March 2016: a few odds and ends on asthma this month and assessing a child in an acute exacerbation, Childline survey, Meningococcus W and paediatric neck lumps. Do leave comments below:
More musings from Dr Waterfield this month – this time on paracetamol for immunisation discomfort. Also the 7 important features of a headache y0u must ask about, a link to a very good paediatric emergency medicine site, NICE quality standards in depression, molluscum contagiosum and more musings from me, this time on paediatric phlebotomy. Do leave comments below.
BCG Lymphadenitis with thanks to Dr Mujahid Hassan
Lymphadenitis is the most common complication of BCG vaccination, and is of two types – suppurative and non-suppurative.
Normal course post-vaccination:
Intradermal injection -> local multiplication of vaccine -> transport to lymphatics via lymph glands -> haematogenous dissemination of BCG.
No clear definition of ‘BCG lymphadenitis,’ proposed definition is when it becomes palpable or concerning for parents.
Can appear as early as two weeks after vaccination, most within 6 months and almost all cases will be within 24 months.
Normally ipsilateral with one or two palpable lymph nodes, but can involve multiple nodes. Normally axillary but can be with cervical/supraclavicular.
- Isolated lymph node enlargement
- BCG vaccination to ipsilateral side
- Absence of tenderness or heat to lump
- Absence of fever
Non-suppurative will resolve within a few weeks – this is a normal reaction and most of these are sub-clinical so go unnoticed.
Suppurative involves an enlarging lymph node with fluctuant appearances, oedema and erythema. Happens in ’30-80%’ of cases of lymphadenitis.
Treatment of suppurative lymphadenitis:
Antibiotics: Previously erythromycin/rifampicin/isoniazid have been used but their clinical role is of dubious significance, so are not used routinely.
Reassurance and followup are what is needed.
Fine Needle Aspiration: Suppurative lymphadenitis can result in spontaneous perforation and sinus formation, which can result in several unpleasant months of dressing and wound care. FNA is thus recommended to prevent this and reduce time for healing.
Surgical excision: Risks of general anaesthesia – other than in extreme cases of failed FNA/multiloculated lymph nodes – far outweigh the potential benefits.
Management pathway and images courtesy of:
WM Chan, YW Kwan, CW Leung. Management of Bacillus Calmette-Guérin Lymphadenitis, Hong Kong Journal of Paediatrics (New Series). Vol 16. No. 2, 2011, available via http://www.hkjpaed.org/details.asp?id=782&show=1234
J Goraya and V Virdi, Bacille Calmette-Guérin lymphadenitis, Postgrad Med J. 2002 June; 78(920): 327–329,
available via http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1742390/pdf/v078p00327.pdf
Neglect and emotional abuse is the safeguarding topic this month. ED advice on the management of minor head injuries, a report from BPSU in hypocalcaemic fits secondary to vitamin D deficiency, the new UK immunisation poster and a bit on crying babies. Hope you find it all helpful. Comments welcome below
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 (1st 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):
|≤ 2 weeks cough||> 2 weeks cough|
|≤ 1 yr
|NPA/PNS for PCR (RSIL)
PNS for culture (local laboratory)
|NPA/PNS for PCR (RSIL)
PNS for culture (local laboratory)
Serum for serology (RSIL)
|≤ 1 yr
|PNS for culture (local laboratory)||Serum for serology (RSIL)|
|> 1 yr to 6 yr|
|6 to 15 yr||Serum for serology (RSIL)|
|> 15 yr|
NPA – nasopharyngeal aspirate; PNS – pernasal swab;
RSIL – Respiratory and Systemic Infections Laboratory, Colindale
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.