I featured a headache guideline from Great Ormond Street Hospital in August 2011’s Paediatric Pearls. My colleague, Dr Simon Whitmarsh, has kindly allowed me to upload his migraine headache patient/parent information leaflet which I hope you and your patients will find useful. Please ensure that, as a courtesy, you acknowledge it as Simon’s work when you use it.
Category Archives: For General Practitioners
Metabolic website
This is the link to the site the junior doctors tend to use for guidelines on what to do in an emergency with just about any metabolic disease. http://www.bimdg.org.uk/
Common breastfeeding problems
My ED consultant colleagues requested that we run a series on “feeding issues” in Paediatric Pearls as it forms a part of the ED trainees curriculum and is a common subject to come up in conversation with parents in the ED. It seems appropriate to begin the series with an article on breastfeeding problems put together by our breastfeeding counsellor, Jo Naylor, and one of the current paediatric trainees, Dr Sarah Prentice. Their full article is downloadable here and I have reproduced some nuggets in this month’s Paediatric Pearls newsletter and below.
| Breastfeeding adequately? | Inadequate milk intake? |
| feeding every 2 – 5 hours for 20 – 40 minutes | infrequent feeds |
| 3-4 wet nappies and changing stool by day 3 | continued urates and/or meconium after day 3 |
| pain free breastfeeding | painful feeds, ineffective sucking |
| weight loss < 10% | weight loss > 10% |
| baby settled between feeds | fretful, hungry baby |
Reminder: handout of local breastfeeding drop-in groups available here.
I intend to cover the following topics over the next few months (some of which have actually already been touched on in previous months): vitamin supplementation, formula milk, gastro-oesophageal reflux, starting solids, allergy, fussy eating, food refusal, dentition and use of bottles, healthy eating, obesity, eating disorders. Please do leave requests for other topics below.
Vitamin D guidance at last!
Take a look at this not-definitive-but-nevertheless-sensible guideline on Vitamin D deficiency in both adults and children which Barts and the London published in January 2011: http://www.icms.qmul.ac.uk/chs/Docs/42772.pdf. Please note that it is NOT a national guideline and the authors acknowledge that more research is needed in this area and that variations in practice are common, even across London.
The Paediatric Pearls newsletters are checked every month by my consultant colleagues. We have been keen to put something together for GPs on vitamin D for a few months now but are struggling with the lack of evidence and consensus in this area. Some of the comments I have received back from my colleagues concerning this guideline include:
- A cut off of 80nmol/l is too high as the lower limit of normal. Most hospitals (including Whipps) use 50nmol/l because symptoms do not tend to be evident until that level.
- The paediatric clinical guideline currently in use at the Royal London Hospital is not quite the same as their Clinical Effectiveness Guideline in that it advocates lower doses of vitamin D therapy (than the BNFc) for a longer period of time. The advantage of this is that no monitoring of calcium levels is required.
- Liquid ergo or colecalciferol are difficult to get hold of nationally and some patients find it hard to find a community pharmacist who will supply it. There is a shortage of it at the moment and it is expensive. It would make practical sense therefore to just treat the deficient ones (<25nmol/l) rather than the asymptomatic insufficient patients (25 to 50nmol/l). This is in practice what the majority of us do, ensuring that the insufficient (and even sometimes the asymptomatic deficient group) ones get vitamin supplementation (400IU/day).
- “Symptomatic” includes general aches and pains and does not just refer to hypocalcaemic tetany or rickets.
- Healthy Start vitamins are available again now and are a better long term option than Abidec or Dalivit as they are free to young mothers and their children and to people on benefits, see http://www.healthystart.nhs.uk/. They should be available at all health centres at low cost (if the family does not qualify for healthy start vouchers) to all breastfeeding babies and then for the over ones when they have moved on to cows’ milk.
- We all agree that children with rickets and bone deformities secondary to vitamin D deficiency should be seen in secondary care as they require a greater degree of monitoring, especially their calcium levels, when first started on high doses of colecalciferol. There is also a risk of cardiomyopathy in this group.
- The Clinical Effectiveness Guideline from the Barts and the London group states that 90% of South Asian people in their region (mainly Tower Hamlets in east London) are vitamin D deficient. We don’t yet seem to have found an answer as to why there are not even more cases of rickets or hypocalcaemic tetany in that region then.
I suspect, as usual, the answer to the vitamin D conundrum is not quite as straight forward as this guideline makes out. Do leave comments below.
This is the 2011 Barts Health Vitamin D guidance, with thanks to pharmacist Nanna Christiansen for allowing me to upload it to this site. Please note that the doses here are not the same as the BNFc. There is a wide range of doses which you can prescribe for Vitamin D deficiency and insufficiency and no national agreement on what constitutes either deficiency or insufficiency.
GP’s July 2011
This month I have reproduced some immunisation myths and truths from Dr Ravindran’s excellent summary published in full somewhere on this blog (use the search function if you can’t find it below). NICE’s UTI guideline has just been reviewed; did you know there was a section called “Do not do recommendations”? Worth a look as we are all guilty of doing some of what we are not supposed to. Our new list of local breastfeeding drop-in groups is out, reduced unfortunately since the cutting back of Childrens centres’ funding. The GMC have clarified parental responsibility nicely and, as a step-parent myself, I was quite pleased to see the sensible point on the end too. Lastly, it is a bit depressing to be told that it takes 3 times longer in the UK for a child with a brain tumour to be diagnosed than in the US. Do leave comments below.
June’s Paediatric Pearls for GPs
June already! A move away from NICE guidelines this month to cover the 2011 BTS/SIGN asthma guidelines. Also a bit from the literature on management of gastro-oesophageal reflux disease and a few pointers about Forced Marriage which is an important safeguarding issue in our region. Do leave comments.
Gastro-oesophageal reflux
Any words of wisdom on this topic very welcome here! A slightly lax lower oesophageal sphincter is pretty normal in the under 1s but a lot of energy is expended in trying to do something about the symptoms. The paper cited in this month’s Paediatric Pearls from the Drugs and Therapeutics bulletin is really rather depressing in its comments on both pharmacological and non-pharmacological management of reflux. Even surgery doesn’t always work. It is particularly common among preterm babies and much has been written about that group of patients too – with similar levels of evidence generated as with term infants. You might want to read: Gastrooesophageal reflux disease in preterm infants: current management and diagnostic dilemmas. J L Birch, S J Newell, Arch Dis Child Fetal Neonatal Ed 2009 or Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the NASPGHAN and the ESPGHAN. J Pediatr Gastroenterol Nutr; 2009 on this topic.
Childhood Peak Expiratory Flow Rates (PEFR)
Children from about 5 years old may be able to use a Peak Flow Meter to record their PEFR. As one of the parameters by which we diagnose a severe or life-threatening asthma exacerbation is the percentage drop in PEFR, it would help to know what a child’s normal PEFR is! Click here for a guide of what you might expect for height. Children don’t always conform to these norms so it is important to know what the child’s own normal PEFR is; a 20% drop in their norm suggests poor control of asthma, a 40% drop suggests a significant exacerbation.
GP May 2011!
May 2011 GP version available here! Can you tell the difference between septic arthritis and transient synovitis? We have a new algorithm to help you. Also a reminder about measles, information on inguinal hernias, NICE on otitis media with effusion and a link to an important discussion on the website about what one can and can not do / take while breastfeeding. Do leave comments below.
Limping child guideline
Limping Child Guideline
(with thanks to Dr Rajashree Ravindran)
Children who have hip pathology may present with a variety of non-specific symptoms. They may present with pain, refusal to bear weight, limp, or decreased movement of the lower extremity. If pain is present it is important to determine where it is coming from, as pelvis and low back pathology may refer pain to the hip region and hip pathology commonly presents with referred thigh or knee pain.[1]
The history should include
- pain characteristics
- trauma (recent/remote)
- mechanical symptoms (catching, clicking, snapping, worse during or after activity)
- systemic symptoms (fever, irritability, weight loss, anorexia)
- inflammatory symptoms (morning stiffness)
- neurological symptoms (weakness, altered sensation)
- gait (limp or not weight bearing)
- effects of previous treatments (including antibiotics, analgesics, anti-inflammatory drugs, physiotherapy)
- The current level of function of the child and development
Examination:
- Temperature and vital signs.
- Musculoskeletal exam including gait assessment: Look, Feel, Move approach to joint examination can be used. It should be noted that it is exceptionally rare to appreciate swelling of the hip on physical exam as it is a deep joint.
- A CNS examination is also vital to exclude any neurological pathology.
- Look for abdominal masses(Neoplasias in children can present with a simple limp)
- Examine the genitalia(testicular torsion may present simply as a limp[2]) and perform an ENT examination
- Look for rashes, bruises in unusual areas and remember the possibility of a non accidental injury.
Common differential diagnosis of limp by age:[2]
| 0-3 years | 3-10years | 10-15 years |
| Septic arthritis or OsteomyelitisDevelopmental dysplasia of hip(usually does not present with pain)Fracture or soft tissue injury (toddler fractures or non accidental injury) | Transient synovitis (Irritable hip)Septic arthritis or osteomyelitisPerthes’ diseaseFracture or soft tissue injury | Slipped Upper Femoral epiphyses(SUFE)Septic arthritis or OsteomyelitisPerthes’ diseaseFracture or soft tissue injury |
| Also consider: | Neoplasms, Neurological/ neuromuscular causes, Rheumatological disease such as Juvenile idiopathic arthritis |
Investigations:
Limp due to trauma: If a traumatic fracture is suspected perform an x ray of the affected site and involve the orthopaedic team as appropriate. Always consider the possibility of non accidental injury in a younger child presenting with fracture.
Atraumatic limp: The algorithm as below can be used for guidance. You may wish to give the parent information leaflet out as part of your “safety netting” as it reminds the family to seek further help if the limp is still present 1 or 2 weeks later.
Algorithm for Child presenting with an atraumatic limp
REFERENCES
1. Frick, S.L., Evaluation of the child who has hip pain. Orthop Clin North Am, 2006. 37(2): p. 133-40, v.
2. Perry, D.C. and C. Bruce, Evaluating the child who presents with an acute limp. BMJ, 2010. 341: p. c4250.
3. Kocher, M.S., D. Zurakowski, and J.R. Kasser, Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am, 1999. 81(12): p. 1662-70.
4. Caird, M.S., et al., Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am, 2006. 88(6): p. 1251-7.
5. Howard, A. and M. Wilson, Septic arthritis in children. BMJ, 2010. 341: p. c4407.
6. Kang, S.N., et al., The management of septic arthritis in children: systematic review of the English language literature. J Bone Joint Surg Br, 2009. 91(9): p. 1127-33.
7. Kocher, M.S., et al., Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am, 2004. 86-A(8): p. 1629-35.
8. Padman, M. and B.W. Scott, (i) Irritable hip and septic arthritis of the hip. 2009. 23(3): p. 153-157.