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August 2012 PDF digest

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August’s PDF only has 4 text boxes but with lots of information crammed into them and extra on the blog.  A great looking PDF on poisoning in children from one of our registrars, an article on stammering from another working with a speech and language therapist and an update on BTS pneumonia guidelines just in time for the winter.  Also a feature on Cardiff’s core info safeguarding work on the evidence behind different types of fractures.  Do leave comments…

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.

 

 

Childhood Peak Expiratory Flow Rates (PEFR)

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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.

Inhalers for asthma

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Most families in the Emergency Department will talk about their child’s “blue” and “brown” inhaler.  Can we, or they, tell which is the reliever and which the preventer? 

 Click here for a printable table of some common inhalers listed by colour.  I have also found a very useful site put together by a pharmacist and a medical student with photos of lots of the inhalers so you can get your patient to identify which one they are on.  Take a look at http://www.rch.org.au/clinicalguide/asthmadevices/

 Device   Comments
Standard metered dose inhaler (MDI)
  • Children < 12 years old unlikely to be able to use it properly without a spacer
  • Small, conveniently pocket-sized
  • Requires shaking and priming
  • Not affected by humidity
MDI and spacer
  • Bulky
  • Better delivery of drug at all ages
  • NICE suggests < 5 years, all inhalers should be given with a spacer device and 5-15 years, at least the corticosteroids should be given with a spacer
Dry powder device
  • Children < 6 years old generally can not use it as it requires a fast, deep breath to activate it
  • Medicine can be blown away if child accidentally breathes out
  • Clearer when the medicine is running out than the MDI
  • Single dose models require loading of capsules for each use
  • Powder sticks together if high humidity

 

http://www.asthma.org.uk/health_professionals/materials_to_help_you_your_patients/index.html has a link to a comprehensive information leaflet for young people over the age of 12 who need to take control of their asthma management and understand their condition.

http://www.nice.org.uk/nicemedia/live/11400/32073/32073.pdf  is the 2000 guideline on asthma management in the < 5 year olds

http://www.nice.org.uk/guidance/index.jsp?action=byID&r=true&o=11450 is the 2002 guideline for 5-15 year olds

December PDF for the ED

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This month’s emergency department version of Paediatric Pearls has information on dehydration from the NICE guideline on gastroenteritis in the under 5s, a bit on seizures and the evidence behind our reluctance to let you request chest x-rays for children.  I’ve featured the NICE guideline on antibiotics for respiratory illness in primary care too as they are also relevant for the children we see in EUCC and the Emergency Department.  I hope you find it helpful; I think the average length of time for each infection is useful information to be able to hand on to parents.  Download December’s Paediatric Pearls here.