Category Archives: For Emergency Departments

BCG lymphadenitis

BCG Lymphadenitis with thanks to Dr Mujahid Hassan

Lymphadenitis is the most common complication of BCG vaccination, and is of two types – suppurative and non-suppurative.

Normal course post-vaccination:
Intradermal injection -> local multiplication of vaccine -> transport to lymphatics via lymph glands -> haematogenous dissemination of BCG.
No clear definition of ‘BCG lymphadenitis,’ proposed definition is when it becomes palpable or concerning for parents.

Can appear as early as two weeks after vaccination, most within 6 months and almost all cases will be within 24 months.
Normally ipsilateral with one or two palpable lymph nodes, but can involve multiple nodes.  Normally axillary but can be with cervical/supraclavicular.
Diagnosis:

  • Isolated lymph node enlargement
  • BCG vaccination to ipsilateral side
  • Absence of tenderness or heat to lump
  • Absence of fever

Non-suppurative will resolve within a few weeks – this is a normal reaction and most of these are sub-clinical so go unnoticed.
Suppurative involves an enlarging lymph node with fluctuant appearances, oedema and erythema.  Happens in ’30-80%’ of cases of lymphadenitis.

Treatment of suppurative lymphadenitis:

Antibiotics: Previously erythromycin/rifampicin/isoniazid have been used but their clinical role is of dubious significance, so are not used routinely.
Reassurance and followup are what is needed.

Fine Needle Aspiration: Suppurative lymphadenitis can result in spontaneous perforation and sinus formation, which can result in several unpleasant months of dressing and wound care.  FNA is thus recommended to prevent this and reduce time for healing.

Surgical excision:  Risks of general anaesthesia – other than in extreme cases of failed FNA/multiloculated lymph nodes – far outweigh the potential benefits.

Non-suppurative

 

 

 

 

 

 

 

 

 

 

 

Suppurative

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Management pathway and images courtesy of:
WM Chan, YW Kwan, CW Leung.  Management of Bacillus Calmette-Guérin Lymphadenitis, Hong Kong Journal of Paediatrics (New Series). Vol 16. No. 2, 2011, available via http://www.hkjpaed.org/details.asp?id=782&show=1234
References:

J Goraya and V Virdi,  Bacille Calmette-Guérin lymphadenitis, Postgrad Med J. 2002 June; 78(920): 327–329,
available via http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1742390/pdf/v078p00327.pdf

 

October 2013 newsletter

Lots of writing on this month’s PDF digest, much of it thanks to our registrars.  Rotavirus oral vaccination, wheezing in the under 2s, bradycardia, conduct disorder, Kawasaki disease and force feeding.  Do leave comments below.

Kawasaki Disease

Dr Yasmeen Moin is one of our senior registrars, currently nursing a broken leg and making good use of her time writing accessible articles for Paediatric Pearls!  This month she has summarised all the salient points about Kawasaki Disease which is not as rare as people think.  Her article is below, under the characteristic “strawberry tongue”.

Kawasaki disease (KD) is an acute febrile childhood vasculitis affecting medium sized arteries, particularly the coronary arteries.

It most commonly affects children aged between 6 months and 4 years, however it can occur in children up to the age of 16.

Diagnosis is based on persistent fever, of 5 days or more, plus 4 of the following:

1) Conjunctivitis – bilateral, bulbar, non suppurative

2) Lymphadenopathy – cervical >1.5 cm

3) Rash – widespread, polymorphous, NOT vesicular

4) Lips and oral mucosa – red cracked lips, “strawberry” tongue, erythematous oral cavity

5) Changes of extremities – erythema, oedema of palms and soles initially, then peeling of skin at a later stage

NB:

Fever is often >39°, remittent and unresponsive to antibiotics and antipyretics.

Incomplete KD can occur where not all diagnostic criteria are met. It is more common in children less than a year old. Think KD when prolonged unexplained fever even if less than four diagnostic criteria.

Children with KD are often extremely irritable. Think KD if fever, irritable and skin manifestations.

KD is often accompanied by concurrent infections which may be misleading.

Why is it important to diagnose?

KD is the commonest cause of acquired cardiac disease in the UK and USA with 25% of untreated cases of KD developing cardiac complications. Timely treatment reduces coronary artery damage by up to 75%.  Children less than 1 year of age with incomplete KD have a higher risk of developing cardiac sequelae.

I’ve not seen one before, how common is it?

KD is relatively common with an annual incidence in the UK and United States of approximately 9-12 per 100 000 children under 5 years (compared to an age- matched incidence of meningococcal disease of approximately 1 per 100 000).

What do I need to do?

Children with suspected KD should be referred to the Paediatric team urgently, as early treatment significantly reduces the risk of long term cardiac artery damage.

If there is a high index of suspicion, referral should be made before 5 days of fever.

Diagnosis is clinical; however there are characteristic laboratory findings:

Elevated WBCs, mainly neutrophils

Markedly elevated ESR and CRP

Hypoalbuminaemia

Normocytic, normochromic anaemia

Mildly elevated LFTs, mainly ALT

Normal platelet count that increases markedly in week two of illness

How is it treated?

Treatment involves admission to a paediatric ward and administration of IV immunoglobulin (IVIG). This causes rapid defervescence and clinical improvement in 80% of cases. High dose aspirin is also commenced (dosing regimen will vary according to local policy). A second dose of IVIG may be required if there is no response to the initial dose. Anti-viral IgG in IVIG may interfere with the efficacy of live vaccines.

An ECHO, looking in particular for coronary artery aneurysms, is usually performed during the initial admission and then at 6 weeks (or sooner, again depending on local policy).

Once the fever has resolved, aspirin is continued at a low dose and in those children with a normal ECHO at 6 weeks, it is discontinued.

What follow up should I expect?

Long term, often lifelong, paediatric cardiology follow up is required. Repeat ECHOs are carried out regularly (as per local policy). Lifelong aspirin and anticoagulant therapy may be required if aneurysms persist, if they are >8mm and if stenoses are identified. Further investigations, such as coronary angiography, may need to be carried out. The long term effects of KD on adult coronary disease are unclear but the family should be given advice on minimising atheroma risk factors. Early monitoring of blood pressure and lipids should be considered.

Parents should be reassured that KD is not contagious and that most children make a full recovery without any long term sequelae.

Useful links

http://www.patient.co.uk/health/kawasaki-disease

http://www.racgp.org.au/afp/2013/july/kawasaki-disease/

References

Kawasaki disease. The importance of prompt recognition and early referral Volume 42, No.7, July 2013 Pages 473-476

Surveillance of Complete Kawasaki Disease in the UK and Ireland, RCPCH

Whipps Cross Paediatric Unit Guidelines

http://circ.ahajournals.org/content/110/17/2747.full.pdf+html provides a full text 26 page in-depth discussion on everything to do with Kawasaki Disease. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease. A Statement for Health Professionals From the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association.  Jane W. Newburger, MD, MPH;Masato Takahashi, MD et al.  Circulation. 2004; 110: 2747-2771

September 2013 round-up

The newsletter this month is mainly a round-up of past posts which have been quite useful for ED doctors and GPs.  It’s quite hard finding your way around Paediatric Pearls when you first start using it so I hope the articles linked to from this month’s newsletter start you off and give you a flavour of the sort of thing you can find on this website.  Thanks to Dr Tom Waterfield who was once a paediatric trainee with us at Whipps and who has now taken over the “From the literature” slot to keep us all up to date with recent relevant publications.

PEWS is not a national score but the idea is worth thinking about nationally.  We use it to try to identify the children who are at most risk of becoming more unwell so that measures can be put in place to reverse this trajectory.  Remember though, a low PEWS does not necessarily mean the child is safe either.  Children need frequent observations when they are in an acute area and staffing levels need to be appropriate to support this.

Do leave any comments on this month’s newsletter below.

July 2013 PDF

Neglect and emotional abuse is the safeguarding topic this month.  ED advice on the management of minor head injuries, a report from BPSU in hypocalcaemic fits secondary to vitamin D deficiency, the new UK immunisation poster and a bit on crying babies.  Hope you find it all helpful.  Comments welcome below

Emotional abuse and neglect

With many thanks to Dr Harriet Clompus, paediatric SpR with an interest in community paediatrics for summarising this core-info topic so neatly and usefully.

Emotional Neglect and Abuse

Core-info, a Cardiff university based research group, examines all areas of child abuse by systematically reviewing worldwide  literature and producing recommendations based on best evidence.  This is a useful resource for paediatricians, general practitioners, health visitors, nurses, social workers, educators.  Find all their reviews at www.core-info.cardiff.ac.uk.

Core-info have produced a leaflet in cooperation with National Society of Prevention of Cruelty against Children (NSCPCC) following a review in 2011 of the available literature on emotional neglect and abuse in children less than 6 years old.  The leaflet is available at NSCPCC resources at www.nspcc.org.uk/inform.  You can also subscribe to CASPAR a news service that signposts you to latest policy, practice and research in child protection.

Definitions of emotional neglect and emotional abuse vary, but all include persistent, harmful interaction with the child by the primary care-giver.

The Core-info/NSPCC leaflet reports one in 10 children in the UK experience severe neglect in childhood.  It uses the WHO definitions for emotional neglect and abuse. (World report on violence and health  (2002) page 60.  Edited by Krug et al)

‘Emotional neglect is the failure of a parent to provide for the emotional development of the child.’

Examples of emotional neglect include:-

–  Ignoring the child’s need to interact

–  Failing to express positive feelings to the child, showing no emotion in interactions with the child

– Denying the child opportunities for interacting and communicating with peers and adults.

‘Emotional abuse includes failure of a care-giver to provide an adequate and supportive environment and includes acts that have an adverse effect on the emotional health and development of a child.  Such acts include restricting a child’s movements, denigration, ridicule, threats and intimidation, discrimination, rejection and other non-physical forms of hostile treatment.’

Examples of emotional abuse include:-

–  Persistently telling a child they are worthless or unloved

–  Bullying a child or frequently making them frightened

– Persistently ridiculing, making fun of or criticising a child.

The core-info/NSCPCC leaflet categorises behaviour/interactions to be concerned about in three different age groups (it only gives data up to 6 years and on mother (not father or other caregiver) interaction, reflecting data collection in studies reviewed).  Attachment to mother is disordered and emotionally neglected children show typical pattern of initially passive and withdrawn and then hostile and disruptive behaviour and developmental delay especially in speech and language.

1) Infant (<12 months old)

  • Mother-child interaction:  mother insensitive and unresponsive to child’s needs.  Rarely speaks to child, describes them as irritating/demanding.  Failing to engage emotionally with child during feeds.  Child unconcerned when mother leaves and when mother returns, child avoids her or does not go to her for comfort.
  • Behaviour:  Quiet and passive child.  May demonstrate developmental delay within first year, particularly in speech and language (particularly if mother has had depression).

2) Toddlers (1-3 years old)

  • Mother-child interaction: More obvious that mother is unresponsive or does not respond appropriately to child (called ‘lacking attunement’).  Mother is often critical of child and ignores signals for help.  Child is angry and avoidant of their mother.
  • Emotionally neglected/abused children grow less passive and more aggressive and hostile, particularly with other children.  They show more memory deficits than other children, including physically abused children.

3) Children (3 -6 years)

  • Mother-child interaction: Mother offers little or no praise, rarely speaks to the child and shows less positive contact.  Mother is unlikely to reach out to the child to relieve distress and the child is unlikely to go to the mother for comfort.  Neglectful mothers are more likely to resort to physical punishment than other mothers.
  • Emotionally neglected children show more speech and language delay than physically abused children.  Girls show more language delay than boys.  Their behaviour is often disruptive (rated more disruptive by parents and teachers than physically abused children or controls). They show little creativity in their play, have difficulty interpreting others emotions and have poor interactions with other children.  They tend to be less likely to help others or expect help themselves.

 

Implications for practice:

–  All practitioners (gps, paediatricians, nursery nurses and teachers, health visitors etc)  need to consider emotional neglect and abuse when assessing a child’s welfare.  The longer a child is left in an emotionally neglectful or emotionally abusive environment, the greater the damage.  However intensive work with families to increase parental sensitivity to their child’s needs, can lead to improvements in child’s emotional development.

Important attachment disorders are recognisable in young infants and merit referral to professionals trained in infant mental health (Waltham forest has a Parent Infant Mental Health Service (PIMHS) which accepts referrals related to disordered attachment in children under 3 years.  PIMHS works with the mother and child to foster healthier attachment (the earlier in a child’s life this is done, the better the outcome).   Any health care professional can refer a family to PIMHS.  See paediatric pearls from May 2012 for more information:- www.paediatricpearls.co.uk/…/the-parent-infant-mental-health-service-pimhs

In older children (>3 years) it can be difficult to know when and where to refer.  Emotional neglect and abuse is by definition a persistent behaviour pattern, so cannot be diagnosed on the basis of one short consultation.  Concerns about parent-child interaction witnessed in a short consultation in A+E or GP surgery may trigger a health-visitor review to gather information, prior to a possible referral to social services.  Information should be sought from all those involved in the child’s care including nursery/school teachers.   If concerns around behaviour witnessed in A+E or GP surgery are severe, an immediate referral to social services may be appropriate.

Professionals should be able to recognise speech and language delay and refer appropriately.  See paediatric pearls from April 2012 www.paediatricpearls.co.uk/…/stages-of-normal-speech-development/.  Many of the features found in emotionally neglected and abused children may also be observed in those with Autistic Spectrum Disorder (ASD) or Attention Deficit and Hyperactivity Disorder (ADHD).  If a child is showing language delay and behavioural disruption they should be referred for a formal child development assessment (either in speech and communication clinic (SACC)  or child development clinic (CDC) – refer to Wood Street Child Development team in WF)

–  Consider risk factors – Core-info’s systematic review did not encompass ‘risk factors’ for emotional neglect and abuse.   However  it states that ‘many of these children live in homes where certain risk factors are present.  Namely – domestic abuse, maternal substance misuse, parental unemployment or mental health issues, an absence of a helpful supportive social network, lack of intimate emotional support and poverty’.

June 2013 ready to go!

Lots of things to talk about this month.  Reminder of what Koplik spots look like, good e-learning on human trafficking, a link to the new primary care guidelines page, night terrors v. nightmares, some good allergy websites and Jess Spedding again on scaphoid injuries.  Do leave comments below.

April/May 2013

April wasn’t quite long enough this year for me to get the newsletter out in time – or something like that anyway.  With thanks to Stephen Flanagan of the London PHE for his input into the measles textbox and Paul Gringras for help with the sleep series again.  Jess has put together another superb article for her minor injuries series and I hope you find the links to the healthy weight clinics helpful for your patients locally.  Click here for the April/May 2013 newsletter.

Wrist injuries

Episode 4 and 5 of Jess Spedding’s minor injuries series are on the wrist.

Like in adults, the wrist is a very common location for injury. As an impulse to falling we stretch out our hands and arms to protect our head and torso, and hence the acronym FOOSH – fall on the outstretched hand, that you may come across in orthopaedic and Emergency Department documentation. The wrist is the most common upper limb fracture in adults, and is most common in children along with the supracondylar (see episode 2 of this series in December 2012 / January 2013). Whilst the supracondylar occurs in the 4-8y age group, wrist fractures which are typically distal radius fractures, can occur
at any age.  Read more….

Episode 5 is on another wrist injury and one that must not be missed – scaphoid fractures.  Read more….