Delayed sleep phase this month and chronotherapy which sounds like quite an undertaking. Also a link to a new parent’s guide to picking up and talking about sexual abuse, links to handy recent uploads to the site, the BSACI guideline on allergic rhinitis and more banging on about vitamin D supplementation – please.
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:
The common assessment framework triangle for assessing children in need this month with some tips on how to press the right buttons with children’s social care referrals. Also a bit on stabilisation and transfer for the ED teams, a reminder not to use 0.18% saline and the start of a minor injuries series. Talipes for the GPs and paediatricians among you.
The information for this topic is taken from a recent comprehensive review (August 2012) that appeared in www.UpToDate.com. Bartshealth employees can access the full text via a link from the intranet.
Ingested foreign bodies (UptoDate.com article, August 2012)
Coins — Coins are by far the most common foreign body ingested by children. Approximately two-thirds of ingested coins are in the stomach by the time of x-ray but those that lodge in the oesophagus for 24 hours after ingestion may need to be removed endoscopically as only 20-30% of these will pass into the stomach on their own. Coins that reach the stomach can be managed expectantly, and most will be passed within one to two weeks. A child who develops any signs or symptoms of obstruction, abdominal pain, vomiting, or fever, needs to come back to the ED urgently.
Button batteries — ingestions of “button” batteries are increasing and are associated with significant morbidity. Animal studies have demonstrated mucosal necrosis within one hour of ingestion and ulceration within two hours, with perforation as early as eight hours after ingestion. It may be difficult to differentiate between a disk battery and a coin on a radiograph. This distinction is most important when the foreign body is in the oesophagus, since batteries require immediate removal whereas coins may not.
Magnets — also increasing. Many of the children with complications from multiple magnet ingestion had underlying developmental delay or autism. In one case, an older child inadvertently swallowed these magnets while using them to imitate a pierced tongue. Two or more strong magnets, especially if ingested at different times, may attract across layers of bowel leading to pressure necrosis, fistula, volvulus, perforation, infection, or obstruction. Radiographs of the neck and abdomen should be performed, including a lateral view. X-rays cannot usually determine whether bowel wall is compressed between the magnets, although the finding of magnets that appear to be stacked but are slightly separated is suggestive. Management depends on the number, location and type of magnets, and on the timing of the ingestion. Ingestion of a single magnet can generally be managed conservatively with serial radiographs while multiple magnets need removing. Laxatives may help with faster bowel emptying if they are not in a place easily accessible with the endoscope.
References at www.uptodate.com.
Take a look at September 2012′s edition of Paediatric Pearls! Safeguarding issues surrounding head and spinal injuries, simple motor tics, chronic fatigue syndrome, the new CATS website and some pointers to gems you might have missed from the last 3 years. Do leave comments.
This summarises the Core-info leaflet on head and spinal injuries in children. Full details are available at www.core-info.cardiff.ac.uk.
**PLEASE REFER ALL SUSPECTED INFLICTED HEAD AND SPINAL INJURIES TO PAEDIATRICS **
Inflicted head injuries
- can arise from shaking and/or impact
- occurs most commonly in the under 2’s
- are the leading cause of death among children who have been abused
- survivors may have significant long term disabilities
- must be treated promptly to minimise long term consequences
- victims often have been subject to previous physical abuse
Signs of inflicted head injury
- may be obvious eg. loss of consciousness, fitting, paralysis, irritability
- can be more subtle eg. poor feeding, excessive crying, increasing OFC
- particular features include retinal haemorrhages, rib fractures, bruising to the head and/or neck and apnoeas
- also look for other injuries including bites, fractures, oral injuries
If inflicted head injury is suspected
- a CT head, skull X-ray and/or MRI brain should be performed
- neuro-imaging findings include subdural haemorrhages +/- subarachnoid haemorrhages (extradural haemorrhages are
more common in non-inflicted injuries)
- needs thorough examination including ophthalmology and skeletal survey
- co-existing spinal injuries should be considered
- any child with an unexplained brain injury need a full investigation eg. for metabolic and haematological conditions, before a diagnosis of abuse can be made
The following diagram comes from http://www.primary-surgery.org:
These CT images are from http://www.hawaii.edu/medicine/pediatrics/pemxray/v5c07.html:
EXTRADURAL (or epidural) haematoma
SUBARACHNOID haemorrhage in a 14 month old
Neuro-imaging for inflicted brain injury should be performed in
- any infant with abusive injuries
- any child with abusive injuries and signs and symptoms of brain injury
Inflicted spinal injuries
- come in 2 categories : neck injuries, and chest or lower back injuries
- neck injuries are most common under 4 months
- neck injuries are often associated with brain injury and/or retinal haemorrhages
- chest or lower back injuries are most common in older toddlers over 9 months
- if a spinal fracture is seen on X-ray or a spinal cord injury is suspected, an MRI should be performed
August’s PDF only has 4 text boxes but with lots of information crammed into them and extra on the blog. A great looking PDF on poisoning in children from one of our registrars, an article on stammering from another working with a speech and language therapist and an update on BTS pneumonia guidelines just in time for the winter. Also a feature on Cardiff’s core info safeguarding work on the evidence behind different types of fractures. Do leave comments…
Click here for this month’s PDF digest! It ‘s quite hard providing a balance of information for GPs and ED juniors now that I am only doing the one newsletter. I think we’ve succeeded this month with neurodevelopmental milestones in Down’s syndrome and essential tremor aimed mainly at GPs and pulled elbow, anaphylaxis and the FEAST study aimed more towards the emergency medicine practitioners. Many thanks to my colleagues who have contributed this month. The FEAST video makes fascinating and inspiring watching for any health professional, regardless of specialty. Do leave comments, questions, suggestions!
With thanks to my colleague, Dr Su Li, for summarising this 2011 NICE guideline for Paediatric Pearls.
Anaphylaxis: assessment to confirm an anaphylactic episode and the decision to refer after emergency treatment for a suspected anaphylactic episode
Anaphylaxis is a severe, life-threatening, generalised hypersensitivity reaction involving
- the airway (pharyngeal or laryngeal oedema) and/or
- breathing (bronchospasm, tachypnoea) and/or
- circulation (hypotension, tachycardia).
There can often be skin and mucosal changes. Patients presenting with these signs and symptoms should be diagnosed as having ‘suspected anaphylaxis’.
Anaphylaxis may be an allergic response that is
- immunologically IgE mediated (foods, venoms, drugs, latex) or
- non-immunologically mediated or
- idiopathic (significant clinical effects with no obvious cause).
This guideline does not make any drug recommendations. These can be found at http://www.resus.org.uk/pages/reaction.pdf.
Patient Centred Care
- Treatment and care should take into account patient’s needs and preferences
- Patients should have the opportunity to make informed decisions about their care and treatment, in partnership with health care professionals
- Good communication between healthcare professionals and patients is essential
- Families and carers should be given the information and support they need
- Care of young people in transition between paediatric and adult services should be planned and managed according to the best practice guidance described in ‘Transition: getting it right for young people’
- Document acute clinical features of the suspected anaphylaxis
- Record the time of onset
- Record the circumstances immediately before the onset of symptoms to help identify possible triggers
- Consider taking blood samples for mast cell tryptase if reaction is thought to be immunologically mediated or idiopathic
- First sample as soon after emergency treatment given
- Second sample 1-2 hours (no more than 4 hours) from onset of symptoms
- A further sample may be required at follow up with the allergy specialist to measure baseline mast cell tryptase
- Children who have had emergency treatment should be admitted to hospital under the care of the paediatric team. The resus council suggests observing the child for a pragmatic (no evidence yet) 6 hours because of the risk of a biphasic reaction.
- Offer the child/parents a referral to an allergy specialist (see www.bsaci.org for registered allergy clinics)
- Offer the child/parents an adrenaline injector in the interim period whilst waiting for a specialist appointment
- Before discharge, offer the child/parents
- Information about anaphylaxis (signs, symptoms, risk of recurrence of symptoms (biphasic reaction)). Parent information leaflet here.
- Information about what to do if a reaction occurs (use adrenaline injector, call emergency services)
- Demonstration on how to use an adrenaline injector see http://www.youtube.com/watch?v=pgvnt8YA7r8 for a clear American description of how to use it.
- Advice about how to avoid potential triggers
- Information about the need for referral and the referral process to an allergy specialist
- Information about patient support groups
- Mast cell tryptase is not always elevated in children, particularly if food is thought to be the allergen or if respiratory compromise is the main clinical feature. It is recommended that further studies be carried out to identify other potential chemical inflammatory mediators.
- There is limited evidence on biphasic reactions. Follow up studies are recommended.
- There are no studies on length of observation period following emergency treatment for suspected anaphylaxis
- There is limited data on the annual incidence or anaphylactic reactions and their associated outcomes.
- The Guideline Development Group feel that referral to specialist services and/or the provision of adrenaline injectors are likely to benefit patients who have experienced a suspected anaphylaxis as a result of decreased anxiety and ongoing support. This benefit is yet to be quantified.