Category Archives: General paediatrics

Diet and mental health

General paediatrics, Mental health, Nutrition

Longitudinal research shows association between progressively higher glycaemic index diet and incidence of depressive symptoms. Experimental exposure to diets with high glycaemic load increases depressive symptoms in healthy volunteers, with moderately large effect.

Mechanism could be repeated and rapid changes in blood glucose, triggering counter regulatory hormones such as cortisol, adrenaline, growth hormone, glucagon.

Appears to be an inflammatory response to high glycaemic index foods too. Adherence to Mediterranean diet reduces markers. Mood disorders have been linked to heightened inflammation, although only in a minority. Observational studies show people with depression score higher for “dietary inflammation” viz trans fats, refined carbohydrates, lower intake of omega 3 fats. Mediated through polyphenols, polyunsaturated fatty acids?

Diet also affects microbiome, which interacts with the brain in bidirectional ways using neural, inflammatory and hormonal signalling pathways. High fibre, polyphenol, unsaturated fats promotes microbial taxa that generate anti-inflammatory metabolites such as short chain fatty acids.

Study of probiotics in healthy volunteers found altered response to a task that requires emotional attention, and may even reduce symptoms of depression.

But no benefit in large trial of Medierranean diet with subclinical depressive symptoms, only small trials of current depression showed benefit. Note context of people’s expectations regarding food/diet, which will likely have a marked effect on wellbeing.

Danger too of stigmatisation if trying to change an individual’s dietary choices.

[Joseph Firth, BMJ 2020;369:m2382]]

Mesial temporal sclerosis

General paediatrics, Neurology

= scarring in hippocampal area of temporal lobe. Commonly found on MRI in focal epilepsy (although focal EEG changes not always indicative of MRI abnormality, and other MRI lesions can account for temporal lobe epilepsy).

Often a history of febrile convulsions but unclear which comes first. Brain injury in early years from viral encephalitis or other cause often explains it.

Adjacent to language areas (assuming same side as language areas, which are usually on the left side in people who are right handed, but can be either side in people who are left handed) so seizures may affect speech. Also close to memory area so may not remember afterwards.

In people with drug resistant temporal lobe epilepsy, surgery can be useful.

COVID19 treatment

General paediatrics, Infectious disease, Rheumatology

Death from COVID19 usually from cytokine storm and multi-organ failure (often resulting in secondary haemophagocytic lymphohistiocytosis).

NICE has risk factors for young people 12-16yrs:

  • Complex life limiting neurodisability

Otherwise you need 2 of the following to justify treatment in ill (hospitalised) patient:

  • Primary immunodeficiency:
  • Secondary immunodeficiency viz:
    • HIV with CD4 count less than 200 cells per mm3
    • solid organ transplant
    • stem cell transplant (HSCT) within 12 months, or with graft versus host disease (GVHD)
    • CAR-T cell therapy in last 24 months
    • induction chemotherapy for ALL etc
  • Immunosuppressive treatment:
    • chemotherapy within the last 3 months
    • cyclophosphamide within the last 3 months
    • corticosteroids greater than 2 mg per kg per day for 28 days in last 4 weeks
    • B-cell depleting treatment in the last 12 months
  • Other conditions:
    • high body mass index (BMI; greater than 95th centile)
    • severe respiratory disease (for example, cystic fibrosis or bronchiectasis with FEV1 less than 60%)
    • tracheostomy or long-term ventilation
    • severe asthma (paediatric intensive care unit [PICU] admission in 12 months)
    • neurodisability and/or neurodevelopmental disorders
    • severe cardiac/chronic kidney/liver disease
    • sickle cell disease or other severe haemoglobinopathy
    • trisomy 21
    • complex or chromosomal genetic or metabolic conditions associated with significant comorbidity, multiple congenital anomalies associated with significant comorbidity
    • bronchopulmonary dysplasia – decisions should be made taking into account degree of prematurity at birth and chronological age
    • infants less than 1 year with cyanotic CHD, or haemodynamically significant acyanotic CHD with history of prematurity, or those due for corrective surgery (to avoid complications or delay)

Steroids

WHO recommends dexamethasone 150mcg/kg once daily for 10 days for severe/critical COVID19 disease, on basis of REACT metanalysis.

Severe defined as any of:

  • Sats <90%
  • Tachypnoea (>30 in over 5s, >40 over 2 etc)
  • Severe respiratory distress

Critical defined as ARDS, septic shock or anything else that would require critical care.

Remdesivir

For Patients at ‘high risk’ of complications (as above, in particular immunocompromise) plus:

  • >4 weeks of age and at least 3kg 
  • Within 10 days of symptoms onset

NOT for patients requiring ventilatory support unless high risk, and not for ALT > 5x upper limit of normal .

5mg/kg loading dose on day 1, followed by 2.5mg/kg once a day for 4 days. May be extended to 10 days in immunocompromised.

Toculizimab is an option for pneumonitis.

Prophylaxis for high risk patients is available:

  • Remdesivir 3 days once daily infusions
  • Paxlovid (Nirmatrelvir +Ritonavir) 300/150mg BD for 5 days

Neutralising antibodies have also been tried but not in guidance.

Sotrovimab [NO LONGER AVAILABLE] – for 12-16yrs, pre-hospitalisation, PCR positive and onset of symptoms within previous 5 days. Not if new oxygen requirement or weight under 40kg. 1% vs 7% placebo hospitalisation or death (85% reduction).

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.

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.

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.