January 2017 brings the second part of information on gangs, the start of a series on urinalysis (specific gravity this month), an update on resus council guidelines and a link to expressing breastmilk. Do leave comments below.
Gianotti Crosti this month, updated “Working Together” safeguarding document, epistaxis and malaria. Also links to a few other useful documents recently uploaded to the Primary Care Guidelines part of the website, with thanks to Redbridge and West Suffolk. All comments welcome.
With many thanks to Dr Harriet Clompus, paediatric SpR with an interest in community paediatrics for summarising this core-info topic so neatly and usefully.
Emotional Neglect and Abuse
Core-info, a Cardiff university based research group, examines all areas of child abuse by systematically reviewing worldwide literature and producing recommendations based on best evidence. This is a useful resource for paediatricians, general practitioners, health visitors, nurses, social workers, educators. Find all their reviews at www.core-info.cardiff.ac.uk.
Core-info have produced a leaflet in cooperation with National Society of Prevention of Cruelty against Children (NSCPCC) following a review in 2011 of the available literature on emotional neglect and abuse in children less than 6 years old. The leaflet is available at NSCPCC resources at www.nspcc.org.uk/inform. You can also subscribe to CASPAR a news service that signposts you to latest policy, practice and research in child protection.
Definitions of emotional neglect and emotional abuse vary, but all include persistent, harmful interaction with the child by the primary care-giver.
The Core-info/NSPCC leaflet reports one in 10 children in the UK experience severe neglect in childhood. It uses the WHO definitions for emotional neglect and abuse. (World report on violence and health (2002) page 60. Edited by Krug et al)
‘Emotional neglect is the failure of a parent to provide for the emotional development of the child.’
Examples of emotional neglect include:-
- Ignoring the child’s need to interact
- Failing to express positive feelings to the child, showing no emotion in interactions with the child
- Denying the child opportunities for interacting and communicating with peers and adults.
‘Emotional abuse includes failure of a care-giver to provide an adequate and supportive environment and includes acts that have an adverse effect on the emotional health and development of a child. Such acts include restricting a child’s movements, denigration, ridicule, threats and intimidation, discrimination, rejection and other non-physical forms of hostile treatment.’
Examples of emotional abuse include:-
- Persistently telling a child they are worthless or unloved
- Bullying a child or frequently making them frightened
- Persistently ridiculing, making fun of or criticising a child.
The core-info/NSCPCC leaflet categorises behaviour/interactions to be concerned about in three different age groups (it only gives data up to 6 years and on mother (not father or other caregiver) interaction, reflecting data collection in studies reviewed). Attachment to mother is disordered and emotionally neglected children show typical pattern of initially passive and withdrawn and then hostile and disruptive behaviour and developmental delay especially in speech and language.
1) Infant (<12 months old)
- Mother-child interaction: mother insensitive and unresponsive to child’s needs. Rarely speaks to child, describes them as irritating/demanding. Failing to engage emotionally with child during feeds. Child unconcerned when mother leaves and when mother returns, child avoids her or does not go to her for comfort.
- Behaviour: Quiet and passive child. May demonstrate developmental delay within first year, particularly in speech and language (particularly if mother has had depression).
2) Toddlers (1-3 years old)
- Mother-child interaction: More obvious that mother is unresponsive or does not respond appropriately to child (called ‘lacking attunement’). Mother is often critical of child and ignores signals for help. Child is angry and avoidant of their mother.
- Emotionally neglected/abused children grow less passive and more aggressive and hostile, particularly with other children. They show more memory deficits than other children, including physically abused children.
3) Children (3 -6 years)
- Mother-child interaction: Mother offers little or no praise, rarely speaks to the child and shows less positive contact. Mother is unlikely to reach out to the child to relieve distress and the child is unlikely to go to the mother for comfort. Neglectful mothers are more likely to resort to physical punishment than other mothers.
- Emotionally neglected children show more speech and language delay than physically abused children. Girls show more language delay than boys. Their behaviour is often disruptive (rated more disruptive by parents and teachers than physically abused children or controls). They show little creativity in their play, have difficulty interpreting others emotions and have poor interactions with other children. They tend to be less likely to help others or expect help themselves.
Implications for practice:
- All practitioners (gps, paediatricians, nursery nurses and teachers, health visitors etc) need to consider emotional neglect and abuse when assessing a child’s welfare. The longer a child is left in an emotionally neglectful or emotionally abusive environment, the greater the damage. However intensive work with families to increase parental sensitivity to their child’s needs, can lead to improvements in child’s emotional development.
- Important attachment disorders are recognisable in young infants and merit referral to professionals trained in infant mental health (Waltham forest has a Parent Infant Mental Health Service (PIMHS) which accepts referrals related to disordered attachment in children under 3 years. PIMHS works with the mother and child to foster healthier attachment (the earlier in a child’s life this is done, the better the outcome). Any health care professional can refer a family to PIMHS. See paediatric pearls from May 2012 for more information:- www.paediatricpearls.co.uk/…/the-parent-infant-mental-health-service-pimhs
- In older children (>3 years) it can be difficult to know when and where to refer. Emotional neglect and abuse is by definition a persistent behaviour pattern, so cannot be diagnosed on the basis of one short consultation. Concerns about parent-child interaction witnessed in a short consultation in A+E or GP surgery may trigger a health-visitor review to gather information, prior to a possible referral to social services. Information should be sought from all those involved in the child’s care including nursery/school teachers. If concerns around behaviour witnessed in A+E or GP surgery are severe, an immediate referral to social services may be appropriate.
- Professionals should be able to recognise speech and language delay and refer appropriately. See paediatric pearls from April 2012 www.paediatricpearls.co.uk/…/stages-of-normal-speech-development/. Many of the features found in emotionally neglected and abused children may also be observed in those with Autistic Spectrum Disorder (ASD) or Attention Deficit and Hyperactivity Disorder (ADHD). If a child is showing language delay and behavioural disruption they should be referred for a formal child development assessment (either in speech and communication clinic (SACC) or child development clinic (CDC) – refer to Wood Street Child Development team in WF)
- Consider risk factors – Core-info’s systematic review did not encompass ‘risk factors’ for emotional neglect and abuse. However it states that ‘many of these children live in homes where certain risk factors are present. Namely – domestic abuse, maternal substance misuse, parental unemployment or mental health issues, an absence of a helpful supportive social network, lack of intimate emotional support and poverty’.
Minor injuries Series: Episode 1 with thanks to Dr Jessica Spedding, PEM trainee, Royal London Hospital, UK
Introduction to minor injuries:
Minor injuries in children are common and mostly self limiting soft tissue injuries that heal with time. Some injuries are particular to paediatrics (pulled elbow) and others are simply much more common in children than adults (supracondylar fracture). Another consideration specific to children is consideration of growth plate involvement, which if does not heal in a good position could lead to asymmetry and growth problems. Injuries involving the growth plate are graded as Salter-Harris 1,2,3,4, or 5 and they will be discussed in more detail in a future episode of this minor injuries series.
You need a systematic approach that assesses for important injuries that need specific management. Your
assessment must always include consideration of non accidental injury (NAI). A sensible approach would include:
- Is the mechanism of injury described consistent with the injury sustained?
- Has the child reached the appropriate stage of development to have sustained the injury in the way described?
- Is there any delay in presentation?
- Has the child (or siblings) presented numerous times before with injuries?
- There is an excellent set of pamphlets that give evidence based guidance on when injuries point to abuse – go to www.core-info.co.uk or look out for the summaries on Paediatric Pearls
Upper limb injuries:
You may have come across the acronym FOOSH. This is a Fall On the Out-Stretched Hand. This mechanism is the natural response to a fall – in order to protect our head and trunk, the reflex is to put our arms out to break our fall. This mechanism causes a number of different injuries, each more prevalent in different age groups (but common in other age groups too). Roughly speaking these could be sequenced as follows:
Age 1-3: distal radius fracture (usually greenstick or torus) or middle third clavicle fracture
Age 4-8: supracondylar fracture (varying degrees of severity, some of which require operative fixation)
Age 9-adulthood: distal radius fracture or scaphoid fracture
However one must still examine unclothed the whole limb to be sure that all sites of injury have been located. In the upper limb this would be from
fingers to shoulder, clavicle and possibly neck, in the lower limb this would be from toes to hips but also checking the pelvis and lower spine.
The first chapter in this series looks at a common elbow problem:
Pulled elbow: (see also http://www.paediatricpearls.co.uk/2012/02/pulled-elbow/)
Proper name – radial head subluxation, mechanism is usually a sudden pulling of the child by their hand (such as to stop them running into the road or swinging a child in play), child presents having cried initially, but soon settles but refuses to use the arm, holding it slightly flexed at the elbow with the arm by their side. When you go to assess them they have no swelling or bruising or distal neurovascular compromise, but are very apprehensive about you trying to bend or pronate/supinate the elbow. In up to half of cases there may not be a “pull” mechanism in which case be more cautious in assuming the diagnosis. Don’t forget a clavicle fracture may present this way. If you feel sure the diagnosis is pulled elbow, attempt a reduction as follows:
Hold their hand as though you were going to shake hands, with your other hand gently cupping underneath the elbow, with elbow partially flexed, then firmly pronate (rotate to palm up position). You should feel the clunk of a reduction, but if not, try a firm supination (back to palm down position). Ideally do this half an hour after some analgesia. If you do not feel a clunk it is probably not reduced but either way stop after two attempts, and then allow the child to be somewhere relaxing and ask their parent to let you know if they start playing – if reduced most will soon realise the pain with movement has gone and start playing normally within a few minutes. If not reassess and consider a differential diagnosis which may include referral for xray.
A move away from NICE guidelines this month to cover the 2011 BTS/SIGN asthma guidelines and a link to a succinct summary of the current UK immunisation schedule written by one of our registrars. Also a bit from the literature on management of gastro-oesophageal reflux disease and a few pointers about Forced Marriage which is an important safeguarding issue in our region. Do leave comments.
June already! A move away from NICE guidelines this month to cover the 2011 BTS/SIGN asthma guidelines. Also a bit from the literature on management of gastro-oesophageal reflux disease and a few pointers about Forced Marriage which is an important safeguarding issue in our region. Do leave comments.
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.
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
- 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) 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:
|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|
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.
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.
The March 2011 version is now published. I have covered the new NICE guideline on food allergy and provided a link to the Allergy Academy which runs some really excellent course on all aspects of allergy in children, including one specifically for ED physicians. There’s a bit on how to get foreign bodies out of noses and a text box on the paediatric early warning system or PEWS. I have reminded you all that children under 18 months with a fracture need to be seen by a paediatrician before discharge for a safeguarding assessment. This guideline comes from a new document put together by the NSPCC and the Welsh Child Protection group. The pamphlet, downloadable here, describes when to suspect physical abuse in children with fractures and is useful reading for all ED practitioners. Do leave comments below.
School refusal is often a symptom of an underlying anxiety disorder. The child may get anxious on separating from their primary caregiver and this manifests itself in different ways depending on the age of the child as much as anything. There are 2 peak age groups who develop school refusal, 5-7 year olds and 11-14 year olds. 25% of school children refuse to attend school at some point in their school career but it becomes a routine problem in about 2% and the longer it goes on, the harder it is to reverse. It is not the same as truancy. It is not a mental illness in itself but many children who feel unable to attend school over a long period do have an underlying mental health issue. Unfortunately funding for CAMHS is being eroded and it is difficult to find good, and timely, help for school refusers. The websites I have listed in December 2010 Paediatric Pearls for GPs may help give parents pointers for why it is happening and how to set about managing it.