September’s newsletter reminds us of the CPD requirements for child safeguarding for all of us, warns us of the dangers of missing Kawasaki Disease, talks about PHE’s #askaboutasthma campaign and describes the differences between fever and sepsis. Do leave comments below:
Updated rhinitis guideline (2017) from the British Association of Allergy and Clinical Immunology http://www.bsaci.org/Guidelines/rhinitis-2nd-edition-guideline
- Allergic rhinitis is common and affects 10–15% of children and 26% of adults in the UK
- Affects quality of life, school and work attendance, and is a risk factor for development of asthma.
- Diagnosed by history and examination, supported by specific allergy tests.
- Topical nasal corticosteroids are the treatment of choice for moderate to severe disease
- Combination therapy with intranasal corticosteroid plus intranasal antihistamine is more effective than either alone and provides second line treatment for those with rhinitis poorly controlled on monotherapy
- Immunotherapy is highly effective when the specific allergen is the responsible driver for the symptoms
- Treatment of rhinitis is associated with benefits for asthma
- Non-allergic rhinitis also is a risk factor for the development of asthma
- Non-allergic rhinitis may be a presenting complaint for systemic disorders such as granulomatous / eosinophilic polyangiitis, sarcoidosis
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:
Education & Employment
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?
- 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
- Association of Young People’s Health – Key Statistics Document 2017 download here: http://www.ayph.org.uk/keydata2017/FullVersion2017.pdf
- 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.
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
- Run to a place of safety
- Turn your phone onto silent
- Turn off vibrate
- Only when safe call police on 999
- 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