Paediatric surgery at Whipps Cross

For General Practitioners, ,

I thought it might be useful to outline the sort of paediatric surgery Whipps offers.  This post is being put together with the help of my surgical colleagues who are keen to continue receiving appropriate paediatric referrals from GPs.  I will be updating it as and when I get the information from the different specialties.

A word from the anaesthetists: As a general rule all of our consultants on the on-call rota are currently able to anaesthetise any child, 3 years or above presenting as an emergency as long as they are ASA 1 or 2 and needing non body cavity surgery (appendicectomy excepted) with an expected duration of less than 2 hours.  (“ASA 1 and 2” are children who are previously fit and well and those with a mild underlying systemic illness such as mild asthma.)  We have three consultants who have had advanced training in paediatric anaesthesia (Drs. Williams, Singh and Radhakrishnan) who undertake regular elective paediatric lists who are happy to anaesthetise younger children.

GENERAL SURGERY (Mr Stephen Brearley) AND UROLOGY (elective surgery from 1 year of age, emergency surgery from 3 years of age):    

Hernias (all types)

Foreskins

Undescended testicles

Lumps of all types

Tongue ties

Thyroglossal cyst

Emergency work in children over the age of 3 eg. suspected appendicitis

Please refer such things as in-grown toenails and verrucae to podiatrists rather than surgeons.

ENT:

(elective work from 6 months of age, emergency work from 3 years of age):

Lead Clinician, Mr. Sam Jayaraj

Dedicated Paediatric ENT clinics at WX:

Mr Jayaraj 3 per month at WX and 2 per month at Forest Medical Centre, Loughton (WX outreach clinic)

Mr Patel 2 per month at WX

Mr Kenyon 1 per month at WX.

N.B. We are in the process of setting up a Paediatric ENT Specialist Community Clinic (SCC) in conjunction with Dr Watkin and our audiological colleagues at Wood Street Clinic – watch this space!

 

ENT Surgical procedures offered at WX 

Tonsillectomy

Adenoidectomy

Oral cavity lesions

Turbinate reduction

Obstructive sleep apnoea assessment

Nasal bone manipulation following trauma

Nasal cautery

Peri-orbital abcess drainage

 Middle ear ventilation tubes (Grommets)

Pre-auricular sinus excision

Pinnaplasty (Mr Jayaraj and Mr Kenyon)

Myringoplasty/tympanoplasty

Mastoidectomy (Mr Nitesh Patel)

 Cervical lymph node excision

Thyroglossal cyst excision

Branchial cyst excision

Tongue tie division

Thyroid surgery (Mr Papesch)

Tertiary paediatric ENT services not available at WX (these are rare conditions which require highly specialised nursing, anaesthetic and allied therapies support):

Cleft lip & palate surgery and craniofacial disorders

Paediatric head & neck malignancy

Cochlear implant surgery

Paediatric airway reconstruction surgery (i.e laryngotracheal reconstructive surgery etc)

Currently we refer these patients to our tertiary paediatric ENT colleagues at Great Ormond Street Hospital

OPHTHALMOLOGY:

Strabismus, eyelid, lacrimal, cataract (with infants being referred to Great Ormond Street where our ophthalmologist with a paediatric interest also works). 

ORTHOPAEDICS:

MAXILLOFACIAL SURGERY:

Umbilical issues

For Emergency Departments, For General Practitioners, ,

This month we have covered umbilical granulomas and hernias as part of the feature on 6-8 week baby checks. Our surgeon with an interest in paediatrics is happy to see children from around 3 years of age if their umbilical hernia has not spontaneously resolved by then.  This topic is covered succintly, including a list of differential diagnoses, in an on-line Australian handbook of neonatal care. Inguinal hernias are a different matter altogether (they carry a far greater risk of becoming incarcerated) and one of the junior paediatricians is working on a “Pearl” about them for the May or June PP edition. 

There is not much evidence published on what to do with umbilical granulomas.   They occur when the inflammatory process at the umbilicus leads to excess granulation tissue preventing the raw area from developing new epithelial tissue.  One theory is that infection has a part to play.  I do nothing when asked about them in the Emergency Department but then I don’t follow up those patients so some GPs may feel that masterly inactivity is not enough!  They tend to take a few weeks to months to clear up.  There are references in the literature to fusidic acid, cool boiled water, salt, silver nitrate and reassurance.  Salt seems to be “in” at the moment.  All comments welcome!

ED version of Paediatric Pearls for March 2011

Child Protection, For Emergency Departments, , , ,

The March 2011 version is now published.  I have covered the new NICE guideline on food allergy and provided a link to the Allergy Academy which runs some really excellent course on all aspects of allergy in children, including one specifically for ED physicians.   There’s a bit on how to get foreign bodies out of noses and a text box on the paediatric early warning system or PEWS.  I have reminded you all that children under 18 months with a fracture need to be seen by a paediatrician before discharge for a safeguarding assessment.  This guideline comes from a new document put together by the NSPCC and the Welsh Child Protection group.  The pamphlet, downloadable here, describes when to suspect physical abuse in children with fractures and is useful reading for all ED practitioners.  Do leave comments below.

March Paediatric Pearls for GPs

For General Practitioners, , ,

The March 2011 version is now published.  I have covered the new NICE guideline on food allergy which I think you will all find helpful and provided a link to the Allergy Academy which runs some really excellent course on all aspects of allergy in children.  We continue with the 6 week check series with some information and pictures on fontanelles, craniosynostosis and positional plagiocephaly.  There’s a bit on how to get foreign bodies out of noses.  Do leave comments below.

FONTANELLES AND HEAD CIRCUMFERENCE AT SIX WEEK CHECK

For General Practitioners, ,

with thanks to Dr Harriet Clompus.

Assessment of fontanelles is an important part of the six week check.  Large fontanelles may indicate a problem in bone ossification or hydrocephaly, while a fused anterior fontanelle can indicate craniosynostosis.  These need to be referred to paediatric outpatients.  Always remember that anterior fontanelle size is very variable (1-4.7 cm in any direction) and always needs to be assessed in context of baby’s head circumference.

A sunken fontanelle indicates dehydration, while a bulging fontanelle indicates raised intracranial pressure (but can be non-pathological – vomiting, crying, coughing – so assess when baby settled!).  These can be discussed with paediatric registrar on-call.

1)      The anterior fontanelle is diamond shaped, 1-4.7 cm in any direction at birth (black infants larger than white) and can widen in first 2 months of life.  Median age of closure is 14 months (4 – 24 months)

 2)      The posterior fontanelle is triangular and is less than 1 cm.  It closes by 6 – 12 weeks.

 

 3)      The size of the fontanelles should always be assessed in conjunction with the head circumference. 

  • Macrocephaly  – familial, hydrocephaly or skeletal disorders such as achondroplasia.
  • Microcephaly  – familial, congenital infections, fetal alcohol syndrome, trisomies

 4)      The quality of the fontanelle  should always be assessed. 

  • Soft fontanelle  – normal
  • Bulging fontanelle – raised intracranial pressure (hydrocephalus, meningitis/encephalitis) .  NB can be non-pathological in crying, coughing or vomiting infant.
  • Sunken fontanelle – dehydration

 

 1)      WIDENED FONTANELLES:  think of…

Achondroplasia

Downs

Hydrocephalus

IUGR

Prematurity

Congenital  Rubella

Neonatal Hypothyroidism (3rd fontanelle)

Osteogenesis Imperfecta

Malnutrition

Rickets/Osteomalacia

 Rickets – Think of rickets in darker skinned, breast fed babies, especially if mothers are veiled.  Infants will often have sweating on the head.  If widened sutures are found check neonatal blood spot for hypothyroidism and refer to outpatients.

 Hydrocephalus – can have widened, bulging fontanelles in conjunction with a large head.

2)      PREMATURE FUSION OF FONTANELLES AND CRANIOSYNOSTOSIS

Closure of anterior fontanelle by six weeks always pathological  (NB  by 3 months 1% of normal infants will have a closed anterior fontanelle). 

Must always assess in conjunction with head circumference – early fusion associated with microcephaly (and less commonly, macrocephaly).

Craniosyntosis is premature closure of cranial suture(s) with skull growth restriction perpendicular to fused suture and compensatory skull overgrowth in unrestricted areas.   Presents with ridging (always pathological beyond one week of life) and abnormal skull shape (usually later than six weeks).

There is a nice background overview (with useful diagrams) to craniosynostosis at http://www.cincinnatichildrens.org/health/info/neurology/diagnose/craniosynostosis.htm.

Primary craniosynostosis is due to abnormal ossification of one or more sutures.  Simple – premature fusion of one suture, complex – premature fusion of multiple sutures.  Causes include rickets, hyperparathyroidism, hyperthyroidism , idiopathic and genetic causes such as Aperts.

Secondary craniosynostosis is caused by premature closure of ALL sutures due to lack of primary brain growth. If you find a child with premature closure of fontanelles or over-riding sutures at six week check you should refer to paediatric outpatients. NB Plagiocephaly (flat occiput) is a non-pathological deformation due to ‘back to sleep’ position – no action required.  It presents with ear on flattened side presenting anteriorly.  Parallelogram shaped head (as opposed to lambdoid suture craniosynostosis trapezoid shaped)

The following articles give lots of information on fontanelles and/or sutures.  The Fuloria article is very thorough and although it focuses on neonatal examination, most of it is still relevant for the six week check.

1) The Abnormal Fontanel, J KIESLER et al Am Fam Physician. 2003 Jun 15;67(12):2547-2552.    http://www.aafp.org/afp/2003/0615/.html  (figure 2 taken from abnormal fontanel)

2)The Newborn Examination: Part I. Emergencies and Common Abnormalities Involving the Skin, Head, Neck, Chest, and Respiratory and Cardiovascular Systems, Fuloria et al, Am Fam Physician. 2002 Jan 1;65(1):61-69.   http://www.aafp.org/afp/2002/0101/p61.html

3) http://www.nice.org/CG037quickrefguide

4) http://www.patient.co.uk/doctor/Examination-of-the-Neonate.htm

5) Craniosynostosis, P Raj et al, emedicine jul 2010 Craniosynostosis : eMedicine Neurology

Neurological examination in babies

For General Practitioners, ,

I have been looking at information on primitive reflexes as I was asked by a GP whether it was significant if he could not elicit a Moro reflex at the newborn check.  Wikipedia has a nice description of the Moro reflex: “it may be observed in incomplete form in premature birth after the 28th week of gestation, and is usually present in complete form by week 34 (third trimester). It is normally present in all infants/newborns up to 4 or 5 months of age, and its absence indicates a profound disorder of the motor system.  An absent or inadequate Moro response on one side is found in infants with hemiplegia, brachial plexus palsy, or a fractured clavicle”.

You need to make sure you are eliciting it correctly first though.  I have found a great site from Utah university with little video clips of aspects of a normal and abnormal neurological examination of a 5 day old.  Take a look at http://library.med.utah.edu/pedineurologicexam/html/newborn_n.html and watch the 2 Moro examples carefully.  Did you know the hands have to come together in the mid-line at the end?

GP version of February 2011’s Paediatric Pearls

For General Practitioners, , , , ,

GP February 2011 reminds us all of the NICE guideline on Attention Deficit and Hyperactivity Disorder. We continue our 6-8 week baby check series with information on the absent red reflex and go back to our “from the literature” box to discuss snoring and obstructive sleep apnoea (OSA). We have relaunched our prolonged jaundice guideline. Please leave comments and questions below.

Snoring children

For Emergency Departments, For General Practitioners,

Amutha reviewed a paper from Brazil in February’s Paediatric Pearls on children who snore.  I thought it was the kind of problem that would go to GPs but she tells me that a lot of the ED juniors ask her about it as well so presumably parents are seeking information on the cause of their sleepless nights from a number of different sources.

 The paper which talks about obstructive sleep apnoea and the need for ENT referral is downloadable in full from http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1808-86942010000500003&lng=en&nrm=iso&tlng=en.  Braz J Otorhinolaryngol. 2010 Oct;76(5):552-6. 

The effects of sleep disturbed breathing during middle- to late-childhood is related to important aspects of behavioral functioning, especially inattention and learning difficulties, that may result in significant functional impairment at school.  Sleep. 2010 Nov 1;33(11):1447-56.  (http://www.ncbi.nlm.nih.gov/pubmed/21102986)