Paediatric Pearls

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

December 2011

www.nice.org.uk/cg134

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’

Recommendations

• 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

Research Recommendations

• 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.

One of our current paediatric SpRs, Dr Anil Krishnaiah, has been looking at some papers on the various paediatric warning scores that are in existence.  Here is his summary of a paper from Sunderland in 2008:

Emerg Med J 2008;25:745-749 doi:10.1136/emj.2007.054965

The PAWS score: validation of an early warning scoring system for the initial assessment of children in the emergency department

P Egdell, L Finlay, D K Pedley

 Existing UK paediatric early warning scoring systems (PEWS) were developed mainly for hospitalised patients and may be less useful for initial assessment in the ED. Until recently these are mainly used to look at admission to the HDU and PICU and trying to produce a system which would recognize those children at risk of admission.

 Assessment of paediatric patients is complicated by the range of normal parameters in different age groups. Inexperienced staff may find it difficult to interpret the significance of physiological readings over a wide range of ages.

 This pilot study was conducted in Sunderland to validate the scoring system by performing a retrospective analysis of 50 consecutive children attending the ED who required admission directly to the paediatric intensive care unit (PICU).  A control group of 50 consecutive children who were admitted from the ED to the general paediatric ward within the same time period was also identified from the ward admission book. They compared the Paediatric Advanced Warning Scores (PAWS) scores between the two groups in order to see whether the PAWS chart would be able to identify those children in need of admission to a critical care area. Primarily the aim of this study was to design and validate a scoring system to identify children attending the ED in need of urgent medical assessment and appropriate intervention. At a trigger score of 3, the PAWS score was able to identify those children requiring admission to the PICU with a sensitivity of 70% and a specificity of 90%.

This pilot evaluation demonstrates that the PAWS chart shows promise as a ‘‘rule-in’’ tool for PICU admission.

Since the introduction of the 4 hour target in the ED, departments have been under increasing strain to assess, treat and admit patients (if required) as quickly as possible. Few studies have been designed to identify if the PEWS score could be used as a triage tool, to detect those patients who will need admission and therefore speed up the process of admitting children to the ward. 

Dr Anil Krishnaiah, Paediatric SpR

My problem with this paper, Anil, is that I want a tool that will “rule-out” predictably ie. one that will tell me reliably which ones I am safe to send home – without overloading the system with too low a threshold for admission.  Anyone got one of those?

This month’s emergency department version of Paediatric Pearls has information on the NICE guideline on ADHD, normal paediatric observations, the updated resuscitation guidelines and a bit from the literature on children who snore.  Do leave comments and questions.

The new ILCOR 2010 resuscitation guidelines are now being taught on all life support courses in the UK. We are allowed this year as a transition year as people get trained up. I have put together a Word document (Useful emergency paediatrics bits and pieces (2)) with all the updated APLS “WETFAG” policies and a table with normal paediatric observations as an aide memoire for those leading paediatric resuscitations or stabilising sick and injured children.

Unfortunately version 5.0 of the APLS manual is not going to be available in hard copy until later this year so there may be a bit of confusion about which guidelines to use. The only thing that will affect the care of the individual child is if the leader loses confidence so please, when the chips are down, use the guideline the leader is comfortable with.

APLS instructors have access to the new manual in draft form through their VLE login. Can I remind you that we all have to do some updated VLE sections and print out a certificate to say we’ve done that before instructing on any courses this year?