Chapter 5 Pain in infancy and childhood

Case 5.1

Astrid is a 9-week-old infant presenting with intermittent, inconsolable crying. She has regular episodes of high-pitched crying, occurring daily in the late afternoon. The crying is accompanied by the drawing up of the lower limbs. These episodes have occurred nearly daily for the last 4 weeks.

Her mother had consulted a medical practitioner and is aware that this is common and that Astrid will ‘grow out’ of the problem. She is, however, desperately tired and requests assistance.

Physical examination reveals no abnormalities.

Questions

1. What is the most likely diagnosis, based only on the history? Give reasons for your answer.

2. Why was it important for Astrid to be assessed by a medical practitioner?

3. Why is this presentation unlikely to be intussusception?

4. What are some of the proposed mechanisms for the development of this disorder?

Case 5.2

Josef is a 9-year-old boy who presents with multiple episodes of abdominal pain over the last 6–8 months. When it occurs, he describes it as relatively constant, not overly ‘intense’ and lasts up to a few hours. It is difficult to pinpoint, although he admits that it is more central than peripheral. He has had no change in bowel habits, does not feel nauseated and has not vomited. These episodes tend to occur in the mornings, and get better later in the day. Episodes occur once every 2–3 weeks. He is otherwise a healthy child. Josef and his mother consulted a medical practitioner for this problem, who did not see the need to conduct any investigations. Physical examination is normal.

Questions

1. Why do you think that the medical practitioner did not see a need to conduct investigations?

2. What is your differential diagnosis?

3. Do you believe that investigations should have been done?

4. You refer Josef to another doctor, who performs a number of tests. Which investigations do you think may have been done?

5. All tests are normal. What is the most likely diagnosis?

6. Briefly describe some of the theories regarding the cause of this problem.

7. What age groups does this condition often affect?

Case 5.3

Robbie, a 5-year-old boy, has bilateral lower limb pain. It is described as diffuse pain, present only late in the day or at night-time. There are no noticeable physical deformities, no swelling, redness, or rashes. The pain has been episodic in nature and started approximately 2 months ago. Robbie’s mother has been giving Robbie leg massages, which appears to help relieve the pain.

Questions

1. What are the possible causes of his pain?

2. What pertinent questions do you wish to ask?

3. Assume that further history taking reveals no additional relevant data, and that physical examination is normal. From this information, what is the most likely diagnosis?

Case 5.4

History

Isha is a 9-year-old girl who presented at her local GP clinic with pain in the right hypochondrium. The pain was mild in intensity with episodes of mild pain lasting for 15–20 minutes or so and then subsiding by itself. The patient experiences approximately 1–2 episodes in a week, starting 2–3 months ago. However, it was not associated with any other symptom and did not hinder any of her activities. Nothing abnormal was found during abdominal examination and it was thought to be non-specific abdominal pain (quite common in school aged children). The doctor prescribed simethicone for symptomatic relief.

Isha presented again after 4 months, and this time the pain would come and go more frequently than before. The medicine prescribed earlier had no effect on the pain. The pain would go away by itself in 20–30 minutes. The patient denied any association with food intake. It was not colicky in nature. Further history revealed the patient also experienced frequent belching and mild nausea without any actual episode of vomiting associated with it, for almost the same duration. Systemic review revealed a moderate degree of allergic rhinitis.

When inquired about the past medical history, Isha’s mother informed the doctor that the child was a diagnosed case of hereditary spherocytosis — a type of haemolytic anaemia — and had been admitted to hospital 1 year ago for the treatment of severe anaemia. At that time she suffered a viral infection (Erythema infectiosum) that triggered severe haemolysis and an aplastic crisis. She was admitted to the hospital with a haemoglobin of 50.0 g/dl (Ref. range 115–150 g/l). Her bilirubin levels rose to 56 µmol/l (Ref range: <12 µmol/l). Urgent bone marrow biopsy revealed a good functioning bone marrow. She was treated with 2 packs of red cells. She was kept under observation for 3 days. Her haemoglobin increased to 90.0 g/dl post transfusion, when she was discharged.

The rest of the history was unremarkable.

Questions

1. Using only this information, list the possible causes of Isha’s presenting symptom(s). Justify your answer.

2. Why was Isha asked about the association of her pain with food? What type of food in particular would have an association with right hypochondrial pain?

3. What is the significance of the colicky nature of pain?

4. How can a bone marrow biopsy help in differentiating the cause of anaemia?

5. Is there any possible relationship between her past history and present complaint?

6. What do you need to examine in this patient?

Physical examination

General	Isha was found to be a relaxed and cooperative child and not complaining of any abdominal pain. Skin was not yellow, although there was mild icterus in sclerae
Vitals	•Pulse rate/min	90
	•Respiratory rate/min	16
	•Blood pressure mm Hg	90/60
	•Height (cm)	130
	•Weight (kg)	35
	•BMI	20.7
	•Temperature (degrees C)	36.6
HEENT	Mild icterus in sclerae. Conjunctivae were both normal with no sign of anaemia
Neck	No lymphadenopathy
Chest	Unremarkable
Abdomen	Examination revealed a soft abdomen with no guarding. None of the viscera were palpable. Given her history of haemolytic anaemia the GP specifically looked for splenomegaly, but neither the spleen nor the liver were palpable. The patient complained of slight tenderness while the liver was being examined
Neurological	Unremarkable

Questions

7. What information can you obtain from these findings? Can you narrow your differential diagnosis?

8. Explain the significance of the mild icterus in the sclerae.

9. How would your differential diagnosis vary if:

a the patent complained of tenderness in the epigastric region instead

b if Murphy’s sign had been positive?

10. What is the significance of splenomegaly in cases with haemolytic aneamias?

11. What investigations are required following her referral to a medical practitioner? Why?

Investigations

Blood studies

At this stage, the medical practitioner decided to repeat a full blood count (FBC), liver function tests (LFT) and get an abdominal ultrasound to see the status of the liver, gallbladder and spleen. The blood test results came back consistent with spherocytosis with moderate anisocytosis and spherocytosis in red cell morphology, although the haemoglobin level was within the normal range. White cell count, platelets and most liver function tests were also normal. However, serum bilirubin came back as 47 µmol/L (average range: 3–15 µmol/L).

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

Genetic disorders, birth defects and structural deformities Miscellaneous cases in infancy and childhood Sports injuries Acute joint pain Acute back pain Upper limb pain

Stay updated, free articles. Join our Telegram channel

Join

Full access? Get Clinical Tree