(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.
(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
(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
(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.
Normal in children is 32-34% (adults 28-36%) depending on the lab
folic acid deficiency
Vit B12 deficiency
sickle cell disease
It stands for Postural Orthostatic Tachycardia Syndrome, an autonomic disturbance
leading to light-headedness, sweating, tremor, palpitations and near syncope in the upright position1
- Heart rate >120bpm on standing
- HR increase > 40bpm after 10 minutes of standing (if aged 12-19 yrs. >30bpm if older)2
- Despite our traditional concern with lying and standing blood pressures, it
is the persistent tachycardia that characterises this health condition. Blood
pressure may not change at all.
- Recognised in age group 12 – 50, female to male ratio of 5:1
- Can be primary (eg. adolescence) or secondary (eg. diabetes, hypermobility)
- Different types and some are associated with a particular gene mutation
- Can be diagnosed on tilt table or active stand test if necessary
- Reassurance, a healthy lifestyle with sufficient aerobic exercise and fluid
intake will help with symptoms and most adolescents grow out of it
- Specific Gravity (in January 2017 newsletter pdf)
- pH ( in Feb 2017 newsletter pdf)
- Nitrites (in March 2017 newsletter pdf)
- Leucocytes (in April 2017 newsletter pdf)
- Red or brown urine does not always mean blood
- High false positive rate (eg. haemoglobinuria, myoglobinuria, concentrated urine, menstrual blood in the urine sample, rigorous exercise) so dipstick positive blood needs to be looked at under the microscope to accurately diagnose haematuria
- False negative possible if specific gravity is < 1007
- Significant haematuria is defined as ≥ 10 red blood cells (≥ 3 in adults) per high-power field in a properly collected and centrifuged urine specimen
- Isolated microscopic haematuria in a well child only really needs further investigation after 3 positive samples over a period of a few months
- Concomitant proteinuria, high BP or a palpable abdominal mass should be investigated promptly
- Possible causes of haematuria in children:
- Viral infections
- Post streptococcal glomerulonephritis
- Henoch Schonlein Purpura
- Wilm’s tumour (median age 3.5 years)
With thanks to Geoff Ferguson, Director of the Parent Infant Centre (www.infantmentalhealth.com) for the following explanation of the Acquarone scales:
The Acquarone Detection Scales for Early Relationships are observational scales that provide a powerful tool for assessing an infant’s capacity to form relationships and a mother’s ability to respond to her infant. The scales have been developed during several decades of clinical practice by Dr Stella Acquarone, who is also the author of several books on infant development and parent infant psychotherapy and Principal of the Parent Infant Clinic. The Parent Infant Clinic is a private service but does have some subsidised places for families with limited financial resources.
There are two scales, a 25 item scale for observations of the infant and a 13 item scale for observations of the mother. In each case observations are divided into four domains: interpersonal, sensorial, motor and affect. Within each domain observers are asked to note the frequency of certain behaviours. For example, when observing ‘calling’ the observer is looking for ‘facial expressions, noises or gestures that seek to produce an affectionate response from the partner’.
A concern about the infant or the mother might be raised if a particular behaviour was never observed, perhaps showing a difficulty in relating, or was constantly observed, perhaps showing a defensive repetitiveness. The scales can be used to establish a thorough observational benchmark against which later changes can be compared.
Click here to see an example.
Vitamin D deficiency in children with thanks to Dr Jini Haldar, paediatric registrar at Whipps Cross University Hospital.
Vitamin D is an essential nutrient needed for healthy bones, and to control the amount of calcium in our blood. There is recent evidence that it may prevent many other diseases. There are many different recommendations for the prevention, detection and treatment of Vitamin D deficiency in the UK. The one outlined below is what we tend to do at Whipps Cross Hospital.
The Department of Health and the Chief Medical Officers recommend a dose of 7-8.5 micrograms (approx. 300 units) for all children from six months to five years of age. This is the dose that the NHS ‘Healthy Start’ vitamin drops provide. The British Paediatric and Adolescent Bone Group’s recommendation is that exclusively breastfed infants receive Vitamin D supplements from soon after birth. Adverse effects of Vitamin D overdose are rare but care should be taken with multivitamin preparations as Vitamin A toxicity is a concern. Multivitamin preparations often contain a surprisingly low dose of Vitamin D.
Indications for measurement of vitamin D
1. Symptoms and signs of rickets/osteomalacia
- Progressive bowing deformity of legs
- Waddling gait
- Abnormal knock knee deformity (intermalleolar distance > 5 cm)
- Swelling of wrists and costochondral junctions (rachitic rosary)
- Prolonged bone pain (>3 months duration)
2. Symptoms and signs of muscle weakness
- Cardiomyopathy in an infant
- Delayed walking
- Difficulty climbing stairs
3. Abnormal bone profile or x-rays
- Low plasma calcium or phosphate
- Raised alkaline phosphatase
- Osteopenia or changes of rickets on x-ray
- Pathological fractures
4. Disorders impacting on vitamin D metabolism
- Chronic renal failure
- Chronic liver disease
- Malabsorption syndromes, for example, cystic fibrosis, Crohn’s disease, coeliac disease
- Older anticonvulsants, for example, phenobarbitone, phenytoin, carbamazepine
5. Children with bone disease in whom correcting vitamin D deficiency prior to specific treatment would be indicated:
- Osteogenesis imperfecta
- Idiopathic juvenile osteoporosis
- Osteoporosis secondary to glucocorticoids, inflammatory disorders, immobility
Symptoms and signs in children of vitamin D deficiency
1. Infants: Seizures, tetany and cardiomyopathy
2. Children: Aches and pains: myopathy causing delayed walking; rickets with bowed legs, knock knees, poor growth and muscle weakness
3. Adolescents: Aches and pains, muscle weakness, bone changes of rickets or osteomalacia
Risk factors for reduced vitamin D levels include:
- Dark/pigmented skin colour e.g. black, Asian populations
- Routine use of sun protection factor 15 and above as this blocks 99% of vitamin D synthesis
- Reduced skin exposure e.g. for cultural reasons (clothing)
- Latitude (In the UK, there is no radiation of appropriate wavelength between October and March)
- Chronic ill health with prolonged hospital admissions e.g. oncology patients
- Children and adolescents with disabilities which limit the time they spend outside
- Institutionalised individuals
- Photosensitive skin conditions
- Reduced vitamin D intake
- Maternal vitamin D deficiency
- Infants that are exclusively breast fed
- Dietary habits – low intake of foods containing vitamin D
- Abnormal vitamin D metabolism, abnormal gut function, malabsorption or short bowel syndrome
- Chronic liver or renal disease
Management depends on the patient’s characteristics:
A. No risk factors
No investigations, lifestyle advice* and consider prevention of risk factors
B. Risk Factors Only
1. Children under the age of 5 years: Lifestyle advice* and vitamin D supplementation.
Purchase OTC or via Healthy Start
Under 1 year: 200 units vitamin D once daily
1 – 4 years: 400 units vitamin D once daily
2. Children 5 years and over – offer lifestyle advice*
C. Risk Factors AND Symptoms, Signs
- Renal function, Calcium, Phosphate, Magnesium (infants), alkaline phosphatase,
- 25-OH Vitamin D levels, Urea and electrolytes, parathyroid hormone
Children can be managed in Primary Care as long as:
- No significant renal impairment
- Normal calcium (If <2.1 mmol/l in infants, refer as there is a risk of seizures)
If further assessment is required consider referral to specialist. **
Patient’s family is likely to have similar risk of Vitamin D deficiency – consider investigation ant treatment if necessary.
*Life style advice
Exposure of face, arms and legs for 5-10 mins (15-25 mins if dark pigmented skin) would provide good source of Vitamin D. In the UK April to September between 11am and 3pm will provide the best source of UVB. Application of sunscreen will reduce the Vitamin D synthesis by >95%. Advise to avoid sunscreen for the first 20-30 minutes of sunlight exposure. Persons wearing traditional black clothing can be advised to have sunlight exposure of face, arms and legs in the privacy of their garden.
Vitamin D can be obtained from dietary sources (salmon, mackerel, tuna, egg yolk), fortified foods (cow, soy or rice milk) and supplements. There are no plant sources that provide a significant amount of Vitamin D naturally.
**Criteria for referral
- Criteria for management in primary care not met
- Deficiency established with absence of known risk factors
- Atypical biochemistry (persistent hypophosphatemia, elevated creatinine)
- Failure to reduce alkaline phosphatase levels within 3 months
- Family history (parent, siblings) with severe rickets
- Infants under one month with calcium <2.1mmmol/l at diagnosis as risk of seizure. (Check vitamin D level of mothers in this group immediately and treat, particularly if breast feeding.)
- If compliance issues are anticipated or encountered during treatment.
- Satisfactory levels of vitamin D not achieved after initial treatment.
Vitamin D levels, effects on health and management of deficiency
|< 25 nmol/l (10micrograms/l)||Deficient. Associated with rickets, osteomalacia||Treat with high dose vitamin D
Lifestyle advice AND vitamin D (ideally cholecalciferol)
• 0 – 6 months: 3,000 units daily
• 6 months – 12 yrs: 6,000 units daily
• 12 – 18 yrs: 10,000 units daily
|vitamin D 25 – 50 nmol/l (10 – 20micrograms/l||Insufficient and associated with disease risk||Over the counter (OTC) Vitamin D supplementation (and maintenance therapy following treatment for deficiency) should be sufficient.
• Lifestyle advice and vitamin D supplementation
< 6 months: 200 – 400 units daily (200 units may be inadequate for breastfed babies)
Over 6 months – 18 years: 400 – 800 units daily
|50 – 75 nmol/l (20 – 30micrograms/l)||Adequate||Healthy Lifestyle advice|
|> 75 nmol/l (30 micrograms/l)||Optimal Healthy||None|
Course length is 8 – 12 weeks followed by maintenance therapy.
Checking of levels again
As Vitamin D has a relatively long half-life levels will take approximately 6 months to reach a steady state after a loading dose or on maintenance therapy. Check serum calcium levels at 3 months and 6 months, and 25 – OHD repeat at 6 months. Review the need for maintenance treatment. NB: the Barts Health management protocol uses lower treatment doses for a minimum of 3 months and then there is no need for repeat blood tests in the majority of cases of children satisfying the criteria for management in primary care.
Serum 25 OHD after 3 months treatment Action
|>80nmol/ml||Recommend OTC prophylaxis and lifestyle advice||as required|
|50 – 80 nmol/mL||Continue with current treatment dose||reassess in 3 months|
|< 50 nmol/mL||Increase dose or, in case of non-adherence/concern refer to secondary care.|
It is essential to check the child has a sufficient dietary calcium intake and that a maintenance vitamin D dose follows the treatment dose and is continued long term.
Some recommend a clinical review a month after treatment starts, asking to see all vitamin and drug bottles. A blood test can be repeated then, if it is not clear that sufficient vitamin has been taken.
Current advice for children who have had symptomatic Vitamin D deficiency is that they continue a maintenance prevention dose at least until they stop growing. Dosing regimens vary and clinical evidence is weak in this area. The RCPCH has called for research to be conducted. The RCPCH advice on vitamin D is at http://www.rcpch.ac.uk/system/files/protected/page/vitdguidancedraftspreads%20FINAL%20for%20website.pdf
Dr Anna Morgan, ED consultant at Barts Health, London is sharing her favourite Apps and Podcasts with us over the next few months (starting with November 2014 edition of the newsletter). Please do add any suggestions of your own below with a short sentence saying why you think it is helpful to your practice: