 = 6.8
Neonatal mortality rate deaths of liveborn infants < 28 days old per 1000 live births. Neonatal
mortality rate for England, Wales and Northern Ireland in 2009 = 2.8. Note that perinatal and
neonatal mortality rates are adjusted by removing terminations of pregnancy and babies born <22
weeks gestation
2.2 Incidence and causes/associations of preterm birth

Approximate UK incidences (live births) are:
Preterm birth (i.e. before 37 completed weeks gestation)

Low birthweight (<2500 g)
Very low birthweight (<1500 g)
Extremely low birthweight (<1000 g)
7%
7%
1.2%
0.5%
All of these incidences are higher in developing countries but lower in some other European
countries.
The incidence of preterm birth appears to be increasing both in the UK and in other countries, and this
is probably the result of:
Increased number of multiple births because of assisted conception

Increased obstetric intervention
Increased use of gestational age assessments (which tends to decrease estimates of gestational age)
An increase in the registration of live births at very low gestation
The following are associated with an increased risk for spontaneous preterm birth:
Social/demographic factors:
Maternal country of birth Africa or Caribbean
Low socioeconomic class
Age <20 or >40 years
Past obstetric or medical history:
Previous preterm birth
Uterine abnormalities
Cervical abnormalities
Current pregnancy:
Multiple pregnancy
Poor nutrition
Low pre-pregnancy weight
Poor pre- and antenatal care
Anaemia
Smoking
Bacteriuria
Genital tract colonization (particularly group B streptococci)
Cervical dilatation >1 cm
Pre-term PROM
2.3 Outcome after pre-term birth

The first national study of survival and long-term follow-up after extreme preterm birth to be
published was the EPICure study. This documented outcome after birth between 20 and 25 weeks
gestation in 1289 live births in the UK and Republic of Ireland in 1995. The study was repeated in
2006, for England only, and also included babies of 26 weeks gestation.
Survival to discharge from hospital was as follows:
1995
2006
22 weeks
23 weeks
24 weeks
25 weeks
26 weeks
1%
11%
26%
44%
5%
16%
42%
65%
75%
Neurodevelopmental follow-up of survivors from the 1995 birth cohort at 30 months showed:
No disability
Severe disability
Mild-to-moderate disability
Died after hospital discharge
Not followed up
49%
24%
24%
2%
1%
Outcome for preterm SGA infants is less well documented but there is some evidence that outcome is
marginally better than that expected in an appropriately grown infant of the same birthweight, i.e. a
baby born at 28 weeks weighing 750 g (below the third centile) would be expected to have the same
outcome as a 25 weeks gestation infant of the same weight (50th centile).
The ethics of resuscitation of extremely preterm infants are controversial and any decisions in
individual cases should be made by the most senior paediatrician available at the time, with parents
views taken into consideration when possible. It seems reasonable to actively resuscitate most
appropriately grown (i.e. more than approximately 500 g) infants greater than 23 weeks gestation
who have reasonable signs of life after birth.
2.4 Small-for-gestational-age babies

The definition of SGA varies between birthweight <3rd centile and a birthweight <10th centile.
Over 50% of babies with birthweight <10th centile are constitutionally small; the rest have IUGR
There are many causes of SGA infants including maternal (hypertension, diabetes, lupus, smoking,
altitude), placental and fetal (multiple gestations, malformations, infections)
Fetal/neonatal complications of IUGR

In utero death/stillbirth
Fetal hypoxia/acidosis (associated with neonatal encephalopathy/birth depression)
Polycythaemia, neutropenia (and increased infection risk), thrombocytopenia
Hypothermia
Hypoglycaemia
Long-term complications of IUGR
Increased risk of neurodevelopmental problems

Hypertension
Diabetes
Hyperlipidaemias
3. RESPIRATORY PROBLEMS
3.1 Surfactant deficiency
Endogenous surfactant is produced by type 2 pneumocytes, which line 510% of the alveolar surface.
Surfactant-containing osmiophilic granular inclusion bodies cause these to appear different from the
thinner and more numerous type 1 pneumocytes, which are responsible for gas exchange.
Composition of endogenous surfactant

Phospholipids 80-85%
The main surface-active components, which lower surface tension at the airalveolar interface
preventing alveolar collapse
Dipalmitoylphosphatidylcholine (DPPC) 4570% is the major constituent of all exogenous
surfactant preparations
Other phospholipids include:
Phosphatidylcholine
Phosphatidylglycerol
Phosphatidylinositol
Phosphatidylethanolamine
Phosphatidylserine
Other lipids 10% (e.g. sphingomyelin)
Surfactant proteins 510%
Facilitate adsorption, spreading and recycling of surfactant and have immunoregulatory properties
Surfactant protein A:
Mainly immune function but also has a role in spreading and recycling of surfactant
Has been shown to increase microbial killing by alveolar macrophages
Increases resistance to inhibitors of surface activity which occurs in sepsis
Surfactant protein B:
Major role in adsorption, spreading and recycling of surfactant
Case reports suggest that congenital deficiency of surfactant protein B is a lethal, autosomal
recessive condition
Surfactant protein C:
Similar function to surfactant protein B

Surfactant protein D:
Immune function
Platelet-activating factor (PAF)

May increase surfactant secretion
Exogenous surfactants
CLD/BPD, chronic lung disease/bronchopulmonary dysplasia; DPPC,

dipalmitoylphosphatidylcholine.
Estimated incidence of surfactant deficiency by gestational age (without maternal steroids)
Gestation (completed
weeks)
Incidence of surfactant
deficiency (%)
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
90
85
80
75
70
60
55
40
25
20
12
6
3
2
<12
Increased incidence of surfactant deficiency in:

Prematurity
Male sex
Sepsis
Maternal diabetes
Second twin
Elective caesarean section
Strong family history
Surfactant deficiency is decreased in:
Female sex
PROM
Maternal opiate use
IUGR
Antenatal glucocorticoids
Prophylactic surfactant
Amniotic fluid (or gastric aspirate) lecithin:sphingomyelin (L:S) ratios:
<1.5 = immature 70% risk of surfactant deficiency

1.51.9 = borderline 40% risk of surfactant deficiency
2.02.5 = mature very small risk unless mother has diabetes
>2.5 = safe
Management of surfactant deficiency

Maternal antenatal corticosteroids (betamethasone or dexamethasone) before preterm birth reduce the
effects of surfactant deficiency and have been shown to:
Reduce neonatal mortality by approximately 31%

Decrease intraventricular haemorrhage by approximately 46%
Reduce the risk of necrotizing enterocolitis (NEC)
Decrease the need for respiratory support for respiratory distress syndrome (RDS)
Decrease the need for neonatal intensive care unit (NICU) admission
Reduce the risk of infection in the first 48 hours
The current Royal College of Obstetricians and Gynaecologists (RCOG) guidelines suggest giving
maternal corticosteroids to women with likely pre-term birth between week 24 and 34+6 of gestation,
and also to consider in those from 23+0 weeks, as well as before any elective caesarean section up to
38+6 weeks.
There is currently no evidence that routine high-frequency oscillation is of any long-term benefit in
preterm infants with surfactant deficiency, although this mode of ventilation may be used as a rescue
in severe cases.
Routine paralysis is not used in most neonatal units. Sedation with opiates and various modes of
trigger ventilation may help reduce the incidence of pneumothoraces.

Exogenous surfactant considerably reduces mortality and incidence of pneumothoraces and chronic
lung disease. Early treatment with surfactant and use of animal rather than synthetic surfactants
enhance these outcomes.
3.2 Chronic lung disease bronchopulmonary dysplasia

Definition respiratory support with supplementary oxygen mechanical ventilation for >28 days
with typical chest radiograph changes (see below). In very-low-birthweight (VLBW) infants an
alternative definition has been suggested requiring oxygen mechanical ventilation >36 weeks
corrected gestational age and typical changes on a chest radiograph.
Risk factors for chronic lung disease
Prematurity
Prolonged mechanical ventilation with high pressures and high fractional inspired oxygen (FiO2)
Lung over-inflation (volutrama or barotrauma) or under-inflation (atelectotrauma)
Oxygen toxicity (free radical mediated)
Pulmonary air leak (pneumothoraces or pulmonary interstitial emphysema)
Patent ductus arteriosus (PDA)
Chorioamnionitis
Postnatal infection (particularly with Ureaplasma urealyticum and cytomegalovirus)
Radiological stages
Stage 1: first few days
Stage 2: 2nd week
Stage 3: 24 weeks
Stage 4: >4 weeks
indistinguishable from surfactant deficiency

generalized opacity of lung fields
streaky infiltrates
hyperinflation, cysts, areas of collapse/consolidation,
cardiomegaly
Management of chronic lung disease

Ventilatory support as required
Randomized controlled trial (RCT) evidence suggests no benefit of a high oxygen saturation target
(i.e. 95-98%) compared with a lower level (9194%)
Good nutrition is of paramount importance; increased alveolar growth accompanies general growth
particularly in the first 12 years
Treatment of underlying exacerbating factors infection, gastro-oesophageal reflux, fits, cardiac
problems, etc.
Dexamethasone the only proven benefit is to facilitate weaning off mechanical ventilation but
concern has been raised over short-term side effects (hyperglycaemia, hypertension, bradycardia,
poor growth, increased risk of sepsis) and long-term side effects (adverse neurodevelopmental
outcome, particularly cerebral palsy)
Inhaled steroids only proven benefit is to reduce the need for systemic steroids
Bronchodilators used only if there is evidence of reversible airway obstruction
Diuretics likely to be of benefit only in the presence of PDA, cor pulmonale or excessive weight
gain
Respiratory syncytial virus (RSV) prophylaxis with monoclonal antibodies (e.g. palivizumab) has
been shown to reduce hospitalization in high-risk cases, but use is controversial because of the
high cost of the drug and the need for monthly intramuscular injections throughout the RSV season
Outcome of babies with chronic lung disease
Most are weaned off supplementary oxygen before discharge home

Few require home oxygen
Most babies discharged on home oxygen are weaned off before 12 years
High risk of readmission to hospital with viral respiratory infections in the first 12 years of life
Increased risk of recurrent cough and wheeze in pre-school age group but most outgrow this
tendency and have normal exercise tolerance in childhood
3.3 Meconium aspiration syndrome (MAS)

Risk factors
Term or post-term (incidence much higher in births after 42 weeks)
Perinatal asphyxia
Rare in preterm but said to occur with congenital listeriosis (more likely to be pus than meconium).
The passage of meconium in fetal distress may be the result of increased secretion of motilin.
Meconium may be inhaled antenatally or postnatally. Antenatal inhalation is more likely in fetal
distress because of abnormal fetal breathing (equivalent to gasping) that occurs with hypoxia and
acidosis.
Major effects of MAS on lung function

Airway blockage:
Increased airway resistance with ballvalve mechanism and gas trapping
High risk of pneumothorax
Chemical pneumonitis
Increased risk of infection:
Even though meconium is sterile
Escherichia coli is the most common infective agent
Surfactant deficiency:
Lipid content of meconium displaces surfactant from alveolar surface
MAS changes on chest radiographs include initial patchy infiltration and hyperinflation.
Pneumothoraces are common at this stage. A more homogeneous opacification of the lung fields may
develop over the next 48 hours, as chemical pneumonitis becomes more of a problem. In severe
cases, changes similar to chronic lung disease may develop over the following weeks.
There is no evidence for routine suction if the baby is vigorous and otherwise in good condition.
Intubation for lower airway suction is only needed if meconium can be seen below the vocal cords.
Thoracic compression and routine bronchial lavage have no proven benefit. Intermittent positivepressure ventilation with a relatively long expiratory time to prevent further gas trapping may be
required in moderate-to-severe MAS. Surfactant replacement therapy in infants with MAS has proven
benefit, but large doses may be required. Extracorporeal membrane oxygenation (ECMO) may be
used in the most severe cases.
3.4 Pneumonia
Pneumonia can be congenital, intrapartum or nosocomial.
Congenital
Onset is usually within 6 hours of birth:
Bacterial:
Streptococci (group B streptococci)
Coliforms (E. coli, Klebsiella, Serratia, Shigella, Pseudomonas spp., etc.)
Pneumococci
Listeria sp.
Viral
CMV
Rubella virus
Coxsackievirus
Other
Toxoplasmosis
Chlamydia sp.
Ureaplasma urealyticum
Candida sp.
Intrapartum
Onset is usually within 48 hours:
Bacterial:
Coliforms (as above)
Haemophilus sp.
Staphylococci
Pneumococci
Listeria sp.
Viral:
Nosocomial
Onset is after 48 hours:
Bacterial:
Staphylococci
Streptococci
Pseudomonas sp.
Klebsiella sp.
Pertussis
Viral:
RSV
Adenovirus
Influenza viruses
Parainfluenza viruses
Common cold viruses
Other:
Pneumocystis jiroveci
3.5 Pulmonary air leak

Pneumothorax
Occurs in up to 1% of otherwise healthy term infants (it is usually asymptomatic)
Overdistension of alveoli is more likely to occur in immature lungs because of a decreased number
of pores of Kohn, which redistribute pressure between alveoli. Air ruptures through overdistended
alveolar walls and moves towards the hilum where it enters the pleural or mediastinal space
More common in surfactant deficiency, MAS, pneumonia and pulmonary hypoplasia
Risk is reduced by volume target ventilation or lower ventilator pressures to avoid overdistension,
faster rate ventilation with shorter inspiratory times, paralysis of infants fighting the ventilator and
surfactant replacement therapy
Pulmonary interstitial emphysema

May occur in up to 25% of VLBW infants, usually confined to those with the worst surfactant
deficiency
May be more common in chorioamnionitis
Alveolar rupture results in small cysts in the pulmonary interstitium
Ventilation is difficult and mortality and incidence of chronic lung disease are high
Pneumomediastinum
May complicate surfactant deficiency or other forms of neonatal lung disease, when it may coexist
with pneumothorax or may be iatrogenic following tracheal rupture secondary to intubation
No symptoms may occur in isolated pneumomediastinum, but respiratory and cardiovascular
compromise is more likely to occur if pneumothorax is also present
3.6 Congenital lung problems

Pulmonary hypoplasia
Primary pulmonary hypoplasia is rare but may present with persistent tachypnoea which resolves
with lung growth several months after birth.
Secondary pulmonary hypoplasia may be the result of:
Reduced amniotic fluid volume Potter syndrome (renal agenesis) or other severe congenital renal
abnormalities resulting in markedly decreased urine volume (infantile [autosomal recessive]
polycystic kidney disease, severe bilateral renal dysplasia, posterior urethral valves)
Preterm rupture of membranes occurs only if membranes ruptured before 26 weeks; 23% of
pregnancies with rupture of membranes before 20 weeks are unaffected; outcome with rupture of
membranes before 24 weeks is usually poor
Amniocentesis mild-to-moderate respiratory symptoms are more likely to occur in the neonatal
period and incidence of respiratory symptoms in the first year of life is increased
Lung compression pulmonary hypoplasia is common in small-chest syndromes including
asphyxiating thoracic dystrophy and thanatophoric dwarfism, diaphragmatic hernia, congenital
cystic adenomatoid malformation and pleural effusions
Reduced fetal movements pulmonary hypoplasia occurs in congenital myotonic dystrophy, spinal
muscular atrophy and other congenital myopathies
Outcome with pulmonary hypoplasia depends on the severity and the underlying cause.
Congenital diaphragmatic hernia
Most common congenital abnormality of the respiratory system incidence is 1 in 25003500

births
Twice as common in males
Other congenital malformations are common: 30% have karyotype abnormalities and 17% have
other lethal abnormalities; 39% have abnormalities in other systems malrotation occurs in 20%;
those with other congenital abnormalities have double the mortality rate
90% are Bochdalek or posterolateral hernias
8590% are left sided
Bilateral pulmonary hypoplasia occurs ipsilateral > contralateral
Usually diagnosed on routine antenatal ultrasound. May present with polyhydramnios. Those who
have a normal routine antenatal ultrasound scan are likely to have a better outcome because the
hernia usually occurs later, allowing for reasonable lung growth. In utero repair and tracheal
plugging have been attempted but with variable outcomes
Respiratory distress (usually severe), heart sounds on the right side of the chest, bowel sounds on
the left side, a scaphoid abdomen and vomiting may be found at birth. Less severe cases may not
present initially but develop increasing respiratory distress over the first 24 hours as the gut
becomes more air filled. Differential diagnosis is congenital cystic adenomatoid malformation (or
even pneumothorax)
During resuscitation
Bag-and-mask positive-pressure ventilation should be avoided
Wide-bore nasogastric tube should be placed as soon as possible to deflate gut and to confirm
diagnosis, and therefore distinguish between differential diagnoses of congenital cystic
adenomatoid malformation or pneumothorax on subsequent chest radiograph
Consider paralysing baby to avoid air swallowing and to reduce the risk of pneumothorax
Surgical management
There is some evidence to suggest that stabilizing the baby before surgery improves outcome
Malrotation is corrected if present; the diaphragmatic defect is usually closed with a synthetic patch
Postoperative care
High-frequency oscillation, nitric oxide or ECMO may be of benefit, but evidence for routine use of
these is lacking
Mortality rate overall is approximately 40%
Survivors may have problems associated with underlying pulmonary hypoplasia
Congenital cystic adenomatoid malformation (CCAM)
Rare, abnormal proliferation of bronchial epithelium, containing cystic and adenomatoid portions
Lower lobes affected more frequently
May disappear or become smaller spontaneously before or after birth
Differential diagnosis is congenital diaphragmatic hernia
Prognosis worse with associated hydrops, preterm birth and with type 3 lesions
Recurrent infection and malignant change have been described
There are three types.
Type 1 CCAM
Single or small number of large cysts
Most common type (50% cases)
May cause symptoms by compression or may be asymptomatic initially
Good prognosis after surgery
Type 2 CCAM
Multiple small cysts
Usually cause symptoms by compression of surrounding normal lung
Prognosis variable
Type 3 CCAM
Airless mass of very small cysts giving the appearance of a solid mass
Worst prognosis
Congenital lobar emphysema
Affected lobe is overinflated

Left upper lobe is most commonly affected (also right middle and upper lobes); rare in lower lobes
More common in boys
Associated with congenital heart disease in approximately one in six cases (usually as a result of
compression of airways by aberrant vessels)
Unaffected lobes in affected lung are compressed
Mediastinal shift and compression of the contralateral lung may also occur
Presents with signs of respiratory distress, wheezing, chest asymmetry and hyperresonance
Chest radiograph shows hyperlucent affected lobe compression of other lobes
Reduced ventilation and perfusion of the affected lobe is seen on a ventilationperfusion scan in
more severe cases
Surgical correction of underlying vascular abnormalities or resection of the affected lobe may be
required but symptoms and signs may resolve following bronchoscopy
Chylothorax
Effusion of lymph into the pleural space as a result of either:
Underlying congenital abnormality of the pulmonary lymphatics
Iatrogenic abnormality after cardiothoracic surgery
Diagnosis by antenatal ultrasound scan allows antenatal drainage by insertion of intercostal drains,
which may reduce the risk of pulmonary hypoplasia and facilitate resuscitation after birth
Ventilatory support may be required postnatally, along with intermittent intercostal drainage
Volume of chyle can be reduced by using a medium-chain triglyceride milk formula or avoiding
enteral feeds for up to several weeks as the underlying abnormality resolves with time; protein and
lymphocyte depletion may complicate this
Surgical treatment is needed for the small number of cases that do not resolve spontaneously
3.7 Chest wall abnormalities

Asphyxiating thoracic dystrophy
Autosomal recessive
Variable severity
Short ribs with bell-shaped chest
May have polydactyly and other skeletal abnormalities also
Long-term prognosis good in infants who survive >1 year
Ellisvan Creveld syndrome

Autosomal recessive
Short ribs, polydactyly, congenital heart disease, cleft lip and palate
Pulmonary hypoplasia is usually not severe and symptoms improve later
Short-rib polydactyly syndromes

Four variants all autosomal recessive
Death from severe respiratory insufficiency occurs in the neonatal period
Thanatophoric dysplasia
Usually sporadic
Very short limbs femur radiograph described as telephone handle shape
Very small, pear-shaped chest
Death from lung/chest hypoplasia occurs in the neonatal period
Camptomelic dysplasia
Autosomal recessive
Very bowed, shortened long bones
Death from respiratory insufficiency usually occurs in childhood
3.8 Upper airway obstruction

Neonates are obligate nasal breathers.
Choanal atresia
Incidence approximately 1:8000

More common in girls
Occurs as a result of a failure of breakdown of bucconasal membrane
May be unilateral or bilateral, bony or membranous
60% associated with other congenital abnormalities including the CHARGE association: C =
colobomas, H = heart defects, A = atresia of choanae, R = retarded growth and development, G =
genital hypoplasia in males, E = ear deformities
Presents at birth with respiratory distress and difficulty passing a nasal catheter. Oral airway
insertion relieves respiratory difficulties. Diagnosis confirmed by contrast study or CT scan
Surgical correction by perforating or drilling the atresia requires postoperative nasal stents
Pierre Robin sequence
Consists of protruding tongue, small mouth and jaw, and cleft palate
Incidence approximately 1:2000
Problems include obstructive apnoea, difficulty with intubation and aspiration
To maintain airway patency and prevent obstructive apnoea, prone position should be used initially;
if this fails an oral airway should be inserted. Intubation may be needed in severe cases who may
eventually require tracheostomy
Glossopexy and other surgical procedures have been attempted with some degree of success
Gradual resolution of airway problems occurs as partial mandibular catch-up growth progresses
during the first few years of life
Laryngomalacia
Most common cause of stridor in the first year of life
Inspiratory stridor increases with supine position, activity, crying and upper respiratory tract
infections
Usually resolves during the second year of life
Upper airway endoscopy is merited if persistent accessory muscle use occurs, with recurrent
apnoea or faltering growth
Subglottic stenosis
May be congenital but usually acquired
Risk factors for acquired subglottic stenosis
Prematurity
Recurrent reintubation
Prolonged intubation
Traumatic intubation
Inappropriately large or small endotracheal tube

Black babies (keloid scar formation)
Oral as opposed to nasal intubation (this is a theoretical but unproven factor)
Infection
Severity is categorized by the MyerCotton staging:
Grade 1 <50% obstruction

Grade 2 5170% obstruction
Grade 3 7199% obstruction
Grade 4 total obstruction
Systemic steroids may facilitate extubation in mild to moderately severe subglottic stenosis. Laser or
cryotherapy to granulomatous tissue seen on upper airway endoscopy may also be of benefit in these
cases. Severely affected babies require surgery anterior cricoid split (laryngotracheal
reconstruction) or tracheostomy.
Tracheomalacia
Causes expiratory stridor

Usually caused by extrinsic compression most commonly as a result of vascular rings
Also associated with tracheo-oesophageal fistula
Surgical treatment of underlying pathology usually leads to resolution, but tracheostomy and
positive-pressure ventilation or CPAP (continuous positive airway pressure) may be required
3.9 Principles of mechanical ventilation in neonates

Aims are to:
ensure adequate oxygenation
adequately remove carbon dioxide to prevent respiratory acidosis
minimize the risk of lung injury (VILI or ventilator-induced lung injury)
Pressure-limited, time-cycled ventilation (PLV) is used most commonly via either an oral or a nasal
endotracheal tube. Patient-trigger modes may improve synchronization with the babys own
respiratory efforts, thus improving oxygenation, reducing the risk of air leak and facilitating
weaning from the ventilator
Volume-targeted ventilation (VTV) is now being used more commonly because of advances in
ventilator technology, along with recent evidence from RCTs suggesting a reduction in several
important clinical outcomes with VTV compared with PLV, including:
Combined death or bronchopulmonary dysplasia (BPD)
Pneumothorax
Hypocapnia
Combined periventricular leukomalacia (PVL) or severe intraventricular haemorrhage (IVH)
Time on ventilator
High-frequency oscillation may be used initially for any cause of neonatal respiratory failure, but is
most often used as rescue in severe cases where conventional ventilation has failed
Nasal CPAP is often used in preterm babies once extubated. This maintains functional residual
capacity and reduces the work of breathing
3.10 Extracorporeal membrane oxygenation

A membrane lung is used to rest the lungs and allow them to recover in severe respiratory failure.
Extracorporeal membrane oxygenation (ECMO) may be:
Venoarterial (VA) blood removed from right atrium (usually via right internal jugular vein) and
returned via a common carotid artery
Venovenous (VV) a double-lumen, right atrial cannula is used
ECMO should be considered in severe neonatal respiratory failure if:
Lung disease is reversible

Infant is >35 weeks gestation
Weight > 2 kg
Cranial ultrasound scan shows no intraventricular haemorrhage > grade 1
No clotting abnormality
Oxygenation index >40 (see below)
Oxygenation index (OI) is used to quantify the degree of respiratory failure. It is measured as:
OI = (Mean airway pressure FiO2 100) PO2
where mean airway pressure is in cmH2O, FiO2 (fractional inspired oxygen) is a fraction and PO2 is
in mmHg (note that to convert kPa to mmHg, multiply by 7.6).
OI >25 indicates severe respiratory failure
OI >40 indicates very severe respiratory failure with a predicted mortality rate of >80% with
conventional treatment therefore consideration to refer for ECMO is appropriate
Other measures of the degree of respiratory failure that can be used include:
Alveolararterial oxygen difference (AaDO2)
AaDO2 = (716 FiO2) PCO2/0.8) PO2
A normal AaDO2 is <50 mmHg.
If >600 mmHg for successive blood gases over 6 hours, then there is severe respiratory failure
with predicted mortality rate >80% with conventional treatment
Ventilation index (VI) = PCO2 RR PIP/1000, where RR is the respiratory rate and PIP is the
peak inspiratory pressure:

VI > 70 indicates severe respiratory failure
VI > 90 indicates very severe respiratory failure suitable for consideration of ECMO
4. CARDIOVASCULAR PROBLEMS
4.1 Patent ductus arteriosus (PDA)
Uncommon in term infants after 12 days
Often presents around third day of life in VLBW infants because left-to-right shunt increases as
pulmonary vascular resistance falls; approximately 40% of VLBW infants with surfactant
deficiency have clinically significant PDA on day 3 of life
Clinical signs systolic or continuous murmur, bounding pulses, wide pulse pressure, active
precordium, and possibly signs of cardiac failure and reduced lower body perfusion
A clinically significant PDA in VLBW infants is associated with an increased risk of:
Pulmonary haemorrhage
Chronic lung disease
IVH
Mortality
Early treatment of PDA with indometacin has been shown to reduce NEC and chronic lung disease
Ibuprofen is likely to be equally effective in closing PDA but has fewer side effects than
indometacin (less NEC and transient renal failure)
4.2 Hypotension
Causes of hypotension in neonates
Hypovolaemia:
Antenatal acute blood loss:
Placental abruption
Placenta praevia
Maternofetal haemorrhage
Twin-to-twin transfusion (usually not acute)
Vasa praevia
Postnatal acute blood loss:
Internal
Intracranial haemorrhage
Intra-abdominal haemorrhage
Intrathoracic/pulmonary haemorrhage
Severe bruising
External:
Dislodged vascular lines

Excessive water loss:
High urine output
High insensible losses common in extreme prematurity
Third spacing:
Hydrops
Pleural effusions
Ascites
Postoperative
Vasodilatation:
Common in preterm infants
Sepsis
Drug induced (tolazoline, prostaglandins, prostacyclin)
Cardiogenic:
Myocardial dysfunction:
Perinatal asphyxia
Metabolic acidosis
Congenital heart disease:
Hypoplastic left heart
Other single-ventricle physiological conditions
Arrhythmias:
Supraventricular tachycardia
Complete heart block
Reduced venous return:
Pulmonary air leak
Pericardial effusion/tamponade
Lung hyperinflation (more common in high-frequency oscillation or with high positive endexpiratory pressure [PEEP])
4.3 Hypertension
Causes of hypertension in neonates
Vascular:
Renal artery thrombosis (associated with umbilical artery catheterization)
Aortic thrombosis (associated with umbilical artery catheterization)
Renal vein thrombosis (more common in infants of mothers with diabetes)
Coarctation of aorta
Middle aortic syndrome
Renal:
Obstructive uropathy
Dysplastic kidneys
Polycystic kidney disease
Renal tumours
Intracranial hypertension
Endocrine:
Hyperthyroidism
Neuroblastoma
Phaeochromocytoma
Drug induced:
Systemic steroids
Inotropes
Maternal cocaine
.4 Cyanosis in the newborn

Causes of cyanosis in neonates
Congenital cyanotic heart disease:
Transposition of the great arteries
Pulmonary atresia
Critical pulmonary stenosis
Severe tetralogy of Fallot
Tricuspid atresia
Ebstein anomaly
Truncus arteriosus
Total anomalous pulmonary venous drainage
Hypoplastic left heart syndrome
Respiratory disease
Methaemoglobinaemia:
Arterial PO2 is normal
Can be congenital:
NADH-methaemoglobin reductase deficiency (autosomal recessive)
Haemoglobin M (autosomal dominant)
Can be iatrogenic:
Secondary to nitric oxide therapy
Nitrate or nitrite ingestion
Treat with intravenous methylene blue
Acrocyanosis and facial bruising also give the appearance of cyanosis
5. GASTROENTEROLOGY AND NUTRITION

5.1 Necrotizing enterocolitis
Incidence varies occurs in about 10% of VLBW infants.
Risk factors
Prematurity
Antepartum haemorrhage
Perinatal asphyxia
Polycythaemia
PDA
PROM
Early enteral feeding has also been suggested because NEC rarely occurs in infants who have not
been fed. However, RCTs suggest that early feeding with small amounts of breast milk is beneficial.
The incidence of NEC in preterm infants is 610 times higher in those fed formula milk compared
with those given breast milk. There is some evidence that enteral vancomycin before initiating milk
feeds reduces the incidence of NEC.
The severity of NEC can be classified using the Bell staging:
Stage1 suspected NEC

General signs temperature instability, lethargy, apnoea
Increased gastric aspirates, vomiting, abdominal distension
Stage 2 confirmed NEC

Stage 1 signs, plus
Upper or lower gastrointestinal bleeding
Intramural gas (pneumatosis intestinalis) or portal vessel gas on abdominal radiograph
Stage 3 severe NEC

Stage 1 and 2 signs, plus
Signs of shock, severe sepsis and/or severe gastrointestinal haemorrhage
Bowel perforation
Complications
Perforation occurs in 2030% of confirmed NEC cases

Overwhelming sepsis
Disseminated intravascular coagulation (DIC)
Strictures occur in approximately 20% cases of confirmed NEC
Recurrent NEC occurs in <5% cases (consider Hirschsprung disease)
Short-bowel syndrome after extensive resection

Lactose intolerance
Medical management
Cardiorespiratory support as required

Stop enteral feeds for 714 days (depending on the severity of illness)
Nasogastric tube on free drainage
Give intravenous fluids/total parenteral nutrition (TPN)
Give intravenous antibiotics
Treatment of thrombocytopenia, anaemia, DIC
Serial abdominal radiographs (to exclude perforation)
Surgical management, may include

Placement of peritoneal drain
Early laparotomy with resection of bowel ileostomy/colostomy; indications for early surgery
include perforation or failing medical management
Late laparotomy bowel resection; most common indication is stricture formation confirmed with
contrast radiographs
5.2 Composition of infant milks
Note that cows milk has an increased casein:lactalbumin ratio (4:1 compared with 2:3 in breast
milk).
5.3 Breast-feeding
Physiology
A surge in maternal prolactin (from the anterior pituitary) occurs immediately postpartum, which
stimulates milk production
Suckling stimulates prolactin receptors in the breast and oxytocin release (from the posterior
pituitary). Oxytocin facilitates the let-down reflex by contraction of breast myoepithelial cells
Colostrum is produced over the first 24 days. Subsequent milk production is controlled mainly by
the amount of suckling or expression
Benefits of breast-feeding
Complications
Mother breast engorgement, breast abscess, poor milk production
Baby poor weight gain/initial excessive weight loss, breast milk jaundice
Drugs contraindicated in breast-feeding mothers
Amiodarone
Antimetabolites (chemotherapy drugs)
Atropine
Chloramphenicol
Dapsone
Doxepin
Ergotamine
Gold
Indometacin
Iodides
Lithium
Oestrogens (decrease lactation)
Opiates (high dose should be avoided but weaning to a low dose may facilitate withdrawal in
infant)
Phenindione
Vitamin D (risk of hypercalcaemia with high dose)
Maternal drugs that should be used with caution/monitoring if breast-feeding
Some antidepressants
Some antihistamines
Carbamazepine
Carbimazole
Clonidine
Co-trimoxazole
Ethambutol
Histamine antagonists
Isoniazid
Gentamicin
Metronidazole (makes milk taste bitter)
Oral contraceptives
Phenytoin
Primidone
Theophylline
Thiouracil
If in doubt refer to British National Formulary or discuss with a pharmacist.
5.4 Fluid and nutritional requirements in neonates

Well term babies require little in the way of fluid and calorie intake during the first few days of life.
Subsequently, over the next few months of life, there is an average fluid intake of approximately 150
ml/kg per 24 hours but this may vary considerably.
Sick or preterm babies are likely to have reduced but variable fluid requirements, and initial fluid
and electrolyte provision should facilitate postnatal weight loss with negative water and sodium
balance. Failure to do this is likely to increase the risk of complications such as PDA, pulmonary
haemorrhage, NEC and chronic lung disease. Close monitoring of fluid balance and individualized
fluid and electrolyte prescription using daily weight, urine output, serum sodium and creatinine are
essential, particularly in sick, extremely preterm infants.
Daily nutritional requirements per kilogram for stable, growing, preterm babies are approximately as
follows:
Protein 3.03.8 g
Energy 110120 kcal
Carbohydrates 3.811.8 g
Fat 520% of calories
Sodium 23 mmol
Potassium 23 mmol
Calcium 23 mmol
Phosphate 1.944.52 mmol
+ other minerals (iron, zinc, copper etc.), trace elements (selenium, manganese etc.) and vitamins

This may be partial, if the baby takes some enteral feeds, or it may be TPN. Indications for TPN
include milk intolerance, poor gut motility (common in extreme prematurity), NEC, postoperative
(congenital malformations, NEC, etc.).
Parenteral nutrition consists of:
Protein up to 3.5 g/kg per day of amino acids (mainly essential amino acids)
Carbohydrates up to 18 g/kg per day. Parenteral nutrition should be given via a central venous
line if dextrose concentration >12.5%
Lipids soya bean oil emulsions (e.g. Intralipid) provide essential fatty acids, a concentrated
source of calories and a vehicle for delivering fat-soluble vitamins; 20% Intralipid is tolerated
better than 10%. Regular monitoring of plasma lipid levels is recommended. SMOF lipid is a
newer preparation which contains soya oil, medium-chain triglycerides, olive oil and fish oils and
has been shown to improve liver function compared with a pure soya-bean oil preparation
Water
Minerals sodium, potassium, calcium, phosphate, magnesium
Trace elements zinc, copper, manganese, selenium, etc.
Water-soluble vitamins
Fat-soluble vitamins
Complications of parenteral nutrition in neonates include:
Sepsis mainly intravenous line related (bacterial/fungal)

Intravenous line extravasation
Venous thrombosis (line related)
Fluid/electrolyte imbalance
Hyperlipidaemia
Nutritional deficiencies
Cholestatic jaundice
See also Chapter 10, Section 3.3.
5.6 Congenital abnormalities of the gastrointestinal system

Oesophageal atresia and tracheo-oesophageal fistula
Occurs as a result of the failure of development of the primitive foregut
Incidence is approximately 1:3000:
85% blind proximal oesophageal pouch with a distal oesophageal to tracheal fistula
10% oesophageal atresia without fistula
5% proximal distal fistula
Polyhydramnios
Excessive salivation
Early respiratory distress
Abdominal distension
Vomiting/choking on feeds
Inability to pass nasogastric tube
Absence of gas in gut on radiograph if no tracheo-oesophageal fistula
Other anomalies in 3050% VACTERL (vertebral, anal, cardiac, tracheo-oesophageal fistula,
ears, renal, limb), rib anomalies, duodenal atresia
Prematurity common
Management
Respiratory support as needed
Riplogle tube (large-bore, double-lumen suction catheter) on continuous suction is placed in the
proximal oesophageal pouch
Surgical management includes early division of the fistula and early or delayed oesophageal
anastomosis. This depends on the distance between the two ends of atretic oesophagus for wide
gaps, delayed anastomosis to allow growth may improve outcome. Cervical oesophagostomy or
colonic transposition may also be used in this situation.
H-type tracheo-oesophageal fistula (tracheo-oesophageal fistula without oesophageal atresia) is
much less common and is usually not associated with preterm birth or other severe anomalies. It may
present in the neonatal period or later with respiratory distress associated with feeding, or recurrent
lower respiratory infections.
Duodenal atresia
Approximately 70% are associated with other congenital anomalies (trisomy 21, congenital heart
disease, malrotation, etc.)
Often diagnosed antenatally with ultrasound double-bubble or polyhydramnios
Usually presents postnatally with bilious vomiting
Malrotation
Occurs as a result of incomplete rotation of the midgut in fetal life resulting in intermittent and
incomplete duodenal obstruction by Ladd bands
Associated with diaphragmatic hernia, duodenal and other bowel atresias and situs inversus
Presents with bilious vomiting and some abdominal distension with sudden deterioration in the
event of midgut volvulus
Upper gastrointestinal contrast studies show the duodenaljejunal flexure on the right of the
abdomen with a high caecum
Meconium ileus
Most common presentation of cystic fibrosis in neonates (1015% cases)
>90% of babies with meconium ileus have cystic fibrosis, so genetic testing for all common
mutations and serum immunoreactive trypsin must be used for confirmation
May present with antenatal perforation, peritonitis and intra-abdominal calcification or postnatally
with intestinal obstruction
Water-soluble contrast enemas may lead to resolution of meconium ileus
Important to distinguish between meconium ileus and meconium plug with meconium plug,
symptoms usually resolve after passage of plug and the problem is not associated with cystic
fibrosis
Anorectal atresia
May have other features of VACTERL association
May be high or low with the puborectalis sling differentiating more likely to be a low lesion in
girls
Colostomy is needed for all high atresias
Renal tract ultrasound scan, micturating cystogram cystoscopy are needed to exclude
rectovaginal, rectourethral or rectovesical fistula or other urinary tract anomaly
High atresias often have problems with faecal incontinence, whereas those with intermediate/low
lesions usually have good outcomes
Occurs as a result of an absence of ganglion cells in either a short or long segment of the bowel; the
rectum and sigmoid colon are most often affected but cases extending to the upper GI tract have
been described
May present with delayed passage of meconium (>24 hours), bowel obstruction relieved by rectal
examination (may be explosive!), enterocolitis or later constipation
Diagnosis is made by rectal biopsy
Regular rectal washouts are required before temporary colostomy formation (usually reversed at 6
months)
Exomphalos (omphalocele)
Results from failure of the gut to return into the abdominal cavity in the first trimester
The defect is covered by peritoneum which may be ruptured at birth
Approximately 75% cases have other congenital anomalies trisomies, congenital heart disease,
Primary or staged surgical closure is required
Topical application of silver sulfadiazine (Flamazine) to promote granulation and epithelialization
of the peritoneal covering of the exomphalos before delayed surgical closure has been shown to
produce good outcomes
Gastroschisis
Incidence in the UK is rising (approximately 1 in 2000 live births) and is now nearly five times as
common as exomphalos
Aetiology unknown but strong association with teenage pregnancy and possibly smoking and
recreational drugs
Much less likely to be associated with other congenital anomalies
Bowel is not covered by peritoneum and therefore becomes stuck together with adhesions; this
leads to functional atresias and severe intestinal motility problems after surgical repair of the
abdominal wall defect

Prognosis is mostly good
6. NEUROLOGICAL PROBLEMS
6.1 Peri-intraventricular haemorrhage
The germinal matrix or layer occurs in the caudothalamic notch of the floor of the lateral ventricles. It
is the site of origin of migrating neuroblasts from the end of the first trimester onwards. By 2426
weeks gestation this area has become highly cellular and richly vascularized. This remains so until
approximately 34 weeks gestation, by which time it has rapidly involuted. The delicate network of
capillaries in the germinal matrix is susceptible to haemorrhage, which is likely to occur with
changes in cerebral blood flow. Preterm infants have decreased autoregulation of the cerebral blood
flow, which contributes to the pathogenesis. In term infants peri-IVH (PIVH) may originate from the
choroid plexus.
Risk factors for PIVH
Prematurity (28% at 25 weeks; <5% after 30 weeks)

Lack of antenatal maternal steroids
Sick and needing artificial ventilation
Hypercapnia
Metabolic acidosis
Pneumothoraces (as a result of increased venous pressure or possibly related to surge in blood
pressure when drained)
Abnormal clotting
Rapid volume infusions (particularly with hypertonic solutions) or increases in blood pressure
with inotropes
Perinatal asphyxia
Hypotension
PDA
Timing of PIVH
50% in first 24 hours

Approximately 1020% days 23
Approximately 2030% days 47
Approximately 10% after the first week
Classification of PIVH
Grade 1 germinal matrix haemorrhage
Grade 2 IVH without ventricular dilatation
Grade 3 IVH with blood distending the lateral ventricle

Grade 4 echogenic intraparenchymal lesion associated with PIVH; previously this was thought to
be an extension of bleeding from the lateral ventricles into the surrounding periventricular white
matter but it is likely to be venous infarction
Several classification systems have been described. The most widely accepted is that of Papile
(above). It may, however, be better to use a more descriptive classification.
Prevention of PIVH
The following have been shown to reduce the incidence of PIVH:
Antenatal steroids
Maternal vitamin K
Indomethacin (but long-term neurodisability is not reduced)
The following have been evaluated but have no proven benefit:
Vitamin E
Ethamsylate
Phenobarbital
Fresh frozen plasma (FFP)
Nimodipine
Clinical presentation of PIVH

Grades 1 and 2 PIVH present silently and are detected by routine ultrasonography
Grade 3 PIVH occasionally presents with shock from blood volume depletion
Grade 4 PIVH may present similarly and occasionally with neurological signs (seizures, hypotonia,
bulging fontanelle)
Sequelae of PIVH
Death
Mortality rate was 59% in one series of large grade 4 PIVH
Post-haemorrhagic ventricular dilatation (PHVD)
Defined as lateral ventricle measurement >4 mm above 97th centile following PIVH
A minority of PIVH cases develop PHVD risk is higher with more severe lesions
Spontaneous resolution occurs in approximately 50% of cases of PHVD; the rest develop
hydrocephalus (i.e. PHVD that requires drainage)
As a sequel to PIVH, communicating hydrocephalus (as a result of malfunction of the arachnoid
villi) is more common than non-communicating hydrocephalus (as a result of blockage of the
cerebral aqueduct)
Early, aggressive intervention with repeated lumbar puncture and/or ventricular taps has not been
shown to be of benefit; drainage should probably be considered if the baby is symptomatic,
cerebrospinal fluid (CSF) pressure is very high (>12 mmHg or 15.6 cmCSF; normal CSF pressure
is 5.25 mmHg or 6.8 cmCSF) or head circumference and/or ventricular measurement on ultrasound
scan is increasing rapidly
Timing of surgical intervention with CSF reservoir or ventriculoperitoneal shunt insertion is
controversial
Drug treatment with acetazolamide with or without diuretics has been shown to be ineffective
Intraventricular fibrinolytic administration is experimental
Adverse neurodevelopment
Cerebral palsy is the most common adverse neurodevelopmental sequel but other and global
problems may also arise
Approximate risk of adverse outcome is as follows:
4% in grades 1 and 2 PIVH if ventricles remain normal size
50% in grade 2 with PHVD or grade 3 PIVH
75% in PIVH requiring shunt
89% with large, grade 4 lesions (difficult to quantify because pathology is varied)

PVL is haemorrhagic necrosis in the periventricular white matter that progresses to cystic
degeneration and subsequent cerebral atrophy. It is often associated with infection
(chorioamnionitis) and may be cytokine mediated. Hypoxia and ischaemia may also play a role. On
ultrasound scan, the initial necrosis appears as echogenicity (often described as flare) within a
few days of the causative insult. This sometimes resolves but it may become a multicystic area
after 14 weeks. The long-term neurological effects are usually bilateral, although initial
ultrasound appearances are sometimes unilateral
Long-term neurodevelopmental effects of cystic PVL are:
Spastic diplegia or tetraplegia (>90%)
Learning difficulties
Seizures (including infantile spasms)
Blindness
Worse outcomes are associated with subcortical PVL. Transient periventricular echodensities are
associated with a risk of spastic diplegia of approximately 510% if they persist for more than 7
14 days
6.3 Neonatal encephalopathy
Neonatal encephalopathy is also known as hypoxicischaemic encephalopathy. The underlying cause

is often unclear but it may originate antenatally, peripartum or postnatally, hence the term perinatal
asphyxia. Other evidence of organ dysfunction often occurs concurrently, especially if the insult
occurs close to the time of birth. Placental insufficiency is a factor in the vast majority of cases.
Pathophysiology of neonatal encephalopathy

Primary and secondary neuronal injuries have been described:
Primary neuronal injury results from energy failure because of the inefficiency of anaerobic
respiration to produce high-energy phosphocreatine and ATP. Glucose utilization increases and
lactic acid accumulates. Energy failure and myocardial dysfunction further exacerbate this, leading
to ion pump failure (Na+/K+-ATPase) and neuronal death as a result of cerebral oedema
Secondary or delayed neuronal injury occurs because there are marked changes in cerebral blood
flow with initial hypoperfusion and then reperfusion after resuscitation. This is associated with
neutrophil activation and is exacerbated by prostaglandins, free radicals and other vasoactive
substances. Excitatory amino acid neurotransmitters such as glutamate and N-methyl D-aspartate
(NMDA) lead to excessive calcium influx and delayed neuronal death. The cellular mechanism for
this may be necrosis or apoptosis (programmed cell death)
This can be staged according to the scheme suggested by Sarnat and Sarnat:
Stage 1 hyperalert, irritable; normal tone and reflexes; signs of sympathetic overactivity; poor
suck; no seizures; symptoms usually resolve <24 hours; good outcome in approximately 99%
Stage 2 lethargic, obtunded, decreased tone and weak suck and Moro reflexes; seizures are
common; approximately 7580% have good outcomes; this is less likely if symptoms persist for >5
days
Stage 3 comatose with respiratory failure; severe hypotonia and absent suck and Moro reflexes;
seizures less common but EEG abnormalities common flat background or burst suppression; over
50% die and majority of survivors have major handicap
Management
Management is largely supportive but recent evidence supports the use of therapeutic hypothermia in
babies >35 weeks gestation.
Therapeutic hypothermia:
Baby cooled to between 33C and 35C by either total body or head-only cooling device
Maximum benefit likely if cooling starts within 6 hours of birth and is continued for 72 hours,
followed by slow warming to normal temperature
RCTs show that the risk of death or severe neurological problems is significantly reduced

Causes of seizures in the newborn
Neonatal encephalopathy
Cerebral infarction:
Usually presents on day 1 or 2
Often presents with focal seizures
Aetiology uncertain but thrombosis secondary to hypercoagulation tendency is a possibility
Outcome good in approximately 50%; the other 50% may develop mono- or hemiplegia or longterm seizure disorder
Intracranial haemorrhage (massive PIVH, subarachnoid or subdural haemorrhage)
Birth trauma (head injury equivalent)
Meningitis
Other sepsis
Congenital infection
Neonatal drug withdrawal
Fifth-day fits (onset day 35, unknown cause, resolve spontaneously)
Hypoglycaemia
Hypocalcaemia
Hypo- or hypermagnesaemia
Inborn errors of metabolism:
Non-ketotic hyperglycinaemia
Sulphite oxidase deficiency
Maple-syrup urine disease
Pyridoxine dependence
Urea cycle defect
Organic acidaemias (e.g. methylmalonic acidaemia)
Structural brain abnormalities (migration disorders, etc.)
Hydrocephalus
Polycythaemia
Neonatal myoclonus not a true seizure, benign and common in preterm infants
Management of neonatal seizures

Investigate for, and treat, underlying condition
Initial treatment with phenobarbital, followed by midazolam, other benzodiazepines and
paraldehyde
Currently no evidence that suppression of clinical or electrographic seizures improves outcome
6.5 Causes of hypotonia in the newborn

Central causes
Neonatal encephalopathy
Infection generalized sepsis, meningitis, encephalitis
Chromosomal abnormalities trisomy 21, 18 or 13
Structural brain abnormalities neuronal migration disorders, etc.
Metabolic disease amino and organic acidaemias, urea cycle defects, galactosaemia, non-ketotic
hyperglycinaemia, peroxisomal disorders, mitochondrial disorders, congenital disorders of
glycosylation, Menkes syndrome
Drugs opiates, barbiturates, benzodiazepines, etc.
Hypothyroidism
Early kernicterus
Spinal cord lesions

Trauma to the cervical spinal cord during delivery usually involves traction and rotation with
forceps
Tumours, cysts and vascular malformations of spinal cord
Spinal muscular atrophy

Myasthenia gravis
6.6 Retinopathy of prematurity

Retinopathy of prematurity (ROP) consists of vascular proliferation secondary to retinal
vasoconstriction. This may progress and lead to fibrosis and scarring
Prematurity and hyperoxia are known associations, but other factors, including hypoxia, are also
implicated
Babies <32 weeks gestation at birth and <1500 g birthweight should be screened by
ophthalmological examination from 30 weeks corrected gestational age
ROP should be described by stage, location, extent and presence of additional disease
ROP stages
Stage 1 demarcation line
Stage 2 ridge
Stage 3 ridge with extraretinal fibrovascular proliferation
Stage 4 subtotal retinal detachment
Stage 5 total retinal detachment
Stages 1 and 2 disease resolves without risk of visual impairment if there is no progression
Stage 3 disease increases the risk of visual impairment
Stages 4 and 5 always lead to visual impairment
ROP location
Zone 1, 2 or 3 (where zone 1 is the most central [i.e. posterior] around the optic disc)
The risk is greatest if zone 1 is affected
ROP extent is described in terms of the number of clock hours.
Plus disease includes tortuosity of the retinal vessels, pupil rigidity and vitreous haze.
Usually stage 3 plus disease should be treated with either cryotherapy or laser therapy, but location
and extent of ROP also determine the need for treatment.
See also Chapter 20.
7. GENITOURINARY PROBLEMS
7.1 Congenital abnormalities of the kidneys and urinary tract
Nephrogenesis (branching and new nephron induction) continues up to 36 weeks gestation, but
glomerular filtration rate is still <5% of adult values at this stage. This increases rapidly in the first
week and then more gradually over the next 2 years to adult values.
The renal function of a neonate is limited by:
Renal blood flow

Glomerular filtration rate
Tubular concentrating and diluting ability
Tubular excretion
Urine output
More than 90% of neonates pass urine within 24 hours of birth. The collecting ducts have increased
sensitivity to antidiuretic hormone (ADH) after birth and urine-concentrating ability increases
rapidly.
Preterm infants have immature tubular function, leading to a high fractional excretion of sodium and
high sodium intake requirements.
Antenatally, congenital renal abnormalities may present with:

Oligohydramnios (Potter syndrome if severe)
Urinary ascites as a result of obstructive uropathy
Other abnormalities seen on antenatal ultrasound scan include:
Obstructive uropathy dilated renal tracts
Cystic dysplasia/polycystic disease
Posterior urethral valves
Mucosal folds in posterior urethra of male infants leading to dilatation of renal tract proximal to
obstruction
Bladder is often hypertrophied
Diagnosed by micturating cystourogram
Suprapubic catheter is inserted initially, followed by surgical resection by cystoscopy or
vesicostomy, followed by later resection
Pelviureteric junction (PUJ) obstruction
Usually unilateral
Diagnosed on antenatal ultrasound scan or presents with abdominal mass
Gross hydronephrosis is associated with decreased renal function (confirmed with 99mTc-labelled
MAG-3 (mertiatide) renogram); nephrectomy is usually required. Ureteroplasty is carried out for
milder cases
Mild renal pelvis dilatation

Should be confirmed on postnatal ultrasound scan and investigated with a micturating cystourogram
to exclude reflux nephropathy, which is a risk for recurrent urinary tract infection and subsequent
scarring
Prune-belly syndrome (megacystismegaureter)

Lax abdominal musculature, dilated bladder and ureters, and undescended testes
Neurogenic bladder
Usually as a result of abnormalities of lumbosacral spine
Ureterocele
Dilatation of distal ureter leading to obstruction
Urethral stricture
Tumours (neuroblastoma, Wilms tumour)

See Chapter 12, Sections 11.6 and 11.7.
7.2 Haematuria in the newborn

Causes of haematuria in the newborn

Acute tubular necrosis
Renal artery or vein thrombosis
Renal stones
Trauma
Tumours
Cystic dysplasia and other malformations
Abnormal clotting
7.3 Causes of acute renal failure in neonates

Prerenal
Hypotension
Dehydration
Indomethacin
Renal
Cystic dysplasia and infant polycystic kidney disease

Renal artery/vein thrombosis
Congenital nephrotic syndrome
DIC
Nephrotoxins, e.g. gentamicin
Postrenal
Obstructive nephropathy
See Section 1.5 for embryology of sexual differentiation.

On examination, note the following:
If gonads are palpable they are nearly always testes
Length of phallus if <2.5 cm stretched length in a term baby it is unlikely that the baby can
function as a male
Severity of hypospadias and fusion of labia
Other dysmorphic features/congenital abnormalities
The parents should be told that the childs sex is uncertain at this stage and that the genitalia are not
normally/completely formed. Prompt diagnosis and appropriate management are essential to resolve
this and to exclude or treat congenital adrenal hyperplasia before electrolyte imbalances occur. Also
gonadal tumours may be a risk.
True hermaphroditism:
Testes and ovaries both present (rare)
Male pseudohermaphroditism underdevelopment ( virilization) of male features:
Androgen insensitivity (= testicular feminization) most common
Defects in testosterone synthesis
Some forms of congenital adrenal hyperplasia
Panhypopituitarism (should be suspected if hypoglycaemia is also present)
Defects in testosterone metabolism (5-reductase most common)
Defects in testicular differentiation (rare)
Female pseudohermaphroditism virilization of female:
Congenital adrenal hyperplasia most common enzyme deficiency is 21-hydroxylase deficiency
( 17-hydroxyprogesterone)
Chromosomal abnormalities:
45X/46XY mosaicism (rare)
Investigations
Karyotype
Daily electrolytes until diagnosis is established
Blood pressure monitoring
Blood sugar monitoring
Abdominal ultrasound scan
Serum hormone assay 17-hydroxyprogesterone, 11-deoxycortisol, testosterone, estradiol,
progesterone, luteinizing hormone, follicle-stimulating hormone
Urine steroid profile
Genitogram/micturating cystourogram
8. INFECTION
8.1 Bacterial infection
Group B streptococcus (GBS)
Up to 20% of pregnant women have genital tract colonization with GBS
Three serotypes have been identified
Neonatal GBS infection may be early (within first few days, usually presenting by 24 hours) or late
(after first week, usually at 34 weeks)
Early disease often presents with septicaemia and respiratory distress (pneumonia or persistent
pulmonary hypertension of the newborn)
Late disease is usually septicaemia or meningitis may be vertical or nosocomial transmission;
antibiotics given intrapartum or in first few days do not always prevent late GBS disease
Serotype 3 is more common in late-onset GBS disease or meningitis if this is part of early onset
disease
Escherichia coli
Usually causes vertical infections in neonates and is often associated with preterm birth; can also
cause nosocomial infection
K1 capsular antigen is the most common serotype
Septicaemia and meningitis are the most common presentations if vertically transmitted; urinary
tract infections and NEC have been noted in nosocomial E. coli sepsis in neonates
Coagulase-negative staphylococci
Most common nosocomial pathogen in neonatal intensive care units
VLBW infants with indwelling catheters are most at risk
Often resistant to flucloxacillin
Gram-positive rod
Outbreaks have been caused by dairy products, coleslaw, pt and undercooked meat
May present with a flu-like illness in pregnant women and then lead to stillbirth or severe neonatal
septicaemia and meningitis
Early and late-onset disease have been noted, similar to GBS
Early onset disease is associated with preterm birth and meconium-stained amniotic fluid (which
is in fact often pus rather than meconium)
A maculopapular or pustular rash is typical
Amoxicillin and gentamicin are the antibiotic combination of choice
Other bacterial pathogens in neonates include
Haemophilus influenzae
Klebsiella spp.
Pseudomonas spp.
Pneumococci
Risk factors for vertically acquired bacterial sepsis
Preterm rupture of membranes

Prolonged rupture of membranes (>1224 h)
Maternal fever (>38C or other signs of chorioamnionitis, e.g. white cell count > 15 109/l)
Maternal colonization with GBS
Fetal tachycardia
Lack of intrapartum antibiotics in the presence of above risk factors
Foul-smelling amniotic fluid
Preterm birth/low birthweight
Twin pregnancy
Low Apgar scores
Risk factors for nosocomial sepsis
Prematurity/low birthweight
SGA infants
Neutropenia
Indwelling catheters
TPN
Surgery
8.2 Congenital viral infection

Cytomegalovirus
Member of the Herpesviridae family (DNA virus)
Transmitted by close personal contact, blood products or breast-feeding. May also be sexually
transmitted
Causes mild symptoms in healthy adults or children
Up to 1% of pregnancies are affected but symptoms occur in less than 10% of those infected
Primary infection or reactivation may occur in affected pregnancies
Symptoms in affected neonates include:
IUGR
Prematurity
Hepatosplenomegaly
Thrombocytopenia
Anaemia
Jaundice (raised conjugated and unconjugated bilirubin often prolonged)
Pneumonitis
Microcephaly
Intracranial calcification
Choroidoretinitis
Osteitis
Long-term neurodevelopmental sequelae are common and include cerebral palsy, learning
disability, epilepsy, blindness and deafness
Diagnosis
Rising specific IgG antibodies in mother or baby

Specific IgM may be raised for up to 16 weeks after primary infection
Virus can be isolated from urine or throat swab
Detection of early antigen fluorescent foci (DEAFF) is a newer technique used to detect viral
antigen from urine and other body fluids
Aciclovir has been used with some success in immunosuppressed adults but may be toxic in
neonates and is not of proven efficacy
Rubella
First-trimester infection of the fetus results in congenital rubella syndrome. The most common
features of this are:
Cataracts
Deafness
IUGR, microcephaly, hepatosplenomegaly, thrombocytopenia, choroidoretinitis and osteitis may also
occur similar to congenital CMV infection. Immunization of children has virtually eradicated
congenital rubella in the UK.
Parvovirus
Parvovirus is a DNA virus. Serotype B19 causes epidemics of erythema infectiosum (slapped
cheeks syndrome or fifth disease) in the winter months. Fetal infection, particularly in the first
trimester, leads to severely decreased red cell production and subsequent severe fetal anaemia,
resulting in heart failure and non-immune hydrops. Fetal blood can be used to confirm the diagnosis
by viral antigen detection with polymerase chain reactions. Fetal blood transfusions may reverse
hydrops and improve outcome.
Neonatal human immunodeficiency virus
Vertically transmitted HIV is the most common cause of childhood AIDS. Approximately a third of
infections are transmitted across the placenta and two-thirds during birth. Babies of all HIV-positive
mothers are also seropositive initially because IgG crosses the placenta. Non-infected infants become
negative by 9 months. There is no evidence of HIV causing an embryopathy. Babies are usually
initially asymptomatic but may present with hepatosplenomegaly and thrombocytopenia in the
neonatal period. The following increase the risk of vertical transmission:
Low maternal CD4 count

High maternal viral load
Presence of p24 antigen in the mother
Preterm birth
Rupture of membranes >4 hours
Vaginal birth
No maternal antiretroviral treatment/poor compliance
Maternal zidovudine (AZT) during the third trimester and labour and given to the infant for 6 weeks
postnatally reduces transmission rate from 25.5% to 8.3%. Other measures leading to avoidance of
above risk factors have been shown to reduce risk further to well under 5%.
Immunizations should be given routinely to infants of HIV-positive mothers with the following
cautions:
Give killed (Salk) rather than live (Sabin) polio vaccine
Give BCG early
Hepatitis B virus
Babies of women who are hepatitis B surface antigen (HbsAg) positive or who have active
hepatitis B during pregnancy should all receive hepatitis B vaccine in the neonatal period, and at 1
and 6 months
Hepatitis B immunoglobulin should be given within 48 hours of birth to all babies of mothers who
are HbsAg positive apart from those with the hepatitis B e antibody
Breast-feeding is not contraindicated
8.3 Fungal and protozoal infections

Candida albicans
Candida sp. may cause superficial mucocutaneous infection or severe systemic sepsis, particularly in
extremely preterm infants. Amphotericin, flucytosine and fluconazole may be used to treat severe
fungal infections.
Toxoplasmosis
Toxoplasma gondii is a unicellular, protozoan parasite

Cats are the definitive hosts. Infection of humans occurs following ingestion of sporocysts after
handling cat faeces, contaminated vegetables or undercooked meat
Toxoplasmosis is a mild illness in healthy adults
Congenital infection is more likely with increasing gestation as the placenta provides less of a
barrier with age. However, severe infection becomes less likely, falling from 75% in the first
trimester to <5% in the third
Severe congenital toxoplasmosis causes:
IUGR
Preterm birth
Hydrocephalus and sequelae
Choroidoretinitis
Intracranial calcification
Hepatitis
Pneumonia
Myocarditis
Babies born with no symptoms may go on to develop choroidoretinitis after months or even years.
Serological diagnosis is made by specific IgG and IgM titres. Treatment of affected pregnant women
with spiramycin reduces the rate of transmission to the fetus but does not reduce the severity of
disease. Affected infants are treated with pyrimethamine and sulfadiazine for up to 1 year.
9. NEONATAL ENDOCRINE PROBLEMS

9.1 Neonatal hypoglycaemia
Definition blood glucose S2.6 mmol/l.
Normal term babies commonly have blood sugars <2.6 mmol/l, particularly in the first 24 hours
(especially if the baby is breast-fed), but are not at risk of any long-term sequelae because they can
utilize alternative fuels (e.g. ketones, lactate). It is therefore unnecessary to perform blood glucose
analysis on healthy term babies.
Infants at risk of clinically relevant hypoglycaemia include:
Those with increased demand/decreased supply, i.e.
Preterm
IUGR
Hypothermia
Infection
Asphyxia
Polycythaemia
Hyperinsulinism:
Infant of a mother with diabetes
Transient neonatal hyperinsulinism
Persistent hyperinsulinaemic hypoglycaemia of infancy (previously called nesidioblastosis)
Islet cell adenoma
Endocrinopathies:
Pituitary (e.g. growth hormone deficiency, septo-optic dysplasia)
Adrenal (e.g. congenital adrenal hyperplasia)
Carbohydrate metabolism disorders:
Glycogen storage disease
Galactosaemia
Amino acidopathies
Organic acidaemias
Fat oxidation defects:
Deficiencies of medium-chain and very-long-chain acyl-coenzyme A dehydrogenases (MCADD
and VLCAD), long-chain hydroxyacyl-coenzyme A dehydrogenase (LCHAD)
Babies at risk of clinically significant hypoglycaemia should be treated immediately with intravenous
dextrose (2 ml/kg 10% dextrose followed by intravenous infusion) if blood glucose is <1.5 mmol/l.
9.2 Panhypopituitarism
Presents with:
Persistent hypoglycaemia
Poor feeding
Micropenis
Hyperbilirubinaemia (conjugated)
Midline facial defects (cleft palate etc.)
Optic atrophy
Low growth hormone, cortisol (may cause hyponatraemia) and thyroid-stimulating hormone
9.3 Adrenal insufficiency

Causes include:
Congenital adrenal hyperplasia:
Most common cause is 21 -hydroxylase deficiency (may or may not involve salt loss)
May be X-linked or autosomal recessive inheritance
SmithLemliOpitz syndrome
Wolman syndrome (liposomal acid lipase deficiency)

Adrenal haemorrhage
Secondary causes:
Panhypopituitarism
Withdrawal from steroid treatment
Management of salt loss is an initial priority, followed by glucocorticoid (hydrocortisone) and
mineralocorticoid (fludrocortisone) replacement.
10. NEONATAL JAUNDICE

10.1 Physiological jaundice
Jaundice becomes visible when serum bilirubin is >80100 mol/l and up to 65% term infants
become clinically jaundiced. However, only 1.2% become sufficiently jaundiced to require treatment
(i.e. >340 mol/l). Physiological jaundice occurs as a result of:
Increased haemolysis:
Bruising
Antibody induced
Relative polycythaemia
Lifespan of red blood cells (in term infants 70 days, in preterm infants 40 days)
Immature hepatic enzyme systems
Shunt bilirubin from breakdown of non-red blood cell haem pigments
Enterohepatic circulation
Breast-fed babies have higher maximum serum bilirubin levels and remain jaundiced for longer.
10.2 Causes of non-physiological jaundice

Jaundice is considered non-physiological if any of the following are present:
Onset before 24 hours of age

Serum bilirubin >270 mol/l
Lasting >14 days (>21 days in preterm infants)
Associated pathological conditions that are known to cause jaundice
Causes of non-physiological jaundice (unconjugated hyperbilirubinaemia):

Haemolysis:
Isoimmunization (Rh, ABO, other)
Spherocytosis, etc.
Glucose-6-phosphate dehydrogenase or pyruvate kinase deficiency

Sepsis
-Thalassaemia
Polycythaemia
Extravasated blood
Increased enterohepatic circulation
Endocrine/metabolic
Rare liver enzyme deficiencies (CriglerNajjar syndrome, etc.)

May be caused by rhesus D (Rh) incompatibility (mother RhD negative, baby RhD positive) or by
other antibodies (c, E, Kell, Duffy, etc.). Approximately 15% of the UK population are RhD negative.
Sensitization occurs from previous pregnancy, antepartum haemorrhage, trauma or antenatal
procedure.
Prevention of haemolytic disease is by the following:
Intramuscular anti-D is given after any possible event leading to sensitization in RhD-negative
women
Maternal serum screening for antibodies at booking with re-testing between 28 and 36 weeks for
RhD-negative women with no antibodies
Referral to a specialist fetal medicine centre for all those with significant levels of antibodies;
initially antibody levels are measured but correlate poorly with the degree of fetal anaemia above
a certain threshold; once this is reached, further monitoring is by ultrasound scanning to detect
signs of hydrops, amniocentesis and spectrophotometric estimation of bilirubin in the amniotic
fluid or fetal blood sampling to detect anaemia
Serial fetal blood transfusions in severe cases
Preterm delivery
Conjugated hyperbilirubinaemia
Causes of conjugated hyperbilirubinaemia:
TPN cholestasis
Viral hepatitis (hepatitis B virus, CMV, herpesvirus, rubella, HIV, Coxsackievirus, adenovirus)
Other infection (toxoplasmosis, syphilis, bacterial)
Haemolytic disease (due to excessive bilirubin)
Metabolic (1-antitrypsin deficiency, cystic fibrosis, galactosaemia, tyrosinaemia, Gaucher disease
and other storage diseases, rotor syndrome, DubinJohnson syndrome)
Biliary atresia
Choledochal cyst
Bile duct obstruction from tumours, haemangiomas, etc.
Note that levels of conjugated bilirubin >25 mol/l should be investigated.
10.3 Management of non-physiological unconjugated hyperbilirubinaemia

The aim of management is to reduce the risk of kernicterus and NICE guidelines have been developed
recently for this purpose, with treatment thresholds that vary according to clinical risks present.
Measurement of bilirubin
Visual inspection alone is not sufficient to estimate the level of bilirubin in a jaundiced baby
Use of a transcutaneous bilirubinometer is recommended in babies >35 weeks gestation and >24
hours old
Serum bilirubin should be measured if <35 weeks gestation, <24 hours old or if transcutaneous
level >250 mol/l
Treatment thresholds are lower for babies who are sick, preterm, have evidence of haemolysis or
rapidly rising serum bilirubin (>200 mol/l per 24 h).
Phototherapy
This is used to treat moderately severe unconjugated hyperbilirubinaemia. Phototherapy photooxidizes and isomerizes bilirubin, facilitating increased excretion via urine and bile.
Intensive phototherapy (i.e. concurrent use of more than one phototherapy device) is used for high
levels of bilirubin pending exchange transfusion or to avoid the need for exchange transfusion as
levels become too close to the threshold for this.
Complications of phototherapy are mainly minor and include:
Diarrhoea
Transcutaneous fluid loss
Rashes
Exchange transfusion
This is used to treat severe unconjugated hyperbilirubinaemia, often with concomitant anaemia, most
commonly as a result of haemolysis. The procedure dilutes bilirubin, removes sensitized red blood
cells and corrects anaemia.
Usually a double-volume exchange transfusion is performed via arterial and central venous lines over
12 hours, replacing the babys blood volume twice with donor blood.
Complications of exchange transfusion include:
Infection and other line-related complications
Fluid and electrolyte disturbance

Thrombocytopenia and coagulopathy
Transfusion reaction
Intravenous immunoglobulin (IVIG) (500 mg/kg over 4 h) is recommended as an adjunct to intensive
phototherapy and exchange transfusion in haemolytic disease or ABO incompatibility if the serum
bilirubin continues to rise rapidly (i.e. >200 mol per 24 h).
10.4 Prolonged jaundice

This is defined as jaundice lasting more than 14 days in term babies and more than 21 days in preterm
babies. NICE guidelines recommend that in preterm and term babies with prolonged jaundice:
Look for pale, chalky stools and/or dark urine that stains the nappy
Measure the conjugated bilirubin
Carry out a full blood count, blood group determination, DAT and urine culture
Ensure that routine metabolic screening has been performed
Follow expert advice about care for babies with a conjugated bilirubin level >25 mol (see
Chapter 12)
11. NEONATAL HAEMATOLOGY/COAGULATION PROBLEMS

11.1 Polycythaemia
See also Chapter 12, Section 10.2.
Definition haematocrit >65%.
Causes
IUGR
Maternal diabetes
Delayed cord clamping
Twin-to-twin transfusion
Maternofetal transfusion
Trisomies (13, 18, 21)
Endocrine disorders (congenital adrenal hyperplasia, thyrotoxicosis, Beckwith syndrome)
Complications
Hypoglycaemia
Jaundice
NEC
Venous thromboses
Stroke
Treatment
Treatment is recommended if the haematocrit is >65% and the patient is symptomatic. A partial
dilutional exchange transfusion should be carried out using physiological (0.9%) saline.
11.2 Haemorrhagic disease of the newborn and vitamin K

Results from relative deficiency of factors II, VII, IX and X and is prevented by vitamin K
Breast milk contains inadequate amounts of vitamin K, so the recommendation in the UK is to give
all babies either a single intramuscular injection of vitamin K at birth or an oral dose at birth
followed by two further oral doses at 12 weeks and 6 weeks in those who are predominantly
breast-fed
May be exacerbated by perinatal asphyxia, liver dysfunction and maternal phenytoin or
phenobarbital
Usually presents between days 2 and 6 with gastrointestinal haemorrhage, umbilical stump
bleeding, nose bleeds or intracranial haemorrhage
Prothrombin time and activated partial thromboplastin are prolonged with normal thrombin time
and fibrinogen
Treat with fresh frozen plasma and intravenous vitamin K blood transfusion
Late haemorrhagic disease may occur between 8 days and 6 months; intracranial haemorrhage is
more common in these cases
11.3 Disseminated intravascular coagulation

This may occur in any sick neonate, e.g. those with:
Sepsis
Placental abruption or other perinatal events
NEC
Meconium aspiration syndrome
Intravascular coagulation leads to thrombocytopenia and coagulopathy as a result of consumption of

platelets, clotting factors and fibrinogen. Fibrinolysis is stimulated leading to accumulation of fibrin
degradation products.
Management of DIC includes:
Treatment of the underlying cause

Platelet transfusion
Transfusion of FFP; cryoprecipitate may be used instead if fibrinogen is low
11.4 Haemophilia A
Almost 40% of cases present in the neonatal period with IVH, cephalohaematoma or excessive
bleeding elsewhere
Antenatal diagnosis is possible by chorionic villous biopsy, if there is a family history
Vaginal birth is safe if uncomplicated but Ventouse delivery should be avoided
Oral vitamin K (rather than intramuscular) should be given
Bleeding should be treated with recombinant factor VIII, but prophylactic treatment is controversial
Clinical features of haemophilia B in neonates are similar to those of haemophilia A.
11.5 Von Willebrand disease

Two forms of von Willebrand disease may present in neonates
Type 2b is autosomal dominant, presents with thrombocytopenia but rarely presents with bleeding
Type 3 is autosomal recessive; presentation is similar to haemophilia A, but girls can be affected
12. NEONATAL ORTHOPAEDIC PROBLEMS

13. FURTHER READING

American Academy of Pediatrics Committee on Drugs (1998). Neonatal drug withdrawal. Pediatrics
101:107988.
Costeloe K, Hennessy E, Gibson AT, Marlow N, Wilkinson AR (2000). The EPICure study: outcomes
to discharge from hospital for infants born at the threshold of viability. Pediatrics 106:65971.
Findlay RD, Taeusch HW, Walther FJ (1996). Surfactant replacement therapy for meconium
aspiration syndrome. Pediatrics 97:4852.
Greenough A, Milner AD, eds (2003). Neonatal Respiratory Disorders, 2nd edn. London: Arnold.
Lucas A, Cole TJ (1990). Breast milk and neonatal necrotising enterocolitis. Lancet 336:151923.
Lucas A, Brooke OG, Morley R, Cole TJ, Bamford MF (1990). Early diet of preterm infants and
development of allergic or atopic disease: randomised prospective study. BMJ 300:83740.

Lucas A, Morley R, Cole TJ, Lister G, Leeson-Payne C (1992). Breast milk and subsequent
intelligence quotient in children born preterm. Lancet 339: 2614.
Nuffield Council on Bioethics (2006). Critical care decisions in fetal and neonatal medicine: Ethical
issues. London: NCB.
Polin RA, Fox WW, Abman SH, eds (2011). Fetal and Neonatal Physiology, 4th edn. London:
Elsevier.
Rennie JM, ed. (2005). Robertons Textbook of Neonatology, 4th edn, London: Elsevier.
Sweet DG, Carnielli V, Griesen G, et al. (2010). European Consensus Guidelines on the Management
of Neonatal Respiratory Distress Syndrome in Preterm Infants 2010 update. Neonatology 97:402
17.
UK Collaborative ECMO Trial Group (1996). UK Collaborative randomised trial of neonatal
ECMO. Lancet 348:7582.
Wood NS, Marlow N, Costeloe K, Gibson AT, Wilkinson AR (2000). EPICure Study Group.
Neurologic and developmental disability after extremely preterm birth [see comments]. N Engl J Med
343:37884.
Websites
www.epicure.ac.uk (Outcome after extremely preterm birth 1995 and 2006)
www.nuffieldbioethics.org (Ethical issues 2006)
www.nice.org.uk (Neonatal jaundice, Clinical Guideline 2010)
www.thecochranelibrary.com (Cooling for newborns with hypoxic-ischaemic encephalopathy 2008)
www.thecochranelibrary.com (Volume targeted versus pressure-limited ventilation in the neonate
2010)
www.thecochranelibrary.com (Elective high frequency oscillatory ventilation versus conventional
ventilation for acute pulmonary dysfunction in preterm infants 2009)
www.thecochranelibrary.com (Ibuprofen for the treatment of patent ductus arteriosus in preterm
and/or low birth weight infants 2010)
Chapter 18
Nephrology
Christopher J D Reid
CONTENTS
1. Embryology
2. Fetal and neonatal renal function
3. Physiology
3.1 Glomerular filtration rate
3.2 Renal tubular physiology
3.3 Reninangiotensinaldosterone system
3.4 Erythropoietin system
3.5 Vitamin D metabolism
4. Investigations
4.1 Urinalysis
4.2 Urine microscopy
4.3 Haematuria
4.4 Proteinuria
4.5 Renal imaging
4.6 Renal biopsy
5. Congenital and urological abnormalities

5.1 Hydronephrosis
5.2 Duplex kidney
5.3 Multicystic dysplastic kidney
5.4 Polycystic kidneys
5.5 Horseshoe kidney
5.6 Hypospadias
5.7 Impalpable testes
5.8 Acute scrotal pain

5.9 Bladder extrophy and epispadias
6. Acidbase, fluid and electrolytes

6.1 Metabolic acidosis
6.2 Metabolic alkalosis
6.3 Body fluid compartments and regulation
6.4 Electrolyte disturbances
7. Renal tubulopathies
7.1 Proximal tubulopathies
7.2 Loop of Henle
7.3 Distal tubule
7.4 Collecting duct
8. Nephrotic syndrome
8.1 Definitions
8.3 Complications
8.4 Treatment
8.5 Congenital nephrotic syndrome
9. Glomerulonephritis
9.1 General clinical features
9.2 Acute post-streptococcal glomerulonephritis
9.3 HenochSchnlein nephritis
9.4 IgA nephropathy
9.5 Systemic lupus erythematosus nephritis
9.6 Shunt nephritis
10. Acute kidney injury

10.1 Classification of acute kidney injury
10.2 Differentiating prerenal and intrinsic renal failure/acute kidney injury
10.3 Initial assessment of acute kidney injury
10.4 Initial management of child with acute kidney injury
10.5 Indications for acute dialysis
10.6 Haemolyticuraemic syndrome
11. Chronic kidney disease, dialysis and transplantation

11.1 Main causes
11.2 Clinical presentations
11.3 Main clinical features
11.4 Dialysis
11.5 Transplantation
12. Urinary tract infection, neuropathic bladder

12.1 Urinary tract infection
12.2 Neuropathic bladder
13. Nocturnal enuresis

13.1 Definitions
13.2 Aetiology
13.3 Assessment
13.4 Treatment
14. Hypertension
14.1 Ambulatory blood pressure monitoring
14.2 Causes of secondary hypertension
14.3 Evaluation of hypertension by increasing level of invasiveness
14.4 Treatment of hypertension
15. Inherited diseases

15.1 Polycystic kidney disease
15.2 Alport syndrome
15.3 Nephronophthisis
16. Nephrocalcinosis and nephrolithiasis

16.1 Nephrocalcinosis
16.2 Nephrolithiasis-stones
17. Further reading
Nephrology
1. EMBRYOLOGY
At the start of week 5 of embryogenesis, the ureteric bud appears
A small branch of the mesonephric duct evolves into a tubular structure which elongates into the
primitive mesenchyme of the nephrogenic ridge
Ureteric bud forms the ureter, and from week 6 onwards repeated branching gives rise to the
calyces, papillary ducts and collecting tubules by week 12
The branching elements also induce the mesenchyme to develop into nephrons proximal and distal
tubules, and glomeruli
Branching and new nephron induction continues until week 36
Abnormalities in the signalling between branching ureteric bud elements and the primitive
mesenchyme probably underlie important renal malformations including renal dysplasia
There are on average 600 000 nephrons per kidney. Premature birth and low weight for gestational
age may both be associated with reduced nephron numbers
This, in turn, may underlie the later development of glomerular hyperfiltration, glomerular sclerosis
and hypertension, and may explain the firmly established inverse association between birthweight
and later adult-onset cardiovascular morbidity
2. FETAL AND NEONATAL RENAL FUNCTION

The placenta receives 50% of fetal cardiac output and the fetal kidneys only 5% of cardiac output. By
36 weeks gestational age nephrogenesis is complete, but glomerular filtration rate (GFR) is <5% of
the adult value.
Creatinine clearance (ml/min) in the human fetus and newborn infant.
The GFR of term infants at birth is approximately 25 ml/min per 1.73 m2, increasing by 50100%
during the first week, followed by a more gradual increase to adult values by the second year of life.
Fractional excretion of sodium (FENa) is:
Normal FENa in older children and adults is around 1% and <1% in sodium- and water-deprived
states
It is very high in the premature fetus, falling with increasing gestation, and it is significantly lower
in the newborn (see figure below), as the kidney adapts to the demands of extrauterine life where
renal tubular conservation of sodium and water is important
Premature neonates still have a relatively high FENa because of immature renal tubular function and
require extra sodium supplementation to avoid hyponatraemia.
Fractional sodium excretion (%) in the human fetus and newborn infant.
Urine-concentrating capacity is low in the premature newborn and leads to susceptibility to

dehydration. Fully mature urine-concentrating capacity is reached later in the first year of life
The plasma bicarbonate concentration at which filtered bicarbonate appears in the urine
(bicarbonate threshold) is low in the newborn (1921 mmol/l), increasing to mature values of 24
26 mmol/l by 4 years. Hence plasma bicarbonate values are lower in infants
Abnormalities in fetal renal function and morphology are mainly inferred from:
Volume of amniotic fluid urinary tract obstruction and/or reduced production of urine by
dysplastic kidneys lead to oligohydramnios or anhydramnios
Appearance of kidneys on antenatal ultrasonography bright echogenicity, lack of corticomedullary
differentiation, cyst formation and hydronephrosis are all signs of fetal renal abnormality
Invasive assessment of fetal renal function includes sampling of fetal urine by fine-needle aspiration
from the fetal bladder.
Usually reserved for selected cases of fetal obstructive uropathy, classically caused by posterior
urethral valves in male fetuses
Analysis of fetal urinary electrolytes and amino acid composition may give further information
about fetal renal function and prognosis for postnatal renal function
Typical features of poor prognosis for renal function (in addition to oligohydramnios and abnormal
ultrasound appearance as detailed above) include high urinary sodium and amino acid levels
(implying tubular damage and failure to reabsorb these)
Severe oligohydramnios may lead to pulmonary hypoplasia. This is the major determinant of
whether newborns with congenital renal abnormalities live or die in the immediate postnatal
period
3. PHYSIOLOGY
3.1 Glomerular filtration rate
GFR is determined by:
The transcapillary hydrostatic pressure gradient across the glomerular capillary bed (P) favouring
glomerular filtration
The transcapillary oncotic pressure gradient () countering glomerular filtration
The permeability coefficient of the glomerular capillary wall, k
Hence GFR = k(P ).
GFR is expressed as a function of body surface area. Absolute values for GFR in millilitres per
minute are corrected for surface area by the formula:
Corrected GFR (ml/min/1:73 m2)
= Absolute GFR (ml/min) 1:73/Surface area
1.73 m2 is the surface area of an average adult male. Normal mature GFR values are 80120 ml/min
per 1.73 m2, and are reached during the second year of life.
GFR can be estimated or measured.
It is estimated from a calculated value using the Schwartz formula:
This method will tend to overestimate GFR in malnourished children with poor muscle mass.
It is measured on a single injection plasma disappearance curve, using inulin, or a radio-isotope such
as chromium-labelled EDTA. After an intravenous injection of a known amount of one of these
substances, a series of timed blood samples is taken over 35 h, and the slope of the curve generated
by the falling plasma levels of the substance gives the GFR. This technique does not require any urine
collection, thus making it suitable for routine clinical use.
3.2 Renal tubular physiology

The renal tubules play a fundamental role in:
Maintaining extracellular fluid volume
Maintaining electrolyte and acidbase homeostasis
These processes are energy demanding and render tubular cells most vulnerable to ischaemic damage
and acute tubular necrosis. The proximal tubule and loop of Henle are the sites of major reabsorption
of most of the glomerular filtrate.
The distal tubule and collecting duct are where fine tuning of the final composition of the urine
occurs.
Diagram of tubular function, showing sites of active (solid arrows) and passive (broken arrows)
transport. The boxed numbers indicate the percentage of glomerular filtrate remaining in the tubule
and the non-boxed numbers the osmolality of the tubular fluid under conditions of antidiuresis.
(Reproduced from Godfrey and Baum, Clinical Paediatric Physiology, p. 368, Cambridge:
Blackwell Scientific Publications, with permission.)
Proximal tubule
The primary active transport system is the Na+/K+ ATPase enzyme, reabsorbing 50% of filtered Na+.
Secondary transport involves coupling to the Na+/H+ antiporter, which accounts for 90% of
bicarbonate reabsorption with some Cl. In addition:
Glucose is completely reabsorbed unless the plasma level is high, in which case glycosuria will
occur
Amino acids are completely reabsorbed, although preterm and term neonates commonly show a
transient aminoaciduria
Phosphate is 8090% reabsorbed under the influence of parathyroid hormone (PTH), which
reduces reabsorption and enhances excretion of phosphate
Calcium is 95% reabsorbed: 60% in the proximal tubule, 20% in the loop of Henle, 10% in the
distal tubule and 5% in the collecting duct
A variety of organic solutes, including creatinine and urate, and some drugs, including trimethoprim
and most diuretics, are secreted in the proximal tubule
Loop of Henle
A further 40% of filtered Na+ is reabsorbed via the Na+/K+/2Cl co-transporter in the thick
ascending limb of the loop of Henle
The medullary concentration gradient is generated here because this segment is impermeable to
water
Loop diuretics block Cl-binding sites on the co-transporter
There is an inborn defect in Cl reabsorption at this same site in Bartter syndrome see Section 7.2
Distal tubule
A further 5% of filtered Na+ is reabsorbed here, via a Na+/Cl co-transporter
Thiazide diuretics compete for these Cl-binding sites and may have a powerful effect if combined
with loop diuretics, which increase NaCl and water to the distal tubule
Aldosterone-sensitive channels (also present in the collecting duct) are involved in regulating K+
secretion. K+ secretion is proportional to:
distal tubular urine flow rate
distal tubular Na+ delivery: so natriuresis is associated with increased K+ secretion and
hypokalaemia (e.g. Bartter syndrome, loop diuretics)
aldosterone level so conditions of elevated aldosterone are associated with hypokalaemia
[pH]1
Collecting duct
A final 2% of filtered Na+ is reabsorbed via aldosterone-sensitive Na+ channels, in exchange for
K+
Spironolactone binds to and blocks the aldosterone receptor, explaining its diuretic and K+-sparing
actions
H+ secreted into urine by H+ ATPase
Antidiuretic hormone (ADH) opens water channels (aquaporins) to increase water reabsorption
3.3 Reninangiotensinaldosterone system
The reninangiotensinaldosterone system (ACE, acetylcholinesterase).

Renin is released from the juxtaglomerular apparatus in response to decreased perfusion to the
kidney, leading to increased angiotensin II levels causing vasoconstriction, and increased
aldosterone release causing enhanced distal tubular sodium and water conservation, and hence
extracellular fluid (ECF) volume expansion
Abnormal renin release resulting in hypertension is associated with most forms of secondary renal
hypertension, e.g. reflux nephropathy and renal artery stenosis
There are syndromes of low-renin hypertension, including:
Conn syndrome primary hyperaldosteronism: high aldosterone leading to ECF volume expansion,
hypertension, hypokalaemia and renin suppression
Liddle syndrome constitutive activation of amiloride-sensitive distal tubular epithelial sodium
channel: ECF volume expansion leading to renin and aldosterone suppression, and hypokalaemia
Pseudohypoaldosteronism is constitutive inactivation of the amiloride-sensitive distal tubular
epithelial Na+ channel, leading to excessive loss of salt and water with ECF volume depletion, and
hyperkalaemia, thus mimicking aldosterone deficiency; renin and aldosterone levels are, however,
high secondary to the ECF volume depletion. There are transient and permanent forms.
3.4 Erythropoietin system

Erythropoietin (EPO) is released by renal peritubular cells and stimulates marrow erythropoiesis
Deficiency of EPO in renal disease is a major cause of the associated anaemia
Recombinant human EPO is available for treatment and prevention of anaemia in renal failure
3.5 Vitamin D metabolism

Vitamin D3 (cholecalciferol) is mainly available from the action of ultraviolet light on its precursor
in the skin
In the liver it is hydroxylated to 25(OH)-vitamin D3
Renal 1-hydroxylase then leads to the production of 1,25(OH)2-vitamin D3, or calcitriol, the most
biologically active vitamin D metabolite, in the kidney
Hypocalcaemia leads to enhanced 1-hydroxylase activity both directly and indirectly, by
stimulating PTH secretion, which also stimulates the enzyme. Other stimuli for increased 1hydroxylase activity include low serum phosphate and growth hormone
Deficiency of renal production of calcitriol underlies the rickets of renal failure
4. INVESTIGATIONS
4.1 Urinalysis
Dipstick testing of urine is routinely used to detect blood, protein, glucose and pH. Multistix can, in
addition, detect leukocyte esterase (a marker of the presence of polymorphs) and nitrite (produced
by the bacterial reduction of nitrate). If the urine appears clear to the naked eye and all panels on a
Multistix are negative, urine infection is almost certainly excluded. Note that urinary haemoglobin
and myoglobin (from rhabdomyolysis) produce a false-positive dipstick test for blood; microscopy of
urine will not, however, reveal red blood cells.
4.2 Urine microscopy

A routine investigation for a urinary tract infection (UTI) and in patients with dipstick haematuria.
The finding of organisms and white blood cells on microscopy is strong supporting evidence for the
presence of a UTI, before a culture result is available. Apart from infection, the major causes of
haematuria in children are glomerular, rather than lower urinary tract. Glomerular red blood cells
appear deformed or dysmorphic when examined by an experienced microscopist, helping to localize
the site of haematuria to the kidneys.
Urinary casts usually signify renal pathology:
Red cell casts isolated renal haematuria or glomerulonephritis
Tubular cell casts acute tubular necrosis
White blood cell casts pyelonephritis, acute tubular necrosis
4.3 Haematuria
The main causes are:
UTI bacterial or other infections including tuberculosis and schistosomiasis
Glomerulonephritis:
Often with proteinuria and urinary casts
Isolated haematuria with no other evidence of clinical renal disease may be the presenting feature
of several important glomerulonephritides, including Alport syndrome and immunoglobulin A
(IgA) nephropathy
Trauma usually a history
Stones usually painful
Tumour
Cystic kidney disease

Bleeding disorders
Vascular disorders, including renal vein thrombosis (especially neonates) and arteritis
Sickle cell disease
False positives see Section 4.1
Factitious Munchausen syndrome or Munchausen syndrome by proxy Other causes of red urine
include beetroot consumption, haemoglobinuria and rifampicin.
4.4 Proteinuria
This is usually detected on dipstick testing. The minimum detectable concentration is 1015 mg/dl, so
in a patient producing a large volume of dilute urine the sticks may be negative even though the total
amount of protein excreted per day may be significant.
In normal afebrile children, urine protein excretion should not exceed 60 mg/m2 per 24 h. Collection
of an accurate 24-h urine collection is difficult in small children. Quantification of proteinuria is best
done on a spot early morning urine sample by measuring urinary albumin (mg/l) and creatinine
(mmol/l), and deriving the albumin:creatinine ratio:
Normal <3 mg/mmol
Microalbuminuria 330 mg/mmol
Proteinuria >30 mg/mmol
Orthostatic proteinuria is detectable when the patient has been in an upright position for several
hours but not when the patient is recumbent. It is important to assess protein excretion on a first
morning sample, when the patient has been recumbent all night, and on an evening sample when the
patient has been up and about all day, because orthostatic proteinuria is a benign condition with a
good prognosis, and does not warrant investigations such as renal biopsy.
4.5 Renal imaging

Ultrasonography
This is a readily available non-invasive investigation that is operator dependent for its interpretation.
It is the standard for antenatal investigation and in almost all renal conditions.
It gives good information about the following:
Size, shape, symmetry and position of kidneys
Hydronephrosis, ureteric dilatation
Bladder distension, bladder emptying post-void, bladder wall thickness
Stones although small ureteric stones may not be seen

Cystic disease, including autosomal dominant and recessive
Tumours, including renal and adrenal tumours
Gross cortical scarring
Vascular perfusion using a Doppler technique
Ultrasonography may not detect minor degrees of scarring. It is not sensitive or specific at detecting
vesicoureteric reflux (VUR). Doppler ultrasonography may reveal renal artery stenosis, but there is a
significant false-negative rate.
Micturating cystourethrogram (MCUG)

Used to look for VUR and the appearance of the bladder outline and also the urethra, specifically
posterior urethral valves in males.
Nuclear medicine isotope scans
DMSA (dimercaptosuccinic acid)

A static scan, i.e. isotope is filtered and retained in renal parenchyma
Assesses divided function and detects cortical scars
Main use is in investigation of UTI and hypertension
Some perfusion defects seen when DMSA is performed during acute UTI may resolve; defects
present 3 months after acute infection are permanent
MAG-3 (mercaptoacetyltriglycine), DTPA (diethylenetriaminepenta-acetic acid)

Dynamic scans, i.e. isotope is filtered, and then excreted from kidney down ureters to bladder
Assess divided function, and drainage and obstruction
Main use is in investigating upper tract dilatation seen on ultrasonography and for follow-up of
surgery for obstructed kidneys or ureters
Indirect radioisotope reflux study is a convenient way of assessing the presence of VUR in children
old enough to cooperate with the scan and void on demand during the scan in practice >3 years
old. It avoids the need for a urethral catheter and has a lower radiation dose than MCUG
Magnetic resonance urography (MRU)

Assesses anatomy of urinary tract when the combination of ultrasonography and nuclear medicine
scans, and often MCUG, have not clarified issues such as ureteric course and insertion
Increasingly commonly used for diagnosis and surgical planning of complex urological disorders
Intravenous urography
Little used now because the combination of ultrasound and isotope scans, and MRU, provides the
required information in most cases, and avoids the risks of anaphylaxis and radiation dose that are
involved with intravenous urography (IVU)

Occasionally used for emergency evaluation of painful haematuria, if ultrasonography is
uninformative, when IVU may reveal a ureteric stone
Renal arteriography
Used to diagnose renal artery stenosis
Approach is via femoral artery; usually requires general anaesthesia in children.
Therapeutic approaches include balloon angioplasty of stenoses and embolization of intrarenal
arteriovenous aneurysms
4.6 Renal biopsy

In general, the main indications for renal biopsy are:
to make a diagnosis
to guide therapy and to assess response to therapy
to assist in giving a prognosis
The following are the most common reasons for renal biopsy in children:
Steroid-resistant nephrotic syndrome

Haematuria and/or proteinuria
Unexplained acute nephritis/acute renal failure
Assessment of renal transplant dysfunction
5. CONGENITAL AND UROLOGICAL ABNORMALITIES

5.1 Hydronephrosis
The main causes of hydronephrosis are as follows:
VUR see Section 12.1
Pelviureteric junction (PUJ) obstruction
Usually detected on antenatal ultrasonography
Occasionally detected during investigation of UTI or abdominal pain
Main aspects of assessment are:
ultrasonography degree of renal pelvic dilatation measured in the anteroposterior diameter:
510 mm mild; 1115 mm moderate; >15 mm severe
MAG-3 renogram findings that suggest significant obstruction are poor drainage despite
furosemide given during scan and impaired function, e.g. <40% on hydronephrotic side
follow-up in the first 2 years after birth is based around ultrasonography every 4 months, with
MAG-3 scan undertaken if hydronephrosis is severe initially, or progressively worsens over

time
surgical correction is by pyeloplasty
Usual when MAG-3 indicates obstruction and/or ultrasonography shows progressive increase in
hydronephrosis
When dilatation is >30 mm, surgery is likely
Surgery is also considered if hydronephrosis is complicated by a proven UTI
Vesicoureteric junction obstruction
Usually detected in the same ways as for PUJ obstruction
Ultrasonography shows renal pelvic and ureteric dilatation
Interventions include stenting the vesicoureteric junction (temporary measure) and surgical
reimplantation
5.2 Duplex kidney

Often detected on antenatal ultrasonography or during investigation of UTI
Two ureters drain from two separate pelvicalyceal systems; ureters sometimes join before common
entry into the bladder, but more commonly have separate entries, with the upper pole ureter
inserting below the lower pole ureter
Common complications associated with duplex systems are:
Obstructed hydronephrotic upper moiety and ureter, often poorly functioning, associated with
bladder ureterocele
Dilatation and swelling of submucosal portion of ureter just proximal to stenotic ureteric
orifice can be seen within bladder on ultrasonography and as a filling defect on MCUG
Ectopically inserted upper pole ureter, entering urethra or vagina; clue to this from history is true
continual incontinence with no dry periods at all, as ectopic ureter bypasses bladder
VUR into lower pole ureter, sometimes causing infection and scarring of this pole
5.3 Multicystic dysplastic kidney
Irregular cysts of variable size from small to several centimetres; no normal parenchyma
Dysplastic atretic ureter
No function on MAG-3 or DMSA scan
Commonly involute over time
No indication for routine surgical removal
Follow-up with ultrasonography at 3 months, then 12 months, 2 years and 5 years
At the 5-year visit, if ultrasonography shows normal contralateral kidney with compensatory
hypertrophy of this kidney, and the child has a normal BP, no proteinuria and normal plasma
creatinine, then reasonable to discharge from long-term hospital follow-up
2040% incidence of VUR into contralateral normal kidney
5.4 Polycystic kidneys

See Section 15.1.
5.5 Horseshoe kidney

Two renal segments fused across midline at lower poles in 95%, upper poles in 5%
Isthmus usually lies low, at the level of the fourth lumbar vertebra immediately below the origin of
the inferior mesenteric artery
Associations include Turner syndrome, LaurenceMoonBiedl syndrome
Usually asymptomatic but increased incidence of PUJ obstruction and VUR, so may develop a UTI
5.6 Hypospadias
Opening of urethral meatus is on the ventral surface of penis, at any point from the glans to base of
penis or even perineum
Meatus may be stenotic and require meatotomy as initial intervention
Foreskin is absent ventrally; it is used in surgical reconstruction of a deficient urethra so
circumcision should not be performed
Usual best age for surgical correction is around 12 months
Chordee is the associated ventral curvature of the penis, seen especially during erection, and this
also requires surgical correction; caused by fibrous tissue distal to the meatus along the ventral
surface of penis
5.7 Impalpable testes

May be intra-abdominal, inguinal or pre-scrotal
Main aim of diagnosis and management is:
to preserve fertility
to reduce risk of malignancy and to enable early detection of malignant change if it occurs
Infants should be referred to paediatric surgeon or urologist by age 6 months
Ultrasonography may detect inguinal testis, but is of limited use for intra-abdominal testis; MRI
may be better, but usually requires general anaesthetic for infant; laparoscopy may be final method
for localising testis
Surgical orchidopexy has 95% success rate; hormonal therapy with human chorionic gonadotrophin
(hCG) <15% success and so surgery is preferred option
Optimum age for surgery is 912 months; usually combined with repair of the associated inguinal
hernia; may require two-stage procedure for intra-abdominal testis
5.8 Acute scrotal pain
Boys presenting with scrotal pain will often need to be assessed by a paediatric surgeon
History and examination are the most important components of assessment
Ultrasonography with colour Doppler to assess testicular blood flow may contribute
Torsion of testicle:
Acute abrupt onset of often severe pain
Early puberty
Swelling of testis and hemiscrotum, often with erythema/discoloration of scrotal skin
Diffuse tenderness of testis
Negative urinalysis
Treatment is surgical exploration
Torsion of appendix of epididymis:
More common than torsion of testicle
Subacute onset of pain over hours
Pre-pubertal
Tenderness localized to the upper pole of testis
Negative urinalysis
If confident of diagnosis may be managed conservatively; however, may be difficult to distinguish
from torsion of testicle so may require surgical exploration
Epididymitis:
Gradual insidious onset of discomfort or pain
Adolescence
Epididymal tenderness
Urinalysis often positive (although may be negative)
May have low-grade fever; raised C-reactive protein (CRP)
Treatment with antibiotics (e.g. co-amoxiclav, cefalexin) if urinalysis suggestive of infection
Trauma:
History usually informative
Trauma may cause a haematocele or testicular haematoma
Hernia or hydrocele:
Not usually acutely painful
Swelling in scrotum, extending into inguinal canal if hernia
No erythema or discoloration of overlying scrotal skin
Hydrocele will transilluminate with pen torch
5.9 Bladder extrophy and epispadias

Rare disorder; more common in boys
Bladder mucosa is exposed (and with exposure and infection becomes friable), bladder muscle
becomes fibrotic and non-compliant
Anus anteriorly displaced
Boys penis has epispadias (dorsal opening urethra) and dorsal groove on glans, with dorsal
chordee and upturning; scrotum is shallow and testes are often undescended
Girls female epispadias with bifid clitoris, widely separated labia
Pubic bones separated

Requires surgical reconstruction; long-term urinary incontinence is common
6. ACIDBASE, FLUID AND ELECTROLYTES

6.1 Metabolic acidosis
A primary decrease in plasma bicarbonate and a decrease in plasma pH as a result of:
Bicarbonate loss, e.g.
Gastrointestinal loss in severe diarrhoea
Renal loss in proximal (type 2) renal tubular acidosis (RTA)
Reduced hydrogen ion excretion, e.g.
Distal (type 1) RTA
Acute and chronic renal failure
Increased hydrogen ion load, e.g.
endogenous load:
inborn errors of metabolism, e.g. maple syrup urine disease, propionic acidaemia
lactic acidosis, e.g. cardiovascular shock
ketoacidosis, e.g. diabetic ketoacidosis (DKA)
exogenous load, e.g. salicylate poisoning
Anion gap
A classification of metabolic acidosis involves assessing the anion gap the gap between anions
and cations made up by unmeasured anions, e.g. ketoacids, lactic acid
Measured as [Na+ + K+] [HCO3 + Cl]; thus normal anion gap is [140 + 4] [24 + 100] = 20
Acidosis may be a normal anion gap, when Cl will be raised, i.e. hyperchloraemic
May be an increased anion gap, when Cl will be normal, i.e. normochloraemic
Examples:
Normal anion gap, hyperchloraemia, acidosis RTA
Na+ 140, K+ 4, Cl 110, HCO3 14, anion gap = 20
Increased anion gap, normochloraemia, acidosis DKA
Na+ 140, K+ 4, Cl 100, HCO3 15, anion gap = 30
6.2 Metabolic alkalosis

A primary increase in plasma bicarbonate and an increase in plasma pH as a result of the following:
Chloride depletion, the most common cause in childhood, leading to low urinary Cl and Clresponsive alkalosis, i.e. as soon as Cl is made available (e.g. as intravenous saline) it is retained
by the kidney at the expense of HCO3, correcting the alkalosis (see also Pseudo-Bartter syndrome,
Section 7.2):
Gastrointestinal loss, e.g. pyloric stenosis, congenital chloride diarrhoea
Furosemide therapy
Cystic fibrosis
Stimulation of H+ secretion by the kidney, with normal urinary Cl and Cl-unresponsive alkalosis,
e.g.
Bartter syndrome (see Section 7.2)
Cushing syndrome
Hyperaldosteronism (see Section 3.3)
Excess intake of base, e.g. excess ingestion of antacid medicine (rare in childhood)
6.3 Body fluid compartments and regulation

Total body water
Total body water (TBW) represents 85% of the body weight (bwt) of preterm infants, 80% in term
infants and 65% in children. In children it is distributed between the intracellular (ICF) and
extracellular (ECF) fluid compartments as follows:
Osmotic equilibrium, cell volume regulation

The major fluid compartments are separated by semipermeable membranes, which are freely
permeable to H2O. Osmotic equilibrium is maintained between the ICF and ECF compartments by
the shift of H2O from lower to higher osmolality compartments
ECF osmolality can be calculated as: [(Na+ + K+) 2] + glucose + urea
A rise in ECF osmolality, e.g. in DKA, will lead to a shift of H2O out of the ICF compartment, and
thus a reduction in ICF volume, i.e. cell shrinkage. Cell shrinkage stimulates the intracellular
accumulation of organic osmolytes, which increases ICF osmolality and leads to a shift of H2O
back into the cell, restoring cell volume
Treatment of DKA may then lead to the rapid reduction of ECF osmolality, but the ICF organic
osmolytes are degraded slowly and thus an osmotic gradient may be created during DKA treatment,
favouring movement of H2O into the cells, causing cerebral oedema
Osmoregulation
A small (34%) increase in ECF osmolality stimulates hypothalamic osmoreceptors to cause
posterior pituitary ADH release, leading to water retention and return of osmolality to normal.
Increases in ECF osmolality also stimulate thirst and water drinking. Significant (>10%) ECF
depletion, even if iso-osmolar, will cause carotid and atrial baroreceptors to stimulate ADH release.
6.4 Electrolyte disturbances

Hyponatraemia
Normal plasma Na+ is 135145 mmol/l. Hyponatraemia is usually defined as plasma Na+ <130
mmol/l. The causes are twofold.
Gain of H2O in excess of Na+

Excess water intake increased volume of appropriately hypotonic urine:
Iatrogenic excess hypotonic oral or intravenous fluid
Psychogenic polydipsia
Acute renal failure oedema and hypervolaemia, oliguria with urine Na+ >20 mmol/l
Syndrome of inappropriate ADH secretion (SIADH) inappropriately raised urine osmolality, i.e.
not maximally dilute; increased body weight; decreased plasma urea and creatinine; absence of
overt renal, liver or cardiac disease
Meningitis or central nervous system tumour
Pneumonia
Intermittent positive pressure ventilation
Drugs, e.g. carbamazepine, barbiturates
Treatment is principally water restriction; for severe hyponatraemia (<120 mmol/l) with
neurological symptoms, correction of plasma Na+ to 125130 mmol/l over 4 h is usually safe and
effective in correcting symptoms
Loss of Na+ in excess of H2O

Renal losses dehydration, but inappropriately high urine volume and urine Na+ content (>20
mmol/l); urine isotonic with plasma
Loop diuretics
Recovery phase of acute tubular necrosis
Tubulopathies (see Section 7.1)
Salt-wasting congenital adrenal hyperplasia; adrenal insufficiency hyperkalaemia
Extrarenal losses dehydration, appropriate oliguria and Na+ conservation with low urine Na+
(usually <10 mmol/l); urine hypertonic
Gastrointestinal tract losses gastroenteritis

Skin losses severe sweating, cystic fibrosis
Treatment involves:
Rehydration and calculation of Na+ deficit as (140 plasma Na+) 0.65 body weight (kg)
Avoid over-rapid correction of hyponatraemia (risk of cerebellopontine myelinolysis)
Hypernatraemia
Usually defined as plasma Na+ >150 mmol/l. There is a shift of H2O from the ICF to the ECF
compartments, so that, in hypernatraemic dehydration, ECF volume is not markedly reduced and thus
typical signs of dehydration are less obvious. The causes are again twofold.
Loss of H2O in excess of Na+

Renal losses inappropriately high urine output, inappropriately low urine osmolality:
Reduced renal concentrating ability preterm neonates
Diabetes insipidus pituitary and nephrogenic (see Section 7.4)
Osmotic diuresis DKA
Extrarenal losses appropriate oliguria and high urine osmolality:
Gastrointestinal losses
Increased insensible H2O loss, e.g. pyrexia and hyperventilation
Inadequate free water intake;
Breastfed neonate with inadequate maternal milk flow
Treatment:
Safest and best given with standard oral rehydration solution
If intravenous treatment is essential, slow (4872 h or 1015 mmol/l per 24 h), correction of
hypernatraemia with frequent measurement of plasma electrolytes is safest; a suggested fluid is 1
litre dextrose 5% + NaCl 25 mmol + KCl 20 mmol
Gain of Na+ in excess of H2O

Increased volume of urine with high Na+ content:
atrogenic excess hypertonic intravenous fluid, e.g. NaHCO3, hypertonic saline
Incorrect reconstitution of infant formula
Accidental or deliberate (e.g. Munchausen syndrome by proxy) salt poisoning
Treatment recognition and removal of underlying cause; access to water while kidneys excrete
excess salt load
Hypokalaemia
Normal plasma K+ is 3.44.8 mmol/l. The following are the main causes of hypokalaemia:
Inadequate provision of K+ with prolonged intravenous fluid administration

Extrarenal losses;
Gastrointestinal losses
Renal losses;
High plasma renin levels:
diuretic use loop and thiazide diuretics
osmotic diuresis DKA (hypokalaemia becomes evident when metabolic acidosis and insulin
deficiency are corrected)
Fanconi syndrome see Section 7.1
Bartter syndrome see Section 7.2
Gitelman syndrome see Section 7.3
distal (type 1) RTA
Low plasma renin levels:
Conn syndrome see Section 3.3
Liddle syndrome see Section 3.3
Cushing syndrome
Shift from ECF to ICF compartment;
Correction of metabolic acidosis
Insulin treatment
High-dose or prolonged salbutamol treatment for asthma
Hyperkalaemia
The following are the main causes:
Excess administration in intravenous fluid
Renal failure acute and chronic
Shift from ICF to ECF;
Metabolic acidosis
Rhabdomyolysis acute tumour lysis (both often associated with acute impairment in renal
function which compounds the hyperkalaemia)
Hypoadrenal states;
Salt-wasting congenital adrenal hyperplasia
Pseudohypoaldosteronism see Section 3.3
Potassium-sparing diuretics spironolactone
Treatment includes:
Exclusion of K+ from diet and intravenous fluids
Cardiac monitor peaked T waves prolonged PR interval widened QRS ventricular
tachycardia terminal ventricular fibrillation
Calcium gluconate to stabilize myocardium
Shift K+ from ECF to ICF:
Correct metabolic acidosis if present in acute renal failure
Salbutamol: nebulized or short intravenous infusion
Insulin and dextrose but extreme caution in young children as there is a risk of hypoglycaemia
Remove K+ from body:
calcium resonium
dialysis
Calcium and hypocalcaemia

Calcium in the body is 40% protein bound (of which 98% is bound to albumin), 48% ionized and
12% complexed to anions such as phosphate or citrate
Normal values are 2.12.6 mmol/l for total Ca2+ and 1.141.30 for ionized (Io) Ca2+
Albumin-corrected Ca2+ equals measured total plasma Ca2+ + [(40 albumin) 0.02] for
example, if total Ca2+ is 1.98 and albumin is 26; corrected Ca2+ = 1.98 + [(40 26) 0.02] = 2.26
Degree of protein binding of plasma Ca2+ is proportional to plasma pH. Beware of correcting
acidosis in renal failure, where total and ionized Ca2+ often already low. Acute rise in pH with
NaHCO3 treatment leads to protein-bound Ca2+ which leads to ionized Ca2+ and may cause
tetany
Monitoring of ionized Ca2+ is useful in intensive care patients, where changes in acidbase and
albumin levels make interpretation of total plasma Ca2+ difficult
Hypocalcaemia
The main symptoms are tetany, paraesthesiae, muscle cramps, stridor and seizures. The main causes
are:
Calcitriol (1,25(OH)2-D3) deficiency;
Dietary deficiency of vitamin D
Malabsorption of vitamin D fat malabsorption syndromes
Renal failure (acute and chronic) 1-hydroxylase deficiency
Liver disease 25-hydroxylase deficiency
Hypoparathyroidism;
Transient neonatal
DiGeorge syndrome 22q11.2 deletion
Post-parathyroidectomy
Pseudohypoparathyroidism;
Autosomal dominant; end-organ resistance to raised levels of PTH
Abnormal phenotype with short stature, obesity, intellectual delay, round face, short neck,
shortened fourth and fifth metacarpals
Acute alkalosis (respiratory or metabolic) or acute correction of acidosis in setting of already
reduced Ca2+
Hyperphosphataemia;
Renal failure (acute or chronic)
Rhabdomyolysis; tumour lysis syndrome
Deposition of Ca2+;
Acute pancreatitis
Treatment includes:
Intravenous 10% calcium gluconate, 0.2 ml (0.045 mmol)/kg, diluted 1:5 with dextrose 5%, over
1015 min with ECG monitoring; followed by intravenous infusion of 10% calcium gluconate at
0.3 ml (0.07 mmol)/kg per day
Oral Ca2+ supplements
Vitamin D, or the analogue alfacalcidol (1-hydroxycholecalciferol), for nutritional deficiency,
hypoparathyroidism and renal failure
Hypercalcaemia
The main symptoms are constipation, nausea, lethargy and confusion, headache, muscle weakness,
and polyuria and dehydration. The main causes are:
Vitamin D therapy;
Renal failure
Dietary vitamin D deficiency
Primary hyperparathyroidism;
Neonatal
Part of multiple endocrine neoplasia syndromes I and II
Williams syndrome;
Heterozygous deletions of chromosomal sub-band 7q11.23 leading to an elastin gene defect in
>90% (detected by fluorescent in situ hybridization [FISH] test)
Hypercalcaemia rarely persists beyond 1 year of age
Familial hypocalciuric hypercalcaemia;
Inactivation of Ca2+-sensing receptor gene in parathyroid cells and renal tubules leads to an
inappropriately high plasma PTH level and inappropriately low urine Ca2+
Macrophage production of 1,25(OH)2-D3;
Sarcoidosis
Subcutaneous fat necrosis prolonged or obstructed labour
Malignant disease;
Treatment includes:
Intravenous hydration plus a loop diuretic
Correction/removal or specific treatment of underlying cause, e.g. steroids for sarcoidosis
Rarely, bisphosphonates
Phosphate and hypophosphataemia

Phosphate is excreted from the kidney under the influence of parathyroid hormone (increases
excretion) and calcitriol (decreases excretion). In hypophosphataemia, calculation of the tubular
reabsorption of phosphate (TRP) is useful.
TRP = 1Fractional excretion of PO43

i.e.
Normally, TRP >85%. If the TRP is <85%, in the presence of low plasma PO43 and a normal PTH
level, this implies abnormal tubular leakage of PO43.
Hypophosphataemia
With appropriately high TRP, i.e. low urinary PO43
Dietary PO43 restriction
Increased uptake into bone the hungry bone syndrome seen after parathyroidectomy for
prolonged hyperparathyroidism, or after renal transplantation with preceding hyperparathyroidism
of chronic renal failure (CRF); see also Hypocalcaemia
With inappropriately low TRP, i.e. high urinary PO43
Hypophosphataemic rickets see Section 7.1
Fanconi syndrome see Section 7.1
Hyperphosphataemia
With high urinary PO43
Tumour lysis syndrome, rhabdomyolysis see also Oliguria, Hyperkalaemia
With low urinary PO43
Chronic renal failure see Section 11.3
Hypoparathyroidism; pseudohypoparathyroidism
Magnesium and hypomagnasaemia

Most filtered Mg2+ is reabsorbed in the distal proximal tubule and the loop of Henle. As with Ca2+,
Mg2+ transport and NaCl transport are associated. Factors enhancing Mg2+ reabsorption include
hypocalcaemia and raised PTH levels. Hypomagnesaemia is often found in patients with
hypocalcaemia and hypokalaemia, and to correct these the magnesium deficiency must also first be
corrected. The following are the main causes of hypomagnesaemia:
Poor dietary intake
Reduced gut absorption
Increased urinary losses:
Recovery from acute tubular necrosis
Post-transplantation diuresis
Drug induced loop and thiazide diuretics; amphotericin B; cis-platinum

Gitelman syndrome see Section 7.3
7. RENAL TUBULOPATHIES
7.1 Proximal tubulopathies
Cystinuria
Defect in reabsorption of and hence excessive excretion of, the dibasic amino acids cystine,
ornithine, arginine and lysine
Not to be confused with cystinosis see below
Autosomal recessive; two separate cystinuria genes on 2p and 19q
Cystine is poorly soluble in normal urine pH; it has increased solubility in alkaline urine
Clinical manifestation is recurrent urinary stone formation
Stones are extremely hard and densely radio-opaque
Diagnosis based on stone analysis, or high cystine level in timed urine collection
Treatment based on high fluid intake (>1.5 l/m2 per day) and alkalinization of urine with oral
potassium citrate
If stones still form, oral D-penicillamine leads to formation of highly soluble mixed disulphides
with cystine moieties
X-linked hypophosphataemic rickets

Also known as vitamin D-resistant rickets
Mutation in PEX gene on X chromosome
Isolated defect in PO43 reabsorption leading to:
Inappropriately low tubular reabsorption of PO43 (TRP) typically <85% with a normal PTH
and calcitriol level
Hypophosphataemia
Earliest sign is alkaline phosphatase (by 34 months)
Plasma PO43 may be normal until 69 months of age
By 12 months, have delayed growth, hypophosphataemia, alkaline phosphatase and radiological
signs of rickets
Other features include delayed dentition and recurrent dental abscesses
Treatment is based on calcitriol or alfacalcidol, and phosphate supplements
Complications of this treatment include hypercalcaemia and nephrocalcinosis
Recent evidence suggests that addition of growth hormone treatment may improve growth and
biochemical disturbance
Proximal (type 2) RTA
Failure to reabsorb filtered HCO3

Renal bicarbonate threshold is low, i.e. HCO3 is present in the urine at levels of plasma HCO3
lower than normal
Distal tubular H + excretion is intact so acid urine can be produced
Normal acidification of urine in response to ammonium chloride load
Normal increase in urine PCO2 in response to 3 mmol/kg oral bicarbonate load
Ability to excrete acid from distal tubule, and the fact that calcium salts are more soluble in acid
urine, is the likely to explain why nephrocalcinosis is not a feature of proximal RTA
May occur as an isolated defect or as part of Fanconi syndrome see below
Symptoms include faltering growth, vomiting and short stature
Treatment requires large doses of alkali (515 mmol/kg per day)
Fanconi syndrome
Diffuse proximal tubular dysfunction, leading to excess urinary loss of the following:
Glucose glycosuria with normal blood glucose
Phosphate hypophosphataemia, low TRP, rickets
Amino acids no obvious clinical consequence
HCO3 leading to proximal RTA
K+ causing hypokalaemia
Na+, Cl and water leading to polyuria and polydipsia, chronic ECF volume depletion, faltering
growth
Tubular proteinuria loss of low-molecular-weight proteins including retinol-binding protein and
N-acetylglucosaminidase
Usual clinical features include polyuria and polydipsia, chronic ECF volume depletion, faltering
growth, constipation and rickets, with features in addition of any underlying condition
Main causes of Fanconi syndrome

Metabolic disorders:
Cystinosis
Tyrosinaemia
Lowe syndrome (oculocerebrorenal syndrome)
Galactosaemia
Wilson disease
Heavy metal toxicity
Lead, mercury, cadmium
Idiopathic
Cystinosis
Autosomal recessive defect in the transport of cystine out of lysosomes. The gene is localized to
chromosome 17p and encodes an integral membrane protein, cystinosin.
Predominant early clinical features are of:

Fanconi syndrome see above
photophobia as the result of eye involvement with corneal cystine crystals
hypothyroidism
Late features include the following:
Renal failure around 810 years of age, if untreated
Pancreatic involvement with diabetes mellitus
Liver involvement with hepatomegaly
Gonadal involvement with reduced fertility
Neurological deterioration and cerebral atrophy
Diagnosis is based on the following:
Cystine crystals in cornea seen by slit-lamp
Peripheral blood white cell cystine level
Antenatal diagnosis available for families with positive history
Treatment
Supportive PO43, NaCl, K+ and NaHCO3 supplements, and high fluid intake; alfacalcidol;
thyroxine
Specific cysteamine, which increases cystine transport out of the lysosome; starting treatment in
early infancy appears to delay onset of renal failure
Other indometacin reduces the GFR, and hence the severe polyuria and secondary polydipsia, and
electrolyte wasting
Renal tubular acidosis classification
Renal tubular acidosis

In normal individuals, urine pH falls as plasma HCO3 decreases through the normal range 2622
mmol/l. In proximal RTA, the curve has a similar shape but is shifted to the left, such that acid urine is
not produced until plasma HCO3 has fallen abnormally low, e.g. 16 mmol/l. In distal RTA, acid urine
cannot be produced regardless of how low the plasma HCO3 falls.
7.2 Loop of Henle

Bartter syndrome
This is caused by an inborn autosomal recessive defect, in the Na+/K+/2Cl co-transporter in the
thick ascending limb of the loop of Henle, leading to NaCl and water wasting
Symptoms are polyuria, polydipsia, episodes of dehydration, faltering growth and constipation;
there may be maternal polyhydramnios with an affected fetus
The resultant ECF volume contraction causes secondary renin secretion and raised aldosterone
levels, with avid Na + and water reabsorption in the distal tubule, and reciprocal K+ and H+
secretion into the urine. (Note that the blood pressure is normal; the hyperreninaemia is a
compensatory response to maintain normal blood pressure in the presence of chronic ECF volume
depletion.) There is also increased renal prostaglandin E2 production
The above changes produce the characteristic biochemical disturbance of
hypochloraemic/hypokalaemic alkalosis
Crucial to the diagnosis is the finding of inappropriately high levels of urinary Cl and Na+
usually >20 mmol/l; urine Ca2+ is normal or high (compare Gitelman syndrome see below)
Therapy involves K+ supplementation combined with prostaglandin synthetase inhibitors, usually
indometacin
Pseudo-Bartter syndrome
The same plasma biochemistry hypochloraemic hypokalaemic alkalosis but appropriately low
levels of urine Cl and Na+ <10 mmol/l
Main causes are:

Cystic fibrosis sweat loss of NaCl and water
Congenital chloride diarrhoea gastrointestinal loss
Laxative abuse gastrointestinal loss
Cyclical vomiting
Note that all the changes of Bartter syndrome, including the high urine electrolyte levels, may be
produced by loop diuretics, which block the same site in the thick ascending limb of the loop of
Henle.
7.3 Distal tubule

Gitelman syndrome
This condition is considered a variant of Bartter syndrome
There is an inborn autosomal recessive defect in the distal tubule Na+/Cl co-transporter
Often asymptomatic, with transient episodes of weakness and tetany with abdominal pain and
vomiting
Patients have hypokalaemic metabolic alkalosis, raised renin and aldosterone, and
hypomagnesaemia with increased urinary magnesium wasting, and hypocalciuria, a feature that
helps distinguish it from classic Bartter syndrome (in which urinary Ca2+ is normal or high see
above)
Biochemical changes resemble those produced by thiazide diuretics, which inhibit this distal tubule
co-transporter
7.4 Collecting duct

Nephrogenic diabetes insipidus
Resistance to action of high circulating levels of ADH
Associated with ADH-receptor gene mutations (X-linked nephrogenic diabetes insipidus) and
aquaporin (water-channel) gene mutations (autosomal recessive nephrogenic diabetes insipidus)
High volumes of inappropriately dilute urine with tendency to hypernatraemic dehydration
Liddle syndrome
See Section 3.3.
Pseudohypoaldosteronism
See Section 3.3.
8. NEPHROTIC SYNDROME
A triad of oedema, proteinuria and hypoalbuminaemia. It is almost always idiopathic in childhood. It
is best classified by response to steroid treatment steroid-sensitive nephrotic syndrome (SSNS; 85
90% cases) or steroid-resistant nephrotic syndrome (SRNS; 1015% cases), because this is the best
predictor of outcome.
8.1 Definitions
Remission negative urinalysis on first morning urine for three consecutive mornings
Relapse 3+ proteinuria on three or more consecutive first morning urines
Frequently relapsing two or more relapses within 6 months of diagnosis; or four or more relapses
per year
Steroid resistant no remission after 4 weeks of prednisolone 60 mg/m2 per day
8.3 Complications
Infection
Typically with Streptococcus pneumoniae;
Pneumonia
Primary pneumococcal peritonitis
Increased risk as a result of:
Tissue oedema and pleural and peritoneal fluid
Loss of immunoglobulin in urine
Immunosuppression with steroid treatment
Thrombosis
Increased risk as a result of:
Loss of antithrombin III and proteins S and C in urine

Increased production of procoagulant factors by liver
Increased haematocrit secondary to reduced oncotic pressure
Swelling of legs, ascites and relative immobility
Steroid therapy
Hypovolaemia
Reduced plasma oncotic pressure leads to shift of plasma water from intravascular space to
interstitial space
Symptoms include oliguria, abdominal pain, anorexia and postural hypotension
Signs include cool peripheries, poor capillary refill and tachycardia
Poor renal perfusion activates the reninangiotensinaldosterone system, and urine Na+ will
therefore be very low usually <10 mmol/L
Occasionally acute tubular necrosis develops secondary to hypovolaemia
Drug toxicity
Most morbidity in childhood nephrotic syndrome arises from side effects of steroid treatment
Nephrotoxicity from ciclosporin or tacrolimus (see below)
8.4 Treatment
Initial presentation
The most commonly used prednisolone regimen in the UK has been:
Prednisolone 60 mg/m2 per day for 4 weeks; then reduce to 40 mg/m2 on alternate days for 4
weeks; then stop
However, there is good evidence from controlled trials that longer duration of initial prednisolone
treatment is associated with fewer relapses and lower total prednisolone dose over the first 2 years.
An example of a 6-month initial course is:
60 mg/m2 per day for 4 weeks; then 40 mg/m2 on alternate days for 4 weeks; 30 mg/m2 on alternate
days for 4 weeks; 20 mg/m2 on alternate days for 4 weeks; 10 mg/m 2 on alternate days for 4
weeks; 5 mg/m2 on alternate days for 4 weeks; then stop
Relapse
In cases of relapse the most commonly used prednisolone regimen is:
Prednisolone 60 mg/m2 per day until in remission; then 40 mg/m2 on alternate days for three doses;
and reduce alternate-day dose by 10 mg/m2 every three doses until 10 mg/m2 on alternate days is
reached; then 5 mg/m2 on alternate days for three doses; then stop
Frequently relapsing or steroid-dependent nephrotic syndrome

Other drugs that have been successfully used to enable control without steroids, or with much lower
doses of steroids, include:
Cyclophosphamide:
Often used as first choice of second-line drug
2 mg/kg for 12 weeks, or 3 mg/kg for 8 weeks
Hair thinning, bone marrow suppression
Tacrolimus (FK506):
Taken twice daily long term, e.g. 1218 months for initial trial
High relapse rate when weaned/stopped
Can cause nephrotoxicity need to monitor plasma tacrolimus levels and GFR
Ciclosporin:
Hirsutism, gum hyperplasia, nephrotoxicity
Mycophenolate mofetil
Most recent immunosuppressive drug tried in nephrotic syndrome
Efficacy may be similar to tacrolimus, but not nephrotoxic
Gastrointestinal intolerance is the most common side effect
Levamisole
Need to monitor full blood count for bone marrow suppression
Steroid-resistant nephrotic syndrome
Patient should be referred to specialist renal unit for assessment including renal biopsy
Usually resistant to other drug treatments also, so full remission not achieved
Aim is to reduce proteinuria so that patient is no longer nephrotic
The most common treatment is alternate-day prednisolone combined with ciclosporin long term
Screen for podocin (NPHS2) mutations patients almost never respond to immunosuppression so
can avoid unnecessary drug toxicity
Angiotensin-converting enzyme (ACE) inhibitor (e.g. enalapril) and/or angiotensin II receptor
blocker (e.g. losartan) often used to treat hypertension, with the added benefit of anti-proteinuric
effect
Significant chance of hypertension and progression to renal failure
If histology is FSGS, associated with 2040% chance of recurrence after transplantation; however,
patients with identifiable podocin or other gene mutations have a much lower risk of disease
recurrence
8.5 Congenital nephrotic syndrome
Onset in first 3 months of life; large placenta usually 40% of birthweight

Almost always resistant to drug treatment; clinically severe with high morbidity from protein
malnutrition, sepsis
Main causes are, in decreasing order of frequency:
Finnish-type congenital nephrotic syndrome most severe; autosomal recessive; gene (NPHS1)
on chromosome 19 normally codes for nephrin, a cell adhesion protein located at the glomerular
slit diaphragm
Diffuse mesangial sclerosis less severe; also autosomal recessive
DenysDrash syndrome includes pseudohermaphroditism and Wilms tumour
FSGS
Secondary congenital nephrotic syndrome congenital syphilis
Treatment is intense supportive care with 20% albumin infusion, nutritional support and early
unilateral nephrectomy (to reduce urinary protein loss), combined with ACE inhibitors and
indometacin (to reduce GFR, and thus protein loss, of remaining kidney)
Eventual progression to renal failure occurs, when remaining kidney is removed, and the child
undergoes dialysis and transplantation
9. GLOMERULONEPHRITIS
9.1 General clinical features
Inflammation of the glomeruli leading to various clinical features, or renal syndromes, which may
include:
Haematuria and/or proteinuria
Nephrotic syndrome
Acute nephritic syndrome with reduced renal function, oliguria and hypertension
Rapidly progressive crescentic glomerulonephritis rapid-onset severe renal failure and
hypertension, usually associated with the histological lesion called a crescent
These renal syndromes are not specific to particular conditions and the same condition may present
with different renal syndromes in different patients
Chronic glomerulonephritis may lead to scarring of the tubulointerstitial areas of the kidney, with
progressive renal impairment
The main causes of glomerulonephritis, and the associated changes in serum complement, include
those shown in the table
The main causes of glomerulonephritis

Normal complement
Reduced complement
Primary renal disease:

FSGS
IgA nephropathy
Primary renal disease:

Acute post-streptococcal GN C3, normal C4 Mesangiocapillary GN
(MCGN) C3 and C4
Systemic disease:
Henoch-Schnlein
nephritis
Systemic disease:
Systemic lupus erythematosus C3 and C4 Shunt nephritis C3 and C4
GN, glomerulonephritis.
9.2 Acute post-streptococcal glomerulonephritis

Onset of reddish-brown (Coca Cola-coloured) urine 1014 days after streptococcal throat or skin
infection
May have any of the renal syndromes described above
Deposition of immune complexes and complement in glomeruli
Investigations include:
Throat swab
Antistreptolysin O (ASO) titre; anti-DNAase B
Typically C3, normal C4
Biopsy if there is significant renal involvement diffuse proliferative glomerulonephritis is seen,
with crescents, in severe cases
Treatment is mainly supportive, with an excellent prognosis for recovery; in very severe cases
involving renal failure, steroids have been used
Note: always check C3 and C4 3 months after acute illness should normalize; if still lowered there
may be another diagnosis, e.g. systemic lupus erythematosus or MCGN, which has much worse
prognosis.
9.3 HenochSchnlein nephritis

Seventy per cent of children with HenochSchnlein purpura will have some degree of renal
involvement, usually just microscopic haematuria with/without proteinuria
They may have any of the renal syndromes described above
They may have a relapsing course
Refer to specialist renal unit if nephrotic, or nephritic, or sustained hypertension because these
patients may require biopsy
Prognosis is difficult to be certain about, but initial clinical severity and histological score on
biopsy guide the prognosis
No convincing evidence that treatment with steroids at onset of rash prevents renal involvement
(though steroids may be used for systemic symptoms such as abdominal and joint pain)
Treatment of severe cases includes steroids, azathioprine or mycophenolate mofetil (MMF); for
very severe crescentic nephritis with renal failure, methylprednisolone combined with intravenous
cyclophosphamide and plasma exchange has been used
Histologically identical to IgA nephropathy see Section 9.4
Follow-up should continue for as long as there continues to be any abnormality on urinalysis
Accounts for 58% of children in end-stage renal failure
9.4 IgA nephropathy

Presents with incidental finding of persistent microscopic haematuria or with an episode of
macroscopic haematuria which is typically associated with concurrent upper respiratory infection
these episodes may be recurrent
Again, may have any of the renal syndromes described above
Prognosis for childhood presentation is quite good, although 1015% will develop proteinuria,
hypertension with/without renal failure during long-term follow-up
Treatment as for HenochSchnlein purpura nephritis; ACE inhibitors used for long-term control of
hypertension and to minimize proteinuria
9.5 Systemic lupus erythematosus nephritis

Again, may present with various renal syndromes
Histologically variable and the condition may change its clinical and histological features and
severity over time
Treatment of nephritis usually steroids + MMF
Patients may also manifest the antiphospholipid/anticardiolipin antibody syndrome, with thrombotic
complications affecting the renal vasculature
9.6 Shunt nephritis

Classically associated with infected ventriculoatrial shunts these are now rarely used so the
condition is rare
Histologically similar to nephritis of subacute bacterial endocarditis
10. ACUTE KIDNEY INJURY

An acute disturbance in fluid and electrolyte homeostasis, typically associated with oliguria (<300
ml/m2 per day) and retention of urea, potassium, phosphate, H+ and creatinine. It is rare in childhood
compared with the incidence in elderly people. The main cause of severe acute renal failure in
otherwise normal children is haemolytic/uraemic syndrome.
10.1 Classification of acute kidney injury

Prerenal failure with reduced renal perfusion
In the early stages, the kidney reacts appropriately producing small volumes of urine with very low
Na+ and high concentration of urea; may be reversible at this stage with fluid therapy (with/without
inotropic support)
If uncorrected, progresses to established acute tubular necrosis
Main causes are:
ECF volume deficiency haemorrhage, diarrhoea, burns, DKA, septic shock with third-space
fluid loss
Cardiac (pump) failure congenital heart disease, e.g. severe coarctation, hypoplastic left
heart, aortic cross-clamping and bypass for correction of congenital heart disease, myocarditis
Intrinsic renal failure

Acute tubular necrosis
Occurs as a result of:
Uncorrected prerenal failure as above
Toxins gentamicin, X-ray contrast, myoglobinuria; gentamicin toxicity most common in neonates,
and may cause non-oliguric renal failure
Acute glomerulonephritis see Section 9
Vascular
Small vessel occlusion haemolytic/uraemic syndrome
Bilateral renal vein thrombosis neonates
Acute renal cortical necrosis neonatal birth asphyxia
Tubulointerstitial nephritis
Drugs non-steroidal anti-inflammatory drugs, furosemide, penicillin, cephalosporins
Postrenal (obstructive) renal failure

Posterior urethral valves is main lesion, but not acute kidney injury
Neuropathic bladder may be acute in:
Transverse myelitis
Spinal trauma or tumour
Stones:
Bilateral pelviureteric junction or ureteral stone or bladder stone
Urethral prolapse of bladder ureterocele
10.2 Differentiating prerenal oliguria and intrinsic renal failure/acute tubular

necrosis
Clinical assessment of circulation in oliguric child is crucial:
Low blood pressure, poor capillary refill and cool peripheries suggest prerenal cause: may
respond to fluid challenge
Normal/raised blood pressure, raised jugular venous pressure (JVP), good peripheral perfusion,
gallop rhythm suggest intravascular volume overload and thus not prerenal, and fluid challenge is
contraindicated (though challenge with loop diuretic may improve urine output)
Urine biochemical indices may help
Urine indices in prerenal and intrinsic renal failure

Urine indices
Prerenal failure
Intrinsic renal failure
Osmolality
Urine Na+
Urine:plasma urea ratio
Fractional excretion of
Na+ (%)
>500
<10
>10:1
<1
<300
>40
<7:1
>1
10.3 Initial assessment of kidney injury failure

History may give clues to diagnosis:
Sore throat and fever 10 days earlier suggests post-streptococcal glomerulonephritis
Bloody diarrhoea and progressive pallor suggest haemolytic/uraemic syndrome
Drug history may reveal use of non-steroidal anti-inflammatory drugs (increasingly used for
childhood fever, earache, etc.)
Examination aims to:
assess circulation see Section 10.2
look for clues to diagnosis drug rash suggests interstitial nephritis; large palpable bladder
suggests acute obstructive nephropathy
Initial investigations:
Blood:
Electrolytes, chloride, urea, creatinine, phosphate, calcium, magnesium, urate, liver function
tests, venous or capillary blood gas
Full blood count, blood film (red blood cell fragments in haemolytic/uraemic syndrome)
Urine:
Urinalysis for blood, protein; glucose (a clue to interstitial nephritis)
Urine microscopy for casts
Urine Na+, urea, creatinine, osmolality see table above
Ultrasonography of urinary tract:
With most causes of acute kidney injury, kidneys appear normal or increased in size, with
slightly increased echogenicity (if kidneys appear small with poor corticomedullary
differentiation, renal failure is chronic)
Rules out or confirms obstruction of urinary tract; stones
Can detect clot in renal vein thrombosis
Renal biopsy if diagnosis not clear from above assessment
10.4 Initial management of child with acute kidney injury

Early liaison with paediatric renal unit
Fluid therapy determined by clinical assessment and urine indices, as above:
Prerenal failure: fluid challenge with physiological 0.9% saline
Intrinsic renal failure:
If clinically euvolaemic, give fluid as insensible loss (300 ml/m2 per day) + urine output
If clinically overloaded, challenge with loop diuretic and restrict to insensible losses
If hypertensive because of ECF volume overload:
Challenge with loop diuretic
Nifedipine or hydralazine as simple vasodilating hypotensives
If hyperkalaemic, treat as in Section 6.4
Note that if anaemic, e.g. in haemolytic/uraemic syndrome, transfusion usually delayed until dialysis
access is established (i.e. until transferred to renal unit), because hyperkalaemia and fluid overload
may be worsened
10.5 Indications for acute dialysis
Severe ECF volume overload severe hypertension, pulmonary oedema, no response to diuretics
Severe hyperkalaemia, not responding to conservative treatment
Severe symptomatic uraemia usually urea >40 mmol/l
Severe metabolic acidosis not controllable with intravenous bicarbonate
To remove fluid to make space for nutrition (intravenous or enteral), intravenous drugs a
common reason in intensive care patients
Removal of toxins haemodialysis will be most effective for low-molecular-weight substances
that are not highly protein bound, including:
Drugs gentamicin, salicylates, lithium
Poisons ethanol, ethylene glycol
Metabolites from inborn errors of metabolism leucine in maple syrup urine disease, ammonia
10.6 Haemolyticuraemic syndrome (HUS)

Most common cause of acute kidney injury in children
Diarrhoea-associated HUS (D+ HUS) is the major type, usually as the result of Escherichia coli
O157, which produces verocytotoxin (also called shiga toxin)
Toxin is released in gut and absorbed, causing endothelial damage especially in renal
microvasculature, leading to microangiopathic haemolytic anaemia with thrombocytopenia and red
blood cell fragmentation (seen on blood film)
The microangiopathy leads to patchy focal thrombosis and infarction, and renal failure which is
often severe and requires dialysis
Brain (fits, focal neurology), myocardium, pancreas and liver are sometimes affected
Treatment is supportive; antibiotic treatment of the E. coli gastroenteritis increases the incidence
and severity of HUS, and is thus contraindicated
Long-term follow-up shows that 1015% will develop hypertension, proteinuria or impaired renal
function
Atypical D HUS is rare but more serious, with recurrent episodes, progressive renal impairment
and higher incidence of neurological involvement:
Autosomal recessive forms associated with disturbances of complement regulation, e.g. mutations
in complement factor H gene
Rare complication of bone marrow transplantation
11. CHRONIC KIDNEY DISEASE, DIALYSIS AND TRANSPLANTATION

A persistent impairment of renal function, classified according to the GFR as mild (6080 ml/min per
1.73 m2), moderate (4059 ml/min per 1.73 m2) and severe (<40 ml/min per 1.73 m2). End-stage
renal failure, where dialysis or transplantation is needed, is reached once GFR <10 ml/min per 1.73
m2.
11.1 Main causes

Congenital dysplasia obstruction

Reflux nephropathy
Chronic glomerulonephritis FSGS, MCGN
Genetically inherited disease:
Hereditary nephritis Alport syndrome, nephronophthisis
Systemic disease HenochSchnlein purpura, systemic lupus erythematosus
11.2 Clinical presentations

Antenatal diagnosis
Faltering growth, poor growth, pubertal delay
Malaise, anorexia
Anaemia
Incidental blood test, urinalysis
Hypertension
11.3 Main clinical features

Poor growth
Anorexia, vomiting (uraemia)
Anaemia, acidosis and renal osteodystrophy see below
Reduced effectiveness of growth hormone, probably as the result of raised levels of insulin-like
growth factor (IGF)-binding protein, and hence less free IGF; levels of growth hormone are normal
Recombinant human growth hormone is effective in improving growth in children with chronic
renal failure, and is licensed for this use
Dietary considerations
Inadequate calorie intake and catabolism worsens acidosis, uraemia and hyperkalaemia in chronic
renal failure; aggressive nutritional management is crucial to control these, and to achieve growth
Children with chronic renal failure often have poor appetite, and infants in particular benefit from
nasogastric or gastrostomy tube feeding
Congenital dysplasia obstruction typically causes polyuria, with NaCl and HCO3 wasting, and
these need supplementing along with generous water intake; note that salt and water restriction is
inappropriate in many children with chronic renal failure, until they reach end-stage renal failure
Protein intake should usually be the recommended daily intake for age; note that protein restriction
is inappropriate for children with chronic renal failure
Dietary restriction of PO43 (dairy produce) combined with use of PO43 binders (e.g. calcium
carbonate) is essential in controlling secondary hyperparathyroidism
Dietary restriction of K+ (fresh fruits, potatoes) is also commonly needed
Anaemia
Dietary iron deficiency
Reduced red blood cell survival in uraemia
Erythropoietin deficiency; recombinant human erythropoietin is available for treatment
Renal osteodystrophy
There are two main contributing processes:
Phosphate retention leads to hypocalcaemia, and both increased PO43 and decreased Ca2+
stimulate secondary hyperparathyroidism:

Subperiosteal bone resorption
Deficient renal 1-hydroxylase activity and deficient 1,25(OH)2-D3 also contributes to
hypocalcaemia, and leads to rickets
Treatment includes control of hyperphosphataemia (see above) and alfacalcidol (1-OHcholecalciferol) or calcitriol
Metabolic acidosis
Contributes to bone disease, because chronic acidosis is significantly buffered by the uptake of H+
into bone in exchange for Ca2+ loss from bone
Hypertension
Depends on the underlying cause of the chronic renal failure
Congenital dysplasia obstruction patients tend to be polyuric, salt wasting and normotensive
Chronic glomerulonephritis, polycystic kidney disease, systemic disease hypertension is common;
usually secondary to increased renin, so ACE inhibitors are often effective
11.4 Dialysis
Once the GFR falls to 10 ml/min per 1.73 m2, the child will usually need dialysis, or transplantation,
to be maintained safely. The two main types of dialysis, peritoneal dialysis and haemodialysis, both
depend on a semipermeable membrane to achieve solute removal (K+, urea, PO43, creatinine, etc.),
and fluid removal.
Infants and small children are better suited to peritoneal dialysis, which is more physiological and
avoids abrupt haemodynamic changes.
PD, peritoneal dialysis
11.5 Transplantation
The proportion of living related donor transplants in paediatric units (50-70% of transplants) is
higher than the national figure overall a parent is usually the donor
Transplantation before the need for dialysis is usually the aim
There are advantages to living related donor transplantation:
Better long-term survival of the graft kidney: approximate figures are 95% at 1 year, 8085% at 5
years, 60% at 10 years
Surgery is planned, so family life can be organized to work around this
Increases the chance of achieving transplantation without dialysis
Human leukocyte antigen (HLA) matching is based around HLA-A, -B and -DR; on average a
parent and child will be matched for one allele, and mismatched for one allele, at each site
The main immunosuppressive drugs are prednisolone, tacrolimus and azathioprine
Children should receive all routine childhood immunisations, and also be immune to tuberculosis,
chickenpox and hepatitis B before transplantation
Children must weigh >10 kg for transplantation to be performed
The main complications of transplantation include:
Early surgical complications bleeding, transplant artery thrombosis, wound infection
Rejection diagnosed on biopsy; usually treatable with extra immune suppression
Opportunistic infection fungal infections, cytomegalovirus, Pneumocystis jiroveci pneumonia
Drug toxicity hypertension, cushingoid changes, hirsutism and nephrotoxicity from ciclosporin
Post-transplantation lymphoproliferative disorder lymphoma-like condition, especially
associated with primary EpsteinBarr virus infection when immunosuppressed
12. URINARY TRACT INFECTION AND NEUROPATHIC BLADDER

12.1 Urinary tract infection
See http://guidance.nice.org.uk/CG54 for published NICE guideline
Most common presenting urinary tract problem 1% boys and 3% girls
Boys outnumber girls until 6 months (posterior urethral valves); thereafter girls outnumber boys
Significance of UTI:
Renal scar gives 1520% risk hypertension
Reflux nephropathy causes 1520% end-stage renal failure
Age at greatest risk for renal damage, age in which symptoms of UTI are least specific, age group
most often seen with fever by general practitioners and age at which proper urine samples are
hardest to obtain infancy
Collection of an uncontaminated urine sample is crucial to accurate diagnosis of UTI methods
include:
Clean catch
Adhesive bag problems with leakage and faecal contamination
Absorbent pad also prone to contamination
Catheter specimen, or suprapubic aspirate suitable if urine sample is needed urgently, e.g.
septic screen in ill infant
Predisposing factors for UTI

VUR:
Familial, behaves as autosomal dominant condition
May be graded according to severity on MCUG
Management based on long-term, low-dose antibiotic prophylaxis (although no convincing
randomized prospective controlled trials have been reported, this remains the standard of care
currently)
Significant spontaneous resolution rate; less likely in grades IV and V
Controlled studies show no benefit for surgery over conservative management for grades IIII
Surgery may be indicated where prophylaxis fails to control infection and where there is
progressive reflux nephropathy; options are reimplantation of ureters or endoscopic injection of
synthetic material at ureteric orifice
Screening of newborn siblings or offspring of index children or parents should be considered
In children who have normal bladder control and no symptoms of detrusor dysfunction, and who
have been free of infection on prophylaxis, evidence suggests that there is little benefit from
continuing prophylaxis beyond age 5 years
Incomplete bladder emptying:
Posterior urethral valves
Neuropathic bladder
Catheterization or instrumentation of urinary tract
Stones
Grading of vesicoureteric flux
Classification of UTI (according to NICE Guidelines)

Atypical UTI
Recurrent UTI
Seriously ill
Poor urine flow
Two or more episodes of UTI with acute pyelonephritis/upper

urinary tract infection
Abdominal or bladder mass

Raised creatinine
Septicaemia
Failure to respond to treatment
with suitable antibiotics within
48 hours
Infection with non-E. coli
organisms
One episode of UTI with acute pyelonephritis/upper urinary tract

infection plus one or more episode of UTI with cystitis/lower
urinary tract infection
Three or more episodes of UTI with cystitis/lower urinary tract
infection
Investigation of UTI (according to NICE Guidelines)

Aims
To identify scarring
To identify underlying abnormalities likely to cause recurrent infection VUR; incomplete
emptying
There has been much debate about the investigation of UTI but the scheme below follows current
NICE Guidelines
Indirect radioisotope reflux study (e.g. MAG-3) see Section 4.5 may be used for subsequent
follow-up of VUR detected on MCUG during infancy
9 10 11 11 10
Prevention of UTI
Non-pharmacological methods:
Avoidance of constipation; correct bottom wiping
Frequent voiding and high fluid intake; double voiding
Lactobacilli in live yoghurt; cranberry juice
Clean intermittent catheterization: requires training of carer or child by specialist nurse
Prophylactic antibiotics
Treatment of UTI
NICE guidelines recommend use of urgent microscopy and culture for diagnosis of UTI in infants <3
years old; and dipstick testing as initial test for children 3 years old:
If the infant or child is younger than 3 months; treat with parenteral antibiotics
If the infant or child is 3 months or older with pyelonephritis/upper urinary tract infection:
Treat with oral antibiotics for 710 days
If oral antibiotics cannot be used, use intravenous antibiotics for 24 days followed by oral
antibiotics for a total duration of 10 days
If the infant or child is 3 months or older with cystitis/lower UTI:
Treat with oral antibiotics for 3 days
If the child is still unwell after 2448 hours they should be reassessed; if no alternative diagnosis,
send urine for culture
>90% childhood UTIs are E. coli
Obstructed kidneys may need drainage
Bladder catheter if bladder outlet obstruction
Nephrostomy insertion if PUJ or VUJ level obstruction
Stones may need removing
Augmented bladders may improve with mucolytic and bacteriostatic washouts:
Parvolex washouts; chlorhexidine washouts
12.2 Neuropathic bladder

Important cause of renal damage:
UTI caused by incomplete emptying
High-pressure VUR
Progressive renal scarring
Causes
Spina bifida, sacral agenesis (maternal diabetes)
Tumour, trauma
Transverse myelitis
Types
Hyperreflexic high pressure, detrusor-sphincter dyssynergia
Atonic large, chronically distended, poorly emptying
Principles of management
Videourodynamic assessment of type of bladder dysfunction

Careful assessment of kidney structure, scarring, function, blood pressure
Improve emptying with clean intermittent catheterization
Anticholinergics (oxybutinin) may help reduce unstable contractions
Augmentation cystoplasty larger capacity, lower pressure
13. NOCTURNAL ENURESIS

See http://guidance.nice.org.uk/CG111 for published NICE guideline
This is a common condition that is benign but which may cause distress and psychological upset to the
child and family. Most children become dry at night 69 months after becoming dry by day, which is
usually by 3 years. As a simple guide, 10% of 5 year olds and 5% of 10 year olds wet the bed at least
one night per week. It is more common in boys.
The NICE guideline referred to above has full and detailed information on all aspects of nocturnal
enuresis.
13.1 Definitions
Primary nocturnal enuresis (80%) never achieved night-time dryness

Secondary nocturnal enuresis recurrence of bedwetting having been dry for >6 months
Initial successful response 14 consecutive dry nights within 16 weeks of starting treatment
Relapse more than 2 wet nights in 2 weeks
Complete success no relapse within 2 years of initial success
13.2 Aetiology
Rarely an organic cause; should be distinguished from true incontinence, e.g. as a result of
neuropathic bladder or ectopic ureter, when child is never dry
Genetic component:
More common where there is a first-degree relative with history of enuresis
Concordance in monozygotic twins twice that in dizygotic twins
No significant excess of major psychological or behavioural disturbance, although family stress,
bullying at school, etc. may trigger secondary enuresis and such factors should be sought in the
history
Evidence from studies that:
In younger children, bladder capacity is reduced compared with non-enuretic children
In older children and adolescents, there is reduction in the normally observed rise in nocturnal
ADH levels and in the decrease in nocturnal urine volume (hence rationale for desmopressin
[DDAVP] treatment see Section 13.4)
13.3 Assessment
Careful history is crucial
Examination should exclude abnormalities of abdomen, spine, lower limb neurology, hypertension
No routine investigations are indicated, other than urinalysis if the enuresis has started recently or if
there are other symptoms suggesting UTI
13.4 Treatment
Sustained and frequent support and encouragement for child and parents from an enthusiastic carer
(doctor, nurse) is the most essential factor in seeing improvement. Any treatment must involve the
child, and depends for success on their motivation.
Star charts; colouring-in charts simple behavioural reward therapy that is successful in many
children, and should be part of the monitoring of all interventions
Enuresis alarms:
Mat on bed attached to bed-side buzzer
Small moisture sensor worn between two layers of underwear with vibrator alarm attached to
pyjamas (has the advantage of detecting wet underwear rather than waiting to detect a wet bed)
More effective than drug therapies in direct comparative trials
Should be mainstay of treatment, but enthusiastic and supportive care, and involvement of child
(e.g. they should get up and change bedding) are crucial to success
Reassess after 4 weeks of use:
Continue with alarm if early signs of some response; if 2 weeks of consecutive dry nights, stop
alarm; consider alarm use again if enuresis recurs
Consider adding desmopressin if no sign of improvement
Drug therapy:
Desmopressin (oral or intranasal) meta-analysis of all published trials showed relatively poor
short-term complete response rate, high relapse rate and poor long-term cure rate; more effective in
older children; useful for short-term control for special situations, e.g. school trip; may be
combined with alarm
Oxybutinin should be restricted to those children with a clear history of detrusor instability
daytime urgency, frequency, urge incontinence many of whom also wet the bed
Imipramine low long-term success rate; high relapse rate; potentially serious side effects; rarely
used
14. HYPERTENSION
Most significant hypertension in childhood is secondary to an underlying cause. Essential
hypertension is a diagnosis of exclusion; the typical patient is an obese adolescent with mild
hypertension and a family history of hypertension.
What is normal?
Blood pressure rises throughout childhood, related to age and height
Depends on method and frequency of measurement

US Task Force on Blood Pressure Control produced centile charts based on 60 000 normal children
and teenagers see www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.pdf
What is abnormal?
Consistently above the 95th centile for age
Loss of normal diurnal pattern
Infants and toddlers may require admission to hospital for blood pressure monitoring to make
diagnosis
14.1 Ambulatory blood pressure monitoring
Ambulatory blood pressure monitoring (ABPM).
14.2 Causes of secondary hypertension

Cause
Renal
Reflux nephropathy
Glomerulonephritis, e.g. FSGS
Renal artery stenosis
Middle aortic syndrome, e.g. neurofibromatosis type
1;
Potentially curable by
surgery/intervention
If unilateral only
Williams syndrome
Coarctation
Endocrine
Phaeochromocytoma
Cushing syndrome
Other
Depends on cause
14.3 Evaluation of hypertension by increasing level of invasiveness
HT, hypertension
14.4 Treatment of hypertension

Short-term treatment of acute hypertension
Most common clinical indication is acute nephritis with salt and water retention; simple and welltolerated combination would be a loop diuretic, e.g. furosemide, plus a vasodilating Ca2+-channel
blocker, e.g. nifedipine
Phaeochromocytoma and blockers, e.g. phenoxybenzamine + labetolol
Urgent treatment of hypertensive encephalopathy

Severe hypertension with headache, vomiting, hyperreflexia, seizures
Principle of treatment is:
controllable reduction with intravenous infusions labetolol; sodium nitroprusside
gradual reduction end-organ damage, e.g. seizures often controlled before normal blood
pressure is seen
risk of treatment is too rapid reduction causing stroke; cortical blindness
Long-term treatment of chronic hypertension
Aim to use single agent if possible, and select long-acting once-daily agent to aid compliance, e.g.
blocker atenolol
Ca2+-channel blocker amlodipine
ACE inhibitor enalapril; logical choice for hypertension secondary to chronic renal disease
(e.g. reflux nephropathy; FSGS); also has an anti-proteinuric effect; relatively contraindicated in
renal artery stenosis
15. INHERITED DISEASES

15.1 Polycystic kidney disease
Autosomal recessive polycystic kidney disease (ARPKD)
Gene is on chromosome 6
Tubular dilatation of distal collecting ducts, i.e. not true cysts
Antenatal ultrasonography large echobright kidneys; oligohydramnios
At birth or early infancy large palpable renal masses; respiratory distress secondary to
pulmonary hypoplasia
At any time signs and symptoms of chronic renal failure; hypertension often very severe
Median age for onset of end-stage renal failure around 12 years, although may cause severe renal
failure in infancy; very variable disease severity even within same family
Always associated with congenital hepatic fibrosis, which may vary from subclinical to causing
liver disease the dominant clinical feature; complications include ascending cholangitis
Autosomal dominant polycystic kidney disease (ADPKD)

At least two gene loci; most common on chromosome 16 (adjacent to tuberous sclerosis gene);
normal gene product is polycystin
True cysts arising from tubules get larger and more numerous with time and hence cause
progressive decline in renal function
An important cause of hypertension and renal failure in adults although may present in childhood
Clinical presentation again, very variable in age and severity:
Antenatal ultrasonography discrete cysts in fetal kidneys (note; always scan parents kidneys)
Microscopic haematuria
Hypertension; renal failure
Incidental finding of renal cysts during abdominal ultrasonography first cysts may not appear
until patient is in 20s; may be unilateral
Associated with cerebral aneurysms and subarachnoid haemorrhage
15.2 Alport syndrome
Hereditary nephritis with sensorineural deafness and anterior lenticonus (conical deformity of lens
of eye seen with slit-lamp)
X-linked (most common) and autosomal recessive forms
X-linked males affected; female carriers all have microscopic haematuria; with lyonization
some females may develop hypertension and renal disease, but with milder and later onset
Autosomal recessive (chromosome 2) both sexes equally severe
Basic defect is in production of subunits for type IV collagen (two subunits coded for on X
chromosome, two on chromosome 2); type IV collagen is located in kidney, eye and inner ear
hence the main clinical features
Presents with incidental finding of microscopic haematuria, or episode of macroscopic haematuria
Deafness around 10 years
Hypertension in mid-teens
Eye signs in midlate teens (not before 12 years)
Average age for end-stage renal failure is 21 years
15.3 Nephronophthisis
Autosomal recessive condition; gene (called NPHP1) on chromosome 2

Produces polyuria (concentrating defect), growth delay and often severe anaemia
Urinalysis typically bland sometimes a trace of glucose
Progresses to end-stage renal failure towards the end of the first decade
Sometimes associated with tapetoretinal degeneration: SeniorLken syndrome
16. NEPHROCALCINOSIS AND NEPHROLITHIASIS

16.1 Nephrocalcinosis
Diffuse speckling calcification is seen on ultrasound scans or plain radiograph.
Distal RTA
Ex-premature neonates:
Furosemide hypercalciuria
Steroids hypercalciuria
Vitamin D treatment for hypophosphataemic rickets:
Enhances tubular reabsorption of Ca2+
Oxalosis:
Autosomal recessive disorder
Primary hyperoxaluria associated with defect in alanine:glyoxylate aminotransferase (AGT)
enzyme, which leads to excess oxalate production and urinary oxalate excretion
Calcium oxalate precipitates, nephrocalcinosis and obstructing stones form, renal failure ensues
Systemic oxalosis joints, heart, blood vessels
Treatment liver transplantation alone if renal function only moderately reduced; sequential liver
then kidney transplantation if renal failure established, with intense dialysis therapy between the
two operations to lower the systemic oxalate burden (simultaneous liverkidney transplantation
presents high risk of oxalate deposition in newly transplanted kidney)
16.2 Nephrolithiasis stones

Uncommon in paediatrics
Painful haematuria
Revealed during investigation into UTI
Important to undertake metabolic analysis of timed urine collection, or of stone itself if possible,
because several metabolic diseases cause stones which may be recurrent
RTA, renal tubular acidosis; UTI, urinary tract infection.
17. FURTHER READING

Webb, NJ, Postlethwaite RJ, eds (2003). Clinical Paediatric Nephrology, 3rd edn. Oxford; Oxford
University Press.
Chapter 19
Neurology
Neil H Thomas
1. Developmental abnormalities of the nervous system

1.1 Normal development of the nervous system
1.2 Neural tube defects
1.3 Hydrocephalus
1.4 Disorders of cortical development
1.5 Other nervous system maldevelopments
2. Neonatal neurology
2.2 Hypoxicischaemic encephalopathy
2.3 Periventricularintraventricular haemorrhage
2.5 Brachial plexus injuries
3. Disorders ofmovement
3.1 Cerebral palsy
3.2 Ataxia
3.3 Dystonia
3.4 Tics, Gilles de la Tourette syndrome
4. Developmental disabilities
4.1 Learning disability
4.2 Autism
4.3 Attention-deficit hyperactivity disorder
4.4 Deficits in attention, motor control and perception
5. Epilepsy
5.1 Diagnosis
5.2 Definition and classification
5.3 Generalized epilepsies
5.4 Partial epilepsies

5.5 Assessment and treatment of epilepsies
5.6 Anticonvulsant drugs
5.7 Management of status epilepticus
6. Non-epileptic seizures
6.1 Anoxic seizures
6.2 Psychogenic seizures
7. Headaches
7.1 Tension headaches
7.2 Migraine
7.3 Other headaches
8. Abnormalities of head size and shape

8.1 Macrocephaly
8.2 Microcephaly
8.3 Abnormal head shape
9. Neuromuscular disorders
9.1 The floppy infant
9.2 Duchenne muscular dystrophy
9.3 Becker muscular dystrophy
9.4 Other muscular dystrophies and congenital myopathies
9.5 Anterior horn cell disease
9.6 Neuropathies
9.7 Acute neuromuscular disorders
9.8 Disorders of neuromuscular junction
10. Central nervous system infections and parainfectious disorders

10.1 Meningitis
10.2 Encephalitis
10.3 Immune-mediated disorders
11. Cerebrovascular disease

11.1 Arterial occlusion
11.2 Venous thrombosis
12. Neuro-oncology
12.1 Posterior fossa tumours
12.2 Brain-stem tumours
12.3 Supratentorial tumours
13. Neurocutaneous disorders
13.2 Other neurocutaneous disorders
14. Neurometabolic diseases

14.1 Amino and organic acid disorders
14.2 Neurotransmitter and urea cycle disorders
14.3 Mitochondrial disease
14.4 Abnormalities of copper metabolism
14.5 Storage disorders
14.6 Leukodystrophies and other neurodegenerative disorders
15. Head injury

15.1 Mild closed head injury
15.2 Severe closed head injury
15.3 Non-accidental head injury
16. Specific neurological lesions

16.1 Cranial nerve lesions
16.2 Disorders of eye movement
16.3 Unequal pupils
17. Neurological investigations

17.1 Electroencephalography
17.2 Evoked potentials
17.3 Peripheral neurophysiology
17.4 Brain imaging
17.5 Lumbar puncture
18. Further reading
Neurology
1. DEVELOPMENTAL ABNORMALITIES OF THE NERVOUS SYSTEM

1.1 Normal development of the nervous system
The exact details of the normal development of the nervous system are complex, but the important
stages can be summarized in the table below:
1.2 Neural tube defects

Spina bifida occulta
Asymptomatic condition characterized by failure of closure of vertebral arch. Occurs in up to 5% of
the population.
Anencephaly
Failure of closure of the rostral aspect of the neural tube; 75% of affected infants stillborn.
Encephalocele
Protrusion of cerebral tissue through midline cranial defect located in frontal or occipital regions.
Meningocele
Cyst formed by herniation of meninges, usually over dorsum of spine. Neurological disability
minimal, risk of bacterial meningitis.
Meningomyelocele
Herniation of meninges, nerve roots and spinal cord through dorsal vertebral defect. Leads to motor
and sensory deficits below lesion, including sphincter disturbance. May be associated with other
malformations of spinal cord including ArnoldChiari malformation (downward displacement of
cerebellar tonsils through foramen magnum). Hydrocephalus may coexist, secondary to Arnold
Chiari malformation or aqueduct stenosis.
Prevention of neural tube defects

Clear evidence that preconceptual folate supplementation prevents production of neural tube defects.
Treatment of neural tube defects
Surgical repair of encephalocele, meningocele, myelomeningocele

Close observation for development of hydrocephalus and surgical treatment
Management of bladder and bowels. Possible intermittent bladder drainage
Orthopaedic management of limb deformities
Assessment of cognitive abilities
Treatment of seizures
1.3 Hydrocephalus
Defined as excess fluid within the cranium
Usually refers to increased volume of cerebrospinal fluid (CSF)
Production of CSF
Secreted by choroid plexus (plasma ultrafiltrate, then modified)
Flows through lateral ventricles, through third and fourth ventricles into posterior fossa and basal
cisterns
Reabsorbed through arachnoid granulations
Terms such communicating and non-communicating or obstructive hydrocephalus are now
obsolete.
Main aetiological mechanisms of hydrocephalus

Over-secretion
Obstruction:
Intraventricular
Extraventricular
Impaired resorption
Choroid plexus papilloma

Tumours, malformations, inflammation (post-haemorrhagic)
Inflammation, tumours, mucopolysaccharidoses
Venous sinus compression
Diagnosis (clinical)
May be asymptomatic
Irritability
Headache
Vomiting
Drowsiness
Increased head circumference
Tense anterior fontanelle
Splayed sutures
Scalp vein distension
Loss of upward gaze (sunsetting)
Neck rigidity
Decreased conscious level
Cranial nerve palsies
Investigations
Ultrasonography (when fontanelle open)

Computed tomography (CT)
Magnetic resonance imaging (MRI)
Measurement of CSF pressure by neurosurgical intervention may be indicated
Management
Decide need for operation by considering symptoms and rate of head growth
Surgical:
Ventriculostomy
Shunting (ventriculoperitoneal, ventriculoatrial)
1.4 Disorders of cortical development:

Lissencephaly
Brain has very few or no gyri, leaving the surface of the brain smooth. Leads to severe motor and
learning disability. Some 65% are associated with mutations in the LIS1 gene. Lissencephaly may be
associated with facial abnormalities and a deletion on chromosome 17p 13.3 in MillerDieker
syndrome.
Polymicrogyria
Increased numbers of small gyri, especially in temporoparietal regions. May be focal or generalized.
Periventricular heterotopia
Aggregation of neurons arrested in their primitive positions. May be part of complex brain
malformation syndromes.
Pachygyria
Thickened abnormal cortex. Depending on extent, may lead to cerebral palsy picture or epilepsy.
Agenesis of corpus callosum

Corpus callosum develops between weeks 10 and 12 of embryonic life. Agenesis may be isolated
(non-syndromic) or part of a syndrome such as Aicardi syndrome. Extent of other malformations
determines disability.
1.5 Other nervous system maldevelopments

DandyWalker malformation
Classic DandyWalker malformation includes:
Complete or partial agenesis of cerebellar vermis
Large cystic formation in posterior fossa due to dilatation of fourth ventricle
Hydrocephalus, which may not develop until adulthood
May be associated with other cerebral malformations. Considered part of a continuum including the
DandyWalker variant (part of vermis present, posterior fossa not enlarged) and megacisterna magna
(complete vermis, large retrocerebellar cyst).
Joubert syndrome
Familial agenesis of cererbellar vermis, associated with episodic hyperpnoea, ataxia and cognitive
impairment
Aqueduct stenosis
Cause of hydrocephalus in 11% of cases. Aqueduct may be reduced in size or may be represented by
numerous channels within aqueduct location. Can occur in X-linked syndrome.
2. NEONATAL NEUROLOGY
Seizures are a major neurological problem in the first 28 days of life.
Classification
Tonic seizures
Multifocal clonic
seizures
Focal clonic seizures
Subtle seizures
Myoclonic seizures
Stiffening of trunk and extremities

Rhythmic clonic movements of different parts of the body and various
seizures
Repetitive clonic movements of the same part of the body
Episodes of stereotyped bicycling, sucking and swallowing movements
Isolated repetitive brief jerks of the body
Causes
Hypoxicischaemic encephalopathy
Intracranial infection
Cerebral malformations
Metabolic disturbances
Withdrawal seizures
Familial neonatal convulsions
2.2 Hypoxicischaemic encephalopathy

The neonatal brain is highly resistant to hypoxiaischaemia compared with that of an adult. The
degree of hypoxiaischaemia necessary to damage the neonatal brain usually leads to impairment of
other organs.
Hypoxiaischaemia leads to depletion of brain phosphocreatine and ATP. Lactate increases.
Clinical features
A 5-minute Apgar score of <6, a metabolic acidosis and hypotension are all suggestive of asphyxia in
term infants.
Hypoxicischaemic encephalopathy in term infants

Stage 1 Hyperalert, tremulousness, poor feeding. Seizures infrequent
Stage 2 Lethargic, obtunded, hypotonic. Seizures may occur
Stage 3 Comatose. Seizures within 1224 hours
Outcome according to severity of hypoxicischaemic encephalopathy

Stage 1 Largely normal
Stage 2 5% die, 25% suffer neurological injury
Stage 3 80% die, 20% suffer neurological injury
2.3 Periventricularintraventricular haemorrhage

Usually a disease of preterm infants. Most haemorrhages originate in the subependymal germinal
matrix.
Potential consequences
Asymptomatic
Catastrophic collapse
Cerebral infarction
Post-haemorrhagic hydrocephalus

This is a pathological term to describe bilateral necrosis of periventricular white matter. Gliosis
ensues. It leads to interruption of the fibres responsible for lower limb and optic function, so that
periventricular leukomalacia is often the underlying pathology to the spastic diplegia and visual
impairment seen in survivors of preterm birth. Evidence now links susceptibility of preoligodendrocytes present between 26 and 34 weeks gestation with production of periventricular
leukomalacia.
2.5 Brachial plexus injuries

Traction injury to the brachial plexus can follow difficulty in delivery of the shoulders and head
during birth. A large baby, narrow birth canal and malpresentation may all contribute. Usually the
nerve roots are stretched but not completely avulsed. Clavicular or humeral fractures may also occur.
Erb palsy
C56 lesion
Affects deltoid, serratus anterior, supraspinatus, infraspinatus, biceps, brachioradialis
Arm is flaccid, adducted and internally rotated
Elbow is extended, wrist flexed (waiters tip)
Klumpke paralysis
C8T1 lesion
Affects intrinsic hand muscles so that flexion of wrist and fingers are affected
Cervical sympathetic involvement may lead to an ipsilateral Horner syndrome
Management
Physiotherapy
Consideration of nerve root surgery
3. DISORDERS OF MOVEMENT
3.1 Cerebral palsy
Cerebral palsy may be defined as a disorder of tone, posture or movement, which is due to a static
lesion affecting the developing nervous system. Despite the unchanging nature of the causative lesion,
its existence in a developing nervous system means that its manifestations may change over time.
Causes of cerebral palsy:

Prenatal insults:
Intrauterine hypoxicischaemic injury
Intrauterine infection
Toxins
Chromosomal disorders
Perinatal insults:
Hypoxicischaemic injury
Bilirubin encephalopathy
Postnatal insults:
Trauma
Bacterial meningitis
Viral encephalitis
Epidemiological studies suggest that at least 80% of cases of cerebral palsy are the result of
prenatally acquired causes. A minority are the result of intrapartum asphyxia.
Classification
Based on distribution of motor impairment and tone variations:
Spastic (characterized by fixed increase in muscular tone):
Hemiplegia
Diplegia
Quadriplegia
Athetoid (dyskinetic, dystonic):
Athetoid: writhing, involuntary pronation and flexion of distal extremity
Choreiform: dancing involuntary rapid semi-purposeful movements of proximal segments of
body
Ataxic:
Mixed
Spastic diplegia is most frequently seen as the result of periventricular leukomalacia in preterm
infants.
Athetoid cerebral palsy may result from either bilirubin encephalopathy or brief profound anoxic
ischaemic episodes.
Associated clinical features
Developmental delay
Tendency to joint contractures
Epilepsy
Perceptual difficulties
Visual and hearing impairment
Poor growth
Children with cerebral palsy need the care of a multidisciplinary team.
3.2 Ataxia
Acute cerebellar ataxia may occur after a viral infection. Appears to be due to both infectious and
post-infectious processes; most commonly follows varicella, plus measles, mumps, herpes simplex,
EpsteinBarr virus, Coxsackievirus and echovirus.
Occult neuroblastoma may also lead to acute ataxia.
A common cause is overdosage of drugs such as carbamazepine, phenytoin and benzodiazepines, plus
piperazine and antihistamines.
Other causes
Posterior fossa tumour
Migraine
Ataxiatelangiectasia
See Section 13.3.
Friedreich ataxia
Classified as a spinocerebellar degeneration

Autosomal recessive condition (9cen-q21)
Gene product frataxin
Involved in modulation of mitochondrial function
Clinical
Onset symptoms first or second decade

Loss of proprioception
Increasing impairment of cerebellar function
Development of pes cavus, nystagmus
Cardiomyopathy develops
Deterioration so that patients are usually not ambulant in 20s or 30s
Treatment
Currently symptomatic
Physiotherapy
Suitable aids and appliances
Antioxidant treatment such as idebenone has been shown to be of benefit in delaying cardiac
deterioration
3.3 Dystonia
Dystonia is a condition in which muscle tone is abnormal without pyramidal involvement. In many
dystonias, muscular tone varies with position of limbs. There may be a dystonic component to
cerebral palsy of hypoxicischaemic origin, but there are a number of clearly defined syndromes in
which dystonia is the main feature.
Torsion dystonia (dystonia musculorum deformans)
Genetically determined
Autosomal dominant with incomplete penetrance
Gene maps to 9q34 in Jewish families (DYT1)
Other unidentified gene responsible in some non-Jewish families
Clinical
Onset usually after 5 years
May be focal or generalized
Dystonia may be task specific, e.g. affected children may not be able to walk forward but can walk
backward normally
Often gradual spread to other parts of the body
Wilson disease should always be excluded
Treatment
High-dose anticholinergic drugs
Occasionally L-dopa
Dopa-responsive dystonia
Described by Segawa
Idiopathic dystonia
Symptoms vary throughout the day
Onset may be in the first 5 years
Gene map to 14q22.1-q22.2 (GTP cyclohydrolase 1)
Symptoms respond dramatically to low-dose L-dopa, which should be continued for life
Other important causes of dystonia

Wilson disease
Juvenile Huntington disease
3.4 Tics, Gilles de la Tourette syndrome
Tics are involuntary movements affecting specific groups of muscles so that that the affected
individual appears to have brief purposeless movements or actions. Tics may be motor or vocal.
Simple tics
Commonly affect children for a few months in mid-childhood
Up to 25% of children
Spontaneous resolution
Multiple tics
Some children are prone to tics of different type
Different motor tics, vocal tics
May not remit entirely
Gilles de laTourette syndrome

Defined by:
Multiple motor tics

One or more vocal tics
Onset before 21 years of age
Duration of >1 year
There is probably a continuum between multiple tics and Gilles de la Tourette syndrome.
Other characteristic features of Tourette syndrome

Echolalia (compulsive repetition of words or phrases just heard)
Coprolalia (compulsive swearing)
Attention-deficit disorder and obsessivecompulsive features are present in 50%
Treatment
Tics may respond to haloperidol, clonidine
4. DEVELOPMENTAL DISABILITIES
4.1 Learning disability
The term learning disability is now generally used in preference to the term mental retardation or
mental handicap. It covers a wide variety of conditions in which cognitive functioning is depressed
below average levels. In the USA, the term mental retardation is retained, with learning disability
being used to refer to failure to achieve cognitive potential.

Learning disability tends to be grouped according to severity: moderate learning disability usually
refers to IQ 5070, with severe learning disability being defined as IQ <50. The term profound
learning disability is sometimes used to refer to IQ <20.
The prevalence of learning disability is difficult to estimate. Prevalence of severe learning disability
has been estimated at 34 per 1000 but, although moderate learning disability is clearly more
common, its exact prevalence remains obscure.
Aetiology
This is easier to determine in severe learning disability.
In severe learning disability, the following potential causes are recognized:
Chromosomal
Genetic
Congenital anomalies
Intrauterine insults
Central nervous system infection
Familial
Unknown (about 20%)
Moderate learning disability

Same range of problems as severe learning disability
Unknown (55%)
Associated problems with learning disability
Cerebral palsy
Visual impairment
Hearing impairment
Behavioural difficulties
Baseline medical investigations for all children
Full history and examination

Karyotype including fragile X
Plasma amino acids
Urine mucopolysaccharide screen
Plasma creatine kinase (in boys aged <5 years)
Other tests may be indicated, depending on clinical features.
4.2 Autism
Autism is a disorder characterized by:
Disturbance of reciprocal social interaction.
Disturbance of communication (including language, comprehension and expression)
Disturbance of behaviour, leading to restriction of behavioural range
All the above findings may be seen in learning-disabled individuals.
Associated features in autism
Learning disability
Epilepsy
Visual impairment
Hearing impairment
Asperger syndrome
Often considered to be on the autistic spectrum. Characterized by autistic features in individuals of
otherwise normal intelligence. Specifically characterized by:
Impairment in social interaction.
Stereotypical behaviour
No specific impairment of language
4.3 Attention-deficit hyperactivity disorder (ADHD)

Some children show impulsive, hyperactive behaviour together with poor concentration and attention.
These children are usually of normal intelligence, although functionally they may achieve less than
their peers. Medication such as methylphenidate or dexamfetamine may be effective.
4.4 Deficits in attention, motor control and perception (DAMP)
Often described as minimal brain damage in older literature

Deficit in motor control and perception often referred to as dyspraxia
Another term for motor difficulties is developmental coordination disorder (DCD)
Children have difficulties as described in varying degrees
Treatment needs to include assessment, but also educational help and a physical programme
(occupational therapy)
5. EPILEPSY
5.1 Diagnosis
Diagnosis of fits, faints and funny turns is based primarily on clinical assessment of such events
with recognition of characteristic patterns, supported by the results of special investigations.
5.2 Definition and classification

Epileptic seizures are clinical events that result from abnormal, excessive electrical discharge from
cerebral neurons.
Epilepsy is the tendency to have recurrent, usually unprovoked, epileptic seizures.
The classification of epilepsies can be approached from the viewpoint of the characteristics of
individual seizures or by identification of epileptic syndromes.
International Classification of Epileptic Seizures (modified from International

League against Epilepsy Classification)
Simple partial seizures (no disturbance of

consciousness)
Partial seizures
Generalized
seizures
Complex partial seizures (disturbance of

consciousness)
Partial seizures with secondary generalization
Absence seizures (typical)
Absence seizures (atypical):
Myoclonic seizures
Clonic seizures
Tonic seizures
Tonicclonic seizures
Atonic seizures
Classification of epileptic syndromes
With motor signs

With somatosensory
symptoms
With autonomic symptoms
With psychic symptoms
Idiopathic
Localization related epilepsies
Benign childhood epilepsy with

centrotemporal spikes (benign rolandic
epilepsy)
Childhood epilepsy with occipital paroxysms
Temporal lobe epilepsy

Frontal lobe epilepsy
Parietal lobe epilepsy
Symptomatic
Occipital lobe epilepsy
Epilepsia partialis continua
Idiopathic
Benign neonatal familial convulsions

Benign neonatal convulsions
Benign myoclonic epilepsy of infancy
Childhood absence epilepsy
Juvenile absence epilepsy
Juvenile myoclonic epilepsy
Epilepsy with grand mal seizures on wakening
Generalized epileptic syndromes

West syndrome (infantile spasms)
Symptomatic/ LennoxGastaut syndrome
cryptogenic Myoclonicastatic epilepsy
Early myoclonic encephalopathy
Symptomatic Ohtahara syndrome
Epileptic syndromes unclassified

as focal or generalized
Neonatal seizures
Severe myoclonic epilepsy in infancy
Epilepsy with continuous spike-waves in
slow-wave sleep
LandauKleffner syndrome
5.3 Generalized epilepsies

Absence seizures
Typical absence seizures, previously termed petit mal epilepsy, is characterized by brief (520 s)
episodes of staring during which the child is unaware of his or her surroundings. Associated with 3-
Hz spike and wave discharge on EEG. Can be precipitated by hyperventilation. Drugs of choice:
sodium valproate, ethosuximide, lamotrigine.
Atypical absences: EEG shows pattern of different frequency.
Myoclonic seizures
Brief sudden generalized muscular jerks. Drugs of choice: sodium valproate, benzodiazepines,
lamotrigine. May be exacerbated by carbamazepine.
Infantile spasms
Onset in first 12 months brief sudden muscular contractions resulting in extension or flexion of the
body. Attacks occur in runs. Associated with disorganized EEG described as hypsarrhythmia, as well
as developmental arrest or regression. May be idiopathic or symptomatic (causes include tuberous
sclerosis, perinatal hypoxicischaemic injury, inborn errors of metabolism). Treatment of choice:
corticosteroids (or adrenocorticotrophic hormone or ACTH) or vigabatrin
Juvenile myoclonic epilepsy

Onset in adolescence myoclonic seizures on wakening from sleep. Treatment of choice: sodium
valproate; carbamazepine may exacerbate seizures.
5.4 Partial epilepsies

Benign childhood epilepsy
with centrotemporal spikes
(benign rolandic epilepsy)
Characterized by predominantly nocturnal partial seizures with a

slight male preponderance. Seizures may affect face or upper
limbs; speech arrest may occur. Excellent prognosis for remission
Complex partial seizures
Characterized by stereotypical behaviour, loss of consciousness

and focal EEG abnormalities. Often arise from temporal lobe foci.
May respond to carbamazepine or sodium valproate
5.5 Assessment and treatment of epilepsy

Clinical assessment of seizure type and frequency
EEG allows more specific classification of seizure type; if standard EEG is normal and further
EEG confirmation is necessary in the face of clear clinical history of epileptic seizures, then sleep
or sleep-deprived EEG may document abnormalities
Imaging (MRI) is indicated in partial seizures and generalized seizures resistant to treatment
Management
Explanation of potential risks and benefits of different therapies

Medication start, depending on frequency and number of seizures
Maintenance of seizure freedom with medication for perhaps 2 years
Subsequent withdrawal of medication
Some forms of partial epilepsy may be amenable to epilepsy surgery; when seizure disorder is
intractable, site of seizure onset can be localized, site is non-eloquent brain
Other forms of treatment steroids, ketogenic diet, vagal nerve stimulation
5.6 Anticonvulsant drugs
5.7 Management of status epilepticus
Prognosis
Of children with epilepsy 70% are seizure-free by their sixteenth birthday. Remission is less likely
in: partial epilepsy, symptomatic epilepsy, some epilepsy syndromes such as juvenile myoclonic
epilepsy or epileptic encephalopathies such as LennoxGastaut syndrome.
6. NON-EPILEPTIC SEIZURES
6.1 Anoxic seizures
Anoxic (or anoxicischaemic) seizures form a group of paroxysmal disorders that are often the main
differential diagnosis to epilepsy. Diagnosis is predominantly by clinical assessment. There are two
important types seen in childhood: breath-holding attacks and reflex anoxic seizures.
Breath-holding attacks are seen in young children, often in the setting of a tantrum. The thwarted
child screams and screams and holds his or her breath, becoming cyanosed and sometimes exhibiting
subsequent convulsive movements. It may be possible to encourage the child to take a breath by gently
blowing on his face. The tendency to have such episodes abates as children become older.
Reflex anoxic seizures are the clinical manifestation of vagocardiac attacks. The precipitant may be
a sudden, unexpected, painful stimulus or occasionally vomiting. Increased sensitivity of the vagus
nerve leads to bradycardia, or even brief asystole, in turn leading to pallor and cerebral anoxia
ischaemia. After collapse, the child may then exhibit convulsive movements. Recovery is
spontaneous. Apart from the risk of injury during a collapse, the prognosis is good with few, if any,
individuals having adverse cerebral effects. The tendency to have such attacks improves with age but
is often not completely abolished. Diagnosis can be confirmed by eliciting bradycardia under
controlled monitoring conditions through the exertion of eyeball pressure.
6.2 Psychogenic seizures

A small proportion of children have episodes of collapse, or even epileptiform attacks, that are under
conscious or subconscious control. The trigger for these episodes is usually some form of
psychological disturbance, which may be deeply hidden.
The nature and setting of the attack are often a clue to the event. The attack itself may include sudden
collapse without, for example, pallor or an epileptiform attack during which the child may respond to
his or her surroundings. The setting of the attack is often to gain maximum attention for the episode.
There is often some form of behavioural trigger to elicit an event.
Prolonged EEG and ECG monitoring may be helpful in supporting the diagnosis and helping families
accept the nature of the attack.
Management is via psychological or psychiatric treatment.
7. HEADACHES
Headache is a common complaint in childhood. Population studies estimate that up to 35% of
children have complained of headache at some time. The most common cause of headache in western
populations is tension or psychogenic headache.
Classification of headache
Tension or psychogenic headache
Migraine
Vascular disorders
Subarachnoid haemorrhage
Hypertension
Arteriovenous malformation
Headaches related to raised intracranial pressure
Tumours
Hydrocephalus
Benign intracranial hypertension
Subdural haematomata
Inflammatory disorders
Meningitis
Vasculitis
Referred pain
Sinusitis
Optic neuritis
Otitis media
Miscellaneous
Refractive errors
Carbon monoxide poisoning
Substance abuse
7.1 Tension headaches
Often occur daily

Generalized, dull may involve band-like compression around head
Worsens over the day
Worse with stress
Normal examination
Anxious or depressed affect
Depressive features in history
Management
Reassurance
Supportive psychotherapy
7.2 Migraine
Defined as a familial disorder characterized by recurrent attacks of headache widely variable in
intensity, frequency and duration. Attacks are commonly unilateral and are usually associated with
neurological and mood disturbance. All of the above characteristics are not necessarily present in
each attack or in each patient.
Classification of migraine:
Common migraine (no aura)
Classic migraine (aura preceding onset of headache)
Complicated migraine (persisting neurological deficit after migraine attack)
Basilar migraine
Migraine variance
Cluster headaches
Treatment
Acute: analgesics, relaxation, occasionally antiemetics
Prophylaxis: avoidance of triggers such as cheese, medication such as pizotifen, propranolol
7.3 Other headaches

Post-traumatic headache
Following concussive head injury. May last several months, then resolves. May persist in the setting
of depression or ongoing litigation.
Headache due to raised intracranial pressure

Worse in early morning. Worse with coughing and bending.
8. ABNORMALITIES OF HEAD SIZE AND SHAPE

Brain growth is usually the most important determinant of head growth. In full-term infants, the rate of
head growth in the first 3 months is 2 cm/month, in the second 3 months 1 cm/month and in the
subsequent 6 months 0.5 cm/month.
8.1 Macrocephaly
Consider:
Familial microcephaly
Hydrocephalus
Chronic subdural haematomas
Associated disorders such as tuberous sclerosis or neurofibromatosis
Metabolic conditions
Investigations depend on rate of growth, deviation from normal and presence of absence of abnormal
neurological signs.
Treatment
If necessary, this is based on underlying pathology.
8.2 Microcephaly
Defined as occipitofrontal head circumference, below two standard deviations for age, sex and
gestational age.
Consider:
Insults during pregnancy

Perinatal insults
Encephalopathies in infancy
Autosomal recessive microcephaly
Investigations
Chromosomes
Antibodies to congenital infections
Metabolic screen
MRI
Consider measurement of maternal plasma amino acids to exclude maternal phenylketonuria
8.3 Abnormal head shape

May be associated with specific syndrome, e.g. achondroplasia or Down syndrome. May be the result
of craniosynostosis.
Craniosynostosis
Premature closure of one or more cranial sutures. Ultimate skull deformity will depend upon which
sutures are involved and the timing of their fusion.
Apert syndrome
Acrocephaly, facial underdevelopment, syndactyly, learning disability.
Crouzon syndrome
Acrocephaly, scaphocephaly or brachycephaly, hypertelorism, exophthalmos, increased intracranial
pressure, learning disability.
9. NEUROMUSCULAR DISORDERS
9.1 The floppy infant
It is important to realize that much of the process leading to a diagnosis in the floppy infant is the
clinical assessment of the infant by history and examination. It is this assessment that should direct
diagnostic investigations. In an era when specific genetic tests for conditions are increasingly
available, a clearer idea of possible diagnoses is even more important.
Causes of hypotonia in infants

General health
Prematurity
Intercurrent illness
Ligamentous laxity
General: neurological
Chromosomal abnormalities e.g Down syndrome

Hypoxicischaemic brain injury (especially early basal ganglia injury)
Metabolic conditions
aminoacidurias
organic acidurias
peroxisomal disorders
Spinal
Cervical cord injury
Anterior horn cell

Poliomyelitis
Peripheral nerve
Peripheral neuropathies
Neuromuscular junction
Transient myasthenia
Congenital myasthenic syndrome
Muscle
Congenital muscular dystrophy
9.2 Duchenne muscular dystrophy

Duchenne muscular dystrophy is easily the most common neuromuscular condition seen in western
European practice.
Inherited as X-linked recessive condition

One-third are new mutations
Incidence 1 in 3500 male births
Female carriers usually asymptomatic, occasionally manifesting carriers
Molecular genetics
Due to mutations in dystrophin gene

Gene approximately 2 million base pairs
Duchenne muscular dystrophy patients produce no dystrophin
Becker muscular dystrophy (allelic, milder form) patients produce abnormal but functional protein
Dystrophin localized to muscle cell membranes
Clinical features
Onset in early years
Some cases identified presymptomatically by abnormal transaminases measured during intercurrent
illness
Sometimes leads to failure to thrive
Early delay in motor milestones
Difficulties in climbing stairs
Lordosis with waddling gait
Pseudohypertrophy of calves
Progressive muscular weakness
Tendency to joint contractures
Typically, boys lose ability to walk between 8 and 12 years
When dependent on wheelchair, boys are prone to develop scoliosis
Respiratory failure supervenes
Also:
Increased incidence of learning disability
Cardiomyopathy occurs
Survival to late teens, early twenties
Diagnosis
High plasma creatine kinase (>5000 IU/l)
Mutations in dystrophin gene
Muscle biopsy dystrophic picture with absent dystrophin
Treatment
No curative treatment
Physiotherapy
Corticosteroids
Appropriate seating
Respiratory support e.g. non-invasive ventilation
Aggressive treatment of cardiac failure
Management of scoliosis
9.3 Becker muscular dystrophy
Allelic disease to Duchenne muscular dystrophy

Milder than Duchenne muscular dystrophy
Patients walk beyond 16 years of age
Similar clinical pattern to Duchenne muscular dystrophy
Cramps can be problematical
Prone to cardiomyopathy
Diagnosis
Duchenne muscular dystrophy and Becker muscular dystrophy distinguished clinically and on muscle
biopsy findings. Nature of genetic mutation can give pointer as to severity of condition but current
routine genetic testing does not distinguish reliably between Duchenne and Becker muscular
dystrophy; it just identifies a dystrophinopathy.
9.4 Other muscular dystrophies and congenital myopathies

Muscular dystrophies are characterized by dystrophic muscle histopathology: muscle fibre necrosis
and regeneration with increased fat and connective tissue. May be progressive or static.
EmeryDreifuss muscular dystrophy
Uncommon X-linked muscular dystrophy (Xq28)

Mild proximal muscular weakness
Joint contractures
Cardiac involvement affected individuals may be prone to sudden cardiac death
Facioscapulohumeral muscular dystrophy
Autosomal dominant muscular dystrophy (4q35)

Facial, scapular and humeral wasting and weakness
Slowly progressive
Other muscles may be involved
Variable expression within families
Limbgirdle muscular dystrophies

Common on a worldwide basis
May be inherited as autosomal dominant (AD) or autosomal recessive (AR) traits (at least three
separate AD and nine AR limbgirdle muscular dystrophies identified so far)
Variations in clinical phenotype
Many are similar to Duchenne muscular dystrophy or Becker muscular dystrophy
Congenital muscular dystrophies

This is a group of disorders in infants characterized by muscular weakness, hypotonia and joint
contractures from birth.
Muscle biopsy shows typical dystrophic changes
Different subtypes now being described
Merosin-negative congenital muscular dystrophy

Characterized by absence of merosin on muscle biopsy
Clinically hypotonia, weakness, contractures
Often associated with learning disability
Functionally, affected children do not achieve independent walking
Merosin-positive congenital muscular dystrophy

Clinically less severe than merosin-negative congenital muscular dystrophy
Congenital muscular dystrophies associated with abnormal glycosylation of dystroglycan

AR
As well as severe weakness, affected individuals have brain malformations
Clinical syndromes include Fukuyama congenital muscular dystrophy (CMD), muscleeyebrain
disease and WalkerWarburg syndrome
Genes include FCMD, POMGnT1, FKRP, LARGE, POMT1
A group of disorders characterized by hypotonia and weakness from birth. Differentiated on clinical
and histological features:
Central cord disease

Nemaline myopathy
Myotubular myopathy
Congenital fibre type disproportion
Myotonic dystrophy
Common (incidence 13.5 per 100 000 live births) neuromuscular condition
AD inheritance (DM1: 19q13) (DM2 predominantly in adults)
Severity appears to be related to size of triplet repeat (CTG) in gene mutation
Condition often unrecognized in mothers

Preceding polyhydramnios
Baby often born unexpectedly flat
Facial weakness, hypotonia
Often requires respiratory support
Joint contractures, especially talipes
Myotonic dystrophy in older children and adults

Facial weakness initially
Then weakness affecting temporalis, sternomastoid, distal leg muscles
Progressive weakness
Difficulties in relaxing muscular contraction, e.g. difficulties in relaxing grip
Cardiac involvement
Diagnosis
Gene mutation analysis
Electromyogram in older children upwards (>34 years of age) shows characteristic dive bomber
discharges
Myotonia congenita (Thomsen disease)
Rare
Autosomal dominant inheritance
Characterized by myotonia, cramps
Muscular hypertrophy is typical
9.5 Anterior horn cell disease

The spinal muscular atrophies are a group of heterogeneous conditions that are characterized by the
clinical effects of anterior horn cell degeneration. The most common spinal muscular dystrophies
(SMAs) in childhood are the autosomal recessive proximal SMAs.
Clinical
Symmetrical muscle weakness of trunk and limbs, more marked proximally than distally and in legs
more than arms
Tongue fasciculation
Investigations confirming neurogenic abnormalities
Genetics
AR
Gene at chromosome 5q11-13
Disease caused by mutations of SMN gene
Severity determining mechanism remains unclear
Childhood onset proximal spinal muscular atrophies

Severity
Synonyms
Functional abilities
Severe
Intermediate
Mild
Type I, acute, WerdnigHoffmann disease

Type II
Type III, KugelbergWelander disease
Unable to sit or walk

Able to sit but not walk
Able to walk
Severe SMA
Incidence 1 in 20 000 live births

In approximately 30% onset is prenatal
Symmetrical weakness
Paralysis of intercostal muscles
Absent deep tendon reflexes
Tongue fasciculation
Death occurs within first 18 months from respiratory failure/infection
Diagnosis
Electromyography (EMG)
Muscle biopsy
Genetic analysis
Intermediate SMA
Autosomal recessive
Usual onset after 3 months
Infant learns to sit
Prone to early scoliosis
Prognosis depends on degree of respiratory muscle involvement
Mild SMA
AR
Able to walk, but proximal weakness evident
Tendon jerks may not be absent
9.6 Neuropathies
Hereditary motor and sensory neuropathies (HMSNs) are the most common degenerative disorders of
the peripheral nervous system. Often known by their eponymous title CharcotMarieTooth disease
(CMT) or peroneal muscular atrophy.
Previously X-linked, AR and AD forms were recognized, but the advent of molecular genetics has
identified numerous genetically distinct forms (see table).
Clinically, affected individuals develop slowly progressive distal weakness with areflexia. In the
early phases, foot drop is often the main clinical problem. In later stages, which in the common forms
may be several decades after onset, hand weakness, joint deformity and distal sensory loss may be
problematical.
Hereditary motor and sensory neuropathies (CharcotMarieTooth disease

[CMT])
AD, autosomal dominant; AR, autosomal recessive; XL, X-linked.

HMSN and Friedreich ataxia are sometimes confused. In HMSN, there is areflexia and evidence of
distal weakness. In Friedreich ataxia is there much more clear ataxia with evidence of loss of joint
position sense. On neurophysiological testing, HMSN patients have abnormal motor conduction,
whereas Friedreich ataxia patients have evidence of a sensory neuropathy.
9.7 Acute neuromuscular disorders

GuillainBarr syndrome
Acute demyelinating disease of peripheral nerves characterized by progressive weakness:
Usually follows viral infection or immunization
Numerous other infections including Campylobacter jejuni gastroenteritis has been implicated
Clinical features
Sudden onset of weakness, usually affecting lower limbs

Ascending paralysis
Usually symmetrical weakness
Pain often prominent feature
Sensory involvement in about 50%
Respiratory muscle weakness may occur

Diagnosis
High CSF protein
A marked slowing of motor neuron conduction velocity
Conduction block
Course
Deterioration over the first 1020 days

Plateau
Recovery
Mortality rate 23% in children
Treatment
Symptomatic
Respiratory support
Plasma exchange
High-dose immunoglobulin
Juvenile dermatomyositis
Systemic illness affecting primarily skin, muscles and gastrointestinal tract
Unlike adult dermatomyositis, juvenile dermatomyositis is not associated with malignancy
Clinical
Age of onset 510 years

May present with fever, muscle pain
Onset can be insidious
Increasing muscular weakness, mainly proximal
Rash involving upper eyelids (heliotrope rash) and periorbital region develops
Rash on extensor surfaces. Calcinosis is a feature
May have difficulty swallowing
Children are often miserable in advance of other symptoms
Diagnosis
Creatine kinase may or may not be raised
Muscle biopsy may show perifascicular atrophy, but changes can be patchy
Treatment
Corticosteroids
Other immunosuppressive treatment such as methotrexate or ciclosporin
9.8 Disorders of neuromuscular junction

Myasthenia gravis
Most common disease of the neuromuscular junction
Caused by antibodies directed against postsynaptic acetylcholine receptors
Clinical features
Onset after 1 year

Adolescent girls most commonly affected
Generalized form affects extraocular muscles first
Then goes on to affect proximal limbs and bulbar muscles
Variable natural course
Diagnosis
Edrophonium test
EMG confirming neuromuscular block
Demonstration of anti-acetylcholine receptor antibodies
Treatment
Anticholinesterase drugs
Immunosuppressants
Thymectomy
Plasma exchange or immunoglobulin infusion acutely
Other myasthenic syndromes

There are rare congenital myasthenic syndromes that result from specific defects in the process of
neuromuscular transmission. Some affect presynaptic mechanisms, others postsynaptic components.
Some of these infants may have joint contractures.
10. CNS INFECTIONS AND PARAINFECTIOUS DISORDERS

10.1 Meningitis
Acute bacterial meningitis remains an important cause of neurological morbidity in childhood.

Causative organisms vary depending on the age of the child and the pattern of infection has been
altered by changing immunization patterns.
Age
Organism
Escherichia coli
Neonatal
Staphylococcus aureus
Escherichia coli
First two months
Streptococcus pneumoniae
Older infants and young children Neisseria meningitidis
Streptococcus pneumoniae
Clinical features
In neonates, meningitis is usually part of septicaemic illness. Symptoms and signs may be nonspecific: lethargy, poor feeding, respiratory distress. Neck stiffness is rarely seen.
In young infants also, signs may be non-specific and meningeal irritation may be absent.
In older children, signs are more typical: lethargy, headache, photophobia, neck stiffness.
Meningococcaemia is associated with a haemorrhagic rash.
Outcome
Neurological sequelae may occur in up to 30% of children: focal neurological deficits, learning
disability, hydrocephalus and deafness may all occur. Mortality is improving with earlier diagnosis
and treatment.
Diagnosis
Lumbar puncture and CSF analysis are definitive. The white cell count is raised with a predominance
of neutrophils, CSF glucose is reduced and protein is raised. Gram staining of CSF and
immunoassays may allow identification of the organism. However, lumbar puncture is contraindicated
if signs of raised intracranial pressure are present or if consciousness is impaired. Treatment then
needs to be aimed at the most likely organisms. Blood cultures can be taken before starting treatment.
Management
Antibiotic treatment agent will depend on age of patient and likely infecting organism
Watch for subdural effusions and hydrocephalus measure head circumference
Evidence re steroid use to prevent neurological sequelae unclear some evidence to support
prevention of deafness in H. influenzae meningitis
Viral meningitis may result from a wide variety of viruses: Coxsackievirus, echoviruses, mumps,
measles, herpes simplex, poliomyelitis, varicella-zoster.
Symptoms similar to bacterial meningitis, but less pronounced

Specific diagnosis may be suggested by other disease stigmata
CSF clear with lymphocytosis
Prognosis of uncomplicated viral meningitis good
Tuberculous meningitis
Generally occurs within 68 weeks of primary pulmonary infection or during miliary tuberculosis
(TB). Most common in age range 6 months to 3 years.
Leads to basal arteritis, which may cause hydrocephalus and cranial neuropathies. Symptoms
otherwise often non-specific lethargy, fever, headache.
CSF high white cell count, predominantly lymphocytes, raised protein often >2 g/l, low glucose;
tuberculous cultures may be positive.
Treatment
Anti-tuberculous chemotherapy
Optimal treatment not determined
Usually triple therapy (rifampicin, isoniazid, pyrazinamide) for at least 6 months but many
authorities suggest a fourth drug for the first 3 months
The place of corticosteroids is unclear but these are often used in the first few months to reduce
inflammation
Mortality and morbidity remain high despite treatment.
10.2 Encephalitis
Numerous viruses may lead to inflammation of the brain: herpes viruses, adenoviruses, arboviruses
and enteroviruses, for example. The underlying causative agent in undiagnosed encephalitis may
remain obscure. It is therefore usual practice to treat with cefotaxime/ceftriaxone, aciclovir and
erythromycin/azithromycin until results are available.
Clinical features confusion, coma, seizures, motor abnormalities. Infection usually starts to resolve
714 days after the onset. However, recovery may be delayed for several months.
Herpes simplex encephalitis
Common
Often focal brain inflammation, located in temporal lobes
High mortality and morbidity rates (50%)
Specific treatment: aciclovir
Investigations for encephalitis
CSF examination/cultures
EEG
Brain imaging
Occasionally, brain biopsy
Treatment
Supportive (fluid management/ventilation if necessary)
Aciclovir
10.3 Immune-mediated and other infectious disorders

Sydenham chorea
Main neurological feature of rheumatic fever

Chorea results from immune reaction triggered by group A streptococcal infection
May be associated with emotional lability
Probably overlaps with PANDAS (psychiatric and neurological diseases associated with
streptococcal infection)
In about 75%, chorea resolves within 6 months
Anti-NMDA receptor encephalitis

Recently recognized, this disorder is caused by antibodies to N-methyl-D-aspartate receptor. Usually
preceded by intercurrent illness, some cases are associated with mycoplasma infection (see below).
Movement disorder (chorea, dystonia)

Autonomic instability
Neuropsychiatric symptoms
Seizures
Treatment is with immunomodulation: corticosteroids, immunoglobulin, plasma exchange,

cyclophosphamide, rituximab.
Subacute sclerosing panencephalitis

Subacute sclerosing panencephalitis (SSPE) is a slow viral infection, caused by an atypical response
to measles infection. Exposure to measles is usually in the first 2 years. Risk of SSPE is higher after
contracting natural measles, compared with that after measles immunization. Median interval between
measles and SSPE is 8 years.
Subtle deficits initially
Increasing memory difficulties
Worsening disabilities: seizures, motor difficulties, learning disability
Mycoplasma encephalitis
Mycoplasma pneumoniae is the most common cause of community acquired pneumonia in adults and
commonly leads to infection in children. It may cause encephalitis, predominantly through immunemediated mechanisms that may respond to steroid administration. The evidence base is small.
Acquired immune deficiency syndrome

This is caused by human immunodeficiency virus (HIV), an RNA retrovirus that eventually leads to
the death of its host cell T4+ lymphocyte.
Neurological features
Neurological features of opportunistic infection such as meningitis or encephalitis
Dementia
11. CEREBROVASCULAR DISEASE

11.1 Arterial occlusion
May result from embolism or thrombosis
Effects of arterial occlusion

Internal carotid
artery
Middle cerebral
artery
Anterior cerebral
artery
Posterior cerebral
Hemiplegia, hemianopia, aphasia if dominant hemisphere

Hemiplegia with upper limb predominance, hemianopia, aphasia if
dominant hemisphere
Hemiplegia affecting predominantly lower limbs
Homonymous hemianopia, ataxia, hemiparesis, vertigo
artery
Investigations
MRI
MR angiography
Possible formal angiography
Carotid Doppler studies
Echocardiography
Full blood count, plasma homocysteine
Clotting studies, especially factor V Leiden, prothrombin 20210A, lipoprotein (a)
The place of measurement of antithrombin III protein C and protein S in the genesis of childhood
stroke remains debatable.
11.2 Venous thrombosis

Less common than arterial occlusion
Produces a variable clinical picture:
Intracranial hypertension
Seizures
Focal neurological signs
Causes
Sepsis:
Otitis media
Sinusitis
Cutaneous infection
Dehydration
Coagulopathy
Treatment
Disputed
Heparin may be given in the acute phase
12. NEURO-ONCOLOGY
Brain tumours are the second most common malignancy in children after leukaemia. In infants,
supratentorial tumours predominate, whereas, in older children, infratentorial tumours are much more
common. The trend reverses in children over 8 years of age with a slight preponderance of
supratentorial tumours.
Central nervous system (CNS) tumours are of varying degrees of malignancy. Those that do
metastasize tend to do so within the CNS. It is also important to note that a benign tumour situated so
that it cannot be removed may have a more serious effect than a malignant tumour differently
situated.
General symptoms and signs associated with brain tumours in children may include headache,
vomiting, papilloedema, cranial nerve palsies and other focal symptoms such as ataxia.
12.1 Posterior fossa tumours

Cerebellar astrocytoma
This is the most common tumour in children; it may involve the vermis or the cerebellar hemispheres
or both. Most are cystic and slow growing.
Treatment is surgical. Occasionally more malignant tumours require radiotherapy also
Medulloblastoma
Common tumour. Highly malignant, rapidly growing. Arises from the cerebellar vermis. Often leads
to hydrocephalus. May metastasize along CSF pathways. Often solid tumours.
Treatment surgery and radiotherapy. Trials have sought to clarify the position of chemotherapy
Outlook has improved: 75% 5-year survival, 50% 10-year survival. Prognosis poorer in young
children. Evidence is emerging that specific genetic constitution of tumour is most important in
determining outcome
Ependymoma
Makes up 610% of childhood tumours. Arises from fourth ventricle. May lead to hydrocephalus and
may metastasize.
Treatment surgical resection and radiotherapy
Poor 5-year survival often related to localization of tumour
CSF, cerebrospinal fluid.
12.2 Brain-stem tumours

Brain-stem gliomas, which may vary in their degree of malignancy, form approximately 15% of brain
tumours in childhood. Peak incidence 59 years of age. Presents with multiple cranial nerve palsies
plus long tract signs. Vomiting may be a feature.
Treatment radiotherapy
Survival poor
12.3 Supratentorial tumours

Cerebral astrocytomas
Presentation depends on location

Often leads to seizures
Low-grade astrocytomas (benign): more common in children
High-grade astrocytomas: fortunately, more rare
Ependymomas
Of ependymomas 3040% are supratentorial
These are more malignant than their infratentorial counterparts
They have a tendency to metastasize and thus prognosis is poor
Optic gliomas
One-third prechiasmatic, two-thirds chiasmatic or postchiasmatic
Generally, these tumours are pilocytic astrocytomas. A quarter occur in the setting of
neurofibromatosis type 1
Clinical presentation prechiasmatic lesions may present late with proptosis with associated
visual loss. Postchiasmatic lesions lead to visual loss
Treatment controversial. Often conservative, but surgery and radiotherapy may be indicated
Craniopharyngioma
Tumour arises from small aggregates of cells that are remnants of the Rathke pouch. The tumour is
either suprasellar or suprasellar and intrasellar. Often cystic.
Clinical features are related to the following:
Endocrine disturbance:
Delayed growth
Hypothyroidism
Diabetes insipidus
Raised intracranial pressure:
Headache
Ataxia
Local features:
Visual disturbance (bitemporal hemianopia)
Depressed consciousness
Vomiting
Nystagmus
Investigations
Skull X-ray may show erosion of dorsum sellae, also calcification
MRI will delineate lesion better
Also, endocrine investigations and visual field mapping.
Treatment
Controversial
Surgery
Radiotherapy
13. NEUROCUTANEOUS SYNDROMES

Neurocutaneous syndromes from a group of unrelated disorders in which skin and neurological
features coexist. Most are genetically determined.
Neurofibromatoses are predominantly inherited disorders.
NF1 gene localized to chromosome 17q11.2.
Diagnostic criteria (two or more are necessary for diagnosis)
Six or more caf-au-lait spots >5 mm in diameter in prepubertal patients and >15 mm in
postpubertal patients
Two or more neurofibromas or one plexiform neurofibroma

Axillary or inguinal freckling
Optic glioma
Two or more iris hamartomas (Lisch nodules)
Typical osseous lesions such as sphenoid dysplasia
First-degree relative affected
Neurological manifestations
Macrocephaly
Learning disability
Epilepsy
Optic gliomas
NF2 gene localized to chromosome 22q11.2.
Diagnostic criteria
Bilateral nerve VIII neurofibromas
Unilateral nerve VIII mass in association with any two of the following: meningioma,
neurofibroma, schwannoma, juvenile posterior capsular cataracts
Unilateral nerve VIII tumour or other spinal or brain tumour as above in first-degree relative

Dominantly inherited disorder with variable expression. Characterized by skin and CNS
abnormalities, although there may be cardiac, renal and bony abnormalities as well. Two mutant
genes: TSC1 (9p34) and TSC2 (16p).
Clinical features
Seizures
Neurodevelopmental impairment
Cutaneous manifestations:
Adenoma sebaceum
Periungual fibromas
Hypopigmented patches
Shagreen patch
Retinal hamartomas
Renal angiolipomas
Cardiac rhabdomyomas
Brain imaging may reveal cortical tubers and subependymal nodules with calcification.
13.3 Other neurocutaneous disorders

Characterized by conjunctival telangiectasia, progressive cerebellar degeneration and immunological
impairment. Multisystem disease with autosomal recessive inheritance. Responsible gene, at least in
some families, mapped to chromosome 11q22-23
Clinical features
Progressive ataxia
Scleral telangiectasia
Abnormalities of cell-mediated and humoral immunity leading to increased sinopulmonary
infections and high incidence of reticuloendothelial malignancies in later life
Diagnosis
Elevated -fetoprotein level

Reduced IgA
Reduced IgD
Inversions and translocations involving chromosomes 7 and 14
Gene mutation analysis
Characterized by port wine stain, facial naevus and ipsilateral leptomeningeal angioma, which leads
to ischaemic injury to the underlying cerebral cortex, in turn leading to focal seizures, hemiparesis
and variable degrees of intellectual deficit.
Rare
Probably inherited as X-linked dominant
Gene NEMO
Characterized by skin lesions initially erythematous, papular, vesicular or bullous lesions on
trunk and limbs, then pustular lesions, then pigmented lesions
3050% of neurological features:
Seizures
Encephalopathy
Eye lesions in 30%
Hypomelanosis of Ito
Also rare
Sporadic inheritance
Hypopigmented areas
CNS involvement common, including seizures and hemimegalencephaly
14. NEUROMETABOLIC DISEASES

Disorders of intermediary metabolism are a huge group of heterogeneous conditions that have effects
of different nature and severity on the nervous system.
14.1 Amino and organic acid disorders

Phenylketonuria
See Chapter 16.
Branched-chain amino acid disorders

See Chapter 16.
Glutaric aciduria type I
Inborn error of lysine and tryptophan catabolism

Leads to extrapyramidal syndrome
Initially, children may develop normally
May be hypotonic or irritable
Chronic subdural haematomas may be present
Acute neurological deterioration occurs
Brain imaging shows striatal changes
Canavan disease
N-Acetylaspartic aciduria
AR (17p13-ter)
Leads to spongy degeneration of the subcortical white matter
Progressive neurological impairment
Death in first decade
14.2 Neurotransmitter and urea cycle disorders

Non-ketotic hyperglycinaemia
AR
Glycine accumulates in body fluids
Neuropathology identifies poor myelination
Clinical:
Poor respiratory effort at birth
Hypotonia
Gradual improvement over first week
Evolution of myoclonic encephalopathy
Severe seizure disorder and major developmental delay ensues
Urea cycle disorders

See Chapter 16.
OCT deficiency
See Chapter 16.
14.3 Mitochondrial disease

Respiratory chain disorders
Abnormalities of mitochondrial energy production produce a variety of clinical syndromes, many of
which have significant neurological features.
Potential clinical features of respiratory chain disorders
Lactic acidosis
Failure to thrive
Progressive external ophthalmoplegia
Myopathy
Seizures
Dementia
Movement disorders
Cardiomyopathy
Retinopathy
Deafness
Specific syndromes
KearnsSayre
syndrome
Progressive external ophthalmoplegia, heart block, cerebellar dysfunction
MERRF
Myoclonic epilepsy with ragged red fibres (on muscle biopsy)
MELAS
Mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like

episodes
Leigh disease
Subacute necrotizing encephalopathy hypotonia progressive deterioration in

neurological abilities
Alpers disease
Grey matter disease. Seizures are a prominent feature. Liver abnormalities are
seen, often late in course of disease
Abnormalities of fatty acid -oxidation

See Chapter 16.
14.4 Abnormalities of copper metabolism

Wilson disease
Autosomal recessive
Excessive accumulation of copper in nervous system and liver due to lack of binding globulin
(ceruloplasmin)
Approximately 30% present with neurological symptoms alone, a third with CNS and liver changes
Leads to movement disorder which may include dystonia, rigidity and chorea, and may also be
characterized by intellectual deterioration and behavioural lability
Diagnosis by biochemical means
Treatment copper chelation therapy with penicillamine
Menkes disease (kinky hair disease)

Uncommon X-linked disorder
Low serum copper and ceruloplasmin
Gene map to Xq13.3 (MNK)
Clinical
Onset neonatal period or early infancy

Hypothermia, poor weight gain
Hair is sparse, brittle
Progressive cerebral infarction occurs, leading to seizures and neurological impairment
Diagnosis confirmed by biochemical or genetic means or by hair examination
Death in first 2 years
14.5 Storage disorders

In these conditions, an enzymatic block leads to accumulation of products of cellular metabolism in
the nervous system.
Sphingolipidoses
These are lysosomal diseases involving disorders of sphingolipid metabolism. Sphingolipids are
important components of CNS membranes:
GM2 gangliosidosis (TaySachs disease): neurodegenerative, onset 39 months, startles, seizures,
blindness
Gaucher disease: types 2 and 3 have neurological involvement: hypotonia, progressive
deterioration, hepatosplenomegaly
NiemannPick disease: types A and C have neurological involvement leading to progressive
deterioration
Fabry disease: presents with painful hands and feet. May run slow progressive course with renal
involvement
These are disorders characterized by accumulation of mucopolysaccharides or glycosaminoglycans in
lysosomes. There are numerous different types:
Hurler disease (MPS 1H): characteristic facies, marked dwarfism, corneal clouding, neurological
involvement progressive. Hydrocephalus may ensue
Sanfilippo disease (MPS III): typical mycopolysaccharidosis features may be mild. However,
severe neurological involvement with intellectual deterioration and seizures
Peroxisomes are cellular organelles containing proteins and enzymes. Peroxisomal disorders are
characterized by accumulation of metabolites normally degraded by peroxisomal enzymes or by
decreased amounts of substances normally synthesized by peroxisomes.
Zellweger syndrome
Presents in neonatal period

High forehead, patent fontanelles. Severe hypotonia and poor sucking or swallowing
Very poor subsequent neurological development
Often associated with cerebral gyral abnormalities
X-linked adrenoleukodystrophy
Relatively common disease which involves CNS and adrenals
Over half present with CNS features. This group present at 48 years with cognitive decline and
progressive gait disturbance
Brain imaging shows leukodystrophy
Levels of very-long-chain fatty acids (VLCFAs) are elevated
14.6 Leukodystrophies and other neurodegenerative disorders

Leukodystrophies are degenerative disorders that affect the white matter of the brain through
abnormalities of myelin. In some, the metabolic features are known, in others the diagnosis is based
on clinical features.
Leukodystrophies
With known metabolic defect
Metachromatic leukodystrophy
Krabbe leukodystrophy
Adrenal leukodystrophy
Canavan disease
Without recognized metabolic defect
PelizaeusMerzbacher disease
Cockayne disease
Alexander disease
Leukodystrophy with subcortical cysts
Leukodystrophy with vanishing white matter
Grey matter disorders

Neuronal ceroidlipofuscinoses (Batten disease)
These disorders are characterized by storage of pigments that are similar to ceroid and lipofuscin.
Although originally thought to be related, genetic analysis has shown them to be separate disorders.
The neuronal ceroidlipofuscinoses (NCLs)
Rett syndrome
Syndrome of dementia, autistic behaviour and motor stereotypes seen in girls.
Classic clinical features
Normal perinatal period and normal first year

Deceleration of head growth from around 9 months
Loss of neurological skills
Hand wringing
Hyperventilation
Gait apraxia
May develop scoliosis
Diagnosis was clinical but now by mutation analysis of MeCP2 gene (Xq28; 80% cases). Mutation
analysis has shown that mutations in this gene lead to severe neonatal encephalopathy in boys. At
least one more gene implicated (CDKL5).
Angelman syndrome
Previously known as happy puppet syndrome
Caused by deletion of chromosome 15q11.2-12, which is maternally inherited
Deletion includes gene for 3 subunit of GABA (-aminobutyric acid) receptor
Clinical features
Severe learning disability

Ataxia
Jerky movements
Seizures
Often cheerful demeanour
15. HEAD INJURY
It has been estimated that 1 in 10 children have a head injury severe enough to impair consciousness.
Boys outnumber girls by 23:1. The overall incidence of head injury is 23 per 1000 population.
Around 5% are severe (Glasgow Coma Scale [GCS] score of 8 or less), 510% moderate (GCS 9
12) and 8590% are minor.
15.1 Mild closed head injury

Clinical features
Impaired consciousness
Lethargy
Crying
Vomiting
Ataxia
Develops immediately or within 68 hours of injury. There is usually complete resolution of

symptoms within 24 hours of the injury.
15.2 Severe closed head injury

Characterized by major loss of consciousness which is deeper and persists longer than in milder head
injury. The greatest neurological deficit usually occurs immediately after the injury. Injuries may be
the result of:
Primary trauma to brain
Secondary changes due to inflammation and ischaemia
Paediatric Glasgow Coma Scale
Eye opening (E)
Best verbal response (V)
Spontaneous
To speech
To pain
None
Oriented
Words
Inappropriate sounds
Vocalization
Cries
None
Obeys command
4
3
2
1
5
4
3
3
2
1
6
Best motor response (M)
Localises pain
Withdraws to pain
Abnormal flexion to pain
Abnormal extension to pain
None
5
4
3
2
1
Clinical assessment
Level of consciousness
Respiratory pattern
Pupil size and reaction
Brain-stem signs
Leakage of CSF
Focal signs
Consider potential of cervical spine fracture
Management
Airway, breathing, circulation

X-ray of cervical spine
Assess intracranial pressure
CT scan
Fluid restriction
After first 45 days supportive care
Late complications
Learning disability (global and specific)

Behavioural disturbance
Motor deficits
Post-traumatic epilepsy
Headaches
15.3 Non-accidental head injury

The incidence of non-accidental head injury is unknown but most estimates almost certainly underdiagnose the problem. Non-accidental head injury may include blunt trauma, sometimes leading to
skull fracture, and the so-called shaken (or shaken-impact) baby syndrome.
Clinical features of shaken baby syndrome

Peak incidence 5 months of age
History inconsistent with severity of injury

Baby presents shocked, possibly apnoeic, following apparent sudden spontaneous collapse at home
Impaired consciousness
Shocked
Irregular breathing
Possible bruising on arms or trunk
Brain imaging identifies acute and/or chronic intracranial bleeding with brain swelling
There may be signs of other non-accidental injury
Mechanism
Unclear
Cerebral parenchyma may be damaged by blunt trauma
Recent evidence suggests brain-stem injury leading to apnoea and ischaemic injury
Prognosis
Non-accidental head injury may lead to death
Prognosis for neurological recovery guarded
16. SPECIFIC NEUROLOGICAL LESIONS

16.1 Cranial nerve lesions
Facial nerve paralysis
Symptoms and signs will depend on location of lesion in the course of the nerve with potential
abnormalities of taste, lacrimation and salivation as well as hyperacusis.
Congenital facial paralysis

May be due to birth trauma or prenatal compression
May also be non-traumatic due to anomalies of nerve and nerve cell body
Moebius syndrome
Bilateral facial paralysis with bilateral abducens paralysis
Other lower cranial nerves may be affected
Up to a quarter have learning disability
Acquired facial palsy (Bell palsy)
Acute, usually idiopathic, paralysis which is unilateral

Weakness maximal for 24 weeks
Complete recovery is usual
Steroids often given, but no evidence to support their use
Other facial paralyses

Lyme disease
Otitis media/mastoiditis
Hypertension
Lower cranial nerve palsies (VIIXII)

Congenital: often present in Chiari I and II malformations
16.2 Disorders of eye movement

Acquired ophthalmoplegia
Nerve III palsy
Common
Most frequently due to closed head trauma, infections and tumours
Nerve IV palsy
Traumatic
Nerve VI palsy
Due to raised intracranial pressure:
Tumours
Benign intracranial hypertension
Congenital ophthalmoplegia
Can affect all the above nerves
Nystagmus
Involuntary, rhythmic, conjugate, oscillatory movements of the eyes that may occur in any plane
Results from dysfunction of complex mechanisms that maintain ocular fixation
Type
Pendular
Cause
Congenital
Acquired disease of brain stem/cerebellum
Horizontal jerk:
Vestibular
End-organ
Gaze evoked Posterior fossa
Rotary
Vestibular or medullary lesions
Roving eye movements of blind children
Opsoclonus
16.3 Unequal pupils
May be due to physiological anisocoria

Establish which pupil is abnormal
Ptosis and large pupil nerve III palsy
Ptosis and constricted pupil Horner syndrome
Extremely important in unconscious patient (much more so than establishment of papilloedema, for
example)
17. NEUROLOGICAL INVESTIGATIONS

17.1 Electroencephalography
The EEG allows an assessment of changes in cortical function. Electrodes applied to the scalp allow
the cortical action potential between two electrodes to be amplified and displayed. The quality of the
normal EEG will depend upon:
Age of the patient
Whether the patient is awake or asleep
Uses
Investigation of patients with seizures

Detection of cerebral dysfunction
Evaluation of depressed consciousness
Investigation of neurodegenerative disorders
Typical EEG appearances
Epilepsies
Three cycle/s spike and wave in typical absences (petit mal)
Four cycle/s spike and wave and poly spike and wave bursts in juvenile myoclonic epilepsy
Clusters of high-amplitude spike and wave complexes in one or both rolandic areas in benign focal
epilepsy with rolandic spikes
Epileptic encephalopathies
High-voltage chaotic slow waves and spike-and-sharp waves in hypsarrhythmia
Spike and waves in absence of seizures and loss of language skills in LandauKleffner syndrome
Slow spikewave discharges at 1.52.5 cycles/s in LennoxGastaut syndrome
Undiagnosed neurological illness
Burst suppression in asphyxia, early myoclonic epilepsy, glycine encephalopathy

Slowing of background in encephalopathies generally
Focal slowing may indicate structural lesions such as cerebral abscess
Focal flattening may indicate subdural haemorrhage or effusion
Diffuse moderate amplitude fast beater activity is the result of some drug intoxications
Suspect cerebral malformation or learning disability

High-voltage activity in the frequency or lower part of characteristic of lissencephaly or
pachygyria
High-voltage posterior spike and wave accentuated by passive eye closure is a feature of Angelman
syndrome
Trains of spikes or sharp waves, at first in sleep, with poorly organized background activity
develop in Rett syndrome
Suspect neurodegenerative disorder
Stereotyped high-voltage polyphasic complexes repeated every few seconds and often associated
with transient reduction in tone subacute sclerosing panencephalitis
Progressive reduction in EEG amplitude after infancy is typical of infantile neuronal ceroid
lipofuschinosis
High-voltage posterior complexes induced by slow stroboscopic activation at less than 0.5 cycles/s
is typical of late infantile neuronal ceroid lipofuschinosis
activity of moderate amplitude develops after 2 years in infantile neuraxonal dystrophy
Multiple spikes superimposed on lateralized large slow waves suggest progressive neuronal
degeneration of childhood, and predict later hepatic involvement
17.2 Evoked potentials
Used to assess the function of auditory, visual and somatosensory pathways.
Auditory brain-stem-evoked potentials

Assessment of peripheral hearing in infants and young children
Visual evoked potentials

Detection of disease in anterior visual pathway
Electroretinogram
Measures response of retina to repeated light flashes
Used in investigation of low vision and in neurological regression
Somatosensory evoked potentials

Diagnosis of spinal cord disease
Intraoperative monitoring
17.3 Peripheral neurophysiology

Measurement of peripheral nerve conduction allows assessment of the function of the motor unit the
anterior horn cell, peripheral axon and innervated muscle.
Nerve conduction studies allow measurement of:
Motor nerve conduction velocity reduced in demyelination
Amplitude of action potential reduced in axonal neuropathies
Sensory nerve conduction velocity reduced in Friedreich ataxia, for example
Electromyography
Denervation: shorter and lower voltage action potentials later giant potentials
Myopathic change: reduced action potentials
17.4 Brain imaging

Computed tomography
Useful in:
Initial evaluation of coma

Trauma
Calcification
Magnetic resonance imaging

Useful in:
Detection of parenchymal lesions, especially white matter lesions
Posterior fossa lesions
17.5 Lumbar puncture

Useful in diagnosis of:
Infection
Demyelinating diseases
Subarachnoid haemorrhage
Benign intracranial hypertension (measure pressure)
18. FURTHER READING

Aicardi J (2009). Diseases of the Nervous System in Childhood. Clinics in Developmental
Medicine, 3rd edn. London: MacKeith Press.
King MD, Stephenson JBP (2009). A Handbook of Neurological Investigations in Children. London:
MacKeith Press
Patten J (1995). Neurological Differential Diagnosis, 2nd edn. New York: Springer Verlag.
Volpe J (2008). Neurology of the Newborn, 5th edn. Philadelphia, PA: WB Saunders.
Chapter 20
Ophthalmology
Ken K Nischal
CONTENTS
1. Basic anatomy of the eye
1.1 Orbits
1.2 Extraocular muscles
1.3 The globe
2. Eyelid abnormalities
2.1 Congenital eyelid abnormalities
2.2 Infections and inflammation of the lids
2.3 Haemangiomas
2.4 Ptosis
3. Lacrimal system disorders

3.1 The watering eye (lacrimation and epiphora)
3.2 The dry eye
4. Proptosis
4.1 Orbital infections
4.2 Orbital tumours
5. Eye movement and strabismus

5.1 Squint (strabismus)
5.2 Nystagmus
6. Diseases of the conjunctiva

6.1 Conjunctivitis
6.2 Other conjunctival disorders
7. Diseases of the cornea

8. Diseases of the sclera
9. Photophobia
10. Causes of a painful red eye
11. Uveal tract disorders (iris, ciliary bodies and choroid)
11.1 Aniridia
11.2 Albinism
11.3 Brushfield spots
11.4 Heterochromia iridis
11.5 Coloboma
11.6 Inflammation of the iris
12. Abnormalities of the pupil

13. Childhood glaucoma
14. Lens disorders
14.1 Developmental anomalies
14.2 Dislocated lens (ectopia lentis)
14.3 Cataract
15. Retinal disorders

16. Infections and the retina
17. Optic nerve disorders
17.1 Papilloedema
17.2 Optic atrophy
18. Metabolic diseases and the eye

20. Ocular trauma
21. Acquired visual loss
22. Visual assessment and refractive errors
22.1 Visual assessment

22.2 Refractive errors
23. Ophthalmological investigations

24. The visually impaired child
25. Further reading
Ophthalmology
1. BASIC ANATOMY OF THE EYE

1.1 Orbits
The orbits are related to the frontal sinus above, the maxillary sinus below, and the ethmoid and
sphenoid sinuses medially. The orbit houses the eyeball, which occupies only one-fifth of the space,
fat and muscle, accounting for the bulk of the remainder. Other orbital structures include the lacrimal
glands, attendant arteries, veins and nerves.
1.2 Extraocular muscles

Six extraocular muscles control the movement of each eye four rectus and two oblique muscles.
Note that an easy way to remember extraocular muscles innervations is L6 SO4/3 (where L = lateral
rectus, innervated by sixth nerve, SO = superior oblique innervated by fourth nerve, and all the rest
innervated by third nerve).
The action of the external ocular muscles with the patient confronting the examiner.
1.3 The globe

The eyelid
Protective cover for the eyeball.
The eyeball
The eyeball.
The most important contents are as follows.
Cornea
A transparent avascular tissue inserted into the sclera at the limbus, functioning as a protective
membrane and a window through which light rays pass en route to the retina. Sensory innervation is
supplied by the first division of the trigeminal nerve. Transparency of the cornea is due to its uniform
structure, avascularity and the state of relative dehydration of the corneal tissues, which is maintained
by the active bicarbonate pump of the endothelium.
Conjunctiva
Thin, transparent mucous membrane that covers the posterior surface of the lids (the palpebral
conjunctiva) and the anterior surface of the sclera (the bulbar conjunctiva).
The sclera
The fibrous outer protective coating of the eye. In the infant, the sclera is thin and translucent with a
bluish tinge.
Uveal tract
Consists of iris, ciliary body and choroid, each of which has a rich vascular supply and pigment. The
choroids vascular supply provides nutrition for 65% of the outer retinal layers.
Anterior chamber
Fluid-filled space between the cornea and the iris diaphragm. The aqueous fluid is secreted by the
ciliary body, reaches the anterior chamber by passing through the pupillary space and drains via the
trabecular meshwork in the periphery of the anterior chamber into the venous circulation. The
aqueous humour provides nutrition for the corneal endothelial surface.
Lens
This lies posterior to the iris and anterior to the vitreous humour, suspended by zonular fibres from
the ciliary body. Anterior to the lens is the aqueous humour, posterior to it the vitreous. The lens of
the newborn infant is more nearly spherical than that of the adult, with greater refractive power
helping to compensate for the relative shortness of the young eye.
Vitreous
A transparent gelatinous structure that fills the posterior four-fifths of the globe. It is firmly attached to
the pars plana anteriorly and has a loose attachment to the retina and optic nerve posteriorly. The
vitreous is about 99% water.
The retina
During the first 23 months of life, children develop the ability to focus images at any range. The
retina contains the sensory receptors: the rods and cones. The fovea centralis is the centre of the
macula and it has the greatest concentration of cones, and therefore has the greatest potential for
visual acuity. Light falling on the fovea and peripheral retina is converted into nerve impulses by the
rods and cones. Nerve fibres emanate from the ganglion cell layer of the retina, coalesce to form the
optic nerve and synapse in the lateral geniculate body. Fibres from the temporal retina travel without
crossing at the chiasma to the ipsilateral visual cortex. Nerve fibres from the nasal retina will
decussate at the chiasma and are directed towards the contralateral visual cortex. The decussation of
nerve fibres causes portions of each retina to image a different part of the visual field.
2. EYELID ABNORMALITIES
2.1 Congenital eyelid abnormalities
Cryptophthalmos
A rare condition in which the skin is continuous over the eyeball with an absence of eyelids.
Coloboma
This is clefting (a defect) of the eyelid, which may occur as an isolated anomaly or in association
with other clefting abnormalities or first arch syndromes (Goldenhar and first arch syndrome).
Management depends on the size of the cleft and the other associated signs. For larger clefts urgent
reconstruction of the lid is necessary. Ocular exposure can be controlled with lubricants.
Ablepharon
Congenital absence of the eyelids; exposure keratopathy is a serious risk to vision.
Ankyloblepharon
Partial or complete fusion of the eyelid margins.
Ectropion
Congenital ectropion is an outward rotation of the eyelid margin present at birth. Associated with
other conditions such as ichthyosis, which may present as collodion baby at birth. It may also be
associated with Down syndrome.
Management may be initially conservative using lubrication. Surgical intervention is indicated for
exposure keratitis and may include skin grafting.
Entropion
Turning inward of the lid margin with lashes rubbing against the conjunctiva.
Epicanthus
Epicanthal folds are folds of skin that extend from the upper eyelid towards the medial canthus. The
epicanthus may give rise to a false appearance of strabismus (pseudosquint).
Telecanthus
There is an increased width between the medial canthi with normal interpupillary distance.
Hypertelorism
Increased intralobular distance.
Hypotelorism
Reduced intralobular distance.
Blepharophimosis
Small eyelids. May be part of the blepharophimosis syndrome.
2.2 Infections and inflammations of the lids
Stye
Infected eyelash follicle.
Chalazion (meibomian cysts)

A chronic granulomatous inflammation of the meibomian gland which results from obstruction of the
gland duct. Usually occurs away from the lid border as a painless hard nodule. Treatment involves the
use of warm compresses to help drainage of the lipid material. Small chalazia may resolve
spontaneously, but incision and drainage may be necessary for persistent ones. Recurrent chalazia
may be a sign of chronic meibomian gland dysfunction and needs referral to a paediatric
ophthalmologist
2.3 Haemangiomas
Capillary haemangiomas can affect either lids and are usually noticed soon after birth as reddish
discolorations of the eyelid which progressively develop into an enlarging mass.. Complete
resolution may take up to the age of 8 years. If large enough to interfere with the visual axis,
intervention with steroids and/or other modalities such as laser therapy may be required. More
recently systemic beta blockers are the favoured treatment.
2.4 Ptosis
Drooping of the upper lid, which may be unilateral or bilateral, congenital or acquired. The most
common cause of ptosis in childhood is simple congenital ptosis, which is due to a dystrophy of the
levator palpebrae superioris muscle.
Causes of ptosis
Congenital ptosis
Dystrophic, e.g. simple congenital ptosis
Non-dystrophic: aponeurotic defect, e.g. neurogenic, mechanical
Acquired ptosis
Aponeurotic (trauma or oedema)
Lid inflammation (trauma, oedema)
Neurogenic (e.g. third nerve palsy, Horner syndrome and Marcus Gunn jaw-winking syndrome)
Myogenic (e.g. progressive external ophthalmoplegia, ocular myopathies and myasthenia
gravis)
Mechanical (e.g. lid tumours and lacerations)
Infections (e.g. encephalitis and botulism)
Syndromes (e.g. SturgeWeber syndrome and neurofibromatosis)
Drugs (e.g. vincristine)
Horner syndrome
This is caused by sympathetic denervation. May be congenital or acquired.
Features
Ptosis (partial)
Miosis (pupil constriction)
Enophthalmus
Anhidrosis (ipsilateral)
Heterochromia iridis (congenital type)
Normal direct and consensual reflex to light
Congenital may be caused by obstetric trauma, with cervical vertebral anomalies, congenital tumours
and infection such as varicella syndrome.
Acquired may be caused by trauma, surgery or tumours such as neuroblastoma.
Marcus Gunn jaw-winking syndrome

This is due to an abnormal synkinesis between the levator and the lateral pterygoid muscle. The
affected eyelid is usually ptotic, but elevates when the jaws open and deviates to the contralateral
side. To perform the test, look for ptosis when the jaw is closed, then ask the child to open his or her
mouth wide; this will result in rising of the ptotic upper lid.
Myasthenia gravis
This is rare in children. However, the presence or absence of fatigability should be determined. The
Tensilon (edrophonium chloride) test should be undertaken in a clinically controlled environment
with resuscitative equipment because it may cause cardiac arrhythmias. A small dose of intravenous
Tensilon should be given and then 30 seconds later, if no adverse effect is noted, a larger volume can
be given. Results are seen within 1 minute and wear off quickly. The child should be on no drugs that
inhibit acetylcholinesterase.
The use of the ice-pack test is controversial in the definitive diagnosis of myasthenia gravis.
Treatment of ptosis
Ptosis of sufficient degree to interfere with vision requires early correction to prevent permanent loss
of vision (amblyopia). Surgical treatment such as levator resection is an option. In severe congenital
ptosis the eyelid can be suspended from the brow and elevated by the frontalis muscle.
3. LACRIMAL SYSTEM DISORDERS
The lacrimal systems function is to produce and remove tears.
Congenital nasolacrimal sac dilatation (mucocele or dacryocystocele)

This presents shortly after birth as a bluish mass in the region of the nasolacrimal sac. Treatment
varies from conservative massage to probing within a few days.
Dacryocystitis
This may be caused by bacterial infection of the nasolacrimal sac associated with nasolacrimal duct
obstruction. It presents with swelling of the nasolacrimal sac region and cellulitis of the surrounding
tissues.
Stenosis or obstruction of the nasolacrimal duct

This may occur in 30% of newborn infants. Signs include mucopurulent discharge or tearing which
may start 35 weeks later. Gentle pressure over the nasolacrimal sac expresses tears and
mucopurulent material from the sac. Spontaneous resolution is common, but probing of the
nasolacrimal duct may be required.
3.1 The watering eye (lacrimation and epiphora)

Lacrimation means excessive secretion of tears, e.g. in crying, whereas epiphora means watering of
the eyes, i.e. overflow because of inadequate drainage. The newborn baby does not usually shed tears
during crying for the first 46 weeks of age.
Causes of epiphora
Blocked nasolacrimal system

Congenital glaucoma
Acquired foreign body
Keratitis and conjunctivitis
Facial palsy
Chronic blepharitis
Migraine
Contact lens
Drugs (e.g. maternal heroin addiction)
Congenital glaucoma (epiphora together with photophobia may herald congenital glaucoma)
Non-patent nasolacrimal system
3.2 The dry eye
The child with a dry eye rarely complains that it is dry, but does complain of a burning sensation. It is
a relatively uncommon problem.
Causes of dry eye

Tear mucin deficiency, e.g. vitamin A deficiency (xerophthalmia), trachoma, burns and Stevens
Johnson syndrome
Tear lipid-layer deficiency
Aqueous tear-deficiency, keratoconjunctivitis sicca
Congenital alacrima
Ectodermal dysplasia dry skin, the anhidrotic type absence of sweat and sebaceous glands,
poor hair formation and abnormalities of nails and teeth
Familial dysautonomia (ReillyDay syndrome autosomal recessive almost exclusively in
children of Ashkenazi Jewish origin): emotional lability, paroxysmal hypertension, sweating,
cold hands and feet, and blotchy skin
Sjgren syndrome uncommon in childhood, arthritis, dryness of mouth and other mucous
membrane and dry eyes, tendency to bronchitis and pneumonia with pulmonary disease
Drug induced
Treatment of dry eyes

Treatment is not always satisfactory. It generally involves avoidance of dry atmosphere (e.g.
excessive central heating), active use of sleeping-room humidification and increasing humidity by the
use of glasses or goggles. The mainstay of treatment is artificial tears.
4. PROPTOSIS
This is defined as abnormal protrusion of the eyeball. Proptosis (exophthalmos) is most easily
appreciated when the examiner looks at the patients eyes from above the top of the head. It may be
unilateral or bilateral (due to pressure from behind) or false (due to prominent eyeball).
Causes of proptosis
Infection such as orbital cellulitis and ethmoiditis
Cavernous sinus thrombosis
Tumours:
Neuroblastoma
Retinoblastoma
Optic nerve glioma
Histiocytosis
Angioma/haemangioma
Rhabdomyosarcoma
Thyrotoxicosis
Craniosynostoses
Dermoid
Orbital encephalocele
Mucocele of the paranasal sinus
Coagulation disorders (haemorrhage) and other orbital and frontal bone osteomyelitis
Investigations
In all cases of proptosis the clinician should determine whether this is bilateral or unilateral,
acquired or congenital, rapidly or slowly progressing if acquired.
All cases of rapidly progressing proptosis need urgent orbital imaging (computed tomography [CT]
or magnetic resonance imaging [MRI]). A CT scan is preferred despite the exposure to X-rays,
because the orbital bony walls are better seen and often destruction of one or more of these may
indicate an aggressive neoplastic condition. In cases of slowly progressive or position-dependent
proptosis, MRI with contrast is helpful to exclude or confirm a haemangioma. If a vascular lesion is
suspected then orbital Doppler ultrasonography is also needed.
Abdominal examination for involvement may occur in histiocytosis X (although proptosis is usually
seen in eosinophilic granuloma which is often localized).
4.1 Orbital infections

Preseptal cellulitis
This occurs when the infection is anterior to the orbital septum. It is more common than orbital
cellulitis. Causes include eyelid trauma, extraocular infection and upper respiratory tract infection
(URTI). Usually unilateral, and no associated proptosis. The causative organism varies with age,
being streptococcal pneumonia and staphylococcal abscess in the neonatal period and Haemophilus
influenzae in later infancy.
Treatment: antibiotic and treatment of the underlying condition, e.g. dacryocystitis.
Orbital cellulitis
An uncommon but serious infection, which may give rise to ocular and septic intracranial
complications. More frequent in children older than 5 years. Over 90% of cases occur secondary to
sinusitis, usually of the ethmoid sinus. H. influenzae type b is the most common organism during
infancy, but other common organisms are staphylococci, causing abscesses, and Streptococcus
pneumoniae.
Presentation: usually with painful red eye and lid oedema; conjunctival chemosis, injection and
axial proptosis with limitation of eye movement. The child is usually pyrexial. Urgent treatment is
needed to avoid cavernous sinus thrombosis.
Treatment: admission to a hospital. Investigations (blood culture, CT scan and sinus radiograph).
Ear, nose and throat (ENT) assessment. Systemic antibiotics initially given intravenously.
4.2 Orbital tumours

The most common primary orbital malignancy in childhood is rhabdomyosarcoma, which usually
occurs between the age of 7 and 8 years and presents with progressive unilateral proptosis.
Secondary metastases (especially neuroblastoma) present with an abrupt onset of proptosis and
ecchymosis which may be bilateral.
Proptosis may be secondary to optic nerve glioma. Dermoid and epidermoid cyst are relatively
uncommon. The most common site of a dermoid cyst is the lateral brow area.
Neuroblastoma is usually associated with ecchymosis and a thorough systemic examination is
warranted if seen.
5. EYE MOVEMENT AND STRABISMUS

5.1 Squint (strabismus)
Definition: misalignment of the visual axis.
Prevalence: approximately 4% of children younger than 6 years of age have strabismus. Some 25%
of children with childhood-onset strabismus have either a parent or a sibling with strabismus.
Pseudostrabismus: this is seen in infants with prominent epicanthal folds, closely placed eyes and
flat nasal bridges. Observation of symmetrical corneal light reflexes or cover testing will confirm or
exclude the presence of true deviation.
Classification of squint
Heterophoria (latent squint)

Concomitant squint (non-paralytic strabismus):
Esotropia (convergent squint) an inward deviation of the eyes (most common type of squint)
Exotropia (divergent squint) an outward deviation of the eyes
Inconcomitant squint (paralytic strabismus)
Causes of strabismus
Congenital
Cranial nerve palsy and developmental abnormalities
Mbius syndrome (association of congenital bilateral facial palsy and bilateral abducens palsy):
facial palsies usually spare lower face. May be inherited, usually sporadic
Duane syndrome: congenital hypoplasia of the nerve VI nucleus. Nerve III compensates by
innervating lateral rectus muscle, resulting in failure of abduction on lateral gaze and globe
retraction (palpebral fissure narrows) on adduction; 1520% are bilateral. Usually sporadic.
Associations include Goldenhar syndrome, hemivertebra and Marcus Gunn jaw winking
Brown syndrome (failure of elevation of the eye, maximal in adduction): usually congenital
developmental anomaly of the superior oblique tendon. Occasionally acquired as a result of
trauma or surgery. Present with abnormal head posture, elevation of the chin and turning the head
away from the affected eye in order to acquire binocular vision. May resolve spontaneously, but
surgery may be indicated, especially when deterioration takes place
Congenital ptosis and myasthenia gravis (rare):
Acquired:
cranial nerve palsies
nerve III lesion: complete ptosis, diplopia, eye turned down and out (unopposed lateral
rectus and superior oblique muscles) and failure of pupil to react to light or accommodation
nerve IV palsy: diplopia and failure of inferior lateral gaze (failure of the superior oblique
muscle)
nerve VI palsy: diplopia and medial gaze (failure of lateral rectus muscle)
Neuromuscular disease: myopathy, myasthenia gravis and botulism.
Infections of the orbit or brain: raised intracranial pressure, e.g. tumour and post-infectious
(MillerFisher syndrome, a variant of GuillainBarr syndrome)
Brain-stem disorders
Causes of esotropia (convergent squint)
Refractory error hypermetropia

Cataract
Lesions of the optic nerve or macular
High refractive error or asymmetrical refractive errors
Causes of exotropia (divergent squint)

Intermittent exotropia is common, and is most evident when the child is tired and fixating on a
distant object. Constant exotropia may be congenital or caused by poor vision in the outward
turning eye
Heterotropia
This is a constant ocular malalignment. Children with heterotropia suppress the image of one eye to
avoid diplopia. Amblyopia will result in the suppressed eye when one eye is used for fixation. Early
diagnostic assessment is needed to prevent permanent loss of vision in one eye. A fixed squint is
commonly found in cerebral palsy, microcephaly and hydrocephalus. The rapid development of a
squint may suggest the possibility of a cerebral tumour.
Amblyopia
This is a term used to describe severe impairment of vision as a result of significant interruption of
normal visual development.
Causes of amblyopia
Strabismus is by far the most common cause
Anisometropia refractive state of one eye significantly different from the other eye
Ametropia high refractive error in both eyes and then deprivation as a result of opacity within
the visual axis such as cataract. Usually unilateral. Strabismus is the most common cause
Treatment
This depends on the cause. If significant refractive error exists, then optical correction must be made
early. Intervention is rarely effective after 8 years of age. Opacities such as cataract should be
treated. If strabismus is present then amblyopia must first be reversed with occlusion therapy before
surgical treatment.
Assessment of squint
It is important to check that the child can see with each eye first, and that each eye moves to a normal
range when tested separately (to exclude paralytic squint). There is a latent tendency for ocular
misalignment under certain conditions, e.g. fatigue, illness and stress.
It is important to remember that squints do not cause imbalance in children unless they are acquired
and causing double vision. These must be urgently referred to the ophthalmologist. Congenital or
early onset squints do not usually cause diplopia. They must be referred to allow gain of binocularity
as soon as possible.
Facial appearance
Squint may be obvious on general inspection; however, a broad epicanthic fold can give the
appearance of a convergent squint. An abnormal head posture may be a sign of a squint.
Corneal reflections
These should be identical in position in both eyes. Using a penlight held about 30 cm (12 inches) from
the eye.
Ocular movements
These should be tested in both horizontal and vertical axes using a small fixation object. Limitation of
movement in one direction suggests a paralytic squint.
The cover test consists of three parts:

Cover test
Uncover test
Alternate cover test
In all three tests the patient looks intently at a target, which may be in any direction of gaze, distant or
near. In each test, each eye is encouraged to take up fixation separately while the other is covered.
Cover test
As the examiner observes one eye, a cover is placed in front of the other eye so as to block its view
of the target. If the observed eye moves to take up fixation, it clearly is not fixating the target, and
manifest deviation (strabismus) is present.
Uncover test
As the cover is removed from the eye after the cover test, the eye emerging from under cover is
observed. If the position of the eye changes, interruption of binocular vision has allowed it to deviate,
and heterophoria (latent squint) is present.
Alternate cover test
The cover is alternately placed in front of one eye and then the other. This tends to break up the
control of heterophoria that may last through a single coveruncover cycle. This test shows the total
deviation of constant squint plus latent squint.
Management of squint
Any squint after the age of 4 months should be referred to an ophthalmologist. A fixed squint (a large
deviation with little movement of the eyes) should be referred early because it is always abnormal.
The following four approaches are possible:
1. Occlusion (occlusion of the good eye encourages the use of squinting eye and the development of
fixation)
2. Correction of refractory errors: spectacles
3. Involvement of orthoptist and paediatric ophthalmologist/strabismologist as with amblyopia
4. Surgery is necessary to gain binocular function and/or to improve social interaction with peers
5.2 Nystagmus
This is defined as involuntary rhythmic movement of one or both eyes about one or more axis.
Broadly divided into three main categories:
1. Nystagmus secondary to a visual deficit
2. Nystagmus secondary to intracranial lesions and drug toxicity
3. Congenital benign idiopathic nystagmus

Each cycle of nystagmus oscillation may have a slow phase and a fast component, in which case it is
called jerk nystagmus. Oscillations without a quick phase are called pendular.
Other classifications
Physiological
Congenital (appear before the age of 6 months): blindness, familial and idiopathic
Acquired nystagmus
(Usually after the age of 6 months)
Spasmus nutans
Ictal nystagmus (with epilepsy)
Cerebellar disease
Spinocerebellar degeneration
Vestibular
Drugs, e.g. carbamazepine
Optic nerve and chiasma tumour (rare)
Spasmus nutans
Acquired nystagmus is characterized by the triad of pendular nystagmus, head nodding and torticollis.
The nystagmus is fine, rapid, horizontal and pendular. Signs usually develop within the first 2 years of
life, but the components of the triad may develop at various times.
It is often benign and self-limiting, resolving in a few months but sometimes years. Some children
with brain tumours may exhibit signs resembling those of spasmus nutans. Therefore careful
assessment and neuroimaging may be required.
Cerebellar nystagmus is the most important sign to recognize. It is usually horizontal and worsens on
looking to the side of the lesion, with the first component directed towards the side of the lesion.
Vestibular nystagmus differs in that the slow phase is directed towards the side of the lesion due to
disorders of labyrinth, vestibular system, vestibular nuclei of the brain stem or cerebellum.
Vertical nystagmus
This is usually due to lesions of the brain stem at the pontomedullary junction (roughly at the foramen
magnum), e.g. achondroplasia or ArnoldChiari malformations. However, early onset cone
dystrophies may also present with vertical nystagmus in children. An ERG is needed to exclude this
diagnosis and a history of photophobia is also noted.
Clinical test for nystagmus
Ask the child to look at a flashlight or a toy held in front of the eye. Ask the child to follow the object
as you move it quickly, first to one side, then to the other, and also up and down. Rotating the child
induces a vestibular nystagmus; on stopping the character of the original nystagmus should return
immediately. If it does not and the amplitude or nature of the nystagmus changes (i.e. horizontal to
multiplanar) then the possibility of acquired neurological disease should be considered and the child
referred.
6. DISEASES OF THE CONJUNCTIVA

6.1 Conjunctivitis
This is the most common conjunctival disease. It may be bacterial, viral, allergic, toxic or part of a
systemic disease.
Bacterial conjunctivitis
Neonatal conjunctivitis (previously referred to as ophthalmia neonatorum)
A common problem with an incidence as high as 719% of all newborns in the first month of life.
Usually bacterial.
Gonococcal conjunctivitis
A hyperacute bacterial conjunctivitis with thick purulent discharge and lid oedema caused by
Neisseria gonorrhoeae (Gram negative). Incubation period 25 days. Requires prompt treatment
because untreated it can rapidly progress to corneal perforation and potentially blinding. Treatment
with systemic antibiotics, usually third-generation cephalosporin for 7 days because of the increasing
resistance, together with topical irrigation of the eyes.
Chlamydia trachomatis
This is the most common organism causing ophthalmia neonatorum in the USA. Infection may vary
from mild inflammation to severe swelling of the lids and copious purulent discharge. Potentially
blinding. Treatment is with tetracycline ointment for 2 months and systemic erythromycin.
Pseudomonas aeruginosa
Usually acquired in the nursery, characterized by the appearance of oedema on days 518, erythema
of the eyelids and purulent discharge. Progression to endophthalmitis and septic shock can occur.
Treatment is with systemic antibiotics. Pseudomonas aeruginosa ulcers may frequently affect young
children and contact lens wearers.
Other bacterial infections in infants and older children

Staphylococci and Haemophilus spp. and Strep. pneumococcus all cause purulent conjunctivitis and
need treatment with systemic antibiotics.
Allergic conjunctivitis
Occurs as a hypersensitivity to dust, pollen, animal dander and other airborne allergens; it is
characterized by tearing and itching with conjunctival oedema. Usually seasonal. Topical anti-mastcell stabilizer or topical steroids are helpful. Systemic antihistamines may be required.
Vernal conjunctivitis
Usually occurs later in the prepubertal period. Atopy may be a factor. Extreme itching is the usual
complaint with redness, watering of the eye and lid swelling. It results in cobble-stone appearance of
the palpebral conjunctiva. Recommended treatment: topical corticosteroid therapy, a mast-cell
inhibitor and cold compress.
Chemical conjunctivitis
Results from irritant substances such as smoke, industrial pollution, sprays, alkalis and acids.
Viral conjunctivitis
Caused by a wide range of viruses, commonly influenza virus, adenovirus and infectious
mononucleosis, and by exanthems such as measles. Characterized by a watery discharge and redness
of the conjunctiva. May be haemorrhagic. Usually self-limiting and no specific treatment is required
unless caused by herpes simplex virus, in which case treatment with topical antiviral agents
(aciclovir) as required.
Other causes of conjunctivitis
Examples of causes are acute systemic disorders, i.e. StevenJohnson syndrome and Kawasaki
disease. Conjunctivitis is usually non-purulent and self-limiting, but in StevenJohnson syndrome
topical steroids are recommended. There are other systemic signs.
6.2 Other conjunctival disorders

Subconjunctival haemorrhage
May occur spontaneously or secondary to trauma, e.g. physical injury (such as non-accidental injury
[NAI]), coughing (such as pertussis), seizure, post-birth or any activity involving Valsalva
manoeuvres. Pertussis infection is an important cause. They usually resolve spontaneously within 2
weeks and do not require treatment.
Limbal dermoid
May be isolated or part of syndrome, e.g. Goldenhar syndrome coronal limbal dermoids appear as
yellowishwhite, usually rounded elevations, sometimes with pigmentation and hair at the apex.
Pigmented lesions
Examples are pigmented limbal naevus, conjunctival haemangioma or increased vascularity, e.g.
ataxia telangiectasia (usually on the temporal side of the bulbar conjunctiva), tumours and infiltrates
of the conjunctiva, e.g. neurofibromatosis, sarcoidosis.
7. DISEASES OF THE CORNEA

Developmental anomalies
Total congenital corneal opacification is rare and needs urgent referral
Microcornea corneal diameter is 9 mm or less, and may be associated with glaucoma, cataract, iris
abnormalities or anterior segment dysgenesis
Corneal dermoid cyst (limbal dermoid)
Congenital coloboma
The cornea is also the site of many systemic diseases:
Mucopolysaccharidosis (e.g. Hurler, MaroteauxLamy, HurlerScheie diseases) produces clouding
of the cornea
Cystinosis seen in the early months of life (involves the deposition of L-cystine in the cornea)
Glaucoma produces hazy and opaque cornea due to corneal oedema
Wilson disease produces KayserFleischer ring (it is a greenish/grey ring along the outer margin of
the cornea)
Infections may cause corneal opacity, e.g. keratitis (also may be caused by vitamin A deficiency
[rare] and injury)
Juvenile chronic arthritis can cause band-shaped keratopathy (a cloudiness across the cornea,
only in the interpalpebral fissure)
Keratoconus characterized by thinning and bulging of the central cornea, which becomes cone
shaped. Descemet membrane may occasionally rupture with sudden and marked corneal oedema
(acute hydrops). Some degree of corneal scarring occurs. Mostly managed conservatively with
contact lenses. Occasionally corneal transplantation is indicated. Usually sporadic. Associations
with atopy, Down syndrome, Marfan syndrome, EhlersDanlos syndrome, aniridia and congenital
rubella
Corneal inflammations are associated with viral, bacterial, fungal and allergic diseases. Bacterial
infection may cause corneal ulcers and abscesses, leading to visual impairment and corneal
perforation. Herpes simplex infection of the cornea may be transmitted from the maternal birth
canal or by direct contact with active lesion, and is a serious infection. Requires urgent attention
and treatment with aciclovir
Deposits
Corneal deposits are not easily visible. Slit-lamp examination is essential. Seen in cystinosis, uric
acid crystals (brownish colour), calcium deposits and other rare conditions.
8. DISEASES OF THE SCLERA

Blue sclera, although seen in certain normal people. It is more common in osteogenesis imperfecta
and EhlersDanlos syndrome.
Yellow discoloration of the sclera indicates jaundice. Black patches on the sclera may be due to
either naevi or thinning of the sclera, which allows the colour of the choroid to show through.
Episcleritis is very rare in infants and children. Inflammation can be either nodular, as in the
chickenpox lesion, or diffuse. Episcleritis is associated with subconjunctival injection and may
involve the overlying conjunctiva as well. Usually causes mild ache in the eye.
Scleritis is characterized by pain on movement, deep redness and mild proptosis. The vision may be
reduced by serous retinal detachment; association with Wegener granulomatosis.
Episcleritis and scleritis may occur in autoimmune disease, dry eyes and graft-versus-host disease.
9. PHOTOPHOBIA
Definition: light sensitivity in normal lighting conditions which makes the child uncomfortable.
Causes of photophobia
Systemic causes: meningitis, encephalitis, migraine, vitamin A deficiency and xeroderma
pigmentosum
Drugs: atropine eye drops, ethosuximide and p-aminosalicyclic acid (PAS)
Ophthalmic causes:
Corneal: most causes of true photophobia are of corneal origin, e.g. epithelial disruption, as with a
foreign body. The most important cause of corneal photophobia is buphthalmos, which is the
hallmark of congenital glaucoma. The corneas are enlarged due to breaks in Descemet membrane
which allows stretching of the cornea in the infantile eye
Iris: anirida, iritis
Uvea: photophobia may be present in albinism (absent uveal pigment) and uveitis. Juvenile chronic
arthritis and spondyloarthropathy account for most cases of paediatric uveitis
Uveitis is classified according to location, clinical characteristics of the inflammatory pathology
with further differentiation based on primary site such as iritis, choroiditis, iridocyclitis or
panuveitis.
Anterior uveitis: characterized by triad of symptoms: pain, redness and photophobia. Causes
include trauma, conditions such as Kawasaki disease, Lyme disease, spondyloarthropathy and
Crohn disease. In severe inflammation vision is reduced. Slit-lamp examination should be used to
assess the extent of the inflammation and in diagnosis
Posterior uveitis: inflammation of the choroid. The only symptoms are visual. Chorioretinitis
may be focal or diffuse, unilateral or bilateral. Causes include toxoplasmosis, cytomegalovirus

(CMV) infection, sarcoidosis, syphilis, TB and toxocariasis. Signs are usually scarring and
pigmentation often with visual impairment. Complications include retinal detachment and
glaucoma
Lens diseases: such as partial cataract.
Optic nerve disease: optic neuritis (although the most important symptom is visual loss)
Vitritis
Retinal problems: retinal dystrophies especially cone dystrophies
10. CAUSES OF A PAINFUL RED EYE
Trauma haemorrhage
Conjunctivitis (bacterial or viral)
Uveitis
Iridocyclitis
Corneal damage: foreign bodies, direct injury, keratitis (e.g. herpes zoster and herpes simplex and
other viral infections)
Glaucoma
Headache: eye pain but without red eye
These all need referral. A spontaneous subconjunctival haemorrhage in children is rare and although
usually painless needs referral. Bacterial or allergic conjunctivitis usually does not need referral
unless persistent or associated with lid swelling or periorbital oedema.
11. UVEAL TRACT DISORDERS (IRIS, CILIARY BODIES AND CHOROID)

11.1 Aniridia
Complete absence of the iris. Hereditary and sporadic forms. The usual mode of inheritance is an
autosomal dominant trait. Aniridia occurs spontaneously in a third of such cases and they may have a
chromosome 11p13 deletion.
Associations of aniridia
Poor vision
Cataract 5085% by the age of 20 years
Glaucoma not present at birth but later in childhood
Optic nerve hypoplasia
Ectopia lentis may also occur in conjunction with aniridia
Aniridia with systemic disease
WAGR syndrome: Wilms tumour, aniridia, genitourinary abnormalities and retardation. Deletion of
the short arm of chromosome 11 usually present. High incidence of bilateral Wilms tumours.
11.2 Albinism
A hereditary error of metabolism within pigment cells. The loss of melanin may be limited to the eye
(ocular albinism), or affect the skin and eye (oculocutaneous albinism).
Ocular albinism
Usually inherited as X-linked.
Features
Males with photophobia, reduced visual acuity, nystagmus and iris transillumination defects with
foveal hypoplasia and scanty retinal pigmentation
Tyrosinase negative
Clinical picture
Hair steely white, pink skin (sensitive to sunburn), reduced visual acuity, nystagmus pinkblue eyes.
This is associated with one or more of the lesions in the large tyrosinase gene at chromosome 11q14
21.
Tyrosinase positive
Clinical picture
Tyrosinase gene is normal. Usually has more pigment and therefore better vision.
Albinism in conjunction with other diseases

ChdiakHigashi syndrome autosomal recessive, albinism, repeated infections, mild bleeding
diathesis, hepatosplenomegaly, peripheral and cranial neuropathy
HermanskyPudlak syndrome autosomal recessive, albinism, platelet dysfunction, pulmonary
fibrosis and inflammatory bowel disease
11.3 Brushfield spots

These are silverygrey spots on the iris. Found in 85% of children with Down syndrome and also in
24% of normal people.
11.4 Heterochromia iridis

Difference in iris colour. May be congenital or acquired.
Congenital
The involved iris is darker
Horner syndrome: ipsilateral hypopigmentation, miosis and ptosis
Waardenburg syndrome (autosomal dominant): lateral displacement of the inner canthi, prominent
root of the nose, white forelock and sensorineural deafness
Acquired
Heterochromia may be result of infiltrative processes such as naevi and melanomatous tumours
11.5 Coloboma
Congenital defect due to failure of some portion of the eye or ocular adnexa to complete growth
resulting in a cleft. They may occur as isolated defects or in association with systemic syndromes.
Usually sporadic, but isolated coloboma may be inherited as a dominant trait.
Iris coloboma
Appears as a keyhole when complete and as a notch when partial; usually affects inferior and nasal
part of the iris.
Optic disc coloboma

Appears as a hole of variable size usually in the temporal side of the margin of the disc:
CHARGE association: coloboma; heart disease; choanal atresia, retarded growth and
development; genital hypoplasia; and ear anomalies
Cat-eye syndrome: tri- or tetrasomy 22, colobomatous microphthalmia, anal atresia and
preauricular skin tags
4P syndrome (WolffHirschhorn syndrome): severe learning difficulties, characteristic face, fishlike mouth, coloboma, epicanthic fold, hypertelorism and squint, congenital heart disease
Trisomy 13 (Patau syndrome): coloboma, cleft lip and palate, and severe cardiac abnormalities
Iris abnormalities not related to coloboma

Nodular lesions of the iris may be seen in the neurofibromatosis (Lisch nodules).
11.6 Inflammation of the iris

Iritis/iridocyclitis/uveitis
The incidence of iridocyclitis is approximately 20% in pauciarticular arthritis, more common in
females with a ratio of 3:1. This is usually bilateral and asymptomatic and it may precede the
arthritis. Common complications include band keratopathy, cataract and secondary glaucoma. As a
result of the pain-free course of iridocyclitis associated with juvenile chronic arthritis, the
recommended follow-up is required: 3-monthly for high risk (pauciarticular onset, ANA positive)
and 6-monthly otherwise. Treatment includes topical corticosteroids and mydriatics.
Half of the patients with mild uveitis have an excellent prognosis, being controlled with topical
medication.
Other causes: measles, mumps, chickenpox, Lyme disease, Kawasaki disease, Reiter syndrome,
Behet disease and sarcoidosis. Diagnosis is made through various immunological and serological
tests.
12. ABNORMALITIES OF THE PUPIL

Anisocoria
This is inequality of the pupils, and may be physiological or due to neurological disorders. In the
absence of associated signs, diagnosis can be difficult as to which pupil is abnormal. Examination in
light and dark will help to diagnose sympathetic and parasympathetic lesions. In Horner syndrome the
anisocoria is greater in the dark, whereas in a parasympathetic lesion the difference is greatest in the
light.
Small pupil
Horner syndrome
Microcoria syndrome: congenital miosis pupil <2 mm in size, when patient looks at a distant
object
Uveitis
Drugs
Large pupil
Adies (Tonic) pupil
Nerve III lesion
Trauma, aniridia, coloboma, complication of surgery and drugs (mydriatics, e.g. atropine)
Abnormal shaped pupil
Coloboma (inferonasal), partial aniridia, hyperplastic pupillary membrane.
Tonic pupil syndrome (Adie syndrome)

Children may present on school screening with failed vision or blurred near vision or photophobia.
The effect is of a pupil slightly larger than the other pupil. Corneal sensation may be reduced. Patients
may be hyporeflexic or areflexic with intact vibration sense.
Leukocoria
White pupillary reflex.
Causes of leukocoria
Retinoblastoma
Cataract
Uveitis
Toxocara spp.
Vitreous haemorrhage
Coloboma
Diagnosis can often be made by direct examination of the eye with an ophthalmoscope. The absence
of a red reflex requires immediate expert attention to determine the cause.
13. CHILDHOOD GLAUCOMA

Definition: damage of the optic nerve with visual field loss caused by, or related to, elevated
pressure within the eye. Normal intraocular pressure in infants and young children is <20 mmHg.
Congenital glaucoma begins within the first 3 years of life, juvenile glaucoma between the age of 3
and 30 years.
Classification broadly into:
primary congenital glaucoma caused by an intrinsic disorder of the aqueous outflow mechanism
secondary glaucoma caused by other ocular diseases or systemic abnormalities
When the intraocular pressure is raised in young children, the cornea usually becomes diffusely
oedematous and enlarged. When the corneal diameter increases, splits occur in Descemet membrane
and damage occurs to the corneal endothelial cells. If intraocular pressure is raised in a child under 2
years of age the eye may enlarge. This is referred to as buphthalmos (ox-eye).
Symptoms include the classic triad of epiphora (tearing), photophobia and blepharospasm (eyelid
squeezing) secondary to corneal irritation. However, only 30% of affected infants demonstrate the
classic symptom complex. Epiphora in glaucoma is differentiated from nasolacrimal duct obstruction
by the presence of rhinorrhoea. When the nasolacrimal duct is obstructed, rhinorrhoea is absent.
Other signs include corneal oedema, corneal and ocular enlargement, conjunctival injection and
visual impairment.
Primary congenital glaucoma

This is caused by an intrinsic disorder of the aqueous outflow drainage more than 50% of glaucoma
is primary; 1 in 10 000 births. Usually bilateral.
Associated ocular problems:
Aniridia
Neurofibromatosis
Hypomelanosis of Ito
Marfan syndrome
Lowe syndrome
Congenital rubella syndrome
Secondary glaucoma
Associated conditions are inflammatory eye disease (in association with juvenile idiopathic arthritis
[JIA]), ectopia lentis and complications of surgery for congenital cataract.
Management of glaucoma
If untreated, glaucoma will inevitably lead to visual loss. Amblyopia is a major complication in
unilateral glaucoma. The treatment remains surgical in most of the cases but sometimes medical
treatment with drugs and laser therapy may help.
Surgical: to establish more normal anterior chamber angle (goniotomy and trabeculectomy) or to
reduce aqueous fluid production (cyclocryotherapy and photocyclocoagulation). Children may need
several operations to lower the intraocular pressure. Long-term medical treatment may also be
necessary
Medical: blockers (e.g. timolol) which act by lowering intraocular pressure. New medications
such as betaxolol (Betopic) 0.25% have fewer systemic side effects
Cyclolaser therapy: cyclophotocoagulation may be successful in reducing intraocular pressure.
Repeated applications may be required because relapse is common
14. LENS DISORDERS

Characteristics to be considered are size, shape, location and transparency. The lens can be affected
by developmental problems, humidity and systemic disease.
14.1 Developmental anomalies

The normal lens should fill the entire pupillary area. Aphakia (absent lens) and microphakia (small
lens) are rare; the latter can be seen as part of microphthalmia in many of the congenital infections
(TORCH).
14.2 Dislocated lens (ectopia lentis)

A subluxed lens is a lens partially displaced from its normal position but remaining within the
pupillary space, whereas a dislocated or luxated lens is completely displaced from the pupil,
implying separation of all or nearly all of the zonular attachments. A reduction in visual acuity is the
most common presenting symptom of subluxation or dislocation of the lens.
Presentation
Blurred vision.
Associations
Marfan syndrome: the most common cause of ectopia lentis (superiorly)
Homocystinuria: the lens usually subluxes inferiorly; other causes include aniridia, trauma,
coloboma and glaucoma
Hereditary lens dislocation: usually bilateral
Treatment
Visual improvement may be achieved with spectacles. A partially dislocated lens is often
complicated by cataract formation, in which case the cataract has to be removed but should be
delayed because of the possible complication of retinal detachment. Anterior dislocation of the lens
may be treated with pupillary dilatation and manual repositioning of the lens by pressure on the
cornea. Complete dislocation of the lens may lead to the development of glaucoma. Asymptomatic
dislocation carries a very good prognosis.
14.3 Cataract
A cataract is a lens opacity. Its main presentation is visual impairment. Up to a third of children with
bilateral congenital cataract remain legally blind even after surgery. Congenital cataract is the most
common remedial cause of blindness in the developed world.
Presentation
Absent red reflex, leukocoria, squint, nystagmus and visual impairment.
Causes of a congenital cataract
Idiopathic
Intrauterine infection (TORCH)
Genetic without systemic problems (autosomal dominant, recessive and X-linked inheritance)
Genetic with systemic problems:
Autosomal dominant hereditary spherocytosis, myotonic dystrophy, incontinentia pigmenti
(rare), Marshall syndrome
Autosomal recessive (rare) congenital ichthyosis, Conradi disease, SmithLemliOpitz
syndrome, Siemens syndrome
X-linked inheritance (rare) Lowe syndrome
Chromosomal abnormalities (trisomy 21, 18 and 13) and Turner syndrome
Metabolic disorders galactosaemia, galactokinase deficiency and hypocalcaemia
Maternal factors, e.g. diabetes mellitus, and drugs in pregnancy, e.g. corticosteroids and
chlorpromazine
Causes of acquired cataract

Drugs such as corticosteroids
Trauma
Metabolic disorders (e.g. diabetes mellitus, hypothyroidism, hypocalcaemia and
pseudohypoparathyroidism)
Radiotherapy
Infections varicella, herpes simplex and Toxocara canis
Atopic dermatitis
Genetic conditions with later presentations such as Down syndrome, myotonic dystrophy, nail
patella syndrome, Alport syndrome, Wilson disease, LaurenceMoonBiedl syndrome, Cockayne
syndrome
Cataract of prematurity
The most common chromosomal abnormality associated with cataract is trisomy 21 usually later
in life
Bilateral congenital cataracts: should be removed early because of interference with visual
development.
Partial cataracts: need careful assessment of the density and size of the lens opacity before removal,
because conservative management is indicated at least until the childs visual status can be adequately
assessed. It is important that metabolic diseases such as galactosaemia, diabetes, hyperthyroidism and
hypocalcaemia are ruled out through appropriate investigation. The most common operation for
cataract is lensectomy and anterior vitrectomy in infants. Aphakic spectacles are required after
surgery. In older children simple lens aspiration with or without implantation of the lens is the
preferred procedure.
15. RETINAL DISORDERS

Colobomas: defects of closure of the embryonic fissure of the optic cup. It may occur unilaterally or
bilaterally.
Myelinated nerve fibres: myelination may continue beyond the optic disc to include the retinal
nerve-fibre layer. It is usually visible as yellowwhite, flame-shaped patches oriented with the
retinal nerve fibres. They may produce clinical signs of leukocoria.
Albinism: albino fundus, usually pale with poor macular development and prominent choroidal
vasculature.
Coat disease: occurs in boys, peak at age 810 years, is predominantly unilateral. Peripheral retinal
telangiectasias and aneurysmal dilatation lead to extensive areas of exudates giving the retina a
yellowwhite appearance, which may produce leukocoria.
Retinitis pigmentosa (RP): a pigmentary retinopathy characterized by night blindness (earliest
symptom), progressive loss of peripheral visual field and loss of central vision (final symptom).
Symptoms may be present in childhood, but usually do not become apparent until the second or third
decade of life.
Early retinal changes shows pigment deposition as seen in the midperipheral retina, progressing to
more diffuse pigment.
Systemic associations include:
Refsum disease
Usher syndrome
LaurenceMoonBiedl syndrome
KearnsSayre syndrome
Retinal detachment
This is a rare condition in childhood. Presentation is usually late and the disease advanced at the time
of diagnosis. It often occurs in a developmentally abnormal eye and it may follow blunt trauma.
Treatment is surgical.
Hypertensive retinopathy
This is rare in children. In the early stages of hypertension no retinal changes are observed. Then the
arterioles narrow and become irregular; retinal oedema will follow with the appearance of flameshaped haemorrhages, cotton-wool spots (retinal nerve-fibre layer infarct) and papilloedema.
Diabetic retinopathy
This is uncommon in children but may occur during or after puberty. Prevalence is related to duration
and control of the disease.
Non-proliferative diabetic retinopathy is characterized by retinal microaneurysms, venous dilatation,
and retinal haemorrhages and exudate. Proliferative form is characterized by neovascularization and
proliferation of fibrovascular tissue on the retina. Most serious form.
Sickle cell retinopathy

Proliferative changes: arteriolar occlusions leading to arteriovenous anastomosis. Vitreous
haemorrhages and retinal detachment.
Non-proliferative changes: deposits, sunburst lesions and salmon-patch haemorrhages.
This is vasoproliferative retinopathy affecting mainly premature infants. The clinical manifestations
range from mild, which is usually transient changes of the peripheral retina, to severe
vasoproliferative changes with scarring, leading to retinal detachment and blindness.
Classification
There are five stages based on the location, extent and severity of the disease. The extent of the
involvement of retinopathy is described as clock hours of retinal circumference affected.
Babies who at birth are <1500 g or who are 31 weeks gestation or less should be screened.
Timing of the first examination
Infants born at or earlier than 25 weeks gestation
Screening at 67 weeks postnatally, then fortnightly until 36 weeks postmenstrual age
Infants born between 26 and 32 weeks gestational age with screening at 67 weeks postnatally, and
at 36 weeks postmenstrual age (or within a week of this to be discharged from hospital)
Treatment
In selective cases, cryotherapy or laser photocoagulation of the peripheral avascular retina has been
shown to be effective in stage 3 disease and to reduce progression to blinding disease. Recent
advances in retinal surgical technique have led to some limited success in treatment of retinal
detachment. The use of anti-VEGF (vascular endothelial growth factor) agents injected intravitreally
may have a role to play in the management of some cases but the long-term effects (if any) of such
agents on the developing neonatal neural system are as yet unknown.
Prevention
Retinopathy of prematurity largely depends on prevention of premature birth and its associated
problems. Despite improvement of our understanding of the natural history and the associated risk
factors, such as high oxygen exposure, prevention remains a major challenge.
In young infants, by far the most common cause of retinal haemorrhage is non-accidental injury. The
haemorrhages may last for many months. Haemorrhage rarely happens accidentally in children or as a
complication of blood disorders such as leukaemia. Proper documentation by an ophthalmologist is
essential.
Retinoblastoma
This is the most common intraocular malignancy of childhood. Incidence 1:14 000 to 1:20 000
births. Caused by a mutation in a growth-suppressor gene. Both alleles have to be affected to develop
the tumour. The most common age of diagnosis is between 1 and 11/2 years with 90% before the age
of 3 years.
Presenting signs: leukocoria 60% and squint 22%. Less than 25% of all cases have a family history
of retinoblastoma.
Treatment
Enucleation of the eye remains the most common therapy, and will result in a cure if the tumour has
not metastasized. Where bilateral tumour is present, the eye with the most extensive tumour with no
possibility of useful vision is enucleated and attempts are made to save the eye with less involvement.
Focal irradiation is used for solitary tumours <15 mm in diameter; systemic chemotherapy is also
available to offer shrinkage of intraocular tumours, and cryotherapy and laser for small tumours.
Long-term follow-up and genetic counselling are required for patients with retinoblastomas.
16. INFECTIONS AND THE RETINA

Congenital infections
Toxoplasmosis: caused by Toxoplasma gondii. Congenital toxoplasmosis. Eight per cent of
severely affected neonates will have chorioretinitis. Ophthalmological complications include
chorioretinitis, which appears as a white elevated mass with surrounding pigmentation on the
retina. Infants may present later with leukocoria or squint; visual deterioration occurs and retinal
detachment is a complication. Treatment is with pyrimethamine and sulfadiazine both for 1 year
Rubella: typical ocular findings include microphthalmia, microcornea, anterior uveitis, cataract,
corneal opacification and glaucoma. The retinopathy in rubella is diffuse but does not affect vision
Cytomegalovirus: ocular manifestation includes microphthalmia, cataracts, keratitis, choroiditis
and optic atrophy. Diagnosis confirmed with tests and isolation of the virus from urine, stool or
throat of the infected neonate. CMV retinitis is especially important to exclude and screen for in
children after bone marrow transplantation or other organ transplantation if a CMV viral load is
detected in the bloodstream
Herpes simplex: the eye can be the site of disseminated herpes and the most common ocular
involvements are blepharoconjunctivitis with vesicles on the eyelids and keratitis. Choroiditis and
inflammation of the vitreous with optic atrophy may also occur, particularly in infants with central
nervous system involvement
HIV: ocular manifestations include retinopathy, usually asymptomatic and characterized by cottonwool spots, retinal haemorrhage and other microvascular abnormalities.
Syphilis: causes bilateral chorioretinitis or salt-and-pepper fundus appearance
Acquired infections
Toxocariasis: ocular involvement rare. Caused by Toxocara canis larvae infection. The change is
usually unilateral. Ocular forms include:
Endophthalmitis: present between the age of 2 and 9 years and most often confused with
retinoblastoma because the red reflex is absent and a complete retinal detachment is present
Macular lesions: presents slightly later and usually a solitary granuloma
Presentation usually composed of strabismus and leukocoria or failed screening examination at
school. Confirmation of infection with ELISA (enzyme-linked immunosorbent assay) for Toxocara
spp. with peripheral eosinophilia on blood film.
Treatment: steroids and to a lesser extent anthelmintic drugs which are not very helpful and do not
restore the lost vision.
Bacterial endocarditis
May give picture of cotton-wool spots; frequently developed in patients with bacterial endocarditis
as a result of septic emboli.
17. OPTIC NERVE DISORDERS

17.1 Papilloedema
Defined as swelling of the optic nerve in association with raised intracranial pressure. The vision is
usually preserved even with marked swelling of the optic disc. The fundoscopic picture is as
follows:
Earliest sign is blurring of the disc margins, followed by elevated disc

Dilated capillary plexus and retinal veins
Absent pulsation of the optic disc
Swollen nerve-fibre bundles
Splinter haemorrhages and more markedly elevated disc; nerve-fibre infarcts (cotton-wool spots)
and exudates follow
Further engorgement and tortuosity of the retinal and disc capillaries, and haemorrhages become
more widespread
Causes of swollen disc in childhood

Bilateral
Papilloedema (raised intracranial pressure, hydrocephalus and benign intracranial hypertension)

Hypertension
Optic neuritis
Bilateral pseudopapilloedema, as in myopia and hypermetropia
Bilateral tumours (e.g. haemangioma, retinoblastoma and hamartoma)
Unilateral
Pseudopapilloedema as in myopia and myelinated nerve fibres and hypermetropia

Tumours: haemangioma, retinoblastoma, optic nerve glioma
Uveitis
Ischaemic optic neuropathy
Unilateral optic neuritis
17.2 Optic atrophy

The optic disc loses its colour and appears sharply demarcated with pale yellowwhite disc. Usually
leads to reduced visual acuity with subsequent visual field defects.
Presentation
Bilateral optic atrophy presents as blindness in early infancy with roving eye movements and sluggish
pupil reaction. Milder degrees of bilateral optic atrophy may cause minor visual defects or squint in
childhood. Unilateral cases may present as a squint.
Inheritance
Recessive or dominant trait.
Association with generalized neurological conditions such as Behr optic atrophy with cerebellar
ataxia, hypotonia and learning difficulties.
Leber optic atrophy occurs in late adolescence, but secondary optic atrophy occurs to papilloedema,
optic neuritis, compressive lesions of the optic nerve or chiasma, trauma and hereditary retinal
disease or glaucoma.
Causes of optic atrophy
Prenatal:
maternal disease
pregnancy problems
Perinatal:
prematurity
asphyxia
Familial
Ocular:
glaucoma
retinal dystrophy
Compressive:
proptosis
space-occupying lesion
Trauma
Optic neuritis
Toxic:
drugs
lead
Meningitis/encephalitis
Leukodystrophies
18. METABOLIC DISEASES AND THE EYE

Corneal abnormality
Mucopolysaccharidoses (except Hunter disease)

Mucolipidosis
Fabry disease
Sialidosis
Cystinosis
Tyrosinaemia (type II)
Visual failure
Juvenile Batten disease

Leukodystrophies
Gangliosidoses
Eye movement disorder

NiemannPick disease type C, sialidosis type I (vertical gaze palsy)
Gaucher disease type 3 (congenital oculomotor apraxia)
Sialidosis type II (nystagmus), type I (nystagmus and myoclonus)

GM2 gangliosidosis type III
Cherry-red spot
TaySachs disease
Sandhoff disease
GM1 gangliosidosis type 1
NiemannPick disease types A, C and D
Sialidosis type 2
Farber disease
Mucolipidosis I

Neurofibromatosis (NF1)
Plexiform neuromas of eyelids often producing ptosis

Conjunctival neurofibroma
Lisch iris nodules
Hamartomas (phakomas) of disc and retina
Fundus pigmentary changes
Optic gliomas
Strabismus
Nystagmus
Proptosis and exophthalmos
Glaucoma: 50% before the age of 2 years (20% after the age of 4)
Choroidal haemangiomas 40%
Wilson disease
KayserFleischer ring.
Tuberous sclerosis
Occurs in 50% of patients, although may not be evident in infancy

Hamartomas of the retina and optic nerve most common
Papilloedema rare
Optic atrophy
The von HippelLindau syndrome

Retinal angiomatosis usually in the midperiphery. Often multiple with both eyes involved in more
than 50% of cases.
Telangiectasia of bulbar conjunctivae (by the age of 46 years), disorder of conjugate eye
movements, convergent squint and nystagmus.
Microphthalmos, corneal opacities, cataract and optic atrophy.
Marfan syndrome
Lens dislocation (usually upward), and iridodonesis (tremulous iris), microphakia, cataract, myopia,
glaucoma and retinal detachment.
Down syndrome
Brushfield spots, cataract, chronic keratopathy, ectropion, glaucoma, keratoconus, lid eversion,
myopia and strabismus.
20. OCULAR TRAUMA

In order to assess the extent of ocular trauma vision should always be assessed first. The severity of
the injuries is dictated by the amount of disruption to the anatomy. This varies from minor laceration
of the eyelids to severe ocular injuries. Examination will require topical anaesthetic to examine the
eye comfortably.
Blunt trauma to the eye may cause iritis or anterior uveitis. Patients will complain of dull eye pain
and light sensitivity. Other signs of iritis include miosis of the pupil, excessive tearing and ciliary
injection. A hyphaema is blood in the anterior chamber of the eye. Complications include re-bleeding,
glaucoma and iron staining of the cornea. Dislocation of the lens may take place after blunt trauma.
Retinal haemorrhage may occur as a result of trauma.
Penetrating injuries to the eye may necessitate examination and should be brief and gentle in order to
avoid exposure of the intraocular contents. Further examination is required in the operating room
under anaesthesia. Topical medication should not be used in penetrating injuries.
21. ACQUIRED VISUAL LOSS

History is vital to ensure that visual loss is really acquired rather than present from birth:
Cortical blindness
Post-traumatic anoxia
Hypotension
Hypoglycaemia
Migraine
Occipital epilepsy
Vitreous haemorrhage
Retinal disease
Optic nerve disease
Optic neuritis
Ischaemia
Trauma
Drugs
Benign intracranial hypertension and pituitary tumour
Hysteria
22. VISUAL ASSESSMENT AND REFRACTIVE ERRORS

22.1 Visual assessment
Visual acuity measurement is the most important test for assessment of visual function. The age of the
child and the level of development dictate what type of test should be used. Fixation reflex is
generally used to evaluate vision in young infants. A 3-month-old infant may be expected to steadily
fixate and begin to follow pen light, toy or face, and by the age of 6 months a child should be able to
follow a fixation target to all fields of gaze, so the level of vision can be estimated by the quality of
fixation response.
From the age of
3 years objective measurement of visual acuity is possible.
Testing the preverbal child

Forced card preferential looking (FCPL): best for children up to 2 years old. Child is given a plain
grey card to look at and on one end is a grating pattern. Attention is drawn to that end if child sees
the grating acuity pattern at a third of a metre
Cardiff Acuity Cards: best for children between 2 and 4 years of age childs gaze is directed to
shapes on grey cards held 50100 cm from the child
Testing verbal children
Kay pictures: child names different shapes at 3 metres either with or without a matching card
LogMAR or Snellen chart with or without matching card
22.2 Refractive errors

Errors in the refractive power of the eye may lead to subnormal visual acuity. This may result from
variation of curvature of the cornea or lens or variation in the axial length of the eye.
The following are the most common forms of refractive error:
Myopia (short-sightedness): this is usually due to an increase in axial length of the eye so objects at
distance are blurred. Myopia is inherited as a multifactorial trait, which may also be associated
with systemic conditions such as Stickler syndrome. Concave lenses are used to correct myopia in
most circumstances
Hypermetropia (far-sightedness): the optical image formed by the hypermetropic eye is focused
behind the retina because the visual axis is short, and therefore convex lenses are used
Astigmatism: this occurs when the cornea, lens or retinal surface has a toric rather than a spherical
shape. This produces a blurred retinal image of object at any distance. Astigmatism can be
corrected by special lenses
Anisometropia: this refers to a condition where the eyes have different refractive errors, with one
worse than the other. It may occur with myopia, astigmatism or absence of the lens, or a
combination of these refractive errors
23. OPHTHALMOLOGICAL INVESTIGATIONS

Visual evoked potentials
This test is used to define vision development in infants. This measures the time taken for a light
stimulus to pass along the visual pathway to the occipital cortex and also the amplitude of the
response.
Electroretinography
Electroretinography (ERG) is an electrical recording of the response of the retina to visual stimulus,
e.g. flash of light. This test is useful in the detection of retinitis pigmentosa and intraocular foreign
bodies.
Electro-oculography
This is based on the standing potential of the eye. The electro-oculogram (EOG) is recorded by
placing skin electrodes adjacent to the inner and outer canthi of the eye. It is useful in detecting
hereditary macular disease and also retinitis pigmentosa and myopic chorioretinal degeneration, and
helps in diagnosis of Best disease.
Ultrasonography
This can be used at times to detect ocular abnormalities that are not usually clinically visualized, such
as opacification of the cornea, lens and vitreous.
Slit-lamp examination (biomicroscopy)

This is used to view various structures of the eye and optical section, e.g., cornea, aqueous, humour,
lens and vitreous, by providing a magnified view. It is often crucial in trauma and in cases such as
iritis.
Colour vision
This is usually performed by using standard Ishihara colour plates with some adaptation of the usual
testing techniques. Ishihara plates test only red/green colour vision deficiency. Other plates may be
used to include blue/yellow testing.
The test is accomplished whenever a child is able to name or trace the test symbol.
Colour vision defect is inherited as an X-linked pattern of inheritance but can also be acquired
secondary to optic or macular disease, as in retinitis pigmentosa, and also as a side effect of drugs
such as rifampicin.
Visual field assessment

This depends on the age and ability of the child. In infants this can be performed by simple
confrontation techniques. The infant sits on a carers lap and the examiner faces the child and attracts
his or her attention centrally, using a toy or a light moved silently from the periphery. A child with
normal fields will readily move his or her head or eyes in the direction of the object or light source.
More formal visual tests can be performed in older children using Goldmann visual field testing.
Ocular coherence tomography

Ocular coherence tomography (OCT) allows visualization of the different layers of the retina and is
extremely useful to detect anatomical abnormalities.
Autofluorescence
Autofluorescence (AF) detects lipofucin fluorescence. It is used to detect retinal dystrophies and can
also detect drusen at the optic nerve head.
24. THE VISUALLY IMPAIRED CHILD

Assessing the visually impaired child
A child may be visually impaired and be:
systemically and developmentally normal: examine the eyes and also look for nystagmus (may be a
sign of foveal hypoplasia)
systemically unwell: metabolic disease or neurometabolic disease
developmentally delayed: consider cortical visual impairment, especially in premature infants
Helping the visually impaired child

Every visually impaired child should be registered as severely visually impaired (with best corrected
visual acuity):
Visual acuity of <3/60 with a full visual field
Visual acuity between 3/60 and 6/60 with a severe reduction of field of vision, such as tunnel
vision
Visual acuity of 6/60 or above but with a very reduced field of vision, especially if a lot of sight is
missing in the lower part of the field
or partially visually impaired (with best corrected visual acuity):
Visual acuity of 3/60 to 6/60 with a full field of vision
Visual acuity of up to 6/24 with a moderate reduction of field of vision or with a central part of
vision that is cloudy or blurry
Visual acuity of up to 6/18 if a large part of field of vision, e.g. a whole half of vision, is missing or
a lot of peripheral vision is missing
Children should be referred to a teacher for the visually impaired and should have a statement of
educational needs.
25. FURTHER READING

American Academy of Ophthalmology (20112012). Basic and Clinical Science Course, Vol 1
Update on General Medicine; Vol 6 Pediatric Ophthalmology and Strabismus. San Francisco, CA:
American Academy of Ophthalmology.
Athreya B (1980). Clinical Methods in Pediatric Diagnosis. London: Van Nostrand Reinhold.
Behrman R, Kleigman R, Jenson H (2000). Nelson Textbook of Paediatrics, 16th edn. Philadelphia,
PA: WB Saunders.
Brodsky M (2010). Pediatric Neuro-Ophthalmology. New York: Springer Verlag.

Polnay L, Hull D (1985). Community Paediatrics. Edinburgh: Churchill Livingstone.
Taylor D, Hoyt C, eds (2005). Pediatric Ophthalmology and Strabismus, 3rd edn. Philadelphia, PA:
Elsevier Saunders Ltd.
Vaughan D, Taylor A (1986). General Ophthalmology, 11th edn. London: Lange.
Wright KW, Spiegel P (2002). Pediatric Ophthalmology and Strabismus. New York: Springer
Verlag.
Zitelli B, Dans H, eds (1992). Paediatric Ophthalmology, 2nd edn. New York: Gower Medical
Publishing.
Chapter 21
Orthopaedics
Vel K Sakthivel
CONTENTS
1. Introduction
2. Embryology
3. Trauma
3.1 Anatomical and physiological differences in the paediatric skeleton
3.2 Injuries unique to the immature skeleton
3.3 Injuries involving the upper limb
3.4 Injuries involving the lower limb
4. Metabolic disorders
4.1 Rickets and osteomalacia
4.2 Osteogenesis imperfecta
4.3 Idiopathic juvenile osteoporosis
5.1 Arthrogrypotic syndromes
5.2 Spina bifida (myelomeningocele)
5.3 Myopathies
6. Lower limb
6.1 Developmental dysplasia of the hip
6.2 Perthes disease (LeggCalvPerthes disease)
6.3 Slipped capital femoral epiphysis
6.4 Congenital talipes equinovarus
6.5 Irritable hip
6.6 Management of a limping child
7. Upper limb
7.1 Orthopaedic brachial plexus palsy
7.2 Trigger thumb
8. Infection
8.1 Osteomyelitis
8.2 Septic arthritis
9. Paediatric spine
9.1 Scoliosis
9.2 Kyphosis
10. Further reading
Orthopaedics
1. INTRODUCTION
This chapter aims to provide the doctor who is training to be a paediatrician with an insight into the
subspecialty of paediatric orthopaedics. The contents of this chapter are by no means exhaustive but
will offer a mode of quick revision to the paediatrician.
2. EMBRYOLOGY
The primitive streak appears at about 12 days after conception
Caudally, cells migrate from ectoderm and endoderm to form mesoderm. The mesoderm forms the
connective tissue
Cranially, the formation of the notochord appears in the second to third week of gestation
Neural crest cells differentiate to form the peripheral and autonomic nervous systems
Somites form on each other side of the notochord and develop into a specific dermatome, myotome
and sclerotome
Limb buds develop between 4 and 6 weeks
Bone develops either in a cartilage model (endochondral ossification) or in a membrane model
(intramembranous ossification)
Primary ossification centres appear between 7 and 12 weeks. They form in the midportion of the
bone anlage. This is responsible for the formation of the diaphysis and the metaphysis
Secondary ossification centres develop in the chondroepiphysis. The ossification centre for the
distal femur occurs at 40 weeks gestation. This is of medicolegal importance because the presence
of this centre is indicative of a complete pregnancy. All the other secondary centres occur
postnatally
There are two types of growth plates
Physis which responds to compressive forces
Apophysis which responds to tensile forces
3. TRAUMA
Orthopaedic trauma accounts for 1520% of accident and emergency department visits in the UK
There are a number of anatomical and physiological variations in the paediatric skeleton that make
this practice different from that of adult practice
3.1 Anatomical and physiological differences in the paediatric skeleton

The bony architecture in children includes a thick periosteum, a growth plate (physis) and an
epiphysis (secondary ossification centre)
The immature skeleton is much more elastic and hence absorbs more stress before actually breaking
The ligaments are stronger than the epiphyseal plates to which they are attached, so the incidence of
sprains and ligamentous injuries is far less in children than of avulsion fractures of the ends of the
bones
The periosteum is thick and extremely active, producing abundant callus aiding fracture healing.
Non-unions are rare in paediatrics
Remodelling helps with reshaping of a healed fracture
The younger the patient and the closer the fracture is to a joint (metaphysis of long bones), the
greater the potential to remodel
Deformities occurring in the plane of motion of the adjacent joint will also remodel better than
otherwise, i.e. a dorsovolar deformity in the distal end of the radius will remodel better than a
fracture that has healed with radial or ulnar deviation
3.2 Injuries unique to the immature skeleton

Growth plate (physeal) fractures
Up to 30% of paediatric fractures involve the growth plate. Most such fractures occur through the
hypertrophic zone. The commonest site of growth plate fractures is the distal radius and ulna
A widely used and accepted classification system was designed by Salter and Harris. This
classification system also has significant prognostic and treatment implications
The SalterHarris classification of growth plate injuries
Greenstick fractures
Greenstick fractures are the most common (50%) fracture affecting children. They are also called
unicortical fractures because one cortex is in continuity. The fracture may be rotated and
angulated
Buckle fractures and plastic deformation

After axial loading, buckling of the metaphyseal bone occurs, leading to a buckle or torus fracture.
This is a very stable fracture and often all that is needed is a few weeks of immobilization for pain
relief
Paediatric bone is more elastic than adult bone it absorbs more energy before fracturing. This
leads to more deformation of the bone before breaking and hence there is a recognized entity called
plastic deformation which is quite regularly seen in a child after an injury
There is no breach of the cortex but a deformity of the bone is seen
3.3 Injuries involving the upper limb

Shoulder
The clavicle is the most commonly fractured long bone in a child
Most of these fractures heal well with non-surgical management methods
Note that the clavicle has two primary ossifying centres. This can be confused with a fracture
Proximal humeral fractures
Usually heal well with non-surgical management, with good potential for remodelling
Humeral shaft fractures should be evaluated with a good history and clinical examination. These
fractures are not common without significant violence. If there is no appropriate history, there
should be a high index of suspicion about non-accidental injury, especially if the fracture is spiral
Elbow
The most common fractures in the elbow occur in the distal humerus. About 75% of such fractures
affect the supracondylar region
Supracondylar fractures occur through the distal metaphysis of the humerus
Clinical examination is very important to assess the vascularity and nerve supply distal to the
fracture. Compartment syndrome should be considered. Any of the three major nerves can be
affected by this fracture
A vascular insult can cause the Volkman ischaemic contracture (about 12%). Ischaemia causes
fibrotic contractures in the forearm muscles. Treatment depends on the type of fracture, varying
from just immobilization of the affected elbow to manipulation under anaesthesia and stabilization
with wires
Forearm, wrist and hand

A Monteggia fracture is a complex injury where there is an ulnar shaft fracture and dislocation of
the radial head
A Galeazzi fracture is the association of a fracture of the shaft of the radius and disruption of the
inferior radioulnar joint
Treatment options range from manipulation under anaesthesia to open reduction and internal
fixation
Distal radial fractures are common, especially when the child falls on to the outstretched hand.
SalterHarris type 2 fractures are the most common fractures affecting the distal radius
Boxer fractures (neck of the fifth metacarpal) are common in the late teens when they suffer a
punching injury
3.4 Injuries involving the lower limb

Pelvis and hip
Uncommon
Usually caused by high-velocity road traffic accidents
Treatment depends on the classification and displacement. It may include:
Manipulation under anaesthesia
Hip spica
Closed or open reduction with internal fixation
Complications include:
Avascular necrosis (incidence of approximately 40%)
Growth arrest leading to deformities such as coxa vara

Non-union which has an incidence of about 5%
Femur fractures
Incidence is about 1% in children aged <12 years

Peak age is between 2 and 5 years
70% occur in the middle third, 20% in the proximal third and 10% in the distal third
The Waddell triad fractured femur, head injury and thoracic injury
Consider non-accidental injury in a child with a femur fracture
Clinical symptoms include pain and deformity. Examine for distal neurovascular deficit
Treatment analgesia, splinting, traction, spica, internal fixation (plate osteosynthesis,
intramedullary nails)
Complications include leg-length discrepancies
Fractures of the tibia and fibula
Most common lower limb fractures in children

Account for about a fifth of paediatric long bone fractures
Clinical symptoms pain and deformity. Assess neurovascular status
Fracture in toddlers spiral fracture of the tibia in a child between 9 months and 3 years:
Low-energy injury
Leads to a limp and to localized warmth and tenderness
Child usually crawls and prefers not to weight bear
Radiographs may be inconclusive initially
Usually heal with no trouble
Treatment generally includes analgesia, splinting. Surgical treatment involves plating, nailing or
external fixation
Knee
The main injuries include meniscal injuries, anterior cruciate ligament injuries and osteochondral
defects. Others include OsgoodSchlatter disease and chondromalacia patellae.
Meniscal injuries:
Usually a twisting injury
Symptoms include pain, effusion, locking, giving way and snapping
Evaluation consists of clinical examination, diagnostic arthroscopy and magnetic resonance
imaging (MRI)
Treatment is arthroscopic, performing either a meniscal repair or partial menisectomy
Discoid meniscus
Congenital abnormality caused by the failure of absorption of the central portion of the meniscus
Incidence is between 3 and 15%, the lateral meniscus being more commonly affected
Symptoms include lateral knee pain, locking or loud clunking. Children sometimes find it unable
to fully extend the knee

Treatment: if symptomatic then needs an arthroscopic partial menisectomy
Anterior cruciate ligament (ACL) injury:
Incidence 0.3/1000 per year
Usually a sporting injury
Can be associated with injury to other ligaments
Management involves physiotherapy
Surgical treatment involves either fixing the avulsed bony fragment or carrying out an ACL
reconstruction
Osteochondral defects (osteochondritis dissecans):
Defect involving bone and cartilage within the knee
Causes discontinuity of the articular cartilage
Aetiology unknown
Most commonly seen in the lateral part of the medial femoral condyle
Signs and symptoms pain, locking, effusion, may present with an acutely locked knee
Treatment analgesia, rest, splintage (if subchondral bone is intact)
Arthroscopic assessment is required. If there is a loose body then that should be removed.
Fixation of the fragment may be undertaken if its amenable
OsgoodSchlatter disease:
Inflammation of the tibial tubercle as a result of repeated tensile forces
Incidence of about 2% of all growth plate injuries
Generally a self-limiting condition; bilateral in about a third of patients; boys affected more than
girls
Rest and analgesia are all that may be required
Adolescent anterior knee pain:
Pain about the knee is a common complaint. Initially hip pathology should be excluded
Usually synonymous with chondromalacia patellae (softening of the retropatellar cartilage)
Patellofemoral maltracking is usually the cause
Other causes such as trauma, infection and neoplasm must be excluded
Treatment is usually physiotherapy but surgery may be required in some selected cases
Foot and ankle

Ankle fractures are classified using the SalterHarris classification:
Usually caused by a twisting force
Cause pain, deformity, swelling
Radiographs are usually conclusive
Treatment includes splintage and analgesia. Can be treated by open reduction and internal fixation
Tarsal and metatarsal fractures occur frequently in the adolescent patient. Diagnosis can prove
difficult:
Treatment is usually by splintage and analgesia. Internal fixation is rarely required
4. METABOLIC DISORDERS
Bone metabolism is explained in detail in Chapter 9.
4.1 Rickets and osteomalacia

Occurs when there is a decrease in serum calcium (may be just the ionized component) or
phosphorus or both
Causes growth abnormalities and abnormal mineralization of the skeleton in children (rickets)
Affects the mineralization of the skeleton in an adult (osteomalacia)
Apathetic and irritable

Short attention span
Short stature (height below the third percentile)
Frontal bossing
Enlargement of skull sutures (hot-cross bun skull)
Delayed dentition
Enlargement of costal cartilages (rachitic rosary)
Pectus carinatum
Delayed weight-bearing milestones
Deformities of lower limbs (genu varum)
Enlarged epiphyseal regions of the long bones
Radiological findings
Cupping and widening of epiphysis
Osteopenia of the metaphysis
The Looser zones represent areas of weakening in the bone. Although they can predispose to
fractures, they do not themselves imply that there is a fracture
Further investigation
Serum calcium, vitamin D and parathyroid hormone (PTH) levels
Treatment
Exposure to sunlight
Vitamin D supplementation (dose depends on the vitamin D/PTH levels)

Defect in type 1 collagen
Four types have been identified by Sillence
Types of osteogenesis imperfecta defined by Sillence
AD, autosomal dominant; AR, autosomal recessive.
Clinical features
Increased fragility of bones but fracture healing process is unaffected

Short stature
Scoliosis
Defective dentinogenesis
Conductive deafness
Ligamentous laxity
Blue sclerae and tympanic membranes
Diagnosis
History
Clinical examination
Radiographs thin cortices and osteopenia
Histologically wide haversian canals, osteocyte lacunae
Management
Aims include fracture management and rehabilitation

May need special techniques to aid fracture management (i.e. Sofield osteotomy)
Ideally would have an internal fixation
Calcitonin and calcium supplements reduce the incidence of fractures
Bisphosphonates
4.3 Idiopathic juvenile osteoporosis

Reduction in mineral and matrix (compare osteomalacia where there is normal matrix but reduced
mineral)
Rare
Self-limiting
Age of onset usually between 8 and 14 years
Resolves spontaneously by 34 years after onset
Clinical features
Bone and joint pain

Growth arrest
Vertebral collapse
Metaphyseal fractures
Diaphysis is less affected (compare osteogenesis Imperfecta in which bone is uniformly affected)
Diagnosis
Serum calcium and phosphorus are normal

Alkaline phosphatase is normal or slightly elevated
Hypercalciuria may be present
Diagnosis is usually by exclusion
Differential diagnoses osteogenesis imperfecta, haematological malignancies, thyrotoxicosis,
Cushing syndrome
Management
Treatment of fractures is similar to that in the normal child
Bracing for scoliosis
5.1 Arthrogrypotic syndromes
Arthrogryposis multiplex congenita
Non-progressive disorder
Congenitally rigid joints
Sensory function is maintained but there is loss of motor function (may mimic polio)
Aetiology
May be neuropathic, myopathic or mixed
Decrease in anterior horn cells in the spinal cord
Possible associations
Oligohydramnios
Intrauterine viral infection
Clinical features
Normal facies
Normal intelligence
Multiple joint contractures
No visceral abnormalities
Associated with teratological hip dislocations, club feet and vertical talus
C-shaped scoliosis
Treatment
Orthopaedically it is aimed at release of soft-tissue contractures, physiotherapy and functional
bracing
Distal arthrogryposis syndrome

Autosomal dominant disorder
Predominantly affects the hands and feet
Ulnar deviation of fingers, flexion contractures at the metacarpophalangeal and proximal
interphalangeal joints
Club foot and vertical talus
Larsen syndrome
Joints less rigid than in arthrogryposis

Multiple joint dislocations
Flattened facies
Scoliosis
Cervical kyphosis
5.2 Spina bifida (myelomeningocele)

This is a disorder of incomplete spinal cord closure or rupture of the cord secondary to
hydrocephalus. It can be:
Spina bifida occulta (defects in the bony vertebral arch but intact cord structures)
Meningocele (sac of meninges without the neural elements)
Myelomeningocele (sac of meninges with the protruding neural elements)
Rachischisis (exposed neural elements with no meninges)
Antenatal diagnosis
Raised -fetoprotein
Ultrasound (anomaly visible on scan)
Clinical features
Neonatal findings such as hip dislocations, hyperextension of the knee, and club feet are common
Fractures are common but, as there are problems with sensory function, diagnosis can be difficult
Signs and symptoms depend on the level of the spinal defect
Increased incidence of allergic reactions, mainly latex sensitivity
Hips:
Flexion contractures with higher level involvement
Dislocation of the hip
Late hip dislocation can be a sign of tethering of the cord
Knees:
Quadriceps weakness causing difficulty in ambulation (key level is L4)
Flexion contractures
Valgus deformity
Ankle and foot:
Rigid club foot
Tight Achilles tendon
Valgus hind foot
Spine:
Scoliosis can be bony or muscular (thoracic level paraplegia) in origin
Rapid curve progression can denote hydrocephalus or a tethered cord
Principles of treatment
Treatment should be directed to mobilize the patient:
Soft-tissue contracture release

Corrective osteotomy, as required
Functional bracing
Surgical treatment may be required, directed at a specific problem, i.e. hip dislocation or scoliosis
Specialized physiotherapy
Custom-made wheelchair
5.3 Myopathies
This is a sex-linked recessive myopathy
Clumsy walking
Calf pseudohypertrophy
Gower sign is positive (gets up using the hands to move up the body to compensate for loss of
antigravity muscles)
Hip extensors are the muscle groups to be affected first
Markedly elevated creatine phosphokinase
Muscle biopsy shows absent dystrophin
Muscle biopsy also shows foci of necrotic tissue infiltration
Treatment is directed to keeping the patient ambulatory
Patients are usually wheelchair bound by age 15 years
Scoliosis is a major concern in treatment
Becker muscular dystrophy
This is a sex-linked recessive myopathy

Similar to Duchenne muscular dystrophy but less severe clinical picture
Red/green colour blindness
Patients live beyond their teens
Dystrophin is present but abnormal
Facioscapulohumeral dystrophy
This is an autosomal dominant disorder

Facial abnormalities
Winging of scapula
Normal creatine phosphokinase
Myotonic myopathies
Myotonia congenita:
Defect is in chromosome 7
Affects chloride channels in the muscles
Hypertrophy seen with no weakness of muscles
Improves with exercise
Paramyotonia congenita:
Affects the sodium channels in the muscles
Symptoms worsen with exposure to cold
Worse in distal upper extremity
Dystrophic myotonia:
Small gonads
Low IQ
Distal involvement
6. LOWER LIMB
6.1 Developmental dysplasia of the hip
Comprises a spectrum of abnormalities from complete dislocation of the hip to mild acetabular
dysplasia
Types of developmental hip dysplasia include dislocated hip, dislocatable hip, subluxable hip and
dysplastic hip
Incidence is 1 in 1000 for established dislocation (15 per 1000 for neonatal instability)
Risk factors include being firstborn, being female, having a breech presentation and family history
Other associated conditions include congenital torticollis, skull or facial abnormalities,
hyperextension of the knee and club feet
Clinical examination includes the Ortolani test (for reducing a dislocated hip) and the Barlow test
(for dislocatable or subluxatable hip)
Hip click suggests an audible or palpable noise while examining the hips, when there are no signs
of instability
Thigh skin creases may or may not be asymmetrical
Teratological dislocation means that there are other associated conditions such as arthrogryposis.
These are typically stiff, high-riding and irreducible dislocations
Screening for this diagnosis includes a neonatal physical examination and, possibly, ultrasound of
the hips
Screening can be general (all newborn babies undergo an ultrasound examination) or selective
(only babies with specific risk factors undergo ultrasound). A protocol is illustrated opposite
Protocol for management of developmental hip dysplasia
Treatments
Early diagnosis Pavlik harness has a success rate of about 85%
Failed Pavlik harness or late presenters (>3 months) will undergo either a closed or an open
reduction augmented with a hip spica
Late presenters, aged >2 years, will almost certainly have, along with the above procedure, a
femoral shortening osteotomy
Even with a successful closed reduction, about 50% of patients will need a pelvic osteotomy later
because there is usually a residual acetabular dysplasia
Complications
Avascular necrosis of the proximal femoral physis

Growth disturbances
Coxa magna
Residual acetabular dysplasia
6.2 Perthes disease (LeggCalvPerthes disease)

This is a non-inflammatory deformity of the femoral head caused by a vascular insult leading to
osteo-necrosis of the capital femoral epiphysis:
It affects more boys than girls (4:1)
Usually presents between 4 and 8 years of age (can have a secondary peak between 10 and 12
years)
Delayed skeletal maturation
Increased incidence with a positive family history or low birthweight
Clinical features
Pain (may present with referred pain in the knee)

Decreased range of motion
Limp
Skeletal age at onset is a significant indicator of prognosis (onset at more than 6 years carries a
significantly poorer prognosis)
15% bilateral involvement (always asymmetrical involvement, compared with multiple epiphyseal
dysplasia which is symmetrical)
Differential diagnosis includes septic arthritis of the hip, epiphyseal dysplasia and hypothyroidism
Investigation
This is by plain radiograph of the pelvis with both hips anteroposterior and frog lateral views
Stages
Initial stage
Fragmentation
Healing
Residual
Severity
This is described in many ways but the most commonly used classification is the Herring lateral
pillar classification:
Group A lateral pillar, lateral third of the femoral head shows collapse of less than 30%
Group B 3050% collapse
Group C >50% collapse of the lateral third of the capital femoral epiphysis
Treatment
Aims to maintain the range of movement and to contain the femoral head in the acetabulum. Softtissue release and corrective osteotomy may be required to achieve this
6.3 Slipped capital femoral epiphysis

Displacement or slipping of the proximal femoral epiphysis on the neck (this is a misnomer and it is
usually the neck that slips out of alignment with the head; the head stays in the acetabulum). The defect
is in the hypertrophic zone of the growth plate.
Incidence
210 in 100 000

Commonly seen in adolescent boys
Risk factors obesity, positive family history
Can be bilateral in about 25% of cases
Clinical symptoms
Pain in the hip or knee

Antalgic gait
Externally rotated limb
Decreased internal rotation of the affected limb
Classification
Classification depends on the duration of the symptoms or on ability:
Acute <3 weeks

Acute on chronic
Chronic >3 weeks
Stable (can weight bear) or unstable (unable to weight bear)
Investigations
Plain anteroposterior radiograph of the pelvis and frog lateral views
Grading on the extent of slip
Treatment
Screw fixation of the epiphysis

Corrective osteotomy may be required in delayed presentations
Prophylactic pinning of the contralateral hip may be considered
Complications include avascular necrosis of the femoral head and chondrolysis
6.4 Congenital talipes equinovarus
Also called club foot

Incidence is 1 in 1000
Male:female ratio is 2:1
No known causes but definite genetic preponderance
Various theories, such as fetal developmental arrest, myogenic and neurogenic problems, or
retracting fibrosis, have been put forward
Various associations, such as Streeter dysplasia, diastrophic dwarfism, arthrogryposis and
myelomeningocele, have been documented
Two types: positional (where the deformity is passively, fully correctable) and structural or rigid
(where the deformity cannot be passively corrected)
It is a three-dimensional deformity involving forefoot adduction and supination with hindfoot
equinus and varus
Earlier treatment improves prognosis
Treatment can be either non-surgical (serial casting, splinting) or surgical (soft-tissue release with
or without corrective osteotomy)
6.5 Irritable hip

Is an idiopathic benign inflammation of the hip joint, which is one of the most common causes of
admission to a paediatric orthopaedic unit
May be confused with septic arthritis but severe spasm, tenderness, pyrexia and a raised CRP (Creactive protein) differentiate sepsis
Perthes disease can be identified on an initial radiograph. If in doubt a repeat radiograph is
undertaken after an interval to compare
Irritable hip usually resolves on its own after the first episode
Management: reassurance, analgesics and physiotherapy (if required) to maintain the range of
movement. Bed rest and traction may help if the pain is severe
6.6 Management of a limping child

History is important, with special emphasis on duration, method of onset and predisposing illness
(if any). Development history should also be obtained
Types of limp:
Short-limbed gait, is caused by lower limb length discrepancy (toe walking could be adaptive
manoeuvre, usually by the younger child)
Antalgic gait, caused by pain. Patients prefer to spend less time on the painful limb and hence the
stance phase is shortened
Trendelenburg gait is caused by a neuromuscular problem (weak abductors)
Equinus gait, caused by tight Achilles tendon complex (idiopathic or neuromuscular).
Hyperextension of the knee could be an adaptive manoeuvre
Circumduction gait, caused by a neuromuscular deficit. Can also be seen in the longer leg, or
when dorsiflexion in the ankle is reduced due to pain.
Examination of the child should be with the above information in mind.
Investigations:
Haematological: FBC, CRP
Ultrasonography of the hip
Plain radiographs of the hip or any particular area of concern
Bone scan
MRI
Foreign body
Trauma (stress fractures)
Inflammatory (Irritable hip, arthritis)
Infective (Osteomyelitis)
Neuromuscular (cerebral palsy, congenital talipes equinovarus)
Perthes disease: idiopathic limb length discrepancy
Tumours
Genu valgum and varum
Is a usual cause for concern

Most of them are physiological and spontaneously resolve
Physiological genu varum (bow legs) is normally present until about 18 months of age
Physiological genu valgum (knock knees) is at its worst at 3 years of age (it can be very dramatic
needing strong reassurance)
Other causes can be idiopathic, metabolic or syndromic.
The intermalleolar and intercondylar distances help in quantifying the problem and monitoring its
progress
Treatment consists of reassurance, observation, correction of metabolic deficiencies (i.e. rickets)
and surgery
Lower limb length discrepancy

Can be true or apparent
Causes:
Idiopathic
Congenital (hypo- or hyperplasia)
Vascular (arteriovenous fistula)
Trauma to the physis
Infection
Neurological
Principles of management
Assess if the discrepancy is progressive or static
Calculate the projected discrepancy (PD) at skeletal maturity. On average, boys attain skeletal
maturity at 16 and girls at 14
Both of the above are done by measuring the limb lengths and plotting them on various graphs and
charts (e.g. the Moseley straight line graph, GreenAnderson growth charts and Paley multiplier
method)
Mild PD, up to 1.5 cm, can be managed with shoe inserts
PD between 1.5 and 5 cm can be treated by carrying out an epiphysiodesis of the longer leg. The
timing of this procedure is very important, because it should be done while the child is still
growing
PD of 5 cm or more should be treated by lengthening the shorter leg
7. UPPER LIMB
7.1 Orthopaedic brachial plexus palsy
Paralysis of the upper limb muscles noted at birth
Incidence is 0.4 per 1000 live births
Causes include pelvic dystocia, shoulder dystocia (upper cervical roots) and breech (lower
cervical roots)
There is a completely flail upper limb at birth, with full recovery in half the children, in a years
time
The presence of Horner syndrome and a total plexus involvement are bad prognostic signs
This is a C56 root problem, manifesting with weakness in the shoulder abductors and external
rotators and elbow flexion and supination
A rarer problem involving the lower roots can sometimes ensue. This affects the C7, C8 and T1
roots and presents as loss of sensation in the hand and loss of finger flexion
A mixed palsy (even rarer) can sometimes occur
Electromyograms can sometimes be helpful but they are not preferred because of the babys age and
the discomfort that they can cause. It is better to follow these children clinically
Treatment involves physiotherapy to keep the joints mobile and supple
Failure of restoration of elbow flexion by 3 months necessitates referral for consideration of
surgery
7.2 Trigger thumb

Caused by nodular enlargement of the flexor tendon. This enlargement makes it difficult for the
tendon to pass through the flexor sheath at certain points
Smaller nodules can pass through with a trigger or snapping sensation
Hence the clinical picture is of either a total or intermittent inability to extend the interphalangeal
joint of the thumb
Treatment consists of reassurance, observation and surgery (if symptoms persist)
8. INFECTION
8.1 Osteomyelitis
Common in children but the incidence is decreasing
In children it is usually acute and follows haematogenous spread (in the adult it usually follows
direct inoculation)
Pathophysiology because the physis forms an avascular barrier there are a lot of end-arteries in
the metaphyseal ends of the long bones. Blood flow is very slow there and this helps bacteria to
settle and multiply there, thus causing infection
Acute (diagnosis with symptoms for <2 weeks), subacute (symptoms for >2 weeks) and chronic
(missed early diagnosis) phases are noted. This depends, to an extent, on the virulence of the
affecting organism and the host immune response
Clinical features fever, pain in the affected limb, avoidance of using the limb, limping (90%
affect the lower limb), reduction of adjacent joint movement (not as severe as septic arthritis)
Previous history of flu-like illness should be elicited and questions about otitis, pharyngitis and
impetigo must be asked
Investigations include full blood count, erythrocyte sedimentation rate (ESR), CRP, blood cultures,
plain radiographs (may be normal in acute osteomyelitis) and bone scan (may sometimes be needed
to confirm diagnosis)
MRI and ultrasonography may also be required. Occasionally single photon emission computed
tomography (SPECT) scans may be required
Differential diagnoses include septic arthritis, fractures, neoplasms and acute infarction episodes
Complications include chronic osteomyelitis, pathological fractures, septic arthritis and growth
arrests or physeal bars
Common causative organisms Staphylococcus aureus (most common), group B streptococci,
Escherichia coli, Haemophilus influenzae, Neisseria meningitidis. The incidence of metacillinresistant S. aureus (MRSA) osteomyelitis is increasing especially in the community
Treatment should include antibiotics to cover the respective organisms. This should usually last for
6 weeks. CRP is a good investigation with which to monitor the progress of treatment
8.2 Septic arthritis
Most commonly affected joints are the hip and the knee
Peak age is 3 years but can affect virtually any age group
Usually involves a single joint if it is an uncomplicated septic arthritis
Pathophysiology the cause is usually transient bacteraemia, direct inoculation or decompression
of a juxta-articular osteomyelitis
Clinical features:
Fever, irritable hip and limp; refusal to use the involved extremity
Painful limited range of motion
Effusion
A typical attitude of the limb (as the child tends to hold the limb with the joint in a position of
maximal comfort)
Pseudoparalysis in the newborn should raise suspicions
Investigations:
Full blood count, ESR, CRP (normal values do not necessarily rule out infection in this age
group)
Blood cultures
Microscopy, culture and sensitivity of the joint aspirate
Plain radiographs
Ultrasonography
MRI and bone scan (can be normal if there is a tense effusion in the joint) may sometimes be
required because diagnosis is often difficult
Treatment:
Consists of early administration of antibiotics and drainage of the purulent effusion in the joint
Splintage may sometimes be required
Prognosis is good if diagnosis is early and treatment is instigated immediately. Delay in treatment
can lead to early secondary arthritis with significant post-septic sequelae
Most common organisms:
Neonate S. aureus, group B streptococci
Child <5 years S. aureus, group A streptococci, Streptococcus pneumoniae
Child >5 years S. aureus, group A streptococci
Adolescent S. aureus, Neisseria gonorrhoeae
Note atypical presentations tuberculosis is on the increase in the western world so has a high
index of suspicion
9. PAEDIATRIC SPINE
9.1 Scoliosis
Prevalence is 0.5 to 3 per 100 (for curves between 10 and 30)
Generally girls are affected more commonly than boys (but this may change for different age
groups)
Three-dimensional deformity (lateral curve and rotational deformity)
Studies show both X-linked and autosomal dominant inheritance
Recent studies have shown that certain hormonal factors, such as melatonin, play an important part
in the progression of this condition
Classification
It can be idiopathic, neuromuscular, congenital, hysterical, functional and mixed with other
associations (mesenchymal, traumatic, osteochondrodystophies, etc.)
It can also be classified into: infantile (03 years), juvenile (310 years) and adolescent (>10
years)
Clinical features
Asymmetry of the shoulder

Asymmetry of the top of the pelvis
Adams forward bend test shows a rib prominence to the side of the curve
Lateral deviation of the head is measured (from the natal cleft) by dropping a plumb line from the
C7 vertebra
Lower limb lengths should be assessed for true and apparent limb-length discrepancy
Truncal shift should also be assessed
Associated features, such as caf-au-lait spots (neurofibromatosis), hairy patch in the lumbosacral
area (spinal dysraphism) and joint laxity (connective tissue disorder) should be noted
Full neurological examination of the lower and upper limbs should be carried out
Investigations
Plain radiographs of the whole spine posteroanterior and lateral (standing views)
MRI and CT may be indicated depending on the neurology present and to assess for any congenital
bony anomalies
Treatment
Identify the curves that are more likely to progress (to be done by a paediatric spinal surgeon)
Bracing (controversial in the UK but more commonly used in the USA)
Surgery with or without spinal fusion
Treat any intraspinal abnormalities such as syringomyelia or dysraphism before attempting curve
correction
9.2 Kyphosis
Normal in the thoracic and sacral regions of the spine

Between T5 and T12, an angle of 2040 is considered normal; 4050 is considered borderline
normal; <20 is termed hypokyphosis and >50 is termed hyperkyphosis.
Causes of kyphosis
10. FURTHER READING

Herring JA (2002). Tachdjians Paediatric Orthopaedics, 3rd edn. Philadelphia, PA: WB Saunders.
Sillence DO, Rimoin DL (1978). Classification of osteogenesis imperfecta. Lancet i:10412.
Staheli LT (2003). Orthopaedic Secrets, 2nd edn. Philadelphia, PA: Hanley & Belfuss.
Staheli LT (2006). Practice of Paediatric Orthopaedics, 2nd edn. Philadelphia, PA: Lippincott
Williams & Wilkins.
Chapter 22
Respiratory
Rebecca Thursfield and Jane C Davies
CONTENTS
1. Anatomy and physiology
1.1 Embryology
1.2 Fetal and postnatal lung growth
1.3 Changes at birth and persistent fetal circulation
1.4 Control of respiration
1.5 Ventilation
1.6 Perfusion
1.7 Interpretation of oximetry and blood gases
1.8 Lung function testing
1.9 Respiratory defence mechanisms
1.10 Environmental influences on lung disease
2. Ear, nose, throat (ENT) and upper airway

2.1 Nose and sinuses
2.2 Cleft lip and palate
2.3 Ears
2.4 Throat
2.5 Larynx
2.6 Malacias
2.7 Sleep disordered breathing
2.8 Tracheo-oesophageal fistula
2.9 Gastro-oesophageal reflux
2.10 Cervical lymphadenopathy
3. Asthma
3.1 Pathophysiology
3.2 Drug treatment
3.3 Acute attack
4. Cystic fibrosis
4.1 Background
4.2 Diagnosis
4.3 Genetics
4.4 Presentation and management
4.5 New/emerging therapies
4.6 Transplantation
5. Other causes of bronchiectasis

6. Bronchopulmonary dysplasia
7. Infections
7.1 Epiglottitis
7.2 Tonsillitis
7.3 Croup
7.4 Tracheitis
7.5 Bacterial pneumonias
7.6 Empyema
7.7 Bronchiolitis
7.8 Viral pneumonia/Pneumonitis
7.9 Tuberculosis and atypical mycobacterial infection
7.10 Infections in the immunocompromised host
8. Inhaled foreign body

9. Pneumothorax
10.1 Spinal cord
10.2 Peripheral nerve
10.3 Neuromuscular junction
10.4 Muscle
10.5 Respiratory failure
10.6 Non-invasive ventilatory support
11. Rare disorders

11.1 Congenital disorders
11.2 Acquired disorders
12. Further reading
Respiratory
1. ANATOMY AND PHYSIOLOGY

1.1 Embryology
In utero development is divided into four stages.
Embryonic up to week 5
Lung bud grows out from the fetal foregut
Single tube branches into two main bronchi
Pseudoglandular weeks 616
Airways grow by branching (out to terminal bronchioles)

Cartilage and lymphatics appear from 10 weeks onwards
Cilia appear
Pulmonary circulation develops, arteries arising from the sixth branchial arches
Canalicular weeks 1724
Conventional architecture of the lung appears

Thinning out of distal cells in preparation for gas exchange
Further development of arterial circulation, and appearance of venous system
Surfactant synthesis begins
Lung fills with fluid (lack of fluid at this and later stage, e.g. with renal agenesis, leads to
pulmonary hypoplasia)
Alveolar sac weeks 2440

Formation of the acinus (respiratory bronchioles, alveolar ducts and alveoli)
Cell differentiation into type I and II pneumocytes
Type I:
>90% of alveolar surface
Major gas-exchanging surface

Type II:
Thought to be the progenitor cell for type I cells
Produces surfactant which maintains surface tension and prevents alveolar collapse during
respiration
Surfactant-associated proteins A and D (hydrophilic) involved mainly in innate immunity
Surfactant-associated proteins B and C (hydrophobic) important for surface tension
1.2 Fetal and postnatal lung growth

Factors affecting fetal lung growth and development include:
Lack of amniotic fluid
Glucocorticoids, thyroid hormones, other hormones increase maturation
Pressure effects (e.g. compression from diaphragmatic hernia, or space-occupying lesion leads to
hypoplasia)
Postnatally, lung development and growth continue for 7 years and may be adversely influenced by:
Ventilation and oxygen toxicity
Early infection (e.g. adenovirus, respiratory syncytial virus [RSV])
Pressure effects of large, space-occupying lesion, e.g. lung cyst
1.3 Changes at birth and persistent fetal circulation

Vaginal delivery compresses the thorax, leading to expulsion of lung fluid and expansion of the lungs
with the first breath. The increase in oxygen content leads to closure of the ductus arteriosus (which in
fetal life diverts right ventricular blood away from the lungs into the systemic circulation), and the
resultant increase in left atrial pressure (from increased pulmonary venous return) closes the foramen
ovale. Thus, the right-sided pulmonary and left-sided systemic circulations become effectively
separated. Persistent fetal circulation describes the situation where the pulmonary vasculature fails to
relax, leading to ongoing right-to-left shunting of (deoxygenated) blood at the ductal and foramen
ovale levels. Infants are severely hypoxic, mimicking the clinical picture of cyanotic congenital heart
disease. Treatment includes ventilation with a high fractional inspired oxygen (FiO2), and
administration of pulmonary vasodilators such as inhaled nitric oxide and prostacyclin.
1.4 Control of respiration

Inspiration is achieved largely by diaphragmatic effort with additional expansion provided by the
intercostal muscles. At rest, expiration is largely passive, although this may become active upon
exercise, or in children with respiratory disease. Expiration against a partially closed glottis both
prolongs this phase and raises airway pressure, leading to increased alveolar gas exchange. This is
observed in the common sign of grunting in infants with respiratory distress.
Respiratory drive is provided by both central (medulla) and peripheral (carotid body)
chemoreceptors. In normal health, high CO2 leads to increased respiratory drive, although in chronic
lung disease sensitivity may be blunted, and there is a dependence on hypoxia for this stimulus.
1.5 Ventilation
Air passes through the trachea, major bronchi and terminal bronchioles (anatomical deadspace)
before reaching the sites of active gas exchange, the alveoli. In normal health, alveolar walls are thin
(one cell thick) facilitating O2 and CO2 exchange. In diseases affecting the alveolus, gas exchange
will be impaired, leading to an increase in respiratory rate in response to both a low O2 and a raised
CO2.
1.6 Perfusion
Perfusion is matched to ventilation via hypoxia-mediated pulmonary vasoconstriction, i.e. vascular
constriction leads to diversion of blood flow away from poorly ventilated to well-ventilated areas,
decreasing ventilationperfusion (
) mismatch. Pulmonary arterial flow will be increased by
vasodilatation in response to both high O2 and low CO2, whereas pulmonary vasoconstriction, and
thus hypertension, is exacerbated by hypoxia and hypercapnia.
1.7 Interpretation of oximetry and blood gases

Pulse oximetry
Non-invasive measure of oxygen saturation based on absorption of light by oxyhaemoglobin
Prone to movement artefact and dependent on good pulse pressure
Widely used, but caution required in interpretation, e.g. normal saturation in a child receiving
supplemental O2 may lead to a false sense of security when there can still be significant respiratory
compromise and hypercapnia
Stable, mature values are reached by 6 months of age; normal values in awake children are 95
100% (for preterm infants) and 97100% (for term infants and children)
Blood gas measurement

Arterial samples are rarely indicated in children outside the intensive care setting
Capillary and venous samples are good surrogates for PCO2 and pH, but not PO2
Transcutaneous measurements of both O2 and CO2 are possible, and end-tidal CO2 is also used in
the paediatric intensive care setting

Normal ranges
pH 7.357.45
PCO2 4.56.0 kPa
Low pH: metabolic acidosis (normal or low PCO2, low HCO3, increased base deficit) or
respiratory acidosis (raised PCO2; pH may be normalized by raised HCO3 if chronic)
1.8 Lung function testing

Infants
Methods for testing lung function in infancy have been developed and are in use in the research
setting, although they are not yet in widespread clinical use. In general, a sedated infant is fitted with
a tightly fitted facemask. After either a tidal breath or, with some methodologies, an assisted
inspiration, a jacket is rapidly inflated around the infants chest, leading to forced expiration, from
which flows and volumes can be measured.
Older children
From the age of between 5 and 7 years, children will usually be able to perform standard lung
function tests. The following values can be obtained:
FVC forced vital capacity, is the total amount of air exhaled upon forced expiration.
FEV1 forced expiratory volume in the first second; gives a measure of large (and medium-sized)
airway obstruction.
The ratio of these two values gives an indication as to the nature of an abnormality. Restrictive lung
diseases such as fibrosis lead to reduction in both parameters, with preservation of the normal ratio
(approximately 80%), whereas obstructive diseases (asthma, cystic fibrosis) lead to a greater
reduction in FEV1 and thus a reduced FEV1:FVC ratio.
FEF2575 forced expiratory flow between defined vital capacity (25% being empty) is a measure of
flow at lower lung volumes, is non-effort dependent, and is thought to be a reasonable representation
of small airway function. However, the coefficient of variation, even in healthy adults, is high.
PEFR peak expiratory flow rate. Although useful as a home monitoring device in patients with
asthma, it can be quite effort dependent and can underestimate significant small airway obstruction.
All of the above measurements can be obtained using a simple spirometer. For more complex
measurements of lung volume, patients perform plethysmography, which involves sitting inside an
airtight box.
RV residual volume is the amount of air left in the lungs after maximal expiration. It is increased in
diseases such as asthma because narrowed small airways prevent complete emptying of more distal
lung and result in air trapping.
In addition to the above, the transfer factor for CO and corrected total lung CO (corrected for lung
volume) give an estimate of the lung diffusion capacity. These measures are reduced in diseases
where alveolae are abnormal and gas exchange is impaired, and increased in the presence of red
blood cells which can absorb CO (e.g. pulmonary haemorrhage or haemosiderosis).
Lung volumes
Flowvolume loop
Obstructive defect
Restrictive defect
1.9 Respiratory defence mechanisms

Pulmonary defences can be mechanical or immunological.
Mechanical defences
Mucociliary clearance, whereby cilia beat in a coordinated fashion bathed in a normal volume and
composition of airway surface liquid, to bring inhaled particles to the throat where they are
swallowed. Abnormal in primary ciliary dyskinesia (problem with ciliary microstructure) and
cystic fibrosis (normal cilia but decreased airway surface liquid volume)
Cough clearance
Immunological defences
Innate:
Phagocytosis by macrophages and neutrophils
Soluble factors including hydrophilic surfactant proteins A and D, lactoferrin, lysozyme,
defensins
Acquired:
Humoral: largely immunoglobulin A (IgA) upper airway, IgG lower airways
Cell mediated
1.10 Environmental influences on lung disease

Cigarette smoke antenatal effect on growing lung is now well established. Between 40 and 60%
of British children are exposed to tobacco smoke at home. Passive smoking in children is
associated with an increased risk of asthma, wheeze, otitis media and sudden infant death
syndrome
Aeroallergens
Atmospheric pollutants ozone, particulates, lead, sulphur dioxide and CO have all been shown to
increase severity of asthma
2. EAR, NOSE, THROAT (ENT) AND UPPER AIRWAY

2.1 Nose and sinuses
Choanal atresia
Unilateral or bilateral. A congenital malformation occurring in approximately 1 per 60 00070 000
births as a result of the failure of the breakdown of the bucconasal membrane, leading to complete
obstruction of the nostril(s). Bilateral choanal atresia presents immediately at birth (because the
neonate is an obligate nose breather) with severe respiratory compromise and inability to pass a
nasal catheter. Artificial oral airway is life saving and surgery is required. It is associated with other
congenital defects, e.g. cardiac.
Allergic rhinitis
This presents as rhinorrhoea, sniffing, altered sense of smell (and taste), itchy eyes and
conjunctivitis. It may be either seasonal (usually triggered by pollens, grasses, etc.) or related to
environmental allergens (e.g. house-dust mite, dogs, cats, horses). Often associated with a history of
atopy in the child or family. Degree of disturbance to a sufferer of severe rhinitis is probably
underestimated (problems with concentration, poor sleep quality, etc.). Management should include
allergen avoidance and topical (nose eyes) administration of corticosteroids or cromoglicate-based
agents. In severe cases, oral antihistamines may be required. Children with allergic rhinitis may also
have nasal polyps.
Nasal polyps
These occur in atopic children and in cystic fibrosis (CF must consider CF diagnosis in any child
with polyps). Children present with runny nose, nasal obstruction, decreased sense of smell and
distortion of nasal shape. Polyps may respond to topical corticosteroids but are often difficult to treat,
necessitating surgical removal. Recurrence post-surgery is unfortunately common.
Epistaxis
Nosebleeds are reasonably common in childhood. They are usually from the Little area on the septum
and often triggered by nose picking. They are more common in inflamed/infected nose (e.g. allergic
rhinitis/polyps). If recurrent/severe, it is essential to rule out a bleeding disorder, e.g. idiopathic
thrombocytopenic purpura, haemophilia, leukaemia, or anatomical abnormality (e.g. haemangioma,
telangiectasia). Pressure under the nasal bridge is usually adequate to halt bleeding. If severe, nose
may need packing. Cauterization may be undertaken for recurrent episodes.
Sinusitis
Frontal sinuses are not aerated until the age of 35 years, so frontal sinusitis is not seen before this
age. Later, it presents with headache/facial pain (made worse by coughing/bending down), nasal
congestion/discharge, concentration problems.

Sinusitis is associated with CF (almost 100% of adult patients have opaque sinuses so a radiograph
is not very useful). It may also be associated with humoral immunodeficiency, e.g. IgA or IgG
subclass deficiency.
Treatment involves decongestants and antibiotics; surgical drainage is required in a minority.
Complications (rare but serious):
Orbital cellulitis
Frontal osteomyelitis
Meningitis/cerebral abscess
Intracranial (including cavernous sinus) thrombosis
2.2 Cleft lip and palate

This is often now diagnosed antenatally on ultrasound scanning. It can be associated with Pierre
Robin sequence (micrognathia and glossoptosis), other dysmorphic syndromes (e.g. Stickler
syndrome, Edwards syndrome), or may occur in isolation, in which case prognosis is usually
excellent. Certain antiepileptic medications are associated with increased incidence and there is
some evidence of prevention with folic acid (as in spina bifida). Familial cases are not uncommon,
making a genetic component very likely.
Main problems
Cosmetic lip cleft is repaired early at approximately 23 months of age
Feeding:
Special teats for bottles are available
Feeding is facilitated by a palatal plate if cleft is severe
There may be associated oropharyngeal incoordination and aspiration of feeds
Cleft palate surgery is usually performed by the age of 1 year
Speech and hearing:
Often associated with frequent ear infections and glue ear
Large cleft can cause speech difficulties
Airway obstruction if due to Pierre Robin sequence some infants require a nasopharyngeal tube
to maintain patency of the upper airway
2.3 Ears
Acute otitis media
Caused by both viruses and bacteria, this is experienced frequently, especially by young children. It
generally presents with otalgia fever and discharge. Examination typically reveals an inflamed,
bulging eardrum with dull tympanic reflection due to middle-ear fluid. Controversy exists as to the
need for and the optimal timing of antibiotics, but a frequently used management strategy is to treat if
symptoms persist beyond 3 days.
Chronic otitis media

Chronic otitis media (glue ear) is a major cause of hearing problems and speech delay; it results from
the accumulation of thick secretions in the middle ear and recurrent acute infections. It may be
associated with adenoidal hypertrophy; adenoidectomy may improve symptoms. Long-term
antibiotics are not very useful.
Insertion of grommets to release the fluid and pressure is often performed. Normally they are extruded
spontaneously after about 69 months. Studies have suggested that swimming is not harmful to a child
with grommets (but they should not dive).
Deafness
Deafness can be conductive or sensorineural.
Conductive deafness
Most common of the two types, detected in up to 34% of schoolchildren; often mild
Almost always secondary to chronic otitis media
Preservation of bone conductance with diminished air conductance
Sensorineural deafness
Less common; 0.20.3% of children and more likely to be severe
Caused by either cochlear or neuronal damage (may be iatrogenic, e.g. aminoglycoside toxicity)
Equal impairment of both bone and air conductance
Causes of sensorineural deafness

Genetic associated with dysmorphic syndromes
Congenital infections (TORCH group toxoplasmosis, other infections, rubella,
cytomegalovirus, herpes simplex)
Birth asphyxia
Severe jaundice
CNS infection:
Post-meningitis
Encephalitis
Cerebral abscess
Aminoglycoside toxicity
Head injury
Treatment:
Hearing aids may be useful if there is some preservation of hearing
Cochlear implants in selected cases
Multidisciplinary approach
Mastoiditis
This has become rare with the use of antibiotics to treat acute otitis media. It results from the
breakdown of the bony walls of mastoid air cells, secondary to ongoing bacterial middle-ear
infection. It presents with high fever, toxicity, irritability, marked focal tenderness over the mastoid
process, discharging ear deafness. If early in the process, it may respond to parenteral antibiotics;
in more severe cases, surgical intervention may be required.
2.4 Throat
Adenotonsillar hypertrophy and airway obstruction
Adenotonsillar hypertrophy is common in childhood, although most cases require no specific
treatment and will resolve with age. More severe cases are associated with certain disease groups,
e.g. sickle-cell anaemia and human immunodeficiency virus (HIV) infection.
Symptoms either relate to recurrent infections or airway obstruction. Obstruction may be obvious to
parents (snoring apnoeic pauses, mouth breathing), or may present with right heart failure and cor
pulmonale if not recognized until late. Polysomnography may reveal obstructive episodes (increased
chest excursion with diminished airflow hypoxia and hypercapnia if severe), although in the
majority of cases diagnosis can be made on the history.
Management is by surgical removal in selected cases.
Oropharyngeal incoordination and aspiration

Swallowing is a complex mechanism requiring intact anatomy and neuromuscular coordination.
Diseases affecting either pathway can lead to saliva and food/drink entering the respiratory tract.
It should be considered as a cause of respiratory symptoms especially in at-risk groups such as:
Preterm babies with immature swallowing mechanisms

Central nervous system (CNS) disease, e.g. cerebral palsy
Anatomical abnormality, e.g. cleft palate/larynx
Any cause of generalized hypotonia especially with bulbar involvement
Aspiration with intact swallow is also seen with severe gastro-oesophageal reflux and tracheooesophageal fistula.
Symptoms may be overt (choking and coughing with feeds) but are often absent. Leads to recurrent
wheeze and aspiration pneumonias. It is diagnosed on video-fluoroscopy. Management depends on
cause but severe cases may require surgical intervention.
2.5 Larynx
Laryngeal web is rare and if complete is obviously incompatible with life. More commonly, it
results in partial laryngeal obstruction, respiratory distress and stridor. Laryngeal cleft is very rare
and occurs due to failure of closure of the tracheo-oesophageal septum at 35 days of embryonic
development. It presents with aspiration, choking, episodes of cyanosis apnoea. Both require
surgical repair.
Haemangioma of the larynx presents with airway obstruction, cough or stridor. It may coexist with
cutaneous haemangiomas so examine the child completely. It is visible as a soft mass on
instrumentation of the airway and may bleed copiously if traumatized or biopsy is attempted. Topical
application of adrenaline may be life saving in such a situation.
Papillomatosis is a rare cause of hoarseness if affecting the larynx. It may present with stridor or
barking cough.
2.6 Malacias
Any tubular component of the respiratory tract may be malacic (floppy).
It results in partial or complete collapse on inspiration although patency is well maintained on
expiration.
Presentation;
Inspiratory stridor, respiratory distress
Apnoea
Feeding problems
Recurrent croupy episodes
Diagnosis can be confirmed on laryngo-/bronchoscopy (although it is usually possible clinically)
Mild cases (the majority) become less severe with growth
Severe cases may benefit from aortopexy or airway stenting
Causes of stridor
Common
Croup
Laryngo-/tracheomalacia
Subglottic stenosis/granuloma (post-intubation)
Vascular ring
Inhaled foreign body (if large and proximally lodged)
Rarer
Epiglottitis (much less common since Hib [Haemophilus influenzae type b] immunization)
External tracheal compression
Mediastinal mass, e.g. lymphoma/leukaemia
Tuberculous lymphadenopathy
Enlargement of heart/great vessels associated with congenital cardiac malformation
Laryngeal web
Haemangioma, papillomatosis
Vocal fold palsy
Vocal fold dysfunction
Hypocalcaemia
2.7 Sleep-disordered breathing

This covers a spectrum of problems, ranging from snoring through to hypoxia/hypercapnia leading to
pulmonary hypertension and cor pulmonale. It may be related to local (e.g. adenotonsillar
hypertrophy) or systemic (e.g. neuromuscular) disease. Take a careful history. Ask specifically about
pauses in breathing signalling sleep apnoea. It may lead to disrupted sleep/nocturnal enuresis/daytime
somnolence/morning headaches (high CO2)/underachievement at school. Definitive diagnosis on
polysomnography (see Section 10.4). Treatment is tailored to cause.
2.8 Tracheo-oesophageal fistula

Failure of normal development of the primitive foregut leads to a fistula connecting the oesophagus
and trachea with or without oesophageal atresia.
Oesophageal atresia presents in the immediate neonatal period with vomiting, choking ( an absence
of gas in the abdomen, depending on the position and size of the fistula). Confirmation is obtained by
attempted passage of a nasogastric tube. This may exist as part of the VACTERL constellation
(vertebral, anal, cardiac, tracheo-oesophageal fistula, ears, renal, limb).
Tracheo-oesophageal fistula without oesophageal atresia will often present later. At its most obvious,
the child may choke with feeds, but equally the history may be one of recurrent chest infections or
wheeze. Diagnosis is made on a tube oesophago-gram (injection of radio-opaque dye into the
oesophagus under pressure to force open a small fistula). It is often missed on bronchoscopy,
particularly flexible bronchoscopy.
Treatment for both conditions is surgical.
2.9 Gastro-oesophageal reflux

There is increased risk of gastro-oesophageal reflux in preterm infants, in neurologically impaired
infants and, probably, in severe chronic lung disease. It may also exacerbate lung problems such as
asthma, which makes differentiating cause and effect difficult. The most commonly used test for
diagnosis is the pH probe. Normal reflux index (percentage of time pH in lower oesophagus <4) is
4% in older children but probably up to 10% in infants. In some centres gastro-oesophageal reflux
disease (GORD) is diagnosed with an impedance study; this detects all reflux events, compared with
a pH study which detects only acid reflux. It also has the advantage of being able to quantify how far
up the oesophagus the child is refluxing. However, interpretation is time-consuming, requires
expertise and there are no standardised data. It is only carried out in specialised centres. Reflux may
lead to episodes of aspiration (may be silent), which if recurrent result in irreversible lung damage.
Medical treatment is with combination of antacid (H2-receptor blocker or proton pump inhibitor) and
prokinetic, e.g. domperidone. If unsuccessful, a Nissen fundoplication may be required.

The most common cause is upper respiratory tract infection. It usually resolves spontaneously,
although small lymph nodes may persist into adult life. If chronic or severe, alternative diagnoses
should be considered, e.g. infectious mononucleosis, dental disease, non-tuberculous mycobacteria,
cat-scratch disease (Bartonella henselae). If generalized, consider alternative diagnoses and look for
supportive signs of malignancy (e.g. lymphoma), HIV, Kawasaki disease.
3. ASTHMA
3.1 Pathophysiology
This is a chronic inflammatory disease of the airways with a well-recognized genetic component in
which many cells are involved, including eosinophils, lymphocytes and mast cells. Airway
inflammation leads to airway oedema, and hyperreactivity resulting in reversible
bronchoconstriction.
If left untreated, the inflammatory changes may eventually become chronic and irreversible, a process
termed airway remodelling.
From both laboratory and epidemiological studies, a protective role for infection against the
subsequent development of asthma has been demonstrated, e.g. there is a decreased incidence in
children with older siblings or raised on farms.
T-lymphocyte populations are biased towards a T-helper (Th2) cell phenotype (interleukin [IL]-4 and
IL-5 secretion, involved in IgE production), as opposed to the Th1 phenotype which is more
commonly found in response to infection.
Symptoms
Symptoms may be classic wheeze and dyspnoea, or a cough variant. They are often worst at night or
in the early morning.
Triggers
Viruses
Allergens (e.g. house-dust mite, cats, dogs)
Cold air
Cigarette smoke
Exercise
Stress/emotional
3.2 Drug treatment

Management
Management should include:
Identification and avoidance of precipitating factors (e.g. house-dust mite, pets, cigarette smoke)
Education importance of long-term prophylaxis
Recognition and management of acute attack (written plan where appropriate)
British Thoracic Society guidelines for asthma management

Step 1 short-acting bronchodilators as needed
addition of low-dose inhaled steroid or other preventer drug if steroid inhaler cannot be
Step 2
taken
>5 years: long-acting bronchodilator, increase steroid dose, and if still not controlled
Step 3
slow-release theophylline or leukotriene antagonist
<5 years: addition of leukotriene antagonist
Step 4 further increase of steroid dose
Step 5 regular oral corticosteroids; referral to respiratory paediatrician
Before stepping up treatment, drug compliance should be checked. Guidelines recommend stepping
down treatment when control is achieved, i.e. aim for best control on lowest dose.
Treatment options beyond step 5 (very rare and needs to be under subspecialist
care)
Continuous subcutaneous terbutaline
Anti-IgE monoclonal antibody (omalizumab)

Alternative immunosuppressive drugs:
Methotrexate can cause bone marrow suppression, liver cirrhosis, GI toxicity (look for
mucositis); requires full blood count (FBC), liver function tests (LFTs) and renal function
monitoring
Azathioprine can cause bone marrow suppression requires FBC monitoring
Ciclosporin can cause gum hypertrophy, hypertrichosis, hypertension, leukopenia, renal
toxicity
Monitor levels, liver and renal function, and BP
Inhaler devices
You should know how to demonstrate each device. It is very important to choose an inhaler that is
suitable for the child.
Metred-dose inhalers have poor lung deposition (most of the drug remains in the mouth and pharynx) and are not to be recommended for
use alone.
Long-acting bronchodilators are useful to gain control instead of increasing steroid dose and in
exercise-induced asthma. Now available in combination delivery devices with corticosteroid, which
may improve compliance.
3.3 Acute attack

Signs of severity:
Inability to talk in sentences

Tachypnoea/tachycardia
Inter-/subcostal recession
Use of accessory muscles of respiration
Quiet or silent chest (poor air entry)
Pulsus paradoxus
Cyanosis (very late sign beware)
In the presence of tachypnoea, a normal CO2 level indicates a severe attack
Management of acute severe asthma

Oxygen
Bronchodilator via a spacer device has been shown to be as effective as, if not more so than, via
nebulizer; can be give continuously. If unsuccessful, give intravenous salbutamol with
cardiovascular monitoring. Watch K+
Aminophylline:
Give loading dose slowly
Systemic (usually intravenous) steroids
Intravenous magnesium sulphate shown to be efficacious in meta-analyses
If respiratory support is required:
Lowest possible inspiratory pressures
Short inspiratory time; long expiratory time
Minimal/no positive end-expiratory pressure to reduce air trapping
Causes of wheeze in childhood

Common
Virus-associated recurrent wheeze

Acute viral infection, e.g. RSV, adenovirus
Asthma
Gastro-oesophageal reflux (and aspiration syndromes)
Cystic fibrosis
Inhaled foreign body
Rare
Distal bronchomalacia
Obliterative bronchiolitis
Bronchiectasis
4. CYSTIC FIBROSIS
4.1 Background
Cystic fibrosis (CF) is the most common lethal recessive disease of white people, with a carrier
frequency of 1:25, leading to disease in 1:2500 births of white babies (>9000 patients in the UK).
Previously regarded as a disease of childhood, increases in survival have swelled the adult CF
population. Median survival for a child born today is estimated at 40 years.
The gene responsible encodes the CF transmembrane conductance regulator (CFTR) and is on
chromosome 7. The primary function of CFTR is as a chloride ion channel, but it also inhibits the
epithelial sodium channel. CF respiratory epithelium therefore fails to secrete chloride ions (fails to
absorb in the sweat gland, hence high sweat electrolytes), and hyperabsorbs sodium ions and thus
H2O, dehydrating the airway surface. Secretions are viscid, impairing mucociliary clearance and thus
host defence.
CFTR is now known to have other functions (related to the transport of other substances, e.g.
bicarbonate, and receptors for bacteria) but they are controversial.
Other organs affected for similar reasons include the gut, pancreas, liver and reproductive tract.
4.2 Diagnosis
Newborn screening (NBS)
All children in the UK have been screened for CF as part of the newborn screening programme
since October 2007
Immunoreactive trypsin (IRT) is raised in the first 6 weeks of life in infants with CF
Infants with IRT >99.5th centile on their Guthrie test have CFTR mutation analysis
As with most screening programmes, there will be some false negatives (approximately 36%) so
CF diagnosis still need be considered in screened children if symptoms are suggestive
Sweat test
Gold standard: values of chloride ions >60 mmol/l are diagnostic (4060 borderline; many
consider cut-off to be 30, particularly for infants)
Traditionally the test required at least 100 mg sweat, but newer methods (e.g. macroduct) require
less
Cases of CF with normal sweat electrolytes have been reported, so if there is a high suspicion for
disease a normal sweat test does not rule out a diagnosis of CF.
Possible causes of false-positive sweat test:
Technique (evaporation leads to increased concentration and decreased volume)

Eczema/dermatitis/ectodermal dysplasia
Severe malnutrition or dehydration
Untreated hypothyroidism/panhypopituitarism
Glycogen storage disease/mucopolysaccharidosis
Glucose-6-phosphate dehydrogenase deficiency
Fucosidosis
Nephrogenic diabetes insipidus
Genetic testing
See Section 4.3.
Nasal potential difference

Mostly used for research purposes but useful in grey cases. Technically challenging in children.
4.3 Genetics
Over 1800 mutations in CFTR have been identified to date. They fall into five classes. The most
common is Phe508del (previously called F508), a class II mutation that leads to defective protein
folding and thus failure to reach the apical membrane. There is a relationship between pancreatic
status and genotype, but correlations for lung disease have been poor to date. Except in rare cases, it
should not be used to provide prognosis.
Most clinical laboratories test for up to 34 of the most common mutations (which detects >90% of
cases in white individuals). This is useful for antenatal testing of subsequent pregnancies.
4.4 Presentation and management

Neonatal
Most common presentation is now a positive NBS result. Some neonates present before screening
with meconium ileus, bowel obstruction secondary to thick inspissated gut contents. It may be
antenatal and be visible as hyperechogenic bowel on an ultrasound scan or lead to meconium
peritonitis. It often requires surgery, although very mild cases occasionally managed medically, e.g.
with Gastrografin.
Rarer early presentations
Pseudo-Bartter syndrome (hypochloraemic, hypokalaemic alkalosis)

Hypoalbuminaemia, oedema, anaemia
Bleeding from vitamin K deficiency
Haemolytic anaemia (vitamin E deficiency)
Pulmonary
Lungs are thought to be normal at birth. Early symptoms such as cough, frequent chesty episodes and
wheeze may be missed or labelled viral infections. Early infection is with a narrow range of
organisms:
Staphylococcus aureus most children in UK receive long-term prophylaxis

Pseudomonas aeruginosa up to 80% of CF patients are chronically infected by the time they
reach adolescence. Bacteria become mucoid, forming biofilms and are more difficult to eradicate
when chronic. Treat with long-term nebulized antibiotics (colomycin or tobramycin/TOBI). Newer
nebulisers, e.g. e-flow and i-Neb, shorten the duration of nebulized antibiotics from 20 min (with
conventional nebulisers) to less than 5 min. Intermittent courses of intravenous antibiotics (always
at least two) are required for some. Macrolide antibiotics are in more common use now. Shown to
improve lung function, although mechanism of action unclear; may be anti-inflammatory
Allergic bronchopulmonary aspergillosis (ABPA) presents with dry cough, wheeze, variable
infiltrates on chest radiograph. Diagnosed with high IgE, raised radioallergosorbent test (RAST)
and precipitins. Skin-prick testing may be helpful. Treated with steroids itraconazole, which may
need to be prolonged
Burkholderia cepacia Gram negative, often highly resistant. Meropenem may be useful.
Associated in approximately 20% with life-threatening septicaemia (cepacia syndrome); patientto-patient spread is well-documented (segregation vital)
Stenotrophomonas maltophilia an emerging pathogen; there is conflicting evidence on whether
it leads to significant deterioration
Atypical mycobacteria quite common. May be an incidental finding. Treat if symptomatic,
persistent or patient is immunosuppressed, e.g. on steroids. Mycobacterium abscessus particularly
likely to be associated with increased disease severity
Airway inflammatory response is excessive. End-result of infection/inflammation is bronchiectasis
(upper lobes common), chronic sputum production, clubbing and hypoxia. May present with asthmalike symptoms (consider CF in cases of difficult/atypical asthma). May have haemoptysis (high
bronchial arterial flow and, if severe, embolization). Ninety per cent of patients die of respiratory
failure.
Other treatments for lung disease

Mainstay of treatment is physiotherapy (regular even when patient is well!) and regular exercise.
Consider bronchodilators if responsive. Many patients are on inhaled steroids (evidence lacking).
Mucolytics: given to aid sputum clearance with physiotherapy because in CF these can be thick and
difficult to clear
Recombinant human DNase;
Degrades viscous neutrophil-derived DNA
Nebulized once daily, at least 1 hour before physiotherapy
Very expensive (7500/patient per year)
Hypertonic (7%) saline:
Nebulized twice daily, just before physiotherapy
Can cause bronchoconstriction, so salbutamol may be given before saline
Extrapulmonary involvement
Pancreas
Exocrine insufficiency
Presents with steatorrhoea and faltering growth
Low stool elastase, high 3-day faecal fat
Treat with pancreatic enzyme supplements (e.g. Creon)
Fat-soluble vitamin supplementation
Nutritional supplements if required
Gastrostomy and supplemental nutrition if severe weight problems
Endocrine problems
CF-related diabetes
More common in older children (815%):
Insidious, non-specific onset
Ketoacidosis is extremely rare (residual pancreatic function)
Usually require insulin. Some evidence that early use of low-dose insulin in pre-diabetic phase
may protect lung function
Carries poorer prognosis, especially in females
Gastrointestinal tract
Distal intestinal obstruction syndrome (previously called meconium ileus equivalent):
Rehydrate and administer Gastrografin, Klean-Prep, etc.
Attention to dietary fibre and enzymes
Hepatic cirrhosis:
Ursodeoxycholic acid may be useful
Nose
Polyps (up to 30%): topical steroid or surgery often recur
Sinusitis
Common caused by obstruction
Same causative organisms as lungs
Infertility
99% males (obstruction and abnormal development of vas deferens)
Females subfertile, but many successful pregnancies. Pulmonary health may be severely affected
during pregnancy need careful monitoring
Arthritis
Probably immune complex mediated

Correlates with pulmonary function tests
Vasculitis
More common in older patients
Osteoporosis
More common with increasing age and severity of lung disease; also long-term steroid use. Many
clinics monitor using bone densitometry
4.5 New/emerging therapies

Gene therapy
Still at clinical trial stage
Liposomes or recombinant viral vectors used as vectors
Anti-infectives
Dry powder antibiotics are currently in phase 3 clinical trials; may improve quality of life by
reducing treatment burden
AZLI (nebulized aztreonam)
CFTR modulation
Oral medications aimed at correcting the defective CFTR protein; these drugs are class specific
A drug for class III mutations (VX-770; CFTR potentiator) has shown improvement in lung function
and weight compared with placebo in phase 2 and 3 trials
A new drugs for class I (premature stop mutations PTC124) in phase 3 clinical trials
Others directed at class II mutations are currently at earlier research stages
Ant-inflammatory
Ibuprofen:
Slows reduction in lung function but has side effects
Not in widespread use in the UK
Novel drugs and drugs already in existence for other uses (such as sildenafil and acetylcysteine)
are undergoing clinical trials to assess their benefit for airway anti-inflammatory drugs.
Caution: some inflammation may be helpful. Complete abrogation of inflammatory response could
lead to increased infective problems
4.6 Transplantation
Heartlung or bilateral lung transplantations are performed, limited by the number of organs
available. More recently, living-related donors have been used; currently there is no advantage but
this will possibly improve with further experience.
Psychological issues are of major importance.
Possible contraindications (vary slightly with different centres)
Long-term use of high-dose steroids

Multiresistant organisms
Previous thoracic surgery
Lack of family support or psychological issues
Severe osteoporosis
Post-transplantation problems
Prolonged immunosuppression and infection
Obliterative bronchiolitis is common
5. OTHER CAUSES OF BRONCHIECTASIS

Symptoms/signs are as for CF depending on severity. It may be visible on chest radiograph but
computed tomography (CT) is more sensitive. Bronchography is no longer used.
Primary ciliary dyskinesia

Previously called immotile cilia syndrome, this is an autosomal recessive problem (several genes
probably involved). Rare: 1 per 15 000 births.
Presentation
Neonatal respiratory distress, rhinorrhoea

Recurrent lower respiratory tract infections possibly leading to bronchiectasis
Sinus disease
Glue ear often does not respond well to grommets
40% have dextocardia abdominal situs inversus (Kartagener syndrome)
Male infertility (female subfertility)
Diagnosis
Nasal brushing for ciliary beat frequency (normal >10 Hz), assessment of beat coordination and
structure (electron microscopy)
Low exhaled/nasal nitric oxide
Genetic testing
Mutations in two genes (DNAI1 and DNAH5) identified in about 40% of families with primary
ciliary dyskinesia
Treatment
Physiotherapy
Antibiotics
ENT and hearing assessment
Genetic counselling
Post-infection
Classically occurs after pertussis, although may also follow measles. May occur after severe
infection with any organism.
Post-airway obstruction
Highlights importance of early detection and removal of foreign bodies (see Section 8)
Tuberculosis obstructive lymphadenopathy
Recurrent infection
For example, immune deficiency (see Section 7.9).
Recurrent aspiration
Idiopathic
This explains up to 60% of cases but other causes must be excluded.
Congenital
Rare.
6. BRONCHOPULMONARY DYSPLASIA
This is chronic lung disease resulting from premature delivery, surfactant deficiency and neonatal
artificial ventilation.
Various definitions exist, all including the requirement for O2 at 28 days.
Other aetiological factors include:
Birth asphyxia
High-concentration O2 administration
Fluid overload
Infection
Vitamin A deficiency antioxidant effects
Of these, barotrauma from ventilation and oxygen toxicity is the most important. Centres using noninvasive ventilation as the first-line therapy (e.g. nasal continuous positive airway pressure [CPAP])
have a lower incidence of bronchopulmonary dysplasia.
Incidence is reduced greatly by both antenatal steroids (increases lung maturation and surfactant
production) and exogenous surfactant. (For further details see Chapter 17.)
Treatment
Long-term O2
Corticosteroids
Diuretics and fluid restriction may be useful
Immunization including flu and Pneumovax
Consider use of palivizumab (see Section 7.7)
Bronchodilators may be useful in wheezy cases
Consider and treat coexisting gastro-oesophageal reflux (immature swallow, reduced muscle tone,
prolonged intubation all increase risk)
Longer-term complications
Reactive airway disease (e.g. risk of severe disease with RSV)

Complications of intubation (e.g. subglottic stenosis, granulation tissue, tracheomalacia)
Pulmonary hypertension and cor pulmonale
Growth and nutritional delay
Neurodevelopmental disability
7. INFECTIONS
7.1 Epiglottitis
This is usually caused by Haemophilus influenzae type b. It is rare since introduction of the Hib
vaccine. Presents with acute-onset stridor, fever and anxiety in the child.
Do not examine throat (may precipitate fatal airway obstruction)
Do not take radiograph (although appearances may be diagnostic, wastes time and is dangerous)
Do not upset child, e.g. taking blood, lying flat
If suspected urgent general anaesthesia, visualization of upper airway and intubation. Rarely need
tracheostomy. Bacterial swabs at intubation. Treat with intravenous third-generation cephalosporin.
7.2 Tonsillitis
Acute tonsillitis is common and self-limiting in childhood. Presentation may be non-specific in the
small child, e.g. irritability, refusal of feeds, fever, febrile convulsion. Older child usually complains
of sore throat. Bacterial and viral causes (commonly adenovirus, rhinovirus, -haemolytic
streptococcus); exudate does not imply bacterial cause.
Indications for tonsillectomy
Recurrent severe attacks of tonsillitis

Tonsillar hypertrophy leading to airway obstruction/sleep-disordered breathing
Associated eustachian tube obstruction with hearing impairment
Recurrent otitis media associated with adenotonsillar infection
7.3 Croup
Viral laryngotracheobronchitis parainfuenza virus, influenza virus, RSV, rhinoviruses

Common between 6 months and 5 years of age; more common in boys than girls
Barking cough and stridor
Child not usually toxic; may have low-grade fever
No evidence in support of humidification
Good evidence for a role for steroids: oral single dose (dexamethasone used in most studies) and
inhaled budesonide effective and no good evidence to support one over the other
Nebulized adrenaline will help in acute situation but effect is short-lived
Severe cases may require intubation and ventilation
May be recurrent
7.4 Tracheitis
Presentation as for croup
Viral (same as croup) and bacterial (Staphylococcus aureus and Haemophilus influenzae)
aetiologies
Bacterial cases often more toxic
Severe cases may require intubation
7.5 Bacterial pneumonias

Presentation
Variable depending on severity
Cough
Tachypnoea other signs of respiratory distress (nasal flaring, grunting, use of accessory muscles)
Fever
Non-specific irritability/vomiting in younger infant
Hypoxia
Chest radiograph: often patchy shadowing in infant and more commonly lobar consolidation in
older child
Aetiology
Pneumococcus sp. is the most common causative organism
With increasing age, Mycoplasma spp. are more prevalent
Staphylococcus aureus is associated with lung abscess (both staphylococci and streptococci may
follow varicella virus infection)
Rarely H. influenzae, streptococci, Klebsiella sp. (remember most pneumonias are viral in younger
child)
Management
Mild cases can be diagnosed clinically and treated with oral antibiotics out of hospital
More severe cases cultures (sputum if available, upper airway secretions, blood):
White blood cell count and differential and C-reactive protein are useful for monitoring response
to treatment (but do not differentiate well between bacterial and viral infections)
Intravenous antibiotics
Hydration (see below)
O2 therapy if required
Rarely, severe cases will require respiratory support
Complications
Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is common. It leads to fluid
retention and thus hyponatraemia, which if severe can lead to cerebral oedema and convulsions.
Monitor electrolytes and osmolality (serum and urine). Management is by fluid restriction and NOT
by administration of sodium.
7.6 Empyema
Collection of pus in pleural space resulting from spread of infection from lung tissue. Presents with
signs of pneumonia plus unilateral decreased air entry, dull percussion note. Patient often has
scoliosis toward the affected side mediastinal shift. Fluid demonstrated on chest radiograph.
Ultrasound may confirm presence of loculation or fibrin strands.
Management
Requires drainage (not just aspiration)
Intrapleural urokinase may assist recovery by breaking down fibrinous material to facilitate
drainage
Intravenous antibiotics
Surgery
Decortication/video-assisted thoracic surgery (VATS)
Offers no advantage over drain + urokinase in the majority of cases
Complications
Bronchopleural fistula
Lung abscess
SIADH
Other causes of pleural effusion
Tuberculosis
Chylothorax (especially post-surgery from thoracic duct ligation)
Congestive heart failure
Hypoalbuminaemia (with peripheral oedema, e.g. nephrotic syndrome)
Malignancies (rare)
Blood in pleural space will have similar chest-radiograph appearance, e.g. post-trauma
7.7 Bronchiolitis
Classically caused by RSV, common in autumn and winter (similar picture can be caused by
influenza, parainfluenza and adenovirus infections). Very common; >80% children under 4 years
possess neutralizing antibodies (although not very effective, hence repeated infections). Causes a
range of symptoms from upper respiratory tract infections in older children and adults to bronchiolitis
in the first 2 years of life. It is the most common cause of pneumonia in the first year.
Presentation
Respiratory distress and coryza
Fever
Hyperinflation
Apnoea in very young infants

Crackles widespread throughout lung fields wheeze
Diagnosis
Immunofluorescence on nasopharyngeal aspirate
Management
Largely supportive
Adequate hydration
Humidified O2 as required
Evidence for use of bronchodilators (e.g. ipratropium bromide or salbutamol) not strong, but used
frequently, often with apparent success
Groups at risk of severe disease

Bronchopulmonary dysplasia or other chronic lung disease, e.g. CF
Congenital heart disease (especially cyanotic or associated with pulmonary
congestion/hypertension)
Immunocompromised children
Disease in these children may lead to respiratory failure and requirement for ventilation
Immunization
No active vaccine is currently available, and early studies with attenuated virus have led to increased
severity in the subsequent infective episode. Anti-RSV immunoglobulin was useful in early studies in
high-risk cases, but there were problems obtaining sufficient quantities and the usual concerns re
blood products.
Humanized monoclonal anti-RSV antibody (palivizumab, Synagis) has been available in Europe since
1999 (1 year earlier in the USA).
Given as monthly intramuscular injections during the RSV season
Shown in trials of babies with bronchopulmonary dysplasia to reduce admissions, but no effect on
the severe end of the disease (paediatric intensive care, mortality)
Recommendations for use vary (commonly chronically O2 dependent in first 2 years of life)
7.8 Viral pneumonia/Pneumonitis

Common viruses
Viral respiratory illnesses are usually caused by influenza, parainfluenza, human metapneumovirus,
adenovirus, RSV or coronavirus. Signs and symptoms are indistinguishable from other pneumonias;
treatment is supportive. Same groups of children as above are at high risk for severe illness.
Influenza
Vaccine to seasonal flu is available and offered to those deemed to be most at risk. The vaccine
contains subgroups of influenza A and B, including influenza AH1N1, following the pandemic in
2009. Neuraminidase inhibitors (e.g. oseltamivir) reduce spread of the virus in the airways if given
within 48 hours of symptoms. Oral and inhaled preparations are available.
Recent viral epidemics
SARS (severe acute respiratory syndrome) Caused by a coronavirus in 2003. Severe clinical picture
in adults with high mortality, but children displayed only symptoms of mild upper respiratory tract
infection (URTI) and recovered quickly.
Avian flu (H5N1)
Caused by a strain of influenza A, this was first seen in 1997 but re-emerged in 2007. Unlike SARS,
H5N1 caused severe disease in children with up to a 50% mortality rate. Limited person-to-person
spread stopped this becoming pandemic.
Swine flu (H1N1)
The WHO declared a pandemic in 2009 following the rapid spread of H1N1, a subtype of influenza
A. It caused mortality in some previously healthy children, but most fatalities were in high-risk
individuals and most healthy individuals had mild symptoms.
7.9 Tuberculosis and atypical mycobacterial infection

See also Chapter 15 Section 5.1.
After a fall in incidence in tuberculosis (TB) worldwide over the last two to three decades following
the development of successful anti-TB chemotherapy, there is now an increase in the number of cases,
in both adults and children. This largely reflects the rapid increase in numbers infected with HIV, but
is also being observed in areas of extreme poverty and overcrowding in countries such as the USA. A
rise in cases of multidrug-resistant infection often results from poor adherence to treatment in index
cases.
Note that TB is a notifiable disease.
This is a prime example of the ability of microorganisms either to exist within a host without causing
adverse effects (TB infection) or to multiply, with or without tissue invasion and spread, and cause
TB disease. Which one of these two situations evolves depends on both host (age, immune status,
nutrition) and bacterial factors (numbers and virulence factors).
Pulmonary TB
The major route of infection is via the respiratory tract (more rarely via the oral route leading to gut
TB must rule out immunodeficiency).
Once organisms have been inhaled they establish themselves in the periphery of the lungs, and elicit a
host inflammatory response (largely via macrophages).
Spread to regional lymph nodes may also cause hilar adenopathy.
If inflammatory response is sufficient to keep the infection in check, the lesion may calcify and form a
Ghon focus, which may be identified later on chest radiograph and be the only evidence of previous
TB in an otherwise well person. This is much rarer in children than in adults, and most of the TB
presenting in children is caused by the primary infection, resulting in the period from infection to
disease often being as short as weeks.
Symptoms
These vary and may be non-specific:
Fever
Irritability
Weight loss and lethargy
Cough
Airway obstruction from lymphadenopathy; may lead to lobar collapse or less frequently to air
trapping
Dyspnoea and respiratory distress in severe cases especially if miliary
Erythema nodosum
Radiology
Can vary greatly from isolated focus to hilar lymphadenopathy, lobar collapse/consolidation to
miliary (seed-like) shadowing throughout lung fields
Large caseating lesions not common in children
Extrapulmonary
TB can infect most organs, in particular the brain, kidneys, gut and bone. Children are more prone
than adults to extrapulmonary infection, the details of which are not discussed further here.
Diagnosis of TB
High index of suspicion is important.
Tuberculin skin testing (TST)

Intradermal administration of purified tuberculin protein will lead to a T-cell-mediated reaction in
sensitized individuals. Depending on the clinical situation, and whether bacillus CalmetteGurin
(BCG) has been administered, the size of the reaction considered to be significant may differ.
Significance of reaction size

Size of reaction (mm)
Significant in:
>15
Any child
High risk birth or arrival from high-risk country
Contact with adults in high-risk group
Young age
Contact with an open known case (if no BCG)
Clinical or radiographic evidence
HIV infection
1015
>5
Microbiology
Sputum (rare in children)

Gastric aspirates (morning)
Bronchoalveolar lavage fluid
Acid-fast bacilli may be visible on staining, otherwise culture requires up to 68 weeks
Some laboratories will test with polymerase chain reaction, although, because this is very sensitive,
false positives can arise.
Interferon- testing
These tests look for specific interferon- secreted by T cells exposed to Mycobacterium
tuberculosis. They do not differ between latent and active TB and are usually performed alongside
TST. There are two tests used in the UK: QuanterFERON Gold is carried out on whole blood and the
T-SPOT TB test on T cells, making it more time-consuming but useful if child is immunosuppressed
or on steroids.
Treatment
Current guidelines state that all cases should receive quadruple therapy. Drug treatment is given in an
initial phase of four drugs, followed by a maintenance phase of two drugs.
Usual firstline
treatment
Isoniazid (6
months)
Potential side effects

Rifampicin (6
months)
Pyrazinamide
(2 months)
Ethambutol
(2 months)
Orange urine/tears
Hepatic enzyme induction (drug interactions)
Liver toxicity
(only active against intracellular, actively dividing forms of the bacteria. Works
best early in the treatment course. Good meningeal penetration if CNS disease)
Visual disturbance (Perform ophthalmic examination)
Avoid in very young children
Additional therapeutic agents for high-risk/drug-resistant disease:
Ciprofloxacin
Clofazimine
Kanamycin
Clarithromycin
Streptomycin (intramuscular rarely used in developed countries)
Children are rarely open cases (i.e. smear positive) and it is therefore unusual that they would be
capable of transmitting the infection. After the first 2 weeks of treatment the child should be allowed
to re-commence normal activities.
Neonatal contact
A neonate born to a mother with active TB is at serious risk of acquiring the disease. If at the time the
maternal diagnosis is realized (and treatment commenced) the infant has no signs of TB, the child
should receive isoniazid prophylaxis, be closely followed up and receive a tuberculin test at 3
months. If negative, this should be repeated along with interferon- test and, if all negative,
prophylaxis stopped. If tuberculin test positive, assessment should be made for active TB. Thereafter,
the guidelines for older children should be followed.
Contact tracing is a major public health issue. Cases of paediatric TB still arise in families where a
parent is known to be infected but children have not been screened.
Pulmonary infection with atypical mycobacteria

Examples include Mycobacterium avium, M. intra-cellulare, M. kansasii and M. malmoense.
Unusual except in immunocompromised individuals or in children with CF. Symptoms range from
those seen with TB infection to much milder presentation with fever or lethargy. In some cases,
diagnosis may be suspected only after new changes are seen on a chest radiograph or, for example, in
CF when the organisms are identified in the sputum. In CF, difficulties may arise in determining
whether such organisms are pathogens. Treatment of a CF child is recommended if the child is unwell
or if sputum is persistently positive.
Treatment
Longer than for M. tuberculosis (up to 2 years). Choice of agents depends on organism and
sensitivities. Usually a combination of the following is used:
Rifampicin
Clarithromycin/azithromycin
Amikacin
Ciprofloxacin
Clofazimine
Ethambutol
Notification and contact tracing are not required.
7.10 Infections in the immunocompromised host

Pneumocystis jiroveci pneumonia (PCP)
Infection is caused by the fungus Pneumocystis jiroveci, formerly known as Pneumocystis carinii
(hence PCP).
Presentation
Onset may be acute or insidious (especially in the older child), with tachypnoea, respiratory distress,
fever, cough, bilateral crackles and hypoxia; often normocapnic in early stages.
Chest radiograph
Classically bilateral interstitial and alveolar shadowing. May be normal, unilateral or focal.
Diagnosis
Occasionally found on nasopharyngeal aspirate (NPA)
Usually requires bronchoalveolar lavage (BAL)
In rare cases, lung biopsy is required
Think
Severe combined immune deficiency states (SCID)

HIV (common in first year of life)
DiGeorge syndrome
(CD40 ligand deficiency; previously called hyper-IgM syndrome)
Treatment
High-dose trimethoprim/sulfamethoxazole (pancytopenia, rash, fever)

Pentamidine or dapsone used less frequently
Steroids role established in HIV; less certain otherwise
If ventilated, consider surfactant
Prophylaxis required after treatment and for any child at risk
Other
Anti-P. jiroveci antibodies are common in healthy children.
Cytomegalovirus
Presentation
Usually insidious radiological appearance and likely immunodeficiencies similar to PCP
May be congenital or acquired
May coexist with extrapulmonary infection ophthalmic examination required
Diagnosis
Antigen (DEAFF, detection of early antigen fluorescent foci) or polymerase chain reaction on NPA
or BAL
Detection in other body fluids, e.g. urine, does not confirm cytomegalovirus as the cause of
pneumonitis
Other
Dual infection with P. jiroveci is not uncommon
Other infections
Organisms causing a similar interstitial picture in immunocompromised patients include:
Measles
Varicella virus
Adenovirus
Fungi
Mycobacteria
Lymphocytic interstitial pneumonitis

Although not related to any particular pathogen, this disorder is often confused with the opportunistic
infections above, and is thus included here. It is seen in children with HIV or occasionally other
immunodeficiency states, but is less common in adults:
Tends to coexist with marked lymphadenopathy parotid hyperplasia and to decrease with falling
CD4 count
Presents either as chronic cough or hypoxia and clubbing if severe
May be asymptomatic and detected radiologically only
Treatment nil if well; usually responds to steroids
When to suspect immune deficiency

Normal children may have up to 10 upper respiratory tract infections per year. Suspect abnormal
immune function if respiratory tract infections are:
Unusually severe or prolonged

Recurrent (although if same site, suspect anatomical abnormality or foreign body)
Any case of pneumonitis/unexplained interstitial disease
Associated with:
Infections in other sites, e.g. skin, liver, gastrointestinal tract, bone
Faltering growth
Persistent or generalized lymphadenopathy
8. INHALED FOREIGN BODY

This will not be diagnosed unless thought about. There are major long-term implications if not
removed, e.g. lobar collapse, bronchiectasis.
Suspect signs
Sudden-onset cough/wheeze/breathlessness
May or may not give history of aspiration
Ask about presence of older siblings in the case of an infant
Unilateral signs: wheeze, absent or diminished air entry, tracheal/mediastinal deviation if severe
Chest radiograph
Either volume loss or hyperexpansion from air trapping on affected side
Hyperexpansion best visualized on expiratory film
Management
Removal under rigid bronchoscopy (flexible bronchoscopy not recommended because removal is
more difficult)
Follow-up ventilation scan should be considered, especially in cases of non-inert foreign body, e.g.
food. Peanuts are a particular problem because nut oil is very irritant and proinflammatory. If
removal is delayed, anti-inflammatory agents, e.g. steroids, may be useful to reduce airway
narrowing
Consider postoperative antibiotics, depending on findings
Education is important, particularly the avoidance of peanuts in young children
9. PNEUMOTHORAX
In children this is usually associated with underlying disease.
Gas trapping (e.g. severe asthma, CF)
Bullae (e.g. Marfan syndrome)
Other Langerhans cell histiocytosis (in association with fibrotic, honeycomb changes on chest
radiograph)
Iatrogenic (high-pressure ventilation), traumatic and postoperative
Symptoms and signs

Dyspnoea, cough, chest pain
Tracheal deviation, asymmetrical chest expansion and breath sounds
Hyperresonance subcutaneous emphysema
Management
Depends on size on chest radiograph (all patients should have one)
If small with minimal symptoms, can be managed conservatively and observed
If larger with significant symptoms give O2 (aids air absorption from pleural space) and drain.
Aspiration may be sufficient, otherwise intercostal drain
Recurrent
Consider pleurodesis:
Surgical pleurectomy more effective but more invasive
Chemical adherence of pleura with either talc or doxycycline; painful
May exclude possibility of future transplantation, e.g. in CF. Consider with care
Confused with:
Neonatal cysts, diaphragmatic hernia, severe hyperinflation, e.g. inhaled foreign body
Can impair respiratory function at any of following sites: spinal cord, peripheral nerve,
neuromuscular junction and muscle.
10.1 Spinal cord

Disorder at levels of the anterior horn cells (atrophy). Autosomal recessive inheritance.
Presents as a floppy infant (WerdnigHoffman disease; with tongue fasciculation, preservation of eye
muscles giving alert facial expression) or in less severe forms, as hypotonia and delayed motor
milestones. Genetic tests are now available to aid diagnosis and classification.
Respiratory involvement always seen in types I and II (diaphragm spared), common in type III. Chest
may be bell shaped. Lungs small.
Previously, severe forms would have been given a grave prognosis once diagnosed and allowed to
die. More and more commonly, particularly in the USA, parents are demanding long-term ventilation.
There are obvious ethical issues regarding this because there is currently no realistic chance of
improvement or cure.
Myelomeningocele
Rarely affects respiration unless very high.
Cervical cord injury

Respiratory involvement depends on level.
10.2 Peripheral nerve

GuillainBarr syndrome
Post-viral inflammatory ascending polyneuropathy
Respiratory involvement common and most serious manifestation (intercostals and diaphragm):
This will be underestimated, unless specifically monitored
Do not assess with peak flow (this may be normal despite respiratory muscle compromise) use
vital capacity
Bulbar involvement may lead to aspiration. Protective intubation may be required
Good prognosis, even in severe cases requiring mechanical ventilatory support. Usual course:
Evolution 24 weeks
Plateau variable
Resolution 24 weeks later
Specific treatments:
Plasmapheresis in some cases
10.3 Neuromuscular junction

Myasthenia gravis
Autoimmune disease with antibodies directed against the acetylcholine (ACh) receptor
Episodic muscle weakness, often mild, e.g. ptosis
Weakness increases with exertion
Management strategies include a trial of anticholinesterase drugs such as pyridostigmine,
thymectomy or immunosuppressive treatments
Congenital myasthenia gravis is an autosomal recessive, non-autoimmune disease in which ACh

synthesis or mobilization is defective. May respond to anticholinesterase drugs, but, if not, severe
cases require long-term ventilatory support (see below) and assistance with feeding.
Neonatal myasthenia gravis is seen in up to 15% of babies born to affected mothers and results from
transplacental passage of autoantibodies. Is transient, but affected infants may have feeding
difficulties or require respiratory support. Treated with anticholinesterase drugs/exchange transfusion
or plasmapheresis occasionally required.
Botulism
Rare
Toxins produced by Clostridium botulinum (usually food borne, especially honey, which should be
avoided in infants under the age of 1) lead to impaired release of ACh at neuromuscular junction.
Bulbar muscles involved early, with respiratory failure in most cases. Good prognosis with
adequate support. Botulinum toxin is currently being used as treatment for certain diseases with
muscular spasm as major component
Tick paralysis
Very rare
10.4 Muscle
Myotonic dystrophy
Floppy infant in severe form
Diaphragm involvement (eventration)
Feeding problems aspiration

Maternal (when congenital) myotonia (muscles slow to relax, e.g. hand shake)
Later problems learning difficulties, cardiac conduction defects, baldness
Triplet-repeat disease (others are Huntington disease, fragile X syndrome, Friedreich ataxia) with
increasing severity in subsequent generations (genetic anticipation)

X-linked
Weakness usually noted towards end of first decade.
Oral glucocorticoid steroids prolong ambulatory phase and delay respiratory failure:
Death is usually from respiratory failure
Preceded by recurrent lower respiratory tract infections aspiration from swallowing
incoordination
Regular overnight sleep studies should be performed to identify nocturnal hypoventilation once
FVC <50% or symptomatic
Nocturnal non-invasive ventilation (NIV) corrects sleep hypoventilation and prolongs average
survival to mid 20s and can prolong life to the fourth decade.
Myopathies
Respiratory involvement variable depending on type
Symptoms include:
Respiratory infections
Morning headaches (CO2 retention)
Daytime drowsiness
Management
Always consider possibility of respiratory involvement
Lung function testing
Polysomnography (overnight O2, CO2, nasal airflow, chest wall movement, heart rate,
respiratory rate EEG, pH probe)
Non-invasive ventilation increasingly used (see below). Use once evidence of respiratory failure
10.5 Respiratory failure

Inability to maintain adequate gas exchange without additional support. If chronic, pulmonary
hypertension and cor pulmonale may occur. Assess severity of respiratory effort (beware, if poor
exhaustion is a late and worrying sign), vital signs, evidence of cor pulmonale, oxygen saturation and
blood gases. Respiratory failure may manifest with hypoxia alone or hypercapnia as well. If the latter,
supplementary oxygen is not an appropriate treatment; child will need non-invasive support (see
below) or intubation.
10.6 Non-invasive ventilatory support

Acute respiratory failure requiring invasive ventilation in the intensive treatment unit setting will not
be dealt with in this chapter, although the systems below can also be administered long term with the
aid of a tracheostomy tube in cases where this is necessary.
Children with the neuromuscular disorders above (plus those with malacic airways and very
occasionally those with chronic lung disease) may have chronic respiratory compromise and benefit
from long-term ventilatory support.
This can be administered as either positive or negative pressure.
Positive pressure
Both continuous (CPAP) and bilevel (bi-PAP) positive airway pressure can be administered through
either a nose- or a facemask.
Both systems can be used at home with or without oxygen depending on the pathology. The devices
are in general well tolerated, the only major problem being one of pressure sores caused by the tightfitting mask.
Negative pressure
Devices, including the cuirass jacket, have also been used in these settings. The jacket is worn around
the chest, with closely fitted seals at either end. Negative pressure applied to the jacket causes
inspiration. Expiration can be passive or assisted.
The benefits of this approach include a more physiological respiratory cycle. However, movement of
the child is limited by the devices, which can also be very noisy.
In the UK, negative pressure is used much less frequently than positive. It is important to remember
that significant weakness of the bulbar muscles, especially with any airway malacia, can lead to
airway collapse and obstruction during applied negative pressure, which can lead to failure of the
device.
11. RARE DISORDERS

11.1 Congenital disorders
Congenital thoracic malformations (CTMs)
Cystic adenomatoid malformation (CCAM)
Type 1 single or multiple large cysts (despite shift effects, usually good postoperative prognosis)
Type 2 multiple small cysts

Type 3 solid mass (poor prognosis)
Lobar sequestration
Mass of non-functional lung; abnormal communication with airway and usually supplied by
systemic circulation
Intra- or extralobar (often associated with other congenital abnormalities and polyhydramnios):
may have derived from accessory lung bud, although exact aetiology is uncertain. Lower lobes
most commonly affected, more often the left
Bronchogenic and duplication cysts
Remnant of primitive foregut derived from abnormal tracheobronchial budding

Form up to 10% of mediastinal masses in children
Contain normal tracheal tissue, filled with clear fluid
May exist in various sites including paraoesophageal, with symptoms varying accordingly
CTMs may be diagnosed antenatally or postnatally but exact diagnosis can be made only on
histological examination after resection. They cannot therefore be considered separately with regard
to management.
Such lesions may be symptomatic:
Recurrent infections, stridor, lobar collapse, dysphagia from oesophageal compression or
haemorrhage
In these cases surgical resection or embolization of the feeding vessel is advised
Imaging with angiography to identify anatomy and blood supply is required before any surgery
Management of asymptomatic lesions is controversial:
Most believe that resection of the lesion is advisable in order to prevent infections, malignant
change (a very small risk that is not necessarily averted by complete resection) or other rare
complications (haemorrhage, pneumothorax or air embolism)
Some believe that asymptomatic lesions should be managed conservatively and the child followed
up
Congenital lobar emphysema

Over-inflation of the lobe as a result of an intrinsic deficiency of bronchial cartilage elastic tissue.
The most common sites
Left upper lobe, right middle and upper lobes. Rare in lower lobes
Presentation
May be asymptomatic; detected on chest radiograph

Neonatal respiratory distress
Chest asymmetry, hyperresonance
Chest radiograph
Hyperlucent region; may be associated compression of other lobes
Ventilationperfusion scan may show absence of ventilationperfusion in more severe cases
Management
Lobectomy of affected lobe if respiratory distress
Mild respiratory distress/asymptomatic children can be managed conservatively because the
emphysematous lobe does not become infected later on and does not affect lung growth
Cardiac work-up: 1:6 have associated cardiac abnormality
Scimitar syndrome
Hypoplastic right lung with anomalous venous drainage (usually to inferior vena cava or right
atrium) systemic collateral arterial supply. Scimitar sign is the vertical line caused by the right
upper lobe pulmonary vein running into the inferior vena cava
May be asymptomatic or lead to recurrent infection
Right lung usually functions well and surgical correction of the vascular abnormalities is usually
recommended
Diaphragmatic hernia
Incidence estimated at around 1 per 25003500 births. More common on the left. Main problems
arise from the associated pulmonary hypoplasia, on both the affected side and the contralateral side
when there is significant mediastinal shift. Diagnosis may be made antenatally on ultrasound
Postnatal presentation includes respiratory distress, scaphoid abdomen and vomiting. Chest
radiograph shows bowel loops inside thorax which may be confused with either cystic
malformation or pneumothorax (use nasogastric tube both to confirm the diagnosis and to deflate
the stomach, reducing the chance of rupture)
Often associated with other malformations, in which case prognosis is worse
Treatment
Surgery required
No clear evidence, but some suggestion that high-frequency oscillatory ventilation may help
Pulmonary hypertension is quite common. May respond to nitric oxide or vasodilators
Extracorporeal membrane oxygenation (ECMO)
Prognosis
With optimal management, including ECMO, mortality rate has decreased from about 5060% to
2040% in recent years

Survivors may have problems associated with underlying pulmonary hypoplasia
Recessively inherited disorder
Absence of liver-derived antiprotease leads to proteolytic destruction of pulmonary tissue and
emphysema on exposure to oxidants, e.g. cigarette smoke and pollutants
Rare for pulmonary problems to arise in children who are more likely to have the associated liver
disease (eventual cirrhosis)
PiMM refers to the homozygous normal state, PiZZ is homozygous deficient, PiSZ also causing
disease
Alveolar proteinosis
Aetiology is uncertain, although some cases presenting as neonates are now known to be the result
of deficiency of surfactant-associated protein B and others are linked to granulocytemacrophage
colony-stimulating factor (gm-csf). Lipid-laden type II pneumocytes desquamate into the alveolar
spaces, leading to increasing hypoxia and respiratory distress
Chest radiograph resembles interstitial lung disease with widespread confluent airspace
shadowing
Diagnosis made on lung biopsy
Prognosis poor
In older child, whole lung lavages may help, but, in infants, the disease is almost universally fatal.
Genetic counselling required
Congenital pulmonary lymphangiectasia

Rare dilatation of pulmonary lymphatics leading to severe neonatal respiratory distress and often
pleural effusions
Associated with congenital cardiac disorders such as obstructed venous drainage
Prognosis very poor
No specific treatment
11.2 Acquired disorders

Obliterative bronchiolitis
Results from viral infection (usually adenovirus (50%) or mycoplasma (1030%) but occasionally
measles or RSV) or can follow lung or bone marrow transplantation
Severe, widespread, small airway obstruction
Dyspnoea, wheeze and hypoxia with eventual pulmonary hypertension
Chest radiograph hyperinflated lungs with patchy pruning of vascular markings
CT patchy areas of air trapping (honeycomb) and poor perfusion

In the early stages there may be some response to bronchodilators or steroids, but often no treatment
is successful. If unilateral, may go on to SwyerJames (also called Macleod) syndrome of unilateral
hyperlucent lung with diminished vascularity.
Haemosiderosis
Repeated episodes of pulmonary haemorrhage lead to accumulation of haemosiderin at the alveolar
level
Haemorrhage may be symptomatic with haemoptysis, or unrecognized, presenting with anaemia
Aetiology is uncertain, although a subgroup of cases is associated with cows milk protein allergy
and positive antibodies, and responds to dietary manipulation
Another subgroup have Goodpasture syndrome (positive anti-glomerular basement membrane
antibodies)
Similar clinical picture may occur with mitral stenosis or connective tissue diseases
Symptoms usually episodic: fever, dyspnoea, wheeze haemoptysis
Chest radiograph may be normal but more commonly patchy shadowing
Diagnosis haemosiderin-laden macrophages in BAL
Management difficult:
Acute treat hypoxia, anaemia
Longer term steroids, hydroxychloroquine or alternative immunosuppressive drugs
Sarcoid
Extremely rare in childhood
Multisystem granulomatous disease; may be confused with TB and chronic granulomatous disease
Symptoms
Dry cough, dyspnoea
Clinical examination often unremarkable in early stages (may lead to clubbing later)
Chest radiograph
Hilar lymphadenopathy
Patchy lung infiltrates
May be associated with extrapulmonary disease (skin, eye, kidney, gut)
Diagnosis
Usually made on biopsy (Kveim test no longer performed)
Treatment
May be self-limiting
Steroids hydroxychloroquine if treatment required
Interstitial lung diseases of childhood (ILDs)

This is a rare and diverse group of conditions leading to damage of the alveolar units and subsequent
failure of adequate gas exchange. In some children an underlying cause is found. In others, there is no
apparent underlying cause and this group can be further subdivided by either histology or clinical
presentation:
50% present in infancy
Often gradual-onset dry cough, tachypnoea, dyspnoea, wheeze, hypoxia, clubbing. Older children
describe chest pain and reduced exercise tolerance
Widespread crackles throughout both lung fields usual, but chest can be clear. Signs of airway
obstruction (barrel chest, apparent hepatomegaly)
Chest radiograph/CT ground-glass appearance, diffuse abnormality
Differential diagnosis includes pneumonitis from opportunistic pathogens, e.g. PCP, extrinsic
allergic alveolitis. Definitive diagnosis will require an open lung biopsy
Histological findings vary from inflammation (more likely to respond to steroids) through to severe
fibrosis (steroids less likely to succeed; antifibrotics, e.g. hydroxychloroquine, may be used)
Prognosis highly variable, ranging from subacute respiratory failure to a plateau phase with
intermittent symptoms, or even recovery in some patients
Pulmonary hypertension may be primary (rare) or more commonly occurs secondary to another
disease, including:
Secondary to chronic hypoxia (chronic lung disease, ILD, obstructive sleep apnoea, severe CF):
Chronic hypoxia leads to pulmonary vasoconstriction and arterial wall change.
If treated early changes are reversible. If not treated, structural changes occur that are permanent
and progressive
Left-to-right shunts (high pulmonary arterial blood flow)
Left heart disease (e.g. left-sided valvular, atrial or ventricular disease):
Multisystemic disorders such as HIV, sarcoidosis, connective tissue
Primary pulmonary hypertension presents with hypoxia, dyspnoea and, if severe, right heart failure.
May present in the neonatal period as persistent fetal circulation (see Section 1.3). Secondary
pulmonary hypertension should be suspected with increasing shortness of breath, increased oxygen
requirement, syncopal episodes or unexpected deterioration not explained by the underlying
diagnosis.
May respond to pulmonary vasodilators:
High O2
Nitric oxide (in ventilated children)
Sildenafil
Prostacyclin
Nifedipine
Prognosis is improving with a 7580% 3-year survival rate.
12. FURTHER READING

Beachey W (2007). Respiratory Care Anatomy and Physiology: Foundations for clinical practice,
2nd edn. London; Mosby.
Chernick V, Boat TF, Wilmott RW, Bush A, eds (2006). Kendigs Disorders of the Respiratory Tract
in Children, 7th edn. London; WB Saunders.
Gibson RL, Burns JL, Ramsey BW (2003). Pathophysiology and management of pulmonary infections
in cystic fibrosis. Am J Respir Crit Care Med 168;91851.
Hull J, Forton J, Thomson A (2008). Oxford Specialist Handbooks in Paediatrics: Paediatric
respiratory medicine. Oxford; Oxford University Press.
Chapter 23
Rheumatology
Nathan Hasson
CONTENTS
1. Juvenile idiopathic arthritis
1.1 Systemic onset disease
1.2 Polyarticular rheumatoid factor negative
1.3 Polyarticular rheumatoid factor positive
1.4 Oligoarticular (persistent and extended)
1.5 Enthesitis-related arthritis
1.6 Juvenile psoriatic arthritis
1.7 Unclassified
2. Other forms of childhood autoimmune arthritis

2.1 Inflammatory bowel disease-related arthritis
2.2 Juvenile sarcoidosis
2.3 Reactive arthritis, including Reiter syndrome
2.4 Rheumatic fever
2.5 Infectious arthritis
2.6 Notes on management of arthritis
3. Connective tissue disorders of childhood

3.1 Dermatomyositis
3.2 Systemic lupus erythematosus
3.3 Neonatal lupus
3.4 Behet syndrome
3.5 Sjgren syndrome
3.6 Scleroderma
3.7 Overlap syndrome including mixed connective tissue disease
4. Childhood vasculitis
4.1 HenochSchnlein purpura

4.2 Kawasaki disease (mucocutaneous lymph node syndrome)
4.3 Polyarteritis nodosa
4.4 Takayasu disease (giant cell arteritis)
4.5 Vasculitis with granuloma
4.6 Differential diagnosis of childhood rheumatic disorders
5.2 Osteopetrosis
5.3 Osteoporosis
5.4 Hemihypertrophy
5.5 Hypermobility
5.6 Toe walking
5.7 Foot drop
5.8 Reflex sympathetic dystrophy
5.9 Non-accidental injury
5.10 Back pain
5.11 Torticollis
6. Further reading
Rheumatology
1. JUVENILE IDIOPATHIC ARTHRITIS

This is the classification for autoimmune arthritis in childhood replacing juvenile
chronic/rheumatoid arthritis and Still disease.
Definition a chronic arthritis that persists for a minimum of 6 consecutive weeks in one or more
joints, starting before the age of 16 years and after active exclusion of other causes.
Epidemiology 1 per 1000 children under 16 years of age.
Classification
By mode of onset during the first 6 months
Eight groups:
Systemic onset
Polyarticular rheumatoid factor negative
Polyarticular rheumatoid factor positive
Oligoarticular persistent
Oligoarticular extended
Enthesitis-related arthritis (enthesis = point of bony insertion of tendon)
Psoriatic
Unclassified
Systemic disease
High remittent fever and rash with one or more of the following: hepatomegaly, splenomegaly,
generalized lymphadenopathy or serositis
Arthritis may be absent at the onset, but myalgia or arthralgia is usually present
Polyarticular onset
Five or more joints develop in the onset period, usually somewhat insidiously and symmetrically
May be further divided by the presence of immunoglobulin M (IgM) rheumatoid factor (also cyclic
citrullinated peptide positive in some)
Oligoarticular onset
The most common mode with four or fewer joints involved, particularly knees and ankles; once a
joint is affected, it always counts even if does not recur
Three clear subgroups have emerged, notably young children with positive anti-nuclear antibodies
(ANAs) who are at risk from chronic iridocyclitis, older boys (aged 9 upwards) who frequently
carry the histocompatible leukocyte antigen (HLA)-B27 and develop enthesitis (now classified as
enthesitis-related arthritis), and those who extend past four joints (extended oligoarticular juvenile
idiopathic arthritis) after 6 months
Others presenting in this way include juvenile psoriatic arthritis, the arthritis of inflammatory
bowel disease and Reiter syndrome, although some are as yet unclassified
1.1 Systemic onset disease

General characteristics
Usually begins before 5 years of age but can occur throughout childhood into adult life
Equal in boys and girls aged <5 years but female predominance in those aged >5 years
Clinical features
High once-daily fever spikes for >2 weeks

Myalgia
Arthralgia
Malaise
Rash salmon-pink or red maculopapular eruption
Lymphadenopathy cervical, epitrochlear, axillary and inguinal
Hepatosplenomegaly
Serositis 40% mainly pericarditis
Hepatitis
Progressive anaemia
Macrophage activation syndrome
Arthritis knees, wrists and carpi, ankles and tarsi, neck, followed by other joints
Investigations
Erythrocyte sedimentation rate (ESR) high

Haemoglobin low (normochromic/normocytic)
White blood cell count raised (neutrophil leukocytosis)
Platelets raised (>400 106/l)
IgM rheumatoid factor negative
ANAs negative

Half will have recurrent episodes of systemic disease
Progressive arthritis occurs in about a third, irrespective of whether there are systemic
exacerbations
The younger the age of onset, the greater the risk of poor growth, both somatic and of joints
Amyloidosis occurs in some children with persistent disease activity, predominantly among
Europeans
Management
Physiotherapy to maintain joint mobility and muscle function
Non-steroidal anti-inflammatory drugs (NSAIDs) to control pain, inflammation and fever
Corticosteroids in severe disease, either as pulsed, intravenous, single daily dose or given on
alternate days
Methotrexate especially for arthritis
Ciclosporin or IvIg (intravenous immunoglobulin) for systemic features
Etanercept (tumour necrosis factor [TNF] receptor NICE approved for 417 year olds) or
infliximab/adalimumab (anti-TNF receptor antibody) for disease that is resistant to other medical
management or for patients in whom there is significant drug toxicity very little is known of longterm toxicity; use in specialist centres only
Anti-interleukin-1 (anti-IL-1; anakinra) effective when other treatments failed or side effects
Anti-IL-6 tocilizumab very successful in patients failing above treatments
1.2 Polyarticular rheumatoid factor negative

Any age, occasionally before the first birthday
Female predominance
Clinical features
Polyarthritis can affect any joint; the most commonly affected are the knees, wrists, ankles, and
proximal and distal interphalangeal joints of the hands; metacarpophalangeal joints are often
spared
Limitation of neck and temporomandibular joint movement is common
Flexor tenosynovitis
Low-grade fever, occasionally
Mild lymphadenopathy and hepatosplenomegaly, occasionally
Investigations
ESR elevated
Haemoglobin may be reduced
White blood count mild neutrophil leukocytosis
Platelets moderate thrombocytosis
ANAs occasionally positive

Variable
May be monocyclic but prolonged over several years with good functional outcome
Recurrent episodes tend to cause progressive deformities
Management
Physiotherapy to maintain and improve joint and muscle function

Splinting to prevent deformity
NSAIDs to control pain and inflammation
Methotrexate is very effective and can be used early on to prevent deformity
Anti-TNF treatment if other disease-modifying anti-rheumatic drugs (DMARDs) have failed
1.3 Polyarticular rheumatoid factor positive

Aged >8 years at onset
Female predominance
Clinical features
Polyarthritis affecting any joint, but particularly the small joints of the wrists, hands, ankles and
feet; knees and hips often early, with elbows and other joints later
Rheumatoid nodules on pressure points, particularly elbows. Vasculitis uncommon and often late,
nailfold lesions, ulceration
Investigations
ESR usually elevated

Haemoglobin moderate anaemia
IgM rheumatoid factor persistently positive and in high titre
Anti-cyclic citrullinated peptide (CCP) may be positive and predictive of prognosis
ANAs may be positive

HLA-DR4 frequently present
Radiographically early erosive changes of affected joints, particularly of hands and feet

Persistent activity with serious joint destruction and poor functional outcome
Additional long-term hazards include atlantoaxial subluxation, aortic incompetence and
amyloidosis
Management
Physiotherapy to maintain and improve joint and muscle function

Splinting to preserve function
NSAIDs
Slow-acting drugs early
Methotrexate
Anti-TNF treatment if other DMARDs failed
Surgical intervention, such as replacement arthroplasties, often required later
1.4 Oligoarticular (persistent and extended)

Under 6 years of age
Female predominance
Clinical features
Arthritis affecting four or fewer joints: commonly knee, ankle, elbow or a single finger
Early local growth anomalies
Risk (2:3) of chronic iridocyclitis in the first 5 years of disease, ANA associated
If four or fewer joints after 6 months then defined as persistent oligoarticular, if more than four
joints are affected it is described as extended oligoarticular
Investigations
ESR may be elevated or normal, initially

Haemoglobin normal
White blood count normal
Platelets normal
ANAs frequently positive
HLA-A2, -DR5 and -DR8

Exacerbations and remissions
Alteration in growth of affected limb
Long-term prognosis of joints good, except for the one in five who develop polyarthritis (five or
more joints) over a period of years (extended)
Iridocyclitis is bilateral in two-thirds; the course is independent of the joints its prognosis
depends on early detection and good management
Management
Physiotherapy to maintain muscle and joint function

NSAIDs help only symptoms not disease
Local corticosteroid injection triamcinolone hexacetonide is most effective
Frequent ophthalmological assessment (3- to 6-monthly)
Methotrexate for extended oligoarticular juvenile idiopathic arthritis
Anti-TNF treatment in extended if methotrexate failed
1.5 Enthesitis-related arthritis

Age 9 years
Male predominance
Clinical features
Peripheral arthritis predominantly affecting the joints of the lower limb

Enthesopathies plantar fascia, Achilles tendon, patella tendon
Acute iritis
Sacroiliac pain in some
either of these can be the presenting feature
Axial disease in some
Investigations
ESR normal to high

Full blood count usually normal
HLA-B27 present in 90%

Functional outcome is good in two-thirds of cases
Some joint extension may occur
Over time, one-third can develop serious hip problems, cervical and other spinal involvement,
impaired temporomandibular function, as well as other features of spondylitis
Management
Physiotherapy, including hydrotherapy, to maintain mobility: particularly important if spinal
involvement occurs
NSAIDs
Local corticosteroid injections; hip arthroplasty may be needed in a small proportion
Sulfasalazine is the disease-modifying drug of choice; methotrexate is also effective
Anti-TNF treatment if other DMARDs failed, especially for axial disease
1.6 Juvenile psoriatic arthritis

An arthritis associated, but not necessarily coincident, with a typical psoriatic rash, or arthritis,
plus at least three of four minor criteria: dactylitis, nail pitting, psoriatic-like rash or family history
of psoriasis
Female predominance
Family history of psoriasis (common) or arthritis (but less so)
Clinical features
Asymmetrical arthritis
Flexor tenosynovitis
Occasionally severe destructive disease
Systemic features rare
Nail pitting
Onycholysis
Psoriasis
Investigations
ESR varies with number of joints, may be high

Haemoglobin may fall
White blood count may increase (neutrophils)
ANAs can be positive
Young onset can be associated with iridocyclitis

Remittingrelapsing course, even into adult life
Occasionally severely destructive
Occasionally spondylitis (inflammation of spinal joints) develops
Management
Physiotherapy
NSAIDs and steroid joint injections
Methotrexate early for polyarticular presentation
Anti-TNF treatment if other DMARDs failed
1.7 Unclassified
All those that do not meet the criteria for the above.
2. OTHER FORMS OF CHILDHOOD AUTOIMMUNE ARTHRITIS

2.1 Inflammatory bowel disease-related arthritis
Arthritis associated with either ulcerative colitis or Crohn disease
Over 4 years of age
Male and female predominance equal
Clinical features
Arthritis usually occurs after the onset of bowel symptoms, but occasionally begins coincident with,
or even precedes, them
Arthritis is usually oligoarticular: knees, ankles, wrists and elbows
Two forms:
Benign peripheral arthritis coinciding with active bowel disease
In older patients, who belong to the spondylitic group, the joint activity does not necessarily link
with bowel activity
Associated features
Erythema nodosum
Pyoderma gangrenosum
Mucosal ulcers
Fever
Weight loss
Growth retardation
Acute iritis in the spondylitic group
Investigations
Platelets normal/elevated
ESR usually elevated
Haemoglobin usually low (normochromic, normocytic)
White blood count normal
ANAs negative
HLA-B27 present in the spondylitic group

Peripheral arthropathy involves few joints and is episodic and benign
Prognosis for joint function is excellent
Prognosis for the spondylitic group is similar to that of ankylosing spondylitis
Management
Physiotherapy as appropriate
Treatment of the underlying bowel disorder
NSAIDs with care, because of gastrointestinal side effects (ibuprofen may be the drug of choice
and use antacids such as ranitidine)
Sulfasalazine or methotrexate may be helpful for both subgroups
Infliximab (anti-TNF treatment) is effective
Causes of erythema nodosum
Idiopathic
Streptococcal infection
Tuberculosis
Leptospirosis
Histoplasmosis
Herpes simplex virus infection
Yersinia sp. infection
Sulphonamides
Oral contraceptive pill
Crohn disease
Ulcerative colitis
Behet syndrome
Sarcoidosis
Hodgkin disease
2.2 Juvenile sarcoidosis
Can occur at any age

Usually presents with painless swelling of joints and marked tenosynovitis
Can have rash
Panuveitis can be severe so regular eye checks must be performed
With musculoskeletal disease lymphadenopathy is not seen; renal disease occurs in children
Angiotensin-converting enzyme (ACE) is raised in at least 50% of children who are patients
Treat with steroids and methotrexate or azathioprine
2.3 Reactive arthritis, including Reiter syndrome

Acute arthritis occurring after an intercurrent infection, without evidence of the causative organism in
the joint. Any age, but particularly male teenagers.
Clinical features
Arthritis
Urethritis/balanitis/cystitis
Typical triad for Reiter syndrom
Conjunctivitis
Mouth ulceration
Fever
Rashes, including keratoderma blennorrhagica (macules pustular on palms, soles, toes, penis)
If only two salient features occur, it is often referred to as incomplete Reiter syndrome.
Investigations
ESR raised
Haemoglobin normal
Mild neutrophil leukocytosis
ANAs negative
Occasionally positive stool or urethral culture (Shigella, Salmonella, Yersinia, Campylobacter,
Chlamydia spp.)
High incidence of HLA-B27

Usually self-limiting, but the arthritis can be severe and persistent
Some may later develop ankylosing spondylitis
Management
Antibiotics initially, if an organism is found

Physiotherapy to maintain function of joints and muscles
NSAIDs
Sulfasalazine if joint problems persist
Conditions associated with HLA-B27 positivity
Ankylosing spondylitis 95% of patients

Reiter syndrome
Arthritis of inflammatory bowel disease and psoriasis
Acute iridocyclitis
Enthesitis-related arthritis of older children
Reactive arthritis following infection with Salmonella and Shigella spp., Yersinia enterocolitica,
Campylobacter sp.
2.4 Rheumatic fever

An inflammatory reaction in joints, skin, heart and central nervous system (CNS) following a group
A haemolytic streptococcal infection
Age generally >3 years
Occurs in both sexes, but in girls more often than boys
Revised Jones criteria

Major manifestations
Carditis (severe pancarditis can occur in first or subsequent attacks)
Polyarthritis (flitting)
Subcutaneous nodules
Chorea
Erythema marginatum
Minor manifestations
Fever
Arthralgia
Previous rheumatic fever and rheumatic heart disease

Raised acute phase (ESR, C-reactive protein)
Prolonged PR interval on ECG
Plus supporting evidence of a preceding streptococcal infection.
Throat swab positive for group A streptococcus, increased anti-streptolysin O and anti-DNAse B
titres.
Investigations
ESR raised if not in cardiac failure

Haemoglobin may fall with chronic disease
White blood count normal or slight rise
ANAs negative
ECG may be abnormal, prolonged PR
Echocardiogram may show valvular or myocardial dysfunction

Average attack lasts 6 weeks
High risk of recurrence in patients who do not receive adequate prophylaxis against streptococcal
infection
Management
Bed rest in the acute phase

Penicillin to eradicate residual streptococcal infection
Salicylate therapy
Corticosteroids in patients with significant carditis
Prophylactic oral or intramuscular penicillin after an attack required into adult life
2.5 Infectious arthritis

Viral
Adenovirus, parvovirus, cytomegalovirus, rubella virus, mumps virus, varicella virus
Lyme disease
Borrelia burgdorferi
Bacterial
Haemophilus sp. (young), staphylococci, streptococci, meningococci, gonococci

Mycobacteria both typical and atypical
Fungal
Blastomycosis, coccidioidomycosis, cryptococci
Histoplasma capsulatum
Other
Mycoplasma spp.
Guinea worm
Differential diagnosis of childhood arthritis
Infections
Post-infectious arthritides
Mechanical, including hypermobility
Juvenile idiopathic arthritis
Neoplasm including acute lymphoblastic leukaemia
Other autoimmune/vasculitic diseases
Rheumatic fever
2.6 Notes on management of arthritis

Physiotherapy, occupational therapy, podiatry, splinting
Arthritis causes contractures and physiotherapy, occupational therapy, podiatry and splinting are used
to overcome this. The physiotherapist teaches active and passive joint movements aiming to maximize
function and avoid contractures. Hydrotherapy is used in early disease. Splinting at night is used to
prevent or help correct fixed flexion deformities. The podiatrist has a specific interest in foot care.
The occupational therapists role is to maximize the childs functioning within as normal an
environment as possible using aids/adaptations as needed.
Orthoses
Orthoses are useful in helping to prevent contractures, maintaining a good position if contractures
have been repaired and providing joint stability
They are particularly useful for helping individual children with mobility
The type of orthoses depends on the childs individual needs
For example, they may be anklefoot orthoses if there is just ankle and foot involvement, extending to
the knee if the knee is involved. Should there be a scoliosis, thoracolumbar orthoses are available.
Side effects of commonly used drugs

NSAIDs gastrointestinal (may need ranitidine, omeprazole), neurological (headaches, mood)
Steroids bone (use calcium, vitamin D), growth, cataract, weight gain
Methotrexate nausea (may need ondansetron) liver and bone marrow toxicity (requires monitoring
of blood count and liver function)
Anti-TNF treatment hypersensitivity reactions, infections, particularly tuberculosis, headaches
Antinuclear antibodies
Not diagnostic or specific for any particular disease
React with various nuclear constituents
Causes of ANA positivity in children

Juvenile idiopathic arthritis
Chronic active hepatitis
Scleroderma
Mixed connective tissue disease
Drugs, e.g. anticonvulsants, procainamide
3. CONNECTIVE TISSUE DISORDERS OF CHILDHOOD

3.1 Dermatomyositis
Non-suppurative myositis with characteristic skin rash and vasculitis
Occurs in girls more often than in boys
Peak incidence at 410 years of age
Clinical features
Muscle pain and occasional tenderness

Muscle weakness limb, girdle, neck, palate, swallowing
Oedema
Skin rash periorbital heliotrope eruption and oedema
Deep red patches over extensor surface of finger joints (Gottron patches), elbows, knees and ankle
joints
Vasculitis and skin ulceration
Nailfold and eyelid dilated capillaries
Retinitis in some
Myocarditis with arrhythmias can occur
Arthralgia/arthritis with contractures
Limited joint mobility
Gastrointestinal dysfunction
Pulmonary involvement
Calcinosis (after 12 years)
Investigations
Magnetic resonance imaging (MRI) of muscles shows inflammation in muscles and perifascicular
areas
ESR usually normal
Serum muscle enzymes (creatine kinase, lactate dehydrogenase) elevated
Electromyography (EMG) shows denervation/myopathy
Muscle biopsy shows inflammation and/or fibre necrosis and small-vessel occlusive vasculitis
ANAs positive in some

Variable
Prognosis usually good with adequate treatment
A small proportion can develop extensive muscle wasting, severe contractures and widespread
calcinosis
Management
Gentle physiotherapy and splinting, followed by more active physiotherapy as muscle inflammation
subsides
Corticosteroids in sufficient dosage to restore function and normalize enzymes
Cytotoxic drugs methotrexate, azathioprine, ciclosporin, cyclophosphamide, if required
Anti-TNF treatment
Careful monitoring is essential, with particular attention to palate and respiratory function, as well
as to possible gastrointestinal problems
3.2 Systemic lupus erythematosus

Onset usually after 5 years of age

Before puberty, female:male incidence ratio 3:1; after puberty 10:1
Higher incidence in black, Oriental, Asian, Native American and Latin American individuals
Can be associated with complement deficiencies of C2 and C4
Possible associations with HLA antigens HLA-B8, -DR2, and -DR3
Clinical features
General malaise
Weight loss
Arthralgia or arthritis
Myalgia and/or myositis
Fever
Mucocutaneous lesions:
Malar rash
Papular, vesicular or purpuric lesions
Vasculitic skin lesions
Alopecia
Oral ulcers
Photosensitivity
Renal disease common, even at onset
Pulmonary pleuritis, interstitial infiltrations
Cardiac pericarditis, myocarditis, LibmanSacks endocarditis
CNS involvement seizures, headache, psychosis
Cerebral dysfunction blurred vision, chorea, transverse myelitis
Gastrointestinal involvement hepatosplenomegaly, mesenteric arteritis, inflammatory bowel
disease
Eye retinitis, episcleritis, rarely, iritis
Raynaud phenomenon, occasionally
Investigations
ESR raised
Haemoglobin low: autoimmune haemolytic anaemia in some; anaemia of chronic disease
Leukopenia mainly lymphopenia
Thrombocytopenia in some
IgM rheumatoid factor may be positive
ANAs strongly positive
Antibodies to double-stranded (ds) DNA usually present in two-thirds
Total haemolytic complement and its components low
Anti-cardiolipin antibodies and lupus anticoagulant may be present
Highly variable
Relates closely to the extent and severity of systemic involvement
Potential causes of death include infectious complications, including bacterial endocarditis
Other problems include myocardial infarction, pulmonary fibrosis and renal failure
Meticulous monitoring essential
Management
Hydroxychloroquine for skin, joints, pulmonary involvement

Corticosteroids for systemically ill patients
Cytotoxic drugs for serious intractable disease
Anti-platelet drugs for thrombotic episodes
Rituximab for refractory renal, CNS and haematological disease
Revised criteria for the classification of systemic lupus erythematosus

A person shall be said to have systemic lupus erythematosus (SLE) if any four or more of 11 criteria
are present:
1. Malar rash
2. Discoid rash
3. Photosensitivity
4. Oral ulcers
5. Arthritis
6. Serositis:
Pleuritis
OR
Pericarditis
7. Renal disorder:
Persistent proteinuria
0.5g/day
OR
Cellular casts
8. Neurological disorder
Seizures disorder
OR
Psychosis
9. Haematological disorder:
Haemolytic anaemia
OR
Leukopenia
OR
Lymphopenia
OR
Thrombocytopenia
10. Immunological
(a) Anti-phospholipid antibodies
OR
(b) Anti-DNA: antibody to native DNA
OR
(c) Anti-Sm: presence of antibody to Sm nuclear

OR
(d) False-positive serological test for syphilis
11. Antinuclear antibody:
An abnormal titre of ANA
3.3 Neonatal lupus

Present in neonatal period; acquired transplacentally
Associated with maternal autoantibodies (particularly Ro/La) and with maternal lupus or Sjgren
syndrome
Clinical features
Rash lesions of discoid lupus or subacute cutaneous lupus

Congenital heart block occasional endocardial fibroelastosis
Thrombocytopenia
Hepatic or pulmonary disease, haemolytic anaemia uncommon
Investigations
ANAs particularly Ro/La

Thrombocytopenia, anaemia, leukopenia
Platelet antibodies positive Coombs test
ECG
Cutaneous and haematological manifestations transient

Congenital heart block permanent
Hepatic fibrosis occasional
Some risk of SLE in teenage or adult years
Management
Symptomatic for transient manifestations
Heart block may require pacemaker
3.4 Behet syndrome
A clinical triad of recurrent oral aphthous ulcers, recurrent genital ulcers and uveitis
Male predominance
High incidence in Japan, the Mediterranean and the Middle East
Clinical features
Oral ulcers
Genital ulcers
Severe uveitis may lead to glaucoma and blindness
Arthritis
Rash skin hypersensitivity
Bowel involvement
Meningoencephalitis, brain-stem lesions and dementia
Treatment
Steroids, thalidomide, anti-TNF treatment are all effective
3.5 Sjgren syndrome

Dry eyes (keratoconjunctivitis sicca)

Dry mouth and carious teeth
Parotitis
May occur alone or in association with other rheumatic disease
Occasional complication of renal disease or lymphoreticular malignancy
3.6 Scleroderma
Localized (majority of paediatric cases)
Morphea: thickened shiny pale skin then darkens as resolves with loss of subcutaneous tissue
Single patch
Multiple patches
Linear: thickened plaque which cause loss of subcutaneous tissues and contractures over joints and
loss of bone growth
Face, forehead and scalp (en coup de sabre)
Limb (en bande)
Diffuse (systemic sclerosis/CREST [calcinosis cutis, Raynaud phenomenon,

oesophageal hypomobility, sclerodactyly, telangiectasia])
Rare in childhood; develop tightening of skin of hands, feet and face; systemic problems include
respiratory and gastrointestinal problems and renal disease
3.7 Overlap syndrome including mixed connective tissue disease

Overlapping features of juvenile idiopathic arthritis, SLE, systemic sclerosis and dermatomyositis
Affects particularly older girls
Clinical features
Arthritis
Tenosynovitis both flexor and extensor tendons of fingers, causing contractures
Raynaud phenomenon common
Myositis
Pleuropericardial involvement
Dysphagia
Parotid swelling
Investigations
ESR high
Haemoglobin often low
White blood count usually normal
Platelets can be low
ANAs positive
Anti-RNP antibodies in high titres indicate the designation of mixed connective tissue disease
Anti-DNA antibodies negative or in low titre
IgM rheumatoid factor occasionally positive

Slowly develops over years
May evolve into other recognizable conditions, such as sclerodactyly and, later, other features of
systemic sclerosis or SLE may appear
Management
Mild disease is managed with NSAIDs and/or antimalarials
More severe disease may require corticosteroids, with or without a cytotoxic agent
Careful monitoring is required to detect signs of potentially serious systemic disease (e.g.
nephritis)
4. CHILDHOOD VASCULITIS
Childhood vasculitis encompasses a wide range of clinical syndromes that are characterized by
inflammatory changes in the blood vessels. The clinical expression of the disease and its severity
depend on the type of pathological change, the site of involvement and the vessel size. The two most
common forms seen in children are HenochSchnlein purpura and Kawasaki disease.
4.1 HenochSchnlein purpura

Inflammation of small vessels, capillaries pre- and postcapillary vessels
May be precipitated by infection, particularly haemolytic streptococci
Onset generally after the age of 3 years; there is a slight male predominance
Clinical features
Petechiae
Rash urticarial lesions evolving into purpuric macules, usually on the legs, feet and buttocks
Cutaneous nodules particularly over the elbows and knees
Localized areas of subcutaneous oedema that affect the forehead, spine, genitalia, hands and feet
Arthritis transient, involving large joints
Gastrointestinal involvement colicky abdominal pain and/or gastrointestinal bleeding
Renal involvement nephritis, occasionally nephrosis
Investigations
ESR normal or high

Full blood count normal
Haematuria and/or proteinuria and/or casts
IgA complexes in glomeruli and involved skin
Serum IgA is often raised

Episodes of HenochSchnlein purpura are self-limiting
Recurrences occasionally occur
Long-term morbidity related to renal involvement
Management
Supportive care
Corticosteroids in severe disease
4.2 Kawasaki disease (mucocutaneous lymph node syndrome)

An acute febrile disease, first described in Japan after the 1940s
Although now seen in all racial groups throughout the world, it appears to be more common in
Oriental individuals
Occurs in young children, even before the first birthday, and has a slight male predominance
Investigations
ESR high
Haemoglobin lowered
White blood count raised
Polymorph leukocytosis
Platelets raised
ANAs negative
Echocardiography arteriogram
Diagnostic criteria
Fever lasting 5 days or more

Bilateral conjunctival injection
Changes in lips and oral cavity
Changes in extremities reddening and oedema of palms and soles followed by desquamation
Polymorphous erythematous rash
Cervical lymphadenopathy
For diagnosis, a fever and four features are required.
Clinical features
As in diagnostic criteria, plus:
Irritability
Pericarditis
Valvular dysfunction
Coronary artery disease

Arthritis and/or arthralgia
Gastrointestinal symptoms
Urethritis
Central nervous system problems aseptic meningitis
Iritis

Acute and convalescent stage lasts up to 10 weeks
Coronary aneurysms or widening in some 20% of cases
Death due to coronary vasculitis causing myocardial infarction or rupture of an aneurysm occurs in
about 1% of cases
Management
Supportive care
Careful observation to detect and manage complications
Salicylate therapy
Intravenous -globulin
Steroids are used and anti-TNF (Infliximab)
4.3 Polyarteritis nodosa

A vasculitis affecting small- to medium-sized muscular arteries in either a generalized or a
cutaneous form
Age range 316 years with equal sex distribution
Clinical features
Fever
Abdominal pain
Arthralgia/myalgia
Rash:
Petechial or purpuric in the generalized form
Tender subcutaneous nodules and livedo reticularis in the cutaneous form
Hypertension
Renal involvement
Neurological disease
Investigations
ESR high
Haemoglobin <10 g/l
Leukocytosis
Urinary abnormalities
Anti-streptolysin O titre (ASOT) elevated in some
Histology focal necrosis in small- and medium-sized arteries

Cutaneous form is usually benign but relapses may occur
Prognosis is worse in the generalized form, depending on the organ involvement
Management
Steroids high dose (2 mg/kg per day) in the generalized form
Steroids and immunosuppressants for severe cases
Penicillin prophylaxis, if streptococcal aetiology is proved
4.4 Takayasu disease (giant cell arteritis)

A panarteritis of the aorta and its large branches leading to thrombosis, stenosis or occlusion
Primarily affects young adult women, but may occur in children
More common in Oriental and black individuals
Clinical features
Claudication in the arms and also the legs, and absent pulses
Myalgia
Hypertension
Malaise
Fever
Investigations
ESR high
Haemoglobin low
White blood count neutrophil leukocytosis
Using a combination of Doppler ultrasound and angiography it is possible to show occlusion,
stenosis or aneurysms
Variable
Management
Steroids with or without cytotoxic therapy
Reconstructive surgery when the disease is inactive
4.5 Vasculitis with granuloma

ChurgStrauss syndrome
A systemic necrotizing vasculitis of small arteries and veins, accompanying asthma and associated
with eosinophilia
Clinical features
Lung involvement asthma, transient pulmonary infiltrates

Rash palpable purpuras and tender subcutaneous nodules
Renal involvement occasionally
Wegener granulomatosis
This also is a necrotizing granulomatous vasculitis of the upper and lower respiratory tracts,
accompanied by glomerulonephritis
Clinical features
Pulmonary granulomas
Destructive granulomas of the ears, nose and sinuses
Rash
Glomerulonephritis
Eye lesions
Special investigation
Anti-neutrophil cytosolic antibodies
Management
Combined therapy with steroids and cyclophosphamide
4.6 Differential diagnosis of childhood rheumatic disorders
Infection
Neoplasm
Blood dyscrasias
Mechanical anomalies, including injury
Biochemical abnormalities
Genetic and/or congenital anomalies
Oddities do occur
Osteogenesis imperfecta is a disorder of connective tissue characterized by bone fragility. The
disease encompasses a phenotypically and genetically heterogeneous group of inherited disorders that
result from mutations in the genes that encode for type 1 collagen. The disorder is manifest in tissues
in which the principal matrix is collagen, namely bone, sclerae and ligaments. The musculoskeletal
manifestations vary from perinatal lethal forms, to moderate forms with deformity, and a propensity to
fracture to clinically silent forms with subtle osteopenia and no deformity, as discussed below.
Osteogenesis imperfecta type I

This is characterized by osteoporosis and excessive bone fragility, distinctly blue sclera and hearing
loss. It has autosomal dominant inheritance, and occurs in 1 per 30 000 live births. Fractures may be
obvious from birth. Hearing impairment is the result of otosclerosis and affects most patients from the
fifth decade, but is rare in the first decade. Some families have dentinogenesis imperfecta with
yellow transparent teeth that are fragile. There is spontaneous improvement with puberty. X-rays
show generalized osteopenia, evidence of previous fractures and callus formation at the site of new
bone formation. The skull X-ray shows wormian bones.
Osteogenesis imperfecta type II

This lethal syndrome is characterized by low birthweight and typical radiological findings of
crumpled bones and beaded ribs. Although autosomal recessive in a few cases, most cases are
autosomal dominant new mutations. It affects 1 per 60 000 live births; 50% are stillborn, the
remainder dying soon after birth from respiratory difficulty because of a defective thoracic cage. It is
worth looking at a picture of the lethal form. X-rays show multiple fracture of the ribs, often beaded,
and crumpled (accordion-like) appearance of the long bones.
Osteogenesis imperfecta type III

This syndrome is characterized by severe bone fragility and multiple fractures in the newborn period
which lead to progressive skeletal deformity. The sclera may be bluish at birth, but become less blue
with age. It is autosomal recessive with clinical variability suggesting genetic heterogeneity. Few
patients survive into adult life. Radiographs show generalized osteopenia and multiple fractures,
without the beading or crumpling of the ribs seen in type II.
Osteogenesis imperfecta type IV

This syndrome is characterized by osteoporosis leading to bone fragility without the other features of
type I. The sclera may be bluish at birth but become less blue as the patient matures. Inheritance is
autosomal dominant. Variable age of onset and variable number of fractures, there is spontaneous
improvement with puberty. Radiographs show generalized osteopenia and fractures, but these are
generally less than the other forms of osteogenesis imperfecta.
Management
For osteogenesis imperfecta type II no therapeutic intervention is helpful. For other forms, careful
nursing of the newborn may prevent excessive fractures. Beyond the newborn period, aggressive
orthopaedic treatment is the mainstay of treatment aimed at prompt splinting of fractures and
correction of deformities. Bisphosphonates such as pamidronate have been shown to be useful.
Genetic counselling is important. Reliable prenatal diagnosis is not available for all forms of
osteogenesis imperfecta, although severely affected fetuses may be confidently recognized by X-rays,
ultrasound scanning and biochemistry.
5.2 Osteopetrosis
Osteopetrosis (marble bone disease, AlbersSchnberg disease) is characterized by a generalized
increase in skeletal density. There are multiple types. The most important two are listed below.
Osteopetrosis congenita
This presents in infancy (autosomal recessive) with faltering growth, hypocalcaemia, anaemia,
thrombocytopenia and, rarely, fractures. Bone encroaching on the marrow cavity leads to
extramedullary haematopoiesis. Optic atrophy and blindness are common, secondary to bone
pressure. Diagnosis is by skeletal survey. Bone marrow transplantation can be curative.
Osteopetrosis tarda
This presents in later childhood, usually with fractures, and manifestations are less severe and
treatment is symptomatic.
5.3 Osteoporosis
This can be idiopathic

Most commonly secondary to corticosteroid use
Seen in conditions causing decreased mobility such as cerebral palsy, neuromuscular diseases
Dual energy X-ray absorptiometry (DXA) scan for bone mineral density
Can cause pathological fractures, particularly of vertebrae
Treat with calcium/vitamin D and bisphosphonates
5.4 Hemihypertrophy
This is often difficult to recognize. It may involve the whole of one side of the body, or be limited in
extent, e.g. to just one leg. It may be congenital, in which case the tissues are structurally and
functionally normal. It has been associated with learning disability, ipsilateral paired internal organs,
and rarely with Wilms tumours or adrenal carcinomas.
Hemihypertrophy can be confused with regional overgrowth secondary to neurofibromatosis type l,
haemangiomas and lymphangiomas.
A fetal overgrowth syndrome, mapped to gene locus 11p15.5.
Clinically the three major features are:
1. Pre- and/or postnatal overgrowth (>90th centile)
2. Macroglossia
3. Abdominal wall defects
The minor defects are:
Characteristic ear signs (ear lobe creases or posterior helical pits)

Facial naevus flammeus
Hypoglycaemia
Organomegaly
Hemihypertrophy.
The diagnosis is based on:

Three major features, or
Two major plus three or more minor features.
Infants are more likely to be delivered prematurely, 35% before 35 weeks. Exomphalos occurs in
50% of cases. Hypoglycaemia, which is usually mild and transient, occurs in 50%. Deaths from
BeckwithWiedemann syndrome can occur in infancy and are mainly caused by problems related to
prematurity or congenital cardiac defects (<10%).
During childhood, the dysmorphic features become less apparent, although the macroglossia may
cause problems with feeding, with speech and occasionally with obstructive apnoea. Surgical tongue
reduction may be required in severe cases.
Overgrowth is most marked in the first few years and is associated with an advanced bone age. It
tends to slow down in late childhood, and most adults are <97th centile. Hemihypertrophy occurs in
25% of cases. Visceromegaly is common and neoplasia occurs in 5%, most commonly with Wilms
tumour followed by adrenocortical carcinoma, hepatoblastoma and neuroblastoma, those children
with hemihypertrophy being the most at risk. By adolescence, the majority lead a normal life. There is
controversy about abdominal tumour screening which some centres advocate should be by regular
abdominal palpation and others by regular ultrasound examination or both.
5.5 Hypermobility
The most common cause of musculoskeletal complaints in childhood related to muscular weakness
in association with hypermobile joints
Causes joint pain and occasionally swelling after exercise
Improves with age
Differential diagnosis includes EhlersDanlos syndrome (skin fragility and hyperextensibility, and
joint hyperextensibility) and Marfan syndrome
Management is exercise to build up strength and reassurance
5.6 Toe walking

Can be a normal finding up until 3 years of age, especially in hypermobile patients; splint ankle
because of over-supination/-pronation
Neurological disorders include cerebral palsy, Duchenne muscular dystrophy, spinal cord
problems, congenital shortening of the Achilles tendon
Leg-length discrepancy
Habit
5.7 Foot drop
Variety of causes
Patient has a stepping gait and lifts the affected limb high to avoid scraping the foot on the floor
The patient is unable to walk on the heel
Possible causes:
Lateral popliteal nerve palsy (look for signs of injury below and lateral to the affected knee)
Peroneal muscle atrophy
Poliomyelitis
5.8 Reflex sympathetic dystrophy

Autonomic nerve dysfunction in a limb results in severe immobilization because of pain
Osteoporosis is associated
Physiotherapy to remobilize is the best treatment
5.9 Non-accidental injury
Non-accidental injury can present as musculoskeletal complaints, frequently seen with bruising
Fractures especially spiral or metaphyseal more commonly in the under-3 age group
Periosteal reactions from rotation injury
Dislocations, especially of the elbow
5.10 Back pain

Hypermobility with core weakness very common now, even in young children
Trauma
Spondylolisthesis/disc herniation
Discitis
Tuberculosis
Leukaemia
Enthesitis-related arthritis sacroiliitis initially later lumbar
Osteoid osteoma/Ewing tumour
Investigations
Radiograph
Bone scan
MRI
FBC, ESR
5.11 Torticollis
Common causes
Sternomastoid tumour
Vertebral anomalies
Muscular spasm related to trapezius weakness common now
Pharyngitis with lymphadenopathy
Retropharyngeal abscess
Sandifer syndrome/gastro-oesophageal reflux
Spinal tumours
Posterior fossa tumours
Atlantoaxial instability especially in Down syndrome
Juvenile idiopathic arthritis systemic onset and polyarticular
6. FURTHER READING
Ansell BM, Rudge S, Schaller JG (1991). A Colour Atlas of Paediatric Rheumatology. Aylesbury:
Wolfe.
Cassidy JT, Petty RE Laxer R, Lindsley C (2011). Textbook of Pediatric Rheumatology, 6th edn.
New York: WB Saunders.
Isenberg DA, Miller JJ (1999). Adolescent Rheumatology. London: Martin Dunitz.
Mier RJ, Brower TJ (1994). Paediatric Orthopaedics. Dordrecht, The Netherlands: Kluwer
Academic.
Brogan PA, Foster HE (2011). The Oxford Handbook of Paediatric Rheumatology. Oxford; Oxford
University Press.
Chapter 24
Statistics
Angie Wade
CONTENTS
1. Study design
1.1 Research questions
1.2 Confounding
1.3 Different types of study
1.4 Bias
2. Distributions
2.1 Outcome measures
2.2 Summarizing variables
2.3 Summarizing differences between two groups
3. Confidence intervals
3.1 Standard error (SE or SEM)
4. Significance tests
4.1 Null hypotheses and p values
4.2 Significance, power and sample size
4.3 Types of tests
4.4 The relationship between p values and confidence intervals
5. Correlation and regression

5.1 Correlation coefficients
5.2 Linear regression
6. Screening tests
7. Things to look out for

7.1 Using inappropriate summaries for numeric data
7.2 Not dealing properly with missing data
7.3 Non-independent measurements treated as independent
7.4 Multiple testing without adjustment
7.5 Patients acting as their own controls
7.6 Testing group changes independently
8. Further reading
Statistics
1. STUDY DESIGN
1.1 Research questions
A research study should always be designed to answer a pre-specified research question. Most
commonly the question relates to a comparison between two groups. For example:
Does taking folic acid early in pregnancy prevent neural tube defects?
Is a new inhaled steroid better than current treatment for improving lung function among cystic
fibrosis patients?
Is low birthweight associated with hypertension in later life?
The question should be specific enough to be answerable. For example, How do I cure diabetes?
and What are the problems associated with diabetes? are too broad.
An acronym that is sometimes used to help make sure a question specific is PICO. This stands for
patient, intervention, comparison, outcome.
Although this cannot be applied to all research questions, it is a useful breakdown that may assist. An
explanation of each part is as follows:
P: what is the patient or problem or population?
Describe the group or groups to which the question applies.
I: intervention or exposure or test being considered
C: is there a comparative intervention? Or perhaps comparison is with healthy individuals?
O: what is the outcome measure? What are you trying to identify differences in?
For example:
P: pregnant women; I: folic acid; C: no folic acid; O: neural tube defect yes/no
P: cystic fibrosis patients; I: new inhaled steroid; C: current treatment; O: lung function
P: newborns; I: low birthweight; C: not low birthweight; O: hypertension
To answer the specified research question, samples of the relevant populations are taken. For
example: pregnant women, cystic fibrosis patients, low-birthweight and normal birthweight
individuals.
Based on what is seen in those samples, inferences are made about the populations from which they
were randomly sampled. For example:
If the women in the sample taking folic acid have fewer neural tube defects, it may be inferred that
taking folic acid during pregnancy will reduce the incidence of neural tube defects in the
population
If among our sample of cystic fibrosis patients, those taking steroids have better lung function on
average than those on current treatment, the inference might be that steroids improve lung function
among cystic fibrosis patients in general.
If there is a difference in hypertensive rates between samples of individuals who were and were
not of low birthweight, it may be inferred that birthweight is associated with later hypertension in
the population in general.
1.2 Confounding
Confounding may be an important source of error. A confounding factor is a background variable (i.e.
something not of direct interest) that:
is different between the groups being compared, and
affects the outcome being studied
For example: In a study to compare the effect of folic acid supplementation in early pregnancy on
neural tube defects, age will be a confounding factor if:
either the folic acid or placebo group tends to consist of older women, and
older women are more, or less, likely to have a child with a neural tube defect
When studying the effects of a new inhaled steroid against standard therapy for cystic fibrosis
patients, disease severity will be a confounder if:
one of the groups (new steroid/standard therapy) consists of more severely affected patients, and
disease severity affects the outcome measure (lung function)
In the comparison of hypertension rates between low and not low birthweight, social class will be
a confounder if:
the low-birthweight babies are more likely to have lower social class, and
social class is associated with the risk of hypertension
If a difference is found between the groups (folic acid/placebo, new steroid/standard therapy and
low/normal birthweight) we will not know whether the differences are, respectively, the results of
folic acid or age, of the potency of the new steroid or severity of disease in the patient, or of
birthweight or social class, respectively.
Confounding may be avoided by matching individuals in the groups according to potential
confounders. For example, we could age match folic acid and placebo pairs or deliberately recruit
individuals of low and normal birthweight from similar social classes.
1.3 Different types of study

Studies are either observational or experimental. Different types of study may be used to address the
same research question, although some will give more evidence than others. The choice of study
design may be influenced by ethical, financial and feasibility issues.
Observational studies
The researchers have observed and reported what happens. They have not changed anything, merely
observed and documented what occurs in one or more groups of individuals, e.g. those who do and
do not take folic acid early in pregnancy.
When an observational study compares two groups, it may be categorized as being a cohort, case
control or cross-sectional study. These studies consider differences between the groups in the future,
in the past and at the present time respectively.
A cohort study will usually categorize currently healthy individuals according to some feature (such
as drinking alcohol or not, smoking or not, eating a high-fat diet or not) and follow the groups forward
in time to see whether one group is more likely to develop disease.
A casecontrol study will usually compare diseased and healthy groups and look back in time to see
what they have done differently in the past that may have led to disease.
Another type of observational study is an ecological study. Here the unit of analysis is a population
rather than an individual and association across different populations is investigated, e.g. an
ecological study may look at the association between prematurity and childhood cancer rates in
different countries to see whether those countries with higher prematurity rates also have higher
levels of childhood cancers.
Experimental studies
In experimental studies, individuals are assigned to groups by the investigator, e.g. pregnant women
will be assigned to take either folic acid or a placebo; cystic fibrosis patients will be assigned to
either the new or current treatment. In both of these examples the second group is known as a control
group.
Note that a control group does not necessarily consist of normal healthy individuals. In the second
example, the control group comprises cystic fibrosis patients on standard therapy.
Individuals should be randomized to groups to remove any potential bias. Randomization means that
each patient has the same chance of being assigned to either of the groups, regardless of their personal
characteristics. Note that random does not mean haphazard or systematic.
Randomization may be adjusted to ensure that the groups are balanced with respect to potential
confounders. It may be stratified or within pair-matched pairs, e.g.:
Pairs of pregnant women of the same age may be selected and one of each pair randomly assigned
folic acid supplementation
Pairs of cystic fibrosis patients of similar disease severity with one randomly selected to receive
the new steroid whereas the other receives standard therapy.
Experimental studies may be:
Double blind neither the patient nor the researcher assessing the patients (or the treating clinician)
knows which treatment the patient has been randomized to receive
Single blind either the patient or the researcher/clinician does not know (usually the patient)
Unblinded (or open) both the patient and the researcher/clinician know
It is preferable that studies are blinded because knowledge of treatment may affect the outcome and
introduce a bias in the results.
Allocation concealment means that the allocation (to treatment or control) is not known before the
individual is entered into the study.
Clinical trials are experimental studies.
Crossover studies
In a crossover (or within-patient) study, each patient receives treatment and placebo in a random
order. Fewer patients are needed than the comparable parallel trials (in which different individuals
are allocated to the two treatment groups) because many between-patient confounders can be
removed, e.g. even though pairs of cystic fibrosis patients may be chosen and randomized to groups
on the basis of their disease severity, this does not ensure that the groups will be of similar age or
sex.
Crossover studies are only suitable for chronic disorders that are not cured but for which treatment
may give temporary relief, e.g. it would not be feasible to do a crossover trial of folic acid in
pregnancy.
There should be no carryover effect of the treatment from one treatment period to the next.
Sometimes it is necessary to leave a gap between the end of the first treatment and the start of the next
to ensure that there is no overlap. This gap period is known as a washout period.
Intention-to-treat analysis
With experimental studies, individuals are allocated to different treatments or interventions.
Allocation is usually randomized and the purpose is to ensure that the groups obtaining the different
treatments are not biased in ways that might confound the study results. However, some individuals
may not adhere to the treatment to which they are allocated, e.g. there may be an active treatment to
be compared with placebo and some of those allocated to the active treatment do not take the
medicine. Furthermore, some of those allocated to placebo may decide to take active treatment
anyway. Although it may be tempting to move these individuals across to the other group for analysis
(so that the active treatment group becomes those allocated to active treatment who complied plus
the placebo patients who decided to take active control anyway, and the placebo group includes
those allocated to active treatment who did not take the treatment), this is not good practice. Those
who did not adhere to their allocated treatments may be biased in a way that affects the results.
The study was designed as experimental to avoid bias caused by allowing personal preference to
determine treatment. Hence, the outcomes for the two allocation groups (those allocated to active
treatment and those allocated to control) should be compared irrespective of how many of each
actually adhered to their allocation. This is known as intention-to-treat analysis.
It may also be useful to perform a per protocol analysis whereby those who do not adhere to the
allocated treatment are excluded from the analyses. Although this may be informative, it should be
noted that the results may be biased.
Comparing study designs

There may be many ways to address a particular research question, e.g. if we wish to determine
whether smoking is causally associated with lung cancer, any of the following would potentially
address this question:
Ecological studies might show a relationship between levels of smoking and lung cancer rates in
different countries/regions
Cross-sectional studies would show that those with lung cancer are more likely to be current
smokers
Casecontrol studies would select a group of lung cancer patients and a group of healthy controls
to see how they differed in previous behaviours (i.e. smoking)
A cohort study would select groups of currently healthy smokers and non-smokers and follow
these forward in time to see whether one group was more likely to develop lung cancer.
A randomized controlled trial (RCT) would randomly allocate healthy individuals to smoke or not
and then see who developed lung cancer
This last study would of course be unethical!
In all of the study types there is the potential for confounding, e.g. if the smokers are more likely to
drink alcohol. In the observational studies (first four) there is more likelihood of there being
confounding factors that may not even be considered or measured. It may be that the tendency to
smoke is associated with some other factor (such as drinking alcohol or dietary factors) that is the
true causation of lung cancer occurring (hence smoking would be falsely declared the causal agent).
The RCT (last study) is not immune from confounding but it is less likely that there will be hidden
confounders.
If a potential confounder such as drinking alcohol is known about, this can be avoided by suitable
design manipulation. For the observational studies this will involve selecting groups similar with
respect to alcohol consumption to compare. For the RCT the randomization can be stratified
according to alcohol consumption or randomization to smoking or not can take place within pairs
matched for alcohol consumption.
1.4 Bias
Bias may take many forms and can invalidate the study results if not taken into account properly when
drawing conclusions.
Sampling bias occurs if some members of the eligible population are more likely to be included in
the sample than others.
Retrospective recall bias occurs if one group is more likely to recall events than the other. This is
often a problem with casecontrol studies.
Publication bias is important when considering systematic reviews. This is the process whereby
some studies (usually those showing significant differences) are more likely to be published.
2. DISTRIBUTIONS
2.1 Outcome measurements
Usually the research question relates to a single primary outcome measure although there may be
many secondary outcomes.
If the measure is reliable then it will be measured consistently under different conditions if the
underlying value has not changed, e.g. does the assessment of a patient depend on who made the
measurement? Or the time of day that it was made (assuming that the patient has not changed the
condition)? If there is variation in measurement that is not associated with change in the patient but
other factors (such as who made the measurement or when), then the measure is unreliable.
A valid measurement will give an accurate assessment, e.g. assessment of gestational age via date of
last menstrual period is less valid than ultrasound dating using fetal measurements early in pregnancy.
Outcomes are either numeric or categoric. It is important to identify the type of each outcome
because this will determine the summary measures and statistical tests that should be used.
Numeric measurements are made on a number scale, e.g. height, weight, blood pressure, IgG level.
Categoric measurements put individuals into one of two or more categories, e.g. positive/negative,
low/medium/high, disease/none, ethnic group, hair colour. If there are only two categories then the
variable is binary.
2.2 Summarizing variables
If the variable is numeric, the distribution of the variable will be either symmetrical or skewed
(tails off unevenly in one direction), e.g. the bar chart in Figure 24.1 shows the heights of a set of
individuals and is reasonably symmetrical, whereas the distribution in Figure 24.2 of their income
levels is upwardly skewed.
When the distribution is symmetrical and bell shaped (i.e. even tailing off in either direction), the
variable is said to be normally distributed (or to follow a normal distribution), e.g. height as
illustrated in Figure 24.1.
Appropriate summaries of the average and spread of the variable are as follows:
Mean and standard deviation if the distribution of the variable is symmetrical

Median and interquartile range (IQR) or range if the distribution is skewed
It is not uncommon to find skewed data incorrectly summarized using the mean
If the mean and standard deviation are valid measurements, then the interval:
(mean 2 standard deviations)
should give a range that will contain most (approximately 95%) of the values
Figure 24.1
Figure 24.2
For example, forced expiratory volume in 1 second (FEV1) is measured in 100 students. The mean
value for this group is 4.5 litres with a standard deviation of 0.5 l. If the values are normally
distributed then approximately 95% of the values lie in the range (4.5 2(0.5)) = (4.5 1) = (3.5, 5.5
l).
If the variable is binary, the number in one category can be expressed as:
A proportion by dividing by the total number
A percentage (%) by multiplying the proportion by 100
The odds by dividing by the number in the other category
For example, if 30 of 50 test positive, the proportion testing positive is 0.6, the percentage is 60%
and the odds of testing positive are 30/20 = 1.5.
2.3 Summarizing differences between two groups

Many studies collect information on two groups and make comparisons between them, e.g. groups
given new or standard treatment, diseased individuals versus healthy controls.
The appropriate comparison statistic to use depends on the type of variable being compared. If the
variable is numeric, then the difference in means or medians will provide a suitable summary to
compare the groups.
If the variable is binary, there are several different summaries that can be used. These are:
The difference in proportions or percentages in the two groups this is sometimes known as the
risk difference or absolute risk reduction (ARR). A value of zero indicates no difference
between groups
The number needed to treat (NNT) which is the inverse of the ARR
The proportion in one group may be divided by the proportion in the other this gives the relative
difference between the proportions in each group and is known as the relative risk or risk ratio
(RR). A value of 1 indicates no difference between groups
An approximation to the relative risk is used for casecontrol studies. This is known as the odds
ratio
For the research questions given in Section 1.1, the suitable summaries of the outcomes may be:
The risk of neural tube defect (number of cases divided by the number of women studied) among
women taking folic acid and those who do not. The relative risk (risk in group taking folic acid
divided by the risk in those who take placebo treatment) would give a measure of how effective the
intervention is in preventing neural tube defects
The difference in average (mean or median) lung function between those given the new steroid and
those given standard therapy will provide a measure of the effectiveness of the new treatment
compared with standard
The difference in percentages of individuals developing hypertension between those who were low
birthweight and normal birthweight (ARR) would provide a useful summary measure
3. CONFIDENCE INTERVALS
3.1 Standard error
Any estimate of a population measurement (mean, proportion, difference in percentages, etc.) should
be presented with a measure of precision. This measure of precision will depend on the sample size
and will take the form of a standard error (SE or standard error of the mean, SEM) or, preferably, a
95% confidence interval.
Larger samples give more precise estimates, smaller standard errors and narrower confidence
intervals.
The confidence interval is calculated using the standard error:
The interval (mean 1.96 SE) is a 95% confidence interval for the population value
The interval (mean 2 SE) is an approximate 95% confidence interval for the population value
We are 95% confident that the true value lies inside the interval. The 95% confidence interval
(sometimes abbreviated to confidence interval, 95% CI or CI) gives the range of population
parameters that the sample leads us to believe are possible, e.g. suppose that 10.75% more of the
low-birthweight group suffer hypertension at some point (compared with those not of low
birthweight) and the 95% CI for this difference is (7.25, 14.25%). We would be reasonably confident
(95%) that, in the population (from which these individuals were a random sample), the increase in
hypertension among those of low birthweight would be at least 7.25% (about 1 in 14) and could be as
much as 14.25% (about 1 in 7).
Compare this with the interpretation if smaller samples had been taken and the 95% CI for the
difference of 10.75% had therefore been wider, say (12.0, 33.5%). In this case we would not be
sure whether there was a positive association between low birthweight and hypertension. Our
samples are compatible (at 95% CI) with 12% fewer and 33.5% more of the low birthweight
individuals being hypertensive. Since the interval contains 0%, the data are compatible with no
difference in hypertension rates.
Note the difference between the standard deviation and the standard error:
Standard deviation (SD) gives a measure of the spread of numeric data values
Standard error (SE) is a measure of how precisely the sample estimate approximates the
population value and can apply to both numeric and categoric outcomes
For example, consider again the FEV1 measurements from 100 students with mean 4.5 l and SD 0.5 l.
The SE can be calculated by combining the SD and the sample size to be 0.05 (details not given).
Hence, an approximate 95% CI for the population mean FEV1 is given by:
(4.5 2(0.05)) = (4.5 0.1) = 4.4, 4.6 l
i.e. we are 95% confident that the population mean FEV1 of students lies in the range 4.44.6 l.
Confidence intervals can similarly be constructed around any summary statistic, e.g. the difference
between two means, a single proportion or percentage, the difference between two proportions. The
SE always gives a measure of the precision of the sample estimate and is smaller for larger sample
sizes.
4. SIGNIFICANCE TESTS
Statistical significance tests, or hypothesis tests, use the sample data to assess how likely some
specified null hypothesis is to be correct. The measure of how likely is given by a probability
known as the p value.
4.1 Null hypotheses and p values

Usually, the null hypothesis is that there is no difference between the groups, e.g. to answer the
research questions in Section 1.1 we test the following null hypotheses:
There is no difference in the incidence of fetuses with neural tube defects between the groups of
pregnant women who do and do not take folic acid supplements
The distribution of lung function is the same in asthma patients who receive the new inhaled steroid
and those on current treatment
Hypertension rates do not differ according to birthweight.
Even if these null hypotheses were true we would not expect the averages or proportions in our
sample groups to be identical. As a result of random variation there will be some difference.
The p value is the probability of observing a difference of that magnitude if the null hypothesis is
true.
As the p value is a probability, it takes values between 0 and 1. Values near to 0 suggest that the null
hypothesis is unlikely to be true. The smaller the p value the more significant the result:
p = 0.05, the result is significant at 5%
The sample difference had a 1 in 20 chance of occurring if the null hypothesis were true.
p = 0.01, the result is significant at 1%
The sample difference had a 1 in 100 chance of occurring if the null hypothesis were true.
Note that statistical significance is not the same as clinical significance.
Although a study may show that the results from drug A are statistically significantly better than for
drug B we have to consider:
The magnitude of the improvement

The costs
The ease of administration
The potential side effects of the two drugs, etc.
before deciding that the result is clinically significant and that drug A should be introduced in
preference to drug B.
4.2 Significance, power and sample size

The study sample may or may not be compatible with the null hypothesis being true.
If the p value is small then there is a low probability of observing the samples if the null hypothesis is
true, and this would lead us to reject the null hypothesis. A p value not near to 0 shows that the data
are compatible with the null hypothesis, e.g.:
If there are many more babies with neural tube defects among the group not taking folic acid, then
this is unlikely to happen given the null hypothesis (no difference in incidence) and the p value will
be low (close to zero). This would lead us to reject the null hypothesis and believe that there is an
association between incidence and folic acid consumption
If the asthma patients receiving the new inhaled steroid have a similar average lung function to
those in the current treatment arm of the trial, this is likely to happen given the null hypothesis
(distributions of lung function do not differ) and the p value will be large (close to 1). We would
therefore have no reason to reject the null; our data are compatible with the null being true (i.e. no
effect of the new treatment)

Hence, on the basis of the study results, we may decide to disbelieve (or reject) the null hypothesis.
In reality, the null hypothesis either is or is not true. This gives the fourfold situation illustrated
below:
Hence the study may lead to the wrong conclusions:

A low (significant) p value (close to zero) may lead us to disbelieve (or reject) the null hypothesis
when it is actually true see box above. This is known as a type I error
For example, suppose, for the comparison of neural tube defects, p = 0.001. This would imply that the
difference in percentage defects observed would have occurred only once in 1000 times if there
really were no association with folic acid. Although very unlikely it is not impossible to have
occurred by chance (for 1 trial in 1000 it would do).
The p value may be high (non-significant, away from zero) when the null hypothesis is false see
box above. This is known as a type II error
For example: in Section 3.1 the second example CI for difference in percentage hypertensive between
low and not low birthweight individuals was (12.0, 33.5%) which is compatible with 0 (p value
will be large, say 0.82) but we cannot exclude the possibility that as many as a third more of the lowbirthweight become hypertensive. The CI is wide because the study is small and hence inconclusive;
the study may have failed to detect a difference that is there.
The power of a study is the probability (usually expressed as a percentage) of correctly rejecting the
null hypothesis when it is false.
Larger differences between the groups can be detected with greater power. The power to identify
correctly a difference of a certain size can be increased by increasing the sample size. Small samples
often lead to type II errors (i.e. there is not sufficient power to detect differences of clinical
importance).
In practice there is a grey area between accepting and rejecting the null hypothesis. The decision will
be made in the light of the p value obtained. We should not draw different conclusions based on a p
value of 0.051 compared with a value of 0.049. The p value is a probability as it gets smaller the
less likely it is that the null hypothesis is true.
4.3 Types of tests
There are many different significance tests and the appropriate one to use depends on the type of
outcome being compared, the number of groups being compared and, in the case of two groups,
whether there is a pairing between groups (e.g. age- and sex-matched pairs of diseased individuals
and healthy controls; the same patient assessed when on two different treatments as part of a
crossover trial).
For comparing two groups the correct tests are:
Binary outcome chi-squared (2) or Fisher exact test (if small numbers)
Numeric normally distributed outcome t-test, paired t-test if samples are paired/matched
Numeric, non-normally distributed outcome (or small numbers) MannWhitney U-test
To compare a normally distributed numeric outcome between more than two groups then analysis of
variance (ANOVA) can be used, e.g. to compare heights between five different ethnic groups.
If the outcome is non-normally distributed, or numbers are very small, then KruskalWallis ANOVA
is appropriate, e.g. to compare incomes between the ethnic groups.
If adjustment is to be made for confounders before comparing the main outcome between groups,
then regression analyses are appropriate. Adjusted estimates of effect are obtained, and these can be
tested against no effect. A p value is obtained for the test of whether the sample is compatible with
the model coefficient being 0.
4.4 The relationship between p values and confidence intervals

The confidence intervals show the range of population scenarios that the sample data are compatible
with, whereas the corresponding significance test assesses compatibility with no difference (the null
hypothesis) only.
If the p value is <0.05, the 95% CI will not contain 0 (or 1 in the case of odds ratios/relative risks),
as both show that the data are not compatible with no difference between groups.
Similarly, if the p value is >0.05, the 95% CI will contain 0 (or 1 depending on the summary
measure), indicating no significant difference (i.e. compatibility of the sample with there being no
difference between groups).
5. CORRELATION AND REGRESSION

Sometimes measurements are made on two continuous variables for each study subject, e.g.:
CD4 count and age
Blood pressure and weight
FEV1 and height
The aim may be to quantify the relationship between the two variables. The data can be displayed in a
scatter plot and this will show the main features of the data.
Figure 24.3 Scatter plot of CD4 count versus age
5.1 Correlation coefficients

The correlation coefficient (sometimes called the Pearson coefficient of linear correlation) is
denoted by r and indicates how closely the points lie to a line.
If r takes values between 1 and +1, the closer it is to 0 the less linear the association between the
two variables. (Note that the variables may be strongly associated but not linearly.)
Negative values of r indicate that one variable decreases as the other increases (e.g. CD4 count falls
with age).
Values of 1 or +1 show that the variables are perfectly linearly related, i.e. the scatter plot points lie
on a straight line.
Correlation coefficients:
Show how one variable increases or decreases as the other variable increases
Do not give information about the size of the increase or decrease
Do not give a measure of agreement
The Pearson r is a parametric correlation coefficient. The Spearman rank correlation is the most
commonly used non-parametric correlation coefficient:
Parametric correlation coefficients quantify the extent of any linear increase or decrease
Non-parametric correlation coefficients quantify the extent of any tendency for one variable to
increase or decrease as the other increases (e.g. exponential increase or decline, increasing in
steps)
Figure 24.4 Scatter plots with different correlation coefficients
A p value attached to a parametric correlation coefficient shows how likely it is that there is no linear
association between the two variables.
A significant correlation does not imply cause and effect.
Note that a correlation of 0 does not necessarily imply no relationship, merely that there is no linear
association.
5.2 Linear regression

A regression equation may be used to predict one variable from others. If there is a single numeric
predictor then this can be represented as a line on the scatter plot (Figure 24.5).
Figure 24.5 CD4 count versus age
The plot shows that the CD4 count falls on average with increasing age. The regression equation
(CD4 = 4.24 [0.64 age]) quantifies that relationship. As age increases by 1 year, the CD4 count
falls on average by 0.64. Ideally this estimate should be presented with a confidence interval to show
the range of population scenarios with which the sample is compatible.
6. SCREENING TESTS
Screening tests are often used to identify individuals at risk of disease. Individuals who are positive
on screening may be investigated further to determine whether they actually have the disease:
Some of those who are screen positive will not have the disease
Some of those who have the disease may be missed by the screen (i.e. test negative)
This gives a fourfold situation as shown in the box below (a, b, c and d are the numbers of
individuals who fall into each of the four categories).
There are several summary measures that are often used to quantify how good a screening test is:
Sensitivity is the proportion of true positives correctly identified by the test:
a/(a + c)
Specificity is the proportion of true negatives correctly identified by the test:
d/(b + d)
Positive predictive value is the proportion of those who test positive who actually have the
disease, a/(a + b)
Negative predictive value is the proportion of those who test negative who do not have the disease,
d/(c + d)
For all of these measures, larger values are associated with better screening tests. The values are
usually multiplied by 100 and presented as percentages, e.g. if 75 out of 100 individuals with the
disease test positive, the sensitivity is 75/100 = 0.75; expressed as a percentage this gives a
sensitivity of 75%.
Note that the positive and negative predictive values depend on the prevalence of the disease, i.e. the
proportion of the total that have disease: (a + c)/(a + b + c + d) and may vary from population to
population.
Likelihood ratios
These compare the probability of the test result given that the individual has the disease to the
probability of the result occurring if they are disease free. They are calculated from the sensitivity
and specificity and are not dependent on disease prevalence.
The likelihood ratio (LR) for a positive test result LR+ = Sensitivity/(1 Specificity)
The likelihood ratio for a negative test result, LR = /(1 Sensitivity)/Specificity
Likelihood ratios can be multiplied by pre-test odds to give post-test odds, e.g. a screening test is
applied to patients with and without disease X. Of 100 who have the disease, 60 test positive; of 200
without the disease, only 20 test positive. From this information the following table can be
constructed:
The following can, therefore, be estimated from this sample of 300 individuals:
Sensitivity = 60/100 = 0.6 or 60%

Specificity = 180/200 = 0.9 or 90%
LR+ = 0.6/(1 0.9) = 6
LR = (1 0.6)/0.9 = 0.44
The positive predictive value is 60/(60 + 20) = 0.75 or 75% (i.e. 75% of those who test positive
actually have the disease in this sample)
The prevalence of the disease in this sample is: (60 + 40)/(100 + 200) = 0.33 or 33%
If a particular patient had a probability of 60% of having the disease (based on age, other risk factors,
etc.) then their prior odds are 60/40 (for every 60 individuals of this type who have disease, 40 do
not) = 1.5.
The posterior odds of the patient having the disease will be determined by the result of the screening
test thus:
If the test is positive (LR+) then the odds of having the disease will be
1.5 6 = 9
If the test is negative (LR), the odds will be
1.5 0.44 = 0.66

Note that, as expected, the odds of having the disease rise if the test is positive and fall if the test is
negative.
A posterior odds of 9 means that the patient is nine times more likely to have the disease than not,
which equates to a probability of 9/10 or 0.9 (as opposed to 0.6 before testing).
A posterior odds of 0.66 equates to a probability of 0.66/1.66, or 0.4 (as opposed to 0.6 before
testing).
7. THINGS TO LOOK OUT FOR

Sometimes mistakes are made when the techniques outlined in the previous sections are applied and
this section gives an overview of those most commonly seen.
7.1 Using inappropriate summaries for numeric data

The use of means with skewed data has already been highlighted (see Section 3.2). All of the data
may not be needed to identify this problem if means (SD) are given for very skewed data. We can
check whether the limits mean 2 SD are valid; if not then this implies skewness and inappropriate
usage of the summaries.
For example: suppose the mean (SD) casual annual income for a group of students is given as 2023
(1450). Then:
Mean + 2SD = 2023 + 2(1450) = 4923
Mean2SD = 20232(1450) = 877
The second limit (877) is invalid because the students would not have earned a negative amount.
The distribution of earnings is probably upwardly skewed with a few students earning relatively
large amounts. Hence the mean is unrepresentative of the group; the median (IQR) would be a better
summary.
7.2 Not dealing properly with missing data

Missing data can occur for many reasons. Often the study aims to collect information on a variety of
background factors and perhaps also multiple outcomes. It is not uncommon to find a relatively large
proportion of the study participants with one or more missing pieces of information. Sometimes the
missing values are replaced by the mean of the available data on that variable or, if repeat
measurements are made, by the last available measurement (this latter case is known as the last
observation carried forward or LOCF). Neither of these is a good option because they pretend that
the data are available when they are not and the resulting estimates will be too precise.
Another approach is to create a missing category and include this in the analysis. Surprisingly, this
may introduce bias in the other estimates and is therefore not recommended.
A complete case analysis may be undertaken whereby any individuals with missing data on any
variables are excluded from the analyses. This is often the default option used by statistical software
packages. However, this is not a good option because the dataset that remains (and on which the
analyses will be performed) may be greatly reduced and also biased (individuals with complete data
may differ from the others in a way that is associated with outcome).
The best way to deal with missing data is via multiple imputation, whereby the values are imputed
and a random element incorporated so that precision is not artificially increased.
7.3 Non-independent measurements treated as independent

Most statistical analyses make inferences based on the assumption that the sample measurements of a
given variable are independent. Non-independence occurs most commonly:
when individuals are measured serially
within cluster randomized trials where groups of individuals within the same unit (e.g. classes of
children, families, GP units, districts, hospital wards) are randomized en masse to different
treatments
When data are grouped in this way, the information obtained is less than what would have been if data
were collected from independent individuals, e.g. taking 1 measure from each of 50 individuals will
always give more information about that measurement and its variation between individuals than
having 10 measures from each of 5 individuals. As we are usually concerned with betweenindividual variation in outcomes in research studies (How well does a treatment work on average?
What is the average effect of disease on individuals? etc.), then this is a problem if not properly
addressed. If there is any form of non-independence, this must be taken into account in the analyses,
otherwise the estimates presented will be overly precise.
Multilevel, hierarchical or random effects models are appropriate for dealing with non-independent
sets of outcome measurements.
7.4 Multiple testing without adjustment

A p value gives the probability of the samples differing by the amount observed if some null
hypothesis were true (see Section 4.1). A p value of 0.05 would mean that a difference that large
would be found only for 5% (or 1 in 20) samples if the null were true. A p value of 0.001 would
mean that it would only occur in 1 in 1000 samples. However, this is based on only one outcome
being compared between groups. If 20 outcomes were compared, then we would expect 1 of them to
yield a p value of 0.05 by chance. If 10 independent outcomes were tested the chance that at least one
would be significant at 5% is 0.41.
If multiple outcomes are compared then the significance levels should be adjusted to take account of
this. A Bonferroni adjustment to the p value will do this.
Subgroup analyses
Another form of multiple testing is when data are considered within subgroups, e.g. a blood pressure
treatment may be found to be non-significant overall but effective in the subgroup of females.
Sometimes, many subgroupings are considered and only one or two significant differences reported
whereas the statistically non-significant differences are not.
The problems with subgroup analyses are those of multiple testing, with the additional problem of
some of the sample sizes being very small. With small samples there is a danger that clinically
important differences will be missed. The study will have been designed to have sufficient power to
detect a clinically important effect with the total sample size, and the subgroups will not have as much
power.
Subgroup differences in outcome can be investigated validly using regression models incorporating
interaction terms to determine whether the differences in outcome between subgroups are statistically
significant. For example, the difference in outcome may be significant in females and insignificant in
males, but this does not necessarily imply that the difference in outcome is significantly different
between males and females, which is what an interaction term formally tests.
7.5 Patients acting as their own controls

Sometimes measurements are made pre- and post-treatment with the idea that patients act as their
own controls. It is assumed that, if the patients improve pre- post-, this is due to treatment.
However, this is not a good study design because there is no measure of how the patients would have
fared over the same time period in the absence of treatment. It is possible that the patients would have
improved anyway. Most patient outcome measures (happiness, blood pressure, general wellbeing.
etc.) will fluctuate over time due purely to random variation rather than any overall trend. Often,
patients are enrolled into trials when their disease is particularly bad (e.g. when blood pressure is
very high) because they may seek care and/or be willing to try new treatments when symptoms are
worse. As they are at a bad point, given random fluctuation, we may expect that they would improve
in the following time period regardless of any treatment. Similarly, if recruited when they were
particularly well, we might expect them to become worse (due to random fluctuation) in the following
time period. Hence, observing a difference in a group pre- and post-treatment does not imply
causality because there is no control group against which to measure the effect of treatment.
7.6 Testing group changes independently
Sometimes individuals are measured at two time points and a control group is similarly assessed. In
this scenario there are two sets of differences to compare: e.g. those for a group pre- posttreatment and the other for a comparable group receiving placebo measured twice over a similar
time-frame. Sometimes the significance of the change pre- post- in each group is calculated
separately using paired tests and the p values for the two tests compared. However, showing a
significant difference in one group and not in the other does not imply a significant difference between
groups.
Depending on the distribution of the within-pair differences (whether or not normally distributed), the
significance of any average change (pre- post-) between the treated and placebo groups should be
assessed using either a two-sample t-test or a MannWhitney U test. This analysis will show whether
the changes in one group are significantly different to the changes in the other.
8. FURTHER READING
Altman DG. Practical Statistics for Medical Research. London: Chapman & Hall, 2006.
Altman DG, Machin D, Bryant TN, Gardner MJ. Statistics with Confidence. London: BMJ Books,
2005.
Bland M. An Introduction to Medical Statistics. Oxford: Oxford University Press, 2008.
Kirkwood BR, Sterne JAC. Essential Medical Statistics. Oxford: Blackwell Science, 2005.
Machin D, Campbell MJ, Walters SJ. Medical Statistics: A textbook for the health sciences.
Chichester: Wiley & Sons, 2007.
Peacock J, Kerry S. Presenting Medical Statistics from Proposal to Publication: A step-by-step
guide. Oxford: Oxford University Press, 2007.
Peat J, Barton B. Medical Statistics: A guide to data analysis and critical appraisal. Oxford: BMJ
Books, Blackwell Publishing, 2007.
Petrie A, Sabin C. Medical Statistics at a Glance. Oxford: Blackwell Publishing, 2005.
Chapter 25
Surgery
Merrill McHoney
CONTENTS
Neonatal surgery
1. Antenatal diagnosis of surgical conditions
2. Congenital oesophageal anomalies
2.1 Oesophageal atresia and tracheo-oesophageal fistula
2.2 Dying spells
3. Neonatal intestinal obstruction

4. Intestinal atresia
4.1 Duodenal obstruction
4.2 Jejunoileal atresia
4.3 Colonic atresia
4.4 Pyloric atresia
5. Malrotation
6. Meconium ileus
7. Hirschsprung disease
8. Anorectal malformations
8.1 Imperforate anus
9. Necrotizing enterocolitis
10. Biliary atresia

11. Anterior wall defects
11.1 Gastroschisis
11.2 Exomphalos
12. Congenital diaphragmatic hernia

12.1 Eventration of the diaphragm
13. Malformations of the airway and lungs

13.1 Choanal atresia
13.2 Laryngeal cleft
13.3 Congenital lobar emphysema
13.4 Congenital cystic adenomatoid malformation
13.5 Pulmonary sequestration
13.6 Bronchogenic cyst
14. Neonatal tumours

14.1 Teratoma
14.2 Sacrococcygeal teratoma
15. Spina bifida

16. Miscellaneous conditions
16.1 Antenatal torsion
16.2 Accessory digit
General paediatric surgery

17. Head and neck surgery
17.1 Ranula
17.2 Lymphatic malformation
17.3 Thyroglossal cyst
17.4 Preauricular pits
17.5 Branchial arch remnants
17.7 Haemangiomas and arteriovenous malformations
17.8 Central venous access
18. Thoracic surgery

18.1 Congenital malformations
18.2 Chest wall deformities
18.3 Oesophageal foreign bodies
18.4 Caustic ingestion

18.5 Parapneumonic effusions
19. Gastrointestinal surgery

19.1 Abdominal wall herniae
19.2 Pyloric stenosis
19.3 Gastrostomy
19.4 Gastro-oesophageal reflux disease
19.6 Appendicitis
19.8 Undescended testis
19.9 Testicular torsion
19.10 Phimosis
19.11 Hypospadias
20. Further reading
Neonatal surgery
1. ANTENATAL DIAGNOSIS OF SURGICAL CONDITIONS

Identify pathology and assess severity/complications
Search for other associated anomalies
In utero intervention thoracoamniotic shunt for a massive congenital cystic adenomatoid
malformation with significant mediastinal shift and hydrops
Modify pregnancy monitoring gastroschisis (in third trimester have weekly ultrasounds and
twice-weekly cardiotocographs for late intrauterine death, have an expectation of preterm labour)
Parental counselling opportunity for karyotyping, consideration of termination of pregnancy,
information regarding early postnatal care and surgery/outcome
Plan delivery/immediate neonatal and surgical care
2. CONGENITAL OESOPHAGEAL ANOMALIES

2.1 Oesophageal atresia and tracheo-oesophageal fistula
Oesophageal atresia (OA) and tracheo-oesophageal fistula (TOF) comprise faulty separation of the
primitive embryonic trachea from the foregut (future oesophagus). Incidence is 1 in 3000 to 1 in 3500.
Many are associated with preterm labour as a result of polyhydramnios.
85% blind proximal oesophageal pouch with a tracheo-oesophageal fistula to the distal pouch
510% pure oesophageal atresia (long gap)
5% H fistula (tracheo-oesophageal) without an oesophageal atresia
Rare oesophageal atresia with upper pouch fistula, or upper and lower pouch fistulae
Associated with tracheomalacia (weakness of tracheal wall due to deficient cartilaginous

development) with resultant narrowing of trachea (gives rise to TOF cough).
Also associated with VACTERL anomalies (vertebral anal, cardiac, tracheal, oesophageal, renal and
limb).
Diagnosis
Antenatal scan polyhydramnios, absent gastric bubble, distended upper oesophagus (interrupted
foetal swallowing)
After birth excessive salivation, choking because of aspiration after every feed, respiratory
distress with or without cyanotic episodes. Other associated anomalies are seen in 3050%
Confirmation failure to pass a large-bore (10 French scale) nasogastric tube (with chest
radiograph to demonstrate that the nasogastric tube is not coiled in the oesophagus)
bronchoscopy at surgery to confirm location of lower pouch fistula and to exclude upper pouch
fistula and laryngeal cleft
Contrast swallow is not indicated (risk of aspiration)
Management
Stop feeds and aspirate upper pouch
Respiratory support as required avoid bag and mask ventilation to reduce gastric distension
Replogle tube sited in the proximal pouch double-lumen tube (with side holes) placed on lowpressure continuous suction preventing suction of the intestinal mucosa against the tube. Larger
lumen requires flushing with 12 ml saline to prevent blockage with tenacious secretions
Antibiotics if evidence of pulmonary aspiration
Minimal handling reduces air swallowing from crying
Echocardiogram ideally before surgery, especially if infant is cyanotic, there is significant
cardiac murmur or infant requires cardiac support. May have duct-dependent lesion requiring
prostaglandin E1 infusion and early cardiac opinion. Repair the oesophageal atresia/tracheooesophageal fistula when stable
Renal ultrasound if urine is passed, this can be delayed until after surgery
Spinal ultrasound to exclude cord tethering (will be asymptomatic in the neonatal period)
Karyotype if infant is dysmorphic or has other system anomalies
Parental counselling
Surgery
Emergency ligation of fistula seen in the premature neonate with respiratory distress syndrome
Common anatomy (OA + TOF) right thoracotomy, ligation of the fistula and primary end-to-end
anastomosis of OA with early extubation. Trans-anastomotic tube passed for feeding. A tight
anastomosis may require a period of paralysis and ventilation
Long-gap may require complex and staged procedures
Complications
Anastomotic leak
Recurrent fistula
Stricture (at anastomosis)
Tracheomalacia
Abnormal oesophageal motility
Missed upper pouch fistula

Reflex bradycardia respiratory arrest vagal stimulation from a distending food bolus
Chylothorax
Acute life-threatening episodes (dying spells)
Episodes of respiratory distress associated with breath holding and or cyanosis. May have several,
sometime overlapping causes, with difficulty identifying main cause.
Missed upper pouch fistula or recurrent fistula. Will require re-do surgery
Severe tracheomalacia exacerbated during feeding or crying, with complete airway collapse,
cyanosis and cessation of stridulous breathing, followed by loss of consciousness, relaxation of the
airway, and recovery. May require surgical intervention (aortopexy)
Gastro-oesophageal reflux disease: investigate with contrast study, pH study or endoscopy.
Surgical management warranted
Outcome
Overall survival rate is 8595%
Highest risk birth weight <1500 g, severe associated anomalies, major congenital heart defect,
ventilator dependency
3. NEONATAL INTESTINAL OBSTRUCTION

Incidence 1 in 5001000 live births. About half will have an atresia or stenosis. After delivery,
swallowed air will reach the small bowel within 30 min, the colon by 34 h and the rectum by 68 h.
May have clinical suspicion from antenatal ultrasound proximal bowel dilatation, double
bubble, echogenic bowel loops (meconium ileus), polyhydramnios
Most present shortly after birth with abdominal distension (delayed in distal obstruction), large
nasogastric aspirate (>50 ml initial volume), bilious vomiting, delayed passage of meconium (>24
h)
Premature neonate delayed passage of meconium expected, bilious nasogastric aspirate may be
the result of intestinal immaturity or sepsis
Passage of flatus will exclude an atresia
Common causes
Malrotation with volvulus

Duodenal atresia, stenosis, extrinsic compression
Jejunoileal atresia, or stenosis
Meconium ileus (simple, complicated)
Meconium plug obstruction

Ileus secondary to sepsis, paralysis/ventilation/medication
Inguinal hernia (incarcerated)
Anorectal malformation
Less common causes

Small left colon syndrome (infant of mother who has diabetes, typical isolated small left colon on
contrast study, which is usually curative)
Megacystis-microcolon-intestinal hypoperistalsis syndrome (see below)
Colonic atresia
Radiological diagnosis
Abdominal radiograph
Proximal obstruction a few dilated loops, mainly in the upper abdomen
Distal numerous throughout most of abdomen (paucity of rectal gas suggests distal colonic or
rectal obstruction)
Partial obstruction will allow some distal gas, often mixed with meconium
Inspect for peritoneal/scrotal calcification (meconium peritonitis/prenatal perforation)
Water-soluble lower gastrointestinal contrast to distinguish distal bowel obstruction
(Hirschsprung disease, ileal atresia, meconium ileus/plug)
Water-soluble upper gastrointestinal contrast to investigate intestinal rotation abnormalities
General management
Nasogastric tube and gastric decompression

Replace nasogastric losses with 0.9% NaCl with KCl, ml for ml
Intravenous fluid replacement
Consider rectal decompression or washout after surgical consultation/review
Broad-spectrum antibiotics if there is suspicion of intestinal ischaemia (red/shiny/oedematous
abdominal wall, abdominal tenderness, absent bowel sounds, metabolic acidosis) or perforation
Megacystismicrocolonintestinal hypoperistalsis syndrome

A rare, usually fatal, condition with degenerative smooth muscle changes in the bowel and renal tract.
Abdominal distension from lax abdominal muscles and a dilated bladder. Incomplete intestinal
rotation, microcolon (barium enema) with poor peristalsis. Ultrasound demonstrates hydronephrosis
and megacystis (differentiate from Hirschsprung disease).
4. INTESTINAL ATRESIA
Development of the intestine is completed by 10 weeks gestation, foregut, midgut and hindgut forming
with their respective blood supplies (coeliac, superior mesenteric and inferior mesenteric arteries).
Liver and pancreas arise from the developing duodenum.
Duodenal failed vacuolization and recanalization of the developing duodenum during weeks 810
of gestation. Greater association with other major anomalies and development anomalies of the
pancreas/biliary tree
Jejunoileal/colonic follows a late intrauterine mesenteric vascular event with sterile ischaemia of
the bowel (resorbed). Associated with abdominal/mechanical abnormalities (gastroschisis,
mucoviscidosis in meconium ileus, with volvulus cystic fibrosis, volvulus secondary to
malrotation)
Relative frequency jejunal > duodenal > ileal > colonic > pyloric
More proximal atresia earlier vomiting, less abdominal distension
Distal atresia delayed presentation of vomiting, more abdominal distension, greater fluid and
electrolyte abnormality
Abdominal radiograph number of dilated bowel loops suggests the approximate level of atresia
A neonate with an intestinal atresia (as opposed to other causes of intestinal obstruction) will fail
to pass any flatus, even after rectal examination
Note: The presence of a few dilated bowel loops is suggestive of a proximal small bowel atresia. It
may however represent an infant with little distal midgut following a major intrauterine mesenteric
vascular event which may be incompatible with life and only identified at surgery.
4.1 Duodenal obstruction
Incidence is 1 in 2500 live births

Intrinsic obstruction atresia, stenosis, web
Extrinsic obstruction annular pancreas, malrotation, pre-duodenal portal vein
50% are associated with other anomalies cardiac, genitourinary, anorectal, OA TOF,
malrotation, congenital diaphragmatic hernia, vertebral
3040% are associated with trisomy 21
80% are periampullary (bilious vomiting), 20% preampullary (non-bilious vomiting)
Prenatal diagnosis
Polyhydramnios in up to 75%
Intrauterine growth restriction, premature delivery in up to 50%
Dilated stomach and proximal duodenum (double bubble) on antenatal ultrasound
Features suggesting trisomy 21 (nuchal translucency)
Postnatal diagnosis
Index of suspicion trisomy 21, oesophageal atresia
Vomiting especially bilious, initial nasogastric aspirate >20 ml with no other obvious cause
Abdominal radiograph double bubble

Caution suggestive double bubble with some distal gas may be duodenal stenosis or bifid biliary
duct but must exclude malrotation volvulus (see below).
Medical management
Nasogastric insertion for gastric decompression, intravenous volume replacement
Assess for other anomalies karyotype if dysmorphic
Surgical care
Laparotomy primary repair (duodenoduodenostomy)
Postoperative nasogastric replacement initial aspirate volume may be high (100150 ml/day),
until duodenal stasis is resolved. Replace ml for ml with 0.9% NaCl (with added KCl)
Complications
Related to co-morbid pathology cardiac, chromosomal
Prolonged bilious aspirates because of poor motility from delayed duodenal peristalsis
Blind loop syndrome chronic duodenal dilatation and secondary bacterial overgrowth
4.2 Jejunoileal atresia
Incidence up to 1 in 10001500 live births

Multiple small bowel atresias jejunal (67%), ileal (25%)
Few associations with chromosomal abnormalities or other system anomalies
Bowel length variable may be foreshortened, risk of short bowel
Postnatal presentation
Persistent bilious vomiting
Abdominal distension most marked with distal atresia, visible bowel loops, fluid and electrolyte
disturbance
Meconium varies from normal colour to grey plugs of mucus
Radiology
Dilated bowel loops number of loops suggests level of atresia (proximal versus distal)
Note: in the neonate, large and small bowel are indistinguishable on radiograph because of the
poor development of the haustral folds and valvulae conniventes
Abdominal calcification meconium peritonitis secondary to an intrauterine perforation
Medical management
Nasogastric tube insertion for gastric decompression, volume replacement
Cardiorespiratory support as required
Surgery
Laparotomy assessment of bowel length and viability, exclusive of multiple atresias, and other
pathology, primary anastomosis (more than one may be required) proximal stoma
Complications
Anastomotic leak
Stricture formation
Nutritional vitamin B12 and bile salt absorption affected from loss of terminal ileum
Short bowel syndrome following catastrophic small bowel loss, the survival prognosis depends
partly on the presence of the ileocaecal valve (30 cm with, 50 cm without). The premature neonate
has a greater capacity for functional adaptation
4.3 Colonic atresia

Rare (5% of all atresias), with an incidence of 1 in 1500 to 20 000 live births. Right colon is most
commonly affected. Associated with anorectal malformation, Hirschsprung disease, small bowel
atresia, renal/cardiac/limb/cerebral abnormalities.
4.4 Pyloric atresia

Rare (<1% of all atresias), 50% are associated with polyhydramnios, non-bilious vomiting from
birth, epigastric distension, single gastric bubble on radiograph, respiratory symptoms are common.
Associated with epidermolysis bullosa.
5. MALROTATION
Interference with the normal return of the fetal intestine into the abdominal cavity.
Population incidence of 1 in 125 (post-mortem examinations). Lifetime risk of symptoms 1 in 60 of
these (i.e. about 1 in 6000 of the general population)
Associated with other abnormalities exomphalos, gastroschisis, diaphragmatic hernia, cardiac
anomalies associated with visceral heterotaxy
Presents with green bile-stained vomiting within the first week (55%), or by 1 month (80%) with
only sporadic cases thereafter
May exist with other abnormalities exomphalos, gastroschisis, diaphragmatic hernia, cardiac
anomalies associated with visceral heterotaxy
Small bowel predominantly in the right abdomen
The narrow mesentery is prone to kinking, and in the event of a volvulus, the entire midgut blood
supply may be compromised, bowel infarction may occur in 6 h with resulting loss of the midgut
Radiology
Gas pattern on plain abdominal radiograph may be normal
Signs of proximal intestinal obstruction asymmetrical and/or sparse distal gas pattern
Contrast study
Failure of the duodenojejunal junction to cross the midline on upper gastrointestinal contrast and lie
to the left of the spine
Corkscrew sign if small bowel volvulus is present
Dilated proximal duodenum with failure of passage of contrast into the second part of the duodenum
Barium enema may show caecum/appendix in the right hypochondrium an unreliable sign alone as
the normal neonatal colon is mobile
Caution bilious vomiting mandates an urgent water-soluble upper gastrointestinal contrast study at
any time of the day/night (even if the infant is well, without abdominal distension or tenderness, with
a normal plain abdominal radiograph and with normal biochemistry/haematology profiles). Clinical
deterioration with abdominal tenderness, cardiorespiratory collapse, metabolic and lactic acidosis,
upper/lower gastrointestinal bleeding is a late sign of compromised bowel and impending death. This
is a life-threatening emergency.
Surgery
Adequate resuscitation
Nasogastric decompression, fluid, broad-spectrum antibiotics
Laparotomy confirm diagnosis, untwist volvulus, assess bowel viability/length, resect necrotic
bowel, proximal stoma/second-look laparotomy for uncertain viability
6. MECONIUM ILEUS
Incidence of 1 in 10002000 live births
8090% will have cystic fibrosis but only 15% of infants with cystic fibrosis will present with
meconium ileus
Thick mucus and viscid meconium, lower lactase/sucrase levels, more albumin and less pancreatic
enzyme
Obstruction of the distended meconium-filled terminal ileum. Small, unused colon, inspissated
pellets of colourless mucus
Complications occur in 50% antenatal volvulus of the distended ileum with atresia, meconium
peritonitis or pseudocyst formation
Antenatal perforation is sterile, postnatal perforation is complicated by bacterial contamination and
systemic sepsis
Diagnosis
Uncomplicated abdominal distension, bilious vomiting, failure to pass meconium, doughy mass
on palpation within 2448 h of birth
Complicated abdominal wall erythema, oedema, meconium staining suggests prenatal
perforation
Cystic fibrosis screen
Radiology
Simple proximal bowel dilatation, few air-filled loops, meconium mottling (soap bubble,
ground glass) often in the right lower quadrant
Complicated calcification (extravasation of meconium into the peritoneal cavity), massive bowel
dilatation (atresia), displaced bowel loops (pseudocyst), ascites
Gastrografin enema can be repeated after diagnosis in a therapeutic manner
Alternative N-acetylcysteine (Mucomyst) by nasogastric tube or per rectum (breaks down
disulphide bridges in tenacious meconium) can be used as adjunctive therapy
Caution Gastrografin is hyperosmolar and draws fluid into the terminal ileum from the
intravascular space, softening the meconium. Adequate fluid resuscitation is vital before and during
use to prevent potentially catastrophic cardiovascular collapse.
Surgery
Simple meconium ileus, following unsuccessful therapeutic enema, laparotomy, instillation of Nacetylcysteine, or enterostomy and irrigation
Complicated meconium ileus may require surgical correction of an atresia, volvulus, pseudocyst,
perforation
Primary anastomosis temporary proximal stoma
Complications
With cystic fibrosis, 1-year survival rate is 7590%
Late complications distal intestinal obstruction syndrome (10%), appendicitis (5%),
intussusception (2%), rectal prolapse (1030%)
Meconium plug obstruction

Failure to pass meconium or only a small inspissated plug, passed after per rectum examination, and
followed by normal meconium. Usually require therapeutic enema. Exclude cystic fibrosis and
Hirschsprung disease, and investigate for underlying cause.
7. HIRSCHSPRUNG DISEASE
Absence of ganglion cells in the myenteric plexus of the most distal bowel; male incidence greater
than female. Occurs in 1 in 5000 births.
Gene on chromosome 10, RET proto-oncogene
Long-segment Hirschsprung disease is familial (47%) with equal sex incidence
Associated with trisomy 21 (515% reports vary between 2 and 15% have Down syndrome),
high frequency of other congenital abnormalities, including multiple endocrine neoplasia
Transition zone in the rectosigmoid junction is most common (>75%)
Total colonic/small bowel involvement (510%) poor prognosis
Presentation
Usually presents in infancy poor feeding, abdominal distension, delayed passage of meconium,
bilious vomiting
Radiological evidence of distal intestinal obstruction with absence of rectal gas
Explosive decompression following rectal examination (passage of gas excludes atresia)
First presentation may be with acute enterocolitis (red, tender, shiny abdomen) severe systemic
collapse. Diarrhoea is offensive blood or ischaemic mucosa. May require emergency
defunctioning colostomy
Enterocolitis can occur pre- or post-surgery, some associated with Clostridium difficile
enterotoxin
Initial management
Nil-by-mouth, intravenous fluids, correction of electrolyte abnormalities, high colonic washouts to
decompress the bowel (feeding tube, not balloon catheter)
Fluid resuscitation + broad-spectrum antibiotics if presenting with enterocolitis
Poor result usually technical but may suggest long segment disease
Diagnosis
Contrast enema identify transition zone, exclude other pathology
Definitive test is suction rectal biopsy for histology
Surgery
Several options of pull-through operations exist (Duhamel, Soave-Swenson) that involve excision
of the involved colon, anastomosis with innervated proximal bowel (propulsion); a small part of
the involved rectum remains (sensation and sphincter innervations)

Still have risk of enterocolitis following surgery (treated as above)
Outcome
Incidence of enterocolitis: 525%, increased in trisomy 21 (2954%), associated cardiac defects,
total colonic involvement (1525%). Overall mortality rate from enterocolitis: 525%
Surgical management for anastomotic leak, pelvic abscess, intestinal obstruction
Medical management of soiling, constipation, frequent loose stools
8. ANORECTAL MALFORMATIONS
8.1 Imperforate anus
Incidence of 1 in 40005000 live births

Association with maternal diabetes
Male (60%) most commonly imperforate anus with rectourethral fistula
Female (40%) most commonly imperforate anus with rectovestibular fistula
Imperforate anus without a fistula is uncommon (5%)
Associated defects are common
Presentation
Clinical examination
Failure to pass meconium, abdominal distension, bilious vomiting (late sign)
Passage of meconium or bubbles per urethra/vagina (high lesion)
Meconium staining beneath perineal skin (low lesion)
Following identification of other VACTERL anomalies (vertebral, anal, cardiac, tracheal,
oesophageal, renal and limb)
Initial management
Nil-by-mouth, intravenous, nasogastric decompression (passage of tube will exclude OA/TOF).
Systematic examination, chest/abdomen/sacral radiograph, echocardiogram, renal ultrasound,
spinal ultrasound (exclude cord tethering), karyotype
Prophylactic antibiotics until communication with renal tract is excluded (trimethoprim)
Invertogram to assess level of rectal atresia (lateral shoot through, infant prone over a foam wedge,
buttock elevated with a radio-opaque marker at the anal position). Thick meconium within distal
bowel or straining (crying) will provide inaccurate results
Surgery
A primary operation (PSARP or posterior sagittal anorectoplasty) can be performed for low
lesions in the neonatal period

Staged procedure for high lesions:
Staged loop colostomy usually with 48 h for high lesions (defunctioning)
Distal loopogram and micturating cystourethrogram to identify anatomy of rectum and
communication with urinary tract (position of fistula vesicoureteric reflux
PSARP
Aim for colostomy closure after healed
Various surgical options may require complex staged procedures, urogenital surgery, dilatation of
new anus, medical management of bowel control (including enema)
Outcome
Dependent on level of lesion, sacral development (S3, -4 and -5 required for urinary continence)
and associated anomalies
Low lesion constipation (40%), soiling (15%), diarrhoea (5%)
High lesion constipation (35%), soiling (55%), diarrhoea (12%)
9. NECROTIZING ENTEROCOLITIS
Pathological response of the immature gastrointestinal tract to perinatal or postnatal injury. Usually
seen in the first 23 weeks of life. Rapid and early introduction of non-breast-milk feeds,
hyperosmolar feeds and bacterial infection are important aetiological factors. Progressive intestinal
mucosal ischaemia, most commonly affecting the caecum, ascending colon and terminal ileum but can
affect the entire intestinal tract.
Risk factors
Prematurity
Intrauterine growth restriction
Antepartum haemorrhage
Perinatal asphyxia (absent or reversed end-diastolic umbilical vessel waveform)
Respiratory distress syndrome
Umbilical artery catheterization
Polycythaemia
Patent ductus arteriosus
Premature rupture of membranes
Sepsis
Radiological signs of necrotizing enterocolitis (NEC)

Thickened bowel loops (non-specific)
Localised bowel distension
Pneumatosis intestinalis (soap bubble appearance in wall of bowel); pathognomonic
Radiological signs of gastrointestinal perforation
Football sign (central, oval abdominal lucency)

Visible falciform ligament an umbilical venous line in situ
Wrigler sign (visualization of both sides of the bowel wall)
Gas outlining the liver (left lateral decubitus view with horizontal beam projection)
Scrotal gas (via a patent processus vaginalis)
Triangles of gas between bowel loops
Upper abdominal lucency, especially over the liver (anteroposterior supine film, vertical beam
projection)
Medical management
Stop enteral feeds for 714 days (depending on severity of illness)

Intravenous antibiotics (broad-spectrum, including metronidazole; consult local unit policy)
Adequate intravenous analgesia
Total parenteral nutrition
Nasogastric tube, on free drainage with hourly aspiration and volume replacement
Remove umbilical lines
Regular abdominal radiographs to exclude perforation or the development of a fixed loop
Needs to be distinguished from cows milk protein intolerance
Complications
Recurrence (10% of cases consider Hirschsprung disease)

Perforation in 2030%
Overwhelming sepsis
Disseminated intravascular coagulation
Stricture formation up to 20%. Consideration of contrast studies assessment of possible
strictures (intolerance of increasing feed volume, intestinal obstruction or recurrent bacterial
translocation after clinical recovery)
Short-bowel syndrome (following extensive surgical resection)
Lactose intolerance >0.5% faecal reducing substances significant
Overall mortality rate is still 2030%
Surgical management
Indications pneumoperitoneum, failure of maximal medical management, stricture formation, fixed
loop palpable mass
Insertion of a peritoneal drain may be life saving for a tense pneumoperitoneum compromising
ventilation, but is not usually definitive
Laparotomy allows diagnosis to be confirmed, extent of disease to be assessed and peritoneal
toilet to be performed and abscess cavities drained
Localized resection with primary anastomosis
Proximal diversion stoma bowel resection

Stoma formation ileostomy or colostomy depending on extent/location of necrotizing enterocolitis
May require more than one procedure, including stoma closure and stricture resection
Spontaneous intestinal perforation is either a different entity to NEC or may represent a small
subgroup of mild localized disease
Usually no prodromal period of unstable or septic-looking baby
Associated with non-steroidal anti-inflammatory use, which may be contributory
No pneumatosis on abdominal radiograph
Sudden abdominal distension and need for ventilation
Laparotomy perforation usually in terminal ileum with otherwise healthy looking bowel
Localized resection with primary anastomosis feasible
10. BILIARY ATRESIA

Incidence is 1 in 800020 000 live births. It is the most common indication for liver transplantation in
childhood.
Extrahepatic biliary atresia progressive obliteration of part or all of the extrahepatic ducts.
Aetiology uncertain
Intrahepatic biliary atresia this is less common and can be either syndromic (Alagille
syndrome) or non-syndromic
Investigations
Liver function tests (often normal enzymes with conjugated hyperbilirubinaemia), clotting
Ultrasound (may be normal, gall bladder may be absent)
Radionuclide technetium-99m-labelled iminodiacetic acid ([99mTc]HDA) scan (unimpaired hepatic
uptake of isotope but failure of excretion into the duodenum after 24 h)
Liver biopsy
Laparotomy surgical cholangiography
Treatment
Hepatoportoenterostomy (Kasai procedure)
Aim for surgery before the infant is 60 days old (high mortality from end-stage liver disease after
this)
Ursodeoxycholic acid to promote bile secretion, fat-soluble vitamin supplementation
Postoperatively high risk of cholecystitis (prompt treatment with intravenous antibiotics)
Fat malabsorption, cirrhosis, liver failure
Liver transplantation may be indicated
Caroli disease
Autosomal recessive, congenital cystic dilatation of the intrahepatic ducts

Recurrent acute cholangitis, biliary lithiasis, risk of cholangiocarcinoma
11. ANTERIOR WALL DEFECTS

11.1 Gastroschisis
There is controversy regarding the aetiology but it is probably the result of the intrauterine rupture of
the right vitelline artery and breakdown of the abdominal wall adjacent to the umbilicus.
Incidence of 1 in 30006000 live births, trend increasing
Typical infant preterm, small for gestational age, lower maternal age, oligohydramnios, antenatal
ingestion of aspirin, illegal drugs (vasoconstrictor side effects), alcohol
Risk of late intrauterine deaths, monitor fetal movements, increased ultrasound and cardiotocogram
in third trimester
Vaginal delivery is not contraindicated
Defect is lateral (usually to the right, 95%) to the intact umbilical cord
Herniation of bowel without a covering sac, stomach, occasionally bladder, but rarely the liver
Intestinal atresia is common, occurring in approximately 20% of cases. Short bowel may
complicate outcome
Rarely associated with lethal chromosomal or major structural abnormalities
Can be confused with a ruptured exomphalos
Management at delivery
Wrap Clingfilm around entire trunk, covering exposed bowel and ensure infant is well supported in
the midline to reduce temperature and fluid evaporative losses
Large-bore nasogastric (NG) tube, intravenous fluids above normal rate. May need bolus to replace
initial losses
Regular visual assessment of bowel viability if closure is delayed, and during neonatal transfer
Surgical management
Undertaken promptly after delivery. May require staged surgical repair after initial silo application
Total parenteral nutrition and trophic milk via nasogastric tube
Delay in establishing feeds is related to poor intestinal motility bilious NG aspirates, abdominal
distension, failure to pass changed stool
Repair of atresia may be deferred until abdominal closure is completed
Outcome
Morbidity is related to short bowel
10% risk of necrotizing enterocolitis
Prognosis is usually good
11.2 Exomphalos
Failure of closure of the abdomen at the umbilical ring
Incidence is 1 in 5000 to 1 in 10 000 live births, trend is decreasing (partly related to termination
of pregnancy following identification of other lethal structural or chromosomal abnormalities)
4070% have associated abnormalities chromosomal (trisomies 13, 18 and 21), cardiac (25%),
genitourinary, gastrointestinal, craniofacial, pulmonary hypoplasia
Syndromic associations BeckwithWiedemann syndrome, prune-belly syndrome and pentalogy of
Cantrell
Antenatal karyotype analysis should be advocated, along with a more detailed anomaly scan.
Parental counselling in cases with severe associated abnormalities may include elective
termination
Management at delivery
Leave cord length long
Cover exomphalos with Clingfilm, as per gastroschisis (reduce temperature/fluid evaporative loss)
Support contents in the midline (vertically tie the umbilical cord to the overhead heater or
incubator)
Assess bowel colour through sac (initially transparent), look for blood (hepatic trauma), avoid sac
rupture
NG decompression, intravenous fluid/electrolyte resuscitation, temperature as per gastroschisis
Clinical assessment dysmorphic features (especially midline defects), karyotype, chest
radiograph, echocardiogram, renal ultrasonography
Early and regular blood glucose measurements (BeckwithWiedemann syndrome)
Early surgical involvement
Surgery
Aim for reduction of abdominal contents and complete closure
May require staged procedures
Massive exomphalos (especially with small abdominal cavity) or infants with multiple
abnormalities may be managed conservatively. Topical application of saline, to allow eschar
formation and skin overgrowth. Delayed surgical management of massive ventral hernia some
years later
Meticulous fluid management
Outcome
Associated defects or chromosomal abnormalities have a major influence on survival
35% mortality, three times that of gastroschisis
12. CONGENITAL DIAPHRAGMATIC HERNIA
Incidence is 1 in 2500 to 1 in 3500 live births

Chromosomal abnormalities found in 530% of cases (trisomies 18 and 13 are most common)
Serious associated anomalies in 40% live-born babies (cardiac and neural tube defects)
Frequent association with intestinal fixation abnormalities including malrotation
Associated lung hypoplasia
Both lungs are structurally abnormal (ipsilateral > contralateral). This is the major determining
factor in the outcome of babies born alive with congenital diaphragmatic hernia
Left-sided is more common than the right (6:1)
90% are a posterolateral defect (Bochdalek hernia)
Poor prognostic factors gestational age <25 weeks at diagnosis, structural cardiac abnormality,
chromosomal abnormality, polyhydramnios, contralateral lung-to-thoracic transverse area ratio
<0.5, contralateral lung-to-head circumference ratio <0.62, left ventricular hypoplasia
Pentalogy of Cantrell
A rare defect resulting from a severe mesodermal fusion failure
Comprises diaphragmatic hernia (retrosternal defect), lower sternal defect, pericardial defect,
major cardiac anomaly and epigastric exomphalos
Congenital cystic adenomatoid malformation

Lung sequestration
Cystic lesions (bronchogenic, thymic, neuroenteric, duplication)
Diaphragm eventration
Postnatal diagnosis
Absence of visible diaphragm

Bowel loops seen in the chest
Tip of nasogastric tube in the chest (only if stomach herniated)
Paucity of bowel loops within abdomen
Contralateral mediastinal shift
Small contralateral lung
Resuscitation at birth
Avoid bag and mask positive-pressure ventilation (minimize visceral distension)
Prompt endotracheal intubation in the delivery room for respiratory distress
Replogle or wide-bore nasogastric tube insertion (will need to be passed beyond the usual
distance)
Chest radiograph to confirm diagnosis, nasogastric tube position and exclude other diagnoses
(congenital cystic adenomatoid malformation, pulmonary sequestration)

Occasional fluoroscopy (eventration) or cross-sectional imaging (congenital cystic adenomatiod
malformation, pulmonary sequestration) to exclude differential diagnosis in difficult cases
Medical management
Minimal stimulation with consideration of paralysis
Abnormal pulmonary vascular reactivity produces reduced lung perfusion, pulmonary hypertension,
right-to-left shunting through the foramen ovale, ductus arteriosus and intrapulmonary vessels
Surfactant used in some centres
Maintain preductal oxygen saturations at 8590%
Minimal ventilation pressures to reduce barotrauma. Iatrogenic injury from ventilation strategies
may be significant and should be minimized
Volume resuscitation and vasopressors (dopamine and dobutamine) often required
Pulmonary vasodilatation with inhaled nitric oxide
High-frequency oscillatory ventilation may be considered when conventional ventilation fails to
correct hypoxia and hypercapnia, or when peak airway pressures remain high (>30 cmH2O)
Extracorporeal membrane oxygenation has not offered consistent results, but is used in some
centres as rescue therapy
Persistent pulmonary hypertension of the newborn is a major determinant of survival and
consideration of the timing of surgery
Surgical management
Stabilization with medical treatment takes priority

Surgical repair includes reduction of the herniated viscera into the abdominal cavity
Closure of the diaphragmatic defect: direct suture a prosthetic patch
Diaphragm agenesis may require more extensive surgical intervention
Complications
Continued medical management of pulmonary hypoplasia
Thoracic wall deformities with growth
Detachment of prosthetic patch: may require further surgery
12.1 Eventration of the diaphragm

Abnormal elevation of an otherwise intact diaphragm
Similar to congenital diaphragmatic hernias, eventration of the diaphragm is more common on the
left
Paralysis of the diaphragm due to phrenic nerve palsy or traumatic/iatrogenic phrenic nerve damage
Presentation is more often less dramatic and later than for those with congenital diaphragmatic
hernia. Due to the limited respiratory reserve, poof feeding or sucking, associated with tiring, is
common
Failure to thrive may be the presenting complaint due to poor feeding. Vomiting may be the
presenting complaint
Failure to recover from a lower respiratory tract infection or recurrent infections may prompt a
chest radiograph which brings the diagnosis to light
Fluoroscopy is diagnostic in most cases. Paradoxical movement of the affected diaphragm is seen
during screening
Surgical correction is via a thoracotomy, thoracoscopy or laparotomy depending on preference
Patient who are asymptomatic or patients who improve without intervention may be treated
conservatively
13. MALFORMATIONS OF THE AIRWAY AND LUNGS

13.1 Choanal atresia
Obstruction at the level of the posterior border of the nasal septum 90% bony, 10% membranous
Incidence of 1 in 10 000
Symptoms from birth (if bilateral) as neonates are obligate nose breathers
Failure to pass a catheter beyond the posterior nares
Transnasal surgical correction with postoperative temporary stenting
Macroglossia
Localized haemangioma, lymphangioma
Generalized hypothyroidism, BeckwithWiedemann syndrome (check blood glucose)
May require surgical reduction
13.2 Laryngeal cleft
Incomplete separation of foregut into trachea and oesophagus

Rare condition, may occur in isolation, involves larynx trachea
Associated with OA/TOF, cardiac, palate, genitourinary anomalies
Feeding aspiration, recurrent pneumonia, stridor, weak cry
May require intubation tracheostomy
Endoscopic assessment
Surgical repair may be complex
13.3 Congenital lobar emphysema (overinflation)

Overexpansion of alveolar spaces segment or lobe (normal lung histology)
Cartilaginous deficiency/abnormality (3550%)
Post-infective alveolar septal fibrosis (30%)

Extrinsic compression cardiomegaly from congenital cardiac anomalies in 15% (ventricular
septal defect, patent ductus arteriosus, tetralogy of Fallot), aneurysmal dilatation of major vessels,
bronchogenic cyst
Acquired preterm or small for gestational age neonates after long-term ventilation
Inspiratory airflow producing a ball-valve defect, air trapping and compression of adjacent lung
Presentation
Some diagnosed antenatally on ultrasound

Usually within a few hours of birth (50%) with severe respiratory distress
Chest asymmetry, hyperresonant
May be asymptomatic at birth, with symptoms by 6 months
Radiology
Left upper lobe (42%), right upper lobe (21%), right mid-lobe (35%), rare in lower lobes
Hyperlucent overexpanded lung
Herniation of emphysematous segment/lung across midline (anterior to mediastinum)
Mediastinal shift
Compression/atelectasis of adjacent lung/lobes
Depression of ipsilateral diaphragm
Ventilationperfusion scan may confirm absent perfusion/ventilation in severe cases
Management
Mild cases conservative, regular review with chest radiograph
Echocardiogram
Most require lobectomy may be required urgently for life-threatening respiratory insufficiency.
Emphysematous lobe may bulge out of the surgical field
Follow-up
After lobectomy, no significant functional impairment
Asymptomatic overdistended lobes do not impair development of normal lung
13.4 Congenital cystic adenomatoid malformation
May be identified on antenatal ultrasound echogenic fetal chest mass hydrops

Some demonstrate resolution after birth (uncertainty regarding pathology/prognosis)
2025% are stillborn or die rapidly from severe respiratory insufficiency
Neonatal period progressive respiratory distress (enlarging lesion with air-trapping)
May require emergency surgery
Symptoms are also related to degree of pulmonary hypoplasia (ipsilateral and contralateral), from
compression
Single lobe in 80%
Displacement of cardiac apex
Hyperresonant hemithorax
Radiology
Chest and abdominal radiograph will help to distinguish between a congenital cystic adenomatoid
malformation and diaphragmatic hernia (demonstrate normal intestinal gas pattern in the former but
not the latter)
Early plain films may be radio-opaque (delayed clearance of lung fluid)
Air-filled cystic spaces, adjacent lung compression, subtle changes (appear normal)
Computed tomography (CT) scan precise anatomical location and extent of disease (see below)
Management
Most will be sufficiently stable for complete preoperative assessment (radiographs and CT)
Symptomatic elective lobectomy
Asymptomatic controversial
13.5 Pulmonary sequestration
Congenitally abnormal non-functioning lung tissue

No communication with the tracheo-bronchial tree
Systemic blood supply from the aorta
Large systemic blood supply can cause high-output cardiac failure
Intralobar pulmonary sequestration

Sequestered lobe is contained within normal lobe. Asymptomatic or recurrent pulmonary sepsis, often
in older children. Venous drainage to the pulmonary system, occasionally to the azygous/hemiazygous.
Extralobar pulmonary sequestration

Sequestered lobe has a separate pleural covering. Most common in left lower lobe, often seen on
antenatal ultrasound. Associated with left-sided congenital diaphragmatic hernia (60%). Also seen
with cardiac anomalies, pericardial defect, pectus excavatum, bronchogenic cysts, vertebral
anomalies. May occur below the diaphragm.
Radiology
Require CT or magnetic resonance imaging (MRI) to identify/locate abnormal arterial supply
Management
Thoracotomy and resection, taking care with identification of blood supply (which is often large)
Surgery advocated for risk infection, malignancy
Outcome is related to associated anomalies
13.6 Bronchogenic cyst

Abnormal bronchial budding. Rarely have any communication with the tracheobronchial tree. Some
show early respiratory distress, recurrent pneumonia; confirm diagnosis on CT. Treatment is by
surgical resection (there is a late risk of sarcomatous change).
14. NEONATAL TUMOURS
50% are diagnosed at delivery; a further 30% are diagnosed within a week of birth
A palpable mass is the most common presentation
Malignant tumours are rare, occurring 1 in 27 000 births
Most solid tumours are benign
Teratoma is the most common neoplasm (45% of all tumours)
Neuroblastoma is the most common malignant tumour (1525%)
14.1 Teratoma
Embryonal neoplasm derived from the germ layers (ectoderm, mesoderm, endoderm)
Most common in paraxial or midline location sacrococcygeal (4564%), mediastinal (10%),
gonadal (1035%), retroperitoneal (5%), cervical (5%), presacral (5%)
Solid, cystic or mixed
80% benign, 20% malignant
14.2 Sacrococcygeal teratoma

Incidence of 1 in 20 000 to 40 000 live births
75% female, 25% male
Associated anomalies (18%)
Diagnosis
Antenatal ultrasound imaging, elevated serum -fetoprotein/human -chorionic gonadotrophin
(see below)
Poor prognosis polyhydramnios, placentomegaly, gestational age <30 weeks
Late presentation features of urinary or intestinal obstruction, lower limb neurology or
malignancy
Imaging plain radiograph, MRI, CT
-Fetoprotein
Normally produced by the fetal liver, also by yolk sac tumour elements. Plot serum levels against a
nomogram (levels fall rapidly following birth). Levels should fall to normal following successful
resection. Elevated levels may suggest malignancy. Rising levels indicate recurrence.
-Subunit human chorionic gonadotrophin

From chorionic syncytiotrophoblastic cells (malignant teratoma). Rising levels after surgery suggest
persistent or recurrent tumour.
Complications
Placentomegaly
Hydrops
Cardiac failure
Malpresentation, premature rupture of membranes, cord prolapse, placental abruption, shoulder
dystocia
Massive bleeding
Surgery
Resection (<2 months at latest) may require combined abdominal and perineal approach.
Technically difficult. Requires excision of coccyx
Follow-up with 3-monthly tumour markers, clinical assessment (PR [rectal examination]) further
imaging
Greatest risk of malignant change surgery after 2 months, incomplete excision, immature elements
on histology
15. SPINA BIFIDA

Defects in the fusion of the neural tube, incidence of 1 in 500 to 1 in 2000 live births
Defects of increasing severity spina bifida occulta, meningocele, myelomeningocele, myelocele
Presentation
Less severe defects may not be apparent at birth, cutaneous stigmata (pigmentation anomalies,
excess hair, lipoma, dermal sinus)

Obvious open lesion skin defect, cord may be protected by pia arachnoid, or there may be an
open neural tube defect (exposed neural plate)
Many are associated with central nervous system abnormalities (hydrocephalus)
Assessment
Level of lesion (cervical, thoracic, lumbar, sacral most will be lumbosacral), and size
Neurological deficit motor and sensory level, spontaneous limb movement, posture. Always
begin sensory assessment from abnormal to normal area
Bladder/bowel function appearance and sensation of perineum; rectal prolapse, absent natal cleft
(paralysis of pelvic floor/sphincters)
Hydrocephalus bulging anterior fontanelle, persistent metopic suture, suture diastasis, setting-sun
eyes, frontal bossing, enlarging head circumference (crossing percentile curves) ArnoldChiari
malformation (see below)
Orthopaedic deformities spine (kyphoscoliosis), hips (congenital dislocation), feet (talipes)
Other abnormalities sacral agenesis (partial/complete), cord tethering, renal tract anomalies
(hypospadias, horseshoe kidney, exstrophy), congenital heart disease, anorectal malformation,
craniofacial anomalies
Neurology level
L3 legs totally paralysed

L4/L5 flexed hip, extended knee, no other movement
S1 movement of the hip and knee, foot can dorsiflex but not plantarflex
S2/S3 normal leg movements, still doubly incontinent
Immediate management
Prone positioning (with attention to prevent faecal soiling of exposed neural tissue)
Cover exposed neural tissue with Clingfilm (wrapped around trunk)
Broad-spectrum antibiotics
Intermittent urinary catheterization
Surgery
Formal closure of defect with reconstruction of anatomical layers

Ventricular shunt for hydrocephalus
Delayed orthopaedic procedures may be required
Clean intermittent catheterization bladder augmentation procedures in later life
Outcome
Poor prognosis with severe hydrocephalus, severe kyphosis, thoracolumbar lesions, associated
malformations, poor social support:

Meningitis and ventriculitis (1015%) requires prompt treatment
Hydrocephalus thoracolumbar lesion (95%), lumbosacral (60%)
Ambulation dependent on level of lesion, orthopaedic abnormalities, intellect. Thoracic and
lumbar (few achieve independence), sacral (most), lumbosacral (many can walk with callipers but
may choose a wheelchair for ease)
Lumbosacral: with clean intermittent catheterization, nearly 90% remain continent
Intellectual development: dependent on level, up to 40% have IQ impairment
16. MISCELLANEOUS CONDITIONS

16.1 Antenatal torsion
Presentation
Non-tender, discoloured scrotal swelling, usually unilateral
Differential diagnosis hydrocele, traumatic haematoma (breech delivery), incarcerated inguinal
hernia (associated with a thickened cord), lesion secondary to patent processus vaginalis
(meconium, intraperitoneal bleeding) infection, gonadal neoplasm
Investigations
Abdominal radiograph may be helpful identification of scrotal contents via patent processus
vaginalis (air within a herniated bowel loop), meconium (antenatal intestinal perforation)
Ultrasound distinguish solid from cystic masses. Useful if concerned about a possible tumour
Management
Testis is considered non-viable at the time of presentation
Many surgeons will not remove ischaemic testis but will elect for early fixation of the contralateral
side
16.2 Accessory digit
Extra digits (polydactyly) may be simple or complex

Tags or digit remnants most common, near metacarpophalangeal joint of little finger
No palpable bone in base, attached by a soft tissue stalk (containing digital nerve and vessels)
Requires surgical excision to prevent formation of a painful neuroma
More complex anatomy requires orthopaedic referral for formal amputation
General paediatric surgery
17. HEAD AND NECK SURGERY

17.1 Ranula
A mucus retention cyst of the sublingual salivary gland caused by partial obstruction of the duct
Presents clinically as soft, occasionally tense, clear swelling on the floor of the mouth
Can increase in size after first appearing
Usually symptomless, although they can be painful
Treatment consists of marsupialization of the cyst by incising the cyst wall and suturing the edges
open; thereby draining the obstructed gland. Only very occasionally is excision required
17.2 Lymphatic malformation (cystic hygroma, lymphangioma)

Is a congenital anamoly caused by the failure of connection of part of the lymphatic system during
embryological development
Lymphangioma is a misnomer, because this is not a tumour associated with cell turnover or
proliferation
A lymphatic malformation (LM) in the head and neck is called a cystic hygroma
Location is the only distinguishing feature from LMs in other sites
Present at birth but not always obvious in the neonatal period, and the presentation is often
precipitated by an unrelated infection (e.g. viral upper respiratory tract infection)
Most common sites of occurrence in order of frequency are:
Neck
Axilla
Chest
Abdominal
Can be identified antenatally
Present clinically as a brilliantly transilluminable multicystic swelling
Usually soft
If infected they can become tense, red and painful; occasionally progressing to abscess formation
Can also cause symptoms by exerting pressure on adjacent structures (e.g. dysphagia, stridor,
respiratory compromise)
Includes haemangiomas, lipomas, dermoid cysts and mixed lesions. Lymphangiomas are rarely of a
pure pathology; commonly they are combined with vascular or fatty elements
Ultrasound used to confirm the diagnosis and assist with identification of macrocystic and
microcystic varieties
Occasionally a CT scan is required to define extent large lesion and anatomic relationships
Treatment options
Conservative management has become the aim commonly after initial presentation and increase in
size these lesions undergo involution; this is also common after infection
Sclerotherapy the most common agent is OK-432, which is a Streptococcus-derived antigen. It is
more successful in predominantly macrocystic lesions. Causes an acute inflammatory reaction
(with acute swelling and symptoms) that causes involution but may have an adverse, temporary
effect on contiguous structures (e.g. stridor)
Surgical excision is sometimes required for larger lesions or those that do not respond to other
modalities of treatment
17.3 Thyroglossal cyst

Thyroid gland develops as a diverticulum at the foramen caecum and descends to its cervical
location in fetal life. Path is marked by the thyroglossal tract. Persistence of part or the entire tract
leads to thyroglossal duct and cyst
Presents as a midline swelling between the tongue and infra-hyoid region. Moves with swallowing
and protrusion of the tongue, although this sign is relatively insensitive
Ultrasound is indicated to identify a normal thyroid gland, and to confirm the diagnosis
Surgical excision includes excision of the cyst, along with the tract (and central portion of the hyoid
bone), all the way to the base of the tongue
17.4 Preauricular pits
Ectodermal inclusions that occur during formation of the auricles of the ear
Shallow, blind-ending pits which end in the subcutaneous tissues
Present at birth and often bilateral
Can become infected and surgical excision is sometimes recommended
17.5 Branchial arch remnants

In weeks 48 of fetal life the cervicofacial region is occupied by four branchial arches with
corresponding pharyngeal pouches with intervening clefts. Persistence or abnormal development
leads to branchial fistulas, sinuses and cysts (least common)

First, third and fourth branchial anomalies are all rare
Second branchial arch fistulas and sinuses are common and are found along the anterior border of
the sternocleidomastoid, usually at the junction of the middle and lower thirds. The tract ascends
between the bifurcation of the carotid artery to the tonsillar fossa

Most common cause of neck swelling over 2 years of age
Usually ascribed to viral infection but can also be secondary to bacterial infections in and around
the head and neck
Nodes of the anterior cervical chain are more commonly affected
Enlargement is usually self-limiting
In toxic children, intravenous antibiotics may be required. Penicillin and flucloxacillin are used to
cover staphylococcal and streptococcal infections
If the infection is not well contained, suppuration and abscess formation supervene. The node is
then tender and fluctuant with overlying redness of the skin. Ultrasound is useful in identifying pus
in the centre if there is uncertainty. Incision and drainage are required
Enlarged lymph nodes may be the result of tuberculous or atypical mycobacterial infection
Cat scratch disease can also present with chronic enlargement. There may not be a memory of the
implicating scratch, which precedes the lymphadenopathy by 34 weeks
Lymphoma may present with enlarged lymph nodes. Abnormal nodes and those that persist for more
than 3 months (without an obvious cause) should be biopsied
17.7 Haemangiomas and vascular malformations

Haemangiomas are vascular tumours that exhibit endothelial hyperplasia (defined by the suffix
angioma)
Present in 2% of newborns; the incidence increases to 10% at 5 years
Several growth factors are thought to be involved in pathogenesis; lead to proliferation of the
vascular tissues in the first months of life, with an increase in the size of the lesion
Many subsequently regress spontaneously
Arteriovenous malformations are always present at birth but may not be evident. Unlike
haemangiomas they have no propensity for regression
A bruit may be evident
Visible lesions may be disfiguring
Complications ulceration, infection, necrosis, bleeding
Haemolysis and activation of the coagulative system may occur with large lesions
Symptoms particular to location may occur (gastrointestinal/pulmonary bleeding, obstruction)
High-output cardiac failure may occur with large arteriovenous malformations that cause a
significant steal
Investigations
Usually include an ultrasound to confirm the diagnosis and extent of the lesion, with Doppler
assessment of flow characteristics
MR or CT scans may be required for lesions in some sites
Angiography may assist in the anatomical definition of arteriovenous malformations
Treatment
Haemangiomas
Conservative management is the mainstay of management of asymptomatic heamangiomas; vascular
malformations that cause no symptoms can also be treated conservatively
Compression therapy can be used for accessible lesions and may accelerate involution of
haemangiomas
Laser therapy used for some superficial lesions that are disfiguring
Embolization/sclerotherapy used for symptomatic lesions multiple treatments may be required
Interferon- shown by some series to be of benefit in haemangiomas that are resistant to other
modalities of treatment. Treatment is required over a few months. Chemotherapy (vincristine,
cyclophosphamide) is sometimes used
Propranolol, the newest treatment option in the management of haemangiomas. It seems particularly
useful in haemangiomas in and around the airway, where it may be the first-line management in
those requiring treatment, and replace complicated surgery
Surgical excision used for lesions that give rise to complications and do not respond to
conservative or other modalities of treatment
Vascular malformations
Sclerotherapy (as for lymphatic malformation see above)
Embolization of large feeding vessels
Surgical excision
17.8 Central venous access

Surgical implantation of a venous access device into a central vein
Venous access device can be either of an externally accessible line (e.g. Hickman no need for
skin penetration and therefore more applicable in younger more needle phobic patient) or
implantable (subcutaneous) type (portacath less likely to dislodge, lower infection rate)
The central veins most commonly used for access in decreasing order of frequency are:
Internal jugular
External jugular
Subclavian
Femoral
Other (e.g. azygous)
Indication
Need for long-term central access for intravenous nutrition (intestinal failure)
Central venous access for chemotherapy (oncology/haematology)
Long-term access for antibiotics or long-term intravenous therapy (e.g. cystic fibrosis, inborn
errors of metabolism, osteogenesis imperfecta)
Need for repeated blood sampling in monitoring or managing disease
Procedure
Can be percutaneous or open
Percutaneous ultrasound-guided access to vein using a Seldinger technique to insert catheter
(advantages: less invasive, less trauma to vein, can re-use veins more often; disadvantages: need
for ultrasonography, unsuitable for deeper veins)
Open cut-down on to vein with direct insertion into vein of choice (advantages: direct
visualization of vein, can be used in smaller children; disadvantages: trauma to veins, possibly
higher infection rate)
Complications
Dislodgement
Line infection
Bleeding/haemothorax
Pneumothorax
Leakage or line breaking
Blockage
Thrombosis (in line or vein itself)
Migration, with cardiac effects (ectopics) if distal migration or access failure if proximal migration
Cardiac tamponade
18. THORACIC SURGERY

18.1 Congenital malformations
Some congenital lesions that are not detected in the antenatal period, and that do not cause
symptoms in the neonatal period, can present in childhood. They often present with recurrent chest
infections and coughing
Congenital diaphragmatic hernia (see Section 12) may remain undetected until a chest infection
supervenes and is detected on chest radiograph. This is especially true for anterior hernias (of
Morgagni)
Eventration of the diaphragm defined as elevation of the hemidiaphragm that results from
paucity of muscle in the absence of a defect. The differential diagnosis is a phrenic nerve palsy.
Eventration can sometimes present in infancy and childhood as repeated chest infections or failure
to recover from a relatively minor chest infection, or an accidental finding
Pulmonary sequestrations, congenital cystic adenomatoid malformation and congenital lobar
cysts may present outside the neonatal period, although they are increasingly being diagnosed
antenatally. Symptomatic lesions are surgically treated after resolution of any acute complications
18.2 Chest wall deformities

Pectus excavatum and pectus carinatum
Pectus excavatum (funnel chest) is more common than pectus carinatum (pigeon chest). Both are
three times more common in boys compared with girls
Aetiology of these conditions is unknown. Some form of growth disturbance in the costochondral
junction is thought to exist, giving rise to depression (excavatum) or protrusion (carinatum) of the
sternum
Associated with congenital abdominal wall defects (congenital diaphragmatic hernia)
Can by asymmetrical or unilateral
Family history in some index cases
Pectus excavatum can be seen in connective tissue diseases such as Marfan and EhlersDanlos
syndromes; a thorough physical examination for the stigmata of these should be carried out
Majority of patients with pectus excavatum have some deformity from birth; only 30% of patients
with pectus carinatum have any abnormality at birth
Can be a worsening of the deformity during growth spurts such as puberty
Most children present because they or their parents are concerned about their appearance.
Sometimes this is severe enough to prevent older children and teenagers from participating in
sports and other activities that cause embarrassment
No significant effect of either condition on cardiorespiratory function. Although there was much
speculation of decreased cardiorespiratory reserve in severely affected children, this has not been
substantiated in studies
Treatment:
Most cases can be managed by reassurance; muscle and breast development mitigate the
appearance
Indication for surgical intervention should be critically scrutinized
Surgical correction has involved highly invasive procedures that resect the costal cartilages,
invert the sternum with placement of metal rods or bars to correct the deformity
A minimally invasive approach is possible and has made surgeons reconsider the indications for
surgery
Poland syndrome
Unknown aetiology
Characterized by hypoplasia or aplasia of the pectoralis major muscle and one or more of the
following: hypoplasia or aplasia of the breast or nipple, aplasia of ribs, or
syndactyly/bradydactyly
Sternal clefts
Occur in isolation or associated with other syndromes, the most common being pentalogy of
Cantrell (sternal cleft, omphalocele, pericardial and cardiac defects, and diaphragmatic hernia)
18.3 Oesophageal foreign bodies

Children swallow a multitude of foreign bodies. Coins are the most common but the list includes
pins, needles, hairclips and small toys. Most of these items traverse the gastrointestinal tract
without any difficulties. Unwitnessed ingestion can come to light because of symptoms, including
choking, coughing, vomiting and regurgitation
If the object fails to get into the duodenum the likeliest site of impaction is at the level of
cricopharyngeus, followed by the aortic and left main bronchus impressions on the oesophagus, the
gastro-oesophageal junction and the pylorus
If the development of symptoms prompts investigation, radio-opaque objects can be seen on
radiograph
In the absence of drooling, a period of observation while allowing fizzy drinks can be tried and
patient reassessed over 4-6 h to see if it passes easily
However, disc batteries cause chemical injury and should be removed immediately if stuck. If
recognized as such on history or radiograph, should be expedited
Chronic hair or fibre (e.g. carpet) ingestion has occasionally lead to trichobezoars that require
laparotomy
Rigid (more versatile) or flexible endoscopy is used for retrieval. Occasionally oesphagotomy is
required for chronic or embedded lesions
18.4 Caustic ingestion

Caustic damage can occur through ingestion of common household products by exploring toddlers
Alkali ingestion more commonly affects the oesophagus, whereas acid ingestion more often affects
the stomach
Oesophagus can be severely affected without any obvious injury
Emergency management (National Poisons Unit):
ABCs (i.e. airway, breathing, circulation)
Steroids have been shown to have no benefit in trials
Endoscopy within the first 24 h to assess injury
Patients can then be observed for symptoms of stricture formation and other complications
including:
Perforation
Mediastinitis
Fistulae formation
Caustic ingestion can therefore have devastating consequences. Major palliation or reconstructive
surgery may be necessary
18.5 Parapneumonic effusions
A transudate into the pleural space during the course of a pneumonic infection
Empyema is defined as pus in the pleural space, an infected parapneumonic effusion
Sometimes clinically difficult to distinguish between these two entities in the child who does not
recover from pneumonia and has signs of an effusion. Continued pyrexia can be caused by the
original disease in the former, or pleural pus in the latter. In either case culture of the fluid is
usually negative
Pressure effects of the fluid, pulmonary consolidation and thickening of the pleura can all limit
chest expansion and deter recovery
Ultrasound is helpful in defining the depth of the effusion, in identifying the presence of loculations
and any pleural thickening, and in visualizing the presence of debris in the fluid to suggest pus
Drainage is indicated by failure to resolve with adequate (albeit presumptive) antibiotic therapy.
Tube thoracoscopy is usually coupled with suction (35 kPa)
Fibrinolytic therapy with urokinase is used if ultrasound shows marked debris or loculations
All patients require aggressive physiotherapy
Chest tube is removed when drainage is 50 ml/day (usually on days 35)
Video-assisted thoracoscopic surgery is an alternative to, or adjunct to, tube drainage alone. It
allows drainage of the pleural space and breaking down of any loculations and decortication in
advanced cases
Surgery (including thoracotomy for decortication) is also required when the lung fails to re-expand
after tube therapy, but has had a much diminished role since the advance of fibrinolytics
Postoperative recovery can be assessed by the return of normal flow patterns on respiratory
function tests in the outpatients
19. GASTROINTESTINAL SURGERY

19.1 Abdominal wall herniae
Umbilical herniae
Umbilicus develops by closure of the cicatrix after the cord thromboses. The cicatrix closes by
fibrosis, probably aided by abdominal wall muscle contraction. Complete closure can take until
year 5 of age
Herniae present as a bulge through a circular defect in the centre of the cicatrix
Usually symptomless, but rarely a cause of abdominal pain
Cosmetic concerns (or teasing) are the main indications for surgery
Surgical correction consists of repair of the defect with strong mattress sutures. This may be
delayed until after the fifth birthday
Supraumbilical hernia
Less common than umbilical hernia
Defect is sited above the cicatrix, therefore elliptical and points downwards
Do not resolve and therefore require surgical closure
Epigastric hernia
Present as intermittent swellings usually midway between the umbilicus and the xiphisternum
Although present from birth, usually present in school-age children, often when the child complains
of incidental (non-related) abdominal pain (although mild pain can be caused by strangulation of
fat in the defect, this is rare)
The defect is often difficult to define
Surgical correction is elective because these hernias are asymptomatic and cause no problems
Inguinal hernia
A congenital abnormality caused by persistence of the patent processus vaginalis, a peritoneal tube
along the path of testicular descent into the scrotum
Incidence in general population is 12%; 10 times more common in boys and in preterm infants
Rare association of inguinal hernia in girls with complete androgen insensitivity syndrome; girls
presenting with inguinal hernia should have their chromosomes checked
Present as intermittent swellings in groin which may reach the scrotum
1020% of boys have a metachronous hernia after index presentation
Irreducibility for prolonged periods can lead to obstruction (abdominal pain, distension and
vomiting) and eventually strangulation (hard, tender swelling)
Elective repair advised
Patients who present with an irreducible hernia require hernia reduction and delayed repair after
the resultant oedema has settled; this generally involves a 24- to 48-h hospitalization and repair
before discharge
Repair consists of reduction of the contents of the hernia, and ligation of the patent processus
through a groin incision or a laparoscopic repair
Hydroceles
Identical to inguinal hernia in aetiology
Usually present as symptomless fluid-filled swellings of the scrotum that are transilluminable, and
are variably reducible
Occasionally present as tense swellings during an acute illness
Unusual variety is a hydrocele confined to a portion of the cord only (encysted hydrocele)
Most hydroceles (unlike hernias) resolve without surgery in the first few years of life. Surgery is
indicated if they fail to resolve
19.2 Pyloric stenosis

A condition of unknown aetiology characterized by hypertrophy of the pyloric muscle, resulting in
gastric outlet obstruction
Occurs in 1 in 5001000 live births, with a male:female ratio of 4:1
Strong family history in some cases
Presentation is that of repeated, progressive, non-bilious, often forceful (typically projectile)

vomiting; most commonly in weeks 46 after birth:
Weight loss and dehydration common at presentation
Pathognomonic sign is a palpable tumour (olive) in the right upper quadrant
May be visible peristalsis
Ultrasound to confirm the diagnosis only if a mass is not palpable:
Dimensions positive for pyloric stenosis wall thickness >4 mm, length >17 mm and diameter
>15 mm (younger or preterm infants may have smaller measurements)
Vomiting of stomach contents with gastric acid leads to a hypokalaemic, hypochloraemic, metabolic
alkalosis
Paradoxical aciduria in late stages
Preoperative preparation is aimed at correcting these abnormalities:
Acute administration of 0.9% saline (1020 ml/kg) is used for resuscitation
Fluid is prescribed at 150 ml/kg per day of 0.45% saline with KCl
When plasma bicarbonate is <25 mmol/l, correction is adequate, and anaesthesia is safe
Surgical correction can be performed through a right upper quadrant incision, a paraumbilical
incision or laparoscopically
The thickened muscle is divided along its entire length down to, but not breaching, the mucosa
Postoperative feeds are generally given after 612 h and most patients are discharged within 2448
h after surgery
19.3 Gastrostomy
Temporary or permanent insertion of tube into stomach
Gastrostomies can be either of a button type (e.g. MicKey or Mini) or tube types (e.g. MIC tube or
percutaneous endoscopic gastrostomy PEG)
The method if fixation to the stomach can be of either a balloon (e.g. MicKey or Mini) or a flange
(e.g. PEGs), or sutured to the stomach wall (Stamm)
Indications can be broadly divided into:
Patients unable to have any oral intake due to anatomical or physiological abnormalities
Patients requiring hyperalimentation of oral feeding to allow growth which cannot be expected to
be achieved with oral intake only
Patients requiring particularly unpalatable feed supplementation
The main types of procedures:
PEG: the gastrostomy is inserted via stab incision in the abdominal wall under vision from the
inside the stomach using an endoscope
Button gastrostomy can either be primarily done laparoscopically or endoscopically
A Stamm gastrostomy is a type of open gastrostomy in which a double purse-string suture on the
stomach is used to fix the gastrostomy tube in place
Complications
Infection, granulation tissue

Leakage
Blockage
Skin excoriation secondary to acid leakage
Separation and intraperitoneal leakage with resulting peritonitis
Unmasking of gastro-oesophageal reflux
19.4 Gastro-oesophageal reflux disease

Gastro-oesophageal reflux (GOR) is defined as involuntary (passive) reflux of gastric contents into
the oesophagus not caused by noxious stimuli. Gastro-oesophageal reflux disease (GORD) is
defined as symptoms and complications arising from GOR
GOR is present in many newborns, in whom it does not necessarily prepresent a clinical disease,
but rather a somewhat delayed physiological development
GORD is more common in neurologically impaired children and those with neuromuscular disease.
Gastrointestinal anomilies associated with a high incidene are: oesophageal atresia, congenital
diaphragmatic hernia and abdominal wall defects
Vomiting is the most common symptom of GOR in an infant, and is usually non-bilious and
effortless
Apnoeas and bradycardias are frequent presenting features in neonates and infants. In some infants,
these symptoms may progress to acute life-threatening events (ALTEs). ALTEs are acute
respiratory events characterized by apnoeas, bradycardias and acute respiratory distress, and
sometimes respiratory arrest
Excessive vomiting can lead to failure to thrive. Haematemesis is an uncommon presenting feature,
but may be present. Older children may be able to describe the typical heartburn associated with
GORD. This retrosternal pain may be associated with a bitter taste in the mouth. Respiratory
symptoms of wheezing and recurrent pneumonias are uncommon but recognized features
Sandifer syndrome is a constellation of abnormal posture (especially back arching) due to muscular
spasm involving the back and neck muscles associated with reflux
Investigations
Investigation consists of a combination of three main investigative tools (pH study, contrast study
and upper GI endoscopy). The choice of first-line investigation is based on a combination of
availability, expertise and symptoms
A 24-h pH study is considered by most as the gold standard investigation. A multi-channel
impedance study can be combined with the pH study, and may become the platinum standard
investigation
Radio-isotope gastric emptying scan (milk scan) can be used to assess gastric emptying reflux
aspiration
Bronchoscopy and bronchoalveolar lavage is sometimes used to detect lipid-laden macrophages as
evidence of aspiration from reflux in those with respiratory symptoms
Oesophageal manometry studies may be indicated in those cases of reflux stricture that cannot be
distinguished from achalasia
Treatment
Conservative management initially
Feed thickening has been shown to reduce the clinical symptoms associated with GOR. Thickening
agents such as alginate (Gaviscon) and pectin are gelling agents that can be added to milk feeds and
result in a thickened feed that remains in the stomach easier than liquid feeds
Pre-thickened milk feeds (e.g. Enfamil AR) contain an easy-to-digest rice starch that thickens in the
stomach and is successful in helping reduce symptoms in some children
Changes in posturing immediately postprandially have been shown to decrease GORD both
clinically and experimentally. The upright position is optimal in the postprandial period
Changes in feeding pattern can be used to achieve a regimen that minimizes symptoms. Smaller
volumes and more frequent feeds may help
Gastrointestinal prokinetics (e.g. domperidone and erythromycin) are used to promote gastric
emptying, reduce episodes of GOR and improve symptoms
Nasojejunal feeding is an alternative to surgical intervention
Indications for surgical intervention
ALTE
Hiatus hernia (GORD will not resolve with medical management)
Recurrent aspiration and pneumonias
Stricture
Failure of, or need for, continued maximum medical management (decreases the need for long-term
medical management, particularly in neurologically normal children)
Barrett oesophagus (relative indication)
Operation
Fundoplication for GORD aims to address/augment the main contributing factors preventing reflux
and to reverse any pathology present
Fundoplication involves wrapping the fundus of the stomach around the lower intra-abdominal
oesophagus
Doppler assessment can identify blood flow, or lack of it, in the bowel wall
Air enema under radiological control is used to reduce the intussusceptions with a success rate of
around 85%; contraindicated if there are signs of perforation
Surgical management is indicated for signs of peritonitis, perforation or a failed air enema
Telescoping of one part of the intestine into the other
Peak incidence between 4 months and 1 year

Most cases are idiopathic ileocolic intussusception; enlarged Peyer patches are believed to be
causative in most of these cases
In 510% there is a pathological lead point Meckel diverticulum, duplication cyst, polyp,
haemangioma or a bleeding point in HenochSchnlein purpura; may present with recurrent
intussusception
A lymphomatous deposit in the bowel wall can act as a lead point
Classic triad of symptoms (but not present in all patients):
Abdominal pain (and drawing up of legs)
Bleeding per rectum (red currant jelly stools)
Palpable mass
Vomiting, constipation or diarrhoea may be present and may predate the occurrence of
intussusception and cause diagnostic difficulty
Complete obstruction may be present, but is usually late in the presentation
Patients can present in extremis, with signs of shock and sepsis
Management careful attention to primary resuscitation and fluid management; this can be the most
important aspect of management:
Children can need up to and beyond 40 ml/kg fluid resuscitation
Triple antibiotics should be started when the diagnosis is suspected
Nasogastric decompression required if there are signs of obstruction
Plain abdominal film may reveal signs of established obstruction and a soft tissue mass may be
seen
Ultrasound scan confirms diagnosis, with the appearance of the typical target leasion of the
telescoping bowel
19.6 Appendicitis
Acute appendicitis is one of the most common paediatric surgical emergencies
Incidence increases with increasing age, but sometimes seen in children aged as young as 2 years
Presentation in the younger child can be atypical and the diagnosis difficult, resulting in later
presentation in these children, with a higher proportion presenting with complicated appendicitis
(mass or abscess formation)
Typical history is of colicky central abdominal pain shifting to right iliac fossa, followed by
vomiting that is usually non-bilious
Characterized by low-grade fever and mild tachycardia; may be fetor
Localized tenderness in the right iliac fossa; localized percussion tenderness may also be present
Advanced cases may be septic, with hypovolaemia and marked fever
May be overt peritonitis to suggest perforation
History in atypical cases may mimic urinary tract infection, with dysuria, frequency and fever
Diarrhoea may be the prominent symptom, especially with a pelvic appendix
Differential diagnoses
Gastroenteritis
Mesenteric adenitis
Ovarian pathology (Mittelschmerz, ruptured follicular cyst)
Pancreatitis
Meckel diverticulitis
Viral illness
Respiratory tract infection
Investigations
Urinalysis to rule out urinary tract infection urgent microscopy if urinalysis is positive, as a
pelvic appendix can give rise to white cells in the urine
In straightforward cases no other investigation required. Raised white blood cells and elevated Creactive protein are often present, but are not specific or sensitive
Ultrasound scan can confirm the diagnosis in some cases that are not clear cut. Particularly useful in
the pubertal female. The typical finding is a dilated, non-compressible appendix. There may be
some free fluid in the right iliac fossa. However, a negative ultrasound scan does not rule out
appendicitis
Repeated examination and careful observation are the most useful tools in doubtful cases
Management
Appendicectomy should be performed as soon as possible by traditional right iliac fossa incision
or laparoscopically
One dose of preoperative antibiotics is given; the postoperative antibiotic regimen will be dictated
by the surgical findings

A congenital remnant of the vitellointestinal duct, which is a connection between the embryonic
gastrointestinal tract and the yolk sac; persistence of part of this tract results in a vitellointestinal
band, cyst, tract or a Meckel diverticulum
Meckel diverticulum contains all layers of the abdominal wall, and often contains ectopic gastric or
pancreatic mucosa
Classically found 60 cm from the ileocaecal valve, is 5 cm long and has an incidence of 2% in the
general population
Clinical presentation depends on resulting complications:
Intussusception can occur with the diverticulum acting as the lead point
Bleeding can occur as a result of ulceration secondary to acid secretion in the ectopic gastric
mucosa. Melaena results, with fresh blood per rectum in cases with massive bleeding.
Haematemesis is sometimes present
Meckel diverticulitis with/without perforation results from inflammation of the mucosa. Signs
and symptoms can often mimic appendicitis
Intestinal obstruction can result from volvulus around the vitellointestinal band, herniation of
small bowel beneath the band or intussusception
May be an incidental finding
Investigations are dictated by the clinical presentation, and can include full blood count, clotting
screen and an abdominal ultrasound which can sometimes identify a Meckel diverticulum or cysts.
A Meckel scan (using 99mTc) relies on the uptake in ectopic gastric mucosa, but gives a falsenegative result in up to 25% of patients
Laparoscopy is sometimes required as an investigative tool
Treatment consists of resection of the diverticulum
Treatment of incidentally found lesions is debated; some advocate excision
19.8 Undescended testis

Defined as undescended if it is not able to be brought down into the scrotum; divided into palpable
and non-palpable
Ectopic testis one that is palpable but located outside the line of normal descent (superficial
inguinal pouch, perineum)
Retractile testis one that can be manipulated into the scrotum and remains there, albeit briefly;
these require no surgical intervention
Incidence of retractile testis at birth varies with gestational age:
At term the incidence is 25%; at 30 weeks gestation it is 2050%
Testicular descent can occur after birth
Overall incidence is 1% at 1 year of age. Thereafter descent is unlikely to occur. As a result of the
inherent risks (torsion, trauma, tumour and impaired spermatogenesis) undescended testes are fixed
in the scrotum
If testis is palpable, the inguinal canal is explored and the testis placed in the scrotum
Boys with non-palpable testis undergo laparoscopy in an attempt to locate the testis. Occasionally
the operation is performed in two stages
19.9 Testicular torsion

Testicular torsion is a surgical emergency
Presentation is with acute testicular pain may be referred to the groin or abdomen
There is usually some swelling at presentation; a secondary hydrocele may be present. The
hemiscrotum may be erythematous in advanced cases. On examination the testis is swollen and
tender
Differential diagnosis and key points:
Epidydimo-orchitis difficult to differentiate, may have positive urinalysis
Torsion of hydatid of Morgagni may be difficult to differentiate; localized tenderness with blue
dot sign on superior pole
Acute enlargement of a hydrocele unable to feel testis through fluid; may have an intercurrent
viral illness
Idiopathic scrotal oedema erythema and oedema affecting the skin of the scrotum (often
bilateral), which extend on to the perineum and inguinal region; testes are non-tender, otherwise the
diagnosis is not entertained
Investigations:
Urinalysis and/or midstream urine should be performed to rule out infection
Doppler ultrasound of the testis is sometimes obtained, but is seldom helpful in doubtful cases;
the torsion may also be intermittent. Awaiting non-helpful ultrasonography can delay intervention
Emergency surgical exploration is required to confirm the diagnosis and save the testis
19.10 Phimosis
Defined as narrowing of the preputial ring that prevents retraction of the foreskin. At birth the
foreskin is usually non-retractile (physiological); this regresses with age
Percentage of boys with retractile foreskin by age: newborn infants, 4%; 1-year-old boys, 50%; 4year-old boys, 90%
Voiding with ballooning of the prepuce is the most common reason for referral, but is a normal
occurrence with physiological phimosis
Recurrent mild ammoniacal irritation of the tip of the foreskin may also occur, but responds to
simple hygienic care
Physiological phimosis is not an indication for circumcision
Pathological phimosis is most commonly the result of balanitis xerotica obliterans. In this
condition, equivalent to lichen sclerosis atrophicus, the foreskin is thickened, inflamed, scarred
and unyielding. Often a sclerotic thickened white scar replaces the supple foreskin. Circumcision
is performed in these cases
Associated or eventual urethral meatal stenosis must be looked for in these boys
Pathological phimosis may rarely be secondary to repeated attacks of infection that cause scarring
Usual infecting organism is Staphylococcus sp. Flucloxacillin or co-amoxiclav is usually
therapeutic
Chronic inflammation may lead to a rigid, fibrous foreskin
19.11 Hypospadias
Hypospadias is an abnormality in which the urethral meatus is situated proximal to the tip of the
penis on its ventral aspect
Anatomically it is described by the position on the meatus as:
Glanular
Coronal
Penile
Penoscrotal
Perineal
Along with the abnormality of the position of the meatus there is often a degree of deficient ventral
development, resulting in curvature of the penis (chordee)
A hooded foreskin is also evidence of a ventral deficiency in penile development
Incidence is around 1:300 live births

Aetiology unknown in most cases seen in conditions associated with deficient testosterone
secretion or responsiveness (disorders of sexual differentiation)
Hypospadias with undescended testis should be investigated as potential cases of disorders of
sexual differentiation
Severe forms of hypospadias (e.g. penoscrotal and perineal) are associated with renal tract (and
occasionally other systems) anomalies
Surgical correction includes correction of any chordee, tubularization of appropriate tissue to
create a new urethra and skin cover. Tissues used to create the urethra include:
Native urethral plate
Preputial skin (hence circumcision is contraindicated in patients with hypospadias)
Buccal or bladder mucosa
Postoperative complications include infection, wound dehiscence, meatal stenosis and fistula
formation
20. FURTHER READING

Arensman R, Bambini DA, Almond PS (2000). Pediatric Surgery (Vademecum). Georgetown, TX:
Landes Bioscience.
Ashcraft KW (2000). Pediatric Surgery, 3rd edn. Philadelphia: WB Saunders Co.
Burge DM, Griffiths DM, Steinbrecher HA, Wheeler RA (2005). Paediatric Surgery, 2nd edn.
London: Edward Arnold Ltd.
Coran A, Pierro A, Geiger J, Spitz L (2007)
Operative Pediatric Surgery, 6th edn. London: Hodder Arnold.
Hutson JM (1988). The Surgical Examination of Children. Oxford: Butterworth-Heinemann Ltd.
Nakayama DK et al. (1997). Critical Care of the Surgical Newborn. Oxford: Blackwell.
Stringer M, Oldham K, Moriquand P, Edward H (2006). Paediatric Surgery and Urology: Long term
outcomes. 2nd edn. Cambridge: Cambridge University Press.
Picture Permissions
The publisher would like to acknowledge the following image sources:

The following figures are reproduced from the BMJ Books publication Advanced Paediatric Life
Support: The Practical Approach 4th edition, The Advanced Life Support Group, 2004.
Infant choking protocolit, page 156
Pathophysiology of drowning, page 170
Hepatology
The following figures are reproduced from BC Decker publication Paediatric Gastrointestinal
Disease 4th edition, Walker, W. Allen et al., 2004.
The two models of hepatic organization, page 343
The three variants of biliary atresia, page 351
Nephrology
The following figures are reproduced from the Blackwell publication The British Journal of
Urology, Vol 81, supplement 2, April 1988, pp. 3338.
Creatinine clearance in the human fetus and newborn infant, page 529
Factional sodium excretion in the human fetus and newborn infant, page 530
The following figure is reproduced from the Blackwell publication Clinical Paediatric Physiology,
Godfrey, S., Baum, J.D., 1979.
Tubular function, page 532
The following figure is reproduced from the Lippincott Williams and Wilkins publication Pediatric
Nephrology 3rd edition, Holliday, M.A., Barrat T.M., Avner D.E., 1994.
Renal tubular acidosis, page 546
The following figure is reproduced from the American Society of Pediatrics publication Pediatrics,
Vol 67, page 396, 1981.
Grading of vesicoureteric reflux, page 558

Every effort has been made to contact holders of copyright to obtain permissions to reproduce
copyright material. However, if any have been inadvertently overlooked, the publisher will be
pleased to make the necessary arrangements at the first opportunity.
Index
abacavir ref 1
ABCDE approach ref 1
abdominal pain ref 1
functional ref 1
non-organic ref 1
recurrent ref 1
abetalipoproteinaemia ref 1, ref 2
ablepharon ref 1
ABO system ref 1
abortion ref 1
Abortion Act 1967 ref 1
absolute risk reduction ref 1
absorption ref 1, ref 2
acanthosis nigricans ref 1
accessory digit ref 1
accident prevention ref 1
acetylation status ref 1
achalasia ref 1
achondroplasia ref 1, ref 2
aciclovir ref 1
acid-base status ref 1
acne ref 1
neonatal ref 1
acquired immune deficiency syndrome ref 1
acrocentric chromosomes ref 1
acrodermatitis enteropathica ref 1
acute chest syndrome ref 1
acute kidney injury ref 1
acylcarnitines ref 1
adaptive immunity ref 1
Addison disease ref 1, ref 2
adenosine cyclic monophosphate (cAMP) ref 1
adenotonsillar hypertrophy ref 1
adenovirus ref 1
Adie syndrome ref 1

adoption ref 1
adrenal gland ref 1
anatomy ref 1
androgens ref 1
cortex ref 1
disorders of
Addison disease ref 1
phaeochromocytoma ref 1
glucocorticoids ref 1
mineralocorticoids ref 1
adrenal hyperplasia ref 1
adrenal insufficiency ref 1, ref 2
adrenal steroid excess ref 1
adrenaline ref 1
adrenarche ref 1
adrenocorticotrophic hormone (ACTH) ref 1
adverse drug reactions ref 1
agenesis of corpus callosum ref 1
airway ref 1
choking ref 1
inadequate protection ref 1
nasal ref 1
obstruction ref 1, ref 2
opening procedures ref 1
oral ref 1
Alagille syndrome ref 1, ref 2, ref 3
albinism ref 1
albumin ref 1
alcohol ref 1
Alexander syndrome ref 1
alkaline phosphatase ref 1
alkalosis ref 1
allergic conjunctivitis ref 1
allergic rhinitis ref 1
alloimmune neonatal thrombocytopenia ref 1
alopecia ref 1
scarring ref 1
alopecia areata ref 1, ref 2
Alpers disease ref 1
1-antitrypsin deficiency ref 1, ref 2
Alport syndrome ref 1
aluminium, abnormalities ref 1
alveolar proteinosis ref 1
ambiguous genitalia ref 1, ref 2
see also intersex disorders

amblyopia ref 1
amenorrhoea ref 1
amino acid disorders ref 1
amino acid metabolism disorders ref 1
homocystinuria ref 1
maple syrup urine diseas ref 1
non-ketotic hyperglycinaemia ref 1
phenylketonuria ref 1
tyrosinaemia ref 1
amino acids ref 1
aminotransferases ref 1
ammonia ref 1
amniotic bands ref 1
amniotic fluid ref 1
amoebiasis ref 1
ampicillin ref 1
amputation ref 1
anaemia ref 1, ref 2, ref 3
aplastic ref 1
haemoglobin defects ref 1
hereditary haemolytic ref 1
iron deficiency ref 1
analysis of variance (ANOVA) ref 1
anaphylaxis ref 1
food-induced ref 1
anencephaly ref 1
aneuploid ref 1
Angelman syndrome ref 1, ref 2
angio-oedema, hereditary ref 1
anion gap ref 1
aniridia ref 1
anisocoria ref 1
anisometropia ref 1
ankyloblepharon ref 1
anorectal atresia ref 1
anorectal malformations ref 1
anorexia nervosa ref 1
antenatal torsion ref 1
anterior horn cell disease ref 1
anterior wall defects ref 1
anthrax ref 1
anti-NMDA receptor encephalitis ref 1
anti-thymocyte globulin ref 1
antiarrhythmics ref 1
antibiotics ref 1
antibodies ref 1
deficiencies ref 1
anticoagulants ref 1
natural ref 1
anticonvulsants ref 1
antigen presentation ref 1
antigen recognition ref 1
antigen-presenting cells ref 1
antihistamines ref 1
antral gastritis ref 1
aortic arch, interruption of ref 1
aortic coarctation see coarctation of aorta
aortic stenosis ref 1, ref 2
critical ref 1
aortopulmonary window ref 1
Apert syndrome ref 1
aphakia ref 1
aplastic anaemia ref 1
aplastic crisis ref 1
apnoea ref 1
appendicitis ref 1
appraisal ref 1
aqueduct stenosis ref 1
arginine vasopressin ref 1
arrhythmias see cardiac arrhythmias
arterial duct ligation ref 1
arterial occlusion ref 1
arterial pulse volume ref 1
arthritis
enthesitis related ref 1
infectious ref 1
inflammatory bowel disease-related ref 1
juvenile idiopathic ref 1
juvenile psoriatic ref 1
oligoarticular ref 1
polyarticular ref 1
reactive ref 1
septic ref 1, ref 2
systemic onset ref 1
arthrogryposis multiplex congenita ref 1
ascites ref 1
Asperger syndrome ref 1, ref 2
aspergillosis ref 1
asphyxiating thoracic dystrophy ref 1
aspirin ref 1
overdose ref 1
asplenia ref 1
asplenia syndrome ref 1
asthma ref 1, ref 2
acute attack ref 1
drug treatment ref 1
pathophysiology ref 1
astigmatism ref 1
astrocytoma ref 1, ref 2, ref 3
asystole ref 1
ataxia telangiectasia ref 1, ref 2, ref 3, ref 4
atazanavir ref 1
atrial arrangement ref 1
atrial isomerism ref 1
atrial septal defect ref 1, ref 2
atrial situs ref 1
atrioventricular connection ref 1
atrioventricular septal defect ref 1
complete ref 1
attention-deficit hyperactivity disorder ref 1, ref 2
audiogram ref 1
audiometry
sweep ref 1
visual reinforced ref 1
audit ref 1
auditory brainstem response ref 1
auscultation ref 1
autism ref 1
autistic spectrum disorder ref 1
assessment ref 1
autofluorescence ref 1
autoimmune haemolytic anaemia ref 1
autoimmune hepatitis ref 1
autoimmune polyglandular syndromes ref 1
autonomy
of children ref 1
respect for ref 1
autosomal dominant conditions ref 1
autosomal recessive conditions ref 1
autosomal recessive congenital agammaglobulinaemia ref 1
auxology ref 1
avian influenza virus ref 1, ref 2
azathioprine ref 1
B-cells ref 1, ref 2

developmental abnormalities ref 1
Bacillus Calmette-Gurin (BCG) vaccine ref 1, ref 2
complications ref 1
back pain ref 1
Back to Sleep Campaign ref 1
bacteraemia/septicaemia ref 1
bacterial endocarditis ref 1
bacterial overgrowth ref 1
balanced translocations ref 1
balloon atrial septostomy ref 1
Bartter syndrome ref 1
basophilic stippling ref 1
basophils ref 1
Batten disease ref 1, ref 2, ref 3, ref 4
Beau lines ref 1
Becker muscular dystrophy ref 1, ref 2
Beckwith-Wiedemann syndrome ref 1, ref 2, ref 3, ref 4
behavioural problems in preschool children ref 1
Behet syndrome ref 1, ref 2
Bells palsy ref 1
beneficence ref 1
benzyl alcohol ref 1
best interests ref 1
bias ref 1
biliary atresia ref 1, ref 2
bilirubin ref 1
metabolism ref 1
bioavailability ref 1
biopsy, skin ref 1
birthmarks ref 1
bladder
extrophy ref 1
neuropathic ref 1
blepharophimosis ref 1
blistering disorders ref 1
autoimmune ref 1
causes ref 1
drug eruptions ref 1
epidermolysis bullosa ref 1
blood film ref 1
blood gas measurement ref 1
blood group antibodies ref 1
blood product transfusion ref 1
acute transfusion reactions ref 1
massive transfusion reactions ref 1

blood-brain barrier ref 1
Blooms syndrome ref 1
body composition ref 1
puberty ref 1
Bohr effect ref 1
bone age ref 1
bone and joint infections ref 1
bone marrow transplantation ref 1, ref 2
bone metabolism ref 1
calcium and phosphate homeostasis ref 1
disorders of ref 1
investigation of abnormalities ref 1
bone tumours ref 1
bosentan ref 1
botulism ref 1, ref 2
bovine spongiform encephalopathy ref 1
brachial plexus injuries ref 1
brachial plexus palsy ref 1
bradycardia ref 1, ref 2
brain imaging ref 1
brain tumours ref 1
brainstem glioma ref 1
brainstem tumours ref 1
branchial arch remnants ref 1
branching enzyme ref 1
breast milk
composition of ref 1
drugs in ref 1
breast-feeding ref 1, ref 2
and allergy ref 1
contraindications ref 1
and diabetes ref 1
and infantile colic ref 1
and infection ref 1
and neurological development ref 1
breast-milk jaundice ref 1
breath-holding ref 1, ref 2
bronchiectasis ref 1
bronchiolitis ref 1, ref 2
obliterative ref 1
bronchogenic cyst ref 1, ref 2
bronchopulmonary dysplasia ref 1
brucellosis ref 1
bruising ref 1, ref 2
Brushfield spots ref 1

bulimia nervosa ref 1, ref 2
bullous ichthyosiform erythroderma ref 1
bullous pemphigoid ref 1
bullying ref 1
burns ref 1, ref 2
assessment ref 1
chemical ref 1
epidemiology ref 1
inhalational injury ref 1
transfer to burns centre ref 1
treatment ref 1
button batteries ref 1
caf-au-lait macules ref 1
caffeine ref 1
calcitonin ref 1
calcitriol deficiency ref 1
calcium ref 1
Campath ref 1
camptomelic dysplasia ref 1
Canavan disease ref 1, ref 2, ref 3
cancer see malignancy
Candida albicans ref 1
candidiasis ref 1
chronic mucocutaneous ref 1, ref 2
capillary haemangioma ref 1, ref 2
captopril ref 1
carbamazepine ref 1
carbohydrate metabolism ref 1
disorders of ref 1
carbohydrates
digestion ref 1
intolerance ref 1
carbon monoxide poisoning ref 1
cardiac arrest
in-hospital ref 1
out-of-hospital ref 1
cardiac arrhythmias ref 1
fetal ref 1
cardiac catheterization ref 1
diagnostic ref 1
interventional ref 1
cardiac obstruction
in sick newborns ref 1

in well children ref 1
cardiac outlines ref 1
cardiac output ref 1
cardiac physiology ref 1
cardiac rhythm, assessment of ref 1
cardiology, fetal ref 1
cardiovascular emergencies ref 1
bradyarrhythmia ref 1
inotropes ref 1
low cardiac output state ref 1
severe heart failure ref 1
shock ref 1
supraventricular tachycardia ref 1
tachycardia ref 1
ventricular tachycardia ref 1
cardiovascular problems of neonate ref 1
cardioversion ref 1
Care Order ref 1
Care Quality Commission (CQC) ref 1
Caroli disease ref 1
carotid thrill ref 1
case-control studies ref 1, ref 2
cat-eye syndrome ref 1
cat-scratch disease ref 1
cataract ref 1
CATCH 22 ref 1
caustic ingestion ref 1
CD4 T-cells ref 1
CD8 T-cells ref 1
CD40 ligand deficiency ref 1
cellulitis
orbital ref 1
preseptal ref 1
central nervous system
infections ref 1
tumours ref 1
central tolerance ref 1
central venous access ref 1
central venous catheters, complications of ref 1
cerebral palsy ref 1, ref 2
feeding problems ref 1
cerebrovascular disease ref 1
cervical lymphadenopathy ref 1, ref 2, ref 3
chalazion ref 1
Chanarin-Dorfman syndrome ref 1

Charcot-Marie-Tooth disease ref 1
CHARGE syndrome ref 1, ref 2, ref 3
Chdiak-Higashi syndrome ref 1, ref 2
chemical burns ref 1
chemical conjunctivitis ref 1
chemokines ref 1
chemotherapy, effects of ref 1
cherry-red spot ref 1
chest compressions ref 1
chest wall abnormalities ref 1
chest wall deformities ref 1
chest X-rays ref 1
chi-squared test ref 1
child abuse
physical abuse ref 1
types of ref 1
Child Assessment Order ref 1
child health surveillance ref 1
pre-school children ref 1
child law ref 1
Children Act 1989 ref 1, ref 2
childrens capacity ref 1
consent ref 1
full legal capacity ref 1
guardians ref 1
ownership of child ref 1
status of children in courts ref 1
wardship ref 1
child protection ref 1
and confidentiality ref 1
child protection and safeguarding ref 1
definition ref 1
emotional abuse ref 1, ref 2
fabricated/induced illness ref 1
neglect ref 1
sexual abuse ref 1, ref 2
CHILD syndrome ref 1
childhood vasculitis ref 1
children
autonomy ref 1
and confidentiality ref 1
moral status of ref 1
ownership of ref 1
research in ref 1
rights of ref 1
status on courts ref 1
see also child law
Children Act 1989 ref 1, ref 2, ref 3
childrens capacity ref 1
1617 years ref 1
Fraser guidelines ref 1
intervening years ref 1
preschool ref 1
Chlamydia trachomatis ref 1
chloramphenicol, grey-baby syndrome ref 1
chlorpromazine ref 1
choanal atresia ref 1, ref 2, ref 3
choking ref 1
cholecystokinin-pancreozymin ref 1
Christmas disease ref 1
chromium, abnormalities ref 1
chromosomes ref 1
autosomal chromosome aneuploidies ref 1
comparative genomic hybridization ref 1
FISH testing ref 1
genetic counselling ref 1
microdeletion syndromes ref 1
multiplex ligation-dependent probe amplification ref 1
quantitative fluorescence polymerase chain reaction ref 1
sex chromosome aneuploidies ref 1
chronic bullous dermatosis of childhood ref 1
chronic fatigue syndrome ref 1
aetiology ref 1
clinical features ref 1
diagnostic criteria ref 1
epidemiology ref 1
initial assessment ref 1
investigation ref 1
management ref 1
prognosis ref 1
chronic granulomatous disease ref 1
Churg-Strauss syndrome ref 1
chylomicrons ref 1
chylothorax ref 1
circulation, checking ref 1
class-switch recombination ref 1
defects in ref 1
cleft lip and palate ref 1
clinical effectiveness ref 1
clinical governance ref 1

education, appraisal and revalidation ref 1
history ref 1
outcome and experience ref 1
patient experience ref 1
patient safety ref 1
Clinical Negligence Scheme for Trusts (CNST) ref 1
clinical pharmacology ref 1
adverse drug reactions ref 1
drug interactions ref 1
drug monitoring ref 1
formulation ref 1
intravenous drugs ref 1
paediatric dosing ref 1
pharmacokinetics and pharmacodynamics ref 1
prescribing outside licence ref 1
clobazam ref 1
clonazepam ref 1
clozapine ref 1
clubbing ref 1
coagulase-negative staphylococci ref 1
coagulation ref 1
coagulation disorders ref 1
neonate ref 1
coagulopathy ref 1
coarctation of aorta ref 1, ref 2
adult-type ref 1
repair ref 1
Coat disease ref 1
Cockaynes syndrome ref 1, ref 2
coeliac disease ref 1
cognitive behavioural therapy ref 1
cohort studies ref 1, ref 2
cold-induced injuries ref 1
collecting duct ref 1, ref 2
collodion baby ref 1
coloboma ref 1, ref 2, ref 3
colon ref 1
colonic atresia ref 1
colour vision ref 1
coma
non-traumatic ref 1
thiopentone-induced ref 1
combined immunodeficiency ref 1
common lymphoid progenitor ref 1
common myeloid progenitor ref 1

common variable immunodeficiency ref 1
communication ref 1, ref 2
comparative genomic hybridization ref 1
complement ref 1, ref 2
deficiency ref 1
computerized axial tomography ref 1
conduct disorders ref 1
confidence intervals ref 1
confidentiality ref 1
and child protection ref 1
and children ref 1
contraception in teenagers ref 1
confounding ref 1
congenital adrenal hyperplasia ref 1
congenital cystic adenomatoid malformation ref 1, ref 2
congenital facial paralysis ref 1
congenital heart disease ref 1
bypass surgery ref 1
drug therapy ref 1
epidemiology ref 1
examination ref 1
non-bypass surgery ref 1
physiology ref 1
syndromes ref 1
congenital infections ref 1
congenital lobar emphysema ref 1, ref 2
congenital myopathies ref 1
congenital pulmonary lymphangiectasia ref 1
conjunctivitis ref 1
neonatal ref 1
Conn syndrome ref 1
connective tissue disorders ref 1
consanguinity ref 1
consent ref 1
ethical basis ref 1
consequentialism ref 1
constipation ref 1
contact dermatitis ref 1
convulsions ref 1
treatment ref 1
Coombs test ref 1
copper, abnormalities ref 1, ref 2

cornea ref 1
clouding ref 1
deposits ref 1
keratitis ref 1
keratoconus ref 1
Cornelia de Lange syndrome ref 1
correlation coefficients ref 1
cortisol ref 1
cover test ref 1
cows milk protein intolerance ref 1
cows milk protein sensitive enteropathy ref 1
cranial nerve lesions ref 1
craniopharyngioma ref 1, ref 2, ref 3
craniosynostosis ref 1
creatinine clearance ref 1
Creutzfeldt-Jakob disease, new variant ref 1
cri du chat syndrome ref 1
Crigler-Najjar syndrome ref 1
Crohns disease ref 1
cross-sectional studies ref 1
crossing over ref 1
crossover studies ref 1
croup ref 1
Crouzon syndrome ref 1
crush injuries ref 1
cryptophthalmus ref 1
Cushing syndrome ref 1
cyanosis ref 1, ref 2
of newborn ref 1
cyclosporin ref 1
cystic adenomatoid malformation ref 1
cystic fibrosis ref 1, ref 2, ref 3
diagnosis ref 1
genetics ref 1
presentation and management ref 1
transplantation ref 1
cystic hygroma ref 1
cystinosis ref 1, ref 2
cystinuria ref 1
cytokines ref 1, ref 2
cytomegalovirus ref 1, ref 2, ref 3, 876
congenital ref 1, ref 2
and fetal malformations ref 1
cytotoxic T-cells ref 1

dacluzimab ref 1
dacryocystitis ref 1
Dandy-Walker malformation ref 1
De Morsier syndrome ref 1
deafness ref 1
debrancher enzyme ref 1
dehydration ref 1
dendritic cells ref 1
Dengue fever ref 1
deontology ref 1
depression ref 1
dermatitis artefacta ref 1
dermatitis herpetiformis ref 1
dermatology ref 1
birthmarks ref 1
blistering disorders ref 1
erythemas ref 1
hair, nails and teeth ref 1
ichthyoses ref 1
neonatal skin disorders ref 1
photosensitive disorders ref 1
pigmentation disorders ref 1
rashes ref 1
structure and function of skin ref 1
dermatomyositis ref 1
dermis ref 1
developmental assessment ref 1
developmental coordination disorder ref 1
developmental delay ref 1, ref 2
causes ref 1
developmental disabilities ref 1
attention-deficit hyperactivity disorder ref 1
autism ref 1
deficits in attention, motor control and perception ref 1
learning disability ref 1
developmental dysplasia of hip ref 1
developmental examination ref 1
developmental milestones ref 1
dextrocardia ref 1
Di George syndrome ref 1, ref 2, ref 3
diabetes insipidus ref 1
nephrogenic ref 1
treatment ref 1
diabetes mellitus ref 1
aetiology ref 1
beta-cell failure ref 1
and breast-feeding ref 1
causes ref 1
diagnosis ref 1
epidemiology ref 1
long-term complications ref 1
management ref 1
maternal, effects on fetus and newborn ref 1
presentation ref 1
risk factors for type 2 ref 1
diabetic ketoacidosis ref 1
diabetic retinopathy ref 1
dialysis ref 1
diaphragm, eventration ref 1
diaphragmatic hernia ref 1
diarrhoea
chronic ref 1
travellers ref 1
diazepam
absorption and pKa ref 1
half-life ref 1
didanosine ref 1
diet, in diabetes mellitus ref 1
dilated cardiomyopathy ref 1
diphtheria vaccine ref 1, ref 2
diploid ref 1
dipyridamole ref 1, ref 2
direct antiglobulin test ref 1
disaccharide absorption disorders ref 1
disseminated intravascular coagulation ref 1
distal arthrogryposis syndrome ref 1
distal tubule ref 1, ref 2
distribution ref 1
diuretics ref 1
DNA ref 1
dobutamine ref 1
doctors
moral conflicts ref 1
moral duties ref 1
dopamine ref 1
Down syndrome ref 1, ref 2, ref 3, ref 4, ref 5, ref 6

drowning ref 1
prognostic signs ref 1
re-warming ref 1
treatment ref 1
drug eruptions ref 1
drug interactions ref 1
drug monitoring ref 1
drug-induced liver disease ref 1
dry eye ref 1
DTPA scan ref 1
Duchenne muscular dystrophy ref 1, ref 2, ref 3, ref 4
Duncan syndrome ref 1
duodenal atresia ref 1
duodenal obstruction ref 1
duplex kidney ref 1
dying spells ref 1
dyskeratosis congenita ref 1
dysmotility ref 1
dysphagia ref 1
dyspraxia ref 1
dystonia ref 1
dystrophic myotonia ref 1
ears ref 1
perforated eardrum ref 1
eating disorders ref 1
Ebstein anomaly ref 1, ref 2
ECG ref 1
echinocandins ref 1
echocardiography ref 1
ectodermal dysplasias ref 1, ref 2
ectopia lentis ref 1
ectropion ref 1
eczema, atopic ref 1
associated conditions ref 1
differential diagnosis ref 1
features ref 1
management ref 1
Edward syndrome ref 1, ref 2
efavirenz ref 1
effector T cells ref 1
Eisenmenger syndrome ref 1
electro-oculography ref 1
electrocution injury ref 1

electroencephalography ref 1
electrolyte disturbances ref 1
electroretinography ref 1
Ellis van Crefeld syndrome ref 1
Embden-Meyerhof pathway ref 1
embryology
cardiovascular system ref 1
central nervous system ref 1
gastrointestinal system ref 1
genitourinary system ref 1
renal system ref 1
respiratory system ref 1
emergencies
airway ref 1
burns ref 1
cardiovascular ref 1
cold-induced injuries ref 1
convulsions ref 1
drowning ref 1
electrocution injury ref 1
non-traumatic coma ref 1
respiratory failure ref 1
resuscitation
cardiac arrest ref 1
post-resuscitation management ref 1
when to stop ref 1
severe head injury ref 1
trauma ref 1
Emergency Protection Order ref 1
Emery-Dreifuss muscular dystrophy ref 1
emollients ref 1
emotional abuse ref 1, ref 2
empyema ref 1
encephalitis ref 1, ref 2
mycoplasma ref 1
encephalocele ref 1
encephalopathy, neonatal ref 1
encopresis and soiling ref 1
endocarditis
bacterial ref 1
infective ref 1
endocrine problems of neonate ref 1
energy balance ref 1
enteral nutrition ref 1, ref 2
choice of feed regimen ref 1

choice of feed type ref 1
dysmotility ref 1
indications for ref 1
methods of feed delivery ref 1
enteric fever ref 1
enterohepatic circulation ref 1
enteroviruses ref 1
entropion ref 1
enuresis ref 1
enzymology ref 1
eosinophilia ref 1
eosinophilic enterocolitis ref 1
eosinophilic oesophagitis ref 1
eosinophilic pustular folliculitis ref 1
eosinophils ref 1
ependymoma ref 1
epicanthus ref 1
epidermis ref 1
epidermolysis bullosa ref 1, ref 2, ref 3, ref 4
epidermolysis bullosa acquisita ref 1
epigastric hernia ref 1
epiglottitis ref 1
epilepsy ref 1
assessment and treatment ref 1
definition and classification ref 1
diagnosis ref 1
generalized ref 1
partial ref 1
prognosis ref 1
see also seizures
episcleritis ref 1
epispadias ref 1
epistaxis ref 1
Epstein-Barr virus ref 1
Erbs palsy ref 1
erythema infectiosum ref 1
erythema marginatum ref 1
erythema migrans ref 1
erythema multiforme ref 1, ref 2
erythema nodosum ref 1, ref 2
erythema toxicum neonatorum ref 1
erythropoietin system ref 1
Escherichia coli ref 1
esotropia ref 1
etanercept ref 1
ethics
ethical issues, technology and law ref 1
and law ref 1
moral theories ref 1
principles ref 1
ethosuximide ref 1
eventration of diaphragm ref 1
evoked potentials ref 1
Ewing sarcoma ref 1
exanthem subitum ref 1
exchange transfusion ref 1
exocrine pancreatic insufficiency ref 1
exome sequencing ref 1
exomphalos ref 1, ref 2
exotropia ref 1
experimental studies ref 1
extracellular fluid volume ref 1
extracorporeal membrane oxygenation ref 1, ref 2
extremely premature infants ref 1
eye ref 1
anterior chamber ref 1
conjunctiva ref 1
cornea ref 1
extraocular muscles ref 1
globe ref 1
lens ref 1
orbits ref 1
retina ref 1
sclera ref 1
uveal tract ref 1
vitreous ref 1
eye examination ref 1, ref 2
colour vision ref 1
electrophysiology ref 1
refractive errors ref 1
visual assessment ref 1
visual fields ref 1
eye movement disorders ref 1, ref 2
nystagmus ref 1, ref 2
squint ref 1
eyelid abnormalities ref 1
congenital ref 1
haemangiomas ref 1
infections and inflammation ref 1
Marcus Gunn jaw-winking syndrome ref 1

myasthenia gravis ref 1
ptosis ref 1
fabricated/induced illness ref 1
Fabry disease ref 1, ref 2
facial nerve paralysis ref 1
facio-scapulohumeral muscular dystrophy ref 1, ref 2
faecal 1-antitrypsin ref 1
faltering growth ref 1
human immunodeficiency virus ref 1
familial adenomatous polyposis coli ref 1
familial combined hyperlipidaemia ref 1
Fanconi syndrome ref 1, ref 2
fat
body content ref 1
digestion ref 1
metabolism ref 1
subcutaneous ref 1
fat oxidation disorders ref 1
fat-soluble vitamins ref 1
feeding problems ref 1
femoral fractures ref 1
fetal alcohol syndrome ref 1, ref 2
fetal haemoglobin ref 1
fetal retinoic acid ref 1
fetal teratogens ref 1
infectious agents ref 1
maternal illness ref 1
fetal valproate syndrome ref 1
fetal warfarin syndrome ref 1
fetus
adaptation to extrauterine life ref 1
circulatory changes at birth ref 1
echocardiography ref 1
growth ref 1
renal function ref 1
see also fetal
Fifth disease see parvovirus B19
first-order kinetics ref 1
first-pass metabolism ref 1
Fisher exact test ref 1
floppy infant ref 1
fluorescence in-situ hybridization (FISH) ref 1
folate, nutritional requirement ref 1
follicle-stimulating hormone ref 1
Fontan operation ref 1

food intolerance ref 1
foot drop ref 1
foreign bodies
inhaled ref 1
oesophageal ref 1
formula milk ref 1
composition of ref 1
formulation ref 1
fostering ref 1
fractures ref 1
femoral ref 1
humerus ref 1
lower limb ref 1
metaphyseal ref 1
ribs ref 1
skull ref 1
upper limb ref 1
fragile X syndrome ref 1, ref 2
Fraser guidelines ref 1
free-field testing ref 1
frenulum, torn ref 1
Friedreich ataxia ref 1, ref 2
frostbite ref 1
Fukuyama congenital muscular dystrophy ref 1
fungal infections ref 1
G-protein receptors ref 1
gabapentin ref 1
galactosaemia ref 1
-glutamyltransferase ref 1
Gardener syndrome ref 1
gasping syndrome ref 1
gastric inhibitory peptide ref 1
gastrin ref 1
gastro-oesophageal reflux ref 1, ref 2, ref 3
investigation ref 1
management ref 1
symptoms and signs ref 1
gastroenteritis ref 1
gastrointestinal bleeding ref 1
gastrointestinal problems of newborn ref 1
gastrointestinal surgery ref 1
gastrointestinal system, congenital abnormalities ref 1
gastroschisis ref 1, ref 2

gastrostomy ref 1
tube feeding ref 1
Gaucher disease ref 1, ref 2, ref 3
gene therapy ref 1
genetic counselling ref 1, ref 2
genetic testing ref 1
genetics
ambiguous genitalia ref 1
chromosomes ref 1
fetal teratogens ref 1
genomic imprinting ref 1
mendelian inheritance ref 1
mitochondrial disorders ref 1
molecular genetics ref 1
preimplantation genetic diagnosis ref 1
prenatal testing ref 1
trinucleotide repeat disorders ref 1
genitourinary problems of newborn ref 1
genomic imprinting ref 1
germ-cell tumours ref 1
German measles see rubella
giardiasis ref 1, ref 2
Gilbert syndrome ref 1
Gilles de la Tourette syndrome ref 1
Gillick principle ref 1
Gitelman syndrome ref 1
Glasgow Coma Scale ref 1, ref 2
glaucoma ref 1, ref 2
glomerular filtration rate ref 1
glomerulonephritis ref 1
acute post-streptococcal ref 1
glucocorticoids ref 1
gluconeogenesis ref 1
glucose 6-phosphatase deficiency ref 1
glucose 6-phosphate dehydrogenase deficiency ref 1, ref 2
glucose 6-phosphate translocase deficiency ref 1
glucose homeostasis ref 1
diabetes mellitus ref 1
physiology ref 1
glucose-galactose malabsorption ref 1
glutaric aciduria type 1 ref 1, ref 2
glycogen metabolism ref 1
glycogen storage disease ref 1
glycolysis ref 1, ref 2
glycosylation, congenital disorders ref 1

Goldenhar syndrome ref 1
golf balls ref 1
gonadotrophins ref 1
granulocytes ref 1
granuloma annulare ref 1
Graves disease ref 1
greenstick fractures ref 1
grey matter disorders ref 1
grey-baby syndrome ref 1
group B streptococcus ref 1
growth ref 1
assessment and investigation ref 1
faltering ref 1
postnatal ref 1
prenatal ref 1
growth disorders ref 1
short stature ref 1
tall stature ref 1
growth hormone ref 1
provocation tests ref 1
treatment ref 1
guanine cyclic monophosphate (cGMP) ref 1
guardians ref 1
Guillain-Barr syndrome ref 1, ref 2
gunshot wounds ref 1
gut hormones ref 1
gynaecomastia ref 1
HAART therapy ref 1
haemangioma ref 1
laryngeal ref 1
haemangiomas, multiple small ref 1
haematology/coagulation problems of neonate ref 1
haematopoietic stem cells ref 1
haematuria ref 1, ref 2
haemoglobin
abnormalities ref 1
defects ref 1
oxygen-dissociation curve ref 1
synthesis ref 1
haemolysis ref 1
haemolytic disease of newborn ref 1
haemolytic-uraemic syndrome ref 1
haemophagocytic lymphohistiocytosis ref 1
haemophilia ref 1, ref 2

Haemophilus influenzae type B vaccine ref 1
haemorrhagic disease of newborn ref 1, ref 2
haemosiderosis ref 1
hair ref 1
half-life ref 1
haloperidol ref 1
hantaviruses ref 1
haploid ref 1, ref 2
Happle syndrome ref 1
harlequin ichthyosis ref 1
Hartnups disease ref 1
Hb C disease ref 1
Hb D disease ref 1
Hb E disease ref 1
head injury ref 1, ref 2, ref 3
cerebral perfusion pressure ref 1
complications in intensive care ref 1
imaging ref 1
mild closed ref 1
non-accidental ref 1
raised intracranial pressure ref 1
severe closed ref 1
head lice ref 1
head and neck surgery ref 1
head shape, abnormal ref 1
headaches ref 1
migraine ref 1
non-organic ref 1
tension ref 1
Heaf test ref 1
hearing ref 1
hearing tests ref 1
heart
anatomy ref 1
globular ref 1
innocent murmurs ref 1
murmurs ref 1
muscle physiology ref 1
rate ref 1, ref 2
rhythm ref 1
sounds ref 1
see also cardiac; cardio
heart block ref 1
heart disease, acquired ref 1
heart failure ref 1, ref 2

drug therapy ref 1
heart-lung transplantation ref 1
Helicobacter pylori ref 1
hemihypertrophy ref 1
Henoch-Schnlein nephritis ref 1
Henoch-Schnlein purpura ref 1, ref 2
heparin ref 1
hepatic metabolism ref 1
hepatitis
acute ref 1
acute infective ref 1
autoimmune ref 1
chronic viral ref 1
idiopathic neonatal ref 1
hepatitis A ref 1
hepatitis B ref 1
congenital ref 1
vaccine ref 1, ref 2
hepatitis C ref 1
hepatoblastoma ref 1
hepatology ref 1
acute hepatitis ref 1
acute liver failure ref 1
chronic liver disease ref 1
jaundice in infancy ref 1
pancreas ref 1
hepatomegaly ref 1
hepatopulmonary syndrome ref 1, ref 2
hepatorenal syndrome ref 1
hepatosplenomegaly ref 1
hereditary elliptocytosis ref 1
hereditary fructose intolerance ref 1
hereditary haemolytic anaemia ref 1
hereditary spherocytosis ref 1
herpes simplex encephalitis ref 1
herpes simplex virus ref 1, ref 2
congenital ref 1
heterochromia iridis ref 1
heterotropia ref 1
Hirschsprung disease ref 1, ref 2, ref 3
hirsutism ref 1, ref 2
HIV, ocular manifestations ref 1
Hodgkin lymphoma ref 1
holoprosencephaly ref 1
Holt-Oram syndrome ref 1

homocystinuria ref 1, ref 2
homologues ref 1
hookworm ref 1
hordeolum ref 1
hormonal problems ref 1
hormone-binding proteins ref 1
hormone-receptor interactions ref 1
hormones ref 1
adrenal gland ref 1, ref 2
anterior pituitary ref 1
control and feedback ref 1
gut ref 1
mode of transmission ref 1
puberty ref 1
regulation ref 1
secretion ref 1
thyroid gland ref 1
transport and metabolism ref 1
Horner syndrome ref 1, ref 2
horseshoe kidney ref 1
human chorionic gonadotrophin ref 1
babies of HIV-positive mother ref 1
clinical manifestations ref 1
diagnosis ref 1
faltering growth ref 1
follow-up of HIV-positive children ref 1
HIV encephalopathy ref 1
lymphocytic interstitial pneumonitis ref 1
neonatal ref 1
opportunistic infections ref 1
recurrent bacterial infections ref 1
thrombocytopenia ref 1
transmission ref 1
treatment ref 1
human papillomavirus vaccine ref 1
human placental lactogen ref 1
Human Rights Act 1998 ref 1
humerus, fractures ref 1
Hunter syndrome ref 1
Huntington chorea ref 1
Hurler syndrome ref 1, ref 2
hydroceles ref 1
hydrocephalus ref 1
hydrogen breath testing ref 1

hydronephrosis ref 1
hydrops fetalis ref 1, ref 2
hyper IgE syndrome ref 1, ref 2
hyperammonaemia ref 1, ref 2
hyperbilirubinaemia
conjugated ref 1
unconjugated ref 1
hypercalcaemia ref 1, ref 2
hypercholesterolaemias ref 1
hyperinsulinism ref 1
hyperkalaemia ref 1
hyperkeratotic eczema ref 1
hypermetropia ref 1
hypermobility ref 1
hypernatraemia ref 1
hyperphosphataemia ref 1, ref 2
hyperpigmentation ref 1
hypersensitivity reactions ref 1
hypersplenism ref 1
hypertelorism ref 1
hypertension ref 1, ref 2, ref 3
treatment ref 1
hypertensive retinopathy ref 1
hyperthyroidism ref 1
management ref 1
hypertrichosis ref 1, ref 2
hypertriglyceridaemias ref 1
hypertrophic cardiomyopathy ref 1
hypertrophic obstructive cardiomyopathy ref 1
hypocalcaemia ref 1, ref 2
hypocalciuria ref 1
hypochondroplasia ref 1
hypogammaglobulinaemia, transient of infancy ref 1
hypoglycaemia ref 1, ref 2
neonatal ref 1
hypokalaemia ref 1
hypomagnesaemia ref 1, ref 2
hypomelanosis of Ito ref 1
hyponatraemia ref 1
hypoparathyroidism ref 1, ref 2
hypophosphataemia ref 1
hypopigmentation ref 1
hypoplastic left heart syndrome ref 1
hypospadias ref 1, 858
hypotelorism ref 1
hypotension ref 1
hypothalamus, anatomy ref 1
hypothermia ref 1
hypothyroidism ref 1, ref 2
congenital ref 1
management ref 1
hypotonia ref 1
hypoxia, chronic ref 1
hypoxic-ischaemic encephalopathy ref 1
ichthyoses ref 1
collodion baby ref 1
harlequin ref 1
inherited ref 1
ichthyosis vulgaris ref 1
idiopathic juvenile osteoporosis ref 1
imaging ref 1
immune deficiency ref 1
immune diversity ref 1, ref 2
immune dysregulation diseases ref 1
immune system ref 1
adaptive immunity ref 1
antibodies ref 1
antigen recognition ref 1
cellular origin and components ref 1
chemokines ref 1
complement ref 1, ref 2
cytokines ref 1, ref 2
haematopoietic stem cells ref 1
innate immunity ref 1
lymphoid organs ref 1
self-tolerance ref 1
T- and B-cells ref 1, ref 2
immune thrombocytopenic purpura ref 1
immune-modulating agents ref 1
immunization ref 1
contraindications ref 1
schedule ref 1
immunization reactions ref 1
immunodeficiency ref 1
categories ref 1
combined ref 1, ref 2
diagnosis ref 1, ref 2
history and examination ref 1
non-infective manifestations ref 1

patterns of infection ref 1
immunodeficiency syndromes ref 1
immunoglobulins ref 1
deficiencies ref 1
immunoglobulin A deficiency ref 1
immunoglobulin A nephropathy ref 1
immunological memory ref 1
immunology ref 1
antibody deficiencies ref 1
combined immunodeficiency ref 1, ref 2
complement deficiency ref 1
defects of interferon-/interleukin-12 axis ref 1
host-pathogen interaction ref 1
hypersensitivity reactions ref 1
immune system ref 1
immunodeficiency syndromes ref 1
immunoglobulins ref 1
immunosuppressants and immune-modulating agents ref 1
phagocytic disorders ref 1
routine vaccination in immunosuppressed patients ref 1
immunosuppressants ref 1
imperforate anus ref 1
impetigo ref 1
imunodysregulation, polyendocrinopathy, enteropathy, X-linked syndrome (IPEX) ref 1
inadequate airway protection ref 1
incontinentia pigmenti ref 1, ref 2, ref 3, ref 4, ref 5
indirect antiglobulin test ref 1
infantile acropustulosis ref 1
infantile cardiac outlines ref 1
infantile seborrhoeic dermatitis ref 1
infections
bone and joint ref 1
central nervous system ref 1
congenital ref 1
eyelid ref 1
fungal ref 1
mycobacterial ref 1
neonatal ref 1
orthopaedics ref 1
parasitic ref 1
recurrent ref 1
urinary tract ref 1
viral ref 1
infectious arthritis ref 1

infectious diseases ref 1
congenital infections ref 1
fever with focus ref 1
fever with no focus/prolonged fever ref 1
fungal infections ref 1
mycobacterial infections ref 1
new and emerging infections ref 1
notification of ref 1
parasitic infections ref 1
pathogenesis of infection ref 1
tropical diseases ref 1
viral infections ref 1
inflammatory bowel disease ref 1
and arthritis ref 1
infliximab ref 1
inguinal hernia ref 1
inhaled foreign body ref 1
inheritance ref 1
inhibin ref 1
innate immunity ref 1
inositol triphosphate system ref 1
inotropes ref 1
adrenaline ref 1
dobutamine ref 1
dopamine ref 1
milrinone ref 1
noradrenaline ref 1
insulin ref 1
administration ref 1, ref 2
intention-to-treat analysis ref 1
interferons ref 1
interquartile range ref 1
intersex disorders ref 1
see also ambiguous genitalia
interstititial lung diseases of childhood ref 1
intestinal atresia ref 1
intestinal failure ref 1
intestinal lymphangiectasia ref 1
intracellular receptors ref 1
intrauterine growth retardation ref 1
intravenous drugs ref 1
maintenance ref 1
monitoring ref 1
intravenous urography ref 1

intussusception ref 1, ref 2
ionization ref 1
iridocyclitis ref 1
iris
coloboma ref 1
heterochromia irides ref 1
inflammation ref 1
iritis ref 1
iron
nutritional requirement ref 1
poisoning ref 1
iron deficiency anaemia ref 1
irritable hip ref 1, ref 2
isomerism ref 1
isovaleric acidaemia ref 1
jaundice, neonatal ref 1, ref 2
approach to ref 1
bilirubin metabolism ref 1
breast-milk ref 1
causes ref 1
conjugated hyperbilirubinaemia ref 1
haemolysis ref 1
physiological ref 1, ref 2
prolonged ref 1
unconjugated hyperbilirubinaemia ref 1
treatment ref 1
jejunoileal atresia ref 1
Jobs syndrome ref 1
jugular venous pressure ref 1
justice ref 1
juvenile dermatomyositis ref 1
juvenile idiopathic arthritis ref 1
juvenile polyps ref 1
juvenile sarcoidosis ref 1
Kaletra ref 1
Kasabach-Merritt syndrome ref 1
Kawasaki disease ref 1, ref 2, ref 3
Kearns-Sayre syndrome ref 1
keloids ref 1
keratitis ref 1
keratoconus ref 1
ketotic hypoglycaemia ref 1
KID syndrome ref 1

kidney
congenital abnormalities ref 1
duplex ref 1
horseshoe ref 1
multicystic dysplastic ref 1
see also renal
kinky hair syndrome see Menkes disease
Klinefelter syndrome ref 1, ref 2
Klumpkes paralysis ref 1
Koebner phenomenon ref 1
koilonychia ref 1
Krabbe disease ref 1
Kruskal-Wallis ANOVA ref 1
kuru ref 1
kyphosis ref 1
lacrimal system disorders ref 1
congenital nasolacrimal sac dilatation ref 1
dacryocystitis ref 1
dry eye ref 1
stenosis/obstruction of nasolacrimal duct ref 1
watering eye ref 1
lactate ref 1
lactose ref 1
intolerance ref 1
lamellar ichthyoses ref 1
lamivudine ref 1
lamotrigine ref 1
Langerhans cell histiocytosis ref 1, ref 2
Larsen syndrome ref 1
laryngeal cleft ref 1, ref 2
laryngeal web ref 1
laryngomalacia ref 1
larynx ref 1
Laurence-Moon-Biedl syndrome ref 1
laxatives ref 1
lead poisoning ref 1
learning disability ref 1
Lebers hereditary optic neuropathy ref 1
Legg-Calv-Perthes disease ref 1
Leigh disease ref 1, ref 2
leishmaniasis ref 1
lens anomalies ref 1
leptospirosis ref 1
Lesch-Nyhan syndrome ref 1, ref 2

leukaemia ref 1
acute lymphoblastic ref 1
acute myeloid ref 1
leukocoria ref 1
leukocyte adhesion deficiency ref 1
leukodystrophies ref 1
leukonychia ref 1
levetiracetam ref 1
lichen planus ref 1, ref 2
lichen simplex chronicus ref 1
Liddle syndrome ref 1
life-sustaining treatment, withholding or withdrawing ref 1
decision-making ref 1
disputes and dissent ref 1
disputes/dissent ref 1
extremely premature infants ref 1
legal framework ref 1
professional guidance ref 1
lightning injury ref 1
likelihood ratios ref 1
limb pains, non-organic ref 1
limb-girdle muscular dystrophy ref 1
limbal dermoid ref 1
linear regression ref 1
lipid disorders ref 1
lipogenesis ref 1
lipolysis ref 1
Lisch nodules ref 1
lissencephaly ref 1
Listeria monocytogenes ref 1
listeriosis ref 1
live vaccines ref 1
liver, drugs and ref 1
liver disease ref 1
chronic ref 1
autoimmune hepatitis ref 1
causes ref 1
chronic viral hepatitis ref 1
liver transplantation ref 1
non-alcoholic fatty liver disease ref 1
portal hypertension ref 1, ref 2
drug-induced ref 1
total parenteral nutrition-induced ref 1
liver failure
acute ref 1
causes ref 1
paracetamol poisoning ref 1
Wilson disease ref 1
end-stage ref 1
liver function tests ref 1
liver phosphorylase deficiency ref 1
liver transplantation ref 1
lobar emphysema, congenital ref 1
lobar sequestration ref 1
long-bone fracture ref 1
long-chain defects ref 1
loop of Henle ref 1, ref 2
loose anagen syndrome ref 1
low-density lipoprotein ref 1
low-renin hypertension ref 1
Lown-Ganong-Levine syndrome ref 1
lumbar puncture ref 1
lung disease
chronic ref 1
congenital ref 1
environmental influences ref 1
lung function testing ref 1
lung transplantation ref 1
luteinizing hormone ref 1
Lyme disease ref 1
lymphocytes ref 1, ref 2
lymphocytic interstitial pneumonitis ref 1, ref 2
lymphocytosis ref 1
lymphoid organs ref 1
lyonization ref 1
McArdle disease ref 1
macrocephaly ref 1
macroglossia ref 1
macrophages ref 1
MAG-3 scan ref 1
magnesium ref 1
magnetic resonance imaging ref 1, ref 2
magnetic resonance urography ref 1
major histocompatibility complex see MHC
malabsorption ref 1
malacias ref 1
malaria ref 1
malignancy ref 1
bone marrow transplantation ref 1

bone tumours ref 1
brain tumours ref 1
environmental factors predisposing to ref 1
germ-cell tumours ref 1
haemophagocytic lymphohistiocytosis ref 1
hepatoblastoma ref 1
Langerhans cell histiocytosis ref 1
late effects of treatment ref 1
leukaemia ref 1
lymphoma ref 1
management ref 1
neuroblastoma ref 1
palliative care ref 1
retinoblastoma ref 1
soft-tissue sarcomas ref 1
syndromes/conditions predisposing to ref 1
tumour-lysis syndrome ref 1
Wilms tumour ref 1
malnutrition ref 1
malrotation ref 1, ref 2
manganese, abnormalities ref 1
Mann-Whitney U-test ref 1
Mantoux test ref 1
maple syrup urine disease ref 1
marasmus ref 1
Marcus Gunn jaw-winking syndrome ref 1
Marfan syndrome ref 1, ref 2, ref 3
mastoiditis ref 1
maternal engraftment ref 1
mean ref 1
measles ref 1
mechanical ventilation ref 1
Meckels diverticulum ref 1, ref 2
meconium aspiration syndrome ref 1
meconium ileus ref 1, ref 2
median ref 1, ref 2
medium-chain acyl-CoA dehydrogenase deficiency ref 1
medulloblastoma ref 1, ref 2, ref 3
megacystis-microcolon-intestinal hypoperistalsis syndrome ref 1
meiosis ref 1
melanocytic naevi ref 1
MELAS ref 1, ref 2
memory cells ref 1
mendelian inheritance
autosomal dominant conditions ref 1

autosomal recessive conditions ref 1
pedigree diagrams ref 1
X-linked dominant conditions ref 1
X-linked recessive conditions ref 1
meningitis ref 1, ref 2
bacterial ref 1
neonatal ref 1
tuberculous ref 1
meningitis C vaccine ref 1
meningocele ref 1
meningomyelocele ref 1
Menkes disease ref 1, ref 2, ref 3
mental health ref 1
merosin-negative congenital muscular dystrophy ref 1
merosin-positive congenital muscular dystrophy ref 1
MERRF ref 1, ref 2
metabolic acidosis ref 1, ref 2, ref 3
metabolic alkalosis ref 1, ref 2
metabolic disorders, ocular manifestations ref 1
metabolic medicine ref 1
abetalipoproteinaemia ref 1, ref 2
acute management ref 1
approach to metabolic case ref 1
basic metabolism ref 1
carbohydrate metabolism disorders ref 1
fat oxidation disorders ref 1
lipid disorders ref 1
long-term management ref 1
mitochondrial disorders ref 1
mucopolysaccharidoses ref 1
organic acidaemias ref 1
peroxisomal disorders ref 1
presentation ref 1
screening ref 1
sphingolipidoses ref 1
urea cycle defects ref 1
metabolic metabolism, amino acid metabolism disorders ref 1
metachromic leukodystrophy ref 1, ref 2
metal-induced hyperpigmentation ref 1
metaphyseal fractures ref 1
methylmalonic acidaemia ref 1
methylparaben ref 1
methylphenidate (Ritalin) ref 1
MHC class I ref 1
MHC class II ref 1

microangiopathic haemolytic anaemia ref 1
microcephaly ref 1, ref 2
microcornea ref 1
microdeletion syndromes ref 1
micturating cystourethrogram ref 1
mid-parental height ref 1
migraine ref 1
miliaria ref 1
milrinone ref 1
mineralocorticoids ref 1
miosis ref 1
mitochondrial disease ref 1
mitochondrial disorders ref 1, ref 2
mitosis ref 1
MMR vaccine ref 1, ref 2
Moebius syndrome ref 1
molecular genetics ref 1
molluscum contagiosum ref 1, ref 2
molybdenum, abnormalities ref 1
Mongolian blue spots ref 1, ref 2
monocytes ref 1, ref 2
monosaccharide absorption disorders ref 1
monosomy ref 1
Monro-Kellie doctrine ref 1
moral conflicts for doctors ref 1
moral duties of doctors ref 1
moral status of children ref 1
motilin ref 1
movement disorders
ataxia ref 1
cerebral palsy ref 1
dystonia ref 1
tics and Tourette syndrome ref 1
mucopolysaccharidoses ref 1, ref 2, ref 3, ref 4
multicystic dysplastic kidney ref 1
multiple endocrine neoplasia syndromes ref 1
multiple sulphatase deficiency ref 1
multiplex ligation-dependent probe amplification ref 1
mumps ref 1
Munchausen syndrome by proxy ref 1
muscle phosphorylase deficiency ref 1
myalgic encephalopathy see chronic fatigue syndrome
myasthenia gravis ref 1, ref 2, ref 3

mycobacterial infections ref 1
mycophenolate mofetil ref 1
mydriasis ref 1
myelomeningocele ref 1
myocoplasma encephalitis ref 1
myoglobinuria ref 1
myopathies ref 1, ref 2
myopia ref 1
myotonia congenita ref 1, ref 2
myotonic dystrophy ref 1, ref 2
naevus flammeus ref 1
nail-patella syndrome ref 1
nails ref 1
nappy rash ref 1
nasal polyps ref 1
nasogastric tube feeding ref 1
nasojejunal feeding ref 1
National Health Service Litigation Authority (NHSLA) ref 1
National Health Service trusts ref 1
National Institute for Clinical Excellence (NICE) ref 1
National Patient Safety Agency (NPSA) ref 1
National Reporting and Learning Service (NRLS) ref 1
necrotizing enterocolitis ref 1, ref 2
neglect ref 1
neonatal cardiac outlines ref 1
neonatal conjunctivitis ref 1
neonatal erythroderma ref 1
neonatal isoimmune thrombocytopenia ref 1
neonatal jaundice ref 1
neonatal lupus ref 1
neonatal lupus erythematosus ref 1
neonatal mortality rate ref 1
neonatal surgery ref 1
neonatal thyrotoxicosis ref 1
neonatal tumours ref 1
neonate
absorption ref 1
body composition ref 1
cardiovascular problems ref 1
endocrine problems ref 1
fluid and nutritional requirements ref 1
gastroenterology and nutrition ref 1
genitourinary problems ref 1
haematology/coagulation problems ref 1

idiopathic hepatitis ref 1
infection ref 1
bacterial ref 1
congenital viral infection ref 1
fungal and protozoal infection ref 1
intestinal obstruction ref 1
neurological problems ref 1
hypotonia ref 1
neonatal encephalopathy ref 1
neonatal seizures ref 1
peri-intraventricular haemorrhage ref 1
periventricular leukomalacia ref 1
retinopathy of prematurity ref 1
neurology ref 1
parenteral nutrition ref 1
persistent pulmonary hypertension ref 1
prematurity ref 1
renal function ref 1
respiratory problems ref 1
chest wall abnormalities ref 1
chronic lung disease ref 1
congenital lung problems ref 1
extracorporeal membrane oxygenation ref 1
mechanical ventilation ref 1
meconium aspiration syndrome ref 1
pneumonia ref 1
pulmonary air leak ref 1
surfactant deficiency ref 1
upper airway obstruction ref 1
skin disorders ref 1
nephrocalcinosis ref 1
nephrolithiasis ref 1
nephrology ref 1
acid-base, fluid and electrolytes ref 1
acute kidney injury ref 1
chronic renal failure ref 1
embryology ref 1
fetal and neonatal renal function ref 1
glomerulonephritis ref 1
hypertension ref 1
inherited diseases ref 1
investigations ref 1
nocturnal enuresis ref 1
physiology ref 1
renal tubulopathies ref 1

urinary tract infection ref 1
urological abnormalities ref 1
nephronophthisis ref 1
nephrotic syndrome ref 1
complications ref 1
congenital ref 1
definitions ref 1
treatment ref 1
nervous system
normal development ref 1
Nethertons syndrome ref 1
neural tube defects ref 1, ref 2
neuro-oncology ref 1
neuroblastoma ref 1
neurocutaneous syndromes ref 1
neurofibromatosis ref 1, ref 2, ref 3
neurohypophysis ref 1
neurological problems of newborn ref 1
neurometabolic diseases ref 1
abnormalities of copper metabolism ref 1
amino and organic acid disorders ref 1
leukodystrophies ref 1
mitochondrial disease ref 1
neurotransmitter and urea cycle disorders ref 1
storage disorders ref 1
neuromuscular disorders ref 1
acute ref 1
anterior horn cell disease ref 1
arthrogrypotic syndromes ref 1
floppy infant ref 1
muscular dystrophies ref 1
myopathies ref 1, ref 2
neuromuscular junction disorders ref 1
neuropathies ref 1
spina bifida ref 1
neuromuscular junction disorders ref 1
neuronal ceroid-lipofuscinoses ref 1
neuropathic bladder ref 1
neuropathies ref 1
neurotransmitter disorders ref 1
neutral-lipid storage disease ref 1
neutropenia ref 1
congenital ref 1
cyclical ref 1
neutrophilia ref 1
neutrophils ref 1, ref 2, ref 3
nevirapine ref 1
Niemann-Pick disease ref 1, ref 2, ref 3, ref 4
nifedipine ref 1
night terrors ref 1
nightmares ref 1, ref 2
nitric oxide ref 1, ref 2
nocturnal enuresis ref 1
non-accidental injury ref 1
non-alcoholic fatty liver disease ref 1
non-bullous ichthyosiform erythroderma ref 1
non-Hodgkin lymphoma ref 1
non-ketotic hyperglycinaemia ref 1, ref 2
non-maleficence ref 1
Noonan syndrome ref 1, ref 2
noradrenaline ref 1
normal distribution ref 1
Norwood operation ref 1
nose and sinuses ref 1
nuchal translucency ref 1
null hypothesis ref 1
number needed to treat ref 1
nutrition
breast-feeding ref 1
fat-soluble vitamins ref 1
folate ref 1
iron ref 1
nutritional assessment ref 1
nutritional requirements ref 1
vitamin B12 ref 1
zinc ref 1
nutritional impairment ref 1
nutritional management ref 1
nutritional supplementation ref 1
nystagmus ref 1, ref 2
vertical ref 1
obesity ref 1
assessment ref 1
causes ref 1
consequences ref 1
constitutional ref 1
management ref 1
obliterative bronchiolitis ref 1
observational studies ref 1
ocular albinism ref 1
ocular coherence tomography ref 1
ocular trauma ref 1
oculocutaneous albinism ref 1
odds ratio ref 1, ref 2
oesophageal atresia ref 1, ref 2
oesophageal foreign bodies ref 1
oesophagus ref 1
oestrogen ref 1
OKT3 ref 1
oligaemic lung fields ref 1
oligohydramnios ref 1
Omenn syndrome ref 1
ophthalmological investigations ref 1
ophthalmology ref 1
amblyopia ref 1
anatomy ref 1
conjunctiva ref 1
cornea ref 1
eye examination ref 1
eyelid abnormalities ref 1
iris inflammation ref 1
lacrimal system disorders ref 1
lens anomalies ref 1
metabolic disorders ref 1
ocular trauma ref 1
optic nerve disorders ref 1
painful red eye ref 1
pupil anomalies ref 1
retinal anomalies ref 1
sclera ref 1
uveal tract disorders ref 1
visual impairment ref 1
ophthalmoplegia
acquired ref 1
congenital ref 1
opiate abuse, maternal ref 1
optic atrophy ref 1
optic disc coloboma ref 1
optic glioma ref 1
optic nerve disorders ref 1
oral rehydration solution ref 1

orbital infections ref 1
orbital cellulitis ref 1
preseptal cellulitis ref 1
orbital tumours ref 1
organic acidaemias ref 1
organic acids ref 1
oropharyngeal incoordination ref 1
orthopaedics ref 1
embryology ref 1
infection ref 1
lower limb ref 1
metabolic disorders ref 1
spine ref 1
trauma ref 1
upper limb ref 1
osmoregulation ref 1
osmotic equilibrium ref 1
osteogenesis imperfecta ref 1, ref 2
osteomalacia ref 1
osteomyelitis ref 1, ref 2
osteopetrosis ref 1
osteoporosis ref 1
idiopathic juvenile ref 1
osteosarcoma ref 1
otitis media ref 1
otoacoustic emissions test ref 1
outcome measurements ref 1
overlap syndrome ref 1
oxazolidinones ref 1
oxcarbazepine ref 1
oxygen therapy ref 1
emergency ref 1
oxygen-dissociation curve ref 1
oxytocin ref 1
p-value ref 1
16p11.2 microdeletion syndrome ref 1
pachygyria ref 1
pachyonychia congenita ref 1
paediatric dosing ref 1
palliative care ref 1
palpation ref 1
pancreas ref 1, ref 2
acute pancreatitis ref 1

chronic pancreatitis ref 1
function ref 1
pancreatic polypeptide ref 1
panhypogammaglobulinaemia ref 1
panhypopituitarism ref 1, ref 2
papilloedema ref 1
papillomatosis ref 1
paracetamol
poisoning ref 1, ref 2
parakeratosis pustulosa ref 1
paramyotonia congenita ref 1
parapneumonic effusions ref 1
parasitic infections ref 1
parathyroid hormone ref 1
paratyphoid ref 1
parenteral nutrition
neonate ref 1
see also total parenteral nutrition
parents, responsibilities, rights, duties and powers ref 1, ref 2
paronychia ref 1
parvovirus B19 ref 1
Patau syndrome ref 1, ref 2, ref 3
patent ductus arteriosus ref 1
Patient Advocacy and Liaison Services (PALS) ref 1
patient experience ref 1
patient safety ref 1
PCT see polymerase chain reaction
peanut allergy ref 1
pectus carinatum ref 1
pediculosis ref 1
pediculosis capitis ref 1
pedigree diagrams ref 1
pelviureteric junction obstruction ref 1
pemphigus ref 1
penicillin, absorption and pKa ref 1
pentalogy of Cantrell ref 1, ref 2
peptic ulcer disease ref 1
peri-intraventricular haemorrhage ref 1
perianal streptococcal infection ref 1
perianal warts ref 1
pericarditis ref 1
perinatal mortality rate ref 1
peripheral neurophysiology ref 1

periventricular heterotopia ref 1
periventricular leukomalacia ref 1, ref 2
periventricular-intraventricular haemorrhage ref 1
peroxisomal disorders ref 1, ref 2
persistent arterial duct ref 1
persistent ductus arteriosus ref 1
persistent fetal circulation ref 1
persistent pulmonary hypertension of newborn ref 1
Perthes disease ref 1
pertussis ref 1
pertussis vaccine ref 1, ref 2
pes excavatum ref 1
Peutz-Jeghers syndrome ref 1
PHACES syndrome ref 1
phaeochromocytoma ref 1, ref 2
phagocytes ref 1, ref 2
phagocytic disorders ref 1
pharmacodynamics ref 1
pharmacokinetics ref 1
phenylketonuria ref 1, ref 2
phenytoin ref 1
phimosis ref 1
phososensitive disorders ref 1
phosphate ref 1
phosphofructokinase deficiency ref 1
phosphorylase-b-kinase deficiency ref 1
photophobia ref 1
phototherapy ref 1
physical abuse ref 1
examination ref 1
history taking ref 1
investigation ref 1
management ref 1
predisposing factors ref 1
specific presentations ref 1
types of injuries ref 1
PIBIDS ref 1
pica ref 1
Pierre Robin syndrome ref 1, ref 2
pigmentation disorders ref 1
caf-au-lait macules ref 1
hyperpigmentation ref 1
hypopigmentation ref 1
tuberous sclerosis ref 1
pimecrolimus ref 1
pituitary gland
anatomy ref 1
anterior
disorders of ref 1
hormones of ref 1
stimulation tests ref 1
treatment of deficiencies ref 1
combined pituitary function test ref 1
disorders of ref 1
panhypopituitarism ref 1
posterior
disorders of ref 1
function tests ref 1
treatment of deficiencies ref 1
pityriasis lichenoides chronica ref 1
pityriasis rosea ref 1
pityriasis rubra pilaris ref 1
pityriasis versicolor ref 1
pKa ref 1
placental physiology ref 1
plasma cells ref 1, ref 2
platelets ref 1
functional abnormalities ref 1
plethoric lung fields ref 1
pneumococcal vaccine ref 1
Pneumocystic jiroveci pneumonia ref 1
pneumomediastinum ref 1
pneumonia ref 1
bacterial ref 1
Pneumocystic jiroveci ref 1
viral ref 1
pneumothorax ref 1, ref 2
poisoning ref 1
poisoning see toxicology
Poland syndrome ref 1
police protection ref 1
polio vaccine ref 1, ref 2
polyarteritis nodosa ref 1
polycystic kidney disease ref 1
polycythaemia ref 1, ref 2
polydipsia ref 1
polyhydramnios ref 1
polymerase chain reaction ref 1

polymicrogyria ref 1
polyposis ref 1
polysorbate ref 1
polysplenia syndrome ref 1, ref 2
polyuria ref 1
Pompe disease ref 1, ref 2
porphyria ref 1, ref 2, ref 3
port wine stain ref 1
portal hypertension ref 1, ref 2
portopulmonary hypertension ref 1
positron emission tomography ref 1
post-enteritis syndrome ref 1
posterior fossa tumours ref 1
posterior urethral valves ref 1
Potter sequence ref 1
Prader-Willi syndrome ref 1, ref 2
preauricular pits ref 1
precocious puberty ref 1
precordium, examination of ref 1
prednisolone ref 1
pregnancy, drugs in ref 1
preimplantation genetic diagnosis ref 1
prematurity ref 1
incidence and causes ref 1
mortality ref 1
outcome ref 1
small-for-gestational-age babies ref 1
prenatal testing ref 1
prescribing outside licence ref 1
progesterone ref 1
progressive familial intrahepatic cholestasis ref 1
prolactin ref 1, ref 2
propionic acidaemia ref 1
proptosis ref 1
orbital infections ref 1
orbital tumours ref 1
propylene glycol ref 1
prostacyclin ref 1
protein metabolism ref 1
protein-energy malnutrition ref 1
protein-losing enteropathy ref 1
proteins, digestion ref 1
proteinuria ref 1
prothrombin time ref 1
proximal tubule ref 1

proximal tubulopathies ref 1
prune-belly syndrome ref 1
pseudo-Bartter syndrome ref 1
pseudohypoaldosteronism ref 1
pseudohypoparathyroidism ref 1, ref 2
pseudomembranous colitis ref 1
Pseudomonas aeruginosa ref 1
pseudostrabismus ref 1
psoriasis ref 1
nail involvement ref 1
ptosis ref 1
pubertal growth spurt ref 1
puberty ref 1
delayed ref 1
discordant ref 1
hormonal control ref 1
physiology ref 1
precocious ref 1
premature thelarche ref 1
Tanner stages ref 1
pulmonary air leak ref 1
pulmonary artery band ref 1
pulmonary atresia ref 1
pulmonary hypertension ref 1, ref 2
arterial ref 1
drug therapy ref 1
hypoxemia-related ref 1
increased pulmonary blood flow ref 1
left heart disease ref 1
persistent of newborn ref 1
thromboembolic ref 1
pulmonary hypoplasia ref 1
pulmonary interstitial emphysema ref 1
pulmonary sequestration ref 1
pulmonary stenosis ref 1, ref 2
pulmonary venous hypertension ref 1, ref 2
pulse ref 1
pulse oximetry ref 1
pulseless electrical activity ref 1
pulseless ventricular tachycardia ref 1
pupils, unequal ref 1
pure-tone audiometry ref 1
purine nucleoside phosphorylase deficiency ref 1
pyloric atresia ref 1

pyloric stenosis ref 1
pyruvate kinase deficiency ref 1
pyruvate metabolism ref 1
22q11 microdeletion ref 1
quantitative fluorescence polymerase chain reaction ref 1
radionuclear angiography ref 1
radiotherapy, effects of ref 1
randomization ref 1
randomized controlled trials ref 1
ranula ref 1
rashes ref 1, ref 2
atopic eczema ref 1
infections and infestations ref 1
psoriasis ref 1
urticaria ref 1
Rastelli operation ref 1
re-feeding syndrome ref 1
re-warming ref 1
reactive arthritis ref 1
reciprocal translocations ref 1
red cells
enzyme defects ref 1
inclusions ref 1
physiology ref 1
transfusion ref 1
transfusions ref 1
red eye ref 1
reduction division ref 1
Reference Nutrient Intake ref 1
reflex sympathetic dystrophy ref 1
reflux oesophagitis ref 1
refractive errors ref 1
Refsums disease ref 1
regression analysis ref 1
Reiter syndrome ref 1
relative risk ref 1
renal arteriography ref 1
renal biopsy ref 1
renal disease ref 1
renal excretion ref 1
renal failure
acute see acute kidney injury
chronic ref 1
neonatal ref 1
renal imaging ref 1
renal osteodystrophy ref 1
renal pelvis dilatation ref 1
renal transplantation ref 1
renal tubular physiology ref 1
renal tubulopathies ref 1
collecting duct ref 1
distal tubule ref 1
loop of Henle ref 1
proximal tubule ref 1
renin ref 1
renin-angotensin-aldosterone system ref 1
repetitive behaviour ref 1
rescue breaths ref 1
research in children ref 1
research questions ref 1
respiration, control of ref 1
respiratory acidosis ref 1
respiratory alkalosis ref 1
respiratory chain disorders ref 1
respiratory failure ref 1, ref 2
apnoea ref 1
asthma ref 1
bronchiolitis ref 1
cardiac causes ref 1
pertussis ref 1
trauma and breathing difficulties ref 1
treatment ref 1
anatomy and physiology ref 1
asthma ref 1
bronchiectasis ref 1
bronchopulmonary dysplasia ref 1
cystic fibrosis ref 1
defence mechanisms ref 1
ear, nose, throat and upper airway ref 1
embryology ref 1
fetal/postnatal lung growth ref 1
infections ref 1
inhaled foreign body ref 1
pneumothorax ref 1
resuscitation
cardiac arrest ref 1

post-resuscitation management ref 1
when to stop ref 1
retinal anomalies ref 1
albinism ref 1
Coat disease ref 1
coloboma ref 1
detachment ref 1
hypertensive retinopathy ref 1
myelinated nerve fibres ref 1
sickle cell retinopathy ref 1
retinal haemorrhage ref 1
retinal infections ref 1
retinitis pigmentosa ref 1
retinoblastoma ref 1, ref 2
retinopathy of prematurity ref 1, ref 2
Rett syndrome ref 1
revalidation ref 1
reverse transcription PCT ref 1
rhabdomyosarcoma ref 1
rheumatic fever ref 1, ref 2
rheumatology ref 1
rib fractures ref 1
rickets ref 1, ref 2
ringworm ref 1
risk difference ref 1
risk management ref 1
risk ratio ref 1
risk reporting ref 1
risk reporting ref 1
rituximab ref 1
RNA ref 1
Robertsonian translocations ref 1
rocker bottom foot ref 1
root cause analysis ref 1
roseola infantum ref 1
Rothmund-Thomson syndrome ref 1, ref 2
rubella ref 1, ref 2
vaccine ref 1, ref 2
Rubinstein-Taybi syndrome ref 1
Russell-Silver syndrome ref 1
salbutamol ref 1
salmon patch ref 1
sample size ref 1
Sanfilippo syndrome ref 1
sarcoid ref 1
sarcoma, soft-tissue ref 1
SARS ref 1
scabies ref 1
scalp scaling ref 1
schistosomiasis ref 1
schizophrenia ref 1
school refusal ref 1
school-aged children
health surveillance ref 1
school refusal ref 1
sleep problems ref 1
Schwachman-Bodian-Diamond syndrome ref 1
Schwachman-Diamond syndrome ref 1
scimitar syndrome ref 1
sclera ref 1
scleritis ref 1
scleroderma ref 1
scoliosis ref 1
screening
cardiology ref 1
hearing ref 1
metabolic medicine ref 1, ref 2
screening tests ref 1
scrotal pain ref 1
sebaceous naevi ref 1
second messengers ref 1
secretin ref 1
seizures ref 1
anoxic ref 1
neonatal ref 1, ref 2
psychogenic ref 1
see also epilepsy
selective serotonin reuptake inhibitors ref 1
selenium, abnormalities ref 1
self-harm ref 1
self-mutilation ref 1
self-poisoning ref 1
sepsis ref 1
septic arthritis ref 1, ref 2
septic shock ref 1, ref 2

septo-optic dysplasia ref 1
sequential segmental arrangement, nomenclature ref 1
Serious Incident Requiring Investigation (SIRI) ref 1
severe acute respiratory syndrome (SARS) ref 1
severe combined immunodeficiency ref 1
sex hormone binding globulin ref 1
sex steroids ref 1
sexual abuse ref 1, ref 2
Shipman, Harold ref 1
shock ref 1
short stature ref 1
assessment ref 1
causes ref 1
constitutional ref 1
familial ref 1
investigation ref 1
short-bowel syndrome ref 1
short-rib polydactyly syndromes ref 1
shunt nephritis ref 1
shunt operation ref 1
shunts
left to right ref 1
mixed ref 1
right to left ref 1
sick sinus syndrome ref 1
sick thyroid syndrome ref 1
sickle cell retinopathy ref 1
sickle-cell disease ref 1
sickle-cell trait ref 1
sickle-cell-Hb C disease ref 1
SIDS see sudden infant death syndrome
significance tests ref 1
sildenafil ref 1
Silver-Russell syndrome ref 1
sinusitis ref 1
Sipple syndrome ref 1
situs ref 1, ref 2
Sjgren syndrome ref 1
Sjgren-Larsson syndrome ref 1
skeletal survey ref 1
skewed distributions ref 1
skin
biopsy ref 1
embryology ref 1
neonatal skin disorders ref 1

structure and function ref 1
skull fractures ref 1
slapped cheek syndrome see parvovirus B19
sleep disordered breathing ref 1
sleep disorders ref 1
sleep problems ref 1
sleep stages ref 1
sleepwalking ref 1
slipped capital femoral epiphysis ref 1
slit-lamp biomicroscopy ref 1
small intestine ref 1
small-for-gestational-age babies ref 1
Smith-Lemli-Opitz syndrome ref 1, ref 2
smoking, and SIDS ref 1
smoking, effects on fetus and newborn ref 1
snake bites ref 1
social skills ref 1
sodium valproate ref 1
somatic hypermutation ref 1
somatic recombination ref 1
sorbitol ref 1
Sotos syndrome ref 1
spasmus nutans ref 1
special education needs ref 1, ref 2
speech discrimination test ref 1
speech and language ref 1
clinical assessment ref 1
delay ref 1
diagnosis of problems ref 1
sphingolipidoses ref 1, ref 2
Fabry disease ref 1, ref 2
Gaucher disease ref 1, ref 2
Niemann-Pick disease ref 1, ref 2
Tay-Sachs disease ref 1, ref 2
spina bifida ref 1, ref 2, ref 3
spinal muscular atrophy ref 1, ref 2
spinal shock ref 1
Spitz naevus ref 1
squint ref 1, ref 2
stabbing ref 1
standard deviation ref 1, ref 2
standard error ref 1
staphylococcal scalded skin syndrome ref 1
statementing ref 1
statistical power ref 1

statistics ref 1
confidence intervals ref 1
correlation and regression ref 1
distributions ref 1
inappropriate summaries for numeric data ref 1
missing data ref 1
multiple testing without adjustment ref 1
non-independent measurements treated as independent ref 1
patients acting as their own controls ref 1
screening tests ref 1
significance tests ref 1
study design ref 1
testing group changes independently ref 1
status epilepticus ref 1
stavudine ref 1
sternal clefts ref 1
steroid creams ref 1
steroid sulphatase deficiency ref 1
Stevens-Johnson syndrome ref 1
stillbirth ref 1
Stills murmur ref 1
stings ref 1
stomach ref 1
storage disorders ref 1
strawberry naevi ref 1
strawberry tongue ref 1
streptokinase ref 1
stridor ref 1
study design ref 1
Sturge-Weber syndrome ref 1, ref 2, ref 3
subacute sclerosing panencephalitis ref 1, ref 2
subconjunctival haemorrhage ref 1
subdural haematoma ref 1
subglottic stenosis ref 1
sucrase-isomaltase deficiency ref 1
sudden infant death syndrome ref 1
communication checklist ref 1
definition ref 1
follow-up ref 1
incidence ref 1
physical examination ref 1
protective factors ref 1
risk factors ref 1
sample taking ref 1
support for family ref 1

suicidal behaviour ref 1
suicide ref 1
Supervision Order ref 1
supratentorial tumours ref 1
supraumbilical hernia ref 1
supraventricular tachycardia ref 1, ref 2, ref 3
surface area ref 1
surfactant deficiency ref 1
surgery ref 1
general paediatric ref 1
neonatal ref 1
suxamethonium sensitivity ref 1
swine flu ref 1
switch operation ref 1
Sydenhams chorea ref 1
syncope ref 1
syndrome of inappropriate antidiuretic hormone secretion ref 1
syphilis ref 1
syphilis, congenital ref 1, ref 2
systemic inflammatory response syndrome ref 1
systemic lupus erythematosus ref 1
drug-induced ref 1, ref 2
nephritis ref 1
T-cell receptor excision circles (TRECs) ref 1
T-cells ref 1, ref 2
T-helper cells ref 1
T-regulatory cells ref 1
t-test ref 1
tachycardia ref 1, ref 2
causes ref 1
supraventricular ref 1, ref 2, ref 3
ventricular ref 1, ref 2, ref 3
tacrolimus ref 1, ref 2
Takayasu disease ref 1
talipes equinovarus ref 1
tall stature ref 1
assessment ref 1
causes ref 1
constitutional obesity ref 1
familial ref 1
investigation ref 1
Tanner stages of puberty ref 1

Tay-Sachs disease ref 1, ref 2, ref 3, ref 4
Tays syndrome ref 1
teeth ref 1
telecanthus ref 1
telogen effluvium ref 1
temper tantrums ref 1
teratogens ref 1, ref 2
teratoma ref 1
sacrococcygeal ref 1
testes, impalpable ref 1
testicular torsion ref 1
tetanus vaccine ref 1, ref 2
tetralogy of Fallot ref 1, ref 2
thalassaemia ref 1
thanatophoric dysplasia ref 1
theophylline, half-life ref 1
thiopentone coma ref 1
Thomsen disease ref 1
thoracic surgery ref 1
throat ref 1
thrombocytopenia ref 1
alloimmune neonatal ref 1
drug-induced ref 1
neonatal isoimmune ref 1
thrombocytopenia and absent radius syndrome ref 1
thyroglossal cyst ref 1
thyroid gland ref 1
anatomy ref 1
disorders
hyperthyroidism ref 1
hypothyroidism ref 1
neoplasia ref 1
physiology ref 1
thyroid-stimulating hormone ref 1
tiagabine ref 1
tics ref 1, ref 2
tinea ref 1
tinea capitis ref 1
tinea corporis ref 1
tinea cruris ref 1
tinea pedis ref 1
tinea versicolor ref 1

tissue plasminogen activator ref 1
toddlers diarrhoea ref 1
toe walking ref 1
tonsillitis ref 1
topiramate ref 1
torticollis ref 1
total anomalous pulmonary venous connection ref 1
total body water ref 1, ref 2
total parenteral nutrition ref 1, ref 2
complications ref 1
home ref 1
indications for ref 1
monitoring ref 1
prescribing ref 1
Tourettes syndrome ref 1
toxic epidermal necrolysis ref 1
toxic shock syndrome ref 1
toxicology ref 1
aspirin overdose ref 1
button batteries ref 1
carbon monoxide ref 1
iron ref 1
lead poisoning ref 1
paracetamol ref 1
tricyclic antidepressants ref 1
toxocariasis ref 1
toxoplasmosis ref 1, ref 2
tracheitis ref 1
tracheo-oesophageal fistula ref 1, ref 2, ref 3
tracheomalacia ref 1
transient hypogammaglobulinaemia of infancy ref 1
transient neonatal pustulosis melanosis ref 1
translocations ref 1
transposition of great arteries ref 1, ref 2
trauma ref 1, ref 2
and breathing difficulties ref 1
travellers diarrhoea ref 1
tricarboxylic acid cycle ref 1
trichothiodystrophy ref 1, ref 2
trichotillomania ref 1
tricuspid atresia ref 1
tricyclic antidepressants, poisoning ref 1
trigger thumb ref 1

trinucleotide repeat disorders ref 1
triple X syndrome ref 1
triploid ref 1
trisomy ref 1, ref 2
tropical diseases ref 1
truancy ref 1
tuberculin tests ref 1
tuberculosis ref 1, ref 2
congenital ref 1
diagnosis ref 1
neonatal contact for mothers ref 1
symptoms and signs ref 1
treatment ref 1
tuberous sclerosis ref 1, ref 2, ref 3, ref 4, ref 5, ref 6
tumour-lysis syndrome ref 1
Turner syndrome ref 1, ref 2
Turners syndrome ref 1
twenty nail dystrophy ref 1
tympanometry ref 1
type I errors ref 1
type II errors ref 1
typhoid ref 1
tyrosinaemia ref 1
tyrosine kinase receptors ref 1
ulcerative colitis ref 1
ultrasonography
ocular ref 1
renal ref 1
umbilical hernia ref 1
UN Convention of Rights of the Child ref 1
unbalanced translocations ref 1
undescended testis ref 1
upper airway obstruction ref 1
intentional ref 1
urate ref 1
urea cycle defects ref 1, ref 2
ureterocele ref 1
urinalysis ref 1
urinary tract
congenital abnormalities ref 1
infection ref 1
urine microscopy ref 1
urological abnormalities ref 1
urticaria ref 1
urticaria pigmentosa ref 1
utilitarianism ref 1
uveal tract disorders ref 1
uveitis ref 1
anterior ref 1
posterior ref 1
vaccination
Bacillus Calmette-Gurin (BCG) vaccine ref 1, ref 2, ref 3
diphtheria ref 1
Haemophilus influenzae type B vaccine ref 1, ref 2
hepatitis B ref 1, ref 2
immunosuppressed patients ref 1
live vaccines ref 1
meningitis C ref 1, ref 2
MMR ref 1, ref 2
pertussis ref 1, ref 2
polio ref 1, ref 2
rubella ref 1, ref 2
tetanus ref 1, ref 2
vaccinations, reactions to ref 1
VACTERL ref 1
varicella, congenital ref 1
varicella zoster virus ref 1
vascular malformations ref 1
vascular rings ref 1
vascular slings ref 1
vasoactive intestinal peptide ref 1
VATER (VACTERL) association ref 1
venous hum ref 1
venous thrombosis ref 1
ventilation ref 1
ventilatory support ref 1
ventricular fibrillation ref 1
ventricular septal defect ref 1, ref 2
ventricular tachycardia ref 1, ref 2, ref 3
ventriculoarterial connection ref 1
vernal conjunctivitis ref 1
very low-density lipoprotein ref 1
vigabatrin ref 1
viral conjunctivitis ref 1
viral haemorrhagic fevers ref 1
viral infections ref 1
virtue ethics ref 1
vision ref 1
visual acuity ref 1
visual evoked potentials ref 1
visual fields ref 1
visual impairment ref 1
visual loss, acquired ref 1
vitamin A ref 1
vitamin B12 ref 1
vitamin D ref 1, ref 2
metabolism ref 1
vitamin E ref 1
vitamin K ref 1
deficiency ref 1, ref 2
vitiligo ref 1
volume of distribution ref 1
von Gierke disease ref 1
von Hippel-Lindau disease ref 1, ref 2
von Recklinghausens disease ref 1
von Willebrand disease ref 1, ref 2
wardship ref 1, ref 2
warfarin ref 1
warts ref 1
perianal ref 1
water regulation ref 1
watering eye ref 1
Wegener granulomatosis ref 1
weight ref 1
Wermer syndrome ref 1
West Nile virus ref 1
wet wraps ref 1
white cells
lymphocytes ref 1
phagocytes ref 1
Williams syndrome ref 1, ref 2
Wilms tumour ref 1
Wilson disease ref 1, ref 2, ref 3, ref 4, ref 5
Wiskott-Aldrich syndrome ref 1, ref 2
Wolff-Hirschhorn syndrome ref 1
X-linked adrenoleukodystrophy ref 1, ref 2
X-linked agammaglobulinemia ref 1, ref 2, ref 3
X-linked chronic granulomatous disease ref 1
X-linked dominant conditions ref 1
X-linked hyper-IgM syndrome ref 1
X-linked hypophosphataemic rickets ref 1

X-linked lymphoproproliferative disease ref 1
X-linked recessive conditions ref 1
X-linked recessive ichthyosis ref 1
xeroderma pigmentosum ref 1
47,XYY males ref 1
Zellweger syndrome ref 1, ref 2, ref 3
zidovudine ref 1
zinc ref 1
abnormalities ref 1
Zollinger-Ellison syndrome ref 1
ENDNOTES
1. Where two or more injections are required at once, these should ideally be given in different
limbs. Where this is not possible, injections in the same limb should be given 2.5 cm apart.
2. Please refer to notes above for general contraindications to immunizations.
3. All immunizations may be complicated by local or general side effects as discussed above.
DTP, diphtheria + tetanus + pertussis; DT, diphtheria + tetanus; OPV, oral polio vaccine; Hib,
Haemophilus influenzae type b; MMR, measles, mumps, rubella; CSM, Committee on Safety of
Medicines (now the Commission on Human Medicines, incorporating the CSM and the Medicines
and Healthcare products Regulatory Agency); Men C, meningitis C.
4. The Back to Sleep Campaign, whereby parents are educated re the protective effect of supine
infant sleeping, is well documented to have led to a very significant drop in the incidence of SIDS in
the UK over the last two decades. Similar campaigns have also been successful in other countries
such as New Zealand, Scandinavia and the USA.
5. Smoking increases the risk of SIDS by up to threefold. There is an increase in risk with increased
likelihood of spontaneous apnoea and decreased ability to compensate after such an episode. Such
effects are likely to be enhanced by intercurrent illness.
6. Do not confuse with glucose-6-phosphate dehydrogenase deficiency (favism) which is X-linked
recessive.
Most metabolic disorders are autosomal recessive remember the exceptions.
7. Conditions that can also present as acute liver failure
8. The e antigen is absent in pre-core mutant.
9. If abnormal consider MCUG (micturating cystourethrogram).
10. Although MCUG should not be performed routinely it should be considered if the following
features are present: dilatation on ultrasonography, poor urine flow, non-E. coli-infection, family
history of vesicoureteric reflux.
11. Ultrasonography in toilet-trained children should include assessment of post-micturition bladder
volume, as a guide to bladder emptying.
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2012 PASTEST LTD

PasTest Revision Books and Intensive Courses

Text prepared in the UK by Keytec Typesetting Ltd, Bridport, Dorset

Fax: 01565 650264

Nancy Tan and Anil Dhawan

Contributors to the Third Edition

Dr R M Beattie BSc MBBS MRCP FRCPCH

Hemant S Bhavsar MBBS DCH MRCPCH MD

Natalie L E Canham MBChB BA (Hons) MRCP (Paeds)

Michael L Capra MBBCH DCH Dip. Obst FRPCH MMedSci (Clinical

Michael P Champion BSc MBBS MRCP FRCPCH

Ruth Charlton MBBS MRCP MRCPCH

Serena Cottrell BSc (Hons) MBBS MRCPI MMed Sci FRCPCH

Jane C Davies MBChB MRCP MRCPCH MD

Professor Anil Dhawan MD FRCPCH

Grenville F Fox MBChB MRCP FRCPCH

Foundation Trust, London

Professor Bobby Gaspar BSc MBBS MRCP (UK) PhD MRCPCH

Helen M Goodyear MBChB MRCP FRCPCH MD MMed

Nathan Hasson MBChB FRCPCH

Professor Nigel Klein BSc MBBS MRCP FRCPCH PhD

Vic Larcher BA MA MB BChir MRCP FRCPCH

Pamela Lee MBBS MRCPCH

Merrill McHoney FRCS(Paed Surg) PhD

Heather Mitchell BM.BCh MD MA FRCPCH MRCP(Paeds) MRCGP DCH

Karyn Moshal MBChB MRCP (UK) MRCPCH DTM+H

Vasanta R Nanduri MBBS DCH MRCP MD FRCPCH

Ken K Nischal FRCOphth

Joanne Philpot BA MBBS MD DCH MRCPCH

Christopher J D Reid MB ChB MRCP (UK) FRCPCH

Vel K Sakthivel FRCS(Ed), FRCS (Orth)

Neil H Thomas MA MB MChir FRCP FRCPCH DCH

Rebecca Thursfield MBChB MRCPCH

Stephen R Tomlin FRPharmS ACPP

Robert M R Tulloh MA DM FRCP FRCPCH

Angie M Wade MSc PhD CSTAT ILTM

Robert Wheeler FRCS MS LLB(Hons) LLM

Preface to the Third Edition

2. Basic cardiac physiology

6. Obstruction in the well child

7. Obstruction in the sick newborn

8. Non-bypass surgery for congenital heart disease

9. Bypass surgery for congenital heart disease

10. Syndromes in congenital heart disease

11. Syncope in childhood

13. Drug therapy for congenital heart disease

14. Acquired heart disease

16. Chest X-rays

17. Cardiac catheterization

19. Further reading

1. DIAGNOSIS OF CONGENITAL HEART DISEASE

Used to be called golf balls

1.2 Epidemiology of congenital heart disease

Incidence also increased by:

Presence of other anomaly or syndrome

1.3 Cardiac anatomy

1.4 Nomenclature for sequential segmental arrangement

Atrial arrangement (atrial situs)

Atrioventricular (AV) connection

Ambiguous (with atrial isomerism)