Coins, magnets and batteries on the menu this month as well as some more cows milk protein allergy resources. A reminder about child developmental milestones courtesy of one of our medical students and NICE on headaches. Do leave comments!
Tag Archives: x-rays
Foreign body ingestion
The information for this topic is taken from a recent comprehensive review (August 2012) that appeared in www.UpToDate.com. Bartshealth employees can access the full text via a link from the intranet.
Ingested foreign bodies (UptoDate.com article, August 2012)
Coins — Coins are by far the most common foreign body ingested by children. Approximately two-thirds of ingested coins are in the stomach by the time of x-ray but those that lodge in the oesophagus for 24 hours after ingestion may need to be removed endoscopically as only 20-30% of these will pass into the stomach on their own. Coins that reach the stomach can be managed expectantly, and most will be passed within one to two weeks. A child who develops any signs or symptoms of obstruction, abdominal pain, vomiting, or fever, needs to come back to the ED urgently.
Button batteries — ingestions of “button” batteries are increasing and are associated with significant morbidity. Animal studies have demonstrated mucosal necrosis within one hour of ingestion and ulceration within two hours, with perforation as early as eight hours after ingestion. It may be difficult to differentiate between a disk battery and a coin on a radiograph. This distinction is most important when the foreign body is in the oesophagus, since batteries require immediate removal whereas coins may not.
Magnets — also increasing. Many of the children with complications from multiple magnet ingestion had underlying developmental delay or autism. In one case, an older child inadvertently swallowed these magnets while using them to imitate a pierced tongue. Two or more strong magnets, especially if ingested at different times, may attract across layers of bowel leading to pressure necrosis, fistula, volvulus, perforation, infection, or obstruction. Radiographs of the neck and abdomen should be performed, including a lateral view. X-rays cannot usually determine whether bowel wall is compressed between the magnets, although the finding of magnets that appear to be stacked but are slightly separated is suggestive. Management depends on the number, location and type of magnets, and on the timing of the ingestion. Ingestion of a single magnet can generally be managed conservatively with serial radiographs while multiple magnets need removing. Laxatives may help with faster bowel emptying if they are not in a place easily accessible with the endoscope.
References at www.uptodate.com.
child abuse and head injuries
This summarises the Core-info leaflet on head and spinal injuries in children. Full details are available at www.core-info.cardiff.ac.uk.
**PLEASE REFER ALL SUSPECTED INFLICTED HEAD AND SPINAL INJURIES TO PAEDIATRICS **
Inflicted head injuries
- can arise from shaking and/or impact
- occurs most commonly in the under 2’s
- are the leading cause of death among children who have been abused
- survivors may have significant long term disabilities
- must be treated promptly to minimise long term consequences
- victims often have been subject to previous physical abuse
Signs of inflicted head injury
- may be obvious eg. loss of consciousness, fitting, paralysis, irritability
- can be more subtle eg. poor feeding, excessive crying, increasing OFC
- particular features include retinal haemorrhages, rib fractures, bruising to the head and/or neck and apnoeas
- also look for other injuries including bites, fractures, oral injuries
If inflicted head injury is suspected
- a CT head, skull X-ray and/or MRI brain should be performed
- neuro-imaging findings include subdural haemorrhages +/- subarachnoid haemorrhages (extradural haemorrhages are
more common in non-inflicted injuries) - needs thorough examination including ophthalmology and skeletal survey
- co-existing spinal injuries should be considered
- any child with an unexplained brain injury need a full investigation eg. for metabolic and haematological conditions, before a diagnosis of abuse can be made
The following diagram comes from http://www.primary-surgery.org:
These CT images are from http://www.hawaii.edu/medicine/pediatrics/pemxray/v5c07.html:
EXTRADURAL (or epidural) haematoma
SUBDURAL haemorrhages in a 4 month old
SUBARACHNOID haemorrhage in a 14 month old
Neuro-imaging for inflicted brain injury should be performed in
- any infant with abusive injuries
- any child with abusive injuries and signs and symptoms of brain injury
Inflicted spinal injuries
- come in 2 categories : neck injuries, and chest or lower back injuries
- neck injuries are most common under 4 months
- neck injuries are often associated with brain injury and/or retinal haemorrhages
- chest or lower back injuries are most common in older toddlers over 9 months
- if a spinal fracture is seen on X-ray or a spinal cord injury is suspected, an MRI should be performed
August 2012 PDF digest
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…
Fractures in child abuse
Metaphyseal fractures, also known as a bucket handle, chip or corner fracture, occur at the growing end of the bone and only in children. Recent fractures are very difficult to see on x-ray and they are often not associated with any clinical sign of soft tissue swelling or bruising. They may become more obvious radiographically after 11 to 14 days. They are thought to happen when the baby has been pulled or swung violently and the relatively weaker growing point of the bone breaks. They have been noted to occur accidentally following birth injuries, following serial casting of talipes or as a consequence of appropriate physiotherapy to newborn babies. (Source: Core-info leaflet)
The picture of a metaphyseal fracture of an infant’s wrist below comes from a 2000 paper on the orthopaedic aspects of child abuse by Kocher et al and published in the Journal of the American Academy of Orthopaedic Surgeons (http://www.jaaos.org/content/8/1/10.abstract):
A spiral fracture refers to the direction in which the bone is fractured. It implies that there has been a twisting force to cause the fracture. Spiral fractures can also occur accidentally in the femur once the child is walking. (Source: Core-info leaflet)
The picture below of a spiral fracture of the femur in a 2 month old comes from http://www.hawaii.edu/medicine/pediatrics/pemxray/v6c02.html (same website has a wealth of other paediatric radiological images on it if you are interested):
A supracondylar fracture is one in the upper arm immediately above the elbow and is highly suggestive of accidental injury. The picture below comes from http://www.kidsfractures.com/, a site put together by 2 American orthopaedic surgeons who say their aim was to make parents’ experience of having a child with a broken bone a little less traumatic but I think much of the language and many of the pictures are more suited to a medical audience.
A simple linear skull fracture is a break in a cranial bone resembling a thin line, without splintering, depression, or distortion of bone. They are equally prevalent in NAI and in accidental injury. The picture below is of a linear right parietal skull fracture and comes from a Rumanian educational website, http://www.medandlife.ro/medandlife602.html.
This compares with a complex skull fracture which is variously defined as:
• a depressed fracture (where the skull is pushed in)
• two or more fractures of the skull
• fractures that cross the sutures (natural joining edges of skull bones) or those that are widening. (Source: Core-info leaflet)
The picture below of a complex skull fracture is from http://www.childabuseconsulting.com/child-abuse-fractures.html which houses other not-very-subtle images of non-accidental burns and bite marks as well.
Rib fractures in infants, particularly posterior ribs, with no history of major trauma are suspicious. The picture below is taken from http://www.learningradiology.com/notes/bonenotes/childabusepage.htm and shows multiple rib fractures with callous formation, the ones of the left 2nd and 6th posterior ribs being the easiest to identify:
BTS 2011 guideline on community acquired pneumonia in children
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.
Antipyretics – single or dual therapy?
Managing Fever in Children with thanks to Dr Ranjev Kainth
Fever, both in primary and secondary care is a frequent presentation. Often, it is a sign of an illness and in the first instance, it is important to establish the most likely underlying causative factor. Once this has been determined, focus often turns to the management of the fever. Two recent articles in Archives highlight the varying practice amongst clinicians both in primary and secondary care.
In accordance with NICE guidelines1, the authors2-3 suggest anti-pyretics should not be used for the sole purpose of controlling fever. Agents such as paracetamol and ibuprofen are often administered to promote comfort in the child when there is fever. In such situations, children may be prescribed single or dual therapy.
In a systematic review, E.Purssell3 examines the evidence for combined anti-pyretic therapy with either paracetamol or ibuprofen alone. He concluded that ‘only marginal benefit was shown for the combined treatment compared with each drug individually which, taken alongside the risk of overdose and further increasing the fear of fever, suggests there is little to recommend this practice’.
With the real risk of parents being unable to accurately measure medication4, it is important clear guidance is given on when and what type of drug therapy is appropriate in clinical situations.
References:
- NICE Guideline: Feverish Illness in Children: Quick reference guideline http://guidance.nice.org.uk/CG47/QuickRefGuide/pdf/English
- McLyntyre, J. Management of fever in Children. Arch Dis Child Dec 2011 V 96;12 P.1173
- Purssell, E. Systematic review of studies comparing combined treatment with paracetamol and ibuprofen, with either drug alone. Arch Dis Child Dec 2011 V 96;12 P.1175
- Beckett, V.L. et al. Accurately administering oral medication to children isn’t child’s play. Arch Dis Child 2011;96:A7 doi:10.1136/adc.2011.212563.14
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.
December PDF for the ED
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.
December 2010 PDF digest for GPs now published!
December’s Paediatric Pearls (GP edition) reminds us all of the NICE guideline on antibiotic prescribing in respiratory tract infections. I would like to do a bit more of the “delayed prescribing” in the Emergency Department but it would require either the family coming back (ie. a “no antibiotic” policy really) or their putting a bottle of amoxicillin in their fridge and potentially not using it as we give out the actual antibiotic in A and E, not prescriptions. We’ve also featured a couple of papers showing that chest x-rays add very little to the management of a child with a respiratory illness which I think most GPs know but it doesn’t harm to remind trainees still in the hospital that, just because the radiology department is at the end of the corridor, it doesn’t mean you have to use it! We continue our 6-8 week baby check series with information on sacral dimples and I have also put in a couple of websites with sensible, empathetic information and advice on school refusal. The beginning of term is stressful for children who find it hard to go to school and parents may find these sites helpful when trying to understand why their child is behaving in that way. Happy New Year to you all!