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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

Antenatal corticosteroids

Neonatology, Respiratory

Proven to reduce the incidence of respiratory distress syndrome (RDS) due to surfactant deficiency.

Meta-analysis shows benefit even for babies near term ie 34-39/40!  Risk ratio 0.74.

Not much data on long term outcomes, of course, but RDS rates high even at 38 weeks so LSCS should not be planned until 39 weeks.

Repeat courses of antenatal steroids (due to threatened delivery) associated with lower birth weight, so should ideally be limited to 3. [https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002771]

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]

The EAT study

Allergy, General paediatrics, Immunology

2016 study of early introduction of six common food allergens into the diet of 1303 breastfed 3 month old infants recruited from a general (not high risk) population.

Randomized.  Breast feeding needed to be maintained until at least 5 months, at least 5 weeks of at least 75% of recommended dose (ie 3g of protein per week) between 3 and 6 months.

2g protein twice weekly was recommended – 2g is roughly:

  • 2 teaspoons peanut butter or 21 Bamba pieces
  • 1 small pot yogurt
  • 1/2 small egg
  • 10g fish
  • 1tsp tahini

In an intention to treat analysis, 7.1% of the standard introduction group (at parental discretion) and 5.6% of the early introduction group developed food allergy to one or more of the six intervention foods (peanuts, egg, cow’s milk, sesame, white fish and wheat) up to 3 years of age (p=0.32, ie no difference).

However, when the analysis was adjusted for adherence to early introduction, there was a statistically significant 67% lower rate of food allergy in the early introduction group (2.4% vs 6.4%; p=0.03), with no cases of peanut allergy (rate was 2.5% in control group) and 75% less egg allergy (1.4% vs 5.5%).  Rate of skin prick test positivity significantly lower for peanut, egg, milk, sesame.

Cooked egg works! Increasing dose, increasing effect.  Modelling suggests 2g protein weekly effective.

Safe!

However, poor adherence to the study protocol (only 32% managed to follow early introduction fully) highlights the challenges around introducing solids.

[Michael Perkins, DOI: 10.1056/NEJMoa1514210]

Cluster headache

General paediatrics, Neurology

Very rare – unilateral, orbital, supraorbital and/or temporal. Pain lasts 15-180mins but attacks occur multiple times a day (or at least on alternate days). Associated with autonomic features eg ipsilateral conjunctival injection, nasal congestion, forehead sweating, miosis, ptosis, agitation. Peak incidence in 20s, males predominate.

Can be episodic (bouts lasting 6-12 weeks every 1-2years) or else chronic.

Treat with high flow O2! Sumatriptan SC better than nasal, Zolmitriptan nasal preferred to oral or sumatriptan. Safe, licensed for kids.

Prophylaxis in adults is with verapamil!

Tension headache

Common, General paediatrics, Neurology, OPD

Tension headache

  • Mild to moderate rather than severe,
  • pressing or tightening rather than pulsatile,
  • Bilateral,
  • Not aggravated by routine physical activity.

Can be continuous. Phonophobia, photophobia, nausea are possible, but if more than one present, and particularly if vomiting or severe nausea, then migraine would be preferred diagnosis.

Often spreads into or arises from neck.

Chronic tension-type headache – as above but on >/15 days/month for at least 3 months. But gets messy – it is possible that a patient can have both this and Chronic migraine, viz only two of the four pain characteristics are present and associated with mild nausea. In all these cases consider Medication-overuse headache.

Idiopathic intracranial hypertension

General paediatrics, Neurology, Surgical

Previously “Benign” Intracranial Hypertension but not entirely benign…

Intracranial hypertension but with normal CSF, and no ventriculomegaly. Presents with usual symptoms of early morning headache, effortless vomiting. VI nerve palsy may be seen, rarely II/IV. Papilloedema is often the first clue.

No sex differential prepubertally, not associated with obesity (contrary to popular belief).

Normal CSF opening pressure is 7.5cm of water <2yr, 13.5 <5yr, 20 over 5yr. Lumbar puncture is therapeutic; 2 step tap procedure is usually used if opening pressure is over 30cm. NB General anaesthetic can give false pos result! Secondary causes include drugs, endocrine conditions.

Since repeated LP is unpleasant, medical therapy can be considered. Topiramate is probably equivalent to the more usual acetazolamide (a diuretic). Steroids should be used for malignant hypertension (ie where there is rapid progression). Any of these treatments may result in a low pressure headache.

Surgical options include Optic nerve sheath fenestration, lumbar-peritoneal shunt.