Common in newborns, presumably due to maternal hormones. Bud underneath the surface, plus swelling of areola/nipple area.
Another peak around puberty, can be unilateral, can be tender. Can progress to be cosmetically problematic.
Exclude a hormonal problem (including prolactinoma and other hormonal tumour):
January 2022 – safety alert from MHRA/CMO regarding deaths where there was a delay in providing emergency transfusion.
Should be agreed criteria for rapid concessionary release of blood products.
One issue is Autoimmune haemolytic anaemia, where the presence of red cell antibodies will complicate cross matching (11% mortality!).
Another issue highlighted is failure to give Prothrombin complex concentrate to reverse warfarin (and some other anticoagulants) where severe or limb/sight threatening bleeding.
Nappy rash is an irritant contact dermatitis affecting the skin where the moist nappy is in contact. It spares intertriginous areas.
Change nappies 6-8 times a day, dry thoroughly, use barrier eg zinc oxide cream.
Differential diagnosis:
Intertrigo (inflammation in the creases) can similarly be infective (bacterial or candidal), eczematous/seborrhoeic or psoriatic.
Common, typically vesicular rather than bullous:
Rare:
For more dramatic blistering:
Upper respiratory infection (“acute laryngotracheobronchitis”) of young children, typically parainfluenza but can be RSV, enterovirus etc.
Classically barking cough, like a seal, with stridor. Often worse on waking, then settles once the panic has passed.
Mild fever typical. Rarely lasts longer than 24 hours.
Severe will cause increasing respiratory distress, with decreasing volume of stridor until respiratory arrest ensues.
An oxygen requirement implies lower rather than upper airway involvement (so the wrong, or mixed, diagnosis), or impending respiratory arrest.
Supportive, and hands off – upsetting the child will provoke worsening of symptoms.
Paracetamol/difflam spray for the throat.
Some kids are prone to recurrent croup. Often strong family history of croup. Smoking doesn’t appear to be a factor! Appears to be same viruses. Tend to be children with reflux and/or atopy. [Pediatrics International, 51: 661–665.] [Annals of Otology, Rhinology & Laryngology 2008;117(6):464-69
26% have microlaryngobronchscopy findings suggestive of reflux – a clinical history is not predictive. 91% responded well to anti-reflux treatment. High rate of recurrence in group with negative findings! Kubba Journal of Laryngology and Otology 2013;127(5):494-500
Airway abnormalities eg tracheomalacia are common in children with recurrent croup and cannot be ruled out based on history (although biphasic stridor is highly suggestive). Having said that, most of the airway abnormalities will have a history of previous intubation, or are younger than 1 year, or are seen while inpatients, which all suggest pretty severe episodes. [Otolaryngology-Head and Neck Surgery 2011;144(4):596-601]
Foreign bodies, respiratory papillomatosis, double aortic arch reported.
Not a great name, as it can persist for up to 6 months!
Large muscle groups, usually limbs but can be face. Can wax and wane with child remaining sleep. Usually bursts lasting seconds, up to a few minutes.
During sleep only, and stops when wakes.
Other normal baby movements include neonatal release phenomena, including tremors (equal amplitude around fixed axis), jitters (recurrent tremor).
Reassuring if baby unbothered by it; baby in first 7 days of life; if it can be suppressed by passive flexion.
Differential would be hypoglycaemia, hypokalaemia; drug withdrawal; HIE or intracranial lesion; myoclonic epilepsy, startle (including hyperekplexia), hyperthyroidism.
[https://doi.org/10.1093/pch/13.8.680]Triad of:
Cool IV fluids, ice packs, bear hugger on cool, etc.
Benzodiazepines, PO/NG cyproheptadine.
RSI.
No role for antipyretics! No evidence for dantrolene. Avoid suxamethonium, fentanyl, alfentanil.
Legal highs now illegal!
=“New psychoactive substances” – no penalty for possession. Generally multiple substances taken simultaneously. Previously sold as herbal incense or “bath salts”. Now online “party pills” etc. Packaging can remain the same but product changed. Mostly from China.
Drug deaths in Scotland 3x higher than in UK as a whole, and higher than any other EU country. Since NPS are unidentifiable and typically multiple substances taken, it is hard to attribute specific deaths. 72% male. Synthetic Cannabinoids, cathinones (stimulant), phenethylamines (hallucinogenic), benzodiazepines. Can be smoked or ingested.
Toxbase has nicknames, but examples are Black mamba, Exodus, Damnation.
Cannabinoids can cause tachycardia, long QT and hypokalaemia. For agitation avoid medication if possible else midazolam. Generally 6 hour effect.
Cathinones snorted or injected as well. Euphoria, intense positive emotion. Dyspnoea, palpitations. Narrow complex arrhythmia. Trismus. Acidosis. Hyperpyrexia. Effects up to 24 hours. Check CK, coagulation, LFTs.
To treat acidosis, treat everything else! Then phone Toxbase!
Phenylethylamines stimulant as above plus hallucinations. Coronary ischaemia, organ failure.
Synthetic benzodiazepines tend to have pseudoscientific names. Flumazenil not used as risk of other drugs emerging to cause seizures etc.
See Serotonin toxicity syndrome for hyperpyrexia, increased muscular activity, autonomic instability.
BRUE (Brief Resolved Unexplained Event) from AAP 2016, replacing ALTE (apparent life threatening event). “Life threatening” is unnecessarily anxiety provoking – and subjective for parents.
“Brief” is by definition less than 1 minute, but typically 20-30 seconds. Only intended for babies under 1yr.
Guidance for “low risk”:
If low risk criteria fulfilled, no investigations are required – consider gas and urinalysis if clinical concern.
Otherwise depends on history and examination. Consider:
Management could then be a period of observation, or discharge home with safety netting.
AAP advises against home cardiorespiratory monitoring given costs and false alarms vs uncertain benefit.
A US study looking at this guidance found that
But I’m disappointed there is no mention in the RHC guidance about SIDS prevention advice.
Associated with range of negative outcomes.
Adverse childhood experiences increase probability of smoking in adulthood. Physical harm in Eastern European countries increases the probability of heavy drinking by about 3.4%, but not in other regions. Exposure to child neglect (little understanding) increases the probability of alcohol abuse by 2.7% in Nordic Countries but not other macro-regions. The experience of a poor relationship with parents is a strong predictor of alcohol abuse for the female subsample in Latin countries (2% higher).
While ACE does not appear to have a substantial effect on excess weight in any macro-region, childhood trauma (physical harm) appears to have a major impact on the likelihood of being obese later in life. Obesity has a more obvious impact on chronic illness than poverty, smoking or alcohol.