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SARS-CoV-2 vaccine

General paediatrics, Immunology, Infectious disease

Mostly against COVID spike (S) protein that facilitates host cell entry.

Pfizer vaccine is mRNA vaccine, completely in vitro derived, uses nanoparticles to aid absorption into host cells which then produce the S protein themselves from the mRNA.

AstraZeneca vaccine is chimp adenovirus vector for genetic sequence – mRNA produced once virus taken up by host cell.

From Autumn 2025, only children over 6/12 who are immunosuppressed are eligible for a COVID booster (given with flu in the autumn). The other clinical risk groups eg chronic heart/lung, DM no longer apply.

This includes:

  • biologics (specifies TNF receptor biologics, IL6/17/12/23 inhibitors),
  • methotrexate, azathioprine, 6MP, MMF (but not hydroxychloroquine or sulfasalazine).
  • High dose steroids for more than 10 days, or moderate dose (0.5mg/kg pred) for more than 4 weeks.

Ideally the vaccine should be given at time of minimum immunosuppression, if treatment is intermittent (eg 2 weeks before/after treatment).

[https://assets.publishing.service.gov.uk/media/68b5be03536d629f9c82a97d/Green-book-chapter-COVID-19_1_9_25.pdf]

Infantile Self-gratification

General paediatrics, OPD

Sometimes called infantile masturbation – but often doesn’t involve touching the genitals at all, which can lead to confusion – can be mistaken for silent reflux, seizures or painful spasms. 

More commonly girls.  Often starts before the age of 1yr, diagnosis often late (median 11 months delay)!  Can happen in car seats, on floor, high chairs, push chairs, falling to sleep etc. 

Characteristic rocking or crossing of legs, often rhythmic. Grunting, sweating, “zoning out” pretty typical.  Can appear tired afterwards (or tiredness is a trigger) and may fall asleep, which might suggest post ictal period!  Some seem to get upset with it!

Key features are distractability, and in particular, irritation when distracted! [Linda Ross etc, ADC 2004]

Fisting often seen in young infants, in older children grasping of clothes or objects, so not just legs! [Hansen, 2009]

https://www.todaysparent.com/baby/baby-health/do-babies-masturbate/
Parent friendly article

Nothing to worry about – but no one likes to talk about it and parents can feel mortified. Very little information on internet about it! Distraction is all that is needed. As they get older it is likely to go away by itself – but otherwise teach that it is a private thing! Avoid shame…

.

BTS/SIGN/NICE Asthma guidance

Common, Emergency medicine, General paediatrics, Respiratory

Latest revision 2025. See also asthma.

Diagnosis is about probability – high probability is recurrent episodes of cough, wheeze, breathlessness, chest tightness plus documented wheeze, atopic history, documented variable PEF or FEV1. Isolated episodic cough is not sufficient. Episodes typically triggered by viral infections, cold air, exertion, laughter or emotion. Start treatment, “typically” 6 weeks inhaled corticosteroids (ICS). If good response to treatment, then diagnosis is confirmed.

Diagnostic algorithm for asthma

If intermediate probability then spirometry with reversibility is preferred initial test for children old enough to do it (Grade D recommendation). If spirometry normal, then do challenge tests and/or Fractional exhaled nitric oxide (FeNO) measurement. For younger children, watchful waiting or trial of treatment [colour code suggests this is appropriate from age 1, but no advice given for under 1…].

FeNO has reasonable positive predictive value, but false positives in allergic rhinitis, rhinovirus and dietary nitrates, plus overlap in values between asthmatics and normal population (especially children).

Red flags –

  • Focal chest signs
  • Abnormal voice or cry
  • Failure to thrive
  • Vomiting
  • Wet/productive cough
  • Nasal polyps

Management

Self management education, written personalized plan. Assess control – consider using Asthma Control Test (ACT) questionnaire or similar.

Assess risk of future attacks. Co-morbid atopic conditions, younger age, obesity, and exposure to environmental tobacco smoke are markers of increased risk (some of these strongly socioeconomically linked, of course).

Ask specifically about medication use and assess prescriptions. Explore attitudes to medication as well as practical barriers to adherence.

Not for routine house dust mite avoidance measures. Avoid smoking and second hand smoke.

Weight loss (including dietary and exercise programmes) for overweight and obese. Breathing exercise programmes can be offered as an adjuvant to pharmacological treatment for adults.

Treatment

ICS are recommended preventer. An asthma attack in the previous 2 years, symptoms 3 days a week, or using reliever 3 days a week, or waking 1 night a week are indications. Give twice daily at least until good control established.

Start at dose appropriate for the severity of the disease. In mild to moderate asthma, no benefit in starting at high dose and weaning. In children, “reasonable” starting dose is Very Low (100mcg twice daily of Clenil or equivalent).

5yrs and over, if add-on is required then choice between inhaled long acting beta agonist (LABA) or leukotriene receptor antagonist (LTRA). Only then increase dose of ICS from very low (100mcg Clenil or equivalent twice daily) to low (200mcg twice daily).

For exercise induced symptoms, generally just a sign that inadequate control! But if otherwise well controlled then give inhaled short acting beta agonist immediately prior to exercise. Then choice between LRTA, LABA, cromoglicate or theophylline.

Acute Severe Asthma

Levels of acute asthma attacks in children
  • Sats under 92%
  • PEF 33-50% of best or predicted
  • Can’t complete sentences in one breath, or too breathless to feed
  • HR >140 (under 5), >125 (over 5)
  • RR>40 (under 5), >30 (over 5)

Life threatening defined as:

  • PEF <33%
  • Exhaustion, poor resp effort [tautology?]
  • Hypotension
  • Cyanosis
  • Silent chest
  • Confusion

Treat –

  • Oxygen
  • MDI plus spacer if mild/moderate
  • If refractory to beta agonist, add ipratropium 250mcg mixed into beta agonist [same dose for everyone]
  • “Consider adding 150mg magnesium sulphate to each neb in first hour if symptoms started <6hrs and presenting with sats <92%” = 0.3ml of 50% MgSO4
  • Give oral steroids early, dose by age.

Second line treatment –

  • Consider single IV bolus of salbutamol (15mcg/kg over 10mins). For bolus dilute to 50mcg/ml with saline/glucose. For infusion, dilute to 200mcg/ml
  • Consider aminophylline for severe asthma unresponsive to maximal doses of bronchodilators and steroids. Loading dose slow injection over 20 mins! Then dilute to 1mg/ml with saline
  • Consider IV MgSO4 40mg/kg over 20 mins – dilute to 10% in saline or glucose.

Systematic review of IV Magnesium in children (2018) – pulmonary function improved, hospitalization and further treatment decreased. MAGNETIC trial of Magnesium nebs did not show a clinically significant improvement in mean asthma severity scores in children with acute severe asthma. But better Asthma Severity Score at 1 hour where saturations <92% at presentation and those with preceding symptoms lasting less than 6 hours [Lancet 2013]. 2022 Metanalysis found no benefit but varying protocols and populations.

Staphylococcal bacteraemia

General paediatrics, Infectious disease

7-14 days IV recommended if uncomplicated. Higher relapse rate with shorter course.

Uncomplicated viz

  • Negative repeat blood cultures
  • Defervescence within 72 hours of treatment
  • No evidence of endocarditis
  • No prosthesis or venous catheter
  • No evidence of metastatic infection
  • No underlying immune issues

I wonder about PVL positive though.

Should echo if high risk for endocarditis, or persistent fever. And joints, abdominal cavity, CNS probably higher risk for treatment failure.

Consider removing catheters

Neonates should get 14 days IV.

If endocarditis, then 4-6 weeks IV treatment.

If osteoarthritis, then 3-6 weeks IV/oral treatment.

[Peds 2020]

Medication Overuse Headache

General paediatrics, Neurology, OPD

Well recognised condition where regular long term use of pain killers eg paracetamol leads to chronic headaches. Tends to be dull, particularly in the morning. And you might still get your migraine on top!

Of course, might be difficult to differentiate from chronic daily migraine (defined as more than 15 days in a month) or other headache that is not well controlled! It appears the majority of those with chronic migraine do not take or are not offered appropriate preventive medication.

To exclude, always have a day free of analgesia (including triptans) after any day where it has been used, and use a maximum of 3 days per week [Dr Abu-Arafeh’s advice] or else maximum 10 days per month.

Congenital diarrhoea

Congenital, Gastro (neonatal), Neonatology

Usually severe and life threatening. May have been polyhydramnios prior to birth. Abdominal distension, even ileus at presentation, weight loss, nappy rash (if acidic stool).

In some of these conditions, symptoms improve through childhood, but may be susceptible to severe gastroenteritis.

Causes –

  • Congenital sodium diarrhoea – metabolic acidosis, low sodium. Can be associated with atresia choanae. Associated with later IBD.
  • Congenital chloride diarrhoea – metabolic alkalosis, low chloride. Treat with salt supplementation.
  • Congenital sucrase-maltase deficiency – no problem with breast milk, may not present until food aversion/intolerance emerges. Higher rates in Eskimo, where diet traditionally low in carbohydrate!
  • Congenital lactase deficiency esp Finland!
  • Congenital fructose (cf fructose malabsorption, IBS like) – hypoglycaemia, jaundice. Sucrose also triggers.
  • Glucose-Galactose intolerance – high sodium.
  • Lysinuric protein intolerance
  • Tufting enteropathy
  • Microvillous inclusion disease

Some lists include pancreatic disorders eg CF, Schwachmann-Diamond, other causes are abetalipoproteinaemia (so check lipids) and IPEX.

If diarrhoea stops with feed withholding, then osmotic rather than secretory. Anion gap (Na+K-Cl-Bic) in the stool greater than 50 (normal 10-20) indicates unidentified acidic substances.

Reducing substances in stool suggest carbohydrate malabsorption but not reliable (and test no longer made) – bacteria break down complex carbohydrates so false pos, molecular methods better.

Low albumin suggests protein losing enteropathy eg IPEX.

[ Int J Mol Sci. 2012; 13(4): 4168–4185. doi: 10.3390/ijms13044168]

Diarrhoea

Clinical, Common, Gastro, General paediatrics

According to NICE, 3 or more loose or liquid stools in a day (or more frequently than is normal for the individual) counts as diarrhoea.

Persisting for more than 14 days makes it chronic.

Acute typically gastroenteritis. Presence of blood and/or mucus suggests more invasive inflammation, viz colitis.

In kids, can occur with pretty much any illness!

Vomiting with diarrhoea makes a primary gut cause more likely, but still not specific.

Doctor-patient communication

Communication, Ethics, Patients

Verbal, non-verbal and paraverbal (tone, pitch, volume) [Ranjan 2015].

Consultations – patient’s opening chat is interrupted by their doctor after mean 18 secs.  Patient talk for 40% of total consultation time, estimated by doctor at 60%.

Wayne et al 2011 – less info given to poorer and minorities, more dialogue and more informative with better educated, more literate patients

Neumann 2011 – decline in medical empathy: significant through medical school,  further declines through residency.  “Hidden” curriculum? Hardening/cynicism? Rosenthal 2011 – humanism and professionalism student module, no decline in 3rd year student empathy.

Chen 2012 – empathy associated with women, non-technological specialty preference, high debt!

Roter and Hall 2006 – doctors like to retain authority but poor at managing confrontation (eg eye contact) and picking up emotional cues of distress

Psychodynamic approach – counter transference (disgust, judgemental), counter resistance (non-compliance).

Narrative as diagnosis!  William Osler – the diagnosis is in the story.

Communication and teamwork “skills” underestimates complexity, the affective component.  Only learned if valued, rather than as something to be acquired. 

“Heroic individualism” valued in medicine, cf dialogue.

Students struggle to make conversation with patients!  Fear of intrusiveness, failure to connect medical issues with psychosocial elements.

Best – learn through active reflection on work based learning (cf how artificial PBL etc are).  Think about values, how they shape communication.  Modelling of democratic values.  Appreciation of complexity of communication.

[ Alan Bleakley, Peninsula medical school – Homer as evidence of honour/shame/face directed behaviours, cf feminine, guilt directed behaviours etc]

Participatory Medicine

Outside of the consultation, doctor-patient communication becomes a mixture of formal and informal, but both tend to be one sided. Formal letters are an essentially one sided message from the doctor to the patient. Informal communication includes requests or questions from the patient to the doctor but again, often one sided as it does not usually lead to a meaningful exchange.

See Participatory medicine.

Oratory

Communication skills are essential to career development, advocacy, leadership. See Oratory.

Difficult conversations

Communication, Generic, Patients

From “Everything happens for a reason – and other lies I’ve loved” by Kate Bowler:

Appendix 1 – absolutely never say this [my comments added]

  • Well, at least… [minimizing]
  • In my long life, I’ve learned… [good for you, have a medal]
  • It’s going to get better, I promise. [fantasy]
  • God needed an angel [only if you watch Ghost, and you think God is sadistic]
  • Everything happens for a reason. [let’s see if you appreciate my theories when you are drowning]
  • I’ve done some research [have you heard about… Forget what the professionals say, there’s bound to be a secret cure out there]
  • When my aunt had cancer [living it, thanks, would rather not have to relive someone else’s – particularly if this my opportunity to NOT think about it]
  • So how are the treatments going? [not nice to have to summarise it and regurgitate it constantly, please check first if I want to talk about it today, sometimes I do, sometimes I don’t]

Appendix 2 – give this a go

  • I’d love to bring you a meal this week [bring me anything, I don’t really know what I need, what are you good at?]
  • You are a beautiful person [nice to know you are doing a good job – without this being some sort of lesson.  And don’t make it sound like a eulogy]
  • I’m so grateful to hear about how you’re doing, and just know that I’m on your team [nice to not have to give you an update, great that you’re informed and concerned, let’s talk about something else]
  • Can I give you a hug?
  • Oh, my friend, that sounds so hard [sometimes it feels like no one wants to hear about how awful it is – simmer down, let them talk]
  • (silence) [the truth is no one knows what to say – pain, tragedy are awkward.  So show up and shut up)

Sometimes our role is just to sit in the rubble with families (Judith Murray).

See Spiritual Care.

Enteral feeding

Gastro, General paediatrics, Nutrition

Freka PEG tube can only be removed orally.  Good if v active, combative patient.  But risk of mucosal burying, so weekly push and pull.  Corflo can be removed by traction.  Need replacing every 18 months. 

Button preferred now, tube can be disconnected as required, replace every 12-18 months.  40% mortality at 5yrs post fundoplication where CP. 40% had no improvement in gagging symptoms.  Only 1 in 8 need subsequent fundo if PEG only done first, so tend not to be done at same time.

Alternatives – jejunal tube via PEG (needs continuous feeds) or jejunal button (less retching but more tube problems eg blockage).

Jejunostomy via Roux en Y potentially primary procedure.  Risk of volvulus.

Oesophagogastric disconnection – (Manchester) stomach detached from oesophagus, which gets plumbed on to Roux en Y instead. 

Bridles for NG/NJ skin fixation issues.

Blended diet for growth issues, feeding tolerance issues, failed jejunal, to avoid fundoplication. Currently not done via NG/NJ.