All posts by Julia

August 2018 uploaded

August brings more returning travellers, this time with dengue fever.  Also adolescent sleep problems, adverse childhood experiences (ACEs), an update on rhinitis and the neurological effects of rotavirus.  Do leave comments below.

July 2018 newsletter published

July 2018 brings HEADSSS as a communication tool in adolescent medicine this month, vaccine hesitancy, chikungunya, empyemas, a good headache course coming to London and appropriate use of the EEG.  Please do leave comments below.

HEADSSS tool

Using HEADSSS assessment by Dr Emma Parish

In the UK we often discuss our ageing population but sometimes fail to see the significant proportion of those in adolescence, between 12 – 19% of the total UK population in 20171.

Engaging this age group can be daunting for health professionals. HEADSSS is an interview prompt or psychosocial tool to use with young people. Still growing in the consciousness of health professionals (and in the letters making up its acronym) HEADS(SS) was first presented in publication in 19882. It has a reported yield of 1 in 3 for identifying concerns that warrant further investigation.

It follows a simple structure remembered by the acronym:

Home

Education & Employment

Activities

Drugs/Drinking

Sex

Self-harm, depression & suicide

Safety (including social media/online)

The great news is that many studies have shown that self-assessment with HEADSSS tools before discussion (completed at home or in waiting rooms) yields equal, and in some cases more, information than conducting the assessment in person. Helpful for time-strapped clinicians and better utilisation of time for young people attending appointments.

Key tips for using HEADSSS

  • Greet young person first, let them introduce others
  • Practice discussing issues that embarrass you
  • Be clear in what you mean by confidentiality relating to discussion
  • See young people on their own routinely (whenever clinically appropriate)
  • Use linking phrases and questions that don’t presume:
    • Do you have a boyfriend/girlfriend?

Vs

  • Do you have someone important in your life?
  • Have you been in a relationship before? Tell me more…

For more details see the RCPCH Young People’s Health Special Interest Group (YPSIG) app – free to download here: https://app.appinstitute.com/heeadsss

Or this short HEADS-ED assessment tool: http://www.heads-ed.com/en/headsed/HEADSED_Tool_p3751.html

  1. Association of Young People’s Health – Key Statistics Document 2017 download here: http://www.ayph.org.uk/keydata2017/FullVersion2017.pdf
  2. Cohen, E, MacKenzie, R.G., Yates, G.L. (1991). HEADSS, a psychosocial risk assessment instrument: Implications for designing effective intervention programs for runaway youth. Journal of Adolescent Health 12 (7): 539-544.

June 2018 PDF published

June 2018 features include the rotavirus immunisation, febrile myoclonus, investigating normochromic anaemia, complications of sinusitis and the first in our adolescence series.  Please do leave comments below:

Benign enlargement of the subarachnoid space in infancy (BESS)

Case history: a 5-month-old boy was referred to clinic because his head circumference had jumped from below the 25th to the 75th centile and his GP felt that he had a prominent anterior fontanelle. He was developmentally normal with some noticeable frontal bossing. There had been concerns about his mother having had “hydrocephalus” when she was a baby.

Benign enlargement of the subarachnoid space in infancy (BESS)

  • usually involves the frontal lobe subarachnoid spaces
  • characterised clinically by a widened fontanelle, macrocephaly and/or frontal bossing
  • M > F
  • often a family history
  • majority are neurodevelopmentally normal
  • head circumference climbs through the centiles, plateauing on one of the top 2 centiles in late infancy
  • unclear pathophysiology
  • a transient accumulation of cerebrospinal fluid in the frontal region or delayed development or function of the arachnoid villi at the sagittal sinus?
  • cranial ultrasound / MRI show extra fluid around the brain frontally but no ventricular enlargement
  • There’s a more scientific and detailed radiological description at https://radiopaedia.org/articles/benign-enlargement-of-the-subarachnoid-space-in-infancy
  • can be complicated by chronic subdural haemorrhage possibly secondary to the stretching of subdural veins (Papasian, 2000)
  • type 1 glutaric aciduria also presents with increasing head size but these children are not developmentally normal and have other signs on their cranial imaging (Biswas, 2016)
  • more information at J Pediatr Neurosci. 2014 May-Aug; 9(2): 129–131 although I’m not convinced of the need for the follow up imaging advocated here, especially if it requires a general anaesthetic
  • The literature suggests that BESS resolves spontaneously by 2 years.
  • The macrocephaly is likely to persist

The head circumference of the baby presented above plateaued between the top 2 centiles at 10 months. He remains neurodevelopmentally normal.

Picture courtesy of Dr Abdel-Rahman Abdel-Halim, from the case https://radiopaedia.org/cases/29

Safeguarding: Run, Hide, Tell

With thanks to Nicci Wotton, safeguarding nurse consultant at Imperial College NHS Trust  for this month’s safeguarding item.
Today’s children are used to filming their lives and sharing with their friends via Snapchat, Instagram etc. Let children know what to do in the
event of a terrorist attack – 5 simple actions:
  1. Run to a place of safety
  2. Hide
  3. Turn your phone onto silent
  4. Turn off vibrate
  5. Only when safe call police on 999

Lyme Disease

The sun’s come out here in the UK and people are venturing into forests for picnics. Timely then for NICE to spoil the fun and publish its guideline on Lyme Disease (NG95, April 2018)
  • Caused by a tick-borne spirochaete of the Borrelia species, which is spread by a bite from  an infected tick
  • Ticks live in many woodland and grassy areas but only a small number carry the bacteria that causes Lyme disease
  • 2,000 to 3,000 diagnoses each year in England and Wales.
  • erythema migrans rash, examples here.
  • Flu-like symptoms to start with. Other symptoms include migratory inflammatory arthritis, uveitis, pain or numbness, trouble with memory, heart block, pericarditis
  • ELISA and immunospot testing are used for diagnosis but false negatives are possible especially in first 4 weeks
  • Treated with doxycycline or amoxicillin
Distribution map of UK cases here as part of a 2017 paper in Brit JGP on Lyme disease as a cause of Bell’s palsy in children as well as adults.

Should I treat an incidentally found high ASOT in a well child?

Antistreptolysin O is an antibody produced by Group A streptococci (GAS). Levels rise 1 – 4 weeks after an infection, peak between week 3 and 5 and may remain detectable for a few weeks after an infection. >200 is abnormal in adults, opinions differ in the literature as to whether children should have the same cut off but most clinicians use this number for everyone.
ASOT does not predict which people will get complications of GAS eg. rheumatic fever, glomerulonephritis. Click here to comment and join the discussion on when ASOT should be measured and what to do with the result

Viral Gastoenteritis: Could it be Cyclical Vomiting?

Children above the age of 5 in the UK can usually cope with viral gastroenteritis without needing medical input. They vomit a few times, move on to the diarrhoeal stage, get thirsty and a bit dehydrated and start drinking just as it all stops, thereby successfully rehydrating themselves and getting on with their lives.  So if a vomiting 9 year old is brought to us by a parent who says they’ve been admitted 4 times before for iv fluids , it is probably worth taking a closer look. The shocked, prostrate child we saw in the ED this weekend (a re-presentation) may have cyclical vomiting. More information about this here. Early treatment with anti-emetics and benzodiazepines may help avoid the need for iv fluids.

table showing stages of cyclical vomiting and therapies
Cyclical Vomiting
Schematic representation of the four phases of Cyclic Vomiting Syndrome and their therapeutic goals. Fleisher et al. BMC Medicine 2005 3:20 doi:10.1186/1741-7015-3-20 Li BUK et al. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Consensus Statement on the Diagnosis and Management of Cyclic Vomiting Syndrome. Journal of Pediatric Gastroenterology and Nutrition 2008; 47 : 379–393 (full text, doses etc.)

May 2018 newsletter published

Cyclical vomiting this month as the message from the front line, BESS as a learning point for those monitoring the size of an infant’s head, milia also for the babies and the perennial problem of whether or not montelukast works to control episodic wheeze.  Do leave comments below: