Typically closes around 12 months of age. Can be bulging (meningitis?), sunken (dehydration), pulsatile (normal!), large (hypothyroidism), small (craniosynostosis). But actually not very predictive of any of these things in isolation.
For example – in Brazilian study of babies with craniosynostosis compared with babies with fontanelle that closed by 6 months, only 36% sensitive for craniosynostosis, and positive predictive value 59%. [https://doi.org/10.1016/j.jped.2021.10.004]
Do not diagnose asthma without objective test.
Feno (if available) >35ppb diagnostic, age 5+. If not diagnostic, measure BDR with spirometry. Diagnose asthma if the FEV1 increase is 12% or more from baseline (or if the FEV1 increase is 10% or more of the predicted normal FEV1).
If spirometer not available, measure PEF twice daily for 2 weeks. Diagnose asthma if PEF variability (expressed as amplitude percentage mean) is 20% or more.
Failing that, either perform skin prick testing to house dust mite or measure total IgE level plus blood eosinophil count. Raised total IgE plus Eos >0.5 considered diagnostic! [Because highlights underlying atopy cf viral wheeze?]
Under 5, prescribe steroids [not just salbutamol!] for 8-12 weeks and review. [No dosage guide for under 5s!?] Then do objective test when they reach 5! If no response, check technique, consider environmental triggers (mould, smoke etc), consider alternative diagnosis, refer.
If making asthma diagnosis, record basis for this in notes.
Suggests stopping after initial trial or else within 12 months, if symptoms settled.
If helps but then symptoms recur, can try moderate ICS dose. After that, 8-12 week trial LTRA.
Uncontrolled = exacerbation requiring oral steroids, or use of SABA 3 days a week or more, or night waking once per week or more.
New section on diagnosis at time of acute presentation!
Refer to a specialist respiratory paediatrician any preschool child with an admission to hospital, or 2 or more emergency department admissions in a 12-month period.
Age 5-11, after low dose ICS, assess ability to manage MART (maintenance and reliever therapy) regimen (none licensed under 12, so would be off label). Start low, go to moderate.
Otherwise would be trial of LRTA, then add LABA, then increase ICS to moderate.
12+, start Anti-inflammatory reliever (AIR) therapy with prn combination ICS/LABA inhaler (only budesonide/formoterol licensed for this). This strategy had lowest rate of severe exacerbations (plus cheaper). If highly symptomatic at presentation could start MART +/- oral steroids with view to stepping down.
If MART required and still symptomatic on moderate dose, check FENO and eosinophil count – refer if either high. Otherwise trial of either a LTRA or a long-acting muscarinic receptor antagonist (LAMA, eg tiotropium).
Beware neuropsychiatric side effects of LTRA/montelukast. Review annually.
Duoresp Spiromax 160/4.5 (powder, 12+) – For MART, 2 inhalations daily in 1-2 divided doses (up to 2 BD); 1 inhalation PRN for relief up to 8 in a day (up to 12 for a limited time but medical assessment recommended).
Symbicort 200/6 (powder, 12+) MART as above. Else AIR – 1 puff PRN, up to 6-8 (up to 12 for limited time).
Symbicort 100/3 MDI 12+ MART – 4 puffs daily in 1-2 divided doses, up to 4 BD. 2 puffs PRN for relief up to 12-16 in a day (max 24)
Wockair 160/4.5 (powder) MART 2 inhalations daily in 1-2 divded doses, up to 2 BD. 1 inhalation PRN up to 6-8 (max 12). Else AIR – as above
House dust mite reduction measures not routinely recommended. Evidence on removal of pets from homes “paradoxical” – no benefit or tolerance if continued presence. If detectable cat antigens without cat, might be benefit to high efficiency vacuum cleaning or additional measures.
Air pollution linked to worse symptoms.
High sodium and low magnesium intake linked to asthma symptoms but poor/no evidence that intervention makes a difference. High intake of fresh fruit and vegetables is associated with less asthma and better pulmonary function but no interventional studies.
Weight loss interventions may help asthma symptoms in overweight/obese, and should be considered, but may require >10% loss for benefit.
Breathing exercises eg Papworth/Buteyko methods can lead to modest improvements in asthma symptoms and quality of life, and reduce bronchodilator requirement, in adults with asthma. Less evidence for effect on lung function or airway inflammation. Insufficient evidence in children.
Monitor asthma symptoms, plus check:
FENO can be considered for monitoring in adults only. Peak flows not routinely indicated for monitoring.
Not much! Separate section on self management. Vaping/smoking. Factors that affect inhaler use eg school/social. Career plans.
Firstly, is there a suicide risk?
Then, consider mental health needs. Is there an alcohol or drug issue?
Are they known to social work? Are there any child protection issues for the young person? Their siblings or other family members? If young person is over 16 then consider Adult Protection measures (Scotland Act 2007).
A proper mental health assessment requires that they are physically well enough (consider intoxication, sedation, pain etc). Consider competency (which can be impaired temporarily by physical illness).
Consider:
Symptoms of light headedness, dizziness, tunnel vision (pre-syncopal), potentially followed by collapse, which can be remembered in most cases. Can be brief posturing or clonus due to hypoxia, but only for a few seconds.
Recovery is fast, within seconds or a minute, once circulation to brain improves – requires that person is left lying on ground and not propped up!
They look pale, feel hot, but once on ground go clammy/sweaty. Heart rate and blood pressure typically low.
Common in teenagers, with growth spurt.
Can be reflex, from pain/fright/emotion. So with blood tests or immunisations, for example – NOT anaphylaxis.
Other differentials are epilepsy and POTS.
Patient/family info at www.stars.org.uk.
For lower tract:
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.
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.
Bacteriuria is not uncommonly seen with bronchiolitis, not always clear if this is true urine infection.
RSV passive immunisation for high risk babies with paluvizimab (Synagis). There’s an important story about the dangers of vaccine development.
HARMONIE trial of Nirsevimab – 83% reduction in RSV hospitalisation, 75% reduction in severe disease. Spain and US doing. Fight for global supply…
See here.
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.
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.
Differential would be myoclonic epilepsy, startle (including hyperekplexia), jitters.
Tanner stages – verbal descriptions but images helpful esp for self assessment.
Pubic Hair Scale (both males and females)
Female Breast Development Scale
For males you then have testicular volume, measured by orchidometer (between £26 and £208):
Cadbury’s Teasers and Truffles (from Celebrations box) are 8ml, equivalent to 50th centile at age 13.
If you only have a ruler, use maximum width in millimetres and the formula: (W-1.5)3 x 0.88, where ss is double scrotal skin thickness (for Tanner stages 1, 2, and 3).