Category Archives: For General Practitioners

Immunisation schedule UK 2011

For General Practitioners,

One of our registrars has put together a concise guide to immunisation in the UK which many fully trained GPs will be very au fait with.  Some in training may appreciate a quick run through!  The schedule changes from time to time but the links below should lead you to the current guidance whenever you access this post.   The current immunisation schedule appears below; click here for Rajashree’s complete concise guide which you can easily print off for your wall….

Routine UK Immunisation schedule (current at May 2011):

Hepatitis B vaccine +/- HBIg Given only to babies born to mothers who are chronically infected with HBV or to mothers who have had acute hepatitis B during pregnancy Vaccine: 1 injection IM

HBIg: 1 injection IM
BCG (0-12 months) Universal vaccination operates only in areas of the country where the TB incidence is 40/100,000 or greater. 1 injection in left upper arm- Intradermal
2 months *DTaP/IPV/Hib(5 in 1 vaccine- Pediacel), Pneumococcal conjugate vaccine(PCV) 1 injection, IM

1 injection IM
3 months Second dose DTaP/IPV/Hib,

Meningitis C vaccine

 1 injection, IM

1 injection IM
4 months Third dose DTaP/IPV/Hib,

 PCV (2nd dose),

MenC (2nd dose)

 1 injection, IM

1 injection IM

1 injection IM
12-13 months PCV (3rd dose),

MenC(3rd dose), Hib (4th dose),

MMR

 1 injection, IM

1 injection, IM

1 injection, IM
3 years 4 months or soon after 2nd dose MMR,

DtaP/IPV or dTaP/IPV booster(4 in 1 vaccine)

 1 injection IM

1 injection IM
12-13years HPV vaccine(Cervical cancer vaccine) for girls only, 3 injections within 6 months, IM
13-18 years *dT/IPV booster 1 injection, IM

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_126898.pdf

Inguinal hernias

For Emergency Departments, For General Practitioners, ,

with thanks to Dr Jemma Say for putting the following information together:

Inguinal Hernias

An indirect inguinal hernia is a protrusion of abdominal contents into the inguinoscrotal or labial canal via an open deep inguinal ring due to the failure of obliteration of the processus vaginalis.

 In fetal life the descent of the testis into the inguinal canal and scrotum is preceded by a small pouch of peritoneum; the processus vaginalis. After birth this peritoneal communication is obliterated, failure to do so results in either a hydrocele or hernia, depending on the degree of fusion.  

 Indirect hernias are more commonly seen in a paediatric population, as opposed to direct inguinal hernias in adult patients, where the musculature is weak and abdominal contents protrude through the wall of the inguinal canal.

Epidemiology

The incidence is 1-2%, occurring 9 times more commonly in males. The majority are found on the right (60%), 15% are bilateral, more commonly with a family history. Presentation is most frequently in infancy.

Increased Incidence

  • Preterm infants (10-30%)
  • Abdominal wall defects (e.g. prune belly syndrome)
  • Connective tissue disorders (e.g. Ehlers Danlos syndrome)
  • Chronic respiratory disease
  • Undescended testes
  • Increased intraabdominal pressure

 

The diagnosis is clinical, although USS can play a role in older children with indeterminate pain. Surgery is indicated for all paediatric patients with inguinal hernia.

The risks of not performing surgery include bowel incarceration or necrosis, and testicular or ovarian compromise and necrosis. This risk is greatest in early infancy; premature infants have an incarceration risk of up to 30%, and therefore often warrant treatment prior to discharge.  Some surgeons keep under close review for a few weeks post discharge so that these still very small babies put on a bit of weight before the operation.

If a patient presents with incarceration, an attempt at reduction should be made and urgent surgery is required, as the risk of reincarceration is as high as 15% if surgery is delayed more than 5 days.

Referral Pathway

All inguinal hernias should be referred, paediatric patients >1 year can be referred to Mr Brearley at Whipps Cross while those <1 should be referred to the Royal London Hospital. Surgery involves either open or laparoscopic techniques (tranperitoneal or preperitoneal approaches). The majority are performed as an outpatient with normal activity resuming within 48 hours.

References

IPEG guidelines for Inguinal Hernia and Hydrocele, Nov 2009. http://www.ipeg.org/education/guidelines/hernia.html

Ashcraft’s Paediatric Surgery, Holcomb G W, Murphy. J P

ABC of General Paediatric Surgery: Inguinal hernia, hydrocele and the undescended testis: BMJ 1996 312:564

Patient Information Leaflets

http://www.patient.co.uk/doctor/Inguinal-Hernias.htm

http://www.bch.nhs.uk/acrobat/PDF%20for%20Web/Inguinal%20Hernia%20Repair.pdf

Video information

Distinguishing indirect and direct inguinal hernia

http://www.youtube.com/watch?v=wAzXSqGybvE

Indirect inguinal hernia repair

http://www.medicalvideos.us/play.php?vid=1108

 

Contraindications to breastfeeding

For General Practitioners, , ,

I was encouraging a mother to breastfeed the other day when she asked if I was sure that was OK with her condition.  Her baby is asymptomatic on a 10 day iv course of penicillin for presumed inadequately treated maternal syphilis.  I wobbled momentarily and the junior doctor and I went away to look it up.  It is OK apparently as long as the mother does not have syphilitic lesions around her nipples.  Take a look at http://pedclerk.bsd.uchicago.edu/page/breastfeeding which is an American teaching site and has a nice summary of when you can and can’t breastfeed.  http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT is an American database of the evidence on the safety of various medicines when breastfeeding.

April 2011 GP Paediatric Pearls hot off the press!

For General Practitioners, , ,

The April 2011 version is now published.   I have covered the recently reviewed NICE guideline on depression in children and young people.  We continue with the 6 week check series with some information on umbilical hernias and granulomas.  And, now that the hay fever season is upon us, we have had a look at the literature on non-sedating antihistamines.

Anti-histamines for the hayfever season!

For Emergency Departments, For General Practitioners

April 2011’s editions of Paediatric Pearls are being published late because there has been a bit of pre-publication discussion about our paragraph on anti-histamines which needed checking up on!  The newsletters go out to all my colleagues for checking prior to publication and occasionally Amutha and I have to go back to the drawing board for one or two of the text boxes.  This month 2 of the text boxes have had to be re-done, the ones on cetirizine and umbilical hernias as the surgeon with an interest in paediatrics at Whipps had some suggested modifications for this latter one.  All goes to show that this site is not just a collection of my own random thoughts….  

The full abstract of the paper on cetirizine is reproduced below:

Drugs. 2004;64(5):523-61.

Cetirizine: a review of its use in allergic disorders.

Curran MP, Scott LJ, Perry CM.

 

Source

Adis International Limited, Auckland, New Zealand. demail@adis.co.nz

 

Abstract

Cetirizine is a selective, second-generation histamine H1 receptor antagonist, with a rapid onset, a long duration of activity and low potential for interaction with drugs metabolised by the hepatic cytochrome P450 system. Cetirizine was generally more effective than other H1 receptor antagonists at inhibiting histamine-induced wheal and flare responses. Cetirizine is an effective and well tolerated agent for the treatment of symptoms of seasonal allergic rhinitis (SAR), perennial allergic rhinitis (PAR) and chronic idiopathic urticaria (CIU) in adult, adolescent and paediatric patients. In adults with these allergic disorders, cetirizine was as effective as conventional dosages of ebastine (SAR, PAR, CIU), fexofenadine (SAR), loratadine (SAR, CIU) or mizolastine (SAR). This agent was significantly more effective, and with a more rapid onset of action, than loratadine in 2-day studies in environmental exposure units (SAR). In paediatric patients, cetirizine was as at least as effective as chlorphenamine (chlorpheniramine) [SAR], loratadine (SAR, PAR) and oxatomide (CIU) in the short term, and more effective than oxatomide and ketotifen (PAR) in the long term. Cetirizine was effective in reducing symptoms of allergic asthma in adults and reduced the relative risk of developing asthma in infants with atopic dermatitis sensitised to grass pollen or house dust mite allergens. It had a corticosteroid-sparing effect in infants with severe atopic dermatitis and was effective in ameliorating reactions to mosquito bites in adults. Cetirizine was well tolerated in adults, adolescents and paediatric patients with allergic disorders. In adult, adolescent and paediatric patients aged 2-11 years, the incidence of somnolence with cetirizine was dose related and was generally similar to that with other second-generation H1 receptor antagonists. Although, its sedative effect was greater than that of fexofenadine in some clinical trials and that of loratadine or fexofenadine in a postmarketing surveillance study. In infants aged 6-24 months, the tolerability profile of cetirizine was similar to that of placebo. Cetirizine did not have any adverse effects on cognitive function in adults, or cognitive function, behaviour or achievement of psychomotor milestones in paediatric patients. Cetirizine was not associated with cardiotoxicity. CONCLUSION: Cetirizine is well established in the treatment of symptoms of SAR, PAR or CIU. It demonstrated a corticosteroid-sparing effect and reduced the relative risk of developing asthma in sensitised infants with atopic dermatitis. Cetirizine was effective in the treatment of allergic cough and mosquito bites; however, its precise role in these indications has yet to be clearly established. On the basis of its favourable efficacy and tolerability profile and rapid onset of action, cetirizine provides an important option for the treatment of a wide range of allergic disorders.

Paediatric surgery at Whipps Cross

For General Practitioners, ,

I thought it might be useful to outline the sort of paediatric surgery Whipps offers.  This post is being put together with the help of my surgical colleagues who are keen to continue receiving appropriate paediatric referrals from GPs.  I will be updating it as and when I get the information from the different specialties.

A word from the anaesthetists: As a general rule all of our consultants on the on-call rota are currently able to anaesthetise any child, 3 years or above presenting as an emergency as long as they are ASA 1 or 2 and needing non body cavity surgery (appendicectomy excepted) with an expected duration of less than 2 hours.  (“ASA 1 and 2” are children who are previously fit and well and those with a mild underlying systemic illness such as mild asthma.)  We have three consultants who have had advanced training in paediatric anaesthesia (Drs. Williams, Singh and Radhakrishnan) who undertake regular elective paediatric lists who are happy to anaesthetise younger children.

GENERAL SURGERY (Mr Stephen Brearley) AND UROLOGY (elective surgery from 1 year of age, emergency surgery from 3 years of age):    

Hernias (all types)

Foreskins

Undescended testicles

Lumps of all types

Tongue ties

Thyroglossal cyst

Emergency work in children over the age of 3 eg. suspected appendicitis

Please refer such things as in-grown toenails and verrucae to podiatrists rather than surgeons.

ENT:

(elective work from 6 months of age, emergency work from 3 years of age):

Lead Clinician, Mr. Sam Jayaraj

Dedicated Paediatric ENT clinics at WX:

Mr Jayaraj 3 per month at WX and 2 per month at Forest Medical Centre, Loughton (WX outreach clinic)

Mr Patel 2 per month at WX

Mr Kenyon 1 per month at WX.

N.B. We are in the process of setting up a Paediatric ENT Specialist Community Clinic (SCC) in conjunction with Dr Watkin and our audiological colleagues at Wood Street Clinic – watch this space!

 

ENT Surgical procedures offered at WX 

Tonsillectomy

Adenoidectomy

Oral cavity lesions

Turbinate reduction

Obstructive sleep apnoea assessment

Nasal bone manipulation following trauma

Nasal cautery

Peri-orbital abcess drainage

 Middle ear ventilation tubes (Grommets)

Pre-auricular sinus excision

Pinnaplasty (Mr Jayaraj and Mr Kenyon)

Myringoplasty/tympanoplasty

Mastoidectomy (Mr Nitesh Patel)

 Cervical lymph node excision

Thyroglossal cyst excision

Branchial cyst excision

Tongue tie division

Thyroid surgery (Mr Papesch)

Tertiary paediatric ENT services not available at WX (these are rare conditions which require highly specialised nursing, anaesthetic and allied therapies support):

Cleft lip & palate surgery and craniofacial disorders

Paediatric head & neck malignancy

Cochlear implant surgery

Paediatric airway reconstruction surgery (i.e laryngotracheal reconstructive surgery etc)

Currently we refer these patients to our tertiary paediatric ENT colleagues at Great Ormond Street Hospital

OPHTHALMOLOGY:

Strabismus, eyelid, lacrimal, cataract (with infants being referred to Great Ormond Street where our ophthalmologist with a paediatric interest also works). 

ORTHOPAEDICS:

MAXILLOFACIAL SURGERY:

Umbilical issues

For Emergency Departments, For General Practitioners, ,

This month we have covered umbilical granulomas and hernias as part of the feature on 6-8 week baby checks. Our surgeon with an interest in paediatrics is happy to see children from around 3 years of age if their umbilical hernia has not spontaneously resolved by then.  This topic is covered succintly, including a list of differential diagnoses, in an on-line Australian handbook of neonatal care. Inguinal hernias are a different matter altogether (they carry a far greater risk of becoming incarcerated) and one of the junior paediatricians is working on a “Pearl” about them for the May or June PP edition. 

There is not much evidence published on what to do with umbilical granulomas.   They occur when the inflammatory process at the umbilicus leads to excess granulation tissue preventing the raw area from developing new epithelial tissue.  One theory is that infection has a part to play.  I do nothing when asked about them in the Emergency Department but then I don’t follow up those patients so some GPs may feel that masterly inactivity is not enough!  They tend to take a few weeks to months to clear up.  There are references in the literature to fusidic acid, cool boiled water, salt, silver nitrate and reassurance.  Salt seems to be “in” at the moment.  All comments welcome!

March Paediatric Pearls for GPs

For General Practitioners, , ,

The March 2011 version is now published.  I have covered the new NICE guideline on food allergy which I think you will all find helpful and provided a link to the Allergy Academy which runs some really excellent course on all aspects of allergy in children.  We continue with the 6 week check series with some information and pictures on fontanelles, craniosynostosis and positional plagiocephaly.  There’s a bit on how to get foreign bodies out of noses.  Do leave comments below.

FONTANELLES AND HEAD CIRCUMFERENCE AT SIX WEEK CHECK

For General Practitioners, ,

with thanks to Dr Harriet Clompus.

Assessment of fontanelles is an important part of the six week check.  Large fontanelles may indicate a problem in bone ossification or hydrocephaly, while a fused anterior fontanelle can indicate craniosynostosis.  These need to be referred to paediatric outpatients.  Always remember that anterior fontanelle size is very variable (1-4.7 cm in any direction) and always needs to be assessed in context of baby’s head circumference.

A sunken fontanelle indicates dehydration, while a bulging fontanelle indicates raised intracranial pressure (but can be non-pathological – vomiting, crying, coughing – so assess when baby settled!).  These can be discussed with paediatric registrar on-call.

1)      The anterior fontanelle is diamond shaped, 1-4.7 cm in any direction at birth (black infants larger than white) and can widen in first 2 months of life.  Median age of closure is 14 months (4 – 24 months)

 2)      The posterior fontanelle is triangular and is less than 1 cm.  It closes by 6 – 12 weeks.

 

 3)      The size of the fontanelles should always be assessed in conjunction with the head circumference. 

  • Macrocephaly  – familial, hydrocephaly or skeletal disorders such as achondroplasia.
  • Microcephaly  – familial, congenital infections, fetal alcohol syndrome, trisomies

 4)      The quality of the fontanelle  should always be assessed. 

  • Soft fontanelle  – normal
  • Bulging fontanelle – raised intracranial pressure (hydrocephalus, meningitis/encephalitis) .  NB can be non-pathological in crying, coughing or vomiting infant.
  • Sunken fontanelle – dehydration

 

 1)      WIDENED FONTANELLES:  think of…

Achondroplasia

Downs

Hydrocephalus

IUGR

Prematurity

Congenital  Rubella

Neonatal Hypothyroidism (3rd fontanelle)

Osteogenesis Imperfecta

Malnutrition

Rickets/Osteomalacia

 Rickets – Think of rickets in darker skinned, breast fed babies, especially if mothers are veiled.  Infants will often have sweating on the head.  If widened sutures are found check neonatal blood spot for hypothyroidism and refer to outpatients.

 Hydrocephalus – can have widened, bulging fontanelles in conjunction with a large head.

2)      PREMATURE FUSION OF FONTANELLES AND CRANIOSYNOSTOSIS

Closure of anterior fontanelle by six weeks always pathological  (NB  by 3 months 1% of normal infants will have a closed anterior fontanelle). 

Must always assess in conjunction with head circumference – early fusion associated with microcephaly (and less commonly, macrocephaly).

Craniosyntosis is premature closure of cranial suture(s) with skull growth restriction perpendicular to fused suture and compensatory skull overgrowth in unrestricted areas.   Presents with ridging (always pathological beyond one week of life) and abnormal skull shape (usually later than six weeks).

There is a nice background overview (with useful diagrams) to craniosynostosis at http://www.cincinnatichildrens.org/health/info/neurology/diagnose/craniosynostosis.htm.

Primary craniosynostosis is due to abnormal ossification of one or more sutures.  Simple – premature fusion of one suture, complex – premature fusion of multiple sutures.  Causes include rickets, hyperparathyroidism, hyperthyroidism , idiopathic and genetic causes such as Aperts.

Secondary craniosynostosis is caused by premature closure of ALL sutures due to lack of primary brain growth. If you find a child with premature closure of fontanelles or over-riding sutures at six week check you should refer to paediatric outpatients. NB Plagiocephaly (flat occiput) is a non-pathological deformation due to ‘back to sleep’ position – no action required.  It presents with ear on flattened side presenting anteriorly.  Parallelogram shaped head (as opposed to lambdoid suture craniosynostosis trapezoid shaped)

The following articles give lots of information on fontanelles and/or sutures.  The Fuloria article is very thorough and although it focuses on neonatal examination, most of it is still relevant for the six week check.

1) The Abnormal Fontanel, J KIESLER et al Am Fam Physician. 2003 Jun 15;67(12):2547-2552.    http://www.aafp.org/afp/2003/0615/.html  (figure 2 taken from abnormal fontanel)

2)The Newborn Examination: Part I. Emergencies and Common Abnormalities Involving the Skin, Head, Neck, Chest, and Respiratory and Cardiovascular Systems, Fuloria et al, Am Fam Physician. 2002 Jan 1;65(1):61-69.   http://www.aafp.org/afp/2002/0101/p61.html

3) http://www.nice.org/CG037quickrefguide

4) http://www.patient.co.uk/doctor/Examination-of-the-Neonate.htm

5) Craniosynostosis, P Raj et al, emedicine jul 2010 Craniosynostosis : eMedicine Neurology