Category Archives: General paediatrics

Attention deficit hyperactivity disorder

Community, General paediatrics

6 of symptoms of inattention or hyperactivity:

    • having a short attention span and being easily distracted
    • making careless mistakes – for example, in schoolwork
    • appearing forgetful or losing things
    • being unable to stick at tasks that are tedious or time-consuming
    • appearing to be unable to listen to or carry out instructions
    • constantly changing activity or task
    • having difficulty organising tasks
    • being unable to sit still, especially in calm or quiet surroundings
    • constantly fidgeting
    • being unable to concentrate on tasks
    • excessive physical movement
    • excessive talking
    • being unable to wait their turn
    • acting without thinking
    • interrupting conversations
    • little or no sense of danger

Needs to be persistent, and in more than just 1 situation (eg home vs school), where no other diagnosis more appropriate, and where it has significant impact on social, academic (or later occupational) life.

Autistic Spectrum Disorder

Community, General paediatrics, Mental health, Neurology

ICD-10 defines autism spectrum disorder as

  • persistent difficulties with social communication and social interaction, and
  • restricted and repetitive patterns of behaviours, activities or interests (this includes sensory behaviour),
  • present since early childhood,
  • to the extent that these limit and impair everyday functioning

Sensory behaviour may be meltdown or withdrawal or other challenging behaviour when too much information or sensation is experienced.  There can be hyper (or hypo) sensitivity to lighting, problems with depth perception, noises or crowds, smells (or licking), pain, taste/textures.

SIGN guidance is that (145):

  • children under 3 with regression in language or social skills should be referred
  • not to screen population
  • that screening instruments are not 100% reliable but have their uses
  • that ASD should be considered in any child with developmental, emotional, psychiatric or behaviour issues, or a genetic syndrome
  • in preschool children typical features may be absent
  • gender differences are important in terms of symptoms and level of impairment

Assessment

  • Lack of shared attention (or late development) eg pointing
  • repetitive behaviour/play
  • resistance to change
  • violent or self injurious behaviour, pica

Types

  • Aspergers – social difficulties in absence of learning or communication problems
  • Pathological demand avoidance – where underlying problem is high level of anxiety about conforming to social demands or not being in control

Support

ARCH, REACH and National Autistic Society

Tuberculosis

General paediatrics, Infectious disease

[needs revising]

Contacts

Offer testing to close contacts of pulmonary or laryngeal TB treated for less than 2 weeks. Over 2yrs, start with Mantoux. If negative, repeat after 6 weeks with IGRA.

Smear positive get immediate assessment for active TB. Smear negative refer to specialist.

Neonates start isoniazid with pyridoxine. Mantoux at 6 weeks.

Mantoux>= 5mm positive regardless of BCG history.

If positive assess for active TB. If assessment negative, complete treatment for latent (6months). If negative reassess for active TB and consider IGRA test. If IGRA negative stop treatment and give BCG.

For under 2yrs, start isoniazid +/- rifampicin and do Mantoux. Latent treatment with rifampicin is just 3/12.

If Mantoux negative continue treatment, assess for active TB after 6/52 and repeat Mantoux. Consider IGRA as above.

IGRA should only be done alone if Mantoux not available or impractical(?!).

Diagnosing active disease

If clinical signs and suspicion, start treatment pending test results.

Do CXR and 3 cough swabs (including 1 early morning). Young children get induced sputum.

Other testing depends on age and whether suspected pulmonary.

  • If suspected pulmonary, then do rapid diagnostic nucleic acid amplification tests (PCR) – usually only 1 per specimen type (deep cough sputum, induced sputum or gastric lavage) AND IGRA+/or Mantoux
  • For extrapulmonary, after imaging, discuss pros/cons of both biopsy and needle aspiration (NOT into formalin…). Do CXR anyway.
  • if clinical suspicion, HIV Positive, need for rapid result or large contact tracing exercise.

[NICE guidance 2016, updated 2019 https://www.nice.org.uk/guidance/ng33]

Stereotypy

Clinical, General paediatrics, Neurology, OPD

Where children present with abnormal movements, consider:

Stereotypies are repetitive non-functional movements, typically hand flapping or twisting, body rocking, head banging/nodding, grimacing, arm flapping. As with tics, there is often a family history, and there is an association with obsessive compulsive tendencies.

They can be present in children with normal development, but are a feature of neurological disorders especially autism spectrum disorder and sensory impairment.  In these children, the movements are part of a period of introspective absorption, they make prefer such activity to conventional social interactions.

There are a number of differences from tics, although they can co-exist:

  • Sterotypy presents younger, eg under 2 yrs.  Tics present from 4 onwards.
  • Tics can vary over time, so grimacing moves on to  shoulder jerks, then moves on to clearing throat.  Stereotypy movements are unchanging.
  • Stereotypy movements are rhythmic, rather than just a single jerk
  • Tics are brief, stereotypy can be prolonged
  • Tics have a premonitory sensation (although only older children may be aware)
  • Tics can be suppressed with effort.  Children with stereotypy can be distracted but may resent it! (Similarly self gratification)

Excitement and stress are triggers for both.  Over time, the child usually becomes aware of social disapproval and may suppress the behaviour except in secret!

[Ulster Med J 2014;83(1):22-30]

 

 

 

Vitamins

General paediatrics, Medical, Nutrition

A -orange or red foods.  Apricots, carrots, peppers, sweet potato, squash.  Also dairy, eggs, oily fish, (famously) liver.

B1 (thiamine) – deficiency causes several different syndromes including Wernicke’s encephalopathy (confusion, ataxia, ocular) and dry (peripheral neuropathy) or wet (cardiac failure) beri-beri. Depends on chronicity.  Classically alcoholism or diet dependent on polished rice. Bread has it!

B6 – fish, potatoes, fruit, fortified breakfast cereal.

C – citrus, blackcurrant, kiwi, berries.  Also peppers, broccoli, Brussel sprouts, potatoes.

B12 – see Vitamin B12.  Found in fish, meat, eggs, milk, fortified breakfast cereal, yeast extract (Marmite).  So a major issue for vegans.  Deficiency classically causes macrocytic anaemia.

Curiously, teenagers often seem to have high levels in my experience.  Apparently this can be a flag for some nasties, namely malignancies, liver and kidney diseases, and can then be accompanied by symptoms of deficiency, due to disrupted pathways…  [QJM 2013]

E – nuts and seeds.

K – green leafy veg.

Folate (folic acid) – green leafy vegetables, broccoli, brussel sprouts.  Oranges, wholegrain cereals, nuts and pulses (peas, chickpeas, kidney beans)

Treatment

If vision loss or other neurological complications of malnutrition, can use IV or IM Pabrinex – vitamins B1,B2, B6, C, nicotinamide and glucose for intravenous or intramuscular administration.

Additionally, vitamins A and B12 may be replaced using high-dose intramuscular injections but may need unlicensed imported product.

Recurrent aphthous ulcers

Common, General paediatrics, OPD

Very wide range of risk factors and causes for aphthous ulcers including any sort of physical or chemical irritation, there are probably genetic factors.

Minor vs major vs herpetiform: how big and painful!  HSV is possible but tends to affect lips and produce crusts.

There is some suggestion that iron, Folic Acid and B12 deficiencies can trigger it.

Food triggers: acidic foods such as tomato, citrus. Nuts, chocolate, wheat and spices.

Cinnamon and benzoates – Glasgow study of adults with RAS or Orofacial granulomatosis and other oral mucosal diseases found significantly higher rates of positive patch testing in both groups (70%, cf 60% of controls!), esp food additives (benzoic acid, salicylic acid, tartrazine, glutamic acid, butylated hydroxytoluene, butylated hydroxyanisole, propylene glycol, sorbic acid and sodium metabisulphite), – 41% contact urticaria cf 22% controls – with high rate for benzoate,  Perfumes and flavourings 40.7% overall, vs 9% controls –  of which cinnamaldehyde most important (32.4%).  Chocolate was mentioned specifically but actually only 3.7% positive.  [QJM. 2000 Aug;93(8):507-11. PMID 10924532]

Aphthous ulcers can be a sign of an underlying problem including inflammatory bowel disease, coeliac disease, Behcet’s and PFAPA syndrome but you would expect other signs and symptoms.

The less obvious cause would be cyclic neutropaenia.

Aphthous ulcers can be a lifelong problem although they tend to be less of an issue after teenage years.

Treatment

Apart from Bonjela, Difflam spray, chlorhexidine mouth rinse.  Cholinesalicylate dental gel (not licensed under 16 years).

Steroids: Hydrocortisone dissolving tablets, else a steroid inhaler sprayed in to the mouth or Betametasone soluble tablets as  mouthwash (unlicensed).

BNFc mentions doxycycline rinsed in mouth!

Salt water rinses, applying teabags or Aloe juice directly to the ulcers!?

Cefalosporins

General paediatrics, Infectious disease, Medical, Microbiology

Cefalosporins have a broader activity than penicillins, esp 3rd generation eg cefotaxime, ceftriaxone which are effective against most gram positives and gram negatives.

Good for meningitis (penetrate inflamed meninges at high dose) but not effective against pseudomonas, enterococcus, listeria, MRSA, and not that great against normal staphs so beware if possible line infection or neonatal meningitis. Some pneumococci can be resistant (1st line meningitis treatment in US is cef with vanc).

Ceftriaxone is drug of choice for Lyme with complications; it is not recommended for immediate treatment of meningococcal disease as any subsequent calcium containing infusions will reduce its plasma levels.

Ceftriaxone also eradicates meningococcal colonization – since cefotaxime is essentially equivalent, no reason to switch just for this indication.

Contraindications to ceftriaxone:

  • Concomitant treatment with intravenous calcium (including total parenteral nutrition) in premature and full-term neonates—risk of precipitation in urine and lungs (fatal reactions) ;
  • full-term neonates with jaundice, hypoalbuminaemia, acidosis, unconjugated hyperbilirubinaemia, or impaired bilirubin binding—risk of developing bilirubin encephalopathy;
  • premature neonates less than 41 weeks corrected gestational age

Paediatric Sepsis 6

Emergency medicine, General paediatrics

Consider sepsis or septic shock if a child has a suspected or proven infection and has at least 2 of the following:

  • Core temperature <36°C or >38.5°C
  • Inappropriate tachycardia (according to local criteria or advanced paediatric life support guidance)
  • Altered mental state (e.g., sleepiness, irritability, lethargy, floppiness, decreased conscious level)
  • Reduced peripheral perfusion or prolonged capillary refill.

If in doubt, seek an experienced opinion!

Within 1 hour of presentation, sepsis should be treated with:

  • Supplemental oxygen
  • IV (or IO) access – within 5 minutes of presentation – and blood tests including blood cultures, blood glucose,  and blood gas.
    • FBC, serum lactate, and CRP should also be ordered for baseline assessment.
    • Low blood glucose should be treated
  • IV or IO antibiotics should be given with broad-spectrum cover as per local policies.
  • Fluid resuscitation should be considered – aim to restore normal circulating volume and physiological parameters. Isotonic fluid (20 mL/kg) should be titrated over 5 minutes and repeated as necessary.
    • Beware fluid overload – look for crepitations and hepatomegaly.
  • Experienced senior clinicians or specialists should be involved and consulted early.
  • Inotropes should be considered early if normal physiological parameters are not restored after giving ≥40 mL/kg of fluids. It is important to note that adrenaline (epinephrine) or dopamine may be given via peripheral IV or IO access.

UK Sepsis Trust have Red Flag screening & action tool –

Start Sepsis6 pathway if ONE red flag:

  • objective change in behaviour or mental state
  • Unrousable or won’t stay awake
  • Looks very ill to HCP
  • Sats under 90% or new need for oxygen
  • Severe tachypnoea
  • Severe tachycardia
  • Bradycardia
  • Not passed urine in last 18h
  • Mottled, ashen or blue skin, lips or tongue
  • Non-blanching rash

Otherwise, any amber flags:

  • Behaving abnormally, not wanting to play
  • Significantly decreased activity/parental concern
  • Sats under 90^% or moderate tachypnoea
  • Moderate tachycardia
  • CRT >=3secs
  • Reduced urine output
  • leg pain
  • Cold feet/hands
  • Immunocompromise

If 2 then do bloods, consider if just 1.  Review by ST4 within 1 hour.

If lactate >2 then start Sepsis6

The GINI study

Allergy, General paediatrics, Immunology, Nutrition, OPD, Respiratory

German study from 1998.

Some potential benefit from using hydrolyzed formula in terms of preventing allergy.  The relative risk for the cumulative incidence of any allergic disease in the intention-to-treat analysis (n = 2252) was:

  • 0.87 (95% CI, 0.77-0.99) for partially hydrolysed whey-based formula (pHF-W),
  • 0.94 (95% CI, 0.83-1.07) for extensively hydrolysed whey-based formula (eHF-W) eg Pepti, and
  • 0.83 (95% CI, 0.72-0.95) for extensively hydrolysed casein-based formula (eHF-C) eg Nutramigen compared with standard cow’s milk formula.

The corresponding figures for atopic eczema/dermatits (AD) were 0.82 (95% CI, 0.68-1.00), 0.91 (95% CI, 0.76-1.10), and 0.72 (95% CI, 0.58-0.88), respectively.

In the per-protocol analysis (ie where patients stuck to protocol) effects were stronger (0.49 for eczema at 1yr). The period prevalence of AD at 7 to 10 years was significantly reduced with eHF-C in this analysis, but there was no preventive effect on asthma or allergic rhinitis.

[J Allergy Clin Immunol. 2013 Jun;131(6):1565-73. doi: 10.1016/j.jaci.2013.01.006. ]

Cochrane review 2009 biased towards GINI data.  Since then big Melbourne study (MACS) not in favour; per protocol analysis for eczema at age 1 yr did not show any benefit (0.55-1.93).

Even with GINI, NNT could be as high as 80!

[http://onlinelibrary.wiley.com/doi/10.1111/pai.12138/full]

15 yr follow up of GINI study – between 11 and 15 years,

  • prevalence of asthma was reduced in the eHF‐C group compared to CMF (OR 0.49, 95% CI 0.26–0.89)
  • cumulative incidence of atopic rhinitis was lower in eHF‐C (risk ratio (RR) 0.77, 95% CI 0.59–0.99]) and the AR prevalence lower in pHF‐W (OR 0.67, 95% CI 0.47–0.95) and eHF‐C (OR 0.59, 95% CI 0.41–0.84).
  • cumulative incidence of eczema was reduced in pHF‐W (RR 0.75, 95% CI 0.59–0.96) and eHF‐C (RR 0.60, 95% CI 0.46–0.77), as was the eczema prevalence between 11 and 15 years in eHF‐C (OR 0.42, 95% CI0.23–0.79).
  • No significant effects were found in the eHF‐W group on any manifestation,nor was there an effect on sensitization with any formula.

[Allergy 2016; 71: 210–219. http://onlinelibrary.wiley.com/doi/10.1111/all.12790/abstract]