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Hyperkalaemia

Emergency medicine, General paediatrics, Renal

Usually due to renal failure. Causes arrhythmia and death…

Treatment

  • Slow injection of calcium – note calcium chloride and gluconate both available so potential for confusion. Dose is 0.11 mmol/kg, to be given over 5–10 minutes, maximum 4.5 mmol (0.11 mmol/kg is equivalent to 0.5 mL/kg of calcium gluconate 10%). Repeat as necessary if ECG changes do not improve.
  • Bicarbonate indicated if hyperkalaemia due to acidosis or renal failure. 
  • Insulin/dextrose – 10ml/kg 10% dextrose (so 5x usual dose for hypoglycaemia!), plus 0.1u/kg insulin (max 10 units), give over 5 mins. Likely peak action at 30 mins.
  • Dialysis.
  • Hydrocortisone if suspected Addisons. 
  • ECG monitoring
  • Repeated salbutamol nebs

Frusemide and calcium resonium only for asymptomatic!

Bronchiolitis

Common, General paediatrics, Microbiology, Respiratory

NICE guidance updated 2021.

Seasonal lower respiratory tract infection of young children, typically caused by Respiratory syncytial virus (RSV) but can be others or mixed.

Classically wheezy cough, wheeze and/or crackles, reduced feeding and increased work of breathing.

Fever not usually high (“consider pneumonia if over 39”)

Diagnosis

Clinical. You would probably have to do 133 Chest x-rays before you found something that would change diagnosis – overuse of CXR associated with increased (and inappropriate) use of antibiotics.

Swabbing for virus identification can help with cohorting and avoidance of nosocomial infection, which can be a major problem.

Management

Ex-prems, chronic lung disease, neuromuscular disorders, haemodynamically significant congenital cardiac disease, immunodeficiency at higher risk, of course.

Admit if sats under 90% if 6/52+ (92% if underlying health problem or under 6/62) – and start oxygen if persistently low.

Admit if feeds less than 50-75% of usual volume, or severe respiratory distress, or reported/observed apnoeas.

NG or orogastric feeds if required – no preference but in theory obstructing nostrils could be unhelpful…

And UTI

Bacteriuria is not uncommonly seen with bronchiolitis, not always clear if this is true urine infection.

Prognosis

Initial coryza 1-3 days. Symptoms peak at 3-5 days. Cough resolves within 3 weeks in 90% but can persist for longer (but perhaps recurrent viruses?).

Prevention

RSV passive immunisation for high risk babies with paluvizimab (Synagis). Limited benefit but does appear to reduce incidence of severe bronchiolitis.

Vaccination in pregnancy effective – antibodies cross, but also prevents Mum getting it and passing it on!

There’s an important story about the dangers of vaccine development.

JCVI recommended Nirsevimab be used first line in 2023 – single injection (half life 71 days). HARMONIE trial – 83% reduction in RSV hospitalisation, 75% reduction in “very severe” disease. Spain and US doing. Fight for global supply so not available…

2025 – programme for high risk babies extended to include all babies born <32/40 (regardless of whether mum received vaccine in pregnancy).

Treatment

See here.

Moulds

Allergy, General paediatrics, Microbiology, Respiratory

Initial studies did not show any relationship between moulds/damp and health, as there was major confounding with socioeconomic status, and because it is hard to quantify mould exposure (with many different mould species).

Then there is the effect of climate, and the built environment – heating, ventilation, insulation, materials etc.

More recently systemic reviews have made it clear there is a link particularly with development of asthma, particularly in older children, and where there is already a family history of atopy.

Coroner ruled death of 2yr old Awaab Ishak in 2020 from granulomatous tracheobronchitis was due to environmental mould exposure from poor housing.

Longitudinal studies have suggested that there may be protective effects but data is limited.

Similarly there is evidence that higher exposure to moulds leads to more asthma exacerbations.

There are genetic polymorphisms that affect ability to break down the fungal protein chitin, and these have been linked to urgent medical care visits, which suggests a non-immune mechanism may be important.

Dampness is linked to mould growth but also to house dust mite, microbial volatile compounds, mycotoxins and endotoxin.

The most studied mould species are Aspergillus, Penicillium, Alternaria and Cladosporium.

Limited evidence that interventions to reduce mould make any difference.

[European respiratory review 2018]

Gynaecomastia

Clinical, Endocrinology, General paediatrics

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):

  • Prepubertal
  • Delayed puberty with no development of penis/testes, no axillary/pubic hair
  • Galactorrhoea
  • Testicular mass

Transfusions

Emergency medicine, General paediatrics, Haem/Oncology

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

Common, Dermatology, General paediatrics

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:

  • candidiasis,
  • atopic dermatitis, seborrhoeic dermatitis
  • psoriasis,
  • Langerhans cell histiocytosis,
  • Acrodermatitis enteropathica (autosomal recessive zinc disorder), else nutritional zinc deficiency – +/- acral dermatitis, alopecia, malabsorptive diarrhoea)

Intertrigo (inflammation in the creases) can similarly be infective (bacterial or candidal), eczematous/seborrhoeic or psoriatic.

Blistering rashes

Clinical, Dermatology, General paediatrics

Common, typically vesicular rather than bullous:

  • Varicella – tends not to affect mouth or palms/soles cf below, but more toxic
  • Coxsackie – Enteroviruses such as coxsackie nearly always involve buccal mucosa and tongue (eg Hand-Foot-Mouth). If nowhere else, Herpangina tends to be posterior mouth ie tonsils, soft palate.
  • HSV stomatitis tend to be more unwell, higher fever, gingivitis, cervical adenopathy, no cutaneous lesions.
  • Gianotti-Crosti syndrome
  • eczema herpeticum ie HSV superinfection of eczema;
  • mycoplasma (but mycoplasma has been associated with every kind of rash!)

Rare:

  • disseminated zoster (starts in a dermatome, immunosuppressed);
  • disseminated HSV;
  • vaccinia

For more dramatic blistering:

  • Bullous impetigo
  • Stevens Johnson syndrome esp with plaques, conjunctivitis, lesions at mucocutaneous junctions
  • Urticaria (rarely)
  • Dermatitis herpetiformis
  • Pemphigoid (v rare in children)
  • Acrodermatitis enteropathica – genetic (recessive) disorder leading to Zn deficiency. Blistering rash esp peripheries, face and nappy; diarrhoea (Normal Zn is 10-23).

Croup

Common, General paediatrics

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.

Management

Supportive, and hands off – upsetting the child will provoke worsening of symptoms.

Paracetamol/difflam spray for the throat.

Recurrent croup

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. 

Benign neonatal sleep myoclonus

Clinical, Common, General paediatrics, Neurology, OPD

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]