Last bit of headaches this month with guidance on management of various primary headaches, including medication overuse headache. Also more on domperidone, psoriasis, respiratory and heart rates to worry about and a link to a new colic summary I’ve put under the Primary Care Guidelines tab. Do leave comments below.
Tag Archives: newborns
Sick and tired – the truth about infantile reflux
Sick and tired – the truth about infantile reflux
By Dr Tom Waterfield
We have all had that difficult conversation regarding “reflux” when a tired parent has come to us with their “sicky child” and an unshakeable belief that their baby has gastro-oesophageal reflux disease. There is often enormous pressure to provide a solution but how do we decide which children need treatment and what treatments should we use? In view of the recent concerns regarding the use of Domperidone I have chosen to review the current evidence base for the management of this common problem.
The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition(NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) produced a useful guideline document in 20091. This concise 50 page document discusses the evidence base for all aspects of gastro-oesophageal reflux and some of the key points are outlined below.
Diagnosis
1) Physiological Gastro-oesophageal reflux (GER) is common; around 50% of healthy infants will display symptoms of GER. These “happy spitters” will be gaining weight and healthy1.
2) Faltering growth is unlikely to be due to GERD and alternate diagnosis such as cow’s milk protein allergy should be considered1.
Investigation
1) The Gold-Standard investigation to make a positive diagnosis of GERD is an impedance study. This has largely replaced the pH study. In this study the changes in the electrical impedance (ie, resistance) between multiple electrodes located along an oesophageal catheter are used to measure reflux. Unlike a pH study the impedance study will also be able to detect non-acidic reflux1.
2) In the majority of cases there will be no role for any other diagnostic test for GERD1
Management
1) Reassurance
Try to avoid treating simple GER. Reassurance is often all that is required. Before starting any treatment have a frank discussion regarding the risks and benefits1.
2) Positioning “Tummy Time”
There is evidence that lying prone improves GERD when compared with lying supine or semi-erect. It is however, not recommended that children sleep prone due to the associated risk of sudden infantile death (SIDS). A sensible compromise might involve allowing the child to lie prone when awake and supervised by the parent. Semi-supine positions (such as sitting in a car seat) are not recommended and may exacerbate reflux symptoms1.
3) Thickened Feeds
Commercially available thickened feeds (anti-reflux feeds) are safe and relatively effective at reducing visible regurgitation1.
4) Buffering agents and Alginates
There is very little evidence to support the use of alginates (e.g. Gaviscon Infant) in the treatment of GERD although their use is likely to be safe1.
5) H2RAs and PPIs (Unlicensed treatments)
Antacid treatment with Histamine 2 Receptor Antagonsists (HR2As) is effective at healing proven oesophagitis in adults but there is very little data to support their use in infancy. H2RAs such as Ranitidine are relatively safe but their effectiveness is unproven and there are high rates of tachyphylaxis thereby limiting their usefulness in the long term1.
Proton Pump Inhibitors (PPIs) such as Lansoprazole and Omeprazole do not demonstrate tachyphylaxis and can be used for longer term acid suppression. Despite this however, randomised placebo controlled studies have failed to demonstrate a benefit of (PPIs) over placebo when treating GERD in infants1.
Some studies have suggested that long term acid suppression with PPIs and H2RAs can lead to increased rates of pneumonia and gastroenteritis1.
6) Prokinetics (unlicensed)
ESPGHAN and NASPGHAN advise against the use of all prokinetic agents including Erythromycin and Domperidone. There is no reliable evidence to support their effectiveness at treating GERD in infants and there have been concerns raised over the potentially cardiotoxic effects of Domperidone2.
Summary
Reflux is very common with half of infants having some symptoms. In the majority of cases reassurance is all that is required. If symptoms are severe and persistent and an alternate diagnosis is unlikely then consider thickened feeds and “tummy time” as a first line treatment. If this is unsuccessful then consider antacids but be aware that the evidence base for these treatments is limited and they are being used off license. Prokinetics play no part in managing GERD in infants and Domperidone use may be cardiotoxic2.
References
1) Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition(NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)Journal of Pediatric Gastroenterology and Nutrition. 49:498–547 # 2009
2) Domperidone: limited benefits with significant risk for sudden cardiac death. Hondeghem LM.J CardiovascPharmacol. 2013 Mar;61(3):218-25.
June newsletter
June’s newsletter has been uploaded. Migraine presentation in adults and children v. tension headaches, baby slings and a bit on acne. Do leave comments below.
Do baby slings cause SIDS?
Paediatric Pearls’ “from the literature” series is written by Luton paediatric registrar, Tom Waterfield. Always inciteful, sometimes wry and eminently readable, this month he shares with us his self-diagnosed neuroses about his new baby son’s sling:
I recently became a first time father and since then my son (Alexander) has turned my life upside down! In the space of two weeks I have morphed from a calm paediatrician into a neurotic and over anxious parent. I often ask myself “is he breathing too fast”, “is he breathing too slowly”, “what was that funny noise” and like all parents I worry about cot death (Sudden Infantile Death Syndrome – SIDS). In the UK the Back to sleep campaign has significantly reduced the risk of SIDS and most parents are now aware of the risks and how to avoid them1.
Link to Back To Sleep Article & Guidelines (www.medscape.com/viewarticle/781979_2)
Like many parents we own a baby sling and Alex loves it. I was happy with the sling until I read an article from the Telegraph on a recent high profile case of SIDS attributed to suffocation secondary to the use of a baby sling2. The case was horrific and triggered the neurotic parent in me. Had I been placing Alex at risk by using a baby sling?
The calm paediatrician in me decided that a quick literature search was required. During that search I found:
1) In the United States the Consumer Product Safety Commission reported a total of 14 deaths attributed to baby slings spanning a period of 20 years3
- 12 of these deaths occurred in children under 4 months of age
- “many” of the deaths occurred in babies with additional risk factors for SIDS
- 3 deaths occurred in 2010 following use of Infantino baby slings
2) A Medline search identified three papers (all case reports/case series)4-6.
- Two articles were only available in Spanish 5,6
- The third was a case report of two babies (both under 4 months of age) who reportedly died from suffocation after being carried in a baby sling6
Summary
From what little literature there is available it would appear that death secondary to use of a baby sling is exceptionally rare. In most cases death has occurred in infants aged less than 4 months who have poor head control and are at risk of suffocation either by direct contact with sling fabric or with extreme neck flexion resulting in airway obstruction. If parents choose to use a sling then they should be encouraged to use them in children over 4 months of age and to be careful to ensure that manufacturer’s guidelines have been followed. Parents may choose not to use slings in children with additional risk factors for SIDS (Prematurity, low birth weight, intercurrent respiratory illness).
References
1) Hendrie JM, Meadows-Oliver M, Expanded Back to Sleep Guidelines. PediatrNurs. 2013;39(1):40-42.
2) http://www.telegraph.co.uk/health/10744051/Warning-over-baby-slings-after-five-week-old-suffocates.html (Last accessed 17/05/2014)
3) http://www.cpsc.gov/en/Newsroom/News-Releases/2010/Infant-Deaths-Prompt-CPSC-Warning-About-Sling-Carriers-for-Babies/ (Last accessed 17/05/2014)
4) Madre C, Rambaud C, Avran D et al. Infant deaths in slings.Eur J Pediatr. 2013 Dec 18.
5) Martin-Fumadó C, Barbería E, Galtés I et al. Death by incorrect use of baby sling: multidisciplinary approach to infant injuries.AnPediatr (Barc). 2013 Apr;78(4):271-2.
6) MaquedaCastellote E, GiliBigatà T, Sánchez Pérez S et al. Infant suffocation associated with the incorrect use of a baby sling.AnPediatr (Barc). 2012 Dec;77(6):416-7.
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
Hypospadias
With thanks to Dr Nikolina Kyprianou for this article and to Mr Devesh Misra, consultant paediatric urologist at the Royal London Hospital, for checking it.
Hypospadias is a congenital abnormality where the male urethral opening is displaced ventrally. It may be displaced anywhere within the glans, the shaft of the penis, the scrotum, or the perineum. It results from failure of the urethral folds to close during fetal development and it is often associated with abnormal penile curvature (chordee) due to disrupted development of the penile shaft. Males with severe uncorrected forms of hypospadias may have difficulties in controlling their urinary stream which may require urination in a sitting position. They can also have erectile dysfunction and infertility (due to impaired semen delivery).
Severity
The location of the urethral meatus classifies the hypospadias and its severity.
Figure 1. Different types of hypospadias
3 classes of severity:
- 1st degree: urethral opening within the glans/subcoronal (50% of cases)
- 2nd degree: urethral opening on the penile shaft (20% of cases)
- 3rd degree: urethral opening within the scrotum or perineum (30% of cases)
Pathogenesis
Hypospadias results due to disruption of the androgenic stimulation that is required for the normal male external genitalia to develop. Environmental factors have been found to be associated with hypospadias suggesting a multifactorial aetiology. These include:
- Advanced maternal age
- Pre-existing maternal diabetes mellitus
- Gestational age before 37 weeks
- History of paternal hypospadias
- Exposure to smoking and pesticides
- IVF
Incidence
Hypospadias is one of the most common congenital abnormalities with an incidence from 0.3 to 0.7% in live male births. It is more common in the Caucasian population and in those of Jewish and Italian descent.
Diagnosis
The diagnosis is usually made during the newborn examination. Physical findings include:
- The appearance of two urethral openings: the first one will be in the normal position at the end of the glans, which will be a blind ending urethral pit. The second is the abnormally located true urethral meatus.
- Abnormal foreskin due to its incomplete closure around the glans leading to the appearance of a dorsal hooded prepuce.
- Abnormal penile curvature (chordee).
In 6% of cases the foreskin is normal and the urethral abnormality only becomes evident during/after circumcision when the glans of the penis is visualised.
Evaluation
Isolated hypospadias: this is only rarely associated with upper genitourinary tract abnormalities and therefore there is no need to
routinely perform imaging studies of the tract.
Cryptorchidism and hypospadias: these patients have an increased risk of disorders of sex development. Cryptorchidism is present in 10% of
patients with hypospadias and is higher in patients with proximal hypospadias (eg. scrotal or perineal urethral meatus). Proximal hypospadias on its own is also associated with disorders of sex development. These patients should be referred to a specialist so that they can have the following investigations:
- Pelvic USS to evaluate internal genitalia.
- Karyotype analysis.
- Serum electrolytes as a screen for salt-wasting forms of congenital adrenal hyperplasia.
Hypospadias with other organ system anomalies eg. Congenital cardiac disease, imperforate anus, limb malformations, or cleft lip. These patients require renal and bladder USS because they are at risk of upper tract abnormalities. They should be referred to a specialist who will also perform genetic testing.
Management
Parents should be advised not to circumcise their baby in order to preserve the foreskin and optimise later surgical choices. These patients need to be referred to the local paediatric urologist who will determine the severity of the hypospadias and the need and timing for surgical correction.
The goal of surgery is to create a straight penis by repairing any curvature (orthoplasty), to create a urethra with its meatus at the tip of the penis (urethroplasty), to reform the glans into a more natural conical configuration (glansplasty), to achieve cosmetically acceptable penile skin coverage, and to create a normal-appearing scrotum. Surgery is usually performed within the first year of life because early correction is associated with improved wound
healing, reduced rate of complications and improved emotional and psychological result. The repair is usually planned as a single-stage procedure, but in infants with severe hypospadias a two-stage repair may be necessary.
Prognosis
With the use of modern instruments, sutures and antibiotics and by performing the procedure at a younger age, the repair of hypospadias has been successful.
For a useful leaflet for parents please follow link and download the PDF document: http://www.patient.co.uk/health/Hypospadias.htm
References:
Baskin LS, Erol A, Li YW, Cunha GR. Anatomical studies of hypospadias. J Urol 1998; 160:1108.
Baskin LS, Ebbers MB. Hypospadias: anatomy, etiology, and technique. J Pediatr Surg 2006; 41:463.
Carlson WH, Kisely SR, MacLellan DL. Maternal and fetal risk factors associated with severity of hypospadias: a comparison of mild and severe cases. J Pediatr Urol 2009; 5:283.
Brouwers MM, Feitz WF, Roelofs LA, et al. Risk factors for hypospadias. Eur J Pediatr 2007; 166:671.
Talipes equinovarus
Talipes (Neonatal Clubfoot) with thanks to Dr Mujahid Hasan and the paediatric physiotherapy department at Barts Health
Newborn babies can present with one of two types of Talipes:
- Congenital Talipes Equinovarus (CTEV or fixed/structural Talipes)
- Positional foot problems
Click here for the Whipps Cross physiotherapists and Muj’s complete, illustrated article.
June 2012 PDF
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.
The Perinatal Parent Infant Mental Health Service (PPIMHS)
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!
December 2011. Happy Christmas!
December 2011 has snippets of information on torticollis (backed up with lots more information on the website), unconscious children, alkaline phosphatase and a link to the Map of Medicine’s recent algorithm for cough in children. Also some pointers for your safeguarding training needs. Download it here.