March 2015: the first post of the new ENT feature this month – glue ear, more help with viral exanthems, important safeguarding information on the UK government’s Prevent Strategy, breastfeeding for mums and research in the paediatric ED.
Last bit of headaches this month with guidance on management of various primary headaches, including medication overuse headache. Also more on domperidone, psoriasis, respiratory and heart rates to worry about and a link to a new colic summary I’ve put under the Primary Care Guidelines tab. Do leave comments below.
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