A quiz! Choose from:

• Heads
• Chests
• Abdomens
• Bones

Can be due to mineral deficiency or toxicity. But can become habitual, in which case motives/consequences should be explored – attention? Escape? Sensory feedback?

Usually iron deficiency, but potentially calcium, zinc. Beware vitamin deficiencies esp C. 

Lead exposure can come from toys sourced from outside EU.
Houses in area built before 1950? Water companies generally screen for this, houses are occasionally notified of a hazard. But lead poisoning can also be a consequence of pica.

Complications are rare but potential for bezoar formation, gastrointestinal side effects. Toxocariasis if faeces is ingested.

Management

• Ignore or avoid negative attention (eye contact, facial expression, speech)
• Other oral stimulation eg. chew wristbands
• Reward keeping hands in pockets?
• Teach edible vs. Non-edible
• Alternative communications methods
• Provide similar smells, textures, colours to play with or eat

[NICE guideline]

Ensure that healthcare professional and assistant available and trained, with resus and monitoring equipment available.  Should have a record of practical experience of sedation under supervision, WBAs etc.

Document informed consent.

Confirm time of last food and fluid – fasting not required for minimal sedation eg nitrous oxide, or where child will maintain verbal contact.  Else 2-4-6 fasting rule.

Prepare child and  family psychologically.

For painless procedure eg imaging, use choral (under 15kg), midazolam.  For painful procedures, use nitrous oxide, oral/IN midazolam +/- local anaesthetic.

If unsuitable, ketamine or IV midazolam (+/- fentanyl) – combination of opioid and ketamine requires anaesthetic training.

[http://www.nice.org.uk/guidance/CG112/chapter/1-Guidance]

No single test. Polycystic kidneys are a common incidental finding at USS, so not sufficient for diagnosis.  Also operator dependent esp teens.

• Hirsutism (even male pattern baldness), But NOT virilisation (eg clitoromegaly, voice changes, musculature).
• acne (moderate to severe),
• irregular periods.  Can be amenorrhoeic, dysfunctional uterine bleeding, infertility but 20% have normal cycle.
• Obesity (35-50%, not all),
• Acanthosis nigricans.

Insulin resistance is associated, and obviously presents the most important long term risk. Acanthosis nigricans is highly associated with insulin resistance, family history of type 2 or gestational diabetes a clue.

Differential includes pregnancy, hypothyroidism, hyperprolactinaemia (mild hyperprolactinaemia commonly seen in PCOS, transient), late onset Congenital Adrenal Hyperplasia (CAH), ovarian/adrenal tumour, Cushing syndrome.

Investigations

• LH/FSH – ratio often high (3:1 or more) but inconsistent so not considered diagnostic
• Testosterone can be high (up to 4.8) – if higher, suggests alternative diagnosis
• Free androgen index (=testosterone x100/SHBG) can be high but our lab only calculates for adults – reference range of up to 7
• SHBG – low in PCOS (and in obesity, hypothyroidism, hyperprolactinaemia). Plus marker of insulin resistance),
• Prolactin, 17OH Progesterone for differential
• Fasting glucose/insulin ratio (under 4.5=insulin resistance, up to 7 in adolescents), glucose tolerance test, lipids.

Manage symptoms (for young people hirsutism, adults infertility) and long term risk viz diabetes and cardiovascular disease.

Note that less than 4 menses per year has higher risk of endometrial cancer.

Consider:

• oral contraceptive pill (OCP) – progesterone only, or combined, or else 12 week cycles of medroxyprogesterone acetate 5mg BD followed by 1 week break – NOT contraceptive!
• Metformin
• Spironolactone (has anti androgen effect)
• Plucking/shaving/electrolysis/laser, eflornithine cream
• Clomiphene for fertility.

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1069067/]