The differences in physiology between adults and children must always be considered and careful calculation of doses for fluids, blood transfusions and drugs based on body weight is crucial to the correct management of injuries, including burns, in children. Underlying malnutrition and immunosuppression from chronic parasitic infections greatly affect wound healing and the risk of infection.

Injuries

Most of the principles of adult trauma also apply to children, but there are important differences. See Unit 16: Acute Trauma Management and the Annex: Primary Trauma Care Manual. The initial assessment and priorities apply to children.

Burns

Burns, especially scald injuries, are very common in children. Children with burns are at increased risk for infection. See pages 5–11 to 5–13 and pages 34–37 in the Annex: Primary Trauma Care Manual.

Surgical infections

The treatment of abscess, pyomyositis, osteomyelitis, and septic arthritis in children is similar to that of adults, although the diagnosis may depend more on physical examination as the history is often limited or unavailable. Systemic illness and fever may overshadow localizing symptoms. Avoid the pitfall of identifying all childhood fever as malaria or other infectious disease.

In the diagnosis of surgical infections, pain is the most important symptom and tenderness the most important sign that differentiates them from infectious diseases. Use the specific sections on abscess in Unit 5: Basic Surgical Procedures and Unit 19: General Orthopaedics for information on management.

Acute abdominal conditions

Abdominal pain
Children commonly complain of abdominal pain. Serial observations are important in making a decision on whether there is an indication to operate. Be concerned about a child with:

The goal in assessing a child with abdominal pain is to determine if peritonitis (inflammation of the lining of the abdominal cavity) is present. The most common causes of peritonitis in children are:

Peritonitis may be difficult to diagnose in young children. The signs of peritonitis are:

Simple methods for assessing the presence of peritonitis include:

Most causes of peritonitis require laparotomy.

Appendicitis

The most common cause of peritonitis in children is appendicitis. The most important physical finding in appendicitis is steady abdominal pain that is localized in the right lower quadrant of the abdomen. There is usually vomiting. If appendicitis is not recognized early and treated, perforation may result. In children under two years of age, most cases of appendicitis are diagnosed after perforation. See pages 7–10 to 7–13 for clinical management.

Bowel obstruction

The clinical signs of a bowel obstruction are the same as in adults and include:

Children swallow air that can increase the amount of distension. The bowel can rupture if it becomes too dilated. The most common causes of bowel obstruction in children are:

Reduction of the intussusception and lysis of adhesions both at laparotomy and herniotomy are the surgical treatments when non-operative management is unsuccessful or in late presentations.

See pages 7–2 to 7–5 for the clinical management of intestinal obstruction and pages 7–13 to 7–14 for the management of intussusception.

If the bowel is blocked with large numbers of Ascaris worms, treat with antihelminthics. If blockage is found at laparotomy, do not open the small intestine, but milk the worms into the large intestine and give antihelminthics postoperatively.

Hernias

The most common hernias in children are:

Umbilical hernias are common in newborns. They are usually asymptomatic. Repair if the hernia has ever been incarcerated, otherwise avoid surgery as spontaneous resolution can occur up to 10 years of age (see pages 8–9 to 8–10 for a description of umbilical herniorraphy).

Inguinal hernias occur where the spermatic cord exits the abdomen. The clinical sign of an inguinal hernia is swelling in the groin. Distinguish hernias from hydrocoeles. Hydrocoeles are collections of fluid around the testicle that often resolve during the first year of life and do not require surgical repair. Hydrocoeles that fluctuate in size, called communicating hydrocoeles, are a form of hernia. These are an exception and require surgery. Refer possible communicating hydrocoeles for definitive diagnosis and treatment.

Surgery in paediatric inguinal hernia is indicated to prevent incarceration. The procedure is high ligation of the sac, but repair is only rarely required. See pages 8–2 to 8–5 for the description of inguinal and umbilical hernia.