Head injury

For Emergency Departments

This month I have featured the 2007 NICE guideline on head injury.  This is because I was looking through it recently trying to find out how long we should be observing children with minor head injuries for in A and E ie. those who do not qualify for a CT.   I was also interested to find out whether we should treat babies, whose fontanelles are still open, differently.  Would it take longer for the signs of intracranial pressure to become obvious in them?  Anyway the guideline answers neither of those questions…

I found a couple of recent Canadian papers on the need for CT scanning in children with minor head injury.  I think many of us are concerned that we are doing too many CTs on children as a result of the NICE guideline.  The radiation dose is not insignificant and some of the children have to be sedated for the investigation which is an added risk too.  Maguire et al (Should a head injured child receive a head CT scan?  A systematic review of clinical prediction rules. Pediatrics 2009;124(1):e145 – e154) say in the introduction to their paper that up to 70% of children presenting to the ED in the USA or Canada with a head injury get a CT scan and 70% to 98% of them are normal.  A more recent attempt at a clinical decision tool for assessing the need for CT has been written up by the Canadian head injury study group: Osmond MH et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ 2010;182(4):341-348.  There is a nice summary of and comment on this paper at www.medscape.com/viewarticle/579598.

The Scottish intercollegiate network (SIGN) put together a very similar guideline on head injury in 2009.  Their patient information leaflet is, in my view, infinitely better than NICE’s.  Have a look at their documents and downloads at http://www.sign.ac.uk/guidelines/fulltext/110/index.html

Inhalers for asthma

For Emergency Departments, For General Practitioners, ,

Most families in the Emergency Department will talk about their child’s “blue” and “brown” inhaler.  Can we, or they, tell which is the reliever and which the preventer? 

 Click here for a printable table of some common inhalers listed by colour.  I have also found a very useful site put together by a pharmacist and a medical student with photos of lots of the inhalers so you can get your patient to identify which one they are on.  Take a look at http://www.rch.org.au/clinicalguide/asthmadevices/

 Device   Comments
Standard metered dose inhaler (MDI)
  • Children < 12 years old unlikely to be able to use it properly without a spacer
  • Small, conveniently pocket-sized
  • Requires shaking and priming
  • Not affected by humidity
MDI and spacer
  • Bulky
  • Better delivery of drug at all ages
  • NICE suggests < 5 years, all inhalers should be given with a spacer device and 5-15 years, at least the corticosteroids should be given with a spacer
Dry powder device
  • Children < 6 years old generally can not use it as it requires a fast, deep breath to activate it
  • Medicine can be blown away if child accidentally breathes out
  • Clearer when the medicine is running out than the MDI
  • Single dose models require loading of capsules for each use
  • Powder sticks together if high humidity

 

http://www.asthma.org.uk/health_professionals/materials_to_help_you_your_patients/index.html has a link to a comprehensive information leaflet for young people over the age of 12 who need to take control of their asthma management and understand their condition.

http://www.nice.org.uk/nicemedia/live/11400/32073/32073.pdf  is the 2000 guideline on asthma management in the < 5 year olds

http://www.nice.org.uk/guidance/index.jsp?action=byID&r=true&o=11450 is the 2002 guideline for 5-15 year olds

Blood test reference ranges

For Emergency Departments, For General Practitioners

Click here for our agreed blood test reference ranges for children.  Ranges may vary from laboratory to laboratory so please check with your own service if you are unsure.  These ranges have been discussed with Whipps Cross Hospital and formally agreed by the paediatric Clinical Improvement Group at the hospital.

My colleague with an interest in haematology asked me to mention, as an addendum to the blood reference ranges, that the lower limit of normal of neutrophils for afrocaribbean children is 1.0 as long as all other parameters are OK.

School refusal

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

School refusal is often a symptom of an underlying anxiety disorder.  The child may get anxious on separating from their primary caregiver and this manifests itself in different ways depending on the age of the child as much as anything.  There are 2 peak age groups who develop school refusal, 5-7 year olds and 11-14 year olds.  25% of school children refuse to attend school at some point in their school career but it becomes a routine problem in about 2% and the longer it goes on, the harder it is to reverse.  It is not the same as truancy.  It is not a mental illness in itself but many children who feel unable to attend school over a long period do have an underlying mental health issue.  Unfortunately funding for CAMHS is being eroded and  it is difficult to find good, and timely, help for school refusers.  The websites I have listed in December 2010 Paediatric Pearls for GPs may help give parents pointers for why it is happening and how to set about managing it.

December PDF for the ED

For Emergency Departments, PDF digests: Emergency Departments, , , , , , ,

This month’s emergency department version of Paediatric Pearls has information on dehydration from the NICE guideline on gastroenteritis in the under 5s, a bit on seizures and the evidence behind our reluctance to let you request chest x-rays for children.  I’ve featured the NICE guideline on antibiotics for respiratory illness in primary care too as they are also relevant for the children we see in EUCC and the Emergency Department.  I hope you find it helpful; I think the average length of time for each infection is useful information to be able to hand on to parents.  Download December’s Paediatric Pearls here.

December 2010 PDF digest for GPs now published!

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

December’s Paediatric Pearls (GP edition) reminds us all of the NICE guideline on antibiotic prescribing in respiratory tract infections.  I would like to do a bit more of the “delayed prescribing” in the Emergency Department but it would require either the family coming back (ie. a “no antibiotic” policy really) or their putting a bottle of amoxicillin in their fridge and potentially not using it as we give out the actual antibiotic in A and E, not prescriptions.  We’ve also featured a couple of papers showing that chest x-rays add very little to the management of a child with a respiratory illness which I think most GPs know but it doesn’t harm to remind trainees still in the hospital that, just because the radiology department is at the end of the corridor, it doesn’t mean you have to use it!  We continue our 6-8 week baby check series with information on sacral dimples and I have also put in a couple of websites with sensible, empathetic information and advice on school refusal.  The beginning of term is stressful for children who find it hard to go to school and parents may find these sites helpful when trying to understand why their child is behaving in that way.  Happy New Year to you all!

November 2010’s Paediatric Pearls for the ED

For Emergency Departments, PDF digests: Emergency Departments, ,

Have a look at the November 2010 Paediatric Pearls PDF digest for information on bronchiolitis, heart murmurs and burns.  The featured NICE guideline this month was Nocturnal Enuresis which, even with the best will in the world, has very little to do with Accident and Emergency!  Those of you who are interested in the topic could look at this month’s GP version.

November’s GP Paediatric Pearls

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

November’s Paediatric Pearls is now published and is available for download here.  It sees the start of our 6 week check series, kicking off with information on heart murmurs.  There is also a bit on bronchiolitis as the season is upon us now and a feature on the NICE guideline on nocturnal enuresis which was published at the end of October 2010.

6-8 week check

For General Practitioners

 The 6-8 week check forms part of a routine set of examinations which are standard practice, although little evidence exists for their efficacy according to http://www.patient.co.uk/doctor/Six-Week-Review-(CHS).htm which is a bit depressing really.  They go on to remind us that it should take place by eight weeks at the latest and should include:

  • A physical examination
  • A review of development
  • An opportunity to give health promotion advice
  • An opportunity for the parent to express concerns

Many aspects of the check overlap with the newborn check done just after birth.  We are going to be featuring different topics from this child health surveillance check in the GP version of Paediatric Pearls over the next few months, starting this month with heart murmurs (see below).  Please do let us know if there are particular topics you want us to cover by adding a comment below.

Enuresis

For General Practitioners

The NICE guidelines on Nocturnal Enuresis were published in October and are featured in November’s Paediatric Pearls.  Download them from http://guidance.nice.org.uk/CG111.  In Waltham Forest, as in many other boroughs, the enuresis service is run by the school nurses.  Their referral form can be downloaded here.  They are a busy team and the child may not be seen for 2 or 3 months so what can you do as their GP in the meantime?  Certainly refer them to www.eric.org.uk for a wealth of information and support, find out what and when they are drinking and their voiding habits, discuss some of the lifestyle changes mentioned in the NICE guideline and then follow NICE’s algorithms in the quick reference guide.

Paul Watson, team leader for health visiting and school nurse teams in Norfolk, has put together a great programme to guide potential referrers through the process.  Have a look here.  Some of the linked documents are only pertinent to Northamptonshire (why not Norfolk?) but the tool is built on the 2010 NICE guideline and is relevant to all health professionals managing a child who wets the bed at night and those wishing to refer a child on to an enuresis service.