Faltering growth

For General Practitioners, ,

I am teaching our local GPVTS trainees this week on faltering growth, food allergy and coeliac disease.  As usual, I have learnt more from preparing their presentation than they are going to learn in the hour it will take me to present it!  I have found a great GP training website set up by a GP in the north of the UK with similar altruistic aims to me.  Have a look at what he has to say on faltering growth at http://www.gp-training.net/training/tutorials/clinical/paediatrics/pgrowth2.htm. 

I have put together an algorithm for managing cows’ milk protein allergy and a table on various different infant formulas which you are welcome to download or comment on.

I used to work in Poole Hospital, Dorset and was pleased to find this patient information leaflet from the dieticians there on tips for families where a child is refusing to eat: http://www.poole.nhs.uk/documents/leaflets/nutrition/My%20Child%20Wont%20Eat.pdf.  It is based on the leaflet “Help, my child won’t eat” which is put together by the Paediatric Group of the British Dietetic Association but not obviously available on-line.

Vitamin D

For General Practitioners

There has been a lot of interest in Vitamin D deficiency recently and a certain lack of consensus on what to do about it.  We certainly do see rickets in our community which we treat with oral ergocalciferol which is notoriously difficult to get hold of in community pharmacies I know.  But full blown rickets is just the tip of the iceberg.  The Department of Health produced a leaflet in January 2010 (http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_111302.pdf ) which is the nearest I can find to a national guideline dealing with the risk of Vitamin D deficiency.

Checking the red reflexes

For General Practitioners, ,

6 week check series – The Absent Red Reflex – with thanks to Dr Sarah Prentice

 Importance of red reflex examination at the 6 week check

Early detection of potentially sight and life-threatening eye disease. Due to the early and time-limited plasticity and development of the eye, any blockage of light to the retina interferes with development of optic neural pathways and can have profound effects on later vision.

 Pathology

                Cataracts

                Retinoblastoma

                High Refractive errors

                Vitreal haemorrhage/opacity

                Corneal scaring (e.g. ocular toxocariasis)

                Retinal tear

                Retinopathy of prematurity

                Persistence of the tunica vasculosa lentis/Persistent hyperplastic primary vitreous (1)

The Examination

                Darkened room

                Ophthalmoscope on +3 dioptres

                Hold 1 foot away

Red reflexes can only be described as normal if they are:                               

Equal in colour, intensity and clarity with no opacities or white spots (2)

 

Handy hints

                For the child that won’t open his/her eyes: try picking/sitting them up or rocking them from sitting to lying.  Having a parent hold them on their shoulder (as if winding them) and looking from behind often works. A feeding child will often open his/her eyes, although breast feeding then makes looking in the eyes logistically tricky.

Children with darker skin tones may have pale retina.  If retinal vessels can be seen and followed to the disc and the reflex is equal bilaterally then this is reassuring.  Comparison with parents’ red reflexes may also help.

Management:

                Normal:   No further follow-up. Will have routine ophthalmology review by school nurse/orthoptist in pre-school years. (5)

                Unable to see red-reflexes or unsure:  Referral to paediatric ophthalmology primary care clinic (if available)

                Absent red reflex:  Urgent referral to paediatric ophthalmologists (should be seen in less than 2 weeks)

                 Family history of neonatal eye disease e.g. retinoblastoma, congenital cataracts:  Routine referral to paediatric  ophthalmologists.

                Low birth-weight/premature infants (at high risk of retinopathy of prematurity):  Should have had ROP screening and follow-up arranged as necessary by neonatal unit.

 References and resources

  1. 1.       Robertson’s Textbook of Neonatology. Fourth Edition. 2005. Edited by Janet M. Rennie.
  2. 2.       American Academy of Pediatrics Policy Statement. Red Reflex Examination in Infants PEDIATRICS Vol. 109 No. 5 May 2002
  3. 3.       Red Reflex Examination in Neonates, Infants, and Children. PEDIATRICS Vol. 122 No. 6 December 2008, pp. 1401-1404 (doi:10.1542/peds.2008-2624)
  4. 4.       www.eyesite.ca/7modules/Module5/html/Mod5Sec1.html  – Good pictures of cataracts, retinoblastoma and glaucoma
  5. 5.       http://www.patient.co.uk/doctor/Vision-Testing-and-Screening-in-Young-Children.htm
  6. 6.       http://www.bartsandthelondon.nhs.uk/docs/poster_red_reflex_print.pdf  Poster of red reflexes and referral pathway from Bart’s and The London.

Attention Deficit Hyperactivity Disorder

For General Practitioners,

I featured the 2008 NICE guideline on ADHD in the February 2011 GP version of the Paediatric Pearls newsletter.  All parents of children who are being assessed for possible ADHD should be given information about local parent training/education programmes, not to insinuate that they are poor parents but in recognition of the fact that parenting skills need to be fully optimised to meet the above average parenting needs for this group of children.  Try http://www.walthamforestclass.gov.uk/familylearning/fm.aspx#parenting  for information on lots of free parenting classes provided by Waltham Forest.

Locally, ADHD is dealt with by the Child and Family Consultation Service and all referrals should go to the child psychiatrists and psychologists there please.

Let’s try and keep prolonged jaundice out of A and E!!

For General Practitioners, Uncategorized

Most babies who are still jaundiced at 2-3 weeks of age are well.  It is important not to miss biliary atresia  which presents as CONJUGATED hyperbilirubinaemia.  The baby will usually, though unfortunately not always, have pale, putty-coloured stools and it is important to pick them up early as the treatment is surgical and has a better outcome if carried out around the age of 6 weeks.  The community midwives in Waltham Forest do the first line investigations for prolonged jaundice.  The following documents are downloadable here:

1)  Prolonged jaundice guideline for midwives

2)  Investigation sheet for prolonged jaundice

We try very hard to keep these babies out of the Emergency Department as they run the risk of coming in well and going out with something they’ve caught while waiting to see us.  They also have to be put in a cubicle and then there is no room for A and E to see all the other children in the department.

Viral rashes

For Emergency Departments, For General Practitioners,

You know when you are not quite sure what the name is of the rash that a child has but you know it is not an acute emergency? I often wish I had done Latin “A” level and could come up with something credible sounding on the spur of the moment. I sent yet another “viral exanthem” child to my dermatology colleagues yesterday because I hesitated for a second too long over a possible diagnosis and lost the confidence of the parent. So today I have been educating myself. Take a look at www.dermnetnz.org for some fantastic images and information on more types of enteroviruses than you could possibly imagine existed.  The site also has some self-directed learning modules on it.

There’s another site worth looking at, aimed at non-health professionals but with some quite useful photos on.  Have a look at http://www.skinsite.com/index_dermatology_diseases.htm.

New APLS guidelines are sort of here…

For Emergency Departments

The new ILCOR 2010 resuscitation guidelines are now being taught on all life support courses in the UK. We are allowed this year as a transition year as people get trained up. I have put together a Word document (Useful emergency paediatrics bits and pieces (2)) with all the updated APLS “WETFAG” policies and a table with normal paediatric observations as an aide memoire for those leading paediatric resuscitations or stabilising sick and injured children.

Unfortunately version 5.0 of the APLS manual is not going to be available in hard copy until later this year so there may be a bit of confusion about which guidelines to use. The only thing that will affect the care of the individual child is if the leader loses confidence so please, when the chips are down, use the guideline the leader is comfortable with.

APLS instructors have access to the new manual in draft form through their VLE login. Can I remind you that we all have to do some updated VLE sections and print out a certificate to say we’ve done that before instructing on any courses this year?

January GP edition here!

For General Practitioners, PDF digests: for General Practitioners, , , ,

January reminds us all of the NICE guideline on head injury and specifically when a child is supposed to be referred for a CT.  We continue our 6-8 week baby check series with information on undescended testes.  There are also links to agreed blood test reference ranges and resources to help with the identification of asthma inhalers.  Download January 2011 GP PDF here.

Undescended testes

For Emergency Departments, For General Practitioners,

Undescended testes (cryptorchidism) with thanks to Dr Sara Waise

 Occasionally when you are examining a male infant, you may think that one or both of his testes has not yet descended into the scrotal sac.    Infant testes are actually quite retractile; ask parents if they are visible in the scrotum when the baby has a warm bath.  At 6 weeks some babies’ testes may still be palpable within the inguinal canal, especially if they were born a bit early.  Infants with a true undescended testis need to be referred to a paediatric surgeon any time from 6 months of age and definitely by 1 year of age.  Our local paediatric surgery service is at the Royal London Hospital, Whitechapel.

One of the junior doctors, Dr Sara Waise, has put together the following notes on undescended testes for Paediatric Pearls: 

Check whether testes are:

  • Present or absent
  • In the inguinal canal
  • High in the scrotum
  • Able to be brought down into the scrotum

 Identify any other congenital defects 

  • May be isolated
  • Can occur as part of genetic or endocrine disorders and for this reason, my colleague with an interest in endocrinology asked me to remind you that bilateral undescended testes need immediate referral.

 If the testis remains undescended at 1 year of age, referral to a urologist is needed.

 Early correction maximises future fertility potential

  • Outcome is poorer for bilateral undescended testes
  • Unclear whether surgical correction fully normalises this

 Surgical correction reduces malignancy risk

  • Facilitates self-examination
  • Risk remains 5-10 times greater than normal following orchidopexy

 

References

Kurpisz,. M., Havryluk, A., Nakonechnyj, A., Chopyak, V. & Kamieniczna, M. (2010). Cryptorchidism and its long-term consequences. Reproductive Biology 10 19-35

Hutson, J.M., Balic, A., Nation, T. & Southwell, B. (2010). Cryptorchidism. Seminars in Pediatric Surgery 19 215-234

http://www.patient.co.uk/health/Undescended-Testis.htm provides a useful, printable overview for parents of boys in whom you have found an undescended testis. 

http://www.patient.co.uk/doctor/Undescended-and-Maldescended-Testes.htm has information for medical professionals and includes information about the ascending testis syndrome in the older child (around 8 to 10 years old).