Category Archives: For Emergency Departments

October 2018 newsletter

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.

September 2018 PDF content

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:

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:

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:

April 2018 newsletter uploaded

NICE on Lyme disease this month – just in time for the weather to pick up and the tics to start biting.  Also a reminder on the risk factors for SIDS, what to do in a terrorist attack, how to manage a child with a non-blanching rash and a discussion on the use of the antistreptolysin O titre.  Do leave comments below:

Late night musings on ASOT

A patient was referred to me in the paediatric cardiology clinic because of a risk that he may have had missed Kawasaki’s disease a couple of weeks earlier and was therefore at risk of having coronary artery aneurysms.  The referring doctor had carried out an antistreptolysin O titer (ASOT) in case the symptoms of a red, sore mouth, rash and later peeling fingers had been secondary to a streptococcal infection rather than KD.  The result came back as 400units/ml (normal is < 200units/ml).  The child was very well when I saw him and had a normal echocardiogram.  What should I do with the elevated ASOT result?

I needed a quick text box as a gap filler for the April edition of the Paediatric Pearls newsletter and thought ASOT results would be a suitable topic but, when I sat down to write it, I opened up a can of worms.  No one really knows what to do with high ASOTs in a well child.  In fact, authors can’t even agree on whether 400 is elevated in a young person.

My reading list is at the foot of this article.  Salient points from these sources are summarised below.

  • The ASOT is ordered primarily to determine whether a previous group A Streptococcus infection has caused a poststreptococcal complication, such as rheumatic fever or glomerulonephritis.  So the start point should be on-going clinical symptoms of strep infection or the effect of a recent infection.  If used in this way, it can be a useful pointer to a causative organism and will guide management.  Rheumatic fever is treated with long term antibiotics.  The ASO test does not predict whether complications will occur following a strep infection, nor does it predict the type or severity of the disease. If symptoms of rheumatic fever or glomerulonephritis are present, an elevated ASO level may be used to help confirm the diagnosis.
  • ASO antibodies are produced a week to a month after an initial strep infection. The amount of ASO antibody (titer) peaks at 3 to 5 weeks after the illness and then tapers off but may remain detectable for several months after the strep infection has resolved.
  • A negative ASO or ASO that is present at very low titers means the person tested most likely has not had a recent strep infection. This is especially true if a sample taken 10 to 14 days later is also negative (low titer of antibody) and if an anti-DNase B test is also negative (low titer of antibody). A small percentage of people with a complication related to a strep infection will not have an elevated ASO. This is especially true with glomerulonephritis that may develop after a skin strep infection.
  • An elevated titer of antibody (positive ASO) or an ASO titer that is rising means that it is likely that the person tested has had a recent strep infection. ASO titers that are initially high and then decline suggest that an infection has occurred and may be resolving.

My conclusion at the end of reading about ASOT and the management of streptococcal infections and complications is that I should only do the ASOT if the child is symptomatic.  If I think they have rheumatic fever, I should treat with antibiotics for a long time (up to 10 years in some cases).  If they do not satisfy the Jones criteria for rheumatic fever and indeed are well now, I do not need to blindly treat an elevated ASOT but it may be prudent to repeat the test a couple of weeks later to ensure it is dropping.

Very good summary article on rheumatic fever: https://patient.info/doctor/rheumatic-fever-pro

Why treat sore throats at all? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1949249/

Cochrane on short term antibiotics: https://www.ncbi.nlm.nih.gov/pubmed/22895944

https://www.annemergmed.com/article/S0196-0644(13)01448-0/fulltext on same topic

https://www.uptodate.com/contents/treatment-and-prevention-of-streptococcal-pharyngitis

March 2018 PDF in time for Easter

NICE on faltering growth this month, paediatric stroke, a reminder of the new epilepsy classification and a contribution from the safeguarding team on what constitutes a “legal high”?  Do leave comments below: