Category Archives: OPD

Headaches and exertion/sport

Neurology, OPD

Not uncommon. Tension headaches tend to get better with exertion, in any case mild by definition so unlikely to be a problem. Some specific exertion-related headaches eg Primary headache with raised cardiac output – pulsating in quality, can last just a few minutes but up to 48 hours! Primary headache with raised venous pressure is related to valsalva manoeuvre eg weight lifting, can last just seconds, rarely more than 30 minutes.

Do MRI, ECG to exclude underlying cause.

Could try more gentle aerobic warm up, NSAID prophylactically, Else triptan/NSAID treatment as required. Beta blockers (esp Non-selective eg propanolol) appear to have some negative effects on aerobic exercise capacity (except when used for treating cardiac failure). They are also banned in competitive sports (due to their use by precision sports athletes eg archery). [Sports Med. 1988 Apr;5(4):209-25. PMID   2897710]

Enuresis

Common, General paediatrics, OPD
  • Primary or secondary – have they ever been dry? Only considered secondary if consistently dry for at least 6 months
  • Neurology – dribbling, ankle jerks, anal tone
  • Daytime or night time

Nocturnal wetting is considered normal up to the age of 7.  Quantify daytime wetting – pants only, patch on clothes, or puddle.

Diagnoses to consider: (not mutually exclusive)

  • Spinal lesion
  • Excessive urine production – diabetes, lack of mature pattern of ADH production at night
  • Excessive bladder tone/poor bladder volume – urgency, posturing
  • Abnormal voiding – straining, intermittent or poor stream. Could be a bladder neck problem, or else incomplete emptying.
  • Inadequate nocturnal awareness

Diaries of input/output, wetting/waking and measuring overnight urine output may be helpful. The expected bladder capacity is (Age + 1)x 30, max 390ml. If night time urine output is substantially greater than this eg 130% of expected, then suggests nocturnal polyuria. Similarly, day time voiding of consistently less than 65% of expected capacity suggests a small bladder. Going 8x a day or more (with a normal fluid intake) is another clue.

Recommended fluid intake (NICE):

  • 4-8 yrs: 1000–1400 ml
  • 9–13 years: 1200–2100 ml (boys sl more!?)

Incomplete bladder emptying can be defined as post void residual urine volume of greater than 20 ml, on more than one ultrasound, without excessive bladder distension before hand.

For bladder problems, exclude UTI/diabetes by urine dipstick testing.

For bladder or bowel problems, look for any signs of constipation, not just hard/painful stools.

Daytime wetting or urinary urgency/frequency

Ensure adequate fluid intake.  Aim for at least 6-8 cups of appropriately sized water-based drinks spread throughout the day (e.g. 200ml for a 7 year old, about a teacup full;  250ml for an 11 year old, about a mug full).  Start with 8 small drinks every day and increase the amount gradually so the bladder gets used to being stretched.

Try avoiding fizzy drinks, blackcurrant, orange, and drinks containing artificial colourings, flavourings and sweeteners, tea/coffee/hot chocolate for a few weeks, then introduce them one at a time to see what effect they have on the bladder.

Aim for 4-7 voids per day.  If child tends to hang on for prolonged periods, ensure adequate fluid intake as above, then consider an alarm to remind them to go (vibrating watch available, £40+).  Do not encourage excessively frequent voiding – bladder will then become less able to contain normal volume.

Check child is properly relaxed going to the toilet.  Feet should be supported if sitting, use child toilet seat if tending to slip through.  Boys should try sitting for some pees each day, as well as standing.  “Don’t push your pee out.  When you think you’re finished, count to 10 and start again.  Tell your teacher if no toilet paper/soap or broken seat/locks etc.” (Snakes and ladders booklet, Kidney Kids Scotland).

Oxybutinin for small bladder (Desmopressin may work but less rational). Tolerterodine, Solifenacin are alternatives but still antimuscarinic, so same side effects.

Night time wetting

Deal with daytime wetting or urgency/frequency first.

Ensure adequate fluid intake through the day, spread evenly through the morning and afternoon/early evening.  Stop drinking an hour before bed time.

Fully empty bladder before bed time.  Try going twice!

Make toilet easily accessible in night – lower bunk, night light, bucket etc

Do not encourage regular or random lifting/waking – there is no evidence that this promotes long term dryness!  Should only be used as temporary short term measure.  Where night time wetting has not responded to management, a young person may find it useful to set an alarm for themselves.

Establish reward system for drinking well through day and helping to change bedding/pyjamas (rather than for staying dry, which is beyond their control).  Choose appropriate goals, choose appropriate reward (choices/time, not necessarily monetary/dietary), choose appropriate format. Dot to dot picture rather than calendar?

Think positively – say  “I can wake up and go to the toilet if I need to in the night!” before going to sleep. Try without nappies/pull-ups from time to time.

Get bed pads or waterproof mattress protector

Consider bed wetting alarm – bedpad or pant sensor? Buzzer or beeper? Alarms from ERIC cost £50-150!  NICE says avoid alarms if doesn’t suit household, emotional stress esp parental blaming, or if infrequent wetting. Will disrupt sleep, of course!  Parents may need to help child wake to alarm, need to do consistently and chart progress.

Offer trial of desmopressin if child over 7yrs, especially if rapid short-term improvement a priority, or if alarm not suitable.  Consider from age 5yrs.  Response rate low for those without obvious polyuria.

Refer to ERIC website (www.eric.org.uk) or helpline  (0845 370 8008) for further support/information

Although primary nocturnal enuresis is still reasonably common up to the age of 7yrs, addressing the issues above should nonetheless be considered in children younger.

Refer to Secondary Care:

  • Bladder dysfunction: straining to pass urine, intermittent or poor stream
  • Abnormal neurology or lumbosacral spine (naevus, hairy patch, pits, asymmetry)
  • Social/emotional factors that are affecting likelihood of improvement
  • Bedwetting not responding to alarm or trial of desmopressin
  • History of recurrent urinary tract infection
  • Day time wetting not improving with first line advice as above

See ERIC (Childhood continence) website for parent information. Hjalmas, J Urol 2004 International evidence based strategy for nocturnal enuresis. International Children’s Continence Society.  NICE guideline 111 nocturnal enuresis

Parenting and constipation

Common, General paediatrics, OPD, Psychology

Parental child-rearing attitudes (as assessed by the Amsterdam version of the Parental Attitude Research Instrument, A-PARI), are associated with constipation in children in Dutch study.

More specifically, both higher and lower scores on the autonomy attitude scale were associated with decreased defecation frequency and increased faecal incontinence. High scores on the overprotection and self-pity attitude scales were associated with increased faecal incontinence.

“Autonomy” reflects emphasis on encouraging independence.  “Overprotection” refers to concern about child with respect to prevention of disappointment and problems for the child, and need to know what’s going on inside child.  “Self pity” refers to irritability and frustration with respect to upbringing, which implies rejection.

More and stronger associations were found for children aged ≥6 years than for younger children.

Authors recommend addressing parenting issues during treatment and even referral to mental health services when parenting difficulties hinder treatment or when the parent–child relationship is at risk.  [Arch Dis Child 2015;100:329-333 doi:10.1136/archdischild-2014-305941]]

 

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.