October’s edition is joint again this month on account of my right radius being fractured and its being too difficult to type and format text boxes with just my left hand… I am obviously not quite as good at ice-skating as I thought I was. All the topics this month should be of interest to both the ED and primary care teams anyway: a paper on paediatric early warning scores, the start of our neurodevelopment series, an update on services for bereaved children and their families and some useful links on the subject of head-lice.
Early warning scores in the ED
One of our current paediatric SpRs, Dr Anil Krishnaiah, has been looking at some papers on the various paediatric warning scores that are in existence. Here is his summary of a paper from Sunderland in 2008:
Emerg Med J 2008;25:745-749 doi:10.1136/emj.2007.054965
The PAWS score: validation of an early warning scoring system for the initial assessment of children in the emergency department
P Egdell, L Finlay, D K Pedley
Existing UK paediatric early warning scoring systems (PEWS) were developed mainly for hospitalised patients and may be less useful for initial assessment in the ED. Until recently these are mainly used to look at admission to the HDU and PICU and trying to produce a system which would recognize those children at risk of admission.
Assessment of paediatric patients is complicated by the range of normal parameters in different age groups. Inexperienced staff may find it difficult to interpret the significance of physiological readings over a wide range of ages.
This pilot study was conducted in Sunderland to validate the scoring system by performing a retrospective analysis of 50 consecutive children attending the ED who required admission directly to the paediatric intensive care unit (PICU). A control group of 50 consecutive children who were admitted from the ED to the general paediatric ward within the same time period was also identified from the ward admission book. They compared the Paediatric Advanced Warning Scores (PAWS) scores between the two groups in order to see whether the PAWS chart would be able to identify those children in need of admission to a critical care area. Primarily the aim of this study was to design and validate a scoring system to identify children attending the ED in need of urgent medical assessment and appropriate intervention. At a trigger score of 3, the PAWS score was able to identify those children requiring admission to the PICU with a sensitivity of 70% and a specificity of 90%.
This pilot evaluation demonstrates that the PAWS chart shows promise as a ‘‘rule-in’’ tool for PICU admission.
Since the introduction of the 4 hour target in the ED, departments have been under increasing strain to assess, treat and admit patients (if required) as quickly as possible. Few studies have been designed to identify if the PEWS score could be used as a triage tool, to detect those patients who will need admission and therefore speed up the process of admitting children to the ward.
Dr Anil Krishnaiah, Paediatric SpR
My problem with this paper, Anil, is that I want a tool that will “rule-out” predictably ie. one that will tell me reliably which ones I am safe to send home – without overloading the system with too low a threshold for admission. Anyone got one of those?
Child Bereavement
It is not unusual for us to see children in clinic with non-specific ailments who have been bereaved and are still trying to come to terms with their loss, sometimes years later. I am sure it is not uncommon in General Practice either. Whenever a child dies at my hospital I worry about how the siblings are going to feel. Children experience death differently according to their age and stage. There is some good advice on “Explaining death to children” and some other useful links at www.bbc.co.uk/health/emotional_health/bereavement/bereavement_childtalk.shtml. www.childbereavement.org.uk/For/ForBereavedFamilies/SuggestedReadingandResources lists some very helpful reading material for all ages of bereaved people.
This month I have been across to the Margaret Centre at Whipps where our Psychological Support Service (PSS) is, to try and get a clearer idea of what sort of support there is in Waltham Forest for bereaved children and their families.
The Zig Zag Children’s Service accepts referrals from health professionals of children aged 3-11 in Waltham Forest with pre- and post-bereavement difficulties. This would include children with a life-limiting illness themselves or those with a family member with a life-limiting illness as well as those who have been bereaved. There is also a service for bereaved young people (11-17yr olds) and adults. Contact the PSS on 0208 539 5592 or by post at The Margaret Centre, Whipps Cross Hospital, Whipps Cross Road, E11 1NR for further information.
They do not offer crisis counselling but there is no stipulated amount of time a family or individual has to wait before being offered an appointment. In the ED we refer the family of a child who has died under our care to this service straight away, a letter is then sent to them suggesting that they ask their GP for a referral if they wish to make use of the child bereavement service. You can download their referral forms here:
Referral form for adults and children
Extra, additional referral form for a child (3-11yrs)
Additional referral form for young person aged 12-17 years
You may be reading this from outside our region. Nationally I can recommend the Child Bereavement Trust which is a UK charity supporting families when a child dies or is bereaved. It also trains health professionals to deal with the effect that a bereavement has on a family and indeed on us, the health professionals. http://www.bereavement.org.uk/home/html_index.asp?p=222 seems to have information on other bereavement services in London. Do leave a comment below if you want to recommend any other services you are aware of.
Some of the Zig Zag staff have added comments below which I think all of us who come across bereaved families will find helpful.
Age of walking
It is not uncommon for us to be referred not-yet-ambulant children just past the 18 month “upper limit of normal” age of walking. The majority of these children are using means other than crawling to get around. I had vague recollections of having seen a table once detailing the 97th centile for walking in children who bottom shuffle, commando crawl or roll everywhere but I spent 2 or 3 fruitless hours searching the literature for it a couple of months ago. So I was ironically excited this month to find that Archives of Disease in Childhood had reproduced it! One of our current registrars, Dr Amy Rogers, has kindly put together an article for Paediatric Pearls with nuggets from that paper (Sharma A Developmental Examination: Birth to 5 Years. Arch Dis Child Educ Pract Ed 2011;96:162-175 doi:10.1136/adc.2009.175901) which summarises normal development and when it would be prudent to refer children for further developmental assessment:
Approach to developmental assessment – birth to 1 year: Motor1
1) Elicit parental/carer concerns. Questions to ask:
- Do you have any concerns about the way your baby moves his arms/legs or body? Have you ever noticed any odd or unusual movements?
- Has your baby ever been too floppy or too stiff?
- Does your baby have a strong preference for one hand and ignore the other hand?
2) Gather information on social/biological risk factors:
Risk factors for poor developmental outcomes
| Biological | Family and social |
| Prenatal: drug/alcohol use, anti-epileptics, infection | Poverty, neglect, abuse, low maternal education, parental mental illness, inadequate parenting, disadvantaged neighborhood, absence of social support network |
| Perinatal: Prematurity, low birth weight | |
| Postnatal: Infection, severe hyperbilirubinaemia, injury, FTT, epilepsy |
3) Observe/elicit behavior and interpret findings
Note posture and movement. Examine tone. Elicit primary (Moro, grasp and asymmetrical tonic neck reflex) and support reflexes (downward, sideward and forward). Video clips of all these reflexes can be seen at http://library.med.utah.edu/pedineurologicexam/html/newborn_n.html.
What is not normal?
- Fisting of hands beyond 3 months
- Poor head control at 4 months
- Primitive reflexes beyond 6 months
- Flexor hypertonia in lower limbs beyond 9 months
- Not sitting unsupported with straight spine by 10 months
- Not walking by 18 months
BUT preterm infants often have delayed motor milestones, early hypotonia and longer lasting asymmetrical tonic neck reflex. Children with atypical pre-walking movement patterns (ie. non-crawlers) are late in achieving independent sitting and walking.
Pre-walking movement pattern and motor milestones (97th percentile)2
| Movement pattern | Sitting (months) | Crawling (months) | Walking (months) |
| Crawling | 12 | 13 | 18.5 |
| None – stand and walk | 11.5 | 14.5 | |
| Creeping/commando crawling | 13 | 15 | 30.5 |
| Rolling | 13 | 14.5 | 24.5 |
| Bottom Shuffling | 15 | 27 |
Refer if concerned as delayed motor development may be a marker for motor disorders and may have a negative impact on a child’s performance in the cognitive and social developmental domains. There is more information on delayed walking in a Patient Plus article written for health professionals available at http://www.patient.co.uk/doctor/Delay-In-Walking.htm.
1 Sharma A Developmental Examination Birth to 5 Years. ADC Educ Pract Ed 2011;96:162-175
2 Robson P. Prewalking locomotor movements and their use in predicting standing and walking. Child Care Health Dev 1984;10:317-30
The ED’s September 2011 pearls…
…are here! A bit on TB for your interest, pain scoring tools and links to growth charts. Also some pointers towards useful e-learning tools. Do leave comments below.
GP’s September 2011 issue now available
It’s the last day of September today so I’ve just got in by the skin of my teeth… In this month’s edition I have done a bit on BCG vaccination from the recently updated NICE guideline on TB, reminded you of where to get the new growth charts from and how to plot ex-prem babies on them and featured a somewhat depressing paper from Archives of Disease in Childhood this month on the effects of maternal obesity on the baby. Do leave comments and questions below.
CPD sites pertinent to paediatrics
Dr Aimee Henderson (GPVTS) says of www.spottingthesickchild.com:
“Spottingthesickchild.com is a useful and easy to navigate online resource which I feel would mostly benefit those who have not had much experience in paediatrics before and who are of a more junior level. The site has a good range of the most common problems in children like abdominal pain and cough, and guides you through various points such as examination and communication. It has useful links to BTS and NICE guidelines. I like the fact that you can monitor your progress in percentage of the site covered. There is also a test you can take (and certificate to print) when you feel you have looked through everything. The only downside is you need to make sure you are somewhere quiet as it is mostly video/audio heavy and you will need to be able to hear it.”
Dr Khalika Hasrat (GPVTS) says of the e-lfh safeguarding modules:
“I found the content of both modules useful, although module 2 was a little repetitive of the issues already raised in module 1. It was a good revision tool and the pictures helped emphasise the warning signs of abuse. The only criticism was that the MCQs were not always worded very clearly, but otherwise a valuable tool.”
Please do leave any other comments on these 2 sites below and especially if you have had a look at the Healthy child module in e-LFH.
Paediatric pain
We currently use 2 recognised pain scores in our Emergency Department, depending on the age of the patient. The FLACC score (ref) was put together at the end of the 1990’s and has been validated for use in pre-verbal children aged 2 months to 7 years. The Wong Baker (“smiley faces”) score is for use in the over 3’s. We also ask older children to give us a mark out of 10 on their pain with 10 being the worst they have ever felt and 1 being not too bad. Our local pain protocol suggests what the health professional should do with the information gleaned and when the child should be reassessed. I have reproduced that table for you here. The UK Department of Health National Service Framework for young people and maternity services says that the prevention, assessment and control of pain in children should be subject to regular audit.
Google translate!
We are supposed to use Language Line now instead of interpreters but I do find talking into a phone rather unfriendly. How about typing on to a computer? Have a look at http://translate.google.com/. For languages like Arabic and Urdu with different scripts you can type phonetically and the appropriate script appears – sometimes… And if you’ve got speakers/head phones the service has some of the languages in spoken form too. I am going to give it a go in clinic next week – can’t imagine it will make me faster but should make the patients laugh anyway…
Combined GP and ED versions for August 2011
Well the BMJ produces 2 journals in one in August so why can’t I? All the topics featured this month are relevant for both GPs and ED doctors – for once – so you have a joint newsletter. I have covered headache this month, Vitamin D (by popular request) and we have started the “Feeding” series requested by my ED senior colleagues. It seems appropriate to have covered breastfeeding first. Do leave comments below.