GIRFEC

Community, Ethics, General paediatrics

Getting it right for every child. A framework for dealing with children and young people, looking at a range of values (SHANARRI).

Children and Young People (Scotland) Act 2014 made provision for Named Person and Child’s plan, but after review in 2019, amid privacy concerns (brought by Christian Institute, among others), government decided not to pursue legislation. Supreme court found that “duty to share information”, although well intentioned, was potentially at odds with article 8 of European convention on Human rights (“Privacy and family life”).

[https://www.gov.scot/publications/getting-right-child-practice-development-panel-report/]

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]]

Remote consultations – use of images

Ethics

Clinical images are part of the medical record. Especially when they are being used to make clinical judgments, they should be retained, which means discussing transfer, storage and use of images.

Transfer – not subject to information governance and data protection rules until received! Whatsapp automatically uses end to end encryption.

Storage – needs to be deleted from your phone/device. NB Whatsapp has option to automatically save to phone. Arrange storage with NHS approved service, or else ask family to retain.

Use – needs specific consent to reproduce in any form, for specified purpose.

Document verbal consent.

If patients are unsure of sharing images, you could try sending illustrative images of the suspected condition.

Remote consultations

Clinical governance, Communication, Generic

Schedule time, rather than fit in between jobs.

Confidentiality: where you are, where they are! “Are you somewhere private?”

Consent before you proceed. “Are you happy for us to talk just now?” “Can you hear me clearly?”

Contemporaneous notes.  Explain why there may be typing noises during conversation.

Beware if not your usual patient, and long term medication/condition.  Consult with GP or other appropriate professionals.

Prob not appropriate where Safeguarding issues or doubt about mental capacity of adults.

“You may need to justify a decision to consult remotely” – not for your convenience!!!

If speaking with a child, use speaker so parents can hear.

Since you can’t see cues and can’t nod in agreement, good to check understanding and summarise what has been said to you.

Say when you will phone back if you need to discuss with someone else.

Easy to become over focussed on one particular issue and forget to assess more fully.

If becomes emotional, respond by showing you have noticed “It sounds as though you are worried/angry/frustrated about…”.  Apologise if becomes hostile.  Focus on what you can do rather than what you can’t do.  Avoid pre-empting what someone is going to say.

If parents not reassured, or your assessment of the seriousness of the condition differs from theirs, err on the side of caution and arrange a face to face consultation.

For long term conditions, it may be helpful for family to have a list of concerns before hand.

When ordering tests, discuss how these will be fed back – consider whether likely to need face to face follow up to discuss results and treatment options.

Wait until the other party has hung up.

See also Remote consultations – use of images.

Audit

Clinical governance, Generic

Process of collecting data against a set of standards, in an attempt to improve compliance with those standards. But often ineffective – especially when no changes made (“closing audit loop”) to improve performance. And slow – by the time you’ve collected the data and summarized it, you’ve wasted time that could be been used to improve things you’ve already seen going wrong.

Often just turns into criticism, with intervention being no more than “perform better”. And then just induces resistance.

Cochrane review of audits in general found median 4.3% improvement with compliance, which isn’t much, but potentially more with incremental gains and repeated audit. And potentially scalable. And about a quarter achieve nothing.

Audit chain only as strong as weakest link – awareness of standards, reliability of processes, feedback.  All aspects of programmed should be designed with a focus on desired change in behaviour, and barriers should be anticipated.

Checklist for doing audit well –

  • Can you recommend actions consistent with established goals and priorities
  • Actions that are under audience’s control?
  • Actions that are specific
  • Can you provide multiple data points as feedback ASAP – and as often as frequency allows
  • Individual as well as general feedback if possible
  • Can you provide comparators that reinforce desired behaviour change
  • Format of feedback – link visuals with summary message, multiple methods, minimize distractions.
  • Actionable plan along with feedback
  • Address barriers
  • Short, actionable message with optional detail
  • Realistic goals.
  • Address credibility. 
  • Anticipate defensive reactions
  • Construct feedback through social interaction

Feedback to clinicians, who all think they’re great, requires careful thought.  Trying to improve already high performance may be a waste of effort, there is a ceiling for most things where organisation close to max capacity.

Patients and the public often surprised by the extent of variation.  They express frustration at difficulties in routinely measuring less technical aspects of care, such as consultation skills and patient centredness.  Patients are an untapped force for change which audit could learn to harness.

[ Revitalising audit, BMJ 2020;368:m213]

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.