Paediatrics

Ordering relevant investigations and making an appropriate paediatric diagnosis Paediatric diagnosis begins with stabilisation, history and examination. Tests should answer a specific question, change management or identify a dangerous alternative. Children have smaller blood volume, age-dependent reference ranges and different pre-test probabilities; indiscriminate testing causes iatrogenic anaemia, false positives, cost and delayed treatment. Order the smallest set of tests that safely distinguishes urgent diagnoses and guides treatment; never let a test delay resuscitation. Learning objectives Formulate a problem representation and prioritised differential before ordering tests. Select age-appropriate laboratory, microbiological and imaging investigations. Interpret results using age, gestation, nutrition, treatment and local disease prevalence. Recognise when bedside tests, referral or empiric treatment are more appropriate than extensive testing. Communicate results, uncertainty, follow-up and safety-netting to families. Diagnostic reasoning sequence Stabilise: airway, breathing, circulation, disability, exposure, glucose, oxygen and urgent treatment. Define the syndrome: respiratory distress, fever, diarrhoea/dehydration, seizure, jaundice, anaemia, malnutrition, rash or developmental concern. Estimate pre-test probability: age, exposure, immunisation, malaria/TB/HIV prevalence, season and comorbidity. Choose a focused test: ask what result would change management. Interpret in context: compare with age-specific ranges and clinical trajectory. Act and reassess: treat, observe, refer or repeat testing only when justified. Core investigations Test Common questions answered Important cautions Point-of-care glucose Hypoglycaemia in altered, shocked, malnourished or very young child Treat severe low glucose immediately; confirm unexpected values Pulse oximetry Hypoxaemia and need for oxygen/referral Check probe, perfusion, motion and waveform Full blood count Anaemia, leukocytosis/leukopenia, platelets Age-specific ranges; malaria, HIV and malnutrition alter results Blood film/RDT Malaria parasites where endemic; morphology Negative test does not exclude other causes of fever Urinalysis/culture UTI, renal disease, dehydration, diabetes Collection method strongly affects contamination Electrolytes/renal/liver tests Dehydration, renal injury, jaundice, drug safety Interpret with fluid status and age Blood culture Sepsis/meningitis pathogen before antibiotics Do not delay antibiotics in a critically ill child Investigating common syndromes Fever Assess danger signs and local malaria risk. Test for malaria where indicated, obtain urine testing in infants with unexplained fever, and take blood cultures for suspected sepsis. Consider HIV, TB, typhoid, meningitis, pneumonia, inflammatory disease and malignancy according to history and examination. Avoid broad “fever panels” without a clinical question. Cough or difficult breathing Pulse oximetry is central. Chest radiograph is reserved for severe, atypical, persistent or complicated disease, suspected foreign body, heart failure or tuberculosis. Viral PCR may be useful in selected outbreaks or isolation decisions but does not replace clinical assessment. Blood tests are not routinely required for uncomplicated bronchiolitis. Diarrhoea and vomiting Clinical dehydration classification comes first. Check glucose and electrolytes in severe dehydration, shock, prolonged vomiting, renal disease or altered consciousness. Stool microscopy/culture is indicated for blood, suspected cholera, persistent disease, outbreak investigation or immunocompromise. Test for parasites according to duration and local epidemiology. Seizure or altered consciousness Check glucose immediately, assess malaria risk and meningitis signs, and consider electrolytes, calcium, toxicology and neuroimaging based on context. Lumbar puncture is urgent when meningitis is suspected after stabilisation and appropriate imaging precautions; never delay empiric antibiotics in a child with suspected bacterial meningitis. Malnutrition Measure weight, length/height, MUAC and oedema. Investigate glucose, haemoglobin, infection and electrolytes in complicated severe acute malnutrition. Chest radiograph, HIV/TB tests, stool or endocrine studies are targeted to clinical clues, not routine in every child. Imaging and procedures Ultrasound: no ionising radiation; useful for abdomen, kidneys, pylorus, collections, heart and some lung disease. Radiographs: use justified views and shielding; interpret with age and clinical findings. CT/MRI: reserve for urgent structural, neurological or complicated disease; weigh radiation, sedation and transfer risks. Lumbar puncture: obtain after stabilisation when meningitis/encephalitis is suspected; check contraindications and measure opening pressure when relevant. Blood sampling: minimise volume, use paediatric tubes and document total blood taken, particularly in neonates and chronically ill children. Reference ranges and test performance Use the laboratory’s age-, sex- and method-specific reference ranges. Gestational age, prematurity, altitude, dehydration, recent transfusion, nutrition and medicines can shift results. Sensitivity, specificity, positive predictive value and negative predictive value depend on prevalence. A normal test may not exclude disease early; a weakly positive test may be false positive when pre-test probability is low. Do not treat the number alone: a laboratory abnormality without a compatible syndrome may represent age variation, sampling error or a non-causal finding. Reassess the child and verify unexpected critical results. Making the diagnosis State the level of certainty: confirmed, probable, possible or ruled out. Separate syndrome from cause (for example, “severe pneumonia with hypoxaemia, likely bacterial”); list immediate threats, comorbidities and social risks. Include severity, complications and response to treatment. When evidence is insufficient, document a working diagnosis and a clear reassessment plan. Communicating results and safety-netting Explain what was tested, what it means, what remains uncertain and what happens next. Give written or demonstrated medication instructions and return precautions. Tell caregivers to return urgently for worsening breathing, inability to drink, repeated vomiting, convulsion, lethargy, cyanosis, reduced urine, persistent fever or new rash. Arrange review of pending cultures, imaging and pathology; never assume the family will be contacted automatically. OSCE checklist Stabilises first and checks glucose/oxygen when indicated. Forms a differential before ordering tests. Chooses age-appropriate, question-driven investigations. Uses local prevalence and age-specific reference ranges. Explains consent, pain reduction, risks, results and follow-up. References SlideShare: Common laboratory investigations in paediatric practice. WHO IMCI and Pocket Book of Hospital Care for Children. WHO child growth standards and Uganda Clinical Guidelines. Safety note: Follow current local protocols for test availability, referral, antibiotic timing, blood-volume limits and interpretation.

Key terms in paediatrics: a clinical foundation Paediatrics is the branch of medicine concerned with the health, growth, development and illness of newborns, infants, children and adolescents. A child is not simply a small adult: normal physiology, drug handling, communication, disease patterns, safeguarding duties and family-centred decision-making change continuously with age. Accurate terminology is therefore essential before examination, prescribing or interpreting statistics. Always record exact age, weight, gestational age, developmental stage and caregiver concerns before making a paediatric assessment. Learning objectives Define the age groups used in newborn and child health. Use terms for growth, development, prematurity, nutrition and illness severity correctly. Distinguish chronological age, corrected age and developmental age. Apply paediatric terminology to history, examination, dosing and referral. Recognise terms that trigger urgent assessment or safeguarding action. Age groups Term Usual definition Clinical importance Fetus Unborn baby from implantation to birth Assess gestational age, fetal growth and antenatal risks Newborn/neonate Birth to 28 completed days High risk of sepsis, respiratory transition problems, jaundice and feeding failure Early neonate Birth to 7 days Birth asphyxia, prematurity, infection and congenital conditions dominate Late neonate 8–28 days Late sepsis, jaundice, feeding and congenital problems remain important Infant Birth to 12 months Rapid growth, immunisation, nutrition and developmental surveillance Child 1–9 years in many clinical programmes Growth, school health, infections and injury prevention Adolescent 10–19 years (WHO convention) Puberty, mental health, sexual/reproductive and risk behaviours Age and maturity terms Chronological and corrected age Chronological age is time since birth. Corrected age is used for a preterm infant until roughly two years: chronological age minus the weeks born before 40 weeks. For example, a 16-week-old infant born at 32 weeks has a corrected age of 8 weeks. Use corrected age when judging development, feeding and growth, but record both ages clearly. Gestational age Gestational age is completed weeks from the first day of the last menstrual period or the best obstetric estimate. A term newborn is usually 37+0 to 41+6 weeks; preterm is below 37 weeks. Very preterm is below 32 weeks and extremely preterm below 28 weeks. Confirm the local definition used by the service. Birth-weight categories Low birth weight is below 2,500 g, very low below 1,500 g and extremely low below 1,000 g. Small for gestational age (SGA) means birth weight below the 10th centile; large for gestational age (LGA) above the 90th. These are not interchangeable: a preterm infant can be appropriate for gestational age while still weighing less than 2,500 g. Growth and nutrition terminology Growth: measurable increase in size—weight, length/height, head circumference and body proportions. Development: progressive acquisition of motor, language, cognitive, social and emotional skills. Growth faltering: inadequate weight gain or downward crossing of centiles; investigate feeding, infection, malabsorption, neglect and social factors. Wasting: low weight-for-length/height, usually acute or recent undernutrition. Stunting: low length/height-for-age, reflecting chronic nutritional or health insult. Underweight: low weight-for-age; it does not distinguish wasting from stunting. Severe acute malnutrition: very low weight-for-height, severe visible wasting or nutritional oedema according to current WHO/UNICEF criteria. Exclusive breastfeeding: breast milk only, apart from prescribed medicines, for the first six months where possible. Developmental terminology Milestones are expected skills, not rigid deadlines. Gross motor includes posture and movement; fine motor includes hand use; language includes understanding and expression; personal-social development includes interaction and self-care. Regression—loss of a previously acquired skill—is always abnormal until proven otherwise. Developmental delay means slower acquisition; global developmental delay affects multiple domains; disability describes functional limitation in the context of environmental barriers. Clinical severity and paediatric emergencies Danger signs require immediate action: inability to drink or breastfeed, repeated vomiting, convulsions, lethargy/unconsciousness, severe respiratory distress, central cyanosis, shock, severe dehydration, hypoglycaemia, severe malnutrition with complications or suspected safeguarding emergency. Well child means no acute illness and normal function for age. Acute illness has recent onset; chronic disease persists or recurs and may affect growth/development. Comorbidity means additional disease; multimorbidity means several ongoing conditions. Complex care involves interacting medical, developmental, family and social needs. Communication and consent Family-centred care: respect caregivers as partners while communicating directly with the child at an age-appropriate level. Assent: a child’s affirmative agreement when developmentally able; legal consent follows local law and capacity rules. Best interests: decisions should maximise safety, health, development and dignity. Confidential adolescent care: explain limits of confidentiality, assess safety and involve caregivers when appropriate and lawful. Safeguarding: unexplained injuries, inconsistent history, fearful behaviour, neglect, sexualised behaviour or failure to thrive require careful documentation and referral. Medication and procedure terms Paediatric prescriptions use weight-based or body-surface-area dosing, but never estimate weight casually when a scale is available. Specify concentration, dose in mg and mL, route, interval, maximum dose and duration. Neonatal dosing may depend on gestational/postnatal age and renal function. Maintenance fluid is not the same as resuscitation fluid. Procedural analgesia and preparation are part of safe care, not optional extras. Exam pearls Corrected age matters for preterm developmental assessment. SGA, low birth weight and prematurity describe different dimensions. Regression is more concerning than isolated mild delay. Exact weight and concentration prevent common dosing errors. A child’s voice and dignity remain central even when the caregiver gives the history. References SlideShare: Pediatric terminology. WHO child-health, growth and development standards. Uganda Clinical Guidelines and national paediatric protocols. Safety note: Age bands and legal consent rules can vary; follow current Ugandan policy and institutional guidance.

Child rights and child-survival strategies Child survival is both a clinical goal and a rights obligation. The United Nations Convention on the Rights of the Child recognises every child’s rights to life, survival and development, non-discrimination, participation, health, education, protection and a family environment. In practice, paediatric care combines prevention, early recognition of illness, quality treatment, safeguarding and action on the social determinants that decide whether a child can reach a health facility and recover. A survival programme succeeds only when families can access respectful, affordable, high-quality care without discrimination. Learning objectives Explain the major child-rights principles relevant to clinical care. Describe evidence-based survival interventions from pregnancy through adolescence. Apply integrated community, primary-care, hospital and referral strategies. Identify barriers, inequities and safeguarding risks that increase preventable deaths. Measure programme performance using coverage, quality and outcome indicators. Core child-rights principles Principle Meaning in paediatrics Practical action Non-discrimination Every child receives care regardless of sex, disability, HIV status, ethnicity, poverty or legal status Remove fees, bias and inaccessible communication Best interests Decisions prioritise safety, health, development and dignity Balance risk, benefit and the child’s voice Survival and development Life-saving care includes nutrition, stimulation, protection and mental health Link treatment to follow-up and early childhood development Participation Children are heard according to age and maturity Explain procedures and seek assent where appropriate Protection Children must be protected from violence, abuse, exploitation and neglect Recognise, document and report safeguarding concerns Continuum of care Before and during pregnancy Survival begins with girls’ education, nutrition, family planning, prevention of adolescent pregnancy, antenatal care, HIV/syphilis/malaria prevention, screening for hypertension and diabetes, and a skilled birth attendant. Birth preparedness and referral plans reduce delays. Respectful maternity care protects both mother and newborn. Birth and the first week Essential newborn care includes thermal protection, immediate skin-to-skin contact, early breastfeeding, clean cord care, newborn resuscitation readiness, infection prevention, danger-sign recognition and timely referral. Prematurity, sepsis, birth asphyxia and congenital problems require skilled assessment. Infancy and childhood High-impact measures include immunisation, exclusive breastfeeding, appropriate complementary feeding, vitamin and micronutrient support where indicated, malaria prevention, oral rehydration and zinc for diarrhoea, pneumonia recognition and antibiotics when indicated, deworming programmes, HIV care, growth monitoring and developmental support. Adolescence Adolescent survival requires mental-health support, injury and violence prevention, sexual and reproductive-health services, HIV/STI prevention, menstrual health, substance-use prevention and confidential, respectful care. Integrated strategies Integrated Management of Childhood Illness Use an integrated approach: assess danger signs, classify illness, treat more than one condition, counsel caregivers, check feeding and arrange follow-up/referral. A single-disease mindset misses malnutrition, malaria, pneumonia, diarrhoea and HIV coexisting in the same child. Community health Community workers support antenatal linkage, immunisation, breastfeeding, sanitation, malaria prevention, home care and early referral. Families need practical messages, not blame. Quality primary care Reliable triage, essential medicines, oxygen, diagnostics, infection prevention, trained staff and respectful communication prevent avoidable deterioration. Referral systems Use clear danger-sign criteria, transport plans, pre-referral treatment, referral notes and feedback to the sending facility. Referral is a clinical intervention, not simply an address. Seven major causes and cross-cutting interventions Prematurity/low birth weight: antenatal corticosteroids where indicated, kangaroo mother care, thermal support, feeding and neonatal infection prevention. Birth complications: skilled attendance, neonatal resuscitation, monitoring and timely operative/referral care. Pneumonia: vaccination, nutrition, smoke reduction, pulse oximetry/oxygen and prompt antibiotics for bacterial disease. Diarrhoea: safe water, sanitation, breastfeeding, rotavirus vaccination, ORS, zinc and continued feeding. Malaria: insecticide-treated nets, vector control, testing and effective treatment; protect pregnant women and infants. Malnutrition: breastfeeding, food security, growth surveillance, treatment of severe acute malnutrition and management of underlying infection. Injuries/violence: safe environments, supervision, child protection, road safety and trauma referral. Equity and social determinants Survival gaps reflect poverty, rural distance, conflict, disability, gender discrimination, low maternal education, food insecurity, unsafe water, poor housing and weak transport. Programmes should disaggregate data by district, sex, wealth, disability and residence. Universal health coverage means services are reachable, acceptable, affordable and effective—not merely available on paper. Never label a preventable death as “caregiver failure” without examining system barriers: transport, cost, medicine stock-outs, disrespect, late recognition and referral delays often interact. Safeguarding in clinical practice Ask privately when abuse, exploitation, child marriage, trafficking or neglect is suspected. Document the child’s words exactly, injuries objectively and actions taken. Follow Ugandan child-protection reporting pathways; do not promise secrecy that cannot be kept. Provide trauma-informed care and avoid repeated, leading questioning. Ensure disability-inclusive communication and safe discharge planning. Monitoring strategy Track input indicators (staff, medicines, oxygen), process indicators (immunisation, antenatal and postnatal coverage, triage time), output indicators (treated pneumonia/diarrhoea, breastfeeding support, referrals completed) and outcome indicators (neonatal, infant and under-five mortality, case fatality, readmission and disability-free survival). Audit deaths for modifiable factors and close the feedback loop. Exam and OSCE pearls The four general CRC principles are non-discrimination, best interests, survival/development and participation. Child survival is a continuum from preconception to adolescence, not only treatment of sick children. IMCI integrates assessment, classification, treatment, counselling and referral. Quality and equity matter as much as numerical service coverage. Safeguarding is part of every paediatric consultation. References SlideShare: Child survival strategies. UNICEF: Convention on the Rights of the Child. WHO/UNICEF child-survival, IMCI and Every Newborn Action Plan guidance. Uganda national child-health and safeguarding policies.

Vital statistics for child survival Vital statistics describe births, deaths, causes of death and population denominators. They allow clinicians, hospitals and ministries to identify preventable deaths, compare communities fairly, plan services and evaluate whether child-survival interventions work. A rate is not a story about an individual child: it is a population measure whose denominator, time period, data source and uncertainty must always be stated. Before interpreting a child-health number, ask: who was counted, what was the denominator, what time period was used, and how complete was registration? Learning objectives Define neonatal, infant, child and under-five mortality measures. Calculate rates, ratios, proportions and case-fatality measures correctly. Interpret live births, stillbirths, perinatal mortality and life expectancy indicators. Recognise sources of bias and limitations in civil registration, surveys and facility data. Use vital statistics to target interventions and audit quality. Key definitions Indicator Definition/formula Use Crude birth rate Live births in a year ÷ mid-year population × 1,000 Population fertility and service planning Neonatal mortality rate Deaths age 0–27 days ÷ live births × 1,000 Quality of pregnancy, birth and newborn care Early neonatal mortality Deaths during first 7 days ÷ live births × 1,000 Birth and immediate newborn care Post-neonatal mortality Deaths age 28 days to under 1 year ÷ live births × 1,000 Infections, nutrition, immunisation and home care Infant mortality rate Deaths before 1 year ÷ live births × 1,000 Overall first-year survival Child mortality (1–4 years) Deaths age 1–4 years ÷ relevant population or life-table denominator Childhood disease and injury burden Under-five mortality rate Probability of dying before age 5 per 1,000 live births SDG 3.2.1 and national child-survival progress Stillbirth rate Stillbirths ÷ total births × 1,000 Fetal and intrapartum care Perinatal mortality rate Stillbirths plus early neonatal deaths ÷ total births × 1,000 Care around labour and first week Important distinctions A ratio compares two quantities; a proportion is a numerator included in its denominator; a rate incorporates a population at risk and time. Mortality rates are often reported per 1,000 live births, whereas case-fatality is deaths among diagnosed cases, usually as a percentage. Never compare a facility case-fatality percentage with a population mortality rate as if they were equivalent. Live birth and stillbirth A live birth shows any sign of life after complete expulsion or extraction—breathing, heartbeat, umbilical pulsation or movement—regardless of gestational age. A stillbirth is fetal death before or during birth after the locally defined gestational/weight threshold. Accurate classification prevents the hidden loss of newborn deaths in stillbirth counts. Maternal and child link Maternal mortality, neonatal mortality and stillbirths share determinants such as antenatal access, hypertension, infection, nutrition, skilled birth attendance and referral. Child-survival dashboards should therefore link maternal, newborn and child indicators. Data sources Civil registration and vital statistics Continuous birth and death registration can provide timely, individual-level data and legal identity, but completeness and cause-of-death certification may be weak. Health-facility records Admission registers, maternity books, neonatal units, immunisation records and death audits support quality improvement but miss children who never reach care. Household surveys Demographic and health surveys estimate mortality where registration is incomplete, but recall error, sampling error and long intervals limit rapid programme management. Sentinel/community surveillance Community health workers, verbal autopsy and disease surveillance identify patterns and causes, though attribution can be uncertain. How to calculate and interpret Define the population, geography and period. Specify the event and age cut-off precisely. Use the correct denominator—live births, total births, population at risk or diagnosed cases. Apply the multiplier (1,000 or 100,000) consistently. Report confidence intervals or uncertainty when estimates come from samples. Compare like with like: same definition, source, age band and time period. Example: if 24 newborns die within 28 days among 4,000 live births, the neonatal mortality rate is (24 ÷ 4,000) × 1,000 = 6 per 1,000 live births. This does not mean six specific babies died in every 1,000; it is a population estimate. Causes of child deaths Use cause-of-death data to direct action: prematurity and birth complications dominate early neonatal deaths; infection, congenital conditions and feeding problems remain important. Beyond the neonatal period, pneumonia, diarrhoea, malaria, malnutrition, HIV, measles, injuries and violence may contribute depending on setting. Multiple conditions can coexist, so a single underlying cause and contributing causes should be documented. Beware of “unknown cause”: incomplete records, late presentation, weak diagnostic capacity and poor certification can hide preventable conditions. Death review should ask what happened before, during and after the facility encounter. Equity analysis Disaggregate mortality by district, rural/urban residence, sex, wealth, disability, refugee status and maternal education. Examine coverage and outcomes together: high immunisation coverage with persistent deaths may indicate quality or access problems. Use rate ratios, rate differences and concentration curves to describe inequality. Interpret small numbers carefully; one or two deaths can produce unstable facility rates. Clinical use and death audit Review triage time, danger-sign recognition, oxygen, fluids, antibiotics, glucose, referral and documentation. Identify avoidable delays: decision to seek care, reaching care and receiving effective care. Link every audit finding to a named action, responsible person and review date. Use trends rather than a single month to judge improvement. Protect confidentiality and communicate findings without blaming families or individual staff. Exam pearls Neonatal mortality covers the first 28 completed days. Infant mortality is death before the first birthday per 1,000 live births. Under-five mortality is a probability, not simply the number of deaths divided by the current under-five population. Perinatal mortality combines stillbirths and early neonatal deaths. Facility data underestimate community deaths; survey estimates have uncertainty. References SlideShare: Vital statistics. WHO indicator metadata: under-five mortality. WHO/UNICEF/UN IGME child-mortality estimates and civil-registration guidance. Uganda health information and child-survival reporting standards. Safety note: Always use the latest national definitions and reporting templates when producing official statistics.