STIs, sexual abuse, eating disorder and haemolytic uraemic syndrome this month. Do leave comments below:
With thanks to Dr David Gardiner, one of our current paediatric FY2 doctors at Homerton University Hospital, for updating us on HUS.
- Profuse diarrhoea that typically turns bloody after 1-3 days
- Abdominal pain (crampy)
- Fever (sometimes)
- Reduced urine output (abrupt onset) but also polyuria/normal urine output (rarer)
- Neurological complications: seizure, coma, cranial nerve palsies, confusion, hallucinations
- Classic triad – anaemia, uraemia and thrombocytopaenia
- Most common in children under the age of 5
- B/P – hypertension
- Blood film: Fragmentation and signs of haemolysis (Coombs test negative)
- Raised WCC and neutrophils, low platelets, low Hb
- Raised LDH
- Clotting screen typically normal (cf DIC)
- Raised bilirubin, low albumin
- Urea and creatinine raised
- Stool for PCR E.Coli
- Refer to secondary care urgently
- Strict input/output fluid monitoring
- Correction of anaemia
- Correction of electrolyte imbalances
- Antihypertensive therapy if required
- Furosemide to induce diuresis
- Report to PHE – can’t go back to school until 2 negative stool samples
This month brings a handout entitled “Towards a healthy lifestyle…” which is a collaboration between dietitians, physiotherapists, psychiatrists and paediatricians at Homerton Hospital. We have found many families are keen to do something about their child’s weight but don’t know where to start. Hopefully this friendly article aiming for families to be “healthy enough” is a good place to start.
Also a bit on faltering growth, on-line safety, BRUE and the investigations that do not need to be done. Tachycardia is (of course) mentioned again. 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