This is the first time in ages I’ve managed to get the finalised version on line in time for the end of the month! NICE on autism this month, a bit on the use of corticosteroids in croup with help from the Cochrane Library, update on secondary prevention of meningococcal disease and a pointer to our local educational psychologist service which is hoping to make stronger links with the borough’s GPs (see also below). Our feeding series continues with an article on colic from one of the junior paediatricians with lots of useful links and updates.
Category Archives: For Emergency Departments
Meningococcus
Had another fatal Meningococcal B case a few weeks ago. Always upsetting. Text book management by the night team, excellent support and fast action by CATS retrieval team, the full services of one of the top PICUs in the country – but that horrible little diplococcus won the battle. Of course it didn’t really, our antibiotics would have killed it off pretty quickly, but the cascade it had set in motion was irreversible. 2 of the juniors involved with the case have separately presented it and looked into aspects of it further – a mark of how deaths like this have an effect on every member of the team. Dr Keir Shiels looked at prophylaxis and secondary prevention:
Neisseria meningitidis is found in the throats of around 15% of the population and is the cause of the much-feared meningococcal septicaemia. The incidence of meningococcaemia has fallen significantly since the advent of vaccines against some strains; and public awareness of the danger of non-blanching rashes is high.
Despite the relatively high prevalence of N. meningitidis as a commensal organism in the population and the relatively low incidence of meningococcaemia, meningococcal sepsis is still a notifiable disease. This stems from the pre-vaccine days when Men A was able to spread epidemically. The HPA still recommends prophylactic antibiotics for contacts of a patient with meningococcaemia.
A recent Cochrane review has been published regarding the effectiveness of different antibiotic regimens in obliterating N. meningitidis from the throats of inoculated hosts. The study has compared the effectiveness of Rifampicin, cefalosporin and Ciproflaxacin and comes to several conclusions which have altered UK HPA Guidelines.
The increasing risk of rifampicin-resistant N. meningitidis, plus the reduced likelihood of compliance with a twice daily prophylaxis for two days, means that for adults and older children, rifampicin is no longer the antibiotic of choice. The HPA now recommend ciproflaxacin to be given as a single one-off dose instead. It is believed that this is at least equally effective, but with far better compliance.
People who require prophylaxis remain as: first degree relatives, people sleeping in the same house, classmates and teacher at school.
Given the risks of using fluoroquinolones in children, the Cochrane review is circumspect in advising the administration of ciprofloxacin to children. However, the HPA leave it to a paediatrician’s discretion to consider the risks of a single one-off dose and still suggest ciprofloxacin as first line consideration. Rifampicin (2 doses daily for 2 days) is now considered second line.
October’s Paediatric Pearls
October’s edition is joint again this month on account of my right radius being fractured and its being too difficult to type and format text boxes with just my left hand… I am obviously not quite as good at ice-skating as I thought I was. All the topics this month should be of interest to both the ED and primary care teams anyway: a paper on paediatric early warning scores, the start of our neurodevelopment series, an update on services for bereaved children and their families and some useful links on the subject of head-lice.
Early warning scores in the ED
One of our current paediatric SpRs, Dr Anil Krishnaiah, has been looking at some papers on the various paediatric warning scores that are in existence. Here is his summary of a paper from Sunderland in 2008:
Emerg Med J 2008;25:745-749 doi:10.1136/emj.2007.054965
The PAWS score: validation of an early warning scoring system for the initial assessment of children in the emergency department
P Egdell, L Finlay, D K Pedley
Existing UK paediatric early warning scoring systems (PEWS) were developed mainly for hospitalised patients and may be less useful for initial assessment in the ED. Until recently these are mainly used to look at admission to the HDU and PICU and trying to produce a system which would recognize those children at risk of admission.
Assessment of paediatric patients is complicated by the range of normal parameters in different age groups. Inexperienced staff may find it difficult to interpret the significance of physiological readings over a wide range of ages.
This pilot study was conducted in Sunderland to validate the scoring system by performing a retrospective analysis of 50 consecutive children attending the ED who required admission directly to the paediatric intensive care unit (PICU). A control group of 50 consecutive children who were admitted from the ED to the general paediatric ward within the same time period was also identified from the ward admission book. They compared the Paediatric Advanced Warning Scores (PAWS) scores between the two groups in order to see whether the PAWS chart would be able to identify those children in need of admission to a critical care area. Primarily the aim of this study was to design and validate a scoring system to identify children attending the ED in need of urgent medical assessment and appropriate intervention. At a trigger score of 3, the PAWS score was able to identify those children requiring admission to the PICU with a sensitivity of 70% and a specificity of 90%.
This pilot evaluation demonstrates that the PAWS chart shows promise as a ‘‘rule-in’’ tool for PICU admission.
Since the introduction of the 4 hour target in the ED, departments have been under increasing strain to assess, treat and admit patients (if required) as quickly as possible. Few studies have been designed to identify if the PEWS score could be used as a triage tool, to detect those patients who will need admission and therefore speed up the process of admitting children to the ward.
Dr Anil Krishnaiah, Paediatric SpR
My problem with this paper, Anil, is that I want a tool that will “rule-out” predictably ie. one that will tell me reliably which ones I am safe to send home – without overloading the system with too low a threshold for admission. Anyone got one of those?
Child Bereavement
It is not unusual for us to see children in clinic with non-specific ailments who have been bereaved and are still trying to come to terms with their loss, sometimes years later. I am sure it is not uncommon in General Practice either. Whenever a child dies at my hospital I worry about how the siblings are going to feel. Children experience death differently according to their age and stage. There is some good advice on “Explaining death to children” and some other useful links at www.bbc.co.uk/health/emotional_health/bereavement/bereavement_childtalk.shtml. www.childbereavement.org.uk/For/ForBereavedFamilies/SuggestedReadingandResources lists some very helpful reading material for all ages of bereaved people.
This month I have been across to the Margaret Centre at Whipps where our Psychological Support Service (PSS) is, to try and get a clearer idea of what sort of support there is in Waltham Forest for bereaved children and their families.
The Zig Zag Children’s Service accepts referrals from health professionals of children aged 3-11 in Waltham Forest with pre- and post-bereavement difficulties. This would include children with a life-limiting illness themselves or those with a family member with a life-limiting illness as well as those who have been bereaved. There is also a service for bereaved young people (11-17yr olds) and adults. Contact the PSS on 0208 539 5592 or by post at The Margaret Centre, Whipps Cross Hospital, Whipps Cross Road, E11 1NR for further information.
They do not offer crisis counselling but there is no stipulated amount of time a family or individual has to wait before being offered an appointment. In the ED we refer the family of a child who has died under our care to this service straight away, a letter is then sent to them suggesting that they ask their GP for a referral if they wish to make use of the child bereavement service. You can download their referral forms here:
Referral form for adults and children
Extra, additional referral form for a child (3-11yrs)
Additional referral form for young person aged 12-17 years
You may be reading this from outside our region. Nationally I can recommend the Child Bereavement Trust which is a UK charity supporting families when a child dies or is bereaved. It also trains health professionals to deal with the effect that a bereavement has on a family and indeed on us, the health professionals. http://www.bereavement.org.uk/home/html_index.asp?p=222 seems to have information on other bereavement services in London. Do leave a comment below if you want to recommend any other services you are aware of.
Some of the Zig Zag staff have added comments below which I think all of us who come across bereaved families will find helpful.
The ED’s September 2011 pearls…
…are here! A bit on TB for your interest, pain scoring tools and links to growth charts. Also some pointers towards useful e-learning tools. Do leave comments below.
CPD sites pertinent to paediatrics
Dr Aimee Henderson (GPVTS) says of www.spottingthesickchild.com:
“Spottingthesickchild.com is a useful and easy to navigate online resource which I feel would mostly benefit those who have not had much experience in paediatrics before and who are of a more junior level. The site has a good range of the most common problems in children like abdominal pain and cough, and guides you through various points such as examination and communication. It has useful links to BTS and NICE guidelines. I like the fact that you can monitor your progress in percentage of the site covered. There is also a test you can take (and certificate to print) when you feel you have looked through everything. The only downside is you need to make sure you are somewhere quiet as it is mostly video/audio heavy and you will need to be able to hear it.”
Dr Khalika Hasrat (GPVTS) says of the e-lfh safeguarding modules:
“I found the content of both modules useful, although module 2 was a little repetitive of the issues already raised in module 1. It was a good revision tool and the pictures helped emphasise the warning signs of abuse. The only criticism was that the MCQs were not always worded very clearly, but otherwise a valuable tool.”
Please do leave any other comments on these 2 sites below and especially if you have had a look at the Healthy child module in e-LFH.
Paediatric pain
We currently use 2 recognised pain scores in our Emergency Department, depending on the age of the patient. The FLACC score (ref) was put together at the end of the 1990’s and has been validated for use in pre-verbal children aged 2 months to 7 years. The Wong Baker (“smiley faces”) score is for use in the over 3’s. We also ask older children to give us a mark out of 10 on their pain with 10 being the worst they have ever felt and 1 being not too bad. Our local pain protocol suggests what the health professional should do with the information gleaned and when the child should be reassessed. I have reproduced that table for you here. The UK Department of Health National Service Framework for young people and maternity services says that the prevention, assessment and control of pain in children should be subject to regular audit.
Google translate!
We are supposed to use Language Line now instead of interpreters but I do find talking into a phone rather unfriendly. How about typing on to a computer? Have a look at http://translate.google.com/. For languages like Arabic and Urdu with different scripts you can type phonetically and the appropriate script appears – sometimes… And if you’ve got speakers/head phones the service has some of the languages in spoken form too. I am going to give it a go in clinic next week – can’t imagine it will make me faster but should make the patients laugh anyway…
Combined GP and ED versions for August 2011
Well the BMJ produces 2 journals in one in August so why can’t I? All the topics featured this month are relevant for both GPs and ED doctors – for once – so you have a joint newsletter. I have covered headache this month, Vitamin D (by popular request) and we have started the “Feeding” series requested by my ED senior colleagues. It seems appropriate to have covered breastfeeding first. Do leave comments below.