Typically closes around 12 months of age. Can be bulging (meningitis?), sunken (dehydration), pulsatile (normal!), large (hypothyroidism), small (craniosynostosis). But actually not very predictive of any of these things in isolation.
For example – in Brazilian study of babies with craniosynostosis compared with babies with fontanelle that closed by 6 months, only 36% sensitive for craniosynostosis, and positive predictive value 59%. [https://doi.org/10.1016/j.jped.2021.10.004]
Do not diagnose asthma without objective test.
Feno (if available) >35ppb diagnostic, age 5+. If not diagnostic, measure BDR with spirometry. Diagnose asthma if the FEV1 increase is 12% or more from baseline (or if the FEV1 increase is 10% or more of the predicted normal FEV1).
If spirometer not available, measure PEF twice daily for 2 weeks. Diagnose asthma if PEF variability (expressed as amplitude percentage mean – the difference between the highest and lowest PEFR readings on a given day, divided by the mean of those readings, averaged over period) is 20% or more.
Failing that, either positive skin prick testing to house dust mite or measure total IgE level plus blood eosinophil count. Raised total IgE plus Eos >0.5 considered diagnostic! [Because highlights underlying atopy cf viral wheeze?]
Under 5, prescribe steroids [not just salbutamol!] for 8-12 weeks and review. [No dosage guide for under 5s!?] Then do objective test when they reach 5! If no response, check technique, consider environmental triggers (mould, smoke etc), consider alternative diagnosis, refer.
If making asthma diagnosis, record basis for this in notes.
Under 5, consider stopping ICS at 3-6 months or else within 12 months.
If helps but then symptoms recur, can try moderate ICS dose. After that, 8-12 week trial LTRA.
Uncontrolled = exacerbation requiring oral steroids, or use of SABA 3 days a week or more, or night waking once per week or more.
New section on diagnosis at time of acute presentation!
Refer to a specialist respiratory paediatrician any preschool child with an admission to hospital, or 2 or more emergency department admissions in a 12-month period.
Age 5-11, start low dose ICS. After that, assess ability to manage MART (maintenance and reliever therapy) regimen (none licensed under 12, so would be off label). Start low (Budesonide 100/3 MDI or 100/6 Turbohaler – see below for brands), 2 puffs/sucks per day in 1-2 divided doses), go to moderate (300-400mcg per day) if necessary. [No evidence for MDI, only for dry powder!]
Otherwise would be trial of LRTA, then add LABA, then increase ICS to moderate.
12+, start Anti-inflammatory reliever (AIR) therapy with prn combination ICS/LABA inhaler (only budesonide/formoterol licensed for this). This strategy had lowest rate of severe exacerbations (plus cheaper). WockAir is cheapest.
If highly symptomatic at presentation could start MART +/- oral steroids with view to stepping down.
If MART required and still symptomatic on moderate dose, check FENO and eosinophil count – refer if either high. Otherwise trial of either a LTRA or a long-acting muscarinic receptor antagonist (LAMA, eg tiotropium).
Beware neuropsychiatric side effects of LTRA/montelukast. Review annually.
Duoresp Spiromax 160/4.5 (powder, 12+ – on NHSL adult formulary) – For MART, 2 inhalations daily in 1-2 divided doses (up to 2 BD); PLUS 1 inhalation PRN for relief up to 8 in a day (up to 12 for a limited time but medical assessment recommended). Also comes in 320/9 but only for maintenance.
Symbicort 100/6 turbohaler (powder) 6+ for maintenance. 12+ for MART
Symbicort 200/6 (powder, 12+ – on NHSL adult formulary) MART as above. Else AIR – 1 puff PRN, up to 6-8 (up to 12 for limited time).
Symbicort 100/3 MDI 12+ MART – 4 puffs daily in 1-2 divided doses, up to 4 BD. 2 puffs PRN for relief up to 12-16 in a day (max 24)
Wockair 160/4.5 (powder) cheapest! (£19) MART 2 inhalations daily in 1-2 divided doses, up to 2 BD. 1 inhalation PRN up to 6-8 (max 12). Else AIR – as above
Fobumix 80/4.5 Easyhaler 6+ for maintenance, 12+ for MART.
Fobumix 160/4.5 Easyhaler 12+ MART or AIR.
House dust mite reduction measures not routinely recommended. Evidence on removal of pets from homes “paradoxical” – no benefit or tolerance if continued presence. If detectable cat antigens without cat, might be benefit to high efficiency vacuum cleaning or additional measures.
Air pollution linked to worse symptoms.
High sodium and low magnesium intake linked to asthma symptoms but poor/no evidence that intervention makes a difference. High intake of fresh fruit and vegetables is associated with less asthma and better pulmonary function but no interventional studies.
Weight loss interventions may help asthma symptoms in overweight/obese, and should be considered, but may require >10% loss for benefit.
Breathing exercises eg Papworth/Buteyko methods can lead to modest improvements in asthma symptoms and quality of life, and reduce bronchodilator requirement, in adults with asthma. Less evidence for effect on lung function or airway inflammation. Insufficient evidence in children.
Monitor asthma symptoms, plus check:
FENO can be considered for monitoring in adults only. Peak flows not routinely indicated for monitoring.
Not much! Separate section on self management. Vaping/smoking. Factors that affect inhaler use eg school/social. Career plans.
[NICE NG245]Firstly, is there a suicide risk?
Then, consider mental health needs. Is there an alcohol or drug issue?
Are they known to social work? Are there any child protection issues for the young person? Their siblings or other family members? If young person is over 16 then consider Adult Protection measures (Scotland Act 2007).
A proper mental health assessment requires that they are physically well enough (consider intoxication, sedation, pain etc). Consider competency (which can be impaired temporarily by physical illness).
Consider:
=Faints, “whitey”. Insufficient blood to the brain, due to immature or hyporesponsive autonomic nervous system control of cardiac output and peripheral vascular tone.
Similar symptoms with POTS but with obvious drop in blood pressure.
Symptoms of light headedness, feeling hot/clammy, dizziness, black spots in vision or tunnel vision (pre-syncopal), potentially followed by collapse, which can be remembered in most cases. Can be brief posturing or clonus due to hypoxia, but only for a few seconds, which freaks everyone out as it looks like an epileptic seizure.
Recovery is fast, within seconds or a minute, once circulation to brain improves – requires that person is left lying on ground and not propped up!
They look pale, feel hot, but once on ground go clammy/sweaty. Heart rate and blood pressure typically low.
Typically fast growing teenagers, but can be anyone. In some, lifelong tendency. You can suffer significant facial trauma from syncope so it’s not trivial, if recurrent can also be disabling with significant psychological co-morbidity. Usually prolonged standing, or standing up after sitting/lying for a while (especially boys going to the toilet for a pee). Other common triggers are physical stimuli (reflex syncope) eg painful procedures, esp immunisation (distinguish from anaphylaxis), cannulation. Some unusual triggers eg hair brushing/combing.
Mostly trivial but potential for injury (eg facial fractures) and can be disabling.
Useful to become aware of triggers, so countermeasures can be tried. But sometimes no warning, which is difficult. Worth asking directly how often symptoms happen, as child might not tell anyone.
Other differentials are epilepsy, arrhythmia. Syncope with exercise is a red flag.
These should all work, probably worth practicing though. And should work within seconds. You hopefully only need to keep doing it for 30-60 seconds. [Krediet, J Appl Physiology 2005 Vol. 99 no. 5, 1697-1703 DOI: 10.1152/japplphysiol.01250.2004] All of the evidence seems to come from the Netherlands! Some evidence for isometric arm/hand exercises, but might be incidental abdominal tensing at same time!
Regular meals/snacks. Avoid big carbohydrate meals though – low GI foods (ie wholegrain/wholemeal) best to avoid big swings in sugar levels. Avoid sugary drinks for the same reason.
Getting hungry is probably bad – have emergency snacks available (oat cakes, nuts, malt loaf, dark chocolate – not high sugar).
Drink plenty – consider increasing to 2-3 litres. Try to drink 1L in the first 2 hours of the day.
Caffeine?
Salt intake may need to be boosted, especially if a “healthy” eater, or losing a lot in sport. Slow salt tablets?
Good cardiovascular fitness.
Could try putting blocks under the foot of the bed to raise it up 2-3 inches! Retrains baroreceptors.
Desmopressin, to increase circulating blood volume?
Beta blockers? Fludrocortisone? See POTS.
Patient/family info at www.stars.org.uk.
For lower tract:
Seasonal lower respiratory tract infection of young children, typically caused by Respiratory syncytial virus (RSV) but can be others or mixed.
Classically wheezy cough, wheeze and/or crackles, reduced feeding and increased work of breathing.
Fever not usually high (“consider pneumonia if over 39”)
Clinical. You would probably have to do 133 Chest x-rays before you found something that would change diagnosis – overuse of CXR associated with increased (and inappropriate) use of antibiotics.
Swabbing for virus identification can help with cohorting and avoidance of nosocomial infection, which can be a major problem.
Ex-prems, chronic lung disease, neuromuscular disorders, haemodynamically significant congenital cardiac disease, immunodeficiency at higher risk, of course.
Admit if sats under 90% if 6/52+ (92% if underlying health problem or under 6/62) – and start oxygen if persistently low.
Admit if feeds less than 50-75% of usual volume, or severe respiratory distress, or reported/observed apnoeas.
NG or orogastric feeds if required – no preference but in theory obstructing nostrils could be unhelpful…
Bacteriuria is not uncommonly seen with bronchiolitis, not always clear if this is true urine infection.
Initial coryza 1-3 days. Symptoms peak at 3-5 days. Cough resolves within 3 weeks in 90% but can persist for longer (but perhaps recurrent viruses?).
RSV passive immunisation for high risk babies with paluvizimab (Synagis). Limited benefit but does appear to reduce incidence of severe bronchiolitis.
Vaccination in pregnancy effective – antibodies cross, but also prevents Mum getting it and passing it on!
There’s an important story about the dangers of vaccine development.
JCVI recommended Nirsevimab be used first line in 2023 – single injection (half life 71 days). HARMONIE trial – 83% reduction in RSV hospitalisation, 75% reduction in “very severe” disease. Spain and US doing. Fight for global supply so not available…
2025 – programme for high risk babies extended to include all babies born <32/40 (regardless of whether mum received vaccine in pregnancy).
See here.
Nappy rash is an irritant contact dermatitis affecting the skin where the moist nappy is in contact. It spares intertriginous areas.
Change nappies 6-8 times a day, dry thoroughly, use barrier eg zinc oxide cream.
Differential diagnosis:
Intertrigo (inflammation in the creases) can similarly be infective (bacterial or candidal), eczematous/seborrhoeic or psoriatic.
Upper respiratory infection (“acute laryngotracheobronchitis”) of young children, typically parainfluenza but can be RSV, enterovirus etc.
Classically barking cough, like a seal, with stridor. Often worse on waking, then settles once the panic has passed.
Mild fever typical. Rarely lasts longer than 24 hours.
Severe will cause increasing respiratory distress, with decreasing volume of stridor until respiratory arrest ensues.
An oxygen requirement implies lower rather than upper airway involvement (so the wrong, or mixed, diagnosis), or impending respiratory arrest.
Supportive, and hands off – upsetting the child will provoke worsening of symptoms.
Paracetamol/difflam spray for the throat.
Some kids are prone to recurrent croup. Often strong family history of croup. Smoking doesn’t appear to be a factor! Appears to be same viruses. Tend to be children with reflux and/or atopy. [Pediatrics International, 51: 661–665.] [Annals of Otology, Rhinology & Laryngology 2008;117(6):464-69
26% have microlaryngobronchscopy findings suggestive of reflux – a clinical history is not predictive. 91% responded well to anti-reflux treatment. High rate of recurrence in group with negative findings! Kubba Journal of Laryngology and Otology 2013;127(5):494-500
Airway abnormalities eg tracheomalacia are common in children with recurrent croup and cannot be ruled out based on history (although biphasic stridor is highly suggestive). Having said that, most of the airway abnormalities will have a history of previous intubation, or are younger than 1 year, or are seen while inpatients, which all suggest pretty severe episodes. [Otolaryngology-Head and Neck Surgery 2011;144(4):596-601]
Foreign bodies, respiratory papillomatosis, double aortic arch reported.
Not a great name, as it can persist for up to 6 months!
Large muscle groups, usually limbs but can be face. Can wax and wane with child remaining sleep. Usually bursts lasting seconds, up to a few minutes.
During sleep only, and stops when wakes.
Differential would be myoclonic epilepsy, startle (including hyperekplexia), jitters.
Tanner stages – verbal descriptions but images helpful esp for self assessment.
Pubic Hair Scale (both males and females)
Female Breast Development Scale
For males you then have testicular volume, measured by orchidometer (between £26 and £208):
Cadbury’s Teasers and Truffles (from Celebrations box) are 8ml, equivalent to 50th centile at age 13.
If you only have a ruler, use maximum width in millimetres and the formula: (W-1.5)3 x 0.88, where ss is double scrotal skin thickness (for Tanner stages 1, 2, and 3).