Category Archives: Uncategorized

Who Has Not Been Asked About Nappy Rash?

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.

NICE has a comprehensive clinical knowledge summary on nappy rash here. Salient points:

  • Skin swabs are not recommended for the management of nappy rash as the results are difficult to interpret.
  • Both Candida and bacteria (such as Staphylococcus aureus) colonize healthy skin and a skin swab may be positive when infection is not present.
  • A swab should only be taken when a secondary bacterial infection is suspected, to guide choice of antibiotic

This picture and more available on the excellent Primary Care Dermatology Society website. Compare this candidiasis picture with ammoniacal dermatitis and napkin eczema.

  • 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.

Signs of Raised Intracranial Pressure (ICP)

From APLS manual 6E

  1. 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.
  2. Abnormal Posture:
    Decorticate (flexed arms, extended legs)
    Decerebrate (extended arms, extended legs)
    Posturing may need to be elicited by a painful stimulus
  3. Abnormal pupillary responses: unilateral or bilateral dilatation suggests raised ICP
  4. 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
  5. Cushing’s Triad: Hypertension, Bradycardia and breathing pattern abnormalities are a late sign of raised ICP

Winter, Vitamin D and Rickets

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.

The Vaccine Knowledge Project

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

(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.

Paediatric Hypertension – measure the ABPM

(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

Child Safeguarding – New RCPCH Resource

(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

Mean Corpuscular Haemoglobin Concentration

(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.

MCHC = (Hb1 ÷ HcT2) x 100

Normal in children is 32-34% (adults 28-36%) depending on the lab

Chronic Anaemia

Iron Deficiency

Thalassaemia

spherocytosis

folic acid deficiency

Vit B12 deficiency

burns patients

sickle cell disease

 

What is PoTS? Is it an illness?

(From June 2017 Paediatric Pearls Newsletter)

It stands for Postural Orthostatic Tachycardia Syndrome, an autonomic disturbance

From support group POTS UK

leading to light-headedness, sweating, tremor, palpitations and near syncope in the upright position1

Definition:

  • 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

 

URINALYSIS

(From June 2017 Paediatric Pearls Newsletter)

Also see:

Blood

  • 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:
    • UTI
    • Viral infections
    • Post streptococcal glomerulonephritis
    • Trauma
    • Henoch Schonlein Purpura
    • Wilm’s tumour (median age 3.5 years)

Resources: