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Plantar warts

Common, Dermatology, General paediatrics

2/3 resolve within 2 years.  In young children, higher spontaneous clearance.  In systematic review, only salicylic acid and aggressive cryotherapy seem to be effective.  Both are user dependent.  In RCT between the 2 and conservative management, no difference detectable after 13 weeks.  So watch and wait, unless causing a lot of pain.

Perianal warts can be transmitted vertically from mother at birth, or potentially from carers changing nappies.

Warticon cream is podophyllotoxin. Else Condyline paint.

Risk factors of allergy

Allergy, General paediatrics, Immunology

Children reported to have taken antibiotics during infancy (0-2yrs) were more likely to have asthma at 7.5yrs, with a dose response pattern.  No association between antibiotic use and atop on skin prick testing however!  Hoskin-Parr, Ped All Imm 2013;24:762 (Avon longitudinal study)

 

At 18/12 of age, babies born by SVD and whose parents suck their dummy are 2.5x less likely to have eczema than those born by LSCS whose parents do not suck their dummies.  Germany/Sweden, Peds 2013;131:e1829

 

Children born outside of US much less likely to have allergic disorder (OR 0.48), although those who have lived in US for 10+yrs have higher odds of eczema and hay fever cf those who have lived in US under 2 years.  But not clear whether children moved from developing or developed country.  Ped 2013;167:554

 

Inverse dose response effect between food diversity in infancy and asthma (OR 0.74).  26% reduction in asthma for every additional item of food added in the first year of life.  Increased risk of food allergy by age 6yr (OR0.7), but no longer statistically significant after excluding children with food allergy in the first year of life.  European cohort, JACI 2014;133:1056

Prognosis of type 1 diabetes

Endocrinology, General paediatrics,

Life expectancy now into 70s.  Rates of diabetic nephropathy have fallen over the last few decades, and progression is dramatically reduced thanks to prevention and treatment strategies.  Cancer and not CVS disease is now the main cause of death!  Survival seems to be as much about dealing with obesity, insulin resistance, hypertension and arterial disease – as you would for type 2.

Food allergy labelling

Allergy, General paediatrics, ,

The UK still currently follows the European Food Information For Consumers Regulation (FIR) that took effect from December 2014.

This applies to unpackaged food eg restaurants, takeaway’s deli’s, bakeries etc. It now also applies to food prepacked for direct sale (PPDS) such as a sandwich made on the premises of a cafe but wrapped (Natasha’s law).

Allergy advice boxes are no longer permitted, although “may contain” advisory labels are. The allergen should be emphasised in the ingredients panel through typeset eg font, style, colour.   The specific type of cereal or nut must also be stated.

The 14 allergens that must be highlighted under UK/European law are: cereals containing gluten (wheat, barley, rye etc), crustaceans (eg shrimp, prawn), molluscs (eg mussel, oyster), eggs, fish, peanuts, nuts, soybeans, milk, celery, mustard, sesame, lupin and sulphur dioxide at levels above 10mg/kg, or 10 mg/litre, expressed as SO2. Lupin and Molluscs added later.

There are some exceptions, where the food is so highly processed that they are no longer capable of triggering an adverse reaction eg fish gelatine in beer/wine, soya in vegetable oil.

If your allergy is not one of those listed, eg lentil, there is no legal duty for the manufacturer to highlight the presence of that ingredient, or for the restaurant to provide a full list of ingredients.  So you need to read the full list of ingredients carefully, and plead with the restaurant for details relevant to your allergy. In the past, some manufacturers highlighted allergens in a separate box, but this is no longer permitted.

The rules list nuts as:

  • almond,
  • hazelnut,
  • walnut,
  • cashew nut,
  • pecan nut,
  • Brazil nut,
  • pistachio nut,
  • macadamia nut or Queensland nut
  • and products made from these nuts.

Other types of nuts, and other foods which are not nuts (even though they are called nuts i.e. chestnuts, pine nuts and coconut), are not named in the rules, even though they are known to cause allergy in some people.

Note that by law, “cereals containing gluten” includes oats! Spelt and Kamut should be declared as containing wheat. Oats contain avenin, rather than gliadin, but related. Products containing oats that have not been contaminated by wheat can be declared “gluten free” by law, so effectively the law considers oats as both containing but not containing gluten…

See also Advisory labels.

(food.gov technical guidance on new labelling law)

There is no legal duty to highlight changes in recipes on packaging.  The same product with the same packaging can sometimes have different ingredients, depending on where it is produced.

The Food Standards Agency (FSA) has ordered councils to encourage restaurant owners to check their ingredients.

Note that non-EU countries will have their own rules eg US has only 10 ingredients that must be highlighted (not molluscs, mustard, celery, or lupin).

Lymphadenopathy

Clinical, Common, General paediatrics, Haem/Oncology, Infectious disease

A good proportion of healthy children will have palpable lymph nodes in the neck.  Mostly these will be under 1cm in diameter.  Acute enlargement as part of an upper respiratory tract infection is usually accompanied by tenderness, and affected nodes will reduce in size over 4-6 weeks.

Guidance from NICE and the Scottish Government provide criteria when children with lymphadenopathy should be urgently referred for suspected cancer.

These criteria include the following:

  • lymph nodes are non-tender and firm/hard
  • lymph nodes are greater than 2 cm in size
  • lymph nodes are progressively enlarging
  • other features of general ill-health, fever or weight loss
  • the axillary nodes are involved (in the absence of local infection or dermatitis)
  • the supraclavicular nodes are involved.

But caveat is “Always refer any patient with Repeat presentations (3 or more times) of any physical symptoms which do not appear to be resolving or following a normal pattern, taking into account parental and patient concern”.

No need to do bloods in the absence of any of these criteria. Not that cancer is the only concern – differential includes developmental lesions (branchial cysts etc), TB, Cat-scratch disease, non-tuberculous mycobacterial infection (esp in neck).  These are always more than 2cm and there may also be systemic features and/or overlying skin discolouration too.

Malignancies often present in the head/neck region.  Hodgkins lymphoma usually affects teenagers, Non-hodgkins tends to affect school age children, neuroblastoma tends to affect pre-school children.  B-symptoms (recurrent fever, weight loss, night sweats, pruritus, lethargy) are only seen in a minority but does suggest more advanced disease, of course.  Airway or voice changes, swallowing difficulty, Horner’s syndrome, superior vena cava syndrome may all be seen due to mass effect. Most neuroblastomas have an abdominal mass.  Nasopharyngeal carcinomas are seen so look in the nose/throat.

Do not resuscitate

Ethics, Generic

The DNR question makes parents feel that their child’s right to life, and quality of life are being questioned. Do it once, then leave it alone. Parents can agree in what circumstances it should be asked again.

Beware self fulfilling prophecies – if you are pessimistic, you may limit what they may achieve in future.

There is no such thing as false hope. Hope is today’s dream for tomorrow, it helps you keep going, putting one foot in front of the other.

Parents have needs too. Helps when professionals presume things will get better, when they acknowledge patient is beautiful, happy, loved; when they are pleased with progress, when they share good news as well as bad.

Careful with words in front of parents and siblings eg end of life pathway, dysmorphic, lethal condition.

The discipline of medicine concerns the manipulation of knowledge under uncertainty (Siddharta Mukherjee).

“When you consider that CPR would be futile for a patient dying from a terminal illness in hospital, there is no need to distress the patient with a discussion about CPR before completing the DNACPR form.”

This was considered appropriate advice until June 2014.  Patients cannot demand futile treatment and so, if the decision has been made not to resuscitate, asking the patient’s views could lead to difficulties if he/she wanted cardiopulmonary resuscitation. In addition, if handled badly, the patient may be left with the misunderstanding that a life-prolonging treatment was being withheld.

In landmark judgement re: Janet Tracey, who had terminal lung cancer, Lord Dyson said the hospital trust violated Mrs Tracey’s right to respect for her private life under Article 8 of the European Convention of Human Rights when they placed a DNR order in her notes without informing her.

“Doctors have a legal duty to consult with and inform patients if they want to place a Do Not Resuscitate (DNR) order on medical notes.  A DNR decision is one which will potentially deprive the patient of life-saving treatment, so there should be a presumption in favour of patient involvement.  There need to be convincing reasons not to involve the patient. Doctors should be wary of being too ready to exclude patients from the process on the grounds that their involvement is likely to distress them”.  June 2014

Relatives of patients should never be asked to make decisions about resuscitation status, but it is good practice to take the opportunity to inform them if a patient is known to be dying. Relatives cannot make treatment decisions unless they have legal powers to do so. Even then, they cannot demand treatment that is considered futile by medical staff. However, if a DNACPR order is written, it may offer an opportunity to inform them (and the patient if appropriate) that the patient is expected to die soon and that active care may continue but will stop short of CPR.

Carl Winspear case 2011 – High court held DNACPR wrote at 3am without consulting family was breach of human rights. Phone call would have been “practicable” albeit inconvenient. The defence that it was a clinical decision declared a “misunderstanding as to the purpose of the consultation… Input into decision making process… Dignity… Family can take on board and respond to news”

When a patient is being discharged home to die, patient and carers should be informed and in agreement with a DNACPR order as the paperwork will be kept in the house and could be discarded if not understood or wanted by the family. If at all possible, a DNACPR order should follow the patient home when death is expected. The existence and benefits of the order should be explained to the patient (if lucid and mobile) and carers, as it will most likely be seen by them and could cause distress if not known about in advance. It will only be effective if accepted by those caring for the patient, as they would be responsible for calling for emergency assistance or not in the event of death.

It should be remembered that the decision not to resuscitate is one for the medical team or the patient, but not the relatives. However, asking for a patient’s agreement with a DNACPR decision already made may cause unnecessary distress. Good, sensitive communication about end-of-life issues is important and may be prompted by a DNACPR order. The issue of time and skills needed to do this is acknowledged and the need for further clarity and discussion is apparent.

Allow Natural Death – preferable terminology?

E-patients

Generic, Patients,

See also Expert patients. E-patients – (Wikipedia) use internet on behalf of themselves or others to get information about medical  conditions.  Tom Ferguson white paper.

  1. E-patients are valuable healthcare resources, and should be recognized as such.
  2. Empowerment is trickier than you might think.  Knowledge may increase but improvements in anxiety, self efficacy, changes in behaviour do not always follow. Patients often know more than doctors realize, they often want to know about things doctors don’t have the answers to (or would avoid answering), and they often want to pass things on to other patients or give feedback to their doctors [Diana Forsythe, medical anthropologist].
  3. Patients can quickly know more about a condition than their doctor.
  4. Hazards of imperfect online health information prob exaggerated. Cf medical errors!
  5. Wherever possible, healthcare should be provided on patient’s “turf”
  6. Clinicians can no longer go it alone
  7. The most effective way of improving health care is collaboratively

In the outside world, a diagnosis (esp a rare one) can seem like a world upturning misfortune that sets you apart.  Online, it is a badge of honour that connects everyone together.

Angela Coulter – paternalism in health care – clinicians underestimate how intimidating the clinical encounter is, patients fear offending their clinician if they assert themselves or offer an agenda.  Clinicians are often unaware of the constraints that prevent patients asking questions in clinic.  Clinicians often believe patients need to be protected from the truth eg uncertainties, bad news.  Patients can often be left feeling inept, diminishing their sense of control.  Paternalistic clinicians often seen as unsympathetic or arrogant, refusing to accept ideas or suggestions.

Try:

  • What do you want to make sure we discuss today?
  • What needs to happen today to make this visit feel successful?

Patient feedback –  can sometimes lead to poor morale – positives need to be celebrated.   Confidentiality must be assured for feedback to be meaningful.

Anisocoria

Clinical, General paediatrics

Which side is abnormal?!

Failure to dilate, failure to contract (usually exogenous anticholinergic, such as Hyoscine patch gone AWOL)?

Is eye lid sagging?  Is skin dry?  Reflexes?

Horners is small pupil with ptosis and dry skin – apical tumour (Pancoast) or lesion in brainstem/neck.

Dilated pupil can be part of third nerve palsy but you would usually also see ptosis and loss of adduction. Adie pupil is sudden onset mydriasis (dilated) with loss of reflexes (usually just ankle jerks) on the same side, can spread to other side.  Usually post viral. Can be excessive sweating. Loss of reflexes can be permanent.

Physiological anisocoria = size difference does not vary according to light/dark.

IgA deficiency

General paediatrics, Immunology

Immunoglobulin A deficiency is the most common primary immunodeficiency.

1 in 700 healthy Western blood donors, but much rarer in some ethnic groups.  FH only in a quarter.

Defined as a serum IgA concentration of < 0.06g/L in patients over 4 years of age, with normal levels of IgG and IgM, which is not secondary to other causes e.g. myeloma.

IgA subclass (IgA1 and IgA2) deficiencies described. IgA deficiency may be found in ataxia-telangiectasia, and IgG subclass deficiencies, drugs (phenytoin, sulfasalazine), chromosomal abnormalities (esp chromosome 18), coeliac disease.

Sometimes seen in families as recessive trait, else dominant with variable penetrance.

Issues:

  • Infection – Most individuals with IgA deficiency are clinically asymptomatic. Otherwise, higher than usual frequency of respiratory (incl sinus) infections, and GI infections esp giardiasis. Recurrent infections more often seen when accompanying IgG subclass deficiency (so consider IVIG, although contains small amount IgA, so might produce antibodies).
  • Associated conditions – Long term follow up has found higher rate of gut and lymphoid malignancies. Increased frequency of coeliac disease, autoimmune disorders and allergy/atopy.
  • Blood transfusion – IgA deficient patients can develop anti-IgA antibodies to blood products (20-40%). But these antibodies also seen not uncommonly in normal population and do not help predict transfusion reactions, so testing controversial. Severe reactions are v rare (1 in >20,000 transfusions).
    • Enhanced surveillance for transfusion reactions recommended, and pre-medication with hydrocortisone/chlorphenamine should be considered.
    • If a patient has previously had a reaction, then plasma reduced products or IgA def donor products (best) recommended. However, danger of delaying transfusion must be weighed against potential risk.
    • Transfusion labs should be informed of patients with the diagnosis.

Pathogenesis of IgA deficiency is presumably abnormalities in Ig class switching. T-cell function normal in most. Possibly part of CVID spectrum?

J Clin Pathol 2001;54:337-338 pmid 11328829