You are a clinician working in an emergency department in Queensland.
You are about to review a 6 week old female called Felicity who was brought in by her father Steven and mother Katie. They tell you the reason they presented was that 'Felicity hasn’t been right'. She has been more unsettled than usual.
Felicity has been unsettled for the past 2 weeks, but worse this evening. She has been intermittently unsettled with periods of crying and back arching. There have been periods of crying of up to 3 to 4 hours in a 24 hour period. She is fussy with breastfeeding, but with normal wet nappies. She is putting on weight appropriately. Felicity has not been pale or lethargic. She has no infective symptoms (i.e. no cough, rhinorrhea, vomiting, diarrhoea). There are no sick contacts.
There were no relevant or concerning findings on perinatal history, developmental history, medical history, medications, allergies, vaccinations, family history, and social history.
Your examination shows an unsettled but not toxic child. There is no evidence of clinical dehydration. Felicity has periods of smiling and being settled. There are no hair tourniquets. She has normal growth. The respiratory, cardiovascular, abdominal, and neurological examinations were all normal.
Questions to discuss about Felicity’s case
What is your differential diagnosis?
How many hours of crying would be ‘normal’ versus ‘excessive’ for Felicity?
How would you define excessive crying (previously termed ‘colic’)?
What would you expect on your review?
Which investigations should you do if you think Felicity has excessive crying (previously termed ‘colic’)?
How would you manage Felicity if you think she had excessive crying (previously termed ‘colic’)?
Normal range for vital signs by age
Normal range for vital signs by age based on Childhood Early Warning Tool (CEWT)
Age
Heart rate (bpm)
Minimum Systolic BP (mmHg)
Respiratory Rate (bpm)
<1 year old
100-159
<75
21-45
1-4 year old
90-139
<80
16-35
5-11 year old
80-129
<85
16-30
12-17 year old
60-119
<90
16-25
Case 2 - Lina
You are a clinician working in an emergency department in Queensland.
You are about to review a 6 week old female called Lina who was brought in by her father Craig and mother Carol. They tell you the reason they presented was that 'Lina hasn’t been right'. She has been slightly more unsettled than usual.
Lina has been slightly more unsettled for the past 48 hours. She is feeding well. There are no infective symptoms. She has normal wet nappies. The unsettled behaviour is not related to feeds and she has not been pale or lethargic. The unsettled behaviour is not episodic. Since birth, she has had effortless vomiting after most feeds. These are usually small in volume, but occasionally large. They can take place a few times a day. They are not bilious or projectile. The child is not irritable or unsettled with either feeding or with vomiting. There are no recent changes in the nature of the vomiting.
There were no relevant or concerning findings on perinatal history, developmental history, medical history, medications, allergies, vaccinations, family history, and social history.
Your examination shows an unsettled but not toxic child. There is no evidence of clinical dehydration. Lina has periods of smiling and being settled. There are no hair tourniquets. She has normal growth. The respiratory, cardiovascular, abdominal, and neurological examinations were all normal.
Questions to discuss about Lina’s case
What is your differential diagnosis?
What do you think of the vomiting? Is this reflux?
What is the difference between gastro-oesophageal reflux (GOR) and gastro-oesophageal reflux disease (GORD)?
Which one do you think Lina has?
How would you manage Lina’s vomiting?
In general, how would you manage GOR versus GORD?
Normal range for vital signs by age
Normal range for vital signs by age based on Childhood Early Warning Tool (CEWT)
Age
Heart rate (bpm)
Minimum Systolic BP (mmHg)
Respiratory Rate (bpm)
<1 year old
100-159
<75
21-45
1-4 year old
90-139
<80
16-35
5-11 year old
80-129
<85
16-30
12-17 year old
60-119
<90
16-25
Case 3 - Katie
You are a clinician working in an emergency department in Queensland.
You are about to review a 6 week old female called Katie who was brought in by her mothers Stella and Victoria. They tell you the reason they presented was that Katie has had a small amount of blood in her stool recently. She has been slightly more unsettled than usual but has been well overall.
Katie has been having intermittent flecks of blood mixed with her stools for the past 2 to 3 days. She has been otherwise well, except for very slight unsettled behaviour. She has no fevers, vomiting, or other infective symptoms. She has not been irritable, pale, or lethargic. She is feeding well, with reassuring weight gain. Katie has had a normal number of wet nappies. Katie is exclusively breastfed.
There were no relevant or concerning findings on perinatal history, developmental history, medical history, medications, allergies, vaccinations, family history, and social history.
Your examination shows a well child. There is no evidence of clinical dehydration. She has normal growth. The respiratory, cardiovascular, abdominal, and gross neurological examinations were all normal. She does not have a fissure on an external perianal examination.
Questions to discuss about Katie’s case
What is your provisional diagnosis?
What differential diagnoses should you consider in an infant with blood in their stool?
What is cow’s milk protein allergy; specifically food protein induced allergic proctocolitis (FPIAP)?
What are the most common triggers?
How is FPIAP diagnosed?
What is the management and prognosis of this condition?
Normal range for vital signs by age
Normal range for vital signs by age based on Childhood Early Warning Tool (CEWT)
Age
Heart rate (bpm)
Minimum Systolic BP (mmHg)
Respiratory Rate (bpm)
<1 year old
100-159
<75
21-45
1-4 year old
90-139
<80
16-35
5-11 year old
80-129
<85
16-30
12-17 year old
60-119
<90
16-25
Case 4 - Nitesh
You are a clinician working in an emergency department in Queensland.
You are about to review a 3 day old male called Nitesh who was brought in by his father Deepak and mother Apoorva. They tell you the reason they presented was that Nitesh appeared yellow.
He needs waking up for his feeds every 3 to 4 hours and falls asleep easily whilst feeding. Nitesh is exclusively breastfed and Apoorva’s milk 'came in' this morning. There is no history of fevers or infective symptoms. The GBS status is unknown.
His birth weight was 3.5 kg. Nitesh was born at 38+2 weeks gestation. There were no relevant or concerning findings on perinatal history, developmental history, medical history, medications, allergies, vaccinations, family history, and social history.
Your examination shows a jaundiced 3 day old. His weight was 3.2 kg. There is no evidence of clinical dehydration. The respiratory, cardiovascular, and abdominal examinations are normal. He has a normal suck, Moro, and Babinski reflex.
Questions to discuss about Nitesh’s case
What are some important aspects to consider in the history and examination?
What are some risk factors for jaundice? Consider maternal and neonatal risk factors.
What do you think about the weight loss? What % of weight loss is considered acceptable?
What investigations (if any) should be considered?
What is the most likely diagnosis?
How is feeding relevant to jaundice?
What is the differential diagnosis if Nitesh was <24 hours old?
What is the management for Nitesh if
His (unconjugated) bilirubin was below the treatment line.
His (unconjugated) bilirubin was above the treatment.
Normal range for vital signs by age
Normal range for vital signs by age based on Childhood Early Warning Tool (CEWT)
Age
Heart rate (bpm)
Minimum Systolic BP (mmHg)
Respiratory Rate (bpm)
<1 year old
100-159
<75
21-45
1-4 year old
90-139
<80
16-35
5-11 year old
80-129
<85
16-30
12-17 year old
60-119
<90
16-25
Case 5 - Belinda
You are a clinician working in an emergency department in Queensland.
You are reviewing 4-week old female called Belinda who was brought in by her mother Linda. She tells you that the reason they presented was that Belinda continues to appear yellow since the first few days of life. She is not sure if it is worse or better.
Belinda has been feeding regularly every 2 to 3 hours. She was initially noted to be jaundiced from the first week of life. Belinda is exclusively breastfed. There is a good amount of wet nappies. There is no history of fevers or infective symptoms. The GBS status is unknown.
Her birth weight was 3.5 kg. There are no relevant or concerning findings on perinatal history, developmental history, medical history, medications, allergies, vaccinations, family history, and social history.
Your examination shows a jaundiced 4 week old. Her weight was 4 kg. There is no evidence of clinical dehydration. The respiratory, cardiovascular, and abdominal examinations are normal. She has a normal suck, Moro, and Babinski reflex.
Questions to discuss about Belinda’s case
At what day of life does the jaundice become ‘prolonged’? Consider if term/preterm.
What is the most likely cause?
What are some differential diagnoses?
What investigations (if any) would you request?
What do you think about the weight gain?
How much weight gain should you expect?
How would you manage Belinda if:
Her bilirubin was unconjugated and below the treatment line with normal Ix otherwise.
Her bilirubin was conjugated and below the treatment line.
Normal range for vital signs by age
Normal range for vital signs by age based on Childhood Early Warning Tool (CEWT)