Paediatric Pearls

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 month’s emergency department version of Paediatric Pearls has information on the NICE guideline on head injury, what to do if you find a child has an undescended testis and some pointers to sites on asthma inhalers.  Download the January 2011 ED version here.

January reminds us all of the NICE guideline on head injury and specifically when a child is supposed to be referred for a CT.  We continue our 6-8 week baby check series with information on undescended testes.  There are also links to agreed blood test reference ranges and resources to help with the identification of asthma inhalers.  Download January 2011 GP PDF here.

This month I have featured the 2007 NICE guideline on head injury.  This is because I was looking through it recently trying to find out how long we should be observing children with minor head injuries for in A and E ie. those who do not qualify for a CT.   I was also interested to find out whether we should treat babies, whose fontanelles are still open, differently.  Would it take longer for the signs of intracranial pressure to become obvious in them?  Anyway the guideline answers neither of those questions…

I found a couple of recent Canadian papers on the need for CT scanning in children with minor head injury.  I think many of us are concerned that we are doing too many CTs on children as a result of the NICE guideline.  The radiation dose is not insignificant and some of the children have to be sedated for the investigation which is an added risk too.  Maguire et al (Should a head injured child receive a head CT scan?  A systematic review of clinical prediction rules. Pediatrics 2009;124(1):e145 – e154) say in the introduction to their paper that up to 70% of children presenting to the ED in the USA or Canada with a head injury get a CT scan and 70% to 98% of them are normal.  A more recent attempt at a clinical decision tool for assessing the need for CT has been written up by the Canadian head injury study group: Osmond MH et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ 2010;182(4):341-348.  There is a nice summary of and comment on this paper at www.medscape.com/viewarticle/579598.

The Scottish intercollegiate network (SIGN) put together a very similar guideline on head injury in 2009.  Their patient information leaflet is, in my view, infinitely better than NICE’s.  Have a look at their documents and downloads at http://www.sign.ac.uk/guidelines/fulltext/110/index.html