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Parent Infant Mental Health

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.

 

Potted background, assessment and management of vitamin D deficiency

Vitamin D deficiency in children with thanks to Dr Jini Haldar, paediatric registrar at Whipps Cross University Hospital.

Introduction

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.

 Prevention

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:

 

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

Lifestyle advice*

Investigations:

  • 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

 

1. Sunlight

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.

2. Diet

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

level effects

management

< 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

level action review
>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.

Follow-up:

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

JINI HALDAR

 

Add your App!

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:

BCG lymphadenitis

BCG Lymphadenitis with thanks to Dr Mujahid Hassan

Lymphadenitis is the most common complication of BCG vaccination, and is of two types – suppurative and non-suppurative.

Normal course post-vaccination:
Intradermal injection -> local multiplication of vaccine -> transport to lymphatics via lymph glands -> haematogenous dissemination of BCG.
No clear definition of ‘BCG lymphadenitis,’ proposed definition is when it becomes palpable or concerning for parents.

Can appear as early as two weeks after vaccination, most within 6 months and almost all cases will be within 24 months.
Normally ipsilateral with one or two palpable lymph nodes, but can involve multiple nodes.  Normally axillary but can be with cervical/supraclavicular.
Diagnosis:

  • Isolated lymph node enlargement
  • BCG vaccination to ipsilateral side
  • Absence of tenderness or heat to lump
  • Absence of fever

Non-suppurative will resolve within a few weeks – this is a normal reaction and most of these are sub-clinical so go unnoticed.
Suppurative involves an enlarging lymph node with fluctuant appearances, oedema and erythema.  Happens in ’30-80%’ of cases of lymphadenitis.

Treatment of suppurative lymphadenitis:

Antibiotics: Previously erythromycin/rifampicin/isoniazid have been used but their clinical role is of dubious significance, so are not used routinely.
Reassurance and followup are what is needed.

Fine Needle Aspiration: Suppurative lymphadenitis can result in spontaneous perforation and sinus formation, which can result in several unpleasant months of dressing and wound care.  FNA is thus recommended to prevent this and reduce time for healing.

Surgical excision:  Risks of general anaesthesia - other than in extreme cases of failed FNA/multiloculated lymph nodes - far outweigh the potential benefits.

Non-suppurative

 

 

 

 

 

 

 

 

 

 

 

Suppurative

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Management pathway and images courtesy of:
WM Chan, YW Kwan, CW Leung.  Management of Bacillus Calmette-Guérin Lymphadenitis, Hong Kong Journal of Paediatrics (New Series). Vol 16. No. 2, 2011, available via http://www.hkjpaed.org/details.asp?id=782&show=1234
References:

J Goraya and V Virdi,  Bacille Calmette-Guérin lymphadenitis, Postgrad Med J. 2002 June; 78(920): 327–329,
available via http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1742390/pdf/v078p00327.pdf

 

Emotional abuse and neglect

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’.

Dr Noimark’s allergy management plans

Lee Noimark is a paediatric allergist at the Royal London Hospital.  He and his team put these allergy action plans together.  Print them out for your patients to give to nursery or school in the event of an allergic reaction.  The labels are self explanatory:

Allergy Action Plan (mild-moderate)

Allergy Action Plan (mild-moderate with asthma)

Allergy Action Plan (severe)

Allergy Action Plan (severe with asthma)

 

minor injuries series 3: ankle injury

Jess has written a lot of information about the assessment and management of ankle injuries which I have uploaded as a PDF here.  I have put the Ottawa ankle rules below as a taster….

The wonderful thing about ankle injuries is that there is a reliable, commonly used, validated assessment of the injury that helps you to decide if an xray is indicated. This tool was developed by a group in Ottawa, Canada and for that reason bears the name “the Ottawa Ankle Rules” which are as follows:

Carry out an ankle xray (AP and lateral) if:

  • The patient could not walk 4 paces immediately after the injury OR
  • The patient cannot walk 4 paces now OR
  • There is bony tenderness along the posterior aspect of the lateral OR
  • medial malleolus from distal tip extending up 6cm
  • (or xray the foot instead if base of 5th metatarsal tenderness)

You are very welcome to carry out an xray in those who do not fit these criteria if you are worried but there is a very low likelihood of there being a bony injury.

Feeding disorders

Fussy eating is one of the most common things that parents present with to both primary and secondary care.  My colleague, Ann Duthie, has kindly allowed me to paraphrase a recent talk she gave to the department on this subject.  I hope you find the structure as sensible, helpful and reassuring as we did.

FEEDING DISORDERS IN CHILDREN encompass the behaviour of those who have difficulty consuming adequate nutrition by mouth (impaired feeding), those who eat too much and those who eat the wrong thing (pica).  We have not covered here eating disorders such as anorexia or bulimia.

Common presentations include:

  • Dysphagia
  • Food refusal
  • Self feeding inadequacy
  • Excessive meal duration
  • Choking, gagging, vomiting
  • Inappropriate mealtime behaviours
  • Food selectivity by type and texture

 

Normal feeding development is as follows:

  • Up to 6 mths – breast/bottle fed milk
  • 6-12 mths – solids introduced and increased in variety & volume.  Milk intake begins to decrease.
  • At 1 yr – teeth; family diet; ½ pt milk/day; change in attitude to food; active and wt gain slows
  • 15 mths – hold spoon, messy feeding, use feeding cup

The child moves from a state of total dependency on parents for food to one in which he/she can exert control & independence to determine what is
eaten, when and how.  Some parents struggle to adapt to this:

  • Messy
  • Feeding cues can be missed
  • Parental fear that insufficient food will be taken, child will lose weight
  • Parents own food preferences
  • Rejection of a food and assumption that child will never like it
  • Time pressures

The health professional must look for an organic cause of food refusal:

Organ system GI disorder Mechanism
Mouth Carious teeth
Structural with oral
dysphagia
Pain
Reluctance to swallow
Pharynx Tonsils
Aspiration
Pain, obstruction
Choke, gag
Oesophagus Reflux oesophagitis
Cows milk allergy
Pain, burning
Stomach Motility disorder Reduced appetite,
discomfort
Colon Constipation Pain, discomfort, reduced
appetite

Children with neurodevelopmental problems or autism may have additional factors affecting their feeding behaviours.

There are 5 key elements to the assessment:

  • How is the problem manifested?
  • Is the child suffering from any disease?
  • Have child’s growth & development been affected?
  • What is the emotional climate like during mealtimes?
  • Are there any great stress factors in the family?

 

Red flags to look out for include:

  • Swallowing difficulty with cough, choke or gag
  • Vomiting/abdominal pain/arching/grimacing/eye watering
  • Recurrent chest infections
  • Stridor on feeding
  • Snoring with sleep apnoeas
  • Constipation

The history is, as always in medicine, of paramount importance and needs to be fairly detailed:

  • Birth History
  • Previous illness (inc. h/o vomiting, respiratory symptoms) & hospitalisations
  • Developmental progress
  • Chronology of feeding problem
    - Diet since birth
  • - Changes of milk formulae
    - Introduction of solids
  • Current diet (typical day)
  • What happens at meal times?
  • Family & Social history

Height and weight must be measured and plotted on an age appropriate growth chart and corrected for prematurity if less than 2 years of age.  Refer children with red flags or significant faltering growth to secondary services.

  • Management of the well child in primary care:
  • Reduce milk intake if necessary (maximum of 500mls total in 24 hours)
  • Encourage family foods
  • Meal time management (see NHS Lothian’s dietetic advice)
  • Aim: Improve infants comfort at meal times, relieve parental fears and improve parent-infant relationship

 

The multidisciplinary approach:

  • Health Visitor – can assess child within home situation
  • Dietician
  • – Nutritional assessment and feeding advice
  • – Calorie enrichment
  • – Calorie supplementation
  • – Enteral feeds (very occasionally)
  • Speech & Language therapist
  • – Direct assessment of feeding & advice in home situation
  • – Parent-child interaction
  • – Is swallow safe?
  • – Toddler feeding groups (eg. Waltham Forest’s “Ooey Gooey” group at Wood Street)

Summary points:

  • Feeding disorders in children are common
  • Occur in healthy children but assessment should be made for organic causes
  • – GI tract problems
  • – Developmental delay
  • – Autistic spectrum disorder
  • Watch out for obligate milk drinkers
  • Meal time management is crucial
  • Involve Health Visitor

 

Further resources:

Weaning your premature baby.  Free download from Leicestershire Dietetic Service 2011

Help! My child won’t eat and My child still won’t eat.  British Dietetic Association.  Available to buy in packs from http://www.ndr-uk.org/

My Child Won’t Eat by C Gonzalez                    – these are both books and the links are to www.amazon.co.uk

New Toddler Taming by C Green

Elisabeth Paice award 2011

We were Highly Commended in the interprofessional award category of the London Deanery’s 2011 Elisabeth Paice awards for educational excellence.  This is a rare glimpse of the Paediatric Pearls unassuming webmaster with our certificate!

Autism services

In Waltham Forest children under 5 who are thought to possibly have a social and communication disorder should be referred to the Community Paediatric Services at Wood Street health centre.  The care pathway is available here.  Older children need to be referred to the Child and Mental Health Service at Thorpe Coombe please.