Paediatric Pearls

More background to pertussis with thanks to Dr Rupa Vora

• whooping cough is caused by Bordetella pertussis, a gram negative pleomorphic bacillus. It is spread by aerosol transmission and the bacteria cause damage by attaching to the respiratory cilia
• it occurs in clusters every 2-5 years during the summer months. We currently have an outbreak with the HPA provisionally reporting 665 cases in the first quarter of 2012 (cf. 1040 cases in 2011, 421 in 2010)
• cases have dropped dramatically since pertussis vaccinations have been introduced. Acellular pertussis vaccination is given at 2 and 3 months, followed by a pre-school booster.  However, protection wanes quickly and has virtually disappeared by 12 years old
• incubation period is 3-12 days and children are most infectious in the first 2-3 weeks. They are most likely to present in the second phase of illness at 3-4 weeks
• can present with coryza (1^st stage which lasts a couple of weeks), paroxysms of cough, difficulty feeding and pneumonia. Younger infants (<6months) may not present with the characteristic ‘whoop’. Older children and adults often present with a persistent cough
• complications include chronic cough (“100 day cough”), hypoglycaemia, seizures, encephalopathy and intracranial haemorrhage
• any infant is vulnerable and up to 50% may need hospitalisation.  Especially vulnerable are ex-prems and those with underlying cardiology, respiratory or neurological problems.  
• In England and Wales, whooping cough is statutorily notifiable.  The diagnosis is usually made on clinical grounds without the requirement for laboratory confirmation
• The UK Health Protection Agency advises a 7 day course of erythromycin or clarithromycin (or azithromycin for 3-5 days if under 4 weeks) to reduce spread.  A pernasal swab to confirm or refute B. pertussis as the causative organism can be carried out.  If the cough has been present for more than two weeks and the child is in the community, serum serology can be sent to Colindale.  See table below:

Appropriate laboratory tests for a sporadic case of pertussis reported to HPA on clinical suspicion (with thanks to Dr Maria O’Callaghan): 

 NPA – nasopharyngeal aspirate; PNS – pernasal swab;

RSIL – Respiratory and Systemic Infections Laboratory, Colindale

Useful websites:

HPA: www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/WhoopingCough/

NHS Choices: www.nhs.uk/Conditions/Whooping-cough/Pages/Introduction.aspx

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.

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.

One of our registrars has put together a concise guide to immunisation in the UK which many fully trained GPs will be very au fait with.  Some in training may appreciate a quick run through!  The schedule changes from time to time but the links below should lead you to the current guidance whenever you access this post.   The current immunisation schedule appears below; click here for Rajashree’s complete concise guide which you can easily print off for your wall….

Routine UK Immunisation schedule (current at May 2011):

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_126898.pdf