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Journal Club: Lumbar Punctures in Children with Febrile Seizures

Journal Club is a revamped monthly feature in the Paediatric Pearls newsletter. I’m happy to receive submissions from any primary or secondary care journal club you are running as long as the paper is relevant to front line health professionals working with children. Please contact me through the contact page.

With thanks this week to Dr Saskia Wills who took us through a paper on the need (or not) for LPs in children with complex febrile seizures. Her full presentation is here.

In brief:

  • The definition of a febrile seizure in this paper is a seizure in a child 6 months to 5 years with a fever >38o and without an underlying CNS infection or a history of afebrile seizures
  • They occur in 2-4% of children <5yrs (peak at 12-18 months)
  • They are classified as complex if they last >15 minutes, have a focal onset, or there are multiple episodes within 24 hours
  • They are often associated with viral infections, especially HHV6
  • The risk is slightly higher in boys and those with a family history of febrile convulsion
  • 1/3 of children will have another febrile seizure in the future, but very few (2.4%) go on to have epilepsy. (The risk of epilepsy, which varies with different presenting features, is discussed here)
  • In a retrospective French study of otherwise well children presenting with complex febrile seizures, only 5 out of 839 (0.7%) had confirmed bacterial meningitis. All of these had had a prolonged seizure plus some ongoing abnormal neurology or sign suggestive of CNS infection. The study concluded that in children with complex febrile seizures but no other signs of CNS infection, LP usually isn’t necessary. The risk of proven CNS disease is higher in those under 1yr and with a prolonged seizure. This study didn’t look at children who had other risk factors for meningitis, such as immunodeficiency.

Paper studied: Guedj R1, Chappuy H2 et al. Do All Children Who Present With a Complex Febrile Seizure Need a Lumbar Puncture? Ann Emerg Med. 2017 Jul;70(1):52-62. PubMed Link.

Managing a Child with a Decreased Conscious Level

With thanks to Dr Dilshad Marikar for looking at the 2016 RCPCH material on managing a child with a decreased conscious level, prompted by his being on call when a 14 year old was brought to the ED with a GCS of 3.

The RCPCH algorithm has a child between 4 weeks and 18 years old enter the Decreased Consciousness (DeCon) pathway if the AVPU is “P” or “U” or if there is a new finding of GCS ≤ 14 which seems quite a low threshold and means that we will all need to use this guideline at some point. See: https://www.rcpch.ac.uk/system/files/protected/page/RCPCH%20DeCon%20Poster%20.pdf – incorporates how to identify and manage the situation and differential diagnoses. The full guideline is available here and the recommendations summary PDF, here. Some salient points:

  • Consider intubation if GCS < 8 and child not improving
  • Give oxygen if O2 saturation is ≤ 95%
  • Check capillary blood glucose within 15 minutes
  • Don’t overlook the possibility of NAI or safeguarding issues

Who Has Not Been Asked About Nappy Rash?

The Avon Longitudinal Study of Parents and Children (ALSPAC) study collected information about nappy rash using self-completed questionnaires answered by parents at the end of the first four weeks of their baby’s life. The study found that 25% of the babies had experienced napkin dermatitis.

NICE has a comprehensive clinical knowledge summary on nappy rash here. Salient points:

  • Skin swabs are not recommended for the management of nappy rash as the results are difficult to interpret.
  • Both Candida and bacteria (such as Staphylococcus aureus) colonize healthy skin and a skin swab may be positive when infection is not present.
  • A swab should only be taken when a secondary bacterial infection is suspected, to guide choice of antibiotic

This picture and more available on the excellent Primary Care Dermatology Society website. Compare this candidiasis picture with ammoniacal dermatitis and napkin eczema.

  • Consider using nappies with the greatest absorbency (for example, disposable gel matrix nappies)
  • Leave nappies off for as long as is practically possible. Clean and change the child as soon as possible after wetting or soiling. Use water, or fragrance-free and alcohol-free baby wipes.
  • Dry gently after cleaning — avoid vigorous rubbing.
  • Bath the child daily — but avoid excessive bathing (such as more than twice a day) which may dry the skin.
  • Do not use soap, bubble bath, or lotions. Advise about skin care.
  • Prescribe a barrier preparation to apply thinly at each nappy change, to protect the skin. Zinc and Castor Oil ointment BP or Metanium® ointment are recommended. Alternatively, white soft paraffin BP ointment or dexpanthenol 5% ointment (Bepanthen®) could be used.
  • For children over 1 month of age, consider prescribing topical hydrocortisone 0.5% or 1% cream once a day for 7 days max.

Signs of Raised Intracranial Pressure (ICP)

From APLS manual 6E

  1. Abnormal oculocephalic reflexes (avoid in patients with neck injuries):
    When the head is turned to the left or right a normal response is for the eyes to move away from the head movement; an abnormal response is no (or random) movement. See video for a demo of normal reflexes.
  2. Abnormal Posture:
    Decorticate (flexed arms, extended legs)
    Decerebrate (extended arms, extended legs)
    Posturing may need to be elicited by a painful stimulus
  3. Abnormal pupillary responses: unilateral or bilateral dilatation suggests raised ICP
  4. Abnormal breathing patterns: There are several recognisable breathing pattern abnormalities in raised ICP. However they are often changeable and may vary from hyperventilation to Cheyne-Stokes breathing to apnoea
  5. Cushing’s Triad: Hypertension, Bradycardia and breathing pattern abnormalities are a late sign of raised ICP

Winter, Vitamin D and Rickets

It’s dark and sun-less again in the UK and everyone’s Vitamin D levels will be at rock bottom over the next couple of months. Rickets is not rare in London and neither are consequent hypocalcaemic fits in our babies and teenagers unfortunately. Hackney CCG has an easy to follow algorithm for prevention and management of Vitamin D deficiency: you can find it here.

There’s even a table which tells you which vitamin preparations are suitable for vegetarians or vegans, which are Kosher and Halal certified and which to avoid in peanut allergy.

The Vaccine Knowledge Project

http://vk.ovg.ox.ac.uk/ is the website of the Vaccine Knowledge Project, managed by a  research group in the Dept of Paediatrics at Oxford University. It is designed to enable people (and their GPs) to make informed decisions about vaccine issues. I stumbled  across it when a friend asked if her teenage son should have Men B vaccine as well as Men  ACWY prior to going to university. Would you have known the answer? It’s all at  http://vk.ovg.ox.ac.uk/menb-vaccine.

Intraosseous needle insertion

(From the August 2017 newsletter)

Intraosseous needle insertion is pretty painful but not as painful as the subsequent infusion of the fluids. In the conscious patient, it is possible to infuse small volumes of lignocaine via the IO to provide pain relief. http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/intraosseous-insertion provides a comprehensive guide to IO needle insertion and use. Appendix 1 of that document has a chart of how much lignocaine (lidocaine) to use according to the weight of the child. Volumes are tiny in the neonate.

Paediatric Hypertension – measure the ABPM

(From the August 2017 newsletter)

In November 2016, NICE published its guidance on hypertension in adults which suggests 24 hour ambulatory blood pressure monitoring in the diagnosis of hypertension. ABPM should be measured in children before treating. It lessens the “white coat” effect and, if their BP is normal while asleep at night, the clinician can be fairly reassured that there is not likely to be a significant underlying cause for their hypertension.

Caveat:- you must get the cuff size right! The largest cuff which can fit on the arm should be used (2/3 the length of the upper arm, bladder 80-100% of the arm circumference). Small cuffs overestimate the blood pressure.

The centile charts for day and night blood pressures are available here at the bottom of the European consensus document. I have also uploaded them to the primary care guidelines tab. The 95th centile is the upper limit of normal. Values are gender specific and are set out according to heights and ages.

Lurbe E et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens. 2016 Oct;34(10):1887-920

Child Safeguarding – New RCPCH Resource

(From the August 2017 newsletter)

As of July 2017, http://www.rcpch.ac.uk/child-protection-evidence is housing all the evidence behind child safeguarding so painstakingly put together by the Cardiff Child PrOtection Systematic REviews project (CORE INFO) in collaboration with NSPCC. It’s a go-to page with links to national and international guidance and resources around safeguarding children.

NSPCC flyers currently available from the RCPCH site:

  • Bruises on children
  • Emotional neglect and emotional abuse in pre-school children
  • Fractures in children
  • Head and spinal injuries in children
  • Neglect and emotional abuse in children aged 5-14
  • Neglect and emotional abuse in teenagers aged 13-18
  • Oral injuries and bites on children
  • Thermal injuries on children

Mean Corpuscular Haemoglobin Concentration

(From June 2017 Paediatric Pearls Newsletter: Last in the “decoding the FBC” series by Dr Xanna Briscoe and Prof Irene Roberts for the time being)

Mean Corpuscular Haemoglobin (MCH) is the amount of haemoglobin per red blood cell.  MCHC is an estimate of the concentration of haemoglobin in a  given number of packed red blood cells.

MCHC = (Hb1 ÷ HcT2) x 100

Normal in children is 32-34% (adults 28-36%) depending on the lab

Chronic Anaemia

Iron Deficiency

Thalassaemia

spherocytosis

folic acid deficiency

Vit B12 deficiency

burns patients

sickle cell disease