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.
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 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.
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.
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