Differentials
Urinary tract infection
SIGNS / SYMPTOMS
In the first few months of life the symptoms of urinary tract infection are often nonspecific and include fever, irritability, lethargy, poor feeding, and poor weight gain.
Malodorous urine is highly suggestive.
INVESTIGATIONS
Positive urinalysis and culture.
Otitis media
SIGNS / SYMPTOMS
Usually aged >6 months. Self-limited (rarely lasts >3 weeks).
Presents with fever, irritability, and persistent crying. Some infants poke or tug at the affected ear.
Tympanic membrane is hyperemic, bulging, and opaque with poor or no mobility.
Otorrhea indicates perforation of the eardrum.
INVESTIGATIONS
Clinical diagnosis.
GERD
SIGNS / SYMPTOMS
Regurgitation is present at birth and becomes more pronounced in the second or third week of life. The regurgitation is often effortless and is worse after meals when the infant is in a recumbent position, or when pressure is applied to the abdomen.
Some infants may present with complications such as faltering growth, aspiration pneumonia, and gastrointestinal bleeding.
INVESTIGATIONS
The diagnosis is mainly clinical. When the diagnosis is ambiguous or when complications are suspected, further investigations may be warranted.
Barium swallow and fluoroscopy may show the gastroesophageal reflux and the presence of peptic esophagitis.
Radionuclide gastroesophagography is a noninvasive test to demonstrate gastroesophageal reflux. Gastroesophageal reflux associated with the appearance of radiotracer in the lung provides evidence that respiratory symptoms are related to the reflux.
24-hour intraesophageal pH monitoring can be used to diagnose gastroesophageal reflux and determine its severity.
Intussusception
SIGNS / SYMPTOMS
Colicky abdominal pain, irritability, lethargy, vomiting, and passage of "currant-jelly" stool.
The pathognomonic sign is an elongated mass in the right upper quadrant or epigastrium with a feeling of emptiness in the right lower quadrant (Dance sign).
INVESTIGATIONS
Plain abdominal radiographs may show dilated loop of intestine, air-fluid levels, paucity of air in the right lower quadrant, minimal fecal content, and a soft mass in the right or mid abdomen.
Abdominal ultrasonography may show a tubular mass (sandwich or pseudokidney sign) in longitudinal views and a target appearance (doughnut sign) in transverse views.
If doubt remains, the diagnosis can be confirmed by radiograph with barium or air insufflation; both procedures are therapeutic as well as diagnostic.
Fracture
SIGNS / SYMPTOMS
History of trauma.
Pain and tenderness at the affected site and inability to move the affected part are characteristic.
Bruises and swelling in the adjacent area.
INVESTIGATIONS
Radiograph of the affected area confirms the fracture.
Anal fissure
SIGNS / SYMPTOMS
Blood is generally present on the surface of the stool. Constipation is common.
Physical exam shows a fissure in the anal area. The fissure is often posterior, below the dentate line.
INVESTIGATIONS
Clinical diagnosis.
Pyloric stenosis
SIGNS / SYMPTOMS
Typically develops in a 3- to 6-week-old infant, but may be seen between 2 and 12 weeks.
Presents with projectile nonbilious vomiting after feeding.
An upper abdominal mass (olive) may be detected by palpation.
INVESTIGATIONS
Abdominal ultrasound shows a pyloric channel length >17 mm and pyloric muscle thickness >4 mm.
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