Raised intracranial pressure this month, nappy rash, complex febrile seizures, tingling side effects of recreational nitrous oxide use and Vitamin D – again….
Please do leave comments below.
Raised intracranial pressure this month, nappy rash, complex febrile seizures, tingling side effects of recreational nitrous oxide use and Vitamin D – again….
Please do leave comments below.
Retinoblastoma mnemonic this month. Plus information on lower sugar content recipes for the reintroduction of cows milk into a child’s diet, labial adhesions, 6 in 1 vaccine and don’t miss infantile spasms as early treatment improves overall prognosis. Do leave comments below.
Children’s cancer information this month – prevalence and red flags, a link to the excellent immunisation resource – Oxford vaccine group – for all those questions about individual immunisations that you can’t always answer, NICE’s recent UTI update and infant dyschezia. Do leave comments below.
Local anaesthetic cream this month (why do some places not use it in the under 1’s?), a link to useful “flash card” learning in the paediatric ED from Leicester, new Movicol doses, diphtheria and the last instalment of urinalysis with bilirubin and urobilinogen. A reminder also to please discuss children with glycosuria and a high BM with a paediatrician – most children have type 1 diabetes and are at risk of DKA at diagnosis. Do leave comments below:
A bit more on babies’ stooling habits this month, NICE’s update on the epilepsies and glycosuria. Also the annual round up of useful blogs to get newcomers off to a good start in their paediatric practice. Please do leave comments below:
www.lifeinthefastlane.com has a great article describing the components of the humble urine dipstick and what we might learn from it. It is available here and I am going to borrow extensively from Dr Mike Cadogan’s work over the next few months but try to put a paediatric slant on it.
Normal range varies by lab but roughly 1.005 to 1.030
< 1.005 – diabetes insipidus, fluid overload, pyelonephritis
> 1.030 – dehydration, glycosuria, SIADH
Falsely high in proteinuria, falsely low in alkaline urine
Glomerular filtrate has a pH of about 7.4 which is acidified to about 6 by the time it is passed as urine.
Causes of alkaline urine (⇑pH)
|
Causes of acidic urine (⇓pH)
|
Old sample, vegetarian diet, salicylate
overdose, UTI, citrus fruit ++, low carb diet
|
Metabolic/respiratory acidosis, diarrhoea, high
protein diet, DKA, cranberries, malabsorption
|
Nitrites on a dipstick test has a positive predictive value of 96% ie. it is highly likely that the child has a UTI. But the test’s negative predictive value is not so good (around 70%) ie. some children still have a UTI even though they have no nitrites in their urine. Why?
The current NICE UTI guideline recommends microscopy and culture to rule out UTI in children younger than 3 but suggests that dipstick urinalysis is enough in older children. They are currently looking at new evidence to see if the dipstick result (leucocytes and nitrites) can be “trusted” in younger children. Update due to be published this year.
Dipstick protein reading | Protein excretion gm/24 hours | Protein excretion mg/dL |
Negative | <0.1 | <10 |
Trace | 0.1-0.2 | 15 |
1+ (and above is abnormal) | 0.2-0.5 | 30 |
2+ | 0.5-1.5 | 100 |
3+ | 2.0-5.0 | 300 |
4+ | >5.0 | >1000 |
Ketones are not normally found in the urine. Produced by the liver as intermediate products of fatty acid metabolism, in normal states they will be completely metabolised. In “starvation” states eg. DKA or vomiting and reduced intake, fever, extreme cold and extreme exercise, the body metabolises increased fat to get the energy it needs to keep functioning. This results in ketonuria. ≥ ++ is abnormal. We often see ketones in the urine of unwell children in the ED. When glucose is present at the same time in the urine, diabetic ketoacidosis is the likely diagnosis.
RESOURCES
http://lifeinthefastlane.com/investigations/urinalysis/
http://labtestsonline.org.uk/understanding/analytes/urinalysis/ui-exams?start=1
https://patient.info/doctor/urine-ketones-meanings-and-false-positives-pro
(From the August 2017 newsletter)
Intraosseous needle insertion is pretty painful but not as painful as the subsequent infusion of the fluids. In the conscious patient, it is possible to infuse small volumes of lignocaine via the IO to provide pain relief. http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/intraosseous-insertion provides a comprehensive guide to IO needle insertion and use. Appendix 1 of that document has a chart of how much lignocaine (lidocaine) to use according to the weight of the child. Volumes are tiny in the neonate.
(From the August 2017 newsletter)
In November 2016, NICE published its guidance on hypertension in adults which suggests 24 hour ambulatory blood pressure monitoring in the diagnosis of hypertension. ABPM should be measured in children before treating. It lessens the “white coat” effect and, if their BP is normal while asleep at night, the clinician can be fairly reassured that there is not likely to be a significant underlying cause for their hypertension.
Caveat:- you must get the cuff size right! The largest cuff which can fit on the arm should be used (2/3 the length of the upper arm, bladder 80-100% of the arm circumference). Small cuffs overestimate the blood pressure.
The centile charts for day and night blood pressures are available here at the bottom of the European consensus document. I have also uploaded them to the primary care guidelines tab. The 95th centile is the upper limit of normal. Values are gender specific and are set out according to heights and ages.
Lurbe E et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens. 2016 Oct;34(10):1887-920
(From the August 2017 newsletter)
As of July 2017, http://www.rcpch.ac.uk/child-protection-evidence is housing all the evidence behind child safeguarding so painstakingly put together by the Cardiff Child PrOtection Systematic REviews project (CORE INFO) in collaboration with NSPCC. It’s a go-to page with links to national and international guidance and resources around safeguarding children.
NSPCC flyers currently available from the RCPCH site: