Category Archives: Common

Lymphadenopathy

Clinical, Common, General paediatrics, Haem/Oncology, Infectious disease

A good proportion of healthy children will have palpable lymph nodes in the neck.  Mostly these will be under 1cm in diameter.  Acute enlargement as part of an upper respiratory tract infection is usually accompanied by tenderness, and affected nodes will reduce in size over 4-6 weeks.

Guidance from NICE and the Scottish Government provide criteria when children with lymphadenopathy should be urgently referred for suspected cancer.

These criteria include the following:

  • lymph nodes are non-tender and firm/hard
  • lymph nodes are greater than 2 cm in size
  • lymph nodes are progressively enlarging
  • other features of general ill-health, fever or weight loss
  • the axillary nodes are involved (in the absence of local infection or dermatitis)
  • the supraclavicular nodes are involved.

But caveat is “Always refer any patient with Repeat presentations (3 or more times) of any physical symptoms which do not appear to be resolving or following a normal pattern, taking into account parental and patient concern”.

No need to do bloods in the absence of any of these criteria. Not that cancer is the only concern – differential includes developmental lesions (branchial cysts etc), TB, Cat-scratch disease, non-tuberculous mycobacterial infection (esp in neck).  These are always more than 2cm and there may also be systemic features and/or overlying skin discolouration too.

Malignancies often present in the head/neck region.  Hodgkins lymphoma usually affects teenagers, Non-hodgkins tends to affect school age children, neuroblastoma tends to affect pre-school children.  B-symptoms (recurrent fever, weight loss, night sweats, pruritus, lethargy) are only seen in a minority but does suggest more advanced disease, of course.  Airway or voice changes, swallowing difficulty, Horner’s syndrome, superior vena cava syndrome may all be seen due to mass effect. Most neuroblastomas have an abdominal mass.  Nasopharyngeal carcinomas are seen so look in the nose/throat.

Antipyretics

Common, General paediatrics

 

Paracetamol prolongs clearance of malaria, and time to total scabbing in chickenpox. So only give for symptomatic benefit, not as routine!

Cochrane did not find any evidence that drugs prevent febrile convulsions, but not much data. Not recommended. Tepid sponging probably does work, but is inferior to drugs.

Ibuprofen probably works a bit quicker, and lasts longer. [Arch Peds Adol Metanalysis, 2004. PMID 15184213]

Alternating paracetamol and ibuprofen was superior in an Israeli study and in a US study.[Arch ped adol 2006 PMID 16461878, Clin peds 2008 PMID 18539869]

Combined? PITCH found combination was more effective than either alone (reducing time with fever over a 24 hour period by 2.5 hours or more) although it did not work faster than ibuprofen alone. No specific benefit was found for symptoms although it was underpowered for subjective comfort. [BMJ 2008 PMID 18765450] A linked cost benefit analysis suggested financial benefits to society for using the combination. On the other hand, use of the combination was associated with significant rates of medication errors and it could be argued that this risk outweighs the potential benefits.

Ibuprofen used as an antipyretic in febrile children with a past medical history of asthma is as least as safe as paracetamol and not likely to exacerbate asthma. [Lesko, Peds 2002]

NICE says:

  • Antipyretic agents (drugs that reduce fever) do not prevent febrile convulsions and should not be used specifically for this purpose.
  • When using paracetamol or ibuprofen in children with fever;
    • continue only as long as the child appears distressed
    • consider changing to the other agent if the child’s distress is not alleviated
    • do not give both agents simultaneously
    • only consider alternating these agents if the distress persists or if it recurs before the next dose is due.

[NICE feverish illness update May 2013 – new CG code: 160]

Sore throat

Common, General paediatrics, Infectious disease,

Tonsillitis, pharyngitis.  See SIGN guideline.

“Doughnut lesions” – multiple small erythematous papules with clear centres – associated with group A streptococcus.

See also pharyngitis treatment.

FeverPAIN scoring system – possibly better than Centor at avoiding antibiotics. For primary care settings, children over 3 and adults.

  • Fever in past 24hrs
  • Purulent tonsils
  • Attends rapidly (ie symptoms <=3 days)
  • Severe tonsil Inflammation
  • No cough/coryza

3 points gives 40-50% risk of strep, so treat at 4 points, consider delayed antibiotics for 3 points.  Not for under 3s, and beware worsening after 3 days which might indicate more severe infection. [PRISM study 2014]

Centor and McIsaac scores to predict group A streptococcal pharyngitis.  One point for each of the following:

  • fever,
  • absence of cough,
  • presence of tonsillar exudates, and
  • swollen, tender anterior cervical nodes [my emphasis].

Centor score is sum (0-4). The McIsaac score (1998) is an adjustment of +1 to account for the increased incidence of GAS in children <15yr and -1 for decreased incidence in those 45+ years.   CDC advises treat empirically at score 3+ or at score 2 if rapid testing positive.

Original studies used small samples, but national US study confirmed validity in 65 000 patients aged 3-14yrs presenting to primary care.  For children, GAS positive rates were:

  • 14% for McIsaac 1
  • 23% for 2
  • 37% for 3
  • 55% for 4

AUC was 0.71 for McIsaac score across all ages.

Fine and Nizet, Archives of Internal Medicine. 172(11):847-52, 2012 Jun 11. PMID  22566485

Other clinical decision rules include:

  • the WHO rule (purulent oropharyngeal exudate and tender enlarged anterior cervical lymph nodes = bacterial pharyngitis);
  • the Abu Reesh rule (purulent oropharyngeal exudate or tender enlarged anterior cervical lymph nodes = bacterial pharyngitis); v low specificity of course
  • the Steinhoff rule (absence of rash, absence of moderate or severe rhinitis, presence of tender enlarged anterior cervical lymph nodes).

Rapid antigen test performs better, 85% sensitivity (similar to Abu Reesh rule) but much better PPV (48%).

Obesity management

Common, General paediatrics, Nutrition, OPD

Public health surveillance use 85th centile as definition for overweight, and 95th centile for obesity (UK says “at risk of obesity”…). Clinical definitions (SACN/RCPCH 2012, NICE) however are different: (UK 1990, use special BMI chart)

  • Obesity = BMI >98th centile for age (2 standard deviations, one tail)
  • Overweight = >91st centile (1.3 SD)

Growth charts then label:

  • Severe obesity = 99.6th centile (2.67 SD)
  • Morbid obesity = 3.33 SD.  High probability of co-morbidity, unlikely to improve by age 16.
  • (some guidelines use Extreme = 4 SD)

Cut off for overweight/obesity high in babies, starts at 18/20 age 2, nadir of 17/19 at age 5, rising to 20/24 at 10 then usual 25/30 at age 18. Girls same as boys, slightly fatter after 10 yrs. [International data, BMJ 320:1242.] Charts are available at the RCPCH.

Centile charts show centile spaces that are equivalent to 2/3 of a standard deviation.  When you get to high centiles, you need something better than “above the 99.8th centile” so you use Z score, which is the number of standard deviations above the mean

Calculators available to calculate BMI and Z-scores eg Phsim.man.ac.uk/SDSCalculator

So secondary referral for:

  • extreme, or
  • ?secondary obesity, eg
    • under 2 yrs with severe (>99.6th centile) obesity
    • short for age
  • co-morbidity eg strong FH type 2 DM, sleep apnoea, idiopathic intracranial hypertension, orthopaedic probs
  • psychological comorbidity,
  • safeguarding.

2nd care history –

  • menstrual hx,
  • sleep eg Chervin questionnaire (adds anything?)

Examination

  • acanthosis nigricans (neck, flexures) – highly associated with insulin resistance
  • buffalo hump.  Striae and obesity as only signs of Cushings v rare. Striae in Cushings more intense red!?
  • Mid-Parental Height – endocrinopathy unlikely if normal growth
  • Waist circumference
  • Goitre – hypothyroidism
  • BP
  • Peak flow
  • Syndrome eg BWS
  • Acne, Hirsutism – polycystic ovary syndrome
  • Telangiectasia

Investigations

Little evidence for investigations, not routine.

  • Fasting glucose, insulin, lipids
  • FBC, U&Es, LFTs
  • TFTs
  • HBA1c
  • SHBG (marker of insulin resistance)

For more severe cases, consider:

  • OGTT – 2hr glucose >11.1=diabetes, 7.8-11.1 = impaired glucose tolerance.  Esp if S Asian, other signs/risks of insulin resistance.
  • ECG
  • Sleep study
  • Molecular genetics (EDTA) eg Prader Willi, Bardet-Biedl syndrome, Cohen syndrome, MOMO syndrome.
  • Urinary cortisol/creatinine
  • Low dose dexamethasone test (more sensitive than above but needs overnight admission) – cortisol should suppress below 100, else suggests Cushings
  • CT head (if suspicion of raised intracranial hypertension

Homa-IR >4.5 for insulin resistance [Score = (Fasting insulin)*(Fasting glucose) / 405, measuring in mg/dl].  Transient increase in insulin resistance seen in puberty, independent of BMI.

Total choles:HDL 3.6 95th, 4.3 99th but no great paed data.

ALT>70 twice should proceed to USS to look for fatty liver, >100 urgent (for differential more than anything, although non alcoholic fatty liver disease can be progressive).

Communication

Delicate! Moral issue too – for example:

  • uncertain benefits on physical health
  • negative psychosocial consequences including uncertainty, fear, stigmatization
  • aggravating inequalities
  • disregarding the social and cultural value of eating
  • infringement upon personal freedom regarding lifestyle choices and raising children

Addressing these issues may avoid resistance [Erasmus medical centre, Obes Rev. 2011 Sep;12(9):669-79. doi: 10.1111/j.1467-789X.2011.00880.x. Epub 2011 May 4]

PHE “All our health” has child (and adult) obesity thread– use opportunistic moments to open up conversations around weight. “Let’s talk about weight” = short conversations guide.

  • Initiate a conversation. Anticipate defensiveness
  • Discuss “healthier weight” concept
  • Positive, non-judgmental language
  • Terms such as ‘obese’ are not generally well accepted by parents/carers

Opportunistic is good, but probably sensible to check that this is a good time, or at least create an invitation to start this conversation. And then, do more questioning and listening than advising.

What works?

The above section may already have brought up issues of low self-esteem and poor motivation. Building a therapeutic relationship, using motivational interviewing skills, is key then, especially where parents/children may have sensed discrimination and bias in the past.

General advice should include: (SIGN)

  • Healthier eating, and decreased calorie intake
  • At least 60 mins of moderately vigorous activity per day, pref habitual eg brisk walking! Given that evidence that moderate/high levels of cardiorespiratory fitness appear to attenuate or even eliminate the risks, just as important to emphasize fitness as weight loss? 
  • Max 2 hours screen time per day!

But as indicated above, probably more important to ask about the blocks, than to say “eat less, move more”.

OSCA 2012 Viner, arch dis child educ (paeds network)

See Prevention and Treatment.