Category Archives: OPD

Transition

Common, General paediatrics, OPD

Jargon for the process of transferring care of child to adult services, or to independent self management.

Paediatricians famously bad at discussing issues such as sex, drugs, alcohol, careers! And famously bad at seeing young people one to one, without parents present!

Raise contraception as soon as puberty comes up in clinic!? But remember that complications of pregnancy probably a bigger issue to discuss!

Ready, steady, go! is RCPCH document on the general principles, whereby you assess readiness for transition, and aim to provide information in an appropriate format (typically in small chunks) and at the right time (young person led). Then ideally one or more joint clinics with adult service, if appropriate.

Screen time

Child protection, Community, General paediatrics, Mental health, OPD, Psychology, Sociology

Sedentary time spent in front of screens programs metabolism and brain neurochem.  Similar to addiction.

But it’s complicated! Partly because there are so many different kinds of activity that can now be done with mobile phones and tablets, and because it’s difficult to control or randomize.

How people interact with screens is changing too. In the mid-2000s in the US, children over 8 spent an average of 6.43 hours a day on electronic media, but this was mainly watching TV.  Evidence of stress response (reduced cortisol increase) on waking after using screens for average 3 hours a day.

But now mobile devices are the centre piece of young people’s social lives.  Boys tend to spend more time gaming, girls more time on social networking.

UK government advice 2026 is 1hr a day but pref less under 5 years, and under 2 only if joint watching/activity with adult.

Effect of high levels of screen time does not seem to be attenuated by equivalent exercise.

High levels of screen time (over 4 hours daily) is associated with poorer school performance. Social skills are poorer. These children tend to form cliques with shared interest, that create further social isolation.

Violent games and media are associated with aggression in children as young as pre-school. Aggression in children can be manifest physically, or verbally, or relationally (ignoring, excluding, spreading rumours). There is also significantly more hostile attribution bias, where you interpret behaviour (such as not being invited to a party) as hostile, even when it is not, or at least ambiguous.

Parental involvement matters – how frequently parents watch TV with their children, discuss content with them, and set limits on time spent playing video games.

Exposure to media violence must also be seen within a risks/resilience approach. [Gentile and Coyne, Aggressive Behaviour 2010] ]

Some evidence that some “social” games themed around cooperation and construction eg Animal crossing have benefits. Similarly, links between media and relational violence pretty weak, but that could be because relational violence content isn’t really examined! Actual content probably more important than time spent playing. Note that in that study of Animal Crossing, background mental health problems seemed to reduce benefit.

Hypertension

Cardiology, Endocrinology, General paediatrics, OPD, Renal

In children under 10, high BP is usually secondary to an underlying disease or condition. Primary hypertension increasingly recognised in older, obese children.

Do repeated measurements, ideally automated home BP monitoring, before diagnosing hypertension. Check manually as well as with automated device. Beware “white coat effect”, even if not clearly anxious.

Use appropriate cuff size – cuff should cover at least 75% of the upper arm from the acromion to the olecranon (should be sufficient space at the antecubital fossa to apply stethoscope!) .  An inappropriately small cuff will overestimate BP.

Long list of causes, so follow the clues.

Family history important, of course.

Examination

So needs thorough history and examination, including:

  • Fundi
  • Bruits, radiofemoral delay
  • Neck for goitre

Complications

Consider then end organ effects –

  • Proteinuria, high creatinine
  • Retinopathy
  • Left ventricular hypertrophy, cardiac failure
  • Abnormal tone and reflexes, cranial nerve deficits if severe

Management

Depends on how high, whether other risk factors (diabetes, chronic kidney disease), symptoms and evidence of end organ damage.

Initially low salt diet, weight loss (if obese).  Remember other morbidities related to obesity.

Acute hypertension might need frusomide and/or nifedipine.

Long term treatment is only going to be started if no improvement with lifestyle measures. Target BP depends on risk factors, as above.

[2016 European Society for Hypertension guidelines]

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…

.

Medication Overuse Headache

General paediatrics, Neurology, OPD

Well recognised condition where regular long term use of pain killers eg paracetamol leads to chronic headaches. Tends to be dull, particularly in the morning. And you might still get your migraine on top!

Of course, might be difficult to differentiate from chronic daily migraine (defined as more than 15 days in a month) or other headache that is not well controlled! It appears the majority of those with chronic migraine do not take or are not offered appropriate preventive medication.

To exclude, always have a day free of analgesia (including triptans) after any day where it has been used, and use a maximum of 3 days per week [Dr Abu-Arafeh’s advice] or else maximum 10 days per month.

Short Stature

Endocrinology, General paediatrics, OPD

Are they really? Plot height and weight, and check figures if in doubt!

Investigate if:

  • Severe short stature = height below the 0.4th centile
  • Height more than 2 centile spaces below the mid-parental height
  • Downwards crossing of more than 1 height centile in 1 year, in a child aged 2 years or over

Is there evidence of chronic disease? Needs full history and examination, including urine dip. Common things would be renal failure, coeliac disease, IBD, hypothyroidism. Endocrine causes tend to produce relatively heavy children, other chronic diseases tend to produce relatively slight children.

Brain tumour symptoms?

Are they dysmorphic? Is one parent dysmorphic? Main syndromes to look out for:

  • Turners – besides short stature, webbed neck, characteristic facies, short metacarpals, broad chest with widely spaced nipples, hyperconvex fingernails and toenails (but can be missed); decreased growth velocity and delayed puberty
  • Short limbs – SHOX mutations eg Leri-Weill dyschrondeostosis but milder variants. Classically mesomelia (short proximal bones) and Madelung deformity (wrist) but these may only become obvious in later childhood.
  • Achondroplasia or hypochondroplasia (FGFR3 (Fibroblast Growth Factor Receptor 3) mutations)

Bone age will be delayed in all except familial and idiopathic. Progressively falls behind in endocrine disorders.

Causes

Constitutional delay – good weight at birth, then “catch down” growth, dropping through centiles in infancy. Growth velocity is then normal, but with delayed bone age and delayed puberty.

Small for gestational age babies tend to catch up in first few years of life with their genetic potential, but can take up 4 years or more. 10% however remain small (more than 2 SDs below MPH) through life. Consider other causes if no catch up in first 6 months of life or still small at 2 years.

Growth hormone deficiency – can be congenital or acquired (head injury, meningitis etc). Early growth tends to be normal (growth hormone doesn’t contribute much in first few years of life). Look for hypoglycaemia in neonatal period, microphallus, midline facial abnormalities.

Investigations

  • Karyotype if dysmorphic or if girl
  • TFTs
  • IGF1 – screening test for Growth hormone problems, but may need GH stimulation testing as limited reference ranges in under 2s
  • FBC, U&Es, LFTs, Vit D, Ferritin
  • TTG antibody
  • LH/FSH, testosterone, oestradiol if pubertal signs
  • Urinalysis
  • Bone age if thinking constitutional
[SPEG Guideline]

Rumination

Gastro, General paediatrics, OPD

A functional gastrointestinal problem, where food or other stomach contents effortlessly comes up into the mouth, where it is either then vomited, spat or swallowed. Odour may be a clue.

Diagnosis is on history, but often misdiagnosed as reflux (and resistant to reflux treatment). Typically no nausea, no nocturnal symptoms, no dysphagia but these do not necessarily exclude the diagnosis.

Treatment is diaphragmatic breathing! Baclofen has been used.

Rome IV criteria. Beware eating disorder.

Pica

Common, Community, General paediatrics, Neurology, Nutrition, OPD

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

Dyschezia

Common, Gastro, General paediatrics, OPD

Baby strains and cries to pass stool but it comes out soft or not at all.  Functional gastrointestinal disorder thought to occur in 0.9 – 5% of infants under 6 months (Rome IV criteria).

Due to poor co-ordination of pelvic floor muscles with increased intra-abdominal pressure generated during stooling. Seen in babies up to 9 months.

Studies have reported symptoms of discomfort around passing normal stool in up to 18% of babies, not all of these children will strictly meet the diagnostic criteria for dyschezia.

Differentiating from true constipation etc requires a clinical history and a normal clinical examination, with the key difference being that the stool is not hard in dyschezia.

No medication (or any form of rectal stimulation) required, can be expected to resolve spontaneously.

Seizures

Clinical, Emergency medicine, General paediatrics, Neurology, OPD

Seizures, fits, funny turns, convulsions, attacks…  None of these really has a medical meaning.  Convulsion suggests rhythmic motor activity, but that’s about it.  The implication of most of these is that there is excessive abnormal, involuntary muscle contraction, usually bilateral.  But more broadly, some involuntary, usually sudden and self terminating episode of abnormal (or at least non-purposeful) activity and/or impaired awareness. Can be sustained or interrupted.

Nottingham RCPCH approved guideline distinguishes:

  • Febrile?
  • Already on anti-epileptic medication?  Consider checking levels, or at least storing sample.
  • Predisposing conditions? eg neurodevelopmental problem, brain injury/surgery.
  • Neonate or young infant? Some additional possibilities eg hypoxic ischaemic encephalopathy (HIE), Fifth day fits, drug withdrawal (neonatal abstinence syndrome), pyridoxine dependent epilepsy.

Most commonly Febrile convulsions ie age related, benign.  Beware complex (multiple seizures in same illness, focal features, prolonged >15 mins) and any abnormal findings eg neck stiffness, bulging fontanelle, prolonged illness, abnormal cognition before/after.

Important differentials are:

  • meningitis
  • encephalitis
  • shaken baby (non-accidental injury)
  • brain tumour/haemorrhage, hydrocephalus
  • ingestion (deliberate or accidental)
  • metabolic (low glucose, calcium/magnesium, low/high sodium)

May represent first evidence of epilepsy.