= papular acrodermatitis. Papules up to 10mm in diameter, esp face and arms/legs.
Often itchy. Can blister.
Viral. Can last 10 days plus, weeks sometimes.
Category Archives: General paediatrics
Self-harm
Issues around confidentiality, competence and safe guarding important here.
Involvement of family members and other carers can be really useful, if the young person agrees. Should be collaborative, of course, giving them opportunities to contribute to planning. But not just about minimising self harm behaviour – empowering and supporting (during acute distress and also in recovery) vital too.
Assessment
- “How is your mood?”
- “Sometimes people who feel down can start to feel hopeless about the future. Has this happened to you?”
- “Have you ever had any thoughts about life not being worth living?” [Hurting yourself different??]
- “Have you thought about how you might do that? Have you done anything towards that plan?”
- Risk is then on a spectrum – engaging with treatment? Loss of protective factors eg family support?
- Discuss removing the method of self harm – with therapeutic collaboration or negotiation, to keep the person safe
- Discuss current support network, any safety plan (see below) or coping strategies
- Problem solve around dynamic risk factors
Refer
Refer to mental health professionals urgently where:
- the person’s levels of concern or distress are rising, high or sustained
- the frequency or degree of self-harm or suicidal intent is increasing
- the person asks for further support from mental health services
- levels of distress in family members or carers of children, young people and adults are rising, high or sustained, despite attempts to help.
Treatment
Work collaboratively with the person, using a strengths-based approach to identify solutions to reduce their distress that leads to self-harm.
Consider developing a safety plan:
- recognise the triggers and warning signs
- individualised coping strategies, including problem solving any barriers to those strategies
- social contacts and settings that can distract from suicidal thoughts or escalating crisis
- family members or friends to provide support and/or help resolve the crisis
- contact details for the mental health service, including out-of-hours services and emergency contact details
- keep the environment safe by working collaboratively to remove or restrict lethal means of suicide.
Underlying depression, anxiety, learning disabilities, autism, eating disorders should all be addressed.
For children and young people with significant emotional dysregulation difficulties who have frequent episodes of self-harm, consider dialectical behaviour therapy adapted for adolescents (DBT-A).
[NICE guidance NG225][BMJ 2017]Alcohol and drug dependency
Early adolescence appears to be a critical time for determining the long term direction of biopsychosocial development. US studies found that those who reported their first alcoholic drink before age 14 (or drug use before age 15) were 3x more likely to develop dependence.
Regular use of cannabis before age 15 seems linked to subsequent psychosis, and risk appears to be 5x higher in daily users of high strength cannabis. But longitudinal study did not find a link after controlling for confounders. Risk probably highest where genetic or other vulnerability.
Large studies in Australia and New Zealand found frequent cannabis use predicts poor educational outcomes – some evidence for poorer memory performance (for days or even weeks after use), which might explain it (controlled for socioeconomic factors).
Inconsistent moderate associations with suicide and attempted suicide.
[National institute on drug abuse 2020]Screening
CRAFFT –
- Have you ever ridden in a Car driven by yourself or someone else who was high or who had been using alcohol/drugs?
- Do you ever use alcohol/drugs to Relax, feel better about yourself or fit in?
- Do you ever use alcohol/drugs when you are Alone?
- Do you ever Forget things you did while using alcohol/drugs?
- Do your family/friends ever tell you that you should cut down?
- Have you been in Trouble while using alcohol/drugs?
2 or more yes answers “suggests an important problem”.
Intervention
Brief motivational intervention almost halved frequency of alcohol bingeing among 13-17yr olds presenting to an Emergency department. But rate also reduced in control groups.
A “confiding” parent-child relationship is linked to lower substance abuse rates. Parental knowledge of the child’s whereabouts is protective, although also likely to be proxy for confiding relationship.
Sympathetic, informed, supportive counselling as good as CBT for adolescent depression and adult alcoholism. Flexibility of services is important.
FRAMES –
- Feedback – personalised, about risk/harm
- Responsibility – emphasis personal responsibility for change
- Advice – give clear advice to change habits
- Menu – offer menu of strategies
- Empathic – and non judgmental
- Self efficacy – aim to increase patient’s confidence to change behaviour
Long COVID
Doesn’t seem to be associated with severity of initial illness.
Long COVID is less common if you are vaccinated already. In a community based study of adults aged 18 to 69 years infected with SARS-CoV-2 before vaccination against covid-19, the odds of experiencing long covid symptoms decreased by an average of 13% after a first covid-19 vaccine dose, with a further 9% decrease in the odds of long covid after a second dose. [https://doi.org/10.1136/bmj-2021-069676]
If you already have long COVID, further COVID immunisations seem to be beneficial, rather than harmful:
- In a non-controlled study of 900 social media users with long COVID, more than half experienced an improvement in symptoms after vaccination compared with 7% who reported a deterioration.19
- A study of 44 vaccinated patients and 22 unvaccinated controls previously admitted to hospital with covid-19 in the UK, which inevitably had limited power to detect clinically relevant effects, found no evidence for vaccination being associated with worsening of long covid symptoms or quality of life.20
- A French study of 455 self-selected participants found reduced long COVID symptom burden and double the rate of remission at 120 days in vaccinated participants compared with unvaccinated controls.
All about symptoms, excluding treatable conditions, then self management. For adults:
Dancing Eye syndrome
or Opsoclonus Myoclonus Syndrome, which is a much less suggestive name, and not only a partially correct description!
Features:
- myoclonus
- rapid involuntary eye movements in all directions (opsoclonus)
But also
- ataxia
- marked irritability, sleep disturbance.
Typically in young children, under 3. About half will have neuroblastoma. The rest assumed to be autoimmune.
Threadworms
=enterobius. Common in young children, probably due to hygiene issues. Also called pinworms. Small (1-2cm), like white threads. Can be intensely itchy, usually in night when worms emerge to lay eggs.
Mebendazole effective at killing live worms in gut, not effective if eggs in vagina. Licensed from age 2 but can be used off license below that. Does not kill eggs however, and main issue is reinfection so consider treating whole family, with repeat doses after 2 weeks when any eggs will have hatched. NHS Inform advice on hygiene:
- Lifespan of threadworms is approximately 6 weeks, so follow hygiene measures for at least this length of time.
- Everyone in the household must follow the advice outlined below.
- Wash all night clothes, bed linen, towels and soft toys (normal temperatures OK but make sure the washing is well rinsed [presumably at start of treatment; dilution more important than soap?]
- Vacuum and dust the whole house esp bedrooms – repeat regularly
- Clean bathroom and kitchen surfaces – again, rinse cloth frequently – repeat regularly
- Avoid shaking out clothes/bedding that may be contaminated with eggs, to prevent eggs being transferred to other surfaces
- Don’t eat food in the bedroom
- Keep fingernails short
- Discourage nail-biting and sucking fingers/thumbs
- Wash hands frequently and scrub under your fingernails esp before eating, after going to the toilet, and before and after changing your baby’s nappy
- wear close-fitting underwear at night and change your underwear every morning
- bathe or shower regularly – it’s particularly important to bathe or shower first thing in the morning: make sure you clean around your anus and vagina to remove any eggs
- don’t share towels
- keep toothbrushes in a closed cupboard and rinse them thoroughly before use!
Eggs probably become unviable after a few days if not in warm and moist environment… Children may of course pick up another threadworm infection from school/nursery…
Sometimes you just have to keep repeating treatment over months/years! Mebendazole is harmless (v little systemic absorption), although symptoms may be caused by clearance of large worm burdens.
Pseudomonas
Typically P. aeruginosa. A biofilm producing gram negative bacterium important in multiresistant infections, particularly in the immunocompromised and in cystic fibrosis.
Pretty ubiquitous in the environment, especially in lakes and rivers. Often found in vases of cut flowers, and in spa/whirlpool baths, where it is associated with folliculitis.
The ability to make biofilms makes infection difficult to treat, as the biofilm prevents penetration by antibiotics. The biofilm allows the bugs to survive in low nutrient environments.
Antibiotic resistance is a major issue, with specific anti-pseudomonal antibiotics often required viz tobramycin, ceftazidine.
Ingesting pseudomonas doesn’t pose much of a hazard, unless you are on antibiotics already and have a disturbed intestinal flora. Aerosolizing pseudomonas on the other hand can be lethal to mice.
[DOI: 10.1007/978-1-4419-0032-6_3]Chest pain
Common in children esp teenagers, often at rest, sharp but brief. Extremely rare to find a cause…
Differential:
- Oesophagitis
- Asthma
- Pulmonary embolism
- Tachyarrhythmia – but you would expect palpitations and colour change, “on/off”
- Precordial catch syndrome
- Costochondritis (Tietze syndrome)
- Catecholamine secreting tumours??
- Cardiomyopathy? Ischaemic cardiomyopathy eg anomalous origin of left coronary artery (from pulmonary artery) – but in kids, either too young to describe pain (infants) or else too mild to present with angina (instead present with failure). Arrhythmogenic ventricular cardiomyopathy (usually right, but biventricular involvement recognised) can present with pain but usually syncopal episodes. [Circulation. 2019;140:e9–e68]
- Fabry’s as cause of bizarre pain (heart involvement but pain usually GI).
- Aortic root problem – as seen in Marfan’s and other connective tissue problems.
So red flags would be syncope, colour change, sudden dizziness/confusion, sweating/clamminess suggesting cardiovascular compromise.
Assuming normal physical examination, and no family history of inherited cardiac problems (or sudden death), if not exertional then can be reassured. Pain killers not usually helpful as pain settles so quickly.
If exertional then needs ECG. Unlikely to be significant cardiac problem if normal.
[Archives 2014]Rett Syndrome
Exclusively females (lethal in males? Or rate of germ cell mutations higher in male germ cells?). Virtually always sporadic – so not exactly X linked dominant.
MECP2 gene on X chromosome.
Developmental arrest at 6-18 months, then regression, loss of speech, stereotypies esp hands.
Often epilepsy, then complications of severe neurodisability eg chronic lung issues.
Not degenerative however – can live into middle life.
Chronic pain
Gate theory useful – it’s not just about the stimulus coming to your nerve endings. That signal has to pass through a gate, to register in your brain, and different things affect whether the gate is more or less open or closed.
A feature of many chronic health conditions, eg juvenile idiopathic arthritis, migraine. Often a feature of chronic fatigue syndrome. Can be part of a functional disorder such as functional abdominal pain. In a limb, can lead to reflex sympathetic dystrophy. But often unexplained.
Think about PTSD – it’s all “in your head” but that doesn’t mean it’s nothing. Or phantom limb pain – there isn’t even a true signal coming from the limb, but you still feel pain.
Pain is performative – no one gets credit for trying to cope and hide it. But you can be accuse of “laying it on thick”.
Having a diagnosis helps socially.
Pain can make you a different person from who you were. Impatience and irritability can be understood, besides an inability to do some activities that might be important to identity (and to relieving stress). Social isolation is common.
Chronic pain also steals any sense of your future because it is too intolerable to imagine more pain.
Fear needs to be detached from pain.
Acceptance therapy – not to accept eternity of pain but to focus on progress and function.
[Haider Warraich podcast with Kate Bowler]