Oxford Handbook of Paediatrics (2 edn)
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Reading and learning paediatrics
Welcome to paediatrics and child health! You will find this area of medicine challenging, rewarding, and above all fun. We have written this handbook to help you develop as a practitioner—whether it’s in the emergency department, inpatient wards, outpatient clinic, or family health surgery.
Six basic goals in your learning
If you are a novice in the field, you will find that every day requires new skills, and sometimes this can seem daunting. Take heart. We hope that this experience will provide an education in the aspects of general paediatrics that are important for all medical practitioners. Your curriculum goals should be the following.
Acquire basic knowledge of growth and development: learn about physical, physiological, and psychosocial change from birth through to adolescence and see how this applies to clinical practice.
Develop communication skills: this will help you to speak to children, adolescents, and their families.
Become competent in physical examination of babies, infants, toddlers, children, and adolescents.
Learn enough core knowledge so that you can make a diagnosis and start treatment of common acute and chronic paediatric illnesses.
Improve your clinical problem-solving skills.
Take a broader perspective and understand more about the upbringing and health of children in modern society, and in our different communities.
As you scan through the handbook you will see that all of the chapters cover some aspect of these points. We hope that you will take time to annotate particularly helpful guides and record what you have learnt. Perhaps, with time, things will not appear quite so daunting.
What next after this foundation?
For those who are using this handbook to progress in their postgraduate level of learning we have been more prescriptive in the next sections. We have itemized certain objectives that are deemed essential for professional conduct, attitudes, skills, and knowledge. Use these as a checklist and monitor your progress as you work through the handbook. Again, most chapters cover aspects of the material that you will need.
Professional conduct and attitudes
Have you learnt to adapt your clinical approach to patients of all ages? Can you communicate with the child or adolescent and family in the clinic? What about dealing with confidentiality and privacy? (see 
p.1038).
Can you communicate clearly and sensitively? How do you break bad news to new parents, or to the newly-diagnosed adolescent with chronic illness or disability? (see p.794).
Do you work well in a team? Do you treat each member of the team with courtesy and recognize the contributions of each?
Are you aware of cultural, ethnic, and socio-economic factors in your practice?
Professional skills
Interviewing ( Chapter 3)
Can you obtain a complete medical history? The history of the perinatal period, immunizations, development, diet, family and social history, and systems review is unique to paediatrics. Can you collect this information in a timely manner—40min in a complex case history. You should also be able to modify the medical history depending on the age of the child, with particular attention to the following age groups—neonate; infant, toddler, school age, and adolescence.
Can you obtain a focused medical history? In an emergency you will need to know what are the important questions to ask—what is going to help you now with your treatment.
Physical examination ( Chapter 3)
Can you complete a full physical examination of an infant, child, and adolescent, including the observation and documentation of normal physical findings? You should be able to do this ‘long case’ examination in less than 10min.
Can you carry out a problem-orientated examination? For example, in the child with a limp: what are the important positive and negative clinical findings?
Are you a good observer? Do you take time to look first?
Can you assess behaviour, neurodevelopment, and pubertal staging?
Communication
Can you establish rapport with the patient and family? Are you able to identify the main concerns of the patient and family? Can you communicate information to both the patient and parent, making sure both understand the diagnosis and treatment plan, and do you give them the opportunity to ask questions?
Can you write a discharge letter for the family doctor?
Can you write a full medical summary for the medical notes?
Can you present to colleagues a well-organized summary of your patient? Can you communicate effectively with other health care workers, including nurses and social workers, and explain the thought process that led to your diagnosis and treatment?
Clinical problem solving
Can you compile a problem list and differential diagnosis for each of the common clinical presentations? Can you use your knowledge of key signs and symptoms, and the frequency and prevalence of diseases at different ages to develop a likely differential diagnosis?
Can you make a management plan of investigations? Can you interpret the results of commonly ordered laboratory tests, such as the full blood count, urinalysis, and serum electrolytes, and recognize that the normal values of some tests may vary with the age of the patient?
Practical procedures ( Chapter 7)
Venepuncture and venous cannulation for blood sampling ( p.203)
Capillary blood sampling ( p.202)
Electrocardiogram (ECG)
Lumbar puncture (LP, p.220)
Suprapubic aspiration of urine ( p.219)
Non-invasive blood pressure (BP) measurement
Urethral catheterization ( p.218)
Urine analysis using standard bedside tests
Blood sugar measurement using standard point-of-care glucometers
Peripheral arterial cannulation ( p.205)
Needle thoracentesis of pleural effusion for microbiology and cytology
Injections: intradermal, subcutaneous (SC), intramuscular (IM), and IV
Insertion of an intraosseous (IO) needle
Administer surfactant
Tracheal intubation of preterm and older child
Chest drain insertion for pneumothorax
Knowledge
During your reading you should consider these questions as a starting point to the knowledge that would be expected of a junior paediatrician.
Growth ( Chapter 13)
What are the intrauterine factors that affect growth of the foetus?
Can you explain how growth charts are used in the longitudinal evaluation of height, weight, and head circumference?
In particular, consider the following.
Can you recognize abnormalities of growth that warrant further evaluation?
What is the significance of crossing centiles on a growth chart?
What is the significance of discrepancies between height, weight, and head circumference?
What are: short stature; constitutional delay; failure to thrive; obesity; microcephaly; and macrocephaly?
Why is following development important in clinical paediatrics?
What are the normal changes in reflexes, tone, and posture in the infant?
What is the normal progression in motor milestones in the first year?
What are the signs of cerebral palsy?
What are the typical presentations of common behavioural problems at various developmental levels and ages?
What are temper tantrums?
How may somatic complaints represent psychosocial problems?
In what types of situations does pathology in the family contribute to childhood behaviour problems?
Nutrition ( Chapter 10)
What factors contribute to the development of failure to thrive in infancy?
What factors contribute to the development of child obesity?
What are the special dietary needs of children with chronic illness?
What caloric intake is needed for normal growth in infants and small children?
Also consider the following.
What are the major differences between human milk and commonly available formulas?
What are the advantages of breastfeeding?
Newborns ( Chapter 6)
What diseases are detected by neonatal blood screening?
What important historical information, physical examination findings, and laboratory data are needed for the differential diagnosis of the following problems:
jitteriness or seizures;
jaundice;
lethargy or poor feeding;
respiratory distress;
cyanosis;
bilious vomiting;
non-bilious vomiting;
hypoglycaemia;
sepsis?
What are the effects of teratogenic agents such as alcohol and phenytoin?
What are the findings and implications of the common chromosomal abnormalities:
trisomy 21;
sex chromosome abnormalities (e.g. Turner’s syndrome, fragile X syndrome);
other genetic disorders (cystic fibrosis, sickle cell disease)?
Common paediatric illnesses
For each of the common ‘presentations’ and ‘conditions’ in this handbook can you review:
cause;
pathophysiology;
natural history;
presenting signs and symptoms;
initial laboratory test and/or imaging needed for diagnosis;
plan for initial management?
