Common paediatric problems by Dr Olga Kapellou

Dr Olga Kapellou photo

Dr Olga Kapellou, MD, FRCPCH, DCH is a Consultant Paediatrician & Neonatologist. She specialised in a number of major London teaching hospitals including Great Ormond Street, Hammersmith, Queen Charlotte’s, Chelsea & Westminster and University College London. Her NHS base is the Homerton Hospital. She does general paediatric outpatient clinics at the Hospital of St John & St Elizabeth and the Portland Hospital. 

 

 

Common paediatric conditions that could affect school performance if left untreated.

There are many conditions that affect school going children. This article, discusses a few conditions and aims to provide a list of comprehensive symptoms for parents to watch out for. As with most things, if caught and treated early, most children will be able to return to their normal routines with minimal disruption.

Iron deficiency

Iron deficiency is the most common nutritional deficiency in children. It can have important consequences on health and development and can occur in up to 9% of toddlers in developed countries with up to 3% of children developing iron deficiency anaemia.

The percentages of children with iron deficiencies are less, in well-nourished, school age, children.

However, some times, some girls may develop iron deficiency in adolescence with the onset of puberty.

There are a number of risk factors apart from nutrition. These can originate around the time of birth. Some of these can be caused by,

  • maternal iron deficiency,
  • prematurity and blood loss during delivery, and
  • an insufficient iron intake in infancy.

Dietary factors include,

  • insufficient iron intake,
  • reduced absorption due to poor sources of iron,
  • introduction of unmodified cow’s milk before one year of age, 
  • cow’s milk protein intolerance and allergy.

Symptoms of iron deficiency are not always obvious. Most frequently, it is revealed incidentally, when a blood test is taken to test some other issue.

Much less frequently, infants present with

  • lethargy,
  • irritability,
  • pallor, and
  • poor feeding.

This level of symptomatic anaemia needs urgent treatment and investigation.

Impairments in cognitive, physical and mental development are well described in iron deficient infants. It seems that the integration of all skills such as movement, coordination, manipulation, strength and speed, i.e. components of gross and fine motor development, require good nutrition including iron.

An important fact to remember is that an iron deficiency may also have a negative impact on social and emotional behaviour as well as on concentration and school performance.

Supplementing iron, is simple, often well tolerated and can be very beneficial with the right monitoring. On certain occasions, further investigations to exclude underlying medical causes become necessary.

In summary, if a child of any age looks pale, tired and there is concern about presence of the risk factors described above, it is important to identify the need for a blood test. Consulting with your GP or Paediatrician and dealing with this can have long term health benefits.

 

Thyroid problems

An underactive thyroid can sometimes be very difficult to suspect and diagnose. The acquired thyroid problems are different from the congenital hypothyroidism for which, there is national screening during the neonatal blood spot test.

The acquired hypothyroidism can have a variety of symptoms and can present at any time between infancy and adolescence. A declining growth in height resulting in a short stature can and needs to be identified early.

Other common symptoms are,

  • altered school performance,
  • cold intolerance,
  • constipation,
  • dry skin and hair,
  • sluggishness,
  • muscle aches and pains or
  • headaches.

Many of these symptoms in combination, should prompt an investigation for thyroid problems. A point to note is that in older children, pubertal problems can be the presenting feature.

 

Constipation

Bowel habits should be observed very carefully in children. The development of constipation can be insidious and deteriorate over a long period of time, in some cases even two years or more. Sometimes, in retrospect, the signs could perhaps have been identified and avoided.

Symptoms range from infrequent bowel evacuation, small hard faeces, difficulty or pain when the child goes to the toilet to faecal incontinence (also known as soiling or encopresis).

The reason it goes unnoticed is that the child may report going to the toilet regularly. It is not unusual to forget or be reluctant to go while at school and then the amount of faeces in the bowel builds up. The reflex for going to the toilet to open bowels cannot return on demand and then the problem perpetuates.   As a rule of thumb you need a minimum of the same amount of time to treat constipation, as it took to develop.

Anticipation is key and there are three main time periods when constipation can be triggered.

  • The first is the transition to solids because the diet may be inadequate in fiber.
  • The second is during toilet training age for a variety of reasons. Toddlers at this age may develop stool withholding behaviour, have low fiber intake or consume excessive amount of cow’s milk which satiates the child and prevents other fluid and solid intake.
  • The third age group which is crucial for prevention of constipation is school entry. During that time the child’s schedule changes which can interfere with toileting.

Acute episodes of constipation can manifest with hard stools and straining in infants. However straining is not necessarily pathological. Pain on passing stools is always abnormal and may lead to stool withholding behaviour. This kind of behaviour can have different manifestations at different ages.

Children who have not had a bowel movement for several days, may end up with faecal impaction. This means that the stools have become very hard and can’t easily move with a normal bowel motion. As a result the child may experience crampy abdominal pains, nausea and vomiting or even headaches. Alternatively, there may be soiling and overflow diarrhoea. This may well require disimpaction regimes, which would involve large amounts of stool softeners over a week until the bowel empties. We genrally avoid enemas in children as they may have an adverse psychological effect and they are not necessarily more effective than disimpaction regimes given orally.

A long term plan for the management of constipation and dietary habits must be made and followed. Following up on the child is important to avoid worsening cycles of recurrent and chronic constipation, which can be very disruptive.

In less that 5% of cases of constipation there may be an underlying cause. Although a serious condition is unlikely in the vast majority of cases, there are circumstances that your doctor will arrange general and specialist investigations if needed.   However, usually the problem is functional and can be solved with the correct habits and diet which will help them throughout their life.

 

Dr Olga Kapellou can be contacted via e-mail at okapellou@doctors.org.uk

 

 

 

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