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!

Dr Aimee Henderson (GPVTS) says of www.spottingthesickchild.com:

“Spottingthesickchild.com is a useful and easy to navigate online resource which I feel would mostly benefit those who have not had much experience in paediatrics before and who are of a more junior level. The site has a good range of the most common problems in children like abdominal pain and cough, and guides you through various points such as examination and communication. It has useful links to BTS and NICE guidelines.  I like the fact that you can monitor your progress in percentage of the site covered. There is also a test you can take (and certificate to print) when you feel you have looked through everything. The only downside is you need to make sure you are somewhere quiet as it is mostly video/audio heavy and you will need to be able to hear it.”

Dr Khalika Hasrat (GPVTS) says of the e-lfh safeguarding modules:

“I found the content of both modules useful, although module 2 was a little repetitive of the issues already raised in module 1. It was a good revision tool and the pictures helped emphasise the warning signs of abuse. The only criticism was that the MCQs were not always worded very clearly, but otherwise a valuable tool.”

Please do leave any other comments on these 2 sites below and especially if you have had a look at the Healthy child module in e-LFH.

This month I have reproduced some immunisation myths and truths from Dr Ravindran’s excellent summary published in full somewhere on this blog (use the search function if you can’t find it below). NICE’s UTI guideline has just been reviewed; did you know there was a section called “Do not do recommendations”? Worth a look as we are all guilty of doing some of what we are not supposed to. Our new list of local breastfeeding drop-in groups is out, reduced unfortunately since the cutting back of Childrens centres’ funding. The GMC have clarified parental responsibility nicely and, as a step-parent myself, I was quite pleased to see the sensible point on the end too. Lastly, it is a bit depressing to be told that it takes 3 times longer in the UK for a child with a brain tumour to be diagnosed than in the US. Do leave comments below.

Less text boxes this month because of the importance of the parental responsibility issues in the ED, highlighted in the featured GMC 0-18 document.  Also a brief look at the recently reapproved UTI NICE guideline.  Did you know they did a section called “Do not do recommendations”?  We have done a quick round up of relevant academic papers for you this month and pointed you to a site aimed at improving our woeful pick up rate of childhood brain tumours.  Do leave comments here.

A move away from NICE guidelines this month to cover the 2011 BTS/SIGN asthma guidelines and a link to a succinct summary of the current UK immunisation schedule written by one of our registrars.  Also a bit from the literature on management of gastro-oesophageal reflux disease and a few pointers about Forced Marriage which is an important safeguarding issue in our region.  Do leave comments.

June already!  A move away from NICE guidelines this month to cover the 2011 BTS/SIGN asthma guidelines.  Also a bit from the literature on management of gastro-oesophageal reflux disease and a few pointers about Forced Marriage which is an important safeguarding issue in our region.  Do leave comments.

Limping Child Guideline

(with thanks to Dr Rajashree Ravindran)

Children who have hip pathology may present with a variety of non-specific symptoms. They may present with pain, refusal to bear weight, limp, or decreased movement of the lower extremity. If pain is present it is important to determine where it is coming from, as pelvis and low back pathology may refer pain to the hip region and hip pathology commonly presents with referred thigh or knee pain.[1]

The history should include

1. pain characteristics
2. trauma (recent/remote)
3. mechanical symptoms (catching, clicking, snapping, worse during or after activity)
4. systemic symptoms (fever, irritability, weight loss, anorexia)
5. inflammatory symptoms (morning stiffness)
6. neurological symptoms (weakness, altered sensation)
7. gait (limp or not weight bearing)
8. effects of previous treatments (including antibiotics, analgesics, anti-inflammatory drugs, physiotherapy)
9. The current level of function of the child and development

Examination:

1. Temperature and vital signs.
2. Musculoskeletal exam including gait assessment: Look, Feel, Move approach to joint examination can be used. It should be noted that it is exceptionally rare to appreciate swelling of the hip on physical exam as it is a deep joint.
3. A CNS examination is also vital to exclude any neurological pathology.
4. Look for abdominal masses(Neoplasias in children can present with a simple limp)
5. Examine the genitalia(testicular torsion may present simply as a limp[2]) and perform an ENT examination
6. Look for rashes, bruises in unusual areas and remember the possibility of a non accidental injury.

Common differential diagnosis of limp by age:[2] 

Investigations:

Limp due to trauma: If a traumatic fracture is suspected perform an x ray of the affected site and involve the orthopaedic team as appropriate. Always consider the possibility of non accidental injury in a younger child presenting with fracture.

Atraumatic limp: The algorithm as below can be used for guidance.  You may wish to give the parent information leaflet out as part of your “safety netting” as it reminds the family to seek further help if the limp is still present 1 or 2 weeks later.

Algorithm for Child presenting with an atraumatic limp

Parent information leaflet

REFERENCES

1.            Frick, S.L., Evaluation of the child who has hip pain. Orthop Clin North Am, 2006. 37(2): p. 133-40, v.

2.            Perry, D.C. and C. Bruce, Evaluating the child who presents with an acute limp. BMJ, 2010. 341: p. c4250.

3.            Kocher, M.S., D. Zurakowski, and J.R. Kasser, Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am, 1999. 81(12): p. 1662-70.

4.            Caird, M.S., et al., Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am, 2006. 88(6): p. 1251-7.

5.            Howard, A. and M. Wilson, Septic arthritis in children. BMJ, 2010. 341: p. c4407.

6.            Kang, S.N., et al., The management of septic arthritis in children: systematic review of the English language literature. J Bone Joint Surg Br, 2009. 91(9): p. 1127-33.

7.            Kocher, M.S., et al., Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am, 2004. 86-A(8): p. 1629-35.

8.            Padman, M. and B.W. Scott, (i) Irritable hip and septic arthritis of the hip. 2009. 23(3): p. 153-157.

The March 2011 version is now published.  I have covered the new NICE guideline on food allergy and provided a link to the Allergy Academy which runs some really excellent course on all aspects of allergy in children, including one specifically for ED physicians.   There’s a bit on how to get foreign bodies out of noses and a text box on the paediatric early warning system or PEWS.  I have reminded you all that children under 18 months with a fracture need to be seen by a paediatrician before discharge for a safeguarding assessment.  This guideline comes from a new document put together by the NSPCC and the Welsh Child Protection group.  The pamphlet, downloadable here, describes when to suspect physical abuse in children with fractures and is useful reading for all ED practitioners.  Do leave comments below.

All professionals who come into contact with children need Level 1 and 2 training.  You can do both levels on-line; register at www.e-lfh.org.uk where the safeguarding courses are listed under “Projects”. 

The Royal College of Paediatrics and Child Health holds a number of courses and advertises others, many of which are open to non-paediatricians.  Have a look at http://www.rcpch.ac.uk/Policy/Child-Protection/Child-Protection-Training. 

The Advanced Life Support Group also run child protection courses which have been developed with RCPCH.  More information about this on- line course from http://www.alsg.org/en/?q=en/cpip.

There is a very good course for paediatricians run at the Hillingdon Hospital twice a year on child protection and court skills.  They run in June and November each year.  See http://www.acpcltd.co.uk/hillingdon_cp_course.html.

Do let me know of any other courses using the Comments feature below.

Please find local safeguarding boards contact details below.  Lots of information on what the LSCB is, training courses on offer, what to do if worried about a child, relevant local contact details etc.:

http://www.walthamforest.gov.uk/index/care/childrenandfamilies/childprotect/lscb.htm

http://www.redbridge.gov.uk/cms/benefits_care_and_health/children_and_families/protecting_and_safeguarding/safeguarding_children_board.aspx

Child Protection Handbook produced by Royal College of Paediatrics and Child Health (RCPCH) available to download in full from http://www.rcpch.ac.uk/Policy/Child-Protection/Child-Protection-Publications.  Do peruse the continually updated list of downloadable documents at this link.  For example the guidelines on when to suspect Fabricated and Induced Illness were updated in 2009 and quite substantially broadened. 

NICE quick reference guideline on When to Suspect Child Maltreatment (July 2009) available at www.nice.org.uk/nicemedia/pdf/CG89QuickRefGuide.pdf

Working Together (March 2010) is a guide to inter-agency working to safeguard and promote the welfare of children http://publications.education.gov.uk/eOrderingDownload/00305-2010DOM-EN-v3.pdf 

In May 2010, after the election, the Department for Children, Schools and Families became the Department for Education.  The safeguarding content is currently split between the 2 websites.  Most of the Every Child Matters information is at www.dcsf.gov.uk/everychildmatters  but some of the more up to date news on safeguarding issues is at http://www.education.gov.uk/childrenandyoungpeople/safeguardingandsocialworkreform.

A useful document on recognising physical abuse in children with fractures has just been published jointly by the NSPCC and Welsh Child Protection Systematic Review Group.  Compulsory reading for GPs and ED physicians I should think.

Do use the comments box below to let me know about any other resources you would recommend.