Organisational skills problems (time management, memory, late and unfinished homework and projects)
Erratic work and academic performance
Poor sleep and other household routines
Difficulty managing finances, impulsive shopping
Compulsive addictions – sex, gambling, video gaming, exercise, eating
Frequent accidents secondary to recklessness
Speeding tickets, car and motorbike accidents
First degree relatives with ADHD
Low self-esteem, chronic under-achievement
ADHD is usually diagnosed after the age of 6 years to allow for the child to mature. Almost all children have times when their behaviour seems unacceptable and age inappropriate. However, when behaviours happen many times a week or daily, ADHD ought to be looked for. NICE guidance allows children to be treated after the age of 5 years and medication makes a huge and quick difference along with psychoeducation and behavioural management.
Resources: The Canadian ADHD Resource Alliance (www.caddra.ca is an excellent resource for professionals with free downloads).
US guidelines have recently changed to allow treatment of some 4 year olds with debilitating features of ADHD (https://www.healthychildren.org/English/news/Pages/Practice -Guideline-for-the-Diagnosis-Evaluation-and-Treatment-of- ADHD.aspx)
Allergic rhinitis is common and affects 10–15% of children and 26% of adults in the UK
Affects quality of life, school and work attendance, and is a risk factor for development of asthma.
Diagnosed by history and examination, supported by specific allergy tests.
Topical nasal corticosteroids are the treatment of choice for moderate to severe disease
Combination therapy with intranasal corticosteroid plus intranasal antihistamine is more effective than either alone and provides second line treatment for those with rhinitis poorly controlled on monotherapy
Immunotherapy is highly effective when the specific allergen is the responsible driver for the symptoms
Treatment of rhinitis is associated with benefits for asthma
Non-allergic rhinitis also is a risk factor for the development of asthma
Non-allergic rhinitis may be a presenting complaint for systemic disorders such as granulomatous / eosinophilic polyangiitis, sarcoidosis
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.