Paediatric Pearls

This service, for parents who are anxious about their relationship with their baby and/or child under 3, resides within North East London NHS Foundation Trust and serves Redbridge, Waltham Forest, Barking and Dagenham and Havering communities.

The PPIMHS teams are made up of psychiatrists, community mental health practitioners and psychotherapists/psychologists and they accept referrals from Health Visitors, GPs, midwives, Children’s Centres workers or other health professionals.  Click here for their referral form.  They may signpost elsewhere after the initial consultation if appropriate or they will offer the parent/carer and infant/child 9-12 sessions to work on the parent-infant relationship.

Groups particularly at risk of having problems with bonding include families with ex-premature babies who have spent a significant amount of time on the Special Care Baby Unit, those where the baby has feeding issues or is difficult to soothe, those where breastfeeding failed to establish and those where there was a traumatic birth or difficult conception and/or pregnancy.  Many of the parents on their case load have a personal history of disturbed attachments and are keen not to let history repeat itself.  A recent audit showed that 41% of their mothers had some sort of mental health diagnosis which means that 59% did not.  Click here for an information leaflet about their service that you might like to give to your patients.

Mums with postnatal depression or post-partum psychosis should be referred directly to a perinatal psychiatrist rather than PPIMHS.  Parents struggling with a crying baby or fussy toddler but with no bonding issues should be referred to their health visitor.  The PPIMHS team is a tier 3 (specialised) service concentrating primarily on the parent-infant relationship.

Symptoms in the baby that might suggest a bonding problem:

extreme clingy behaviours, fussy, difficult to soothe, abnormal self-soothing behaviours (eg. head-banging, hair-pulling, scratching), excessive sleep problems, extreme feeding problems, lack of verbal and non-verbal communication, stiff or floppy posture, extreme fearfulness or watchfulness, lack of interest in the world, no comfort sought from parents, avoids eye contact with parents, smiles very little.

Symptoms in the parent:

high anxiety and panic about the baby, excessive A and E or GP presentations, feeling frightened of harming the baby, lack of separation between parent and baby, baby never put down, excessive sterilising of bottles and toys, detached feelings about the baby, no pride in their development, anger about baby as if baby intends to upset the parent, feelings of failure as a parent, inability to cope.

There is some evidence around this issue and around maternal stress during pregnancy and the effect of high maternal cortisol levels on the foetus’ developing brain.  I have asked the Waltham Forest PPIMHS psychologists to write a bit about that and correct anything I have written about their service!

December 2011 has snippets of information on torticollis (backed up with lots more information on the website), unconscious children, alkaline phosphatase and a link to the Map of Medicine’s recent algorithm for cough in children.  Also some pointers for your safeguarding training needs.  Download it here.

This is the first time in ages I’ve managed to get the finalised version on line in time for the end of the month!  NICE on autism this month, a bit on the use of corticosteroids in croup with help from the Cochrane Library, update on secondary prevention of meningococcal disease and a pointer to our local educational psychologist service which is hoping to make stronger links with the borough’s GPs (see also below).  Our feeding series continues with an article on colic from one of the junior paediatricians with lots of useful links and updates.

My ED consultant colleagues requested that we run a series on “feeding issues” in Paediatric Pearls as it forms a part of the ED trainees curriculum and is a common subject to come up in conversation with parents in the ED.  It seems appropriate to begin the series with an article on breastfeeding problems put together by our breastfeeding counsellor, Jo Naylor, and one of the current paediatric trainees, Dr Sarah Prentice.  Their full article is downloadable here and I have reproduced some nuggets in this month’s Paediatric Pearls newsletter and below. 

Reminder: handout of local breastfeeding drop-in groups available here.

I intend to cover the following topics over the next few months (some of which have actually already been touched on in previous months):  vitamin supplementation, formula milk, gastro-oesophageal reflux, starting solids, allergy, fussy eating, food refusal, dentition and use of bottles, healthy eating, obesity, eating disorders.    Please do leave requests for other topics below.

May 2011 GP version available here!  Can you tell the difference between septic arthritis and transient synovitis?  We have a new algorithm to help you.  Also a reminder about measles, information on inguinal hernias, NICE on otitis media with effusion and a link to an important discussion on the website about what one can and can not do / take while breastfeeding.  Do leave comments below.

with thanks to Dr Jemma Say for putting the following information together:

Inguinal Hernias

An indirect inguinal hernia is a protrusion of abdominal contents into the inguinoscrotal or labial canal via an open deep inguinal ring due to the failure of obliteration of the processus vaginalis.

 In fetal life the descent of the testis into the inguinal canal and scrotum is preceded by a small pouch of peritoneum; the processus vaginalis. After birth this peritoneal communication is obliterated, failure to do so results in either a hydrocele or hernia, depending on the degree of fusion.  

 Indirect hernias are more commonly seen in a paediatric population, as opposed to direct inguinal hernias in adult patients, where the musculature is weak and abdominal contents protrude through the wall of the inguinal canal.

Epidemiology

The incidence is 1-2%, occurring 9 times more commonly in males. The majority are found on the right (60%), 15% are bilateral, more commonly with a family history. Presentation is most frequently in infancy.

Increased Incidence

• Preterm infants (10-30%)
• Abdominal wall defects (e.g. prune belly syndrome)
• Connective tissue disorders (e.g. Ehlers Danlos syndrome)
• Chronic respiratory disease
• Undescended testes
• Increased intraabdominal pressure

The diagnosis is clinical, although USS can play a role in older children with indeterminate pain. Surgery is indicated for all paediatric patients with inguinal hernia.

The risks of not performing surgery include bowel incarceration or necrosis, and testicular or ovarian compromise and necrosis. This risk is greatest in early infancy; premature infants have an incarceration risk of up to 30%, and therefore often warrant treatment prior to discharge.  Some surgeons keep under close review for a few weeks post discharge so that these still very small babies put on a bit of weight before the operation.

If a patient presents with incarceration, an attempt at reduction should be made and urgent surgery is required, as the risk of reincarceration is as high as 15% if surgery is delayed more than 5 days.

Referral Pathway

All inguinal hernias should be referred, paediatric patients >1 year can be referred to Mr Brearley at Whipps Cross while those <1 should be referred to the Royal London Hospital. Surgery involves either open or laparoscopic techniques (tranperitoneal or preperitoneal approaches). The majority are performed as an outpatient with normal activity resuming within 48 hours.

References

IPEG guidelines for Inguinal Hernia and Hydrocele, Nov 2009. http://www.ipeg.org/education/guidelines/hernia.html

Ashcraft’s Paediatric Surgery, Holcomb G W, Murphy. J P

ABC of General Paediatric Surgery: Inguinal hernia, hydrocele and the undescended testis: BMJ 1996 312:564

Patient Information Leaflets

http://www.patient.co.uk/doctor/Inguinal-Hernias.htm

http://www.bch.nhs.uk/acrobat/PDF%20for%20Web/Inguinal%20Hernia%20Repair.pdf

Video information

Distinguishing indirect and direct inguinal hernia

http://www.youtube.com/watch?v=wAzXSqGybvE

Indirect inguinal hernia repair

http://www.medicalvideos.us/play.php?vid=1108

The April 2011 version is now published.   I have covered the recently reviewed NICE guideline on depression in children and young people.  We continue with the 6 week check series with some information on umbilical hernias and granulomas.  And, now that the hay fever season is upon us, we have had a look at the literature on non-sedating antihistamines.

This month we have covered umbilical granulomas and hernias as part of the feature on 6-8 week baby checks. Our surgeon with an interest in paediatrics is happy to see children from around 3 years of age if their umbilical hernia has not spontaneously resolved by then.  This topic is covered succintly, including a list of differential diagnoses, in an on-line Australian handbook of neonatal care. Inguinal hernias are a different matter altogether (they carry a far greater risk of becoming incarcerated) and one of the junior paediatricians is working on a “Pearl” about them for the May or June PP edition. 

There is not much evidence published on what to do with umbilical granulomas.   They occur when the inflammatory process at the umbilicus leads to excess granulation tissue preventing the raw area from developing new epithelial tissue.  One theory is that infection has a part to play.  I do nothing when asked about them in the Emergency Department but then I don’t follow up those patients so some GPs may feel that masterly inactivity is not enough!  They tend to take a few weeks to months to clear up.  There are references in the literature to fusidic acid, cool boiled water, salt, silver nitrate and reassurance.  Salt seems to be “in” at the moment.  All comments welcome!

The March 2011 version is now published.  I have covered the new NICE guideline on food allergy which I think you will all find helpful and provided a link to the Allergy Academy which runs some really excellent course on all aspects of allergy in children.  We continue with the 6 week check series with some information and pictures on fontanelles, craniosynostosis and positional plagiocephaly.  There’s a bit on how to get foreign bodies out of noses.  Do leave comments below.

Secondary craniosynostosis is caused by premature closure of ALL sutures due to lack of primary brain growth. If you find a child with premature closure of fontanelles or over-riding sutures at six week check you should refer to paediatric outpatients. NB Plagiocephaly (flat occiput) is a non-pathological deformation due to ‘back to sleep’ position – no action required.  It presents with ear on flattened side presenting anteriorly.  Parallelogram shaped head (as opposed to lambdoid suture craniosynostosis trapezoid shaped)

The following articles give lots of information on fontanelles and/or sutures.  The Fuloria article is very thorough and although it focuses on neonatal examination, most of it is still relevant for the six week check.

1) The Abnormal Fontanel, J KIESLER et al Am Fam Physician. 2003 Jun 15;67(12):2547-2552.    http://www.aafp.org/afp/2003/0615/.html  (figure 2 taken from abnormal fontanel)

2)The Newborn Examination: Part I. Emergencies and Common Abnormalities Involving the Skin, Head, Neck, Chest, and Respiratory and Cardiovascular Systems, Fuloria et al, Am Fam Physician. 2002 Jan 1;65(1):61-69.   http://www.aafp.org/afp/2002/0101/p61.html

3) http://www.nice.org/CG037quickrefguide

4) http://www.patient.co.uk/doctor/Examination-of-the-Neonate.htm

5) Craniosynostosis, P Raj et al, emedicine jul 2010 Craniosynostosis : eMedicine Neurology