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
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
Antistreptolysin O is an antibody produced by Group A streptococci (GAS). Levels rise 1 – 4 weeks after an infection, peak between week 3 and 5 and may remain detectable for a few weeks after an infection. >200 is abnormal in adults, opinions differ in the literature as to whether children should have the same cut off but most clinicians use this number for everyone.
ASOT does not predict which people will get complications of GAS eg. rheumatic fever, glomerulonephritis. Click here to comment and join the discussion on when ASOT should be measured and what to do with the result
Children above the age of 5 in the UK can usually cope with viral gastroenteritis without needing medical input. They vomit a few times, move on to the diarrhoeal stage, get thirsty and a bit dehydrated and start drinking just as it all stops, thereby successfully rehydrating themselves and getting on with their lives. So if a vomiting 9 year old is brought to us by a parent who says they’ve been admitted 4 times before for iv fluids , it is probably worth taking a closer look. The shocked, prostrate child we saw in the ED this weekend (a re-presentation) may have cyclical vomiting. More information about this here. Early treatment with anti-emetics and benzodiazepines may help avoid the need for iv fluids.
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.
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.
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 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.
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.
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.
Decorticate (flexed arms, extended legs)
Decerebrate (extended arms, extended legs)
Posturing may need to be elicited by a painful stimulus
Abnormal pupillary responses: unilateral or bilateral dilatation suggests raised ICP
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
Cushing’s Triad: Hypertension, Bradycardia and breathing pattern abnormalities are a late sign of raised ICP
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.