Monthly Archives: May 2011

Limping child guideline

Child Protection, For Emergency Departments, For General Practitioners, , , , ,

Limping Child Guideline

(with thanks to Dr Rajashree Ravindran)

Children who have hip pathology may present with a variety of non-specific symptoms. They may present with pain, refusal to bear weight, limp, or decreased movement of the lower extremity. If pain is present it is important to determine where it is coming from, as pelvis and low back pathology may refer pain to the hip region and hip pathology commonly presents with referred thigh or knee pain.[1]

The history should include

  1. pain characteristics
  2. trauma (recent/remote)
  3. mechanical symptoms (catching, clicking, snapping, worse during or after activity)
  4. systemic symptoms (fever, irritability, weight loss, anorexia)
  5. inflammatory symptoms (morning stiffness)
  6. neurological symptoms (weakness, altered sensation)
  7. gait (limp or not weight bearing)
  8. effects of previous treatments (including antibiotics, analgesics, anti-inflammatory drugs, physiotherapy)
  9. The current level of function of the child and development

 

Examination:

  1. Temperature and vital signs.
  2. Musculoskeletal exam including gait assessment: Look, Feel, Move approach to joint examination can be used. It should be noted that it is exceptionally rare to appreciate swelling of the hip on physical exam as it is a deep joint.
  3. A CNS examination is also vital to exclude any neurological pathology.
  4. Look for abdominal masses(Neoplasias in children can present with a simple limp)
  5. Examine the genitalia(testicular torsion may present simply as a limp[2]) and perform an ENT examination
  6. Look for rashes, bruises in unusual areas and remember the possibility of a non accidental injury.

 

Common differential diagnosis of limp by age:[2] 

0-3 years 3-10years 10-15 years
Septic arthritis or OsteomyelitisDevelopmental dysplasia of hip(usually does not present with pain)Fracture or soft tissue injury (toddler fractures or non accidental injury) Transient synovitis (Irritable hip)Septic arthritis or osteomyelitisPerthes’ diseaseFracture or soft tissue injury Slipped Upper Femoral epiphyses(SUFE)Septic arthritis or OsteomyelitisPerthes’ diseaseFracture or soft tissue injury

 

Also consider: Neoplasms, Neurological/ neuromuscular causes, Rheumatological disease such as Juvenile idiopathic arthritis

 

Investigations:

Limp due to trauma: If a traumatic fracture is suspected perform an x ray of the affected site and involve the orthopaedic team as appropriate. Always consider the possibility of non accidental injury in a younger child presenting with fracture.

Atraumatic limp: The algorithm as below can be used for guidance.  You may wish to give the parent information leaflet out as part of your “safety netting” as it reminds the family to seek further help if the limp is still present 1 or 2 weeks later.

Algorithm for Child presenting with an atraumatic limp

Parent information leaflet

REFERENCES

1.            Frick, S.L., Evaluation of the child who has hip pain. Orthop Clin North Am, 2006. 37(2): p. 133-40, v.

2.            Perry, D.C. and C. Bruce, Evaluating the child who presents with an acute limp. BMJ, 2010. 341: p. c4250.

3.            Kocher, M.S., D. Zurakowski, and J.R. Kasser, Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am, 1999. 81(12): p. 1662-70.

4.            Caird, M.S., et al., Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am, 2006. 88(6): p. 1251-7.

5.            Howard, A. and M. Wilson, Septic arthritis in children. BMJ, 2010. 341: p. c4407.

6.            Kang, S.N., et al., The management of septic arthritis in children: systematic review of the English language literature. J Bone Joint Surg Br, 2009. 91(9): p. 1127-33.

7.            Kocher, M.S., et al., Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am, 2004. 86-A(8): p. 1629-35.

8.            Padman, M. and B.W. Scott, (i) Irritable hip and septic arthritis of the hip. 2009. 23(3): p. 153-157.

Immunisation schedule UK 2011

For General Practitioners,

One of our registrars has put together a concise guide to immunisation in the UK which many fully trained GPs will be very au fait with.  Some in training may appreciate a quick run through!  The schedule changes from time to time but the links below should lead you to the current guidance whenever you access this post.   The current immunisation schedule appears below; click here for Rajashree’s complete concise guide which you can easily print off for your wall….

Routine UK Immunisation schedule (current at May 2011):

Hepatitis B vaccine +/- HBIg Given only to babies born to mothers who are chronically infected with HBV or to mothers who have had acute hepatitis B during pregnancy Vaccine: 1 injection IM

HBIg: 1 injection IM
BCG (0-12 months) Universal vaccination operates only in areas of the country where the TB incidence is 40/100,000 or greater. 1 injection in left upper arm- Intradermal
2 months *DTaP/IPV/Hib(5 in 1 vaccine- Pediacel), Pneumococcal conjugate vaccine(PCV) 1 injection, IM

1 injection IM
3 months Second dose DTaP/IPV/Hib,

Meningitis C vaccine

 1 injection, IM

1 injection IM
4 months Third dose DTaP/IPV/Hib,

 PCV (2nd dose),

MenC (2nd dose)

 1 injection, IM

1 injection IM

1 injection IM
12-13 months PCV (3rd dose),

MenC(3rd dose), Hib (4th dose),

MMR

 1 injection, IM

1 injection, IM

1 injection, IM
3 years 4 months or soon after 2nd dose MMR,

DtaP/IPV or dTaP/IPV booster(4 in 1 vaccine)

 1 injection IM

1 injection IM
12-13years HPV vaccine(Cervical cancer vaccine) for girls only, 3 injections within 6 months, IM
13-18 years *dT/IPV booster 1 injection, IM

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_126898.pdf

Inguinal hernias

For Emergency Departments, For General Practitioners, ,

with thanks to Dr Jemma Say for putting the following information together:

Inguinal Hernias

An indirect inguinal hernia is a protrusion of abdominal contents into the inguinoscrotal or labial canal via an open deep inguinal ring due to the failure of obliteration of the processus vaginalis.

 In fetal life the descent of the testis into the inguinal canal and scrotum is preceded by a small pouch of peritoneum; the processus vaginalis. After birth this peritoneal communication is obliterated, failure to do so results in either a hydrocele or hernia, depending on the degree of fusion.  

 Indirect hernias are more commonly seen in a paediatric population, as opposed to direct inguinal hernias in adult patients, where the musculature is weak and abdominal contents protrude through the wall of the inguinal canal.

Epidemiology

The incidence is 1-2%, occurring 9 times more commonly in males. The majority are found on the right (60%), 15% are bilateral, more commonly with a family history. Presentation is most frequently in infancy.

Increased Incidence

  • Preterm infants (10-30%)
  • Abdominal wall defects (e.g. prune belly syndrome)
  • Connective tissue disorders (e.g. Ehlers Danlos syndrome)
  • Chronic respiratory disease
  • Undescended testes
  • Increased intraabdominal pressure

 

The diagnosis is clinical, although USS can play a role in older children with indeterminate pain. Surgery is indicated for all paediatric patients with inguinal hernia.

The risks of not performing surgery include bowel incarceration or necrosis, and testicular or ovarian compromise and necrosis. This risk is greatest in early infancy; premature infants have an incarceration risk of up to 30%, and therefore often warrant treatment prior to discharge.  Some surgeons keep under close review for a few weeks post discharge so that these still very small babies put on a bit of weight before the operation.

If a patient presents with incarceration, an attempt at reduction should be made and urgent surgery is required, as the risk of reincarceration is as high as 15% if surgery is delayed more than 5 days.

Referral Pathway

All inguinal hernias should be referred, paediatric patients >1 year can be referred to Mr Brearley at Whipps Cross while those <1 should be referred to the Royal London Hospital. Surgery involves either open or laparoscopic techniques (tranperitoneal or preperitoneal approaches). The majority are performed as an outpatient with normal activity resuming within 48 hours.

References

IPEG guidelines for Inguinal Hernia and Hydrocele, Nov 2009. http://www.ipeg.org/education/guidelines/hernia.html

Ashcraft’s Paediatric Surgery, Holcomb G W, Murphy. J P

ABC of General Paediatric Surgery: Inguinal hernia, hydrocele and the undescended testis: BMJ 1996 312:564

Patient Information Leaflets

http://www.patient.co.uk/doctor/Inguinal-Hernias.htm

http://www.bch.nhs.uk/acrobat/PDF%20for%20Web/Inguinal%20Hernia%20Repair.pdf

Video information

Distinguishing indirect and direct inguinal hernia

http://www.youtube.com/watch?v=wAzXSqGybvE

Indirect inguinal hernia repair

http://www.medicalvideos.us/play.php?vid=1108

 

Contraindications to breastfeeding

For General Practitioners, , ,

I was encouraging a mother to breastfeed the other day when she asked if I was sure that was OK with her condition.  Her baby is asymptomatic on a 10 day iv course of penicillin for presumed inadequately treated maternal syphilis.  I wobbled momentarily and the junior doctor and I went away to look it up.  It is OK apparently as long as the mother does not have syphilitic lesions around her nipples.  Take a look at http://pedclerk.bsd.uchicago.edu/page/breastfeeding which is an American teaching site and has a nice summary of when you can and can’t breastfeed.  http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT is an American database of the evidence on the safety of various medicines when breastfeeding.

April 2011 ED version

For Emergency Departments, , ,

NICE has recently reviewed its guideline on depression in children and young people – an important diagnosis to be aware of when treating children in the ED.  We have also looked at the evidence around non-sedating antihistamines and found you a “how to do it” video on pulled elbows, and indeed one on umbilical hernia repair in an adult!  Umbilical hernias are common and benign, inguinal hernias may not be.  Read all about it here!

April 2011 GP Paediatric Pearls hot off the press!

For General Practitioners, , ,

The April 2011 version is now published.   I have covered the recently reviewed NICE guideline on depression in children and young people.  We continue with the 6 week check series with some information on umbilical hernias and granulomas.  And, now that the hay fever season is upon us, we have had a look at the literature on non-sedating antihistamines.

Anti-histamines for the hayfever season!

For Emergency Departments, For General Practitioners

April 2011’s editions of Paediatric Pearls are being published late because there has been a bit of pre-publication discussion about our paragraph on anti-histamines which needed checking up on!  The newsletters go out to all my colleagues for checking prior to publication and occasionally Amutha and I have to go back to the drawing board for one or two of the text boxes.  This month 2 of the text boxes have had to be re-done, the ones on cetirizine and umbilical hernias as the surgeon with an interest in paediatrics at Whipps had some suggested modifications for this latter one.  All goes to show that this site is not just a collection of my own random thoughts….  

The full abstract of the paper on cetirizine is reproduced below:

Drugs. 2004;64(5):523-61.

Cetirizine: a review of its use in allergic disorders.

Curran MP, Scott LJ, Perry CM.

 

Source

Adis International Limited, Auckland, New Zealand. demail@adis.co.nz

 

Abstract

Cetirizine is a selective, second-generation histamine H1 receptor antagonist, with a rapid onset, a long duration of activity and low potential for interaction with drugs metabolised by the hepatic cytochrome P450 system. Cetirizine was generally more effective than other H1 receptor antagonists at inhibiting histamine-induced wheal and flare responses. Cetirizine is an effective and well tolerated agent for the treatment of symptoms of seasonal allergic rhinitis (SAR), perennial allergic rhinitis (PAR) and chronic idiopathic urticaria (CIU) in adult, adolescent and paediatric patients. In adults with these allergic disorders, cetirizine was as effective as conventional dosages of ebastine (SAR, PAR, CIU), fexofenadine (SAR), loratadine (SAR, CIU) or mizolastine (SAR). This agent was significantly more effective, and with a more rapid onset of action, than loratadine in 2-day studies in environmental exposure units (SAR). In paediatric patients, cetirizine was as at least as effective as chlorphenamine (chlorpheniramine) [SAR], loratadine (SAR, PAR) and oxatomide (CIU) in the short term, and more effective than oxatomide and ketotifen (PAR) in the long term. Cetirizine was effective in reducing symptoms of allergic asthma in adults and reduced the relative risk of developing asthma in infants with atopic dermatitis sensitised to grass pollen or house dust mite allergens. It had a corticosteroid-sparing effect in infants with severe atopic dermatitis and was effective in ameliorating reactions to mosquito bites in adults. Cetirizine was well tolerated in adults, adolescents and paediatric patients with allergic disorders. In adult, adolescent and paediatric patients aged 2-11 years, the incidence of somnolence with cetirizine was dose related and was generally similar to that with other second-generation H1 receptor antagonists. Although, its sedative effect was greater than that of fexofenadine in some clinical trials and that of loratadine or fexofenadine in a postmarketing surveillance study. In infants aged 6-24 months, the tolerability profile of cetirizine was similar to that of placebo. Cetirizine did not have any adverse effects on cognitive function in adults, or cognitive function, behaviour or achievement of psychomotor milestones in paediatric patients. Cetirizine was not associated with cardiotoxicity. CONCLUSION: Cetirizine is well established in the treatment of symptoms of SAR, PAR or CIU. It demonstrated a corticosteroid-sparing effect and reduced the relative risk of developing asthma in sensitised infants with atopic dermatitis. Cetirizine was effective in the treatment of allergic cough and mosquito bites; however, its precise role in these indications has yet to be clearly established. On the basis of its favourable efficacy and tolerability profile and rapid onset of action, cetirizine provides an important option for the treatment of a wide range of allergic disorders.