Essential Paediatrics in Primary Care

A. Sahib El-Rahdi, Steve Gregson, Paul Navreet, Asad Rahman

• Verlag: CRC Press
• Jahr: 2021
• ISBN:
  9781000477108
• Auflage: 1
• Thema: Medicine
• Thema: Family Medicine & General Practice

'Anyone practising generalist paediatrics should have the material within these chapters either hard-wired in, or at the fingertips. This book is ideal for the primary care bookshelf...The authors have ensured that clinicians' paediatric knowledge and skills can only grow with familiarity of their material.' From the Foreword by John Spicer Essential Paediatrics in Primary Care covers the entire breadth of paediatric practice. Written by a team with frontline experience of the challenges and dilemmas faced in diagnosing and treating children in primary care, this practical text contains clear, evidence-based guidance about managing children in primary care and considers when referral to hospital is appropriate. The concise, list-based format enables a rapid, confident and knowledgeable diagnosis to be reached in the short time available in general practice. This reference book is invaluable for General Practitioners and GP trainees wanting to keep abreast of recent progress in paediatric care, but is also ideal for nurse practitioners, health visitors, medical students and paediatricians considering a career in general practice.

CHAPTER 1

The newborn

NEONATAL HEALTH PROMOTION

(See Table 1.1)

TABLE 1.1 Health promotion offered to children up to 4 months of age

Age	Intervention
Soon after birth	General examination with particular emphasis on eyes, heart, hips Vitamin K administration: usually offered as a single IM dose. Some parents choose the oral preparation, in which case this is given at birth, at 7–10 days and at 28 days BCG vaccination is offered to: ❍ All infants living in areas of the UK where the annual incidence is ≥ 40/100 000 ❍ All infants with a parent or grandparent who was born in a country where the annual incidence is ≥ 40/100 000 Hepatitis B vaccine: the first dose is given to babies whose mothers or close family have been infected with hepatitis B (see also Chapter 8) Advice regarding reducing the risk of sudden infant death
5–6 days old	Blood spot test for hypothyroidism, phenylketonuria. Screening for sickle cell disease and cystic fibrosis
First month	Newborn hearing screen Hepatitis B vaccine: 2nd dose if this was given after birth
New-birth visit (around 12 days)	Home visit by the midwife or health visitor to assess the child and family health needs, including identification of mental health needs Distribution of ‘Birth to Five’ guide and the personal Child Health record
6–8 weeks	General physical examination with particular emphasis on eyes, heart and hips Immunisation: see Table 1.2 Review of general progress and delivery of key messages about parenting and health promotion Hepatitis B vaccine: 3rd dose
3 months	Immunisation: see Table 1.2
4 months	Immunisation: see Table 1.2

BCG = Bacillus Calmette-Guérin; IM = intramuscularly.

TABLE 1.2 Normal immunisation schedule for all people < 18 years in the UK

Age	Immunisation
2 months	DTaP/IPV/HiB (1st dose), plus
	PCV in a separate injection, plus
	Rotavirus (orally)
3 months	DTaP/IPV/HiB (2nd dose), plus
	Men C in a separate injection, plus
	Rotavirus (orally)
4 months	DTaP/IPV/HiB (3rd dose), plus
	Men C in a separate injection, plus
	PCV (2nd dose) in a separate injection
12–13 months	HiB/Men C (as one injection), plus
	MMR (as one injection), plus
	PCV (3rd dose) in a separate injection
3 years +	Pre-school booster of DTaP/IPV, plus
	MMR
12–13 years (girls)	HPV in three injections: the 2nd one is given 1–2 months after the 1st; and the
	3rd is given about 6 months after the 1st
13–15 years	Td/IPV booster
	Men C booster in a separate injection

DTaP = diphtheria, tetanus and pertussis; HiB = Haemophilus influenzae type B; HPV = Human papillomavirus; IPV = polio; Men C = meningitis C; MMR = measles, mumps and rubella; PCV = pneumococcal conjugate vaccine; Td/IPV = Tetanus, low dose diphtheria and polio.

NEONATAL EXAMINATION (THE BABY CHECK)

GPs and midwives may be required to perform a neonatal examination soon after birth for home deliveries and where there is early discharge from obstetric units. GPs routinely perform a baby examination at 6 weeks. The examination aims to:

• ➤ Detect congenital abnormalities which may be present in 3–5% of infants. These should be explained to parents, recorded and referred if appropriate.
• ➤ Establish a baseline for subsequent examination.
• ➤ Ensure there are no signs of infection or metabolic disease.
• ➤ Perform measurements of weight and head circumference (HC) and plot them on a centile chart. A newborn’s weight may decrease 10% below birthweight in the first week, but should regain or exceed birthweight by 14 days of life. Newborns should grow at approximately 25–30 g/day during the first three months.

Neonatal examination should include the following areas:

• ➤ Review of family history, including maternal diseases, sexually transmitted disease, medications (Box 1.1), and alcohol and tobacco consumption.
• ➤ Parental concerns should be elicited.
• ➤ General examination: Much information can be gained by simple observation without disturbing the child. Is the general appearance normal? Does the baby look well nourished? Are there any dysmorphic features?

BOX 1.1 Drugs which cross the placenta and may have an adverse effect, including teratogenicity on the unborn baby

• Anaesthetics and sedatives, e.g. halothane causing alteration of DNA synthesis in vitro reported to cause skeletal defects
• Anticoagulants (e.g. warfarin causing an embryopathy with growth retardation, skeletal and CNS abnormalities)
• Antibiotics (e.g. aminoglycosides causing 8th cranial nerve toxicity; tetracyclines producing dental discolouration, enamel hypoplasia)
• Cytotoxic drugs (e.g. methotrexate causing craniofacial anomalies)
• Alcohol, causing fetal alcohol syndrome
• Tobacco smoking, causing an increased incidence of growth retardation and developmental delay
• Oestrogens, causing precocious puberty and cervical/vaginal adenocarcinoma near puberty
• Anticonvulsants (e.g. phenytoin causing fetal hydantoin syndrome)
• Addicting drugs (e.g. cocaine causing eye and skeletal defects)
• Psychotherapeutics (e.g. lithium causing heart valve defects, Ebstein’s anomaly)
• Analgesics (e.g. aspirin associated with skeletal and heart defects, cleft lip and palate, hypospadias)

• ➤ Skin:
  • ➣ Colour is an important index of the function of the cardiorespiratory system. Normal colour in Caucasian infants is reddish pink. Infants of diabetic mothers are pinker than average.
  • ➣ Evidence of jaundice, best detectable in bright natural light.
  • ➣ Peripheral cyanosis, caused by peripheral circulatory instability.
  • ➣ Mottling (cutis marmorata) may be due to circulatory instability.
  • ➣ Capillary haemangioma (see ‘Birthmarks’ below).
• ➤ Skull (Fig 1.1):
  • ➣ Palpation of the suture lines and the size and tension of the anterior fontanelle is performed. Great v...