Category Archives: For General Practitioners

BTS 2011 guideline on community acquired pneumonia in children

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In October 2011 the British Thoracic Society updated its guidelines on community acquired pneumonia in children.  Dr Michael Eyres looked at it in more detail for Paediatric Pearls.  He was also part of our local audit team contributing to the national audit.  The results showed that we, despite insisting on as few investigations as possible, are still doing too many chest x-rays, blood cultures and CRP measurements.  Think – will it change management?

Here are the basics:

When to consider pneumonia

Persistent fever > 38.5°C     +     chest recessions    + tachypnoea

Investigations

• CXR should not be considered routine and is not required in children who do not need admission.

• Acute phase reactants including CRP are not useful in distinguishing viral from bacterial infection and should not
be tested routinely. Blood cultures also do not need to be routinely taken.

• Daily U&Es are required in children receiving IV fluids.

 

Severity assessment

• Children with oxygen saturations <92% need hospital referral.

• Auscultation findings of absent breath sounds with dullness to percussion need hospital referral.

• Children should be reassessed if symptoms persist.

 

General management

• Give parents information on managing fever, preventing dehydration and identifying deterioration.

• Children with oxygen saturations <92% need oxygen.

• NG tubes should be avoided in severe respiratory compromise and in infants.

• Chest physio is not beneficial and should not be performed in pneumonia.

 

Antibiotics

• All children with a clear clinical diagnosis of pneumonia should receive antibiotics as bacterial and viral
infections cannot be reliably distinguished. However most children younger than 2 years presenting with mild symptoms of respiratory distress (this would
include the bronchiolitics) do not usually require antibiotics.

• Amoxicillin is the oral first-line for all children as it is effective, well tolerated and cheap.

• Macrolides if no response to first-line / suspected mycoplasma or chlamydia / very severe disease.

• Augmentin if pneumonia associated with influenza.

• Oral agents are effective even in severe pneumonia; IV is needed only if unable to tolerate oral or there are
signs of septicaemia, empyema or abscess.

 

Follow-up

• Children with severe pneumonia or complications should be followed up after discharge until they have recovered completely and
CXR is near normal. Follow-up CXR is not otherwise required, but may be considered in round pneumonia, collapse or if symptoms persist.

 

 

Feeding disorders

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Fussy eating is one of the most common things that parents present with to both primary and secondary care.  My colleague, Ann Duthie, has kindly allowed me to paraphrase a recent talk she gave to the department on this subject.  I hope you find the structure as sensible, helpful and reassuring as we did.

FEEDING DISORDERS IN CHILDREN encompass the behaviour of those who have difficulty consuming adequate nutrition by mouth (impaired feeding), those who eat too much and those who eat the wrong thing (pica).  We have not covered here eating disorders such as anorexia or bulimia.

Common presentations include:

  • Dysphagia
  • Food refusal
  • Self feeding inadequacy
  • Excessive meal duration
  • Choking, gagging, vomiting
  • Inappropriate mealtime behaviours
  • Food selectivity by type and texture

 

Normal feeding development is as follows:

  • Up to 6 mths – breast/bottle fed milk
  • 6-12 mths – solids introduced and increased in variety & volume.  Milk intake begins to decrease.
  • At 1 yr – teeth; family diet; ½ pt milk/day; change in attitude to food; active and wt gain slows
  • 15 mths – hold spoon, messy feeding, use feeding cup

The child moves from a state of total dependency on parents for food to one in which he/she can exert control & independence to determine what is
eaten, when and how.  Some parents struggle to adapt to this:

  • Messy
  • Feeding cues can be missed
  • Parental fear that insufficient food will be taken, child will lose weight
  • Parents own food preferences
  • Rejection of a food and assumption that child will never like it
  • Time pressures

The health professional must look for an organic cause of food refusal:

Organ system GI disorder Mechanism
Mouth Carious teeth
Structural with oral
dysphagia		 Pain
Reluctance to swallow
Pharynx Tonsils
Aspiration		 Pain, obstruction
Choke, gag
Oesophagus Reflux oesophagitis
Cows milk allergy		 Pain, burning
Stomach Motility disorder Reduced appetite,
discomfort
Colon Constipation Pain, discomfort, reduced
appetite

Children with neurodevelopmental problems or autism may have additional factors affecting their feeding behaviours.

There are 5 key elements to the assessment:

  • How is the problem manifested?
  • Is the child suffering from any disease?
  • Have child’s growth & development been affected?
  • What is the emotional climate like during mealtimes?
  • Are there any great stress factors in the family?

 

Red flags to look out for include:

  • Swallowing difficulty with cough, choke or gag
  • Vomiting/abdominal pain/arching/grimacing/eye watering
  • Recurrent chest infections
  • Stridor on feeding
  • Snoring with sleep apnoeas
  • Constipation

The history is, as always in medicine, of paramount importance and needs to be fairly detailed:

  • Birth History
  • Previous illness (inc. h/o vomiting, respiratory symptoms) & hospitalisations
  • Developmental progress
  • Chronology of feeding problem
    – Diet since birth
  • – Changes of milk formulae
    – Introduction of solids
  • Current diet (typical day)
  • What happens at meal times?
  • Family & Social history

Height and weight must be measured and plotted on an age appropriate growth chart and corrected for prematurity if less than 2 years of age.  Refer children with red flags or significant faltering growth to secondary services.

  • Management of the well child in primary care:
  • Reduce milk intake if necessary (maximum of 500mls total in 24 hours)
  • Encourage family foods
  • Meal time management (see NHS Lothian’s dietetic advice)
  • Aim: Improve infants comfort at meal times, relieve parental fears and improve parent-infant relationship

 

The multidisciplinary approach:

  • Health Visitor – can assess child within home situation
  • Dietician
  • – Nutritional assessment and feeding advice
  • – Calorie enrichment
  • – Calorie supplementation
  • – Enteral feeds (very occasionally)
  • Speech & Language therapist
  • – Direct assessment of feeding & advice in home situation
  • – Parent-child interaction
  • – Is swallow safe?
  • – Toddler feeding groups (eg. Waltham Forest’s “Ooey Gooey” group at Wood Street)

Summary points:

  • Feeding disorders in children are common
  • Occur in healthy children but assessment should be made for organic causes
  • – GI tract problems
  • – Developmental delay
  • – Autistic spectrum disorder
  • Watch out for obligate milk drinkers
  • Meal time management is crucial
  • Involve Health Visitor

 

Further resources:

Weaning your premature baby.  Free download from Leicestershire Dietetic Service 2011

Help! My child won’t eat and My child still won’t eat.  British Dietetic Association.  Available to buy in packs from http://www.ndr-uk.org/

My Child Won’t Eat by C Gonzalez                    – these are both books and the links are to www.amazon.co.uk

New Toddler Taming by C Green

June 2012 PDF

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June’s PDF digest is ready for consumption.  Both APLS and NICE have lost paraldehyde from their status epilepticus algorithms, a link to Working Together and an article on sticky eyes v. conjunctivitis.  Blood pressure centile charts and a plug for the London Deanery’s communication skills courses.  Do leave comments below.

May 2012 ready a week early!

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Click here for May’s PDF digest of Paediatric Pearls.  Perinatal infant-maternal mental health this month from both SIGN and our local services, diarrhoea and vomiting fluid calculation, pertussis, bruise assessment in NAI and food allergy.  Also a couple of links to useful parenting support sites.  Do leave comments!

The Perinatal Parent Infant Mental Health Service (PPIMHS)

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The PPIMHS teams are made up of perinatal psychiatrists, community mental health practitioners and psychotherapists/psychologists and they accept referrals from Health Visitors, GPs, midwives, Children’s Centres workers or other health professionals and self-referrals.  Click here for their referral form.  They may signpost elsewhere after the initial consultation if appropriate or they will offer the parent/carer and infant/child 9-12 sessions to work on the parent-infant relationship and/or psychiatric support as required.

Groups particularly at risk of having problems with bonding include families with ex-premature babies who have spent a significant amount of time on the Special Care Baby Unit, those where the baby has feeding issues or is difficult to soothe, those where breastfeeding failed to establish and those where there was a traumatic birth or difficult conception and/or pregnancy.  Many of the parents on their case load have a personal history of disturbed attachments and are keen not to let history repeat itself.  A recent audit showed that 41% of their mothers had some sort of mental health diagnosis which means that 59% did not.  Click here for an information leaflet about their service that you might like to give to your patients.

Mums with postnatal depression or post-partum psychosis should be referred directly to PPIMHS.  Parents struggling with a crying baby or fussy toddler but with no bonding issues should be referred to their health visitor.  The PPIMHS team is a tier 3 (specialised) service concentrating primarily on the parent-infant relationship and perinatal mental health.

Symptoms in the baby that might suggest a bonding problem:

extreme clingy behaviours, fussy, difficult to soothe, abnormal self-soothing behaviours (eg. head-banging, hair-pulling, scratching), excessive sleep problems, extreme feeding problems, lack of verbal and non-verbal communication, stiff or floppy posture, extreme fearfulness or watchfulness, lack of interest in the world, no comfort sought from parents, avoids eye contact with parents, smiles very little.

Symptoms in the parent:

high anxiety and panic about the baby, excessive A and E or GP presentations, feeling frightened of harming the baby, lack of separation between parent and baby, baby never put down, excessive sterilising of bottles and toys, detached feelings about the baby, no pride in their development, anger about baby as if baby intends to upset the parent, feelings of failure as a parent, inability to cope.

There is some evidence around this issue and around maternal stress during pregnancy and the effect of high maternal cortisol levels on the foetus’ developing brain.  I have asked the Waltham Forest PPIMHS psychologists to write a bit about that and correct anything I have written about their service!

Oral rehydration guideline

For Emergency Departments, For General Practitioners,

Most children who are dehydrated presenting to UK emergency departments can be rehydrated orally. 

  • Give 50ml/kg ORS solution over 4hrs, plus ORS solution for maintenance, often and in small amounts (even by syringe or spoon)
  • Continue breast feeding
  • Consider supplementing with usual fluids (but not fruit juices or carbonated drinks) if a child without red flag symptoms or signs (see http://www.nice.org.uk/CG84) refuses to take sufficient ORS solution.  Don’t give solids.
  • Consider giving ORS solution via ng tube if child is unable to take it or continues to vomit (esp. with red flag symptoms/signs)
  • Monitor carefully

This is a worked example for a 3 year old child weighing 14kgs who has been assessed as about 5% dehydrated.

Maintenance = 100mls/kg for first 10kgs and 50mls/kg for next 10 kgs = 1000mls + 200mls = 1200mls over 24 hours

Replacement = 5 x 14 x 10 = 700mls over the first 4 hours (extra to maintenance needs)

Therefore the child needs 225mls per hour for the first 4 hours (1200/24 + 700/4), followed by 50mls (1200/24) per hour.

The 225 mls is best given as 18 mls every 5 minutes or 56mls every 15 minutes if vomiting seems to have stopped or if using nasogastric tube.

They should have 5mls/kg = 70mls extra diarolyte (ORS) with each diarrhoeal stool or vomit.

Give parents written information to go home with so they understand that diarrhoea may continue for a few days but this does not matter as long as they are able to get enough fluid in the top end.  The NICE guideline parent information is at http://guidance.nice.org.uk/CG84/PublicInfo/pdf/English.

Whooping cough outbreak 2012

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More background to pertussis with thanks to Dr Rupa Vora

  • whooping cough is caused by Bordetella pertussis, a gram negative pleomorphic bacillus. It is spread by aerosol transmission and the bacteria cause damage by attaching to the respiratory cilia
  • it occurs in clusters every 2-5 years during the summer months. We currently have an outbreak with the HPA provisionally reporting 665 cases in the first quarter of 2012 (cf. 1040 cases in 2011, 421 in 2010)
  • cases have dropped dramatically since pertussis vaccinations have been introduced. Acellular pertussis vaccination is given at 2 and 3 months, followed by a pre-school booster.  However, protection wanes quickly and has virtually disappeared by 12 years old
  • incubation period is 3-12 days and children are most infectious in the first 2-3 weeks. They are most likely to present in the second phase of illness at 3-4 weeks
  • can present with coryza (1st stage which lasts a couple of weeks), paroxysms of cough, difficulty feeding and pneumonia. Younger infants (<6months) may not present with the characteristic ‘whoop’. Older children and adults often present with a persistent cough
  • complications include chronic cough (“100 day cough”), hypoglycaemia, seizures, encephalopathy and intracranial haemorrhage
  • any infant is vulnerable and up to 50% may need hospitalisation.  Especially vulnerable are ex-prems and those with underlying cardiology, respiratory or neurological problems.  
  • In England and Wales, whooping cough is statutorily notifiable.  The diagnosis is usually made on clinical grounds without the requirement for laboratory confirmation
  • The UK Health Protection Agency advises a 7 day course of erythromycin or clarithromycin (or azithromycin for 3-5 days if under 4 weeks) to reduce spread.  A pernasal swab to confirm or refute B. pertussis as the causative organism can be carried out.  If the cough has been present for more than two weeks and the child is in the community, serum serology can be sent to Colindale.  See table below:

 

Appropriate laboratory tests for a sporadic case of pertussis reported to HPA on clinical suspicion (with thanks to Dr Maria O’Callaghan): 

Age Clinical symptoms
≤ 2 weeks cough > 2 weeks cough
≤ 1 yr

Hospitalised

 NPA/PNS for PCR (RSIL)

PNS for culture (local laboratory)

 NPA/PNS for PCR (RSIL)

PNS for culture (local laboratory)

Serum for serology (RSIL)
≤ 1 yr

community

 PNS for culture (local laboratory) Serum for serology (RSIL)
> 1 yr to 6 yr
6 to 15 yr Serum for serology (RSIL)
> 15 yr

 NPA – nasopharyngeal aspirate; PNS – pernasal swab;

RSIL – Respiratory and Systemic Infections Laboratory, Colindale

Useful websites:

HPA: www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/WhoopingCough/

NHS Choices: www.nhs.uk/Conditions/Whooping-cough/Pages/Introduction.aspx

Joint March and April edition of PP published!

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With apologies for missing March – time management issues….

Functional abdominal pain this month with a link to a handy patient information leaflet, pubertal and growth issues, neonatal spots and some not-for-the-faint-hearted youtube videos on intraosseous line insertion for the ED practitioners amongst you.  Do leave comments!

Stages of normal speech development

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With thanks to Fionnuala O’Driscoll, Speech and Language Therapist at Wood Street Specialist Children’s Services for the table below:

Age (years) 0-1 1-2 2-3 3-4 4-5 5-6 6-7
Attention and Listening Distractible Single channelled Single channelled but flexible Shared attention Shared and integrated attention Able to focus for longer periods of time Can spend hours on chosen activity
Play and Social Interaction Exploratory, relational or constructive.Eye contact and turn taking from birth. Symbolic or pretend play.Turn taking in play from 18 months. Pretend and imaginary play.Plays with others in small groups. Role play.Cooperative play develops.May like simple jokes. Chooses own friends.Learn to turn take in conversation.Can discuss emotions. Able to play games by rules.Plans sequences of pretend events in play. Group play with less pretend play.Can play alone happily.
Understanding of Language Understands a few simple words (bye bye) Understands familiar words and phrases in context Follows simple instructions and later short stories Follows short stories and longer instructions Understands stories, longer instructions and conversations Understands 13,000 words.Beginning to reason and understand abstract concepts Understanding of vocabulary doubles in size.Understands abstract concepts. Can reason, predict, and infer.
Use of Language Cooing, babble, simple words First words and later 2 word phrases 2-3 word phrases – longer phrases Longer 4-5 word sentences usually well formed (4 yr) Well formed sentences combining up to 8 words.Tells simple sequence of events. Longer sentences with mostly appropriate grammar.Tells simple stories. Uses language for a range of purposes e.g. persuade, question, negotiate, discuss.Tells more complex stories.
Speech p, b, m, w and vowels n, t, dSpoken words not always recognizable. k, g, ng, h f, s, l, y sh, z, v, ch, th, r, clusters    May have difficulty with multisyllabic words (hospital) Generalising speech sounds to connected speech Generally mature by 7 years old